Kirsten Meurer

Improving outcomes in hernia repair by the use of light meshes--a comparison of different implant constructions based on a critical appraisal of the literature.

BackgroundDespite convincing advantages offered by meshes, their use in hernia surgery remains controversial because of fears concerning the long-term effects of their implantation. To improve biocompatibility, a large variety of newly developed light meshes has been introduced to the market.This overview of the literature aimed to establish whether absolute material reduction (g per implanted mesh), use of absorbable components, and coating by inert materials are evidence-based ways to improve biocompatibility of meshes.MethodA review of the current English and German language literature on the outcome of groin und incisional hernia mesh repair was performed. Both basic research and clinical trials were used as sources of data. Meta-analyses and randomized controlled trials were given priority and were referred to whenever possible.ResultsOperative technique was an independent prognostic factor for the clinical outcome. Mesh construction and composition as characterized by pore size and filament structure appeared to be more important determinants of foreign body reaction after implantation than absolute material reduction of 1 g or more per implant. No data exist about an oncogenic effect of alloplastic materials in humans, but disturbed fertility in animal studies remains an issue of concern and should be further investigated.ConclusionsAccording to data from current randomized controlled trials and retrospective studies, light meshes seem to have some advantages with respect to postoperative pain and foreign body sensation. However, their use is associated with increased recurrence rates. Light meshes offer no advantages with respect to alleviating severe chronic groin pain. At the same time, experimental data reveal that material composition and mesh structure may significantly affect foreign body reaction.

IN VITRO COMPARISON OF THREE DIFFERENT MESH CONSTRUCTIONS

Background:  Material amount and pore size have been recently discussed as probable important determinants of biocompatibility of mesh implants used in hernia repair. This study aimed to find out whether other constructional parameters affect the extent of early foreign body reaction in vitro.

Redo-Surgery following Curative Resection of Pancreatic Carcinoma: The Difference between True and Suspected Recurrence

Background: Improving results have led to an extension of indications for re-resection of recurrent pancreatic carcinoma. Methods: Among 410 patients who received surgery for histologically proven pancreatic cancer, 17 underwent re-resection for a suspected local recurrence and were evaluated for overall survival, clinicopathological and perioperative data. Results: At the initial operation, resection was curative (R0/R1) in all 17 patients. Indication for re-resection was a suspected or proven recurrence of pancreatic cancer in all patients. Re-resection was possible in 5 patients. The remaining patients received a redo of the pancreaticojejunostomy or bilioenteric anastomosis (n = 2), exploration with biopsy (n = 4), and a palliative bypass (n = 6). Perioperative mortality was 6%. Median overall survival was 25 months (range 10–152 months) and 7 months following re-resection (5–29 months). In 5 of 17 patients, histology showed chronic pancreatitis (n = 4) or a benign stricture at the hepaticojejunostomy (n = 1), whereas all other patients had histologically proven recurrence. Re-resection or redo of the anastomosis was possible in 5 of 5 patients with chronic pancreatitis but only in 2 of 12 patients with true recurrence (p = 0.003). Conclusions: Curative reoperation for recurrent pancreatic carcinoma is rarely feasible. Due to the potential for chronic pancreatitis or benign strictures as an underlying pathology, operable patients should be explored.

Appendicitis in the elderly. CRP value as decision support for diagnostic laparoscopy

BACKGROUND The diagnosis of acute appendicitis in the elderly bears many pitfalls due to a broad range of differential diagnoses and uncommon clinical presentation. This may result in late detection of appendicitis leading to poor outcome. The aim of this study was to examine the characteristics of appendicitis in elderly patients in order to facilitate early diagnosis. MATERIALS AND METHODS All patients who underwent appendectomy in our institution were prospectively recorded over a 30 month period. Data on patients age (>60 years versus < or =60 years), clinical findings, the inflammatory parameters leucocytes and C-reactive protein (CRP) and histological-findings (perforated versus non-perforated) were collected. Statistical analysis was carried out by ROC analysis, chi(2) and t-tests. RESULTS In the examination period 403 patients underwent appendectomy and 11.2% (n=45) were older than 60 years. These patients were characterized by significantly more frequent perforations compared to those patients < or =60 years (35.6% versus 7.0%, p< or =0.05), peritonitis (42.2% versus 9.5%, p< or =0.05), conversion to open surgery (23% versus 5%, p< or =0.005), longer postoperative hospital stay (9.2 days versus 4.3 days, p< or =0.05) and a higher complication rate (28.9% versus 3.6%, p< or =0.005). CRP values in patients >60 years were on average 123.2 mg/l and significantly higher than in patients < or =60 years (35.5 mg/l, p< or =0.005). The ROC analysis resulted in a CRP cut-off value of 101.9 mg/l for patients >60 years for the existence of a perforation with a specificity of 72.4% and a sensitivity of 81.3% (AUC 0.811). CONCLUSIONS The CRP value showed a strong correlation with respect to the grade of inflammation and perforation. In conclusion, elderly patients with symptoms of appendicitis and a CRP value higher than 102 mg/l should undergo early diagnostic laparoscopy.

Effects of Intra-Arterial Octreotide on Pancreatic Texture: A Randomized Controlled Trial

Background and Aims: Octreotide is suggested to harden the pancreas, thus facilitating the construction of a pancreatic anastomosis and lowering the risk of postoperative fistula. We tested the hypothesis that intra-arterial application of octreotide in the gastroduodenal artery during pancreatectomy may increase pancreatic hardness. Material and Methods: A single-center, prospective, double-blinded, randomized controlled trial with parallel assignment was conducted. Patients planned for a pancreatoduodenectomy or a total pancreatectomy, who had a palpatory and durometer proven (<40 Shore units) soft pancreas, were assigned to receive intraoperatively either 5 mL 500µg octreotide or 5 mL 0.9% saline solution as a bolus injection in the gastroduodenal artery. Pancreatic hardness was measured before, early, and late after intervention. The investigator performing the durometer measurements and pathologist were masked to group assignment. The primary outcome was increased pancreatic hardness. Analysis was by intention to treat. This trial is registered at http://www.clinicaltrials.gov (ID NCT01400100). Results: A total of 12 patients received octreotide and 13 received saline solution. Pancreatic hardness marginally increased in the octreotide group: 0.67 ± 2.3 Shore units, whereas it decreased in the control group: −2.15 ± 2.7 Shore units. The difference was statistically significant, p = 0.029 (95% confidence interval = −4.87 to −0.77). Histology did not find any correlate for this clinically irrelevant hardening effect. Conclusions: A single bolus application of octreotide did not deliver a clinically relevant increase in pancreatic hardness. Future studies on the hardening effect of octreotide should employ repeated or continuous preoperative administration of this drug.

Diagnostic double strike in the emergency room - two cases of complete pancreatic ruptures due to bicycle handlebar injuries on two consecutive days

BackgroundPancreatic injuries are rare in cases of blunt abdominal trauma and therefore easily misdiagnosed at time of hospital admission. They are associated with a significantly elevated morbidity and lethality. Bicycle handlebar injuries are the most common cause of pancreatic trauma in children and adolescents.Case presentationWe report two cases of a 23-year-old Caucasian woman and a 15-year-old Caucasian boy who presented to our clinic with a similar history of a bicycle accident on 2 consecutive days. Both suffered from a fall from a bicycle with bicycle handlebar injury 4 and 6 days prior to admission in our clinic. Emergency distal pancreatectomies were performed in both cases.ConclusionsPancreatic injuries must be highly suspected in bicycle handlebar injuries, even if amylase/lipase levels or ultrasound findings seem unremarkable. The best initial strategies are early computed tomography and a quick referral to a level 1 trauma center. Distal pancreatectomy is the treatment of choice in cases of complete rupture of the pancreatic body.

Surprising Twist in the Plot – Sister Mary Joseph’s Nodule of Pancreatic Cancer Mimicking Wound Infection after Umbilical Hernia Repair

Umbilical hernia repair is the second most common type of hernia surgery after inguinal hernia repair. Depending on the surgical technique, complications occur in 5–25% and include wound infections and abscesses [1]. Pancreatic cancer is a fatal disease most commonly diagnosed at an advanced stage. It is typically asymptomatic or causes unspecific symptoms. Over 80% of the patients do not qualify for curative surgical resection due to locally advanced or metastasized disease. Common sites of metastasis include liver, lungs, peritoneum, and lymph nodes [2]. Umbilical metastasis originating from pancreatic cancer, also known as Sister Mary Joseph’s nodule (SMJN), is an extremely rare occurrence [3]. We report the cases of two patients who presented to our department with ulcerated umbilical lesions and had a history of umbilical hernia repair.

Small Bowel Obstruction due to a Giant Meckel's Diverticulum

Background: Meckels diverticulum is the most common congenital anomaly of the gastrointestinal tract, with an average length of 3 cm. Complications occur in 6.4% and most commonly include inflammation and gastrointestinal bleeding. Preoperative diagnosis is demanding and achieved in 4%. Case Report: A 34-year-old otherwise healthy patient presented with an acute abdomen due to small bowel obstruction. Computed tomography scan could not identify the underlying cause. Emergency laparotomy was performed, and a torqued giant Meckels diverticulum measuring 17 cm was found as the underlying cause for the small bowel obstruction. Resection of the affected ileum segment and ileo-ileal reconstruction were performed. The postoperative course was uneventful. Conclusion: In extremely rare cases, small bowel obstruction in an otherwise healthy patient might be caused by torsion of a symptomatic giant Meckels diverticulum.

Zukunft der Chirurgie in NRW – Ergebnisse einer Internet-basierten Online-Umfrage unter Chirurginnen und Chirurgen

Einleitung: Der Nachwuchsmangel in der Medizin trifft besonders die Chirurgie. Die demographische Entwicklung, der steigende Frauen-Anteil, sowie die besonderen Bedurfnisse der jungen Generation in Bezug auf die „Work-Life-Balance“ und die Vereinbarkeit von Beruf und Familie erfordern[for full text, please go to the a.m. URL]