Michael Butters

The German Registry for Natural Orifice Translumenal Endoscopic Surgery: Report of the First 551 Patients

Objective:To analyze patient outcome in the first 14 months of the German natural orifice translumenal endoscopic surgery (NOTES) registry (GNR). Summary Background Data:NOTES is a new surgical concept, which permits scarless intra-abdominal operations through natural orifices, such as the mouth, vagina, rectum, or urethra. The GNR was established as a nationwide outcome database to allow the monitoring and safe introduction of this technique in Germany. Methods:The GNR was designed as a voluntary database with online access. All surgeons in Germany who performed NOTES procedures were requested to participate in the registry. The GNR recorded demographical and therapy data as well as data on the postoperative course. Results:A total of 572 target organs were operated in 551 patients. Cholecystectomies accounted for 85.3% of all NOTES procedures. All procedures were performed in female patients using transvaginal hybrid technique. Complications occurred in 3.1% of all patients, conversions to laparoscopy or open surgery in 4.9%. In cholecystectomies, institutional case volume, obesity, and age had substantial effect on conversion rate, operation length, and length of hospital stay, but no effect on complications. Conclusions:Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application. Transvaginal hybrid NOTES cholecystectomy is a practicable and safe alternative to laparoscopic resection even in obese or older patients.

Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP

IntroductionChronic pain after hernia repair is common, and it is unclear to what extent the different operation techniques influence its incidence. The aim of the present study was to compare the three major standardized techniques of hernia repair with regard to postoperative pain.Patients and methodsTwo hundred and eighty male patients with primary hernias were prospectively, randomly selected to undergo Shouldice, tension-free Lichtenstein or laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty repairs. Patients were examined after 52 months with emphasis on chronic pain and its limitations to their quality of life.ResultsChronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein repair and in 15% after TAPP repair. Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein and in 11% after TAPP repair. Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice, 13% after Lichtenstein and 2.4% after TAPP repair.ConclusionChronic pain after hernia surgery is significantly more common with the open approach to the groin by Shouldice and Lichtenstein methods. The presence of the prosthetic mesh was not associated with significant postoperative complaints. The TAPP repair represents the most effective approach of the three techniques in the hands of an experienced surgeon.

Total gastrectomy : Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age

OBJECTIVE The authors conducted a study of patients who underwent total gastrectomy for gastric malignancy to elucidate contributing factors that lead to successful management of this disease in geriatric patients. SUMMARY BACKGROUND DATA The average mortality rate for patients undergoing stomach surgery due to carcinoma is 7.8% according to the literature overview, still relatively high. Even higher mortality rates are observed for geriatric patients after a total gastrectomy. Because of epidemiologic changes, a total gastrectomy is required with growing frequency in these high-risk patients. METHODS The study involved 380 patients with a gastric malignancy. Risks and benefits of a total gastrectomy with radical lymphadenectomy at an advanced age were analyzed retrospectively in 163 patients older than 70 years of age. The results achieved in these patients were compared with those observed in 217 younger patients. RESULTS The 30-day mortality and morbidity rates for the elderly patients were 3% and 33.7%, respectively; for the younger patients, they were 0.46% and 21.2%, respectively. A statistically significant correlation was found between the presence of risk factors, the occurrence of complications, and the mortality rate. No difference was seen between the two age groups when risk factors were absent. The 5-year survival rate was 30%, with no difference between young and elderly patients. CONCLUSIONS The data prove that a total gastrectomy with a radical lymphadenectomy can be carried out safely in older patients, with long-term results comparable to those achieved in younger patients.

Glucose homeostasis and endocrine pancreatic function in patients with chronic pancreatitis before and after surgical therapy

In a prospective clinical-experimental study, 15 consecutive patients with chronic pancreatitis, operated on because of severe pain, were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th day postoperatively, and 3 months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, and pancreatic polypeptide were determined. As indicated by the k value, glucose tolerance improved postoperatively in 10 patients (66.6%); three patients (19.9%) showed no change, and one patient (6.6%) was worse. Only one patient (6.6%) developed evident diabetes mellitus immediately postoperatively. Pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (p < 0.01). The stimulation of pancreatic polypeptide after oral glucose was significantly lower postoperatively (p < 0.01). Duodenum-preserving pancreas head resection does not lead to an impairment of glucose tolerance in the majority of patients; a deterioration was observed only in few cases (13.3%).

Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters

We assessed the nutritional status of general surgery patients with and without cancer from a western European population in this prospective study. Anamnestic (weight development, abdominal complaints) and anthropometric (fat tissue measurements) data were collected on six groups of patients: cancer of the stomach (n = 13), pancreas (n = 13), colorectal (n = 23), breast (n = 12), and two control groups with benign diseases, ages 20-45 and 50-75 y. From these data, body mass index and ideal body weight were calculated. Concentrations of albumin, transferrin, retinol-binding protein, prealbumin, and creatinine height index were determined by biochemical tests. A weight loss of more than 10% was found in only 31% of gastric and 61% of pancreatic cancer patients. Significant values from anthropometric data were also found only in these groups. In biochemical tests, only the creatinine height index was reduced in all patients with pancreatic cancer. The remaining laboratory changes were so unspecific in all other parameters that no conclusions could be drawn as to the status of the patients nutritional condition. For the evaluation of nutritional status, only relatively simple and inexpensive anamnestic and anthropometric measurements are necessary.

Transverse coloplasty pouch after total mesorectal excision: Functional assessment of evacuation

PURPOSEColon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction.METHODSThirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin® enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire.RESULTSTotal mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction.CONCLUSIONSTransverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.

Analysis of the First 217 Appendectomies of the German NOTES Registry.

Objective: To analyze the feasibility and safety of Natural Orifice Transluminal Endoscopic Surgery (NOTES) appendectomy, and to analyze separately the transvaginal appendectomy (TVAE) and the transgastric appendectomy (TGAE) procedures. Background: Laparoscopic appendectomy has rare but relevant complications, namely incisional hernias and neuralgia at the trocar sites, which can potentially be avoided by the NOTES techniques. Methods: The first 217 data sets of the largest NOTES registry worldwide—the German NOTES registry—were analyzed with respect to demographic data, procedural data, and short-term outcomes. Furthermore, TVAEs were compared with TGAEs. Results: Almost all procedures were performed in hybrid technique (median of percutaneous trocars: 1). Median age (TVAE: 30.5 yrs vs TGAE: 25 yrs; P < 0.017), body mass index (TVAE: 22.8 kg/m2 vs TGAE: 24.1 kg/m2; P < 0.016), and American Society of Anesthesiologists (ASA) classification (I/II/III; TVAE: 57.1%/41.8%/1.0% vs TGAE: 27.8%/69.4%/2.8%; P < 0.003) significantly differed between both access techniques. Whereas the median number of percutaneous trocars (TVAE: 1 vs TGAE: 1; P < 0.450), the need of additional trocars (TVAE: 6.6% vs TGAE: 13.9%; P < 0.156), the intra, and also postoperative rate of complications (TVAE: 0%/5.5% vs TGAE: 0%/11.1%; P < 1.000/0.258), and the median postoperative hospital stay (TVAE: 3 d vs TGAE: 3 d; P < 0.152) were comparable; the median procedural time (TVAE: 35 minutes vs TGAE: 96 minutes; P < 0.001) and conversion to laparotomy rate (TVAE: 0% vs TGAE: 5.6%; P < 0.023) were significantly less after TVAE. Conclusions: The evaluation of the largest patient collective so far indicates that hybrid NOTES appendectomy is a safe procedure, with advantages for the transvaginal technique with respect to procedural time and conversion rate.

[Duration of the preventive use of antibiotics in colorectal surgery--single administration versus short-term prevention].

SummaryThe effect of a combination of 4 g mezlocillin and 0.5 g metronidazol for the prophylaxis against infections in a one-shot dose immediately preoperatively compared to a short-time dose of 2 days given to 90 patients with resection of colorectal carcinoma was investigated in a prospective and randomized study. 6 patients developed a wound infection in the early postoperative phase; 4 of these infections (3 were severe, 1 was mild) occurred in the one-shot group and 2 in the short-time prophylaxis group. After more than 20 days postoperatively 3 late infections were observed which had a mild course (2 cases in the one-shot group, 1 case in the short-time prophylaxis group). All infections were localized in the sacral wound region in patients with abdominoperineal resection. The abdominal wounds healed per primam in each case. Besides those, 26 infections of the urinary tract were observed, which occurred significantly more often after the one-shot dose (40.9%) than with the short-time prophylaxis (18.6%). Intraoperative smears of the lumen of the bowels showed a remaining bacterial settlement. Besides Bacteroides species, especially Escherichia coli were found among the isolates. Moreover in some cases Clostridium, Klebsiella, Proteus and Pseudomonas could be identified. Smears of the site of operation (sacral/peritoneal cavity) were contaminated in over 50%, above all by Bacteroides species; besides those, E. coli were found most often. The subcutaneous smears showed a growth of the germs only in a few cases. Aerobic bacteria in 93.8%, anaerobic bacteria except for thetaiotaomicron and B. asaccharolyticus in 85.1%. 90% of the an aerobic bacteria were sensitive to metronidazol. The results prove that the one-shot dose of the antibiotic combination of mezlocillin/metronidazol for the prophylaxis against wound infections is equivalent to the short-time dose of 48 hours. The healing of the sacral wound after abdominoperineal resection still presents a problem. In 4 of the 6 patients with a sacral wound infection the intra-operatively found germs were identical to the postoperative isolates. A remarkable fact is that the examination of the intra-operatively isolated germs in those patients demonstrates full sensitivity to the employed antibiotic combination. This indicates that not only the applied antibiotic but also other factors such as the surgical technique are responsible for the healing of the sacral wound.ZusammenfassungIn einer prospektiven, randomisierten Studie wurde die Wirkung einer Kombination von 4 g Mezlocillin und 0,5 g Metronidazol zur Infektionsprophylaxe als Einmalgabe unmittelbar präoperativ gegenüber einer Kurzzeitgabe von 2 Tagen an 90 Patienten mit Resektion eines colorectalen Carcinoms untersucht. In der frühen postoperativen Phase entwickelten insgesamt 6 Patienten eine Wundinfektion; davon traten 4 Infektionen (3 schwere, 1 leichte) in der „one shot”-Gruppe und 2 Infektionen in der Kurzzeitprophylaxe-Gruppe auf. Nach mehr als 20 Tagen postoperativ wurden 3 Spätinfekte beobachtet, die alle leicht verliefen (2 Fälle in der „one shot”-Gruppe, 1 Fall in der Kurzzeitprophylaxe-Gruppe). Alle Infekte waren in der sacralen Wunde bei Patienten mit abdominoperinealer Rectumamputation lokalisiert. Die abdominellen Wunden heilten in jedem Fall primär. Daneben wurden 26 Harnwegsinfekte beobachtet, die signifikant häufiger nach der „one shot”-Gabe auftraten (40,9%) als bei der Kurzzeitprophylaxe (18,6%). Intraoperative Abstriche aus dem Darmlumen zeigten in allen Fällen verbliebene bakterielle Besiedlung. Unter den Isolaten fand sich neben Bacteroides-Species vor allemEscherichia coli; außerdem konntenClostridium, Klebsiella, Proteus undPseudomonas nachgewiesen werden. Abstriche aus dem Operationsgebiet (Sacral-/Peritonealhöhle) waren in mehr als 50% der Fälle kontaminiert, vor allem mitBacteroides-Species; daneben fand sich am häufigstenE. coli. Die subcutanen Abstriche zeigten nur in Einzelfällen ein Keimwachstum. Aerobier, ausgenommenPseudomonas aeruginosa, waren zu 93,8% Mezlocillinsensibel, Anaerobier außer B.thetaiotaomicron undB. asaccharolyticus zu 85,1%. 90% der Anaerobier waren Metronidazol-sensibel. Die Ergebnisse beweisen, daß die Einmalgabe der Antibioticakombination Mezlocillin/Metronidazol zur Wundinfektionsprophylaxe einer Kurzzeitgabe über 48 h gleichwertig ist. Problematisch ist nach wie vor die Heilung der sacralen Wunde nach abdominoperinealer Rectumamputation. 4 der 6 Patienten mit sacralem Wundinfekt zeigten eine Übereinstimmung der intraoperativ gefundenen Keime mit den postoperativen Isolaten. Bemerkenswerterweise ergab die Austestung der intraoperativ isolierten Keime bei diesen Patienten volle Empfindlichkeit gegenüber der verwendeten Antibioticakombination. Dies deutet daraufhin, daß für die Heilung der sacralen Wunde nicht allein das applizierte Antibioticum, sondern auch andere Faktoren, wie z. B. die chirurgische Technik verantwortlich sind.

Gastrektomie im hohen Lebensalter

Between 1969 and 1983 a total of 152 patients underwent total gastrectomy. 58 patients were older than 70 years. Surgical lethality was 14.47% with only minor differences between those patients younger than 70 and the older ones: 13.8 and 15.5%, respectively. Moreover, it did not make any major difference whether surgery was curative or merely palliative. Of 27 patients with the tumor stage TNM IV, only one patient died. Of the 66, who were operated upon during the recent 5 years period between 1979 and 1983, only one patient died. These results suggest that this remarkable decline of lethality is due to a precise standardisation of surgical technique, improvements in preoperative management of the patient and aftercare. 5 years survival rate was 17.3%; again there was no major difference between the group of patients older than 70 and those being younger than 70 years (16.5% and 19.4% respectively). It is of interest that the patients having additional splenectomy presented with an essentially worse prognosis as opposed to those without splenectomy although there were no differences between the TNM-stages. Even if the small numbers of patients can not yet be definitely conclusive, these preliminary results indicate that the indication for splenectomy in the course of total gastrectomy should be critically evaluated.SummaryBetween 1969 and 1983 a total of 152 patients underwent total gastrectomy. 58 patients were older than 70 years. Surgical lethality was 14.47% with only minor differences between those patients younger than 70 and the older ones: 13.8 and 15.5%, respectively. Moreover, it did not make any major difference whether surgery was curative or merely palliative. Of 27 patients with the tumor stage TNM IV, only one patient died. Of the 66, who were operated upon during the recent 5 years period between 1979 and 1983, only one patient died. These results suggest that this remarkable decline of lethality is due to a precise standardisation of surgical technique, improvements in preoperative management of the patient and aftercare. 5 years survival rate was 17.3%; again there was no major difference between the group of patients older than 70 and those being younger than 70 years (16.5% and 19.4% respectively). It is of interest that the patients having additional splenectomy presented with an essentially worse prognosis as opposed to those without splenectomy although there were no differences between the TNM-stages. Even if the small numbers of patients can not yet be definitely conclusive, these preliminary results indicate that the indication for splenectomy in the course of total gastrectomy should be critically evaluated.ZusammenfassungZwischen 1969 und 1983 wurde bei insgesamt 152 Patienten eine totale Magenentfernung vorgenommen. 58 Patienten befanden sich jenseits des 70. Lebensjahres. Die Operationsletalität betrug 14,47%, wobei zwischen den unter 70jährigen Patienten und den über 70jährigen mit 13,8% bzw. 15,5 nur ein geringer Unterschied bestand. Weitgehend unabhängig zeigte sich die Letalität auch davon, ob die Operation einen kurativen oder palliativen Charakter hatte. So verstarb von 27 Patienten im TNM-IV-Stadium lediglich einer. Ebenfalls nur ein Patient verstarb von den 66, die im letzten 5-Jahres-Intervall (1979–1983) operiert wurden. Diese wesentliche Senkung der Letalität wird auf eine präzise Systematisierung der Operationstechnik sowie auf eine verbesserte Operationsvorbereitung und Nachbetreuung zurückgeführt. Die 5-Jahres-Heilungsrate betrug 17,3%; wiederum bestand zwischen den unter 70jährigen und den über 70jährigen Patienten mit 16,5% bzw. 19,4% kein wesentlicher Unterschied. Bemerkenswerterweise hatten die Patienten mit zusätzlicher Splenektomie eine wesentlich schlechtere Prognose als die Patienten mit erhaltener Milz trotz gleicher Verteilung der TNM-Stadien. Zwar erlaubt die Patientenzahl noch keine definitive Aussage, jedoch sollte nach diesem Ergebnis die Indikation zur Begleitsplenektomie bei totaler Magenentfernung stets sorgfältig abgewogen werden.

110. Operative Therapie des Dünndarmileus bei besonderer Berücksichtigung der Patienten mit fortgeschrittenem Tumorleiden

SummaryBetween 1979 and 1984 a total of 233 patients underwent surgical treatment of small bowel obstruction. In 43 patients (18.4%) the obstruction was caused by an advanced tumor disease (peritoneal carcinosis, local recurrence). In patients with benign obstruction the operative mortality was 5.2%; in the tumor patients it was 14%. Wound infection and cardio-pulmonary disturbances were the most frequent complications. The mean survival time of the tumor patients was 159 days. In 65% of these patients the operation had a significant palliative effect.ZusammenfassungZwischen 1979 und 1984 wurden insgesamt 233 Patienten mit einem Dünndarmileus operiert. Bei 43 Patienten (18,4%) lag dem Ileus ein fortgeschrittenes Tumorleiden (Peritonealcarcinose, lokaler Rezidivtumor) zugrunde. Die Operationsletalität bei den Patienten mit benigner Ursache des Ileus betrug 5,2%; bei den Patienten mit maligner Ursache betrug sie 14%. Die wichtigsten Komplikationen waren der Wundinfekt sowie kardio-pulmonary Störungen. Die mittlere Überlebenszeit bei den Tumorpatienten nach palliativer Operation betrug 159 Tage. Für etwa 65% dieser Patienten stellte die Operation eine deutlich empfundene Palliation dar.Between 1979 and 1984 a total of 233 patients underwent surgical treatment of small bowel obstruction. In 43 patients (18.4%) the obstruction was caused by an advanced tumor disease (peritoneal carcinosis, local recurrence). In patients with benign obstruction the operative mortality was 5.2%; in the tumor patients it was 14%. Wound infection and cardio-pulmonary disturbances were the most frequent complications. The mean survival time of the tumor patients was 159 days. In 65% of these patients the operation had a significant palliative effect.