O. Haase

Comparison of EORTC Quality of Life Core Questionnaire (EORTC-QLQ-C30) and Gastrointestinal Quality of Life Index (GIQLI) in patients undergoing elective colorectal cancer resection

BackgroundEORTC-QLQ-C30 questionnaires and GIQLI questionnaires are used to evaluate post-operative quality of life (QoL). It was not clear whether results of both instruments are comparable. Therefore, the level of agreement between both QoL questionnaires was evaluated in patients undergoing elective colorectal cancer resection.MethodsPre-operatively, 7 and 30 days after surgery 116 patients answered the EORTC-QLQ-C-30 and the GIQLI questionnaires in random order. Individual questions with similar content from each questionnaire were compared. Data for global QoL, physical (PF), emotional (EF) and social function (SF) were linearly transformed to fit a scale from 0 to 100. Data from the two instruments were correlated and the level of agreement between them was calculated according to the method of Bland and Altman.ResultsA total of 308 data sets [(pre-op. n=116; 7th pod n=101; 30th post-operative day (pod) n=91)] were evaluated. Both instruments detected a reversible reduction of QoL after surgery and gave inferior results for patients with conditions known to impair QoL. EORTC-QLQ-C30 was more sensitive than GIQLI. The correlation between the two questionnaires for global QoL, PF and EF was good (r=0.53–0.66, p<0.01), but no correlation for SF was detected (r=−0.44, p=0.44). Linearly transformed scores from the two instruments differed considerably from −13 (95%CI −51 to 24) points (QoL) to 10 (−38 to 58) points (PF).ConclusionAlthough EORTC-QLQ-C30 scores and GIQLI scores from patients undergoing elective colorectal cancer surgery did correlate well, the level of agreement between the two instruments was quite low. Perioperative QoL data from the two instruments cannot be compared with each other.

Systematic evaluation of different approaches for minimizing hemodynamic changes during pneumoperitoneum

BackgroundCapnoperitoneum (CP) compromises hemodynamic function during laparoscopy. Three therapeutic concepts were evaluated with an aim to minimize the hemodynamic reaction to CP: First, a controlled increase of intrathoracic blood volume (ITBV) by intravenous fluids; second, partially reduced sympathetic activity by the β1-blocker esmolol; and third, a decrease in mean arterial pressure (MAP) by the vasodilator sodium nitroprusside.MethodsFor this study, 43 pigs were assigned to treatment with fluid and sodium nitroprusside (group A) or with esmolol (group B). In both groups, the pigs were assigned to head-up, head-down, or supine position, resulting in three different subgroups. Invasive hemodynamic monitoring was established including left heart catheter and cardiac oxygen lung water determination (COLD) measurements. Measurements were documented before CP with the animals in supine position, after induction of a 14-mmHg CP with the animals in each body position, after a 10% reduction in MAP by vasodilation, and after an increase in ITBV of about 30% by infusion of 6% hydroxyethylstarch solution.ResultsIncreasing ITBV improved hemodynamic function in all body positions during CP. Esmolol reduced cardiac output and myocardial contractility. Sodium nitroprusside did not improve hemodynamic function in any body position.ConclusionsOptimizing volume load is effective for minimizing hemodynamic changes during CP in the head-up and in head-down positions. In general, β1-blockers cannot be recommended because they might additionally compromise myocardial contractility and suppress compensatory reaction of the sympathetic nerve system. Vasodilation has not improved hemodynamic parameters during CP.

Acute partial segmental thrombosis of the corpus cavernosum: imaging findings on ultrasound, computed tomography, and magnetic resonance imaging

Partial segmental thrombosis of the corpus cavernosum is a rare disease of unknown etiology; the thrombosis is always located in the proximal part of the corpus cavernosum, usually unilaterally. Typical clinical presentation with perineal pain and swelling in combination with cross-sectional imaging allows one to confidentially establish this diagnosis.

Methodological quality of randomised controlled trials comparing short-term results of laparoscopic and conventional colorectal resection.

BackgroundRandomised, controlled trials (RCT) and systematic reviews of RCT with meta-analysis are considered to be of highest methodological quality and therefore are given the highest level of evidence (Ia/b). Although, “low-quality” RCT may be downgraded to level of evidence IIb, the methodological quality of each individual RCT is not respected in detail in this classification of the level of evidence.Materials and methodsWithin a systematic Cochrane Review of RCT on short-term benefits of laparoscopic or conventional colorectal resections, the methodological quality of all included RCT was evaluated. All RCT were assessed by the Evans and Pollock questionnaire (E and P increasing quality from 0–100) and the Jadad score (increasing quality from 0–5).ResultsPublications from 28 RCT printed from 1996 to 2005 were included in the analysis. Methodological quality of RCT was only moderate [E & P 55 (32–84); Jadad 2 (1–5)]. There was a significant correlation between the E & P and the Jadad score (r = 0.788; p < 0.001). Methodological quality of RCT slightly increased with increasing number of patients included (r = 0.494; p = 0.009) and year of publication (r = 0.427; p = 0.03). Meta-analysis of all RCT yielded clinically relevant differences for overall and local morbidity when compared to meta-analysis of “high-quality” (E & P > 70) RCT only.ConclusionThe methodological quality of reports of RCT comparing laparoscopic and open colorectal resection varies considerably. In a systematic review, methodological quality of RCT should be assessed because meta-analysis of “high-quality” RCT may yield different results than meta-analysis of all RCT.

Current evidence for laparoscopic surgery of colonic cancer

ZusammenfassungHintergrundDie Entwicklung videoendoskopischer Techniken erlaubt die minimal-invasive Resektion von Kolonkarzinomen.FragestellungDieses Manuskript untersucht die Frage, ob Unterschiede im intraoperativen sowie kurz-, mittel- und langfristigen Verlauf bei laparoskopischen oder konventionellen Resektionen von Kolonkarzinomen bestehen.Material und MethodeEs wurden randomisierte, kontrollierte Studien oder Metaanalysen aus diesen Studien ausgewertet.ErgebnisseLaparoskopische Resektionen von Kolonkarzinomen gehen mit etwas häufigeren intraoperativen Komplikationen und einer längeren Operationszeit bei geringerem Blutverlust einher. Die Gesamtkomplikationsquote und die Quote lokal-chirurgischer Komplikationen sind nach laparoskopischer Resektion eines Kolonkarzinoms weniger häufig. Die Inzidenz allgemeiner postoperativer Komplikationen und die Sterblichkeit sind bei beiden Operationstechniken nicht wesentlich verschieden. Der Krankenhausaufenthalt ist nach laparoskopischer Resektion kürzer, aber auch wesentlich von der perioperativen Behandlung abhängig. Die onkologischen Ergebnisse beider Operationstechniken (Tumorrückfall, Überleben) sind nicht verschieden. Wundimplantationen sind nach beiden Operationstechniken sehr selten, treten nach laparoskopischen Resektionen aber tendenziell etwas häufiger auf.SchlussfolgerungenLaparoskopische Resektionen von Kolonkarzinomen haben klinisch relevante Vorteile für den Patienten im kurz- bis mittelfristigen postoperativen Verlauf. Die onkologischen Ergebnisse beider Operationstechniken sind vergleichbar. Die vorliegenden Daten gelten bei Sigmaresektionen und links- oder rechtsseitigen Hemikolektomien. Zu laparoskopischen oder konventionellen erweiterten Resektionen bei Flexuren- oder Transversumkarzinomen gibt es keine hochwertige Evidenz. Geeignete Patienten mit Kolonkarzinomen sollten von laparoskopisch versierten Chirurgen laparoskopisch reseziert werden.AbstractBackgroundThe development of modern videoendoscopy enables surgeons to perform laparoscopic resection of colonic cancer.AimThis manuscript evaluated the literature concerning clinically relevant differences in the short and long-term course after laparoscopic or conventional resection of colonic cancer.MethodsAn investigation of meta-analyses from randomized controlled clinical trials comparing laparoscopic and conventional surgery for colonic cancer was carried out.ResultsThe incidence of intraoperative complications was higher during laparoscopic surgery, the duration of surgery was increased and blood loss was less when compared to open surgery. Overall morbidity and the incidence of surgical complications were decreased after laparoscopic surgery. General morbidity and mortality were not different after laparoscopic or open resection of colonic cancer. Duration of hospital stay was shorter but was also associated with the type of perioperative care (i.e. traditional or enhanced recovery). Following minimally invasive or conventional resection, the incidence of tumor recurrence (local and distant) and the duration of survival (overall and disease-free) showed no differences. Wound implantations were rare after both operative techniques but with a tendency to occur more often after laparoscopic than open resection.ConclusionLaparoscopic resection of colonic cancer has clinically relevant short-term benefits for the patients and long-term results are not different from open colectomy. However, most of the patients included in randomized controlled trials underwent right or left colectomy and sigmoid or rectosigmoid resections. Data with a high level of evidence concerning carcinomas of the flexures or the transverse colon do not exist. Suitable patients with colonic cancer should undergo laparoscopic resection by experienced surgeons.BACKGROUND The development of modern videoendoscopy enables surgeons to perform laparoscopic resection of colonic cancer. AIM This manuscript evaluated the literature concerning clinically relevant differences in the short and long-term course after laparoscopic or conventional resection of colonic cancer. METHODS An investigation of meta-analyses from randomized controlled clinical trials comparing laparoscopic and conventional surgery for colonic cancer was carried out. RESULTS The incidence of intraoperative complications was higher during laparoscopic surgery, the duration of surgery was increased and blood loss was less when compared to open surgery. Overall morbidity and the incidence of surgical complications were decreased after laparoscopic surgery. General morbidity and mortality were not different after laparoscopic or open resection of colonic cancer. Duration of hospital stay was shorter but was also associated with the type of perioperative care (i.e. traditional or enhanced recovery). Following minimally invasive or conventional resection, the incidence of tumor recurrence (local and distant) and the duration of survival (overall and disease-free) showed no differences. Wound implantations were rare after both operative techniques but with a tendency to occur more often after laparoscopic than open resection. CONCLUSION Laparoscopic resection of colonic cancer has clinically relevant short-term benefits for the patients and long-term results are not different from open colectomy. However, most of the patients included in randomized controlled trials underwent right or left colectomy and sigmoid or rectosigmoid resections. Data with a high level of evidence concerning carcinomas of the flexures or the transverse colon do not exist. Suitable patients with colonic cancer should undergo laparoscopic resection by experienced surgeons.

Influence of pre-operative fluid infusion on volume status during oesophageal resection – a prospective trial

Background: Perioperative fluid therapy is controversially debated in surgery. In malnourished and hypovolaemic patients, a restrictive fluid regimen may lead to hypoperfusion and increased incidence of complications. The present prospective cohort study was performed to assess whether pre‐operative i.v. fluid administration improves intraoperative cardiac preload in patients undergoing oesophageal resection.

Perspectives in sequential pneumatic compression of the lower extremities (SCD) for laparoscopic surgery.

Abstract During most cases of laparoscopic surgery, a pneumoperitoneum of 12–14 mm Hg CO2 is established. Athough not always detected in healthy patients, a pneumoperitoneum will cause clinically relevant pathophysiological changes. Among other side effects, a pneumoperitoneum will alter the venous blood return from the lower extremities and depress cardiac function. Results from experimental and clinical studies concerning the influence of a pneumo-peritoneum on venous blood return and cardiac function are reviewed and a simple model of cardiac function impairment during laparoscopic surgery with a pneumoperitoneum is presented. Sequential pneumatic compression of the lower extremities is effective in reducing venous stasis during and after conventional surgery. Several clinical trials determined the hemodynamic effect of intraoperative SCD (sequential compression device) during laparoscopic surgery. In the following text the results of these studies are summarized and possible implications for the clinical use of SCD in laparoscopic surgery are discussed. Allthough potential benefits of SCD-therapy have been shown only in studies of low methodological quality, intraoperative SCD-therapy is recommended during prolonged laparoscopic surgery.

Effect of increasing cardiac preload, sympathetic antagonism, or vasodilation on visceral blood flow during pneumoperitoneum.

Background and aimsAn impaired visceral perfusion caused by pneumoperitoneum may contribute to morbidity after laparoscopic surgery. The following three therapeutic concepts: increasing cardiac preload, controlled vasodilation, or selective sympathetic antagonism, were evaluated regarding a possible increase of visceral blood flow during pneumoperitoneum with carbon dioxide.MethodsForty three pigs were assigned to treatment with an increase of preload and vasodilation (group A) or selective sympathetic antagonism with esmolol (group B). In both groups, pigs were assigned to head-up, head-down, or supine position. Perfusion of the vena porta and renal artery was measured by transonic volume flow meters and documented before capnoperitoneum, after induction of a 14-mmHg capnoperitoneum in each body position, after controlled vasodilation with sodium nitroprusside, and after controlled increase of intravascular volume by colloidal infusion.ResultsIncreasing intravascular volume improved portal blood flow in all body positions (p<0.05), but not renal blood flow. Medication of esmolol did not alter the measured parameters in any body position compared to control. Vasodilation with sodium nitroprusside reduced renal blood flow in supine and in head-up position.ConclusionAn optimal intravascular volume was most effective in improving portal blood flow during capnoperitoneum in this trial. Esmolol had no negative effects on portal and renal blood flow. Patients with renal dysfunction might be treated carefully with sodium nitroprusside during capnoperitoneum.

Influence of postoperative fluid management on pulmonary function after esophagectomy.

Abstract Purpose : The aim of this study was to investigate the effects of a restrictive vs. a liberal postoperative fluid therapy guided by intrathoracic blood volume index (ITBVI) on hemodynamic and pulmonary function in patients undergoing elective esophagectomy. Perioperative fluid therapy may influence postoperative physiology and morbidity after esophageal surgery. Definitions of adequate infusion amounts and evident rules for a fluid therapy are missing. Methods : After esophagectomy, 22 patients were randomized either to a restrictive group (RG) with low range of ITBVI (600–800 ml/m2) or a liberal group (LG) with normal ITBVI (800–1000 ml/m2). Infusion regimen was modified twice a day according to transpulmonary thermodilution measurements until the 5th postoperative day. Primary endpoint was paO2/FIO2-ratio. Secondary endpoints were pulmonary function, fluid balance and hemodynamic as well as morbidity. Results : Demographic and surgical details did not differ between both groups. The calculated sample size was not reached. There were no postoperative differences in paO2/FIO2-ratio, ITBVI, hemodynamic parameters, or morbidity either. Cumulative fluid uptake was 4.1 liter less in the RG on the 5th postoperative day (p = 0.01), and pulmonary function was better in these patients (area under curve day 2–7 for forced vital capacity (FVC), forced expiratory volume in one second (FEV’), peak expiratory flow (PEF) each < 0.05). Conclusion : ITBVI guided restrictive infusion therapy yields a lower fluid uptake, but may not result in a difference of clinical relevant parameters. A fluid restriction after esophagectomy should always be combined with hemodynamic monitoring because additional infusions may be required.

Continuous local analgesic therapy reduces pain after radical inguinal/iliacal lymph node dissection

BackgroundTo optimize postoperative pain therapy after a radical inguinal/iliacal lymph node dissection (RILND), we investigated the influence of a continuous application of a local anaesthetic via a subfascial wound catheter in the abdominal wall in addition to a standardized systemic analgesia.Materials and methodsBetween July 2007 and December 2009, 50 patients with stage III/IV of melanoma disease received, in an observational study, a systemic analgesic therapy. Of these patients, 30 were additionally treated with a subfascial catheter. Main outcome criterion was the pain under mobilisation at the first postoperative morning registered via a visual analogue score. Minor criteria were the analgesic requirement, the specific (surgical) complications and the day of discharge.ResultsPatients treated with the subfascial catheter had significant less pain at the first postoperative morning in rest (p = 0.02) and after mobilisation (p = 0.03) without increased morbidity (p = 0.45). Less patients of the treatment group needed a supplementary analgesic medication (p = 0.01) and were able to leave hospital earlier than patients of the control group (p = 0.01).ConclusionsA subfascially placed pain catheter enhances postoperative pain therapy after RILND.