Philipp Hildebrand

New Insights into the Epidemiology and Etiology of Fournier’s Gangrene: A Review of 33 Patients

AbstractBackground:Fournier’s gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment.Methods:We analyzed data from 33 patients with Fournier’s gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene.Results:18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40–79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2–28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%.Conclusion:Fournier’s gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier’s gangrene than urological sources.

Laparoscopic ultrasound navigation in liver surgery: technical aspects and accuracy

The functional–anatomic structure of the liver according to Couinaud classification based on the intrahepatical course of the vascular structures is the basis of all modern liver surgery. Consequently, the use of intraoperative ultrasound is an undisputed requirement for every liver resection. Exact following of the planned resection plane can be realized only with the application of permanent online navigation based on intraoperative ultrasound during the dissection of the hepatical tissue. Now that the authors have established ultrasound navigated resection in open liver surgery using a navigated parenchymal dissecting instrument, they intend to transfer this technique from open to laparoscopic liver surgery. A special adapter was developed to connect an ultrasound-based navigation system to laparoscopic instruments. The authors present the first results in terms of technical aspects and feasibility.

Laparoscopic colorectal resection for benign polyps not suitable for endoscopic polypectomy

Background and aimsEndoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk for perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative.Materials and methodsBetween January 1993 and December 2004, more than 2,500 endoscopic polypectomies were performed at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Germany. In patients which could not be treated by endoscopic polypectomy due to size, location, and/or risk of complications, a laparoscopic colorectal resection was performed. All data were prospectively assessed in our “colorectal resection” database.ResultsThe database analysis revealed 58 patients with endoscopically not resectable colorectal polyps who underwent a laparoscopic colorectal resection (intend to treat). In 54 patients, the operative procedure could be finished by the laparoscopic approach (study population). The conversion rate was 6.9% (four of 58). An ileocolic resection was performed in 20 patients (37.0%), and 14 patients (25.9%) underwent an anterior rectal resection. A right colectomy was necessary in 12 patients (22.2%), and six patients (11.1%) underwent a sigmoid resection. In the remaining two patients, a left colectomy and a resection of the transverse colon were performed. Intra- and postoperative complications occurred in five patients (9.3%). Perioperative mortality was not registered. The histopathological work-up revealed benign disease in all cases.ConclusionLaparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of benign colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps enriches the therapeutic spectrum.

Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period

IntroductionIn contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis.ObjectiveThe aim of this study was to analyze surgical challenge in right-sided diverticulitis.Materials and methodsAll patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996–2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry.ResultsFrom a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens.DiscussionAs right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.

Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas

BackgroundLymphadenectomy is performed to assess patient prognosis and to prevent metastasizing. Recently, it was questioned whether lymph node metastases were capable of metastasizing and therefore, if lymphadenectomy was still adequate. We evaluated whether the nodal status impacts on the occurrence of distant metastases by analyzing a highly selected cohort of colon cancer patients.Methods1,395 patients underwent surgery exclusively for colon cancer at the University of Lübeck between 01/1993 and 12/2008. The following exclusion criteria were applied: synchronous metastasis, R1-resection, prior/synchronous second carcinoma, age < 50 years, positive family history, inflammatory bowel disease, FAP, HNPCC, and follow-up < 5 years. The remaining 421 patients were divided into groups with (TM+, n = 75) or without (TM-, n = 346) the occurrence of metastasis throughout a 5-year follow-up.ResultsFive-year survival rates for TM + and TM- were 21% and 73%, respectively (p < 0.0001). Survival rates differed significantly for N0 vs. N2, grading 2 vs. 3, UICC-I vs. -II and UICC-I vs. -III (p < 0.05). Regression analysis revealed higher age upon diagnosis, increasing N- and increasing T-category to significantly impact on recurrence free survival while increasing N-and T-category were significant parameters for the risk to develop metastases within 5-years after surgery (HR 1.97 and 1.78; p < 0.0001).ConclusionsBesides a higher T-category, a positive N-stage independently implies a higher probability to develop distant metastases and correlates with poor survival. Our data thus show a prognostic relevance of lymphadenectomy which should therefore be retained until conclusive studies suggest the unimportance of lmyphadenectomy.

Surgical management of acute upper gastrointestinal bleeding:still a major challenge.

BACKGROUND/AIMS Acute upper gastrointestinal bleeding (UGIB) that cannot be managed with conservative interventional techniques is a life-threatening condition. This study assesses patient outcome and the role of different risk factors. METHODOLOGY We retrospectively analyzed data from 91 patients (58 men, 33 women) admitted between 2000 and 2009 and who underwent surgery for UGIB requiring transfusion. RESULTS Mean patient age was 67.4 years. Overall mortality was 34.1%. Causes of bleeding were duodenal ulcer in 57 patients (62.6%) and gastric ulcer in 25 (27.5%). A median number of 21 blood units (range 6-120) were transfused. Surgical treatment consisted of non-resective surgery (52.7%), Billroth II (31.9%), Billroth I (4.4%) or gastric wedge resection (4.4%). The use of anticoagulants (p=0.040), a need for postoperative ventilation (p=0.007) and an intensive care unit (ICU) length of stay >7 days (p=0.004) were identified as significant risk factors for mortality. Transfusions of more than 10 units of blood (p=0.013), the need for further surgery (p=0.021), a prolonged ICU length of stay (p=0.000) and recurrent bleeding (p=0.029) we identified as significant risk factors for postoperative complications (such as pneumonia, sepsis, re-bleeding and anastomotic leakage). CONCLUSIONS Over the past decade, mortality has not decreased in patients requiring surgery for acute UGIB despite diagnostic and therapeutic advances, explained by the fact that these cases represent a negative selection of patients after unsuccessful conservative treatment as well as by the rising age of the population and associated increases in comorbidity. Resective surgery, a need for postoperative ventilation and a prolonged ICU length of stay should be added to the list of significant risk factors for mortality.

Evaluation of the quality of life after surgical treatment of chronic pancreatitis.

OBJECTIVE Pain is the main symptom of chronic pancreatitis. However, in addition to an improvement in pain symptoms, an increase in the quality of life also influences therapeutic success. The present paper evaluates the influence of surgery on chronic pancreatitis, and the early and late postoperative quality of life. PATIENTS From March 2000 until April 2005, 51 patients underwent surgical treatment for chronic pancreatitis at our institution. INTERVENTION Thirty-nine (76.5%) patients were operated on according to the Frey procedure and, in 12 (23.5%) patients, a Whipple procedure was performed. STUDY DESIGN Patient data were documented throughout the duration of the hospital stay. Postoperative follow-up data were recorded retrospectively. MAIN OUTCOME MEASURES Postoperative follow-up with postoperative pain scores and quality of life were carried out using a standardized questionnaire. RESULTS During a median follow-up period of 50 months, an improvement in pain scores was observed in 92.3% of the patients in the Frey group and in 66.7% in the Whipple group. The indices for global quality of life and for physical and emotional status increased in both surgical groups. CONCLUSION For patients with chronic pancreatitis, the decisive factor is the quality of life, particularly concerning pain and metabolic changes. The Frey procedure seems to offer advantages with respect to long-term freedom of pain and low risk of surgery-induced pancreatic insufficiency.

Navigation in der Viszeralchirurgie

Die Integration von Navigationstechniken ist bislang besonders in Fachbereichen gelungen, die die Registrierung auf starre Körperstrukturen ausrichten können (z. B. Orthopädie und Neurochirurgie). In der Viszeralchirurgie steht in erster Linie die Leber im Mittelpunkt der Navigation, da die intrahepatischen Gefäßstrukturen sowohl für die diagnostischen Verfahren als auch für therapeutische Resektionsverfahren eine Leit- und Zielstruktur bieten. Wir beschreiben die Anwendung eines ultraschallbasierten Navigationssystem in der interventionellen, offenen und laparoskopischen Leberchirurgie.

Design and development of adapters for electromagnetic trackers to perform navigated laparoscopic radiofrequency ablation

BackgroundLaparoscopic radiofrequency ablation (RFA) is an accepted approach to treat unresectable liver tumours distinguishing itself from other techniques by combining minimal invasiveness and the advantages of a surgical approach. The major task of laparoscopic RFA is the accurate needle placement to achieve complete tumour ablation. The use of an ultrasound-based, laparoscopic online-navigation system could increase the safety and accuracy of punctures. To connect such a system with the laparoscopic ultrasound (LUS) transducer or the RFA needle especially designed adapters are needed. In this article we present our first experiences and prototypes for different sterilizable adapters for an electromagnetic navigation system for laparoscopic RFA.MethodsAll adapters were constructed with the help of a standard 3D CAD software. The adapters were built from medical stainless steel alloys and polyetherketone (PEEK). Prototypes were built in aluminium and polyoxymethilen (POM). We have designed and developed several adapters for the connection of electromagnetical tracking systems with different RFA needles and a laparoscopic ultrasound transducers.ResultsBased on earlier experiences of the initial version of the adapter, sterilisable adapters have been developed using biocompatible materials only. After short introduction, the adapters could be mounted to the laparoscopic ultrasound probe and the RFA needle under sterile conditions without any difficulties. Laboratory tests showed no disturbance of laparoscopic navigation system by the adapters. Anatomic landmarks in the liver could be safely reached. The adapters showed good feasibility, ergonomics, sterilizability and stability.ConclusionThe development of usable adapters is the prerequisite for accurate tracking of a RFA needle for laparoscopic navigation purposes as well as 3D navigated ultrasound data acquisition. We designed, tested and used different adapters for the use of a laparoscopic navigation system for the improvement of laparoscopic RFA.

Interventionelle Therapie von Lebermetastasen

Interventional Therapy of Liver Metastases If non-resectable liver metastases remain untreated, the median survival only comes to a few months. While searching for alternative therapies, a number of procedures, which cause devitalization of metastases by different modes of action, has been invented. Among these procedures count thermal radiofrequency ablation (RFA), laser-induced thermotherapy, cryoablation, transarterial chemoembolization, focused ultrasound, microwave ablation, intratumoral injection of cytotoxic substances and electrolysis. In the meantime, numerous methods have left the experimental stage and are clinically evaluated at present. However, existing data are offen still poor. Thermal radiofrequency ablation is favored by many users because of its results, its easy handling, different modes of application and consecutive individual optimal usage as well as its cost efficiency in spite of apparent comparable effectiveness to other interventional procedures. Before their oncological role is evaluated with certainty, all procedures should be limited to palliative situations, i.e. to the treatment of patients, who are not suitable for surgical resection. In the future, prospective studies must evaluate the role of RFA and other procedures in the treatment of liver metastases.