Reinhold Kafka-Ritsch

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear.In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal.However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias.Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

A Critical Comparison of Robotic Versus Conventional Laparoscopic Splenectomies

The benefit of robotic systems for general surgery is a matter of debate. We compare our initial series of robotic splenectomies with our first series of conventional laparoscopic ones. A retrospective analysis of the first six robotic versus the first six conventional laparoscopic splenectomies is presented. Patients were matched with regard to age, bodymass index, ASA score, and preoperative platelet levels. All procedures were performed by a single surgeon. Size and weight of the resected specimens were comparable in both groups. Median overall operating time was 154 (range, 115–292) min for the robotic and 127 (range, 95–174) min for the laparoscopic group. No complications occurred. There were no open conversions. The median postoperative hospital stay was 7 (robotic group) and 6 (laparoscopic group) days. Median average costs were

Videobronchoscopic guidance makes percutaneous dilational tracheostomy safer

6927 for the robotic procedure versus

Postoperative Morbidity Following Chemoradiation for Locally Advanced Low Rectal Cancer

4084 for the conventional laparoscopic procedure (p < 0.05). Minimally invasive splenectomies are feasible using either conventional laparoscopic techniques or the da Vinci™ robotic system. In this analysis, procedures performed with the da Vinci™ robotic system resulted in prolonged overall operative time and significantly higher procedural costs. The use of a robotic system for laparoscopic splenectomy offers, at this stage, no relevant benefit and thus is not justified.

Assessment of risk-independent follow-up to detect asymptomatic recurrence after curative resection of colorectal cancer.

BackgroundPercutaneous dilational tracheostomy (PDT) can be performed under either conventional bronchoscopic or videobronchoscopic guidance. Only the latter procedure provides the surgeon with direct visual information. This study prospectively assessed procedural parameters and complications of PDT guided by conventional bronchoscopy (CB) or videobronchoscopy (VB).MethodsConsecutive intensive care unit (ICU) patients who underwent PDT were enrolled in this study. Videobronchoscopy was available in two ICUs, whereas CB was available in three ICUs. Demographic data, procedural variables, and complications were recorded.ResultsIn this study, 36 patients underwent PDT guided by VB (group V), and 38 patients underwent PDT guided by CB (group C). The two groups were well matched in terms of gender, anatomic aspects, and positioning of the patient. Operating time, procedural difficulty, and extent of tracheal bleeding were not different between the two groups. Group V showed a tendency to younger age (p = 0.055). Surgeons significantly more often considered PTD to be “completely safe” in group V (92% vs 61% in group C). The skin incisions were smaller (p = 0.003), and the extent of stomal bleeding was less (p = 0.001). Complications were tendentiously less frequent in group V (5.5%) than in group C (23.7%; p = 0.062).ConclusionsThe surgeon performing PDT guided by VB has a higher degree of safety, resulting in less bleeding than with PDT guided by CB.

Enterolithiasis-associated ileus in Crohn's disease.

BackgroundPostoperative morbidity remains a significant clinical problem and may alter long-term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. The aim of the present study was to identify a potential long-term effect of postoperative morbidity.MethodsAnalysis of prospectively collected data of 90 consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (cT3/4, Nx, M0/1) adenocarcinoma of the mid and lower third of the rectum during a 7-year period (1996–2002).ResultsMajor postoperative complications occurred in 17.8% and minor complications in 26.6% of patients. Hospital mortality and 30-day mortality was 0%. Infectious complications were seen in 34.5%. The leading causes of infectious complications were anastomotic leakage and perineal wound infection. Postoperative morbidity was statistically significantly associated with gender (P < 0.05), pre-therapeutic haemoglobin level (P < 0.05), ASA score (P < 0.05), hospitalisation (P < 0.001) and clinical long-time course (P < 0.01). Moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease-free (P < 0.05) and overall survival (P < 0.05).ConclusionEarly postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. Gender, pre-therapeutic haemoglobin level and ASA score indicate patients at risk for early postoperative complications and may therefore serve as predictive features.

Letter to the Editor: Surgical Treatment of the Open Abdomen in Patients with Abdominal Sepsis Using the Vacuum Assisted Closure System

Background and aimsColorectal cancer is one of the leading causes of cancer death. We analyzed the value of standardized, risk-independent postoperative surveillance.Materials and methodsBetween 1995 and 2001, 564 patients with colorectal cancer underwent standardized oncologic resection. One hundred thirty-four were unable to take part in the surveillance program, while 430 patients were grouped as follows: group I (n=272, risk-independent follow-up), group II (n=113, follow-up at other departments), and group III (n=45, no follow-up).ResultsThe 5-year cancer-specific survival rate for UICC III and IV was significantly higher in group I (87%) as compared to group II (35%). In group I, the 5-year disease-free survival rate was 70%. Cancer recurrence occurred at mean 17 (±12) months after colorectal resection and yielded a 5-year survival rate of 63%. Reresection was performed in 17 (35%) patients, of whom ten remained disease-free (5-year survival rate, 91%). The money spent for one patient’s 5-year follow-up was 1665.ConclusionsA standardized, risk-independent follow-up program allows early diagnosis of asymptomatic recurrence of colorectal cancer. Reresection improves the 5-year survival rate in this setting.

Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?

Stasis of the flow of the intestinal contents, ingested material and unfavorable composition of the chylus can lead to the formation of enteroliths inside the bowel. Enterolithiasis represents a rare disorder of the gastrointestinal tract that can be associated with intermittent abdominal pain or more serious complications such as bleeding or obstruction. Enterolithiasis in Crohns disease represents an extremely rare condition and usually occurs only in patients with a long symptomatic history of Crohns disease. We report an unusual case of enterolithiasis-related intestinal obstruction in a young male patient with Crohns disease (A2L3B1 Montreal Classification for Crohns disease 2005) undergoing emergency laparotomy and ileocoecal resection. In addition, we present an overview of the relevant characteristics of enterolithiasis on the basis of the corresponding literature.

The Innsbruck sentinel lymph node study in colorectal cancer – a pilot study

We read with great interest the article by Wondberg et al. titled ‘‘Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis’’ [1] in the December 2008 issue of World Journal of Surgery. In recent years the application of negative intra-abdominal pressure has become a promising treatment strategy in critically ill patients with abdominal compartment syndrome, open abdomen, or even severe abdominal septic complications [2–4]. Because to date only a few studies on intra-abdominal vacuum-assisted closure (VAC) therapy in patients with abdominal sepsis have been published, the article by Wondberg et al. seems to be especially important. However, the low rate of fascial closure reported in this study was somewhat surprising and led us to conclude that the VAC system may have been applied too late or too long. In addition, some important considerations regarding the use of the VAC system were not mentioned in the article: First, the authors did not state the time interval between first surgery (scheduled surgery with postoperative complications versus emergency surgery) and application of the VAC system, nor did they indicate the number of operations performed before the application of the negative pressure therapy. Second, the absolute duration of VAC therapy was unclear, and the authors did not differentiate between intra-abdominal and subcutaneous use of the VAC system. In our opinion, these facts represent crucial elements for evaluation of the effect of the VAC system in abdominal surgery, because the extent of fascial retraction and the rate of fascial closure depend in large part on the time of first application and the duration of VAC therapy. In fact, we have observed that VAC therapy alone can prevent fascial retraction only for a few days, because continual muscular tension of the abdominal wall apparently exceeds the effect of the maximal negative pressure of the VAC system. We therefore believe, that the stability of the abdominal wall in patients with prolonged VAC therapy can be sustained only by additional measures. Thus, since 2004 we have used three or four interrupted dynamical sutures with elastic vessel loops (a measure proposed by T. Wild, Medical University, Vienna, Austria) to achieve and maintain approximation of the fascial margins in every patient treated with abdominal VAC therapy. With this technique, the effect of the negative pressure therapy is not impaired at all, and a complete fascial closure is feasible in the majority of patients with abdominal sepsis after several days. In view of the low VAC-associated morbidity in the study by Wondberg et al., we want to affirm the increasing importance of the VAC system in the management of critically ill patients with septic abdomen, because it allows rapid control of peritonitis and an easy return to the abdominal cavity. However, further studies and randomized controlled trials are necessary to define the optimal use of the VAC system in septic abdominal surgery.

Innsbrucker Studie von Wächterlymphknoten bei kolorektalem Karzinom – eine Pilotstudie

BACKGROUND Diagnosis and treatment of diverticulitis in immunosuppressed patients are more challenging than in immunocompetent patients, as maintenance immunosuppressive therapies may mask symptoms or impair the patients ability to counteract the local and systemic infective sequelae of diverticulitis. The purpose of this study was to compare the in-hospital mortality and morbidity due to diverticulitis in immunosuppressed and immunocompetent patients and identify risk factors for lethal outcomes. METHODS This retrospective study included consecutive in-patients who received treatment for colonic diverticulitis at our institution between April 2008 and April 2014. Patients were divided into immunocompetent and immunosuppressed groups. Primary end points were mortality and morbidity during treatment. Risk factors for death were evaluated. RESULTS Of the 227 patients included, 15 (6.6%) were on immunosuppressive therapy for solid organ transplantation, autoimmune disease, or cerebral metastasis. Thirteen of them experienced colonic perforation and showed higher morbidity (p = 0.039). Immunosuppressed patients showed longer stays in hospital (27.6 v. 14.5 d, p = 0.016) and in the intensive care unit (9.8 v. 1.1 d, p < 0.001), a higher rate of emergency operations (66% v. 29.2%, p = 0.004), and higher in-hospital mortality (20% v. 4.7%, p = 0.045). Age, perforated diverticulitis with diffuse peritonitis, emergency operation, C-reactive protein > 20 mg/dL, and immunosuppressive therapy were significant predictors of death. Age (hazard ratio [HR] 2.57, p = 0.008) and emergency operation (HR 3.03, p = 0.003) remained significant after multivariate analysis. CONCLUSION Morbidity and mortality due to sigmoid diverticulitis is significantly higher in immunosuppressed patients. Early diagnosis and treatment considering elective sigmoid resection for patients with former episodes of diverticulitis who are wait-listed for transplant is crucial to prevent death.