Rene Warschkow

Transvaginal rigid-hybrid natural orifice transluminal endoscopic surgery technique for anterior resection treatment of diverticulitis: a feasibility study.

BackgroundIn laparoscopic anterior resection, minilaparotomy still is required. Recently, transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy have been described. Reports on operations that require removal of larger specimens, as in anterior resection, are scarce and limited primarily to small case series and case reports. The current study aimed to evaluate the feasibility and safety of transvaginal rigid-hybrid NOTES anterior resection (tvAR) for symptomatic diverticular disease.MethodsAll female patients presenting with symptomatic diverticulitis of the sigmoid colon were candidates for inclusion in the study. The exclusion criteria specified failure to sign informed consent, previous colorectal resection, anesthesiologic contraindication for pneumoperitoneum, liver failure and coagulopathy, severe acute diverticular bleeding, internal fistula with abscess (Hinchey 2b), perforated diverticulitis with peritonitis (Hinchey 3 or 4), gynecologic or urologic contraindications, and absence of preoperative gynecologic examination. A preoperative and 2-week postoperative gynecologic examination was performed. Quality of life and sexual function were assessed preoperatively and 6xa0weeks postoperatively.ResultsOf 70 patients, 45 (64.3%) were scheduled for tvAR. Five patients were withdrawn at the beginning of laparoscopy with no transvaginal access performed. Of the remaining 40 patients with attempted tvAR, 4 patients underwent conversion to a minilaparotomy (Pfannenstiel incision) and 2 patients were converted to a total median laparotomy. For 34 patients (85%), the operation was completed transvaginally. A total of 2 major complications and 10 minor complications occurred. No serious postoperative gynecologic morbidity was experienced. At 6xa0weeks postoperatively, sexual function did not differ significantly from preoperative status.ConclusionsFor symptomatic diverticular disease, TvAR is feasible, although the presented technique requires laparoscopic expertise and further refinement.

Is Routine Cholecystectomy Justified in Severely Obese Patients Undergoing a Laparoscopic Roux-en-Y Gastric Bypass Procedure? A Comparative Cohort Study

BackgroundThe aim of the present study was to evaluate the risks and benefits of concurrent prophylactic cholecystectomy (CPC) during laparoscopic Roux-en-Y gastric bypass (LRYGB).MethodsFrom December 2000 to November 2006, CPC during LRYGB was only performed in the presence of gallbladder pathology (nu2009=u2009140). Beginning in December 2006, CPC was performed during all LRYGB procedures (nu2009=u2009134). Exclusion criteria were open bypass procedure, previous bariatric surgery other than gastric banding, and previous cholecystectomy (CCE) or necessary concurrent CCE due to gallbladder pathology.ResultsDuring a median follow-up of 3.1xa0years, 26 (18.6%; 95% CI, 12.9–25.9%) of 140 patients without CPC subsequently required a CCE, leading to a gallbladder disease-free survival rate at 5xa0years of 77.4% (95% CI, 67.3–87.6%). Multivariate analysis identified a distal LRYGB and excess weight loss of >75% at 2xa0years to be significant risk factors for the development of biliary complications while a preoperative BMIu2009>u200950xa0m2/kg was protective. In the second series, prophylactic CCE was not associated with prolonged hospitalization or operative time. The postoperative complications were not related to the CPC.ConclusionsThe present data indicate that a substantial number of patients develop gallbladder complications after LRYGB. Furthermore, CPC can safely be performed during LRYGB. Based on these findings, CPC should be considered a reasonable approach in severely obese patients undergoing LRYGB.

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias–preliminary clinical and functional results of a prospective case series

BACKGROUNDnBecause fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus.nnnMETHODSnTwenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery.nnnRESULTSnTotal reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent.nnnCONCLUSIONSnLMAH seems to be feasible, safe, and has no significant side effects.

Is a barium swallow complementary to endoscopy essential in the preoperative assessment of laparoscopic antireflux and hiatal hernia surgery

BackgroundBarium swallow is considered essential in the preoperative assessment of gastroesophaeal reflux disease and hiatal hernias. The objective of this study was to investigate the effective value of a barium swallow if complementary to the commonly recommended endoscopy before laparoscopic antireflux and hiatal hernia surgery.MethodsWe prospectively evaluated 40 consecutive patients who were tested with preoperative barium swallow and endoscopy before laparoscopic surgery for gastroesophageal reflux disease and/or symptomatic hiatal hernia. Results regarding the presence and the type of hiatal hernia found by barium swallow and endoscopy were correlated with the intraoperative finding as the reference standard.ResultsIntraoperative findings revealed 21 axial, 7 paraesophageal, and 12 mixed hiatal hernias. Barium swallow and endoscopy allowed the diagnosis of hiatal hernia in 75% and 97.5%, respectively (pxa0=xa00.003). The correct classification of hiatal hernia was confirmed in 50% by barium swallow and 80% by endoscopy (pxa0=xa00.005).ConclusionsAlthough barium swallow is recommended as an important diagnostic tool in the workup before surgical antireflux and hiatal hernia therapy, our results suggest that if mandatory endoscopy is performed preoperatively, a barium swallow does not provide any further essential information. It seems that barium swallow can be omitted as a basic diagnostic test before primary laparoscopic antireflux and hiatal hernia surgery.

Randomized controlled trial of bilateral superficial cervical plexus block versus placebo in thyroid surgery.

Bilateral superficial cervical block during thyroid surgery can reduce postoperative pain but its value is unclear. This randomized clinical trial assessed the efficacy of such regional anaesthesia on postoperative pain after thyroid surgery performed under general anaesthesia.

Anastomotic Leakage Is Associated with Impaired Overall and Disease-Free Survival after Curative Rectal Cancer Resection: A Propensity Score Analysis

AbstractBackgroundnWhether anastomotic leakage (AL) has a negative impact on survival remains a matter of debate. This study aimed to assess the impact of AL on the overall and disease-free survival of patients undergoing curative resection of stages 1–3 rectal cancer using propensity-scoring methods.MethodsIn a single-center study, 570 patients undergoing curative resection of stages 1–3 rectal cancer between January 2002 and December 2011 were assessed. The mean follow-up period was 4.7xa0±xa02.9xa0years. Patients who did and did not experience AL were compared using Cox regression and propensity score analyses.ResultsOverall, 51 patients (8.9xa0%) experienced an AL. The characteristics of the patients were highly biased concerning AL (propensity score, 0.16xa0±xa00.12 vs. 0.09xa0±xa00.07; Pxa0<xa00.001). Anastomotic leakage was uniformly associated with a significantly increased risk of mortality in unadjusted analysis [hazard ratio (HR) 2.30; 95xa0% confidence interval (CI) 1.40–3.76; Pxa0=xa00.003], multivariable Cox regression (HR 2.27; 95xa0% CI 1.33–3.88; Pxa0=xa00.005), and propensity score-adjusted Cox regression (HR 2.07; 95xa0% CI 1.21–3.55; Pxa0=xa00.014). Similarly, disease-free survival was significantly impaired in patients who experienced AL according to unadjusted analysis (HR 1.88; 95xa0% CI 1.19–2.95; Pxa0=xa00.011), multivariable Cox regression (HR 1.90; 95xa0% CI 1.17–3.09; Pxa0=xa00.014), and propensity score-adjusted Cox regression (HR 2.31; 95xa0% CI 1.40–3.80; Pxa0=xa00.002).ConclusionsThis is the first propensity score-based analysis providing evidence that oncologic outcome may be impaired after curative rectal cancer resection in patients with AL.

Laparoscopic mesh-augmented hiatoplasty as a method to treat gastroesophageal reflux without fundoplication: single-center experience with 306 consecutive patients

BACKGROUNDnLaparoscopic fundoplication represents the surgical standard treatment of gastroesophageal reflux disease. However, because of persisting side effects the method is not without controversy. Laparoscopic mesh-augmented hiatoplasty might be an alternative.nnnMETHODSnIn 306 consecutive patients the perioperative course and symptomatic outcome was analyzed after a mean follow-up period of 52 months.nnnRESULTSnThe mean DeMeester symptom score decreased from 5.3 to 2.0 (P < .001). Acid-suppressive therapy on a regular basis was discontinued in 79% of patients. The gas bloating value decreased from .7 to .5 (P = .031), and the dysphagia value increased from .5 to .9 (P < .001). Belching and vomiting were possible in 93% and 88% of patients, respectively. Mesh-related complications with the need for reoperation occurred in 1% of patients.nnnCONCLUSIONSnLaparoscopic mesh-augmented hiatoplasty is safe and does have an antireflux effect even without fundoplication. Side effects seem to be reasonable.

A comparative cross-sectional study of personality traits in internists and surgeons

BACKGROUNDnA stereotype of surgeons personality persists in the general public and among health-care professionals. Only a few studies have attempted to describe this surgical personality in detail. The aim of this study was to investigate the personality traits of surgeons compared with internists and to prove the existence of a stereotype among health-care professionals concerning surgeons.nnnMETHODSnTo investigate the existence of a stereotype, nursing staff members in a public tertiary referral 900-bed hospital rated the personality traits of internists and surgeons. Simultaneously, all internists and surgeons in the same hospital were asked to complete the Freiburg Personality Inventory-the most frequently used German self-report form.nnnRESULTSnThree hundred and thirty-four of 543 (62%) eligible nursing staff members participated; their responses confirmed the existence of a stereotype. A total of 253 of 284 eligible doctors completed the self-report form for a response rate of 89%. Compared with the general population, internists differed in most of 12 personality domains, whereas surgeons differed in 6 of 12 personality traits. The self-assessment revealed a statistically significant excess of achievement orientation (P = .00005) and extraversion (Pxa0<xa0.00001) among surgeons and decreased aggressiveness (P = .00012) among internists. No significant difference was found between board-certified surgeons and internists in any of the 12 personality domains.nnnCONCLUSIONnThis study identified a clear discrepancy between the self- and external assessment of personality but only among surgeons. This outcome provides an opportunity for surgeons to reflect on any potential lack of self-awareness and its impact on interdisciplinary patient care.

Repair of Paraesophageal Hiatal Hernias–Is a Fundoplication Needed? A Randomized Controlled Pilot Trial

BACKGROUNDnThe need for a fundoplication during repair of paraesophageal hiatal hernias (PEH) remains unclear. Prevention of gastroesophageal reflux represents a trade-off against the risk of fundoplication-related side effects. The aim of this trial was to compare laparoscopic mesh-augmented hiatoplasty with simple cardiophrenicopexy (LMAH-C) with laparoscopic mesh-augmented hiatoplasty with fundoplication (LMAH-F) in patients with PEH.nnnSTUDY DESIGNnThe study was designed as a patient- and assessor-blinded randomized controlled pilot trial, registration number: DRKS00004492 (www.germanctr.de/). Patients with symptomatic PEH were eligible and assigned by central randomization to LMAH-C or LMAH-F. Endpoints were postoperative gastroesophageal reflux, complications, and quality of life 12 months postoperatively.nnnRESULTSnForty patients (9 male, 31 female) were randomized. Patients were well matched for baseline characteristics. At 3 months, the DeMeester score was higher after LMAH-C compared with LMAH-F (40.9 ± 39.9 vs. 9.6 ± 17; p = 0.048). At 12 months, the reflux syndrome score was higher after LMAH-C compared with LMAH-F (1.9 ± 1.2 vs. 1.1 ± 0.4; p = 0.020). In 53% of LMAH-C patients and 17% of LMAH-F patients, postoperative esophagitis was present (p = 0.026). Values of dysphagia (2.1 ± 1.6 vs 1.9 ± 1.4; p = 0.737), gas bloating (2.6 ± 1.4 vs 2.8 ± 1.4; p = 0.782), and quality of life (116.0 ± 16.2 vs 115.9 ± 15.8; p = 0.992) were similar. Relevant postoperative complications occurred in 4 (10%) patients and did not differ between the groups.nnnCONCLUSIONSnLaparoscopic repair of PEH should be combined with a fundoplication to avoid postoperative gastroesophageal reflux and resulting esophagitis. Fundoplication-related side effects do not appear to be clinically relevant. Multicenter randomized trials are required to confirm these findings.

Anal fistula plug: a prospective evaluation of success, continence and quality of life in the treatment of complex fistulae

Curing complex anal fistula without compromising continence can be extremely challenging. This study investigated the healing rate, continence and quality of life of patients after treatment of complex anal fistula of cryptoglandular origin with a bioprosthetic plug.