Wieland Raue

Transvaginal-hybrid vs. single-port-access vs. ‘conventional’ laparoscopic cholecystectomy: a prospective observational study

PurposeIn the recent past, access to the peritoneal cavity has involved primarily ‘natural orifice transluminal’ and ‘single-port access’ techniques, which are based on laparoscopy. The most frequently performed procedure using these new developments is cholecystectomy. Few studies compare more than one ‘new’ method with the ‘golden standard’ of laparoscopic cholecystectomy. Here we present the results of the first prospective observational study comparing standard laparoscopic cholecystectomy with single-port cholecystectomy as well as transvaginal-hybrid cholecystectomy.MethodsFifty-one patients were included in a prospective observational study (20 four-trocar laparoscopic, 15 transvaginal-hybrid, 16 single-port cholecystectomies). Endpoints of the study were operative time, length of hospital stay and postoperative level of pain (numeric analogue score, while coughing). Conversion rates and complications are reported as well.ResultsMedian operating times did not differ among all three access methods [55 (35–135) min vs. 65 (35–95) min vs. 68 (35–98) min]. Hospital stay was significantly shorter in the transvaginal-hybrid group [3 (3–12) days] and in the single-port group [3 (1–9) days], compared to the four-trocar laparoscopic group [4 (2–17) days]. Pain score was significantly diminished in the transvaginal-hybrid group during the early postoperative course.ConclusionsConcerning the length of hospital stay, transvaginal-hybrid cholecystectomy and single-port cholecystectomy appear to be superior to ‘conventional’ laparoscopic cholecystectomy. Additionally, transvaginal-hybrid access is associated with significantly less pain in the early postoperative course.

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.

Comparison of electrical velocimetry and transthoracic thermodilution technique for cardiac output assessment in critically ill patients

Background and objective The results of studies validating the assessment of cardiac output by pulmonary artery thermodilution and a modified algorithm using thoracic bioimpedance/electrical velocimetry in patients undergoing elective cardiac surgery are conflicting. The present observational study was designed to detect whether electrical velocimetry measurements are comparable to transthoracic thermodilution in septic patients after major general surgery. Methods Cardiac output was assessed simultaneously by thoracic bioimpedance measurement/electrical velocimetry and transthoracic thermodilution technique (PiCCO) in 30 patients with severe systemic inflammatory response syndrome or sepsis with haemodynamic instability being treated in the surgical intensive care unit of an university hospital. Results Thirty simultaneous measurements were taken with both methods. The Bland–Altman analysis of agreement revealed a bias of −0.3 l min−1 with a precision of ±1.9 l min−1 and wide limits of agreement (−4.1–3.5 l min−1). The percentage error was 54%. Conclusion There was poor agreement between the values of cardiac output estimation by transthoracic thermodilution and those by electrical velocimetry. Electrical velocimetry could not replace invasive monitoring in this trial.

Volume Therapy and Cardiocircular Function during Hyperthermic Intraperitoneal Chemotherapy

Background: Surgical cytoreduction and simultaneous hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis is afflicted with a high incidence of postoperative complications. The knowledge of intraoperative volume therapy during surgery and chemotherapy is limited. On the other hand, the choice of a ‘liberal’ or ‘restrictive’ regimen of fluid administration has a deep impact on the postoperative morbidity. The aim of this observational trial was to report detailed data on volume replacement and cardiocircular function during the HIPEC procedure. Methods: Eighteen consecutive patients undergoing cytoreductive surgery and HIPEC for peritoneal carcinomatosis were enrolled. The intraoperative volume administration was observed as well as the postoperative morbidity and mortality. Cardiofunctional data were assessed by the invasive transthoracic thermodilution technique. Results: The study showed that large amounts of volume (1,240 ml h–1; range: 810–1,570 ml h–1) are given during the HIPEC procedure to replace fluid loss and maintain a stable circulatory function. Signs of a hyperdynamic status during intraoperative intraperitoneal chemotherapy were not found. Conclusions: During surgical cytoreduction and simultaneous HIPEC, large amounts of volume were administered. HIPEC in itself did not lead to an increased fluid requirement. Further prospective studies with larger populations are needed to investigate whether goal-oriented therapies and a restricted volume regimen can contribute to decrease the postoperative morbidity.

A prospective randomized trial: The influence of intraoperative application of fibrin glue after radical inguinal/iliacal lymph node dissection on postoperative morbidity

BACKGROUND Effects of intraoperative application of fibrin glue following combined radical inguinal and iliacal lymph node dissection (RILND) on the amount of postoperative lymphatic secretion are discussed controversially. To detect whether fibrin glue application results in a decreased lymphatic secretion following RILND a randomized patient blinded clinical trial was conducted. METHOD Between September 2003 and September 2006 58 patients with stage IV melanoma underwent therapeutic RILND and were randomized into two groups. 29 Patients received 4 cc fibrin glue after RILND whereas 29 patients were only irrigated with saline 0.9 percent. Postoperatively all patients received two inguinal and one iliacal closed suction drain. The main outcome criteria were the duration of drain placement in the wound. Minor criteria were the total amount of secretion and the length of hospital stay. RESULTS There was no difference between the treatment and the control group in the duration of drain placement (fibrin group: 4 days (1-27); control group 5 days (1-26); p=0.64). The total amount of fluid was 310 cc (30-6005) in the fibrin group vs. 365 cc (30-3945 cc) in the control group (p=0.9) and the length of hospital stay 10 days (3-41) (group 1) compared to 11 days (3-41) (p=0.99) were not different between both groups either. CONCLUSION Intraoperative application of 4 cc fibrin glue does not reduce the length of drain placement, drain output or hospitalisation of patients undergoing RILND with melanoma metastasis to the lymph node basin.

Long‐term results of quality of life after standard laparoscopic vs. robot‐assisted laparoscopic fundoplications for gastro‐oesophageal reflux disease. A comparative clinical trial

The role of telematic surgical approach in gastro‐oesophageal reflux disease (GERD) is still unclear.

Nissen versus Dor Fundoplication for Treatment of Gastroesophageal Reflux Disease: A Blinded Randomized Clinical Trial

Introduction: Fundoplication techniques for treatment of gastroesophageal reflux are discussed concerning impairments and success. This randomized trial was conducted to compare Nissen’s wrap and the anterior partial technique (Dor) concerning patients’ quality of life (QoL) and functional data after a mid-term follow-up. Methods: In a 24-month period, 64 patients were equally randomized into group A (Nissen’s fundoplication) and group B (180° anterior partial fundoplication). After a mean follow-up of 18 months, all patients were examined and interviewed using standardized QoL questionnaires (Gastrointestinal Quality of Life Index), Visick score, 24-hour pH-metry and esophageal manometry. Data of 57 patients (group A: 27, group B: 30) could be analyzed. Results: After partial fundoplication, 9 patients (30%) stated the operative results were worse than perfect. Only 2 patients (7%) evaluated the outcome after Nissen’s fundoplication as unsuccessful (p = 0.04). However, postoperative Gastrointestinal Quality of Life Index showed no differences between groups (p = 0.5). Additionally, functional data were not different (DeMeester 10 vs. 12, p = 0.17, and lower esophageal sphincter pressure 13 vs. 12 mm Hg, p = 0.5). Conclusion: The anterior partial fundoplication technique did not lead to disadvantages in postoperative QoL, physiological function and reflux control when compared to Nissen’s approach in a mid-term follow-up.

Article originalRéhabilitation rapide en chirurgie colique : résultats d'une étude prospectiveFast track rehabilitation in colonic surgery: results of a prospective trial

Objective. – In elective large bowel surgery the incidence of general complications with standard perioperative care is up to 27%. Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection. The aim of a fast track management is to reduce the number of general complications and the length of hospital stay. Material and methods. – We prospectively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia, an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery. Results. – One hundred thirty-two consecutive patients aged an average of 66 years (range 22–88) were operated by laparotomy (n =71) or laparoscopy (n =61) and treated with the fast track rehabilitation protocol. Surgical complications occurred in 15 patients (11 %), four of these had an anastomotique leakage (3%). General complications occurred in 11 patients (8 %), the mortality was 1 %. The median length of hospital stay was four days (range 3–77) and 14 patients (11%) had to be readmitted. Conclusion. – Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study.

Initial Results after Implementation of a Multimodal Treatment for Peritoneal Malignancies

Abstract Introduction : Peritoneal carcinomatosis represents a clinical condition with a limited perspective concerning long term survival. The combination of surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) represents a complex multimodal therapeutic management concept with promising results for prolongation of survival. For the identification of pitfalls during implementation of the HIPEC procedure into clinical practice an observational study was conducted. Methods : Between 2005 and 2009 data from all patients treated with cytoreductive surgery and HIPEC for peritoneal carcinomatosis was prospectively collected and analysed. Results : During the observational interval a total of 42 patients underwent surgical treatment for peritoneal carcinomatosis. In 34 patients the complete procedure with surgical cytoreduction and HIPEC was performed. Perioperative mortality (6%) and morbidity (35%) was similar to other reported series. Twenty-five patients (76%) survived the 18 months follow-up period after complete procedure. Conclusion : The multimodal therapeutic treatment concept of surgical cytoreduction and following HIPEC leads to promising results for patients suffering from peritoneal carcinomatosis. However this treatment concept is afflicted with a relevant risk of postoperative complications.

Multimodal approach for treatment of peritoneal surface malignancies in a tumour-bearing rat model.

PurposeSurgical cytoreduction of peritoneal surface malignancy of colorectal origin in combination with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) has become an established treatment approach. Only a few of animal models for scientific research on various therapeutic strategies have been described yet. The feasibility of an established rat model with a peritoneal surface malignancy from colorectal origin for treatment investigation should be examined in this study.MethodsPeritoneal surface malignancy of colonic origin was induced in 90 male BD IX rats. Animals were randomised into six groups (15 animals per one control and five treatment groups). One treatment group underwent only surgical debulking. The animals of the other four treatment groups received additional interventions: hyperthermic intraperitoneal chemotherapy with mitomycin or gemcitabine, photodynamic therapy or taurolidine lavage. Twenty-one days after treatment, the intraperitoneal status was investigated. Tumour weight, count of tumour nodules and experimental Peritoneal Carcinosis Index (ePCI) were detected.ResultsExtended surgical cytoreduction and additional treatments including HIPEC were feasible in this rat model. All treatment groups had a significant lower tumour weight, account of tumour nodes and ePCI if compared with the control group. Comparing the additional therapies only HIPEC with mitomycin lead to relevant tumour reduction after surgery.ConclusionThis rat model is suitable for research on the multimodal treatment of peritoneal malignancies. A persisting cytoreductive effect of surgical tumour debulking could be proven. Only additional HIPEC therapy with mitomycin showed a significant tumour reduction. This animal model provides the opportunity to investigate different therapeutic strategies.