Search

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) represent the most common precancerous cystic lesions of the pancreas. The aim of our study was to investigate if resection for non-invasive IPMNs alters quality of life (QoL) in a long-term follow-up. Methods: Patients (n = 50) included in the analysis were diagnosed and resected from 2010 to 2016. QoL was assessed at a median of 5.5 years after resection. At that point in time, the current QoL as well as the QoL before resection was evaluated retrospectively. The standardised European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Pancreatic Cancer (EORTC QLQ – PAN26) was applied for the QoL assessment. Results: After a median of 66 months postoperatively, the total QoL score significantly worsened (92.13 vs. 88.04, p = 0.020, maximum achievable score = 100) for patients (median age at surgery 68.0 years), mostly due to digestive symptoms. During the same follow-up period, median Eastern Cooperative Oncology Group (ECOG) performance status did not worsen (p = 0.003). Conclusions: Long-term QoL statistically significantly worsened after pancreatic resection for IPMN. The extent of worsening, however, was small, and QoL still remained excellent. Therefore, resection in cases of IPMN is appropriate, if indicated carefully.

Background AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2 insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2 insufflators in patients undergoing the most frequently performed laparoscopic procedures. Methods One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2 insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien–Dindo grade complications, surgical side effect and length of hospital stay. Results Patients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56–94] in group A vs. 69 min [52–93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0–3] in group S vs. 2 [0–4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay. Conclusion This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2 insufflator for short elective surgeries. ClinicalTrials.gov (NCT01740011).

Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic wall can rapidly lead to aneurysm induction through bacterial seeding into atheromatous lesions with consecutive life-threatening rupture. We summarize all published data on this rare and lethal disease to evaluate therapeutic approaches and give valid treatment recommendations because there are no guidelines.A systematic review of the literature was conducted screening EMBASE and MEDLINE databases following the PRISMA guidelines with search period from first description to August 25, 2021.There were 72 cases of C septicum aortitis reported in 64 publications. Endovascular aortic repair (EVAR) was performed in a minority of patients (n = 6) unfit for surgery but lacked long-term survivors. Antibiotic treatment was beneficial in a bridge to surgery concept, but up to now harbored a 6-month mortality rate of 100% (median overall survival, 0.5 months) when no additional aortic repair was performed. Open aortic repair was the only potential curative approach but was accompanied with a 90-day-mortality of 26.7% (4/15).Open aortic repair combined with perioperative antibiotic treatment should be offered to all patients as the only potentially curative approach. If applicable, resection of a coexisting colonic tumor should be performed after successful aortic repair. Alternatively, long-term antibiotic treatment can be offered to patients unfit for surgery in a palliative setting. Endovascular aortic repair has been performed on a minority of patients with a high risk for stent graft infection and should remain a salvage strategy when therapeutic pressure demands acute intervention in patients unfit for surgery.

Background: The step-up approach, using either flexible endoscopy or a minimal invasive retroperitoneal access, has reduced mortality and morbidity in patients with acute pancreatitis. The use of fully covered self-expanding metal stents (FCSEMS) or lumen apposing metal stents (LAMS) facilitates endoscopic necrosectomy and drainage of walled-off necrosis (WON). The aim of our analysis was to investigate the 30/90/365-day mortality and morbidity rates of the subtypes of the revised Atlanta classification for acute pancreatitis. Materials and Methods: We conducted a retrospective analysis of all patients (n = 302) treated with acute pancreatitis in our institution from January 2014 to July 2017. Mortality, morbidity, management of fluid collections, interventions, complications, and new onset of diabetes were recorded. Results: In 30.8% (n = 93/302) of patients, pancreatic fluid collection developed. Out of these, 58.1% (54/93) required intervention, consisting of endoscopic treatment in 63% (34/54) or multidisciplinary approach in 37% (20/54). Overall, 90-day mortality rate according to Kaplan-Meier Estimator was 3.7%. Overall, 1-year mortality rate was 6.2%. One-year mortality for uncomplicated acute pancreatic fluid collection, pseudocyst, and WON were 5.4%, 2.6%, and 13.5%, respectively. Hemorrhage in case of metal stent treatment (FCSEMS/LAMS) occurred in 14.3%. If LAMS was combined with double pigtail stent-in-stent, bleeding was seen in 5.3%. No transperitoneal necrosectomy was needed. Conclusions: Treating acute pancreatitis with a step-up approach, including stent-in-stent procedures, leads to low mortality rates and few stent-associated bleeding complications and minimizes necessity for open transperitoneal surgical necrosectomy.

Despite the significant improvement concerning perioperative mortality, pancreatoduodenectomy is still a challenging procedure. Pancreatic fistula is the most common complication underlying 30-day mortality. More than 61 surgical techniques of pancreatic anastomosis with a vast number of variations have been published. Moreover, various risk factors favoring the development of postoperative pancreatic fistulas have been identified. This review article presents an outline of ways to achieve the optimal pancreatic anastomosis, concentrating on technical aspects. The following parameters were assessed in this question: pancreatojejunostomy, pancreaticogastrostomy, stents, tissue patches and sealants, surgical experience, and center-specific technique. With regard to current literature, there is no scientific evidence of an optimal pancreatic anastomotic technique. A distinct inhomogeneity among the trials concerning definitions, patient selection, anastomotic technique, and patient management is important to mention. The best strategy for reducing pancreatic fistula rate includes a standardized institutional concept of pancreatic anastomosis, documentation of surgical quality, and continuous enhancement by benchmarking.

Background Ganglioneuromas (GNs) are extremely rare, slowly growing, benign tumors that can arise from Schwann cells, ganglion cells, and neuronal or fibrous tissues. Due to their origin from the sympathetic neural crest, they show neuroendocrine potential; however, most are reported to be hormonally inactive. Nevertheless, complete surgical removal is recommended for symptom control or for the prevention of potential malignant degeneration. Case Report A 30-year-old female was referred to our oncologic center due to a giant retroperitoneal and mediastinal mass detected in computed tomography (CT) scans. The initial symptoms were transient nausea, diarrhea, and crampy abdominal pain. There was a positive family history including 5 first- and second-degree relatives. Presurgical biopsy revealed a benign ganglioneuroma. Total resection (TR) of a 35 × 25 × 25 cm, 2550-g tumor was obtained successfully via laparotomy combined with thoracotomy and partial incision of the diaphragm. Histopathological analysis confirmed the diagnosis. Surgically challenging aspects were the bilateral tumor invasion from the retroperitoneum into the mediastinum through the aortic hiatus with the need of a bilateral 2-cavity procedure, as well as the tumor-related displacement of the abdominal aorta, the mesenteric vessels, and the inferior vena cava. Due to their anatomic course through the tumor mass, the lumbar aortic vessels needed to be partially resected. Postoperative functioning was excellent without any sign of neurologic deficit. Conclusion Here, we present the largest case of a TR of a GN with retroperitoneal and mediastinal expansion. On review of the literature, this is the largest reported GN resected and was performed safely. Additionally, we present the first systematic literature review for large GN (> 10 cm) as well as for resected tumors growing from the abdominal cavity into the thoracic cavity.

Das Pankreaskarzinom hat steigende Inzidenz und ist trotz Verbesserung der Uberlebenszeit das gastrointestinale Karzinom mit der schlechtesten Prognose. Bei nur 20 % besteht zum Diagnosezeitpunkt Resektabilitat. Grunde fur die Inoperabilitat sind Fernmetastasen oder ein lokal fortgeschrittenes Tumorstadium. Die stark subjektiv gepragte Einschatzung der lokalen Operabilitat wurde in den vergangenen Jahren durch eine Klassifizierung der Resektabilitat ersetzt, die inzwischen in alle Leitlinien aufgenommen wurde. Die Basis fur die Einschatzung ist eine Bildgebung mit Multidetektor-Computertomographie (MD-CT), Spiral-CT des Pankreas und/oder Magnetresonanztomographie (MRT). Beurteilt wird die Lagebeziehung des Tumors zu den peripankreatischen Gefasen (V. porta, V. mesenterica superior, A. hepatica, A. mesenterica superior und Truncus coeliacus). Dabei wird unterschieden, ob der Tumor Kontakt hat bzw. wie weit er diese Gefase umscheidet. Daraus resultiert die Einteilung als operabel, „borderline“ resektabel und lokal fortgeschritten (primar nicht resektabel). Diese Klassifizierung der Resektabilitat hat entscheidenden Einfluss auf die Therapie. Wahrend resektable Tumoren primar reseziert werden, erfolgt bei den beiden anderen Gruppen heute eine neoadjuvante Therapie mit Restaging und anschliesendem Resektionsversuch. Mit diesem Regime wurden Resektionsraten bis zu 61 % bei „borderline“ resektablen und lokal fortgeschrittenen (primar nicht resektablen) Karzinomen erzielt. Derartige Eingriffe sind wegen der Erweiterung auf Gefasresektionen technisch sehr anspruchsvoll. Inwieweit damit in der Routine die Resektionsraten erhoht und das Uberleben verbessert werden, untersuchen aktuelle Studien. Die Beurteilung der Resektabilitat nach den vorgestellten Kriterien ist heute Standard und die Basis fur eine stadiengerechte Therapie beim Pankreaskarzinom.

Parastomal hernias (PSHs) are a common and challenging issue. In previous studies, three-dimensional (3D) funnel mesh devices have been used successfully for the repair of PSHs. We performed an analysis of prospectively collected data of patients who underwent a same-sided stoma reposition with 3D funnel-shaped mesh augmentation in intraperitoneal (IPOM) position at our department between the years of 2012 and 2015. Primary outcome parameters were intra- and postoperative surgical complications and recurrence rate during the follow-up period. Fifty-six patients could be included in this analysis. PSH repair was performed in 89.3% as elective surgery and in 73% in laparoscopic technique. A concomitant incisional hernia (EHS type 2 and 4) was found in 50% and repaired in a single-step procedure with PSH. Major postoperative complications requiring redo surgery (Clavien–Dindo ≥3b) were identified in 8.9% (5/56). Overall recurrence rate was 12.5% (7/56). Median follow-up time was 38 months, and a 1-year follow-up rate of 96.4% was reached. PSH repair with 3D funnel mesh in IPOM technique is safe, efficient and easy to perform in laparoscopic and open surgical approaches providing advantageous results compared to other techniques. Furthermore, simultaneous detection and treatment of concomitant incisional hernias has shown favorable. However, the mesh funnel distends and becomes shortened encasing a bulky bowel mesentery and further shrinkage happens eccentric. Changing mesh construction according to lengthening the funnel could possibly lead to reduction in recurrence.

Funnel mesh implants can be used for both prevention and repair of parastomal hernia (PSH). We aimed to prove the practice of such implants as well as the magnetic resonance (MR) presentability in humans. Five patients were surgically treated for laparoscopic PSH prevention, and five patients underwent laparoscopic repair of manifest and symptomatic PSH with iron-loaded 3-D funnel meshes in an intraperitoneal onlay technique. MR investigation was performed on postoperative day 7 to assess mesh delineation, and additionally 6 and 12 months postoperatively to evaluate hernia recurrences and biocompatibility of mesh integration. We could demonstrate precise mesh depiction and delineation with MR in all 10 cases, as well as accurate assessment of the surrounding tissue. No funnel alterations and no functional change of the stoma bowel patency occurred due to the tightly fitting funnel implant. We documented no mesh-related complications, no PSH formation, and no stoma prolapse occurrence during the follow-up period of 1 year comprising all ten cases. The pilot use of a new method of MR investigation using a mesh with enhanced signal through the addition of iron particles into the polyvinylidene fluoride base material provides detailed mesh depiction. Furthermore, funnel mesh implantation seems to offer a safe and promising surgical alternative for both PSH prevention and treatment.

In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development. We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position. PSH developed in three patients (3.75 %). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75 %) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3–47) months. The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.

Bei Patienten mit gastroosophagealer Refluxkrankheit (GERD) sind bei hohem Leidensdruck und unzureichendem Ansprechen auf die medikamentose Therapie interventionelle Verfahren die einzige Option zur Verbesserung der Symptome und damit der Lebensqualitat. In der klinischen Praxis ist entscheidend, ob eine Hiatushernie (HH) vorhanden ist oder nicht bzw. ob diese groser oder kleiner als 2–3 cm ist. Symptomatischen Patienten mit HH > 2–3 cm sollte eine laparoskopische Fundoplikation mit Hiatoplastik empfohlen werden. Patienten mit einer groseren HH kommen nicht mehr fur eine endoskopische Therapie infrage, da ein Verschluss der HH endoskopisch nicht moglich ist. Bei den neuen laparoskopischen Methoden (LINX, Elektrostimulation) ist dieser Verschluss zwar theoretisch moglich, allerdings fehlen hier ausreichende Daten, und die eigentlichen Vorteile der Methoden gehen dabei zum Teil verloren. Zurzeit kann Patienten mit GERD und HH auserhalb von Studien nur eine laparoskopische Fundoplikation mit Hiatoplastik empfohlen werden, da nur fur diese Methode uberzeugende Langzeitdaten vorhanden sind. Hier wiederum scheint es in der klinischen Praxis nicht so wichtig zu sein, welche Art von Fundoplikation durchgefuhrt wird, entscheidend scheint die Erfahrung des Chirurgen mit der jeweiligen Technik zu sein.

The aim of this study was to evaluate a new method of parastomal hernia (PSH) repair by using a hybrid approach with a cylindrical-shaped mesh of 4 cm funnel length.In a pilot prospective case series, 12 patients underwent surgical repair of PSHs with a combined laparoscopic and ostomy-opening approach. After laparoscopic adhesiolysis, the ostomy opening was excised from outside and the bowel was closed. The hernia sac was excised after reduction of its content. Then, the bowel was guided through the funnel of the mesh and the implant was manually transferred into the peritoneal cavity through the hernia defect. Next, the fascial margins were narrowed with sutures. Laparoscopy was continued, and the mesh was placed and fixed with absorbable tacks in the proper position. Finally, the diverted bowel was shortened outside of the abdomen and the stoma was matured in its original location.We documented no mesh-associated complications. Only one superficial peristomal wound defect occurred. No unplanned conversions were needed, and median duration of the operations was 72 minutes. There was no recurrence during the short-term follow-up of median 4 months (ranged from 3 to 8 months).The technique described gives several advantages, such as a minimally invasive hybrid approach creating a real three-dimensional mesh-covered barrier between the trephine and stomal limb and optional shortening of a concomitant prolapse. When needed due to a concomitant incisional hernia, a second flat mesh can be laparoscopically placed in an intraperitoneal position.

Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures. From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences. One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12–146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured. The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p