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Purpose Infectious complications are as high as 30% in elective colorectal surgery. In recent years, several studies have discussed the topic of preoperative bowel decontamination prior to colorectal surgery in order to reduce postoperative infectious complications and have found significant effects of oral antibiotic administration with a large variety of drugs used. No study has evaluated the combination of oral paromomycin and metronidazole in this context. Methods We performed a prospective single-center study with a matched-pair retrospective cohort to evaluate postoperative infectious complications (superficial site infections, organ space abscess, anastomotic leakage) in elective colorectal surgery. Patients A total of 120 patients were available for study inclusion; 101 gave informed consent and were included. A total of 92 patients were matched and subsequently analyzed. We could show a reduction in overall infectious complications in the intervention group (15.2% vs 30.8%, p = 0.018; odds ratio 0.333, 95% CI 0.142–0.784) as well as a reduction in superficial surgical site infections (8.7 vs 19.6%, p = 0.041, OR 0.333, 95% CI 0.121–0.917). The frequency of the other infectious complications such as intraabdominal abscesses and anastomotic leakage showed a tendency towards decreased frequencies in the intervention group (OR 0.714, 95% CI 0.235–2.169 and OR 0.571; 95% CI 0.167–1.952, respectively). Finally, the oral antibiotic administration led to an almost significantly reduced length of stay (12.24 days vs 15.25 days; p = 0.057). Conclusions Oral paromomycin and metronidazole with intravenous ertapenem effectively reduce infectious complications in elective colorectal surgery. Trial registration The study was registered at Clinicaltrials.gov (NCT03759886) December 17, 2018

Background In chronic anticoagulant users undergoing surgery, bleeding and thromboembolism are common and serious complications. Many studies on mainly elective or minor emergency surgical procedures with low associated risks have focused on these outcomes. In comparison, patients undergoing high-risk emergency abdominal surgical procedures have not received sufficient attention. This study aimed to compare outcomes between oral anticoagulant users and nonusers who required emergency laparotomy for high-risk abdominal emergencies. Methods Patients who underwent surgery for abdominal emergencies at our institution between January 2012 and July 2019 were retrospectively reviewed. Results There were 875 patients, including 370 anticoagulant users and 505 nonusers. Of the 370 anticoagulant users, 189 (51.3), 77 (20.8%), 45 (12.2%), and 59 (15.9%) were prescribed antiplatelets, a vitamin k antagonist, a direct oral anticoagulant, and a combination drug regimen, respectively. The most common high-risk emergencies requiring surgery in both groups were perforated viscus (25.7% vs 40.9%), mesenteric ischemia with enteric necrosis (27% vs 12.8%), and bowel obstruction (17.6% vs 28.1%). The overall bleeding rate was higher (29.2% vs 22%, p = 0.015) in anticoagulant users than in nonusers, but the major bleeding rate was similar (17.8% vs 14.1%, p = 0.129) between the two groups. The rates of thromboembolic events and mortality were significantly higher in anticoagulant users than in nonusers (25.7% vs 9.7%, p < 0.0001 and 39.7% vs 31.1%, p = 0.01, respectively). Liver cirrhosis, peripheral arterial diseases, reoperation, and blood product transfusion were independent predictors of the overall risk of bleeding or TEEs, according to the multivariate analysis. In this model, liver cirrhosis had the largest overall effect on mortality, followed by pneumonia, thromboembolism, peripheral arterial disease, blood product transfusion, and atrial fibrillation. The use of oral anticoagulants was not an independent predictor of either bleeding or in-hospital mortality. The use of oral anticoagulants was associated with a decreased risk of all-cause in-hospital mortality. Conclusion Based on our results, the continued use of oral anticoagulants is more protective than harmful considering the overall outcomes in this subset of patients.

Zusammenfassung Einleitung Adipositas-Chirurgie ist weltweit etabliert und sicher durchführbar. Mit steigender Expertise werden auch zunehmend Risikopatienten operiert, die z.B. bei Organdysfunktion zu adipös für eine geplante Organtransplantation sind. Patienten und Methoden In dem Zeitraum 1/13 bis 6/9 wurden 653 Patienten an unserem Zentrum adipositaschirurgisch versorgt. Die Daten wurden retrospektiv ausgewertet und es fanden sich unter den 653 Patienten 34 Patienten mit dialysepflichtiger Niereninsuffizienz, hochgradiger Herzinsuffizienz (linksventrikuläre Ejektionsfraktion < 30 %) oder Leberzirrhose (Child-Pugh-Stadium A und B). Das Minimum-Follow-up beträgt 12 Monate. Ergebnisse Bei 5 der 34 Patienten (14,7 %) kam es zu einem komplizierten Verlauf. Folgende Komplikationen traten auf: 3x Wundheilungsstörung mit konservativer Therapie, 1x subkutane Nachblutung bei einem Patienten mit LVAD (konservative Therapie) und 1 Shunt-Verschluss, der operativ revidiert wurde. Schlussfolgerung Adipositaschirurgische Eingriffe sind auch bei Risikopatienten mit geringer Morbidität und Mortalität durchführbar.

Acute mesenteric ischemia is a life-threatening acute condition, which requires an interdisciplinary approach, including vascular recanalization and surgical treatment. Visual evaluation of intestinal perfusion might be misleading, and therefore, additional tools are necessary to reliably be able to resect the ischemic intestine. Hyperspectral imaging (HSI) has been shown to be feasible and safe for real-time assessment of tissue perfusion in visceral surgery but has never been used in cases of acute mesenteric ischemia. Therefore, we applied HSI in acute mesenteric ischemia to evaluate it for potential aid in the objectively discriminating ischemic and well-perfused intestine during explorative laparotomy.We recorded HSI measurements in 11 cases of acute mesenteric ischemia during explorative laparotomy. We evaluated the recorded images for macroscopic visual perfusion quality and divided it into three groups. Of those three groups, we calculated and compared the HSI indexes of tissue saturation, near-infrared perfusion index, organ hemoglobin index, and tissue water index, as well as the reflectance spectra.We found significant differences in tissue saturation (0.7% versus 0.45%; P = 0.002) and near-infrared perfusion index (0.58 versus 0.23; P 0.001) in poorly perfused intestinal segments compared with the viable intestine. Furthermore, we could detect an increasing peak at 630 nm of the reflectance spectra in less viable tissues, indicating a maximum in necrotic tissues. We attributed this peak to an increase in met-hemoglobin content in necrotic tissues, which is supported by the increase in the HSI organ hemoglobin index.HSI is able to discriminate tissue perfusion in acute mesenteric ischemia reliably and therefore might be helpful for resection. In addition, HSI gives information on tissue viability via reflectance spectra.

Introduction The role of preoperative upper-gastrointestinal (GI) gastroscopy has been discussed with controversy in bariatric surgery. The aim of this study was to evaluate the incidence of upper-GI pathologies detected via endoscopy prior to bariatric surgery along with their clinical significance for patients’ management. Material and Methods In our single center prospectively established database of obese patients, who underwent bariatric surgery from January 2011 to December 2017, we retrospectively analyzed the perioperative endoscopic findings along with their influence on patients’ management. Results In total, 636 obese patients with median BMI (body mass index) of 49 kg/m2 [range 31–92] received an upper-GI endoscopy prior to bariatric surgery. Among the surgical procedures, laparoscopic Roux-Y-gastric bypass (72.6%; n = 462) was the most frequent operation. Endoscopically detected pathological conditions were peptic ulcer 3.5% (22/636), Helicobacter pylori (Hp) gastritis 22.4% (143/636), and gastric or duodenal polyps 6.8% (43/636). Reflux esophagitis could be detected in 139/636 patients (21.9%). Barrett’s esophagus (BE) was histologically diagnosed in 95 cases (15.0%), whereas BE was suspected endoscopically in 75 cases (11.3%) only. Esophageal adenocarcinomas were detected in 3 cases (0.5%). Change of the operative strategy due to endoscopically or histologically detected pathologic findings had to be performed in 10 cases (1.6%). Conclusion Preoperative upper-GI endoscopy identifies a wide range of abnormal endoscopic findings in obese patients, which may have a significant impact on decision-making, particularly regarding the most suitable bariatric procedure and the appropriate follow-up. Therefore, preoperative upper-GI endoscopy should be considered in all obese patients prior to bariatric procedure.

Background The objective of this study was to analyze outcomes and determine independent predictors of subsequent reoperation following emergency laparotomy (EL). Materials and methods Patients undergoing EL (n = 854) from 2012 to 2018 at our institution were retrospectively assessed. Postoperative complications, in-hospital mortality and predictive factors were assessed. Results Among the studied patients, 307 (35.9) required subsequent reoperation, and 547 (64.1%) did not. The mean number of surgeries was 2.02 ± 1.54, with a median of 2 (range 1–10). Viscus organ perforation had the highest reoperation rate (25.6%), followed by hemorrhage (16.1%), anastomotic leakage (15.4%), mesenteric ischemia (14.9%), and bowel obstruction (11.9%). The incidence of postoperative complications was higher in reoperated patients (100%) than in non-reoperated patients (58.9%). There were 305 deaths, with an overall in-hospital mortality rate of 35.7%; 175 (57%) occurred in the reoperated group, and 130 (23.8%) occurred in the non-reoperated group. In multivariate regression (N = 854), an American Society of Anesthesiologists (ASA) class of 3 or above (OR, 4.27; 95% CI, 2.54–7.18), coexisting liver cirrhosis of Child grade B or above (OR, 2.50; 95% CI, 1.46–4.29), coexisting cardiac arrhythmia (OR, 1.59; 95% CI, 1.10–2.30), and steroid use (OR, 1.95; 95% CI, 1.01–3.77) strongly predicted reoperation. Conclusion Our data showed notably high mortality due to subsequent reoperation, and there was a steady increase in mortality as the number of reoperations increased. A high ASA class, liver cirrhosis, cardiac arrhythmia and steroid use were independently associated with the risk of subsequent reoperation.

Die Hyperspektralbildgebung („HyperSpectral Imaging“ [HSI]) erlaubt quantitative Gewebeanalysen uber die Limitationen des menschlichen Auges hinaus. Somit dient es als neues Diagnostikinstrument der optischen Eigenschaften verschiedener Gewebe. Im Gegensatz zu anderen intraoperativen bildgebenden Methoden ist HSI kontaktlos, nichtinvasiv und bedarf keiner Kontrastmittelapplikation. Die Messungen nehmen nur wenige Sekunden in Anspruch und storen somit die Operationsablaufe unwesentlich. Erste HSI-Anwendungen in der Viszeralchirurgie sind vielversprechend mit dem Potenzial optimierter Ergebnisse. Aktuelle Konzepte, Moglichkeiten und neue Perspektiven der HSI-Technologie sowie deren Limitationen werden in dieser Arbeit diskutiert.

Postoperative Komplikationen konnen nach komplexen viszeralonkologischen Operationen zu erheblichen Beeintrachtigungen des Patienten und daraus resultierend zu einer prolongierten postoperativen stationaren Verweildauer fuhren. Daher sollte die aktive Gestaltung der praoperativen Phase einen wichtigen Bestandteil der praoperativen/neoadjuvanten Therapie darstellen. Ziel der vorliegenden Arbeit ist eine kritische Darstellung aktueller Prahabilitationskonzepte sowie deren Anwendbarkeit und Entwicklungspotenzial in der Viszeralchirurgie. Anhand einer selektiven Literaturubersicht werden aktuelle Studien und Konzepte vorgestellt und Therapiealgorithmen prasentiert. Die vorliegenden Studien unterscheiden sich in Zielgrosen, Gestaltung und zeitlichem Rahmen der Intervention. Insgesamt zeigen die Studienergebnisse positive Effekte einer aktiven Steigerung der korperlichen Fitness in der praoperativen Phase in Bezug auf die Lebensqualitat, Rekonvaleszenz und postoperative pulmonale Komplikationsrate. Neben der Beurteilung des individuellen Komplikationsrisikos mittels Spiroergometrie kann durch ein gezieltes Ernahrungs- und Aufbauprogramm die Leistungsfahigkeit vor viszeralchirurgischen Operationen gesteigert und somit Einfluss auf das postoperative Komplikationsrisiko genommen werden. Die Leistungsfahigkeit ist als modifizierbarer Risikofaktor zu verstehen, der auch in einem kurzen Zeitfenster praoperativ positiv beeinflusst werden kann. Die individuelle praoperative Versorgung optimiert die physische und psychische Verfassung der Patienten. Zur Sicherstellung der geforderten individuellen Versorgung mussen Ansatze geschaffen werden, die sich dezentral umsetzen lassen.

This study evaluated the use of hyperspectral imaging for the determination of the resection margin during colorectal resections instead of clinical macroscopic assessment. The used hyperspectral camera is able to record light spectra from 500 to 1000 nm and provides information about physiologic parameters of the recorded tissue area intraoperatively (e.g., tissue oxygenation and perfusion). We performed an open-label, single-arm, and non-randomized intervention clinical trial to compare clinical assessment and hyperspectral measurement to define the resection margin in 24 patients before and after separation of the marginal artery over 15 min; HSI was performed each minute to assess the parameters mentioned above. The false color images calculated from the hyperspectral data visualized the margin of perfusion in 20 out of 24 patients precisely. In the other four patients, the perfusion difference could be displayed with additional evaluation software. In all cases, there was a deviation between the transection line planed by the surgeon and the border line visualized by HSI (median 1 mm; range − 13 to 13 mm). Tissue perfusion dropped up to 12% within the first 10 mm distal to the border line. Therefore, the resection area was corrected proximally in five cases due to HSI record. The biggest drop in perfusion took place in less than 2 min after devascularization. Determination of the resection margin by HSI provides the surgeon with an objective decision aid for assessment of the best possible perfusion and ideal anastomotic area in colorectal surgery.

Purpose Gastric cancer (GC) patients with peritoneal metastasis (PM) have poor prognosis. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in combination with systemic chemotherapy is a novel treatment option for patients in stage IV of the disease. Materials and methods Between November 2015 and June 2018, prospective data collection was performed in 24 patients with GC and PM (median age, 57; range, 44-75 years). These patients underwent 46 PIPAC procedures with a median number of 2 interventions per patient (range, 1-6). A laparoscopic access was used and a combined therapy of cisplatin and doxorubicin aerosol was administered. Results The median peritoneal carcinomatosis index before the 1st PIPAC was 14 (range, 2-36), and the median ascites volume in patients before the 1st PIPAC was 100 mL (range, 0-6 mL, 300 mL). Eleven patients, who received 2 or more PIPAC procedures, had decreased and stable volumes of ascites, while only 3 patients displayed increasing volume of ascites. The median overall survival was 121 days (range, 66-625 days) after the 1st PIPAC procedure, while 8 patients who received more than 3 PIPAC procedures had a median survival of 450 days (range, 206-481 days) (P=0.0376). Conclusions Our data show that PIPAC is safe and well tolerated, and that the production of ascites can be controlled by PIPAC in GC patients. Patients, who received 2 or more PIPAC procedures, reported a stable overall quality of life. Further studies are required to document the significance of PIPAC as a palliative multimodal therapy. Trial registration ClinicalTrials.gov Identifier: NCT03100708.

Background Surgical outcome to extremes of age is understudied. The purpose of this study was to evaluate the patient characteristics and incidence of postoperative morbidity and in-hospital mortality among patients aged 90 years and older who underwent surgery in comparison to younger controls. Methods Patients aged 90 years or older (n = 80; mean age, 92.36 ± 2.37) were matched for surgical treatment with patients aged 79 years or younger (n = 80; mean age, 55.98 ± 15.95) taken from the same cohort. Results The overall morbidity and mortality rates were 57.5% and 31.3% in the elderly vs. 47.5% and 23.1% in the younger group respectively. Patient groups aged 90 years or older and 79 years or younger each had 4 and 6 predictive factors for morbidity and 10 and 9 predictive factors for mortality respectively. Conclusion while advanced age carries an increased risk of morbidity and mortality, it seems that age in itself is no barrier to surgery. Despite the comparably high prevalence of chronic disease, elderly patients in this study fared quite well.

Purpose:Intensive exercise is known to be accompanied by a rapid release of cell-free DNA (cfDNA). The physiological significance of cfDNA release for performance diagnostics has not been studied. The authors analyzed the release of cfDNA during bicycle exercise and its correlation with physiological parameters.Methods:Eleven male athletes performed an incremental cycling test. Venous blood was collected before and immediately after exercise and after 90 min of recovery. Since the amount of cfDNA is influenced by preanalytical parameters like DNA extraction and quantification method, the authors applied different measurement approaches based on quantitative real-time polymerase chain reaction. They compared a direct measurement procedure not requiring cfDNA extraction for a short (L1PA290) and a long fragment (L1PA2222) and a procedure for extracted cfDNA for a short (LTR570) and long fragment (LTR5323) with primers targeting the repetitive sequences L1PA2 and LTR5 in both assays, respectively.Results:With the exception of LTR5323, the procedures revealed significant increases of cfDNA postexercise, whereas the direct approach showed lower interindividual variance in cfDNA values. When linking cfDNA levels to parameters of exercise performance the authors observed that, especially, the measurement based on L1PA2222 correlated significantly with exercise markers. These correlations were similar to the relationship of the performance markers among themselves.Conclusions:cfDNA is a possible physiological marker to assess and predict exercise performance in athletes. In addition, the results indicate that using cfDNA as a marker in exercise physiology requires careful selection of a suitable measurement technique, whether it is eluted DNA or directly quantified.

Although achalasia presents with typical symptoms such as dysphagia, regurgitation, weight loss, and atypical chest pain, the time until first diagnosis often takes years and is frustrating for patients and nevertheless associated with high costs for the healthcare system. A total of 563 patients were interviewed with confirmed diagnosis of achalasia regarding their symptoms leading to diagnosis along with past clinical examinations and treatments. Included were patients who had undergone their medical investigations in Germany. Overall, 527 study subjects were included (male 46%, female 54%, mean age at time of interview 51 ± 14.8 years). Dysphagia was present in 86.7%, regurgitation in 82.9%, atypical chest pain in 79%, and weight loss in 58% of patients before diagnosis. On average, it took 25 months (Interquartile Range (IQR) 9-65) until confirmation of correct diagnosis of achalasia. Though, diagnosis was confirmed significantly quicker (35 months IQR 9-89 vs. 20 months IQR 8-53; p < 0.01) in the past 15 years. The majority (72.1%) was transferred to three or more specialists. Almost each patient underwent at least one esophagogastroduodenoscopy (94.2%) and one radiological assessment (89.3%). However, esophageal manometry was performed in 70.4% of patients only. The severity of symptoms was independent with regard to duration until first diagnosis (Eckardt score 7.14 ± 2.64 within 12 months vs. 7.29 ± 2.61 longer than 12 months; P = 0.544). Fifty-five percent of the patients primarily underwent endoscopic dilatation and 37% a surgical myotomy. Endoscopic dilatation was realized significantly faster compared to esophageal myotomy (1 month IQR 0-4 vs. 3 months IQR 1-11; p < 0.001). Although diagnosis of achalasia was significantly faster in the past 15 years, it still takes almost 2 years until the correct diagnosis of achalasia is confirmed. Alarming is the fact that although esophageal manometry is known as the gold standard to differentiate primary motility disorders, only three out of four patients had undergone this diagnostic pathway during their diagnostic work-up. Better education of medical professionals and broader utilization of highly sensitive diagnostic tools, such as high-resolution manometry, are strictly necessary in order to correctly diagnose affected patients and to offer therapy faster.

Esophageal adenocarcinoma (EA) and its precancerous condition Barrett's esophagus (BE) are multifactorial diseases with rising prevalence rates in Western populations. A recent meta-analysis of genome-wide association studies (GWAS) data identified 14 BE/EA risk loci located in non-coding genomic regions. Knowledge about the impact of non-coding variation on disease pathology is incomplete and needs further investigation. The aim of the present study was (i) to identify candidate genes of functional relevance to BE/EA at known risk loci and (ii) to find novel risk loci among the suggestively associated variants through the integration of expression quantitative trait loci (eQTL) and genetic association data. eQTL data from two BE/EA-relevant tissues (esophageal mucosa and gastroesophageal junction) generated within the context of the GTEx project were cross-referenced with the GWAS meta-analysis data. Variants representing an eQTL in at least one of the two tissues were categorized into genome-wide significant loci (P < 5?0⁻⁸) and novel candidate loci (5?0⁻⁸ ≤ P ≤ 5?0⁻⁵). To follow up these novel candidate loci, a genetic association study was performed in a replication cohort comprising 1,993 cases and 967 controls followed by a combined analysis with the GWAS meta-analysis data. The cross-referencing of eQTL and genetic data yielded 2,180 variants that represented 25 loci. Among the previously reported genome-wide significant loci, 22 eQTLs were identified in esophageal mucosa and/or gastroesophageal junction tissue. The regulated genes, most of which have not been linked to BE/EA etiology so far, included C2orf43/LDAH, ZFP57, and SLC9A3. Among the novel candidate loci, replication was achieved for two variants (rs7754014, Pcₒmbinₑd = 3.16?0⁻⁷ and rs1540, Pcₒmbinₑd = 4.16?0⁻⁶) which represent eQTLs for CFDP1 and SLC22A3, respectively. In summary, the present approach identified candidate genes whose expression was regulated by risk variants in disease-relevant tissues. These findings may facilitate the elucidation of BE/EA pathophysiology. CA extern

Purpose: There is evidence from various surgical specialties that incisional negative pressure wound therapy (iNPWT) might reduce postoperative surgical site infections (SSIs). In visceral and general surgery, there is varying evidence of its efficacy in reducing surgical site infections.Methods: A prospectively registered patient cohort of 43 patients with abdominal wall and visceral surgery received treatment with iNPWT and was compared to a matched retrospective cohort to analyze its effects on SSI occurrence and respective risk factors. Groups were matched by procedure, sex, body mass index and age. We used two different systems of iNPWT: (i) PREVENATM or (ii) self-made epicutaneous iNPWT from common VAC material.Results: We could not find a total reduction in postoperative SSIs by application of iNPWT. But within the iNPWT cohort, patients with self-made iNPWT suffered more often from SSIs compared to the commercial iNPWT subgroup. No patient specific risk factors could be identified to advocate the use of iNPWT.Conclusion: Our data do not support the use of an incisional negative pressure wound therapy on closed wounds in midline laparotomy incisions. Although, differences exist between the commmercial and self-made systems.

Intraoperative pathologic findings during bariatric surgery are relatively rare. Gastrointestinal stromal tumors (GISTs) are commonly located in the stomach and account for

Die Inzidenz des Osophaguskarzinoms ist in Deutschland in den letzten Jahren steigend. Ziel der vorliegenden Arbeit ist die Diskussion der okonomischen Aspekte der onkologischen Osophaguschirurgie im deutschen DRG-System mit Fokus auf den Zusammenhang zwischen Mindestmengengrenzen und Ergebnisqualitat sowie Kosten. Die Marge der DRG G03A ist gering und wird schnell aufgezehrt, wenn Komplikationen den postoperativen Verlauf bestimmen. Eine aktuelle Analyse der deutschen Krankenhausabrechnungsdaten konnte einen signifikanten Unterschied der Klinikletalitat zwischen Kliniken mit und ohne Erreichen der Mindestmengen der Osophagektomie belegen. US-amerikanische Daten zeigen, dass neben patientenrelevanten Parametern das Fallvolumen des Chirurgen relevant fur die Kosten der Behandlung ist. Derartige kostenbezogene Analysen liegen in Deutschland derzeit nicht vor. Zukunftig erstrebenswert ist die wissenschaftliche Validierung belastbarer Mindestmengengrenzen fur die onkologische Osophagusresektion.

In der Chirurgie des fortgeschrittenen Magenkarzinoms gab es in den letzten Jahren einige neue Entwicklungen, z. B. die minimal-invasive Chirurgie und Robotik. Der nachfolgende Beitrag ordnet die Innovationen in Bezug auf Effektivitat und Sicherheit ein.