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Journal of gastrointestinal surgery 27(1), 47-55 (2023). doi:10.1007/s11605-022-05515-6, Published by Springer, New York, NY

Injuries of the acetabulum are often challenging in treatment and aftercare. One reason is the required surgical approach, which has high complication rates, including vascular lesion, hernias, and wound infection. We present an alternative endoscopic-assisted approach for the internal fixation of acetabular fractures to avoid the Pfannenstiel incision. An endoscopic approach similar to that used for endoscopic hernia surgery was used. The ilioinguinal approach’s lateral window was used to achieve reduction and insertion of a reconstruction plate. The purpose of this study is to describe a minimally invasive technique as a possible method to reduce hospitalization and complications. Another goal is to give detailed technical recommendations and to assess the potential pitfalls of this surgical approach. The APACHE technique is a safe and suitable minimally-invasive approach for the successful treatment of complex acetabular fractures and can be considered in similar cases., Technique Video Video 1 This video describes the key aspects of the anterior plating of the acetabulum in hemiendoscopic technique. The images show an anterior fracture of the left acetabulum. The first picture shows a schematic drawing of the abdomen and illustrates the approach to visualize the pubic bone and the acetabulum. A balloon trocar is placed in the preperitoneal space to bluntly dissect it for surgery. The second picture shows the infraumbilical midline incision of about 15 mm. One more incision can be seen more caudal also in the midline. The infraumbilical port is used primarily for the endoscope whereas further ports can be used for numerous instruments. The tissue is then dissected from medial to lateral starting from the pubic tubercle, using a raspatory and a laparoscopic scissor. The arcus mortis needs to be identified and clipped. The iliopectineal fascia is released and divided from the pelvic brim and os pubis by careful retraction of the femoral vessels cranially and laterally. This step is essential to place the plate safely beneath the vessels. The fracture reduction is achieved through the lateral window of the ilioinguinal approach. A large-fragment titanium reconstruction plate is used for plate fixation. The distal trocar is used to drill the threaded hole using a 3.2 mm twist drill bicortically into the superior pubic ramus.

Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality. Precipitating events, including hemorrhage and infections, contribute to ACLF development, but the role of surgery remains unknown. We investigated the development of ACLF in patients with cirrhosis undergoing surgery. In total, 369 patients with cirrhosis were included in the study. The clinical and laboratory data were collected prior to and on days 1-2, 3-8, and 9-28, and at 3 and 12 months after surgery. Surgery type was classified as limited or extensive, as well as liver and nonliver surgery. A total of 39 patients had baseline ACLF. Surgery was performed during acute decompensation in 35% of the rest of the 330 patients, and 81 (24.5%) developed ACLF within 28 days after surgery. Surrogate markers of systemic inflammation were similar in patients who developed ACLF or not. Age, sex, serum sodium, baseline bacterial infection, and abdominal nonliver surgery were independent predictors for the development of ACLF after surgery. Patients who developed ACLF within 28 days after surgery had a higher mortality at 3, 6, and 12 months. Survival did not differ between patients with ACLF at surgery and those developing ACLF after surgery. Development of ACLF within 28 days after surgery and elevated alkaline phosphatase and international normalized ratio were independent predictors of 90-day mortality. Independent predictors of 1-year all-cause mortality were alkaline phosphatase, Model for End-Stage Liver Disease score, and preoperative hepatic encephalopathy, whereas nonliver surgery was associated with improved survival. ACLF frequently develops in patients with cirrhosis undergoing surgery, especially in those with active bacterial infection, lower serum sodium, and kidney or coagulation dysfunction. Prognoses of ACLF both at and after surgery are similarly poor. Patients with cirrhosis should be carefully managed perioperatively.

Zusammenfassung Hintergrund Die prophylaktische totale Gastrektomie ist die Therapie der Wahl bei Patienten mit nachgewiesener pathogener Keimbahnmutation im CDH1-Gen und hierdurch hohem Risiko für die Entwicklung eines diffusen hereditären Magenkarzinoms (HDGC). Minimalinvasive Operationsverfahren wurden in den letzten Jahren im Bereich der onkologischen Magenchirurgie etabliert. Patienten und Methoden Insgesamt 12 Patienten wurden zwischen 2013 und März 2018 in unserem Zentrum für erbliche Tumorerkrankungen aufgrund einer nachgewiesenen CDH1-Keimbahnmutation betreut und in unserer Klinik prophylaktisch gastrektomiert. Die perioperativen Ergebnisse wurden in einer Datenbank prospektiv erfasst. Ergebnisse Es erfolgte in 5 Fällen eine offene (Zeitraum: 2013 – 2015) und in 7 Fällen eine minimalinvasive (Zeitraum: 2016 – 2017) prophylaktische Gastrektomie. Das mediane Alter im Gesamtkollektiv (7 Frauen und 5 Männer) lag bei 42 (19 – 60) Jahren. Die durchschnittliche Operationszeit betrug 291 ± 72 Minuten (offen: 269 ± 70; minimalinvasiv: 307 ± 75). Die perioperative 60-Tage-Mortalität und die Anastomoseninsuffizienzrate betrugen 0%. Bei 3 Patienten kam es zu postoperativen Komplikationen (jeweils einmal II, IIIa, IVb nach Clavien-Dindo-Klassifikation), entsprechend einer Morbidität von 25% (3/12). Die postoperative Liegedauer lag bei 14,5 ± 6,2 Tagen (offen: 16,2 ± 7,9; minimalinvasiv: 13,3 ± 5,0). Bei 10 Patienten (10/12; 83%) wurden in der histologischen Aufarbeitung intramukosale Karzinome (pT1a) diagnostiziert, 9 davon mit multifokaler Ausbreitung. Fortgeschrittene Karzinome (≥ pT1b) und Lymphknotenmetastasen lagen in keinem Fall vor. Schlussfolgerung Patienten mit Verdacht auf ein erhöhtes Risiko für ein hereditäres diffuses Magenkarzinom sollten in einem interdisziplinären Zentrum für erbliche Tumorerkrankungen betreut werden. Die minimalinvasive (laparoskopische) prophylaktische totale Gastrektomie ist ein machbares und sicheres risikoreduzierendes Verfahren bei Patienten mit CDH1-Genmutation und erblichem Magenkrebs. Demzufolge sollte, bei fehlenden Kontraindikationen und vorhandener Expertise, die minimalinvasive Operation bei diesem speziellen Kollektiv das Standardverfahren sein.

Zusammenfassung Hintergrund Malignome des Ösophagus zählen zu den häufigsten krebsbedingten Todesursachen. Den einzigen kurativen Therapieansatz stellt die radikale Ösophagektomie, eingebettet in ein multimodales Therapiekonzept, dar. Ziel der Untersuchung war die Analyse von Langzeitentwicklungen in der operativen Therapie des Ösophaguskarzinoms und deren Einflüsse auf das kurz- (1-JÜR), mittel- (5-JÜR) und langfristige (10-JÜR) Überleben. Patienten und Methoden Es wurden retrospektiv 301 Patienten am Universitätsklinikum Bonn untersucht, bei denen zwischen 1989 und 2012 eine Ösophagusresektion durchgeführt wurde. Um mögliche Trends im Management und Veränderungen hinsichtlich der Prognose zu analysieren, wurden 2 Kohorten (Kohorte A: operiert 1989 – 2000, Kohorte B: operiert 2001 – 2012) gebildet und bez. demografischer Daten, Tumorentität, Stadium, Komplikationsrate und Überleben miteinander verglichen. Ergebnisse In der Kohorte B wurden signifikant ältere Patienten in niedrigeren Tumorstadien mit einer größeren Lymphknotenausbeute operiert, eine Zunahme des Adenokarzinoms (AC) war zu beobachten. Während sich die Gesamtmorbidität nicht signifikant veränderte, konnte eine geringere Rate an Anastomoseninsuffizienzen in Kohorte B (5,5%) verglichen mit Kohorte A (12,3%) bei gleichzeitigem Anstieg der kardialen Ereignisse (A: 3,6% vs. B: 12,3%) nachgewiesen werden. Die 30-Tage-Krankenhausmortalität lag bei insgesamt 2,7% und fiel von 5% (Kohorte A) signifikant (p = 0,05) auf 0,7% (Kohorte B). Das mittlere Überleben betrug in der Kohorte A 46 ± 6,5 Monate. In Kohorte B überlebten Patienten mit 53 ± 7,2 Monaten signifikant länger (p = 0,03). In der univariaten Analyse hatten das lokale Tumorstadium, der Resektionsgrad, die Anzahl der befallenen Lymphknoten (LK), der Lymphknotenquotient (LNR) sowie das Auftreten postoperativer Komplikationen einen Einfluss auf das Überleben, wohingegen in der multivariaten Analyse nur noch T-Stadium, R-Status und LNR als unabhängige Prognosefaktoren galten. Schlussfolgerung Patienten, die sich einer onkologischen Ösophagusresektion unterziehen, sind heutzutage älter als noch vor einigen Jahren. Die frühzeitigere Tumordiagnose, eine radikalere Operationstechnik mit radikalerer Lymphknotendissektion und weniger Anastomoseninsuffizienzen sowie eine verbesserte perioperative Medizin scheinen diesen demografischen Nachteil zu kompensieren. Die größte prognostische Bedeutung beim Ösophaguskarzinom hat die LNR.

Neuroendocrine tumours (NET) are rare neoplasms, but the incidence is permanently increasing. Most of the NETs are slow proliferating and clinically silent, and for that reason, they are often diagnosed at a stage with advanced disease. The complexity and diversity of the NET-biology require the treatment of patients in specialised centres to guarantee a qualified, multidisciplinary treatment planning. At our institution, we developed an interdisciplinary model for the assessment and treatment of NET. The aim was to adapt the guidelines to the clinical practice, exchange of current knowledge, and a tailored approach to the individual patient. In our team are included medical professionals from pathology, radiology, oncology, gastroenterology, oncological surgery, and nuclear medicine. In this paper, we describe step-by-step a procedural algorithm for the management of patients with neuroendocrine tumours, focusing on midgut-NETs in terms of therapy.

Purpose Laparoscopic surgery (LS) has proved superior compared to conventional surgery (CS) regarding morbidity, length of hospital stay, rate of wound infection and time until recovery. An improved preservation of the postoperative immune function is assumed to contribute to these benefits though the role of the local peritoneal immune response is still poorly understood. Our study investigates the peritoneal immune response subsequent to abdominal surgery and compares it between laparoscopic and conventional surgery to find an immunological explanation for the clinically proven benefits of LS. Methods Wistar rats (N = 140) underwent laparoscopic cecum resection (LCR; N = 28), conventional cecum resection (CCR; N = 28), laparoscopic sham operation (LSO; N = 28), conventional sham operation (CSO; N = 28), or no surgical treatment (CTRL; N = 28). Postoperatively, peritoneal lavages were performed, leukocytes isolated and analyzed regarding immune function and phagocytosis activity. Results Immune function was inhibited postoperatively in animals undergoing LCR or CCR compared to CTRL reflected by a lower TNF-α (CTRL 3956.65 pg/ml, LCR 2018.48 pg/ml (p = 0.023), CCR 2793.78 pg/ml (n.s.)) and IL-6 secretion (CTRL 625.84 pg/ml, LCR 142.84 pg/ml (p = 0.009), CCR 169.53 pg/ml (p = 0.01)). Phagocytosis was not affected in rats undergoing any kind of surgery compared to CTRL. Neither cytokine secretion nor phagocytosis activity differed significantly between laparoscopic and conventional surgery. Conclusions According to our findings the benefits associated with LS compared to CS cannot be explained by differences in the postoperative peritoneal innate immune response. Further studies are needed to elucidate the causes for a more favorable postoperative outcome in patients after LS compared to CS.

Hintergrund: Das Papillenkarzinom ist ein seltener Tumor des Gastrointestinaltrakts und unterscheidet sich bezuglich der Prognose von anderen periampullaren Tumoren. Die Analyse des Uberlebens sowie moglicher Prognosefaktoren ist aufgrund der geringen Inzidenz des Karzinoms schwierig. Ziel dieser Studie war die Analyse des Kurz- und Langzeituberlebens sowie die Identifikation prognostischer Faktoren bei Patienten mit Papillenkarzinom und Duodenopankreatektomie und Rekonstruktion mittels Pankreatogastrostomie. Patienten und Methoden: Zwischen 1989 und 2008 wurden 76 Patienten mit einem Papillenkarzinom duodenopankreatektomiert, die Rekonstruktion erfolgte mittels Pankreatogastrostomie. Im Rahmen einer retrospektiven Analyse wurden verschiedene Faktoren (Demografie, perioperative Faktoren, Histopathologie) und ihr Einfluss auf das Kurz- und Langzeituberleben untersucht. Die statistische Analyse erfolgte mittels Kaplan-Meier-Kurven, mogliche prognostische Parameter wurden einer uni- und multivariaten Analyse mit Cox-Regression unterzogen. Ergebnisse: Die 5-Jahres-Uberlebensrate (JUR) betrug 46 %, die 10-JUR 26 %. In der univariaten Analyse war der einzig relevante Parameter bezuglich des Uberlebens der Lymphknotenstatus (LK-Status). In der multivariaten Analyse konnten Geschlecht, Alter, Grading sowie insbesondere der N-Status als signifikante Parameter identifiziert werden. Schlussfolgerung: In dem aktuell untersuchten Patientenkollektiv hat der Lymphknotenstatus die hochste prognostische Vorhersagekraft bezuglich des Langzeituberlebens bei Patienten mit Papillenkarzinomen.

The aim of our retrospective analysis was to compare the results of incisional hernia repair by porcine small intestinal submucosa-derived (SIS) meshes with those obtained by alloplastic polypropylene-based (PP) meshes in comparable surgical indications by matched-pair design. We hypothesized that in incisional hernia, SIS mesh repair is associated with fewer recurrences and SSO than PP mesh repair in incisional hernias. Twenty-four matched pairs (SIS vs. PP mesh repair between 1 January 2005 and 31 December 2013) were identified by matching criteria: gender, age, comorbidities, body mass index, EHS hernia classification, mesh implantation technique, CDC wound classification, and source of contamination/primary surgery leading to incisional hernia. Minimal follow-up time was 24 months. Means and standard deviations were compared by paired t test; categorial data were compared by McNemar’s test. Poisson’s distribution and negative binominal distribution were employed to detect significant correlation. There were no statistically significant differences between both groups in the pre- and perioperative factors and the follow-up times. There were significantly more wound complications (19 vs. 12, p = 0.041), longer hospital stay (22.0 ± 6.3 vs. 12.0 ± 3.1 days, p = 0.010), and significantly more recurrent hernias (25 vs. 12.5%, p = 0.004) after SIS mesh repair. Both the Poisson’s distribution and the negative binominal distribution unveiled significantly more complication points (3–6 vs. 1–2) per month after SIS mesh repair. There is no advantage of SIS meshes compared to PP meshes in incisional hernia repair with different degrees of wound contamination in this matched-pair analysis. Further prospective and randomized trials or at least registry studies such as the EHS register with standardized and defined conditions are warranted.

Introduction Postoperative ileus (POI) is a frequent complication after abdominal surgery (AS). Until today, neither a prophylaxis nor an evidence-based therapy exists. This originates from the absence of objective parameters evaluating the severity and duration of POI resulting in clinical trials of modest quality. The SmartPill®, a capsule which frequently measures pH value, temperature and intraluminal pressure after swallowing, offers an elegant option for analysing gastrointestinal (GI) transit times and smooth muscle activity in vivo. As the use in patients in the first months after AS is not covered by the marketing authorisation, we aim to investigate the safety and feasibility of the SmartPill® immediately after surgery. Additionally, we analyse the influence of prokinetics and laxatives as well as standardised physiotherapy on postoperative bowel contractility, as scientific evidence of its effects is still lacking. Methods and analysis The PIDuSA study is a prospective, single-centre, two-arm, open-label trial. The SmartPill® will be applied to 55 patients undergoing AS having a high risk for POI and 10 patients undergoing extra-abdominal surgery rarely developing POI. The primary objective is the safety of the SmartPill® in patients after surgery on the basis of adverse device effects/serious adverse device effects (ADE/SADE). The sample size suggests that events with a probability of 3% could be seen with a certainty of 80% for at least once in the sample. Secondary objective is the analysis of postoperative intestinal activity in the GI tract in both groups. Furthermore, clinical signs of bowel motility disorders will be correlated to the data measured by the SmartPill® to evaluate its significance as an objective parameter for assessing POI severity. Additionally, effects of prokinetics, laxatives and physiotherapy on postoperative peristaltic activity recorded by the SmartPill® will be analysed. Ethics and dissemination The protocol was approved by the federal authority (94.1.05-5660-8976) and the local ethics committee (092/14-MPG). Findings will be disseminated through publications and conference presentations. Trial registration number NCT02329912; Pre-results.

Whereas sleeve gastrectomy (SG) in its beginnings was mainly performed to treat super-obesity, it has become as popular as gastric bypass in the treatment of obesity of any class. In contrast to this, the persisting problems of early staple line leaks and poor long-term results of SG regarding weight loss and new onset of gastroesophageal reflux have become increasingly obvious. The mini-gastric bypass (MGB) with its low complication rates and possibly better long-term results may be a good alternative to SG, especially in super-obesity. In this context, two groups of mostly super-obese patients (SG and MGB) of a single bariatric center were retrospectively analyzed and compared for perioperative and early postoperative outcomes. Between August 2007 and March 2015, 169 patients underwent MGB, while 118 patients were operated by SG. Both groups were comparable for BMI at baseline (MGB = 54.1 kg/m2 vs. SG = 54.6 kg/m2, p = 0.657). Mean operation time (81.7 vs. 112.1 min, p

The case-study reminds of adenocarcinoma of the small intestine as a rare complication of Crohn's disease. A few more than 100 of these cases have been published. Epidemiological studies concerning small bowel carcinoma showed consumption of sugar and carbohydrates as pathogenetic factors, other conditions like ileostoma, ileumconduit, Crohn's disease and coeliac disease have been identified to some extent. An adenoma-carcinoma sequence as in large intestine carcinoma has been discussed. Immunohistochemical and oncogenetic findings failed to demonstrate any result of practical clinical value. Diagnosis of early stages of adenocarcinoma of the small intestine is very difficult and thus might be impossible to differentiate from exacerbation or progressive stenosis of preexisting Crohn's disease. If non-invasive diagnostic measures (ultrasound, small bowel enema, CT-scan, intestinoscopy, radiography, NMR-Sellink, capsule-endoscopy) fail to clear the situation a diagnostic laparoscopy or even laparotomy should not be delayed. This constitutes the only chance to discover early stages which can possibly be cured in accordance with oncosurgical principles. Otherwise the prognosis remains poor with a high percentage of late stages and a 5-year-survival-rate between 20 and 50 percent.

Background: Cystic lesions of the pancreas resembling intraductal papillary mucinous neoplasms (IPMN) have been reported to develop in an increased rate following liver transplantation and immunosuppression. The cause for this possible association is thus far elusive. Presentation of the case: We report on a 60-year-old male patient who developed an extensive multicystic change of the entire pancreas, suspicious for IPMN, under follow-up after liver transplantation for secondary sclerosing cholangitis. A total pancreaduodenectomy with splenectomy was performed. The postoperative histopathological assessment revealed a multifocal branch duct IPMN of the gastric subtype showing low-grade dysplasia. Discussion: In the absence of evidence-based guidelines for the management of suspected IPMNs in liver transplant recipients, each patient’s management should be discussed in detail. Conclusion: Prospective studies may help to understand the disease and identify risk factors for malignant transformation in IPMNs after liver transplantation for treatment optimization.

Incipient intraductal papillary mucinous neoplasms (IPMNs) are poorly described subcentimeter pancreatic cysts with papillae and mucin similar to IPMNs. They are larger than pancreatic intraepithelial neoplasia but do not meet the cutoff size for IPMNs (≥ 1 cm). GNAS codon 201 mutations are hallmark genetic alterations of IPMNs. Hence, we sought to determine the GNAS status of incipient IPMNs to better classify these lesions. Incipient IPMNs from 3 institutions were histologically reassessed, manually microdissected, and the genomic DNA was extracted. Using a sensitive digital ligation technique, the mutational status of KRAS at codon 12 and GNAS at codon 201 was determined. We included 21 incipient IPMNs from 7 male and 12 female patients with a median age of 63 years (range, 40 to 76 y). Most patients underwent surgery for pancreatic ductal adenocarcinoma (N = 8) or ampullary adenocarcinoma (N = 3). The median incipient IPMN size was 4 mm (range, 2 to 7 mm), and a majority had gastric-foveolar (N = 11) or intestinal (N = 5) differentiation. The maximum dysplasia observed was intermediate, and most of the lesions had intermediate-grade dysplasia. Mutational analysis revealed KRAS codon 12 mutations in all 21 incipient IPMNs, whereas 7 lesions (33%) in 7 individual patients harbored GNAS codon 201 mutations. The presence of GNAS 201 mutations in incipient IPMNs suggests that a fraction of these cysts are in fact small IPMNs. Morphologically, incipient IPMNs do not appear to be high-risk lesions. Additional studies in a larger cohort are needed to define the relationship of incipient IPMNs to larger IPMNs and, more importantly, to determine their clinical significance.

Laparoscopic surgery (LS) is gaining popularity worldwide because of benefits like faster recovery, earlier hospital discharge, and better cosmetic results. In hemophiliacs, surgery in general harbors an increased risk for severe complications. Whether LS or conventional surgery (CS) should be recommended in these patients is controversial and therefore the issue of our present study.We performed a retrospective matched-pair analysis including laparoscopically operated non-hemophiliacs (LONH), laparoscopically operated hemophiliacs (LOH), and conventionally operated hemophiliacs (COH) concerning duration of surgery, drainages, hospital stay, complications, factor use (VIII, IX, and X), and blood values. Mann-Whitney U test was used (significance level P = 0.05).No significant differences were found in duration of surgery and drains in laparoscopically or conventionally operated hemophiliacs versus matched pairs. Complication rate did not differ among the different groups. Concerning the total duration of hospital stay (t-DHOS) and the postoperative duration of hospital stay (p-DHOS), there was no statistical difference between LOH versus matched LONH. However, in COH versus matched LOH, a longer time was required for preparation and recovery (t-DHOS, P = 0.04; p-DHOS, P 0.001). Also, the median factor supply perioperatively including the day of surgery did not differ between laparoscopically versus conventionally operated hemophiliacs.Our study underscores the safety and benefits of laparoscopic procedures in hemophiliacs by showing a significantly shorter hospital stay for these patients resulting in reduced therapeutic costs and a faster mobilization. Still, the surgical and perioperative management of hemophiliacs continues to be a challenge requiring an experienced interdisciplinary team.

Due to an extensive use of modern imaging, incidental pancreatic cysts are increasingly diagnosed these days. Fortunately, comprehensive research over the past years has remarkably improved our pathogenetic and clinical understanding of pancreatic cysts that, as we know, are in majority harmless. However, mucinous cysts including intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, as well as solid pseudopapillary neoplasms harbor relevant potential for developing into a lethal invasive cancer and may therefore require immediate surgical resection or at least close surveillance. In order to allow an optimized clinical management, it is crucial to gather reliable information about entity as well as biologic behavior of every cyst detected. Unfortunately, in the absence of reliable biomarkers and by just applying currently available diagnostic means such as clinical and radiologic criteria or cyst fluid cytology, there is still a risk for incorrect preoperative diagnoses. This may be followed by inappropriate treatment possibly resulting in severe morbidity or even mortality.In this review article, we summarize some of the salient recent advances in molecular diagnostics of pancreatic cysts. Herein, we put particular focus on the emerging field of biomarker research in pancreatic cyst fluid based on protein, DNA, and microRNA analyses.

The female breast rarely constitutes the primary localization for non-Hodgkin’s lymphoma (NHL). The incidence of primary breast lymphoma (PBL) lies between 0.04 and 1.1% for all breast tumors and 1.7–2.2% for all extranodal NHL. Mostly it occurs during the child-bearing period, during pregnancy or lactation. In general, children between the ages of 8 and 10 years are most frequently affected by Burkitt’s lymphoma. Methods for classification, detection and especially treatment of this condition continue being a subject of discussions and research. We present and evaluate the rare case of a 12-year-old girl with bilateral gigantic breast tumors treated during a surgical mission with “Doctors without borders” (MSF, “medecins sans frontiers”) in the zone of civil war in the Democratic Republic of Congo. The monstrous bilateral breast hypertrophy, symmetrical, rapidly growing, consequently ulcerating and severely bleeding had to be treated by bilateral mastectomy as a salvage procedure. Examinations through histopathology was not feasible and other facilities like ultrasound, CT, MRI and further laboratory examinations were not available.. The patient died 27 days after the surgical procedure. The histological result received by later examination in Germany showed a bilateral high malignant B cell lymphoma (Burkitt lymphoma) of the breast.

Laparoscopic cholecystectomy (LC) is nowadays the standard method for cholecystectomy. Recently, surgeons attempt to introduce even less-invasive surgical procedures, such as single-port LC or LC through natural orifice transluminal endoscopic surgery (NOTES). The number of studies showing the feasibility of these techniques increased during the last years, but specific complications that correlated with these new techniques are still not apparent. Here, we report on a case with an unusual complication, iatrogenic right diaphragm injury in single-port LC. A 72-year-old man underwent single-port LC because of symptomatic cholecystolithiasis. During the operation, the long rigid straight forceps holding the fundus of the gallbladder slipped off toward the right diaphragm and caused a 1-cm full-thickness diaphragmatic tear. Laparoscopic suture repair was performed, and the patient recovered uneventfully. In using long forceps in single-port LC or transvaginal NOTES-LC, reticulating and bent instruments may avoid this unusual but possible complication in these operations.

Purpose Diaphragmatic hernias (DHs) are divided into congenital and acquired hernias, most of which are congenital. Among acquired DHs, up to 80% are left-sided, only a few iatrogenic DHs have been reported, and bilateral hernias are extremely rare. For diagnostic reasons, many DHs are overlooked by ultrasonography or X-ray and are only recognized at a later stage when complications occur. Methods In 2009, we performed three partial diaphragm replacements in our clinic for repairing DHs using a PERMACOL™ implant. Results As all patients had uneventful postoperative courses and the clinical outcomes were very good, we present one special case of a 65-year-old male with a giant iatrogenic bilateral DH with an enterothorax. Conclusion We see a good indication for diaphragm replacements by using a PERMACOL™ implant for fixing especially DHs with huge hernial gaps and in cases with fragile tissue.

A 62 year-old patient with therapy-refractory pouchitis after proctocolectomy for ulcerative colitis was admitted with hematochezia and abdominal discomfort. A malignant melanoma (MM) was found after repeated biopsies of the pouch. Complete staging revealed no evidence for distant metastases and the patient underwent abdominoperineal pouch resection. Six weeks later, the patient was readmitted because of severe general deterioration and diffuse metastatic spread to the liver was found. The patient died of hepatorenal syndrome shortly thereafter. Patients with inflammatory bowel disease are at increased risk of developing cancer, including rarities such as MM. Our experience stresses the importance of repeated biopsies in therapy-refractory pouchitis.

Acute abdomen is a common and often complicated condition inthe emergency department. Etiology may vary from harmless toextremely severe causes, any of which can present the samenonspecific symptoms. Impalement or penetrating injuries of thelower genital tract are rare and frequently related to unusual sexualhabits [2]. Evaluating the mechanism of trauma may be difficult aspatients are often unwilling or unable to provide the necessaryinformation.An 18-year-old woman presented at the emergency departmentwith sudden and severe lower abdominal pain in the early morning.Initial history did not reveal trauma or previous illness.Physical examination showed a tense abdomen with diffuseguarding and rare bowel sounds. Laboratory evaluation showed awhite blood cell count of 25.7/nL and C-reactive protein of 84 mg/L.Urinalysis exhibited 150 Ery/μL, 100 leukocytes/μL, and a negativepregnancytest. Abdominal ultrasound was normal but X-rayrevealedair in the peritoneal cavity.Laparoscopy was performed for suspected gastrointestinal perfo-ration. Turbid and blood-stained perihepatic fluid was found andhyperemia of the parietal peritoneum was suggestive of earlyperitonitis. No perforation was found in the upper abdomen. In therectovaginal pouch there was a 4-cm wide laceration through thevagina vault, with transvaginal loss of carbon dioxide gas.Following irrigation with 5 liters of warm saline, repair wasperformed laparoscopically with a continuous PDS II suture (3-0,Lahodny) and fixed with two resorbable clips. Intravenous cephazolin(3×2 g) and metronidazole (2×500 mg) were administered to thepatient for 7 days. Review of the gynecologic history revealed forcefulsexual intercourse as the cause of the injury. The patient's recoveryfrom surgery was uneventful.Impalement injuries of the vagina are seldom described in theliteratureandincludesevereinjuriesoftherectum,bladder,peritoneal,duodenum, diaphragm, and lung [1–3].The most common symptom in women with vaginal impale-ment injury is vaginal bleeding after coitus with no history ofcongenital abnormalities, gynecologic operation, pregnancy, orbirth [4]. Careful gynecologic history is necessary and should beaccompanied by vaginal examination and ultrasound or radiogra-phy when indicated.Vaginal bleeding as the classical symptom was absent in thepresent case and the clinical aspect was that of an acute abdomenwith diffuse peritonitis. In such cases, full evaluation may lead tolaparoscopy.Conflict of interestNo conflicts of interest exist.References

Background Laparoscopic appendectomy (LA) has become one of the most common surgical procedures to date. To improve and standardize this technique further, cost-effective and reliable animal models are needed. Methods In a pilot study, 30 Wistar rats underwent laparoscopic caecum resection (as rats do not have an appendix vermiformis), to optimize the instrumental and surgical parameters. A subsequent test study was performed in another 30 rats to compare three different techniques for caecum resection and bowel closure. Results Bipolar coagulation led to an insufficiency of caecal stump closure in all operated rats (Group 1, n = 10). Endoloop ligation followed by bipolar coagulation and resection (Group 2, n = 10) or resection with a LigaSure™ device (Group 3, n = 10) resulted in sufficient caecal stump closure. Conclusions We developed a LA model enabling us to compare three different caecum resection techniques in rats. In conclusion, only endoloop closure followed by bipolar coagulation proved to be a secure and cost-effective surgical approach.