Bericht über den Workshop „Workflow Rektumkarzinom II” am 10. / 11.11.2006 in Burghausen

The task force "workflow rectal cancer II" defined operative techniques in lower rectal cancer, especially the total mesorectal excision and an improved technique of abdominalperineal resection. New aspects for treatment of rectal cancer with primary distant metastases are described. Due to newer publications a concept of bidirectional procedure with surgery and radiochemotherapy is recommended, where the operation must not be inevitably the first step. In anastomoses below 6 cm of the anocutaneous verge a reservoir should be performed on principle due to better functional results. The colon-j-pouch with a maximal loop length of 6 cm is best investigated under these conditions, the other procedures should be further evaluated.

Qualitätsindikatoren bei Diagnostik und Therapie des Rektumkarzinoms

Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators of quality were compiled as indicator profile for a summarizing evaluation. The indicators selected should potentially show an appreciable variation of the quality target and in addition should be decisive for the outcome. For the evaluation of the clinical diagnostic the frequency of the determination of the pretherapeutic T, N and M categories and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the number of histologically examined lymph nodes and the proportion of lymphnode positive patients. Process quality of treatment was defined by the following indicators: proportion of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic bladder dysfunction at hospital discharge. The indicators for the quality of the performance of treatment were differentiated between surrogate indicators that can be determined immediately after accomplishment of primary surgical therapy giving strong clues for the further course of disease at an early date, and definite indicators. Important surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination, R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality of mesorectal excision (proportion of incomplete mesorectal excision). The definite indicators include the 5-year local recurrence rate and the 5-year overall survival rate. The corresponding quantifying parameters for the individual indicators are specified in this paper with precise figures.

[Surgical therapy of diverticulitis]

The prevalence of sigmoid diverticular disease is increasing in western, industrialised countries. Practice parameters recommend surgical treatment for complicated disease or after the second episode of chronic recurrent disease. Surgical intervention should also be considered for younger patients after a first episode severe enough to require treatment. The preferred surgical procedure is elective sigmoid resection with primary anastomosis. Additional resection of the lower colon descendens is necessary when this region is also affected. Two-stage surgery is recommended for patients in emergency situations, i. e. severe or generalized peritonitis or extensive localized abscess formation, especially when the treating hospital is non-specialized. Segmentary resection without anastomosis and Hartmann's procedure is performed first (blind closure of the rectum with terminal colostomy). Restoration of colorectal continuity is performed at the earliest three months postoperatively. The preferred surgical technique is laparoscopy, provided the surgeon has the necessary expertise. Numerous studies have proven significant advantages of laparoscopy, although it is a completely new procedure with a long learning curve of 50-60 operations. Therefore, conversion to the conventional method should not be seen as a personal failure but rather as a responsible decision in favor of the patient's well-being.

Laparoscopic Surgery Today (Br J Surg 2006; 93: 779-780)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Analgesie in der Kolonchirurgie

BACKGROUND

The goal of our study was to evaluate the morphine-sparing effect of nonsteroidal anti-inflammatory drugs (NSAIDs) following both conventional and laparoscopic colon surgery.

MATERIALS AND METHODS

In this prospective, randomized clinical trial, 180 patients were assigned to three groups. Two groups received either paracetamol or parecoxib/valdecoxib in addition to piritramid via patient-controlled or nurse-controlled analgesia pump. Patients in the control group received piritramid only. The total piritramid consumption during hospital stay was recorded.

RESULTS

Total opioid consumption was significantly lower in the two groups who received NSAIDs. Comparing conventional and laparoscopic surgery, the latter group had much lower opioid consumption.

CONCLUSION

The use of NSAIDs following colon surgery significantly reduces postoperative opioid consumption.

Enhanced matrix degradation after withdrawal of TGF-beta1 triggers hepatocytes from apoptosis to proliferation and regeneration

TGF-beta1 is a profibrogenic cytokine participating in deposition of extracellular matrix in fibrotic disorders. In liver, its anti-proliferative/apoptotic effect on hepatocytes promotes fibrosis. The tetracycline-controlled double-transgenic TA(LAP-2)/p(tet)TGF-beta1 mouse provides a model for reversible liver fibrosis. In livers of TGF-beta1-expressing mice, hepatocytes showed synchronous apoptosis detected by DNA laddering and active caspase-3 staining that disappeared when expression of transgenic TGF-beta1 was switched off. In these 'off' mice, perisinusoidal liver fibrosis resolved within 21 days accompanied by elevated proliferation of hepatocytes. Here, we have specified the intermediary stages (2-3 days off and 6 days off) in terms of (i) proliferation (by immunohistochemical staining of proliferating cell nuclear antigen and expression of cyclin D1 mRNA) and (ii) extracellular matrix remodelling processes (by measuring mRNA expression of matrix metalloproteinases-2 and -13 (mmp-2 and mmp-13) and tissue inhibitor of matrix metalloproteinases 1 (timp-1) and quantitative morphometric analysis. In summary, we show a rapidly declining timp-1 mRNA level together with lastingly high mmp-2 and mmp-13 mRNA levels after 2-3 days, suggesting that high matrix-degrading potential represents a prerequisite for the markedly enhanced proliferation of hepatocytes in the early stages after switching off transgenic TGF-beta1.

Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials

BACKGROUND

We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques.

METHODS

After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately.

RESULTS

The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations.

CONCLUSION

In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.

Laparoscopic hernia repair?TAPP or/and TEP?

BACKGROUND

Of various endoscopic hernia repair procedures, TAPP and TEP have been selected for routine use.

METHODS

Results from Medline research were analysed.

RESULTS

There is a similar risk for postoperative morbidity for both techniques. The recurrence rate in large single-centre series is between 0% and 3.4%. There were numerous indications for both procedures, whereby a transperitoneal TAPP can also be applied in cases of previous preperitoneal operations.

CONCLUSION

Randomised trials comparing both methods of hernia repair are lacking. Seven non-randomised studies showed no differences in recurrence rate and morbidity. In general the learning curve for is shorter in favour of TAPP repair.

Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials

BACKGROUND

For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest.

METHODS

After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately.

RESULTS

Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different.

CONCLUSION

Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Stellenwert radiärer Reformatierungen in der CT-Diagnostik der Lungenarterienembolie

PURPOSE

To evaluate the diagnostic value of radial reformatting of axial multislice CT (MS-CT) data sets in the presumptive diagnosis of pulmonary embolism.

MATERIALS AND METHODS

In 126 cases with the presumptive diagnosis of an acute pulmonary embolism, 4- and 8-slice axial MS-CT data sets were radially reformatted. The pulmonary vessels were evaluated by five experienced radiologists who determined the number of thrombi at the level of the segmental and subsegmental arteries. A pulmonary artery was considered as thrombosed if it showed at least one unambiguous filling defect on two consecutive sections. It was determined whether the artery was uniformly opacified without filling defects, contained thrombotic material or was completely occluded by a blood clot. Pulmonary vessels that could not be evaluated because of moving artifacts or inadequate opacification were classified as negative. Finally, all experts gave a subjective estimate concerning the simplicity of the diagnosis for both reconstructions.

RESULTS

The diagnosis of thromboembolism at a subsegmental level was significantly different for axial sections and radial reconstruction: at 4-slice CT, 77 subsegmental thromboembolisms were found in axial sections vs. 98.6 in radial reconstructions; at 8-slice CT, 23.6 in axial sections vs. 31.2 in radial reconstructions; and using the combined evaluation, 103.2 in axial sections vs. 130.6 in radial reconstructions, with a significance of p = 0.043. The five judges did not find any significant differences in the number of the blood clots in each pulmonary segment. Concerning the simplicity of the diagnosis, the subjective judgment classified the radial reconstructions as better in 49.7 % and the axial sections as better in 22 %. The radial reconstructions of the 4-slice CT were classified as better in 45.7 % vs. 25 % and the 8-slice CT as better in 66 % vs. 16 %.

CONCLUSION

Using radial multiplanar reformatting of the MS-CT data sets improves significantly the recognition of subsegmental pulmonary embolism.

Changes in negative symptoms and EEG in schizophrenic patients after repetitive transcranial magnetic stimulation (rTMS): an open-label pilot study

The effects of repetitive transcranial magnetic stimulation (rTMS) on schizophrenic negative symptoms (NS) and EEG topography were investigated in this pilot study. 10 patients with predominant NS were treated with 10 Hz rTMS over the left dorsolateral prefrontal cortex for 5 days. For NS ratings, the Scale for the Assessment of Negative Symptoms (SANS) was used. Both ratings and EEG recordings were obtained pre- and post-rTMS. Electrical activity changes were computed by Low Resolution Brain Electromagnetic Tomography. SANS showed an improvement after rTMS, from 49.0 (SD: 10.7) to 44.7 (SD: 11.8) (means). EEG frequency bands were changed fronto-temporally (right) and were mainly decreases in delta- and beta- and increases in alpha1-activity, as well as decreases in beta-activity in the temporal and parieto-occipital regions (left). Although we are aware of the limitations of this study, we assume a slight improvement in NS. The EEG findings refer to a possible neurophysiologic correlate of their improvement after rTMS.

The AESOP robot system in laparoscopic surgery: increased risk or advantage for surgeon and patient?

BACKGROUND

The aim of this study was to examine the advantages and risks of the Automated Endoscopic System for Optical Positioning (AESOP) 3000 robot system during uncomplicated laparoscopic cholecystectomies or laparoscopic hernioplasty.

METHODS

In a randomized study, we examined two groups of 120 patients each with the diagnosis cholecystolithiasis respectively the unilateral inguinal hernia. We worked with the AESOP 3000, a robotic arm system that is voice-controlled by the surgeon. The subjective and objective comfort of the surgeon as well as the course and length of the operation were measured.

RESULTS

The robot-assisted operations required significantly longer preparation and operation times. With regard to the necessary commands and manual camera corrections, the assistant group was favored. The same was true for the subjective evaluation of the surgical course by the surgeon.

CONCLUSIONS

Our study showed that the use of AESOP during laparoscopic cholecystectomy and hernioplasty is possible in 94% of all cases. The surgeon must accept a definite loss of comfort as well as a certain loss of time against the advantage of saving on personnel.

Mitochondrial genotype and risk for Alzheimer's disease: cross-sectional data from the Vienna-Transdanube-Aging "VITA" study

The Vienna Transdanube Aging (VITA) study searches for early markers of Alzheimer's disease (AD) by examining the mental status in a community-based cohort of 606, 75-years old volunteers that are then related to various clinical and genetic analyses. To determine whether mutations in mtDNA are involved in expression of AD, the mtDNA of 79 "control" participants is screened for alterations by sequencing of "hot-spot-regions". This study on mtDNA mutations has eliminated the influence of aging on the occurrence of mtDNA alterations by sequencing samples from persons at the age of exactly 75 years. Thus, our cohort reveals a snap-shot of mitochondrial sequences of elderly persons. So far, a high percentage (56%) of persons with known or unknown mutations in the fragments analyzed were found. These data will be compared in due time to a cohort of participants with proven late-onset AD.

The standard of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy?

METHOD

Literature review.

RESULTS

Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones.

CONCLUSION

The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

Gallenblasensteinleiden?immer eine Operationsindikation?

There is consensus that symptomatic cholecystolithiasis presents an indication for cholecystectomy. Today the surgical method of choice is the laparoscopic technique, which has proven its superiority in numerous randomized studies. Epidemiologic studies showed that 10-15% of all gallstone patients develop complications so that a prophylactic cholecystectomy is repeatedly being discussed. A few older studies based on conventional cholecystectomies, however, showed no decisive advantage for a prophylactic cholecystectomy, but rather clearly higher costs. Therefore a wait-and-see policy is generally recommended for asymptomatic gallstones. The analysis of our large group of patients showed that acute cholecystitis as well as common bile duct stones occur significantly more often with increasing duration of the gallstone disease. The older the patient, the longer the operation time, the more frequent a conversion, and the higher the morbidity of the procedure. Considering the minor impairment of daily activities with the laparoscopic technique, the present concept of treatment for asymptomatic and mildly symptomatic cholecystolithiasis needs to be scrutinized.

Diagnosis and classification of inguinal hernias

BACKGROUND

The aim of this prospective clinical study was to determine whether the presence of a hernia, its size, and its type can be established preoperatively by clinical and ultrasound, examination.

METHODS

The study population comprised 220 consecutive patients referred to our department for the surgical management of an inguinal hernia. On admission, both inguinal regions were examined clinically and by ultrasound. All patients were operated on laparoscopically.

RESULTS

In regard to the intraoperative findings for both inguinal regions, clinical and ultrasound examination for the diagnosis of inguinal hernia yielded a high total rate of accuracy of 93% respective 94%. However, when the same methods were used to differentiate between lateral and medial hernia, the total rate of accuracy fell to only 54% respective 62%. In the determination of inguinal hernia size, it was even lower: 50% respective 53%.

CONCLUSIONS

Although a diagnosis of inguinal hernia can be established reliably by clinical and ultrasound examination, only an approximate classification is possible by these methods.

Endoscopic inguinal hernia repair in comparison with Shouldice and Lichtenstein repair. A systematic review of randomized trials

AIMS

This article provides an overview of randomized studies which compare endoscopic hernia repair techniques (TAPP/TEP) with the Shouldice and Lichtenstein repair.

METHODS

Systematic analysis of 33 published studies which meet the criteria of a randomized controlled trial with a high evidence level.

RESULTS

The majority of the studies document statistically significant advantages of the endoscopic repair techniques in relation to wound pain (15/22), need for analgesics (16/21), return-to-work time (16/22) and physical activity (18/25), although only one study showed significant advantages of the Lichtenstein method. Six of 28 studies showed a lower morbidity in comparison to open approaches, although 22 of 28 studies documented no significant difference. The first long-term studies with follow-up periods between 5 and 6 years also show advantages of the endoscopic techniques.

CONCLUSION

Even with cautious interpretation of the data, it is clear that endoscopic techniques are more comfortable for patients and that morbidity is no higher than for open procedures. Due to the short follow-up periods final evaluation regarding long-term complications and recurrence is not yet possible.

[Atypical Leriche syndrome]

A 73-year old woman presented with mild paraparesis and hypesthesia of the legs. Furthermore, she complained dizziness, fainting and dyspnea. There was a history of peripheral artery disease, diabetes mellitus, arterial hypertension and chronic atrial fibrillation. Five years ago she had breast cancer with removal of the left mamma and additional radiation therapy. Cardiac catheterization at that time demonstrated no significant coronary stenoses. A contrast-enhanced CT-scan excluded lumbal spinal metastases. Instead, a subtotal occlusion of the abdominal aorta was noticed, but was initially interpreted as a chronic thrombosis because there were no typical symptoms and only moderate pain. About 24 hours later the patient developed an acute ischemic syndrome of the legs with progressive paraparesis, cold and pale legs in combination with acidosis and hyperventilation. Color-coded duplex ultrasound showed only a small turbulent flow in the ilial arteries, highly suspicious of a complete occlusion of the distal aorta. Angiography revealed an acute total occlusion of the infrarenal aorta without collaterals. During surgical intervention, complete obstruction of the abdominal aorta above the bifurcation was confirmed. Subsequent embolectomy was performed and an embolus consisting of several layers of different age was extracted. After successful surgical intervention with subsequent clinical improvement, the patient's clinical condition deteriorated a few day later. She died on day 9 after surgery from a complete ischemia of the small intestine and the colon ascendens.

Laparoscopic transperitoneal procedure for routine repair of groin hernia

BACKGROUND

Laparoscopic transperitoneal hernioplasty (TAPP) repair of inguinal hernias is thought to be a difficult surgical technique with high complication rates. The present study evaluated TAPP based on prospective documentation.

METHODS

The primary aim of the study was analysis of the individual learning curve, comparing consultants with trainees. Secondary endpoints included postoperative morbidity, time of disability and rate of recurrence.

RESULTS

A total of 8050 TAPP repairs have been performed since 1993. By 2001, 99.9 per cent of all hernia repairs were done by TAPP. The median operation time dropped from 50 min in the first 600 cases to 42 min thereafter. The morbidity rate decreased from 9.3 to 2.6 per cent, and the rate of recurrence from 4.8 to 0.4 per cent. Within the same interval the proportion of training procedures increased from 1.7 to 44.9 per cent in 2001. Morbidity and recurrence rates were similar for trainees and consultants.

CONCLUSION

TAPP is an effective and safe technique. It can be performed in a standard way for all inguinal and femoral hernias. The present results indicate that TAPP is possible in a routine setting, as well as in the training situation for young surgeons.

Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center

BACKGROUND

We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [transabdominal preperitoneal patch (TAPP)]

METHOD

We employed a prospective consecutive single-center trial lasting from April 1993 to December 2000.

RESULTS

In our study, 5524 consecutive patients underwent 6860 laparoscopic hernia repairs. The median age in group A (unilateral repair, n = 4188) was 58 years (16-94 years), and that in group B (simultaneous bilateral repair, n = 1336) was 60 years (19-97 years) in (simultaneous bilateral repair, n = 1336). Morbidity in group A was 3.2% (135/4188) with a 0.6% reoperation rate (24/4188); in group B morbidity was 5.0% (67/1336) with a 1.4% reoperation rate. (19/1336). Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period (1-84 months) (follow-up rate 93.1%) 38 recurrences were observed in group A (0.9%) and 17 in group B (0.6%; 17/2672) (p = 0.2668). Median time off work was 14 days after unilateral (2-63 days) and 17 days after bilateral repair (3-100 days) (p = 0.1359). Pain levels (numerical analogue scale) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair.

CONCLUSION

Compared to unilateral repair, bilateral simultaneous laparoscopic hernia repair (TAPP) is safe, comfortable for patients, and cost-effective, without increased morbidity or recurrence risk. Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair.

Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study

BACKGROUND

Laparoscopic transperitoneal hernia repair (TAPP) has proved its efficiency in elective surgery. However, TAPP results with incarcerated hernias still are unknown.

METHODS

Data from a prospective study were evaluated with regard to TAPP repair for both chronically and acutely incarcerated hernias.

RESULTS

During a 6-year period, 220 incarcerated hernias were repaired (194 via TAPP). The median operation time for TAPP was 55 min. An accompanying resection therapy became necessary for only four of the emergency cases (11.1%) and two of the chronically incarcerated cases (1.3%) in the TAPP group. Postoperative morbidity was 2.8% in the emergency group and 3.8% in the chronically incarcerated group, which does not differ from the rate for TAPP used on reducible hernias. One recurrence was found 26 months after TAPP reconstruction (0.5%).

CONCLUSION

Laparoscopic inguinal hernia repair (TAPP) represents an efficient therapeutic concept in the treatment of both chronically and acutely incarcerated inguinal hernias.

Mutation analysis in Turkish patients with hereditary fructose intolerance

Thirteen Turkish patients with hereditary fructose intolerance (HFI) were screened for the three common mutations, A149P, A174D and N334K, in the aldolase B gene that have been detected frequently in European population. We found that nine of the patients carry the A149P mutation in both alleles, which corresponds to a frequency of about 55%. Single-strand conformation analysis of all coding exons of the gene was also performed to detect unknown mutations in four patients not carrying the three common mutations. No aberrant migration patterns were observed in these patients.

[Selective pre- intra- and postoperative bile duct diagnosis--an efficient and low complication regimen within the scope of laparoscopic cholecystectomy. Early and late results of a prospective study]

INTRODUCTION

The discussion of diagnostic pre- and intraoperative procedures of the common bile duct (CBD) for laparoscopic cholecystectomy is still open.

METHODS

Results of a prospective study of 4000 laparoscopic cholecystectomies were evaluated, adhering to the concept of selective common bile duct examination. In 1999 an inquiry was performed on 1197 patients an average of 38.7 months postoperatively to judge this concept.

RESULTS

Three hundred and nineteen patients (8%) examined preoperatively by ERC revealing a CBD stone in 126 cases. The morbidity of this procedure was 3.1%. In 0.18% a lesion of the common bile duct was documented following laparoscopic cholecysTectomy. A intraoperative cholangiography was performed in 67 patients (1.7%) because of unclear anatomy or to exclude a CBD stone. Perioperatively a CBD stone was found in 0.5% of cases. Additionally, in 0.3% the same problem occurred in the long-term follow-up, so that the risk for unknown CBD stones following the selective diagnostic concept is 0.8%.

CONCLUSION

The concept of selective diagnostic procedures of the common bile duct shows a low morbidity with sufficient efficiency in avoiding CBD stones as well as duct lesions. Therefore it is recommended for routine use in laparoscopic cholecystectomy.

Clinical and experimental results on cardiac troponin expression in Duchenne muscular dystrophy

BACKGROUND

Because of controversial earlier studies, the purpose of this study was to provide novel experimental and additional clinical data regarding the possible reexpression of cardiac troponin T (cTnT) in regenerating skeletal muscle in Duchenne muscular dystrophy (DMD).

METHODS

Plasma from 14 patients (mean age, 7.5 years; range, 5.7-19.4 years) with DMD was investigated for creatine kinase (CK), the CK MB isoenzyme (CKMB), cTnT and cardiac troponin I (cTnI), and myoglobin. cTnT concentrations were measured by an ELISA (second-generation assay; Roche) using the ES 300 Analyzer. cTnI, myoglobin, and CKMB were measured by an ELISA using the ACCESS System (Beckman Diagnostics). Troponin isoform expression was studied by Western blot analysis in remnants of skeletal muscle biopsies of three patients with DMD and in an animal model of DMD (mdx mice; n = 6).

RESULTS

There was no relation of cTnT and cTnI to clinical evidence for cardiac failure. cTnI concentrations remained below the upper reference limit in all patients. cTnT was increased (median, 0.11 microg/L; range, 0.06-0.16 microg/L) in 50% of patients. The only significant correlation was found for CK (median, 3938 U/L; range, 2763-5030 U/L) with age (median, 7.5 years; range, 6.8-10.9 years; r = -0.762; P = 0.042). Western blot analysis of human or mouse homogenized muscle specimens showed no evidence for cardiac TnT and cTnI expression, despite strong signals for skeletal muscle troponin isoforms.

CONCLUSIONS

We found no evidence for cTnT reexpression in human early-stage DMD and in mdx mouse skeletal muscle biopsies. Discrepancies of cTnT and cTnI in plasma samples of DMD patients were found, but neither cTnT nor cTnI plasma concentrations were related with other clinical evidence for cardiac involvement.

Complex mitochondriopathy associated with 4 mtDNA transitions

In a 33-year-old man, mitochondriopathy was diagnosed upon short stature, auditory impairment, gynaecomastia, hypogonadism, vertical ophthalmoplegia, cerebral atrophy, leucencephalopathy, cataract, hypertrabeculated left ventricle, hypothyroidism, diabetes mellitus, glomerulonephritis necessitating kidney transplantation, general wasting, polyneuropathy, abnormally high lactate levels on exercise, partially reduced cytochrome-c oxidase staining and abnormally structured mitochondria on muscle biopsy. Mitochondrial DNA (mtDNA) analysis revealed 1 novel (A15662G) and 3 known mtDNA transition(s) (T3398C, T4216C, G15812A) affecting the cytb and ND1 gene, respectively. Three of the patient's transitions were also detected in blood leukocytes of the patient's maternal grandmother, mother and brother. Mutant mtDNA was heteroplasmic at >75% in the patient's skeletal muscle.

Update: what is left for laparoscopic hernia repair?

The risks, benefits and costs of laparoscopic hernia repair are still being debated. According to a current survey on the situation of hernia surgery in Germany in 1996, laparoscopic hernioplasty was done in about 60% of the answering hospitals; about a quarter of all hernia repairs are done laparoscopically. Since April 1993, about 2, 700 laparoscopic hernia repairs were done at Marienhospital Stuttgart. The operating time was on the average 50 min. The rate of complications was about 3%. The postoperative period of disablement was a median of 20 days; included in this time was the postoperative hospital stay. The recurrence rate was about 1%. It is remarkable that laparoscopic hernia repair was equally efficient in repairing unilateral primary hernias, recurrent hernias or bilateral hernias. The cost analysis showed that the application of multipath articles will make the operation costs of laparoscopic hernia repair only about DM 100 higher than for a conventional operation.

[Laparoscopic hernia therapy (TAPP) as a teaching operation]

INTRODUCTION

Because of an increasing number of endoscopic hernia procedures, it is important to look into the possibility of standardizing these techniques helping surgeons to acquire the operative skills necessary.

MATERIAL AND METHODS

To discuss these aspects, the documented data on TAPP operations that have been carried out in this department since 1993 were analyzed. The results of teaching procedures were compared with those of experts after they had gotten past the learning and development curve.

RESULTS

A total of 778 teaching procedures were performed by 10 surgeons with an individual experience of 30.5 operations (median). Before starting the first procedure, 89 were done by assistants operating the camera. The morbidity of teaching operations was 1.9% compared to 1.4% for those performed by experts. After a median follow-up of 23 months there were two recurrences (0.23%) in the expert group and none in the teaching group (follow-up 16 months).

CONCLUSION

Because of the potentials of standardization of the TAPP technique, the results of teaching were equal to expert operations. Therefore, TAPP is suitable for application in a routine setting.

Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation

BACKGROUND

Even though the introduction of endoscopic surgical techniques to inguinal hernia therapy dates back 10 years, only a few data exist concerning the problem of development of a recurrence after endoscopic repair. Similarly there are only anecdotal reports on the feasibility of an endoscopic reintervention for this situation. For the first time we are able to present data of a prospective study on both issues.

STUDY DESIGN

We analyzed the data of a prospectively documented series of 46 transperitoneal hernia repair reinterventions after endoscopic hernia repair. In 33 patients from our own clinic we evaluated the cause of recurrence after transperitoneal hernia repair. Together with these and 13 more patients sent to us from external clinics we examined the efficiency of an endoscopic reoperation.

RESULTS

When implanting a 13 x 8-cm mesh with an incision (phase I) we found the main cause of recurrence to be that the mesh was too small (47.4%) and the region of the mesh incision was insufficient (42.1%). After a change to a 15 x 10-cm implant without incision (phase II) the main cause of recurrence was found to be a mesh dislocation (38.9%) and the rate of recurrence dropped from 2.8% (phase I) to 0.36% (phase II). The transperitoneal reoperation lasted for a median of 75 minutes (range 45 to 170 minutes) for the medial recurrence and a median of 110 minutes (range 65 to 190 minutes) for the lateral recurrence (p = 0.009). The total rate of complications was 10.9%, and the rate of re-recurrence was 0% after a median followup of 26 months (range 2 to 72 months).

CONCLUSIONS

To avoid hernia recurrence after transperitoneal hernia repair operations a sufficiently large mesh (at least 15 x 10 cm) has to be implanted, preferably without an incision, after an extensive parietalization. The endoscopic reoperation for recurrence can be done only in a transperitoneal way and is effective with comparably low complication rates. The procedure is significantly easier for a medial recurrence compared with a lateral recurrence. This method of reoperation should be reserved for endoscopically experienced surgeons.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair

BACKGROUND

At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment.

METHODS

In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction.

RESULTS

The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair.

CONCLUSION

Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.