A methodological protocol for the development of a national guideline on perioperative management of gastrointestinal tumors in Germany

BACKGROUND

The success of abdominal cancer surgery depends not only on the surgery itself but is influenced by the overall perioperative management. Given the multitude of perioperative measures and the ever-increasing number of studies on perioperative management, it is difficult to keep track and provide evidence-based perioperative management. The planned guideline on perioperative management will review the existing evidence and derive treatment recommendations.

METHODS

The processing of the evidence is carried out by 6 working groups according to an 8-step scheme: after drafting the guideline questions in PICO format (1), a systematic literature search is carried out (2), and the records found are screened by two independent reviewers from the coordination team. Subsequently, the full texts of the potentially relevant articles are made available to the working groups for full text screening (3). All articles to be included are reviewed for methodological quality (4) before summary of findings tables are generated (5). In line with the GRADE approach, confidence in the evidence is assessed (6) before a recommendation is derived from the evidence, using a modified GRADE Evidence to Decision Framework (7). Finally, all recommendations are compiled and agreed within the guideline group (8).

DISCUSSION

Guidelines serve as foundation for therapy decisions in everyday clinical practice and should therefore be based on up-to-date research results. However, while primary studies and systematic reviews are critically reviewed for their methodological quality, the process of guideline development is often not comprehensible. A protocol with predefined methodology should therefore create transparency and strengthen confidence in the recommendations.

TRIAL REGISTRATION

The guideline is registered in the AWMF (Association of the Scientific Medical Societies) Guideline Register (088-010OL).

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Liquid Chromatographic Determination of Major Organic Acids in Apple Juice and Cranberry Juice Cocktail: Collaborative Study

Twelve laboratories collaboratively studied a liquid chromatographic method for determination of quinic, malic, and citric acids in cranberry juice cocktail and apple juice. Samples are passed through a disposable silica cartridge, filtered, and directly injected into the chromatograph. The mobile phase is 0.2M KH2PO4 (pH 2.4). Two reverse phase columns are used, with UV detection at 214 nm. Six samples of cranberry juice cocktail and 6 samples of apple juice were sent to each collaborator. Repeatability and reproducibility coefficients of variation ranged from 1.2 to 7.6% and from 2.9 to 14.7%, respectively, for quinic, malic, and citric acid levels above 0.10%. The precision of the method is satisfactory. The method has been adopted official first action.

Determination of Patulin in Apple Juice by Liquid Chromatography: Collaborative Study

An AOAC International-International Union of Pure and Applied Chemistry-International Fruit Juice Union (AOAC-IUPAC-IFJU) collaborative study was conducted to evaluate a liquid chromatographic (LC) procedure for determination of patulin in apple juice. Patulin is a mold metabolite found naturally in rotting apples. Patulin is extracted with ethyl acetate, treated with sodium carbonate solution, and determined by reversed-phase LC with UV detection at 254 or 276 nm. Water, water-tetrahydrofuran, or water-acetonitrile was used as mobile phase. Levels determined in spiked test samples were 20, 50,100, and 200 μg/L. A test sample naturally contaminated at 31 μg/L was also included. Twenty-two collaborators in 10 countries analyzed 12 test samples of apple juice. Recoveries averaged 96%, with a range of 91-108%. Repeatability relative standard deviations (RSDr) ranged from 10.9 to 53.8%. The reproducibility relative standard deviation (RSDR) ranged from 15.1 to 68.8%. The LC method for determination of patulin in apple juice has been adopted first action by AOAC INTERNATIONAL.

[Transanal total mesorectal excision-a critical appraisal]

INTRODUCTION

Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence.

METHOD

The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken.

RESULTS

A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME.

CONCLUSION

Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

[Globalization: challenges in abdominal surgery for migrants and refugees]

The increasing number of refugees, migrants and international travelers influences the surgical spectrum of abdominal diseases. The aim of this review is to familiarize surgeons with specific diseases which are endemic in the patients' countries of origin and are likely to be diagnosed with increasing incidence in Germany. Low levels of hygiene in the countries of origin or refugee camps is associated with a high incidence of numerous infections, such as helminth infections, typhoid fever or amoebiasis, which if untreated can cause surgical emergencies. Historically, some of them were common in Germany but have been more or less eradicated because of the high socioeconomic standard. Echinococcosis and Chagas disease are frequently treated surgically while schistosomiasis can mimic intestinal cancer. Abdominal tuberculosis presents in a variety of abdominal pathologies and frequently causes diagnostic uncertainty. Sigmoid volvulus has a very low incidence among Europeans, but is one of the most common abdominal surgical conditions of adults in endemic countries. The number of patients who eventually undergo surgery for these conditions might be relatively low; however, surgeons must be aware of them and consider them as differential diagnoses in refugees and migrants with acute or chronic abdominal symptoms.

[Quality indicators for colon cancer surgery : Evidence-based development of a set of indicators for the outcome quality]

BACKGROUND

Quality assessment in surgery is gaining in importance. Although sporadic recommendations for quality indicators (QI) in oncological colon surgery can be found in the literature, these are usually not systematically derived from a solid evidence base. Moreover, reference ranges for QI are unknown.

OBJECTIVE

The aim of this initiative was the development of evidence-based QI for oncological colon resections by an expert panel invited by the German Society of General and Visceral Surgery (DGAV). Reference ranges from the literature and reference values from the Study, Documentation, and Quality Center (StuDoQ)|Colon Cancer Register were compared in order to deduce recommendations which are tailored to the German healthcare system.

RESULTS

Based on the most recent scientific evidence and agreed by expert consensus, five QI for oncological colon surgery were defined and evaluated according to the QUALIFY tool. Mortality, MTL30 (mortality, transfer to another acute care hospital, or length of stay ≥30 days), anastomotic leakage requiring reintervention, surgical site infections necessitating reopening of the wound and ≥12 lymph nodes in the specimen qualified as QI owing to their relevance, scientific nature, and practicability. Based on the results of the systematic literature search and the statistical analysis of the StuDoQ|Colon Cancer Register, preliminary reference values are proposed for each QI.

CONCLUSION

The presented set of QI seems appropriate for quality assessment of oncological colon surgery in the context of the German healthcare system. The validity of the QI and the reference values must be reviewed within the framework of their implementation. The StuDoQ|Colon Cancer Register provides a suitable infrastructure for collecting clinical data for quality assessment and risk adjustment.

Efficacy of Community-Based Exercise Therapy Among African American Patients With Peripheral Artery Disease: A Randomized Clinical Trial

IMPORTANCE

African American individuals are 2 times more likely than non-Hispanic white individuals to have peripheral artery disease (PAD). Structured community-based exercise therapy improves walking distance among patients with PAD, but these patients require motivation to adhere to therapy.

OBJECTIVE

To assess whether motivational interviewing (MI) is more efficacious than Patient-Centered Assessment and Counseling for Exercise (PACE) or control to improve walking distance in African American patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

In this 3-group randomized clinical trial, 174 African American patients with PAD were studied from May 1, 2012, to November 30, 2016, at health care centers, churches, and health fairs in Wichita, Kansas; Kansas City, Kansas, and Kansas City, Missouri.

INTERVENTIONS

Patients were randomized in a 1:1:1 fashion to 1 of 3 groups (57 to MI, 57 to PACE, and 60 to control). The 2 counseling interventions were delivered biweekly for 3 months and monthly for 3 months followed by a 6-month maintenance phase with limited contact. Control participants received a mailing at 3 and 9 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was 6-month change in 6-minute walking performance. Secondary outcomes included 12-month change in walking performance and 6- and 12-month changes in quality of life.

RESULTS

A total of 174 African American patients (mean [SD] age, 64.2 [11.2] years; 128 [74.0%] female) were studied. At 6 months, mean (SE) change in walking distance by group was as follows: MI, -3.42 (4.55) m; PACE, 2.74 (6.00) m; and control, -0.18 (4.40) m. At 12 months, mean (SE) change in walking distance by group was as follows: MI, -7.75 (5.50) m; PACE, 13.75 (6.13) m; and control, -1.08 (5.73) m. Comparing each of the intervention arms (MI and PACE) with the control arm, no statistically significant increases in walking distance at 6 months (MI: change, -2.10 m; 95% CI, -16.54 to 12.35 m; PACE: change, 2.31 m; 95% CI, -11.36 to 15.97 m) or 12 months (MI: change, -5.56 m; 95% CI, -21.18 to 10.06 m; PACE: change, 14.24 m; 95% CI, -1.85 to 30.34 m) were found. Compared with MI, PACE resulted in a statistically significant increase in walking distance at 12 months of 19.80 m (95% CI, 3.33-36.28 m).

CONCLUSIONS AND RELEVANCE

In a cohort of African American patients with PAD, MI was not efficacious in improving walking distance at 6 or 12 months. The results of this study do not support the use of MI to improve walking performance in African American patients with PAD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01321086.

Evaluation of the New ISGLS Definitions of Typical Posthepatectomy Complications

Background and Objectives:

The International Study Group of Liver Surgery established the first internationally standardized definitions and grading for posthepatectomy hemorrhage, posthepatectomy liver failure, and bile leakage. We aimed to correlate these definitions and grades of complications with objective parameters of the postoperative course, namely, mortality and length of stay, to assess the usefulness in clinical routine.

Methods:

A total of 415 patients underwent hepatic surgery between 2004 and 2014. Uni- and multivariate analyses were made for correlations of posthepatectomy hemorrhage, posthepatectomy liver failure, and bile leakage with perioperative parameters and mortality.

Results:

Of the total, 25 (6.1%) patients developed a posthepatectomy hemorrhage Grade A, 3 (0.7%) patients a posthepatectomy hemorrhage Grade B, and 1 (0.2%) patient a posthepatectomy hemorrhage Grade C; 23 (5.5%) patients had a posthepatectomy liver failure Grade A, 24 (5.8%) patients a posthepatectomy liver failure Grade B, and 7 patients (1.6%) a posthepatectomy liver failure Grade C. Bile leakage Grade A occurred in 10 (2.4%) patients, bile leakage Grade B in 24 (5.8%) patients, and bile leakage Grade C in 7 (1.6%) patients. Mortality was significantly increased in patients with posthepatectomy hemorrhage Grades B and C and in patients with posthepatectomy liver failure Grades A, B, and C. Three (42.9%) patients with bile leakage Grade C died.

Conclusion:

Our data indicate that the new definitions correlate well with mortality and duration of hospital stay.

Characterization of a lung epithelium specific E-cadherin knock-out model: Implications for obstructive lung pathology

The airway epithelium regulates responses to aeroallergens, acting as a physical and immunological barrier. In asthma, epithelial barrier function and the expression of adherens junction protein E-cadherin is compromised, but it is unknown whether this is cause or consequence of the disease. We hypothesized that airway epithelial loss of E-cadherin is a critical step in the development of manifestations of asthma. We generated a transgenic mouse model with conditional loss of E-cadherin in lung epithelial cells at birth and onwards. We observed normal lung development at the time of birth in mice lacking E-cadherin in the lung epithelium. However, E-cadherin deficiency led to progressive epithelial damage in mice growing into adulthood, as evidenced by airway epithelial denudation, decreased zonula occludens (ZO)-1 expression, loss of ciliated cells, and enlarged alveolar spaces. In addition, spontaneous goblet cell metaplasia with mucus production was observed. These epithelial changes were accompanied by elevated levels of the epithelial-derived chemokine CCL17, infiltration of eosinophils and dendritic cells, and mucus production. In conclusion, loss of E-cadherin induces features in the lung reminiscent of those observed in asthma, indicating that the disruption of E-cadherin-mediated cell-cell contacts may play a key role in the development of asthma manifestations.

[The Kono-S anastomosis in surgery for Crohn's disease : First results of a new functional end-to-end anastomotic technique after intestinal resection in patients with Crohn's disease in Germany]

BACKGROUND

Recurrent disease at the anastomotic site after bowel resection represents a major problem in patients with Crohn's disease. In 2011, a new anastomotic technique (Kono-S anastomosis) was published, which as a functional end-to-end anastomosis creating a wide anastomotic diameter aimed to reduce the rate of recurrence after surgery.

AIM

To evaluate the Kono-S anastomosis with respect to early and late postoperative complications and recurrence rate after surgical intestinal resection in patients with Crohn's disease at a university center.

PATIENTS AND METHODS

All patients with Crohn's disease who underwent Kono-S anastomoses between June 2015 and December 2016 at the Department of Surgery, University Medical Centre Mannheim, were included in the study. After obtaining informed consent, patient data regarding surgery and hospital stay were recorded in a prospective database. Follow-up was carried out by structured telephone interviews including disease progression, medication and surveillance. Statistical analysis was performed using the Graph Pad Prism 7 software. Ethics board approval was obtained from the Medical Ethics Commission II of the Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany (No. 2017-575N-MA).

RESULTS

A total of 53 patients (32 female and 21 male) were included in this study. The median procedural time was 157 min. The median follow-up was 12 months (range 4-23 months). Of the patients 3 developed early postoperative complications with a Clavien-Dindo score ≥ III and 25 patients with or without symptoms were controlled by endoscopy and/or magnetic resonance imaging (MRI) and no anastomotic recurrence was detected. No endoscopic interventions were necessary and 16 patients were symptom-free with no further specific therapy or controls.

DISCUSSION

The Kono-S anastomosis is a safe anastomotic method with low morbidity. In the early follow-up recurrence rates of Crohn's disease at the anastomotic site were low. In the literature a reoperation rate of 5 % per year is given for patients with Crohn's disease after intestinal resection, so that in the long-term observation a valid statement on recurrence rate is possible. A potential advantage of the morphological end-to-end configuration of the Kono-S anastomosis is the better endoscopic dilatation compared to a side-to-side anastomosis.

CONCLUSION

The Kono-S anastomotic technique has a low morbidity. In the early follow-up observational period no recurrence occurred in the anastomosis area in this series. Long-term data must clarify whether this technique is advantageous with respect to this aspect in the long run.

Survival after resection of appendiceal carcinoma by hemicolectomy and less radical than hemicolectomy: a population-based propensity score matched analysis

AIM

The operative treatment for non-metastatic appendiceal carcinoma is controversial despite the recommendation of right hemicolectomy (RH) by many researchers. The aim of this population-based study was to compare outcomes after RH and less radical resection than right hemicolectomy (LRH).

METHOD

A total of 1144 patients who underwent resection with additional lymphadenectomy of Stages I-III appendiceal carcinoma from 2004 to 2012 were identified in the Surveillance, Epidemiology and End Results database. Overall survival (OS) and cancer-specific survival (CSS) after RH and LRH were assessed by unadjusted and risk-adjusted Cox regression analysis and by propensity score matched analysis.

RESULTS

A total of 855 (74.7%) patients underwent RH and 289 (25.3%) underwent LRH. In an unadjusted analysis, survival after LRH and RH did not differ in OS [hazard ratio (HR) 0.95, 95% CI 0.71-1.26, P = 0.707] and CSS (HR 0.95, 95% CI 0.69-1.32, P = 0.762). The 5-year OS and CSS in patients who underwent RH were 71.6% (95% CI 67.8-75.6%) and 76.4% (95% CI 72.8-80.3) compared with 73.8% (95% CI 67.9-80.2) and 78.7% (95% CI 73.2-84.7) in patients with LRH, respectively. No relevant difference in survival between LRH and RH could be observed in a multivariable analysis (OS, HR 0.90, 95% CI 0.65-1.25, P = 0.493; CSS, HR 0.87, 95% CI 0.60-1.26, P = 0.420) and after propensity score adjusted analysis (OS, HR 0.87, 95% CI 0.62-1.22, P = 0.442; CSS, HR 0.97, 95% CI 0.67-1.40, P = 0.883).

CONCLUSIONS

In this retrospective analysis, survival after RH for non-metastatic appendiceal carcinoma was not statistically significantly superior to LRH. Hence, LRH with lymphadenectomy might be sufficient for treatment of non-metastatic appendiceal carcinoma.

Preoperative hypoalbuminemia is an independent risk factor for increased high-grade morbidity after elective rectal cancer resection

PURPOSE

This study investigated the association of preoperative hypoalbuminemia and postoperative complications after elective resection for rectal cancer.

METHODS

From September 2009 to December 2014, all patients who underwent elective rectal resection for adenocarcinoma of the rectum were identified using a prospective colorectal cancer database. Hypoalbuminemia was defined as a serum albumin < 35 g/L. Characteristics and outcomes of hypoalbuminemic patients were compared to those of patients with normal albumin levels. Potential risk factors for postoperative major morbidity, defined as Clavien-Dindo ≥ grade 3, were analyzed by both univariate and multivariate analyses.

RESULTS

Three hundred seventy patients met the inclusion criteria. Hypoalbuminemic patients (67/370 (18%)) were significantly older and had more advanced tumor stages and more comorbidities (more ASA III, higher percentage of diabetics). Furthermore, they were more likely to undergo abdominoperineal resection instead of low anterior resection and less likely to be operated laparoscopically. On univariate analysis, a higher BMI, advanced tumor stages, diabetes, open procedures, pre- and postoperative hypoalbuminemia, a higher decrease in albumin (∆ preop-postop), and conversion were significantly associated with postoperative high-grade morbidity. On multivariate analysis, diabetes, advanced tumor stages, a higher decrease in the albumin level, as well as preoperative hypoalbuminemia turned out to be independent risk factors for postoperative high-grade morbidity.

CONCLUSIONS

Hypoalbuminemia is an independent risk factor for postoperative high-grade morbidity. As a low-cost and easy accessible test, serum albumin should be used as a prognostic tool to detect patients at risk for adverse outcomes after resection for rectal cancer.

Genetic structure of West Greenland populations of lumpfish Cyclopterus lumpus

In this study, 11 microsatellite markers were used to determine the structure of West Greenlandic lumpfish Cyclopterus lumpus populations across six spawning locations spanning >1500 km and compared with neighbouring populations in Canada and Iceland. To evaluate whether data allow for identification of origin of C. lumpus in Greenlandic waters, genetic assignment analysis was performed for 86 C. lumpus sampled on a feeding migration. Significant structuring with isolation by distance was observed in the West Greenland samples and two major subpopulations, north and south, were suggested. Based on F_ST values, closer relationships were observed between Greenland and Canada, than Greenland and Iceland. Surprisingly, the North Greenland population showed more similarities with Canadian samples, than did the geographically closer south-west Greenland population. Origin could be assigned for a high proportion of non-spawning fish and demonstrated a marked east-west spatial separation of fish of Greenlandic and Icelandic genotypes.

Long-term functional outcome of colonic resections: how much does faecal impairment influence quality of life?

AIM

Older data suggest that colonic resection has a negative impact on continence and quality of life. The aim of this study was to evaluate the functional outcome of colonic resections for colonic cancer and diverticulitis and its influence on quality of life.

METHODS

Patients who underwent colonic resection between 2005 and 2013 were identified from a prospective database. A survey with two questionnaires [Faecal Incontinence Quality of Life (FIQL) scale, Short Form 12 (SF-12)] and additional questions concerning bowel function was sent to all patients.

RESULTS

Colonic resection was performed in 362 patients in the study period; 297 patients returned the questionnaires (response rate 82.0%). Faecal urgency or incontinence more than once a month was present in 15% of patients and 25% of patients reported that bowel symptoms limited their quality of life. The mean total FIQL score for all patients was 3.58. The SF-12 score was comparable to a reference population without prior colonic resection. Patients after right-sided resections had liquid stool more often than others (45.3% vs 38.7%, P = 0.011). No differences in bowel function and quality of life were detected between resections for colonic cancer and diverticulitis.

CONCLUSION

Most patients experience no limitation in bowel function after segmental colectomy. Those with limitations in bowel function still seem to cope well, as the quality of life is not severely affected. Nevertheless, most patients with lower functional scores also had lower quality of life scores. Whether surgery is a relevant factor has to be questioned, as the prevalence of faecal incontinence in a comparable population without prior surgery is almost identical.

Anaesthesia for elective inguinal hernia repair in rural Ghana - appeal for local anaesthesia in resource-poor countries

Local anaesthesia has been identified as the most favourable anaesthesia for elective inguinal hernia repair with respect to complication rate, cost-effectiveness, and overall patient satisfaction.

Operation theatre notes in all seven hospitals in the Northern Region in Ghana over the period of 1 year were reviewed. Only 22.4% out of 1038 repairs were performed under local anaesthesia while predominantly spinal and general anaesthesia were used (48.0 and 29.6%, respectively). African surgeons chose local anaesthesia far less frequently than visiting overseas surgeons (15.6 versus 27.7%, respectively).

All surgeons in resource-poor countries should be encouraged to use local anaesthesia more frequently for elective inguinal hernia repair. Valuable resources in sub-Saharan African hospitals could be saved, especially if used in combination with outpatient surgery.

The technique should be taught in teaching institutions. A simple step-by-step technique is described.

[Obstacles and facilitators of conducting studies - the perspective of colorectal cancer centers' coordinators]

INTRODUCTION

Clinical trials and health services research are crucial pillars for improving patient care. This paper examines factors inhibiting and promoting the study activity and the knowledge and use of trial registries (e. g. DRKS, StudyBox) as an opportunity to learn about existing studies.

MATERIAL AND METHODS

The coordinators of 274 cancer center sites certified according to the requirements of the German Cancer Society were surveyed using a standardized online questionnaire. Data were analyzed using descriptive and bivariate statistics to identify associations with characteristics of the sites (e. g. patient volume, ownership, teaching status).

RESULTS

176 sites participated in the survey (64.2 %). The central obstacle to study participa-tion from the centers' view is the low number of existing studies. General knowledge of the population about studies was considered low. Trial registries are known to almost all respondents, but are rarely used.

DISCUSSION

The results of the survey suggest that comprehensive measures are needed to sustainably increase the study activity. These include, for example, better information about studies, for example through appropriate databases, and (industry-independent) research funding. One possible way to sensitize patients for studies could be the comprehensive education of the population about the purpose of studies.

A pilot single-centre randomized trial assessing the safety and efficacy of lateral pararectus abdominis compared with transrectus abdominis muscle stoma placement in patients with temporary loop ileostomies: the PATRASTOM trial

AIM

Transrectal stoma placement is considered the standard technique for positioning a stoma. A prospective series using a novel method of lateral pararectal stoma placement recently revealed a remarkably low stoma herniation rate. A randomized trial was conducted to compare the lateral pararectal with the transrectal stoma position with regard to parastomal herniation, stoma-related morbidity and quality of life.

METHOD

Adult patients undergoing elective placement of a temporary loop ileostomy were eligible for inclusion. Patients were intra-operatively randomized to undergo either a lateral pararectal or a transrectal ileostomy. The primary end-point was the rate of parastomal herniation. Secondary end-points included other stoma-related complications and quality of life. Sample size calculation resulted in 54 patients having to be analysed to detect a difference of parastomal herniation of 30% with an 80% power and a 5% significance level. The trial was registered with the German Clinical Trials Register (registration number DRKS00003534).

RESULTS

Between April 2012 and April 2014, 30 patients were randomized to each group. The incidence of parastomal herniation did not differ between the lateral pararectal (5 of 27) and the transrectal group (4 of 29; P = 0.725). There was also no significant difference regarding other stoma-related complications and the EORTC quality of life scales C30 and CR29.

CONCLUSION

The incidence of parastomal herniation and other stoma-related complications did not differ between the groups. However, due to the limited sample size a small difference in favour of one of the two stoma placement techniques cannot be entirely ruled out.

Micromachined Fused Silica Liquid Core Waveguide Capillary Flow Cell

A planar, chip-based flow cell for UV-vis absorbance detection in HPLC is presented. The device features a microfabricated free-standing liquid core waveguide (LCW) capillary detection tube of long path length that is based on total internal reflection. We report on the linearity and calibration slope characteristics of lithographically produced LCWs with different interior/exterior geometries. 3D ray tracing was indispensable in modeling behavior in the more demanding geometries: multipath behavior may be intrinsic to these waveguides with consequent nonlinearity. Fortunately, nonlinearity in lithographically easy-to-produce waveguide geometries (such as with a flat, concave exterior and a round interior) is not as detrimental as might be initially expected. Experimental performance is predictably affected by the attainable surface quality of the LCW and efficient and reproducible coupling of the input light into the LCW.

ADAM10 mediates the house dust mite-induced release of chemokine ligand CCL20 by airway epithelium

BACKGROUND

House dust mite (HDM) acts on the airway epithelium to induce airway inflammation in asthma. We previously showed that the ability of HDM to induce allergic sensitization in mice is related to airway epithelial CCL20 secretion.

OBJECTIVE

As a disintegrin and metalloprotease (ADAM)s have been implicated in chemokine shedding, we sought to determine their involvement in HDM-induced release of chemokines, including CCL20, by airway epithelial cells.

METHODS

We studied the effects of pharmacological ADAM inhibitors as well as ADAM10 and ADAM17 siRNA downregulation on chemokine release using (multiplex) ELISA in supernatants from HDM-exposed human bronchial epithelial 16HBE cells and primary normal human bronchial epithelial cells (NHBE) at 4-24 h.

RESULTS

House dust) mite markedly increased CCL20 levels in both 16HBE and NHBE cells (16-24 h). In 16HBE cells, the HDM-induced increase was observed as early as 4 h upon exposure and the use of specific inhibitors indicated the involvement of ADAM10/17-mediated shedding. siRNA knockdown of ADAM10, but not of ADAM17, significantly reduced the HDM-induced release of CCL20 in both 16HBE and NHBE cells. A similar effect was observed for HDM-induced CCL2, CCL5, and CXCL8 release in NHBE cells. The HDM-induced increase in CCL20 levels was not affected by protein synthesis inhibitor cycloheximide nor protein transport inhibitor monensin, indicating that HDM induces surface shedding of chemokines.

CONCLUSION

Our data show for the first time that ADAM10 activity contributes to HDM-induced shedding of chemokines, including CCL20. The ADAM10/CCL20 axis may be a target for novel therapeutic strategies in asthma.

Ischemic and injured bowel evaluation by Fluorescence imaging

AIM

Although fluorescence has been proposed for estimation of bowel perfusion decades ago it is still not widely used. In emergency situations like mesenteric ischemia, fluorescence might give objective criteria to evaluate the perfusion and guide the decisions of surgeons.

METHOD

The use of near-inrafrared angiography by PinPoint (Novadaq) in a serial of four emergency situations of acute mesenteric ischemia has been evaluated in a university hospital setting.

RESULTS

The use of the near-infrared tool is in emergency situations easy to handle and little time-consuming. The angiography showed clearly the perfusion in regions that were not estimated as recoverable by the surgeons. In one of the cases a significant amount of bowel could be spared by use of the system.

CONCLUSION

Although the assessment of the perfusion with the applied system is comprehensible, it would be desirable to evaluate a threshold level in order to further objectify it. While the surgeons who used the tool were subjectively assured by the expressiveness it would need a randomized and maybe experimental setting to evaluate objectively the amount of spared bowel length.

Accumulation of small hyaluronan oligosaccharides in tumour interstitial fluid correlates with lymphatic invasion and lymph node metastasis

BACKGROUND

Association studies have implicated the glycosaminoglycan hyaluronan (hyaluronic acid, HA) and its degrading enzymes the hyaluronidases in tumour progression and metastasis. Oligosaccharides of degraded HA have been ascribed a number of biological functions that are not exerted by high-molecular-weight HA (HMW-HA). However, whether these small HA oligosaccharides (sHA) have a role in tumour progression currently remains uncertain due to an inability to analyse their concentration in tumours.

METHODS

We report a novel method to determine the concentration of sHA ranging from 6 to 25 disaccharides in tumour interstitial fluid (TIF). Levels of sHA were measured in TIF from experimental rat tumours and human colorectal tumours.

RESULTS

While the majority of HA in TIF is HMW-HA, concentrations of sHA up to 6 μg ml(-1) were detected in a subset of tumours, but not in interstitial fluid from healthy tissues. In a cohort of 72 colorectal cancer patients we found that increased sHA concentrations in TIF are associated with lymphatic vessel invasion by tumour cells and the formation of lymph node metastasis.

CONCLUSIONS

These data document for the first time the pathophysiological concentration of sHA in tumours, and provide evidence of a role for sHA in tumour progression.

Multi-parametric MRI of rectal cancer - do quantitative functional MR measurements correlate with radiologic and pathologic tumor stages?

PURPOSE

The purpose of this study is two-fold. First, to evaluate, whether functional rectal MRI techniques can be analyzed in a reproducible manner by different readers and second, to assess whether different clinical and pathologic T and N stages can be differentiated by functional MRI measurements.

MATERIALS AND METHODS

54 patients (38 men, 16 female; mean age 63.2 ± 12.2 years) with pathologically proven rectal cancer were included in this retrospective IRB-approved study. All patients were referred for a multi-parametric MRI protocol on a 3 Tesla MR-system, consisting of a high-resolution, axial T2 TSE sequence, DWI and perfusion imaging (plasma flow -s PFTumor) prior to any treatment. Two experienced radiologists evaluated the MRI measurements, blinded to clinical data and outcome. Inter-reader correlation and the association of functional MRI parameters with c- and p-staging were analyzed.

RESULTS

The inter-reader correlation for lymph node (ρ 0.76-0.94; p<0.0002) and primary tumor (ρ 0.78-0.92; p<0.0001) apparent diffusion coefficient and plasma flow (PF) values was good to very good. PFTumor values decreased with cT stage with significant differences identified between cT2 and cT3 tumors (229 versus 107.6 ml/100ml/min; p=0.05). ADCTumor values did not differ significantly. No substantial discrepancies in lymph node ADCLn values or short axis diameter were found among cN1-3 stages, whereas PFLn values were distinct between cN1 versus cN2 stages (p=0.03). In the patients without neoadjuvant RCT no statistically significant differences in the assessed functional parameters on the basis of pathologic stage were found.

CONCLUSION

This study illustrates that ADC as well as MR perfusion values can be analyzed with good interobserver agreement in patients with rectal cancer. Moreover, MR perfusion parameters may allow accurate differentiation of tumor stages. Both findings suggest that functional MRI parameters may help to discriminate T and N stages for clinical decision making.

Recurrence after endoscopic mucosal resection-therapy failure?

PURPOSE

To evaluate the success and complication rates of endoscopic mucosal resections (EMR) for large flat adenomas and to identify risk factors for adenoma recurrence.

METHODS

We evaluated all consecutive patients treated with EMR at our institution between 2003 and 2005 that fulfilled the following criteria: >10-mm diameter, Paris 0-Is and 0-IIa-c, and endoscopic follow-up. We conducted univariate analysis and multivariate analysis using a non-stratified logistic regression model to identify possible influencing factors.

RESULT

In a median follow-up period of 6 years, we analyzed 177 EMR procedures, with a mean size of 21 mm. The majority of the resections were in the right colon. Recurrence occurred in 29 patients. Further treatment of patients with recurrence was endoscopic in 27 patients, whereas 1 patient was treated with transanal endoscopic microsurgery and one underwent surgery. The variables influencing the multivariate model were resection technique, immediate complication age, and histology.

CONCLUSIONS

We show that EMR can achieve a long-term clearance of large flat adenomas. A recurrence after EMR does not equal to failed therapy. The possibility of recurrence has to be considered in the clinical implementation of EMR. An important part of the stratifying factors for follow-up is the procedural assessment of the effectiveness of the resection and the resection technique.

House dust mite-induced calcium signaling instigates epithelial barrier dysfunction and CCL20 production

BACKGROUND

House dust mite (HDM) affects the immunological and physical barrier function of airway epithelium, leading to allergic sensitization, airway remodeling, and eosinophilic inflammation in mouse models, although the mechanisms are still largely unknown.

OBJECTIVE

Given the implications for adenosine triphosphate (ATP)-dependent Ca(2+) signaling in allergic sensitization in mice, we sought to determine the role of intracellular Ca(2+) concentration ([Ca(2+)](i)) in HDM-induced barrier dysfunction and pro-inflammatory activity of bronchial epithelium.

METHODS

We investigated the effect of HDM on accumulation of [Ca(2+)](i) levels, barrier function, and CCL20 release in human bronchial epithelial 16HBE cells and primary bronchial epithelial cells (PBECs) from healthy subjects and asthma patients. Involvement of ATP-dependent activation of purinergic receptors and downstream Ca(2+) influx was studied, using the ATP hydrolyzing agent apyrase, the purinergic receptor agonist PPADS, the calcium chelator BAPTA-AM, and calpain inhibitors.

RESULTS

Asthma PBECs were more susceptible to HDM-induced barrier dysfunction, CCL20 secretion, and Ca(2+) influx than healthy PBECs. Furthermore, we show that the HDM-induced increase in CCL20 in PBECs and 16HBE cells and the HDM-induced barrier dysfunction in 16HBE cells are dependent on [Ca(2+)](i) accumulation. Additionally, we demonstrate that [Ca(2+)](i) accumulation is initiated partly through the activation of purinergic receptors, which contributes to HDM-induced epithelial barrier dysfunction by disruption of cell-cell contacts, but not CCL20 secretion.

CONCLUSION

Our data show for the first time that Ca(2+) signaling plays a crucial role in barrier dysfunction and the pro-inflammatory response of bronchial epithelium upon HDM exposure and may thus have important implications for the development of allergic asthma.

The effect of a clinical pathway for enhanced recovery of rectal resections on perioperative quality of care

PURPOSE

There is ample evidence of the benefits of clinical pathways (CPs), but this study is the first to investigate the potential additional benefits of a CP for rectal resections in a setting with an already established policy of enhanced postoperative recovery.

METHODS

We compared 36 patients who underwent rectal resections with ileostomy placement and were treated according to a CP (CP group) with 67 patients treated before CP implementation (prepathway group). Indicators of process quality were placement of central venous line and epidural catheter, day of removal of Foley catheter in relation to removal of the epidural catheter, day of first mobilization, day of resumption of regular diet, day of first passage of stool through the stoma, and length of stay. Outcome quality was assessed by morbidity, mortality, reoperation, and readmission rates.

RESULTS

We found that patients in the CP group resumed regular diet significantly sooner (p = 0.001). There were no significant differences regarding the day of first mobilization (p = 0.69), epidural catheter (p = 0.74), central venous line placement (p = 0.92), and removal of Foley catheter (p = 0.23). The first stool was passed through the stoma earlier (p = 0.04) in the prepathway group. Median length of hospital stay was significantly shorter in the CP group (12.5 vs. 15.0 days; p = 0.008). There were no significant changes in outcome quality, except for a significantly higher need for revisional surgery in the CP group (13.9 vs. 3%, p = 0.05).

CONCLUSIONS

After implementation of a CP for rectal resections, one parameter of process quality improved and length of stay decreased.

Transgastric appendicectomy

Background

Experimental studies and small anecdotal reports have documented the potential and feasibility of transgastric appendicectomy. This paper reports the results of the new technique in a selected group of patients.

Methods

From April 2010 transgastric appendicectomy was offered to all patients with acute appendicitis, but without generalized peritonitis or local contraindications.

Results

Of 111 eligible patients 15 agreed to undergo the transgastric operation. After conversion of the first case to laparoscopy because of severe inflammation and adhesions, the following 14 consecutive transgastric procedures were completed. Two patients with initial peritonitis required laparoscopic lavage 4 days after transgastric appendicectomy, but no leaks were detected at the appendiceal stump or stomach.

Conclusion

These preliminary results have shown the feasibility of this innovative procedure. Additional studies, however, are required to demonstrate the specific advantages and disadvantages of this approach, and define its role in clinical surgery.

Zertifizierte Darmkrebszentren aus Sicht der Zentrumsleitungen: Ergebnisse einer Schlüsselpersonenbefragung

Seit 2003 zertifiziert die Deutsche Krebsgesellschaft (DKG) Organkrebszentren in Deutschland: Nach 8 Jahren Praxis gibt es mehr als 600 zertifizierte Krebszentren, die eine wie im Nationalen Krebsplan geforderte „qualitätsgesicherte onkologische Versorgung“ in Deutschland ermöglichen. Dabei behandeln die mehr als 200 zertifizierten Darmkrebszentren rund 25 % aller Darmkrebsneuerkrankungen. In diesem Artikel wird der Frage nachgegangen, welche Veränderungen das Zertifizierungskonzept in die Zentren gebracht hat.

[Significance of drains in surgery]

Placing drains is one the most common procedures following operations in surgical disciplines. The indication for placing a drain is, however, usually based on a traditional belief rather than being evidence-based. This paper presents an overview of the literature regarding the indications and the evidence level for placing drains following operations in visceral, vascular, thoracic and orthopeedic surgery as well as traumatology. In visceral surgery the indications for placing drains could be clarified over the past decades but in other surgical fields the level of evidence needs further investigation and clarification through future studies. The available data suggest that in most cases a prophylactic drainage can be avoided. In addition, drains may lead to increased morbidity and higher treatment costs.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]

BACKGROUND

Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany.

MATERIAL AND METHODS

A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively.

RESULTS

The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years.

CONCLUSIONS

Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

The composition of house dust mite is critical for mucosal barrier dysfunction and allergic sensitisation

BACKGROUND

House dust mite (HDM) allergens have been reported to increase airway epithelial permeability, thereby facilitating access of allergens and allergic sensitisation.

OBJECTIVES

The authors aimed to understand which biochemical properties of HDM are critical for epithelial immune and barrier responses as well as T helper 2-driven experimental asthma in vivo.

METHODS

Three commercially available HDM extracts were analysed for endotoxin levels, protease and chitinase activities and effects on transepithelial resistance, junctional proteins and pro-inflammatory cytokine release in the bronchial epithelial cell line 16HBE and normal human bronchial cells. Furthermore, the effects on epithelial remodelling and airway inflammation were investigated in a mouse model.

RESULTS

The different HDM extracts varied extensively in their biochemical properties and induced divergent responses in vitro and in vivo. Importantly, the Greer extract, with the lowest serine protease activity, induced the most pronounced effects on epithelial barrier function and CCL20 release in vitro. In vivo, this extract induced the most profound epithelial E-cadherin delocalisation and increase in CCL20, CCL17 and interleukin 5 levels, accompanied by the most pronounced induction of HDM-specific IgE, goblet cell hyperplasia, eosinophilic inflammation and airway hyper-reactivity.

CONCLUSIONS

This study shows the ability of HDM extracts to alter epithelial immune and barrier responses is related to allergic sensitisation but independent of serine/cysteine protease activity.

Extended resections for colorectal cancer - indications for supraradical lymphadenectomy

The laparoscopic approach to standard resections in colorectal cancer has proven that it may provide equal rates of R0 resections and adequate retrieval of lymph nodes as open procedures if performed by experienced hands. There might be difficulties in more advanced tumors or those with lymphatic spread beyond typical drainage areas and more extensive operations might be required. An atypical pattern of lymphatic spread often is associated with other adverse factors such as multifocality of primary cancers and adverse tumorbiological factors such as grade. Such patient subgroups may be defined beforehand and include particularly patients with underlying ulcerative colitis. Repetitively, extended lymph node dissection approaches have been advocated, however neither in randomised trails nor in meta-analysis has a more favourable outcome of patients undergoing such extended lymphatic dissections been demonstrated. Sticking to the rules of classical dissection of lymphatic drainage basins with removal of adequate lymph node numbers is one corner stone for successful treatment of colorectal cancer. The other one refers to a detailed description of the procedure performed in order to make the surgical procedure trackable.

Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection of large lateral spreading tumors currently are technically limited by complications such as bleeding, perforation, and disturbed large procedural sites, leading to incomplete resection and secondary surgery. Further technical improvements are necessary. The authors previously demonstrated the effectiveness of a focused water jet for elevation of the lamina submucosa in animal studies. For the first time, the clinical application of selective tissue elevation by pressure (STEP) for the treatment of colorectal adenomas as a prospective single-arm human trial is presented.

METHODS

This trial evaluated 59 patients who had primary colorectal adenomas with diameters exceeding 12 mm classified as 0-IIa or 0-IIb according to Paris classification. A submucosal cushion was created with a flexible water jet applicator using the Helix HydroJet. The adenoma was subsequently resected with a mucosal resection snare. All results were recorded. The resected specimens were assessed histologically.

RESULTS

A total of 59 patients underwent resection of 70 lesions with a maximum diameter of 80 mm (mean, 27 mm). Submucosal elevation with the water jet dissector was possible in all cases and locations from the pectinate line to the ileocecal valve. Of the 70 lesions, 64 (91%) were resected completely in one session. Histologically, the resected specimens were found to be adenocarcinomas (n = 2, 3%), adenomas with high-grade intraepithelial neoplasia (n = 24, 34%), adenomas with low-grade intraepithelial neoplasia (n = 38, 54%), and hyperplastic polyps (n = 6, 9%). Hemostasis during the resection was necessary in 24 cases (34%). No perforation required surgical intervention.

CONCLUSION

This first clinical trial to analyze STEP technique demonstrated that STEP used to elevate large mucosal lesions in any location is feasible and facilitates EMR for colorectal adenoma.

Expression of selenium-containing proteins in human colon carcinoma tissue

Selenium may be beneficial in reducing the risk of cancer incidence and mortality in many cancer types such as liver, prostate, colorectal and lung. However, despite the extensive recent research on selenium and selenium-containing proteins, there are still open questions concerning their expression in certain human cancer types, including colorectal carcinoma. Therefore, the expression level of the selenoproteins thioredoxin reductases 1 and 2 (TRXR-1 and TRXR-2) and glutathione peroxidases 1 and 4 (GPX1 and GPX4) in human colon carcinoma tissues was investigated. Up-regulation of TRXR-1 in the colon carcinoma specimens was found both in disease stage-dependent and independent analyses. No differences were found for TRXR-2 expression levels. GPX1 was up-regulated in carcinoma tissues at both the protein and mRNA levels. GPX4 was also up-regulated at the protein level, except for the samples derived from stage III patients. The expression of TRXR-1, GPX1 and GPX4, but not TRXR-2 is differently regulated in cancer as compared to healthy colonic tissue.