[Patient advanced directives from the perspective of surgery patients-new aspects and aims : Living wills of patients before planned surgery]

BACKGROUND

Patient advance directives and other forms of precautionary medical provisions have arisen from patients' determination to influence and decide about medical treatment even in extreme situations. Although this topic is very present in the media, clinical experience indicates that the majority of patients are not yet aware of this subject. This current investigation aimed to collect data about the familiarity and degree of distribution of patient medical advance directives. Furthermore, it was examined how a routine question concerning patient's provisions in a preoperative setting is perceived by the patients and from which source information about this topic should be provided.

METHODS

Between April 2017 and October 2017 a total of 200 patients were randomly selected prior to planned surgery and interviewed anonymously using a standardized questionnaire.

RESULTS

Of the patients surveyed 78.8% stated that they knew about the possibility of patient advance directives. Of the patients interviewed 26.3% stated they had drawn up an advance directive, 20.7% had a precautionary power of attorney and 12.3% had signed a care directive. Among the influencing factors in drawing up an advance directive, age, as well as familial and disease-related causes, were identified as significant factors. The overwhelming majority of respondents (77.6%) wished to be approached on the subject of precautionary medical provisions before a planned operation.

CONCLUSION

Despite an increasing proportion of patients who have drawn up an advance directive, there is still a great need for information on the subject. Doctors should address patients on the topic before planned interventions.

[Laparoscopic liver resection]

Laparoscopic liver surgery has become an established procedure in the treatment of liver tumors. Due to its short-term and long-term advantages, the number of centers with experience in laparoscopic liver surgery has greatly increased in the last few years. The complexity of the interventions performed has nearly reached the level of open surgery. This article describes the importance of laparoscopic hepatic surgery and discusses the evidence for the procedure. In addition, the indications for the most frequently resected tumors, metastases of colorectal cancer and hepatocellular carcinoma are explained together with important aspects of certain tumor localizations. In addition, the authors explain the technical aspects of the surgical technique and give an overview on new developments. To illustrate the possibilities of laparoscopic liver surgery, a video of a complete laparoscopically performed associating liver partition and portal vein ligation (ALPPS) procedure is available as supplementary material.

Arterial Blood Supply of Liver Segment IV and Its Possible Surgical Consequences

The risk of ischemia of segment IV after split liver resection is high. This anatomical study was done to identify the arterial blood supply and the intrahepatic distribution of liver segment IV. The anatomy of segment IV was studied in 29 livers from adult cadavers. To identify the arterial blood supply of segment IV, water and ink were injected into the various branches of the hepatic artery and the outflow through segment IV and discoloration of the liver parenchyma were observed. In 23 of the 29 livers (79.3%), the arterial perfusion of segment IV was separated by a line drawn from the left side of the inferior vena cava at the top of and lateral to the falciform ligament to the medial point of the gallbladder bed. The area lateral to this line was supplied mainly by the right hepatic artery, and the area medial to it was supplied mainly by the left hepatic artery. In addition to the classification system of Couinaud, we describe here a new division of liver segment IV based on arterial blood supply. These anatomical findings may be useful in defining the resection line for split liver to prevent necrosis of segment IV.

Liver injury following blunt abdominal trauma: a new mechanism-driven classification

Purposes

The current classifications for blunt liver trauma focus only on the extent of liver injury. However, these scores are independent from the localization of liver injury and mechanism of trauma.

Methods

The type of liver injury after blunt abdominal trauma was newly classified as type A when it was along the falciform ligament with involvement of segments IVa/b, III, or II, and type B when there was involvement of segments V–VIII. With the use of a prospectively established database, the clinical, perioperative, and outcome data were analyzed regarding the trauma mechanism, as well as the radiological and intraoperative findings.

Results

In 64 patients, the type of liver injury following blunt abdominal trauma was clearly linked with the mechanism of trauma: type A injuries (n = 28) were associated with a frontal trauma, whereas type B injuries (n = 36) were found after complex trauma mechanisms. The demographic data, mortality, ICU stay, and hospital stay showed no significant differences between the two groups. Interestingly, all patients with type A ruptures required immediate surgical intervention, whereas six patients (16.7 %) with type B ruptures could be managed conservatively.

Conclusions

This new classification for blunt traumatic hepatic injury is based on the localization of parenchymal disruption and correlates with the mechanism of trauma. The type of liver injury correlated with the necessity for surgical therapy.

[Closing the abdominal wall - challenges and possible solutions]

The most common complications after abdominal surgery - wound infections and the development of incisional hernia - are associated with the opening and closing of the abdominal wall. Depending on the selection of patients, wound infection rates of up to 19 % and hernia rates of up to 38 % are reported. Based on a summary of the actual literature, the abdominal wall should be closed with continuous slowly absorbable sutures with a suture length to wound length ratio of over 4 using small stitches. While antiseptic suture material may help to reduce wound infections after abdominal incision, preventing the development of incisional hernia is still a unsolved problem. As there is still no standard surgical technique for abdominal wall closure, surgeons should pay greater attention to the standardisation and documentation of techniques and wound care.

[Advance health care directives as seen by surgical patients]

BACKGROUND

Progressive health care implies progress also in physician/patient interaction, especially with regard to moribund patients and their relatives. Advance health care directives emerged from the desire to influence medical treatment even in borderline situations. In spite of the present political and public discussions in Germany, advance directives are rarely of much importance in everyday surgical practice. By means of questionnaires, this study aimed at the frequency of advance directives among the patients of a surgical hospital and at related influencing factors.

METHODS

Between August 2007 and January 2008, 450 patients at our hospital were interviewed, prior to scheduled surgery, on the topic of advance health care directives by means of anonymous questionnaires. In addition to questions about the existence of or the intention to draw up advance directives, the study focussed particularly on the relationship between patient and attending physician. Patient-specific and sociodemographic data were collected as well.

RESULTS

Of the patients interviewed, 16.7% stated they had drawn up advance directives, while 21.3% did not know about the possibility of drawing up such a document. A mere 9.7% of the patients interviewed saw no need for such directives, whereas the majority (65.3%) considered it an option. Among the factors influencing the drawing up of advance directives, age and prior experience with severe disease figured significantly. Of the patients interviewed, 64.8% wished for more information on the topic of advance health care directives and health care proxies. The wish was expressed by 80.1% of patients that the attending surgeon mention the topic prior to surgery.

CONCLUSIONS

Although the proportion of patients that draw up advance health care directives continues to be less than one fifth, surgical patients have a great need for information regarding the topic. Surgical hospital personnel should also set themselves to this task.

[Intraarterial thrombolysis in acute limb ischaemia: alternative treatment and basic principles of further interventions]

INTRODUCTION

Intraarterial thrombolysis of acute arterial occlusions in the lower limbs is an established therapeutic procedure. However, its value as a primary treatment is discussed controversially and it is mostly seen as a competing procedure to primary vascular surgical interventions.

METHODS

From January 2001 to December 2004, we performed a total of 132 intraarterial thrombolysis procedures in 112 patients with acute or subacute ischaemia of the lower limbs. In the majority of the cases, there was an ischaemia of stage I or II a according to Rutherford, a few further cases were in stage II b at the start of treatment. The patients' ages at the time of thrombolysis was 64.7+/-11.3 years (mean value+/-standard deviation, range: 27-91 years). There were 46 female and 86 male patients.

RESULTS

The average duration of thrombolysis was 35.2+/-20.8 hours (mean+/-standard deviation, range: 6-142 hours). As median 2 (range: 0-8) angiographic controls were performed. In 100 cases (75.8%), an operation could be avoided by thrombolysis alone or in combination with an supplementary intervention. On the other hand, in 32 cases (24.2%) a subsequent operative therapy including 10 major amputations (7.6%) was necessary. Because of hemorrhagic complications, 15 thrombolysis procedures (11.4%) had to be terminated prematurely but only 2 patients required an inguinal revision. Therapy-related mortality was 0.8% (1 patient).

CONCLUSION

In the majority of our patients, primary intraarterial thrombolysis was successful and often led to the discovery of the underlying vascular lesion. It can serve both as a therapeutic alternative to a primary vascular surgical intervention and as the foundation further interventional or vascular surgical therapies although this cannot always be predicted for individual cases.