An Effective System of Surgical Treatment of Lymphedema

Background

Effective surgical treatments for lymphedema now can address the fluid and solid phases of the disease process. Microsurgical procedures, including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), target the fluid component that predominates at earlier stages of the disease. Suction-assisted protein lipectomy (SAPL) addresses the solid component that typically presents later as chronic, nonpitting lymphedema of an extremity. We assess the outcomes of patients who underwent selective application of these three surgical procedures as part of an effective system to treat lymphedema.

Methods

This is a retrospective chart review of patients with lymphedema who underwent complete decongestive therapy followed by surgical treatment with SAPL, LVA, or VLNT. The primary outcomes measured were postoperative volume reduction (SAPL), daily requirement for compression garments and lymphedema therapy (VLNT and LVA), and the incidence of severe cellulitis.

Results

Twenty-six patients were included in the study, of which 10 underwent SAPL and 16 underwent LVA or VLNT. The average reduction of excess volume by SAPL was 3,212 mL in legs and 943 mL in arms, or a volume reduction of 87 and 111 %, respectively, when compared with the unaffected, opposite sides. Microsurgical procedures (VLNT and LVA) significantly reduced the need for both compression garment use (p = 0.003) and lymphedema therapy (p < 0.0001). The overall rate of cellulitis decreased from 58 % before surgery to 15 % after surgery (p < 0.0001).

Conclusions

When applied appropriately to properly selected patients, surgical procedures used in the treatment of lymphedema are effective and safe.     

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.     

Surgical management of Crohn’s disease

Introduction

Crohn’s disease is an inflammatory bowel disease that can affect the entire gastrointestinal tract. It is chronic and incurable, and the mainstay of therapy is medical management with surgical intervention as complications arise. Surgery is required in approximately 70% of patients with Crohn’s disease. Because repeat interventions are often needed, these patients may benefit from bowel-sparing techniques and minimally invasive approaches. Various bowel-sparing techniques, including strictureplasty, can be applied to reduce the risk of short-bowel syndrome.

Methods

A review of the available literature using the PubMed search engine was undertaken to compile data on the surgical treatment of Crohn’s disease.

Results and conclusion

Data support the use of laparoscopy in treating Crohn’s disease, although the potential technical challenges in these settings mandate appropriate prerequisite surgical expertise.     

Minimally invasive surgical treatment of sigmoid diverticulitis

Introduction

Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications.

Methods

A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis.

Results

In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning.

Conclusion

Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.     

Technical Improvement of Total Pharyngo-Laryngo-Esophagectomy for Esophageal Cancer and Head and Neck Cancer

Purpose

Total pharyngo-laryngo-esophagectomy (PLE) is highly invasive, and the subsequent reconstruction is difficult. The purpose of this study was to clarify the techniques that can decrease the surgical stress and allow for safe reconstruction after this operation.

Methods

The surgical method and clinical outcomes of total PLE were reviewed in 12 patients with either cervicothoracic esophageal cancer or double cancer of the esophagus and pharynx. Microscopic venous anastomosis was principally performed, and arterial anastomosis was added, if needed.

Results

A narrow gastric tube was used in ten patients, including two patients who underwent free jejunal interposition, while the colon was used as the main reconstructed organ in two other patients. Staged operations were performed in three high-risk patients. All six patients treated after 2010 were able to undergo thoracoscopic and/or laparoscopic surgery. No critical postoperative complications developed, although minor anastomotic leakage developed in two patients who were successfully treated conservatively.

Conclusion

When performing PLE, it is important to decrease the surgical stress and ensure a reliable reconstruction by adopting techniques that are appropriate for each case, such as thoracoscopic and laparoscopic surgery, staged operations, microvascular anastomosis, and muscular flaps.     

Diagnostik des Extremit?tenlymph?dems mit bildgebenden Verfahren

Purpose

The aim of this study was the evaluation of different imaging methods for the diagnostics of extremity lymphedema.

Material and methods

The study was based on a review of literature research and experience of performance in lymphoscintigraphic function test by 2,060 patients in part combined with sonography and indirect lymphangiography.

Results

Standardized quantitative lymphoscintigraphy is the only functional test of the lymphatic system that delivers accurate information on lymph transport in extremity lymphedema. Sonography allows the detection of interstitial fluid but cannot distinguish the origin. Indirect lymphangiography delivers information about morphological changes of superficial lymph vessels.

Conclusions

Early lymphedema is only detectable with a lymphoscintigraphic function test. In cases of clinical lymphedema, clinical examination is more reliable than sonography. Sonography can be used for diagnosis of local changes and swellings and indirect lymphangiography serves for planning a reconstructive operation.     

Minimally invasive oesophagectomy versus open surgery: is there an advantage?

Background

Oesophageal resection is the main method of curative treatment for cancer of the oesophagus. Despite advances in surgical technology and postoperative care, the survival rate and prognosis of people undergoing oesophagectomy is still poor. The use of minimally invasive techniques in oesophageal surgery offers hope of reduced recovery time due to a reduction in surgical trauma. Although the first reports of thoracoscopy- and laparoscopy-assisted oesophagectomy emerged some 20 years ago, there is still no consensus that the outcomes are clearly superior to outcomes following conventional open surgery. Increasingly, some surgeons promote the use of minimally invasive techniques for oesophagectomy but questions remain over its safety and efficacy compared with open surgery.

Methods

We conducted a systematic review of the literature to compare minimally invasive techniques for oesophagectomy to open surgery. The outcomes of interest for efficacy and safety included mortality, operative complications, recurrence, and quality of life.

Results

There were 28 included comparative studies. No randomised controlled studies (RCTs) were available and therefore the data need to be interpreted with caution.

Conclusion

Recommendations for future research are discussed. We argue that it is difficult to conduct an RCT for this procedure due to ethical considerations and suggest ways that future nonrandomised studies could be improved.     

Epidemiologie und Therapie der peripheren arteriellen Verschlusskrankheit (PAVK) unter Genderaspekten

Objective

This literature review comments on gender differences for prevalence, epidemiology, risk factors and therapy in patients with peripheral arterial occlusive disease (PAOD).

Material and methods

For the literature review Medline (PubMed) was searched for relevant studies on PAOD before December 2013. Keywords used were “peripheral arterial disease”, “gender”, “bypass”, “intervention” and “outcome”.

Results

Women have a higher age-adjusted risk for PAOD and for women it is more often asymptomatic so that the disease is treated at an advanced stage. According to some studies women receive secondary prophylactic measures and interventional or surgical treatment less often than men. In addition, they suffer more frequently from bypass failure, impaired wound healing, bleeding complications and amputation. On the other hand, studies after infrainguinal reconstruction show similar patency and limb salvage rates to men and the differences for subsequent endovascular therapy are also only marginal. Possible reasons for the differences may be, besides the gender-specific cardiovascular risk profile, the estrogen concentration and different anatomical conditions with different vessel calibres.

Conclusion

In PAOD there are gender differences. Clear guidelines for gender-specific treatment recommendations do not exist; however, they would be important for the long-term therapeutic success.     

Dupuytren's disease: current state of the art

Background

This review article critically examines the current literature for Dupuytren's disease.

Methods

Five procedures are considered: dermofasciectomy, limited fasciectomy, segmental aponeurectomy, needle aponeurotomy, and collagenase injection. Studies regarding the efficacy of these treatments focus primarily on the initial degree of correction, rate of recurrence, and complications.

Results

No one treatment has been declared superior and substantial controversy exists. Comparison between studies has been hampered by the absence of uniform definitions for clinical success and measurable disease progression. Traditional post-operative care includes formal therapy and night splinting, but recent studies have questioned the value of these adjuncts.

Conclusion

The extent of involvement at which the surgeon should intervene was previously well accepted by convention, but as the paradigm shifts towards less invasive procedures, treatment may be offered at an earlier stage. Future research should be structured to recognize the value-based decision making used by patients when selecting treatment.     

Anastomosen im oberen Gastrointestinaltrakt

Background

Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development.

Methods

A Pubmed search was perfomed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses.

Conclusions

There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.     

Exoskelettales Rehabilitationstraining bei Querschnittgelähmten

Background

Treatment of midshaft clavicle fractures underwent a fundamental change from nonoperative towards surgical therapy. The process of fracture consolidation is protracted and therapy is susceptible to complications.

Risk factors for complications

Recent studies provided evidence of poor results after nonoperative treatment of displaced fractures and identified risk factors for complications. The main complications leading to revision surgery are malunion with clavicle shortening and nonunion. Patients often complain about discomfort from implanted hardware and hypaesthesia due to the surgical approach.

Aim of this article

This article describes diagnostic steps and the classification of midshaft clavicle fractures as well as the planning of the therapeutic concept.

Treatment

Nonoperative treatment nowadays is considered the therapeutic standard for undisplaced fractures only. Displaced and multifragmentary fractures are treated by open reduction and internal plate fixation; simple fracture patterns can be fixed internally by elastic nails. Revision surgery of midshaft clavicle nonunion involves autologous spongiosa graft. Complex and chronic cases of osteitis with large bone defects may require specialized procedures such as free vascularized fibula grafts or corticoperiosteal bone graft.     

Hirschsprung disease in adulthood: An alternative surgical approach using a U-shaped circular anastomosis

Aim-Background

Hirschsprung Disease (HD), congenital intestinal aganglionosis, or aganglionic megacolon represents a congenital abnormality which is characterized by the absence of neural crest-derived enteric neural ganglia along a variable length of the intestine. Affecting mainly children, it is an infrequent clinical entity in adulthood.

Case report

The case of a 23-year-old female with an acute faecal impaction and history of chronic constipation and long-term use of laxatives is presented. An alternative surgical technique (curvilinear stapler) for coloanal anastomosis and review of the literature are discussed.

Results

A successful U-shaped anastomosis 1.5-2 cm above the dentate line, with no postoperative stricture or incontinence as assessed by manometry is described below in this case report.

Conclusion

Proctocolectomy by curvilinear staplers represents an efficacious treatment method for aganglionosis, offering a good quality of life to patients with Hirschsprung.     

Minimally Invasive Video-Assisted Thyroidectomy for Benign Thyroid Disease: An Evidence-Based Review

Background

A decade after nearly all surgical disciplines developed minimally invasive techniques, the first report of a single case of minimally invasive thyroidectomy was published. Minimally invasive video-assisted thyroidectomy (MIVAT) is now considered the most widely practiced and most easily reproducible minimally invasive procedure for thyroidectomy. The aim of this review was to analyze the treatment of benign thyroid diseases by MIVAT.

Methods

A systematic evidence-based literature review focusing on three questions was carried out. Additional data were obtained on the basis of our personal experience. (1) Are minimally invasive procedures indicated in the treatment of thyroid diseases? (2) Is MIVAT a safe technique and what are the demonstrated advantages? (3) Since different thyroid diseases may be treated by MIVAT, is it of any value in the treatment of benign thyroid diseases?

Results

MIVAT can be considered an appropriate treatment of some thyroid diseases; it represents a safe procedure with the same incidence of complications as traditional surgery, and also has advantages in terms of both cosmetic result and postoperative distress.

Conclusions

In spite of an increasing trend toward performing more extensive procedures other than thyroidectomy alone during videoscopic procedures, the current literature seems to reaffirm that the main and safest indication for MIVAT is benign disease.

     

Minimally invasive surgery: national trends in adoption and future directions for hospital strategy

Background

Surgeons have rapidly adopted minimally invasive surgical (MIS) techniques for a wide range of applications since the first laparoscopic appendectomy was performed in 1983. At the helm of this MIS shift has been laparoscopy, with robotic surgery also gaining ground in a number of areas.

Methods

Researchers estimated national volumes, growth forecasts, and MIS adoption rates for the following procedures: cholecystectomy, appendectomy, gastric bypass, ventral hernia repair, colectomy, prostatectomy, tubal ligation, hysterectomy, and myomectomy. MIS adoption rates are based on secondary research, interviews with clinicians and administrators involved in MIS, and a review of clinical literature, where available. Overall volume estimates and growth forecasts are sourced from The Advisory Board Company’s national demand model which provides current and future utilization rate projections for inpatient and outpatient services. The model takes into account demographics (growth and aging of the population) as well as non demographic factors such as inpatient to outpatient shift, increase in disease prevalence, technological advancements, coverage expansion, and changing payment models.

Results

Surgeons perform cholecystectomy, a relatively simple procedure, laparoscopically in 96 % of the cases. Use of the robot as a tool in laparoscopy is gaining traction in general surgery and seeing particular growth within colorectal surgery. Surgeons use robotic surgery in 15 % of colectomy cases, far behind that of prostatectomy but similar to that of hysterectomy, which have robotic adoption rates of 90 and 20 %, respectively.

Conclusions

Surgeons are using minimally invasive surgical techniques, primarily laparoscopy and robotic surgery, to perform procedures that were previously done as open surgery. As risk-based pressures mount, hospital executives will increasingly scrutinize the cost of new technology and the impact it has on patient outcomes. These changing market dynamics may thwart the expansion of new surgical techniques and heighten emphasis on competency standards.     

Zystische Adventitiadegeneration

Background

This article describes the surgical resection procedures and percutaneous interventional therapy options for individual cases of rare cystic adventitial degeneration. The methods include percutaneous transluminal angioplasty (PTA) and ultrasound or computed tomography (CT) guided aspiration of the cystic contents. Due to the various therapy options preinterventional and preoperative assessment is important for a decision on the suitable therapy.

Method

A critical assessment of the therapy options, in particular ultrasound-guided cyst aspiration, will be presented exemplified by case examples and taking the etiology and pathomorphology into consideration. In addition a critical review of the literature between 1980 and 2012 will be presented.

Results

Sonography allows an accurate assessment for an adequate therapeutic approach due to the high site resolution. A review of the individual cases presented in the literature and own experience (using the methods in three selected cases) show that percutaneous, ultrasound-guided aspiration of cyst contents is primarily successful in the majority of cases and allows a long-term absence of recurrence in 60–70?% of cases. Surgical resection of recurrences is not affect by a prior cyst puncture.

Conclusion

The therapy of choice is surgical cyst enucleation or resection of the section of artery affected with a venous interpositional graft. In selected cases with solitary and small cysts, ultrasound-guided puncture with aspiration of the cyst contents can be used as a non-traumatic method. Sonography can be decisive for selection of an adequate therapy.     

Impact of novel off-pump coronary artery bypass simulator on the surgical training

Objectives

We evaluated the utility of novel simulator for off-pump coronary artery bypass grafting for surgical residents.

Methods

The novel simulator system “BEAT, YOUCAN” has 2 components. (1) A pink disposable silicone vessel model having a 3-layer structure mimicking the internal mammary artery. The disposable silicone vessels mimicking the coronary artery are embedded in a 4 × 7-cm yellow silicone piece. (2) A beating table with a holder compatible with the yellow silicone piece. The arbitrary heartbeat pattern and angle are compatible with the controller. With aforementioned simulator, four cardiovascular surgical residents with no experience as an operator in coronary artery bypass grafting performed end-to-side anastomosis with 7-0 polypropylene, simulating the anastomosis of the mammary to the coronary artery. For each anastomosis, the time to complete the anastomosis, the number of sutures placed, and the number of troubles were recorded. The performance of the anastomosis was evaluated and compared between early (1–10th anastomoses) and late phase (30–40 anastomoses) using the special made score with full mark of 25 points.

Results

In total, 160 anastomoses were done (early, 40; late, 40). The time to complete anastomosis was significantly shortened with practice, and the number of troubles in each anastomosis was significantly decreased. The number of sutures placed in each anastomosis had become stable at late phase. The performance score also significantly improved with practice. The learning curve for operative time and the number of events plateaued at approximately the 30th anastomosis.

Conclusion

The novel simulator is effective for cardiovascular trainees.     

Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery

Background

Efforts to improve approaches to the so called “parametrium” with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection.

Methods

The literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors’ laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer.

Results

The anatomic entity commonly termed the “posterior parametrium” can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations.

Conclusions

The incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called “posterior parametrium.”     

The Safety of Laparoscopic Hand-Sutured Gastrojejunostomy in Gastric Bypass for the Treatment of Morbid Obesity

Background

Laparoscopic Roux-en-Y gastric bypass is the most commonly adopted bariatric procedure. The predominant majority of surgeons construct the anastomoses using stapled techniques. We describe our technique of complete laparoscopically sutured gastrojejunal anastomosis (GJA) and its outcomes.

Methods

Electronic database was used to collect data retrospectively for patients undergoing laparoscopic gastric bypass at the senior author's bariatric institutions. The results shown represent median (interquartile range).

Results

Between April 2002 and April 2012, 1,754 consecutive patients (78 % female) aged 43 (35–50)?years with BMI 51 (44.5–56.7)?kg/m² underwent laparoscopic gastric bypass (1,679 primary bypasses, 75 revision procedures). All the GJA were hand-sutured. The operative mortality was 0.17 %. Four patients (0.22 %) developed GJA/gastric pouch leak of whom two died, while a further three patients (0.17 %) needed endoscopic dilatation of GJA stricture during the initial 2 years after surgery.

Conclusions

In the hands of an experienced laparoscopic surgeon, laparoscopic hand-sutured GJA in patients undergoing gastric bypass is safe and effective with very low anastomotic leak and stricture rates.