Operative Behandlung von Rektumkarzinomen im Vergleich

BACKGROUND: The laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients. METHODS: From 01/01/2000-31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection. RESULTS: 237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585). CONCLUSION: Laparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.     

Medical action for global security (MEDACT): Founding statement

Two principles should underpin the provision of primary health care to refugees: (a) that refugees should have the same access to quality primary care services as the local population, and (b) any specialist service should have the goal of full integration of the refugee into normal general practice. The various ways in which medical care can be provided to refugees and the knowledge, skills and attitudes important to such provision are described. One way in which such a service was provided in east Kent is reported. The term ‘refugee’ encompasses newly arrived refugees who are awaiting a decision from the Home Office, as well as those who have been given permission to stay, either as recognized Refugees under the provisions of the 1951 United Nations Convention, or with Exceptional or Indefinite Leave to Remain.     

Laparoscopic cholecystectomy. A recommendable indication in acute cholecystitis?

While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.     

Using e-learning for maintenance of ALS competence

ContextA well-suited e-learning program might be a feasible strategy to maintain competence following a resuscitation course.AimThis study had 2 aims: (1) to examine the effect of an e-learning program as a booster of competence acquired from an Advanced Life Support (ALS) course. (2) To identify factors related to the use of the e-learning program.Materials and methodsThe study contained two parts pertaining to the two aims. The first part was a prospective single blinded randomised controlled study on junior doctors. The intervention was the monthly use of an e-learning program during one year and effect was measured as ALS-competence, a composite of a knowledge and skills test.The second part was a telephone interview of the intervention group. An interview guide was constructed based on existing knowledge of e-learning. In order to identify factors explaining the use of e-learning a univariate correlation was used to select significant variables to be included in a multiple regression analysis.ResultsOf the 134 invited to participate, 103 accepted the invitation. There were 79/103 (77%) participants, 40/51 in the intervention group and 39/52 in the control group. There was no difference between the groups with regards to ALS competence. Only ‘social interaction’ was an individually significant factor influencing the use of the e-learning program.ConclusionsThis study did not demonstrate an effect of an e-learning program as a booster of competence acquired from an ALS course. The primary factor influencing the use of e-learning was the lack of social interaction.     

International Emergency Medicine: A Review of the Literature From 2008

As the specialty of emergency medicine (EM) continues to evolve in countries around the world, and as interest in international emergency medicine (IEM) continues to grow within the United States, the IEM Literature Review Group recognizes a need for a high‐quality, consolidated, and easily accessible evidence base of literature. In response to that need, the group created an annual publication that strives to provide readers with access to the highest quality and most relevant IEM research. This publication represents our fourth annual review, covering the top 26 IEM research articles published in 2008. Articles were selected for the review according to explicit, predetermined criteria that include both methodologic quality and perceived impact of the research. It is our hope that this annual review will act as a forum for disseminating best practices while also stimulating further research in the field of IEM.