Insular carcinomas of the thyroid exhibit poor prognosis and long-term survival in comparison to follicular and papillary T4 carcinomas

Background Insular thyroid carcinoma was described as a tumor with aggressive behavior, and patients usually present themselves with an advanced tumor stage. Whether the insular component is an independent factor for poor prognosis remains unclear. Therefore, in the present study, we compared the survival of patients with advanced insular, follicular, and papillary thyroid cancer. Materials and methods The clinical behavior of tumors in three groups of patients with T4 thyroid carcinoma—8 patients with insular, 11 patients with follicular, and 21 patients with papillary thyroid carcinomas—was compared. Disease-free survival and disease-specific death were analyzed statistically. Cox regression analysis was used to evaluate the influence of histotype and other prognostic factors. Results At 3 years, survival was 37.5% (mean 26 months) among patients with insular thyroid carcinoma, 80% (mean 59 months) among those with follicular, and 89% (mean 126 months) among those with papillary thyroid carcinomas (p = 0.007). Disease-free survival in patients without initial distant metastasis was worst in patients with insular thyroid carcinoma (20%) compared to those with follicular (75%) and those with papillary thyroid carcinomas (71%). Conclusion Patients with advanced insular thyroid carcinoma have a poorer outcome in comparison to patients with similar advanced stage who have follicular or papillary thyroid carcinoma.     

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome

Purpose

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.

Methods

Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann’s procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.

Results

Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p =?0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p =?0.001), and increased operation time (105 vs. 84 min., p =?0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p <?0.001). Complication rate (44 vs. 24%, p =?0.092), mortality (12 vs. 0%, p =?0.061), overall number of surgeries (3.4 vs. 2.4, p =?0.017), enterostomy rate (76 vs. 36%, p =?0.001), and length of hospital stay (25 vs. 18.8 days, p =?0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p =?0.005) and with fungal infection (100 vs. 49%, p =?0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p <?0.001), enterostomy rate (81 vs. 48%, p =?0.017), and anastomotic leakage (29 vs. 6%, p =?0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p =?0.014).

Conclusion

Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

     

Karydakis Flap for Recurrent Pilonidal Disease

Background

Patients undergoing surgery for recurrent pilonidal disease are at high risk of developing re-recurrence. The present retrospective analysis was performed to compare long-term results in patients with recurrent disease undergoing midline excision surgery compared to patients undergoing the Karydakis flap procedure.

Methods

Only patients with previous excision surgery apart from simple abscess incision were included. Disease recurrence was defined as the need for repeat surgery.

Results

A total of 124 patients underwent surgery for recurrent pilonidal disease. Group 1 consisted of 37 patients (25 excision + midline closure, 12 excision + lay-open). Group 2 consisted of 87 patients (Karydakis flap). There were no statistically significant differences between the groups with regard to patient’s age, duration of disease, body mass index, or sex. The average number of previous surgeries was significantly higher in group 1 patients (2.1 vs. 1.8, p = 0.019). The overall 1-year recurrence rate was 43 % in group 1 and 3 % in group 2 (p < 0.0001). The wound dehiscence rate after the Karydakis flap procedure was as high as 43 % between years 2005 and 2009, but it fell to 10 % thereafter (p = 0.02).

Conclusions

Karydakis flap procedure is superior to midline excision surgery in patients presenting with recurrent pilonidal disease.     

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”

Purpose

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS).

Materials and methods

Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis???loop ileostomy or a Hartmann’s procedure) after 24–48?h.

Results

Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n?=?17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n?=?5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).

Conclusion

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

     

Erhöhtes Rezidivrisiko nach primärem medianem Wundverschluss bei Patienten mit Pilonidalsinus

BACKGROUND: There is a high incidence of postoperative complications and late recurrences after operative therapy of a pilonidal sinus.The optimal treatment strategy is still matter of discussion.We studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure. MATERIALS AND METHODS: A total of 73 patients (62 male and 11 female, mean age 26.6 years) underwent a total of 79 operations between 1992 and 2001.Thirty patients (38%) were previously operated on because of a pilonidal sinus.Twenty-four were treated in our institution by an open procedure (five after simple abscess incision, 19 after sinus excision) and 52 by primary midline closure. Another three patients received skin flap procedures. RESULTS: Follow-up was possible for 65 patients (82%) for a median of 50 months.Recurrent pilonidal sinus occurred in 22 cases: 18 after primary midline closure (42%) and four after open procedure (21%, P=0.4).We found no relapse following the three skin flap procedures. There was a significantly higher relapse rate in patients operated with recurrent disease (12/25 vs 10/40; P<0.05). CONCLUSIONS: Despite of numerous previously operated patients (38%), there was a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure. Alternative operative techniques creating a lateral wound or the various skin flap procedures may be promising alternatives.We are in the process of changing our treatment strategy for patients suffering from a pilonidal sinus.     

Benefit of Kupffer cell modulation with glycine versus Kupffer cell depletion after liver transplantation in the rat: effects on postischemic reperfusion injury, apoptotic cell death graft regeneration and survival.

Inhibition or destruction of Kupffer cells (KC) may protect against ischemia-reperfusion (IR) induced primary graft nonfunction (PNF) in liver transplantation. Besides KC activation, PNF is characterized by microvascular perfusion failure, intrahepatic leukocyte accumulation, cell death and hepatocellular dysfunction. KCs can be inactivated by different agents including gadolinium chloride (GdCl3), methyl palmitate (MP) and glycine. The effects of three KC inactivators on IR-injury after rat liver transplantation were compared in the present study. Lewis liver donors were treated with GdCl3, MP, glycine or saline (control). Liver grafts were transplanted following 24 h storage (UW solution). KC populations and IR damage were assessed by histologic analysis, quantitative real-time polymerase chain reaction (RT-PCR) and intravital microscopy. The number of hepatic ED-1 positive macrophages was diminished after GdCl3 (114.8+/-4.4/mm2 liver tissue) and MP treatment (176.0+/-5.0), versus the glycine (263.9+/-5.5) and control (272.1+/-5.6) groups. All three treatment modalities downregulated phagocytic activity for latex particles, paralleled by reduced microvascular injury (acinar perfusion index, GdCl3: 0.75+/-0.03; MP: 0.83+/-.03; glycine: 0.84+/-0.03; 0.63+/-0.03). Quantitative RT-PCR revealed elevated myeloperoxidase mRNA after glycine versus GdCl3 and MP pretreatment (3.2- and 3.4-fold, P=0.011, respectively), without difference to controls (2.9-fold of glycine). TNFalpha-mRNA was reduced after glycine- (5.2-fold), GdCl3- (19.7-fold), MP-treatment (39.5-fold) compared with controls. However, profound prevention of intrahepatic cell death and liver graft failure was solely achieved with glycine preconditioning. Different than GdCl3 and MP, glycine modulates rather than destroys KCs. Glycine appears to preserve cell viability and to TNFalpha/leukocyte dependent organ regeneration capacity, which is related to increase graft survival following liver transplantation.     

Treatment of the anastomotic complications in patients with Crohn's disease

Purpose  

Postoperative anastomotic complications in patients with Crohn's disease undergoing bowel resections have a detrimental influence on the long-term outcome. The aim of this study was to evaluate whether patients' prognosis is affected by various treatment strategies of anastomotic complications.     

Sinus pilonidalis und Hidradenitis suppurativa: 2 anspruchsvolle Hauterkrankungen

Die Gastroenterologie - Sinus pilonidalis und Hidradenitis suppurativa sind 2 dermatologische Erkrankungen, die mit Bildung von Fisteln und Abszessen einhergehen und meist operativ behandelt...