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Innovative Surgical Sciences

The Rapid Journal of the German Society of Surgery

Editor-in-Chief: Jähne, Joachim

Editorial Board: Dziki, Adam / Jauch, Karl-Walter / Karpeh, Martin S. / Kitajima, Masaki / Mansfield, Paul / Pohlemann, Tim / Primrose, John / Hang-Kwang, Yang

4 Issues per year

Open Access
Online
ISSN
2364-7485
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Abstracts DGCH

Published Online: 2018-03-14 | DOI: https://doi.org/10.1515/iss-2018-2002

Surgical research: Novel therapeutics, Biomarker, Targeted Therapy

AKR1B10 as potential predictor and therapeutic target in gemcitabine resistant pancreatic ductal adenocarcinomas

(Abstract ID: 841)

J. Lohmann1, J. Li1, A. Renner2, F. Popp1, M. Popp1, A. Quaas1, S.-H. Chon1, H. A. Schlößer1, A. Altendorf-Hofmann1, T. Knösel2, T. Kalinski3, P. J. Nelson2, H. Alakus1, C. J. Bruns1, Y. Zhao1

1Universitätsklinikum Köln

2Universitätsklinikum der LMU München

3Otto-von-Guericke University, Magdeburg

Background:

Pancreatic ductal adenocarcinoma (PDAC) is one of the most challenging tumors. Despite the introduction of gemcitabine and modern combined chemotherapeutic regimens (e.g. Nab-paclitaxel/Gemzar, FOLFIRINOX), the response rates are still limited. It makes PDAC remain a chemoresistant tumor. A major challenge is a tumor-specific modulation of the microenvironment (desmoplastic reaction of the tumor stroma). Our previous studies showed that Aldo-keto reductase family 1 member B10 (AKR1B10) is highly expressed in stem-cell-side population cells and gemcitabine resistant cells. In this study, we want to investigate if AKR1B10 is a predictive marker in PDAC. We aim at exploring the role of AKR1B10 in cancer metabolism, tumor microenvironment, drug resistance and metastasis of PDAC.

Materials and methods:

We quantified expression of AKR1B10 in PDAC cell lines with different metastatic potential, as well as gemcitabine or 5-FU resistant sublines. We obtained fresh tumor, corresponding normal tissue, FFPE samples and serum samples from the same patients. Serum from gender-matched healthy donors was also collected. In particular, we compared serum levels of AKR1B10 in patients with or without metastasis as well as with or without standard adjuvant therapy. Knock-in and silencing of AKR1B10 in human PDAC cell lines and patient derived cells was used to analyze gain and loss of biological function in PDAC cells in vitro and in vivo. The effect of different AKR1B10 inhibitors, for example natural compound Curcumin, on regulation of epithelial mesenchymal transition and fatty acid/lipid synthesis was analyzed and compared to the knock-out cell lines.

Results:

AKR1B10 was enriched in tumor tissue compared to corresponding non-malignant tissue of PDAC patients. A negative prognostic impact of AKR1B10 expression was externally validated in 176 PDAC cases from the TCGA database. Gemcitabine-resistant cells showed a higher percentage of side population cells compared to the parental cell lines. AKR1B10 was dramatically overexpressed in stem cell like side populations of gemcitabine resistant variants but decreased in 5-FU resistant variants. Downregulation of AKR1B10 either by silencing or administration of curcumin showed a significant inhibition of AKR1B10 protein expression and a decrease of stem like subpopulations. may reverse EMT process and reduce metastasis.

Conclusion:

Our results demonstrate a remarkable negative prognostic impact of AKRB10 on the biology of PDAC. AKRB10 is overexpressed in tumor samples of PDAC and may indicate response to treatment with gemcitabine. Inhibition of AKR1B10 expression either by knock down strategy or inhibitors may restore sensitivity to gemcitabine treatment. Taken together, AKRB10 might be useful as a prognostic marker or therapeutic target in PDAC.

DGCH/DGKCH: Innovative concepts of surgical training

Immersive Patient Simulators as a tool for an „Objective structured clinical examination“ (OSCE)

(Abstract ID: 248)

R. Kleinert1, P. S. Plum1, R. Datta1, S.-H. Chon1, M. Bludau1, C. J. Bruns1

1Universitätsklinikum Köln

Background:

Immersive patient simulators (IPS) allow an illusionary immersion into a synthetic world. Students can freely navigate and interact with the virtual surrounding and treat virtual patients in a “game like” environment (Serious Game). The “Objective structured clinical examination” (OSCE) is a commonly used examination in medicine. Surgical OSCE tests procedural knowledge and interpretation of results. In recent studies, we proved a positive impact on declarative and procedural knowledge. Hence it was our aim to test the impact of training with IPS on OSCE outcome.

Materials and methods:

5th year students (n=60) underwent training with our proprietary ISP (ALICE: Artificial Learning Interface of Clinical Education). OSCE performance was measured before and immediately after simulator training. I addition, performance of these students training was compared to a control group of 180 students who prepared for OSCE with the classical educational methods (books etc.).

Results:

Training with ALICE had positive impact on procedural knowledge gain. Students showed a high motivation when using the simulator and most of them had fun while using it. ALICE showed positive impact on OSCE performance. Comparison between simulator group and the control group showed no difference in parameters “correct diagnosis” and “correct therapy”.

Conclusion:

ALICE positively influenced increase in declarative knowledge and is a suitable tool for OSCE preparation.

Establishing a structured doctoral program for medical doctoral degrees in the Department of Surgery at the University Hospital Heidelberg

(Abstract ID: 323)

T. Wiedenmann1, M. Friedrich1, T. Harbers1, A. L. Mihaljevic1

1Universitätsklinikum Heidelberg

Background:

Physicians not only need medical knowledge but also scientific competences to be able to find the best treatments for their patients at all times. However, curricula for medical studies in Germany often focus very little on the training of scientific skills with the doctoral thesis usually being the only scientific project during the course of medical studies. We are aiming to improve the scientific expertise of medical students with a structured program for obtaining a medical doctoral degree in the Department of Surgery at the University Hospital Heidelberg.

Materials and methods:

The doctoral program supports students of medicine and dental medicine during their doctoral thesis work in the Department of Surgery with a structured curriculum. All participants regularly take part in Journal Clubs and workgroup meetings to promote scientific exchange among students and their supervisors. Furthermore, participation in a seminar of good scientific practice and in a scientific conference is compulsory for all students. Further courses (experimental techniques, statistical analysis, animal handling, scientific writing, etc.) must be chosen according to interests and specific needs of the doctoral thesis project. To help with successful planning of the project, to give additional scientific advice, and to encourage critical discussions about the project, a thesis advisory committee, consisting of the project supervisor and two additional researchers, accompanies every student during the work on his doctoral thesis. Students register for participation in the doctoral program at the beginning of their research work. During the registration process, students are asked about the general frameworks of their doctoral thesis, such as planned total duration, amount of time dedicated to fulltime research work or motivation for joining the doctoral program, and the answers are analyzed.

Results:

Between November 2016 and September 2017 44 students registered for participation in the structured doctoral program. The participants expect an average duration of research work of 15 ± 6 months (mean ± SD) until completion of their doctoral thesis. Most participants choose experimental research projects (54%), followed by clinical research projects (33%) and projects combining experimental and clinical research methods (13%). 43% of registered students plan to make use of the possibility to interrupt their medical studies for one semester to be able to work on their research project for 6 months full-time. 52% are willing to work more than 6 months full-time, therefore pausing their studies for more than one semester. Only 5% of participants enrolled in the doctoral program exclusively work part-time or less than one semester full-time for their doctoral degree. Students name “Access to training workshops” and “Scientific exchange” as the main reasons for registering to the doctoral program.

Conclusion:

A structured doctoral program attracts mostly enthusiastic students with ambitious research plans. Further follow-up is needed to determine if participating students benefit from a better performance during their doctoral thesis, e.g. determined by publication success or results from doctoral thesis evaluations.

Influence of spaced learning on long-term laparoscopic performance - a pilot study

(Abstract ID: 85)

M. Boettcher1, J. Boettcher1, L. Klippgen1, S. Mietzsch1, K. Reinshagen1

1Universitätsklinikum Hamburg-Eppendorf

Background:

Spaced, hypercondensed learning has been shown to be extraordinary effective in various areas like traditional knowledge or motor skill acquisition like laparoscopic suturing. Some people believe that frequent pausing instead of active pauses (which are an integral part of the spaced learning concept to reduce interference) are sufficient. To evaluate the long-term effects of the concept on complex motos skills like laparoscopic suturing was the aim of the study.

Materials and methods:

To evaluate the effectiveness of spaced learning, subjects were trained either trained for 4 hours in a hands-on course to perform 4 surgeon's square knots on a bowel model. After one year the same subjects were asked to perform the same procedure in much more complex setting (esophageal atresia with tracheoesophageal fistula model). All subjects were medical students and novice in open and laparoscopic suturing. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan score) and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation.

Results:

Twenty students were included in the study; after simple randomization, ten were trained using the classic “spaced learning” concept and ten were trained with similar interuptions but passive pauses. After one year the performance was reassessed in a more complex model (to test transferability and long-term acquisition). Both groups had comparable baseline characteristics and improved after training significantly regarding all aspects assessed in this study. Subjects that trained via classic “spaced learning” were superior in terms of suture performance, knot quality and suture strength.

Conclusion:

The spaced learning concept is very suitable for complex motor skill acquisition like laparoscopic suturing and knot tying. It significantly improves long-term laparoscopic performance and knot quality. Thus, we recommend to incorporate spaced learning with active pauses into training courses and surgical programs.

Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles.

(Abstract ID: 954)

S. Zundel1, S. Shavit1, P. Szavay1

1Kantonsspital Luzern

Background:

Varicocele is a common urologic anomaly in adolescent males but evidence based treatment guidelines do still not exist. Hydroceles are known to be a common complication after surgical therapy, but clinical relevance is obscure since no objective grading system exists.

We aimed to introduce a standardized indication-to-treat protocol and proof its efficacy by analyzing the outcome of our patients. Secondly, we aimed to better define the most relevant postoperative complication.

Materials and methods:

The protocol included an initial assessment with clinical grading of varicoceles and evaluation of testicular volume, ultrasound evaluation of testicular volume and calculation of the atrophy index. Indication for surgical treatment was defined to be testicular volume asymmetry > 20%, increasing volume asymmetry when reaching a difference of 20%, discomfort and pain or bilateral varicocele. Standard treatment was the Palomo procedure (laparoscopically since 2005). All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015.

Results:

129 patients with right varicocele were referred to institution. 70 were treated because of volume asymmetry > 20%, discomfort or pain. 26 of the 28 patients treated for volume asymmetry showed a catch up growth. Postoperative hydroceles were detected in 51%; 29 patients presented with a grade I hydrocele, three patients with a grade II hydrocele and four patients with a grade III hydrocele.

Conclusion:

Our treatment protocol allowed judicious indication for surgery and our postoperative outcomes are in accordance to the literature. The high rate of catch up growth in operated cases presents a veritable indicator for successful treatment in cases where more precise parameters like semen quality or paternity rate are not yet detectable. The introduced grading system for postoperative hydroceles proofed to be a valid and appropriate instrument and promises comparability of future studies.

DGCH: Ethical aspects of maximal surgical treatment escalation

Decompressive laparotomy as salvage therapy for abdominal compartment syndrome during extracorporeal membrane oxygenation. Outcome and implications.

(Abstract ID: 464)

T. R. Glowka1, J.-C. Schewe1, S. Münster1, C. Putensen1, J. C. Kalff1, D. Pantelis1

1Universitätsklinikum Bonn

Background:

Extracorporeal membrane oxygenation (ECMO) is increasingly used in tertiary care centers. However, indications remain uncertain and outcome is poor. With emerging use, more and more surgical problems occur, even in primarily “non-surgical” patients. Besides vascular complications, abdominal compartment syndrome (ACS) is a relevant problem during ECMO therapy regularly requiring decompressive laparotomy (DL).

Materials and methods:

Over a three-year-period, all patients undergoing ECMO at Bonn University Medical Center were included. Indication for ECMO therapy, demographic factors, comorbidities, overall morbidity, ACS and DL frequency and mortality were recorded.

Results:

175 (109 male, 66 female) patients underwent ECMO therapy with an overall mortality of 65%. Main indications were acute respiratory distress syndrome (n=65), postpericardiotomy syndrome after elective cardiac surgery (n=37), myocardial infarction (n=25), extracorporeal cardiopulmonary resuscitation (n=11), and other conditions (n=37). Ninety-one were performed as veno-venous (vv) ECMO and 84 were performed as veno-arterial (va) ECMO. In 36 patients CPR preceded ECMO. Eleven patients (6%) developed ACS and underwent DL, of which only three patients survived (mortality of DL combined with ECMO 73%). Risk factors for mortality were older age (P=0.032), a Charlson Comorbidity Index (CCI) > 1 (P=0.004), a SAPS II score >= 42 on ICU admission (P=0.013) and >= 44 on ECMO start, respectively (P=0.004). Multivariate analysis revealed CCI and SAPS at ECMO start as significant risk factors.

Conclusion:

ECMO plus ACS is a life-threatening combination with a devastating outcome. Nearly every tenth va ECMO required DL for ACS. Awareness for this complication should lead to abdominal pressure surveillance and early interventions, eventually avoiding ACS.

Increase in interest and number of advance health care directives and other provisions

(Abstract ID: 652)

T. Lang1, K. Fedtke1, T. Serrano Contreras2, M. Schreiner1, F. Kehl1, M. R. Schön1, C. Justinger1

1Städtisches Klinikum Karlsruhe

2Karlsruher Institut für Technologie (KIT), Karlsruhe

Background:

Advance health care directives (AD) emerged from the desire to influence medical treatment even in borderline situations. In February 2017, the German Federal Court of Justice has concretized the requirements for a valid advance health care directive as general standard forms are not a sufficient instrument to refer to the patient's will. This has led to increased discussions and information about AD and other means of provision in general. By means of questionnaires, this study aimed at the frequency of advance directives and other provisions among the patients undergoing anesthesia and at related influencing factors.

Materials and methods:

Between April and September 2016, 200 patients were handed out an anonymous questionnaire prior to scheduled surgery, on the topic of advance health care directives, of which 148 (74%) were returned. In addition to questions about the existence of or the intention to draw up ADs, 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, 80.4% stated they knew about advance directives but only 25.6% had drawn up one, while 13.5% did not know about the possibility of drawing up such a document.

Overall, the majority (84.5 %) has already made an AD or considers doing so an option.

Most patients (79.7 %) believed that the physicians will take an AD into account in decisions about further treatment.

37.8 % of the patients wished more information on that topic while 42.6% stated that they feel well informed. Most people (77.0%) preferred to receive this information from their general practitioner (GP).

As well, 77.0% of patients wished that the attending surgeon mentions the topic prior to surgery.

Conclusion:

Although the proportion of patients that draws up advance health care directives rises, surgical patients have a great need for information regarding the topic. Physicians and other hospital personnel should inform patients before planned surgery.

Maximal therapy in elderly patients with liver malignancy: where is the limit?

(Abstract ID: 714)

B. Ergün1, K. Jansen1, R. Bergholz1, M. Koch1, E.-G. Achilles1, U. Herden1, L. Fischer1, B. Nashan1, J. Li1

1Universitätsklinikum Hamburg-Eppendorf

Background:

As the average age of the population is getting older there is an increasing number of elderly patients in need of maximal medical treatment. Regarding liver resection in elderly patients there is still only few data about risk and benefit balance. Till now it is unknown where the limit is for performing aggressive liver resection in this population.

Materials and methods:

A retrospective study was conducted for liver resection in a tertiary referral center between July 2012 and December 2016. A total of 501 patients were included and the patients were analyzed according to the age (under 75 years or older) at the surgery. The preoperative factors analyzed with ACS Risk Score were compared to postoperative morbidity and mortality between the groups.

Results:

79 out of 501 patients were considered as elderly with age > 75 years. The postoperative 90-day mortality for minor and major liver resections as hemihepatectomy right or left was zero. The morbidity was comparable in elderly and younger patients. However a 90-day mortality of 26.3% was found in elderly patients undergoing extended hemihepatectomy in contrast to 7.1% in the group of young patients (p<0.05) (Table 1). In the multivariate analysis, we found that the rate of liver-surgery specific complications (liver failure, bile leakage, hemorrhage or infection) was comparable in both groups. Whereas non-surgical postoperative complication, in form of cardiological or neurological complication, occurred more often in the elderly patients undergoing extended hemihepatectomy, and was found to be associated with a higher mortality (p< 0.01).

Table:

Conclusion:

Except extended hemihepatectomy, major liver resection such as right or left hepatectomy performed in specialized institute is safe and can achieve excellent perioperative outcome in patients 75 years and above. We believe that strategy to identify the risk population and goal-orientated treatment is desired to improve also the results after extended hemihepatectomy in this cohort.

DGCH: European Reference Networks in Surgery

Encouraging student-driven clinical research in Germany and Europe: The CHIR-Net SIGMA network.

(Abstract ID: 76)

M. Friedrich1, P. Frey2, L. Rädeker2, C. Fink2, A. Leuck2, J. Neudecker3, A. L. Mihaljevic2

1, Heidelberg

2Universitätsklinikum Heidelberg

3Charité - Universitätsmedizin Berlin

Background:

Evidence should define and guide modern clinical care, yet many relevant questions in surgical practice remain unconfirmed by substantial data. Evidence-based medicine (EbM) requires both the implementation of its principles in day-to-day work as well as the acquisition of new evidence, preferably by randomized-controlled trials and systematic reviews. Meaningful clinical research however is challenging to conduct and its overall infrastructure in Germany was - until recently -considered poor as compared to other leading countries. While this has been significantly improved following the establishment of the Studienzentrum der Deutschen Gesellschaft für Chirurgie (SDGC) and the Surgical clinical trial network CHIR-Net, limited focus has been put on training, teaching and recruitment of medical students to become competent clinical researchers and clinician scientists.

Materials and methods:

To address these challenges, the CHIR-Net has established a student-initiated and -led clinical trial network (SIMGA; student-initiated German Medical Audit) in 2017. Inspired by similar initiatives from the United Kingdom, this network enables students to participate in academic research projects and serves as exchange platform between students and research-experienced physicians. As part of the SIGMA network, students contribute to national multi-center trials while improving clinical and research skills and gaining an insight into clinical academia.

Results:

To ensure continuing comprehensive clinical research in surgery, the CHIR-Net aims to establish a student-driven multicenter research network in Germany, which is embedded in both the national CHIR-Net as well as pan-European and international frameworks.

Given the above mentioned challenges, CHIR-Net SIGMA has the following objectives:

Creation of a national multicenter network of medical students and associated clinician scientists, clinical researches and associated professions (biostatisticians, study nurses etc.). Establishment of a clinical trial infrastructure to enable the conduct of student-led multicenter clinical trials. Education and training of medical students in clinical trial methodology, regulatory affairs and ethical clinical trial conduct. Design, initiation, conduction, analysis and publication of prospective multicenter clinical trials initiated and led by medical students.

Conclusion:

SIGMA (Student-Initiated German Medical Audits) is a product of strong collaboration between clinical scientists and medical trainees, enabling students to contribute to high-quality clinical trials. Additionally, participants are offered extensive training to support the next generation of research-active clinicians. Starting in 2018, SIGMA will perform its first multicenter observational study in Germany and be part of a multi-national trial run in 13 European countries, Australia and New Zealand.

CHIR-Net SIGMA organigram
Picture:

CHIR-Net SIGMA organigram

DGCH: Free topics

Management of visceral artery aneurysms over three decades

(Abstract ID: 37)

S. Regus1, W. Lang1

1Universitätsklinikum Erlangen

Background:

Introduction:

True visceral artery aneurysms (VAA) should be treated under elective conditions in dependency on maximum diameter. In this respect the traditional accepted threshold is 2 cm, whereas VAA sizing less than 2cm should conservatively be observed without invasive treatment. The aim of this study was to review differences in the treatment outcome over three decades.

Materials and methods:

This was a retrospective review of all treated VAAs at one institution from 1985 to 2015. Patients demographics, aneurysm characteristics, management and outcome were recorded with special regard to differences in the course of time.

Results:

31 true VAA in 29 patients (74% female) were repaired (5 ruptured, 26 intact). Mean diameter was 30.3 ± 1mm for intact and 38.0 ± 9mm for ruptured VAA (rVAA) (p = NS). The most patients were asymptomatic (67.8% asymptomatic, 16.1% symptomatic without rupture and 16.1% with rupture). There was a vice-versa situation in chosen treatment techniques between the first (1985 - 2000) and the second (2001 - 2015) time period (first period: 75% open surgery and 25% endovascular; second period: 27% open surgery and 83% endovascular; p = 0.009). Open surgery included aneurysm ligation and resection with (end- to-end-anastomosis, graft interposition or without blood flow reconstruction, while endovascular technique was exclusively coil embolization. Immediate technical success was 80.6% for all procedures. The technical success rate was similar between the two time periods (69% in the first, 93% in the second; p = 0.101). Conversion to open surgery due to technical failures was necessary after 3 endovascular repairs (20%). The overall 30-day-mortality rate decreases in the course of time (25% in the first and 0% in the second period; p = 0.038). Furthermore there was a lower 30- day mortaliy rate after endovascular repair (20% after open surgery, 0% after coil embolization; p = 0.038). There was no decrease in 30-day mortality rate of rVAA (100% in the first and 20% in the second period; p = NS).

Conclusion:

In the fact of medical progress and a growing number of endovascular procedures, this study presents a decrease in mortality rate after elective aneurysm repair over three decades. This might become an argument to reduce the 2-cm-threshold in highly selected individuals.

Surgeon's experience affects outcome of forearm arteriovenous fistulae more than outcomes of upper arm fistulae

(Abstract ID: 38)

S. Regus1, V. Almási-Sperling1, U. Rother1, A. Meyer1, W. Lang1

1Universitätsklinikum Erlangen

Background:

There is still an ongoing discussion about the influence of vascular surgeons experience on the immediate and long-term outcome of newly created arteriovenous fistula (AVF) for patients on hemodialysis (HD). The aim of this study was to compare failure and patency rates of AVF between experienced consultants and resident trainees with special focus on location of the anastomosis on the forearm or upper arm.

Materials and methods:

Between November 2012 and September 2016 159 patients (83 on HD and 76 preemptive) received an AVF (90 radiocephalic (RCAVF) on the forearm; 69 brachiocephalic (BCAVF) in the elbow) by two experienced vascular surgeons (group A; N = 74) or five residents in training with one to four years of experience (group B; N = 85). We compared the two groups for demographic and treatment data, immediate failures (IF), bleeding complications and patency rates.

Results:

There were no significant differences in demographic data between the two groups. Vessel diameter were significantly lower for forearm compared to upper arm arteries (p = 0.026) and veins (p = 0.05). There was a significantly increased risk for IF in group B for RCAVF (p = 0.003), but not for BCAVF (1.000). Furthermore the cumulative PP was reduced in group B for RCAVF (p < 0.001), but not for BCAVF (p = 0.899).

Conclusion:

Surgeons experience seems to have more influence on the immediate and long-term outcome of newly created forearm AVF compared to those located on the upper arm.

Ruptured giant splenic cyst in a 11 year old girl treated with percutaneous sclerosis and partial splenectomy: Case report and review of the literature

(Abstract ID: 195)

P. Lüse1, M. Milosevic1, D. Cholewa1, S. Berger1

1Inselspital, Universitätsspital Bern

Background:

Giant splenic cysts are rare. The mainstay of surgical treatment is partial splenectomy with complete resection of the cyst. Percutaneous treatment with different sclerosing agents were proposed in the past with varying results.

Materials and methods:

We report the case of an 11-year-old girl with a ruptured giant epidermoid cyst of the spleen. She was admitted to our emergency department with abdominal pain after mild blunt abdominal trauma. Initial FAST and CT showed a vast amount of free fluid and a rupture of the spleen (grade III) inappropriate for the minimal trauma and the normal hemoglobin levels. During follow up, a giant splenic cyst developed with a volume of about 1900ml. Serological tests excluded an Echinococcus infection. Elevated serum tumor markers CA 19-9 and CEA established the diagnosis of a congenital epidermoid splenic cyst. The large extent of the cyst made a successful resection by partial splenectomy unlikely. Therefore, an ultrasound guided percutaneous catheter drainage and sclerotherapy with Polidocanol 3% was performed repeatedly. Although the splenic cyst did not resolve, its size decreased to 180ml. A subsequent partial splenectomy was assisted by radiofrequency (RF) ablation technique.

Results:

An ultrasound follow up at 6 and 12 months after surgery showed no cystic structure in the spleen. The blood samples were normal with no signs of Howell Jolly bodies and CEA and CA 19-9 levels have also decreased to almost normal limits. Histopathological examination confirmed a congenital epidermoid splenic cyst with a squamous epithelium lining.

Conclusion:

First line treatment of large splenic cysts remains complete resection of the splenic cyst with preservation of as much splenic tissue as possible. Percutaneous Polidocanol sclerotherapy can be tried in selected cases or may help to reduce the cyst size in preparation for partial splenectomy. The tumor markers CEA, CA 19-9 are helpful to evaluate the cyst origin and the progress of treatment with sclerosing agents. Radiofrequency ablation technique may help to reduce intraoperative bleeding.

The role of transurethral catheter in patients receiving thoracic epidural analgesia: necessary or needless?

(Abstract ID: 216)

A. Ali1, A. Pertschy1, E. Klar1

1Universitätsmedizin Rostock

Background:

Thoracic epidural analgesia is today widely used for postoperative pain control in patients undergoing major visceral and thoracic surgery. Many patients however may experience postoperative urinary retention (POUR). This study was designed to answer the question whether POUR is increased by removal of the urinary catheter during ongoing epidural analgesia as compared with simultaneously maintaining drainage of the urinary bladder.

Materials and methods:

The retrospective and prospective observational study was conducted from January to October 2016. Seventy- one patients undergoing major visceral (n=50) and thoracic (n=21) surgery, who received an intraoperative epidural analgesia for postoperative pain control, were included. Removal of the transurethral catheter was performed under thoracic epidural analgesia (TEA) in 33 patients (group 1) and after discontinuation of TEA in 38 patients (group 2). The anesthetic solution consisted of ropivacaine, 0.2%, and fentanyl 10 μg in both groups. Urinary retention, the necessity of re-catheterisation and the epidural infusion rate at which the urinary catheter was removed in group 1 were recorded.

Results:

Two patients in group 1 (n=2/33) required re-catheterisation for postoperative urinary retention when the transurethral catheter was removed under thoracic epidural analgesia; the incidence of POUR in this group was 6%. The average epidural continuous infusion rate at the time of decatheterisation in patients who developed postoperative urinary retention and in those who did not developed POUR was identical (4mL/h), In group 2 also two patients (2/38) required re-catheterisation for postoperative urinary retention when the transurethral catheter was removed after discontinuation of TEA; the incidence of POUR in this group was 5.2%. There was no significant difference in the incidence of POUR between both groups.

Conclusion:

Early removal of the transurethral catheter under thoracic epidural analgesia seems feasible and has no influence on the outcome of postoperative urinary retention. The transurethral catheter can be removed independent of the epidural analgesia to reduce the risk of urinary tract infection.

Can antiarrhythmic prophylaxis avoid postoperative atrial fibrillation after major lung resection?

(Abstract ID: 446)

A. Gassa1, S. Stange1, F. Dörr1, M. Heldwein1, J. Y. Seo1, S. Macherey1, T. Wahlers1, K. Hekmat1

1Universitätsklinikum Köln

Background:

Postoperative atrial fibrillation is the most frequently occurring complication in patients undergoing thoracic surgery and causes significant morbidity. Therefore strategies are imperative for preventing postoperative arrhythmia. We aimed to validate the use of preoperative administration of antiarrhythmic medication on the occurrence rate of postoperative atrial fibrillation by performing a systematic review.

Materials and methods:

The literature research was executed according to a structured protocol. A systematic research in Medline and the Cochrane Database of Systematic reviews was performed on 20th September 2017 for articles published since 2000. The strategy used was (<atrial fibrillation>) AND (<lung surgery> OR <pulmonary resection>) AND (<amiodarone> OR <antiarrhythmic prophylaxis>). Articles in languages different from German and English were excluded. We excluded studies that used other antiarrhythmic drugs than amiodarone, magnesium or beta-blockers.

Results:

Our systematic literature research revealed 86 articles. After exclusion of all non-relevant publications six papers with a total number of 1,240 patients were included in this work. Five studies described prospective randomized trials and one was designed retrospectively. 437 patients received amiodarone, 219 patients were treated with magnesium-sulfate and 64 patients got a beta-blocker as antiarrhythmic prophylaxis undergoing anatomical pulmonary resection. In total, 520 patients received placebo as control. Four studies dealing with amiodarone as antiarrhythmic prophylaxes showed a significant lower occurrence rate of postoperative atrial fibrillation varying from 9% to 14% compared to the non-drug group varying from 16% to 33% (p <0.05). Two studies failed to show a significant difference in the drug group receiving beta-blocker. Additionally the length of ICU stay was significantly lower in the group of patients with amiodarone as prophylaxis in two studies (26 hours and 46 hours versus 44 hours and 84 hours, p <0.05). No difference of length of hospital stay and costs in any of the mentioned antiarrhythmic drug group was observed.

Table:

Conclusion:

Postoperative atrial fibrillation occurs in up to 35% after major lung resection. Risk factors which increase the postoperative occurrence of arrhythmias are the extent of lung resection, sex, higher age, intrapericardial pneumonectomy and mediastinal dissection. In a risk constellation the administration of antiarrhythmic drugs before surgery seems to be an appropriate way to reduce the postoperative occurrence of atrial fibrillation. Amiodarone is the best studied drug to prevent atrial fibrillation and might therefore be the drug of first choice.

Is video-assisted thoracoscopic surgery better than open thoracotomy in the management of pleural empyema?

(Abstract ID: 449)

A. Gassa1, F. Dörr1, M. Heldwein1, J. Y. Seo1, S. Stange1, S. Macherey1

1Universitätsklinikum Köln

Background:

Pleural empyema or parapneumonic effusion can result in a lethal state with organized pus, lung restriction and sepsis. In most cases, it is caused by pneumonia. According to EACTS consensus, we differentiate between three stages of pleural empyema. If medical treatment fails, thoracic surgery will be necessary to perform pleural debridement or decortication. Since the 1990s, minimal invasive surgery such as video- assisted thoracoscopic surgery (VATS) is playing a major role and overtook open thoracotomy. We performed a systematic literature review to evaluative differences in VATS versus open thoracotomy in patients with stage 2 or 3 empyema.

Materials and methods:

A systemic research in Medline and the Cochrane Database of Systematic reviews was performed on 20th September 2017 for articles published since 1990. The strategy consisted of (<adults with pleural empyema> OR <parapneumonic effusion> OR <empyema thoracis>) AND (<decortication> OR <open surgery>) AND (<video-assisted thoracoscopic surgery> OR <VATS>). Articles in languages different from German and English were excluded.

Results:

A total of 121 articles were found using Medline and none in Cochrane Database of Systematic reviews. 18 studies reporting on 2,301 patients were deemed to be relevant. These studies investigated the duration of thoracic chest drainage, length of hospital or ICU stay, duration of operation time, morbidity and mortality as primary end points. If surgeons decided intraoperatively to perform open thoracotomy (OT) instead of VATS, it would be noted as conversion rate to OT. 1,075 patients undergoing VATS stayed significantly shorter in hospital due to shorter duration of chest tube drainage (range days 4-10 vs. 5-18, p < 0.001) and due to less postoperative complications in comparison with 991 patients undergoing OT. Conversion rate from VATS to OT varied between 10% and 50% of planned VATS in stage 3 empyema.

Conclusion:

The surgeon's decision on the surgical procedure depends on visceral pleural thickness in chest CT scan and biochemical analysis of pleural effusion. VATS is a safe and effective procedure for pleural debridement. OT should still be considered in severe cases in patients with stage 3 pleural empyema. Preoperative accurate preparations and early diagnostic reduce the risk of reintervention or postoperative complications.

AntiSepticsˊ Magnitude for the Prevention of Surgical Site InfectiONS in abdominal surgery - The SIMPSONS Trial (DRKS00011174)

(Abstract ID: 473)

J. C. Harnoß1, O. Assadian2, A. Kramer3, P. Probst1, C. Müller-Lantzsch1, L. Scheerer1, T. Bruckner1, M. K. Diener1, M. W. Büchler1, A. B. Ulrich1

1Universitätsklinikum Heidelberg

2Medizinische Universität Wien

3Ernst-Moritz-Arndt-Universität Greifswald

Background:

The prevention of surgical site infections (SSIs) in abdominal surgery has received increasing attention during the past decades. Accordingly, several high impact clinical trials analysed the role of skin antisepsis. The additive benefit of the long-term effective (remanent) antiseptic chlorhexidine was investigated against other combinations. However, effectiveness of chlorhexidine in alcoholic solutions versus alcohol-based skin preparations alone is still unclear.

Materials and methods:

In a prospective controlled clinical cohort trial, patients scheduled for abdominal surgery received preoperative skin antisepsis with 2% chlorhexidine + 70% iso-propanol (CA) or 70% iso-propanol (PA) alone. The primary endpoint SSI incidence was evaluated on postoperative day (POD) 10. Univariate analysis, and a multivariate logistic regression model, correcting for known independent risk factors of SSI, were conducted.

Results:

During the two study periods 500 patients undergoing elective midline laparotomy were included (CA: n=221, PA: n=279). On POD 10 the incidence of superficial and deep SSIs differed significantly (CA vs. PA: 6.6% (14/212) vs. 12.3% (32/260), p=0.038). In the multivariate analysis, skin antisepsis with CA was an independent factor for SSI incidence (p=0.034).

Conclusion:

This trial was the first confirming the benefit of adding the remanent agent chlorhexidine to alcohol for skin antisepsis compared to alcohol alone. Future studies should analyse the justification of different agents with more sustained antimicrobial activities, such as chlorhexidine gluconate, octenidine-dihydrochloride or quaternary ammonium compounds, as antimicrobial compounds of alcoholic skin preparations.

Feasibility of ultrasound-guided vacuum-assisted biopsy in the assessment of soft-tissue tumors

(Abstract ID: 554)

M. Simidjiiska-Belyaeva1, K. Harati1,I. Stricker1, O. Belyaev2, A. Tannapfel1, A. Daigeler3, M. Lehnhardt1

1BG Universitätsklinikum Bergmannsheil, Bochum

2St. Josef-Hospital - Unviersitätsklinikum Bochum

3BG Unfallklinik Tübingen

Background:

Obtaining an accurate histologic diagnosis prior to excision of a soft-tissue mass is of utmost importance. There is no consensus on the biopsy technique which should be used. This pilot study aimed to compare the safety and efficacy of ultrasound-guided vacuum-assisted biopsy (US-VAB) to those of US-guided and CT-guided conventional core needle biopsy (US-CNB and CT-CNB) and open incisional biopsy (OB).

Materials and methods:

A prospective observational study was performed (ethic approval RUB Nr. 15-5882). A single experienced surgeon performed diagnostic US-VAB in 50 consecutive patients with soft-tissue tumors between September 2016 and September 2017, using the VACORA system by BARD. 3 to 5 samples per patient were obtained. All biopsies were performed in an outpatient setting under local anesthesia. Results were compared to historical control groups of US-CNB, CT-CNB, and OB performed at our institution between 2013 and 2016.

Results:

There were 26 females and 24 males at the mean age of 60±12 years. 54% of tumors were localized in the lower extremity, 26% in the trunk and 20% in the lower extremity. 50% of tumors were malignant: sarcoma n=19, cancer metastasis n=3, lymphoma n=2, malignant melanoma n=1. Of the benign lesions lipomas were predominant n=14, the rest were chronic inflammation n=7, and fibromas n=4. Tumor size averaged 143±74 mm. Adequate tissue samples with a mean length of 20±5 mm and diameter of 5±1 mm were obtained in all patients. The duration of procedure was 5±2 minutes, 4±1 ml of Xylocain 2% was used. No complication occured. Accuracy in discrimination between malignant and benign lesions was 96% and was higher than any of the control bioptic methods. Accuracy of determining tumor grading of sarcomas was 95% (18/19).

Table:

Conclusion:

Ultrasound-guided vacuum-assisted biopsy offered supreme diagnostic accuracy. Comlication rate was zero and price was much lower than in CT-guided and open biopsy. US-VAB is an accurate, safe, fast and reasonably priced outpatient diagnostic procedure for patients with soft-tissue tumors.

Clinical characteristics of capnocytophaga canimorsus: a case report and systematic literature review

(Abstract ID: 631)

M. Aziz M.1, S. Stahl1

1Klinikum Lüdenscheid

Background:

Capnocytophaga canimorsus is a Gram-negative bacterium found in the oral cavities of between 25.5% and 74% dogs and 17% cats. Infections with this rod-shaped bacterium can lead to life-threatening septicemia, with an overall mortality rate of 26%, and is often accompanied with a history of exposure to canines. It is reported that patients with prior splenectomy, alcoholism or presence of immune deficiency are more susceptible to infection. As described in several case reports, an infection with C. canimorsus can lead to serious conditions such as septic shock, organ failure, disseminated intravascular coagulation (DIC), hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura (TTP), endocarditis, gangrene of the extremities and meningitis. We report a case of a patient with no related predisposition who developed a septic shock, multiorgan failure and gangrene of the extremities following a dog bite to the right index finger. We also performed a systematic literature review of 39 cases published in the last ten years.

Materials and methods:

We searched the Ovid MEDLINE (2007 to July 1, 2017) database for “Capnocytophaga canimorsus” and “sepsis”. To minimize the effects of indexing bias, we further included literature from an extensive Internet literature search and indexed articles. Only English full-text articles were evaluated. Nonsystematic reviews of the scientific literature were classified as expert opinions. Our initial search provided us with 107 articles. Furthermore, we excluded off-topic publications (e.g., genomic analysis, DNA sequencing and association with joint arthroplasty) and literature reviews, which led to a total of 23 relevant articles. The reasons for exclusion were documented systematically.

Results:

Our review reveals that 45% of the patients with septic shock involving C. canimorsus had none of the commonly reported risk factors at the time of admission. Llittle research has been conducted in the reviewed literature to examine comorbidities, such as cardiovascular, respiratory, endocrinological and hematological diseases as a possible risk factor. In the majority of case reports, smoking was not considered a risk factor. Nonetheless, tobacco use has also been reported to enhance C. canimorsus growth by increased acquisition of iron, which provides a favourable environment for the bacteria to grow.

Time to diagnosis exceeds on average 13 days. Initial symptoms included fever (58%), symptoms of gastrointestinal nature (45%), pain (23%) and malaise (23%).

Only four other cases of altered confusional state were reported. Livedo racemosa and sepsis due to C. canimorsus infection has previously been described in two cases. Organ failure, followed by acute respiratory distress syndrome (ARDS) were the most common clinical features. Our review confirms that diagnostics were confirmed through blood cultures on average nine days after blood sampling (median: 5.5 days; min: 2 days; max: 30 days). Initial trauma (i.e. dog bite) was reported on average four days before admission (median: 2 days; min: 1.5 days; max: 28 days).

Conclusion:

This case demonstrates the necessity for rapid diagnosis, early surgical debridement and antibiotic treatment. A thorough patient history can contribute to the awareness of a potential C. canimorsus infection. Complication rates may be reduced by early PCR screening and surgical debridement as well as appropriate antibiotic treatment.

Merendino procedure versus transhiatal resection: Which procedure offers better outcome and quality of life?

(Abstract ID: 726)

A.-K. Eichelmann1, M. Nikitina1, P. Slepecka1, N. Senninger1, D. Palmes1

1Universitätsklinikum Münster

Background:

A limited resection of the cardia with resection of the esophagogastric junction can either be performed by the Merendino procedure with reconstruction by an isoperistaltic jejunal interposition or by transhiatal resection of the distal esophagus with reconstruction by a stomach tube. The aim of the study was to compare postoperative complications and quality of life between both procedures.

Materials and methods:

Between 2011 and 2017, 22 patients with Merendino reconstruction and 17 patients with transhiatal resection were included in the retrospective analysis. Esophagojejunal anastomosis was performed in 17 patients with a stapler in the Merendino group (77,3%), while a stapler-based esophagogastric anastomosis was performed in 16 patients in the transhiatal group (94%). Occurrence of postoperative complications (according to Clavien-Dindo classification), length of stay and quality of life regarding gastrointestinal symptoms (dysphagia, reflux, pain, eating disorders) were compared and tested for significant differences between the study groups using Mann-Whitney-U test and Fisher Exact test (p<0.05).

Results:

In the transhiatal group, median age of the patients was significantly higher than in the Merendino group (71 years [53-92] vs. 57,5 years [19-75], p=0.0002). Moreover, postoperative length of stay was prolonged in the transhiatal group (35,9 +/- 28,1 days vs. 18,2 +/- 10,6 days, p=0.0002) and patients who underwent a transhiatal resection had a higher rate of anastomotic leakage (24% vs. 9%, p=0.0171). On the other hand, the complication rate according to Clavien-Dindo grade 1-5 was similar between both groups (p=0.1694). Regarding quality of life, 14% of the patients who underwent a reconstruction after Merendino suffered from dysphagia.

Conclusion:

Our study suggests that both the Merendino procedure and transhiatal resection for limited resection of the cardia are similar with regard to complication rates and functional outcome. Because of the fact that the Merendino procedure aims to substitute the lower oesophageal sphincter by isoperistaltic jejunal interposition, this procedure should be preferred especially in younger patients.

Pediatric medical devices and surgical instruments in Germany: a status report

(Abstract ID: 756)

L. Tüshaus1, C. Härtel1, R. Wendlandt1, A.-P. Schulz1, F. Frielitz1, E. Herting1, L. Wuensch1

1Universitätsklinikum Lübeck

Background:

Children are entitled to a safe medical care, which should reflect the current state of science and technology. Nevertheless, the design and development of medical devices and surgical tools for the pediatric field is still a challenge. Due to regulations, higher development costs and the small market share of pediatric medical devices, development in this field is more complicated and burdensome.

Results:

We are reporting about the current situation of pediatric medical devices in Germany, with particular focus on clinical needs, regulatory framework and healthcare economics. A comparison with pediatric medicines in Germany carried out. We address the different roles of the stakeholders (users, developers, manufacturers, participating authorities, patients and their parents) involved.

We are providing an overview about the development of medical devices for this special population in Germany. Ongoing R&D projects, network activities (e. g. PedMedDev @ Germany, www.pedmeddev.org) and funding opportunities, which are aiming to promote and improve development and innovation of medical products for children and adolescents in Germany, are discussed.

Conclusion:

The design and development of pediatric medical devices and surgical instruments is requiring special considerations. There is a need of well-designed medical devices for children. In the context of legislation and regulation pediatric medical devices are not particularly been considered and promoted (a “pediatric gap”).

Panton-Valentine leucocidin (PVL) abscesses in children and young adults - An infection on the rise?

(Abstract ID: 886)

K. Schulte1, J.-P. Schmalfeldet1, E. P. M. Lorenz1

1St. Hedwig-Krankenhaus Berlin

Background:

Staphylococcus aureus is emerging globally. Treatment of infections is complicated by increasing antibiotic resistance. Panton-Valentine leukocidin (PVL) is a ß-pore forming cytotoxin. The presence of PVL is associated with increased virulence of certain isolates of Staphylococcus aureus. It can cause necrotic lesions involving the skin or mucosa or necrotic haemorrhagic pneumonia. PVL creates pores in the membranes of infected cells. PVL is produced from the genetic material of a bacteriophage which infects Staphylococcus aureus, making it more virulent.

Materials and methods:

A 15-year-old immunocompetent male was seen in the emergency department complaining of a painful and rapidly progressive swelling in the left gluteal region. He had been suffering from multiple skin abscesses in the past, which had needed surgical excision.

A gluteal abscess was diagnosed clinically and operatively excised the same day. The postoperative course of the patients was uneventful and the patient was discharged one day postoperatively.

In the microbiological analysis a methicillin-susceptible Staphylococcus aureus was isolated and the presence of lukF-lukS genes for PVL were determined.

In order to avoid further spread of the cytotoxin the patient underwent an ambulant antibiotic eradication therapy with Cotrimoxazole 960mg twice daily for 14 days and rifampicin 600mg once daily for three days.

Results:

The case shows the importance of having a possible infection with PVL in young and immunocompetent patients in mind. Especially when recurrent, otherwise uncomplicated abscesses are reported or there are recent travels in the patients' history. Up to one third of skin abscesses in travellers have been found to be PVL-positive. Predominately after travels to Africa and South East Asia.

It is to note that even if travels are not present in the history of the patient, an infection with PVL cannot surely be ruled out. As PVL is highly virulent, an infection should also be suspected when close contacts suffer from similar symptoms.

Conclusion:

An infection with PVL should be suspected and ruled out in young immunocompetent patients with recurrent cutaneous abscesses or affected contacts. It should likewise be considered in the differential diagnosis of acute, severe community acquired pneumonia.

Retrospective analysis about the perioperative management of patients with hemorrhagically coagulation disorders of the University of Bonn

(Abstract ID: 894)

C. Nicklaus1, P. Lingohr1, G. Goldmann1

1Universitätsklinikum Bonn

Background:

Due to the rarity of patients with hereditary hemorrhagically coagulation disorders there are very few retrospective analyses about their perioperative management. Thanks to the long existence of the Haemophilia Centre at the University Clinic in Bonn and its size you can find a high quantity of number of patients and achieve a high number of cases concerning surgical interventions. This retrospective study is intended to statistically deduce surgical interventions performed on patients of the Haemophilia Centre at the University Clinic of Bonn.

Materials and methods:

In a retrospective cross-sectional analysis, we collected and statistically examined the data of patients including for example the type of surgery, the duration of the stay in the hospital, uses of factor supplements, factor levels as well as the complication rate during a time frame between 1974-04/2015.

Results:

We gathered the data of 1410 surgeries on 665 patients. Surgical interventions were performed amongst all specialties.

Conclusion:

As of right now the study is still being analyzed. The final results are expected by the beginning of 2018. Initial results seem to suggest that there are no particular abnormalities in the factors studied.

DGCH: Innovative concepts and motivation in surgical training

Sustainability takes time: Effects of the psychologically tailored interventions on hand hygiene compliance in the PSYGIENE cluster-randomized controlled trial after two years of follow-up

(Abstract ID: 331)

I. F. Chaberny1, B. Lutze1, C. Krauth2, K. Lange2, J. T. Stahmeyer2, T. von Lengerke2

1Universitätsklinikum Leipzig

2Medizinische Hochschule Hannover

Background:

First-year follow-up results of the PSYGIENE cluster-randomized controlled trial, a project funded by the German Federal Ministry of Health (grant no.: INFEKT-019) and conducted on the intensive care and hematopoietic stem cell transplantation units at Hannover Medical School, had shown increased alcoholic-based hand hygiene compliance both in the study arm using interventions psychologically tailored to wards based on the Health Action Process Approach (HAPA), and the study arm using the standard German Clean Care is Safer Care-campaign (Aktion Saubere Hände [ASH]) [1]. To test whether the psychologically tailored PSYGIENE-interventions lead to sustainable increases in hand hygiene compliance compared to the ASH after two years of follow-up.

Materials and methods:

Tailored interventions targeted wards and were informed by problem-focused interviews with physicians and staff nurses (response rates: 100%) and a written survey on HAPA-factors (physicians: 71%; nurses: 63%). In educational sessions for physicians and nurses, and feedback discussions with staff nurses, 29 behaviour change techniques (BCTs) [2] were used in the “tailoring”-arm, and 15 in the ASH-arm. Compliance observations adhered to WHO-/ASH-standards.

Results:

Given similar baseline compliance (tailoring: 54%, ASH: 55%, p=.581), tailoring was associated with increases in both follow-up years (2014: 64%, 2015: 70%, p=.001), while compliance in the ASH-arm decreased from 68% in 2014 to 64% in 2015 (p=.007). Comparisons of increases from 2013 to 2015 and compliance in 2015 were also in favour of the “tailoring”-arm (p=.005 and p=.001). While trends among nurses were similar, among physicians tailoring vs. ASH did not differ in increases from 2013 to 2015 (+15% and +12%, p=.658) and rates in 2015 (63% vs. 61%, p=.632). However, the increase of +6% in the “tailoring”-arm from 2014 to 2015 differed from the respective decrease of -9% in the ASH-arm (p=.016).

Conclusion:

After two years, psychological tailoring based on the HAPA-model was associated with a more sustainable increase in hand hygiene compliance, despite limited didactic methods (educational training sessions and feedback discussions) and the restriction of the tailored interventions to one year. However, regarding physicians still more research on interventions geared to this target group is needed.

Satisfaction of surgical residents with training procedure planning - results of a survey

(Abstract ID: 734)

J. Doerner1, C. Schneider2, M. Strik2, M. Stumpf3, Y. Dittmar4, J. K. Seifert5, H. Zirngibl6, J.-P. Ritz7, F. Koch7

1HELIOS Universitätsklinikum Wuppertal

2HELIOS Klinikum Berlin-Buch

3HELIOS Klinikum Pforzheim

4HELIOS Klinikum Meiningen

5HELIOS Klinikum Siegburg

6HELIOS Klinikum Wuppertal

7HELIOS Kliniken Schwerin

Background:

Performing surgical procedures under structured supervision is a critical component of surgical training. However, surgeons in training frequently may not perform procedures due to economical (time) and qualification requirements. Moreover, increasing use of laparoscopic surgery further impairs timely access to surgical training. Decision-making regarding assignation of procedures to individuals and teams has a significant impact not only on acquisition of skills, but also on overall motivation. The satisfaction of surgical residents in Germany has not been interrogated systematically as yet.

Materials and methods:

We performed a prospective study by modifying the usual process of assignment by senior peers, to the proactive involvement of surgical residents in day-to-day procedural planning of elective surgical cases. During the intervention period, planning was performed jointly by a resident physician and the senior peer in charge of the assignments. Satisfaction was determined using a 30-item anonymized online questionnaire. The survey included mostly quantitative questions across different areas related to satisfaction with OR planning. 41 individuals spanning all levels of training from 6 participating centers were eligible to participate. Participating centers included two primary care hospitals, one specialized care center, two tertiary care and one university hospital. The questionnaire was sent to the participants at baseline and in a slightly modified version after three months, after completion of the interventional period. Here we report the baseline results.

Results:

There was a 73% response rate. All senior physicians responsible for OR planning were male. Sex distribution among participants was equal (48% male, 52% female). Only one third (31%) of participants was fairly or totally satisfied with their surgical training in general, 42% were satisfied with guidance during the surgical procedures. 62% of participants had performed their first training appendectomy and open hernia repair during the first year of training, 65% of participants had performed supervised cholecystectomy after their second year of training. Chief and senior surgeons only infrequently (38% and 55% respectively: never or rarely) let trainees perform easier sub-steps (like open cholecystectomy) during more extended and complex procedures. 79% of participants reported that they had rarely or never been assigned to perform procedures they felt inadequately prepared for. Overall satisfaction was associated with perceived systematic training surgery planning, equal distribution of training procedures among all residents of a unit and sub-step assistance.

Conclusion:

Surgical residents feel well prepared for procedures they are entrusted to perform. Systematic planning, equal distribution of teaching procedures amongst residents and assistance of sub-steps may result in improved overall satisfaction of surgical residents. Shortly, we hope to report on the effect of the intervention regarding resident satisfaction and hope to see an improvement owed to more active involvement in the decision of distribution of surgeries in a unit.

DGCH: New surgical procedures, hybrid techniques and robotics

Minimally invasive Ivor Lewis Esophagectomy with Robotic Assistance: ICG fluorescence gastric mobilization with 5mm scope and thoracic robotic assisted Esophagectomy with standard circular stapled anastomosis - modular step up approach for safe introduction of new technology

(Abstract ID: 205)

H. Fuchs1, R. Lambertz1, W. Schröder1, J. M. Leers1, C. J. Bruns1

1Universitätsklinikum Köln

Background:

The use of robotic technology in abdominal surgery in Europe is rapidly increasing. Aim of this study is to evaluate the introduction of new technologies in a center of excellence for upper gastrointestinal surgery.

Materials and methods:

A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the center for the future of surgery (San Diego, CA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the davinci xi and stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>250 esophageal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic thoracic assisted Ivor Lewis esophagectomy.

Results:

From 02/2017 - 09/2017, a total of 30 cases were performed: cholecystectomy, n=8; right colectomy, n=1; fundoplication, n=3, splenectomy, n=1; Heller myotomy n=4; gastric mobilization, n=5; gastrectomy, n=1; pancreatic tail resection, n=1; thoracic esophagectomy, n=7). All cases were performed safely without operation-associated complications. Level of difficulty was increased based on our modular step up approach without quality compromises. Video documentation using the new technology is provided.

Conclusion:

The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.

Transoral Thyroid Surgery - Successful implementation of the TOETVA procedure within an international Thai-Austrian-German cooperation project.

(Abstract ID: 297)

E. Karakas1, A. Anuwong2, K. Ketwong2, G. Klein3

1Krankenhaus Maria Hilf, Alexianer GmbH, Krefeld

2Police General Hospital, Pathumwan, Bangkok

3Landeskrankenhaus Wiener Nestadt, Wiener Neustadt

Background:

Natural orifice transluminal endoscopic transoral parathyroidectomy and thyroidectomy was first described by German study groups several years ago. This led to and optimized and routinely used transoral endoscopic thyroidectomy vestibular approach (TOETVA) technique implemented by Anuwong. Herein we report the preparation, step-by-step implementation, and first promising results for TOETVA of an international surgical cooperation.

Materials and methods:

Our Thai-Austrian-German cooperation started in June 2017. Between June and September 2017 TOETVA procedures were performed female and male patient(s) presenting with single thyroid nodules or sporadic primary hyperparathyroidism and solitary parathyroid adenoma. TOETVA was performed using 3 laparoscopic ports inserted at the oral vestibule and CO2 insufflation pressure at 6-8 mmHg was used. Each surgery was performed using laparoscopic instruments and ultrasonic or bipolar devices. Surgical outcome, complications, conversions to open technique were determined.

Results:

Six patients presented with single thyroid nodules while one patient suffered from sporadic primary hyperparathyroidism with a left sided parathyroid adenoma. No conversion to conventional open surgery was necessary. Average tumor size was 2cm (1-3cm). Median blood loss was 20mL (6-100mL). No temporary or permanent hoarseness or mental nerve injury occured, while transient hypoparathyroidism was evident after successful parathyroid resection. Five patients developed a slight postoperative hematoma of the skin. No infection was identified.

Conclusion:

TOETVA was shown to be safe and feasible. This approach shows promise for patients who are motivated to avoid a neck scar. After successful implementation further TOETVA procedures are destined in strictly selected patients.

TOETVA
Picture:

TOETVA

Interdisciplinary Robotic-Assisted Rectopexy and Colposacropexy

(Abstract ID: 398)

G. Virakas1, B. Mann1

1Augusta-Kranken-Anstalt Bochum

Background:

The prevalence of the pelvic floor disorders increases by the elderly patients significantly. Predominantly you can find these disorders among the female patients. The clinical symptoms are usually multifactorial and often very complex. The main disorders are the bladder emptying disorder or the urine incontinence due to dorsal cystocele, obstructive defecation syndrom (ODS) with ventral rectocele, rectal intussusception or complete rectal prolaps. Usually you can observe the descent of the whole pelvic floor. In the rarest cases only one compartment is affected. Very often two or all three compartments are involved. Hence the initial diagnosis and especially the surgical therapy requires the good interdisciplinary approach by the pelvic floor team consisting of urologists, gynecologists and colorectal surgeons. With our video we would like to present the interdisciplinary robotic-assisted ventral rectopexy with simultaneous colposacropexy.

Materials and methods:

After completing the learning curve with more than 40 robotic-assisted ventral rectopexies, we performed the first 8 interdisciplinary combined robotic-assisted ventral rectopexies with simultaneous colposacropexy. The procedure is performed completely with the DaVinci Si System (Intuitive Surgical Inc, Sunnyvale CA, USA) with a 4-arm configuration. The procedure begins with the exposure of the promontory. Incision of the peritoneum on the right side pararectal to the peritoneal fold and continuing hockeybeat-like to the left. Exposure of the rectovaginal space to the pelvic floor. Fixation of the partly resorbable mesh on the ventral rectal wall at the lowest point as well as on the promontory. This is followed by deperitonealisation of the vaginal stump or cervix ventrally and fixing two meshes or the Y mesh to the anterior and posterior wall of the vagina, as well as to the promontory. Peritoneum is closed with a running self-locking suture.

Results:

The first cases show a good feasibility of the interdisciplinary robotic-assisted procedure that requires the high experience of all the participating disciplines.

Conclusion:

The disorders of the pelvic floor in elderly female patients are very multifactorial and complex and thus require the close collaboration of the urologists, gynecologists and colorectal surgeons in the diagnosis and especially in the surgical therapy. The interdisciplinary robotic-assisted rectopexy and colposacropexy is a good example of such cooperation with very good short-term results and high acceptance and satisfaction of the patients. The high experience of the participating disciplines in robotic surgery is obligatory.

Evaluation of the instrument guidance in laparoscopic surgery and development of an audiovisual real-time feedback system based on optic instrument tracking

(Abstract ID: 657)

J. Rolinger1, N. Model1, J. Miller1, J. Johannink1, A. Kirschniak1, K. Jansen1

1Universitätsklinikum Tübingen

Background:

During a laparoscopic intervention, the instruments used will be outside the visual field of the camera and are therefore potentially harmful for the patients. The negative consequences, especially thermic damage to neighboring organs, have already been pointed out in previous publications. The goal of this study was evaluating the incidence of these situations during a laparoscopic “index- surgery” (here: cholecystectomy), as well as correlating it to the experience of the surgeon. In addition, we evaluated the influence of an audio-visual real-time feedback system, that was developed by this study group on the basis of optical instrument tracking.

Materials and methods:

This prospective proband study used an already established surgery trainer (“Tübinger-Trainer”) using porcine livers. The test subjects goal was to perform a laparoscopic cholecystectomy following a standardized surgical process. The primary endpoint was the number of incidences, where the surgical instrument (here: monopolar hook) was outside the visual field of the laparoscopic camera. For the first part of this study the test subjects results where compared according to their level of experience. We compared medical students (n=26) to experienced surgeons (n=3). For the second part of this study the probands where randomized into an intervention group, which used a real-time audio-visual feedback system during surgery, and a control group.

Results:

The number of incidences, in which the surgical instruments were outside the visual field of the camera, where on average 26,9 (range: 4 - 99) among the medical students and 5,3 (range: 1 - 13) among the experienced surgeons. Using the real-time audio-visual feedback system, the intervention study group had a significantly better improvement in comparison to the control study group, looking at the primary endpoint.

Conclusion:

During the course of a laparoscopic cholecystectomy the surgical instrument is multiple times outside the surgeon's line of sight. The frequency of these incidences depends on the surgeon's experience and can be significantly reduced using a real-time audio-visual feedback system based on optical instrument tracking.

Establishing a Novel Benchmark for Surgical Workflow Analysis in Next Generation Surgical Robots

(Abstract ID: 770)

M. Wagner1, S. Bodenstedt2, L. Mündermann3, M. Apitz1, L. Maier-Hein4, S. Speidel5, B. P. Müller1, H. Kenngott1

1Universitätsklinikum Heidelberg

2Nationales Centrum für Tumorerkrankungen, Standort Dresden

3KARL STORZ GmbH & Co. KG, Tuttlingen

4Deutsches Krebsforschungszentrum, Heidelberg

5NCT Partnerstandort Dresden

Background:

Context-Awareness and workflow analysis are key for the next generation of surgical robots. Cognitive surgical robots will learn from experience and perform complex tasks (semi-)autonomously. However, up until now research in surgical workflow analysis was limited to laparoscopic cholecystectomy due to a lack of high quality clinical data sets. To address this problem we created and tested a dataset of laparoscopic colorectal surgeries as a novel benchmark for workflow analysis algorithms.

Materials and methods:

In a first step laparoscopic video as well as surgical device data (insufflator, OR light, camera parameters) were collected for 30 laparoscopic surgeries in a sensor operating room, evenly divided into 10 occurrences of sigmoid resection (SR), rectal resection (RR), proctocolectomy (PC). A surgical expert then annotated each video by assigning each frame one of thirteen surgical phases (preparation, mobilization sigmoid, dissection of rectum etc.). In a third step the whole dataset was tested with different workflow analysis algorithms in the setting of an international endoscopic vision challenge with four independent teams competing. Here, 24 surgeries were used as training data and 6 surgeries as test data. As metrics the accuracy (percentage of correct classification) and Jaccard index (JI, overlap of algorithm classification and surgical annotation divided by their union) were chosen.

Results:

In total 96 hours of video and about 2.97 million sensor data points were collected and annotated with 626 changes of the surgical phase resulting in phase duration of 18.9±16.8 min. The longest phase in SR was mobilization of sigmoid with 42.8±24.1 min and dissection of rectum in RR (45.4±21.3 min) and PC (51.2±9.7min). The second longest phase was extra-abdominal preparation of anastomosis for SR (36.0±11.3 min), RR (36.9±15.0min) and PC (44.2±7.18min).

The workflow analysis algorithms achieved between 21% overall accuracy with an average JI of 8% (weakest algorithm) and 61% overall accuracy with an average JI of 40% (strongest algorithm). However, even for the strongest algorithm the average JI varied between 18% and 78% for the 6 test surgeries.

Conclusion:

We created a novel dataset of colorectal surgeries as a challenging benchmark for workflow analysis algorithms. Our results show that the problem of workflow analysis is not yet solved. Collaboration of surgeons and computer-scientist is key to advance this field and lay the foundation for the next generation context-aware surgical robots.

DGCH: Treatment optimisation integrading treatment concepts from operative and non-operative specialities

The effect of low-threshold access to acute geriatric medicine for patients aged 65 and over after colorectal surgery

(Abstract ID: 427)

A. Deiss1, R. Schneider1, M. Hirschburger1

1Klinikum Worms

Background:

Several studies have proven acute geriatric units' effectiveness on reducing the morbidity and mortality after major surgery.

Medical care of people aged 65 or over in geriatric units has shown a functional benefit compared to regular hospital care, and increases the likelihood of being discharged to their homes.

The hospital Worms, a tertiary care level clinic, annexed an established, well functioning division of geriatric medicine in 2015 and thereby permits low-threshold access to a geriatric unit.

We wanted to present and evaluate a general surgical geriatric cooperation for the management of the elderly after colorectal surgery.

Materials and methods:

A retrospective study compared discharge management of all patients who needed colorectal surgery (n = 332) with an age above 65. To evaluate the benefit of a geriatric unit care introduced in the acute phase following surgery, two periods have been defined:

  1. Period 1: 01/2014-06/2015: No geriatric unit available at Worms hospital, n=138

  2. Period 2: 07/2015-12/2016: Acute geriatric unit at Worms hospital, n=194

We detected the surgical methods, overall hospital stay, days in the ICU, main complications, deaths, discharge destination (home or nursing home), including transfer to the geriatric division, length of geriatric hospitalization and 30 days hospital readmission rate. The data was compared between the two mentioned groups.

Results:

Discharge destination

In all, n=196 (59.0%) patients were discharged to their homes.

Period 1

5.1% of the patients were transferred to a geriatric division in another hospital. Following their geriatric stay, 42.9% went home. Following their surgical stay, 61.8% went home.

Period 2

18.0% of the patients were moved to the acute geriatric ward at Worms hospital. Following their geriatric stay, 28.6% went home. Following their surgical stay, 64.2% went home.

Length of hospital stay

Period 1

Median stay in the general surgery division was 17.9 days, with an average of 5.9 days in the ICU, resulting in a median length of hospital stay of 23.0 days. The average time spent on the geriatric ward was 18.0 days.

Period 2

Median stay in the general surgery division was 16.3 days, with an average of 6.9 days in the ICU, resulting in a median length of hospital stay of 22.2 days. The average time spent on the geriatric ward was 18.8 days.

30 days readmission

Period 1

Overall readmission rate was 15.2% (n=21).

Period 2

Overall readmission rate was 14.4% (n=28).

Conclusion:

A surgical geriatric cooperation is clinical feasible. Low-threshold access to a geriatric unit aims to increase clinical transfer.

The clinical management of colorectal surgeries at the elderly deals with high complication rates, such as infections, cardiac decompensation, electrolyte imbalance or re-laparotomy.

Cooperation with the acute geriatric unit of Worms hospital could show a small reduction of 30 days readmission rate from 15,2% (period 1) to 14,4% (period 2).

A shortening in surgical hospitalization time from 23 d (period 1) to 22.2 d (period 2) was observed.

Transfer to geriatric unit was not identified as a predictive variable for discharge to home.

Starting January 2017, we provide regular geriatric rounds (twice a week) to early identify eligible patients with required rehabilitation potential. Future data is necessary to show if prompt patient selection can lead to lower morbidity and mortality as well as earlier transfer and resultant higher likelihood of being discharged to a domestic environment.

Priority Setting Partnership (PSP) Pancreatic Cancer - bringing together clinicians, patients and carers to discuss research priorities

(Abstract ID: 763)

R. Klotz1, C. Dörr-Harim1, A. L. Mihaljevic1

1Universitätsklinikum Heidelberg

Background:

It is estimated that pancreatic cancer will replace breast cancer as the third most common cause of cancer death in 2017. The prognosis of pancreatic cancer with a relative 5-year survival of 8% is still one of the worst of all types of cancer. Research projects on pancreatic cancer are currently initiated by industry or scientists, usually without involving other stakeholders (treating physicians, patients, family members, caregivers, nurses, etc.). However, there is a mismatch between available research evidence and the research preferences of consumers, i.e. patients and carers. Consequently, patient involvement is an upcoming topic in clinical research and health-care politics.

The Priority Setting Partnership pancreatic cancer aims to identify and prioritize the top 10 open research questions / uncertainties on treatment of pancreatic cancer. Together with the UK-based James Lind Alliance, a non-profitmaking PSP initiative established in 2004, patients, caregivers, doctors and other relevant stakeholders will be involved as equal partners. This project intends to increase patient involvement, interdisciplinary cooperation and awareness of this disease. The resulting list of priorities will serve as a guideline for future research questions.

Materials and methods:

A Steering Group with representatives from all stakeholders was established (01-04/2017). A nationwide online survey on unanswered research questions addressing all stakeholders is performed (08-11/2017). Duplicates and questions outside the topic will be removed. The perceived uncertainties will be checked against current evidence via a systematic search for literature to ensure they are valid. An interim list of priorities will be achieved via a second online survey. Prioritizing, by consensus, the top 10 list of shared treatment uncertainties/priorities will be performed. The 10 most important research questions will be publicized and relevant research projects will be initiated.

Results:

The survey was carried out from August to November 2017. At the congress, first results of the nationwide online survey and the corresponding literature search can be presented. The consecutive steps of the ongoing PSP will explained and discussed.

Conclusion:

The identified questions are intended to initiate patient-relevant research and research funding, thus improving the care of those most affected by pancreatic cancer. The presented PSP establishes the transparent, validated JLA method for the first time in Germany and is the first PSP on the subject of pancreatic cancer world-wide.

DGCH: Personalized medicine and multimodal treatment concepts

Oncological outcome of the first 66 patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies at the Medical University of Vienna (Austria)

(Abstract ID: 43)

T. Braunschmid1, J. S. Bhangu1, G. Prager1, M. Bergmann1, A. Stift1, T. Bachleitner-Hofmann1

1Universitätsklinikum Wien

Background:

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising therapeutic option for patients with peritoneal surface malignancies (pseudomyxoma peritonei, peritoneal mesothelioma and peritoneal metastasis from colorectal cancer). The aim of this analysis was to evaluate the morbidity and oncologic outcome of the first 58 patients treated with CRS and HIPEC at the Medical University of Vienna, Austria.

Materials and methods:

In 2011 a HIPEC program was established. Patient demographics, operation details, morbidity and survival data were continuously collected in a prospective database. Morbidity and mortality after CRS and HIPEC were graded according to the Clavien Dindo classification.

Results:

Sixty-six patients (39 female; median age 55.0 years, range: 18.3-76.7 years) received a total of 70 CRS and HIPEC-procedures. The indications for treatment were appendiceal malignancy / pseudomyxoma peritonei (23/66), peritoneal metastasis from colorectal (31/66), gastric (2/66) or small intestinal cancer (2/66) and peritoneal mesothelioma (8/66). The 30-day-mortality was 3.0% (2/66 patients). The mean follow up of the patients is currently 19.3 months (range: 0.4-72.2 months), with 40/66 patients (60.6%) having a follow-up of more than 12 months. Fifteen patients (22.7%) have died during follow-up (mean follow-up in these patients: 18.3 months, range: 1-38 months), 16 patients (24.2%) are alive with disease and 35 patients (53.0%) have no evidence of disease.

Conclusion:

This survey illustrates the importance of accurate documentation and workup for quality management during constitution of a new therapeutic concept. With CRS and HIPEC an excellent longterm-outcome can be achieved in carefully selected patients with peritoneal surface malignancies.

Inflammatory Properties of Small Bowel Fluid from Patients with IBD

(Abstract ID: 178)

F. Kühn1, Y. Liu2, R. Vasan2, F. Adiliaghdam2, E. Liu2, S. Hamarneh2, R. Hodin2

1Universitätsklinikum der LMU München

2Massachusetts General Hospital, Boston

Background:

Luminal contents play a crucial role in the induction and maintenance of intestinal inflammation. Patients with Crohn's disease benefit from diversion of the fecal stream, with immediate recurrence of inflammation after restoration of intestinal continuity. Furthermore, pouchitis after ileo-anal anastomosis for ulcerative colitis does not occur prior to ostomy closure. These observations support the premise that exposure to factors within the fecal stream is a critical component in inciting phenotypic expression of IBD. And, yet, the components within the fecal milieu that play a role in activating the inflammatory pathways still remain unknown. Recent data has demonstrated that levels of the anti-inflammatory mucosal defense factor Intestinal alkaline phosphatase (IAP) are reduced in colon biopsies of patients with IBD. Here, we aimed to examine the inflammatory properties of ileal fluid from patients with and without IBD. Our central hypothesis is that pro-inflammatory factors in intestinal contents activate inflammatory cascades in the intestinal epithelial lining and that targeting these factors/pathways can present novel therapeutic approaches to treat IBD.

Materials and methods:

Ileal fluid samples from patients with and without IBD were collected from patients with an ileostomy seen in the surgical clinic at Massachusetts General Hospital, Boston. The effluent was centrifuged and the supernatant assayed by ELISA for key pro-inflammatory cytokines. Human THP1 macrophages were exposed to the fluid and assayed for cytokine expression. IAP Activity was measured using the para-Nitrophenylphosphate (pNPP) assay. Demographics and clinical characteristics of patients were obtained from the medical records and correlated with inflammatory properties.

Results:

Ileal fluid from 23 patients (15 IBD, 8 non-inflammatory controls) with a median age of 56 years (range; 29-94) was collected and assayed. TNF-a levels were significantly higher in ileal fluid of IBD patients than in controls (92.1 ± 29.9pg/ml vs. 33.6 ± 9.4pg/ml; p = 0.03) whereas IL-8 levels were similar (50.1 ± 11.9 vs. 35.3 ± 7.4; p > 0.05). IAP activity was significantly lower in patients with IBD than in patients without underlying inflammatory disease (14.6 ± 1.4 U/mg protein vs. 23.3 ± 2.2 U/mg protein; p=0.002). The inflammatory response of THP1 cells exposed to ileal fluid showed an individual cytokine profile for each patient and did not correlate with the cytokine levels in the original sample or the underlying disease. Further patient characteristics (e.g., gender, age, time of surgery) did not show any correlation with luminal ileal inflammatory properties.

Conclusion:

Analysis of Ileal luminal contents showed significantly higher TNFa levels and lower IAP activity in patients with IBD. The individual inflammatory response profile of each patient could serve as a basis for determining the risk for recurring disease or pouchitis in stoma patients with IBD.

Gender-related impact of surgery for colorectal carcinoma - differences in men and women?

(Abstract ID: 204)

E. M. Teegen1

1Charité - Universitätsmedizin Berlin

Background:

Colorectal cancer (CRC) is one of the most frequent malignancies worldwide. Gender-related variations in the realization and effectiveness of surgery, radiation and chemotherapy in men and women might influence oncological outcome and survival. Especially colorectal surgery is influenced by certain differences of both genders.

The aim of this investigation was to evaluate gender-related differences of the risk and effectivness of colorectal surgery for CRC and their impact on oncological outcome and survival.

Materials and methods:

This study presents a retrospective analysis of 906 patients, who received surgery for CRC from 2010 to 2014 and who were registered at our comprehensive cancer center. Adult patients with a curative treatment option were included. Demographic data, histopathological results as well as parameters like the surgical procedure and postoperative complications were evaluated. Subgroup analysis was performed according to age, UICC stadium and tumor localization.

Results:

We found a significantly different localization of tumors in women and men. The prevalence of CRC of the proximal colon was significantly higher in women (39.9%) than in men (32.8%). The conversion rate was significantly higher in male patients (p=0.001). Furthermore, surgical complications like a secondary stoma, anastomotic leakage and reoperations were more often necessary in men. The overall survival of women (59.9 months) was significantly better compared to men (55.6 months, p=0.027).

Conclusion:

Women presented with more proximal localized tumors, were healthier and developed significantly less complications, which might be a reason for the significantly better survival of women with CRC compared to male patients after surgery for CRC. Modern surgical strategies, especially minimal invasive surgery might help, to minimize complication rates in men due to the narrow pelvis.

Erector spinae plane block as a contributor to multimodal postoperative pain management after bariatric surgery

(Abstract ID: 455)

J. Ortmann1, M. Büsing1, H.-G. Bone1

1Klinikum Vest-Knappschaftskrankenhaus Recklinghausen

Background:

Postoperative pain after bariatric surgery poses a major burden on patients and health care providers. Although there is a high incidence of obstructive sleep apnea and obesitas hypoventilation syndrome opioids are an essential part of the analgetic therapy with a relevant risk of respiratory compromise.

Searching for alternatives we applied a recently established truncal block to 5 selected patients with a high risk of respiratory adverse events.

Materials and methods:

Currently, pain therapy after general anesthesia in bariatric patients is limited to NOPAs and piritramid. The latter is delivered postoperatively via a PCA-infusion pump resulting in a cumulative dose of 10 to 50mg in the first 24h.

From Mai to September 2017 we performed in 5 patients on top an erector spinae plane block. We decided to use the block because of severe obstructive sleep apnea in 4 patients with signed informed consent on the day before surgery. One patient received the ESP as a rescue block after failure of standard therapy.

Using either a linear or a convex ultrasound probe we scanned in the parasaggital plane searching for the ribs with lung sliding in the intercostal spaces. Sliding medially, the convex appearing ribs are replaced by the flatter shaped tranverse processes. The relevant structures are from deep to superficial: transverse process, erector spinae muscle, trapezius muscle, subcutaneous tissue and cutis. After local anesthesia at the cephaled edge of the probe, a 22G, 80mm block needle was advanced in-plane in a caudad direction aiming at the transverse process. The correct needle tip position was confirmed by hydrolocation lifting the erector spinae muscle off the transverse process. 20ml 0,375% ropivacaine with 75μg clonidine and 5μg suprarenin/ml were administered resulting in a linear spread deep to the erector spinae muscle bilaterally.

Results:

A 38-year-old male patient with a BMI of 41kg/m2 was scheduled for ventral hernia repair and received an ESP block pre-operatively. In the PACU he required 15mg piritramid. During the following 20h he demanded 4mg piritramid via PCA.

A 54-year-old male suffering from an BMI of 50kg/m2 received an omega-loop gastric bypass with an ESP block placed in advance. His NRS remained under 4 at rest with 2mg piritramid on the day of the procedure and 8mg on the day after.

The third block was performed in a 33-year-old female with a BMI of 44kg/m2 undergoing sleeve gastrectomy. Via PCA she demanded a cumulative dose of 8mg piritramid during the first 24h postoperatively.

The fourth patient, a 29-year-old male with an BMI of 43 kg/m2 needed 22,5mg piritramid in the PACU and another 6mg during the following 21 h via the PCA.

The last 60-qear-old female patient with an BMI of 36kg/m2 was scheduled for post-bariatric plastic surgery. In the PACU she needed 30mg piritramid in a short course of time with beginning hypopnea. After thorougly assessing the risks and the benefits of the possibilities she received an ESP block in lateral position. She was relocated to the ward requiring 10mg piritramid on the day of operation after block performance and 12mg on the day after.

Conclusion:

The erector spinae plane (ESP) block with a favourable risk-benefit ratio may become a useful tool to decrease opioid consumption and to increase the patients satisfaction by early ambulation. Especially in the context of fast-track concepts, regional anesthetic techniques of relative simplicity may play an important role to optimize outcome and reduce costs. Further clinical investigation must be undertaken to clearly prove efficacy.

DGCH: Quality management and management of discharge

The separation of septic and aseptic procedure rooms is no longer mandatory.

(Abstract ID: 474)

J.-C. Harnoß1, O. Assadian2, M. K. Diener1, T. Müller3, R. Baguhl3, M. Dettenkofer4, L. Scheerer1, T. Kohlmann3, C.-D. Heidecke3, S. Gessner3, M. W. Büchler1, A. Kramer3

1Universitätsklinikum Heidelberg

2Medizinische Universität Wien

3Ernst-Moritz-Arndt-Universität Greifswald

4Klinikum Konstanz, Singen

Background:

During the last 40 years various measures were established to prevent surgical site infections. The aim of this study was to analyse, whether strict separation of septic and aseptic procedure rooms is still mandatory.

Materials and methods:

An exploratory, prospective observational study was conducted in order to investigate the microbial concentration in an operating room without a room ventilating system. During 16 septic and 14 aseptic operations the microbial load was analysed with an air sampler (50 cm and 1 m from the operative field) and sedimentation plates (1 m from the operative field, and contact culture on the walls). The means and standard deviations of the microbial results were compared using GEE models (generalized estimation equations).

Results:

No significant differences were found between septic and aseptic operations with respect to the overall microbial concentration in the room air (401.7 ± 176.3 versus 388.2 ± 178.3 CFU/m3; p = 0.692 [CFU, colony-forming units]) or sedimentation 1 m from the operative field (45.3 ± 22.0 versus 48.7 ± 18.5 CFU/m2/min; p = 0.603) and on the walls (35.7 ± 43.7 versus 29.0 ± 49.4 CFU/m2/min; p = 0.685). Only between the microbial spectra associated with the two types of procedure relevant differences were found: sedimentation of Escherichia coli and Enterococcus faecalis in septic operations and staphylococcus aureus and pseudomonas stutzeri in aseptic operations, up to 30 minutes after the end of the procedure.

Conclusion:

These data suggest that septic and aseptic procedures do not need further separation. This might result in financial benefits for surgery departments and might allow for more flexible planning, a better use of surgical capacities and lower construction-related investment costs.

The manuscript was published with Dtsch Arztebl Int 2017; 114:465-72.

Postoperative complications after treatment of oral squamous cell carcinoma (OSCC) patients

(Abstract ID: 617)

S. Wolfer1, T. Foos1, A. Kunzler1, C. Ernst1, S. Schultze-Mosgau1

1Universitätsklinikum Jena

Background:

Postoperative morbidity plays an important role in patient's recovery and rehabilitation. The purpose of this study is to evaluate the surgical outcome of patients after treatment of oral squamous cell carcinoma (OSCC) with special focus on postoperative local and medical complications.

Materials and methods:

This retrospective cohort study uses the evaluation of medical records at the department of Oral and Maxillofacial Surgery, Jena University Hospital and investigates the surgical outcome for OSCC patients. This research also analyses common clinical and demographical parameters like age, gender, TNM-stage, UICC-stage, tumor differentiation, risk behavior, Karnofsky-index, duration of operation and length of hospital stay. Descriptive statistics were performed with Chi2-test or Fisher's-exact test for categorical and with t-test or ANOWA-test for continuous variables. Correlation between the parameters was tested with Spearman's correlation test. Multivariate analysis was computed with the multivariate Poisson-regression. P < 0.05 was considered as statistically significant.

Results:

From an included study population of 419 OSCC patients with a median age of 61.0 years 373 (89%) patients were analyzed for local and 413 (99%) patients for medical complications. 205 (55%) patients had local and 102 (25%) patients had medical postoperative complications. The univariate analysis shows that patients with local complications had more operative revisions (p< 0.001) and a 5-day longer postoperative hospital stay (p< 0.0001) than patients without local complications. Patients with medical complications are with approximately 9 years significant older (p= 0.0013), had more T4-tumors (p= 0.0109) and a worse UICC-stage (p= 0.0350). They also had more operative revisions (p= 0.0120) and an 8-day longer hospital stay (p< 0.0001) than patients without medical complications. Smoking (p= 0.004), the Karnofsky-index (p= 0.001), operative revisions (p< 0.0001) and the postoperative hospital stay (p< 0.0001) were identified as independent variables for local complications whereas for medical complications age (p= 0.006), Karnofsky-index (p= 0.01) and the postoperative hospital stay (p< 0.0001) were independent variables after multivariate analysis. The need for operative revision correlated noticeably positively with local complications. For medical complications we saw a strong positive correlation with age and Karnofsky-index. Local and medical complications are positively correlated with each other as well. Anyway, both resulted in conspicuous longer hospital stay.

Conclusion:

For local complications, behavioral and surgical aspects influences postoperative outcome while for medical complications the age and the patient's constitutional situation tend to be important facts. Anyway, postoperative complications should be avoided in every case not least because of resulting longer hospital stay with followed more costs.

DGCH: Management of emergency room and central emergency admission

Diagnostic and therapeutic approach to rectal foreign bodies

(Abstract ID: 157)

P. Kokemohr1, J. Jähne1, L. Haeder1

1Diakovere Henriettenstift, Hannover

Background:

Patients with a rectal foreign body are still a rare entity in general surgery departments but with an increasing incidence over the last years. Sometimes difficult to treat and due to a lack of standardized treatment options the aim of the study was to present our clinical experiences with the diagnostic and therapeutic approach to rectal foreign bodies (RFB).

Materials and methods:

Data were collected retrospectively from the patient's records of 20 patients who were treated due to a rectal foreign body between 2006 and 2016. Patient's demographics circumstances of insertion, inserted objects, clinical presentation, laboratory and imaging results as well as surgical treatment and duration of hospital stay were analyzed.

Results:

22 cases with 20 patients (80 % male) presented at the emergency room (ER). Mean age was 38. 5 +/-13. 7 years. In 68. 2% of cases the cause of RFB was due to sexual preferences. The following objects were inserted: six dildos, three vibrators, two bottles, one glass, one deodorant, one apple, one fever thermometer, multiple glass fragments and razor blades in one patient and six unknown objects. For 18 rectal foreign bodies manual peranal removal without anesthesia was possible in the emergency room, but two patients required intravenous analgesia. Two patients were transferred to the operating room and the foreign body was removed via the anus under general anesthesia. Open surgery with a laparotomy was necessary for two complicated cases. One patient was in need of surgery due to a vacuum generated by the RFB, while the second patient suffered from a sigmoid perforation. In all cases, there was no morbidity or mortality

Conclusion:

The number of patients with a rectal foreign body is increasing. Due to our experience, we suggest an algorithm for the management of RFBs in our department. All patients who present with an RFB to the emergency room get a full physical and rectal examination. Due to the object, the location of the object and the symptoms of the patient, blood samples or an X-ray will be performed. If the patients and the examination show no sign of acute abdomen or perforation, first step is to try to remove the RFB in the emergency room by hands and when this is not possible, to remove the RFB by surgical instruments or endoscopy on a proctoscopy chair in lithotomy position. When the removal of the RFB is not successful, next attempt to remove the foreign body should be made under general anesthesia with full relaxation of the sphincter muscle in the operating room. Only if all these steps are unsuccessful or the patient presents with acute abdomen as a sign of peritonitis and perforation laparoscopic or open surgery becomes necessary.

DGCH: Sense and nonsense in the modification of surgical procedures

Delayed gastric emptying and morbidity after pylorus-preserving versus pylorus-resecting pancreaticoduodenectomy – An up-to-date systematic review and meta-analysis

(Abstract ID: 585)

U. Klaiber1, P. Probst1, O. Strobel1, C. W. Michalski1, M. K. Diener1, M. W. Büchler1, T. Hackert1

1Universitätsklinikum Heidelberg

Background:

Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreaticoduodenectomy (ppPD). Recent studies have suggested that resection of the pylorus is associated with decreased DGE rates. However, superiority of pylorus-resecting PD (prPD) was not shown in a current randomized controlled trial (RCT). This meta-analysis summarizes the existing evidence of the effectiveness and safety of ppPD compared to prPD.

Materials and methods:

RCTs and non-randomized studies (NRS) comparing outcomes of ppPD and prPD were searched systematically in MEDLINE, Web of Science and CENTRAL. Random effects meta-analyses were performed and the results presented as weighted odds ratios (OR) or mean differences (MD) with their corresponding 95% confidence interval (c.i.). Subgroup analyses were performed to account for inter-study heterogeneity between RCTs and NRS.

Results:

Three RCTs and eight NRS with a total of 992 patients were included. Quantitative synthesis across all studies showed superiority of prPD regarding DGE (OR 2.71, 95% c.i. 1.48 to 4.96; p=0.001) and length of hospital stay (MD +3.26 days, 95% c.i. -1.04 to +5.48; p=0.004). Subgroup analyses including only RCTs showed no significant statistical differences between the two procedures regarding DGE and all other effectiveness and safety measures.

Conclusion:

PrPD is not superior to ppPD regarding DGE and other relevant outcomes. The implicit methodological limitations of non-randomized trials bear relevant sources of bias leading to overestimation of treatment effects. Based on the present level I evidence studies, this meta-analysis shows no superiority of prPD - consequently ppPD should remain the standard of care.

DGCH: Telemedicine

A web-based prehabilitation concept in patients with esophageal carcinoma scheduled for esophagectomy (case report)

(Abstract ID: 368)

D. Pfirrmann1, P. Simon1, I. Gockel2

1Universitätsmedizin Mainz

2Universitätsklinikum Leipzig

Background:

Esophageal adenocarcinoma (Barrett's carcinoma) requires immediate surgical treatment. Neoadjuvant therapy, consisting of radio-/-chemotherapy, represents the standard care prior surgery. An individual preparation for surgery in terms of physical (pre) conditioning is recommended but not obligatory. However, studies focusing on physical improvements in the preoperative period, are rare, but show promising results. The internet could be an appropriate tool to support these patients in their home environment with individual exercise recommendations. However, previous web-based interventions are heterogeneous in outcome measures and methodology and do not provide online guided exercise programs prior to surgery yet.

Materials and methods:

Here, we present a case report (male, 56 years), who passed the perioperative exercise intervention of the internet-based perioperative exercise program (iPEP-study). The patient was supervised by a sports scientist for ten weeks prior to surgery. In this time frame, we steadily increased the exercise frequency from 3 times a week to a daily exercise program. At study start, immediately prior to surgery, and three months after hospitalization, the patient performed a treadmill test until volitional exhaustion. The results of his functional- and fitness measurement at study start formed the sport therapeutic basis for the weekly exercise recommendations. With respect to the influence of the neoadjuvant (Radio-/Chemo-) therapy, weekly subjective feedback by the patient allowed an immediate adjustment of exercise frequency or intensity. The recommendations consisted of endurance training, volumetric exercises, flexibility training, and strength exercises.

Results:

The web-based exercise concept was well tolerated and did not result in adverse events. The time of physical activity increased from 85 minutes in the first week, to 215 minutes per week immediately prior surgery (average time of weekly exercise: 139 minutes). In the period prior to surgery, the patient was able to maintain body weight (90 kg) and performance level, expressed as VO2max (23 ml/kg/min). However, during postoperative phase a weight loss was observed (10 kg) not achieving baseline condition (VO2max pre 23.2 ml/kg/min vs. VO2max post 22.8 ml/kg/min).

Conclusion:

Based on the literature and supported by our case report, we recommend that presurgical waiting period should be effectively used to stabilize or to improve physical function in order to overcome surgical stress. The web-based exercise concept supported a regular and close contact, independent of time and place and should be taken into consideration as an addition to the multidisciplinary treatment. Tailored support was easily integrated into patients' home environment and exercise related uncertainty and anxiety were eliminated by weekly communication. Due to individual reaction to neoadjuvant therapy, a flexible, individual and supervised intervention design is required addressing these challenges.

DGCH: Translational and international research

Realizing the Potential of Surgical Data Science – Chances and Challenges for the Surgeon

(Abstract ID: 773)

M. Wagner1, M. Apitz1, S. Bodenstedt2, S. Speidel3, L. Maier-Hein4, B. P. Müller1, H. Kenngott1

1Universitätsklinikum Heidelberg

2Nationales Centrum für Tumorerkrankungen, Standort Dresden

3NCT Partnerstandort Dresden

4Deutsches Krebsforschungszentrum, Heidelberg

Background:

Digitalization of society and healthcare create an ever growing amount of data. Machine learning algorithms and so called artificial intelligence (AI) allow to recover knowledge from this data. In surgery, this development led to the identification of “Surgical Data Science” (SDS) as an emerging field of research. During an international workshop of experts from surgery, computer-science, computer-assisted surgery and robot-assisted surgery discussed key clinical applications and key challenges. Here, “Surgical data science aims to improve the quality of interventional healthcare and its value through the capture, organization, analysis and modelling of data.” Moreover, “Improvement may result from understanding processes and strategies, predicting events and clinical outcome, assisting physicians in decision-making and planning execution, optimizing the ergonomics of systems, controlling devices before, during and after treatment, and from advances in prevention, training, simulation and assessment.”

Materials and methods:

Based on the discussions during the workshop and the experience of the authors in the development of computer-based assistance systems for surgery the chances as well as the challenges of SDS will be discussed. Also, the surgical responsibilities in creating SDS-based assistance systems will be highlighted.

Results:

To create useful, but also ethically responsible assistance-systems for surgery based on SDS a number of surgical steps are necessary.

First, surgeons have to define the aim of the development, may it be for example (semi-)autonomous cognitive robots, decision-support systems for complex cases in the tumor board or data-driven training systems for surgical novices.

Second, ethical considerations have to be taken into account. Here, patients as well as care-givers perspectives in terms of data-protection, surveillance, legal responsibility in case of errors etc. have to be addressed.

Third, to advance SDS the creation of high quality, comprehensive data sets provided by surgeons is crucial. Here, the specific features of surgical patient care and surgical data, i.e. the focus on highly individual procedures for each patient involving numerous care-givers and data-producing devices, have to be reflected in the data models created by computer-scientists.

Fourth, instead of wasting efforts by curating department-specific data-bases, the surgical community has to claim their share when data warehouses across university-hospitals are created within the medical informatics initiative and make sure not only genomics data, but also surgical data (operation videos, surgical device data, procedural data) is curated for research purposes.

Fifth, surgeons have to guide the translational research process from application of novel data-driven technologies to tackle clinical problems with computer-scientists over the development of data-based products with the industry to the conduct of high-quality studies to proof benefit for the patient and justify reimbursement by insurance agencies.

Conclusion:

SDS may be a way to realize the promises of digitalization and artificial intelligence for the improvement of surgical patient care. However, as surgeons it is our responsibility to guide and to advance SDS but also to define limits based on ethical considerations for patients and surgeons alike.

About the article

Published Online: 2018-03-14


Citation Information: Innovative Surgical Sciences, Volume 3, Issue s1, Pages s232–s281, ISSN (Online) 2364-7485, DOI: https://doi.org/10.1515/iss-2018-2002.

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© The Author(s) 2018, published by De Gruyter, Berlin/Boston. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0

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