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  • 1
    Language: English
    In: Langenbeck's archives of surgery, January 2012, Vol.397(1), pp.69-74
    Description: The efficacy of Heller myotomy in patients 〉40 years-a significant predictor suggesting a favorable response to pneumatic dilation-has been questioned. The aim of our study was to evaluate the results obtained in patients aged 40 years undergoing minimally invasive surgery (MIS) for achalasia. In January 2008, we established the MIS technique for achalasia in our clinic. In the following period from January 2008 to March 2011, 74 patients underwent primary laparoscopic myotomy for achalasia. The procedure was accomplished with an anterior 180° semifundoplication according to Dor in all patients. The Eckardt score and the Gastrointestinal Quality of Life Index (GQLI) served as outcome measures. The median age of patients was 45.5 years (range, 18-85 years) with a median duration of preoperative achalasia symptoms of 57 months (range, 2-468 months). There were no conversions to open surgery and-except for one patient with a sterile pleural effusion-no postoperative complications. At a median follow-up of 12 months, the preoperative Eckardt score of 7.0 (range, 3-12) was found to be significantly decreased to a median of 2 (range, 0-6; P 40 years, the postoperative Eckardt score obtained in the older patient population was not significantly lower (P = 0.074). There was no statistically significant difference between the two groups with respect to the postoperative GQLI (P = 0.860). Neither gender nor preoperative Botox injection or pneumatic dilation inserted a significant influence on the postoperative clinical outcome (P 〉 0.05). Laparoscopic Heller myotomy for achalasia is associated with a high success rate as the primary therapeutic option and after failure of endoscopic therapy. It can be performed safely and with favorable outcomes also in patients 〉40 years. However, the long-term durability of the procedure remains to be established.
    Keywords: Esophageal Achalasia -- Surgery ; Esophagus -- Surgery ; Laparoscopy -- Methods
    ISSN: 14352443
    E-ISSN: 1435-2451
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  • 2
    In: Circulation, 2013, Vol.127(3), pp.417-418
    Description: A 63-year-old man was admitted to our emergency department because of abdominal pain with distension and ischemia of both lower limbs for the past 2 hours. Previously, he had vomited extremely following alcoholic excess and an opulent meal. In his previous history, distal esophageal stenosis was obvious after surgical therapy of Boerhaave syndrome 3.5 years earlier with primary suturing of the distal esophageal perforation and anterior semifundoplication. At clinical examination, the patient presented with stable cardiopulmonary function. The abdomen was massively distended and tender, and both legs were blue, revealing signs of prolonged ischemia with absent palpable pulses of the femoral artery in both groins. Palsy of the legs was not yet apparent. Computed tomography of the chest and abdomen …
    Keywords: Medicine ; Anatomy & Physiology;
    ISSN: 0009-7322
    E-ISSN: 15244539
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  • 3
    Language: English
    In: The American Journal of Surgery, December 2018, Vol.216(6), pp.1063-1069
    Description: Surgical outcome to extremes of age is understudied. The purpose of this study was to evaluate the patient characteristics and incidence of postoperative morbidity and in-hospital mortality among patients aged 90 years and older who underwent surgery in comparison to younger controls. Patients aged 90 years or older (n = 80; mean age, 92.36 ± 2.37) were matched for surgical treatment with patients aged 79 years or younger (n = 80; mean age, 55.98 ± 15.95) taken from the same cohort. The overall morbidity and mortality rates were 57.5% and 31.3% in the elderly vs. 47.5% and 23.1% in the younger group respectively. Patient groups aged 90 years or older and 79 years or younger each had 4 and 6 predictive factors for morbidity and 10 and 9 predictive factors for mortality respectively. while advanced age carries an increased risk of morbidity and mortality, it seems that age in itself is no barrier to surgery. Despite the comparably high prevalence of chronic disease, elderly patients in this study fared quite well.
    Keywords: Surgery ; Elderly Patients ; Morbidity ; Mortality
    ISSN: 0002-9610
    E-ISSN: 1879-1883
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  • 4
    In: American Journal of Gastroenterology, 2008, Vol.103(4), pp.856-864
    Description: BACKGROUND: The etiology of achalasia is still unknown. The current theories of chronic inflammation leading to autoimmune response with destruction and loss of the inhibitory myenteric ganglion cells enlighten its pathogenesis in a limited way only. Interstitial cells of Cajal (ICC) have been shown to be involved in nitrergic neurotransmission of the lower esophageal sphincter (LES). AIM: To investigate the significance of ICC and neuronal nitric oxide synthase (n-NOS) in esophageal wall tissue of patients undergoing surgery for achalasia. METHODS: In 53 patients with a median age of 45 (6–78) yr undergoing surgery for achalasia, the immunoreactivity of ICC (CD117/c-kit) and n-NOS was assessed. In 42 patients, biopsies were taken from the LES high-pressure zone during Heller myotomy, whereas in 11 patients with end-stage achalasia and a decompensated megaesophagus, the complete esophagus was resected. A semiquantitative analysis was carried out and ICC and n-NOS impairments were classified into four grades. Staining intensity was correlated with preoperative clinical, radiologic, and manometric findings and with long-term postoperative Eckardt score. RESULTS: Grade III/IV ICC reduction (severe reduction to complete loss) was seen in 59.5% of all biopsy specimens of the LES high-pressure zone. Patients with grade III/IV ICC reduction had a significantly longer duration of achalasia symptoms (3 [0–43] yr) than patients with minor to marked (grade I/II) impairment (1 [0–16] yr, P= 0.028). A majority (72.5%) of tissue samples revealed severe reduction to complete loss of n-NOS immunoreactivity. The preoperative Eckardt score was statistically significantly different between patients with grade I/II and those with grade III/IV n-NOS reductions (P= 0.031). CD117 (c-kit) positivity was statistically significantly correlated with n-NOS staining intensity (correlation coefficient r= 0.781, P 〈 0.0001). CONCLUSION: The present results suggest that in the pathogenesis of achalasia, especially in the development of the LES high-pressure zone, depletion of ICC networks and potential changes in the electrical activity of smooth muscle cells may play a crucial role. The reduction in CD117-positive ICC in a few patients also seemed to be of relevance, even if the cells of Auerbachʼs plexus were unscathed. The associated reduced NOS release might underlie the profound ICC impairment and could possibly be responsible for the lack of LES relaxation, because of missing inhibitory neurotransmission. It is unclear, however, whether the ICC loss is primarily caused by the accelerated attrition of mature cells or their impaired regeneration.
    Keywords: Achalasia -- Development And Progression ; Achalasia -- Care And Treatment ; Neurons ; Nitric Oxide;
    ISSN: 0002-9270
    E-ISSN: 15720241
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  • 5
    Language: English
    In: The American Journal of Surgery, 2010, Vol.200(2), pp.291-297
    Description: The objective of this study was to examine the outcomes of comparisons between laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia. The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using classic and modern meta-analytic methods. Significantly fewer cases of hematoma/seroma formation were observed in the laparoscopic group in comparison with the Lichtenstein group (odds ratio, .38; .15–.96; = .04). A matter of great importance is the higher relative risk of overall recurrence in the transabdominal preperitoneal group compared with the totally extraperitoneal group (relative risk, 3.25; 1.32–7.9; = .01). Laparoscopic versus open mesh repair for recurrent inguinal hernia was equivalent in most of the analyzed outcomes.
    Keywords: Meta-Analysis ; Evidence Based ; Publication Bias ; Recurrent Inguinal Hernia ; Totally Extraperitoneal ; Transabdominal Preperitoneal ; OPM ; Open Preperitoneal Mesh ; Stoppa ; Giant Prosthetic Reinforcement of the Visceral Sac ; Lichtenstein Procedure
    ISSN: 0002-9610
    E-ISSN: 1879-1883
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  • 6
    Language: English
    In: Digestive diseases and sciences, May 2011, Vol.56(5), pp.1432-7
    Description: This study investigated the long-term clinical course of patients with Schatzki rings, who were treated by single bougie dilation. Furthermore, it analyzed possible predictors for the time of recurrence. A total of 133 patients (100 males, 33 females) with a mean age of 57 ± 14.6 years who were treated by single dilation with the use of Maloney bougies without the aid of fluoroscopy were prospectively registered and followed-up for a mean duration of 58.3 months (range 12-240 months). Duration of remission was evaluated by Kaplan-Meier estimates with regard to recurrence. Log-rank test was performed to analyze possible predictors for the time to second dilation (recurrence). No complications occurred and all patients were symptom-free at the first follow-up examination 4 weeks after dilation. However, later on, 73 patients required a second dilation. The estimate remission rates were 63.8% (95% CI: 55.6-72.0%) after 2 years, 44.3% (95% CI: 35.4-53.4%) after 5 years, and 39.9% (95% CI: 30.5-49.3%) after 10 years. Neither the initial morphological findings, nor age or gender determined the need for repeated dilation. Only patients treated with a large bougie diameter (≥52 F) seemed to have a tendency for a longer time until symptomatic recurrence. Single dilation of symptomatic Schatzki rings is a safe and effective therapy. However, more than half of the patients will need a second treatment. Recurrences are unrelated to initial morphological findings, age, or gender. Only the treatment with a large bougie diameter (≥52 F) showed a tendency for a longer time of remission.
    Keywords: Dilatation -- Methods ; Esophageal Stenosis -- Surgery ; Esophagogastric Junction -- Pathology
    ISSN: 01632116
    E-ISSN: 1573-2568
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  • 7
    In: International Journal of Cancer, 15 October 2016, Vol.139(8), pp.1696-1702
    Description: We explored the relationship between socio‐economic characteristics and cancer stage at presentation. Patients admitted to a university hospital for diagnosis and treatment of cancer provided data on their education, vocational training, income, employment, job, health insurance and postcode. Tumor stage was classified according to the Union International Contre le Cancer (UICC). To analyze disparities in the likelihood of late‐stage (UICC III/IV . I/II) diagnoses, logistic regression models adjusting for age and gender were used. Out of 1,012 patients, 572 (59%) had late‐stage cancer. Separately tested, increased odds of advanced disease were associated with post‐compulsory education compared to college degrees, with apprenticeship and no vocational training, with unemployment, disability pension, jobs with a low hierarchy level, blue collar jobs and with low income. Health insurance and community size were not related with late‐stage cancer. Jointly modelled, there was evidence for an independent effect of unemployment (odds ratio (OR) 1.7, CI 1.0–2.8), disability pension (OR 1.8, CI 1.0–3.2) and very low income (OR 2.6, CI 1.1–6.1) on the likelihood of advanced disease stage. It is of great concern that these socio‐economic gradients occur even in systems with equal access to health care. What's new? Low‐income cancer patients tend to die earlier than more affluent patients. But why is this so? Large cancer registries haven't provided an answer. In this German study, the authors analyzed individual patient data rather than the aggregated datasets of registries. The study found that, even with equal access to health care, low‐income and unemployed patients were more likely to present with late‐stage cancer at diagnosis. It is important to determine the reasons for this effect, as prognosis is considerably improved with early treatment.
    Keywords: Health Disparities ; Unemployment ; Income ; Education ; Rural/Urban ; Screening
    ISSN: 0020-7136
    E-ISSN: 1097-0215
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  • 8
    Language: English
    In: BMC Surgery, 01 July 2017, Vol.17(1), pp.1-8
    Description: Abstract Background Cost reduction measures in medicine are gaining greater importance nowadays, especially in high-volume procedures such as laparoscopic appendectomy (LAE). Currently there are two common methods of dissecting the appendix from the caecal pole: linear stapler and endoloops. The endoloop is the cheaper device but can only be used in uncomplicated cases of appendicitis. Therefore both methods are used in LAE depending on intraoperative findings. The goal of this study was to retrospectively evaluate possible cost reduction due to increased use of endoloop in LAE in our general surgery department of a tertiary referral university hospital. Methods We previously used the stapler for appendix dissection in LAE as our local protocol but introduced the endoloop as standard method in 2015 to reduce intraoperative costs. We conducted a retrospective analysis of patients who underwent LAE between June 2014 and October 2015 in our department. Our purpose is to show the effects on cost reduction during the introductory period adjusting for a potential bias due to the individual learning curve of every surgeon. We estimated costs for LAE by taking into account average device costs and duration of operation (DO) as well as patient outcome. Results A total of 177 patients underwent LAE, 73 in 2014 (phase I) and 104 in 2015 (phase II). The median DO was 61 (± 24 SD) min during the entire period, and increased by 14 min from phase I to II (from 51 (±23 SD) min to 65 (±24 SD) min respectively, p 〈 0.001). The use of endoloops increased from 10% to 55% (p 〈 0.001). Patients’ characteristics and outcomes did not differ significantly. A median saving of 5.9€ per operation was calculated in phase II compared to phase I (p = 0.80). Conclusion Introducing the endoloop as standard device for LAE leads to a marginal reduction in intraoperative costs without increasing negative outcomes. In our model the cost-reduction achieved by cheaper devices was overcome by increased costs for DO during the initial phase of use of endoloops. A longer follow up might show a more pronounced cost reduction.
    Keywords: Laparoscopic Appendectomy ; Endoloop ; Stapling Device ; Cost-Reduction
    E-ISSN: 1471-2482
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  • 9
    Language: English
    In: The Annals of Thoracic Surgery, November 2013, Vol.96(5), pp.1840-1845
    Description: There is an increasing trend to include patients with esophageal carcinoma invading the muscularis propria (pT2) in neoadjuvant therapy regimens. But it is unclear which patients have prognostic benefit from this strategy. The aim of this study was to assess the prognosis and prognostic factors in patients with pT2 esophageal adenocarcinoma to further optimize treatment strategies. Included were patients with pT2 esophageal adenocarcinoma treated operatively at three centers specializing in upper gastrointestinal surgery. There were 159 patients (139 male) without induction therapy; median age was 64.5 years. Survival was analyzed by univariate and multivariate analysis. In 37% of patients (n = 59), no lymph node involvement (pN0) was detected. Overall 5-year survival rate for all patients was 37%; for pN0 patients it was 62%, and for patients with lymph node metastases (pN+) it was 24%. Median number of examined lymph nodes was 26. Extracapsular lymph node involvement (ELNI) was evident in 55 of 100 pN+ patients with a 5-year survival rate of 14%. Patients without ELNI had a 5-year survival rate of 36% (  = 0.041). Results were comparable in all participating hospitals. Thirty-day and 90-day mortality rates of the entire collective were 2.6% and 3.8%, respectively. Multivariate analysis of prognosis revealed the lymph node ratio ( 〈 0.001) and the pN-ELNI category (  = 0.005) as significant parameters (pN0 hazard ratio 1 [reference]; pN+ without ELNI hazard ratio 2.2, 95% confidence interval: 1.2 to 3.8); pN+ with ELNI hazard ratio 2.5, 95% confidence interval: 1.5 to 4.5). The prognosis of patients with esophageal adenocarcinoma invading the muscularis propria without lymph node metastasis is very good. However, in this study, about 30% had extracapsular lymph node involvement, which reflects particularly aggressive biological tumor behavior.
    Keywords: 7;
    ISSN: 0003-4975
    E-ISSN: 1552-6259
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  • 10
    Language: English
    In: Journal of the American College of Surgeons, March 2012, Vol.214(3), pp.306-312
    Description: The aim of this prospective study was to assess internal anal sphincter (IAS) innervation in patients undergoing total mesorectal excision (TME) by intraoperative neuromonitoring (IONM). Fourteen patients underwent TME. IONM was carried out through pelvic splanchnic nerve stimulation under continuous electromyography of the IAS. Anorectal function was assessed with the digital rectal examination scoring system and a standardized questionnaire. Nine of 11 patients who underwent low anterior resection had positive IONM results, with stimulation-induced increased IAS electromyographic amplitudes (median 0.23 μV (interquartile range [IQR] 0.05, 0.56) vs median 0.89 μV (IQR 0.64, 1.88), p 〈 0.001) after TME. The patients with the positive IONM results were continent after stoma closure. Of 2 patients with negative IONM results, 1 had fecal incontinence after closure of the defunctioning stoma and received a permanent sigmoidostomy. In the other patient the defunctioning stoma was deemed permanent due to decreased anal sphincter function. In 3 patients who underwent abdominoperineal excision, IONM assessed denervation of the IAS after performance of the abdominal part. This study demonstrated that IONM of IAS innervation in rectal cancer patients is feasible and may predict neurogenic fecal incontinence.
    Keywords: Aged–Innervation ; Aged, 80 and Over–Physiology ; Anal Canal–Etiology ; Autonomic Nervous System–Methods ; Electromyography–Surgery ; Feasibility Studies–Surgery ; Fecal Incontinence–Surgery ; Female–Surgery ; Humans–Surgery ; Male–Surgery ; Middle Aged–Surgery ; Monitoring, Intraoperative–Surgery ; Prospective Studies–Surgery ; Rectal Neoplasms–Surgery ; Rectum–Surgery ; Surveys and Questionnaires–Surgery ; Treatment Outcome–Surgery ; Abridged;
    ISSN: 1072-7515
    E-ISSN: 1879-1190
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