Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Postoperative pancreatic fistulas represent the most frequent complication after distal and segmental pancreatectomy and occur with a frequency of up to 50 %. There are many technical variations of pancreatic stump treatment for reduction of fistula rates after distal resection. Most of these techniques have only been analyzed in retrospective studies and the evidence for or against a specific technique is low. ⋯ Extended stapler compression time and mesh augmentation of the stapler line can be valid methods to reduce fistula rates. Central pancreatectomy is a relatively rarely used procedure where the right-sided pancreatic remnant is closed in the same fashion as during distal pancreatectomy and the left-sided remnant is connected to the intestines with a pancreaticojejunostomy or pancreaticogastrostomy. In conclusion, postoperative pancreatic fistula rates are still a relevant clinical problem after distal pancreatectomy and further studies on potentially improved novel techniques are required.
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Review Comparative Study
[Current standards of abdominal wall closure techniques : Conventional suture techniques].
The most frequent complications following midline abdominal laparotomy include incisional hernias, which develop in 10-15 % of patients and surgical site infections in 15-25 % of cases; however, the risk of these complications can be reduced by the surgical technique and the use of special suture materials. In 2010, the INLINE meta-analysis performed by the Study Centre of the German Society of Surgery (SDGC) revealed that a continuous suture technique using slowly absorbable suture material resulted in the lowest risk of developing postoperative incisional hernia after elective midline laparotomy. ⋯ Current evidence shows that slowly absorbable monofilament suture material using a continuous suture technique provides the best results with regard to incisional hernia rates after elective midline laparotomy. Triclosan-coated sutures cannot be recommended as a standard suture material as they failed to reduce surgical site infections. For emergency laparotomies no evidence exists to recommend a specific kind of suture technique or a special suture material.
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There is a high incidence of incisional hernias in specific high-risk patient populations. For these patients, the prophylactic placement of mesh during closure of the abdominal wall incision has been investigated in several prospective studies. ⋯ Prophylactic mesh implantation should be the standard of care during construction of an elective end colostomy and will become the standard of care for midline laparotomies in patients at high risk of incisional hernias.
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Mediastinitis occurs as a severe complication of thoracic and cardiac surgical interventions and is the result of traumatic esophageal perforation, conducted infections or as a result of lymphogenic and hematogenic spread of specific infective pathogens. Treatment must as a rule be accompanied by antibiotics, whereby knowledge of the spectrum of pathogens depending on the pathogenesis is indispensable for successful antibiotic therapy. Polymicrobial infections with a high proportion of anaerobes are found in conducted infections of the mediastinum and after esophageal perforation. ⋯ For treatment of fungal infections (e.g. Candida, Aspergillus and Histoplasma) established and novel azoles, amphotericin B and echinocandins seem to be successful; however, detection of Candida, particularly in mixed infections does not always necessitate treatment. Mediastinitis is still a severe infectious disease with a high mortality, which necessitates an early and broad spectrum antibiotic therapy; however, with respect to optimal duration of therapy and selection of antibiotics, data from good quality comparative studies are lacking.
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Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor disease, which rapidly leads to death if untreated. In Germany the incidence of newly occurring disease is expected to reach a peak in the coming 5 years. An R0 resection for MPM is technically impossible; therefore, the aim of surgical procedures is to achieve the maximum amount of cytoreduction. ⋯ The type and extent of surgery are currently controversially discussed. Within multimodal therapy concepts including cytoreductive surgery, long-term remission is possible in selected patients. When choosing the appropriate surgical therapy the high incidence of recurrence has to be borne in mind.