To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter ...randomized controlled trial.
PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications.
A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up.
From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters.
The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.
Background
Abdominal surgery results in neuronal mediator release and subsequent acute intestinal hypomotility. This phase is followed by a longer lasting inflammatory phase resulting in ...postoperative ileus (POI). Calcitonin gene‐related peptide (CGRP) has been shown to induce motility disturbances and in addition may be a candidate mediator to elicit neurogenic inflammation. We hypothesized that CGRP contributes to intestinal inflammation and POI.
Methods
The effect of CGRP in POI was tested in mice treated with the highly specific CGRP receptor antagonist BIBN4096BS and in CGRP receptor‐deficient (RAMP‐1−/−) mice. POI severity was analyzed by cytokine expression, muscular inflammation and gastrointestinal (GI) transit. Peritoneal and muscularis macrophages and mast cells were analyzed for CGRP receptor expression and functional response to CGRP stimulation.
Key Results
Intestinal manipulation (IM) resulted in CGRP release from myenteric nerves, and a concurrent increased interleukin (IL)‐6 and IL‐1β transcription and leukocyte infiltration in the muscularis externa and increased GI transit time. CGRP potentiates IM‐induced cytokine transcription within the muscularis externa and peritoneal macrophages. BIBN4096BS reduced cytokine levels and leukocyte infiltration and normalized GI transit. RAMP1−/− mice showed a significantly reduced leukocyte influx. CGRP receptor was expressed in muscularis and peritoneal macrophages but not mast cells. CGRP mediated macrophage activation but failed to induce mast cell degranulation and cytokine expression.
Conclusions & Inferences
CGRP is immediately released during abdominal surgery and induces a neurogenic inflammation via activation of abdominal macrophages. BIBN4096BS prevented IM‐induced inflammation and restored GI motility. These findings suggest that CGRP receptor antagonism could be instrumental in the prevention of POI.
Postoperative ileus (POI) is a sequela of abdominal surgery and originates from an intestinal inflammation triggered by resident muscularis macrophages. Within murine bowel tissue and primary cell cultures, we demonstrate that the neurotransmitter calcitonin gene‐related peptide (CGRP) aggravates the surgery‐induced inflammation by targeting resident muscularis and peritoneal macrophages. Functional gastrointestinal transit measurements and histochemical leukocyte counts showed that the highly specific CGRP receptor antagonist BIBN4096BS reduces the postoperative inflammation and prevents POI in wildtype but not in CGRP receptor deficient mice.
There are several existing systemic 1st- line therapies for advanced hepatocellular carcinoma (HCC), including atezolizumab/bevacizumab (Atez/Bev), sorafenib and lenvatinib. This study aims to ...compare the effectiveness of these three 1st-line systemic treatments in a real-world setting for HCC, focusing on specific patient subgroups analysis.
A total of 177 patients with advanced HCC treated with Atez/Bev (n = 38), lenvatinib (n = 21) or sorafenib (n = 118) as 1st line systemic therapy were retrospectively analyzed and compared. Primary endpoints included objective response rate (ORR), progression-free survival (PFS) and 15-month overall survival (15-mo OS). Subgroups regarding liver function, etiology, previous therapy and toxicity were analyzed.
Atez/Bev demonstrated significantly longer median 15-month OS with 15.03 months compared to sorafenib with 9.43 months (p = 0.04) and lenvatinib with 8.93 months (p = 0.05). Similarly, it had highest ORR of 31.6% and longest median PFS with 7.97 months, independent of etiology. However, significantly superiority was observed only compared to sorafenib (ORR: 4.2% (p < 0.001); PFS: 4.57 months (p = 0.03)), but not comparing to lenvatinib (ORR: 28.6% (p = 0.87); PFS: 3.77 months (p = 0.10)). Atez/Bev also resulted in the longest PFS in patients with Child-Pugh A and ALBI 1 score and interestingly in those previously treated with SIRT. Contrary, sorafenib was non inferior in patients with impaired liver function.
Atez/Bev achieved longest median PFS and 15-mo OS independent of etiology and particularly in patients with stable liver function or prior SIRT treatment. Regarding therapy response lenvatinib was non-inferior to Atez/Bev. Finally, sorafenib seemed to perform best for patients with deteriorated liver function.
Early revision procedures after pancreatic head resection significantly increase mortality. Due to their complexity, secondary operations at a later stage rank amongst the most demanding surgical ...procedures. We sought to critically analyze indications and outcome from early revision and subsequent redo procedures following distal pancreatic resection (DPR).
During a 5-year period 53 subsequent patients undergoing DPR were identified from a pancreatic resection database and analyzed regarding indication for and outcome of early revision and late redo procedures.
Six patients (11%) underwent early revision procedures during the same hospital stay. Indications were peritonitis (n = 3), intraabdominal hemorrhage (n = 2) and oncologic re-resection (n = 1). Four patients (7.6%) were readmitted after 192 days (d) on average (range 53 - 538d) and underwent subsequent redo surgery due to occurrence of metastases in 2 cases, and insufficiency of an ascendo-rectostomy and adhesive ileus. Hospital stay and mortality were significantly increased after early revision surgery (40d vs. 18d; 33% vs. 0%). Splenectomy during DPR was carried out in all patients requiring early operative reintervention, compared to 63% in patients without secondary surgery (p < 0.07).
Early revision surgery following DPR increases postoperative mortality and length of hospital stay. Risk factors were complex injuries (e.g. gun shot wound), concomitant portal hypertension with collateral circulation and splenectomy. Subsequent redo surgery following DPR was performed on average within 7 month following the index operation without mortality and with comparable morbidity. Indications were recurrent malignant disease and complications of the intestine.
Although only a low percentage of abdominal surgical interventions are performed using a robotic platform, the total number has significantly increased in recent years and robotic surgery (RS) is no ...longer limited only to university hospitals. Despite the increasing popularity and many innovations in the field of robotic surgery with new devices, the data situation is confusing.
This review deals with the current areas of application of robotic devices in abdominal surgery and whether there are any advantages compared to laparoscopic surgery (LS).
The current international literature was evaluated and is critically discussed with a particular focus on clinical trials.
While the disadvantages include high costs and longer times of surgery, the advantages are a stable optical platform and the high mobility even in confined spaces; however, no high-quality, randomized controlled trial in abdominal surgery is currently available that could demonstrate an advantage of RS compared to LS.
Although no clear advantages of RS for the patients could so far be demonstrated, it seems to be at least equivalent to LS. Undisputed is the level of comfort for the surgeon. Once the costs of RS can be reduced, LS will probably be replaced for most indications.
Distal pancreatectomy is performed less frequently than pancreatic head resection. Secondary operations due to postoperative complications are surgically complex and demanding, hence often ...interdisciplinary approaches are pursued. We have analysed the indications and outcome of revision surgery and interventional procedures subsequent to pancreatic left resection.
Between 2001 and 2009 we prospectively evaluated 61 patients regarding demographic factors, hospital stay, diagnosis, closure technique, redo operations and interventions, morbidity and mortality.
Major complications without redo procedures were observed in 4 (9 %) of 44 patients. 8 (13 %) patients underwent early (7 +/- 8 days) postoperative revision procedures. A significant in-crease in hospital stay and mortality appeared in this group. Interventional procedures (7 x CT-guided abscess drains, 1 x haemorrhage with angio-graphic coiling, 1 x transgastral stenting of a pseudocyst) were performed significantly later (22 +/- 11 days p. o., p < 0,01) in 9 (15 %) patients.
Pancreatic fistulas and related complications represent the most common indications for revisions, but can usually be controlled by interventional procedures. In contrast to secondary surgery, interventional revisions do not significantly increase the length of hospital stay or mortality. There was no benefit of any certain closure technique of the pancreatic remnant.
Abstract
Background
Abdominal surgery results in neuronal mediator release and subsequent acute intestinal hypomotility. This phase is followed by a longer lasting inflammatory phase resulting in ...postoperative ileus (
POI
). Calcitonin gene‐related peptide (
CGRP
) has been shown to induce motility disturbances and in addition may be a candidate mediator to elicit neurogenic inflammation. We hypothesized that
CGRP
contributes to intestinal inflammation and
POI
.
Methods
The effect of
CGRP
in
POI
was tested in mice treated with the highly specific
CGRP
receptor antagonist
BIBN
4096
BS
and in
CGRP
receptor‐deficient (
RAMP
‐1
−/−
) mice.
POI
severity was analyzed by cytokine expression, muscular inflammation and gastrointestinal (
GI
) transit. Peritoneal and muscularis macrophages and mast cells were analyzed for
CGRP
receptor expression and functional response to
CGRP
stimulation.
Key Results
Intestinal manipulation (
IM
) resulted in
CGRP
release from myenteric nerves, and a concurrent increased interleukin (
IL
)‐6 and
IL
‐1
β
transcription and leukocyte infiltration in the muscularis externa and increased
GI
transit time.
CGRP
potentiates
IM
‐induced cytokine transcription within the muscularis externa and peritoneal macrophages.
BIBN
4096
BS
reduced cytokine levels and leukocyte infiltration and normalized
GI
transit.
RAMP
1
−/−
mice showed a significantly reduced leukocyte influx.
CGRP
receptor was expressed in muscularis and peritoneal macrophages but not mast cells.
CGRP
mediated macrophage activation but failed to induce mast cell degranulation and cytokine expression.
Conclusions & Inferences
CGRP
is immediately released during abdominal surgery and induces a neurogenic inflammation via activation of abdominal macrophages.
BIBN
4096
BS
prevented
IM
‐induced inflammation and restored
GI
motility. These findings suggest that
CGRP
receptor antagonism could be instrumental in the prevention of
POI
.
Venous thromboembolism (VTE) is a common complication in patients undergoing surgery. The risk for VTE is determined by the combination of individual predisposing factors and features of the specific ...type of surgery. Although the knowledge about VTE has increased enormously during the last years VTE-prophylaxis is still inadequate. The goals of our study were to assess the correctness of the adjusted pharmacological prophylaxis, and the difference of the VTE-risks in the different surgical departments.
During a three months period, 451 patients were prospective included. These patients were admitted to the Departments of Vascular and General Surgery and of Traumatology of our hospital. Based on the modified Hertfelder's VTE-risk-assessment model, we scored the patients and categorized them into 4 groups: low, moderate, high and very high risk for VTE. We enrolled every admitted patient taking their medical history and reviewing medical documents.
The mean cumulative risk value for VTE-risk was 3.68 (median 3.5, minimum: 0, maximum: 13 and standard deviation: 2.206), whereas 20.2% of our patients had a low, 27.2% middle, 21.7% high and 30.9% very high risk. The patients with vascular procedures had significantly higher mean value (5.03, SD 2.2) than the patients with general operations (3.6, SD 2.2) and those who underwent traumatology (3.06, SD 1,8) (P value <0.001). The majority of patients (n=356), (78.9%) received VTE-prophylaxis with low dose of low molecular weight heparin (LMWH). Of the remaining patients, 40 (8.9%) received therapeutic dose and 55 (12.2%) received none VTE-prophylaxis.
The VTE-risk for surgical patients remains high, despite all efforts for prophylaxis. The main reason may be that risk-assessment is time consuming and not standardized. We demonstrated that VTE-risk for patients in vascular surgery is significantly higher than the VTE-risk for patients in general and trauma surgery. We also showed that the VTE-risk in some patients was underestimated and prophylaxis was inadequate. Therefore, it is recommended to emphasize more on short risk-assessment, adequate prophylaxis and optimal dosage in order to prevent deep venous thrombosis and embolism disease.
Anorectal malignant melanoma is a rare tumor with a poor prognosis. Typical symptoms (bleeding, pain, perianal mass) are characteristic of hemorrhoids. This, together with the high rate of amelanotic ...tumors, often delays diagnosis. No therapy guidelines exist.
Based on our own experience of surgically treated patients and an extensive literature search, we present a stage-dependent therapeutic concept.
Eight patients (six women) with a mean age of 65 ± 8 years were treated at our institution. Six underwent abdominoperineal resection; two had local excision. Two patients additionally underwent inguinal lymph node dissection. Median survival was 12 months with a disease-free survival of 6 months. Forty treatment studies with a total of 1,970 cases could be identified. Prognostic factors are age, time to correct diagnosis, tumor extent, tumor stage, and perineural invasion. The impact of lymph node metastases and R0 resection varies. Surgery is the only effective therapy. Local excision is sufficient when free resection margins are achieved.
Locally limited tumors should be resected; if possible using local excision. Larger tumors or tumors with sphincter infiltration often require abdominoperineal resection with curative intent. When regional lymph node metastases are present, we advise regional lymphadenectomy of the affected area. In the case of distant metastases, palliative surgery is needed for metastasectomy and in cases of incontinence or refractory pain.
Zusammenfassung
Hintergrund
Zwar wird aktuell nur ein Bruchteil der abdominalchirurgischen Eingriffe robotisch-assistiert durchgeführt, die Gesamtanzahl ist jedoch in den letzten Jahren deutlich ...steigend und robotisches Operieren (RO) keinesfalls mehr nur auf Universitätskliniken begrenzt. Trotz der zunehmenden Verbreitung und vieler Innovationen im Bereich der robotischen Chirurgie mit neuen Plattformen ist die Datenlage unübersichtlich.
Fragestellung
Die Übersichtsarbeit beschäftigt sich mit den aktuellen Einsatzgebieten robotischer Plattformen in der Abdominalchirurgie und der Fragestellung, inwieweit Vorteile gegenüber der laparoskopischen Chirurgie (LO) bestehen.
Material und Methoden
Es erfolgte eine Auswertung und kritische Diskussion der internationalen Literatur.
Ergebnisse
Während als Nachteile hohe Kosten und längere Operationszeiten aufgeführt werden, werden als Vorteile u. a. die stabile optische Plattform sowie die hohe Beweglichkeit selbst auf engstem Raum genannt. Jedoch gibt es bis zum jetzigen Zeitpunkt keine qualitativ hochwertige, randomisiert-kontrollierte Studie in der Abdominalchirurgie, die einen Vorteil des RO verglichen mit dem LO nachweisen konnte.
Schlussfolgerungen
Auch wenn hinsichtlich des RO für den Patienten bislang kein eindeutiger Vorteil nachgewiesen werden konnte, so scheint es zumindest gleichwertig zum LO zu sein. Unbestritten ist der höhere Komfort für den Operateur. Sobald die Kosten für das RO deutlich gesenkt werden, wird das LO vermutlich in den meisten Indikationen verdrängt werden.
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