Jeff Love and Johannes Schmidt offer a fresh translation of Schelling's enigmatic and influential masterpiece, widely recognized as an indispensable work of German Idealism. The text is an ...embarrassment of riches—both wildly adventurous and somberly prescient. Martin Heidegger claimed that it was "one of the deepest works of German and thus also of Western philosophy" and that it utterly undermined Hegel's monumental Science of Logic before the latter had even appeared in print. Schelling carefully investigates the problem of evil by building on Kant's notion of radical evil, while also developing an astonishingly original conception of freedom and personality that exerted an enormous (if subterranean) influence on the later course of European philosophy from Schopenhauer and Kierkegaard through Heidegger to important contemporary theorists like Slavoj Zðizûek. This translation of Schelling's notoriously difficult and densely allusive work provides extensive annotations and translations of a series of texts (by Boehme, Baader, Lessing, Jacobi, and Herder), hard to find or previously unavailable in English, whose presence in the Philosophical Investigations is unmistakable and highly significant. This handy study edition of Schelling's masterpiece will prove useful for scholars and students alike.
To describe outcome after pancreatic surgery in the first 6 years of a mandatory nationwide audit.
Within the Dutch Pancreatic Cancer Group, efforts have been made to improve outcome after pancreatic ...surgery. These include collaborative projects, clinical auditing, and implementation of an algorithm for early recognition and management of postoperative complications. However, nationwide changes in outcome over time have not yet been described.
This nationwide cohort study included consecutive patients after pancreatoduodenectomy (PD) and distal pancreatectomy from the mandatory Dutch Pancreatic Cancer Audit (January 2014-December 2019). Patient, tumor, and treatment characteristics were compared between 3 time periods (2014-2015, 2016-2017, and 2018-2019). Short-term surgical outcome was investigated using multilevel multivariable logistic regression analyses. Primary endpoints were failure to rescue (FTR) and in-hospital mortality.
Overall, 5345 patients were included, of whom 4227 after PD and 1118 after distal pancreatectomy. After PD, FTR improved from 13% to 7.4% odds ratio (OR) 0.64, 95% confidence interval (CI) 0.50-0.80, P <0.001 and in-hospital mortality decreased from 4.1% to 2.4% (OR 0.68, 95% CI 0.54-0.86, P =0.001), despite operating on more patients with age >75 years (18%-22%, P =0.006), American Society of Anesthesiologists score ≥3 (19%-31%, P <0.001) and Charlson comorbidity score ≥2 (24%-34%, P <0.001). The rates of textbook outcome (57%-55%, P =0.283) and major complications remained stable (31%-33%, P =0.207), whereas complication-related intensive care admission decreased (13%-9%, P =0.002). After distal pancreatectomy, improvements in FTR from 8.8% to 5.9% (OR 0.65, 95% CI 0.30-1.37, P =0.253) and in-hospital mortality from 1.6% to 1.3% (OR 0.88, 95% CI 0.45-1.72, P =0.711) were not statistically significant.
During the first 6 years of a nationwide audit, in-hospital mortality and FTR after PD improved despite operating on more high-risk patients. Several collaborative efforts may have contributed to these improvements.
Abstract
Background
Although robotic pancreatoduodenectomy has shown promising outcomes in experienced high-volume centres, it is unclear whether implementation on a nationwide scale is safe and ...beneficial. The aim of this study was to compare the outcomes of the early experience with robotic pancreatoduodenectomy versus open pancreatoduodenectomy in the Netherlands.
Methods
This was a nationwide retrospective cohort study of all consecutive patients who underwent robotic pancreatoduodenectomy or open pancreatoduodenectomy who were registered in the mandatory Dutch Pancreatic Cancer Audit (18 centres, 2014–2021), starting from the first robotic pancreatoduodenectomy procedure per centre. The main endpoints were major complications (Clavien–Dindo grade greater than or equal to III) and in-hospital/30-day mortality. Propensity-score matching (1 : 1) was used to minimize selection bias.
Results
Overall, 701 patients who underwent robotic pancreatoduodenectomy and 4447 patients who underwent open pancreatoduodenectomy were included. Among the eight centres that performed robotic pancreatoduodenectomy, the median robotic pancreatoduodenectomy experience was 86 (range 48–149), with a 7.3% conversion rate. After matching (698 robotic pancreatoduodenectomy patients versus 698 open pancreatoduodenectomy control patients), no significant differences were found in major complications (40.3% versus 36.2% respectively; P = 0.186), in-hospital/30-day mortality (4.0% versus 3.1% respectively; P = 0.326), and postoperative pancreatic fistula grade B/C (24.9% versus 23.5% respectively; P = 0.578). Robotic pancreatoduodenectomy was associated with a longer operating time (359 min versus 301 min; P < 0.001), less intraoperative blood loss (200 ml versus 500 ml; P < 0.001), fewer wound infections (7.4% versus 12.2%; P = 0.008), and a shorter hospital stay (11 days versus 12 days; P < 0.001). Centres performing greater than or equal to 20 robotic pancreatoduodenectomies annually had a lower mortality rate (2.9% versus 7.3%; P = 0.009) and a lower conversion rate (6.3% versus 11.2%; P = 0.032).
Conclusion
This study indicates that robotic pancreatoduodenectomy was safely implemented nationwide, without significant differences in major morbidity and mortality compared with matched open pancreatoduodenectomy patients. Randomized trials should be carried out to verify these findings and confirm the observed benefits of robotic pancreatoduodenectomy versus open pancreatoduodenectomy.
This nationwide study in 18 centres compared the surgical outcomes of 698 patients who underwent robotic pancreatoduodenectomy with those of 698 propensity-score-matched patients who underwent open pancreatoduodenectomy. The rates of major complications and mortality did not differ significantly, whereas robotic pancreatoduodenectomy was associated with less intraoperative blood loss, a longer operating time, a shorter hospital stay, fewer grade B/C chyle leaks, and fewer wound infections than open pancreatoduodenectomy.
The relation between type of postoperative complication and not receiving chemotherapy after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim was to investigate which patient ...factors and postoperative complications were associated with not receiving adjuvant chemotherapy.
Patients who underwent resection (2014–2017) for PDAC were identified from the nationwide mandatory Dutch Pancreatic Cancer Audit. The association between patient-, tumor-, center-, treatment characteristics, and the risk of not receiving adjuvant chemotherapy was analyzed with multivariable logistic regression.
Overall, of 1306 patients, 24% (n = 312) developed postoperative Clavien Dindo ≥3 complications. In-hospital mortality was 3.5% (n = 46). Some 433 patients (33%) did not receive adjuvant chemotherapy. Independent predictors (all p < 0.050) for not receiving adjuvant chemotherapy were older age (odds ratio (OR) 0.96), higher ECOG performance status (OR 0.57), postoperative complications (OR 0.32), especially grade B/C pancreatic fistula (OR 0.51) and post-pancreatectomy hemorrhage (OR 0.36), poor tumor differentiation grade (OR 0.62), and annual center volume of <40 pancreatoduodenectomies (OR 0.51).
This study demonstrated that a third of patients do not receive chemotherapy after resection of PDAC. Next to higher age, worse performance status and lower annual surgical volume, this is mostly related to surgical complications, especially postoperative pancreatic fistula and post-pancreatectomy hemorrhage.
The Berlin lectures in The Grounding of Positive Philosophy, appearing here for the first time in English, advance Schelling's final "existential system" as an alternative to modernity's reduction of ...philosophy to a purely formal science of reason. The onetime protégé of Fichte and benefactor of Hegel, Schelling accuses German Idealism of dealing "with the world of lived experience just as a surgeon who promises to cure your ailing leg by amputating it." Schelling's appeal in Berlin for a positive, existential philosophy found an interested audience in Kierkegaard, Engels, Feuerbach, Marx, and Bakunin. His account of the ecstatic nature of existence and reason proved to be decisive for the work of Paul Tillich and Martin Heidegger. Also, Schelling's critique of reason's quixotic attempt at self-grounding anticipates similar criticisms leveled by poststructuralism, but without sacrificing philosophy's power to provide a positive account of truth and meaning. The Berlin lectures provide fascinating insight into the thought processes of one of the most provocative yet least understood thinkers of nineteenth-century German philosophy.
Background
Conversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch ...national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery.
Methods
Patients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage.
Results
Out of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (
p
= 0.025 and
p
= 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (
p
= 0.002 and
p
= 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322–3.551) and DFS (1.592, 1077–2.353). Conversion was an independent predictor of DFS (1.525, 1.071–2.172), but not of OS.
Conclusion
Technical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.
Abstract
Background
Surgical site infections (SSIs) are common complications after colorectal procedures and remain an important source of morbidity and costs. Preoperative oral antibiotic ...prophylaxis is a potential infection control strategy, but its effectiveness without simultaneous use of mechanical bowel preparation (MBP) is unclear. In this study, we aimed to determine whether preoperative oral antibiotics reduce the risk of deep SSIs in elective colorectal surgery.
Methods
We performed a before–after analysis in a teaching hospital in the Netherlands. Patients who underwent surgery between January 2012 and December 2015 were included. On 1 January 2013, oral antibiotic prophylaxis with tobramycin and colistin was implemented as standard of care prior to colorectal surgery. The year before implementation was used as the control period. The primary outcome was a composite of deep SSI and/or mortality within 30 days after surgery.
Results
Of the 1410 patients, 352 underwent colorectal surgery in the control period and 1058 in the period after implementation of the antibiotic prophylaxis. We observed a decrease in incidence of the primary endpoint of 6.2% after prophylaxis implementation. When adjusted for confounders, the risk ratio for development of the primary outcome was 0.58 (95% confidence interval, 0.40–0.79). Other findings included a decreased risk of anastomotic leakage and a reduction in the length of postoperative stay.
Conclusions
Preoperative oral antibiotic prophylaxis prior to colorectal surgery is associated with a significant decrease in SSI and/or mortality in a setting without MBP. Preoperative oral antibiotics can therefore be considered without MBP for patients who undergo colorectal surgery.
Implementation of preoperative oral antibiotic prophylaxis with tobramycin and colistin as standard of care for elective colorectal surgery led to a 42% relative risk reduction for the composite outcome of deep surgical site infection and/or mortality.
Translated here into English for the first time, F. W. J. Schelling's 1842 lectures on the Philosophy of Mythology are an early example of interdisciplinary thinking. In seeking to show the ...development of the concept of the divine Godhead in and through various mythological systems (particularly of ancient Greece, Egypt, and the Near East), Schelling develops the idea that many philosophical concepts are born of religious-mythological notions. In so doing, he brings together the essential relatedness of the development of philosophical systems, human language, history, ancient art forms, and religious thought. Along the way, he engages in analyses of modern philosophical views about the origins of philosophy's conceptual abstractions, as well as literary and philological analyses of ancient literature and poetry.
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