Oettle H.,Charité - Medical University of Berlin |
Neuhaus P.,Charité - Medical University of Berlin |
Hochhaus A.,Universitatsklinikum Jena |
Hartmann J.T.,University of Kiel |
And 9 more authors.
JAMA - Journal of the American Medical Association | Year: 2013
IMPORTANCE: The prognosis for patients with pancreatic cancer is poor, even after resection with curative intent. Gemcitabine-based chemotherapy is standard treatment for advanced pancreatic cancer, but its effect on survival in the adjuvant setting has not been demonstrated. OBJECTIVE: To analyze whether previously reported improvement in disease-free survival with adjuvant gemcitabine therapy translates into improved overall survival. DESIGN, SETTING, AND PATIENTS: CONKO-001 (Charité Onkologie 001), a multicenter, open-label, phase 3 randomized trial to evaluate the efficacy and toxicity of gemcitabine in patients with pancreatic cancer after complete tumor resection. Patients with macroscopically completely removed pancreatic cancer entered the study between July 1998 and December 2004 in 88 hospitals in Germany and Austria. Follow-up ended in September 2012. INTERVENTIONS: After stratification for tumor stage, nodal status, and resection status, patients were randomly assigned to either adjuvant gemcitabine treatment (1g/m2 d 1, 8, 15, q 4 weeks) for 6 months or to observation alone. MAIN OUTCOMES AND MEASURES: The primary end point was disease-free survival. Secondary end points included treatment safety and overall survival, with overall survival defined as the time from date of randomization to death. Patients lost to follow-up were censored on the date of their last follow-up. RESULTS: A total of 368 patients were randomized, and 354 were eligible for intention-to-treat-analysis. By September 2012, 308 patients (87.0%[95% CI, 83.1%-90.1%]) had relapsed and 316 patients (89.3% [95% CI, 85.6%-92.1%]) had died. The median follow-up time was 136 months. The median disease-free survival was 13.4 (95% CI, 11.6-15.3) months in the treatment group compared with 6.7 (95% CI, 6.0-7.5) months in the observation group (hazard ratio, 0.55 [95% CI, 0.44-0.69]; P < .001). Patients randomized to adjuvant gemcitabine treatment had prolonged overall survival compared with those randomized to observation alone (hazard ratio, 0.76 [95%CI, 0.61-0.95]; P = .01), with 5-year overall survival of 20.7% (95% CI, 14.7%-26.6%) vs 10.4% (95% CI, 5.9%-15.0%), respectively, and 10-year overall survival of 12.2% (95% CI, 7.3%-17.2%) vs 7.7% (95% CI, 3.6%-11.8%). CONCLUSIONS AND RELEVANCE: Among patients with macroscopic complete removal of pancreatic cancer, the use of adjuvant gemcitabine for 6 months compared with observation alone resulted in increased overall survival as well as disease-free survival. These findings provide strong support for the use of gemcitabine in this setting. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN34802808.
Brinkmann L.,Klinik fur Allgemein und Viszeralchirurgie |
Lorenz D.,Klinik fur Allgemein und Viszeralchirurgie
Chirurg | Year: 2011
In recent years scarless surgery (axillo-bilateral-breast aproach [ABBA], natural orifice transluminal endoscopic surgery [NOTES], single-port surgery) has gained importance in order to improve postoperative outcome in laparoscopic surgery. As part of this effort minilaparoscopic surgery might be a suitable alternative concerning cosmetic outcome without implementing a completely new technique. Due to the definition minilaparoscopic surgery is based on instruments which reduce the total length of trocar incisions to less than 2.5 cm. Nevertheless the total number of incisions is similar to conventional laparoscopic techniques. Most recent indications for minilaparoscopic surgery are cholecystectomy, appendectomy, hernia and colorectal surgery. This article describes the technical aspects and feasibility of minilaparoscopic cholecystectomy and transabdominal preperitoneal hernia repair (TAPP).While the trocar positions remain in the original setting the laparoscopic surgeon benefits from experience gained in conventional laparoscopic surgery. Although the cosmetic outcome is not comparable to single-port surgery, in the author's opinion minilaparoscopic surgery is a useful alternative in scarless surgery due to the fact that it is easy to adapt without establishing a completely new technique. © Springer-Verlag 2011.
Schiedeck T.H.,Klinik fur Allgemein und Viszeralchirurgie
Chirurg | Year: 2013
Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon. © 2013 Springer-Verlag Berlin Heidelberg.
Knappmann C.,Klinik fur Allgemein und Viszeralchirurgie
Lymphologie in Forschung und Praxis | Year: 2015
Morbid obesity is increasing dramatically worldwide, significantly limiting life expectancy due to the associated comorbidities. Since purely conservative treatment measures offer limited chances of permanent and effective weight reduction, various surgical techniques have been developed. With these techniques, 80 % of overweight can be reduced, offering a means of permanently resolving morbid obesity.
Metzger J.,Klinik fur Allgemein und Viszeralchirurgie
Praxis | Year: 2015
The risk of strangulation in case of a inguinal hernia is low. Patients with a symptomatic inguinal hernia should undergo an operation. Morbidity and mortality in inguinal hernia surgery are very rare. There is also non-conservative treatment of inguinal hernias. Trusses should no longer be recommended. Watchful waiting is an option for men with minimally symptomatic or asymptomatic inguinal hernias. But patients must be informed that there is a high risk of becoming symptomatic. © 2015 Verlag Hans Huber, Hogrefe AG, Bern.
Meyer H.-J.,Klinik fur Allgemein und Viszeralchirurgie |
Wilke H.,Klinik fur Internistische Onkologie
Deutsches Arzteblatt | Year: 2011
Background: Gastric cancer has become less common but remains among the leading causes of death from cancer, with a 5-year survival rate of only 20% to 25%. Although diagnostic techniques have im - proved, most patients with gastric cancer in the Western world (unlike in some Asian countries) already have locally advanced disease when diagnosed and may thus need not only surgery, but also perioperative chemotherapy and/or radiotherapy. Method: Articles published from 2000 to 2010 and containing the terms "gastric cancer," "surgery," and "chemotherapy" in combination with "review" or "randomized trial" were retrieved by a search in the Cochrane Library and Medline databases and selectively reviewed. Results: Complete (R0) resection of the tumor remains the standard treatment whenever possible. Complete endoscopic resection suffices only in special types of carcinoma that are confined to the gastric mucosa. Depending on the histological findings, either a subtotal distal gastrectomy or a total (perhaps extended total) gastrectomy can be performed. The long-term benefit of systematic D2 lymphadenectomy has now been shown in a randomized trial: the rates of tumor-related death and of local or regional recurrence were found to be significantly lower with D2 than with D1 lymphadenectomy. Multimodal treatment strategies including perioperative chemotherapy and/or radiotherapy can fur - ther improve local and regional tumor control and lessen the rate of systemic metastasis. Conclusion: The standardization of surgical procedures lowered the operative risk in the treatment of gastric cancer. Patients with locally advanced disease can now derive additional benefit from perioperative chemotherapy with an increase of the 5-year survival rates of more than 10%.
Peitsch W.K.J.,Klinik fur Allgemein und Viszeralchirurgie
Surgical Endoscopy and Other Interventional Techniques | Year: 2014
Background: Laparoscopic and endoscopic procedures generally are accepted for repair of primary and recurrent hernias that follow conventional (anterior) repair. This report discusses transabdominal preperitoneal (TAPP) for incarcerated hernias, scrotal hernias, and hernias after radical prostatectomy, as well as hernia recurrences after TAPP and totally extraperitoneal (TEP) procedures (complex hernias). Studies with long-term results of hernia recurrences are missing. This study aimed to determine hernia recurrence rates for adults after a modified TAPP procedure. The records of patients who had hernia repair surgery at a general hospital 2, 7, 12, and 17 years earlier were analyzed. Living patients were requested to complete a questionnaire to complement information from their hospital records. Methods: A retrospective analysis was undertaken that included 5,764 patients who had undergone hernia repair surgery 2-17 years earlier at a single large center. Between 1993 and 2009, a modified TAPP procedure was performed for 5,764 patients (median age, 59.1 years) to repair 6,776 hernias (93.9% of all hernia repairs), including 6,126 primary hernias (87.4%) and 884 recurrent hernias (12.6%). These included 994 complicated hernias (14.2%) closed by a modified TAPP (89.3% of all femoral hernias, 85.9% of scrotal hernias, 79.1% of incarcerated hernias, and 92.7% of hernias after radical prostatectomy). Limited financial and staff resources did not permit a quantitative follow-up study within a reasonable time of all 5,764 patients who had hernia surgery 2-18 years earlier. To obtain quantitative results of hernia recurrences after a modified TAPP, the patients were divided into four subgroups and requested to complete a questionnaire. These four patient subgroups whose surgeries had been performed 2 years earlier (241 patients with 277 hernias), 7 years earlier (285 patients with 376 hernias), 12 years earlier (401 patients with 544 hernias), and 17 years earlier (181 patients with 222 hernias) represented the complete group of hernia sufferers. Patients with symptoms after hernia surgery (n = 5) were invited for a medical checkup by a specialist in hernia surgery at our outpatient unit. Results: The sex, age, and the number of complex hernias of the patients did not differ significantly among the four patient subgroups or in comparison with the entire group. The patients who had received surgery in 1994, 1999, 2004, and 2009 were quizzed by a questionnaire and represented all patients who had hernia surgery from 1993 to 2009. The follow-up response of the living patients in each of the subgroups ranged from 89.5% of those who had hernia surgery 17 years earlier to 95.9% of those who had surgery 2 years earlier. The primary end point of the study was the hernia recurrence rate after a modified TAPP for primary, recurrent, and complex hernias performed 2, 7, 12, and 17 years earlier. The secondary end points of the study focused on the following questions: Is a modified TAPP practicable with acceptable recurrence rates for complex hernias? Do relapse rates show individual surgeon-dependent differences in relation to the learning curve? How many years of postoperative follow-up evaluation are required to determine quantitative recurrence rates (>90% recurrence)? All inguinal and femoral hernias were repaired with a modified TAPP procedure. Hernia defects larger than 1 x 1 cmwere closed with nonabsorbable sutures before the mesh was implanted. Within 17 years after surgery, 4 (4.3%) of the 94 study participants treated with a modified TAPP procedure for primary or recurrent inguinal and femoral hernias experienced recurrent hernias (4 recurrences after 117 hernioplasties, 3.4%). Within 12 years after surgery, 4 (1%) of 302 patients experienced recurrent hernias (4 recurrences after 398 modified TAPP procedures, 1%). Within 7 years after surgery for inguinal or femoral hernias, 8 (3.2%) of 251 patients had relapsed (8 recurrences after 337 modified TAPP procedures, 2.4%). Within 2 years after a modified TAPP, only 1 of 230 patients (0.4%) experienced a recurrent hernia (1 relapse after 265 hernioplasties, 0.4%). After the modified TAPP procedure, 52.9% (n = 9) of the patients with a recurrent hernia had a second repair at our hospital, and 35.3% (n = 6) had the second repair at other hospitals, whereas 2 patients (11.8%) renounced a repeat surgical intervention. The recurrence rate after a modified TAPP procedure for all the patients (n = 896) was 1.8%. The study participants with primary hernias (n = 765) had a 1.7% recurrence rate, whereas the rate for recurrent hernias after anterior repair (n = 131) was 2.3%. Incarcerated hernias (n = 47) and hernias after radical prostatectomy (n = 22) that were closed by the modified TAPP procedure resulted in no hernia recurrences. Only 1 of 47 patients with scrotal hernias had a hernia relapse. Of all the hernia recurrences between 1993 and 2009 (n = 76), 60.5% (n = 46) developed within 2 years after surgery, whereas 15.8% (n = 12) occurred after more than 5 years, and 4% (n = 3) occurred after more than 10 years. The recurrence rates also were higher for surgeons in the early period after completion of their personal learning curves (<50 modified TAPP procedures performed on their own responsibility). Conclusions: In a retrospective long-term study (2-17 years) from a single center with 1,108 patients and 1,123 modified TAPP procedures (93.9% of all hernia repairs), the hernia recurrence rate was 1.7%for adults with primary hernias (n = 765 patients) and 2.3%for adults with recurrent hernias after anterior repair (n = 131 patients). A modified TAPP procedure with suturing of hernia defects larger than 1 x 1 cm can be used as the standard procedure without recurrences for femoral hernias, incarcerated hernias, and hernias after radical prostatectomy, with low recurrence rates for scrotal hernias (2%). To collect quantitative data on hernia recurrence rates, postoperative follow-up studies longer than 10 years are needed (4% of recurrences developed later than 10 years after surgery). © Springer Science+Business Media 2013.
Intraoperative complications of the lower gastrointestinal tract : Prevention, recognition and therapy [Intraoperative Komplikationen des unteren Gastrointestinaltraktes: Prävention, Erkennung, Therapie]
Ritz J.-P.,Klinik fur Allgemein und Viszeralchirurgie
Chirurg | Year: 2015
Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2–12 % of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided. © 2015, Springer-Verlag Berlin Heidelberg.
Schiedeck T.H.K.,Klinik fur Allgemein und Viszeralchirurgie
Chirurg | Year: 2015
Major complications only rarely occur after rectal prolapse surgery. Generally, the spectrum of possible complications should always be considered depending on the selected surgical procedure. Minor complications in all techniques have been described in up to 36 %. The commonest complication is bleeding with 2–5 %, urinary tract infections and wound infections. Finally, the risk of recurrence must be considered, which shows substantial differences (4–40 %); therefore, no operation technique can be given preference based solely on the risk of recurrence. Therapy decisions are always more individualized and must take the personal environment of the patient as well as the experience of the surgeon into consideration. © 2015, Springer-Verlag Berlin Heidelberg.
Ruppert R.,Klinik fur Allgemein und Viszeralchirurgie
Chirurg | Year: 2016
The treatment for hemorrhoids ranges from conservative management to surgical procedures. The procedures are tailored to the individual grading of hemorrhoids and the individual complaints. The standard Goligher classification of the hemorrhoids is the basis for further treatment and no differentiation is made between segmental hemorrhoids and circular hemorrhoids. In the case of advanced circular hemorrhoid disease the surgical procedure with a stapler, so-called stapler anopexy, is the procedure of choice. © 2016 Springer-Verlag Berlin Heidelberg