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OBJECTIVE: The aim of this study was to assess the influence of regional lymph node (RLN) retrieval on stage migration and survival in pancreatic cancer. METHODS: A total of 7,685 stage I and II pancreatic cancer patients were identified in the Surveillance, Epidemiology, and End Results database in 2004–2011. The impact of RLN was assessed using Cox regression, propensity score methods, and joinpoint regression. RESULTS: In 3,079 patients, 1 to 10 RLNs were retrieved; in 2,799 patients, 11 to 19 RLNs, and in 1,807 patients, 20+ RLNs. The rate of node-positive pancreatic cancer increased with the number of retrieved RLN. This trend continued beyond 10 retrieved RLN (P < 0.001). In unadjusted analysis, retrieval of RLN did not influence survival (P = 0.178). When adjusting for significant bias in staging variables (P < 0.001), retrieval of 20+ RLNs compared to 11 to 19 RLNs was associated with an increased survival in node-negative (hazard ratio, 0.78; 95% confidence interval, 0.62–0.98; P = 0.033) and node-positive cancer (hazard ratio, 0.83; 95% confidence interval, 0.74–0.93; P = 0.002). CONCLUSIONS: This population-based propensity score–adjusted investigation demonstrated that more retrieved RLNs in pancreatic cancer decreases the rate of stage migration and improves the oncological outcome in node-negative and positive cancer. Contradictory results may be explained by a bias in the cancer characteristics for a different extent of RLN retrieval. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

De Deken J.,Visceral | De Deken J.,Catholic University of Leuven | Kocabayoglu P.,University of Duisburg - Essen | Moers C.,University of Groningen
Current Opinion in Organ Transplantation | Year: 2016

Purpose of review: This article summarizes novel developments in hypothermic machine perfusion (HMP) as an organ preservation modality for kidneys recovered from deceased donors. Recent findings: HMP has undergone a renaissance in recent years. This renewed interest has arisen parallel to a shift in paradigms; not only optimal preservation of an often marginal quality graft is required, but also improved graft function and tools to predict the latter are expected from HMP. The focus of attention in this field is currently drawn to the protection of endothelial integrity by means of additives to the perfusion solution, improvement of the HMP solution, choice of temperature, duration of perfusion, and machine settings. HMP may offer the opportunity to assess aspects of graft viability before transplantation, which can potentially aid preselection of grafts based on characteristics such as perfusate biomarkers, as well as measurement of machine perfusion dynamics parameters. Summary: HMP has proven to be beneficial as a kidney preservation method for all types of renal grafts, most notably those retrieved from extended criteria donors. Large numbers of variables during HMP, such as duration, machine settings and additives to the perfusion solution are currently being investigated to improve renal function and graft survival. In addition, the search for biomarkers has become a focus of attention to predict graft function posttransplant. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Holler J.P.N.,Visceral | Ahlbrandt J.,Intensive Care and Pain Medicine | Burkhardt E.,Justus Liebig University | Gruss M.,Klinikum Hanau GmbH | And 5 more authors.
Annals of Surgery | Year: 2013

OBJECTIVE:: To determine the effect of peridural analgesia on long-term survival in patients who underwent surgical treatment of colorectal carcinoma. BACKGROUND:: Clinical and animal studies suggest a potential benefit of peridural analgesia on morbidity and mortality after cancer surgery. The effect of peridural analgesia on long-term outcome after surgery for colorectal cancer remains undefined. METHODS:: From 2003 to 2009, there were 749 patients who underwent surgery for colorectal carcinoma under general anesthesia with or without peridural analgesia. Clinical data were reviewed retrospectively and analyzed with multivariate analysis and Kaplan-Meier plots. RESULTS:: There were 442 patients who received peridural analgesia and 307 patients who did not receive peridural analgesia. A substantial survival benefit was observed in patients who received peridural analgesia (5-year survival rate: peridural analgesia, 62%; no peridural analgesia, 54%; P < 0.02). The hazard rate for death was decreased by 27% in patients who received peridural analgesia. When peridural analgesia was included simultaneously in a Cox model with the confounding factors age, American Society of Anesthesiologists classification, and stage, there was a significant survival benefit in patients who received peridural analgesia. In patients with America Society of Anesthesiologists classification 3 to 4, there was significantly greater survival with peridural analgesia than without peridural analgesia (P < 0.009). CONCLUSIONS:: Peridural analgesia may improve survival in patients underwent surgery for colorectal carcinoma. The survival benefit with peridural analgesia was greater in patients who had greater medical morbidity. © 2013 Lippincott Williams and Wilkins.

Reibetanz J.,Visceral | Jurowich C.,Visceral | Erdogan I.,University of Würzburg | Nies C.,Marienhospital Osnabruck | And 5 more authors.
Annals of Surgery | Year: 2012

Objective: Adrenocortical carcinoma (ACC) is a rare malignancy with an unfavorable prognosis. The impact of a locoregional lymph node dissection (LND) has never been defined in this disease. We report the disease-specific outcome of patients treated with or without LND during primary adrenalectomy. Methods: The medical records of patients followed by the German ACC Registry were retrospectively reviewed. Patients with incomplete resection or distant metastases were excluded. Only if the histologic analysis retrieved 5 or more lymph nodes, an intended LND was assumed (LND group). The predefined primary end point of the study was disease-specific survival. Results: Of 283 included patients, 47 patients (16.6%) were treated with LND, whereas 236 patients (83.4%) underwent surgery without LND. Patients who underwent LND had a larger median tumor size (12.0 cm, range: 2.3-30 cm vs 10.0 cm, range: 4.0-39 cm, P = 0.007) and were more often treated by multivisceral resection (LND: 47.8% vs no-LND: 18.1%; P < 0.001). The other baseline characteristics (age, sex, endocrine activity, Weiss score, Ki-67 index, and adjuvant treatment) did not differ significantly. Median follow-up of all patients still alive was 40 months (range: 6-326). Multivariate analysis adjusted for age, tumor stage, multivisceral resection, adjuvant treatment, and lymph nodes status on preoperative imaging demonstrated a significantly reduced risk for tumor recurrence (hazard ratio: 0.65; 95% confidence interval: 0.43-0.98; P = 0.042) and for disease-related death (hazard ratio: 0.54; 95% confidence interval: 0.29-0.99; P = 0.049) in LND patients when compared with no-LND patients. Conclusions: Our retrospective data indicate that locoregional LND improves tumor staging and leads to a favorable oncologic outcome in patients with localized ACC. © 2012 by Lippincott Williams & Wilkins.

Bauer K.,Visceral | Porzsolt F.,University of Ulm | Henne-Bruns D.,University of Ulm
Journal of Gastric Cancer | Year: 2014

Purpose: According to current guidelines, perioperative chemotherapy is an integral part of the treatment strategy for advanced gastric cancer. Randomized controlled studies have been conducted in order to determine whether perioperative chemotherapy leads to improved R0 resection rates, fewer recurrences, and prolonged survival. The aim of our project was to critically appraise three major studies to establish whether perioperative chemotherapy for advanced, potentially resectable gastric cancer can be recommended on the basis of their findings. Materials and Methods: We analyzed the validity of the three most important studies (MAGIC, ACCORD, and EORTC) using a standardized questionnaire. Each study was evaluated for the study design, patient selection, randomization, changes in protocol, participating clinics, preoperative staging, chemotherapy, homogeneity of subjects, surgical quality, analysis of the results, and recruitment period. Results: All three studies had serious shortcomings with respect to patient selection, homogeneity of subjects, changes in protocol, surgical quality, and analysis of the results. The protocols of the MAGIC and ACCORD-studies were changed during the study period because of insufficient recruitment, such that carcinomas of the lower esophagus and the stomach were examined collectively. In neither the MAGIC study nor the ACCORD study did patients undergo adequate lymphadenectomy, and only about half of the patients in the chemotherapy group could undergo the treatment specified in the protocol. The EORTC study had insufficient statistical power. Conclusions: We concluded that none of the three studies was sufficiently robust to justify an unrestrained recommendation for perioperative chemotherapy in cases of advanced gastric cancer. © 2014 by The Korean Gastric Cancer Association.

Schwarzbach M.,Visceral | Hasenberg T.,University of Heidelberg | Linke M.,University of Heidelberg | Kienle P.,University of Heidelberg | And 2 more authors.
International Journal of Colorectal Disease | Year: 2011

Purpose: Clinical pathways (CPs) are increasingly used to improve quality of care. However, evidence if such improvements are also feasible in fast-track colorectal surgery is lacking. This study evaluates effects of a CP for fast-track colonic resections with respect to process and outcome quality. Methods: We compared 78 consecutive patients undergoing colonic resections in 2008 and being treated with a CP (CP group) with 133 consecutive patients treated without CP between 2006 and 2007 (pre-CP group). Indicators for process quality were epidural catheter placement, postoperative mobilisation, resumption of solid diet, Foley catheter removal and length of stay. Outcome quality was measured through morbidity, mortality, re-operations and readmissions. Results: In the CP group, patients received epidural analgesia significantly more often (87.2% vs. 75.2%; p∈=0.04), were mobilized (38.9% vs. 20.6% on the day of surgery; p∈=∈0.03) and resumed a solid diet earlier (60.5% vs. 49.6% on day 1; p∈=∈0.002). Foley catheter removal and length of stay did not differ between the groups. There were no significant differences regarding morbidity (28.2% vs. 32.3%), mortality (1.2% vs. 2.3%), re-operations (6.4% vs. 9.0%) and readmissions (2.6% vs. 3.8%). Conclusions: After CP implementation for fast-track surgery of the colon, several indicators of process quality improved while others such as length of stay remained unaltered. There were no significant changes in outcome parameters. CPs are a viable instrument to improve specific aspects of perioperative process management, but their selective benefits have to be critically weighed against the infrastructural and personal efforts required for design and implementation. © 2011 Springer-Verlag.

Ronellenfitsch U.,University of Mannheim | Schwarzbach M.,Visceral | Kring A.,University of Mannheim | Kienle P.,University of Mannheim | And 2 more authors.
Obesity Surgery | Year: 2012

Background: Bariatric surgery demands a multidisciplinary approach and enhanced recovery schemes. Such schemes are complex and cumbersome to introduce into practice. This study evaluates if a clinical pathway (CP) facilitates implementation of an enhanced recovery scheme in bariatric surgery with the goal of improving perioperative quality of care. Methods: We compared 65 consecutive patients who underwent bariatric surgery in 2009 and were treated with a CP (CP group) with 64 consecutive patients treated without CP in 2007/2008 (pre-CP group). Process quality indicators were catheter management, postoperative mobilization, spirometer training, vitamin B supplementation, diet resumption, intake of supplement drinks, and length of stay. Outcome quality was measured through morbidity, mortality, re-operations, and re-admissions. Results: In the CP group, foley catheters were removed earlier (p<0.0001), patients were mobilized more often on the surgery day (CP group 92.3% vs. pre-CP group 78.1%, p=0.03), used spirometers more often (56.9% vs. 28.1%, p=0.002), were more often supplemented with vitamin B (100% vs. 31.3%, p<0.0001), and received oral supplement nutrition more often (100% vs. 59.4%, p<0.0001). Median length of stay was shorter in the CP group (6 vs. 7 days, p=0.007). There was no significant difference in mortality, morbidity, re-operations, and re-admissions. Conclusions: Following implementation of an enhanced recovery CP for bariatric surgery, several indicators of process quality improved while outcome quality remained unchanged. A CP seems useful for optimizing treatment of bariatric surgery patients according to enhanced recovery principles. However, future studies are required to better determine which elements of care can be improved most. © Springer Science+Business Media LLC 2012.

Bauer K.,Visceral | Schroeder M.,University of Ulm | Porzsolt F.,University of Ulm | Henne-Bruns D.,University of Ulm
Journal of Gastric Cancer | Year: 2015

The purpose of this study was to determine if international guidelines differ in their recommendations concerning additive therapy for advanced, but potentially curable, gastric cancer. A systematic search of the English and German literature was conducted in the databases Medline, Cochrane Database, Embase, and PubMed. The search terms used were ‘guidelines gastric cancer,’ ‘guidelines stomach cancer,’ and ‘Leitlinien Magenkarzinom.’ Six different guidelines published after January 1, 2010, in which the tumors were classified according to the seventh edition of the TNM system (2010), were identified. Although the examined guidelines were based on the same study results, their recommendations concerning accompanying therapy for gastric cancer differ considerably. While perioperative chemotherapy is recommended in Germany, Great Britain, and large parts of Europe, postoperative adjuvant radiochemotherapy or perioperative chemotherapy is recommended in the USA and Canada. In Japan, postoperative adjuvant chemotherapy is recommended.The results of identical studies were interpreted differently in different countries. Since considerable effort is required for each country to separately test relevant studies for their validity and suitability, an international cooperation could simplify the creation of a common basis for guidelines and contribute to improved comparability of international guidelines. © 2015 by The Korean Gastric Cancer Association.

Wilhelm T.,Head Neck and Facial Plastic Surgery | Metzig A.,Visceral
Surgical Endoscopy | Year: 2010

Background: The transoral endoscopic approach for thyroid surgery was based on a previous attempt to reach the thyroid gland by an axilloscope. In contrast to this single-port access, endoscopic minimally invasive thyroidectomy (eMIT) uses three access points (sublingual and bivestibular). This results in a sufficient triangulation of instruments, making surgical procedures in the anterior neck region possible. Methods: The idea and development of the eMIT technique are described in detail. Anatomic studies, the development of the surgical access in a cadaver study, and the animal study for safety and feasibility of this transoral endoscopic approach for surgery of the anterior neck are outlined. Also, the foundations and ethical aspects are addressed in the context of developing a surgical innovation, which resulted in the first clinical application of this technique in humans. Results: The preclinical studies regarding endoscopic minimally invasive thyroidectomy proofed feasibility in a human cadaver studies as well as safety in a short-time survival animal study. The first clinical application in a 53-year old patient was successful without any significant complications; expected benefits (no postoperative pain or dysphagia, no visible scar) could be demonstrated. Conclusions: The eMIT technique represents a promising new surgical approach for endoscopic surgery in the anterior neck region. The whole development was based on principles for surgical innovation published after the authors' preclinical studies. At this writing, after an initial clinical study with humans, the time has come to compare this new technique with other endoscopic and minimally invasive approaches in a prospective randomized multicenter trial. © 2010 Springer Science+Business Media, LLC.

Wilhelm T.,Head Neck and Facial Plastic Surgery | Metzig A.,Visceral
World Journal of Surgery | Year: 2011

Background: We have developed a new approach for endoscopic minimally invasive thyroidectomy (eMIT) in anatomical studies. Safety and feasibility were demonstrated in an animal study and then the eMIT technique was applied for the first time successfully in humans on the 18 March 2009. Methods: In a prospective study, we performed this eMIT technique on eight patients suffering from nodular change of the thyroid gland. All patients were evaluated regarding recurrent laryngeal nerve function, intra- and postoperative complications, and postoperative outcome, particularly with respect to swallowing disorders. Results: A total thyroidectomy and a partial resection were performed in four cases each. In three cases, a conversion to open surgery was necessary due to specimen size. No local infection at the incision site or within the cervical spaces occurred within the direct postoperative course. No intraoperative bleeding necessitating conversion to open surgery was observed. In one case, a permanent palsy of the right recurrent laryngeal nerve was noted. Voice function and breathing were not affected. Paresthesia of the mental nerve did not occur in all patients and in those in which it did occur, it resolved within 3 weeks. Mean follow-up time was 10.9 months. Conclusions: The experimental development of the eMIT technique has led to its first clinical application in humans. In this prospective proof-of-concept study in humans, the thyroid gland was reached via the transoral endoscopic approach in an anatomically defined layer without any relevant damage to vessels. Limitations to this technique are determined by specimen volume (up to 30 ml) and nodule size (up to 20 mm). © 2010 Société Internationale de Chirurgie.

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