[Future of University Medicine: How Important are Research and Teaching? - An Inventory]. / Zukunft der Universitätsmedizin: Welchen Stellenwert haben Forschung und Lehre noch? ­ Eine Bestandsaufnahme.

The requirements and challenges for the university hospitals in Germany are changing. Especially in surgical subjects, it is more and more difficult to adequately serve these three pillars of university medicine - clinic, research and education. This survey was intended to determine the status quo of general and visceral surgery at universities, in order to provide a basis for proposed solutions.For this online survey, 1505 visceral surgeons at the 38 university clinics were contacted. The questionnaire contained 29 questions on the structure of the clinic, scientific motivation, opportunities for time-off and the appreciation of academic achievements. The type and scope of student courses and the preparation for them were also determined. With regard to patient care, the type and number of services and the course of surgical training were examined. Based on the data published on the websites of the individual clinics on the number, gender, position and academic title of the doctors, a demographic analysis of university visceral surgeons could also be created.Of 1505 surgeons successfully contacted, 352 took part in the survey, which corresponds to a response rate of 23.4%. Of the participants, 93.5% were scientifically active, the majority being in the field of clinical data collection. Many indicated that they were also active in translational and/or experimental research, while educational research was rarely named. 45% confirmed that they could perform scientific work during their normal working hours. The reward for this activity was mostly in the form of time-off for congresses and clinical appreciation. Most participants stated that they were involved in 3-4 student courses per week, with 24.4% reporting that they were not adequately prepared for them.The compatibility of the classic three pillars of clinic, research and teaching continues to be of great relevance. There is a high level of motivation among the participating visceral surgeons not to neglect research and teaching, despite increasing economic pressure in the field of patient care. However, arrangements must be created in order to reward and promote commitment in research and teaching in a structured way.

Adherence to fast track measures in colorectal surgery-a survey among German and Austrian surgeons.

PURPOSE: The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement. METHODS: Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel. RESULTS: While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains). CONCLUSION: The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.

Surgical treatment for pancreatic cystic lesions-implications from the multi-center and prospective German StuDoQ|Pancreas registry.

PURPOSE: The detection of pancreatic cystic lesions (PCL) causes uncertainty for physicians and patients, and international guidelines are based on low evidence. The extent and perioperative risk of resections of PCL in Germany needs comparison with these guidelines to highlight controversies and derive recommendations. METHODS: Clinical data of 1137 patients who underwent surgery for PCL between 2014 and 2019 were retrieved from the German StuDoQ|Pancreas registry. Relevant features for preoperative evaluation and predictive factors for adverse outcomes were statistically identified. RESULTS: Patients with intraductal papillary mucinous neoplasms (IPMN) represented the largest PCL subgroup (N = 689; 60.6%) while other entities (mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), neuroendocrine tumors, pseudocysts) were less frequently resected. Symptoms of pancreatitis were associated with IPMN (OR, 1.8; P = 0.012) and pseudocysts (OR, 4.78; P < 0.001), but likewise lowered the likelihood of MCN (OR, 0.49; P = 0.046) and SCN (OR, 0.15, P = 0.002). A total of 639 (57.2%) patients received endoscopic ultrasound before resection, as recommended by guidelines. Malignancy was histologically confirmed in 137 patients (12.0%), while jaundice (OR, 5.1; P < 0.001) and weight loss (OR, 2.0; P = 0.002) were independent predictors. Most resections were performed by open surgery (N = 847, 74.5%), while distal lesions were in majority treated using minimally invasive approaches (P < 0.001). Severe morbidity was 28.4% (N = 323) and 30d mortality was 2.6% (N = 29). Increased age (P = 0.004), higher BMI (P = 0.002), liver cirrhosis (P < 0.001), and esophageal varices (P = 0.002) were independent risk factors for 30d mortality. CONCLUSION: With respect to unclear findings frequently present in PCL, diagnostic means recommended in guidelines should always be considered in the preoperative phase. The therapy of PCL should be decided upon in the light of patient-specific factors, and the surgical strategy needs to be adapted accordingly.

Is there a weekend effect in emergency surgery for colorectal carcinoma? Analysis from the German StuDoQ registry.

BACKGROUND: Higher postoperative mortality has been observed among patients who received emergency colorectal surgery on the weekend compared to during the week. The aim of this study was to determine whether the weekday of emergency surgery affects the 30-day mortality and postoperative course in emergency colorectal surgery. METHODS: Prospectively acquired data from the 2010-2017 German StuDoQ|Colorectal surgery registries were analysed. Differences in 30-day mortality, transfer and length of stay (MTL30) (primary endpoints), postoperative complications, length of stay and pathological results of resected specimens (secondary endpoints) were assessed. Multivariable analysis was performed to identify independent risk factors for postoperative outcome. RESULTS: In total, 1,174 patients were included in the analysis. Major postoperative complications and the need for reoperation were observed more frequently for emergency colorectal surgery performed during the week compared to the weekend (23.01 vs. 15.28%, p = 0.036 and 17.96% vs. 11.11%, p = 0.040, respectively). In contrast, patients who received emergency surgery on the weekend presented with significantly higher UICC tumour stages (UICC III 44.06 vs. 34.15%, p = 0.020) compared to patients with emergency colorectal surgery on a weekday. Emergency surgery performed during the week was an independent risk factor for the development of severe postoperative complications (OR 1.69 [1.04-2.74], p = 0.033) and need for reoperation (OR 1.79 [1.02-3.05], p = 0.041) in the multivariable analysis. CONCLUSION: Emergency surgery for colorectal carcinoma in Germany is performed with equal postoperative MTL30 and mortality throughout the entire week. However, emergency surgery during the week seems to be associated with a higher rate of severe postoperative complications and reoperation.

Preoperative calcitonin testing improves the diagnosis of medullary thyroid carcinoma in female and male patients.

AIM: Calcitonin (Ctn) measurement in patients with thyroid disease could potentially increase the detection rates of medullary thyroid carcinoma (MTC) but remains a controversial issue. The aim of this study was to evaluate routine preoperative Ctn measurements. METHODS: All patients with thyroid surgery documented in the prospective StuDoQ|Thyroid registry between March 2017 and September 2020 were included. Cutoff levels for Ctn were determined with receiver-operating characteristic analyses to assess the preoperative diagnosis of MTC in subgroups for females and males. FINDINGS: In 29 590 of 39 679 patients (75%) participating in the registry, routine preoperative Ctn testing was performed. In 357 patients (227 females and 130 males), histopathology confirmed MTC with a mean tumor size of 14.7 mm (±12.43). Biochemical cure was achieved in 71.4% of the patients. Ctn levels between 11 and 20 pg/mL were seen in 2.6% of the patients, and only 0.7% of the patients had Ctn levels above 21 pg/mL. Cutoff levels for the diagnosis of MTC were 7.9 pg/mL for females and 15 pg/mL for males (P < 0.001). The sensitivity and specificity for females were 95 and 98%, and 96 and 97% for males, respectively. CONCLUSION: Routine Ctn testing is a reliable predictor for MTC and provides the opportunity for earlier thyroidectomy before lymph node metastases occur, resulting in a better prognosis. Females with Ctn levels >7.9 pg/mL and males >15 pg/mL without any other extrathyroidal sources for an elevated Ctn should be monitored. Thyroid surgery should be considered if Ctn levels are increasing or ultrasound detects suspicious thyroid lesions.

Safety of anastomoses in colorectal cancer surgery in octogenarians: a prospective cohort study with propensity score matching.

BACKGROUND: Up to 20 per cent of all operations for patients with colorectal cancer (CRC) are performed in octogenarians. Anastomotic leakage is a leading cause of morbidity and death after resection for CRC. The aim of this study was to assess the rate of anastomosis creation, the risk of anastomotic leakage and death in surgery for left-sided CRC in elderly patients. METHODS: This prospective cohort study compared patients less than 80 and 80 or more years with left-sided CRC resection performed between 2013 and 2019. Data were provided from a risk-adjusted surgical quality-assessment system with 219 participating centres in Germany. Outcome measures were the rate of anastomoses, anastomotic leakages, death at 30 days and 2-year overall survival (OS). Propensity score matching was used to control for selection bias and compare subgroups of patients of less than 80 and 80 or more years. RESULTS: Out of 18 959 patients, some 3169 (16.7 per cent) were octogenarians. Octogenarians were less likely to receive anastomoses (82.0 versus 92.9 per cent, P < 0.001; odds ratio 0.50 (95 per cent c.i. 0.44 to 0.58), P < 0.001). The rate of anastomotic leakages did not differ between age groups (8.6 versus 9.7 per cent, P = 0.084), but 30-day mortality rate after leakage was significantly higher in octogenarians (15.8 versus 3.5 per cent, P < 0.001). Overall, anastomotic leakage was the strongest predictor for death (odds ratio 4.95 (95 per cent c.i. 3.66 to 6.66), P < 0.001). In the subgroup with no leakage, octogenarians had a lower 2-year OS rate than younger patients (71 versus 87 per cent, P < 0.001), and in the population with anastomotic leakage, the 2-year OS was 80 per cent in younger and 43 per cent in elderly patients (P < 0.001). After propensity score matching, older age remained predictive for not receiving an anastomosis (odds ratio 0.54 (95 per cent c.i. 0.46 to 0.63), P < 0.001) and for death (odds ratio 2.60 (95 per cent c.i. 1.78 to 3.84), P < 0.001), but not for the occurrence of leakages (odds ratio 0.94 (95 per cent c.i. 0.76 to 1.15), P = 0.524). CONCLUSION: Anastomotic leakage is not more common in octogenarians, but an age of 80 years or older is an independent factor for not receiving an anastomosis in surgery for left-sided CRC. The mortality rate in the case of leakage in octogenarians was reported to exceed 15 per cent.

Pylorus resection versus pylorus preservation in pancreatoduodenectomy (PyloResPres): study protocol and statistical analysis plan for a German multicentre, single-blind, surgical, registry-based randomised controlled trial.

INTRODUCTION: Partial pancreatoduodenectomy (PD) is the treatment of choice for various benign and malignant tumours of the pancreatic head or the periampullary region. For reconstruction of the gastrointestinal passage, two stomach-preserving PD variants exist: pylorus preservation PD (ppPD) or pylorus resection PD (prPD) with preservation of the stomach. In pancreatic surgery, delayed gastric emptying (DGE) remains a serious complication after PD with an incidence varying between 4.5% and 45%, potentially delaying hospital discharge or further treatment, for example, adjuvant chemotherapy. Evidence is lacking to assess, which variant of PD entails fewer postoperative DGE. METHODS AND ANALYSIS: The protocol of a large-scale, multicentre, pragmatic, two-arm parallel-group, registry-based randomised controlled trial (rRCT) using a two-stage group-sequential design is presented. This patient-blind rRCT aims to demonstrate the superiority of prPD over ppPD with respect to the overall incidence of DGE within 30 days after index surgery in a German real-world setting. A total of 984 adults undergoing elective PD for any indication will be randomised in a 1:1 ratio. Patients will be recruited at about 30 hospitals being members of the StuDoQ|Pancreas registry established by the German Society of General and Visceral Surgery. The postoperative follow-up for each patient will be 30 days. The primary analysis will follow an intention-to-treat approach and applies a binary logistic random intercepts model. Secondary perioperative outcomes include overall severe morbidity (Clavien-Dindo classification), blood loss, 30-day all-cause mortality, postoperative hospital stay and operation time. Complication rates and adverse events will be closely monitored. ETHICS AND DISSEMINATION: This protocol was approved by the leading ethics committee of the Medical Faculty of the Ludwig-Maximilians-Universität, Munich (reference number 19-221). The results will be published in a peer-reviewed journal and presented at international conferences. Study findings will also be disseminated via the website (http://www.dgav.de/studoq/pylorespres/). TRIAL REGISTRATION NUMBER: DRKS-ID: DRKS00018842.

[Surgical treatment of esophageal cancer-Indicators for quality in diagnostics and treatment]. / Chirurgische Therapie des Ösophaguskarzinoms ­ Qualitätsindikatoren für Diagnostik und Therapie.

BACKGROUND: Within the framework of the quality initiative of the German Society for General and Visceral Surgery (DGAV) a review article was compiled based on a systematic literature search. Recommendations for the current diagnostics and treatment of esophageal cancer were also elaborated. METHODS: The systematic literature search was carried out in March 2019 according to the PRISMA criteria using the MEDLINE databank. The recommendations were formulated based on a consensus in the DGAV. RESULTS AND CONCLUSION: Operations below the currently valid minimum quantity threshold should no longer be carried out. There are many indications that the minimum quantity in Germany should be raised to ≥20 resections/year/hospital in order to comprehensively improve the quality. Prehabilitation programs with endurance, strength and intensive breathing training as well as nutritional therapy improve patient outcome. The current treatment of esophageal cancer is stage-dependent and incorporates endoscopic resection of (sub)mucosal low-risk tumors (T1m1-3 or T1sm1 low risk), primary esophagectomy of submucosal high-risk tumors (T1a), submucosal cancer (T1sm2-3) and T2N0 tumors, multimodal treatment with neoadjuvant chemoradiotherapy or perioperative chemotherapy and operations for advanced stages. Esophagectomy is nowadays carried out in one stage as a so-called hybrid procedure (laparoscopy and muscle-preserving thoracotomy) or as a total minimally invasive operation (laparoscopy and thoracoscopy).

Short-Term Outcomes of Surgery for Graves' Disease in Germany.

BACKGROUND: Surgical treatment of Graves' disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome. METHODS: Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student's t-test or Fisher's exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05. RESULTS: A total of 1808 patients with GD with a median age of 44 (range 14-85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare. CONCLUSION: Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.

The Effect of Day of the Week on Morbidity and Mortality From Colorectal and Pancreatic Surgery.

BACKGROUND: A number of studies have revealed higher postoperative mortality after operations that were performed toward the end of the week. It is not yet known whether a day-of-the-week effect exists after visceral surgical procedures for cancer in Germany. METHODS: Data on resections of carcinomas of the colon, rectum (2010-2017), and head of the pancreas (2014-2017) (n = 19 703) that had been prospectively acquired by the Study, Documentation, and Quality Center of the German Society for General and Visceral Surgery were analyzed in relation to the day of the week on which the operation was performed. The primary endpoint was postoperative 30-day mortality; the secondary endpoints were complications, length of hospital stay, and MTL30 (a combined outcome criterion that is positive if the patient has died, is still in the hospital, or has been transferred to another acute care hospital 30 days after the index procedure). RESULTS: Resections of colon carcinomas that were performed on Mondays were associated with more advanced tumor stages (T4: 18.4% vs. 15.7%, p <0.001), higher 30-day mortality (3.5% vs. 2.3%, p = 0.004), and a more frequently positive MTL30 (10.5% vs. 8.5%, p = 0.004). Among patients who underwent pancreatic head resections, those whose procedures were on Tuesday had higher mortality (6.2% vs. 3.8%; p = 0.021). Among those who underwent surgery for rectal carcinoma, the day of the week on which the procedure was performed had no effect on postoperative morality. Multivariate analysis revealed that the independent risk factors for postoperative mortality were colonic resection on a Monday (odds ratio [OR]: 1.45; 95% confidence interval [1.11; 1.92], p = 0.008) and pancreatic head resection on a Tuesday (OR: 1.88 [1.18; 2.91], p = 0.006). CONCLUSION: Elective surgery for carcinoma of the colon or pancreatic head is associated with slightly higher mortality if per - formed toward the beginning of the week. On the other hand, the day of the week has no effect on the outcome of surgery for rectal carcinoma.

Current Practice of Surgery for Benign Goitre-An Analysis of the Prospective DGAV StuDoQ|Thyroid Registry.

BACKGROUND: To evaluate the current indications, resection strategies and short-term outcomes of surgery for benign goitre in a country with endemic goitre. METHODS: Data of patients who underwent surgery for benign goitre were retrieved from the prospective StuDoQ/Thyroid registry and retrospectively analysed regarding the patient's demographics, indications for surgery, surgical procedures, histology, and perioperative outcomes. RESULTS: In a 15-month period, 12,888 patients from 83 departments underwent thyroid resections for benign conditions. Main indications for surgery were exclusion of malignancy (68%), compression symptoms (20.7%) and hyperthyroidism (9.7%). Preoperative fine needle aspiration cytology was performed in only 12.2% of patients with the indication "exclusion of malignancy". Thyroidectomy (49.8%) or hemithyroidectomy (36.9%) were performed in 86.7% of patients. Minimally invasive or alternative surgical techniques were applied in only 2.2%. Intraoperative neuromonitoring was used in 98.4% of procedures, in 97.5% of patients at least one parathyroid gland was visualized, and in 15.3% of patients parathyroid tissue was autografted, respectively. The rates of unilateral and bilateral transient recurrent nerve palsy were 3.6% and 0.07% of nerves at risk, the rate of transitory hypoparathyroidism was 15.3%. The rates of postoperative bleeding and wound infections requiring reoperation were 1.4% and 0.07%, respectively. CONCLUSIONS: The indication "exclusion of malignancy" is made too liberally, and there is a strong attitude to perform complete thyroid resections. Postoperative hypoparathyroidism is the major complication after surgery for benign thyroid disease, thus requiring more awareness.

Indications for the Surgical Management of Benign Goiter in Adults.

BACKGROUND: Thyroidectomy is still three to six times more common in Germany than in the USA, Great Britain, and the Scandinavian countries. Thus, the question is often asked whether thyroidectomy in Germany is being performed for the correct indications. METHODS: This review is based on studies and guidelines containing information on the indications for surgery in benign goiter and Graves' disease; these publications were retrieved by a systematic literature search in the Medline and Cochrane Library databases (1990-2016). The indications recommended here were determined by vote by the German Society for General and Visceral Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV). RESULTS: On the basis of the available evidence (levels 2-4), and in the absence of prospective studies, the indications for surgery in goiter include a well-founded suspicion of malignancy, local compressive symptoms, and, rarely, cosmesis. In hyperthyroid goiter and Graves' disease, surgery is a potential alternative to radio - iodine therapy, particularly if the volume of the thyroid gland exceeds 80 mL, in patients with advanced or active orbitopathy, and in female patients who are, or plan to be, pregnant. Large, asymptomatic, euthyroid nodular goiter without any suspicion of malignancy and scintigraphically "cold" nodules without any other evidence of malignancy are not indications for surgery. Thyroid operations of higher levels of difficulty (e.g., recurrent goiter, retrosternal extension, Graves' disease) should be carried out in institutions with special expertise in thyroid surgery. CONCLUSION: The decision to operate should be made on an interdisciplinary basis and in conformity with the relevant guidelines after all of the appropriate diagnostic studies have been performed. The radicality of any proposed surgical procedure should be weighed against its potential complications.

Influence of change in surgical practice for benign thyroid disease on postsurgical outcome-Single-center experience in 1400 patients.

PURPOSE: To evaluate the rate of surgical complications during the change from subtotal resection to hemithyroidectomy or thyroidectomy over a period of 17 years. METHODS: All operations for benign goiter at our hospital were analyzed for the periods 1996-2002 (Group 1) and 2003-2012 (Group 2). The groups were compared for recurrent laryngeal nerve damage, hypocalcemia, and other surgical complications directly postoperatively. RESULTS: In total, 1462 patients were operated on for goiter between 1996 and 2012. There were 1219 patients who underwent a primary thyroid operation, whereas 50 patients had surgery for recurrence. Postoperative histology revealed thyroid cancer in 193 patients (13.2%). In Group 1, 42.7% of all operated lobes were performed as lobectomies and 57.3% as subtotal resections; in Group 2, 74.4% were performed as lobectomies and 25.6% as subtotal resections. No differences were found for reduced vocal cord function (2.4% vs. 1.9%, p = 0.746) and recurrent laryngeal nerve paralysis in the postoperative laryngoscopy (2.9% vs. 1.8%, p = 0.675). Postoperative hypoparathyroidism was detected in 13.66% in Group 1 and in 19.80% in Group 2 after bilateral resections (p = 0.037). There was no difference in the rate of reoperations for cancer between both groups (43.4% vs. 52.1%, p = 0.182). CONCLUSION: Surgical practice changed from subtotal to lobectomies for benign goiter over a period of 17 years without change in laryngeal nerve damage but with increasing rates of postoperative hypocalcemia.

The DGAV risk calculator: development and validation of statistical models for a web-based instrument predicting complications of colorectal cancer surgery.

PURPOSE: The purpose of this study is to provide a web-based calculator predicting complication probabilities of patients undergoing colorectal cancer (CRC) surgery in Germany. METHODS: Analyses were based on records of first-time CRC surgery between 2010 and February 2017, documented in the database of the Study, Documentation, and Quality Center (StuDoQ) of the Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), a registry of CRC surgery in hospitals throughout Germany, covering demography, medical history, tumor features, comorbidity, behavioral risk factors, surgical procedures, and outcomes. Using logistic ridge regression, separate models were developed in learning samples of 6729 colon and 4381 rectum cancer patients and evaluated in validation samples of sizes 2407 and 1287. Discrimination was assessed using c statistics. Calibration was examined graphically by plotting observed versus predicted complication probabilities and numerically using Brier scores. RESULTS: We report validation results regarding 15 outcomes such as any major complication, surgical site infection, anastomotic leakage, bladder voiding disturbance after rectal surgery, abdominal wall dehiscence, various internistic complications, 30-day readmission, 30-day reoperation rate, and 30-day mortality. When applied to the validation samples, c statistics ranged between 0.60 for anastomosis leakage and 0.85 for mortality after rectum cancer surgery. Brier scores ranged from 0.003 to 0.127. CONCLUSIONS: While most models showed satisfactory discrimination and calibration, this does not preclude overly optimistic or pessimistic individual predictions. To avoid misinterpretation, one has to understand the basic principles of risk calculation and risk communication. An e-learning tool outlining the appropriate use of the risk calculator is provided.

The pancreatic surgery registry (StuDoQ|Pancreas) of the German Society for General and Visceral Surgery (DGAV) - presentation and systematic quality evaluation.

BACKGROUND: Pancreatic resections are among the most complex procedures in visceral surgery. While mortality has decreased substantially over the past decades, morbidity remains high. The volume-outcome correlation in pancreatic surgery is among the strongest in the field of surgery. The German Society for General and Visceral Surgery (DGAV) established a national registry for quality control, risk assessment and outcomes research in pancreatic surgery in Germany (DGAV SuDoQ|Pancreas). METHODS: Here, we present the aims and scope of the DGAV StuDoQ|Pancreas Registry. A systematic assessment of registry quality is performed based on the recommendations of the German network for outcomes research (DNVF). RESULTS: The registry quality was assessed by consensus criteria of the DNVF in regard to the domains Systematics and Appropriateness, Standardization, Validity of the sampling procedure, Validity of data collection, Validity of statistical analysis and reports, and General demands for registry quality. In summary, DGAV StuDoQ|Pancreas meets most of the criteria of a high-quality clinical registry. CONCLUSION: The DGAV StuDoQ|Pancreas provides a valuable platform for quality assessment, outcomes research as well as randomized registry trials in pancreatic surgery.

Analysis of the First 217 Appendectomies of the German NOTES Registry.

OBJECTIVE: To analyze the feasibility and safety of Natural Orifice Transluminal Endoscopic Surgery (NOTES) appendectomy, and to analyze separately the transvaginal appendectomy (TVAE) and the transgastric appendectomy (TGAE) procedures. BACKGROUND: Laparoscopic appendectomy has rare but relevant complications, namely incisional hernias and neuralgia at the trocar sites, which can potentially be avoided by the NOTES techniques. METHODS: The first 217 data sets of the largest NOTES registry worldwide-the German NOTES registry-were analyzed with respect to demographic data, procedural data, and short-term outcomes. Furthermore, TVAEs were compared with TGAEs. RESULTS: Almost all procedures were performed in hybrid technique (median of percutaneous trocars: 1). Median age (TVAE: 30.5 yrs vs TGAE: 25 yrs; P < 0.017), body mass index (TVAE: 22.8 kg/m vs TGAE: 24.1 kg/m; P < 0.016), and American Society of Anesthesiologists (ASA) classification (I/II/III; TVAE: 57.1%/41.8%/1.0% vs TGAE: 27.8%/69.4%/2.8%; P < 0.003) significantly differed between both access techniques. Whereas the median number of percutaneous trocars (TVAE: 1 vs TGAE: 1; P < 0.450), the need of additional trocars (TVAE: 6.6% vs TGAE: 13.9%; P < 0.156), the intra, and also postoperative rate of complications (TVAE: 0%/5.5% vs TGAE: 0%/11.1%; P < 1.000/0.258), and the median postoperative hospital stay (TVAE: 3 d vs TGAE: 3 d; P < 0.152) were comparable; the median procedural time (TVAE: 35 minutes vs TGAE: 96 minutes; P < 0.001) and conversion to laparotomy rate (TVAE: 0% vs TGAE: 5.6%; P < 0.023) were significantly less after TVAE. CONCLUSIONS: The evaluation of the largest patient collective so far indicates that hybrid NOTES appendectomy is a safe procedure, with advantages for the transvaginal technique with respect to procedural time and conversion rate.

Impact of staged surgery on quality of life in refractory ulcerative colitis.

INTRODUCTION: Coloproctomucosectomy (CPM) with ileopouchanal anastomosis (IPAA), as the procedure of choice for surgical management of ulcerative colitis (UC), is commonly performed either as a 2- or 3-staged procedure. For patients with considerable immunosuppression, reduced nutritional or general health status, and as part of emergency treatment, a 3-staged (3S) procedure is recommended by guidelines to minimize perioperative complication rates compared to 2-staged (2S) procedure. However, the necessity of additional hospitalization and surgery is suspect to affect quality of life (QoL). In this prospective, observational study, we evaluate the long-term QoL after 2- and 3-staged interventions of CPM with IPAA for patients with UC. PATIENTS AND METHODS: Between 1997 and 2011, a total of 233 patients underwent CPM and had a 2- or 3-staged procedure. In 108 patients, surgical procedure was completed, and evaluation of QoL was performed by specific questionnaires (IBDQ, FIQoL, SF-12, CCS) up to 20 years after ileostomy closure. Data were collected within the framework of a prospective study. RESULTS: Observing a total of 84 patients (2S: n = 59; 3S: n = 25), QoL measured by IBDQ was higher after CPM, compared to preoperative (2S: 15 â†’ 31; 3S: 17 â†’ 28; p < 0.01), with no differences between 2S or 3S procedures (p > 0.05). Specific QoL assessment concerning incontinence and stool frequency (CCS, FIQoL) did not differ either (CCS: 2S:3S = 12:15; p > 0.05). General health-related QoL, determined by SF-12 score, did not differ between 2S or 3S procedures. CONCLUSION: The indication for a 2-staged or 3-staged procedure should be adjusted to the severity of the underlying disease, nutritional status of the patient, and the extent of immunosuppression at the time of surgery. It should not be affected by the fear of complications or a reduced quality of life by additional surgery in 3-staged versus 2-staged procedures.

Bipolar radio-frequency-induced thermofusion of intestinal tissue - In vivo evaluation of a new fusion technique in an experimental study.

PURPOSE: Bipolar radio-frequency-induced thermofusion (BiRTh) of intestinal tissue might replace conventional stapling devices which are associated with technical and functional complications. Previous results of our study group confirmed the feasibility to fuse intestinal tissue using BiRTh-induced thermofusion ex vivo. The aim of this study was now to evaluate the efficacy of fusing intestinal tissue in vivo by BiRTh-induced thermofusion. MATERIALS AND METHODS: In male Wistar rats a blind bowel originating from the caecum was closed either by BiRTh (n = 24) or conventional suture (n = 16). At 6 h, 48 h, 4 days, and 2 weeks after the procedure caecum bursting pressure was measured to compare both groups. RESULTS: In total 18 of 21 (85.7%) thermofused and 15 of 16 (93.7%) sutured cecal stumps were primarily tight and leakage-proof (p > 0.05). The operative time was comparable in both groups without significant differences. Both groups showed increases in bursting pressure over the post-operative period. The mean bursting pressure for thermofusion was 47.8, 48.3, 55.2, and 68.0 mmHg, compared to 69.8, 51.5, 70.0 and 71.0 mmHg in the hand-sutured group (p > 0.05) after 6 h, 48 h, 4 days, and 2 weeks, respectively. CONCLUSION: These results suggest that BiRTh-induced thermofusion is a safe and feasible method for fusing intestinal tissue in this experimental in vivo model and could be an innovative approach for achieving gastrointestinal anastomoses.

Differential protein expression and oncogenic gene network link tyrosine kinase ephrin B4 receptor to aggressive gastric and gastroesophageal junction cancers.

Transmembrane tyrosine-kinase Ephrin receptors promote tumor progression and/or metastasis of several malignancies including leukemia, follicular lymphoma, glioma, malignant pleural mesothelioma, papillary thyroid carcinoma, sarcomas and ovarian, breast, bladder and non-small cell lung cancers. They also drive intestinal stem cell proliferation and positioning, control intestinal tissue boundaries and are involved in liver, pancreatic and colorectal cancers, indicating involvement in additional digestive system malignancies. We investigated the role of Ephrin-B4 receptor (EPHB4), and its ligand EFNB2, in gastric and gastroesophageal junction cancers in patient cohorts through computational, mathematical, molecular and immunohistochemical analyses. We show that EPHB4 is upregulated in preneoplastic gastroesophageal lesions and its expression further increased in gastroesophageal cancers in several independent cohorts. The closely related EPHB6 receptor, which also binds EFNB2, was downregulated in all tested cohorts, consistent with its tumor-suppressive properties in other cancers. EFNB2 expression is induced in esophageal cells by acidity, suggesting that gastroesophageal reflux disease (GERD) may constitute an early triggering event in activating EFNB2-EPHB4 signaling. Association of EPHB4 to both Barrett's esophagus and to advanced tumor stages, and its overexpression at the tumor invasion front and vascular endothelial cells intimate the notion that EPHB4 may be associated with multiple steps of gastroesophageal tumorigenesis. Analysis of oncogenomic signatures uncovered the first EPHB4-associated gene network (false discovery rate: 7 × 10(-90) ) composed of a five-transcription factor interconnected gene network that drives proliferation, angiogenesis and invasiveness. The EPHB4 oncogenomic network provides a molecular basis for its role in tumor progression and points to EPHB4 as a potential tumor aggressiveness biomarker and drug target in gastroesophageal cancers.