Perioperative Blood Management of Preoperative Anemia Determines Long-Term Outcome in Patients with Pancreatic Surgery.

BACKGROUND/PURPOSE: Anemia affects the postoperative course of patients undergoing a major surgical procedure. However, it remains unclear whether anemia has a different impact on the long-term outcome of patients with malignant or benign pancreatic disease. METHODS: A retrospective analysis of patients undergoing pancreatic surgery for pancreatic malignancies or chronic pancreatitis was conducted between January 2012 and June 2018 at the University Hospital Dresden, Germany. The occurrence of preoperative anemia and the administration of pre-, intra-, and postoperative blood transfusions were correlated with postoperative complications and survival data by uni- and multivariate analysis. RESULTS: A total of 682 patients were included with 482 (70.7%) undergoing surgical procedures for pancreatic malignancies. Univariate regression analysis confirmed preoperative anemia as a risk factor for postoperative complications > grade 2 according to the Clavien-Dindo classification. Multivariate regression analyses indicated postoperative blood transfusion as an independent risk factor for postoperative complications in patients with a benign (OR 20.5; p value < 0.001) and a malignant pancreatic lesion (OR 4.7; p value < 0.01). Univariate and multivariate analysis revealed preoperative anemia and pre-, intra-, and postoperative blood transfusions as independent prognostic factors for shorter overall survival in benign and malignant patients (p value < 0.001-0.01). CONCLUSION: Preoperative anemia is a prevalent, independent, and adjustable factor in pancreatic surgery, which poses a significant risk for postoperative complications irrespective of the entity of the underlying disease. It should therefore be understood as an adjustable factor rather than an indicator of underlying disease severity.

[Importance of preoperative and intraoperative imaging for operative strategies]. / Bedeutung der prä- und intraoperativen Bildgebung für die operative Strategie.

Recent advances in preoperative and postoperative imaging have an increasing influence on surgical decision-making and make more complex surgical interventions possible. This improves the possibilities for frequently occurring challenges and promoting improved functional and oncological outcome. This manuscript reviews the role of preoperative and intraoperative imaging in surgery. Various techniques are explained based on examples from hepatobiliary surgery and neurosurgery, in particular real-time procedures, such as the online use of augmented reality and in vivo fluorescence, as well as new and promising optical techniques including imaging of intrinsic signals and vibrational spectroscopy.

Circulating tumour cells and outcome in non-metastatic colorectal cancer: a prospective study.

BACKGROUND: Circulating tumour cells (CTC) in the blood have been accepted as a prognostic marker in patients with metastatic colorectal cancer (CRC). Only limited data exist on the prognostic impact of CTC in patients with early stage CRC using standardised detection assays. The aim of this study was to elucidate the role of CTC in patients with non-metastatic CRC. METHODS: A total of 287 patients with potentially curable CRC were enrolled, including 239 patients with UICC stage I-III. CTC were measured in the blood using the CellSearch system preoperatively and on postoperative days 3 and 7. The complete patient group (UICC I-IV) and the non-metastatic cohort (UICC I-III) were analysed independently. Patients were followed for 28 (0-53) months. Prognostic factors for overall and progression-free survival were analysed using univariate and multivariate analyses. RESULTS: CTC were detected more frequently in patients with metastatic disease. No clinicopathological variables were associated with CTC detection in non-metastatic patients. CTC detection (⩾1 CTC per 7.5 ml blood) in the blood was significantly associated with worse overall survival (49.8 vs 38.4 months; P<0.001) in the non-metastatic group (UICC I-III), as well as in the complete cohort (48.4 vs 33.6 months; P<0.001). On multivariate analysis CTC were the strongest prognostic factor in non-metastatic patients (hazard ratio (HR) 5.5; 95% confidence interval (CI) 2.3-13.6) as well as in the entire study group (HR 5.6; 95% CI 2.6-12.0). CONCLUSIONS: Preoperative CTC detection is a strong and independent prognostic marker in non-metastatic CRC.

Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy.

BACKGROUND: Postoperative ileus is a common problem after abdominal surgery. It was postulated that coffee intake would decrease postoperative ileus after colectomy. METHODS: This was a multicentre parallel open-label randomized trial. Patients with malignant or benign disease undergoing elective open or laparoscopic colectomy were assigned randomly before surgery to receive either coffee or water after the procedure (100 ml three times daily). The primary endpoint was time to first bowel movement; secondary endpoints were time to first flatus, time to tolerance of solid food, length of hospital stay and perioperative morbidity. RESULTS: A total of 80 patients were randomized, 40 to each group. One patient in the water arm was excluded owing to a change in surgical procedure. Patient characteristics were similar in both groups. In intention-to-treat analysis, the time to the first bowel movement was significantly shorter in the coffee arm than in the water arm (mean(s.d.) 60·4(21·3) versus 74·0(21·6) h; P = 0·006). The time to tolerance of solid food (49·2(21·3) versus 55·8(30·0) h; P = 0·276) and time to first flatus (40·6(16·1) versus 46·4(20·1) h; P = 0·214) showed a similar trend, but the differences were not significant. Length of hospital stay (10·8(4·4) versus 11·3(4·5) days; P = 0·497) and morbidity (8 of 40 versus 10 of 39 patients; P = 0·550) were comparable in the two groups. CONCLUSION: Coffee consumption after colectomy was safe and was associated with a reduced time to first bowel action.

[Surgery and management: natural partners]. / Chirurgie und Management: natürliche Partner.

The term management is a description of the functions: planning, organization, leadership and control in institutions and the corresponding persons holding these powers. In order to efficiently lead a department of surgery, surgeons need to possess management qualities and have to be able to act as team leaders. Good management of a surgical department leads to avoidance of complications and increased profits as well as more efficient use of operating room capacities and a better organization within the department.

[How much business management does a surgeon need?]. / Wie viel Betriebswirtschaft braucht der Chirurg?

The present day healthcare system in Germany is rapidly changing, even more so after the introduction of diagnosis-related groups. The basic requirements for every surgeon remain manual skills, a profound clinical knowledge and the ability for clinical decision-making even in difficult situations. However, these key elements of surgical education no longer fulfill the requirements for today's leaders in surgery. New requirements, consisting of administrative duties, strategic decision-making and department management are too complex to be made only intuitively. Nowadays surgeons also need a profound education in management skills and knowledge of economic mechanisms in order to run an efficient, profitable, patient-oriented surgical department. Every surgeon who aims at obtaining a leadership position should acquire the necessary knowledge and skills.

[Surgery of hepatobiliary tumors]. / Hepatobiliäre tumorchirurgie.

Surgical R0 resection of primary and secondary hepatobiliary tumors, such as colorectal liver metastases, hepatocellular carcinoma, cholangiocellular carcinoma and gall bladder carcinoma, remains the only potentially curative treatment option. The extent of involvement of lymph node metastases seems to be an independent prognostic factor in these tumors. The prognostic value of a systematic lymph node dissection in hepatobiliary tumors still remains unclear as there is a lack of prospective randomized trials. However, local lymphadenectomy (hepatoduodenal ligament and retropancreaticoduodenal lymph nodes) can be easily performed with low mortality and morbidity rates and may be helpful in better staging of the patients. Further randomized trials are necessary in order to define the relevance of lymph node dissection in hepatobiliary surgery.

Biological damage induced by ionizing cosmic rays in dry Arabidopsis seeds.

In September 1987 dry seeds containing embryos of the crucifer plant Arabidopsis thaliana (L.) Heynh, were flown in orbit for 13 days on the Kosmos 1887 satellite. The seeds were fixed on CNd detectors and stored in units of Biorack type I/O. One unit was exposed inside, another one outside the satellite. The temperature profile of the flown seeds inside the satellite was simulated on earth in an identical backup control sample (BC). An additional control (SC) was studied with the original seeds sample. By use of the CNd-detector, HZE-tracks were measured with a PC-assisted microscope. The biological damages were investigated by growing the seeds under controlled climatic conditions. The following biological endpoints of the cosmic radiation damage were studied: germination, radicle length, sublethality, morphological aberrations, flower development, tumorization, embryo lethality inside the siliques. The summarized damage (D) and the mutation frequencies of embyronic lethal genes were calculated. The following results were obtained: the damages increase significantly in orbit at all biological endpoints; germination and fiowerings especially, as well as embryo lethality of fruits and lethal mutation frequency, were maximum mostly for HZE-hit seeds. Additionally, an increase of damage was observed for the seeds of the outside-exposed Biorack in comparison to the inside ones, which was probably caused by less radiation shielding and free space vacuum. The significance of the results obtained is discussed with respect to stress and risk and, thus, the quality of the RBE-factors and heavy ionizing radiation all needed for the very definition of radiation protection standards in space.

Early and late damages induced by heavy charged particle irradiation in embryonic tissue of Arabidopsis seeds.

Early and late effects of accelerated heavy ions (HZE) on the embryonic tissue of Arabidopsis thaliana seeds were investigated seeing that initial cells of the plant eumeristems resemble the original cells of animal and human tissues with continuous cell proliferation. The endpoints measured were lethality and tumorization in the M1-generation for early effects and embryonic lethality in the M2-generation for late effects. The biological endpoints are plotted as functions of the physical parameters of the irradiation i.e. ion fluence (p/cm2), dose (Gray), charge Z and linear energy transfer (LET). The results presented contribute to the estimation of the principles of biological HZE effects and thus may help to develop a unified theory which could explain the whole sequence from physical and chemical reactions to biological responses connected with heavy ion radiation. Additionally, the data of this paper may be used for the discussion of the quality factor for heavy ion irradiation needed for space missions and for HZE-application in radio-therapy by use of accelerators (UNILAC, (SIS/ESR), BEVALAC).

Biological effects of heavy ions in Arabidopsis seeds.

Irradiation of dry seeds of Arabidopsis with heavy ions (HZE-particles) produced by UNILAC-accelerator (GSI, Darmstadt) yielded aberrations in varied developmental endpoints such as survival rate and embryo vitality. The damage increased with particle density and charge. Cross sections in the range of 0.2-1.0 micrometer2 for Ne and Ar and 2.0-10.0 micrometers2 for Xe were estimated. Soaked seeds were more sensitive than dry seeds (cross-section 2.0-10.0 micrometers2 for Ar). The induced total damage in the irradiated seeds was estimated adding the different damages weighted by certain factors. These results will be used as base data for the interpretation and evaluation of spaceflight experiments on the biological effects of cosmic radiation.

Life sciences: radiobiological advanced biostack experiment.

The radiobiological properties of the heavy ions of cosmic radiation were investigated on Spacelab 1 by use of biostacks, monolayers of biological test organisms sandwiched between thin foils of different types of nuclear track detectors. Biostacks were exposed to cosmic radiation at several locations with different shielding environments in the module and on the pallet. Evaluations of the physical and biological components of the experiment to date indicate that in general they survived the spaceflight in good condition. Dosimetric data are presented for the different shielding environments.