[Impact of Age and Comorbidity on Perioperative Mortality after 250 Pancreatic Head Resections]. / Einfluss des Lebensalters und der Begleiterkrankungen auf die perioperative Mortalität nach 250 Pankreaskopfresektionen.

INTRODUCTION: In line with the current demographic development, elderly patients make up an increasing proportion of surgical patients. It is still unclear under which conditions pancreatic surgery can be performed with low mortality in these patients. PATIENTS AND METHODS: From 2009 to 2014, 250 consecutive pancreatoduodenectomies (PDs) were performed in a non-university hospital. Perioperative data were documented prospectively. Based on median patient age (< 70 years vs. ≥ 70 years), a retrospective analysis of perioperative morbidity and mortality was performed. In addition, subgroup analyses were conducted. RESULTS: Older patients had a significantly higher frequency of cardiovascular comorbidities (p = 0.04), diabetes mellitus (p = 0.01), impaired renal function (p = 0.01) and a higher ASA classification (p < 0.01). Also, surgical procedures due to malignancy were significantly more common in this group (p < 0.01). Morbidity was equally high in both groups (< 70 years: 57 % vs. ≥ 70 years: 65 %; p = 0.02). Mortality was significantly higher in patients over 70 years of age (< 70 years: 1.4 % vs. ≥ 70 years: 9.1 %; p < 0.01). In a multivariate analysis, only liver cirrhosis (p < 0.01) and age (≥ 70 years; p = 0.04) were independent risk factors for postoperative mortality. However, it was also demonstrated that, under certain conditions, even much older patients (≥ 80 years; n = 34) may be subjected to surgery with a low mortality (3 %). DISCUSSION: In elderly patients, PD is more frequently indicated in cases of malignancy. All in all, perioperative mortality in patients over 70 years of age is significantly elevated. Under certain conditions, however, even much older patients may safely undergo pancreatic surgery.

[Computed Tomography-Based Planimetry of the Pancreatic Transection Line in Risk Evaluation for Postoperative Pancreatic Fistula after Pancreatic Head Resection]. / Orthograde Planimetrie der Pankreasschnittfläche anhand der präoperativen Computertomografie zur Risikoeinschätzung einer postoperativen Pankreasfistel nach Pankreaskopfresektion.

BACKGROUND: Postoperative pancreatic fistula is a relevant complication after pancreatoduodenectomy. Therefore, preoperative detection of high risk patients may be important. We evaluated preoperative CT-imaging by planimetry at the expected resection plane along the superior mesenteric vein and correlated the results with the incidence of postoperative pancreatic fistula. PATIENTS AND METHODS: From 2009 to 2013, 123 patients with pancreatoduodenectomy underwent homogenous preoperative imaging and reconstruction of the pancreatojejunostomy. Planimetry was performed at a multiplanar reconstruction of the pancreatic transection plane (diameter, range, duct width, area) as well as the calculation of ratios (duct width/pancreatic diameter; D/P-ratio). The measured values were correlated with the incidence of postoperative pancreatic fistula. RESULTS: Planimetry showed a significant difference of the pancreatic transection plane in relation to the incidence of postoperative pancreatic fistula. A thick parenchyma and a tiny duct are significant risk factors. In 84 % or, respectively, 94 % of the patients with postoperative pancreatic fistula, a duct width of less than 20 % of the pancreatic diameter was observed (D/P ratio < 0.2; p < 0.01). The D/P ratio was the only independent risk factor in multivariate analysis. DISCUSSION: The incidence of postoperative pancreatic fistula correlates significantly with the morphology of the pancreatic transection plane. The risk increases significantly with a D/P ratio of < 0.2.

[Symptoms, Diagnostics, Treatment and Classification of 22 Patients with Postpancreatectomy Haemorrhage (PPH) in a Series of 400 Consecutive Pancreatic Head Resections and Pancreatectomies]. / Symptomatik, Diagnostik, Therapie und Klassifikation von 22 Patienten mit Postpankreatektomie-Hämorrhagien (PPH) in einer Serie von 400 konsekutiven Pankreaskopfresektionen und Pankreatektomien.

Introduction: Postpancreatectomy haemorrhage (PPH) is a dangerous complication after pancreatic resection. Patients and Methods: From 2006 to 2015, 400 consecutive pancreatic head resections and pancreatectomies were performed and prospectively documented. This study analysed incidence, treatment and outcome of patients with PPH. Results: Incidence of PPH was 5.5 % (n = 22). PPH occurred in a median of eight days after pancreatic surgery with an equal frequency of symptoms being caused by gastrointestinal bleeding (n = 11) and abdominal bleeding (n = 11). Postoperative pancreatic fistulas (POPF) were significantly more frequent in case of PPH (45 % POPF in case of PPH vs. 20 % POPF in case of no PPH, p < 0.01). PPH was more frequent after pancreatogastrostomy (8/70; 11 %) than after pancreatojejunostomy (11/281; 4 %; p = 0.01). The majority of bleedings after pancreatogastrostomy came from the intragastric cut surface of the pancreas. During the first week, relaparotomy was significantly more frequent (n = 5; 56 %) than in late PPH (n = 1; 8 %; p = 0.01). In late PPH, interventions (angiography; n = 7, endoscopy; n = 4) were more frequent. In 16 severe cases, surgical/interventional bleeding control (n = 12) or relevant transfusions of more than 3 units of packed red blood cells (n = 4) were performed. Compared with the whole group, mortality was significantly increased in case of PPH (13.6 % in case of PPH vs. 3.7 % in case of no PPH; p = 0.03). Conclusion: PPH is an episodic and potentially life-threatening complication with an increased mortality rate, which is frequently associated with impaired healing of the pancreatic anastomosis. Diagnostic investigation and treatment of PPH requires an experienced surgical centre with a close cooperation with endoscopy and (interventional) radiology.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach.

INTRODUCTION: For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry. METHODS: Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery. RESULTS: Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up. CONCLUSIONS: Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.

[Pancreatojejunostomy in pancreatic head resection using a resorbable monofilament for internal drainage of the anastomosis - clinical experience and perioperative results]. / Pankreatojejunostomie bei der Pankreaskopfresektion unter Verwendung eines resorbierbaren monofilen Fadens zur inneren Schienung der Anastomose - klinische Erfahrungen und perioperative Ergebnisse.

BACKGROUND: Pancreatic fistulas are relevant in perioperative outcome, morbidity and mortality after pancreatic head resection. We analysed the potential benefit of an internal pancreatic duct draining technique by a resorbable monofilament suture if performing a two-layer duct-to-mucosa pancreatojejunostomy. PATIENTS AND METHODS: From 2006 to 2010, 139 pancreatic head resections were performed in our department (124 pylorus-preserving, 15 Whipple). Indications for surgery were malignancies (n = 97), chronic pancreatitis (n = 24) or others (n = 18). In 64 cases, internal drainage of the pancreatic anastomosis was performed as described. Perioperative results were evaluated by the ISGPF classification (International Study Group for Pancreatic Fistula, type A-C) and Accordion classification (degree 1-6). RESULTS: Pancreatic anastomosis was performed in 99 cases as pancreatojejunostomy and in 41 cases as pancreatogastrostomy. Morbidity (Accordion 1-6) was 48 %, and mortality was 5.8 %. Pancreatic fistulas (A-C) occurred in 27 (19.4 %) cases. Only one patient died as a direct consequence of a pancreatic fistula (type C fistula after pylorus-preserving pancreatic head resection and pancreatogastrostomy). In the subgroup of patients with a two-layer duct-to-mucosa pancreatojejunostomy with internal pancreatic duct drainage by a resorbable monofilament suture (n = 64), a pancreatic fistula occurred in 20.3 % (n = 13). According to the ISGPF classification, they were type A (n = 10), type B (n = 2) and type C fistulas (n = 1). In this subgroup with pancreatic duct drainage, morbidity (Accordion 1-6) was 55 % (n = 35) and mortality (Accordion 6) was 6.2 % (n = 4). Complications due to the pancreatic duct drainage were not observed. CONCLUSION: Internal drainage of the duct-to-mucosa pancreatojejunostomy using monofilament suture material is a safe and feasible method. Pancreatic fistula occurred in 20 % both in the entire group as well as in subgroups with or without pancreatic duct drainage. A reduction of the rate of pancreatic fistula could not be achieved by internal drainage of the pancreatojejunostomy.

Uptake and subcellular distribution of [3H]arachidonic acid in murine fibrosarcoma cells measured by electron microscope autoradiography.

We have used quantitative electron microscope autoradiography to study uptake and distribution of arachidonate in HSDM1C1 murine fibrosarcoma cells and in EPU-1B, a mutant HSDM1C1 line defective in high affinity arachidonate uptake. Cells were labeled with [3H]arachidonate for 15 min, 40 min, 2 h, or 24 h. Label was found almost exclusively in cellular phospholipids; 92-96% of incorporated radioactivity was retained in cells during fixation and tissue processing. All incorporated radioactivity was found to be associated with cellular membranes. Endoplasmic reticulum (ER) contained the bulk of [3H]arachidonate at all time points in both cell types, while mitochondria, which contain a large portion of cellular membrane, were labeled slowly and to substantially lower specific activity. Plasma membrane (PM) also labeled slowly, achieving a specific activity only one-sixth that of ER at 15 min in HSDM1C1 cells (6% of total label) and one-third of ER in EPU-1B (10% of total label). Nuclear membrane (NM) exhibited the highest specific activity of labeling at 15 min in HSDM1C1 cells (twice that of ER) but was not preferentially labeled in the mutant. Over 24 h, PM label intensity increased to that of ER in both cell lines. However, NM activity diminished in HSDM1C1 cells by 24 h to a small fraction of that in ER. In response to agonists, HSDM1C1 cells release labeled arachidonate for eicosanoid synthesis most readily when they have been labeled for short times. Our results therefore suggest that NM and ER, sites of cyclooxygenase in murine fibroblasts, are probably sources for release of [3H]arachidonate, whereas PM and mitochondria are unlikely to be major sources of eicosanoid precursors.

Preservation of arachidonoyl phospholipids during tissue processing for electron microscopic autoradiography.

To facilitate autoradiographic subcellular localization of arachidonoyl phospholipids, the retention of radioactivity during tissue processing of murine fibrosarcoma cells labeled in vitro with 3H-arachidonate was assessed. Approximately 94% of cell radioactivity was incorporated into phospholipids. During tissue processing, extraction of radioactivity was monitored by liquid scintillation spectrometry. Fixation of cells in glutaraldehyde-tannic acid, postfixation in osmium tetroxide, en bloc staining in uranyl magnesium acetate, dehydration in ethanol, and embedding in Epon resulted in preservation of 93.5% of total tissue radioactivity. Analysis of extracted radioactivity by thin layer chromatography revealed that no specific class of phospholipids was selectively extracted. Fixation with osmium tetroxide alone was nearly as effective as the complete fixation protocol and resulted in retention of 90.0% of radioactivity. However, fixation with glutaraldehyde-tannic acid alone without osmium tetroxide post-fixation led to extraction of 69.8% of total cell radioactivity. Thus, osmium tetroxide is crucial in the preservation of arachidonoyl phospholipids and presumably forms extensive cross-links between polyunsaturated acyl residues. This degree of preservation of arachidonoyl phospholipids is indicative of spatial fixation of the radiolabeled moieties and will permit quantitative studies of subcellular loci of eicosanoid metabolism by electron microscopic autoradiography.

Effect of Nosema algerae on the house fly Musca domestica (Diptera: Muscidae).

Larvae of Musca domestica were exposed to spores of Nosema algerae on the surface of their diet. Infective concentrations (IC50 and IC90) for the larvae were 3.6 x 10(4) and 1.6 x 10(6) spores/cm2, respectively. The disease appeared to cause no larval mortality, but the longevity of adult females was reduced. At 30 days post-infection, there were at least 1 x 10(7) spores per fly in all dosage groups. At lower dosages, the development of spores was delayed and fewer spores were produced.

Isolation and restriction endonuclease cleavage of Anaplasma marginale DNA in situ in agarose.

Bacterial restriction endonucleases were used to produce DNA cleavage patterns that could be useful as tools to study the relatedness among Anaplasma marginale isolates. Bovine erythrocytes infected with A. marginale were lysed, washed, and embedded in agarose. The embedded erythrocytes and bacterial pathogens were partially digested by sequential infiltration of the agarose with acetone, lysozyme, sodium dodecyl sulfate, and proteinase K. The unfragmented genomic DNA was left supported and protected in a porous matrix. The DNA was digested in situ in agarose under the following conditions: (i) brief treatment with phenol, (ii) brief washing with distilled water, and (iii) adjustment of restriction enzyme digestion mixture to compensate for the volume of the agarose. The cleaved DNA was electrophoresed horizontally to produce a DNA cleavage pattern. Of 19 restriction enzymes screened, 12 produced distinct DNA bands from the genomes of each of the five A. marginale isolates examined. The DNA cleavage pattern produced from each isolate with a given restriction enzyme was reproducible. However, the DNA cleavage patterns produced from different isolates with a given restriction enzyme were not necessarily identical. This procedure could be modified for general bacterial DNA isolation, in situ agarose digestion, and manipulations.

Physical map of the Bartonella bacilliformis genome.

The genome of Bartonella bacilliformis was shown to be a single circular DNA molecule of about 1,600 kbp having six NotI, four SfiI, and two CeuI sites. A physical map of the DNA was constructed by contour-clamped homogeneous electric field pulsed-field gel electrophoresis of DNA restriction fragments. rRNA operons, the invasion-associated locus, and a flagellin gene were located on the map by hybridization.

Selective uptake of [3H]arachidonic acid into the dense tubular system of human platelets.

We have used quantitative electron microscopic autoradiography to characterize the subcellular distribution of arachidonoyl phospholipids following brief (5 minutes) exposure of unstimulated human platelets to [3H]arachidonic acid. Labeled arachidonate was taken up rapidly and incorporated into phospholipids. Phospholipid radioactivity was preserved and spatially fixed during tissue processing for electron microscopy. Analysis of autoradiographs showed that following a brief exposure to 750 nmol/L [3H]arachidonate, there is selective labeling of an internal membrane compartment composed of the dense tubular system and the open canalicular system. The plasma membrane, platelet granules, and nonmembranous cytoplasm were not labeled. Since the open canalicular system is continuous with the plasma membrane and since phospholipids in continuous membranes are freely diffusible, our observations indicate that [3H]arachidonate was incorporated into phospholipids within the dense tubular system and not the open canalicular system. Thus, the dense tubular system, known to contain cyclooxygenase activity, incorporates arachidonate selectively following brief exposure to this fatty acid, presumably to concentrate it in proximity to enzymes for icosanoid synthesis.

Gel-bound resealed red cell membranes: a new type of semi-artificial organ.

A novel type of semi-artificial organ is described, which uses resealed enzyme fille red cell ghosts bound to a matrix as an active metabolizing system. The stability and the selectivity of the system is discussed with enclosed glutaminase and urease as examples.