Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy.

BACKGROUND: Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF. METHODS: From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome. RESULTS: In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously (n = 6, 40%) or metachronously (n = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy (n = 3), stenting (n = 6), or suturing (n = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition. CONCLUSION: Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.

Microsurgical training course for clinicians and scientists: a 10-year experience at the Münster University Hospital.

BACKGROUND: Microsurgical techniques are an important part of clinical and experimental research. Here we present our step-by-step microsurgery training course developed at the Münster University Hospital. The goal of this course was to create a short, modular curriculum with clearly described and easy to follow working steps in accordance with the Guidelines for Training in Surgical Research in Animals by the Academy of Surgical Research. METHODS: Over the course of 10 years, we conducted an annual 2.5 day (20 h) microsurgical training course with a total of 120 participants. RESULTS: Prior to the course, 90% of the participants reported to have never performed a microanastomosis before. During the 10 years a total of 84.2% of the participants performed microanastomoses without assistance, 15% required assistance and only 0.8% failed. CONCLUSIONS: Our step-by-step microsurgery training course gives a brief overview of the didactic basics and the organization of a microsurgical training course and could serve as a guide for teaching microsurgical skills. During the 2.5-day curriculum, it was possible to teach, and for participants to subsequently perform a microsurgical anastomosis. The independent reproducibility of the learned material after the course is not yet known, therefore further investigations are necessary. With this step-by-step curriculum, we were able to conduct a successful training program, shown by the fact that each participant is able to perform microvascular anastomoses on a reproducible basis.

Impact of preoperative risk factors on outcome after gastrectomy.

BACKGROUND: Gastrectomy is associated with relevant postoperative morbidity. However, outcome of surgery can be improved by careful selection of patients. The objective of the current study was therefore to identify preoperative risk factors that might impact on patients' further outcome after surgical resection. METHODS: Preoperative risk factors having respectively different surgical risk scores for major complex surgery (including Cologne Risk Score, p-/o-POSSUM, and NSQIP risk score) of patients that underwent gastrectomy for AEG II/III tumors and gastric cancer were correlated with complications according to Clavien-Dindo and outcome. Patients who underwent surgery in palliative intention were excluded from further analysis. RESULTS: Subtotal gastrectomy was performed in 23%, gastrectomy in 59%, and extended gastrectomy in 18% in a total of 139 patients (mean age: 64 years old). Thirty six percent experienced a minor complication (Dindo I-II) and 24% a major complication (Dindo III-V), which resulted in a prolonged hospital stay (p < 0.001). In-hospital mortality (=Dindo V) was 2.5%. Besides age, type of surgical procedure impacted on complications with extended gastrectomy showing the highest risk (p = 0.005). The o-POSSUM score failed to predict mortality accurately. We observed a highly positive correlation between predicted morbidity respectively mortality and occurrence of complications estimated by p-POSSUM (p = 0.005), Cologne Risk (p = 0.007), and NSQIP scores (p < 0.001). CONCLUSION: The results demonstrate a significant association between different risk scores and occurrence of complications following gastrectomy. The p-POSSUM, Cologne Risk, and NSQIP score exhibited superior performance than the o-POSSUM score. Therefore, these scores might allow identification and selection of high-risk patients and thus might be highly useful for clinical decision making.

Risk factors for allograft failure in liver transplant recipients.

BACKGROUND: With regard to quality of life and organ shortage, follow-up after liver transplantation (LT) should consider risk factors for allograft failure in order to avoid the need for re-LT and to improve the long-term outcome of recipients. Therefore, the aim of this study was to explore potential risk factors for allograft failure after LT. MATERIAL AND METHODS: A total of 489 consecutive LT recipients who received follow-up care at the University Hospital of Muenster were included in this study. Database research was performed, and patient data were retrospectively reviewed. Risk factors related to donor and recipient characteristics potentially leading to allograft failure were statistically investigated using binary logistic regression analysis. Graft failure was determined as graft cirrhosis, need for re-LT because of graft dysfunction, and/or allograft-associated death. RESULTS: The mean age of recipients at the time of LT was 50.3 ±â€Š12.4 years, and 64.0 % were male. The mean age of donors was 48.7 ±â€Š15.5 years. Multivariable statistical analysis revealed male recipient gender (p = 0.04), hepatitis C virus infection (HCV) (p = 0.014), hepatocellular carcinoma (HCC) (p = 0.03), biliary complications after LT (p < 0.001), pretransplant diabetes mellitus (p = 0.03), and/or marked fibrosis in the initial protocol biopsy during follow-up (p = 0.001) to be recipient-related significant and independent risk factors for allograft failure following LT. CONCLUSION: Male recipients, patients who received LT for HCV or HCC, those with pretransplant diabetes mellitus, and LT recipients with biliary complications are at high risk for allograft failure and thus should be monitored closely.

Successful management of passenger lymphocyte syndrome in an ABO-compatible, nonidentical isolated bowel transplant: a case report and review of the literature.

BACKGROUND: Passenger lymphocyte syndrome (PLS), a subtype of graft-versus-host disease, is a rare disorder encountered mainly in ABO-mismatched hematopoietic stem cell transplantation and infrequently in all types of ABO-mismatched solid organ transplantation. We here report the fifth case of PLS in small bowel transplantation (SBTx) and the first one describing the successful management of PLS in a cadaveric, isolated SBTx. CASE REPORT: A 60-year-old Caucasian female with blood group A D+ suffering from short bowel syndrome received a small bowel transplant from a 32-year-old Caucasian female with blood group O D+ (HLA mismatch 2/6). After onset of massive hemolysis on Postoperative Day 9 the positive direct and indirect antiglobulin tests showing antibodies against A1 and A2 red blood cells (RBCs) led to the diagnosis of PLS. This complication was successfully treated by transfusion of blood group O RBC transfusions, increased immunosuppression, and plasmapheresis. CONCLUSION: In the event of severe hemolysis and anemia after ABO-mismatched SBTx, PLS should be considered. In our case successful treatment consisted of transfusion of donor-specific RBCs, increased immunosuppression, and plasmapheresis.

Pre-emptive endoscopic vacuum therapy for treatment of anastomotic ischemia after esophageal resections.

Background and study aims Endoscopic vacuum therapy (EVT) is a promising new approach for the treatment of anastomotic leakage in the gastrointestinal tract. Here, we present the first case series demonstrating successful use of EVT for the treatment of post-esophagectomy anastomotic ischemia prior to development of leakage. Patients and methods Between 2012 and 2015, intraluminal EVT was performed in eight patients with anastomotic ischemia following esophagectomy. The primary outcome measure was successful mucosal recovery. Secondary outcome measures were duration of treatment, number of sponge changes, septic course, and associated complications. Results Complete mucosal recovery was achieved in six patients (75 %) with different degrees of anastomotic ischemia. In two patients (25 %), small anastomotic leaks developed, which resolved by continuing the EVT treatment. Median duration of EVT treatment until mucosal recovery was 16 days (range 6 - 35), with a median of 5 sponge changes per patient (range 2 - 11). No EVT-associated complications were noted. Three patients developed anastomotic stenoses, which were treated by endoscopic dilation therapy. Conclusion This is the first case series to demonstrate that the early use of EVT potentially modulates clinical outcomes and infection parameters in patients with anastomotic ischemia following esophagectomy. Further studies are needed to define the indications and patients who are most likely to benefit from early EVT.

A practical guide for small bowel transplantation in rats-review of techniques and models.

BACKGROUND: Animal models are a central aspect in research on small bowel transplantation (SBTx). Among them, rats are the preferred species because of their widespread availability and cost effectiveness. Because the complexity of the surgical procedure could per se influence the outcome of an experiment, a standardized and comparable technique is important. Based on of the vast amount of different models and surgical techniques published to this point, a review seemed necessary to guide investigators when choosing the suitable model. MATERIALS AND METHODS: A systematic literature search of original articles published between 1965 and 2016 using the Medline Database regarding techniques of SBTx in rats was conducted according to the Preferred reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing a new technique or evaluating different techniques were considered. RESULTS: A total of 38 publications fulfilled the selection criteria and were included. Data from these publications were regarded as too heterogeneous for statistical analysis. Depending on graft length and placement, full-length and reduced length heterotopic and orthotopic models were differentiated. Important factors concerning a good survival rate are the chosen model (heterotopic has a better outcome compared with orthotopic), a vascular flush of the graft in situ, a careful luminal flush of the graft, adequate fluid resuscitation, and a warm ischemia time of less than 40 min. CONCLUSIONS: SBTx in rats remains a complex and challenging procedure, which necessitates a standardized technique as well as sufficient training. By choosing the optimal experimental model, applying established strategies, and proven techniques, a standardized and scientifically reliable model can be achieved.

Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study.

BACKGROUND: Perforations and anastomotic leakages of the upper gastrointestinal (GI) tract cause a high morbidity and mortality rate. Only limited data exist for endoscopic vacuum therapy (EVT) in the upper GI tract. METHODS: Fifty-two patients (37 men and 15 women, ages 41-94 years) were treated (12/2011-12/2015) with EVT for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 39), iatrogenic esophageal perforation (n = 9) and Boerhaave syndrome (n = 4). After diagnosis, polyurethane sponges were endoscopically positioned with a total of 390 interventions and continuous negative pressure of 125 mm of mercury (mmHg) was applied to the EVT-system. Sponges were changed endoscopically twice per week. Clinical and therapy-related data and mortality were analyzed. RESULTS: After 1-25 changes of the sponge at intervals of 3-5 days with a mean of 6 sponge changes and a mean duration of therapy of 22 days, the defects were healed in 94.2 % of all patients without revision surgery. In three patients (6 %), EVT failed. Two of these patients died due to hemorrhage related to EVT. Four postinterventional strictures were observed during the follow-up of up to 4 years. CONCLUSION: Esophageal wall defects of different etiology in the upper gastrointestinal tract can be treated successfully with EVT, considering that indication for EVT should be weighed carefully. EVT can be regarded as a novel life-saving therapeutic tool.

Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy.

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.

Esophageal Cancer Specific Risk Score Is Associated with Postoperative Complications Following Open Ivor-Lewis Esophagectomy for Adenocarcinoma.

BACKGROUND/AIMS: Surgery for esophageal cancer is associated with a high morbidity and mortality. With this study, we investigated if a validated preoperative risk score correlates with overall morbidity, mortality, anastomotic insufficiency, respiratory complications and with the severity of complications after open Ivor-Lewis esophagectomy. METHODS: A total of 94 patients undergoing esophageal resection for adenocarcinoma between 2005 and 2009 were included. Patients were assigned using the preoperative risk score according to Schröder et al. [Langenbecks Arch Surg 2006;391:455-460] and the Dindo classification regarding the severity of complications. RESULTS: Of all the patients, 12% had a 'normal', 54% a 'moderate' and 34% a 'high' preoperative risk score. Postoperative complications occurred in 79%. Furthermore, 36 or 21 or 14 or 7% of patients experienced complications of category I/II or III or IV or V, respectively. There was a significant association between preoperative risk score and overall morbidity (p = 0.010), mortality (p = 0.035) and anastomotic insufficiency (p = 0.023). Furthermore, higher preoperative risk score was significant related to increasing severity of postoperative complications (grade IV according to the Dindo classification: p = 0.018, Dindo grade V: p = 0.035). Neoadjuvant therapy consisting of cisplatin and 5-fluorouracil had no influence. CONCLUSION: As we demonstrated, a significant association between preoperative risk score and occurrence and severity of postoperative complications after open Ivor-Lewis esophagectomy, standardized, organ-specific pre- and postoperative categorizations might be useful for individual clinical decision making in this group of patients.

PET/CT predicts survival in patients undergoing primary surgery for esophageal cancer.

INTRODUCTION: Positron emission tomography combined with computed tomography (PET/CT) is increasingly being used in the staging of esophageal cancer, and some recent studies suggested the maximal standardized uptake value (SUVmax) as a prognostic factor for prediction of survival of these patients. However, data on correlations between SUVmax and other established prognostic markers is rare, and the impact of neoadjuvant treatment on SUVmax ability to predict outcome is not clear. The aim of the present study was therefore to evaluate the prognostic significance of the SUVmax in patients with or without neoadjuvant therapy (NAT) by comparing SUVmax to different established prognostic factors and survival. METHODS: Esophageal cancer patients receiving either neoadjuvant therapy or no pretreatment before surgery were included in our study, and correlations between SUVmax and prognostic factors such as tumour/nodal stage, grading, tumour length or survival were investigated. RESULTS: Between January 2004 and December 2011, a total of 114 patients was included (mean age 63 years, 96 men, 36 SCC, 78 adenocarcinoma). A number of 74 patients underwent neoadjuvant therapy. The median follow-up was 52 months. The SUVmax was significantly correlated to initial tumour stage (p = 0.000) and tumour length (p ≤ 0.010). Survival was significantly better in patients undergoing primary surgery if SUVmax was <6 compared to SUVmax >6 (p = 0.008), whereas neither neoadjuvant-treated patients in general (p = 0.950) nor the different subgroups of responders showed a comparable correlation between survival and SUVmax (complete responder p = 0.808, partial responder p = 0.409, nonresponder p = 0.529). CONCLUSION: The SUVmax highly correlates with well-known prognostic factors and survival of esophageal cancer patients after surgery but only in case of primary surgery and not if patients received neoadjuvant therapy.

Postoperative complications do not affect long-term outcome in esophageal cancer patients.

BACKGROUND: As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients. METHODS: Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study. RESULTS: SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival. CONCLUSIONS: This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.

Treatment options for postoperatively infected abdominal wall wounds healing by secondary intention.

PURPOSE: We present our current clinical approach for the treatment of postoperatively infected wounds of the abdominal wall healing by secondary intention that may help in the design of a randomized controlled trial to develop a standardized wound treatment pathway. METHODS: Patients with postoperatively infected abdominal wounds treated with either Advanced Wound Care (AWC) dressings or vacuum-assisted closure (VAC) therapy were enrolled in the study. Follow-up was carried out prospectively for wound healing and incidence of incisional hernia at the earliest 3 years after surgery. RESULTS: Sixty-two patients were included and wounds were initially treated antiseptically for 5.19 ± 2.91 days. Prior to VAC therapy, AWC dressings were applied for 8.75 ± 2.93 days to reduce reinfection. Greater wound size (>12 × 6 × 6cm) and extensive secretion (>200 ml/day) argued for the VAC system. Overall incidence of incisional hernia was 20.4%, with 18.4% occurring in AWC-treated patients and 27.3% in VAC-treated patients. Based on these results, a wound treatment pathway was established in our department. CONCLUSION: The established wound treatment pathway has helped to increase both workflow efficacy and outcome in the treatment of abdominal wounds. Wound size, amount of secretion, and status of infection were the parameters we used for the determination of appropriate treatment. The observational data gathered during the initiation of our pathway lay the basis for future randomized controlled trials that will determine the most appropriate treatment options in the setting of a standardized wound treatment pathway.

Merendino Resection vs. Transhiatal Gastric Conduit After Resection of the Cardia and the Gastroesophageal Junction.

BACKGROUND: Reconstruction after combined cardia resection and removal of the gastroesophageal junction can be carried out by the Merendino procedure or via a gastric conduit. This study compares postoperative complications and quality of life for both approaches. METHODS: All patients who underwent Merendino or gastric conduit reconstruction from 2011-2017 were included. Both groups were investigated regarding postoperative length of stay, complications, and gastrointestinal quality of life. RESULTS: 45 patients were identified, of which, 39 remained for analysis: 22 patients in the Merendino group and 17 patients in the gastric conduit group. The median age of patients in the gastric conduit group (71 (53-92) years) was significantly higher than in the Merendino group (58 (19-75) years), P = .0002. Hospital stay was significantly longer in the gastric conduit group (35.9 (11-82) days vs. 18.2 (7-43) days, P = .0299) and incidence of anastomotic leakage was higher (24% vs. 9%, P = .0171). General incidence of complications (Clavien-Dindo) did not vary (P = .1694). However, grade 5 complications only occurred in the Merendino group (n = 1). Evaluation of long-term outcome and quality of life showed dysphagia to only have occurred in the Merendino group (n = 3, 14%). DISCUSSION: Both approaches have advantages and disadvantages: The Merendino procedure showed reduced incidence of anastomotic leakage and shorter hospital stay but was associated with a higher in-hospital mortality rate. Discrepancies in subgroup populations as well as small patient numbers limit the interpretation of the findings. This study does however provide a first comparison of these surgical approaches and may serve as a basis for further investigation.

Role of angiotensin-1 receptor blockade in cirrhotic liver resection.

BACKGROUND: The regeneration capacity of cirrhotic livers might be affected by angiotensin-1 (AT1) receptors located on hepatic stellate cells (HSC). The effect of AT1 receptor blockade on microcirculation, fibrosis and liver regeneration was investigated. MATERIALS AND METHODS: In 112 Lewis rats, cirrhosis was induced by repetitive intraperitoneal injections of CCl(4) . Six hours, 3, 7 and 14 days after partial hepatectomy or sham operation, rats were sacrificed for analysis. Animals were treated with either vehicle or 5 mg/kg body weight losartan pre-operatively and once daily after surgery by gavage. Microcirculation and portal vein flow were investigated at 6 h. The degree of cirrhosis was assessed by Azan Heidenhein staining, activation of HSC by desmin staining, apoptosis by ssDNA detection and liver regeneration by Ki-67 staining. Changes in expression of various genes important for liver regeneration and fibrosis were analysed at 6 h and 3 days. Haemodynamic parameters and liver enzymes were monitored. RESULTS: Losartan treatment increased sinusoidal diameter, sinusoidal blood flow and portal vein flow after partial hepatectomy (P<0.05), but not after sham operation. AT1 receptor blockade resulted in increased apoptosis early after resection. HSC activation was reduced and after 7 days, a significantly lower degree of cirrhosis in resected animals was observed. Losartan increased the proliferation of hepatocytes at late time-points and of non-parenchymal cells early after partial hepatectomy (P<0.05). Tumour necrosis factor (TNF)-α was significantly upregulated at 6 h and stem cell growth factor (SCF) was downregulated at 3 days (P<0.05). CONCLUSION: Losartan increased hepatic blood flow, reduced HSC activation and liver fibrosis, but interfered with hepatocyte proliferation after partial hepatectomy in cirrhotic livers.

Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension.

BACKGROUND: Access-related problems are one of the major causes of morbidity in elderly patients with chronic kidney disease. The aim of this study was to assess potential risks and benefits in elderly patients comparing forearm arteriovenous fistula (AVF) and perforating vein AVF below the elbow for primary vascular access. METHODS: A retrospective comparison of elderly patients (65.7 ± 9.3 years, 70.4% male patients, 36.2% late referral) undergoing primary vascular access surgery using forearm AVF (n = 50) and perforating vein AVF (n = 55) was performed over a 2-year period, including a multivariate analysis of potential risk factors and benefits of primary patency (PP = intervention-free access survival) and secondary patency (SP = access survival until abandonment). RESULTS: Patency rates after 24 months were significantly higher in patients with perforating vein AVF (PP + SP: 78.2%) compared to forearm AVF (PP: 62%, SP: 56%, P = 0.04). Presence of diabetes mellitus in patients with forearm AVF was associated with a decreased PP [odds ratio (OR): 3.6, 95% confidence interval (CI): 0.9-13.8] and SP (OR: 4.8, 95% CI: 1.3-17.9), and arterial hypertension was associated with a lower PP (OR: 6.7, 95% CI: 0.8-53.9), whereas the presence of hyperparathyroidism was associated with higher PP and SP (OR: 0.2, 95% CI: 0.1-0.7). In contrast, PP and SP in patients with perforating vein AVF were not influenced by comorbidities. CONCLUSIONS: Perforating vein AVF is superior to forearm AVF in elderly patients with diabetes and arterial hypertension due to the proximal fistula location, probably caused by an improved artery distensibility during fistula maturation.

Impact of failed allograft nephrectomy on initial function and graft survival after kidney retransplantation.

The management of an asymptomatic failed renal graft remains controversial. The aim of our study was to explore the effect of failed allograft nephrectomy on kidney retransplantation by comparing the outcome of recipients who underwent graft nephrectomy prior to retransplantation with those who did not. Retrospective comparison of patients undergoing kidney retransplantation with (group A, n = 121) and without (group B, n = 45) preliminary nephrectomy was performed, including subgroup analysis with reference to patients with multiple (≥2) retransplantations and patients of the European Senior Program (ESP). Nephrectomy leads to increased panel reactive antibody (PRA) levels prior to retransplantation and is associated with significantly increased rates of primary nonfunction (PNF; P = 0.05) and acute rejection (P = 0.04). Overall graft survival after retransplantation was significantly worse in group A compared with group B (P = 0.03). Among the subgroups especially ESP patients showed a shorter graft survival after previous allograft nephrectomy. On the multivariate analysis, pretransplant graft nephrectomy and PRA >70% were independent and significant risk factors associated with graft loss after kidney retransplantation. Nephrectomy of the failed allograft was not beneficial for retransplant outcome in our series. Patients with failed graft nephrectomy tended to have a higher risk of PNF and acute rejection after retransplantation. The possibility that the graft nephrectomy has a negative impact on graft function and survival after retransplantation is worth studying further.

Impact of PET-CT on primary staging and response control on multimodal treatment of esophageal cancer.

BACKGROUND: The predictive value of positron emission tomography-computed tomography (PET-CT) in primary staging and response control in patients with esophageal carcinoma (EC) is under discussion. In the present study initial staging and metabolic response of PET-CT was correlated with tumor regression and survival in patients with multimodal treatment of EC. METHODS: The authors conducted a retrospective analysis on a prospective database for 83 patients with EC (42 squamous cell, 39 adenocarcinoma, 2 anaplastic carcinoma) undergoing PET-CT for primary staging. Twenty-four of the patients underwent primary esophagectomy, 9 had palliative treatment, and 50 neoadjuvant radiochemotherapy (cisplatin, 5-fluorouracil; 50.4 Gy). The PET-CT study was repeated 6 weeks after induction of chemotherapy and compared with endoscopic ultrasound (EUS). For response control, the metabolic response (tumor standardized uptake value [SUV] reduction) was correlated with histopathologic (ypT0-4) and histomorphologic response (tumor regression) and survival. RESULTS: At primary staging 81 of 83 EC (97.5%) showed an increased SUV uptake correlating with the EUS tumor stage. Suspicious lymph nodes were detected in 51 (61.4%) patients by PET-CT and 66 (79.5%) were detected by EUS. Fifteen patients had additional findings on PET-CT examination leading to a change in therapy in 9 patients (10.3%). Of 50 patients receiving a second PET-CT study, a SUV reduction >50% correlated with major histomorphologic response (tumor regression grade 4, <10% vital tumor cells) and histopathologic response (ypT0 ypN0). Furthermore, these patients showed a significantly increased survival (33.1 ± 3.5 months) compared to non-responders (21.7 ± 3.3 months; p = 0.02) and patients after primary surgery (29 ± 3.2 months; p = 0.05). CONCLUSIONS: The present study shows that PET-CT is a valuable tool for primary staging and response control in multimodal treatment of patients with EC.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group.

PURPOSE: Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS: The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS: Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION: The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

Effects of therapy modifications during the last decade on the outcome of patients undergoing esophagectomy for esophageal cancer.

BACKGROUND: During the last decade, numerous therapeutic regimes were assessed to improve the outcome of patients with esophageal carcinoma. We analyzed the impact of therapy alterations, including the establishment of a standardized clinical pathway and the introduction of an interdisciplinary tumor conference on the outcome of patients undergoing esophagectomy because of esophageal cancer. METHODS: Three hundred one patients were included (204 adenocarcinoma and 97 squamous cell carcinoma) who underwent an esophagectomy between 2006 and 2015. Patients were divided into 3 groups: interval A (2006-2008), interval B (2009-2011) and interval C (2012-2015) and evaluated separately focusing on therapy management and patients' outcome. RESULTS: Over the time periods, the incidence of tumor entity of adenocarcinoma increased from 61% to 76.2% (P=0.059). Patients with an initial tumor stage uT1 increased significantly from 4% to 15.9% over the intervals (P=0.002), while positive nodal involvement remained comparable (P=0.237). Patients in the later interval suffered from greater physical impairments preoperatively, represented by a significantly increased American Society Anesthesiologists (ASA) score (P=0.023) and a reduced Karnofsky Index (P<0.001). The tumor conference was accompanied by an increasing implementation of neoadjuvant therapy (27.1% vs. 42.2%, P=0.097). After establishing the clinical pathway 30-day mortality decreased (P=0.67). Grad III anastomotic leakage decreased significantly from 6.5% to 2% (P=0.01). However, gastrointestinal (P=0.007), pulmonary complications (P<0.001) including pneumonia (P<0.001) increased. Over the past ten years both overall survival and relapse-free survival prolonged (P=0.056 and P=0.063, respectively). CONCLUSIONS: Patients' collective suffering from esophageal cancer has changed over the last decade. Continuous further developments of the therapy regimes are needed to meet the requirements of reducing perioperative mortality and extending survival time.