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BACKGROUND AND AIMS: The overall evidence on the association between gallbladder conditions (GBC: gallstones and cholecystectomy) and pancreatic cancer (PC) is inconsistent. To our knowledge, no previous investigations considered the role of tumour characteristics on this association. Thus, we aimed to assess the association between self-reported GBC and PC risk, by focussing on timing to PC diagnosis and tumour features (stage, location, and resection). METHODS: Data derived from a European case-control study conducted between 2009 and 2014 including 1431 PC cases and 1090 controls. We used unconditional logistic regression models to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) adjusted for recognized confounders. RESULTS: Overall, 298 (20.8%) cases and 127 (11.6%) controls reported to have had GBC, corresponding to an OR of 1.70 (95% CI 1.33-2.16). The ORs were 4.84 (95% CI 2.96-7.89) for GBC diagnosed <3 years before PC and 1.06 (95% CI 0.79-1.41) for ≥3 years. The risk was slightly higher for stage I/II (OR = 1.71, 95% CI 1.15-2.55) vs. stage III/IV tumours (OR = 1.23, 95% CI 0.87-1.76); for tumours sited in the head of the pancreas (OR = 1.59, 95% CI 1.13-2.24) vs. tumours located at the body/tail (OR = 1.02, 95% CI 0.62-1.68); and for tumours surgically resected (OR = 1.69, 95% CI 1.14-2.51) vs. non-resected tumours (OR = 1.25, 95% CI 0.88-1.78). The corresponding ORs for GBC diagnosed ≥3 years prior PC were close to unity. CONCLUSION: Our study supports the association between GBC and PC. Given the time-risk pattern observed, however, this relationship may be non-causal and, partly or largely, due to diagnostic attention and/or reverse causation.
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Doenças da Vesícula Biliar , Neoplasias da Vesícula Biliar , Neoplasias Pancreáticas , Estudos de Casos e Controles , Doenças da Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/epidemiologia , Neoplasias da Vesícula Biliar/etiologia , Humanos , Modelos Logísticos , Pâncreas/patologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/etiologia , Fatores de Risco , Neoplasias PancreáticasRESUMO
BACKGROUND/OBJECTIVES: Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP. METHODS: An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient. RESULTS: Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients. CONCLUSIONS: This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.
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Pancreatite Crônica/cirurgia , Pancreatite Crônica/terapia , Consenso , Humanos , Dor Intratável/etiologia , Dor Intratável/terapia , Pancreatectomia , Cisto Pancreático/complicações , Cisto Pancreático/cirurgia , Pancreaticoduodenectomia , Pancreaticojejunostomia , Pancreatite Crônica/complicações , Fatores de Risco , Tempo para o TratamentoRESUMO
BACKGROUND: Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy. METHODS: Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer. RESULTS: There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age. CONCLUSION: Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.
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Doenças Autoimunes/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Pancreatite Crônica/diagnóstico , Adulto , Idoso , Antígenos Glicosídicos Associados a Tumores/sangue , Doenças Autoimunes/terapia , Biomarcadores/sangue , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunoglobulina G/sangue , Masculino , Pessoa de Meia-Idade , Pâncreas/diagnóstico por imagem , Neoplasias Pancreáticas/terapia , Pancreatite Crônica/terapia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
Background: Family history (FH) of pancreatic cancer (PC) has been associated with an increased risk of PC, but little is known regarding the role of inherited/environmental factors or that of FH of other comorbidities in PC risk. We aimed to address these issues using multiple methodological approaches. Methods: Case-control study including 1431 PC cases and 1090 controls and a reconstructed-cohort study (N = 16 747) made up of their first-degree relatives (FDR). Logistic regression was used to evaluate PC risk associated with FH of cancer, diabetes, allergies, asthma, cystic fibrosis and chronic pancreatitis by relative type and number of affected relatives, by smoking status and other potential effect modifiers, and by tumour stage and location. Familial aggregation of cancer was assessed within the cohort using Cox proportional hazard regression. Results: FH of PC was associated with an increased PC risk [odds ratio (OR) = 2.68; 95% confidence interval (CI): 2.27-4.06] when compared with cancer-free FH, the risk being greater when ≥ 2 FDRs suffered PC (OR = 3.88; 95% CI: 2.96-9.73) and among current smokers (OR = 3.16; 95% CI: 2.56-5.78, interaction FHPC*smoking P-value = 0.04). PC cumulative risk by age 75 was 2.2% among FDRs of cases and 0.7% in those of controls [hazard ratio (HR) = 2.42; 95% CI: 2.16-2.71]. PC risk was significantly associated with FH of cancer (OR = 1.30; 95% CI: 1.13-1.54) and diabetes (OR = 1.24; 95% CI: 1.01-1.52), but not with FH of other diseases. Conclusions: The concordant findings using both approaches strengthen the notion that FH of cancer, PC or diabetes confers a higher PC risk. Smoking notably increases PC risk associated with FH of PC. Further evaluation of these associations should be undertaken to guide PC prevention strategies.
Assuntos
Neoplasias Pancreáticas/epidemiologia , Fumar/efeitos adversos , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Anamnese , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Neoplasias Pancreáticas/genética , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is usually diagnosed in late adulthood; therefore, many patients suffer or have suffered from other diseases. Identifying disease patterns associated with PDAC risk may enable a better characterization of high-risk patients. METHODS: Multimorbidity patterns (MPs) were assessed from 17 self-reported conditions using hierarchical clustering, principal component, and factor analyses in 1705 PDAC cases and 1084 controls from a European population. Their association with PDAC was evaluated using adjusted logistic regression models. Time since diagnosis of morbidities to PDAC diagnosis/recruitment was stratified into recent (<3 years) and long term (≥3 years). The MPs and PDAC genetic networks were explored with DisGeNET bioinformatics-tool which focuses on gene-diseases associations available in curated databases. RESULTS: Three MPs were observed: gastric (heartburn, acid regurgitation, Helicobacter pylori infection, and ulcer), metabolic syndrome (obesity, type-2 diabetes, hypercholesterolemia, and hypertension), and atopic (nasal allergies, skin allergies, and asthma). Strong associations with PDAC were observed for ≥2 recently diagnosed gastric conditions [odds ratio (OR), 6.13; 95% confidence interval CI 3.01-12.5)] and for ≥3 recently diagnosed metabolic syndrome conditions (OR, 1.61; 95% CI 1.11-2.35). Atopic conditions were negatively associated with PDAC (high adherence score OR for tertile III, 0.45; 95% CI, 0.36-0.55). Combining type-2 diabetes with gastric MP resulted in higher PDAC risk for recent (OR, 7.89; 95% CI 3.9-16.1) and long-term diagnosed conditions (OR, 1.86; 95% CI 1.29-2.67). A common genetic basis between MPs and PDAC was observed in the bioinformatics analysis. CONCLUSIONS: Specific multimorbidities aggregate and associate with PDAC in a time-dependent manner. A better characterization of a high-risk population for PDAC may help in the early diagnosis of this cancer. The common genetic basis between MP and PDAC points to a mechanistic link between these conditions.
Assuntos
Carcinoma Ductal Pancreático/epidemiologia , Biologia Computacional , Neoplasias Pancreáticas/epidemiologia , Análise de Sistemas , Biologia de Sistemas , Biomarcadores Tumorais/genética , Carcinoma Ductal Pancreático/diagnóstico , Carcinoma Ductal Pancreático/genética , Estudos de Casos e Controles , Análise por Conglomerados , Comorbidade , Bases de Dados Genéticas , Europa (Continente)/epidemiologia , Análise Fatorial , Humanos , Modelos Logísticos , Análise Multivariada , Razão de Chances , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/genética , Análise de Componente Principal , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Patients with obstructive jaundice due to periampullary tumours may undergo preoperative biliary drainage (PBD). The effect of PBD on the microbiome of the biliary system and on postoperative outcome remains unclear. METHODS: A single-centre retrospective study of patients with obstructive jaundice due to periampullary cancer, treated between July 2007 and July 2015, was undertaken. Intraoperative bile samples were obtained for microbiological analysis after transection of the common bile duct. Postoperative complications were registered. RESULTS: Of 290 patients treated, intraoperative bile samples were present for 172 patients (59·3 per cent) who had PBD and 118 (40·7 per cent) who did not. Contamination of bile was increased significantly in patients who underwent stenting (97·1 per cent versus 18·6 per cent in those without stenting; P < 0·001). PBD resulted in a shift in the biliary microbiome from Escherichia coli in non-stented patients (45 per cent versus 19·2 per cent in stented patients; P = 0·009) towards increased contamination with Enterococcus faecalis (9 versus 37·7 per cent respectively; P = 0·008) and Enterobacter cloacae (0 versus 20·4 per cent; P = 0·033). This shift was associated with a high incidence of bacterial resistance against ampicillin-sulbactam (63·6 per cent versus 18 per cent in patients with no PBD; P < 0·001), piperacillin-tazobactam (30·1 versus 0 per cent respectively; P = 0·003), ciprofloxacin (28·5 versus 5 per cent; P = 0·047) and imipenem (26·6 versus 0 per cent; P = 0·011). The rate of wound infection was higher in patients with a positive bile culture (21·0 per cent versus 6 per cent in patients with sterile bile; P = 0·002). Regression analysis revealed the presence of Enterococcus faecium (odds ratio 2·83, 95 per cent c.i. 1·17 to 6·84; P = 0·021) and Citrobacter species (odds ratio 5·09, 1·65 to 15·71; P = 0·005) as independent risk factors for postoperative wound infection. CONCLUSION: There are fundamental differences in the biliary microbiome of patients with periampullary cancer who undergo PBD and those who do not. PBD induces a shift of the biliary microbiome towards a more aggressive and resistant spectrum, which requires a differentiated perioperative antibiotic treatment strategy.
Assuntos
Bile/microbiologia , Neoplasias do Ducto Colédoco/complicações , Drenagem , Icterícia Obstrutiva/terapia , Microbiota , Cuidados Pré-Operatórios , Idoso , Ampola Hepatopancreática/cirurgia , Antibacterianos/uso terapêutico , Colangite/epidemiologia , Citrobacter/isolamento & purificação , Neoplasias do Ducto Colédoco/cirurgia , Farmacorresistência Bacteriana Múltipla , Infecções por Enterobacteriaceae/epidemiologia , Enterococcus faecalis/isolamento & purificação , Feminino , Alemanha/epidemiologia , Infecções por Bactérias Gram-Positivas/epidemiologia , Humanos , Icterícia Obstrutiva/etiologia , Masculino , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Stents , Infecção da Ferida Cirúrgica/epidemiologiaRESUMO
Hypoxia-inducible factor 1α (Hif1α) is a key regulator of cellular adaptation and survival under hypoxic conditions. In pancreatic ductal adenocarcinoma (PDAC), it has been recently shown that genetic ablation of Hif1α accelerates tumour development by promoting tumour-supportive inflammation in mice, questioning its role as the key downstream target of many oncogenic signals of PDAC. Likely, Hif1α has a context-dependent role in pancreatic tumorigenesis. To further analyse this, murine PDAC cell lines with reduced Hif1α expression were generated using shRNA transfection. Cells were transplanted into wild-type mice through orthotopic or portal vein injection in order to test the in vivo function of Hif1α in two major tumour-associated biological scenarios: primary tumour growth and remote colonization/metastasis. Although Hif1α protects PDAC cells from stress-induced cell deaths in both scenarios-in line with the general function Hif1α-its depletion leads to different oncogenic consequences. Hif1α depletion results in rapid tumour growth with marked hypoxia-induced cell death, which potentially leads to a persistent tumour-sustaining inflammatory response. However, it simultaneously reduces tumour colonization and hepatic metastases by increasing the susceptibility to anoikis induced by anchorage-independent conditions. Taken together, the role of Hif1α in pancreatic tumorigenesis is context-dependent. Clinical trials of Hif1α inhibitors need to take this into account, targeting the appropriate scenario, for example palliative vs adjuvant therapy.
RESUMO
Pancreatic cancer patients presenting with borderline resectable or locally advanced unresectable tumors remain a therapeutic challenge. Despite the lack of high quality randomized controlled trials, perioperative neoadjuvant treatment strategies are often employed for this group of patients. At present the FOLFIRINOX regimen, which was established in the palliative setting, is the backbone of neoadjuvant therapy, whereas local ablative treatment, such as stereotactic irradiation and irreversible electroporation are currently under investigation. Resection after modern multimodal neoadjuvant therapy follows the same principles and guidelines as upfront surgery specifically regarding the extent of resection, e.g. lymphadenectomy, vascular resection and multivisceral resection. Because it is still exceedingly difficult to predict tumor response after neoadjuvant therapy, a special treatment approach is necessary. In the case of localized stable disease following neoadjuvant therapy, aggressive surgical exploration with serial frozen sections at critical (vascular) margins might be necessary to minimize the risk of debulking procedures and maximize the chance of a curative resection. A multidisciplinary and individualized approach is mandatory in this challenging group of patients.
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Pancreatectomia/métodos , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Terapia Combinada/métodos , Progressão da Doença , Eletroporação , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , Excisão de Linfonodo/métodos , Terapia Neoadjuvante/métodos , Pâncreas/patologia , Neoplasias Pancreáticas/mortalidade , Prognóstico , Radiocirurgia , Análise de SobrevidaRESUMO
OBJECTIVES: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial. BACKGROUND: PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications. METHODS: A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up. RESULTS: From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters. CONCLUSIONS: The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.
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Pancreatopatias/cirurgia , Pancreaticoduodenectomia , Pancreaticojejunostomia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha/epidemiologia , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatopatias/mortalidade , Fístula Pancreática/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Qualidade de Vida , Fatores de RiscoRESUMO
BACKGROUND: Benign and malignant pathologies of the pancreas can result in a relevant chronic disease burden. This is aggravated by morbidities resulting from surgical resections as well as from progression of the underlying condition. OBJECTIVE: The aim was to summarize the current evidence regarding epidemiology, pathophysiology, diagnosis and treatment of endocrine and exocrine pancreatic insufficiency, as well as of pancreatic pseudocysts. MATERIAL AND METHODS: A selective literature search was performed and a summary of the currently available data on the surgical sequelae after pancreatic resection is given. RESULTS: Reduction of healthy pancreatic parenchyma down to 10-15 % leads to exocrine insufficiency with malabsorption and gastrointestinal complaints. Orally substituted pancreatic enzymes are the therapy of choice. Loss of pancreatic islets and/or islet function leads to endocrine insufficiency and pancreoprivic diabetes mellitus. Inflammatory, traumatic and iatrogenic injuries of the pancreas can lead to pancreatic pseudocysts, which require endoscopic, interventional or surgical drainage if symptomatic. Finally, pancreatic surgery harbors the long-term risk of gastrointestinal anastomotic ulcers, bile duct stenosis, portal vein thrombosis and chronic pain syndrome. CONCLUSION: As the evidence is limited, an interdisciplinary and individually tailored approach for delayed pancreatic morbidity is recommended.
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Diabetes Mellitus/etiologia , Diabetes Mellitus/terapia , Insuficiência Pancreática Exócrina/etiologia , Insuficiência Pancreática Exócrina/terapia , Síndromes de Malabsorção/etiologia , Síndromes de Malabsorção/terapia , Pancreatopatias/cirurgia , Pseudocisto Pancreático/etiologia , Pseudocisto Pancreático/terapia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Transversais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Insuficiência Pancreática Exócrina/diagnóstico , Insuficiência Pancreática Exócrina/epidemiologia , Síndromes de Malabsorção/diagnóstico , Síndromes de Malabsorção/epidemiologia , Pseudocisto Pancreático/diagnóstico , Pseudocisto Pancreático/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologiaRESUMO
Pancreatic cancer is associated with the worst prognosis of all gastrointestinal malignancies. The major reasons for the dismal outcome are late diagnosis due to unspecific symptoms and aggressive tumor biology. Although highly effective chemotherapeutic options have emerged within the last decade, radical resection offers the only chance of cure. Only 10-20% of patients are resectable at presentation, and 30-40% present with borderline resectable or locally advanced/unresectable tumors. Even if resectable, the 5-year-survival rate after complete resections remains unsatisfactory, with less than 25%. This article gives an overview on current therapy standards as well as on new approaches especially for locally advanced tumors and outlines the importance of ongoing research to improve prognosis.
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Carcinoma Ductal Pancreático/cirurgia , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Carcinoma Ductal Pancreático/diagnóstico , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/terapia , Ablação por Cateter/métodos , Terapia Combinada/métodos , Medicina Baseada em Evidências , Alemanha/epidemiologia , Humanos , Excisão de Linfonodo , Invasividade Neoplásica , Estadiamento de Neoplasias , Pancreatectomia/métodos , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/terapia , Guias de Prática Clínica como Assunto , Prognóstico , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Turquia/epidemiologiaAssuntos
Cárdia , Transtornos de Deglutição/etiologia , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/cirurgia , Fundoplicatura , Gastroscopia , Hérnia Hiatal/diagnóstico , Hérnia Hiatal/cirurgia , Laparoscopia , Idoso , Cárdia/cirurgia , Comorbidade , Diagnóstico Diferencial , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: Surgical treatment of incisional hernia includes implantation of a mesh. The use of synthetic grafts in contaminated fields results in an increased risk of infection. In these cases a potential advantage is described for biological repair material. Evidence for this problem is lacking; therefore, we initiated a survey among surgeons in Germany concerning this question. MATERIAL AND METHOD: A survey concerning indications, experience and techniques of using synthetic and biological meshes was sent to 60 surgical departments. The emphasis of the survey was on the differentiation of clean and contaminated fields. RESULTS: The survey was answered by 42 %. The use of biological repair material was preferred in clean-contaminated, contaminated and soiled fields. Synthetic meshes were preferred in clean, rarely in clean-contaminated and not in contaminated or soiled situations. Primary suture repair was chosen in clean fields and barely in contaminated fields. For closure of giant hernias a component separation technique (CST) was favored by the majority of respondents. A single stage repair was preferred by most of the surgeons even in cases with simultaneous stoma takedown. A total of 72 % of the respondents were satisfied with the use of biological repair material, but the reimbursement was considered to be inappropriate. DISCUSSION: Although the response rate was low, this survey gives an idea of the attitude towards the use of synthetic and biological meshes. Biological repair material is favored for hernia repair in contaminated or soiled fields. The advantage of this choice is a one stage repair despite the contamination. As the results of this survey are not able to provide arguments for the use of different meshes this question should be further investigated with a randomized controlled trial.
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Técnicas de Fechamento de Ferimentos Abdominais , Materiais Biocompatíveis , Hérnia Abdominal/cirurgia , Hérnia Incisional/cirurgia , Telas Cirúrgicas , Atitude do Pessoal de Saúde , Humanos , Recidiva , Reoperação , Infecção da Ferida Cirúrgica/cirurgia , Inquéritos e Questionários , Técnicas de SuturaRESUMO
BACKGROUND AND AIMS: In spite of huge developments in liver surgery during the last decades, morbidity and mortality continue to pose problems in this field. The aim of this study was to identify preoperative predictors for postoperative mortality and morbidity in liver surgery. MATERIAL AND METHODS: In a single-center study, an extensive analysis of a prospective database, including clinical criteria and laboratory tests of patients undergoing liver surgery between July 2007 and July 2012 was performed. Cutoff values of selected laboratory tests were calculated. RESULTS: In all, 337 patients were included in the study. Univariate analysis showed a statistically significant association of preoperative bilirubin, lactate, hemoglobin levels, platelet count, and prothrombin time with postoperative morbidity and mortality. Multivariate analysis revealed preoperatively elevated serum bilirubin and lactate levels as independent predictors for increased postoperative morbidity and mortality after liver surgery. CONCLUSIONS: The identified laboratory values showed a statistically significant association with postoperative morbidity and mortality in liver surgery and might be helpful in preoperative patient selection.
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Bilirrubina/sangue , Hepatectomia/efeitos adversos , Ácido Láctico/sangue , Hepatopatias/sangue , Hepatopatias/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hepatectomia/mortalidade , Humanos , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: The aim of this study is to define the significance of hyponatremia as a marker of anastomotic leakage after colorectal surgery. METHODS: All anastomoses in colorectal surgery performed at a single institution between July 2007 and July 2012 (n = 1,106) were retrospectively identified. Serum sodium levels and leukocyte values measured when an anastomotic leak was diagnosed by CT scan and/or surgical reintervention (n = 81) were compared to the values preferably on postoperative day 5 in the absence of an anastomotic leak (n = 1,025). RESULTS: The leak rate in anastomoses of the rectum was 9.0 %, while the leak rate of the other anastomoses was 5.4 %. Mean serum sodium level was 138.8 mmol/l in the group with an anastomotic leak and 140.5 mmol/l in the group without. Hyponatremia (<136 mmol/l) was present in 23 % of patients in the group with an anastomotic leak and in 15 % in the group without (p < 0.001). In multivariate analysis, leukocytes and serum sodium level remained as significant markers of an anastomotic leak. As a marker of an anastomotic leak, hyponatremia had a specificity of 93 % and a sensitivity of 23 %, while the presence of either leukocytosis or hyponatremia had a sensitivity of 68 %, a specificity of 75 %, a positive predictive value of 18 %, and a negative predictive value of 97 %. CONCLUSIONS: Hyponatremia could be a specific and relevant marker of anastomotic leakage after colorectal surgery. If hyponatremia and leukocytosis are present after colorectal surgery, anastomotic leakage should be suspected and a CT scan with rectal contrast dye is recommended.
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Fístula Anastomótica/sangue , Fístula Anastomótica/diagnóstico , Neoplasias Colorretais/cirurgia , Hiponatremia/etiologia , Leucocitose/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/etiologia , Biomarcadores/sangue , Neoplasias Colorretais/sangue , Neoplasias Colorretais/patologia , Feminino , Humanos , Hiponatremia/diagnóstico , Contagem de Leucócitos , Leucocitose/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment "surgical operating room" has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.
Assuntos
Laparoscopia/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Intensificação de Imagem Radiográfica/instrumentação , Cirurgia Assistida por Computador/instrumentação , Simulação por Computador , Difusão de Inovações , Desenho de Equipamento , Previsões , Gastroenterologia/instrumentação , Gastroenterologia/tendências , Cirurgia Geral/instrumentação , Cirurgia Geral/tendências , Humanos , Imageamento Tridimensional , Laparoscopia/tendências , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Modelos Anatômicos , Cirurgia Endoscópica por Orifício Natural/instrumentação , Cirurgia Endoscópica por Orifício Natural/tendências , Intensificação de Imagem Radiográfica/tendências , Radiologia Intervencionista/instrumentação , Radiologia Intervencionista/tendências , Robótica/instrumentação , Robótica/tendências , Design de Software , Cirurgia Assistida por Computador/tendências , Equipamentos CirúrgicosRESUMO
HISTORY AND ADMISSION FINDINGS: In a 17-year-old girl recurrent duodenal ulcer bleeding had led to severe anemia. INVESTIGATIONS: Sonography and computed tomography revealed a partially cystic tumour of the pancreatic head and suspicious hepatic lesions. TREATMENT AND PATHOLOGICAL DIAGNOSIS: A partial duodenopancreatectomy was performed and two liver metastases were resected. Histological examination of the resected pancreatic specimen revealed a solid pseudopapillary neoplasm of the pancreas (SPN) with hepatic metastases. CLINICAL COURSE AND PROGNOSIS: The seven remaining liver metastases were removed in a second procedure (right hepatectomy). One year later two new liver metastases were treated by radiofrequency ablation. Two years after the initial operation, the patient is well and tumor-free. CONCLUSION: SPN is a rare cystic tumor that is mainly found in young women. Direct tumor infiltration of stomach or duodenum can cause gastrointestinal bleedings in rare cases. Resection of the primary tumor and surgical or interventional removal of metastases are the treatment of choice.
Assuntos
Adenocarcinoma Papilar/secundário , Úlcera Duodenal/etiologia , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/secundário , Recidiva Local de Neoplasia/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Úlcera Péptica Hemorrágica/etiologia , Adenocarcinoma Papilar/diagnóstico , Adenocarcinoma Papilar/patologia , Adenocarcinoma Papilar/cirurgia , Adolescente , Ablação por Cateter , Comportamento Cooperativo , Diagnóstico Diferencial , Úlcera Duodenal/patologia , Úlcera Duodenal/cirurgia , Feminino , Hepatectomia , Humanos , Comunicação Interdisciplinar , Fígado/patologia , Fígado/cirurgia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Pâncreas/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Úlcera Péptica Hemorrágica/patologia , Úlcera Péptica Hemorrágica/cirurgia , Recidiva , ReoperaçãoRESUMO
Hepatocyte transplantation is considered to be an alternative to orthotopic liver transplantation. Cells can be used to bridge patients waiting for a donor organ, decrease mortality in acute liver failure, and support metabolic liver diseases. The limited availability of primary human hepatocytes for such applications has led to the generation of alternative hepatocyte-like cells from various adult stem or precursor cells. The aim of this study was to generate hepatocyte-like cells from adipose-derived mesenchymal stem cells (Ad-MSCs) for clinical applications, which are available "off the shelf." Epigenetic changes in hepatocyte-like cells were induced by 5-azacytidine, which, in combination with other supplements, leads to significantly improved metabolic and enzymatic activities compared to nontreated cells. Cells with sufficient hepatic features were generated with a four-step protocol: 5-azacytidine (step 1); epidermal growth factor (step 2); fibroblast growth factor-4, dexamethasone, insulin-transferrin-sodium-selenite, and nicotinamide (step 3); and hepatocyte growth factor, dexamethasone, insulin-transferrin-sodium-selenite, and nicotinamide (step 4). Generated differentiated cells had higher phase I (CYP1A1/2, CYP2E1, CYP2B6, CYP3A4) and phase II activities compared to the undifferentiated cells. A strong expression of CYP3A7 and a weak expression of 3A4, as well as the important detoxification markers α-fetoprotein and albumin, could also be detected at the mRNA level. Importantly, urea metabolism (basal, NH4-stimulated, NH4- and ornithine-stimulated) was comparable to freshly isolated human hepatocytes, and unlike cryopreserved human hepatocytes, this activity was maintained after 6 months of cryopreservation. These findings suggest that these cells may be suitable for clinical application, especially for treatment of urea cycle disorders.
Assuntos
Tecido Adiposo/fisiologia , Metilação de DNA , Hepatócitos/fisiologia , Células-Tronco Mesenquimais/fisiologia , Ureia/metabolismo , Tecido Adiposo/citologia , Tecido Adiposo/metabolismo , Adiposidade/efeitos dos fármacos , Técnicas de Cultura de Células , Diferenciação Celular/genética , Diferenciação Celular/fisiologia , Processos de Crescimento Celular/fisiologia , Células Cultivadas , Criopreservação , Feminino , Hepatócitos/citologia , Hepatócitos/metabolismo , Humanos , Transplante de Fígado/métodos , Masculino , Transplante de Células-Tronco Mesenquimais/métodos , Células-Tronco Mesenquimais/citologia , Células-Tronco Mesenquimais/metabolismoRESUMO
PURPOSE: Despite recent advances in clinical imaging modalities, differentiation of pancreatic masses remains difficult. Here, we tested the diagnostic accuracy of molecular-based imaging including 3'-deoxy-3'-[(18)F]fluorothymidine (FLT) positron emission tomography (PET) and [(18)F]fluorodeoxyglucose (FDG) PET/CT in patients with suspected pancreatic masses scheduled to undergo surgery. METHODS: A total of 46 patients with pancreatic tumours suspicious for malignancy and scheduled for resective surgery were recruited prospectively. In 41 patients, FLT PET and FDG PET/CT scans were performed. A diagnostic CT performed on a routine basis was available in 31 patients. FLT PET and FDG PET/CT emission images were acquired according to standard protocols. Tracer uptake in the tumour [FDG and FLT standardized uptake value (SUV)] was quantified by the region of interest (ROI) technique. For FDG PET/CT analysis, correct ROI placement was ensured via side-by-side reading of corresponding CT images. RESULTS: Of 41 patients, 33 had malignancy, whereas 8 patients had benign disease. Visual analysis of FDG and FLT PET resulted in sensitivity values of 91% (30/33) and 70% (23/33), respectively. Corresponding specificities were 50% (4/8) for FDG PET and 75% (6/8) for FLT PET. In the subgroup of patients with contrast-enhanced CT (n = 31), sensitivities were 96% (PET/CT), 88% (CT alone), 92% (FDG PET) and 72% (FLT PET), respectively. Mean FLT uptake in all malignant tumours was 3.0 (range SUV(max) 1.1-6.5; mean FDG SUV(max) 7.9, range 3.3-17.8; p < 0.001). CONCLUSION: For differentiation of pancreatic tumours, FDG PET and FDG PET/CT showed a higher sensitivity but lower specificity than FLT PET. Interestingly, visual analysis of FLT PET led to two false-positive findings by misinterpreting physiological bowel uptake as pathological FLT uptake in the pancreas. Due to the limited number of patients, the clinical value of adding FLT PET to the diagnostic workup of pancreatic tumours remains to be determined.