Transplant Nephrectomy: A Comparative Study of Timing and Techniques in a Single Institution.

BACKGROUND Transplant nephrectomy (TN) has historically been associated with high morbidity and mortality rates. Our objective is to share our own experience and compare indications and surgical outcomes between early and late TN and intracapsular (ICAN) and extracapsular allograft nephrectomy (ECAN) techniques. MATERIAL AND METHODS Our study included all 69 TN procedures performed between January 2010 and February 2021. Of these, 17 TN procedures were performed within the first 60 days after transplantation (referred to as 'early'), while the remaining 52 procedures were performed later ('late'). Within the late allograft nephrectomy (AN) group, we compared the outcomes of intracapsular (ICAN) and extracapsular (ECAN) techniques. We conducted a statistical analysis using the chi-square test and the 2-sample t test. RESULTS The primary indication for early TN was surgical transplant complications (94.1%), with 58.8% of these cases requiring emergency surgery. Morbidity (major complications) occurred in 47.1% of cases, and mortality was 5.9%. In contrast, graft intolerance syndrome was the leading indication for late TN (76.9%), with elective surgery performed in 88.5% of cases. Morbidity (major complications) occurred in 11.5% of cases, and mortality was 3.8%. Within the late TN group, 82.7% of cases were treated with ICAN and 17.3% with ECAN. Blood transfusion was required during surgery in 17.3% of cases, with no significant difference between the groups. Multivariate logistic regression analysis revealed that the timing of surgery was the only statistically significant predictor of complication occurrence. CONCLUSIONS Our data suggest that TN can be performed with relatively low morbidity. However, early TN remains the only independent risk factor for developing adverse outcomes.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study.

AIM: The reversal of diverting loop ileostomy (DLI) is one of surgical trainees' first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons. METHOD: This retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon's level of training. The secondary endpoint was postoperative intestinal motility dysfunction. RESULTS: Surgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC [Formula: see text] 3 (OR, 4.348; 96% CI, 1670-11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043-1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300-12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120-3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155-0.733; p = 0.006). CONCLUSION: Even though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Controversy Over Liver Transplantation or Resection for Neuroendocrine Liver Metastasis: Tumor Biology Cuts the Deal.

BACKGROUND: In patients with neuroendocrine liver metastasis (NELM), liver transplantation (LT) is an alternative to liver resection (LR), although the choice of therapy remains controversial. In this multicenter study, we aim to provide novel insight in this dispute. METHODS: Following a systematic literature search, 15 large international centers were contacted to provide comprehensive data on their patients after LR or LT for NELM. Survival analyses were performed with the Kaplan-Meier method, while multivariable Cox regression served to identify factors influencing survival after either transplantation or resection. Inverse probability weighting and propensity score matching was used for analyses with balanced and equalized baseline characteristics. RESULTS: Overall, 455 patients were analyzed, including 230 after LR and 225 after LT, with a median follow-up of 97 months [95% confidence interval (CI): 85-110 months]. Multivariable analysis revealed G3 grading as a negative prognostic factor for LR [hazard ratio (HR)=2.22, 95% CI: 1.04-4.77, P =0.040], while G2 grading (HR=2.52, 95% CI: 1.15-5.52, P =0.021) and LT outside Milan criteria (HR=2.40, 95% CI: 1.16-4.92, P =0.018) were negative prognostic factors in transplanted patients. Inverse probability-weighted multivariate analyses revealed a distinct survival benefit after LT. Matched patients presented a median overall survival (OS) of 197 months (95% CI: 143-not reached) and a 73% 5-year OS after LT, and 119 months (95% CI: 74-133 months) and a 52.8% 5-year OS after LR (HR=0.59, 95% CI: 0.3-0.9, P =0.022). However, the survival benefit after LT was lost if patients were transplanted outside Milan criteria. CONCLUSIONS: This multicentric study in patients with NELM demonstrates a survival benefit of LT over LR. This benefit depends on adherence to selection criteria, in particular low-grade tumor biology and Milan criteria, and must be balanced against potential risks of LT.

Influence of using simulated or real patients on undergraduate medical students acquiring competencies in medical conversations in surgery: A prospective, controlled study.

Background: Communication with patients and their relatives as well as with colleagues and students is an essential part of every physician's daily work. An established method for teaching communication skills is using simulated patients (SPs). However, teaching with SPs is often subjectively perceived by medical students as less instructive than teaching with real patients (RPs). Studies that analyze the influence of SPs compared to RPs for acquiring competencies are lacking. The aim of the present study was therefore to investigate the impact of SPs on long-term learning success for communication skills compared to RPs. Material and Methods: Study participants were undergraduate third-year medical students who attended a communication unit and were randomized into three groups. The first group trained the role-play part with a SP (SP-group). The second group trained with a SP but thought that the patient was a RP because the students and the tutors were told that they were a RP by the principal investigator (incognito patient group [IP-group]). The third group and their tutors trained with a RP and were told that the patient was a RP (real patient group [RP-group]). Five to 12 weeks after completing the training, the study participants completed a curricular summative objective standardized clinical examination. Results: There were 146 students who participated in the study. There were no significant differences between the three study groups at the informed consent stations and for those conducting anamnesis interviews. Conclusion: Communication skills training with SPs appears to be equivalent to training with RPs in terms of competency development in communication-based assessments in surgery. Therefore, SPs should be used in these curricula, especially at an early stage, to enable the students to practice adequate communication skills.

Carbonic-anhydrase IX expression is increased in thyroid cancer tissue and represents a potential therapeutic target to eradicate thyroid tumor-initiating cells.

The expression of Carbonic-anhydrase IX (CAIX) in thyroid cancer (TC) subtypes was determined and its role in cancer cell growth and tumor-initiating cells (TICs) investigated. Immunohistochemistry in 114 TC patients revealed that CAIX expression was increased in tumor specimens of papillary, follicular and anaplastic TCs compared to normal thyroid tissue. Clinicopathological data indicated that lymph node metastases were more frequent in patients with high CAIX expression. The Cancer Genome Atlas database analysis demonstrated that a strong CAIX-mRNA expression was associated with advanced tumor stages and poor survival in TCs. In TC cell lines, CAIX expression was elevated in tumorspheres compared to monolayer cultures and was associated with an increased expression of stemness markers. Genetic knockdown or pharmacological inhibition of CAIX suppressed cell proliferation and the TIC ability to form tumorspheres by an induction of apoptosis and cell-cycle arrest. These findings suggest CAIX as a potential prognostic marker and a therapeutic target for thyroid cancer.

The association of age with decline in renal function after low anterior resection and loop ileostomy for rectal cancer: a retrospective cohort prognostic factor study.

BACKGROUND: Low anterior resection (LAR) is often performed with diverting loop ileostomy (DLI) for anastomotic protection in patients with rectal cancer. We aim to analyze, if older patients are more prone to a decline in kidney function following creation and closure of DLI after LAR for rectal carcinoma versus younger patients. METHODS: A retrospective cohort study from a database including 151 patients undergoing LAR for rectal carcinoma with DLI was used. Patients were divided in two age groups (Group A: <65 years, n = 79; Group B: ≥65 years, n = 72). For 123 patients undergoing DLI reversal prognostic factors for an impairment of serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) 3 months after DLI reversal was analyzed using a multivariate linear regression analysis. RESULTS: SCr before LAR(T0) was significant higher in Group B (P = 0.04). Accordingly, the eGFR at T0 in group B was significantly lower (P < 0.001). No patients need to undergo hemodialysis after LAR or DLI reversal. Age and SCr at T0were able to statistically significant predict an increase in SCr (P<0.001) and eGFR (P=0.001) three months after DLI reversal (The R² for the overall model was .82 (adjusted R² = .68). CONCLUSION: DLI creation may result in a reduction of eGFR in older patients 3 months after DLI closure. Apart from this, patients do not have a higher morbidity after creation and closure of DLI resulting from LAR regardless of their age.

DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis.

PURPOSE: The management of patients with suspected appendicitis remains a challenge in daily clinical practice, and the optimal management algorithm is still being debated. Negative appendectomy rates (NAR) continue to range between 10 and 15%. This prospective study evaluated the accuracy of a diagnostic pathway in acute appendicitis using clinical risk stratification (Alvarado score), routine ultrasonography, gynecology consult for females, and selected CT after clinical reassessment. METHODS: Patients presenting with suspected appendicitis between November 2015 and September 2017 from age 18 years and above were included. Decision-making followed a clear management pathway. Patients were followed up for 6 months after discharge. The hypothesis was that the algorithm can reduce the NAR to a value of under 10%. RESULTS: A total of 183 patients were included. In 65 of 69 appendectomies, acute appendicitis was confirmed by histopathology, corresponding to a NAR of 5.8%. Notably, all 4 NAR appendectomies had other pathologies of the appendix. The perforation rate was 24.6%. Only 36 patients (19.7%) received a CT scan. The follow-up rate after 30 days achieved 69%, including no patients with missed appendicitis. The sensitivity and specificity of the diagnostic pathway was 100% and 96.6%, respectively. The potential saving in costs can be as much as 19.8 million €/100,000 cases presenting with the suspicion of appendicitis. CONCLUSION: The risk-stratified diagnostic algorithm yields a high diagnostic accuracy for patients with suspicion of appendicitis. Its implementation can safely reduce the NAR, simultaneously minimizing the use of CT scans and optimizing healthcare-related costs in the treatment of acute appendicitis. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02627781 (December 2015).

[Introduction of an interdisciplinary tumor board leads to improvement of treatment outcome of cholangiocarcinoma (bile duct cancer)]. / Einführung eines interdisziplinären Tumorboards führt zur Verbesserung der Behandlungsergebnisse von Cholangio- und Gallenblasenkarzinomen.

BACKGROUND: Cholangiocarcinoma (CCA, bile duct cancer) is a rare malignant disease with a poor prognosis. For several years interdisciplinary tumor boards (TuB) with the participation of experts from various disciplines have been organized to optimize medical treatment for patients suffering from oncological diseases. OBJECTIVE: This study addressed the question whether the introduction of TuB leads to a better life expectancy and quality of life for patients with CCA. MATERIAL AND METHODS: In this retrospective study 161 patients treated for CCA were investigated. The patient collective was divided in two groups (TuB+ vs. TuB-) and a propensity score matching was carried out. RESULTS: The patient group TuB+ included 109 patients (67.7%) and the control group (TuB-) included 52 patients (32.3%). Using propensity score matching 84 patients in the TuB+ and 50 in the TuB group were identified and matched. The survival rates of the matched patients demonstrated an advantage for patients in the TuB+ group (1-year survival rate 61.9%, 5­year survival rate 23.6%, 10-year survival rate 18.0%) over patients in the TuB-group (1-year survival rate 32.0%, 5­year survival rate 8.0%, 10-year survival rate 0%) with p < 0.001. The results of the univariate (hazard ratio, HR 0.513, 95% confidence interval, CI 0.350-0.751, p = 0.001) and the multivariate Cox proportional hazard models (HR 0.459, 95% CI 0.303-0.694, p < 0.001) showed a significant benefit in survival for patients in the TuB+ group. CONCLUSION: This article shows that the introduction of a TuB meeting can provide a measurable benefit for patients with CCA. Hence it is recommended that all cases of patients with CCA should be discussed in a TuB.

Sarcopenia as a prognostic factor for survival in patients with locally advanced gastroesophageal adenocarcinoma.

BACKGROUND AND AIMS: Patients with gastric cancer often show signs of malnutrition. We sought to evaluate the influence of sarcopenia in patients with locally advanced, not metastasized, gastric or gastro-esophageal junction (GEJ) cancer undergoing curative treatment (perioperative chemotherapy and surgery) on morbidity and mortality in order to identify patients in need for nutritional intervention. PATIENTS AND METHODS: Two-centre study, conducted in the Frankfurt University Clinic and Krankenhaus Nordwest (Frankfurt) as part of the University Cancer Center Frankfurt (UCT). 47/83 patients were treated in the FLOT trial (NCT01216644). Patients´ charts were reviewed for clinical data. Two consecutive CT scans were retrospectively analyzed to determine the degree of sarcopenia. Survival was calculated using the Kaplan-Meier method, multivariate analysis was performed using the Cox regression. RESULTS: 60 patients (72.3%) were male and 23 (27.7%) female. 45 patients (54.2%) had GEJ type 1-3 and 38 (45.8%) gastric tumors, respectively. Sarcopenic patients were significantly older than non-sarcopenic patients (mean age 65.1 years vs. 59.5 years, p = 0.042), terminated the chemotherapy significantly earlier (50% vs. 22.6%, p = 0.037) and showed higher Clavien-Dindo scores, indicating more severe perioperative complications (score ≥3 43.3 vs. 17.0%, p = 0.019). Sarcopenic patients had a significantly shorter survival than non-sarcopenic patients (139.6 ± 19.5 [95% CI, 101.3-177.9] vs. 206.7 ± 13.8 [95% CI, 179.5-233.8] weeks, p = 0.004). Multivariate Cox regression analysis showed that, besides UICC stage, sarcopenia significantly influenced survival. CONCLUSION: Sarcopenia is present in a large proportion of patients with locally advanced gastric or GEJ cancer and significantly influences tolerability of chemotherapy, surgical complications and survival.

Surgical resection of neuroendocrine tumor liver metastases as part of multimodal treatment strategies: A propensity score matching analysis.

BACKGROUND: It remains unclear whether liver resection as part of multimodal therapy of neuroendocrine liver metastases (NELM) is superior to non-surgical (interventional and medication-based) treatment alone. This study should determine if patients with NELM undergoing hepatic surgery in addition to non-surgical treatment have improved overall survival compared to patients undergoing non-surgical therapy alone. METHODS: 123 patients undergoing treatment of NELM between 1995 and 2014 were included in this retrospective cohort study. Two groups were formed: (A) surgery and non-surgical therapy and (B) non-surgical treatment alone. To minimize the bias of patient selection propensity score matching was used. RESULTS: There was significantly better overall survival for group A (152 months, 95%CI: 119-185) compared to group B (63 months, 95%CI: 45-81) measured from the initial diagnosis of the metastases (P = 0.003). After propensity score matching, 37 patients undergoing surgical resection of NELM within a multimodal treatment were compared to 37 patients undergoing non-surgical treatment. Under these circumstances, surgery had no significant influence on survival (group A: 134 months, 95% CI: 94-173; group B: 76 months, 95% CI: 53-99, P = 0.23). Based on a multivariate Cox proportional hazard model, only Ki-67 of primary tumor >20% (HR, 50.776; 95%CI, 4.056-635.71; P = 0.002) and no resection of primary tumor (HR, 10.464; 95%CI, 1.873-58.448; P = 0.007) remained independent risk factors. CONCLUSION: After minimizing patient selection bias, patients with hepatic resection as integral of multimodal therapy of NELM do not have better overall survival than those receiving non-surgical treatment alone.

Do they teach what they need to? An analysis of the impact of curriculum mapping on the learning objectives taught in a lecture series in surgery.

Introduction: Curriculum mapping shows concordances and differences between the intended and the taught curriculum. To our knowledge, no previous studies describe the effects that this mapping has on the curriculum. The aim of the present study is to map the content of a lecture series in surgery to the National Catalogue of Learning Objectives in Surgery and analyze the effects this mapping has on the content of the following lecture series. Methods: All lecturers in the lecture series were directly observed by a minimum of two reviewers and learning objectives and the level of competence were documented. After the lecture series, the results were visualized within the catalog of learning objectives and were sent to the lecturers. In the following lecture series, learning objectives were documented correspondingly. Results: In the first lecture series, 47% of the learning objectives were taught. After the mapping, the number of learning objectives that were taught increased to 59% (p < 0.001). The increase was found in all surgical disciplines and in all levels of competences without any changes in the average duration of the lectures. Conclusions: The presented method for mapping a curriculum effectively increased the number of taught learning objectives without requiring longer lecture durations.

The Safety Level of Total Central Venous Access Port Implantation Performed by Residents.

OBJECTIVE: The implantation of totally implantable venous access ports (TIVAPs) is one of the first procedures surgical residents learn. Complications after implantation procedures have a major impact on patient outcomes, as it may lead to a delay of chemotherapy regimens or of parenteral nutrition. The aim of this study was to compare the outcomes after totally implantable venous access ports implantations done by resident and attending surgeons. DESIGN: The study was performed as a retrospective analysis. SETTING: The study took place in primary care at the Department of General and Visceral Surgery at Frankfurt University Hospital. PARTICIPANTS: A total of 760 primary totally implantable venous access ports implantations performed between March 2008 and December 2016 were included in a database. Three groups of surgeons doing the implantations were defined: Group A (residents alone), Group B (resident with help), and Group C (attending surgeons). RESULTS: There was a significant difference between the surgeon groups in operation time (p < 0.001). The groups differed between Group A (mean, 49; SD, 22) and Group C (mean, 39; SD, 20); p < 0.001) and Group B (mean, 53; SD, 23) and Group C (mean, 39; SD, 20; p < 0.001). The incidence of surgical site infections between Groups A and C (3.6% vs. 0.3%; p = 0.003) and Groups B and C (2.5% vs. 0.3%; p = 0.027) differed also significantly. Based on multivariable logistic regression analysis operation time in minutes (OR, 1.04; 95%CI, 1.03-1.06; p < 0.001) was an independent risk factor for any intraoperative complications. For any postoperative complications younger age of the patient (OR, 0.98; 95%CI, 0.97-0.99; p = 0.004) and benign primary disease (OR, 3.25; 95%CI, 1.55-6.64; p = 0.002) were independent risk factors based on multivariable regression analysis. Based on multivariable regression analysis a lower body mass index of the patient (OR, 0.93; 95%CI, 0.86-0.99; p = 0.044), benign primary disease (OR, 2.89; 95%CI, 1.07-7.79; p = 0.036), and no chemotherapy (OR, 3.55; 95%CI, 1.50-8.39; p = 0.004) were independent risk factors for postoperative catheter infections. Surgeon group was no risk factor, neither for intraoperative and postoperative complications, nor for catheter explantation due to complications. CONCLUSION: Residents performing alone or residents performing with help can safely handle a central venous access port implantation. In patients with several risk factors, however, an attending should assist.

Emotion recognition and extraversion of medical students interact to predict their empathic communication perceived by simulated patients.

BACKGROUND: This study assessed the impact of medical students' emotion recognition ability and extraversion on their empathic communication, as perceived by simulated patients in a training context. METHODS: This study used a crossed-effect data structure and examined 245 students in their fourth year of medical school. The students' personality traits were assessed based on a self-assessment questionnaire of the short form of the Big Five Inventory; their emotion recognition ability was measured using a performance test (Diagnostic Analysis of Nonverbal Accuracy-2, Adult Facial Expressions). Simulated patients evaluated the medical students' empathic communication. RESULTS: Students with a combination of high emotion recognition ability and extraversion received more positive ratings from simulated patients than their fellow students with a combination of emotion recognition ability and low extraversion. The main effects of emotion recognition or extraversion were not sufficient to yield similar effects. There were no other effects related to the remaining Big Five variables. CONCLUSIONS: The results support the hypothesis that to build rapport with patients, medical staff need to combine emotional capabilities with a dispositional interest in interpersonal encounters.

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study.

OBJECTIVES: The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65 years of age. METHODS: This study included patients aged 65 years and older who underwent CRC resection between 2003 and 2013 at a single-center institution. Patients were divided into two groups: Group A (65-74 years old) and Group B (≥75 years old). RESULTS: Multivariable logistic analysis of 415 patients revealed serum albumin levels on the third postoperative day (POD) (Odds Ratio (OR), 0.44; 95% CI, 0.21-0.94; P = 0.03) and C-reactive protein (CRP) levels (OR, 1.05; 95% CI, 1.00-1.01; P = 0.04) in patients with colon cancer as predictive factors for morbidity. In addition, the multivariable logistic analysis revealed serum albumin levels (OR, 0.27; 95% CI, 0.08-0.87; P = 0.03) in patients with rectal cancer as predictive factors for morbidity. The multivariate Cox Proportional Hazards Model identified re-intervention for colon cancer (Hazard Ratio (HR), 4.57; 95% CI, 1.36-15.4 P = 0.01) and for rectal cancer (HR, 11.8; 95% CI, 1.08-129 P = 0.04) as a predictive factor for 30-day mortality. Serum albumin level on the third POD was predictive of 30-day mortality (HR, 0.30; 95% CI, 0.13-0.71; P = 0.01) and of 1-year mortality (HR, 0.34; 95% CI, 0.17-0.66; P < 0.01) in patients with colon cancer. CONCLUSION: Age is not predictive of postoperative morbidity and mortality in patients with CRC. Serum albumin levels on the third POD can predict morbidity and mortality for colon and rectal carcinoma in older patients undergoing colorectal resections.

[The Medical Examination - Between Desire and Reality - Analysis of Consensus Between the Second Part of the Medical Licensing Exam (IMPP) and the National Catalogue of Expertise-based Learning Goals in Surgery (NKLC)]. / Medizinische Prüfung zwischen Wunsch und Wirklichkeit ­ Analyse der Übereinstimmung zwischen dem 2. Abschnitt der ärztlichen Prüfung und dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie.

Background The working party of the German Society for Surgery (DGCH) on undergraduate surgical education has developed a national expertise-based catalogue of learning goals in surgery (NKLC). This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP are congruent with the NKLC and which thematic focus is emphasised. Materials and Methods Firstly, a guideline and evaluation sheet were developed in order to achieve documentation of the individual examination questions of the second licensing examination with respect to the learning goals of the NKLC. In a retrospective analysis from autumn 2009 to autumn 2014, eleven licensing examinations in human medicine were screened independently by three different reviewers. In accordance with the guideline, the surgical questions were identified and subsequently matched to the learning goals of the NKLC. The analysis included the number of surgical learning goals as well as the number of surgical questions for each examination, learning goal, and different levels of expertise (LE). Results Thirteen reviewers from six surgical disciplines participated in the analysis. On average, reviewers agreed on the differentiation between surgical and non-surgical questions in 79.1% of all 3480 questions from 11 licensing examinations. For each examination (n = 320 questions), 98.8 ± 22.6 questions (min.: 69, max.: 150) were rated as surgical. For each surgical learning goal addressed, 2.2 ± 0.3 questions (min.: 1, max.: 16) were asked. For each examination, 23.5 ± 6.3 questions (min.: 11; max.: 31) referred to learning goals of LE 3, 52.5 ± 16.7 questions (min.: 34; max.: 94) addressed learning goals of LE 2 and 22.8 ± 7.7 questions (min.: 9; max.: 34) were related to learning goals of LE 1. 64 learning goals (27.8% of all learning goals of the NKLC) were not reflected in the examinations. With a total of 70 questions, the most frequently examined surgical topic was "disorders of the rheumatic spectrum". Conclusion The number of surgical examination questions in the German second medical licensing examination seems to be sufficient. However, the questions seem to be unevenly distributed between different surgical areas of undergraduate education. In order to achieve a more homogenous representation of relevant surgical topics, improved alignment is needed between the state examination with existing catalogues of learning goals by the IMPP.

Education in thyroid surgery: a matched-pair analysis comparing residents and board-certified surgeons.

PURPOSE: Resident participation in operative procedures is mandatory in educational residency programs but remains controversial, especially in the context of patient safety. This study compared the surgical quality and outcomes of thyroidectomies performed by surgical residents (RESs) and board-certified surgeons (BCSs). METHODS: This retrospective matched-pair study included patients undergoing thyroidectomies for multinodular goiter, Grave's disease and early-stage thyroid cancer that were performed by a RES with BCS supervision between 2006 and 2014. The intraoperative and postoperative course, complication rates and handling of the recurrent laryngeal nerve (RLN) and parathyroid glands were analyzed. RESULTS: In total, 112 thyroidectomies that were performed by a RES fulfilled the inclusion criteria and were matched 1:1 with BCS patients. We included 88 hemithyroidectomies, 80 subtotal thyroidectomies and 56 total thyroidectomies. No significant differences in the handling of the RLN or parathyroid glands, the rates of postoperative RLN palsies or the rates of hypocalcaemia were found. No intraoperative complications led to the replacement of the RES as the surgeon-in-charge. Three RES and two BCS patients experienced postoperative haemorrhages (p = 0.205), and three surgical site infections (p = 1.000) occurred in each group. The mean operative time and the length of stay did not differ significantly between the two groups. CONCLUSIONS: Major aspects of patient safety in thyroid surgery are not affected by resident participation. Thyroidectomies performed by RES are not significantly longer and reveal no differences in length of stay or complication rates. The economic burden of resident involvement is modest.

The clinical relevance of the Fong and the Nordlinger scores in the era of effective neoadjuvant chemotherapy for colorectal liver metastasis.

PURPOSE: The clinical risk scores (CRSs) of Fong and Nordlinger are used to predict the outcome of patients with colorectal liver metastases (CRLMs). This study investigated whether CRSs could predict the overall survival of patients with CRLM treated with or without neoadjuvant chemotherapy prior to resection. METHODS: Patients with CRLM undergoing liver resection were analyzed retrospectively. The primary outcome measure was overall survival with vs. without neoadjuvant chemotherapy. RESULTS: Between August 2002 and October 2011, 300 patients underwent liver resection for CRLMs at a large university hospital in Germany. Group A comprised 117 patients who received neoadjuvant chemotherapy and group B comprised 71 patients who did not. The Fong score predicted overall survival for patients who did not receive chemotherapy (p = 0.02), but not for those treated with chemotherapy (p = 0.69). The Nordlinger score was not predictive for either of the groups (p = 0.71 vs. p = 0.08 for groups A and B, respectively). Subgroup analysis of the Nordlinger score identified better overall survival in the high-risk group treated with chemotherapy (p = 0.05). Multivariate analysis identified a resection margin of <1 cm [OR 0.622 (95% CI: 0.17-2.31); p = 0.044], age >60 years [OR 0.535 (95% CI: 0.16-1.77); p = 0.022] and number of metastases >4 [OR 0.189 (95% CI: 0.06-0.61); p = 0.018] as independent prognostic factors for overall survival. CONCLUSION: Thus, CRSs were not reliable prognostic tools for patients treated with neoadjuvant chemotherapy before liver resection in this analysis.

Posthepatectomy liver failure.

BACKGROUND: Posthepatectomy liver failure (PHLF) is one of the most serious complications after liver resection and is still reported in up to 8% after liver resection. AIMS: To provide an overview about the current status of risk analysis and definition of PHLF. Prevention and treatment is also discussed. METHODS: A literature review was carried out on PubMed using the terms 'liver failure', 'posthepatectomy' and 'liver surgery' to search relevant papers. DISCUSSION: PHLF remains a serious problem in patients undergoing major liver resection. Adequate preoperative risk assessment and an optimal postoperative treatment are essential for PHLF prevention.