Postoperative results, pathologic outcome, and long-term patency rate of autologous vein reconstruction of the mesentericoportal axis after pancreatectomy.

PURPOSE: In advanced pancreatic cancer (PC), en-bloc vein resection and reconstruction (VR) is a curative option in oncologic pancreatectomy. However, few data about long-term patency rates after autologous venous reconstruction are available. We aimed to analyze whether early postoperative morbidity is increased by additional VR. Furthermore, pathologic outcomes and long-term patency rates after applying autologous vein material are examined. METHODS: Data on patients who underwent surgical resection for suspicious malignancy were collected prospectively. Early postoperative complications, as well as the circumferential resection margins were analyzed retrospectively. Patients with VR (VR+) were compared with patients without vein resection (VR-). Vein reconstruction was always performed by autologous vein replacement, followed by a 6-month application of Enoxaparin. Patency rates of the mesenteric vessels in long-term follow-up exams were determined by contrast-enhanced computed tomography (CT) every 3 months. RESULTS: Two hundred nineteen pancreatic resections for suspicious malignancy were performed. In 82 patients, VR occurred (37.4%). No significant differences between VR+ and VR- were observed concerning 30-day mortality and postoperative morbidity. R0 rate did not differ between the two groups. By applying autologous vein material, the average patency rate was 90%. CONCLUSION: In terms of tumor free resection margins, equal oncologic results can be achieved by additional vein resection. Because the patency rate is high in follow-up, and early postoperative complication rates are not increased in patients with VR+, vein resection and reconstruction should be performed if oncologically necessary. The application of autologous vein reconstruction followed by a 6-month enoxaparin treatment seems to yield favorable technical results.

Adherence to Dietary Behavior Recommendations Moderates the Effect Between Time Since Metabolic and Bariatric Surgery and Percentage Total Weight Loss.

PURPOSE: Metabolic and bariatric surgery (MBS) is the gold standard in treating severe obesity. Previous research implies that different psychological and behavior-related factors might be critical for MBS' sustained success. Yet adherence to dietary behavior recommendations and its impact on weight development is rarely examined. This study investigated the relationship between adherence to dietary behavior recommendations and the percentage of total weight loss (%TWL) after MBS. MATERIALS AND METHODS: This study is a cohort study (acquisition in Germany). N = 485 patients after MBS, being in grade III of obesity (body mass index (BMI) ≥ 40 kg/m2) pre-MBS, were included. Participants answered a standardized assessment on the relevant constructs, including adherence to dietary behavior recommendations, depression symptoms, weight, diet, and MBS characteristics. RESULTS: BMI pre-MBS, type of MBS, age, regularity of physical activity, and depression symptoms were identified as significant covariates of %TWL and adherence. Within 6 months after MBS, adherence seems to peak, F(5,352) = 12.35, p < .001. Adherence and time since MBS predict %TWL. A higher adherence (moderator) is related to a higher %TWL, R2 = 52.65%, F(13,344) = 31.54, p < .001. CONCLUSION: After MBS, adherence to dietary behavior recommendations seems crucial for maximizing its success. Implications for the optimization of MBS' success in aftercare management arise. In particular, behavior modification interventions should be routinely implemented.

Pathohistological subtype predicts survival in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas.

OBJECTIVE: To investigate different subtypes of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and their prognostic value. BACKGROUND: IPMNs of the pancreas are estimated to have a better prognosis than pancreatic ductal adenocarcinomas (PDACs). In addition to the different growth types (ie, main duct vs. branch duct types), the histological subtypes of IPMNs (ie, intestinal, pancreatobiliary, gastric, and oncocytic type) are prognostically relevant. These subtypes can be characterized by different mucin (MUC) expression patterns. In this study, we analyzed the IPMNs from 2 pancreatic cancer referral centers by correlating the MUC expression, histological subtype, and clinical outcome. METHODS: We re-evaluated all resections due to a pancreatic tumor over a period of 15 years. Cases with IPMNs were identified, and the subtypes were distinguished using histopathological analysis, including the immunohistochemical analysis of MUC (ie, MUC1, MUC2, and MUC5AC) expression. Furthermore, we determined clinical characteristics and patient outcome. RESULTS: A total of 103 IPMNs were identified. On the basis of the MUC profile, histopathological subtypes were classified into the following categories: intestinal type [n = 45 (44%)], pancreatobiliary type [n = 41 (40%)], gastric type [n = 13 (12%)], and oncocytic type [n = 4 (4%)]. The following types of resections were performed: pancreatic head resections [n = 77 (75%)], tail resections [n = 16 (15%)], total pancreatectomies [n = 5 (5%)], and segment resections [n = 5 (5%)]. The 5-year survival of patients with intestinal IPMNs was significantly better than pancreatobiliary IPMNs (86.6% vs. 35.6%; P < 0.001). The pancreatobiliary subtype was strongly associated with malignancy [odds ratio (OR): 6.76], recurrence (P < 0.001), and long-term survival comparable with that of PDAC patients. CONCLUSIONS: Evaluation of IPMN subtypes supports postoperative patient prognosis prediction. Therefore, subtype differentiation could lead to improvements in clinical management. Potentially identifying subgroups with the need for adjuvant therapy may be possible.

Malignancy in chronic pancreatitis: analysis of diagnostic procedures and proposal of a clinical algorithm.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is characterized by its poor prognosis, and some benign conditions and syndromes, including chronic pancreatitis (CP), are risk factors for pancreatic carcinoma. However, the differential diagnosis of CP from PDAC is difficult for clinicians because PDAC frequently causes inflammation within the pancreas. Therefore, patients with CP exhibit not only an elevated risk of cancer, but they are also in danger of underdiagnosis. METHODS: The present study retrospectively analyzed 29 patients with pancreatic cancer who fulfilled our definition of "chronic pancreatitis" to identify characteristics to aid in the differential diagnosis between chronic pancreatitis with and without pancreatic cancer. All parameters were subjected to univariate analysis. RESULTS: We identified several factors that differed significantly between the CP patients and patients with CP and synchronous PDAC, and these characteristics were used to develop a diagnostic algorithm. The performance of the algorithm was externally validated in a different panel of patients from the Department of Surgery, Medical Faculty Mannheim. CONCLUSION: The present study succeeded in identifying characteristics that significantly differed in patients with and without PDAC in CP. These characteristics were integrated in a diagnostic algorithm that might help to improve diagnostic of PDAC in CP.

Google goes cancer: improving outcome prediction for cancer patients by network-based ranking of marker genes.

Predicting the clinical outcome of cancer patients based on the expression of marker genes in their tumors has received increasing interest in the past decade. Accurate predictors of outcome and response to therapy could be used to personalize and thereby improve therapy. However, state of the art methods used so far often found marker genes with limited prediction accuracy, limited reproducibility, and unclear biological relevance. To address this problem, we developed a novel computational approach to identify genes prognostic for outcome that couples gene expression measurements from primary tumor samples with a network of known relationships between the genes. Our approach ranks genes according to their prognostic relevance using both expression and network information in a manner similar to Google's PageRank. We applied this method to gene expression profiles which we obtained from 30 patients with pancreatic cancer, and identified seven candidate marker genes prognostic for outcome. Compared to genes found with state of the art methods, such as Pearson correlation of gene expression with survival time, we improve the prediction accuracy by up to 7%. Accuracies were assessed using support vector machine classifiers and Monte Carlo cross-validation. We then validated the prognostic value of our seven candidate markers using immunohistochemistry on an independent set of 412 pancreatic cancer samples. Notably, signatures derived from our candidate markers were independently predictive of outcome and superior to established clinical prognostic factors such as grade, tumor size, and nodal status. As the amount of genomic data of individual tumors grows rapidly, our algorithm meets the need for powerful computational approaches that are key to exploit these data for personalized cancer therapies in clinical practice.

Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial.

IMPORTANCE: The prognosis for patients with pancreatic cancer is poor, even after resection with curative intent. Gemcitabine-based chemotherapy is standard treatment for advanced pancreatic cancer, but its effect on survival in the adjuvant setting has not been demonstrated. OBJECTIVE: To analyze whether previously reported improvement in disease-free survival with adjuvant gemcitabine therapy translates into improved overall survival. DESIGN, SETTING, AND PATIENTS: CONKO-001 (Charité Onkologie 001), a multicenter, open-label, phase 3 randomized trial to evaluate the efficacy and toxicity of gemcitabine in patients with pancreatic cancer after complete tumor resection. Patients with macroscopically completely removed pancreatic cancer entered the study between July 1998 and December 2004 in 88 hospitals in Germany and Austria. Follow-up ended in September 2012. INTERVENTIONS: After stratification for tumor stage, nodal status, and resection status, patients were randomly assigned to either adjuvant gemcitabine treatment (1g/m2 d 1, 8, 15, q 4 weeks) for 6 months or to observation alone. MAIN OUTCOMES AND MEASURES: The primary end point was disease-free survival. Secondary end points included treatment safety and overall survival, with overall survival defined as the time from date of randomization to death. Patients lost to follow-up were censored on the date of their last follow-up. RESULTS: A total of 368 patients were randomized, and 354 were eligible for intention-to-treat-analysis. By September 2012, 308 patients (87.0% [95% CI, 83.1%-90.1%]) had relapsed and 316 patients (89.3% [95% CI, 85.6%-92.1%]) had died. The median follow-up time was 136 months. The median disease-free survival was 13.4 (95% CI, 11.6-15.3) months in the treatment group compared with 6.7 (95% CI, 6.0-7.5) months in the observation group (hazard ratio, 0.55 [95% CI, 0.44-0.69]; P < .001). Patients randomized to adjuvant gemcitabine treatment had prolonged overall survival compared with those randomized to observation alone (hazard ratio, 0.76 [95% CI, 0.61-0.95]; P = .01), with 5-year overall survival of 20.7% (95% CI, 14.7%-26.6%) vs 10.4% (95% CI, 5.9%-15.0%), respectively, and 10-year overall survival of 12.2% (95% CI, 7.3%-17.2%) vs 7.7% (95% CI, 3.6%-11.8%). CONCLUSIONS AND RELEVANCE: Among patients with macroscopic complete removal of pancreatic cancer, the use of adjuvant gemcitabine for 6 months compared with observation alone resulted in increased overall survival as well as disease-free survival. These findings provide strong support for the use of gemcitabine in this setting. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN34802808.

Quality of Care Transition During Hospital Discharge, Patient Safety, and Weight Regain After Bariatric Surgery: a Cross-Sectional Study.

PURPOSE: Bariatric surgery is established as the gold standard in the treatment of severe obesity. However, a significant proportion of patients experience a substantial weight regain afterwards. Previous research focused predominantly on patients' personal factors. Yet, critical discharge process factors that contribute to patient's adherence after surgical interventions are rarely examined. This study investigated whether high quality of care transitions in discharge management influences weight regain and the likelihood of experiencing adverse patient safety incidents. MATERIALS AND METHODS: A cross-sectional study with 578 patients after bariatric surgery was conducted. Participants answered a standardized assessment on the quality of care transition from hospital to home-, surgery-, and nutrition-related characteristics as well as patient safety incidents. RESULTS: Significant weight regain was observed 24 months after surgery. The association between time since surgery and weight regain was weaker in patients with high quality of care transitions (B = 2.27, p < .001). Higher quality of care transition was also significantly related to a lower likelihood of unplanned hospital readmissions (OR = 0.67) and fewer medication complications (OR = 0.48) after surgery. CONCLUSION: This study sheds first light on the key influence of high quality of care transitions after bariatric surgery. Improvement efforts into effective discharge processes may establish smoother care transitions and help patients to assume responsibility and compliance with behavioral recommendations after surgery. Moreover, adverse patient safety incidents are less frequent after high quality care transitions indicating both high quality of health services for patients and reducing costs for the health care system.

Needs and Demands for e-Mental Health Interventions in Individuals with Overweight and Obesity: User-Centred Design Approach.

INTRODUCTION: Several studies indicate an association between mental disorders and overweight or obesity. E-Mental health interventions offer an effective way to overcome barriers to health care access for individuals with overweight and obesity. The objective of this study was to examine the needs and demands for e-mental health interventions among individuals with overweight and obesity. METHODS: A cross-sectional study was conducted from 2020 to 2021 in Germany. A total of 643 participants were recruited through specialized social media platforms and the Alfried-Krupp hospital in Essen, Germany. Sociodemographic and medical data were analysed, as well as data on depressive symptoms and on the needs and demands for e-mental health interventions. RESULTS: Contact with and recommendation by experts appear to be key aspects in the acceptance and use of e-mental health interventions. In summary, most participants preferred a 20-30-min weekly session via smartphone over a 4-month period. The highest preference in terms of features included practicing coping skills and being provided with information; in regard to desired topics, nutrition consultation, quality of life, and adapting to new life situations were considered most important. DISCUSSION: e-Mental health interventions can be highly beneficial for individuals, especially when developed through a user-centred design approach. The results of the study indicate which content and design are preferred and, thereby, provide valuable information for consideration when developing a tailored e-mental health intervention.

68Ga-Labeled Fibroblast Activation Protein Inhibitor (68Ga-FAPI) PET for Pancreatic Adenocarcinoma: Data from the 68Ga-FAPI PET Observational Trial.

The fibroblast activation protein (FAP) is highly expressed on carcinoma-associated fibroblasts in the stroma of pancreatic cancer and thus is a promising target for imaging and therapy. Preliminary data on PET imaging with radiolabeled FAP inhibitors (FAPIs) demonstrate superior tumor detection. Here we assess the accuracy of FAP-directed PET in patients with pancreatic cancer. Methods: Of 64 patients with suspected or proven pancreatic cancer, 62 (97%) were included in the data analysis of the 68Ga-FAPI PET observational trial (NCT04571086). All of these patients underwent contrast-enhanced CT, and 38 patients additionally underwent 18F-FDG PET. The primary study endpoint was the association of 68Ga-FAPI PET uptake intensity and histopathologic FAP expression. Secondary endpoints were detection rate, diagnostic performance, interreader reproducibility, and change in management. Datasets were interpreted by 2 masked readers. Results: The primary endpoint was met: The association between 68Ga-FAPI SUVmax and histopathologic FAP expression was significant (Spearman r, 0.48; P = 0.04). For histopathology-validated lesions, 68Ga-FAPI PET showed high sensitivity and positive predictive values (PPVs) on per-patient (sensitivity, 100%; PPV, 96.3%) and per-region (sensitivity, 100%; PPV, 97.0%) bases. In a head-to-head comparison versus 18F-FDG or contrast-enhanced CT, 68Ga-FAPI detected more tumor on a per-lesion (84.7% vs. 46.5% vs. 52.9%), per-patient (97.4% vs. 73.7% vs. 92.1%), or per-region (32.6% vs. 18.8% vs. 23.7%) basis, respectively. 68Ga-FAPI PET readers showed substantial overall agreement on the basis of the Fleiss κ: primary κ, 0.77 (range, 0.66-0.88). Minor and major changes in clinical management occurred in 5 patients (8.4%) after 68Ga-FAPI PET. Conclusion: We confirmed an association of 68Ga-FAPI PET SUVmax and histopathologic FAP expression in pancreatic cancer patients. Additionally, we found high detection rate and diagnostic accuracy, superior to those of 18F-FDG PET/CT. 68Ga-FAPI might become a powerful diagnostic tool for pancreatic cancer work-up.

Fibroblast-Activation Protein PET and Histopathology in a Single-Center Database of 324 Patients and 21 Tumor Entities.

We present an overview of our prospective fibroblast-activation protein inhibitor (FAPI) registry study across a 3-y period, with head-to-head comparison of tumor uptake in 68Ga-FAPI and 18F-FDG PET, as well as FAP immunohistochemistry. Methods: This is an interim analysis of the ongoing 68Ga-FAPI PET prospective observational trial at our department. Patients who underwent clinical imaging with 68Ga-FAPI PET between October 2018 and October 2021 were included. Tracer uptake was quantified by SUVmax for tumor lesions and by SUVmean for normal organs. PET tumor volume (40% isocontour) and tumor-to-background ratios were calculated. Correlation between SUVmax and FAP staining in tissue samples was analyzed. Results: In total, 324 patients with 21 different tumor entities underwent 68Ga-FAPI imaging; 237 patients additionally received 18F-FDG PET. The most common tumor entities were sarcoma (131/324, 40%), pancreatic cancer (67/324, 21%), and primary tumors of the brain (22/324, 7%). The mean primary tumor SUVmax was significantly higher for 68Ga-FAPI than 18F-FDG among pancreatic cancer (13.2 vs. 6.1, P < 0.001) and sarcoma (14.3 vs. 9.4, P < 0.001), and the same was true for mean SUVmax in metastatic lesions of pancreatic cancer (9.4 vs. 5.5, P < 0.001). Mean primary tumor maximum tumor-to-background ratio was significantly higher for 68Ga-FAPI than 18F-FDG across several tumor entities, most prominently pancreatic cancer (14.7 vs. 3.0, P < 0.001) and sarcoma (17.3 vs. 4.7, P < 0.001). Compared with 18F-FDG, 68Ga-FAPI showed superior detection for locoregional disease in sarcoma (52 vs. 48 total regions detected) and for distant metastatic disease in both sarcoma (137 vs. 131) and pancreatic cancer (65 vs. 57), respectively. Among 61 histopathology samples, there was a positive correlation between 68Ga-FAPI SUVmax and overall FAP immunohistochemistry score (r = 0.352, P = 0.005). Conclusion: 68Ga-FAPI demonstrates higher absolute uptake in pancreatic cancer and sarcoma, as well as higher tumor-to-background uptake along with improved tumor detection for pancreatic cancer, sarcoma, and other tumor entities when compared with 18F-FDG. 68Ga-FAPI is a new tool for tumor staging with theranostic potential.

Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial.

BACKGROUND: The ideal closure technique of the pancreas after distal pancreatectomy is unknown. We postulated that standardised closure with a stapler device would prevent pancreatic fistula more effectively than would a hand-sewn closure of the remnant. METHODS: This multicentre, randomised, controlled, parallel group-sequential superiority trial was done in 21 European hospitals. Patients with diseases of the pancreatic body and tail undergoing distal pancreatectomy were eligible and were randomly assigned by central randomisation before operation to either stapler or hand-sewn closure of the pancreatic remnant. Surgical performance was assessed with intraoperative photo documentation. The primary endpoint was the combination of pancreatic fistula and death until postoperative day 7. Patients and outcome assessors were masked to group assignment. Interim and final analysis were by intention to treat in all patients in whom a left resection was done. This trial is registered, ISRCTN18452029. FINDINGS: Between Nov 16, 2006, and July 3, 2009, 450 patients were randomly assigned to treatment groups (221 stapler; 229 hand-sewn closure), of whom 352 patients (177 stapler, 175 hand-sewn closure) were analysed. Pancreatic fistula rate or mortality did not differ between stapler (56 [32%] of 177) and hand-sewn closure (49 [28%] of 175; OR 0·84, 95% CI 0·53­1·33; p=0·56). One patient died within the fi rst 7 days after surgery in the hand-sewn group; no deaths occurred in the stapler group. Serious adverse events did not differ between groups. INTERPRETATION: Stapler closure did not reduce the rate of pancreatic fistula compared with hand-sewn closure for distal pancreatectomy. New strategies, including innovative surgical techniques, need to be identified to reduce this adverse outcome. FUNDING: German Federal Ministry of Education and Research.

Cystic adventitial degeneration of the popliteal artery.

Cystic adventitial degeneration (CAD) of the popliteal artery is a rare, but well-recognized, disorder leading to claudication. Usually, surgical treatment is indicated. So far, <400 patients have been described. We report on a series of three patients with CAD. Because we observed local recurrence of CAD after local resection, we conclude that 360° resection and venous interposition is preferable for a favorable outcome. Furthermore, we review etiology, pathology, and different surgical treatment approaches.

Determinants of Acceptance of Weight Management Applications in Overweight and Obese Individuals: Using an Extended Unified Theory of Acceptance and Use of Technology Model.

Overweight and obesity carry a tremendous burden in terms of physiological and psychological comorbidities. There is a great variety of weight management applications to support weight reduction, but a systematical analysis of individuals' needs and requirements to adopt sustaining lifestyle changes is missing so far. This study aimed to assess the acceptance of such applications and its underlying predictors in individuals with overweight/obesity. A cross-sectional study was conducted, including 439 overweight/obese individuals. Health-related internet use and acceptance of weight management applications were examined using a modified questionnaire based on the Unified Theory of Acceptance and Use of Technology (UTAUT). The general acceptance of weight management applications was high, with significant age differences. Compared to older individuals, younger ones showed a higher acceptance. BMI was not significantly associated with acceptance. Besides psychometric data and eHealth-related data, performance expectancy, effort expectancy, and social influence proved to be significant predictors for acceptance. The total variance explanation provided by the extended UTAUT model was 61.2%. The knowledge of the influencing factors on acceptance might be useful in developing, optimizing, and establishing weight management applications. For determining acceptance and its predictors of weight management applications, the UTAUT model is a valid approach.

Predicting Acceptance of e-Mental Health Interventions in Patients With Obesity by Using an Extended Unified Theory of Acceptance Model: Cross-sectional Study.

BACKGROUND: The rapid increase in the number of people who are overweight and obese is a worldwide health problem. Obesity is often associated with physiological and mental health burdens. Owing to several barriers to face-to-face psychotherapy, a promising approach is to exploit recent developments and implement innovative e-mental health interventions that offer various benefits to patients with obesity and to the health care system. OBJECTIVE: This study aims to assess the acceptance of e-mental health interventions in patients with obesity and explore its influencing predictors. In addition, the well-established Unified Theory of Acceptance and Use of Technology (UTAUT) model is compared with an extended UTAUT model in terms of variance explanation of acceptance. METHODS: A cross-sectional web-based survey study was conducted from July 2020 to January 2021 in Germany. Eligibility requirements were adult age (≥18 years), internet access, good command of the German language, and BMI >30 kg/m2 (obesity). A total of 448 patients with obesity (grades I, II, and III) were recruited via specialized social media platforms. The impact of various sociodemographic, medical, and mental health characteristics was assessed. eHealth-related data and acceptance of e-mental health interventions were examined using a modified questionnaire based on the UTAUT. RESULTS: Overall, the acceptance of e-mental health interventions in patients with obesity was moderate (mean 3.18, SD 1.11). Significant differences in the acceptance of e-mental health interventions among patients with obesity exist, depending on the grade of obesity, age, sex, occupational status, and mental health status. In an extended UTAUT regression model, acceptance was significantly predicted by the depression score (Patient Health Questionnaire-8; ß=.07; P=.03), stress owing to constant availability via mobile phone or email (ß=.06; P=.02), and confidence in using digital media (ß=-0.058; P=.04) and by the UTAUT core predictors performance expectancy (ß=.45; P<.001), effort expectancy (ß=.22; P<.001), and social influence (ß=.27; P<.001). The comparison between an extended UTAUT model (16 predictors) and the restrictive UTAUT model (performance expectancy, effort expectancy, and social influence) revealed a significant difference in explained variance (F13,431=2.366; P=.005). CONCLUSIONS: The UTAUT model has proven to be a valuable instrument to predict the acceptance of e-mental health interventions in patients with obesity. The extended UTAUT model explained a significantly high percentage of variance in acceptance (in total 73.6%). On the basis of the strong association between acceptance and future use, new interventions should focus on these UTAUT predictors to promote the establishment of effective e-mental health interventions for patients with obesity who experience mental health burdens.

Development and Validation of Dietary Behavior Inventory-Surgery (DBI-S) in the Scope of International Post-Bariatric Surgery Guidelines and Recommendations.

(1) Dietary behavior is highly relevant for patients after bariatric surgery. No instrument exists assessing adherence to medical guidelines concerning the dietary behavior of patients after bariatric surgery. The aim of this study was to develop and validate such an instrument. (2) Data from patients after bariatric surgery (n = 543) were collected from March to May 2022. The development of the DBI-S was theory-based and interdisciplinary. Items' and content validity of the DBI-S were examined. (3) The final version of the DBI-S consists of 13 items. Convergent validation was confirmed by significant correlations between DBI-S score and attitude towards healthy food (r = 0.26, p = <0.001) and impulsivity (r = −0.26, p = <0.001). Criterion validity was confirmed by significant correlations between DBI-S score and pre-/post-surgery BMI difference (r = −0.14, p = 0.002), pre-/post-surgery weight difference (r = 0.13, p = 0.003), and quality of life (r = 0.19, p = <0.001). Cluster analysis confirmed the ability to distinguish between two dietary behavior clusters (rather healthy and rather unhealthy). (4) The DBI-S is an economic and valid instrument to assess the adherence of post-bariatric surgery patients to the relevant dietary behavior recommendations and guidelines and can distinguish between rather unhealthy and healthy dietary behavior.

Generalized Anxiety as a Risk Factor for Dysfunctional Eating Behavior after Obesity Surgery during the COVID-19 Pandemic.

Purpose: The present study investigates the impact of obesity surgery on mental health (i.e., eating behavior and distress) during the COVID-19 pandemic. Methods: Two hundred fifty-four participants were recruited via social media. One hundred fourteen (44.53%) of them were surgery candidates (waiting for obesity surgery), while 142 (55.46%) had already undergone surgery. Participants who underwent surgery were compared to participants that did not yet undergo surgery in terms of mental burden (depression and anxiety), as well as safety and eating behavior. Further moderation analyses attempted to identify risk factors for increased COVID-19-related dysfunctional eating behavior after surgery. Results: Participants who underwent surgery showed generally lower levels of depression and general anxiety on a trend level. Moderation analyses suggested that people with high levels of generalized anxiety actually show more dysfunctional COVID-19-specific eating behavior after obesity surgery. Conclusion: On a trend level, obesity surgery appears to attenuate symptoms of generalized anxiety and depression. Yet, surgery patients with high levels of generalized anxiety exhibit even higher levels of dysfunctional eating during the COVID-19 pandemic. It is therefore particularly important to support people at risk.

Association of cell death mechanisms and fibrosis in visceral white adipose tissue with pathological alterations in the liver of morbidly obese patients with NAFLD.

The role of visceral white adipose tissue (vWAT) in the progression of non-alcoholic liver disease (NAFLD) with its sub entities non-alcoholic fatty liver and steatohepatitis (NAFL; NASH) is underinvestigated. We thus explored mechanisms of fibrosis and regulated cell death in vWAT and liver tissue. In NAFLD, women displayed significantly more fibrosis in vWAT than men, and collagen 1α mRNA expression was significantly upregulated. The degrees of fibrosis in vWAT and liver tissue correlated significantly. The size of vWAT-resident adipocytes in NAFLD correlated negatively with the local degree of fibrosis. The extent of apoptosis, as measured by circulating M30, positively correlated with the degree of fibrosis in vWAT; necrosis-associated HMGB1 mRNA expression was significantly downregulated in vWAT and liver tissue; (iii) necroptosis-related RIPK-3 mRNA expression was significantly upregulated in vWAT; and autophagy-related LC3 mRNA expression was significantly downregulated in vWAT, while upregulated in the liver. Thus, the different cell death mechanisms in the vWAT in NAFLD are regulated independently while not ruling out their interaction. Fibrosis in vWAT may be associated with reduced adipocyte size and thus partially protective against NAFLD progression.Abbreviations: ATG5: autophagy related 5; BAS: bariatric surgery; BMI: body mass index; ELISA: enzyme-linked immunosorbent assay; EtOH: ethanol; FFAs: free fatty acids; HCC: hepatocellular carcinoma; HMGB1: high-mobility group box 1 protein; IHC: immunohistochemistry; IL: interleukin; LC3: microtubule-associated proteins 1A/1B light chain 3B; M30: neoepitope K18Asp396-NE displayed on the caspase-cleaved keratin 18 fragment; M65: epitope present on both caspase-cleaved and intact keratin 18; NAFL: non-alcoholic fatty liver; NAFLD: non-alcoholic fatty liver disease; NAS: NAFLD activity score; NASH: non-alcoholic steatohepatitis; NLRP3: nucleotide-binding oligomerization domain, leucine-rich repeat and pyrin domain containing 3; qRT-PCR: quantitative real-time polymerase-chain reaction; r: Pearson's correlation coefficient (r); rs: Spearman's rank correlation coefficient; RIPK3: receptor-interacting serine/threonine-protein kinase 3; T2DM: type 2 diabetes mellitus (T2DM); TUNEL: terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling; vWAT: visceral WAT; WAT: white adipose tissue.

Intraductal papillary mucinous tumors of the pancreas: biology, diagnosis, and treatment.

Pancreatic intraductal papillary mucinous neoplasms (IPMNs) rank among the most common cystic tumors of the pancreas. For a long time they were misdiagnosed as mucinous cystadenocarcinoma, ductal adenocarcinoma in situ, or chronic pancreatitis. Only in recent years have IPMNs been fully recognized as clinical and pathological entities, although their origin and molecular pathogenesis remain poorly understood. IPMNs are precursors of invasive carcinomas. When resected in a preinvasive state patient prognosis is excellent, and even when they are already invasive, patient prognosis is more favorable than with ductal adenocarcinomas. Subdivision into macroscopic and microscopic subtypes facilitates further patient risk stratification and directly impacts treatment. There are main duct and branch duct IPMNs, with the main duct type including the intestinal, pancreatobiliary, and oncocytic types and the branch duct type solely harboring the gastric type. Whereas main duct IPMNs have a high risk for malignant progression, demanding their resection, branch duct IPMNs have a much lower risk for harboring malignancy. Patients with small branch duct/gastric-type IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance.

Amplification of the urokinase-type plasminogen activator receptor (uPAR) gene in ductal pancreatic carcinomas identifies a clinically high-risk group.

The serine protease urokinase-type plasminogen activator (uPA) and its receptor (uPAR) are known to be involved in the invasion and metastasis of many solid tumors. In this study, we analyzed the role of the uPAR/uPA system in both the development and progression of pancreatic cancer in invasive ductal adenocarcinomas of the pancreas (PDA) and their premalignant precursors (PanIN lesions) in 50 patients with long-term clinical follow-up. We found overexpression of the uPAR in 48 of 50 invasive carcinomas as well as in a large proportion of high-grade PanIN lesions by immunohistochemistry and in situ hybridization. Fluorescence in situ hybridization analysis showed both high- and low-level amplification of the uPAR gene in approximately 50% of cases with strictly identical patterns between invasive cancers and their accompanying precursor lesions. These results suggest that PDA may develop from PanIN lesions along an alternative rather than a sequential molecular pathway. The detection of the gene amplification of uPAR was a highly significant, adverse prognostic parameter (P < 0.001) because it likely renders the tumors more sensitive to uPA and its proproliferative and anti-apoptotic signals. We conclude that the activation of the uPAR/uPA system is an early event in the development of PDA and that uPAR gene amplifications identify a subgroup of particularly aggressive tumors, making the uPAR/uPA system a critical and highly promising target for therapeutic interventions.

Risk-adapted anastomosis for partial pancreaticoduodenectomy reduces the risk of pancreatic fistula: a pilot study.

BACKGROUND: Pancreatic fistula (PF) is the main cause of postoperative morbidity and mortality after pancreatectomy. Two reasons for PF are a "soft" pancreatic texture and a narrow pancreatic duct (high-risk gland). Pancreaticojejunostomy (PJ) may lead to a higher fistula rate in such glands. In the literature there are no data available on risk-adapted assignment of pancreatogastrostomy (PG) in a high-risk gland. Therefore, an observational pilot study was conducted to address this issue. METHODS: Since January 2007 the concept of a "risk-adapted pancreatic anastomosis" (RAP) was introduced (PG for high-risk glands). The PF rate, morbidity, and mortality during this period (January 2007 to December 2008, n = 74) were compared to those between January 2004 and December 2006 (n = 119, only PJ). PF was defined according to the International Study Group on Pancreatic Surgery. RESULTS: Through RAP the PF rate was reduced from 22 to 11% (P = 0.0503). Grade C PF rate was reduced from 6.7 to 1.4% (P = 0.1569) and grade A PF from 6 to 1.4% (P = 0.2537). The PF-associated mortality was reduced from 3.4 to 1.4%. PG revealed a PF rate of 7% and PJ accounted for 19% of PFs (P = 0.1765). There was no incidence of grade C PF following PG. The incidence of intraluminal hemorrhage (P = 0.0422) and delayed gastric emptying (P = 0.0572) was higher following PG. CONCLUSIONS: The rate of PF could be significantly reduced with the use of RAP. One should be cautious about the indication for PG, since it is associated with a higher rate of intraluminal hemorrhage and delayed gastric emptying. There are no long-term results on PG with respect to its durability and function. A general recommendation for its use cannot currently be made.