Falciform ligament wrap for prevention of gastroduodenal artery bleed after pancreatoduodenectomy.

BACKGROUND: The present study aims to assess the effectiveness and current evidence of a pedicled falciform ligament wrap around the gastroduodenal artery stump for prevention of erosion hemorrhage after pancreatoduodenectomy (PD). METHODS: Retrospective data were pooled for meta-analysis. At the own center, patients who underwent PD between 2012 and 2015 were retrospectively analyzed based on the intraoperative performance of the wrap. A systematic literature review and meta-analysis was performed that combined the published and the obtained original data. The following databases were searched: Medline, Embase, Web of Science, and the Cochrane Library. RESULTS: At the own center, a falciform ligament wrap was performed in 39 of 196 PDs (20%). The wrap group contained more ampullary neoplasms, but the pancreatic fistula rate was not significantly different from the nonwrap group (28% versus 32%). In median, erosion hemorrhage occurred after 21.5 d, and it was lethal in 39% of the patients. Its incidence was not significantly lower in the wrap group (incidence: 7.7% versus 9.6% in the nonwrap group). The systematic literature search yielded four retrospective studies with a high risk of bias; only one study was controlled. When the five data sets of published and own cases with a falciform ligament wrap were pooled, the incidence of erosion hemorrhage was 5 of 533 cases (0.9%) compared with 24 of 297 cases (8.1%) without the wrap. CONCLUSIONS: The reported incidence of erosion hemorrhage after the falciform ligament wrap is low, but there are still insufficient controlled data to support its general use.

Prominin-1 allows prospective isolation of neural stem cells from the adult murine hippocampus.

Prominin-1 (CD133) is commonly used to isolate stem and progenitor cells from the developing and adult nervous system and to identify cancer stem cells in brain tumors. However, despite extensive characterization of Prominin-1(+) precursor cells from the adult subventricular zone, no information about the expression of Prominin-1 by precursor cells in the subgranular zone (SGZ) of the adult hippocampus has been available. We show here that Prominin-1 is expressed by a significant number of cells in the SGZ of adult mice in vivo and ex vivo, including postmitotic astrocytes. A small subset of Prominin-1(+) cells coexpressed the nonspecific precursor cell marker Nestin as well as GFAP and Sox2. Upon fluorescence-activated cell sorting, only Prominin-1/Nestin double-positive cells fulfilled the defining stem cell criteria of proliferation, self-renewal, and multipotentiality as assessed by a neurosphere assay. In addition, isolated primary Prominin-1(+) cells preferentially migrated to the neurogenic niche in the SGZ upon transplantation in vivo. Finally, despite its expression by various stem and progenitor cells, Prominin-1 turned out to be dispensable for precursor cell proliferation in vitro and in vivo. Nevertheless, a net decrease in hippocampal neurogenesis, by ∼30% was found in Prominin-1 knock-out mice, suggesting other roles in controlling adult hippocampal neurogenesis. Remarkably, an upregulation of Prominin-2 was detected in Prominin-1-deficient mice highlighting a potential compensatory mechanism, which might explain the lack of severe symptoms in individuals carrying mutations in the Prom1 gene.

Beliefs about stress moderate the association between COVID-19-related work demands and burnout symptoms in physicians.

The present study set out to investigate the role of different stress beliefs (positive and negative beliefs about stress, as well as perceived control) on the association between central COVID-19-related work demands and burnout symptoms in physicians during the second lockdown of the SARS-CoV-2 pandemic. N = 154 practicing physicians (mean [SD] age = 37.21 [9.43] years]; 57.14% female) participated in our cross-sectional German-wide online survey and answered questions about sociodemographic factors, their current work situation, their stress beliefs, and their current burnout symptoms. Moderation analyses revealed significant interaction effects between stress beliefs and specific COVID-19-related work demands on the prediction of burnout symptoms, most consistent with respect to perceived control. Positive believes about stress and its controllability were cross-sectional associated with reduced, negative believes about stress however with enhanced associations between COVID-19-related work demands and burnout symptoms. This finding indicates, if confirmed by longitudinal research, the potential of the usage of stress beliefs in prevention programs for physicians in order to mitigating negative effects of chronic stress.

[The digital operating room : Chances and risks of artificial intelligence]. / Der digitale Operationssaal : Chancen und Risiken künstlicher Intelligenz.

At the central workplace of the surgeon the digitalization of the operating room has particular consequences for the surgical work. Starting with intraoperative cross-sectional imaging and sonography, through functional imaging, minimally invasive and robot-assisted surgery up to digital surgical and anesthesiological documentation, the vast majority of operating rooms are now at least partially digitalized. The increasing digitalization of the whole process chain enables not only for the collection but also the analysis of big data. Current research focuses on artificial intelligence for the analysis of intraoperative data as the prerequisite for assistance systems that support surgical decision making or warn of risks; however, these technologies raise new ethical questions for the surgical community that affect the core of surgical work.

Pancreatoduodenectomy with or without prophylactic falciform ligament wrap around the gastroduodenal artery stump for prevention of pancreatectomy hemorrhage.

BACKGROUND: The purpose of this study is to evaluate whether wrapping of the pedicled falciform ligamentum flap around the gastroduodenal artery (GDA) stump/hepatic artery can significantly decrease the incidence of erosion hemorrhage after pancreatoduodenectomy (PD). METHODS/DESIGN: This is a randomized controlled multicenter trial involving 400 patients undergoing PD. Patients will be randomized into two groups. The intervention group consists of 200 patients with a prophylactic wrapping of the GDA stump using the pedicled falciform ligament. The control group consists of 200 patients without the wrap. The primary endpoint is the rate of postoperative erosion hemorrhage of the GDA stump or hepatic artery within 3 months. The secondary endpoints are postpancreatectomy hemorrhage stratified according to the texture of the pancreas, postoperative pancreatic fistula (POPF), postoperative rate of therapeutic interventions, morbidity, and mortality. DISCUSSION: Only few retrospective studies investigated the effectiveness of a falciform ligament wrap around the GDA for prevention of erosion hemorrhage. Erosion hemorrhage occurs in up to 6-9% of cases after PD and is most frequently evoked by a POPF. Erosion hemorrhage is associated with a remarkable mortality of over 30%. The rate of hemorrhage after performing the wrap is reported to be low. However, there exist no prospectively controlled data to support its general use. Therefore, the presented randomized controlled trial will provide clinically relevant evidence of the effectiveness of the wrap with statistical significance. TRIAL REGISTRATION: clinicaltrials.gov, NCT02588066 ; Registered on 27 October 2015.

Use of activity tracking in major visceral surgery-the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. "Early mobilization" is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands. METHODS/DESIGN: Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity. DISCUSSION: Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02834338 . Registered on 15 June 2016.