[Sealing of the hepatic resection area using hemostat devices does not improve results of adequate surgery]. / Versiegelung der Leberresektionsfläche mit Gewebsklebematerialien bewirkt keine weitere Verbesserung adäquater Chirurgie.

PURPOSE: In hepatic resections, there has been a high quality demand. The aim of this systematic clinical, prospective, unblinded unicenter observational study with two arms in an unselected patient cohort was to investigate whether hemostat device can significantly improve outcome in resective liver surgery, in particular, in high risk patients. METHODS: All consecutive patients (mean age, 60.5 [range, 17 - 96] years) who underwent hepatic resection (ntotal = 770) were prospectively documented in a computer-based registry at a university hospital (tertiary center) over a time period of 10 years and retrospectively evaluated specifically with regard to the use (-/+; in daily practice and intraoperative decision-making) of hemostat device (Tissucol(®), n = 59/Tachocomb(®), n = 202/combination, n = 55) indicated (among others) by drainage volume, inflammatory parameters and rate of specific complications (nvalidated = 541 [100 %]). RESULTS: Most frequently, (a-)/typical segmental resections were used: n = 192/90 (3-segment resection, only n = 38). 1) For the assignment of patients to the two different groups (-/+ hemostat device), weight loss and type of resection were found as significant factors (trend: ASA, cirrhosis), for the amount of drainage volume, ASA, sex, Karnofsky Performance Scale and also type of resections using independent distributed statistical tests (such as χ(2), U test [Mann/Whitney]; H test [Kruskal-Willis]; correlation coefficient by Spearman) - no impact: smoking, diabetes, BMI, ethanol. 2) Not taking into account these parameters, the use of hemostat device was characterized by an increased drainage volume (negative control < Tissucol = Tachocomb < combination). 3) Using multifactorial analysis of variance, it was found even under correction by the factors with significant impact elucidated in the single test that the application of hemostat device onto the hepatic resection area resulted unexpectedly rather in an increase than a decrease of the drainage volume but 4) under accompanying more pronounced increase of the white blood cell count (leucocytosis). 5) General and specific complications such as postoperative bleeding, biliary fistula and subhepatic abscess were not further lowered in a significant manner using hemostat device. CONCLUSION: Adequate surgery in the operative management of hepatic resection area cannot further be improved or optimized using hemostat device. In this context, drainage volume may not be considered a sufficient rather an orienting parameter. However, there is an inflammatory response detectable most likely indicated by a(n un-)specific effusion and increase of white blood cell count, which can be interpreted as a) being characteristic for the problematic group of patients, in whom hemostat device was decided to be useful and was finally used in daily prectice, or b) reactive inflammation to foreign material.

[Antibiotic Consumption and the Development of Antibiotic Resistance in Surgical Units]. / Antibiotikaverbrauch und Resistenzentwicklung in der Chirurgie.

BACKGROUND: Antibiotic resistence is increasing worldwide. AIM: A longitudinal analysis of the influence of the density of antibiotic use on the development of resistance in surgical units was undertaken. MATERIAL AND METHODS: Over five years the incidence of pathogens and the resistance rates of isolates from patients of normal surgical units and those of a surgical ICU at a university hospital were examined. The resistence rates were correlated with the density of antibiotic use - calculated from the antibiotic consumption (in DDD) and the number of patient-days. RESULTS: At both units, Enterobacteriaceae and Enterococci were mostly cultured. Among the Enterobacteriaceae, E. coli, Klebsiella spp., Proteus mirabilis and Enterobacter predominated. In the group of Enterococci, E. faecalis predominated at wards whereas at ICU E. faecium was the most frequent. Anaerobes ranked third at normal wards and Candida spp. at ICU. From 2007 to 2011, there was an increasing resistance against ciprofloxacin in P. mirabilis (r = 0.87; p = 0.054) and against imipenem (r = 0.86; p = 0.06) and piperacillin (r = 0.81; p = 0.09) in P. aeruginosa at normal wards. At ICU, the resistance rates of imipenem in P. aeruginosa rose (r = 0.88; p = 0.049). Resistance against ciprofloxacin in E. coli increased (r = 0.65; p = 0.23). Due to the increasing use of ciprofloxacin and meropenem at normal wards, the density of antibiotic usage rose 1.4 %/year (r = 0.94; p = 0.02). Despite the increase of meropenem use at ICU (r = 0.9; p = 0.035), the total antibiotic uptake rate remained almost constant. The antibiotic usage density was 3-fold higher at ICU than at normal wards. At normal wards, the ciprofloxacin usage correlated with the rate of resistance against ciprofloxacin in P. mirabilis P. m. At ICU, an association was detected between the uptake rate of ceftazidime and the rate of resistance against cefotaxime in the CES group. In P. aeruginosa, the use of piperacillin and the rate of resistance against piperacillin correlated. CONCLUSION: The high uptake rates of fluoroquinolones and carbapenems were accompanied by increases in resistances. The resistance rates are influenced by hygiene management and microbiological diagnostics. The extensive use of carbapenems should be reassessed on both units to counter further development of antibiotic resistance.

[Current Situation of Antibiotic Prophylaxis in Obesity and Metabolic Surgery - Data Analysis from the Study for Quality Assurance in Operative Treatment of Obesity in Germany]. / Aktueller Stand der Antibiotikaprophylaxe in der Adipositas- und metabolischen Chirurgie - Datenanalyse aus der Studie zur Qualitätskontrolle der operativen Therapie der Adipositas in Deutschland.

BACKGROUND: Since January 2005, the situation of metabolic and obesity surgery in Germany has been constantly evaluated by the German Bariatric Surgery Registry (GBSR). Data registration is performed using an internet online database with prospective data collection. All registered data were analysed in cooperation with the Institute of Quality Assurance at the Otto-von-Guericke University Magdeburg. METHODS: Data collection includes primary and revision/redo-procedures. A main focus of the current study is the analysis of data regarding the perioperative management, in particular, administration of antibiotics. RESULTS: Since 2005 a significant increase of primary bariatric procedures has been reported. For evaluation of the antibiotic regimen 12 296 primary operations including 684 balloons (BIB), 2950 gastric bandings (GB), 5115 Roux-en-Y-gastric bypasses (RYGBP), 120 Scopinaro's biliopancreatic diversions (BPD), 164 duodenal switches (DS), 3125 sleeve gastrectomies (SG) and 138 other procedures were analysed. In total 77.3 % of the patients with primary procedures received perioperative antibiotics. Patients without concomitant comorbidities received antibiotics significantly less often compared to those with comorbidities. Wound infection rates were comparable for patients who underwent either gastric banding or sleeve gastrectomy. CONCLUSION: Surgery has been accepted step by step as a treatment for morbid obesity and its comorbidities in Germany during the last few years. There is only little experience in the literature regarding antibiotic therapy as well as prophylaxis in bariatric surgery. Based on the results of the current study we recommend rather the selective than the routine use of antibiotics depending on different parameters, e.g., operative time, preoperative BMI and concomitant comorbidities.

Bariatric surgery in adolescents and young adults--safety and effectiveness in a cohort of 345 patients.

OBJECTIVE: To examine the safety and effectiveness of adolescent bariatric surgery and to improve treatment recommendations for this age group. DESIGN: Prospective longitudinal registry. Since January 2005, patients undergoing bariatric surgery in Germany are enlisted in an online registry called 'study for quality assurance in obesity surgeries'. SUBJECTS: Adolescents and young adults up to the age of 21 years, operated from January 2005 to December 2010. MEASUREMENTS: Weight, BMI, comorbidities, complication rates. RESULTS: N=345 primary procedures were recorded by 58 hospitals. N=51 patients were under the age of 18 years. Follow-up information was available for 48% (n=167) of patients, with an average observation period of 544±412 days (median: 388 days). The most common surgical techniques were gastric banding (n=118, 34.2%), gastric bypass (n=116, 33.6%) and sleeve gastrectomy (n=78, 22.6%). Short-term complications (intra-operative; general postoperative; specific postoperative) were slightly lower for gastric banding (0.8%; 2.5%; 0.8%) than for gastric bypass (2.6%; 5.2%; 1.7%) or sleeve gastrectomy (0%; 9.0%; 7.7%). In accordance with published findings, weight and BMI reduction were lower for gastric banding (-28 kg; -9.5 kg m(-2)) compared to gastric bypass (-50 kg; -16.4 kg m(-2)) P< 0.001 or sleeve gastrectomy (-46 kg; -15.4 kg m(-2)) P< 0.001. Outcomes did not differ between the <18 and ≥18-year-old patients. CONCLUSION: Like in adults, bariatric surgery has low short-term complication rates and results in sustained weight loss in adolescents. However, the missing long-term observations prohibit a final conclusion about lasting effectiveness and safety. Clinical trials with structured follow-up programs and mechanisms to ascertain patient adherences are needed.

International quality assurance project in colorectal cancer-unifying diagnostic and histopathological evaluation.

PURPOSE: Several European countries are undertaking quality control projects in colorectal cancer. These efforts have led to improvements in survival, but a comparison between different projects reveals questionable results. The aim of this study is the presentation of results from hospitals in three different European countries participating in the International Quality Assurance in Colorectal Cancer (IQACC) project. METHODS: For this publication, patients with cancer of the colon or rectum treated in 2009 and 2010 and recorded in the IQACC (Germany, Poland and Italy) were analysed. The comparison included number of patients, age, preoperative diagnostics (CT of the abdomen and thorax, MRI, colonoscopy, ultrasound, tumour markers), surgical approach, metastasis, height of rectal cancer and histopathological examination of a specimen (T stage, N stage and MERCURY classification for rectum resection). For short-term outcomes, general complications, wound dehiscence, tumour-free status at discharge, anastomotic leakage and in-hospital mortality were analysed. RESULTS: A total of 12,691 patients (6,756 with colon cancer, 5,935 with rectal cancer) were included in the analysis. Preoperative diagnostics differed significantly between countries. For pT and pN stages, several quality differences could be demonstrated, including missing stages (colon cancer: pT 5.7-12.5 %, pN 2.5-11.0 %; rectal cancer: pT 1.1-5.6 %, pN 1.1-15.5 %). The most relevant differences for short-term outcomes in colon cancer were found in general complications (4.2-22.8 %) and tumour-free status at discharge (74.5-91.7 %). In-hospital deaths ranged between 2.5 and 4.3 % and did not show significant differences. For rectal cancer, the country with the highest percentage of tumours localised less than 4 cm from the anal verge (16.0 %) showed the lowest frequency of amputation (8.5 %). Outcome differences were found for general complications (3.2-18.8 %), anastomotic leakage (0-4.3 %) and tumour-free status at discharge (72.9-87.6 %). In-hospital deaths ranged between 1.1 and 3.2 %. CONCLUSION: This study demonstrates the feasibility of an international quality assurance project in colorectal cancer. This concept ensures data analysis based on a comparable data input. Differences in preoperative diagnostics, completeness of histopathological evaluation and short-term outcomes for Germany, Poland and Italy might result from disparities in socioeconomic factors and implementation of existing guidelines. Further activities are necessary to warrant the use of common standards in outcome control.

[Collaboration of general surgeons with neurosurgeons: what does a general surgeon need to know about neurosurgery?]. / Zusammenarbeit der Neurochirurgie mit der Allgemeinchirurgie: Was muss der Allgemeinchirurg von der Neurochirurgie wissen?

BACKGROUND: The most freq+uent disorders and injuries requiring the joint attention of general surgeons and neurosurgeons are presented and analysed in this review. METHODS: The priorities and prognosis concerning diagnostic and surgical measures for patients in coma with multiple injuries, extra- and intraspinal tumours and brain metastases are analysed. RESULTS: The urgency of general surgical and neurosurgical measures is not ruled by a preformatted pattern but by the vital needs of the individual patient. CONCLUSION: The differentiation of vital from non-vital operations or with regard to prognosis necessary from inadequate general surgical and neurosurgical measures is of fundamental importance. The successive order of general surgical and neurosurgical interventions must be adjusted to the needs of each individual patient.

[Rectal cancer surgery in Germany - a 10-year-analysis based on the data of the "Institute of Quality Assurance in Operative Medicine" at the Otto-von-Guericke University Magdeburg]. / Rektumkarzinomchirurgie in Deutschland - eine 10-Jahres-Übersicht auf der Grundlage der Daten des AN-Instituts für Qualitätssicherung in der operativen Medizin gGmbH an der Otto-von-Guericke-Universität Magdeburg.

BACKGROUND: The treatment of rectal cancer has undergone pronounced changes during the last two decades. There has been a significant improvement in local tumour control due to consequent use of neo-adjuvant therapy and total mesorectal excision in cases of distal rectal cancer. The presented analysis examines the realisation of the multimodal therapy for rectal cancer under the conditions of routine patient-centred care over a period of ten years. METHOD: The data acquired in the prospective multicentre observational study "Quality Assurance - Rectal Cancer" from the years 2000 to 2010 were analysed. N = 33,724 patients were documented. The resection rate was 95.2 %. The rate of curative resection was 84.2 %. RESULTS: No change was detected in perioperative total morbidity and lethality during the course of the study. The percentage of patients with neo-adjuvant treatment and curative resection rose from 5.6 % (2000) to 40.5 % (2012). The rate of performed TME in distal rectal cancer rose from 75.2 % (2000) to 95.3 % (2012). For patients who underwent curative resection in the years 2000/2001 the 5-year local recurrence rate was 11.7 %, while it was found to be 4.6 % for patients who were thus treated in the years 2005/2006 (p < 0.001). There was no improvement of total survival. CONCLUSION: While an increase in the use of neo-adjuvant treatment for rectal cancer and the establishment of TME in routine patient-centred care have led to a significant improvement in local tumour control with a constant total morbidity and lethality, there is no detectable influence on the patients' total survival.

[Quality assurance in colorectal cancer in Europe AD 2011]. / Qualitätssicherung beim kolorektalen Karzinom in Europa AD 2011.

INTRODUCTION: Malignant tumours are the second largest cause of death in Europe. Colorectal cancer takes second place within this group and is responsible for every eighth tumour-related death. CURRENT SITUATION: Surgical quality assurance requires a prospective observational study, any different type of study is not possible. A complete recording of all treated patients is a prerequisite for quality assurance. Currently, there are quality assurance programmes in Sweden, Norway, Denmark, Great Britain, Spain, Belgium, the Netherlands as well as the multinational study for patients from Germany, Poland and Italy. These projects deliver comprehensive information regarding the treatment of colorectal cancer. However, this information is deeply rooted in the organisation of the health-care system in the given country and is not easily transferable into international settings. Also, an interpretation of the collected data is often possible only within the given health-care system. FUTURE PERSPECTIVES: First, unified initial diagnostics is a prerequisite for quality assurance -  for the local extent and exclusion / confirmation of distant metastases. Until these criteria are unified, any comparison is limited, including a comparison of survival. Second, quality-of-life is not recorded in any of the current projects. Third, the main focus of a quality assurance project must be on therapy-dependent factors. The most sensible method of quality control remains within the connection of preoperative diagnostics (estimate of a best-case scenario), the surgical technique (the actual result) and a standardised pathological examination (evaluation of the actual result). These parameters can be recorded and compared within a quality assurance project regardless of the limitations of the national health-care systems. There is no alternative to a unified diagnostics model and unified histopathological evaluation, a complete picture of treatment quality is also not possible without systematic analysis of the quality of life.

[Influence of mucinous and signet-ring cell differentiation on epidemiological, histological, molecular biological features, and outcome in patients with colorectal carcinoma]. / Einfluss des muzinösen und siegelringzelligen Subtyps auf epidemiologische, histologische und molekularbiologische Eigenschaften sowie auf die Prognose des kolorektalen Karzinoms.

BACKGROUND: Colorectal cancer (CRC) is one of the most common malignancies in the Western world. Histopathologically, adenocarcinomas are mostly diagnosed. Mucinous and signet-ring cell subtypes occur with a very low incidence. However, these subtypes differ remarkably in terms of clinical, histological and molecular biological characteristics. The aim of this review is to present a detailed analysis of current knowledge regarding differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC along with potential consequences for daily practice. METHODS: For this report all articles with relevant information on differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC found via Pubmed searches were analysed. Furthermore, findings of our previous study were included. RESULTS: Mucinous CRC occur with a reported incidence of 10 - 20 % in Western countries and are predominantly found in younger patients and females. They are more often diagnosed in the proximal colon and present with a higher stage at diagnosis. Furthermore, there is a higher rate of lymph node-positive tumours and peritoneal carcinomatosis. Results of molecular biological studies confirm that they may represent a different tumour entity. The response to well established chemotherapy regimens is poorer which may be attributed to the higher rate of microsatellite-instable tumours and an increased mucin secretion. The poorer outcome is likely related to the higher stage at the time of diagnosis. Signet-ring cell type CRC are rare with an incidence ranging between 0,9 % to 4 %. They are also more common in the right colon and are associated with a poorer outcome compared to adenocarcinoma and mucinous CRC. CONCLUSIONS: However, it should be noted that most of the results come from studies with a very low number of patients which can be attributed to the low incidence of mucinous and signet-ring cell CRC. Based on the findings of the present analysis, a more radical surgical approach should be considered providing that the exact preoperative histology is available. Furthermore, the histological subtype should be taken into account in future chemotherapy trials to avoid unnecessary therapy. A closer follow-up, especially for patients with signet-ring cell CRC should be discussed. In the near future, a more tailored therapy in patients with colorectal cancer would be highly desirable.

[Surgical treatment of carcinomas of the oesophagogastric junction - results achieved in multicentre studies]. / Multizentrische Ergebnisse der chirurgischen Therapie der Karzinome des ösophagogastralen Übergangs.

BACKGROUND: Adenocarcinomas of the oesophagogastric junction are increasingly being considered as a separated tumour entity. The prognosis is rather poorer compared with that for distal gastric cancer. Data from a multicentre study as part of research on clinical care aim to reflect the current situation in surgical treatment after inauguration of neoadjuvant modalities. PATIENTS AND METHOD: As part of the ongoing prospective multicentre observational study QCGC 2 (German Gastric Cancer Study 2), 544 adenocarcinomas of the oesophagogastric junction (AEG 1-3) were registered from 01/01/2007 to 12/31/2009. RESULTS: Patients underwent surgical intervention in 108 (76.6 %) of the 141 surgical departments which provided data to the study. In 391 patients (82.5 %), R0 resection was achieved. Almost 60 % of the carcinomas of the oesophagogastric junction were approached in departments with no more than 10 of these tumour lesions through the whole study period (3 years). Endoscopic ultrasonography was performed in 283 cases (53 %); the rate of neoadjuvant treatment was 34.4 % (n = 187). Intraoperative fresh frozen section was only included in intraoperative decision-making in 242 patients (60.8 %). In the revealed heterogeneous spectrum of surgical interventions, a limited number of transthoracic approaches (20 %) and a mediastinal lymphadenectomy rate of only 47 % were found. Hospital lethality was 6.6 %. In the adenocarcinomas of the oesophagogastric junction, a significantly lower median survival (25 months) compared with distal gastric cancer (38 months) was observed depending on the tumour stage. In addition, 5-year survival rate of AEG patients (33.1 %) was distinctly lower than for patients with distal gastric cancer (41.4 %). There was no significantly better survival by neoadjuvant treatment in the group of investigated patients. CONCLUSION: The results in the treatment of carcinomas of the oesophagogastric junction in the multicentre setting including surgical departments of each profile and region even after introduction of multimodal therapeutic concepts are not satisfying. In particular, modern diagnostic and surgical strategies need to be widely used or their percentage has to be increased. In this context, centralisation of the surgical care of this specific tumour entity appears reasonable.

[The development process of colon cancer centres]. / Der Prozess der Entwicklung von Zentren am Beispiel des Darmkrebszentrums.

Colon carcinomas are the most common malignant tumours in the Western world. Important findings about the overall quality of medical care have been reported in multi-centre observational studies. A quality enhancement of therapeutic care can be achieved by an additional increase in diagnostic and therapeutic measures in the interdisciplinary setting. The development of colon cancer centres improves the chance to objectively observe the results of medical care induced by the development of an interdisciplinary and cross-sectoral unit that includes a comprehensive medical care for patients. The implementation of the current medical findings based on evidence in clinical routine, the inspection of the usage of guidelines by external specialists as part of an audit and the continuous correction of analysed deficits in the course of treatment guarantee a continuous improvement of service.

[Implications of nutritional status for onset and characteristics of experimental acute pancreatitis in a mouse model]. / Auswirkungen des Ernährungszustands auf die Ausprägung einer experimentellen akuten Pankreatitis der Maus.

BACKGROUND: Due to uncontrolled activation of digestive enzymes produced within the pancreas, acute pancreatitis is a disease with a great potential for complications and variable course. Since the pathophysiological steps of human pancreatitis can only be inadequately investigated, various animal models were established to study the course of disease. The model of supramaximal caerulein stimulation allows to gain insights into intracellular events of the early phase of acute pancreatitis. Usually, overnight fasted animals are used for the model of acute pancreatitis to achieve a maximum zymogen granula accumulation and a standardised initial situation due to diminished secretion of CCK. Furthermore, the role of the nutritional state for pathogenesis and course of acute pancreatitis is controversially discussed. The aim of the study was to investigate the impact of the nutritional status on pancreatic injury in experimental acute pancreatitis. METHODS: Using standardised supramaximal caerulein stimulation (dose: 50 µg/kg; time intervals, 1/h; max. 7×), acute oedematous interstitial pancreatitis in fasted and non-fasted mice was induced. Pancreatic injury was locally characterised by pancreatic oedema, histopathological alterations and the release of pancreatic enzyme to the serum while systemic alterations were objectified by IL-6, CRP und pulmonal MPO. RESULTS: 1) Increased pancreatic serum enzyme levels after induction of acute pancreatitis in non-fasted animals do not reflect a greater affection of the pancreas since amylase and lipase in serum and pancreatic tissue correlate proportionally. The induction of acute pancreatitis provoked release of 1.3 % and 0.7 % of amylase and lipase, respectively, independently of nutritional status. 2) Neither local nor systemic parameters of pancreatic injury were significantly altered by the nutritional regimen. Pathohistologic investigations revealed increase of zymogen granula portion and cell size in non-fasted mice but no further differences compared with fasted animals. 3) During a 16-hour recovery period (no further caerulein injection), local and systemic parameters normalised. DISCUSSION: In the relatively mild model of pancreatitis induced by hormonal hyperstimulation, there was no greater pancreatic injury despite higher intrapancreatic enzyme accumulation in non-fasted animals indicating a steady state between potentially damaging and protective factors and mechanisms.

[Acute appendicitis - clinical health-service research on the current surgical therapy]. / Akute Appendizitis - Klinische Versorgungsforschung zur aktuellen chirurgischen Therapie.

INTRODUCTION: With about 135,000 operations every year appendectomy is one of the most frequent surgical operations in Germany. Acute appendicitis has shown changes in diagnosis and therapy with time. The status of the laparoscopic appendectomy has had to be redefined recently. The aim of this study was to make an analysis of the current surgical therapy for appendicitis and the individual procedures. PATIENTS AND METHODS: Three prospective multi-centre quality assurance studies (1988 / 89, 1996 / 97; 2008 / 09) of the "An-Institut" acquired 17,732 treatments from all supply levels of Germany. RESULTS: The average age of patients increased within of the three studies from 25.7 to 34.6 years. Within the studies in 1996 / 97 and in 2008 / 09 the share of laparoscopic appendectomy advanced from 33.1 to 85.8 percent. In the study from 2008 / 09 the laparoscopic appendectomy showed a significant advantage over the conventional technique in terms of wound-healing disturbances (p < 0.001) and a clinical duration of stay (p < 0.001). At no stage of the appendix inflammation did the laparoscopic appendectomy lead to a significant increase of intraabdominal abscesses. Compared with the conventional technique the operating time was shorter (46.6 min vs. 53.5 min). Currently the use of a stapler is the mostly frequently applied method of appendiceal stump closure (83.6 percent). CONCLUSION: The laparoscopic appendectomy is the most common method of current operative therapy. In comparison to former publications, there is no proof of any disadvantages of laparoscopic appendectomy.

[New data on quality assurance in bariatric surgery in Germany]. / Aktuelle Daten der Qualitätssicherungsstudie für operative Therapie der Adipositas in Deutschland.

BACKGROUND: Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg. METHODS: The voluntary data registration occurs in an internet online data bank. All primary bariatric procedures as well as re- and redo-procedures are documented. Follow-up data were collected once a year. Participation in the quality assurance study is obligatory for certificated centres. RESULTS: Since 2005 13,879 bariatric procedures have been performed at 83 hospitals. The number of primary procedures has increased from 596 in 2005 to 11,835 in 2010. Revisional surgery has been performed in 1,438 patients since 2005. Sleeve gastrectomy (SG) is the major procedure with 1,564 operations in 2010. The mean BMI was 48.8 kg/m². The incidence of comorbidities was 84.8%. CONCLUSION: Bariatric surgery has become more accepted in Germany. Beside the Roux-en-Y gastric bypass, sleeve gastrectomy is the most frequently performed operation. BMI and incidence of comorbidities are still high in comparison with literature values. Due to the lack of evidence, more randomised studies are necessary to standardise operative techniques and evaluate patient selection criteria. Quality assurance studies support a detailed analysis of these parameters.

Mismatch repair deficiency, chemotherapy and survival for resectable gastric cancer: an observational study from the German staR cohort and a meta-analysis.

PURPOSE: In a post hoc analysis of the MAGIC trial, patients with curatively resected gastric cancer (GC) and mismatch repair (MMR) deficiency (MMRd) had better median overall survival (OS) when treated with surgery alone but worse median OS when treated with additional chemotherapy. Further data are required to corroborate these findings. METHODS: Between April 2013 and December 2018, 458 patients with curatively resected GC, including cancers of the esophagogastric junction Siewert type II and III, were identified in the German centers of the staR consortium. Tumor sections were assessed for expression of MLH1, MSH2, MSH6 and PMS2 by immunohistochemistry. The association between MMR status and survival was assessed. Similar studies published up to January 2021 were then identified in a MEDLINE search for a meta-analysis. RESULTS: MMR-status and survival data were available for 223 patients (median age 66 years, 62.8% male), 23 patients were MMRd (10.3%). After matching for baseline clinical characteristics, median OS was not reached in any subgroup. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd and MMRp had a HR of 0.67 (95% CI 0.13-3.37, P = 0.63) and 1.44 (95% CI 0.66-3.13, P = 0.36), respectively. The meta-analysis included pooled data from 385 patients. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd had an improved OS with a HR of 0.36 (95% CI 0.14-0.91, P = 0.03), whereas those with MMRp had a HR of 1.18 (95% CI 0.89-1.58, P = 0.26). CONCLUSION: Our data support a positive prognostic effect for MMRd in GC patients treated with surgery only and a differentially negative prognostic effect in patients treated with perioperative chemotherapy. MMR status determined by preoperative biopsies may be used as a predictive biomarker to select patients for perioperative chemotherapy in curatively resectable GC.

Factors influencing the quality of total mesorectal excision.

BACKGROUND: Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence. METHODS: Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME. RESULTS: From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality. CONCLUSION: TME quality was influenced by patient- and treatment-related factors.

Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009.

AIM: The goal of this registry study was to compare open surgery with planned laparoscopy and then with laparoscopic to open conversion for rectal cancer surgery. METHOD: The study included 17,964 rectal cancer patients, operated on between 1 January 2000 and 31 December 2009, from 345 hospitals in Germany. All statistical tests were two-sided, with the χ(2) test (Pearson correlation) for patients and tumour characteristics. Fisher's exact test was used for complications and 30-day mortality. RESULTS: Of the 17,964 rectal cancer patients, 16,308 (90.8%) had an open procedure and 1656 (9.2%) were started with a laparoscopy. The 1455 patients with completed laparoscopic operations had fewer intra-operative and postoperative complications (5.4%vs 7.0%, P = 0.020, and 20.5%vs 25.8%, P < 0.001, respectively) and a lower 30-day mortality rate (1.1%vs 1.9%, P = 0.023). Of the 1656 planned laparoscopies, 201 (12.1%) were converted to open. The converted group suffered more intra-operative complications (18.9%vs 3.6% for completed laparoscopy and 7.0% for open surgery, P < 0.0001) and postoperative complications (32.3%vs 18.9% for completed laparoscopy and 25.8% for open operations, P < 0.0001). The converted group also had a higher 30-day mortality rate (2.0%vs 1.0% for completed laparoscopy and 1.9% for open surgery, P = 0.043). CONCLUSION: The more favourable patient profile provided justification for a laparoscopic procedure. For those converted to an open procedure, however, there were significantly more complications than planned open surgery patients. A move away from the standard open procedure for rectal cancer surgery and towards laparoscopy is not yet feasible.

[Phytobezoar in the common hepatic duct - rare cause of obstructive jaundice following pancreatoduodenectomy: case report and review of the literature]. / Phytobezoar des Ductus hepaticus communis - seltene Differenzialdiagnose einer Cholestase im Langzeitverlauf nach Kausch-Whipple-Operation: Fallbericht und Literaturübersicht.

Obstruction of bile flow following pancreatoduodenectomy can be caused by stenosis of the hepaticojejunostomy created at the time of surgery, obstruction of the bile-draining jejunal loop, stones or, very rarely, ingested foreign bodies in the common hepatic duct. In analogy with endoscopic sphincterotomy or the once popular side-to-side-choledochduodenostomy, the creation of a hepaticojejunostomy eliminates the barrier of the sphincter Oddi, enabling intestinal content such as ingested foreign bodies or food fibers to migrate into the bile duct. We report on the case of a patient developing biliary tract obstruction due to fibrous material in the common hepatic duct 15 years after pancreatoduodenectomy. In addition, an overview of the literature on the rare phenomenon of foreign body-associated obstructive jaundice is given.

Endorectal ultrasound in rectal carcinoma--do the literature results really correspond to the realities of routine clinical care?

BACKGROUND AND STUDY AIMS: This multicenter, prospective, country-wide quality-assurance study at more than 300 hospitals in Germany was designed to characterize and analyze the diagnostic accuracy of rectal endoscopic ultrasound (EUS) in the routine clinical staging of rectal carcinoma (depth of tumor infiltration). PATIENTS AND METHODS: Patients were surveyed between 1 January 2000 and 31 December 2008. Those who received neoadjuvant therapy after EUS were excluded. The correspondence between the EUS assessment of tumor depth (uT) and that determined by histology (pT) was calculated, and the influence of hospital volume upon the sensitivity, specificity, and positive and negative predictive values was investigated. RESULTS: At 384 hospitals providing care at all levels, 29 206 patients were included; of the 27 458 treated by surgical resection, EUS was performed for 12 235 (44.6 %). Of these, 7096 did not receive neoadjuvant radiochemotherapy, allowing a uT-pT comparison. The uT-pT correspondence was 64.7 % (95 % confidence interval [CI] 63.6 % - 65.8 %); the frequency of understaging was 18 % (95 %CI 17.1 % - 18.9 %) and that of overstaging was 17.3 % (95 %CI 16.4 % - 18.2 %). The kappa coefficient was greatest in the category T1 (κ = 0.591). For T3 tumors κ was 0.468. The poorest correspondence was found for T2 and T4 tumors (κ = 0.367 and 0.321, respectively). A breakdown by hospital volume showed that the uT-pT correspondence was 63.2 % (95 %CI 61.5 % - 64.9 %) for hospitals undertaking ≤ 10 EUS/year, 64.6 % (95 %CI 62.9 % - 66.2 %) for doing 11 - 30 EUS/year, and 73.1 % (95 %CI 69.4 % - 76.5 %) for those hospitals performing > 30 EUS/year. CONCLUSIONS: In clinical routine, the diagnostic accuracy of transrectal ultrasound in staging rectal carcinoma does not attain the very good results reported in the literature. Only in the hands of diagnosticians with a large case volume of rectal carcinoma patients can EUS lead to therapy-relevant decisions.

Quality assessment of colorectal cancer care: an international online model.

AIM: We present an alternative approach to quality assessment in colorectal cancer, enabling a direct comparison of improvement at the level of the care provider. METHOD: In 2000, a quality assessment project in colorectal cancer in Germany was started. Data were provided for every patient treated for colorectal cancer. The enrolment questionnaire described patient data, risk factors, reason for hospitalization, diagnostics prior to surgery, surgical procedures, intraoperative complications, general and surgical complications in postoperative period, pathological report and discharge status. RESULTS: From 2000 to 2007, there were 57 429 patients included in the study. The total number of 372 hospitals that took part in the project varied from 153 to 281 per year. The overall resection rate for colon cancer was 97.1% and 94.8% for rectal cancer. Although the localization of rectal tumours did not vary, the percentage of abdominoperineal excisions fell from 26.1% in 2000 to 21.3% in 2008 (P < 0.001). Hospital mortality for colon cancer varied between 3.2% and 4.2% (P Pearson chi-square 0.032, linear-by-linear 0.257) and for rectal cancer between 2.7% and 3.7% (P Pearson chi-square 0.233). Patient age was not related to in-hospital mortality. CONCLUSION: The proposed model of quality assessment shows validity and results comparable to population-based studies. It does not require support from the health care system, making its implementation possible in every hospital worldwide.