Effect of artificial or autologous coverage of the pancreatic remnant or anastomosis on postoperative pancreatic fistulas after partial pancreatectomy: meta-analysis of randomized clinical trials.

BACKGROUND: Postoperative pancreatic fistulas remain a driver of major complications after partial pancreatectomy. It is unclear whether coverage of the anastomosis or pancreatic remnant can reduce the incidence of postoperative pancreatic fistulas. The aim of this study was to evaluate the effect of autologous or artificial coverage of the pancreatic remnant or anastomosis on outcomes after partial pancreatectomy. METHODS: A systematic literature search was performed using MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) up to March 2024. All RCTs analysing a coverage method in patients undergoing partial pancreatoduodenectomy or distal pancreatectomy were included. The primary outcome was postoperative pancreatic fistula development. Subgroup analyses for pancreatoduodenectomy or distal pancreatectomy and artificial or autologous coverage were conducted. RESULTS: A total of 18 RCTs with 2326 patients were included. In the overall analysis, coverage decreased the incidence of postoperative pancreatic fistulas by 29% (OR 0.71, 95% c.i. 0.54 to 0.93, P < 0.01). This decrease was also seen in the 12 RCTs covering the remnant after distal pancreatectomy (OR 0.69, 95% c.i. 0.51 to 0.94, P < 0.02) and the 4 RCTs applying autologous coverage after pancreatoduodenectomy and distal pancreatectomy (OR 0.53, 95% c.i. 0.29 to 0.96, P < 0.04). Other subgroup analyses (artificial coverage or pancreatoduodenectomy) showed no statistically significant differences. The secondary endpoints of mortality, reoperations, and re-interventions were each affected positively by the use of coverage techniques. The certainty of evidence was very low to moderate. CONCLUSION: The implementation of coverage, whether artificial or autologous, is beneficial after partial pancreatectomy, especially in patients undergoing distal pancreatectomy with autologous coverage.

Career goals of surgeons in Switzerland.

PURPOSE: Recent studies from the United States and Germany have shown a general decline in the number of surgical residents, as trainees increasingly prioritize a positive work-life balance. The current study sought to evaluate the career goals of surgeons in Switzerland. METHODS: Members of the Swiss College of Surgeons, being surgical consultant or attending regardless of specialty, were surveyed online as to their purported career goals, future employment ideals, aspired leadership positions, and managerial training. RESULTS: A total of 269 questionnaires were analysed. Most participants (93%) were board- certified and 30% of participants were female. With regard to desired specialty, 50% of participants intended to pursue a career in visceral surgery followed by general surgery, traumatology, hand and plastic surgery, vascular surgery and thoracic surgery. Regardless of specialty, 53% of respondents strived for the position of senior physician, while 28% indicated a desire to become chief physician. In terms of work environment, most participants preferred to seek employment at a cantonal hospital, followed by a rural hospital, a university hospital, private practice or a non-clinical setting. About half of respondents favoured the option of part time employment of 80% or less and about a quartile intended to retire before 62 years of age. CONCLUSION: The current study found that surgeons in Switzerland remain highly motivated to pursue leadership positions in their respective fields. Going forward, the challenge will lie in reconciling the needs of the respective departments with the personal ambition, career opportunities, and desired work-life balance of young trainees.

Schistosomiasis (Schistosoma mansoni)-a rare cause of complex liver cysts.

In this paper, we describe the case of a 40-year-old patient with an expanding and symptomatic complex liver cyst. Despite comprehensive diagnostics, including labs, imaging and biopsy, a clear etiology could not be determined. As a result, a partial liver resection was performed. The histopathological examination revealed evidence of schistosomas. We postulate that the displacement of the portal fields created a pseudocyst and that the resultant ischemia was the root cause of the patient's discomfort. Postoperatively, the patient received an antihelmintic therapy with praziquantel with which she was able to fully recover.

Minimally invasive versus open pancreatic surgery: meta-analysis of randomized clinical trials.

BACKGROUND: Widespread implementation of the minimally invasive technique in pancreatic surgery has proven to be challenging. The aim of this study was to compare the perioperative outcomes of minimally invasive (laparoscopic and robotic) pancreatic surgery with open pancreatic surgery using data obtained from RCTs. METHODS: A literature search was done using Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Web of Science; all available RCTs comparing minimally invasive pancreatic surgery and open pancreatic surgery in adults requiring elective distal pancreatectomy or partial pancreatoduodenectomy were included. Outcomes were mortality rate, general and pancreatic surgery specific morbidity rate, and length of hospital stay. RESULTS: Six RCTs with 984 patients were included; 99.0 per cent (486) of minimally invasive procedures were performed laparoscopically and 1.0 per cent (five) robotically. In minimally invasive pancreatic surgery, length of hospital stay (-1.3 days, -2 to -0.5, P = 0.001) and intraoperative blood loss (-137 ml, -182 to -92, P < 0.001) were reduced. In the subgroup analysis, reduction in length of hospital stay was only present for minimally invasive distal pancreatectomy (-2 days, -2.3 to -1.7, P < 0.001). A minimally invasive approach showed reductions in surgical site infections (OR 0.4, 0.1 to 0.96, P = 0.040) and intraoperative blood loss (-131 ml, -173 to -89, P < 0.001) with a 75 min longer duration of surgery (42 to 108 min, P < 0.001) only in partial pancreatoduodenectomy. No significant differences were found with regards to mortality rate and postoperative complications. CONCLUSION: This meta-analysis presents level 1 evidence of reduced length of hospital stay and intraoperative blood loss in minimally invasive pancreatic surgery compared with open pancreatic surgery. Morbidity rate and mortality rate were comparable, but longer duration of surgery in minimally invasive partial pancreatoduodenectomy hints that this technique in partial pancreatoduodenectomy is technically more challenging than in distal pancreatectomy.

Does Side Really Matter? Survival Analysis among Patients with Right- Versus Left-Sided Colon Cancer: A Propensity Score-Adjusted Analysis.

BACKGROUND: Right- and left-sided colon cancer are increasingly regarded as two independent disease entities based on different gene expression profiles as well as underlying genetic mutations. Data regarding prognosis and survival are heterogeneous and more favorable in cases of left-sided colon cancer. OBJECTIVE: The purpose of this study was to evaluate the long-term oncological outcome for patients with left-sided versus right-sided stage I-III colon cancer. METHODS: Overall, 318 consecutive patients who underwent surgery for right- or left-sided sided colon cancer between 2001 and 2014 were analyzed. Analysis was performed applying a prospectively maintained database with respect to overall, disease-specific, and relative survival, using Cox regression and propensity score analyses. RESULTS: A total of 155 patients (48.7%) presented with right-sided colon cancer and 163 patients (51.3%) presented with left-sided colon cancer. In risk-adjusted Cox regression analysis, tumor location had no significant impact on overall survival (hazard ratio [HR] 1.53, 95% confidence interval [CI] 0.80-2.92; p = 0.197), disease-specific survival (HR 1.36, 95% CI 0.76-2.44; p = 0.301), and relative survival (HR 1.70, 95% CI 0.89-3.27; p = 0.107). After propensity score matching, the results from risk-adjusted Cox regression analysis were confirmed. Stratified by American Joint Committee on Cancer stage, patients with right-sided stage II colon cancer had a statistically significant superior relative survival compared with patents with left-sided colon cancer. CONCLUSIONS: No significant negative impact on overall, disease-specific, or relative survival could be observed in patients with right- versus left-sided colon cancer after risk adjustment, using multivariable Cox regression and propensity score analyses.

Peridural analgesia does not impact survival in patients after colon cancer resection: a retrospective propensity score-adjusted analysis.

PURPOSE: To assess the putative impact of peridural analgesia on oncological outcome in patients undergoing resection of stages I-IV colon cancer. METHODS: In a single-center study, 876 patients undergoing resection for primary colon cancer (AJCC stages I-IV) between 2001 and 2014 were analyzed. Mean follow-up of the entire cohort was 4.2 ± 3.5 years. Patients who did and did not receive peridural analgesia were compared using Cox regression and propensity score analyses. RESULTS: Overall, 208 patients (23.7%) received peridural analgesia. Patients' characteristics were biased with regard to the use of peridural analgesia (propensity score 0.296 ± 0.129 vs. 0.219 ± 0.108, p < 0.001). After propensity score matching, the use of peridural analgesia had no impact on overall (HR 0.81, 95% CI 0.59-1.11, p = 0.175), cancer-specific (HR 0.72, 95% CI 0.48-1.09, p = 0.111), and disease-free survival (HR 0.89, 95% CI 0.66-1.19, p = 0.430). The 5-year overall survival after propensity score matching was 60.9% (95% CI 54.8-67.7%) for patients treated with peridural analgesia compared with 54.1% (95% CI 49.5-59.1%) for patients not treated with peridural analgesia. Cancer-specific and disease-free survival showed similar non-significant results. CONCLUSIONS: Peridural analgesia in patients after colon cancer resection was not associated with a better oncological outcome after risk adjusting in multivariable Cox regression and propensity score analyses. Hence, oncological outcome should not serve as a reason for the use of peridural analgesia in patients with colon cancer.

Urgent surgery in colon cancer has no impact on survival.

BACKGROUND AND OBJECTIVES: Despite advances in early detection of colon cancer, a minority of patients still require urgent surgery. Whether such urgent conditions result in poor outcome remains a topic of debate. METHODS: Using a prospectively maintained database, patients suffering exclusively from colon cancer and receiving either elective or emergent resection between 2001 and 2014 were analyzed with respect to overall, disease-specific, and relative survival using Cox regression and propensity score analyses. RESULTS: From a total of 877 patients analyzed, 2.7% (24) presented with complications requiring urgent surgery. Propensity-scoring identified strongly biased patient characteristics (0.097 ± 0.069 vs 0.028 ± 0.043; P < 0.001). An unadjusted Cox proportional hazards regression analysis revealed urgent surgery as a statistically significant prognostic factor with an approximately 207% increased risk of mortality (hazard ratio [HR] = 3.07; 95% confidence interval [CI]: 1.62-5.81; P = 0.003). After adjusting the data according to the propensity score analysis, urgent surgery was not associated with a decreased overall (HR = 1.67; 95%CI; 0.84-3.36; P = 0.174), disease-specific (HR = 1.62; 95% CI; 0.81-3.24; P = 0.201) or relative survival (HR = 1.86; 95% CI: 0.92-3.79; P = 0.086). CONCLUSIONS: After risk-adjustment, using multivariable Cox regression and propensity score analyses, no significant disadvantage could be noted with regard to overall, disease-specific, or relative survival in patients with exclusively colon cancer who received emergent oncological resection.

Epigenetic inactivation of ST6GAL1 in human bladder cancer.

BACKGROUND: Posttranslational protein modifications are known to modulate key biological processes like proliferation and apoptosis. Accumulating evidence shows that ST6GAL1, an enzyme that catalyzes the transfer of sialic acid onto galactose-containing substrates, is aberrantly expressed in various cancers and may affect cell motility and invasion. This is the first study to describe ST6GAL1 expression and regulation in human bladder cancer. METHODS: ST6GAL1 mRNA expression levels in human cell lines (UROtsa, RT4, RT112 and J82) and tissue samples (n = 15 normal urothelium (NU), n = 13 papillary non-invasive tumors (pTa), n = 12 carcinoma in situ (CIS), n = 26 muscle invasive tumors (pT2-4)) were assessed using real-time PCR. In addition, ST6GAL1 protein expression was evaluated using immunohistochemistry. Promoter methylation analysis was performed using methylation-specific PCR (MSP) in cell lines (n = 4) and patient samples (n = 23 NU, n = 12 CIS, n = 29 pTa, n = 41 pT2-4). Epigenetic ST6GAL1 gene silencing was confirmed by in vitro demethylation of bladder cell lines. Data were validated by analysis of an independent bladder tumor data set (n = 184) based on The Cancer Genome Atlas (TCGA) portal. RESULTS: Semi-quantitative ST6GAL1 real-time PCR expression analysis showed two distinct trends: In muscle-invasive tumors ST6GAL1 expression was downregulation by 2.7-fold, while papillary non-invasive tumors showed an increased ST6GAL1 mRNA expression compared to normal urothelium. ST6GAL1 loss in muscle-invasive tumors was associated with increasing invasiveness. On the protein level, 69.2% (n = 45/65) of all tumors showed a weak ST6GAL1 protein staining (IRS ≤ 4) while 25.6% (16/65) exhibited a complete loss (IRS = 0) of ST6GAL1 protein. Tumor-specific DNA methylation of the ST6GAL1 promoter region was frequently found in pT2-4 tumors (53.6% (22/41)), whereas only 13.8% (4/29) of pTa tumors showed ST6GAL1 promoter methylation. Normal urothelium remained unmethylated. Importantly, we significantly revealed an inverse correlation between ST6GAL1 mRNA expression and ST6GAL1 promoter merthylation in primary bladder cancer. These findings were clearly verified by the TCGA public data set and in vitro demethylation assays functionally confirmed ST6GAL1 promoter methylation as a potential regulatory factor for ST6GAL1 gene silencing. CONCLUSIONS: Our study characterizes for the first time ST6GAL1 expression loss caused by aberrant ST6GAL1 promoter methylation potentially indicating a tumor suppressive role in bladder carcinogenesis.

Epigenetic inactivation of ITIH5 promotes bladder cancer progression and predicts early relapse of pT1 high-grade urothelial tumours.

Inter-α-trypsin inhibitor heavy chain 5 (ITIH5) has been associated with tumour suppression in various cancers. However, its putative role in bladder cancer is completely unknown. Therefore, we initiated a study analysing ITIH5 expression as well as its prognostic and functional impact on human urothelial cancers (UCs). Expression analysis showed a clear down-regulation of ITIH5 mRNA in 61% (n = 45) of UCs, especially in muscle-invasive tumours (P < 0.001). ITIH5 loss in UCs was further evident on protein level (65.5%, n = 55) as detected by immunohistochemistry. DNA methylation analysis demonstrated tumour-specific ITIH5 promoter methylation in 50% of papillary none-invasive pTa (n = 30) and 68% of invasive (n = 28) UCs. Aberrant ITIH5 promoter methylation in bladder tumours was tightly linked (P < 0.001) with loss of ITIH5 mRNA expression, which was furthermore functionally confirmed by demethylation analysis in cell lines. Pyrosequencing analysis revealed that ITIH5 promoter hypermethylation was closely associated with progressive bladder cancers. Subsequently, a large cohort (n = 120) of clinically challenging pT1 high-grade UC was analysed for ITIH5 expression. Of clinical significance, we found an association between loss of ITIH5 expression and unfavourable prognosis of UC patients without distant metastasis at first diagnosis (recurrence-free survival; hazard ratio: 4.35, P = 0.048). Functionally, ITIH5 re-expression in human RT112 bladder cancer cells led to both suppression of cell migration and inhibition of colony spreading. Hence, we provide evidence that down-regulation of ITIH5 by aberrant DNA hypermethylation may provoke invasive phenotypes in human bladder cancer. Moreover, ITIH5 protein might become a prognostic biomarker for relapse risk stratification in high-grade UC patients.

Rotationally stable screw-anchor versus sliding hip screw plate systems in stable trochanteric femur fractures: a biomechanical evaluation.

OBJECTIVES: The rotationally stable screw-anchor plate system (RoSA) is unique in using a novel screw-blade combination. This investigation tested the hypothesis whether RoSA is advantageous over the sliding hip screw plate system (SHS) with regard to stiffness, failure load, displacement, and migration in stable trochanteric femur fractures (OTA 31A1.1). METHODS: Thirteen femur pairs (mean age = 79 years; range, 64-92 years) received implants of either the RoSA or SHS (Koenigsee Implants, Allendorf, Germany). Beginning with 300 N and under consecutive 300 N load-increase steps (2000 cycles, 0.5 Hz) the femurs were cycled until failure. Specimens were evaluated for fragment displacement in both frontal and rotational planes and for migration. A survival analysis was carried out. RESULTS: With regard to stiffness (526 ± 195 N/mm vs 358 ± 143 N/mm; P = 0.006) and the failure load (2838 ± 781 N vs 2262 ± 863 N; P = 0.012), the RoSA proved superior to the SHS. Furthermore, RoSA demonstrated higher rotational stability in comparison to the SHS (1800 N: 0 ± 0 degrees vs 1.1 ± 1.3 degrees; P = 0.015; failure point: 0 ± 0 degrees vs 2.3 ± 2.6 degrees; P = 0.008), measuring rotation about femoral neck axis over time. Whereas cutout occurred only in the RoSA system (n = 3; P = 0.110), the SHS underwent plastic deformation in 7 cases (n = 7; P = 0.003). In one case (7%), the insertion of the RoSA blade resulted in iatrogenic cut-through caused by a jamming of the screw and the blade. CONCLUSIONS: The fixation of stable trochanteric femur fractures with RoSA in cadavers led to greater primary stability under cyclic load, with significant advantages with regard to stiffness, failure load, and rotational stability, compared with the SHS. A detrimental effect was its migration tendency, which began at 1800 N and occurred in the cranial direction. A meticulous insertion technique was a prerequisite to avoid iatrogenic perforation of the femoral head. Our results will have to be substantiated by further biomechanical and clinical trials using an optimized RoSA system.

Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial.

PURPOSE: To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students. METHODS: In 2007-2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE). RESULTS: Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts. CONCLUSIONS: The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.