Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)?

PURPOSE: We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study. METHODS: Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP. RESULTS: We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group. CONCLUSION: Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.

Does speed equal quality? Time pressure impairs minimally invasive surgical skills in a prospective crossover trial.

BACKGROUND: Time pressure can cause stress, subsequently influencing surgeons during minimally invasive procedures. This trial aimed to investigate the effect of time pressure on surgical quality, as assessed by force application and errors during minimally invasive surgical tasks. METHODS: Sixty-three participants (43 surgical novices trained to proficiency and 20 surgeons) performed four laparoscopic tasks (PEG transfer, precise Cutting, balloon resection, surgical knot) both with and without time pressure. The primary endpoint was the mean and maximal force exertion during each task. Secondary endpoints were the occurrence of predefined errors and the self-assessed stress level. RESULTS: Time pressure led to a significant shortening of the task time in all four tasks. However, significantly more errors were noticed under time pressure in one task (suture precision P < 0.001). Moreover, time pressure led to a significant increase in mean force in all tasks (PEG: P < 0.001; precision cutting: P = 0.001; surgical knot: P < 0.001; balloon: P = 0.004). In three tasks the maximal force application (PEG: P < 0.001; precision cutting: P < 0.001; surgical knot: P = 0.006) increased significantly. Performing the tasks under time pressure significantly increased the stress level. Cohort analysis revealed that time pressure impaired the performance of both, surgical novices and surgeons but novices were more strongly affected compared to surgeons. CONCLUSION: Time pressure during minimally invasive surgery may improve procedural time but impair the quality of surgical performance in terms of the incidence of errors and force exertion. Experience may only partially compensate for the negative influence of time pressure.

[Highlights of pancreatic surgery: extended indications in pancreatic neuroendocrine tumors]. / Highlights der Pankreaschirurgie: erweiterte Indikationen bei neuroendokrinen Tumoren des Pankreas.

Advanced pancreatic neuroendocrine tumors (paNET) are mostly characterized by infiltration of vascular structures and/or neighboring organs. The indications for resection in these cases should be measured based on the possibility of an R0 resection. Although the data situation for this rare entity is limited, small case series have shown a significant survival advantage in patients who underwent a radical resection in locally advanced stages of paNET. Both vascular reconstruction and multivisceral resection, when performed at experienced centers, should be considered as curative treatment options. The very special biological behavior of the paNET and the often young patient age justify a much more aggressive approach compared to the pancreatic ductal adenocarcinoma.

Short-term preoperative drainage is associated with improved postoperative outcomes compared to that of long-term biliary drainage in pancreatic surgery.

PURPOSE: The treatment of choice for patients presenting with obstructive cholestasis due to periampullary carcinoma is oncologic resection without preoperative biliary drainage (PBD). However, resection without PBD becomes virtually impossible in patients with obstructive cholangitis or severely impaired liver cell function. The appropriate duration of drainage by PBD has not yet been defined for these patients. METHODS: A retrospective analysis was conducted on 170 patients scheduled for pancreatic resection following biliary drainage between January 2012 and June 2018 at the University Hospital Dresden in Germany. All patients were deemed eligible for inclusion, regardless of the underlying disease entity. The primary endpoint analysis was defined as the overall morbidity (according to the Clavien-Dindo classification). Secondary endpoints were the in-hospital mortality and malignancy adjusted overall and recurrence-free survival rates. RESULTS: A total of 170 patients were included, of which 45 (26.5%) and 125 (73.5%) were assigned to the short-term (< 4 weeks) and long-term (≥ 4 weeks) preoperative drainage groups, respectively. Surgical complications (Clavien-Dindo classification > 2) occurred in 80 (47.1%) patients, with significantly fewer complications observed in the short-term drainage group (31.1% vs. 52%; p = 0.02). We found that long-term preoperative drainage (unadjusted OR, 3.386; 95% CI, 1.507-7.606; p < 0.01) and periampullary carcinoma (unadjusted OR, 5.519; 95% CI, 1.722-17.685; p-value < 0.01) were independent risk factors for postoperative morbidity, based on the results of a multivariate regression model. The adjusted overall and recurrence-free survival did not differ between the groups (p = 0.12). CONCLUSION: PBD in patients scheduled for pancreatic surgery is associated with substantial perioperative morbidity. Our results indicate that patients who have undergone PBD should be operated on within 4 weeks after drainage.

Perioperative Blood Management of Preoperative Anemia Determines Long-Term Outcome in Patients with Pancreatic Surgery.

BACKGROUND/PURPOSE: Anemia affects the postoperative course of patients undergoing a major surgical procedure. However, it remains unclear whether anemia has a different impact on the long-term outcome of patients with malignant or benign pancreatic disease. METHODS: A retrospective analysis of patients undergoing pancreatic surgery for pancreatic malignancies or chronic pancreatitis was conducted between January 2012 and June 2018 at the University Hospital Dresden, Germany. The occurrence of preoperative anemia and the administration of pre-, intra-, and postoperative blood transfusions were correlated with postoperative complications and survival data by uni- and multivariate analysis. RESULTS: A total of 682 patients were included with 482 (70.7%) undergoing surgical procedures for pancreatic malignancies. Univariate regression analysis confirmed preoperative anemia as a risk factor for postoperative complications > grade 2 according to the Clavien-Dindo classification. Multivariate regression analyses indicated postoperative blood transfusion as an independent risk factor for postoperative complications in patients with a benign (OR 20.5; p value < 0.001) and a malignant pancreatic lesion (OR 4.7; p value < 0.01). Univariate and multivariate analysis revealed preoperative anemia and pre-, intra-, and postoperative blood transfusions as independent prognostic factors for shorter overall survival in benign and malignant patients (p value < 0.001-0.01). CONCLUSION: Preoperative anemia is a prevalent, independent, and adjustable factor in pancreatic surgery, which poses a significant risk for postoperative complications irrespective of the entity of the underlying disease. It should therefore be understood as an adjustable factor rather than an indicator of underlying disease severity.

Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses: A Prospective, Randomized Controlled Trial.

BACKGROUND: Soft tissue abscesses are among the most frequently encountered medical problems treated by different surgeons. Standard therapy remains incision and drainage with sterile saline irrigation during postoperative wound healing period. Aim of this prospective randomized controlled trial was to compare sterile irrigation versus nonsterile irrigation. STUDY DESIGN: A single center randomized controlled trial was performed to investigate postoperative wound irrigation. The control group used sterile irrigation, and the intervention group used nonsterile irrigation. Primary endpoints were reinfection and reintervention rates, assessed during follow-up controls for up to 2 years. Secondary endpoints were the duration of wound healing, inability to work, pain and quality of life. RESULTS: Between 04/2016 and 05/2017, 118 patients were randomized into two groups, with 61 allocated to the control- and 57 to the intervention group. Reinfection occurred in a total of 4 cases (6.6%) in the sterile protocol and 4 (7%) in the nonsterile protocol. Quality of life and pain values were comparable during the wound healing period, and patients treated according to the nonsterile irrigation protocol used significantly fewer wound care service teams. Despite equal wound persistence rates, a substantially shorter amount of time off from work was reported in the nonsterile protocol group (p value 0.086). CONCLUSION: This prospective, randomized trial indicates that a nonsterile irrigation protocol for patients operated on for soft tissue abscesses is not inferior to the standard sterile protocol. Moreover, a nonsterile irrigation protocol leads to a shorter period of inability to work with comparable pain and quality of life scores during the wound healing period.

Measurements of a 'normal vulva' in women aged 15-84: a cross-sectional prospective single-centre study.

OBJECTIVE: Accurate and detailed description of a 'normal vulva' is rare, even though a few studies have dealt with the topic of normal measurements of parts of the external female genitalia. This leads to a situation with a wide range of existing diagnoses concerning 'normal' vulvar morphology. DESIGN: Cross-sectional prospective single-centre study. SETTING: From August 2015 to April 2017, we included 657 women in our gynaecological and uro-gynaecological outpatient clinic of the Cantonal Hospital Lucerne. POPULATION OR SAMPLE: We recruited white women aged 15-84 years. METHODS: Standardised defined measurements were taken of the clitoral gland, distance from the base of the gland to the urethral orifice, length of introitus, length of perineum, length of labia majora, and length and width of labia minora. Furthermore, we recorded baseline characteristics. MAIN OUTCOME MEASURES: The length of labia minora (r = -0.364, P < 0.001, n = 657) as well as the length of the perineum (r = -0.095, P = 0.014, n = 657) are inversely correlated with age. A positive correlation between body mass index and the length of the labia majora (r = 0.150, P < 0.001, n = 657) and the length of the introitus (r = 0.097, P = 0.014, n = 657) was found. RESULTS: We provide detailed data on age-related dimensions and description of the external female genitalia in a homogeneous group of white women. CONCLUSION: With our data, we present a baseline for the appearance of a normal white vulva, which could be used to establish standards for indications for gynaecological cosmetic surgery. TWEETABLE ABSTRACT: This study presents data on the standard dimensions of the external female genitalia and is, to our knowledge, the biggest cohort presented on this topic by now.

Sustainability in humanitarian surgery during medical short-term trips (MSTs): feasibility of inguinal hernia repair in rural Nigeria over 6 years and 13 missions.

PURPOSE: Surgical teaching missions are known to contribute significantly in reducing the local burden of disease. However, the value of short-term medical service trips (MSTs) remains under debate. Humanitarian surgery is highly dependent on funding, and consequently, data evaluation is needed to secure funding for future projects. The aim of this trial is to evaluate the results of 6-year MSTs to rural Nigeria with a specific emphasis on hernia repairs. METHODS: Retrospective series of consecutive operations performed between 2011 and 2016 in rural Nigeria during 13 MSTs. Operations were categorized into type and number of procedures and origin of the surgeon. In terms of inguinal hernia repairs additional data was evaluated such as frequency of local anaesthesia (LA) and the type of hernia. The total amount of disability-adjusted life years (DALYs) averted during each mission are presented and discussed with regard to sustainability of these missions. RESULTS: From 2011 to 2016, a total of 1674 patients were operated. Of these, 1302 patients were operated for 1481 hernias of which 36.7% accounting as inguinoscrotal hernias. The percentage of operations performed by Nigerian staff increased from 31 to 55%. Overall, eighteen percent of the operations was solely performed by Nigerians. Totally, we averted 8092.83 DALY's accounting for 5.46 DALY's per hernia. CONCLUSION: The presented missions contribute significantly to an improvement in local healthcare and decrease the burden of disease. We were able to show the sustainable character of these surgical missions. As a next step, we will analyse the cost-effectiveness of MSTs.

Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications.

OBJECTIVE: The primary aim was to evaluate the number of complications following locking plate fixation of proximal humeral fractures in country X and in country Y. The secondary aim was to identify risk factors for complications. METHODS: Multicentre retrospective case series of 282 consecutive patients with proximal humeral fractures, treated with a locking plate between 2010 and 2014. SETTING: two level 1 trauma centres in country X and one in country Y. Data pertaining to demographics, postoperative complications and re-operations were collected. Fractures were classified according to the AO and Hertel classifications and experienced surgeons assessed the quality of reduction and plate fixation on the postoperative X-rays. Outcomes of the two different countries were compared and logistic regression analysis was performed to analyse the relationship between risk factors and complications. RESULTS: During a median follow-up of 370 days, 196 complications were encountered in 127 patients (45%). The most frequent complications were: screw perforation in the glenohumeral joint (23%), persistent shoulder complaints (16%), avascular necrosis of the humeral head (10%) and secondary fracture displacement (5%). In 80 patients (28%), 132 re-operations were performed. The patients operated in country X had significantly more complications compared with the patients operated in country Y. For implant-related complications, advanced age, non-anatomic reduction of the greater tuberosity, and country of operation were risk factors. CONCLUSION: The use of locking plates for proximal humeral fractures was associated with a high number of complications in both countries; the patients operated in country Y, however, had better results compared with the patients operated in country X. LEVEL OF EVIDENCE: IV.

Absolute or relative stability in minimal invasive plate osteosynthesis of simple distal meta or diaphyseal tibia fractures?

INTRODUCTION: Minimal invasive plate osteosynthesis in simple distal meta or diaphyseal tibia fractures can be applied using absolute (lag screw and neutralisation plate; LSN) or relative stability (bridge plate; BP). The primary aim of the study was to compare time to radiological union and time to full weight bearing in the two groups (LSN vs. BP). Reduction was performed either percutaneously or by a minimally open approach (mini open). Secondary aim was to analyse the number of complications between both groups. METHODS: Retrospective single centre review of patients with a simple distal meta or diaphyseal tibia fracture operated with a Locking Compression Plate (LCP) between 2009 and 2015 in a Level one Trauma Centre. Postoperative radiographs were assessed in a standardised manner. Time to radiological fracture union and time to full weight bearing were observed. Callus index and postoperative complications were analysed. RESULTS: Fifty-seven patients with a minimum follow-up of 6 months were analysed. Forty-eight patients had a shaft (AO/OTA Type 42) and nine a distal tibia fracture (AO/OTA Type 43). Forty patients were treated with using the LSN concept and 17 patients with the BP concept. Median time to radiological fracture union was statistically significant shorter (p=0.04) in the LSN group with 19 weeks compared to 27 weeks in the BP-group. Time to full weight bearing was 10 weeks in both groups. A total (including implant removal) of 35 reoperations were performed in the LSN-group and 18 in the BP-group. Wound healing disorders (deep surgical site infections) were seen less the LSN group in 3/40 (7.5%) compared to the BP-group with 3/17 (17.6%). In the LSN group, there was no statistical difference in time to union or weight bearing between a percutaneous or mini open approach. CONCLUSION: Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. If a percutaneous reduction is not feasible for the insertion of a lag screw, a mini-open approach does not lead to a delay in fracture healing.

[Distal humerus fracture-extensile approaches]. / Distale Humerusfraktur ­ Zugänge und Erweiterungen.

The majority of dislocated, intra-articular fractures are treated with an open reduction and internal fixation. In this paper we describe a variety of dorsal approaches to the distal humerus. Beside the dorsal approach through an olecranon osteotomy we also discuss the alternative dorsal approaches without osteotomy and their advantages and drawbacks. Moreover we discuss the preoperative planning and operative procedure. Early functional rehabilitation, without weight bearing, is important to achieve an optimal outcome. Finally we present the results of the last 6 years of patients treated operatively in our clinic with distal humeral fractures.

Examining the risks and benefits of considering both the traditional dose--response and hormesis in arriving at an acceptable exposure level.

In examining traditional dose-response and hormesis, we have considered the case examples of pulmonary hyperplasia following inhalation of carbon black and pulmonary hyperplasia after methyleneindolenine (3MEIN) exposures, development of irreversible pulmonary fibrosis, effect of continuous exercise and low-level lead exposures, and colorectal cancer. Adaptation can be used to estimate conventional dose responses. All cases discussed provided increased information about the reactions if hormetic features were included. In only the shigatoxin case was there clear irrefutable evidence that beneficial hormetic properties exist and must be considered; however, the one-in-six advantage is too great to ignore the potential benefits of hormesis. We recommend such hormetic properties be considered together with conventional dose responses to improve estimates of chemical risk.

Invited response to definition of hormesis (EJ Calabrese and LA Baldwin).

Calabrese and Baldwin have proposed the Theory of Hormesis to explain a variety of disparate data. We evaluated the explanation using examples of pulmonary injury, radiation injury to white blood cells and selenium as an essential element, reducer of carcinogenesis and a potential toxicant. Calabrese and Baldwin have fulfilled many of the criteria allowing generalizability of their theory. They have gathered data extensively. These data were logically consistent with their experiences. They needed to examine critically the theory and any theories competing with it. At this point, each theory must be proved, disproved or its limitations clearly stated. It is in this phase that most work is still being accomplished. This examination is important because it provides referents for vigorous outside criticism, the final phase. Calabrese and Baldwin are to be complimented on seeking outside comment. Considerable refinement of the theory has taken place with time.

Digital papillomatosis in a confined Beagle.

Papillomavirus-induced papillomas were diagnosed on multiple digits of all 4 feet of a young Beagle. No other cutaneous or oral involvement was identified. Papillomavirus antigen was confirmed by immunoperoxidase localization within keratinocyte nuclei. In addition to the typical basophilic intranuclear inclusions associated with papillomavirus infections, keratinocytes within the papillomas contained large, eosinophilic cytoplasmic inclusions that previously have been described in a Boxer with cutaneous lesions associated with a papillomavirus infection. The papillomas in this Beagle regressed completely within 2 months of the initial diagnosis.

Plasmid and chromosomal basis of tolerance to cadmium and resistance to antibiotics in normal bovine duodenal bacterial flora.

Cadmium (Cd) tolerance and antibiotic resistance was studied in duodenal flora of 20 normal bovine samples. Twelve bacterial isolates (5 Staphylococcus spp, 4 Enterococcus faecalis, 2 Bacillus spp, and a Pseudomonas sp) were grown in Luria broth containing 0.05 to 0.8 mM of cadmium chloride (CdCl). All isolates displayed multiple antibiotic resistance, with 2 Enterococcus strains and Pseudomonas pickettii demonstrating resistance to 12/17 antibiotics tested. With the exception of Staphylococcus sp, all contained plasmid DNA. Curing to remove plasmid DNA determined if Cd tolerance and/or antibiotic resistance was plasmid or chromosomally mediated. None of the bacteria became sensitive to CdCl after curing, suggesting that tolerance was not plasmid-mediated. Six bacteria became sensitive to antibiotics after curing indicating that antibiotic2 resistance was plasmid mediated. Two of these bacteria became sensitive to multiple antibiotics; a Staphylococcus sp became sensitive to ampicillin, ceftiofur and cephalothin, and a Enterococcus strain became sensitive to neomycin, oxacillin, and tiamulin. All of the isolates were probed for the presence of known Cd-resistance genes (cadA, cadC, and cadD). DNA-DNA hybridization revealed cadA- and cadC-related sequences in chromosomal DNA of a Staphylococcus sp, an Enterococcus strain, and in plasmid DNA of another Staphylococcus sp. No cadD-related sequences were detected in any of the 12 isolates even under reduced stringency of hybridization.

Osmotic stress-dependent serine phosphorylation of the histidine kinase homologue DokA.

BACKGROUND: Two-component systems consisting of histidine kinases and their corresponding receivers are widespread in bacterial signal transduction. In the past few years, genes coding for homologues of two-component systems were also discovered in eukaryotic organisms. DokA, a homologue of bacterial histidine kinases, is an element of the osmoregulatory pathway in the amoeba Dictyostelium. The work described here addresses the question whether DokA is phosphorylated in vivo in response to osmotic stress. RESULTS: We have endogenously overexpressed individual domains of DokA to investigate post-translational modification of the protein in response to osmotic shock in vivo. Dictyostelium cells were labeled with [32P]-orthophosphate, exposed to osmotic stress and DokA fragments were subsequently isolated by immunoprecipitation. Thus, a stress-dependent phosphorylation could be demonstrated, with the site of phosphorylation being located in the kinase domain. We demonstrate biochemically that the phosphorylated amino acid is serine, and by mutational analysis that the phosphorylation reaction is not due to an autophosphorylation of DokA. Furthermore, mutation of the conserved histidine did not affect the osmostress-dependent phosphorylation reaction. CONCLUSIONS: A stimulus-dependent serine phosphorylation of a eukaryotic histidine kinase homologue was demonstrated for the first time in vivo. That implies that DokA, although showing typical structural features of a bacterial two-component system, might be part of a eukaryotic signal transduction pathway that involves serine/threonine kinases.

Cholinesterase activity:muscarinic receptor ratios in canine and feline brains.

In response to findings that brain cholinesterase (ChE): muscarinic cholinergic receptor density (mChR) ratio is highly conserved between bird species (I), this study investigated the conservation of brain ChE:mChR between 2 mammalian species. Whole brains of 7 normal greyhounds, 14 normal non-greyhound dogs, and 8 normal cats, were assayed for ChE, mChR and protein. The same assays were made on cerebrum, cerebellum and brainstem from the greyhounds and 6 of the non-greyhound dogs. The Ellman assay was used to measure serum ChE activity, mChR were labelled with tritiated quinuclidinyl benzilate, and protein was measured by Lowry assay. Brain ChE:mChR was not highly conserved between the species. There was a statistically significant difference in brain mChR between greyhounds and non-greyhounds but this did not translate to a statistically significant difference in mean ChE:mChR. Measurement of ChE:mChR is unlikely to be useful in endangered carnivores for which normal ChE levels are unknown, because it cannot be assumed that endangered species would have the same ChE:mChR as their domestic relatives.

Pulmonary diseases caused by airborne contaminants in swine confinement buildings.

Exposure to toxic gases and particles or dusts while working or living in confinement animal systems pose a pulmonary health hazard. The severity of lung impairment from exposure to such environment is investigated using intratracheal instillation, intratracheal nebulization, and inhalation procedures. Ability to deliver particles with intratracheal instillation that are evenly distributed throughout the lung depends on the material used for injection. Pulmonary histopathology reflects anatomic changes following inhalation or instillation of chemicals or particles. Endobronchial saline washings of bronchioles and alveoli allow measurement of markers of pulmonary inflammation such as total nucleated cell (leukocyte) counts and those of macrophages, neutrophils and lymphocytes; TNF-alpha, and collagen concentration are used to further evaluate pulmonary response to endotoxin or dust exposure. Alveolar epithelial cells have an important role in clearing pulmonary fluid and maintaining the structure of lung tissue. After repeated exposure, damage to epithelial cells may result in their death, causing edema and collagen deposition that may lead to fibrosis.