Benchmarking outcomes for distal pancreatectomy: critical evaluation of four multicenter studies.

BACKGROUND: Benchmarking is a validated tool for outcome assessment and international comparison of best achievable surgical outcomes. The methodology is increasingly applied in pancreatic surgery and the aim of the review was to critically compare available benchmark studies evaluating distal pancreatectomy (DP). METHODS: A literature search of English articles reporting on benchmarking DP was conducted of the electronic databases MEDLINE and Web of Science (until April 2023). Studies on open (ODP), laparoscopic (LDP), and robotic DP (RDP) were included. RESULTS: Four retrospective multicenter studies were included. Studies reported on outcomes of minimally invasive DP only (n = 2), ODP and LDP (n = 1), and RDP only (n = 1). Either the Achievable Benchmark of Care™ method or the 75th percentile from the median was selected to define benchmark cutoffs. Robust and reproducible benchmark values were provided by the four studies for intra- and postoperative short-term outcomes. CONCLUSION: Benchmarking DP is a valuable tool for obtaining internationally accepted reference outcomes for open and minimally invasive DP approaches with only minor variances in four international cohorts. Benchmark cutoffs allow for outcome comparisons between institutions, surgeons, and to monitor the introduction of novel minimally invasive DP techniques.

Reproducibility of the CROSS Trial Results in the Multimodal Treatment of Esophageal Cancer in Daily Practice: A Single Center Retrospective Observational Study.

Background: Treatment of nonmetastatic esophageal cancer with curative intention remains a major challenge. Neoadjuvant radiochemotherapy followed by surgery, as described in the CROSS trial in 2012, has been established as a standard of care. With this retrospective observational study, we aimed to analyze the results of the CROSS regimen in daily practice over the last 10 years at the St. Clara Hospital, a Swiss center for esophageal surgery. Methods: To determine the clinical outcome in our daily practice, the medical records of all patients with potentially curable localized esophageal cancer (T1N1 or T2-3N0-1 M0) treated with radiochemotherapy in neoadjuvant intention according to the CROSS regimen were reviewed. The primary endpoint was overall survival. Furthermore, an overall survival analysis of the subgroups of patients who exactly met the inclusion criteria of the CROSS trial with respect to age and weight loss before therapy was performed. The Kaplan-Meier method was used to estimate survival and compared by the log-rank test. Results: From January 2012 to January 2022, 91 patients with T1N1 or T2-3N0-1M0 esophageal cancer underwent neoadjuvant radiochemotherapy according to the CROSS regimen. The median age was 70 years (range 31-86 years), and 26 (29%) patients were over 75 years of age. Weight loss of more than 10% was observed in 23 (25%) patients. 77 (85%) patients underwent esophagectomy, and complete resection (R0) was obtained in 73 (95%) of them. The median overall survival was 41 months, compared to 49.4 months in the CROSS trial. The overall survival rate at 12 months was 85% and at 24 months, it was 68%, very similar to the CROSS trial results. 51% of the patients fully met the inclusion criteria of the CROSS trial with respect to age and pretherapeutic weight loss. Their overall survival rate at 12 months was 94% at St. Clara Hospital versus 82% in the CROSS trial (p=0.04), and at 24 months, 81% versus 67% (p=0.05). Conclusion: Overall, in a center specialized for the multimodal treatment of nonmetastatic esophageal cancer, the results of the CROSS trial seem to be well reproducible in daily practice.

Dual role of tumour-infiltrating T helper 17 cells in human colorectal cancer.

BACKGROUND: The immune contexture predicts prognosis in human colorectal cancer (CRC). Whereas tumour-infiltrating CD8+ T cells and myeloid CD16+ myeloperoxidase (MPO)+ cells are associated with favourable clinical outcome, interleukin (IL)-17-producing cells have been reported to correlate with severe prognosis. However, their phenotypes and functions continue to be debated. OBJECTIVE: To investigate clinical relevance, phenotypes and functional features of CRC-infiltrating, IL-17-producing cells. METHODS: IL-17 staining was performed by immunohistochemistry on a tissue microarray including 1148 CRCs. Phenotypes of IL-17-producing cells were evaluated by flow cytometry on cell suspensions obtained by enzymatic digestion of clinical specimens. Functions of CRC-isolated, IL-17-producing cells were assessed by in vitro and in vivo experiments. RESULTS: IL-17+ infiltrates were not themselves predictive of an unfavourable clinical outcome, but correlated with infiltration by CD8+ T cells and CD16+ MPO+ neutrophils. Ex vivo analysis showed that tumour-infiltrating IL-17+ cells mostly consist of CD4+ T helper 17 (Th17) cells with multifaceted properties. Indeed, owing to IL-17 secretion, CRC-derived Th17 triggered the release of protumorigenic factors by tumour and tumour-associated stroma. However, on the other hand, they favoured recruitment of beneficial neutrophils through IL-8 secretion and, most importantly, they drove highly cytotoxic CCR5+CCR6+CD8+ T cells into tumour tissue, through CCL5 and CCL20 release. Consistent with these findings, the presence of intraepithelial, but not of stromal Th17 cells, positively correlated with improved survival. CONCLUSIONS: Our study shows the dual role played by tumour-infiltrating Th17 in CRC, thus advising caution when developing new IL-17/Th17 targeted treatments.

Intraoperative neuromonitoring for surgical training in thyroid surgery: its routine use allows a safe operation instead of lack of experienced mentoring.

BACKGROUND: The aim of the present study was to evaluate the influence of intraoperative neuromonitoring (NM) on surgical training. The results of thyroidectomy performed by inexperienced surgeons under the supervision of a consultant surgeon without intraoperative neuromonitoring (ioNM) were compared to those of the operations performed without experienced assistance but under neuromonitoring control. MATERIALS AND METHODS: The study included the thyroid operations performed in our Department between 2005 and 2012. Among them, residents or fellows performed 1,116 procedures. Seven hundred sixty-five operations were conducted without neuromonitoring (NV group) and 351 with NM group. In the NV group 375 unilateral and 390 bilateral operations were performed. In the NM group 149 unilateral and 202 bilateral operations were performed. Primary end point of the study was the incidence of postoperative recurrent laryngeal nerve palsy. A secondary end point was the impact of ioNM on operating time and operative strategy. RESULTS: The incidence of recurrent laryngeal nerve (RLN) palsy was 2.6 % in the NV group and 2.7 % in the NM group [p = ns]. One case of bilateral RLN palsy was observed in the NV group. The operative time was longer in the NM group for both lobectomy and total thyroidectomy (50 vs. 56 min and 76 vs. 81 min, respectively; p < 0.05). CONCLUSIONS: The routine use of intermittent intraoperative neuromonitoring during thyroid operations does not reduce the incidence of RLN palsy. Nevertheless, it allows inexperienced surgeons to perform a safe operation with a complication rate comparable to that obtained under supervision of an experienced surgeon. Moreover, ioNM could avoid the unfortunate occurrence of a bilateral RLN palsy.

Pancreatojejunal leakage after pancreas head resection: anatomic and surgeon-related factors.

Leakage of pancreatojejunostomies after pancreatic resections remains a challenge even at high volume centers. We here utilized a simple pancreas anatomy classification to study the effect of pancreatic anatomy on the development of pancreatic fistula after pancreas resection and pancreatojejunostomies. Also, the effect of surgical experience on the development of pancreatic fistulas was studied. Three hundred ninety-one patients undergoing pancreatic resections and reconstruction with a pancreatojejunostomy were studied. Closed suction drain was placed behind the anastomosis, and drainage fluid was collected postoperatively. A twofold increase over the serum amylase level was considered a fistula and was classified as described by the International Study Group on Pancreatic Fistula Definition. In 67 patients, the structural quality of the pancreatic parenchyma and the diameter of the pancreatic duct were classified as being <2 mm (2 points), between 2 and 5 mm (1 point), or >5 mm (0 points). The pancreatic parenchyma was assessed as being soft (2 points), intermediate (1 point), or hard (0 points). Pancreatic leakage as a function of surgeons' experience was also studied. Leakage was found in 25.1%, 8.9% being of type A, 10.2% being of type B, and 5.9% of type C. Pancreatic fistulas were only observed in patients with a score of 2 points or more. Age over 70 years, operations >6 h, and extended lymphadenectomy or surgeons experience were not associated with a higher leakage rate. In this study, leakage after pancreatojejunostomy was only associated with pancreatic anatomy, classified with a simple score. That score might improve comparability of studies on pancreatic leakage. Furthermore, drainage of pancreatic anastomosis might safely be omitted in patients with a low risk score for leakage.

[Ileus disease]. / Ileuskrankheit.

Intestinal obstruction may be mechanical or non-mechanical (adynamic ileus). Adhesions and external hernias are the most common causes of obstruction in small intestine, whereas carcinoma, sigmoid diverticulitis, and volvulus are the most common causes in large intestine obstruction. Distension of the intestine caused by gas and fluid accumulation in the obstructed segment is the key pathophysiological mechanism initiating ileus with subsequent multiorgan failure and death. Surgery should always be undertaken if complete obstruction or strangulation is suggested and ileus is established. Before operation, the fluid and electrolyte balance should be restored and decompression instituted by means of a nasogastric tube. Delaying the operation because of improvement in patient well-being during resuscitation is only justified in those suffering from large intestine obstruction due to colorectal carcinoma. Purely nonoperative treatment is safe only in the presence of incomplete obstruction and best utilized in patients with postoperative adynamic ileus or repeated episodes of partial obstruction.

[Incision and closure of the abdominal wall]. / Chirurgische Durchtrennung und Verschluss der Bauchdecke.

Access to the abdominal cavity must be performed in such a way that surgical treatment procedures can be performed safely. For skin incision, scalpel and electrocautery are equivalent. Subcutaneous tissue and fascias must be divided by electrocautery to minimize blood loss. The best way to close the abdominal cavity is by an all layer, slowly absorbable, running suture with a suture: wound length ratio of at least 4:1. Closing the peritoneal layer is not necessary. Subcutaneous sutures and drains do not reduce the risk of wound complications. Staples should be used for closing the skin.

The incidence of iliac aneurysms in patients with abdominal aortic aneurysms: comparison of four centers in Europe and the USA.

BACKGROUND: The purpose of this study was to compare the anatomy of the aortoiliac vessels in patients scheduled for infrarenal abdominal aortic aneurysm (AAA) repair in four different countries. MATERIAL AND METHODS: Consecutives series of 100 preoperative CT-scans were evaluated at each center. Diameters of the suprarenal aorta, maximal diameter of the aneurysm, right and left common and external iliac artery as well as the hypogastric arteries were recorded and compared between each center. RESULTS: Configuration of the AAA above bifurcation was similar at each center. The dimensions of the aortic bifurcation and the common iliac arteries were different among the centers. Common iliac arteries with diameters over 25 mm were significantly more common at center 1 (p < 0.001, p = 0.002 and p < 0.001). Among centers 2, 3 and 4 there was no significant difference in common iliac diameters. CONCLUSIONS: Configuration of the iliac arteries in AAA was significantly different for Swiss patients compared to American, Austrian and German patients. Reasons for these differences are unclear, epidemiological or genetic factors may be responsible.

Encapsulation into sterically stabilised liposomes enhances the immunogenicity of melanoma-associated Melan-A/MART-1 epitopes.

Tumour-associated antigens (TAA)-specific vaccination requires highly immunogenic reagents capable of inducing cytotoxic T cells (CTL). Soluble peptides are currently used in clinical applications despite an acknowledged poor immunogenicity. Encapsulation into liposomes has been suggested to improve the immunogenicity of discrete antigen formulations. We comparatively evaluated the capacity of HLA-A2.1 restricted Melan-A/MART-1 epitopes in soluble form (S) or following inclusion into sterically stabilised liposomes (SSL) to be recognised by specific CTL, to stimulate their proliferation and to induce them in healthy donors' peripheral blood mononuclear cells (PBMC), as well as in melanoma-derived tumour-infiltrating lymphocytes (TIL). HLA-A2.1(+), Melan-A/MART-1-NA-8 melanoma cells served as targets of specific CTL in 51Cr release assays upon pulsing by untreated or human plasma-treated soluble or SSL-encapsulated Melan-A/MART-1 27-35 (M27-35) or 26-35 (M26-35) epitopes. These reagents were also used to stimulate CTL proliferation, measured as 3H-thymidine incorporation, in the presence of immature dendritic cells (iDC), as antigen-presenting cells (APC). Induction of specific CTL upon stimulation with soluble or SSL-encapsulated peptides was attempted in healthy donors' PBMC or melanoma-derived TIL, and monitored by 51Cr release assays and tetramer staining. Na-8 cells pulsing with SSL M27-35 resulted in a five-fold more effective killing by specific CTL as compared with equal amounts of S M27-35. Encapsulation into SSL also provided a partial (50%) protection of M27-35 from plasma hydrolysis. No specific advantages regarding M26-35 were detectable in these assays. However, at low epitope concentrations (

Phase I/II clinical trial of a nonreplicative vaccinia virus expressing multiple HLA-A0201-restricted tumor-associated epitopes and costimulatory molecules in metastatic melanoma patients.

We performed a phase I/II clinical trial in metastatic melanoma patients with an ultraviolet (UV)-inactivated nonreplicating recombinant vaccinia virus enabling the expression, from a single construct, of endoplasmic reticulum-targeted HLA-A0201-restricted Melan-A/MART-1(27-35), gp100(280-288), and tyrosinase(1-9) epitopes, together with CD80 and CD86 costimulatory proteins. Corresponding soluble peptides were used to boost responses and granulocyte-macrophage colony-stimulating factor was used as systemic adjuvant. Safety and immunogenicity, as monitored with in vitro-restimulated peripheral blood mononuclear cells by cytotoxic T lymphocyte precursor (CTLp) frequency analysis and tetramer staining, were specifically addressed. Of 20 patients entering the protocol, 2 had to withdraw because of rapidly progressing disease. Immune responses were evaluated in 18 patients (stage III, n = 5; stage IV, n = 13) and increases in specific CTLp frequencies were observed in 15. In 16 patients responsiveness against all 3 antigens could be analyzed: 7 (43%), including all stage III cases, showed evidence of induction of CTLs specific for the three epitopes, and 2 (12%) and 4 (25%), respectively, showed reactivity against two or one tumor-associated antigen. In three stage IV patients no specific CTL reactivity could be induced. Increases in CTLp frequency were detected mostly after viral vaccine injections. However, in a majority of patients final CTLp levels were comparable to initial levels. Tetramer characterization of Melan-A/MART-1(27-35)-specific CTLs during the protocol also suggested preferential expansion after recombinant virus administration. Vector-specific humoral responses, frequently undetectable in stage IV patients, did not appear to prevent tumor-associated antigen-specific CTL induction. Aside from a single occurrence of transient grade 3 leukopenia, no major clinical toxicity was reported. Seventeen of 18 patients completed the 3-month trial (one patient died before the last delayed-type hypersensitivity test). Three displayed regression of individual metastases, seven had stable disease, and progressive disease was observed in seven patients. This is the first report on the administration of a UV-inactivated recombinant vaccinia virus coexpressing five transgenes in cancer patients. The results described here, in terms of safety and immunogenicity, support the use of this reagent in active specific immunotherapy.

[Swiss surgery: quo vadis? Reader and market analysis for strategic positioning of a specialty journal]. / Swiss Surgery: Quo vadis? Leser- und Marktanalyse zur strategischen Positionierung einer Fachzeitschrift.

UNLABELLED: Scientific journals currently face challenges including cost pressures caused by economic constraints, increasing rivalry among competitors, limited market potential of non-english speaking journals, increasing medical specialization with resulting market fragmentation, and internet-based competition. We therefore analyzed strategic opportunities of the journal Swiss Surgery on the basis of customer surveys and of a market analysis. RESULTS: Swiss surgeons expressed their interest in the continuation of the journal but also indicated their support for changes in its concept and for an increased use of electronic media. An international market analysis points-out the difficulties of national, non-english speaking journals in gaining impact points and in attracting authors and readers of scientific medical articles. Therefore, a journal such as Swiss Surgery should identify and use publication niches. RECOMMENDATION: The demand for a concept addressing surgical training including continuous postgraduate education was confirmed by the customers of Swiss Surgery. A corresponding offer does not presently exist in the area and could become the new focus of the journal. This change of concept may have a number of consequences: A journal focusing on surgical training and education should use the results of readers' surveys rather than impact point assignment to evaluate quality. The journal should increasingly use electronic services including data bases, pictures, videos and closed user groups to supplement the print version. At short term, however, the printed version should be continued and not be substituted by the electronic version in order to maintain the established brand "Swiss Surgery".

Endothelin receptor antagonists: structures, synthesis, selectivity and therapeutic applications.

Endothelin (ET) was discovered in 1988 and is the most potent vasoconstrictive peptide known to date. It exists in three isoforms (ET-1 to ET-3) and acts on two endothelin receptor subtypes, the endothelin-A (ET(A))-receptor and the endothelin-B (ET(B))-receptor. Endothelin receptor antagonists are novel therapeutics in clinical development for different cardiovascular, cerebrovascular, and renal diseases. Several different structural classes of endothelin receptor antagonists have been discovered within the last decade, starting from peptidic- and peptidomimetic structures to small organic molecules suitable as therapeutics for oral administration. Focussing on the small organic molecules, the different structural classes of ET-receptor antagonists are described with respect to synthesis, structure-activity-relationships, receptor-subtype-selectivity profile, and where possible, intended therapeutic indications.

Pentopyranosyl oligonucleotide systems. Part 11: Systems with shortened backbones: (D)-beta-ribopyranosyl-(4'-->3')- and (L)-alpha-lyxopyranosyl-(4'-->3')-oligonucleotides.

The (L)-alpha-lyxopyranosyl-(4'-->3')-oligonucleotide system-a member of a pentopyranosyl oligonucleotide family containing a shortened backbone-is capable of cooperative base-pairing and of cross-pairing with DNA and RNA. In contrast, corresponding (D)-beta-ribopyransoyl-(4'-->3')-oligonucleotides do not show base-pairing under similar conditions. We conclude that oligonucleotide systems can violate the 'six-bonds-per-backbone-unit' rule by having five bonds instead, if their vicinally bound phosphodiester bridges can assume an antiperiplanar conformation. An additional structural feature that seems relevant to the cross-pairing capability of the (L)-alpha-lyxopyranosyl-(4'-->3')-oligonucleotide system is its (small) backbone/basepair axes inclination. An inclination which is similar to that in B-DNA seems to be a prerequisite for an oligonucleotide system's capability to cross-pair with DNA.

L-alpha-lyxopyranosyl (4'-->3') oligonucleotides: a base-pairing system containing a shortened backbone.

[formula: see text] The L-alpha-lyxopyranosyl (4'-->3') oligonucleotide system shows cooperative base-pairing in spite of containing only five instead of the usual six covalent bonds per repetitive backbone unit. In contrast, corresponding D-beta-ribofuranosyl (4'-->3') oligonucleotides do not show adenine-thymine pairing under comparable conditions. The difference in pairing behavior relates to the conformation of the two systems' vicinal 3',4'-phosphodiester substituents, which is diaxial in the lyxopyranosyl system and 3'-axial-4'-equatorial in the ribopyranosyl system.

Pyranosyl-RNA: chiroselective self-assembly of base sequences by ligative oligomerization of tetranucleotide-2',3'-cyclophosphates (with a commentary concerning the origin of biomolecular homochirality).

BACKGROUND: Why did Nature choose furanosyl-RNA and not pyranosyl-RNA as her molecular genetic system? An experimental approach to this problem is the systematic comparison of the two isomeric oligonucleotide systems with respect to the chemical properties that are fundamental to the biological role of RNA, such as base pairing and nonenzymic replication. Pyranosyl-RNA has been found to be not only a stronger, but also a more selective pairing system than natural RNA; both form hairpin structures with comparable ease. Base sequences of pyranosyl-RNA can be copied by template-controlled replicative ligation of short activated oligomers (e.g. tetramer-2',3'-cyclophosphates) under mild and potentially natural conditions. The copying proceeds with high regioselectivity as well as chiroselectivity: homochiral template sequences mediate the formation of the correct (4'-->2')-phosphodiester junction between homochiral tetramer units provided they have the same sense of chirality as the template. How could homochiral template sequences assemble themselves in the first place? RESULTS: Higher oligomers of pyranosyl-RNA can self-assemble in dilute solutions under mild conditions by ligative oligomerization of tetramer-2',3'-cyclophosphates containing hemi self-complementary base sequences. The only side reaction that effectively competes with ligation is hydrolytic deactivation of 2',3'-cyclophosphate end groups. The ligation reaction is highly chiroselective; it is slower by at least two orders of magnitude when one of the (D)-ribopyranosyl units of a homochiral (D)-tetramer-2',3'-cyclophosphate is replaced by a corresponding (L)-unit, except when the (L)-unit is at the 4' end of the tetramer and carries a purine, when the oligomerization rate can be approximately 10% of that shown for a homochiral isomer. The oligomerization of homochiral tetramers is not, or only weakly, inhibited by the presence of the non-oligomerizing diastereomers. CONCLUSIONS: Available data on the chiroselective self-directed oligomerization of tetramer-2',3'-cyclophosphates allow us to extrapolate that sets of tetramers with different but mutually fitting base sequences can be expected to co-oligomerize stochastically and generate sequence libraries consisting of predominantly homochiral (D)- and (L)-oligomers, starting from the racemic mixture of tetramers containing all possible diastereomers. Such a capability of an oligonucleotide system deserves special attention in the context of the problem of the origin of biomolecular homochirality: breaking molecular mirror symmetry by de-racemization is an intrinsic property of such a system whenever the constitutional complexity of the products of co-oligomerization exceeds a critical level.

Watson-Crick base-pairing properties of bicyclo-DNA.

A series of sequences of the DNA analog bicyclo-DNA, 6-12 nucleotides in length and containing all four natural nucleobases, were prepared and their Watson-Crick pairing properties with complementary RNA and DNA, as well as in its own series, were analyzed by UV-melting curves and CD-spectroscopy. The results can be summarized as follows: bicyclo-DNA forms stable Watson-Crick duplexes with complementary RNA and DNA, the duplexes with RNA generally being more stable than those with DNA. Pyrimidine-rich bicyclo-DNA sequences form duplexes of equal or slightly increased stability with DNA or RNA, whereas purine-rich sequences show decreased affinity to complementary DNA and RNA when compared with wild-type (DNA-DNA, DNA-RNA) duplexes. In its own system, bicyclo-DNA prefers antiparallel strand alignment and strongly discriminates for base mismatches. Duplexes are always inferior in stability compared with the natural ones. A detailed analysis of the thermodynamic properties was performed with the sequence 5'-GGATGGGAG-3'x 5'-CTCCCATCC-3' in both backbone systems. Comparison of the pairing enthalpy and entropy terms shows an enthalpic advantage for DNA association (delta deltaH = -18 kcal x (mol)-1)) and an entropic advantage for bicyclo-DNA association (delta deltaS = 49 cal x K(-1) x mol(-1), leading to a delta deltaG 25 degrees C of -3.4 kcal x mol(-1) in favor of the natural duplex. The salt dependence of Tm for this sequence is more pronounced in the case of bicyclo-DNA due to increased counter ion screening from the solvent. Furthermore bicyclo-DNA sequences are more stable towards snake venom phosphodiesterase by a factor of 10-20, and show increased stability in fetal calf serum by a factor of 8 compared with DNA.

Bicyclo-DNA: a Hoogsteen-selective pairing system.

BACKGROUND: The natural nucleic acids (DNA and RNA) can adopt a variety of structures besides the antiparallel double helix described by Watson and Crick, depending on base sequence and solvent conditions. Specifically base-paired DNA structures with regular backbone units include left-handed and parallel duplexes and triple and quadruple helical arrangements. Given the base-pairing pattern of the natural bases, preferences for how single strands associate are determined by the structure and flexibility of the sugar-phosphate backbone. We set out to determine the role of the backbone in complex formation by designing DNA analogs with well defined modifications in backbone structure. RESULTS: We recently developed a DNA analog (bicyclo-DNA) in which one (gamma) of the six torsion angles (alpha-zeta) describing the DNA-backbone conformation is fixed in an orientation that deviates from that observed in B-DNA duplexes by about + 100 degrees , a shift from the synclinal to the antiperiplanar range. Upon duplex formation between homopurine and homopyrimidine sequences, this analog preferentially selects the Hoogsteen and reversed Hoogsteen mode, forming A-T and G-C+ base pairs. Base-pair formation is highly selective, but degeneracy is observed with respect to strand orientation in the duplex. CONCLUSIONS: The flexibility and orientation of the DNA backbone can influence the preferences of the natural bases for base-pairing modes, and can alter the relative stability of duplexes and triplexes.