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OBJECTIVE: A multi-national high-volume center study was undertaken to evaluate outcomes after primary surgery (PS) or neoadjuvant treatment followed by surgery (NAT/S) in cT2 staged adenocarcinomas of the esophagus (EAC) and gastroesophageal junction (GEJ). BACKGROUND: Optimal treatment approach with either NAT/S or PS for clinically staged cT2cNany or cT2N0 EAC and GEJ remains unknown due to the lack of randomized controlled trials. METHODS: Retrospective analysis of prospectively maintained databases from ten centers was performed. Between 01/2012-08/2023 645 patients who fulfilled inclusion criteria of GEJ Siewert type I, II or EAC with cT2 status at diagnosis underwent PS or NAT/S with curative intent. Primary endpoint was overall survival (OS). RESULTS: In the cT2cNany cohort 192 patients (29.8%) underwent PS and 453 (70.2%) underwent NAT/S. In all cT2cN0 patients (n=333), NAT/s remained the more frequent treatment (56.2%). Patients undergoing PS were in both cT2 cohorts older (P<0.001) and had a higher ASA classification (P<0.05). R0 resection showed no differences between NAT/S and PS in both cT2 cohorts (P>0.4).Median OS was 51.0 months in the PS group (95% CI 31.6-70.4) versus 114.0 months (95% CI 53.9-174.1) in the NAT/S group (P=0.003) of cT2cNany patients. For cT2cN0 patients NAT/S was associated with longer OS (P=0.002) and disease-free survival (DFS) (P=0.001). After propensity score matching of cT2N0 patients, survival benefit for NAT/S remained (P=0.004). Histopathology showed that 38.1% of cT2cNany and 34.2% of cT2cN0 patients were understaged. CONCLUSIONS: Due to unreliable identification of cT2N0 disease, all patients should be offered a multimodal therapeutic approach.
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BACKGROUND: Retrosternal oesophageal reconstructions with collar anastomoses can become necessary when the stomach is either unavailable for oesophageal replacement, or orthotopic reconstruction is deemed impractical. Our aim was to analyse our results regarding technical approaches and outcomes. MATERIALS AND METHODS: All patients undergoing primary and secondary oesophageal retrosternal reconstructions with collar anastomoses at our centre (2019-2023) were retrospectively analysed and individual surgical reconstruction options were presented. RESULTS: Overall, twelve patients received primary (n = 5; 42.7%) or secondary (n = 7; 58.3%) reconstructions; ten with colonic interposition and two with gastric pull-up. Male/female ratio was 4:8; median age 66 years (30-87). Charlson-Comorbidity-Score (CCS) was 5 (1-7); 8/12 patients (67%) had ASA-classification score ≥ 3. We observed no conduit necrosis, but one patient (8.3%) with a leakage of the oesophago-colonostomy which was successfully treated by endoscopic vacuum therapy. Four patients (33.3%) acquired nosocomial pneumonia. Additional drainages for pleural fluid collections were necessary in three patients (25%). Overall comprehensive-complication-index (CCI) was 26.2 (0-44.9). Length-of-stay (LOS) was 22 days median (15-40). There was no 90-days mortality. Overall, CCI during the follow-up (FU) period at median 26 months (16-50) was 33.7 (0-100). 10 out of 12 patients were on sufficient oral nutrition at 12 months FU. CONCLUSION: Primary and secondary oesophageal retrosternal reconstructions encompass diverse entities and typically requires tailored decision-making. These procedures, though rare, are feasible with acceptable complication rates and positive functional outcomes when performed in experienced hands.
Subject(s)
Anastomosis, Surgical , Esophagectomy , Humans , Male , Female , Aged , Middle Aged , Retrospective Studies , Aged, 80 and over , Adult , Anastomosis, Surgical/methods , Esophagectomy/methods , Esophagoplasty/methods , Postoperative Complications/surgery , Postoperative Complications/etiology , Plastic Surgery Procedures/methods , Treatment Outcome , Esophageal Neoplasms/surgery , Esophageal Neoplasms/pathologyABSTRACT
BACKGROUND: Total neoadjuvant therapy (TNT) has been used for patients with locally advanced rectal cancer. The optimal sequence of chemoradiotherapy (CRT) and chemotherapy (CT) is a matter of debate. METHODS: We performed a pooled analysis of the CAO/ARO/AIO-12 and OPRA multicenter, randomized phase 2 trials to identify patient subsets that could benefit from one TNT sequence over the other regarding disease-free survival (DFS). Patients with stage II/III rectal cancer were randomized to CRT (50.4-54 Gy) with either induction (INCT-CRT) or consolidation CT (CRT-CNCT) with fluorouracil, leucovorin, oxaliplatin (CAO/ARO/AIO-12 and OPRA) or capecitabine and oxaliplatin (OPRA) followed by mandatory total mesorectal excision (TME) (CAO/ARO/AIO-12) or selective watch-and-wait surveillance (OPRA). 311 and 324 patients were recruited from June 15, 2015 to January 31, 2018; and from April 12, 2014 to March 30, 2020 in the two trials, respectively. Pretreatment clinical and tumor characteristics included were age, sex, ECOG, cT-category, cN-category, clinical UICC stage, location from anal verge, and tumor grade. FINDINGS: In total, 628 eligible patients were included in the pooled analysis (CAO/ARO/AIO-12, n = 304; OPRA, n = 324). Of those, 313 were randomly assigned to the INCT-CRT group, and 315 to the CRT-CNCT group. Median follow-up was 43 months (IQR, 35-49) months in the CAO/ARO/AIO-12 trial and 61,2 months (IQR, 42-68,4) in the OPRA trial. Pooled analysis of baseline clinical and tumor characteristics did not identify any subgroups of patients that would benefit by the one TNT sequence over the other with regard to DFS. INTERPRETATION: To our knowledge, this is the first pooled analysis of two randomized trials after direct head-to-head comparison of both TNT sequences. Both trials reported higher rates of complete response with CRT-CNCT, and this should be considered the preferred TNT sequence if organ preservation is a priority.
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BACKGROUND: Animated videos have become popular in teaching medical students, although there is a certain lack of evidence concerning its efficacy. Surgery seems to be an ideal field for its application, since animations are very helpful to understand anatomic structures and complex procedures. The aim of this study was to investigate the effects of animated videos compared to textbooks on learning gain. METHODS: A prospective 2-arm cohort study with 5th-year medical students was conducted during their 2-week surgical training module. The initial cohort of students received textbook sections on 3 major topics in visceral surgery as learning medium (text cohort). During the following semester, the second cohort of students received 3 animated whiteboard videos (animated videos) containing equivalent content (video cohort). All participants completed a multiple-choice test consisting of 15 questions on the learning content at baseline (pre-test) and after the learning period (post-test) and answered an additional evaluation questionnaire. RESULTS: Both cohorts were similar in their descriptive data and demonstrated significant learning gain during the 2-week learning period. The video cohort achieved better results (80% vs 73% correct answers; P = .028) and a higher learning gain (17% vs 11%; P = .034) in the post-test compared to the text cohort. The estimated learning time was longer in the video cohort (62 min vs 37 min; P < .001) and watching the videos resulted in higher learning gain (21% vs 6%; P < .001). Subgroups with higher learning gain by video learning were female gender (20% vs 11%; P = .040), native German speakers (18% vs 11%; P = .009), students without prior surgical experience (19% vs 12%; P = .033) and those undecided concerning a surgical career (22% vs 9%; P = .020). Interestingly, "low digital orientation" students benefited from videos (22% vs 13%; P = .021), whereas "high digital orientation" students did not. CONCLUSIONS: Animated videos increase medical students' learning gain and interest in surgery.
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BACKGROUND AND AIMS: Despite recent advancements in medical and surgical techniques in patients suffering from Crohn`s Disease (CD), postoperative morbidity remains relevant due to a long-standing, non-curable disease burden. As demonstrated for oncological patients, perioperative enhanced recovery concepts provide great potential to improve postoperative outcome. However, robust evidence about the effect of perioperative enhanced recovery concepts in the specific cohort of CD patients is lacking. METHODS: In a prospective single-center study, all patients receiving ileocecal resection due to CD between 2020 and 2023 were included. A specific perioperative enhanced recovery concept (ERC) was implemented and patients were divided into two groups (before and after implementation). The primary outcome focused on postoperative complications as measured by the Comprehensive Complication Index (CCI), secondary endpoints were severe complications, length of hospital stay, and rates of re-admission. RESULTS: 83 patients were analyzed of which 33 patients participated in the enhanced recovery program (postERC). While patient characteristics were comparable between both groups, ERC resulted in significantly decreased rates of overall and severe postoperative complications (CCI: 21.4 versus 8.4, p=0.0036; Clavien Dindo >2: 38% versus 3.1%, p=0.0002). Additionally, postERC-patients were earlier ready for discharge (6.5 days versus 5 days, p=0.001) and rates of re-admission were significantly lower (20% versus 3.1%, p=0.03). In a multivariate analysis, the recovery concept was identified as independent factor to reduce severe postoperative complications (p=0.019). CONCLUSION: A specific perioperative enhanced recovery concept significantly improves the postoperative outcome of patients suffering from Crohn`s Disease.
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Objective: Postoperative pulmonary embolism (PE) is a rare but potentially life-threatening complication, which can be treated with extracorporeal membrane oxygenation (ECMO) therapy, a novel therapy option for acute cardiorespiratory failure. We postulate that hospitals with ECMO availability have more experienced staff, technical capabilities, and expertise in treating cardiorespiratory failure. Design: A retrospective analysis of surgical procedures in Germany between 2012 and 2019 was performed using hospital billing data. High-risk surgical procedures for postoperative PE were analyzed according to the availability of and expertise in ECMO therapy and its effect on outcome, regardless of whether ECMO was used in patients with PE. Methods: Descriptive, univariate, and multivariate analyses were applied to identify possible associations and correct for confounding factors (complications, complication management, and mortality). Results: A total of 13,976,606 surgical procedures were analyzed, of which 2,407,805 were defined as high-risk surgeries. The overall failure to rescue (FtR) rate was 24.4% and increased significantly with patient age, as well as type of surgery. The availability of and experience in ECMO therapy (defined as at least 20 ECMO applications per year; ECMO centers) are associated with a significantly reduced FtR in patients with PE after high-risk surgical procedures. In a multivariate analysis, the odds ratio (OR) for FtR after postoperative PE was significantly lower in ECMO centers (OR, 0.75 [0.70-0.81], P < 0.001). Conclusions: The availability of and expertise in ECMO therapy lead to a significantly reduced FtR rate of postoperative PE. This improved outcome is independent of the use of ECMO in these patients.
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BACKGROUND: Acute appendicitis is a global disease with high incidence. The main objective was to assess the association between time from admission to surgery (TAS) and surgery during emergency hours with operative outcome in light of conflicting evidence. METHODS: This is a retrospective population-wide analysis of hospital billing data (2010-2021) of all adult patient records of surgically treated cases of acute appendicitis in Germany by TAS. The primary outcome was a composite clinical endpoint (CCE; prolonged length of stay, surgical site infection, interventional draining after surgery, revision surgery, ICU admission and/or in-hospital mortality). Cases of complicated appendicitis were identified using diagnosis (ICD-10) and procedural codes (resection beyond appendectomy). RESULTS: 855 694 patient records were included, of which 27·6% (236,481) were complicated cases of acute appendicitis. 49·0% (418,821) were females and median age was 37 (interquartile range 22·5-51·5). Age, male sex, and comorbidity were associated with an increased proportion of CCE and in-hospital mortality. TAS was associated with a clinically relevant increase of CCE after 12 h in complicated appendicitis [Odd's ratio (OR), 1·19, 95% CI: 1·14-1·21] and after 24 h in uncomplicated appendicitis (OR 1·10, 95% CI: 1·02-1·19). Beyond the primary endpoint, the proportion of complicated appendicitis increased after TAS of 72 h. Surgery during emergency hours (6 pm-6.59 am) was associated with an increase of CCE and mortality (OR between 1·14 and 1·49). Age, female sex, night-time admission, weekend admission, a known previous surgery, obesity, and therapeutic anticoagulation were associated with delayed performance of surgery. CONCLUSION: This work found an increase of a CCE after TAS of 12 h for complicated appendicitis and an increase of the CCE after TAS of 24 h for uncomplicated appendicitis with a stable proportion of complicated appendicitis in these time windows. Both CCE and mortality were increased if appendectomy was performed during emergency hours.
Subject(s)
Appendectomy , Appendicitis , Humans , Appendicitis/surgery , Appendicitis/mortality , Male , Female , Retrospective Studies , Adult , Middle Aged , Appendectomy/adverse effects , Germany/epidemiology , Time-to-Treatment/statistics & numerical data , Young Adult , Hospital Mortality , Treatment Outcome , Length of Stay/statistics & numerical data , Cohort Studies , Time FactorsABSTRACT
Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.
Subject(s)
Crohn Disease , Margins of Excision , Recurrence , Humans , Crohn Disease/surgery , Crohn Disease/pathology , Male , Female , Adult , Risk Factors , Retrospective Studies , Middle Aged , Postoperative Complications/etiology , Postoperative Complications/epidemiology , Young Adult , Aged , Postoperative PeriodABSTRACT
About one third of all colorectal carcinomas (CRC) are localised in the rectum. As part of a multimodal therapy concept, neoadjuvant therapy achieves downstaging of the tumour in 50-60% of cases and a so-called complete clinical response (cCR), defined as clinically (and radiologically) undetectable residual tumour after completion of neoadjuvant therapy, in 10-30% of cases.In view of the perioperative morbidity and mortality associated with radical rectal resection, including the occurrence of a symptom complex known as low anterior resection syndrome (LARS) and the need for deviation, at least temporarily, the question of the risk-benefit balance of organ resection in the presence of cCR has been raised. In this context, the therapeutic concept of a "watch-and-wait" approach with omission of immediate organ resection and inclusion in a structured surveillance regime, has emerged.For a safe, oncological implementation of this option, it is necessary to develop standards in the definition of a suitable patient clientele and the implementation of the concept. In addition to the initial correct selection of the patient group that is suitable for a primarily non-surgical procedure, the inherent goal is the early and sufficient detection of tumour recurrence (so-called local regrowth) during the "watch-and-wait" phase (surveillance).In this context, in this paper we address the questions of: 1. the optimal timing of initial re-staging, 2. the criteria for assessing the clinical response and selecting the appropriate patient clientele, 3. the rhythm and design of the surveillance protocol.
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Colorectal Neoplasms , Rectal Neoplasms , Humans , Rectal Neoplasms/diagnosis , Rectal Neoplasms/surgery , Postoperative Complications , Syndrome , Rectum , Pathologic Complete ResponseABSTRACT
INTRODUCTION: Major postoperative bleeding (mPOB) is the most common complication after bariatric surgery. Its intesity varies from self-limiting to life-threatening situations. Comprehensive decision-making and treatment strategies are mandatory but not established yet. METHODS: We retrospectively analyzied our prospectively collected database of our bariatric patients during 2012-2022. The primary study endpoint was major postoperative bleeding (mPOB) defined as hemoglobin drop > 2 g/dl or clinically relevant bleeding requiring intervention (transfusion, endoscopy or surgery). Secondary endpoints were overall complications according to Clavien-Dindo-Classification and comprehensive-complication-index (CCI). RESULTS: We identified 1017 patients, of whom 667 underwent gastric bypass (GB) and 350 sleeve gastrectomy (SG). Major postoperative bleeding occured in 39 patients (total 3.8%; 5.1% after GB and 2.3% after SG). Patients with mPOB were more often diagnosed with type 2 diabetes (p = 0.039), chronic kidney failure (p = 0.013) or received antiplatelet drug treatment (p = 0.003). The interval from detection to intervention within 24 h was 92.1% (35/39). Blood transfusions were necessary in 20/39 cases (total 51.3%; 45.2% after GB and 75% after SG; p = 0.046). Luminal bleeding only occured after GB (19/31; 61.3%), while all mPOB after SG were intraabdominal (p = 0.002). Reoperations were performed in 21/39 (total 53.8%; 48.4% after GB and 75% after SG; p = 0.067). CCI in patients with mPOB was 34.7 overall, with 31.2 after GB and 47.9 after SG (p = 0.005). CONCLUSION: The clinical appearance of mPOB depends on the type of surgery with severe bleedings after SG. We suggest a surgery first approach for mPOB after SG and an endoscopy first approach after GB.
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Bariatric Surgery , Diabetes Mellitus, Type 2 , Gastric Bypass , Obesity, Morbid , Humans , Obesity, Morbid/surgery , Diabetes Mellitus, Type 2/surgery , Diabetes Mellitus, Type 2/complications , Retrospective Studies , Treatment Outcome , Bariatric Surgery/adverse effects , Gastric Bypass/adverse effects , Postoperative Hemorrhage/epidemiology , Postoperative Hemorrhage/etiology , Postoperative Hemorrhage/therapy , Gastrectomy/adverse effects , Postoperative Complications/etiologyABSTRACT
PURPOSE: Coronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany. METHODS: This is a retrospective population-wide analysis of hospital billing data (2012-2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic. RESULTS: Of a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%). CONCLUSION: During lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection.
Subject(s)
COVID-19 , Diverticulitis , Humans , Retrospective Studies , COVID-19/epidemiology , Pandemics , Cohort Studies , Communicable Disease Control , Diverticulitis/surgery , Hospitalization , Germany/epidemiologyABSTRACT
Loss of intestinal epithelial barrier function is a hallmark in digestive tract inflammation. The detailed mechanisms remain unclear due to the lack of suitable cell-based models in barrier research. Here we performed a detailed functional characterization of human intestinal organoid cultures under different conditions with the aim to suggest an optimized ex-vivo model to further analyse inflammation-induced intestinal epithelial barrier dysfunction. Differentiated Caco2 cells as a traditional model for intestinal epithelial barrier research displayed mature barrier functions which were reduced after challenge with cytomix (TNFα, IFN-γ, IL-1ß) to mimic inflammatory conditions. Human intestinal organoids grown in culture medium were highly proliferative, displayed high levels of LGR5 with overall low rates of intercellular adhesion and immature barrier function resembling conditions usually found in intestinal crypts. WNT-depletion resulted in the differentiation of intestinal organoids with reduced LGR5 levels and upregulation of markers representing the presence of all cell types present along the crypt-villus axis. This was paralleled by barrier maturation with junctional proteins regularly distributed at the cell borders. Application of cytomix in immature human intestinal organoid cultures resulted in reduced barrier function that was accompanied with cell fragmentation, cell death and overall loss of junctional proteins, demonstrating a high susceptibility of the organoid culture to inflammatory stimuli. In differentiated organoid cultures, cytomix induced a hierarchical sequence of changes beginning with loss of cell adhesion, redistribution of junctional proteins from the cell border, protein degradation which was accompanied by loss of epithelial barrier function. Cell viability was observed to decrease with time but was preserved when initial barrier changes were evident. In summary, differentiated intestinal organoid cultures represent an optimized human ex-vivo model which allows a comprehensive reflection to the situation observed in patients with intestinal inflammation. Our data suggest a hierarchical sequence of inflammation-induced intestinal barrier dysfunction starting with loss of intercellular adhesion, followed by redistribution and loss of junctional proteins resulting in reduced barrier function with consecutive epithelial death.
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INTRODUCTION: Internal hernia is one of the most frequent long-term complications after laparoscopic gastric bypass surgery (RYGB). Surgical treatment of an internal hernia itself has risks that can largely be avoided by the implementation of institutional standards and a structured approach. MATERIAL AND METHODS: From 2012 until 2022, we extracted all consecutive bariatric cases from the prospectively collected national database (StuDoQ). Data from all patients undergoing internal hernia repair were then collected from our hospital information management system and retrospectively analyzed. We compared patient characteristics and surgical outcome of patients before and after the implementation of standard operating procedures for institutional and perioperative aspects (first vs. second time span). RESULTS: Overall, 37 patients were identified (median age 43 years, 86.5% female). Internal hernia was diagnosed after substantial weight loss (17.2 kg/m2) and on average about 34 months after RYGB. Baseline characteristics (age, sex, BMI, achieved total weight loss% and time interval to index surgery were comparable between the two groups). After local standardization, the conversion rate decreased from 52.6 to 5.6% (p = 0.007); duration of surgery from 92 to 39 min (p = 0.003), and length of stay from 7.7 to 2.8 days (p = 0.019). CONCLUSION: In this study, we could demonstrate that the surgical therapy of internal hernia after gastric bypass can be significantly improved by implementing institutional and surgical standards. The details described (including a video) may provide valuable information for non-specialized surgeons to avoid pitfalls and improve surgical outcomes.
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Gastric Bypass , Humans , Female , Adult , Male , Gastric Bypass/adverse effects , Retrospective Studies , Internal Hernia , Databases, Factual , HerniorrhaphyABSTRACT
PURPOSE: A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis. METHODS: Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis. RESULTS: In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly. CONCLUSION: Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.
Subject(s)
Colectomy , Colon, Sigmoid , Diverticulitis , Hospital Mortality , Humans , Colectomy/adverse effects , Colectomy/statistics & numerical data , Colon, Sigmoid/surgery , Diverticulitis/surgery , Incidence , Postoperative Complications/epidemiologyABSTRACT
Low-grade appendiceal mucinous neoplasms (LAMN) are rare and are diagnosed in at least 0.13% of appendectomies in Germany, although significant underreporting is likely. Perforation of the tumors can result in abdominal mucinous collections, so-called pseudomyxoma peritonei (PMP). The challenge in the treatment of LAMN is the adequate approach to the incidental finding of these tumors. If a mucinous neoplasm is preoperatively suspected in cases of an acute condition, usually appendicitis, it must be weighed up whether a conservative approach is justifiable or whether immediate appendectomy is necessary. If this is the case, an intraoperative perforation of the appendix must be avoided and the complete abdominal cavity must be inspected for mucin deposits. If conservative treatment is possible, further treatment should take place at a specialized center. If the neoplasm is first found incidentally during surgery, perforation of the appendix should also be avoided and the entire abdominal cavity should be inspected for a PMP. If a PMP is present cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) should be performed in a specialized center. If LAMN are found during the postoperative histological work-up, it should be evaluated whether a perforation was present and mucin collections are noted in the surgical report. In the case of LAMN without evidence of a PMP, appendectomy is the adequate treatment. In cases of intra-abdominal mucinous collections, samples should be taken and further treatment should be performed at a center with sufficient expertise. An ileocecal resection or oncological hemicolectomy is not indicated. After adequate treatment, all patients should receive a follow-up using cross-sectional imaging (preferably magnetic resonance imaging, MRI) and determination of the tumor markers CEA, CA 19-9 and CA 125.
Subject(s)
Adenocarcinoma, Mucinous , Appendiceal Neoplasms , Neoplasms, Cystic, Mucinous, and Serous , Peritoneal Neoplasms , Pseudomyxoma Peritonei , Humans , Peritoneal Neoplasms/pathology , Peritoneal Neoplasms/surgery , Adenocarcinoma, Mucinous/diagnosis , Adenocarcinoma, Mucinous/surgery , Incidental Findings , Pseudomyxoma Peritonei/diagnosis , Pseudomyxoma Peritonei/therapy , Pseudomyxoma Peritonei/pathology , Appendiceal Neoplasms/diagnosis , Appendiceal Neoplasms/surgeryABSTRACT
BACKGROUND: Neoplasms of the vermiform appendix are rare. They comprise a heterogeneous group of entities requiring differentkinds of treatment. METHODS: This review is based on publications retrieved by a selective literature search in the PubMed, Embase, and Cochranedatabases. RESULTS: 0.5% of all tumors of the gastrointestinal tract arise in the appendix. Their treatment depends on their histopathologicalclassification and tumor stage. The mucosal epithelium gives rise to adenomas, sessile serrated lesions, adenocarcinomas,goblet-cell adenocarcinomas, and mucinous neoplasms. Neuroendocrine neoplasms originate in neuroectodermal tissue. Adenomasof the appendix can usually be definitively treated by appendectomy. Mucinous neoplasms, depending on their tumorstage, may require additional cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC). Adeno -carcinomas and goblet-cell adenocarcinomas can metastasize via the lymphatic vessels and the bloodstream and should thereforebe treated by oncological right hemicolectomy. Approximately 80% of neuroendocrine tumors are less than 1 cm in diameterwhen diagnosed and can therefore be adequately treated by appendectomy; right hemicolectomy is recommended if the patienthas risk factors for metastasis via the lymphatic vessels. Systemic chemotherapy has not been shown to be beneficial forappendiceal neoplasms in prospective, randomized trials; it is recommended for adenocarcinomas and goblet-cell adenocarcinomasof stage III or higher, in analogy to the treatment of colorectal carcinoma.
Subject(s)
Adenocarcinoma , Appendiceal Neoplasms , Appendix , Hyperthermia, Induced , Humans , Appendiceal Neoplasms/diagnosis , Appendiceal Neoplasms/surgery , Prospective Studies , Adenocarcinoma/pathology , Adenocarcinoma/surgery , AppendectomyABSTRACT
INTRODUCTION: Surgical risk calculators can estimate risk probabilities for postoperative outcomes utilizing patient-specific risk factors. They provide meaningful information for obtaining informed consent. The aim of the present paper was to evaluate the predictive value of the surgical risk calculators by the American College of Surgeons in German patients undergoing total pancreatectomy. METHODS: Data for patients who underwent total pancreatectomy between 2014 and 2018 were acquired from the Study, Documentation, and Quality Center of the German Society for General and Visceral Surgery. Risk factors were entered manually into the surgical risk calculators and calculated risks were compared with actual outcomes. RESULTS: Of the 408 patients analysed, predicted risk was higher in patients with complications except for the prediction of re-admission (P = 0.127), delayed gastric emptying (P = 0.243), and thrombosis (P = 0.256). In contrast, classification of patients into below, above, or average risk by the surgical risk calculators only produced meaningful results for discharge to nursing facility (P < 0.001), renal failure (P = 0.003), pneumonia (P = 0.001), serious complications, and overall morbidity (both P < 0.001). Assessment of discrimination and calibration showed poor results (scaled Brier scores 8.46 per cent or less). CONCLUSION: Overall surgical risk calculator performance was poor. This finding promotes the development of a specific surgical risk calculator applicable to the German healthcare system.
Subject(s)
Pancreatectomy , Surgeons , Humans , United States , Pancreatectomy/adverse effects , Pancreas , Patient Discharge , RegistriesABSTRACT
BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is estimated to have claimed more than 6 million lives globally since it started in 2019. Germany was exposed to two waves of coronavirus disease 2019 in 2020, one starting in April and the other in October. To ensure sufficient capacity for coronavirus disease 2019 patients in intensive care units, elective medical procedures were postponed. The fraction of major abdominal cancer resections affected by these measures remains unknown, and the most affected patient cohort has yet to be identified. METHODS: This is a register-based, retrospective, nationwide cohort study of anonymized 'diagnosis-related group' billing data provided by the Federal Statistical Office in Germany. Cases were identified using diagnostic and procedural codes for major cancer resections. Population-adjusted cancer resection rates as the primary endpoint were compared at baseline (2012-2019) to those in 2020. RESULTS: A change in resection rates for all analyzed entities (esophageal, gastric, liver, pancreatic, colon, rectum, and lung cancer) was observed from baseline to 2020. Total monthly oncological resections dropped by 7.4% (8.7% normalized to the annual German population, P =0.011). Changes ranged from +3.7% for pancreatic resections ( P =0.277) to -19.4% for rectal resections ( P <0.001). Reductions were higher during lockdown periods. During the first lockdown period (April-June), the overall drop was 14.3% (8.58 per 100 000 vs. 7.35 per 100 000, P <0.001). There was no catch-up effect during the summer months except for pancreatic cancer resections. In the second lockdown period, there was an overall drop of 17.3%. In subgroup analyses, the elderly were most affected by the reduction in resection rates. There was a significant negative correlation between regional SARS-CoV-2 incidences and resections rates. This correlation was strongest for rectal cancer resections (Spearman's r : -0.425, P <0.001). CONCLUSIONS: The pandemic lockdowns had a major impact on the oncological surgical caseload in Germany in 2020. The elderly were most affected by the reduction. There was a clear correlation between SARS-CoV-2 incidences regionally and the reduction of surgical resection rates. In future pandemic circumstances, oncological surgery has to be prioritized with an extra focus on the most vulnerable patients.