[Perioperative antibiotic prophylaxis for pancreas resections with and without preoperative bile drainage : Is there room for improvement?] / Perioperative Antibiotikaprophylaxe bei Pankreasresektionen mit und ohne präoperative Galleableitung : Gibt es Verbesserungspotenzial?

BACKGROUND: Whether an immediate surgical treatment or preoperative bile drainage (PBD) should be performed in cases of obstructive jaundice caused by a pancreatic carcinoma has been a matter of controversy for decades. The aim of this study based on in-house patient data was to evaluate both the influence of PBD on septic complications and to analyze intraoperative bile samples in patients with PBD in order to formulate current recommendations for antibiotic treatment. MATERIAL AND METHODS: Relevant data from all pancreatic resections performed in this hospital from January 2013 to December 2017 were collected in a prospective database and were retrospectively analyzed. Depending on the presence of a PBD the collected data were checked for postoperative complications. In addition, the spectrum of bacteria on bile duct swabs was analyzed in patients with PBD and the sensitivity to ampicillin-sulbactam was tested according to the resistogram. Subsequently, an antibiotics recommendation for the practice was compiled. RESULTS: Within the period under consideration 197 pancreas resections were performed in this hospital, 122 of which were duodenopancreatectomies and 20 total pancreatectomies (n = 142). A PBD was performed in 28.2% (40/142) of the patients. There were no significant differences in mortality, intra-abdominal abscesses, post-pancreatectomy hemorrhages (PPH) or postoperative pancreatic fistulas (POPF) depending on a PBD. On the other hand, a significantly higher rate of postoperative wound infections was found in patients with PBD (+PBD 18/40, 45.0% vs. -PBD 13/102, 12.7%, P < 0.0001). Bacteriobilia was found in 86.8% (33/38) of patients with PBD. In 47.4% (18/38) of patients with PBD at least 1 detected bacterium of the bile duct culture was not sensitive to ampicillin-sulbactam. Regarding the antibiotics piperacillin-tazobactam 8 patients (21%) and ciprofloxacin or imipenem 4 patients each (10.5%) showed a bacterium with resistance. CONCLUSION: In general, the indications for a PBD should be strictly applied. If a PBD needs to be performed, perioperative antibiosis should be optimized to minimize subsequent complications. A hospital adjusted perioperative antibiotic prophylaxis should be developed and preoperatively obtained swab results, e. g. within endoscopic retrograde cholangiopancreatography (ERCP) can be used to increase the effectiveness of perioperative antibiotics. Based on an internal analysis of intraoperative bile duct swabs, ciprofloxacin is used in this hospital for the perioperative antibiotic treatment of patients with PBD.

[Sacral nerve modulation in coloproctology]. / Sakrale Nervenmodulation in der Koloproktologie.

Sacral nerve modulation and stimulation (SNM/SNS) is a minimally invasive treatment for fecal incontinence, which has become widely established in recent years. Modulation of sacral nerve roots occurs through an electrode which is placed in the sacral foramina S2-4. By complex spinal and supraspinal mechanisms, rectal compliance is improved and anal incontinence episodes are reduced. The use of SNM is a suitable therapeutic option for nearly all causes of fecal incontinence refractory to conservative treatment. In the majority of patients, a significant reduction of incontinence episodes or a complete relief of symptoms is achieved. These results are also observed in long-term follow-up. Although the efficacy of SNM in constipation is less well established, it may be considered in patients who fail to respond to conservative measures. The role of further potential indications for SNM/SNS in coloproctological disorders is discussed in the present review.

International Study Group of Pancreatic Surgery Definitions for Postpancreatectomy Complications: Applicability at a High-Volume Center.

INTRODUCTION: The perioperative morbidity following pancreas surgery remains high due to various specific complications: postoperative pancreatic fistula, postpancreatectomy hemorrhage, and delayed gastric emptying. The International Study Group of Pancreatic Surgery has defined these complications. The aim of this study is to evaluate the clinical applicability, to validate the International Study Group of Pancreatic Surgery definition, and to evaluate the postoperative morbidity. METHODS: Between 2004 and 2014, 769 patients underwent resection. Data were collected in a prospective database. Univariate examination was performed using the χ2-test. Continuous data were tested with the Mann-Whitney U-test. Student's t-tests and Fisher's exact tests were performed. RESULTS: A total of 542 patients were included in this study. In all, 91 (16.8%) patients developed postoperative pancreatic fistula, 69 of them clinically relevant grades B and C postoperative pancreatic fistula. Grades B and C postoperative pancreatic fistulas were significantly associated with a longer hospital stay. The postoperative pancreatic fistula grade significantly correlated with re-operation. Totally, 32 (5.9%) patients developed postpancreatectomy hemorrhage. Postpancreatectomy hemorrhage grade was significantly associated with re-operation and 30-day mortality. In all, 14 of 19 patients with grade C postpancreatectomy hemorrhage (73.7%) were re-operated; 3 had a simultaneous postoperative pancreatic fistula C. Grade B postpancreatectomy hemorrhage significantly prolonged hospital stay. Grade C postpancreatectomy hemorrhage significantly prolonged intensive care unit stay. Grade C postpancreatectomy hemorrhage led to longer intensive care unit stay but a shorter hospital stay. Delayed gastric emptying occurred in 131 (24.2%) patients. The delayed gastric emptying grade was significantly associated with re-operation. Nine of the re-operated patients had a simultaneous postoperative pancreatic fistula C. Grades A, B, and C delayed gastric emptying were associated with prolonged hospital- and intensive care unit stay. CONCLUSION: Delayed gastric emptying is the most common specific complication after pancreas resection, followed by postoperative pancreatic fistula and postpancreatectomy hemorrhage. The International Study Group of Pancreatic Surgery definitions are well applicable in clinical routine and the different grades correlate well with severity of clinical condition, length of hospital or intensive care unit stay, and mortality. Their widespread use can contribute to a more reproducible and reliable comparison of surgical outcomes in pancreas surgery.

Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.

OBJECTIVES: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial. BACKGROUND: PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications. METHODS: A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up. RESULTS: From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters. CONCLUSIONS: The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.

[Chronic pancreatitis. Operation indications and procedures]. / Chronische Pankreatitis. Operationsindikation und -verfahren.

Chronic pancreatitis can lead to intractable pain, pancreatic duct obstruction, duodenal stenosis and vascular compression syndromes. Surgical interventions can effectively treat these symptoms. Endoscopic procedures are principally possible but rarely lead to a lasting relief of symptoms. The type of surgical intervention should be selected depending on the morphological changes of the pancreas. Up to 90 % of patients present with an inflammatory mass in the head of the pancreas. In these cases a duodenum-preserving pancreatic head resection (DPPHR) modified according to Beger, Frey or Berne should be preferred. These procedures are comparable in terms of the postoperative course. The Kausch-Whipple procedure is indicated in all cases where malignancy is suspected. According to the current literature, patients with an inflammatory mass in the pancreatic head benefit more from a DPPHR than a Kausch-Whipple procedure. Drainage procedures may be useful for the treatment of pseudocysts or in rare situations with purely ductal obstructions. The decision as to which procedure is appropriate should be taken in an interdisciplinary cooperation between gastroenterologists and surgeons.

[Redo intervention and complication management in bariatric surgery]. / Redo-Eingriffe und Komplikationsmanagement in der bariatrischen Chirurgie.

Morbid obesity and the associated comorbidities are rapidly increasing worldwide. Bariatric surgery has proven to be an effective treatment option. In 2011 more then 340,000 bariatric procedures were performed worldwide which is accompanied by a growing demand for revision bariatric procedures due to complications or failure, such as insufficient weight loss or weight regain.Redo operation procedures as well as the management of complications require a profound preoperative medical history and diagnostic investigation in combination with an exact knowledge of the anatomical changes made in the primary procedure.

Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture.

AIM: Surgical site infection (SSI) is a common complication following ileostomy closure with a frequency of up to 40%. This prospective randomized controlled trial was initiated to compare two surgical techniques - direct suture (DS) and purse-string suture (PSS) - used to close the wound following ileostomy closure. The primary end-point was the SSI rate. Secondary end-points were cosmetic outcome [using two validated scales: the Patient and Observer Scar Assessment Scale (POSAS) and the Body Image Questionnaire (BIQ)] and the influence of other factors on the SSI rate. METHOD: Of a total of 99 patients screened, 84 were included in this study. Forty-three patients were randomized into the PSS group and 41 were randomized into the DS group. Follow up was performed within 3 days after surgery, at discharge, and 30 days and 6 months after the operation. RESULTS: In the PSS group there were no cases of SSI compared with 10 (24%) cases in the DS group (P = 0.0004). There were no statistically significant differences in cosmetic outcome between the two groups. No other statistically significant factors influencing the incidence of SSI could be identified. CONCLUSION: The rate of SSI is significantly lower following PSS than following DS, and both techniques have a similar cosmetic outcome. PSS closure should be considered as standard of care for wound closure after ileostomy reversal.

[Pancreatic anastomosis -- a video comparison of different techniques]. / Die Pankreasanastomose - ein Videovergleich unterschiedlicher Anastomosentechniken.

INTRODUCTION: The pancreatic anastomosis seems to be the most difficult and dangerous anastomosis in general surgery, especially in a soft pancreas. Many techniques have been described. The techniques most often used are: anastomosis of the pancreas to the jejunum as a pancreatico-jejunostomy (duct-to-mucosa anastomosis) or as a pancreato-jejunostomy (invaginating anastomosis). Another widely used anastomosis for reconstruction after pancreatic head resection is from the stomach to the pancreas, i.e., pancreato-gastrostomy. In literature the data concerning postoperative complications (pancreatic fistula, postoperative bleeding and others) are not consistent. INDICATIONS: Reconstruction after pancreatic head resection. PROCEDURE: Anastomosis between small intestine or stomach and the pancreas. CONCLUSION: There is no gold standard for pancreatic anastomosis. Thus, of the different commonly used techniques, in our opinion, the best technique for each surgeon seems to be the one that he/she is most familiar with.

[Significance of drains in surgery]. / Stellenwert von Drainagen in der Chirurgie.

Placing drains is one the most common procedures following operations in surgical disciplines. The indication for placing a drain is, however, usually based on a traditional belief rather than being evidence-based. This paper presents an overview of the literature regarding the indications and the evidence level for placing drains following operations in visceral, vascular, thoracic and orthopeedic surgery as well as traumatology. In visceral surgery the indications for placing drains could be clarified over the past decades but in other surgical fields the level of evidence needs further investigation and clarification through future studies. The available data suggest that in most cases a prophylactic drainage can be avoided. In addition, drains may lead to increased morbidity and higher treatment costs.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]. / Offenes Abdomen 2009. Umfrage zu Behandlungsstrategien des offenen Abdomens in Deutschland.

BACKGROUND: Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany. MATERIAL AND METHODS: A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively. RESULTS: The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years. CONCLUSIONS: Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Gene expression profiling of liver metastases and tumour invasion in pancreatic cancer using an orthotopic SCID mouse model.

The prognosis of pancreatic adenocarcinoma is affected by early metastases and local tumour invasion beyond surgical margins. Gene expression profiling in pancreatic cancer tissue is complicated due to the high amount of RNAses being present in human tissue and that of suitable models. In order to demonstrate early metastases, the models should take into account the anatomical environment of the tumour. Using the orthotopic transplantation of pancreatic tumour cells in SCID (severe combined immunodeficiency) mice, these interactions are taken into consideration. In order to identify genes associated with local tumour invasion and metastases in ductal pancreatic cancer, we investigated a human pancreatic tumour cell line derived from an orthopic pancreatic tumour model in SCID mice. Differential gene expression was performed on the basis of microarray technique. The human MiaPaca-2 cell line was implanted orthotopically in SCID mice. Transcriptional profiling was performed on fresh frozen tissue derived from the primary tumour, the tumour invasion front and the liver metastases. Differentially expressed genes were identified using statistical analyses, and were validated with external databases and with immunohistochemistry. A total of 1066 of 14 500 genes were significantly differentially expressed. Comparing the primary tumour with the tumour invasion front, there were 614 statistically significant up- and 348 downregulated genes. Twenty-five statistically significant up- and 181 downregulated genes were identified comparing the liver metastases with the primary tumour. Eight genes (PAI-1, BNIP3l, VEGF, NSE, RGS4, HSP27, GADD45A, PTPN14) were chosen and validated in a semi-quantitative immunohistochemical analysis, which revealed a positive correlation to the array data. Overrepresentation analyses revealed a total of 66 significantly regulated pathways associated with cell proliferation, cell stress, cell communication metabolic and cytokine function. In conclusion, model marker genes for local invasion and liver metastases can be identified using transcriptional profiling in the SCID mouse. Overrepresentation analysis secures a good and fast overview about the significantly regulated genes and can assign genes to certain pathways. These marker genes can be related to the apoptotic cascade, angiogenesis and cell interaction.

[Elective colon resection in Germany. A survey of the perioperative anesthesiological management]. / Elektive Kolonresektionen in Deutschland. Umfrage zum perioperativen anästhesiologischen Management.

BACKGROUND: Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany. METHODS: In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection. RESULTS: The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia. CONCLUSION: In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

Postoperative complications of pancreatic cancer surgery.

The incidence of ductal adenocarcinoma of the pancreas has been increasing worldwide in recent years. About 5% to 25% of all pancreatic cancers are resectable and only curatively resected patients enjoy a favourable outcome. But even in experienced centers a postoperative morbidity of 30-50% and a mortality around or underneath 5% is reported. As long term-survival is rare and complications are frequent the quality of life for the remaining months or years is of paramount importance. The most severe complications lead to reoperations, prolonged hospital stay, fatigue, and nutritional disorders thereby markedly compromising quality of life. Therefore, prevention and management of complications after pancreatic resections are reviewed. Prevention of disastrous complications is possible using a decent surgical technique and handling the soft pancreatic remnant in cancer patients carefully. The end-to-side, duct-to-mucosa anastomosis is the most preferred technique. The therapy of pancreatic leakage should be individualized and completion pancreatectomy should only be an option for recurrent hemorrhage, and a necrotic pancreatic stump. The continuous postoperative observation of the patient is of paramount importance to diagnose other severe complications, such as hemorrhage and septic complications, in time. Only early diagnosis and management of these complications can improve outcome and save life. Pancreaticoduodenectomy can be a safe procedure in experienced institutions, where the whole medical team is able to diagnose and treat these complications at any time.

[Detection of micrometastases after curative resection for ductal adenocarcinoma of the pancreas]. / Detektion von Mikrometastasen nach kurativer Resektion duktaler Adenokarzinome des Pankreas.

OBJECTIVES: Despite apparently curative resection adenocarcinomas of the pancreas early recur. Thus, the pathological examination should be enriched by sensitive methods to detect minimal residual disease (MRD). Mutant K-ras is the most promising genetic alteration in ductal adenocarcinoma and may serve to detect malignant cells by polymerase chain reaction (PCR) based techniques. Therefore, we set out to detect K-ras mutations by PCR for evaluation of MRD in patients after curative resection of pancreatic adenocarcinoma. PATIENTS AND METHODS: Tumor tissue and corresponding paraaortic lymph nodes were obtained from 51 patients, who underwent surgery for pancreatic head tumors. The paraaortic lymph nodes were staged as tumor-free by routine histopathology in all cases diagnosed for ductal adenocarcinoma (study group, n = 40) or other tumors (control group, n = 11). Therefore, DNA of both primary tumors and lymph nodes was extracted and analysed by a PCR-based assay with respect to mutated K-ras. As a positive control the human pancreatic cancer cell line PaTu-8902 was used. RESULTS: K-ras mutations were detected in 73 % (29/40) of primary tumors of ductal adenocarcinomas and in 17 % (5/29) in the corresponding paraaortic lymph nodes, which were diagnosed as tumor-free by routine pathology. The identical type of point mutation was found in primary tumors and corresponding lymph nodes by use of sequence specific primers. In the control group no K-ras mutation was detected. CONCLUSION: Tumor cell DNA can be detected sensitively in tumor- and lymph node specimen with the described method. Routinely assessed, this method is able to detect MRD and could enrich the pathological examination, in order to determine prognostic relevant subgroups of patients.