Applicability of the surgical risk calculator by the American College of Surgeons in the setting of German patients undergoing complete pancreatectomy: multicentre study using data from the StuDoQ|Pancreas registry.

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.

Potential for cure and predictors of long-term survival after radiofrequency ablation for colorectal liver metastases: A 20-years single-center experience.

BACKGROUND: Additional radiofrequency ablation (RFA) of liver-limited colorectal liver metastases (CRLM) improves overall (OS) and recurrence-free survival (RFS) over systemic therapy alone. We aimed to assess the potential and predictive factors of long-term survival and cure to optimize patient selection for RFA application. METHODS: Retrospective review of a prospectively maintained single-center database of consecutive patients undergoing RFA for liver-limited CRLM after systemic therapy between 2002 and 2020. Clinicopathologic characteristics and KRAS/BRAF-genotype data (tested routinely since 2010) were correlated to RFS and OS. Cure was defined as ≥10-years RFS (long-term survival as ≥5-years OS) following RFA. RESULTS: For the entire cohort of 158 patients (median follow-up 13.6 years), co-occurrence of three factors, RECIST-defined response, number of ≤3 CRLM, and ≤3 cm maximum size determined a survival plateau that distinguished cured from non-cured patients (10-years RFS: 15.5% vs 0%, p < 0.0001). Among 59 patients (37.3%) being tested, 4(6.8%) were BRAF-mt, 15(25.4%) KRAS-mt, and 40(67.8%) KRAS/BRAF-wt. OS (median follow-up 8.3 years) was estimated to be higher with KRAS/BRAF-wt compared to a mutant KRAS or BRAF status (5-years OS: 22.8% vs 3.4%, p = 0.0018). CONCLUSION: This study indicates about 15% chance of cure following RFA of low-volume liver-limited CRLM after downsizing by systemic therapy and a negative effect of KRAS or BRAF mutation on long-term survival after CRLM ablation. These findings may improve clinical decision-making in patients potentially candidate to RFA of CRLM and encourage further investigations on molecular factors determining an oligometastatic state of CRLM curable with focal ablative therapy.

[The Impact of Lockdown during the COVID-19 Pandemic on Care for Elective Patients (C-elective Study) - Results of a Multicenter Survey]. / Die Auswirkung des Lockdowns während der COVID-19-Pandemie auf die Versorgung von elektiven Patienten (C-elective-Studie).

BACKGROUND: Due to the COVID-19-related lockdown regulations, surgical clinics had to cut down elective procedures. The impact of the cancellation and postponing surgery on patients is unclear. METHODS: All patients from six hospitals with canceled surgery during the first lockdown (03/16-04/24/2020) were asked to answer a questionnaire. RESULTS: In total, 225 patients took part. In 88 (39.1%) patients, the disease-related complaints changed, mainly towards an increase in severity (82.6%). That was especially true for hernia patients (44.4%). In 4% of the cases, there was a complication requiring surgery in the time interval between the original date of the operation and the interview. For about a third, the cancelation of scheduled surgery caused major administrative difficulties. Most of the patients (76.3%) understood the measures taken, though 40.4% of them considered that their indication was very urgent. DISCUSSION AND CONCLUSION: The overall complication rate was low, and patients agreed to the measures taken; however, especially hernia patients showed increasing symptoms and some acute incarcerations. It seems reasonable to monitor symptomatic patients closely, in order to prioritise them when surgical capacity is restricted.

First Report of a Late Lethal Pulmonary Biliary Embolism following Hepatic Microwave Ablation.

Microwave ablation (MWA) is an established tool in modern therapy of hepatic malignomas. Although it is generally a safe procedure, severe complications related to MWA have been reported in the literature. We report on the first case of a fatal pulmonary biliary embolism following hepatic MWA. The development of pulmonary biliary embolisms is possible and should be considered particularly in the case of by extensive ablation near liver veins.

[Diffuse malignant peritoneal mesothelioma (DMPM) - a rare diagnosis]. / Das diffuse maligne peritoneale Mesotheliom (DMPM) ­ eine seltene Diagnose.

Diffuse malignant peritoneal mesothelioma (DMPM) is a rare diagnosis, found more frequently in men than in women. Symptoms are unspecific abdominal disorders making that diagnosis difficult to set. Causes of DMPM are yet to be discovered in entirety. Asbestos exposure is the reason for approximately 7 % of all peritoneal mesotheliomas. Until the evaluation of systematic cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) DMPM was a fatal diagnosis with a median overall survival (OS) of 4-13 months. The prognosis of DMPM dramatically improved with implementation of CRS and HIPEC to an OS of 30-92 month nowadys. CRS and HIPEC were performed in this case.

Establishing a student-run free clinic in a major city in Northern Europe: a 1-year experience from Hamburg, Germany.

BACKGROUND: Student-Run Free Clinics (SRFCs) have been an integral part of US medical schools since the 1960s and provide health care to underserved populations. In 2018, we established an SRFC in Hamburg, Germany, a major city in Northern Europe. The aim of this study was to describe the central problems and to investigate the usefulness of an SRFC in a country with free access to medical care, such as Germany. METHODS: All consecutive patients treated at the SRFC Hamburg between February 2018 and March 2019 that consented to this study were analyzed regarding clinical characteristics, diagnosis, readmission rate and country of origin. RESULTS: Between February 2018 and March 2019, 229 patients were treated at the SRFC in Hamburg. The patients came from 33 different countries with a majority (n = 206, 90%) from countries inside the European Union. The most common reasons for visiting the SRFC were infections (23.2%), acute or chronic wounds (13.5%) and fractures (6.3%). CONCLUSION: Our multicultural patients suffer mainly from infections and traumatological and dermatological diseases. We find similarities to published Canadian SRFC patient cohorts but differences in diseases and treatment modalities compared to US SRFCs. Importantly, we demonstrate the relevance and necessity of the SRFC in a major city in Northern Europe.

Correlation between SACE (Subjective Angiographic Chemoembolization Endpoint) score and tumor response and its impact on survival after DEB-TACE in patients with hepatocellular carcinoma.

PURPOSE: To asses angiographic and computed tomographic success criteria during and after transcatheter arterial drug-eluting bead chemoembolization (DEB-TACE) in patients with hepatocellular carcinoma (HCC) and its impact on progression-free survival (PFS) and overall survival (OS). METHODS: In this retrospective single-center study, 50 patients with unresectable HCC having undergone DEB-TACE from January 2010 to July 2015 were assessed. The angiographic endpoint was classified by Subjective Angiographic Chemoembolization Endpoint (SACE) scale. Relative tumor density in arterial (DArt) and portal venous phase (DPV) computed tomography post- versus pre-DEB-TACE were calculated, respectively. Tumor response according to modified Response Criteria in Solid Tumors (mRECIST) was assessed. Univariate Kaplan-Meier and Cox regression analysis were carried out. RESULTS: SACE scores I, II, III, and IV were found in 1 (2%), 20 (40%), 15 (30%), and 14 (28%) patients, respectively. Median OS and PFS were 14.2 and 5.5 months, respectively. Death rates at 6 months, 1 year and 2 years were 24%, 38%, and 52%, respectively. SACE score during DEB-TACE significantly correlated with local and overall mRECIST results (local: p < 0.001, r = 0.49, overall: p = 0.042, r = 0.29) and inversely correlated with DPV (p = 0.005, r = - 0.40). In univariate analysis, progressive disease (PD) according to mRECIST and increase of DArt and DPV were associated with significantly shorter PFS. Modified RECIST independently predicted OS (hazard ratio for complete remission vs. PD = 0.15, 95% confidence interval 0.03-0.68, p = 0.014). CONCLUSIONS: A direct impact of SACE on PFS or OS could not be shown. However, SACE significantly correlated with local and overall mRECIST tumor response that again significantly predicted OS. We therefore postulate an indirect impact of SACE on OS. Consequently, complete embolization should be attempted.

[Benign multicystic peritoneal mesothelioma (BMPM) - a surprising differential diagnosis in case of an expected intraabdominal abscess formation]. / Das benigne multizystische peritoneale Mesotheliom (BMPM) ­ Eine überraschende Differenzialdiagnose bei Verdacht auf einen intraabdominellen Abszess.

The benign multicystic peritoneal mesothelioma is a rare disease. Most frequently, young women in reproductive age are affected by this disease. Nevertheless, there are known cases of multicystic peritoneal mesothelioma in male patients. The pathogenesis remains uncertain. Whereas asbestos fibers can cause the development of malignant mesothelioma, the exposure to asbestos particles cannot induce this type of mesothelioma. An inflammatory genesis is discussed as well as the idea of a neoplastic development. Since a high rate of recurrence after surgery is observed, an aggressive surgical treatment is recommended. The complete resection of affected tissue is recently considered to be the therapy of choice. The combination of complete surgical tumor reduction with an intraperitoneal hyperthermic chemotherapy (HIPEC) seems to be promising. Although malignant transformation is detected very rarely a close follow up in centers with high surgical and oncological expertise is recommended.

Impact of Systemic Therapy and Recurrence Pattern on Survival Outcome after Radiofrequency Ablation for Colorectal Liver Metastases.

Background: Most patients undergoing radiofrequency ablation (RFA) of colorectal liver metastasases (CLM) develop disease recurrence, but little is known about the effect of recurrence patterns and/or systemic therapy on outcome. In this study, we examined the recurrence patterns and survival after systemic therapy plus RFA in patients with unresectable CLM without extrahepatic disease. The aims were to analyze the effect of recurrence patterns on survival and to assess the relative benefit contributed by systemic therapy and local ablation to disease control and patient outcome. Methods: From January 2002 to December 2012, 113 patients underwent RFA of liver-limited CLM after systemic therapy. Univariate and multivariate analyses for associations between clinical and/or treatment-related variables, recurrence-free survival (RFS), recurrence patterns, and overall survival (OS) were carried out. Results: Of 113 patients, 105 (92.8%) had disease recurrence (median RFS: 6.1 months). Lower post-recurrence OS was observed after early (≤6 months) than after late recurrence (8.5 versus 24.0 months, p < 0.001). Recurrence sites were RFA-sites only (4.8%), liver-only (57.1%), lung-only (10.5%), or multiple (27.6%); the corresponding post-recurrence OS was 21, 19, 39, and 7 months (p < 0.001), respectively. Response to pre-RFA systemic therapy was the strongest predictor for OS (hazard ratio [HR] 5.28), RFS (HR 3.30), early (odds ratio [OR] 6.34) and multiple-site recurrence (OR 3.83) (p < 0.01), respectively; only responders achieved 5-year OS and RFS (29% and 12% versus 0% and 0% for non-responders, p < 0.001, respectively). Conclusions: Survival after RFA for liver-limited CLM is strongly linked to the timing and pattern of non-local disease recurrence. Local ablation efficacy is necessary but not sufficient to obtain long-term disease control. Effective pre-RFA systemic therapy does favourably affect the incidence, timing and patterns of recurrence and long-term survival and appears essential for the tailoring of RFA application to maximize patient benefit.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum.

OBJECTIVE: Zenker´s diverticulum (ZD) is a rare cause of dysphagia. Various surgical and flexible endoscopic therapies are available with either higher morbidity or either higher recurrence rate. Therefore, improved treatment options are needed. MATERIAL AND METHODS: This case report involves an 83-year-old female patient with symptomatic ZD. Under flexible endoscopic control, a new 5 mm fully rotatable surgical stapler was used for the dissection of the septum between the ZD and the esophageal lumen. An ultrathin endoscope and the 5 mm stapler were introduced together through a flexible overtube under conscious sedation. RESULTS: ZD treatment with this new stapler technique was feasible and effective in our patient. Procedure time was 10 min. Clinical symptoms improved immediately and the patient could be discharged the day after the procedure. CONCLUSION: The described stapler technique under flexible endoscopic control is the first report of this new treatment option for ZD. This new technique under conscious sedation may have some potential advantages compared to standard techniques such as better long-term results and lower complication rates. Further studies are needed.

Selection criteria for radiofrequency ablation for colorectal liver metastases in the era of effective systemic therapy: a clinical score based proposal.

BACKGROUND: At present, there are no widely accepted criteria for the use of radiofrequency ablation (RFA) for the treatment of colorectal liver metastases (CLM) in the context of effective modern-agent therapies. We aimed to define selection criteria for patients with liver-limited CLM who may benefit from adding RFA to systemic therapy with respect to long-term disease control. METHODS: Between 2002 and 2007, 88 consecutive patients received RFA for liver-only CLM during partial remission (PR), stable disease (SD), or progressive disease (PD) after systemic therapy. At a median follow-up of 8.2 years (range 5.2-11.1 years), clinical data were correlated to overall survival (OS) and recurrence-free survival (RFS). RESULTS: Poor OS and RFS correlated significantly with PD to systemic therapy before RFA (HR 5.46; p < 0.0001; and HR 6.46; p < 0.0001), number of ≥4 CLM (HR 3.13; p = 0.0005; and HR 1.77; p = 0.0389), and carcinoembryonic antigen (CEA) level of ≥100 ng/ml (HR 1.67; p = 0.032; and HR 1.67; p = 0.044). The presence of four criteria (PR, ≤3 CLM, ≤3 cm maximum size, and CEA ≤100 ng/ml) selected a subgroup (n = 23) with significantly higher probabilities for OS and RFS at 5 years (39% and 22%,respectively) compared to those without any or up 3 of these criteria (0-27% and 0-9%, p < 0.001, respectively). CONCLUSIONS: A score based on four criteria (response to systemic therapy, ≤3 CLM, ≤3 cm size, low CEA value) may allow to select patients with liver-only CLM for whom additional use of RFA most likely adds benefit in an attempt to achieve long-term disease control. Almost one-fourth of patients fulfilling these four criteria may achieve 5-year survival without disease recurrence following effective systemic plus local RFA treatment.

The LiverSurgeryTrainer: training of computer-based planning in liver resection surgery.

PURPOSE: The training of liver surgeons depends on local conditions such as the specialization of the clinic, the spectrum of cases, and the instructing surgeons. We present the LiverSurgeryTrainer a software application to support the training of prospective surgeons in preoperative decision making. METHODS: The LiverSurgeryTrainer visualizes radiological images, volumetric information, and interactive 3D models of patients' liver anatomy. In addition, it provides special interaction techniques and tools to perform individual resections on the training data. To assess the correctness of decisions made by the learner, comments and decisions from experienced liver surgeons are provided for each case. To complete the case, additional material concerning the actual surgery (e.g., videos, reports) is presented. The application workflow is derived from a scenario-based design process and is based on an instructional design model. RESULTS: The LiverSurgeryTrainer was evaluated in several steps. A formative usability evaluation identified workflow and user interface flaws that were resolved in further development process. A summative evaluation shows the improvement of the LiverSurgeryTrainer in nearly all analyzed aspects. First results of a learning success evaluation show that learners experience a learning effect. CONCLUSION: Our training system allows surgeons to train procedures and interaction techniques for computer-based planning of liver interventions. The evaluations showed acceptance and usability.

Surgical treatment of pain in patients with chronic pancreatitis.

BACKGROUND/AIMS: The objectives of the research were to compare the outcomes of pancreatoduodenectomy (PD) (Kausch-Whipple or Traverso-Longmire) and resection with drainage operations (RDO) (Frey or Partingtone-Rochelle) in patients suffering from chronic pancreatitis (CP), in management of pain syndrome and quality of life provided by these kinds of surgical procedures. METHODOLOGY: From 2002 to 2008 sixteen patients suffering from CP underwent PD and 16 underwent RDO. Treatment results for the two groups were analyzed with respect to postoperative complications and results of the questionnaire MOS SF-36 v.2(TM). RESULTS: In the immediate postoperative period more complications were observed in the PD group (a<0.05). In both groups a positive effect on removing the painful syndrome and improvement of the quality of life (p<0.01) were observed. In the PD group there were the best results of management by General Health difference criterion (a<0.01). A greater improvement of Physical Functiong value (a<0.01) was noticed in patients who underwent RDO. CONCLUSIONS: Both PD and RDO adequately remove pain syndrome and improve the quality of life in patients suffering from CP. Under equal conditions the preference should be given to RDO, as improvement in life quality of operated patients is greater.

[Innovative application of radiofrequency in hepatic surgery. Preliminary experience]. / Un'applicazione innovativa della radiofrequenza in chirurgia epatica: esperienza preliminare.

Intraoperative blood loss has long been identified as one of the major morbidity and mortality predictors in liver surgery. A new approach towards achieving bloodless resection is the use of heat coagulative necrosis in healthy liver tissue, creating a zone of necrosis in which resection can be performed with a scalpel. We have used it for a variety of liver resections ranging from wedge resection to trisegmentectomy to establish the best indications. From March 2005 to June 2006 we performed 31 liver resections on 22 consecutive patients using this method. The most common indication was metastatic colorectal cancer (77.2%). We treated a heterogeneous patient series in terms of tumour location and extent of resection. Resectability was enhanced by means of downsizing chemotherapy (2 cases) and induction of portal hypertrophy (1 case). Twelve patients with metastatic colorectal cancer received adjuvant chemotherapy after the primary operation according to histological staging. Metastatic liver disease was synchronous in 7 cases and metachronous in 8 (mean time to metastasis 25.3 months). The operative spectrum ranged from parenchyma-saving atypical resections to extended right hepatectomy. With two exceptions, intraoperative blood loss was lower than 100 ml. Four patients (18.2%) developed surgery-related complications consisting in abscess formation at the resection site. Liver resection using the sealer device would appear to be a safe, time-efficient method, though it requires extensive knowledge of the anatomy of the intrahepatic vessels. Resections in the proximity of hilar structures or large vessels are not indicated for fear of thermal damage. Extended resections are possible if performed with a hybrid technique with conventional hilar preparation. In our experience this new application of radiofrequency-assisted liver resection seems to be effective and safe and may afford a number of advantages (no blood loss, short resection time. etc.) in selected cases.

Impact of intraoperative radiotherapy (IORT) on survival of patients with unresectable hilar cholangiocarcinoma.

BACKGROUND/AIMS: The cure or long-term survival of hilar cholangiocarcinoma patients can only be achieved after complete tumor resection. Many patients though suffer from unresectable hilar cholangiocarcinoma, and palliative treatment is therefore the only therapeutic option. In cases of unresectable bile duct cancer, intraoperative radiotherapy (IORT) is an additional option during surgery. The aim of this study was to compare the efficacy of IORT to surgery alone in patients with unresectable hilar cholangiocarcinoma. METHODOLOGY: Palliative IORT (group 1) was performed on 9 patients (4 female/5 male); surgery alone (group 2) was performed in a case-matched group of 9 patients (4 female, 5 male) with unresectable hilar cholangiocarcinoma. The mean ages were 52.9 years (group 1) and 57.2 years (group 2). The two groups had comparable local tumor extension and stages of tumor disease according to UICC 6th edition. Group 1 was also compared to all 36 patients (n=36) suffering from unresectable cholangiocarcinoma treated without IORT (Group 3). RESULTS: The survival of patients after IORT was significantly improved compared to surgery alone in this study. The median survival time was 23.3 months (group 1) versus 9.4 months (group 2) and 5.7 month (group 3). The one year and two year actuarial survival rates are: 56% and 42% (group 1), 33% and 0% (group 2), 25% and 8% (group 3). CONCLUSIONS: Palliative surgery including IORT is safe for patients with unresectable hilar cholangiocarcinoma. The benefit shown by this investigation is a significant improvement of survival time after application of IORT in the palliative situation. A prospective study with randomization is needed to confirm these first results in a larger cohort.