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1.
Injury ; 51(9): 1979-1986, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32336477

RESUMO

INTRODUCTION: Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures. PATIENTS AND METHODS: We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification. RESULTS: The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety. CONCLUSIONS: Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.


Assuntos
Traumatismos Abdominais , Ferimentos não Penetrantes , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/cirurgia , Adulto , Alemanha , Humanos , Pâncreas/diagnóstico por imagem , Pâncreas/lesões , Pâncreas/cirurgia , Pancreatectomia , Estudos Retrospectivos , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia , Adulto Jovem
2.
Asian J Surg ; 43(1): 227-233, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30982560

RESUMO

BACKGROUND: Many techniques have been developed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy, but POPF rates remain high. The aim of our study was to analyze POPF occurrence after closure of the pancreatic remnant by different operative techniques. METHODS: Between 2006 and 2017, 284 patients underwent distal pancreatectomy in our institution. For subgroup analysis the patients were divided into hand-sewn (n = 201) and stapler closure (n = 52) groups. The hand-sewn closure was performed in three different ways (fishmouth-technique, n = 27; interrupted transpancreatic U-suture technique, n = 77; common interrupted suture, n = 97). All other techniques were summarized in a separate group (n = 31). Results were gained by analysis of our prospective pancreatic database. RESULTS: The median age was 63 (range 23-88) years. 74 of 284 patients (26%) were operated with spleen preservation (similar rates in subgroups). ASA-classes, median BMI as well as frequencies of malignant diseases, chronic pancreatitis, alcohol and nicotine abuse were also comparable in the subgroups. Neither the rates of overall POPF (fishmouth-technique 30%, common interrupted suture 40%, stapler closure 33% and interrupted U-suture 38%) nor the rates of POPF grades B and C showed significant differences in the subgroups. However is shown to be associated with pancreatic function and parenchymal texture. CONCLUSION: In our experience the technique of pancreatic stump closure after distal resection did not influence postoperative pancreatic fistula rate. As a consequence patient specific reasons rather than surgical techniques may be responsible for POPF formation after distal pancreatectomy.


Assuntos
Pâncreas/cirurgia , Pancreatectomia/métodos , Fístula Pancreática/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Técnicas de Fechamento de Ferimentos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
3.
BMC Cancer ; 19(1): 979, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31640628

RESUMO

BACKGROUND: One critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability. The decision between primary surgery versus upfront local or systemic cancer therapy seems especially to differ between pancreatic cancer centers. In our cohort study, we analyzed the independent judgement of resectability of five experienced high volume pancreatic surgeons in 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer. METHODS: Pretherapeutic CT or MRI scans of 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer were evaluated by 5 independent pancreatic surgeons. Resectability and the degree of abutment of the tumor to the venous and arterial structures adjacent to the pancreas were reported. Interrater reliability and dispersion indices were compared. RESULTS: One hundred ninety-four CT scans and 6 MRI scans were evaluated and all parameters were evaluated by all surgeons in 133 (66.5%) cases. Low agreement was observed for tumor infiltration of venous structures (κ = 0.265 and κ = 0.285) while good agreement was achieved for the abutment of the tumor to arterial structures (interrater reliability celiac trunk κ = 0.708 P < 0.001). In patients with vascular tumor contact indicating locally advanced disease, surgeons highly agreed on unresectability, but in patients with vascular tumor abutment consistent with borderline resectable disease, the judgement of resectability was less uniform (dispersion index locally advanced vs. borderline resectable p < 0.05). CONCLUSION: Excellent agreement between surgeons exists in determining the presence of arterial abutment and locally advanced pancreatic cancer. The determination of resectability in borderline resectable patients is influenced by additional subjective factors. TRIAL REGISTRATION: EudraCT:2009-014476-21 (2013-02-22) and NCT01827553 (2013-04-09).


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Consenso , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Carcinoma Ductal Pancreático/diagnóstico por imagem , Alemanha , Humanos , Imageamento por Ressonância Magnética , Neoplasias Pancreáticas/diagnóstico por imagem , Estudos Prospectivos , Cirurgiões/psicologia , Tomografia Computadorizada por Raios X
4.
BJS Open ; 3(4): 490-499, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31388641

RESUMO

Background: This study evaluated the outcome and survival of patients with radiologically suspected intraductal papillary mucinous neoplasms (IPMNs). Methods: IPMN management was reviewed according to Fukuoka risk factors and IPMN localization, differentiating main-duct (MD), mixed-type (MT) and branch-duct (BD) IPMNs. Perioperative results were compared with those of patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) over the same interval (2010-2014). Overall (OS) and disease-specific (DSS) survival rates were calculated and subgroups compared. Results: Of 142 patients with IPMNs, 26 had MD-IPMN, eight had MT-IPMN and 108 had BD-IPMN. Some 74 per cent of patients with MD- and MT-IPMN were managed by primary resection, whereas this was used in only 27·8 per cent of those with BD-IPMN. The risk of secondary resection and malignant transformation for BD-IPMNs smaller than 20 mm was 8 and 2 per cent respectively during follow-up. Pancreatic head resection of IPMNs was associated with an increased risk of postoperative pancreatic fistula grade B/C compared with resection of PDAC (12 of 33 (36 per cent) versus 41 of 221 (18·6 per cent) respectively; P = 0·010), and greater morbidity and mortality (Clavien-Dindo grade III: 15 of 33 (45 per cent) versus 56 of 221 (25·3 per cent) respectively; grade IV: 1 (3 per cent) versus 7 (3·2 per cent); grade V: 2 (6 per cent) versus 2 (0·9 per cent); P = 0·008). Five-year OS and DSS rates in patients with MD-IPMN were worse than those for MT- and BD-IPMN (OS: 44, 86 and 97·4 per cent respectively, P < 0·001; DSS: 60, 100 and 98·6 per cent; P < 0·001). Patients with invasive IPMN had worse OS and DSS rates than those with non-invasive dysplasia (OS: IPMN-carcinoma (10 patients) 33 per cent, high-grade dysplasia 100 per cent, intermediate-grade dysplasia 63 per cent, low grade-dysplasia 100 per cent, P < 0·001; DSS: IPMN-carcinoma 43 per cent, all grades of dysplasia 100 per cent, P < 0·001). Patients with high-risk stigmata had poorer survival than those without risk factors (OS: high-risk stigmata (35 patients) 55 per cent, worrisome features (31) 95 per cent, no risk factors (76) 100 per cent, P < 0·001; DSS: 71, 100 and 100 per cent respectively, P < 0·001). Conclusion: The risk of malignant transformation was very low for BD-IPMNs, but the development of high-risk stigmata was associated with disease-specific mortality. Patients with IPMN had greater morbidity after resection than those having resection of PDAC.


Assuntos
Pancreatectomia , Neoplasias Intraductais Pancreáticas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Neoplasias Intraductais Pancreáticas/mortalidade , Neoplasias Intraductais Pancreáticas/cirurgia , Complicações Pós-Operatórias , Fatores de Risco , Resultado do Tratamento
5.
Chirurg ; 89(5): 374-380, 2018 May.
Artigo em Alemão | MEDLINE | ID: mdl-29464308

RESUMO

BACKGROUND: The incidence of intrahepatic cholangiocarcinoma (ICC) is increasing worldwide. Surgical resection is the only curative treatment option. AIM OF THE STUDY: This study analyzed the prognostic factors after resection of ICC. MATERIAL AND METHODS: A total of 84 patients were surgically treated under potentially curative intent. Perihilar and distal cholangiocarcinomas were excluded. The 5­year survival was analyzed with respect to tumor stage (TNM), number of lesions, complete surgical resection (R0), peritoneal carcinosis and postoperative complications. RESULTS: The 5­year survival was 27% and 77% of patients underwent R0 resections. In the univariate analysis a T stage >2, an N+ situation or an R+ resection as well as peritoneal and multilocular intrahepatic spread were associated with a poorer prognosis. Postoperative complications also negatively influenced survival. On multivariate analysis the absence of peritoneal spread, node-negative tumor stages, singular hepatic lesions and a low T stage as well as the absence of complications were associated with improved survival. DISCUSSION: The prognosis of ICC is poor even after successful surgical resection. Well-known tumor characteristics such as TNM are relevant prognostic factors. Surgical resection is accompanied by postoperative complications (most frequently biliary), which negatively influence survival. Adjuvant strategies are urgently needed to improve long-term survival even after complete surgical resection.


Assuntos
Neoplasias dos Ductos Biliares , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma , Neoplasias dos Ductos Biliares/cirurgia , Colangiocarcinoma/cirurgia , Hepatectomia , Humanos , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
6.
Zentralbl Chir ; 142(2): 226-231, 2017 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-25076165

RESUMO

Background: Resistance to antibiotics is a worldwide increasing problem. A well-known example is methicillin resistant Staphylococcus aureus, MRSA. What is the relevance of MRSA on a surgical ICU? Patients/Material and Methods: On a 20 bed academic SICU/intermediate care ward 14,976 patients were treated in a seven-year period. We identified only 98 MRSA-positive patients. 56 (57 %) of them were merely colonised, 42 (43 %) suffered from an MRSA infection. A control group comprised 56 similar patients without MRSA detection. Results: Patients with MRSA infection had a higher mortality rate (OR 4.18; p = 0.002), but only 4 out of 20 patients died due to the MRSA infection. APACHE 2 score of more than 20 was predictive for being colonised with MRSA (OR 3.08; p = 0.04), but it was not a risk factor for developing an MRSA infection (OR 1.03; p = 0.95). Patients with MRSA colonisation did not have a higher mortality rate than patients without. Conclusion: Outcome depended on severity of the disease, but not on the MRSA colonisation status. Patients with MRSA infection were more likely to die, but the reason of death rarely was MRSA.


Assuntos
Infecção Hospitalar/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Staphylococcus aureus Resistente à Meticilina , Complicações Pós-Operatórias/epidemiologia , Infecções Estafilocócicas/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Portador Sadio/epidemiologia , Infecção Hospitalar/mortalidade , Estudos Transversais , Feminino , Alemanha , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Infecções Estafilocócicas/mortalidade
7.
J Gastrointest Surg ; 21(2): 330-338, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27896656

RESUMO

BACKGROUND: Morbidity after pancreas resection is still high with postoperative pancreatic fistulas (POPF) being the most frequent complication. However, exocrine insufficiency seems to protect from POPF. In clinical practice, patients showing increased postoperative systemic amylase concentrations appear to frequently develop POPF. We therefore retrospectively examined the occurrence of systemic amylase increase after pancreas resections and its association with the clinical course. PATIENTS AND METHODS: Perioperative data from 739 consecutive pancreas resections were assessed in a prospectively maintained SPSS database. Serum and drain amylase concentrations were determined by routine clinical chemistry. POPFs were graded into A-C according to ISGPF definitions. RESULTS: In patients with reduced serum amylase (n = 89) on day 1 after pancreatoduodenectomy, clinically relevant POPFs were not observed. In patients with normal serum amylase concentrations, clinically relevant POPFs occurred in 9 %, while in 39 % of the patients with more than three times elevated amylase concentrations, a clinically relevant postoperative fistula was observed (p < 0.001). Systemic hyperamylasemia detected on postoperative day 1 after pancreatoduodenectomy was further a good predictor for clinically relevant POPFs (AUROC = 0.797, p < 0.001). CONCLUSION: Patients with a high risk for developing clinically relevant POPFs can be identified on the first postoperative day by determining serum amylase.


Assuntos
Amilases/metabolismo , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreatite/enzimologia , Pancreatite/etiologia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Drenagem/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/enzimologia , Complicações Pós-Operatórias/enzimologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
8.
Ann Surg ; 263(3): 440-9, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26135690

RESUMO

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.


Assuntos
Pancreatopatias/cirurgia , Pancreaticoduodenectomia , Pancreaticojejunostomia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha/epidemiologia , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatopatias/mortalidade , Fístula Pancreática/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco
9.
Eur J Surg Oncol ; 41(10): 1300-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26253194

RESUMO

BACKGROUND: A combination of platin-based perioperative chemotherapy (PBPC) plus surgical resection has become the standard of care in Europe for locally advanced esophagogastric adenocarcinoma (EGAC). In contrast to preoperative chemotherapy, the postoperative administration of chemotherapy is omitted in a high percentage of patients. We conducted this database study to analyse the impact of postoperative completion of perioperative chemotherapy on patient outcome. METHODS: Patients with EGAC (cT3-4 and/or cN+) were treated with preoperative PBPC plus curative surgical resection. Patient demographics, postoperative tumour stages, histopathological regression (HPR) and administration of postoperative chemotherapy were correlated with overall survival. RESULTS: Of one-hundred-thirty-four patients, 76 received preoperative docetaxel, folinic acid, fluorouracil, oxaliplatin (FLOT), 53 patients epirubicin, cisplatin, folinic acid (ECF) and 5 epirubicin, oxaliplatin, capecitabine (EOX) chemotherapy. The 5-year-survival for the whole collective was 58%. Designated postoperative chemotherapy was omitted in 36% of the patients. 5-year-survival was 75.8% in patients who received pre- and post-operative chemotherapy and 40.3% in patients with only preoperative chemotherapy (p < 0.001). Histopathological regression, postoperative nodal status and administration of postoperative chemotherapy were identified as independent prognostic factors. Analysis of subgroups revealed a pronounced survival benefit after administration of postoperative chemotherapy in patients with ypN+ stages (5-year-survival 64.5% vs 9.7%, p = 0.002) and poor HPR (5-year-survival 55.5% vs 19.3%, p = 0.015). CONCLUSION: Our study provides further evidence that administration of postoperative chemotherapy may contribute to the achieved survival benefit of PBPC in patients with EGAC and implies a beneficial effect especially in presence of lymphonodular tumour involvement and limited HPR.


Assuntos
Adenocarcinoma/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Esofágicas/tratamento farmacológico , Esofagectomia , Gastrectomia , Neoplasias Gástricas/tratamento farmacológico , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Capecitabina/administração & dosagem , Quimioterapia Adjuvante/métodos , Cisplatino/administração & dosagem , Bases de Dados Factuais , Docetaxel , Epirubicina/administração & dosagem , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Junção Esofagogástrica/patologia , Feminino , Fluoruracila/administração & dosagem , Humanos , Estimativa de Kaplan-Meier , Leucovorina/administração & dosagem , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Compostos Organoplatínicos/administração & dosagem , Oxaliplatina , Período Pós-Operatório , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Taxoides/administração & dosagem , Resultado do Tratamento
10.
Chirurg ; 86(7): 662-9, 2015 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-25312491

RESUMO

BACKGROUND: An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades. OBJECTIVES: This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years. PATIENTS AND METHODS: The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012. RESULTS: Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival. CONCLUSION: During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.


Assuntos
Adenocarcinoma/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Analgesia Epidural/tendências , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Quimiorradioterapia Adjuvante/tendências , Terapia Combinada/tendências , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Esofagectomia/tendências , Feminino , Humanos , Laparoscopia/tendências , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Toracotomia/tendências
11.
Chirurg ; 86(1): 33-7, 2015 Jan.
Artigo em Alemão | MEDLINE | ID: mdl-25492242

RESUMO

BACKGROUND: Laparoscopic pancreas resections are performed with increasing frequency for pancreatic neuroendocrine tumors and other benign and malignant diseases. OBJECTIVES: This article describes the complications arising from laparoscopic resection of pancreatic neuroendocrine tumors and compares them to complications arising from similar open procedures. METHODS: Case series, reports, trials and meta-analyses were analyzed and the results are described and discussed. RESULTS: The types and the frequencies of complications are comparable for laparoscopic and open resection of pancreatic neuroendocrine tumors. The lack of the ability to perform an intraoperative examination of the pancreas to detect the tumors can be alleviated by laparoscopic ultrasound examination or in the case of tumors expressing somatostatin receptors by preoperative DOTATATE positron emission tomography (PET) computed tomography (CT) scanning. CONCLUSION: The complications arising from the resection of pancreatic neuroendocrine tumors do not justify a recommendation for a laparoscopic or open approach.


Assuntos
Carcinoma Neuroendócrino/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/etiologia , Carcinoma Neuroendócrino/diagnóstico , Estudos Transversais , Humanos , Imagem Multimodal , Neoplasias Pancreáticas/diagnóstico , Tomografia por Emissão de Pósitrons , Complicações Pós-Operatórias/epidemiologia , Tomografia Computadorizada por Raios X , Ultrassonografia
12.
Zentralbl Chir ; 140(6): 633-9, 2015 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-23846534

RESUMO

PURPOSE: It was the aim of this study to investigate the complementary diagnostic performance of a combined pelvic and thoracoabdominal magnetic resonance imaging (MRI) examination and positron emission tomography (PET) enhanced by image fusion in patients with suspected rectal cancer recurrence. PATIENTS AND METHODS: Thirty-one patients with clinically suspected recurrence from rectal cancer were retrospectively included, who had received MRI (high resolution pelvic MRI combined with thoracoabdominal MRI performed during continuous table translation) and (18)F-FDG-PET within 30 days. MRI alone, PET alone, and MRI and PET combined including fusion images were analysed by two observers in consensus. The likelihood of malignancy of all detectable lesions was rated on a 5-point Likert scale. The standard of reference consisted of histopathology and follow-up imaging. Confidence ratings were analysed with a jackknife free response receiver-operator characteristic paradigm (JAFROC). Further test characteristics were derived by considering "probably malignant" and "definitely malignant" lesions as positive test results. RESULTS: The reference standard comprised 150 malignant lesions (48 local, 102 distant). JAFROC analysis revealed overall figures-of-merit of 0.73 for MRI, 0.63 for PET, and 0.83 for the combined approach (differences significant). The sensitivities of MRI, PET and the combined approach were 85.4, 52.1, and 95.8 % for local recurrence and 61.8, 47.1, and 81.4 % for distant recurrence, respectively. CONCLUSION: The combination of local high-resolution MRI, thoracoabdominal continuously moving table MRI and FDG-PET supported by image fusion improves lesion detection in recurrent rectal cancer.


Assuntos
Aumento da Imagem/instrumentação , Aumento da Imagem/métodos , Processamento de Imagem Assistida por Computador/métodos , Imageamento por Ressonância Magnética/instrumentação , Imageamento por Ressonância Magnética/métodos , Imagem Multimodal/instrumentação , Imagem Multimodal/métodos , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/cirurgia , Tomografia por Emissão de Pósitrons/instrumentação , Tomografia por Emissão de Pósitrons/métodos , Neoplasias Retais/diagnóstico , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fluordesoxiglucose F18 , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Estudos Retrospectivos , Sensibilidade e Especificidade
13.
Chirurg ; 86(3): 276-82, 2015 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-24824001

RESUMO

BACKGROUND: Minimally invasive techniques are being used increasingly more in pancreatic surgery. Compared to resections of the pancreatic head and tail, total pancreatectomy is rarely performed. As no pancreatic anastomosis has to be made and open resection usually needs a wide laparotomy, a laparoscopically assisted technique seems desirable. AIM: The objective of this article is to report the initial results of laparoscopically assisted total pancreatectomy in three patients. MATERIAL AND METHODS: This series included two patients with a main duct type intraductal papillary mucinous neoplasm (IPMN) and one patient with pancreatic metastases from a renal carcinoma. RESULTS: All three resections were achieved laparoscopically. Reconstruction was performed through the retrieval incision. Operative time, blood loss, intermediate care and hospital stay were similar to a control group of open resections in seven patients. CONCLUSION: In this small group of selected patients laparoscopic total pancreatectomy is feasible when carried out in centers with high expertise in laparoscopy and pancreatic surgery.


Assuntos
Adenocarcinoma Mucinoso/cirurgia , Carcinoma Ductal Pancreático/cirurgia , Carcinoma Papilar/cirurgia , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pancreatectomia/métodos , Neoplasias Pancreáticas/secundário , Neoplasias Pancreáticas/cirurgia , Idoso , Estudos de Viabilidade , Feminino , Humanos , Laparoscopia/instrumentação , Masculino , Pessoa de Meia-Idade , Pancreatectomia/instrumentação , Esplenectomia/métodos , Instrumentos Cirúrgicos
14.
J Pathol ; 234(3): 410-22, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25081610

RESUMO

Cancer cell invasion takes place at the cancer-host interface and is a prerequisite for distant metastasis. The relationships between current biological and clinical concepts such as cell migration modes, tumour budding and epithelial-mesenchymal transition (EMT) remains unclear in several aspects, especially for the 'real' situation in human cancer. We developed a novel method that provides exact three-dimensional (3D) information on both microscopic morphology and gene expression, over a virtually unlimited spatial range, by reconstruction from serial immunostained tissue slices. Quantitative 3D assessment of tumour budding at the cancer-host interface in human pancreatic, colorectal, lung and breast adenocarcinoma suggests collective cell migration as the mechanism of cancer cell invasion, while single cancer cell migration seems to be virtually absent. Budding tumour cells display a shift towards spindle-like as well as a rounded morphology. This is associated with decreased E-cadherin staining intensity and a shift from membranous to cytoplasmic staining, as well as increased nuclear ZEB1 expression.


Assuntos
Adenocarcinoma/patologia , Transição Epitelial-Mesenquimal , Invasividade Neoplásica/patologia , Biomarcadores Tumorais/análise , Humanos , Imageamento Tridimensional , Imuno-Histoquímica
15.
Chirurg ; 85(7): 628-35, 2014 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-25000930

RESUMO

INTRODUCTION: In the past decades various techniques of esophagectomy for the curative treatment of esophageal cancer have been described. Especially minimally invasive techniques of esophagectomy have been used increasingly in the last decade. Technical issues and results of hybrid laparoscopic-thoracotomic en bloc esophagectomy with intrathoracic esophagogastric anastomosis (HMIE) are presented and discussed in the article. PATIENTS AND METHODS: Between May 2013 and April 2014 a total of 23 patients underwent esophagectomy for esophageal cancer at the University of Freiburg Medical Center. Of these patients 10 were treated by HMIE and the other 13 patients had open esophagectomy (OE). RESULTS: A detailed description of the operative technique of HMIE is given in a step-by-step fashion. Margin negative resection was achieved in all patients after HMIE and OE and the median lymph node yield of lymphadenectomy in HMIE and OE (29 vs. 27) was nearly the same. The medium duration of the operation (347 min vs. 412 min) and median length of stay on the intensive care unit (6 days vs. 9 days) and hospital (13 days vs. 17 days) were decreased in HMIE patients compared to OE, respectively. Overall postoperative morbidity (40 % vs. 69 %) and especially pulmonary morbidity (10 % vs. 46 %) were also favorable in HMIE. No anastomotic leakage and postoperative in-hospital mortality occurred after HMIE. CONCLUSION: The HMIE procedure combines the advantages of minimally invasive operative approaches on especially postoperative pulmonary morbidity after esophagectomy with the high safety of anastomosis and reconstruction achieved in OE. Further advantages are shorter duration of operation and shorter length of hospital stay in HMIE.


Assuntos
Anastomose Cirúrgica , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Esôfago/cirurgia , Laparoscopia/métodos , Estômago/cirurgia , Toracotomia/métodos , Idoso , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Humanos , Excisão de Linfonodo/métodos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/etiologia
16.
Zentralbl Chir ; 139(1): 17-9, 2014 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-24585190

RESUMO

Laparoscopic total gastrectomy for early and advanced gastric cancer is an exacting procedure which is increasingly performed in specialised institutions. Not only gastric resection and extended lymphadenectomy but especially the reconstruction by oesophagojejunostomy is a technically demanding and vulnerable operative step. In this article we present our laparoscopic technique of total gastrectomy with extended lymphadenectomy and complete intracorporal reconstruction by end-to-side circular stapled oesophagojejunostomy. The operative technique of the gastric resection, the extended lymphadenectomy and the reconstruction are described in detail in a step-by-step approach and demonstrated in a supplemental video.


Assuntos
Anastomose Cirúrgica/métodos , Esôfago/cirurgia , Gastrectomia/métodos , Jejuno/cirurgia , Laparoscopia/métodos , Excisão de Linfonodo/métodos , Neoplasias Gástricas/cirurgia , Grampeamento Cirúrgico/métodos , Anastomose em-Y de Roux/métodos , Humanos , Estadiamento de Neoplasias , Neoplasias Gástricas/patologia , Técnicas de Sutura , Gravação em Vídeo
17.
Chirurg ; 85(2): 139-46, 2014 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-24435832

RESUMO

INTRODUCTION: This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy. PATIENTS AND METHODS: From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler. RESULTS: Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively. CONCLUSIONS: Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/métodos , Laparoscopia/métodos , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Adulto , Idoso , Ductos Biliares Intra-Hepáticos/cirurgia , Carcinoma Hepatocelular/patologia , Feminino , Hepatectomia/instrumentação , Artéria Hepática/cirurgia , Humanos , Laparoscopia/instrumentação , Tempo de Internação , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Veia Porta/cirurgia , Complicações Pós-Operatórias/etiologia , Instrumentos Cirúrgicos , Grampeamento Cirúrgico/instrumentação , Carga Tumoral
19.
Chirurg ; 82(8): 691-7, 2011 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-21340587

RESUMO

BACKGROUND: Whereas pancreatic tail resection is routinely and safely performed in several institutions, laparoscopic resection of the pancreatic head is only performed by a handful of surgeons worldwide, none of them in Germany. PATIENTS AND METHODS: We review our experience with 9 laparoscopic pancreatic head resections (lap-PPPD) performed between March and September 2010. The operations were performed using a hybrid approach with complete laparoscopic pylorus-preserving pancreatic head resection and successive reconstruction via a small retrieval incision. Perioperative outcome was compared to 605 open pancreatic head resections (1997-2010). RESULTS: In the group lap-PPPD 3 out of 9 conversions had to be performed due to oncologic reasons. There were no significant differences in perioperative outcome when comparing open-PPPD to lap-PPPD. CONCLUSION: Laparoscopic pancreatic head resection with hybrid open reconstruction combines the potential advantages of laparoscopic resection with the safety of an open pancreatic anastomosis. Even at the beginning of the learning curve the procedure can be performed with no concessions to safety or duration of the operation.


Assuntos
Ampola Hepatopancreática/cirurgia , Carcinoma Ductal Pancreático/cirurgia , Neoplasias do Ducto Colédoco/cirurgia , Laparoscopia/métodos , Tumores Neuroendócrinos/cirurgia , Cisto Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreatite Crônica/cirurgia , Complicações Pós-Operatórias/etiologia , Lesões Pré-Cancerosas/cirurgia , Idoso , Estudos de Viabilidade , Feminino , Humanos , Complicações Intraoperatórias/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/métodos , Reoperação , Estudos Retrospectivos
20.
Zentralbl Chir ; 136(2): 129-34, 2011 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-21348000

RESUMO

BACKGROUND: Intra-abdominal hypertension (IAH) has a high prevalence among critically ill patients. It is increasingly recognised as a risk factor for poor outcome. PATIENTS / MATERIAL AND METHODS: A review of the literature including explicit management instructions was performed. We report the standardised techniques for intra-abdominal pressure (IAP) measurement as well as consensus definitions and treatment recommendations ranging from conservative measures to decompression laparotomy. RESULTS: The abdominal compartment syndrome (ACS) is defined as a sustained IAH > 20 mmHg accompanied by new organ dysfunctions. It occurs predominantly in surgical patients and is associated with a poor outcome. Organ dysfunctions related to IAH mainly concern the kidneys and -respiratory system. The mechanism of action essentially is a perfusion deficit. Clinical judgement alone does not allow a valid estimate of intra-abdominal pressure. CONCLUSION: In patients at risk the IAP should be measured. In case of IAH conservative options for lowering the pressure are mandatory. Decompression laparotomy should be considered if conservative measures fail.


Assuntos
Abdome , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/cirurgia , Descompressão Cirúrgica/métodos , Algoritmos , Síndromes Compartimentais/etiologia , Diagnóstico Diferencial , Humanos , Pressão Hidrostática , Laparoscopia , Manometria/métodos , Fatores de Risco
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