[Quality indicators for pancreatic surgery : Scientific derivation and clinical relevance]. / Qualitätsindikatoren für die Pankreaschirurgie : Wissenschaftliche Herleitung und klinische Relevanz.

Quality indicators are by definition indirect measures of quality. The selection for the field of pancreatic surgery was based on the clinical relevance and controllability, scientific evidence and the practicability of data acquisition. In terms of outcome quality, hospital mortality, the composite endpoint MTL30 (mortality-transfer-length of stay), and major complications (Clavien-Dindo classification grades 3b and 4) were chosen as being essential. With respect to structural quality, the presence of interventional radiology with constant availability was considered essential. To evaluate target values two strategies were used: a systematic literature search and evaluation of the current numbers from the German Society for General and Visceral Surgery (DGAV) StuDoQ|Pancreas registry for the years 2014-2016. The results are presented in the following consensus statement.

[Abdominal vacuum therapy for the open abdomen - a retrospective analysis of 82 consecutive patients]. / Intraabdominelle Vakuumtherapie des offenen Abdomens - Eine retrospektive Analyse von 82 konsekutiven Patienten.

BACKGROUND: The therapy for open abdomen remains challenging. Abdominal vacuum therapy seems to simplify the treatment and to enable a direct fascial closure in a high percentage of the patients. PATIENTS AND METHODS: A retrospective analysis of 82 consecutive patients who underwent abdominal vacuum therapy between January 2005 and December 2007 was undertaken. Indications, -duration of treatment, complications as well as rate and type of abdominal wall closure were evaluated. RESULTS: The 82 consecutive patients consisted of 46 % female and 54 % male patients with a median age of 65.5 years. The most frequent diagnoses were colorectal carcinoma (24 %, n = 28, colon n = 18 and rectum n = 10), inflammatory bowel dis-ease (13 %), perforated peptic ulcer (9 %), necrotising pancreatitis (7 %), peritoneal carcinosis (5 %), ileus (5 %) and mesenteric ischaemia (4 %). The predominant indication for vacuum therapy was peritonitis (88 %). Vacuum therapy treatment was applied for a median of 6 days (range: 1-73 days). 18 patients (22 %) received intraabdominal foam dressings without the fenestrated polyurethane layer. In 70 % of all cases the abdominal vacuum therapy was performed without complications. 16 patients (19.5 %) developed intestinal fistulas. However, fistulas were not observed among the patients who were treated with foam dressings without a polyurethane layer. Abdominal bleeding was observed in 8 patients (10 %) and a persistent abdominal compartment syndrome was seen in one patient. Nine patients (11 %) died during hospitalisation. After completion of the intraabdominal vacuum therapy, -direct fascial closure was feasible in 35 patients (43 %). In 47 patients (57 %) an absorbable synthetic mesh was required for fascial closure. Symptomatic incisional hernias -occurred in 22 % of the patients. CONCLUSION: Abdominal vacuum therapy simplifies the treatment of patients with abdominal catastrophes such as peritonitis or necrotising pancreatitis. The cost-effective intraperitoneal use of a foam dressing without a fenestrated polyurethane layer was possible without an increased rate of fistulas. This retrospective analysis demonstrates that abdominal vacuum therapy can be performed without complications in the majority of patients. Furthermore, direct fascial closure is possible in almost half of the patients.

Protective role of HO-1 for alcohol-dependent liver damage.

BACKGROUND/AIMS: Alcoholic liver disease is continuously increasing in developed countries being a leading cause of death worldwide. Chronic ethanol consumption induces oxidative stress by accumulation of reactive oxygen intermediates (ROI) while reducing the cellular antioxidant defense. Induction of heme oxygenase-1 (HO-1) may protect primary human hepatocytes (hHeps) from such damage. Thus, the aim of this study was to investigate the potential of polyphenols to protect hHeps from ethanol-dependent oxidative damage. METHODS: hHeps were isolated by collagenase perfusion. ROI and cellular glutathione (GSH) were measured by fluorescent-based assays. Cellular damage was determined by lactate dehydrogenase (LDH) leakage and staining for apoptosis and necrosis. Nuclear translocation of Nrf2 and HO-1 expression were analyzed by Western blot. RESULTS: Ethanol and TGF-ß rapidly increase ROI and reduce GSH in hHeps, causing apoptosis with a release of approximately 40% total LDH after 72 h. Similar to incubation with hemin preincubation and co-incubation of cells with nifedipine, verapamil and quercetin significantly reduce oxidative stress and resulting cellular damage, in a dose-dependent manner, by initiating nuclear translocation of Nrf2 which in turn induces HO-1 under the control of p38 and ERK. Blocking of HO-1 activity with ZNPP9 reverses the protective effect of all three substances. CONCLUSION: Our results suggest that increasing HO-1 activity in hHeps protects them from oxidative stress-dependent damage. As polyphenols have great potential to induce HO-1 expression, they may play an important role for future therapeutic strategies to protect liver from oxidative stress-dependent damage observed during chronic alcohol consumption.

[Carcinoma of the pancreas at the site of an intraductal papillary mucinous neoplasia]. / Pankreaskarzinom auf dem Boden eines intraduktal papillär-muzinösen Tumors.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are intraductally located, mucin-producing cystic neoplasms of the pancreas with a malignant potential. We report about a 54-year-old female who underwent segmental resection of the pancreas for non-invasive IPMN. The surgical margins were tumour-negative. Three years later a highly suspicious tumour of the pancreatic tail was detected during routine follow-up. Resection of the pancreatic tail was performed. The histological analysis revealed an adenocarcinoma. This case suggests the development of a pancreatic carcinoma from a non-invasive IPMN and raises the question about the extent of surgery of non-invasive IPMNs of the pancreas.

Intrasplenic or subperitoneal hepatocyte transplantation to increase survival after surgically induced hepatic failure?

BACKGROUND: As a basis for future clinical questions, we evaluated the efficacy of hepatocyte transplantation in a surgical model using a subperitoneal or intrasplenic approach for cell implantation. METHODS: In rats, acute liver failure was induced by subtotal hepatectomy. Series of allogenic hepatocyte transplantations were performed by varying cell number, site, and sequence of cell transplantation. RESULTS: Following subperitoneal or intrasplenic cell implantation subsequent to liver surgery, no survival benefit was achieved when compared to the control groups. However, intrasplenic cell implantation 24 h prior to liver surgery revealed a statistically significantly higher animal survival (72 vs. 29%). CONCLUSION: According to our experience, both timing and site of cell implantation played an important role in hepatocyte transplantation. Intrasplenic hepatocyte transplantation 1 day before liver surgery showed the best results in terms of survival. Consequently, we were able to establish a model of hepatocyte transplantation which may be the basis for further investigations evaluating potential treatment modalities to overcome deleterious postoperative liver insufficiency.

Selective induction of human hepatic cytochromes P450 2B6 and 3A4 by metamizole.

The pyrazolone drug metamizole is a widely used analgesic. Analysis of liver microsomes from patients treated with metamizole revealed selectively higher expression of cytochromes P450, CYP2B6 and CYP3A4 (3.8- and 2.8-fold, respectively), and 2.9-fold higher bupropion hydroxylase activity compared with untreated subjects. Further investigation of metamizole and various derivatives on different potential target genes in human primary hepatocytes demonstrated time- and concentration-dependent induction by metamizole of CYP2B6 (7.8- and 3.1-fold for mRNA and protein, respectively, at 100 muM) and CYP3A4 (2.4- and 2.9-fold, respectively), whereas other genes (CYP2C9, CYP2C19, CYP2D6, NADPH:cytochrome P450 reductase, ABCB1, constitutive androstane receptor (CAR), pregnane X receptor (PXR)) were not substantially altered. Using reporter gene assays, we show that metamizole is not acting as a direct ligand to either PXR or CAR, suggesting a phenobarbital-like mechanism of induction. These data warrant further studies to elucidate the drug-interaction potential of metamizole, especially in patients with long-term treatment.

Changes in serum levels of growth factors in healthy individuals after living related liver donation.

INTRODUCTION: To obtain better insight into the kinetics of hepatic growth factors following partial hepatectomy for living related liver donation, we investigated the postoperative changes in serum levels of hepatocyte growth factor (HGF), epidermal growth factor (EGF), vascular epidermal growth factor (VEGF), and transforming growth factor-alpha (TGF-alpha). PATIENTS AND METHODS: Eighteen healthy donors undergoing right hepatectomy for living related donation were enrolled in this study. Serum levels of HGF, EGF, VEGF, and TGF-alpha were measured using enzyme-linked immunosorbent assay kits before surgery, at 2 hours after resection, and daily during 5 days postoperatively. RESULTS: Mean preoperative HGF serum levels in healthy adults were 778 +/- 64 pg/mL. Within 2 hours after operation, they significantly increased to 9608 +/- 3111 pg/mL afterward decreasing to 2726 +/- 241 at day 1 and 2283 +/- 250 pg/mL at day 2. Hereafter HGF serum levels stabilized at increased levels until day 5 (2109 +/- 138, 2047 +/- 219, 2283 +/- 336 pg/mL, respectively). At all time points, the differences between pre- and postoperative HGF levels were significant (P < .01). In contrast, VEGF and EGF serum levels showed no significant differences between pre- and postoperative levels at all time points. TGF-alpha was not detected using a commercially available test with a detection limit of 10 ng/mL, suggesting only low TGF-alpha serum levels following liver resection. CONCLUSION: Significantly increased HGF serum levels after hepatectomy demonstrate its crucial role among the other investigated growth factors in regeneration of the remnant liver tissue during the early period after the operation.

[Clinical results of intestinal and multivisceral transplantation at the Charité, Berlin. A case series]. / Klinische Ergebnisse der Dünndarm- und Multiviszeraltransplantation an der Berliner Charité - Eine Fallserie -

BACKGROUND AND OBJECTIVE: Intestinal transplantation (ITx) is the only causal therapy of short bowel syndrome (SBS). Long-term survival after ITx has been improved significantly during the last years. The experience with ITx at the Charite, Campus Virchow Klinikum, are described and discussed. PATIENTS AND METHODS: Twelve isolated ITx and one multivisceral transplantation (including stomach, pancreatodudenal complex, small intestine, liver, ascending colon, right kidney, and adrenal gland) were performed. Mean recipient age was 37.7+/-10.6 yrs (median: 35 yrs; range: 27 - 58 yrs; M:F = 8:5). All patients had irreversible SBS (0 - 30 cm residual bowel length; mean: 11.8+/-11.4 cm; median: 13 cm). RESULTS: 6-months and 1-year patient and graft survival were 85 % (11/13) and 77 % (10/13), respectively. Reasons for graft loss and patient death were necrotizing enterocolitis, severe, muromonab-resistent, acute rejection, and graft ischemia due to complex coagulopathy. All other patients had good long-term outcome. They received enteral nutrition at six hours after operation and were persistently off total parenteral nutrition (TPN) by week two after ITx. CONCLUSION: ITx as established in our centre, with 1-year-patient and graft survival rates of 77 %, reflects current international standard. ITx is complementary to conservative and other operative methods of treating SBS. Referral and indication criteria need wider dissemination to prevent life-threatening complications of TPN.

[Mesenteric artery occlusion as a rare complication of thromboangiitis obliterans]. / Mesenterialarterienverschluss als seltene Komplikation bei Thrombangiitis obliterans.

Mesenteric artery occlusions are rare complications of Thrombangiitis obliterans (Buerger's disease). We report on a 30-year old male with Thrombangiitis obliterans and mesenteric occlusion as a complication of this disease. Because of unclear abdominal pain, laparoscopy was performed which showed small bowel infarction and reduced liver perfusion. After small bowel resection and a second examination, ischemia of the intestinum continued. Angiography was performed, which showed central occlusion of the celiac trunk and the superior mesenteric artery. Relaparotomy with the embolectomy of the superior mesenteric artery, venous bypass from the sup.mes.art. to the hepatic arteries and repeated small bowel resection was performed. The patient recovered completely and was discharged from hospital after 3 weeks. After a further admission to the hospital 3 weeks later with abdominal pain caused by acute occlusion of the right colonic artery and severe ischemia of the right hemicolon, a right hemicolectomy was performed. Now, one year after the last hospital admission, the patient shows no sign of having any abdominal problems.

Simultaneous carotid artery reconstruction in patients undergoing other surgical interventions.

Abstract. We performed 343 vascular reconstructions of the supraaortal arteries from April 1996 to April 2000. Of these patients, 30 underwent combined vascular reconstructions - 22 combined extrathoracal and 8 combined transthoracal reconstructions. In 15 patients, carotid endarterectomy was combined with other cervical surgical interventions. In 10 patients, the vascular operation was combined with surgical interventions in other regions. No permanent complications were observed 8-52 months postoperatively, with the exception of one hemiparesis in the complex vascular operations. Consequently, we recommend the simultaneous surgical approach after careful individual assessment.