Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization.

Objective: To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Background: Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized. Methods: A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases. Results: Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001). Conclusions: This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.

Maternal and direct dietary polyphenol supplementation affect growth, carcass and meat quality of sheep and goats.

The beneficial effects of polyphenol intake such as improved nitrogen retention make them interesting feed supplements for ruminants. In contrast, dietary polyphenols may have adverse effects on the bioavailability of nutrients and palatability of the feed which might impair growth performance. The beneficial and adverse effects might differ between different ruminant species as well as between direct intake and intake of polyphenol metabolites via suckling when supplemented to lactating dams. This study investigated the effects of maternal and direct polyphenol supplementation via grape seed extract in sheep and goats on growth, slaughter performance, meat quality and fatty acid profile. The diet of lactating East Friesian Dairy sheep (n = 11) and Saanen goats (n = 9) and of their lambs (n = 16) and kids (n = 13), respectively, was supplemented either with grape seed extract (dams: 7.4% and offspring: 5.6%, P) or without (C). This resulted in four groups per species, namely maternalC/offspringC, maternalC/offspringP, maternalP/offspringC, and maternalP/offspringP. In lambs but not in goats, maternalP increased average daily gain and improved slaughter performance whereas offspringP had no effect. Maternal and offspring diet did not affect physicochemical meat quality in lambs, but direct intake of grape seed extract increased rancid aroma of burger patties. In goat kids, both maternal and offspring diets slightly affected meat colour. While groups of meat fatty acids (FAs) were not affected by diet in both species, maternalP in lambs as well as maternalP and offspringP in goat kids increased the meat n-6 to n-3 FA ratio compared to the respective control groups. In goat kid but not in lamb meat, direct intake of polyphenols affected the proportions of several rumen biohydrogenation intermediates. In conclusion, grape seed extract can be applied in both the maternal and offspring diets in sheep and goats while maintaining or even improving offspring growth performance and carcass quality. Only few species-specific effects of grape seed extract supplementation were observed, and additive effects were scarce. Larger studies are required to confirm the observed species-specific growth response to maternalP during lactation. The underlying reasons for this differential response need to be further evaluated.

Small bowel perforation after low-velocity trauma: a case report.

We report the case of a 63-year-old patient with a low-velocity abdominal trauma and bowel perforation. The patient slipped on a wet floor and fell down the stairs. On admission, the patient complained about abdominal pain. A computed tomography scan showed traumatic hematoma of the jejunum in the left upper quadrant and a small amount of intra-abdominal air. Also rib fractures on the left side were diagnosed. We performed a diagnostic laparoscopy and found a bowel perforation, which was manually repaired.

The effect of arm-crank exercise training on power output, spirometric and cardiac function and level of autonomy in persons with tetraplegia.

Studies on the effects of exercise training in persons with cervical spinal cord injury (CSCI) are scarce. The aim of this study was to determine the effect of an 8-week stationary arm-crank exercise (ACE) training programme on the level of autonomy, exercise performance, pulmonary functional parameters and resting heart rate variability (HRV) in persons with CSCI. Quadriplegia Index of Function (QIF), arm-crank peak power output (Ppeak), spirometric variables, and HRV indices were measured before and after the training programme in a group of 11 persons with CSCI. ACE training increased Ppeak in both groups (p < 0.05), whereas maximum voluntary ventilation (MVV) and low frequency HRV (LF) improved only in the lower CSCI group (p < 0.05). Moreover, QIF and Ppeak were significantly correlated before (r = 0.88; p < 0.01) and after (r = 0.86; p < 0.01) the training period. However, no significant changes were found in the level of autonomy (QIF) as a result of the intervention. Therefore, stationary ACE training appears to be a feasible and effective method for aerobic exercise in persons with tetraplegia and a short-term intervention is able to significantly improve exercise capacity, cardiac autonomic regulation and respiratory muscle endurance, regardless of the absence of significant immediate changes in the level of autonomy.

Transfer of total phenols from a grapeseed-supplemented diet to dairy sheep and goat milk, and effects on performance and milk quality.

Polyphenols are known to affect digestion of ruminants, whereas there is little information about their metabolic effects. In a 2 × 2-factorial experiment the effects of supplementing a phenolic grapeseed extract were compared in 11 East Friesian dairy sheep and 9 Saanen goats. The concentrate supplemented with 7.4 g/100 g DM grapeseed extract had contents of 3.5 g additional phenols/100 g DM and was compared with a low phenolic control concentrate. Performance, total phenols in blood, milk, urine and feces, antioxidant capacity of the blood, and saliva properties were examined. The experiment lasted for 11 wk from parturition to late lactation, with an initial adaptation phase of 1 wk. Milk yield was measured daily after weaning at about 7 wk after parturition. Blood, milk, saliva, feces and urine were sampled 4, 3, 2, 2 and 2 times per animal, respectively. The phenolic diet increased phenol concentrations in blood (+10% and 17% in wk 5 and wk 11, respectively) and in milk (+32% in wk 5) on some of the sampling weeks. There were no clear species differences in phenol concentrations in blood plasma, milk, urine and feces. However, at the end of the experiment the supplemented goats had a higher (48%) urinary phenol concentrations than the non-supplemented goats. A weak relationship (P < 0.05) was found between phenol intake and phenol excretion with milk for sheep but not goats. The phenolic diet did not influence blood antioxidant capacity and tannin binding capacity of the saliva. The saliva of the goats had a higher tannin binding capacity than sheep saliva. The effects of the extract on milk yield were inconsistent between sheep and goats. In general, goats had higher feed and nutrient intakes, were heavier, and yielded more milk. Additionally, milk protein and lactose contents were lower and milk urea content was higher in goats than sheep. In conclusion, supplementing grapeseed extract to sheep and goats elevated phenol concentrations in milk and blood to a certain extent, but most of the phenols were lost via urine. The study gave another indication that goats seem to have developed coping mechanisms like a higher salivary tannin binding capacity, mechanisms which are less pronounced in sheep.

Clinical relevance of the plasminogen activator inhibitor type 1--a multifaceted proteolytic factor.

The plasminogen activator inhibitor type-1 (PAI-1) is a multifaceted proteolytic factor. It not only functions as an inhibitor of the protease uPA (urokinase-type plasminogen activator), but also plays an important role in signal transduction, cell adherence, and cell migration. Thus--an apparent paradox considering its name--although it inhibits uPA during blood coagulation, it actually promotes invasion and metastasis. In the early 1990s, clinical evidence associated elevated PAI-1 levels in tumor tissue with poor clinical outcome in primary breast cancer. These clinical data have since been supported by experimental evidence that the concerted action of uPA, its cell surface receptor uPA-R, and PAI-1 facilitates invasion and metastasis. The strong prognostic impact of PAI-1 in primary breast cancer has been validated by international research groups assessing fresh tumor tissue extracts by ELISA. There is clinical evidence that high-risk patients with elevated PAI-1 in their tumor benefit from adjuvant systemic therapy. uPA also has a strong prognostic impact in primary breast cancer. In node-negative breast cancer, risk-group selection for adjuvant systemic therapy based on tumor levels of both PAI-1 and uPA is close to routine clinical use. Also in other malignancies such as ovarian, esophageal, gastric, colorectal or hepatocellular cancer, elevated PAI-1 is associated with tumor aggressiveness and poor patient outcome. This abundant clinical evidence implicating PAI-1 as a key factor for tumor invasion and metastasis renders it a promising target for tumor therapy. Novel therapeutic approaches targeting the PAI-1/uPA interaction are already in pre-clinical testing.