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- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie (Chirurgische Klinik I) (40) (remove)
(1) Background: Locoregional lymphadenectomy (LND) in adrenocortical carcinoma (ACC) may impact oncological outcome, but the findings from individual studies are conflicting. The aim of this systematic review and meta-analysis was to determine the oncological value of LND in ACC by summarizing the available literature. (2) Methods: A systematic search on studies published until December 2020 was performed according to the PRISMA statement. The primary outcome was the impact of lymphadenectomy on overall survival (OS). Two separate meta-analyses were performed for studies including patients with localized ACC (stage I–III) and those including all tumor stages (I–IV). Secondary endpoints included postoperative mortality and length of hospital stay (LOS). (3) Results: 11 publications were identified for inclusion. All studies were retrospective studies, published between 2001–2020, and 5 were included in the meta-analysis. Three studies (N = 807 patients) reported the impact of LND on disease-specific survival in patients with stage I–III ACC and revealed a survival benefit of LND (hazard ratio (HR) = 0.42, 95% confidence interval (95% CI): 0.26–0.68). Based on results of studies including patients with ACC stage I–IV (2 studies, N = 3934 patients), LND was not associated with a survival benefit (HR = 1.00, 95% CI: 0.70–1.42). None of the included studies showed an association between LND and postoperative mortality or LOS. (4) Conclusion: Locoregional lymphadenectomy seems to offer an oncologic benefit in patients undergoing curative-intended surgery for localized ACC (stage I–III).
Background: The adequate choice of perioperative antibiotic prophylaxis (PAP) could influence the risk of surgical site infections (SSIs) in general surgery. A new local PAP guideline was implemented in May 2017 and set the first-generation cefazolin (CFZ) instead the second-generation cefuroxime (CXM) as the new standard prophylactic antibiotic. The aim of this study was to compare the risk of SSIs after this implementation in intra-abdominal infections (IAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Germany analyzing patients after emergency surgery during 2016 to 2019 (n = 985), of which patients receiving CXM or CFZ were selected (n = 587). Propensity score matching was performed to ensure a comparable risk of SSIs in both groups. None-inferiority margin for SSIs was defined as 8% vs. 4%. Results: Two matched cohorts with respectively 196 patients were compared. The rate of SSIs was higher in the CFZ group (7.1% vs. 3.6%, p = 0.117) below the non-inferiority margin. The rate of other postoperative infections was significantly higher in the CFZ group (2.0% vs. 8.7%, p = 0.004). No other differences including postoperative morbidity, mortality or length-of-stay were observed. Conclusion: Perioperative antibiotic prophylaxis might be safely maintained by CFZ even in the treatment of intra-abdominal infections.
Die Offene Abdomen Therapie (OAT) stellt eine der größten Herausforderungen im Bereich der Chirurgie dar. Ziel war es ein offenes, kostenloses und internationales Register zu entwickeln, um eine Basis für zukünftige Therapien und den Weg zu einer evidenzbasierten Leitlinie zu legen.
Es wurden 630 Fälle identifiziert welche mittels OAT behandelt wurden und im Rahmen einer gemischt retrospektiven als auch prospektiven Datenauswertung in das von uns entwickelte Register eingetragen. Schwerpunkte waren dabei einerseits die Praktikabilität des Registers zu testen als auch Einflussfaktoren für eine erfolgreiche OAT zu finden.
Es konnte gezeigt werden, dass das Register in seiner Konzeption funktioniert und in der ersten Auswertungen Einflussfaktoren für eine erhöhte Faszienverschlussrate gefunden werden konnten. Der verbesserte Faszienverschluss am Ende der Therapie mit zeitgleich reduzierter Komplikationsrate ist möglich.
Aus diesem Grund besitzt die konsequente Nutzung des Registers von behandelnden Einrichtungen, die wo immer mögliche lückenlose Dokumentation, sowie die multizentrische Auswertung der Daten einen hohen Stellenwert in Hinsicht auf Prävention, Therapie und Nachsorge der OAT.
Die Adipositaschirurgie ist die effektivste Methode in der Behandlung der Adipositas. Bei extrem adipösen Patientin ist eine primäre Operation oftmals riskant. Die Anlage eines Magenballons als erster Schritt von Mehrstufenkonzepten kann die Operabilität gewährleisten und die perioperative Sicherheit erhöhen. Durch den Magenballon wird ein signifikanter Gewichtsverlust erreicht. Der postoperative Gewichtsverlust fällt allerdings schwächer aus. Es ist wichtig, den Patienten realistische Therapieergebnisse zu vermitteln, um überhöhte Erwartungen und Unzufriedenheit zu vermeiden. Die Sleevegastrektomie eignet sich besonders für extrem adipöse Patienten, da diese eine geringere Komplikationsrate aufweist und einfach in einen Roux-en-Y Bypass umzuwandeln ist.
Background
Endoscopic vacuum therapy (EVT) is an evidence-based option to treat anastomotic leakages of the upper gastrointestinal (GI) tract, but the technical challenges and clinical outcomes of patients with large defects remain poorly described.
Methods
All patients with leakages of the upper GI tract that were treated with endoscopic negative pressure therapy at our institution from 2012–2021 were analyzed. Patients with large defects (>30 mm) as an indicator of complex treatment were compared to patients with smaller defects (control group).
Results
Ninety-two patients with postoperative anastomotic or staplerline leakages were identified, of whom 20 (21.7%) had large defects. Compared to the control group, these patients required prolonged therapy (42 vs. 14 days, p < 0.001) and hospital stay (63 vs. 26 days, p < 0.001) and developed significantly more septic complications (40 vs. 17.6%, p = 0.027.) which often necessitated additional endoscopic and/or surgical/interventional treatments (45 vs. 17.4%, p = 0.007.) Nevertheless, a resolution of leakages was achieved in 80% of patients with large defects, which was similar compared to the control group (p = 0.42). Multiple leakages, especially on the opposite side, along with other local unfavorable conditions, such as foreign material mass, limited access to the defect or extensive necrosis occurred significantly more often in cases with large defects (p < 0.001).
Conclusions
Overall, our study confirms that EVT for leakages even from large defects of the upper GI tract is feasible in most cases but comes with significant technical challenges.
Robotic-assisted colon surgery may contain advantages over the laparoscopic approach, but clear evidence is sparse. This study aimed to analyze postoperative inflammation status, short-term outcome and cost-effectiveness of robotic-assisted versus laparoscopic left hemicolectomy. All consecutive patients who received minimal-invasive left hemicolectomy at the Department of Surgery I at the University Hospital of Wuerzburg in 2021 were prospectively included. Importantly, no patient selection for either procedure was carried out. The robotic-assisted versus laparoscopic approaches were compared head to head for postoperative short-term outcomes as well as cost-effectiveness. A total of 61 patients were included, with 26 patients having received a robotic-assisted approach. Baseline characteristics did not differ among the groups. Patients receiving a robotic-assisted approach had a significantly decreased length of hospital stay as well as lower rates of complications in comparison to patients who received laparoscopic surgery (n = 35). In addition, C-reactive protein as a marker of systemic stress response was significantly reduced postoperatively in patients who were operated on in a robotic-assisted manner. Consequently, robotic-assisted surgery could be performed in a cost-effective manner. Thus, robotic-assisted left hemicolectomy represents a safe and cost-effective procedure and might improve patient outcomes in comparison to laparoscopic surgery.
CD137 und CD137L stellen ein Rezeptor-Liganden-Paar dar, welches auf vielen Immunzellen exprimiert wird und eine wichtige Rolle im Rahmen der Immunstimulation spielt. CD137L fungiert jedoch nicht nur als Ligand sondern auch als Rezeptor und vermittelt als ein solcher Signale in die ihn exprimierende Zelle. Neben seinem Vorkommen auf Immunzellen wird CD137L auch von einigen Tumorzellen exprimiert, unter anderem auch auf denen des Kolonkarzinoms. In dieser Tumorentität korreliert eine hohe CD137L-Expression mit dem Auftreten von Fernmetastasen und einer insgesamt schlechteren Prognose. Die genaue Rolle von CD137L im Kolonkarzinom ist bislang kaum erforscht. Im Rahmen dieser Arbeit wurden daher die Auswirkungen einer CD137L-Aktivierung auf die Proliferation sowie die Proteinexpression und -sekretion von Kolonkarzinomzellen untersucht.
Die Ergebnisse deuten erstmals darauf hin, dass die CD137L-Stimulation in vitro die Proliferation der entarteten Zellen reduziert und die Expression bzw. Sekretion der Proteine Vimentin, TLR7, VEGF und PDGF steigert.
Hieraus wird geschlossen, dass eine Stimulation des von den Kolonkarzinomzellen exprimierten CD137L dazu führt, dass sich der Phänotyp der Tumorzellen von einem epithelialen in Richtung eines mesenchymalen Zelltyps verändert. Darüber hinaus werden vermehrt Proteine exprimiert und sezerniert, welche über unterschiedliche Signalwege an der Invasion und Migration der entarteten Zellen beteiligt sind.
Folglich lässt sich annehmen, dass CD137L eine entscheidende Rolle im Metastasierungsprozess von humanen Kolonkarzinomzellen spielt. Sollte sich dies in weiterführenden Untersuchungen bestätigen, könnte eine pharmazeutische Beeinflussung der beteiligten Signalwege möglicherweise die Prognose von an Kolonkarzinomen erkrankten Patient:innen deutlich verbessern.
Background
Colorectal cancer incidence increases with patient age. The aim of this study was to assess, at the nationwide level, in-hospital mortality, and failure to rescue in geriatric patients (≥ 80 years old) with colorectal cancer arising from postoperative complications.
Methods
All patients receiving surgery for colorectal cancer in Germany between 2012 and 2018 were identified in a nationwide database. Association between age and in-hospital mortality following surgery and failure to rescue, defined as death after complication, were determined in univariate and multivariate analyses.
Results
Three lakh twenty-eight thousands two hundred and ninety patients with colorectal cancer were included of whom 77,287 were 80 years or older. With increasing age, a significant relative increase in right hemicolectomy was observed. In general, these patients had more comorbid conditions and higher frailty. In-hospital mortality following colorectal cancer surgery was 4.9% but geriatric patients displayed a significantly higher postoperative in-hospital mortality of 10.6%. The overall postoperative complication rate as well as failure to rescue increased with age. In contrast, surgical site infection (SSI) and anastomotic leakage (AL) did not increase in geriatric patients, whereas the associated mortality increased disproportionately (13.3% for SSI and 29.9% mortality for patients with AI, both p < 0.001). Logistic regression analysis adjusting for confounders showed that geriatric patients had almost five-times higher odds for death after surgery than the baseline age group below 60 (OR 4.86; 95%CI [4.45–5.53], p < 0.001).
Conclusion
Geriatric patients have higher mortality after colorectal cancer surgery. This may be partly due to higher frailty and disproportionately higher rates of failure to rescue arising from postoperative complications.
Background
Adrenalectomies are rare procedures especially in childhood. So far, no large cohort study on this topic has been published with data on to age distribution, operative procedures, hospital volume and operative outcome.
Methods
This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). All adrenal surgeries (defined by OPS codes) of patients between the age 0 and 21 years in Germany were included.
Results
A total of 523 patient records were identified. The mean age was 8.6 ± 7.7 years and 262 patients were female (50.1%). The majority of patients were between 0 and 5 years old (52% overall), while 11.1% were between 6 and 11 and 38.8% older than 12 years. The most common diagnoses were malignant neoplasms of the adrenal gland (56%, mostly neuroblastoma) with the majority being younger than 5 years. Benign neoplasms in the adrenal gland (D350) account for 29% of all cases with the majority of affected patients being 12 years or older. 15% were not defined regarding tumor behavior. Overall complication rate was 27% with a clear higher complication rate in resection for malignant neoplasia of the adrenal gland. Bleeding occurrence and transfusions are the main complications, followed by the necessary of relaparotomy. There was an uneven patient distribution between hospital tertiles (low volume, medium and high volume tertile). While 164 patients received surgery in 85 different “low volume” hospitals (0.2 cases per hospital per year), 205 patients received surgery in 8 different “high volume” hospitals (2.8 cases per hospital per year; p<0.001). Patients in high volume centers were significant younger, had more extended resections and more often malignant neoplasia. In multivariable analysis younger age, extended resections and open procedures were independent predictors for occurrence of postoperative complications.
Conclusion
Overall complication rate of adrenalectomies in the pediatric population in Germany is low, demonstrating good therapeutic quality. Our analysis revealed a very uneven distribution of patient volume among hospitals.