Andre L Mihaljevic

Technische Universität München, München, Bavaria, Germany

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Publications (19)35.86 Total impact

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    ABSTRACT: Despite improvements in liver surgery over the past decades, hemostasis during hepatic resections remains challenging. This multicenter randomized study compares the hemostatic effect of a collagen hemostat vs. a carrier-bound fibrin sealant after hepatic resection.
    Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie. 06/2014;
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    ABSTRACT: Gastric cancer accounts for 5 % of cancer deaths. Successful implementation of guideline-recommended treatment procedures should result in population-based outcome improvements despite the still poor prognosis. In this context, the objective of this study was to compare the outcome of gastric cancer by different levels of hospital care. Total of 8,601 patients with invasive gastric cancer documented between 1998 and 2012 by the Munich Cancer Registry were evaluated. Tumour and therapy characteristics and outcome were analysed in regard to five levels of hospital care: three levels were defined for general hospitals (level I-III), while university hospitals and speciality hospitals were grouped as separate classes. Survival was investigated using the Kaplan-Meier-method, computing relative survival, and by multivariate Cox proportional hazard regression. The average age differed between 66 years in university hospitals and 75 years in hospitals providing a basic level of care (level I). No survival differences were found for patients treated in different levels of hospital care in 75 % of the patient cohort, namely the M0 patients. A better survival could only be shown for patients with M1 at diagnosis when treated in a university or level III hospital compared to those treated in other hospitals. The outcome difference of M1 patients is most likely caused by selection effects concerning health status differences and not by processes of health care attributable to level of hospital care. Thus, this study demonstrates and confirms appropriate treatment and care of gastric cancer over all levels of hospital care.
    Journal of Cancer Research and Clinical Oncology 03/2014; · 2.91 Impact Factor
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    ABSTRACT: The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes. In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs. Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy. Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.
    European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 09/2013; · 2.56 Impact Factor
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    ABSTRACT: BACKGROUND: Bleeding during hepatic surgery is associated with prolonged hospitalization and increased morbidity and mortality. The Veriset™ haemostatic patch is a topical haemostat comprised of an absorbable backing made of oxidized cellulose and self-adhesive hydrogel components. It is designed to achieve haemostasis quickly and adhere to tissues without fixation. METHODS: A prospective, randomized, multicentre, single-blinded study (n = 50) was performed to compare the use of a Veriset™ haemostatic patch with a fibrin sealant patch (TachoSil® ) (control) in the management of diffuse bleeding after hepatic surgery. Patients were randomized following the confirmation of diffuse bleeding requiring the use of a topical haemostat. Time to haemostasis was assessed at preset intervals until haemostasis was achieved. RESULTS: Both groups were similar in comorbidities and procedural techniques. The median time to haemostasis in the group using the Veriset™ haemostatic patch was 1.0 min compared with 3.0 min in the control group (P < 0.001; 3-min minimum application time for the control patch). This result was independent of bleeding severity and surface area. Both products had similar safety profiles and no statistical differences were observed in the occurrence of adverse or device-related events. CONCLUSIONS: Regardless of bleeding severity or surface area, the Veriset™ haemostatic patch achieved haemostasis in this setting significantly faster than the control device in patients undergoing hepatic resection. It was safe and easy to handle in open hepatic surgery.
    HPB 12/2012; · 1.94 Impact Factor
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    ABSTRACT: OBJECTIVES:: The objective of the HASTA trial was to compare hand suture versus stapling loop ileostomy closure in a randomized controlled trial. BACKGROUND:: Bowel obstruction is one of the main and the clinically and economically most relevant complication following closure of loop ileostomy after low anterior resection. The best surgical technique for closure of loop ileostomy has not been defined yet. METHODS:: HASTA trial is a multicenter pragmatic randomized controlled surgical trial with 2 parallel groups to compare hand suture versus stapling for closure of loop ileostomy. The primary endpoint was the rate of bowel obstruction within 30 days after ileostomy closure. RESULTS:: A total of 337 randomized patients undergoing closure of loop ileostomy after low anterior resection because of rectal cancer in 27 centers were included. The overall rate of postoperative ileus after ileostomy closure was 13.4%. Seventeen of 165 (10.3%) patients in the stapler group and 27 of 163 (16.6%) in the hand suture group developed bowel obstruction within 30 days postoperatively [odds ratio (OR) = 1.72; 95% confidence interval (CI): 0.89-3.31 = 0.10]. Duration of surgical intervention was significantly shorter in the stapler group (15 minutes; P < 0.001). Multivariable analysis of potential risk factors did not reveal any significant correlation with development of postoperative ileus. Rate of anastomotic leakage (stapler: 3.0%, hand suture: 1.8%, P = 0.48) did not differ significantly as well as all other secondary endpoints. CONCLUSIONS:: Hand-sewn anastomosis versus stapler ileo-ileostomy for ileostomy closure are equally effective in terms of postoperative bowel obstruction, with stapler anastomosis leading to a shorter operation time. Postoperative ileus after ileostomy reversal remains a relevant complication.
    Annals of surgery 11/2012; 256(5):828-836. · 7.90 Impact Factor
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    ABSTRACT: BACKGROUND: The optimal strategy for abdominal wall closure has been an issue of ongoing debate. Available studies do not specifically enroll patients who undergo emergency laparotomy and thus do not consider the distinct biological characteristics of these patients. The present randomized controlled trial evaluates the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy. Methods/design The CONTINT trial is a multicenter, open label, randomized controlled trial with a twogroup parallel design. Patients undergoing a primary emergency midline laparotomy are enrolled in the trial. The two most commonly applied strategies of abdominal wall closure after midline laparotomy are compared: the continuous, all-layer suture technique using slowly absorbable monofilament material (two Monoplus(R) loops) and the interrupted suture technique using rapidly absorbable braided material (Vicryl(R) sutures). The primary endpoint within the CONTINT trial is an incisional hernia within 12 months or a burst abdomen within 30 days after surgery. As reliable data on this primary endpoint is not available for patients undergoing emergency surgery, an adaptive interim analysis will be conducted after the inclusion of 80 patients, allowing early termination of the trial if necessary or modification of design characteristics such as recalculation of sample size. DISCUSSION: This is a randomized controlled multicenter trial with a two-group parallel design to assess the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy. Trial registration NCT00544583.
    Trials 05/2012; 13(1):72. · 2.21 Impact Factor
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    ABSTRACT: BACKGROUND: Postoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality and remain one of the most frequent surgical complications. Approximately 14% to 30% of all patients undergoing elective open abdominal surgery are affected and methods to reduce surgical site infection rates warrant further investigation and evaluation in randomized controlled trials. METHODS: To investigate whether the application of a circular plastic wound protector reduces the rate of surgical site infections in general and visceral surgical patients that undergo midline or transverse laparotomy by 50%. BaFO is a randomized, controlled, patient-blinded and observer-blinded multicenter clinical trial with two parallel surgical groups. The primary outcome measure will be the rate of surgical site infections within 45 days postoperative assessed according to the definition of the Center for Disease Control. Statistical analysis of the primary endpoint will be based on the intention-to-treat population. The global level of significance is set at 5% (2 sided) and sample size (n = 258 per group) is determined to assure a power of 80% with a planned interim analysis for the primary endpoint after the inclusion of 340 patients. DISCUSSION: The BaFO trial will explore if the rate of surgical site infections can be reduced by a single, simple, inexpensive intervention in patients undergoing open elective abdominal surgery. Its pragmatic design guarantees high external validity and clinical relevance. Trial registration http://www.clinicaltrials.gov NCT01181206. Date of registration: 11 August 2010; date of first patient randomized: 8 September 2010.
    Trials 05/2012; 13(1):57. · 2.21 Impact Factor
  • André L Mihaljevic, Helmut Friess, Christoph Schuhmacher
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    ABSTRACT: Following the first successful gastric resection for gastric cancer by Theodor Billroth in 1881 surgery has made tremendous progress leading to improved surgical mortality and morbidity. However, while treatment of early gastric cancer is frequently curative, 5-year survival rates for advanced gastric cancer remain dismal despite the application of perioperative multimodal treatment concepts. In this article we will outline key clinical trials that have lead to an improvement in treatment of gastric cancer patients with specific emphasis on the last 20 years. We will then outline recent concepts and key clinical trials that are currently being conducted in the field. Finally we will outline open questions that remain to be elucidated in the future. J. Surg. Oncol © 2012 Wiley Periodicals, Inc.
    Journal of Surgical Oncology 04/2012; · 2.64 Impact Factor
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    ABSTRACT: An important factor for successful therapy of poisoning with organophosphorus compounds (OP) is the rapid restoration of blocked respiratory muscle function. To achieve this goal, oximes are administered for reactivation of inhibited acetylcholinesterase (AChE). Unfortunately, clinically used oximes, e.g. obidoxime and pralidoxime, are of limited effectiveness in poisoning with different OP nerve agents requiring the search for alternative oximes, e.g. HI 6. In view of substantial species differences regarding reactivation properties of oximes, the effect of HI 6 was investigated with sarin, tabun and soman exposed human intercostal muscle. Muscle force production by indirect field stimulation and the activity of the human muscle AChE was assessed. 30 μM HI 6 resulted in an almost complete recovery of sarin blocked muscle force and in an increase of completely inhibited muscle AChE activity to approx. 30% of control. In soman or tabun exposed human intercostal muscle HI 6 (50 and 100 μM) had no effect on blocked muscle force or on inhibited human muscle AChE activity. In addition, HI 6 up to 1000 μM had no effect on soman blocked muscle force indicating that this oxime has no direct, pharmacological effect in human tissue. These results emphasize that sufficient reactivation of AChE is necessary for a beneficial therapeutic effect on nerve agent blocked neuromuscular transmission.
    Toxicology Letters 09/2011; 206(1):72-6. · 3.15 Impact Factor
  • André L. Mihaljevic, Helmut Friess
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    ABSTRACT: ZusammenfassungBei zystischen Raumforderungen ist aufgrund der weiten Spanne an möglichen Differentialdiagnosen mit sehr unterschiedlichen Prognosen eine fundierte Diagnostik angezeigt. Selbst dann kann nicht immer präoperativ eine sichere Diagnose gestellt werden, da viele zystische Raumforderungen nur durch eine feingewebliche pathologische Untersuchung eines Operationspräparates sicher diagnostiziert werden können, sodass präoperativ Unsicherheiten verbleiben. Die einzelnen Krankheitsbilder verlangen oftmals nach einer individualisierten chirurgischen Intervention, die der Prognose, der Pathologie, den Komorbiditäten und der Ausdehnung der Erkrankung Rechnung tragen muss. Hierbei kommt das gesamte Spektrum der Pankreaschirurgie zur Anwendung, wodurch sich die Notwendigkeit ergibt, solche Patienten in einem Pankreaszentrum mit entsprechender diagnostischer, konservativer und chirurgischer Expertise zu behandeln. Nach einer Darstellung des präoperativen klinischen Vorgehens sowie der Indikationen für einzelne Operationsverfahren werden diese individualisierten chirurgischen Interventionen im Anschluss kurz dargestellt.
    Viszeralmedizin. 01/2011; 27:214-224.
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    ABSTRACT: The purpose of this review is to highlight the molecular mechanisms leading to the development and progression of pancreatic ductal adenocarcinoma (PDAC) with particular emphasis on tumor cell proliferation, local invasion, and metastasis. Recent advances in the field of PDAC biology have shed light on the molecular events that trigger PDAC initiation and maintenance. It is now clear that apart from the genetic alterations within the tumor cells, interactions of the tumor with its environment are necessary for proliferation and invasion. Interestingly, a number of developmental signaling pathways are reactivated in PDAC. Progress has also been made in the understanding of the molecular events that govern the process of metastasis. Although our understanding of the mechanisms underlying PDAC pathobiology are more advanced than ever, little progress has been made in the clinical treatment of PDAC, and successful bench-to-bedside transfer of knowledge to boost new treatment options is still unsatisfying.
    Langenbeck s Archives of Surgery 03/2010; 395(4):295-308. · 1.89 Impact Factor
  • André L Mihaljevic, Jörg Kleeff, Helmut Friess
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    ABSTRACT: The purpose of this paper is to illuminate the origin and current results of the duodenum-preserving pancreatic head resection (DPPHR) developed by Beger in the 1970s, as well as its simplified Berne modification, for patients suffering from chronic pancreatitis (CP). Indications for the procedures and their results are presented on the basis of available data. A selected review was made of the available data on the DPPHR developed by Beger and its modifications. The organ-sparing DPPHR developed by Beger, and its modifications, provide better pain relief, better preservation of exocrine and endocrine pancreatic function, and a superior quality of life compared with the more radical pancreaticoduodenectomy (PD, with or without pylorus-preservation), once the standard treatment for patients with CP. Recently published data on the long-term follow-up of studies comparing PD to DPPHR indicate that the initial benefits of DPPHR over PD might be less pronounced in the long-run. The organ-preserving DPPHR developed by Beger, and its modifications, have become established and well-evaluated surgical treatment options for patients with CP.
    Journal of hepato-biliary-pancreatic sciences. 10/2009; 17(6):735-44.
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    ABSTRACT: Recent advances in molecular biology, biochemistry and genetics have broadened our understanding of tumourigenesis and of the maintenance and spread of pancreatic cancer far beyond traditional microscopic histopathological analysis. While the main focus of pancreatic cancer research has been on pancreatic ductal adenocarcinoma, molecular research has also led to a better understanding of rare tumours of the pancreas, as well as to the definition of previously unknown tumour entities that can only be identified through the application of molecular tools. Furthermore, molecular analysis increasingly reveals the genetic and cell biological heterogeneity of established tumour entities, making subclassification of tumours possible. Genetic and molecular approaches may, therefore, not only lead to a better understanding of the pathogenesis of pancreatic tumours, but also culminate in more precise diagnosis as well as individually tailored treatment strategies for affected patients.
    Pancreatology 06/2009; 9(4):334-9. · 2.04 Impact Factor
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    ABSTRACT: The formation of the pancreatic duct system is the result of the fusion of 2 embryonic buds, the ventral and dorsal primordia. Frequently, this fusion process is localized in the pancreatic head; variations, however, may account for the structural diversity of the duct system. Pancreatic duct anomalies and diversity of body and tail are thought to be casuistic. Ninety-nine consecutive adult autopsies with reference to macroscopic anomalies in the distal part of the gland were evaluated. Pancreatograms were performed after large duodenal papilla cannulation. Ducts parallel to gland axis with a diameter of at least one third of the main pancreatic duct at the junction point and aberrant duct with different shapes and/or abnormal third-degree ductuli architecture were noted. Our study revealed a 9.9% frequency of main pancreatic duct diversity in the pancreatic corpus and tail. Eleven atypical ducts were visible, 9 cranially and 2 caudally from the main pancreatic duct. The pancreatic duct system in the body and the tail presents abnormal configuration not described in the past.
    Pancreas 01/2009; 38(3):318-21. · 2.95 Impact Factor
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    ABSTRACT: Autoimmune pancreatitis (AIP) is a chronic fibroinflammatory disease of the pancreas characterised by lymphoplasmacytic infiltrates, interstitial fibrosis, periductal inflammation and periphlebitis. Although first described more than four decades ago, it has not gained widespread attention until the 1990s when new insights into its aetiology, clinical presentation and management were discovered. Although nowadays widely accepted as a form of chronic pancreatitis, recent evidence suggests that AIP might not be confined to the pancreas but rather be an inflammatory pancreaticobiliary disease (autoimmune pancreatocholangitis, AIPC) with possible systemic involvement and association with other autoimmune disorders. This article reviews current concepts of AIP with special focus on the histopathological features of the disease.
    Minerva gastroenterologica e dietologica 01/2009; 54(4):365-74.
  • A. L. Mihaljevic, I. Esposito, H. Friess, J. Kleeff
    European Surgery-acta Chirurgica Austriaca - EUR SURG. 01/2009; 41(6):250-267.
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    ABSTRACT: Chronic pancreatitis (CP), a benign, inflammatory process of the pancreas, can cause severe pain, diabetes mellitus, steatorrhoea, and weight loss and often leads to a significant reduction in the quality of life. In the past decade our knowledge of the pathophysiology of CP has increased together with the number and quality of treatment options available for this disease. In addition to pharmacological and endoscopic treatment modalities, surgical drainage and resection procedures have become increasingly important since they have the potential to provide superior long-term results in patients with CP. The classical and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by organ-sparing procedures like the duodenum preserving pancreatic head resection and its variants. The latter allow better preservation of the exocrine and endocrine pancreatic function, and provide adequate pain relieve and improvement in the quality of life of CP patients.
    Baillière&#x027 s Best Practice and Research in Clinical Gastroenterology 02/2008; 22(1):167-81. · 3.16 Impact Factor
  • Andre L. Mihaljevic, Jörg Kleeff, Helmut Friess
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    ABSTRACT: Zusammenfassung Iatrogene Gallenwegskomplikationen nach laparoskopischen Cholezystektomien oder endoskopischen Interventionen sind mit einer erheblichen Morbidität und Mortalität für den Patienten vergesellschaftet. Ein frühzeitiges Erkennen der Komplikationen, für deren Einteilung verschiedenste Klassifikationssysteme zur Verfügung stehen, ist mit einer deutlichen Prognoseverbesserung assoziiert. Das Management solcher Komplikationen richtet sich nach Schwere, Typ und Lokalisation der Verletzung sowie nach dem Zeitpunkt der Erstdiagnose. Ihre Behandlung sollte immer an einem Zentrum mit hoher Kompetenz in hepatobiliärer Chirurgie, Endoskopie und interventioneller Radiologie vorgenommen werden. Neben endoskopischen Verfahren und perkutanen transhepatischen Interventionen nimmt die chirurgische Rekonstruktion des Galleabflusses einen wichtigen Stellenwert in der Therapie dieser Patienten ein. Die meisten Patienten sind auf eine langfristige Nachsorge angewiesen und die besten Ergebnisse werden bei interdisziplinärer Zusammenarbeit zwischen Chirurgie, Endoskopie und interventioneller Radiologie erzielt.
    Chirurgische Gastroenterologie 01/2008; 24(2):115-123. · 0.14 Impact Factor
  • A. L. Mihaljevic, I. Esposito, H. Friess, J. Kleeff
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    ABSTRACT: BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) and chronic pancreatitis (CP) represent frequent, and devastating diseases of the pancreas. Although the treatment for both conditions has improved over the past decades, overall prognosis remains poor necessitating the development of new treatment options, which in turn requires a deeper understanding of the underlying pathophysiology including genetic, molecular, and histopathologic changes occurring in both diseases. METHODS: Review of the literature. RESULTS: Significant progress has been made in the field of pancreatic research deepening our understanding of PDAC and CP development and maintenance. The landmark findings will be outlined in this article drawing attention to the common pathologic pathways of both diseases. On a histopathologic level, PDAC development from precursor lesions has been described in detail. Furthermore, genetic changes during PDAC initiation and maintenance have recently been discovered. However, the exact role of many molecular alterations found in PDAC remains unclear. In CP, new concepts have changed our understanding of the disease and the finding and characterization of pancreatic stellate cells have given us a better understanding of the mechanism of pancreatic fibrosis, a hallmark of CP. CONCLUSIONS: Our growing knowledge of the underlying molecular and histopathologic changes occurring in PDAC as well as CP has given us an unprecedented insight into the causes and mechanisms of PDAC and CP development. GRUNDLAGEN: Das duktale Adenokarzinom des Pankreas sowie die chronische Pankreatitis stellen zwei häufige und schwerwiegende Erkrankungen der Bauchspeicheldrüse dar. Auch wenn sich die Behandlung dieser Erkrankungen in den letzten Jahrzehnten deutlich verbessert hat, bleibt doch die Prognose in beiden Fällen schlecht, so dass die Entwicklung neuer Behandlungsoptionen notwendig erscheint. Dies wiederum setzt ein tieferes Verständnis der zu Grunde liegende Pathophysiologie, einschließlich der molekularen, genetischen und histopathologischen Veränderungen, voraus. METHODIK: Übersichtsarbeit auf der Grundlage einer selektiven Literaturausarbeitung. ERGEBNISSE: Wesentliche Fortschritte im Bereich der Pankreasforschung haben unser Verständnis des duktalen Adenokarzinoms sowie der chronischen Pankreatitis vertieft. Die grundlegenden Erkenntnisse werden in diesem Artikel skizziert werden, mit besonderem Fokus auf den gemeinsamen pathophysiologischen Grundlagen beider Erkrankungen. Die Entwicklung des duktalen Adenokarzinoms aus Vorläuferläsionen ist in der Zwischenzeit im Detail beschrieben. Des Weiteren sind grundlegende genetische Veränderungen der Entwicklung und Ausbreitung des PDAC identifiziert worden. Viele molekulare Veränderungen sind jedoch in ihrer Bedeutung nicht genau bekannt oder noch nicht ausreichend untersucht worden. In der chronischen Pankreatitis haben neue Konzepte unser Verständnis der Erkrankung grundlegend verändert. Die Entdeckung und Charakterisierung von pankreatischen Sternzellen hat zu einem besseren Verständnis der Genese der Pankreasfibrose, eines der wesentlichen Charakteristika der chronischen Pankreatitis, beigetragen. SCHLUSSFOLGERUNGEN: Unser wachsendes Wissen über die molekularen und histopathologischen Grundlagen des Pankreaskarzinoms sowie der chronischen Pankreatitis haben uns einen nie dagewesenen Einblick in die Entstehung dieser Erkrankungen ermöglicht. KeywordsPancreatic cancer-Chronic pancreatitis-Pathogenesis-Genetic alterations-Pancreatic stellate cells-Desmoplasia-Signaling pathways-Histopathology SchlüsselwörterPankreaskarzinom-Chronische Pankreatitis-Pathogenese-Genetische Veränderungen-Pankreatische Sternzellen-Desmoplasie-Signalkaskaden-Histopathologie
    European Surgery 41(6):250-267. · 0.15 Impact Factor