D Henne-Bruns

Universität Ulm, Ulm, Baden-Württemberg, Germany

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Publications (315)577.43 Total impact

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    ABSTRACT: Aim: We analyzed survival of patients diagnosed with ampullary cancer (AC) and pancreatic ductal adenocarcinomas (PDAC). Patients and Methods: Between 1996 and 2009, 505 and 69 patients diagnosed with PDAC and AC, respectively, were identified. Overall survival was analyzed according to tumor entity, therapeutic approach and pathological tumor stage. Results: The 5-year overall survival rate of patients with AC (37%; 95% confidence interval 25-49%) was remarkably higher compared to PDAC patients (7%; 95% confidence interval 5-10%). In both cohorts, surgical resection improved survival. Analysis of pathological factors revealed a survival benefit for patients staged with small primary tumors (pT1/2) and exclusion of distant metastases (M0) for both PDAC and AC. Interestingly, absence of lymph node metastasis substantially improved survival in AC, but not in PDAC. Conclusion: Overall survival of patients with AC is superior compared to that of patients with PDAC. Therapeutically, adequate regional lymph node dissection seems particularly important for the surgical management of AC.
    Anticancer research 06/2014; 34(6):3011-3020. · 1.71 Impact Factor
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    ABSTRACT: During the last 15 years, there was tremendous progress in minimally invasive surgery and minimal-access surgery. Many conventional surgical procedures were replaced by these techniques, resulting in a wide range of benefits for the patients. In kidney transplantation, many centers choose an approach to the iliac fossa through an oblique or J-shaped incision. This might have possible disadvantages due to the extent of tissue trauma. Thus, we introduced a minimal-access kidney transplantation technique (MAKT) as a transplantation method in our center. We retrospectively analyzed this technique used for 11 living-donor kidney transplants and report here our experience.
    Transplantation Proceedings 06/2014; 46(5):1286-9. · 0.95 Impact Factor
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    Katrin Bauer, Franz Porzsolt, Doris Henne-Bruns
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    ABSTRACT: According to current guidelines, perioperative chemotherapy is an integral part of the treatment strategy for advanced gastric cancer. Randomized controlled studies have been conducted in order to determine whether perioperative chemotherapy leads to improved R0 resection rates, fewer recurrences, and prolonged survival. The aim of our project was to critically appraise three major studies to establish whether perioperative chemotherapy for advanced, potentially resectable gastric cancer can be recommended on the basis of their findings. We analyzed the validity of the three most important studies (MAGIC, ACCORD, and EORTC) using a standardized questionnaire. Each study was evaluated for the study design, patient selection, randomization, changes in protocol, participating clinics, preoperative staging, chemotherapy, homogeneity of subjects, surgical quality, analysis of the results, and recruitment period. All three studies had serious shortcomings with respect to patient selection, homogeneity of subjects, changes in protocol, surgical quality, and analysis of the results. The protocols of the MAGIC and ACCORD-studies were changed during the study period because of insufficient recruitment, such that carcinomas of the lower esophagus and the stomach were examined collectively. In neither the MAGIC study nor the ACCORD study did patients undergo adequate lymphadenectomy, and only about half of the patients in the chemotherapy group could undergo the treatment specified in the protocol. The EORTC study had insufficient statistical power. We concluded that none of the three studies was sufficiently robust to justify an unrestrained recommendation for perioperative chemotherapy in cases of advanced gastric cancer.
    Journal of gastric cancer. 03/2014; 14(1):39-46.
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    ABSTRACT: The ubiquitously expressed serine/threonine specific casein kinase 1 (CK1) family plays important roles in the regulation of various physiological processes. Small-molecule inhibitors, such as the CK1δ/ε selectively inhibitor IC261, have been used to antagonize CK1 phosphorylation events in cells in many studies. Here we present data to show that, similarly to the microtubule destabilizing agent nocodazole, IC261 depolymerizes microtubules in interphase cells. IC261 treatment of interphase cells affects the morphology of the TGN and Golgi apparatus as well as the localization of CK1δ, which co-localizes with COPI positive membranes. IC261-induced depolymerization of microtubules is rapid, reversible and can be antagonized by pre-treatment of cells with taxol. At lower concentrations of IC261, mitotic spindle microtubule dynamics are affected; this leads to cell cycle arrest and, depending on the cellular background, to apoptosis in a dose-dependent manner. In addition, FACS analysis revealed that IC261 could induce apoptosis independent of cell cycle arrest. In summary this study provides additional and valuable information about various IC261-induced effects that could be caused by microtubule depolymerization rather than by inhibition of CK1. Data from studies that have used IC261 as an inhibitor of CK1 should be interpreted in light of these observations.
    PLoS ONE 01/2014; 9(6):e100090. · 3.53 Impact Factor
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    ABSTRACT: About 10% of all cancer patients will develop brain metastases during advanced disease progression. Interestingly, the vast majority of brain metastases occur in only three types of cancer: Melanoma, lung and breast cancer. In this review, we focus on summarizing the prognosis and impact of surgical resection of brain metastases originating from gastrointestinal cancers such as esophageal, gastric, pancreatic and colorectal cancer. The incidence of brain metastases is <1% in pancreatic and gastric cancer and <4% in esophageal and colorectal cancer. Overall, prognosis of these patients is very poor with a median survival in the range of only months. Interestingly, a substantial number of patients who had received surgical resection of brain metastases showed prolonged survival. However, it should be taken into account that all these studies were not randomized and it is likely that patients selected for surgical treatment presented with other important prognostic factors such as solitary brain metastases and exclusion of extra-cranial disease. Nevertheless, other reports have demonstrated long-term survival of patients upon resection of brain metastases originating from gastrointestinal cancers. Thus, it appears to be justified to consider aggressive surgical approaches for these patients.
    International Journal of Molecular Sciences 01/2014; 15(9):16816-16830. · 2.46 Impact Factor
  • Katrin Bauer, Franz Porzsolt, Doris Henne-Bruns
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    ABSTRACT: According to the recommendations of the German S3 guideline, perioperative chemotherapy is an integral part of the treatment concept for advanced gastric cancer. The leading trial which examined the effects of perioperative chemotherapy is the MAGIC study. An examination of the validity of this study with a standardized method revealed shortcomings in the six areas: design, protocol, selection of patients, randomization / homogeneity of patient groups, quality of the surgical care and the statistical evaluation. These shortcomings and their influence on the study results are described in this paper to reveal the importance of these effects for discussion in guidelines committees.
    Hepato-gastroenterology 10/2013; 60(127):1822-2. · 0.77 Impact Factor
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    ABSTRACT: Our aim was to determine predictive factors for the diagnosis and postoperative complications of acute appendicitis. Data sets of 1,439 consecutive adults and children who had an appendectomy between 1999 and 2008 were retrospectively analyzed. A mild acute appendicitis was present in 50 % (n = 722) and a severe acute appendicitis in 25 % (n = 355) of the patients. No signs of any pathology were found in 6 % (n = 82). Gender, white blood count (WBC), C-reactive protein (CRP), and ultrasound (US) examination were important indicators of mild acute and severe acute appendicitis in adults and children. Postoperative complications occurred in 16 % (237/1,439), mainly consisting of wound infections (8 %, n = 122) and bowel dysfunction (5 %, n = 76). Sixty-two patients (4.3 %) required reoperations. One patient died (1/1,439, 0.07 % mortality rate). Age, pathology, and the presence of bacteria in the intraoperative swab were important predictive factors for postoperative complications in adults and children. Time since onset of symptoms and type of operation were also associated with postoperative complications among adults. Complications developed in 21 and 9 % of the adults (155/754 and 10/125) who had open and laparoscopic surgery, respectively. Besides history and clinical examination, WBC, CRP, and US examination remain important factors for diagnosing acute appendicitis. Complications are related to the pathology, presence of bacteria, and type of operation. Early diagnosis within 48 h may be important. A laparoscopic procedure in adults may also cause fewer wound infections.
    Langenbeck s Archives of Surgery 07/2013; · 1.89 Impact Factor
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    ABSTRACT: Background/Aims: The long-term success of multivisceral resections for cancer is difficult to forecast due to the complexity of factors influencing the prognosis. The aim of our study was to assess the predictivity of a Bayes network for the postoperative outcome and survival. Methodology: We included each oncologic patient undergoing resection of 4 or more organs from 2002 till 2005 at the Ulm university hospital. Preoperative data were assessed as well as the tumour classification, the resected organs, intra- and postoperative complications and overall survival. Using the Genie 2.0 software we developed a Bayes network. Results: Multivisceral tumour resections were performed in 22 patients. The receiver operating curve areas of the variables "survival >12 months" and "hospitalisation >28 days" as predicted by the Bayes network were 0.81 and 0.77 and differed significantly from 0.5 (p: 0.019 and 0.028, respectively). The positive predictive values of the Bayes network for these variables were 1 and 0.8 and the negative ones 0.71 and 0.88, respectively. Conclusions: Bayes networks are useful for the prognosis estimation of individual patients and can help to decide whether to perform a multivisceral resection for cancer.
    Hepato-gastroenterology 06/2013; 60(125):1009-1013. · 0.77 Impact Factor
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    ABSTRACT: Background: A Bayes Network was developed for individual risk prediction after cholecystectomy. Validity and robustness were compared with logistic regression analysis (LR). Methods: Clinical databases were created at the Ulm University and St. Franziskus Flensburg hospitals between 2001 and 2010 were comprised of hospitalized cholecystolithiasis patients serving as model and test cohorts, respectively. The probabilities of in-hospital death, prolonged hospitalization (>7 days), relaparotomy and erythrocyte transfusions were predicted based solely on admission data by BN and LR. ROC curves were calculated. Results: The Ulm and Flensburg cohorts consisted of 1,029 and 1,842 patients, respectively. The areas under the ROC curves for predicting death were 94% (p = 0.8) for both BN and LR, 70 vs. 76% (p < 0.001) for prolonged hospitalization, 69 vs. 68% (p = 0.8) for relaparotomy, and 84 vs. 78% (p = 0.1) for ET. Predictability declined for both methods when explanatory values were changed randomly. In contrast to LR, the BN revealed a good robustness to missing values. Conclusion: Both BN and MR predicted the death risk quite accurately. The advantage of BN consists of its robustness to missing values. Moreover, its graphical representation may be helpful for clinical decision making.
    Digestive surgery 04/2013; 30(1):28-34. · 1.37 Impact Factor
  • Zentralblatt für Chirurgie 03/2013; · 0.69 Impact Factor
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    ABSTRACT: BACKGROUND:: Focused unilateral or minimally invasive parathyroidectomy for primary hyperparathyroidism (pHPT) depends on the successful preoperative localization of parathyroid adenomas. The aim of this prospective study was to determine the accuracy of C-11 methionine positron emission tomography/computed tomography (Met-PET/CT), a novel localization procedure for hyperfunctional parathyroid tissue. METHODS:: Preoperative Met-PET/CT scans of the neck and mediastinum of 102 patients undergoing parathyroidectomy for pHPT were preoperatively evaluated by a radiologist and a nuclear medicine physician and prospectively documented. The results of Met-PET/CT were compared with intraoperative and histopathological findings. RESULTS:: pHPT was caused by a single-gland adenoma in 97 patients, whereas 5 patients had multiglandular disease. Met-PET/CT correctly located a single-gland adenoma in 83 of 97 (86%) patients with pHPT (sensitivity 91%). The positive predictive value of Met-PET/CT in localizing a single-gland adenoma was 93%. Of the 5 patients with multiglandular disease, Met-PET/CT identified 2 hyperfunctioning parathyroid glands in 1 patient, 1 gland in 3 individuals, and was negative in the fifth patient (sensitivity 80%). A highly significant correlation was observed between true-positive findings and the size (mean = 1.81 ± 0.84 cm) and weight (mean = 1.50 ± 2.56 g) of parathyroid adenoma, whereas patients with false-negative findings had significantly smaller (mean = 1.09 ± 0.41 cm) and lighter (mean = 0.37 ± 0.29 g) glands (P < 0.001 and P = 0.001, respectively). CONCLUSIONS:: This study demonstrates the high accuracy of Met-PET/CT in the preoperative localization of parathyroid adenomas in a large series of patients with pHPT.
    Annals of surgery 03/2013; · 7.90 Impact Factor
  • Claas Brockschmidt, Doris Henne-Bruns, Mathias Wittau
    Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation. 02/2013; 11(1):82.
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    ABSTRACT: To assess anxiety and depression symptoms, suicidal ideation, and health-related quality of life (HRQOL) in a large series of consecutive patients with primary hyperparathyroidism (pHPT) before and after parathyroidectomy. This prospective multicenter study investigated preoperative and postoperative depression, anxiety, suicidal ideation, and HRQOL in patients with pHPT and compared these variables with a control group with nontoxic thyroid nodules. The study included 194 patients with pHPT and 186 control subjects. Depression was evaluated with the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9, which also assessed suicidal ideation. Anxiety was evaluated with the HADS. Health-related quality of life was measured with the 36-Item Short Form survey. Parathyroidectomy achieved a 98% cure rate. Preoperatively, severe depression (HADS score ≥ 11) was seen in 20% of the pHPT group and 9% of the control group. The Patient Health Questionnaire-9 detected moderate to severe depression in 17% of the patients with pHPT and 7% of the control subjects. Patients with pHPT had higher HADS anxiety scores (mean, 7.7) than control subjects (P < .01) or the German normative sample (P < .001). Compared with control subjects, patients with pHPT had significantly lower 36-Item Short Form survey preoperative physical and mental health summary scores (42.7 vs 49.5 and 41.2 vs 46.8, respectively; P = .001 for both comparisons). At 12 months follow-up, depression and anxiety decreased significantly in patients with pHPT; the prevalence of suicidal ideation was more than halved from the baseline (10.7% vs 22%; P = .008). Both physical and mental health scores (45.7 and 47.7, respectively) improved in patients with pHPT (P < .001 each) but not in control subjects. Depression, anxiety, and decreased HRQOL appear to be related to pHPT. Successful parathyroidectomy seems to reduce psychopathologic symptoms and improve HRQOL in this setting.
    JAMA surgery. 02/2013; 148(2):109-15.
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    F Porzsolt, D Ittner, D Henne-Bruns
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    ABSTRACT: Background: Prevention programmes should only be recommended if they achieve what they promise to achieve. Therefore, we checked the variation and validity of recommendations for screening for colorectal cancer of nine organisations.Methods: We analysed the information concerning recommended screening age, guaiac faecal occult blood test (gFOBT), faecal immunological test (FIT), faecal DNA test, sigmoidoscopy, colonoscopy, double-contrast examination/double-contrast barium enema, and virtual colonoscopy/CT colonography in the following three steps: 1) we gathered the references quoted by the nine organisations; 2) references were categorised according to mortality, incidence and sensitivity/specificity; 3) the validity of references that reported reduced mortality attributed to screening were evaluated.Results: Evidence of occult faecal blood was the only screening method recommended by all nine organisations. Colonoscopy was recommended by seven organisations. Fifteen of the 33 references used endpoints other than mortality to justify screening. One publication was a meta-analysis. Eleven of 17 publications evaluated the gFOBT, three evaluated sigmoidoscopy, one FIT, one coloscopy, and one general diagnosis of the intestine. On average, two of nine validity criteria were completely fulfilled, five only partially, and two were not fulfilled. In two publications, none of the validity criteria were completely met.Conclusion: Analysis of screening for colorectal cancer revealed that nine organisations had different goals and different recommendations. Scrupulous and thorough evaluation of the scientific studies in relation to mortality, upon which these recommendations are based, revealed numerous shortcomings and therefore could not sufficiently substantiate the international recommendations for screening for colorectal cancer. It would be useful to establish a consensus about which data have to be collected to provide a reliable basis for health-care decisions.
    Zentralblatt für Chirurgie 01/2013; · 0.69 Impact Factor
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    ABSTRACT: CK1δ, a member of the casein kinase 1 family, is involved in the regulation of various cellular processes and has been associated with the pathophysiology of neurodegenerative diseases and cancer. Therefore recently, interest in generating highly specific inhibitors for personalized therapy has increased enormously. However, the efficacy of newly developed inhibitors is affected by the phosphorylation state of CK1δ. Cellular kinases phosphorylating CK1δ within its C-terminal domain have been identified but still more information regarding the role of site-specific phosphorylation in modulating the activity of CK1δ is required. Here we show that Chk1 phosphorylates rat CK1δ at serine residues 328, 331, 370, and threonine residue 397 as well as the human CK1δ transcription variants 1 and 2. CK1δ mutant proteins bearing one, two or three mutations at these identified phosphorylation sites exhibited significant differences in their kinetic properties compared to wild-type CK1δ. Additionally, CK1δ co-precipitates with Chk1 from HT1080 cell extracts and activation of cellular Chk1 resulted in a significant decrease in cellular CK1δ kinase activity. Taken together, these data point towards a possible regulatory relationship between Chk1 and CK1δ.
    PLoS ONE 01/2013; 8(7):e68803. · 3.53 Impact Factor
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    ABSTRACT: Pancreatic cancer is a fatal disease with a 5-year survival rate below 5%. Most patients are diagnosed at an advanced tumor stage and existence of distant metastases. However, involvement of the central nervous system is rare in pancreatic cancer. We retrospectively analyzed all cases of brain metastases in pancreatic cancer reported to date focusing on patient characteristics, clinical appearance, therapy and survival. Including our own, 12 cases of brain metastases originating from pancreatic cancer were identified. In three patients brain metastases were the first manifestation of pancreatic cancer. All other patients developed brain metastases during their clinical course. In most cases, the disease progressed rapidly and the patients died within weeks or months. However, two patients showed long-term survival. Of note, both patients received resection of the pancreatic cancer as well as curative resection of the metachronous brain metastases. Brain metastases in pancreatic cancer are a rare condition and usually predict a very poor prognosis. However, there is evidence that resection of brain metastases of pancreatic cancer can be immensely beneficial to patient's survival, even with the chance for cure. Therefore, a surgical approach in metastatic pancreatic cancer should be considered in selective cases.
    International Journal of Molecular Sciences 01/2013; 14(2):4163-73. · 2.46 Impact Factor
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    ABSTRACT: BACKGROUND: Obesity has been associated with increased incidence of colorectal cancer. Adipose tissue dysfunction accompanied with alterations in the release of adipocytokines has been proposed to contribute to cancer pathogenesis and progression. The aim of this study was to analyze plasma concentrations of several adipose tissue expressed hormones in colorectal cancer patients (CRC) and morbidly obese (MO) patients and to compare these concentrations to clinicopathological parameters. METHODS: Plasma concentrations of adiponectin, resistin, leptin, active plasminogen activator inhibitor (PAI)-1, monocyte chemotactic protein (MCP)-1, interleukin (IL)-1 alpha, and tumor necrosis factor (TNF)-alpha were determined in 67 patients operated on for CRC (31 rectal cancers, 36 colon cancers), 37 patients operated on for morbid obesity and 60 healthy blood donors (BD). RESULTS: Compared to BD, leptin concentrations were lowered in CRC patients whereas those of MO patients were elevated. Adiponectin concentrations were only lowered in MO patients. Concentrations of MCP-1, PAI-1, and IL-1 alpha were elevated in both CRC and MO patients, while resistin and TNF-alpha were similarly expressed in MO and CRC patients compared to BD. Resistin concentrations positively correlated with tumor staging (p<0.002) and grading (p=0.015) of rectal tumor patients. CONCLUSIONS: The results suggest that both MO and CRC have low-grade inflammation as part of their etiology.
    BMC Cancer 11/2012; 12(1):545. · 3.33 Impact Factor
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    ABSTRACT: A 31-year-old pregnant woman presented with refractory severe hypercalcemia due to an advanced neuroendocrine tumor masquerading as hyperemesis gravidarum. Octreotide therapy and extensive tumor debulking surgery resulted in symptom control. After a prolonged stay in the intensive care unit due to parapneumonic acute respiratory distress syndrome, the patient delivered a healthy child. Neuroendocrine tumors are a rare complication of pregnancy and a seldom cause of refractory hypercalcemia.
    Der Internist 10/2012; · 0.33 Impact Factor
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    ABSTRACT: BACKGROUND: Our aim was to compare long-term results of adjuvant treatment of colon cancer (CC) and rectal cancer (RC). Adjuvant chemotherapy of CC improved overall survival (OS), whereas that of RC remained at the level achieved by 5-fluorouracil (5-FU). METHODS: We separately conducted 2 identically designed adjuvant trials in CC and RC. Patients were assigned to adjuvant chemotherapy with 5-FU alone, 5-FU + folinic acid (FA), or 5-FU + interferon-alfa. The first study enrolled patients with stage IIb/III CC, and the second study enrolled patients with stage II/III RC. All patients with RC received postoperative irradiation. RESULTS: Median follow-up for all patients with CC (n = 855) and RC (n = 796) was 4.9 years. The pattern and frequency of recurrence differed significantly, especially lung metastases, which occurred more frequently in RC (12.7%) than in CC (7.3%; P < .001). Seven-year OS rates for 5-FU, 5-FU + FA, and 5-FU + IFN-alfa were 54.1% (95% confidence interval [CI], 46.5-61.0), 66.8% (95% CI, 59.4-73.1), and 56.7% (95% CI, 49.3-63.4) in CC and 50.6% (95% CI, 43.0-57.7), 56.3% (95% CI, 49.4-62.7), and 54.8% (95% CI, 46.7-62.2) in RC, respectively. A subgroup analysis pointed to a reduced local recurrence (LR) rate and an increased OS by the addition of FA in stage II RC (n = 271) but not in stage III RC (n = 525). CONCLUSION: FA increased 7-year OS by 12.7 percentage points in CC but was not effective in RC. Based on these results and the pattern of metastases, our results suggest that the chemosensitivity of CC and RC may be different. Strategies different from those used in CC may be successful to decrease the frequency of distant metastases in RC in the future.
    Clinical Colorectal Cancer 10/2012; · 1.80 Impact Factor
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    ABSTRACT: BACKGROUND: A variety of multimodal treatment options are available for colorectal cancer and many patients want to be involved in decisions about their therapies. However, their desire for autonomy is limited by lack of disease-specific knowledge. Visual aids may be helpful tools to present complex data in an easy-to-understand, graphic form to lay persons. The aim of the present study was to evaluate the treatment preferences of healthy persons and patients using visual aids depicting multimodal treatment options for colorectal cancer. METHODS: We designed visual aids for treatment scenarios based on four key studies concerning multimodal treatment of colorectal cancer. The visual aids were composed of diagrams depicting outcome parameters and side effects of two treatment options. They were presented to healthy persons (n = 265) and to patients with colorectal cancer (n = 102). RESULTS: Most patients and healthy persons could make immediate decisions after seeing the diagrams (range: 88% -- 100%). Patients (79%) chose the intensive-treatment option in the scenario with a clear survival benefit. In scenarios without survival benefit, all groups clearly preferred the milder treatment option (range: 78% - 90%). No preference was seen in the scenario depicting equally intense treatment options with different timing (neoadjuvant vs. adjuvant) but without survival benefit. CONCLUSIONS: Healthy persons' and patients' decisions using visual aids seem to be influenced by quality-of-life aspects rather than recurrence rates especially in situations without survival benefit. In the future visual aids may help to improve the management of patients with colorectal cancer.
    BMC Medical Informatics and Decision Making 10/2012; 12(1):118. · 1.60 Impact Factor

Publication Stats

3k Citations
577.43 Total Impact Points

Institutions

  • 2002–2014
    • Universität Ulm
      • • Clinic of General and Visceral Surgery
      • • Institute of General Medicine
      Ulm, Baden-Württemberg, Germany
  • 2009
    • University of Greifswald
      • Center for Internal Medicine
      Greifswald, Mecklenburg-Vorpommern, Germany
    • St. Franziskus-Hospital
      Köln, North Rhine-Westphalia, Germany
  • 2008
    • Martin Luther University of Halle-Wittenberg
      • Institute for Pathology
      Halle-on-the-Saale, Saxony-Anhalt, Germany
  • 2007
    • National and Kapodistrian University of Athens
      Athínai, Attica, Greece
  • 1993–2003
    • Christian-Albrechts-Universität zu Kiel
      Kiel, Schleswig-Holstein, Germany
  • 2001
    • Poznan University of Medical Sciences
      Posen, Greater Poland Voivodeship, Poland
    • Zhejiang University
      Hang-hsien, Zhejiang Sheng, China
  • 1994–1998
    • HELIOS Klinik Kiel
      Kiel, Schleswig-Holstein, Germany
  • 1987–1993
    • University of Hamburg
      • Department of General, Visceral and Thoracic Surgery Department and Clinic
      Hamburg, Hamburg, Germany
  • 1987–1991
    • University Medical Center Hamburg - Eppendorf
      Hamburg, Hamburg, Germany
  • 1990
    • University of Chicago
      • Department of Surgery
      Chicago, IL, United States