[Show abstract][Hide abstract] ABSTRACT: Hospital volume, surgeons' experience, and adequate management of complications are factors that contribute to a better outcome after pancreatic resections. The aim of our study was to analyze trends in indications, surgical techniques, and postoperative outcome in more than 1,100 pancreatic resections.
One thousand one hundred twenty pancreatic resections were performed since 1994. The vast majority of operations were performed by three surgeons. Perioperative data were documented in a pancreatic database. For the purpose of our analysis, the study period was sub-classified into three periods (A 1994 to 2001/n = 363; B 2001 to 2006/n = 305; C since 2007 to 2012/n = 452).
The median patient age increased from 51 (A) to 65 years (C; P < 0.001). Indications for surgery were pancreatic/periampullary cancer (49%), chronic pancreatitis (CP; 33%), and various other lesions (18%). About two thirds of the operations were pylorus-preserving pancreaticoduodenectomies. The frequency of mesenterico-portal vein resections increased from 8% (A) to 20% (C; P < 0.01). The overall mortality was 2.4% and comparable in all three periods (2.8%, 2.0%, 2.4%; P = 0.8). Overall complication rates increased from 42% (A) to 56% (C; P < 0.01).
Mortality remained low despite a more aggressive surgical approach to pancreatic disease. An increased overall morbidity may be explained by more clinically relevant pancreatic fistulas and better documentation.
World Journal of Surgical Oncology 12/2015; 13(1):525. DOI:10.1186/s12957-015-0525-6 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Postoperative pancreatic fistula is a relevant complication after pancreatoduodenectomy. Therefore, preoperative detection of high risk patients may be important. We evaluated preoperative CT-imaging by planimetry at the expected resection plane along the superior mesenteric vein and correlated the results with the incidence of postoperative pancreatic fistula. Patients and Methods: From 2009 to 2013, 123 patients with pancreatoduodenectomy underwent homogenous preoperative imaging and reconstruction of the pancreatojejunostomy. Planimetry was performed at a multiplanar reconstruction of the pancreatic transection plane (diameter, range, duct width, area) as well as the calculation of ratios (duct width/pancreatic diameter; D/P-ratio). The measured values were correlated with the incidence of postoperative pancreatic fistula. Results: Planimetry showed a significant difference of the pancreatic transection plane in relation to the incidence of postoperative pancreatic fistula. A thick parenchyma and a tiny duct are significant risk factors. In 84 % or, respectively, 94 % of the patients with postoperative pancreatic fistula, a duct width of less than 20 % of the pancreatic diameter was observed (D/P ratio < 0.2; p < 0.01). The D/P ratio was the only independent risk factor in multivariate analysis. Discussion: The incidence of postoperative pancreatic fistula correlates significantly with the morphology of the pancreatic transection plane. The risk increases significantly with a D/P ratio of < 0.2.
Georg Thieme Verlag KG Stuttgart · New York.
Zentralblatt für Chirurgie 08/2015; DOI:10.1055/s-0035-1546193 · 1.19 Impact Factor
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 07/2015; DOI:10.1016/j.ejso.2015.07.010 · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction The value of extended resection (portal vein, multivisceral) in patients with pancreatic adenocarcinoma (PDAC) is not well defined. We analyzed the outcome after standard resection (standard pancreaticoduodenectomy (SPR)), additional portal vein (PV) and multivisceral (MV) resection in PDAC patients. Methods Clinicopathologic, perioperative, and survival data of patients undergoing pancreatic head resection (PHR) for PDAC 1994–2014 were reviewed from a prospective database. Results Three hundred fifty nine patients had PHR for PDAC: 208 (58 %) underwent SPR, 131 (36 %) additional PV, and 20 (6 %) MV. The postoperative complication rate in MV (65 %) was slightly higher than in PV (56 %) or SPR (50 %; p = 0.32). MV patients had higher in-hospital mortality (10 %) than SPR (3.8 %) and PV (1.5 %) patients (p = 0.12). Nodal status was comparable, whereas more patients in PV and MV had final R0 resection (p = 0.02). Five-year survival was 7 % after MV versus 17 % in patients without MV (p = 0.07). Multivariate survival analysis identified resection margin, nodal disease, blood transfusions, and MV are set as independent risk factors for overall survival. Conclusion Multivisceral pancreatic head resections for PDAC are associated with increased perioperative morbidity and mortality, without improving oncologic outcome. Portal vein resection can be performed safely to reach R0 resection and its survival benefits.
Journal of Gastrointestinal Surgery 01/2015; 19(3). DOI:10.1007/s11605-014-2725-8 · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hintergrund
Die Therapie des Ösophaguskarzinoms wurde in den letzten 25 Jahren durch die Zunahme der Inzidenz von Adenokarzinomen, durch Modifikationen der chirurgischen Technik und die Einführung multimodaler Therapieschemata beeinflusst.
In der vorliegenden Arbeit werden die Entwicklung dieser Faktoren und ihr Einfluss auf Kurz- und Langzeitergebnisse nach Ösophagusresektion anhand der in der eigenen Klinik in den letzten 25 Jahren behandelten Patienten analysiert.
Patienten und Methoden
Die Analyse umfasst 366 Patienten mit der Diagnose Ösophaguskarzinom, die zwischen 1988 und 2012 am Universitätsklinikum Freiburg ösophagusreseziert wurden. Die Therapiezeiträume wurden in vier Gruppen unterteilt (1988–1994; 1995–2001; 2001–2006; 2007–2012) und verglichen.
Im Untersuchungszeitraum ist ein deutlich zunehmender Anteil von Adenokarzinomen nachweisbar (21 %, 37 %, 61 %, 64 %, p
Der Chirurg 10/2014; DOI:10.1007/s00104-014-2877-9 · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Pancreatic ductal adenocarcinoma (PDAC) is characterized by an aggressive biology and poor prognosis. Experimental evidence has suggested a role for the transcriptional repressor Zinc finger E-box binding homeobox 1 (ZEB1) in epithelial-mesenchymal transition, invasion, and metastasis in PDAC. ZEB1 expression has been observed in cancer cells as well as stromal fibroblasts. Our study aimed to evaluate the prognostic value of ZEB1 expression in PDAC tissue. Methods Patient baseline and follow-up data were extracted from a prospectively maintained database. After clinicopathologic re-review, serial sliced tissue slides were immunostained for ZEB1, E-cadherin, vimentin, and pan-cytokeratin. ZEB1 expression in cancer cells and adjacent stromal fibroblasts was graded separately and correlated to routine histopathologic parameters and survival after resection. Results A total of 117 cases of PDAC were included in the study. High ZEB1 expression in cancer cells and in stromal cancer-associated fibroblasts was associated with poor prognosis. There was also a trend for poor prognosis with a lymph node ratio of greater than 0.10. In line with its role as an inducer of epithelial-mesenchymal transition, ZEB1 expression in cancer cells was positively correlated with Vimentin expression and negatively with E-Cadherin expression. In multivariate analysis, stromal ZEB1 expression grade was the only independent factor of survival after resection. Conclusion Our data suggest that ZEB1 expression in cancer cells as well as in stromal fibroblasts are strong prognostic factors in PDAC. Stromal ZEB1 expression is identified for the first time as an independent predictor of survival after resection of PDAC. This observation suggests that therapies targeting ZEB1 and its downstream pathways could hit both cancer cells and supporting cancer-associated fibroblasts.
Surgery 07/2014; 156(1):97-108. DOI:10.1016/j.surg.2014.02.018 · 3.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcome of individual surgeons in different institutions, however, are scarce. We evaluated the perioperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high-volume university department and (later) in a community hospital with low prior experience in major pancreatic surgery.
Journal of Gastrointestinal Surgery 06/2014; 18(8). DOI:10.1007/s11605-014-2555-8 · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a retrospective study we analyzed the impact of neoadjuvant chemotherapy (CTx) with the PELF - protocol (Cisplatin, Epirubicin, Leukovorin, 5-Fluoruracil) on mortality, recurrence and prognosis of patients with advanced gastric carcinoma, UICC stages Ib-III.
64 patients were included. 26 patients received neoadjuvant CTx followed by surgical resection, 38 received surgical resection only. Tumor staging was performed by endoscopy, endosonography, computed tomography and laparoscopy. Patients staged Ib - III received two cycles of CTx according to the PELF-protocol. Adjuvant chemotherapy was not performed at all.
Complete (CR) or partial response (PR) was seen in 20 patients (77%), 19% showing CR and 58% PR. No benefit was observed in 6 patients (23%). Two of these 6 patients displayed tumor progression during CTx. Major toxicity was defined as grade 3 to 4 neutropenia or gastrointestinal side effects. One patient died under CTx because of neutropenia and was excluded from the overall patient collective. The curative resection rate was 77% after CTx and 74% after surgery only. The perioperative morbidity rate after CTx was 39% versus 66% after resection only. Recurrence rate after CTx was 38% and 61% after surgery alone; we detected an effective reduction of locoregional recurrence (12% vs. 26%). The overall survival was 38% after CTx and 42% after resection only. The 5-year survival rates were 45% in responders, 20% in non - responders and 42% in only resected patients. A subgroup analysis indicates that responders with stage III tumors may benefit with respect to their 5-year survival in comparable patients without neoadjuvant CTx. As to be expected, non-responders with stage III tumors did not benefit with respect to their survival. The 5-year-survival was approximated using a Kaplan-Meier curve and compared using a log-rank test.
In patients with advanced gastric carcinoma, neoadjuvant CTx with the PELF- protocol significantly reduces the recurrence rate, especially locoregionally, compared to surgery alone. In our study, there was no overall survival benefit after a 5-year follow-up period. Alone a subgroup of patients with stage III tumors appear to benefit significantly in the long term from neoadjuvant CTx.
BMC Surgery 01/2014; 14(1):5. DOI:10.1186/1471-2482-14-5 · 1.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Postpancreatectomy hemorrhage is a rare but often severe complication after pancreatic resection. The aim of this retrospective study was to define incidence and risk factors of postpancreatectomy hemorrhage and to evaluate treatment options and outcome.
Clinical data was extracted from a prospectively maintained database. Descriptive statistics, univariate and multivariate risk factor analysis by binary logistic regression were performed with SPSS software at a significance level of p = 0.05.
N = 1,082 patients with pancreatic resections between 1994 and 2012 were included. Interventional angiography was successful in about half of extraluminal bleeding. A total of 78 patients (7.2 %) had postpancreatectomy hemorrhage (PPH), and 29 (2.7 %) were grade C PPH. Multivariate modeling disclosed a learning effect, age, BMI, male sex, intraoperative transfusion, portal venous and multivisceral resection, pancreatic fistula and preoperative biliary drainage as independent predictors of severe postpancreatectomy hemorrhage. High-risk histopathology, age, transfusion, pancreatic fistula, postpancreatectomy hemorrhage and pancreatojejunostomy in pancreatoduodenectomies were independent predictors of mortality.
Our study identifies clinically relevant risk factors for postpancreatectomy hemorrhage and mortality. Interventional treatment of extraluminal hemorrhage is successful in about half of the cases and if unsuccessful constitutes a valuable adjunct to operative hemostasis. Based on our observations, we propose a treatment scheme for PPH. Risk factor analysis suggests appropriate patient selection especially for extended resections and pancreatogastrostomy for reconstruction in pancreatoduodenectomy.
Journal of Gastrointestinal Surgery 01/2014; 18(3). DOI:10.1007/s11605-013-2437-5 · 2.39 Impact Factor