Maximilian Brunner’s research while affiliated with Friedrich-Alexander-University Erlangen-Nürnberg and other places

INTRODUCTION: Localized cystic lymphangiomas (CL) are rare benign tumors deriving from the lymphatic system. CL is diagnosed more frequently in children than in the adult population and, although commonly affecting the cervical and axillary regions, can develop in various parts of the body. Abdominal cystic lymphangioma (ACL) comprises less than 5% of all CL cases. CASE PRESENTATION: A 35-year-old female patient with a history of benign appendectomy in childhood was transferred to our tertiary center for the operative management of a suspected extensive pseudomyxoma peritonei (PMP). In accordance with the multidisciplinary team discussion, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was planned. Intraoperatively, a typical “jelly belly” with high disease burden throughout the abdominal cavity and the small pelvis was found. A multi-visceral resection with complete cytoreduction (CCR 0) was performed. The postoperative histopathological findings revealed a diffuse, partially cystic lymphangiomatosis involving the peritoneum extensively without evidence of PMP or malignancy. CONCLUSIONS: ACLs are uncommon in the adult population, and diffuse peritoneal involvement is even rarer. Surgical management with complete resection is the preferred treatment option. Other benign cysts, as well as infectious diseases and malignancy, should be considered during the preoperative workup.

The aim of the present study was to identify risk factors associated with postoperative morbidity and mortality in patients undergoing isolated left pancreatectomy and those undergoing left pancreatic resection as part of a multivisceral resection. We performed a retrospective analysis of 296 adult patients who underwent elective left pancreatectomy from 2005 to 2022 at the University Hospital Erlangen. Patient demographics, pre- and intraoperative findings, along with postoperative outcomes, were collected and tested as predictive factors for various short-term postoperative parameters. Isolated left pancreatectomy (LP) was performed in 173 patients, while 123 patients underwent left pancreatectomy as part of a multivisceral resection (multivisceral LP). Multivisceral LP was associated with a higher rate of major morbidity (27% vs. 17%, p = 0.043) and mortality (7% vs. 2%, p = 0.046) compared to LP. Independent risk factors for major morbidity included the need for intraoperative blood transfusion and oncological lymphadenectomy in the LP group and longer operative time in the multivisceral LP group. CR-POPF was associated with the indication for surgery in the LP group. Independent risk factors for re-surgery included intraoperative blood transfusion in the LP group and ASA III or IV in the multivisceral LP group. Cardiovascular diseases were associated with higher mortality in the LP group, while COPD was the only risk factor for mortality in the multivisceral LP group. Multivisceral left pancreatectomy is associated with worse outcomes compared to isolated left pancreatectomy. In both groups, relevant risk factors predict postoperative complications. Patients with these identified risk factors should receive close monitoring during the postoperative course to anticipate outcomes with an increased risk of complications.

Purpose: To assess the association between neoadjuvant therapy and overall survival (OS) in patients with left-sided resectable pancreatic cancer (RPC) compared to upfront surgery. Background: Left-sided pancreatic cancer is associated with worse OS compared to right-sided pancreatic cancer. Although neoadjuvant therapy is currently seen as not effective in patients with RPC, current randomized trials included mostly patients with right-sided RPC. Methods: International multicenter retrospective study including consecutive patients after left-sided pancreatic resection for pathology-proven RPC, either after neoadjuvant therapy or upfront surgery in 76 centers from 18 countries on 4 continents (2013-2019). Primary endpoint is OS from diagnosis. Time-dependent Cox regression analysis was performed to investigate the association of neoadjuvant therapy with OS, adjusting for confounders at time of diagnosis. Adjusted OS probabilities were calculated. Results: Overall, 2,282 patients after left-sided pancreatic resection for RPC were included of whom 290 patients (13%) received neoadjuvant therapy. The most common neoadjuvant regimens were (m)FOLFIRINOX (38%) and gemcitabine-nab-paclitaxel (22%). After upfront surgery, 72% of patients received adjuvant chemotherapy, mostly a single-agent regimen (74%). Neoadjuvant therapy was associated with prolonged OS compared to upfront surgery (adjusted HR=0.69 [95%CI 0.58-0.83]) with an adjusted median OS of 53 vs. 37 months (P=0.0003) and adjusted 5-year OS rates of 47% vs. 35% (P=0.0001) compared to upfront surgery. Interaction analysis demonstrated a stronger effect of neoadjuvant therapy in patients with a larger tumor (Pinteraction=0.003) and higher serum CA19-9 (Pinteraction=0.005). In contrast, the effect of neoadjuvant therapy was not enhanced for splenic artery (Pinteraction=0.43), splenic vein (Pinteraction=0.30), retroperitoneal (Pinteraction=0.84), and multivisceral (Pinteraction=0.96) involvement. Conclusions: Neoadjuvant therapy in patients with left-sided RPC was associated with improved OS compared to upfront surgery. The impact of neoadjuvant therapy increased with larger tumor size and higher serum CA19-9 at diagnosis. Randomized controlled trials on neoadjuvant therapy specifically in patients with left-sided RPC are needed.

Objective Splenectomy is regularly performed in total and distal pancreatectomy due to technical reasons, lymph node dissection and radicality of the operation. However, the spleen serves as an important organ for competent immune function, and its removal is associated with an increased incidence of cancer and a worse outcome in some cancer entities (Haematologica 99:392–398, 2014; Dis Colon Rectum 51:213–217, 2008; Dis Esophagus 21:334–339, 2008). The impact of splenectomy in pancreatic cancer is not fully resolved (J Am Coll Surg 188:516–521, 1999; J Surg Oncol 119:784–793, 2019). Methods We therefore compared the outcome of 193 pancreatic cancer patients who underwent total or distal pancreatectomy with (Sp) or without splenectomy (NoSp) between 2015 and 2021 using the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. In addition, we integrated our data into the existing literature in a meta-analysis of studies on splenectomy in pancreatic cancer patients. Results There was no difference between the Sp and NoSp groups regarding histopathological parameters, number of examined or affected lymph nodes, residual tumor status, or postoperative morbidity and mortality. We observed a significantly prolonged survival in pancreatic cancer patients who underwent total pancreatectomy, when a spleen-preserving operation was performed (median survival: 9.6 vs. 17.3 months, p = 0.03). In this group, splenectomy was identified as an independent risk factor for shorter overall survival [HR (95%CI): 2.38 (1.03 – 6.8)]. In a meta-analysis of the existing literature in combination with our data, we confirmed splenectomy as a risk factor for a shorter overall survival in pancreatic cancer patients undergoing total pancreatectomy, distal pancreatectomy, or pancreatic head resection [HR (95%CI): 1.53 (1.11 – 1.95)]. Conclusion Here, we report on a strong correlations between removal of the spleen and the survival of pancreatic cancer patients undergoing total pancreatectomy. This should encourage pancreatic surgeons to critically assess the role of splenectomy in total pancreatectomy and give rise to further investigations.

Background: Over 6000 pancreaticoduodenectomies are performed each year in Germany, and hepaticojejunostomy is a crucial step of the procedure. An anastomotic leak of hepaticojejunostomy can cause major postoperative complications. The aim of this trial was to compare the morbidity and efficiency of continuous versus interrupted suturing for hepaticojejunostomy in pancreaticoduodenectomy. Methods: In a randomized, controlled, single-center trial (German Clinical Trials Register No. DRKS00024395), patients scheduled for elective open partial pancreatoduodenectomy with hepaticojejunostomy between January 2020 and May 2023 were randomly assigned in a 1:1 ratio to suturing of the hepaticojejunostomy with either a continuous or an interrupted technique. The primary endpoint was anastomotic leakage from the hepaticojejunostomy in the first three days after surgery. Further perioperative parameters were secondary endpoints, including later leakage, other complications, the duration of hepaticojejunostomy, and the cost of hepaticojejunostomy. Results: The 100 patients in the trial consisted of 50 in each group. The rate of early anastomotic leakage was 2% in both groups (95% confidence interval for the difference, [-5.5%; 5.5%]; p = 1.000). As for the secondary endpoints, there were no relevant intergroup differences in any other short-term or long-term morbidity parameters. Continuous suturing of the hepaticojejunostomy was, however, 31% faster and 68% cheaper in material costs. Conclusion: These data imply that continuous and interrupted suturing techniques yield equally good clinical outcomes in hepaticojejunostomies of hepatic ducts with diameter 5 mm or more. Continuous suturing is, however, both faster and cheaper.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) represents the standard treatment for therapy-refractory, malignant or complicated ulcerative colitis (UC) and can be performed as a 2-stage or 3-stage procedure. This study aimed to compare the short- and long-term outcomes after 2- and 3-stage IPAA in patients with UC in our department. A retrospective analysis of 176 patients with UC who received 2- or 3-stage restorative proctocolectomy with IPAA at our institution from 2001 to 2021 was performed. Outcomes for short-term (morbidity, longer hospital stay, readmission) and long-term (pouch failure and quality of life) parameters were compared between the 2- and 3-stage procedure. Regarding short-term outcomes for all patients, in-hospital morbidity and readmission rates after any surgical stage were observed in 69% and 24%, respectively. Morbidity and readmission did not differ significantly between the 2- and 3-stage procedure in uni- and multivariate analysis. Median length of hospital stay for all stages was 17 days. The 3-stage procedure was identified as an independent factor for longer hospital stay (OR 3.8 (CI 1.3–10.8), p = 0.014). Pouch failure and failure of improved quality of life during long-term follow-up occurred both in 10% of patients, with no significant differences between the 2- and 3-stage procedure in uni- and multivariate analysis. Our data suggest that both the 2- and 3-stage proctocolectomy with IPAA demonstrate favourable and comparable postoperative short- and long-term outcomes, with a high rate of improved quality of life in patients with UC.