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OBJECTIVE: This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide.BACKGROUND: Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience.METHODS: Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie.RESULTS: A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%).CONCLUSION: This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

Background Glucocorticoid excess leads to muscle atrophy and weakness in patients with endogenous Cushing’s syndrome. Insulin-like growth factor I (IGF-I) is known to have protective effects on muscle loss. We hypothesized that individual serum IGF-I concentrations might be predictive for long-term myopathy outcome in Cushing’s syndrome. Patients and methods In a prospective longitudinal study of 31 patients with florid Cushing’s syndrome, we analyzed IGF-I and IGF binding protein 3 (IGFBP 3) concentrations at the time of diagnosis and following surgical remission over a period of up to 3 years. We assessed muscle strength by grip strength measurements using a hand grip dynamometer and muscle mass by bio-impedance measurements. Findings Individual serum IGF-I concentrations in the postoperative phase were strongly predictive of long-term grip strength outcome (rs = 0.696, P ≤ 0.001). Also, lower IGF-I concentrations were associated with a lower muscle mass after 3 years (rs = 0.404, P = 0.033). While patients with high IGF-I s.d. scores (SDS; >1.4) showed an improvement in grip strength within the follow-up period (P = 0.009), patients with lower IGF-I SDS (≤−0.4) had a worse outcome with persisting muscle dysfunction. In contrast, preoperative IGF-I concentrations during the florid phase of Cushing’s syndrome did not predict long-term muscle function outcome (rs = 0.285, P = 0.127). Conclusion Lower individual IGF-I concentrations 6 months after curative surgery for Cushing’s syndrome are associated with adverse long-term myopathy outcome and IGF-I might be essential for muscle regeneration in the early phase after correction of hypercortisolism.

The robotic system was introduced to overcome the technical limitations of conventional laparoscopy. For complex oncological operations, it appears to offer further advantages. With regard to hiatal hernia repair, its role has yet to be determined. All consecutive patients who received elective laparoscopic or robot-assisted hiatal hernia repair at a single institution between January 2016 and July 2020 were retrospectively evaluated. We compared both techniques with particular focus on their short-term outcome. A propensity score-matched comparison considering clinical and surgical covariates was also performed between the two groups. 140 patients were included, and 55 (39.3%) underwent a robot-assisted procedure. The baseline demographics and the frequency of previous abdominal operations were comparable for both groups. The size of the hiatal hernia did not differ significantly between the groups (p = 0.06). The mean operative time was significantly longer for the robot-assisted procedure (149 vs. 125 min; p

Endogenous Cushing's syndrome (CS) is a rare cause of secondary osteoporosis. The long‐term consequences for bone metabolism after successful surgical treatment remain largely unknown. We assessed bone mineral density and fracture rates in 89 patients with confirmed Cushing's syndrome at the time of diagnosis and 2 years after successful tumor resection. We determined five bone turnover markers at the time of diagnosis, 1 and 2 years postoperatively. The bone turnover markers osteocalcin, intact procollagen‐IN‐propeptide (PINP), alkaline bone phosphatase, CTX‐I, and TrAcP 5b were measured in plasma or serum by chemiluminescent immunoassays. For comparison, 71 sex‐, age‐, and body mass index (BMI)‐matched patients in whom Cushing's syndrome had been excluded were studied. None of the patients received specific osteoanabolic treatment. At time of diagnosis, 69% of the patients had low bone mass (mean T‐score = −1.4 ± 1.1). Two years after successful surgery, the T‐score had improved in 78% of patients (mean T‐score 2 years postoperatively −1.0 ± 0.9). The bone formation markers osteocalcin and intact PINP were significantly decreased at time of diagnosis (p ≤ 0.001 and p = 0.03, respectively), and the bone resorption marker CTX‐I and TrAcP 5b increased. Postoperatively, the bone formation markers showed a three‐ to fourfold increase 1 year postoperatively, with a moderate decline thereafter. The bone resorption markers showed a similar but less pronounced course. This study shows that the phase immediately after surgical remission from endogenous CS is characterized by a high rate of bone turnover resulting in a striking net increase in bone mineral density in the majority of patients.

Background Recently, sleeve gastrectomy (SG) has become one of the most important procedures in bariatric surgery. Short-term results show that SG is a feasible, safe, and effective operation treating obesity and its related co-morbidities. Now, the main focus is on long-term data after SG. Objectives The aim of this study was to analyze perioperative and long-term results after SG in the German Bariatric Surgery Registry. Setting National database, Germany. Methods Perioperative data of primary SG (n = 21525) and follow-up data for 5 years ± 6 months (n = 435, 18.3% of 2375 SG performed between 2005 and 2011) were analyzed. After a review of the literature long-term results were compared with international data. Results Mean baseline body mass index (BMI) was 51.1 kg/m2. Two hundred ninety-eight (68.5%) patients were female and 137 (31.5%) were male. Of patients, 90% had ≥1 co-morbidities. Mean operation time was 86 minutes. General postoperative complications occurred in 4.1% and special complications in 4.6% (staple-line leaks 1.6%). Mean maximum BMI loss was 18.0 ± 6.8 kg/m2 and BMI loss after 5 years was 14.3 ± 7.4 kg/m2 (P Conclusions The current results showed that SG is a safe and effective procedure in bariatric surgery. BMI loss was significant 5 years after SG. Most co-morbidities were significantly improved, but gastroesophageal reflux has often worsened. The follow-up rate was very low, which is a persistent problem in German bariatric surgery.

Background: The impact of estrogens (E2) on the growth hormone (GH)/IGF-I axis is known to depend on route of administration: While oral E2 increases GH and decreases IGF-I, transdermal E2 has only limited or no effect. However, data concerning the impact of E2 on IGF binding protein 3 (IGFBP 3) and ALS are less clear. One study in girls demonstrated higher ALS with oral E2, while the opposite was suggested for postmenopausal women. No data are available for healthy premenopausal women.Methods: We measured IGF-I, IGFBP 3 and ALS in fasted healthy adults (93 males (M), 35 premenopausal women without E2-containing oral contraception (FPRE), 37 premenopausal women with E2-containing oral contraception (FPREOC) and 34 postmenopausal women (FPOST)). IGF-I and IGFBP 3 were measured using the IDS-iSYS chemiluminescence immunoassay, and ALS by an in-house immunofluorometric assay (limit of quantification (LoQ) < 50 mU/ml, range 50 - 4000 mU/mL).Results: Median age (range) was 33 (20 - 76), 28 (20 - 44), 24 (21 - 36) and 56 (49 - 70) years for M, FPRE, FPREOC and FPOST, respectively. As expected, IGF-I was lower in FPREOC compared to FPRE (median IGF-I xULN (IQR) 0.56 (0.45 - 0.73) and 0.72 (0.63 – 0.80), P = 0.0017, Kruskal-Wallis). ALS was significantly higher in FPREOC compared to all other groups (mean ALS in M, FPRE, FPREOC and FPOST: 636, 708, 861 and 648 mU/mL, respectively, ANOVA P < 0.0001, Dunnett’s post-hoc test: M vs FPREOC: P < 0.0001, FPRE vs FPREOC: P = 0.0007, FPOST vs FPREOC: P < 0.0001). IGFBP 3 was not different in females with and without oral E2 (median IGFBP 3 xULN (IQR) FPREOC vs FPRE: 0.62 (0.54 - 0.67) vs 0.60 (0.49 – 0.76), Kruskal-Wallis P = 0.295, Dunn’s post-hoc test: P > 0.9999). This was also true between all other groups (Dunn’s post-hoc test: P ≥ 0.4). In our adult cohort, ALS exhibited negative correlation with age (Pearson r = -0.282, P = 0.0003), similar to IGF-I and IGFBP 3. While IGF-I exhibited a moderate negative correlation to BMI (Pearson r = -0.25, P = 0.0013), IGFBP 3 and ALS were not significantly related to BMI.Conclusion: While IGF-I, IGFBP 3 and ALS all are known to be secreted in response to GH, and IGF-I and ALS are assumed to be produced by the same cells in the liver (hepatocytes), the three GH dependent biomarkers appear to be differently regulated by metabolic factors and oral E2. Only IGF-I has some modest association with BMI. Oral E2 is associated with reduced IGF-I, unchanged IGFBP 3 but increased ALS. While the mechanism behind the differential regulation remains to be uncovered, E2 therapy must be taken into account when interpreting IGF-I and ALS concentrations.

Zusammenfassung Einleitung Pathologische Fistelungen des arteriellen Systems zu luminalen Organsystemen stellen eine Herausforderung in ihrem adäquaten Management dar. Ziel Wissenschaftlicher Fallbericht zur kombiniert gefäßchirurgisch und interventionell-radiologischen Versorgung einer seltenen rechtsseitigen uretero-iliakalen Fistel unter Diskussion des Vorgehens und Zusammenfassung gewonnener klinischer Erfahrungen. Fallkonstellation Stationäre Aufnahme eines 79-jährigen Patienten mit Hämaturie und Blasentamponade bei aktinisch bedingten Ureterstrikturen beidseits infolge neoadjuvanter Radiochemotherapie (im Rahmen der Vorbereitung einer abdominoperinealen Rektumexstirpation wegen suprasphinktären Karzinoms [ypT3ypN0M0]). Das Labor erbrachte eine Anämie, die transabdominale Sonografie eine Harnstauung bds. Die CT wies keine manifeste Blutung infolge wechselnder Hämorrhagieepisoden nach. Interventionelle Maßnahmen Zunächst erfolgten Blasenspülung und Katheterwechsel in den Ureteren. Aufgrund der ausgelösten rechtsseitigen endoluminalen Blutung in den rechten Ureter wurde die kombiniert gefäßchirurgische/interventionell-radiologische Versorgung mit i) Amplatzer-Insertion (AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, U.S.A.) in die A. iliaca interna dextra und ii) rechts-iliacalem Stenting durch „cross-over“-Manöver von links-femoral vorgenommen. Verlauf Infolge einer Dissektion am arteriellen Zugang rechts-femoral erfolgte eine Gefäßdesobliteration und Intimarefixation in der A. femoralis superficialis dextra. Der Patient stabilisierte sich zeitgerecht (u. a. periinterventionelle ITS-Betreuung) bei Entlassung am 15. postinterventionellen Tag ohne Anhalt für lokales Rektumkarzinomrezidiv. Eine Re-Blutung war nicht aufgetreten. Weiterhin waren Doppel-J-Katheterwechsel erforderlich. Zusammenfassung Die zügige Hybrid-Operation ist im präsentierten Fall als absolut indizierte und prognostisch aussichtsreiche Vorgehensweise für die rezidivierende arterielle Blutung einer uretero-iliakalen Fistel anzusehen. Schlussfolgerung Das minimal-invasive Herangehen mittels Stenting ist die Methode der Wahl im stufenweisen und zeitgerechten Management der potenziell lebensbedrohlichen uretero-iliakalen Fistel bei arterieller endoluminaler Blutung und drohendem hämorrhagischen Schock.

Morbid obesity in both adolescents and adults has risen in an alarming rate. Bariatric surgery is playing an increasing role in pediatric surgery. However, current evidence is limited regarding its safety and outcome.Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered. For the current analysis, all adolescent and adult subjects that had undergone laparoscopic sleeve gastrectomy (LSG) from 2005 to 2014 were considered.LSG represents the most common bariatric procedure in Germany with a proportion of 48.1% in adolescent and 48.7% in adult obese in 2014. LSG was performed in 362 adolescent and 15,428 adult subjects. Pre-operative BMI was comparable between the two populations. However, adult obese had more frequently coexisting comorbidities (p 0.01). Complication rates and mortality (0 vs. 0.2%) did not differ significantly. Adolescents achieved a BMI reduction of 16.8 and 18.0 kg/mLSG is a safe therapeutic option that can be performed in adolescents without mortality. Late adolescents experienced the highest weight loss; resolution rate of comorbidities was lower in adults. All future efforts should now be focused on the evaluation of the long-term outcomes of LSG in the pediatric population.

Seit der ersten Lebertransplantation durch Starzl 1963 gehoren Tumoren zu deren Indikationsspektrum. Vorteile der Transplantation sind die simultane Behandlung des Tumors, moglicher intrahepatischer Metastasen und der zugrunde liegenden Lebererkrankung. Die ersten Ergebnisse waren durch hohe Rezidiv- und geringe Uberlebensraten ernuchternd. Erst durch Selektionskriterien, multimodale Therapiekonzepte, neue Immunsuppressiva und intensivierte Nachsorge wurde das Outcome verbessert. Recherche und Auswertung der aktuellen Literatur. Haufigste Indikation sind die primaren Lebertumoren mit dem hepatozellulare Karzinom (HCC) an erster Stelle. Durch Etablierung von Selektionskriterien (Mailand-Kriterien) fur das HCC werden Funfjahresuberlebensraten von 75 % bei

Background Laparoscopic sleeve gastrectomy (SG) is an upcoming procedure in bariatric surgery and is currently performed worldwide. Staple line leakage, as the most frequent and most feared complication, is still a major concern. Methods Since 2005 data from patients undergoing bariatric procedures in Germany have been prospectively registered in an online database and analyzed. All patients who had undergone primary SG within a 7-year period were considered for analysis. Results Using the German Bariatric Surgery Registry, data from more than 11,800 SGs were collected between January 1, 2005, and December 31, 2013. Staple line leak rate decreased from 6.5% to 1.4%. Male sex, higher body mass index, concomitant sleep apnea, conversion to laparotomy, longer operation time, a combination of buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate compared with when using either buttresses or oversewing alone. On multivariable analysis, operation time and year of procedure only had a significant impact on staple line leakage rate. Conclusions Owing to the growing experience a constant decrease in the leakage rate after SG has been observed. Staple line disruption may still lead to sepsis, multiorgan dysfunction, and increased mortality. The results of the current study demonstrated that there are factors that increase the risk of leakage and which would enable surgeons to define risk groups, select patients more carefully, and offer closer follow-up during the postoperative course with early recognition and adequate treatment.

Objectives: Chronic constipation is a common childhood problem and often caused or worsened by abnormal dynamics of defecation. The aim of this study was to assess the benefit of pelvic floor physical therapy (PFPT), a novel treatment in pediatrics for the treatment of chronic constipation with dyssynergic defecation. Methods: This was a retrospective study of 69 children seen at a pediatric neurogastroenterology program of a large tertiary referral center for chronic constipation and dyssynergic defecation, determined by anorectal manometry and balloon expulsion testing. We compared the clinical outcome of patients who underwent PFPT (n = 49) to control patients (n = 20) whom received only medical treatment (laxatives/stool softeners). Additionally, characteristics of the treatment group were analyzed in relation to therapeutic response. Results: Thirty-seven (76%) of the patients who received physical therapy had improvement in constipation symptoms, compared to 5 (25%) of the patients on conservative treatment (p < 0.01). Additionally, patients who received pelvic physical therapy had fewer hospitalizations for cleanouts (4 vs. 25%, p = 0.01) and ­colonic surgery than those that were treated with medical therapy exclusively (0 vs. 10%, p = 0.03). Among the patients who received physical therapy, those that suffered from anxiety and/or low muscle tone had a higher response rate (100%). There were no adverse effects from the intervention. Conclusion: The new field of pediatric PFPT is a safe and effective intervention for children with dyssynergic defecation causing or contributing to chronic constipation, particularly in children whose comorbidities include anxiety and low ­muscle tone.

The population are getting older and obesity is growing. Laparoscopic sleeve gastrectomy (LSG) is increasingly used worldwide but is still used with skepticism in the elderly. The purpose of our analysis is to judge the security of LSG in patients older than 60 years compared to patients younger than 60 years. This retrospective review included data of all patients in Germany who underwent LSG between January 2005 and December 2016.The data were published online in the German Bariatric Surgery Registry. A total of 21,571 operations were gathered and divided into two groups: group I, patients

Since 1 January 2005, the outcomes of bariatric surgeries have been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg. Data are collected in an online data bank. Data collection began in 2005 for the results of gastric banding (GB) and in 2006 for sleeve gastrectomies (SGs). In addition to primary bariatric operations, data regarding the complications of revision procedures and redo operations have been analyzed. Participation in the quality assurance study is required for all certified centers in Germany. SGs are a popular redo operation after failed gastric banding. Using the German Bariatric Surgery Registry, we analyzed data from 137 SGs that were used in a one-step approach after GB and 37 SGs that were used in a two-step approach. Leakage rates for primary SGs dropped to 1.9 %. The incidence of leakage after a one-step SG after GB is significantly higher (4.4 %) than for a two-step approach (0 %). SGs are popular procedures after failed GB in Germany, but the complication rates for one-step band removal are higher than for a two-step approach. After examining the data, we suggest performing band removal and SG as a two-step procedure. Further analysis is necessary to evaluate the optimal time period between band removal and SG. Follow-up investigations must be performed to determine if SG is an effective and safe option after GB.

Tumorresektionen im Bereich des oberen Gastrointestinaltraktes stellen anspruchsvolle Eingriffe dar, die unverandert mit einer relevanten Morbiditat und Mortalitat assoziiert sind. Zur Reduktion der perioperativen Komplikationsrate ist eine gezielte praoperative Risikoanalyse und Patientenselektion unter Berucksichtigung des Ernahrungszustandes und der Komorbiditaten wichtig. Die Anastomoseninsuffizienz zahlt zu den haufigsten chirurgischen Komplikationen und erfordert neben einer fruhzeitigen Diagnose die umgehende Einleitung einer adaquaten Therapie. Ein rein konservatives Vorgehen ist bei kleinen, gut drainierten Insuffizienzen sowie bei zervikalen Leckagen moglich. Die chirurgische Intervention hat ihren Stellenwert bei Leckagen im fruhen postoperativen Verlauf, bei ausgedehnten Defekten mit diffuser Mediastinitis sowie bei Interponatnekrosen. Die Mehrzahl der Leckagen lasst sich in der heutigen Zeit durch minimal-invasive endoskopische Techniken, wie die Stentimplantation und die endoluminale Vakuumtherapie, erfolgreich behandeln. Die gastrale Entleerungsstorung nach Osophagusresektion stellt ein haufiges Problem dar, welches sich durch eine medikamentose und endoskopische Intervention gut beherrschen lasst. Der Nutzen einer Pyloroplastik im Rahmen des Primareingriffes ist umstritten. Der Chylothorax ist eine seltene, aber ernsthafte Komplikation. Bei der primaren Behandlung sollte konservativen Therapiekonzepten der Vorzug gegeben werden. Fur das erfolgreiche Management postoperativer Komplikationen sind eine fachubergreifende enge Zusammenarbeit sowie das Vorhandensein einer geeigneten Infrastruktur mit festen Algorithmen von entscheidender Bedeutung. Aus diesen Grunden ist eine Konzentration solcher Eingriffe in spezialisierten Zentren wunschenswert.

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (

Surgery remains the mainstay of potentially curative treatment of esophageal cancer; however, esophageal resection is still associated with a relevant morbidity and mortality. Furthermore, patients frequently suffer from concomitant comorbidities and present in a reduced nutritional status. The rationale of minimally invasive surgery is the reduction of surgical trauma with subsequent minimization of (pulmonary) complications and mortality without compromising oncological quality. Minimally invasive esophageal resection was established nearly two decades ago and since then some centers worldwide have adopted this approach as the preferred option for surgical treatment of esophageal cancer. Minimally invasive esophageal resection can be safely performed and provides excellent results in experienced hands. Currently, there is only one randomized trial available comparing open and minimally invasive resection. It was demonstrated that the latter significantly reduced pulmonary complications with comparable mortality and oncological outcome. However, in the majority of studies these convincing results could not be confirmed. Reduced blood loss and a shortened hospital stay were shown to be the main advantages of the minimally invasive approach. Due to technical modifications, patient selection and a remarkable heterogeneity of current studies, a final conclusion on the value of minimally invasive esophagectomy is difficult to be drawn. Based on the current evidence, a noncritical use of minimally invasive resection for esophageal cancer cannot be recommended; however, in selected patients and with appropriate expertise this approach is at least comparable to open esophagectomy.

Der Diabetes mellitus Typ 2 (T2DM) ist eine chronisch progrediente Erkrankung mit hoher Inzidenz. Bei Patienten mit einem T2DM findet sich uberdurchschnittlich haufig eine Adipositas, die eine wichtige Rolle bei der Entwicklung der Insulinresistenz spielt. Die Basistherapie des T2DM umfasst eine Ernahrungstherapie, eine Erhohung der korperlichen Aktivitat und eine Lebensstilanderung, meist in Kombination mit einer Pharmakotherapie. Insbesondere bei adiposen Patienten mit T2DM werden jedoch die metabolischen Therapieziele durch eine fehlende signifikante Gewichtsreduktion oft nicht erreicht. Die Pankreastransplantation spielt derzeit bei der Behandlung des T2DM nur eine untergeordnete Rolle. Die bariatrische Chirurgie gewahrleistet bei der Mehrzahl der Adiposen eine langfristige signifikante Gewichtsreduktion. Bei einem hohen Prozentsatz zeigt sich im kurz- bis mittelfristigen Verlauf nach dem operativen Eingriff eine komplette Remission des T2DM. Als Ursachen werden Gewichtsverlust mit einer Erhohung der Insulinsensitivitat und die Beeinflussung verschiedener gastrointestinaler Hormone durch die Operationen diskutiert. Problematisch fur die abschliesende Beurteilung sind die wenigen derzeit verfugbaren Langzeitergebnisse. Die Durchfuhrung eines bariatrischen Verfahrens sollte vor allem bei adiposen Patienten mit einem T2DM, einem BMI > 35 kg/m 2 und schwer kontrollierbarer diabetischer Stoffwechsellage erwogen werden. Eine Ausweitung der Indikationsstellung auf normal- bzw. nur leicht ubergewichtige Patienten mit T2DM kann trotz der positiven Ergebnisse nicht uneingeschrankt empfohlen werden. Die Erforschung der Wirkmechanismen bariatrischer Eingriffe hat zu einem tieferen Verstandnis der Pathophysiologie des T2DM beigetragen. Diese Erkenntnisse konnten zukunftig als Basis fur die Entwicklung weniger invasiver und pharmakologischer Therapiemoglichkeiten dienen, um somit die Behandlung des T2DM individueller gestalten und weiter verbessern zu konnen.

Background: Since January 12005, the outcomes of bariatric surgeries have been recorded in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg. Methods: Data are collected in an online data bank. Data collection began in 2005 for the results of Roux-en-Y Gastric Bypass (RYGB). In addition to primary bariatric operations, data regarding the complications and the amelioration of comorbidities have been analyzed. Participation in the quality assurance study is required for all certified centers in Germany. Results: Roux-en-Y Gastric Bypass is the most popular bariatric operation in Germany. There were 5115 operations performed from 2005 to 2010. A circular anastomosis was performed in 1587 patients, and a linear anastomosis was performed in 2734 patients. In 783 patients the hand-sewn technique was used. The leakage rate for the linear technique is 1.6%, and the leakage rate is 1.2% for circular anastomosis and 1.4% for hand-sewn technique. The overall postoperative complication rate was significantly higher using the circular technique than using the linear or hand-sewn approach. Conclusion: RYGB is a popular procedure in Germany. The complication rate has decreased since 2005. A comparison of hand sewn versus linear and versus circular anastomosis indicated a higher complication rate in circular gastrojejunal junctions.

Hintergrund: Die Studie zur Qualitatssicherung in der operativen Therapie der Adipositas (GBSR) untersucht seit 2005 die aktuelle Situation der Adipositas- und metabolischen Chirurgie in Deutschland. Mithilfe einer Onlinedatenbank werden die Daten prospektiv erfasst und retrospektiv analysiert. Die Datenerfassung erfolgt in Zusammenarbeit mit dem Institut fur Qualitatssicherung in der operativen Medizin der Otto-von-Guericke-Universitat Magdeburg. Methode: Im Rahmen der prospektiven freiwilligen Datenerfassung werden die Primaroperationen sowie die Re- und Redo-Eingriffe erfasst. Hierbei werden unter anderem Daten zur Antibiotikaprophylaxe dokumentiert und ausgewertet. Ergebnisse: Seit dem Jahr 2005 ist ein stetiger Anstieg der dokumentierten Primaroperationen zu verzeichnen. Die vorliegende Auswertung zur Antibiotikaprophylaxe bezieht sich auf 12 296 Primareingriffe mit 684 Magenballonimplantationen (BIB), 2950 Magenbandoperationen (Gastric Banding, GB), 5115 Magenbypassoperationen (RYGBP), 120 biliopankreatische Diversionen nach Scopinaro (BPD), 164 Duodenal-Switch-Eingriffe (DS), 3125 Sleeve-Gastrektomien (SG) und 138 weitere Operationen. Insgesamt erfolgte bei 77,3 % der Patienten bei der Primaroperation eine Antibiotikaprophylaxe. Patienten mit Komorbiditaten erhalten signifikant haufiger eine Antibiotikaprophylaxe als Patienten ohne Begleiterkrankungen. Beim Vergleich der Wundinfektionsrate fur das GB und die SG findet sich kein signifikanter Unterschied. Fazit: Die Anzahl Adipositas- und metabolisch-chirurgischer Eingriffe hat in Deutschland zugenommen. Zur Notwendigkeit und Dosierung der Antibiotikaprophylaxe existieren in der Literatur nur Empfehlungen geringer Evidenz. Aufgrund der Daten der Qualitatssicherungsstudie fur operative Therapie in Deutschland ergibt sich die Empfehlung perioperativer Antibiotikagaben in Abhangigkeit der Komorbiditaten, des BMI und der Operationsdauer.

Die zunehmende Pravalenz der morbiden Adipositas geht auch in Deutschland mit einer deutlichen Zunahme von adipositas- und metabolisch-chirurgischen Eingriffen einher. Chirurgische und insbesondere metabolische Langzeitkomplikationen konnen Folge verschiedener restriktiver und malabsorptiver Operationsmethoden sein. Das Ziel der kompakten Kurzubersicht ist es, basierend auf einer selektiven Literaturrecherche und eigenen klinischen Erfahrungen die metabolischen Langzeitkomplikationen, die mit den verschiedenen bariatrischen Eingriffen assoziiert sind, darzustellen einschlieslich der davon abzuleitenden Richtlinien einer Supplementation. Nach restriktiven OP-Verfahren wie dem Gastric Banding und der Sleeve-Gastrektomie sind Pouchdilatation und Bandmigration ebenso wie eine Refluxerkrankung schwerwiegende Langzeitkomplikationen. Nutritive Defizite nach restriktiven Verfahren betreffen meist die B-Vitamine. Malabsorptive Methoden wie die biliopankreatische Diversion, der Duodenal Switch und der Magenbypass sind mit Eisen-, Folsaure-, Vitamin-B1-, Vitamin-B12- und Vitamin-D-Defiziten assoziiert. Aufgrund der metabolischen und chirurgischen Komplikationen nach adipositaschirurgischen Eingriffen muss eine lebenslange Nachsorge der Patienten erfolgen. Die derzeitigen Leitlinien der Chirurgischen Arbeitsgemeinschaft Adipositastherapie (CAADIP) der DGAV zur Supplementation sollten dem klinisch tatigen Adipositas- und metabolischen Chirurgen hinsichtlich seiner obligatorischen Weiterbetreuungsverpflichtung nachhaltig bewusst sein.

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy with gastric tube reconstruction. Little is known about risk factors that can predict this debilitating complication. Patients who underwent elective esophagectomy from 2008 to 2016 in a single center were retrospectively reviewed. Diagnosis of DGE was based on clinical, radiological, and endoscopic findings. Uni- and multivariate analyses were performed to identify patient-, tumor-, and procedure-related factors that increase the risk of DGE. One hundred eighty-two patients were included. Incidence of DGE was 39.0%. Overall, 27 (14.8%) needed an endoscopic intervention. Patients in the DGE group had a longer hospital stay (p

Staple line leak after laparoscopic sleeve gastrectomy (LSG) still represents the most feared complication. The purpose of this study was to investigate whether there are factors that increase the risk for a leakage. Furthermore, we aimed to analyze the impact of a leak on weight change and resolution of comorbidities. Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered. For the current analysis, all adult subjects that had undergone primary LSG from 2005 to 2014 were considered. Overall, 241/15,756 (1.53%) patients experienced a leak. The occurrence of a leakage resulted in a significant increase of the mortality rate (3.7 vs. 0.2%; p

Background:Chemoresistance is a main obstacle to effective esophageal cancer (EC) therapy. We hypothesize that altered expression of microRNAs (miRNAs) play a role in EC cancer progression and resistance to 5-fluorouracil (5-FU) based chemotherapeutic strategies.Methods:Four pairs of esophageal adenocarcinoma (EAC) cell lines and corresponding 5-FU resistant variants were established. The expression levels of miRNAs previously shown to be involved in the general regulation of stem cell pathways were analyzed by qRT-PCR. The effects of selected miRNAs on proliferation, apoptosis, and chemosensitivity were evaluated both in vitro and in vivo. We identified a particular miRNA and analyzed its putative target genes in 14 pairs of human EC tumor specimens with surrounding normal tissue by qRT-PCR as well as Wnt pathway associated genes by immunohistochemistry in another 45 EAC tumor samples.Results:MiR-221 was overexpressed in 5-FU resistant EC cell lines as well as in human EAC tissue. DKK2 was identified as a target gene for miR-221. Knockdown of miR-221 in 5-FU resistant cells resulted in reduced cell proliferation, increased apoptosis, restored chemosensitivity, and led to inactivation of the Wnt/-catenin pathway mediated by alteration in DKK2 expression. Moreover, miR-221 reduction resulted in alteration of EMT-associated genes such as E-cadherin and vimentin as well as significantly slower xenograft tumor growth in nude mice. RT2 profiler analysis identified a substantial dysregulation of 4 Wnt/-catenin signaling and chemoresistance target genes as a result of miR-221 modulation: CDH1, CD44, MYC, and ABCG2.Conclusion:MiR-221 controls 5-FU resistance of EC partly via modulation of Wnt/-catenin-EMT pathways by direct targeting of DKK2 expression. MiR-221 may serve as a prognostic marker and therapeutic target for patients with 5-FU resistant EAC.

Laparoscopic sleeve gastrectomy (LSG) is currently being performed with increasing frequency worldwide. It offers an excellent weight loss and resolution of comorbidities in the short term with a very low incidence of complications. However, the ever present risk of a staple line leak is still a major concern. Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered in an online database and analyzed at the Institute of Quality Assurance in Surgical Medicine. For the current analysis, all patients that had undergone primary sleeve gastrectomy for morbid obesity within a 7-year period were considered. Using the GBSR, data from 5.400 LSGs were considered for analysis. Staple line leak rate decreased during the study period from 6.5 to 1.4 %. Male gender, higher BMI, concomitant sleep apnea, conversion to laparotomy, longer operation time, use of both buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate. On multivariate analysis, operation time and year of procedure only had a significant impact on staple line leak rate. The results of the current study demonstrated that there are factors that increase the risk of a leakage which would enable surgeons to define risk groups, to more carefully select patients, and to offer a closer follow-up during the postoperative course with early recognition and adequate treatment. All future efforts should be focused on a further reduction of serious complications to make the LSG a widely accepted and safer procedure.

Einleitung: Operative Eingriffe im Bereich der Speiseröhre sind auch in ausgewiesenen Zentren unverändert mit einer relevanten Morbidität und Mortalität assoziiert. Dies betrifft insbesondere pulmonale Komplikationen. Hinzu kommt, dass betroffene Patienten stenosebedingt einen reduzierten[zum vollständigen Text gelangen Sie über die oben angegebene URL], 133. Kongress der Deutschen Gesellschaft für Chirurgie

There is a growing amount of data supporting the concept that cancers originating from the proximal and distal colon are distinct clinicopathological entities. The incidence of MSI and BRAF mutation is strongly associated with right sided tumor location, whereas there are conflicting results for KRAS mutation rates. However, to date, no data exist whether and to what extent defined colonic subsites influence MSI status, KRAS and BRAF mutation rates. We selected primary colon cancer from 171 patients operated on at our institution between 2007 and 2010. BRAF, KRAS mutation rates and microsatellite instability were determined and correlated with clinicopathological features and tumor location. MSI-h cancers were significantly associated with poor histological grade but a lower rate of distant metastases. KRAS-mutated tumors were linked to lower T-stage and better differentiation. Colon carcinomas with BRAF mutation were significantly associated with distant metastatic spread and poor histological grade. Furthermore, we found that MSI-h status, KRAS and BRAF mutation rates varied remarkably among the colonic subsites irrespective of right- and left-sided origin, respectively. The results of the current study provide further evidence that a simple classification into right- and left-sided colon carcinoma does not represent the complexity of this tumor entity.

Komplikationen nach Eingriffen am Osophagus und am osophagogastralen Ubergang beeinflussen signifikant das kurz- und langfristige Outcome der Patienten sowie die perioperative Mortalitat, die Kosten und das Uberleben. Pulmonale Komplikationen sowie die Anastomoseninsuffizienz sind nach wie vor die haufigsten und dramatischsten Komplikationen. Vor allem die Mortalitat in Assoziation mit einer Nahtinsuffizienz hat in den letzten Jahren durch eine fruhzeitige Diagnostik mittels Computertomographie und Endoskopie und einer hierauf basierenden interdisziplinaren Initialtherapie abgenommen. Wichtig in diesem Zusammenhang ist die Differenzierung zwischen Anastomoseninsuffizienz und signifikanter Interponatnekrose, am besten mittels Endoskopie. In den letzten Jahren haben sich vor allem endoskopisch-interventionelle Techniken zur Behandlung der intrathorakalen Anastomoseninsuffizienz etabliert. Die entscheidende Grundvoraussetzung fur jedes Therapiekonzept ist neben der Patientenselektion immer die suffiziente Drainage der Leckage. Das therapeutische Spektrum bei einer Anastomoseninsuffizienz ist vielschichtig und umfasst die konservativ-symptomatische Therapie bei kleinen, gut drainierten Fisteln, die interventionelle Drainageeinlage, endoskopische Methoden zum Fistelverschluss oder die Implantation wieder entfernbarer Osophagusstents sowie die operative Revision der Anastomose bis hin zur Diskontinuitatsresektion bei einer Interponatnekrose.

Background. Evidence-based data on optimal approach for prophylaxis of deep venous thrombosis (VTE) and pulmonary embolism (PE) in bariatric operations is discussed. Using antithrombotic prophylaxis weight adjusted the risk of VTE and its complications have to be balanced with the increased bleeding risk. Methods. Since 2005 the current situation for bariatric surgery has been examined by quality assurance study in Germany. As a prospective multicenter observational study, data on the type, regimen, and time course of VTE prophylaxis were documented. The incidences of clinically diagnosed VTE or PE were derived during the in-hospital course and follow up. Results. Overall, 11,835 bariatric procedures were performed between January 2005 and December 2010. Most performed procedures were 2730 gastric banding (GB); 4901 Roux-en-Y-gastric bypass (RYGBP) procedures, and 3026 sleeve gastrectomies (SG). Study collective includes 72.5% (mean BMI 48.1 kg/m2) female and 27.5% (mean BMI 50.5 kg/m2) male patients. Incidence of VTE was 0.06% and of PE 0.08%. Conclusion. VTE prophylaxis regimen depends on BMI and the type of procedure. Despite the low incidence of VTE and PE there is a lack of evidence. Therefore, prospective randomized studies are necessary to determine the optimal VTE prophylaxis for bariatric surgical patients.

The molecular carcinogenesis of lung cancer has yet to be clearly elucidated. We investigated the possible oncogenic function of SEC62 in lung cancer, which was predicted based on our previous findings that lung and thyroid cancer tissue samples exhibited increased Sec62 protein levels. The SEC62 gene locus is at 3q26.2, and 3q amplification is reportedly the most common genomic alteration in non–small cell lung cancer. We analyzed SEC62 mRNA and protein levels in tissue samples from lung cancer patients by real-time quantitative PCR, Western blot, and IHC and found significantly increased SEC62 mRNA and protein levels in tumors compared with tumor-free tissue samples from the same patients. Correlation analyses revealed significantly higher Sec62 levels in tumors with lymph node metastases compared with nonmetastatic tumors, as well as in poorly compared with moderately differentiated tumors. On the basis of these promising results, we examined the role of Sec62 in cancer cell biology in vitro . Cell migration assays with lung and thyroid cancer cells showed distinct stimulation of migration in SEC62 -overexpressing cells and inhibition of migration in Sec62-depleted cells. Moreover, we found that SEC62 silencing sensitized the cells to thapsigargin-induced endoplasmic reticulum stress. Thus, our results indicate that SEC62 represents a potential candidate oncogene in the amplified 3q region in cases of non–small cell lung cancer and harbors various functions in cancer cell biology.

Hintergrund: Das kolorektale Karzinom (KRK) zahlt weltweit zu einer der haufigsten Krebserkrankungen. Histologisch finden sich in der Mehrzahl der Falle Adenokarzinome. Fur den muzinosen und siegelringzelligen Subtyp zeigen sich sehr geringe Inzidenzraten. KRK mit dieser Differenzierung weisen jedoch erhebliche klinische, histologische und molekularbiologische Unterschiede auf. Ziel der vorliegenden Ubersichtsarbeit ist eine detaillierte Analyse der bisher gefundenen Unterschiede zwischen klassischen Adenokarzinomen und muzinosen sowie siegelringzelligen KRK. Methode: Basierend auf einer systematischen PubMed-Recherche einschlieslich eigener Untersuchungsergebnisse erfolgte die Analyse samtlicher klinischer, histologischer und molekularbiologischer Unterschiede. Ergebnisse: Muzinose KRK treten in der westlichen Welt mit einer Inzidenz von 10 – 20 % auf. Sie sind am haufigsten im rechten Kolon lokalisiert und weisen zum Zeitpunkt der Diagnose meist ein fortgeschrittenes Stadium auf. Ebenso findet sich eine hohere Rate nodal positiver Karzinome sowie eine synchrone peritoneale Dissemination. Die Ergebnisse molekularbiologischer Untersuchungen lassen darauf schliesen, dass muzinose KRK eine biologisch differente Tumorentitat reprasentieren. Als Ursache fur die schlechtere Ansprechrate auf etablierte Chemotherapien werden die hohere Rate Mikrosatelliten-instabiler Tumore sowie eine gesteigerte Muzinproduktion diskutiert. Die schlechtere Prognose scheint am ehesten auf die bereits fortgeschritteneren Tumorstadien bei Diagnose zuruckzufuhren zu sein. Siegelringzellige KRK treten mit einer Inzidenz von 0,9 % bis 4 % auf und finden sich vornehmlich im rechten Kolon. Sie weisen ein aggressives tumorbiologisches Verhalten auf und sind mit einer schlechteren Prognose als klassische Adenokarzinome und muzinose KRK assoziiert. Schlussfolgerung: Problematisch fur die endgultige Beurteilung beider histologischer Subtypen sind die geringen Fallzahlen sowie die zum Teil schlechte Vergleichbarkeit einiger Studien. In chirurgischer Hinsicht ergibt sich die Forderung einer hoheren Radikalitat beim operativen Vorgehen, sofern eine exakte praoperative Diagnose moglich ist. Wunschenswert ware des Weiteren eine Berucksichtigung des histologischen Subtyps bei Chemotherapiestudien, um zukunftig unnotige Therapien zu vermeiden sowie eine engmaschigere Nachsorge vor allem von Patienten mit siegelringzelligen KRK zu gewahrleisten. Vorrangiges Ziel sollte eine optimierte und individuellere Therapie von Patienten mit KRK sein.

Gastric stump carcinoma after gastric surgery for benign disease is now widely recognized as a distinct clinical entity. An electronic literature search was performed in the MEDLINE database to identify relevant studies concerning epidemiology, prognosis, treatment, aetiology and pathology of gastric stump carcinoma. The references reported in these studies were used to complete the literature search. It can be assumed that approximately 10 % of patients who had undergone a distal gastric resection for benign disease will develop a carcinoma in the gastric remnant about 15 to 20 years after the primary procedure. The incidence is reported to be higher in males and following Billroth II resection. The site of tumour growth is predominantly in the anastomotic area, but may occur anywhere in the stump. Enterogastric reflux, achlorhydria, bacterial overgrowth, and genetic factors appear to be the major factors involved in the aetiopathogenesis of the gastric stump cancer. Unfortunately, a significant proportion of patients presents with synchronous metastases. Clinical symptoms are mainly attributed to locally advanced tumour growth. Surgical therapy comprises total removal of the gastric remnant and the jejunal segment including modified lymphadenectomy (D2 lymphadenectomy and jejunal mesentery). Surveillance of patients with endoscopy and multiple biopsies should be initiated from the tenth postoperative year and may provide the means to diagnose tumours at an early stage.

Weight loss is associated with increased levels of adiponectin with a greater increase observed following Roux-en-Y gastric bypass (RYGB) compared to restrictive procedures. However, currently there are no data on changes in adiponectin following laparoscopic sleeve gastrectomy (LSG). Ghrelin was reported to be also produced by the salivary glands. There are also no data available regarding its changes following bariatric surgery.The present study examined weight loss, and salivary ghrelin and HMW adiponectin levels in 43 morbidly obese subjects undergoing three different types of bariatric surgery.We found that weight loss following LSG is superior to laparoscopic adjustable gastric banding (LAGB) and comparable to RYGB at 12 months after surgery. Although blood glucose decreased similarly following all three procedures, fasting insulin continuously declined only in LSG and RYGB patients. Changes in both fasting and postprandial salivary ghrelin greatly varied between all three procedures with no similarities to changes in serum ghrelin reported in the literature. HMW adiponectin significantly increased following LSG, and this increase was more marked than in LAGB patients and almost identical compared to RYGB.Weight loss following LSG is comparable to RYGB in the short term. Changes in HMW adiponectin are comparable following LSG and RYGB which may further contribute to the successful results after LSG. Furthermore, the results of the present study support the hypothesis that there is an autonomous production of ghrelin in salivary glands irrespective of nutritional status and weight loss.

Background While carcinoma of the colon is a common malignancy, primary carcinoma of the appendix is rare. Many retrospective reviews outlined experience from different centers on appendiceal neoplasms. However, the study population is often small because it is so rare. The aim of this study was to analyze the type of surgery and survival of patients with appendiceal malignancies using data from a German multi-center observational study (31 341 patients). Methods During a five-year period, 196 consecutive patients with malignant appendiceal tumors were distributed into four groups: appendiceal carcinoids, adenocarcinoma, mucinous adenocarcinoma and adenosquamous carcinoma. The following parameters were analyzed: demographics, clinical presentation, comorbidities, type and appropriateness of surgery, final pathology and survival. Results Adenocarcinoma had the highest incidence (50.5%). The most common presentation was that of acute appendicits. Mean age at presentation was youngest for carcinoid tumors. Carcinoid tumors had lowest tumor size and localized disease was present in 72.9%. Metastatic spread at presentation was highest for adenosquamous and mucinous adenocarcinoma and each had a distinct pattern. Right hemicolectomy was performed in 71.4%, limited resection in 11.7%. Overall 5-year survival was 83.1% for carcinoid vs. 49.2% for non-carcinoid tumors. Histological subtype and tumor stage significantly affected survival. Conclusions Long-term outcome of carcinoid tumors is superior to non-carcinoid neoplasms. Among all appendiceal neoplasms, adenosquamous carcinoma is the rarest histological subtype which is most commonly associated with advanced tumor stage and worst prognosis. Appropriate oncologic resection is being performed in a significant percentage of cases in Germany. However, the high rate of right hemicolectomy in patients with small carcinoid tumors needs to be critically discussed.

Purpose Colorectal cancer is one of the most common malignancies in the Western world. In the past two decades, a growing amount of data has been reported suggesting that carcinomas of the right and left colon should be considered as different tumour entities. The aim of this review is to present a detailed analysis of the current knowledge regarding differences between right- and left-sided colon cancer and potential consequences for daily practice. Methods For this report all articles with relevant information on differences between right- and left-sided colon carcinoma found via Pubmed searches were analysed. Furthermore, findings of a previous study performed by our group were included. Results Patients with right-sided colon cancer are significantly older, predominantly women, with a higher rate of comorbidities. Most of the large epidemiological studies reported a continued rightward shift of colorectal cancer. Histopathologically, carcinoma of the right colon show a higher percentage of poorly differentiated, locally advanced tumours with a higher rate of mucinous carcinoma and different pattern of metastatic spread. Survival is significantly worse in patients with right-sided carcinomas. There are numerous genetic differences which account for the distinct carcinogenesis and biological behaviour. Conclusions The numerous findings regarding differences between right- and left-sided colon cancers should have an impact on colon cancer screening and therapy. Firstly, there are defined risk groups which should receive complete colonoscopy, particularly if they present with symptoms suspicious for colon carcinoma. Furthermore, location of the colon cancer should be considered before group stratification into genetic, clinical and especially chemotherapy trials. A more tailored approach to colon cancer treatment would be highly desirable if future trials further support the hypothesis of two distinct tumour entities.

BACKGROUND: Obesity is increasing worldwide at an alarming rate. Particularly in Western countries, obesity and related problems have become a serious medical problem and an enormous socio-economic burden. DISCUSSION: Currently, surgery is the only avail-able treatment for patients with severe obesity which leads to sustained weight loss and cure of co-morbidities in the majority of the patients. The increase in the number of bariatric opera-tions and the occasional failure and complications of these surgical procedures have resulted in an increased need for revision surgery. Overall, 10-25 % of patients are expected to need a revision for failure of the primary bariatric procedure. The main indications for revision procedures are inadequate weight loss, surgery-related complications as well as surgical emergencies and long-term complications caused by malnutrition or -vitamin deficiencies. Unfortunately, there are currently no randomised trials to answer the ques-tion as to which operation should be performed in which patient and after which procedure. Deci-sions are often influenced by the expertise and preference of the operating surgeon as well as by patient’s preference. Thus, a systematic review of published data to this complex issue appears to be helpful and important for daily surgical prac-tise. CONCLUSIONS: Revision bariatric procedures are technically more complex and associated with increased postoperative complications. These operations should basically be performed in cen-tres with profound expertise in this field of surgery, and - whenever possible - laparoscopically. However, every abdominal surgeon should be able to diagnose and treat some acute complica-tions. After failed restrictive procedures, revision is recommended only in cases of complications but with adequate weight loss at the time of -fail-ure. Otherwise, conversion to combined procedures should be considered. After the failure of combined procedures, further weight loss or successful treatment of complications can be achieved by adding more restriction and / or malabsorption components. The latter is associated with an increased risk of nutri-tional sequelae.

SummaryThe Klippel-Trénaunay syndrome (KTS) is a congenital disorder of vascular malformations characterized by the clinical trias of naevi flammei, varicosis and hypertrophy of the affected limb. According to its clinical development KTS can be diagnosed directly post partum or becomes apparent in the course of the development particularly regarding incomplete forms. The most described symptoms next to swelling are pain and augmented sweating of the affected extremity. Complications of KTS are bleeding from mechanically traumatised vascular malformations or widened vessels, but also thromboembolic events are reported. We report on two patients with KTS and one patient with angiodysplasia, who developed deep vein thromboses in the affected limb at young age. None of the patients suffered from thrombophilia or other predisposing risk factors for thrombosis. KTS and other angiodysplastic disorders seem to be a risk factor for thromboembolic complications even at young age. A comprehensive counceling of the patients concerning the prevention of complications and especially the symptoms of thromboembolic events is important for early diagnosis and immediate therapy.

For the management of endoscopically irretrievable polyps, several minimally invasive procedures are currently available as alternatives to conventional laparotomy. However, the high rate of malignant transformation despite initially benign histology continues to be a problem. Within the framework of a prospective multicenter observational study, all patients with adenomatous polyps unsuitable for endoscopic removal and with benign histology were investigated. In addition to an analysis of the perioperative course and the definitive histology, the overall and disease-free survival rates of patients with malignant transformation of colorectal adenomas were also calculated. A total of 525 patients (median age 65.3 years; median body mass index 25.6 kg/m2) underwent a laparoscopic resection. Conversion to laparotomy became necessary in 17 (3.2%) cases. The perioperative morbidity rate was 20.8%, and malignant transformation occurred in a total of 18.1% of the adenomatous polyps. The median number of lymph nodes removed was 12, and lymph node metastases were seen in a total of 14.8% of the patients (T1 – 4.8%, T2 – 19.4%, T3 – 25%, T4 – 100%). Estimated 5-year overall and disease-free survival rates were 92.4% and 80.6%, respectively. For the management of endoscopically unresectable polyps, laparoscopic resection is currently the technique of choice. In addition to the benefits of minimally invasive surgery, in the hands of an experienced surgeon it achieves results comparable with those of open surgery. In view of the high rate of malignant transformation and the absence of unequivocal factors predictive of already present malignant transformation, an oncologically radical operation is essential. In the elderly patient presenting with comorbidities limited resection aiming to minimize surgical trauma in potentially benign disease may be considered. In such a case, however, frozen-section histology is obligatory.

Adjuvant chemotherapy for resected rectal cancer is widely used. However, studies on adjuvant treatment following neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) have yielded conflicting results. Recent studies have focused on adding oxaliplatin to both preoperative and postoperative therapy, making it difficult to assess the impact of adjuvant oxaliplatin alone. This study was aimed at determining the impact of (i) any adjuvant treatment and (ii) oxaliplatin-containing adjuvant treatment on disease-free survival in CRT-pretreated, R0-resected rectal cancer patients. Patients undergoing R0 TME following 5-fluorouracil (5FU)-only-based CRT between January 1, 2008, and December 31, 2010, were selected from a nationwide registry. After propensity score matching (PSM), comparison of disease-free survival (DFS) using Kaplan-Meier analysis and log-rank test was performed in (i) patients receiving no vs. any adjuvant treatment and (ii) patients treated with adjuvant 5FU/capecitabine without vs. with oxaliplatin. Out of 1497 patients, 520 matched pairs were generated for analysis of no vs. any adjuvant treatment. Mean DFS was significantly prolonged with adjuvant treatment (81.8 ± 2.06 vs. 70.1 ± 3.02 months, p

BACKGROUND The safe and appropriate use of long-acting beta-agonists (LABAs) for the treatment of asthma has been widely debated. In two large clinical trials, investigators found a potential risk of serious asthma-related events associated with LABAs. This study was designed to evaluate the risk of administering the LABA salmeterol in combination with an inhaled glucocorticoid, fluticasone propionate. METHODS In this multicenter, randomized, double-blind trial, adolescent and adult patients (age, ≥12 years) with persistent asthma were assigned to receive either fluticasone with salmeterol or fluticasone alone for 26 weeks. All the patients had a history of a severe asthma exacerbation in the year before randomization but not during the previous month. Patients were excluded from the trial if they had a history of lifethreatening or unstable asthma. The primary safety end point was the first serious asthma-related event (death, endotracheal intubation, or hospitalization). Noninferiority of fluticasone–salmeterol to fluticasone alone was defined as an upper boundary of the 95% confidence interval for the risk of the primary safety end point of less than 2.0. The efficacy end point was the first severe asthma exacerbation. RESULTS Of 11,679 patients who were enrolled, 67 had 74 serious asthma-related events, with 36 events in 34 patients in the fluticasone–salmeterol group and 38 events in 33 patients in the fluticasone-only group. The hazard ratio for a serious asthmarelated event in the fluticasone–salmeterol group was 1.03 (95% confidence interval [CI], 0.64 to 1.66), and noninferiority was achieved (P = 0.003). There were no asthma-related deaths; 2 patients in the fluticasone-only group underwent asthmarelated intubation. The risk of a severe asthma exacerbation was 21% lower in the fluticasone–salmeterol group than in the fluticasone-only group (hazard ratio, 0.79; 95% CI, 0.70 to 0.89), with at least one severe asthma exacerbation occurring in 480 of 5834 patients (8%) in the fluticasone–salmeterol group, as compared with 597 of 5845 patients (10%) in the fluticasone-only group (P

Obesity is a modern-day phenomenon that is increasing throughout the world. The aim of the present study was to provide data to establish whether the laparoscopic approach to colorectal surgery in the obese patient represents a risk or, rather, a benefit for the patient.The data presented in this paper were obtained within the framework of a prospective multicenter study initiated by the "Laparoscopic Colorectal Surgery Study Group (LCSSG)" and performed on 5,853 recruited patients. The perioperative course was compared between the three groups: nonobese, obesity grade I, and obesity grade II/III.Increasing body mass index correlated with a highly significant increase in the duration of the operation (nonobese 167 min, grade I 182 min, grade II/III 191 min; p0.001) and in the conversion rate (nonobese 5.5%, obesity grade I 7.9%, obesity grade II/III 13.1%; p0.001). The intraoperative complication rate also showed a tendency to increase (nonobese 5.0%, grade I 6.2%, grade II/III 7.1%; p = 0.219). In contrast, no significant differences were found between the groups with regard to the postoperative complication rate (nonobese 20.7%, grade I 21.0%, grade II/III 20.2%), the reoperation rate (nonobese 4.1%, grade I 3.9%, grade II/III 3.6%), and the postoperative mortality rate (nonobese 1.1%, grade I 1.9%, grade II/III 1.8%).Laparoscopic colorectal surgery is clearly more technically demanding in the obese patient. Apart from this, however, it is not associated with any increased risk of postoperative complications, and thus demonstrates that the pathologically overweight patient can benefit to a particular degree from the laparoscopic modality.

Lymphorrhea is an uncommon but potentially life-threatening complication following surgical procedures which strongly influences the outcome of surgical patients. Persistent lymphocutaneous fistula is mainly associated with an increased risk of local infections and wound complications. Chylous ascites and chylothorax can result in malnutrition, metabolic deterioration and immunosuppression that increase postsurgical morbidity. Diagnosis can easily be made by the characteristic milky-beige appearance of chylous fluid. Laboratory investigation of the drainage fluid (chylomicrons, triglycerides) enables to confirm diagnosis. Initial therapy favors conservative measures including drainage, pressure dressings, total parenteral nutrition and diet modifications. But this takes sometimes several weeks to control the chylous leak and leads to prolonged hospitalisation. Surgical options are only recommended if conservative therapy fails. However, surgical re-interventions are associated with significant incidence of morbidity and mortality. In addition, surgery may occasionally fail to identify the leak. Some promising new techniques have recently been introduced (application of octreotide or etilefrine, low-dose radiotherapy, use of sclerosing agents, subatmospheric pressure dressings or percutaneous embolization of cisterna chyli), which - alone or in combination with well-established conservative measures - may have the potential to avoid surgical re-interventions. Prevention of lymphorrhea during primary operation is of major importance. The present study focuses on current diagnostic and therapeutic options in the treatment of lymphocutaneous fistula, chylous ascites and chylothorax as the most frequent entities of lymphorrhea.

Zink ist ein essenzielles Spurenelement und wird fur eine Vielzahl von Zellfunktionen benotigt. Fruhgeborene konnen eine negative Zinkbilanz aufweisen und sind daher besonders anfallig fur einen symptomatischen Zinkmangel. Wir berichten uber ein Fruhgeborenes mit ausgepragtem klinischen Bild eines histologisch und laborchemisch diagnostizierten Zinkmangels, der unter einer oralen Zinksubstitution rasch vollstandig abheilte.