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Zusammenfassung Einleitung Die postoperative Pankreasfistel (POPF) zählt zu den häufigsten Komplikationen in der Pankreaschirurgie. Sie ist oftmals mit einem verlängerten Krankenhausaufenthalt, erhöhten Behandlungskosten und einer Reduktion an Lebensqualität verbunden. Ziel der vorliegenden Studie war es, die gängige Praxis bez. der Behandlung einer klinisch relevanten Pankreasfistel (CR-POPF) bundesweit zu erfassen und die Durchführung eines ambulanten Drainagemanagements zu evaluieren. Methoden Zur Erhebung des (ambulanten) Managements klinisch relevanter Pankreasfisteln und des ambulanten Drainagemanagements wurde ein Fragebogen bestehend aus 34 Parametern in 9 thematischen Blöcken entworfen und an 211 Kliniken in Deutschland versendet, welche die Mindestmenge von 12 Pankreasresektionen/Jahr erreichen. Die statistische Auswertung erfolgte mit SPSS 21. Ergebnisse 62% der angeschriebenen Kliniken (n = 131) nahmen an der Umfrage teil. Ambulantes Drainagemanagement bei Patienten mit Pankreasfistel wird von den meisten Kliniken durchgeführt (n = 100, 76,3%). Jedoch praktizieren 30% der Kliniken (n = 40) in nur 5% ihrer CR-POPF-Fälle eine ambulante Behandlung. Eine Korrelation zwischen der Fallzahl und der Häufigkeit eines ambulanten Managements wurde nicht beobachtet. Meistens sind die Entlasskriterien (n = 98, 74,8%), das Drainagemanagement (n = 95, 72,5%) und die Kriterien zur Drainageentfernung (n = 74, 56,5%) nicht standardisiert, sondern erfolgen individuell. In Zentren mit standardisiertem Vorgehen sind die Kriterien zur Drainageentfernung durch eine Sekretionsmenge Zusammenfassung Es handelt sich hierbei um die erste bundesweite Umfrage zur Evaluation des ambulanten Drainagemanagements bei Patienten mit CR-POPF. Trotz spärlicher Datenlage praktizieren die meisten deutschen Pankreaschirurgen eine ambulante Weiterbehandlung bei Pankreasfistel. Jedoch haben die wenigsten Kliniken einen definierten Standard bez. Entlassung aus der Klinik, der ambulanten Versorgung und der Drainageentfernung. Wir empfehlen die Definition von Entlasskriterien sowie einen Managementalgorithmus zur Optimierung des perioperativen Verlaufs und möglicherweise Ausweitung der ambulanten Behandlung von Patienten mit Drainage bei CR-POPF.

Intraoperative bile analysis during pancreatoduodenectomy (PD) is performed routinely at specialized centers worldwide. However, it remains controversial if and how intraoperative bacterobilia during PD affects morbidity and its management. The aim of the study was a systematic review and meta-analysis of intraoperative bacterobilia and its impact on patient outcome after PD. Five relevant outcomes of interest were defined, and a systematic review of the literature with meta-analysis was performed according to the PRISMA guidelines. A total of 28 studies (8523 patients) were included. The median incidence of bacterobilia was 58% (interquartile range 51–67%). The most frequently isolated bacteria were Enterococcus species (51%), Klebsiella species (28%), and Escherichia coli (27%). Preoperative biliary drainage was significantly associated with bacterobilia (86 vs. 25%; RR 3.27; 95% confidence interval (CI) 2.42–4.42; p

Background Pancreatic ductal adenocarcinoma (PDAC) represents the fourth most common cause of cancer mortality and it is expected to become the second most common cause of cancer mortality by 2020 in the USA. Objective Which strategies for the detection and treatment of an early stage pancreatic adenocarcinoma and its precursor lesions are to be applied? Results Currently, there is no effective general screening program for pancreatic cancer due to the low incidence and the lack of an accurate and inexpensive diagnostic method; however, in patients with a positive history of hereditary pancreatic cancer or in patients with a known sporadic germline mutation that is associated with an increased risk of pancreatic cancer, frequent screening is highly recommended to detect and to treat early stage PDAC. Moreover, patients with a precursor lesion for pancreatic cancer (namely a mucinous pancreatic neoplasm) should undergo an oncological pancreatic resection to prevent the development of late stage pancreatic cancer. In future, additional biomarkers from a liquid biopsy, such as circulating tumor cells, exosomes or circulating tumor DNA may improve the early detection of pancreatic cancer. Conclusion The early detection and treatment of pancreatic cancer and its precursor lesions can help to improve the dismal prognosis of this aggressive tumor type.

KRAS is the key mutated gene in pancreatic ductal adenocarcinoma (PDAC). Emerging evidence indicates that KRas modulates endocytic uptake. The present study aimed to explore the fate of early endosomal trafficking under the control of KRas expression in PDAC. Surprisingly, PANC-1 cells lacking KRas exhibited significantly enlarged early and late endosomes containing internalized dextran and epidermal growth factor. Endosome enlargement was accompanied by reduced endosomal degradation. Both KRas silencing and lysosomal blockade caused an upregulation of the master regulator of early endosome biogenesis, RAB5A, which is likely responsible for the expansion of the early endosomal compartment, because simultaneous KRAS/RAB5A knockdown abolished endosome enlargement. In contrast, early endosome shrinkage was seen in MIA PaCa-2 cells despite RAB5A upregulation, indicating that distinct KRas-modulated responses operate in different metabolic subtypes of PDAC. In conclusion, mutant KRAS promotes endosomal degradation in PDAC cell lines, which is impaired by KRAS silencing. Moreover, KRAS silencing activates RAB5A upregulation and drives PDAC subtype-dependent modulation of endosome trafficking.

Die Indikationsstellung zur chirurgischen Resektion zystischer Pankreastumoren ist komplex und das operative Risiko fur den Patienten muss haufig gegenuber dem Risiko einer malignen Entartung abgewogen werden. Ziel der Arbeit ist ein Uberblick uber die Ergebnisse der minimalinvasiven Operationstechniken bei zystischen Pankreastumoren. Es erfolgte eine orientierende, systematische Literatursuche unter Verwendung der Medline-Datenbank (PubMed) sowie eine selektive Ubersichtsdarstellung. Es liegen bisher keine randomisierten kontrollierten Studien zum Vergleich der offenen und minimalinvasiven Resektion zystischer Tumoren vor. Retrospektive Fallserien bescheinigen den minimalinvasiven Techniken die Machbarkeit und Sicherheit sowie eine vergleichbare Morbiditat nach distaler Pankreatektomie (DP), Pankreatoduodenektomie (PD), zentraler (CP) und totaler Pankreatektomie sowie der Enukleation. Wahrend die meisten DP laparoskopisch durchgefuhrt werden, ist die Erfahrung fur die minimalinvasive PD mit dem Roboter groser, jedoch auf wenige spezialisierte Zentren verteilt. Insgesamt ist die Zahl der publizierten Falle minimalinvasiver organsparender Pankreasresektionen (CP oder Enukleation) bei zystischen Tumoren sehr gering; die verfugbaren selektionierten Ergebnisse jedoch zunachst positiv. Die minimalinvasive Chirurgie bei zystischen Pankreastumoren hat das Potenzial, das operative Trauma der Patienten bei gleichen oder geringeren Komplikationsraten zu reduzieren. Voraussetzung ist eine zunehmende Spezialisierung insbesondere bei komplexen Operationen. Bei diesen Eingriffen wird der klinische Einsatz des Roboters ansteigen. Eine prospektive Dokumentation der Ergebnisse ist im Rahmen der Qualitatssicherung anzustreben.

Jahrlich erkranken weltweit gut eine Million Menschen an Karzinomen des Magens sowie des gastroosophagealen Ubergangs („adenocarcinomas of the esophagogastric junction“, AEG). Sie gehoren weltweit zu den haufigsten Krebstodesursachen. Die komplette Resektion des Primartumors inklusive onkologisch radikaler Lymphadenektomie ist die einzig kurative Therapie fur die meisten Tumorstadien. Das interdisziplinare Vorgehen richtet sich dabei nach der Stadieneinteilung, das operative zusatzlich nach der exakten Tumorlokalisation sowie der histologischen Differenzierung. Wahrend sich die Risikoprofile und verschiedene epidemiologische Charakteristika unterscheiden, weisen AEG und Adenokarzinome des Magens ahnliche Vorlauferlasionen und molekulare Veranderungen auf. Plattenepithelkarzinome des Osophagus unterscheiden sich in der Atiologie, den molekularen Alterationen und in den therapeutischen Ansatzen; sie bedurfen daher einer separaten Darstellung.

Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery associated with extended hospitalization, increased medical costs, and reduced quality of life. The aim of the present study was to analyze the feasibility of ambulatory drainage and develop an ambulatory management algorithm. Patients with POPF grade B or C (according to the ISGPF classification) between Jan. 2005 and Dec. 2014 that required persistent drainage were identified from a prospectively collected database. Postoperative events and clinical outcomes were retrospectively analyzed. A total of 132 out of 887 patients (14.8%) developed a POPF (grade B or C), and 45 (34.1%) were discharged from the hospital with percutaneous drainage. For patients with grade B fistulas, the mean hospital stay was significantly shorter compared to patients with grade C fistulas (mean 27.7 vs. 40 days; p = 0.0285). About 40% of patients with ambulatory drainage developed a complication, but only 28.9% required readmission. Of those, 52.9% did not require specific treatment and 26.3% were treated with a new drain placement. None of the patients developed major complications, and there was no difference in the frequency of complications between the two groups (p = 0.872). The duration of drain persistence was significantly shorter for patients with grade B fistulas than for those with grade C fistulas (52.2 vs. 85.9 days; p = 0.0007). Ambulatory drainage management is feasible in selected patients. No severe complications occurred during ambulatory drainage management. A management algorithm is recommended as this could possibly reduce medical costs and improve quality of life.

OBJECTIVE The aim of this study was to test the hypothesis that intraoperative frozen section (FS) and re-resection results to achieve R0 status are associated with different long-term outcomes in pancreatic cancer patients. BACKGROUND Recent data have challenged the survival benefit of additional resection in patients with pancreatic cancer in case of positive FS to achieve clear pathological section (PS). METHODS Patients who underwent surgery for exocrine pancreatic malignancy with curative intent were identified from a prospective database. Data were stratified by resection margin (group I: FS-R0 → PS-R0; group II: FS-R1 → PS-R0; group III: FS-R1 → PS-R1). Associations with survival were analyzed by univariate and multivariate analyses. RESULTS A total of 483 patients met the inclusion criteria. Of these, 61 patients were excluded due to R2 or Rx status. Three hundred seventeen (75%) patients were allocated to margin group I, 32 (8%) to group II, and 73 (17%) to group III. Median overall survival in group I, II, and III was 29, 36, and 12 months (P < 0.001). There was no significant difference in survival between patients in Group I and II (P = 0.849), whereas patients in group III had significantly poorer outcome than group I (P < 0.001) and II (P = 0.039). The prognostic value of margin group status was confirmed on multivariate analysis (hazard ratio = 1.694, 95% confidence interval 1.175-2.442). CONCLUSIONS FS analysis with intraoperative re-resection should be performed routinely in patients undergoing pancreatic cancer surgery with the aim to achieve a R0 resection.

Obwohl lange skeptisch betrachtet, hat sich die roboterassistierte Pankreaschirurgie an einigen Zentren bereits heute zum Standard entwickelt, sowohl fur die Pankreaslinks- als auch fur die Pankreaskopfresektion. Die Roboterassistenz scheint gerade bei der Kopfresektion (oder totalen Pankreatektomie) Vorteile gegenuber der laparoskopischen Operation hinsichtlich der Moglichkeit und Erlernbarkeit der Organ- oder Gefasanastomosen zu bieten. Der Einsatz des Roboters ist naturlich mit hohen Kosten verbunden und nur ein professionelles Roboterprogramm an Zentren wird eine hohe chirurgische und onkologische Qualitat, angemessene Operationszeiten und kurzere Verweildauern dauerhaft generieren konnen. Neue Technologien wie intraoperative Fluoreszenzdarstellung oder „augmented reality“ werden zusatzliche Indikationen fur die roboterassistierte Pankreaschirurgie definieren.

Electroporation is a common method for transfection with different kinds of molecules by electrical permeabilization of the plasma membrane. With the increasing use of organoids as a culturing method for primary patient material in the last years, efficient transfer methods of components for genetic engineering in this 3D culture system are in need. Especially for organoids, the efficiency of genetic manipulations depends on a successful transfection. Thus, this protocol was developed to facilitate the electroporation of organoids and to prove its universal functionality in different entities. Human colorectal, pancreatic, hepatic and gastric cancer organoids were successfully electroporated with small and large plasmids in comparison. Based on GFP encoding vectors, the transfection efficiency was determined by FACS. No extensive preparation of the cells or special, cost-intensive electroporation buffers are necessary, and the protocol can be performed within one day.

Physiological liver cell replacement is central to maintaining the organ's high metabolic activity, although its characteristics are difficult to study in humans. Using retrospective 14 C birth dating of cells, we report that human hepatocytes show continuous and lifelong turnover, maintaining the liver a young organ (average age < 3 years ). Hepatocyte renewal is highly dependent on the ploidy level. Diploid hepatocytes show an seven-fold higher annual exchange rate than polyploid hepatocytes. These observations support the view that physiological liver cell renewal in humans is mainly dependent on diploid hepatocytes, whereas polyploid cells are compromised in their ability to divide. Moreover, cellular transitions between these two subpopulations are limited, with minimal contribution to the respective other ploidy class under homeostatic conditions. With these findings, we present a new integrated model of liver cell generation in humans that provides fundamental insights into liver cell turnover dynamics.

Ampullary cancer represents approximately 6% of the malignant periampullary tumors. An early occurrence of symptoms leads to a 5-year survival rate after curative surgery of 30 to 67%. In addition to the tumor stage, the immunohistological subtypes appear to be important for postoperative prognosis. The aim of this study was to analyze the different subtypes regarding their prognostic relevance. A total of 170 patients with ampullary cancer were retrospectively analyzed between 1999 until 2016 after pancreatic resection. Patients were grouped according to their pathohistological subtype of ampullary cancer (pancreatobiliary, intestinal, mixed). Characteristics among the groups were analyzed using univariate and multivariate models. Survival probability was analyzed by the Kaplan-Meier method. An exact subtyping was possible in 119 patients. A pancreatobiliary subtype was diagnosed in 69 patients (58%), intestinal in 41 patients (34.5%), and a mixed subtype in 9 patients (7.6%). Survival analysis showed a significantly worse 5-year survival rate for the pancreatobiliary subtype compared with the intestinal subtype (27.5% versus 61%, p p

Patients with borderline resectable pancreatic cancer are increasingly explored after neoadjuvant treatment protocols. A complete resection, then, frequently includes the resection of the mesentericoportal axis. Portosystemic shunting for advanced tumours with infiltration of the splenic vein or cavernous transformation of the portal vein can enable complete tumour resection and prevent portovenous congestion of the intestine. The aim of this study was to report the results of this technique for selected patients. Patients operated for pancreatic cancer at our department between September 2012 and December 2017 using intraoperative portosystemic shunting were included in this retrospective analysis. Some 11 patients with pancreatectomy and simultaneous portosystemic shunting were included. The median age was 65.1 years. A distal splenorenal shunt and a temporary mesocaval shunt were accomplished in 5 and 4 cases, respectively. Two patients were operated using persistent mesocaval shunts (from the coronary, splenic or inferior mesenteric veins). The median operating time was 9.43 h. All but one patient were resected with tumour-negative resection margins; 5 patients had relevant complicated postoperative courses. There was one case of in-hospital mortality but no further 30- or 90-day mortality or graft-associated complications. Five patients were alive after a median follow-up of 24.6 months. The median postoperative survival was 12 months. Portosystemic shunting at the time of extended pancreatectomy is technically challenging but feasible and enables complete tumour resection in cases in which standard vascular reconstruction is limited by cavernous transformation or to prevent sinistral portal hypertension with acceptable morbidity in selected cases. Considering the limited overall survival, the potential individual patient benefit needs to be weighed against the considerable morbidity of advanced tumour resections.

There are 3 main types of incisions in major open, elective abdominal surgery: the midline incision (MI), the transverse incision (TI) and the modified Makuuchi incision (MMI). This study aimed to compare these approaches regarding wound complications and hernias, with a special focus on suture material and previous laparotomies.Patients who underwent elective abdominal surgery between 2015 and 2016 were retrospectively analyzed. Uni- and multivariate analyses were computed using stepwise binary and multifactorial regression models.In total, 696 patients (406 MI, 137 TI and 153 MMI) were included. No relevant differences were observed for patient characteristics (e.g., sex, age, body mass index [BMI], American Society of Anesthesiologists [ASA] score). Fewer wound complications (TI 22.6% vs MI 33.5% vs MMI 32.7%, P = .04) occurred in the TI group. However, regarding the endpoints surgical site infection (SSI), fascial dehiscence and incisional hernia, no risk factor after MI, TI, and MMI could be detected in statistical analysis. There was no difference regarding the occurrence of fascial dehiscence (P = .58) or incisional hernia (P = .97) between MI, TI, and MMI. In cases of relaparotomies, the incidence of fascial dehiscence (P = .2) or incisional hernia (P = .58) did not significantly differ between the MI, TI, or MMI as well as between primary and reincision of each type. On the other hand, the time to first appearance of a hernia after MMI is significantly shorter (P = .03) than after MI or TI, even after previous laparotomy (P = .003).In comparing the 3 most common types of abdominal incisions and ignoring the type of operative procedure performed, TI seems to be the least complicated approach. However, because the incidence of fascial dehiscence and incisional hernia is not relevantly increased, the stability of the abdominal wall is apparently not affected by relaparotomy, even by repeated MIs, TIs, and MMIs. Therefore, the type of laparotomy, especially a relaparotomy, can be chosen based on the surgeon's preference and planned procedure without worrying about increased wound complications.

Background The present study aims to assess the effectiveness and current evidence of a pedicled falciform ligament wrap around the gastroduodenal artery stump for prevention of erosion hemorrhage after pancreatoduodenectomy (PD). Methods Retrospective data were pooled for meta-analysis. At the own center, patients who underwent PD between 2012 and 2015 were retrospectively analyzed based on the intraoperative performance of the wrap. A systematic literature review and meta-analysis was performed that combined the published and the obtained original data. The following databases were searched: Medline, Embase, Web of Science, and the Cochrane Library. Results At the own center, a falciform ligament wrap was performed in 39 of 196 PDs (20%). The wrap group contained more ampullary neoplasms, but the pancreatic fistula rate was not significantly different from the nonwrap group (28% versus 32%). In median, erosion hemorrhage occurred after 21.5 d, and it was lethal in 39% of the patients. Its incidence was not significantly lower in the wrap group (incidence: 7.7% versus 9.6% in the nonwrap group). The systematic literature search yielded four retrospective studies with a high risk of bias; only one study was controlled. When the five data sets of published and own cases with a falciform ligament wrap were pooled, the incidence of erosion hemorrhage was 5 of 533 cases (0.9%) compared with 24 of 297 cases (8.1%) without the wrap. Conclusions The reported incidence of erosion hemorrhage after the falciform ligament wrap is low, but there are still insufficient controlled data to support its general use.

Die Tumoren der Papille und des Duodenums umfassen eine heterogene Gruppe von verschiedenen, gut- oder bosartigen Entitaten und reichen von benignen Polypen uber gastrointestinale Stromatumoren (GIST) und neuroendokrinen Tumoren bis zum Adenokarzinom. Dementsprechend sind die Anamnese, Symptomatik, Diagnostik und auch die Therapie unterschiedlich. Eine besondere Herausforderung ist unter anderem die stadien- und risikoadaptierte Therapieform bei Patienten mit familiarer adenomatoser Polyposis (FAP) und Duodenalpolypen oder bei neuroendokrinen Tumoren. Die chirurgische Therapie stutzt sich dabei in der Regel auf eine multimodale Voruntersuchung (Endoskopie und nichtinvasive Bildgebung) und grenzt sich von endoskopischen Therapieansatzen und -indikationen ab. Die chirurgische Therapie dieser Erkrankungen ist anspruchsvoll, oft mit einer relevanten Morbiditat assoziiert und erfordert eine hohe Expertise der primaren Versorgung, aber auch des moglichen Komplikationsmanagements.

Enhanced recovery after surgery (ERAS) programs have been introduced increasingly into major visceral surgery. Key elements target on early drain removal and mobilization of the patients; however, reporting of adherence to ERAS protocols has often been insufficiently assessed. The present study aims to prospectively evaluate ERAS compliance after major visceral surgery. A prospective pilot study was designed, and 34 patients scheduled for major hepatopancreatic or gastric surgery were followed postoperatively until postoperative day (POD) 10. Analgesia and drain management, diet, mobilization, willingness to exercise, and the use of discharge criteria were accurately assessed within an established ERAS protocol scenario. Thirty-one cases were analyzed that consisted of 54.8 % major pancreatic, 29.0 % hepatic, and 16.1 % gastric resections. The median hospital stay was 12.5 days, and 83.9 % of the patients met the objective criteria before discharge. By POD 4, wound, epidural, and urinary catheters were still in place in 70, 60, and 40 % of the patients, respectively. Fifty percent of the patients ambulated out of bed until POD 2. The cumulative duration of postoperative mobilization per day ranged from 15 to 155 min, and only 40 % of the patients felt comfortable with additional mobilization or physical exercise. Adherence to ERAS protocols is poorly reported. The results indicate a discrepancy between ERAS targets and actual practice in comorbid patients undergoing major visceral surgery, need for a prompt redefinition of ERAS mobilization targets, need for the improvement of counseling, and need for the implementation of ERAS principles.

Many patients with chronic pancreatitis (CP) undergo a step-up approach with interventional procedures as first-line treatment and resection reserved for later stages. The aim of this study was to identify predictive factors for a significant clinical improvement (SCI) after surgical treatment. All patients operated for CP between September 2012 and June 2017 at our center was retrospectively reviewed. A prospective patient survey was conducted to measure patients postoperative outcome. The primary endpoint SCI was defined as stable health status, positive weight development and complete pain relief without routine pain medication. Additionally, risk factors for relaparotomy were analyzed. A total of 89 patients with a median follow-up of 38 months were included. In most cases, a duodenum-preserving pancreatic head resection (n = 48) or pancreatoduodenectomy (n = 28) was performed. SCI was achieved in 65.3% (n = 47) of the patients after the final medium follow-up of 15.0 months (IQR: 7.0–35.0 months), respectively. Patients with a longer mean delay (7.7 vs 4 years) between diagnosis and surgical resection were less likely to achieve SCI (P = .02; OR .88; 95%CI .80–98). An endocrine insufficiency was a negative prognostic factor for SCI (P = .01; OR .15; 95%CI .04–68). In total, 96.2% of the patients had a complete or major postoperative relief with a mean pain intensity reduction from 8.1 to 1.9 on the visual analogue scale. The results support that surgical resection for CP should be considered at early stages. Resection can effectively reduce postoperative pain intensity and improve long-term success.

To test the detectability of a liquid fiducial marker injected into ex vivo pancreas tumour tissue on magnetic resonance imaging (MRI) and computed tomography (CT). Furthermore, its injection performance using different needle sizes and its structural stability after fixation in formaldehyde were investigated. Liquid fiducial markers with a volume of 20–100 µl were injected into freshly resected pancreas specimens of three patients with suspected adenocarcinoma. X‑ray guided injection was performed using different needle sizes (18 G, 22 G, 25 G). The specimens were scanned on MRI and CT with clinical protocols. The markers were segmented on CT by signal thresholding. Marker detectability in MRI was assessed in the registered segmentations. Marker volume on CT was compared to the injected volume as a measure of backflow. Markers with a volume ≥20 µl were detected as hyperintensity on X‑ray and CT. On T1- and T2-weighted 3T MRI, marker sizes ranging from 20–100 µl were visible as hypointensity. Since most markers were non-spherical, MRI detectability was poor and their differentiation from hypointensities caused by air cavities or surgical clips was only feasible with a reference CT. Marker backflow was only observed when using an 18-G needle. A volume decrease of 6.6 ± 13.0% was observed after 24 h in formaldehyde and, with the exception of one instance, no wash-out occurred. The liquid fiducial marker injected in ex vivo pancreatic resection specimen was visible as hyperintensity on kV X‑ray and CT and as hypointensity on MRI. The marker’s size was stable in formaldehyde. A marker volume of ≥50 µL is recommended in clinically used MRI sequences. In vivo injection is expected to improve the markers sphericity due to persisting metabolism and thereby enhance detectability on MRI.

PURPOSE To define proteomic differences between pancreatic ductal adenocarcinoma (pDAC) and pancreatic neuroendocrine tumor (pNET) by matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI MSI). EXPERIMENTAL DESIGN Ninety-three pDAC and 126 pNET individual tissues are assembled in tissue microarrays and analyzed by MALDI MSI. The cohort is separated in a training (52 pDAC and 83 pNET) and validation set (41 pDAC and 43 pNET). Subsequently, a linear discriminant analysis (LDA) model based on 46 peptide ions is performed on the training set and evaluated on the validation cohort. Additionally, two liver metastases and a whole slide of pDAC are analyzed by the same LDA algorithm. RESULTS Classification of pDAC and pNET by the LDA model is correct in 95% (39/41) and 100% (43/43) of patients in the validation cohort, respectively. The two liver metastases and the whole slide of pDAC are also correctly classified in agreement with the histopathological diagnosis. CONCLUSION AND CLINICAL RELEVANCE In the present study, a large dataset of pDAC and pNET by MALDI MSI is investigated, a class prediction model that allowed separation of both entities with high accuracy is developed, and differential peptide peaks with potential diagnostic, prognostic, and predictive values are highlighted.

Background. Organoid cultures of human pancreatic ductal adenocarcinoma (PDAC) have become a promising tool for tumor subtyping and individualized chemosensitivity testing. PDACs have recently been grouped into different molecular subtypes with clinical impact based on cytokeratin-81 (KRT81) and hepatocyte nuclear factor 1A (HNF1A). However, a suitable antibody for HNF1A is currently unavailable. The present study is aimed at establishing subtyping in PDAC organoids using an alternative marker. Methods. A PDAC organoid biobank was generated from human primary tumor samples containing 22 lines. Immunofluorescence staining was established and done for 10 organoid lines for cystic fibrosis transmembrane conductance regulator (CFTR) and KRT81. Quantitative real-time PCR (qPCR) was performed for CFTR and HNF1A. A chemotherapeutic drug response analysis was done using gemcitabine, 5-FU, oxaliplatin, and irinotecan. Results. A biobank of patient-derived PDAC organoids was established. The efficiency was 71% (22/31) with 68% for surgical resections and 83% for fine needle aspirations. Organoids could be categorized into the established quasimesenchymal, exocrine-like, and classical subtypes based on KRT81 and CFTR immunoreactivity. CFTR protein expression was confirmed on the transcript level. CFTR and HNF1A transcript expression levels positively correlated (n=10; r=0.927; p=0.001). PDAC subtypes of the primary tumors and the corresponding organoid lines were identical for most of the cases analyzed (6/7). Treatment with chemotherapeutic drugs revealed tendencies but no significant differences regarding drug responses. Conclusions. Human PDAC organoids can be classified into known subtypes based on KRT81 and CFTR immunoreactivity. CFTR and HNF1A mRNA levels correlated well. Furthermore, subtype-specific immunoreactivity matched well between PDAC organoids and the respective primary tumor tissue. Subtyping of human PDACs using CFTR might constitute an alternative to HNF1A and should be further investigated.

Early mobilization is one essential item within the enhanced recovery after surgery (ERAS) concept, but lacks solid evidence and a standardized assessment. The aim was to monitor and increase the postoperative mobilization of patients after major visceral surgery by providing a continuous step count feedback using activity tracking wristbands. The study was designed as a randomized controlled single-center trial (NCT02834338) with two arms (open and laparoscopic surgery). Participants were randomized to either receive feedback of their step counts using an activity tracker wristband or not. The primary study endpoint was the mean step count during the first 5 postoperative days (PODs). A total of 132 patients were randomized. After laparoscopic operations, the average step count during PODs 1–5 was significantly increased by the feedback compared with the control group (P

Infectious complications (ICs) after mesh-reinforced ventral hernioplasty often lead to prolonged and complicated hospitalizations. As early diagnosis and management can mitigate complications, early prediction is important. Our aim was to determine whether postoperative blood tests are valuable predictors of IC. We retrospectively analyzed 373 patients who underwent conventional ventral hernioplasty with mesh augmentation between 2008 and 2011. The clinical outcome was correlated with postoperative serum C-reactive protein (CRP) and white blood cell counts (WBC) and assessed by area under the curve (AUC) analysis of the receiver operating characteristics curve. ICs occurred in 51 (13.7%) patients, who required further management. Among these, 48 patients developed a procedure-related complication, the most frequent being surgical site infection (n = 44). The infections appeared after a median postoperative delay of 12 days. Serum CRP was superior to WBC in the prediction of a complicated course. A maximum CRP

Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery and is associated with extended hospitalisation, increased medical costs, and reduced quality of life. The aim of the present study was to assess the treatment of POPF in Germany, with a special focus on outpatient drain management in patients with clinically relevant POPF (CR-POPF).A questionnaire evaluating postoperative management once a CR-POPF is diagnosed - especially focusing on ambulatory drain management - was developed and sent to 211 German hospitals performing 12 pancreatic operations per year. Statistical analysis was carried out using SPSS 21.The final response rate was 62% (n = 131). Outpatient drainage management is performed by most of the responding hospitals (n = 100, 76.3%). However, 30% of hospitals (n = 40) perform outpatient treatment only in 5% of their cases with clinically relevant POPF. There was no correlation between case load of the pancreatic centres and frequency of outpatient drain management. In general, discharge criteria for patients with drained POPF (n = 98, 74.8%), the drain management itself (n = 95, 72.5%) and criteria for drain removal (n = 74, 56.5%) are not standardised but made individually. In centres with standardised drain management criteria for drain removal, these criteria were drain volume 20 ml (29.8%), no fluid collection (25.2%), no elevation of drain amylase/lipase (25.2%) and no specific symptoms (22.1%).This is the first survey in Germany evaluating outpatient drain management in patients with CR-POPF. Although the data in the literature are rare, the majority of German pancreatic surgeons perform outpatient drain management. However, discharge criteria, outpatient care and drain removal are standardised in only the minority of centres. Therefore, we recommend the evaluation of discharge criteria and a management algorithm for patients with drained CR-POPF to improve the perioperative course.Die postoperative Pankreasfistel (POPF) zählt zu den häufigsten Komplikationen in der Pankreaschirurgie. Sie ist oftmals mit einem verlängerten Krankenhausaufenthalt, erhöhten Behandlungskosten und einer Reduktion an Lebensqualität verbunden. Ziel der vorliegenden Studie war es, die gängige Praxis bez. der Behandlung einer klinisch relevanten Pankreasfistel (CR-POPF) bundesweit zu erfassen und die Durchführung eines ambulanten Drainagemanagements zu evaluieren.Zur Erhebung des (ambulanten) Managements klinisch relevanter Pankreasfisteln und des ambulanten Drainagemanagements wurde ein Fragebogen bestehend aus 34 Parametern in 9 thematischen Blöcken entworfen und an 211 Kliniken in Deutschland versendet, welche die Mindestmenge von 12 Pankreasresektionen/Jahr erreichen. Die statistische Auswertung erfolgte mit SPSS 21.62% der angeschriebenen Kliniken (n = 131) nahmen an der Umfrage teil. Ambulantes Drainagemanagement bei Patienten mit Pankreasfistel wird von den meisten Kliniken durchgeführt (n = 100, 76,3%). Jedoch praktizieren 30% der Kliniken (n = 40) in nur 5% ihrer CR-POPF-Fälle eine ambulante Behandlung. Eine Korrelation zwischen der Fallzahl und der Häufigkeit eines ambulanten Managements wurde nicht beobachtet. Meistens sind die Entlasskriterien (n = 98, 74,8%), das Drainagemanagement (n = 95, 72,5%) und die Kriterien zur Drainageentfernung (n = 74, 56,5%) nicht standardisiert, sondern erfolgen individuell. In Zentren mit standardisiertem Vorgehen sind die Kriterien zur Drainageentfernung durch eine Sekretionsmenge 20 ml (29,8%), den fehlenden Nachweis eines intraabdominellem Verhalts (25,2%), einen fehlenden Amylase-/Lipasenachweis im Sekret (25,2%) sowie das Fehlen spezifischer Symptome (22,1%) definiert.Es handelt sich hierbei um die erste bundesweite Umfrage zur Evaluation des ambulanten Drainagemanagements bei Patienten mit CR-POPF. Trotz spärlicher Datenlage praktizieren die meisten deutschen Pankreaschirurgen eine ambulante Weiterbehandlung bei Pankreasfistel. Jedoch haben die wenigsten Kliniken einen definierten Standard bez. Entlassung aus der Klinik, der ambulanten Versorgung und der Drainageentfernung. Wir empfehlen die Definition von Entlasskriterien sowie einen Managementalgorithmus zur Optimierung des perioperativen Verlaufs und möglicherweise Ausweitung der ambulanten Behandlung von Patienten mit Drainage bei CR-POPF.

The case of a 64-year-old man with spontaneous acute abdominal bleeding is presented. Under suspicion of an atypical hepatocellular carcinoma an extended left hemihepatectomy was performed. Histological diagnosis after surgical therapy revealed a primary hepatic choriocarcinoma. During follow-up within 5 months several metastases were detected. Because of the number and localization of the metastases, there was no further curative surgical option and palliative systemic chemotherapy was initiated. Primary choriocarcinoma of the liver is an important differential-diagnosis in hypervascularized lesions of the liver. This tumor-entity is highly aggressive, with rapid tendency for metastatic spreading. This correlates with the poor prognosis of 12 months after tumor-detection.

Complete surgical resection with microscopically tumor-free resection margins (R0) is the most important survival determinant for patients with localized pancreatic cancer. The medial and posterior resection margins are the dominant sites of microscopic tumor involvement, and outline the so-called mesopancreas. In this study, we present a modified surgical approach to the superior mesenteric artery, celiac trunc, and mesopancreas during pancreatoduodenectomy, which enables a comfortable exposure and radical en bloc clearance of the mesopancreas and the tissue adjacent to the superior mesenteric artery. The dissection of the mesopancreas is directed from the ventral aspect of the portal vein downward along the superior mesenteric artery and the celiac trunc, before the transection of the duodenal mesentery is accomplished. The described technique complements the established surgical approaches to pancreatic head tumors, and is indicated in the absence of portal vein infiltration. J. Surg. Oncol. 2016;113:668-671. © 2016 Wiley Periodicals, Inc.

In den letzten zehn Jahren hat sich das deutsche Gesundheitssystem zunehmend gewandelt. Kliniken stehen unter deutlichem okonomischen Druck und betriebswirtschaftliches Wissen wird auch fur Mediziner immer wichtiger, auch um mit der Klinikverwaltung optimal im Sinne der Patienten zusammenarbeiten zu konnen. Medizin und Okonomie stehen hierbei nicht im Widerspruch zueinander. Durch effizientere Leitung einer Abteilung lassen sich haufig Ressourcen einsparen, Prozessablaufe besser gestalten und auch fur den Patienten vorteilhafte Ergebnisse bezuglich Service und medizinischer Qualitat erzielen. In den letzten Jahren hat das Angebot an okonomischen und betriebswirtschaftlichen Zusatzstudiengangen und Weiterbildungsangeboten fur Mediziner stetig zugenommen und wird im Folgenden beleuchtet.

In den letzten zehn Jahren hat sich das deutsche Gesundheitssystem zunehmend gewandelt. Kliniken stehen unter deutlichem ökonomischen Druck und betriebswirtschaftliches Wissen wird auch für Mediziner immer wichtiger, auch um mit der Klinikverwaltung optimal im Sinne der Patienten zusammenarbeiten zu können. Medizin und Ökonomie stehen hierbei nicht im Widerspruch zueinander. Durch effizientere Leitung einer Abteilung lassen sich häufig Ressourcen einsparen, Prozessabläufe besser gestalten und auch für den Patienten vorteilhafte Ergebnisse bezüglich Service und medizinischer Qualität erzielen.In den letzten Jahren hat das Angebot an ökonomischen und betriebswirtschaftlichen Zusatzstudiengängen und Weiterbildungsangeboten für Mediziner stetig zugenommen und wird im Folgenden beleuchtet.

In den letzten zehn Jahren hat sich das deutsche Gesundheitssystem zunehmend gewandelt. Kliniken stehen unter deutlichem okonomischen Druck und betriebswirtschaftliches Wissen wird auch fur Mediziner immer wichtiger, auch um mit der Klinikverwaltung optimal im Sinne der Patienten zusammenarbeiten zu konnen. Medizin und Okonomie stehen hierbei nicht im Widerspruch zueinander. Durch effizientere Leitung einer Abteilung lassen sich haufig Ressourcen einsparen, Prozessablaufe besser gestalten und auch fur den Patienten vorteilhafte Ergebnisse bezuglich Service und medizinischer Qualitat erzielen. In den letzten Jahren hat das Angebot an okonomischen und betriebswirtschaftlichen Zusatzstudiengangen und Weiterbildungsangeboten fur Mediziner stetig zugenommen und wird im Folgenden beleuchtet.

Cancer stem cells (CSCs) have been implicated in the initiation and maintenance of tumour growth as well as metastasis. Recent reports link stemness to epithelial–mesenchymal transition (EMT) in cancer. However, there is still little knowledge about the molecular markers of those events. In silico analysis of RNA profiles of 36 pancreatic ductal adenocarcinomas (PDAC) reveals an association of the expression of CD95 with EMT and stemness that was validated in CSCs isolated from PDAC surgical specimens. CD95 expression was also higher in metastatic pancreatic cells than in primary PDAC. Pharmacological inhibition of CD95 activity reduced PDAC growth and metastasis in CSC-derived xenografts and in a murine syngeneic model. On the mechanistic level, Sck was identified as a novel molecule indispensable for CD95's induction of cell cycle progression. This study uncovers CD95 as a marker of EMT and stemness in PDAC. It also addresses the molecular mechanism by which CD95 drives tumour growth and opens tantalizing therapeutic possibilities in PDAC.

No international consensus regarding the resection of the para-aortic lymph node (PALN) station Ln16b1 during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) has been reached. The present retrospectively investigated 264 patients with PDAC who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005–2015. In 95 cases, the PALN were separately labelled and histopathologically analysed. Metastatic PALN (PALN+) were found in 14.7% (14/95). PALN+ stage was associated with increased regional lymph node metastasis. The median overall survival (OS) of patients with metastatic PALN and with non-metastatic PALN (PALN−) was 14.1 and 20.2 months, respectively. Five of the PALN+ patients (36%) survived >19 months. The OS of PALN+ and those staged pN1 PALN− was not significantly different (P = 0.743). Patients who underwent surgical exploration or palliative surgery (n = 194) had a lower median survival of 8.8 (95% confidence interval: 7.3–10.1) months. PALN status could not be reliably predicted by preoperative computed tomography. We concluded that the survival data of PALN+ cases is comparable with advanced pN+ stages; one-third of the patients may expect longer survival after radical resection. Therefore, routine refusal of curative resection in the case of PALN metastasis is not indicated.

Background/Objectives PPH is the main cause of mortality (up to 50%) after pancreatic resection. Due to differences in time of onset, localization and clinical impairment, there is no consistent management algorithm. Methods Between 1994 and 2014 the occurrence of PPH in 115 out of 1 450 patients from a prospectively collected database was analyzed. The cohort was divided into two time periods: 1994–2009 and 2010–2014. The differences between the two groups were analyzed. Results The overall incidence of PPH was 7.9%. The main causes of hemorrhage were the pancreatic anastomosis (31.1%) and the splanchnic arteries (23.5%). In the first period, there were more anastomotic hemorrhages (40.0% vs. 20.4%, p = 0.02), while in the second period more hemorrhages from the splanchnic arteries occurred (12.3% vs. 37%, p = 0.002). Bleeding control was achieved by relaparotomy (45.7%), noninterventionally (22.8%), endoscopically (19.7%) and angiographically (13.4%). In the second period, the relevance of interventional angiography significantly increased (24.6% vs. 4.3%, p = 0.001), whereas endoscopy lost importance (7% vs. 30%, p = 0.001). The in-hospital case fatality rate after PPH was 27.4%, with higher case fatality rate following extraluminal hemorrhage (23.9% vs. 3.4%, p Conclusions A shift in the management of PPH could be seen over the two periods. Interventional angiography has gained more importance in the treatment of severe extraluminal hemorrhage of the splanchnic arteries. Adequate treatment of PPH is crucial to improve the outcome.

The biology of pancreatic acinar cell cystadenomas has not been clearly defined. However, a non-neoplastic process, caused by a cell differentiation failure leading to a cystic transformation, has been discussed, as well as a benign neoplastic lesion. Pancreatic acinar cell cystadenomas usually consist of thin-walled unilocular or multilocular cysts, and mural nodules have been described in two cases of a recent series. In one of these nodules, chromosomal imbalances were detected, which provided preliminary evidence for a neoplastic process. The aim of the current study was to further characterize the lesions by molecular analyses. In four cases without mural nodules, the clonality was assessed by performing mutational analyses within the highly variable displacement-loop region of the mitochondrial DNA. As a result, no closer correlation was identified between different foci within the tumors than between the tumors and adjacent normal pancreatic acinar tissue, indicating polyclonality of these lesions. Further molecular analyses revealed no mutations of the β-catenin and K-ras genes. In addition, no immunohistochemical evidence was identified for mutations of Smad4 or p53. In conclusion, the results of the current study demonstrated that pancreatic acinar cell cystadenomas are non-neoplastic lesions, with the potential exception of those rare cases with mural nodules.

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas belong to the heterogeneous group of cystic pancreatic lesions and have been diagnosed more frequently in recent years. Diagnosis and differentiation from other cystic lesions (pseudocysts, serous-cystic neoplasias [SCN], mucinous-cystic neoplasias [MCN], intraductal papillary-mucinous neoplasias [IPMN] and solid pseudopapillary neoplasias [SPN]) is often challenging. IPMN of the pancreas are considered as precursor lesions for the development of invasive pancreatic cancer. However, depending on the morphological (MD-IPMN, BD-IPMN) and histological subtype (intestinal, pancreatobiliary, oncocytic or gastric) the malignant potential of IPMNs varies significantly. Hence, early diagnosis and selection of the appropriate therapeutic strategy is necessary for optimal outcome and cure. There is a strong consensus for the resection of all MD-IPMN. Small BD-IPMN without signs of malignancy can be followed by observation. The increasing understanding of the histopathology and tumour biology of IPMN has led to an amendment of the 2006 International Association of Pancreatology (IAP) guidelines for the treatment of cystic pancreatic tumours. In consideration of recent data, recommendations for observation and/or follow-up of IPMN cannot be given definitely.

This study evaluates the anorectal and genitourinary function of patients treated by preoperative short-term radiotherapy (RT) or chemoradiotherapy (CRT) followed by surgery and surgery alone for rectal cancer.For this study, a total of 613 patients, who were identified from a prospective rectal cancer database, underwent anterior resection of the rectum between October 2001 and December 2007. Standardized questionnaires were used to determine fecal incontinence, urinary, and sexual function. Relevant clinical variables were evaluated using univariate and multivariate analyses. Independent predictors of functional outcome were identified by a binary logistic regression analysis.The data of 263 (43 %) patients were available for analysis. On multivariate analysis, neoadjuvant RT (P 0.01) and low anterior resection (LAR) (P = 0.049) were associated with fecal incontinence. In univariate analysis, fecal incontinence was linked to preoperative neoadjuvant treatment (RT and/or CRT vs. LAR) (P 0.01). The hazard ratio for developing fecal incontinence was 3.3 (1.6-6.8) for patients who received RT. One hundred twenty-five patients (51.2 %) experienced urinary incontinence following surgery, the majority of whom were female (P 0.01). On univariate analysis, male sexual function was associated with age (P 0.01), ASA class (P = 0.01) and LAR (P = 0.01).Multimodal therapy of low rectal cancer increases the incidence of fecal incontinence and negatively affects sexual function. The potential benefits of RT or CRT need to be balanced against the risk of increased bowel dysfunction when determining the appropriate treatment for individual patients with rectal cancer.

The International Study Group of Rectal Cancer (ISREC) has proposed a generally applicable definition and severity grading of (AL) after sphincter-preserving resection of the rectum. This work has been carried out to test for validity.A total of 746 patients who were identified from a prospective rectal cancer database underwent sphincter-preserving anterior resection of the rectum between October 2001 and January 2011. The incidence and severity of AL was determined using the criteria established by the ISREC. Patients with AL were categorized according to the ISREC scheme. The clinical outcomes were analyzed and compared between the groups.The overall AL rate was 7.5% (56/746). The 56 patients with AL were distributed among the different groups as follows: Grade A, 16%; grade B, 23%; and grade C, 61%. Compared with the grade A patients, grades B and C patients had significantly elevated serum C-reactive protein levels (P.01). None of the grade A patients were transferred to the intensive care unit (ICU). Their further hospital stay was uneventful. The length of stay in the ICU was significantly longer for grade C patients compared with grade B patients (P.001). The median hospital stay of grade C patients was significantly longer than that of grades A and B patients (P.001).The definition and severity grading of AL after anterior resection of the rectum proposed by the ISREC provides a simple, easily applicable, and valid classification. Using this classification system may facilitate comparison of results from different studies on AL after sphincter-preserving rectal surgery.

Pancreatic cystic lesions (PCL), including intraductal papillary mucinous neoplasia (IPMN), harbor different malignant potential and the optimal management is often challenging. The present study aims to depict the compliance of experts with current consensus guidelines and the accuracy of treatment recommendations stratified by the medical specialty and hospital volume.An international survey was conducted using a set of 10 selected cases of PCL that were presented to a cohort of international experts on pancreatology. All presented cases were surgically resected between 2004 and 2015 and histopathological examination was available. Accuracy of the treatment recommendations was based on the European and international consensus guideline algorithms, and the histopathological result.The response rate of the survey was 26% (46 of 177 contacted experts), consisting of 70% surgeons and 30% gastroenterologists/oncologists (GI/Onc). In the case of main-duct IPMN (MD-IPMN), surgeons preferred more often the surgical approach in comparison with the GI/Onc (55 versus 44%). The mean accuracy rate based on the European and international consensus guidelines, and the histopathological result, were 71/76/38% (surgeons), and 70/73/34% (GI/Onc), respectively. High-volume centers achieved insignificantly higher accuracy scores with regard to the histopathology. Small branch-duct IPMN with cysts2 cm and malignant potential were not identified by the guideline algorithms.The survey underlines the complexity of treatment decisions for patients with PCL; less than 40% of the recommendations were in line with the final histopathology in this selected case panel. Experts and consensus guidelines may fail to predict malignant potential in small PCL.

Hintergrund: Zystische Pankreaslasionen (PCL) werden zunehmend diagnostiziert und besitzen ein unterschiedliches malignes Potenzial. Die praoperative Differentialdiagnose von muzinosen Neoplasien (MCN) oder Hauptgang-IPMN is oft eine Herausforderung, aber beeinflusst moglicherweise entscheidend das Patientenuberleben. Die vorliegende Studie fasst die Zystenflussigkeitsmarker fur die Differentialdiagnose von PCL systematisch zusammen. Methodik: Eine systematische Literatursuche und Meta-Analyse wurde entsprechend der PRISMA-Empfehlungen und unter Berucksichtigung der Datenbanken Medline, Embase, Web of Science und Cochrane Library durchgefuhrt. Ergebnisse: Die Literatursuche ergab 4547 Abstracts und 90 Volltextartikel wurden gescreent. Schlieslich konnten 51Studien in die Meta-Analyse eingezogen werden. Die Tumormarker CEA, CA19 – 9, CA125 und CA72 – 4 wurden in jeweils 38, 16, 4 und 4 Arbeiten untersucht; 26 Studien wurden uber andere Marker publiziert. Insgesamt inkludieren alle Studien 4087 Patienten mit einer medianen Kohortengrose von 52. Die meisten Studien hatten ein hohes Biasrisiko (65%). Die Testgenauigkeit von CEA fur die Differentialdiagnose von muzinosen/nicht-muzinosen (n = 15 Studien), bzw. benignen/malignen (n = 20 Studien) PCL erreichte eine mediane gepoolte Sensitivitat/Spezifitat/Akkuranz von jeweils 73%/78%/77% bzw. 68%/83%/78%. Die verwendeten CEA Schwellenwerte reichten von 5 – 1000 ng/ml, jedoch wurde meistens 192 ng/ml verwendet. Die statistischen Testgrosen von Zysten-CA19 – 9 waren zeigten keine klare Tendenz fur eine mogliche Differenzierung von malignen PCL. Einige neue Marker zeigten hingegen vielversprechende Testgrosen, aber benotigen eine weitere Validierung. Schlussfolgerung: CEA ist der am besten untersuchte Zystenflussigkeits-Marker fur die Differenzierung von PCL, jedoch weist es nur eine moderate Akkuranz auf. Eine Verbesserung der Testgenauigkeit scheint nur durch eine Kombination mit neuen Markern moglich.

Background Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. “Early mobilization” is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands. Methods/design Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity. Discussion Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization. Trial registration ClinicalTrials.gov identifier: NCT02834338. Registered on 15 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1782-1) contains supplementary material, which is available to authorized users.