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Contains fulltext : 238998.pdf (Publisher’s version ) (Open Access) BACKGROUND: Pancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study. METHODS: An online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts. RESULTS: The response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis. CONCLUSION: This international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.

Neben dem prognostisch fuhrenden systemischen Rezidiv ist eine hohe Rate an Lokalrezidiven ein relevantes Problem in der Chirurgie des Pankreaskarzinoms. Anspruch der chirurgischen Resektion als Grundlage eines kurativen Therapiekonzepts muss die Verbesserung der lokalen Kontrolle sein. Die aktuelle Datenlage bezuglich Haufigkeit, Relevanz und Risikofaktoren des Lokalrezidivs wird zusammengefasst und daran abgeleitet werden Strategien zur Reduktion des Lokalrezidivs unter besonderer Berucksichtigung chirurgischer Resektionstechniken dargestellt. Es erfolgte eine Analyse und Bewertung aktueller wissenschaftlichen Literatur zum Thema. Ein Lokalrezidiv tritt nach Resektion eines Pankreaskarzinoms als erste Rezidivmanifestation bei 20–50 % der Patienten auf. Die erhebliche Variation der Lokalrezidivraten hangt von chirurgischer Qualitat, (neo)adjuvantem Therapieregime sowie von Design der Nachsorge und Dauer der Nachbeobachtung ab. Ein R1-Status ist ein wichtiger Risikofaktor fur das Lokalrezidiv und deutet auf die Relevanz der lokal radikalen Resektion hin. Bei den meisten Lokalrezidiven handelt es sich um perivaskulare Rezidive oder Lymphknotenrezidive. Chirurgisch technische Ansatzpunkte zur Verbesserung der Lokalrezidivrate betreffen daher die Lymphadenektomie, die Dissektion direkt an den Oberbauchgefasen unter Mitnahme der periarteriellen Gefasplexus und die Gefasresektion. Die Sicherheit und onkologische Effektivitat der radikalen Resektionstechniken beim Pankreaskarzinom im Kontext der multimodalen Therapie muss in prospektiven Studien weiter evaluiert werden.

Die Resektion ist die einzige kurative Therapieoption beim Pankreaskarzinom. Adjuvante Chemotherapie kann das krankheitsfreie Uberleben und Gesamtuberleben nach Resektion verbessern. Zurzeit werden daruber hinaus neoadjuvante Konzepte in zahlreichen Studien untersucht. Zusammenfassung der aktuellen Datenlage bezuglich adjuvanter und neoadjuvanter Therapie des Pankreaskarzinoms. Analyse der wissenschaftlichen Literatur und Leitlinien. Nach Resektion eines Pankreaskarzinoms sollte eine moglichst intensive Chemotherapie mit mFOLFIRINOX, Gemcitabin plus Capecitabin oder Gemcitabin/5-Fluorouracil(5-FU)-Monotherapie durchgefuhrt werden. Neoadjuvante Konzepte sind vielversprechend, sollten aber in prospektiven Studien weiter evaluiert werden.

Initial recurrence mapping of resected pancreatic ductal adenocarcinoma (PDAC) could help in stratifying patient subpopulations for optimal postoperative follow-up. The aim of this systematic review and meta-analysis was to investigate the initial recurrence patterns of PDAC and to correlate them with clinicopathological factors.MEDLINE and Web of Science databases were searched systematically for studies reporting first recurrence patterns after PDAC resection. Data were extracted from the studies selected for inclusion. Pooled odds ratios (ORs) and 95 per cent confidence intervals were calculated to determine the clinicopathological factors related to the recurrence sites. The weighted average of median overall survival was calculated.Eighty-nine studies with 17 313 patients undergoing PDAC resection were included. The weighted median rates of initial recurrence were 20·8 per cent for locoregional sites, 26·5 per cent for liver, 11·4 per cent for lung and 13·5 per cent for peritoneal dissemination. The weighted median overall survival times were 19·8 months for locoregional recurrence, 15·0 months for liver recurrence, 30·4 months for lung recurrence and 14·1 months for peritoneal dissemination. Meta-analysis revealed that R1 (direct) resection (OR 2·21, 95 per cent c.i. 1·12 to 4·35), perineural invasion (OR 5·19, 2·79 to 9·64) and positive peritoneal lavage cytology (OR 5·29, 3·03 to 9·25) were significantly associated with peritoneal dissemination as initial recurrence site. Low grade of tumour differentiation was significantly associated with liver recurrence (OR 4·15, 1·71 to 10·07).Risk factors for recurrence patterns after surgery could be considered for specific surveillance and treatments for patients with pancreatic cancer.El mapeo del patrón de recidiva inicial tras la resección de un adenocarcinoma ductal pancreático (pancreatic ductal adenocarcinoma, PDAC) podría ayudar a estratificar subpoblaciones de pacientes para un seguimiento postoperatorio óptimo. El objetivo de esta revisión sistemática con metaanálisis fue investigar los patrones de recidiva inicial de PDAC y correlacionarlos con factores clínico-patológicos. MÉTODOS: Se realizaron búsquedas sistemáticas en las bases de datos MEDLINE y Web of Science para seleccionar estudios que presentaran información sobre los patrones de recidiva inicial después de la resección del PDAC. Se extrajeron los datos de los estudios seleccionados para su inclusión en el metaanálisis. Se calcularon las razones de oportunidades agrupadas (pooled odds ratio, OR) y los i.c. del 95% para definir los factores clínico-patológicos relacionados con las localizaciones de la recidiva. Se estimó el promedio ponderado de la mediana de la supervivencia global.Se incluyeron 89 estudios con 17.313 pacientes a los que se realizó una resección por PDAC. Las tasas medias ponderadas de las localizaciones de la recidiva inicial fueron del 20,8% para la locorregional, 26,5% para las hepáticas, 11,4% para el pulmón y 13,5% para la diseminación peritoneal. La mediana ponderada de supervivencia global fue de 19,8 meses (locorregional), 15,0 meses (hígado), 30,4 meses (pulmón) y 14,1 meses (diseminación peritoneal). El metaanálisis demostró que la resección R1 (inicial) (OR 2,21, i.c. del 95% 1,12-4,35), la invasión perineural (OR 5,19; i.c. del 95% 2,79-9,64) y la positividad de la citología del lavado peritoneal (OR 5,29; i.c. del 95% 3,03-9,25) se asociaron significativamente con la diseminación peritoneal como localización de recidiva inicial. El bajo grado de diferenciación tumoral se asoció significativamente con la recidiva hepática (OR 4,15; i.c. del 95%: 1,71-10,07). CONCLUSIÓN: Se podrían tener en cuenta estos factores de riesgo de los patrones de recidiva tras la cirugía para realizar un seguimiento y tratamiento específicos en pacientes con cáncer de páncreas.

The session participants were Prof. Caroline Verbeke (CV) from The Department of Pathology Oslo University and Prof. Marcus Wolfgang Büchler (WMB) from the Department of General, Visceral and Transplantation Surgery at the University Hospital Heidelberg. The participants had to assume the problem of the surgical treatment of pancreatic cancer with the reflection to radicality.

Objective Malnutrition is associated with poor survival in pancreatic cancer patients. Nutritional scores show great heterogeneity diagnosing malnutrition. The aim of this study was to find the score best suitable to identify patients with malnutrition related to worse survival after surgery for PDAC. Methods Risk of malnutrition was evaluated preoperatively using twelve nutritional assessment scores. Patients were followed-up prospectively for at least 3 years. Patients at risk for malnutrition were compared to those not at risk according to each score using Kaplan Meier survival statistics. Results A total of 116 Patients receiving a PDAC resection in curative intent were included. Malnutrition according to the Subjective Global Assessment score (SGA), the Short Nutritional Assessment Questionnaire (SNAQ) and the INSYST2 score was associated with worse overall survival (SGA: at-risk: 392 days; not at-risk: 942 days; p = 0.001; SNAQ: at-risk: 508 days; not at-risk: 971 days; p = 0.027; INSYST2: at-risk: 538 days; not at risk: 1068; p = 0.049). In the multivariate analysis SGA (HR of death 2.22, 95% CI 1.37-3.6, p = 0.002) was associated with worse overall survival. Conclusion Malnutrition as defined by the Subjective Global Assessment is independently associated with worse survival in resected PDAC patients. The SGA should be used to stratify PDAC patients in clinical studies. If severely malnourished patients according to the SGA profit from intensified nutritional therapy should be evaluated in a randomized controlled trial.

Objective Some studies have indicated that resecting the pylorus during partial pancreatoduodenectomy (PD) may lead to reduced delayed gastric emptying (DGE). Randomized controlled trials (RCTs) showed conflicting results regarding superiority of pylorus-resecting PD (prPD) compared to the pylorus-preserving procedure (ppPD). The aim of this individual patient data meta-analysis was to investigate risk factors on an individual patient level which may explain the observed differences between the existing RCTs. Methods RCTs comparing ppPD and prPD were searched systematically in MEDLINE, Web of Science and CENTRAL. Individual patient data (IPD) from existing RCTs were included. The primary endpoint was DGE according to the International Study Group of Pancreatic Surgery (ISGPS) adjusted for age, sex and body-mass-index (BMI). The meta-regression model was applied to the IPD of the RCTs. Mixed effects models were applied to perform meta-analyses. Results IPD from 418 patients (three RCTs) were used for quantitative synthesis. There was no significant statistical difference between ppPD and prPD regarding DGE adjusted for age, sex and BMI (OR 0.72; 95%-CI: 0.41 to 1.22) and DGE grade (RR 1.01; 95%-CI: 0.64 to 1.57). Regarding other relevant perioperative and postoperative outcome parameters, there were also no significant differences among the two techniques. Conclusion This IPD meta-analysis comparing preservation and resection of the pylorus during PD confirmed that the resection of the pylorus is not superior to the pylorus-preserving procedure regarding DGE. The pylorus should therefore be preserved whenever possible. Further RCT are futile, because their results are unlikely to change the pooled estimate for DGE.

Background Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate curative-intent resection in PDAC. Methods A review of the literature addressing current technical advances in surgery for PDAC was performed, and current state-of-the-art surgical techniques summarized. Results Artery-first and uncinate-first approaches, dissection of the anatomical triangle between the coeliac and superior mesenteric arteries and the portomesenteric vein, and radical antegrade modular pancreatosplenectomy were introduced to enhance the completeness of resection and reduce the risk of local recurrence. Elaborated techniques for resection and reconstruction of the mesenteric–portal vein axis and a venous bypass graft-first approach frequently allow resection of PDAC with venous involvement, even in patients with portal venous congestion and cavernous transformation. Arterial involvement does not preclude surgical resection per se, but may become surgically manageable with recent techniques of arterial divestment or arterial resection following neoadjuvant treatment. Conclusion Advanced techniques of surgical resection and vessel reconstruction provide a toolkit for curative-intent surgery in borderline resectable and locally advanced PDAC. Effects of these surgical approaches on overall survival remain to be proven with high-level clinical evidence.

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.La incidencia de complicaciones linfáticas tras el trasplante renal (post-kidney-transplantation lymphatic, PKTL) varía considerablemente en la literatura. Esto se debe en parte a que no se ha establecido una definición universalmente aceptada. Este estudio tuvo como objetivo proponer una definición aceptable para las complicaciones PKTL y un sistema de clasificación de la gravedad basado en la estrategia de tratamiento. MÉTODOS: Se realizó una búsqueda sistemática de la literatura relevante en MEDLINE y Web of Science. Se logró un consenso para la definición y la clasificación de gravedad de las PKTL entre veinte centros de trasplante de alto volumen.En 32 de los 87 estudios incluidos se definía la linforrea/linfocele. Sesenta y tres artículos describían como se trataban las PKTL, pero ninguno calificó la gravedad de las mismas. La definición propuesta para la linforrea fue la de un débito diario superior a 50 ml de líquido (no orina, sangre o pus) a través del drenaje o del orificio cutáneo tras su retirada, más allá del 7º día postoperatorio del trasplante renal. La definición propuesta para linfocele fue la de una colección de líquido de tamaño variable adyacente al riñón trasplantado, tras haber descartado un urinoma, hematoma o absceso. Las PKTL de grado A fueron aquellas con escaso impacto o que no requirieron tratamiento invasivo; las PKTL de grado B fueron aquellas que precisaron intervención no quirúrgica y las PKTL de grado C aquellas en que fue necesaria la reintervención quirúrgica. CONCLUSIÓN: Se propone una definición clara y una clasificación de gravedad basada en la estrategia de tratamiento de las PKTLs. La definición propuesta y el sistema de calificación en 3 grados son razonables, sencillos y fáciles de comprender, y servirán para estandarizar los resultados de las PKTL y facilitar las comparaciones entre los diferentes estudios.

Chronic pancreatitis (CP) is associated with elevated plasma levels of bacterial lipopolysaccharide (LPS) and we have demonstrated reduced acinar cell autophagy in human CP tissue. Therefore, we investigated the role of autophagy in experimental endotoxin-induced pancreatic injury and aimed to identify LPS in human CP tissue. Pancreatic Atg7-deficient mice were injected with a single sub-lethal dose of LPS. Expression of autophagy, apoptosis, necroptosis, and inflammatory markers was determined 3 and 24 h later utilizing immunoblotting and immunofluorescence. The presence of LPS in pancreatic tissue from mice and from patients and healthy controls was determined using immunohistochemistry, immunoblots, and chromogenic assay. Mice lacking pancreatic autophagy exhibited local signs of inflammation and were particularly sensitive to the toxic effect of LPS injection as compared to control mice. In response to LPS, Atg7Δpan mice exhibited enhanced vacuolization of pancreatic acinar cells, increase in TLR4 expression coupled to enhanced expression of NF-κΒ, JNK, and pro-inflammatory cytokines by acinar cells and enhanced infiltration by myeloid cells (but not Atg7F/F controls). Cell death was enhanced in Atg7Δpan pancreata, but only necroptosis and trypsin activation was further amplified following LPS injection along with elevated pancreatic LPS. The presence of LPS was identified in the pancreata from all 14 CP patients examined but was absent in the pancreata from all 10 normal controls. Altogether, these results support a potential role for metabolic endotoxemia in the pathogenesis of CP. Moreover, the evidence also supports the notion that autophagy plays a major cytoprotective and anti-inflammatory role in the pancreas, and blunting metabolic endotoxemia-induced CP.

Background Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta-analysis, the impact of perioperative PLT on PHLF and mortality was evaluated. Methods MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non-randomized studies (MINORS) criteria. Meta-analyses were performed using Mantel–Haenszel tests with a random-effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals. Results Thirteen studies containing 5260 patients were included in the meta-analysis. Two different cut-off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater. Conclusion A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.

Background Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial. Methods Between August and October 2014, patients undergoing abdominal surgery received preoperative skin antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174). Results In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034). Conclusion This study showed a benefit of adding chlorhexidine to alcohol for skin antisepsis in reducing early SSI compared with alcohol alone.

Die Diagnose intraduktaler papillar-muzinoser Neoplasien (IPMN) des Pankreas hat mit der zunehmenden Verbreitung moderner abdomineller Bildgebungsverfahren in den letzten Jahren stark zugenommen. Trotz des malignen Potenzials werden insbesondere viele Seitengang-IPMN nicht sofort operiert, sondern uberwacht. In den Fukuoka-Guidelines wurden im Jahr 2012 Risikofaktoren fur eine potenziell maligne Transformation von Seitengang-IPMN zusammengefasst. Die Leitlinien definieren sog. „high-risk stigmata“, bei deren Vorliegen eine Resektion durchgefuhrt werden sollte, sowie „worrisome features“, bei welchen eine Uberwachung zunachst empfohlen wird. Diese Therapierichtlinien werden jedoch kontrovers diskutiert, da auch viele Seitengang-IPMN, die „worrisome features“ zeigen, ein relevantes malignes Potenzial aufweisen. Der vorliegende Artikel fasst die Indikation zur Operation und Moglichkeiten der chirurgischen Therapie von Seitengang-IPMN zusammen.

Background Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome. Methods Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery. Results Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications. Conclusion None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Background In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of the present report is to verify the value of the International Study Group of Pancreatic Fistula definition and grading of postoperative pancreatic fistula and to update the International Study Group of Pancreatic Fistula classification in light of recent evidence that has emerged, as well as to address the lingering controversies about the original definition and grading of postoperative pancreatic fistula. Methods The International Study Group of Pancreatic Fistula reconvened as the International Study Group in Pancreatic Surgery in order to perform a review of the recent literature and consequently to update and revise the grading system of postoperative pancreatic fistula. Results Based on the literature since 2005 investigating the validity and clinical use of the original International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former “grade A postoperative pancreatic fistula” is now redefined and called a “biochemical leak,” because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula. Conclusion This new definition and grading system of postoperative pancreatic fistula should lead to a more universally consistent evaluation of operative outcomes after pancreatic operation and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula. Use of this updated classification will also allow for more precise comparisons of surgical quality between surgeons and units who perform pancreatic surgery.

Background/objectives Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP. Methods An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach’s alpha reliability coefficient. Results Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40–55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients. Conclusions This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Hintergrund Magenstumpfkarzinome entstehen im Restmagen nach partieller Gastrektomie. Wahrend die Haufigkeit des Magenkarzinoms abnimmt, bleibt die Inzidenz des Magenstumpfkarzinoms aufgrund einer langen Latenzzeit stabil. Nachdem die chirurgische Therapie von Magenulzera durch partielle Gastrektomien an Bedeutung verloren hat, entwickeln sich zunehmend Magenstumpfkarzinome nach onkologischen Resektionen.

Nach Einfuhrung der totalen mesorektalen Exzision (TME) in der kurativen Behandlung des Rektumkarzinoms hat sich die Rolle der neoadjuvanten Therapie gewandelt. Durch die verbesserte Operationstechnik konnte die Lokalrezidivrate allein durch die Chirurgie nach den TME-Kriterien auf unter 8 % gesenkt werden. Auch wenn die lokale Kontrolle mittels praoperativer Bestrahlung weiter verbessert werden konnte, hat dies nicht zu einem allgemeinen Uberlebensvorteil vorbestrahlter Patienten gefuhrt. Leitliniengerecht sollten alle Patienten im UICC-II- und -III-Stadium vorbehandelt werden. Die stadienbasierte Indikationsstellung zur neoadjuvanten Therapie hat jedoch Schwachen. Zum einen stellen die Patienten mit T3-Tumoren eine prognostisch sehr heterogene Gruppe dar, zum anderen ist die praoperative Lymphknotendiagnostik zu ungenau. Im Gegensatz dazu hat sich in den letzten Jahren der zirkumferenzielle Resektionsrand (CRM) als wichtiger prognostischer Parameter etabliert. Patienten, bei denen eine grose Nahe/Infiltration der Hullfaszie (positiver CRM) zum/durch den Tumor besteht, haben eine hohere Lokalrezidivrate und ein schlechteres Uberleben. Mit hochauflosender MRT-Untersuchung des Beckens kann bei Patienten mit Rektumkarzinom der praoperative CRM mit einer hohen Sensitivitat und Spezifitat bestimmt werden. Das mittels MRT verbesserte T‑Staging bzw. die Vorhersage der Resektionsrander konnen ein wichtiges Kriterium zur Selektion von Patienten fur studienbasierte Therapieansatze ohne neoadjuvante Therapie sein.

Gefasresezierende Eingriffe und die damit verbundene Notwendigkeit der Rekonstruktion zur Aufrechterhaltung insbesondere der Leber- und Dunndarmperfusion sind v. a. in der chirurgischen Therapie des Pankreaskarzinoms von Bedeutung. Die R0-Resektion ist dabei der einzig kurative Therapieansatz. Eine Infiltration des Tumors in venose oder arterielle Gefase und die damit verbundene Resektion und Rekonstruktion zur vollstandigen Tumorentfernung und Sicherstellung einer ausreichenden Perfusion der abhangigen Organe stellt eine der grosten Herausforderungen in der Pankreaschirurgie dar. Zudem ist die onkologische Wertigkeit – im Hinblick auf arterielle Gefasresektionen – umstritten. In dieser Ubersichtsarbeit werden – basierend auf der aktuellen Literatur – die Indikationen und technischen Aspekte venoser sowie arterieller Resektionen und Rekonstruktionen in der Therapie des Pankreaskarzinoms dargestellt und diskutiert. Es wurde eine systematische Literaturrecherche in Medline, Embase und der Cochrane Library durchgefuhrt, um Studien zu identifizieren, in denen die Ergebnisse venoser oder arterieller Gefasresektionen und -rekonstruktionen in der Pankreaschirurgie vorgestellt werden. Ein Pankreaskarzinom mit Gefasinfiltration ist nicht prinzipiell als irresektabel anzusehen, sondern muss in jedem Fall auf die Moglichkeit einer kurativen Resektion uberpruft werden, wobei ein entscheidender Faktor die Differenzierung zwischen venosen und arteriellen Gefasbeteiligungen ist. Fur die venose Gefasresektion stehen abhangig vom Ausmas des Tumorbefalls verschiedene sichere technische Optionen bereit. Arterielle Gefasresektionen sind mit einer erhohten Morbiditat und Mortalitat verbunden. Bei selektionierten Patienten kann durch eine arterielle Gefasresektion eine vollstandige Tumorresektion und ein verlangertes Uberleben erreicht werden.

Durch die flachendeckende Etablierung moderner Verfahren hat sich die Tracheotomie zu einem Routineeingriff in der Intensivmedizin entwickelt. Durch die Tracheotomie konnen negative Effekte einer prolongierten translaryngealen Intubation auf die Larynx- und Trachealschleimhaut bis hin zur Trachealstenose vermindert werden. Weiterhin wird die Langzeitbeatmung bei kritisch kranken Patienten erleichtert. Es gibt allerdings keine eindeutige Evidenz uber den optimalen Zeitpunkt der Tracheotomie bei Intensivpatienten. Fur die sichere und erfolgreiche Durchfuhrung mussen die speziellen Indikationen und Kontraindikationen sowohl fur die plastische Tracheotomie als auch fur die perkutane dilatative Tracheotomie (PDT) zwingend beachtet werden. Insbesondere nach PDT kann es beim Wechsel der Trachealkanule zu potenziell gefahrlichen Situationen kommen. Ein standardisiertes und strukturiertes Vorgehen ist daher sinnvoll.

Background/research question: Pancreatic surgery is a large and complex field of research. Several evidence gaps exist for specific diseases or surgical procedures. An overview on existing knowledge is needed to plan and prioritise future research. The aim of this project is to create a systematic[for full text, please go to the a.m. URL], Nützliche patientenrelevante Forschung; 21. Jahrestagung des Deutschen Netzwerks Evidenzbasierte Medizin