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Kappenberger AS, Schardey J, Wirth U, Kühn F, Werner J, Zimmermann P. Clinical outcomes and perioperative morbidity and mortality following segmental resections of the colon for Crohn's colitis. Int J Colorectal Dis 2024; 39:36. [PMID: 38456914 PMCID: PMC10923963 DOI: 10.1007/s00384-024-04596-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a chronic inflammatory bowel disease of a multifactorial pathogenesis. Recently numerous genetic variants linked to an aggressive phenotype were identified, leading to a progress in therapeutic options, resulting in a decreased necessity for surgery. Nevertheless, surgery is often inevitable. The aim of the study was to evaluate possible risk factors for postoperative complications and disease recurrence specifically after colonic resections for CD. PATIENTS AND METHODS A total of 241 patients who underwent colonic and ileocaecal resections for CD at our instiution between 2008 and 2018 were included. All data was extracted from clinical charts. RESULTS Major complications occurred in 23.8% of all patients. Patients after colonic resections showed a significantly higher rate of major postoperative complications compared to patients after ICR (p = < 0.0001). The most common complications after colonic resections were postoperative bleeding (22.2%), the need for revision surgery (27.4%) and ICU (17.2%) or hospital readmission (15%). As risk factors for the latter, we identified time interval between admission and surgery (p = 0.015) and the duration of the surgery (p = 0.001). Isolated distal resections had a higher risk for revision surgery and a secondary stoma (p = 0.019). Within the total study population, previous bowel resections (p = 0.037) were identified as independent risk factors for major perioperative complications. CONCLUSION The results indicate that both a complex surgical site and a complex surgical procedure lead to a higher perioperative morbidity in colonic resections for Crohn's colitis.
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Affiliation(s)
- Alina-Sophie Kappenberger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchionini Str. 15, 81377, Munich, Germany.
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Koch DT, Koliogiannis D, Drefs M, Schirren M, von Ehrlich-Treuenstätt V, Nieß H, Renz B, Ilmer M, Andrassy J, Guba MO, Werner J, Kühn F. Baseline Interleukin-6 as a Preoperative Biomarker for Liver Fibrosis. Visc Med 2024; 39:184-192. [PMID: 38205272 PMCID: PMC10775852 DOI: 10.1159/000535627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction Liver (hepatic) fibrosis (LF) is characterized by impaired function and regenerative capacity of the liver and can lead to significantly increased morbidity and mortality in the context of surgical liver resection (LR). For this reason, it is crucial to identify the extent of LF preoperatively. Interleukin-6 (IL-6) is known to play a key role in the pathogenesis of LF, but its exact value as a preoperative marker is unknown. This study aimed to investigate the correlation between preoperatively determined IL-6 and the presence of LF. Methods In this prospective study, IL-6 was determined in 134 consecutive patients undergoing LR. Patients with liver cirrhosis (LC) and patients with clinical or laboratory signs of inflammation were excluded. LF was graded by a blinded pathologist with regard to the degree of LF according to the Desmet classification (0-4). Baseline IL-6 and degree of LF were correlated. Results A total of 134 patients were prospectively included prior to LR. For 104 patients, LF was graded and inflammatory parameters were available. Thirty-five of these patients showed LC (Desmet 4), and another 33 patients showed preoperatively elevated inflammatory markers. Two of the remaining patients were liver transplant patients. These patients were excluded from the final analysis. According to Desmet, the remaining 34 patients had LF grade 0 or 1 (none or minimal LF) in 26 cases and LF grade 2 or 3 (moderate-to-severe LF) in 8 cases. Correlation of LF with preoperatively determined IL-6 yielded significantly higher IL-6 levels in the group of patients with moderate-to-severe LF (Desmet 2 or 3) compared to the group with none or minimal LF (Desmet 0 or 1; p = 0.0495). Conclusion In the context of LR, our results showed a correlation of preoperatively determined IL-6 with the extent of LF present. Higher serum baseline IL-6 concentrations were associated with a higher degree of LF, whereas no other blood parameter or score was that predictive for LF. Our results suggest that baseline IL-6 might serve as a valuable parameter to assess LF prior to LR. More patients need to be analyzed to further evaluate and confirm the predictive accuracy of IL-6 for LF.
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Affiliation(s)
- Dominik Thomas Koch
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz Drefs
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | - Malte Schirren
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Hanno Nieß
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Biobanc of the Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Bernhard Renz
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Matthias Ilmer
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | - Markus O. Guba
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- Transplantation Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Liver Center Munich, LMU University Hospital, LMU Munich, Munich, Germany
- Biobanc of the Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
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Duan R, von Ehrlich-Treuenstätt VH, Kakoschke SC, Schardey J, Wirth U, Albertsmeier M, Renz BW, Andrassy J, Bazhin AV, Hodin RA, Werner J, Ilmer M, Kühn F. Effect of Surgery on Postoperative Levels of the Gut Homeostasis-Regulating Enzyme Intestinal Alkaline Phosphatase. J Am Coll Surg 2024; 238:70-80. [PMID: 37870235 DOI: 10.1097/xcs.0000000000000879] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Intestinal homeostasis is a crucial factor for complication-free short- and long-term postoperative recovery. The brush border enzyme intestinal alkaline phosphatase (IAP) is an important regulator of gut barrier function and intestinal homeostasis and prevents endotoxemia by detoxifying lipopolysaccharides (LPSs). As IAP is predominantly secreted by enterocytes in the duodenum, we hypothesized that pancreaticoduodenectomy (PD) leads to a significantly stronger decrease in IAP than other major abdominal surgery. STUDY DESIGN Pre- and postoperative blood, stool, and intestinal samples were collected from patients undergoing PD, as well as other major surgical procedures without duodenectomy. The samples were analyzed using enzyme histochemistry, the para -nitrophenyl phosphate method for IAP, and the limulus amebocyte lysate assay for LPS. RESULTS Overall, 88 patients were prospectively enrolled in the study. Fecal IAP activity negatively correlated with serum LPS (r = -0.3603, p = 0.0006). PD led to a significant decline in IAP compared to preoperative baseline levels (p < 0.0001). The decline in IAP correlated with the length of proximal small intestinal resection (r = 0.4271, p = 0.0034). Compared to controls, PD was associated with a much more pronounced reduction in IAP-also after adjusting for surgical trauma (operative time, blood loss; r = 0.4598, p = 0.0086). Simultaneously, PD triggered a clearly more prominent increase in serum LPS compared to controls (p = 0.0001). Increased postoperative LPS was associated with an elongated hospitalization (r = 0.7534, p = 0.0062) and more prominent in pancreatic cancer (p = 0.0009). CONCLUSIONS Based upon the functional roles for IAP, supplementation with exogenous IAP might be a new treatment option to improve short- and long-term outcome after PD.
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Affiliation(s)
- Ruifeng Duan
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Viktor H von Ehrlich-Treuenstätt
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Sara C Kakoschke
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Josefine Schardey
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Ulrich Wirth
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Markus Albertsmeier
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Bernhard W Renz
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
| | - Joachim Andrassy
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
| | - Alexandr V Bazhin
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Hodin)
| | - Jens Werner
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
| | - Matthias Ilmer
- From the Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany (Duan, von Ehrlich-Treuenstätt, Kakoschke, Schardey, Wirth, Albertsmeier, Renz, Andrassy, Bazhin, Werner, Ilmer)
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
| | - Florian Kühn
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany (Renz, Bazhin, Werner, Ilmer, Kühn)
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Schardey J, Lu C, Neumann J, Wirth U, Li Q, Jiang T, Zimmermann P, Andrassy J, Bazhin AV, Werner J, Kühn F. Differential Immune Infiltration Profiles in Colitis-Associated Colorectal Cancer versus Sporadic Colorectal Cancer. Cancers (Basel) 2023; 15:4743. [PMID: 37835436 PMCID: PMC10571767 DOI: 10.3390/cancers15194743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Chronic inflammation is a significant factor in colorectal cancer (CRC) development, especially in colitis-associated CRC (CAC). T-cell exhaustion is known to influence inflammatory bowel disease (IBD) progression and antitumor immunity in IBD patients. This study aimed to identify unique immune infiltration characteristics in CAC patients. METHODS We studied 20 CAC and 20 sporadic CRC (sCRC) patients, who were matched by tumor stage, grade, and location. Immunohistochemical staining targeted various T-cell markers (CD3, CD4, CD8, and FOXP3), T-cell exhaustion markers (TOX and TIGIT), a B-cell marker (CD20), and a neutrophil marker (CD66b) in tumor and tumor-free mucosa from both groups. The quantification of the tumor immune stroma algorithm assessed immune-infiltrating cells. RESULTS CAC patients had significantly lower TOX+ cell infiltration than sCRC in tumors (p = 0.02) and paracancerous tissues (p < 0.01). Right-sided CAC showed increased infiltration of TOX+ cells (p = 0.01), FOXP3+ regulatory T-cells (p < 0.01), and CD20+ B-cells (p < 0.01) compared to left-sided CAC. In sCRC, higher tumor stages (III and IV) had significantly lower TIGIT+ infiltrate than stages I and II. In CAC, high CD3+ (p < 0.01) and CD20+ (p < 0.01) infiltrates correlated with improved overall survival. In sCRC, better survival was associated with decreased TIGIT+ cells (p < 0.038) and reduced CD8+ infiltrates (p = 0.02). CONCLUSION In CAC, high CD3+ and CD20+ infiltrates relate to improved survival, while this association is absent in sCRC. The study revealed marked differences in TIGIT and TOX expression, emphasizing distinctions between CAC and sCRC. T-cell exhaustion appears to have a different role in CAC development.
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Affiliation(s)
- Josefine Schardey
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Can Lu
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
- Department of Colorectal Surgery and Oncology (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education & Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310058, China
- Zhejiang Provincial Clinical Research Center for CANCER & Cancer Center of Zhejiang University, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jens Neumann
- Department of Pathology, Ludwig-Maximilians University, 81377 Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Qiang Li
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Tianxiao Jiang
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Alexandr V. Bazhin
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 80336 Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Hospital Munich, 81377 Munich, Germany
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Weß V, Schuster-Winkelmann P, Karatekin YH, Malik S, Beigel F, Kühn F, Gropp R. Humanized NSG Mouse Models as a Preclinical Tool for Translational Research in Inflammatory Bowel Diseases. Int J Mol Sci 2023; 24:12348. [PMID: 37569722 PMCID: PMC10418464 DOI: 10.3390/ijms241512348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
The development of animal models reflecting the pathologies of ulcerative colitis (UC) and Crohn's disease (CD) remains a major challenge. The NOD/SCID/IL2rγnull (NSG) mouse strain, which is immune-compromised, tolerates the engraftment of human peripheral blood mononuclear cells (PBMC) derived from patients with UC (NSG-UC) or CD (NSG-CD). This offers the opportunity to examine the impact of individual immunological background on the development of pathophysiological manifestations. When challenged with ethanol, NSG-UC mice exhibited a strong pro-inflammatory response, including the development of edemas, influx of human T cells, B cells and monocytes into the mucosa and submucosa, and elevated expression of the inflammatory markers CRP and CCL-7. Fibrotic alterations were characterized by an influx of fibroblasts and a thickening of the muscularis mucosae. In contrast, the development of pathological manifestations in NSG-CD mice developed without challenge and was signified by extensive collagen deposition between the muscularis propria and muscularis mucosae, as observed in the areas of strictures in CD patients. Vimentin-expressing fibroblasts supplanting colonic crypts and elevated expression of HGF and TGFß corroborated the remodeling phenotype. In summary, the NSG-UC and NSG-CD models partially reflect these human diseases and are powerful tools to examine the mechanism underlying the inflammatory processes in UC and CD.
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Affiliation(s)
- Veronika Weß
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
| | - Paula Schuster-Winkelmann
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
| | - Yasemin Hazal Karatekin
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
| | - Simge Malik
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
| | - Florian Beigel
- Department of Medicine II, Hospital of the Ludwig-Maximilian University Munich, Marchioninistr. 15, 81377 München, Germany;
| | - Florian Kühn
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
| | - Roswitha Gropp
- Department of General, Visceral und Transplantation Surgery, Hospital of the Ludwig-Maximilian University Munich, Nussbaumstr. 20, 80336 Munich, Germany; (V.W.); (P.S.-W.); (Y.H.K.); (S.M.); (R.G.)
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Drefs M, Schömer Cuenca S, Wirth U, Kühn F, Burian M, Werner J, Zimmermann P. Predictors of outcome for treatment of enterovaginal fistula : Therapeutical strategies for treatment. Int J Colorectal Dis 2023; 38:187. [PMID: 37420132 PMCID: PMC10329052 DOI: 10.1007/s00384-023-04453-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Enterovaginal fistulas represent a serious complication of various diseases and therapeutic procedures, often associated with complicated clinical courses and massive impairment of quality of life. As underlying conditions and procedures are multifarious, therapeutic approaches are challenging and have to be tailored individually. As the therapeutic management is complex and individualized, multiple surgical interventions might be necessary. METHODS The aim of this study was to identify possible predictors for outcome in the treatment enterovaginal fistula patients. The study was realized as a retrospective analysis. Ninety-two patients treated with enterovaginal fistulas between 2004 and 2016 were analyzed. Patient characteristics, therapeutic data, and endoscopic findings were stratified according to etiology, closure rate and time, as well as recurrence of fistula. Main outcome measure was the overall rate of fistula closure. RESULTS Overall therapeutic success rate was 67.4%. Postoperatively derived fistulas were most frequent (40.2%), mainly after rectal surgery (59.5%). Postoperative and non-IBD-inflammation associated fistulas had better outcome than IBD-, radiotherapy-, and tumor-related fistulas (p = 0.001). Successful fistula closure was observed more frequently after radical surgical interventions, best results observed after transabdominal surgery (p < 0.001). Fistula recurrence was also less frequently observed after radical surgical therapies (p = 0.029). A temporary stoma was associated with higher incidence of fistula closure (p = 0.013) and lower incidence of fistula recurrence (p = 0.042) in the postoperative subgroup, as well as shortened therapy period in all groups (p = 0.031). CONCLUSION Enterovaginal fistulas are a result of various etiologies, and treatment should be adjusted accordingly. A very sustainable, rapid, and persistent therapeutic success can be expected after radical surgical approaches with temporary diverting stoma. This is especially true for postoperatively derived fistulas.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | | | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Maria Burian
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich 81377, Germany.
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Li C, Wirth U, Schardey J, Ehrlich-Treuenstätt VV, Bazhin AV, Werner J, Kühn F. An immune-related gene prognostic index for predicting prognosis in patients with colorectal cancer. Front Immunol 2023; 14:1156488. [PMID: 37483596 PMCID: PMC10358773 DOI: 10.3389/fimmu.2023.1156488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/13/2023] [Indexed: 07/25/2023] Open
Abstract
Background Colorectal cancer (CRC) is one of the most common solid malignant burdens worldwide. Cancer immunology and immunotherapy have become fundamental areas in CRC research and treatment. Currently, the method of generating Immune-Related Gene Prognostic Indices (IRGPIs) has been found to predict patient prognosis as an immune-related prognostic biomarker in a variety of tumors. However, their role in patients with CRC remains mostly unknown. Therefore, we aimed to establish an IRGPI for prognosis evaluation in CRC. Methods RNA-sequencing data and clinical information of CRC patients were retrieved from The Cancer Genome Atlas (TCGA) and The Gene Expression Omnibus (GEO) databases as training and validation sets, respectively. Immune-related gene data was obtained from the ImmPort and InnateDB databases. The weighted gene co-expression network analysis (WGCNA) was used to identify hub immune-related genes. An IRGPI was then constructed using Cox regression methods. Based on the median risk score of IRGPI, patients could be divided into high-risk and low-risk groups. To further investigate the immunologic differences, Gene set variation analysis (GSVA) studies were conducted. In addition, immune cell infiltration and related functional analysis were used to identify the differential immune cell subsets and related functional pathways. Results We identified 49 immune-related genes associated with the prognosis of CRC, 17 of which were selected for an IRGPI. The IRGPI model significantly differentiates the survival rates of CRC patients in the different groups. The IRGPI as an independent prognostic factor significantly correlates with clinico-pathological factors such as age and tumor stage. Furthermore, we developed a nomogram to improve the clinical utility of the IRGPI score. Immuno-correlation analysis in different IRGPI groups revealed distinct immune cell infiltration (CD4+ T cells resting memory) and associated pathways (macrophages, Type I IFNs responses, iDCs.), providing new insights into the tumor microenvironment. At last, drug sensitivity analysis revealed that the high-risk IRGPI group was sensitive to 11 and resistant to 15 drugs. Conclusion Our study established a promising immune-related risk model for predicting survival in CRC patients. This could help to better understand the correlation between immunity and the prognosis of CRC providing a new perspective for personalized treatment of CRC.
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Affiliation(s)
- Chao Li
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Alexandr V. Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
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8
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Lu C, Zhang X, Schardey J, Wirth U, Heinrich K, Massiminio L, Cavestro GM, Neumann J, Bazhin AV, Werner J, Kühn F. Molecular characteristics of microsatellite stable early-onset colorectal cancer as predictors of prognosis and immunotherapeutic response. NPJ Precis Oncol 2023; 7:63. [PMID: 37393364 DOI: 10.1038/s41698-023-00414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/15/2023] [Indexed: 07/03/2023] Open
Abstract
The incidence of early-onset colorectal cancer (EO-CRC, in patients younger than 50) is increasing worldwide. The specific gene signatures in EO-CRC patients are largely unknown. Since EO-CRC with microsatellite instability is frequently associated with Lynch syndrome, we aimed to comprehensively characterize the tumor microenvironment (TME) and gene expression profiles of EO-CRC with microsatellite stable (MSS-EO-CRC). Here, we demonstrated that MSS-EO-CRC has a similar pattern of tumor-infiltrating immune cells, immunotherapeutic responses, consensus molecular subtypes, and prognosis as late-onset CRC with MSS (MSS-LO-CRC). 133 differential expressed genes were identified as unique gene signatures of MSS-EO-CRC. Moreover, we established a risk score, which was positively associated with PD-L1 expression and could reflect both the level of tumor-infiltrating immune cells and the prognosis of MSS-EO-CRC patients. Application of this score on the anti-PD-L1 treatment cohort demonstrated that the low-risk score group has significant therapeutic advantages and clinical benefits. In addition, candidate driver genes were identified in the different-sidedness of MSS-EO-CRC patients. Altogether, MSS-EO-CRC exhibits distinct molecular profiles that differ from MSS-LO-CRC even though they have a similar TME characterization and survival pattern. Our risk score appears to be robust enough to predict prognosis and immunotherapeutic response and therefore could help to optimize the treatment of MSS-EO-CRC.
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Affiliation(s)
- Can Lu
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention (Ministry of Education), The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for CANCER & Cancer Center of Zhejiang University, Hangzhou, China
| | - Xiaopeng Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
- Institute of Laboratory Medicine, University Hospital of LMU Munich, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III, University Hospital, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Luca Massiminio
- Experimental Gastroenterology Laboratory, Gastroenterology and Endoscopy Department, San Raffaele Scientific Institute, Milano, Italy
| | - Giulia Martina Cavestro
- Experimental Gastroenterology Laboratory, Gastroenterology and Endoscopy Department, San Raffaele Scientific Institute, Milano, Italy
| | - Jens Neumann
- Institute of Pathology, Medical Faculty, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany.
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, Munich, Germany.
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9
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Li Q, Weitz J, Li C, Schardey J, Weiss L, Wirth U, Zimmermann P, Bazhin AV, Werner J, Kühn F. Smoking as a risk factor for colorectal neoplasms in young individuals? A systematic meta-analysis. Int J Colorectal Dis 2023; 38:114. [PMID: 37147435 PMCID: PMC10163071 DOI: 10.1007/s00384-023-04405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND AND AIMS Early-onset colorectal neoplasms (EoCRN) include both benign and malign colorectal tumors, which occur before the age of 50. The incidence of EoCRN is rising worldwide. Tobacco smoking has previously been proven to be related to the development of various tumor types. However, its relationship with EoCRN is not clearly defined. Hence, we carried out a systematic review and a meta-analysis to evaluate the relationship between smoking status and the risk of EoCRN. METHODS A systematic search of PubMed, EMBASE, and Web of Science up to September 7, 2022, was performed for studies that evaluated the association of smoking status with EoCRN. The quality of the case-control study was evaluated with the Newcastle‒Ottawa Scale. The quality of the cross-sectional studies was evaluated with the American Health Care Research and Quality checklist. Fixed-effects models were used to pool odds ratios (ORs) to evaluate the relationship between the risk of developing EoCRN and smoking status. The meta-analyses were performed with Review Manager version 5.4, and funnel plots and publication bias tests were produced by STATA software. RESULTS A total of six studies were included in this meta-analysis. After pooling the results of these six studies, we found that current smokers carry a relatively high risk of developing EoCRN (OR, 1.33; 95% confidence interval [CI], 1.17-1.52) compared to never-smokers. Ex-smokers were not at a significantly increased risk for developing EoCRN (OR, 1.00; 95% CI, 0.86-1.18). DISCUSSION Smoking behavior is significantly associated with an increased risk for developing EoCRN and might be one of the reasons for the increasing incidence. Ex-smokers who quit are not at significant risk of developing EoCRN.
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Affiliation(s)
- Qiang Li
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Jutta Weitz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Chao Li
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Lena Weiss
- Department of Medicine III, University Hospital, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, 81377, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany.
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, 81377, Munich, Germany.
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10
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Li Q, von Ehrlich-Treuenstätt V, Schardey J, Wirth U, Zimmermann P, Andrassy J, Bazhin AV, Werner J, Kühn F. Gut Barrier Dysfunction and Bacterial Lipopolysaccharides in Colorectal Cancer. J Gastrointest Surg 2023:10.1007/s11605-023-05654-4. [PMID: 36973501 PMCID: PMC10366024 DOI: 10.1007/s11605-023-05654-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/24/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Inflammation is known to be an essential driver of various types of cancer. An increasing number of studies have suggested that the occurrence and development of colorectal cancer (CRC) are linked to the inflammatory microenvironment of the intestine. This assumption is further supported by the fact that patients with inflammatory bowel disease (IBD) are more likely to develop CRC. Multiple studies in mice and humans have shown that preoperative systemic inflammatory response is predictive of cancer recurrence after potentially curative resection. Lipopolysaccharides (LPS) are membrane surface markers of gram-negative bacteria, which induce gut barrier dysfunction and inflammation and might be significantly involved in the occurrence and development of CRC. METHODS A selective literature search was conducted in Medline and PubMed, using the terms "Colorectal Cancer", "Gut Barrier", "Lipopolysaccharides", and "Inflammation". RESULTS Disruption of intestinal homeostasis, including gut barrier dysfunction, is linked to increased LPS levels and is a critical factor for chronic inflammation. LPS can activate the diverse nuclear factor-κB (NF-κB) pathway via Toll-like receptors 4 (TLR4) to promote the inflammatory response, which aggravates gut barrier dysfunction and encourages CRC development. An intact gut barrier prevents antigens and bacteria from crossing the intestinal endothelial layer and entering circulation. In contrast, a damaged gut barrier triggers inflammatory responses and increases susceptibility to CRC. Thus, targeting LPS and the gut barrier might be a promising novel therapeutic approach for additional treatment of CRC. CONCLUSION Gut barrier dysfuction and bacterial LPS seem to play an important role in the pathogenesis and disease progression of colorectal cancer and therefore require further investigation.
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Affiliation(s)
- Qiang Li
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Viktor von Ehrlich-Treuenstätt
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, 81377, Munich, Germany.
- Bavarian Cancer Research Center (BZKF), Partner Site Munich, 81377, Munich, Germany.
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11
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Cavestro GM, Mannucci A, Balaguer F, Hampel H, Kupfer SS, Repici A, Sartore-Bianchi A, Seppälä TT, Valentini V, Boland CR, Brand RE, Buffart TE, Burke CA, Caccialanza R, Cannizzaro R, Cascinu S, Cercek A, Crosbie EJ, Danese S, Dekker E, Daca-Alvarez M, Deni F, Dominguez-Valentin M, Eng C, Goel A, Guillem JG, Houwen BBSL, Kahi C, Kalady MF, Kastrinos F, Kühn F, Laghi L, Latchford A, Liska D, Lynch P, Malesci A, Mauri G, Meldolesi E, Møller P, Monahan KJ, Möslein G, Murphy CC, Nass K, Ng K, Oliani C, Papaleo E, Patel SG, Puzzono M, Remo A, Ricciardiello L, Ripamonti CI, Siena S, Singh SK, Stadler ZK, Stanich PP, Syngal S, Turi S, Urso ED, Valle L, Vanni VS, Vilar E, Vitellaro M, You YQN, Yurgelun MB, Zuppardo RA, Stoffel EM. Delphi Initiative for Early-Onset Colorectal Cancer (DIRECt) International Management Guidelines. Clin Gastroenterol Hepatol 2023; 21:581-603.e33. [PMID: 36549470 DOI: 10.1016/j.cgh.2022.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Patients with early-onset colorectal cancer (eoCRC) are managed according to guidelines that are not age-specific. A multidisciplinary international group (DIRECt), composed of 69 experts, was convened to develop the first evidence-based consensus recommendations for eoCRC. METHODS After reviewing the published literature, a Delphi methodology was used to draft and respond to clinically relevant questions. Each statement underwent 3 rounds of voting and reached a consensus level of agreement of ≥80%. RESULTS The DIRECt group produced 31 statements in 7 areas of interest: diagnosis, risk factors, genetics, pathology-oncology, endoscopy, therapy, and supportive care. There was strong consensus that all individuals younger than 50 should undergo CRC risk stratification and prompt symptom assessment. All newly diagnosed eoCRC patients should receive germline genetic testing, ideally before surgery. On the basis of current evidence, endoscopic, surgical, and oncologic treatment of eoCRC should not differ from later-onset CRC, except for individuals with pathogenic or likely pathogenic germline variants. The evidence on chemotherapy is not sufficient to recommend changes to established therapeutic protocols. Fertility preservation and sexual health are important to address in eoCRC survivors. The DIRECt group highlighted areas with knowledge gaps that should be prioritized in future research efforts, including age at first screening for the general population, use of fecal immunochemical tests, chemotherapy, endoscopic therapy, and post-treatment surveillance for eoCRC patients. CONCLUSIONS The DIRECt group produced the first consensus recommendations on eoCRC. All statements should be considered together with the accompanying comments and literature reviews. We highlighted areas where research should be prioritized. These guidelines represent a useful tool for clinicians caring for patients with eoCRC.
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Affiliation(s)
- Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Mannucci
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesc Balaguer
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Spain
| | - Heather Hampel
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, California
| | - Sonia S Kupfer
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, Illinois
| | - Alessandro Repici
- Gastrointestinal Endoscopy Unit, Humanitas University, Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Sartore-Bianchi
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Toni T Seppälä
- Faculty of Medicine and Medical Technology, University of Tampere and TAYS Cancer Centre, Arvo Ylpön katu, Tampere, Finland; Unit of Gastroenterological Surgery, Tampere University Hospital, Elämänaukio, Tampere, Finland; Applied Tumor Genomics Research Program and Department of Surgery, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Vincenzo Valentini
- Department of Radiology, Radiation Oncology and Hematology, Università Cattolica del Sacro Cuore di Roma, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Clement Richard Boland
- Department of Medicine, Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Randall E Brand
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tineke E Buffart
- Department of Medical Oncology. Amsterdam UMC, Location de Boelelaan, Amsterdam, The Netherlands
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Renato Cannizzaro
- SOC Gastroenterologia Oncologica e Sperimentale Centro di Riferimento Oncologico di Aviano (CRO) IRCCS 33081, Aviano, Italy
| | - Stefano Cascinu
- Oncology Department, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, United Kingdom; Division of Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Maria Daca-Alvarez
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Deni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mev Dominguez-Valentin
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
| | - Cathy Eng
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Ajay Goel
- Department of Molecular Diagnostics & Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, California
| | - Josè G Guillem
- Department of Surgery and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Britt B S L Houwen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew F Kalady
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Luigi Laghi
- Department of Medicine and Surgery, University of Parma, Parma, and Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrew Latchford
- Lynch Syndrome Clinic, Centre for Familial Intestinal Cancer, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, United Kingdom
| | - David Liska
- Department of Colorectal Surgery and Edward J. DeBartolo Jr Family Center for Young-Onset Colorectal Cancer, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Lynch
- Department of Gastroenterology, M. D. Anderson Cancer Center, Houston, Texas
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Mauri
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy; IFOM ETS - The AIRC Institute of Molecular Oncology, Milan, Italy
| | - Elisa Meldolesi
- Department of Radiology, Radiation Oncology and Hematology, Università Cattolica del Sacro Cuore di Roma, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Pål Møller
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, Oslo, Norway
| | - Kevin J Monahan
- Lynch Syndrome Clinic, Centre for Familial Intestinal Cancer, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, United Kingdom; Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, United Kingdom
| | - Gabriela Möslein
- Surgical Center for Hereditary Tumors, Ev. BETHESDA Khs. Duisburg, Academic Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Caitlin C Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Karlijn Nass
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Kimmie Ng
- Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Cristina Oliani
- Medical Oncology, AULSS 5 Polesana, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Enrico Papaleo
- Centro Scienze della Natalità, Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Swati G Patel
- University of Colorado Anschutz Medical Center and Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Marta Puzzono
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Remo
- Pathology Unit, Mater Salutis Hospital, ULSS9, Legnago, Verona, Italy
| | - Luigi Ricciardiello
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Italy
| | - Carla Ida Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Salvatore Siena
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, and Department of Hematology Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Satish K Singh
- Department of Medicine, Section of Gastroenterology, VA Boston Healthcare System and Boston University, Boston, Massachusetts
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sapna Syngal
- Brigham and Women's Hospital, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuele Damiano Urso
- Chirurgia Generale 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University Hospital of Padova, Padova, Italy
| | - Laura Valle
- Hereditary Cancer Program, Catalan Institute of Oncology, Oncobell Program, Bellvitge Biomedical Research Center (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain; Centro de Investigación Biomédica en Red en Cáncer (CIBERONC), Madrid, Spain
| | - Valeria Stella Vanni
- Centro Scienze della Natalità, Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marco Vitellaro
- Unit of Hereditary Digestive Tract Tumours, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Yi-Qian Nancy You
- Department of Colon & Rectal Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew B Yurgelun
- Brigham and Women's Hospital, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Raffaella Alessia Zuppardo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena M Stoffel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine and Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan
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Knoblauch M, Kühn F, von Ehrlich-Treuenstätt V, Werner J, Renz BW. Diagnostic and Therapeutic Management of Early Colorectal Cancer. Visc Med 2023; 39:10-16. [PMID: 37265550 PMCID: PMC10230821 DOI: 10.1159/000526633] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/17/2022] [Indexed: 03/03/2024] Open
Abstract
Background Early colorectal cancer (eCRC) is defined as cancer that does not cross the submucosal layer of the colon or rectum, including carcinoma in situ (pTis), pT1a, and pT1b. Early carcinomas differ in their prognosis depending on the risk profile. The differentiation between low and high risk is essential. The low-risk group includes R0-resected, well (G1) or moderately (G2) differentiated tumors without lymphatic vessel invasion (L0), without blood vessel invasion (V0) and a tumor size ≤3 cm. In this constellation, the estimated risk of lymph node metastasis is around 1% or below. The high-risk group includes tumors with incomplete resection (Rx), poor (G3) or undifferentiated (G4) carcinomas, and/or lymphatic and blood vessel invasion (L1) and size ≥3 cm. In a "high-risk" situation, there is a risk for lymph node metastasis of up to 23%. Summary The incidence of eCRC is rising with a rate of 10% in all endoscopically removed lesions during colonoscopy. For a correct histological evaluation, all suspected lesions should be completely resected. In case of a pT1 lesion in the rectum, pelvic magnetic resonance imaging should be performed to evaluate for suspicious lymph nodes. The therapeutic approach for eCRC is based on histological assessment and ranges from endoscopic resection to radical oncological surgery. The advantages, disadvantages, and associated risks of the individual treatment strategy need to be carefully discussed on a tumor board and with the patient. Key Messages Treatment options for early colorectal cancer depend on the histological assessment. Poorly differentiated carcinomas, a Kudo ≥ SM2 classified lesion, and a Haggitt level 4 always represent a "high-risk" situation. It should also be mentioned that in rectal cancer, local surgical tumor excision (full-wall excision) is also sufficient for pT1 carcinomas with a "low-risk" constellation (G1/G2; L0, size <3 cm) and an R0 resection.
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An L, Wirth U, Koch D, Schirren M, Drefs M, Koliogiannis D, Niess H, Andrassy J, Guba M, Bazhin AV, Werner J, Kühn F. Metabolic Role of Autophagy in the Pathogenesis and Development of NAFLD. Metabolites 2023; 13:metabo13010101. [PMID: 36677026 PMCID: PMC9864958 DOI: 10.3390/metabo13010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 12/31/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a spectrum of liver disease, ranging from simple steatosis to hepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Liver fibrosis, which portends a poor prognosis in NAFLD, is characterized by the excessive accumulation of extracellular matrix (ECM) proteins resulting from abnormal wound repair response and metabolic disorders. Various metabolic factors play crucial roles in the progression of NAFLD, including abnormal lipid, bile acid, and endotoxin metabolism, leading to chronic inflammation and hepatic stellate cell (HSC) activation. Autophagy is a conserved process within cells that removes unnecessary or dysfunctional components through a lysosome-dependent regulated mechanism. Accumulating evidence has shown the importance of autophagy in NAFLD and its close relation to NAFLD progression. Thus, regulation of autophagy appears to be beneficial in treating NAFLD and could become an important therapeutic target.
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14
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Schardey J, Huber T, Kappenberger AS, Horné F, Beger N, Weniger M, Werner J, Kühn F, Wirth U. [Expected effects of the new continuing education regulations in general and visceral surgery : Survey among Bavarian surgeons and residents]. Chirurgie (Heidelb) 2023; 94:155-163. [PMID: 36260140 PMCID: PMC9898356 DOI: 10.1007/s00104-022-01738-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The new competency-based continuing education regulations for surgical training (WBO) came into effect in Bavaria in August 2022. METHODS From May to July 2022, we conducted an anonymized online survey among Bavarian general and visceral surgeons and surgical residents (ÄiW). The aim was to survey expectations of the effects of the new WBO. RESULTS The response rate was 35%. In total data could be collected from 80 persons, 36 ÄiW (45%), 30 specialists and senior physicians (37.5%) and 14 chief physicians (17.5%). The majority of respondents worked at a university hospital (38.8%) or a regular provider (35%). A strengthening of the competence to act through implementation of the new WBO is seen by 41.3% and 55.7% see independent operating under partial supervision by the instructor as a goal. Of the respondents 50% see the required case numbers as not achievable and 55.1% deny reaching them in the expected period of 6 years. About 60% do not expect to be able to train the same number of ÄiWs in the same amount of time. Almost 75% of the respondents state that from their point of view, a good continuing education with the achievement of a solid competence to act would not work without overtime hours. About 44% of the respondents expect that a full surgical training would continue to be possible at their institution. CONCLUSION Both among the instructors and among the trainees there is a tendency to fear that realistic training, in particular the achievement of the guideline figures, will no longer be possible in the usual further training time. This necessitates the consistent implementation of structured continuing education with a high degree of transparency in training.
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Affiliation(s)
- Josefine Schardey
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland ,Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - Tobias Huber
- Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland ,Abteilung für Allgemein‑, Viszeral- und Transplantationschirurige, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Alina Sophie Kappenberger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland
| | - Fabian Horné
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland ,Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - Nicola Beger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland ,Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - Maximilian Weniger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland ,Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - Jens Werner
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland
| | - Florian Kühn
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland ,Chirurgische Arbeitsgemeinschaft Junge Chirurgen (CAJC), Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - Ulrich Wirth
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurige, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377 Munich, Deutschland
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Kühn F, Schulz C, Weimann A, Scheiermann P, Seyfried S, Reissfelder C. Interdisciplinary Discussion on Postoperative Management in Visceral Medicine. Visc Med 2022; 38:363-366. [PMID: 37970581 PMCID: PMC10642535 DOI: 10.1159/000526392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2023] Open
Affiliation(s)
- Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Christian Schulz
- Medical Department II, University Hospital, LMU, Munich, Germany
- DZIF Deutsches Zentrum für Infektionsforschung, Partner Site Munich, München, Germany
| | - Arved Weimann
- Department for General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| | - Patrick Scheiermann
- Department of Anesthesiology, LMU University Hospital, Campus Großhadern, Munich, Germany
| | - Steffen Seyfried
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Drefs M, Schardey J, von Ehrlich-Treuenstätt V, Wirth U, Burian M, Zimmermann P, Werner J, Kühn F. Endoscopic Treatment Options for Gastrointestinal Leaks. Visc Med 2022; 38:311-321. [PMID: 37970585 PMCID: PMC10642546 DOI: 10.1159/000526759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients. Methods We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
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Deniz S, Öcal O, Kühn F, Angele MK, Werner J, Streitparth F. Interventional Radiology Options after Visceral Surgery. Visc Med 2022; 38:334-344. [PMID: 37970584 PMCID: PMC10642547 DOI: 10.1159/000526772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2023] Open
Abstract
Background Postoperative management of patients undergoing visceral surgery can present challenging clinical situations with significant morbidity and mortality. Interventional radiological techniques offer quick, safe, and effective minimally invasive treatment options in the postoperative management of visceral surgery. Summary Most commonly done procedures include - but are not limited to - fluid or abscess drainage, biliary diversion, bleeding embolization, and re-canalization of a thrombosed vessel. While bleeding from side branches after hepatobiliary and pancreatic surgeries can be managed by coil embolization, the hepatic arterial injury should be managed by stent-graft placement. Hepatic venous complications can require a transhepatic or transjugular approach, whereas the transjugular intrahepatic portosystemic shunt approach has a higher clinical success rate in patients with portal vein thrombosis. Biliary leakages require multidisciplinary management, and interventional radiology can offer an efficient treatment, especially in patients with biliodigestive anastomosis. Key Messages Interventional radiology provides a broad spectrum of procedures in the management of patients with recent visceral surgery.
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Affiliation(s)
- Sinan Deniz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Osman Öcal
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Florian Kühn
- Department General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Martin Kurt Angele
- Department General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jens Werner
- Department General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
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Kühn F, Schulz C. Postoperative Management in Visceral Medicine. Visc Med 2022; 38:309-310. [PMID: 37970580 PMCID: PMC10642541 DOI: 10.1159/000526587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2023] Open
Affiliation(s)
- Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
| | - Christian Schulz
- Medical Department II, University Hospital, LMU, Munich, Germany
- DZIF Deutsches Zentrum für Infektionsforschung, Partner Site Munich, München, Germany
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Schardey J, von Ahnen T, Schardey E, Kappenberger A, Zimmermann P, Kühn F, Andrassy J, Werner J, Arbogast H, Wirth U. Antibiotic Bowel Decontamination in Gastrointestinal Surgery—A Single-Center 20 Years’ Experience. Front Surg 2022; 9:874223. [PMID: 35651691 PMCID: PMC9150795 DOI: 10.3389/fsurg.2022.874223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery. Methods Based on 20 years’ experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications. Results A total of n = 477 cases of gastrointestinal surgery in gastric cancer (n = 80), sigmoid cancer (n = 168), and rectal cancer (n = 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed. Conclusion Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.
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Affiliation(s)
- Josefine Schardey
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Thomas von Ahnen
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
| | - Emily Schardey
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Alina Kappenberger
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Helmut Arbogast
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Correspondence: Ulrich Wirth
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20
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Kühn F, Hasenhütl SM, Hofmann FO, Wirth U, Drefs M, Werner J, Schiergens TS. Endoscopic Vacuum Therapy for Left-Sided Colorectal Anastomotic Leak Without Fecal Diversion. Dis Colon Rectum 2022; 65:421-428. [PMID: 34775405 DOI: 10.1097/dcr.0000000000001959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy for the treatment of rectal anastomotic leak has been shown to be effective and safe. The majority of patients are treated after fecal diversion to avoid further septic complications. OBJECTIVE To report the effectiveness of endoscopic vacuum therapy for rectal anastomotic leak without diversion compared to secondary stoma creation. DESIGN Retrospective cohort analysis. SETTINGS University hospital, single-center. PATIENTS Patients undergoing sigmoid or rectal resection without fecal diversion during primary surgery who were treated with endoscopic vacuum therapy for clinically relevant anastomotic leak. MAIN OUTCOME MEASURES Treatment success (sepsis control, granulation and closure of the leak cavity, and no subsequent interventional or surgical procedure required); treatment duration; complications associated with endoscopic vacuum therapy; outpatient treatment; and restoration of intestinal continuity in diverted patients. RESULTS Fifty-seven patients were included. In 20 patients (35%), endoscopic vacuum therapy was initiated without secondary diversion since the leak was extraperitoneal, and the sponge could be placed into the leak cavity with an adequate seal toward the lumen. In 18 patients (90%), this approach was successful. None of these patients required subsequent diversion in the further course of their disease. In two patients, secondary diversion was necessary due to treatment failure. Balloon dilatation for luminal stenosis was required in two patients. When comparing patient and treatment characteristics of patients with and without a stoma, including treatment success and duration, no significant differences were found. Restoration of intestinal continuity was achieved in 69% of diverted patients. LIMITATIONS Unrandomized, retrospective study design; confounding factors of treatment assignment; low patient numbers and short follow-up of diverted patients; and low statistical power. CONCLUSION In this single-institution study, endoscopic vacuum therapy for rectal anastomotic leak was successful in 90% of patients without diversion with regard to sepsis control, granulation of the leak cavity, avoidance of surgery, and long-term stoma-free survival. See Video Abstract at http://links.lww.com/DCR/B737.TERAPIA ENDOSCÓPICA POR ASPIRACIÓN AL VACÍO EN CASOS DE FUGA ANASTOMÓTICA RECTO-CÓLICA IZQUIERDA SIN OSTOMÍA DE PROTECCIÓNANTECEDENTES:Se ha demostrado que la terapia endoscópica por aspiración al vacío en casos de fuga anastomótica recto-cólica izquierda en el tratamiento de la fuga anastomótica rectal es eficaz y segura. La mayoría de los casos beneficiaron del tratamiento después de la confeción de un ostomía de protección para evitar más complicaciones sépticas.OBJETIVO:Demostrar la efectividad de la terapia endoscópica por aspiración al vacío en casos de fuga anastomótica recto-cólica izquierda sin ostomía de protección comparada con los casos que tuvieron la creación de una ostomía secundaria.DISEÑO:Análisis de cohortes de tipo retrospectivo.AJUSTE:Hospital universitario, unicéntrico.PACIENTES:Aquellos pacientes sometidos a una resección sigmoidea o rectal sin ostomía de protección durante una cirugía primaria, y que fueron tratados con terapia endoscópica por aspiración al vacío en caso de fuga anastomótica clínicamente relevante.PRINCIPALES MEDIDAS DE RESULTADO:Tratamiento exitoso (control de la sepsis, granulación y cierre de la cavidad de la fuga, sin requerir procedimiento quirúrgico o intervención ulteterior); duración del tratamiento; complicaciones asociadas con la terapia endoscópica por aspiración al vacío; tratamiento ambulatorio; restablecimiento de la continuidad intestinal en los pacientes portadores de ostomía.RESULTADOS:Se incluyeron 57 pacientes. En 20 pacientes (35%), se inició la terapia endoscópica por aspiración al vacío sin derivación secundaria, ya que la fuga era extraperitoneal y la esponja podía colocarse en la cavidad de la fuga con un sellado adecuado hacia el lumen. En 18 pacientes (90%), este enfoque fue exitoso. Ninguno de estos pacientes requirió una derivación posterior durante la evolución de la enfermedad. En dos pacientes, fue necesaria una derivación secundaria debido al fracaso del tratamiento. Se requirió dilatación con balón por estenosis luminal en dos pacientes. Al comparar las características de los pacientes y del tratamiento con y sin ostomía, incluido el éxito y la duración del tratamiento, no se encontraron diferencias significativas. El restablecimiento de la continuidad intestinal se logró en el 69% de los pacientes derivados.LIMITACIONES:Diseño de estudio retrospectivo no aleatorio; factores de confusión en la asignación del tratamiento; escaso número de pacientes y seguimiento a corto plazo de los pacientes ostomizados; bajo poder estadístico.CONCLUSIÓN:En este estudio de una sola institución, la terapia al vacío por vía endoscópica en casos de fuga anastomótica rectal fue exitosa en el 90% de los pacientes sin derivación con respecto al control de la sepsis, granulación de la cavidad de la fuga, como se evitó la cirugía y la sobrevida sin ostomía a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B737. (Traducción-Dr. Xavier Delgadillo).
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
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Schardey J, Zehl S, Kappenberger AS, Zimmermann P, Beigel F, Schiergens TS, Kasparek MS, Kühn F, Werner J, Wirth U. It is not NOD2 - genetic and clinical risk factors for postoperative complications following ileocolic resection in Crohn's disease. Int J Colorectal Dis 2022; 37:1901-1908. [PMID: 35913516 PMCID: PMC9388399 DOI: 10.1007/s00384-022-04223-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the role of the nucleotide oligomerization domain 2 (NOD2) mutation status and other risk factors for the incidence of postoperative complications after ileocolic resection for Crohn's disease (CD). METHODS Data of 138 patients consecutively undergoing ileocolic resection for CD at a tertiary academic referral center were retrospectively analyzed including single nucleotide polymorphism (SNP) data of the NOD2 gene. Uni- and multivariate regression analysis was performed to identify factors associated with increased risk of severe postoperative complications. RESULTS From 114 patients (83%), the NOD2 mutation status was available. Of these, 60 (53%) had a NOD2 wildtype, whereas eleven (10%) were homozygous for the high risk p.Leu1007fsX1008 (rs2066847) variant. Major postoperative complications occurred in 28 patients (20%). Twenty-seven of these (96%) were intraabdominal septic complications such as anastomotic leakage or abscess. Male gender (P = 0.029; OR 3.052, the duration of CD (time [months] from initial diagnosis of CD to surgery; P = 0.001; OR 1.009), previous abdominal surgery for CD (P = 0.017; OR 3.49), and the presence of enteric fistulas (P = 0.023; OR 3.21) were identified as independent risk factors for major postoperative complications. Homozygosity for the NOD2 high-risk variant p.Leu1007fsX1008 did not show increased postoperative morbidity in the short and long-term outcome. CONCLUSIONS We could detect independent risk factors for major postoperative complications after ileocolic resection for Crohn's disease. However, patients with the high-risk variant p.Leu1007fsX1008 of the NOD2 gene did not show increased postoperative morbidity.
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Affiliation(s)
- Josefine Schardey
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sophie Zehl
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Alina S. Kappenberger
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Petra Zimmermann
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Florian Beigel
- grid.5252.00000 0004 1936 973XDepartment of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Tobias S. Schiergens
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael S. Kasparek
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany ,Department of Visceral Surgery, Josephinum, Munich, Germany
| | - Florian Kühn
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Werner
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ulrich Wirth
- grid.5252.00000 0004 1936 973XDepartment of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 Munich, Germany
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22
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Abstract
Let
X
=
(
X
t
)
t
≥
0
X=(X_t)_{t\geq 0}
be a one-dimensional Lévy process such that each
X
t
X_t
has a
C
b
1
C^1_b
-density w. r. t. Lebesgue measure and certain polynomial or exponential moments. We characterize all polynomially bounded functions
f
:
R
→
R
f\colon \mathbb {R}\to \mathbb {R}
, and exponentially bounded functions
g
:
R
→
(
0
,
∞
)
g\colon \mathbb {R}\to (0,\infty )
, such that
f
(
X
t
)
−
E
f
(
X
t
)
f(X_t)-\mathbb {E} f(X_t)
, resp.
g
(
X
t
)
/
E
g
(
X
t
)
g(X_t)/\mathbb {E} g(X_t)
, are martingales.
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23
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Kühn F, Beger N, Solyanik O, Wirth U, Schardey J, Zimmermann P, Karcz KW, Andrassy J, Angele M, Werner J. [Diverticular disease: Indications for surgery]. MMW Fortschr Med 2021; 163:44-47. [PMID: 34767223 DOI: 10.1007/s15006-021-0407-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Florian Kühn
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany.
| | - Nicola Beger
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Olga Solyanik
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, München, Germany
| | - Ulrich Wirth
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Josefine Schardey
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Petra Zimmermann
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Konrad W Karcz
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Joachim Andrassy
- Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Martin Angele
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Campus Großhader, München, Germany
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
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24
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Kühn F, Duan R, Ilmer M, Wirth U, Adiliaghdam F, Schiergens TS, Andrassy J, Bazhin AV, Werner J. Targeting the Intestinal Barrier to Prevent Gut-Derived Inflammation and Disease: A Role for Intestinal Alkaline Phosphatase. Visc Med 2021; 37:383-393. [PMID: 34722721 DOI: 10.1159/000515910] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/16/2021] [Indexed: 02/02/2023] Open
Abstract
Background Intestinal alkaline phosphatase (IAP) as a tissue-specific isozyme of alkaline phosphatases is predominantly produced by enterocytes in the proximal small intestine. In recent years, an increasing number of pathologies have been identified to be associated with an IAP deficiency, making it very worthwhile to review the various roles, biological functions, and potential therapeutic aspects of IAP. Summary IAP primarily originates and acts in the intestinal tract but affects other organs through specific biological axes related to its fundamental roles such as promoting gut barrier function, dephosphorylation/detoxification of lipopolysaccharides (LPS), and regulation of gut microbiota. Key Messages Numerous studies reporting on the different roles and the potential therapeutic value of IAP across species have been published during the last decade. While IAP deficiency is linked to varying degrees of physiological dysfunctions across multiple organ systems, the supplementation of IAP has been proven to be beneficial in several translational and clinical studies. The increasing evidence of the salutary functions of IAP underlines the significance of the naturally occurring brush border enzyme.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Ruifeng Duan
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Matthias Ilmer
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Fatemeh Adiliaghdam
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tobias S Schiergens
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital of LMU Munich, Munich, Germany
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25
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Heiliger C, Piecuch J, Frank A, Andrade D, von Ehrlich-Treuenstätt V, Evtimova D, Kühn F, Werner J, Karcz K. Laparoscopic intraarterial catheterization with selective ICG fluorescence imaging in colorectal surgery. Sci Rep 2021; 11:14753. [PMID: 34285284 PMCID: PMC8292501 DOI: 10.1038/s41598-021-94244-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
The quality of mesorectal resection is crucial for resection in rectal cancer, which should be performed by laparoscopy for better outcome. The use of indocyanine green (ICG) fluorescence is now routinely used in some centers to evaluate bowel perfusion. Previous studies have demonstrated in animal models that selective intra-arterial ICG staining can be used to define and visualize resection margins in rectal cancer. In this animal study, we investigate if laparoscopic intra-arterial catheterization is feasible and the staining of resection margins when performing total mesorectal excision with a laparoscopic medial to lateral approach is possible. In 4 pigs, laparoscopic catheterization of the inferior mesenteric artery (IMA) is performed using a seldinger technique. After a bolus injection of 10 ml ICG with a concentration of 0.25 mg/ml, a continuous intra-arterial perfusion was established at a rate of 2 ml/min. The quality of the staining was evaluated qualitatively. Laparoscopic catheterization was possible in all cases, and the average time for this was 30.25 ± 3.54 min. We observed a significant fluorescent signal in all areas of the IMA supplied, but not in other parts of the abdominal cavity or organs. In addition, the mesorectum showed a sharp border between stained and unstained tissue. Intraoperative isolated fluorescence augmentation of the rectum, including the mesorectum by laparoscopic catheterization, is feasible. Inferior mesenteric artery catheterization and ICG perfusion can provide a fluorescence-guided roadmap to identify the correct plane in total mesorectal excision, which should be investigated in further studies.
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Affiliation(s)
- Christian Heiliger
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany.
| | - Jerzy Piecuch
- Klinika Chirurgii Ogolnej, Metabolicznej i Medycyny Ratunkowej w Zabrzu, Slaski Universytet Medyczny w Katowicach, Katowicach, Poland
| | - Alexander Frank
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Viktor von Ehrlich-Treuenstätt
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Dobromira Evtimova
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
| | - Konrad Karcz
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Marchioninistrasse 15, 81377, Munich, Germany
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26
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Wirth U, Schardey J, von Ahnen T, Zimmermann P, Kühn F, Werner J, Schardey HM, Rau BM, Gumpp J. Oral antibiotic bowel decontamination in open and laparoscopic sigmoid resections for diverticular disease. Int J Colorectal Dis 2021; 36:1667-1676. [PMID: 33606074 PMCID: PMC8279973 DOI: 10.1007/s00384-021-03890-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE There is an ongoing debate on whether or not to use oral antibiotic bowel decontamination in colorectal surgery, despite the numerous different regimens in terms of antibiotic substances and duration of application. As we routinely use oral antibiotic bowel decontamination (selective decontamination of the digestive tract (SDD) regimen and SDD regimen plus vancomycin since 2016) in surgery for diverticular disease, our aim was to retrospectively analyze the perioperative outcome in two independent centers. METHODS Data from two centers with a routine use of oral antibiotic bowel decontamination for up to 20 years of experience were analyzed for the perioperative outcome of 384 patients undergoing surgery for diverticular disease. RESULTS Overall morbidity was 12.8%, overall mortality was 0.3%, the overall rate of anastomotic leakage (AL) was 1.0%, and surgical site infections (SSIs) were 5.5% and 7.8% of all infectious complications including urinary tract infections and pneumonia. No serious adverse events were related to use of oral antibiotic bowel decontamination. Most of the patients (93.8%) completed the perioperative regimen. Additional use of vancomycin to the SDD regimen did not show a further reduction of infectious complications, including SSI and AL. CONCLUSION Oral antibiotic decontamination appears to be safe and effective with low rates of AL and infectious complications in surgery for diverticular disease.
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Affiliation(s)
- Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University of Munich, Marchioninistr. 15, D-81377 Munich, Germany
| | - Josefine Schardey
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University of Munich, Marchioninistr. 15, D-81377 Munich, Germany
| | - Thomas von Ahnen
- Department of General, Visceral, Vascular and Endocrine Surgery, Agatharied Hospital, Hausham, Germany
| | - Petra Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University of Munich, Marchioninistr. 15, D-81377 Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University of Munich, Marchioninistr. 15, D-81377 Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University of Munich, Marchioninistr. 15, D-81377 Munich, Germany
| | - Hans Martin Schardey
- Department of General, Visceral, Vascular and Endocrine Surgery, Agatharied Hospital, Hausham, Germany
| | - Bettina M. Rau
- Department of Surgery, Kliniken des Landkreises Neumarkt, Neumarkt, Germany
| | - Julia Gumpp
- Department of Surgery, Kliniken des Landkreises Neumarkt, Neumarkt, Germany
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27
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Liu Y, Cavallaro PM, Kim BM, Liu T, Wang H, Kühn F, Adiliaghdam F, Liu E, Vasan R, Samarbafzadeh E, Farber MZ, Li J, Xu M, Mohad V, Choi M, Hodin RA. A role for intestinal alkaline phosphatase in preventing liver fibrosis. Am J Cancer Res 2021; 11:14-26. [PMID: 33391458 PMCID: PMC7681079 DOI: 10.7150/thno.48468] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Rationale: Liver fibrosis is frequently associated with gut barrier dysfunction, and the lipopolysaccharides (LPS) -TLR4 pathway is common to the development of both. Intestinal alkaline phosphatase (IAP) has the ability to detoxify LPS, as well as maintain intestinal tight junction proteins and gut barrier integrity. Therefore, we hypothesized that IAP may function as a novel therapy to prevent liver fibrosis. Methods: Stool IAP activity from cirrhotic patients were determined. Common bile duct ligation (CBDL) and Carbon Tetrachloride-4 (CCl4)-induced liver fibrosis models were used in WT, IAP knockout (KO), and TLR4 KO mice supplemented with or without exogenous IAP in their drinking water. The gut barrier function and liver fibrosis markers were tested. Results: Human stool IAP activity was decreased in the setting of liver cirrhosis. In mice, IAP activity and genes expression decreased after CBDL and CCl4 exposure. Intestinal tight junction related genes and gut barrier function were impaired in both models of liver fibrosis. Oral IAP supplementation attenuated the decrease in small intestine tight junction protein gene expression and gut barrier function. Liver fibrosis markers were significantly higher in IAP KO compared to WT mice in both models, while oral IAP rescued liver fibrosis in both WT and IAP KO mice. In contrast, IAP supplementation did not attenuate fibrosis in TLR4 KO mice in either model. Conclusions: Endogenous IAP is decreased during liver fibrosis, perhaps contributing to the gut barrier dysfunction and worsening fibrosis. Oral IAP protects the gut barrier and further prevents the development of liver fibrosis via a TLR4-mediated mechanism.
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28
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Lin S, Kühn F, Schiergens TS, Zamyatnin AA, Isayev O, Gasimov E, Werner J, Li Y, Bazhin AV. Experimental postoperative ileus: is Th2 immune response involved? Int J Med Sci 2021; 18:3014-3025. [PMID: 34220330 PMCID: PMC8241774 DOI: 10.7150/ijms.59354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022] Open
Abstract
Rationale: Postoperative ileus (POI) is a frequent complication arising after gastrointestinal surgery but pathogenesis of POI is still not fully understood. While Th1 immune cells are implicated in POI, the involvement of Th2 cells has not yet been clarified. Given the impact of reactive oxygen species (ROS) in the regulation of Th1 and Th2 balance, we hypothesized that not only Th1 but also Th2 immune response can be involved in the development of experimental POI. Methods: The intestinal transit test was performed using carbon gum arabic. Electron microscopy was employed to assess tissue morphology and the presence of immune cells. Cytokines, IgE and ROS were measured. Immune cells from Peyer's patches were analyzed by Flow Cytometry and toluidine blue staining was used for detection of mast cells. Transcriptional factors were analyzed by Western blot. Results: POI is associated with an increase in both Th2 cytokines and Th2 cells. We have further demonstrated that POI induces a Th2-dependent activation of memory and non-memory B cells. This was accompanied by an increase in a number of mast cells in the colon of POI mice as well by an increased IgE and histamine plasma levels. We found that POI-induced accumulation of ROS was associated with an increased expression of the transcriptional factors HMBGI, NF-κB, and p38. This increased expression seemed to be associated with a Th2 response. Conclusion: Th2 immune response can be involved in the activation of mast cells in POI, which was associated with ROS mediated activation of NF-κB and p38 MAPK signaling pathway.
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Affiliation(s)
- Sisi Lin
- Department of Pathophysiology, Institute of Digestive Disease, Tongji University School of Medicine, 200092, Shanghai, China.,Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany
| | - Andrey A Zamyatnin
- Institute of Molecular Medicine, Sechenov First Moscow State Medical University, 119991, Moscow, Russia.,Department of Cell Signaling, Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991, Moscow, Russia
| | - Orkhan Isayev
- Department of Histology, Embryology and Cytology, Azerbaijan Medical University, Baku, Azerbaijan
| | - Eldar Gasimov
- Department of Histology, Embryology and Cytology, Azerbaijan Medical University, Baku, Azerbaijan
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany
| | - Yongyu Li
- Department of Pathophysiology, Institute of Digestive Disease, Tongji University School of Medicine, 200092, Shanghai, China
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany
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29
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Kühn F, Janisch F, Schwandner F, Gock M, Wedermann N, Witte M, Klar E, Schiffmann L. Comparison Between Endoscopic Vacuum Therapy and Conventional Treatment for Leakage After Rectal Resection. World J Surg 2020; 44:1277-1282. [PMID: 31965274 DOI: 10.1007/s00268-019-05349-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic leakage after rectal resection represents a severe complication for the patient and requires an early and appropriate management. Endoscopic vacuum therapy (EVT) has become the treatment of choice for anastomotic leakage after rectal resection in several institutions in Germany, and commercially available systems are currently distributed in approximately 30 countries worldwide. However, there is no evidence that EVT is superior to any other treatment for anastomotic leakage after rectal resection. METHODS Twenty-one patients treated with EVT for anastomotic leakage after rectal resection were retrospectively compared to a historical cohort of 41 patients that received conventional treatment. Primary endpoints were death, treatment success and long-term preservation of intestinal continuity. Secondary endpoints were length of hospital stay and duration of treatment. RESULTS There was no difference in mortality (p = 0.624). The intention-to-treat analysis showed a significantly higher success rate of EVT compared to conventional treatment (95.2% vs. 65.9%, p = 0.011). EVT was associated with preservation of intestinal continuity in a significant higher percentage of patients than patients undergoing conventional treatment (86.7% vs. 37.5%, p = 0.001). Conventional treatment tended to a shorter length of hospital stay (31.1 vs. 42.2 days, p = 0.066) but with no difference in overall duration of treatment. Time until closing of a diverting stoma did not differ between groups (10.2 months in the EVT group vs. 9.4 months in the conventional treatment group, p = 0.721). CONCLUSION According to this retrospective study, conventional therapy and EVT are both options for the treatment of anastomotic leakage after rectal resection. EVT might be more effective in terms of definite healing and preservation of intestinal continuity.
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Affiliation(s)
- Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Janisch
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Nicole Wedermann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
- Department of General, Visceral and Thoracic Surgery, Helios Klinikum Aue, Gartenstraße 6, 08280, Aue, Germany.
- Department of Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
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30
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Adiliaghdam F, Cavallaro P, Mohad V, Almpani M, Kühn F, Gharedaghi MH, Najibi M, Rahme LG, Hodin RA. Targeting the gut to prevent sepsis from a cutaneous burn. JCI Insight 2020; 5:137128. [PMID: 33004693 PMCID: PMC7566703 DOI: 10.1172/jci.insight.137128] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/26/2020] [Indexed: 12/13/2022] Open
Abstract
Severe burn injury induces gut barrier dysfunction and subsequently a profound systemic inflammatory response. In the present study, we examined the role of the small intestinal brush border enzyme, intestinal alkaline phosphatase (IAP), in preserving gut barrier function and preventing systemic inflammation after burn wound infection in mice. Mice were subjected to a 30% total body surface area dorsal burn with or without intradermal injection of Pseudomonas aeruginosa. Mice were gavaged with 2000 units of IAP or vehicle at 3 and 12 hours after the insult. We found that both endogenously produced and exogenously supplemented IAP significantly reduced gut barrier damage, decreased bacterial translocation to the systemic organs, attenuated systemic inflammation, and improved survival in this burn wound infection model. IAP attenuated liver inflammation and reduced the proinflammatory characteristics of portal serum. Furthermore, we found that intestinal luminal contents of burn wound-infected mice negatively impacted the intestinal epithelial integrity compared with luminal contents of control mice and that IAP supplementation preserved monolayer integrity. These results indicate that oral IAP therapy may represent an approach to preserving gut barrier function, blocking proinflammatory triggers from entering the portal system, preventing gut-induced systemic inflammation, and improving survival after severe burn injuries.
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Affiliation(s)
- Fatemeh Adiliaghdam
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Cavallaro
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vidisha Mohad
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marianna Almpani
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Shriners Hospital for Children, Boston, Massachusetts, USA.,Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Florian Kühn
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of General, Visceral and Transplant Surgery, Hospital of the University of Munich, Munich, Germany
| | - Mohammad Hadi Gharedaghi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mehran Najibi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laurence G Rahme
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Shriners Hospital for Children, Boston, Massachusetts, USA.,Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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31
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Karsten MM, Kühn F, Blohmer JU, Rose M, Fischer F, Kowalski C, Breidenbach C, Grittner U, Schilling R, Ferencz J, Pauler L, Matthesius G, Seemann J, Lenz J, Straubing L, Du Bois M. PRO B - PROM bei Brusterkrankungen – neue Wege in der Versorgung bei metastasiertem Brustkrebs. Geburtshilfe Frauenheilkd 2020. [DOI: 10.1055/s-0040-1717856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- MM Karsten
- Charité Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - F Kühn
- Charité Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - JU Blohmer
- Charité Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - M Rose
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Psychosomatik
| | - F Fischer
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Psychosomatik
| | | | | | - U Grittner
- Charité – Universitätsmedizin Berlin, Institut für Biometrie und Klinische Epidemiologie
| | - R Schilling
- Charité – Universitätsmedizin Berlin, Institut für Biometrie und Klinische Epidemiologie
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Kühn F, Klein M, Laven H, Börner N, Weinberger T, Streitparth F, Werner J, Schiergens TS. Specific Management of Patients with Acute Abdomen during the COVID-19 Pandemic: A Surgical Perspective from Germany. Visc Med 2020; 36:417-420. [PMID: 33173797 PMCID: PMC7360493 DOI: 10.1159/000509122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 01/19/2023] Open
Abstract
During the current COVID-19 pandemic, the triage, assessment, and management of patients presenting to the emergency department with critical conditions has become -challenging. The clinical features of COVID-19 are heterogeneous and subtle in many cases. They may easily be overlooked in the case of other acute diseases. Gastrointestinal symptoms are common in patients with COVID-19 as SARS-CoV-2 is able to enter gastrointestinal epithelial cells. However, these complaints can also be caused by a COVID-19-independent concomitant abdominal pathology. Therefore, patients with acute abdominal pain and fever need to be assessed very thoroughly. Based on a clinical case, we present our approach of managing emergency patients with acute abdomen and concomitant suspicion of -COVID-19.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Matthias Klein
- Emergency Department, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Henning Laven
- Department of Anesthesiology, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral, and Transplant Surgery, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Tobias Weinberger
- Department of Internal Medicine I, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Florian Streitparth
- Department of Clinical Radiology, Hospital of the Ludwig-Maximilian University of Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
| | - Tobias S. Schiergens
- Department of General, Visceral, and Transplant Surgery, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
- Emergency Department, Hospital of the Ludwig Maximilian University of Munich, Munich, Germany
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Pross T, Kühn F, Karsten M, Kendel F, Feufel M, Speiser D. Fortbildung von Kooperationspartnern zur Stärkung der transsektoralen Versorgung am Zentrum Berlin des Deutschen Konsortiums Familiärer Brust- und Eierstockkrebs. Geburtshilfe Frauenheilkd 2020. [DOI: 10.1055/s-0040-1718084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- T. Pross
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - F. Kühn
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - M.M. Karsten
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
| | - F. Kendel
- Charité – Universitätsmedizin Berlin, Institut für Geschlechterforschung in der Medizin
| | - M.A. Feufel
- Technische Universität Berlin, Institut für Psychologie und Arbeitswissenschaft
| | - D. Speiser
- Charité – Universitätsmedizin Berlin, Klinik für Gynäkologie mit Brustzentrum
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Abstract
Background Despite constant improvements in diagnostic as well as interventional and surgical techniques, acute mesenteric ischemia (AMI) remains a life-threatening emergency with high mortality rates. The time to diagnosis of AMI is the most important predictor of patients' outcome; therefore, prompt diagnosis and intervention are essential to reduce mortality in patients with AMI. The present review was performed to analyze potential risk factors and to help find ways to improve the outcome of patients with AMI. Summary Whereas AMI only applies to approximately 1% of all patients with an "acute abdomen," its incidence is rising up to 10% in patients >70 years of age. The initial clinical stage of AMI is characterized by a sudden onset of strong abdominal pain followed by a painless interval. Depending on the extent of disease, the symptoms of nonocclusive mesenteric ischemia (NOMI) and patients with a venous thrombosis can be very different from those of acute occlusive ischemia. Biphasic contrast-enhanced CT represents the gold standard for the diagnosis of arterial and venous occlusion. In case of a central occlusion of the superior mesenteric artery or signs of peritonitis, immediate surgery should be performed. If major bowel resection becomes necessary, critical residual intestinal length limits must be kept in mind. Endovascular techniques for arterial occlusion have taken on a much greater importance today. For stable patients with NOMI, interventional catheter angiography is recommended because it enables diagnosis and treatment with selective application of vasodilators. Depending on its degree, interventional treatment with a transhepatic catheter lysis should be considered for acute and chronic portal vein thrombosis. Key Message The prompt and targeted use of the appropriate diagnostics and interventions appears to be the only way to reduce the persistently high mortality rates for AMI.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ernst Klar
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
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Rentsch M, McSharry C, Kühn F, Sint A, Ganschow P, Werner J, Schiergens T. Indication for surgical therapy in ulcerative colitis. coloproctology 2020; 42:339-344. [DOI: 10.1007/s00053-020-00440-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Kühn F, Zimmermann J, Beger N, Wirth U, Hasenhütl SM, Drefs M, Chen C, Burian M, Karcz WK, Rentsch M, Werner J, Schiergens TS. Endoscopic vacuum therapy for treatment of rectal stump leakage. Surg Endosc 2020; 35:1749-1754. [PMID: 32314078 DOI: 10.1007/s00464-020-07569-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Symptomatic rectal stump leakage (RSL) is a serious complication after discontinuity resection and requires immediate surgical, interventional, or endoscopic therapy. Re-operations are associated with high morbidity and mortality in these mostly very ill patients. Endoscopic vacuum therapy (EVT) has been established for management of anastomotic leakage; however, its effectiveness for RSL treatment has not been analyzed in detail yet. METHODS A retrospective analysis of patients treated with EVT for RSL between 2001 and 2018 analyzing factors predicting therapy success and duration was carried out. RESULTS Fifty-six patients with RSL at a median age of 66 years were included. Of these, 18 patients (32%) had been referred for EVT from external departments or institutions. RSL was associated with a relevant clinical deterioration in all patients, and 55 patients (98%) had been classified as ASA 3 and 4, preoperatively. In 9 patients (16%), additional surgical revision was necessary with initiation of EVT. In 47 patients (84%), EVT was successful and local control of the inflammatory focus was achieved. The median duration of therapy was 20 days. Two patients (4%) suffered from minor EVT-associated bleeding that was endoscopically controlled. Preoperative radiation of the pelvis was significantly associated with EVT failure (P = 0.035), whereas patient age represented a predictive factor for therapy length (P = 0.039). In 12 patients (21%), restoration of intestinal continuity was achieved in the further course. CONCLUSIONS We present the first specific series on EVT for RSL. EVT for RSL was shown to be an effective and safe minimal-invasive treatment option, avoiding surgical revision in the majority of patients.
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Affiliation(s)
- Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Julia Zimmermann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nicola Beger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sandro M Hasenhütl
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Moritz Drefs
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Chen Chen
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maria Burian
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - W Konrad Karcz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
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Kühn F, Adiliaghdam F, Cavallaro PM, Hamarneh SR, Tsurumi A, Hoda RS, Munoz AR, Dhole Y, Ramirez JM, Liu E, Vasan R, Liu Y, Samarbafzadeh E, Nunez RA, Farber MZ, Chopra V, Malo MS, Rahme LG, Hodin RA. Intestinal alkaline phosphatase targets the gut barrier to prevent aging. JCI Insight 2020; 5:134049. [PMID: 32213701 PMCID: PMC7213802 DOI: 10.1172/jci.insight.134049] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Gut barrier dysfunction and gut-derived chronic inflammation play crucial roles in human aging. The gut brush border enzyme intestinal alkaline phosphatase (IAP) functions to inhibit inflammatory mediators and also appears to be an important positive regulator of gut barrier function and microbial homeostasis. We hypothesized that this enzyme could play a critical role in regulating the aging process. We tested the role of several IAP functions for prevention of age-dependent alterations in intestinal homeostasis by employing different loss-of-function and supplementation approaches. In mice, there is an age-related increase in gut permeability that is accompanied by increases in gut-derived portal venous and systemic inflammation. All these phenotypes were significantly more pronounced in IAP-deficient animals. Oral IAP supplementation significantly decreased age-related gut permeability and gut-derived systemic inflammation, resulted in less frailty, and extended lifespan. Furthermore, IAP supplementation was associated with preserving the homeostasis of gut microbiota during aging. These effects of IAP were also evident in a second model system, Drosophilae melanogaster. IAP appears to preserve intestinal homeostasis in aging by targeting crucial intestinal alterations, including gut barrier dysfunction, dysbiosis, and endotoxemia. Oral IAP supplementation may represent a novel therapy to counteract the chronic inflammatory state leading to frailty and age-related diseases in humans.
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Affiliation(s)
- Florian Kühn
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
- Department of General, Visceral and Transplant Surgery, Hospital of the University of Munich, Munich, Germany
| | - Fatemeh Adiliaghdam
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Cavallaro
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Sulaiman R. Hamarneh
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alexander R. Munoz
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Yashoda Dhole
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Juan M. Ramirez
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Enyu Liu
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Robin Vasan
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Yang Liu
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Ehsan Samarbafzadeh
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Rocio A. Nunez
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Z. Farber
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Vanita Chopra
- Department of Neurology,, MGH, Harvard Medical School, Boston, Massachusetts, USA
| | - Madhu S. Malo
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
| | - Laurence G. Rahme
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
- Shriners Hospital for Children, Boston, Massachusetts, USA
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard A. Hodin
- Department of Surgery, Massachusetts General Hospital (MGH), Harvard Medical School, Boston, Massachusetts, USA
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Schwandner F, Klimars U, Gock M, Schiffmann L, Witte M, Schiergens T, Rentsch M, Klar E, Kühn F. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg 2020; 24:411-417. [PMID: 30825120 DOI: 10.1007/s11605-019-04171-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND A defunctioning stoma can become necessary in a relevant number of patients undergoing gastrointestinal surgery. As a matter of course, patients seek an early closure of the stoma. However, preoperative management of these patients varies and the prediction of continence after stoma removal can become challenging. Patients might be fully continent despite low manometric pressures and vice versa. An easy and reliable way to predict continence after stoma reversal would improve patients' management and outcome. Although frequently performed in various surgical centers in Germany, there is no published data on the water-holding test. Hence, this is the first study evaluating the role of the test in clinical practice. METHOD We performed a prospective pilot study to evaluate the role of anorectal manometry and the water-holding procedure as a predictor of postoperative continence prior to stoma reversal. Inclusion criteria were a successfully passed water-holding test, any type of fecal diversion and the possibility of restoring intestinal continuity. Preoperative low manometric pressure levels were not an exclusion criteria for stoma reversal. Fifty-two patients with ostomy were consecutively enrolled in this study between October 2013 and February 2016. Anorectal manometry was performed in all patients prior to stoma reversal. After stoma removal, patients were followed-up for 6 months. Postoperative incontinence was determined using the Wexner incontinence score. RESULTS A total of 52 patients (38 males, 14 females) were included at an average age of 59 (range 33-83) years. Most frequent indications for intestinal diversion were rectal cancer surgery, IBD-related surgery, or surgery for diverticular disease. Low anterior rectal resection was performed in 17 patients (32.7%), followed by a proctocolectomy in 9 (17.3%), colectomy in 9 (17.3%), and recto-sigmoid resection in 7 patients (13.5%). Median time from stoma creation to reversal was 206 days (range 48-871 days). All patients had successfully passed the standardized water-holding test. At the same time, the majority of patients had low preoperative manometric pressure values and would normally not have been reversed at that point. The median postoperative Wexner incontinence score was at 1.5 (range 0-20), 0.5 (range 0-14), and 0 (range 0-11) at 14, 60, and 180 days after stoma reversal. Low preoperative manometric squeeze and/or resting pressure levels were not associated with a higher postoperative incontinence score at 14, 60, or 180 days after stoma reversal. CONCLUSION A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.
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Affiliation(s)
- Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ulrich Klimars
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Leif Schiffmann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Tobias Schiergens
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Goedecke M, Kühn F, Stratos I, Vasan R, Pertschy A, Klar E. No need for surgery? Patterns and outcomes of blunt abdominal trauma. Innov Surg Sci 2019; 4:100-107. [PMID: 31709301 PMCID: PMC6817729 DOI: 10.1515/iss-2018-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 09/03/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM). Materials and methods Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury. Results Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001). Conclusion NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.
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Affiliation(s)
- Maximilian Goedecke
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.,Department of Oral and Maxillofacial Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Munich, Munich, Germany
| | - Ioannis Stratos
- Department of Trauma, Hand and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Robin Vasan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Annette Pertschy
- Department of General, Visceral, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Ernst Klar
- Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany
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Schiffmann L, Wedermann N, Schwandner F, Gock M, Klar E, Kühn F. Neoadjuvant radio-chemotherapy prolongs healing of anastomotic leakage after rectal resection treated with endoscopic vacuum therapy. Therap Adv Gastroenterol 2019; 12:1756284819877606. [PMID: 31579099 PMCID: PMC6759710 DOI: 10.1177/1756284819877606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/27/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Neoadjuvant radiochemotherapy (nRCT) is an important component in the treatment of advanced rectal cancer. Endoscopic vacuum therapy (EVT) has become the treatment of choice for anastomotic leakage after rectal resection in many institutions in Germany. Published case series report on average success and stoma reversal rates of more than 80%. However, so far, there is no distinct report on the potential influence of nRCT on EVT. METHODS A total of 11 patients treated with EVT for anastomotic leakage after nRCT and rectal resection were retrospectively compared with a cohort of eight patients with rectal anastomotic leakage without neoadjuvant treatment. Primary endpoints were death, treatment success, and long-term preservation of intestinal continuity. Secondary endpoint was the duration of treatment. Statistical analysis was performed using Statistical Package for Social Science (SPSS) version 23.0. RESULTS There was no difference in mortality (0%), success rate (90.9% versus 100%, p = 0.381), or long-term preservation of continuity (63.6% versus 62.5%, p = 0.960). After nRCT, patients showed a significant longer duration of EVT (31.1 days versus 15.9 days, p = 0.040) which was associated with a significantly higher number of sponge applications (9.6 versus 5.0, p = 0.042). CONCLUSIONS In our analysis, EVT showed success in over 90% of patients with anastomotic leakage after rectal resection for colorectal cancer, regardless of neoadjuvant treatment. However, in case of anastomotic leakage, nRCT seems to be associated with the need for a significant longer duration of EVT.
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Affiliation(s)
| | - Nicole Wedermann
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Frank Schwandner
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Germany
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Sint A, Lutz R, Assenmacher M, Küchenhoff H, Kühn F, Faist E, Bazhin AV, Rentsch M, Werner J, Schiergens TS. Monocytic HLA-DR Expression for Prediction of Anastomotic Leak after Colorectal Surgery. J Am Coll Surg 2019; 229:200-209. [PMID: 30905855 DOI: 10.1016/j.jamcollsurg.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/26/2019] [Accepted: 03/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Earlier detection of anastomotic leakage (AL) after colorectal procedures could minimize the detrimental clinical impact of AL and thereby reduce morbidity and mortality. STUDY DESIGN We conducted a prospective study with assessment of the diagnostic accuracy of monocytic HLA-DR (mHLA-DR) expression compared with WBCs, C-reactive protein (CRP), and procalcitonin (PCT) in predicting AL in patients undergoing elective colorectal operation with anastomosis. RESULTS Comparison of the blood marker values on postoperative day (POD) 4 revealed significant differences for all markers, but the difference for mHLA-DR was highly significant (15% expression of monocytes in AL patients vs 34% in patients without AL; p = 0.001). Together with WBC (p = 0.026), mHLA-DR expression was the only test to show significance on day 3 (14% vs 31%; p < 0.001). Receiver operating characteristic analysis revealed that mHLA-DR expression had superior diagnostic accuracy compared with all other diagnostic markers both on POD 3 (mHLA-DR area under the curve [AUC] 0.928; WBC AUC 0.734; CRP AUC 0.707; PCT AUC 0.672) and POD 4 (mHLA-DR AUC 0.887; WBC AUC 0.738; CRP AUC 0.709; PCT AUC 0.696). Monocytic HLA-DR had a negative predictive value of at least 94% on PODs 3 and 4, as well as specificity and positive predictive values of 100% at a threshold of 23% on POD 3 and 24% on POD 4, respectively. CONCLUSIONS Expression of mHLA-DR appears to be a more accurate predictor for AL after colorectal operation compared with WBC, CRP, and PCT. It represents a promising test to precisely monitor the perioperative course of high-risk patients and contribute to safer discharge.
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Affiliation(s)
- Alena Sint
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rebecca Lutz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Helmut Küchenhoff
- Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Eugen Faist
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
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Abstract
BACKGROUND In recent decades, developments in drug therapy have significantly postponed the need for surgery. Nevertheless, the majority of patients with Crohn's disease still require one or more surgical interventions during the course of their disease. An analysis of epidemiological data as well as the surgical results of our own patients should help to identify risk factors for early surgery, re-operations and perioperative complications. METHODS A retrospective analysis including 120 consecutive patients with Crohn's disease and needing surgical intervention was carried out at the University Hospital of Rostock (UMR), Germany. Statistical analysis was performed using SPSS. RESULTS A total of 284 operations were recorded in 120 patients, of which 207 were performed on the UMR. The mean age at first surgery was 38 years (range: 17 - 66); initial diagnosis of Crohn's was on average at the age of 30 (range: 9 - 62). Each patient was operated 2 - 3 times during the course of their disease (range 1 - 9). Patients older than 30 years had significantly shorter time interval to the first operation. The number of operations per patient was significantly influenced by the localisation and behaviour of the disease. Penetrative behavior was associated with more frequent operations and terminal ileum involvement (L1) with significantly less frequent operations. Risk factors for complication of at least grade III according to Clavien-Dindo included greater age at surgery and at first diagnosis, decreased albumin levels and increased CRP. Anastomotic leakages were also associated with these risk factors as well as preoperative intake of > 20 mg prednisolone equivalent per day or cumulative dosage of 280 mg over the last 14 days prior to surgery. Anastomosis configuration and microscopic involvement of the resection margins had no statistically significant influence on the development of anastomotic leakage. CONCLUSION Diagnosis after the age of 30 was associated with a significantly earlier need for surgery in this analysis. Patients with terminal ileum involvement (L1) had a significantly lower surgical frequency than patients with colon or combined Crohn's disease. Age, albumin, CRP and a steroid medication > 20 mg per day were predictors for perioperative complications.
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Affiliation(s)
- Florian Kühn
- Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Klinikum der Universität München, Campus Großhadern, München.,Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, Rostock
| | - Maximilian Nixdorf
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, Rostock
| | - Frank Schwandner
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, Rostock
| | - Ernst Klar
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, Rostock
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Pérot P, Mullins CS, Naville M, Bressan C, Hühns M, Gock M, Kühn F, Volff JN, Trillet-Lenoir V, Linnebacher M, Mallet F. Expression of young HERV-H loci in the course of colorectal carcinoma and correlation with molecular subtypes. Oncotarget 2016; 6:40095-111. [PMID: 26517682 PMCID: PMC4741882 DOI: 10.18632/oncotarget.5539] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/13/2015] [Indexed: 01/02/2023] Open
Abstract
Background Expression of the human endogenous retrovirus (HERV)-H family has been associated with colorectal carcinomas (CRC), yet no individual HERV-H locus expression has been thoroughly correlated with clinical data. Here, we characterized HERV-H reactivations in clinical CRC samples by integrating expression profiles, molecular patterns and clinical data. Expression of relevant HERV-H sequences was analyzed by qRT-PCR on two well-defined clinical cohorts (n = 139 pairs of tumor and adjacent normal colon tissue) including samples from adenomas (n = 21) and liver metastases (n = 16). Correlations with clinical and molecular data were assessed. Results CRC specific HERV-H sequences were validated and found expressed throughout CRC disease progression. Correlations between HERV-H expression and lymph node invasion of tumor cells (p = 0.0006) as well as microsatellite instable tumors (p < 0.0001) were established. No association with regard to age, tumor localization, grading or common mutations became apparent. Interestingly, CRC expressed elements belonged to specific young HERV-H subfamilies and their 5′ LTR often presented active histone marks. Conclusion These results suggest a functional role of HERV-H sequences in colorectal carcinogenesis. The pronounced connection with microsatellite instability warrants a more detailed investigation. Thus, HERV-H sequences in addition to tumor specific mutations may represent clinically relevant, truly CRC specific markers for diagnostic, prognostic and therapeutic purposes.
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Affiliation(s)
- Philippe Pérot
- Cancer Biomarkers Research Group, Joint Unit Hospices Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, Pierre Bénite, France.,Current address: Institut Pasteur, Laboratory for Pathogen Discovery, Paris, France
| | - Christina Susanne Mullins
- Cancer Biomarkers Research Group, Joint Unit Hospices Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, Pierre Bénite, France.,Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie, EMR 3738 Lyon Claude Bernard University, Institut de Cancérologie des Hospices Civils de Lyon, Lyon, France
| | - Magali Naville
- Institut de Génomique Fonctionnelle de Lyon, Ecole Normale Supérieure de Lyon, CNRS/Université Lyon I, Lyon, France
| | - Cédric Bressan
- Cancer Biomarkers Research Group, Joint Unit Hospices Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Maja Hühns
- Institute of Pathology, University Medicine Rostock, Rostock, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University Medicine Rostock, Rostock, Germany
| | - Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University Medicine Rostock, Rostock, Germany
| | - Jean-Nicolas Volff
- Institut de Génomique Fonctionnelle de Lyon, Ecole Normale Supérieure de Lyon, CNRS/Université Lyon I, Lyon, France
| | - Véronique Trillet-Lenoir
- Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie, EMR 3738 Lyon Claude Bernard University, Institut de Cancérologie des Hospices Civils de Lyon, Lyon, France
| | - Michael Linnebacher
- Department of General Surgery, Molecular Oncology and Immunotherapy, University Medicine Rostock, Rostock, Germany
| | - François Mallet
- Cancer Biomarkers Research Group, Joint Unit Hospices Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, Pierre Bénite, France
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Abstract
Background The primary treatment of ulcerative colitis (UC) is conservative; surgical intervention is carried out in the case of therapy-refractory situation, imminent or malignant transformation, or complications. Surgery for UC should be indicated by interdisciplinary means. Despite the development of drug therapy – in particular the introduction of biologics -, a surgical intervention becomes necessary in a relevant proportion of patients with UC throughout lifetime. Methods A selective literature search was conducted, taking into account the current studies, reviews, meta-analyses, and guidelines. PubMed served as a database. The present work gives an overview of the surgical options, outcome as well as peri- and postoperative management for patients with UC. Results Approximately 20% of patients with UC will require surgery during the course of their disease. The rate of colectomy after a disease duration of 10 years is at approximately 16%. Unlike Crohn's disease, UC is principally surgically curable since it is naturally limited to the colon and rectum. Restorative proctocolectomy with an ileal pouch-anal anastomosis represents the surgical treatment of choice. Large studies show a postoperative complication rate of around 30% and a low mortality of 0.1% for this procedure. Chronic pouchitis is one of the main factors limiting the surgical success of curing UC. Despite a high postoperative complication rate, there is a long-term pouch success rate of >90% after 10 and 20 years of follow-up. Conclusion A close cooperation between the various disciplines in the pre- and postoperative setting is essential for an optimal outcome of patients with UC. Despite a 30% rate of early postoperative complications, normal quality of life can ultimately be reached in more than 90% of patients in experienced centers.
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Affiliation(s)
- Florian Kühn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
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45
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Kühn F, Philipp M, Klar E, Witte M. [Treatment of a subsequently detected, iatrogenic colonic perforation via minimal-invasive rendezvous procedure]. Z Gastroenterol 2014; 52:818-20. [PMID: 25111722 DOI: 10.1055/s-0034-1366615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Laparoscopic surgery as primary therapeutical option for iatrogenic colonic perforation after colonoscopy can be complemented by intraoparative colonoscopy in order to detect and treat even difficult accessible lesions. Via the presented method minimal invasisve detection and therapy of perforation can be conducted safely and can lead to reduction of morbidity.
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46
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Timper K, Fenske W, Katan M, Kühn F, Arici B, Schütz P, Frech N, Rutishauser J, Kopp P, Stettler C, Müller B, Christ Crain M. Copeptin in the Diagnosis and Differential Diagnosis of Diabetes Insipidus – The ‘CoSIP-Study’. Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1372046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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47
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Kühn F, Rau BM, Klar E, Schiffmann L. [Endoscopic vacuum therapy after iatrogenic oesophageal perforation--a case report]. Zentralbl Chir 2013; 139:98-100. [PMID: 23619772 DOI: 10.1055/s-0032-1328100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- F Kühn
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Rostock, Deutschland
| | - B M Rau
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Rostock, Deutschland
| | - E Klar
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Rostock, Deutschland
| | - L Schiffmann
- Abteilung für Allgemeine, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Rostock, Deutschland
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48
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Kühn F, Dieterich M, Klar E, Gerber B, Prinz C. Primary Malignant Vaginal Melanoma - Case Report and Review of the Literature. Geburtshilfe Frauenheilkd 2012; 72:740-743. [PMID: 25258467 DOI: 10.1055/s-0032-1315006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 04/02/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022] Open
Abstract
With fewer than 250 cases published worldwide, primary vaginal melanoma is an extremely rare malignant entity which is mostly diagnosed in advanced stages. The estimated incidence of vaginal melanoma is 0.026/100 000 women per year. The poor prognosis for advanced tumour stages and different therapies used in very limited numbers of patients require precise preoperative staging and a planned interdisciplinary therapeutic approach.
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Affiliation(s)
- F Kühn
- Chirurgische Klinik und Poliklinik, Universität Rostock, Rostock, Germany
| | - M Dieterich
- Universitätsfrauenklinik und Poliklinik, Universität Rostock, Rostock, Germany
| | - E Klar
- Chirurgische Klinik und Poliklinik, Universität Rostock, Rostock, Germany
| | - B Gerber
- Universitätsfrauenklinik und Poliklinik, Universität Rostock, Rostock, Germany
| | - C Prinz
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, KMG Klinikum Güstrow, Güstrow, Germany
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49
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Dusemund F, Bucher B, Meyer S, Thomann R, Kühn F, Bassetti S, Sprenger M, Baechli E, Sigrist T, Schwietert M, Amin D, Hausfater P, Carre E, Schuetz P, Gaillat J, Regez K, Bossart R, Schild U, Müller B, Albrich WC. Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance. Eur J Clin Microbiol Infect Dis 2012; 32:51-60. [PMID: 22886090 DOI: 10.1007/s10096-012-1713-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/23/2012] [Indexed: 01/27/2023]
Abstract
Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.
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Affiliation(s)
- F Dusemund
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
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Articus K, Baier M, Tracik F, Kühn F, Preuss UW, Kurz A. A 24-week, multicentre, open evaluation of the clinical effectiveness of the rivastigmine patch in patients with probable Alzheimer's disease. Int J Clin Pract 2011; 65:790-6. [PMID: 21645184 DOI: 10.1111/j.1742-1241.2011.02713.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cholinesterase inhibitors form the mainstay of treatment for persons with mild-to-moderate Alzheimer's disease (AD). The rivastigmine patch may increase compliance and the proportion of patients maintaining an efficacious dose compared with oral cholinesterase inhibitors. OBJECTIVE To investigate the proportion of patients who reached and maintained the target rivastigmine patch dose compared with the target rivastigmine capsule dose reported in clinical trials. METHODS This was a multicentre, 24-week, open-label study in persons with probable AD and a Mini-Mental State Examination (MMSE) score of ≥ 10 and ≤ 26. The primary outcome was the proportion of patients (ITT population) treated with 9.5 mg/24 h rivastigmine patch for at least 8 weeks at week 24. Secondary outcomes included week 24 MMSE, Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC), Trail Making Test Part A (TMT-A) and Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL) scores. RESULTS Overall, 208 participants received treatment and 155 (74.5%) completed the study. Within the ITT population, 147/182 patients (80.8%; 95% CI 75.0-86.5%) were treated for at least 8 weeks with the 9.5 mg/24 h rivastigmine patch; 135/182 patients (74.2%; 95% CI 67.8-80.5%) were treated for at least 8 weeks and completed the study. The most common adverse events were nausea (10.1% of patients), erythema (8.7%), pruritus (8.2%) and vomiting (7.2%). At week 24, patients treated with the rivastigmine patch showed improvements on MMSE, ADCS-ADL, ADCS-CGIC and TMT-A scores. Caregivers reported acceptance, preference and satisfaction with the patch. CONCLUSION Transdermal delivery may allow more patients to reach and maintain therapeutic doses of rivastigmine compared with oral rivastigmine.
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Affiliation(s)
- K Articus
- Novartis Pharma GmbH, Nuremberg, Germany.
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