Treatment for gastrointestinal and pancreatic neuroendocrine tumours: a network meta-analysis

BACKGROUND

Several available therapies for neuroendocrine tumours (NETs) have demonstrated efficacy in randomised controlled trials. However, translation of these results into improved care faces several challenges, as a direct comparison of the most pertinent therapies is incomplete.

OBJECTIVES

To evaluate the safety and efficacy of therapies for NETs, to guide clinical decision-making, and to provide estimates of relative efficiency of the different treatment options (including placebo) and rank the treatments according to their efficiency based on a network meta-analysis.

SEARCH METHODS

We identified studies through systematic searches of the following bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (Ovid); and Embase from January 1947 to December 2020. In addition, we checked trial registries for ongoing or unpublished eligible trials and manually searched for abstracts from scientific and clinical meetings.

SELECTION CRITERIA

We evaluated randomised controlled trials (RCTs) comparing two or more therapies in people with NETs (primarily gastrointestinal and pancreatic).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data to a pre-designed data extraction form. Multi-arm studies were included in the network meta-analysis using the R-package netmeta. We separately analysed two different outcomes (disease control and progression-free survival) and two types of NET (gastrointestinal and pancreatic NET) in four network meta-analyses. A frequentist approach was used to compare the efficacy of therapies.

MAIN RESULTS

We identified 55 studies in 90 records in the qualitative analysis, reporting 39 primary RCTs and 16 subgroup analyses. We included 22 RCTs, with 4299 participants, that reported disease control and/or progression-free survival in the network meta-analysis. Precision-of-treatment estimates and estimated heterogeneity were limited, although the risk of bias was predominantly low. The network meta-analysis of progression-free survival found nine therapies for pancreatic NETs: everolimus (hazard ratio [HR], 0.36 [95% CI, 0.28 to 0.46]), interferon plus somatostatin analogue (HR, 0.34 [95% CI, 0.14 to 0.80]), everolimus plus somatostatin analogue (HR, 0.38 [95% CI, 0.26 to 0.57]), bevacizumab plus somatostatin analogue (HR, 0.36 [95% CI, 0.15 to 0.89]), interferon (HR, 0.41 [95% CI, 0.18 to 0.94]), sunitinib (HR, 0.42 [95% CI, 0.26 to 0.67]), everolimus plus bevacizumab plus somatostatin analogue (HR, 0.48 [95% CI, 0.28 to 0.83]), surufatinib (HR, 0.49 [95% CI, 0.32 to 0.76]), and somatostatin analogue (HR, 0.51 [95% CI, 0.34 to 0.77]); and six therapies for gastrointestinal NETs: 177-Lu-DOTATATE plus somatostatin analogue (HR, 0.07 [95% CI, 0.02 to 0.26]), everolimus plus somatostatin analogue (HR, 0.12 [95%CI, 0.03 to 0.54]), bevacizumab plus somatostatin analogue (HR, 0.18 [95% CI, 0.04 to 0.94]), interferon plus somatostatin analogue (HR, 0.23 [95% CI, 0.06 to 0.93]), surufatinib (HR, 0.33 [95%CI, 0.12 to 0.88]), and somatostatin analogue (HR, 0.34 [95% CI, 0.16 to 0.76]), with higher efficacy than placebo. Besides everolimus for pancreatic NETs, the results suggested an overall superiority of combination therapies, including somatostatin analogues. The results indicate that NET therapies have a broad range of risk for adverse events and effects on quality of life, but these were reported inconsistently. Evidence from this network meta-analysis (and underlying RCTs) does not support any particular therapy (or combinations of therapies) with respect to patient-centred outcomes (e.g. overall survival and quality of life).

AUTHORS' CONCLUSIONS

The findings from this study suggest that a range of efficient therapies with different safety profiles is available for people with NETs.

Immunohistochemical analysis of the expression of cancer-associated fibroblast markers in esophageal cancer with and without neoadjuvant therapy

Esophageal carcinoma (EC) is one of the most aggressive human malignancies with high rates of resistance to conventional anticancer treatment. Cancer-associated fibroblasts (CAFs) are an important part of the tumor microenvironment and associated with tumor progression. COL11A1, SPARC, and CD90 have been identified as rather specific CAF markers, with COL11A1 expression particularly shown to influence response to chemotherapy. We investigated the impact of CAFs in esophageal cancer with a special focus on response to neoadjuvant treatment (nTX). Two collections of esophageal carcinomas were investigated: 164 cases treated with primary resection and 256 cases receiving nTX before resection. The expression of CAF markers was determined using next-generation tissue microarray (ngTMA®) technology and immunohistochemistry. The presence of COL11A1 and SPARC in fibroblasts within both primary resected cases and nTX-treated cases was associated with unfavorable clinicopathological variables such as higher (y)pT category and lymphatic invasion (p<0.001 each). The presence of COL11A1-positive CAFs was associated with worse overall survival in primary resected cases (HR: 2.162, p = 0.004, CI 95% 1.275-3.686). While in tumors showing regression after nTX, COL11A1-positive CAFs were detected less frequently, SPARC-positive CAFs were enriched after nTX, in both responding and non-responding patients (p < 0.001). Our results support the concept of CAFs as an important factor of tumor promotion and maintenance in EC. The population of CAFs increases with tumor progression and decreases, partly depending on the subtype, after regression following nTX. CAFs may serve as potential target for future therapeutic approaches for these highly aggressive tumors.

Association of Surgical Volume and Quality Management in Thyroid Surgery: A Two-Nation Multicenter Study

BACKGROUND

High-volume caseload in thyroid surgery is associated with lower postoperative complication rates resulting to better outcomes. The aim of the present study was to investigate the correlation of the departments' annual number of thyroid surgeries on the adherence to consensus guidelines and on the implementation of measures for quality assurance.

METHODS

In 2016, we sent an anonymous electronic survey with questions related to the perioperative management in thyroid surgery to all directors of departments in operative medicine in Switzerland and Austria. We compared the pre- and postoperative management with the summarized recommendations of the four most frequently used consensus guidelines. Analogously, we analyzed the implementation of six measures for quality assurance related to thyroid surgery for each participating department. Using logistic regression analysis, we evaluated the correlation of number of guidelines respected and number of measures for quality assurance with the departments' annual number of surgeries performed. Furthermore, we evaluated the number of departments providing thyroid cancer surgery and their experience in neck dissection.

RESULTS

The management corresponded in 64.0% to the summarized recommendations. Adherence to the summarized recommendations and implementation of measures for quality assurance were significantly more likely with increasing numbers of surgeries performed (p = 0.049 and p < 0.001). Ninety-two departments provided thyroid cancer surgery, whereas 12/92 (13.0%) were not able to perform central and/or lateral neck dissection.

CONCLUSION

Consensus guidelines are insufficiently implemented within thyroid surgery, and quality management is associated with surgical volume.

Therapeutic Options for Neuroendocrine Tumors: A Systematic Review and Network Meta-analysis

IMPORTANCE

Multiple therapies are currently available for patients with neuroendocrine tumors (NETs), yet many therapies have not been compared head-to-head within randomized clinical trials (RCTs).

OBJECTIVE

To assess the relative safety and efficacy of therapies for NETs.

DATA SOURCES

PubMed, Embase, the Cochrane Central Register of Controlled Trials, trial registries, meeting abstracts, and reference lists from January 1, 1947, to March 2, 2018, were searched. Key search terms included neuroendocrine tumors, gastrointestinal neoplasms, therapy, and randomized controlled trial.

STUDY SELECTION

Randomized clinical trials comparing 2 or more therapies in patients with NETs (primarily gastrointestinal and pancreatic) were evaluated. Thirty RCTs met the selection criteria.

DATA EXTRACTION AND SYNTHESIS

Pairs of independent reviewers screened studies, extracted data, and assessed the risk of bias. A network meta-analysis with a frequentist approach was used to compare the efficacy of therapies; the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was used.

MAIN OUTCOMES AND MEASURES

Disease control, progression-free survival, overall survival, adverse events, and quality of life.

RESULTS

The systematic review identified 30 relevant RCTs comprising 3895 patients (48.4% women) assigned to 22 different therapies for NETs. These therapies showed a broad range of risk for serious and nonserious adverse events. The network meta-analyses included 16 RCTs with predominantly a low risk of bias; nevertheless, precision-of-treatment estimates and estimated heterogeneity were limited. The network meta-analysis found 7 therapies for pancreatic NETs: everolimus (hazard ratio [HR], 0.35 [95% CI, 0.28-0.45]), everolimus plus somatostatin analogue (HR, 0.35 [95% CI, 0.25-0.51]), everolimus plus bevacizumab plus somatostatin analogue (HR, 0.44 [95% CI, 0.26-0.75]), interferon (HR, 0.37 [95% CI, 0.16-0.83]), interferon plus somatostatin analogue (HR, 0.31 [95% CI, 0.13-0.71]), somatostatin analogue (HR, 0.46 [95% CI, 0.33-0.66]), and sunitinib (HR, 0.42 [95% CI, 0.26-0.67]), and 5 therapies for gastrointestinal NETs: bevacizumab plus somatostatin analogue (HR, 0.22 [95% CI, 0.05-0.99]), everolimus plus somatostatin analogue (HR, 0.31 [95% CI, 0.11-0.90]), interferon plus somatostatin analogue (HR, 0.27 [95% CI, 0.07-0.96]), Lu 177-dotatate plus somatostatin analogue (HR, 0.08 [95% CI, 0.03-0.26], and somatostatin analogues (HR, 0.40 [95% CI, 0.21-0.78]) with higher efficacy than placebo and suggests an overall superiority of combination therapies.

CONCLUSIONS AND RELEVANCE

The findings from this study suggest that a range of efficient therapies with different safety profiles is available for patients with NETs.

A specific expression profile of LC3B and p62 is associated with nonresponse to neoadjuvant chemotherapy in esophageal adenocarcinomas

Paclitaxel is a powerful chemotherapeutic drug, used for the treatment of many cancer types, including esophageal adenocarcinomas (EAC). Autophagy is a lysosome-dependent degradation process maintaining cellular homeostasis. Defective autophagy has been implicated in cancer biology and therapy resistance. We aimed to assess the impact of autophagy on chemotherapy response in EAC, with a special focus on paclitaxel. Responsiveness of EAC cell lines, OE19, FLO-1, OE33 and SK-GT-4, to paclitaxel was assessed using Alamar Blue assays. Autophagic flux upon paclitaxel treatment in vitro was assessed by immunoblotting of LC3B-II and quantitative assessment of WIP1 mRNA. Immunohistochemistry for the autophagy markers LC3B and p62 was applied on tumor tissue from 149 EAC patients treated with neoadjuvant chemotherapy, including pre- and post-therapeutic samples (62 matched pairs). Tumor response was assessed by histology. For comparison, previously published data on 114 primary resected EAC cases were used. EAC cell lines displayed differing responsiveness to paclitaxel treatment; however this was not associated with differential autophagy regulation. High p62 cytoplasmic expression on its own (p ≤ 0.001), or in combination with low LC3B (p = 0.034), was associated with nonresponse to chemotherapy, regardless of whether or not the regiments contained paclitaxel, but there was no independent prognostic value of LC3B or p62 expression patterns for EAC after neoadjuvant treatment. p62 and related pathways, most likely other than autophagy, play a role in chemotherapeutic response in EAC in a clinical setting. Therefore p62 could be a novel therapeutic target to overcome chemoresistance in EAC.

Prognostic relevance of autophagy markers LC3B and p62 in esophageal adenocarcinomas

Esophageal adenocarcinomas (EAC) are aggressive tumors with considerable rates of chemoresistance. Autophagy is a lysosome-dependent degradation process, characterized by the formation of vesicles called autophagosomes, and has been implicated in cancer. Protein light chain 3 B (LC3B) and p62 are associated with autophagosomal membranes and degraded. We aimed to assess the impact of basal autophagy on EAC. In EAC cell lines, an increase in LC3B and p62 was observed with increasing concentrations of the autophagy inhibitor chloroquine, which indicates functional basal autophagy. LC3B and p62 immunohistochemistry was performed on primary resected EAC. High LC3B and p62 expression was associated with earlier tumor stages (p < 0.05). High nuclear and cytoplasmic p62 staining were associated with a better prognosis (p = 0.006; p = 0.028). Various combinations of p62 expression with or without LC3B expression identified different prognostic groups. Tumors with low total p62 (p = 0.007) or low LC3B/low p62 expression had the worst outcome (p = 0.007; p = 0.005). A combination score of dot-like/cytoplasmic p62 and nuclear p62 staining was an independent prognostic parameter (p = 0.033; HR = 0.6). This study highlights the potential significance of basal autophagy in EAC biology. Tumors with low LC3B and p62 expression show the most aggressive behavior and may be candidates for autophagy regulating therapeutics.

Expression patterns of programmed death-ligand 1 in esophageal adenocarcinomas: comparison between primary tumors and metastases

Expression analysis of programmed death-ligand 1 (PD-L1) may be helpful in guiding clinical decisions for immune checkpoint inhibition therapy, but testing by immunohistochemistry may be hampered by heterogeneous staining patterns within tumors and expression changes during metastatic course. PD-L1 expression (clone SP142) was investigated in esophageal adenocarcinomas using tissue microarrays (TMA) from 112 primary resected tumors, preoperative biopsies and full slide sections from a subset of these cases (n = 24), corresponding lymph node (n = 55) and distant metastases (n = 17). PD-L1 expression was scored as 0.1-1, >1, >5, >50% positive membranous staining of tumor cells and any positive staining of tumor-associated inflammatory infiltrates and/or stroma cells. There was a significant correlation with overall PD-L1 expression between the full slide sections and the TMA (p = 0.001), but not with the corresponding biopsies. PD-L1 expression in tumor cells >1% was detected in 8.0% of cases (9/112) and 51.8% of cases (58/112) in tumor-associated inflammatory infiltrates and/or stroma cells of primary tumors. Epithelial expression in metastases was found in 5.6% of cases (4/72) and immune cell expression in 18.1% of cases (13/72), but did not correlate with the expression pattern in the primary tumor. Overall PD-L1 expression in the primary tumor did not influence survival. However, PD-L1 expression was correlated with the number of CD3+ tumor-infiltrating lymphocytes in the tumor center, and a combinational score of PD-L1 status/CD3+ tumor-infiltrating lymphocytes was correlated with patients' overall survival.

The advantages of extended subplatysmal dissection in thyroid surgery-the "mobile window" technique

PURPOSE

Minimal access thyroidectomy, using various techniques, is widely known, but respective data on thyroidectomy for thyroid cancer with lymphadenectomy is scarce. The present study aims to evaluate the feasability of extended subplatysmal dissection in combination with a small incision ("mobile window" technique).

METHODS

A retrospective study was performed analysing data from 93 patients. All patients suffered from thyroid carcinoma and underwent (total) thyroidectomy, bilateral cervico-central (levels VI and VII) and functional lateral neck dissection (levels II to V) on the side of the malignancy. In group A, consisting of 47 patients, the operation was performed by a traditional Kocher incision (minimal range 6-7 cm), in 46 patients (group B) a mini-incision (≤4 cm) was made. Intra- and postoperative morbidity as well as oncological accuracy were assessed.

RESULTS

There was no significant difference between the two groups comparing postoperative pathological diagnosis, intra- and postoperative complications and the number of removed lymph nodes. However, operating time was slightly longer in group A and thyroid weight was heavier in group B.

CONCLUSIONS

Extended subplatymsal dissection allows thyroidectomy and even lateral lymphadenectomy for thyroid carcinoma via "mobile" mini-incision. The procedure is safe, of equivalent oncological accuracy compared to traditional incision and the cosmetic results are excellent.

High intratumoural but not peritumoural inflammatory host response is associated with better prognosis in primary resected oesophageal adenocarcinomas

The host inflammatory response plays an important role in many solid malignancies. Studies on oesophageal adenocarcinomas (EACs) point towards a beneficial role of pronounced immunoreaction, however, congruent results have yet to be obtained. We analysed 111 primary resected EAC using a tissue microarray containing three cores of the tumour centre and the periphery per case. Overall inflammation was assessed by histomorphology. Tumour infiltrating lymphocytes (TILs) were characterised by immunohistochemistry for CD3, CD8 and FoxP3, and evaluated by image analysis (Aperio ImageScope). High levels of inflammation in the tumour centre, but not the periphery were associated with better patient survival (p = 0.001), similar to high counts of intratumoural FoxP3+, CD3+, CD8+ TILs (p = 0.001; p = 0.027; p = 0.038) and a combination of CD3+/CD8+/FoxP3+ TILs, the latter displaying three different prognostic groups (triple high/mixed/triple low; p=0.003). Intratumoural inflammation [hazard ratio (HR) = 0.432; p = 0.030], FoxP3+ TIL counts (HR = 0.411; p = 0.033) and the combination CD3+/CD8+/FoxP3+ TILs (HR = 0.173; p = 0.006) were also independent prognostic parameters. In summary, both high grade total inflammation and high TIL counts in the tumour centre, but not the tumour periphery, show a beneficial prognostic impact on EAC. This may be a target for novel therapeutic options but also serves as prognostic indicator in these tumours.

Treatment options for spontaneous and postoperative sclerosing mesenteritis

Sclerosing mesenteritis is a rare pathology with only a few described cases in the literature. The etiology is unclear; however, several potential triggers, including abdominal surgery and abdominal trauma, have been discussed. The pathology includes a benign acute or chronic inflammatory process affecting the adipose tissue of the mesenterium. Despite it being a rare disease, sclerosing mesenteritis is an important differential diagnosis in patients after abdominal surgery or patients presenting spontaneously with signs of acute inflammation and abdominal pain. We present here three cases with sclerosing mesenteritis. In two cases, sclerosing mesenteritis occurred postoperatively after abdominal surgery. One patient was treated because of abdominal pain and specific radiological signs revealing spontaneous manifestation of sclerosing mesenteritis. So far there are no distinct treatment algorithms, so the patients were treated differently, including steroids, antibiotics and watchful waiting. In addition, we reviewed the current literature on treatment options for this rare disease.

Impact of peritumoral and intratumoral budding in esophageal adenocarcinomas

Tumor budding has prognostic significance in many carcinomas and is defined as the presence of detached isolated single cells or small cell clusters up to 5 cells at the invasion front (peritumoral budding [PTB]) or within the tumor (intratumoral budding [ITB]). For esophageal adenocarcinomas (EACs), there are currently only few data about the impact of this morphological feature. We investigated tumor budding in a large collective of 200 primarily resected EACs. Pancytokeratin staining was demonstrated to be superior to hematoxylin and eosin staining for the detection of buds with substantial to excellent interobserver agreement and used for subsequent analysis. PTB and ITB were scored across 10 high-power fields (HPFs). The median count of tumor buds was 130/10 HPFs for PTB (range, 2-593) and 80/10 HPFs for ITB (range, 1-656). PTB and ITB correlated significantly with each other (r = 0.9; P < .001). High PTB and ITB rates were seen in more advanced tumor categories (P < .001 each); tumors with lymph node metastases (P < .001/P = .002); and lymphatic, vascular, and perineural invasion and higher tumor grading (P < .001 each). Survival analysis showed an association with worse survival for high-grade ITB (P = .029) but not PTB (P = .385). However, in multivariate analysis, lymph node and resection status, but not ITB, were independent prognostic parameters. In conclusion, PTB and ITB can be observed in EAC to various degrees. High-grade budding is associated with aggressive tumor phenotype. Assessment of tumor budding, especially ITB, may provide additional prognostic information about tumor behavior and may be useful in specific cases for risk stratification of EAC patients.

Total Thyroidectomy for Amiodarone-induced Thyrotoxicosis in the Hyperthyroid State

Amiodarone is a potent antiarrhythmic agent, indicated for the treatment of refractory arrhythmias, which may lead to thyrotoxicosis. In these patients, thyroidectomy is a valid therapeutic option. Antithyroid therapy in the immediate preoperative setting and the subsequently accepted minimal delay until thyroidectomy have not been clearly defined yet. The aim of the present study was to show, that total thyroidectomy under general anaesthesia in patients with amiodarone-induced thyrotoxicosis (AIT) is safe without necessarily obtaining an euthyroid state preoperatively.We conducted a retrospective cohort study of prospectively gathered data on 11 patients undergoing total thyroidectomy under general anaesthesia between January 2008 and December 2013 for AIT at our University Hospital.All patients were preoperatively treated with carbimazole, steroids and β-receptor antagonists. Additionally, 3 patients received potassium perchlorate and in one patient carbimazole was changed to propylthiouracil. Plasmapheresis was performed in 3 patients. Only one patient was euthyroid at the time of operation. There were no significant intra- and postoperative complications, especially no signs of thyroid storm. One patient could postoperatively be removed from the cardiac transplant waiting list due to improved cardiac function.Improvements in the interdisciplinary surgical management for AIT between cardiologists, endocrinologists, anaesthetists and endocrine surgeons provide the basis of safe total thyroidectomy under general anaesthesia in hyperthyroid state. Early surgery without long delay for medical antithyroid treatment (with its potential negative side effects) is recommended.

Epstein-barr virus in gastro-esophageal adenocarcinomas - single center experiences in the context of current literature

Epstein–Barr virus (EBV)-associated gastric carcinomas (GC) represent a distinct and well-recognized subtype of gastric cancer with a prevalence of around 10% of all GC. In contrast, EBV has not been reported to play a major role in esophageal adenocarcinomas (EAC) and adenocarcinomas of the gastro-esophageal junction (GEJ). We report our experiences on EBV in collections of gastro-esophageal adenocarcinomas from two surgical centers and discuss the current state of research in this field. Tumor samples from 465 primary resected gastro-esophageal adenocarcinomas (118 EAC, 73 GEJ, and 274 GC) were investigated. Presence of EBV was determined by EBV-encoded small RNAs (EBER) in situ hybridization. Results were correlated with pathologic parameters (UICC pTNM category, Her2 status, tumor grading) and survival. EBER positivity was observed in 14 cases. None of the EAC were positive for EBER. In contrast, we observed EBER positivity in 2/73 adenocarcinomas of the GEJ (2.7%) and 12/274 GC (4.4%). These were of intestinal type (seven cases) or unclassifiable (six cases), while only one case was of diffuse type according to the Lauren classification. No association between EBV and pT, pN, or tumor grading was found, neither was there a correlation with clinical outcome. None of the EBER positive cases were Her2 positive. In conclusion, EBV does not seem to play a role in the carcinogenesis of EAC. Moreover, adenocarcinomas of the GEJ show lower rates of EBV positivity compared to GC. Our data only partially correlate with previous reports from the literature. This highlights the need for further research on this distinct entity. Recent reports, however, have identified specific epigenetic and genetic alterations in EBV-associated GC, which might lead to a distinct treatment approach for this specific subtype of GC in the future.

Introduction of a new policy of no nighttime appendectomies: impact on appendiceal perforation rates and postoperative morbidity

BACKGROUND

Working hour limitations and tight health care budgets have posed significant challenges to emergency surgical services. Since 1 January 2010, surgical interventions at Berne University Hospital between 23:00 and 08:00 h have been restricted to patients with an expected serious adverse outcome if not operated on within 6 h. This study was designed to assess the safety of this new policy that restricts nighttime appendectomies (AEs).

METHODS

The patients that underwent AE from 1 January 2010 to 31 December 2011 ("2010-2011 group") were compared retrospectively with patients that underwent AE before introduction of the new policy (1 January 2006-31 December 2009; "2006-2009 group").

RESULTS

Overall, 390 patients were analyzed. There were 255 patients in the 2006-2009 group and 135 patients in the 2010-2011 group. Patients' demographics did not differ statistically between the two study groups; however, 45.9 % of the 2006-2009 group and 18.5 % of the 2010-2011 group were operated between 23:00 and 08:00 h (p < 0.001). The rates of appendiceal perforations and surgical site infections did not differ statistically between the 2006-2009 group and the 2010-2011 group (20 vs. 18.5 %, p = 0.725 and 2 vs. 0 %, p = 0.102). Additionally, no difference was found for the hospital length of stay (3.9 ± 7.4 vs. 3.4 ± 6.0 days, p = 0.586). However, the proportion of patients with an in-hospital delay of >12 h was significantly greater in the 2010-2011 group than in the 2006-2009 group [55.6 vs. 43.5 %, p = 0.024, odds ratio (95 % confidence interval 1.62 (1.1-2.47)].

CONCLUSIONS

Restricting AEs from 23:00 to 08:00 h does not increase the perforation rates and occurrence of clinical outcomes. Therefore, these results suggest that appendicitis may be managed safely in a semielective manner.

Paediatric thyroid surgery is safe--experiences at a tertiary surgical centre

PRINCIPLES

Thyroidectomy in children is rare and mostly performed because of thyroid neoplasms. The aim of this study based on prospective data acquisition was to evaluate whether thyroid surgery in children can be performed as safely as in adults when undertaken by a team of adult endocrine surgeons and paediatric surgeons.

METHODS

Between 2002 and 2012, 36 patients younger than 18 years underwent surgery for thyroid gland pathologies. All surgical procedures were performed by an experienced endocrine surgeon and a paediatric surgeon. Baseline demographic data, surgical procedure, duration of operation, length of hospital stay, and postoperative morbidity and mortality were analysed.

RESULTS

The median age of all patients was 13 years (range 2-17 years), with predominantly female gender (n = 30, 83%). The majority of operations were performed because of benign thyroid disease (n = 27, 75%) and only a minority because of malignancy or genetic abnormality with predisposition for malignant transformation (MEN) (n = 9, 25%). Total thyroidectomy was performed in the majority of the patients (n = 24, 67%). The median duration of the surgical procedure was 153 minutes (range 90-310 minutes). The median hospital stay was 5 days (3-1 days). One patient developed persistent hypoparathyroidism after neck dissection due to cancer. One persistent and two temporary recurrent nerve palsies occurred.

CONCLUSION

This study demonstrated that paediatric thyroidectomy is safe as performed by this team of endocrine and paediatric surgeons, with acceptable morbidity even when total thyroidectomy was performed in the case of benign disease.

[Treatment practice in patients with isolated blunt splenic injuries. A survey of Swiss traumatologists]

BACKGROUND

The non-operative management (NOM) of blunt splenic injuries has gained widespread acceptance. However, there are still many controversies regarding follow-up of these patients. The purpose of this study was to survey active members of the Swiss Society of General and Trauma Surgery (SGAUC) to determine their practices regarding the NOM of isolated splenic injuries.

MATERIALS AND METHODS

A survey of active SGAUC members with a written questionnaire was carried out. The questionnaire was designed to elicit information about personal and facility demographics, diagnostic practices, in-hospital management, preferred follow-up imaging and return to activity.

RESULTS

Out of 165 SGAUC members 52 (31.5%) completed the survey and 62.8% of all main trauma facilities in Switzerland were covered by the sample. Of the respondents 14 (26.9%) have a protocol in place for treating patients with splenic injuries. For initial imaging in hemodynamically stable patients 82.7% of respondents preferred ultrasonography (US). In cases of suspected splenic injury 19.2% of respondents would abstain from further imaging. In cases of contrast extravasation from the spleen half of the respondents would take no specific action. For low-grade injuries 86.5% chose to admit patients for an average of 1.6 days (range 0-4 days) with a continuously monitored bed. No differences in post-discharge activity restrictions between moderate and high-grade splenic injuries were found.

CONCLUSION

The present survey showed considerable practice variation in several important aspects of the NOM of splenic injuries. Not performing further CT scans in patients with suspected splenic injuries and not intervening in cases of a contrast extravasation were the most important discrepancies to the current literature. Standardization of the NOM of splenic injuries may be of great benefit for both surgeons and patients.

Intraperitoneal mesh implantation for fascial dehiscence and open abdomen

BACKGROUND

Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe.

METHODS

A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint.

RESULTS

The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p = 0.025) and dirty abdominal cavities (5% vs. 34%; p = 0.01).

CONCLUSIONS

Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdomen.

Morbidity rate of reoperation in thyroid surgery: a different point of view

BACKGROUND

Goitre recurrence is a common problem following subtotal thyroid gland resection for multinodular goitre disease. The aim of the present study was to evaluate morbidity rate in relation to the side of initial and redo-surgery for recurrent disease.

METHODS

A total of 1699 patients underwent consecutive thyroid gland surgery between 1997 and 2010 at our institution. One hundred and eighteen patients (6.9%) underwent redo-surgery for recurrent disease after subtotal resection. One hundred and nine patients with complete follow-up were included in the present study.

RESULTS

Recurrent disease was found in 79 patients (72.5%) in the ipsilateral lobe and in 30 patients (27.5%) in the contralateral lobe. The incidence of permanent recurrent laryngeal nerve palsy was significantly higher in patients undergoing redo-surgery on the ipsilateral lobe compared to patients undergoing initial operation (3.8% vs. 1.1%; p = 0.03), whereas no difference was found in patients with contralateral redo-surgery compared to patients undergoing initial operation (p = 1.0). Independent risk factors for contralateral recurrent disease were age at primary operation <37 years (OR 4.86; 95% CI 1.58-15.01) and time to recurrence <20 years (OR 6.53; 95% CI 2.23-19.01).

CONCLUSION

Morbidity rate for recurrent disease after subtotal resection was significantly higher for ipsilateral redo-surgery compared to initial surgery, whereas redo-surgery can be performed safely on the contralateral lobe. Young age at primary operation and short time to recurrence are independent risk factors for contralateral recurrent disease.

Impact of surgical technique on operative morbidity and its socioeconomic benefit in thyroid surgery

PURPOSE

The aim of this retrospective cohort study was to evaluate the rate of complications in relation to the extent of surgery and some of its consequences.

METHODS

Between 1972 and 2010, a total of 5,277 consecutive thyroid gland surgeries with 7,383 nerves at risk were performed at our teaching institution. Data of all patients undergoing thyroidectomy were collected prospectively. A total of 2,867 subtotal resections (first study period from 1972 to 1990) were compared with 2,410 extended thyroid resections involving at least a hemithyroidectomy (second period from 1991 to 2010).

RESULTS

The incidence of permanent recurrent laryngeal nerve palsy in primary operations was significantly higher in the first period compared to the second period (3.6 vs. 0.9 %; p < 0.001). Permanent hypoparathyroidism decreased from 3.2 % in the first period to 0.8 % in the second period (p < 0.001). The incidence of recurrent goiter surgery decreased from 11.1 % in the first period to 8.1 % in the second period (p < 0.001). No significant difference was found in permanent recurrent laryngeal nerve palsy in recurrent disease between the two periods. The socioeconomic benefits of an extended thyroid resection in our patient population are 360 preventable operations, 90 preventable permanent recurrent laryngeal nerve palsies, and 58 preventable cancers. Furthermore, 37 preventable radioiodine ablations and 15 preventable deaths were associated with more radical thyroid resection.

CONCLUSION

Improvements in surgical technique and change in surgical strategy significantly decreased the prevalence of recurrent laryngeal nerve palsy, hypoparathyroidism, and recurrent disease as well as reduced public health costs associated with recurrent goiter.

[The abdominal catastrophe]

Patients with an abdominal catastrophe are in urgent need of early, interdisciplinary medical help. The treatment plan should be based on medical priorities and clear leadership. First priority should be given to achieve optimal oxygenation of blood and stabilization of circulation during all treatment-phases. The sicker the patient, the less invasive the (surgical) treatment should to be, which means "damage control only". This short article describes 7 important, pragmatic rules that will help to increase the survival of a patient with an abdominal catastrophe. Preexisting morbidity and risk factors must be included in the overall risk-evaluation for every therapeutic intervention. The challenge in patients with an abdominal catastrophe is to carefully balance the therapeutic stress and the existing resistance of the individual patient. The best way to avoid abdominal disaster, however, is its prevention.

Intrathyroid adenomas in primary hyperparathyroidism: are they frequent enough to guide surgical strategy?

BACKGROUND

Ectopic parathyroid adenoma, including intrathyroid adenoma, is a common cause of failed parathyroid operations. The aim of this study was to evaluate the operative strategy/outcome in patients with primary hyperparathyroidism (pHPT), with special regard to intrathyroid adenomas.

METHOD

The authors performed an analysis of all patients receiving operative treatment for pHPT from 2003 through 2005. The operative strategy consisted of systematic perithyroid exploration followed by extended cervical exploration in cases where the adenoma was not found initially. In cases of persistent, high intraoperative parathyroid hormone levels, hemithyroidectomy was performed on the side with higher suspicion of intrathyroid adenoma or with more extended thyroid changes.

RESULTS

During the study, 115 patients received surgical treatment for sporadic pHPT. A single parathyroid adenoma (normal parathyroid position) was found in 95 patients (82.6%), ectopic single adenoma was found in 7 patients (6.1%), and double adenomas were found in 10 (8.7%) patients. Operative failure occurred in 3 cases (2.6%). In all, 4 of 7 ectopic single adenomas were intrathyroidal and were removed by hemithyroidectomy according to the authors' standard protocol.

CONCLUSION

The strategy of (a) cervical exploration, (b) extended cervical exploration, and (c) hemithyroidectomy was highly successful for removing undetectable intrathyroid parathyroid adenomas during primary intervention, thereby reducing the risks associated with reintervention.

Laparoscopic incisional hernia repair is feasible and safe after liver transplantation

BACKGROUND

Incisional hernia is a common complication after liver transplantation. The current study evaluated incidence and risk factors for incisional hernia and compared laparoscopic and open hernia repair in terms of feasibility and outcome.

METHODS

A cohort of 225 patients was prospectively investigated. The median follow-up period was 61 months (range, 6-186 months). The study cohort had 31 patients who underwent open repair and 13 who underwent laparoscopic repair.

RESULTS

Incisional hernia, found in 57 patients (25%), had occurred after a median of 17 months (range, 5-138 months). The significant risk factors were male gender (p = 0.001) and body mass index (BMI) greater than 25 kg/m(2) (p = 0.002). A trend toward a lower recurrence rate (15% vs 35%; p = 0.28) and fewer surgical complications (15% vs 19%; p = 0.99) was found in the laparoscopic group.

CONCLUSIONS

Incisional hernia is a frequent complication after liver transplantation. Associated risk factors are male gender and a BMI greater than 25 kg/m(2). Laparoscopic hernia repair for such patients is feasible and safe.

Bridging hyperacute liver failure by ABO-incompatible auxiliary partial orthotopic liver transplantation

Uncontrollable intracranial pressure elevation in hyperacute liver failure often proves fatal if no suitable liver for transplantation is found in due time. Both ABO-compatible and auxiliary partial orthotopic liver transplantation have been described to control such scenario. However, each method is associated with downsides in terms of immunobiology, organ availability and effects on the overall waiting list.

Extended Resection for Thyroid Disease has Less Operative Morbidity than Limited Resection

BACKGROUND

Theodor Kocher, surgeon and Nobel laureate, has influenced thyroid surgery all over the world: his treatment for multinodular goiter-subtotal thyroidectomy-has been the "Gold Standard" for more than a century. However, based on a new understanding of molecular growth mechanisms in goitrogenesis, we set out to evaluate if a more extended resection yields better results.

METHODS

Four thousand three hundred and ninety-four thyroid gland operations with 5,785 "nerves at risk" were prospectively analyzed between 1972 and 2002. From 1972 to 1990, the limited Kocher resections were performed, and from 1991 to 2002 a more radical resection involving at least a hemithyroidectomy was performed.

RESULTS

The incidence of postoperative nerve palsy was 3.6%; in the first study period and 0.9%; in the second (P < 0.001, Fisher's exact). Postoperative hypoparathyroidism decreased from 3.2%; in the first period to 0.64%; in the second (P < 0.01). The rate of reoperation for recurrent disease was 11.1%; from 1972 to 1990 and 8.5%; from 1991 to 2002 (P < 0.01).

CONCLUSIONS

Extended resection for multinodular goiter not only significantly reduced morbidity, but also decreased the incidence of operations for recurrent disease. Our findings in a large cohort corroborate the suggestions that Kocher's approach should be replaced by a more radical resection, which actually was his original intention more than 130 years ago.

[Acute "difficult" gastrointestinal bleeding]

Gastrointestinal bleeding with its point of origin outside the reach of conventional gastro- and colonoscopy represents an extraordinary diagnostic and therapeutic challenge. Bleeding may originate from the small bowel distal to the duodenojejunal junction (middle gastrointestinal bleeding) or from the biliary tree (haemobilia) or from the pancreatic ductal system (haemosuccus pancreaticus). This particular type of gastrointestinal bleeding is often intermittend and caused by a variety of different pathologies. Angiography is the diagnostic method of choice for further investigation. It allows precise localization of the bleeding site and simultaneous interventional therapy (embolization/coiling). The importance of further diagnostic modalities such as scintigraphy, capsule endoscopy, push-enteroscopy and double-balloon-enteroscopy is discussed.

Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection—long term results

Background

It is not known whether pylorus-preserving duodenopancreatectomy is as effective as the classical Whipple procedure in the resection of pancreatic and periampullary tumours. A prospective randomized trial was undertaken to compare the results of the two procedures.

Methods

Clinical data, histological findings, short-term results, survival and quality of life of all patients having surgery for suspected pancreatic or periampullary cancer between June 1996 and September 2001 were analysed.

Results

Two hundred and fourteen patients were randomized to undergo either a standard or a pylorus-preserving Whipple resection. After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple operation and 64 pylorus-preserving resection) were entered into the trial. Of these, 110 patients with proven adenocarcinoma (57 standard Whipple and 53 pylorus-preserving resection) were analysed for long-term survival and quality of life. There was no difference in perioperative morbidity. Long-term survival, quality of life and weight gain were identical after a median follow-up of 63·1 (range 4–93) months. At 6 months, capacity to work was better after the pylorus-preserving procedure (77 versus 56 per cent; P = 0·019).

Conclusion

Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma

BACKGROUND

Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma.

METHODS

Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models.

RESULTS

Fifty-eight patients (15.8 per cent) underwent surgical exploration only, 97 patients (26.5 per cent) underwent palliative bypass surgery and 211 patients (57.7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9.0 per cent, stage II in 18.0 per cent, stage III in 68.7 per cent and stage IV in 4.3 per cent of patients who underwent resection. Resection was curative (R0) in 75.8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41.2 per cent), classical Whipple resection (37.0 per cent), left pancreatic resection (13.7 per cent) and total pancreatectomy (8.1 per cent). The in-hospital mortality and cumulative morbidity rates were 2.8 and 44.1 per cent respectively. The overall actuarial 5-year survival rate was 19.8 per cent after resection. Survival was better after curative resection (R0) (24.2 per cent) and in lymph-node negative patients (31.6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival.

CONCLUSION

Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained.

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma

Background

Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma.

Methods

Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models.

Results

Fifty-eight patients (15·8 per cent) underwent surgical exploration only, 97 patients (26·5 per cent) underwent palliative bypass surgery and 211 patients (57·7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9·0 per cent, stage II in 18·0 per cent, stage III in 68·7 per cent and stage IV in 4·3 per cent of patients who underwent resection. Resection was curative (R0) in 75·8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41·2 per cent), classical Whipple resection (37·0 per cent), left pancreatic resection (13·7 per cent) and total pancreatectomy (8·1 per cent). The in-hospital mortality and cumulative morbidity rates were 2·8 and 44·1 per cent respectively. The overall actuarial 5-year survival rate was 19·8 per cent after resection. Survival was better after curative resection (R0) (24·2 per cent) and in lymph-node negative patients (31·6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival.

Conclusion

Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained.

[Stomata--surgical standards]

The placement of an intestinal stoma is still a common procedure despite the recent advantages in intestinal surgery. It is mandatory to apply meticulously sound surgical principles in order to achieve good results. Nevertheless, intestinal stomas are envisioned with a high perioperative morbidity which is mostly caused by surgical inadequacy. This can lead to considerable problems in management of the stoma in the long term and ultimately will affect quality of life of the patient. The cumulative morbidity can be given by 50% with prolaps, hernia, stenosis and necrosis as well as stoma retraction being the most relevant. In contrast, an adequate intestinal stoma will positively affect the quality of life of the patient. The availability of devices developed by the industry and the inauguration of a professional service in certain hospitals simplified the management of patients with a stoma. This significantly improved the standards of care especially regarding preoperative preparation and postoperative management. Thus, most patients are able to maintain an active and socially integrated life with minimal physical and psychical limitations.

[Pro and contra lymphadenectomy in papillary and follicular thyroid gland carcinoma]

Patients with papillary and follicular thyroid carcinomas are said to have an excellent long-term prognosis. However, over 90% of papillary carcinomas have synchrone lymph node metastases. Based on clinical, histopathologic and molecular-biological factors, different patient groups can be defined with an increased recurrence rate and disease related mortality-rate of up to 50% in the long-term follow-up of 30 years. Therefore, not only the extent of the surgical resection of the thyroid cancer but also the lymph node dissection as an oncologic correct surgical procedure is of great importance. Although the position of surgical lymphadenectomy is still discussed controversially there are increasing reasons to support the concept of a radical initial operation following the rules of oncologic surgery. We consider total thyroidectomy and modified neck-dissection as the standard operation in well differentiated thyroid carcinoma. In unilateral carcinoma both the central and the ipsilateral cervico-lateral lymph node compartments are dissected. In multicentric bilateral carcinomas a bilateral cervico-central and cervico-lateral lymphadenectomy has to be performed.

[Stent or surgical bypass as palliative therapy in obstructive jaundice]

During the last decades, the mortality following pancreatic resections has decreased tremendously due to advances in operative technique and perioperative management. In order to examine if similar improvements have been achieved for surgical palliation of obstructive jaundice, we conducted an analysis of our series of surgical bypass procedures.

METHODS

Data from all patients undergoing surgical palliation after exploration for pancreatic carcinoma, were prospectively recorded.

RESULTS

Between 1.11.93 to 1.11.99 a total of 348 patients were treated with a tumor of the pancreas. 74 of these patients received a bypass procedure: there were 40 double bypass, 20 biliary and 14 gastric bypass procedures. Overall morbidity and mortality was 35% and 1.2% respectively. Median in-hospital stay was 12 days (range 6-37). Median survival time was 5 months (range 1-25). Neither the type of surgical palliation, age nor perioperative risk assessment according to the ASA classification affected perioperative mortality. In contrast, jaundiced patients had significantly more postoperative complications than non-jaundiced patients (58% versus 18%; p = 0.001).

CONCLUSIONS

Surgical palliation can nowadays be performed with great safety. A double bypass procedure consisting of a hepatojejunostomy combined with a gastrojejunostomy seems to be the procedure of choice for patients with unresectable pancreatic carcinoma.

[Surgery of pancreatic carcinoma]

Pancreatic cancer is the third leading neoplasm of the gastrointestinal system and has a dismal prognosis. The majority of patients are no more suitable for resection at time of diagnosis due to early development of distant metastases or major infiltration of adjacent structures. However, due to the resistance of pancreatic cancer against radiation and chemotherapy, radical resection represents the only therapy with a potential for cure. For the surgical treatment of pancreatic head cancer, the classical Whipple operation is still the standard procedure but during the last two decades, pylorus-preserving pancreatoduodenectomy has been evolved as a more conservative procedure in order to omit the consequences of partial gastrectomy. For cancer of the pancreatic body and tail, distal pancreatectomy or total pancreatectomy represent the current standard treatment. More radical methods like regional pancreatectomy and resection with extended lymph node dissection have failed so far to demonstrate any improvements in long-term survival compared to the standard types of resection. To further improve the treatment of pancreatic cancer, prospectively randomized trials are needed to compare extended surgical procedures with the standard types of resection and the efficiency of various adjuvant therapies.

[Liver resection for liver metastases--1998 Bern Symposium]

The increasing knowledge of the anatomy and function of the liver made the surgical resection of liver metastases currently to the therapy of choice. Although liver metastasis is an advanced stage in tumor-progression, surgery achieves the best long-term results due to a better understanding of the carcinogenesis (i.e. micrometastases) and the prognostic risk factors. This study summarizes the results of 109 resections of colorectal and non-colorectal liver metastases during a period of 59 months at our department. Four different surgical techniques (extended hepatectomy vs. segmental resection vs. atypical resection vs. biopsy) were investigated. For resections a tumour-free resection margin of at least 10 mm was always attempted to achieve. The accumulated morbidity of all techniques together was 23%. Although the morbidity was higher for extended resections (Encephalopathy 16% vs. 2.3% for segmental resections, Liver insufficiency 23% vs. 4.7%), compared to the limited resection procedures, the long-term survival improved. The overall mortality was 2.7%. Survival was higher in patients with resection of colorectal than non colorectal metastases. Our results indicate that liver resection, under observance of the anatomical and functional margins (i.e. an adequate resection margin), is the only potentially curative therapy for liver metastases. An extensive formal resection, although inducing a higher perioperative morbidity, is superior to the limited resection techniques and results in an increased long-term survival. One reason is the increased probability of co-resection of preoperatively undetected local micrometastases.

[Pylorus preserving or classical Whipple operation in tumors. Initial clinical results of a prospective randomized study]

During the last decades, the classical Whipple resection (cWhipple) and pylorus-preserving Whipple (ppWhipple) operation have been evolved for the resection of cancer of the pancreatic head. However no definitive answer exists whether the more conservative ppWhipple indeed equalizes the short and long term results of the cWhipple procedure.

METHODS

Therefore we conducted a randomized prospective trial in a non-selected, consecutive patient series. All relevant data concerning patient's demographics, intraoperative and histological findings as well as postoperative mortality morbidity and follow-up after discharge were analyzed.

RESULTS

From 6/96 to 10/99 139 patients with suspicion of pancreatic or periampullary tumor were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat). Based on the inclusion and exclusion criteria, 93 of these patients were finally analyzed in the study. There were 51 cWhipple and 42 ppWhipple resections. There were no differences concerning age, sex, ASA classification, tumor type and stage, length of ICU- and in-hospital stay. However, the ppWhipple group had a significant shorter operation time. There was no difference in mortality and morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 76 patients with histological proven pancreatic or periampullary carcinoma were analyzed. There was no difference in tumor recurrence and in long-term survival after a median follow-up of 1.5 years (0.1-3.5).

CONCLUSION

Our intermediate results demonstrate that cWhipple and ppWhipple are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.

Acute necrotizing pancreatitis: treatment strategy according to the status of infection

OBJECTIVE

To determine benefits of conservative versus surgical treatment in patients with necrotizing pancreatitis.

SUMMARY BACKGROUND DATA

Infection of pancreatic necrosis is the most important risk factor contributing to death in severe acute pancreatitis, and it is generally accepted that infected pancreatic necrosis should be managed surgically. In contrast, the management of sterile pancreatic necrosis accompanied by organ failure is controversial. Recent clinical experience has provided evidence that conservative management of sterile pancreatic necrosis including early antibiotic administration seems promising.

METHODS

A prospective single-center trial evaluated the role of nonsurgical management including early antibiotic treatment in patients with necrotizing pancreatitis. Pancreatic infection, if confirmed by fine-needle aspiration, was considered an indication for surgery, whereas patients without signs of pancreatic infection were treated without surgery.

RESULTS

Between January 1994 and June 1999, 204 consecutive patients with acute pancreatitis were recruited. Eighty-six (42%) had necrotizing disease, of whom 57 (66%) had sterile and 29 (34%) infected necrosis. Patients with infected necrosis had more organ failures and a greater extent of necrosis compared with those with sterile necrosis. When early antibiotic treatment was used in all patients with necrotizing pancreatitis (imipenem/cilastatin), the characteristics of pancreatic infection changed to predominantly gram-positive and fungal infections. Fine-needle aspiration showed a sensitivity of 96% for detecting pancreatic infection. The death rate was 1.8% (1/56) in patients with sterile necrosis managed without surgery versus 24% (7/29) in patients with infected necrosis (P <.01). Two patients whose infected necrosis could not be diagnosed in a timely fashion died while receiving nonsurgical treatment. Thus, an intent-to-treat analysis (nonsurgical vs. surgical treatment) revealed a death rate of 5% (3/58) with conservative management versus 21% (6/28) with surgery.

CONCLUSIONS

These results support nonsurgical management, including early antibiotic treatment, in patients with sterile pancreatic necrosis. Patients with infected necrosis still represent a high-risk group in severe acute pancreatitis, and for them surgical treatment seems preferable.

Liver nodules resembling focal nodular hyperplasia after hepatic venous thrombosis

We report the case of focal nodular hyperplasia-like nodular hepatic lesions, that developed in the liver of a 35-year-old Caucasian female who required orthotopic liver transplantation for Budd-Chiari syndrome. The rapid development of focal nodular hyperplasia-like lesions in a severe hepatic vascular disorder and in the absence of cirrhosis may represent an additional argument in favor of the vascular origin of focal nodular hyperplasia. The pathogenesis of the nodules is not clear, but pathological arterialization of the liver in hepatic vein thrombosis may be a candidate mechanism.

Randomized prospective trial of pylorus-preserving vs. Classic duodenopancreatectomy (Whipple procedure): initial clinical results

During the past decades, the classic Whipple resection (cWhipple) and the pylorus-preserving Whipple (ppWhipple) operation have been advanced for the resection of cancer of the pancreatic head. However, no definitive answer exists as to whether the more conservative ppWhipple operation indeed equalizes the short- and long-term results of the cWhipple procedure. Therefore we conducted a randomized prospective trial in a nonselected series of consecutive patients. Demographics, diagnostic, intraoperative, and histologic findings (tumor type and tumor stage of these patients) as well as postoperative mortality, morbidity, and follow-up after discharge were analyzed. For statistical evaluation Kruskal-Wallis and chi-square tests were used where appropriate. Survival was analyzed according to Kaplan-Meier curves, and differences were examined using the log-rank test. From June 1996 to April 1999, a total of 114 patients with suspected pancreatic or periampullary tumors were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat) operation. Based on the inclusion and exclusion criteria, 77 of these patients were included in the final analysis. Forty had a cWhipple and 37 had a ppWhipple resection. There were no differences with regard to age, sex distribution, ASA classification, histologic classification, UICC stage, length of stay in the intensive care unit, and length of hospital stay. The ppWhipple group had a significantly shorter operative time, reduced blood loss, and fewer blood transfusions. There was no difference in mortality, but the cWhipple group showed a significantly higher total morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 61 patients with histologically proven pancreatic or periampullary carcinoma were analyzed. There were no differences in tumor recurrence or in long-term survival at a median follow-up of 1.1 years (range 0.1 to 2.9 years). Our initial results demonstrate that the cWhipple and ppWhipple operation are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.

Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon

PURPOSE

Stercoral perforation of the colon is reported to be a rare disease with poor prognosis. The aim of this study was to determine the frequency of stercoral perforation of the colon, to define diagnostic criteria for stercoral perforation of the colon, and to analyze the patient outcome in a university hospital gastrointestinal surgery unit.

METHODS

From November 1993 until November 1998 all surgically treated patients with a colorectal disease were prospectively recorded in a computerized database. Diagnosis of stercoral perforation of the colon was made if 1) the colonic perforation was round or ovoid, exceeded 1 cm in diameter, and lay antimesenteric; 2) fecalomas were present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site were present microscopically. Any additional colon pathology led to exclusion from the diagnosis of stercoral perforation of the colon. Using the same criteria, 81 cases in the literature were found to qualify and were further analyzed.

RESULTS

In a five-year period 1,295 patients underwent colorectal interventions through laparotomy. A total of 566 (44 percent) cases were emergencies, 220 (17 percent) of these caused by colonic perforation. Seven patients had stercoral perforation of the colon. The incidence of stercoral perforation of the colon was 0.5 percent of all surgical colorectal procedures through laparotomy, 1.2 percent of all emergency colorectal procedures, and 3.2 percent of all colonic perforations. The mean age of the patients was 59 (median, 64; range, 22-85) years. All perforations were situated in the left hemicolon or upper rectum. The round or ovoid perforation had a mean diameter of 3.6 cm. Fecalomas were present in all patients and protruded from the perforation site or were found within the free abdominal cavity in three of them. Generalized stercoral peritonitis was a constant finding. Using a colonic resection without immediate restoration of continuity, an extensive intraoperative lavage, and antibiotics, there was no in-hospital mortality. Analysis of the reports in the literature revealed additionally that 28 percent of patients with stercoral perforation of the colon have multiple stercoral ulcers in the colon and that substantial mortality is encountered if only minor surgical procedures of treatment are used.

CONCLUSIONS

The incidence of stercoral perforation of the colon seemed to have been underestimated. The reason for this might be the lack of defined diagnostic criteria for this disease. Low mortality is obtained by early surgical eradication of the affected part of the colon, including all stercoral ulcers, and by aggressive therapy for peritonitis.

Conservative surgical treatment of diffuse peritonitis

BACKGROUND

Peritonitis is, even today, a significant source of death and complications. The objective of this study was to determine the morbidity and mortality rates, the incidence of reoperations, and the need for additional treatment strategies (on demand) in patients with diffuse peritonitis.

METHODS

Prospective analysis including all patients (n = 258) with diffuse peritonitis admitted to our surgical service between November 1993 and April 1998 who underwent a uniform surgical treatment concept of peritonitis including early intervention, source control, and extensive intraoperative lavage.

RESULTS

The 258 patients with diffuse peritonitis averaged a mean Mannheim Peritonitis Index of 27.1 points (range, 11-43 points). Source control at the initial operation was possible in 230 of the patients (89%), of those, 21 patients (9%) needed reintervention. In 28 patients (11%), source control was not possible at the initial operation. Twenty of these patients (71%) had to undergo additional treatment strategies (on demand) such as continuous lavage and/or laparostomy. Overall 228 of the 258 patients (88%) needed just 1 initial surgical intervention. The overall morbidity rate was 41%; the rate of reoperation was 12%, and the hospital mortality rate was 14%.

CONCLUSIONS

A conservative surgical treatment concept supplemented with "extensive" intraoperative lavage reduces the reoperation rate compared with other treatment standards of peritonitis and achieves a low mortality rate in patients with diffuse peritonitis.

Early acute cellular rejection: no effect on late hepatic allograft function in man

Whereas early acute cellular rejection, even if successfully treated, seems to have an impact on late function and survival of kidney and heart transplants, little quantitative data are available on its effect(s) on liver transplants. Routine liver function tests, the functioning liver cell mass (galactose elimination capacity) and microsomal metabolic capacity (aminopyrine breath test) were determined prospectively in 37 consecutive patients 1 year after liver transplantation. Of these, 19 (7 females and 12 males, 32-69 years of age) had previously required treatment for at least one biopsy proven acute cellular rejection episode occuring a median 7 days after grafting, while 18 (6 females and 12 males, 30-67 years of age) had not. The functioning liver cell mass and microsomal metabolic capacity were both within normal limits for the majority of patients and did not differ significantly between patients with and without previous acute cellular rejection episodes. In contrast to other solid organ transplants, early acute cellular rejection episodes do not affect late function of liver allografts in man.

[Surgery of the goiter]

Surgery of the goiter has been greatly influenced by Theodor Kocher all over the world. Dedicated to his understanding of goiterogenesis he is considered the father of the prevention and elimination of the wide spread iodine deficiency goiter disease in Switzerland by introducing the iodinesation of salt. Therefore Switzerland is the only country in Europe, which is no longer an iodine deficiency region but remains an endemic goiter region. The traditional conservative Kocher type of surgical resection of the multinodular goiter showed to harbour the problem of a high recurrence rate. The analysis of our Bernese data (3193 thyroid operations with 4395 nerves at risk) brought us to the point to question this traditional surgical strategy. In order to lower the recurrence rate and in addition to lower surgical morbidity we started from 1990 to resect much more thyroid tissue in order to resect all pathologic thyroid tissue. This meant as a minimal surgical procedure, a thyroidectomy on one side followed by a subtotal resection on the contralateral side in case of bilateral disease. The surgical concept in parallel was supported by the novel molecular biological concept of goiterogenesis presented by our Bernese research team, which could demonstrate that the potential for goiterogenesis and clonal growth of functional and morphological independent cluster is distributed all over the whole thyroid gland. Therefore a more radical resection at the first operation will resect much more potential clones at risk to become recurrent goiters than the 'old' conservative resection type. With the more radical initial resection combined with a routine demonstration of the recurrent laryngeal nerve and the parathyroid glands we could reduce the recurrent laryngeal nerve palsy from 2.7% (nerves at risk) in the early period (1972-1990) to 0.7% with the more radical resection (1991-1996, p < 0.05). In parallel the postoperative hypoparathyroidism of the early period of 3.6% could be lowered to 1% in the actual series (p < 0.05). Theodor Kocher's conservative thyroid gland surgical concept has now one century later found a correction by a Bernese team again, which could significantly reduce the morbidity of thyroid gland surgery and as well, will greatly reduce the incidence of recurrent goiter disease after initial surgery in our endemic region.

Primary liver disease as a determinant for acute rejection after liver transplantation

BACKGROUND

Graft rejection and infection remain major problems following liver transplantation; both are heavily influenced by the immunosuppressive regimen. Despite the disparity in the primary disease leading to transplantation, all patients receive the same posttransplant immunosuppressive treatment in a given center. The aim of this study is to detect a possible effect of the underlying disease on the incidence of early acute rejection episodes after orthotopic liver transplantation (OLT).

PATIENTS AND METHODS

Retrospective analysis on all 101 consecutive liver transplants performed in 95 patients between 1983 and March 1998; five of these patients, surviving less than 30 days, were not included. The immunosuppressive regimen was based on conventional triple therapy during the whole study period. The diagnosis and treatment of acute rejection within the first 30 days post-OLT was uniform throughout the whole study period.

RESULTS

Though there were no differences with respect to patients' characteristics [age, child classification, number of HLA-mismatches or cytomegalovirus (CMV)-serocompatibility], patients with primary biliary cirrhosis (PBC) showed a significant increase of acute rejection after OLT compared with the other patients transplanted for other liver diseases (P = 0.024). The incidence of infection was not elevated in patients transplanted for PBC when compared with other diagnoses.

CONCLUSION

Our results indicate that primary liver disease may be a determinant for acute graft rejection in PBC. Furthermore, these results suggest that immunosuppressive regimens based on the underlying disease should be considered.

[New approaches to the surgical treatment of diffuse peritonitis]

OBJECTIVE

We intend to analyze if additional treatment concepts are necessary in any case as a part of the standard therapy next to the well established principle of source control in the treatment of secondary peritonitis.

DESIGN

A treatment concept with early intervention, source control and extensive intraoperative lavage (20-301) should be evaluated as a standard procedure in a prospective survey. Additional treatment concepts will be applied only for special reason (on demand).

RESULTS

From 11/1993 to 9/1997 241 patients with diffuse peritonitis were treated with the concept mentioned above. Additional treatment concepts as continuous postoperative lavage (n = 20) and staged lavage (n = 4) were applied as primary treatment in 24 patients only (10%), mainly for impossibility of source control and evisceration. Source control at the initial operation was possible in 216 patients (90%). Due to secondary evisceration 3 patients had to undergo laparostomy for staged lavage later. Severity of peritonitis was determined according to the Mannheim Peritonitis Index (median 26, range 15-43). The primary causes of peritonitis were perforation, leakage and abscess after operation (n = 56), followed by diverticular (n = 42) and gastric or duodenal perforation (n = 39). The hospital mortality rate was 14% in the whole group, and the postoperative morbidity rate was 39%.

CONCLUSIONS

Due to progress in intensive care and antibiotic treatment only a few patients (ca. 10%) need additional therapies such as postoperative or staged lavage. Surgical source control in combination with intraoperative lavage is sufficient in most of the patients with diffuse peritonitis.