Comparison of 17,641 patients with right- and left-sided colon cancer: differences in epidemiology, perioperative course, histology, and survival

PURPOSE

There is a growing amount of data suggesting that carcinomas of the right and left colon should be considered as different tumor entities. Using the data and analysis compiled in the German multicentered study "Colon/Rectum Cancer," we aimed to clarify whether the existing differences influence clinical and histological parameters, the perioperative course, and the survival of patients with right- vs left-sided colon cancer.

METHODS

During a 3-year period data on all patients with colon cancer were evaluated. Right- and left-sided cancers were compared regarding the following parameters: demographic factors, comorbidities, and histology. For patients who underwent elective surgery with curative intent, the perioperative course and survival were also analyzed.

RESULTS

A total of 17,641 patients with colon carcinomas were included; 12,719 underwent curative surgery. Patients with right-sided colon cancer were significantly older, and predominantly women with a higher rate of comorbidities. Mortality was significantly higher for this group. Final pathology revealed a higher percentage of poorly differentiated and locally advanced tumors. Rate of synchronous distant metastases was comparable. However, hepatic and pulmonary metastases were more frequently found in left-sided, peritoneal carcinomatosis in right-sided carcinomas. Survival was significantly worse in patients with right-sided carcinomas on an adjusted multivariate model (odds ratio, 1.12).

CONCLUSIONS

We found that right- and left-sided colon cancers are significantly different regarding epidemiological, clinical, and histological parameters. Patients with right-sided colon cancers have a worse prognosis. These discrepancies may be caused by genetic differences that account for distinct carcinogenesis and biological behavior. The impact of these findings on screening and therapy remains to be defined.

Primary appendiceal carcinoma--epidemiology, surgery and survival: results of a German multi-center study

BACKGROUND

While carcinoma of the colon is a common malignancy, primary carcinoma of the appendix is rare. Many retrospective reviews outlined experience from different centers on appendiceal neoplasms. However, the study population is often small because it is so rare. The aim of this study was to analyze the type of surgery and survival of patients with appendiceal malignancies using data from a German multi-center observational study (31 341 patients).

METHODS

During a five-year period, 196 consecutive patients with malignant appendiceal tumors were distributed into four groups: appendiceal carcinoids, adenocarcinoma, mucinous adenocarcinoma and adenosquamous carcinoma. The following parameters were analyzed: demographics, clinical presentation, comorbidities, type and appropriateness of surgery, final pathology and survival.

RESULTS

Adenocarcinoma had the highest incidence (50.5%). The most common presentation was that of acute appendicitis. Mean age at presentation was youngest for carcinoid tumors. Carcinoid tumors had lowest tumor size and localized disease was present in 72.9%. Metastatic spread at presentation was highest for adenosquamous and mucinous adenocarcinoma and each had a distinct pattern. Right hemicolectomy was performed in 71.4%, limited resection in 11.7%. Overall 5-year survival was 83.1% for carcinoid vs. 49.2% for non-carcinoid tumors. Histological subtype and tumor stage significantly affected survival.

CONCLUSIONS

Long-term outcome of carcinoid tumors is superior to non-carcinoid neoplasms. Among all appendiceal neoplasms, adenosquamous carcinoma is the rarest histological subtype which is most commonly associated with advanced tumor stage and worst prognosis. Appropriate oncologic resection is being performed in a significant percentage of cases in Germany. However, the high rate of right hemicolectomy in patients with small carcinoid tumors needs to be critically discussed.

Colon carcinoma--classification into right and left sided cancer or according to colonic subsite?--Analysis of 29,568 patients

BACKGROUND

It is common to distinguish between right and left colon cancer (RCC and LCC). But, little is known about the influence of its exact location on the tumor stage and characteristics when considering the colonic subsite within the right or left colon.

METHODS

During a five-year period, 29,568 consecutive patients were evaluated by data from the German multi-centered observational study "Colon/Rectal Carcinoma". Patients were split into 7 groups, each group representing a colonic subsite. They were compared regarding demographic factors, tumor stage, metastatic spread and histopathological characteristics.

RESULTS

Analysis of tumor differentiation and histological subtype revealed a linear correlation to the ileocecal valve, supporting the right and left side classification model. However, cancers arising from the RCC's cecum (52.3%) and LCC's splenic flexure (51.0%) showed the highest proportion of UICC stage III/IV tumors and lymphatic invasion, whereas the RCC's ascending colon (46.5%) and LCC's descending (44.7%) showed the lowest, which supports a more complex classification system, breaking down the right and left sides into colonic subsites.

CONCLUSIONS

Age, tumor grade and histological subtype support the right and left side classification model. However, gender, UICC stage, metastatic spread, T and N status, and lymphatic invasion correlated with a specific colonic subsite, irrespective of the side. The classification of RCC or LCC provides a general understanding of the tumor, but identification of the colonic subsite provides additional prognostic information. This study shows that the standard right and left side classification model may be insufficient.

Laparoscopic approach to colorectal procedures in the obese patient: risk factor or benefit?

BACKGROUND

Obesity is a modern-day phenomenon that is increasing throughout the world. The aim of the present study was to provide data to establish whether the laparoscopic approach to colorectal surgery in the obese patient represents a risk or, rather, a benefit for the patient.

METHOD

The data presented in this paper were obtained within the framework of a prospective multicenter study initiated by the "Laparoscopic Colorectal Surgery Study Group (LCSSG)" and performed on 5,853 recruited patients. The perioperative course was compared between the three groups: nonobese, obesity grade I, and obesity grade II/III.

RESULTS

Increasing body mass index correlated with a highly significant increase in the duration of the operation (nonobese 167 min, grade I 182 min, grade II/III 191 min; p < 0.001) and in the conversion rate (nonobese 5.5%, obesity grade I 7.9%, obesity grade II/III 13.1%; p < 0.001). The intraoperative complication rate also showed a tendency to increase (nonobese 5.0%, grade I 6.2%, grade II/III 7.1%; p = 0.219). In contrast, no significant differences were found between the groups with regard to the postoperative complication rate (nonobese 20.7%, grade I 21.0%, grade II/III 20.2%), the reoperation rate (nonobese 4.1%, grade I 3.9%, grade II/III 3.6%), and the postoperative mortality rate (nonobese 1.1%, grade I 1.9%, grade II/III 1.8%).

CONCLUSION

Laparoscopic colorectal surgery is clearly more technically demanding in the obese patient. Apart from this, however, it is not associated with any increased risk of postoperative complications, and thus demonstrates that the pathologically overweight patient can benefit to a particular degree from the laparoscopic modality.

Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently being performed with increasing frequency worldwide. It offers an excellent weight loss and resolution of comorbidities in the short term with a very low incidence of complications. However, the ever present risk of a staple line leak is still a major concern.

METHODS

Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered in an online database and analyzed at the Institute of Quality Assurance in Surgical Medicine. For the current analysis, all patients that had undergone primary sleeve gastrectomy for morbid obesity within a 7-year period were considered.

RESULTS

Using the GBSR, data from 5.400 LSGs were considered for analysis. Staple line leak rate decreased during the study period from 6.5 to 1.4 %. Male gender, higher BMI, concomitant sleep apnea, conversion to laparotomy, longer operation time, use of both buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate. On multivariate analysis, operation time and year of procedure only had a significant impact on staple line leak rate.

CONCLUSIONS

The results of the current study demonstrated that there are factors that increase the risk of a leakage which would enable surgeons to define risk groups, to more carefully select patients, and to offer a closer follow-up during the postoperative course with early recognition and adequate treatment. All future efforts should be focused on a further reduction of serious complications to make the LSG a widely accepted and safer procedure.

Prospective evaluation of circulating hepatocytes by alpha-fetoprotein messenger RNA in patients with hepatocellular carcinoma

BACKGROUND

The significance of alpha-fetoprotein (AFP) messenger RNA as a surrogate marker for isolated tumor cells in the blood of patients with hepatocellular carcinoma (HCC) is controversial. Our goals were to correlate AFP mRNA with tumor recurrence and overall survival after patients with HCC received curative operations and to analyze AFP mRNA findings in control patients.

METHODS

In this prospective controlled study, RNA was purified from the blood of 85 patients with HCC before, during, and after therapy and from 116 control patients. Complementary DNA synthesis by reverse transcriptase and polymerase chain reaction amplification was performed with primers specifically for the AFP gene. Patients with HCC were divided into 4 subgroups depending on the therapy performed: (1) orthotopic liver transplantation (OLT), (2) resection, (3) transarterial chemoembolization, and (4) no therapy.

RESULTS

AFP mRNA was detected in 28% of the patients with HCC and 3% of the control patients (P <.01) before therapy. Of patients with HCC and OLT, 2 of the 6 patients who were AFP mRNA positive had a recurrence; none of the 4 patients who were negative had a recurrence. In the HCC patients who underwent tumor resection or received no therapy, the survival rates did not differ between patients who were AFP mRNA positive and negative (P =.21 and P =.94, respectively). After the tumor resection, no difference in survival at 2 years was evident in patients who were AFP mRNA positive versus those who were AFP mRNA negative. In the HCC patients who had curative operations (OLT and resection) the sensitivity and specificity of this test for tumor recurrence were 73% and 53%, respectively, excluding surgical mortality. The International Union Against Cancer tumor stages in the subgroups of OLT and resection showed no differences between patients with positive and negative findings (P =.76 and P =.15, respectively). AFP mRNA results and serum AFP levels revealed no correlation (P =.45).

CONCLUSIONS

The qualitative measurement of AFP mRNA in the blood of patients with HCC is not a clinically relevant method for determining therapy and prognosis, especially if AFP mRNA is detected during the surgical procedure or any other liver manipulation.

Laparoscopic resection for endoscopically unresectable colorectal polyps: analysis of 525 patients

BACKGROUND

For the management of endoscopically irretrievable polyps, several minimally invasive procedures are currently available as alternatives to conventional laparotomy. However, the high rate of malignant transformation despite initially benign histology continues to be a problem.

METHODS

Within the framework of a prospective multicenter observational study, all patients with adenomatous polyps unsuitable for endoscopic removal and with benign histology were investigated. In addition to an analysis of the perioperative course and the definitive histology, the overall and disease-free survival rates of patients with malignant transformation of colorectal adenomas were also calculated.

RESULTS

A total of 525 patients (median age 65.3 years; median body mass index 25.6 kg/m(2)) underwent a laparoscopic resection. Conversion to laparotomy became necessary in 17 (3.2%) cases. The perioperative morbidity rate was 20.8%, and malignant transformation occurred in a total of 18.1% of the adenomatous polyps. The median number of lymph nodes removed was 12, and lymph node metastases were seen in a total of 14.8% of the patients (T1--4.8%, T2--19.4%, T3--25%, T4--100%). Estimated 5-year overall and disease-free survival rates were 92.4% and 80.6%, respectively.

CONCLUSIONS

For the management of endoscopically unresectable polyps, laparoscopic resection is currently the technique of choice. In addition to the benefits of minimally invasive surgery, in the hands of an experienced surgeon it achieves results comparable with those of open surgery. In view of the high rate of malignant transformation and the absence of unequivocal factors predictive of already present malignant transformation, an oncologically radical operation is essential. In the elderly patient presenting with comorbidities limited resection aiming to minimize surgical trauma in potentially benign disease may be considered. In such a case, however, frozen-section histology is obligatory.

Validation of the ‘Marburg bone bank system’ for thermodisinfection of allogenic femoral head transplants using selected bacteria, fungi, and spores

The Marburg Bone Bank System 'Lobator sd-2' is widely used to process human femoral heads removed during aseptic surgery by thermal disinfection. The inactivating capacity of the thermodisinfection system was validated in compliance with current standards using a newly developed femoral head model. The following micro-organisms, bacteria and fungi, taken from the American Type Culture Collection were investigated: Staphylococcus aureus, Staphyloccus epidermidis, Enterococcus faecium, Pseudomonas aeruginosa, Bacillus subtilis including spores, Clostridium sporogenes, Mycobacterium terrae, Candida albicans and Aspergillus niger spores. Highly enriched suspensions of these micro-organisms were applied to the centre of the femoral heads. The reduction in the number of micro-organisms was determined by counting the colony-forming units (cfu) before and after processing the spiked test device in the 'Lobator sd-2' system. Vegetative bacteria, fungi and fungal spores were completely inactivated (reduction factor >/=6 log(10)). The numbers of B. subtilis and C. sporogenes spores, both known to be heat-resistant, were reduced by one to two orders of magnitude. These bacteria serve as a model for spore forming pathogens which are not relevant in femoral heads from living donors. By processing human femoral heads from living donors by thermal disinfection using the Marburg Bone Banking system, a high level of safety is achieved regarding clinically relevant pathogens. To further increase the safety of the thermally treated femoral heads, we recommend that the medical history and present state of the donor, as well as the necessary serological tests should be taken into account.

Influence of anatomical subsite on the incidence of microsatellite instability, and KRAS and BRAF mutation rates in patients with colon carcinoma

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

Weight loss and changes in salivary ghrelin and adiponectin: comparison between sleeve gastrectomy and Roux-en-Y gastric bypass and gastric banding

BACKGROUND

Weight loss is associated with increased levels of adiponectin with a greater increase observed following Roux-en-Y gastric bypass (RYGB) compared to restrictive procedures. However, currently there are no data on changes in adiponectin following laparoscopic sleeve gastrectomy (LSG). Ghrelin was reported to be also produced by the salivary glands. There are also no data available regarding its changes following bariatric surgery.

METHODS

The present study examined weight loss, and salivary ghrelin and HMW adiponectin levels in 43 morbidly obese subjects undergoing three different types of bariatric surgery.

RESULTS

We found that weight loss following LSG is superior to laparoscopic adjustable gastric banding (LAGB) and comparable to RYGB at 12 months after surgery. Although blood glucose decreased similarly following all three procedures, fasting insulin continuously declined only in LSG and RYGB patients. Changes in both fasting and postprandial salivary ghrelin greatly varied between all three procedures with no similarities to changes in serum ghrelin reported in the literature. HMW adiponectin significantly increased following LSG, and this increase was more marked than in LAGB patients and almost identical compared to RYGB.

CONCLUSIONS

Weight loss following LSG is comparable to RYGB in the short term. Changes in HMW adiponectin are comparable following LSG and RYGB which may further contribute to the successful results after LSG. Furthermore, the results of the present study support the hypothesis that there is an autonomous production of ghrelin in salivary glands irrespective of nutritional status and weight loss.

Is a one-step sleeve gastrectomy indicated as a revision procedure after gastric banding? Data analysis from a quality assurance study of the surgical treatment of obesity in Germany

BACKGROUND

Since 1 January 2005, the outcomes of bariatric surgeries have been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg.

METHODS

Data are collected in an online data bank. Data collection began in 2005 for the results of gastric banding (GB) and in 2006 for sleeve gastrectomies (SGs). In addition to primary bariatric operations, data regarding the complications of revision procedures and redo operations have been analyzed. Participation in the quality assurance study is required for all certified centers in Germany.

RESULTS

SGs are a popular redo operation after failed gastric banding. Using the German Bariatric Surgery Registry, we analyzed data from 137 SGs that were used in a one-step approach after GB and 37 SGs that were used in a two-step approach. Leakage rates for primary SGs dropped to 1.9 %. The incidence of leakage after a one-step SG after GB is significantly higher (4.4 %) than for a two-step approach (0 %).

CONCLUSION

SGs are popular procedures after failed GB in Germany, but the complication rates for one-step band removal are higher than for a two-step approach. After examining the data, we suggest performing band removal and SG as a two-step procedure. Further analysis is necessary to evaluate the optimal time period between band removal and SG. Follow-up investigations must be performed to determine if SG is an effective and safe option after GB.

Comparison of the efficacy of virus inactivation methods in allogeneic avital bone tissue transplants

Several procedures for inactivating viruses are used presently in the context of bone tissue transplants. Common methods used are gamma irradiation (25 kGy), treatment with moist heat (82.5 degrees C/15 min., lobator-sd2-system) as well as chemical sterilisation using peracetic acid-ethanol treatment (PES, 2% peracetic acid, 96% ethanol, Aqua [2:1:1], 200 mbar, agitation, 4 hours). Based on national and international guidelines, we tested the antivirucidal effectiveness of these methods in human bone transplants. Three enveloped viruses: human immunodeficiency virus type 2 (HIV-2), pseudorabies virus (PRV), bovine virus diarrhoea virus (BVDV), and three non-enveloped viruses were used: hepatitis A virus (HAV), poliovirus (PV-1), porcine/bovine parvovirus (PPV, BPV). Defatted spongiosa cuboids served as model in chemical treatment experiments, while cortical diaphyses were used in gamma irradiation experiments, and the effects of thermal treatment were tested in prepared femoral heads. The log(10) reduction was measured by cytopathogenic effects after virus titration (TCID(50)/mL). A dose of at least 33.9 kGy (bone model) at -30 +/- 5 degrees C was necessary to achieve a sufficient reduction (4 log(10) steps) of BPV, the most resistant one of all viruses investigated. Thermal treatment as well as PES treatment led to a reduction of virus titres by more than 4 log(10). Only HAV showed a reduction below 4 log(10) (2.87) with PES. After validation of the defatting step included for HAV-infected cells, a HAV-reduction of over 7 log(10) was found. All three sterilisation methods tested are recommended for bone transplant sterilisation, but only provided that additional safety measures (anamnestic informations, infectious serology, PCR in case of multiorgan donors) are taken.

Virus inactivation in bone tissue transplants (femoral heads) by moist heat with the 'Marburg bone bank system'

Several virus inactivation procedures like heat treatment, gamma irradiation and chemical sterilization are used to increase the safety of bone tissue transplants. In this study we present data on the virus-inactivating effect of heat disinfection on human femoral heads, using the Marburg bone bank system 'Lobator sd-2'. Three enveloped viruses (human immunodeficiency virus type 2 [HIV-2], bovine viral diarrhoea virus as a model for Hepatitis C virus [HCV], and the herpesvirus pseudorabies virus), and three non-enveloped viruses (hepatitis A virus, poliomyelitis virus, and bovine parvovirus) were investigated. In a model system the central part of human femoral heads was contaminated with the respective cell-free virus suspension, establishing a direct contact between virus and native bone tissue. The core temperature in the femoral heads during the sterilization process was determined in additional model experiments. A temperature of 82.5 degrees C, given by the manufacturer as the effective temperature for virus inactivation, was maintained for at least 15 min in decartilaged femoral heads with a diameter of < or = 56 mm. Heat treatment using the Lobator sd-2 inactivated all viruses in human femoral heads below the detection limit (at least by a factor of > or =4 log(10)). By combining a well-focussed anamnesis of the donors and serological testing for relevant infection markers (anti-HIV-1/2, HBsAg, anti-HBcore, anti-HCV, TPHA) with heat treatment of femoral heads in the Lobator sd-2 system, a high safety level is achieved. To further increase virus safety of cadaveric bone transplants, it is recommended that multi-organ donors are tested by nucleic acid testing (i.e. polymerase chain reaction) for HIV, HBV and HCV genome.

[Influence of mucinous and signet-ring cell differentiation on epidemiological, histological, molecular biological features, and outcome in patients with colorectal carcinoma]

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignancies in the Western world. Histopathologically, adenocarcinomas are mostly diagnosed. Mucinous and signet-ring cell subtypes occur with a very low incidence. However, these subtypes differ remarkably in terms of clinical, histological and molecular biological characteristics. The aim of this review is to present a detailed analysis of current knowledge regarding differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC along with potential consequences for daily practice.

METHODS

For this report all articles with relevant information on differences between classical adenocarcinoma and mucinous, and signet-ring cell CRC found via Pubmed searches were analysed. Furthermore, findings of our previous study were included.

RESULTS

Mucinous CRC occur with a reported incidence of 10 - 20 % in Western countries and are predominantly found in younger patients and females. They are more often diagnosed in the proximal colon and present with a higher stage at diagnosis. Furthermore, there is a higher rate of lymph node-positive tumours and peritoneal carcinomatosis. Results of molecular biological studies confirm that they may represent a different tumour entity. The response to well established chemotherapy regimens is poorer which may be attributed to the higher rate of microsatellite-instable tumours and an increased mucin secretion. The poorer outcome is likely related to the higher stage at the time of diagnosis. Signet-ring cell type CRC are rare with an incidence ranging between 0,9 % to 4 %. They are also more common in the right colon and are associated with a poorer outcome compared to adenocarcinoma and mucinous CRC.

CONCLUSIONS

However, it should be noted that most of the results come from studies with a very low number of patients which can be attributed to the low incidence of mucinous and signet-ring cell CRC. Based on the findings of the present analysis, a more radical surgical approach should be considered providing that the exact preoperative histology is available. Furthermore, the histological subtype should be taken into account in future chemotherapy trials to avoid unnecessary therapy. A closer follow-up, especially for patients with signet-ring cell CRC should be discussed. In the near future, a more tailored therapy in patients with colorectal cancer would be highly desirable.

Metabolic surgery and nutritional deficiencies

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered as the main risks of metabolic surgery with its malabsorptive but also restrictive procedures. The aim of this review was to characterize the most relevant metabolic complications specific for the various bariatric procedures, which, subsequently, require a permanent surveillance and supplementation, respectively. Furthermore, we aimed to identify if there are diagnostic and therapeutic measures that can prevent those complications. Restrictive bariatric surgery such as "gastric banding" and "sleeve gastrectomy" can be associated with deficiencies related to B-vitamins whereas iron, folate, vitamin B1, B12 and D deficiencies are associated with the malabsorptive procedure such as "biliopancreatic diversion," "duodenal switch" and "Roux-en-Y gastric bypass". Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical and dietetic surveillance. The recently published guidelines of the "American Association of Bariatric and Metabolic Surgery" are the basis for recommendations on supplementation and treatment following weight loss surgery.

Circular Versus Linear Versus Hand-Sewn Gastrojejunostomy in Roux-en-Y-Gastric Bypass Influence on Weight Loss and Amelioration of Comorbidities: Data Analysis from a Quality Assurance Study of the Surgical Treatment of Obesity in Germany

Background: Since January 1 2005, the outcomes of bariatric surgeries have been recorded in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at Otto-von-Guericke University Magdeburg.

Methods: Data are collected in an online data bank. Data collection began in 2005 for the results of Roux-en-Y-Gastric Bypass (RYGB). In addition to primary bariatric operations, data regarding the complications and the amelioration of comorbidities have been analyzed. Participation in the quality assurance study is required for all certified centers in Germany.

Results: Roux-en-Y Gastric Bypass is the most popular bariatric operation in Germany. There were 5115 operations performed from 2005 to 2010. A circular anastomosis was performed in 1587 patients, and a linear anastomosis was performed in 2734 patients. In 783 patients, the hand-sewn technique was used. The leakage rate for the linear technique is 1.6%, and the leakage rate is 1.2% for circular anastomosis, and 1.4% for hand-sewn technique.

Conclusion: Roux-en-Y-Gastric Bypass is a popular procedure in Germany. The complication rate has decreased since 2005. The amelioration of comorbidities is not influenced by the anastomosis technique. Additional data are necessary to evaluate the long-term effect of linear versus hand-sewn and versus circular-stapled gastrojejunal anastomosis regarding pouch dilatation, small bowel dilatation, and consecutive weight loss.

[Nutrient Deficiencies after Bariatric Surgery - Systematic Literature Review and Suggestions for Diagnostics and Treatment]

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered the main risks of metabolic surgery and its restrictive and malabsorbant surgical procedures. The aim of this compact short overview based on a selective literature search and our own clinical experience is to characterise the long-term metabolic complications, which are specific for the various bariatric procedures, and to refine the published guidelines for supplementation. Restrictive bariatric procedures can be associated with well-known surgical problems such as pouch dilatation or band migration, e.g., after gastric banding. After sleeve gastrectomy, emerging reflux disease can become a substantial problem. The most frequent deficiencies after restrictive procedures are related to B-vitamins whereas iron, folate, vitamin B1 and B12 and vitamin D deficiencies are associated with the malabsorptive procedure such as biliopancreatic diversion, duodenal switch and Roux-en-Y gastric bypass. Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical follow-up investigations. The currently available guidelines of German Society of Treatment of Obesity (CAADIP) of DGAV for supplementation should be known and followed, in particular, by the physicians who i) are exceptionally involved in medical care of obese people and ii) do it in full awareness of the obligatory postoperative clinical observation.

[Revision after failed bariatric surgery--review of complications and current therapeutic options]

BACKGROUND

Obesity is increasing worldwide at an alarming rate. Particularly in Western countries, obesity and related problems have become a serious medical problem and an enormous socio-economic burden.

DISCUSSION

Currently, surgery is the only avail-able treatment for patients with severe obesity which leads to sustained weight loss and cure of co-morbidities in the majority of the patients. The increase in the number of bariatric operations and the occasional failure and complications of these surgical procedures have resulted in an increased need for revision surgery. Overall, 10-25 % of patients are expected to need a revision for failure of the primary bariatric procedure. The main indications for revision procedures are inadequate weight loss, surgery-related complications as well as surgical emergencies and long-term complications caused by malnutrition or -vitamin deficiencies. Unfortunately, there are currently no randomised trials to answer the question as to which operation should be performed in which patient and after which procedure. Decisions are often influenced by the expertise and preference of the operating surgeon as well as by patient's preference. Thus, a systematic review of published data to this complex issue appears to be helpful and important for daily surgical practise.

CONCLUSIONS

Revision bariatric procedures are technically more complex and associated with increased postoperative complications. These operations should basically be performed in centres with profound expertise in this field of surgery, and - whenever possible - laparoscopically. However, every abdominal surgeon should be able to diagnose and treat some acute complications. After failed restrictive procedures, revision is recommended only in cases of complications but with adequate weight loss at the time of failure. Otherwise, conversion to combined procedures should be considered. After the failure of combined procedures, further weight loss or successful treatment of complications can be achieved by adding more restriction and/or malabsorption components. The latter is associated with an increased risk of nutritional sequelae.

Synchronous multifocal colorectal carcinoma in a patient with delayed diagnosis of ulcerative pancolitis

Patients with ulcerative colitis face an increased lifetime risk of developing colorectal cancer. Relatively often, the patients present with multiple synchronous or metachronous tumors. Here, we report a case of ulcerative colitis-associated synchronous multifocal colorectal carcinomas. A 36-year-old male presented with symptoms of persisting abdominal pain that had lasted for several months. Histology of the colonic biopsies showed active ulcerative pancolitis with extensive multifocal low- and high-grade dysplasia. Regardless of the diagnosis and medical advice, the patient initially refused therapy, and proctocolectomy was delayed for 12 months. In the resection specimen, four clinically unsuspected, partly mucinous adenocarcinomas accompanied by several foci of low- and high-grade dysplasia were found in the left colon and rectum. At the time of colectomy, advanced tumor stage was diagnosed and classified as pT3c(4) pN1(2/120) M0 V1 R0, UICC stage IIIB, G2. Furthermore, a mucinous cystadenoma was found in the appendix in the setting of ulcerative colitis. We discuss the neoplastic transformation, current surveillance guidelines, and the therapeutic management in ulcerative colitis.

Hybrid laparoscopic versus fully robot-assisted minimally invasive esophagectomy: an international propensity-score matched analysis of perioperative outcome

BACKGROUND

Currently, little is known regarding the optimal technique for the abdominal phase of RAMIE. The aim of this study was to investigate the outcome of robot-assisted minimally invasive esophagectomy (RAMIE) in both the abdominal and thoracic phase (full RAMIE) compared to laparoscopy during the abdominal phase (hybrid laparoscopic RAMIE).

METHODS

This retrospective propensity-score matched analysis of the International Upper Gastrointestinal International Robotic Association (UGIRA) database included 807 RAMIE procedures with intrathoracic anastomosis between 2017 and 2021 from 23 centers.

RESULTS

After propensity-score matching, 296 hybrid laparoscopic RAMIE patients were compared to 296 full RAMIE patients. Both groups were equal regarding intraoperative blood loss (median 200 ml versus 197 ml, p = 0.6967), operational time (mean 430.3 min versus 417.7 min, p = 0.1032), conversion rate during abdominal phase (2.4% versus 1.7%, p = 0.560), radical resection (R0) rate (95.6% versus 96.3%, p = 0.8526) and total lymph node yield (mean 30.4 versus 29.5, p = 0.3834). The hybrid laparoscopic RAMIE group showed higher rates of anastomotic leakage (28.0% versus 16.6%, p = 0.001) and Clavien Dindo grade 3a or higher (45.3% versus 26.0%, p < 0.001). The length of stay on intensive care unit (median 3 days versus 2 days, p = 0.0005) and in-hospital (median 15 days versus 12 days, p < 0.0001) were longer for the hybrid laparoscopic RAMIE group.

CONCLUSIONS

Hybrid laparoscopic RAMIE and full RAMIE were oncologically equivalent with a potential decrease of postoperative complications and shorter (intensive care) stay after full RAMIE.

Adjuvant treatment for resected rectal cancer: impact of standard and intensified postoperative chemotherapy on disease-free survival in patients undergoing preoperative chemoradiation-a propensity score-matched analysis of an observational database

AIMS

Adjuvant chemotherapy for resected rectal cancer is widely used. However, studies on adjuvant treatment following neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) have yielded conflicting results. Recent studies have focused on adding oxaliplatin to both preoperative and postoperative therapy, making it difficult to assess the impact of adjuvant oxaliplatin alone. This study was aimed at determining the impact of (i) any adjuvant treatment and (ii) oxaliplatin-containing adjuvant treatment on disease-free survival in CRT-pretreated, R0-resected rectal cancer patients.

METHOD

Patients undergoing R0 TME following 5-fluorouracil (5FU)-only-based CRT between January 1, 2008, and December 31, 2010, were selected from a nationwide registry. After propensity score matching (PSM), comparison of disease-free survival (DFS) using Kaplan-Meier analysis and log-rank test was performed in (i) patients receiving no vs. any adjuvant treatment and (ii) patients treated with adjuvant 5FU/capecitabine without vs. with oxaliplatin.

RESULTS

Out of 1497 patients, 520 matched pairs were generated for analysis of no vs. any adjuvant treatment. Mean DFS was significantly prolonged with adjuvant treatment (81.8 ± 2.06 vs. 70.1 ± 3.02 months, p < 0.001). One hundred forty-eight matched pairs were available for analysis of adjuvant therapy with or without oxaliplatin, showing no improvement in DFS in patients receiving oxaliplatin (76.9 ± 4.12 vs. 79.3 ± 4.44 months, p = 0.254). Local recurrence rate was not significantly different between groups in either analysis.

CONCLUSION

In this cohort of rectal cancer patients treated with neoadjuvant CRT and TME surgery under routine conditions, adjuvant chemotherapy significantly improved DFS. No benefit was observed for the addition of oxaliplatin to adjuvant chemotherapy in this setting.