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Intraoperative video recording in abdominal surgery has become indispensable for educational and scientific reasons. Documentation of open surgery is still technically demanding. Since no perfect camera system exists, modern action cameras may offer a solution to this problem. A head-mounted ActionPro X7 camera (ACTIONPRO, Roethenbach, Germany) was tested in 50 open abdominal surgeries. Full HD (High Definition) videos were of excellent quality and allowed a first-person view of the operation field. Short battery life of approximately 80 min, wearing discomfort, and recurrent connectivity problems were significant limitations. Modern action cameras can provide high-quality videos in open abdominal surgery. They offer an inexpensive and widely available alternative for surgical video documentation. (1) First-time usage of an action camera in major open abdominal surgery. (2) Handsfree filming allowing easy documentation of versatile technical approaches and special intraoperative observations. (3) High-quality footage filmed with a cost-effective camera.

Zwei Patientinnen wurden aufgrund einer Ketoazidose aufgenommen. Die Serumglukose war moderat erhoht. Die Patientinnen wiesen neurologische und abdominale Symptome auf. Die Medikation bestand aus Metformin, Insulin glargin und Empagliflozin bzw. aus Glimepirid, Insulin detemir und Empagliflozin. Unter Therapie mit intravenoser Flussigkeitsgabe sowie Infusion von Insulin, Glukose, Pufferlosung und Kalium normalisierten sich pH-Wert und Blutzucker. Unser Fallbericht beschreibt zwei Falle einer atypischen Ketoazidose mit moderater Blutzuckererhohung unter Therapie mit Natrium-Glukose-Kotransporter-2(SGLT2)-Inhibitoren.

Background. Tissue-bound fibrin sealants are used in a wide array of surgical procedures. The microenvironmental interaction between sealant and application site is often poorly evaluated due to a lack of suitable experimental models. Methods. A physiological incubation biosimulator (PIBS) was developed to test biological sealants in an ex vivo setup under physiological conditions comparable to the microenvironment at application site (temperature, humidity, pressure). PIBS was validated by a study on the effectiveness of TachoSil for leak closure at pancreatic resection sites. Defined defects in a thoracic membrane of porcine origin were sealed by TachoSil. Integrity of the sealing was tested in the presence of active pancreatic fluid over 60 minutes. Heat-inactivated pancreatic fluid and electrolyte solution served as controls. The time to leakage was recorded and experimental groups were analyzed by Kaplan-Meier analysis. Results. PIBS produced reliable results. TachoSil lead to a leakage rate of 96% after incubation with active pancreatic fluid (p = 34), which was significantly higher compared with heat-inactivated pancreatic fluid (p = 34, 52%) or electrolyte solution (p = 20, 19%). Conclusion. PIBS is an effective tool to evaluate microenvironmental effects on the adhesive strength of biomaterials. Tissue sealing effect of TachoSil is diminished in a “pancreatic” microenvironment rich with pancreatic enzymes. Our results might therefore explain the reason of the findings of randomized controlled trials recently published on this subject.

An accurate blood-based RAS mutation assay to determine eligibility of metastatic colorectal cancer (mCRC) patients for anti-EGFR therapy would benefit clinical practice by better informing decisions to administer treatment independent of tissue availability. The objective of this study was to determine the level of concordance between plasma and tissue RAS mutation status in patients with mCRC to gauge whether blood-based RAS mutation testing is a viable alternative to standard-of-care RAS tumor testing. RAS testing was performed on plasma samples from newly diagnosed metastatic patients, or from recurrent mCRC patients using the highly sensitive digital PCR technology, BEAMing (beads, emulsions, amplification, and magnetics), and compared with DNA sequencing data of respective FFPE (formalin-fixed paraffin-embedded) tumor samples. Discordant tissue RAS results were re-examined by BEAMing, if possible. The prevalence of RAS mutations detected in plasma (51%) vs. tumor (53%) was similar, in accord with the known prevalence of RAS mutations observed in mCRC patient populations. The positive agreement between plasma and tumor RAS results was 90.4% (47/52), the negative agreement was 93.5% (43/46), and the overall agreement (concordance) was 91.8% (90/98). The high concordance of plasma and tissue results demonstrates that blood-based RAS mutation testing is a viable alternative to tissue-based RAS testing.

Die Pankreasanastomose ist die „Achillesferse“ der Pankreaschirurgie. Trotz bedeutender Fortschritte in der Anastomosentechnik bleibt die Rate an postoperativen Pankreasfisteln sehr hoch. Aus diesem Grund sind verschiedene supportive Ansatze zur Sicherung der Pankreasanastomose weiterhin von Interesse. Dieser Review prasentiert die neuesten evidenzbasierten Erkenntnisse fur mogliche Masnahmen zur Sicherung der Pankreasanastomose. Die jungsten Metaanalysen, randomisierten kontrollierten Studien und die grosten retrospektiven Serien uber die Rolle von Pankreasgangstents, separater Schlingenfuhrung, Anastomosenabdichtungen mit autologem Material und Zieldrainagen bei Pankreaskopfresektionen wurden berucksichtigt. Der Stellenwert von Somatostatinanaloga, perioperativer Ernahrung und Volumenmanagement wird kritisch diskutiert. Die Evidenzlage fur die meisten supportiven Masnahmen ist ungenugend und bleibt damit kontrovers. Der Einsatz von Somatostatinanaloga und Zieldrainagen sowie das restriktive perioperative Volumenmanagement haben sich als effektiv erwiesen. Dagegen kann die routinemasige Einlage von Pankreasgangstents nicht befurwortet werden. Andere Ansatze wie die separate Schlingenfuhrung und die Anwendung von Ligamentum-teres/falciforme-Patches sind noch nicht ausreichend untersucht. Obwohl technische Sorgfalt und Chirurgenerfahrung ihre fuhrende Rolle bei der Konstruktion einer sicheren Pankreasanastomose beibehalten, bieten manche supportive Masnahmen eindeutiges Potenzial, welches in grosen und gut konzipierten prospektiven Studien untersucht werden sollte.

Die Inzidenz der malignen Erkrankungen, die zum Verschluss des distalen Gallengangs fuhren, steigt kontinuierlich. Die haufigste Ursache ist das Pankreaskarzinom. Die Mehrheit der Patienten mit distalem malignem Gallenwegsverschluss leiden zum Zeitpunkt der Diagnosestellung an einem nicht mehr kurativ resektablen Tumor, sodass palliative Konzepte im Vordergrund stehen. Hauptziel der effektiven Palliation ist der dauerhafte Erhalt der Lebensqualitat. Dabei stehen verschiedene medikamentose, zytostatische, endoskopische, chirurgische, radiotherapeutische und supportive Masnahmen zur Verfugung. Eine zentrale Rolle spielt die fruhzeitige Entlastung der Gallenwegsobstruktion und der begleitenden Duodenalstenose mittels endoskopischer Stentanlage oder chirurgischer Anlage von Bypassanastomosen zum Gallengang und Magen. Die genauen Indikationsgebiete der Endoskopie und der Chirurgie in der palliativen Behandlung des malignen distalen Gallenwegsverschlusses sind kontrovers und nicht endgultig definiert, sodass das Management dieser Patienten einen interdisziplinaren Umgang an Kliniken mit hoher Expertise benotigt.

A 5-year-old boy sustained blunt abdominal trauma in a car crash. The buckle mechanism of the five-point harness of his child safety seat compressed his upper abdomen causing an isolated complete pancreatic rupture. Diagnosis was delayed due to subtle symptoms and normal initial findings. A CT scan confirmed diagnosis. An emergency limited central pancreatic resection was performed. The outcome was excellent.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

Postoperative pancreatic fistula (POPF) is the most common complication following distal pancreatectomy. This retrospective study investigated the effects of autologous fibrin sealant (VivostatA matched pairs analysis was performed to compare the incidence of clinically relevant POPF of 41 patients who underwent a distal pancreatectomy with application of autologous fibrin sealant (VivostatClinically relevant POPF were present in 11 patients in the study group (27%) and in 13 patients in the control group (32%,POPF cannot be prevented under treatment with autologous fibrin sealant (Vivostat

Acinar cell carcinomas (ACC) and adenomas (ACA) of the pancreas are rare entities. Sufficient knowledge about occurrence and prognosis is scarce. A retrospective chart review of our database was performed for all patients who had undergone pancreatic surgery between 2006 and 2018. Results were compared to recent literature findings. Nine patients were diagnosed with ACC and four patients with ACA of the pancreas in the study period. ACC patients were older and more often male than patients of the ACA group. ACC were mainly localized in the pancreatic head, whereas ACA were more often found in the distal pancreas. Tumor markers are not necessarily elevated, even in case of malignancy. ACC and ACA are very rare pancreatic tumors. Both entities account for less than 1% of all pancreatic neoplasms. Diagnosis is challenging due to unspecific radiologic features and clinical symptoms. Nevertheless, a patient complaining of abdominal discomfort and an unclear hypodense pancreatic lesion should undergo surgical exploration.

Introduction: Pancreatic cancer is a lethal disease and often asymptomatic. Therefore, it is most often diagnosed at an advanced stage. The standard approach in a metastasized tumor stage is palliative chemotherapy. However, the prognosis remains extremely poor. Case Report: We present the case of a patient who was diagnosed with a cancer of the head of the pancreas with hepatic metastases. After receiving palliative intended chemotherapy with the FOLFIRINOX regimen, staging computed tomography revealed the disappearance of the liver metastases and local resectability of the pancreatic head tumor. The patient underwent an uneventful Whipple’s procedure. Surprisingly, pathohistological investigation revealed a complete pathological response. Conclusion: Pathological complete response after FOLFIRINOX treatment in hepatic metastasized pancreatic cancer is extremely rare. It enables surgical resection and increases the survival rate significantly.

Background: Pancreatic cancer is a fatal disease most often diagnosed at an advanced stage. Most patients already suffer from irresectable tumor or distant metastases being most commonly found in the liver or the lung. However, cerebral metastases occur extremely rare.Methods: We performed a retrospective analysis of our database to identify all patients diagnosed with pancreatic cancer and cerebral metastases who underwent surgical treatment in our department from January 2004 to November 2016.Results: Only 0.2% (4 of 2492) were diagnosed with cerebral metastases. Two patients had surgical resection of the cerebral metastases. One patient underwent palliative radiation therapy and the fourth patient received only palliative therapy. Mean interval between initial diagnosis and development of brain metastases was 8.5 months (range 1-20). Mean survival period after diagnosis of brain metastases was 4.75 months (range 1-10).Conclusions: Cerebral metastases of pancreatic cancer occur extremely rare. They are associated with an advanced tumor stage, commonly liver and lung metastases. All patients presenting with neurological symptoms, multifocal metastases, and significantly elevated CA 19-9 levels are suspicious of sustaining cerebral metastases and should undergo brain imaging.

Aberrations within the PI3K/AKT signaling axis are frequently observed in numerous cancer types, highlighting the relevance of these pathways in cancer physiology and pathology. However, therapeutic interventions employing AKT inhibitors often suffer from limitations associated with target selectivity, efficacy, or dose-limiting effects. Here we present the first crystal structure of autoinhibited AKT1 in complex with the covalent-allosteric inhibitor borussertib, providing critical insights into the structural basis of AKT1 inhibition by this unique class of compounds. Comprehensive biological and preclinical evaluation of borussertib in cancer-related model systems demonstrated a strong antiproliferative activity in cancer cell lines harboring genetic alterations within the PTEN, PI3K, and RAS signaling pathways. Furthermore, borussertib displayed antitumor activity in combination with the MEK inhibitor trametinib in patient-derived xenograft models of mutant KRAS pancreatic and colon cancer. Significance: Borussertib, a first-in-class covalent-allosteric AKT inhibitor, displays antitumor activity in combination with the MEK inhibitor trametinib in patient-derived xenograft models and provides a starting point for further pharmacokinetic/dynamic optimization.

The most frequent malignancy of the pancreas is the pancreatic ductal adenocarcinoma (PDAC). Despite many efforts PDAC has still a dismal prognosis. Biomarkers for early disease stage diagnosis as a prerequisite for a potentially curative treatment are still missing. Novel blood-based markers may help to overcome this limitation. Methods: Prior to surgery plasma levels of thrombospondin-2 (THBS2), which was recently published as a novel biomarker, and CA19-9 from 52 patients with histologically proven PDAC were determined, circulating cell-free (cfDNA) was quantified. 15 patients with side-branch IPMNs without worrisome features and 32 patients with chronic pancreatitis served for comparison. Logit (logistic regression) models were used to test the performance of single biomarkers and biomarker combinations. Results: CA19-9 and THBS2 alone showed comparable c-statistics of 0.80 and 0.73, respectively, improving to 0.87 when combining these two markers. The c-statistic was further increased to 0.94 when combining CA19-9 and THBS2 with cfDNA quantification. This marker combination performed best for all PDAC stages but also for PDACs grouped by stage. The greatest improvement over CA19-9 was seen in the group of stage I PDAC, from 0.69 to 0.90 for the three marker combination. Conclusion:These data establish the combination of CA19-9, THBS2 and cfDNA as a composite liquid biomarker for non-invasive diagnosis of early-stage PDAC. peerReviewed

Aims/hypothesis Incretin-based therapies have been associated with an increased risk of pancreatitis. Recently, various histological abnormalities have been reported in human pancreatic tissue from brain-dead organ donors that had been exposed to incretin-based drugs. In the present study we examined pancreatic tissue collected at surgery. Methods Human pancreatic tissue from seven type 2-diabetic patients treated with incretin-based drugs (type 2-I), six diabetic patients without incretin treatment (type 2-NI), eleven patients without diabetes (no diabetes) and nine brain-dead organ donors (BDOD) was examined. Results Fractional beta-cell area was reduced in the type 2-NI group compared to the no diabetes group (p

Hintergrund: Die postoperative Pankreasfistel nach Pankreaslinksresektion ist bis heute ein ungelostes Problem, denn unabhangig von der Verschlusstechnik entwickeln etwa 30 % der Patienten nach einer Pankreaslinksresektion eine Pankreasfistel. Erstmals wurde bei Pankreaslinksresektionen autologes Fibrin (Vivostat®) zum additiven Abdichten des Pankreasabsetzungsrands verwendet. Ziel war es, zu untersuchen, ob ein verandertes postoperatives Ergebnis vorliegt. Patienten/Material und Methoden: Im Jahr 2015 wurde eine technische Fallserie bei 15 Patienten durchgefuhrt. Im Rahmen von Pankreaslinksresektionen wurde autologer Fibrinkleber auf den Pankreasabsetzungsrand appliziert. Ergebnisse: Bei 5/15 Patienten (33 %) trat eine Pankreasfistel auf. In einem Fall trat eine Grad-A-Fistel auf (1/15, 6,7 %), wahrend eine Grad-B-Fistel in 4/15 Fallen (26,7 %) vorlag. Bei 75 % (3/4) der Patienten mit einer Grad-B-Fistel war eine Antibiotikatherapie ausreichend. Nur bei einem Patienten war postoperativ eine CT-gesteuerte Drainagenanlage erforderlich. Schlussfolgerung: Autologer Fibrinkleber ist unkompliziert anzuwenden und scheint gut vertraglich. Postoperative Pankreasfisteln nach Pankreaslinksresektionen scheinen sich dadurch allerdings nicht vermeiden zu lassen.

The gastrointestinal hormone GLP-1 is released from enteroendocrine L-cells and augments postprandial insulin secretion. In patients with type 2 diabetes, the incretin effect is markedly diminished. It is unclear, whether this is due to a reduction in the abundance of L-cells in the intestine.Ileal tissue samples from 10 patients with and 10 patients without diabetes that underwent surgery for the removal of colon tumors were included. Tissue sections were stained for GLP-1, Ki67, TUNEL and chromogranin A.The number of L-cells was not different between patients with and without diabetes in either crypts (1.81±0.21% vs. 1.49±0.24%, respectively; p=0.31) or villi (1.07±0.16% vs. 0.83±0.10%, respectively; p=0.23). L-cell number was higher in crypts than in villi (p0.0001). L-cell replication was detected rarely and not different between the groups. L-cell apoptosis was similar in patients with and without diabetes in both crypts (7.84±2.77% vs. 8.65±3.77%, p=0.85) and villi (4.48±2.89% vs. 8.62±4.64%, p=0.42). Chromogranin A staining was found in a subset of L-cells only.Intestinal L-cell density is higher in crypts than in villi. Chromogranin A is not a prerequisite for GLP-1 production. L-cell density and turnover are not different between patients with and without diabetes. Thus, alterations in the number of GLP-1 producing cells do not explain the reduced incretin effect in patients with type 2 diabetes.

BACKGROUNDIsoflurane has shown better control of intensive care sedation than propofol or midazolam and seems to be a useful alternative. However, its effect on survival remains unclear.OBJECTIVEThe objective of this study is to compare mortality after sedation with either isoflurane or propofol/mid

e16750 Background: GP-2250, a novel oxathiazine derivative, displayed apoptotic cytotoxicity against various tumor cell lines but not normal cells. It was therefore tested whether its antineoplastic potential - alone or in combination – could be leveraged specifically against pancreatic cancer. Methods: GP-2250 is a cancer metabolism-based therapeutic. It depleted metabolic energy through inhibition of the enzyme GAPDH (glyceraldehyde-3-phosphate dehydrogenase) which is rate limiting for aerobic glycolysis. ATP was decreased in a time- and dose-dependent manner in pancreatic tumor cell lines and ROS was increased. Mitochondrial dysfunction was triggered by an increased expression of Bax and decreased expression of Bcl2, leading to apoptosis. Cytotoxicity of GP-2250 was ROS-dependent. It was blocked by N-acetylcysteine. Results: GP-2250 substantially increased the sensitivity of pancreatic tumor cells to various chemotherapeutics in particular to gemcitabine (Gem). At doses which were inactive or barely active per se, the combination of GP-2250 and Gem caused striking cytotoxicity in patient-derived primary tumor cells in vitro, pointing to a strong synergy between the two agents. This finding was substantiated in vivo by patient-derived xenograft (PDX) studies in nude mice. While GP-2250 and Gem, given as monotherapy (500 mg/kg and 50 mg/kg respectively, 2x/week), showed only a limited antineoplastic response, the combination treatment resulted in a significantly higher anti-tumor activity as shown in further PDX. Tumor regression was found in 5 out of 9 PDX based on RECIST criteria. Stable disease was reached in 3 of the remaining grafts. In 1 xenograft, which was unresponsive to Gem, the combination treatment nevertheless achieved a reduction in tumor growth which significantly exceeded that of GP-2250 monotherapy. Conclusions: GP-2250 is a novel cancer metabolism-based therapeutic. GP-2250, in combination with Gem, strongly reduces tumor growth in patient-derived xenografts exceeding by far the response to monotherapy. GP-2250 is being evaluated in a Phase I clinical trial in patients diagnosed with advanced pancreatic cancer (Clinical Trial NCT03854110).

Aberrations within the PI3K/AKT signaling axis are frequently observed in numerous cancer types, highlighting the relevance of these pathways in cancer physiology and pathology. However, therapeutic interventions employing AKT inhibitors often suffer from limitations associated with target selectivity, efficacy, or dose-limiting effects. Here we present the first crystal structure of autoinhibited AKT1 in complex with the covalent-allosteric inhibitor borussertib, providing critical insights into the structural basis of AKT1 inhibition by this unique class of compounds. Comprehensive biological and preclinical evaluation of borussertib in cancer-related model systems demonstrated a strong antiproliferative activity in cancer cell lines harboring genetic alterations within the PTEN, PI3K, and RAS signaling pathways. Furthermore, borussertib displayed antitumor activity in combination with the MEK inhibitor trametinib in patient-derived xenograft models of mutant

The MDACC group recommends to extend the current borderline classification for pancreatic cancer into three groups: type A patients with resectable/borderline tumor anatomy, type B with resectable/borderline resectable tumor anatomy and clinical findings suspicious for extrapancreatic disease and type C with borderline resectable and marginal performance status/severe pre-existing comorbidity profile or age80. This study intents to evaluate the proposed borderline classification system in a multicenter patient cohort without neoadjuvant treatment.Evaluation was based on a multicenter database of pancreatic cancer patients undergoing surgery from 2005 to 2016 (n = 1020). Complications were classified based on the Clavien-Dindo classification. χMost patients (55.1%) were assigned as type A patients, followed by type C (35.8%) and type B patients (9.1%). Neither the complication rate, nor the mortality rate revealed a correlation to any subgroup. Type B patients had a significant worse progression free (p 0.001) and overall survival (p = 0.005). Type B classification was identified as an independent prognostic marker for progression free survival (p = 0.005, HR 1.47).The evaluation of the proposed classification in a cohort without neoadjuvant treatment did not justify an additional medical borderline subgroup. A new subgroup based on prognostic borderline patients might be the main target group for neoadjuvant protocols in future.

Continuously rising incidence and prevalence, frequent hospitalisation, development of opioid dependence, and early retirement of young people demonstrate the enormous socioeconomic impact of chronic pancreatitis. The aims of therapy include pain relief, improved quality of life, management of complications, cancer prevention and preservation of function. Since medical and endoscopic approaches of conservative therapy have proved to be ineffective in the long term, surgery remains the mainstay of treatment and should be considered as early as possible. Surgery encompasses a wide spectrum of methods, ranging from simple drainage procedures and conventional resections to various hybrid techniques. The choice of optimal surgical management should consider the unique pathomorphologic changes of each patient and be performed at a high-volume pancreas centre. This review presents the current evidence-based state of knowledge about chronic pancreatitis from a surgical point of view with a practical summary of therapeutic strategies according to the available guidelines and considering the most recent literature.Die enorme sozioökonomische Auswirkung der chronischen Pankreatitis lässt sich durch stetig steigende Inzidenz und Prävalenz, häufige Hospitalisierungen, Entwicklung von Opiatabhängigkeit und vorzeitige Verrentung von jungen Menschen eindeutig demonstrieren. Ziele der Therapie sind die frühestmögliche Schmerzbefreiung mit Verbesserung der Lebensqualität, Beseitigung von Komplikationen und Karzinomvorbeugung unter maximalem Funktionserhalt. Da die konservative Behandlung alleine langfristig weitestgehend ineffektiv ist, spielt die chirurgische Therapie eine zentrale Rolle und sollte möglichst frühzeitig eingesetzt werden. Das Spektrum der operativen Verfahren ist sehr breit und umfasst reine Drainageeingriffe, klassische resektive Verfahren und parenchymschonende Hybridtechniken. Die Wahl des optimalen therapeutischen Managements sollte die konkreten pathomorphologischen Besonderheiten bei jedem individuellen Patienten berücksichtigen und wenn möglich an spezialisierten Pankreaszentren erfolgen. Diese Übersichtsarbeit präsentiert den aktuellen evidenzbasierten Wissensstand über die chronische Pankreatitis aus chirurgischer Sicht. Eine praxisorientierte Zusammenfassung der therapeutischen Strategien wird entsprechend der gültigen Leitlinien unter Berücksichtigung der neuesten Erkenntnisse aus der Literatur dargestellt.

Background Postoperative pancreatic fistula (POPF) is a major factor for morbidity and mortality after pancreatic resection. Risk stratification for POPF is important for adjustment of treatment, selection of target groups in trials and quality assessment in pancreatic surgery. In this study, we built a risk-prediction model for POPF based on a large number of predictor variables from the German pancreatic surgery registry StuDoQ|Pancreas. Methods StuDoQ|Pancreas was searched for patients, who underwent pancreatoduodenectomy from 2014 to 2016. A multivariable logistic regression model with elastic net regularization was built including 66 preoperative und intraoperative parameters. Cross-validation was used to select the optimal model. The model was assessed via area under the ROC curve (AUC) and calibration slope and intercept. Results A total of N = 2488 patients were included. In the optimal model the predictors selected were texture of the pancreatic parenchyma (soft versus hard), body mass index, histological diagnosis pancreatic ductal adenocarcinoma and operation time. The AUC was 0.70 (95% CI 0.69–0.70), the calibration slope 1.67 and intercept 1.12. In the validation set the AUC was 0.65 (95% CI 0.64–0.66), calibration slope and intercept were 1.22 and 0.42, respectively. Conclusion The model we present is a valid measurement instrument for POPF risk based on four predictor variables. It can be applied in clinical practice as well as for risk-adjustment in research studies and quality assurance in surgery.

A 68-year-old asymptomatic patient was incidentally diagnosed with an intraductal papillary mucinous neoplasia (IPMN) of the pancreas with a pancreaticogastric fistula. He had a history of a right sided nephrectomy due to a renal cell carcinoma 9 years before. The patient underwent an uneventful total pancreatectomy and wedge resection of the stomach. The patient’s medical history was studied and compared to recent literature via PubMed. Pathohistological evaluation confirmed a mixed type IPMN of an intestinal subtype with pancreaticogastric fistula. Pancreaticogastric fistula due to benign IPMN is extremely rare. Surgical resection including wedge resection of the stomach is the treatment of choice.

A 76-year-old Moroccan patient with a medical history of sigmoid carcinoma suffered from weight loss of 15 kg and abdominal pain. Laparoscopy showed disseminated miliary peritoneal lesions, prima vista suspicious for disseminated peritoneal cancer spread. Patient’s medical history was reprocessed and compared to recent literature via PubMed. Pathological evaluation revealed granulomas and an infection with miliary intraabdominal tuberculosis (TB) was proven. Symptoms of TB may vary and findings can be misleading. An interdisciplinary approach is needed for diagnosis and treatment.

Pancreatic cancer (PC) is a lethal disease with a poor prognosis. It is typically asymptomatic and therefore most often diagnosed at an advanced stage. A primary unresectable PC can become resectable in case of tumor regression turning palliative into neoadjuvant therapy. We present a 67-year old female patient who was diagnosed with a locally advanced adenocarcinoma of the pancreatic head. After receiving palliative intended chemotherapy with the FOLFIRINOX regimen, staging computed tomography revealed local resectability of the pancreatic head tumor. The patient underwent an uneventful total pancreatectomy. Pathohistological investigation revealed a pathologic complete response (pCR). pCR after FOLFIRINOX treatment in primary unresectable PC is extremely rare. It might enable surgical resection and can increase the survival rate.

Background Use of anesthetic conserving devices (ACD) for inhalational isoflurane sedation in Intensive Care Units (ICU) has grown in recent years, and healthcare professionals are concerned about isoflurane pollution and exposure-related health risks. Real-time measurements to determine isoflurane exposure in ICU personnel during short-term patient care procedures and ACD handling have not yet been performed. Methods Isoflurane concentrations in the breathing zones of ICU staff (25 cm around the nose and mouth) were measured, by photoacoustic gas monitoring, during daily practice including tracheal suctioning, oral hygiene, body care, and patient positioning. Isoflurane pollution was further determined during ACD replacement, syringe filling, and after isoflurane spillages. Results The average mean isoflurane concentration 25 cm above patients' tracheostoma was 0.3 ppm. Mean (cmean) and maximum (cmax) isoflurane exposure in personnel's breathing zones during patient care ranged from 0.4 to 1.9 ppm and 0.7 to 6.6 ppm, respectively. Isoflurane exposure during ACD replacement was cmean 0.5 to 17.4 ppm and cmax 0.8 to 114.3 ppm. Isoflurane concentrations during ACD syringe filling ranged from 2.4 to 9.1 ppm. The maximum isoflurane concentrations after spillage were dose-dependent. Conclusions Use of ACDs and patient physical manipulation are accompanied by isoflurane pollution. Baseline concentrations did not exceed long-term exposure limits, but short-term limits were occasionally exceeded during patient care procedures and ACD handling. Spillages should be avoided, especially when air-conditioning and scavenging systems are unavailable.

Background: Von Hippel-Lindau (VHL) disease may occur at various localisations which can be both intra- and extrapancreatic as well as challenging to diagnose by medical imaging. Case Report: A positron emission tomography/magnetic resonance imaging in a 40-year-old woman was performed to monitor a haemangioblastoma. Additionally, it showed findings which were considered to be a pancreatic neuroendocrine tumour (pNET) and retroumbilical metastasis. The suspected metastasis was laparoscopically resected; however, pathological evaluation did not lead to a clear categorisation. Consequently, the pancreatic head was resected in which a pNET and various acinar cell cystadenomas were found. Conclusion: Diagnostic and therapy of advanced VHL disease can be difficult; if in doubt, a surgical approach may establish clarity.

In pancreatic surgery pre-operative biliary drainage (PBD) is associated with bacteribilia, which increases the risk for surgical site infections (SSIs).This study is a retrospective observational cohort design that compared micro-organisms of intra-operative bile duct cultures with micro-organisms of SSIs after pancreaticoduodenectomy.From January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy or hepaticojejunostomy for benign and malignant peri-ampullary lesions. Surgical site infections occurred in 10% (87/887). Cultures of SSIs with corresponding intra-operative bile duct cultures were available for 59 patients. Sixty-four percent (38/59) had undergone PBD. Pre-operative biliary drainage was associated with positive intra-operative bile duct cultures in 95% (36/38), versus 48% (10/21; p≤0.001). The correlation of SSIs with intra-operative bile duct cultures was 59% (35/59). There was a significant association between the micro-organisms cultured from SSIs and the corresponding bile duct cultures for Enterococcus spp., Escherichia coli, Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae with extended spectrum ß-lactamase (ESBL), and Candida spp.After pancreaticoduodenectomy, SSIs are often caused by the same micro-organisms that are present on intra-operative bile duct cultures, especially after PBD. Therefore, intra-operative bile duct cultures should be performed routinely to adjust the antibiotic prophylaxis according to the local hospital surveillance data.

Die Autoimmunpankreatitis (AIP) ist eine seltene Form der Pankreatitis und betrifft etwa 5% der Patienten mit chronischer Pankreatitis. Die Grundzuge der Entitat wurden erstmals 1961 durch Sarles et al. beschrieben, die bei mehreren Patienten eine idiopathische chronische Pankreatitis mit Hypergammaglobulinamie nachweisen konnten und eine autoimmune Genese dieser Entzundung postulierten [1]. Ab 1995–34 Jahre spater–wurde die Autoimmunpankreatitis als eigene Krankheitsentitat etabliert [2].

Fur Chirurgen ist es wichtig, sich mit Clostridium-difficile-Infektionen (CDI) auseinanderzusetzten, da die Inzidenz und die Virulenz dieser potenziell lebensbedrohlichen Erkrankung zunehmen. Das Ziel der vorliegenden Studie war, zu untersuchen, wie haufig CDI bei chirurgischen Patienten vorkommen, welche Therapiemasnahmen erfolgreich sind und welche Faktoren fur einen todlichen Verlauf pradisponieren. Es wurde eine retrospektive Kohortenanalyse durchgefuhrt. Von Januar 2004 bis Juni 2012 lag die Inzidenz im Universitatsklinikum St. Josef Hospital Bochum uber alle Fachabteilungen verteilt bei 0,6 % (1669/301.919). Die Inzidenz der CDI in der Viszeralchirurgie lag bei 0,9 % (179/18.864). Im Jahr 2004 gab es in der Viszeralchirurgie einen Patienten mit CDI, 2011 stieg die Gesamtzahl auf 41 an. 84 % (151/179) der viszeralchirurgischen Patienten hatten vor dem Auftreten der CDI eine Antibiotikatherapie erhalten. Zur Therapie der CDI erhielten 75 % (134/179) Metronidazol, 60 % (107/179) erhielten Vancomycin und 44 % (79/179) erhielten eine Kombinationstherapie, Tygecyclin oder Fidaxomidin. Die Gesamtletalitat betrug 7 % (12/179). Es bestand eine erhohte Letalitat bei CDI-assoziierter Sepsis, Wiederaufnahme auf die Intensivstation, Katecholamintherapie und Reintubation. Bei 4 % (7/179) erfolgte eine Kolektomie. Nach Kolektomie verstarben trotz intensivmedizinischer Maximaltherapie 86 % (6/7) der Patienten. Die meisten viszeralchirurgischen Patienten mit CDI konnen konservativ behandelt werden, allerdings besteht eine hohe Letalitat, wenn aufgrund der CDI eine intensivmedizinische Therapie erforderlich wird. Die Letalitat nach Kolektomie betragt fast 100 %, weil die Operation meistens als Ultima Ratio im Vollbild der Sepsis erfolgt. Hauptrisikofaktor fur eine CDI ist eine vorausgegangene Antibiotikatherapie.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Postoperative peritonitis is still one of the most common causes of postoperative mortality after abdominal surgery. Over the last three decades, improvements in surgical technique and intensive care management have reduced the frequency of postoperative peritonitis, especially after major abdominal surgery. Still, mortality from abdominal sepsis is high, and successful treatment of postoperative peritonitis remains a challenge. Early diagnosis and appropriate and immediate initiation of an effective therapy is the cornerstone of successful treatment of postoperative peritonitis. The treatment of postoperative peritonitis relays on three principles: focus elimination, intensive care management, and antibiotic therapy. While treatment options for source control and intensive care management constantly improved, rapidly continuing emergence of postoperative peritonitis with resistant microorganisms is responsible for an increasing number of treatment failures among surgical patients.

Background Former studies already revealed the anti-neoplastic properties of the anti-infective agent Taurolidine (TRD) against many tumor species in vitro and in vivo. Its anti-proliferative and cell death inducing capacity is largely due to its main derivative Taurultam (TRLT). In this study it could be demonstrated, that substance 2250 - a newly defined innovative structural analogue of TRLT - exhibits an anti-neoplastic effect on malignant pancreatic carcinoma in vitro and in vivo. Methods The anti-neoplastic potential of substance 2250 as well as its mode of action was demonstrated in extensive in vitro analysis, followed by successful and effective in vivo testings, using xenograft models derived from established pancreatic cancer cell lines as well as patient derived tissue. Results Our functional analysis regarding the role of oxidative stress (ROS) and caspase activated apoptosis showed, that ROS driven programmed cell death (PCD) is the major mechanisms induced by substance 2250 in pancreatic carcinoma. What is strongly relevant towards clinical practice is especially the observed inhibition of patient derived pancreatic cancer tumor growth in mice treated with this new substance in combination with its sharply higher metabolic stability. Conclusion These encouraging results provide new therapeutical opportunities in pancreatic cancer treatment and build the basis for further functional analysis as well as first clinical studies for this promising agent.

This study aimed to evaluate the effect of a new combined method of covering the pancreatic anastomosis or stump with a cyanoacrylate and a falciform patch (CAFP) on the occurrence of postoperative pancreatic fistula (POPF). Patients undergoing a pancreaticoduodenectomy (PD) or a distal pancreatectomy (DP) were recruited over a period of 12 months. The pancreaticojejunostomy in PD and the stump in DP were sealed with cyanoacrylate glue and wrapped in a falciform patch. Incidence and severity of POPF and associated postoperative complications were retrospectively compared with historical controls of 750 PD and 336 DP at the same institution and with current data from the literature. The new method was applied in 27 PD and 25 DP. The rate of clinically relevant POPF after PD with CAFP was 22.2% compared to 14.4% in historical patients, p = 0.26. The rate of clinically relevant POPF after DP with CAFP was 36% compared to 30% in historical patients, p = 0.65. Sealing the pancreatic anastomosis or stump with a combination of a cyanoacrylate glue and a falciform patch didn’t reduce the rate of POPF after major pancreatic resections.