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Background: In addition to the prognostically important systemic recurrence, a high rate of local recurrence is a relevant problem of pancreatic cancer surgery. Improvement of local control is a requirement for surgical resection as a prerequisite for a potentially curative treatment. Objectives: Summary of the current evidence on frequency, relevance, and risk factors of local recurrence. Presentation of strategies for reduction of local recurrence with a special focus on surgical resection techniques. Material and methods: Analysis and appraisal of currently available scientific literature on the topic. Results and conclusion: Local recurrences occur as the first manifestation of tumor recurrence in 20–50% of patients after resection of pancreatic cancer. The considerable variations of reported local recurrence rates depend on the quality of surgery, regimens of (neo)adjuvant therapy as well as the design of surveillance and duration of follow-up. An R1 status is an important risk factor for local recurrence highlighting the relevance of a local radical resection. The majority of local recurrences consist of perivascular and lymph node recurrences. Therefore, lymphadenectomy, radical dissection directly at the celiac and mesenteric vessels including resection of the periarterial nerve plexus and vascular resection are starting points for improving surgical resection techniques. The safety and efficacy of radical resection techniques in the context of multimodal treatment of pancreatic cancer have to be further evaluated in prospective studies. [ABSTRACT FROM AUTHOR]

Nebennierenrindenkarzinome (ACC) sind seltene und aggressive Neoplasien, die aufgrund einer hohen Lokalrezidiv- und Metastasierungsrate (bis zu 85 %) mit einer sehr begrenzten Überlebenszeit assoziiert sind. So liegt das 5‑Jahres-Überleben bei Patienten mit ACC und Lymphknotenmetastasen oder lokaler Infiltration bei 50 %, mit Fernmetastasen unter 15 %. Die einzige kurative Option und sinnvolle Therapiemöglichkeit ist eine R0-Resektion mit lokoregionärer und renohilärer sowie paraaortokavaler Lymphadenektomie. Die Therapie solcher Patienten sollte daher in Zentren geplant und durchgeführt werden. Auch bei einem Lokalrezidiv oder Fernmetastasen sollte eine mit neoadjuvanter/adjuvanter Chemotherapie und/oder Radiatio kombinierte R0-Resektion angestrebt werden. Im Falle eines asymptomatischen nichtresektablen Befundes ist von einer Debulking-Operation abzuraten. Die Primäroperation kann auch minimalinvasiv erfolgen, jedoch nur wenn dabei die onkologischen Prinzipien eingehalten werden (Radikalität, Intaktheit der Kapsel, Lymphadenektomie), da gezeigt wurde, dass das Überleben nach offener und minimalinvasiver Resektion vergleichbar ist. Eine palliative Resektion ist nur bei Symptomatik angezeigt. [ABSTRACT FROM AUTHOR]

Background Chyle leak is a well known but poorly characterized complication after pancreatic surgery. Available data on incidence, risk factors and clinical significance of chyle leak are highly heterogeneous. Methods For this cohort study all patients who underwent pancreatic surgery between January 2008 and December 2012 were identified from a prospective database. Chyle leak was defined as any drainage output with triglyceride content of 110 mg/dl or more. Risk factors for chyle leak were assessed by univariable and multivariable analyses. The clinical relevance of chyle leak was evaluated using hospital stay and resolution by 14 days for short-term outcome and overall survival for long-term outcome. Results Chyle leak developed in 346 (10·4 per cent) of 3324 patients. Pre-existing diabetes, resection for malignancy, distal pancreatectomy, duration of surgery 180 min or longer, and concomitant pancreatic fistula or abscess were independent risk factors for chyle leak. Both isolated chyle leak and coincidental chyle leak (with other intra-abdominal complications) were associated with prolonged hospital stay. Some 178 (87·7 per cent) of 203 isolated chyle leaks and 90 (70·3 per cent) of 128 coincidental chyle leaks resolved with conservative management within 14 days. Initial and maximum drainage volumes were associated with duration of hospital stay and success of therapy by 14 days. Impact on survival was restricted to chyle leaks that persisted at 14 days in patients with cancer undergoing palliative surgery. Conclusion Chyle leak is a relevant complication, with an incidence of more than 10 per cent after pancreatic surgery, and has a major impact on hospital stay. Drainage volume is associated with hospital stay and success of therapy. [ABSTRACT FROM AUTHOR]

Background Enucleation is used increasingly for small pancreatic tumours. Data on perioperative outcome after pancreatic enucleation, especially regarding the significance and risk factors associated with postoperative pancreatic fistula ( POPF), are limited. This study aimed to assess risk-dependent perioperative outcome after pancreatic enucleation, with a focus on POPF. Methods Patients undergoing enucleation for pancreatic lesions between October 2001 and February 2014 were identified from a prospective database. A detailed analysis of morbidity was performed. Risk factors for POPF were assessed by univariable and multivariable analyses. Results Of 166 enucleations, 94 (56·6 per cent) were performed for cystic and 72 (43·4 per cent) for solid lesions. Morbidity was observed in 91 patients (54·8 per cent). Severe complications occurred in 30 patients (18·1 per cent), and one patient (0·6 per cent) died. Reoperation was necessary in nine patients (5·4 per cent). POPF was the main determinant of outcome and occurred in 68 patients (41·0 per cent): grade A POPF, 34 (20·5 per cent); grade B, ten (6·0 per cent); and grade C, 24 (14·5 per cent). Risk factors independently associated with POPF were: cystic tumour, localization in the pancreatic tail, history of pancreatitis and cardiac co-morbidity. Only cystic morphology was independently associated with clinically relevant POPF (grade B or C), occurring after enucleation in 25 (27 per cent) of 94 patients with cystic tumours versus nine (13 per cent) of 72 patients with solid tumours. Tumour size and distance to the main duct were not associated with risk of POPF. Conclusion Enucleation is a safe procedure in appropriately selected patients with a low rate of severe complications. POPF is the main determinant of outcome and is more frequent after the enucleation of cystic lesions. [ABSTRACT FROM AUTHOR]

Despite significant progress the therapy of peritonitis remains challenging. With a mortality of up to 20% peritonitis is a predominant cause of death due to surgical infections. An early and efficient source control combined with effective antibiotic therapy and modern intensive care and sepsis therapy are definitive for the outcome and prognosis of secondary peritonitis. In approximately 90% of patients an effective source control can be achieved by one single operation with extensive peritoneal lavage. A reoperation is necessary in only about 10% of patients. The aggressive concepts of planned relaparotomy or open packing are associated with increased morbidity and are indicated only in rare cases. The gold standard is to attempt a definitive source control by one single operation. An operative revision should be performed only on demand. The antibiotic therapy should begin with a broadly calculated empirical therapy and should later be adapted to microbiological findings. The therapy of sepsis requires standardized and state of the art intensive care. [ABSTRACT FROM AUTHOR]

Background: Infection of pancreatic necrosis (IPN) is strongly associated with sepsis and multiple organ dysfunction and is an absolute indication for surgery. Patients with IPN are critically ill at the time of surgery and may benefit from a minimally invasive approach with reduced surgical trauma. Recently, several minimally invasive necrosectomy techniques have been reported. However, the effects and potential dangers of a pneumoperitoneum in IPN cases are unknown. This study aimed to determine the effects of a pneumoperitoneum on systemic cytokine levels, bacterial translocation, and systemic organ complications in a rat model of IPN.Methods: For this study, IPN was induced in Wistar rats using retrograde intraductal infusion of 3% taurocholate. After 8 h, the animals were subjected to either laparoscopy (pneumoperitoneum at 8 mmHg) or laparotomy for 1 h and killed after 1 or 3 h. Severe acute pancreatitis with IPN was proved by serum amylase and lipase, histology, tissue activity of myeloperoxidase (MPO), and bacteriology. Systemic levels for interleukin-10 (IL-10), IL-6, tumor necrosis factor-alpha (TNF-alpha), and lipopolysaccarides were determined by enzyme-linked immunoassay (ELISA). Systemic organ damage and dysfunction were evaluated using MPO activity (lung), serum creatinine (kidney), and serum aminotransferases (liver).Results: Necrotizing pancreatitis developed in all the animals. Most of the animals (85%) had proven infected necrosis. Elevated cytokine levels and deteriorated organ parameters demonstrated systemic inflammation and organ failure. Although there was a tendency toward a higher level of proinflammatory cytokines after laparotomy, there were no significant differences between laparotomy and laparoscopy. Furthermore, these alterations were not accompanied by any differences in bacterial translocation (lipopolysaccharides), systemic organ damage, or mortality between laparoscopy and laparotomy.Conclusion: In the current model of infected pancreatic necrosis, a pneumoperitoneum did not result in increased cytokine release or bacterial translocation. However, the putative advantage of less surgical trauma with the laparoscopic approach did not play a significant role in the setting of severe acute pancreatitis with IPN. [ABSTRACT FROM AUTHOR]

Follow-up data included postoperative tumor-directed therapy, disease status, and survival. By multivariable analysis tumor grading, extent of lymph node metastasis, IPMN context, and vascular resections were independently associated with overall and disease-free 5YS. [Extracted from the article]

Encouraging observed 5-year survival with upfront resection and adjuvant therapy for pancreatic ductal adenocarcinoma in a large contemporary series Follow-up data included postoperative tumor-directed therapy, disease status, and survival. By multivariable analysis tumor grading, extent of lymph node metastasis, IPMN context, and vascular resections were independently associated with overall and disease-free 5YS. [Extracted from the article]

SUMMARY. Anastomotic leakage is the main factor (up to 30%) for postoperative morbidity and mortality after esophageal resection. Compromised anastomotic perfusion after dissection of supplying vessels for gastric tube formation and tension on the suture line are the two main reasons for anastomotic insufficiency. To prevent anastomotic leakage, a new technique for gastric tube formation after esophageal resection has been developed and introduced into surgical practice: the fundus rotation gastroplasty (FRG). The following paper summarizes rationale, technique and early results of this new technique. It is shown that the FRG is a safe and effective technique for esophageal reconstruction and offers important advantages over conventional gastroplasties: (i) the improved perfusion of the oral part of the tube; (ii) the gain of tube length allowing for a safer performance of even pharyngeal anastomosis as shown by the low insufficiency rate of 9%; and (iii) the increase of remaining gastric reservoir supporting physiologic stomach and gut function. Therefore, the FRG seems to be an alternative and safe method for esophageal reconstruction, especially for high anastomotic locations. [ABSTRACT FROM AUTHOR]

Analyzes the incidence and interaction of arteriolar vasomotion and capillary flow motion during critical perfusion conditions in neighboring peripheral tissues using intravital fluorescence microscopy. Exterioration of the tissue preparation for intravital microscopy; Incidence of arteriolar vasomotion and capillary flow motion.

Presents information on a study which analyzed the incidence and interaction of arteriolar vasomotion and capillary flow motion during critical perfusion conditions in neighboring peripheral tissues using intravital fluorescence microscopy. Information on vasomotion; Influence of muscle arteriolar vasomotion and capillary flow motion on microcirculation of neighboring tissues; Methodology; Results and discussion.

B Background: b Postoperative pancreatic fistula (POPF) is the most important complication after pancreatic surgery and is associated with major morbidity, increased use of resources, and prolonged hospital stay. The occurrence and the grade of POPF were significantly associated with increased treatment costs in all cases and in subgroups of different resections (e.g. mean costs of 15,741.51€ without and of 54,023.20€ with POPF after pancreatoduodenectomy; p< 0.0001). POPF resulted in uncovered costs and was associated with a deficit in total, after different resections, and within single DRGs. [Extracted from the article]

B Background: b Postoperative pancreatic fistula (POPF) is the most important complication after pancreatic surgery and is associated with major morbidity, increased use of resources, and prolonged hospital stay. The occurrence and the grade of POPF were significantly associated with increased treatment costs in all cases and in subgroups of different resections (e.g. mean costs of 15,741.51€ without and of 54,023.20€ with POPF after pancreatoduodenectomy; p< 0.0001). POPF resulted in uncovered costs and was associated with a deficit in total, after different resections, and within single DRGs. [Extracted from the article]

Background: Mültimodal treatment concepts enhance options for sürgery in locally advanced pancreatic düctal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate cürative-intent resection in PDAC. Methods: A review of the literatüre addressing cürrent technical advances in sürgery for PDAC was performed, and cürrent state-of-the-art sürgical techniqües sümmarized. Results: Artery-first and üncinate-first approaches, dissection of the anatomical triangle between the coeliac and süperior mesenteric arteries and the portomesenteric vein, and radical antegrade modülar pancreatosplenectomy were introdüced to enhance the completeness of resection and redüce the risk of local recürrence. Elaborated techniqües for resection and reconstruction of the mesenteric-portal vein axis and a venous bypass graft-first approach frequently allow resection of PDAC with venoüs involvement, even in patients with portal venoüs congestion and cavernoüs transformation. Arterial involvement does not preclude surgical resection per se, but may become surgically manageable with recent techniques of arterial divestment or arterial resection following neoadjuvanttreatment. Conclusion: Advanced techniques of surgical resection and vessel reconstruction provide a toolkit for curative-intent surgery in borderline resectable and locally advanced PDAC. Effects of these surgical approaches on overall survival remain to be proven with high-level clinical evidence. [ABSTRACT FROM AUTHOR]