Publications by authors named "Daniel Palmes"

56 Publications

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy.

J Gastrointest Surg 2021 Feb 24. Epub 2021 Feb 24.

Department of Medical Controlling, University Hospital of Muenster, Nils-Stensen-Str. 8, 48149, Muenster, Germany.

Background: Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL.

Methods: All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging.

Results: 42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28).

Conclusion: Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies.
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http://dx.doi.org/10.1007/s11605-021-04955-wDOI Listing
February 2021

Merendino Resection vs. Transhiatal Gastric Conduit After Resection of the Cardia and the Gastroesophageal Junction.

Am Surg 2021 Jan 27:3134820983185. Epub 2021 Jan 27.

Department of General, Visceral and Transplant Surgery, University of Muenster, Germany.

Background: Reconstruction after combined cardia resection and removal of the gastroesophageal junction can be carried out by the Merendino procedure or via a gastric conduit. This study compares postoperative complications and quality of life for both approaches.

Methods: All patients who underwent Merendino or gastric conduit reconstruction from 2011-2017 were included. Both groups were investigated regarding postoperative length of stay, complications, and gastrointestinal quality of life.

Results: 45 patients were identified, of which, 39 remained for analysis: 22 patients in the Merendino group and 17 patients in the gastric conduit group. The median age of patients in the gastric conduit group (71 (53-92) years) was significantly higher than in the Merendino group (58 (19-75) years), = .0002. Hospital stay was significantly longer in the gastric conduit group (35.9 (11-82) days vs. 18.2 (7-43) days, = .0299) and incidence of anastomotic leakage was higher (24% vs. 9%, = .0171). General incidence of complications (Clavien-Dindo) did not vary ( = .1694). However, grade 5 complications only occurred in the Merendino group (n = 1). Evaluation of long-term outcome and quality of life showed dysphagia to only have occurred in the Merendino group (n = 3, 14%).

Discussion: Both approaches have advantages and disadvantages: The Merendino procedure showed reduced incidence of anastomotic leakage and shorter hospital stay but was associated with a higher in-hospital mortality rate. Discrepancies in subgroup populations as well as small patient numbers limit the interpretation of the findings. This study does however provide a first comparison of these surgical approaches and may serve as a basis for further investigation.
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http://dx.doi.org/10.1177/0003134820983185DOI Listing
January 2021

Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience.

PLoS One 2020 23;15(7):e0235680. Epub 2020 Jul 23.

Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany.

Aims: The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome.

Methods: Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation.

Results: Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards.

Conclusion: nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235680PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377418PMC
September 2020

Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy.

Thorac Cardiovasc Surg 2020 Mar 1. Epub 2020 Mar 1.

Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Münster, Germany.

Background:  Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF.

Methods:  From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome.

Results:  In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously ( = 6, 40%) or metachronously ( = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy ( = 3), stenting ( = 6), or suturing ( = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition.

Conclusion:  Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.
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http://dx.doi.org/10.1055/s-0039-1700970DOI Listing
March 2020

Impact of preoperative risk factors on outcome after gastrectomy.

World J Surg Oncol 2020 Jan 24;18(1):17. Epub 2020 Jan 24.

Department of Surgery, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.

Background: Gastrectomy is associated with relevant postoperative morbidity. However, outcome of surgery can be improved by careful selection of patients. The objective of the current study was therefore to identify preoperative risk factors that might impact on patients' further outcome after surgical resection.

Methods: Preoperative risk factors having respectively different surgical risk scores for major complex surgery (including Cologne Risk Score, p-/o-POSSUM, and NSQIP risk score) of patients that underwent gastrectomy for AEG II/III tumors and gastric cancer were correlated with complications according to Clavien-Dindo and outcome. Patients who underwent surgery in palliative intention were excluded from further analysis.

Results: Subtotal gastrectomy was performed in 23%, gastrectomy in 59%, and extended gastrectomy in 18% in a total of 139 patients (mean age: 64 years old). Thirty six percent experienced a minor complication (Dindo I-II) and 24% a major complication (Dindo III-V), which resulted in a prolonged hospital stay (p < 0.001). In-hospital mortality (=Dindo V) was 2.5%. Besides age, type of surgical procedure impacted on complications with extended gastrectomy showing the highest risk (p = 0.005). The o-POSSUM score failed to predict mortality accurately. We observed a highly positive correlation between predicted morbidity respectively mortality and occurrence of complications estimated by p-POSSUM (p = 0.005), Cologne Risk (p = 0.007), and NSQIP scores (p < 0.001).

Conclusion: The results demonstrate a significant association between different risk scores and occurrence of complications following gastrectomy. The p-POSSUM, Cologne Risk, and NSQIP score exhibited superior performance than the o-POSSUM score. Therefore, these scores might allow identification and selection of high-risk patients and thus might be highly useful for clinical decision making.
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http://dx.doi.org/10.1186/s12957-020-1790-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982377PMC
January 2020

Impact of nighttime procedures on outcomes after liver transplantation.

PLoS One 2019 22;14(7):e0220124. Epub 2019 Jul 22.

Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany.

Background: Sleep deprivation is a well-known risk factor for the performance of medical professionals. Solid organ transplantation (especially orthotopic liver transplantation (oLT)) appears to be vulnerable since it combines technically challenging operative procedures with an often unpredictable start time, frequently during the night. Aim of this study was to analyze whether night time oLT has an impact on one-year graft and patient survival.

Material And Methods: Deceased donor oLTs between 2006 and 2017 were retrospectively analyzed and stratified for recipients with a start time at day (8 a.m. and 6 p.m.) or at night (6 p.m. to 8 a.m.). We examined donor as well as recipient demographics and primary outcome measure was one-year patient and graft survival.

Results: 350 oLTs were conducted in the study period, 154 (44%) during daytime and 196 (56%) during nighttime. Donor and recipient variables were comparable. One-year patient survival (daytime 75.3% vs nighttime 76.5%, p = 0.85) as well as graft survival (daytime 69.5% vs nighttime 73.5%, p = 0.46) were similar between the two groups. Frequencies of reoperation (daytime 53.2% vs nighttime 55.1%, p = 0.74) were also not significantly different.

Conclusion: Our retrospective single center data derived from a German transplant center within the Eurotransplant region provides evidence that oLT is a safe procedure irrespective of the starting time. Our data demonstrate that compared to daytime surgery nighttime liver transplantation is not associated with a greater risk of surgical complications. In addition, one-year graft and patient survival do not display inferior results in patients undergoing nighttime transplantation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0220124PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645562PMC
February 2020

Expanding the donor pool in kidney transplantation: Should organs with acute kidney injury be accepted?-A retrospective study.

PLoS One 2019 13;14(3):e0213608. Epub 2019 Mar 13.

Department of Internal Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany.

Background: Given the gap between patients in need of a renal transplantation (RTx) and organs available, transplantation centers increasingly accept organs of suboptimal quality, e.g. from donors with acute kidney injury (AKI).

Methods: To determine the outcome of kidney transplants from deceased donors with AKI (defined as ≥ AKIN stage 1), all 107 patients who received a RTx from donors with AKI between August 2004 and July 2014 at our center were compared to their respective consecutively transplanted patients receiving kidneys from donors without AKI. 5-year patient and graft survival, frequencies of delayed graft function (DGF), acute rejections and glomerular filtration rate (eGFR, CKD-EPI) were assessed.

Results: Patient survival was similar in both groups, whereas death-censored and overall graft survival were decreased in AKI kidney recipients. AKI kidney recipients showed higher frequencies of DGF and had a reduced eGFR at 7 days, three months and one and three years after RTx. However, mortality was noticeably lower compared to waiting list candidates. Rejection-free survival was similar between groups.

Conclusions: In our cohort, both short-term and long-term renal function was inferior in recipients of AKI kidneys, while patient survival was similar. Our data indicates that recipients of donor AKI kidneys should be carefully selected and additional factors impairing short- and long-term outcome should be minimized to prevent further deterioration of graft function.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213608PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6415810PMC
December 2019

Long-Term Quality of Life Assessment After Successful Endoscopic Vacuum Therapy of Defects in the Upper Gastrointestinal Tract Quality of Life After EVT.

J Gastrointest Surg 2019 02 14;23(2):280-287. Epub 2018 Nov 14.

Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. W1, 48149, Muenster, Germany.

Background: Accumulating evidence indicates that anastomotic leakages and perforations of the upper gastrointestinal tract (uGIT) can be treated successfully with endoscopic vacuum therapy (EVT). So far, no data is available regarding the long-term quality of life (QoL) after successful EVT of defects in the uGIT.

Methods: We present a prospective survey on long-term Qol of 52 patients treated by EVT for defects of the uGIT. Results are compared with 63 of 221 patients treated by esophagectomy without anastomotic insufficiency (w/o EVT) between 12/2011 and 12/2015. The Gastrointestinal Quality of Life-Index (GIQLI) score was determined by a 36-item questionnaire of 25 respondents with EVT and 50 respondents w/o EVT.

Results: The response rate was 78.95% (75/95) including 25 survey respondents who were treated with EVT for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 19), iatrogenic esophageal perforation (n = 4), and Boerhaave syndrome (n = 2) and 50 respondents with complication-free esophagectomy w/o EVT. The median follow-up was 19 months for EVT patients and 21 months for patients w/o EVT. Except for "social function" (p = 0.009) in favor for patients w/o EVT, the median GIQLI score did not differ significantly between both study groups concerning the categories 'symptoms', 'emotions', 'physical functions', and 'medical treatment' resulting in a total median GIQLI score of 83 in EVT versus 96.5 in patients w/o EVT (p = 0.185). Spearman Rho analysis revealed that a high GIQLI score correlated with a low ASA score (p < 0.001), a benign pathology (p = 0.001), and a hospital stay less than 21 days (p < 0.001).

Conclusion: EVT in the uGIT is well tolerated by the patients and accompanied by a satisfactory long-term QoL.
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http://dx.doi.org/10.1007/s11605-018-4038-9DOI Listing
February 2019

The weekend effect in liver transplantation.

PLoS One 2018 24;13(5):e0198035. Epub 2018 May 24.

Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany.

Background: The weekend effect describes a phenomenon whereby patients admitted to hospitals on weekends are at higher risk of complications compared to those admitted during weekdays. However, if a weekend effect exists in orthotopic liver transplantation (oLT).

Methods: We analyzed oLT between 2006 and 2016 and stratified patients into weekday (Monday to Friday) and weekend (Saturday, Sunday) groups. Primary outcome measures were one-year patient and graft survival.

Results: 364 deceased donor livers were transplanted into 329 patients with 246 weekday (74.77%) and 83 weekend (25.23%) patients. Potential confounders (e.g. age, ischemia time, MELD score) were comparable. One-year patient and graft survival were similar. Frequencies of rejections, primary-non function or re-transplantation were not different. The day of transplantation was not associated with one-year patient and graft survival in multivariate analysis.

Conclusions: We provide the first data for the Eurotransplant region on oLT stratified for weekend and weekday procedures and our findings suggest there was no weekend effect on oLT. While we hypothesize that the absent weekend effect is due to standardized transplant procedures and specialized multidisciplinary transplant teams, our results are encouraging showing oLT is a safe and successful procedure, independent from the day of the week.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0198035PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967797PMC
December 2018

Risk factors for allograft failure in liver transplant recipients.

Z Gastroenterol 2018 07 16;56(7):745-751. Epub 2018 Jan 16.

University Hospital Muenster, Department of Medicine B, Gastroenterology and Hepatology, Muenster, Germany.

Background: With regard to quality of life and organ shortage, follow-up after liver transplantation (LT) should consider risk factors for allograft failure in order to avoid the need for re-LT and to improve the long-term outcome of recipients. Therefore, the aim of this study was to explore potential risk factors for allograft failure after LT.

Material And Methods: A total of 489 consecutive LT recipients who received follow-up care at the University Hospital of Muenster were included in this study. Database research was performed, and patient data were retrospectively reviewed. Risk factors related to donor and recipient characteristics potentially leading to allograft failure were statistically investigated using binary logistic regression analysis. Graft failure was determined as graft cirrhosis, need for re-LT because of graft dysfunction, and/or allograft-associated death.

Results: The mean age of recipients at the time of LT was 50.3 ± 12.4 years, and 64.0 % were male. The mean age of donors was 48.7 ± 15.5 years. Multivariable statistical analysis revealed male recipient gender (p = 0.04), hepatitis C virus infection (HCV) (p = 0.014), hepatocellular carcinoma (HCC) (p = 0.03), biliary complications after LT (p < 0.001), pretransplant diabetes mellitus (p = 0.03), and/or marked fibrosis in the initial protocol biopsy during follow-up (p = 0.001) to be recipient-related significant and independent risk factors for allograft failure following LT.

Conclusion: Male recipients, patients who received LT for HCV or HCC, those with pretransplant diabetes mellitus, and LT recipients with biliary complications are at high risk for allograft failure and thus should be monitored closely.
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http://dx.doi.org/10.1055/s-0043-125225DOI Listing
July 2018

EPOR/βcR-independendent effects of low-dose epoetin- in porcine liver transplantation.

Biosci Rep 2017 Dec 5;37(6). Epub 2017 Dec 5.

Department of General and Visceral, Division of Surgical Research Surgery, University Hospital Muenster, Muenster, Germany.

Ischemia-reperfusion injury (IRI) remains a key component of graft damage during transplantation. Erythropoietin (EPO) induces anti-inflammatory and anti-apoptotic effects via the EPOR/βcR complex, with a potential risk of thrombosis. Previous work indicates that EPO has EPOR/βcR-independent protective effects via direct effects on the endothelium. As the EPOR/βcR receptor has a very low affinity for EPO, we aimed to test the hypothesis that EPO doses below the level that stimulate this receptor elicit cytoprotective effects via endothelial stimulation in a porcine liver transplantation model. Landrace pigs underwent allogenic liver transplantation (follow-up: 6 h) with a portojugular shunt. Animals were divided into two groups: donor and recipient treatment with low-dose EPO (65 IU/kg) or vehicle, administered 6 h before cold perfusion and 30 min after warm reperfusion. Fourteen of 17 animals (82.4%) fulfilled the inclusion criteria. No differences were noted in operative values between the groups including hemoglobin, cold or warm ischemic time. EPO-treated animals showed a significantly lower histopathology score, reduced apoptosis, oxidative stress, and most important a significant up-regulation of endothelial nitric oxide (NO) synthase (eNOS). Donor and recipient treatment with low-dose EPO reduces the hepatic IRI via EPOR/βcR-independent cytoprotective mechanisms and represents a clinically applicable way to reduce IRI.
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http://dx.doi.org/10.1042/BSR20171007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715127PMC
December 2017

Investigating the Lymphatic System by Dual-Color Elemental Mass Spectrometry Imaging.

Contrast Media Mol Imaging 2017 29;2017:4035721. Epub 2017 Jan 29.

Department of General and Visceral Surgery, University Hospital Muenster, 48149 Muenster, Germany.

Secondary lymphedema accompanied with strong restrictions in quality of life is still major side effects in cancer therapy. Therefore, dedicated diagnostic tools and further investigation of the lymphatic system are crucial to improve lymphedema therapy. In this pilot study, a method for quantitative analysis of the lymphatic system in a rat model by laser ablation (LA) with inductively coupled plasma mass spectrometry imaging (ICP-MSI) is presented. As a possible lymph marker, thulium(III)(1R,4R,7R,10R)-,','','''-tetramethyl-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetate (Tm-DOTMA) is introduced and compared to the clinically used magnetic resonance imaging contrast agent gadolinium(III)2,2',2''-(10-((2R,3S)-1,3,4-trihydroxybutan-2-yl)-1,4,7,10-tetraazacyclododecane-1,4,7-triyl)triacetate (Gd-DO3A-butrol). Gadobutrol functioned as standard contrast media in MRI lymphangiography to detect lymphatic flow qualitatively. Thus, Tm-DOTMA was investigated as lymphatic marker to detect lymphatic flow quantitatively. Both contrast agents were successfully used to visualize the lymphatic flow in successive lymph nodes in LA-ICP-MS due to lower limits of detection compared to MRI. Furthermore, the distribution of contrast agents by multicolored imaging showed accumulation in specific areas (sectors) of the lymph nodes after application of contrast agents in different areas.
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http://dx.doi.org/10.1155/2017/4035721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612703PMC
August 2018

Endoscopic Vacuum Therapy (EVT)-a New Concept for Complication Management in Bariatric Surgery.

Obes Surg 2017 09;27(9):2499-2505

Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. W1, D-48149, Muenster, Germany.

Background: Bariatric surgery is the most efficient therapy for morbid obesity. Staple line and anastomotic leakage are the most feared postoperative complications after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy (LSG). Traditional treatment options like revisional surgery and endoscopic stent placement are associated with high morbidity and mortality as well as variable success rates. Endoscopic vacuum therapy (EVT) has shown to be a new successful and feasible treatment option for leaks of different etiology after major gastro-esophageal surgery.

Method: We report a case of the EVT principle being applied in a patient with three major leaks located apart from each other within the gastric staple line after LSG for morbid obesity (BMI 62.7). EVT was initiated on postoperative day 8.

Results: In total, 18 endoscopic interventions were performed in 72 days, the vacuum sponge being replaced endoscopically every 4 days. Hospital length of stay was 106 days. No relevant procedure related complications were observed during the course of therapy and during the follow up.

Conclusion: EVT of postoperative leaks in the upper GI tract has been shown to be feasible and safe. It combines defect closure and effective drainage and allows a periodic inspection of the wound cavity. In case of therapeutic failure, it does not jeopardize surgical repair or stent placement. Even though the techniques and materials used in EVT still vary considerably according to local expertise, EVT has the potential to succeed as a nonsurgical, feasible, safe, and effective treatment option for postoperative leaks in bariatric surgery.
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http://dx.doi.org/10.1007/s11695-017-2783-6DOI Listing
September 2017

A practical guide for small bowel transplantation in rats-review of techniques and models.

J Surg Res 2017 06 16;213:115-130. Epub 2017 Mar 16.

Division of Experimental Surgical Research, Department of General and Visceral Surgery, University Hospital of Muenster, Muenster, Germany. Electronic address:

Background: Animal models are a central aspect in research on small bowel transplantation (SBTx). Among them, rats are the preferred species because of their widespread availability and cost effectiveness. Because the complexity of the surgical procedure could per se influence the outcome of an experiment, a standardized and comparable technique is important. Based on of the vast amount of different models and surgical techniques published to this point, a review seemed necessary to guide investigators when choosing the suitable model.

Materials And Methods: A systematic literature search of original articles published between 1965 and 2016 using the Medline Database regarding techniques of SBTx in rats was conducted according to the Preferred reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing a new technique or evaluating different techniques were considered.

Results: A total of 38 publications fulfilled the selection criteria and were included. Data from these publications were regarded as too heterogeneous for statistical analysis. Depending on graft length and placement, full-length and reduced length heterotopic and orthotopic models were differentiated. Important factors concerning a good survival rate are the chosen model (heterotopic has a better outcome compared with orthotopic), a vascular flush of the graft in situ, a careful luminal flush of the graft, adequate fluid resuscitation, and a warm ischemia time of less than 40 min.

Conclusions: SBTx in rats remains a complex and challenging procedure, which necessitates a standardized technique as well as sufficient training. By choosing the optimal experimental model, applying established strategies, and proven techniques, a standardized and scientifically reliable model can be achieved.
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http://dx.doi.org/10.1016/j.jss.2017.02.026DOI Listing
June 2017

Successful management of passenger lymphocyte syndrome in an ABO-compatible, nonidentical isolated bowel transplant: a case report and review of the literature.

Transfusion 2017 06 28;57(6):1396-1400. Epub 2017 Mar 28.

Department of General and Visceral Surgery.

Background: Passenger lymphocyte syndrome (PLS), a subtype of graft-versus-host disease, is a rare disorder encountered mainly in ABO-mismatched hematopoietic stem cell transplantation and infrequently in all types of ABO-mismatched solid organ transplantation. We here report the fifth case of PLS in small bowel transplantation (SBTx) and the first one describing the successful management of PLS in a cadaveric, isolated SBTx.

Case Report: A 60-year-old Caucasian female with blood group A D+ suffering from short bowel syndrome received a small bowel transplant from a 32-year-old Caucasian female with blood group O D+ (HLA mismatch 2/6). After onset of massive hemolysis on Postoperative Day 9 the positive direct and indirect antiglobulin tests showing antibodies against A1 and A2 red blood cells (RBCs) led to the diagnosis of PLS. This complication was successfully treated by transfusion of blood group O RBC transfusions, increased immunosuppression, and plasmapheresis.

Conclusion: In the event of severe hemolysis and anemia after ABO-mismatched SBTx, PLS should be considered. In our case successful treatment consisted of transfusion of donor-specific RBCs, increased immunosuppression, and plasmapheresis.
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http://dx.doi.org/10.1111/trf.14086DOI Listing
June 2017

Animal Models of Secondary Lymphedema: New Approaches in the Search for Therapeutic Options.

Lymphat Res Biol 2017 03 27;15(1):2-16. Epub 2017 Jan 27.

Department of General and Visceral Surgery, University Hospital Münster , Münster, Germany .

Secondary lymphedema is still a worldwide problem. Symptomatic approaches to lymphedema therapy have been mainly used, with complete decongestive therapy as the cornerstone. Due to a lack of regenerative therapy, researchers have established various animal models to obtain insights into pathomechanisms and to reveal the best therapeutic option. Since the first reproducible and reliable animal model of lymphedema was reported in dogs, the technique of circumferential excision of lymphatic tissue has been translated mainly to rodents to induce secondary lymphedema. In these models, various promising pharmacological and surgical approaches have been investigated to improve secondary lymphedema therapy. Imaging modalities are crucial to detect the extent of lymphatic dysfunction and decide the best therapy. The gold standard of lymphoscintigraphy is currently limited by poor spatial resolution and lack of quantification. Animal models could help to bridge a gap in improving morphological correlation and quantifying lymphatic functionality. This review summarizes the animal models used in lymphatic research and focuses on new therapeutic options and requirements for imaging modalities to visualize the lymphatic system.
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http://dx.doi.org/10.1089/lrb.2016.0015DOI Listing
March 2017

Pre-emptive endoscopic vacuum therapy for treatment of anastomotic ischemia after esophageal resections.

Endoscopy 2017 May 20;49(5):498-503. Epub 2017 Jan 20.

Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany.

 Endoscopic vacuum therapy (EVT) is a promising new approach for the treatment of anastomotic leakage in the gastrointestinal tract. Here, we present the first case series demonstrating successful use of EVT for the treatment of post-esophagectomy anastomotic ischemia prior to development of leakage.  Between 2012 and 2015, intraluminal EVT was performed in eight patients with anastomotic ischemia following esophagectomy. The primary outcome measure was successful mucosal recovery. Secondary outcome measures were duration of treatment, number of sponge changes, septic course, and associated complications.  Complete mucosal recovery was achieved in six patients (75 %) with different degrees of anastomotic ischemia. In two patients (25 %), small anastomotic leaks developed, which resolved by continuing the EVT treatment. Median duration of EVT treatment until mucosal recovery was 16 days (range 6 - 35), with a median of 5 sponge changes per patient (range 2 - 11). No EVT-associated complications were noted. Three patients developed anastomotic stenoses, which were treated by endoscopic dilation therapy.  This is the first case series to demonstrate that the early use of EVT potentially modulates clinical outcomes and infection parameters in patients with anastomotic ischemia following esophagectomy. Further studies are needed to define the indications and patients who are most likely to benefit from early EVT.
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http://dx.doi.org/10.1055/s-0042-123188DOI Listing
May 2017

Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study.

Surg Endosc 2017 06 5;31(6):2687-2696. Epub 2016 Oct 5.

Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. W1, 48149, Muenster, Germany.

Background: Perforations and anastomotic leakages of the upper gastrointestinal (GI) tract cause a high morbidity and mortality rate. Only limited data exist for endoscopic vacuum therapy (EVT) in the upper GI tract.

Methods: Fifty-two patients (37 men and 15 women, ages 41-94 years) were treated (12/2011-12/2015) with EVT for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 39), iatrogenic esophageal perforation (n = 9) and Boerhaave syndrome (n = 4). After diagnosis, polyurethane sponges were endoscopically positioned with a total of 390 interventions and continuous negative pressure of 125 mm of mercury (mmHg) was applied to the EVT-system. Sponges were changed endoscopically twice per week. Clinical and therapy-related data and mortality were analyzed.

Results: After 1-25 changes of the sponge at intervals of 3-5 days with a mean of 6 sponge changes and a mean duration of therapy of 22 days, the defects were healed in 94.2 % of all patients without revision surgery. In three patients (6 %), EVT failed. Two of these patients died due to hemorrhage related to EVT. Four postinterventional strictures were observed during the follow-up of up to 4 years.

Conclusion: Esophageal wall defects of different etiology in the upper gastrointestinal tract can be treated successfully with EVT, considering that indication for EVT should be weighed carefully. EVT can be regarded as a novel life-saving therapeutic tool.
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http://dx.doi.org/10.1007/s00464-016-5265-3DOI Listing
June 2017

Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy.

Dis Esophagus 2017 Feb;30(3):1-8

Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany.

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.
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http://dx.doi.org/10.1111/dote.12459DOI Listing
February 2017

Esophageal Cancer Specific Risk Score Is Associated with Postoperative Complications Following Open Ivor-Lewis Esophagectomy for Adenocarcinoma.

Dig Surg 2016 25;33(1):58-65. Epub 2015 Nov 25.

Department of General and Visceral Surgery, Muenster University Hospital, Mx00FC;nster, Germany.

Background/aims: Surgery for esophageal cancer is associated with a high morbidity and mortality. With this study, we investigated if a validated preoperative risk score correlates with overall morbidity, mortality, anastomotic insufficiency, respiratory complications and with the severity of complications after open Ivor-Lewis esophagectomy.

Methods: A total of 94 patients undergoing esophageal resection for adenocarcinoma between 2005 and 2009 were included. Patients were assigned using the preoperative risk score according to Schröder et al. [Langenbecks Arch Surg 2006;391:455-460] and the Dindo classification regarding the severity of complications.

Results: Of all the patients, 12% had a 'normal', 54% a 'moderate' and 34% a 'high' preoperative risk score. Postoperative complications occurred in 79%. Furthermore, 36 or 21 or 14 or 7% of patients experienced complications of category I/II or III or IV or V, respectively. There was a significant association between preoperative risk score and overall morbidity (p = 0.010), mortality (p = 0.035) and anastomotic insufficiency (p = 0.023). Furthermore, higher preoperative risk score was significant related to increasing severity of postoperative complications (grade IV according to the Dindo classification: p = 0.018, Dindo grade V: p = 0.035). Neoadjuvant therapy consisting of cisplatin and 5-fluorouracil had no influence.

Conclusion: As we demonstrated, a significant association between preoperative risk score and occurrence and severity of postoperative complications after open Ivor-Lewis esophagectomy, standardized, organ-specific pre- and postoperative categorizations might be useful for individual clinical decision making in this group of patients.
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http://dx.doi.org/10.1159/000439442DOI Listing
September 2016

Comparison of Endoscopic Vacuum Therapy Versus Stent for Anastomotic Leak After Esophagectomy.

J Gastrointest Surg 2015 Jul 13;19(7):1229-35. Epub 2015 May 13.

Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geb. W1, D-48149, Muenster, Germany,

Background: Endoscopic vacuum therapy is a novel option for the management of esophageal leaks. This study compares endoscopic vacuum therapy versus placement of covered stents for anastomotic leaks after esophagectomy.

Methods: N = 45 consecutive patients with anastomotic leaks following esophagectomy (including patients referred to our center from other hospitals for complication management) were managed by endoscopic therapy at our institution from January 2009 to February 2015. Outcomes of stent and endoscopic vacuum therapy were analyzed retrospectively.

Results: Thirty patients received endoscopic stent placement and 15 endoscopic vacuum therapy. In the stent group, seven patients were switched to endoscopic vacuum and four to surgery. Classified by type of initial endoscopic therapy, the success rate (anastomotic healing, patient recovered) was higher for endoscopic vacuum therapy (endoscopic vacuum 93.3%, stent 63.3 %; p = 0.038). Classified by final endoscopic therapy (after switches in therapy), success rates were 86.4 and 60.9% (p = 0.091), respectively. There was no difference observed in mortality, duration of therapy, and length of hospital stay between the study groups.

Conclusions: Endoscopic vacuum therapy might be more effective than endoscopic stent placement in the management of esophageal anastomotic leaks.
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http://dx.doi.org/10.1007/s11605-015-2847-7DOI Listing
July 2015

Perioperative chemotherapy in gastroesophageal cancer. A retrospective monocenter evaluation of 42 cases.

PLoS One 2015 9;10(4):e0122974. Epub 2015 Apr 9.

Department of Medicine, Hematology and Oncology, University of Muenster, Muenster, Germany.

Background: Perioperative chemotherapy increases the overall and progression-free survival of patients suffering from resectable adenocarcinomas of the lower esophagus, gastroesophageal junction and stomach (GEC). Comparing different chemotherapy regimens platin-based protocols with 5-fluorouracil (5-FU)/calcium folinate (CF) or oral fluoropyrimidines were favorable in terms of efficacy and side-effects. However, there is no consensus which regimen is the most efficacious.

Methods: 42 consecutive patients with resectable GEC (UICC II and III) were treated with 3 pre- and postoperative chemotherapy cycles each consisting of epirubicin, oxaliplatin and capecitabine (EOX). We analyzed the overall survival, progression-free survival and toxicity retrospectively in comparison to published data.

Results: The median overall survival in our cohort was 29 months and the progression-free survival was 17 months. The most frequent grade 3 and 4 toxicities during preoperative chemotherapy were diarrhea (16.7%), leukocytopenia (9.5%) and nausea (9.5%); overall 38.1% of our patients suffered from grade 3 or 4 toxicity. Surgery was carried out in 83% of our patients, 69% of those achieved R0 resection.

Conclusion: Comparing our data with the results of previously published randomized trials EOX is at least non-inferior with regard to overall survival, progression-free survival and toxicity. In conclusion, EOX is an appropriate perioperative therapy for patients with resectable GEC.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122974PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4391860PMC
December 2015

Postoperative complications do not affect long-term outcome in esophageal cancer patients: reply.

World J Surg 2015 May;39(5):1322-4

Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Muenster, Germany,

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http://dx.doi.org/10.1007/s00268-015-2960-5DOI Listing
May 2015

PET/CT predicts survival in patients undergoing primary surgery for esophageal cancer.

Langenbecks Arch Surg 2015 Feb 9;400(2):229-35. Epub 2015 Jan 9.

Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Muenster, Germany.

Introduction: Positron emission tomography combined with computed tomography (PET/CT) is increasingly being used in the staging of esophageal cancer, and some recent studies suggested the maximal standardized uptake value (SUVmax) as a prognostic factor for prediction of survival of these patients. However, data on correlations between SUVmax and other established prognostic markers is rare, and the impact of neoadjuvant treatment on SUVmax ability to predict outcome is not clear. The aim of the present study was therefore to evaluate the prognostic significance of the SUVmax in patients with or without neoadjuvant therapy (NAT) by comparing SUVmax to different established prognostic factors and survival.

Methods: Esophageal cancer patients receiving either neoadjuvant therapy or no pretreatment before surgery were included in our study, and correlations between SUVmax and prognostic factors such as tumour/nodal stage, grading, tumour length or survival were investigated.

Results: Between January 2004 and December 2011, a total of 114 patients was included (mean age 63 years, 96 men, 36 SCC, 78 adenocarcinoma). A number of 74 patients underwent neoadjuvant therapy. The median follow-up was 52 months. The SUVmax was significantly correlated to initial tumour stage (p = 0.000) and tumour length (p ≤ 0.010). Survival was significantly better in patients undergoing primary surgery if SUVmax was <6 compared to SUVmax >6 (p = 0.008), whereas neither neoadjuvant-treated patients in general (p = 0.950) nor the different subgroups of responders showed a comparable correlation between survival and SUVmax (complete responder p = 0.808, partial responder p = 0.409, nonresponder p = 0.529).

Conclusion: The SUVmax highly correlates with well-known prognostic factors and survival of esophageal cancer patients after surgery but only in case of primary surgery and not if patients received neoadjuvant therapy.
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http://dx.doi.org/10.1007/s00423-014-1264-9DOI Listing
February 2015

Effect of Simvastatin on Physiological and Biological Outcomes in Patients Undergoing Esophagectomy.

Ann Surg 2015 Dec;262(6):e119

Department of General and Visceral Surgery University Hospital of Muenster Muenster, Germany.

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http://dx.doi.org/10.1097/SLA.0000000000001004DOI Listing
December 2015

Postoperative complications do not affect long-term outcome in esophageal cancer patients.

World J Surg 2014 Oct;38(10):2652-61

Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Münster, Germany,

Background: As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients.

Methods: Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study.

Results: SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival.

Conclusions: This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.
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http://dx.doi.org/10.1007/s00268-014-2590-3DOI Listing
October 2014

Treatment options for postoperatively infected abdominal wall wounds healing by secondary intention.

Langenbecks Arch Surg 2012 Dec 10;397(8):1359-66. Epub 2012 Aug 10.

Department of General and Visceral Surgery, University Hospital of Münster, Waldeyerstr.1, 48149, Münster, Germany.

Purpose: We present our current clinical approach for the treatment of postoperatively infected wounds of the abdominal wall healing by secondary intention that may help in the design of a randomized controlled trial to develop a standardized wound treatment pathway.

Methods: Patients with postoperatively infected abdominal wounds treated with either Advanced Wound Care (AWC) dressings or vacuum-assisted closure (VAC) therapy were enrolled in the study. Follow-up was carried out prospectively for wound healing and incidence of incisional hernia at the earliest 3 years after surgery.

Results: Sixty-two patients were included and wounds were initially treated antiseptically for 5.19 ± 2.91 days. Prior to VAC therapy, AWC dressings were applied for 8.75 ± 2.93 days to reduce reinfection. Greater wound size (>12 × 6 × 6cm) and extensive secretion (>200 ml/day) argued for the VAC system. Overall incidence of incisional hernia was 20.4%, with 18.4% occurring in AWC-treated patients and 27.3% in VAC-treated patients. Based on these results, a wound treatment pathway was established in our department.

Conclusion: The established wound treatment pathway has helped to increase both workflow efficacy and outcome in the treatment of abdominal wounds. Wound size, amount of secretion, and status of infection were the parameters we used for the determination of appropriate treatment. The observational data gathered during the initiation of our pathway lay the basis for future randomized controlled trials that will determine the most appropriate treatment options in the setting of a standardized wound treatment pathway.
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http://dx.doi.org/10.1007/s00423-012-0988-7DOI Listing
December 2012

Current concepts in the management of leakages after esophagectomy.

Thorac Cancer 2012 May;3(2):117-124

Department of General and Visceral Surgery, University Hospital of Muenster, Muenster, Germany.

Esophagectomy is a high-risk procedure that, despite advances over past years, is still associated with high morbidity and mortality. Anastomotic insufficiency is a devastating surgical complication as it is linked to postoperative morbidity and is the main cause for postoperative mortality. It can lead to sepsis and necessitate re-operation, further increasing morbidity and mortality through additional complications brought on by the repeated invasive procedures. However, not all anastomotic leakages entail such a critical course of events and can be sufficiently dealt with by less invasive measures. As a consequence, the approach to anastomotic leakage must be carefully selected in order to minimize additional procedure-related risks while ensuring adequate therapy. In this setting, less invasive treatments such as esophageal stents and clips, application of vicryl plugs in combination with fibrin glue, and endoscopic insertion of vacuum sponges, have emerged in recent years and become a viable alternative in the management of certain leakages. This review presents current algorithms for detection, classification and treatment of leakages after esophagectomy.
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http://dx.doi.org/10.1111/j.1759-7714.2012.00117.xDOI Listing
May 2012

Type of steatosis influences microcirculation and fibrogenesis in different rat strains.

J Invest Surg 2011 ;24(6):273-82

Division of Surgical Research, Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany.

This study investigates the impact of rat strain on the development of nonalcoholic fatty liver disease (NAFLD) focusing on morphological features and microcirculation. Male rats of Lewis, Wistar, and Sprague Dawley (n = 6 per strain and group) were randomized into a high-fat group which was fed with a special high-fat nutrition for a 3-week period and a control group which received standard nutrition. Intravital microscopy was used for the evaluation of microcirculation and correlated to morphological changes using a fatty liver scoring system. All three strains receiving a high-fat diet developed a grade 3 steatosis (>66% liver cell steatosis). Whereas Lewis showed a solely microvesicular steatosis, Wistar developed a mixed form and Sprague Dawley showed a pure macrovesicular steatosis and the highest degree of fibrosis and hepatocyte damage. Microcirculatory results revealed that sinusoidal density was already affected by a microvesicular steatosis and decreased with increasing macrovesicular proportion (Lewis: 18%, Wistar: 31%, Sprague Dawley: 23%). The degree of steatosis correlates with reduced blood flow velocity in central veins as well as in sinusoids (Lewis: 28%, Wistar: 39%, Sprague Dawley 44%). The densities of hepatocytes and hepatic stellate cells were only impaired once macrovesicular cell steatosis (Wistar and Sprague Dawley) was present. The development of NAFLD in the rat revealed strain-specific morphological features correlating with microcirculatory changes that should be considered in further studies using these models.
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http://dx.doi.org/10.3109/08941939.2011.586094DOI Listing
March 2012

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group.

Langenbecks Arch Surg 2011 Aug 29;396(6):857-66. Epub 2011 Jun 29.

Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.

Purpose: Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.

Materials And Methods: The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).

Results: Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.

Conclusion: The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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http://dx.doi.org/10.1007/s00423-011-0818-3DOI Listing
August 2011