Publications by authors named "Norbert Senninger"

144 Publications

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

A novel histidine-tryptophan-ketoglutarate formulation ameliorates intestinal injury in a cold storage and ex vivo warm oxygenated reperfusion model in rats.

Biosci Rep 2020 05;40(5)

Klinik für Allgemein-, Viszeral- und Transplanationschirurgie, Universitätsklinikum Münster, Münster, Germany.

Aim: The present study aims to evaluate protective effects of a novel histidine-tryptophan-ketoglutarate solution (HTK-N) and to investigate positive impacts of an additional luminal preservation route in cold storage-induced injury on rat small bowels.

Methods: Male Lewis rats were utilized as donors of small bowel grafts. Vascular or vascular plus luminal preservation were conducted with HTK or HTK-N and grafts were stored at 4°C for 8 h followed by ex vivo warm oxygenated reperfusion with Krebs-Henseleit buffer for 30 min. Afterwards, intestinal tissue and portal vein effluent samples were collected for evaluation of morphological alterations, mucosal permeability and graft vitality.

Results: The novel HTK-N decreased ultrastructural alterations but otherwise presented limited effect on protecting small bowel from ischemia-reperfusion injury in vascular route. However, the additional luminal preservation led to positive impacts on the integrity of intestinal mucosa and vitality of goblet cells. In addition, vascular plus luminal preservation route with HTK significantly protected the intestinal tissue from edema.

Conclusion: HTK-N protected the intestinal mucosal structure and graft vitality as a luminal preservation solution. Additional luminal preservation route in cold storage was shown to be promising.
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http://dx.doi.org/10.1042/BSR20191989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199455PMC
May 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

Indications for resection and perioperative outcomes of surgery for pancreatic neuroendocrine neoplasms in Germany: an analysis of the prospective DGAV StuDoQ|Pancreas registry.

Surg Today 2019 Dec 25;49(12):1013-1021. Epub 2019 Jun 25.

Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany.

Purpose: Pancreatic neuroendocrine neoplasms (pNENs) are rare, and their surgical management is complex. This study evaluated the current practice of pNEN surgery across Germany, including its adherence with guidelines and its perioperative outcomes.

Methods: Patients who underwent surgery for pNENs (April 2013-June 2017) were retrieved from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery and retrospectively analyzed.

Results: A total of 287 patients (53.7% male) with a mean age of 59.2 ± 14.2 years old underwent pancreatic resection for pNENs. Tumors were localized in the pancreatic head (40.4%), body (23%), or tail (36.6%). A total of 239 (83.3%) patients underwent formal resection with lymphadenectomy, 40 (14%) parenchyma-sparing resection, and 8 (2.8%) only exploration. Fifty (17.4%) patients underwent a minimally invasive approach. Among the 245 patients with complete pathological information, 42 (17.1%) had distant metastases, 78 (31.8%) had stage I tumors, 74 (30.2%) stage II, and 51 (20.8%) stage III. A total of 112 (45.7%) patients had G1 tumors, 101 (41.2%) G2, and 24 (9.8%) G3. Nodal involvement on imaging was an independent predictor of lymph node metastasis according to the multivariable analysis (odds ratio: 0.057; 95% confidence interval: 0.016-0.209; p < 0.01). R0 resection was reported in 240 (83.6%) patients. The 30- and 90-day mortality rates were 2.8% and 4.2%, respectively.

Conclusion: In Germany the rate of potential curative resection for pNEN is high. However, formal pancreatic resection seems to be overrepresented, while minimally invasive resection is underrepresented.
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http://dx.doi.org/10.1007/s00595-019-01838-1DOI Listing
December 2019

Clinical impact of circulating LAPTM4B-35 in pancreatic ductal adenocarcinoma.

J Cancer Res Clin Oncol 2019 May 18;145(5):1165-1178. Epub 2019 Feb 18.

Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1 (W1), 48149, Münster, Germany.

Purpose: LAPTM4B is upregulated in a wide range of cancers associated with poor prognosis. However, the clinical impact of LAPTM4B as diagnostic and prognostic marker in pancreatic ductal adenocarcinoma (PDAC) remains unknown. Thus, the aim of the present study was to investigate the expression of LAPTM4B as circulating marker in PDAC.

Methods: Expression analysis of LAPTM4B-35 in pancreatic tissue and preoperative blood serum samples of 169 patients with PDAC UICC Stages I-IV (n = 98), chronic pancreatitis (n = 41), and healthy controls (n = 30) by immunohistochemistry, Western blot, and ELISA. Descriptive and explorative statistical analyses of LAPTM4B-35's potential as diagnostic and prognostic marker in PDAC.

Results: Expression of LAPTM4B-35 was significantly increased in tumor tissue and corresponding blood serum samples of patients with PDAC (each p < 0.001) and it could well discriminate PDAC from healthy controls and chronic pancreatitis (p < 0.001; p = 0.0037). LAPTM4B-35 in combination with CA.19-9 outperforms the diagnostic accuracy with an AUC of 0.903 (p < 0.001), sensitivity of 82%, and specificity of 92%. Kaplan-Meier survival analysis revealed an improved overall survival in PDAC UICC I-IV with low expression of circulating LAPTM4B-35 (17 versus 10 months, p = 0.039) as well as an improved relapse-free survival in curatively treated PDAC UICC I-III (16 versus 10 months; p = 0.037). Multivariate overall and recurrence-free survival analyses identified LAPTM4B-35 as favorable prognostic factor in PDAC patients (HR 2.73, p = 0.021; HR 3.29, p = 0.003).

Conclusion: LAPTM4B-35 is significantly deregulated in PDAC with high diagnostic and prognostic impact as circulating tumor marker.
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http://dx.doi.org/10.1007/s00432-019-02863-wDOI Listing
May 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

Simvastatin ameliorates total liver ischemia/reperfusion injury via KLF2-mediated mechanism in rats.

Clin Res Hepatol Gastroenterol 2019 04 28;43(2):171-178. Epub 2018 Sep 28.

Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, 430071 Wuhan, Hubei, PR China. Electronic address:

Objective: The total hepatic ischemia/reperfusion injury (IRI) involves the fact that both liver and gut are subjected to warm ischemia, which is a complex unavoidable process encountered during liver transplantation and a serious threat to graft outcome. The ways to improve hepatic IRI are currently limited. The aim of the present study was to explore the protective effect of simvastatin on total hepatic IRI and examine the underlying mechanisms.

Methods: Male Sprague Dawley rats were subjected to total (100%) hepatic warm ischemia to induce hepatic IRI. Thirty-six male rats (250-300 g) were randomly divided into three groups: sham, IRI control and simvastatin (1 mg/kg) pretreatment 0.5 h before surgery. Serum samples and liver tissues were collected after reperfusion at 6 and 24 h for further studies.

Results: Simvastatin pretreatment significantly decreased the values of the transaminases alanine aminotransferase and aspartate aminotransferase and improved histological alterations according to improved Suzuki's Score (P < 0.05). Moreover, simvastatin upregulated the expression of Kruppel-like factor 2 (KLF2), phosphorylated endothelial nitric oxide synthase and thrombomodulin (P < 0.05). Furthermore, simvastatin pretreatment affected superoxide dismutase and malondialdehyde activities (P < 0.05) to reduce oxidative stress, and inhibited levels of high-mobility group box-1, CD68, toll-like receptor 4, tumor necrosis factor α, interleukin-1β and interleukin-6 (P < 0.05) to suppress inflammatory response.

Conclusion: Simvastatin pretreatment ameliorates total hepatic IRI via a KLF2-mediated protective mechanism. Simvastatin may be used as a potential prophylactic treatment strategy for clinical trials against hepatic IRI.
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http://dx.doi.org/10.1016/j.clinre.2018.08.014DOI Listing
April 2019

The ambiguous role of microRNA-205 and its clinical potential in pancreatic ductal adenocarcinoma.

J Cancer Res Clin Oncol 2018 Dec 22;144(12):2419-2431. Epub 2018 Sep 22.

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

Purpose: Early treatment of pancreatic ductal adenocarcinoma (PDAC) is significantly delayed due to the lack of liquid biopsy markers for early diagnosis at surgically resectable tumor stages. Recent studies suggest that microRNA-205 (miR-205) is involved in PDAC progression by post-transcriptional regulation of epithelial-to-mesenchymal transition (EMT). However, the clinical potential of miR-205 as diagnostic and prognostic marker remains undefined and its exact role in PDAC is still ambiguous. This retrospective study is a substantial contribution to this on-going scientific discussion.

Methods: Expression analysis of miR-205 and its molecular targets in PDAC cell lines (n = 5), human tissue (n = 73), and blood serum samples (n = 85) by qRT-PCR, tissue microarray immunohistochemistry, and western blot. Descriptive and explorative statistical analysis of miR-205's clinical potential for diagnosis and prognosis of PDAC.

Results: The expression of miR-205 differs more than 2000-fold (p < 0.001) between epithelial and mesenchymal-like human PDAC cell lines correlating with EMT-marker expression of E-cadherin, vimentin, fibronectin, and ZEB-1. Expression of miR-205 is significantly upregulated in carcinoma tissue (eightfold, p = 0.028) and serum (2.3-fold, p = 0.023) of PDAC patients compared to age-matched healthy controls. In our patient collective circulating miR-205 in combination with CA.19-9 outperforms the diagnostic accuracy of CA.19-9 alone with an AUC of 0.890 (p < 0.001), sensitivity of 0.867, and specificity of 0.933. Though non-significant, low expression of circulating miR-205 is more frequent in advanced tumor stages combined with a worse overall survival (6.9 vs. 11.9 months, p = 0.176).

Conclusion: Besides its controversial role in carcinogenesis, miR-205 shows high potential as a solid and liquid biopsy marker in PDAC. This result is an urgent call for larger confirmatory multi-center studies.
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http://dx.doi.org/10.1007/s00432-018-2755-9DOI Listing
December 2018

Circulating microRNA-99 family as liquid biopsy marker in pancreatic adenocarcinoma.

J Cancer Res Clin Oncol 2018 Dec 17;144(12):2377-2390. Epub 2018 Sep 17.

Department of General, Visceral and Transplantation Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1 (W1), 48149, Münster, Germany.

Purpose: Recently, we identified the microRNA-99 family as unfavorable prognostic factor in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to evaluate its value as circulating biomarker for PDAC.

Methods: Tissue and corresponding preoperative blood samples of 181 patients with PDAC UICC Stages I-IV (n = 90), intraductal papillary mucinous neoplasm (IPMN, n = 11), chronic pancreatitis (n = 40), pancreatic cystadenoma (n = 20), and age-matched healthy blood serum controls (n = 20) were collected between 2014 and 2017 prospectively. Expression of microRNA-21 as confirmatory marker and the microRNA-99 family, consisting of microRNA-99a, -99b, and -100, was analyzed by qRT-PCR. Target analysis of insulin-like growth factor 1 receptor (IGF1R) was performed using tissue array immunohistochemistry and Western blotting.

Results: Expression of microRNA-99 family members was significantly increased in macrodissected tumor tissue and corresponding blood serum samples (p < 0.05) of patients with PDAC of all stages. Correspondingly, its target protein IGF1R was upregulated (p < 0.001) in carcinoma tissue. Circulating and tissue-related microRNA-100 could well discriminate PDAC from healthy samples with area under the receiver operating characteristic (ROC) curve (AUC) values of 0.81 and 0.85, respectively. Low expression of circulating microRNA-100 was associated with significantly improved overall survival (p = 0.004) and recurrence-free survival (p = 0.03) in multivariate analyses. Circulating microRNA-21 was overexpressed in PDAC with fair discrimination between PDAC and healthy controls (AUC = 0.71) and decreased overall survival (p = 0.046) and recurrence-free survival (p = 0.03) in PDAC patients.

Conclusions: Multivariate survival and ROC analyses identified circulating microRNA-100 as potential diagnostic and prognostic marker in PDAC patients.
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http://dx.doi.org/10.1007/s00432-018-2749-7DOI Listing
December 2018

Clinical Impact of Epithelial-to-Mesenchymal Transition Regulating MicroRNAs in Pancreatic Ductal Adenocarcinoma.

Cancers (Basel) 2018 Sep 13;10(9). Epub 2018 Sep 13.

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

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive carcinoma entities worldwide with early and rapid dissemination. Recently, we discussed the role of microRNAs as epigenetic regulators of Epithelial-to-Mesenchymal Transition (EMT) in PDAC. In this study, we investigated their value as diagnostic and prognostic markers in tissue and blood samples of 185 patients including PDAC, non-malignant pancreatic disorders, and age-matched healthy controls. Expression of the microRNA-200-family (microRNAs -141, -200a, -200b, -200c, -429) and microRNA-148a was significantly downregulated in tissue of PDAC Union internationale contre le cancer (UICC) Stage II. Correspondingly, stromal PDAC tissue showed strong expression of Fibronectin, Vimentin, and ZEB-1 (Zinc finger E-box-binding homeobox) versus low expression of E-cadherin. Transient transfection of microRNA-200b and microRNA-200c mimics resulted in the downregulation of their key target ZEB-1. Inversely, blood serum analyses of patients with PDAC UICC Stages II, III, and IV showed a significant over-expression of microRNA-200-family members, microRNA-148a, microRNA-10b, and microRNA-34a. Correspondingly, Enzyme-linked Immunosorbent Assay (ELISA) analyses revealed a significant over-expression of soluble E-cadherin in serum samples of PDAC patients versus healthy controls. The best diagnostic accuracy to distinguish between PDAC and non-PDAC in this patient collective could be achieved in tissue by microRNA-148a with an area under the receiver-operating-characteristic (ROC) curve (AUC) of 0.885 and in blood serum by a panel of microRNA-141, -200b, -200c, and CA.19-9 with an AUC of 0.890. Both diagnostic tools outreach the diagnostic performance of the currently most common diagnostic biomarker CA.19-9 (AUC of 0.834). Kaplan Meier survival analysis of this patient collective revealed an improved overall survival in PDAC patients with high expression of tissue-related microRNA-34a, -141, -200b, -200c, and -429. In conclusion, EMT-regulating microRNAs have great potential as liquid and solid biopsy markers in PDAC patients. Their prognostic and therapeutic benefits remain important tasks for future studies.
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http://dx.doi.org/10.3390/cancers10090328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162771PMC
September 2018

Implementation of Current ENETS Guidelines for Surgery of Small (≤2 cm) Pancreatic Neuroendocrine Neoplasms in the German Surgical Community: An Analysis of the Prospective DGAV StuDoQ|Pancreas Registry.

World J Surg 2019 01;43(1):175-182

Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany.

Background: ENETS guidelines recommend parenchyma-sparing procedures without formal lymphadenectomy, ideally with a minimally invasive laparoscopic approach for sporadic small pNENs (≤2 cm). Non-functioning (NF) small pNENs can also be observed. The aim of the study was to evaluate how these recommendations are implemented in the German surgical community.

Methods: Data from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery were analyzed regarding patient's demographics, tumor characteristics, surgical procedures, histology and perioperative outcomes.

Results: Eighty-four (29.2%) of 287 patients had sporadic pNENs ≤2 cm. Forty-three (51.2%) patients were male, and the mean age at diagnosis was 58.8 ± 15.6 years. Twenty-five (29.8%) pNENs were located in the pancreatic head. The diagnosis pNEN was preoperatively established in 53 (65%) of 84 patients. Sixty-two (73.8%) patients had formal pancreatic resections, including partial pancreaticoduodenectomy or total pancreatectomy (21.4%). Only 22 (26.2%) patients underwent parenchyma-sparing resections and 23 (27.4%) patients had minimally invasive procedures. A lymphadenectomy was performed in 63 (75.4%) patients, and lymph node metastases were diagnosed in 6 (7.2%) patients. Eighty-two (97.7%) patients had an R0 resection. Sixty (72%) tumors were classified G1, 24 (28%) tumors G2. Twenty-seven (32.2%) of 84 patients had postoperative relevant Clavien-Dindo grade ≥3 complications. Thirty- and 90-day mortalities were 2.4% and 3.6%.

Conclusions: ENETS guidelines for surgery of small pNENs are yet not well accepted in the German surgical community, since the rate of formal resections with standard lymphadenectomy is high and the minimally invasive approach is underused. The attitude to operate small NF tumors seems to be rather aggressive.
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http://dx.doi.org/10.1007/s00268-018-4751-2DOI Listing
January 2019

Prophylactic Ureteral Stenting in Colectomy Patients: Who Is at Risk?

Dis Colon Rectum 2018 08;61(8):e356-e357

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

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http://dx.doi.org/10.1097/DCR.0000000000001141DOI Listing
August 2018

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

Preoperative prediction of curative surgery of perihilar cholangiocarcinoma by combination of endoscopic ultrasound and computed tomography.

United European Gastroenterol J 2018 Mar 25;6(2):263-271. Epub 2017 May 25.

Department of Transplant Medicine, University of Münster, Münster, Germany.

Background: Perihilar cholangiocarcinomas are often considered incurable. Late diagnosis is common. Advanced disease therefore frequently causes questioning of curative surgical outcome.

Aim: This study aimed to develop a prediction model of curative surgery in patients suffering from perihilar cholangiocarcinomas based on preoperative endosonography and computer tomography.

Methods: A cohort of 81 patients (median age 67 (54-75) years, 62% male) with perihilar cholangiocarcinoma was retrospectively analyzed. Multivariate logistic regression analysis of staging variables taken from the European Staging System was performed and applied to ROC analysis.

Results: The correlation of predicted rates of eligibility for surgery with actual rates reached AUC values between 0.652 and 0.758 for endosonography and computer tomography ( < 0.05 each). Best prediction for curative surgical option was achieved by combining endosonography and computer tomography (AUC: 0.787; 95% CI 0.680-0.893,  < 0.0001). A predictive model (pSurg) was developed using multivariate analysis.

Conclusions: Our predictive web-based model pSurg with inclusion of T, N, M, B, PV, HA and V stage of the recently published European Staging System for perihilar cholangiocarcinoma results in highly significant predictability for curative surgery when combining preoperative endosonography and computer tomography, thus allowing for better patient selection in terms of possibility of curative surgery.
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http://dx.doi.org/10.1177/2050640617713651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833220PMC
March 2018

Relevance of Postoperative Peak Transaminase After Elective Hepatectomy.

Ann Surg 2017 12;266(6):e59-e60

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

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http://dx.doi.org/10.1097/SLA.0000000000001500DOI Listing
December 2017

Comment on: MicroRNA Expression as a Predictive Marker for Gemcitabine Response After Surgical Resection of Pancreatic Cancer.

Ann Surg Oncol 2017 12 1;24(Suppl 3):669. Epub 2017 Nov 1.

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

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http://dx.doi.org/10.1245/s10434-017-6207-6DOI Listing
December 2017

Effect of Continuous Motion Parameter Feedback on Laparoscopic Simulation Training: A Prospective Randomized Controlled Trial on Skill Acquisition and Retention.

J Surg Educ 2018 Mar - Apr;75(2):516-526. Epub 2017 Aug 31.

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

Objective: To investigate the effect of motion parameter feedback on laparoscopic basic skill acquisition and retention during a standardized box training curriculum.

Design: A Lap-X Hybrid laparoscopic simulator was designed to provide individual and continuous motion parameter feedback in a dry box trainer setting. In a prospective controlled trial, surgical novices were randomized into 2 groups (regular box group, n = 18, and Hybrid group, n = 18) to undergo an identical 5-day training program. In each group, 7 standardized tasks on laparoscopic basic skills were completed twice a day on 4 consecutive days in fixed pairs. Additionally, each participant performed a simulated standard laparoscopic cholecystectomy before (day 1) and after training (day 5) on a LAP Mentor II virtual reality (VR) trainer, allowing an independent control of skill progress in both groups. A follow-up assessment of skill retention was performed after 6 weeks with repetition of both the box tasks and VR cholecystectomy.

Setting: Muenster University Hospital Training Center, Muenster, Germany.

Participants: Medical students without previous surgical experience.

Results: Laparoscopic skills in both groups improved significantly during the training period, measured by the overall task performance time. The 6 week follow-up showed comparable skill retention in both groups. Evaluation of the VR cholecystectomies demonstrated significant decrease of operation time (p < 0.01), path length of the left and right instrument, and the number of movements of the left and right instruments for the Hybrid group (all p < 0.001), compared to the box group. Similar results were found at the assessment of skill retention.

Conclusion: Simulation training on both trainers enables reliable acquisition of laparoscopic basic skills. Furthermore, individual and continuous motion feedback improves laparoscopic skill enhancement significantly in several aspects. Thus, training systems with feedback of motion parameters should be considered to achieve long-term improvement of motion economy among surgical trainees.
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http://dx.doi.org/10.1016/j.jsurg.2017.08.015DOI Listing
December 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

The Non Operative Treatment for Acute Appendicitis (NOTA) Study: Is Less Surgery Better Surgery?

Ann Surg 2017 06;265(6):E83-E84

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

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http://dx.doi.org/10.1097/SLA.0000000000001323DOI Listing
June 2017

[Register of Difficult Surgical Situations].

Zentralbl Chir 2018 Feb 28;143(1):55-59. Epub 2017 Apr 28.

Klinik für Adipositas Chirurgie und Metabolische Chirurgie, Sana Klinikum Offenbach, Deutschland.

Every surgical problem that increases the likelihood of intraoperative and postoperative complications is considered to be a difficult surgical situation. Based on this definition, Korenkov et al. proposed to classify patients according to the following intraoperative difficulty levels (I to IV): (I) ideal situation (easy to operate, no problems), (II) fairly easy/manageable/simple (some minor difficulties may occur), (III) difficult/problematic (difficult to operate; some operative techniques are considerably more difficult than others), and (IV) very difficult (every operative step is difficult/challenging). Kaafrani et al. proposed a severity classification for intraoperative adverse events. Depending on the severity level, classes range from I (injury requiring no repair) to VI (intraoperative death). Clavien and colleagues published a globally established classification system for postoperative complications. In this classification, the severity of postoperative complications ranges from severity grade I (minimal deviation from the normal postoperative course) to severity grade V (death of patient). Based on the proposed classifications and the problems of individual surgical decision-making, we had the idea to create a Register of Difficult Intraoperative Situations (DIS register). The basic principle of such a register is the collection of an individual expert's experiences. The scientific analysis should focus on patients with apparent modifications in treatment due to difficult intraoperative situations. Registration and processing of enrolled cases will be performed anonymously based on an appropriate IT platform. The main goal of this register is to develop an accessible database for practising surgeons. This will provide an opportunity for every surgeon to find out what other surgeons did in similar situations.
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http://dx.doi.org/10.1055/s-0043-104769DOI Listing
February 2018

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

Challenges in pancreatic adenocarcinoma surgery - National survey and current practice guidelines.

PLoS One 2017 7;12(3):e0173374. Epub 2017 Mar 7.

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

Background: Pancreatic ductal adenocarcinoma (PDAC) remains one of the most deadly cancers in Europe and the USA. There is consensus that radical tumor surgery is the only viable option for any long-term survival in patients with PDAC. So far, limited data are available regarding the routine surgical management of patients with advanced PDAC in the light of surgical guidelines.

Methods: A national survey on perioperative management of patients with PDAC and currently applied criteria on their tumor resectability in German university and community hospitals was carried out.

Results: With a response rate of 81.6% (231/283) a total of 95 (41.1%) participating departments practicing pancreatic surgery in Germany are certified as competence and reference centers for surgical diseases of the pancreas in 2016. More than 95% of them indicate to carry out structured and interdisciplinary therapies along with an interdisciplinary pre- and postoperative tumor board. The majority of survey respondents prefer the pylorus-preserving partial pancreatoduodenectomy (93.1%) with standard lymphadenectomy for cancer of the pancreatic head. Intraoperative histological evaluation of the resection margins is used regularly by 99% of the survey respondents. 98.7% of survey respondents carry out partial or complete vein resection, 126 respondents (54.5%) would resect tumor adjacent arteries, and 102 respondents (44.2%) would perform metastasectomy if complete PDAC resection (R0) is possible.

Conclusion: Evidence-based and standardized pancreatic surgery is practiced by a large number of hospitals in Germany. However, a significant number of survey respondents support an extended radical tumor resection in patients with advanced PDAC even when not indicated by current clinical guidelines.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0173374PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340358PMC
August 2017

The consensus on liver autotransplantation from an international panel of experts.

Hepatobiliary Pancreat Dis Int 2017 Feb;16(1):10-16

Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China; Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Xiangya Hospital of Central South University, Changsha 410013, China.

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http://dx.doi.org/10.1016/s1499-3872(16)60175-3DOI Listing
February 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

Box- or Virtual-Reality Trainer: Which Tool Results in Better Transfer of Laparoscopic Basic Skills?-A Prospective Randomized Trial.

J Surg Educ 2017 Jul - Aug;74(4):724-735. Epub 2017 Jan 13.

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

Objective: Simulation training improves laparoscopic performance. Laparoscopic basic skills can be learned in simulators as box- or virtual-reality (VR) trainers. However, there is no clear recommendation for either box or VR trainers as the most appropriate tool for the transfer of acquired laparoscopic basic skills into a surgical procedure.

Design: Both training tools were compared, using validated and well-established curricula in the acquirement of basic skills, in a prospective randomized trial in a 5-day structured laparoscopic training course. Participants completed either a box- or VR-trainer curriculum and then applied the learned skills performing an ex situ laparoscopic cholecystectomy on a pig liver. The performance was recorded on video and evaluated offline by 4 blinded observers using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Learning curves of the various exercises included in the training course were compared and the improvement in each exercise was analyzed.

Setting: Surgical Skills Lab of the Department of General and Visceral Surgery, University Hospital Muenster.

Participants: Surgical novices without prior surgical experience (medical students, n = 36).

Results: Posttraining evaluation showed significant improvement compared with baseline in both groups, indicating acquisition of laparoscopic basic skills. Learning curves showed almost the same progression with no significant differences. In simulated laparoscopic cholecystectomy, total GOALS score was significantly higher for the box-trained group than the VR-trained group (box: 15.31 ± 3.61 vs. VR: 12.92 ± 3.06; p = 0.039; Hedge׳s g* = 0.699), indicating higher technical skill levels.

Conclusions: Despite both systems having advantages and disadvantages, they can both be used for simulation training for laparoscopic skills. In the setting with 2 structured, validated and almost identical curricula, the box-trained group appears to be superior in the better transfer of basic skills into an experimental but structured surgical procedure.
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http://dx.doi.org/10.1016/j.jsurg.2016.12.009DOI Listing
May 2018

Downregulation of CXCR1 ameliorates experimental colitis: evidence for CXCL1-CXCR1-mediated immune cell recruitment.

Int J Colorectal Dis 2017 Mar 10;32(3):315-324. Epub 2016 Dec 10.

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

Purpose: Inflammatory conditions like inflammatory bowel diseases (IBD) are characterized by increased immune cell infiltration. The chemokine ligand CXCL1 and its receptor CXCR1 have been shown to be involved in leukocyte adhesion, transendothelial recruitment, and chemotaxis. Therefore, the objective of this study was to describe CX3CL1-CX3CR1-mediated signaling in the induction of immune cell recruitment during experimental murine colitis.

Methods: Acute colitis was induced by dextran sodium sulfate (DSS), and sepsis was induced by injection of lipopolysaccharide (LPS). Serum concentrations of CXCR1 and CXCL1 were measured by ELISA. Wild-type and CXCR1 mice were challenged with DSS, and on day 6, intravital microscopy was performed to monitor colonic leukocyte and platelet recruitment. Intestinal inflammation was assessed by disease activity, histopathology, and neutrophil infiltration.

Results: CXCR1 was upregulated in DSS colitis and LPS-induced sepsis. CXCR1 mice were protected from disease severity and intestinal injury in DSS colitis, and CXCR1 deficiency resulted in reduced rolling of leukocytes and platelets.

Conclusions: In the present study, we provide evidence for a crucial role of CXCL1-CXCR1 in experimental colitis, in particular for intestinal leukocyte recruitment during murine colitis. Our findings suggest that CXCR1 blockade represents a potential therapeutic strategy for treatment of IBD.
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http://dx.doi.org/10.1007/s00384-016-2735-yDOI Listing
March 2017

Liver Transplantation for Hepatic Trauma: A Study From the European Liver Transplant Registry.

Transplantation 2016 11;100(11):2372-2381

1 Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.2 Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University Paris-Sud, Villejuif, France.3 Division of Hepatopancreatobiliary and Transplantation Surgery, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.4 Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany.5 Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.6 Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgery and Transplantation, University of Modena and Reggio Emilia, Modena, Italy.7 Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.8 Department of General and Visceral Surgery, University Hospital of Muenster, Muenster, Germany.9 Department of Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.10 Unit of Surgery and Liver Transplantation, Hospital Universitario Reina Sofia, Córdoba, Spain.11 Transplant Institute, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden.12 Department of Abdominal, Visceral and Transplantation Surgery, Charité Universitätsmedizin, Campus Virchow, Berlin, Germany.13 Department of General and Transplant Surgery, University Hospital Essen, Essen, Germany.14 Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany.15 Unità Operativa Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy.16 Liver Transplant Center, General Surgery Unit, A.O. Città della Salute e della Scienza, Molinette Hospital, University of Turin, Turin, Italy.17 Liver Transplant Unit, Hospital Juan Canalejo, La Coruna, Spain.18 Abdominal Trasplant Unit, Universitary Clinical Hospital, Santiago de Compostela, Spain.19 Hepatic-Biliary-Pancreatic Surgery and Liver Transplant Unit, University Hospital Virgen del Rocío of Seville, Seville, Spain.20 Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium.21 Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium.22 Department of Visceral and Transplantation Surgery, University Hospitals, Geneva, Switzerland.23 Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic.24 Department of General and Visceral Surgery, Goethe University Hospital and Clinics, Frankfurt, Germany.25 Department of Visceral, Transplant, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany.26 Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany.27 Service de Chirurgie Digestive et Transplantation, University Lille Nord de France, Centre Hospitalier Universitaire Lille, Lille, France.28 The Liver Unit, Queen Elizabeth Hospital Birmingham Edgbaston, Birmingham, United Kingdom.29 Institute of General Surgery and Liver Transplantation, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.30 Department of Surgery, Pope John XXIII Hospital, Bergamo, Italy.31 Department of Experimental Medicine and Surgery, Section of Transplantation, Tor Vergata University of Rome, Rome, Italy.32 Division of Transplantation, Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands.33 Department of Surgery and Organ Transplantation, Porto, Portugal.34 Department of HBP Surgery and Transplant, Hospital Universitari Vall d'Hebro'n, Autonomous University of Barcelona, Barcelona, Spain.35 Service of General and Digestive Surgery and Abdominal Organ Transplantation, "Doce de Octubre", University Hospital, Madrid, Spain.36 Liver Unit, Gregorio Marañón University Hospital, Madrid, Spain.37 Unidad de Trasplante Hepatico, Hospital Universitarro Puerta de Hierro, Madrid, Spain.38 Hepatobiliopancreatic Surgery and Transplantation Unit, La Fe University Hospital, Valencia, Spain.39 Inonu University, Liver Transplantation Institute, Malatya, Turkey.

Background: Liver transplantation is the most extreme form of surgical management of patients with hepatic trauma, with very limited literature data supporting its use. The aim of this study was to assess the results of liver transplantation for hepatic trauma.

Methods: This retrospective analysis based on European Liver Transplant Registry comprised data of 73 recipients of liver transplantation for hepatic trauma performed in 37 centers in the period between 1987 and 2013. Mortality and graft loss rates at 90 days were set as primary and secondary outcome measures, respectively.

Results: Mortality and graft loss rates at 90 days were 42.5% and 46.6%, respectively. Regarding general variables, cross-clamping without extracorporeal veno-venous bypass was the only independent risk factor for both mortality (P = 0.031) and graft loss (P = 0.034). Regarding more detailed factors, grade of liver trauma exceeding IV increased the risk of mortality (P = 0.005) and graft loss (P = 0.018). Moreover, a tendency above the level of significance was observed for the negative impact of injury severity score (ISS) on mortality (P = 0.071). The optimal cut-off for ISS was 33, with sensitivity of 60.0%, specificity of 80.0%, positive predictive value of 75.0%, and negative predictive value of 66.7%.

Conclusions: Liver transplantation seems to be justified in selected patients with otherwise fatal severe liver injuries, particularly in whom cross-clamping without extracorporeal bypass can be omitted. The ISS cutoff less than 33 may be useful in the selection process.
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http://dx.doi.org/10.1097/TP.0000000000001398DOI Listing
November 2016

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

Cytomegalovirus Treatment Strategy After a Liver Transplant: Preemptive Therapy or Prophylaxis for Cytomegalovirus Seropositive Donor and Recipient.

Exp Clin Transplant 2016 Aug;14(4):419-23

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

Objectives: Cytomegalovirus infections cause the most frequent infection after solid-organ transplant. While Cytomegalovirus prophylaxis is established in high-risk patients (donor+/ recipient-), data on Cytomegalovirus prophylaxis in other serostatus constellation are rare. The aim of this study was to evaluate the influence of Cytomegalovirus treatment strategy after a liver transplant (preemptive therapy vs general prophylaxis) in the largest group of patients: Cytomegalovirus seropositive donor and recipient.

Materials And Methods: Forty-seven seropositive recipients of seropositive donor liver transplants (D+/R+, 2005-2012) were included in this retrospective study. Twenty-one patients received oral valganciclovir as Cytomegalovirus prophylaxis 100 days after transplant. Cytomegalovirus infection and Cytomegalovirus disease were monitored during the first 6 months.

Results: A Cytomegalovirus infection could be detected in 4 out of 47 patients (8.5%), including Cytomegalovirus disease in 2 patients (Cytomegalovirus pneumonia and Cytomegalovirus-CNS disease). Three of these patients received no Cytomegalovirus prophylaxis (P = .408). Eight patients developed a graft failure; this occurred more frequently among patients without Cytomegalovirus prophylaxis (P = .044). Patients receiving Cytomegalovirus prophylaxis more often developed leukopenia. No difference was seen regarding the number of platelets, hemoglobin, and creatinine.

Conclusions: Cytomegalovirus prophylaxis can minimize the risk of Cytomegalovirus reactivation and graft failure. However, disadvantages of the prophylaxis as leukopenia should be considered.
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August 2016