Publications by authors named "Tim Glowka"

27 Publications

  • Page 1 of 1

Active smokers show ameliorated delayed gastric emptying after pancreatoduodenectomy.

BMC Surg 2021 Jul 31;21(1):316. Epub 2021 Jul 31.

Department of Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.

Background: Delayed gastric emptying (DGE) is the most common complication following pancreatoduodenectomy (PD). The data about active smoking in relation to gastric motility have been inconsistent and specifically the effect of smoking on gastric emptying after PD has not yet been investigated in detail.

Methods: 295 patients at our department underwent PD between January 2009 and December 2019. Patients were analyzed in relation to demographic factors, diagnosis, pre-existing conditions, intraoperative characteristics, hospital stay, mortality and postoperative complications with special emphasis on DGE. All complications were classified according to the definitions of the International Study Group on Pancreatic Surgery.

Results: 274 patients were included in the study and analyzed regarding their smoking habits (non or former smokers, n = 88, 32.1% vs. active smokers, n = 186, 68.6%). Excluded were patients for whom no information about their smoking habits was available (n = 3), patients who had had gastric resection before (n = 4) and patients with prolonged postoperative resumption to normal diet independently from DGE (long-term ventilation > 7 days, fasting due to pancreatic fistula) (n = 14). Smokers were younger than non-smokers (61 vs. 69 years, p ≤ 0.001) and mainly male (73% male vs. 27% female). Smoking patients showed significantly more pre-existing pulmonary conditions (19% vs. 8%, p = 0.002) and alcohol abuse (48% vs. 23%, p ≤ 0.001). We observe more blood loss in smokers (800 [500-1237.5] vs. 600 [400-1000], p = 0.039), however administration of erythrocyte concentrates did not differ between both groups (0 [0-2] vs. 0 [0-2], p = 0.501). 58 out of 88 smokers (66%) and 147 out of 186 of non-smokers (79%) showed malign tumors (p = 0.019). 35 out of 88 active smokers (40%) and 98 out of 188 non- or former smokers (53%) developed DGE after surgery (p = 0.046) and smokers tolerated solid food intake more quickly than non-smokers (postoperative day (POD7 vs. POD10, p = 0.004). Active smokers were less at risk to develop DGE (p = 0.051) whereas patients with pulmonary preexisting conditions were at higher risk for developing DGE (p = 0.011).

Conclusions: Our data show that DGE occurs less common in active smokers and they tolerate solid food intake more quickly than non-smokers. Further observation studies and randomized, controlled multicentre studies without the deleterious effect of smoking, for instance by administration of a nicotine patch, are needed to examine if this effect is due to nicotine administration.
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http://dx.doi.org/10.1186/s12893-021-01311-2DOI Listing
July 2021

Chronic Liver Disease Increases Mortality Following Pancreatoduodenectomy.

J Clin Med 2021 Jun 7;10(11). Epub 2021 Jun 7.

Department of Surgery, University Hospital Bonn, 53127 Bonn, Germany.

According to the International Study Group of Pancreatic Surgery (ISGPS), data about the impact of pre-existing liver pathologies on delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) according to the definitions of the International Study Group of Pancreatic Surgery (ISGPS) are lacking. We therefore investigated the impact of DGE after PD according to ISGPS in patients with liver cirrhosis (LC) and advanced liver fibrosis (LF). Patients were analyzed with respect to pre-existing liver pathologies (LC and advanced LF, = 15, 6% vs. no liver pathologies, = 240, 94%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications, with special emphasis on DGE. DGE was equally distributed (DGE grade A, = 1.000; B, = 0.396; C, = 0.607). Particularly, the first day of solid food intake ( = 0.901), the duration of intraoperative administered nasogastric tube (NGT) ( = 0.812), the rate of re-insertion of NGT ( = 0.072), and the need for parenteral nutrition ( = 0.643) did not differ. However, patients with LC and advanced LF showed a higher ASA (American Society of Anesthesiologists) score ( = 0.016), intraoperatively received more erythrocyte transfusions ( = 0.029), stayed longer in the intensive care unit ( = 0.010) and showed more intraabdominal abscess formation ( = 0.006). Moreover, we did observe a higher mortality rate amongst patients with pre-existing liver diseases ( = 0.021), and reoperation was a risk factor for higher mortality ( ≤ 0.001) in the multivariate analysis. In our study, we could not detect a difference with respect to DGE classified by ISGPS; however, we did observe a higher mortality rate amongst these patients and thus, they should be critically evaluated for PD.
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http://dx.doi.org/10.3390/jcm10112521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8201140PMC
June 2021

[Postoperative dumping-syndrome with relevant impairment of glucose homeostasis - relief by continuous glucose monitoring and individual therapy with GLP-1 receptor agonists].

Z Gastroenterol 2021 Jun 15;59(6):556-559. Epub 2021 Jun 15.

Innere Medizin, Krankenhaus St. Marienwörth, Bad Kreuznach, Germany.

Dumping syndromes are a common side effect after partial or total gastric resection. The symptoms may be diverse, with vasomotoric reactions, collapse tendencies and digestive disorders (early dumping) as well as blood sugar derailment as a result of too fast absorption of glucose (late dumping).Entrenched therapy concepts, including personalized nutritional concepts and the use of medication as octreotide or diazoxide, will not always lead to the desired results. It is then, that individual therapy concepts have to be found to restore the patient's quality of life, as shown in this case study.
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http://dx.doi.org/10.1055/a-1324-4136DOI Listing
June 2021

Intensified Endoscopic Evaluation for Biliary Complications After Orthotopic Liver Transplantation.

Ann Transplant 2021 Apr 6;26:e928907. Epub 2021 Apr 6.

Department of Surgery, University Hospital Bonn, Bonn, Germany.

BACKGROUND Biliary complications are common causes of morbidity and mortality after liver transplantation. MATERIAL AND METHODS From 2013 to 2018, 102 whole-organ liver transplantations were conducted in our department. Patients were closely monitored for biliary complication development. In all suspected cases, patients underwent either endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangial drainage. Patients' demographic characteristics, preexisting conditions, and perioperative characteristics, as well as morbidity and mortality, were analyzed. Risk factors for 1-year survival were calculated. RESULTS Of the 102 patients, 43 (42%) experienced biliary complications. In comparison with patients without biliary complications, patients with biliary complications exhibited the following risk factors: underlying liver disease (viral hepatitis; P=0.009), blood group A (P=0.005), and previous abdominal surgery (P=0.037). Neither perioperative characteristics, especially duration of cold ischemia (P=0.86), nor postoperative course differed between patients with and without biliary complications. Risk factors for mortality within 1 year were cirrhosis caused by entities other than viral hepatitis (P=0.017), cardiac comorbidities (P=0.019), re-transplantation (P=0.032), and reduced organ weight (P=0.002). Biliary complications, postoperative hemorrhage, primary nonfunction, and repeated surgery worsened outcome; moreover, serum bilirubin trough in the first 30 days after transplantation might be prognostic for mortality (P=0.043). CONCLUSIONS Biliary complications adversely affect outcome after liver transplantation. Neither frequency nor outcome of biliary complications was improved by intensified endoscopic evaluation. Patients on the waiting list for liver transplants should also be closely monitored for cardiac comorbidities.
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http://dx.doi.org/10.12659/AOT.928907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035812PMC
April 2021

Secondary ARDS Following Acute Pancreatitis: Is Extracorporeal Membrane Oxygenation Feasible or Futile?

J Clin Med 2021 Mar 2;10(5). Epub 2021 Mar 2.

Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany.

Objective: To assess the feasibility of extracorporeal membrane oxygenation (ECMO) or life support (ECLS) as last resort life support therapy in patients with acute pancreatitis and subsequent secondary acute respiratory distress syndrome (ARDS).

Methods: Retrospective analysis from January 2013, to April 2020, of ECMO patients with pancreatitis-induced ARDS at a German University Hospital. Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, fluid balance, need for decompressive laparotomy, amount of blood products, prognostic scores (CCI (Charlson Comorbidity Index), SOFA (Sequential Organ Failure Assessment), RESP(Respiratory ECMO Survival Prediction), SAVE (Survival after Veno-Arterial ECMO)), and the total known length of survival were assessed.

Results: A total of = 495 patients underwent ECMO. Eight patients with acute pancreatitis received ECLS (seven veno-venous, one veno-arterial). Five (71%) required decompressive laparotomy as salvage therapy due to abdominal hypertension. Two patients with acute pancreatitis (25%) survived to hospital discharge. The overall median length of survival was 22 days. Survivors required less fluid in the first 72 h of ECMO support and showed lower values for all prognostic scores.

Conclusion: ECLS can be performed as a rescue therapy in patients with pancreatitis and secondary ARDS, but nevertheless mortality remains still high. Thus, this last-resort therapy may be best suited for patients with fewer pre-existing comorbidities and no other organ failure.
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http://dx.doi.org/10.3390/jcm10051000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958117PMC
March 2021

Open Abdomen Treatment in Acute Pancreatitis.

Front Surg 2020 14;7:588228. Epub 2021 Jan 14.

Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany.

Severe acute pancreatitis (SAP) is a heterogeneous and life-threatening disease. While recent guidelines recommend a stepwise approach starting with non-surgical techniques, emergency laparotomy remains inevitable in certain situations. Open abdomen treatment (OAT) may follow, potentially resulting in additional risks for severe morbidity. Causative factors and clinical impact of OAT in SAP are poorly understood and therefore issue of the present study. A retrospective analysis of patients admitted to the Department of General, Visceral, Thoracic and Vascular Surgery at University of Bonn suffering from acute pancreatitis (ICD K.85) between 2005 and 2020 was performed. Medical records were screened for demographic, clinical and outcome parameters. Patients who received primary fascial closure (PFC) were compared to those patients requiring OAT. SAP-specific scores were calculated, and data statistically analyzed ( = 0.05). Among 430 patients included, 54 patients (13%) had to undergo emergency laparotomy for SAP. Patients were dominantly male (72%) with a median age of 51 years. Indications for surgery were infected necrosis (40%), suspected bowel perforation (7%), abdominal compartment syndrome (5%), and acute intra-abdominal hemorrhage (3%). While 22 patients (40%) had PFC within initial surgery, 33 patients (60%) required OAT including a median of 12 subsequent operations (SD: 6, range: 1-24). Compared to patients with PFC, patients in the OAT group had significantly fewer biliary SAP ( = 0.031), higher preoperative leukocyte counts ( = 0.017), higher rates of colon resections ( = 0.048), prolonged ICU stays ( = 0.0001), and higher morbidity according to Clavien-Dindo Classification ( = 0.002). Additionally, BISAP score correlated positively with the number of days spent at ICU and morbidity ( = 0.001 and = 0.000002). Both groups had equal mortality rates. Our data suggest that preoperative factors in surgically treated SAP may indicate the need for OAT. The procedure itself appears safe with equal hospitalization days and mortality rates compared to patients with PFC. However, OAT may significantly increase morbidity through longer ICU stays and more bowel resections. Thus, minimally invasive options should be promoted for an uncomplicated and rapid recovery in this severe disease. Emergency laparotomy will remain ultima ratio in SAP while patient selection seems to be crucial for improved clinical outcomes.
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http://dx.doi.org/10.3389/fsurg.2020.588228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841327PMC
January 2021

A novel P2X2-dependent purinergic mechanism of enteric gliosis in intestinal inflammation.

EMBO Mol Med 2021 Jan 17;13(1):e12724. Epub 2020 Dec 17.

Department of Surgery, University of Bonn, Bonn, Germany.

Enteric glial cells (EGC) modulate motility, maintain gut homeostasis, and contribute to neuroinflammation in intestinal diseases and motility disorders. Damage induces a reactive glial phenotype known as "gliosis", but the molecular identity of the inducing mechanism and triggers of "enteric gliosis" are poorly understood. We tested the hypothesis that surgical trauma during intestinal surgery triggers ATP release that drives enteric gliosis and inflammation leading to impaired motility in postoperative ileus (POI). ATP activation of a p38-dependent MAPK pathway triggers cytokine release and a gliosis phenotype in murine (and human) EGCs. Receptor antagonism and genetic depletion studies revealed P2X2 as the relevant ATP receptor and pharmacological screenings identified ambroxol as a novel P2X2 antagonist. Ambroxol prevented ATP-induced enteric gliosis, inflammation, and protected against dysmotility, while abrogating enteric gliosis in human intestine exposed to surgical trauma. We identified a novel pathogenic P2X2-dependent pathway of ATP-induced enteric gliosis, inflammation and dysmotility in humans and mice. Interventions that block enteric glial P2X2 receptors during trauma may represent a novel therapy in treating POI and immune-driven intestinal motility disorders.
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http://dx.doi.org/10.15252/emmm.202012724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799361PMC
January 2021

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease-A Retrospective Analysis of 76 Cases in a Tertiary Center.

Biology (Basel) 2020 Oct 22;9(11). Epub 2020 Oct 22.

Department of Surgery, University Hospital of Bonn, 53127 Bonn, Germany.

(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were "additional surgery" (OR 5.3) and "bowel anastomosis" (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients' outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.
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http://dx.doi.org/10.3390/biology9110349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690599PMC
October 2020

Transpapillary tissue sampling of biliary strictures: balloon dilatation prior to forceps biopsy improves sensitivity and accuracy.

Sci Rep 2020 10 15;10(1):17423. Epub 2020 Oct 15.

Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.

The early and definitive diagnosis of malignant bile duct stenoses is essential for a timely and adequate therapy. However, tissue sampling with transpapillary brush cytology (BC) or forceps biopsy (FB) remains challenging. With this study, we aimed to compare the effectiveness and safety of different tissue sampling modalities (BC, FB without/after previous balloon dilatation). Standardized database research identified all patients, who underwent endoscopic retrograde cholangiography with BC and/or FB for indeterminate bile duct stenosis between January 2010 and April 2018 and with a definitive diagnosis. 218 patients were enrolled (149 cases with malignant and 69 with benign disease). FB had a significant higher sensitivity than BC (43% vs. 16%, p < 0.01). Prior balloon dilatation of the stenosis improved the sensitivity of FB from 41 to 71% (p = 0.03), the NPV from 36 to 81% (p < 0.01) and the accuracy from 55 to 87% (p < 0.01). The complication rates did not differ significantly between the modalities. In our center FB turned out to be the diagnostically more effective procedure. Balloon dilatation of the stenosis before FB had a significant diagnostic benefit and was not associated with a higher complication rate.
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http://dx.doi.org/10.1038/s41598-020-74451-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566456PMC
October 2020

Update on Shunt Surgery.

Visc Med 2020 Jun 14;36(3):206-211. Epub 2020 Apr 14.

Department of Surgery, University of Bonn, Bonn, Germany.

Background: Bleeding from esophagogastric varices is a life-threatening complication from portal hypertension. It occurs in 15% of patients and has a mortality rate of 20-35%.

Summary: The primary therapy for variceal bleeding is medical. In cases of recurrent bleeding, a definitive therapy is required. In cases of parenchymal decompensation, liver transplantation is the causal therapy, but if liver function is preserved, portal decompression is the therapy of choice. The use of the transjugular intrahepatic portosystemic shunt (TIPS) has achieved widespread acceptance, although evidence for surgical shunts is comparable or better in patients with good hepatic reserve. The type of surgical shunt depends on the patent veins of the portomesenteric system. If total occlusion is present, a devascularization procedure might be indicated.

Key Messages: Therapy, taking into account liver function, morphology of the portovenous system, and imminent liver transplantation, should be performed by an interdisciplinary team of gastroenterologists, interventional radiologists, and gastrointestinal surgeons.
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http://dx.doi.org/10.1159/000507125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383297PMC
June 2020

[Surgical treatment of primary sclerosing cholangitis : Experiences from 30 years in a single center cohort with 173 consecutive patients].

Chirurg 2021 Feb;92(2):148-157

Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.

Background: In recent years substantial progress has been made in the treatment, surveillance and understanding of the pathogenesis of primary sclerosing cholangitis (PSC); however, in most cases liver transplantation (LTX) is still the only curative option for cancer or end-stage liver disease (ELD). In rare cases a partial liver resection is a possible curative treatment of a PSC-associated cholangiocellular carcinoma (CCC). These operations represent a significant additional burden for PSC patients.

Objective: Due to the rarity of PSC detailed studies regarding hepato-pancreato-biliary (HPB) surgery are lacking. The aim of this study was to analyze the surgical indications and prognosis of PSC patients.

Patients And Methods: A single center retrospective cohort study from 1990 to 2020 was carried out. In this study patients with PSC were included and investigated with respect to factors associated with surgery and the prognosis.

Results: As a consequence of PSC-associated conditions, in 62 patients (36%) a major HPB operation or explorative laparotomy was necessary. The prevalence of chronic inflammatory bowel disease was significantly higher in these patients (P < 0.019). An LTX was carried out in 46 patients (73%) because of ELD. A liver resection (LR) was performed in 8 patients (11%) and 9 patients only underwent an explorative laparotomy. The overall survival in the LTX subgroup was significantly longer than patients who underwent LR and explorative laparotomy (258 months; 95% confidence interval, CI 210-306 months vs. 88 months; 95% CI 16-161 months vs. 13 months; 95% CI 3-23 months; p < 0.05, respectively).

Conclusion: The majority of patients with PSC have to be operated on because of the disease with substantial risks for morbidity and mortality. Curative treatment options are lacking, thus underlining the need for effective early detection and treatment strategies for PSC-CCC.
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http://dx.doi.org/10.1007/s00104-020-01197-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875955PMC
February 2021

HPV-associated anal lesions in HIV+ patients: long-term results regarding quality of life.

Int J Colorectal Dis 2020 Jun 26;35(6):1103-1110. Epub 2020 Mar 26.

Department of Surgery, University Hospital of Bonn, Sigmund-Freud-Str. 25, Bonn, Germany.

Purpose: HIV infection and concomitant HPV-associated anal lesions may significantly impact on patients' quality of life (QoL), as they are predicted to have negative effects on health, psyche, and sexuality.

Material And Methods: Fifty-two HIV+ patients with HPV-associated anal lesions were enrolled in a survey approach after undergoing routine proctologic assessment and therapy for HPV-associated anal lesions if indicated over a time span of 11 years (11/2004-11/2015). Therapy consisted of surgical ablation and topic treatment. QoL was analyzed using the SF-36 and the CECA questionnaires.

Results: Fifty-two of 67 patients (77.6%) were successfully contacted and 29/52 provided full information. The mean age was 43.8 ± 12.8 years. The median follow-up from treatment to answering of the questionnaire was 34 months. Twenty-one percent (6/29) of the patients reported suffering from recurrence of condyloma acuminata, three patients from anal dysplasia (10.3%). In the SF-36, HIV+ patients did not rate their QoL as significantly different over all items after successful treatment of HPV-associated anal lesions. In the CECA questionnaire, patients with persisting HPV-associated anal lesions reported significantly higher emotional stress levels and disturbance of everyday life compared to patients who had successful treatment (71.9/100 ± 18.7 vs. 40.00/100 ± 27.4, p = 0.004). Importantly, the sexuality of patients with anal lesions was significantly impaired (59.8/100 ± 30.8 vs. 27.5/100 ± 12.2, p = 0.032).

Conclusion: HPV-associated anal lesions impact significantly negative on QoL in HIV+ patients. Successful treatment of HPV-associated anal lesions in HIV+ patients improved QoL. Specific questionnaires, such as CECA, seem to be more adequate than the SF-36 in this setting.
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http://dx.doi.org/10.1007/s00384-020-03567-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245587PMC
June 2020

[The Devascularisation Procedure for the Treatment of Fundic and Oesophageal Varices in Portal Hypertension - a Retrospective Analysis of 55 Cases].

Zentralbl Chir 2018 Oct 24;143(5):480-487. Epub 2018 Oct 24.

Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland.

Background: The most dangerous complication of portal hypertension is the formation of oesophageal varices, as the risk of bleeding is up to 80%. In order to reduce pressure reduction in the portosystemic circulation and as secondary prophylaxis, the TIPSS procedure has proven successful. In patients with portal vein thrombosis, portosystemic shunt surgery is possible to reduce the risk of variceal bleeding. However, if thrombosis of the mesentericoportal axis or hepatic encephalopathy is imminent, interventional or surgical creation of a portosystemic shunt is contraindicated. As a last resort to avoid recurrent bleeding or in case of inexorable bleeding, a devascularisation procedure may be indicated. The aim of this study was to investigate perioperative complications, morbidity and mortality, the incidence of postoperative recurrent bleeding, and patient survival after devascularisation surgery.

Patients And Methods: We retrospectively analysed 55 patients with a history of variceal haemorrhage or acute bleeding without the possibility of an invasive or operative portosystemic shunt for complication rate, recurrent variceal recurrence, rebleeding and survival.

Results: While complications for elective surgery were 61%, they increased significantly in emergency surgeries (75%, p = 0.002), especially for severe complications (Dindo/Clavien grade III - V° [14 vs. 58%, p = 0.002]). Devascularisation significantly reduced varicosis occurrence. Furthermore, only 16% of patients suffered recurrent bleeding in a follow-up period of up to 24 years. Median survival (MS) after devascularisation surgery was 169 ± 23 months. After elective surgery, MS was 194 ± 25 months, but after emergency surgery only 49 ± 16 months. No patient showed any hepatic encephalopathy during their hospital stay.

Discussion: Devascularisation surgery is well suited for secondary prophylaxis in patients with fundic and oesophageal varices and portal hypertension with no possibility of portosystemic shunt or with impending hepatic encephalopathy. However, if the operation is performed in an emergency situation, significantly more major complications occur and the outcome is significantly worse. Therefore, especially in the absence of an opportunity of lowering pressure in the portal venous system and with progressive varices, elective devascularisation should be considered at an early stage.
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http://dx.doi.org/10.1055/a-0710-5095DOI Listing
October 2018

Response to the Letter to the Editor by Winiszewski et al.

J Crit Care 2018 12 23;48:474. Epub 2018 Sep 23.

Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jcrc.2018.09.026DOI Listing
December 2018

[The Impact of Supra- and Infracolic Reconstruction on Delayed Gastric Emptying Following Pancreatoduodenectomy].

Zentralbl Chir 2020 Feb 11;145(1):27-34. Epub 2018 Sep 11.

Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland.

Background: Delayed gastric emptying (DGE) is the most frequent complication following pancreatoduodenectomy. While antecolic and retrocolic reconstruction does not influence the occurrence of DGE, infracolic reconstruction might alleviate DGE due to the vertical position of the distal stomach compared to supracolic reconstruction. Supra- and infracolic reconstruction have not yet been compared.

Patients: 138 patients underwent pylorus-preserving pancreatoduodenectomy with retrocolic reconstruction at our department between 2011 and 2017. Of these, 105 were reconstructed with supracolic duodenoenterostomy and 33 with infracolic duodenoenterostomy. Patients were analysed with respect to demographic factors, diagnosis, pre-existing conditions, intraoperative characteristics, hospital stay and morbidity and mortality with special emphasis on DGE. All complications were classified according to the definitions of the International Study Group on Pancreatic Surgery.

Results: The two groups were comparable with respect to diagnosis, medical history, intraoperative characteristics, morbidity and mortality. DGE was equally distributed between supra- and infracolic reconstruction (DGE stage A/B/C25/14/10 vs. 12/5/2, p = 0.274). With DGE, intensive care unit stay (p = 0.007) and hospital stay (p = 0.001) are significantly delayed. Risk factor analysis showed that pre-existing diabetes (p = 0.047) and major complications (Clavien stage III - V, p = 0.048) are risk factors for DGE, while the use of somatostain-analogues seems to have a protective effect (p = 0.021).

Conclusion: Supra- or infracolic reconstruction does not influence the frequency of DGE following pancreatoduodenectomy. When DGE occurs, hospital stay is delayed. Somatostatin analogues may act prophylactically on DGE.
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http://dx.doi.org/10.1055/a-0632-1977DOI Listing
February 2020

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo.

J Vis Exp 2018 08 4(138). Epub 2018 Aug 4.

Institute for Laboratory Animal Science & Experimental Surgery, RWTH Aachen University.

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent hemorrhages at a later stage. The exact effects of plasma coagulation on liver tissue are only poorly examined. In our porcine model, the coagulation effects can be examined close to the clinical application. A combined laser Doppler flowmeter and spectrophotometer documents microcirculation changes during coagulation at 8 mm tissue depth noninvasively, providing quantifiable information about hemostasis beyond the subjective clinical impression. The temperature at coagulation site is assessed with an infrared thermometer prior and post coagulation and with a thermographic camera during coagulation, a measurement of the gas beam temperature is not possible due to the upper threshold of the devices. The depth of coagulation is measured microscopically on hematoxylin/eosin stained sections after calibration with an object micrometer and gives an exact information about the power setting-coagulation depth-relation. The sealing effect is examined on the bile ducts as it is not possible for a plasma coagulator to seal larger blood vessels. Burst pressure experiments are carried out on explanted organs to rule out blood pressure related effects.
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http://dx.doi.org/10.3791/57355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126626PMC
August 2018

Decompressive laparotomy for the treatment of the abdominal compartment syndrome during extracorporeal membrane oxygenation support.

J Crit Care 2018 10 24;47:274-279. Epub 2018 Jul 24.

Department of Surgery, University of Bonn, Bonn, Germany. Electronic address:

Purpose: Extracorporeal membrane oxygenation (ECMO) is increasingly used with various indications. The clinical course can be complicated by an abdominal compartment syndrome (ACS). A decompressive laparotomy (DL) can be an option.

Materials And Methods: Between 2014 and 2016 175 patients underwent ECMO support. Indications, demographic data, comorbidities, morbidity, mortality and length of stay were analyzed.

Results: Indications for ECMO were acute respiratory distress syndrome (n = 65), postpericardiotomy syndrome (n = 37), myocardial infarction (n = 26), extracorporeal cardiopulmonary resuscitation (n = 11), and others (n = 36). ECMO support was performed as veno-venous (VV, n = 91) or veno-arterial (VA, n = 84). Eleven patients developed ACS (VV-ECMO: n = 4; VA-ECMO: n = 7) and underwent DL. Three patients survived to hospital discharge. Risk factors were age (57 vs. 60.5 years, P = 0.032), a Charlson comorbidity index >1 (CCI, P = 0.004), a Simplified Acute Physiology Score (SAPS II) ≥ 42 at admission to ICU (P = 0.013) and ≥44 at the beginning of ECMO support (P = 0.004). When an ACS/DL occurred, mortality did not differ (DL: n = 11; 73% vs. no DL: n = 164; 65%; P = 0.749). Multivarate analysis revealed CCI and SAPS as independent predictors for mortality.

Conclusions: Approximately 10% of patients undergoing VA-ECMO support developed an ACS. If DL is undertaken, SAPS II scores can be used as predictive factor for mortality.
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http://dx.doi.org/10.1016/j.jcrc.2018.07.024DOI Listing
October 2018

Argon and helium plasma coagulation of porcine liver tissue.

J Int Med Res 2017 Oct 29;45(5):1505-1517. Epub 2017 Jun 29.

2 Institute for Laboratory Animal Science & Experimental Surgery, RWTH Aachen University, Aachen, Germany.

Objective Argon plasma coagulation (APC) and helium plasma coagulation (HPC) are electrosurgical techniques that provide noncontact monopolar electrothermal haemostasis. Although these techniques have been widely used clinically during the last three decades, their in vivo effects on liver tissue remain unclear. Methods We investigated the effects of different power levels (10-100 W) of APC and HPC on liver coagulation in 11 Landrace pigs. Capillary blood flow and capillary blood flow velocity were recorded with a combined laser Doppler flowmeter and spectrophotometer. The temperature, clinical biochemical parameters, blood gas parameters, bile duct-sealing effect, and coagulation depth were measured. Results APC and HPC significantly reduced the capillary blood flow and capillary blood flow velocity compared with baseline flow. No significant temperature change was measured on the liver surface immediately after coagulation. The clinical biochemical and blood gas parameters were not different before and after coagulation. The coagulation depth was positively correlated with the device power setting. Conclusions These results prove that APC and HPC provide sufficient superficial haemostasis. No significant systemic effects occurred following coagulation. The depth of the coagulation effect can be controlled through selection of the output power level.
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http://dx.doi.org/10.1177/0300060517706576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5718717PMC
October 2017

Delayed gastric emptying following pancreatoduodenectomy with alimentary reconstruction according to Roux-en-Y or Billroth-II.

BMC Surg 2017 Mar 20;17(1):24. Epub 2017 Mar 20.

Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.

Background: Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD) with published incidences as high as 61%. The present study investigates the impact of bowel reconstruction techniques on DGE following classic PD (Whipple-Kausch procedure) with pancreatogastrostomy (PG).

Methods: We included 168 consecutive patients who underwent PD with PG with either Billroth II type (BII, n = 78) or Roux-en-Y type reconstruction (ReY, n = 90) between 2004 and 2015. Excluded were patients with conventional single loop reconstruction after pylorus preserving procedures. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay and demographic factors.

Results: No difference was observed between BII and ReY regarding frequency of DGE. Overall rate for clinically relevant DGE was 30% (ReY) and 26% (BII). BII and ReY did not differ in terms of demographics, morbidity or mortality. DGE significantly prolongs ICU (four vs. two days) and hospital stay (20.5 vs. 14.5 days). Risk factors for DGE development are advanced age, retrocolic reconstruction, postoperative hemorrhage and major complications.

Conclusions: The occurrence of DGE can not be influenced by the type of alimentary reconstruction (ReY vs. BII) following classic PD with PG. Old age and major complications could be identified as important risk factors in multivariate analysis.

Trial Registration: German Clinical Trials Register (DRKS) DRKS00011860 . Registered 14 March 2017.
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http://dx.doi.org/10.1186/s12893-017-0226-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359898PMC
March 2017

Risk factors for delayed gastric emptying following distal pancreatectomy.

Langenbecks Arch Surg 2016 Mar 27;401(2):161-7. Epub 2016 Jan 27.

Department of Surgery, University of Bonn, Sigmund-Freud-Strasse 25, Bonn, 53105, Germany.

Purpose: Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy and other types of upper gastrointestinal surgery with published incidences as high as 60 %. The present study examines the incidence of DGE following distal pancreatic resection (DPR).

Methods: Between 2002 and 2014, 100 patients underwent conventional DPR at our department. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay, and demographic factors.

Results: Overall incidence of DGE was 24 %. No difference in age, gender, or other demographic factors was observed in patients with DGE. Perioperative characteristics (splenectomy rate, closure technique of the pancreatic remnant, operation time, blood loss and transfusion, ICU, ASA score) were comparable. Major complications were associated with DGE (11/24 patients (46 %) vs. 19/76 patients (25 %) without DGE) and the rate of pancreatic fistula was significantly higher in the group of patients with DGE (14/24 patients (58 %) vs. 27/76 patients (36 %), P = 0.047). In multivariate analysis, a periampullary malignancy was shown to be a significant factor for DGE development. DGE significantly prolonged hospital stay (14 vs. 22 days).

Conclusions: DGE is a substantial complication not only after pancreatoduodenectomy, but it also occurs frequently after DPR. Prevention of pancreatic fistula might reduce its incidence, especially in patients with malign pathology.
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http://dx.doi.org/10.1007/s00423-016-1374-7DOI Listing
March 2016

Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View.

Viszeralmedizin 2014 Dec;30(6):409-15

Department of Surgery, University of Bonn, Bonn, Germany.

Background: Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

Methods: Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

Results: The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

Conclusion: The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.
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http://dx.doi.org/10.1159/000369575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513833PMC
December 2014

Oxygen Insufflation in University of Wisconsin Solution Ameliorates Reperfusion Injury in Small Bowel after Cold Storage and Reperfusion.

Ann Transplant 2015 Aug 13;20:469-77. Epub 2015 Aug 13.

Institute for Laboratory Animal Science & Experimental Surgery, RWTH Aachen University, Aachen, Germany.

BACKGROUND Results in small bowel transplantation are inferior compared to other solid organ transplantations, among other reasons, due to a specific vulnerability to ischemia/reperfusion injury. New strategies are needed to improve organ storage. Here we compare static cold storage in University of Wisconsin solution to storage supplemented with molecular oxygen gas insufflation. MATERIAL AND METHODS Rat small bowel was retrieved and either stored unoxygenated (UW) or oxygenated (UW+O2) for 18 h at 4°C. Biochemical parameters, mucosal function, Toll-like receptor upregulation, and parameters of structural integrity were evaluated following isolated reperfusion in vitro for 30 min at 37°C. RESULTS Oxygenation showed: ATP concentration was 82 times higher; lactate dehydrogenase release was continuously lower over 30 min; malondialdehyde, a final product of lipid peroxidation (UW+O2 vs. UW; 2.7±0.92 nmol/mL vs. 17.22±10.1 nmol/mL; P<0.05) and nitric oxide concentration (0.87±0.27 µmol/L vs. 2.17±0.29 µmol/L; P<0.001) were significantly lower; whereas mucosal functional integrity (galactose uptake) was better preserved (0.47±0.18 mg/dL vs. 0.35±0.05 mg/dL). Amelioration of tissue damage could be demonstrated by reduced apoptosis (3.3±1.2 AU vs. 28.4±10 AU; P>0.05), and preserved subcellular integrity. Toll-like receptors were significantly less upregulated (TLR2 0.32±0.1 vs. 2.1±1.5-fold and TLR4 1.53±1.14 vs. 11.79±5.4-fold; P<0.05). CONCLUSIONS Oxygenated storage is superior to standard storage in University of Wisconsin solution in terms of energetics, tissue damage, and mucosal integrity.
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http://dx.doi.org/10.12659/AOT.893732DOI Listing
August 2015

Fibroblast growth factor receptor 1 gene amplification in pancreatic ductal adenocarcinoma.

Histopathology 2013 Aug 28;63(2):157-66. Epub 2013 Jun 28.

Institute of Pathology, University Hospital of Bonn, Bonn, Germany.

Aims: Pancreatic ductal adenocarcinomas (PDACs) are chemoresistant, resulting in extremely poor survival of patients; therefore, novel molecular targets, even in small subsets of genetically characterized tumours, are urgently needed. Tyrosine kinase receptor inhibitors (TKIs) are already in clinical use. The aims of this study were to examine the gene copy number and expression of fibroblast growth factor receptor 1 (FGFR1) in 155 patients with PDAC, and investigate the effects of the FGFR-specific inhibitor BGJ398 on FGFR1-amplified pancreatic tumour cells in vitro.

Methods And Results: Fluorescence in-situ hybridization (FISH) and immunohistochemical analysis of 155 PDACs were performed using tissue microarrays. Amplification of FGFR1 was found in 2.6% (4/155) of cases. Four per cent of tumours (5/125) were shown to express FGFR1 by immunohistochemistry. Sequence analysis demonstrated an activating KRAS mutation (exon 2) in all FGFR1-amplified cases. The FGFR1-amplified pancreatic carcinoma cell line PT45P1 showed high levels of FGFR1 mRNA and protein expression. Proliferation of this cell line can be inhibited using the FGFR1 inhibitor BGJ398.

Conclusions: FGFR1 represents a potential new therapeutic target in a subset of patients harbouring FGFR1-amplified tumours. Identification of pancreatic cancers harbouring FGFR1 amplification may be important in preselecting patients and/or interpreting clinical studies using TKIs.
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http://dx.doi.org/10.1111/his.12115DOI Listing
August 2013

Association of socio-economic status and stage of pancreatic cancer at time of surgery in a German setting.

Hepatogastroenterology 2012 Nov-Dec;59(120):2614-7

Department of Surgery, University of Bonn Medical Center, Bonn, Germany.

Background/aims: Curative resection has been proven to be one of the most important factors determining outcome in pancreatic cancer patients. Advanced stage of pancreatic cancer at diagnosis is strongly associated with a low socioeconomic status (SES), and patients from affluent areas have better cancer survival than patients from deprived areas. We tested, in our population of pancreatic cancer patients, the hypothesis that surrogates representing a lower SES or demographic factors (DGF) linked to rural areas are associated with a more advanced disease stage at presentation.

Methodology: Between 1989 and 2008, patients with pancreatic adenocarcinoma and pancreaticoduodenectomy were identified from our pancreatic resection database. DGF, SES surrogates and tumor stage were obtained from patients' files together with pathology reports, a residents' registration office questionnaire and telephone interviews with patients and family members.

Results: Follow-up was completed in 117 patients. There were no significant differences regarding tumor stage (local size and lymph node metastases), or the likelihood of negative resection margins in relation to the patients' DGF or any surrogate parameters for SES. Furthermore, comparison of two different treatment periods showed no significant advances regarding secondary cancer prevention within 20 years.

Conclusions: Longer waiting times for appointments combined with less sensitive imaging techniques and consecutive later referral to a cancer specialist are likely to be associated with inferior quality of medical results. Therefore, a lively debate is currently underway in Germany concerning the harmonization of reimbursement modes for statutory and private health insurance. Our data with no negative correlation of low SES or unfavorable DGF and disease stage at time of presentation or the likelihood for a curative resection, do not promote the universal accusation of health care disparities solely based on economic issues in Germany.
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http://dx.doi.org/10.5754/hge10334DOI Listing
March 2013

Improved functional recovery after facial nerve reconstruction by temporary denervation of the contralateral mimic musculature with botulinum toxin in rats.

Neurorehabil Neural Repair 2011 Jan 7;25(1):15-23. Epub 2010 Oct 7.

Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Jena, Germany.

Background: Even optimal nerve reconstruction after facial nerve damage leads to defective reinnervation because of misdirected axonal sprouting and polyinnervation of the end plates of the facial muscles.

Objective: The authors studied whether temporary chemical denervation of the contralateral nonlesioned hemiface with botulinum toxin (BTX) would increase regeneration of the lesioned buccal branch of the facial nerve and improve functional recovery of the whisker pad.

Methods: The experiments were performed in 65 adult rats distributed in 4 interventions: (1) buccal-buccal nerve anastomosis (BBA), (2) BBA plus ipsilateral injection of BTX into the whisker pad, (3) BBA plus contralateral BTX injection, or (4) BTX injection without any surgery. Sequential preoperative and postoperative retrograde fluorescence tracing at 4 weeks after surgery quantified the accuracy of reinnervation. Functional recovery was measured by biometrical image analysis of whisking behavior at 12 weeks after surgery.

Results: After BTX injection without any surgery, muscle paralysis was transient, and the animals restored normal nerve terminals and normal vibrissal function at 8 weeks after treatment. After BBA and ipsilateral or contralateral BTX injection, the degree of correct reinnervation increased significantly to 61% in comparison to 27% after BBA without any other intervention. Enhanced correct reinnervation was accompanied by a significant improvement of whisking after contralateral but not after ipsilateral injection of BTX.

Conclusions: These results provide evidence that transient contralateral muscle paralysis helps improve the morphological and functional regeneration after facial nerve repair.
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http://dx.doi.org/10.1177/1545968310376058DOI Listing
January 2011

Emergency Kausch-Whipple procedure: indications and experiences.

Pancreas 2010 Mar;39(2):156-9

Department of Surgery, University of Bonn Medical Center, Bonn, Germany.

Objective: Pancreaticoduodenectomy is a demanding procedure even in selected patients but becomes formidable when performed in cases of emergency. This study analyzed our experience with urgent pancreatoduodenectomies; special emphases were put on the evaluation of diagnostic means and the validation of existing indications for performance of this procedure.

Methods: Three hundred one patients who underwent pancreatoduodenectomy between 1989 and 2008 were identified from a pancreatic resection database and reviewed for emergency indications.

Results: Six patients (2%) underwent emergency pancreatoduodenectomy. Indications included endoscopy-related perforation, postoperative complications, and uncontrollable intraduodenal tumor bleeding. Length of stay and occurrence of nonsurgical complications were increased in emergency compared with elective pancreatoduodenectomies. Although increased, no significant differences were found regarding mortality and surgery-related complications.

Conclusions: Indications for emergency pancreatoduodenectomies were based on clinical decisions rather than on radiologic diagnostics. Urgent pancreatic head resections may be considered as an option in selected patients if handling of local complications by interventional measures or limited surgery seems unsafe.
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http://dx.doi.org/10.1097/MPA.0b013e3181bb98d2DOI Listing
March 2010

Operative re-intervention following pancreatic head resection: indications and outcome.

J Gastrointest Surg 2009 Aug 7;13(8):1503-9. Epub 2009 May 7.

Department of Surgery, University of Bonn Medical Center, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.

Background: This study analyzed indication and outcome regarding operative re-intervention following pancreatoduodenectomy (PD) and pancreatogastrostomy (PG) with special emphasis on complications related to redo surgery.

Patients And Methods: Two hundred eighty-five patients who underwent PD with PG between 1989 and 2008 were identified from a pancreatic resection database and indications for repeat surgery were registered. Patients with and without reoperation were analyzed with regard to gender, age, underlying disease, length of hospital stay, mortality rate, and postoperative complications.

Results: Thirty-one patients (11%) underwent operative reintervention. Early intra-abdominal extraluminal postoperative bleeding was the main cause for redo surgery followed by abdominal abscesses. Thirteen percent of patients with and 1.9% without secondary surgery died during the postoperative course. Forty-five percent of reoperated patients had to undergo at least one more operation resulting in doubling of the length of hospital stay. There was no correlation between patients' gender, age, and underlying disease and the need for operative reintervention. However, redo surgery was associated with higher incidence of delayed gastric emptying, pancreatic fistula and bleeding, and non-surgery related complication. Intra-abdominal bleeding and abscesses, insufficiencies of bilio-digestive and gut anastomosis, wound infections, and pancreatitis were observed significantly more often in patients with secondary surgery.

Conclusions: Complications after pancreatic resection that require operative re-intervention are associated with a notably increased mortality, ranging between 13% and 60%. Apart from the surgeon's experience in selecting patients and his/her personal technical skills in performing a pancreaticoduodenectomy, timely anticipation and determined management of postoperative complications is essential for improving the outcome of this operation.
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http://dx.doi.org/10.1007/s11605-009-0905-8DOI Listing
August 2009
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