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Frank Makowiec Stefan Post Hans-Detlev Saeger Norbert Senninger Heinz Becker Michael Betzler Heinz J. Buhr Ulrich T. Hopt German Advanced Surgical Treatment Study Group 《Journal of gastrointestinal surgery》2005,9(8):1080-1087
Despite decreasing mortality rates, morbidity is still high after pancreatic head resection. Comparative data in the United
States and Europe show a relationship between hospital volume and mortality. Treatment strategies vary frequently, partially
because of the lack of evidence-based data. We performed a multi-institutional analysis in Germany evaluating current numbers,
indications, techniques, and complication rates of pancreatic head resection. Questionnaires were completed by seven high-volume
surgical departments regarding quantitative and qualitative aspects of pancreatic head resections in the period from 1999
to 2004 (five prospective and two retrospective institutional databases). A total of 1454 pancreatic head resections (944
for malignancy) were reported. Mean annual hospital volume ranged from 14 to 52 (10 to 43 in malignancy). Mortality was between
1.1% and 4.8%, morbidity was between 24% and 46%, and pancreatic leakage was between 9% and 20%. In malignant disease, all
centers perform standard lymphadenectomy and regard arterial infiltration as a contraindication for resection. However, the
rate of portal vein resection varied from 0% to 28%. No consensus is seen on the type of surgery for malignancy and chronic
pancreatitis. After resection for pancreatic cancer less than one fourth of the patients receive adjuvant therapy. The results
of our analysis in Germany confirm that pancreatic head resection can be performed with low mortality in specialized units.
Variations in indications, operative technique, and perioperative care may demonstrate the lack of evidence-based data and/or
personal and institutional experience. The low number of patients receiving adjuvant therapy after resection of pancreatic
cancer suggests that more efforts must be made to establish novel adjuvant therapies under randomized study conditions.
Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18,
2005 (oral presentation). 相似文献
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BACKGROUNDS: Exogenous glucagon rapidly stimulates insulin secretion. This test has been used to estimate insulin secretory capacity, which may predict oral glucose tolerance in patients after pancreas transplantation. METHODS: In 32 pancreas-kidney transplant recipients, in 10 nondiabetic kidney transplant recipients, and in 9 healthy control subjects, a glucagon stimulation test (1 mg i.v.) and a 75-g oral glucose tolerance test were performed with determination of glucose, insulin, and C-peptide profiles. RESULTS: Of 16 pancreas transplant recipients with the lowest insulin responses after glucagon, 7 had an impaired oral glucose tolerance, in contrast to 1 of 16 with high insulin responses (P=0.037). A low insulin response after glucagon was associated with significantly lower 120-min glucose concentrations (P=0.043) and a lower integrated incremental insulin response after oral glucose (P=0.006). CONCLUSIONS: In pancreas-kidney transplant recipients, a low insulin response after intravenous glucagon predicts a reduced insulin response after oral glucose and an impaired oral glucose tolerance. This simple test may be helpful in the follow-up of pancreas transplant recipients. 相似文献
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Arif Asif Hector Castro Ahmed Ameen Waheed Vishesh Kumar Syed S Haqqie Gary Siskin Roy O Mathew Darius Mason Tushar Vachharajani Ali Nayer Donna Merrill Muhammad UT Akmal Loay Salman 《Seminars in dialysis》2013,26(4):E30-E32
A retrospective study evaluating the pattern of blood pressure and its related complications before, during, and after percutaneous hemodialysis interventions was performed in patients presenting with asymptomatic hypertension. Hemodialysis patients undergoing percutaneous interventions including tunneled hemodialysis catheter insertion, percutaneous balloon angioplasty and thrombectomy procedure, and stage II hypertension (systolic blood pressure ≥160 mmHg) were included in this analysis. Blood pressure medications were not used while midazolam and fentanyl were routinely administered. Patients were followed for up to 4 weeks to monitor any complications. The mean blood pressure before, during, and after the procedures were 185 ± 18/96 ± 14, 172 ± 22/92 ± 15, and 153 ± 25/87 ± 14, respectively. There was a statistically significant difference between the blood pressure readings before and after the procedure (before = 185 ± 18/96 ± 14, after = 153 ± 25/87 ± 14; p = 0.001). None of the patients had a stroke, myocardial infarction, or acute pulmonary edema before, during, or after the procedure or during the 4‐week follow‐up period. A significant reduction in blood pressure was observed after the procedure without the administration of any antihypertensive medication. These results suggest that the reduction in blood pressure observed after percutaneous dialysis access interventions (particularly in the presence of midazolam and fentanyl) may make it unnecessary to treat asymptomatic hypertension prior to these procedures. 相似文献
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Jens Hoeppner Birte Kulemann Garbriel Seifert Goran Marjanovic Andreas Fischer Ulrich Theodor Hopt Hans-Jürgen Richter-Schrag 《Surgical endoscopy》2014,28(5):1703-1711
Background
Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.Methods
From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.Results
In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1–78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤10 versus >10 mm (68 vs. 64 %; p = 0.479).Conclusion
CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase. 相似文献9.
Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection 总被引:7,自引:0,他引:7
Hartwig Riediger M.D. Frank Makowiec M.D. Eva Fischer Ulrich Adam M.D. Ulrich T. Hopt M.D. 《Journal of gastrointestinal surgery》2006,10(8):1106-1115
The role of superior mesenteric-portal vein resection (SM-PVR) for vein invasion or tumor adherence during pancreatoduodenectomy
(PD) is still under debate. We investigated morbidity, mortality, and long-term survival in patients who underwent PD with
or without SM-PVR. Between July 1994 and December 2004, 222 PD (78% pylorus preserving, 19% Whipple, and 3% total pancreatectomy)
were performed for malignant disease. Fifty-three patients (24%) had PD with SM-PVR. Sixty-eight percent of the venous resections
were performed as wedge excisions and 32% as segmental resections. Long-term survival was analyzed in 165 patients with pancreatic
(n=110), ampullary (n=33), or distal bile (n=22) duct cancer using univariate (log-rank) and multivariate (Cox regression)
methods. In patients undergoing PD with SM-PVR and conclusive histologic examination of the resected vein specimen (n=42),
60% had true tumor involvement of the venous wall, whereas 40% had no proven tumor infiltration. In the complete study group,
negative resection margins were obtained in 69% of patients with SM-PVR and in 79% of patients without SM-PVR (P=0.09). Median duration of surgery was 500 minutes (SM-PVR) versus 440 minutes (no SM-PVR; P<0.001). Volume of intraoperatively transfused blood was 600 ml (median) in both groups. Postoperative surgical complications/mortality
occurred in 23%/3.8% (SM-PVR) versus 35%/4.1% (no SM-PVR); P=0.09/0.9. Analysis of long-term survival in all 165 patients included 41 with SM-PVR. Five-year survival rates were 15% in
cancer of the pancreatic head, 22% in ampullary cancer, and 24% in distal bile duct cancer (P=0.02). Long-term survival was not influenced by the need for SM-PVR in any of the different tumor entities. In multivariate
analysis, a positive resection margin (P<0.01, relative risk [RR]: 1.8, 95% confidence interval [CI]: 1.2–2.7), a histologically undifferentiated tumor (P=0.01, RR: 1.7, 95% CI: 1.1–2.5), and the tumor entity (P<0.01) were significant predictors of survival. Univariate survival analysis of the 110 patients with cancer of the pancreatic
head revealed that a histologically undifferentiated tumor (P=0.05) and positive resection margins (P=0.02) were associated with a poorer survival. In multivariate analysis, the resection margin (P=0.02, RR: 5.1, 95% CI: 1.1–2.8) and a histologically undifferentiated tumor (P=0.05, RR: 3.8, 95% CI: 1.0–2.5) significantly influenced survival. After PD, perioperative morbidity and long-term survival
in patients with SM-PVR were similar to those of patients without vein resection. In case of tumor adherence or infiltration,
combined resection of the pancreatic head and the vein should always be considered in the absence of other contraindications
for resection.
Initial results were presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando,
Florida, May 18–21, 2003 (poster). 相似文献
10.
Hartwig Riediger Tobias Keck Ulrich Wellner Axel zur Hausen Ulrich Adam Ulrich T. Hopt Frank Makowiec 《Journal of gastrointestinal surgery》2009,13(7):1337-1344
Introduction Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the
status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have
been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore,
evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio.
Methods Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182
patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body,
and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy
(3%). Survival was analyzed by the Kaplan–Meier and Cox methods.
Results In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive
LN. Median tumor size was 30 (7–80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range
0–22). Median LN ratio was 0.1 (0–0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis,
a LN ratio ≥ 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio ≥ 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio ≥ 0.2 (p < 0.02; relative risk RR 1.6), LN ratio ≥ 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined
nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival.
Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly
in patients with two or more LN involved.
Conclusions Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic
cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio
may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein
related outcome and therapy studies.
Presented in part at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 2008 in San Diego and
at the Annual Meeting of the German Cancer Society, February 2008 in Berlin, Germany 相似文献