Sebastian Hempel

Introduction: Internal hernias through the foramen of Winslow have a very low incidence. This is why they are often not taken into consideration as a differential diagnosis in cases of mechanical ileus. However, rapid diagnosis and treatment are essential for the patient´s outcome. Early surgical intervention is crucial in reducing morbidity and mortality. Presentation of case: A 58-year-old male patient presented with nonspecific abdominal symptoms. Computed tomography (CT) raised suspicion of the cecum herniating through the foramen of Winslow into the lesser sac. Urgent surgical exploration using a laparoscopic approach was planned, and the radiologic suspicion was confirmed intraoperatively. To reposition the incarcerated and dilated cecum to its typical location, conversion to open surgery and colotomy were performed. As it still showed signs of malperfusion, an ileocecal resection was performed, restoring continuity with a side-to-end ileocolic anastomosis at the ascending colon. The postoperative course was uneventful. Discussion: Clinical history and presentation of incarcerated Winslow hernia often remain nonspecific. The key diagnostic tool is the contrast-enhanced CT scan; nevertheless, a diagnosis is often only made intraoperatively. Herniating bowel structures, such as the cecum, suffer from interrupted mesenteric circulation and venous congestion, causing ischemia and dilatation. This can compromise hepatic perfusion and biliary drainage due to the distended bowel compressing the hepatoduodenal ligament. Severe complications, such as perforation, thrombosis, or bleeding, up to and including death, may occur. Conclusion: By reporting this case, awareness of internal hernias should be strengthened so as not to miss this rare but important differential diagnosis.

Introduction: Pancreatic surgery remains associated with significant morbidity. Pancreatoduodenectomy (PD) with high-risk stigmata for postoperative pancreatic fistula (POPF) may delay or hinder administration of adjuvant therapy. Total pancreatectomy (TP) prevents POPF-associated complications but implies permanent exocrine and endocrine insufficiency. Islet autotransplantation (IAT) has the potential to compensate endocrine function. Methods and analysis: XANDTX is a single-centre randomized controlled pilot trial comparing high-risk PD with TP and simultaneous IAT in patients with periampullary cancer. After screening for eligibility and obtaining informed consent, a total of 32 adult patients will be intraoperatively randomized in a 1:1 ratio. The primary hypothesis is that TP with IAT prevents POPF-associated complications and leads to a shorter period to initiation of adjuvant therapy and a higher overall rate of adjuvant therapy administration. Secondary endpoints include perioperative morbidity and mortality, metabolic outcome, quality of life (QoL) and oncological long-term outcome. Each patient will be followed up for 5 years. Discussion: The XANDTX pilot trial will aim to provide surgical and oncological feasibility and safety data of total pancreatectomy with simultaneous islet autotransplantation in management of resectable periampullary cancer. The results will form the basis for a further confirmatory controlled study. Trial registration: This study was registered on ClinicalTrials.gov (NCT05843877) on February 27, 2023 and EudraCT (2023-507773-17-00) on April 18, 2024.

The use of steroids in pancreatic surgery may reduce complications through the anti-inflammatory potential. We aimed to evaluate the impact of hydrocortisone (HC) on postoperative morbidity after pancreatoduodenectomy (PD). The data were retrospectively extracted from a prospective clinical database. Complicatons after PD with 100 mg HC intravenously (i.v.) for 48 h and a corresponding propensity score-matched cohort without HC were evaluated by using logistic regression analyses. We analyzed 691 patients who underwent PD over a period of ten years. After propensity score matching, 220 patients (110 patients in each group) remained. Postoperative complications were comparable in both groups (p = 0.56). Major complications (CDC ≥ 3) did not differ significantly, n = 44 (40%) for non-HC n = 45 (40.9%) and HC group (p = 0.89). There was no difference (p = 0.88) in the POPF incidence, non-HC, n = 31 (28.2%) and HC group, n = 30 (27.3%). After stratifying for fistula risk score (FRS), results remained equal and no difference was observed in CDC ≥ 3 in the low (p = 1), intermediate (p = 0.82) and high-risk (p = 0.74) group. HC has been suggested to be effective in reducing postoperative morbidity, but the evidence is controversial. The benefit of HC in reducing postoperative complications after pancreatoduodenectomy cannot be supported in the present study.

Background: Distal pancreatectomy (DP) can worsen pancreatic endocrine function. Effects on glucose metabolism and underlying mechanisms after DP remains a topic of significant interest and not yet fully understood. This study aimed to examine the impact of DP on blood glucose homeostasis with a particular focus on metabolic outcomes and development of postoperative diabetes. Methods: Considered were all patients who underwent DP between 01/2010 and 09/2021 and participated simultaneously in extended blood glucose monitoring with a 12 months follow-up. Blood samples were analyzed for markers of pancreatic endocrine function both fasting and after an oral glucose tolerance test preoperatively and 3 and 12 months after DP. Results: Included patients (n = 69) were preoperatively categorized into three groups according to American Diabetes Association (ADA) criteria: 17 patients (24.6%) were normoglycemic (NG), 22 (31.9%) had prediabetes (impaired fasting glucose / impaired glucose tolerance – IFG/IGT) and 30 (43.5%) had diabetes mellitus (DM). In the NG subgroup, beta-cell function (HOMA2%B - updated homeostasis model assessment) significantly decreased from 117.4% (101.1–135%) to 66.9% (49.7–102.1%) at 12 months postoperatively (p < 0.05). Insulin sensitivity (HOMA2%S) significantly increased from 48.2% (33.4–66.9%) to 63.5% (49.8–86%) at 12 months postoperatively (p < 0.05). In the IFG/IGT subgroup, there was a non-significant trend of decreased HOMA2%B and increased HOMA2%S postoperatively. Postoperatively, 11.8% of NG patients and 60% of prediabetic patients developed DM. Conclusion: DP already leads to significant changes in glucose metabolism within a 12 month follow-up period. Patients with preoperative prediabetes are particularly at high risk of developing postoperative DM. Therefore, the indication for DP should be critically evaluated, especially in cases with a relative indication for surgery. If possible parenchymal sparing surgical options should be contemplated. Trial registration: Not applicable.

Background: The risk of postoperative pancreatic fistula (POPF), one of the most dreaded complications after pancreatic surgery, can be predicted from preoperative imaging and tabular clinical routine data. However, existing studies suffer from limited clinical applicability due to a need for manual data annotation and a lack of external validation. We propose AutoFRS (automated fistula risk score software), an externally validated end-to-end prediction tool for POPF risk stratification based on multimodal preoperative data. Materials and methods: We trained AutoFRS on preoperative contrast-enhanced computed tomography imaging and clinical data from 108 patients undergoing pancreatic head resection and validated it on an external cohort of 61 patients. Prediction performance was assessed using the area under the receiver operating characteristic curve (AUC) and balanced accuracy. In addition, model performance was compared to the updated alternative fistula risk score (ua-FRS), the current clinical gold standard method for intraoperative POPF risk stratification. Results: AutoFRS achieved an AUC of 0.81 and a balanced accuracy of 0.72 in internal validation and an AUC of 0.79 and a balanced accuracy of 0.70 in external validation. In a patient subset with documented intraoperative POPF risk factors, AutoFRS (AUC: 0.84 ± 0.05) performed on par with the uaFRS (AUC: 0.85 ± 0.06). The AutoFRS web application facilitates annotation-free prediction of POPF from preoperative imaging and clinical data based on the AutoFRS prediction model. Conclusion: POPF can be predicted from multimodal clinical routine data without human data annotation, automating the risk prediction process. We provide additional evidence of the clinical feasibility of preoperative POPF risk stratification and introduce a software pipeline for future prospective evaluation. Export

Zusammenfassung Hintergrund Die Pankreaschirurgie ist nach wie vor mit einer signifikanten Morbidität vergesellschaftet. Bei einer gleichzeitig zunehmend alternden Gesellschaft mit gesteigerter Morbidität ist die Risikostratifizierung und Indikationsstellung daher von besonderer Bedeutung. Fragestellung Inwiefern beeinflusst Multimorbidität des Patienten das postoperative Outcome nach pankreaschirurgischen Eingriffen? Material und Methoden Auswertung und Zusammenfassung der bestehenden Literatur. Ergebnisse Die postoperative Morbidität nach Pankreaschirurgie bleibt hoch. Relevante Nebenerkrankungen wie Leberzirrhose, kardiale und pulmonale Komorbidität sowie eine fortgeschrittene Niereninsuffizienz erhöhen das perioperative Morbiditäts- und Mortalitätsrisiko enorm. In pankreaschirurgischen High-volume-Zentren liegt die Gesamtmortalität jedoch unter 5 %. Schlussfolgerungen Pankreaschirurgische Eingriffe bei schwerer Komorbidität sind in Zentren mit ausgewiesener Expertise sicher möglich. Dennoch sind eine sorgfältige Indikationsstellung und gute Patientenselektion essenziell für das postoperative Outcome.

Das Pankreaskarzinom stellt Chirurgen vor große Herausforderungen. Neue Therapiekonzepte und fortschrittliche Operationstechniken eröffnen jedoch Möglichkeiten für Patienten mit fortgeschrittenen und initial inoperablen Tumoren. Multiviszerale Resektionen und arterio-venöse Gefäßrekonstruktionen in spezialisierten Zentren können im Vergleich zur Palliation die Überlebenschancen deutlich verbessern. Der Artikel beleuchtet aktuelle Kriterien der Resektabilität, die Bedeutung des „Mesopankreas“, die arterio-venösen Rekonstruktionsmöglichkeiten und die Indikationen für komplexe chirurgische Eingriffe. Article published online: 05 September 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Objective: Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF). Summary Background Data: TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking. Methods: Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life. Results: After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P=0.857). Conclusions: This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.

(1) Background: The postoperative morbidity rate after pancreatic head resection remains high, partly due to infectious complications. The primary aim of this study was to analyze the influence of selective decontamination of the digestive tract (SDD) on the postoperative infection rate after pancreatic surgery. (2) Methods: From January 2019, the standard of care for patients undergoing pancreatic head resections at the Department for Visceral, Thoracic, and Vascular Surgery, University Hospital Dresden was the preoperative oral administration of SDD. The influence of SDD was evaluated for patients operated on between January 2019 and June 2020 in comparison to a propensity score-matched cohort, extracted from an existing database including all pancreatic resections from 2012 to 2018. The primary endpoint of the study was the shift of the bacterial load on the intraoperative bile swab test. The secondary endpoint was the association of SDD with postoperative complications. (3) Results: In total, 200 patients either with SDD (n = 100; 50%) or without SDD (non-SDD, n = 100; 50%) were analyzed. In the patient group without a preoperative biliary stent, 44% (n = 11) of the non-SDD group displayed positive bacterial results, whereas that was the case for only 21.7% (n = 10) in the SDD group (p = 0.05). Particularly, Enterobacter species (spp.) were reduced from 41.2% (n = 14) (non-SDD group) to 23.5% (n = 12) (SDD group) (p = 0.08), and Citrobacter spp. were reduced by 13.7% (p = 0.09) from the non-SDD to the SDD cohort. In patients with a preoperative biliary stent, the Gram-negative Enterobacter spp. were significantly reduced from 52.2% (n = 12) in the non-SDD group to 26.8% (n = 11) in the SDD group (p = 0.04). Similarly, Citrobacter spp. decreased by 20.6% from 30.4% (n = 7) to 9.8% (n = 4) in the non-SDD compared to the SDD group (p = 0.04). In general, deep fluid collection and abscesses occurred more frequently in the non-SDD group (36%; n = 36 vs. 27%; n = 27; p = 0.17). (4) Conclusions: Adoption of SDD before pancreatic head surgery may reduce the bacterial load in bile fluid. SDD administration does not significantly affect the postoperative infectious complication rate after pancreatic head resections.