Georg Wiltberger

Preoperative Endoscopy and Its Impact on Perioperative Management in Bariatric Surgery

Background: The role of preoperative upper-gastrointestinal endoscopy for bariatric surgery is still understood only with controversy. The aim of this study was to evaluate the prevalence of endoscopic findings and its impact on perioperative management. Methods: Patients who underwent bariatric surgery at our center between 2010 and 2013 were systematically analyzed from a prospective database. Results: Two hundred and twelve patients with a median body mass index of 50 kg/m2 (range 29-87) underwent 216 bariatric procedures at our center between 2010 and 2013. All patients received preoperative upper endoscopy. In 159 cases (75%), the endoscopy was performed at our center. These cases were included in this study. In 37 cases (23%), no abnormal findings were detected. In 122 cases (76%), upper endoscopy revealed pathologies. No further treatment was necessary in 24 cases (15%). Medical treatment was changed in 81 cases (51%). The operation was delayed due to medical treatment and re-endoscopy in 13 cases (8%). The surgical approach was changed in 4 cases (3%). Conclusion: Routinely performed preoperative endoscopy before bariatric surgery revealed a high prevalence of gastrointestinal diseases with a significant impact on perioperative management in two thirds of the cases. Therefore, we recommend routine gastroscopy about 2-4 weeks prior to surgery.

Mental Status in Patients Before and After Liver Transplantation

BACKGROUND In contrast to the well-described beneficial organic effects of liver transplantation (OLT) in patients with end-stage liver disease, changes in the mental status of patients after OLT remain poorly understood. The current study seeks to evaluate the influence of OLT on anxiety, depression, and dispositional optimism in patients with end-stage liver disease. MATERIAL AND METHODS Questionnaires were sent to patients on the OLT waiting list and patients after OLT. Depression/anxiety and dispositional optimism were assessed using the HADS and LOT-R questionnaires, respectively. These findings were compared to results from the general population. RESULTS The number of returned questionnaires was 292 of 940 (31.1%; 57 patients on the liver transplant waiting list: waiting group, 235 liver transplant recipients: OLT group). Both depression and anxiety scores were significantly higher in the waiting group when compared to the OLT group (p<0.05) and the general population (anxiety: p<0.001, depression: p<0.05), respectively. The OLT group was characterized by significantly higher anxiety scores (p<0.001) compared to the general population. Depression and summation scores did not differ (p>0.05). Dispositional optimism was higher in the OLT group compared to the waiting group (p<0.05) and to the general population (p<0.01). The waiting group had equal values as the general population (p>0.05). CONCLUSIONS Besides beneficial effects on liver function, OLT appears to be associated with significant improvements in depression and anxiety and a more optimistic view of life.

Alternative treatment of symptomatic pancreatic fistula

BACKGROUND The management of symptomatic pancreatic fistula after pancreaticoduodenectomy is complex and associated with increased morbidity and mortality. We here report continuous irrigation and drainage of the pancreatic remnant to be a feasible and safe alternative to total pancreatectomy. MATERIALS AND METHODS Between 2005 and 2011, patients were analyzed, in which pancreaticojejunal anastomosis was disconnected because of grade C fistula, and catheters for continuous irrigation and drainage were placed close to the pancreatic remnant. Clinical data were monitored and quality of life was evaluated. RESULTS A total of 13 of 202 patients undergoing pancreaticoduodenectomy required reoperation due to symptomatic pancreatic fistula. Ninety-day mortality of these patients was 15.3%. Median length of stay on the intensive care unit and total length of stay was 18 d (range 3-45) and 46 d (range 33-96), respectively. Patients with early reoperation (<10 d) had significantly decreased length of stay on the intensive care unit and operation time (P < 0.05). Global health status after a median time of 22 mo (range 6-66) was nearly identical, when compared with that of a healthy control group. Mean follow-up was 44.4 mo (±27.2). Four patients (36.6 %) died during the follow-up period; two patients from tumor recurrence, one patient from pneumonia, and one patient for unknown reasons. CONCLUSIONS Treatment of pancreatic fistula by continuous irrigation and drainage of the preserved pancreatic remnant is a simple and feasible alternative to total pancreatectomy. This technique maintains a sufficient endocrine function and is associated with low mortality and reasonable quality of life.

Impact of different immunosuppressive regimens on the health‐related quality of life following orthotopic liver transplantation

The influence of immunosuppression on the recipients’ quality of life (QoL) is of major importance after OLT and has not yet been evaluated.

Antibody-Mediated Rejection of Arterialised Venous Allografts Is Inhibited by Immunosuppression in Rats

Objectives and Design We determined in a rat model (1) the presence and dynamics of alloantibodies recognizing MHC complexes on quiescent Brown-Norway (BN) splenic cells in the sera of Lewis (LEW) recipients of Brown-Norway iliolumbar vein grafts under tacrolimus immunosuppression; and (2) the presence of immunoglobulins in the wall of acute rejected vein allografts. Materials and Methods Flow cytometry was used for the analysis of day 0, 14 and 30 sera obtained from Lewis recipients of isogeneic iliolumbar vein grafts (group A) or Brown-Norway grafts (group B, C) for the presence of donor specific anti-MHC class I and II antibodies. Tacrolimus 0.2 mg/kg daily was administered from day 1 to day 30 (group C). Histology was performed on day 30. Results Sera obtained preoperatively and on day 30 were compared in all groups. The statistically significant decrease of anti MHC class I and II antibody binding was observed only in allogenic non-immunosuppressed group B (splenocytes: MHC class I - day 0 (93%±7% ) vs day 30 (66%±7%), p = 0.02, MHC class II - day 0 (105%±3% ) vs day 30 (83%±5%), p = 0.003; B-cells: MHC class I - day 0 (83%±5%) vs day 30 (55%±6%), p = 0.003, MHC class II - day 0 (101%±1%) vs day 30 (79%±6%), p = 0.006; T-cells: MHC class I - day 0 (71%±7%) vs day 30 (49%±5%), p = 0.04). No free clusters of immunoglobulin G deposition were detected in any experimental group. Conclusion Arterialized venous allografts induce strong donor-specific anti-MHC class I and anti-MHC class II antibody production with subsequent immune-mediated destruction of these allografts with no evidence of immunoglobulin G deposition. Low-dose tacrolimus suppress the donor-specific antibody production.

Outcome after open surgery repair in endovascular-suitable patients with ruptured abdominal aortic aneurysms.

BACKGROUND Endovascular aneurysm repair (EVAR) has been suggested in several studies to be superior to open surgery repair (OSR) for the treatment of ruptured abdominal aortic aneurysms (rAAAs), but this finding might be affected by selection bias based on aneurysm morphology and patient characteristics. We tested rAAA anatomy according to EVAR suitability in patients undergoing OSR to assess the impact on mortality. PATIENTS AND METHODS This retrospective analysis reports on 83 patients with rAAAs treated between November 2002 and July 2013. Pre-operative computed tomography (CT) scans were evaluated based on EVAR suitability and were determined by blinded independent reviewers. CT scans were lacking due to acquisition in an external institution with no availability (n = 9) or solely ultrasound evaluations (n = 8). In addition patient characteristics and outcomes were assessed. RESULTS All patients who underwent OSR and who had available preoperative CT scans were included in the study (n = 66). In summary, 42 % of the patients (28/66; 95 % confidence interval [CI], 30.5 - 54.4) were considered eligible for EVAR according to pre-operative CT scans and 58 % of the patients (38/66; 95 % CI, 45.6 - 69.5) were categorized as unsuitable for endovascular repair. Patients suitable for EVAR had a significantly lower prevalence of in-hospital deaths (25 % [7/28]; 95 % CI, 9 - 41) in contrast to patients unsuitable for EVAR (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02). CONCLUSIONS EVAR-suitable patients had a highly significant mortality reduction undergoing OSR. Thus, the present study proposes that EVAR suitability is a positive predictor for survival after open repair of rAAA.

Pancreaticoduodenectomy in the Elderly Patient: Age-Adapted Risk Assessment

Background: Older patients are increasingly faced with pancreatic surgery because of shifting demographics. The differential effects of aging on surgical outcomes remain vague, while the elderly patient is often neglected in clinical trials. Methods: Medical records of 370 patients who underwent pancreaticoduodenectomy were analyzed. Patients were then subdivided into 3 groups according to age and comorbidities. Results: Overall mortality was 5% and did not significantly differ between age-matched groups. Increasing age was linked to a higher prevalence of diabetes mellitus (p < 0.001) and preoperative cardiovascular comorbidities (p < 0.001). Independent risk factors for major complications were age over 70 years (p = 0.018; OR 2.3), elevated body mass index (p = 0.004; OR 0.2) and cardiovascular comorbidities (p = 0.022; OR = 2.6). Patients who were older (>70 years), obese and had cardiovascular disease had an increased risk of major complications when compared with the younger study population (p = 0.010). Conclusions: Pancreatic surgery in elderly patients showed similar mortality rates as in younger patients. Nevertheless, a careful risk assessment is particularly important because older patients who are considered to be high risk suffer more frequently from major surgical complications compared with young patients that have similar risk profiles.

Prognostic significance of TIE2-expressing monocytes in hilar cholangiocarcinoma.

Angiopoietins (Angs) play a pivotal role in angiogenesis and inflammation, and are associated with prognosis in malignancies. Monocyte express Ang‐receptor TIE2 and correlate with prognosis in cancer. We aimed to investigate the prognostic value of Angs and TIE2‐expressing monocytes (TEMs) in cholangiocarcinoma.

The challenge of liver resection in benign solid liver tumors in modern times – in which cases should surgery be done?

Background Due to improved diagnostical and therapeutical approaches, benign liver tumors represent a challenge in clinical management. We here report our experience with patients undergoing liver resection for benign liver tumors. Methods 188 One hundred eighty-eight consecutive patients, who underwent surgery for solid benign liver tumors from 1992 - 2014, were analyzed retrospectively. The focus was on diagnostic pathways, indications for surgery, and perioperative and postoperative quality of life (QoL). Results Of 188 patients, 100 had focal nodular hyperplasia (FNH) (53.2 %), 33 had hepatocellular adenoma (17.5 %), and 55 had hemangioma (29.3 %). In most patients, there was more than one 1 indication for liver resection, including tumor-associated symptoms (n = 82, 43.6 %), suspicion of malignancy (n = 104, 55.3 %), tumor disease in the medical history (n = 48, 25.5 %), or tumor enlargement (n = 27, 14.4 %). Serious complications (>grade III;, Clavien-Dindo) occurred in 9.5 % of patients. Perioperative mortality was 0.5 %. Patient pain scores decreased over time (p < 0.001). QoL after liver resection significantly improved (p = 0.007). Conclusion Uncertainty of the tumor entity remains an issue in preoperative diagnostics. If indicated, liver resection for benign liver tumors represents a safe approach and leads to significant improvements of QoL.

Outcome and complications of combined liver and pancreas resections: a retrospective analysis

Abstract Background: Combined resections of the liver and pancreas are related to high complication and mortality rates. The present study assessed the outcome of these procedures and identified specific risk factors for morbidity and mortality. Methods: Between January 2001 and April 2012, 28 combined liver/pancreas resections were performed at our institution. All patients were retrospectively analysed using a database with regards to baseline characteristics, surgical procedures, complications and survival. Results: Among the pancreatic resections, there were 12 (42.9%) Kausch–Whipple (KW), 9 (32.1%) pylorus-preserving pancreaticoduodenectomy (PPPD), 6 (21.4%) distal pancreatectomies (DP) and 1 (3.6%) total pancreaticoduodenectomy (TPD). In 12 (48.9%) cases, major complications (grade IIIb–V) were observed. Overall survival was 35 months (SD = 40.5) and the 3-year survival rate was 35.7% (1-year survival rate: 50%). Discussion: Combined resections of the liver and pancreas are associated with high complication rates, especially if major liver resections are performed. Therefore, it is mandatory to do a thorough evaluation of potential patients.