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/m(2) (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

Liver transplantation in patients with a history of migration: A German single center comparative analysis

Liver transplant (LT) programs in Germany increasingly face a multiethnic patient population. To date no outcome data for LT in patients with a history of migration is available for Germany. This complicates decision-making before wait-listing such patients. We conducted a single-center cohort analysis of all primary LT between April 2007 and December 2015, stratified for the history of migration to investigate differences in the outcome. We found transplant rates resembling the proportion of persons with a history of migration in the general public in the region of our center. Differences were found concerning age at LT and prevalence of underlying diseases. Re-Transplant rates, Kaplan-Meier Estimates for overall survival, also after stratification for viral hepatitis, sex, ethnicity or presence of a language-barrier showed no statistical differences. The multivariate analysis showed no migration-related covariate associated with a negative outcome. These results stand in contrast to most of the previous evidence from North America and the UK and need to be taken into consideration during the wait-listing process of patients with a history of migration in need of a LT in centers in the Eurotransplant region

Highly differential count of circulating and tumor infiltrating immune cells in patients with non-HCV/non-HBV hepatocellular carcinoma

BACKGROUND Liver transplantation and liver resection are curative options for early hepatocellular carcinoma (HCC). The outcome is in part depended on the immunological response to the malignancy. In this study, we aimed to identify immunological profiles of non-HCV/non-HBV HCC patients. METHODS Thirty-nine immune cell subsets were measured with multicolor flow cytometry. This immunophenotyping was performed in peripheral blood (PB) and tumor specimens of 10 HCC resection patients and 10 healthy donors. The signatures of the highly differential leukocyte count (hDIF) were analyzed using multidimensional techniques. Functional capability was measured using intracellular IFN-γ staining (Trial Registration DRKS00013567). RESULTS The hDIF showed activation (subsets of T-, B-, NK- and dendritic cells) and suppression (subsets of myeloid-derived suppressor cells and T- and B-regulatory cells) of the antitumor response. Principal component analysis of PB and tumor infiltrating leukocytes (TIL) illustrated an antitumor activating gradient. TILs showed functional capability by secreting IFN-γ but did not kill HCC cells. CONCLUSIONS In conclusion, the measurement of the hDIF shows distinct differences in immune reactions against non-HBV/non-HCV HCC and illustrates an immunosuppressive gradient toward peripheral blood. TRIAL REGISTRATION DRKS00013567

Perivascular Tumor-Infiltrating Leukocyte Scoring for Prognosis of Resected Hepatocellular Carcinoma Patients

Liver resection is a curative treatment for hepatocellular carcinoma (HCC). Tumor-infiltrating leukocytes (TILs) are important players in predicting HCC recurrence. However, the invasive margin could not be confirmed as relevant for HCC. The migration of immune cells into HCC may originate from intratumoral vessels. No previous study has examined perivascular (PV) infiltration. Tumors from 60 patients were examined. Immunohistochemistry was performed against CD3, CD8, CD20, and CD66b. TILs were counted in the PV regions using an algorithm for quantification of the tumor immune stroma (QTiS). The results were correlated with overall (OS) and disease-free survival (DFS), clinical parameters, and laboratory values. PV infiltration of TILs was predominant in resected HCC. Higher PV infiltration of CD3(+) (p = 0.016) and CD8(+) (p = 0.028) independently predicted better OS and DFS, respectively. CD20(+) showed a trend towards better DFS (p = 0.076). Scoring of CD3(+), CD8(+), and CD20(+) independently predicted OS and DFS (p < 0.01). The amount of perivascular-infiltrating CD3(+) cells is an independent predictor of better OS, and CD8(+) cells independently predict prolonged DFS. Our novel perivascular infiltration scoring (PVIS) can independently predict both DFS and OS in resected HCC patients

Dynamics of Peripheral Blood Immune Cells during the Perioperative Period after Digestive System Resections: A Systematic Analysis of the Literature

An operation in itself is a kind of trauma and may lead to immunosuppression followed by a bounce back. Not many studies exist that describe dynamics of the distribution of peripheral blood (PB) immune cells during the perioperative period. Considering this scarcity, we aggregated the data on the dynamics of immune cells in patients with digestive system resections during the perioperative period and the relationship with short- and long-term prognoses. By the systematic retrieval of documents, we collected perioperative period data on white blood cells (WBC), lymphocytes, neutrophil–lymphocyte ratio (NLR), CD4+ T cells, CD8+ T cells, helper T cells (Th), B cells, natural killer cells (NK), dendritic cells (DCs), regulatory T cells (Tregs), regulatory B cells (Bregs), and Myeloid derived suppressor cells (MDSC). The frequency and distribution of these immune cells and the relationship with the patient’s prognosis were summarized. A total of 1916 patients’ data were included. Compared with before surgery, WBC, lymphocytes, CD4+ cells, CD8+ T cells, MDSC, and NK cells decreased after surgery, and then returned to preoperative levels. After operation DCs increased, then gradually recovered to the preoperative level. No significant changes were found in B cell levels during the perioperative period. Compared with the preoperative time-point, Tregs and Bregs both increased postoperatively. Only high levels of the preoperative and/or postoperative NLR were found to be related to the patient’s prognosis. In summary, the surgery itself can cause changes in peripheral blood immune cells, which might change the immunogenicity. Therefore, the immunosuppression caused by the surgical trauma should be minimized. In oncological patients this might even influence long-term results

Extended resection in pancreatic metastases: feasibility, frequency, and long-term outcome: a retrospective analysis

Background: Metastases to the pancreas are rare, accounting for less then 2 % of all pancreatic malignancies. However, both the benefit of extended tumor resection and the ideal oncological approach have not been established for such cases; therefore, we evaluated patients with metastasis to the pancreas who underwent pancreatic resection. Methods: Between 1994 and 2012, 676 patients underwent pancreatic surgery in our institution. We retrospectively reviewed patients’ medical records according to survival, and surgical and non-surgical complications. Student’s t-test and the log-rank test were used for statistical analysis. Results: Eighteen patients (2.7 %) received resection for pancreatic metastases (12 multivisceral resections and 6 standard resections). The pancreatic metastases originated from renal cell carcinoma (n = 10), malignant melanoma (n = 2), neuroendocrine tumor of the ileum (n = 1), sarcoma (n = 1), colon cancer (n = 1), gallbladder cancer (n = 1), gastrointestinal stromal tumor (n = 1), and non-small cell lung cancer (n = 1). The median time between primary malignancy resection to metastasectomy was 83 months (range, 0–228 months). Minor surgical complications (Grade I-IIIa) occurred in six patients (33.3 %) whereas major surgical complications (Grade IIIb-V) occurred in three patients (16.6 %). No patients died during hospitalization. The median follow-up was 76 months (range, 10–165 months). One-year, 3-year and 5-year survival for standard resection versus multivisceral resection was 83, 50, and 56 % versus 83, 66, and 50, respectively. Twelve patients died after a median of 26 months (range, 5–55 months). Conclusions: A surgical approach with curative intent is justified in select patients suffering from metastases to the pancreas and offers good long-term survival. The resection of pancreatic metastases of different tumor types was associated with favorable morbidity and mortality when compared with resection of the primary pancreatic malignancies. Our findings also demonstrated that multivisceral resection was feasible, with acceptable long term outcomes, even though morbidity rates tended to be higher after multivisceral resection than after standard resection