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Detemble C, Heil J, Malkomes P, Faqar Uz Zaman F, Sliwinski S, Stickl F, Werneburg E, Faqar Uz Zaman F, Bechstein WO, Schnitzbauer AA. [Digital applications in prehabilitation before major visceral surgery procedures]. Chirurgie (Heidelb) 2024:10.1007/s00104-024-02078-x. [PMID: 38649473 DOI: 10.1007/s00104-024-02078-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Prehabilitation is of becoming of growing interest in the medical specialist societies, especially before major surgical procedures in older and frail patients. The body of evidence in steadily growing. OBJECTIVES Are there good digital solutions for a remote prehabilitation program at home? METHODS Narrative review of the evidence and current study activities in analogous and digital prehabilitation. RESULTS Prehabilitation is becoming increasingly more important in the optimal preparation of patients before major surgical procedures. With the help of tailored programs patients can be improved and the risk of complications can be significantly lowered. With an optimal selection, this is not associated with a deterioration of the prognosis for patients with cancer during the intervention lasting for 3-6 weeks. There is still a lack of results and good evidence from well-designed trials for digital solutions. CONCLUSION Prehabilitation can be safely implemented in the preparation of patients before major surgical procedures. Digital solutions are currently being developed and tested and could possibly increase the acceptance in the currently intensifying resource shortages.
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Affiliation(s)
- Charlotte Detemble
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Jan Heil
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Patrizia Malkomes
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Fatima Faqar Uz Zaman
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Svenja Sliwinski
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Franziska Stickl
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Elisabeth Werneburg
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Fatima Faqar Uz Zaman
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Andreas A Schnitzbauer
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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Sliwinski S, Faqar-Uz-Zaman SF, Heil J, Mohr L, Detemble C, Dreilich J, Zmuc D, Bechstein WO, Becker S, Chun F, Derwich W, Schreiner W, Solbach C, Fleckenstein J, Filmann N, Schnitzbauer AA. Predictive value of a novel digital risk calculator to determine early patient outcomes after major surgery: a proof-of-concept pilot study. Patient Saf Surg 2024; 18:13. [PMID: 38610002 PMCID: PMC11010393 DOI: 10.1186/s13037-024-00395-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND A structured risk assessment of patients with validated and evidence-based tools can help to identify modifiable factors before major surgeries. The Protego Maxima trial investigated the value of a new digitized risk assessment tool that combines tools which can be easily used and implemented in the clinical workflow by doctors and qualified medical staff. The hypothesis was that the structured assessment and risk-grouping is predictive of short-term surgical quality reflected by complications and overall survival. METHODS The Protego Maxima Trial was a prospective cohort analysis of patients undergoing major surgery (visceral, thoracic, urology, vascular and gynecologic surgeries) as key inclusion criterion and the absence of an acute or acute on chronically decompensated pulmo-cardiovascular decompensation. Patients were risk-scored with the software (The Prehab App) that includes a battery of evidence-based risk assessment tools that allow a structured risk assessment. The data were grouped to predefined high and low risk groups and aggregate and individual scores. The primary outcome was to validate the predictive value of the RAI score and the TUG for overall survival in the high and low risk groups. Secondary outcomes were surgical outcomes at 90-days after surgery (overall survival, Clavien-Dindo (CD) 1-5 (all complications), and CD 3-5 (major complications)). The study was carried out in accordance with the DIN ISO 14,155, and the medical device regulation (MDR) at Frankfurt University Hospital between March 2022 and January 2023. RESULTS In total 267 patients were included in the intention to treat analysis. The mean age was 62.1 ± 12.4 years. Patients with a RAI score > 25 and/or a timed up and go (TUG) > 8 s had a higher risk for mortality at 90 days after surgery. The low-risk group predicted beneficial outcome and the high-risk group predicted adverse outcome in the ROC analysis (Area Under the Curve Receiver Operator Characteristics: AUROC > 0.800; p = 0.01). Risk groups (high vs. low) showed significant differences for 90-day survival (99.4% vs. 95.5%; p = 0.04) and major complications (16.4% vs. 32.4%; p < 0.001). CONCLUSION The proof-of-concept trial showed that a risk assessment with 'The Prehab App' may be viable to estimate the preoperative risk for mortality and major complications before major surgeries. The overall performance in this initial set of data indicated a certain reliability of the scoring and risk grouping, especially of the RAI score and the TUG. A larger data set will be required to proof the generalizability of the risk scoring to every subgroup and may be fostered by artificial intelligence approaches. TRIAL REGISTRATION Ethics number: 2021-483-MDR/MPDG-zuständig monocentric; The Federal Institute for Pharmaceuticals and Medical Devices/BfArM, reference number: 94.1.04-5660-13655; Eudamed: CIV-21-07-0307311; German Clinical Trial Registry: DRKS 00026985.
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Affiliation(s)
- Svenja Sliwinski
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Jan Heil
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Wolf O Bechstein
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sven Becker
- Department for Gynecology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Felix Chun
- Department for Urology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Wojciech Derwich
- Department for Vascular Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Waldemar Schreiner
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Christine Solbach
- Department for Gynecology, Frankfurt University Hospital, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Pain Center, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Andreas A Schnitzbauer
- Department for General, Visceral, Transplant and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
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Sliwinski S, Sammons MK, Koca F, El Youzouri H, Vogl T, Bechstein W. Broncho biliary fistula following interventional radiology for hepatic metastases. Z Gastroenterol 2024. [PMID: 38604220 DOI: 10.1055/a-2207-7533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Bronchobiliary fistulas are defined as an abnormal communication between the biliary system and the bronchial tree. They are extremely rare complications of radiofrequency or microwave ablation. A 39-year-old woman with a history of neuroendocrine pancreatic carcinoma suffering from liver metastasis was treated with microwave ablation (MWA). In this case report, we present a case of intractable biliptysis from a bronchobiliary fistula secondary to an MWA. The patient was diagnosed by endoscopic retrograde cholangiopancreatograph and hepatobiliary scintigraphy. Treatment involved a right hemihepatectomy, a redo-hepaticojejunostomy, and the surgical placement of a transhepatic drain. After 6 weeks of drain placement, this could be removed. The fistula was thus successfully treated.
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Affiliation(s)
- Svenja Sliwinski
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Mary Katherine Sammons
- Department of Dermatology, Allergology and Venereology, University Medical Center Schleswig Holstein Lübeck Campus, Lübeck, Germany
| | - Faruk Koca
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Hanan El Youzouri
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Thomas Vogl
- Department of Radiology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Wolf Bechstein
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt, Germany
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Sliwinski S, Werneburg E, Faqar-Uz-Zaman SF, Detemble C, Dreilich J, Mohr L, Zmuc D, Beyer K, Bechstein WO, Herrle F, Malkomes P, Reissfelder C, Ritz JP, Vilz T, Fleckenstein J, Schnitzbauer AA. A toolbox for a structured risk-based prehabilitation program in major surgical oncology. Front Surg 2023; 10:1186971. [PMID: 37435472 PMCID: PMC10332323 DOI: 10.3389/fsurg.2023.1186971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.
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Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Elisabeth Werneburg
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Katharina Beyer
- Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| | - Wolf O. Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Florian Herrle
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Romed Klinik Prien am Chiemsee, Klinik für Allgemein- und Viszeralchirurgie, Prien am Chiemsee, Germany
| | - Patrizia Malkomes
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Christoph Reissfelder
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg P. Ritz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Helios Clinics Schwerin, Department for General and Visceral Surgery, Schwerin, Germany
| | - Tim Vilz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Department of Pain Medicine, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A. Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
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Faqar-Uz-Zaman SF, Sliwinski S, Detemble C, Filmann N, Zmuc D, Mohr L, Dreilich J, Bechstein WO, Fleckenstein J, Schnitzbauer AA. Study protocol for a pilot trial analysing the usability, validity and safety of an interventional health app programme for the structured prehabilitation of patients before major surgical interventions: the PROTEGO MAXIMA trial. BMJ Open 2023; 13:e069394. [PMID: 37019492 PMCID: PMC10439343 DOI: 10.1136/bmjopen-2022-069394] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/14/2023] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Major surgery is associated with a high risk for postoperative complications, leading to an increase in mortality and morbidity, particularly in frail patients with a reduced cardiopulmonary reserve. Prehabilitation, including aerobic exercise training, aims to improve patients' physical fitness before major surgery and reduce postoperative complications, length of hospital stay and costs. The purpose of the study is to assess the usability, validity and safety of an app-based endurance exercise software in accordance with the Medical Device Regulation using wrist-worn wearables to measure heart rate (HR) and distance. METHODS AND ANALYSIS The PROTEGO MAXIMA trial is a prospective, interventional study with patients undergoing major elective surgery, comprising three tasks. Tasks I and II aim to assess the usability of the app, using evaluation questionnaires and usability scenarios. In Task IIIa, patients will undergo a structured risk assessment by the Patronus App, which will be correlated with the occurrence of postoperative complications after 90 days (non-interventional). In Task IIIb, healthy students and patients will perform a supervised 6 min walking test and a 37 min interval training on a treadmill based on HR reserve, wearing standard ECG limb leads and two smartwatches, which will be driven by the test software. The aim of this task is to assess the accuracy of HR measurement by the wearables and the safety, using specific alarm settings of the devices and lab testing of the participants (interventional). ETHICS AND DISSEMINATION Ethical approval was granted by the Institutional Review Board of the University Hospital of Frankfurt and by the Federal Institute for Pharmaceuticals and Medical Products (BfArM, reference number 94.1.04-5660-13655) on 7 February 2022. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings. TRIAL REGISTRATION NUMBERS European Database on Medical Devices (CIV-21-07-037311) and German Clinical Trial Registry (DRKS00026985).
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Affiliation(s)
- Sara Fatima Faqar-Uz-Zaman
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Svenja Sliwinski
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Charlotte Detemble
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Dora Zmuc
- MCL Medical Center Ljubljana, Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lisa Mohr
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
| | - Julia Dreilich
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
| | - Wolf O Bechstein
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
| | - Johannes Fleckenstein
- Department of Sports Medicine and Exercise Physiology, Institute for Sports Science, Goethe University Frankfurt, Frankfurt, Germany
- Pain Centre, Klinikum Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A Schnitzbauer
- Department for General, Visceral, Transplant and Thoracic Surgery, Hospital of the Goethe University Frankfurt Surgery Centre, Frankfurt am Main, Germany
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Sliwinski S, Heil J, Franz J, El Youzouri H, Heise M, Bechstein WO, Schnitzbauer AA. A critical appraisal of the ISGLS definition of biliary leakage after liver resection. Langenbecks Arch Surg 2023; 408:77. [PMID: 36735087 PMCID: PMC9898433 DOI: 10.1007/s00423-022-02746-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 10/20/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The International Study Group of Liver Surgery (ISGLS) defined post-hepatectomy biliary leakage as drain/serum bilirubin ratio > 3 at day 3 or the interventional/surgical revision due to biliary peritonitis. We investigated the definition's applicability. METHODS A retrospective evaluation of all liver resections over a 6-year period was performed. ROC analyses were performed for drain/serum bilirubin ratios on days 1, 2, and 3 including grade A to C (analysis I) and grade B and C biliary leakages (analysis II) to test specific cutoff values. RESULTS A total of 576 patients were included. One hundred nine (18.9%) postoperative bile leakages occurred (19.6% of the whole population grade A, 16.5% grade B/C). Areas under the curve (AUC) for analysis I were 0.841 (day 1), 0.846 (day 2), and 0.734 (day 3). The highest sensitivity (78% on day 1/77% on day 2) and specificity (78% on day 1/79% on day 2) in analysis I were obtained for a drain/serum bilirubin ratio of 2.0. AUCs for analysis II were similar: 0.788 (day 1), 0.791 (day 2), and 0.650 (day 3). The highest sensitivity (73% on day 1/71% on day 2) and specificity (74% on day 1/76% on day 2) in analysis II were detected for a drain/serum bilirubin ratio of 2.0 on postoperative day 2. CONCLUSION Biliary leakages should be defined if the drain/serum bilirubin ratio is > 2.0 on postoperative day 2.
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Affiliation(s)
- Svenja Sliwinski
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - Jan Heil
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Josephine Franz
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Hanan El Youzouri
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Michael Heise
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Wolf O Bechstein
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Andreas A Schnitzbauer
- Department for General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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Faqar-Uz-Zaman SF, Anantharajah L, Baumartz P, Sobotta P, Filmann N, Zmuc D, von Wagner M, Detemble C, Sliwinski S, Marschall U, Bechstein WO, Schnitzbauer AA. The Diagnostic Efficacy of an App-based Diagnostic Health Care Application in the Emergency Room: eRadaR-Trial. A prospective, Double-blinded, Observational Study. Ann Surg 2022; 276:935-942. [PMID: 35925755 DOI: 10.1097/sla.0000000000005614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of the app-based diagnostic tool Ada and the impact on patient outcome in the emergency room (ER). BACKGROUND Artificial intelligence (AI)-based diagnostic tools can improve targeted processes in healthcare delivery by integrating patient information with a medical knowledge base and a machine learning system, providing clinicians with differential diagnoses and recommendations. METHODS Patients presenting to the ER with abdominal pain self-assessed their symptoms using the Ada-App under supervision and were subsequently assessed by the ER physician. Diagnostic accuracy was evaluated by comparing the App-diagnoses with the final discharge diagnoses. Timing of diagnosis and time to treatment were correlated with complications, overall survival, and length of hospital stay. RESULTS In this prospective, double-blinded study, 450 patients were enrolled and followed up until day 90. Ada suggested the final discharge diagnosis in 52.0% (95% CI [0.47, 0.57]) of patients compared to the classical doctor-patient interaction, which was significantly superior with 80.9% (95% CI [0.77, 0.84], P<0.001). However, when diagnostic accuracy of both were assessed together, Ada significantly increased the accuracy rate (87.3%, P<0.001), when compared to the ER physician alone. Patients with an early time point of diagnosis and rapid treatment allocation exhibited significantly reduced complications (P<0.001) and length of hospital stay (P<0.001). CONCLUSION Currently, the classical patient-physician interaction is superior to an AI-based diagnostic tool applied by patients. However, AI tools have the potential to additionally benefit the diagnostic efficacy of clinicians and improve quality of care.
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Affiliation(s)
- Sara F Faqar-Uz-Zaman
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Luxia Anantharajah
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Philipp Baumartz
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Paula Sobotta
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Germany
| | - Dora Zmuc
- MCL Medical Center Ljubljana, Ljubljana, Slovenia
| | - Michael von Wagner
- Executive Department for Medical IT-Systems and Digitalization, Frankfurt University Hospital, Germany.,Department of Internal Medicine I, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Svenja Sliwinski
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | | | - Wolf O Bechstein
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Andreas A Schnitzbauer
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Sliwinski S, Trojan J, Mader C, Vogl T, Bechstein W. Liver resection after Transjugular Portosystemic Stent Shunt (TIPSS). Z Gastroenterol 2022; 61:390-393. [PMID: 35697061 DOI: 10.1055/a-1791-2192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractHepatocellular carcinoma (HCC) often arises in cirrhotic livers. Generally, decompensated liver cirrhosis is a contraindication to surgery. Even in compensated liver cirrhosis, liver resection for HCC carries a high risk of post-hepatectomy liver failure and decompensation of cirrhosis. Thus, in current staging systems such as the Barcelona Classification of Liver Cancer (BCLC) or the Hong Kong Classification of Liver Cancer (HKLC), liver resection is limited to smaller tumors in compensated cirrhosis. While transjugular portosystemic stent shunts (TIPSS) are widely used for the treatment of complications of portal hypertension such as recurrent esophageal bleeding or refractory ascites, the presence of a TIPSS is generally considered a contraindication for liver resection. Herein, we describe – to our knowledge for the first time – liver resection of an intermediate HCC with a diameter of 11 cm in a patient who had previously received a TIPSS for decompensated cirrhosis. With open surgery, radical resection (R0) was able to be achieved, and the patient left the hospital after 6 days following an uncomplicated postoperative course. Thus, in highly selected cases, liver resection following TIPSS may be considered.
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Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant, and Thoracic Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Jörg Trojan
- Department of Internal Medicine, Hospital of the Goethe University Frankfurt Center of Internal Medicine, Frankfurt am Main, Germany
| | - Christoph Mader
- Department of Radiology, Hospital of the Goethe University Frankfurt Center of Radiology, Frankfurt am Main, Germany
| | - Thomas Vogl
- Department of Radiology, Hospital of the Goethe University Frankfurt Center of Radiology, Frankfurt am Main, Germany
| | - Wolf Bechstein
- Department of General, Visceral, Transplant, and Thoracic Surgery, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
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9
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Al-Thihli K, Afting C, Al-Hashmi N, Mohammed M, Sliwinski S, Al Shibli N, Al-Said K, Al-Kasbi G, Al-Kharusi K, Merle U, Füllekrug J, Al-Maawali A. Deficiency of acyl-CoA synthetase 5 is associated with a severe and treatable failure to thrive of neonatal onset. Clin Genet 2020; 99:376-383. [PMID: 33191500 DOI: 10.1111/cge.13883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/28/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Abstract
Failure to thrive (FTT) causes significant morbidity, often without clear etiologies. Six individuals of a large consanguineous family presented in the neonatal period with recurrent vomiting and diarrhea, leading to severe FTT. Standard diagnostic work up did not ascertain an etiology. Autozygosity mapping and whole exome sequencing identified homozygosity for a novel genetic variant of the long chain fatty acyl-CoA synthetase 5 (ACSL5) shared among the affected individuals (NM_203379.1:c.1358C>A:p.(Thr453Lys)). Autosomal recessive genotype-phenotype segregation was confirmed by Sanger sequencing. Functional in vitro analysis of the ACSL5 variant by immunofluorescence, western blotting and enzyme assay suggested that Thr453Lys is a loss-of-function mutation without any remaining activity. ACSL5 belongs to an essential enzyme family required for lipid metabolism and is known to contribute the major activity in the mouse intestine. Based on the function of ACSL5 in intestinal long chain fatty acid metabolism and the gastroenterological symptoms, affected individuals were treated with total parenteral nutrition or medium-chain triglyceride-based formula restricted in long-chain triglycerides. The patients responded well and follow up suggests that treatment is only required during early life.
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Affiliation(s)
- Khalid Al-Thihli
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.,Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Oman
| | - Cassian Afting
- Department of Internal Medicine IV, Heidelberg University Hospital, Heidelberg, Germany
| | - Nadia Al-Hashmi
- Department of Pediatrics and National Genetic Center, Royal Hospital, Ministry of Health, Muscat, Oman
| | - Mohammed Mohammed
- Department of Pediatrics and National Genetic Center, Royal Hospital, Ministry of Health, Muscat, Oman
| | - Svenja Sliwinski
- Department of Internal Medicine IV, Heidelberg University Hospital, Heidelberg, Germany
| | - Naema Al Shibli
- Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Khoula Al-Said
- Department of Pediatrics and National Genetic Center, Royal Hospital, Ministry of Health, Muscat, Oman
| | - Ghalia Al-Kasbi
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Khalsa Al-Kharusi
- Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Oman
| | - Uta Merle
- Department of Internal Medicine IV, Heidelberg University Hospital, Heidelberg, Germany
| | - Joachim Füllekrug
- Department of Internal Medicine IV, Heidelberg University Hospital, Heidelberg, Germany
| | - Almundher Al-Maawali
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.,Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Oman
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10
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Rädeker L, Schwab M, Frey PE, Friedrich M, Sliwinski S, Steinle J, Fink CA, Leuk A, Ganschow P, Ottawa GB, Klose C, Feißt M, Dörr-Harim C, Tenckhoff S, Mihaljevic AL. [Design and Evaluation of a Clinical Investigator Training for Student-lead Prospective Multicentre Clinical Trials: a CHIR-Net SIGMA Research-based Learning Project]. Zentralbl Chir 2019; 145:521-530. [PMID: 31658485 DOI: 10.1055/a-1007-1995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Scientific skills are not sufficiently taught during medical training, neither in medical school nor during postgraduate education. This results in a lack of clinician scientists. In order to counter this problem, the surgical study network (CHIR-Net) founded SIGMA (Student-initiated German Medical Audit). This paper describes the development, performance and evaluation of a Clinical Investigator Training (CIT) aiming to qualify students to autonomously conduct clinical trials. MATERIAL AND METHODS Based on the Kern cycle, a curriculum was developed, composed of three parts: online tutorials, a workshop and a follow-up period. The educational objectives were defined according to Bloom's taxonomy of knowledge. The learning objectives were based on the requirements of the "Network of Coordinating Centers for Clinical Trials" and the German Medical Association as well as content relevant to clinical studies. A wide range of educational instruments and assessments were used. By including all relevant professional groups involved in clinical trials, an interconnected working environment for students was generated. The increase in knowledge was assessed by a multiple-choice pre/post exam. The satisfaction of participants was analysed by a 5-point Likert scale, on which 5 indicated full approval. RESULTS The first SIGMA CIT was realised in 2018; the workshop took place in Heidelberg in February. Thirty-two medical students from thirteen different centres participated. On average, 53.8 ± 8.3% of questions were answered correctly in the pre-test, compared with 71.2 ± 7.2% in the post-test (p < 0.0001). The maximal individual improvement was 30%; the lowest difference compared to the pre-test was 5%. Subjective evaluation results were positive with an average result of 4.63 ± 0.34 on a 5-point Likert scale. CONCLUSION It is feasible to teach medical students the fundamentals of clinical trials. A compact Clinical Investigator Training using modern principles of teaching is able to prepare students for an autonomous performance of clinical trials.
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Affiliation(s)
- Lukas Rädeker
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Marius Schwab
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Pia Elena Frey
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Mirco Friedrich
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Svenja Sliwinski
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Julia Steinle
- Medizinische Fakultät, Fachbereich 05, Westfälische Wilhelms-Universität Münster, Deutschland
| | - Christoph A Fink
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Alexander Leuk
- Medizinische Fakultät, Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Petra Ganschow
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Deutschland
| | - Gregor Benedikt Ottawa
- Koordinierungszentrum für Klinische Studien (KKS), Universitätsklinikum Heidelberg, Deutschland
| | - Christina Klose
- Institut für Medizinische Biometrie und Informatik (IMBI), Medizinische Fakultät der Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Manuel Feißt
- Institut für Medizinische Biometrie und Informatik (IMBI), Medizinische Fakultät der Ruprecht-Karls-Universität Heidelberg, Deutschland
| | - Colette Dörr-Harim
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Universitätsklinikum Heidelberg, Deutschland
| | - Solveig Tenckhoff
- Studienzentrum der Deutschen Gesellschaft für Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Deutschland
| | - André L Mihaljevic
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Universitätsklinikum Heidelberg, Deutschland
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Müller R, Köhne R, Sliwinski S. Über Silikone. XLVI. Definierte Siloxane mit mono-, tri- und tetrafunktionellen Baueinheiten. ACTA ACUST UNITED AC 2004. [DOI: 10.1002/prac.19590090112] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Besançon R, Chouaf L, Jouvet A, Sliwinski S, Belin MF, Fèvre-Montange M. Developmental expression of tryptophan hydroxylase mRNAs in the rat pineal gland: an in situ hybridization study. Brain Res Mol Brain Res 1995; 29:253-62. [PMID: 7609613 DOI: 10.1016/0169-328x(94)00256-e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The expression of messenger RNAs encoding for tryptophan hydroxylase (TPOH), the first enzyme involved in serotonin and melatonin synthesis, has been investigated by in situ hybridization during the development of the rat pineal gland. TPOH mRNAs were detected as early as the twentieth day of gestation (E20) in the rat embryo before any nerve ending was observed in the pineal gland. After birth, their expression increased strongly, and attained a plateau during the second week. This coincides with the setting up of sympathetic innervation. From day 17 (D17), the TPOH mRNA expression diminished. These results indicate that noradrenergic innervation is not involved in the initiation of rat pinealocyte differentiation, but might modulate cell maturation. This study showed the existence of three types of cells arranged in patches in the young rat pineal gland (D6): regions in which cells expressed TPOH mRNAs, regions in which cells expressed vimentin, an intermediate filament protein present in the cytoskeleton of immature cells, and regions in which both TPOH mRNAs and vimentin are expressed. In older rat pineal gland (D20), almost all cells express TPOH mRNAs, and some cells still express vimentin. This suggests that all cells do not reach the same level of differentiation at the same time in the rat pineal gland.
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Affiliation(s)
- R Besançon
- INSERM CJF 90-10, Laboratoire d'Anatomie Pathologique, Faculté de Médecine Alexis Carrel, Lyon, France
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