Background and Aims:The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the co

The Clavien-Dindo classification of surgical complications: five-year experience.

Postoperative pancreatic fistula: an international study group (ISGPF) definition.

Background. Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences. Methods. An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easyto-apply definition of POPF, graded primarily on clinical impact. Results. A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient’s hospital course. Conclusions. The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed. (Surgery 2005;138:8-13.)

Special article Postoperative pancreatic fistula: An international study group (ISGPF) definition

Infectious Diseases Society of America.

The clinical successes in immunotherapy have been both astounding and at the same time unsatisfactory. Countless patients with varied tumor types have seen pronounced clinical response with immunotherapeutic intervention; however, many more patients have experienced minimal or no clinical benefit when provided the same treatment. As technology has advanced, so has the understanding of the complexity and diversity of the immune context of the tumor microenvironment and its influence on response to therapy. It has been possible to identify different subclasses of immune environment that have an influence on tumor initiation and response and therapy; by parsing the unique classes and subclasses of tumor immune microenvironment (TIME) that exist within a patient's tumor, the ability to predict and guide immunotherapeutic responsiveness will improve, and new therapeutic targets will be revealed.

Understanding the tumor immune microenvironment (TIME) for effective therapy.

Transaxilläre Schilddrüsenchirurgie – nicht alles was neu ist, ist auch gut

Sir We would like to commend Thomas and colleagues for their single-centre study of resection margin involvement after caudate lobe surgery for colorectal cancer liver metastases (CRLM). Khan and co-workers1 found, in patients with CRLM, that a higher proportion of caudate versus noncaudate resections had positive resection margins (57 versus 32 per cent; P = 0·001), whereas this study concludes there is no such trend. Despite a higher rate of positive margins in caudate lobe resections, this was not statistically significant (4 versus 2·1 per cent; P = 0·520). In Khan and colleagues’ study 52 patients had caudate lobe resections, compared with only 25 in this study. We are concerned that the small sample size and lower incidence of margin involvement overall may have resulted in a type II error in this study and that it may be underpowered to report the outcome of such resections. Further, the fact that almost all resections were performed by the same experienced surgeon may limit the applicability of the findings to other centres. Significantly, the authors do not clarify the study group’s composition with respect to chronology of the development of metastatic disease. Up to 24 per cent of patients with newly diagnosed colorectal cancer have synchronous hepatic metastases, whereas Manfredi and co-workers2 reported a 5-year cumulative metachronous liver metastasis rate of 14·5 per cent in their population-wide study. It is generally held that synchronicity suggests more aggressive and advanced disease, and is associated with poorer outcomes. It is also true that synchronous CRLM are more often bilobar and more numerous3. These facts may be important in predicting those who will benefit from caudate lobe surgery. Without knowing the composition of the group studied with respect to chronology, it is difficult to determine the precise clinical relevance of the findings. A. Lawson McLean and C. D. Russell Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK (e-mail: a.lawson-mclean@sms.ed.ac.uk) DOI: 10.1002/bjs.8716

Author's reply: Clinical significance of liver ischaemia after pancreatic resection (Br J Surg 2011; 98: 1760–1765)

SummaryIn order to identify those patients with severe or necrotising disease who benefit from early initiated intensive care therapy, it is of utmost importance to assess the severity of

Graduierung der akuten Pankreatitis: klinische Präsentation und biochemische Marker

The case presented deals with the complicated course of a laparoscopic cholecystectomy in a 45-year-old female patient due to cholecystolithiasis. The patient complained that during the operation an injury to the small intestine occurred, which was only operatively treated at midday of the despite massive pain and insufficient pain treatment. The intervention was claimed to have resulted in mental and physical suffering. The case is assessed by two independent experts in the sense of a "scientifically founded comment" with respect to the decision of the arbitration board and taking the surgical standards into consideration.

Komplizierter Verlauf einer laparoskopischen Cholezystektomie

Cachexia leads to a loss of weight, especially by loosing fat and muscles. It is a major problem occurring in patients with advanced cancer. The existence of the cancer-cachexia-syndrome is a prognostic factor. Cancer-cachexia occurs in many patients with pancreatic cancer, and one can find it in up to 80% of deaths in patients with pancreatic cancer. The syndrome can occur in a very early state of the disease. The exact mechanism is not entirely understood, many cytokines seem to be involved in the process. In a co-culture model of peripheral mononuclear cells and tumorcells the interactions of the cells were examined. It was shown, that PBMCs of cachectic cancer patients cultured in a Boyden chamber with tumor cells can induce the production of IL-6. Aim of this study was to show, which mechanism is important in the induction if cachexia by PBMCs.

M.W. Büchler

Papers

Transaxilläre Schilddrüsenchirurgie – nicht alles was neu ist, ist auch gut

Author's reply: Clinical significance of liver ischaemia after pancreatic resection (Br J Surg 2011; 98: 1760–1765)

Graduierung der akuten Pankreatitis: klinische Präsentation und biochemische Marker

Komplizierter Verlauf einer laparoskopischen Cholezystektomie

Die Rolle peripherer mononukleärer Zellen bei der Entwicklung der Kachexie bei Patienten mit Pankreaskarzinom