Single chest drain is not inferior to double chest drain after robotic esophagectomy: a propensity score-matched analysis.

Background: Chest drain management has a significant influence on postoperative recovery after robot-assisted minimally invasive esophagectomy (RAMIE). The use of chest drains increases postoperative pain by irritating intercostal nerves and hinders patients from early postoperative mobilization and recovery. To our knowledge, no study has investigated the use of two vs. one intercostal chest drains after RAMIE. Methods: This retrospective cohort study evaluated patients undergoing elective RAMIE with gastric conduit pull-up and intrathoracic anastomosis. Patients were divided into two groups according to placement of one (11/2020-08/2022) or two (08/2018-11/2020) chest drains. Propensity score matching was performed in a 1:1 ratio, and the incidences of overall and pulmonary complications, drainage-associated re-interventions, radiological diagnostics, analgesic use, and length of hospital stay were compared between single drain and double drain groups. Results: During the study period, 194 patients underwent RAMIE. Twenty-two patients were included after propensity score matching in the single and double chest drain group, respectively. Time until removal of the last chest drain [postoperative day (POD) 6.7 ± 4.4 vs. POD 9.4 ± 2.7, p = 0.004] and intensive care unit stay (4.2 ± 5.1 days vs. 5.3 ± 3.5 days, p = 0.01) were significantly shorter in the single drain group. Overall and pulmonary complications, drainage-associated events, re-interventions, number of diagnostic imaging, analgesic use, and length of hospital stay were comparable between both groups. Conclusion: This study is the first to demonstrate the safety of single intercostal chest drain use and, at least, non-inferiority to double chest drains in terms of perioperative complications after RAMIE.

Drainless robot-assisted minimally invasive oesophagectomy-randomized controlled trial (RESPECT).

BACKGROUND: The purpose of this randomized trial is to evaluate the early removal of postoperative drains after robot-assisted minimally invasive oesophagectomy (RAMIE). Evidence is lacking about feasibility, associated pain, recovery, and morbidity. METHODS/DESIGN: This is a randomized controlled multicentric trial involving 72 patients undergoing RAMIE. Patients will be allocated into two groups. The "intervention" group consists of 36 patients. In this group, abdominal and chest drains are removed 3 h after the end of surgery in the absence of contraindications. The control group consists of 36 patients with conventional chest drain management. These drains are removed during the further postoperative course according to a standard algorithm. The primary objective is to investigate whether postoperative pain measured by NRS on the second postoperative day can be significantly reduced in the intervention group. Secondary endpoints are the intensity of pain during the first week, analgesic use, number of postoperative chest X-ray and CT scans, interventions, postoperative mobilization (steps per day as measured with an activity tracker), postoperative morbidity and mortality. DISCUSSION: Until now, there have been no trials investigating different intraoperative chest drain strategies in patients undergoing RAMIE for oesophageal cancer with regard to perioperative complications until discharge. Minimally invasive approaches combined with enhanced recovery after surgery (ERAS) protocols lower morbidity but still include the insertion of chest drains. Reduction and early removal have been proposed after pulmonary surgery but not after RAMIE. The study concept is based on our own experience and the promising current results of the RAMIE procedure. Therefore, the presented randomized controlled trial will provide statistical evidence of the effectiveness and feasibility of the "drainless" RAMIE. TRIAL REGISTRATION: ClinicalTrials.gov NCT05553795. Registered on 23 September 2022.

How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery.

PURPOSE: Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. METHODS: All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. RESULTS: Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. CONCLUSIONS: The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

[Preoperative diagnostics and typing of abdominal soft tissue sarcomas]. / Präoperative Diagnostik und Typisierung abdomineller Weichteilsarkome.

BACKGROUND: Abdominal sarcomas are a heterogeneous group of rare soft tissue tumors and can be localized intraperitoneally or retroperitoneally. A pretherapeutic differentiated subtyping is essential for planning an individual, multimodal treatment concept in an interdisciplinary team of experts. OBJECTIVE: The central aspects of histology acquisition, imaging diagnostics and (molecular) pathological subtyping of abdominal soft tissue sarcomas are described in detail. MATERIAL AND METHODS: Imaging and pathological diagnostics are depicted based on the German S3 guidelines on adult soft tissue sarcomas, a current literature search and personal experiences at the Sarcoma Center at the National Center for Tumor Diseases in Dresden (NCT/UCC). RESULTS: Preoperative imaging and (molecular) pathological subtyping of abdominal soft tissue sarcomas place high demands on surgeons, radiologists and pathologists. Genome analyses of sarcomas have the potential to identify points of attack for individualized treatment options. The limitations of resectability can only be assessed by experienced sarcoma surgeons at specialized centers. CONCLUSION: The treatment of abdominal soft tissue sarcomas at an experienced center is associated with a better prognosis. Even at the first suspicion of an abdominal sarcoma, a referral to an experienced center should be made in order to guarantee optimal expertise in diagnostics and treatment.

[The suffering surgeon-How do German surgeons protect themselves? : Survey of the German Society of General and Visceral Surgery on the extent of occupational safety measures and health burden among German surgeons]. / Der leidende Chirurg ­ Wie schützen Chirurgen sich selbst? : DGAV-Umfrage zur Verbreitung von Arbeitssicherheitsmaßnahmen und Gesundheitsbelastung bei deutschen Chirurgen.

BACKGROUND: There are few data on how surgeons implement occupational safety measures to protect their own health and how they assess their subjective health burden. OBJECTIVE: In times of a shortage of surgeons it makes sense to examine these relationships in order to evaluate future-oriented adjustments to increase the attractiveness of the profession of "surgeon". MATERIAL AND METHODS: An online questionnaire was sent to the registered members of the German Society for General and Visceral Surgery (DGAV) in October 2016. The members were asked about the application of occupational safety measures, individual living conditions, working conditions and the subjective health burden depending on the level of training and type of hospital (basic, standard, maximum care). RESULTS: The response rate was 21% (1065/5011). Occupational safety measures were not strictly implemented: routine use of dosimeters, thyroid radiation protection, smoke extraction and protective goggles only took place in 40% (427/1065), 39% (411/1065), 10% (104/1065) and 5% (55/1065), respectively. The majority of surgeons (51%, 548/1065) rated their lifestyle as unhealthy. The majority of them are senior physicians, 46% (250/548) consider their job to be a health hazard. The proportion of chief physicians and assistant physicians is only 21% (115/548) and 18% (98/548). CONCLUSION: Guidelines for standardizing the perioperative protection of German surgeons are desirable. Health-promoting behavior could have a positive effect on the occupational safety of surgeons and ultimately also on patient safety. This can contribute to increasing the attractiveness of the profession "surgeon" in the long term.

[Evidence for robotic surgery in oncological visceral surgery]. / Evidenz der Roboter-Chirurgie in der onkologischen Viszeralchirurgie.

The superiority of minimally invasive operative methods compared to open surgery with respect to various parameters of short-term outcome with adequate oncological long-term results has already been confirmed for many tumor entities in high-quality studies. The continuously expanding robotic surgery offers certain additional benefits in minimally invasive oncological visceral surgery, such as a high-resolution stable 3­dimensional view, optimal freedom of movement in situ, elimination of natural tremor and better ergonomics. This article evaluates whether these postulated advantages are reflected in an improvement of the short-term perioperative and long-term oncological results compared to conventional minimally invasive surgery in oncological visceral surgery (rectum, colon, stomach, esophagus, pancreas, liver) according to the criteria of evidence-based medicine. With the exception of colorectal surgery, there are currently no randomized controlled studies comparing robotic to laparoscopic surgery in oncological visceral surgery. There is still a clear imbalance between the exponentially expanding application of robotic surgery and the existing lack of high-quality evidence. Further randomized controlled clinical trials urgently need to be performed especially considering the great technological development potential of robotic surgery.

Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection.

BACKGROUND: Previous studies have demonstrated stapler hepatectomy and use of various energy devices to be safe alternatives to the clamp-crushing technique in elective hepatic resection. In this randomized trial, the effectiveness and safety of stapler hepatectomy were compared with those of parenchymal transection with the LigaSure™ vessel sealing system. METHOD: Patients scheduled for elective liver resection at two tertiary-care centres were randomized during surgery to stapler hepatectomy or transection with the LigaSure™ device. Total intraoperative blood loss was the primary efficacy endpoint. Transection time, duration of operation, perioperative complications and length of hospital stay were recorded as secondary endpoints. RESULTS: A total of 138 patients were analysed, 69 in the LigaSure™ and 69 in the stapler hepatectomy group. Baseline characteristics were well balanced between the groups. Mean intraoperative blood loss was significantly higher in the LigaSure™ group than the stapler hepatectomy group: 1101 (95 per cent c.i. 915 to 1287) versus 961 (752 to 1170) ml (P = 0·028). The parenchymal transection time was significantly shorter in the stapler group (P = 0·005), as was the total duration of operation (P = 0·027). Surgical morbidity did not differ between the groups, nor did the grade of complications. CONCLUSION: Stapler hepatectomy was associated with reduced blood loss and a shorter duration of operation than the LigaSure™ device for parenchymal transection in elective partial hepatectomy. Registration number: NCT01858987 (http://www.clinicaltrials.gov).

[Robotics in the operating room : Out of the niche into widespread application]. / Robotik im Operationssaal : Aus der Nische in die breite Anwendung.

In the last few years robotic surgery has progressed from being confined to a small niche to a widespread application in routine visceral surgery; however, evidence for superiority of robotic surgery compared to laparoscopy from randomized studies with a sufficient number of patients is still lacking in most fields of visceral surgery. For complex operations that necessitate an extensive reconstruction phase, such as pancreatectomy, gastrectomy and esophagectomy, there is a potential benefit for the permanent and justified use of robotic surgery. Even in operations where delicate nerve preparation and radical surgical resection are simultaneously necessary, such as rectal resection, robotic surgery may provide certain benefits. In the long term there is a great potential for the integration of innovative techniques, such as navigation or other medical imaging procedures into robotic surgery, which can currently only partially be estimated. Care must be taken to avoid premature euphoria; however, due to the assumed great potential there is an urgent need for randomized studies to evaluate the possible benefits of robotic surgical techniques in visceral surgery in order to generate evidence for the welfare of patients.

[Robotic Pancreatic Surgery]. / Roboterchirurgie des Pankreas.

Pancreatic surgery is one of the most challenging fields in visceral surgery. However, laparoscopic pancreatic surgery has not become the standard of care as yet, especially because of the very demanding reconstruction of anastomoses in pancreaticoduodenectomy. Robotic surgery has been a recent advance in laparoscopy. Its benefits are a better 3D view, a greater degree of freedom corresponding to that of the human hand, and tremor elimination. These factors greatly facilitate the intracorporeal suturing and knot-tying, which offers a technical advantage in performing pancreaticojejunostomy as compared with laparoscopic resections. However, only a few centres are offering this procedure for pancreatic resections. Retrospective analyses show that robotic pancreatic resections are safe und oncologically adequate if performed by experienced surgeons. Prospective, randomised trials comparing laparoscopic and robotic pancreatic resection techniques are not available to date.

[Intra-abdominal and retroperitoneal sarcomas]. / Intraabdominelle und retroperitoneale Sarkome.

Sarcomas are a heterogeneous group of rare tumors that originate from mesenchymal tissue. Radical R0 resection is the only curative option, which is especially challenging in retroperitoneal or intra-abdominal sarcomas. This article describes the current data on optimal interdisciplinary and primarily surgical therapy of visceral sarcomas. Surgical resection of retroperitoneal sarcomas must be performed according to the principle of radical compartmental resection, i.e. with complete excision of the mass along with en bloc visceral resection of adjacent organs and tissues covering the tumor, which also contains any not obviously infiltrated neighboring organs. The main objective is R0 resection without opening the tumor capsule in the primary operation because the best long-term results can be achieved with this approach.

[Nerve-preserving low anterior rectum resection]. / Nervenschonende offene tiefe anteriore Rektumresektion beim Rektumkarzinom.

AIM: The Performance of an oncological low anterior rectum resection with preservation of the sympathic and parasympathic nerves is illustrated. INDICATION: The total mesorectal excision (TME) by Robert Heald et al. is the gold standard for rectal cancer operations which has lowered drastically the local recurrence rate. As the survival data improve, the new focus is the postoperative quality of life with preserving of the bladder and sexual function. METHOD: We demonstrate an anterior rectal cancer operation with preserving of the sympathetic and parasympathetic nerves step by step. CONCLUSION: The critical parts of preserving the nerves with the N. hypogastricus superior and inferior as well as the neurovascular bundle "erigent pillar" are demonstrated.

[Minimally invasive surgery of primary and secondary liver tumors : indications, techniques and results]. / Minimalinvasive Chirurgie primärer und sekundärer Lebertumoren : Patientenselektion, Verfahrenswahl, Ergebnisse.

BACKGROUND: Initially, mainly superficial liver lesions were resected laparoscopically but now even major resections are performed using a minimally invasive procedure. Careful selection of suitable patients is of key importance. AIMS AND METHODS: This article describes the current state of the art in patient selection and choice of the appropriate laparoscopic technique based on a review of the recent literature. Perioperative and oncological outcome parameters of laparoscopic liver resection are presented. RESULTS: Laparoscopic liver resection offers significant benefits compared to open liver resection in terms of reduced intraoperative blood loss, reduced overall and liver-specific complications and length of hospital stay without compromising oncological outcomes. CONCLUSION: Lesions in the peripheral anterolateral segments (segments 2, 3, 4b, 5 and 6) are particularly suitable for laparoscopic liver resection. Access to the posterosuperior segments 1, 4a, 7 and 8 is more challenging but safe and feasible in experienced centers.

Divalent cations (Mg2+, Ca2+) differentially influence the beta 1 integrin-mediated migration of human fibroblasts and keratinocytes to different extracellular matrix proteins.

Directed migration of keratinocytes and fibroblasts is a fundamental prerequisite in wound healing. Cation-dependent affinity changes of integrins are responsible for cell adhesion to and deadhesion from extracellular matrix proteins and have been implicated in driving cell migration. The specific requirements for divalent cations in the integrin-dependent migration of human dermal fibroblasts and human epidermal keratinocytes to various extracellular matrix proteins have been studied in vitro using blindwell Boyden chambers. The migration of the tested cells to collagen type I was mediated by the alpha 2 beta 1 integrins, to fibronectin by the combined action of the alpha 3 beta 1 and the alpha 5 beta 1 integrin, and the migration of fibroblasts to laminin dependent both on the alpha 2 beta 1 and the alpha 6 beta 1 integrins. No migration of keratinocytes to laminin was detected. Mg2+ alone induced cell migration with an optimum at 2 mM for fibroblasts and at 10 mM for keratinocytes. Ca2+ alone at 2 mM only marginally enhanced fibroblast and keratinocyte migration. At higher concentrations Ca2+ suppressed the stimulatory Mg2+ effect. 2 mM Ca2+ combined with 2 mM Mg2+ showed an additive stimulatory effect on the migration of fibroblasts to fibronectin. These data suggest that extracellular divalent cations differentially influence the integrin-mediated cell migration. A concentration gradient of Mg2+/Ca2+, as reported in tissue injury, thus may play a regulatory role in cell migration required for tissue remodelling.

Envenomation by the colubrid snake Atractaspis bibronii: a case report.

A reptile caretaker was bitten and envenomated by Atractaspis bibronii while handling a box of "non-venomous" colubrid feeder snakes. The patient was bitten on a finger by a single fang. Pain and swelling were noted within 10 min and dissipated over the ensuing 3 days. This case report adds to the limited number of bites by A. bibronii already found in the literature and reviews what is currently known about the species.