Peritoneal metastasis in gastric cancer: results from the German database.

BACKGROUND: Patients with peritoneal metastases of gastric cancer have a poor prognosis with a median survival of 7 months. A benefit of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) could be shown in several selected patient cohorts but remains controversial. The aim of this study was, to reflect the results of a national German HIPEC registry initiated by the German Society of General and Visceral Surgery (DGAV). METHODS: The DGAV HIPEC registry StuDoQ|Peritoneum documents patients with peritoneal malignancy contributed from 52 hospitals. All consecutive documented patients from 2011 until 2016 (n = 3078) were treated with CRS and HIPEC and were analysed. A total of 315 (10%) suffered from gastric cancer and were analysed. RESULTS: A complete data set of 235 patients was available for this study, including 113 male (48.1%) and 122 female (51.9%) patients with a median age of 53.4 years (SD ± 11.9). The median PCI was 8.0 (range 1-30). A complete cytoreduction was achieved in 121 patients (71.6%). Postoperative complications (Clavien-Dindo grades 3-4) occurred in 40 patients (17%). The median overall survival (OS) time was 13 months. The 5-year survival rate was 6%. According to the PCI from 0-6 (n = 74); 7-15 (n = 70) and 16-39 (n = 24) the median OS differs significantly (18 months vs. 12 months vs. 5 months; p = 0.002). CONCLUSIONS: CRS and HIPEC in selected patients with gastric cancer and peritoneal spread can improve survival when they are treated in centers. An accurate staging and patient selection are of major importance to achieve long-term survival.

Real-time lymphography by indocyanine green fluorescence: improved navigation for regional lymph node staging.

OBJECTIVES: Lymphatic imaging is an important step for the identification of lymphonodal positive disease in solid malignancies. Various methods have been established to detect positive lymph nodes, but the available diagnostic tools leave some inherent drawbacks. The aim of this study was to validate the indocyanine green (ICG) guided approach for transcutaneous and transmesenterial navigation with accurate lymph vessel and node identification for regional lymph node staging in solid malignancies. METHODS: After institutional review board approval, a planar fluorescence imaging system was applied for lymphography and lymph node detection using ICG. A total of 96 patients were recruited and subject to fluorescence navigation for axillary (n = 46), inguinal (n = 16), and mesenterial (n = 34) visualization to analyze technical and clinical feasibility of the method after regional lymph node dissection and the applicability. RESULTS: Overall fluorescence imaging identified lymphatic vessels and the SLN in 92 out of 96 patients (detection rate: 96%) after a mean injection of 7 mg ICG. Sensitivity based on fluorescent emission of ICG navigation was 95.6% in 65 out of 68 patients with lymph node dissection. All solid tumors were feasible for fluorescence-guided navigation with a broad spectrum. CONCLUSION: Fluorescence-guided real-time lymphography with navigation to regional lymph nodes enables accurate visualization for a broad spectrum of different solid tumors with potential lymphonodal spread. In addition, the technique can be applied for lymphography in non-malignant diseases. With reference to the broad application spectrum, institutional investment in camera equipment can be justified.

Intraoperative localization of occult colorectal tumors during laparoscopic surgery by magnetic ring markers-a pilot study.

PURPOSE: Intraoperative localization of small tumors or malignant polyps has been an important issue in laparoscopic colon surgery. We have developed a new method for preoperative endoscopic tumor marking using a ring-shaped magnetic marker. METHODS: In a pilot study, 28 patients with small colonic (n = 23) or rectal tumors (n = 5) underwent endoscopic magnetic clipping prior to laparoscopic resection. A cap carrying a high-power neodymium ring magnet was mounted on the tip of a colonoscope. Near the lesion, the ring magnet was released and clipped to the colorectal wall. Standard laparoscopic instruments were used to find the magnet intraoperatively. RESULTS: Endoscopic fixation of a ring magnet next to the tumor by clipping was technically feasible in all 28 patients. Intraoperative localization of the marked lesions was successful in 27 of 28 patients (96 %). All patients underwent magnet-guided radical laparoscopic resection of the tumor with an average proximal and distal resection margin of 101 and 63 mm, respectively. In one case, the magnet could not be found due to preoperative migration. Surgical complications related to magnetic clip application or intraoperative tumor localization were not observed. However, there was one case with an intraoperative perforation of the colon by the magnet, which was obviously caused by unchecked action with a laparoscopic instrument. CONCLUSIONS: Preoperative endoscopic labeling of colonic lesions with on-the-scope magnetic markers is simple and safe. Intraoperative tumor localization during laparoscopic colorectal surgery can be achieved reliably without additional equipment such as ultrasound or fluoroscopy.

An experimental study to evaluate the Fluobeam 800 imaging system for fluorescence-guided lymphatic imaging and sentinel node biopsy.

BACKGROUND: Visualization of the lymphatic system is challenging. Lymphatic imaging is a crucial diagnostic tool for benign and malignant lymphatic pathologies. Fluorescence-guided imaging allows selective lymphatic mapping and sentinel lymph node (SLN) identification. There are a few fluorescence systems, but some drawbacks remain due to technical and ergonomic aspects. The aim of this study was to evaluate the feasibility of the new Fluobeam 800 imaging system. METHODS: After approval by the ethics committee, the system was evaluated for lymphography and SLN biopsy in an animal model. Five pigs each with 4 lymph node (LN) stations (n = 20 LN stations) were subjected to lymphatic imaging using indocyanine green (ICG). Additionally, the use of ICG was compared with ICG adsorbed to human serum albumin (ICG-HSA). Lymphatic vessels and SLN identification rates were measured. RESULTS: After injection, a clear fluorescence signal of the lymphatic vessels was visualized leading to the LN station. Overall, ICG fluorescence imaging identified a mean of 2.0 lymphatic vessels and 1.1 (range = 1-2) SLN in 20 of 20 LN stations. Reverse lymphography was feasible. A clinical difference in resolution was not detected between use of ICG-HSA and ICG. CONCLUSION: This is the first study analyzing the feasibility of the Fluobeam 800 imaging system allowing transcutaneous real-time imaging. It enables detection of the SLN by fluorescence retention with increased detection depth and resolution. After fixation to the ceiling, the ergonomics advanced for simultaneous field navigation and dissection. The new system can be applied for lymphatic imaging for lympatico-reconstructive surgery and SLN biopsy.

The effect of biofeedback pelvic floor training with ACTICORE1 on urinary incontinence: a multicenter randomized clinical pilot trial.

Background: Pelvic floor training with biofeedback has been shown to significantly reduce symptoms of urinary incontinence. The present study aimed to evaluate the effectiveness of pelvic floor training with the ACTICORE1 biofeedback device, which uses a noninsertable pelvic floor sensor with a digital interface. Materials and methods: A multicenter randomized controlled clinical pilot study in Germany was conducted between October 2021 and January 2022. The intervention group was instructed to use ACTICORE1 for 6 min daily to train the pelvic floor for 12 weeks. The control group was instructed not to do any pelvic floor training. Over 18-year-old men and women with urinary incontinence and an International Consultation on Incontinence Questionnaire score (ICIQ) of ≥5 were included in the study. The primary endpoint was the ICIQ score 12 weeks after enrollment. The secondary endpoints were the ICIQ score and quality of life using the EG-5D-3L questionnaire 4, 8, and 12 weeks after patients' enrollment. Results: A total of 40 individuals with urinary incontinence were recruited for the present study (35 females, 5 males; 40% lost to follow-up). In terms of biometric data, both groups did not differ. At 4, 8, and 12 weeks, the ICIQ scores of those in the ACTICORE1 group decreased from 12.9 to 7.5. The ICIQ score in the control group decreased from 11.0 to 10.5. The intraindividual improvement of patients in the ACTICORE group was statistically significant. Conclusion: Biofeedback training with ACTICORE1 significantly reduces symptoms of urinary incontinence after 12 weeks.

High rate of solitary sentinel node metastases identification by fluorescence-guided lymphatic imaging in breast cancer.

BACKGROUND: The lymph node status was shown to be an important prognostic factor for breast cancer, but controversial issues remain. There has been increased focus on optimizing the visualization of lymph nodes for an accurate and selective approach to axillary lymph nodes. Fluorescence-guided lymphatic imaging is a potential candidate for further research on remaining controversies. METHODS: Forty-seven patients were subject to injection of indocyanine green for navigation to the SLN based on fluorescent dye retention detection. In two groups, patients either received intended axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) for superstaging or isolated SLNB for minimal-invasive staging. The prospective study was designed to evaluate the technical feasibility with focus on solitary positive SLN. RESULTS: Visualization of lymphatic vessels with bright fluorescence of the SLN was feasible in 46 of 47 patients. Eighteen of 19 nodal positive patients were correctly identified with a sensitivity of 94.7% in all patients after ALND. After immunohistochemistry, in 19 of 25 overall nodal positive patients (76%) the SLN was the only positive lymph node. CONCLUSION: Fluorescence-guided imaging using fluorescence retention detection allows transcutaneous navigation with a high rate of solitary positive SLN identification as an alternative technique for further research.

Ultrastaging of colon cancer by sentinel node biopsy using fluorescence navigation with indocyanine green.

PURPOSE: Lymph node status is the most important prognostic factor in colon cancer, but the role of sentinel lymph node biopsy (SLNB) as a tool for identification of micrometastatic disease and extraanatomical lymph nodes for adjuvant strategies and a tailored approach still remains unclear. Indocyanine green (ICG) fluorescence detection is a new method for SLNB allowing real-time lymphography and lymph node detection. This study was designed to evaluate the feasibility of fluorescence-guided sentinel lymph node detection in colon carcinoma. METHODS: Twenty six patients with colon adenocarcinoma were prospectively included in this study. Intraoperatively, a peritumorous injection with a mean of 2.0 ml ICG was performed, followed by lymphatic mapping and SLNB. Clinical feasibility, detection rate, and sensitivity of the method were analyzed. RESULTS: No adverse reactions occurred due to the injection of ICG. Overall, ICG fluorescence imaging identified 1.7 sentinel lymph node (SLN) in average in 25 out of 26 patients (detection rate, 96%). Metastatic involvement of the SLN was found in nine out of 11 nodal positive patients by conventional histopathology. The sensitivity of the method was 82% for colon carcinoma, respectively. CONCLUSION: ICG fluorescence imaging is a new, feasible method for SLNB of colon carcinoma and enables ultrastaging with improved accuracy but with limited validity due to the small number of cases. One advantage of this technique is real-time visualization of lymphatic vessels and SLNB without radiation exposure. Further, larger series are necessary to analyze the role of fluorescence-guided SLNB for colon cancer.

Current trends and emerging future of indocyanine green usage in surgery and oncology: a literature review.

Ever since Kitai first performed fluorescent navigation of sentinel lymph nodes (SLNs) using indocyanine green (ICG) dye with a charge-couple device and light emitting diodes, the intraoperative use of near infrared fluorescence has served a critical role in increasing our understanding in various fields of surgical oncology. Here the authors review the emerging role of the ICG fluorophore in the development of our comprehension of the lymphatic system and its use in SLN mapping and biopsy in various cancers. In addition, they introduce the novel role of ICG-guided video angiography as a new intraoperative method of assessing microvascular circulation. The authors attempt to discuss the promising potential in addition to assessing several challenges and limitations in the context of specific surgical procedures and ICG as a whole. PubMed and Medline literature databases were searched for ICG use in clinical surgical settings. Despite ICG's significant impact in various fields of surgical oncology, ICG is still in its nascent stages, and more in-depth studies need to be carried out to fully evaluate its potential and limitations.

One hundred consecutive cases of sentinel lymph node mapping in colon cancer-the results of prospective, single--centre feasibility study with implementation of immunohistochemical staining.

PURPOSE: Although the importance of sentinel node biopsy (SNB) in colon cancer (CC) has not been clearly established, this method is proposed as potentially enabling more appropriate staging by means of immunohistochemistry (IHS). The aim of the study was to evaluate the SNB method used in CC treatment taking into consideration the results of the IHS examination. MATERIALS AND METHODS: In the period from May 2005 to September 2010 in the 1st Department of Surgical Oncology and General Surgery, Wielkopolska Cancer Centre, 100 SNB in CC were performed. Sentinel nodes (SN) were identified intraoperatively with the use of Patent Blue dye. In the case of negative hematoxylin and eosin staining, the SN material was subjected to immunohistochemical examination. Finally, the histopathological findings of sentinel and non-sentinel lymph nodes were compared with the results of the immunohistochemical staining. RESULTS: At least one SN was identified in 99 of 100 patients (99%). The SN was the only place of metastases in 12.1% (12/99) of the patients. The accuracy of SNB in determining the regional lymph node status was 93.9% (93/99). The sensitivity of the method was 83.3% (30/36). The false-negative rate amounted to 16.7% (6/36). Upstaging obtained by the implementation of the immunohistochemical method was 10% (7/70). CONCLUSIONS: The application of the immunohistochemical staining enables upstaging of some patients, potentially benefiting from adjuvant chemotherapy. For full and definitive assessment of SNB in CC, further research is required especially in terms of additional factors determining a patient's eligibility for this procedure.

The Effect of an Abdominal Binder on Postoperative Pain After Laparoscopic Incisional Hernia Repair­A Multicenter, Randomized Pilot Trial (ABIHR-I) of the Intraperitoneal Onlay-Mesh Technique.

BACKGROUND: Incisional hernias with apertures measuring less than 7 cm can generally be treated adequately with the laparoscopic intraperitoneal onlay-mesh (IPOM) technique. The wearing of an abdominal binder after surgery is often recommended in order to promote wound healing and prevent recurrent herniation. We carried out a multicenter, randomized pilot trial to evaluate the utility of abdominal binders. METHODS: The trial was conducted from May 2019 to December 2020. Persons with a laparoscopic IPOM procedure for treatment of an incisional hernia were included in the trial and randomized preoperatively (1:1). The patients in the abdominal binder group wore an abdominal binder during the day for 14 days after surgery, while those in the control group wore no binder. The primary endpoint was pain at rest on postoperative days 1, 2, and 14, as measured on a visual analog scale. The secondary endpoints were overall subjective well-being, the rates of wound infection, recurrence, and complications, mobility, and the rate and size of postoperative seromas (on postoperative days 1, 2, and 14). RESULTS: Forty patients were included. Three were excluded because of conversion to an open surgical technique. The biometric and perioperative data of the abdominal binder group (n = 18) and the control group (n = 19) did not differ to any statistically significant extent. The patients in the binder group had significantly less postoperative pain (F [dfn, dfd]) 4.44, 95% confidence interval [1; 35]; p = 0.042).The patients in the binder group also had better overall subjective well-being and a higher rate of postoperative seroma formation, but these differences did not reach statistical significance. There was less limitation of mobility than in the control group; however, this difference also did not attain statistical significance. CONCLUSION: An abdominal binder may reduce pain after incisional hernia repair with the IPOM technique. The postoperative use of analgesic medication was not measured.

ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy is a selective approach to axillary staging of breast cancer with reduced morbidity. Current detection methods including radioisotope and blue dye show good results but some drawbacks are remaining. Indocyanine green (ICG) fluorescence detection was evaluated as a new method for SLN biopsy in breast cancer allowing both transcutaneous visualization of lymphatic vessels and intraoperative identification of SLN. METHODS: Forty-three women with clinically node negative breast cancer received subareolar injection of ICG for fluorescence detection of SLN. All patients underwent either planned axillary lymph node dissection (ALND) with SLN biopsy or selective SLN biopsy to determine need for ALND. Clinical feasibility, detection rate, sensitivity, and axillary recurrence after isolated SLN biopsy were analyzed. RESULTS: Overall ICG fluorescence imaging identified 2.0 SLN in average in 42 of 43 patients (detection rate: 97.7%). Metastatic involvement of the SLN was found in 17 of 18 nodal positive patients by conventional histopathology (sensitivity: 94.4%). Immunohistochemistry revealed isolated tumor cells in five further cases. There was only one false-negative case in 43 patients (5.6%). In 17 of 23 overall nodal positive patients, the SLN was the only positive lymph node. After a median follow-up of 4.7 years none of the patients presented with axillary recurrence. CONCLUSION: ICG fluorescence imaging is a new method for SLN biopsy in breast cancer with acceptable sensitivity and specificity comparable to conventional methods. One advantage of this technique is that it allows transcutaneous visualization of lymphatic vessels and intraoperative lymph node detection without radioisotope.

Perineal colostomy with spiral smooth muscle graft for neosphincter reconstruction following abdominoperineal resection of very low rectal cancer: long-term outcome.

BACKGROUND: To avoid abdominal colostomy and improve quality of life, several types of anorectal reconstruction following abdominoperineal resection have been proposed. The aim of this study was to assess functional results and the quality of life of patients with very low rectal cancer after abdominoperineal resection and neosphincter reconstruction by perineal colostomy with a colonic muscular cuff. PATIENTS AND METHODS: Twenty-seven patients who had undergone neosphincter reconstruction with a perineal spiral cuff plasty after abdominoperineal resection were included in a retrospective study to evaluate long-term outcome. The functional results were analyzed using anal manometry and the continence score. The quality of life was measured with the global and disease-specific questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 and C38. RESULTS: Median follow-up time was 105 months (range, 18-185 mo). The median Holschneider continence score of the study sample was 13 (continent), with a range of 10 (partially continent) to 16 (continent), thus demonstrating satisfactory functional results. The functional assessment was completed by neosphincter manometry which revealed a median resting vs compression pressure of 40 vs 96 cmH2O with a range of 5 to 81 cmH2O vs 49 to 364 cmH2O. The quality-of-life analyses showed an above-average score for both global health and disease-specific status. CONCLUSION: Spiral cuff colostomy with reconstruction after abdominoperineal resection of very low distal rectal cancer offers a surgical option for a selective group of patients with reasonable functional long-term results and an improved quality of life.

Treatment of benign colorectal strictures by temporary stenting with self-expanding stents.

BACKGROUND: The application of stents in benign colorectal strictures is considered controversial. The aim of the present study was to assess effectiveness and complications associated with colorectal stent placement in benign colorectal disease. PATIENTS AND METHODS: Fourteen patients with benign colorectal strictures who had undergone previous surgery (colorectal anastomotic stenosis, 13; neosphincter scar stenosis, one) were treated with covered self-expanding metal stent or plastic stent. Placement of the stent was performed with combined endoscopy and contrast enhanced fluoroscopy. RESULTS: Self-expanding stents were successful implanted in all 14 patients without acute procedure-related complications. All patients experienced immediate decompression after stent placement with expansion and patency of the stent. Relief of bowel obstruction for at least 12 months was achieved in seven of 14 patients (50%). Anastomotic fistula healed in four of six patients (67%). Despite the initial success of stenting, re-operations had to be performed in two of seven patients because of late recurrence of the stricture after a mean follow-up of 37 months. CONCLUSIONS: Temporary insertion of self-expanding stents is a safe procedure that may be effective in selected cases of benign colorectal stricture. However, repeat surgery will be necessary in a considerable number of patients due to primary or secondary failure of stenting.

Upgrade of an optical navigation system with a permanent electromagnetic position control: a first step towards "navigated control" for liver surgery.

INTRODUCTION: The main problems of navigation in liver surgery are organ movement and deformation. With a combination of direct optical and indirect electromagnetic tracking technology, visualisation and positional control of surgical instruments within three-dimensional ultrasound data and registration of organ movements can be realised simultaneously. METHODS: Surgical instruments for liver resection were localised with an infrared-based navigation system (Polaris). Movements of the organ itself were registered using an electromagnetic navigation system (Aurora). The combination of these two navigation techniques and a new surgical navigation procedure focussed on a circumscribed critical dissection area were applied for the first time in liver resections. RESULTS: This new technique was effectively implemented. The position of the surgical instrument was localised continuously. Repeated position control with observation of the navigation screen was not necessary. During surgical resection, a sonic warning signal was activated when the surgical instrument entered a "no touch" area--an area of reduced safety margin. CONCLUSION: Optical tracking of surgical instruments and simultaneous electromagnetic registration of organ position is feasible in liver resection.

Laparoscopic Treatment of an Incarcerated Meckel's Diverticulum in a Femoral Hernia.

Meckel's diverticulum (MD) is the persistence of the omphalomesenteric duct. It is usually asymptomatic but may present with bleeding, infections, and intestinal obstruction. It also may be a content of a hernia sac, a so-called Littre hernia. Herein, we will present the case of a 75-year-old female, who suffered from a painful swelling of the right inguinal region. Ultrasound imaging detected an inguinal hernia with incarcerated blind ending small bowel. Immediately, a laparoscopy was conducted. We diagnosed a right femoral hernia with an incarcerated MD. A TAPP (transabdominal preperitoneal) procedure was performed and the MD tangential stapled. Due to an uneventful postoperative course, the patient left the hospital after two days. An incarceration of a MD in a femoral hernia is rare. Tangential resection of the MD with simultaneous hernia repair in a TAPP technique seems to be a sufficient approach, when it is conducted by an experienced surgeon.

Construct validity testing of a laparoscopic surgery simulator (Lap Mentor): evaluation of surgical skill with a virtual laparoscopic training simulator.

BACKGROUND: Before surgical simulators can be implemented for assessment of surgical training, their construct validity should be assessed. METHODS: Nine novices (NOV), nine medical students (MS), and nine residents (RES) underwent a laparoscopic skills training on the virtual reality (VR) simulator Lap Mentor. Assessment of laparoscopic skill was based on parameters measured by the computer system before and after training. RESULTS: Significant difference existed between RES and NOV at seven of nine tasks before training on the VR simulator. After the training in some tasks significant differences were observed between the experienced group (RES) and the nonexperienced groups (MS and NOV) or between medical groups (RES and MS) and nonmedical group (NOV). CONCLUSIONS: Performance parameters of the Lap-Mentor can be used to distinguish between subjects with varying laparoscopic experience.

Response to preoperative short-course radiotherapy in locally advanced rectal cancer: value of f-fluorodeoxyglucose positron emission tomography.

BACKGROUND: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is increasingly used to monitor response to multimodality cancer treatment. Preoperative short-course radiotherapy (SCRT) has been shown to improve outcome in locally advanced rectal cancer (LARC). We evaluated the value of FDGPET in monitoring response to SCRT. PATIENTS AND METHODS: 32 patients with LARC scheduled for SCRT underwent FDG-PET, magnetic resonance imaging and endorectal ultrasound both before and after SCRT. A comparison group of 16 patients, undergoing preoperative radiochemotherapy (RCT), received an extra FDG-PET 17 days after starting RCT (effective dose of 30.6 Gy). For response assessment, FDG uptake (maximum standardized uptake value, SUVmax), percent SUVmax difference, tumor regression grade (TRG), and UICC downstaging and downsizing were considered. RESULTS: SCRT resulted in a significant median SUVmax reduction of 39.3%. Median SUVmax reduction did differ between SCRT and the early scans after 17 days of RCT (39.3 vs. 50.8%). Downstaging after SCRT was observed in 16/32, downsizing in 7/32 patients. There was no correlation between SUVmax reduction and downstaging/ downsizing or TRG. CONCLUSION: For the first time, we were able to demonstrate functional response after SCRT. In contrast to morphological imaging and histopathology, our results indicate that FDG-PET can monitor early effects of SCRT. Further followup is warranted to establish SUVmax reduction as a surrogate marker for the response of SCRT.

Use of fiberoductoscopy for the management of patients with pathological nipple discharge: experience of a single center in Poland.

BACKGROUND: Pathological nipple discharge (PND) is associated with serious clinical and diagnostic issues. Fiberoductoscopy (FDS) is a new diagnostic option in PND patients. This study summarizes our initial experience of FDS for the management of PND patients in a single center in Poland and assesses its safety. METHODS: A total of 256 women with PND were included in this prospective, case-controlled, single-center study between 2006 and 2014. Of the 250 patients who underwent FDS, 154 had mammary duct lesions and 96 had no visible lesions. Subsequently, 129 patients with lesions identified by FDS underwent microductectomy and the lesions were pathologically evaluated. RESULTS: The mean duration of FDS examination was 17 min. The most frequent intraductal lesion was amputation of a duct (35.1%), followed by circular narrowing or hyperplasia (22.7%). Final histological findings were unremarkable in 11.6% of cases, whereas mammary duct papilloma, duct ectasia, and ductal carcinoma in situ were detected in 71.3, 10.9, and 6.2% of cases, respectively. CONCLUSIONS: FDS is an innovative method for visualizing intraductal mammary lesions and allows accurate selection of mammary ducts with suspicious lesions that require surgical removal in women with PND.

Bilirubin, urobilinogen, pancreas elastase and bile acid in drain fluid. The GBUP-study: Analysis of biomarkers for a colorectal anastomotic leakage.

PURPOSE: A colorectal anastomotic leakage (CAL) is a major complication after colorectal surgery and leads to high rates of morbidity and prolonged hospital stay. The study aims to evaluate the benefit of using bilirubin, urobilinogen, pancreas elastase and bile acid in the drain fluid (DF) as a predictive marker for the CAL. METHODS: From June 2015 to October 2017 100 patients, who underwent left hemicolectomy (LH), sigma resection (SR), high anterior resection (HAR), low anterior resection (LAR) or reversal of Hartmann's Procedure (ROHP) were included in this monocentric non-randomized prospective clinical trial. During the first four postoperative days (POD) the concentration of bilirubin, urobilinogen, pancreas elastase and bile acid in the DF was measured. RESULTS: In total 100 patients were recruited. 17 were excluded due to intraoperative decisions to conduct a protective stoma. 6 patients had a CAL. The patients of the control group (n = 77) and the patients who suffered from a CAL (n = 6) had no increased concentration of urobilinogen and pancreas elastase in the DF. The concentration of bile acid in the DF of the patients who suffered from a CAL differed from those of the control group on the 4th POD (p = 0.055).The concentration of bilirubin in the DF of the patients who suffered from a CAL significantly differed from those of the control group on the 1st POD (p = 0.031) and on the 3rd POD (p = 0.041). CONCLUSION: Bilirubin and bile acid in the DF may function as a predictive marker for a CAL.

Intraoperative ductoscopy in women undergoing surgery for breast cancer.

BACKGROUND: Extensive intraductal disease represents an important clinical problem in the management of patients with invasive or in situ breast cancer. The purpose of this study was to determine the value of intraoperative ductoscopy for detection of intraductal neoplasia in women with breast cancer. METHODS: Intraoperative ductoscopy was performed in 54 women undergoing operation for breast cancer. A rigid gradient index microendoscope (0.7 mm) was used for all examinations. Ductoscopy findings were documented prospectively and correlated with preoperative mammography and histology of the resection specimen. RESULTS: Fifty of 54 (92%) patients were examined successfully. Ductoscopy identified intraductal lesions (ie, red patches, ductal obstruction, or microcalcifications) in 25 of 50 (50%) patients. Abnormal ductoscopic appearance was found in 19 of 23 patients with extensive intraductal disease (82%). Mammographic microcalcifications were observed in 15 of those 19 patients and in 3 patients with normal ductoscopy (78%). The combined sensitivity of both methods was 95%. Patients with an abnormal ductal appearance on ductoscopy, compared with those with a normal ductal appearance, had a greater incidence of extensive intraductal spread of cancer (76% vs 16%) and a greater incidence of positive surgical margins (44% vs 12%). CONCLUSIONS: High-resolution ductoscopy is able to detect extensive intraductal disease in a considerable number of women with breast cancer. In selected patients, a combination of both preoperative imaging and intraoperative ductoscopy may help to avoid incomplete resections and re-excisions.