The impact of prior endoscopic or surgical therapy on open Zenker's diverticulum surgery: analysis on a large single center cohort : Comparison of primary and revisional open surgery for Zenker's diverticulum.

BACKGROUND: Endoscopic treatment of Zenker's diverticulum is an attractive minimally invasive alternative compared to the classic open approach. However, increased recurrence rate were reported. In case of relapse, endoscopic therapy might be repeated, or alternatively open surgery is performed. This study aimed to identify potential differences in the outcomes between primary or secondary surgical treatment in Zenker's diverticulum. METHODS: From January 2003 to April 2019, 227 subsequent patients underwent surgical diverticulectomy and cervical myotomy at the surgical department of TUM. 41 of 227 patients had received previous therapy, either open or endoscopic. Perioperative parameters in priorly untreated patients were retrospectively compared to those after previous therapy (mostly endoscopic) with special regard to perioperative data and postoperative complications. Univariate and multivariate regression analyses were performed to identify predictors for postoperative complications. RESULTS: We could show that the number of complications (p = 0.047) in pretreated patients is significant higher as well as the severity after Clavien-Dindo (p = 0.025). Stapler line leakage, wound infections, and operative revision rate was higher also pretreated group. Pretreatment and surgery time showed a significant association with postoperative complications in univariate analysis. In multivariate analysis, pretreatment remained a significant independent predictor of complications. CONCLUSION: The present data indicate that endoscopic therapy might represent a risk factor for postoperative complications in case of relapse surgery. Therefore primary open surgery should be debated in patients with an increased high risk of relapse.

Emergency Telemedicine Mobile Ultrasounds Using a 5G-Enabled Application: Development and Usability Study.

BACKGROUND: Digitalization affects almost every aspect of modern daily life, including a growing number of health care services along with telemedicine applications. Fifth-generation (5G) mobile communication technology has the potential to meet the requirements for this digitalized future with high bandwidths (10 GB/s), low latency (<1 ms), and high quality of service, enabling wireless real-time data transmission in telemedical emergency health care applications. OBJECTIVE: The aim of this study is the development and clinical evaluation of a 5G usability test framework enabling preclinical diagnostics with mobile ultrasound using 5G network technology. METHODS: A bidirectional audio-video data transmission between the ambulance car and hospital was established, combining both 5G-radio and -core network parts. Besides technical performance evaluations, a medical assessment of transferred ultrasound image quality and transmission latency was examined. RESULTS: Telemedical and clinical application properties of the ultrasound probe were rated 1 (very good) to 2 (good; on a 6 -point Likert scale rated by 20 survey participants). The 5G field test revealed an average end-to-end round trip latency of 10 milliseconds. The measured average throughput for the ultrasound image traffic was 4 Mbps and for the video stream 12 Mbps. Traffic saturation revealed a lower video quality and a slower video stream. Without core slicing, the throughput for the video application was reduced to 8 Mbps. The deployment of core network slicing facilitated quality and latency recovery. CONCLUSIONS: Bidirectional data transmission between ambulance car and remote hospital site was successfully established through the 5G network, facilitating sending/receiving data and measurements from both applications (ultrasound unit and video streaming). Core slicing was implemented for a better user experience. Clinical evaluation of the telemedical transmission and applicability of the ultrasound probe was consistently positive.

Effective operating room (OR) utilization by performing low-complex surgical procedures during the 2020 corona pandemic.

PURPOSE: The SARS-CoV-2 pandemic has almost stopped all elective surgical treatment throughout the world. As operating room (OR) capacities are reduced everywhere to ensure availability of intensive care capacities, especially low-complex surgical procedures are often postponed. These include totally implantable central-venous access ports which are important for the oncologic treatment of cancer patients. METHODS: In our study, we investigated the potential of an outpatient surgical centre (OSC) in terms of workflow effectiveness compared to the central operating room complex (COR) of a university hospital using low-complex surgical procedures as an example. Data of 524 consecutive patients who received a Port-a-cath procedure (422 implantations (80.5%) and 102 explantations (19.5%)) in our department between February 2019 and February 2020 were evaluated. RESULTS: A total of 277 patients were operated in outpatient surgical centre (OSC), and 247 patients received the procedure in the central OR (COR) complex. Grade II and III complications according to the Clavien-Dindo classification occurred in 5.2% (OSC) and 7.3% (COR) of patients. Incision-to-suture time was significantly quicker in the OSC group (36 vs. 42 min., p < 0.032). Total OR time (01:08 vs. 01:20 h) and preparation-to-incision time were also shorter in the OSC group (12 vs. 17 min., p < 0.002). CONCLUSION: In order to ensure effective OR utilization especially in times of the corona pandemic, the use of smaller decentralized OR units, e.g., outpatient surgical centres, for performing low-complex surgical cases is beneficial. Our study revealed shorter total OR and preparation-to-incision times.

Machine Learning in the OR: A Collaborative Environment for Surgical Interventions in Visceral Medicine.

Modern surgical methods are becoming increasingly sophisticated and the number of technical devices that are used during these interventions is increasing. However, the surgical operating room (OR) remains a mere conglomerate of unconnected medical devices. The increase in the complexity of device functionality, in addition to the demands of surgery, pushes human mental capacity to its limit. Hence, an "intelligent" collaborative support system would be more than welcome. We envision a "human-like" intelligent system, which could support the surgical team as a situation-aware consultant. This so-called "active collaborative support system" (ACSS) is based on four main pillars: real-time data inflow, a comprehensive knowledge-base, access to the Internet of Things (surgical devices), and an understanding of human language through natural language processing. Recent advances in the area of AI are bringing this ambitious goal within reach, but there is still a considerable amount of work to be done, including the establishment of a new way of thinking in the collaboration between surgeons and computer scientists/engineers, and possibly one day with intelligent machines-provided that AI systems can be sufficiently trusted.

5th-Generation Mobile Communication: Data Highway for Surgery 4.0.

INTRODUCTION: 5th generation cellular mobile communications (5G) is one of the main requirements for the digital future. The new standard will offer high bandwidths (10GB/s), low latency (<1ms), and a high quality of service. It is not yet known whether 5G performance is sufficient for demanding eHealth applications (e.g., telemedicine). MATERIAL AND METHODS: We evaluated 5G performance in two different medical applications (person/asset track & tracing and video data transmission for telesurgery) to appraise the impact of this new technology. In addition, a Delphi study was conducted evaluating the expectations and acceptance of 5G in the medical field in general. RESULTS: Delphi study revealed that 5G has great potential for the future information transfer in the healthcare domain, and an increase of research activities for 5G applications in hospitals is needed. Clinical evaluation proved technical feasibility and accuracy of the 5G track & trace prototype solution. For the telepresence use case, the video stream data rate varied between 900KB-1MB/s (7.2-8 Mb/s). The data rate of the robotic control command varied between 2.4-7.2KB/s (19.2-57.6Kb/s). Delay time (latency) ranged between 2-60ms depending on the transmitted data packet length. Seventy-five percent of data packets were processed after 30ms. CONCLUSION: 5G data transmission volume, rate, and latency met the requirements for real-time track & trace and telemedicine applications. Especially for the latter, 5G data transmission offers a high potential and further research should be carried out.

Enhanced Visualization: From Intraoperative Tissue Differentiation to Augmented Reality.

BACKGROUND: Optimal visualization of the operative field and methods that additionally provide supportive optical information form the basis for target-directed and successful surgery. This article strives to give an overview of current enhanced visualization techniques in visceral surgery and to highlight future developments. METHODS: The article was written as a comprehensive review on this topic and is based on a MEDLINE search and ongoing research from our own group and from other working groups. RESULTS: Various techniques for enhanced visualization are described comprising augmented reality, unspecific and targeted staining methods, and optical modalities such as narrow-band imaging. All facilitate our surgical performance; however, due to missing randomized controlled studies for most of the innovations reported on, the available evidence is low. CONCLUSION: Many new visualization technologies are emerging with the aim to improve our perception of the surgical field leading to less invasive, target-oriented, and elegant treatment forms that are of significant benefit to our patients.

Surgical data processing for smart intraoperative assistance systems.

Different components of the newly defined field of surgical data science have been under research at our groups for more than a decade now. In this paper, we describe our sensor-driven approaches to workflow recognition without the need for explicit models, and our current aim is to apply this knowledge to enable context-aware surgical assistance systems, such as a unified surgical display and robotic assistance systems. The methods we evaluated over time include dynamic time warping, hidden Markov models, random forests, and recently deep neural networks, specifically convolutional neural networks.

Endoluminal perforation of a magnetic antireflux device.

BACKGROUND: The history of surgical antireflux treatment is coined by the search for better alternatives to Nissen fundoplication. Implantable devices are one option, beginning with the "Angelchik" prosthesis 30 years ago. However, this procedure was left soon because of the high rate of foreign body connected problems (migration, perforation). A modern approach is a magnetic sphincter augmentation device (LINX Reflux Management System, Torax Medical, Shoreview, MN, USA), a magnetic chain which is implanted laparoscopically. Advantages reported are simplicity to apply and good results in reflux control, with up to now only rare complication rates as reported in the literature (Lipham et al. in Dis Esophagus, 2014). METHODS: We report one case of erosion of the esophagus by a LINX system resulting in severe dysphagia. RESULTS: A complete endoluminal removal could be achieved by a prototype OTSC-clip remover. Complete remission could be achieved. The technique is presented in detail (video). CONCLUSIONS: In principle, total endoscopic removal of the LINX device is feasible in case of major erosion.

Developments in flexible endoscopic surgery: a review.

Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel - for long a "white spot" for gastrointestinal endoscopy - and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.