Millifluidic magnetophoresis-based chip for age-specific fractionation: evaluating the impact of age on metabolomics and gene expression in yeast.

A novel millifluidic process introduces age-based fractionation of S. pastorianus var. carlsbergensis yeast culture through magnetophoresis. Saccharomyces yeast is a model organism for aging research used in various industries. Traditional age-based cell separation methods were labor-intensive, but techniques like magnetic labeling have eased the process by being non-invasive and scalable. Our approach introduces an age-specific fractionation using a 3D-printed millfluidic chip in a two-step process, ensuring efficient cell deflection in the magnetic field and counteracting magnetic induced convection. Among various channel designs, the pinch-shaped channel proved most effective for age differentiation based on magnetically labeled bud scar numbers. Metabolomic analyses revealed changes in certain amino acids and increased NAD+ levels, suggesting metabolic shifts in aging cells. Gene expression studies further underlined these age-related metabolic changes. This innovative platform offers a high-throughput, non-invasive method for age-specific yeast cell fractionation, with potential applications in industries ranging from food and beverages to pharmaceuticals.

The first robotic-assisted hysterectomy below the bikini line with the Dexter robotic system™.

Background: Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™. Objectives: The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform. Materials and Methods: A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany. Main outcome measures: Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach. Results: The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day. Conclusion: RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.

Two sides of the same coin? The association between suicide stigma and suicide normalisation.

AIMS: Evidence suggests that suicide stigma (i.e. negative attitudes towards persons affected by suicide/suicidality) and suicide normalisation (i.e. liberal attitudes towards suicide) are both associated with increased suicide risk. Despite conceptual similarities and potential interaction, suicide stigma and suicide normalisation have usually been investigated separately. We used cross-sectional data from a community sample to test the association between suicide stigma and suicide normalisation as well as to identify their respective determinants and consequences. METHODS: Participants were N = 3.269 adults recruited from an established online-panel using quotas to reflect the composition of the German general population with regard to age, gender, education and region. We collected information about suicide stigma, suicide normalisation, intentions to seek help for suicidality, current suicidality, suicide literacy, negative mood and socio-demographic variables. We used regression modelling to determine the association between suicide stigma and suicide normalisation as well as to identify their determinants and consequences. RESULTS: Suicide stigma and suicide normalisation were inversely associated so that higher suicide stigma scores were linked to lower suicide normalisation. More suicide stigma was associated with reduced intentions to seeking professional help, increased willingness to seek help from family and friends and lower odds to experience current suicidality, however the association between suicide stigma and intentions to seek professional help diminished after controlling for confounding variables. Increased suicide normalisation was linked to reduced intentions to seek help from professionals or family and friends, as well as higher odds to experience current suicidality, even after controlling for confounding variables. CONCLUSIONS: Our findings suggest that interventions to reduce public suicide stigma are at risk to unintentionally increase suicide normalisation, which appears to be a key barrier to seeking help for suicidality. Future research should therefore identify strategies to improve attitudes towards persons affected by suicidality that avoid normalisation, i.e. do not convey the message of suicide as an acceptable solution for difficult life situations. One strategy with great potential to safely reduce public suicide sigma could be interventions that stimulate interpersonal contact with affected persons sharing their recovery story.

Spacecraft sample collection and subsurface excavation of asteroid (101955) Bennu.

Carbonaceous asteroids, such as (101955) Bennu, preserve material from the early Solar System, including volatile compounds and organic molecules. We report spacecraft imaging and spectral data collected during and after retrieval of a sample from Bennu's surface. The sampling event mobilized rocks and dust into a debris plume, excavating a 9-meter-long elliptical crater. This exposed material is darker, spectrally redder, and more abundant in fine particulates than the original surface. The bulk density of the displaced subsurface material was 500 to 700 kilograms per cubic meter, which is about half that of the whole asteroid. Particulates that landed on instrument optics spectrally resemble aqueously altered carbonaceous meteorites. The spacecraft stored 250 ± 101 grams of material, which will be delivered to Earth in 2023.

Perovskite-organic tandem solar cells with indium oxide interconnect.

Multijunction solar cells can overcome the fundamental efficiency limits of single-junction devices. The bandgap tunability of metal halide perovskite solar cells renders them attractive for multijunction architectures1. Combinations with silicon and copper indium gallium selenide (CIGS), as well as all-perovskite tandem cells, have been reported2-5. Meanwhile, narrow-gap non-fullerene acceptors have unlocked skyrocketing efficiencies for organic solar cells6,7. Organic and perovskite semiconductors are an attractive combination, sharing similar processing technologies. Currently, perovskite-organic tandems show subpar efficiencies and are limited by the low open-circuit voltage (Voc) of wide-gap perovskite cells8 and losses introduced by the interconnect between the subcells9,10. Here we demonstrate perovskite-organic tandem cells with an efficiency of 24.0 per cent (certified 23.1 per cent) and a high Voc of 2.15 volts. Optimized charge extraction layers afford perovskite subcells with an outstanding combination of high Voc and fill factor. The organic subcells provide a high external quantum efficiency in the near-infrared and, in contrast to paradigmatic concerns about limited photostability of non-fullerene cells11, show an outstanding operational stability if excitons are predominantly generated on the non-fullerene acceptor, which is the case in our tandems. The subcells are connected by an ultrathin (approximately 1.5 nanometres) metal-like indium oxide layer with unprecedented low optical/electrical losses. This work sets a milestone for perovskite-organic tandems, which outperform the best p-i-n perovskite single junctions12 and are on a par with perovskite-CIGS and all-perovskite multijunctions13.

Bariatric surgery in liver cirrhosis.

Introduction: Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial. Material and Methods: Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed. Results: Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation. Conclusion: BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Dynamic slab segmentation due to brittle-ductile damage in the outer rise.

Subduction is the major plate driving force, and the strength of the subducting plate controls many aspects of the thermochemical evolution of Earth. Each subducting plate experiences intense normal faulting1-9 during bending that accommodates the transition from horizontal to downwards motion at the outer rise at trenches. Here we investigate the consequences of this bending-induced plate damage using numerical subduction models in which both brittle and ductile deformation, including grain damage, are tracked and coupled self-consistently. Pervasive slab weakening and pronounced segmentation can occur at the outer-rise region owing to the strong feedback between brittle and ductile damage localization. This slab-damage phenomenon explains the subduction dichotomy of strong plates and weak slabs10, the development of large-offset normal faults6,7 near trenches, the occurrence of segmented seismic velocity anomalies11 and distinct interfaces imaged within subducted slabs12,13, and the appearance of deep, localized intraplate areas of reduced effective viscosity14 observed at trenches. Furthermore, brittle-viscously damaged slabs show a tendency for detachment at elevated mantle temperatures. Given Earth's planetary cooling history15, this implies that intermittent subduction with frequent slab break-off episodes16 may have been characteristic for Earth until more recent times than previously suggested17.

[Implementation of the principle of supported employment in Germany : Position paper of a task force of the DGPPN]. / Umsetzung der Prinzipien des Supported Employment in Deutschland : Positionspapier einer Task-Force der DGPPN.

The effects of mental diseases on the employment and working situation can be substantial. They are one of the main reasons for inability to work and reduced earning capacity. Against this background the question arises about suitable occupational reintegration measures for people with severe mental illnesses. In recent years, the principle of supported employment has been internationally shown to be increasingly more successful. In this context mentally ill people are primarily placed at a position of the first employment market and supported on-site by a job coach. This concept is inclusive, individual and evidence based. Despite proven effectiveness, it has so far been insufficiently implemented in German-speaking regions. In the future it will be a matter of considering the individual needs for assistance of mentally ill people more intensively than previously and to respond with functional and in a best-case scenario, multiprofessional and flexible offers.

Variations in color and reflectance on the surface of asteroid (101955) Bennu.

Visible-wavelength color and reflectance provide information about the geologic history of planetary surfaces. Here we present multispectral images (0.44 to 0.89 micrometers) of near-Earth asteroid (101955) Bennu. The surface has variable colors overlain on a moderately blue global terrain. Two primary boulder types are distinguishable by their reflectance and texture. Space weathering of Bennu surface materials does not simply progress from red to blue (or vice versa). Instead, freshly exposed, redder surfaces initially brighten in the near-ultraviolet region (i.e., become bluer at shorter wavelengths), then brighten in the visible to near-infrared region, leading to Bennu's moderately blue average color. Craters indicate that the time scale of these color changes is ~105 years. We attribute the reflectance and color variation to a combination of primordial heterogeneity and varying exposure ages.

An enhanced prognostic score for overall survival of patients with cancer derived from a large real-world cohort.

BACKGROUND: By understanding prognostic biomarkers, we gain insights into disease biology and may improve design, conduct, and data analysis of clinical trials and real-world data. In this context, we used the Flatiron Health Electronic Health Record-derived deidentified database that provides treatment outcome and biomarker data from >280 oncology centers in the USA, organized into 17 cohorts defined by cancer type. PATIENTS AND METHODS: In 122 694 patients, we analyzed demographic, clinical, routine hematology, and blood chemistry parameters within a Cox proportional hazard framework to derive a multivariable prognostic risk model for overall survival (OS), the 'Real wOrld PROgnostic score (ROPRO)'. We validated ROPRO in two independent phase I and III clinical studies. RESULTS: A total of 27 variables contributed independently and homogeneously across cancer indications to OS. In the largest cohort (advanced non-small-cell lung cancer), for example, patients with elevated ROPRO scores (upper 10%) had a 7.91-fold (95% confidence interval 7.45-8.39) increased death hazard compared with patients with low scores (lower 10%). Median survival was 23.9 months (23.3-24.5) in the lowest ROPRO quartile Q1, 14.8 months (14.4-15.2) in Q2, 9.4 months (9.1-9.7) in Q3, and 4.7 months (4.6-4.8) in Q4. The ROPRO model performance indicators [C-index = 0.747 (standard error 0.001), 3-month area under the curve (AUC) = 0.822 (0.819-0.825)] strongly outperformed those of the Royal Marsden Hospital Score [C-index = 0.54 (standard error 0.0005), 3-month AUC = 0.579 (0.577-0.581)]. We confirmed the high prognostic relevance of ROPRO in clinical Phase 1 and III trials. CONCLUSIONS: The ROPRO provides improved prognostic power for OS. In oncology clinical development, it has great potential for applications in patient stratification, patient enrichment strategies, data interpretation, and early decision-making in clinical studies.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination.

BACKGROUND: The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services. METHODS: We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases. RESULTS: We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare. CONCLUSIONS: Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Lazy Sundays: role of day of the week and reactivity on objectively measured physical activity in older people.

BACKGROUND: The aim of this study was to assess the effect of day of the week and wearing a device (reactivity) on objectively measured physical activity (PA) in older people. METHODS: Walking duration as a measure for PA was recorded from 1333 German community-dwelling older people (≥65 years, 43.8% women) over 5 days using accelerometers (activPAL). Least-square means of PA with 95%-confidence intervals (95%-CI) from multi-level analysis were calculated for each day of the week and each measurement day (days after sensor attachment). RESULTS: Walking duration on Sundays was significantly lower compared to working days (Sunday vs. Monday-Friday: - 12.8 min (95%-CI: - 14.7; - 10.9)). No statistically significant difference compared to working days was present for Saturdays. The linear slope for measurement day and walking duration was marginal and not statistically significant. CONCLUSIONS: Studies using PA sensors in older people should assess Sundays and working days to adequately determine the activity level of the participants.

The predictive and prognostic significance of liquid biopsy in advanced epidermal growth factor receptor-mutated non-small cell lung cancer: A prospective study.

OBJECTIVE: To determine the predictive and prognostic roles of three blood-based biomarkers: circulating tumour DNA (ctDNA), circulating tumour cells (CTC) and carcinoembryonic antigen (CEA), in patients with advanced epidermal growth factor receptor-mutated (EGFR+) lung cancer. MATERIALS AND METHODS: We recruited 28 patients with 103 serial blood samples. We performed mutational analyses for EGFR mutations using droplet digital PCR (ddPCR) on ctDNA. We evaluated the accuracy of EGFR mutation detection in ctDNA compared with tissue biopsy. We also quantified CTCs, ctDNA and CEA in serially collected blood samples, and evaluated the baseline and changes in these blood-based biomarkers with clinical outcomes. RESULTS: EGFR mutation detection in plasma was highly concordant as compared with tissue biopsy. Detectable baseline ctDNA was associated with higher disease burden (p < 0.01). Early disappearance of ctDNA at 4 weeks was associated with radiological response at 12 weeks of treatment (p = 0.01) and improved progression free survival (PFS) (HR 5.47, 95%CI 1.32-22.72, p = 0.02) and overall survival (OS) (HR 5.46, 95%CI 1.28-23.22, p = 0.02). A decrease in CTC count at 4 weeks was associated with improved PFS (HR 3.81, 95%CI 1.13-12.79, p = 0.03) but not OS. 85% of patients with radiological progression had a ctDNA rise compared with 22% of patients with stable disease (p=0.01). ctDNA rise was seen on average 170 days prior to radiological progression. There is a significant association between the rise of CEA level with radiological progression (p=0.001). CONCLUSION: Early change in ctDNA, CTC and CEA levels may be long-term predictors of treatment benefit and failure prior to availability of radiological response data.

Cohort-level disease prediction by extrapolation of individual-level predictions in transition dairy cattle.

Dairy cattle experience metabolic stress during the transition from late gestation to early lactation resulting in higher risk for several economically important diseases (e.g. mastitis, metritis, and ketosis). Metabolic stress is described as a physiological state composed of 3 processes: nutrient metabolism, oxidative stress, and inflammation. Current strategies for monitoring transition cow nutrient metabolism include assessment of plasma non-esterified fatty acids and beta-hydroxybutyrate concentrations around the time of calving. Although this method is effective at identifying cows with higher disease risk, there is often not enough time to implement intervention strategies to prevent health disorders from occurring around the time of calving. Previously, we published predictive models for early lactation diseases at the individual cow level at dry-off. However, it is unknown if predictive probabilities from individual-level models can be aggregated to the cohort level to predict cohort-level incidence. Therefore, our objective was to test different data aggregation methods using previously published models that represented the 3 components of metabolic stress (nutrient metabolism, oxidative stress, and inflammation). We included 277 cows from five Michigan dairy herds for this prospective cohort study. On each farm, two to four calving cohorts were formed, totaling 18 cohorts. We measured biomarker data at dry-off and followed the cows until 30 days post-parturition for cohort disease incidence, which was defined as the number of cows: 1) having one or more clinical transition disease outcome, and/or 2) having an adverse health event (abortion or death of calf or cow) within each cohort. We tested three different aggregation methods that we refer to as the p-central, p-dispersion, and p-count methods. For the p-central method, we calculated the averaged predicted probability within each cohort. For the p-dispersion method, we calculated the standard deviation of the predicted probabilities within a cohort. For the p-count method, we counted the number of cows above a specified threshold of predicted probability within each cohort. We built four sets of models: one for each aggregation method and one that included all three aggregation methods (p-combined method). We found that the p-dispersion method was the only method that produced viable predictive models. However, these models tended to overestimate incidence in cohorts with low observed counts and underestimate risk in cohorts with high observed counts.

Cohort-level disease prediction using aggregate biomarker data measured at dry-off in transition dairy cattle: A proof-of-concept study.

During the transition from late gestation to early lactation, dairy cattle are at increased risk for disease. Herd-level monitoring for disease risk involves evaluating multiple factors, including food intake, cow density, and biomarkers of nutrient metabolism. Biomarkers that are measured include non-esterified fatty acids (NEFA) and beta-hydroxybutyrate (BHB), which are usually measured in a subset of the herd (i.e. cohort). If a certain proportion of cows in the cohort are above a specific threshold for a biomarker, the cohort is considered at high risk of disease. Few previous studies have investigated other methods to aggregate individual cow-level data to the cohort level. We designed a proof-of-concept study to determine if biomarker aggregation methods may be useful to predict cohort incidence of adverse health events including 1) clinical diseases: mastitis, metritis, retained placenta, ketosis, lameness, pneumonia, milk fever, displaced abomasum, 2) and abortion or death of the calf or the cow. The study design was a prospective cohort study that used cows (N = 277) from five Michigan commercial dairy herds. Multiple cohorts of cows (two to four cohorts per farm, 18 total) were enrolled that shared the same dry-off date. We tested three different methods (central, dispersion, and count) to aggregate individual cow data (i.e. biomarkers and covariates) measured at dry-off. The central method consisted of calculating the average value of each variable within a cohort, and the dispersion method involved taking the standard deviation or mean absolute deviation about the median of each variable within a cohort. The count method consisting of counting the number of cows above a specific threshold for each variable within a cohort. We used best subsets selection to select a bouquet of candidate models for each aggregation method and averaged the predictions over the model set. We built 4 sets of Poisson regression models: one for each aggregation method and a combined model that included all three methods. We evaluated the models based on goodness-of-fit, model calibration using scoring rules, and comparison of observed versus predicted counts. The central and the combined method produced models that had good fit and model calibration. These results indicate that it may be possible to use aggregate measures to predict cohort disease incidence as early as dry-off. The next step is to test biomarker aggregation methods in studies with larger sample sizes.

Application of confocal, SHG and atomic force microscopy for characterizing the structure of the most superficial layer of articular cartilage.

The surface of articular cartilage plays a crucial role in attenuating and transmitting mechanical loads in synovial joints to facilitate painless locomotion. Disruption to the surface of articular cartilage causes changes to its frictional properties instigating the deterioration of the tissue. In this study, we physically peeled the most superficial layer, a transparent membrane of 20.0 ± 4.7 µm thick, from the central loading region of femoral condyles of sheep. The ultrastructure of this layer without interference from the underlying cartilage was independently investigated using confocal, second harmonic generation and atomic force microscopy. We found that the most superficial layer contains chondrocytes, densely packed collagen, coarse elastic fibres and a fine elastic network. The elastic fibres are most prevalent at the surface of the layer, where collagen and chondrocyte densities are lowest. At the interface of this most superficial layer with the underlying bulk cartilage, a dense fibrillar network exists, formed mainly by collagen fibrils and elastin microfibrils. By contrast, the interface of the underlying cartilage with the most superficial layer contains collagen fibrils, fine microfibrils and microfibrils distinctively laced on one side. The findings of this study will play an important role in understanding the mechanical function and wear resistance of articular cartilage, and in developing more promising tissue engineering techniques to treat cartilage defects and osteoarthritis. LAY DESCRIPTION: The chronic pain and dysfuction in synovial joints caused by osteoarthritis can have a debilitating impact on daily activities for sufferers. Osteoarthritis is characterised by the deterioration of the articular cartilage. Despite intensive research, the wear mechanism of articular cartilage and the progression of osteoarthritis remain unclear in the literature. Articular cartilage is a resilient tissue that provides a low friction surface to facilitate painless locomotion. The surface of articular cartilage plays a crucial role in attenuating and transmitting mechanical loads. Disruption at the surface of articular cartilage causes changes to its frictional properties, instigating the deterioration of the tissue. Despite this, the definition of the most superficial layer of articular cartilage, as well as its composition and microstructure, have endured a long history of debate, clouding our understanding of the early progression of osteoarthritis. In order to investigate the surface of articular cartilage independently from the underlying cartilage, we physically peeled a transparent membrane of 20.0 ± 4.7 µm thickness, the most superficial layer, from the central loading region of the femoral condyles of sheep. Using confocal, second harmonic generation and atomic force microscopy, we found that the most superficial layer contains cartilage cells (chondrocytes), densely packed collagen, coarse elastic fibres and a fine elastic network. The coarse elastic fibres are most prevalent at the surface of the layer where collagen and chondrocyte densities are lowest. Furthermore, we investigated the surfaces at the interface of the most superficial layer with the underlying articular cartilage. At the interface of this most superficial layer with the underlying bulk cartilage, a dense fibrillar network exists, formed mainly by collagen fibrils and elastin microfibrils. In contrast, the interface of the underlying cartilage with the most superficial layer contains collagen fibrils, fine microfibrils and microfibrils distinctively laced on one side. The findings of this study have confirmed that there is a most superficial layer that is able to be removed using a tangential force. Through the application of advanced imaging technologies, we have shown that this most superficial layer is cellular and have detailed its composition and ultrastructure. Due to the close association between the form and function of tissues, the findings of this study will play an important role in understanding the mechanical function and wear mechanism of articular cartilage. This may lead to the development of more promising tissue engineering techniques to treat cartilage defects and osteoarthritis.

Robot-Assisted Oesophagectomy: Recommendations Towards a Standardised Ivor Lewis Procedure.

A considerable number of reports have been published on the feasibility, techniques, and early postoperative results of robotic-assisted oesophageal surgery. However, these are mostly smaller case series, suggesting that the robot-assisted Ivor Lewis procedure is still in the implementation phase and far from being standardised. Oesophageal surgeons from seven robotic university centres in Germany, experienced in both minimally invasive and robot-assisted minimally invasive surgery, took part in a workshop on robot-assisted surgery. An intensive exchange of opinions and experiences, followed by a step-by-step re-enactment of the operation in a cadaver lab, enabled us to develop a standardised robot-assisted Ivor Lewis surgical workflow, which is presented here. Systematic and objective comparison of experiences and results using a robot-assisted Ivor Lewis procedure has made it possible to develop a standardised surgical workflow that is now clinically applied in our centres. It is hoped that standardisation of this procedure will help to maintain patient safety, prevent medical errors, and facilitate the learning curve, while introducing robotic surgery into a centre.