[Conversion to outpatient treatment beyond the hybrid DRG-A view abroad]. / Ambulantisierung jenseits der Hybrid-DRG ­ ein Blick ins Ausland.

Outpatient visceral surgery is still in its infancy in Germany. While hernia repair that can be performed on an outpatient basis is still being discussed in this country, larger visceral surgery procedures such as thyroidectomy, fundoplication, bariatric procedures and colorectal resection are increasingly being performed abroad on an outpatient basis or in a short inpatient setting (< 24 h). The USA is the pioneer of outpatient care. Due to the private sector character of the American health insurance system, structures were created that ensure seamless care for patients. Overall, a look abroad shows that outpatient surgical procedures are a promising development that can also be further promoted in Germany through appropriate measures and strategies.

The Combination of Laparoscopic and Robotic Surgery: First Experience with the Dexter Robotic System™ in Visceral Surgery.

INTRODUCTION: For over two decades, abdominal surgical procedures have been safely performed robotically. After the first patent expiration, alternative robotic systems entered the market. The Dexter Robotic System™ is a small-format, modular, and robotic platform consisting of a surgeon's console, two patient carts with instrument arms, and one endoscope arm. We report our initial experiences with Dexter since its installation at our visceral surgery department. METHODS: The system and surgical setup are described. Demographic and perioperative data of all operated patients as well as the system docking times were analyzed. RESULTS: From 56 procedures performed with Dexter, the most common ones included cholecystectomy (n = 15), inguinal hernia repair (TAPP; unilateral n = 15; bilateral n = 3), and right oncologic hemicolectomy (n = 15). The median docking time was 6 min (2-16 min) and was reduced to 4 min in the last tertile of procedures performed. CONCLUSIONS: In our experience, Dexter can be implemented without any major challenges, and visceral surgical procedures of simple to medium complexity can be performed safely. The simplicity and accessibility of the system along with the ease of switching between robotics and laparoscopy could be particularly suitable for beginners in robotic surgery.

The distribution of robotic surgery in general and visceral surgery departments in Switzerland - a nationwide inquiry.

Objectives: Since its introduction as a clinical technique, robotic surgery has been extended to different fields of surgery. However, the indications as well as the number of robotic procedures varied in different institutions. The aim of this investigation was to evaluate the current use of robotic surgery in general and digestive surgery in Switzerland. Methods: All Swiss surgical departments that are recognized training institutes for postgraduate training in surgery by the Swiss Institute of Medical Education (SIWF) were queried with a detailed questionnaire regarding the use of robotic surgery techniques and were analyzed regarding hospital size and type of hospital. Results: Ninety-three departments were queried, and 67 % (n=63) answered the survey. Fifty-eight were public, and five were private institutions. Seventeen (26 %) of the queried departments used robotic surgery in digestive surgery. Four out of 17 (23 %) of the departments that performed robotic surgery were private hospitals, while 13 (77 %) were public institutions. In the majority of departments, robotic surgery of the rectum (n=12; 70.6 %) and colon (n=11; 64.7 %) was performed, followed by hernia procedures (n=8; 47.1 %) and fundoplication (n=7; 41.2 %). Less frequently, pancreatic resections (n=5; 29.4 %), cholecystectomy (n=4; 23.5 %), adrenalectomy (n=4; 23.5 %), gastric bypass (n=3; 17.7 %), gastric sleeve (n=3; 17.7 %), hepatic procedures (n=2; 11.7 %), or small bowel resections (n=1; 5.9 %) were performed as robotic procedures. More than 25 procedures per year per department were performed for hernia surgery (n=5 departments), gastric bypass (n=2 departments), cholecystectomy, fundoplication, and colon surgery (each n=1 department). Conclusions: The number and range of robotic procedures performed in Switzerland varied widely. Higher accreditation for general surgery or subspecialization of visceral surgery of the department was positively associated with the use of robotic techniques, reflecting an unequal availability of robotic surgery.

Reduction of red blood cell transfusion with a patient blood management protocol in urological and visceral surgery: a before-after study.

BACKGROUND: Although Patient Blood Management (PBM) is recommended by international guidelines, little evidence of its effectiveness exists in abdominal surgery. The aim of this study was to evaluate the benefits of the implementation of a PBM protocol on transfusion incidence and anaemia-related outcomes in major urological and visceral surgery. METHODS: In this before-after study, a three-pillar PBM protocol was implemented in 2020-2021 in a tertiary care centre, including preoperative correction of iron-deficiency anaemia, intraoperative tranexamic acid administration, and postoperative restrictive transfusion. A historical cohort (2019) was compared to a prospective cohort (2022) after the implementation of the PBM protocol. The primary outcome was the incidence of red blood cell transfusion intraoperatively or within 7 days after surgery. RESULTS: Data from 488 patients in the historical cohort were compared to 499 patients in the prospective cohort. Between 2019 and 2022, screening for iron deficiency increased from 13.9% to 69.8% (p < 0.01), tranexamic acid administration increased from 9.5% to 84.6% (p < 0.01), and median haemoglobin concentration before transfusion decreased from 77 g.L-1 to 71 g.L-1 (p = 0.02). The incidence of red blood cell transfusion decreased from 11.5% in 2019 to 6.6% in 2022 (relative risk 0.58, 95% CI 0.38-0.87, p = 0.01). The incidence of haemoglobin concentration lower than 100 g.L-1 at discharge was 24.2% in 2019 and 21.8% in 2022 (p = 0.41). The incidence of medical complications was comparable between the groups. CONCLUSION: The implementation of a PBM protocol over a two-year period was associated with a reduction of transfusion in major urological and visceral surgery.

[The new continuing education regulations-A challenge for visceral surgery : Results of a survey among DGAV members and solution strategies of the Young Surgeons]. / Die neue Weiterbildungsordnung ­ eine Herausforderung für die Viszeralchirurgie : Ergebnisse einer Umfrage unter DGAV-Mitgliedern und Lösungsstrategien der Jungen Chirurgie.

BACKGROUND: The new competency-based further training regulations (nWBO) for surgical training have been adopted by all German state medical associations. METHODS: From May to June 2023 the Young Surgeons' Working Group (CAJC) conducted an anonymous online survey among the 5896 members of the German Society for General and Visceral Surgery (DGAV). OBJECTIVE: The survey aimed to assess expectations regarding the nWBO and to develop strategies for enhancing surgical training. RESULTS: With 488 participants (response rate 8.3%) the study is representative. The respondents consisted of 107 continuing education assistants (WBA 21.9%), 69 specialist physicians, and 188 senior physicians (specialist physicians 14.1% and senior physicians 38.5%), as well as 107 chief physicians (21.9%). The majority worked in regular care providers (44%), followed by maximum care providers (26.8%) and university clinics (20.1%). Only 22% considered the required operative spectrum of the new medical specialist training regulations (nWBO) to be realistic. Half of the respondents believed that full training in their clinic according to the new catalog will no longer be possible and 54.6% considered achieving the target numbers in 6 years to be impossible or state that they can no longer train the same number of continuing education assistants (WBAs) in the same time frame. Endoscopy (17.1-18.8%), fundoplication (15.4-17.7%) and head and neck procedures (12.1-17.1%) were consistently mentioned as bottlenecks across all levels of care. Rotations for balance were reported to be already established or not necessary in 64.7%. In 48% it was stated that the department had established the partial steps concept. The importance of a structured training concept was considered important by 85% of WBAs, compared to 53.3% of chief physicians (CÄ). If a structured training concept was present in the department, the achievability of the target numbers was significantly assessed more positively in the univariate analysis. In the multivariate analysis, male gender and the status of "habilitated/professor" were independent factors for a more positive assessment of the nWBO. Objective certification of training was considered important by 51.5%. CONCLUSION: Concerns surround the nWBO and the sentiment is pessimistic. Additional requirements and hospital reforms could exacerbate the situation. Collaboration and rotations are crucial but still insufficiently implemented. Quality-oriented certification could enhance the quality of training.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis.

STUDY OBJECTIVE: Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DESIGN: Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING: Postoperative pain treatment. PATIENTS: Adult patients undergoing visceral cancer surgery. INTERVENTIONS: Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MEASUREMENTS: Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. MAIN RESULTS: 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. CONCLUSIONS: Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

Conditioned Canine Cadavers for Near-Natural Interprofessional Veterinary and Human Surgery Training.

Both medical and veterinary students find that the use of cadavers is critical to learning anatomical structures and surgical techniques. The use of human cadavers and the resulting user emotions are driven by serious ethical issues that are currently much less pronounced in veterinary education. Ethically sourced canine cadavers, thus, are more readily available. Aesthetics such as odor and visual appearance, though, influence both learner and educator motivation. We have investigated a way of delaying cadaver decomposition by post-mortem in situ, chemical-free, gastrointestinal lavage. We are convinced that canine cadavers, conditioned as described here, will improve the outcome of cadaver-based surgical skills training by facilitating preparation, reducing the number of required cadavers, postponing decomposition, improving the surgeon's haptic-tactile response to organ and tissue handling and suturing, and, possibly most importantly, increasing learners' and educators' focus due to the significantly improved aesthetics. We hypothesize that skill transfer for medical students and doctors, because of the similar abdominal anatomy, may be easier when training with conditioned canine cadavers as compared to artificial simulators or pigs in vivo.

Cost saving in implementing ERAS protocol in emergency abdominal surgery.

INTRODUCTION: ERAS (Enhanced Recovery After Surgery) protocol is now proposed as the standard of care in elective major abdominal surgery. Implementation of the ERAS protocol in emergency setting has been proposed but his economic impact has not been investigated. Aim of this study was to evaluate the cost saving of implementing ERAS in abdominal emergency surgery in a single institution. METHODS: A group of 80 consecutive patients treated by ERAS protocol for gastrointestinal emergency surgery in 2021 was compared with an analogue group of 75 consecutive patients treated by the same surgery the year before implementation of ERAS protocol. Adhesion to postoperative items, length of stay, morbidity and mortality were recorded. Cost saving analysis was performed. RESULTS: 50% Adhesion to postoperative items was reached on day 2 in the ERAS group in mean. Laparoscopic approach was 40 vs 12% in ERAS and control group respectively (p ,002). Length of stay was shorter in ERAS group by 3 days (9 vs 12 days p ,002). Morbidity and mortality rate were similar in both groups. The ERAS group had a mean cost saving of 1022,78 € per patient. CONCLUSIONS: ERAS protocol implementation in the abdominal emergency setting is cost effective resulting in a significant shorter length of stay and cost saving per patient.

[Safety of patient care on an interprofessional training ward in visceral surgery]. / Sicherheit der Patientenversorgung auf einer viszeralchirurgischen interprofessionellen Ausbildungsstation.

BACKGROUND: Interprofessional training wards (ITW) are increasingly being integrated into teaching and training concepts in visceral surgery clinics. OBJECTIVE: How safe is patient care on an ITW in visceral surgery? MATERIAL AND METHODS: Data collection took place from November 2021 to December 2022. In this nonrandomized prospective evaluation study the frequency and severity of adverse events (AE) in 3 groups of 100 patients each in a tertiary referral center hospital for visceral surgery were investigated. The groups consisted of patients on the ITW and on the conventional ward before and after implementation of the ITW. The Global Trigger Tool (GTT) was used to search for AE. Simultaneously, a survey of the treatment was conducted according to the Picker method to measure patient reported outcome. RESULTS: Baseline characteristics and clinical outcome parameters of the patients in the three groups were comparable. The GTT analysis found 74 nonpreventable and 5 preventable AE in 63 (21%) of the patients and 12 AE occurred before the hospital stay. During the hospital stay 50 AE occurred in the operating theater and 17 on the conventional ward. None of the five preventable AE (in 1.7% of the patients) was caused by the treatment on the ITW. Patients rated the safety on the ITW better than in 90% of the hospitals included in the Picker benchmark cohort and as good as on the normal ward. CONCLUSION: The GTT-based data as well as from the patients' point of view show that patient care on a carefully implemented ITW in visceral surgery is safe.

Oncological recurrence following pathological complete response after neoadjuvant treatment in patients with esophageal cancer - a retrospective cohort study.

BACKGROUND: To evaluate recurrence in patients with post-neoadjuvant pathological complete response (pCR) and in patients with complete response of primary tumor but persisting lymphatic spread of disease (non-pCR, ypT0ypN +) of esophageal cancer. METHODS: Seventy-five patients (63 pCR, 12 non-pCR) were analyzed retrospectively. Pattern and incidence of local and distant recurrence as well as the impact on overall (OS) and disease-free survival (DFS) were evaluated. The efficacy of neoadjuvant chemotherapy according to FLOT protocol was compared to neoadjuvant chemoradiation according to CROSS protocol. RESULTS: In the pCR group, isolated local recurrence was diagnosed in 3%, while no isolated local recurrence was observed in the non-pCR group due to the high incidence of distant recurrence. Distant recurrence was most common in both cohorts (isolated distant recurrence: pCR group 10% to non-pCR group 55%; simultaneous distant and local recurrence: pCR group 3% to non-pCR group 18%). Median time to distant recurrence was 5.5 months, and median time to local recurrence was 8.0 months. Cumulative incidence of distant recurrence (with and without simultaneous local recurrence) was 16% (± 6%) in pCR patients and 79% (± 13%) in non-pCR patients (hazard ratio (HR) 0.123) estimated by Kaplan-Meier method. OS (HR 0.231) and DFS (HR 0.226) were significantly improved in patients with pCR compared to patients with non-pCR. Advantages for FLOT protocol compared to CROSS protocol, especially with regard to distant control of disease (HR 0.278), were observed (OS (HR 0.361), DFS (HR 0.226)). CONCLUSION: Distant recurrence is the predominant site of treatment failure in patients with pCR and non-pCR grade 1a regression, whereby recurrence rates are much higher in patients with non-pCR.

[Organization of continuing education at a university hospital]. / Organisation der Weiterbildung an einer Universitätsklinik.

Continuing education at German university hospitals is individually organized within the framework of the continuing education regulations. In the personal organization (University Medical Center Schleswig-Holstein, Campus Luebeck) three sections (common trunk, medical specialist for visceral surgery and additional qualification in special visceral surgery) and two lines (clinical line and academic clinical line) are differentiated. The whole training is flanked by the mediation of technical competence even outside the operating room (Lübeck toolbox, RoSTraC curriculum, suture courses etc.). Future concepts for continuing education must take the healthcare structure in hospitals, the increasing specialization and the increasing technical complexity into account.

Proximal gastrectomy and double-tract reconstruction vs total gastrectomy in gastric and gastro-esophageal junction cancer patients - a systematic review and meta-analysis protocol (PROSPERO registration number: CRD42021291500).

BACKGROUND: In Germany and Western Europe, gastroesophageal junction cancer (AEG) and proximal gastric cancer are currently treated with (transhiatal-extended) total gastrectomy (TG) according to the latest treatment guidelines. TG leads to a severe and long-lasting impairment of postoperative health-related quality of life (HRQoL) of the treated patients. Recent studies have suggested that HRQoL of these patients could be improved by proximal gastrectomy with double-tract reconstruction (PG-DTR) without compromising oncologic safety. Our aim is therefore to conduct a randomized controlled non-inferiority trial comparing PG-DTR with TG in AEG II/III and gastric cancer patients with overall survival as primary endpoint and HRQoL as key secondary endpoint. METHODS: This protocol is written with reference to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P 2015) statement. We will conduct searches in the electronic databases MEDLINE, Web of Science Core Collection, ScienceDirect, and Cochrane Library. We will also check references of relevant studies and perform a cited reference research. Titles and abstracts of the records identified by the searches will be screened, and full texts of all potentially relevant articles will be obtained. We will consider randomized trials and non-randomized studies. The selection of studies, data extraction, and assessment of risk of bias of the included studies will be conducted independently by two reviewers. Meta-analysis will be performed using RevMan 5.4 (Review Manager (RevMan) Version 5.4, The Cochrane Collaboration). DISCUSSION: This systematic review will identify the current study pool concerning the comparison of TG and PG-DTR and help to finally refine the research questions and to allow an evidence-based trial design of the planned multicenter randomized-controlled trial. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review. Study findings will be shared by publication in a peer-reviewed journal. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021291500.

AR visualizations in laparoscopy: surgeon preferences and depth assessment of vascular anatomy.

Introduction: This study compares five augmented reality (AR) vasculature visualization techniques in a mixed-reality laparoscopy simulator with 50 medical professionals and analyzes their impact on the surgeon. Material and methods: ​​The different visualization techniques' abilities to convey depth were measured using the participant's accuracy in an objective depth sorting task. Demographic data and subjective measures, such as the preference of each AR visualization technique and potential application areas, were collected with questionnaires. Results: Despite measuring differences in objective measurements across the visualization techniques, they were not statistically significant. In the subjective measures, however, 55% of the participants rated visualization technique II, 'Opaque with single-color Fresnel highlights', as their favorite. Participants felt that AR could be useful for various surgeries, especially complex surgeries (100%). Almost all participants agreed that AR could potentially improve surgical parameters, such as patient safety (88%), complication rate (84%), and identifying risk structures (96%). Conclusions: More studies are needed on the effect of different visualizations on task performance, as well as more sophisticated and effective visualization techniques for the operating room. With the findings of this study, we encourage the development of new study setups to advance surgical AR.

Rectal colonization is predictive for surgical site infections with multidrug-resistant bacteria in abdominal surgery.

PURPOSE: Superficial surgical site infections (SSI) are a common complication after abdominal surgery. Additionally, multidrug-resistant organisms (MDRO) have shown an increasing spread in recent years with a growing importance for health care. As there is varying evidence on the importance of MDRO in different surgical fields and countries as causative agents of SSI, we report our findings of MDRO-caused SSI. METHODS: We assembled an institutional wound register spanning the years 2015-2018 including all patients with abdominal surgery and SSI only, including demographics, procedure-related data, microbiological data from screenings, and body fluid samples. The cohort was examined for the frequency of different MDRO in screenings, body fluids, and wound swabs and assessed for risk factors for MDRO-positive SSI. RESULTS: A total of 138 out of 494 patients in the register were positive for MDRO, and of those, 61 had an MDRO isolated from their wound, mainly multidrug-resistant Enterobacterales (58.1%) followed by vancomycin-resistant Enterococcus spp. (19.7%). As 73.2% of all MDRO-carrying patients had positive rectal swabs, rectal colonization could be identified as the main risk factor for an SSI caused by a MDRO with an odds ratio (OR) of 4.407 (95% CI 1.782-10.896, p = 0.001). Secondly, a postoperative ICU stay was also associated with an MDRO-positive SSI (OR 3.73; 95% CI 1.397-9.982; p = 0.009). CONCLUSION: The rectal colonization status with MDRO should be taken into account in abdominal surgery regarding SSI prevention strategies. Trial registration Retrospectively registered in the German register for clinical trials (DRKS) 19th December 2019, registration number DRKS00019058.

Evaluation of the Analgesic Efficacy of Undiluted Intraperitoneal and Incisional Ropivacaine for Postoperative Analgesia in Dogs after Major Abdominal Surgery.

Recommendations for intraperitoneal (IP) and incisional (INC) administration of local anaesthetics after visceral surgery exist, but evidence is scarce. This prospective, randomized, blinded, controlled, clinical trial compared postoperative pain in dogs undergoing major abdominal surgery. Sixteen client-owned dogs were anaesthetized with a standardized balanced protocol including opioids and received either 2 mg/kg ropivacaine IP (0.27 mL/kg) and a 1 mg/kg INC splash (0.13 mL/kg) or equal volumes of saline. Influence of the treatment on heart rate (HR) and postoperative pain was assessed using the Short Form of the Glasgow Composite Pain Scale (GCPS-SF), a dynamic interactive visual analogue scale (DIVAS) and mechanical nociceptive threshold testing (MNT). Data was tested with mixed ordinal regression and log linear mixed models for 0.5, 1, 2, 3, 4, 6, 8, 10 and 12 h after extubation. Rescue analgesia was given to 3/8 dogs after ropivacaine and 0/8 dogs after saline. GCPS-SF and MNT were not different between groups. DIVAS was slightly higher after ropivacaine (odds increased by 5.44 (confidence interval (CI) 1.17-9.96, p = 0.012)), and HR after ropivacaine was 0.76 * that after saline (CI 0.61-0.96, p = 0.02) with no effect of time (p = 0.1). Undiluted ropivacaine IP and INC was not beneficial for postoperative analgesia.

[Expected effects of the new continuing education regulations in general and visceral surgery : Survey among Bavarian surgeons and residents]. / Erwartete Effekte der neuen Weiterbildungsordnung in der Allgemein- und Viszeralchirurgie : Eine Umfrage unter bayerischen Chirurg*innen und Weiterbildungsassistent*innen.

INTRODUCTION: The new competency-based continuing education regulations for surgical training (WBO) came into effect in Bavaria in August 2022. METHODS: From May to July 2022, we conducted an anonymized online survey among Bavarian general and visceral surgeons and surgical residents (ÄiW). The aim was to survey expectations of the effects of the new WBO. RESULTS: The response rate was 35%. In total data could be collected from 80 persons, 36 ÄiW (45%), 30 specialists and senior physicians (37.5%) and 14 chief physicians (17.5%). The majority of respondents worked at a university hospital (38.8%) or a regular provider (35%). A strengthening of the competence to act through implementation of the new WBO is seen by 41.3% and 55.7% see independent operating under partial supervision by the instructor as a goal. Of the respondents 50% see the required case numbers as not achievable and 55.1% deny reaching them in the expected period of 6 years. About 60% do not expect to be able to train the same number of ÄiWs in the same amount of time. Almost 75% of the respondents state that from their point of view, a good continuing education with the achievement of a solid competence to act would not work without overtime hours. About 44% of the respondents expect that a full surgical training would continue to be possible at their institution. CONCLUSION: Both among the instructors and among the trainees there is a tendency to fear that realistic training, in particular the achievement of the guideline figures, will no longer be possible in the usual further training time. This necessitates the consistent implementation of structured continuing education with a high degree of transparency in training.

Pathological complete response in multimodal treatment of esophageal cancer: a retrospective cohort study.

To evaluate pathological complete response (pCR, ypT0ypN0) after neoadjuvant treatment compared with non-complete response (non-CR) in patients with esophageal cancer (EC), and 393 patients were retrospectively analyzed. Survival probability was analyzed in patients with: (i) pCR vs non-CR; (ii) complete response of the primary tumor but persisting lymphatic metastases (non-CR-T0N+) and (iii) pCR and tumor-free lymphnodes exhibiting signs of postneoadjuvant regression vs. no signs of regression. (i) Median overall survival (mOS) was favorable in patients with pCR (pCR: mOS not reached vs. non-CR: 41 months, P < 0.001). Multivariate analysis revealed that grade of regression was not an independent predictor for prolonged survival. Instead, the achieved postneoadjuvant TNM-stage (T-stage: Hazard ratio [HR] ypT3-T4 vs. ypT0-T2: 1.837; N-stage: HR ypN1-N3 vs. ypN0: 2.046; Postneoadjuvant M-stage: HR ypM1 vs. ycM0: 2.709), the residual tumor (R)-classification (HR R1 vs. R0: 4.195) and the histologic subtype of EC (HR ESCC vs. EAC: 1.688) were prognostic factors. Patients with non-CR-T0N+ have a devastating prognosis, similar to those with local non-CR and lymphatic metastases (non-CR-T + N+) (non-CR-T0N+: 22.0 months, non-CR-T + N-: mOS not reached, non-CR-T + N+: 23.0 months; P-values: non-CR-T0N+ vs. non-CR-T + N-: 0.016; non-CR-T0N+ vs. non-CR-T + N+: 0.956; non-CR-T + N- vs. non-CR-T + N+: <0.001). Regressive changes in lymphnodes after neoadjuvant treatment did not influence survival-probability in patients with pCR (mOS not reached in each group; EAC-patients: P = 0.0919; ESCC-patients: P = 0.828). Particularly, the achieved postneoadjuvant ypTNM-stage influences the survival probability of patients with EC. Patients with non-CR-T0N+ have a dismal prognosis, and only true pathological complete response with ypT0ypN0 offers superior survival probabilities.

Longitudinal dynamics of gut bacteriome and mycobiome interactions pre- and post-visceral surgery in Crohn's disease.

Introduction: Alterations of the gut microbiome are involved in the pathogenesis of Crohn's disease (CD). The role of fungi in this context is unclear. This study aimed to determine postoperative changes in the bacterial and fungal gut communities of CD patients undergoing intestinal resection, and to evaluate interactions between the bacteriome and mycobiome and their impact on the patients' outcome. Methods: We report a subgroup analysis of a prospective cohort study, focusing on 10 CD patients whose fecal samples were collected for bacterial 16S rRNA and fungal ITS2 genes next-generation sequencing the day before surgery and on the 5th or 6th postoperative day. Results: No significant differences in bacterial and fungal diversity were observed between preoperative and postoperative stool samples. By in-depth analysis, significant postoperative abundance changes of bacteria and fungi and 17 interkingdom correlations were detected. Network analysis identified 13 microbial clusters in the perioperative gut communities, revealing symbiotic and competitive interactions. Relevant factors were gender, age, BMI, lifestyle habits (smoking, alcohol consumption) and surgical technique. Postoperative abundance changes and identified clusters were associated with clinical outcomes (length of hospital stay, complications) and levels of inflammatory markers. Conclusions: Our findings highlight the importance of dissecting the interactions of gut bacterial and fungal communities in CD patients and their potential influence on postoperative and disease outcomes.

Do task and item difficulty affect overestimation of one's hand hygiene compliance? A cross-sectional survey of physicians and nurses in surgical clinics of six hospitals in Germany.

BACKGROUND: One barrier to hand hygiene compliance is overestimation of one's own performance. Overconfidence research shows that overestimation tends to be higher for difficult tasks, which suggests that the magnitude of overestimation also depends on how it is assessed. Thus, we tested the hypothesis that overestimation was stronger for hand hygiene indications with low compliance (i.e., high difficulty), and the hypothesis that self-reported overall compliance based on a single item is higher than based on "5 Moments of Hand Hygiene" (WHO-5) items, since the single item implies an aggregation across indications. METHODS: In the WACH trial (German Clinical Trials Register [DRKS] ID: DRKS00015502), a questionnaire survey was conducted among physicians and nurses in nine surgical clinics (general/visceral surgery or orthopedics/trauma surgery) of six German hospitals. Self-reported compliance was assessed both by a single item and the WHO-5-items using percentage scales. These were compared with each other and with direct observations. Relative frequencies of the WHO-5 indications used to calculate the WHO-5-based self-reported overall compliance rate were estimated by a systematized review of the literature (see appendix). In analysis, t-tests, Chi2-tests and multiple linear regressions were used. RESULTS: Ninety-three physicians (response rate: 28.4%) and 225 nurses (30.4%) participated. Significant compliance differences between physicians and nurses were found for direct observations and were in favor of nurses, while no such differences were found for self-reports. Across the WHO-5, overestimation showed inverse correlations with observed compliance (physicians: r = -0.88, p = 0.049; nurses: r = -0.81, p = 0.093). Support for the hypothesis that the self-reported overall compliance based on one item is higher than that based on WHO-5 items was found for physicians (M = 87.2 vs. 84.1%, p = 0.041; nurses: 84.4 vs. 85.5%, p = 0.296). Exploratory analyses showed that this effect was confined to orthopedic/trauma surgeons (89.9 vs. 81.7%, p = 0.006). CONCLUSION: Among physicians, results indicate stronger hand hygiene overestimation for low-compliance indications, and when measurements are based on a single item versus the five WHO-5 items. For practice, results contribute to infection prevention and control's understanding of overestimation as a psychological mechanism that is relevant to professional hand hygiene.