[Technique and Study Results of Laparoscopic Gastrectomy for Gastric Cancer]. / Technik und Studienlage der laparoskopischen Gastrektomie bei Magenkarzinom.

The aim of this paper was to describe the technique of laparoscopic gastrectomy for gastric carcinoma and to present a review of current international studies on this topic.The first part describes and documents a standard laparoscopic gastrectomy for carcinoma. In the second part, after an EMBASE and PubMed search, a total of 123 quality-relevant randomised (RCT) and non-randomised (non-RCT) studies on laparoscopic gastrectomy are identified from a primary total of 3,042 hits by systematic narrowing. The study results are then summarised conclusively for the target criteria of feasibility, outcome, oncological quality, morbidity and mortality.Both, laparoscopic subtotal resection for distal gastric carcinomas and laparoscopic gastrectomy can now be performed safely and with few complications. In a recent literature review of a total of 15 RCTs with 5,576 patients (laparoscopic 2,793 vs. open 2,756), there were no significant differences in terms of feasibility, intraoperative outcome and oncological quality (R0 and lymph node harvest). Surgical morbidity and mortality were comparable. Patients after laparoscopic surgery showed a significantly faster early postoperative recovery with a lower overall morbidity. In contrast, the operating time was significantly longer - by a mean of 45 min - compared to the open technique. The advantages of the laparoscopic technique were equally evident in studies on early gastric carcinoma and advanced carcinomas (>T2).Laparoscopic gastrectomy for gastric carcinoma is safe to perform and shows better early postoperative recovery. Complication rates, morbidity and mortality as well as long-term oncological results are comparable with open surgery.

Use of fluorescence imaging and indocyanine green during laparoscopic cholecystectomy: Results of an international Delphi survey.

BACKGROUND: Published empirical data have increasingly suggested that using near-infrared fluorescence cholangiography during laparoscopic cholecystectomy markedly increases biliary anatomy visualization. The technology is rapidly evolving, and different equipment and doses may be used. We aimed to identify areas of consensus and nonconsensus in the use of incisionless near-infrared fluorescent cholangiography during laparoscopic cholecystectomy. METHODS: A 2-round Delphi survey was conducted among 28 international experts in minimally invasive surgery and near-infrared fluorescent cholangiography in 2020, during which respondents voted on 62 statements on patient preparation and contraindications (n = 12); on indocyanine green administration (n = 14); on potential advantages and uses of near-infrared fluorescent cholangiography (n = 18); comparing near-infrared fluorescent cholangiography with intraoperative x-ray cholangiography (n = 7); and on potential disadvantages of and required training for near-infrared fluorescent cholangiography (n = 11). RESULTS: Expert consensus strongly supports near-infrared fluorescent cholangiography superiority over white light for the visualization of biliary structures and reduction of laparoscopic cholecystectomy risks. It also offers other advantages like enhancing anatomic visualization in obese patients and those with moderate to severe inflammation. Regarding indocyanine green administration, consensus was reached that dosing should be on a milligrams/kilogram basis, rather than as an absolute dose, and that doses >0.05 mg/kg are necessary. Although there is no consensus on the optimum preoperative timing of indocyanine green injections, the majority of participants consider it important to administer indocyanine green at least 45 minutes before the procedure to decrease the light intensity of the liver. CONCLUSION: Near-infrared fluorescent cholangiography experts strongly agree on its effectiveness and safety during laparoscopic cholecystectomy and that it should be used routinely, but further research is necessary to establish optimum timing and doses for indocyanine green.

Assessing the development status of intraoperative fluorescence imaging for anatomy visualisation, using the IDEAL framework.

Objectives: Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: visualising anatomy, assessing tissue perfusion, identifying/localising cancer and mapping lymphatic systems. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging used to visualise anatomical structures using the IDEAL framework, a framework designed to describe the stages of innovation in surgery and other interventional procedures. Design: IDEAL staging based on a thorough literature review. Setting: All publications on intraoperative fluorescence imaging for visualising anatomical structures reported in PubMed through 2020 were identified for five surgical procedures: cholangiography, hepatic segmentation, lung segmentation, ureterography and parathyroid identification. Main outcome measures: The IDEAL stage of research evidence was determined for each of the five procedures using a previously described approach. Results: 225 articles (8427 cases) were selected for analysis. Current status of research evidence on fluorescence imaging was rated IDEAL stage 2a for ureterography and lung segmentation, IDEAL 2b for hepatic segmentation and IDEAL stage 3 for cholangiography and parathyroid identification. Enhanced tissue identification rates using fluorescence imaging relative to conventional white-light imaging have been documented for all five procedures by comparative studies including randomised controlled trials for cholangiography and parathyroid identification. Advantages of anatomy visualisation with fluorescence imaging for improving short-term and long-term postoperative outcomes also were demonstrated, especially for hepatobiliary surgery and (para)thyroidectomy. No adverse reactions associated with fluorescent agents were reported. Conclusions: Intraoperative fluorescence imaging can be used safely to enhance the identification of anatomical structures, which may lead to improved postoperative outcomes. Overviewing current research knowledge using the IDEAL framework aids in designing further studies to develop fluorescence imaging techniques into an essential intraoperative navigation tool in each surgical field.

Assessing the development status of intraoperative fluorescence imaging for perfusion assessments, using the IDEAL framework.

OBJECTIVES: Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures. DESIGN: Narrative literature review with analysis of IDEAL stage of each field of study. SETTING: All publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery. MAIN OUTCOME MEASURES: The IDEAL stage of research evidence was determined for each specialty field using a previously described approach. RESULTS: 196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported. CONCLUSIONS: Using fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit.

Totally Laparoscopic versus Open Gastrectomy for Gastric Cancer: a Matched Pair Analysis.

BACKGROUND: Laparoscopic gastrectomy has been established for treatment of early gastric cancer (EGC) especially in Eastern Asian countries. Currently, it still needs evaluation for advanced gastric cancer (AGC, T ≥ 2). Difficulty is how far Asian study data are valid for western conditions. METHODS: Out of 502 patients who underwent gastric cancer surgery between 2003 and 2016 at Klinikum Suedstadt Rostock 90 patients were selected for a retrospective study to compare totally laparoscopic D2-gastrectomy (LG, n = 45) with open D2-gastrectomy (OG, n = 45). The groups were matched by age, gender and tumour stage (TNM). RESULTS: Average age was 62.9 years (33 - 83), 42.2% were female. There were no differences between both study groups concerning BMI, ECOG and comorbidities. Amounts of EGC and AGC were 35.5% and 64.4% in LG, 28.9% and 71.0% in OG (p = 0.931). In LG-group 53.3% of the patients and in OG-group 51.1% of the patients were nodal negative (p = 0.802). 31.1% of patients in LG and in 33.3% in OG (p = 0.821) undergone perioperative chemotherapy. Total gastrectomy was performed in 73.3% in LG and 82.2% in OG, subtotal resections were done in 26.7% in LG and 17.8% in OG (p = 0.310). Resection free margins (R0) were recognized in 97.8% of the patients in both groups, and for EGC in all cases (p = 0.928). Total numbers of retrieved lymph nodes were significant higher in LG (33.1, 17 - 72) than in OG (28.2, 14 - 57). A significant longer operation time was noticed for laparoscopic gastrectomy in contrast to open surgery (+ 43.0 ± 27.2 min, p = 0.0054). Overall morbidity in OG (44.4%) was twice as high as in LG (22.2%, p < 0.05) due to lower rate of minor complications (Clavien I - II) in LG (LG vs. OG: 13.3% vs. 37.8%, p = 0.0078). For major complications (Clavien ≥ III) no difference between both groups was detected (LG vs. OG: 8.8% vs. 6.6%, p = 0.69). LG showed a significant faster postoperative recovery with earlier oral fluid intake (LG vs. OG: 25.9 h vs. 46.2 h) and shorter time to first flatus (LG vs. OG: 81.6 vs. 102.6 h). Patients after LG were earlier out of bed (LG vs. OG: 69.7 h vs. 108.7 h) and also hospital stay was significantly shorter (11.9 days in LG vs. 16.3 days in OG, p = 0.037). 30- and 90-days mortality was equal for LG and OG (0 and 2.2% per group). After a median follow up of 51.9 month (1 - 117) there were similar results for 3- and 5-year overall survival (OS for LG: 75.6% and 64.6% vs. OG: 68.9% and 64.6%, p = 0.446). Also no differences for 3- and 5-year OS were detected concerning patients without lymph node metastases (LG: 91.7% and 83.4% vs. OG: 91.3% and 78.3%, p = 0.658) or lymph node positive patients (LG: 47.6% and 38.1% vs. OG: 40.9% and 31.8%, p = 0.665). CONCLUSION: Despite western conditions laparoscopic D2 gastrectomy is certainly a save and feasibly approach for surgical therapy of EGC and AGC with low morbidity and mortality, and faster postoperative recovery. The oncologic outcome seems to be equivalent to open surgery.

[Fluorescence Cholangiography in Comparison to Radiographic Cholangiography During Laparoscopic Cholecystectomy]. / ICG-Fluoreszenzcholangiografie im Vergleich zur konventionellen Röntgencholangiografie im Rahmen einer laparoskopischen Cholezystektomie.

BACKGROUND: The reported incidence rate of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is 0.3%. However, routine use of intraoperative cholangiography (IOC) is a controversial, due to the additional cost and radiation exposure. The aim of this study was to assess the application of fluorescence cholangiography (FC) in comparison to IOC and to LC without any intraoperative imaging. MATERIALS AND METHODS: This prospective study included 230 patients undergoing LC in our institution. The subjects were divided into two groups. In the first group, with 170 patients, both FC and IOC were performed following a standardised protocol. In second group, with 60 patients, FC was compared to LC without any intraoperative imaging. The data were then analysed with respect to procedure time and identification of predefined anatomical structures. RESULTS: The mean age and body mass index in the first group were 54.4 ± 15.7 years and 27.9 ± 5.7 kg/m², respectively. The mean operative time was 67.6 ± 23.3 min. FC was performed more rapidly than IOC (1.5 ± 0.9 vs.7.3 ± 5.0 min) and visualised the cystic duct (DC) in 67.5% of patients and the common bile duct (DHC) in 66.2% of patients before dissection of Calot's triangle. During dissection, DC and DHC were detected in 95.9% and 71.2% of patients, respectively. BMI > 25 kg/m² and male gender significantly reduced the identification rate of DC before dissection of Calot's triangle. Bile leakage from the liver bed after cholecystectomy was found in 3 cases (1.8%) by FC. In 2 patients (1.2%), IOC visualised the DC joining directly to the right hepatic duct. In 1 of these 2 cases (0.6%), the anatomical variation was identified first by FC. Intraductal filling defects were detected in 9 patients (5.3%) using IOC, compared to 1 patient (0.6%) using FC. In the second group, the visualisation rates of DC and DHC were 80.0 and 53.3%, respectively, with FC and 60.0 and 43.3%, respectively, during LC without any imaging. Surgeons confirmed an increase in safety in 70.0% of patients using FC. CONCLUSION: FC is a simple procedure for non-invasive real-time visualisation of bile duct anatomy during LC. Earlier identification of biliary anomalies and bile leakage increases the operative safety and enables immediate care. In obese patients, FC has limited validity.

Clinical NOTES appendectomy study: comparison of transvaginal NOTES appendectomy in hybrid technique with laparoscopic appendectomy.

PURPOSE: The proposed advantages of NOTES are aimed to assess the comparison with standard procedures. Complications are a major focus of its evaluation. We initiated a prospective comparison between transvaginal hybrid appendectomy versus laparoscopic appendectomy. PATIENTS AND METHODS: For each, NOTES and laparoscopic appendectomy, 10 consecutive female patients participated in the study with follow-up documentation for 35 days and after 1 year. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient's consent. Pre- and postoperative gynecological examinations were performed. Questionnaire-based evaluation included issues related to quality of life in addition to objective clinical findings. The study is approved by the ethics committee of the University of Rostock. RESULTS: All women returned questionnaires for evaluation. Age and BMI are comparable. Overall procedure time was significantly shorter in laparoscopy. The only postoperative complication consisted of an intra-abdominal abscess after laparoscopic appendectomy. One patient of the NOTES group suffered from new abdominal pain 3 weeks postoperatively; a mini-laparoscopy showed a normal situation. Significant differences (p < 0.05) of the questionnaire-based comparison with advantages for the NOTES group were found in following items: reduced activity at day 1-14, postoperative pain at day 1, general health conditions at day 1-3 and quality of life at day 3. NOTES patients wished significantly earlier to be discharged and started significantly earlier with activities, but no differences existed after 4 weeks. CONCLUSIONS: Transvaginal flexible appendectomy appears to be a safe procedure performed in hybrid technique. Data from the study point to shortened recovery intervals and improved quality of life.

[Nutritional recommendations, supplementation, and physical activity program following Roux-en-Y gastric bypass for morbid obesity]. / Ernährungsumstellung, Supplementation und Bewegungsprogramm nach Roux-Y-Magenbypass.

The number of gastric bypass operations (RYGB) needed worldwide is increasing annually due to the obesity epidemic.Yet the success of this treatment is only guaranteed if an appropriate exercise therapy, a corresponding change of diet, and an adequate supplementation take hold in the aftercare program.Subject to pre-existing musculoskeletal diseases, exercise therapy should start about 4 weeks after the operation and comprise alternating cardiovascular and connective tissue-restitution training. The required change of diet focuses on small portions of calorie-reduced as well as protein- and vitamin enriched food. The standard daily intake should be between 800 and 1,200 kcal. However, after RYGB, nutritive deficiencies have been registered for proteins in 1-3%, for iron in 45-52%,vitamin B12 in 33-37%, folic acid in about 35%, calcium in 10-12%, and vitamins in 10-45% of the patients. For this reason,laboratory analysis at regular intervals is necessary in the follow-up and an appropriate supplementation of minerals, vitamins,and trace elements must be implemented.