A senior surgical resident can safely perform complex esophageal cancer surgery after surgical mentoring program-experience of a European high-volume center.

Previous studies have shown that surgical residents can safely perform a variation of complex abdominal surgeries when provided with adequate training, proper case selection, and appropriate supervision. Their outcomes are equivalent when compared to experienced board-certified surgeons. Our previously published training curriculum for robotic assisted minimally invasive esophagectomy already demonstrated a possible reduction in time to reach proficiency. However, esophagectomy is a technically challenging procedure and comes with high morbidity rates of up to 60%, making it difficult to provide opportunities to train surgical residents. We aimed to investigate if a surgical resident could safely perform complex esophageal surgery when a structured modular teaching curriculum is applied. A structured teaching program based on our previously published modular step-up approach was applied by two experienced board-certified esophageal surgeons. Our IRB-approved (Institutional Review Board) database was searched to identify all Ivor-Lewis esophagectomies performed by the selected surgical resident from August 2019 to July 2021. The cumulative sum method was used to analyze the learning curve of the surgical resident. Outcomes of patients operated by the resident were then compared to our overall cohort of open, hybrid, and robotic Ivor-Lewis esophagectomies from May 2016 to May 2020. The total cohort included 567 patients, of which 65 were operated by the surgical resident and 502 patients were operated by experienced esophageal cancer surgeons as the control group. For baseline characteristics, a significant difference for BMI (Body mass index) was observed, which was lower in the resident's group (25.5 kg/m2 vs. 26.8 kg/m2 (P = 0.046). A significant difference of American Society of Anesthesiologists- and Eastern Cooperative Oncology Group-scores was seen, and a subgroup analysis including all patients with American Society of Anesthesiologists I and Eastern Cooperative Oncology Group 0 was performed revealing no significant differences. Postoperative complications did not differ between groups. The anastomotic leak rate was 13.8% in the resident's cohort and 12% in the control cohort (P = 0.660). Major complications (Clavien-Dindo ≥ IIIb) occurred in 16.9% of patients in both groups. Oncological outcome, defined by harvested lymph nodes (35 vs. 32.33, P = 0.096), proportion of lymph node compliant performed operations (86.2% vs. 88.4%, P = 0.590), and R0-resection rate (96.9% vs. 96%, P = 0.766), was not compromised when esophagectomies were performed by the resident. The resident completed the learning curves after 39 cases for the total operating time, 38 cases for the thoracic operating time, 26 cases for the number of harvested lymph nodes, 29 cases for anastomotic leak rate, and finally 58 cases for the comprehensive complication index. For postoperative complications, no significant difference was seen between patients operated in the resident group versus the control group, with a third of patients being discharged with a textbook outcome in both cohorts. Furthermore, no difference in oncological quality of the resection was found, emphasizing safety and feasibility of our training program. A structured modular step-up for training a surgical resident to perform complex esophageal cancer surgery can successfully maintain patient safety and outcomes.

Analysis of training pathway to reach expert performance levels based on proficiency-based progression in robotic-assisted minimally invasive esophagectomy (RAMIE).

BACKGROUND: Robotic-assisted minimally invasive esophagectomy (RAMIE) was first introduced in 2003 and has since then shown to significantly improve the postoperative course. Previous studies have shown that a structured training pathway based on proficiency-based progression using individual skill levels as measures of reach of competence can enhance surgical performance. The aim of this study was to evaluate and help understand our pathway to reach surgical expert levels using a proficiency-based approach introducing RAMIE at our German high-volume center. METHODS: All patients undergoing RAMIE performed by two experienced surgeons for esophageal cancer since the introduction of the robotic technique in 2017 was included in this analysis. Intraoperative outcomes and postoperative outcomes were included in the analysis. The cumulative sum method was used to analyze how many cases are needed to reach expert levels for different performance characteristics and skill sets during robotic-assisted minimally invasive esophagectomy. RESULTS: From 06/2017 to 03/2022, a total of 154 patients underwent RAMIE at our facility and were included in the analysis. An advancement in performance level was observed for total operating time after 70 cases and for thoracic operative time after 79 cases. Lymph node yield showed an increase up until case 60 in the CUSUM analysis. Length of hospital stay stabilized after case 55. The CCI score inflection point was at case 55 in both CUSUM and regression analyses. Anastomotic leak rate stabilized at case 38 and showed another inflection point after case 83. CONCLUSION: Our data and analysis showed the progression from proficient to expert performance levels during the implementation of RAMIE at a European high-volume center. Further analysis of surgeons, especially with a different training status has yet to reveal if the caseloads found in this study are universally applicable. However, skill acquisition and respective measures of such are diverse and as a great range of number of cases was observed, we believe that the learning curve and ascent in performance levels cannot be defined by one parameter alone.

Laparoscopic ischemic conditioning prior esophagectomy in selected patients: the ISCON trial.

Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14 days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12-18 days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45 minutes (range: 25-230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2 days (range: 2-4 days). Esophagectomy was completed in all patients after a median of 14 days (range: 12-28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.

Mapping the Lymphatic Drainage Pattern of Esophageal Cancer with Near-Infrared Fluorescent Imaging during Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE)-First Results of the Prospective ESOMAP Feasibility Trial.

While the sentinel lymph node concept is routinely applied in other surgical fields, no established and valid modality for lymph node mapping for esophageal cancer surgery currently exists. Near-infrared light fluorescence (NIR) using indocyanine green (ICG) has been recently proven to be a safe technology for peritumoral injection and consecutive lymph node mapping in small surgical cohorts, mostly without the usage of robotic technology. The aim of this study was to identify the lymphatic drainage pattern of esophageal cancer during highly standardized RAMIE and to correlate the intraoperative images with the histopathological dissemination of lymphatic metastases. Patients with clinically advanced stage squamous cell carcinoma or adenocarcinoma of the esophagus undergoing a RAMIE at our Center of Excellence for Surgery of the Upper Gastrointestinal Tract were prospectively included in this study. Patients were admitted on the day prior to surgery, and an additional EGD with endoscopic injection of the ICG solution around the tumor was performed. Intraoperative imaging procedures were performed using the Stryker 1688 or the FIREFLY fluorescence imaging system, and resected lymph nodes were sent to pathology. A total of 20 patients were included in the study, and feasibility and safety for the application of NIR using ICG during RAMIE were shown. NIR imaging to detect lymph node metastases can be safely performed during RAMIE. Further analyses in our center will focus on pathological analyses of ICG-positive tissue and quantification using artificial intelligence tools with a correlation of long-term follow-up data.

Hybrid laparoscopic versus fully robot-assisted minimally invasive esophagectomy: an international propensity-score matched analysis of perioperative outcome.

BACKGROUND: Currently, little is known regarding the optimal technique for the abdominal phase of RAMIE. The aim of this study was to investigate the outcome of robot-assisted minimally invasive esophagectomy (RAMIE) in both the abdominal and thoracic phase (full RAMIE) compared to laparoscopy during the abdominal phase (hybrid laparoscopic RAMIE). METHODS: This retrospective propensity-score matched analysis of the International Upper Gastrointestinal International Robotic Association (UGIRA) database included 807 RAMIE procedures with intrathoracic anastomosis between 2017 and 2021 from 23 centers. RESULTS: After propensity-score matching, 296 hybrid laparoscopic RAMIE patients were compared to 296 full RAMIE patients. Both groups were equal regarding intraoperative blood loss (median 200 ml versus 197 ml, p = 0.6967), operational time (mean 430.3 min versus 417.7 min, p = 0.1032), conversion rate during abdominal phase (2.4% versus 1.7%, p = 0.560), radical resection (R0) rate (95.6% versus 96.3%, p = 0.8526) and total lymph node yield (mean 30.4 versus 29.5, p = 0.3834). The hybrid laparoscopic RAMIE group showed higher rates of anastomotic leakage (28.0% versus 16.6%, p = 0.001) and Clavien Dindo grade 3a or higher (45.3% versus 26.0%, p < 0.001). The length of stay on intensive care unit (median 3 days versus 2 days, p = 0.0005) and in-hospital (median 15 days versus 12 days, p < 0.0001) were longer for the hybrid laparoscopic RAMIE group. CONCLUSIONS: Hybrid laparoscopic RAMIE and full RAMIE were oncologically equivalent with a potential decrease of postoperative complications and shorter (intensive care) stay after full RAMIE.

Time to endoscopic vacuum therapy-lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center.

OBJECTIVE OF THE STUDY: In esophageal surgery, anastomotic leak (AL) remains one of the most severe and critical adverse events after oncological esophagectomy. Endoscopic vacuum therapy (EVT) can be used to treat AL; however, in the current literature, treatment outcomes and reports on how to use this novel technique are scarce. The aim of this study was to evaluate the outcomes of patients with an AL after IL RAMIE and to determine whether using EVT as an treatment option is safe and feasible. MATERIAL AND METHODS: This study includes all patients who developed an Esophagectomy Complications Consensus Group (ECCG) type II AL after IL RAMIE at our center between April 2017 and December 2021. The analysis focuses on time to EVT, duration of EVT, and follow up treatments for these patients. RESULTS: A total of 157 patients underwent an IL RAMIE at our hospital. 21 patients of these (13.4%) developed an ECCG type II AL. One patient died of unrelated Covid-19 pneumonia and was excluded from the study cohort. The mean duration of EVT was 12 days (range 4-28 days), with a mean of two sponge changes (range 0-5 changes). AL was diagnosed at a mean of 8 days post-surgery (range 2-16 days). Closure of the AL with EVT was successful in 15 out of 20 patients (75%). Placement of a SEMS (Self-expandlable metallic stent) after EVT was performed in four patients due to persisting AL. Overall success rate of anastomotic sealing independently of the treatment modality was achieved in 19 out of 20 Patients (95%). No severe EVT-related adverse events occurred. CONCLUSION: This study shows that EVT can be a safe and effective endoscopic treatment option for ECCG type II AL.

Using an Endoluminal Functional Lumen Imaging Probe (EndoFLIP™) to Compare Pyloric Function in Patients with Gastroparesis to Patients After Esophagectomy.

BACKGROUND: Gastroparesis (GP) occurs in patients after upper gastrointestinal surgery, in patients with diabetes or systemic sclerosis and in idiopathic GP patients. As pyloric dysfunction is considered one of the underlying mechanisms, measuring this mechanism with EndoFLIP™ can lead to a better understanding of the disease. METHODS: Between November 2021 and March 2022, we performed a retrospective single-centre study of all patients who had non-surgical GP, post-surgical GP and no sign of GP after esophagectomy and who underwent our post-surgery follow-up program with surveillance endoscopies and further exams. EndoFLIP™ was used to perform measurements of the pylorus, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling. RESULTS: We included 66 patients, and successful application of the EndoFLIP™ was achieved in all interventions (n = 66, 100%). We identified 18 patients suffering from non-surgical GP, 23 patients suffering from GP after surgery and 25 patients without GP after esophagectomy. At 40, 45 and 50 ml balloon filling, the mean distensibility in gastroparetic patients was 8.2, 6.2 and 4.5 mm2/mmHg; 5.4, 5.1 and 4.7 mm2/mmHg in post-surgical patients suffering of GP; and 8.5, 7.6 and 6.3 mm2/mmHg in asymptomatic post-surgical patients. Differences between symptomatic and asymptomatic patients were significant. CONCLUSION: Measurement with EndoFLIP™ showed that asymptomatic post-surgery patients seem to have a higher pyloric distensibility. Pyloric distensibility and symptoms of GP seem to correspond.

Assessment of pyloric sphincter physiology after Ivor-Lewis esophagectomy using an endoluminal functional lumen imaging probe.

OBJECTIVE OF THE STUDY: The most common functional complication after Ivor-Lewis esophagectomy is the delayed emptying of the gastric conduit (DGCE) for which several diagnostic tools are available, e.g. chest X-ray, upper esophagogastroduodenoscopy (EGD) and water-soluble contrast radiogram. However, none of these diagnostic tools evaluate the pylorus itself. Our study demonstrates the successful measurement of pyloric distensibility in patients with DGCE after esophagectomy and in those without it. METHODS AND PROCEDURES: Between May 2021 and October 2021, we performed a retrospective single-centre study of all patients who had an oncological Ivor-Lewis esophagectomy and underwent our post-surgery follow-up programme with surveillance endoscopies and computed tomography scans. EndoFlip™ was used to perform measurements of the pylorus under endoscopic control, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling. RESULTS: We included 70 patients, and EndoFlip™ measurement was feasible in all patients. Successful application of EndoFlip™ was achieved in all interventions (n = 70, 100%). 51 patients showed a normal postoperative course, whereas 19 patients suffered from DGCE. Distensibility proved to be smaller in patients with symptoms of DGCE compared to asymptomatic patients. For 40 ml, 45 ml and 50 ml, the mean distensibility was 6.4 vs 10.1, 5.7 vs 7.9 and 4.5 vs 6.3 mm2/mmHg. The differences were significant for all three balloon fillings. No severe EndoFlip™ treatment-related adverse events occurred. CONCLUSION: Measurement with EndoFlip™ is a safe and technically feasible endoscopic option for measuring the distensibility of the pylorus. Our study shows that the distensibility in asymptomatic patients after esophagectomy is significantly higher than that in patients suffering from DGCE. However, more studies need to be conducted to demonstrate the general use of EndoFlip™ measurement of the pylorus after esophagectomy.

Surgical approach to advanced Siewert II cancer: beyond the borders? The West Side.

The surgical approach to Siewert type II cancer should be individualized as there is no "one size fits all" option. Criteria for individualization are epidemiological, functional, oncologic and surgical items. However, our preferred procedure for advanced adenocarcinoma of the esophagogastric junction type II is esophagectomy, if this or transhiatal extended gastrectomy are both possible with R0 resection. Esophagectomy has the advantages of a longer esophageal safety margin, complete mediastinal lymphadenectomy, easier anastomosis, routine minimal invasive gastrolysis with abdominal lymphadenectomy and preservation of a gastric reservoir.

Minimally invasivE versus open total GAstrectomy (MEGA): study protocol for a multicentre randomised controlled trial (DRKS00025765).

INTRODUCTION: The only curative treatment for most gastric cancer is radical gastrectomy with D2 lymphadenectomy (LAD). Minimally invasive total gastrectomy (MIG) aims to reduce postoperative morbidity, but its use has not yet been widely established in Western countries. Minimally invasivE versus open total GAstrectomy is the first Western multicentre randomised controlled trial (RCT) to compare postoperative morbidity following MIG vs open total gastrectomy (OG). METHODS AND ANALYSIS: This superiority multicentre RCT compares MIG (intervention) to OG (control) for oncological total gastrectomy with D2 or D2+LAD. Recruitment is expected to last for 2 years. Inclusion criteria comprise age between 18 and 84 years and planned total gastrectomy after initial diagnosis of gastric carcinoma. Exclusion criteria include Eastern Co-operative Oncology Group (ECOG) performance status >2, tumours requiring extended gastrectomy or less than total gastrectomy, previous abdominal surgery or extensive adhesions seriously complicating MIG, other active oncological disease, advanced stages (T4 or M1), emergency setting and pregnancy.The sample size was calculated at 80 participants per group. The primary endpoint is 30-day postoperative morbidity as measured by the Comprehensive Complications Index. Secondary endpoints include postoperative morbidity and mortality, adherence to a fast-track protocol and patient-reported quality of life (QoL) scores (QoR-15, EUROQOL EuroQol-5 Dimensions-5 Levels (EQ-5D), EORTC QLQ-C30, EORTC QLQ-STO22, activities of daily living and Body Image Scale). Oncological endpoints include rate of R0 resection, lymph node yield, disease-free survival and overall survival at 60-month follow-up. ETHICS AND DISSEMINATION: Ethical approval has been received by the independent Ethics Committee of the Medical Faculty, University of Heidelberg (S-816/2021) and will be received from each responsible ethics committee for each individual participating centre prior to recruitment. Results will be published open access. TRIAL REGISTRATION NUMBER: DRKS00025765.

[Surgical Treatment of Esophageal Cancer-New Technologies, Modern Concepts]. / Chirurgische Therapie des Ösophaguskarzinoms ­ neue Technologien, moderne Konzepte.

In Germany esophageal cancer is mostly treated in specialized centers according to national and international guidelines in a multimodal and interdisciplinary setting. In the next few years centralization of esophageal surgery will continue in Germany due to new national regulations on minimum case volumes. This article highlights new technologies for surgical treatment of esophageal cancer and also depicts the current oncological concepts from the perspective of a high-volume center.

[ICG lymph node mapping in cancer surgery of the upper gastrointestinal tract]. / ICG-Lymphknoten-Mapping in der Tumorchirurgie des oberen Gastrointestinaltrakts.

The importance of the assessment of the N­status in gastric carcinoma, tumors of the gastroesophageal junction and esophageal cancer is undisputed; however, there is currently no internationally validated method for lymph node mapping in esophageal and gastric cancer. Near-infrared fluorescence imaging (NIR) is an innovative technique from the field of vibrational spectroscopy, which in combination with the fluorescent dye indocyanine green (ICG) enables intraoperative real-time visualization of anatomical structures. The ICG currently has four fields of application in oncological surgery: intraoperative real-time angiography for visualization of perfusion, lymphography for visualization of lymphatic vessels, visualization of solid tumors, and (sentinel) lymph node mapping. For imaging of the lymph drainage area and therefore the consecutive lymph nodes, peritumoral injection of ICG must be performed. Several studies have demonstrated the feasibility of peritumoral injection of ICG administered 15 min to 3 days preoperatively with subsequent intraoperative visualization of the lymph nodes. So far prospective randomized studies on the validation of the method are still lacking. In contrast, the use of ICG for lymph node mapping and visualization of sentinel lymph nodes in gastric cancer has been performed in large cohorts as well as in prospective randomized settings. Up to now, multicenter studies for ICG-guided lymph node mapping during oncological surgery of the upper gastrointestinal tract are lacking. Artificial intelligence methods can help to evaluate these techniques in an automated manner in the future as well as to support intraoperative decision making and therefore to improve the quality of oncological surgery.

Robot-assisted minimally invasive esophagectomy (RAMIE) vs. hybrid minimally invasive esophagectomy: propensity score matched short-term outcome analysis of a European high-volume center.

INTRODUCTION: Transthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center. PATIENTS AND METHODS: Six hundred and eleven patients that underwent transthoracic Ivor-Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases. Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016-April 2021 (HE) after a propensity-score matching analysis was performed. RESULTS: Six hundred and eleven patients were analyzed. 107 patients underwent RAMIE. Of these, a total of 76 patients underwent a robotic thoracic reconstruction using the updated standardized circular stapled anastomosis (RAMIE group). A total of 535 patients underwent HE (Hybrid group). Seventy patients were propensity-score matched in each group and analysis revealed no statistically significant differences in baseline characteristics. RAMIE patients had a significantly shorter ICU stay (p = 0.0218). Significantly more patients had no postoperative complications (Clavien Dindo 0) in the RAMIE group [47.1% vs. 27.1% in the HE group (p = 0.0225)]. No difference was seen in lymph node yield and R0 resection rates. Anastomotic leakage rates when matched were 14.3% in the hybrid group vs. 4.3% in the RAMIE group (p = 0.07). CONCLUSION: Our analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien-Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE. Furthermore it shows that both procedures provide excellent short-term oncologic outcomes, regarding lymph node harvest and R0 resection rates. A randomized controlled trial comparing RAMIE and HE is still pending and will hopefully contribute to ongoing discussions.

There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy.

INTRODUCTION: Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. PATIENTS AND METHODS: 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. RESULTS: 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. CONCLUSION: Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study.

BACKGROUND: Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology. METHODS: Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental. RESULTS: All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE. CONCLUSION: The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.

Pathophysiology of gastroesophageal reflux disease-which factors are important?

BACKGROUND: Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease. METHODS: For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI). RESULTS: In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m2 (range, 20-45 kg/m2); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%. CONCLUSIONS: In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.

[Surgical treatment of esophageal cancer-New technologies, modern concepts]. / Chirurgische Therapie des Ösophaguskarzinoms ­ neue Technologien, moderne Konzepte.

In Germany esophageal cancer is mostly treated in specialized centers according to national and international guidelines in a multimodal and interdisciplinary setting. In the next few years centralization of esophageal surgery will continue in Germany due to new national regulations on minimum case volumes. This article highlights new technologies for surgical treatment of esophageal cancer and also depicts the current oncological concepts from the perspective of a high-volume center.

Tumor Microenvironment of Esophageal Cancer.

Esophageal cancer is among the top ten most deadly cancers worldwide with adenocarcinomas of the esophagus showing increasing incidences over the last years. The prognosis is determined by tumor stage at diagnosis and in locally advanced stages by response to (radio-)chemotherapy followed by radical surgery. Less than a third of patients with esophageal adenocarcinomas completely respond to neoadjuvant therapies which urgently asks for further strategies to improve these rates. Aiming at the tumor microenvironment with novel targeted therapies can be one strategy to achieve this goal. This review connects experimental, translational, and clinical findings on each component of the esophageal cancer tumor microenvironment involving tumor angiogenesis, tumor-infiltrating immune cells, such as macrophages, T-cells, myeloid-derived suppressor cells, and cancer-associated fibroblasts. The review evaluates the current state of already approved concepts and depicts novel potentially targetable pathways related to esophageal cancer tumor microenvironment.

[Impact of COVID-19 on oncological surgery of the upper gastrointestinal tract]. / Auswirkungen von COVID-19 auf die onkologische Chirurgie des oberen Gastrointestinaltrakts.

BACKGROUND: The outbreak of the coronavirus disease 2019 (COVID-19) pandemic imposed limitations for elective surgery, impacting the associated hospital standards worldwide. As certain treatment windows must be adhered to in oncological surgery, the limited intensive care unit (ICU) capacity had to be critically distributed in order to do justice to both acutely ill and oncology patients. This manuscript summarizes the impact of COVID-19 on the management of oncological surgery of the upper gastrointestinal tract and particularly esophageal surgery in German medical centers. MATERIAL AND METHODS: A survey of German centers for esophageal surgery was performed on the impact of COVID-19 on operative management for esophageal surgery during the first lockdown. After inspection, assessment, critical analysis and interpretation, the results were compared to the international literature. RESULTS AND DISCUSSION: Initial recommendations of international societies warned for caution and restraint regarding interventions of the upper gastrointestinal tract that were not absolutely necessary. Oncological surgery should be performed under strict restrictions, especially only after negative testing for COVID-19 and only with sufficiently available personal protective equipment for the personnel. Furthermore, minimally invasive procedures were preferably not recommended. In diseases with alternative treatment options, such as definitive chemoradiotherapy of esophageal squamous cell carcinoma, these should be given priority when possible. In the further development of the pandemic, it was shown that due to a high standardization of preoperative management, postoperative results comparable to pre-pandemic times could be achieved particularly with respect to the diagnostics of infections.