Technological advancements in surgical laparoscopy considering artificial intelligence: a survey among surgeons in Germany.

PURPOSE: The integration of artificial intelligence (AI) into surgical laparoscopy has shown promising results in recent years. This survey aims to investigate the inconveniences of current conventional laparoscopy and to evaluate the attitudes and desires of surgeons in Germany towards new AI-based laparoscopic systems. METHODS: A 12-item web-based questionnaire was distributed to 38 German university hospitals as well as to a Germany-wide voluntary hospital association (CLINOTEL) consisting of 66 hospitals between July and November 2022. RESULTS: A total of 202 questionnaires were completed. The majority of respondents (88.1%) stated that they needed one assistant during laparoscopy and rated the assistants' skillfulness as "very important" (39.6%) or "important" (49.5%). The most uncomfortable aspects of conventional laparoscopy were inappropriate camera movement (73.8%) and lens condensation (73.3%). Selected features that should be included in a new laparoscopic system were simple and intuitive maneuverability (81.2%), automatic de-fogging (80.7%), and self-cleaning of camera (77.2%). Furthermore, AI-based features were improvement of camera positioning (71.3%), visualization of anatomical landmarks (67.3%), image stabilization (66.8%), and tissue damage protection (59.4%). The reason for purchasing an AI-based system was to improve patient safety (86.1%); the reasonable price was €50.000-100.000 (34.2%), and it was expected to replace the existing assistants' workflow up to 25% (41.6%). CONCLUSION: Simple and intuitive maneuverability with improved and image-stabilized camera guidance in combination with a lens cleaning system as well as AI-based augmentation of anatomical landmarks and tissue damage protection seem to be significant requirements for the further development of laparoscopic systems.

Optimal timing for antimicrobial prophylaxis to reduce surgical site infections: a retrospective analysis of 531 patients.

It has been revealed that the administration of an antimicrobial prophylaxis (AP) reduces the rate of surgical site (SSI) following colorectal cancer surgery. Nevertheless, the optimal timing of this medication remains unclear. The aim of this study was to determine more precisely the optimal time for administering antibiotics and to see if this could reduce the number of possible surgical site infections. The files of individuals who underwent colorectal cancer surgery at the University Hospital Brandenburg an der Havel (Germany) between 2009 and 2017 were analyzed. Piperacillin/tazobactam, cefuroxime/metronidazole and mezlocillin/sulbactam were administered as AP regimens. Timing of AP was obtained. The primary objective was the rate of SSIs based on CDC criteria. Multivariate analysis took place to identify risk factors for SSIs. A total of 326 patients (61.4%) received an AP within 30 min, 166 (31.3%) between 30 and 60 min, 22 (4.1%) more than 1 h before surgery, and 15 (2.8%) after surgery. In 19 cases (3.6%) a SSI occurred during hospital stay. A multivariate analysis did not identify AP timing as a risk factor for the occurrence of SSIs. With significance, more surgical site occurrences (SSO) were diagnosed when cefuroxime/metronidazole was given. Our results suggest that AP with cefuroxime/metronidazole is less effective in reducing SSO compared with mezlocillin/sulbactam and tazobactam/piperacillin. We assume that the timing of this AP regimen of < 30 min or 30-60 min prior to colorectal surgery does not impact the SSI rate.

Gastric Balloon Implantation as Part of Morbid Adiposity Therapy Changes the Structure of the Stomach Wall.

PURPOSE: The implantation of a gastric balloon (also known as intragastric balloon) is an established and reversible endoscopic procedure for adiposity therapy. Structural changes of the stomach wall are expected to occur with gastric balloon implantation; however, until now these changes have rarely been investigated. METHODS: We compared the histological structure of the stomach wall after gastric-sleeve resection in a group of patients following gastric balloon implantation and a group without previous gastric balloon implantation. RESULTS: Following gastric balloon implantation, the tunica muscularis was found to be significantly thicker than without gastric balloon implantation. The enlarging of the tunica muscularis is not caused by hyperplasia of the leiomyocytes, but by hypertrophy of the leiomyocytes and an increase in collagen fibers (fibrosis). CONCLUSION: A longer-lasting hypertrophy of the tunica muscularis, particularly in the corpus, should be taken into account when surgical treatment follows gastric balloon implantation. The staple suture height should be adjusted to the altered tissue composition since reduced tissue elasticity must be expected due to fibrosis.

Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series.

Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.

Laparoscopic-endoscopic Rendezvous Procedures for Upper Gastrointestinal Tumors Guided by Laser-supported Reverse Diaphanoscopy: A Modified Technique.

INTRODUCTION: Precisely locating benign upper gastrointestinal tumors during laparoscopic-endoscopic surgery remains difficult and inaccurate. We describe reverse laser-supported diaphanoscopy (RLSD) for locating gastrointestinal tumors during laparoscopic surgery and present prospective evaluation results of the first cases. MATERIALS AND METHODS: We studied 13 patients [women:men=7:6; mean age, 67 (range, 41 to 83) y] who underwent gastroscopic-laparoscopic rendezvous procedures during 2015 to 2018. Surgery duration, marking duration, and specimen resection size were recorded. The largest and smallest specimen resection margins were measured. RESULTS: After locating tumors using RLSD, patients underwent successful resections. Histopathologic examination confirmed 5 cases of gastrointestinal stromal tumor; 3, neuroendocrine tumors; 2, heterotopic pancreatic tissue; 1, leiomyoma; 1, adenoma; 1, hyperplastic polyp. We employed 4 to 6 marks, depending on tumor location and size. The average marking duration was 14 minute (1 to 21 min); the average surgery duration, 73 minute (37 to 143 min). The smallest resection median margin was 2.0 mm (1.0 to 5.0 mm); the largest, 7.0 mm (2.0 to 12.0 mm). CONCLUSIONS: RLSD precisely locates gastric benign tumors during laparoscopic-endoscopic rendezvous procedures.

Giant hepatocellular carcinoma with bone metastasis in a young adult, emerged from pigmented adenoma with beta-Catenin activation: A case report.

INTRODUCTION: Hepatocellular carcinomas (HCC) that are very large in size are a very rare finding in young adult. The malignant transformation of a pigmented hepatocellular adenoma (HCA) with beta-Catenin activation is a possible cause for appearance of HCC. PRESENTATION OF CASE: We present the case of a 33-year-old male with a huge HCC with bone metastasis, emerged from pigmented HCA with beta-Catenin activation. As a two-stage surgical procedure, a left hepatectomy followed by a partial rib resection was performed. DISCUSSION: Giant hepatocellular carcinomas mostly develop in non-cirrhotic livers and at time of diagnosis an extrahepatic spread occurs in up to 15%. In the present case, the progression from a benign HCA to malignant HCC was documented, as a unique finding. Surgical resection is the only curative treatment and was successfully performed in this case. CONCLUSION: Hepatobiliary surgery with resection of metastases is the treatment with best long-term survival for patients with huge HCC. Molecular characterization as well as pigmentation analysis is useful tools for risk assessment of HCA.