Robotic-Assisted versus Laparoscopic Surgery for Rectal Cancer: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center.

Background: The popularity of robotic-assisted surgery for rectal cancer is increasing, but its superiority over the laparoscopic approach regarding safety, efficacy, and costs has not been well established. Methods: A retrospective single-center study was conducted comparing consecutively performed robotic-assisted and laparoscopic surgeries for rectal cancer between 1 January 2016 and 31 September 2021. In total, 125 adult patients with sporadic rectal adenocarcinoma (distal extent ≤ 15 cm from the anal verge) underwent surgery where 66 were operated on robotically and 59 laparoscopically. Results: Severe postoperative complications occurred less frequently with robotic-assisted compared with laparoscopic surgery, as indicated by Clavien-Dindo classification grades 3b-5 (13.6% vs. 30.5%, p = 0.029). Multiple logistic regression analyses after backward selection revealed that robotic-assisted surgery was associated with a lower rate of total (Clavien-Dindo grades 1-5) (OR = 0.355; 95% CI 0.156-0.808; p = 0.014) and severe postoperative complications (Clavien-Dindo grades 3b-5) (OR = 0.243; 95% CI 0.088-0.643; p = 0.005). Total inpatient costs (median EUR 17.663 [IQR EUR 10.151] vs. median EUR 14.089 [IQR EUR 12.629]; p = 0.018) and surgery costs (median EUR 10.156 [IQR EUR 3.551] vs. median EUR 7.468 [IQR EUR 4.074]; p < 0.0001) were higher for robotic-assisted surgery, resulting in reduced total inpatient profits (median EUR -3.196 [IQR EUR 9.101] vs. median EUR 232 [IQR EUR 6.304]; p = 0.004). Conclusions: In our study, robotic-assisted surgery for rectal cancer resulted in less severe and fewer total postoperative complications. Still, it was associated with higher surgery and inpatient costs. With increasing experience, the operative time may be reduced, and the postoperative recovery may be further accelerated, leading to reduced surgery and total inpatient costs.

Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Surgical Site Infection in Patients with Inflammatory Bowel Disease-A Monocentric, Retrospective Cohort Study.

(1) Background: Surgical site infections (SSIs) are a relevant problem with a 25% incidence rate after elective laparotomy due to inflammatory bowel disease (IBD). The aim of this study was to evaluate whether stricter hygienic measures during the COVID-19 pandemic influenced the rate of SSI. (2) Methods: This is a monocentric, retrospective cohort study comparing the rate of SSI in patients with bowel resection due to IBD during COVID-19 (1 March 2020-15 December 2021) to a cohort pre-COVID-19 (1 February 2015-25 May 2018). (3) Results: The rate of SSI in IBD patients with bowel resection was 25.8% during the COVID-19 pandemic compared to 31.8% pre-COVID-19 (OR 0.94; 95% CI 0.40-2.20; p = 0.881). There were seventeen (17.5%) superficial and four (4.1%) deep incisional and organ/space SSIs, respectively, during the COVID-19 pandemic (p = 0.216). There were more postoperative intra-abdominal abscesses during COVID-19 (7.2% vs. 0.9%; p = 0.021). The strictness of hygienic measures (mild, medium, strict) had no influence on the rate of SSI (p = 0.553). (4) Conclusions: Hygienic regulations in hospitals during COVID-19 did not significantly reduce the rate of SSI in patients with bowel resection due to IBD. A ban on surgery, whereby only emergency surgery was allowed, was likely to delay surgery and exacerbate the disease, which probably contributed to more SSIs and postoperative complications.

Role of visceral fat on postoperative complications and relapse in patients with Crohn's disease after ileocecal resection: Is it overrated?

INTRODUCTION: The role of visceral fat in disease development, particularly in Crohn´s disease (CD), is significant. However, its preoperative prognostic value for postoperative complications and CD relapse after ileocecal resection (ICR) remains unknown. This study aims to assess the predictive potential of preoperatively measured visceral and subcutaneous fat in postoperative complications and CD recurrence using magnetic resonance imaging (MRI). The primary endpoint was postoperative anastomotic leakage of the ileocolonic anastomosis, with secondary endpoints evaluating postoperative complications according to the Clavien Dindo classification and CD recurrence at the anastomosis. METHODS: We conducted a retrospective analysis of 347 CD patients who underwent ICR at our tertiary referral center between 2010 and 2020. We included 223 patients with high-quality preoperative MRI scans, recording demographics, postoperative outcomes, and CD recurrence rates at the anastomosis. To assess adipose tissue distribution, we measured total fat area (TFA), visceral fat area (VFA), subcutaneous fat area (SFA), and abdominal circumference (AC) at the lumbar 3 (L3) level using MRI cross-sectional images. Ratios of these values were calculated. RESULTS: None of the radiological variables showed an association with anastomotic leakage (TFA p = 0.932, VFA p = 0.982, SFA p = 0.951, SFA/TFA p = 0.422, VFA/TFA p = 0.422), postoperative complications, or CD recurrence (TFA p = 0.264, VFA p = 0.916, SFA p = 0.103, SFA/TFA p = 0.059, VFA/TFA p = 0.059). CONCLUSIONS: Radiological visceral obesity variables were associated with postoperative outcomes or clinical recurrence in CD patients undergoing ICR. Preoperative measurement of visceral fat measurement is not specific for predicting postoperative complications or CD relapse.

Immune Phenotypic Characterization of a TRAIL-Knockout Mouse.

The TNF-superfamily member TRAIL is known to mediate selective apoptosis in tumor cells suggesting this protein as a potential antitumor drug target. However, initial successful pr-clinical results could not be translated into the clinic. Reasons for the ineffectiveness of TRAIL-targeting in tumor therapies could include acquired TRAIL resistance. A tumor cell acquires TRAIL resistance, for example, by upregulation of antiapoptotic proteins. In addition, TRAIL can also influence the immune system and thus, tumor growth. We were able to show in our previous work that TRAIL-/- mice show improved survival in a mouse model of pancreatic carcinoma. Therefore, in this study we aimed to immunologically characterize the TRAIL-/- mice. We observed no significant differences in the distribution of CD3+, CD4+, CD8+ T-cells, Tregs, and central memory CD4+ and CD8+ cells. However, we provide evidence for relevant differences in the distribution of effector memory T-cells and CD8+CD122+ cells but also in dendritic cells. Our findings suggest that T-lymphocytes of TRAIL-/- mice proliferate at a lower rate, and that the administration of recombinant TRAIL significantly increases their proliferation, while regulatory T-cells (Tregs) from TRAIL-/- mice are less suppressive. Regarding the dendritic cells, we found more type-2 conventional dendritic cells (DC2s) in the TRAIL-/- mice. For the first time (to the best of our knowledge), we provide a comprehensive characterization of the immunological landscape of TRAIL-deficient mice. This will establish an experimental basis for future investigations of TRAIL-mediated immunology.

Robotic-Assisted versus Laparoscopic Proctectomy with Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: An Analysis of Clinical and Financial Outcomes from a Tertiary Referral Center.

Background: Robotic-assisted colorectal surgery is gaining popularity, but limited data are available on the safety, efficacy, and cost of robotic-assisted restorative proctectomy with the construction of an ileal pouch and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Methods: A retrospective study was conducted comparing consecutively performed robotic-assisted and laparoscopic proctectomy with IPAA between 1 January 2016 and 31 September 2021. In total, 67 adult patients with medically refractory UC without proven dysplasia or carcinoma underwent surgery: 29 operated robotically and 38 laparoscopically. Results: There were no differences between both groups regarding postoperative complications within 30 days according to Clavien-Dindo classification' grades 1−5 (51.7% vs. 42.1%, p = 0.468) and severe grades 3b−5 (17.2% vs. 10.5%, p = 0.485). Robotic-assisted surgery was associated with an increased urinary tract infection rate (n = 7, 24.1% vs. n = 1, 2.6%; p = 0.010) and longer operative time (346 ± 65 min vs. 281 ± 66 min; p < 0.0001). Surgery costs were higher when operated robotically (median EUR 10.377 [IQR EUR 4.727] vs. median EUR 6.689 [IQR EUR 3.170]; p < 0.0001), resulting in reduced total inpatient profits (median EUR 110 [IQR EUR 4.971] vs. median EUR 2.853 [IQR EUR 5.386]; p = 0.001). Conclusion: Robotic-assisted proctectomy with IPAA can be performed with comparable short-term clinical outcomes to laparoscopy but is associated with a longer duration of surgery and higher surgery costs. As experience increases, some advantages may become evident regarding operative time, postoperative recovery, and length of stay. The robotic procedure might then become cost-efficient.

[The importance of radiotherapy in rectal cancer-an update from a surgeon's perspective]. / Der Stellenwert der Strahlentherapie beim Rektumkarzinom ­ ein Update aus Sicht des Chirurgen.

BACKGROUND: Neoadjuvant chemoradiotherapy was implemented in the treatment of rectal cancer for UICC stages II and III in 2004. Recent studies have provided new insights with respect to the indications and sequence of radiotherapy in the concept of multimodal treatment. OBJECTIVE: The aim of the study was to review the status of radiotherapy in the context of current developments in the treatment of rectal cancer, such as magnetic resonance imaging (MRI)-based surgery, total neoadjuvant therapy and the watch and wait strategy for complete clinical remission. RESULTS: The indications for neoadjuvant radiotherapy based on the clinical T and N stages are not exact and can lead to overtreatment in 18-27% of cases. Radiotherapy is associated with a worsening of anorectal and urogenital functions. Local recurrence rates of 3% with surgery alone can be achieved in patients with negative circumferential resection margins (low risk cancer) in MRI. For rectal cancer with high-risk features, such as cT4 tumor, positive circumferential resection margins and extramural vascular invasion, an improved disease-free survival and a lower rate of distant metastases could be achieved with total neoadjuvant therapy compared to standard neoadjuvant chemoradiotherapy in recent phase III randomized trials. Pathological complete remission is achieved in 28% of patients after total neoadjuvant therapy. CONCLUSION: The high rate of complete remission has fired the debate regarding watch and wait after total neoadjuvant therapy; however, no prospective randomized phase III trials comparing total mesorectal resection vs. watch and wait in complete clinical remission have been published. Hence, resection remains the gold standard in this scenario given the excellent long-term oncological results.

[Surgical site infections-Prevention and treatment strategies]. / Postoperative Wundinfektionen ­ Vermeidungs- und Behandlungsstrategien.

Surgical site infections (SSI) are the most frequent nosocomial infection in Germany. They are defined as an infection of the surgical site that occurs within 30 days after a surgical procedure. The diagnostic criteria include localized pain or tenderness, localized swelling, erythema, excess warmth, purulent drainage from the incision and cultural detection of pathogens in an aseptically obtained specimen from the incision. Wound infections are differentiated into superficial incisional (grade 1), deep incisional (grade 2) and infections of organs and body cavities in the region of the operation (grade 3). Risk factors for SSI include anemia, immunosuppression, diabetes mellitus, obesity, smoking and malnutrition. The crucial preoperative preventive measures are antisepsis of the surgical area and antibiotic prophylaxis. Intraoperative subcutaneous wound irrigation with an antiseptic solution reduces SSI in visceral surgery. The primary treatment encompasses the liberal debridement of the wound.

Oligosymptomatic vs. symptomatic incisional hernias--who benefits from open repair?

INTRODUCTION: Incisional hernias are one of the most often complications in abdominal surgery and therefore present a significant surgical and socioeconomic problem. To date, incisional hernias are always an indication for surgery, regardless of the patient's symptoms. However, it remains unclear to what extent the surgery actually results in symptomatic improvement and whether a relevant risk of incarceration exists. The purpose of this study was to investigate the motivation that led to incisional hernia repairs and whether patients benefit from surgery with regard to pain and subjective criteria. MATERIALS AND METHODS: This prospective study included patients who underwent open abdominal incisional hernia repair using mesh implantation. Data collection was done preoperatively and 6 months postoperatively. The intensity of pain was evaluated using the Numeric Analog Scale (NAS). Patients were divided according to their preoperative level of pain into oligosymptomatic (NAS 0-3) and symptomatic (NAS 4-10) groups, and the postoperative outcome of both groups was compared. RESULTS: Ninety patients were prospectively enrolled: 45 males (50.0%) and 45 females (50.0%); 43 patients (47.8%) were oligosymptomatic preoperatively, while 47 patients (52.2%) reported relevant pain. The most frequent motivation for surgery named by the oligosymptomatic patients was fear of incarceration (79.1%), while the symptomatic patients mostly mentioned pain (76.6%). At 6 months postoperatively, significantly more oligosymptomatic patients complained of relevant pain (p < 0.001). In the symptomatic patient group, there was a significant reduction in relevant pain (p < 0.001). At that time, the level of relevant pain was comparable in both groups (33.3% versus 35.6%). Seven of 87 patients (8.0%) experienced recurrence within 6 months. Three patients with acute incarceration were treated with emergency repair (3.2%). CONCLUSIONS: In patients with oligosymptomatic incisional hernias, fear of incarceration is the most frequent motivation for surgical treatment, even though the actual risk of incarceration seems to be rather low. If the incisional hernia causes relevant discomfort preoperatively, the surgery provides significant relief. In contrast, there is no improvement regarding pain in the oligosymptomatic patient group. This leads to the conclusion that, in the case of oligosymptomatic incisional hernias, the general indication for surgical revision should be viewed critically.

Sustainability of skill courses for general and visceral surgery--evaluation of the long-term effect.

BACKGROUND: Surgical skills courses are becoming increasingly popular. This study focuses on their long-term effects. PARTICIPANTS AND METHODS: Participants in a 1-week general and visceral surgery course were included. Exercises in conventional and laparoscopic surgery were conducted under tutor guidance. Eighteen months after the course at the earliest (18-90), all participants (n = 756) from 1999 to 2005 received a standardized questionnaire on the surgical training situation, the learning success, the implementation of acquired skills in routine clinical practice, and the value of skills courses. RESULTS: We evaluated 459 of 756 participants (60.7%). The percentage of participants fully confident in their ability to suture a simple and a difficult anastomosis increased from 56.9% and 21.6% before to 93.5% and 59.3% after the course (p < 0.05). An improved surgical technique after the course was reported by 86.9%. Instrument handling changed after the course in 76.9%, and 68.1% stuck to this change. The evaluation showed that 89.5% wanted skill courses to become an integral part of surgical training. CONCLUSION: Participants in a general and visceral surgery course profit from long-term modification and improvement of their surgical technique. The course is still rated positively many years later. A 1-week skills course in general and visceral surgery is an attractive module with long-term effects on surgical training.

Laparoscopic and open inguinal hernia repair with alloplastic material: do the subjective and objective parameters differ in the long-term course?

INTRODUCTION: Management with alloplastic materials has become the standard procedure in inguinal hernia surgery. The aim of this study was to evaluate the long-term results after laparoscopic and open groin hernia repair with alloplastic material in a large patient population. MATERIALS AND METHODS: We included patients in the study who underwent elective laparoscopic total extraperitoneal (TEP) inguinal hernia repair or Lichtenstein surgery between January 1998 and December 2004 for either unilateral or bilateral inguinal hernia. Patient data were recorded by a prospective online data recording system and evaluated after a minimum follow-up time of 12 (12 to 103) months by standardized questionnaires. Both objective (chronic pain, chronic dysesthesia, recurrence, and postoperative recovery) and subjective (cosmetic result, scar formation, and the choice of surgical procedure) parameters were surveyed. RESULTS: Seven hundred eighty-two patients with 923 inguinal hernias underwent surgery in the study period. Five hundred fifty-three patients returned the questionnaire; 62 died during the follow-up. In the remaining 491 patients, TEP was used in 292 patients (375 hernias) and the Lichtenstein procedure in 199 patients (206 hernias). TEP was significantly superior to the Lichtenstein procedure for 2 objective parameters: chronic dysesthesia and return to normal work. Regarding the subjective parameters, TEP was superior in the cosmetic results and the choice of surgical procedure. 3.1% of the patients after TEP versus 8.5% after Lichtenstein were dissatisfied with the cosmetic result (P=0.008). If secondary inguinal hernia surgery were required, 89.4% of the patients would choose TEP again versus 76.1% the Lichtenstein procedure (P<0.001). CONCLUSIONS: Whereas the Lichtenstein procedure was not significantly better in any of the evaluated parameters, TEP was superior especially in the subjective parameters.