Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up.

AIMS: Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial. METHODS: In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score. RESULTS: The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806]. CONCLUSION: In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. REGISTRATION NUMBER: DRKS00014690 ( https://www.drks.de ).

Wave-Vector Dependence of the Dynamics in Supercooled Metallic Liquids.

We present a detailed investigation of the wave-vector dependence of collective atomic motion in Au_{49}Cu_{26.9}Si_{16.3}Ag_{5.5}Pd_{2.3} and Pd_{42.5}Cu_{27}Ni_{9.5}P_{21} supercooled liquids close to the glass transition temperature. Using x-ray photon correlation spectroscopy in a previously uncovered spatial range of only a few interatomic distances, we show that the microscopic structural relaxation process mimics the structure and presents a marked slowing down at the main average interparticle distance. This behavior is accompanied by dramatic changes in the shape of the intermediate scattering functions, which suggest the presence of large dynamical heterogeneities at length scales corresponding to a few particle diameters. A ballisticlike mechanism of particle motion seems to govern the structural relaxation of the two systems in the highly viscous phase, likely associated with hopping of caged particles in agreement with theoretical studies.

Dissection with LigaSure Impact™ versus conventional resection in pylorus-preserving partial pancreatoduodenectomy (DISSECT): a single-institution randomized controlled trial.

PURPOSE: In partial pancreatoduodenectomy, appropriate effective hemostasis during dissection is of major importance for procedural flow, operation time, and postoperative outcome. As ligation, clipping, or suturing of blood vessels is time-consuming and numerous instrument changes are required, the primary aim of this randomized controlled trial was to assess whether LigaSure Impact™ exhibits benefits over named conventional dissection techniques in patients undergoing pylorus-preserving partial pancreatoduodenectomy. METHODS: This single-institution, randomized, superiority trial was performed between September 27, 2009, and February 24, 2012. Patients undergoing pylorus-preserving partial pancreatoduodenectomy were allocated to the study arms in a 1:1 ratio based on an unstratified block randomization with random block sizes to receive either dissection with LigaSure Impact™ or conventional dissection. The primary endpoint was operation time. Secondary endpoints included peri- and postoperative morbidity and mortality, intraoperative blood loss, and length of hospital stay. To observe a time reduction of 40 min, 51 patients per arm were required. The primary analysis was the intention to treat. RESULTS: The mean operation time did not differ between the Ligasure Impact™ (308 min; SD: 56 min; range: 155-455 min) and the conventional dissection (318 min; SD: 90 min, range: 175-550 min) (p = 0.531). Moreover, LigaSure Impact™ dissection did not show significant advantages over conventional dissection in terms of peri- and postoperative morbidity and mortality, intraoperative blood loss, or length of hospital stay. CONCLUSIONS: The application of LigaSure Impact™ dissection in pylorus-preserving partial pancreatoduodenectomy does not increase effectiveness and safety of dissection. TRIAL REGISTRATION: DRKS00000166.

Colloidal crystallite suspensions studied by high pressure small angle x-ray scattering.

We report on high pressure small angle x-ray scattering on suspensions of colloidal crystallites in water. The crystallites made out of charge-stabilized poly-acrylate particles exhibit a complex pressure dependence which is based on the specific pressure properties of the suspending medium water. The dominant effect is a compression of the crystallites caused by the compression of the water. In addition, we find indications that also the electrostatic properties of the system, i.e. the particle charge and the dissociation of ions, might play a role for the pressure dependence of the samples. The data further suggest that crystallites in a metastable state induced by shear-induced melting can relax to a similar structural state upon the application of pressure and dilution with water. X-ray cross correlation analysis of the two-dimensional scattering patterns indicates a pressure-dependent increase of the orientational order of the crystallites correlated with growth of these in the suspension. This study underlines the potential of pressure as a very relevant parameter to understand colloidal crystallite systems in aqueous suspension.

Resolving high-speed colloidal dynamics beyond detector response time via two pulse speckle contrast correlation.

We report an alternate light scattering approach to measure intermediate scattering function and structures of colloidal suspension by using two-pulse speckle contrast correlation analysis. By systematically controlling time-delays between two laser pulses incident on the sample, we are able to monitor transient evolution of coherent diffraction pattern, from which particle dynamics at different length and time scales are obtained simultaneously. Our result demonstrates the feasibility of utilizing a megapixel detector to achieve sufficient data statistics in a short amount of time while enabling microsecond time-resolution. Ultimately, this method provides means to measure high-speed dynamics well beyond the time response limit of a large area two-dimensional (2D) detector.

Single shot speckle and coherence analysis of the hard X-ray free electron laser LCLS.

The single shot based coherence properties of hard x-ray pulses from the Linac Coherent Light Source (LCLS) were measured by analyzing coherent diffraction patterns from nano-particles and gold nanopowder. The intensity histogram of the small angle x-ray scattering ring from nano-particles reveals the fully transversely coherent nature of the LCLS beam with a number of transverse mode 〈Ms〉 = 1.1. On the other hand, the speckle contrasts measured at a large wavevector yields information about the longitudinal coherence of the LCLS radiation after a silicon (111) monochromator. The quantitative agreement between our data and the simulation confirms a mean coherence time of 2.2 fs and a x-ray pulse duration of 29 fs. Finally the observed reduction of the speckle contrast generated by x-rays with pulse duration longer than 30 fs indicates ultrafast dynamics taking place at an atomic length scale prior to the permanent sample damage.

Breakdown of the x-ray resonant magnetic scattering signal during intense pulses of extreme ultraviolet free-electron-laser radiation.

We present results of single-shot resonant magnetic scattering experiments of Co/Pt multilayer systems using 100 fs long ultraintense pulses from an extreme ultraviolet (XUV) free-electron laser. An x-ray-induced breakdown of the resonant magnetic scattering channel during the pulse duration is observed at fluences of 5 J/cm(2). Simultaneously, the speckle contrast of the high-fluence scattering pattern is significantly reduced. We performed simulations of the nonequilibrium evolution of the Co/Pt multilayer system during the XUV pulse duration. We find that the electronic state of the sample is strongly perturbed during the first few femtoseconds of exposure leading to an ultrafast quenching of the resonant magnetic scattering mechanism.

Robotic-assisted paraesophageal hernia repair--a case-control study.

AIMS: The da Vinci® telemanipulation system offers a wide range of precise movements and 3D visualization with depth perception and magnification effect. Such a system could be useful for improving minimally invasive procedures-as in the case of large hiatal hernia with paraesophageal involvement (PEH) repair. Studies reporting on the robotic-assisted PEH repair are scarce, and a comparison to the standard operation techniques is lacking. Therefore, we decided to investigate the feasibility and safety of robotic-assisted surgery (RAS) compared to conventional laparoscopic (CLS) and open surgery (OS) for the first time. METHODS: We investigated 42 patients for the perioperative outcome after PEH repair. Twelve patients were operated on with RAS, 17 with CLS, and 13 with OS. Operating time, intraoperative blood loss, intra- and postoperative complications, mortality, and duration of hospital stay were analyzed in each method. RESULTS: On average, operating time in the RAS group was 38 min longer, and the intraoperative blood was loss 217 ml lower compared to OS. Both results were similar to the CLS group. The intraoperative complication rate was similar in all groups. The postoperative complication rate in the RAS group was significantly lower than the OS group, though again similar to the CLS group. The hospital stay was 5 days shorter in the RAS group than the OS group and once again similar to the CLS group. CONCLUSION: The results show that RAS is feasible and safe. It appears to be an alternative to OS due to lower intraoperative blood loss and potentially fewer postoperative complications, as well as shorter hospital stay. Though, RAS is not superior to CLS.

Comparison of two different transection techniques in liver surgery-an experimental study in a porcine model.

AIMS: Postoperative morbidity and mortality after liver resection is closely related to the degree of intraoperative blood loss; the majority of which occurs during transection of the liver parenchyma. Many approaches and devices have therefore been developed to limit bleeding, but none has yet achieved perfect results up to now. The aim of this standardized chronic animal study was to compare the safety and efficacy of the LigaSure™ Vessel Sealing System (LVSS) with the stapler technique, which is one of the modern techniques for transecting the parenchyma in liver surgery. METHODS: Sixteen pigs underwent a left liver resection (LLR). Eight pigs received a LLR by means of an Endo GIA, whereas the other eight pigs underwent liver parenchymal transection followed by simultaneous sealing by the LVSS. The operating time, transection time, blood loss during transection, and time of hemostasis were measured on the day of LLR (postoperative day 0/POD 0). Animals were re-explored on postoperative day 7 (POD 7) and the transection surface of remnant liver was observed for fluid collection (hematoma, biloma, and abscess), necrosis, and other pathologies. A biopsy was taken from the area of transection for histopathological examination. RESULTS: All animals survived until POD 7. Operating time and transection time of the liver parenchyma on POD 0 was significantly shorter in the stapler group. There was no significant difference between the two groups in terms of blood loss during transection, time of hemostasis and number of sutures for hemostasis on POD 0, morbidity rate, as well as the histopathological examination on POD 7. Furthermore, the material costs were significantly higher in the stapler group than in the LVSS group. CONCLUSION: In this standardized chronic animal study concerning transection of the parenchyma in liver surgery, LVSS seems not only to be safe, but also comparable with the stapler technique in terms of morbidity and mortality. Additionally, LVSS significantly reduces material costs. However, the transection time is significantly longer for LVSS than for the stapler resection technique.

High contrast x-ray speckle from atomic-scale order in liquids and glasses.

The availability of ultrafast pulses of coherent hard x rays from the Linac Coherent Light Source opens new opportunities for studies of atomic-scale dynamics in amorphous materials. Here, we show that single ultrafast coherent x-ray pulses can be used to observe the speckle contrast in the high-angle diffraction from liquid Ga and glassy Ni(2)Pd(2)P and B(2)O(3). We determine the thresholds above which the x-ray pulses disturb the atomic arrangements. Furthermore, high contrast speckle is observed in scattering patterns from the glasses integrated over many pulses, demonstrating that the source and optics are sufficiently stable for x-ray photon correlation spectroscopy studies of dynamics over a wide range of time scales.

Single shot spatial and temporal coherence properties of the SLAC Linac Coherent Light Source in the hard x-ray regime.

We measured the transverse and longitudinal coherence properties of the Linac Coherent Light Source (LCLS) at SLAC in the hard x-ray regime at 9 keV photon energy on a single shot basis. Speckle patterns recorded in the forward direction from colloidal nanoparticles yielded the transverse coherence properties of the focused LCLS beam. Speckle patterns from a gold nanopowder recorded with atomic resolution allowed us to measure the shot-to-shot variations of the spectral properties of the x-ray beam. The focused beam is in the transverse direction fully coherent with a mode number close to 1. The average number of longitudinal modes behind the Si(111) monochromator is about 14.5 and the average coherence time τ(c)=(2.0±1.0) fc. The data suggest a mean x-ray pulse duration of (29±14) fs behind the monochromator for (100±14) fc electron pulses.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS: A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS: A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS: Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Gelation Dynamics upon Pressure-Induced Liquid-Liquid Phase Separation in a Water-Lysozyme Solution.

Employing X-ray photon correlation spectroscopy, we measure the kinetics and dynamics of a pressure-induced liquid-liquid phase separation (LLPS) in a water-lysozyme solution. Scattering invariants and kinetic information provide evidence that the system reaches the phase boundary upon pressure-induced LLPS with no sign of arrest. The coarsening slows down with increasing quench depths. The g2 functions display a two-step decay with a gradually increasing nonergodicity parameter typical for gelation. We observe fast superdiffusive (γ ≥ 3/2) and slow subdiffusive (γ < 0.6) motion associated with fast viscoelastic fluctuations of the network and a slow viscous coarsening process, respectively. The dynamics age linearly with time τ ∝ tw, and we observe the onset of viscoelastic relaxation for deeper quenches. Our results suggest that the protein solution gels upon reaching the phase boundary.

X-ray holographic microscopy with zone plates applied to biological samples in the water window using 3rd harmonic radiation from the free-electron laser FLASH.

The imaging of hydrated biological samples - especially in the energy window of 284-540 eV, where water does not obscure the signal of soft organic matter and biologically relevant elements - is of tremendous interest for life sciences. Free-electron lasers can provide highly intense and coherent pulses, which allow single pulse imaging to overcome resolution limits set by radiation damage. One current challenge is to match both the desired energy and the intensity of the light source. We present the first images of dehydrated biological material acquired with 3rd harmonic radiation from FLASH by digital in-line zone plate holography as one step towards the vision of imaging hydrated biological material with photons in the water window. We also demonstrate the first application of ultrathin molecular sheets as suitable substrates for future free-electron laser experiments with biological samples in the form of a rat fibroblast cell and marine biofouling bacteria Cobetia marina.

Slow aging dynamics and avalanches in a gold-cadmium alloy investigated by x-ray photon correlation spectroscopy.

Results of a x-ray photon correlation spectroscopy experiment on the very weakly first order martensitic transformation of a Au50.5Cd49.5 single crystal are presented. Slow non-equilibrium-dynamics are observed in a narrow temperature interval in the direct vicinity of the otherwise athermal phase transformation. These dynamics are associated with the martensite-aging effect. The dynamical aging is accompanied by an avalanchelike behavior which is identified with an incubation-time phenomenon.

Imaging the in-plane magnetization in a Co microstructure by Fourier transform holography.

We report on experiments using Fourier transform holography to image the in-plane magnetization of a magnetic microstructure. Magnetic sensitivity is achieved via the x-ray magnetic circular dichroism effect by recording holograms in transmission at off-normal incidence. The reference beam is defined by a narrow hole milled at an inclined angle into the opaque mask. We present magnetic domain images of an in-plane magnetized cobalt element with a size of 2 µm × 2 µm× 20 nm. The domain pattern shows a multi-vortex state that deviates from the simple Landau ground state.

Dynamics at the liquid-vapor interface of a supercooled organic glass former.

We investigated the dynamics near the liquid-vapor interface of the supercooled model organic glass former dibutyl phthalate by using surface-sensitive x-ray scattering techniques. Our results reveal significant enhancement of the relaxation rate over a wide length-scales range. The analysis of the dispersion relation of long-wavelength surface fluctuations yields a nonzero value of the share modulus near the free surface. At the molecular level, the dynamics in the near surface region (10-15 nm) is inhomogeneous. The mobility is decreasing with increasing distance from the free surface. Below the bulk glass transition, two distinct relaxation times were observed differing by 1 order of magnitude. The observed fast relaxation proves the existence of a high mobility liquidlike surface layer of 10 nm thickness on top of a frozen in bulk system.

Measuring temporal speckle correlations at ultrafast x-ray sources.

We present a new method to extract the intermediate scattering function from series of coherent diffraction patterns taken with 2D detectors. Our approach is based on analyzing speckle patterns in terms of photon statistics. We show that the information obtained is equivalent to the conventional technique of calculating the intensity autocorrelation function. Our approach represents a route for correlation spectroscopy on ultrafast timescales at X-ray free-electron laser sources.

Success and complication parameters for laparoscopic surgery: a benchmark for natural orifice transluminal endoscopic surgery.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) currently represents an issue of particular interest among surgeons and gastroenterologists. The principle of NOTES is the reduction of the operative trauma by using natural orifices of the human body to access the abdominal cavity. Regarding the tendency to further minimization of the surgical trauma, NOTES may be considered as a logical step in the evolution of minimally invasive surgery. Pioneers of this technique regard NOTES as the successor to laparoscopic surgery in enabling surgeons and gastroenterologists to conduct scarless surgery. This might not only lead to better cosmetic results but also enhance the prospect of decreases in wound infections and incisional hernias, as well as reducing operative stress, postoperative immobility, and pain. MATERIAL AND METHODS: In this article the authors collect and review the existing literature concerning NOTES and establish a benchmark for the assessment of this new technique by stating results from conventional minimally invasive surgery as the gold standard. CONCLUSION: It is shown that publications investigating possible advantages or long-term results of NOTES are scarce. However, the investigation and verification of potential advantages and disadvantages represent the most important step in the development of a new technique. Only proven advantages would justify the broad implementation of a new technique in relation to its specific risks. Conventional laparoscopic surgery as the current standard of minimally invasive surgery will be the benchmark for NOTES with regard to most issues. Superiority of NOTES in at least several issues would be the best argument for its further implementation into clinical practice.

No relevant difference in quality of life and functional outcome at 12 months' follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication.

PURPOSE: The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD). METHODS: Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients' QOL and functional outcome were investigated using disease-specific questionnaires. RESULTS: There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group. CONCLUSION: The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months' follow-up.