[How I Teach It: Robotic Surgery in the Upper GI Tract]. / How I Teach It: robotische Chirurgie am oberen Gastrointestinaltrakt.

In this manuscript, we present our concept for training in robotic surgery of the upper gastrointestinal tract. The training concept presented here focuses on the two surgical "user groups", assistants (table assists) and specialists (surgeons), and presents the core aspects of training for each group separately.For table assistants, we present opportunities for early involvement in robotics and our approach to learning the first steps in preparing for surgery, assisting during surgery, as well as communication as a key factor in robotic surgery and alternative training.For specialists who are to learn how to perform robotic procedures independently, we discuss virtual training using SimNow Trainer and our preferred early clinical application. We will also present assistance options such as the dual console setup and the telestration system. Finally, we present our training concept for developing robotic surgical skills in the upper gastrointestinal tract through a combination of partial steps and increasing difficulty of the procedures. In our view, it is essential to teach the stepstones of robotic surgery and to master them safely. To this end, training must be structured and regular so that more complex sub-steps and procedures can be taken over step by step.

NCR, an Inflammation and Nutrition Related Blood-Based Marker in Colon Cancer Patients: A New Promising Biomarker to Predict Outcome.

Background: Colorectal carcinoma (CRC) is a heterogeneous disease, and differences in outcomes have been reported among patients diagnosed with the same disease stage. Prognostic and predictive biomarkers provide information for patient risk stratification and guide treatment selection. Although numerous studies have analyzed the effects of systemic inflammatory factors on CRC outcomes, clinical significance remains to be elucidated. In particular, the treatment strategy of colon cancer patients is different from that of rectal cancer due to outcome and recurrence differences. The identification of patients with a poor prognosis who might benefit from intensive treatment approaches is clinically necessary. Methods: This study aimed to evaluate the value of different blood-based markers and assess the significance of our newly developed inflammatory-nutrition-related biomarker (NCR = BMI × albumin/CRP) in patients with colon cancer. A two-stage design was used with 212 patients with colon cancer (CC) in the discovery cohort (n = 159) and in an external validation cohort (n = 53). Results: A lower preoperative NCR level was significantly correlated with a worse prognosis, sidedness, undifferentiated histology, nodal involvement, and advanced UICC stage. We compared the NCR with other established prognostic indices and showed that the NCR is a more reliable indicator of a poor prognosis for patients with CC. Patients with low NCR levels experienced a significantly shorter Overall Survival (OS) than patients with high levels. Multivariate analysis confirmed preoperative NCR levels as an independent predictor for overall survival with a hazard ratio of 3.3 (95% confidence interval 1.628−6.709, p < 0.001). Finally, we confirmed the predictive value of the NCR in an independent validation cohort and confirmed NCR as an independent prognostic factor for OS. Conclusion: Taken together, we discovered a new prognostic index (NCR) based on BMI, albumin, and CRP levels as an independent prognostic predictor of OS in patients with colon cancer. In all UICC stages, our newly developed NCR marker is able to distinguish patients with better and worse prognoses. We, therefore, propose that NCR may serve as a supplement to the TNM staging system to optimize the risk stratification in CC patients towards personalized oncology. In particular, NCR can be used in clinical trials to stratify patients with UICC II and III tumors and help better select patients who might benefit from adjuvant treatment.

Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis.

PURPOSE: Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis. METHODS: We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess. RESULTS: Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50 years and a diameter of the appendix in the sonography ≥ 13 mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy. CONCLUSION: Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.

Treatment with the Neurotrophic Protein S100B Increases Synaptogenesis after Traumatic Brain Injury.

Release of neurotrophic and growth factors such as S100 calcium-binding protein B (S100B) yields an endogenous repair mechanism following traumatic brain injury (TBI). Although nanomolar S100B concentrations enhance hippocampal progenitor cell proliferation, neuronal differentiation, and cognitive recovery, micromolar concentrations may foster inflammatory effects counteracting neuroplasticity. The purpose of the present study was to investigate the effect of S100B on synaptogenesis and microglial activation following experimental TBI. Male Sprague-Dawley rats (n = 40) were subjected to lateral fluid percussion or sham injury, and S100B (50 ng/h) or phosphate buffered saline (PBS) was infused into the lateral ventricle for 7 days using osmotic micropumps. The animals were euthanized on day 5 or, 5 weeks post-injury, and 5 µm sections, 100 µm apart (bregma -3.3 to -5.6mm) were analyzed histologically. Cell proliferation was assessed injecting the mitotic marker Bromodeoxyuridine (BrdU) on day 2. S100B enhanced significantly the synaptophysin (SYN) expression and microglial activation (ectodysplasin [ED1]) in the hippocampus in TBI and uninjured sham animals. The glial activation (glial fibrillary acidic protein [GFAP], S100B immunoreactive cells), axonal injury (APP) and cell death (terminal deoxynucleotidyl transferase dUTP nick end labeling [TUNEL]) were not altered. Triple-labelling with BrdU, NeuN, and SYN confirmed a significant participation of S100B in hippocampal synaptogenesis in TBI and uninjured sham animals. Our results demonstrate that S100B augments hippocampal neuro- and synaptogenesis in TBI and uninjured sham animals, thereby improving cognitive function as demonstrated earlier. The S100B-induced microglial activation does not counteract this effect within the first 5weeks. Further studies are required to elucidate respective cellular signaling mechanisms and possible long-term effects.

Comparison of Cinematic Rendering and Computed Tomography for Speed and Comprehension of Surgical Anatomy.

Importance: Three-dimensional (3-D) volume rendering has been shown to improve visualization in general surgery. Cinematic rendering (CR), a novel 3-D visualization technology for postprocessing of computed tomographaphy (CT) images, provides photorealistic images with the potential to improve visualization of anatomic details. Objective: To determine the value of CR for the comprehension of the surgical anatomy. Design, Setting, and Participants: This preclinical, randomized, 2-sequence crossover study was conducted from February to November 1, 2018, at University Hospital of Erlangen, Germany. The 40 patient cases were evaluated by 18 resident and attending surgeons using a prepared set of CT and CR images. The patient cases were randomized to 2 assessment sequences (CR-CT and CT-CR). During each assessment period, participants answered 1 question per case that addressed crucial issues of anatomic understanding, preoperative planning, and intraoperative strategies. After a washout period of 2 weeks, case evaluations were crossed over to the respective second image modality. Main Outcomes and Measures: The primary outcome measure was the correctness of answers. Secondary outcome was the time needed to answer. Results: The mean (SD) interperiod differences for the percentage of correct answers in the CR-CT sequence (8.5% [7.0%]) differed significantly from those in the CT-CR sequence (-13.1% [6.3%]) (P < .001). The mean (SD) interperiod differences for the time spent to answer the questions in the CR-CT sequence (-18.3 [76.9] seconds) also differed significantly from those in the CT-CR sequence (52.4 [88.5] seconds) (P < .001). Subgroup analysis revealed that residents as well as attending physicians benefitted from CR visualization. Analysis of the case assessment questionnaire showed that CR added significant value to the comprehension of the surgical anatomy (overall mean [SD] score, 4.53 [0.75]). No carryover or period effects were observed. Conclusions and Relevance: The visualization with CR allowed a more correct and faster comprehension of the surgical anatomy compared with conventional CT imaging, independent of level of surgeon experience. Therefore, CR may assist general surgeons with preoperative preparation and intraoperative guidance.

Prognostic subdivision of pT2 rectal carcinomas.

PURPOSE: The aim of the present study is to explore the prognostic impact of a subdivision of pT2 by the depth of invasion into the muscularis propria in rectal carcinomas. METHODS: Data from 269 consecutive patients with rectal carcinoma treated with primary tumor resection and lymph node dissection between 1986 and 2012 were analyzed with respect to locoregional and distant recurrence, disease-free survival, and overall survival. The depth of invasion into the muscularis propria of pT2 carcinomas was categorized by the pathologist into two groups: pT2a, invasion into the inner half of the muscularis propria; pT2b, invasion into the outer half of the muscularis propria. RESULTS: One hundred nineteen of the 269 patients (44.2%) were classified pT2a and 150 patients (55.8%) were classified pT2b. In univariate analysis, significant differences between pT2a and pT2b carcinomas were found for locoregional recurrences (5-year rates 5.3 vs 14.0%; p = 0.025), distant metastases (14.1 vs 18.7%; p = 0.026), disease-free survival (78.2 vs 62.5%; p = 0.022), and overall survival (87.4 vs 72.5%; p = 0.013). In multivariate Cox regression analysis, the pT2 subdivision was found to be an independent risk factor for locoregional recurrence (hazard ratio 2.6; p = 0.023), disease-free survival (HR 1.4; p = 0.022), and overall survival (HR 1.5; p = 0.020), but only marginally for distant metastasis (HR 1.7; p = 0.083). Other independent prognostic factors were lymph node status, lymphatic invasion, and grading. CONCLUSIONS: The depth of invasion into the muscularis propria is an independent prognostic factor for pT2 rectal carcinomas that will support decision-making for preoperative, surgical, and postoperative treatment.