Uniportal robotic assisted surgery for anatomical lung resection-First German experience.

BACKGROUND: Uniportal robotic-assisted thoracic surgery (uRATS) has emerged as a promising technique with potential advantages over multiportal approaches. This study aims to evaluate our initial outcomes of uRATS. MATERIAL AND METHODS: Five patients underwent anatomic lung resections with systematic nodal dissection through a uniportal robotic approach by one surgeon. The results were compared to the results of the first five uniportal video-assisted thoracic surgery (uVATS) anatomical resections performed by the same surgeon. RESULTS: No adverse events occurred during the uRATS-procedures. Comparable surgical outcomes were observed between uRATS and uVATS, including hospital stays, complication rates, and blood loss. The average procedural time was slightly but non-significantly longer in the uRATS-group. Average pain-scores were lower in the uRATS group. One patient in each group experienced major postoperative complications, with one case of in-hospital mortality in the uRATS-group. CONCLUSION: The outcomes of uRATS/uVATS were comparable, highlighting the potential and the feasibility of this technique. Prospective studies comparing the learning curves, complication rate and hospital-stay are required in order to justify the superiority of robotics over uVATS.

Artificial intelligence for detection of microsatellite instability in colorectal cancer-a multicentric analysis of a pre-screening tool for clinical application.

BACKGROUND: Microsatellite instability (MSI)/mismatch repair deficiency (dMMR) is a key genetic feature which should be tested in every patient with colorectal cancer (CRC) according to medical guidelines. Artificial intelligence (AI) methods can detect MSI/dMMR directly in routine pathology slides, but the test performance has not been systematically investigated with predefined test thresholds. METHOD: We trained and validated AI-based MSI/dMMR detectors and evaluated predefined performance metrics using nine patient cohorts of 8343 patients across different countries and ethnicities. RESULTS: Classifiers achieved clinical-grade performance, yielding an area under the receiver operating curve (AUROC) of up to 0.96 without using any manual annotations. Subsequently, we show that the AI system can be applied as a rule-out test: by using cohort-specific thresholds, on average 52.73% of tumors in each surgical cohort [total number of MSI/dMMR = 1020, microsatellite stable (MSS)/ proficient mismatch repair (pMMR) = 7323 patients] could be identified as MSS/pMMR with a fixed sensitivity at 95%. In an additional cohort of N = 1530 (MSI/dMMR = 211, MSS/pMMR = 1319) endoscopy biopsy samples, the system achieved an AUROC of 0.89, and the cohort-specific threshold ruled out 44.12% of tumors with a fixed sensitivity at 95%. As a more robust alternative to cohort-specific thresholds, we showed that with a fixed threshold of 0.25 for all the cohorts, we can rule-out 25.51% in surgical specimens and 6.10% in biopsies. INTERPRETATION: When applied in a clinical setting, this means that the AI system can rule out MSI/dMMR in a quarter (with global thresholds) or half of all CRC patients (with local fine-tuning), thereby reducing cost and turnaround time for molecular profiling.

[Recommendations for treatment of diverticular disease]. / Empfehlungen zur Therapie der Divertikelkrankheit.

BACKGROUND: Diverticular disease is of major clinical and health economic importance in Germany. Treatment recommendations in many international guidelines have changed significantly in recent years. The German national S2k guidelines are currently being revised. OBJECTIVE: To summarize the most important clinical aspects in the management of diverticular disease from a surgical perspective. MATERIAL AND METHODS: The recommendations were compiled based on current national and international guidelines and a selective literature search. RESULTS: Acute uncomplicated diverticulitis without risk factors can be treated on an outpatient basis without antibiotics. For patients with complicated diverticulitis, hospital admission with parenteral antibiotic treatment is recommended. In the case of abscess formation >5 cm, percutaneous drainage can be performed. The indications for immediate sigmoid resection are free perforation and failure of conservative treatment. Elective resection is indicated in chronic recurrent diverticulitis with complications; all other indications are increasingly based on the individual quality of life of the patient. CONCLUSION: Uncomplicated diverticulitis is increasingly being treated on an outpatient basis and without antibiotics. Apart from emergency settings, the indications for surgery are increasingly dependent on the quality of life. Elective sigmoid resection should be performed as laparoscopic surgery with primary anastomosis after obtaining results of computed tomography and total colonoscopy.

Incisional hernia rate after ileostomy closure in lateral pararectal stoma versus transrectal stoma placement: follow-up of the randomized PATRASTOM trial.

AIM: Because damage to the rectus abdominis muscle during ileostomy placement and reversal might be a risk factor for the development of stoma-site incisional hernia (SSIH), we hypothesized that positioning of the stoma lateral to the rectus abdominis muscle might prevent SSIH. METHOD: To investigate whether a lateral pararectal stoma position lowers the incidence of SSIH in comparison with a transrectal position, a follow-up study of the PATRASTOM trial, which had randomized stoma placement (lateral pararectal versus transrectal), was conducted. All former participants were invited simultaneously for a follow-up visit in September 2016, 2 years after database closure of the PATRASTOM trial. For patients who were not able to attend the follow-up, the electronic chart as well as MRI/CT scans were reviewed with regard to the presence of SSIH. RESULTS: Follow-up - either clinical or radiological - was available for 47 of the 60 PATRASTOM participants. The median duration of follow-up was 3.4 years (interquartile range 3.0-4.1 years). SSIH occurred in 3 of 23 patients (13.0%) in the lateral pararectal group compared with 7 of 24 patients (29.2%) in the transrectal group (P = 0.287). Four of the 10 patients diagnosed with SSIH had already undergone or were scheduled for hernia repair. Of the patient and procedure characteristics which may have an impact on the development of incisional hernia none was a significant risk factor for SSIH. CONCLUSION: In the present follow-up study, no difference in the incidence of SSIH was found between lateral pararectal and transrectal stoma construction in an elective setting.

Clinical, oncological, and functional outcomes of Da Vinci (Xi)-assisted versus conventional laparoscopic resection for rectal cancer: a prospective, controlled cohort study of 51 consecutive cases.

PURPOSE: Despite the increasing use of telemanipulators in colorectal surgery, an additional benefit in terms of improved perioperative results is not proven. The aim of the study was to compare clinical, oncological, and functional results of Da Vinci (Xi)-assisted versus conventional laparoscopic (low) anterior resection for rectal cancer. METHODS: Monocenter, prospective, controlled cohort study with a 12-month follow-up of bladder and sexual function using the validated questionnaires International Prostate Symptom Score, International Index of Erectile Function, and Female Sexual Function Index. RESULTS: Fifty-one patients were included (18, Da Vinci (Xi) assisted; 33, conventional laparoscopy). Conversion to an open approach was more common in the Da Vinci cohort (p = 0.012). In addition, surgery and resumption of a normal diet took longer in the robotic group (p = 0.005; p = 0.042). Surgical morbidity and oncological quality did not differ. There was no difference in most functional domains, except for worsened ability to orgasm (p = 0.047) and sexual satisfaction (p = 0.034) in women after conventional laparoscopy. Moreover, we found a higher rate of improved bladder function in the conventional laparoscopy group (p = 0.023) and less painful sexual intercourse among women in the robot-assisted group (p = 0.049). CONCLUSION: In contrast to the ROLARR trial, a higher conversion rate was found in the robotic cohort, which may in part be explained by a learning curve effect. Nevertheless, the Da Vinci-assisted approach showed favorable results regarding sexual function.

[The Kono-S anastomosis in surgery for Crohn's disease : First results of a new functional end-to-end anastomotic technique after intestinal resection in patients with Crohn's disease in Germany]. / Die Kono-S-Anastomose in der Chirurgie des Morbus Crohn : Erste Ergebnisse einer neuen, funktionellen End-zu-End-Anastomosentechnik nach intestinaler Resektion bei Patienten mit Morbus Crohn in Deutschland.

BACKGROUND: Recurrent disease at the anastomotic site after bowel resection represents a major problem in patients with Crohn's disease. In 2011, a new anastomotic technique (Kono-S anastomosis) was published, which as a functional end-to-end anastomosis creating a wide anastomotic diameter aimed to reduce the rate of recurrence after surgery. AIM: To evaluate the Kono-S anastomosis with respect to early and late postoperative complications and recurrence rate after surgical intestinal resection in patients with Crohn's disease at a university center. PATIENTS AND METHODS: All patients with Crohn's disease who underwent Kono-S anastomoses between June 2015 and December 2016 at the Department of Surgery, University Medical Centre Mannheim, were included in the study. After obtaining informed consent, patient data regarding surgery and hospital stay were recorded in a prospective database. Follow-up was carried out by structured telephone interviews including disease progression, medication and surveillance. Statistical analysis was performed using the Graph Pad Prism 7 software. Ethics board approval was obtained from the Medical Ethics Commission II of the Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany (No. 2017-575N-MA). RESULTS: A total of 53 patients (32 female and 21 male) were included in this study. The median procedural time was 157 min. The median follow-up was 12 months (range 4-23 months). Of the patients 3 developed early postoperative complications with a Clavien-Dindo score ≥ III and 25 patients with or without symptoms were controlled by endoscopy and/or magnetic resonance imaging (MRI) and no anastomotic recurrence was detected. No endoscopic interventions were necessary and 16 patients were symptom-free with no further specific therapy or controls. DISCUSSION: The Kono-S anastomosis is a safe anastomotic method with low morbidity. In the early follow-up recurrence rates of Crohn's disease at the anastomotic site were low. In the literature a reoperation rate of 5 % per year is given for patients with Crohn's disease after intestinal resection, so that in the long-term observation a valid statement on recurrence rate is possible. A potential advantage of the morphological end-to-end configuration of the Kono-S anastomosis is the better endoscopic dilatation compared to a side-to-side anastomosis. CONCLUSION: The Kono-S anastomotic technique has a low morbidity. In the early follow-up observational period no recurrence occurred in the anastomosis area in this series. Long-term data must clarify whether this technique is advantageous with respect to this aspect in the long run.

Survival after resection of appendiceal carcinoma by hemicolectomy and less radical than hemicolectomy: a population-based propensity score matched analysis.

AIM: The operative treatment for non-metastatic appendiceal carcinoma is controversial despite the recommendation of right hemicolectomy (RH) by many researchers. The aim of this population-based study was to compare outcomes after RH and less radical resection than right hemicolectomy (LRH). METHOD: A total of 1144 patients who underwent resection with additional lymphadenectomy of Stages I-III appendiceal carcinoma from 2004 to 2012 were identified in the Surveillance, Epidemiology and End Results database. Overall survival (OS) and cancer-specific survival (CSS) after RH and LRH were assessed by unadjusted and risk-adjusted Cox regression analysis and by propensity score matched analysis. RESULTS: A total of 855 (74.7%) patients underwent RH and 289 (25.3%) underwent LRH. In an unadjusted analysis, survival after LRH and RH did not differ in OS [hazard ratio (HR) 0.95, 95% CI 0.71-1.26, P = 0.707] and CSS (HR 0.95, 95% CI 0.69-1.32, P = 0.762). The 5-year OS and CSS in patients who underwent RH were 71.6% (95% CI 67.8-75.6%) and 76.4% (95% CI 72.8-80.3) compared with 73.8% (95% CI 67.9-80.2) and 78.7% (95% CI 73.2-84.7) in patients with LRH, respectively. No relevant difference in survival between LRH and RH could be observed in a multivariable analysis (OS, HR 0.90, 95% CI 0.65-1.25, P = 0.493; CSS, HR 0.87, 95% CI 0.60-1.26, P = 0.420) and after propensity score adjusted analysis (OS, HR 0.87, 95% CI 0.62-1.22, P = 0.442; CSS, HR 0.97, 95% CI 0.67-1.40, P = 0.883). CONCLUSIONS: In this retrospective analysis, survival after RH for non-metastatic appendiceal carcinoma was not statistically significantly superior to LRH. Hence, LRH with lymphadenectomy might be sufficient for treatment of non-metastatic appendiceal carcinoma.