Drainless robot-assisted minimally invasive oesophagectomy-randomized controlled trial (RESPECT).

BACKGROUND: The purpose of this randomized trial is to evaluate the early removal of postoperative drains after robot-assisted minimally invasive oesophagectomy (RAMIE). Evidence is lacking about feasibility, associated pain, recovery, and morbidity. METHODS/DESIGN: This is a randomized controlled multicentric trial involving 72 patients undergoing RAMIE. Patients will be allocated into two groups. The "intervention" group consists of 36 patients. In this group, abdominal and chest drains are removed 3 h after the end of surgery in the absence of contraindications. The control group consists of 36 patients with conventional chest drain management. These drains are removed during the further postoperative course according to a standard algorithm. The primary objective is to investigate whether postoperative pain measured by NRS on the second postoperative day can be significantly reduced in the intervention group. Secondary endpoints are the intensity of pain during the first week, analgesic use, number of postoperative chest X-ray and CT scans, interventions, postoperative mobilization (steps per day as measured with an activity tracker), postoperative morbidity and mortality. DISCUSSION: Until now, there have been no trials investigating different intraoperative chest drain strategies in patients undergoing RAMIE for oesophageal cancer with regard to perioperative complications until discharge. Minimally invasive approaches combined with enhanced recovery after surgery (ERAS) protocols lower morbidity but still include the insertion of chest drains. Reduction and early removal have been proposed after pulmonary surgery but not after RAMIE. The study concept is based on our own experience and the promising current results of the RAMIE procedure. Therefore, the presented randomized controlled trial will provide statistical evidence of the effectiveness and feasibility of the "drainless" RAMIE. TRIAL REGISTRATION: ClinicalTrials.gov NCT05553795. Registered on 23 September 2022.

Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)?

PURPOSE: We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study. METHODS: Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP. RESULTS: We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group. CONCLUSION: Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.

How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery.

PURPOSE: Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. METHODS: All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. RESULTS: Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. CONCLUSIONS: The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

[Rectal neuroendocrine tumors: surgical therapy]. / Rektale neuroendokrine Tumoren: chirurgische Therapie.

The incidence of rectal neuroendocrine tumors (NET) has increased in recent years. Most of these neoplasms are asymptomatic and are diagnosed by colonoscopy screening, which could be one of the reasons for the increasing occurrence. As less than 1 % of rectal NET produce serotonin they are practically never discovered due to a carcinoid syndrome. The current guidelines of the European (ENETS) and North American (NANETS) Neuroendocrine Tumor Societies support clinicians with useful diagnostic and treatment algorithms. The most important criteria for therapy are tumor size and histopathological risk factors for metastases. For well-differentiated rectal neuroendocrine neoplasms < 1 cm, local endoscopic or surgical excision is recommended. Due to the lack of evidence tumors sized 1-2 cm represent a grey area for prognosis and treatment. All NET > 1.5 cm must be excised by radical surgery as low anterior rectal resection or abdominoperineal extirpation with total mesorectal excision (TME). Resectable liver and lung metastases of well-differentiated NETs should be surgically treated with curative intent.