Wissenschaftliches Programm

Background: The management of malignant pleural mesothelioma (MPM) remains challenging with poor patient survival. Local therapies such as hyperthermic intrathoracic cisplatin (HITOC) have shown good tumor control in selected patients. HITOC was shown to increase MPM drug exposure while limiting systemic side effects but alternative mechanisms for HITOC are still lacking. Here, we hypothesized that HITOC induces an immune response directed against MPM which decreases cancer related mortality.

Methods: A perfusion circuit was downsized to administer cisplatin in the thoracic cavity of MPM bearing mice at normo (37°C, ITOC) or hyperthermic (39°C, HITOC) conditions for 30 minutes. Tumor platinum content and distribution were determined by inductively coupled plasma mass spectrometry (ICP-MS) and by laser ablation ICP-MS respectively. The impact of (H)ITOC on the MPM immune microenvironment was questioned using flow cytometry and immunohistochemistry. Tumor growth and survival was assessed in immunocompetent and T-cell deficient mice. Finally, the combination of HITOC with anti-CTLA-4 and anti-PD-1 antibodies was evaluated in immunocompetent animals.  

Results: MPM tumor control and mouse survival were significantly improved by HITOC compared to controls (ITOC, saline 37 and 39°C). This correlated with higher tumor platinum content that was mainly located at the surface of tumors. Furthermore, HITOC enhanced MPM infiltration by cytotoxic T-cells and decreased the level of protumor  (M2-like) macrophages at day 7. The beneficial impact of HITOC on tumor control and mice survival was lost in immunocompromised animals. Interestingly, HITOC significantly induced PD-1 and CTLA-4 immune checkpoint molecules expression and administration of dual immune checkpoint blockade after HITOC increased of almost two fold the median survival of the animals.

Conclusions: HITOC improves MPM control through a T lymphocyte immune mediated response. The potentiation of the immune checkpoint blockade response by HITOC opens new perspectives for the combination of immune checkpoint inhibitors with HITOC in clinic.

Background: Neuroblastoma is the most common solid childhood tumor outside the central nervous system. Metastatic and relapsed disease in neuroblastoma patients still has a poor prognosis. New treatment methods to improve therapy and outcomes for patients with advanced neuroblastoma are urgently needed. However, clinical trials currently only allow for testing few substances in even fewer patients. This increases the need to improve and advance preclinical tumor models to preselect favorable candidates for novel therapeutics.

Aims: This study investigates the advantages and limitations of using bioreactor-based perfused 3D models in for preclinical drug testing in solid tumors exemplified in neuroblastoma.

Materials and Methods: We established perfused bioreactor-based 3D models using neuroblastoma cell lines and tissue slice-culture and evaluated cell viability. Several inhibitors against hypoxia-related factors, associated with tumor progression, were tested including Aqb011 against aquaporin 1 (AQP1) and SLC-0111 against carbonic-anhydrase IX (CAIX). Isothermal microcalorimetry was used for measuring real time thermogenesis in 3D cell and tissue constructs.

Results: 3D neuroblastoma cell constructs presented with similar morphological features compared to neuroblastoma cells in intact tumor tissue featuring small, round and blue cells. Perfused neuroblastoma slice-culture maintained its primary structure in the bioreactor for up to 10 days. Both 3D neuroblastoma cell constructs and neuroblastoma tissue responded to inhibition with significant decrease of thermogenesis measured by microcalorimetry, if the correlating hypoxic factor (AQP1 or CAXI) was expressed. The AQP1 inhibitor Aqb011 and the CAIX inhibitor SLC-0111 decrease heat production of 3D neuroblastoma cultures

Conclusions: We newly establish two preclinical models for neuroblastoma cells and tissue in a 3D structure. Drug response monitoring can be applied in these models using isothermal microcalorimetry. Monitoring times can be increased by use of the perfused bioreactor. Our models are an important first step to preclinically evaluate new drugs using patient-derived tumor tissue exemplified for neuroblastoma.

Background: Novel therapeutic approaches are needed for patients with pleural mesothelioma (PM), an aggressive cancer driven by asbestos exposure. Our phase II clinical trial for localized chemotherapy with cisplatin-fibrin after surgery (INFLuenCe – Meso) investigated safety and efficacy of this novel approach.

Aim: To identify biomarkers associated with outcomes for future application in patient selection.

Methods: We collected tumor tissues at surgery, before start of localized treatment, from all patients enrolled (n=23). FFPE tissues were immunohistochemically stained for p21 (cisplatin resistance) and Ki-67 (proliferation). Using Qupath software, we classified tumor cells from stroma. Number of positive cells (%) were automatically counted from 1,050 - 208,751 tumor cells/slide. For P21, we also differentiated weak (1), moderate (2) and strong (3) staining. Thus, we also acquired H-score (sum of intensity x % positive cells). The association between marker expression and clinical parameters and disease outcomes including progression free survival (PFS) and overall survival (OS) was analysed by SPSS software.

Results: Ki-67 staining index (%) ranged from 1.2 - 44 (median 12.4). P21 staining index and H–score (range (median)) are 0 - 96 (21) and 0 - 225 (32), respectively. High Ki-67 labelling index was significantly associated with shorter PFS (p=0.001, median (95% CI): 26.6 (11.7 - 41.6) vs 8.6 (6.8 -10.4) months) and OS (p<0.001, 39 (27.2 – 50.9) vs 16 (12.3 – 19.6) months) (figure 1). There was no association between clinical parameters and Ki-67 or p21 staining. p21 staining index and H-score showed no association with disease outcomes.

Conclusion: Although a small patient cohort, Ki-67 showed significant association with disease outcomes for patients receiving localized cisplatin-fibrin. We are currently assessing Ki-67 in tissues collected at diagnosis to confirm the association with survival prior to therapy. Ki-67 may be useful for the selection of patients for this treatment regimen.

Platelet-derived peripheral serotonin has pleiotropic effects on coagulation, metabolism, tissue regeneration, and cancer growth; however, the effect of serotonin on the tumor microenvironment remains understudied. Peripheral serotonin–deficient (Tph1−/−) mice displayed reduced growth of subcutaneous and orthotopically injected syngeneic murine pancreatic and colorectal cancers with enhanced accumulation of functional CD8+ T cells compared to control C57BL/6 mice, resulting in extended overall survival. Subcutaneous and orthotopic syngeneic tumors from Tph1−/− mice expressed less programmed cell death 1 ligand 1 (PD-L1), suggesting serotonin-mediated regulation. Serotonin enhanced expression of PD-L1 on mouse and human cancer cells in vitro via serotonylation, which is the formation of covalent bonds between glutamine residues and serotonin, resulting in activation of small G proteins. Serotonin concentrations in metastases of patients with abdominal tumors negatively correlated to the number of CD8+ tumor-infiltrating T cells. Depletion of serotonin cargo or inhibition of serotonin release from thrombocytes decreased growth of syngeneic pancreatic and colorectal tumors in wild-type mice, increased CD8+ T cell influx, and decreased PD-L1 expression. Pharmacological serotonin depletion with oral fluoxetine or intraperitoneal injection of the TPH1 inhibitor telotristat augmented the effects of programmed cell death protein 1 (PD-1) checkpoint blockade and triggered long-term tumor control in mice subcutaneously inoculated with syngeneic colorectal and pancreatic tumors. Overall, peripheral serotonin weakens effector functions of CD8+ T cells within tumors. Clinically approved serotonin targeting agents alone or in combination with PD-1 blockade provided long-term control of established tumors in murine models, warranting further investigation of the clinical translatability of these findings.

Due to the livers remarkable capacity to regenerate, the gold standard to treat liver cancer is the surgical resection of tumors (hepatectomy). However, if the future liver remnant is too small, regeneration is impaired and consequently leads to liver failure, thus limiting intervention at advanced cancer stages. During regeneration, unresectable occult micrometastases can start to regrow leading to cancer relapse, probably due to the growth-inducing microenvironment of the regenerating liver. Therefore, tumor-targeting treatments that do not impair liver regeneration are needed. Here we use tumor-specific immunotherapies during the perioperative window after cancer resection in a murine liver regeneration and tumor model. Overall, this project aims to prevent cancer relapse during liver regeneration.

To mimic liver regeneration after tumor resection, we developed a mouse model, which combines the injection of tumor cells into the portal vein with 68% hepatectomy. This allows us to study the dynamics of cancer relapse due to regenerative processes. By using specific knockout mouse lines of immunomodulatory molecules such as PD-L1, PD-1 and LAG-3 and administering blocking antibodies to wild type mice, we study the effect of immunotherapy on liver regeneration and liver metastases.

Liver metastases grow faster after partial hepatectomy. Furthermore, blocking of PD-1, PD-L1 and LAG-3 does not impair liver regeneration and can be safely administered during the perioperative window. Administration of anti-PD-1 and anti-LAG-3 antibodies during liver regeneration in micrometastases-carrying mice reduces tumor growth.

Background

Cosmetic limb lengthening surgeries are rare. After having had a longtime desire to be taller a 22-year-old, 163,5 cm tall healthy Asian man weighing 62kg underwent upper and lower leg lengthening by 12 cm and 6 cm respectively. Full recovery was achieved shortly after each lengthening step. However due to aesthetic reasons the patient requested bilateral femoral shortening by 4 cm 24 months after the index surgery.

Aim

To examine the bone newly generated during the process of distraction osteogenesis.

Methods

Bilateral 4cm bone segments removed from the lengthening zone were analyzed histologically, radiologically and using an electron microscope.

Results

High resolution CT scan revealed a well-organized lamellar bone with a dense cortical

layer and marrow hole. Both specimens revealed similar HU values (1128 HU, 1247 HU) to compact bone.

Histological analysis illustrated an outer well-defined compact bone layer consisting of

partially dense lamellae. The osteocytes and vascularization were regular.

Scanning electron microscopy revealed a well-organized lamellar bone structure. Stratified

polygonal bone cells with meshing or stretching of pods indicated cell growth. Bone

formation surfaces with osteoblasts and blood vessels were visible. The Ca/P ratio was 1:1.65, which is similar to that of regular bone.

Conclusion

This to our knowledge unique case of examining regenerated human bone after limb lengthening reveals that distraction osteogenesis with a nail potentially results in a bone morphology that is comparable to that in native human adult bony macro- and micro-anatomy.

Background: Robotic incisional hernia repair (RIHR) with sublay mesh is gaining traction as a minimally-invasive alternative to open retro-rectus reconstruction (OIHR). Obesity is a known risk factor for complications following hernia repair.

Aim: The objective of this study is to compare the clinical outcomes and costs of RIHR versus OIHR with sublay mesh in overweight patients.

Methods: Patients with a body mass index (BMI) of 25-35 kg/m2 who underwent OIHR or RIHR with sublay mesh over a 2 years' period were included. Recurrent hernias after mesh repair were excluded. The main outcome was length of hospital stay (LOS). Secondary outcomes included surgical site complications (SSC), visual analog pain score (VAS), analgesic methods,  and general complications.

Results: Ninety patients were included, 45 in each group. The mean length of stay (LOS) was significantly shorter in RIHR (6.8 days ± 4.6 vs. 2.3 days ± 2, p < 0.001), as were VAS at day 0 (3.0 ± 2.7 vs. 1.7 ± 1.8, p = 0.005) and day 1 (4.2 ± 2.2 vs. 2.4 ± 1.8, p < 0.001), with a significant reduction in morphine consumption and epidural analgesia. The mean operative time was 163 min. ± 65 in OIHR and 191 min. ± 94 in RIHR (p = 0.06), despite a higher proportion of component separation in the robotic group (18% vs 33.3%, p = 0.005). The open group had higher rates of SSC (20% vs 2.2%, p = 0.015) and general complications (40% vs 13.3%, p = 0.004). General costs per diagnosis showed a mean reduction of 4797 CHF in the robotic group, mostly due to reduced hospitalization costs (9364 CHF vs. 3472 CHF).

Conclusion: The robotic approach improved post-operative outcomes of incisional hernia repair with sublay mesh compared to the open approach in overweight patients, without significantly increasing operative time and costs.

Background

The repair of complex ventral hernias often requires component separation due to the large width or localization of the hernia. M. transversus abdominis release (TAR) is a useful technique in these situations. When performed as open surgery, however, the morbidity is high. Robotic-assisted TAR (r-TAR) may reduce morbidity.

Aim

We intend to contribute a video, demonstrating the surgical technique of r-TAR and report our early postoperative outcomes.

Material and Methods

Early postoperative outcomes and morbidity of r-TAR procedures performed in our facility between June 2022 and December 2023 were prospectively collected and analyzed. A video demonstrating r-TAR will be provided.

Results

14 r-TAR procedures have been performed in the mentioned period. Patients’ median age was 59.5 years [range 47-78] and showed a median Body Mass Index (BMI) of 30.3 kg/m² [range 22.8 – 46.1 kg/m²]. 57 % of the patients had a BMI of 30 or higher (Obesity WHO Class I or higher). Median duration of the surgical procedure was 317 minutes [range 184 – 407 minutes]. Patients showed a low level of pain in the postoperative course with a median value of 3.5 [range 0 – 7] on the visual analog scale on day 1 after surgery. Median hospital stay was 5.5 days [range 1 – 7]. There was no readmission to the hospital. Morbidity occurred in 2 Patients. One developed a cardiac decompensation with the need for pharmacological intervention and one developed a clinically relevant seroma with consecutive CT-guided aspiration. (Clavien-Dindo Grade II and IIIa). Median Comprehensive Complication Index (CCI) was 0 [range 0 – 26.2]

Discussion and Conclusion

r-TAR provides the possibility to treat complex ventral hernias minimal-invasively and therefore with very low morbidity even in obese patients. A disadvantage is the long operative time, however through gaining more experience in performing r-TAR, operative times are expected to decrease.

BACKGROUND

The use of surgical robots is increasing in the field of visceral surgery. Recently, new robotic platforms have entered the market. Dexter Robotic System is a computer-assisted surgical device with two working arms and one camera arm. The purpose of this study was to assess the implementation this innovative robotic system in general visceral surgery.

METHOD

This prospective study investigated the efficiency in elective cholecystectomy and inguinal hernia surgery of the Dexter robot. The Primary endpoints was safety, defined by device related adverse events. Secondary endpoints were performance of the Robotic System (defined as completion of the robotic procedure), operative parameters and surgeons' comfort. Patients were consented for participation and the study was approved by the Ethical committee.

RESULTS

The first 25 consecutive Dexter robotic assisted elective procedures (14 hernia, 11 cholecystectomies) were included. No device related adverse events occurred. 24 operations could be completed robotically. One hernia procedure was converted to a laparoscopic operation, due to a software failure of the Dexter-system. The median robot usage time were 55 minutes (IQR 41-5-79.5) for cholecystectomy and 95 minutes (IQR 90.5-115.25) in hernia, while the operating time amounted 99 minutes (IQR 84-133) in cholecystectomy and 131 minutes (IQR 124.75-153.75) in hernia. The median docking time of the Dexter robot was 7 minutes (IQR 7-10.5). Operators perceived comfort as high, median 4 (IQR 4-10.5, Discomfort Score range 4-16) and subjective stress levels as low, median 25 (IQR 10-35, Mental Effort Questionnaire range 10-60). (This study is ongoing, we expect to include 50 cases until June 2023)

Conclusion

This world's first clinical study of the Dexter Robotic System in general visceral surgery demonstrates a safe and efficient implementation of this innovative robotic system in clinical practice. Further studies will refine the effective applications of the Dexter Robotic System and its advantages over conventional surgical techniques.

Background: In the treatment of umbilical and epigastric hernias, during the last years were developed robotic-assisted techniques to avoid intraperitoneal mesh placement. Robotic-assisted transabdominal preperitoneal (eTAPP) and totally extraperitoneal (eTEP) were described and studies reported that both techniques were safe and achieved optimal results. However, no evidence is reported regarding the best technique.

Aims: The aim of our study was to assess the safety and effectiveness of the robotic-assisted eTEP compared to eTAPP with suprapubic trocar insertion to treat umbilical and epigastric hernias.

Material&Methods: We selected from a prospectively maintained database patients who underwent robotic-assisted umbilical and epigastric hernia repair with a suprapubic approach, either eTEP or eTAPP. We retrieved clinical and follow-up data and a statistical analysis was carried out.

Results: During the study period, 53 patients were included. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male and the mean BMI was 28.0 ± 5.9 kg/m². Most hernias were umbilical (81.1%) and primary (83.0%). Operative time was slightly shorter for eTEP than eTAPP (106 ± 43 min vs. 126 ± 74 min, p=0.232). No intraoperative complications occurred. Postoperatively, only a case of bleeding and a seroma were recorded. The length of follow-up was 11.3 ± 6.4 months in the eTEP group vs. 20.5 ± 9.7 months in the eTAPP group and no case of recurrence, chronic pain, or significant dysesthesia was recorded.

Conclusions: In our study, we found that the eTEP approach to treat epigastric and umbilical hernias was safe and feasible and achieved excellent perioperative and follow-up results. The outcomes were similar to patients undergoing the eTAPP approach, but with the advantages of a shorter operative time and not entering the peritoneum.

Background/Aims

Minimal invasive inguinal hernia repair shows proven advantages over open operations. One of the established techniques is the transabdominal preperitoneal (TAPP) repair whose basic principles as state of the art were first described by Arregui et al. in 1992. With the introduction of the robotic platform, TAPP has been adjusted to robotic assisted TAPP (rTAPP) with the result of overcoming the laparoscopic limitations using a three-dimensional high-resolution camera and articulated instruments. This enabled the rTAPP repair to become an established surgical procedure throughout Europe for the treatment of inguinal hernias.
The results of our initial experience with a cohort of 259 patients are presented and discussed with regard to the added value of the robotic technique in inguinal hernia repair.

Methods

A retrospective chart review was performed in patients who underwent rTAPP inguinal hernia repair between 2020 and 2021 using the da Vinci platform (Intuitive Surgical Inc.) and a prosthetic mesh. Data collected included patient demographics, past medical history, details related to the surgical procedure, perioperative outcomes, and short and long term follow up.

Results

A total of 259 patients submitted to rTAPP hernia repair were identified with mean age of 55.9 years, an average BMI of 25.1 kg/m^2 and a median risk of ASA-II.
59.5 percent of all patients underwent unilateral hernia repair, whereas 40.5 percent bilateral. Same day discharge could be achieved in 38 percent. Surgical complications were less than 2 percent and included hematoma, seroma, surgical site infection and pain. Neither mortality nor conversion to open surgery occurred.

Conclusion

Our early experience has demonstrated that the rTAPP inguinal hernia repair is a safe and feasible approach. It allows also smaller hospitals with a robotic platform to perform this procedure on a regular basis and enables teaching of younger surgeons when a second console is present.

Background: Minimally-invasive repair of large inguinal and femoral hernia may be technically challenging but impose a lower risk of postoperative wound-infections and recurrences rates. Therefore, a minimally-invasive approach can be considered even in larger inguinal and femoral hernias.

Aim: To highlight technical aspects and anatomical landmarks in a video report of three cases addressing inguinal and femoral hernia.                 

Material and Methods: Three patients underwent the following procedures: Transabdominal pre-peritoneal inguinal hernia repair (TAPP) for bilateral large direct hernia, totally extra-peritoneal inguinal hernia repair (TEP) for large indirect hernia and TEP for large, bilateral femoral hernia.

Results: The video demonstrates the operative techniques and special technical considerations in minimally-invasive large inguinal and femoral hernia repair using TEP and TAPP. The preparation of anatomical landmarks is highlighted, as well as the appropriate technique for hernia sac reduction. In large direct hernia repair using the TAPP technique, the reduction of the dilated transversalis fascia is demonstrated as well as the circular mesh fixation using absorbable fixation devices. There were no conversions or postoperative complications.

Conclusion: Minimally-invasive, pre-peritoneal repair of large inguinal and femoral hernia is safe and may be considered, especially in patients with a high risk of local wound infections and in bilateral hernias.

Background: Prophylactic mesh augmentation (PMA) in midline laparotomy closure is an increasing trend in elective procedures to prevent incisional hernias (IH). It gained less traction in the emergency setting due to fear of an increased risk of surgical site infections (SSI).

Aims: This study intended to profile the risk of IH and SSI in patients undergoing an emergency laparotomy to determine potential beneficiaries of a PMA, devoid of risk factors for SSI. It is a preliminary step necessary prior to conducting a safe clinical evaluation of PMA in this setting.

Material and Methods: Patients who underwent an emergency midline laparotomy between January 2019 and January 2021 in a single tertiary centre were included retrospectively from an institutional database. Patients’ baseline characteristics, pre-operative and intra-operative parameters, and post-operative outcomes were recorded and analysed. Statistical analysis included Fisher's exact test, ANOVA F-test and Scheffé test.

Results: Among the 87 patients, 11.5% presented an SSI, 11.5% an IH, 5.7% both events, and 71.3% none of them. Univariate analysis didn't reveal specific factors associated with occurrence of IH. Incidence of SSI was significantly associated with the following eight risk factors: obesity (p=0.016), chronic liver disease (50.0% in SSI group vs. 10.0% in IH group, p=0.010), leucocytosis (17.93 ±13.57 [G/L] in SSI group vs. 12.54 ±6.35 [G/L] in IH group, p=0.030), anaemia (97.8 ±25.3 [g/L] in SSI group vs. 114.4 ±19.4 [g/L] in IH group, p=0.029), long operative time (293 ±182 minutes in SSI group vs. 152 ±62 minutes in IH group, p=0.002), preoperative fever (p=0.039) and antibiotic therapy (p=0.033), and delayed parietal closure (50.0% in SSI group vs. 20.0% in IH group, p=0.037).

Conclusions: Individual and intra-operative characteristics have been identified and may be utilised as exclusion criteria to increase safety and adhesion to future clinical trials evaluating applicability of PMA in emergency laparotomy.

Background: Ventral midline incisional hernia (VMIH) is common and recurrence rates remain of concern after gold-standard open repairs. Personalized optimization and risk stratification are traditionally performed through preoperative considerations regarding patients’ general and medical status and occulting mechanical factors.

Aim: The aim of this retrospective observational cohort study is to identify mechanical parameters potentially influencing VMIH recurrence (VMIHR) after repair.

Methods: Data were derived from an institutional quality database. Patients who underwent VMIH open repair with retromuscular or preperitoneal non-absorbable mesh reinforcement, confirmed by an available preoperative CT scan for biomechanical measurements, between June 2012 – June 2020 in a single centre, were included. Exclusion criteria were non-open repairs, non-midline hernias, absence of preoperative scan, absence of mesh reinforcement, intraperitoneal/bridging mesh positions, biologic/biosynthetic mesh and use of component separation techniques. The main outcome was VMIHR, a symptomatic clinically confirmed recurrence re-operated in the same institution within 36 months maximum following primary open repair. Patients with/without recurrence were compared using standard analytic tools.

Results: Fourty-eight patients met the inclusion criteria of which 11 (23%) developed VMIHR. The following parameters were statistically significantly associated with VMIHR: smaller visceral fat surface (mean of 244.9 cm^2 in the recurrence group vs 286.3 cm^2 in non-recurrence group, p = 0.0295), smaller mesh length (17.2 cm vs 23 cm, p = 0.001), smaller total mesh surface (315.2 cm^2 vs 550.1 cm^2, p = 0.0095), coated meshes (p = 0.033), absorbable suture for mesh anchoring (p = 0.043) and a greater largest defect width/mesh width ratio (0.42 vs 0.29, p = 0.0146).

Conclusion: When focusing on mechanical parameters, non-modifiable and patient-related parameters seem to play a limited role. However, using uncoated meshes of larger dimensions (greater than/equal to 3.5x defect size) than suggested previously (defect size + 5cm) resulted in fewer recurrences. This may help orientate further larger prospective trials.

Background

Adequate pain control after surgery is of utmost importance to reduce complications, length of hospital stays, and, ultimately, costs. Transversus abdomins plane block (TAPB) is a relatively new pain management technique, and its benefits were preliminarily proven in morbidly obese patients undergoing laparoscopic bariatric procedures.

Aim

This study aimed to assess the effectiveness of TAPB in patients undergoing either primary or revisional bariatric surgery.

Materials and methods 

In this prospective randomized double-blind controlled trial, we enrolled patients undergoing bariatric surgery from July 2020 to July 2021. Patients were randomly allocated into the TAPB group (n = 51) or the port-site infiltration (PSI) group (n = 62). Both groups received a solution of 40 ml Ropivacaine 0.25%. We included patients undergoing any type of bariatric surgery, no exclusion criteria were applied. The primary endpoint was the pain on the visual analogue scale (VAS) 24 hours after operation. Secondary endpoints were VAS at 3, 6, 12 and 18 hours, complications, time of first walk and flatus, operative time, length of hospital stay, the need for additional drugs.

Results

We randomized 51 patients in the TAPB group and 62 patients in the PSI group. No anesthetic infiltration-related complication was recorded. At 24 hours after surgery, pain on the VAS was 2.5 ± 2.6 vs 2.3 ± 2.1 (p=0.661) in the TAPB and PSI groups, respectively. Similar results were found at 3, 6, 12 and 18 hours. No significant differences were found in operative time, time of first flatus and first walk, as well as length of hospital stay and overall satisfaction score.

Conclusions

Laparoscopic TAPB and PSI with local anesthetics have similar clinical outcomes. Both are valid methods to improve postoperative pain management in patients undergoing bariatric surgery.

Background / Aims

Hepatocellular carcinoma (HCC) usually occurs within an underlying chronic liver disease such as cirrhosis with limited liver function. Liver resection is an effective treatment option. Most studies investigating the benefits of anatomic (ALR) versus non-anatomic (NALR) liver resections in cirrhotic HCC patients involve Asian populations with different underlying chronic liver diseases. NALR limits the resection of liver parenchyma, and therefore could reduce postoperative liver failure, while the effects on survival rates remain unclear. European data are desperately needed.

Material and Methods

This is a retrospective and prospective multicentre cohort study, including all patients undergoing liver resection for HCC between 2009 and 2020 from 3 specialised centres in Switzerland and Germany. Patients were stratified for cirrhosis and no cirrhosis. Complications and survival rates were analysed using univariate and multivariate Cox regression models.

Results

298 patients were included. Median follow-up time was 52.76 months. 158/298 (53%) patients presented with cirrhosis. Cirrhotic patients after ALR (n=64/158) showed a significantly longer ICU stay (p=0.017) and postoperative in-hospital stay (p=0.007) compared to after NALR (n=94/158), while the NALR group showed significantly more postoperative complications (p<0.001), but the rate of liver insufficiency was not significantly different after NALR versus ALR (p=0.846). Overall survival (OS) and recurrence free survival (RFS) in cirrhotic versus non-cirrhotic patients were not significantly different (adjusted HR 0.78 (95% CI 0.53-1.15, p=0.21) and adjusted HR 0.82 (95% CI 0.64-1.24, p=0.27), respectively). A trend towards better OS and RFS could be observed favouring NALR in cirrhotic patients (for OS adjusted HR 0.55 (95% CI 0.28-1.07, p=0.08) and for RFS adjusted HR 0.55 (95% CI 0.30-1.01, p=0.06)).

Conclusions

European patients with cirrhosis could benefit from NALR regarding longer OS and RFS. NALR is associated with a significantly higher complication rate compared to ALR, but not with a higher rate of postoperative liver insufficiency.

Purpose

Hepatectomy remains associated with complication rates around 30-50%. Delayed return of gastrointestinal function (DRGF) has been reported in 10-20%. This study aimed to assess DRGF predictors after hepatectomy.

Methods

This study included all consecutive adult patients undergoing hepatectomy between 01/2010 and 12/2019. DRGF was defined as need of postoperative nasogastric tube (NGT) insertion. Patients leaving the operation room with a NGT were excluded.  Independent DRGF predictors were identified with multivariable logistic binary regression.

Results 

A total of 502 patients were included. DRGF occurred in 82 patients (16%). Among DRGF patients, 17% (n=14) needed a second NGT placement. DRGF incidences were similar before and after Enhanced Recovery After Surgery implementation (16/78=21% vs. 66/423=16%, p=0.281). DRGF was more frequent after major hepatectomy (55/239=23% vs. 27/263=10%, p<0.001).

DRGF occurred more frequently in patients with preoperative embolization (26/88=30% vs. 55/407=14%, p<0.001), biliary anastomosis (20/48=42% vs. 61/450=14%, p<0.001), and extrahepatic resection (37/108=34% vs. 45/393=11%, p<0.001). Patients with DRGF had longer median operation duration (374 vs. 263 min., p<0.001) and higher median blood loss (1088 vs. 701 mL, p<0.001). DRGF patients developed more pneumonias (14/22=64% vs. 8/22=36%, p<0.001) and had longer median length of stay (19 vs. 8 days, p<0.001).

On multivariable analysis, operation duration (OR 1, 95%CI 1.002-1.008, p<0.001) and postoperative biloma/biliary leak (OR 3.3, 95%CI 1.8-7.7, p<0.001) were independently associated with DRGF occurrence.

Conclusion 

Postoperative DRGF occurred in 16% of the patients and was associated with longer length of stay. Surgery duration and postoperative biloma/biliary leak were found as independent predictors of DRGF.

Background/objective: In the setting of minimally invasive liver surgery (MILS), training in robotic liver resections (RLR) usually follows previous experience in laparoscopic liver resections (LLR). The aim of our study was to assess the learning curve (LC) of RLR of a surgeon who started RLR and LLR training concomitantly.

Methods: We retrospectively analyzed consecutive RLRs and LLRs by a surgeon trained simultaneously in both techniques (Surg1); procedures by a second surgeon who only performed LLRs were used as control (Surg2). Data were analyzed focusing on operative time, difficulty of the procedures (IWATE score), intra- and postoperative complications. A regression model was used to adjust for confounders and a Cumulative Sum (CUSUM) analysis was carried out to assess the learning phases.

Results: Two-hundred-forty-five procedures were identified (RobSurg1, n=75, LapSurg1, n=102, LapSurg2, n=68). Mean IWATE was 4.0, 4.3 and 5.8 (p<0.001) in each group respectively. According to the CUSUM analysis of the adjusted operative times the learning phase was estimated in 40 cases (RobSurg1), 40 cases (LapSurg1), 48 cases (LapSurg2); for IWATE score was 38 cases (RobSurg1), 33 cases (LapSurg1), 38 cases (LapSurg2) respectively. Conversions to open surgery (6.7%, 10.8%, 5.9% in each group respectively; p=0.442) were uniformly distributed over the time. Postoperative morbidity plateaued after 42 cases for RLRs; such analysis for LLRs wasn’t reliable as most of the complications occurred in the late phase where both surgeons performed the most demanding cases.

Conclusion: Our preliminary experience showed a similar LC of 40 cases for low and intermediate difficulty RLR and LLR. Concomitant training in both techniques may be an option for beginners in MILS. Larger data including anatomically major and high difficulty robotic and laparoscopic hepatectomies are needed to assess the second phase of the simultaneous training in both MILS techniques.

Background: A comprehensive outcome analysis of ex situ right split liver graft transplantation (RSLT) is currently lacking. Aim: Benchmarking outcomes of RSLT against best achievable results from whole LT offers a novel comparative approach.
Material&Methods: This retrospective study includes all consecutive ex-situ RSLT for adult recipients performed from 2014-2019 at 4 high volume transplant centers (>70 LT/year). Outcomes including overall morbidity expressed by the comprehensive complication index (CCI) and graft related complications were compared to the published benchmark cutoffs for whole graft LT.
Results: We included 129 ex-situ RSLT with 76% H45678 (n=98) and 24% (n=31) H5678 grafts. The median follow-up was 4.8 years. Overall and severe 1-year morbidity expressed by the CCI were within established whole graft LT benchmarks (Table 1). Biliary complication rates were slightly higher than the benchmark due to the occurrence of cut-surface leaks. The arterial thrombosis rate was outside the benchmark cutoff (7% vs ≤4.4%) leading to a higher retransplantation
rate. However, overall 1-year graft and recipient mortality were well within the benchmark cutoffs, resulting in a 5-year overall recipient survival of 88.5% (Figure 1). Selecting benchmark cases for RSLT defined by low-risk recipient-donor criteria including static cold storage time ≤10h and recipient MELD≤20 points, did not significantly reduce overall morbidity nor arterial complication rate. In contrast, the type of split graft (H45678 vs.H5678) did impact on both arterial and biliary complications.
Conclusion: This large multicenter series of ex-situ right split grafts disclosed an overall 1-year morbi-mortality comparable to the best achievable results in whole graft LT. The results show that the main morbidity burden in adult RSLT is related to technical criteria rather than graft-recipient matching.

Background: The gold standard in pediatric split liver transplantation (SLT) is living donation (LD) providing high-quality grafts with short static cold storage (SCS).

Aim: This study investigates the protective effect of hypothermic oxygenated perfusion (HOPE) on ex-situ partial grafts from deceased donors in comparison to standard ex-situ Static-Split and LD SLT.

Material&Methods: We included all consecutive HOPE-Split, Static-Split and LD SLT performed from 2018-2022 at a single center. The primary endpoint was early ischemia-reperfusion injury (IRI) based on reperfusion biopsy (graded from none/0 to severe/4), the occurrence of post reperfusion syndrome (PRS, drop≥30% of systolic arterial pressure) and post-LT transaminase release.

Results: A total of 46 SLT (14 HOPE-Split, 17 Static-Split, and 15 LD) were included. With a median perfusion duration of 100min, HOPE-Split had a significant decrease of SCS compared to Static-Split (473 min vs 538 min; p=0.02) with similar total preservation time (p=0.13) (Table 1). This translated into lower rates of mild to severe IRI (grade≥2; p=0.03) and significantly reduced neutrophilic infiltrate than Static-Split (p=0.04; Fig.1). The PRS was also reduced in HOPE-Split (0% vs 35%, p=0.02) with less transaminase release. Despite prolonged SCS (473 vs 117min, p<0.001), HOPE-Split was comparable to LD regarding grade≥2 IRI (64 vs 40%; p=0.17) and PRS (0 vs 6.7% p=0.34), with however higher transaminase release (571 vs 244 UI/L/100g; p=0.004) (Figure 1). Overall, 3-months surgical complications, graft and recipient survival did not differ among groups (Table 1).

Conclusion: HOPE allowed improved preservation of ex-situ split grafts compared to static cold storage, resulting in similar early IRI profiles then LD grafts. Preservation with HOPE may offer a promosing strategy to improve outcomes and expand selection criteria in split LT for pediatric recipients.

Background: Colorectal Cancer is the fourth most leading cause of death due to cancer worldwide. Between 25 to 50% of affected patients develop liver metastases. The incidence of hilar lymph node (LN) metastases is up to 14% after pathological examination. Today, it is still controversial whether to perform hilar lymphadenectomy (LA) in patients with colorectal liver metastases (CRLM) that are suitable for resection or not.

Aims: This study investigated the role of hilar LA in patients with CRLM and its impact on morbidity, mortality and recurrence.

Material and methods: In patients with hilar LA, LN were immunohistochemically stained with a pancytokeratin cocktail (CK22) and afterwards histologically examined for single cells (< 0.2mm), micro- (0.2-2mm) and macro-metastases (>2mm). Morbidity and mortality were analysed using descriptive statistics.

Results: 125 patients with CRLM resection were included, 55 of which underwent tumour resection with hilar LA and 68 without. An average of 10 hilar LN were resected. 3/55 (10.9%) showed hilar LN metastases in preoperative imaging and 10/55 (18.2%) showed micrometastases after CK22 staining (p = 0.039).

In the LA group, more patients had complications higher than grade II according to Clavien Dindo than in the non-lymphadenectomy (NLA) group, but without significant difference (LA 41.9%, NLA 29.5%, p = 1.06).

Recurrence rates were higher in the NLA group than in the LA group (LA: 21, 38.2%; NLA: 37, 54.4%; p = 0.074) but appeared later (LA: mean 7 months; NLA: mean 13 months; p = 0.012).

Conclusion: The use CK22 leads to improved detection of LN micrometastases and therefore allows for a more accurate staging.

LA in CRLM does not significantly increase postoperative complication rate. In general, recurrence rates are lower in patients with CRLM undergoing LA, but this was not significant.

BACKGROUND

Continuous assessment of surgical skills is important for surgical education, but conventional clinical outcome measures might not be granular enough to discriminate surgical performance. Current procedure rating scales require expert input and are time consuming, and therefore not systematically applied. An automated computer vision (CV) assessment of a representative part of the procedure would be efficient.

AIMS

To preliminarily analyze whether CV-based surgical video analysis of a procedure subset could be meaningful.

METHODS

Videos of laparoscopic cholecystectomies were annotated for detailed steps, tasks, and intra-operative events (bleeding, stone excretion). Annotations were completed by three surgeons and went through consensus and quality review. All annotated non-complicated cholecystectomies were selected to compare OR-time, clinical complications, overall number of task segments (surrogate for procedure flow), number of distinct segments during the dissection of the hepato-cystic triangle step (See above), and duration of dissection of hepato-cystic triangle step for expert surgeons and residents.

RESULTS

37 videos were analyzed, 18 of residents and 19 of expert surgeons. Skin-to-skin procedure time and rate of complications were similar for both groups (p=0.2922 and p=1.000, respectively). Counts for distinct task segments in the overall case and within the dissection of the hepato-cystic triangle step were significantly lower in the senior cohort (38.1+/-10.7 vs 51.8+/-25.1 minutes and 10.6+/-10.7 vs 17.4+/-11.0 minutes, p=0.0354 and p=0.0074, respectively). The time to dissect the hepato-cystic triangle was significantly lower when performed by expert surgeons (7.4+/-4.3 vs 18.53.5+/-11.6 minutes, p=0.0004). 13 intra-operative events were observed for the expert surgeons and 24 for the residents (p=0.7384).

CONCLUSIONS

This data shows that video-based analyses of a critical subset of a procedure has the potential to discriminate surgical performance and automation through CV may be valuable. With further research, this might become a useful tool to monitor resident’s procedure fluidity as a surrogate for training status.

Background / Aim

Elective laparoscopic cholecystectomy is a very common procedure. Indications include symptomatic cholecystolithiasis. Even if preoperative imaging does not show any signs of cholecystitis, we hypothesize that cholecystolithiasis is associated with a chronic inflammation of the gallbladder. If this is the case, indication for elective cholecystectomy should be widened also for asymptomatic cholecystolithiasis. Therefore we aimed to investigate a large cohort of patients after elective cholecystectomy and to analyse their postoperative histopathological diagnosis.

Material and Methods

This is a retrospective cohort study, consecutively including all patients receiving elective cholecystectomy for cholecystolithiasis without cholecystitis on imaging between 2014 and 2020. Postoperative histopathological diagnosis of the surgical specimens was recorded as well as patient related and outcome related parameters.

Results

2258 patients underwent elective cholecystectomy for cholecystolithiasis between 2014 and 2020. 752/2258 (33%) showed chronic inflammation of the gallbladder mucosa in the postoperative histology despite a lack of preoperative signs of cholecystitis (blood parameters and imaging). In total, 77/2258 (3.4%) resection specimens were not sent for histopathological examination due to unremarkable macroscopic appearance of the gallbladder. Dysplasia or neoplasia was detected in 44/2258 (1.9%) patients. Interestingly, the majority of these 44 patients (n=30, 68.2%) presented with chronic inflammation of the gallbladder on histopathological examination. Association of chronic inflammation and dysplasia/neoplasia with cholecystolithiasis was significant (p<0.001).

Conclusion

Cholecystolithiasis is significantly associated with chronic inflammation of the gallbladder mucosa in a high proportion of patients. A majority of patients with incidentally diagnosed dysplasia or neoplasia showed chronic inflammation of the gallbladder associated with cholecystolithiasis. Patients with asymptomatic cholecystolithiasis should be evaluated for cholecystectomy in order to avoid chronic inflammatory processes and potential development of dysplasia or neoplasia.

Background

Smoking cessation interventions are not always a top priority for surgeons when managing the lung cancer patient, mostly due to the sharing of responsibility within multidisciplinary teams.

Aims

A clear overview of how continuous smoking affects the therapeutic outcome, the negative impact on multimodal therapy, and the potential role the thoracic surgeon can take on, should convince thoracic surgeons to take matters in their own hands and become more proactive.

Material&Methods

We reviewed all resources made available to lung cancer specialists between 01.01.2021 and 01.01.2023 by the International Association for the Study of Lung Cancer, as well as the cross references relevant for this content.

Results
Nicotine reduces the efficacy of various anticancer agents (chemo- and immunotherapy agents alike), as well as that of radiotherapy. Quitting smoking at or around diagnosis improves the overall survival by 19 – 29 % compared to smoking continuation.

80% of patients with lung cancer diagnosis believe there is nothing to be gained from cessation, and less than 50 % of lung cancer patients quit after diagnosis. Among different medical professions, thoracic surgeons have one of the highest compliance rates in smoking cessation interventions.

The costs for a smoking cessation intervention, ranging between 150 - 300 CHF, are covered only by some insurance companies, and often only partially.

Conclusions

We found two key aspects a thoracic surgeon should strongly consider when planning the treatment: smoking cessation immediately affects the treatment outcome; and that they are one of the most able actors in convincing cancer patients to quit smoking. We argue that a smoking cessation intervention should always be integrated in each consultation of lung cancer patients, and raise the question whether an opt-out strategy, with complete cost coverage by the insurance companies, would be feasible and advisable in Switzerland, to further increase patient compliance rates.

Background

Chordomas are rare, malignant, slow growing and locally destructive tumors, that arise from notochord cells anywhere along the spine. To date, the knowledge is restricted to case-reports. The annual incidence is estimated as 8 per 10’000’000 cases. Surgical en bloc resection with negative margins is the only curative treatment for this disease.

Aim

Case report that aims to highlight this rare disease and its management.

Material & Methods

Initial symptoms, operation, pathology, and post-operative course in a 72-year-old female patient.

Results

After 2 years of progredient pain in the upper thoracic spine with mild radiation to the left arm and leg but no defaults, this patient was presented to a neurologist. Chest MRI revealed in the left hemithorax a paravertebral mass of 2,7x2x1,2cm in size, at the thoracic vertebrae T2/T3 extending to the foraminal and epidural nerves with extensive dural sack contact (Figure1 A,B,C). Morphologically, a benign schwannoma or chondroma was expected and referred for surgery.

Robot assisted paravertebral extra-capsular resection of the tumor was performed en bloc by a thoracic surgeon in attendance of a neurosurgeon. Complete resection was achieved without affecting the dural sac. Total operation time was 65min, blood loss <20ml. Postoperative course was uneventful; discharge at day three. In the three-week follow-up, the patient was well with only minimal remaining pain.

The removed tumor (Figure1 C) was surprisingly soft for an expected schwannoma or chondroma and showed lobular structure and myxoid ground substance. Histology revealed a cell population of epitheliod cells and eosinophilic cytoplasmic borders (Figuer2 A (H&E)).

The immune profile showed typical co-expression of Pan-Cytokeratin, epithelial membrane antigen and S100-protein positivity. More importantly, Brachyury protein (T-box transcription factor T) showed nuclear expression (Figure2 B), which is highly characteristic for chordoma.

Conclusion

There is limited literature on chordoma due to its rarity. Primary treatment is surgical resection with wide-margins, while preserving neurological function.

Background

Lipomas are well-circumscribed, slow-growing mesenchymal tumors originating from adipose tissue with a benign entity. Mediastinal location is uncommon and rarely produce mediastinal compartment syndrome even at considerable size. Surgical excision is usually postponed until symptomatic, leading to increase morbidity associated with surgery which generally reqiures cardiopulmonary support.

Aim

Case report of a patient with symptomatic mediastinal lipoma.

Material & Methods

Preoperative symptoms, operation, pathology, and post-operative course in a 75-year-old male patient.

Results

The patient initially presented with a performance impairment. Computed tomography (CT) scan revealed a 9x8.5cm mediastinal retrocardiac lipoma, first classified as oligosymptomatic. Two years later, progredient retrosternal pressure, decline in performance and recurrent syncope episodes prompted a new CT scan, now showing an increase of the lipoma to 10x8cm, compressing the left atrium and pulmonary veins (Figure1, A, B, C). Echocardiography at rest demonstrated no obstruction of flow and a regular output, but interdisciplinary concerns about potentially abrupt and fatal insufficiency during increased exercise led to the referral of surgery.

By right anterolateral thoracotomy and a retro- and trans-pericardial approach, the lipoma was successfully resected en bloc in its capsule without any intraoperative complication (Figure1 D). Stand-by extracorporeal life support (ECLS) was present in case of hemodynamic insufficiency during cardiac manipulations or bleeding but was not required. Total blood loss was <250ml, total operation time 185 min.

Histology confirmed a mature lipoma with no evidence of malignancy.

Post-operatively, the patient was extubated after 4 hours, transferred from the intensive care unit to the ward after 24 hours and discharged at day 7 in good condition. The following day a short re-hospitalization was necessary due to an episode of atrial fibrillation. In the 3-month follow up, the patient is totally free of symptoms.

Conclusion

Large symptomatic retrocardiac lipomas are rare. This case illustrates a safe approach with good patient outcome in a specialized center. This should encourage to treat patients earlier, before they develop life-threatening symptoms.

Introduction: Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a rare, debilitating disease characterized by pathological changes that obstruct both sides of the pulmonary arteries (PA). The underlying pathophysiology is poorly understood.

Aim: trying to understand the possible contribution of microRNAs to CTEPH pathophysiology, we here analysed the expression of four candidate microRNAs in pulmonary endarterectomy (PEA) specimens.

Methods: MicroRNA specific RT-qPCR for miR-939, miR-942, let-7b and let-7d was done on RNA from PEA specimens of 50 CTEPH patients and from PAs resected from explant lungs of 48 transplant recipients (25 due to COPD, and including 22 with PH). Associations between microRNA expression and clinical presentation (not all factors available for every patient) were assessed by Spearman correlation. MicroRNA expression between CTEPH and reference PAs was compared by Mann Whitney test.

Results: Expression levels in left-side PEA-derived tissues correlated negatively with: CRP for let-7d (n = 49, R = -0.29, p=0.039) Fig. 1A, oxygen saturation (SpO₂) at peak 6-minute walk distance for miR-939 (n = 44, R = -0.39, p=0.007) Fig. 1B, and Right Jamieson classification for miR-942 (n = 40, R = -0.34, p=0.03) Fig. 1C. Right-side samples let-7d levels correlated negatively with mPAP (n = 42, R = -0.33, p=0.031) Fig. 1D. Contrastingly, mean expression levels of miR-942 showed positive correlation with mPAP (n = 49, R = 0.28, p=0.049) Fig. 1E and Borg Scale showed a similar tendency with miR-939 (n = 50, R = 0.31, p=0.027) Fig. 1F. Compared to reference PAs, right-side expression of miR-942 reached significance (n = 47 CTEPH vs n = 46 Reference, p=0.0001).

Conclusion: Correlations with clinical parameters suggest that miRNAs may be associated with clinical presentation of CTEPH. Furthermore, the significant elevation compared to reference PA tissue suggest that microRNA dysregulation might be involved in CTEPH pathophysiological mechanisms, encouraging us to investigate further.

Background

Sternoclavicular joint (SCJ) infection is rare. Surgery is usually the treatment of choice but there is no generally admitted approach.

Aims

The goal of this study was to evaluate the clinical and functional results after extended surgical treatment.

Materials&Methods

This single-center cohort study included 14 patients, with a mean age of 53 years (range 28-70) between May 2011 and August 2021. Extended surgery consisted of initial debridement with removal of the joint capsule, partial resection of ipsilateral manubrium sterni, of the medial part of the clavicle and sometimes of the first rib and VAC dressings. The procedure was repeated each 3-4 days until no microorganisms were identified. Analysis of the risk factors, complications, recurrence rate was performed from the clinical files. Prospective cosmetic and functional results were assessed using the standardized Quick-DASH questionnaire (0-100 points, the lowest value the best).

Results

Initial symptoms consisted of local tenderness, swelling and pain in 13/14 (92.8%) patients, but only 3/14 (21.4%) had fever and elevated infectious parameters. Microorganisms were found in 13/14 (92.8%), most often staphylococcus (64.3%). Interestingly, 50% of the patients had no risk factors for infection. The average number of operations was 4. Complications grade 3 or more according to the Clavien-Dindo classification were observed in 5/14 (35.7%) patients. There was no in-hospital mortality. Recurrence was seen in 2 patients (14.3%). In one, initial mediastinitis recurred during hospitalization; in one, recurrence was diagnosed 2 months after hospital discharge. Clinical and functional assessment after a mean time interval of 47 months (2.3-103) revealed excellent cosmetic results without instability of the shoulder girdle, no residual pain and no functional impairment. The mean Quick DASH score for our patient population was 4.5 / 100 points.

Conclusions

Extended surgical treatment of SCJ infection leads to very satisfying clinical and functional results.

Background

Approximately 5% of patients presenting with lung cancer show chest wall invasion, either limited to the parietal pleura or involvement of the intercostal muscles, the ribs and vertebral bodies or extension into the soft tissue below. Due to higher postoperative complication rates, difficulties in achieving complete resection and generally lower survival rates of patients with these advanced tumors, lung cancer invading the chest wall was considered a relative contraindication for surgery for a long time. With good results being subsequently reported in the 1960s, thoracotomy with en bloc resection became the traditional and potential curative approach in lung cancer with chest wall invasion.

Aims

Ongoing improvements in techniques and instruments for video-assisted thoracoscopic surgery (VATS), especially in uniportal VATS, have allowed lung surgery to become more minimally invasive with faster postoperative rehabilitation. Thus, offering minimally invasive resection for an individual subgroup of patients with lung cancer and chest wall involvement.

We describe our preferred technique for minimally invasive en bloc lung and chest wall resection step-by-step, including outcomes.

Material & Methods

From January 2016 to December 2020, 1.9% of all anatomical lung resections performed at our center required en bloc chest wall resection which goes beyond extrapleural lung mobilization. In 18.8% of these cases, an extended minimally invasive resection by uniportal or hybrid VATS was performed.

Results

Figure 1 illustrates complete uniportal VATS chest wall resection using a single incision, followed by minimally invasive chest wall reconstruction with (Figure 2) or without mesh implantation.

Conclusions

The uniportal VATS technique is one of the least invasive approaches in thoracic surgery, which is associated with very low morbidity and complication rates. In selected cases, uniportal or hybrid VATS chest wall resection is an excellent therapeutic option in patients with lung cancer and chest wall involvement.

Backgraound:

Management of ectopic parathyroid adenoma of the mediastinum is a rare and challenging problem, undermost due to difficult localization. The use of video-assisted techniques has amplified the thoracic surgeon’s ability for treatment, especially with the implementation of robotic systems, as magnified vision and precise dissection ability might improve the results.

Hence, we report our series of robotic-assisted thoracoscopic resections (RATS) of aberrant parathyroid adenomas in the mediastinum.

Material&Method:

We performed a retrospective data-analysis of all patients with proven hyperparathyroidism due to ectopic adenomas of the parathyroid gland in the mediastinum, who underwent RATS with the Da Vinci system (S/ Si/ X/ Xi Intuitive, Sunnyvale, CA, USA) at our institution between 2004 – 2022. Primary outcome was the pre- and intraoperative level of parathyroid hormone (PTH). Perioperative morbidity and mortality served as secondary outcomes.

Results:

Eight patients (median age 62 years, 75% female) were treated at our institution. Hyperparathyroidism was diagnosed by high above normal level of PTH. Preoperatively at least one imaging modality (PET-CT;FDG or Choline, MRI or CT) was performed in all patients demonstrating a lesion in the upper ventral mediastinal compartment. Three out of eight patients (37.5%) had history of unsuccessful surgical attempts in the past (3 by cervicotomy, 1 by cervicotomy and sternotomy). One patient had sternotomy for coronary bypass (table1).

In all patients, robotic resection was performed as planned without any intraoperative complications. Preoperative and intraoperative value of PTH was measured proofing effective resection of the adenoma (table 1).

Median hospitalization time was 3.5 days. No surgical related postoperative complications. Three patients showed postoperative PTH levels below standard value. Only one patient was symptomatic needing pharmaceutical treatment. The 90-day mortality rate was zero.

Concusions:

Effective minimal-invasive resection of ectopic mediastinal parathyroid adenomas can be performed without intra- or postoperative complications even in patients that underwent previous interventions via sternotomy.

Background: Concomitant cholecysto- and choledocholithiasis is common. Standard treatments are ERCP followed by cholecystectomy or laparoendoscopic rendez-vous. ERCP has drawbacks such as post-ERCP-pancreatitis (5%) or -bleeding (5%) and potentially more than one intervention to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with papillary balloon dilation and pushing of concrements to the duodenum has not been evaluated prospectively. The aim of the study was to evaluate this procedure regarding safety and stone clearance rate.

Methods: Prospective single centre intervention study. 80 consecutive patients admitted to our institution between 1/2021 and 4/2022 with suspected or confirmed choledocholithiasis (stones ≤ 6 mm) and known cholecystolithiasis were included. Success of the procedure was defined as lack of filling defects in the intraoperative control cholangiography and absence of symptoms at 6 weeks follow up. Simon’s two stage design was used to determine sample size. Aiming for 95% positive outcomes (no pancreatitis) and tolerating at most 15% negative outcomes, power analysis revealed 57 participants (80% power, alpha 0.05).

Results: 57/80 patients (71%) fulfilled the inclusion criteria. While there was no postoperative pancreatitis, 2 patients (3.5%) had asymptomatic amylasemia 4h postoperatively. Stone clearance was achieved in 54 patients (94%). The main reason for failed stone clearance was the inability to push the guide wire along the concrement into the duodenum. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Median intervention time was 28 min (14-129 min).

Conclusions: Intraoperative bile duct clearance by balloon dilation of the sphincter of Oddi appears to be safe and highly feasible. Its overall superiority to the current standards requires evaluation in a randomized controlled trial.

Background Laparoscopic cholecystectomy is a very frequent intervention and sometimes also performed together with bariatric surgery. Cystic duct remnant, defined as a residual cystic duct of > 1cm in length, may be source of recurrent stones and subsequent hepatobiliary complications. Increased incidence of gallstone formation after Roux-en-Y gastric bypass (RYGB)  associated with altered post-operative anatomy makes the management of symptomatic common bile duct (CBD) stones together with a large cystic duct remnant challenging.

Aim: We describe here the case of a patient after RYGB presenting a large remnant cystic duct containing recurrent stones and CBD-stones. He underwent a combined treatment by laparoscopic neo-cholecystectomy and stone-extraction by trans-gastric endoscopic retrograde cholangio-pancreatography (TGERCP).

Material&Methods: A 45-year-old woman, with a history of RYGB and cholecystectomy 11 years earlier, presented at our emergency department with symptomatic CBD-stones and early cholangitis. Radiological assessment revealed a dilated cystic duct remnant, mimicking a neo-gallbladder, containing multiples stones (Figure 1).

Results: After initial 6-days antibiotic treatment diagnostic laparoscopy was performed and a stone containing bulging cystic duct remnant found. Intraoperative cholangiography also demonstrated a very low cysto-choledochal junction and stones in the CBD (Figure 2). The neo-gallbladder was resected and sent for histological examination. After gastrotomy with intra-gastric insertion of a 15mm trocar (Figure 3), TGERCP with papillotomy was performed by the gastroenterologist and a 6mm stone extracted. Gastrotomy-closure was done with 2 horizontal V-lock sutures. The patient had an uneventful postoperative follow-up.

Conclusions: Long cystic remnant with recurrent stones may cause serious problems especially after RYGB. It has been shown that laparoscopy-assisted TGERCP is a feasible and safe solution in such patients. Laparoscopic completion-cholecystectomy/cystic-resection of a symptomatic remnant gallbladder/cystic duct is well established. Combining the two procedures during the same laparoscopic intervention is feasible and safe.

Background

Laparoscopic cholecystectomy (LC) is the treatment of choice for cholecystolithiasis. It is among the most common surgical interventions with well-known risks for complications. Randomized trials have sought to determine whether this procedure can be performed on an outpatient basis.

Aim

This study aims to summarize outcomes from RCT comparing LC in an outpatient versus inpatient setting.

Methods

A systematic literature search was performed using CENTRAL, MEDLINE (via PubMed) and Web of Science for all RCT investigating LC. A meta-analysis of outcomes was not possible due to poor reporting.

Results

Out of 27 articles, 4 RCT were found investigating a total of 385 patients. Two studies reported a discharge rate of 92% in the outpatient group after 5.7 hours or within 4-8 hours postoperatively. The single trials reported no differences in morbidity, admission, patient satisfaction, or quality of life. With regards to the costs of intervention, two studies reported a benefit favouring the outpatient group (CHF 195 vs. CHF 922 and CHF 2805 vs. CHF 3312 for outpatient vs. inpatient setting, respectively), although one study did not reach the same conclusion.

Conclusion

The available RCT show the feasibility and safety of LC. No differences were found in terms of patient satisfaction and morbidity in an outpatient setting. However, outcomes have not yet been confirmed by large trials and the eligible population is unclear. Outcomes of interest are morbidity, mortality, readmission, cost of intervention, and patient satisfaction. Due to the increasing costs in the health care system, further trials are needed to perform a risk-cost-benefit analysis of outpatient LC.

Background:The role of neoadjuvant chemotherapy with or without radiotherapy in resectable pancreatic cancer has yet to be defined. This Metanalysis aims to explore the benefit of a neoadjuvant treatment in resectable pancreatic cancer compared with upfront surgery in terms of overall survival.

Methods: MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with primary resectable pancreatic cancer treated with or without neoadjuvant treatment from January 2000 to December 2022. The quality assessment of the included studies was based on the Newcastle–Ottawa quality scale. Secondary outcomes included disease free survival, pathological lymph-node rate, overall and R0 resection rate.

Results: A total of eleven studies (seven randomized controlled trials and four cohort studies) with 9774 patients were included. Neoadjuvant treatment was found to be significantly associated to increased overall survival (p<0.001; OR: 0.82; 95% CI: 0.73 – 0.92) and disease-free survival (p<0.001; OR: 0.73; 95% CI: 0.59 – 0.89). The association of radiotherapy showed no additional benefit to chemotherapy alone in terms of overall survival in the subgroup analysis. Patients undergoing neo-adjuvant treatment were also found to be significantly associated with a higher R0 resection rate (p<0.001; OR: 1.67; 95% CI: 1.31 – 2.15) and negative lymph-node status (p<0.001; OR: 0.41; 95% CI: 0.26 – 0.64).

Conclusion:Neoadjuvant treatment seems to offer an advantage in terms of overall and disease-free survival in comparison to patients undergoing up-front surgery for primary resectable pancreatic cancer. Further RCTs should confirm these findings to generalize the indication of neoadjuvant treatment in this settig.

Background

Several evidence gaps still need to be addressed in pancreatic surgery research. In our times of scarcity of resources in finances and time, research activities should be prioritized according to their clinical and political relevance.

Aim

Prioritize research topics in pancreatic surgery based on existing evidence and expert voting.

Methods

A digital survey among national and international pancreatic societies was performed over the course of six months. International experts were asked to rate their "Top 5" research topics requiring an RCT based on the 76 research topics from the Evidence Map of Pancreatic Surgery. Moreover, experts rated the importance of having an RCT for existing evidence gaps i.e. from the eleven research topics currently without an existing RCT.

Results

A total of 149 surgeons from 30 countries contributed to this study. Currently, the most relevant research topic is vascular resection in pancreatic surgery (39 votes). Radical antegrade modular pancreatosplenectomy (RAMPS) versus standard distal pancreatectomy was ranked second (30 votes). Celiac axis resection versus standard resection and spleen management in distal pancreatectomy were ranked third and fourth (both 27 votes). Finally, the time point for surgery for chronic pancreatitis was ranked fifth with 25 votes.

With regard to the eleven evidence gaps, the topic of RAMPS versus standard distal pancreatectomy and total versus partial pancreatectomy were both rated as having "very high priority" to have an RCT.

Conclusion

Research activities should be based on objective prioritization. The current study allows researchers and funding bodies to address the most relevant research questions based on a systematic evidence overview evaluated by pancreatic surgeons worldwide. This will allow for clinically relevant, high-quality evidence while also saving resources.

Background: Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal neoplasm. The majority of patients with initially localized disease develops tumor recurrence even after oncological resection.

Aims: We aim to identify characteristics of patients with aggressive tumor biology and high risk of early recurrence which might benefit from early precision therapy rather than major surgery. We investigate spatially organized tumor and immune cell determinants of PDAC recurrence.

Material&Methods: PDACs (n=284) were classified according to recurrence site as liver (n=93/33%), lung (n=49/17%), local (n=31/11%), peritoneal recurrences (n=38/13%) and no-recurrence (n=73/26%). Spatial compartments were identified with fluorescent imaging followed by transcriptomic (pancytokeratin⁺ tumor cell compartment) and proteomic (CD45⁺ leukocyte compartment) analysis for immune pathway associated targets by using a digital spatial profiling platform. Finally, 10tumors of each group underwent immunophenotypic analysis by multiplex immunofluorescence. A validation cohort (n=109) was examined in parallel.

Results: The no-recurrence group shows high immunogenicity, adaptive immune responses and is rich in pro-inflammatory chemokines, GZMB and aSMA⁺ fibroblasts. PDACs with liver and peritoneal recurrences display low immunogenicity, stemness phenotype and innate immune responses, whereas those with peritoneal metastases are additionally rich in FAP⁺ fibroblasts. PDACs with local and lung recurrences display interferon gamma signaling and mixed adaptive and innate immune responses, but with different leading immune cell populations. Tumors with local recurrences overexpress dendritic cell markers, those with lung recurrences neutrophilic markers. Except the exclusive presence of RNF43-mutations in the no-recurrence group, no further genetic differences were seen. The no-recurrence group exhibited the best, whereas liver and peritoneal recurrences poorest prognosis with median overall survival of 16 and 12.5months.

Conclusions: We found distinct spatial and microenvironmental profiles on gene and protein level in each recurrence group, which differed from each other as well as from the no-recurrence group. These findings may help to inform personalized adjuvant/neoadjuvant and surveillance strategies including immunotherapeutic modalities.

Background: AB0 incompatible kidney transplantation has become a genuine treatment for end-stage renal disease. Non-inferiority in long term graft function compared to AB0 compatible transplantation has been shown. However, the assumed burden due to complications owing to increased immunosuppression inherent to AB0 incompatible transplantation has not yet been quantified.

Aim: The aim of the study was to determine if AB0 incompatible recipients have additional morbidity and whether this burden is justified or whether kidney paired donation programs should be advocated.

Methods: From January 2000 to March 2020 46 AB0 incompatible living kidney transplantations were performed. Patients were matched with AB0 compatible recipients according to sex, age, underlying disease, year of transplantation, and duration of dialysis. Number and duration of readmissions, surgical complication rates according to Clavien-Dindo and its comprehensive complication index (CCI), kidney function, occurrence of new onset diabetes, as well as tumor incidence were analyzed.

Results: Readmission rate was not higher in AB0 incompatible recipients. The median difference in length of hospital stay for readmissions, CCI during primary hospital stay, and CCI for readmissions at 3, 6, 12 and >12 months after transplantation were comparable. Incidence of tumor and new onset diabetes after transplantation was not increased in incompatible recipients.

Conclusion: AB0 incompatible recipients do not suffer from a higher burden compared to AB0 compatible recipients. We currently recommend not delaying transplantation in ABO incompatible pairs.

Background

The gap between available donor grafts and patients on the waiting lists is constantly growing, leading to an increased utilization of high-risk kidney grafts. The use of these organs requires new strategies of organ optimization and assessment before transplantation. Hypothermic machine perfusion (HMP) is standard for kidneys obtained from donation after circulatory death (DCD), whereas evidence for additional oxygenation to HMP is still very limited and an objective assessment of HMP-perfused kidneys is lacking.

Aims

This study aims to determine whether Flavin mononucleotide (FMN) is a feasible and suitable marker for the assessment of kidney injury. 

Methods & Methods

In a porcine model, the feasibility of assessing DCD kidney grafts during hypothermic oxygen perfusion (HOPE) was explored. A DCD group with warm ischemia times (WIT) of 30 and 60 minutes, mimicking a clinically relevant scenario, and a DBD group (donation after brain death) as control. Kidneys were subjected to two hours of static cold storage (SCS) followed by two hours of end-ischemic HOPE with real-time FMN measurement. FMN values were then related to initial ischemic damage.

Results

We demonstrate, first, feasibility of FMN measurement in perfused kidneys, and secondly its correlation with the WIT. Accordingly, perfusate FMN was significantly higher in the 60-minute WIT group (n=4) compared with the 30-minute WIT (n=4) and DBD group (n=4) (reference 1, 2 & 3). FMN release also correlated with DAMP signaling. Finally, ATP replenishment was best in DBD kidneys, followed by DCD kidneys with 30 and then by 60 minutes of WIT.

Conclusions

This study proves feasibility of FMN measurement in kidneys during HOPE. In addition, we reveal a correlation between FMN quantification and pre-existing kidney injury. Based on this, real-time FMN measurement during HOPE may be an objective assessment tool in the near future to accept high-risk kidneys for transplantation while minimizing post-transplant dysfunction.

Background:

RefluxStop is a non-active, implantable medical device intended to reduce esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). RefluxStop does not affect the esophageal lumen and thus might also be suited for patients with esophageal hypomotility.

Aim:

To report short-/midterm functional outcomes after implantation of RefluxStop.

Materials&Methods:

All patients who received laparoscopic implantation of the RefluxStop device from 09/2018-12/2022 in a university hospital were included for retrospective analysis. Subjective (GERD-HRQL-questionnaires; after six weeks and every six-month thereof) and objective data (24h-pH-manometry, barium swallows and upper endoscopies) are reported as functional outcome parameters.

Results:

Forty-five patients were included. Median age was 49.3y (min 28.1– max 76.8), median Body Mass Index 28kg/m2 (19-34), and 21 patients were female (46.7%). Nine patients (20%) had esophagitis Los Angeles grade C or more, 3 had non-acidic reflux (7%), and 32 (71%) had esophageal motility disorders.

Primary presenting symptoms were typical in 31(69%), pain or dysphagia in 5(11%), respiratory in 8(18%) and nausea in 1 patient (2%). GERD-HRQL score was significantly reduced from baseline to 6 weeks postop (23.9 and 4.3 (p < 0.001)) and to last follow-up (6.8, p = 0.021).

In the last follow-up, after a median of 3.2y, primary presenting symptoms were gone in 31(69%), improved in 6(13%), and stayed the same in 2(4%). Typical symptoms were gone or improved in 34 of 37 patients (92%), dysphagia and pain in 12 of 15 patients (80%), and respiratory symptoms in all of 14 patients. De novo bloating occurred in 1 patient and was improved or gone in 5 patients; no diarrhea was seen.

Conclusions:

RefluxStop shows promising results over four years in a challenging patient population burdened with GERD and esophageal motility disorders.

Background:

Laparoscopic hiatal hernia repair with RefluxStop is an innovative technique to treat patients with gastroesophageal reflux disease (GERD). While feasibility and safety of this technique have already been demonstrated, consistent 12-months follow-up data is lacking.

Aims:

To report 12-months outcomes and complications of a novel surgical anti-reflux technique with RefluxStop.

Materials & Methods:

Among the 60 patients who underwent hiatal hernia surgery with RefluxStop since 2020 at our institution, we performed a retrospective chart review of the first 30 patients who achieved a minimal follow-up of 12 months. Follow-up data were reviewed until December 2022. Primary outcome was the clinical improvement of GERD related symptoms (heartburn and regurgitation) at 3 and 12 months after surgery. Secondary outcomes were need for dilatations and occurrence of implant related complications.

Results:

The median follow-up was 19.5 months (range, 13-31). Preoperatively, 23 patients (76.7%) presented with esophageal dysmotility, and the median length of the concomitant hiatal hernia was 4cm (range, 2-8). Mean GERD-HRQL score (0-75 points) was 37.6 ± 15.8 before surgery, 4.2 ± 7.1 at 3 months, and 4.4 ± 6.9 at 12 months (p<0.001) (Figure 1). Three patients (10%) required postoperatively balloon dilatation due to persistent dysphagia. One patient experienced an asymptomatic partial migration of the implant (Figure 2), one patient presented with a recurrence of hiatal hernia after 2 years who required surgical repair, and in one case the implant was removed after 16 months to due persisting left thoracic pain.

Conclusions:

This study confirmed excellent clinical outcomes beyond 1 year with significant improvement of reflux symptoms in all patients.

Background: Nissen and Toupet fundoplication are the predominant procedures in the treatment of large hiatal hernias. Nevertheless, these techniques may cause relevant side-effects such as increased bloating or dysphagia, thus impairing the patient’s quality of life.

Aim: To evaluate the mid-term outcome after mesh-enforced hiatoplasty and anterior fundoplication in large hiatal hernia repair.                              

Material and Methods: Prospective single-center study investigating the clinical, endoscopic and radiological outcome after laparoscopic, mesh-enforced hiatoplasty and anterior fundoplication in patients with large hiatal hernias.

Results: Ninety-nine patients were operated between 2012 - 2022 and met all the inclusion criteria including postoperative computed tomography (CT). 68% were female, mean age was 71 ± 10 years, 72% of the patients needed proton pump inhibitors (PPI) prior to surgery. In all patients, more than 20% of the stomach was located supra diaphragmatic, in 65% more than 50% of the stomach was herniated. Mean operation time was 152 ± 45 minutes, there were no major intraoperative complications and one short-term postoperative complication demanding operative revision due to early recurrence. Mean length of stay was 5.1 ± 1.9 days. Upper endoscopy was performed in 94% after 16 weeks and showed a correct position in all cases. Clinical and CT follow-up were obtained in all patients after 1.6 ± 1 years. 87% had a correct position of the fundoplication in CT, 6% had a slippage and 7% a recurrent hernia. Two patients needed operative revision. 84% of patients reported their clinical outcome as excellent, 10% as good. Mean Gastrointestinal Qualitiy of Life Index was 126 ± 14. 98% of patients would perform the surgery again.

Conclusion: Mesh-enforced hiatoplasty and anterior fundoplication in large hiatal hernia repair is safe and leads to a high rate of patient satisfaction. The radiological outcome poorly correlates with clinical symptoms or patient reported outcome.

Background: Paraoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Gastropexy without fundoplication, in which the stomach is attached to the anterior abdominal wall is an accepted alternative procedure and considered a low-risk intervention. However, outcomes and functional results are hardly described in literature. Our study aim to evaluate short-term outcomes and the long-term quality of life of patients that underwent a gastropexy as treatment for PEH.

Methods:  Single center cohort analysis of all consecutive patients who underwent hiatal repair and gastropexy for PEH without fundoplication from 2015 to 2021. Postoperative outcomes and functional results were retrospectively collected via chart review of postoperative routine follow-up. Reflux symptoms developed postoperatively were reported using the published and validated quality of life questionnaire: GERD-Health Related Quality of Life Qestionnaire (GERD-HRQL). Postoperative complications were reported according to Clavien-Dindo complication grade.

Results: Thirty patients (median age: 72years (65-80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17-50) months, one patient was lost. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL score of 4 (1-6). 72% (n=21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2-19) versus 3 (0-6), p=0.100.

Conclusion:  Gastropexy without fundoplication was performed by laparoscopy in the majority of cases with acceptable complications rates.  Two-thirds of patient’s report symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good.  Although the rate of PEH recurrence requiring a new re-intervention remains increased (23%), it does not seem to affect long-term functional results.

Background

Treatment of Esophageal Cancer (EC) consists of neoadjuvant radiochemotherapy (RCT) followed by resection. However, esophagectomy is associated with considerable morbidity in patients already burdened with comorbidities, malnutrition, and unhealthy lifestyle.

In this context, a watch and wait (WW) strategy has gained importance in patients with complete response to RCT and has been adopted by our center a decade ago.

Aim

To investigate independent predictors for recurrence in patients with EC undergoing WW.

Material&Methods

We retrospectively analyzed data of all patients with potentially curable EC and complete response to RCT from 01/2014–12/2020 at a tertiary university hospital. Patients underwent staging (computed tomography (CT), upper endoscopy with ultrasound and biopsies (EUS), and positron-emission tomography (PET)), followed by RCT with restaging six weeks after completion. Routine follow-up consisted of EUS every three and CT every six months. Clinical data were extracted from electronic medical records. Factors associated with recurrence were adjusted for patient- and tumor-characteristics in multivariate regression analysis.

Results

A total of 40 patients were included. Of these, 22 (55%) had cancer recurrence. Tumor type was squamous cell carcinoma in 24 (60%) and adenocarcinoma in 16 (40%), respectively. T3-stage was most frequent (n=26, 65%), 35 (88%) patients were nodal-positive. Mean age was 67 years (SD 8.8), 30 (75%) patients were male. Recurrence occurred after a mean of 413 days (SD 171). Multivariate analysis revealed a circumferential tumor extent >50% in staging (OR 15.229, p=0.017) and dysphagia at restaging (OR 6.336, p=0.023) as independent risk factors for recurrence.

Conclusion

The current study revealed tumor extent and dysphagia as independent risk factors for recurrence. These predictors may help in the early identification of patients with EC recurrence, thus contributing to a personalized follow-up.

Background: Minimally invasive oesophagectomy (MIE) with intrathoracic anastomosis is increasingly used in treating patients with oesophageal cancer. Anastomotic leakage (AL) remains a critical perioperative complication, despite recent advances in surgical techniques. It remains unclear to what extent the size of the circular stapler (CS), a 25 mm CS or a bigger CS, may affect the incidence of AL. 

Aims: This study aimed to evaluate whether the CS size in oesophagogastrostomy affects the postoperative AL rates and related morbidity in MIE.

Methods: We conducted a retrospective review of consecutive patients who had undergone thoracic MIE between August 2014 and July 2019 using a CS oesophagogastric anastomosis at the level of the Vena azygos. The patients were grouped according to CS size (mm): small-sized (SS25) and large-sized (LS29). The patient demographics, data regarding morbidity, and clinical outcomes were compared. The primary outcome measure was the AL rate related to the stapler size.

 Results: A total of 119 patients were included (SS25: n = 65; LS29: n = 54). Except for the distribution of squamous cell carcinoma, the demographics were similar in each group. The AL rate was 3.7% in the LS29 group and 18.5% in the SS25 group (p = 0.01). The major morbidity (CD ≥ 3a) was significantly more frequent in the SS25 group compared with the LS29 group (p = 0.02). CS size, pulmonary complications, and cardiovascular disease were independent risk factors for AL in the multivariate analysis.

Conclusions: A 29 mm CS is associated with significantly improved surgical outcomes following standard MIE at the level of the azygos vein and should be conducted whenever technically feasible.

Background & Aims:

The aim of this study was to define “optimal” outcomes in total (TG), distal (DG), pylorus preserving (PPG) and proximal gastrectomy (PG) for gastric adenocarcinoma.

Material & Methods:

From a cohort of 8550 oncological gastrectomies, performed over a 5-year period in 36 specialized centers on 4 continents, we selected a low-risk benchmark (BM) group of 1899 patients (22.2%) fulfilling criteria of low comorbidity (ASA score ≤2, age ≤65 years, no relevant comorbidities).

Endpoints included postoperative morbidity according to Clavien-Dindo (CD) and the comprehensive complication index (CCI). BM values were defined as the 25^th/75^th percentile of median outcome parameters in participating centers to represent best achievable results.

Results:

BM patients were predominantly male (56.3%) with a median (IQR) age of 54 (47-60) years. TG, DG, PPG, and PG was performed in 22.7%, 54.1%, 17.9%, and 5.3% cases via open (25.8%), laparoscopic (61.6%) or robotic assisted (12.7%) access (Table 1).

BM patients had a median hospital stay of 9 days without difference between resection types. 17.6% developed at least one complication with a median CCI of 20.9, and 3.2% experienced major morbidity (≥CD IIIB). Postoperative morbidity was related to anastomotic leakage (TG 3.0%, PG 1.0%, DG 0.6%, PPG 0.9%), abdominal fluid collections (2.1%), pancreatic (0.7%) and lymphogenic (0.8%) fistula, and pulmonary complications (1.4%). Duodenal stump leakage rate was 0.5%, and 30- and 90-day mortality was 0.94% and 1.73%, respectively.

BM values in BM patients were ≤20.0% and ≤7.1% for overall and major complications, ≤3.4% for escalation of care, ≤11.6% for readmission, ≤27.9 for the CCI, 0% and ≥28 for positive resection margins and LN yield, and 0% for 30- and 90-day mortality (Table 2).

Conclusion:

This study is the first to present BM values for oncological gastrectomy to evaluate performance in curative surgery for gastric adenocarcinoma.

Background

Routine reconstruction of intestinal continuity after esophagectomy consists of a tubularized stomach pulled up in the posterior mediastinum. However, the extent of previous resection or tissue quality can result in the inability of the stomach to be used in this route and necessitates alternatives.

Requirements for a successful conduit include adequate length, reliable vascular supply, and sufficient functionality to allow for deglutition. The stomach, jejunum, and colon have all been proposed as potential solutions, same as the retrosternal, transthoracic, or antesternal routes.

Aims & Methods:

This video illustrates the use of different conduits and pull-routes in non-routine situations. These are demonstrated by reporting cases treated in this center.

Backgroud  Although laparoscopy is widely used in oncologic digestive surgery, open surgery remains the preferred approach in many centers for gastric cancer, especially in advanced disease

Aims To assess long-term survival and recurrence in patients undergoing laparoscopic (LG) versus open (OG) gastrectomy for cancer, in a European reference center

Methods  All consecutive patients with gastric adenocarcinoma undergoing oncologic gastrectomy with curative intent between January 2007 and December 2021 were retrospectively analyzed. Clinico-pathological characteristics, survival and recurrence were compared between LG and OG patients. The x2 test was used for categorical variables and the t-test for continuous ones. Survival was assessed with the Kaplan-Meier method and log-rank test, as well as a multivariable Cox regression analysis

Results Among the 145 included patients, n=99 (68.3%) were in the OG and n=46 (31.7%) in the LG group. Baseline demographics were similar between the two groups, as were tumor location, perioperative chemotherapy administration and extent of resection (total gastrectomy in 65.2% LG vs 74.7% OG patients, p=0.236). R0 resection was obtained in 80% LG and 78.4% OG patients (p=0.973). Open surgery was associated with a higher lymph node yield compared to laparoscopic surgery (28.5±13.4 vs 22.7±9.8, p=0.03), whereas overall postoperative morbidity was similar (30.4% in LG vs 35.3% in OG patients, p=0.560). Overall median survival was similar between the two groups (46 months, (95% CI 36.9-55.1) for LG versus 130 months, (95% CI 49-211) for OG patients, p=0.976), as was median disease-free survival (11 months, 95%CI 5.7-16.3 for LG versus 7 months, 95% 5.2-8.8 for OG p, p=0.910). Metachronous peritoneal carcinomatosis appeared more frequently in OG than LG patients (31.3% versus 15.2% respectively, p=0.040)

Conclusions  Laparoscopic gastrectomy, although associated with an inferior lymph node yield, provides similar immediate postoperative results and long-term survival compared to open surgery for gastric cancer

Background: Colorectal cancer (CRC)  infiltration by T lymphocytes is associated with prolonged survival. However, immune infiltration spontaneously occurs in <20% of tumors and no therapies able to promote it are currently available. CRC tissue is populated by gut bacteria translocated across the neoplastic epithelium. We previously showed that direct contact between tumor cells and bacteria induces overexpression of genes encoding immune cell-recruiting chemokines in tumor cells, and we identified a panel of bacterial species associated with enhanced chemokine expression, high T cell infiltration and favorable prognosis.

Aims: In this project we tested the ability of identified bacterial species to boost T cell infiltration and promote tumor regression in orthotopic CRC experimental models.

Material and methods: Luciferase-expressing mismatch repair (MMR)-proficient or -deficient murine CRC cells from established cell lines were injected intra-cecum in syngeneic mice. Tumor growth was monitored by bioluminescence. Bacterial species of interest, defined as Operational Taxonomic Units (OTUs), were cultured under anaerobic conditions, and, following tumor development, were administered to tumor-bearing mice by oral gavage. In specific experiments, bacteria administration was combined with immunological checkpoint blockade (ICB), based on injection of anti-PD-1 antibodies. Immune cell infiltration was evaluated by flow cytometry, following tumor harvesting and enzymatic tissue digestion.

Results: In MMR-deficient tumors, known to be immunogenic and responsive to immunotherapy, administration of the bacterial species OTU8, was sufficient to reduce tumor growth. In MMR-proficient tumors, scarcely infiltrated by immune cells and poorly responsive to ICB, OTU8, did not per se affect tumor growth, but enhanced infiltration by cytotoxic CD8+ T cells, ultimately leading, in combination with anti-PD-1 antibodies, to tumor growth inhibition.

Conclusion: We demonstrated that administration of defined bacteria promotes endogenous immune responses against CRC. Gut microbiota conditioning might represent an innovative therapeutic strategy to enhance responsiveness to ICB and to broaden its indication beyond MMR-deficient tumors.

Introduction

Retrospective cohort studies with limited sample sizes suggest that the incidence of appendix cancer may be increased in patients having surgery for colorectal cancer.

Objective

To determine whether patients who underwent surgery for colorectal cancer are at higher risk of appendix cancer.

Methods

Cases of colorectal and appendix cancer were identified from the NICER (National Institute for Cancer Epidemiology and Registration, Switzerland) database based on ICD-10 codes for the period 2009-2019. Incidental cases of appendix cancer (all histological types) were extracted from patients who underwent surgery for colorectal cancer and from the general population followed by cantonal cancer registries. Standardized incidence ratios were calculated.

Results

Twenty-eight thousand nine-hundred and thirty-four cases of colorectal cancer and 1,350 cases of appendix cancer were identified over the study period (10 years). After exclusion of cases of appendix cancer, 22,705 patients underwent surgery for colorectal cancer (at-risk population). In these patients, 43 cases of appendix cancer occurred over the follow-up period, including 35 NETs. In the reference population without any history of surgery for colorectal cancer, 1,305 incidental cases of appendix cancer occurred during the same period. This corresponds to an age-standardized incidence of 20.52 per 100,000 person-year in the at-risk population, and of 1.61 per 100,000 person-year in the reference population. The age-standardized incidence ratio for appendix cancer is 12.74 (95% CI: 12.02-13.45) in the at-risk population when compared to the reference population. However, most of these cases were synchronous cancers. To exclude potentiall information bias, a sensitivity analysis including only cases of left-sided colorectal cancer (colon and rectum) was performed. In this population, the age-standardized incidence ratio for metachronous appendix cancer is 8.67 (95% CI: 7.13-10.20).

Conclusion

The incidence of appendix cancer is increased in patients having surgery for colorectal cancer. The incidence may, however, be too low to consider routine prophylactic appendectomy during surgery for colorectal cancer.

Background

Until recently the use of positron emission tomography (PET) CT for staging in colorectal cancer (CRC) has been limited to the detection of distant metastasis in advanced disease. But with the introduction of neoadjuvant treatments in CRC accurate nodal staging has become more relevant.

Aims

The aim of the study was to assess the staging accuracy for nodal and distant metastasis of PET/CT compared to computed tomography (CT) alone in CRC.

Material & Methods

A retrospective analysis of 539 cases with CRC staged with PET/CT-and or CT between 2015 and 2021 in a Swiss tertiary referral center was performed. The clinical stage of both modalities was compared with the pathological stage.

Results

A total of 539 patients were analyzed. The median age at time of diagnosis was 69 (IQR 59-77) years. The male/female ratio was 58.4 vs. 41.6%. UICC stages were determined as follows: I n=68 (12.6%), II n=129 (23.9%), III n=214 (39.7%), IV n=124 (23.0%), indeterminable n=4 (0.7%). 310 patients (57.5%) were nodal positive on pathological examination. CT alone compared to PET/CT was able to predict nodal involvement with a sensitivity of 69% (95%;CI 63-74%) and 75% (95%;CI 70-80%), respectively. The specificity was 80% (95%;CI 74-85%) for both. The positive predictive value was 84% for PET/CT (CI 79-88%) vs 82% for CT (CI 76-82%). Distant metastases were detected by PET/CT in n=108/124 (87.1%) patients compared to n=76/124 (61.3%) in CT alone. Concordance between pathologic staging and PET/CT with regard to the presence or absence of distant metastasis was given in 476/539 (88.3%) cases compared with 370/539 (68.6%) for CT.

Conclusion

PET/CT compared to CT alone in CRC staging did offer a marginal gain of 6% improved sensitivity in the detection of nodal involvement and a 25% additional yield in correct metastasis detection.

Background: At difference with other tumors, in human colorectal cancer (CRC) neutrophil infiltration predicts favorable clinical outcome. Mechanisms underlying these effects remain unclear. Neutrophils represent a front-line arm of immune responses to bacteria. Notably, CRC tissues are infiltrated by bacteria of the gut microbiota.

Aim: In this project we investigated the capacity of CRC-associated bacteria to trigger neutrophils’ anti-tumor potential.

Materials & Methods: For in vivo studies, human CRC cells from established cell lines were injected intra-cecum (i.c.) into immunodeficient NSG mice and chemokine gene expression was assessed in i.c xenografts by quantitative PCR (qPCR).  Bacterial species most abundant in human CRC, defined as Operational Taxonomic Unit (OTU)5 and OTU2, were expanded in vitro under anaerobic conditions and incubated with CRC cells or neutrophils from peripheral blood of healthy donors or patients. Chemokine gene expression was assessed in CRC cells by qPCR, and chemokine release was evaluated culture supernatants by ELISA. Ability of CRC culture supernatants to induce neutrophils migration was tested in migration assays. Bacteria-induced neutrophil activation was evaluated by flow cytometry based on surface marker expression. Neutrophils’ culture supernatants were incubated with CRC cells and tumor cell viability was evaluated by flow cytometry after 24 hours.

Results: CRC cell exposure to gut bacteria in vivo, as occurring in i.c. tumors, boosted the expression of genes encoding neutrophil-recruiting chemokines. In vitro, OTU5 promoted release of these chemokines by CRC cells and neutrophils’ migration more efficiently than OTU2. Furthermore, OTU5 induced neutrophil activation more effectively than OTU2, as indicated by surface marker modulation. Most importantly, OTU5 triggered in neutrophils the release of cytotoxic factors with tumoricidal activity.

Conclusions: Our data unravel a critical role of CRC-associated bacteria on neutrophils’ recruitment and activation and suggests that gut microbiota conditioning might represent an innovative therapeutic approach to elicit neutrophil-mediated anti-tumor effects.

Background: Ruptured mucinous appendix neoplasms can develop into pseudomyxoma peritonei (PMP). Early stages of PMP are ruptured tumors and/or presence of mucus in the right lower quadrant during appendectomy. A surgical approach towards this early stage is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), which is currently under intense debate. This study retrospectively analysed patients with mucinous appendix neoplasms undergoing active surveillance instead of CRS/HIPEC.

Aims: To assess disease free survival in patients undergoing active surveillance after diagnosis of low-grade mucinous appendix neoplasms presenting with rupture/local PMP.

Material & Methods: Overall, seventeen patients in the period of 2012 – 2022 were included. Patients underwent annual abdominal imaging and planned diagnostic laparoscopy.

Results: Indications for appendectomy were appendicitis (n=10), mucocele (n=6) or persistent abdominal pain (n=1). Appendectomy was performed laparoscopic (n=13), open (n=2), and two patients underwent coecal resection. Histopathology revealed LAMN (n=13), mucocele (n=3), and one serrated adenoma. Follow-up was mainly performed by MRI (70%) and re-laparoscopy scheduled after an average of 11.8 months. Median follow-up was 41 months. Two patients (12%) presented with PMP lesions in the right upper quadrant and subsequently underwent CRS/HIPEC.

Conclusions: Our findings suggest that active surveillance including diagnostic laparoscopy offers a valid strategy to avoid CRS/HIPEC in patients with ruptured low-grade mucinous neoplasms or localized PMP. Long-term follow-up data is however required to validate this strategy.

Objective

Anastomotic leak (AL) after CRS-HIPEC is associated with significant morbidity and mortality. A diverting ostomy (DO) could mitigate the consequences of AL but remains controversial due to stoma-related morbidity and risk for recurrence. This multicentre retrospective study aimed to assess the value of DO on morbidity and survival after multiple large bowel anastomoses and HIPEC in patients with colorectal (CR) peritoneal metastases (PM).

Methods

Multicenter retrospective analysis of consecutive CR patients undergoing curatively intended CRS-HIPEC for PM. All patients had at least 2 large bowel anastomoses with (WO) or with no (NO) diverting ostomy. The comparative groups were adjusted for age, gender, PCI, systemic chemotherapy, past surgical history, and CRS completeness with a propensity score matching. Predictors for survival and morbidity were searched for by Cox regression and multivariable analysis, respectively.

Results

Between 2006-2022, 140/183 patients were analyzed after propensity score matching: 95 patients WO and 45 NO were comparable for the main covariates (gender, age, PCI, comorbidity, past surgical history, resected organs). NO patients had a higher incidence of anastomotic leak (15.6 vs 6.7%, p=0.1), comparable severe complication rate (Clavien >3a) (24.4 vs 25.6%, p=0.9) and 90-days mortality (2.2 vs 0%, p=0.16). Median hospital stay was 14 vs 21 days for NO and WO, respectively (p < 0.01), see Table 1. Ostomy was an independent predictor for mortality (OR 3.7, p = 0.009) and recurrence (OR 3.1, p = 0.01) but not for survival, see Figures 1 and 2, respectively.

Conclusion

Diverting ostomy did not reduce morbidity after multiple large bowel anastomoses and HIPEC in this study but was associated with longer hospital stay, and increased mortality and recurrence. Routine use can hence not be recommended.

Background: The number of elderly patients with a diagnosis of colorectal cancer (CRC) is increasing. Considering the short life expectancy, surgery may not always be the best treatment option.

Aims: The aim of this study was to assess postoperative morbidity and mortality, oncologic outcomes, and loss of autonomy.

Material&Methods: We included patients 80 years and older who underwent elective resection for CRC following ERAS protocol between January 2010 and May 2021. Clinical and follow-up data were retrospectively retrieved from a prospectively maintained and audited database for ERAS patients. The primary endpoint was overall survival, secondary endpoints were surgical morbidity, and the rate of return to pre-operative living conditions 3 months after surgery.

Results: Ninety-four patients underwent colonic (73%) or rectal (27%) resection, in 85 (90%) laparoscopically. The mean age was 84.6±3.6 years, and 49 (52%) were female. Most (78%) patients were ASA>= 3 and 90 (95%) had at least one comorbidity. After surgery 22 (23%) patients had a Clavien-Dindo >=3 complication and 2 (2%) patients died. A stoma was constructed in 22 (23%) patients and reversed in 11 (50%). The length of hospital stay was 12.7±12.6 days; 67 (71%) patients were discharged home and 27 (29%) patients to rehabilitation or post-acute care institutes, of which 7 were lost to follow-up, and 3 required long-term institutionalization. Overall, 87 (96%) returned to their pre-operative living conditions directly or after short-term rehabilitation. Mean follow-up was 51±34 months, 3y overall survival was 77%, and disease-free survival was 87%. By the end of follow-up, 36 (38%) patients had died, of which only 9 (10%) were due to cancer.

Conclusions: Our study suggests that elderly patients undergoing elective surgery, despite significant postoperative morbidity, have a very high probability to return to preoperative living conditions and excellent disease-free and overall survival.

Background

Complications such as anastomotic leakage or surgical site infections after colorectal surgery remain a major concern. Several individual perioperative quality improvement measures have been found to reduce postoperative complications.

Aim

The aim of this study was to evaluate the introduction of a combination of nine perioperative interventions in a colorectal bundle (CB) for the reduction of postoperative complications.

Patients & Methods

This prospective, multicenter, observational study was performed in nine Swiss cantonal and tertiary referral centers. Data on left sided colorectal resections was collected 6 months prior and 6 months after the implementation period of one month for the CB. The primary endpoint was the mean comprehensive complication index (CCI) at 30 days.

Results

Between October 2020 and December 2022 1142 patients were included of which 198 had to be censored due to pandemic related capacity reductions, leaving 944 for final analysis (n=552 controls, n=392 CB). Median age was 66 years, gender distribution was equal (50/50%). Median ASA score was 2 in both groups while 16% of cases were emergencies in controls and 7.7% during the CB phase. In the control group, 45% were teaching procedures and 35.7% oncological resections (42% and 45% during the CB phase, respectively).

The mean CCI in controls was 11.7 vs. 10.4 in CB (p=0.33). Twelve patients (2.1%) of the controls vs. 11 (2.8%) in the CB group developed an anastomotic leakage (p=0.53) while surgical site infections occurred in 45 (8.1%) controls and 35 (8.9%) patients in the CB group (p=0.72). The mortality was 1.6% vs. 0.8% (p=0.37) in controls and CB patients, respectively.

Conclusion

EvaCol is the first prospective Swiss, multicenter, cohort study in colorectal surgery in a decade. Considering the already low complication rates in the control group, the study failed to show a clinically relevant and statistically significant reduction of complications with the introduction of the CB.

Background: Prokinetics are postulated to accelerate bowel movement after colon surgery.

Aim: To determine whether or not prokinetics shorten the number of days to first gas and first stools.

Material and Methods: A prospective monocentric cohort study was conducted in a tertiary care center, including consecutive patients who had colon resection between July 2020 and December 2022. Time to first gas and/or first stools was compared between patients who received post-operative prokinetics (domperidone) and those who did not.

Results: Two-hundred and fifty-six patients were included. Prokinetics tended to decrease the number of days to first passage of stools (3.17+/-1.57 versus 3.29+/-1.75, p=0.579) when compared to standard management without prokinetics. On a day-to-day analysis, the proportion of patients who had first gas on POD1 (post-operative day) (62% versus 38%, p<0.001) and POD2 (75% versus 25%, p<0.001) was higher with prokinetics. Similarly, the proportion of patients who had first stools on POD2 (76.6% versus 23.4%, p<0.001) and POD3 (71.8% versus 28.2%, p<0.001) was higher with prokinetics.

Conclusion: After colon resection, prokinetics shorten the time to first passage of gas and stools.

Background:

With partners in the National Referral Hospital in Honiara (Solomon Islands), Hand surgeons from a Swiss tertiary hospital have started a cooperation with the aim to sustainably improve hand and reconstructive surgical care in this country with a light house effect for the entire South Pacific region. The widely dispersed population of these small island states, 25% of which live below the poverty line, with significant geographical distances between the individual islands, often only reached by the simplest means of transportation, lead to a situation with very limited medical and special surgical care, as well as major challenges and needs for support in long-term development.

Aim:

The aim of this study is to report on progress since the start of an 8-module training cooperation.

Material & Methods:

The dynamics of the numbers of hand surgical patients, delays from injury to referral and from initial specialist review to definitive treatment are presented since the start of the training program. Success of treatment is evaluated via pathology-specific outcome measures, and general outcomes such as complications, re-operations and secondary procedures. The data is extracted from the local Trauma and Orthopedic Database.

Results:

The data extraction is still ongoing at the date of abstract submission and will be critically evaluated and presented at the time of the Swiss College of Surgeons – Annual Meeting June 2023.

Conclusion:

International cooperations in low and middle income countries such as HandsON need to be ongoing subject to critical evaluation in order to meet the aim to progressively and sustainably support and enable surgeons in training on site with local, national and international networking, using local infrastructure and resources, in order to guarantee sustainable change and excellence in surgical patient care. This includes the collection of all relevant data for the measurement of change and progress, and their critical evaluation including audits and research projects.

BACKGROUND

Research shows that a sleep duration of at least seven hours is associated with peak performance. However, job requirements and other factors might lead to insufficient sleep impacting the surgeon’s fitness for surgery, particularly during residency.

AIMS

To analyze the surgeon’s sleep and fitness before surgical procedures and their impact on complications with a sub-analysis for residents.
 

METHODS

Surgeons performing minimally invasive procedures were asked to report sleep duration for the night before and their fitness for the procedure. Fitness - as the general readiness for surgery - was reported on a Likert scale with the items “not fit at all”, “not fit”, “neutral”, “fit” and “very fit”. Items were analyzed across cohorts and procedures with and without complications.

RESULTS

Since 09-2021, we received 391 responses; 83 (22.2%) came from residents, 308 (78.8%) from junior faculty, senior faculty, or consulting surgeons. On 177 (45.3%) occasions, participants had 7 or more hours of sleep before surgery and felt “fit” or “very fit” for 304 (77.7%) surgeries. With 6.1 (+/-1.1) hours, residents slept less than the senior cohort with 6.6 (+/-1.6) hours (p=0.0077). In 34 (41.0%) of surgeries, residents indicated to have been “fit” or “very fit”, while the senior cohort reported the same categories in 270 (87.7%) of cases (p=0.0001). Positive correlations were observed between sleep and fitness and age and fitness (both p<0.0001). Rate of sufficient sleep (44.8% vs 45.4%) and “fit” or “very fit” rating (75% vs 78.3%) was comparable between patients with and without intra- or postoperative complications (p=1.0000 and P=0.8155, respectively).

CONCLUSION

This data shows that sleep is not optimal before many surgeries. Although without impact on clinical outcomes in this analysis, we should explore ways to improve sleep before performing procedures and support - particularly residents - in their general readiness for surgical procedures.

Background

Medical education was and still is challenged by COVID-19 pandemic, and several strategies were implemented by the universities worldwide in order to maintain a good level of education.

Aim

Aim of this work is to point out how strategies adopted in a German university hospital reached students and how they felt comfortable with the solutions proposed in order to define future possibilities in modern teaching.

Material & Methods

A questionnaire was answered by medical students at the end of the 8^th and 10^th semester in a German university hospital asking them about their perception of medical education during pandemic as well as about strategies adopted from the faculty. Values are presented as mean [± standard deviation] and median [range] for continuous variables. Dichotomic variables are presented as absolute number as well as percent. Groups were compared with the Student t-test for independent samples.

Results

A total of 92 out of 117 students answered the questionnaire (78.6% response rate). Students felt disadvantaged in their medical education because of the pandemic on a scale from 0 (absolutely not) to 10 (completely) 5.34 ± 2.3 (range 0-10 points), regardless of semester, gender and whether they aimed a surgical career or not. During pandemic they missed mostly practical exercises (93.5%), followed by contact with other students (65.2%). Presence lessons were missed (28.3%) at least. Among the strategies offered to maintain education, recorded lessons were mostly appreciated (8.2/10 points) followed by skills lab (7.44/10 points). Live-stream lessons were considered as less comfortable (6.6/10 points).

Conclusions

Several aspects of medical education were replaced satisfactorily during pandemic, others need to be adapted in the future in order to meet students` needs and expectations, like more tutorial showing clinical examination techniques and less live-stream lessons. Theoretical online education could be an option beyond COVID-19 as highly appreciated by students.   

Background

In recent years, clinical nurse is an increasingly in demand position in the Swiss health care system.

There are not many outcome measurements of this professional group in comparison to the physician professional group in the Swiss health care system. There are no such outcome measurements in emergency rooms.

Patient satisfaction, along with other parameters, is one method of measuring the quality of care.

Aims

To compare the quality of treatment by either clinical nurses or residents based on patient satisfaction in an emergency room in Swiss health care system.

Material and methods

Patient satisfaction was assessed, using an anonymous, validated questionnaire supplemented with emergency room specific additional questions.

Either clinical nurses or residents treated respondents. Medical specialists closely supervised both groups. The staff were not aware of the ongoing survey.

Several Satisfaction scores were compared between occupational groups. The result was considered significant if p<=0.005.

Results

The response rate was good at 40%. Patient satisfaction was good regardless of care provider. All satisfaction scores showed no significant differences between groups.

Conclusions

We conclude that in our setting patient satisfaction with treatment by clinical nurses is on par with that provided by residents.

Background

Achieving surgical autonomy can be considered the ultimate goal of surgical training. Nevertheless, the transition from supervised surgery to operating alone remains a "jump in at the deep end" and provokes stress not only for surgical residents but also for surgical teachers.

Innovative Head-mounted Augmented Reality (AR) devices, enable visualization of the operating field and teaching from remote. Therefore utilization of AR glasses, may be a novel approach to achieve autonomy for young surgeons.

Aims

The aim of this pilot study was to analyze the feasibility of AR application in surgical training and to assess its` impact on intraoperative stress.

Methods

Head-mounted Realwear Navigator® 500 glasses (Figure 1a&b) and TeamViewer Software were used. Initial "dry lab" testing of AR glasses was performed in combination of the Symbionix LAP MENTOR™ (Figure 2a).
Subsequently Selected residents performed various surgical procedures either semi-autonomously (SA) (on demand consultation of senior surgeon, who is in theatre but not scrubbed) or with AR glasses (permanent remote supervision by senior surgeon, who is not in theatre). Intraoperative stress of operating residents, (measured by intraoperative heart rate (Polar® pulse belt) and State-Trait Anxiety Inventory (STAI) questionnaire) were evaluated.

Results

After "Dry Lab" testing, N=5 senior residents performed N=20 procedures. Intraoperative peak median heart rate of residents increased significantly as compared to preoperative values (median 110 (IQR 98-124) vs. 88bpm (IQR 75-100); p=0.021). No AR related adverse events occurred and all procedures were completed with AR glasses. Intraoperative peak pulse rate was significantly reduced compared with the semi-autonomous group 115 versus 93bpm (p=0.032). Likewise, subjectively perceived stress according to STAI, was significantly lower in the AR group (p=0.023).

Conclusion and Relevance

The use of AR glasses is safe and leads to a reduction in intraoperative stress for young surgeons.

Further studies are required to define the impact of AR on future surgical training programs.

Background

Due to time and socioeconomic challenges (working time regulations, work-life balance, cost pressures), laparoscopic surgical training can no longer be solely done on patients.

Aim

The aims of this study were to capture the current level and the future needs of laparoscopic training in Switzerland.

Material & Methods

A web-based survey was sent to all SIWF/IFSM-accredited general surgery teaching hospitals in Switzerland.

Results

The overall response rate was 56% (48/86) and 86% (19/22) for category A hospitals. 32 (66%) of them participate in educational networks. In-house laparoscopy courses are offered periodically at 25 (52%) hospitals, mainly limited to basic skill courses. Self-training sites are available at 40 (83%) hospitals and are used infrequently (Figure 1). Besides commercial (27) and self-made (7) box trainers, high fidelity trainers are available in 16 (33%) hospitals. There is a mandatory training curriculum only in 7 (15%) clinics and 15 (31%) offer a structured assessment on the simulator. In 25 (52%) centers manual skills are assessed only during the annual evaluation interview based on the procedure catalog. The majority of teaching hospitals do not believe, that residents upon board certification are ready to operate independently. However, they agree in the usefulness of simulator training (Figure 2). There is a trend to restructure the training curriculum from a number-based to a performance-based curriculum (53%) and to establish tools to assess the manual skills of residents (56%).

Conclusion

The current surgical curriculum does not meet today’s requirements, is heterogenous and not well structured in Switzerland. However, teaching hospitals increasingly organize themselves within training networks. Training on simulators is accepted, but not all hospitals have simulators or structured training curricula on simulators.

Background

Simulation training has proved to be beneficial in many fields of professions including medicine. In a first step we evaluated if medical students planning to enter the surgical field rate their manual dexterity as good or above average and if this self-assessment (SA) correlates with the actual performance in a surgical simulation.

Methods

Basic surgical tasks have been performed by medical students in the 3^rd and 4^th year for a total of 4 rounds on 2 identical Lap-Sim® surgical simulators. Two questionnaires, one before (SA of manual dexterity amongst other parameters on a 5 step scale) and one after the simulation (SA of the performance during the simulation concerning the respect for tissue, time and motion efficiency, SA of simulation influence on perception of manual dexterity) had to be answered.

Descriptive statistics stratified by career goal (surgical/ undecided/ nonsurgical) for outcomes of simulation parameters are reported. Associations between surgical career goal and SA of manual dexterity with three performance parameters (tissue damage, time and path length) are estimated in linear regression models.

Results

Out of 102 participating students 41 stated surgery as their career goal, 18 a nonsurgical field, and 43 were undecided. 87.8% of the surgical group rated their dexterity as good or above average (86.1% in the undecided group), 88.9% of the nonsurgical group as below average or good. An association of SA with tissue damage has been found statistically significant (p=0.033). The figure shows the influence of surgical simulation on SA of manual dexterity. Especially the undecided participants seem to be influenced a lot.

Conclusions

A correlation of self-assessed manual dexterity has been found in the surgical group for tissue damage, but not for time and path length. Simulation training might help students in decision making for a surgical field and therefore recruit future surgeons.

Background

Training surgical residents requires diligence, time and effort. Currently, working hours are restricted to 50 hours per week. Recently, however, the Swiss union for residents and attendings (VSAO) proposed a further restriction to a maximum of 42 hours a week for patient care with an additional 4 hours dedicated to structured education.

Aim

This study sought to quantify the amount of time residents required for patient care and structured education. Furthermore, the quality of structured education was evaluated.

Methods

A time tracking survey was conducted at a surgical department in Switzerland over the course of four weeks. Residents recorded the time spent on predefined activities in time slots of 15 minutes. In addition, an opinion poll was taken to estimate the quality of structured education.

Results

A total of 76 working days were analysed. The average work time per week was 48.4h (95%-CI: 46h to 50.9h). The majority of time was spent on administrative duties (19h) followed by patient care (13.2h) and meetings (6.6h). On average, respondents received a total of 9.6h of structured education (5.6h operating time, 2.1h direct teaching and 1.9h lectures). When combined, this resulted in a total of 38.8 + 9.6 working hours per week (95%-CI: Range 40h + 8h to 38h + 10h). Qualitatively, residents acknowledged that the majority of the provided structured education was helpful in their surgical training and that improvements in teaching should be tailored towards individual needs.

Conclusion

Participants of the study indicated a high degree of satisfaction with the currently available structured education. Indeed, the balance between workload and structured education exceeded the demands made by the VSAO. Based on these results, there appears to be a greater need for more flexible planning than a reduction of work time.

Background

Es ist erwiesen, dass der Umfang und der Zeitpunkt der chirurgischen Eingriffe einen entscheidenden Schritt in der Versorgung polytraumatisierter Patienten darstellen. Im Gegensatz dazu ist weniger bekannt, welche spezifischen Faktoren bei der Bewertung der physiologischen Belastung durch chirurgische Eingriffe am stärksten gewichtet werden sollten. Darüber hinaus gibt es nur wenige Hinweise darauf, welche Körperregionen und Operationsverfahren mit einer höheren chirurgischen Belastung und physiologischen Auswirkung verbunden sind.

Aims

Ziel dieser Studie war die Annäherung an eine Expertendefinition der Surgical Load.

Material&Methods

Ein standardisierter Fragebogen wurde von Experten des Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma Komitees entwickelt und von Mitgliedern der SICOT-Gesellschaft online ausgefüllt. Die Fragen umfassten die Relevanz und Zusammensetzung der Surgical Load, Kriterien für das operative Staging und die Quantifizierung der Surgical Load hinsichtlich chirurgischer Interventionen in verschiedenen Körperregionen mittels einer Likert Skale von 1 bis 5 (maximum).

Results

196 Traumatologen aus 63 Ländern (Berufserfahrung (median): 13 Jahre) nahmen zwischen dem 27.06.22 und dem 16.08.22 teil. Die Surgical Load (SL) wurde von 77% der Befragten als sehr wichtig und von 20.9 % als wichtig angesehen. Intraoperativer Blutverlust (43.2%) und Weichteilschäden (29.6%) wurden von den teilnehmenden Chirurgen als die wichtigsten Faktoren gewählt. Die Entscheidung für ein stufenweises Vorgehen wurde von der betroffenen Körperregion diktiert (56.1%), gefolgt vom Blutungsrisiko (18.9%) und der Komplexität der Fraktur (9.2%). Offene chirurgische Eingriffe am Becken (SL=3.55), an der Wirbelsäule (SL=3.36), an den langen Röhrenknochen (SL Humerus=3.01; SL Femur=3.33) und am Knie- (SL=3.24) bzw. am Ellenbogengelenk (SL=3.12) wurden hinsichtlich ihrer Surgical Load am höchsten gewichtet. Perkutane oder intramedulläre Eingriffe sowie Frakturen in distalen anatomischen Regionen wie Händen, Knöcheln und Füßen wurden in Bezug auf ihre Surgical Load durchweg niedriger eingestuft.

Conclusions

Angesichts der Notwendigkeit, grössere Frakturen zeitnah zu fixieren, scheinen die Chirurgen ihre Strategien für das Staging bei polytraumatisierten Patienten und die Berücksichtigung der Surgical Load angepasst zu haben.

The goal of this study was to define variables that predict the treatment strategy in polytrauma patients.

This retrospective cohort study included polytrauma patients. Patients who died within 72h of admission were excluded. The primary outcome was surgical treatment strategy: Early total care (ETC), safe definitive surgery (SDS), and damage control orthopaedics (DCO). Definitive osteosynthesis defined as fracture stabilization that did not require secondary osteosynthesis. Variables of interest included in the prediction model were: injury severity (abbreviated injury scale, AIS), and pathophysiologic parameters at admission of the four vicious cycles (hemorrhagic shock, coagulopathy, hypothermia, and soft tissue trauma).

Results

Inclusion of 696 patients. The mean age of patients was 53.8 (SD 20.2) years, mean injury severity score (ISS) was 21.6 (SD 10.9) points, and overall mortality was 15.1%. Strata: 42 (6.0%) had ETC, 345 (49.6%) SDS, and 309 (44.4%) DCO. Increased AIS spine was associated with ETC (OR 1.7, 95%CI 1.1 to 2.8, p = 0.023); increased AIS of the extremity was associated with SDS (upper extremity: OR 2.4, 95%CI 1.6 to 3.6, p < 0.001, lower extremity: 1.6, 95%CI 1.3 to 2.1, p < 0.001); increased AIS head was associated with DCO (OR 1.3, 95%CI 1.1 to 1.5). The prediction of SDS was highest when all physiologic parameters including hemorrhagic shock, temperature, coagulation, and soft tissue were taken into consideration (AUC 0.8, 95%CI 0.7 to 0.9).

Conclusion

SDS is a frequently used surgical treatment strategy (up to 50%), especially in resuscitated polytrauma patients. Injury pattern and distribution affect the surgical strategy of fracture fixation beside patient’s physiology.

BACKGROUND:
The Watson Trauma Pathway Explorer^® is an outcome prediction tool invented by the University Hospital of Zurich in collaboration with IBM^®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis within 21 days and death within 72 h.

AIM:
The hypothesis was how lactate values woud be associated with the incidence of sepsis.

MATERIALS & METHODS:
Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to sepsis presence, and lactate values were measured at formerly defined time points from admission until 21 days after admission for both groups. Differences between groups were analyzed; time points with lactate as independent predictor for sepsis were identified. The predictive quality of lactate at 2 and 12 h after admission was evaluated. Threshold values between groups at all timepoints were calculated.

RESULTS:
Lactate levels differed from less than 2 h after admission until the end of the observation period (21 d). Lactate represented an independent predictor for sepsis from 12 to 48 h and 14 d to 21 d after admission relative to ISS levels. AUROC was poor at 2 and 12 h after admission with a slight improvement at the 12 h mark. Lactate levels decreased over time at a range of 2 [mmol/L] for 6-8 h after admission.

CONCLUSIONS:
These insights may allow for time-dependent referencing of lactate levels and anticipation of subsequent sepsis, although further parameters must be considered for a higher predictability.

Background

Thoracic injuries are a very common entity throughout all age groups. Patient characteristics as well as injury pattern influence the outcome. With rising numbers of geriatric patients, characteristics of this patient group need to be better defined.

Aims

The aim of this study was to investigate the influence of age on outcome after thoracic trauma.

Material&Methods

The study design was a retrospective analysis from patients suffering from blunt thoracic trauma treated at a level I trauma center throughout five years. We included 663 patients over the age of 17. Patient characteristics as well as comorbidities, injury pattern, adverse events and mortality during hospitalization were obtained. The influence of age was evaluated in a matched pair analysis. Patients with the same pattern of injury and gender but different age (above/below 70 years) were matched. Regression analysis was performed to test for predictors for complications.

Results

The mean age of the study population was 57+/-19 years, 69% were male, 54% of patients had comorbidities. Patients had on average 5.1 +/- 3.9 rib fractures. Pneumothorax was present in 204 (31%), lung contusions in 136 (21%) and hemothorax was present in 109 patients (16%). 23% of patients were treated by chest tube insertion. The overall complication rate was 36%, mortality was 10%.

The matched pair analysis of 70 pairs showed more comorbidities in the older age group. They had significantly less pulmonary contusions and pneumothoraces than the younger patients. The length of stay was shorter for older patients. However, they had a significantly higher mortality rate.

Number of broken ribs, comorbidities and ISS were predictors for adverse outcome.

Conclusions

Older patients who suffer from rib fractures present with different intrathoracic injuries patterns than their younger counterparts. Numeric age might not be the best predictor for adverse outcome, nevertheless it was associated with higher mortality.

Background

Clavicle fractures are often accompanied by multiple rib fractures. The combination of these injuries results in decreased stability of the chest wall making these patients vulnerable to prolonged hospitalization and (respiratory) complications. This study aims to assess whether performing clavicle fixation would improve clinical outcomes by adding chest wall stability.  

Methods

A prospective multicenter study was performed including all adult patients with both multiple rib fractures and ipsilateral clavicle fractures admitted between January 2018 and March 2021. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was the hospital length of stay. The secondary outcomes were, duration of mechanical ventilation, intensive care unit length of stay, pain, complications, and quality of life at 6 weeks and 12 months of follow-up.

Results

A total of 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was found between clavicle fixation and the hospital length of stay (mean difference=2.3, 95% CI -2.1 to 6.8, p=0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which five underwent secondary clavicle fixation. 

Conclusion

In patients with combined, ipsilateral clavicle and multiple rib fractures, plate fixation of the clavicle does not reduce hospital length of stay, pain, or (pulmonary) complications, nor does it improve quality of life.

Background

Die Strategien für Behandlungsprotokolle bei instabilen Beckenringverletzungen weisen internationale Unterschiede auf. Je nach Institution und Region haben sich abhängig von der verfügbaren technischen Ausstattung unterschiedliche Versorgungsalgorithmen etabliert.

Aims

Das Ziel dieser internationalen Studie war es, Behandlungsstandards für instabile Beckenringverletzungen zu ermitteln.

Material&Methods

Ein standardisierter Fragebogen wurde von Experten des Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma Komitees entwickelt. Dieser Fragebogen anschliessend von Mitgliedern der SICOT-Society online ausgefüllt. Themenschwerpunkte hierbei waren Behandlungsstrategien, Klassifizierung, Staging-Verfahren und präoperative Planung. Die Antwortmöglichkeiten für die Behandlungsstrategien waren: 1) Immer (I), 2) Oft (O), 3) Selten (S), 4) Nie (N). Die Stratifizierung erfolgte nach geografischen Regionen.

Results

358 erfahrene Traumatologen aus 83 Ländern (Erfahrung >5 Jahre=79%) nahmen an der Umfrage vom 05.09.22 bis 12.10.22 teil. Die Klassifikationen Y&B (52%) und Tile/AO (47%) werden gleichermaßen verwendet. Rescue-Screws (RS), C-Clamps (CC) und Angioembolisation (AE) werden in der klinischen Praxis weltweit eingesetzt (I+O: RS=24%, CC=25%, AE=21%). Perkutane Techniken werden von 57% der Befragten regelmäßig durchgeführt (I+O), wogegen 65 % nie navigierte Techniken anwenden. Die externe Fixierung ist weltweit ein häufig durchgeführter Eingriff (I+O=71%). Pelvic-Packing wird in weltweiter Praxis nicht in großem Umfang angewandt, da 28% der Chirurgen sie nie und 47% nur selten verwenden. REBOA wird nur in bestimmten Kontinenten eingesetzt, insbesondere in Europa/Nordamerika (I+O=19%/10%), während international 68% der Teilnehmer REBOA nie anwenden. Nur 7 % der Befragten führen nie ein präoperatives 3D-Planungs-CT durch.

Conclusions

Die aktuelle internationale Studie ist die erste, die regionale Unterschiede und globale Ähnlichkeiten in den Behandlungsstrategien instabiler Beckenringverletzungen aufzeigt. Die grössten Unterschiede zeigen sich bei der Anwendung fortgeschrittener Techniken. Ein neuer internationaler Konsens und standardisierte Behandlungsrichtlinien sind unerlässlich.

Background

Die Fixierung mittels ISG-Schrauben ist eine praktikable Behandlungsoption bei hinteren Beckenringverletzungen. In den vergangenen zehn Jahren wurde die navigierte Schraubenversorgung eingeführt, die dem Chirurgen intraoperativ ein dreidimensionales Sichtfeld bietet. Diese Technik erfordert jedoch ein fortschrittlicheres Setup.

Aims

Ziel dieser Studie war es, das Outcome von navigierten ISG-Schrauben mit dem von nicht navigierten ISG-Schrauben zu vergleichen.

Material&Methods

Es wurde eine retrospektive Kohortenstudie von Patienten mit traumatischen Beckenringverletzungen in einem Haus der Maximalversorgung durchgeführt. Eingeschlossen wurden Patienten im Alter von ≥15 Jahren, die mit einer elektiven ISG-Verschraubung versorgt wurden. Die Patienten wurden nach der Behandlungsstrategie stratifiziert (Gruppe NV: navigierte Schrauben vs. Gruppe CV: konventionelle Schrauben). Outcome: Implantatbedingte Komplikationen: Bruch, Lockerung, intraforaminale/Fehlpositionierung der Schrauben, Reoperation.

Results

Zwischen 11/2014 und 08/2021 wurden insgesamt 204 Patienten (Durchschnittsalter 61±20 Jahre, durchschnittlicher ISS 17±10) eingeschlossen. 65 Patienten (64±21 Jahre) wurden mit navigierten Schrauben versorgt, während 139 Patienten (59±20 Jahre) mit konventionellen perkutanen Schrauben am hinteren Beckenring versorgt wurden. Beide Gruppen waren vergleichbar in Bezug auf Alter, ISS und Frakturmorphologie. Die navigierte Gruppe wies schwerwiegendere Komorbiditäten auf (ASA; NV: 2,92±0,78 vs. CV: 2,54±0,87, p=0.003). Die Gesamtkomplikationsraten der Hardware unterschied sich nicht signifikant (p=0.805). Allerdings traten Schraubenfehlstellungen nur in der CV-Gruppe auf mit 6.5%; davon 3.6% mit intraforaminaler Positionierung (vs. NV: 0 %). Außerdem waren die Raten für Reoperationen/Implantatentfernungen nach Frakturkonsolidierung in der NV-Gruppe geringer (NV: 9.2% vs. CV: 21.6%, p=0.05).

Conclusions

Die navigierte Schraubenfixation des hinteren Beckenrings führt zu einer optimalen Präzision der Schraubenplatzierung bei Traumapatienten. Patienten mit schweren Komorbiditäten sowie komplizierten knöchernen Korridoren könnten von einem navigierten Eingriff profitieren. Künftige Studien sollten sich auf die Kriterien für die Patientenauswahl für navigierte Verfahren konzentrieren.

Introduction: Early patient assessment is important for surgical decision making in severely injured patients. Moreover it is known that early fracture fixation is beneficial, such as those in stable condition or those who respond well to resuscitation. The aim of this systematic review is to identify parameters that indicate risk factors for an unfavorable outcome and early complications. In addition, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation.

Methods: A systematic review was performed of peer-reviewed articles in English or German published between January 1, 2000, and May 15 2022 (PUBMED) according to PRISMA guidelines. The primary outcome was the pathophysiologic response to polytrauma, including coagulopathy, shock/hemorrhage, hypothermia, and soft tissue injury to determine the treatment strategy with the least number of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were combined.

Results: The initial systematic search for MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), hemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable, and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/blood/shock; lactate, systolic blood pressure and hemoglobin, hypothermia; thresholds in degrees Celsius/soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma, and musculoskeletal trauma.

Conclusion: In this systematic literature review, we summarize the publications by focusing on the different pathways that stimulate pathophysiologic cascades and distant organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.

Background

Die perkutane Verschraubung des Iliosakralgelenks (ISG) bei instabilen Beckenringfrakturen mit Rescue-Screws ist eine etablierte Behandlung zur raschen Stabilisierung des hinteren Beckenrings und des hämodynamischen Status. Dieser Eingriff wird unter erschwerten Bedingungen durchgeführt und kann daher mit Komplikationen verbunden sein.

Aims

Ziel unserer Studie war es, das Outcome von Rescue-Screws mit elektiven ISG-Verschraubungen zu vergleichen.

Material&Methods

Es wurde eine retrospektive Studie über Traumapatienten mit akuten Beckenringverletzungen in einem Haus der Maximalversorgung durchgeführt. Eingeschlossen wurden Patienten ≥15 Jahre, die mittels ISG- oder transsakraler Verschraubung versorgt wurden. Rescue-Screws wurden definiert als sofortige chirurgische Stabilisierung mittels ISG-Verschraubung nach Eintritt in den Schockraum. Die Patienten wurden nach der Behandlungsstrategie stratifiziert (RS: Rescue-Screws; EL: Elektive Schraubeneinlage). Outcome: Implantatbedingte Komplikationen: Bruch, Lockerung, intraforaminale/Fehlpositionierung der Schrauben, Reoperation.

Results

252 Patienten wurden zwischen 11/2014 und 08/2021 eingeschlossen. 48 Patienten (43±18 Jahre) wurden mit Rescue-Screws versorgt; 204 Patienten (61±20 Jahre) erhielten EL. Die RS-Gruppe war häufiger polytraumatisiert (p<0.001) als die EL-Gruppe (89.6 % vs. 46.1 %) und wies einen höheren ISS auf (30±12 vs. 17±10). Instabile Beckenringfrakturen wurden in der RS-Gruppe häufiger diagnostiziert (p<0.001) als in der EL-Gruppe (91.7 % vs. 48.0 %), ebenso wie ein begleitender Schock (37.5 % vs. 3.4 %). In der RS-Gruppe traten häufiger Implantatkomplikationen auf (25.0% vs. 10.8%, p=0.018). Hinsichtlich der Reoperationen vor (p=0.986) oder nach (p=0.110) der Frakturkonsolidierung gab es keinen Unterschied.

Conclusions

Die Versorgung instabiler Beckenringfrakturen mittels Rescue-Screws scheint eine praktikable Behandlungsoption für schwer verletzte Patienten zu sein. Trotz eines höheren Gesamtrisikos für Implantatkomplikationen sind Rescue-Screws nicht mit erhöhten Revisionsraten verbunden, was auf eine geringe klinische Relevanz besagter Komplikationen hinweist. Weitere Studien sind erforderlich, um Rescue-Screws mit anderen Notfallinterventionen des Beckenringes (z. B. C-Clamps) zu vergleichen.

Introduction:

Pleural mesothelioma has a high risk of recurrence. Promising preclinical results of intracavitary cisplatin-fibrin after (extended) pleurectomy/decortication were followed by phase I and II clinical trials.

Aim:

Long-term outcomes from these patients were compared to historical controls who also underwent induction chemotherapy followed by surgery, but without local cisplatin-fibrin.

Methods:

Patient data were collected between 2008 and 2021, in a prospective observational cohort study. Kaplan-Meier curves were compared between the treatment (n=25) and historical control group (n=65) for overall survival and in-treatment-recurrence-free survival. Time-varying hazard ratios were estimated from a Cox model including the covariates gender, Charlson Comorbidity Index (CCI), tumor stage and histology. Odds ratios were estimated for the outcomes post-OP major morbidities, reoperation, severe side effects, Clavien Dindo ≥ 3 and between-group differences were estimated for duration of hospitalization.

Results:

Baseline characteristics were comparable between the two groups. Kaplan-Meier curves for overall survival seemed to suggest that patients benefit from the new treatment in the beginning until 17 months, but after that, the survival probability was smaller in the treatment group. The overall average estimated hazard ratio for in-treatment-field recurrence or death of treatment vs. control was 0.81 (95% CI 0.48 to 1.38). Adjusted odds ratios of treatment vs. control were 1.38 (95% CI 0.53 to 3.63) for post-operative major morbidities, 1.14 (0.38 to 3.21) for reoperation and 0.19 (0.01 to 1.09) for severe side effects (table).

Conclusion:

In this observational comparison, final conclusions can not be drawn for any of the outcomes that intracavitary therapy is better than standard of care, due to the small sample size. Intracavitary therapy is wanting to have a protective effect against in-treatment-field recurrence with no increase in severe side effects. Larger trials would be needed to confirm the flipping of the Kaplan-Meier curves for overall survival.

Background

Little is known about the role of extracellular vesicles (EVs) in Pleural Mesothelioma (PM). EVs mediate in cell-cell communication, therefore understanding the composition of the vesicles may help to identify potential markers for early diagnosis and new targets of this devastating disease.

Aims

Our goal is to study the transcriptomic profile of EVs secreted by pleural mesothelioma cell lines (PM-EVs).

Materials&Methods

We established primary cell cultures from pleural effusion of 4 PM patients. We cultured cells in serum free medium for 24 hours and isolated EVs from cell culture supernatants using Qiagen Exoeasy kit. RNA was extracted using the mirVana PARIS kit followed by transcriptome sequencing. Data was mapped on the GRCh38 genome, gene expression was calculated using Kallisto. Publicly available data from 32 healthy plasma samples (GSE100206) was analysed analogously. Differentially expressed genes were analysed using edgeR. Enriched pathways were called with fgsea and MSigDB hallmarks of cancer.

Results

We identified 15,822 expressed genes in the mesothelioma EV samples, with a significant number of long non-coding RNAs (2,052) (Fig.A). By comparing gene expression of healthy and PM-EVs, we identified genes upregulated in mesothelioma (logFC over 5, FDR less than 0.05), including long non-coding RNAs already shown to be associated with cancer: SNHG15 (linked with worse overall survival in mesothelioma) and SNHG17 (associated with cell cycle progression and proliferation in a pan-cancer study) (Fig.B). Epithelial-to-Mesenchymal Transition, Glycolysis and Hypoxia were the most enriched processes in PM-EVs (FDR less than 10^-7) (Fig.C). 

Conclusions

We characterised transcriptomic profiles of EVs obtained from mesothelioma primary cell lines and compared them with transcriptomic profiles of vesicles from healthy samples. We identified genes upregulated in mesothelioma secretome and their key molecular processes. In next steps, we will study the main drivers of the key processes and their association with patients’ clinical features. More primary cells will be screened in the next months.

Objective: does perioperative intravenous (iv) administration of lidocaine lowers morphine consumption and pain intensity after video-assisted thoracoscopic surgery (VATS). The primary endpoint was the evaluation of the Silverman integrated approach (SIA) score (combining morphine consumption and pain intensity (visual analogue score - VAS), range from -200 to +200) when coughing within the first 24 hours. Secondary endpoints were length of hospital stay, time to first defecation, postoperative nausea and/or vomiting, 30-day mortality, and chronic pain.

Methods: patients undergoing VATS with a planned duration of ≤90 minutes were randomized within an intention-to-treat setting in this double-blind, placebo-controlled superiority trial. They received iv lidocaine or placebo at a bolus of 1.5 mg/kg 30 minutes before incision, followed by a continuous iv infusion of 3.0 mg/kg/h until 2 hours after skin closure. Painkiller protocols were standardized; patient recieved a morphine-based PCA iv pump. VAS was evaluated when resting and when coughing in a follow-up at 1, 2, 4, 8, 16, 24 and 48 hours, 14 days, 3 and 6 months postoperatively.

Results: 28 patients were included in the lidocaine group, 24 recived placebo. Patient’s characteristics were similar in both groups. SIA score when coughing was significantly lower in the lidocaine group (-22.01 ± 88.61 vs. 20.15 ± 78.85; p=0.044). This beneficial effect was mainly driven by lower visual analogue scale (VAS) pain score (4.60 ± 1.64 vs. 5.52 ± 1.65; p=0.024). Morphine consumption tended to be lower in the lidocaine group (21.26 ± 9.39mg vs. 18.22 ± 12.87mg; p=0.266). Secondary outcomes were similar in all groups. 

Conclusion: our results suggest that perioperative iv administration of lidocaine reduces pain scores after VATS surgery. However, the beneficial clinical effects are limited. Nevertheless, iv lidocaine may be helpful as part of a multimodal analgesia protocol or with patients in whom the use of other analgesics is contraindicated.

Background
Bronchoscopic lung volume reduction (BLVR) with valves excludes one whole lobe while lung volume reduction surgery (LVRS) allows tailored treatment by resection of only heterogeneous, hardly perfused target areas. We hypothesize that by (bilateral) LVRS, more areas of low attenuation (LAA, ≤ - 950 houndsfield units) can be resected more precisely, thus generating more functional improvement than BLVR.

Methods
Empysema patients treated with BLVR and LVRS at our institution between August 2019 and October 2020 were collected prospectively and analyzed retrospectively. LVRS responders were defined as patients with a postoperative improvement of at least 10% in FEV1 in combination with 10% delta in 6-minute-walking-distance (6MWD) or residual volume (RV) or diffusion capacity (DLCO), within the BLVR group additionally with a chest CT scan proven target lobe atelectasis. We performed LAA measurement in preoperative CT scan and 3 months (LVRS) or 1 month (BLVR) postoperatively. Functional improvement as well as LAA reduction was measured in each group and the groups compared with each other.

Results
29 patients underwent LVRS, 19 were responders (5 bilateral LVRS, 14 unilateral), 3 were lost for follow up. Within the BLVR group (n=29), 18 were responders. In bilateral LVRS, improvement of 6MWD and FEV1 was significantly higher than in BLVR (table 1), accompanied by an significantly higher LAA-reduction (22.18 vs 9.54, p=0.009). In unilateral LVRS, LAA-reduction was not significantly higher (12.06 vs 9.54, p=0.267), while 6MWD and FEV1 still showed a higher postoperative improvement. RV reduction and DLCO improvement did not differ significantly between the groups (table 1).

Conclusion
LVRS might lead to significantly more functional improvement than BLVR with valves, maybe due to more resected LAA, especially in bilateral surgery. This concept may justify favoring primary bilateral LVRS over BLVR with valves in bilateral heterogeneous emphysema.

Background/Aims
To define potential risk factors strongly correlating with postoperative complications in patients with non-small cell lung cancer (NSCLC). The comprehensive regression analysis will result in the most relevant risk factors that can be implemented into clinical practice to predict therapy related complications.

Material and Methods
A series of 300 patients with NSCLC, UICC Stages 0 to IIIB (8th-Edition of TNM) was retrospectively enrolled from 2017 to 2020. The therapy related complications were classified according to Clavien-Dindo Classification. The complications Grade IIIa and higher were considered "major complications" and our primary endpoint. The secondary endpoint was postoperative in-hospital mortality. A final logistic regression model with selected parameters due to confounding, redundancy and overfitting criteria should predict major complications.

Results
Eighty-four out of 300 patients (28%) developed major postoperative complications including 15 patients (5%) in-hospital mortality. The diffusion capacity of the lung to carbon monoxide (DLCO) was identified as a strong risk factor for major complications. In the group of patients with "major postoperative complications" the DLCO % of pred. was significantly lower than in the group with “no or minor complications” (DLCO % of pred. mean [SD]: 63.9% [16.3] vs. 73.6% [19.9] respectively; p<0.001). According to the final logistic regression model adjusted for age and sex, three parameters were  identified to predict major complications: the DLCO, open surgery (compared to minimally invasive surgery) and surgery  duration. The final logistic regression model had an accuracy of 73% (c-statistic) to predict major complications.

Conclusions 
The high DLCO, short duration of surgery and, if possible, the choice of a minimally invasive approach have the strongest impact on the absence of major postoperative complications. The accuracy of 73% predicting quite diverse major complications seems reasonable. The prediction of more specific complication grades may probably enhance the predictive power of such a regression model including clinical predictors.

Background:

In patients with stage IIIB, stage IIIC and stage IV non-small cell lung cancer (NSCLC), guidelines generally recommend systemic therapy with or without radiotherapy. Despite this treatment, complete response remains rare.

However, in a selected group of patients with either residual disease after partial response to first-line systemic treatment, or oligo-recurrence, surgical resection within a salvage concept is under evaluation as an additional treatment option. Currently, clinical data on the outcome of this approach are scarce.

Aims:

We aimed to assess short- and long-term outcomes of salvage surgery in advanced NSCLC.

Material&Methods:

We retrospectively identified 35 patients with initial stage IIIB, IIIC, or IV NSCLC who underwent anatomical lung resection to treat local relapse or residual disease. All patients had initially received systemic treatment with or without radiotherapy. Patients were only included if surgical resection had not been part of the first-line treatment approach.

Results:

Among 35 patients (54% male, mean age 60.2±10.9 years), the initial clinical UICC stage was IIIB in 4, IIIC in 4, IVA in 22, and IVB in 5 cases. The indication for salvage resection was residual disease after first-line treatment in 21 cases and local relapse in 14 cases. Anatomical lung resections included 22 lobectomies, 11 pneumonectomies, 1 bilobectomy and 1 segmentectomy. R0-resection was achieved in 94.3% and pathological complete response was found in 22.9% of all resections. 30-and 90-day mortality were 0% and 11.4%, respectively.

mOS and progression-free-survival (calculated from the date of salvage surgery) of the entire cohort were 69 months [95% CI 37 – 101 months] and 22 months [95% CI: 0 – 45months] respectively.

Conclusion:

In selected patients with advanced stage NSCLC presenting with local relapse or residual disease after systemic treatment, anatomical salvage lung resections are associated with a favorable short- and long-term outcome. However, further prospective evaluation of this treatment approach is required.

Background:

We present the case of a 31-year-old female who was referred to our institution for an anterior mediastinal mass. The patient complained of severe retrosternal pain and fatigue. The initial diagnostic work up, including a chest X-ray and a computed tomography angiography, revealed an anterior mediastinal mass with suspicion of infiltration of the brachiocephalic vein and left phrenic nerve (Fig1). Myasthenia gravis associated antibodies were found negative. The tumor was biopsied extensively thoracoscopically, using a robotic-assisted approach.

Aims:

Pre-treatment histological diagnosis of rare thymic lesions can pose difficulties to differentiate, lead to false treatment concepts and even change after complete surgical resection.

Material and Methods

The histology of biopsy revealed a type B1 Thymoma and due to intraoperatively seen macroscopical pericardial invasion patient underwent 3 cycles of neo-adjuvant chemotherapy. The re-staging computed tomography showed partial regression without any signs of infiltration of the brachiocephalic vein (Fig2). Therefore, complete tumor resection via sternotomy was performed. Surprisingly, the definitive histology showed no signs of thymic malignancy. The surgical specimen was sent for a second opinion to an external expertise center.

Results

Finally, the diagnosis of diffuse thymic fibrosis was set (Fig3). The initial surgical biopsy tissue samples were also sent externally, where the diagnosis of diffuse thymic fibrosis was proven retrospectively. Postoperative recovery was uneventful. The 6-month follow-up computed tomography was unremarkable.

Conclusion:

The definitive diagnosis of mediastinal tumors can be puzzling, even when surgical biopsies are performed. Diffuse thymic fibrosis might be an underdiagnosed entity, as there are not many cases published. According to the literature, in the absence of another primary thymic lesion (neoplasm or cyst), thymic fibrosis is a rare histological diagnosis, difficult to differentiate. The etiology is uncertain, altered immunity and/or infection may play a role. Second or expert opinions on thymic specimens might be of clinical significance before a final treatment plan is settled.

Background:

In patients with oligometastatic non-small cell lung cancer (NSCLC), systemic therapy in combination with local ablative treatment of the primary tumor and all metastatic sites is associated with improved prognosis. However, for patient selection and treatment allocation, further knowledge about the genetic and immunological characteristics of the oligometastatic state are necessary.

Aims:

Here, we aimed to perform a molecular characterization of primary NSCLC and its corresponding brain metastases.

Material&Methods:

We identified 51 oligometastatic NSCLC patients with synchronous (<3 months) or metachronous (>3 months) brain metastases who underwent surgical resection of the primary tumor and the brain metastases. Genetic characterization of the primary tumor and the corresponding metastases was performed on matching tissue by targeted sequencing. In addition, mRNA-based expression analysis of the immune checkpoints PD-L1 and CTLA-4 was performed.

Results:

Targeted sequencing was successful in 48 paired samples.  Oncogenic alterations were present in 34 primary tumors (70.8%) and 41 brain metastases (85.4%). The driver alteration of the primary tumor was most commonly preserved in the corresponding brain metastasis (32 out of 34 cases, 94.1%). KRAS-mutations (n=21) and EGFR-mutations (n=4) were the most common oncogenic drivers. Private alterations of the brain metastases were found in 5 patients with synchronous metastases and in 5 patients with metachronous metastases. Expression profiles of PD-L1 and CTLA-4 were lower in the brain metastasis compared with the primary tumor.

Conclusions:

In oligometastatic NSCLC, genetic alterations of the primary tumor were maintained in the majority of brain metastases. This suggests that most brain metastases should respond to targeted treatment directed against the primary tumor’s mutational profile. Private genetic alterations of the brain metastases occured in both synchronous and metachronous oligometastatic settings. Expression levels of PD-L1 and CTLA-4 differed between the primary tumor and the brain metastases and reflect a diverging immune microenvironment, suggestive for potentially different therapeutic approaches in this cohort.

Background: Resectable locally advanced non-small cell lung cancers (NSCLCs) are managed by multimodal approaches including systemic therapies followed by surgery. The recent inclusion of immunotherapy in neoadjuvant protocols has significantly improved tumor responses. In selected situations, bulky N2, N3 or oligometastatic NSCLCs with treated metastasis have shown excellent regression following chemo-immunotherapy and could be considered for surgery.

Aims: We here compare the oncological outcomes of stage IIIA (single N2) with stage IIIB (bulky N2, N3) or oligometastatic stage IV NSCLCs managed by chemo-immunotherapy followed by surgery.

Material&Methods: We reviewed all patients treated in our institution between April 2017 and June 2022 for a locally advanced or oligometastatic NSCLC with chemo-immunotherapy followed by surgery in our prospectively collected database. We recorded, for each patient, the clinico-pathological characteristics, perioperative complications and oncological outcomes.

Results: Forty-eight patients (27 single station N2 stage IIIA (group 1) and 21 bulky N2, N3 or oligometastatic NSCLC (group 2)) were identified. Patient characteristics were comparable between groups. Surgery consisted in lobectomy (81%), bilobectomy (17%) or pneumonectomy (2%). Complete resection was achieved in 46 (95%) patients with R1 resection in two patients due to lymph node effraction. Complete tumor pathological response was achieved in 26% in group 1 and 33% in group 2. Postoperative morbidity was 48% in group 1 and 81% in group 2 (p=0.05). There was no mortality. Median follow-up was 16 months (IQR: 9-32). Progression-free survival was 6 months (IQR: 3-18) in group 1 and 5 months (IQR: 2-7) in group 2 (p=0.04). Overall recurrence rate was 40% (comparable between groups (p=0.08)) and consisted, in majority, of distant metastasis. Overall survival was comparable between groups (p=0.05) (Figure 1).

Conclusions: The inclusion of immunotherapy in induction protocols has improved tumor response and allowed to consider advanced NSCLCs for surgical resection with good postoperative and oncological outcomes.

Background: Iliac access is crucial for successful performance of endovascular aortic and iliac repair (EVAR).

Aims: Stenotic and/or very small caliber external (EIA) or common iliac arteries (CIA) complicate the introduction of sheaths sized >=12 French (>=4.7 mm) and may lead to severe complications. Therefore EVAR outcome in these anatomies deteriorate and access improving procedures preventing iliac rupture should be considered.

Material&Methods: Between July 2021 and December 2022 all iliac access vessels for EVAR with sheath size outer diameter (OD) >=4.7 mm were analyzed and hostile access (HA) were identified. HA was defined as a ratio vessel inner diameter (ID)/sheath OD (RVS) <1. All access assisting therapies pre- and intraoperatively and all access related complications were analyzed and compared to the RVS. Early endpoints were technical success (excluded aneurysm), pre- or intraoperative additional interventions, intraoperative technical problems and 30 day mortality. Short follow-up endpoints were stentgraft patency and access related reintervention rate.

Results: 102 patients with 177 iliacal accesses were examined and 29 HA identified. 13 procedures with a RVS >0.8 needed no access assistance. In 7 cases a short stenosis (5-18mm length/ RVS 0.8- 0.64) of EIA or CIA could be preplanned balloon-dilated without complications. Eight patients endured a dissection or bleeding. Five patients needed reoperation because of unsuccessful attempt of introducing the sheath, all had a RVS <0.65. Two were treated by lumbotomie and access of the CIA, and two by covered stentgraft as intraluminall conduit and EVAR was performed second-stepwise. Technical success was 100% and 30 day mortality 0%. Short time follow up showed a 100% patency rate and no reintervention was necessary.

Conclusions: HA can identified preoperatively, and access improving procedures should be planned. In access sites with RVS<0.65 a direct femoroiliacal access should be avoided and primary lumbotomy or intraluminal conduit should be considered.

Background:

In patients with peripheral arterial disease (PAD), heavily calcified lesions are difficult to treat appropriately with conventional balloons and are frequently associated with stent failure and an increased risk of vascular complications.

Intravascular lithotripsy (IVL) with Shockwave Medical Peripheral device is unique among all current technologies in its ability to modify calcium circumferentially and transmurally, thus modifying conduit compliance to facilitate definitive endovascular treatment and improve subsequent outcomes.

The aim of this study is to report our initial results using this device.

Methods:

From September 2021 to November 2022, the data of all consecutive patients who received IVL teatment in our department were reviewed.

Patients were followed using a standardized protocol, with duplex ultrasound, peripheral pressure measurement and clinical exam at 1,3, and 12 months.

The primary endpoint was procedural success defined as post treatment residual stenosis <50%.

Secondary outcomes were Major adverse events (MAE) during follow-up, patency rates and functional outcomes including improvement in ankle–brachial index (ABI) and Fontaine category assessed at 1 and 3 months.

Results:

Among the 17 patients included, 47% were male and 53% female. The mean age was 72 years (SD 11.5). Smokers represented 71% of the patients, 94 % had Hypercholesteremia and 88% had hypertension.

In 5 patients, IVL was used to improve iliac artery compliance to allow passage through the iliac artery of introducers for endovascular aneurysm repair. In the remaining 12 patients, the indication for endovascular treatment were symptomatic PAD with 3 patients presenting with critical limb ischemia.

The device was used 13 times in the iliac arteries (43%), 4 times in the common femoral arteries (13%) and 11 times in the femoropopliteal axis (37%). Additional material was used in 11 patients with a total of 9 (75%) drug coated balloons and 8 (67%) self-expanding stents.

Procedural success has been achieved in 16 patients (94%). One 1 major adverse event (3%) occurred due to a distal embolus requiring thromboaspiration. During the mean follow-up of 2.7 months (range 1-6), 3 deaths occurred. No major amputation was observed.

Target vessel patency was 100% at 1 and 3 months. The ABI improved in 77 % of patients at 1 month and in 63% of patients at 3 months. The Fontaine stage improved in 88% of the patients at 1 month and in 100% at 3 months.

Conclusion:

The use of IVL seems to be safe and effective in the treatment of calcified arteries. It allows for a very good procedural success with minimal rate of local complications. Moreover, excellent early patency and good functional outcomes were observed. Longer follow-up and more patients are required to confirm these excellent initial results.

Background

Aortoiliac thrombectomies have become more common during the Covid-19 pandemic. Classic surgical thrombectomy of the aorta and iliac arteries through an incision in the groin vessels harbours the risk of embolization to the viscero-renal as well as hypogastric arteries while percutaneous endovascular thrombectomy techniques can lead to peripheral embolization to the lower limb.

Aim

To describe a novel, percutaneous technique that tackles the above issues and to present our initial experience using it.

Methods

The principle of the technique is to percutaneously place large bore sheaths in the iliac arteries that deliberately occlude the latter to protect the lower limbs from embolization. Through one of these sheats, over the wire Fogarty^® catheters can be placed and inflated in the ostia of the coeliac trunk, superior mesenteric artery, renal arteries and hypogastric arteries as needed. A large thrombectomy balloon catheter is then used to bring any aorto-iliac thrombus into the sheaths whereafter thrombus is removed from the sheaths by simply deflating their valves. Additional endovascular procedures of the aorto-iliac branches can be performed as needed.

Results

We report eight EmboSafe procedures in 7 patients (3 male, 4 female) with a median age of 61 (53-60). Sheaths were sized between 18F and 24F. Additional endovascular procedures had to be performed in 5 (62.5%) procedures, including relining of a renal briding stentgraft (figure1), thrombectomy of the coeliac trunk (figure2), kissing stentgrafts in the aortic bifurcation, thrombectomy of a hypogastric artery, one CERAB and stenting of a renal artery (figure3). All procedures were technically successful and all patients had palpable foot pulses on completion of the procedures. No patient had clinical signs of peripheral embolization.

Conclusion

EmboSafe is a very valid addition to the vascular surgeon’s armamentarium when treating aorto-iliac thrombotic events because it is minimally invasive while still protecting against embolization and while offering the flexibility to perform additional endovascular procedures.

Background: GORE®EXCLUDER®iliac branch endoprosthesis (EXIBE) is an approved stentgraft for treatment of either iliac aneurysms or lengthening iliac sealing zones. As the EXIBE only comes in one mainbody size implantation in narrow anatomies can lead to infolding or stenosis of the selfexpandable EXIBE. VIABAHN®VBX (VBX) was launched in Switzerland 2019 as balloonexpandable stentgraft with high radial force and postdilatated diameter >13mm.

Aims: Using VBX as relining stent may allow to maintain an adequate diamater for both EIA and IIA component of EXIBE.

Material&Methods: Between January 2019 and December 2022 50 EXIBEs were implanted at our institution. We identified patients with narrow bifurcations (£16mm) or distal common iliac arteries (£16mm), or severe narrow anatomies having both, and analyzed the used techniques. Simultaneous-relining-technique (SRT) implies VBX as IIA-component solitary or additional to the selfexpandable component and an additive VBX as EIA-relining. Simultaneous-ballooning-technique (SBT) was done without an additional EIA-VBX. The outcome of all patients was analyzed retrospectively regarding IIA and EIA patienty and anatomy-related reintervention rate.

Results: 26 implantations were performed in narrow anatomies. In 10 patients we used the SBT, in 15 the SRT. 8 patients (80%) out of the SBT treated patients had a narrow bifurcation. One patient was neither treated by SBT nor SRT. 11 patients showed a severe narrow anatomy, 9 (82%) of them were treated by SRT. The median follow-up time was 7 months (0-44 months). The IIA and IEA patency rate was 100%. Reinterventions were necessary in 3 patients (7.7%), one was the patient treated without SBT or SRT, two patients had a SBT and showed both severe narrow iliac anatomy.

Conclusion: We achieved a satisfying outcome of EXIBE procedures with both techniques. Either SBT or SRT should be considered in narrow iliac anatomies. In severe narrow anatomy the SRT seems to be the better technical solution using EXIBE.

Background: Since January 2019 the Gore® Viabahn® VBX balloon expandable endoprosthesis (VBX) is available in Switzerland. The use of this new balloon-expandable stentgraft is comparable to the preexisting products, but is characterized by a very high radial force and the possibility of severe overdilating.

Aims: The aim of this study was to analyze our experiences with the VBX since launching this stengraft at our institution.

Material&Methods: From January 2019 until December 2022 all implantations of VBX were analyzed retrospectively regarding indication for implantation, technical success, graft-related complication and reintervention rate.

Results: 201 VBX were implanted in 99 patients at our institution. We used 100 VBX (49.8%) as chimneys or bridging stentgrafts in branched and chimney endovascular aortic and iliac repair. As tube stentgraft in solitary internal iliacal aneurysm 7 VBX (3.5%) were implanted. In stenotic or kinked 63 (31.3%) and in occluded iliac arteries or grafts 31 VBX (15.4%) were used. Technical success rate (full opened stentgraft during intervention and in the postoperative imaging) of all VBX deployments was 97.5%. Only one recoiling in treatment of a severe graft kinking occurred and was dilated forthwith by a selfexpandable venous stent. Six stentgraft-related complications were detected postoperative (3 %). Out of these two VBX (1%) occluded during follow-up, one chimney to the renal artery and one VBX in a stenotic internal iliac artery. The other four patients showed a stenosis of the VBX without occlusion not caused by recoiling but by digital or balloon compression after deployment, two of them needed a reintervion.

Conclusions: VBX is a stentgraft with a wide range of application possibilities. Product related complications are rare. As main complication we noticed the compressibility of the VBX after deployement, which may lead to severe stenosis. Therefore using this stentgraft requires caution in situations where pressure from outside can occur.

Percutaneous creation of arteriovenous fistulae (pAVF) is an established alternative to a conventional upper arm cephalic or basilic vein fistula. Several studies have shown high technical success and maturation rates. However, secondary interventions and surgical procedures are often necessary to achieve maturation.

Prospective data collection of the first consecutive patients undergoing the creation of pAVF between April 2020 and December 2022 at two vascular surgery centres focused on secondary procedures.

PAVF creation with the Ellipsys® vascular access system was attempted in 27 patients. We achieved technical success in 25 patients. Two pAVF occluded silently, and an alternative vascular access was created. One patient refused further secondary procedures, and renal replacement therapy was continued using a tunnelled hemodialysis catheter. In 10 patients, primary maturation of the cephalic or distal basilic vein was achieved. In four recently created pAVF, maturation still needs to be evaluated. Secondary procedures were necessary in 10/22 (45%) of pAVF created. Six patients needed transposition or superficialisation procedures (4 basilic, one brachial and one cephalic vein). One patient required three additional procedures before the fistula could be used successfully (additional angioplasty of the fistula, superficialisation of the basilic vein and correction of cubital vein stenosis by excision and end-to-end anastomosis). In one patient, a cubital communicating vein had to be ligated. Four patients needed angioplasties of the juxtaanastomotic region, two in combination with a DPV angioplasty. Maturation was achieved in 18/21 pAVF (86%) after a mean of 88 days with a mean fistula flow of 880 ml/ min.

We firmly believe pAVF is a promising alternative to creating a conventional upper arm fistula. After pAVF creation with the Ellipsys® system, nearly half of our patients required a secondary procedure. However, the rate of mature and functional fistula achieved was comparable to published results after conventional upper arm fistula.

Background

Hemodialysis vascular accesses should be created at the most distal level regarding possible complications during hemodialysis. Preoperative vein mapping ultrasound (VMU) is needed for arteriovenous fistula (AVF) planning. As vein diameter can be influenced by examinational circumstances such as room temperature, hypovolemia and especially by the sympathectomy effect of plexus block (PB)-mediated vasodilatation, the moment and place performing ultrasound can be crucial.

Aims

To test the hypothesis whether intraoperative VMU under PB helps to identify more distally located veins for AVF-creation, we compared the impact of using PB and intraoperative sonographic reevaluation of vein suitability to AVF created under local and general anesthesia.

Methods

All patients undergoing an AVF operation with intraoperative VMU between January 2018 and December 2022 were analyzed retrospectively. The preoperative vein mapping was conducted by an angiologist at the outpatient clinic and the level of AVF was planned by the vascular surgeon. The procedures were performed either under PB (group1) or local or general anesthesia (group2). Eventual AVF-proximalization (PROX) during follow-up was recorded.

Results

Out of 74 AVF operations in 56 had intraoperative VMU (36 in group1, 20 in group2). A more distal access level was possible in group1 in 17 out of 36 (47.2%) (OR 3.579, 95% CI 0.99-12.82) versus 4 out of 20 (20%) in group2. The AVF-distalization rate in group1 was significantly higher ( p = 0.044). Eight PROX were performed in group1, half of them had a AVF-distalization, in group2 we identified one PROX out of the patients with AVF creation as planned.

Conclusions

PB leads to a higher chance of AVF-distalization using intraoperative VMU. Of course a part of those patients will need a PROX. As this rate seems acceptable, we recommend plexus anesthesia and the systematic use of intraoperative VMU to identify suitable veins a more distal level for AVF creation. A further follow-up is needed.

Background

Port-a-Cath systems are established totally implanted central venous access systems. Associated complication rate differ in literature from 4%-19%. In our center experienced surgical residents perform implantation with younger surgical trainees. A consultant is always available. In a defined specific procedure, the surgical autonomy and early teaching skills of the trainees can be encouraged.

Aims

We evaluated our outcome in Port-a-Cath implantations in a trainee-teach-trainee environment and compared it to current literature.

Material & Methods

All Port-a-Cath systems implanted from January 2021 till December 2022 were retrospectively analyzed. Surgery time, implantation technique, early (<30d) and late (>30d) complications were recorded. Implantation was done according to in-house protocol. First, an attempt was made to expose the cephalic vein. When this was not reached within 30 minutes, the consultant was informed. If necessary, the subclavian vein was punctured under supervision.

Results

A total of 158 Port-a-Cath systems were implanted. In 85% of the patients the procedure was performed under local anesthesia, in 15% under general anesthesia. The average surgery time was 71 minutes. The cephalic vein was exposed in 91% of the patients. In 9%, canulation of the subclavian vein had to be performed, whereas two times the subclavian artery was punctured, but it was immediately corrected. Four early complications (one pneumothorax, one pulmonary embolism, two catheter kinks) and five late complications (three infections, one disruptive location and one catheter-associated thrombosis of the subclavian vein) were registered. Overall, the complication rate was 6% (n=9).

Conclusion

Our complication rates in Port-a-Cath implantation are comparable to the more favorable results in the literature and it is achieved by young surgical residents.

Critical limb threatening ischemia(CLTI) is associated with significant mortality and limb loss Its treatment is based more on the surgeon’s preference than scientific evidence. The randomized controlled BEST-CLI study provide evidence to help make a decision when treating CLTI patients. We wonder if this is applicable to reality.

To evaluate if the inclusion/exclusion criteria of the BEST-CLI study were applicable to the real-life of a vascular surgery unit in a university hospital

We retrospectively collected data from all the patients treated for CLTI in our institution in 2022. We looked at the number of patients that could be randomized based on the inclusion/exclusion criteria from the BEST-CLI study, the number of patient with a prior vein evaluation, and the type of treatment, endovascular or open surgery.

In 2022, 124patients were hospitalized for CLTI, with a Rutherford stage of 3 in 27%(34/124), 4 in 65%(80/124)and 5 in 8%(10/124). Inclusion criteria were met in 73%(91/124)patients, 1%(1/124) was not candidate for both open and endovascular treatment, 25%(31/124) had inadequate aortoiliac inflow and 1%(1/124) had inadequate outflow. Based on the exclusion criteria 24%(30/124) were then excluded, 2%(2/124) for excessive surgical risk, 21%(26/124) for prior index limb infrainguinal stenting associated with restenosis, and 2%(2/124) for prior enrollment in a study. Of the 124 patients, 50%(62) were finally eligible for randomization. An adequate single segment of great saphenous vein was present in 31%(19/62). In this group, 37%(7/19) had open and 63%(12/19) endovascular surgery. No vein was available in 21%(13/62) and 46%(6/13) had open and 54%(7/13)endovascular surgery. Patients with no prior vein evaluation(48%(30/62)) were all offered endovascular surgery

The BEST-CLI study does not reflect real life conditions as only 50% of our patients were eligible for randomization. This is mostly due to inadequate aortoiliac inflow, or a previous treatment of the index limb, which are features frequently seen in CLTI patients.

In the era of percutaneous endovascular mechanical thrombectomy, surgical thrombectomy for extended iliofemoral vein thrombosis (DVT) is only performed as a last resort. While thrombectomy of the iliac veins is simple, surgical thrombectomy of the femoral and popliteal vein is more complex, because a thrombectomy catheter inserted in the groin will not pass distally, as it will invariably get stuck in the valves of the femoral and popliteal vein. Comerota has described a technique to circumvent this obstacle by performing a cutdown to the distal posterior tibial vein and passing a Fogarty catheter up. The end of this Fogarty catheter is retrieved in the groin and joined with the end of a second Fogarty catheter, which can then be advanced peripherally through the valves. We describe a development of this technique by performing a percutaneous puncture of the posterior tibial vein under sonographic guidance, advancing a guidewire, which is retrieved in the venotomy in the groin. An over-the-wire Fogarty catheter is advanced over the guidewire for the popliteal and femoral vein thrombectomy.

Retrospective analysis of consecutive patients treated from March 2021 – Sep 2022.

We performed the procedure in 9 patients. Median age was 28y, there were 4 men and 5 women. All patients had severe venous claudication or phlegmasia because of extended ilio-femoral vein thrombosis. Three patients had persistent symptoms after percutaneous mechanical endovascular thrombectomy and iliac vein stenting. Surgical thrombectomy of the popliteal and femoral vein was achieved in all patients. After a median follow-up of 7 months (2-21 months), all patients had patent popliteal and femoral veins.

The Comerota procedure allows surgical thrombectomy of the popliteal femoral vein. Our modification using percutaneous puncture of the posterior tibial vein avoids the surgical cutdown and offers the possibility of phlebography of the popliteal and femoral veins as a completion control.

Sarcopenia is a surrogate marker for malnutrition and frailty, which has been linked to higher complication rates and prolonged length of stay (LOS) after surgery. The aim of this study was to assess the association between CT-derived markers of sarcopenia and postoperative clinical outcomes after endovascular aortic repair.

A retrospective study identified 490 consecutive patients operated between January 2016 and December 2020 for endovascular aneurysm aortic repair. Among this population, 130 patients were included in this interim analysis. Two radiological markers of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: Skeletal Muscle Area (SMA) and Skeletal Muscle Index (SMI). The definition of preoperative sarcopenia was based on pre-established SMI cut-off values. The main postoperative endpoint was defined as the occurrence of a combination of any aorta-related reinterventions and death.

Among the 130 patients, the median age was 75 years (IQR 70-80) and 105 (81%) were males. A majority of patients were operated for infrarenal abdominal aortic aneurysm (62%).14 (11%) had preoperative sarcopenia. Except for lower BMI in the sarcopenic group (22.4 kg/m² vs 24.6 kg/m², p = 0.01), both groups were comparable. There was no difference in length of hospital stay (LOS) (5 vs. 5 days, p = 0.92). In the postoperative period, there was a lower rate of the combined endpoint in the non-sarcopenic group (11.2% vs 21%) but it did not reach statistical significance (p = 0.40). No association was found between lower SMI, lower SMA and the combined postoperative endpoint in the univariate analysis.

Although no association was found between sarcopenia and postoperative risk of reintervention and death, a trend was found when analyzing separately two CT-derived markers. The analysis of the entire cohort could bring more information regarding the exact role of preoperative sarcopenia.