Laparoscopic surgery for benign and malign diseases of the digestive system:Indications,limitations,and evidence

The laparoscopic technique was introduced in gastrointestinal surgery in the mid 1980s.Since then,the development of this technique has been extraordinary.Triggered by technical innovations(stapling devices or coagulation/dissecting devices),nowadays any type of gastrointestinal resection has been successfully performed laparoscopically and can be performed laparoscopically dependent on the patient’s condition.This summary gives an overview over 30 years of laparoscopic surgery with focus on today’s indications and evidence.Main indications remain the more common procedures,e.g.,appendectomy,cholecystectomy,bariatric procedures or colorectal resections.For all these indications,the laparoscopic approach has become the gold standard with less perioperative morbidity.Regarding oncological outcome there have been several highquality randomized controlled trials which demonstrated equivalency between laparoscopic and open colorectal resections.Less common procedures like esophagectomy,oncological gastrectomy,liver and pancreatic resections can be performed successfully as well by anexperienced surgeon.However,the evidence for these special indications is poor and a general recommendation cannot be given.In conclusion,laparoscopic surgery has revolutionized the field of gastrointestinal surgery by reducing perioperative morbidity without disregarding surgical principles especially in oncological surgery.

Perioperative chemotherapy for advanced gastric cancer - results from a tertiary-care hospital in Germany

BACKGROUND Neoadjuvant/perioperative chemotherapy is the recommended treatment for advanced stages of gastric cancer(>T2,N+)before tumour resection in many European guidelines.However,there is no consensus as to whether perioperative chemotherapy is as effective in distal as in proximal tumours,in addition to a relevant uncertainty concerning appropriate treatment modalities for elderly patients.AIM To investigate the role of perioperative chemotherapy in advanced gastric cancer in patients from a German tertiary clinic with respect to efficacy,localisation,and age.METHODS We performed a retrospective analysis of 158 patients from our clinic with adenocarcinoma of the stomach or the gastroesophageal junction who underwent resection between 2008 and 2016.The data were evaluated particularly in relation to patient age,tumour site,and perioperative therapy.RESULTS Administration of perioperative chemotherapy did not lead to a significant survival advantage in our study population.The 5-year survival rates were 40%for patients who received perioperative chemotherapy and 29%for the group without perioperative chemotherapy(P=0.125).Our patients were on average distinctly older than patients in most of the published randomised controlled trials.Patients elder than 75 years received perioperative chemotherapy far less frequently.Patients with a proximal tumour received perioperative chemotherapy much more often.CONCLUSION This analysis reconfirms our previous data concerning the effectiveness of perioperative chemotherapy for advanced gastric cancer.There is reasonable doubt that the quality of the existing randomized controlled trials is sufficient to generally justify perioperative chemotherapy in patients with advanced gastric cancer independent of tumour localization or age.

Orthotopic liver transplantation for giant liver haemangioma: A case report

In liver haemangiomas, the risk of complication rises with increasing size, and treatment can be obligatory. Here we present a case of a 46-year-old female who suffered from a giant haemangioma causing severe portal hypertension and vena cava compression, leading to therapy refractory ascites, hyponatremia and venostasis-associated thrombosis with pulmonary embolism. The patients did not experience tumour rupture or consumptive coagulopathy. Surgical resection was impossible because of steatosis of the non-affected liver. Orthotopic liver transplantation was identified as the only treatment option. The patient's renal function remained stable even though progressive morbidity and organ allocation were improbable according to the patient's lab model for end-stage liver disease(lab MELD) score. Therefore, non-standard exception status was approved by the European organ allocation network "Eurotransplant". The patient underwent successful orthotopic liver transplantation 16 mo after admission to our centre. Our case report indicates the underrepresentation of morbidity associated with refractory ascites in the lab MELD-based transplant allocation system, and it indicates the necessity of promptly applying for non-standard exception status to enable transplantation in patients with a severe clinical condition but low lab MELD score. Our case highlights the fact that liver transplantation should be considered early in patients with non-resectable, symptomatic benign liver tumours.

Mesh implants: An overview of crucial mesh parameters

Hernia repair is one of the most frequently performed surgical interventions that use mesh implants. This article evaluates crucial mesh parameters to facilitate selection of the most appropriate mesh implant, considering raw materials, mesh composition, structure parameters and mechanical parameters. A literature review was performed using the Pub Med database. The most important mesh parameters in the selection of a mesh implant are the raw material, structural parameters and mechanical parameters, which should match the physiological conditions. The structural parameters, especially the porosity, are the most important predictors of the biocompatibility performance of synthetic meshes. Meshes with large pores exhibit less inflammatory infiltrate, connective tissue and scar bridging, which allows increased soft tissue ingrowth. The raw material and combination of raw materials of the used mesh, including potential coatings and textile design, strongly impact the inflammatory reaction to the mesh. Synthetic meshes made from innovative polymers combined with surface coating have been demonstrated to exhibit advantageous behavior in specialized fields. Monofilament, largepore synthetic meshes exhibit advantages. The value of mesh classification based on mesh weight seems to be overestimated. Mechanical properties of meshes, such as anisotropy/isotropy, elasticity and tensile strength, are crucial parameters for predicting mesh performance after implantation.

Bcl-2 degradation is an additional pro-apoptotic effect of polo-like kinase inhibition in cholangiocarcinoma cells

AIM To examine the influence on apoptotic mechanisms following inhibition of polo-like kinases as therapeuticallyapproach for cholangiocellular cancer treatment. METHODS As most cholangiocarcinomas are chemotherapyresistant due to mechanisms preventing tumor cell death, we investigated the effect of Cisplatin on cholangiocellular carcinoma(CCA) cell lines KMCH-1 and Mz-Ch-1. Polo-like kinases(PLK) are important regulators of the cell cycle and their inhibition is discussed as a potential therapy while PLK inhibition can regulate apoptotic mediators. Here, cells were treated with PLK inhibitor BI6727(Volasertib), Cisplatin, and in combination of both compounds. Cell viability was assessed by MTT; apoptosis was measured by DAPI staining and caspase-3/-7 assay. Western blot and q RT-PCR were used to measure expression levels of apoptosis-related molecules Bax and Bcl-2. RESULTS The cell viability in the CCA cell lines KMCH-1 and Mz-Ch-1 was reduced in all treatment conditions compared to vehicle-treated cells. Co-treatment with BI6727 and cisplatin could even enhance the cytotoxic effect of cisplatin single treatment. Thus, co-treatment of cisplatin with BI6727 could slightly enhance the cytotoxic effect of the cisplatin in both cell lines whereas there was evidence of increased apoptosis induction solely in Mz-Ch-1 as compared to KMCH-1. Moreover, PLK inhibition decreases protein levels of Bcl-2; an effect that can be reversed by the proteasomal degradation inhibitor MG-132. In contrast, protein levels of Bax were not found to be altered by PLK inhibition. These findings indicate that cytotoxic effects of Cisplatin in Mz-Ch-1 cells can be enhanced by co-treatment with BI6727.CONCLUSION In conclusion, BI6727 treatment can sensitize CCA cells to cisplatin-induced apoptosis with proteasomal Bcl-2 degradation as an additional pro-apoptotic effect.

Segmental intrahepatic cholestasis as a technical complication of the transjugular intrahepatic porto-systemic shunt

BACKGROUND Segmental intrahepatic cholestasis caused by transjugular intrahepatic portosystemic shunt(TIPS)(SIC-T),is a rare complication of this technique and only referred by case reports.Thus,we conducted a systematic,retrospective analysis to provide evidence regarding prevalence and consequences of this TIPS-induced bile duct compression.AIM To assess prevalence and outcome of SIC-T in a large TIPS-cohort.METHODS In this retrospective cohort study,we screened the institutional databases for all consecutive patients that were treated by TIPS-placement or TIPS-revision between January 2005 and August 2013.We analyzed radiologic images for signs of biliary congestion.Cases that were indicative of SIC-T were reviewed by two independent radiologists and additional patient data was collected.Descriptive statistics of patient demographics,indications for TIPS and procedural details were registered.Logistic regression analysis was performed to identify predictors for the development of SIC-T.RESULTS We analyzed 135 cirrhotic patients who underwent TIPS(mean age 55 years,79%male gender).Etiology of cirrhosis was alcohol in most cases and indications for TIPS were mainly refractory ascites and recurrent variceal bleeding.TIPS revision was necessary in 31 patients.We identified 4 cases(2.9%)of SIC-T in direct proximity of the TIPS-stent.Diagnosis was confirmed by CT-scan,MRI or endoscopic retrograde cholangio pancreaticography(ERCP).In two patients TIPS was implanted via the right and in one through the medial hepatic vein.One patient received TIPS-prolongation by multiple revisions.Most patients were asymptomatic but one cholangitic abscess necessitated a transhepatic drain.Logistic regression analysis identified TIPS-placement other than from medial hepatic vein to right portal vein as risk factor(OR 21.0)for SIC-T.CONCLUSION SIC-T ads to(mostly late)complications in the interventional treatment of cirrhotic portal hypertensions and can lead to cholangitic abscesses.Patients,particularly with multiple interventions,should be screened for SIC-T.

The Game of Life, Decision and Communication

The game of life represents a spatial environment of cells that live and die according to fixed rules of nature. In the basic variant of the game a cell’s behavior can be described as reactive and deterministic since each cell’s transition from an actual state to a subsequent state is straight-forwardly defined by the rules. Furthermore, it can be shown that the alive cells’ spatial occupation share of the environment decreases quickly and levels out at a really small value (around 3%), virtually independent of the initial number of alive cells. In this study we will show that this occupation share can be strongly increased if alive cells become more active by making non-deterministic sacrificial decisions according to their individual positions. Furthermore, we applied signaling games in combination with reinforcement learning to show that results can be even more improved if cells learn to signal for navigating the behavior of neighbor cells. This result stresses the assumption that individual behavior and local communication supports the optimization of resourcing and constitute important steps in the evolution of creature and man.

Paediatric primary care in Germany during the early COVID-19 pandemic:the calm before the storm

Objectives Globally,the COVID-19 pandemic has a major impact on healthcare provision.The effects in primary care are understudied.This study aimed to explore changes in consultation numbers and patient management during the COVID-19 pandemic,and to identify challenges for patient care.Design Survey of paediatric primary care practices on consultation numbers and patient management changes,and semistructured interviews to identify challenges for patient care.Surveys and interviews were partially linked in an explanatory sequential design to identify patient groups perceived to be at higher risk for worse care during the pandemic.Setting In and around Düsseldorf,a densely populated area in Western Germany.The primary care facilities are spread over an area with approximately 2 million inhabitants.Participants Primary care in Germany is provided through practices run by self-employed specialist physicians that are contracted to offer services to patients under public health insurance which is compulsory to the majority of the population.The sample contained 44 paediatric primary care practices in the area,the response rate was 50%.Results Numbers of consultations for scheduled developmental examinations remained unchanged compared with the previous year while emergency visits were strongly reduced(mean 87.3 less/week in March-May 2020 compared with 2019,median reduction 55.0%).Children dependent on developmental therapy and with chronic health conditions were identified as patient groups receiving deteriorated care.High patient numbers,including of mildly symptomatic children presenting for health certificates,in combination with increased organisational demands and expected staff outages are priority concerns for the winter.Conclusions Primary care paediatricians offered stable service through the early pandemic but expected strained resources for the upcoming winter.Unambiguous guidance on which children should present to primary care and who should be tested would help to allocate resources appropriately,and this guidance needs to consider age group specific issues including high prevalence of respiratory symptoms,dependency on carers and high contact rates.

Artificial intelligence in pancreatic surgery:current applications

Surgery plays a central role in the treatment of benign and malignant pancreatic diseases.Artificial intelligence(AI)is an important upcoming technology to support surgeons in pre-,intra-,and postoperative diagnosis,decision-making and training toward an optimized patient care.Current AI applications show a promising role in the evaluation of preoperative images for prediction of malignancy and resectability,intraoperative decision support,surgical training as well as a postoperative risk stratification to per-sonalize the management of complications.This scoping review summarizes the most up to date developments of AI in pancreatic surgery with the highest available level of evidence.