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Liver surgery is the cornerstone of the curative treatment of malignant liver tumors. However, the liver anatomy is very complex, and liver surgery is still associated with relevant morbidity despite many technical advances. The Brisbane nomenclature is used worldwide to classify liver resection. However, this nomenclature has several limitations as multiple terms are used for the same type of resection. Non-anatomical resections, multiple resections, and combined bilio-vascular resections were not mentioned. Therefore, new terminologies have been proposed for the precise and simple classification of liver resection. Furthermore, in recent years, many technical innovations have been introduced in liver surgery, such as 3D imaging systems and indocyanine green fluorescence, for better preoperative and intraoperative identification of tumor localization and critical vascular structures. Minimally invasive techniques are used more frequently in liver surgery. Potential benefits include less intraoperative blood loss, less pain, and a shorter hospital stay. The implementation of robotic systems also has an impact on liver surgery, and the number of cases reported in the literature is constantly increasing. The potential benefits of robotic liver resection over laparoscopic liver resection will be the subject of future studies.

Simple Summary: The use of Artemia as a supplement to commercial feed during the nursery period, i.e., from post-larvae 10 up to post-larvae 30, is a common procedure in the shrimp industry. This practice provides larger and more resilient post-larvae (PL) that perform better in grow-out ponds. However, the production of brine shrimp is limited to a few natural salt lakes or man-made salt ponds worldwide, subject to strongly fluctuating yields and product quality. Therefore, ongoing research is focused on finding adequate live food alternatives. Nematodes, commonly known as worms, are animals that greatly fulfil the requirements to be used as live feed for aquatic organisms. Nematodes can be reactivated from their desiccated state by simple rehydration. Additionally, they are rich in protein and fatty acids, making them a favorable nutritional diet for shrimp larvae culture. This study demonstrated that nematodes can substitute Artemia in a co-feeding regime for the nursery of shrimp in a biofloc system, increasing the survival of the post-larvae after 20 days. This study evaluated nematodes as an alternative to live Artemia when provided in a co-feeding regime to Pacific white shrimp (Penaeus vannamei) post-larvae (PL) reared in a biofloc nursery system. A 20-day experiment employing PL11 was performed for an evaluation of four dietary groups: control [C] (fed exclusively with a dry commercial feed); artificial Artemia [AA] (dry feed composed of extracted and processed Artemia cysts and dry commercial feed); live Artemia and dry commercial feed [LA]; and nematodes and dry commercial feed [N] (Panagrolaimus sp. dry nematodes). The diets were provided twice a day, with the remaining six feed provisions being a commercial dry feed for all experimental groups. A biofloc system was chosen as it offers a potentially sustainable approach to intensive shrimp farming. Alkalinity and pH in the [N] group were significantly higher in the last 5 days of the experiment (p < 0.05), likely causing the significantly lower nitrite levels observed in that same group (p < 0.05). Total and volatile suspended solids were significantly lower in the two live feed groups when compared with [C] and [AA] (p < 0.05). Although PL fed the dry diets exhibited higher growth rates (p < 0.05), the [N] and [LA] groups presented significantly higher final survivals (p < 0.05). No differences were found for survival after a salinity stress test (p ≥ 0.05). These results suggest that nematodes can successfully substitute Artemia in a co-feeding regime for P. vannamei PL reared in biofloc nursery systems. [ABSTRACT FROM AUTHOR]

In 2019, the FLOT4 protocol was established as the new standard for perioperative therapy in patients with locally advanced gastroesophageal and gastric cancer. Whether this protocol is beneficial in a real‐world setting remains a question with limited answers to date. In our study, a large cohort of unselected patients treated with FLOT4 was analyzed and compared to protocols based on 5‐FU/platinum derivative. This retrospective analysis included patients with locally advanced gastroesophageal and gastric cancer treated with perioperative FLOT or 5‐FU/platinum derivative at University Hospital, Bonn between 2010 and 2022 in a curative setting (n = 99). Overall survival, disease‐free survival, therapy response and therapy complications were analyzed. Patients treated with FLOT showed a statistically significant longer median overall survival of 57.8 vs 28.9 months (HR: 0.554, 95% CI: 0.317‐0.969, P =.036). Moreover, pathological tumor regression (pTR) was significantly higher in the FLOT group compared to the 5‐FU/platinum group (P =.001). Subgroup analysis showed a favorable survival benefit for the FLOT vs 5‐FU/platinum derivate in patients with AEG and non‐signet cell carcinoma. Overall, FLOT was tolerated well but CTCAE ≥3 grade neutropenia and diarrhea occurred more often within the FLOT group. Similar to the prospective phase II/III trials, FLOT4 was the best protocol for patients with locally advanced gastroesophageal and gastric cancer as perioperative therapy in terms of overall survival and pathological response rate compared to 5‐FU/platinum derivative protocols. Interestingly, patients with gastroesophageal cancer benefitted more from this therapy. In contrast, patients with signet ring cells appear not to benefit from addition of docetaxel. [ABSTRACT FROM AUTHOR]

Background: Postoperative ileus (POI) is an iatrogenic complication of abdominal surgery, mediated by a severe inflammation of the muscularis externa (ME). We demonstrated that orally applicated CPSI-2364 prevents POI in rodents by blockade of p38 MAPK pathway and abrogation of NO production in macrophages. In the present experimental swine study we compared the effect of orally and intravenously administered CPSI-2364 on POI and examined CPSI-2364 effect on anastomotic healing. Methods: CPSI-2364 was administered preoperatively via oral or intravenous route. POI was induced by intestinal manipulation of the small bowel. ME specimens were examined by quantitative PCR for CCL2 chemokine gene expression and myeloperoxidase activity. Functional analyzes included measurement of ileal smooth-muscle ex vivo contractility, in vivo intestinal and colonic transit. Furthermore, anastomotic healing of a rectorectostomy after CPSI-2364 treatment was assessed by perianastomotic hydroxyproline concentration, a histochemically evaluated healing score and anastomotic bursting pressure (ABP). Results: CPSI-2364 abolished inflammation of the ME and improved postoperative smooth muscle contractility and intestinal transit independently of its application route. Hydroxyproline concentration and ABP measurement revealed no wound healing disturbances after oral or intravenous CPSI-2364 treatment whereas histological scoring demonstrated delayed anastomotic healing after intravenous treatment. Conclusion: CPSI-2364 effectively prevents POI in swine independently of its application route. Impairment of anastomotic healing could be observed after intravenous but not oral preoperative CPSI-2364 treatment. Subsumed, an oral preoperative administration of CPSI-2364 appears to be a safe and efficient strategy for prophylaxis of POI. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This study presents a detailed documentation of a total endoscopic anterior pelvic approach (TAPA) for plate fixation of a symphyseal disruption. The purpose of this work is to describe a minimally invasive technique as a possible method for reducing complications and hospitalization. Other goals included giving technical recommendations and assessing potential pitfalls and problems of this new surgical approach. Surgery was performed in an interdisciplinary setting by an experienced orthopaedic and general surgeon. The first endoscopic approach used to visualize the injury was the same as is used for endoscopic hernia surgery. The repositioning of the symphysial rupture was achieved either through external fixation or indirectly with traction and a pelvic binder. Plate positioning and fixation were achieved through two additional, minimally invasive incisions. The endoscopic approach shows multiple advantages, such as no detachment of the rectus abdominis muscle and smaller skin incisions. Furthermore, this approach could lessen the incidence of hernia and postoperative pain. We see the presented technique as a simple and innovative surgical method for treating symphyseal disruption. [ABSTRACT FROM AUTHOR]

Abstract: Background: Heme oxygenase (HO-1) protects against inflammation. In this study, we investigated the protective function of hemin-induced HO-1 against lipopolysaccharide (LPS)-induced ileus. Methods: Rats received LPS intraperitoneally 24 h after intraperitoneal hemin pretreatment or placebo. We also injected zinc protoporphyrin (ZnPP, 3rd group), an inhibitor of HO-1, intraperitoneally 2 h before LPS administration. To assess intestinal muscle function, we examined muscularis strip contractility in an organ bath and measured gastrointestinal transit in vivo. We investigated inflammation within the muscularis using polymerase chain reaction (interleukin [IL]-6, inducible nitric oxide synthase (iNOS), HO-1 and IL-10) 6 and 24 h after LPS. Results: Hemin significantly improved in vitro intestinal muscularis contractility (P < 0.001). In addition, hemin prevented LPS-induced dysmotility in vivo (gastrointestinal transit, geometric center: 8.39 ± 0.33 versus 5.68 ± 0.44; P < 0.001). In Zinc protoporphyrin (ZnPP)-treated animals, both parameters were significantly decreased compared with the hemin group. Messenger RNA expression demonstrated a significant reduction in IL-6 (6 h, hemin: 127.6 ± 36.7 versus LPS: 14,431 ± 5407; 24 h: 1.58 ± 0.39 versus 11.15 ± 2.59; P < 0.01) and iNOS (6 h: 2516 ± 985 versus 50,771 ± 13,321; 24 h: 55.11 ± 10.55 versus 257.1 ± 43.18; P < 0.001) in hemin-treated animals. Anti-inflammatory HO-1 messenger RNA levels (6 h, hemin: 116.3 ± 18.55 versus LPS: 26.02 ± 3.64; 24 h: 18.46 ± 2.69 versus 2.80 ± 0.32; P < 0.001) were increased. There was no significant difference in IL-10 levels at 6 and 24 h. ZnPP reversed the anti-inflammatory hemin effects. Conclusions: Hemin induction of HO-1 diminishes LPS-induced sepsis. Heme oxygenase-1 has a central role in preventing sepsis-induced ileus. This benefit is reversed by HO-1 inhibition with ZnPP. [Copyright &y& Elsevier]

Abdominal surgery results in an activation of immune cells of the bowel wall and a consecutive cytokine and nitric oxide (NO) release leading to an inflammation of the muscularis externa and a bowel paralysis, the so-called postoperative ileus (POI). In addition to the local inflammation, major surgical trauma can also lead to a variable pronounced systemic inflammation up to its maximum variant, the systemic inflammatory response syndrome (SIRS), with hypotension, capillary leak and a breakdown of the intestinal barrier function followed by multi-organ dysfunction (MODS). Until now, neither for SIRS nor for POI, a prophylaxis or an evidence-based treatment exists. Since the pioneering work from Kevin Tracey and his group in the late 90s characterizing the role of the vagus nerve in inflammation and describing the cholinergic anti-inflammatory pathway (CAIP) for the first time, substantial efforts have been made in the research field of neuro-immune interactions. Today, the anti-inflammatory potential of vagus nerve stimulation is moving more and more into focus resulting in new therapeutic approaches. This review focuses on the role of the CAIP in the development of SIRS and POI. Furthermore, new therapeutic options like transcutaneous vagus nerve stimulation are highlighted. [ABSTRACT FROM AUTHOR]

Background: The new competency-based further training regulations (nWBO) for surgical training have been adopted by all German state medical associations., Methods: From May to June 2023 the Young Surgeons' Working Group (CAJC) conducted an anonymous online survey among the 5896 members of the German Society for General and Visceral Surgery (DGAV)., Objective: The survey aimed to assess expectations regarding the nWBO and to develop strategies for enhancing surgical training., Results: With 488 participants (response rate 8.3%) the study is representative. The respondents consisted of 107 continuing education assistants (WBA 21.9%), 69 specialist physicians, and 188 senior physicians (specialist physicians 14.1% and senior physicians 38.5%), as well as 107 chief physicians (21.9%). The majority worked in regular care providers (44%), followed by maximum care providers (26.8%) and university clinics (20.1%). Only 22% considered the required operative spectrum of the new medical specialist training regulations (nWBO) to be realistic. Half of the respondents believed that full training in their clinic according to the new catalog will no longer be possible and 54.6% considered achieving the target numbers in 6 years to be impossible or state that they can no longer train the same number of continuing education assistants (WBAs) in the same time frame. Endoscopy (17.1-18.8%), fundoplication (15.4-17.7%) and head and neck procedures (12.1-17.1%) were consistently mentioned as bottlenecks across all levels of care. Rotations for balance were reported to be already established or not necessary in 64.7%. In 48% it was stated that the department had established the partial steps concept. The importance of a structured training concept was considered important by 85% of WBAs, compared to 53.3% of chief physicians (CÄ). If a structured training concept was present in the department, the achievability of the target numbers was significantly assessed more positively in the univariate analysis. In the multivariate analysis, male gender and the status of "habilitated/professor" were independent factors for a more positive assessment of the nWBO. Objective certification of training was considered important by 51.5%., Conclusion: Concerns surround the nWBO and the sentiment is pessimistic. Additional requirements and hospital reforms could exacerbate the situation. Collaboration and rotations are crucial but still insufficiently implemented. Quality-oriented certification could enhance the quality of training., (© 2024. The Author(s).)

The requirements and challenges for the university hospitals in Germany are changing. Especially in surgical subjects, it is more and more difficult to adequately serve these three pillars of university medicine - clinic, research and education. This survey was intended to determine the status quo of general and visceral surgery at universities, in order to provide a basis for proposed solutions.For this online survey, 1505 visceral surgeons at the 38 university clinics were contacted. The questionnaire contained 29 questions on the structure of the clinic, scientific motivation, opportunities for time-off and the appreciation of academic achievements. The type and scope of student courses and the preparation for them were also determined. With regard to patient care, the type and number of services and the course of surgical training were examined. Based on the data published on the websites of the individual clinics on the number, gender, position and academic title of the doctors, a demographic analysis of university visceral surgeons could also be created.Of 1505 surgeons successfully contacted, 352 took part in the survey, which corresponds to a response rate of 23.4%. Of the participants, 93.5% were scientifically active, the majority being in the field of clinical data collection. Many indicated that they were also active in translational and/or experimental research, while educational research was rarely named. 45% confirmed that they could perform scientific work during their normal working hours. The reward for this activity was mostly in the form of time-off for congresses and clinical appreciation. Most participants stated that they were involved in 3-4 student courses per week, with 24.4% reporting that they were not adequately prepared for them.The compatibility of the classic three pillars of clinic, research and teaching continues to be of great relevance. There is a high level of motivation among the participating visceral surgeons not to neglect research and teaching, despite increasing economic pressure in the field of patient care. However, arrangements must be created in order to reward and promote commitment in research and teaching in a structured way., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Practice makes perfect - a saying that everyone has certainly heard. Surgeons of all levels of training can demonstrably practice to some extent on simulators. This training outside the operating theatre and independent of patients makes sense, both ethically and financially. Although the effectiveness of simulation in surgery has been proven several times, simulation training is not a mandatory part of surgical specialist training in Germany. Simulation covers a very wide range in terms of application, effort and costs. This review is intended to give an overview of the systems and their areas of application and the target group. The focus lies on the commonly available systems and possible advantages and disadvantages. Practical skills are in the foreground and all three pillars of general and visceral surgery - conventional techniques, laparoscopy and robotics - are taken into account. However, simulators alone do not achieve cost-benefit effectiveness. The full potential of such an investment can only be exploited with a site-specific, structured training concept in which simulation training according to the post-graduate year and appropriate allocation to surgeries in the operating room are closely interlinked. It should always be possible to train basic skills on site. The significant additional costs for complex simulation systems are possible, depending on the financial resources, or should be purchased in a network or for national courses. The techniques of immersive virtual reality in combination with artificial intelligence and deformation algorithms will certainly play a decisive role for the future of simulation, whereby the use of the available systems must be a primary goal. The integration of simulation into specialist training should be striven for, not least in order to justify the costs., Competing Interests: Tobias Huber has a non financial research cooperation regarding simulation in laparoscopic camera navigation with Surgical Science Sweden. Tobias Huber receives funding from BMBF, DFG, UM Mainz, Liver Foundation, Gutenberg Lehrkolleg Mainz, Alexander Karl Stiftung Mainz. Florentine Hüttl receives funding from the German Society of Surgery. Peter Grimminger is a Proctor for Intuitive Surgical. Hauke Lang, Laura Hanke, Lukas Vradelis and Nils Sommer declare no conflict of interest. Shown Simulators have been supported by intramural educational funding of the university medical center Mainz and Alexander Karl-Stiftung, Mainz, Germany., (Thieme. All rights reserved.)

Introduction: Complications following the creation of permanent intestinal ostomies are common and lead to serious problems in the stoma care of affected patients. The aim of this prospective, single-centre follow-up study was to record the rate of late complications in our own patient group and to identify potential risk factors., Methods: All patients who received a permanent intestinal ostomy in our clinic within the period 2006 - 2016 were included in the study. 50 patients gave their informed consent and participated in our follow-up (14 female [28%], 36 male [72%]). The analysis of stoma-associated complications was performed by review of medical records and a systematic follow-up (standardised questionnaire, clinical examination, and ultrasound of the abdominal wall)., Results: Indications included malignancy (n = 27; 54%), anastomotic leakage (n = 10; 20%), acute diverticulitis (n = 7; 14%), IBD (n = 5; 10%) and rarer indications. The top 3 late complications were peristomal skin irritation (n = 25, 50%), parastomal hernia (n = 14; 28%) and prolapse (n = 9; 18%). Acute diverticulitis resulted in increased stomal retraction (p = 0.012). Double-barreled stomata were associated with increased herniation rates (p = 0.044) and prolapse (p = 0.047). Ileostomies were associated with peristomal skin irritation (p = 0.021). Age, sex or emergency stoma creation did not constitute independent risk factors for the development of late complications in our group of patients., Conclusion: Professional pre- and postoperative stoma therapy and care includes preoperative marking of a stoma site and structured stoma-specific follow-up by stoma therapists, surgeons and general practitioners, as well as stringent and early treatment of structural complications. This can prevent and mitigate late complications of permanent intestinal stomata. Interestingly, stoma placement was not an independent risk factor for late complications in an emergency situation., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)