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Purpose In the era of minimal-invasive surgery, the introduction of robotic liver surgery (RS) was accompanied by concerns about the increased financial expenses of the robotic technique in comparison to the established laparoscopic (LS) and conventional open surgery (OS). Therefore, we aimed to evaluate the cost-effectiveness of RS, LS and OS for major hepatectomies in this study. Methods We analyzed financial and clinical data on patients who underwent major liver resection for benign and malign lesions from 2017 to 2019 at our department. Patients were grouped according to the technical approach in RS, LS, and OS. For better comparability, only cases stratified to the Diagnosis Related Groups (DRG) H01A and H01B were included in this study. Financial expenses were compared between RS, LS, and OS. A binary logistic regression model was used to identify parameters associated with increased costs. Results RS, LS and OS accounted for median daily costs of 1,725 €, 1,633 € and 1,205 €, respectively (p p = 0.420) and total costs (16,648 € vs. 14,578 €, p = 0.076) were comparable between RS and LS. Increased financial expenses for RS were mainly caused by intraoperative costs (7,592 €, p p = 0.004), length of stay (HR [95% CI] = 8.8 [1.9–41.6], p = 0.006) and development of major complications (HR [95% CI] = 2.9 [1.7–5.1], p Conclusions From an economic perspective, RS may be considered a valid alternative to LS for major liver resections.

Abstract Purpose Robotic-assisted minimally invasive esophagectomy (RAMIE) has become one standard approach for the operative treatment of esophageal tumors at specialized centers. Here, we report the results of a prospective multicenter registry for standardized RAMIE. Methods The German da Vinci Xi registry trial included all consecutive patients who underwent RAMIE at five tertiary university centers between Oct 17, 2017, and Jun 5, 2020. RAMIE was performed according to a standard technique using an intrathoracic circular stapled esophagogastrostomy. Results A total of 220 patients were included. The median age was 64 years. Total minimally invasive RAMIE was accomplished in 85.9%; hybrid resection with robotic-assisted thoracic approach was accomplished in an additional 11.4%. A circular stapler size of ≥28 mm was used in 84%, and the median blood loss and operative time were 200 (IQR: 80–400) ml and 425 (IQR: 335–527) min, respectively. The rate of anastomotic leakage was 13.2% (n=29), whereas the two centers with >70 cases each had rates of 7.0% and 12.0%. Pneumonia occurred in 19.5% of patients, and the 90-day mortality was 3.6%. Cumulative sum analysis of the operative time indicated the end of the learning curve after 22 cases. Conclusions High-quality multicenter registry data confirm that RAMIE is a safe procedure and can be reproduced with acceptable leak rates in a multicenter setting. The learning curve is comparably low for experienced robotic surgeons.

Background Extrahepatic transection of the right hepatic artery and right portal vein before parenchymal dissection is a widely used standard for minimal invasive right hepatectomy. Hereby, hilar dissection represents a technical difficulty. We report our results of a simplified approach in which the hilar dissection is omitted and the line of dissection is defined with ultrasound. Methods Patients undergoing minimally invasive right hepatectomy were included. Ultrasound-guided hepatectomy (UGH) was defined by the following main steps: (1) ultrasound-guided definition of the transection line, (2) dissection of the liver parenchyma according to the caudal approach, (3) intraparenchymal transection of the right pedicle and (4) of the right liver vein, respectively. Intra- and postoperative outcomes of UGH were compared to the standard technique. Propensity score matching was performed to adjust for parameters of perioperative risk. Results Median operative time was 310 min in the UGH group compared to 338 min in the control group (p = 0.013). No differences were observed for Pringle maneuver duration (35 min vs. 25 min; p = ns) nor postoperative transaminases levels (p = ns). There was a trend toward a lower major complication rate in the UGH group (13 vs. 25%) and a shorter median hospital stay (8 days vs. 10 days); however, both being short of statistical significance (p = ns). Bile leak was observed in zero cases of UGH compared to 9 out of 32 cases (28%) for the control group (p = 0.020). Conclusions UGH appears to be at least comparable to the standard technique in terms of intraoperative and postoperative outcomes. Accordingly, transection of the right hepatic artery and right portal vein prior to the transection phase can be omitted, at least in selected cases. These results need to be confirmed in a prospective and randomized trial. Graphical Abstract

Background Anastomotic leakage and postoperative pancreatic fistula (POPF) may occur after pancreatic head resection, also in the setting of pancreato-gastric reconstruction. For adequate complication management, a variety of non-standardized treatments are available. Still, data on clinical evaluation of endoscopic methods remain scarce. Based on our interdisciplinary experience on endoscopic treatment of retro-gastric fluid collections after left-sided pancreatectomies, we developed an innovative endoscopic concept with internal peri-anastomotic stent placement for patients with anastomotic leakage and/or peri-anastomotic fluid collection. Methods Over the period of 6 years (2015–2020) we retrospectively evaluated 531 patients after pancreatic head resections at the Department of Surgery, Charité–Unversitätsmedizin Berlin. Of these, 403 received reconstruction via pancreatogastrostomy. We identified 110 patients (27.3%) with anastomotic leakage and/or peri-anastomotic fluid collection and could define four treatment groups which received either conservative treatment (C), percutaneous drainage (PD), endoscopic drainage (ED), and/or re-operation (OP). Patients were grouped in a step-up approach for descriptive analyses and in a stratified, decision-based algorithm for comparative analyses. The study’s primary endpoints were hospitalization (length of hospital stay) and clinical success (treatment success rate, primary/secondary resolution). Results We characterized an institutional, post-operative cohort with heterogenous complication management following pancreato-gastric reconstruction. The majority of patients needed interventional treatments (n = 92, 83.6%). Of these, close to one-third (n = 32, 29.1%) were treated with endoscopy-guided, peri-anastomotic pigtail stents for internal drainage as either primary, secondary and/or tertiary treatment modality. Following a decision-based algorithm, we could discriminate superior primary—(77,8% vs 53.7%) and secondary success rates (85.7% vs 68.4%) as well as earlier primary resolutions (11.4 days, 95%CI (5.75–17.13) vs 37.4 days, 95%CI (27.2–47.5)] in patients receiving an endoscopic compared to percutaneous management. Conclusion This study underscores the importance of endoscopy-guided approaches for adequate treatment of anastomotic leakage and/or peri-anastomotic fluid collections after pancreatoduodenectomy. We herein report a novel, interdisciplinary concept for internal drainage in the setting of pancreato-gastric reconstruction.

Background Robotic pancreatic surgery (RPS) is associated with high intraoperative costs compared to open pancreatic surgery (OPS). However, it remains unclear whether several advantages of RPS such as reduced surgical trauma and a shorter postoperative recovery time could lead to a reduction in total costs outweighing the intraoperative costs. The study aimed to compare patients undergoing OPS and RPS with regards to cost-effectiveness in a propensity score-matched (PSM) analysis. Methods Patients undergoing OPS and RPS between 2017 and 2019 were included in this monocentric, retrospective analysis. The controlling department provided financial data (costs and revenues, net loss/profit). A propensity score-matched analysis was performed or OPS and RPS (matching criteria: age, American society of anesthesiologists (ASA) score, gender, body mass index (BMI), and type of pancreatic resection) with a caliper 0.2. Results In total, 272 eligible OPS cases were identified, of which 252 met all inclusion criteria and were thus included in the further analysis. The RPS group contained 92 patients. The matched cohorts contained 41 patients in each group. Length of hospital stay (LOS) was significantly shorter in the RPS group (12 vs. 19 days, p = 0.003). Major postoperative morbidity (Dindo/Clavien ≥ 3a) and 90-day mortality did not differ significantly between OPS and RPS (p > 0.05). Intraoperative costs were significantly higher in the RPS group than in the OPS group (7334€ vs. 5115€, p < 0.001). This was, however, balanced by other financial categories. The overall cost-effectiveness tended to be better when comparing RPS to OPS (net profit—RPS: 57€ vs. OPS: − 2894€, p = 0.328). Binary logistic regression analysis revealed major postoperative complications, longer hospital stay, and ASA scores < 3 were linked to the risk of net loss (i.e., costs > revenue). Conclusions Surgical outcomes of RPS were similar to those of OPS. Higher intraoperative costs of RPS are outweighed by advantages in other categories of cost-effectiveness such as decreased lengths of hospital stay.

Background To investigate whether liver venous deprivation (LVD) as simultaneous, portal vein (PVE) and right hepatic vein embolization offers advantages in terms of hypertrophy induction before extended hepatectomy in non-cirrhotic liver. Materials and Methods Between June 2018 and August 2019, 20 patients were recruited for a prospective, non-randomized study to investigate the efficacy of LVD. After screening of 134 patients treated using PVE alone from January 2015 to August 2019, 14 directly matched pairs regarding tumor entity (cholangiocarcinoma, CC and colorectal carcinoma, CRC) and hypertrophy time (defined as time from embolization to follow-up imaging) were identified. In both treatment groups, the same experienced reader (> 5 years experience) performed imaging-based measurement of the volumes of liver segments of the future liver remnant (FLR) prior to embolization and after the standard clinical hypertrophy interval (~ 30 days), before surgery. Percentage growth of segments was calculated and compared. Results After matched follow-up periods (mean of 30.5 days), there were no statistically significant differences in relative hypertrophy of FLRs. Mean ± standard deviation relative hypertrophy rates for LVD/PVE were 59 ± 29.6%/54.1 ± 27.6% (p = 0.637) for segments II + III and 48.2 ± 22.2%/44.9 ± 28.9% (p = 0.719) for segments II–IV, respectively. Conclusions LVD had no significant advantages over the standard method (PVE alone) in terms of hypertrophy induction of the FLR before extended hepatectomy in this study population.

Purpose Artificial organs might serve as alternative solutions for whole organ transplantation. Decellularization of a liver provides a non-immunogenic matrix with the advantage of three afferent systems, the portal vein, the hepatic artery and the bile duct. This study aims to evaluate the recellularization of rat livers with islets of Langerhans via the bile duct and the portal vein for the comparison of different perfusion routes. Methods Rat livers were decellularized in a pressure-controlled perfusion manner and repopulated with intact isolated islets of Langerhans via either the portal vein or the bile duct. Results Repopulation via the portal vein showed islet clusters stuck within the vascular system demonstrated by ellipsoid borders of thick reticular tissue around the islet cluster in Azan staining. After recellularization via the bile duct, islets were distributed close to the vessels within the parenchymal space and without a surrounding reticular layer. Large clusters of islets had a diameter of up to 1000 µm without clear shapes. Conclusion We demonstrated the bile duct to be superior to the portal vein for repopulation of a decellularized rat liver with islets of Langerhans. This technique may serve as a bioengineering platform to generate an implantable and functional endocrine neo-pancreas and provide scaffolds with the anatomic benefit of three afferent systems to facilitate co-population of cells.

Purpose The concept of “textbook outcome” (TO) as composite quality measure depicting the ideal surgical has not yet been defined for patients undergoing major hepatectomy (MH) for perihilar cholangiocarcinoma (PHC). This study sought to propose a uniform definition through a systematic literature review as well as to identify patient- or procedure-related factors influencing TO. Methods In this retrospective study, we analyzed all patients undergoing MH for PHC at our department between January 2005 and August 2019. After conducting a systematic literature search, we defined TO as the absence of 90-day mortality and major complications, no hospital readmission within 90 days after discharge, and no prolonged hospital stay ( Results Of 283 patients, TO was achieved in 67 (24%) patients. Multivariate analysis revealed that preoperative biliary drainage was associated with a decreased (OR= 0.405, 95% CI: 0.194–0.845, p=0.016) and left-sided-resection (OR= 1.899, 95% CI: 1.048–3.440, p=0.035) with increased odds for TO. Overall survival (OS) and DFS (disease-free survival) did not differ significantly between the outcome groups (OS: p=0.280, DFS: p=0.735). However, there was a trend towards better overall survival, especially in the late course with TO. Conclusion Our analysis proposed a uniform definition of TO after MH for PHC. We identified left hepatectomy as an independent factor positively influencing TO. In patients where both right- and left-sided resections are feasible, this underlines the importance of a careful selection of patients who are scheduled for right hepatectomy.

Purpose The aim of this study was to analyze the impact of minimally invasive intermittent Pringle maneuver (IPM) on postoperative outcomes in patients with hepatocellular carcinoma (HCC) and liver cirrhosis. Methods In this retrospective cohort study, we evaluated the safety of IPM in patients with HCC who underwent minimally invasive liver resection during five years at our center. Factors influencing the use of IPM were examined in univariate and multivariate regression analysis. Cases with use of IPM (IPM) and those without use of IPM (no IPM) were then compared regarding intraoperative and postoperative outcomes after propensity score matching (PSM) for surgical difficulty. Results One hundred fifty-one patients underwent liver resection for HCC at our center and met inclusion criteria. Of these, 73 patients (48%) received IPM with a median duration of 18 min (5–78). One hundred patients (66%) had confirmed liver cirrhosis. In multivariate analysis, patients with large tumors (≥ 3 cm) and difficult tumor locations (segments VII or VIII) were more likely to undergo IPM (OR 1.176, p = 0.043, and OR 3.243, p = 0.001, respectively). After PSM, there were no differences in intraoperative blood transfusion or postoperative complication rates between the IPM and no IPM groups. Neither did we observe any differences in the subgroup analysis for cirrhotic patients. Postoperative serum liver function tests were not affected by the use of IPM. Conclusions Based on our findings, we conclude that the use of IPM in minimally invasive liver resection is safe and feasible for patients with HCC, including those with compensated liver cirrhosis.

Vor dem Hintergrund der wachsenden Okonomisierung der klinischen Medizin haben in den vergangenen Jahrzehnten auch in chirurgischen Disziplinen die Themen Risiko- und Komplikationsmanagement an Bedeutung gewonnen. Eine Schlusselrolle zur validen Qualitatskontrolle kommt dabei der standardisierten und reproduzierbaren Erhebung von Outcome- und Komplikationsdaten zu. In dieser Arbeit wird ein an der Chirurgischen Klinik der Charite Universitatsmedizin Berlin implementiertes digitales Systems hinsichtlich seiner Praktikabilitat zum peri- und postoperativen Komplikationsmonitoring im Rahmen der Qualitatssicherung analysiert.

While minimally invasive liver surgery has been increasingly adopted at least for minor resections, experience with robotic liver surgery is still limited to a few highly specialized centers. Due to the fear of abdominal adhesions, a history of prior surgeries is still used as an argument for open approaches. Clinical data of all consecutive robotic resections at our center, using the da Vinci Xi surgical system, between April, 2018 and December, 2020, were collected and analyzed as part of a prospective, post-marketing observational study (DRKS00017229). Prior abdominal surgeries were specified according to the surgical approach and localization. Baseline and perioperative outcome criteria were compared between patients with prior surgeries (PS) and patients with no prior surgeries (NPS) in univariate and multivariate analyses. Out of the 126 patients undergoing robotic liver resections, 59% had a history of abdominal surgeries, which were most often colorectal resections (28%) followed by liver resections (20%). Patients with NPS were more likely to undergo robotic liver resection for hepatocellular carcinoma or benign tumors, and to have underlying liver cirrhosis when compared to patients with PS. Other baseline characteristics as well as the extent of resections were similar. Duration of surgery (258 min), conversion rates (6%), and postoperative complications rates (21% Clavien–Dindo ≥ 3) showed no differences between NPS and PS. A subgroup of patients with a history of prior liver surgery showed a longer duration of surgery in univariate analysis. However, this was not confirmed in multivariate analysis which instead revealed tumor entity and liver cirrhosis as independently correlated with duration of surgery. We propose robotic liver resection to be safe and feasible, including in patients with prior abdominal surgeries. Each patient should be evaluated for a minimally invasive procedure regardless of a history of previous operations.

Background Due to the COVID-19 pandemic, an extensive reorganisation of healthcare resources was necessary—with a particular impact on surgical care across all disciplines. However, the direct and indirect consequences of this redistribution of resources on surgical therapy and care are largely unknown. Methods We analysed our prospectively collected standardised digital quality management document for all surgical cases in 2020 and compared them to the years 2018 and 2019. Periods with high COVID-19 burdens were compared with the reference periods in 2018 and 2019. Results From 2018 to 2020, 10,723 patients underwent surgical treatment at our centres. We observed a decrease in treated patients and a change in the overall patient health status. Patient age and length of hospital stay increased during the COVID-19 pandemic (p = 0.004 and p = 0.002). Furthermore, the distribution of indications for surgical treatment changed in favour of oncological cases and less elective cases such as hernia repairs (p Clavien-Dindo, with a significant increase of postoperative mortality (p = 0.01). Conclusion During the COVID-19 pandemic we did not see an increase in the occurrence, or the severity of postoperative complications. Despite a slightly higher rate of mortality and specific complications being more prevalent, the biggest change was in indication for surgery, resulting in a higher proportion of older and sicker patients with corresponding comorbidities. Further research is warranted to analyse how this changed demographic will influence long-term patient care.

SummaryDue to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

Background Additive/adjuvant chemotherapy as concept after local treatment of colorectal metastases has not been proven to be successful by phase III trials. Accordingly, a standard of care to improve relapse rates and long-term survival is not established and adjuvant chemotherapy cannot be recommended as a standard therapy due to limited evidence in literature. The PORT trial aims to generate evidence that post-resection/ablation/radiation chemotherapy improves the survival in patients with metastatic colorectal cancer. Methods Patients to be included into this trial must have synchronous or metachronous metastases of colorectal cancer—either resected (R0 or R1) and/or effectively treated by ablation or radiation within 3–10 weeks before randomization—and have the primary tumor resected, without radiographic evidence of active metastatic disease at study entry. The primary endpoint of the trial is progression-free survival after 24 months, secondary endpoints include overall survival, safety, quality of life, treatments (including efficacy) beyond study participation, translational endpoints, and others. One arm of the study comprising 2/3 of the population will be treated for 6 months with modified FOLFOXIRI or modified FOLFOX6 (investigator´s choice, depending on the performance status of the patients but determined before randomization), while the other arm (1/3 of the population) will be observed and undergo scheduled follow-up computed tomography scans according to the interventional arm. Discussion Optimal oncological management after removal of colorectal metastases is unclear. The PORT trial aims to generate evidence that additive/adjuvant chemotherapy after definitive treatment of colorectal metastases improves progression free and overall survival in patients with colorectal cancer. Trial registration This study is registered with clinicaltrials.gov (NCT05008809) and EudraCT (2020–006,144-18).

Background Robotic-assisted pancreatic surgery is limited to specialized high-volume centers and selected patient cohorts. Especially for patients with a history of previous abdominal surgeries, the standard procedure remains open surgery due to the fear of complications caused by abdominal adhesions. Methods Clinical data of all consecutive patients undergoing robotic-assisted pancreatic surgery using the daVinci Xi system (Intuitive Surgical) at our center (Department of Surgery, Universitätsmedizin Berlin, Germany) were collected prospectively and further analyzed from October 2017 to October 2020. Prior abdominal surgeries were specified according to the surgical approach and localization. In univariate and multivariate analysis, baseline and perioperative parameters of patients with a history of prior abdominal surgeries (PS) were compared to those of patients with no history of prior abdominal surgeries (NPS). Results Out of 131 patients undergoing robotic-assisted pancreatic surgery, 62 (47%) had a history of abdominal surgery. Previous procedures included most often appendectomy (32%) followed by gynecological surgery (29%) and cholecystectomy (27%). 24% of PS had received multiple surgeries prior to the robotic-assisted pancreatic resections. Baseline characteristics and comorbidities were comparable between the groups. We did not detect differences in the duration of surgery (262 min), conversion rates (10%), and postoperative complications between NPS and PS. Postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), and in-house mortality showed no significant differences between the two groups. Multivariate analysis revealed male sex and high BMI as a potential predictive factor for severe postoperative complications. Other characteristics like the type of pancreatic resection, ASA, and underlying malignancy showed no difference in the multivariable analysis. Conclusions We propose robotic-assisted pancreatic surgery to be safe and feasible for patients with a history of minor prior abdominal surgery. Hence, each patient should individually be evaluated for a minimally invasive approach regardless of a history of previous operations.

Die minimal-invasive Leberchirurgie stellt an erfahrenen Zentren heute das Standardvorgehen dar, wobei sich Techniken und Strategien standig weiterentwickeln. Es erfolgte eine Analyse englischsprachiger Literatur zur minimal-invasiven und robotisch assistierten Leberchirurgie. Der aktuelle wissenschaftliche Stand wurde zusammengefasst und anhand eigener Zentrumserfahrungen bewertet. Vorteile der minimal-invasiven gegenuber der konventionell-offenen Technik zeigen sich bei leberchirurgischen Eingriffen in verbesserten perioperativen Ergebnissen. Bedenken im Hinblick auf intraoperative Komplikationen und mogliche Kompromisse bei der onkologischen Radikalitat konnten inzwischen durch eine Vielzahl von Publikationen ausgeraumt werden. Erste Berichte uber die robotisch assistierte Technik scheinen bekannte Vorteile der laparoskopischen Leberchirurgie zu bestatigen. Die Datenlage zur robotisch assistierten Leberchirurgie ist entsprechend dem kurzen Erfahrungszeitraum einiger weniger Zentren aber begrenzt und erlaubt noch keine abschliesenden Schlusse. Eine Steigerung der intraoperativen Sicherheit und eine Erweiterung des operativen Spektrums hin zu hoch komplexen Leberresektionen sind aber wahrscheinlich. Schon wahrend der Lernkurve scheinen sich bekannte Vorteile der laparoskopischen Leberchirurgie auch fur die robotisch assistierte Leberchirurgie zu bestatigen. Entsprechend eigenen Zentrumserfahrungen wird die minimal-invasive Leberchirurgie durch die robotisch assistierte Technik zukunftig sinnvoll erganzt werden. Insbesondere werden technisch hoch komplexe Resektionen mit Rekonstruktion ermoglicht.

Background Within the last years, single-incision laparoscopic cholecystectomy (SLC) emerged as an alternative to multiport laparoscopic cholecystectomy (MLC). SLC has advantages in cosmetic results, and postoperative pain seems lower. Overall complications are comparable between SLC and MLC. However, long-term results of randomized trials are lacking, notably to answer questions about incisional hernia rates, long-term cosmetic impact and chronic pain. Methods A randomized trial of SLC versus MLC with a total of 193 patients between December 2009 and June 2011 was performed. The primary endpoint was postoperative pain on the first day after surgery. Secondary endpoints were conversion rate, operative time, intraoperative and postoperative morbidity, technical feasibility and hospital stay. A long-term follow-up after surgery was added. Results Ninety-eight patients (50.8%) underwent SLC, and 95 patients (49.2%) had MLC. Pain on the first postoperative day showed no difference between the operative procedures (SLC vs. MLC, 3.4 ± 1.8 vs. 3.7 ± 1.9, respectively; p = 0.317). No significant differences were observed in operating time or the overall rate of postoperative complications (4.1% vs. 3.2%; p = 0.731). SLC exhibited better cosmetic results in the short term. In the long term, after a mean of 70.4 months, there were no differences in incisional hernia rate, cosmetic results or pain at the incision between the two groups. Conclusions Taking into account a follow-up rate of 68%, the early postoperative advantages of SLC in relation to cosmetic appearance and pain did not persist in the long term. In the present trial, there was no difference in incisional hernia rates between SLC and MLC, but the sample size is too small for a final conclusion regarding hernia rates. Trial registration German Registry of Clinical Trials DRKS00012447

Aufgrund der Diskrepanz zwischen der Anzahl zunehmend benotigter Nieren zur Transplantation und der fortbestehend niedrigen Zahlen hirntoter Spender gewinnt die Moglichkeit zur Nierenlebendspende an Bedeutung. Untersucht werden Indikation und Spenderevaluierung bei der Nierenlebendspende. Hierzu wurden die Statistiken der Deutschen Stiftung Organtransplantation (DSO) ausgewertet. Die Grundlagenarbeiten und Expertenempfehlungen werden diskutiert. Die Nierenlebendspende stellt eine exzellente Option fur Patienten mit terminaler Niereninsuffizienz dar. Eine sorgfaltige Abklarung potenzieller Spender und deren Nachsorge ist unabdingbar. Es besteht groses Potenzial zur Ausweitung von Lebendspendeprogrammen.

Total mesorectal excision (TME) has become the standard treatment for rectal cancer in the middle and lower third. Meanwhile, many international trials have confirmed the noninferiority of laparoscopic TME compared to the open technique. Nevertheless, in the presence of anatomical limitations, such as narrow, obese, male pelvises as well as large rectal tumors, the adequate resection of the lower third of the rectum according to oncological criteria, is still challenging even for specialized colorectal surgeons. Therefore, the implementation of innovative approaches, such as robotic-assisted and transanal TME (TaTME) should shed light on this anatomically complex region and guarantee an oncological radical resection and the best possible preservation of neural structures. The advantages of this technique have so far only been provided by retrospective cohort studies by large international centers. Therefore, international prospective randomized trials are currently recruiting patients to analyze the surgical and oncological outcome of TaTME compared to conventional techniques. This article describes the TaTME technique per se, the fields of application and the current data situation. Practical recommendations for the safe implementation of this operative procedure are also presented. The TaTME procedure is reserved for highly specialized colorectal centers with a high volume of rectal cancer cases and appropriate expertise in minimally invasive visceral surgery.Die totale mesorektale Exzision (TME) ist der Goldstandard im Kontext der multimodalen Behandlung des Rektumkarzinoms im mittleren und unteren Drittel. Der transanale Zugang ist eine Erganzung des zunehmend laparoskopischen Vorgehens, welcher gerade bei anatomischen Limitationen bei der onkologisch adaquaten Resektion des distalen Rektums Abhilfe schaffen soll. Die Nichtunterlegenheit in chirurgischen und onkologischen Parametern wird gegenuber konventionellen (laparoskopisch/offen) Operationsmethoden derzeit intensiv beforscht. Eine sichere Implementation dieser herausfordernden Technik ist an ein modulares Trainingskurrikulum gebunden.

Zurzeit unterliegt die moderne Chirurgie einem deutlichen Wandel im Sinne der Einfuhrung moderner Technologien und innovativer Techniken. Die robotisch-assistierte Chirurgie oder moderne Techniken der Visualisierung stellen die Chirurgie vor bisher ungeahnte Herausforderungen hinsichtlich moglicher und sinnvoller Einsatzgebiete. Soll eine Innovation nicht lediglich als „Machbarkeitsbeweis“ und Zeichen des ungebremsten Fortschrittes eine interessante Singularitat bleiben, sondern einen festen Platz im Rahmen standardisierter Therapieablaufe bekommen, bedarf es fester Regularien, welche den Weg von der Innovation hin zur Einfuhrung in die Klinik flankieren. Dieser Ubersichtsartikel soll Defizite der bis dato praktizierten Modelle der Einfuhrung neuer Technologien in die Klinik kritisch beleuchten und neue Aspekte und Wege aufzeigen, welche die Einfuhrung von Innovationen im Hinblick insbesondere auf die Patientensicherheit verbessern konnen.

Lebermetastasen stellen die haufigste sekundar maligne Erkrankung der Leber dar. Zahlen zur Inzidenz kolorektaler und nichtkolorektaler Lebermetastasen lassen sich aufgrund mangelnder Erfassung in Registern nur unzureichend untersuchen. Daten zur neoadjuvanten Therapie sind begrenzt und meist retrospektiv analysiert. Zusammenfassung und Bewertung der Sinnhaftigkeit neoadjuvanter Therapiekonzepte fur kolorektale und nichtkolorektale Lebermetastasen. Die Analyse erfolgte auf Grundlage der europaischen und US-amerikanischen Leitlinien und umfasste deutsche und englischsprachige Publikationen. Ergebnisse und Empfehlungen werden zusammengefasst und es wird ein Uberblick uber die Literatur gegeben. Die neoadjuvante Therapie von Lebermetastasen erfolgt in heterogener Intention, sowohl die Selektion biologisch gunstiger Tumoren als auch die Konversion eines inoperablen Befundes in einen resektablen Befund sind klassische Beweggrunde fur eine neoadjuvante Therapie. Die Sinnhaftigkeit neoadjuvanter Therapiekonzepte fur kolorektale und insbesondere nichtkolorektale Lebermetastasen ist dem aktuellen Stand der Literatur und Leitlinien folgend nicht durchgehend schlussig zu beantworten. Die Erstellung der Therapiestrategie in der klinischen Praxis folgt in der Regel folgenden Kriterien: Metastasierungsmuster, Komplexitat der Resektion und biologische Faktoren (metachrone/synchrone Metastasen, Prognosefaktoren). Beim metastasierten kolorektalen Karzinom ist die Neoadjuvans im Kontext einer Konversionstherapie Standard. Biologische Selektion gunstiger Tumoren als Basis der Neoadjuvans bei resektablen Lasionen ist beim kolorektalen Karzinom kein durchgehender Standard. Nichtkolorektale Lebermetastasen werden nur im Rahmen individueller Konzepte reseziert.

Minimally invasive techniques have been broadly introduced to liver surgery during the last couple of years. In this study, we aimed to report the incidence and potential risk factors for incisional hernia (IH) as well as health-related quality of life (HRQoL) after laparoscopic liver resections (LLR). All patients undergoing LLR between January 2014 and June 2017 were contacted for an outpatient hernia examination. In all eligible patients, photo documentation of the scar was performed and IH was evaluated by clinical examination and by ultrasound. Patients also completed a questionnaire to evaluate IH-specific symptoms and HRQoL. Obtained results were retrospectively analyzed with regard to patients’ characteristics, perioperative outcomes and applied minimally invasive techniques, such as multi-incision laparoscopic liver surgery or hand-assisted/single-incision laparoscopic surgery (HALS/SILS). Of 184 patients undergoing surgery, 161 (87.5%) met the inclusion criteria and 49 patients (26.6%) participated in this study. After a median time of 26 months (range 19–50 months) after surgery, we observed an overall incidence of IH of 12%. Five of 6 patients were overweight or obese (BMI ≥ 25) and 5 of 6 hernias were located at the umbilical site. Univariate analysis suggested the performance status at time of operation (ASA score ≥ 3; HR 5.616, 95% CI 1.012–31.157, p = 0.048) and the approach (HALS/SILS, HR 6.571, 95% CI 1.097–39.379, p = 0.039) as potential risk factors for IH. A higher frequency of hernia-related physical restrictions (HRR; p = 0.058) and a decreased physical functioning (p = 0.17) were noted in patients with IH; however, both being short of statistical significance. Advantages of laparoscopic surgery with regard to low rates of IH can be translated to minimally invasive liver surgery. Even though there are low rates of IH, patients with poor performance status at the time of operation should be monitored closely. While patients’ characteristics are hard to influence, it might be worth focusing on surgical factors such as the approach and the closure of the umbilical site to further minimize the rate of IH.

Karzinome der intra- und extrahepatischen Gallenwege sind durch eine geringe Inzidenz und durch ein ausgesprochen heterogenes Erscheinungsbild charakterisiert. Zusammenfassung und Bewertung aktueller chirurgischer Strategien bei der Therapie maligner Gallengangserkrankungen. Es erfolgte eine Analyse englischsprachiger Publikationen sowie europaischer und US-amerikanischer Leit- und Richtlinien zur chirurgischen Therapie maligner Gallengangserkrankungen. Ergebnisse und Empfehlungen wurden zusammengefasst und anhand eigener Zentrumserfahrungen bewertet. Die Chirurgie gilt als die einzige kurativ intendierte Therapie, wobei zu wesentlichen Fragestellungen prospektiv-randomisierte Studien fehlen und existierende Leitlinien auf geringer Evidenz basieren. Strategien und das Resektionsausmas unterscheiden sich bei Karzinomen der intra- und extrahepatischen Gallenwege abhangig von Lokalisation, Grose und Anzahl der Tumoren sowie durch deren Lagebeziehung zu umliegenden Strukturen zum Teil erheblich. Entsprechend ist zur Erstellung eines individualisierten Gesamtkonzeptes und zur suffizienten Durchfuhrung der meist komplexen Resektion eine ausreichende Erfahrung in der Behandlung dieser Tumoren von ubergeordneter Bedeutung.

Patients with peritoneal metastases suffer from physical and psychological distress. The aim of our investigation was to identify highly distressed patients, collect demographic data, and examine correlations between distress score and clinical outcome. This retrospective analysis included all patients who were treated for peritoneal surface malignancies with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in our department. Psycho-oncological screening was conducted preoperatively. From a total of 213 patients, 105 (49.3%) participated in the psycho-oncological screening. Women had a higher score (6.2 ± 2.6) compared to men (4.8 ± 3.4; p = 0.02). Age (p = 0.15) and Peritoneal Cancer Index (p = 0.90) had no significant influence on the score. The postoperative rate for surgical (19/73) or non-surgical complications (20/73) in highly distressed patients was comparable to patients with low distress (9/31, 11/31; p = 0.46, p = 0.28). Psychological problems due to sadness (Odds Ratio [OR] 2.69; p = 0.009), sleeplessness (OR 3.01; p = 0.004), and the physical ability to get around (OR 2.65; p = 0.01) were identified as having the greatest impact on distress scores. The mean distress score in patients with peritoneal surface malignancies is high (5.4 ± 2.7), is not related to the medical prognosis of the patients due to their underlying disease, and showed no correlation to the complication rate. Sadness and problems with sleep and getting around have a major influence on this score.

Die Leistenhernienchirurgie stellt fur Allgemein- und Viszeralchirurgen elektiv wie auch notfallmasig eine zentrale Aufgabe dar. Als Standardprozedur gilt sie im deutschen DRG-System als eher erlosschwach, was insbesondere im kostenintensiven universitaren Umfeld zu einem okonomischen Ungleichgewicht fuhren kann. Ziel dieser Analyse war neben der Untersuchung des Einflusses von klinischen Faktoren auf die Kosten und den Deckungsbeitrag auch die okonomische Gesamtevaluation der elektiven Leistenhernienchirurgie an einem Universitatskrankenhaus. Eingeschlossen in die Analyse wurden alle Patienten nach elektiver Leistenhernienoperation an 2 Standorten der Charite – Universitatsmedizin Berlin aus den Jahren 2014 und 2015. Ausgewertet wurde der Einfluss von klinischen Patienten- und Operationsfaktoren auf das okonomische Ergebnis der Falle. Insgesamt wurden 419 Patienten eingeschlossen, mehrheitlich nach Lichtenstein-Operation (44,9 %) und laparoskopischer Operation (53,9 %). Den grosten Einfluss auf das okonomische Ergebnis hat das Auftreten von postoperativen Komplikationen. Auch ein patientenbezogener Gesamtschweregrad (PCCL) von >1, mehr als 8 kodierte Nebendiagnosen sowie eine Verweildauer von unter 2 Tagen haben einen signifikant negativen Einfluss auf den Deckungsbeitrag. Insgesamt fuhrt die elektive Leistenhernienchirurgie zu einer Unterdeckung im Mittel von 651 € pro Fall. Bei der elektiven Leistenhernienchirurgie im universitaren Umfeld handelt es sich um einen hochgradig defizitaren Eingriff. Da jedoch eine vollstandige Einstellung dieser Therapie keine Alternative darstellt, bedarf es multifaktorieller Ansatzpunkte, um das okonomische Ergebnis zu verbessern.

A considerable number of reports have been published on the feasibility, techniques, and early postoperative results of robotic-assisted oesophageal surgery. However, these are mostly smaller case series, suggesting that the robot-assisted Ivor Lewis procedure is still in the implementation phase and far from being standardised. Oesophageal surgeons from seven robotic university centres in Germany, experienced in both minimally invasive and robot-assisted minimally invasive surgery, took part in a workshop on robot-assisted surgery. An intensive exchange of opinions and experiences, followed by a step-by-step re-enactment of the operation in a cadaver lab, enabled us to develop a standardised robot-assisted Ivor Lewis surgical workflow, which is presented here. Systematic and objective comparison of experiences and results using a robot-assisted Ivor Lewis procedure has made it possible to develop a standardised surgical workflow that is now clinically applied in our centres. It is hoped that standardisation of this procedure will help to maintain patient safety, prevent medical errors, and facilitate the learning curve, while introducing robotic surgery into a centre.

Predicting post-hepatectomy liver failure (PHLF) after extended right hepatectomy following portal vein embolization (PVE) from serial gadoxetic acid-enhanced magnetic resonance imaging (MRI). Thirty-six patients who underwent hepatectomy following PVE were evaluated prospectively with gadoxetic acid-enhanced MRI examinations at predefined intervals during the course of their treatment, i.e., before and 14 days and 28 days after PVE as well as 10 days after hepatectomy. Relative enhancement (RE) and volume of the left and right liver lobes were determined. The study population was divided into two groups with respect to signs of PHLF. Differences between the two groups were assessed using the Mann-Whitney U test, and predictive parameters for group membership were investigated using ROC and logistic regression analysis. RE of the left lobe prior to PVE versus 14 days after PVE was significantly lower in patients with PHLF than in those without PHLF (Mann-Whitney U test p

Single-incision laparoscopic surgery (SILS) is growing in popularity. The increased diameter of the umbilical incision might raise questions about the possibility of a greater risk of postoperative incisional hernia in comparison to conventional laparoscopy. This study aims to disclose the frequency of incisional hernia after SILS in long-term follow-up as well as to reveal the factors predisposing patients to this feared complication. The patient collective consists of cholecystectomy and appendectomy patients, who were operated on using SILS technique. Follow-up was achieved through letter correspondence, telephone interview, and clinical examination. Effects of demographic variables and operative parameters including age, sex, BMI, ASA score, duration of surgery, pre-existing hernia as well as postoperative incidence of incisional hernia were investigated using univariate and multivariate analyses. A total of 286 cases with complete follow-up were included in the analyses. Mean follow-up duration was 58.4 months. 192 patients (67.1%) underwent cholecystectomy; 94 (32.9%) had an appendectomy. The study collective consisted of 218 women (76.2%) and 68 men (23.8%). Mean age at the date of the operation was 38.5 (median 36, range 13–74). In 5 cases (1.7%), the surgical approach was converted into conventional laparoscopy. Intraoperative complication rate was 0.3% and postoperative complication rate was 5.9%. 7 patients (2.4%) developed an incisional hernia. Obese patients had an incisional hernia incidence of 10.9%. 3 out of 19 patients (15.8%) with a pre-existing umbilical hernia developed an incisional hernia during follow-up. Obesity and pre-existing umbilical hernia proved to have a significant association with incisional hernia incidence in univariate and multivariate analyses. Sex, age, procedure (appendectomy vs cholecystectomy), presence of acute inflammation, and duration of surgery did not show a statistically significant association with incisional hernia. Detection of incisional hernia necessitates a long follow-up duration. Obesity and pre-existing umbilical hernia are associated with a higher incidence of this complication. Following a careful patient selection, SILS offers a safe approach for cholecystectomy and appendectomy procedures.

Bei der Bewertung einer speziellen Operationstechnik oder einer bestimmten Behandlungsstrategie nach genau definierten Qualitatskriterien oder -indikatoren spielt die individualisierte und masgeschneiderte Therapie eine wichtige Rolle, da hier Abweichungen von generellen Empfehlungen, wie in Leitlinien definiert, genauestens begrundet, dokumentiert und evaluiert werden mussen. Ziel dieses Leitthemenartikels ist es daher, die individualisierte Therapie des Rektumkarzinoms dahingehend anhand der vorliegenden Evidenz zu prufen und im Kontext des Behandlungsalgorithmus bestehender Leitlinien zu diskutieren. Neben einer Literaturrecherche wurde die aktualisierte deutsche S3-Leitlinie zum kolorektalen Karzinom als Basis herangezogen. Gerade beim Rektumkarzinom des mittleren und unteren Drittels sind von der Vorbehandlung, der eigentlichen Operation bis hin zur Nachbehandlung und Nachsorge individuelle, patienten- und tumorbezogene Parameter bei der interdisziplinaren Entscheidungsfindung zur optimalen Therapie von wegweisender Bedeutung.

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Die Grenzbereiche der Lebertransplantation liegen vor allem in der Ausweitung der Indikation (hepatozellulares Karzinom, [perihilares] Cholangiokarzinom, Empfanger mit gravierenderen Nebendiagnosen bzw. „weichen“ Kontraindikationen) und technisch anspruchsvollen Rekonstruktionsverfahren der vaskularen Strukturen (bei Portalvenenthrombose bzw. schwieriger arterieller Anschlussmoglichkeit) sowie einer Erweiterung des Spenderpools mit suboptimalen Organen (altere Spender, steatotische Lebern). Anhand personlicher Erfahrungen im klinischen Alltag und entsprechender Literaturrecherche legen wir in diesem Artikel die aktuelle Situation dar. In Deutschland zeigt sich eine deutliche Abnahme des 1‑Jahres-Uberlebens. Der Anteil an „schwer vermittelbaren“ („marginalen“) Spenderorganen verhalt sich dabei reziprok zum massiv erniedrigten Spenderaufkommen und parallel zur steigenden Wartelistenmortalitat (WL). Gleichzeitig nimmt der Anteil an stationaren WL-Patienten mit Mehrorganversagen zu. Eine ergebnisorientierte und -kontrollierte Lebertransplantation erlaubt heutzutage kaum noch ein Vordringen in ehemalige Grenzbereiche. Solange sich die aktuellen Bedingungen nicht andern, wird ein Verschieben der Grenzen des chirurgisch Machbaren kaum moglich sein. Vielmehr kann in der aktuellen Situation durch restriktivere Indikationsstellung und Organakzeptanz nur versucht werden, die ehemals erreichten Erfolge mit exzellentem Kurz- und Langzeituberleben (1-Jahres-Uberleben von 90 %, 20-Jahres-Uberleben von 50 %) wieder zu ermoglichen.

MELD attempts to objectively predict the risk of mortality of patients with liver cirrhosis and is commonly used to prioritize organ allocation. Despite the usefulness of the MELD, updated metrics could further improve the accuracy of estimates of survival. To assess and compare the prognostic ability of an enzymatic 13C-based liver function test (LiMAx) and distinct markers of liver function to predict 3-month mortality of patients with chronic liver failure. We prospectively investigated liver function of 268 chronic liver failure patients without hepatocellular carcinoma. Primary study endpoint was liver-related death within 3 months of follow-up. Prognostic values were calculated using Cox proportional hazards and logistic regression analysis. The Cox proportional hazard model indicated that LiMAx (p

Die zytoreduktive Chirurgie mit anschliesender hyperthermer intraperitonealer Chemotherapie (HIPEC) in Kombination mit einem multimodalen Therapiekonzept stellt fur Patienten mit niedrig malignen Neoplasien des Peritoneums, wie beispielsweise dem Pseudomyxoma peritonei, eine inzwischen etablierte und bevorzugte Therapie dar. In den letzten Jahren konnten zahlreiche grose retrospektive bzw. erste prospektive randomisiert kontrollierte Studien die Effektivitat dieses Therapieverfahrens fur Erkrankungen, wie beispielsweise das diffuse maligne peritoneale Mesotheliom, das peritoneal metastasierte kolorektale Karzinom oder das Ovarialkarzinom bei ausgewahlten Patienten belegen. Dieser Beitrag soll eine Ubersicht uber die zytoreduktive Chirurgie und HIPEC sein sowie relevante Aspekte in der Indikationsstellung bei Patienten mit unterschiedlichen Grunderkrankungen beleuchten. Dies soll als Hilfestellung fur den klinischen Alltag dienen und Alternativen zur rein onkologisch-palliativen Therapie beim Nachweis von Peritonealkarzinose aufzeigen.

Das fruhe Versagen der arteriovenosen (AV-)Fistel als Dialysezugang fur Patienten mit terminaler Niereninsuffizienz ist zunachst durch „clotting“ und/oder Thrombose bedingt, spater durch Stenosen aufgrund hoher Druckbelastung und der Wandspannung der Vene. Perianastomotisch herrschen Turbulenzbereiche, die eine niedrige Scherspannung fordern. Niedrige Scherspannung und hohe Wandspannung fordern die neointimale Hyperplasie. Die Uberlegung, die Stenosebildung durch ein externes Device zu reduzieren, konnte in langeren Offenheitsraten mit weniger Interventionen fur den Dialysepatienten resultieren. Das VasQ™ Device (Laminate Medical Technologies, Tel Aviv, Israel) ist eine externe Unterstutzung, welche den Fluss in der Fistel verbessern und die Ausbildung der Neointimahyperplasie begrenzen soll. Wir berichten uber die Ergebnisse der ersten 10 Patienten, die das Device bei einem „brachiocephalica shunt“ an unserer Klinik erhalten haben. Die Indikationsstellung erfolgte interdisziplinar im Shuntzentrum bei zu schmaler Shuntvene am Unterarm. Kontrollparameter waren intraoperative Komplikationen, intra- und postoperative Flowmessungen und die Funktionalitat der AV-Fistel via Kontaktaufnahme mit dem betreffenden Dialysezentrum. Es traten keine Komplikationen bei der AV-Fistelanlage auf. Nach 6 Monaten liefen alle AV-Fisteln problemlos und neun Patienten erhielten bereits Dialyse daruber. Nach 12 Monaten liefen 8 Dialyseshunts problemlos. Das VasQ™ Device ist sicher einsetzbar und verhindert moglicherweise Anastomosenstenosen und verbessert so AV-Fistel-Offenheitsraten.

Die Therapie des hepatozellularen Karzinoms (HCC) umfasst chirurgische, interventionelle und systemische Ansatze. Diese Ubersichtsarbeit beleuchtet den Stellenwert chirurgischer Therapieansatze in der multimodalen Behandlung des HCC unter Berucksichtigung aktueller Literatur, entsprechender deutscher Leit- und Richtlinien sowie Entwicklungen im Bereich der Organspende in Deutschland. Kurative Therapieoptionen des HCC umfassen die Lebertransplantation, die Leberteilresektion und je nach Grose auch lokal ablative Verfahren. Beim HCC in der zirrhotischen Leber gilt beim Erfullen der „Mailand-Kriterien“ die Lebertransplantation als Therapie der Wahl. In Anbetracht des Organmangels in Deutschland und verbesserter Ergebnisse nach Leberteilresektion kann bei ausreichender Leberfunktion alternativ eine Leberteilresektion erfolgen. Bei multinodularem Befund, regionaler Lymphknotenmetastasierung oder Makrogefasinvasion muss individuell uber die Moglichkeit einer Resektion entschieden werden, wobei letztere beiden Kriterien eine Transplantation grundsatzlich ausschliesen. Lokal ablative Verfahren konnen bei singularen, kleinen HCC alternativ zur Resektion in Abhangigkeit des Patientenwunsches erwogen werden. Ist eine kurativ intendierte Resektion des HCC in der nichtzirrhotischen Leber moglich, so orientieren sich die Strategien an den allgemeinen Grundsatzen der onkologischen Leberchirurgie. Kurative Therapieoptionen des HCC umfassen die Lebertransplantation, die Leberteilresektion und lokal ablative Verfahren. Aktuelle Entwicklungen im Bereich der Organspende und technische Fortschritte in der minimal-invasiven Leberchirurgie sollten in die Entscheidungsfindung im Tumorboard einfliesen.

Minimal-invasive Schilddrusen- und Nebenschilddrusenresektionen bei gutartigen und bosartigen Tumoren werden selten durchgefuhrt. In jungster Zeit wurden vielversprechende neue endoskopische transorale Ansatze am vorderen Hals mit guten Ergebnissen und geringen Komplikationsraten beschrieben. Diese Studie beschreibt die erste klinische Serie in Deutschland mit der transoralen endoskopischen Thyreoidektomie („transoral endoscopic thyroidectomy – vestibular approach“, TOETVA) und zeigt technische Probleme und Losungen auf. Die Technik wurde fur Hemithyreoidektomien bei Patienten ohne vorhergehende Halsoperationen indiziert. Die technischen Schritte bestanden aus einem 10 mm langen Schnitt an der Innenseite der Unterlippe, gefolgt von einer subplatysmalen Hydrodissektion. Dann wurde ein stumpfer Dissektorstab eingefuhrt, der einen Raum zwischen Platysma und infrahyoidaler Muskulatur schaffte. Uber die Zugange an der Innenseite der Unterlippe wurden pramental drei Trokare (ein Optiktrokar, zwei Arbeitstrokare) eingesetzt. Nach der Teilung der geraden Muskulatur wurde der Schilddrusenisthmus durchtrennt. Anatomische Strukturen wie die A. thyroidea superior, die Nebenschilddrusen und der N. laryngeus reccurens konnten mit entsprechender Vergroserung am Monitor problemlos identifiziert werden. Intermittierendes Neuromonitoring wurde zur Vermeidung einer Nervus-laryngeus-recurrens-Parese routinemasig eingesetzt. Durch die subplatysmale Dissektion ergab sich ein optimales Operationsfeld zur Darstellung von Schilddruse und Nebenschilddrusen. Mehrere kritische Schritte und passende Losungen wurden definiert. 1. Position des Teams und technische Verbesserung durch den Einsatz eines 4K-Laparoskopieturms, der eine bessere Sicht auf die Anatomie ermoglicht, insbesondere bei der Praparation des N. laryngeus recurrens; 2. laterale und kraniale Positionierung der seitlichen Trokare zur Vermeidung einer Lasion des Nervus mentalis; 3. initiale Hydrodissektion des subplatysmalen Raumes; 4. Verwendung eines Dissektors, der schrittweise das Operationsfeld im anterioren zervikalen Bereich schafft; 5. die infrahyoidale Muskulatur wird mithilfe ausen fixierter Haltenahte zuruckgezogen; 6. intraoperatives Neuromonitoring, das routinemasig uber die Trokare oder perkutan durch eine 1 mm Inzision durchgefuhrt wird; 7. Extraktion des Praparates mittels eines Bergebeutels; 8. Drainagen sind moglich, konnen aber bei kleinem Operationsfeld vermieden werden. Die neue TOETVA-Technik ist eine gute Option fur selektierte Patienten, um transorale Schilddrusen- und Nebenschilddrusenoperationen durch den vestibularen pramentalen Zugang zu ermoglichen. Weitere klinische Studien sind notig, um Indikationen und Sicherheit der Technik zu evaluieren.

The incidence of neuroendocrine tumors (NET) increases with age. Lately, the diagnosis of NET was mainly caused by early detection of small NET (

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS). Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann’s procedure) after 24–48 h. Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%). The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

Both liver transplantation (LT) and liver resection (LR) represent curative treatment options for hepatocellular carcinoma (HCC) in patients with liver cirrhosis. In this study, we have compared outcomes between historical and more recent patient cohorts scheduled either for LT or LR, respectively. Clinicopathological data of all patients with HCC and cirrhosis who underwent LT or LR between 1989 and 2011 were evaluated. Overall survival of patients with HCC within the Milan criteria (MC) was analyzed focusing on changes between different time periods. In total, 364 and 141 patients underwent LT and LR for HCC in cirrhosis, respectively. Among patients with HCC within MC, 214 and 59 underwent LT and LR, respectively. Postoperative morbidity (37 vs. 11%, P

Major abdominal surgery may lead to a systemic inflammatory response (SIRS) with a risk of organ failure. One possible trigger for a postoperative hepatic dysfunction is an altered hepatic blood flow during SIRS, resulting in a decreased oxygen delivery. This pilot study investigated the role of liver dysfunction measured by the LiMAx test after major abdominal surgery, focussing on open and laparoscopic surgical approaches. We prospectively investigated 25 patients (7 females and 18 males, age range 55–72 years) scheduled for upper abdominal surgery. The LiMAx test, ICG-PDR and duplex sonography were carried out preoperatively, followed by postoperative days (PODs) 1, 3, 5 and 10. Laboratory parameters and clinical parameters were measured daily. Clinical outcome parameters were examined at the end of treatment. The population was divided into group A (laparotomy) versus group B (laparoscopy). LiMAx values decreased significantly on POD 1 (290 µg/kg/h, P

Obesity is linked to inferior transplant outcome. Bariatric surgery (BS) is an established treatment of morbid obesity. We provide an overview on BS in the field of kidney (KT) and liver transplantation (LT). In end-stage renal disease (ESRD) and KT patients, BS seems safe and feasible. Complication rates were slightly higher compared to the non-transplant population, whereas weight loss and improvement of comorbidities were comparable. Sleeve gastrectomy (SG) was the preferred procedure before KT and superior to gastric bypass (GB) in regard to mortality and morbidity. If conducted after KT, both procedures showed comparable results. BS before LT was associated with high complication rates, in particular after GB. Albeit distinct complications, SG conducted after LT showed the best results. Immunosuppression (IS) changes after BS were rare.