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Background: Bipolar sealing devices are routinely used to seal blood vessels. The aim of the study is to evaluate the feasibility and safety of colonic sealing with the use of the bipolar energy devices in rats as model for experimental appendectomy. Methods: Seventy-five male Wistar rats underwent a cecal resection with four different bipolar sealing devices or a linear stapler. The harvesting procedure was performed immediately or at postoperative day (POD) 7. The sealing front bursting pressure (BP) was measured in both groups. At POD7, the resection line was clinically examined and the hydroxyproline (HDP) levels were determined. Hematoxylin and Eosin (H&E) staining was used for histopathological evaluation of the sealing front as well. Results: There was no mortality and no insufficiency. The BPs between the bipolar sealing devices showed no statistical differences. The early phase of the seal (POD 0) provides a low BP with an 30.8% increase until POD 7. The BPs in the stapler group showed significant better values. The hydroxyproline levels did not differ statistically between the groups. Histopathologically, there were more signs of ischemic necrosis in the stapler group than in the sealing devices groups. Conclusion: The resection and sealing of the cecum as an experimental appendectomy model with the use of bipolar energy devices proved feasible and safe in rats. The different energy devices in this study produce comparable results. To justify clinical practice in humans, several studies on the underlying mechanisms of early stage wound healing are needed.

Abstract The analysis of blood plasma or serum as a non-invasive alternative to tissue biopsies is a much-pursued goal in cancer research. Various methods and approaches have been presented to determine a patient’s tumour status, chances of survival, and response to therapy from serum or plasma samples. We established PNB-qPCR (Pooled, Nested, WT-Blocking qPCR), a highly specific nested qPCR with various modifications to detect and quantify minute amounts of circulating tumour DNA (ctDNA) from very limited blood plasma samples. PNB-qPCR is a nested qPCR technique combining ARMS primers, blocking primers, LNA probes, and pooling of multiple first round products for sensitive quantification of the seven most frequent point mutations in KRAS exon 2. Using this approach, we were able to characterize ctDNA and total cell-free DNA (cfDNA) kinetics by selective amplification of KRAS mutated DNA fragments in the blood plasma over the course of tumour resection and the surrounding days. Whereas total cfDNA concentrations increased over the surgical and regenerative process, ctDNA levels showed a different scheme, rising only directly after tumour resection and about three days after the surgery. For the first time, we present insights into the impact of surgery on the release of ctDNA and total cfDNA.

Anastomotic leakage (AL) is a potentially life-threatening complication following colorectal cancer (CRC) resection. In this study, we aimed to unravel longitudinal changes in microbial structure before, during, and after surgery and to determine if microbial alterations may be predictive for risk assessment between sufficient anastomotic healing (AS) and AL prior surgery. We analysed the microbiota of 134 colon mucosal biopsies with 16S rRNA V1-V2 gene sequencing. Samples were collected from three location sites before, during, and after surgery, and patients received antibiotics after the initial collection and during surgery. The microbial structure showed dynamic surgery-related changes at different time points. Overall bacterial diversity and the abundance of some genera such as Faecalibacterium or Alistipes decreased over time, while the genera Enterococcus and Escherichia_Shigella increased. The distribution of taxa between AS and AL revealed significant differences in the abundance of genera such as Prevotella, Faecalibacterium and Phocaeicola. In addition to Phocaeicola, Ruminococcus2 and Blautia showed significant differences in abundance between preoperative sample types. ROC analysis of the predictive value of these genera for AL revealed an AUC of 0.802 (p = 0.0013). In summary, microbial composition was associated with postoperative outcomes, and the abundance of certain genera may be predictive of postoperative complications., (© 2024. The Author(s).)

Hyperspectral imaging (HSI) is a non-invasive and contactless technique that enables the real-time acquisition of comprehensive information on tissue within the surgical field. In this pilot study, we investigated whether a new HSI system for minimally-invasive surgery, TIVITA ® Mini (HSI-MIS), provides reliable insights into tissue perfusion of the proximal and distal esophagogastric anastomotic sites during 21 laparoscopic/thoracoscopic or robotic Ivor Lewis esophagectomies of patients with cancer to minimize the risk of dreaded anastomotic insufficiency. In this pioneering investigation, physiological tissue parameters were derived from HSI measurements of the proximal site of the anastomosis (esophageal stump) and the distal site of the anastomosis (tip of the gastric conduit) during the thoracic phase of the procedure. Tissue oxygenation (StO 2 ), Near Infrared Perfusion Index (NIR-PI), and Tissue Water Index (TWI) showed similar median values at both anastomotic sites. Significant differences were observed only for NIR-PI (median: 76.5 vs. 63.9; p = 0.012) at the distal site (gastric conduit) compared to our previous study using an HSI system for open surgery. For all 21 patients, reliable and informative measurements were attainable, confirming the feasibility of HSI-MIS to assess anastomotic viability. Further studies on the added benefit of this new technique aiming to reduce anastomotic insufficiency are warranted.

Purpose: Coronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany., Methods: This is a retrospective population-wide analysis of hospital billing data (2012-2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic., Results: Of a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%)., Conclusion: During lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection., (© 2023. The Author(s).)

Introduction: Intraoperative near-infrared fluorescence angiography with indocyanine green (ICG-FA) is a well-established modality in gastrointestinal surgery. Its main drawback is the application of a fluorescent agent with possible side effects for patients. The goal of this review paper is the presentation of alternative, non-invasive optical imaging methods and their comparison with ICG-FA., Material and Methods: The principles of ICG-FA, spectral imaging, imaging photoplethysmography (iPPG), and their applications in gastrointestinal surgery are described based on selected published works., Results: The main applications of the three modalities are the evaluation of tissue perfusion, the identification of risk structures, and tissue segmentation or classification. While the ICG-FA images are mainly evaluated visually, leading to subjective interpretations, quantitative physiological parameters and tissue segmentation are provided in spectral imaging and iPPG. The combination of ICG-FA and spectral imaging is a promising method., Conclusions: Non-invasive spectral imaging and iPPG have shown promising results in gastrointestinal surgery. They can overcome the main drawbacks of ICG-FA, i.e. the use of contrast agents, the lack of quantitative analysis, repeatability, and a difficult standardization of the acquisition. Further technical improvements and clinical evaluations are necessary to establish them in daily clinical routine.

Purpose: Superficial surgical site infections (SSI) are a common complication after abdominal surgery. Additionally, multidrug-resistant organisms (MDRO) have shown an increasing spread in recent years with a growing importance for health care. As there is varying evidence on the importance of MDRO in different surgical fields and countries as causative agents of SSI, we report our findings of MDRO-caused SSI., Methods: We assembled an institutional wound register spanning the years 2015-2018 including all patients with abdominal surgery and SSI only, including demographics, procedure-related data, microbiological data from screenings, and body fluid samples. The cohort was examined for the frequency of different MDRO in screenings, body fluids, and wound swabs and assessed for risk factors for MDRO-positive SSI., Results: A total of 138 out of 494 patients in the register were positive for MDRO, and of those, 61 had an MDRO isolated from their wound, mainly multidrug-resistant Enterobacterales (58.1%) followed by vancomycin-resistant Enterococcus spp. (19.7%). As 73.2% of all MDRO-carrying patients had positive rectal swabs, rectal colonization could be identified as the main risk factor for an SSI caused by a MDRO with an odds ratio (OR) of 4.407 (95% CI 1.782-10.896, p = 0.001). Secondly, a postoperative ICU stay was also associated with an MDRO-positive SSI (OR 3.73; 95% CI 1.397-9.982; p = 0.009)., Conclusion: The rectal colonization status with MDRO should be taken into account in abdominal surgery regarding SSI prevention strategies. Trial registration Retrospectively registered in the German register for clinical trials (DRKS) 19th December 2019, registration number DRKS00019058., (© 2023. The Author(s).)

Background: Hyperspectral Imaging (HSI) is a reliable and safe imaging method for taking intraoperative perfusion measurements. This is the first study translating intraoperative HSI to an in vivo laparoscopic setting using a CE-certified HSI-system for minimally invasive surgery (HSI-MIS). We aim to compare it to an established HSI-system for open surgery (HSI-Open)., Methods: Intraoperative HSI was done using the HSI-MIS and HSI-Open at the Region of Interest (ROI). 19 patients undergoing gastrointestinal resections were analyzed in this study. The HSI-MIS-acquired images were aligned with those from the HSI-Open, and spectra and parameter images were compared pixel-wise. We calculated the Mean Absolute Error (MAE) for Tissue Oxygen Saturation (StO 2 ), Near-Infrared Perfusion Index (NIR-PI), Tissue Water Index (TWI), and Organ Hemoglobin Index (OHI), as well as the Root Mean Squared Error (RMSE) over the whole spectrum. Our analysis of parameters was optimized using partial least squares (PLS) regression. Two experienced surgeons carried out an additional color-change analysis, comparing the ROI images and deciding whether they provided the same (acceptable) or different visual information (rejected)., Results: HSI and subsequent image registration was possible in 19 patients. MAE results for the original calculation were StO 2 orig. 17.2% (± 7.7%) , NIR-PI orig.  16.0 (± 9.5), TWI orig.  18.1 (± 7.9), OHI orig.  14.4 (± 4.5). For the PLS calculation, they were StO 2 PLS  12.6% (± 5.2%), NIR-PI PLS  10.3 (± 6.0), TWI PLS  10.6 (± 5.1), and OHI PLS  11.6 (± 3.0). The RMSE between both systems was 0.14 (± 0.06). In the color-change analysis; both surgeons accepted more images generated using the PLS method., Conclusion: Intraoperative HSI-MIS is a new technology and holds great potential for future applications in surgery. Parameter deviations are attributable to technical differences and can be reduced by applying improved calculation methods. This study is an important step toward the clinical implementation of HSI for minimally invasive surgery., (© 2023. The Author(s).)

Background: Recent studies have shown that hyperspectral imaging (HSI) combined with neural networks can detect colorectal cancer. Usually, different pre-processing techniques (e.g., wavelength selection and scaling, smoothing, denoising) are analyzed in detail to achieve a well-trained network. The impact of post-processing was studied less., Methods: We tested the following methods: (1) Two pre-processing techniques (Standardization and Normalization), with (2) Two 3D-CNN models: Inception-based and RemoteSensing (RS)-based, with (3) Two post-processing algorithms based on median filter: one applies a median filter to a raw predictions map, the other applies the filter to the predictions map after adopting a discrimination threshold. These approaches were evaluated on a dataset that contains ex vivo hyperspectral (HS) colorectal cancer records of 56 patients., Results: (1) Inception-based models perform better than RS-based, with the best results being 92% sensitivity and 94% specificity; (2) Inception-based models perform better with Normalization, RS-based with Standardization; (3) Our outcomes show that the post-processing step improves sensitivity and specificity by 6.6% in total. It was also found that both post-processing algorithms have the same effect, and this behavior was explained., Conclusion: HSI combined with tissue classification algorithms is a promising diagnostic approach whose performance can be additionally improved by the application of the right combination of pre- and post-processing.

Objective: This NEUROmonitoring System (NEUROS) trial assessed whether pelvic intraoperative neuromonitoring (pIONM) could improve urogenital and ano-(neo-)rectal functional outcomes in patients who underwent total mesorectal excisions (TMEs) for rectal cancer., Background: High-level evidence from clinical trials is required to clarify the benefits of pIONM., Methods: NEUROS was a 2-arm, randomized, controlled, multicenter clinical trial that included 189 patients with rectal cancer who underwent TMEs at 8 centers, from February 2013 to January 2017. TMEs were performed with pIONM (n=90) or without it (control, n=99). The groups were stratified according to neoadjuvant chemoradiotherapy and sex, with blocks of variable length. Data were analyzed according to a modified intention-to-treat protocol. The primary endpoint was a urinary function at 12 months after surgery, assessed with the International Prostate Symptom Score, a patient-reported outcome measure. Deterioration was defined as an increase of at least 5 points from the preoperative score. Secondary endpoints were sexual and anorectal functional outcomes, safety, and TME quality., Results: The intention-to-treat analysis included 171 patients. Marked urinary deterioration occurred in 22/171 (13%) patients, with significantly different incidence between groups (pIONM: n=6/82, 8%; control: n=16/89, 19%; 95% confidence interval, 12.4-94.4; P =0.0382). pIONM was associated with better sexual and ano-(neo)rectal function. At least 1 serious adverse event occurred in 36/88 (41%) in the pIONM group and 53/99 (54%) in the control group, none associated with the study treatment. The groups had similar TME quality, surgery times, intraoperative complication incidence, and postoperative mortality., Conclusion: pIONM is safe and has the potential to improve functional outcomes in rectal cancer patients undergoing TME., Competing Interests: W.K., D.W.K., and H.L. are involved in patents, as part of the university service inventions for pIONM (DE 10 2010 019 796 B4; EP 2589410 B1). The remaining authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Colon conduit is an alternative approach to reconstructing the alimentary tract after esophagectomy. Hyperspectral imaging (HSI) has been demonstrated to be effective for evaluating the perfusion of gastric conduits, but not colon conduits. This is the first study to describe this new tool addressing image-guided surgery and supporting esophageal surgeons to select the optimal colon segment for the conduit and anastomotic site intraoperatively., Patients and Methods: Of 10 patients, eight who underwent reconstruction with a long-segment colon conduit after esophagectomy between 01/05/2018 and 01/04/2022 were included in this study. HSI was recorded at the root and tip of the colon conduit after clamping the middle colic vessels, allowing us to evaluate the perfusion and appropriate part of the colon segment., Results: Anastomotic leak (AL) was detected in only one (12.5%) of all the enrolled patients (n = 8). None of the patients developed conduit necrosis. Only one patient required re-anastomosis on postoperative day 4. No patient needed conduit removal, esophageal diversion, or stent placement. There was a change in the anastomosis site to proximal in two patients intraoperatively. There was no need to change the side of colon conduit intraoperatively in any patient., Conclusion: HSI is a promising and novel intraoperative imaging tool to objectively assess the perfusion of the colon conduit. It helps the surgeon to define the best perfused anastomosis site and the side of colon conduit in this type of operation., (© 2023. The Author(s).)

Purpose: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new, palliative approach for patients with peritoneal surface malignancies (PSMs). Its main goals are to control symptoms and ascites. For this experimental procedure, treatment efficacy and patient safety need to be closely monitored., Methods: We performed a prospective registry study for patients with PSMs. Cisplatin (C) (7.5 mg/m 2 body surface) and doxorubicin (D) (1.5 mg/m 2 ) were administered laparoscopically via PIPAC., Results: Between November 2015 and June 2020, we recorded data from 108 patients and 230 scheduled procedures. Tumor burden, patient fitness, quality of life, operating time and in-hospital stay remained stable over consecutive procedures. We recorded 21 non-access situations and 14 intraoperative complications (11 intestinal injuries, and three aspirations while inducing anesthesia). Three or more previous abdominal surgeries or cytoreductive surgery (CRS) with intraperitoneal hyperthermic chemoperfusion (HIPEC) were risk factors for non-access and intestinal injuries (χ 2 , p ≤ 0.01). Five Grade IV and three Grade V postoperative complications according to the Clavien-Dindo Classification (CDC) occurred. Median overall survival was 264 days (interquartile range 108-586). Therapies were primarily discontinued because of death (34%), progressive (26%), or regressive (16%) disease., Conclusion: PIPAC is effective in stabilizing PSMs and retaining quality of life in selected patients. Earlier abdominal surgeries and CRS with HIPEC should be considered when determining the indication for PIPAC. Randomized controlled studies are needed to evaluate PIPAC's therapeutic benefits compared to systemic chemotherapy (sCHT) alone., Trial Registration: NCT03100708 (April 2017)., (© 2022. The Author(s).)

Background: Low anterior resection for rectal cancer is commonly associated with a diverting stoma. In general, the stoma is closed 3 months after the initial operation. The diverting stoma reduces the rate of anastomotic leakage as well as the severeness of a potential leakage itself. Nevertheless, anastomotic leakage is still a life-threatening complication and might reduce the quality of life in the short and long term. In case of leakage, the construction can be converted into a Hartmann situation or it could be treated by endoscopic vacuum therapy or by leaving the drains. In recent years, endoscopic vacuum therapy has become the treatment of choice in many institutions. In this study, the hypothesis is to be evaluated, if a prophylactic endoscopic vacuum therapy reduces the rate of anastomotic leakage after rectal resections., Methods: A multicenter parallel group randomized controlled trial is planned in as many as possible centers in Europe. The study aims to recruit 362 analyzable patients with a resection of the rectum combined with a diverting ileostoma. The anastomosis has to be between 2 and 8 cm off the anal verge. Half of these patients receive a sponge for 5 days, and the control group is treated as usual in the participating hospitals. There will be a check for anastomotic leakage after 30 days. Primary end point is the rate of anastomotic leakages. The study will have 60% power to detect a difference of 10%, at a one-sided alpha significance level of 5%, assuming an anastomosis leakage rate of 10%-15%., Discussion: If the hypothesis proves to be true, anastomosis leakage could be reduced significantly by placing a vacuum sponge over the anastomosis for 5 days., Trial Registration: The trial is registered at DRKS: DRKS00023436. It has been accredited by Onkocert of the German Society of Cancer: ST-D483. The leading Ethics Committee is the Ethics Committee of Rostock University with the registration ID A 2019-0203., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Schiffmann, Becker, Develing, Varga-Szabo, Scheidereiter-Krüger, Zirngibl, Seifert, Biermann, Schlüter, Tumczak, Weimann, Jansen-Winkeln, Wallstabe, Schwandner, Denecke, Schafmayer, Kamaleddine, Stier, Haegele, Kindler, Michling, Horling and Denzer.)

Problem: Similarity measures are widely used as an approved method for spectral discrimination or identification with their applications in different areas of scientific research. Even though a range of works have been presented, only a few showed slightly promising results for human tissue, and these were mostly focused on pathological and non-pathological tissue classification., Methods: In this work, several spectral similarity measures on hyperspectral (HS) images of in vivo human tissue were evaluated for tissue discrimination purposes. Moreover, we introduced two new hybrid spectral measures, called SID-JM-TAN(SAM) and SID-JM-TAN(SCA). We analyzed spectral signatures obtained from 13 different human tissue types and two different materials (gauze, instruments), collected from HS images of 100 patients during surgeries., Results: The quantitative results showed the reliable performance of the different similarity measures and the proposed hybrid measures for tissue discrimination purposes. The latter produced higher discrimination values, up to 6.7 times more than the classical spectral similarity measures. Moreover, an application of the similarity measures was presented to support the annotations of the HS images. We showed that the automatic checking of tissue-annotated thyroid and colon tissues was successful in 73% and 60% of the total spectra, respectively. The hybrid measures showed the highest performance. Furthermore, the automatic labeling of wrongly annotated tissues was similar for all measures, with an accuracy of up to 90%., Conclusion: In future work, the proposed spectral similarity measures will be integrated with tools to support physicians in annotations and tissue labeling of HS images.

Background: Intraoperative imaging assists surgeons during minimally invasive procedures. Hyperspectral imaging (HSI) is a noninvasive and noncontact optical technique with great diagnostic potential in medicine. The combination with artificial intelligence (AI) approaches to analyze HSI data is called intelligent HSI in this article., Objective: What are the medical applications and advantages of intelligent HSI for minimally invasive visceral surgery?, Material and Methods: Within various clinical studies HSI data from multiple in vivo tissue types and oncological resections were acquired using an HSI camera system. Different AI algorithms were evaluated for detection and discrimination of organs, risk structures and tumors., Results: In an experimental animal study 20 different organs could be differentiated with high precision (> 95%) using AI. In vivo, the parathyroid glands could be discriminated from surrounding tissue with an F1 score of 47% and sensitivity of 75%, and the bile duct with an F1 score of 79% and sensitivity of 90%. Furthermore, ex vivo tumor tissue could be successfully detected with an area under the receiver operating characteristic (ROC) curve (AUC) larger than 0.91., Discussion: This study demonstrates that intelligent HSI can automatically and accurately detect different tissue types. Despite great progress in the last decade intelligent HSI still has limitations. Thus, accurate AI algorithms that are easier to understand for the user and an extensive standardized and continuously growing database are needed. Further clinical studies should support the various medical applications and lead to the adoption of intelligent HSI in the clinical routine practice., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Hyperspectral imaging (HSI) during surgical procedures is a new method for perfusion quantification and tissue discrimination. Its use has been limited to open surgery due to large camera sizes, missing color video, or long acquisition times. A hand-held, laparoscopic hyperspectral camera has been developed now to overcome those disadvantages and evaluated clinically for the first time., Methods: In a clinical evaluation study, gastrointestinal resectates of ten cancer patients were investigated using the laparoscopic hyperspectral camera. Reference data from corresponding anatomical regions were acquired with a clinically approved HSI system. An image registration process was executed that allowed for pixel-wise comparisons of spectral data and parameter images (StO 2 : oxygen saturation of tissue, NIR PI: near-infrared perfusion index, OHI: organ hemoglobin index, TWI: tissue water index) provided by both camera systems. The mean absolute error (MAE) and root mean square error (RMSE) served for the quantitative evaluations. Spearman's rank correlation between factors related to the study design like the time of spectral white balancing and MAE, respectively RMSE, was calculated., Results: The obtained mean MAEs between the TIVITA® Tissue and the laparoscopic hyperspectral system resulted in StO 2 : 11% ± 7%, NIR PI: 14±3, OHI: 14± 5, and TWI: 10 ± 2. The mean RMSE between both systems was 0.1±0.03 from 500 to 750 nm and 0.15 ±0.06 from 750 to 1000 nm. Spearman's rank correlation coefficients showed no significant correlation between MAE or RMSE and influencing factors related to the study design., Conclusion: Qualitatively, parameter images of the laparoscopic system corresponded to those of the system for open surgery. Quantitative deviations were attributed to technical differences rather than the study design. Limitations of the presented study are addressed in current large-scale in vivo trials., (© 2022. The Author(s).)

Objectives: Hand-sewn and stapled intestinal anastomoses are both daily performed routine procedures by surgeons. Yet, differences in micro perfusion of these two surgical techniques and their impact on surgical outcomes are still insufficiently understood. Only recently, hyperspectral imaging (HSI) has been established as a non-invasive, contact-free, real-time assessment tool for tissue oxygenation and micro-perfusion. Hence, objective of this study was HSI assessment of different intestinal anastomotic techniques and analysis of patients' clinical outcome., Methods: Forty-six consecutive patients with an ileal-ileal anastomoses were included in our study; 21 side-to-side stapled and 25 end-to-end hand-sewn. Based on adsorption and reflectance of the analyzed tissue, chemical color imaging indicates oxygen saturation (StO 2 ), tissue perfusion (near-infrared perfusion index [NIR]), organ hemoglobin index (OHI), and tissue water index (TWI)., Results: StO 2 as well as NIR of the region of interest (ROI) was significantly higher in stapled anastomoses as compared to hand-sewn ileal-ileal anastomoses (StO 2 0.79 (0.74-0.81) vs. 0.66 (0.62-0.70); p<0.001 NIR 0.83 (0.70-0.86) vs. 0.70 (0.63-0.76); p=0.01). In both groups, neither anastomotic leakage nor abdominal septic complications nor patient death did occur., Conclusions: Intraoperative HSI assessment is able to detect significant differences in tissue oxygenation and NIR of hand-sewn and stapled intestinal anastomoses. Long-term clinical consequences resulting from the reduced tissue oxygenation and tissue perfusion in hand-sewn anastomoses need to be evaluated in larger clinical trials, as patients may benefit from further refined surgical techniques., Competing Interests: Competing interests: Authors state no conflict of interest., (© 2022 the author(s), published by De Gruyter, Berlin/Boston.)

Anastomotic insufficiencies still represent one of the most severe complications in colorectal surgery. Since tissue perfusion highly affects anastomotic healing, its objective assessment is an unmet clinical need. Indocyanine green-based fluorescence angiography (ICG-FA) and hyperspectral imaging (HSI) have received great interest in recent years but surgeons have to decide between both techniques. For the first time, two data processing pipelines capable of reconstructing an ICG-FA correlating signal from hyperspectral data were developed. Results were technically evaluated and compared to ground truth data obtained during colorectal resections. In 87% of 46 data sets, the reconstructed images resembled the ground truth data. The combined applicability of ICG-FA and HSI within one imaging system might provide supportive and complementary information about tissue vascularization, shorten surgery time, and reduce perioperative mortality., Competing Interests: The authors declare no conflicts of interest., (© 2022 Optica Publishing Group under the terms of the Optica Open Access Publishing Agreement.)

Background: A perfusion deficit is a well-defined and intraoperatively influenceable cause of anastomotic leak (AL). Current intraoperative perfusion assessment methods do not provide objective and quantitative results. In this study, the ability of hyperspectral imaging (HSI) to quantify tissue oxygenation intraoperatively was assessed., Methods: 115 patients undergoing colorectal resections were included in the final analysis. Before anastomotic formation, the bowel was extracted and the resection line was outlined and imaged using a compact HSI camera, in order to provide instantaneously quantitative perfusion assessment., Results: In 105 patients, a clear demarcation line was visible with HSI one minute after marginal artery transection, reaching a plateau after 3 min. In 58 (55.2%) patients, the clinically determined transection line matched with HSI. In 23 (21.9%) patients, the clinically established resection margin was entirely within the less perfused area. In 24 patients (22.8%), the HSI transection line had an irregular course and crossed the clinically established resection line. In four cases, HSI disclosed a clinically undetected lesion of the marginal artery., Conclusions: Intraoperative HSI is safe, well reproducible, and does not disrupt the surgical workflow. It also quantifies bowel surface perfusion. HSI might become an intraoperative guidance tool, potentially preventing postoperative complications.

Innovations and new advancements in intraoperative real-time imaging have gained significant importance in the field of gastric cancer surgery in the recent past. Currently, the most promising procedures include indocyanine green fluorescence imaging (ICG-FI) and hyperspectral imaging or multispectral imaging (HSI, MSI). ICG-FI is utilized in a broad range of clinical applications, e.g., assessment of perfusion or lymphatic drainage, and additional implementations are currently investigated. HSI is still in the experimental phase and its value and clinical relevance require further evaluation, but initial studies have shown a successful application in perfusion assessment, and prospects concerning non-invasive tissue and tumor classification are promising. The application of machine learning and artificial intelligence technologies might enable an automatic evaluation of the acquired image data in the future. Both methods facilitate the accurate visualization of tissue characteristics that are initially indistinguishable for the human eye. By aiding surgeons in optimizing the surgical procedure, image-guided surgery can contribute to the oncologic safety and reduction of complications in gastric cancer surgery and recent advances hold promise for the application of HSI in intraoperative tissue diagnostics.

Background: Superficial surgical site infections (SSSIs) are a major reason for morbidity after abdominal surgery. Microbiologic isolates of SSSIs vary widely geographically. Therefore, knowledge about the specific bacterial profile is of paramount importance to prevent SSSI., Methods: We performed a subgroup analysis of the microbiological isolates from patients with SSSI after abdominal surgery that were included in our institutional wound register. We aimed at identifying predominant strains as well as risk factors that would predispose for SSSI with certain bacteria., Results: A total of 494 patients were eligible for analysis. Of those 313 had received wound swaps, with 268 patients yielding a bacterial isolate. Enterobacterales (31.7%) and Enterococcus spp. (29.5%) were found as main bacteria in SSSI, with 62.3% of the wounds being polymicrobial. As risk factors for changes in bacterial isolates, we identified operative revision (OR 3.032; 95%CI 1.734-5.303) in multivariate analysis. Enterococcus spp. showed a significant increase in patients after revision surgery (p<0.001). Antibiotic therapy was neither influential on bacterial changes nor on the presence of Enterococcus spp. in SSSI., Conclusion: Our study accentuates the high frequency of Enterococcus spp. in SSSI after abdominal surgery, while identifying surgical revision as major risk factor. The results urge vigilance in the treatment of patients with surgical revisions to include Enterococcus spp. in the prevention and treatment strategies., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: Novel intraoperative imaging techniques, namely, hyperspectral (HSI) and fluorescence imaging (FI), are promising with respect to reducing severe postoperative complications, thus increasing patient safety. Both tools have already been used to evaluate perfusion of the gastric conduit after esophagectomy and before anastomosis. To our knowledge, this is the first study evaluating both modalities simultaneously during esophagectomy., Methods: In our pilot study, 13 patients, who underwent Ivor Lewis esophagectomy and gastric conduit reconstruction, were analyzed prospectively. HSI and FI were recorded before establishing the anastomosis in order to determine its optimum position., Results: No anastomotic leak occurred during this pilot study. In five patients, the imaging methods resulted in a more peripheral adaptation of the anastomosis. There were no significant differences between the two imaging tools, and no adverse events due to the imaging methods or indocyanine green (ICG) injection occurred., Conclusions: Simultaneous intraoperative application of both modalities was feasible and not time consuming. They are complementary with regard to the ideal anastomotic position and may contribute to better surgical outcomes. The impact of their simultaneous application will be proven in consecutive prospective trials with a large patient cohort.

Introduction: Due to the current COVID-19 pandemic, surgical training has become increasingly challenging due to required social distancing. Therefore, the use of virtual reality (VR)-simulation could be a helpful tool for imparting surgical skills, especially in minimally invasive environments. Visual spatial ability (VSA) might influence the learning curve for laparoscopic surgical skills. However, little is known about the influence of VSA for surgical novices on VR-simulator training regarding the complexity of different tasks over a long-term training period. Our study evaluated prior VSA and VSA development in surgical trainees during VR-simulator training, and its influence on surgical performance in simulator training., Methods: In our single-center prospective two-arm randomized trial, VSA was measured with a tube figure test before curriculum training. After 1:1 randomization, the training group (TG) participated in the entire curriculum training consisting of 48 different VR-simulator tasks with varying difficulty over a continuous nine-day training session. The control group (CG) performed two of these tasks on day 1 and 9. Correlation and regression analyses were used to assess the influence of VSA on VR-related surgical skills and to measure procedural abilities., Results: Sixty students (33 women) were included. Significant improvements in the TG in surgical performance and faster completion times were observed from days 1 to 9 for the scope orientation 30° right-handed (SOR), and cholecystectomy dissection tasks after the structured 9-day training program. After training, the TG with pre-existing low VSA scores achieved performance levels similar to those with pre-existing high VSA scores for the two VR simulator tasks. Significant correlations between VSA and surgical performance on complex laparoscopic camera navigation SOR tasks were found before training., Conclusions: Our study revealed that that all trainees improved their surgical skills irrespective of previous VSA during structured VR simulator training. An increase in VSA resulted in improvements in surgical performance and training progress, which was more distinct in complex simulator tasks. Further, we demonstrated a positive relationship between VSA and surgical performance of the TG, especially at the beginning of training. Our results identified pre-existing levels of VSA as a predictor of surgical performance., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

In-depth characterization has introduced new molecular subtypes of gastric cancer (GC). To identify these, new approaches and techniques are required. Liquid biopsies are trendsetting and provide an easy and feasible method to identify and to monitor GC patients. In a prospective cohort of 87 GC patients, extracellular vesicles (EVs) were isolated from 250 µL of plasma. The total RNA was isolated with TRIZOL. The total RNA amount and the relative mRNA levels of CD44, PTEN, and FASN were measured by qRT-PCR. The isolation of EVs and their contained mRNA was possible in all 87 samples investigated. The relative mRNA levels of PTEN were higher in patients already treated by chemotherapy than in chemo-naïve patients. In patients who had undergone neoadjuvant chemotherapy followed by gastrectomy, a decrease in the total RNA amount was observed after neoadjuvant chemotherapy and gastrectomy, while FASN and CD44 mRNA levels decreased only after gastrectomy. The amount of RNA and the relative mRNA levels of FASN and CD44 in EVs were affected more significantly by chemotherapy and gastrectomy than by chemotherapy alone. Therefore, they are a potential biomarker for monitoring treatment response. Future analyses are needed to identify GC-specific key RNAs in EVs, which could be used for the diagnosis of gastric cancer patients in order to determine their molecular subtype and to accompany the therapeutic response.

Hyperspectral imaging (HSI) is a novel optical imaging modality, which has recently found diverse applications in the medical field. HSI is a hybrid imaging modality, combining a digital photographic camera with a spectrographic unit, and it allows for a contactless and non-destructive biochemical analysis of living tissue. HSI provides quantitative and qualitative information of the tissue composition at molecular level in a contrast-free manner, hence making it possible to objectively discriminate between different tissue types and between healthy and pathological tissue. Over the last two decades, HSI has been increasingly used in the medical field, and only recently it has found an application in the operating room. In the last few years, several research groups have used this imaging modality as an intraoperative guidance tool within different surgical disciplines. Despite its great potential, HSI still remains far from being routinely used in the daily surgical practice, since it is still largely unknown to most of the surgical community. The aim of this study is to provide clinical surgeons with an overview of the capabilities, current limitations, and future directions of HSI for intraoperative guidance.

The accurate detection of malignant tissue during colorectal surgery impacts operation outcome. The non-invasive spectral imaging combined with machine learning (ML) methods showed to be promising for tumor identification. However, large spectral range implies large computing time. To reduce the number of features, ML methods (e.g. logistic regression and convolutional neuronal network CNN) were evaluated based on four physiological tissue parameters to automatically classify cancer and healthy mucosa in resected colon tissue. A ROC AUC of 0.81 was achieved with the CNN. This study shows that the use of only specific wavelengths bands can detect cancer.Clinical Relevance- These outcomes support the possibility to automatically classify colon tumor based on physiological parameters calculated using only specific wavelength bands. Hence, future image-guided colorectal surgeries can be performed with real-time multispectral imaging.

Background: Incisional negative wound pressure therapy (iNPWT) is a relatively novel dressing technique with the aim of reducing postoperative wound infections and dehiscence in high-risk wounds after all kinds of surgical procedures. There is a lack of theoretical knowledge about the way those dressing would ameliorate wound healing. One aspect is the reduction of superficial tension, but significant remaining seroma might still cause deep wound infections. The aim of this study was the evaluation of technical modifications of the standard iNPWT dressing to increase seroma evacuation., Methods: iNPWT dressings were applied on the porcine abdominal wall, and an incremental pressure ramp from 50 to 200 mmHg was performed. The resulting wound pressures were measured using (i) balloon manometry and (ii) esophageal manometry catheter. Seroma evacuation was analyzed with a seroma model. All measurements were performed with (i) standard iNPWT dressing, (ii) wound gauze diverted through the incision, and (iii) placement of suction drain tube into iNPWT., Results: Due to the modifications of the iNPWT dressing, the vacuum applied by the iNPWT dressing could be transferred into the wound and was not only restricted to superficial layers. More importantly, placement of wound gauzes or suction drain tubes led to complete extraction of wound seroma. The placement of the suction drain tube showed the best combination of increased intrawound pressure as well as seroma evacuation., Conclusion: Addition of a suction drain tube to the iNPWT dressing leads to an improved function of the iNPWT dressing in our ex vivo model., Competing Interests: The authors have no conflict of interest to declare in relation to this study., (Copyright © 2021 Matthias Mehdorn and Boris Jansen-Winkeln.)

Introduction: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a challenging operation. Especially the mobilization of the pouch into the pelvis can be complex. Adequate perfusion of the pouch is required for optimal healing and functioning., Methods: With hyperspectral imaging (HSI) wavelengths between 500 and 1,000 nm can be analyzed in addition to visible light and by reflecting patterns. This intraoperative procedure is non-invasive, contact-free, and no contrast medium is needed. Fifteen patients undergoing IPAA were examined prospectively, and the pouch was evaluated by HSI intraoperatively. HSI was measured in standardized fashion at 4 defined locations of the J-pouch. Each measurement took about 10 s. The clinical postoperative course was assessed in all patients and correlated to the intraoperative HSI findings., Results: Mean near-infrared perfusion and oxygenation of patients showed values ≥74% for all defined pouch areas, revealing good blood supply. Three minor anastomotic leaks were detected by standard pouchoscopy in the postoperative course, which could be treated conservatively with endosponge therapy., Conclusion: HSI values of perfusion and oxygenation of the IPAA were high. The leak rate is associated with redo procedures. This is reflected by the current literature and most likely related to the higher complexity of the revisional pouch operation. HSI has proved itself as a quick and effective new intraoperative tool to evaluate pouch perfusion objectively and quantitatively., Competing Interests: All authors have no competing interests, except Hannes Koehler − he is an employee of the company “Diaspective vision,” the manufacturer of the used hyperspectral camera., (Copyright © 2021 by S. Karger AG, Basel.)