[Minimally Invasive Techniques for Anastomosis in the Gastrointestinal Tract]

Aufgrund des zunehmenden Einsatzes der Robotik im Bereich der Chirurgie des Gastrointestinaltraktes bietet dieser Beitrag einen Leitfaden zu unterschiedlichen Anastomosentechniken bei der robotisch assistierten transthorakalen Ivor-Lewis-Ösophagektomie (RAMIE), der robotisch assistierten onkologischen Gastrektomie (RAMIG) sowie der robotischen Hemikolektomie rechts. Es werden die relevanten Operationsschritte dargestellt mit Fokus auf die verschiedenen Rekonstruktionen mittels robotisch assistierter Naht oder Verwendung eines Stapler Devices.

Die onkologische Entscheidungsfindung und insbesondere die Wahl der chirurgischen Therapie und das Ausmaß der Resektion hängen immer von der Lokalisation des Tumors, der Histologie und den individuellen Risikofaktoren des Patienten ab. Beim Magenkarzinom im Stadium ≥ IB wird ein multimodales Vorgehen empfohlen, das eine perioperative Chemotherapie in Kombination mit einer chirurgischen Resektion mit kurativer Absicht umfasst. Für Patienten mit lokal fortgeschrittenen Adenokarzinomen oder Plattenepithelkarzinomen des Ösophagus ist die multimodale Behandlung heute ebenfalls der Goldstandard. Nach Abschluss der neoadjuvanten Vorbehandlung sowie Durchführung eines Re-Stagings erfolgt komplettierend die operative Resektion.

Bei dem nicht metastasierten Kolonkarzinom ist eine primäre radikale onkologische Resektion im Sinne eines kurativen Therapiekonzeptes durchzuführen, gefolgt von einer adjuvanten Therapie bei fortgeschrittenem Befund.

Dieses Manuskript sowie das begleitende Video erläutern die Rekonstruktionstechnik nach RAMIG sowohl als robotisch genähte Technik mittels V-Lock-3–0-Nähten als auch die Rekonstruktion mittels Linearstapler als alternative Technik. Für die RAMIE wird die Rekonstruktion mittels Zirkularstapler und intrathorakaler Anastomose als Standard gezeigt. Für die robotische Hemikolektomie wird eine Rekonstruktion mittels Linearstapler gezeigt.

Verschiedene Möglichkeiten der robotischen Rekonstruktion sowohl nach robotischer Gastrektomie, nach robotischer Hemikolektomie als auch nach robotischer Ösophagektomie beinhalten robotisch genähte Techniken sowie die Anwendung von Stapler Devices. Eine Evidenz zum Vergleich der verschiedenen Techniken, insbesondere in der robotischen Chirurgie im Gastrointestinaltrakt, fehlt bislang, die Methoden zeigen sich in der klinischen Anwendung jedoch sicher durchführbar mit guten postoperativen Ergebnissen. Kommende Studien werden sich einem Vergleich der unterschiedlichen Rekonstruktionsmethoden in der robotischen Chirurgie widmen.

Navigated laparoscopic microwave ablation of tumour mimics in pig livers: a randomized ex-vivo experimental trial

BACKGROUND

In order to efficiently perform laparoscopic microwave ablation of liver tumours precise positioning of the ablation probe is mandatory. This study evaluates the precision and ablation accuracy using the innovative laparoscopic stereotactic navigation system CAS-One-SPOT in comparison to 2d ultrasound guided laparoscopic ablation procedures.

METHODS

In a pig liver ablation model four surgeons, experienced (n = 2) and inexperienced (n = 2) in laparoscopic ablation procedures, were randomized for 2d ultrasound guided laparoscopic or stereotactic navigated laparoscopic ablation procedures. Each surgeon performed a total of 20 ablations. Total attempts of needle placements, time from tumor localization till beginning of ablation and ablation accuracy were analyzed.

RESULTS

The use of the laparoscopic stereotactic navigation system led to a significant reduction in total attempts of needle placement. The experienced group of surgeons reduced the mean number of attempts from 2.75 ± 2.291 in the 2d ultrasound guided ablation group to 1.45 ± 1.191 (p = 0.0302) attempts in the stereotactic navigation group. Comparable results could be observed in the inexperienced group with a reduction of 2.5 ± 1.50 to 1.15 ± 0.489 (p = 0.0005). This was accompanied by a significant time saving from 101.3 ± 112.1 s to 48.75 ± 27.76 s (p = 0.0491) in the experienced and 165.5 ± 98.9 s to 66.75 ± 21.96 s (p < 0.0001) in the inexperienced surgeon group. The accuracy of the ablation process was hereby not impaired as postinterventional sectioning of the ablation zone revealed.

CONCLUSION

The use of a stereotactic navigation system for laparoscopic microwave ablation procedures of liver tumors significantly reduces the attempts and time of predicted correct needle placement for novices and experienced surgeons without impairing the accuracy of the ablation procedure.

Hand-Assisted Retroperitoneoscopic Donor Nephrectomy Compared to Anterior Approach Open Donor Nephrectomy: Improved Long-Term Physical Component Score in Health-Related Quality of Life in Living Kidney Donors

BACKGROUND

Health-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up.

MATERIAL AND METHODS

This is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA.

RESULTS

This study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population.

CONCLUSIONS

LKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up.

3D vs. 4K Display System - Influence of "State-of-the-art"-Display Technique On Surgical Performance (IDOSP-Study) in minimally invasive surgery: protocol for a randomized cross-over trial

Background

Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual task. The reduction from real life 3D to virtual two-dimensional (2D) sight is a major challenge in minimally invasive surgery (MIS). A 3D display technique has been shown to reduce operation time and mistakes and to improve the learning curve. Therefore, the use of a3D display technique seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics, a 4K display technique was recently introduced to MIS. Due to its high resolution and zoom effect, surgeons should benefit from it. The aim of this study is to evaluate if “state-of-the-art” 3D- vs. 4K-display techniques could influence surgical performance.

Methods

A randomized, cross-over, single-institution, single-blinded trial is designed. It compares the primary outcome parameter “surgical performance”, represented by “performance time ”and “number of mistakes”, using a passive polarizing 3D and a 4K display system (two arms) to perform different tasks in a minimally invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (National Aeronautics and Space Administration (NASA) Task Load Index) and the learning curve. Unexperienced novices (medical students), non-board-certified, and board-certified abdominal surgeons participate in the trial (i.e., level of experience, 3 strata). The parkour consists of seven tasks (for novices, five tasks), which will be repeated three times. The 1st run of the parkour will be performed with the randomized display system, the 2nd run with the other one. After each run, the mental stress load is measured. After completion of the parkour, all participants are evaluated by an ophthalmologist for visual acuity and stereoscopic vision with five tests. Assuming a correlation of 0.5 between measurements per subject, a sample size of 36 per stratum is required to detect a standardized effect of 0.5 (including an additional 5% for a non-parametric approach) with a power of 80% at a two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled.

Discussion

Complex surgical procedures are performed in a minimally invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance.

Trial registration

ClinicalTrials.gov, NCT03445429. Registered on 7 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3330-7) contains supplementary material, which is available to authorized users.

Glomerulocapillary miRNA response to HLA-class I antibody in vitro and in vivo

Changes in miRNA expression glomerular of capillaries during antibody-mediated rejection (ABMR) are poorly understood and could contribute to the deleterious inflammation and fibrosis of ABMR via suppression of target genes. A better understanding could lead to novel diagnostic tools and reveal novel therapeutic targets. We explored deregulated miRNAs in an glomeruloendothelial in vitro model of ABMR due to class I human leukocyte antigen (HLA) with and without complement activation. We studied a set of 16 promising candidate miRNAs in microdissected glomeruli a confirmation set of 20 human transplant biopsies (DSA+) compared to 10 matched controls without evidence for ABMR. Twelve out of these 16 glomerulocapillary miRNAs could successfully be confirmed as dysregulated in vivo with 10 upregulated (let-7c-5p, miR-28-3p, miR-30d-5p, miR-99b-5p, miR-125a-5p, miR-195-5p, miR-374b-3p, miR-484, miR-501-3p, miR-520e) and 2 downregulated (miR29b-3p, miR-885-5p) in DSA+ vs.

CONTROLS

A random forest analysis based on glomerular miRNAs identified 18/20 DSA+ and 8/10 controls correctly. This glomerulocapillary miRNA signature associated with HLA class I-DSA could improve our understanding of ABMR and be useful for diagnostic or therapeutic purposes.

Prospective Analyses of Circulating B Cell Subsets in ABO-Compatible and ABO-Incompatible Kidney Transplant Recipients

Immunosuppressive strategies applied in renal transplantation traditionally focus on T cell inhibition. B cells were mainly examined in the context of antibody-mediated rejection, whereas the impact of antibody-independent B cell functions has only recently entered the field of transplantation. Similar to T cells, distinct B cell subsets can enhance or inhibit immune responses. In this study, we prospectively analyzed the evolution of B cell subsets in the peripheral blood of AB0-compatible (n = 27) and AB0-incompatible (n = 10) renal transplant recipients. Activated B cells were transiently decreased and plasmablasts were permanently decreased in patients without signs of rejection throughout the first year. In patients with histologically confirmed renal allograft rejection, activated B cells and plasmablasts were significantly elevated on day 365. Rituximab treatment in AB0-incompatible patients resulted in long-lasting B cell depletion and in a naïve phenotype of repopulating B cells 1 year following transplantation. Acute allograft rejection was correlated with an increase of activated B cells and plasmablasts and with a significant reduction of regulatory B cell subsets. Our study demonstrates the remarkable effects of standard immunosuppression on circulating B cell subsets. Furthermore, the B cell compartment was significantly altered in rejecting patients. A specific targeting of deleterious B cell subsets could be of clinical benefit in renal transplantation.

Onset and progression of de novo donor-specific anti-human leukocyte antigen antibodies after BK polyomavirus and preemptive immunosuppression reduction

BACKGROUND

BK polyomavirus (BKPyV) viremia/nephropathy and reduction in immunosuppression following viremia may increase the risk of alloimmune activation and allograft rejection. This study investigates the impact of BKPyV viremia on de novo donor anti-human leukocyte antigen (HLA)-specific antibodies (dnDSA).

PATIENTS AND METHODS

All primary renal transplants at East Carolina University from March 1999 to December 2010, with at least 1 post-transplant BKPyV viral load testing, were analyzed. Patients were negative for anti-HLA antibodies to donor antigens (tested via single antigen beads) at transplantation and at first BKPyV testing.

RESULTS

Nineteen of 174 patients (11%) tested positive for BKPyV viremia. Within 24 months of BKPyV viremia detection, 79% of BKPyV-viremic patients developed dnDSA. Only 20% of BKPyV viremia-persistent cases, compared to 86% of BKPyV viremia-resolved cases, developed dnDSA (P = 0.03). Poor allograft survival was evident in BKPyV viremia-persistent patients (60% failure by 2 years post BKPyV diagnosis) and in BKPyV viremia-resolved patients with dnDSA (5-year post BKPyV diagnosis allograft survival of 48%).

CONCLUSIONS

Post-transplant BKPyV viremia and preemptive immunosuppression reduction is associated with high rates of dnDSA. When preemptively treating BKPyV viremia, dnDSA should be monitored to prevent allograft consequences.

25 Years of Kidney Transplantation--A Period of Change

At the University of Cologne Hospital, 1062 kidney transplants in adults and 136 pediatric transplants were performed between 1990 and 2014. Immunosuppressive therapy was changed during this time period from a therapy with anti-lymphocyte globulin induction followed by a triple therapy to a period using induction (IL2 receptor antagonists) followed by low dose tacrolimus, mycophenolate mofetil and steroids. Antiviral therapy has been constant during the 25 years, consisting of ganciclovir or valganciclovir. Major change occurred in the age of donors and recipients, with more than a third of both now being older than 65 years. Living donation has increased in number and proportion, at the same time the number of deceased donors rapidly declined. Longer time periods on dialysis resulted not only in an increased risk profile of the recipients, but were also accompanied by a significantly higher number of mismatches for the allocated kidney, since the relative importance of waiting time in the allocation process increased. Multivariate analysis showed that immunological factors such as HLA-match and panel reactive antibody are relevant factors, even in a single center analysis.

Impact of de novo donor-specific HLA antibodies detected by Luminex solid-phase assay after transplantation in a group of 88 consecutive living-donor renal transplantations

De novo donor-specific HLA antibodies (DSA) after renal transplantation are known to be correlated with poor graft outcome and the development of acute and chronic rejection. Currently, data for the influence of de novo DSA in patient cohorts including only living-donor renal transplantations (LDRT) are limited. A consecutive cohort of 88 LDRT was tested for the occurrence of de novo DSA by utilizing the highly sensitive Luminex solid-phase assay for antibody detection. Data were analyzed for risk factors for de novo DSA development and correlated with acute rejection (AR) and graft function. Patients with de novo DSA [31 (35%)] showed a trend for inferior graft function [mean creatinine change (mg/dL/year) after the first year: 0.15 DSA (+) vs. 0.02 DSA (-) (P = 0.10)] and a higher rate of AR episodes, especially in case of de novo DSA of both class I and II [6 (55%), (P = 0.05)]. Antibody-mediated rejection (AMR) appeared in five patients and was significantly correlated with de novo DSA (P = 0.05). Monitoring for de novo DSA after LDRT may help to identify patients at risk of declining renal function. Especially patients with simultaneous presence of de novo DSA class I and class II are at a high risk to suffer AR episodes.

Mucinous cystic neoplasm or non-parasitic liver cyst? - A challenging diagnosis

BACKGROUND/AIMS

Mucinous cystic neoplasms (MCN) are rare liver lesions. Radiological features include internal septa or septal thickening. Imaging often fails in the differential diagnosis to non-parasitic liver cysts (NPLC), resulting in inadequate surgery. The aim of the study was to evaluate if both lesions could be differentiated pre-operatively.

METHODOLOGY

Retrospective study with literature review.

RESULTS

Twenty-six patients (22 female, 68±12 years) underwent laparoscopic deroofing for NPLC. Histo-pathological specimens showed 2 MCN (both female) with recurrence rates of 4% (NPLC) and 100% (MCN), and a time-to-recurrence of 3 months. In both cases no radiological features of MCN were seen pre-operatively. Follow-up time was 7 and 12 years with emergence of radiological features of MCN in one case. PubMed search showed 137 hits for “MCN” and 540 hits for “mucinous cystadenoma” and “liver”; 207 studies were reviewed: one prospective, 13 non-systematic reviews, 57 retrospective, 120 case reports and 16 expert opinions. The largest MCN-series included 44 subjects.

CONCLUSIONS

If MCN shows no characteristic radiological features, thus mimicking NPLC, pre-operative radiological differentiation is impossible. During long time course characteristic radiological morphology of MCN could appear. Early recurrence of a supposed NPLC is suspicious for MCN. Due to the literature review pre-operative imaging is inaccurate for the differential diagnosis and complete surgical excision of MCN is crucial.

Understanding trends and predictors of outcome in elderly renal transplant recipients: an analysis of the UNOS registry

The continuously growing number of patients of advanced age with end-stage renal disease demands adequate treatment in the form of renal transplantation. Despite the benefits of transplantation in elderly recipients, the mortality risk remains clearly higher compared to younger recipients. This report aims to give an actual overview of outcomes in deceased donor transplantation of advanced age recipients, by comparing graft and patient survival of transplants recorded in the United Network for Organ Sharing registry from 2000 to 2012, between three age groups: 70-84, 50-69, and 35-49 years of age. Subsequently, risk factors for graft failure and death were analyzed for elderly (70-84 years) recipients and their mortality compared to young (35-49 years) recipients. Elderly recipients showed higher death-censored graft survival and lower patient survival (log-rank p<0.001). Graft failure was highly associated with expanded criteria donors and delayed graft function (DGF) (<0.001). The strongest risk factors for death were peripheral vascular disease, DGF, and previous allograft failure (p<0.001). The overall relative risk of death was more than four times higher for elderly than for young recipients (hazard ratio, 4.36; confidence interval, 4.13-4.59; p<0.001). Furthermore, the impact of previously identified, pre-transplant risk factors for death among elderly recipients and young recipients was analyzed and differed clearly between the subgroups. This report investigated risk factors and outcomes in elderly recipients similar to previous reports, but in a more recent transplant population, up to 2012. While mortality is elevated in elderly recipients, differences for subgroups defined by pre-transplant risk factors can help to better compare the risk between elderly and younger recipients.