An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG

A systematic mapping study of mapping modelling languages

Context - Various research teams, as well as individual researchers, have investigated mapping modelling languages. However, systematic studies that provide a structured overview of this research on this topic have not been conducted. It is noticeable that this leaves a big gap in the context of a modelling language. Conducting these studies could lead to a better understanding of the characteristics of mapping modelling languages, which would be of great importance for the future development of this area of research. Objective - The aim of the study is to assess the state of knowledge about mapping modelling languages and assist stakeholders in making informed decisions. This is carried out by identifying existing mapping modelling languages, and their characteristics. Another objective of this thesis is to identify potential mapping modelling languages that can support the generation of a blended modelling environment. Method - In order to achieve the goal, we conducted a systematic mapping study of mapping modelling languages. Our search showed that we had 2913 potential studies that were relevant to our topic. After the selection process, the final set of primary papers was 29. The information that was of importance for this study was derived according to the categories of a well-defined classification framework. Results - The analysis of the extracted data showed the following main findings: (i) most of the primary studies research focused on providing solution proposals, (ii) the largest number of publications was in 2010, (iii) most papers mention mapping modelling languages that allow the definition of unidirectional mapping rules, (iv) the most common cardinality was 1:N, (v) graphical syntax has been proposed in many primary studies, (vi) most studies suggest mapping modelling languages that can be used to define relationships between RDF models, (vii) documentation and implementation were available for a very small number of mapping modelling languages. Conclusion - These results can help the research community to identify research gaps on mapping modelling languages as well as identify possible directions for future research.

A systematic mapping study of mapping modelling languages

Context - Various research teams, as well as individual researchers, have investigated mapping modelling languages. However, systematic studies that provide a structured overview of this research on this topic have not been conducted. It is noticeable that this leaves a big gap in the context of a modelling language. Conducting these studies could lead to a better understanding of the characteristics of mapping modelling languages, which would be of great importance for the future development of this area of research. Objective - The aim of the study is to assess the state of knowledge about mapping modelling languages and assist stakeholders in making informed decisions. This is carried out by identifying existing mapping modelling languages, and their characteristics. Another objective of this thesis is to identify potential mapping modelling languages that can support the generation of a blended modelling environment. Method - In order to achieve the goal, we conducted a systematic mapping study of mapping modelling languages. Our search showed that we had 2913 potential studies that were relevant to our topic. After the selection process, the final set of primary papers was 29. The information that was of importance for this study was derived according to the categories of a well-defined classification framework. Results - The analysis of the extracted data showed the following main findings: (i) most of the primary studies research focused on providing solution proposals, (ii) the largest number of publications was in 2010, (iii) most papers mention mapping modelling languages that allow the definition of unidirectional mapping rules, (iv) the most common cardinality was 1:N, (v) graphical syntax has been proposed in many primary studies, (vi) most studies suggest mapping modelling languages that can be used to define relationships between RDF models, (vii) documentation and implementation were available for a very small number of mapping modelling languages. Conclusion - These results can help the research community to identify research gaps on mapping modelling languages as well as identify possible directions for future research.

Prognostic value of ascites in patients with liver cirrhosis undergoing cardiac surgery

<jats:title>Abstract</jats:title><jats:sec> <jats:title>Introduction</jats:title> <jats:p>Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis. However, the prognostic value of ascites on postoperative morbidity and mortality after cardiac surgery remains uninvestigated.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>A retrospective study included 69 patients with preoperatively diagnosed liver cirrhosis who underwent cardiac surgery between January 2009 and January 2018 at the Department of Cardiothoracic Surgery, University Hospital of Cologne, Germany. The patients were divided into ascites and non-ascites groups based on preoperatively diagnosed ascites. Thirty-day mortality, postoperative complications, length of stay, and blood transfusions were analyzed postoperatively.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>Out of the total of 69 patients, 14 (21%) had preoperatively diagnosed ascites. Ascites group had more postoperative complications such as blood transfusions (packed red blood cells: 78.6% vs. 40.0%, <jats:italic>p</jats:italic> = 0.010; fresh frozen plasma: 57.1% vs. 29.1%, <jats:italic>p</jats:italic> = 0.049), acute kidney injury (78.6% vs. 45.5%, <jats:italic>p</jats:italic> = 0.027), longer ICU stay (8 vs. 3 days, <jats:italic>p</jats:italic> = 0.044) with prolonged mechanical ventilation (57.1% vs. 23.6%, <jats:italic>p</jats:italic> = 0.015) and tracheotomy (28.6% vs. 3.6%, <jats:italic>p</jats:italic> = 0.003). The 30-day mortality rate was significantly higher in the ascites group than in the non-ascites group (35.7% vs. 5.5%, <jats:italic>p</jats:italic> = 0.002).</jats:p> </jats:sec><jats:sec> <jats:title>Conclusion</jats:title> <jats:p>Ascites should be implemented in preoperative risk score assessments in cirrhotic patients undergoing cardiac surgery. Preoperative treatment of ascites could reduce the negative impact of ascites on postoperative complications after cardiac surgery. However, this needs to be thoroughly investigated in prospective randomized clinical trials.</jats:p> </jats:sec><jats:sec> <jats:title>Graphical abstract</jats:title> </jats:sec&gt

Valve-in-Valve TAVR versus Redo Surgical Aortic Valve Replacement: Early Outcomes

Objective This study aimed to assess short-term outcomes of patients with failed aortic valve bioprosthesis undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) or redo surgical aortic valve replacement (rSAVR). Methods Between 2009 and 2019, 90 patients who underwent ViV-TAVR ( n =73) or rSAVR ( n =17) due to failed aortic valve bioprosthesis fulfilled the inclusion criteria. Groups were compared regarding clinical end points, including in-hospital all-cause mortality. Patients with endocarditis and in a need of combined cardiac surgery were excluded from the study. Results ViV-TAVR patients were older (78.07.4 vs. 62.1 +/- 16.2 years, p =0.012) and showed a higher prevalence of baseline comorbidities such as atrial fibrillation, diabetes mellitus, hyperlipidemia, and arterial hypertension. In-hospital all-cause mortality was higher for rSAVR than in the ViV-TAVR group (17.6 vs. 0%, p <0.001), whereas intensive care unit stay was more often complicated by blood transfusions for rSAVR patients without differences in cerebrovascular events. The paravalvular leak was detected in 52.1% ViV-TAVR patients compared with 0% among rSAVR patients ( p <0.001). Conclusion ViV-TAVR can be a safe and feasible alternative treatment option in patients with degenerated aortic valve bioprosthesis. The choice of treatment should include the patient's individual characteristics considering ViV-TAVR as a standard of care

Viral load of SARS-CoV-2 in surgical smoke in minimally invasive and open surgery: a single-center prospective clinical trial

Abstract At the beginning of the COVID-19 pandemic, it was assumed that SARS-CoV-2 could be transmitted through surgical smoke generated by electrocauterization. Minimally invasive surgery (MIS) was targeted due to potentially higher concentrations of the SARS-CoV-2 particles in the pneumoperitoneum. Some surgical societies even recommended open surgery instead of MIS to prevent the potential spread of SARS-CoV-2 from the pneumoperitoneum. This study aimed to detect SARS-CoV-2 in surgical smoke during open and MIS. Patients with SARS-CoV-2 infection who underwent open surgery or MIS at Heidelberg University Hospital were included in the study. A control group of patients without SARS-CoV-2 infection undergoing MIS or open surgery was included for comparison. The trial was approved by the Ethics Committee of Heidelberg University Medical School (S-098/2021). The following samples were collected: nasopharyngeal and intraabdominal swabs, blood, urine, surgical smoke, and air samples from the operating room. An SKC BioSampler was used to sample the surgical smoke from the pneumoperitoneum during MIS and the approximate surgical field during open surgery in 15 ml of sterilized phosphate-buffered saline. An RT-PCR test was performed on all collected samples to detect SARS-CoV-2 viral particles. Twelve patients with proven SARS-CoV-2 infection underwent open abdominal surgery. Two SARS-CoV-2-positive patients underwent an MIS procedure. The control group included 24 patients: 12 underwent open surgery and 12 MIS. One intraabdominal swab in a patient with SARS-CoV-2 infection was positive for SARS-CoV-2. However, during both open surgery and MIS, none of the surgical smoke samples showed any detectable viral particles of SARS-CoV-2. The air samples collected at the end of the surgical procedure showed no viral particles of SARS-CoV-2. Major complications (CD ≥ IIIa) were more often observed in SARS-CoV-2 positive patients (10 vs. 4, p = 0.001). This study showed no detectable viral particles of SARS-CoV-2 in surgical smoke sampled during MIS and open surgery. Thus, the discussed risk of transmission of SARS-CoV-2 via surgical smoke could not be confirmed in the present study

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG. The online version contains supplementary material available at 10.1007/s00464-023-10614-9