Transhiatal and transthoracic resection in adenocarcinoma of the esophagus: Does the operative approach have an influence on the long-term prognosis?

BACKGROUND: The goal of the present analysis was to investigate the long-term prognosis for adenocarcinoma of the esophagus treated with either the transhiatal (TH) or the transthoracic (TT) operative approach. METHODS: Between September 1985 and March 2004, esophageal resection due to carcinoma was performed on a total of 424 patients. This manuscript takes into account the 150 patients suffering from adenocarcinoma of the esophagus in whom a transhiatal resection of the esophagus was performed. In the event of transmural tumor growth and a justifiable risk of surgery, the transthoracic resection was selected. An extended mediastinal lymph node dissection, however, was only carried out in the course of the transthoracic approach. RESULTS: The transthoracic resection of the esophagus demonstrated a higher rate of general complications (p = 0.011) as well as a higher mortality rate (p = 0.011). The mediastinal dissection of the lymph nodes, however, revealed no prognostic influence. Considering all of the 150 patients with adenocarcinoma, as well as only those patients who had undergone curative resections (R0), the transhiatal approach was seen to demonstrate a better five-year survival rate of 32.1% versus 35.1%, with a median survival time of 24 versus 28 months, as compared with those who had undergone a transthoracic approach with a five-year survival rate of 13.6% (all patients) versus 17.7% (R0 resection) with a median survival time of 16 versus 17 months (p < 0.05). CONCLUSION: The prognosis in patients with adenocarcinoma of the esophagus is influenced by the depth of the tumor (pT) and the pM-category, as shown in the multivariate analysis. The present analysis did not demonstrate a relevant difference in survival for patients with N0 and N1 stages undergoing transhiatal or transthoracic esophagectomy. It is questionable, if a more extensive mediastinal lymph node dissection, in addition to the clearance of abdominal lymph nodes, offers prognostic advantages in adenocarcinoma of the esophagus. However, the morbidity and mortality associated with the transthoracic approach is higher

Modeling the pelvic region for non-invasive pelvic intraoperative neuromonitoring

Finite element analysis (FEA) of electric current distribution in the pelvis minor may help to assess the usability of non-invasive surface stimulation for continuous pelvic intraoperative neuromonitoring. FEA requires generation of quality volumetric tetrahedral mesh geometry. This study proposes the generation of a suitable mesh based on MRI data. The resulting volumetric mesh models the autonomous nerve structures at risk during total mesorectal excision. The model also contains the bone, cartilage, fat, skin, muscle tissues of the pelvic region, and a set of electrodes for surface stimulation. The model is ready for finite element analysis of the discrete Maxwell’s equations

Multifunctional surface probe for less invasive stimulation of sacral somatic and autonomic outflow under EMG feedback control

Invasive electric stimulation of sacral somatic and autonomic outflow is used for treatment of urinary and anorectal functional disturbances and selective monitoring of the autonomic nerve-sparing technique in pelvic surgery, the so called pelvic intraoperative neuromonitoring. The aim of this experimental study was to investigate a less invasive approach for simultaneous stimulation of sacral somatic and autonomic outflow and concomitant recording of feedback

Resection rectopexy-laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum : preliminary results

Abstract PURPOSE: Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping. METHODS: Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients&#039; preoperative anorectal and urogenital function and their functional results at the 3-month follow-up. RESULTS: Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up ((p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed. CONCLUSIONS: Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor. PMID: 23435617 [PubMed - in process

Transsacral rectocele following combined neurinoma resection: A case report

Introduction: This report describes for the first time a case of a transsacral rectocele after combined abdominotranssacral tumour resection. Furthermore, we demonstrate a method for laparoscopic defect repair. Presentation of case: A 44-year-old Caucasian female presented to our hospital with strange gurgling sounds and a painless subdermal swelling in her lower back after resection of a presacral neurinoma two years earlier. Magnetic resonance imaging (MRI) showed a huge rectocele through a sacral defect extending into the subcutaneous tissue. We performed a laparoscopic defect repair with the implantation of a self-fixating mesh graft. Five days after surgery, the patient was discharged in a good general condition. Five months after the operation, a follow-up MRI showed a good postoperative result with the correct position of the rectum. Discussion: The repair of transsacral prolapses with attachment of a mesh is complicated by the high rigidity of the pelvis and its surrounding structures. The key criteria in choosing the method of operative approach are the size and content of the prolapse. Huge sacral defects with bowel prolapses require a transabdominal approach to enable repositioning the bowel into the abdomen and excluding bowel injuries and inner hernias. Conclusion: A laparoscopic approach provides a good intraoperative visibility for a safe retrorectal preparation and mesh graft repair of sacral defects

Surgical Education in the Digital Age - Virtual Reality, Augmented Reality and Robotics in the Medical School

Kuhn S, Huettl F, Deutsch K, Kirchgassner E, Huber T, Kneist W. Chirurgische Ausbildung im digitalen Zeitalter – Virtual Reality, Augmented Reality und Robotik im Medizinstudium. Zentralblatt fur Chirurgie. 2021;146(1):37-43.BACKGROUND: The digital transformation of healthcare is changing the medical profession. Augmented/Virtual Reality (AR/VR) and robotics are being increasingly used in different clinical contexts and require supporting education and training, which must begin within the medical school. There is currently a large discrepancy between the high demand and the number of scientifically proven concepts. The aim of this thesis was the conceptual design and structured evaluation of a newly developed learning/teaching concept for the digital transformation of medicine, with a special focus on the influence of surgical teaching.; METHODS: Thirty-five students participated in three courses of the blended learning curriculum "Medicine in the digital age". The 4th module of this course deals with virtual reality, augmented reality and robotics in surgery. It is divided into the following course parts: (1) immersive surgery simulation of a laparoscopic cholecystectomy, (2) liver surgery planning using AR/VR, (3) basic skills on the VR simulator for robotic surgery, (4) collaborative surgery planning in virtual space and (5) expert discussion. After completing the overall curriculum, a qualitative and quantitative evaluation of the course concept was carried out by means of semi-structured interviews and standardised pre-/post-evaluation questionnaires.; RESULTS: In the qualitative evaluation procedure of the interviews, 79 text statements were assigned to four main categories. The largest share (35%) was taken up by statements on the "expert discussion", which the students consider to be an elementary part of the course concept. In addition, the students perceived the course as a horizon-widening "learning experience" (29% of the statements) with high "practical relevance" (27%). The quantitative student evaluation shows a positive development in the three sub-competences knowledge, skills and attitude.; CONCLUSION: Surgical teaching can be profitably used to develop digital skills. The speed of the change process of digital transformation in the surgical specialty must be considered. Curricular adaptation should be anchored in the course concept. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Postprocessing algorithm for automated analysis of pelvic intraoperative neuromonitoring signals

Two dimensional pelvic intraoperative neuromonitoring (pIONM®) is based on electric stimulation of autonomic nerves under observation of electromyography of internal anal sphincter (IAS) and manometry of urinary bladder. The method provides nerve identification and verification of its’ functional integrity. Currently pIONM® is gaining increased attention in times where preservation of function is becoming more and more important. Ongoing technical and methodological developments in experimental and clinical settings require further analysis of the obtained signals. This work describes a postprocessing algorithm for pIONM® signals, developed for automated analysis of huge amount of recorded data. The analysis routine includes a graphical representation of the recorded signals in the time and frequency domain, as well as a quantitative evaluation by means of features calculated from the time and frequency domain. The produced plots are summarized automatically in a PowerPoint presentation. The calculated features are filled into a standardized Excel-sheet, ready for statistical analysis

Surgical therapy of primary intestinal lymphangiectasia in adults

Primary intestinal lymphangiectasia (PIL) is a rare disorder, especially in adults. It causes a local disruption of chylus transport and is part of the exudative gastroenteropathies. Conservative therapy includes dietary measures or somatostatin medication. Taking the differential diagnosis of PIL into consideration is a major challenge, since patients suffering from PIL may present with diarrhoea and lymphedema or chylous ascites. This can be explained by the chronic lymphedema of the bowel leading to dilation of the vessels (intraluminal loss) and sometimes even to a rupture (peritoneal loss). Push-pull enteroscopy and capsule endoscopy are the proper interventional diagnostic tools to discover PIL. Exploratory laparoscopy may be useful in unclear cases. Surgical resection of the altered intestine has been described with positive results. Exploratory laparoscopy may even be a diagnostic tool in unclear cases. Resection of the altered intestine is a treatment option in symptomatic and treatment-refractory cases