BACKGROUND:Minimally invasive resection rectopexy is an effective treatment for obstructive defecation syndrome (ODS) in carefully selected patients, offering favorable functional outcomes with potentially reduced surgical trauma. As minimally invasive techniques continue to advance in colorectal surgery, integrating resection rectopexy with Natural Orifice Specimen Extraction (NOSE) or minilaparotomy retrieval may further enhance postoperative bowel function by minimizing constipation and fecal incontinence. We hypothesize that surgical outcomes are influenced by the severity of disease. METHODS:Between January 2019 and June 2022, 85 patients with ODS underwent minimally invasive resection rectopexy. Patient characteristics were assessed using standardized questionnaires. Surgical outcomes, complications, and patient satisfaction were evaluated at 1, 3, and 6 months postoperatively. Symptom severity was quantified using the Wexner Constipation Score (WCS), Wexner Incontinence Score (WIS), and Altomare Obstructive Defecation Syndrome (AOS) Score. Repeated measures ANOVA was performed to assess longitudinal changes in these measures over time. RESULTS:All procedures were successfully completed laparoscopically without conversion. The mean patient age was 58.5 years (SD = 16.5). Complications were classified as Clavien-Dindo grade IIIa (n = 3), IIIb (n = 8), and IVa (n = 1). Repeated measures ANOVA demonstrated significant postoperative improvements in WCS (p < 0.0001) and AOS (p < 0.0001). Although WIS changes were not statistically significant, a gender-specific effect was observed (p = 0.011). Post hoc analyses revealed no significant temporal effects for WIS across genders. Follow-up was limited to 6 months. CONCLUSION:Minimally invasive resection rectopexy provides substantial symptom relief, particularly in reducing constipation and obstructive defecation. While outcomes for fecal incontinence remain variable, the procedure seems safe, feasible, and markedly improves the quality of life in patients with ODS. Long-term outcomes and recurrence rates require further study.

Predictive modeling for metastasis in oncology has gained significant traction due to its potential to improve prognosis, guide treatment strategies and enhance patient outcomes. Current methods leverage advancements in machine learning, genomics and imaging technologies to predict the likelihood of cancer spread. Techniques such as logistic regression, decision trees, support vector machines and neural networks have been employed to analyze clinical, pathological, and molecular data. Genomic profiling, liquid biopsies, and radiomics are increasingly integrated into these models to identify metastatic patterns and risk factors. Despite these advances, challenges persist, including data heterogeneity, model interpretability, and the need for larger, high-quality datasets for validation. Furthermore, the integration of artificial intelligence with precision medicine offers promising avenues for more personalized metastasis predictions. Future directions focus on enhancing model accuracy through deep learning, improving the interpretability of black-box models, and incorporating multi-omics data to capture the complexity of metastatic mechanisms. With the advent of advanced computational tools and growing datasets, predictive modeling in oncology is poised to revolutionize metastasis management, offering clinicians' valuable insights for early detection and tailored treatment strategies.

BACKGROUND:To assess the efficacy of the stapled transanal rectal resection (STARR) procedure in treating obstructed defecation syndrome (ODS) in patients with rectocele and rectoanal intussusception grade II-III, focusing on symptom resolution, functional improvement, and pain reduction. METHODS:This prospective study included patients undergoing STARR for ODS. Preoperative parameters such as anal pain, smearing, itching, bleeding, and obstructed defecation symptoms were assessed using standardized questionnaires (Wexner and Altomare). Functional outcomes, including constipation, incontinence, and obstruction, were evaluated at baseline and at 1, 3, and 6 months postoperatively. Pain levels were categorized into mild (0-3), moderate (4-7), and severe (8-10). Primary endpoints included functional improvement, pain reduction, and resolution of anal symptoms. Secondary endpoints included complication rates, hospital stay duration, and patient satisfaction. Statistical analysis included paired t-tests and one-way repeated measures ANOVA. RESULTS:Significant improvements were observed postoperatively. Anal smearing (35%) resolved by 3 months, while anal itching (42.5%) and bleeding (75%) significantly declined, stabilizing by 6 months. Severe pain (17.5%) was noted during hospitalization but fully resolved within 1 month, with 97.5% reporting only mild pain at 6 months. Patient satisfaction was 85%. Complication rates were low (7.5% Clavien-Dindo grade I/IIIa), and no reoperations were required. CONCLUSIONS:STARR effectively improves functional outcomes and alleviates ODS symptoms, including pain, smearing, itching, and bleeding. Low complication rates and high patient satisfaction support its use as a viable surgical option, though long-term follow-up is warranted.

Every surgical procedure presents challenges for surgeons before, during, and after the operation. This review aims to explore strategies for anticipating and addressing these challenges in kidney transplant surgeries. Specifically, it focuses on equipping surgeons with the knowledge necessary to navigate vascular anatomical variations encountered during kidney retrieval and transplantation. By elucidating both typical and uncommon anatomical configurations, surgeons can better anticipate challenges and optimize surgical outcomes. The review underscores the critical importance of understanding kidney vascular anatomical variations in the context of transplantation. By providing insights into preoperative planning and mitigating intraoperative challenges, this knowledge has the potential to significantly improve outcomes for patients undergoing kidney transplantation.

Obstructive Defecation Syndrome (ODS) significantly affects the quality of life and is often associated with rectocele, rectoanal intussusception, and dolichosigma. Robot-assisted rectosacropexy followed by sigmoid resection may offer an effective therapeutic approach. This study included 7 female patients (mean age 61.14 years, BMI 27.17) with confirmed ODS and no prior treatment for rectal prolapse or dolichosigma. Using standardized scores (Wexner, Altomare ODS), outcomes were assessed preoperatively and at 1, 3, and 6 months postoperatively. Robot-assisted rectosacropexy with mesh placement and subsequent sigmoid resection were performed in two surgical stages. Significant improvements in constipation (Wexner score reduced from 14.1 to 8.7, p < 0.01) and ODS symptoms (Altomare ODS score from 19.1 to 5.6, p < 0.01) were noted at 6 months. Continence (Wexner Incontinence Score) improved from 13.4 to 7.1. No conversions or major complications occurred, and all patients reported satisfaction with the treatment. Robot-assisted rectosacropexy followed by sigmoid resection is a safe and effective two-step approach for ODS. Further studies are needed to explore its long-term efficacy and functional outcomes.

Lipedema often remains undiagnosed in patients with obesity, leading to mismanagement of treatment. Because of this, despite remarkable weight loss after bariatric surgery and decreases in hip and abdomen circumference, some patients show only small decreases in the circumference of the extremities and report persistent limb pain. We present the first scoping review to systematically explore the reported patient characteristics, clinical outcomes, and diagnostic challenges of lipedema in patients undergoing metabolic bariatric surgery, to identify gaps in current practice and promote earlier diagnosis and tailored treatment. A search in PubMed, Embase, Medline, and Cochrane was conducted, from inception to December 19th, 2023. We consider as inclusion criteria original articles, case reports, and case series of lipedema after metabolic bariatric surgery. Among the included studies, a total of 49 patients were reported, and all were female. The mean age of cases was 42.43 (range 24–63) years old, and the mean BMI was 49.92 kg/m2. In the majority of the included patients, a sleeve gastrectomy was performed (25 patients, 51

Background: The method of transecting the pancreatic parenchyma during pancreatic resection may influence the rate of complications, including pancreatic fistula and bleeding. The objective of this study was to compare the transection of the pancreatic parenchyma during pancreatoduodenectomy with monopolar electrocautery versus scalpel in terms of postoperative complications. Methods: A retrospective analysis of patients with open pancreatoduodenectomy from the German DGAV StuDoQ|Pancreas registry (January 2013 to December 2021) was performed. Transection of the pancreatic parenchyma with a scalpel versus monopolar electrocautery was compared regarding postoperative pancreatic fistula B/C, post-pancreatectomy hemorrhage B/C, and major complications (Clavien -Dindo classification >= 3) rates. Multivariable analysis with adjustment for potential confounders and surgical center cluster effect was performed. Results: Overall, 6,752 patients were included in the study. In 4,072 (60.3%), transection was performed with a scalpel and, in 2,680 (39.7%), with electrocautery. Transection with electrocautery was associated with higher postoperative pancreatic fistula B/C (15.4% vs 12.8%; P = .003), post-pancreatectomy hemorrhage B/C (11% vs 7.4%; P < .001), and major complications (33.4% vs 29.6%; P = .001) rates. In the multivariable analysis, after adjustment for potential confounders and surgical center, the association of the transection method with postoperative pancreatic fistula B/C (odds ratio = 1.01; 95% CI, 0.79-1.2; P = .962), post-pancreatectomy hemorrhage B/C (odds ratio = 1.23; 95% CI, 0.94-1.6; P = .127), and major complications (odds ratio = 1.09; 95% CI, 0.93-1.27; P =.297) was not significant. Conclusion: The study found no significant association between transection of the pancreatic parenchyma during open pancreatoduodenectomy with a scalpel compared with monopolar electrocautery regarding pancreatic fistula, postoperative bleeding, or overall major complication rates. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background: Various technologies exist to remove surgical smoke. Despite high significance in surgical practice, comparative in-vivo performance data are missing.Study design: The performance of five smoke management technologies (venting, passive filtering, active filtering, circular filtration, electrostatic precipitation) was analysed in-vivo by three different laparoscopic interventions (cholecystectomy, atypic liver resection, colon surgery) with high-energy surgical instruments. Surgical smoke formation/evacuation was characterised by various aerosol-analytical instruments. In addition, operational parameters like CO2 consumption and capnoperitoneal pressure were determined.Results: The half-life of particle concentration was found to be a suitable parameter to describe smoke elimination efficacy and varied between (10 -45) s. It is shown that the efficacy of smoke elimination technologies based on particle removal by evacuation can also be predicted by simple equations. Furthermore, it was found that the combination of surgical cutter and tissue defines charge and polarity of surgical smoke that influences especially the efficacy of electrostatic precipitation. Depending on the smoke elimination technology, the CO2 consumption varied between (0.5 -16) L/min, the capnoperitoneal stability between (2 -17) %.Conclusions: Each smoke elimination technology showed advantages and disadvantages. Simple charcoal filters rapidly degrade and should be exchanged regularly during surgery. Active filtering is efficient for smoke management, but the unstable capnoperitoneum interferes with surgery. Circular filtration forms a stable capnoperitoneum, but the valveless trocar promotes relevant levels of smoke release into the environment. Electrostatic precipitation was found to be most efficient for smoke management with minimal CO2 consumption and highly-stable capnoperitoneum.

Abstract Obesity has been recognized as a chronic disorder by the World Health Organisation (WHO) and was first reported in the Paleolithic age. In the recent years there has not been an international collaborative that facilitates professional cooperation on a worldwide level to increase the output of high-level evidence in the fields of obesity treatment and metabolic and bariatric surgery (MBS). In other surgical and medical fields, international collaborative research networks have shown to increase the quality and amount of treatment-changing evidence. In general, Global Collaborative Research in MBS (GCRMBS) should have the following goals: (1) clinical specialty–based research in obesity and MBS, (2) designing research protocols and studies to generate long-term data in obesity and MBS, (3) understanding the uncommon/rare complications and events associated with obesity and MBS, (4) increasing the number of participants in research and (5) investigating ethical and racial disparities in bariatric research. This review gives an overview of the current status and the future of international collaborative research in MBS.

Background/objectives: The aim of this study was to evaluate the impact of perioperative fluid administration in pancreatic surgery. Methods: Patients who underwent pancreatic resections were identified from our institution's prospectively maintained database. Fluid balances were recorded intraoperatively and at 24hr postoperatively. Patients were stratified into tertiles of fluid administration (low, medium, high). Adjusted multivariable analysis was performed and outcome measures were postoperative complications.Results: A total of 211 patients were included from 2012 to 2017. Complication rates were POPF(B/C) 19.4%, DGE(B/C) 14.7%, PPH(C) 10.0% and CDC >= IIIb 26.1%. In multivariable analysis, high perioperative fluid balance was an independent risk factor associated with POPF (OR = 10.5, 95%CI 2.7-40.7, p = .001), CDC (OR = 2.5, 95%CI 1.2-5.3, p < .002), DGE (OR = 2.3, 95%CI 1.0-5.2, p = .017), PPH (OR = 6.7 95%CI 2.2 -20.0, p = .038) and reoperation (OR = 3.1, 95%CI 1.6-6.2, p = .006). In multivariable analysis with intraoperative and postoperative fluid balances as separate predictors, intraoperative (OR = 2,5, 95%CI 1.2 -5.5, p = .04) and postoperative fluid balance (OR = 2.5, 95%CI 1.2-5.5, p = .02) were predictors of POPF. Postoperative fluid balance was the only predictor for mortality (OR = 4.5, 95%CI 1.0-18.9, p = .041) and predictor for CDC (OR = 2.0, 95%CI 1.0-4.0, p = .043) and OHS days (OR = 6.9, 95%CI 0.03-13.7, p = .038).Conclusions: High postoperative fluid balance in particular is associated with postoperative morbidity. Maintaining a fluid-restrictive strategy postoperatively should be recommended for patients undergoing pancreatic surgery.

CCR Translation for This Article from Plectin-1 as a Novel Biomarker for Pancreatic Cancer

PURPOSE:Rectosigmoid resection rectopexy has been established as an effective therapy for obstructive defecation syndrome. The addition of the NOSE-technique provides an even less invasive approach avoiding minilaparotomy, but can be technically challenging. Application of a robotic platform has been proposed to facilitate the specimen extraction and fashioning of the intracorporeal anastomosis and has been proven to be effective in left-sided colectomies.METHODS:After establishing laparoscopic rectosigmoid-resection-rectopexy with NOSE, we modified our technique by addition of the robotic platform. Whenever robotic capacity was available, elective patients scheduled for rectosigmoid resection rectopexy for obstructive defecation syndrome were operated robotically assisted. Demographic and intraoperative data were prospectively collected. Follow up was assessed using the Wexner constipation score, Wexner incontinence score, and Altomare ODS score.RESULTS:The NOSE-RRR technique was completed in all 31 patients. The mean operative time was 166 min (range 67-230). No conversion was required. The median hospital stay was 5 days (range 3-28). Four patients had minor complications (Clavien I). Two patients were reoperated (Clavien IIIb). Functional scores improved significantly postoperatively. Mean Wexner incontinence score was 7.1 preoperatively, 6.9 after 1 month, and decreased significantly to 3.93 after 3 months (p < 0.001). Mean Altomare ODS score was 17.47 preoperatively and 6.93/5.03 after 1/3 months (p < 0.001). Wexner constipation score (12.83) also showed a significant improvement after 1/3 months (6.97/6.67; p < 0.001).CONCLUSION:NOSE-RRR can be performed safely with a low rate of manageable complications. The technique provides a significant improvement for ODS-Symptoms.

The hallmark of chronic pancreatitis is its intractable pain. Endoscopic or interventional treatment is considered the first-line treatment of patients with chronic pancreatitis. However, surgery is superior to endoscopic therapy and may also be more cost-effective. The most common indication for surgery for chronic pancreatitis is intractable pain despite endoscopic intervention. Drainage procedures are the procedure of choice in patients with a dilated pancreatic duct (≥5mm) without an inflammatory mass in the head of the pancreas. The most common drainage procedure is the Partington–Rochelle procedure. It consists of an incision of the pancreatic duct at the anterior surface of the pancreas from the tail to the head of the pancreas. Calculi in the pancreatic ducts can then be removed and segmental stenosis can be relieved. The procedure is completed by a Roux-en-Y jejunal limb sutured side-to-side to the pancreatic duct. It is associated with low morbidity and mortality rates (about 1%). However, drainage is inferior to resection regarding pain and complication management. The Frey procedure is a hybrid procedure that also encompasses partial resection of the pancreatic head, but is often also considered a drainage procedure. Compared to the Partington–Rochelle procedure, the Frey procedure improves the long-term outcome. “Small duct” chronic pancreatitis is rare. Treatment of choice is the longitudinal V-shaped excision of the ventral pancreas, a modified drainage procedure.

Introduction In view of the limited capacities in intensive care units and the increasing economic burden, identification of risk factors could allow better and more efficient planning. Therefore, the aim of this study was to assess independent risk factors for the duration of intensive care unit stay after pancreatoduodenectomy (PD). Methods 147 patients who underwent pancreatoduodenectomy in the time period from 2013 to 2015 were identified from a prospective database and a retrospective analysis was performed. The primary endpoint was length of time spent in the ICU. A retrograde analysis was performed using univariate and multivariate regression analysis. All pre-, intra- and post-operative parameters were considered in the analysis. Results Themedian time spent in the intensive care unit (ICU) is one day. The univariate analysis demonstrated increased pack years, cerebrovascular events, anticoagulation, elevated creatinine and CA 19-9 as preoperative risk factors. In multivariate analysis, antihypertensive medication (AHT; OR 2.46; 95% CI 1.57-3.87; p = 0.05), operation time (OR 1.01; 95% CI 1.00-1.01; p = 0.03), extended LAD (OR 5.46; 95% CI 2.77-10.75; p = 0.01) and severe PPH (OR 4.01; 95% CI 2.07-7.76; p = 0.04) are significant risk factors for longer ICU stay. Discussion Patients with cardiovascular risk factors and elevated preoperative creatinine level are at greater risk for a prolonged ICU stay. Risk and benefit of an extended LAD should be weighed during the operation. Median duration on ICU/ IMC after PD is one day or less for patients without risk factors. Whether routine monitoring in the ICU/IMC after PD is necessary must be clarified in further studies.

Minimally invasive resection techniques for the treatment of various pathologies of the pancreas are potentially advantageous for the treated patients in terms of restitution time and postoperative morbidity, but are a technical challenge for the responsible surgeon. The introduction of robotic assistance in visceral surgery offers a possibility for further distribution of minimally invasive procedures in pancreatic surgery.The aim of this study was to examine the possibilities for developing robotic pancreatic surgery in Germany. The data are based on the quality reports of the hospitals for the years 2015-2019 combined with a selective literature search.The number of quality reports available decreased from 1635 to 1594 between 2015 and 2019. A median of 96 clinics performed 11-20, 56 clinics 21-50 and 15 clinics more than 50 pancreaticoduodenectomies. For distal resections, there were 35 clinics with 11-20, 14 clinics with 21-50 and two clinics with more than 50 procedures. In relation to all clinics with at least five distal resections per year, minimally invasive procedures were performed at only 29 clinics; a ratio to laparoscopic left resections of over 50% was reported in only seven clinics.According to the literature, the learning curves for robotic pancreatic distal resection and pancreaticoduodenectomy diverge. While the learning curve for robotic distal resection is completed after around 20 procedures, the learning curve for robotic pancreaticoduodenectomy has several plateaus, which are reached after around 30, 100 and 250 procedures.Due to the decentralised structure of pancreatic surgery in Germany, a nationwide introduction of robotic pancreatic surgery is unlikely. The routine use of robotic pancreaticoduodenectomy will probably be restricted to high volume centres in the foreseeable future.

Hybrid laparoscopic techniques have been proposed as a good transition from open to complete minimally invasive approach especially in complex surgical procedures. This meta-analysis aimed to compare the outcomes of hybrid laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy. A systematic literature research was performed according to PRISMA guidelines. A broad search strategy with terms “laparoscopy” and “pancreatoduodenectomy” was used. Included studies were analyzed by quantitative meta-analysis using the metafor package for R software. Of 655 identified articles, 627 were excluded and 28 articles fully assessed, including 14 comparative studies, 8 case series and 6 case reports. Extracted data included intraoperative variables and postoperative outcome parameters. The predefined inclusion criteria were met by 14 comparative studies, and 371 patients were pooled in the meta-analysis. Hybrid laparoscopic pacreatoduodenectomy was associated with significantly longer operative time (I2 0%, p = 0,01, Mean HPD 494,6 min, Mean OPD 421,6 min, WMD 67 min, 95% CI 14–120 min). For all other postoperative outcome parameters, no statistically significant differences were found. A nonsignificant reduction in intraoperative transfusion rate (I2 20%, p = 0,2, proportion HPD 2%, proportion OPD 1,6%, OR 0,44, 95% CI 0,16–1,27) and blood loss (I2 95%, p = 0,1, Mean HPD 397,2 ml, Mean OPD 1017,8 ml, MD − 601 ml, 95% CI − 1311–108) was observed for hybrid pancreatoduodenectomy in comparison to open surgery. This meta-analysis demonstrates significantly increased operation time for hybrid laparoscopic compared to open pancreatoduodenectomy. Intraoperative variables as well as postoperative parameters and major morbidity were comparable for both techniques. Overall results of this meta-analysis demonstrated the hybrid technique as a safe procedure in high-volume centers offering aspects of a safe transition to fully laparoscopic pancreatoduodenectomy.