Introduction Incisional hernia remain an important complication after abdominal surgery. Repair often includes use of synthetic mesh, but certain risk factors for complication after mesh hernia repair have been described. Among these, immunosuppression due to co-existing conditions is hypothesized to increase postoperative complications, but data is scarce and contradicting. Therefore, the aim was to assess outcome after mesh hernia repair in immunosuppressed patients. Material & methods Patients with and without immunosuppression undergoing elective incisional hernia repair at our clinic between 2010 and 2019 were analyzed in this retrospective study. Pre-existing conditions, details of immunosuppression, postoperative course and outpatient follow-up for hernia recurrence were collected and impact of clinical variables on outcome was analyzed. Propensity score matching was performed for comparison of cohorts. Results Immunosuppression was associated with increased postoperative complications in the overall cohort of 732 patients undergoing incisional ventral hernia repair in univariate but not multivariate analysis (p = 0.036 and p = 0.25, respectively). Overall postoperative complications did not differ between patients with immunosuppression compared to the matched collective. However, use of > 2 immune suppressive agents and immunosuppression history > 48 months showed significant impact on postoperative complications in univariate and multivariate analysis (p = 0.003/p = 0.023 and p = 0.018/p = 0.03, respectively). Age (< 60 years), duration of surgery (> 120 min), midline hernia according to EHS classification and number of immunosuppressive agents administered were identified as important risk factors for recurrence in immunocompromised patients (p = 0.045, p = 0.023, p = 0.012 and 0.049, respectively). Conclusion In this study, overall safety with desirable outcome of mesh implantation in immunosuppressed patients was documented. Furthermore, data suggested significant impact of number of immunosuppressive agents as a predicator of postoperative complications in this collective, possibly enabling risk stratification within this subgroup.

Transanal total mesorectal excision (TaTME), a novel approach for treating low rectal cancer, holds promise. However, concerns exist in certain countries about their oncologic safety due to less-than-optimal outcomes on global studies. This research seeks to evaluate the long-term oncologic outcomes focusing on local recurrence rate and overall survival after TaTME surgery in Germany. This study analyzed data from patients who underwent elective TaTME surgery between 2014 and 2021 in four certified colorectal cancer centers in Germany. Primary endpoints were 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary outcomes encompassed overall survival (OS), operative time, completeness of local tumor resection, lymph node resection, and postoperative complications. A total of 378 patients were analyzed (mean age 61.6 years; 272 males, 72

Synchronous liver metastases occur in approximately 15–20

Introduction: The development of chronic kidney disease (CKD) is a common and significant complication, contributing to morbidity after liver transplantation (LT). Cytomegalovirus (CMV) infection is common in the overall population, and relevant reinfection after LT may occur. CMV-associated kidney damage has been discussed, but the clinical significance on CKD development after LT remains unclear. Methods: A total of 745 patients who underwent LT between 2006 and 2017 were included in this retrospective analysis. Clinical data, as well as laboratory parameters, were analyzed. Univariate and multivariate analysis were performed. Results: The univariate analysis revealed significantly impaired estimated glomerular filtration rates (eGFRs) in patients with histories of CMV infection (81.4 (8–137) mL/min vs. 90.0 (5–147) mL/min; p = 0.004). This effect was confirmed in the multivariate analysis. Post-LT, eGFR was impaired in patients with CMV (re)infection at 6, 12, 36, and 60 months, 10 years, and 15 years after LT. Immunosuppressive levels were comparable between groups. Overall survival was negatively affected by CMV infection (p = 0.001). Discussion: A clinically significant detrimental impact of CMV infection on renal function was observed, that could individualize clinical risk evaluation prior and after LT further. However, the pathophysiological mechanisms behind this observation are not yet understood.

INTRODUCTION:Cytomegalovirus (CMV)-infection and reactivation remain a relevant complication after liver transplantation (LT). The recipient and donor serum CMV-IgG-status has been established for risk stratification when choosing various pharmaceutical regimens for CMV-prophylaxis in the last two decades. However, factors influencing course of CMV-infection in LT remain largely unknown. In this study, the impact of immunosuppressive regimen was examined in a large cohort of patients.METHODS:All patients that underwent primary LT between 2006 and 2018 at the Charité-Universitaetsmedizin, Berlin, were included. Clinical course as well as histological and laboratory findings of patients were analyzed our prospectively maintained database. Univariate and multivariate regression analysis for impact of variables on CMV-occurrence was conducted, and survival was examined using Kaplan-Meier analysis.RESULTS:Overall, 867 patients were included in the final analysis. CMV-infection was diagnosed in 325 (37.5%) patients after transplantation. Significantly improved overall survival was observed in these patients (Log rank = 0.03). As shown by correlation and regression tree classification and regression tree analysis, the recipient/donor CMV-IgG-status with either positivity had the largest influence on CMV-occurrence. Analysis of immunosuppressive burden did not reveal statistical impact on CMV-infection, but statistically significant inverse correlation of cumulative tacrolimus trough levels and survival was found (Log rank < .001). Multivariate analysis confirmed these findings (p = .02).DISCUSSION:CMV-infection remains of clinical importance after LT. Undergone CMV-infection of either recipient or donor requires prophylactic treatment. Additionally, we found a highly significant, dosage-dependent impact of immunosuppression (IS) on long-term outcomes for these patients, underlying the importance of minimization of IS in liver transplant recipients.

Background and Objectives: After liver transplantation (LT), long-term immunosuppression (IS) is essential. IS is associated with de novo malignancies, and the incidence of colorectal cancer (CRC) is increased in LT patients. We assessed course of disease in patients with de novo CRC after LT with focus of IS and impact on survival in a retrospective, single-center study. Materials and Methods: All patients diagnosed with CRC after LT between 1988 and 2019 were included. The management of IS regimen following diagnosis and the oncological treatment approach were analyzed: Kaplan–Meier analysis as well as univariate and multivariate analysis were performed. Results: A total of 33 out of 2744 patients were diagnosed with CRC after LT. Two groups were identified: patients with restrictive IS management undergoing dose reduction (RIM group, n = 20) and those with unaltered regimen (maintenance group, n = 13). The groups did not differ in clinical and oncological characteristics. Statistically significant improved survival was found in Kaplan–Meier analysis for patients in the RIM group with 83.46 (8.4–193.1) months in RIM and 24.8 (0.5–298.9) months in the maintenance group (log rank = 0.02) and showed a trend in multivariate cox regression (p = 0.054, HR = 14.3, CI = 0.96–213.67). Conclusions: Immunosuppressive therapy should be reduced further in patients suffering from CRC after LT in an individualized manner to enable optimal oncological therapy and enable improved survival.

Background Colectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. The objective of this study was to determine anastomotic leakage rates and treatment after taIPAA as well as short- and long-term pouch function. Methods We conducted a retrospective analysis of a prospective database of all patients undergoing taIPAA at an academic tertiary referral center in Germany, between 01/03/2015 and 31/08/2019. Patients with indications other than ulcerative colitis or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded for short- and long-term follow up due to diverging postoperative care yet considered for evaluation of anastomotic leakage. Results A total of 22 patients undergoing taIPAA during the study time-window were included in analysis. Median age at the time of surgery was 32 ± 12.5 (14–54) years. Two patients developed an anastomotic leakage at 11 days (early anastomotic leakage) and 9 months (late anastomotic leakage) after surgery, respectively. In both patients, pouches could be preserved with a multimodal approach. Twenty patients out of 22 met the inclusion criteria for short and long term follow-up. Data on short-term pouch function could be obtained in 14 patients and showed satisfactory pouch function with only four patients reporting intermittent incontinence at a median stool frequency of 9–10 times per day. In the long-term we observed an inflammation or “pouchitis” in 11 patients and a pouch failure in one patient. Conclusion Postoperative complication rates in patients with benign colorectal disease remain an area of concern for surgical patient safety. In this pilot study on 22 selected patients, taIPAA was associated with two patients developing anastomotic leakage. Future large-scale validation studies are required to determine the safety and feasibility of taIPAA in patients with ulcerative colitis.

Summary Due to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

INTRODUCTION:The laparoscopic approach for TME is proven to be non-inferior in oncological outcome compared to open surgery. Anatomical limitations in the male and obese pelvis with resulting pathological shortcomings and high conversion rates were stimuli for alternative approaches. The transanal approach for TME (TaTME) was introduced to overcome these limitations. The aim of this study was to evaluate the outcomes of TaTME for mid and low rectal cancer at our center.METHODS:TaTME is a hybrid procedure of simultaneously laparoscopic and transanal mesorectal excision. A retrospective analysis of all consecutive TaTME procedures performed at our center for mid and low rectal cancer between December 2014 and January 2020 was conducted.RESULTS:A total of 157 patients underwent TaTME, with 72.6% receiving neoadjuvant chemoradiation. Mean tumor height was 6.1 ± 2.3 cm from the anal verge, 72.6% of patients had undergone neoadjuvant chemoradiotherapy, and 34.2% of patients presented with a threatened CRM upon pretherapeutic MRI. Abdominal conversion rate was 5.7% with no conversion for the transanal dissection. Early anastomotic leakage occurred in 7.0% of the patients. Mesorectum specimen was complete in 87.3%, R1 resection rate was 4.5% (involved distal resection margin) and in 7.6%, the CRM was positive. The three-year local recurrence rate of 58 patients with a follow-up ≥ 36 months was 3.4%. Overall survival was 92.0% after 12 months, and 82.2% after 36 months.CONCLUSION:TaTME can be performed safely with acceptable long-term oncological outcome. Low rectal cancer can be well addressed by TaTME, which is an appropriate alternative with low conversion, local recurrence, adequate mesorectal quality and CRM positivity rates.

Introduction: Colectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis (UC) is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. Objective of this study was to determine anastomotic leakage (AL) rates and treatment after taIPAA as well as short- and long-term pouch function. Patients and Methods: Data from a prospectively collected database of all patients undergoing taIPAA in our center between March 2015 and August 2019 was analyzed retrospectively. Patients with indications other than UC or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded. Results: Of 23 patients undergoing taIPAA in our center 20 patients met the inclusion criteria, with a median age of 36 years at the time of pouch formation. Overall prevalence of AL was 10% with one early (11 days after operation) and one late AL (19 months after operation). In both patients pouches could be preserved with a multimodal approach based on endosponge therapy. Data on short-term pouch function could be obtained in 11 (55.8%) patients and was satisfactory in all cases. In the long-term we observed a pouchitis rate of 57.9% and a pouch failure rate of 5.3%. Conclusion: In our study, taIPAA surgery is a safe procedure and results in good patient outcome. The rate of AL is comparable to transabdominal IPAA. In order to fully evaluate the risks and benefits of taIPAA further studies with larger cohorts of patients are required.

BACKGROUND:A common postoperative complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) is the development of marginal ulcers (MUs) at the gastrojejunal anastomosis. Several risk factors, such as smoking, seem to have an impact on the development of MUs.OBJECTIVE:Very little is known about how much smoking increases the risk. We therefore reviewed our patients regarding their smoking behavior and the development of MUs after LRYGB.SETTING:Primary care hospital and a university hospital.METHODS:This study included 249 patients who underwent LRYGB surgery between 2010 and 2015 with at least 2 years of follow-up at a single institution. This retrospective analysis focused on the development of marginal ulcers after LRYGB, the time of appearance, and possible risk factors.RESULTS:A total of 27 (10.8%) patients in this study developed MUs. The majority of MUs (66.7%) occurred within the first postoperative year. Smoking is an independent and statistically significant predictor of the development of MUs with a 4.6-fold greater risk (P = .003). Light, moderate, and heavy daily smokers have the same rate of MUs (17.4% versus 17.1% versus 17.9%, respectively). Light smokers with <10 cigarettes per day are at significantly increased risk for MUs compared with nonsmokers (17.4 versus 4.2%, respectively; P = .027). Former and current smokers are at comparable risks for MUs (13.3% versus 17.5%, respectively; P = .685).CONCLUSION:The described incidence of 10.8% shows that marginal ulcers are one of the most important and frequent complications after LRYGB. Smoking at every intensity is associated with an extraordinary risk of MU formation after LRYGB and therefore, smoking cessation before bariatric surgery must be strongly recommended.