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Purpose: Although participation in multidisciplinary tumor boards (MTBs) is an obligatory quality criterion for certification, there is scarce evidence, whether MTB recommendations are consistent with consensus guidelines and whether they are followed in clinical practice. Reasons of guideline and tumor board deviations are poorly understood so far. Methods: MTB's recommendations from the weekly MTB for gastrointestinal cancers at the University Cancer Center Leipzig/Germany (UCCL) in 2020 were analyzed for their adherence to therapy recommendations as stated in National German guidelines and implementation within an observation period of 3 months. To assess adherence, an objective classification system was developed assigning a degree of guideline and tumor board adherence to each MTB case. For cases with deviations, underlying causes and influencing factors were investigated and categorized. Results: 76% of MTBs were fully adherent to guidelines, with 16% showing deviations, mainly due to study inclusions and patient comorbidities. Guideline adherence in 8% of case discussions could not be determined, especially because there was no underlying guideline recommendation for the specific topic. Full implementation of the MTBs treatment recommendation occurred in 64% of all cases, while 21% showed deviations with primarily reasons of comorbidities and differing patient wishes. Significantly lower guideline and tumor board adherences were demonstrated in patients with reduced performance status (ECOG-PS ≥ 2) and for palliative intended therapy (p = 0.002/0.007). Conclusions: The assessment of guideline deviations and adherence to MTB decisions by a systematic and objective quality assessment tool could become a meaningful quality criterion for cancer centers in Germany. [ABSTRACT FROM AUTHOR]

Purpose: This observational study explored the association between hospital volume and short-term outcome following gastric resections for non-bariatric indication, aiming to contribute to the discussion on centralization of complex visceral surgery in Germany.Methods: Based on complete national hospital discharge data from 2010 to 2015, the association between hospital volume and in-hospital mortality was evaluated according to volume quintiles and volume deciles. Case-mix differences regarding surgical indication, age, sex, and comorbidities were considered for risk adjustment. In addition, rates of major complications and failure to rescue were analyzed across hospital volume categories.Results: Inpatient episodes (72,528) with gastric resection were analyzed. Risk-adjusted mortality in patients treated in very low volume hospitals (median volume of 5 surgeries per year) was higher (12.0% [95% CI 11.4 to 12.5]) compared to those treated in very high volume hospitals (50 surgeries per year; 10.6% [10.0 to 11.1]). Failure to rescue patients with complications was 28.1% [27.0 to 29.3] in very low volume hospitals and 22.7% [21.6 to 23.8] in very high volume hospitals. Differences were similar within the subgroup of patients operated for gastric cancer.Conclusions: Treatment in very high volume hospitals is associated with a lower in-hospital mortality compared to treatment in very low volume hospitals. This effect seems to be determined by the ability to rescue patients who experience complications. As the observed benefit is only related to very high volumes, the results do not clearly indicate that centralization may improve short-term results substantially, unless a very high degree of centralization would be achieved. Possibly, further research focusing on other outcome measures, such as clinical processes or long-term results, might lead to divergent conclusions. [ABSTRACT FROM AUTHOR]

Background: Cholangiocarcinoma (CCA) is a fatal cancer of the bile duct with a poor prognosis owing to limited therapeutic options. The incidence of intrahepatic CCA (iCCA) is increasing worldwide, and its molecular basis is emerging. Environmental factors may contribute to regional differences in the mutation spectrum of European patients with iCCA, which are underrepresented in systematic genomic and transcriptomic studies of the disease., Methods: We describe an integrated whole-exome sequencing and transcriptomic study of 37 iCCAs patients in Germany., Results: We observed as most frequently mutated genes ARID1A (14%), IDH1, BAP1, TP53, KRAS, and ATM in 8% of patients. We identified FGFR2::BICC1 fusions in two tumours, and FGFR2::KCTD1 and TMEM106B::ROS1 as novel fusions with potential therapeutic implications in iCCA and confirmed oncogenic properties of TMEM106B::ROS1 in vitro. Using a data integration framework, we identified PBX1 as a novel central regulatory gene in iCCA. We performed extended screening by targeted sequencing of an additional 40 CCAs. In the joint analysis, IDH1 (13%), BAP1 (10%), TP53 (9%), KRAS (7%), ARID1A (7%), NF1 (5%), and ATM (5%) were the most frequently mutated genes, and we found PBX1 to show copy gain in 20% of the tumours. According to other studies, amplifications of PBX1 tend to occur in European iCCAs in contrast to liver fluke-associated Asian iCCAs., Conclusions: By analyzing an additional European cohort of iCCA patients, we found that PBX1 protein expression was a marker of poor prognosis. Overall, our findings provide insight into key molecular alterations in iCCA, reveal new targetable fusion genes, and suggest that PBX1 is a novel modulator of this disease., (© 2024 The Author(s). Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

The surgical treatment of gastric cancer has arrived at a turning point towards the routine application of minimally invasive techniques. After the first results of prospective randomized trials from Asia confirmed the surgical and oncological safety, the latest results of international trials provided evidence for minimally invasive gastrectomy of advanced gastric cancer in a multimodal setting. A new addition in the field of minimally invasive procedures is robotic-assisted surgical techniques, which have already been implemented for these indications in many centers in Germany. The technical advantages that are applicable in the robotics setting in comparison to laparoscopy lead to a rapid dissemination of the procedure but still need to be evaluated in controlled trials. Further developments for the surgical treatment of gastric cancer are found in the field of intraoperative imaging procedures. In this field various technologies are available, such as fluorescence imaging using a near-infrared camera, which requires the use of a fluorescent agent or the hyperspectral camera system, which does not require the application of a fluorophore and merges pictures from visible and non-visible wavelengths to a functional image. It is to be expected that in the future various technological advancements can make a valuable contribution to the surgical treatment of gastric cancer in the clinical routine, especially if they support and facilitate the use of minimally invasive surgical techniques.

Background: Within the framework of the quality initiative of the German Society for General and Visceral Surgery (DGAV) a review article was compiled based on a systematic literature search. Recommendations for the current diagnostics and treatment of esophageal cancer were also elaborated., Methods: The systematic literature search was carried out in March 2019 according to the PRISMA criteria using the MEDLINE databank. The recommendations were formulated based on a consensus in the DGAV., Results and Conclusion: Operations below the currently valid minimum quantity threshold should no longer be carried out. There are many indications that the minimum quantity in Germany should be raised to ≥20 resections/year/hospital in order to comprehensively improve the quality. Prehabilitation programs with endurance, strength and intensive breathing training as well as nutritional therapy improve patient outcome. The current treatment of esophageal cancer is stage-dependent and incorporates endoscopic resection of (sub)mucosal low-risk tumors (T1m1-3 or T1sm1 low risk), primary esophagectomy of submucosal high-risk tumors (T1a), submucosal cancer (T1sm2-3) and T2N0 tumors, multimodal treatment with neoadjuvant chemoradiotherapy or perioperative chemotherapy and operations for advanced stages. Esophagectomy is nowadays carried out in one stage as a so-called hybrid procedure (laparoscopy and muscle-preserving thoracotomy) or as a total minimally invasive operation (laparoscopy and thoracoscopy).

Background: With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. Daily laboratory tests are used to screen patients for postoperative complications. The course of inflammatory indicators after esophagectomy after different surgical approaches has not been described yet. The aim of the study was to describe the postoperative C-reactive protein (CRP) and leukocyte levels after different surgical approaches for esophagectomy and relate it to postoperative complications., Methods: Between 2010 and 2018, 217 consecutive patients underwent thoracoabdominal esophagectomy with gastric conduit reconstruction. Blood tests to assess CRP and leukocytes were performed daily in all patients. Differences between treatment groups were analyzed with a linear mixed model. All postoperative complications were recorded in a prospective database. Prognostic factors were analyzed using multivariate logistic regression modeling., Results: The study evaluated 4 different esophagectomy techniques: open (n = 57), hybrid (n = 53), totally minimally invasive (n = 52), and robot-assisted minimally invasive (n = 55). The increase of inflammatory indicators was significantly higher after open esophagectomy on the first 2 postoperative days compared with the 3 minimally invasive procedures (P < .001). Postoperative CRP values exceeding 200 mg/L on the second postoperative day and open esophagectomy were independently associated with postoperative complications., Conclusions: Open esophagectomy results in significantly higher CRP and leukocyte values compared with hybrid, minimally invasive, and robot-assisted minimally invasive esophagectomy. Open esophagectomy and a CRP increase on the second postoperative day above 200 mg/L are independent positive predictors for postoperative complications in multivariate analysis., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Neoadjuvant or perioperative therapy with radical surgery is a meaningful approach to improve the prognosis of gastric cancer. The FLOT regimen (5-fluorouracil, leucovorin, oxaliplatin, docetaxel) has been established as a perioperative concept in Germany and is also increasingly being used internationally. The prognostic significance of neoadjuvant chemoradiotherapy has to be awaited based on the results of currently active studies. The microsatellite instability (MSI) status has increasingly gained in importance with respect to decision-making processes in the interdisciplinary tumor board as patients with MSI tumors probably do not benefit from neoadjuvant therapy. Patients with only initial stages of locally advanced MSI tumors (cT2, N0) and those with comorbidities could be spared from neoadjuvant therapy. This article critically deals with the current state of the art concepts as well as with ongoing studies with respect to neoadjuvant and perioperative treatment of gastric cancer. For this purpose, the essential already published and the active studies are presented.

Introduction: Laparoscopic antireflux surgery and medical therapy with proton pump inhibitors are gold standards of gastroesophageal reflux treatment. On account of limited resources and increasing healthcare needs and costs, in this analysis, not only optimal medical results, but also superiority in health economics of these 2 methods are evaluated., Methods: We performed an electronic literature survey in MEDLINE, PubMed, Cochrane Library, ISRCTN (International Standard Randomization Controlled Trial Number) as well as in the NHS Economic Evaluation Database, including studies published until 1/2017. Only studies considering the effect size of QALY (Quality-Adjusted Life Years) (with respect to different quality of life-scores) as primary outcome comparing laparoscopic fundoplication and medical therapy were included. Criteria of comparison were ICER (Incremental Cost-Effectiveness Ratio) and ICUR (Incremental Cost-Utility Ratio). Superiority of the respective treatment option for each publication was worked out., Results: In total, 18 comparative studies were identified in the current literature with respect to above-mentioned search terms, qualifying for the defined inclusion criteria. Six studies were finally selected for analyses. Out of 6 publications, 3 showed superiority of laparoscopic fundoplication over long-term medical management based on current cost-effectiveness data. Limitations were related to different time intervals, levels of evidence of studies and underlying resources/costs of analyses, healthcare systems and applied quality of life instruments., Conclusion: Future prospective, randomized trials should examine this comparison in greater detail. Additionally, there is a large potential for further research in the health economics assessment of early diagnosis and prevention measures of reflux disease and Barrett's esophagus/carcinoma., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Achalasia is a primary oesophageal motility disorder. Although aetiology remains mainly unknown, a genetic risk variant, rs28688207 in HLA-DQB1, showed strong achalasia association suggesting involvement of immune-mediated processes in the pathogenesis. High-resolution manometry recognises three types of achalasia. The aim of our study was to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 across the high-resolution manometry subtypes., Methods: This was a cross-sectional retrospective study. Achalasia patients from tertiary centres in the Czech Republic ( n  = 163), Germany ( n  = 114), Greece ( n  = 70) and controls were enrolled. All subjects were genotyped for the rs28688207 insertion. The Kruskal-Wallis test was used for the genotype-phenotype analysis., Results: A total of 347 achalasia patients (type I - 89, II - 210, III - 48) were included. The overall frequency of the rs28688207 was 10.3%. The distribution of the insertion was significantly different across the high-resolution manometry subtypes ( p  = 0.038), being most prevalent in type I (14.6%), followed by type II (9.5%) and III (6.3%)., Conclusion: The frequency of the HLA-DQB1 insertion differs among high-resolution manometry achalasia subtypes. The insertion is most prevalent in type I, suggesting that immune-mediated mechanisms triggered by the insertion may play a more prominent role in the pathogenesis of this subtype.