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The aim of this technical note is a step-by-step description of a fully robotic abdominothoracic esophagectomy with an intrathoracic esophagogastrostomy. We report on our technique and short-term results of 75 patients undergoing an Ivor-Lewis esophagectomy using a fully robotic 4-arm approach in the abdominal and thoracic phase with a hand-sewn intrathoracic anastomosis. There are several important steps and differences to consider compared to the conventional minimal invasive approach (patient's positioning, anaesthesiological set up, port placement, gastric conduit pull up, technique of esophagostrostomy). Mean operative time was 392 minutes (240-610) with a 94% R0 resection status. Conversion to open procedure occurred in 2 (2.6%) in the abdominal, and 14 (18.2%) in the thoracic phase. Main reasons for conversion were problems during the lifting of the gastric conduit and difficulties in the construction of the esophagogastrostomy. The rate dropped during the last 20 patients (1/20 (10%). Our results suggest that the reported technique is safe and feasible. It satisfies the oncological principles and provides the advantages of robotic assisted minimal invasive surgery.

Die roboterassistierte Chirurgie kann einige der Limitierungen der laparoskopischen Leberchirurgie uberwinden und ist ein vielversprechender Ansatz, den Anteil minimalinvasiver Eingriffe an der Leber zu erhohen. Der vorliegende Beitrag soll einen Uberblick uber die aktuelle Literatur geben. Ferner werden die Ergebnisse einer Umfrage zur roboterassistierten Leberchirurgie unter deutschen Kliniken mit viszeralchirurgisch genutztem DaVinci-System dargestellt und die perioperativen Daten zweier Roboterzentren prasentiert.

Background Dynamic variables of fluid responsiveness (FR), such as pulse pressure variation (PPV), have been shown to predict the response to a fluid challenge accurately. A recently introduced non-invasive technology based on the volume-clamp method (CNAP™) offers the ability to measure PPV continuously (PPVCNAP). However, the accuracy regarding the prediction of FR in the operating room has to be proved. Methods We compared PPVCNAP with an invasive approach measuring PPV using the PiCCO technology (PPVPiCCO). We studied 47 patients undergoing major open abdominal surgery before and after a passive leg-raising manoeuvre and i.v. fluid resuscitation. A positive response to a volume challenge was defined as ≥15% increase in stroke volume index obtained with transpulmonary thermodilution. Bootstrap methodology was used with the grey zone approach to determine the area of inconsistency regarding the ability of PPVPiCCO and PPVCNAP to predict FR. Results In response to the passive leg-raising manoeuvre, PPVPiCCO predicted FR with a sensitivity of 81% and a specificity of 72% [area under the curve (AUC) 0.86] compared with a sensitivity of 76% and a specificity of 72% (AUC 0.78) for PPVCNAP. Regarding the volume challenge in the operating room, PPVPiCCO predicted FR with a sensitivity of 87% and a specificity of 100% (AUC 0.97) compared with a sensitivity of 91% and specificity of 93% (AUC 0.97) for PPVCNAP. The grey zone approach identified a range of PPVPiCCO values (11–13%) and PPVCNAP values (7–11%) for which FR could not be predicted reliably. Conclusions Non-invasive assessment of FR using PPVCNAP seems to be interchangeable with PPVPiCCO in patients undergoing major open abdominal surgery. Clinical trial registration NCT02166580.

Minimally invasive laparoscopic surgery for rectal cancer has undergone a significant evolution during the last decades and has become the standard approach in specialized centers with better short-term and comparable oncological outcome to open surgery. The laparoscopic approach remains challenging and has various inherent technical challenges particularly associated with rectal cancer resection. Robotic colorectal surgery using the da Vinci® surgical system has been successfully introduced into clinical practice during recent years and provides specific technical advantages. Studies have shown that the robotic approach in colorectal surgery is safe and feasible with comparable results. It is associated with low conversion rates, more R0 situations for low rectal cancer with larger tumors and more neoadjuvant treatment compared to standard laparoscopy. Robot-assisted surgery is an attractive development of minimally invasive surgery and should also be further evaluated with mandatory monitoring of outcome parameters in registries in Germany.

Hintergrund: Die abdominothorakale Osophagusresektion nach Ivor Lewis zahlt zu den komplexen viszeralchirurgischen Eingriffen. In den letzten Jahren wurden zunehmend Teilschritte in minimalinvasiver Technik durchgefuhrt, jedoch ist insbesondere die intrathorakale Anastomose bei dem heutigen Stand der apparativen und technischen Mittel nach wie vor eine Herausforderung. Wir berichten detailliert uber den Einsatz des Da Vinci-Robotersystems und unsere Technik bei der Osophaguschirurgie. Material und Methoden: In einer prospektiven Datensammlung erfolgte die Auswertung der im Universitatsklinikum Schleswig-Holstein, Campus Kiel, im Zeitraum von November 2013 bis November 2015 durchgefuhrten roboterassistierten Osophagusoperationen. Ergebnisse: Insgesamt 56 Patienten unterzogen sich einer roboterassistierten Operation an der Speiserohre, wobei 43 Ivor-Lewis-, 10 McKeown-Prozeduren bei Karzinomen sowie 3 Enukleationen von Leiomyomen durchgefuhrt wurden. Bei 53 (93,4 %) der Patienten konnte ein R0-Resektionsstatus erreicht werden, die mittlere Lymphknotenausbeute betrug 23 (14–75). 45 der Patienten (80,5 %) wurden neoadjuvant vorbehandelt. Die mittlere OP-Zeit betrug 412 min (120–610). Eine Konversion auf ein offenes Verfahren war bei 19 (34,1 %) notwendig, wobei dies uberwiegend (17 Patienten) im thorakalen Teil der Operation notwendig war. Bei 43 Patienten wurde eine intrathorakale Osophagogastrostomie angelegt; bei der initial angelegten Seit-zu-Seit-Osophagogastrostomie entwickelten 4 von 5 Patienten eine Leckage, sodass die Technik auf ein handgenahtes Verfahren umgestellt wurde (Leckage bei 3 von 20 Patienten). Andere Majorkomplikationen waren eine Leckage im Magenschlauch bei 2 (3,6 %), eine bronchotracheale Fistel bei 2 (3,6 %), mesenteriale Ischamie bei 1 (1,8 %), Peritonitis durch dislozierte Ernahrungssonde bei 1 (1,8 %), pulmonale Komplikationen bei 19 (34 %) der Patienten. Vier (7,1 %) der Patienten verstarben postoperativ aufgrund einer Lungenarterienembolie, eines Myokardinfarkts sowie eines septischen Kreislaufversagens. Schlussfolgerung: Die roboterassistierte minimalinvasive Osophagusresektion kann technisch und onkologisch sinnvoll angewandt werden. Die Einfuhrung dieser Technik sollte in einem strukturierten Programm mit einer kritischen und intensiven Evaluation eigener Ergebnisse und einem Austausch mit anderen Gruppen erfolgen. Dadurch konnen „Pitfalls“ vermieden werden und eine schnellere Lernkurve erreicht werden. Weitere technische Entwicklungen und Erfahrungen konnten dazu fuhren, dass diese Technik zunehmende Anwendung findet.

Conventional laparoscopy is the gold standard in bariatric surgery. Internationally, robot-assisted surgery is gaining in importance. Up to now there are only few reports from Germany on the use of the system in bariatric surgery. Since January 2017 we have been performing robot-assisted gastric bypass surgery. It remains unclear whether the use of the robotic system has advantages over the well-established laparoscopic technique. Within a period from January to early August 2017 a total of 53 gastric bypass operations were performed. Of these 16 proximal redo Roux-en-Y gastric bypass operations were performed with the DaVinci Si system versus 29 laparoscopic procedures. A retrospective analysis of the perioperative course was carried out. Body weight, body mass index (BMI), Edmonton obesity staging system (EOSS) and American Society of Anesthesiologists (ASA) classification did not show significant differences. There were also no significant differences in terms of estimated blood loss, intraoperative complications, duration of surgery, postoperative inflammatory parameters and weight loss. There was no mortality and no need for revisional surgery in either group. After laparoscopic surgery there was a delayed occurrence of a leak of the gastrojejunostomy followed by readmission and endoscopic negative pressure wound therapy. The results show that the proximal Roux-en-Y gastric bypass can be performed safely and efficiently using the DaVinci surgical system. Significant differences to the conventional laparoscopic procedure were not found. Larger randomized controlled trials are needed to define the role of the DaVinci system in bariatric surgery.

BACKGROUND The surgical treatment of pancreatic head tumours is one of the most complex procedures in general surgery. In contrast to colorectal surgery, minimally-invasive techniques are not very commonly applied in pancreatic surgery. Both the delicate dissection along peri- and retropancreatic vessels and the extrahepatic bile ducts and subsequent reconstruction are very demanding with rigid standard laparoscopic instruments. The 4-arm robotic surgery system with angled instruments, unidirectional movement of instruments with adjustable transmission, tremor elimination and a stable, surgeon-controlled 3D-HD view is a promising platform to overcome the limitations of standard laparoscopic surgery regarding precise dissection and reconstruction in pancreatic surgery. INDICATION Pancreatic head resection for mixed-type IPMN of the pancreatic head. PROCEDURE Robot-assisted, minimally-invasive pylorus-preserving pancreaticoduodenectomy (Kausch-Whipple procedure). CONCLUSION The robotic approach is particularly suited for complex procedures such as pylorus-preserving pancreatic head resections. The fully robotic Kausch-Whipple procedure is technically feasible and safe. The advantages of the robotic system are apparent in the delicate dissection near vascular structures, in lymph node dissection, the precise dissection of the uncinate process and, especially, bile duct and pancreatic anastomosis.

Robotic liver resection can overcome some of the limitations of laparoscopic liver surgery; therefore, it is a promising tool to increase the proportion of minimally invasive liver resections. The present article gives an overview of the current literature. Furthermore, the results of a nationwide survey on robotic liver surgery among hospitals in Germany with a DaVinci system used in general visceral surgery and the perioperative results of two German robotic centers are presented.

Minimally invasive laparoscopic surgery for rectal cancer has undergone a significant evolution during the last decades and has become the standard approach in specialized centers with better short-term and comparable oncological outcome to open surgery. The laparoscopic approach remains challenging and has various inherent technical challenges particularly associated with rectal cancer resection. Robotic colorectal surgery using the da Vinci® surgical system has been successfully introduced into clinical practice during recent years and provides specific technical advantages. Studies have shown that the robotic approach in colorectal surgery is safe and feasible with comparable results. It is associated with low conversion rates, more R0 situations for low rectal cancer with larger tumors and more neoadjuvant treatment compared to standard laparoscopy. Robot-assisted surgery is an attractive development of minimally invasive surgery and should also be further evaluated with mandatory monitoring of outcome parameters in registries in Germany.

The surgical treatment of pancreatic head tumours is one of the most complex procedures in general surgery. In contrast to colorectal surgery, minimally-invasive techniques are not very commonly applied in pancreatic surgery. Both the delicate dissection along peri- and retropancreatic vessels and the extrahepatic bile ducts and subsequent reconstruction are very demanding with rigid standard laparoscopic instruments. The 4-arm robotic surgery system with angled instruments, unidirectional movement of instruments with adjustable transmission, tremor elimination and a stable, surgeon-controlled 3D-HD view is a promising platform to overcome the limitations of standard laparoscopic surgery regarding precise dissection and reconstruction in pancreatic surgery.Pancreatic head resection for mixed-type IPMN of the pancreatic head.Robot-assisted, minimally-invasive pylorus-preserving pancreaticoduodenectomy (Kausch-Whipple procedure).The robotic approach is particularly suited for complex procedures such as pylorus-preserving pancreatic head resections. The fully robotic Kausch-Whipple procedure is technically feasible and safe. The advantages of the robotic system are apparent in the delicate dissection near vascular structures, in lymph node dissection, the precise dissection of the uncinate process and, especially, bile duct and pancreatic anastomosis.

Abdominothoracic oesophageal resections, also known as Ivor Lewis procedures, are complex visceral surgery procedures. In recent years, substeps have increasingly been performed using minimally invasive techniques. However, intrathoracic anastomosis is still a challenge given the instrumental and technological possibilities available to date. This article provides a detailed description of the use of the Da Vinci robotic system and our techniques in oesophageal surgery.In a prospective data collection, we analysed the robotic-assisted oesophageal surgeries performed at the University Hospital of Schleswig-Holstein, Campus Kiel, between November 2013 and November 2015.A total of 56 patients underwent robotic-assisted oesophageal surgery, with 43 patients undergoing the Ivor Lewis technique, 10 patients undergoing the McKeown procedure and 3 patients undergoing enucleation of a leiomyoma. A complete tumour resection (R0 margin) was achieved in 53 patients (93.4%); the mean number of resected lymph nodes was 23 (14-75). Forty-five (80.5%) patients received an induction therapy. Mean operative time was 412 min (120-610); mean hospital stay was 19 days (4-145). A conversion to open surgery was necessary in 19 (34.1%) cases, most notably in the thoracic part of the surgical procedure (17 patients). Forty-three patients received intrathoracic oesophagogastrostomy; 4 out of 5 patients with an initial side-to-side anastomosis developed a leakage, whereupon the technique was switched to a hand-sewn procedure (leakage in 3 out of 20 patients). Other major morbidities included leakage of the gastric conduit in 2 patients (3.6%), airway fistula in 2 patients (3.6%), mesenteric ischaemia in one patient (1.8%), and peritonitis due to a dislocated feeding tube in one other patient. Pulmonary complications occurred in 19 patients (34%). Four patients (7.1%) died of pulmonary embolism, heart attack, and septic organ failure.Robotic-assisted, minimally invasive oesophagectomy is a feasible and useful approach for oncological surgery. This technique should be implemented in a structured program with an extensive and critical evaluation of the users' own results and an exchange with other experienced work teams. This helps to avoid pitfalls and to speed up the learning curve. Further technological developments and increasing experience might lead to a more widespread use of this technique.

Objective: For hepatocellular carcinoma (HCC) a 5-year survival rate over 75% is achieved within Milan-criteria (MC), but expanded criteria (UCSF- and Bologna-criteria) show similar survival rates.Management of the waiting list remains controversial and living donation and rescue allocation may help to reduce waiting time for patients outside MC in Germany. Methods: 110 Patients listed for liver transplantation at UKSH Kiel from 1998 - 2014 with HCC were analysed. Assuming that patients outside the MC had a longer waiting time for primary-donor organs, we compared the outcome of patients with rescue-allocated organs outside the MC and primary-allocated organs. Studied parameters were impact of MC, allocation-mode, waiting time, radiological and histological tumour-assessment and the impact of bridging therapy on the outcome after transplantation. Results: Radiological tumour-assessment compared to pathological report of the explant liver differed in 28%. Patients allocated by rescue-allocated donor organs had a significant shorter waiting time, but 5-year tumour free survival was significantly worse compared to primarily allocated organs. Patients within and beyond MC but within UCSF-criteria as well as patients receiving TACE inside and outside MC showed no significant difference in survival rates. Multilocular tumour lesions and a cumulative tumour size >8 cm had a significant impact on 5-year survival and tumour-free survival. Conclusion: Rescue-allocated organs may help to reduce waiting time for patients with a no-progressive tumour disease outside MC. Radiological assessment was not optimal to stratify HCC-patients on the waiting list. Besides MC and TACE standardized radiological assessment, additional parameters and biomarkers could help to improve survival and select patients for transplantation by monitoring the aggressiveness of tumour growth.

Tumors of the liver hilum frequently cause obstructive cholestasis. When a curative resection of the tumor is impossible, palliative bile drainage is indicated. A hepatojejunostomy is performed if conservative treatment fails or if irresectability is proven during an initial laparotomy. In patients with peritoneal carcinosis and mesentery retraction, a hepatogastrostomy may represent a helpful alternative. An experimental study was designed to compare the bile drainage effectiveness of a hepatogastrostomy versus a hepatojejunostomy. Two-month-old outbred piglets were used in all experiments. The animals were randomized into three groups (hepatojejunostomy, hepatogastrostomy alone, hepatogastrostomy and proton pump inhibitors). Obstructive cholestasis was induced by common bile duct ligation; hepatojejunostomy and hepatogastrostomy were performed 2 weeks later. The serum bilirubin levels were monitored weekly. All animals were killed 4 weeks after the drainage operation. Following a hepatojejunostomy (n = 5) all animals showed decreasing cholestasis parameters. All animals (n = 3) died within 3–5 days after a hepatogastrostomy due to gastrointestinal bleeding caused by gastric ulcers and ulcers of the liver surface. The administration of pantoprazole prevented these bleeding complications. In animals treated by hepatogastrostomy and proton pump inhibitors (n = 5), bile drainage effectiveness was similar to that following hepatojejunostomy. A hepatogastrostomy represents an alternative treatment option for surgical bile drainage with a similar effectiveness to that of a hepatojejunostomy. To prevent postoperative gastrointestinal bleeding, proton pump inhibitors should be used.

Background/Aims : Adult bone marrow contains progenitors capable of generating hepatocytes. Here a new liver failure model is introduced to assess whether bone marrow-derived progeny contribute to liver regeneration after acute hepatotoxic liver failure. Methods : Retrorsine was used to inhibit endogenous hepatocyte proliferation, before inducing acute liver failure by carbon tetrachloride. Bone marrow chimeras were generated before inducing liver failure to trace bone marrow-derived cells. Therefore, CD45 and major histocompatibility complex (MHC) class I dimorphic rat models were applied. Results : Early after acute liver failure a multilineage inflammatory infiltrate was observed, mainly consisting of granulocytes. In long-term experiments small numbers of CD90 + /CD45 − cells of donor origin occurred in clusters associated with portal triads. Bone marrow cell infusion was not able to enhance liver regeneration. Cellular hypertrophy was the predominant way of liver mass regeneration in models applying retrorsine. Conclusions : Retrorsine pretreatment did not affect sensitivity for carbon tetrachloride. A multilineage inflammatory infiltrate was observed in rats whether pretreated with retrorsine or not. Few donor cells co-expressing CD90 (THY 1) were present in recipient livers, which may resemble donor-derived hematopoietic progenitors or oval cells. No other donor cells within liver parenchyma were detected. This is in contrast to other cell infusion models of acute cell death.

Background The pancreatic anastomosis is still the Achilles heel in partial pancreatoduodenectomy (PPD). Methods This study describes retrospectively a series of 441 patients who underwent standard or extended PPD and reconstruction by either pancreatogastrostomy or pancreatojejunostomy over a period of 13 years (1988–2000). Results Reconstruction of the pancreatic remnant was achieved by pancreatogastrostomy in 250 patients (56·7 per cent) and by pancreatojejunostomy in 191 patients (43·3 per cent). The leakage rate of the pancreatic anastomosis was 2·8 per cent after pancreatogastrostomy versus 12·6 per cent after pancreatojejunostomy (P < 0·001), whereas other surgical complications (bile leakage, haemorrhage, pancreatitis) were identical in the two groups. The leakage rate after standard PPD with or without vascular reconstruction was 2·0 per cent (four of 205 patients) after pancreatogastrostomy and 11·5 per cent (18 of 156) after pancreatojejunostomy (P < 0·001); following extended PPD it was 6·7 per cent (three of 45) after pancreatogastrostomy and 17·1 per cent (six of 35) after pancreatojejunostomy. The mortality rate due to leakage was 1·6 per cent (four of 250 patients) after pancreatogastrostomy versus 5·2 per cent (ten of 191) after pancreatojejunostomy (P = 0·037). Conclusion Pancreatogastrostomy is a safe and reliable method of reconstruction after PPD that may be associated with a lower leakage and mortality rate than pancreatojejunostomy.

Background. Donor lymphocytes infused after organ transplantation can have strong immunoregulatory effects. Application of such protocols for transplant tolerance induction in a clinical setting will, however, require combination of specific immunomodulatory strategies with nonspecific immunosuppressive medication for safety reasons. The aim of this study was to analyze the effects of immunosuppressive treatment on tolerance induction protocols by posttransplantation donor lymphocyte infusion. Methods. The interaction of postoperative donor leukocyte infusion with different types, dosage, and timing of immunosuppressive drugs were studied in a rat model of heart transplantation. Results. Tolerance could be achieved if donor cell infusion was combined with delayed, but not immediate, low-dose cyclosporine treatment, and this was associated with activation and apoptosis of host lymphocytes. In contrast, combinations with an antibody against the interleukin 2 receptor led to long-term graft survival but severe chronic rejection, and combinations with high-dose cyclosporine or sirolimus led to acute rejection. Conclusions. Postoperative donor leukocyte infusion is a potential way for tolerance induction, but the type, dose, and timing of medication are highly critical for its efficacy.

INTRODUCTION While gastric cancer shows an increased incidence in elderly patients, the rate of younger patients affected by this disease represents up to 15 %. Younger patients are frequently diagnosed with advanced tumor stages with a poor prognosis although literature data on this issue are controversial. PATIENTS AND METHODS 643 patients with primary gastric carcinoma were operated in our institution between March 1986 and December 2000. No neoadjuvant treatment was administered in these patients. We analysed the data of these patients retrospectively. A comparison of the results between patients younger than 40 years (n = 38, median age 37 years) and older than 70 years (n = 182, median age 75 years) was performed. RESULTS The radical (R0-) resectability rate was rather high for both, younger (78.9 %) and elderly (76.9 %) patients. Postoperative morbidity was higher in elderly than in younger patients (32.9 % vs. 23.2 %; p < 0.05), as well as the postoperative mortality (7.7 % vs. 2.6 %; p < 0.05). Both younger and elderly patients showed advanced (II to IV) tumor stages (76.3 % vs. 73.3 %, n. s.). There was a significant difference between the rate of diffuse carcinomas in young and elderly patients (63.2 % vs. 22.5 %). The 5-years survival rate following R0-resection was significantly higher for younger patients (54.2 % vs. 32.9 %; p = 0.01), differences occurred only after the second postoperative year. CONCLUSIONS The resectability of gastric carcinoma is not related to the patients age. Due to comorbidity, postoperative morbidity may be increased in elderly patients. Although both younger and elderly patients show advanced tumor stages, diffuse carcinomas are more frequent in younger patients. The short-term prognosis is similar for both age groups, long-term results are better for younger patients. The different life expectancy should be considered when interpreting these results.

Hintergrund: Eine kuravtive Therapioption zur Behandlung des lokal begrenzten Osophaguskarzinoms stellt die abdominothorakale Osophagusresektion mit Magenhochzug und Anlage einer intrathorakalen Anastomose dar. In den letzten Jahren wurden zunehmend Teilschritte dieser Operation in minimal invasiver Technik durchgefuhrt. Nach wie vor ist die Anlage der intrathorakalen Anastomose in minimal invasiver Technik bei dem heutigen Stand der apparativen und technischen Mittel eine Herausforderung. Seit einiger Zeit wird in unserer Klinik das 4 armige Roboter-Plattform-Systems bei Osophagusresektionen eingesetzt. Gerade beim thorakalen Teil der Operation kommen die Vorteile dieses Systems voll zum Vorschein. Material und Methoden: Die klinischen und operativen Daten der Patienten, die sich eine roboterassistierte Osophagusresektion unterzogen, werden untersucht. Zusatzlich erfolgt ein Vergleich der OP- und insbesondere der Anastomosentechnik zu den bislang veroffentlichten Ergebnissen. Ergebnisse: Zum Zeitpunkt der Abstrakterstellung wurden bislang n = 9 Patienten in roboterassistierten Technik operiert. Eine Konversion war in einem Fall notwendig aufgrund positiver Resektionsrander und Notwendigkeit zur Nachresektion. Es wurden initial 4 Seit zu Seit-Anastomosen in Staplertechnik angelegt, anschliesend auf eine Handnaht umgestiegen. Die OP Zeiten konnten im Verlauf von 620 min mit zunehmender Routine sowohl operativ als auch perioperativ auf 412 min reduziert werden. Bei 3 Patienten traten Majorkomplikationen auf, die Mortalitat liegt derzeit bei 0. Schlussfolgerung: Die roboter-assistierte minimal invasive Osophagusresektion kann sicher und technisch sinnvoll durchgefuhrt werden. Sowohl eine komplette ausgedehnte Lymphadenektomie als auch eine intrathorakale Anastomose ist prazise und komfortabel unter idealen Sichtbedingungen (3D Sicht) moglich.

Ivor Lewis oesophagectomy is one of the approaches used worldwide for treating oesophageal cancer. The adoption of minimally invasive oesophagectomy has increased worldwide since its first description more than 15 years ago. However, minimally invasive oesophagectomy with a chest anastomosis has advantages. By using a four-arm robotic platform, not only the preparation of the gastric tube and mobilisation of the oesophagus but also the intrathoracic anastomosis of the oesophagogastrostomy can be performed in a comfortable and safe way.The indication for oesophageal resection is oesophageal cancer.The operative procedure comprises robotic-assisted abdominothoracal oesophageal resection with reconstruction by a gastric tube and intrathoracic anastomosis (Ivor Lewis procedure).Robotic abdominal and thoracic minimally invasive esophagectomy is feasible, and safe with a complete lymph node dissection. Especially the intrathoracic anastomosis of the oesophagogastrostomy can be performed in a comfortable and safe way.

Einleitung: Das HCC ist mit einer Inzidenz von 5,9 % die 6 häufigste Krebserkrankung (General World Cancer Statistic 2011). Bei fortgeschrittenener Leberzirrhose bietet die Lebertransplantation (LTx) eine kurative Therapiemöglichkeit. Um die Sterberate auf der Warteliste zu senken erfolgte[for full text, please go to the a.m. URL], 129. Kongress der Deutschen Gesellschaft für Chirurgie

Parathyroidectomy (PT) corrects tertiary hyperparathyroidism in patients who have received renal grafts but can result in deterioration of renal function.To compare different surgical procedures for their effect on renal function and efficacy to cure tertiary hyperparathyroidism.A retrospective cohort study.University clinic.Eighty-three patients with functioning renal grafts receiving PT for the first time.Group 1 received an incomplete PT, with at least 1 entire parathyroid gland (PG) remaining in situ (n = 12). Group 2 received an incomplete PT, with the most morphologically conserved PG partially resected (n = 22). Group 3 received a complete PT, with autotransplantation of PG tissue (n = 49).The primary end point was the postoperative change in glomerular filtration rate. Secondary end points were rates of redialysis, hypercalcemia, and hyperparathyroidism within 5 years.A decrease in glomerular filtration rate occurred postoperatively in 75 patients (90%) and correlated significantly with the extent of PG resection. Recovery of renal function at month 6 was observed in group 1, but not in groups 2 and 3 (P.001). Seven patients (8%) needed permanent dialysis (1 in group 2 and 6 in group 3). Hypercalcemia was abrogated in 78 patients (94%), without significant differences among the groups. Assessment of parathyroid hormone levels in accordance with target ranges from the Kidney Disease Outcomes Quality Initiative guidelines did not reveal significant differences in the rates of recurrent hyperparathyroidism.Incomplete PT preserving at least 1 entire PG does not cause deterioration of renal graft function and provides long-term correction of hypercalcemia and tertiary hyperparathyroidism.

Hintergrund: Die operative Behandlung des Osophaguskarzinoms besteht u. a. aus einer abdominothorakalen Osophagusresektion mit Magenhochzug und Anlage einer intrathorakalen Anastomose (Prozedur nach Ivor Lewis). In den letzten Jahren wurden zunehmend Teilschritte dieser Operation in minimalinvasiver Technik durchgefuhrt, jedoch ist die intrathorakale Anastomose in minimalinvasiver Technik bei dem heutigen Stand der apparativen und technischen Mittel nach wie vor eine Herausforderung. Mit der Hilfe eines 4-armigen Roboterplattformsystems ist es moglich, sowohl den abdominellen als auch den thorakalen Teil der Operation mit intrathorakaler Anastomose in roboterassistierter, minimalinvasiver Technik durchzufuhren. Indikation: Operative Behandlung eines Osophaguskarzinoms (Adenokarzinom). Prozedur: Roboterassistierte, minimalinvasive abdominothorakale Osophagusresektion mit intrathorakaler Anastomose (Ivor-Lewis-Prozedur). Schlussfolgerung: Die roboterassistierte minimalinvasive Osophagusresektion kann sicher und technisch sinnvoll durchgefuhrt werden. Sowohl eine komplette ausgedehnte Lymphadenektomie als auch eine intrathorakale Anastomose ist prazise und komfortabel unter idealen Sichtbedingungen (3-D-Sicht) moglich. Gerade bei der Anlage der intrathorakalen Anastomose kommen die Vorteile des Robotersystems zum Vorschein.

Background and Objectives There have been reports on improved prognosis after TME for middle and lower rectal cancer. No prospective randomized studies have yet been performed. This is a large single institution series evaluating its own results of TME. Methods This retrospective study analyses data of 337 patients with middle and lower rectal cancer, treated with either curative or palliative intention between 1990 and 1998. Results Of all patients, 212 had lower rectal and 125 middle rectal carcinomas. The rate of rectal resections with TME was 96%. A total of 223 patients were treated by anterior rectal resection; 92 patients had to undergo abdomino-perineal resection. Ten patients were operated by a Hartmann resection. Postoperative morbidity was 35% with a leakage rate of 9%. Postoperative mortality was 4%. The rate of local recurrence was 8.6%. The 5-year survival rate after curative resection was 69.3%. The multivariate analysis outlined the tumor stage as independent prognostic factor. Conclusions In our experience, TME is feasible with acceptable postoperative morbidity and low mortality. The local recurrence rate can be decreased to lower than 10%. The almost 70% 5-year survival rate indicates a clear benefit for the patients. These findings recommend TME as standard procedure for middle and lower rectal cancer. J. Surg. Oncol. 2004;86:115–121. © 2004 Wiley-Liss, Inc.

Aim One of the most important limiting prognostic factor in patients with gastric cancer is the occurrence of peritoneal carcinomatosis which can be correlated with tumor cell dissemination during resection of advanced tumors. The aim of these experiments was to analyse the role of adjuvant intraperitoneal immunotherapy in prevention of peritoneal carcinomatosis. As target was chosen the 17-1A antigen as it was present in 96% of our patients with gastric cancer.

Background/Aims: Although the incidence of primary gastric carcinoma is decreasing, the majority of patients in Western countries are still diagnosed with advanced tumor stages. In many cases surgical therapy can be performed only by multivisceral resections including the pancreas. Methods: Between April 1986 and April 1997, thirty-three patients with primary gastric carcinoma underwent gastric resection and segmental/total pancreatectomy at our institution (21 males, 12 females; median age 57 years). The operative and pathologic findings and clinical course in these patients were analyzed retrospectively. Results: In all patients total gastrectomy with D2 lymphadenectomy was performed. In 26 patients (79%) the pancreatic tail was also resected. Other resections included the pancreatic head in 5 patients (15%) and the whole pancreas in 2 cases (6%). Radical (R0) resections were possible in 73% of all cases (n = 24). 22 patients (67%) had stage-IV disease due to liver/peritoneal metastases (n = 11) or to extensive lymph node metastases (N3, n = 11). Histology showed a predominance of the diffuse type according to Laurén (n = 16, 49%). Intraoperatively suspected tumor infiltration of the pancreas was confirmed by histology only in 39% (n = 13) of the examined resection specimens. Postoperative morbidity was 36% (n = 12) and mortality was 9% (n = 3). Five patients developed pancreatitis or peripancreatic abscess, 2 with a lethal outcome. Overall the median survival was 13 months. Following R0 resection median survival was 17 months. If the pancreas was microscopically not infiltrated, median survival was 23 months. Conclusion: Pancreatic invasion in patients with gastric carcinoma is often associated with positive lymph nodes and liver metastases or peritoneal carcinomatosis. Intraoperatively, true pancreas invasion is difficult to differentiate from inflammatory reactions. Postoperative morbidity and mortality are increased by pancreatic resection, mainly due to pancreatitis or peripancreatic abscess. Curative (R0) resection improves prognosis and even long-term survival can be achieved in selected individual cases. Palliative resections can be performed for local complications like bleeding or obstruction refractory to other therapies.

While gastric cancer shows an increased incidence in elderly patients, the rate of younger patients affected by this disease represents up to 15 %. Younger patients are frequently diagnosed with advanced tumor stages with a poor prognosis although literature data on this issue are controversial.643 patients with primary gastric carcinoma were operated in our institution between March 1986 and December 2000. No neoadjuvant treatment was administered in these patients. We analysed the data of these patients retrospectively. A comparison of the results between patients younger than 40 years (n = 38, median age 37 years) and older than 70 years (n = 182, median age 75 years) was performed.The radical (R0-) resectability rate was rather high for both, younger (78.9 %) and elderly (76.9 %) patients. Postoperative morbidity was higher in elderly than in younger patients (32.9 % vs. 23.2 %; p0.05), as well as the postoperative mortality (7.7 % vs. 2.6 %; p0.05). Both younger and elderly patients showed advanced (II to IV) tumor stages (76.3 % vs. 73.3 %, n. s.). There was a significant difference between the rate of diffuse carcinomas in young and elderly patients (63.2 % vs. 22.5 %). The 5-years survival rate following R0-resection was significantly higher for younger patients (54.2 % vs. 32.9 %; p = 0.01), differences occurred only after the second postoperative year.The resectability of gastric carcinoma is not related to the patients age. Due to comorbidity, postoperative morbidity may be increased in elderly patients. Although both younger and elderly patients show advanced tumor stages, diffuse carcinomas are more frequent in younger patients. The short-term prognosis is similar for both age groups, long-term results are better for younger patients. The different life expectancy should be considered when interpreting these results.

Das Angiomyolipom gehort zu den seltenen Tumorentitaten der Leber. Bis zum Jahr 2000 sind weltweit weniger als 100 Falle beschrieben. Die Histogenese ist unklar, der Tumor zeichnet sich durch einen stark variierenden Anteil reifer Fettzellen, Blutgefase und glatter Muskulatur aus. Wesentlich haufiger findet sich das Angiomyolipom in der Niere.