Abdominal Surgeons Research Articles

P-15 Combined gastrectomies: Survival outcomes in patients with locally advanced gastric cancer

The survival of patients with locally advanced gastric cancer (GC) takes several months. Radical operations are extremely complex and remain the prerogative of several of the best abdominal surgeons of the world. The search for an optimal treatment plan for GC patients (GCP) with stage T3-4N0-2M0 was realized. I examined factors in terms of precise prediction of 5-year survival (5YS) of locally advanced GCP after complete (R0) combined gastrectomies (G).

IDEAL study: magnetic resonance imaging for suspected deep endometriosis assessment prior to laparoscopy is as reliable as radiological imaging as a complement to transvaginal ultrasonography.

To compare the value of using one-stop magnetic resonance imaging (MRI) vs standard radiological imaging as a supplement to transvaginal ultrasonography (TVS) for the preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. This prospective observational study compared the diagnostic value of the standard preoperative imaging practice of our center, which involves expert TVS complemented by intravenous urography (IVU) for the evaluation of the ureters and double-contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and cecum, with that of expert TVS complemented by a 'one-stop' MRI examination evaluating the upper abdomen, pelvis, kidneys and ureters as well as rectum and sigmoid on the same day, for the preoperative triaging of 74 women with clinically suspected deep endometriosis. The findings at laparoscopy were considered the reference standard. Patients were stratified according to their need for monodisciplinary surgical approach, carried out by gynecologists only, or multidisciplinary surgical approach, involving abdominal surgeons and/or urologists, based on the extent to which endometriosis affected the reproductive organs, bowel, ureters, bladder or other abdominal organs. Our standard preoperative imaging approach and the combined findings of TVS and MRI had similar diagnostic performance, resulting in correct stratification for a monodisciplinary or a multidisciplinary surgical approach of 67/74 (90.5%) patients. However, there were differences between the estimation of the severity of disease by DCBE and MRI. The severity of rectal involvement was underestimated in 2.7% of the patients by both TVS and DCBE, whereas it was overestimated in 6.8% of the patients by TVS and/or DCBE. Complementary to expert TVS, 'one-stop' MRI can predict intraoperative findings equally well as standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

A foreign body (a coin) of Meckel’s diverticulum in a two-year-old child

Meckels diverticulum is a sac-like bulge of the wall of ileum formed in result of incomplete closure of the viteline duct that participates in nutrition of the embryo.
 Aim. To familiarize a wide community of colleagues with an interesting clinical case of a foreign body (a coin) in Meckels diverticulum. In the article, approaches to diagnostics and operative treatment of such patients are given. This clinical observation is of interest to abdominal surgeons from the point of view that Meckels diverticulum is most commonly identified by clinical symptoms present in diverticulitis, bleeding or perforating ulcer, in intestinal obstruction caused by formation of a node or of invagination.
 Conclusion. A situation in which a blunt-ended foreign body permitted to identify Meckels diverticulum, is described as casuistically rare.

Presidential Lecture of the Japanese Association for Chest Surgery in 2019

The Japanese Association for Chest Surgery, JACS, was established in 1984. The Japanese Association for Thoracic Surgery, JATS, was founded in 1964 by thoracic surgeons, but cardiovascular surgeon came to occupy a large number, and it was necessary to establish a society exclusively for thoracic surgeon. And we use the name “Chest” instead of “Thoracic” for the academic society, because abdominal surgeons do esophageal surgery in Japan. In this meaning, thoracic surgery usually means chest surgery in Japan. Both cardiovascular surgeons and thoracic surgeons are members of the Japan Surgery Society, JSS. JSS has about 40,000 members, and JACS accounts for about 8% of the JSS membership.

Retroperitoneal teratoma misdiagnosed as a gastric stromal tumor: A case report.

The misdiagnosis of retroperitoneal teratoma as a gastric stromal tumor is rarely reported. There are numerous abdominal organs, and retroperitoneal tumors are easily concealed by organs situated more anteriorly on the abdomen; therefore, retroperitoneal tumors are easily misdiagnosed as human digestive system tumors by abdominal surgeons. We herein present the case of a 39-year-old female patient who was diagnosed with a gastric stromal tumor (GST) on preoperative examination, whereas the postoperative diagnosis was retroperitoneal mature cystic teratoma. Such cases are clinically rare. In the present case, the tumor was located in the retroperitoneum, near the lesser gastric curvature, without an obvious gap. The anterior surface of the tumor was concealed by the lesser gastric curvature and did not move significantly with breathing and changes in posture. In such cases, a preoperative misdiagnosis is very likely. The aim of the present study was to improve our understanding of the presentation of retroperitoneal teratomas, thereby gaining more clinical experience and hopefully reducing the rate of misdiagnosis.

ОСОБЕННОСТИ ПРОТЕЗИРОВАНИЯ ГРЫЖЕВОГО ДЕФЕКТА ПРИ ХИРУРГИЧЕСКОМ ЛЕЧЕНИИ ПОСЛЕОПЕРАЦИОННЫХ ВЕНТРАЛЬНЫХ ГРЫЖ

The article provides an overview of literature on the surgical treatment of postoperative ventral hernias (POVH), development trends and controversial questions of the problem. Today, according to many researchers, the frequency of POVH is up to 20-26% of the total number of external hernias of the abdomen, which give way to the primacy only to groin hernias. The recurrence rates of POVH remain high, reaching between 4.5-90% after the use of autoplasty methods and 3-19.5% after alloplasty methods. Incomplete satisfaction with the results of surgical treatment of POVH has helped to find new ways of hernioplasty using prosthetics, which allows increase the effectiveness of surgical treatment and reduces the incidence of complications. Increased intraabdominal pressure is the most common etiological factor in the development of purulent-inflammatory complications, leads to relapse, and increases the numbers of fatalities among patients with large POVH. The great interests among abdominal surgeons are issues of improving the quality of hernioplasty using prosthetic materials and methods of prevention of development inflammatory complications in the area of surgical wound. Keywords: Postoperative ventral hernia, hernioplasty, laparotomy, purulent complications.

A183 UPPER GASTROINTESTINAL CAUSTIC INJURIES: A SINGLE CENTRE CASE SERIES

Abstract Background Caustic esophageal and gastric injury is a rare, but potentially lethal event. The 2017 American Association of Poison Control reported only 193,000 cases of caustic ingestion (1). Caustic agents are acidic or alkaline. The pH of the ingested substance dictates the type of injury and the area of the gastrointestinal track most at risk. The most common culprit agents are alkaline including, for example, bleaches, drain openers and dishwashing detergents. Due to the rarity and natural history of this disease there are very few high-quality studies for clinicians to refer to when managing these patients. Aims We present three cases of caustic ingestion and provide a review of current best practice standards. Methods Between August and September 2019, three patients were admitted to Sunnybrook Health Sciences Centre at the University of Toronto for caustic injury. All three patients were referred to the gastroenterology service and underwent an esophagogastroduodenoscopy (EGD) to assess the degree of esophageal and gastric injury. Patients were followed both in hospital and in the outpatient setting for ongoing surveillance and repeated endoscopic evaluation. Patient demographics, treatment, endoscopic findings and outcomes were collected. Results Three patients intentionally ingested caustic agents, were admitted to hospital and managed by the gastroenterology service. Patients were a mix of ages, genders and ethnicities. All ingestions were strong alkali agents including sodium hydroxide and sodium hypochlorite. All patients underwent an EGD within 24 hours of presentation and caustic injury was graded using the Zargar classification (2). All patients were started on intravenous proton pump inhibitor therapy. All patients were initially made nothing per mouth and ability to resume feeds was assessed based on symptoms. Patient 1, Zargar grade 1, was able to resume oral intake within 48 hours and progressed to a regular diet without complications. Patient 2, Zargar grade 2a, required 5 days of TPN and bowel rest after which a liquid diet was initiated and advanced without complications. The third patient, had a severe injury (Zargar grade 3b), requiring a prolonged hospital stay. He was on TPN for three weeks before transitioned to tube feeds. Conclusions Caustic mucosal injuries are an infrequent, but potentially lethal event requiring urgent assessment and management by a team including gastroenterologists, thoracic and abdominal surgeons, dieticians and intensivists. High-quality evidence to guide management of caustic injuries remains limited. In our case series, there was a wide spectrum of degree of mucosal injury. All 3 patients were managed in a consistent fashion based on current recommendations. Two of three cases had a rapid recovery with the ability to resume oral intake and return home. The third patient remains in hospital, requiring a high level of supportive care. Funding Agencies None

Characteristics of gastrointestinal stromal tumors incidentally discovered during abdominal surgery.

835 Background: Gastrointestinal Stromal Tumors (GISTs) are rare sarcomas with 5000 new cases each year. Despite their low incidence, surgeons should be familiar with this pathology since GISTs can be encountered incidentally during abdominal surgery. Methods: A retrospective series was conducted by querying pathology and operative reports from a community cancer center between 2005 and 2019 for all GIST diagnoses. Patients identified to have incidental GISTs discovered intra-operatively while undergoing surgery for another diagnosis were the focus of this study. Patient and tumor characteristics were evaluated. Results: A total of 195 patients had a diagnosis of a resected GIST during our study period. Of these 195, 48 patients were incidentally discovered to have a GIST excised during another index operation. The average age of these patients was 62 years old, 27 were female and 21 male. The primary location of these incidental GISTs in descending frequency was stomach (62.5%, n = 30), small bowel (31.3%, n = 15), colon (4.2%, n = 2) and esophagus (2.1%, n = 1). The average GIST size for the cohort was 1.7cm, with stomach, small bowel, colon and esophagus measured at 1.8cm, 1.7cm, 0.65cm and 0.30cm, respectively. Mitotic rate was < 5 mitosis/50 HPF in 96% of patients. Incidental GISTs were identified during the following surgery: colon (n = 14), bariatric (n = 13), non-bariatric gastric (n = 10), hernia (n = 4), pancreatic (n = 3), esophageal (n = 2) and other (n = 2). Most incidental GISTs were discovered during elective surgery (81.3%, n = 39) compared to emergency surgery (18.8%, n = 9), and for benign disease (n = 33) compared to malignant (n = 15). Conclusions: Approximately one quarter of all GISTs resected at our community cancer center in 15 years were discovered incidentally, and during a wide variety of abdominal surgeries for both benign and malignant disease. Almost all these GISTs were < 2cm, benign, and should be cured with the incidental resection. Abdominal surgeons should be aware of unexpectedly finding small GISTs and should not be apprehensive about resecting since they have indolent characteristics. Larger lesions should trigger expert surgical oncology consultation.

Systematic review protocol examining the influence of surgeon personality on perioperative decision making in abdominal surgery

IntroductionThere is limited published literature exploring how the personality traits of surgeons may influence preoperative decision making, particularly in the context of visceral/abdominal surgery. Multiple validated personality scoring systems exist...

What Can Complex Abdominal Wall Hernia Surgeons Learn About Quality of Life From Ancient Greek Philosophers?

Ancient philosophers were the first to explore the concept of quality of life. Their conceptual views although complemented, challenged or replaced by other schools of thought such as Positivism, still underpin many modern thoughts pertaining to quality of life. QoL and its measurement are vital in healthcare. Often it is a perceived deterioration in QoL that prompts a surgical consult. Here, we outline some Greek philosophical thoughts about quality of life and highlight implica

International classification of abdominal wall planes (ICAP) todescribe mesh insertion for ventral hernia repair.

Nomenclature for mesh insertion during ventral hernia repair is inconsistent and confusing. Several terms, including 'inlay', 'sublay' and 'underlay', can refer to the same anatomical planes in the indexed literature. This frustrates comparisons of surgical practice and may invalidate meta-analyses comparing surgical outcomes. The aim of this study was to establish an international classification of abdominal wall planes. A Delphi study was conducted involving 20 internationally recognized abdominal wall surgeons. Different terms describing anterior abdominal wall planes were identified via literature review and expert consensus. The initial list comprised 59 possible terms. Panellists completed a questionnaire that suggested a list of options for individual abdominal wall planes. Consensus on a term was predefined as occurring if selected by at least 80 per cent of panellists. Terms scoring less than 20 per cent were removed. Voting started August 2018 and was completed by January 2019. In round 1, 43 terms (73 per cent) were selected by less than 20 per cent of panellists and 37 new terms were suggested, leaving 53 terms for round 2. Four planes reached consensus in round 2, with the terms 'onlay', 'inlay', 'preperitoneal' and 'intraperitoneal'. Thirty-five terms (66 per cent) were selected by less than 20 per cent of panellists and were removed. After round 3, consensus was achieved for 'anterectus', 'interoblique', 'retro-oblique' and 'retromuscular'. Default consensus was achieved for the 'retrorectus' and 'transversalis fascial' planes. Consensus concerning abdominal wall planes was agreed by 20 internationally recognized surgeons. Adoption should improve communication and comparison among surgeons and research studies.

CSF-diverting shunts: Implications for abdominal and pelvic surgeons; a review and pragmatic overview.

The optimal management of patients with ventriculoperitoneal or lumboperitoneal shunts undergoing abdominal or pelvic surgery for unrelated reasons is often unclear due to the paucity of guidelines in this field. In this review, we outline key issues in managing these patients. Specifically, we address issues relating to pre-operative planning, avoidance of shunt-related complications such as infection and malfunction, and specific management of neurological symptoms in the post-operative period.A retrospective study was carried out analysing correspondence between general surgeons and a specialist hydrocephalus unit over a 4-year period relating to management of patients with ventriculoperitoneal and lumboperitoneal shunts undergoing abdominal or pelvic surgery. A literature review was carried out to identify available evidence in this field. 30 queries from general surgeons were identified comprising 12 main themes. 16 relevant publications were identified. We summarised these to answer these queries.The management of shunted patients may present challenges and uncertainties in an abdominal or pelvic surgery setting. This paper provides guidelines and clarity in this field by discussing and summarising reported data in the literature.

Междисциплинарные проблемы в онкоурологии

A multidisciplinary approach is currently a necessary and standard approach in treatment of cancer patients. The main goals of the multidisciplinary approach include coordinated highly effective interaction of medical specialists to timely identify, prescribe and conduct planned treatment, as well as prevention and correction of adverse events of treatment to achieve most lasting effect of treatment. The article discusses role of multidisciplinary team, including an oncologist, urologist, pathomorphologist, molecular genetics, radiologist, medical oncologist, radiation therapist, neurosurgeon, orthopedic surgeon, endovascular, thoracic and abdominal surgeons for effective treatment of oncourological patients. To solve existing problems, it is necessary to create common standards for the treatment of oncological diseases, develop and improve an oncological care system, improve logistics and improve skills of specialists or train specialists in the required profile.

Laparoscopic repair of hiatal hernia.

Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons. Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017. There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery. Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

The Transplant Surgeon: An Unlikely, Yet Suitably Qualified, Member of The Complex Neuro Endocrine Multi-Disciplinary Team

Curative surgery for retro-peritoneal tumours involving vascular structures is challenging and multi-visceral resection is often required to obtain clear resection margins. Abdominal transplant surgeons have considerable experience in all aspects of visceral, vascular and retro-peritoneal surgery. Application of these skills to resect tumours involving vascular structures, and re-implant organs to preserve function is unique. We present the case of a 15- year old girl with a complex retro-peritoneal tumour which was resected en-bloc with the kidneys and vena-cava followed by auto-transplantation of the left kidney. Seven years later, the patient represented with a recurrent tumour which was successfully excised in its entirety. We discuss how innovative surgical strategies can be performed safely on an individualized basis. We highlight the importance of balancing the benefits of the ‘technically possible procedure’ with its risks, along with consideration of the outcomes of treatment and non-treatment alike.

Photoacoustic gas monitoring for anesthetic gas pollution measurements and its cross-sensitivity to alcoholic disinfectants

BackgroundReal-time photoacoustic gas monitoring is used for personnel exposure and environmental monitoring, but its accuracy varies when organic solvents such as alcohol contaminate measurements. This is problematic for anesthetic gas measurements in hospitals, because most disinfectants contain alcohol, which could lead to false-high gas concentrations. We investigated the cross-sensitivities of the photoacoustic gas monitor Innova 1412 (AirTech Instruments, LumaSense, Denmark) against alcohols and alcoholic disinfectants while measuring sevoflurane, desflurane and isoflurane in a laboratory and in hospital during surgery.Methods25 mL ethyl alcohol was distributed on a hotplate. An optical filter for isoflurane was used and the gas monitor measured the ‘isoflurane’ concentration for five minutes with the measuring probe fixed 30 cm above the hotplate. Then, 5 mL isoflurane was added vaporized via an Anesthetic Conserving Device (Sedana Medical, Uppsala, Sweden). After one-hour measurement, 25 mL isopropyl alcohol, N-propanol, and two alcoholic disinfectants were subsequently added, each in combination with 5 mL isoflurane. The same experiment was in turn performed for sevoflurane and desflurane. The practical impact of the cross-sensitivity was investigated on abdominal surgeons who were exposed intraoperatively to sevoflurane. A new approach to overcome the gas monitor’s cross-sensitivity is presented.ResultsCross-sensitivity was observed for all alcohols and its strength characteristic for the tested agent. Simultaneous uses of anesthetic gases and alcohols increased the concentrations and the recovery times significantly, especially while sevoflurane was utilized. Intraoperative measurements revealed mean and maximum sevoflurane concentrations of 0.61 ± 0.26 ppm and 15.27 ± 14.62 ppm. We replaced the cross-sensitivity peaks with the 10th percentile baseline of the anesthetic gas concentration. This reduced mean and maximum concentrations significantly by 37% (p < 0.001) and 86% (p < 0.001), respectively.ConclusionPhotoacoustic gas monitoring is useful to detect lowest anesthetic gases concentrations, but cross-sensitivity caused one third falsely high measured mean gas concentration. One possibility to eliminate these peaks is the recovery time-based baseline approach. Caution should be taken while measuring sevoflurane, since marked cross-sensitivity peaks are to be expected.

Elektive Versorgung von Leistenhernien in der universitären Chirurgie – eine ökonomische Herausforderung

Elective and emergency inguinal hernia surgery is acentral task for general and abdominal surgeons. As astandard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in acost-intensive environment of auniversity hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at auniversity hospital. All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated. Atotal of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, apatient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and aduration of hospital stay of less than 2days had asignificantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to anegative contribution margin of € 651 per case. Elective inguinal hernia surgery in the environment of auniversity hospital has a high financial deficit; however, since acomplete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.

Options and Management of Vascular Reconstruction in the Context of Abdominal Surgery and its Perioperative Care - Selection of Typical Clinical Situations and Cases

Interdisciplinary cooperation between surgeons can help to optimise outcome in the management of complex surgical diseases. The indication for surgical intervention has gradually expanded in advanced multivisceral tumour growth, with iatrogenic vascular injuries in the field of abdominal and oncological surgery and mesenteric ischemia. Appropriate expertise in vascular surgery is then essential, although this is not always available or in all hospitals. Narrative review based on current scientific references in the relevant literature and our own clinical and surgical experiences in decision making, the approach in clinical management and various options of vascular reconstruction in abdominal surgery. Prognosis is still limited in pancreatic cancer. R0 resection is the only curative therapeutic option - thus, the surgeon has to provide specific intraoperative expertise. Arterial reconstruction is still controversial, due to increased postoperative morbidity and limited evidence. But in specific cases, venous reconstruction has been established in clinical practice. In addition, in retroperitoneal sarcoma with advanced/extended tumour growth, reconstruction of the infiltrated inferior V.cava or common iliac artery by means of patch plasty or autologous bypass/segmental vascular prosthesis can become necessary as part of multivisceral resections. During inflammatory processes or with tumour adhesions/infiltrations to surrounding anatomical structures, intraoperative vascular injuries or postoperative vascular alterations can occur, further complicated by anatomical variants. The extremely strict demands on the abdominal surgeons, in particular in mesenteric ischemia, are influenced by i) a competent assessment of the mesenteric vessels based on ii) adequate imaging as well as iii) appropriate time management. Prompt recanalisation can play a decisive role for the prognosis. Vascular reconstructions in abdominal surgery, in particular, in oncological surgery, require great expertise of the surgeon. In this context, competent preoperative diagnostic testing, extensive specific experience in vascular surgery/interventions, appropriate interdisciplinary case management, adequate surgical tactic and technique are all important.

P-143 - Gastric cancer: system approach

Introduction: Search of optimal diagnosis and treatment strategies for gastric cancer (GC) patients (GCP) (T1-4N0-2M0) realized. Methods: We analyzed data of 788 consecutive GCP (age=57±9.4 years; tumor size=5.4±3.1 cm) radically operated (R0) and monitored in 1975-2019 (m = 550, f = 238; distal gastrectomies=460, proximal gastrectomies=163, total gastrectomies=165, combined gastrectomies with resection of pancreas, liver, diaphragm, colon transversum, esophagus, duodenum, splenectomy, small intestine, kidney, adrenal gland=241; D2-lymphadenectomy=513, D3-4=275; T1=235, T2=219, T3=179, T4=155; N0=432, N1=108, N2=248; G1=222, G2=161, G3=405; early GC = 162, invasive=626; only surgery=620, adjuvant chemoimmunotherapy-AT=168 (5-FU + thymalin/taktivin). Multivariate Cox modeling, clustering, SEPATH, Monte Carlo, bootstrap and neural networks computing were used to determine any significant dependence. Results: Overall life span (LS) was 2136.6±2311.4 days and cumulative 5-year survival (5YS) reached 58.4%, 10 years – 52.3%, 20 years – 40.3%. 314 GCP lived more than 5 years (LS = 4323.2±2297.4 days), 171 GCP – more than 10 years (LS = 5855.4±2083.6 days). 286 GCP died because of GC (LS = 650.7±345.1 days). AT significantly improved 5YS (69% vs. 56.4%) (P = 0.0176 by log-rank test). Cox modeling displayed that 5YS of GCP significantly depended on: phase transition (PT) early—invasive GC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G, AT, procedure type, blood cell circuit, prothrombin index, hemorrhage time, residual nitrogen, ESS, gender (P = 0.000-0.046). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive GC (rank=1), PT N0—N12 (rank=2), healthy cells/CC (3); erythrocytes/CC (4), thrombocytes/CC (5), glucose (6), prothrombin index (7); monocytes/CC (8), lymphocytes/CC (9), eosinophils/CC (10), stick neutrophils/CC (11), segmented neutrophils/CC (12), leucocytes/CC (13). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0). Conclusion: Survival outcomes after radical procedures significantly depended on: 1) PT “early-invasive cancer”; 2) PT N0--N12; 3) Cell Ratio Factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) GC characteristics; 9) procedure type; 10) anthropometric data. Optimal diagnosis and treatment strategies for GC are: 1) screening and early detection; 2) availability of experienced abdominal surgeons because of the complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunotherapy for GCP with unfavorable prognosis.

3D vs. 4K Display System - Influence of \u201cState-of-the-art\u201d-Display Technique On Surgical Performance (IDOSP-Study) in minimally invasive surgery: protocol for a randomized cross-over trial

BackgroundThree-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual task. The reduction from real life 3D to virtual two-dimensional (2D) sight is a major challenge in minimally invasive surgery (MIS). A 3D display technique has been shown to reduce operation time and mistakes and to improve the learning curve. Therefore, the use of a3D display technique seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics, a 4K display technique was recently introduced to MIS. Due to its high resolution and zoom effect, surgeons should benefit from it. The aim of this study is to evaluate if “state-of-the-art” 3D- vs. 4K-display techniques could influence surgical performance.MethodsA randomized, cross-over, single-institution, single-blinded trial is designed. It compares the primary outcome parameter “surgical performance”, represented by “performance time ”and “number of mistakes”, using a passive polarizing 3D and a 4K display system (two arms) to perform different tasks in a minimally invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (National Aeronautics and Space Administration (NASA) Task Load Index) and the learning curve. Unexperienced novices (medical students), non-board-certified, and board-certified abdominal surgeons participate in the trial (i.e., level of experience, 3 strata). The parkour consists of seven tasks (for novices, five tasks), which will be repeated three times. The 1st run of the parkour will be performed with the randomized display system, the 2nd run with the other one. After each run, the mental stress load is measured. After completion of the parkour, all participants are evaluated by an ophthalmologist for visual acuity and stereoscopic vision with five tests. Assuming a correlation of 0.5 between measurements per subject, a sample size of 36 per stratum is required to detect a standardized effect of 0.5 (including an additional 5% for a non-parametric approach) with a power of 80% at a two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled.DiscussionComplex surgical procedures are performed in a minimally invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance.Trial registrationClinicalTrials.gov, NCT03445429. Registered on 7 February 2018.