Aim: Over the past decade, transcatheter aortic valve implantation (TAVI) has matured into a valid treatment strategy for elderly patients with severe aortic stenosis. TAVI programs will grow with its adoption in low-risk patients. The aim of this study was to evaluate safety and feasibility of early discharge protocols, either home or back to a referring hospital.
Methods: Consecutive patients undergoing TAVI between July 2017 and July 2019 were stratified into three discharge pathways from TAVI center: (1) early home (EXPRES); (2) early transfer to referring hospital (R-EXPRES); and (3) routine discharge (standard). Baseline, procedural, and 30-day outcomes were prospectively collected and compared per discharge pathway.
Results: In total, 22 (5%) patients were enrolled in the EXPRES cohort [median age 78 (IQR: 73-81); mean Society of Thoracic Surgeons (STS) 2.4% ± 1.5%], 121 (29%) in the R-EXPRES cohort [median age 81 (IQR: 77-84); mean STS 4.3% ± 2.8%], and 269 (65%) in the routine discharge cohort [median age 80 (IQR: 75-85); mean STS 4.4% ± 3.1%]. EXPRES patients trended to be younger (P = 0.13) and had lower STS (P = 0.02). Early clinical outcome was similar through the different pathways including re-hospitalization rate. Median length of stay was one day longer for R-EXPRES vs. routine discharge patients [5 (IQR: 4-7) vs. 4 (IQR: 3-6); P < 0.01]. Median length of stay (LOS) was two days (IQR: 1-3 days) for EXPRES patients.
Conclusion: Early discharge pathways home and to referral hospitals are safe and help streamline TAVI programs. LOS in referring hospitals may be further reduced.
Transcatheter aortic valve replacement (TAVR) is a safe and effective treatment strategy for severe aortic stenosis. However, peri-procedural complications can have a significant impact on acute and longer-term morbidity and mortality. Therefore, this review article provides a practical overview on how to prevent and manage the common and also rare but life-threatening peri-procedural TAVR complications.
Severe calcific aortic stenosis (AS) and coronary artery disease (CAD) have common risk factors and are frequently encountered in the same patient in clinical practice. CAD has been reported in ≥ 50% of AS patients undergoing both surgical treatment and transcatheter aortic valve implantation (TAVI). In the last two decades, TAVI has been established as a less invasive alternative to surgery. Recently, more and more young and low surgical risk patients undergo TAVI. Despite the high prevalence of CAD in patients treated with TAVI, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty. This review provides an updated overview of the current knowledge about this topic and offers points for reflection about the best approach to use.
The impact of sex on baseline characteristics and morphological and clinical presentation of degenerative aortic stenosis has been widely demonstrated but poorly understood. Moreover, differently from valve surgery, where patients were predominantly male, both sexes have been well represented in percutaneous treatment of aortic stenosis (AS), and women appeared to derive greater benefit with transfemoral aortic valve implantation (TAVI) compared to surgical treatment. This review focuses on sex-specific differences in epidemiology, pathophysiology, diagnostic issues, treatment options, and clinical outcomes of degenerative AS. Moreover, we evaluate how sex-based TAVI management, from device selection to procedural tricks, may affect outcomes.
Aim: In uniportal thoracoscopic major pulmonary resection, it is important to appropriately manage significant vessel injury, to ensure patient safety and minimize conversion to thoracotomy. We analyzed cases of significant vessel injury and investigated efficacy of an algorithm to manage bleeding during thoracoscopic uniportal major pulmonary resection.
Methods: A total of 169 patients underwent “uniportal thoracoscopic major pulmonary resection” (lobectomy or segmentectomy) at our department between February 2019 and April 2021. These patients were classified into groups with (group A, n = 8) and without (group B, n = 161) intraoperative massive bleeding. Patient characteristics and perioperative results were compared between the two groups. Patients with significant vessel injury and conversion to thoracotomy were analyzed in detail.
Results: Group B had significantly less blood loss (A: 197 ± 173 g; B: 42 ± 74 g, P < 0.0001) and shorter-duration postoperative drainage (A: 2.6 ± 1.8 days; B: 1.6 ± 1.3 days, P = 0.036). There were no group differences in any other factors. The most frequently injured vessel in group A was the pulmonary artery (75%). Emergent conversion was required in four cases (cases 7, 76, 128, and 133; 2.4%) due to intraoperative bleeding. No patient developed catastrophic bleeding or required an intraoperative transfusion.
Conclusion: We managed significant vessel injury appropriately during uniportal thoracoscopic major pulmonary resection using the troubleshooting algorithm. The algorithm for the uniportal approach was considered effective and easy to apply even by less-experienced surgeons.
Aim: We aimed to evaluate trifecta outcomes after Retzius-sparing robot-assisted radical prostatectomy (rs-RARP).
Methods: We evaluated 1488 patients who had undergone rs-RARP at our institution from 2011 to 2019. All patients filled out questionaries for functional outcomes before surgery, and only patients with baseline continence and IIEF-5 scores of > 16 were included. Biochemical recurrence (BCR) was defined as two consecutive prostatic specific antigen levels of > 0.2 ng/mL after rs-RARP. Postoperative continence was defined as the use of no pads. Potency was defined as the ability to achieve erections for sexual intercourse, with or without phosphodiesterase-5 (PDE-5) inhibitors. A multivariable logistic regression model was performed to identify predictors of trifecta outcome.
Results: In total, 1240 patients were included in the analysis. During the 24-month follow-up time, 149 patients (11.9%) harbored BCR. Urinary continence was observed in 981 patients (79.5%), while 171 (13.8%) still used a safety pad daily after 24 months. Sexual potency was reported in 643 patients (51.9%), of whom 379 (30.6%) had spontaneous erections and 264 (21.3%) used a PDE-5 inhibitor. Overall, the trifecta outcome was reached by 42.1% of the study’s population. The trifecta outcome was easily reached by younger patients and patients who underwent a full nerve-sparing (NS) prostatectomy. In the multivariable model, age [odds ratio (OR) = 0.89; 95% confidence interval (CI): 0.84-0.90; P < 0.01] and type of NS surgery [partial NS (OR = 3.34; 95%CI: 1.01-11; P = 0.04) full NS (OR = 4.57; 95%CI: 1.86-12; P < 0.01)] resulted as independent predictors.
Conclusion: rs-RARP is associated with optimal trifecta outcome rate. Age and NS technique are independent predictors of trifecta outcomes.
Endoscopic submucosal dissection (ESD) is rapidly becoming the standard treatment for superficial gastrointestinal tumors because ESD can achieve complete local resection facilitating thorough pathological examination of the resected specimen. The pocket-creation method (PCM) has been established to perform safe and reliable ESD obtaining a high-quality pathological specimen. A minimal mucosal incision using PCM minimizes leakage of submucosally injected solution, which results in prolonged mucosal elevation. A limited-space submucosal pocket created using PCM makes the endoscope tip stable. A conical cap, small-caliber-tip transparent (ST) hood is used when performing PCM. The submucosa can be cut along the ideal dissection line just above the muscularis with minimal thermal damage because the tip of the ST hood produces both traction and countertraction to stretch the submucosal tissue in the pocket. PCM is recommended as the standard strategy not only for colorectal ESD but also for upper-gastrointestinal ESD. It is expected that the use of traction techniques will make PCM easier to perform.
Endoscopic spine surgery (ESS) is an ultra-minimally invasive technique through which spinal pathology can be addressed via sub-centimeter incisions with negligible soft tissue disruption. However, concerns exist regarding the steep learning curve, operative time, and radiation exposure to the surgical team. The use of intraoperative navigation, mixed reality, and robotics in the setting of ESS is currently being explored, and the early evidence suggests that such technologies may help mitigate these issues. The application of these technologies in ESS as well as the associated literature is reviewed herein.
Bariatric surgery is the cornerstone of treatment for severe obesity. In evaluating patients for such procedures, surgeons must be aware of the potential complications, including post-operative gastroesophageal reflux disorder (GERD). This review article outlines the current literature regarding GERD prior to and after bariatric surgery. It aims to establish a framework for evaluating and managing GERD in both the pre- and post-operative setting for common bariatric procedures such as the sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric band, duodenal switch type procedures as well as one-anastomosis gastric bypass. This review also outlines the latest recommendations from major international bariatric societies for screening prior to surgery, the incidence of GERD after each respective procedure and a summary of current trends in the management of post-operative GERD after bariatric surgery.
Superficial non-ampullary duodenal epithelial tumors (SNADETs) are rare, but their incidence is increasing recently. Considering the invasiveness of pancreatoduodenectomy, endoscopic treatment is widely accepted as an option for maintaining patients’ quality of life. SNADETs larger than 20 mm are an indication for duodenal ESD, and intramucosal cancer can be cured by ESD. Duodenal ESD is extremely difficult with a high risk of adverse events. However, some modified treatment techniques such as the water pressure method or the pocket creation method have been proposed to improve outcomes. Furthermore, evidence is accumulating that protection of the mucosal defect reduces delayed adverse events after duodenal endoscopic treatments. Moreover, endoscopic drainage of the bile and pancreatic juice is effective as conservative management even in cases with delayed perforation.
With the rising prevalence of obesity, there has been a steady rise in the number of bariatric surgeries performed worldwide. As expected, there has also been an increase in the number of revisional surgeries performed to manage acute and chronic postoperative complications. This review will discuss the major complications that can arise from the most common bariatric surgeries, their diagnosis, medical management, and potential revisional surgical options.
In recent years, an increasing number of bioprostheses have been implanted, and in the near future more and more patients will be candidates for reoperation due to structural deterioration of the valve. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become a safe and effective alternative to surgery and is currently approved for higher-risk, inoperable patients. From the most recent studies, early mortality has decreased and improvements in symptoms and quality of life of treated patients have been documented. ViV TAVR is a complex procedure that can present many pitfalls and therefore must be performed in high volume centers and with experienced staff because the risk of peri- and post-procedural complications is much higher than TAVR on native valve. In this review, we analyze the main procedural issues reported in the literature during ViV TAVR procedures: elevated postprocedural gradients, coronary obstruction and thrombosis of the leaflets of the bioprosthesis. Because of the opening of TAVR to younger and younger patients, thus with a longer life expectancy than the durability of the bioprosthesis, the next challenge will be the management of the lifetime strategy of patients with aortic stenosis, as the first type of intervention will influence all future therapeutic choices of our patient.
Aim: The purpose of the study was to describe our surgical technique of salvage robot-assisted radical prostatectomy (sRARP) in patients who underwent primary high-intensity focused ultrasound (HIFU) and to report the perioperative, functional, and oncological outcomes during the first year follow up. The secondary aim of the study was to review the current literature evidence on this topic.
Methods: We retrospectively extracted, from our prospective RARP database, all the patients who underwent sRARP for biochemical recurrence after primary HIFU. All the surgical interventions were performed by a single surgeon following our total anatomical reconstruction (TAR) technique. Demographics, perioperative, functional, and oncological results were collected up to one year follow-up.
Results: Eleven patients underwent post-HIFU sRARP with TAR technique at our institution. All the surgical procedures were uneventful. All the complication recorded were classified as Clavien-Dindo Grade I. Continence rate at 1-, 3-, 6-, and 12-month post intervention was 36.3%, 45.5%, 63.6 %, and 81.1%, respectively. Medium PSA at 12 months follow-up was 0.2 ng/mL (SD 0.01), with no Biochemical Failure (BCF) recorded.
Conclusion: sRARP with TAR technique is a safe and feasible procedure in patients with BCF after primary HIFU. No major complications were recorded, with good oncological and functional results after one year follow up.
The advent of modern diagnostic techniques and improved patient monitoring in the setting of clinical trials has led to an increased diagnosis of oligometastatic prostate cancer (OMPC), defined as three-to-five metastatic deposits in a single organ or multiple organs. OMPC is increasingly diagnosed in men who were in the past considered to have organ-confined disease. OMPC occurs at the transition between localized prostate cancer and widespread metastases. Our review evaluates the available evidence regarding robot-assisted cytoreductive prostatectomy feasibility and oncological outcomes in oligometastatic settings. We also consider the limitations and future directions for this approach. We performed a non-systematic PubMed and Google Scholar search. We screened pertinent studies published from 2014 up to May 2021. Our search identified 524 records. After excluding duplication, 54 full-text articles were identified and were screened for eligibility. We found nine papers (863 patients) that met the inclusion criteria for the review. The outcomes evaluated were 1-, 3-, and 5-year progression-free survival, cancer-specific and overall survival rates. Our review article demonstrates the feasibility and safety of Robot-assisted radical prostatectomy in patients with OMPC with proven oncological benefits. Prospective studies are ongoing and may provide further solid evidence.
IT knife nano® (Olympus Medical Co., Tokyo, Japan) is a knife device specialized for esophageal and colorectal endoscopic submucosal dissection (ESD). The IT knife nano has a smaller insulated tip than that of the IT knife 2, making it easier to handle the submucosal layer in the colorectum. The disk behind the insulated tip is also smaller to reduce thermal damage to the muscle layer. Furthermore, the IT knife nano is considered to have more power for incision because the IT knife nano has a large amount of electric current at the blade compared to other devices. Therefore, the IT knife nano can resect a larger amount of submucosal layer tissue at once, enabling a faster and more reliable detachment of the submucosal dissection as well as a circumferential mucosal incision. When performing submucosal dissection using an IT knife nano, the knife should be moved from the outside to the inside. While in a difficult situation, moving the knife gradually from the center (inside) to the outside can help perform a safe colorectal ESD. The IT knife nano is considered an option for difficult situations, such as lesions with severe fibrosis, or when rapid submucosal dissection is required. We herein provided technical aspects of the IT knife nano in detail and compared it with other needle-type devices.
Widespread adoption of colorectal endoscopic submucosal dissection (ESD) in clinical practice is lagging despite the peer evidence that it permits en bloc resection of large lesions that can be curative and facilitate pathological staging, thereby improving management. Limited adoption of colorectal ESD is likely due to technical challenges and a steep learning curve. Most conventional ESD devices are used without fixing the target, making them difficult to maneuver and thus creating a potential risk of perforation. Comparatively, a scissor-type knife, such as the SB Knife Jr, enables grasping of the target tissue, facilitating controlled dissection of tissue being held between the blades. This potentially prevents unexpected muscular layer injury. Colorectal ESD with the SB Knife Jr does not require complex endoscopic maneuvering or advanced skills for safe ESD. Since the incision and dissection procedure using the SB Knife Jr is different from that of conventional ESD knives, familiarization with its features is vital. In this review, we focus on the use of the SB Knife Jr for colorectal ESD. The basic colorectal ESD procedure using the SB Knife Jr consists of grasping, pulling, and cutting. By repeating these steps, circumferential incision, submucosal dissection, and hemostasis can be performed with a single device. For incision and dissection, a circumferential mucosal incision is performed similar to “cutting paper”. Submucosal dissection is performed with the image of “connecting the dots at the appropriate dissection depth”. The SB Knife Jr is useful as a secondary device in challenging ESD procedures, and surgeons should master its use.
Colorectal endoscopic submucosal dissection (ESD) is now widely performed and firmly established in the treatment of early-stage colorectal cancer. In particular, there have been many studies on difficult cases of colorectal ESD. Difficult cases can be divided into two groups: difficult dissection of the lesions and difficult approach to the lesion. In most cases, a combination of strategies can solve the problem. Challenging lesions such as those in the anal canal and ileum can also be treated from an anatomical perspective. In the rectum, there are no limits to size or circumference. In addition, the indications for ESD in patients without risk of metastasis other than deep invasion are being considered. Therefore, when ESD is performed on difficult lesions, it is necessary to ensure the quality of dissection.
The prevalence of obesity in both the United States and worldwide has grown significantly over the last several decades. With this growing pandemic, more patients are seeking surgical alternatives to achieve weight loss goals. Bariatric surgery has multiple proven health benefits, including weight loss and resolution of several co-morbidities, including diabetes. Advances in surgical techniques, including laparoscopy, have allowed bariatric surgery to increase in popularity among obese patients. However, bariatric surgery is not without complications. Key to successful weight loss surgery includes appropriate pre-operative laboratory workup, a multidisciplinary approach with other health care providers, proper peri-operative techniques as well as close post-operative follow up. This article will highlight several important criteria bariatric surgeons should bear in mind when evaluating patients in pre-operative, peri-operative and post-operative states to help prevent common complications seen in weight loss surgery.
Endoscopic submucosal dissection (ESD) is widely performed to treat superficial colorectal tumors because it enables en bloc resection of various types of lesions. However, ESD sometimes leads to deleterious adverse events, such as perforation and delayed bleeding. Therefore, determining the precise preoperative indication for ESD is vitally important. Furthermore, small lesions with fibrosis and semi-large lesions can be managed using underwater endoscopic mucosal resection, and the “true” indication for ESD is for the treatment of larger lesions, for which ESD carries a higher risk. Here, we reviewed the devices, techniques (i.e., pocket creation method, water pressure method, and clip and flap method), traction (i.e., clip with line, pulley method, and clip with ring), suturing (i.e., line-assisted complete closure, loop clip, clip-on-clip closure method, mucosal incision around the mucosal defect, and hand-suturing), and countermeasures to address complications (i.e., bleeding after ESD, perforation, and post-ESD coagulation syndrome) that facilitate easier and safer ESD.
Although the diagnostic and therapeutic opportunities for superficial nonampullary duodenal epithelial tumors (SNADETs) have been increasing, the natural history and treatment outcomes remain unclear. Due to the anatomical characteristics of the duodenum, clinicians should be more sensitive to the occurrence of complications for tumors in the duodenum compared to other gastrointestinal tumors. Recently, with the expectation of minimally invasive treatment, cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR) have been accepted as simple and safe endoscopic treatments for SNADETs. In our institution, CSP achieved good treatment outcomes: a median procedure time of 3 (range, 1-23) min, an en bloc resection rate of 96.9%, an R0 resection rate of 50.0%, and a low incidence of adverse events (no delayed bleeding and no intra- and postoperative perforation). Moreover, UEMR also achieved good treatment outcomes: a median procedure time of 5 (range, 1-104) min, an en bloc resection rate of 82.9%, an R0 resection rate of 52.0%, and a low incidence of adverse events (delayed bleeding occurred in 2.6% of cases, and there were no incidences of no intra- and postoperative perforation). Residual recurrences occurred in two lesions (4.1%) that were treated with CSP and three lesions (4.8%) that were treated with UEMR, but these recurrences could be treated by re-endoscopic resection. Although there are limited data on these treatments for SNADETs, some previous reports and our data suggest that CSP could be indicated for adenomas sized 10 mm or less and that UEMR could be indicated for adenomas sized 10-20 mm and for intramucosal carcinomas. However, at present, the number of cases evaluated is still insufficient, and further studies are needed to evaluate long-term outcomes with enough cases.
Bariatric surgery procedures are increasing exponentially with the obesity epidemic. Early complications are defined as those that occur within the first 30 days after surgery. Some of the most common early complications are leaks, bleeding, stricture or stenosis and bezoar, all of which can be diagnosed and treated endoscopically. Upper endoscopy has been proven to be safe in the early postoperative period and different endoscopic modalities, like stenting, clipping, overstitch, among others, are part of the armamentarium the endoscopist should have available to address complications and potentially avoid the morbidity and mortality associated with re-operation.
Gastrointestinal bleeding following bariatric surgery is a relatively rare adverse event but constitutes a significant cause of morbidity. It requires a high index of suspicion, early diagnosis, and prompt management, as it can lead to rapid deterioration and potential mortality. In most cases, GI bleeding is self-limited and does not necessitate emergent reoperation. For some patients, however, control of postoperative hemorrhage may require various procedural-based interventions via surgical, endoscopic, or radiologic approaches. Recent studies suggest that endoscopic therapies to manage intraluminal bleeding post-bariatric surgery are becoming increasingly popular given their high efficacy rate and favorable safety profile. Currently, there is no consensus on the management of early or late GI hemorrhage after metabolic surgery. Therefore, the aim of this review is to summarize the effectiveness of several treatment options and outline management algorithms for this subset of bariatric patients based on the established literature.
Internal hernia formation is a feared complication following bariatric surgery. Protrusion of the small bowel through mesenteric defects can result in volvulus presenting with symptoms of bowel obstruction. If left untreated, patients may go on to develop bowel ischemia with possible perforation or necrosis necessitating emergent surgical exploration with resection. In severe cases, extensive bowel resection is required, leading to short-gut syndrome, which can have devastating consequences for the already nutritionally vulnerable bariatric patient. This review presents a comprehensive summary of various surgical techniques and technical factors implicated in the formation of internal hernias. The clinical presentation of patients with internal hernias, appropriate diagnostic work-up, and effective management and treatment strategies are discussed based on the established literature.
As transcatheter aortic valve implantation (TAVI) expands to younger and low-risk patients with longer life expectancies, the need for post-TAVI coronary access and reintervention for failing transcatheter heart valve (THV) is expected to increase. Commissural alignment in TAVI may facilitate subsequent coronary access, avoiding severe overlap with the THV commissures, and potentially redo-TAVI. The ability to traverse a THV to access the coronary ostia is related to anatomic factors (coronary height and sino-tubular junction (STJ) height and width) and valve-related features. Furthermore, recent evidence suggests that commissural alignment after TAVI may have an impact on THV’s hemodynamics and durability. Several studies have provided technique modifications to obtain commissural alignment with available self-expanding TAVI devices. However, future efforts should aim to refine THV and delivery system designs to make neo-commissural alignment easier and safer. An individualized decision-making approach is recommended in device selection when considering future coronary access and redo-TAVI to facilitate the lifetime management of patients with aortic valve and coronary artery disease. This review aims to provide an overview of available evidence for neo-commissural alignment and strategies to achieve more anatomic valve implantation further.
To maximize the effectiveness of colonoscopy in decreasing the incidence and mortality of colorectal cancer (CRC), high-quality colonoscopy procedures are essential. Considering that the colonoscopy quality varies among endoscopists, it is important to understand the endoscopist factors that influence the colonoscopy quality. In this paper, we reviewed the endoscopist factors related to colonoscopy quality. There are several quality indicators of colonoscopy, among which the adenoma detection rate is the most established indicator with evidence of its correlation with post-colonoscopy CRC. With respect to lesion detectability during colonoscopy, there are other measurements such as the sessile serrated lesion detection rate; however, further evidence on their relationships with post-colonoscopy CRC is needed. Previous studies that have examined the endoscopist characteristics influencing colonoscopy quality have suggested that several factors, including experience, the volume of colonoscopy procedures, and endoscopist specialty, are related to lesion detectability. However, discrepancies exist regarding the studies’ results; in particular, the influence of endoscopist specialty on coloscopy quality is controversial. Some recent studies have demonstrated that endoscopist specialty is not related to lesion detectability when considering confounding factors. Furthermore, it has been reported that nurse endoscopists can provide high-quality colonoscopy after training. It may be possible for endoscopists to improve their colonoscopy quality, regardless of specialty. Training, monitoring, and feedback of colonoscopy quality measurements are useful interventions for endoscopists to ensure high-quality procedures. Owing to the continuous development of endoscopic technologies, it is believed that training is useful for both inexperienced and experienced endoscopists.
Colorectal cancer (CRC) screening can reduce the incidence and mortality of CRC, and many countries with moderate-to-high incidences of CRC have implemented population screening programs. Colonoscopy plays a pivotal role in the context of CRC screening as the primary screening modality, the diagnostic exam after a positive noninvasive test, the therapeutic procedure for resecting detected neoplasms, and the surveillance exam after the removal of neoplastic lesions. Although colonoscopy outperforms other noninvasive tests in detecting colorectal neoplasms, it is associated with higher cost, manpower, and invasiveness. Owing to the heterogeneity of healthcare systems in terms of the scale of health revenue, population demographics, and the payment systems in each country, the optimal or most cost-effective screening strategy may vary. Accordingly, economic appraisal of different approaches is essential, especially in organized screening programs within which the resources and the clinical capacity are constrained, and each step of the screening flow needs careful monitoring. The therapeutic procedures applied to manage screening-detected lesions and subsequent surveillance procedures also contribute to substantial additional costs. The level of willingness to pay is affected by various factors, including demographics, income, educational level, and health consciousness, and largely affects the optimal strategies. Herein, we systematically review and summarize the current evidence regarding the cost-effectiveness of colonoscopic screening, related therapeutic procedures, and subsequent surveillance and provide a balanced view from the perspective of population screening programs. It was revealed that 10-year colonoscopy is the most effective strategy compared to other strategies under the higher willingness-to-pay threshold or low colonoscopy cost. There are, however, discrepancies in the results among studies from different countries, which could be associated with the different cost parameters and assumptions used in the models. As for various therapeutic procedures for colorectal neoplasms such as polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection, strategies based on the risk of advanced histology or deep submucosal invasion based on image-enhanced endoscopy are the least expensive and avoid more recurrences. Furthermore, subsequent surveillance strategies that are based on the risk of CRC are more cost-effective. This article provides a comprehensive review of the literatures and a balanced view from the perspective of population screening programs.
Aim: Video-assisted thoracoscopic surgery (VATS) is now a gold standard in treating early-stage empyema, while much debate still exists considering the effectiveness of this approach for late-stage empyema. Most concerns arise from the crowded rib cage, narrow working space, and ability to free trapped lungs quickly, mainly if uniportal VATS is used. However, unlike uniportal VATS lobectomy, there is no consensus about standard steps for uniportal VATS decortication to ensure smooth and effective surgery. We try to offer standard, easy-to-replicate steps for this approach to evaluate the efficacy and safety of the “start away from empyema” approach for uniportal VATS decortication in the management of stage II and III empyema.
Methods: A prospective case series study has been conducted on 25 patients. All patients with stage II and III empyema were admitted to the Cardiothoracic Surgery Department between October 2017 and March 2020. VATS procedure was done under general anesthesia by a double-lumen tube for selective ventilation. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, and complications were recorded.
Results: Twenty-five patients were enrolled in this study with a median age of 35 years. The duration of illness ranged between 14 and 60 days, with a median (IQR) of 25 (17) days. In (88%) of the patients, there was a successful outcome defined as a near-complete resolution on Chest X-ray (scoring of 3 or 4) and chest US (scoring of 2 or 3). Only three (12%) patients had a partially successful outcome. All patients with partial success suffered from infection associated with malignant effusion.
Conclusion: “Start away from empyema” approach for uniportal VATS decortication in stage II and III empyema could be safe and effective in treating loculated nonmalignant pleural effusion.
Recent developments and breakthroughs in artificial intelligence (AI) for colonoscopy have the potential to improve the quality of colonoscopy. Computer-aided detection for colorectal polyps has been shown to increase the adenoma detection rate by more than 10%. Furthermore, recently developed computer-aided quality assessment (CAQ) systems, such as real-time withdrawal speed monitoring, are expected to provide additional gain in colonoscopy practice. However, the added clinical value of combining AI techniques is uncertain. This paper provides an overview of the latest evidence on CAQ systems and identifies knowledge gaps that need to be filled before widespread implementation.
Nutritional deficiencies can develop into challenging problems in patients undergoing metabolic surgery for weight loss. In order to prevent the development of serious complications, effective screening algorithms and routine supplementation should be employed in the postoperative period. This paper outlines the nutritional function of different positions of the gastrointestinal tract, and common nutritional deficiencies associated with sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch. We present appropriate screening/supplementation protocols for each metabolic surgery, supplementation regimens when nutritional deficiencies develop, and surgical approaches to overcome nutritional deficiencies refractory to medical management.
Bariatric surgery is the most effective treatment for morbidly obese patients. Studies investigating the relationship between bariatric surgery and gastroesophageal reflux disease (GERD) are discordant. Depending on the type of intervention, pre-existing GERD can improve, worsen, or develop “de novo” in previously unaffected patients. Therefore, a review of the literature is performed to evaluate the effects of different bariatric surgical procedures on GERD. Currently, the bariatric surgical procedures more frequently performed are laparoscopic sleeve
Aims: We present the technique of a combined endoscopic and robotic approach for Mirizzi syndrome (MS) and report the short- and long-term results.
Methods: Between July 2012 and August 2020, all patients with suspected MS underwent endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic confirmation and placement of the biliary stent. Subtotal cholecystectomy was then performed with the assistance of a surgical robot. The common bile duct was closed with a cuff of the gallbladder over a biliary stent. ERCP was repeated 6-8 weeks after surgery to remove the biliary stent and confirm the patency of common bile duct. The operative outcomes and long-term results were prospectively collected.
Results: Twenty-two patients (10 males and 12 females) were included in the study. All patients underwent the planned robotic subtotal cholecystectomy and pre- and postoperative ERCP. The median age was 65.5 years (range 16-89 years). The median operative time was 212.5 min (range 125-510 min), and the median blood loss was 35 mL (range 7-700 mL). The median postoperative hospital stay was four days (range 3-15 days). Four patients (18.2%) developed postoperative complications including two intra-abdominal collections (9.1%), one wound infection (4.5%), and one atrial fibrillation with pneumonia (4.5%). The last patient also represented the only operative mortality. The median follow-up was 45.6 months; none developed recurrent cholangitis or jaundice, but one patient (4.5%) had a recurrent common bile duct stone which was successfully removed by ERCP.
Conclusion: The proposed combined endoscopic and robotic approach can provide favorable short- and long-term outcomes for patients with MS.
We performed robot-assisted thoracoscopic esophagectomy in lateral decubitus position (LDP) with camera rotation and manual hand control assignment to reproduce the visualization and manipulation of open esophagectomy or thoracoscopic esophagectomy in LDP. Four robotic ports and two 12 mm assistant ports were placed. The camera image for the operator was vertically and horizontally inverted by camera rotation to create an operative view similar to that achieved under open thoracotomy. We used a forward-oblique viewing endoscope with a 30° down-facing orientation. The mediastinal view was obtained by single lung ventilation, artificial pneumothorax by carbon dioxide insufflation, and trachea retraction by the assistant. The right and left hands were assigned to any combination of two out of the three arms depending on the situation. The remaining arm was used as an assistant to create an adequate surgical view. The robotic platform is useful to manage aortic injury by direct suturing.
Aim: Small bowel capsule retention is rare, with a rate of approximately 2%, defined as visible retention on plain film of abdomen (PFA) after 14 days. Currently, PFA is performed if the capsule is not seen to reach the large bowel during recording. Alternatively, for upper gastrointestinal (UGI) capsule studies, the risk of retention is determined if the capsule fails to reach the small bowel during recording. Given the similar physical specifications of the capsules (Medtronic) used, we considered whether 14-day PFA is no longer required for small bowel capsules not observed in the large bowel.
Methods: The use of patency capsules in our lab allows careful selection of small bowel capsule studies to minimize the risk of retention. All PFAs performed over a five-year period were reviewed to determine if careful selection and use of patency negate the need for capsule retention PFA screening.
Results: In total, 688 small-bowel capsules were performed during the study period, and 3.6% had prior patency capsules. Thirty-one PFAs with a query of capsule retention were performed during the study period on 28 patients. This included 15 females, and the median age was 53.5 years. None of the films demonstrated capsule retention.
Conclusion: Our data suggest that 14-day PFA may no longer be required for small bowel capsules not seen to reach the large bowel. Advice regarding symptoms of capsule retention and precaution with magnetic resonance imaging, similar to current UGI capsule advice, may suffice. This may reduce the burden on radiology imaging slots and, in particular, eliminate unnecessary radiation exposure and repeat hospital attendance for patients.
Aim: We evaluated the reduction of mechanical complications (MCs) in circumferential minimally invasive spinal surgery (c-MIS) to treat adult spinal deformity (ASD) using lateral lumbar interbody fusion and a percutaneous pedicle screw.
Methods: Patients with ASD who underwent c-MIS with a follow-up period of > 24 months were enrolled. Groups were as follows: c-MIS using 5.5 mm rods (P group), c-MIS using a 5.5 mm single rod with cement augmentations in the upper instrumented vertebra (UIV)/UIV + 1 (B group), c-MIS using 6 mm rods (6P group), and multi-rod
Results: Overall, 146 patients with ASD who underwent c-MIS were included. The incidence of PJK was significantly lower in the P and M groups than in the B group, and rod fracture was significantly lower in the M group than in the B and P groups. In the MC group, preoperative PT, postoperative PI-LL, and PSA were significantly larger than those in the non-MC group. Use of the 5.5 mm single rod and postoperative PI-LL were significant risk factors for MCs.
Conclusion: The complication incidence decreased with improvements in surgical techniques and measures. Use of the 5.5 mm single rod and postoperative PI-LL were significant risk factors for MCs.
Bariatric surgery continues to grow as a treatment modality for obesity and weight-related comorbidities. The anatomic rearrangement can produce unique anatomic complications, as well as functional problems that are correctible with revisional operations. Understanding the unique subset of complications and the options available for correction can allow surgical solutions to be tailored to both the patient’s anatomy, and the symptoms or pathologies they are targeting. Revisional operations are becoming increasingly common, as the proportion of the general population who have previously undergone bariatric surgery continues to increase. Revisional bariatric operations are associated with an increased risk of complications and longer hospital stays, but in experienced centers can be performed safely, and often using minimally invasive approaches.
Achalasia is a primary motility disorder of unknown origin. Palliative treatment is often adopted to resolve its symptoms by eliminating the resistance due to a non-relaxing and hypertensive lower esophageal sphincter. There are three available effective treatment modalities: pneumatic dilation, laparoscopic Heller myotomy with fundoplication, and peroral endoscopic myotomy. In choosing the proper treatment, it is important to remember that the esophagus lacks peristalsis in patients with achalasia. So once the lower esophageal sphincter is eliminated, reflux may occur with the potential of causing reflux symptoms, esophagitis, peptic strictures, Barrett’s esophagus, and cancer. For this reason, we believe that laparoscopic myotomy offers the best chance in most patients of improving esophageal emptying while protecting them from abnormal reflux.
Avoiding tension during hernia repair is the goal of every surgeon. In the setting of laparoscopic paraesophageal hernia (PEH) repair, tension along esophageal length (axial) and between the crura (radial) should be considered. The aim of this narrative review is to summarize the current knowledge on techniques for axial and radial tension assessment and possible minimization during laparoscopic PEH repair.
The development of a tailored, patient-specific medical and surgical approach is becoming the object of intense research. In robotic urologic surgery, where a clear understanding of case-specific surgical anatomy is considered a key point to optimizing the perioperative outcomes, such philosophy has gained increasing importance. Recently, significant advances in three-dimensional (3D) virtual modeling technologies have fueled the interest in their application in the field of robotic minimally invasive surgery for kidney and prostate tumors. The aim of the review is to provide a synthesis of current applications of 3D virtual models for robot-assisted radical prostatectomy and partial nephrectomy. Medline, PubMed, the Cochrane Database, and Embase were screened for literature regarding the use of 3D augmented reality (AR) during robot-assisted radical prostatectomy and partial nephrectomy. The use of 3D AR models for intraoperative surgical navigation has been tested in prostate and kidney surgery. Its application during robot-assisted radical prostatectomy has been reported by different groups as influencing the positive surgical margins rate and guiding selective bundle biopsy. In robot-assisted partial nephrectomy, AR guidance improves surgical strategy, leading to higher selective clamping, less healthy parenchyma loss, and better postoperative kidney function. In conclusion, the available literature suggests a potentially crucial role of 3D AR technology in improving perioperative results of robot-assisted urological procedures. In the future, artificial intelligence may represent the key to further improving this promising technology.
Due to the technical improvements in endoscopes and armamentarium, flexible ureterorenoscopy (fURS) has increased in the management of nephrolithiasis over the last decade. fURS is a challenging procedure and therefore limited in some regions. To overcome these challenges, a master-slave robotic system might help dominate fURS. As with other robotic systems, the ergonomic deficits of fURS play an important role in the development of a new robot. All ureterorenoscopy (URS) robots thus far consist of a surgeon’s console and the manipulator of a flexible ureterorenoscope. Handling and maneuverability of the different systems vary, but the master-salve system is common to all robots. Optimal ergonomics and comparable surgical results to conventional flexible URS demonstrate the successful use of some of these robots. In this narrative review, we provide an update on the robot-assisted flexible ureterorenoscopy, the different systems, and the final role and future perspective of robotic fURS.
The future of minimally invasive treatment of gastroesophageal reflux disease (GERD) will be realized through collaborative precision medicine more than any foreseeable new technology. Multidisciplinary foregut societies are fostering the collaboration and expertise needed to provide a personalized treatment of GERD. Patient-centric therapy will consider combination therapies’ clinical successes. Taking a patient uncontrolled on medication to controlled via a combination of medicine and a procedure will replace the historical mutual exclusivity of acid-suppressive medication or surgery as a treatment for GERD. Research directed at precision medicine will focus on subgroup analysis rather than randomized controlled trials. Recognition of the crural diaphragm as a reflux barrier which fails in GERD patients regardless of the presence of an axial hernia has resulted from modalities such as 3-D high-resolution impedance manometry, endoscopic ultrasound, functional luminal impedance planimetry. More precise patient selection for purely endoscopic therapies will be possible.The concept of hernia reduction will be replaced by calibration of the crural repair to restore its sphincteric function. Partnering a surgically calibrated hernia repair partnered with interventional gastrointestinal endoscopic reinforcement of the lower esophageal sphincter will foster physician alliances and offer patient-centric alternatives to traditional fundoplication. As such, laparoscopic Nissen Fundoplication will lose its historical primacy and be relegated to the most severe GERD. Magnetic sphincter augmentation (LINX®), varing degrees of partial fundoplication, and endoluminal therapies with or without hiatal hernia repair will become the mainstay of GERD AntiReflux Procedures. Radio Frequency modulation (Stretta®) may be an alternative to neuromodulators in treating the acid-sensitive esophagus. The nascent era of endoscopic robotics will improve precision, reproducibility and revive natural orifice transluminal endoscopic surgery.
The prevalence of gastrointestinal reflux disease and reflux-related complications continue to rise, and treatment options are limited. Medical management alone is often ineffective and chronic use carries inherent risk. Magnetic sphincter augmentation represents a reasonable and viable treatment option for appropriately selected patients. Compared to surgical wraps, magnetic sphincter augmentation (MSA) may provide similar rates of patient satisfaction, anti-acid medication cessation, and decreased esophageal acid exposure. Additionally, MSA may lower postoperative gas bloat symptoms and better preserve the ability to belch or vomit, versus surgical wraps. Magnetic sphincter augmentation, however, is still relatively new, and further study is needed to evaluate and compare outcomes more appropriately to that of surgical wraps.
The idea of using magnets to control the esophago-gastro-intestinal flow of contents dates back almost 20 years, from the first bench experiment in 2003, published in 2006, while the first clinical application at the anal level to prevent fecal incontinence took place in 2010 by means of a device called FENIX magnetic anal sphincter augmentation (MAS). The clinical experiences with MAS ranged from satisfactory success to partial failure depending on the various studies. The nonrandomized comparisons of MAS with sacral nerve stimulation (SNS) and artificial bowel sphincter (ABS) showed a similar effectiveness in fecal continence and quality of life, whereas the adverse events were more frequent and severe with MAS compared to SNS. ABS either failed to work or required an explantation for infection in 40% of patients, whereas MAS showed these adverse events in only 20% of cases. The comparison of MAS with anal slings and bulking infiltrations provided similar continence results, although with a shorter duration, whereas MAS showed more adverse events. Recently MAS has been withdrawn from the market, creating major inconveniences for surgeons and patients. Nevertheless, this can represent an opportunity for a system that reinforces the anal sphincter with “two magnetic plaques” to be finally implemented for use in patients after completing animal experimentation. This system offers various advantages compared with MAS: it has simpler operational activity, easier surgical implanting procedure, the possibility of “tailored” sphincter augmentation, and should turn out to cost less.
Open Roux-en-Y hepaticojejunostomy (RYHJ) is the treatment of choice for bile duct injuries (BDI) sustained during laparoscopic cholecystectomy. Although in recent years the mini-invasive approach has been explored at expert centers, laparoscopic RYHJ for challenging surgical scenarios has rarely been attempted. We herein report two cases of RYHJ for BDI in highly complex surgical scenarios, such as right posterior BDI or failure of previous repairs, with special emphasis on the technical aspects through the embedded videos. The first was an intraoperative repair in a 55-year-old female who suffered a Strasberg type C (transection of the aberrant right hepatic duct) thermal lesion. The second was an iterative repair in a 54-year-old female with a history of a Strasberg type E1 lesion (injury of the main hepatic duct more than 2 cm from the confluence) that had been repaired intraoperatively with an end-to-end anastomosis over a T-tube nine months before referral. Both patients had an uneventful recovery and were discharged four and five days after surgery. After 2.5 and 4 years of follow-up, both patients are asymptomatic and have normal imaging and laboratory tests. To our knowledge, there is no other report in the literature regarding intraoperative laparoscopic right posterior RYHJ for BDI. Laparoscopic RYHJ for BDI repair in the hands of expert laparoscopic biliary surgeons is feasible and safe, even in very challenging surgical scenarios, as herein reported, offering the benefits of mini-invasive surgery. Future high-quality and long-term comparative studies are necessary to elucidate its potential superiority against the standard open approach.
Aim: We retrospectively compared and evaluated the safety, efficacy, and 1-year outcomes of 200-W Thulium laser vaporization of the prostate (ThuVAP) and the GreenLight high-performance system (HPS) 120-W system for benign prostatic hyperplasia (BPH).
Methods: Between February 2019 and December 2021, 137 patients with lower urinary tract symptoms secondary to BPH underwent ThuVAP. Between October 2014 and April 2019, 233 patients underwent GreenLight HPS 120-W vaporization of the prostate (HPS-PVP). Prostate-specific antigen (PSA) levels, International Prostate Symptom Scores (IPSS), quality of life (QOL) scores, overactive bladder symptom scores (OABSS), post-void residual (PVR), and maximum flow rates (Qmax) were evaluated before and 1, 3, 6, and 12 months after surgery.
Results: Mean ages in the ThuVAP and HPS-PVP groups were 73.7 and 73.4 years, respectively. Prostate volumes (PV) were 77.0 and 61.4 mL (P < 0.001), respectively. Significant improvements were observed in IPSS, QOL scores, OABSS, Qmax, and PVR in both groups 1 to 12 months after surgery. Laser and hospitalization times were significantly shorter and approximate tissue removal (ΔPV) was significantly larger in the ThuVAP group than in the HPS-PVP group (means, 49.4 min vs. 62.5 min, P < 0.001, means, 4.9 days vs. 5.4 days, P = 0.007, means,
Conclusion: Both procedures are safe and useful for BPH obstruction. Based on shorter operating and hospitalization times, fewer complications, and more efficient tissue removal, ThuVAP is a more favorable and effective treatment than HPS-PVP.
The use of transcatheter aortic valve replacement (TAVR) for care of symptomatic severe aortic stenosis has increased over the last years; after initially treating patients at prohibitive or high surgical risk, nowadays the procedure can be considered for intermediate or low surgical risk. Although thrombotic events (ischemic stroke, myocardial infarction, and leaflet thrombosis) decreased in patients at lower risk, antithrombotic therapy after TAVR is still recommended. However, the optimal antithrombotic regimen is a still matter of debate due to the lack of randomized data and the concomitant increased risk of bleeding events. In the present review, we analyze current data, recommendations of international guidelines and consensus documents, and potential future scenarios with a rational approach of separation of patients with or without a pre-procedural indication for long-term oral anticoagulant therapy.
Mastery of endoscopic submucosal dissection (ESD) requires a deep understanding of not only the technique but also the preparation, electrosurgical unit, its peripherals, and probable procedural complications. An endoscope with a water-jet function is suitable for gastric ESD. A transparent attachment on the tip of the endoscope is necessary. The mucosal preparation is important for proper lesion recognition and precise device movement during the procedure and to reduce the risk of complications. A needle-type knife allows accurate tissue dissection and is especially useful for dissecting fibrosis in the submucosa. A partially insulated-type knife prevents current transmission from the tip of the needle to the deep tissues, thus reducing the risk of unintentional perforation or bleeding. When using a scissor-type knife, stable device movement is possible and unintended tissue dissection is minimized. The electrosurgical unit mode must be adjusted according to the different tissue conditions. The basic techniques for ESD incision and dissection should be mastered, and the appropriate knives, accessories, strategy, and traction device should be methodically selected by each operator. The main complications of ESD are bleeding and perforation, which should be treated appropriately when they occur.
Aim: To describe the currently available evidence regarding the efficacy and safety of intraureteral indocyanine green (ICG) instillation for ureteral identification in colorectal surgery.
Methods: Systematic search of PubMed and Scopus through May 2022 reported according to PRISMA 2020. Studies reporting treatment of patients < 18 years, with unavailable full-text, reviews, editorials, animal studies, and studies including non-colorectal operations were excluded.
Results: Seven retrospective studies, published between 2020 and 2022, were identified, in which 142 patients (43% females) were evaluated, of which three were undertaken in the USA, two in Japan, and two in India. The most common indications for surgery were cancer in 58 patients (41%) and diverticular disease in 52 patients (36.6%). Most patients involved underwent robotic surgery (70%), while the remaining patients had laparoscopic surgery. The intraoperative ureteral injury was reported in one patient, while adverse effects (mainly transient hematuria) were reported in 10% of the study population (14 patients). The use of intrauretal ICG prolonged surgery by a median of 12.8 minutes.
Conclusion: Intraoperative visualization of ureters using ICG in colorectal surgery is safe and effective, according to the results of this study. However, this technique still bears the potential disadvantages of ureteral catheterization. Research is focusing on future dyes combining the ICG properties with renal excretion to minimize the need for stents. Further comparative studies are needed to reach safe results.
Hybrid revascularization of multivessel coronary artery disease by combining coronary artery bypass grafting (CABG) and chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a relatively novel concept. Hybrid CABG-CTO PCI aims to combine the durable clinical benefits of a left internal mammary artery graft (ideally minimally invasively) with the durability of CTO PCI in non-left anterior descending vessels. This review assesses the current evidence for performing hybrid CTO PCI-CABG and pre-procedural planning considerations.
The recent application of novel technologies to the robot-assisted radical prostatectomy (RARP) procedure has provided a new perspective and demonstrated potential usefulness in surgical planning, intraoperative navigation, and education of both patients and healthcare professionals, allowing for a patient-tailored prostate cancer (PCa) treatment. Integration of novel techniques into robotic surgery has improved the accuracy of surgery and has demonstrated a potential benefit in functional and oncological outcomes in patients with PCa. However, further randomized and prospective studies are needed to assess and validate the role of these technologies in clinical practice. The aim of this review is to summarize the current evidence on the new emerging techniques, such as three-dimensional (3D) imaging and printing, augmented reality (AR), and confocal microscopy (CM), and their impact on RARP and its oncological outcomes.
Laparoscopic sleeve gastrectomy (SG) has reached wide popularity during the last 15 years, owing to limited morbidity and mortality rates, very successful weight loss results, and impact on comorbidities. However, the postoperative development or worsening of gastroesophageal reflux disease (GERD) is one of the most important drawbacks of this surgical procedure. To date, there is great heterogeneity concerning the definition of GERD, the indication for SG in patients with GERD, and the standardization of pre and postoperative diagnostic pathways. In patients with severe obesity, a strictly symptom-based diagnosis of GERD is unreliable. In fact, a high rate of silent GERD (s-GERD, asymptomatic patients despite objective evidence of GERD) has been reported. Moreover, patients with preoperative s-GERD have a significantly higher risk of experiencing GERD symptoms after SG. For these reasons, the reflux burden and the competence of the anti-reflux barrier should be carefully assessed during the preoperative work-up of patients undergoing SG. Ambulatory pH monitoring (APM) and high-resolution manometry (HRM) are useful diagnostic tools that could provide valuable evidence in the guidance of surgical strategy. In this review, we evaluate the current literature concerning the use of APM and HRM in the diagnostic pathway before SG, as well as their predictive value for the evolution of GERD in the postoperative course. Moreover, we propose a diagnostic algorithm for preoperative GERD assessment, which includes validated symptom questionnaires, upper gastrointestinal endoscopy, APM, and HRM.
Over the past decades, the significant development in endoscopic imaging has revolutionized digestive endoscopy. Real-time optical diagnosis has become possible using different tools and techniques (dye-based and virtual chromoendoscopy) such as narrow band imaging, flexible spectral imaging color enhancement, i-Scan, blue-laser imaging and linked-color imaging. Polyp detection and characterization, and prediction of depth of invasion of colorectal cancers have improved remarkably. Confocal laser endomicroscopy and endocytoscopy have allowed the evaluation of lesions on a cellular level. Not far from the horizon are newer technological innovations such as artificial intelligence and texture and color enhancement imaging that are now being studied for their potential to further improve mucosal visualization, optical diagnosis and virtual histology. This review gives an overview of image-enhanced endoscopy (IEE) and discusses its clinical applications and future directions in the lower gastrointestinal (GI) tract.
The incorporation of magnetic fields into surgery to reduce the invasiveness of minimally invasive surgery led to the creation of magnetic-assisted surgery. External magnets coupled with their internal counterparts assist during surgical procedures, avoiding the need for additional trocars. Multiple advances have been made in this field in the past 15 years, with new promising technologies being developed. This review centers on the history of
Significant technical changes and a shift toward a transoral approach have occurred in the management of Zenker’s diverticulum over the past three decades. Transoral stapling is already an established and commonly performed procedure. Zenker peroral endoscopic myotomy (Z-POEM) and Zenker peroral endoscopy septotomy (Z-POES) are innovative techniques that are rapidly spreading and replacing more traditional therapeutic options. This review provides an overview of the current status of minimally invasive transoral management to assess whether a tailored approach is feasible and safe and may improve quality of life and reduce recurrence rates.
Aim: Hilar cholangiocarcinoma is an aggressive malignancy with a poor prognosis, for which only surgical resection offers potential cure. Because of its complex location in the porta hepatis, the standard surgical approach has been open surgery. With the gradual increase in the use of minimally invasive surgery, we aimed to describe our single institutional experience of robotic resection of hilar cholangiocarcinoma. To the best of our knowledge, this is the largest published series in North America.
Methods: Between 2016-2022, we prospectively followed all patients who underwent robotic extrahepatic biliary resection for hilar cholangiocarcinoma.
Results: Robotic resection of hilar cholangiocarcinoma was performed on 21 patients of median age 72 years, 16 (76%) of whom underwent concomitant hepatectomy. All patients initially presented with jaundice and underwent preoperative drainage. Median operative time was 458 minutes and the estimated blood loss was 150 mL. There were no intraoperative complications or conversions to open surgery. The length of stay was five days, with one readmission at 30 days. There were three postoperative complications and one postoperative mortality (at 90 days). R0 was attained in 90% (19/21) of cases and R1 in 10% (2/21). Our median follow-up time was 21 months. At the final follow-up, 15 patients were alive with no evidence of disease and six died.
Conclusion: Robotic resection of hilar cholangiocarcinoma is safe and feasible and achieves excellent outcomes. We believe that robotic surgery will soon be an accepted approach for complex hepatobiliary resections, such as for hilar cholangiocarcinoma.