Surgical Endoscopy And Other Interventional Techniques最新文献

Background: The transition from medical student to surgical resident involves a significant shift in responsibility, learning style, and hands-on training complexity. Navigating all these professional hurdles can be a challenge, and residents may struggle with various aspects of these throughout their training, which can lead to the need for remediation. Residency programs must facilitate efforts to identify and address both technical and non-technical deficiencies through targeted remediation.

Materials and methods: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a review of technical and non-technical components of resident remediation.

Results: The two primary components of remediation in a residency program are technical and non-technical skill competencies. The role of the program director is essential to guiding and facilitating the remediation process for residents. Additionally, efforts to prevent remediation are important to implement within a residency program's structure. Current resources focus on technical and non-technical skills remediation. Program design and video-based assessments play crucial roles in technical skills remediation. For non-technical skills remediation, these address resident deficiencies in professionalism, interpersonal skills and communication.

Conclusion: Resident remediation is a complex yet essential responsibility for surgical training programs. It requires structured strategies tailored to both technical and non-technical skills, grounded in timely identification and consistent support. Effective remediation begins with early recognition of deficits and the development of clear, personalized improvement plans. These plans must outline specific goals, measurable outcomes, and mechanisms for progress assessment.

Background: The anchor-pronged clip has been widely adopted for closure of large defects, offering enhanced tensile strength and grasping ability. However, reported real-world device and patient adverse events are limited in literature. Our focus is to identify the most commonly reported adverse events, device issues, and their clinical implications.

Methods: The Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was analyzed from February 1, 2023 to December 31, 2024 to report post-marketing surveillance data on these anchor pronged clips.

Results: Approximately 135 reported cases with 187 device issues and 30 patient adverse events were examined. The most reported device problems were due to activation, position, or separation (53.5%). Common indications included defect closures after endoscopic submucosal dissection (ESD) (29.9%) and endoscopic mucosal resection (EMR) (23.9%). From the total reports analyzed, patient adverse events were noted in 21.1% (n  =  30) of cases which comprised of hemorrhage (43.3%; n  =  13), perforation (10.0%; n  =  3), abdominal pain (6.7%; n  =  2) among others.

Conclusions: Our analysis of the MAUDE database suggests that the MANTIS^™ clip demonstrates a favorable safety profile, particularly considering its intended use for closing large defects after advance tissue resections and ulcerations - procedures that inherently carry a higher risk of complications. This study provides valuable insight to help inform the risk/benefit discussions with patients and guide the development of future design iterations, ultimately enhancing patient outcomes and safety.

Background: Indocyanine green (ICG) fluorescence imaging is increasingly incorporated into robotic liver resections (RLR), yet clinical practice regarding timing, dosage, and staining techniques is divergent. This international expert survey aimed to characterize current practices for ICG in RLR.

Methods: Experts in RLR were invited to participate based on surgical volume (experience of $\ge$ 50 RLR and $\ge$ 30 annual RLR). A 74-item questionnaire was developed following a literature search and reviewed by a steering committee. The survey addressed indications, timing, dosage, imaging technology, benefits, limitations, training, and future directions of ICG use. Responses collected between September and October 2025 were analyzed.

Results: Seventy experts from 19 countries completed the survey, corresponding to an 88% response rate. Centers performed a median of 180 annual liver resections, including 55 RLR. Most experts used ICG (96%) during RLR. Anatomical demarcation (91%), tumor localization (60%), and biliary anatomy assessment (60%) were the most frequent indications. 60% of experts use preoperative ICG, while intraoperative ICG is mainly administered for demarcation (67%) and biliary tract visualization (40%). Considerable heterogeneity exists in dosage, timing, and staining techniques, particularly in cirrhotic livers and for tumor localization. 53% of the experts had standard operating procedures, whereas 64% expressed the need for a higher degree of standardization. Reported benefits of ICG use included improved anatomical orientation, margin assessment, lesion detection, and support during complex resections. Perceived limitations included background fluorescence, tissue penetration and variable staining in diseased parenchyma. 80% anticipated improved outcomes with combined ICG and three-dimensional image-guidance.

Conclusion: ICG fluorescence is widely used in RLR and is an important cornerstone for precision-guided robotic liver surgery. Standardized clinical practice guidelines, structured training, and technological improvements in imaging and navigation systems are claimed to optimize its clinical use.

Objective: Surgery remains the gold standard for non-metastatic esophageal cancer. Oncologic resection is considered adequate when 15 regional lymph nodes are sampled and specimen margins are negative. We hypothesize that racial and regional disparities exist in who receives an adequate oncologic resection.

Methods: The National Cancer Database (NCDB) was queried from 2010 to 2021 for patients who underwent esophagectomy for cancer. Exclusion criteria included stage IV disease and incomplete data. Adequate resection was defined as ≥ 15 lymph nodes removed and negative margins. A multivariable regression model identified factors associated with adequate resection, and survival was assessed using Kaplan-Meier curves.

Results: 11,451 patients were included. Of these, 5153 (45.0%) had an adequate oncologic resection. Black patients had increased odds of an inadequate resection compared to white patients (OR 1.490, 95%CI 1.227-1.809, p < 0.01). Patients treated at community or comprehensive cancer programs had higher odds of inadequate resection than those treated at academic programs. Medicaid patients had higher odds of an inadequate resection compared to those with private insurance (OR 1.397, 95%CI 1.172-1.664, p = < 0.01), while a minimally invasive esophagectomy (MIE) had 24.0% decreased odds of inadequate resection, and robotic-assisted esophagectomy (RAMIE) had 35.4% decreased odds compared to open surgery (95%CI 0.695-0.830, p < 0.01; 95%CI 0.567-0.735, p < 0.01). Controlling for stage, 5-year survival was higher for patients with an adequate resection. Resection adequacy improved from 38.5% in 2010 to 60.1% in 2021, with increases in MIE and RAMIE.

Conclusion: Disparities persist in who receives adequate resection for esophageal cancer, though overall resection adequacy has improved, these findings should be interpreted in the context of evolving practice patterns.

Background: Recurrent benign biliary strictures after failed hepaticojejunostomy remain a major surgical challenge, particularly in East Asia. This study aimed to evaluate the feasibility and mid-term outcomes of a structured, risk-adapted protocol for redo laparoscopic Roux-en-Y hepaticojejunostomy (RYHJ).

Methods: Between June 2019 and December 2024, 26 consecutive patients underwent redo laparoscopic RYHJ performed by a single surgeon. Patients were preoperatively stratified according to the Hobson adhesion grade (I-V) into low-risk (I-II), moderate-risk (III), and high-risk (IV-V) groups. In patients classified as high risk, a standardized intraoperative strategy incorporating indocyanine green (ICG) fluorescence cholangiography via pre-established percutaneous transhepatic cholangiodrainage and refined anastomotic techniques was applied. Key operative steps were prospectively video documented. Primary and secondary endpoints included technical success, perioperative outcomes, and biliary patency during follow-up.

Results: Redo laparoscopic reconstruction was successfully completed in all patients. The median operative time was 210 min (range 150-378) and median blood loss was 55 mL (range 10-200).Patients with higher Hobson grades demonstrated increased technical complexity and a higher incidence of early postoperative bile leakage. In the final six high-risk cases, no bile leaks or anastomotic strictures were observed during a median follow-up of 36 months, despite increased operative complexity.

Conclusions: Redo laparoscopic RYHJ using Hobson-guided protocols yielded durable mid-term outcomes with acceptble morbidity. In high-risk patients, the standardized use of ICG fluorescence and refined anastomotic techniques contributed to improved safety, representing a reproducible and clinically practical technical refinement for complex redo biliary surgery.

Background: Anal fistula is a common and challenging condition to manage, requiring a balance between achieving healing and preserving continence. Video-assisted anal fistula treatment (VAAFT) is a minimally invasive, endoscopic approach that allows direct visualisation and debridement of the fistula tract. Although short-term outcomes are promising, evidence regarding its long-term durability remains limited. This study provides one of the longest follow-up assessments of VAAFT outcomes to date.

Methods: This observational study utilises a prospectively maintained database of patients who underwent VAAFT between November 2014 and June 2016 at a single UK centre. All patients with a minimum of five years of follow-up were included. Data collected included sex, age, fistula type (simple vs. complex), comorbidities (inflammatory bowel disease and diabetes mellitus), smoking status, previous fistula surgery, and subsequent fistula-related procedures (if any). The primary outcome was healing, defined as the absence of fistula-related symptoms at review. Secondary outcomes were postoperative continence deterioration and complications.

Results: A total of 74 patients underwent VAAFT during the study period, and 48 patients (mean age 48 years, SD 13, 58.3% male) completed a minimum of 5 years' follow-up (median 79 months, IQR 67-82). The majority (77%) were complex-type fistula (versus simple). At their most recent follow-up appointment, 66.7% achieved healing and a further 27% reported partial symptomatic improvement. Only one reported worsened continence (loss of flatus control), and there was one self-resolving haematoma. Follow-up duration was comparable between healed and symptomatic groups. No significant association was found between healing and sex, age, fistula type, or surgical history.

Conclusion: VAAFT provides durable symptom relief for many patients and carries a low risk of complications or continence impairment. However, long-term complete healing rates appear modest, underscoring the importance of appropriate patient selection and counselling. Further prospective studies are warranted to refine indications and optimise long-term outcomes.

Background: A relatively high rate of early gastric cancer is missed during esophagogastroduodenoscopy (EGD). This study aimed to identify the risk factors associated with missed early gastric cancer (MEGC).

Methods: A retrospective study was conducted on 763 pathologically confirmed early gastric cancer lesions. Patients were categorized as initially detected early gastric cancer (IDEGC; no EGD in the previous 6-36 months) or MEGC (≥ 1 negative EGD in that interval). Independent risk factors for MEGC were identified through multivariable analysis.

Results: The MEGC rate was 22.0% (168/763). Independent risk factors were male sex (OR = 1.849) and endoscopists' age ≥ 45 years (OR = 2.737). Protective factors were lesion size ≥ 12 mm (OR = 0.616), sedation (OR = 0.376), observation time ≥ 5 min (OR = 0.625), and image-enhanced endoscopy (IEE) technology application (OR = 0.316). MEGC causes were categorized into exposure errors (35.1%), perceptual errors (34.5%), sampling errors (29.2%), and inadequate preparation (1.2%). Errors types correlated with lesion locations. 50.6% of MEGC cases were deemed potentially avoidable. A higher annual endoscopist EGD volume was inversely correlated with the technically attributable MEGC rate (r = -0.495).

Conclusion: MEGC risk may be reduced through targeted interventions for high-risk populations (male), optimized endoscopic examination protocols (ensuring adequate observation time, applying sedation and IEE technology), and enhanced training in advanced technologies for older endoscopists.

Background: Minimally invasive treatment for high-risk gastrointestinal stromal tumor (GIST) remains controversial for the concerns including intra-operative rupture and tumor spillage. This study aimed to compare the long-term oncological outcomes in the high-risk GIST patients receiving laparoscopic and open surgery.

Methods: We conducted a retrospective study on patients with high-risk GISTs of the stomach undergoing curative resection by laparoscopic or open approach from 2002 to 2024 at a single medical center. Propensity score matching was applied to adjust for tumor size and tumor location between these two groups at a 1:1 ratio. We evaluated the peri-operative and long-term oncological outcomes.

Results: There were 184 patients with high-risk GISTs of the stomach recruited. The clinical demographics including age and gender were similar between the laparoscopic and open groups. The mean tumor size was significantly larger in the open group (13.4 ± 7.4 cm versus 5.7 ± 3.5 cm, p < 0.001). After matching, 34 patients in each group were analyzed with comparable tumor sizes and locations. The laparoscopic group was associated with a shorter hospital stay (9.7 ± 2.3 days versus 12.4 ± 4.0 days, p = 0.013). Otherwise, the operation time, blood loss, and the ratio of receiving adjuvant target therapy were similar between groups. Kaplan-Meier RFS analysis showed no difference between the open and laparoscopic groups either in 10-year RFS (82.7% versus 73.6%, p = 0.739) or 10-year OS (90.0% versus 96.9%, p = 0.588). Multivariate analysis showed the surgical approach was not a significant risk factor affecting RFS or OS.

Conclusion: Laparoscopic resection is a safe and feasible surgical approach in selected gastric high-risk GIST patients, providing comparable oncologic outcomes to open surgery with a shorter hospital stay.

Background: Gastrectomy has evolved significantly with advancements in minimally invasive surgery, particularly with the advent of single-incision laparoscopic surgery (SILS). Despite its benefits, SILS faces challenges related to instrument crowding and loss of triangulation. Robotic assistance in SILS, known as single-incision robotic-assisted surgery (SIRAS), may overcome these issues, offering greater precision and maneuverability. This study aimed to explore the technical feasibility and safety of SIRAS for distal gastrectomy using the SHURUI System (SR-ENS-600).

Materials and methods: A cohort of 13 gastric cancer patients who underwent SIRAS between February and June 2024 were compared with a retrospective group of 25 patients who underwent multi-port robotic-assisted surgery (RAS) between September 2019 and May 2020. The primary endpoints were to evaluate surgical outcomes, including operation time, blood loss, lymph node retrieval, complications, postoperative recovery, and surgical task load.

Results: The mean (SD) surgical time for SIRAS was 287.00 (39.83) minutes, significantly longer than the RAS group (258.84[38.23]) (P = 0.041). The SIRAS group exhibited higher times for docking (P < 0.001) and lymph node dissection (P = 0.003). There were no significant differences in blood loss and lymph node retrieval between the two groups (P > 0.05). There was no short-term postoperative complication reported in the SIRAS group. One patient in the RAS group experienced intra-abdominal infection, and another patient in the RAS group had postoperative bleeding. The SIRAS group had lower postoperative pain scores (P = 0.011) and higher quality-of-life scores (P = 0.05) than the RAS group, while the first assistant had higher physical fatigue (P = 0.04).

Conclusion: SIRAS using the SR-ENS-600 system for distal gastrectomy is technically feasible and safe. Despite some challenges, it offers advantages in terms of reduced postoperative pain and improved quality of life. The small sample size of this initial experience limits the generalizability of the findings, and larger-scale studies are warranted.

Background: Although the clinical efficacy of body composition assessment has been explored in many other cancer types, few studies have focused on periampullary cancer. Furthermore, despite the global rise in minimally invasive pancreaticoduodenectomy (PD), its safety and feasibility in patients with sarcopenic obesity remain unclear. We aimed to investigate the impact of body composition assessment on outcomes after PD and to evaluate the safety of minimally invasive PD in patients with sarcopenic obesity.

Methods: Between 2015 and 2023, we included patients who underwent PD performed by surgeons who had surpassed the learning curve and were histologically diagnosed with periampullary cancer. Body composition was assessed using the axial images at the L3 vertebra level obtained from contrast-enhanced computed tomography.

Results: Among 717 patients, 558 (77.8%) underwent open PD and 159 (22.2%) received minimally invasive PD. In multivariate logistic regression analysis, sarcopenic obesity (odds ratio [95% confidence interval]: 1.84 [1.23-2.77]; P = 0.003) was identified as an independent predictor of complications after PD, whereas high body mass index (≥ 25 kg/m²) and sarcopenia were not. Among patients with sarcopenic obesity, the open and minimally invasive PD groups demonstrated comparable short-term surgical outcomes-including complication rates-as well as oncologic outcomes such as the number of harvested lymph nodes and R0 resection rates.

Conclusion: This study demonstrated that computed tomography-derived body composition variables could be helpful in predicting complications after PD. Additionally, minimally invasive PD could be carefully performed by experienced surgeons even in patients with sarcopenic obesity.