Translational gastroenterology and hepatology最新文献

Background: YouTube^® has provided a forum to share surgical videos in the public domain which may be used for education. The quality of surgery and accompanying educational material is unknown. YouTube^® videos of gastrectomy with D2 lymphadenectomy (D2-LND) for gastric cancer were evaluated for quality and completeness.

Methods: YouTube^® was searched using the terms "D2 lymphadenectomy" and "Gastric Cancer" for open and laparoscopic videos. The Korean Laparoscopic Gastrointestinal Surgical Society (KLASS) outlined 22 steps that define quality and completeness of D2-LND. These guidelines were used to score D2-LND for each video. Four physician reviewers independently scored each surgical video. Scores were compared using Student's t-test.

Results: Ten laparoscopic and 10 open surgery videos were assessed. Each video was scored for quality and completeness and assigned a score out of 22. Mean score for open D2-LND was 15 (95% CI: 12.54-17.46). Mean score for laparoscopic D2-LND was 15.4 (95% CI: 14.34-16.46; P=0.77). The most consistently performed steps were the dissection of lymph node stations 1, 3, 4 and 5. The most commonly omitted steps were the dissection of lymph node station 6: exposure and identification of the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein.

Conclusions: There is a wide range of quality and completeness of D2-LND videos. On average, D2-LND videos are only two-thirds complete.

The detection and removal of polyps at colonoscopy is core to the current colorectal cancer (CRC) prevention strategy. However, colonoscopy is flawed with a well described miss rate and variability in detection rates associated with incomplete protection from CRC. Consequently, there is significant interest in techniques and technologies which increase polyp detection with the aim to remedy colonoscopy's ills. Technologic advances in colonoscope imaging are numerous and include; increased definition of imaging, widening field of view, virtual technologies to supplant conventional chromocolonoscopy (CC) and now computer assisted detection. However, despite nearly two decades of technologic advances, data on gains in detection from individual technologies have been modest at best and heterogenous and conflicted as a rule. This state of detection technology science is exacerbated by use of relatively blunt metrics of improvement without consensus, the myopic search for gains over single generations of technology improvement and an unhealthy focus on adenomatous lesions. Yet there remains cause for optimism as detection gains from new technology, while small, may still improve CRC prevention. The technologies are also readily available in current generation colonoscopes and have roles beyond simply detection such as lesion characterization, further improving their worth. Coupled with the imminent expansion of computer assisted detection the detection future from colonoscope imaging advances looks bright. This review aims to cover the major imaging advances and evidence for improvement in polyp detection.

Background: Early stage liver cancer is often treated with hepatic resection or transplantation for curative intent. Microwave ablation (MWA) is often performed in patients who are poor surgical candidates, patients with limited multifocal disease, disease close to hepatic vasculature, but can also be performed with curative intent in case of small lesions. The purpose of this study is to evaluate safety and efficacy of MWA of liver tumors with final ablation zone ≤5 mm from the heart.

Methods: A retrospective review was conducted on patients with hepatic cancer who underwent MWA between 1/2015 and 6/2019. Patients with a final ablation zone ≤5 mm to the heart were included. For these patients, imaging obtained prior, during and after procedure along with procedure reports were used to identify tumor and ablation characteristics, and electronic medical records were used to identify patient demographics and disease status.

Results: A total of 17 patients had liver tumors with ablation zone ≤5 mm to the heart. Mean lesion size was 18.2 mm (range, 10-33 mm) and mean follow-up period was 10.4 months. Of note 82% of patients had multifocal disease at time of MWA of lesion close to the heart. Two patients had pneumothorax, one of which required chest tube placement. None of the patients had cardiac arrhythmias or other complications. Overall 12/17 of the patients had disease progression within the liver at different sites from ablated lesions. One patient had residual disease and one had local recurrence. In addition, 4/17 patients, had no disease progression or recurrence and one underwent liver transplantation prior to follow-up imaging.

Conclusions: MWA of liver lesions with ablation zone ≤5 mm to the heart is safe and effective, however, it can be technically challenging.

Minimally invasive surgery has moved from the fringe of pediatric surgery to the mainstream to address a variety of problems. Pancreatic pathology, though uncommon and complex, is frequently amenable to laparoscopic intervention. Indications for pediatric pancreatic operative intervention includes trauma, congenital hyperinsulinemia and neoplasm. Children may require distal pancreatectomy, subtotal pancreatectomy, enucleation, lateral pancreaticojejunostomy and pancreaticoduodenectomy. Of these operations, all but pancreaticoduodenectomy have been successfully described in children using a minimally invasive approach. Traumatic transection of the main pancreatic duct may require operative intervention if endoscopic techniques are unsuccessful. Distal pancreatectomy has been successfully utilized in this circumstance. Additionally, near total pancreatectomy may also be performed laparoscopically although successful reports are limited. Enucleation, especially with the use of intraoperative ultrasound may avoid a large laparotomy for isolated benign masses. Finally, chronic pancreatitis resulting in a dilated main pancreatic duct may benefit from a lateral pancreaticojejunostomy. This operation has also successfully been performed in children. Included is a review of pediatric pancreatic minimally invasive operations paired with corresponding pathology.

Background: Ulcerative colitis (UC) is an aggressive disease in the pediatric population and a cause of significant, lifelong morbidity. The aim of this study is to compare surgical complications in pediatric patients undergoing laparoscopic vs. open surgical treatment for UC.

Methods: We queried the Kids' Inpatient Database (KID) for all cases of UC undergoing surgical treatment in 2009 and 2012. We identified patients who received total colectomy without proctectomy (n=413) or total proctocolectomy (n=196) and performed univariate and multivariate analyses comparing laparoscopic vs. open procedures.

Results: In pediatric UC patients undergoing total colectomy without proctectomy, open procedures were associated with more complications than laparoscopic, including fluid and electrolyte disorders (40% vs. 28%), surgical wound dehiscence (6% vs. 2%), septicemia (18% vs. 2%), and gastrointestinal disorders (16% vs. 7%) among others, all P<0.05. Likewise, in patients with UC undergoing total proctocolectomy, there were more complications in open vs. laparoscopic technique, including increased transfusion requirements (25% vs. 7%, P=0.001) and significantly more gastrointestinal upset, including nausea, vomiting, and diarrhea (11% vs. 1%, P=0.003). In multivariate analysis, patients who underwent total colectomy with or without proctectomy had an increased risk of experiencing any complication when their procedure was performed in an open or non-elective fashion (all odds ratio >2.4; all P<0.001).

Conclusions: The laparoscopic approach was associated with significantly lower rates of surgical complications in pediatric patients undergoing total colectomy with or without proctectomy for UC. These findings demonstrate that laparoscopic technique compares favorably, and may be preferable, to the open approach in selected pediatric patients with UC.

Background: Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis.

Methods: Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables.

Results: Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P<0.0001).

Conclusions: Same-day discharge for laparoscopic uncomplicated appendectomy should be the new standard of care. This study found no differences in outcomes between the timing of discharge, with a significantly lower cost of stay for patients discharged home the same day.

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

Herbal products including herbal medicines are worldwide used in large amounts for treating minor ailments and for disease prevention. However, efficacy of most herbal products has rarely been well documented through randomized controlled trials in line with evidence-based medicine concepts, which could be used to estimate the benefit/risk ratio. Instead, much better documented are adverse reactions such as liver injury associated with the consumption of some herbal products, so called herb-induced liver injury (HILI), which represents a clinical challenge. In order to establish HILI as valid diagnosis, the use of a diagnostic algorithms such as Roussel Uclaf Causality Assessment Method (RUCAM) is widely recommended, although physicians in some countries are reluctant to use RUCAM for their HILI cases. This review on worldwide HILI and RUCAM, developed as part of the artificial intelligence ideas, reveals that China is the leading country with 24 publications on HILI cases that were all assessed for causality using RUCAM, followed by Korea with 15 reports, Germany with 9 reports, the US with 7 reports, and Spain with 6 reports, whereas the remaining countries provided less than 4 reports. The total number of assessed HILI cases is 12,068 worldwide derived from 80 publications but in each report HILI case numbers were variable in a range from 1 up to 6,971. This figure compares with 46,266 cases of drug-induced liver injury (DILI) published worldwide from 2014 to early 2019 also assessed for causality by RUCAM. The original version of RUCAM was validated and established in 1993 and updated in 2016 that should be used in future HILI cases. RUCAM is an objective, structured, and validated method, specifically designed for liver injury. It is a scoring system including case data elements to be assessed and scored individually to provide a final score in five causality gradings. Among the 11,404/12,068 HILI (94.5%) cases assessable for evaluation, causality gradings were highly probable in 4.2%, probable in 15.5%, possible in 70.3%, and unlikely or excluded in 10.0%. To improve the future reporting of RUCAM based HILI cases, recommendations include the strict adherence to instructions outlined in the updated RUCAM and, in particular, to follow prospective data collection on the cases to ensure completeness of case data. In conclusion, RUCAM can well be used to assess causality in suspected HILI cases, and additional efforts are now required to increase the quality of the reported cases.

Background: Operative intervention for pediatric pancreas diseases is rare. Our goal is to gain a better understanding of the indications and outcomes relating to pancreas surgery in children. We hypothesized that these operations are safe and effective in this population.

Methods: With IRB approval, we performed a retrospective review of data of pediatric patients (<18 years) who underwent pancreas operations at Children's Medical Center in Dallas, Texas from January 2005 to December 2018. These procedures included distal, central and total pancreatectomy, pancreaticoduodenectomy, and lateral pancreatojejunostomy. Demographics, surgical indication, and operative and postoperative outcomes were examined.

Results: Forty-six children underwent 47 pancreas operations. Pancreatic mass was the most common indication for resection (n=28, 60%), followed by traumatic injury (n=10, 21%) and chronic pancreatitis (n=8, 17%). The overall complication rate was 0.55 (range, 0-3) complications per procedure, including 4 pancreatic leaks. The overall unexpected hospital visit rate (emergency department and readmissions) was 0.76 (range, 0-6) visits per patient. There were no mortalities.

Conclusions: While pancreas operations are rare procedures in children, our data demonstrate clear indications in this population with an associated low complication rate. This retrospective series highlights the role of pancreas resection in children.