Skull base chordomas (SBC) are rare malignant tumors and few factors have been found to be reliable markers for clinical decision making and survival prognostication. The aim of the present work was to identify specific prognostic factors potentially useful for the management of SBC patients.

Abstract Background The main objective of this study was to generate a hemodynamically stable swine model to detect spreading depolarizations (SDs) using electrocorticography (ECoG) and intrinsic optical signal (IOS) imaging and laser speckle flowmetry (LSF) after a 30-h middle cerebral artery (MCA) occlusion (MCAo) in German Landrace Swine. Methods A total of 21 swine were used. The study comprised a training group (group 1, n = 7), a group that underwent bilateral craniectomy and MCAo (group 2, n = 10) and a group used for 2,3,5-triphenyltetrazolium (TTC) staining (group 3, n = 5). Results In group 2, nine animals that underwent MCAo survived for 30 h, and one animal survived for 12 h. We detected MCA variants with 2 to 4 vessels. In all cases, all of the MCAs were occluded. The intensity changes exhibited by IOS and LSF after clipping were closely correlated and indicated a lower blood volume and reduced blood flow in the middle cerebral artery territory. Using IOS, we detected a mean of 2.37 ± (STD) 2.35 SDs/h. Using ECoG, we detected a mean of 0.29 ± (STD) 0.53 SDs/h. Infarctions were diagnosed using histological analysis. TTC staining in group 3 confirmed that the MCA territory was compromised and that the anterior and posterior cerebral arteries were preserved. Conclusions We confirm the reliability of performing live monitoring of cerebral infarctions using our MCAo protocol to detect SDs.

Abstract Background Myelin basic protein (MBP) is the second most abundant protein in central nervous system myelin. Since the 1980s, it has been regarded as a marker of brain tissue injury in both trauma and disease. There have been no recent reports regarding MBP in aneurysmal subarachnoid haemorrhage (SAH). Methods One hundred four SAH patients with ruptured aneurysms underwent endovascular treatment within 24 h of rupture, and 156 blood samples were collected: 104 on days 0–3, 32 on days 4–6 and 20 on days 9–12 post-SAH. MBP levels were assayed using ELISA and compared with the clinical status on admission, laboratory results, imaging findings and treatment outcome at 3 months. Results MBP levels on days 0–3 post-SAH were significantly higher among poor outcome patients (p < 0.001), non-survivors (p = 0.005), patients who underwent intracranial intervention (p < 0.001) and patients with intracerebral haemorrhage (ICH; p < 0.001). On days 4–6 post-SAH, significantly higher levels were found following intracranial intervention (p = 0.009) and ICH (p = 0.039). There was clinically relevant correlation between MBP levels on days 0–3 post-SAH and 3-month Glasgow Outcome Scale (cc = − 0.42) and also ICH volume (cc = 0.48). All patients who made a full recovery had MBP levels below detection limit on days 0–3 post-SAH. Following endovascular aneurysm occlusion, there was no increase in MBP in 86 of the 104 patients investigated (83%). Conclusions The concentration of MBP in peripheral blood after intracranial aneurysm rupture reflects the severity of the brain tissue injury (due to surgery or ICH) and correlates with the treatment outcome. Endovascular aneurysm occlusion was not followed by a rise in MBP in most cases, suggesting the safety of this technique.

Mission Statement: To promote the art and science of surgery by publishing relevant peer-reviewed research to assist the surgeon in optimizing patient care. JAMA Surgery will also serve as a forum for the discussion of issues pertinent to surgery, such as the education and training of the surgical workforce, quality improvement, and the ethics and economics of health care delivery.

In the Original Investigation titled “Association of Postoperative Infection With Risk of Long-term Infection and Mortality,”1 published online November 6, 2019, there was an error in a percentage in Figure 1. At the split, the percentage in the right box should have been 96.4% instead of 46.4% so the sentence reads, “635 671 Patients (96.4%) had no infection within 30 d postoperatively.” This article was corrected online.

To help reduce surgical site infections, a large multicenter health care system implemented a policy that required personnel who had scrubbed to use disposable perioperative jackets. Stapleton and colleagues retrospectively reviewed the cases of 60 009 patients who underwent these clean procedures and compared the rate of surgical site infections before and after policy implementation. Despite spending more than $1.7 million on disposable jackets, there was no significant reduction in surgical site infections, suggesting that perioperative attire has no association with such infections. Invited Commentary Continuing Medical Education

In the Surgical Innovations article, “Primary Fascial Closure During Minimally Invasive Ventral Hernia Repair,”1 published online December 26, 2019, an error appeared in the text. The 95% CI of a relative risk for a study by Ahonens et al was misreported as 2.8 to 13.3. The correct 95% CI is 0.08 to 0.36. The article has been corrected online.

In Reply Thank you for your interest in our article, “Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock.”1 We believe Gauss et al have misread our statistical approach and are incorrectly interpreting the absolute standardized differences (ASD) as P values. There is a growing momentum to use P value alternatives, such as ASDs, in clinical research.2,3 Absolute standardized differences assess the magnitude of differences between groups (specifically, the absolute value of the difference in means, mean ranks, or proportions divided by the pooled standard deviation). We used ASD rather than standard significance tests because using multiple significant tests to evaluate baseline variables can be misleading. Each test carries a 5% probability of type 1 error; with multiple statistical tests, the type I error rate becomes exaggerated, resulting in an inflated probability of a significant difference between groups based on random chance alone. The use of ASD mitigates the risk of amplifying type 1 errors. Groups were considered imbalanced for any variable that had absolute standardized differences greater than 0.392. All baseline variables had an ASD less than 0.392, suggesting that groups were not imbalanced for these variables.

To the Editor We read with interest the article of Sims et al,1 who reported that low-dose supplementation of arginine vasopressin reduced blood transfusion products and mortality in patients with traumatic hemorrhagic shock in their article in JAMA Surgery.1 Regarding the application of low-dose vasopressin for trauma patients in clinical practice, we should discuss some points referring to previous clinical studies.

To the Editor The work of Sims et al1 on low-dose supplementation of arginine vasopressin in patients with trauma and hemorrhagic shock has gained our greatest interest. We applaud the authors for their work, which we consider an important contribution to the trauma community and ongoing controversy on the use of vasopressors in hemorrhagic shock after trauma.

Despite the remarkable progress in transplant over 65 years, organ transportation has not been innovated. The current system is challenged by expense, time, and safety. Unmanned aircraft systems (UAS) capable of on-demand life-urgent delivery of organs, blood, and medications may represent a pathway toward saving lives in transplant and beyond.1 In the last 5 years, dramatic advances in UAS technologies have been realized. Unmanned aircraft system technologies allow for ranges of more than 1000 miles, speeds faster than 150 miles per hour, and vertical takeoff and landing. Further, artificial intelligence technologies have ushered in a new era of autonomous flight, allowing for pilotless travel. Our group recently showed that UAS technologies can be used to move human organs.1

The uptake of bariatric surgery remains low in the United States, with fewer than 1% of eligible patients undergoing this life-saving treatment.1 In addition to the obesity bias that delays referral for surgery, some continue to fear the short- and long-term risks of surgery. To date, most long-term outcome data have focused on Roux-en-Y gastric bypass (RYGB),2 but sleeve gastrectomy (SG) is now the most common bariatric operation in the United States.3 A better understanding of its long-term outcomes may help allay some of these fears.

In an attempt to minimize missed injury rates, potentially decrease mortality, and enhance rapid patient disposition, standard-dose whole-body computed tomographic (WBCT) imaging has become ubiquitous at trauma centers for the hemodynamically stable patient admitted with trauma.1,2 The radiation dose from WBCT ranges from 10 to 20 mGy, which results in an approximately 0.08% estimated lifetime cancer mortality for 45-year-old persons.3 Risk of mortality due to missed injury is therefore higher than the risk of future radiation-induced cancer.

Abstract Background For supratentorial craniotomy, surgical access, and closure technique, including placement of subgaleal drains, may vary considerably. The influence of surgical nuances on postoperative complications such as cerebrospinal fluid leakage or impaired wound healing overall remains largely unclear. With this study, we are reporting our experiences and the impact of our clinical routines on outcome in a prospectively collected data set. Method We prospectively observed 150 consecutive patients undergoing supratentorial craniotomy and recorded technical variables (type/length of incision, size of craniotomy, technique of dural and skin closure, type of dressing, and placement of subgaleal drains). Outcome variables (subgaleal hematoma/CSF collection, periorbital edema, impairment of wound healing, infection, and need for operative revision) were recorded at time of discharge and at late follow-up. Results Early subgaleal fluid collection was observed in 36.7% (2.8% at the late follow-up), and impaired wound healing was recorded in 3.3% of all cases, with an overall need for operative revision of 6.7%. Neither usage of dural sealants, lack of watertight dural closure, and presence of subgaleal drains, nor type of skin closure or dressing influenced outcome. Curved incisions, larger craniotomy, and tumor size, however, were associated with an increase in early CSF or hematoma collection (p < 0.0001, p = 0.001, p < 0.01 resp.), and larger craniotomy size was associated with longer persistence of subgaleal fluid collections (p < 0.05). Conclusions Based on our setting, individual surgical nuances such as the type of dural closure and the use of subgaleal drains resulted in a comparable complication rate and outcome. Subgaleal fluid collections were frequently observed after supratentorial procedures, irrespective of the closing technique employed, and resolve spontaneously in the majority of cases without significant sequelae. Our results are limited due to the observational nature in our single-center study and need to be validated by supportive prospective randomized design.

Abstract Background The evidence for subperiosteal drainage (SPD) versus subdural drainage (SDD) in chronic subdural hematoma (CSDH) remains controversial, and most surgeons prefer to use SDD over SPD. We aim to assess the latest evidence on the use of SPD compared to SDD in patients with CSDH undergoing burr hole evacuation. Methods We performed a systematic literature search on topics that assesses the use of SPD compared to SDD in patients with CSDH up until November 2019 from PubMed, EuropePMC, Cochrane Central Database, ScienceDirect, ProQuest, and ClinicalTrials.gov. The primary outcome was recurrent CSDH, and the secondary outcomes were mortality, surgical morbidities, and modified Rankin Score (mRS). Results There were a total of 3241 subjects from 10 studies. SPD was shown to reduce recurrent CSDH (OR 0.66 [0.52, 0.84], p < 0.001; I2: 17%, p = 0.30) compared to SDD. Recurrent CSDH was lower in SPD group in subgroup analysis at 3-months (OR 0.63 [0.49, 0.81]; I2: 68%, p = 0.04) and 6-months (OR 0.66 [0.51, 0.85], p = 0.001; I2: 77%, p = 0.01) follow-up. However, there was no difference in CSDH recurrence upon subgroup analysis of RCTs. Similar mortality was demonstrated between SPD and SDD group (p = 0.13). The occurrence of parenchymal injury/new neurological deficit was significantly lower in SPD group (OR 0.26 [0.14, 0.51], p < 0.001; I2: 49%, p = 0.08). The rate of seizure, (p = 0.57), postoperative bleeding (p = 0.29), and infection (p = 0.25) were shown to be similar in both SPD and SDD group. Overall, the rate of surgical morbidity was significantly lower in SPD group (OR 0.61 [0.44, 0.85], p = 0.003; I2: 16%, p = 0.25). mRS at the end of follow-up was similar in SPD and SDD group (p = 0.12). Conclusion SPD was associated with less CSDH recurrence, but similar rate of mortality, seizures, postoperative bleeding, and infections compared to SDD. The rate of parenchymal injury/new neurological deficit was lower in the SPD group.

The level VI lymph nodes are anatomically connected to the level VII lymph nodes and papillary thyroid carcinoma (PTC) can metastasis to both regions. The aim of this study was to identify clinicopathologic factors associated with level VII lymph node metastasis. Between March 2015 and September 2016, a total of 275 consecutive patients were operated on for PTC with prophylactic level VII dissection at the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, ZheJiang, China. Patients with PTC were performed via video-assisted approach. Multivariate logistic regression analysis was performed to evaluate the associations between clinicopathologic factors. Of the 275 subjects enrolled in this study, 79 patients (28.73%) showed lymph node metastasis to the level VII. The multivariate logistic regression analysis showed ultrasonography-positive lymph nodes (p < 0.001), the location of primary carcinoma (p = 0.002) and hashimoto thyroiditis (HT) (p = 0.04) were associated with level VII lymph node metastasis. Based on the results of our study, we considered central-compartment lymph node dissection (CLND) as an integral strategy. On the basis of surgery safety, transcervical level VII lymph node dissection could be considered for PTC patients with high risk factors such as ultrasonography-positive lymph nodes, tumor located in middle and lower thirds of the thyroid lobe and the patients without HT. In future, prognostic significance of level VII lymph node dissection should be evaluated through long-term surveillance.

Cervical pathologies are addressed through a variety of anterior and posterior approaches and minimally invasive procedures have been successfully applied during the last decades. Posterior cervical foraminotomy (PCF) should be proposed with isolated foraminal stenosis.

To compare the perioperative outcomes and safety of transperitoneal laparoscopic adrenalectomy with those of retroperitoneal laparoscopic adrenalectomy for patients with pheochromocytoma. We searched PubMed, EMBASE and the Cochrane Central Register for studies from 1999 to 2019 to assess the perioperative outcomes and safety of transperitoneal laparoscopic adrenalectomy and the retroperitoneal approach for laparoscopic adrenalectomy in patients with pheochromocytoma. After data extraction and quality assessments, we used RevMan 5.2 to pool the data. Four retrospective studies were obtained in our meta-analysis. Patients who underwent retroperitoneal laparoscopic adrenalectomy were associated with shorter operative time (WMD: 34.91, 95% CI: 27.02 to 42.80, I2 = 15%; p < 0.01), less intraoperative blood loss (WMD: 139.32, 95% CI: 125.38 to 153.26, I2 = 0, p < 0.01), and a shorter hospital stay (WMD: 2, 95% CI: 1.18 to 2.82, I2 = 82%, p < 0.01) than patients who underwent transperitoneal laparoscopic adrenalectomy. No significant differences were found in the complication rate (OR: 1.58, 95% CI: 0.58 to 4.33, I2 = 0; p = 0.38) or in the incidence of hemodynamic crisis (OR: 0.74, 95% CI: 0.19 to 2.94, p = 0.67) between the two groups. Retroperitoneal laparoscopic adrenalectomy could achieve better perioperative outcomes than the transperitoneal approach for patients with pheochromocytoma.

The Acknowledgment was omitted from this article and appears below.

The original article was updated to correct the author listing: the last five author names were reversed.

BACKGROUND Upper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods. METHODS Total 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively. RESULTS Of 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients. CONCLUSIONS Bleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.

BACKGROUND This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes. METHODS The TRUVEN database was queried using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with α = 0.05. RESULTS 66,116 patients were included (LIHR: N = 23,010; OIHR: N = 43,106). Robotic-assisted procedures were excluded due to small sample size (N = 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%, p = 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%; p < 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h, p = 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%; p < 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014), p < 0.001. CONCLUSIONS The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.

BACKGROUND Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease. METHODS Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease. RESULTS Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence. CONCLUSION Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective. REGISTRATION NO CRD42017074783.

BACKGROUND Laparoscopic suturing and knot tying is essential for advanced laparoscopic procedures and requires training outside of the operating room. However, personal instruction by experienced surgeons is limitedly available. To address this, the concept of combining e-learning with practical training has become of interest. This study aims to investigate the influence of the first-person perspective in instructional videos, as well as the feasibility of a completely self-directed training curriculum for laparoscopic suturing and knot tying. MATERIALS AND METHODS Ninety-one laparoscopically naïve medical students were randomised into two groups training with e-learning videos in either the first-person perspective (combining endoscopic view and view of hands/instruments/forearm motion) or the endoscopic view only. Both groups trained laparoscopic suturing and knot tying in teams of two until reaching predefined proficiency levels. Blinded, trained raters regularly assessed the participants' performance by using validated checklists. After training, participants filled out questionnaires regarding training experience and personal characteristics. RESULTS Average training time to reach proficiency did not differ between groups [first-person perspective (min): 112 ± 44; endoscopic view only (min): 109 ± 47; p = 0.746]. However, participants from both groups perceived the first-person perspective as useful for learning new laparoscopic skills. Both groups showed similar baseline performances and improved significantly after training [Objective Structured Assessment of Technical Skills (OSATS) (max. 37 points): first-person perspective: 30.3 ± 2.3; endoscopic view only: 30.8 ± 2.3]. All participants managed to reach proficiency, needing 8-43 attempts without differences between groups. Visuospatial abilities (mental rotation) seemed to enhance the learning curve. CONCLUSION Modifying instructional videos to the first-person perspective did not translate into a better performance in this setting but was welcomed by participants. Completely self-directed training with the use of e-learning can be a feasible training approach to achieve technical proficiency in laparoscopic suturing and knot tying in a training setting.

BACKGROUND In the era of competency-based surgical education, VBC has gained increased attention and may enhance the efficacy of surgical education. The objective of this systematic review was to summarize the existing evidence of video-based coaching (VBC) and compare VBC to traditional master-apprentice-based surgical education. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCT) assessing VBC according to the PRISMA and Cochrane guidelines. The MEDLINE, EMBASE, and COCHRANE and Researchgate databases were searched for eligible manuscripts. Standard mean difference (SMD) of performance scoring scales was used to assess the effect of VBC versus traditional training without VBC (control). RESULTS Of 627 studies identified, 24 RCTs were eligible and evaluated. The studies included 778 surgical trainees (n = 386 VBC vs. n = 392 control). 13 performance scoring scales were used to assess technical competence; OSATS-GRS was the most common (n = 15). VBC was provided preoperative (n = 11), intraoperative (n = 1), postoperative (n = 10), and perioperative (n = 2). The majority of studies were unstructured, where identified coaching frameworks were PRACTICE (n = 1), GROW (n = 2) and Wisconsin Coaching Framework (n = 1). There was an effect on performance scoring scales in favor of VBC coaching (SMD 0.87, p < 0.001). In subgroup analyses, the residents had a larger relative effect (SMD 1.13; 0.61-1.65, p < 0.001) of VBC compared to medical students (SMD 0.43, 0.06-0.81, p < 0.001). The greatest source of potential bias was absence of blinding of the participants and personnel (n = 20). CONCLUSION Video-based coaching increases technical performance of medical students and surgical residents. There exist significant study and intervention heterogeneity that warrants further exploration, showing the need to structure and standardize video-based coaching tools.

BACKGROUND Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. METHODS An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. RESULTS Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. CONCLUSIONS Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

BACKGROUND Bariatric surgery is in high demand and patients generally undergo an extensive work-up process to maximize the success of surgery, especially in universal healthcare systems. Although valuable, this work-up process can lead to attrition before surgery. Therefore, we aim to assess patient and health system factors associated with attrition after bariatric surgery referral in a universal healthcare system. METHODS This was a population-based study of all patients aged ≥ 18 referred for bariatric surgery in Ontario, Canada from 2009 to 2015. Primary outcome was patients who dropped out of bariatric surgery after referral. Predictors of attrition after referral included patient demographics, clinical, institutional, and socioeconomic variables. Odds ratios and 95% CIs were estimated by multilevel logistic regression models. RESULTS From 17,703 patients that were referred for bariatric surgery, 4122 patients dropped after the initial referral. Male patients, increasing age, and longer wait times for surgery were significantly (P < 0.0001) associated with higher odds of attrition. Additionally, smoker status, immigration status, unemployment, and disability were significant factors (P < 0.0001) predicting attrition. Patients who lived in lowest income quintile neighborhoods, when compared to those from the richest neighborhoods, had significantly higher odds of attrition (P = 0.02). Sleep apnea was associated with lower odds of attrition while diabetes and heart failure both with higher odds of attrition. CONCLUSION Even in a universal healthcare system, there are various factors that could lead to increased odds of attrition before bariatric surgery. Clear disparities exist for certain marginalized populations. Further studies are warranted to ensure equitable utilization of bariatric surgery for all patients.

BACKGROUND POEM has been successfully performed in patients with spastic esophageal disorders (SED), such as diffuse esophageal spasm, jackhammer esophagus, and type 3 achalasia. We performed a systematic review and meta-analysis to evaluate its efficacy in these patients and if total average myotomy length and prior medical or endoscopic treatments affected clinical success. METHODS PubMed, EMBASE, Google-Scholar, Scopus, and Cochrane Review were searched for studies on POEM in SED from 2008 to September 2018. Clinical success was determined by Eckardt score (≤ 3) at follow-up. Sub-group analysis was performed based on myotomy length and evaluates the effect of prior treatments on clinical success. RESULTS 9 studies with 210 patients were included in the final analysis. We found that the pooled rate of clinical success for POEM was 89.6% (95% CI 83.5-93.1, 95% PI 83.4-93.7, I2 = 0%). In three studies (50 patients), where total myotomy length was < 10 cm, the pooled rate of clinical success was 91.1% (95% CI 79.5-96.4, I2 = 0%). In six studies (160 patients), the length was > 10 cms and the pooled rate of clinical success was 89.1% (95% CI 83.0-93.2, I2 = 0%). The difference between these results was not statistically significant (p = 0.69). Additionally, a meta-regression analysis showed that prior treatment status did not significantly affect the primary outcome (p = 0.43). CONCLUSIONS While it is well known that POEM is a safe and effective treatment for spastic esophageal disorders, we conclude that variation in total myotomy length and prior endoscopic or medical treatments did not have a significant effect on clinical success.

BACKGROUND Completion total gastrectomy with radical lymphadenectomy for remnant gastric cancer is a technically demanding procedure. No previous studies have compared laparoscopic to robotic-assisted completion gastrectomy, whereas a few small case series have reported benefits of minimally invasive surgery over open surgery. The aim of this study is to assess the effectiveness and feasibility of robotic-assisted compared with laparoscopic completion gastrectomy for the treatment of remnant gastric cancer. METHODS We retrospectively reviewed data from 55 patients who underwent minimally invasive completion gastrectomy for remnant gastric cancer at the Severance Hospital of Yonsei University Health System from April 2005 to July 2017. Of the 55 patients, 30 patients underwent laparoscopic and 25 underwent robotic-assisted completion total gastrectomy. We compared the patients' demographics, operative outcomes, and postoperative outcomes. RESULTS Operation time was longer in the robotic-assisted surgery group (225 vs 292 min, P < 0.001), but both groups had similar estimated blood loss. The laparoscopic surgery group had a 13.3% (four patients) rate of conversion to open surgery because of severe adhesions, whereas no patients in the robotic group underwent conversion to laparoscopic or open surgery (P = 0.058). Mean hospital stay, postoperative complications, and recovery were similar in both groups. Pathology results, including the number of retrieved lymph nodes, did not differ between groups. CONCLUSION Laparoscopic and robotic approaches are both feasible and safe for remnant gastric cancer, with comparable short-term outcomes. However, the robotic approach demonstrated a lower conversion rate than laparoscopy, although the statistical difference was marginal.

BACKGROUND Acute upper gastrointestinal bleeding is a life-threatening medical condition with a relevant risk of re-bleeding even after initial endoscopic hemostasis. The implantable HemoPill monitor contains a novel telemetric sensor to optically detect blood in the stomach allowing the surveillance of high-risk patients for re-bleedings. METHODS In this pre-clinical porcine study, bleeding has been simulated by injecting porcine blood into the stomach of a pig through an implanted catheter using a syringe pump. The effect of the sensor position in the stomach, the gastric food content, and the bleeding intensity was investigated. RESULTS Sensitivity and specificity of the sensor reached more than 87.5% when the sensor was positioned close to the source of bleeding. Solid food had a higher negative impact on sensitivity than liquid food but a positive impact on specificity. A heavy bleeding was more likely to be detected by the sensor but was also associated with a lower likelihood for true-negative results than weaker bleedings. CONCLUSIONS The study clearly demonstrated the capability of the HemoPill sensor prototype to detect clinically relevant bleedings with high sensitivity and specificity (> 80%) when the sensor was positioned close to the bleeding site. The sensors proved to be robust against artefact effects from stomach content. These are favorable findings that underline the potential benefit for the use of the HemoPill sensor in monitoring patients with a risk of re-bleeding in the upper gastrointestinal tract.

INTRODUCTION Laparoscopic liver resection (LLR) for tumors involving segment VII has been considered a contraindication. Herein, our proposed laparoscopic technique for segment VII lesions using a rubber band retraction method and flexible laparoscope is introduced. METHODS A combination of elastic rubber band retraction method and flexible laparoscope was applied to access segment VII lesion. The perioperative outcomes and pathologic results were compared between patients with segment VII lesions (group 1) and patients with tumors in other segments (group 2) to evaluate feasibility and safety of the proposed laparoscopic approach for segment VII lesions. RESULTS Among 167 patients who underwent LLR from May 2014 to October 2017, the study population included 17 patients with tumors in segment VII (group 1) and 66 patients with tumors in other segments (group 2). The demographics of the two groups were comparable. One open conversion occurred in group 2 due to bleeding. The mean tumor size was 2.6 ± 1.0 and 2.5 ± 1.5 cm (p = 0.392) and surgical margin was 1.2 ± 0.7 and 1.3 ± 1.2 cm (p = 0.344) in group 1 and group 2, respectively. The mean operation time was 151 ± 63 and 131 ± 57 min (p = 0.596) and estimated mean blood loss was 294 ± 281 and 306 ± 405 mL (p = 0.610), in group 1 and group 2, respectively. The mean postoperative hospital stay was 6.1 ± 1.5 and 6.4 ± 2.7 days (p = 0.064) in group 1 and group 2. Two postoperative complications in both groups and no postoperative mortality occurred. CONCLUSION The combination technique of rubber band retraction and flexible laparoscopic camera allowed feasible and safe LLR for segment VII lesions that showed postoperative outcomes comparable to other segment lesions.

BACKGROUND Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR). METHODS A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case-control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale. RESULTS The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16-4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL. CONCLUSION The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST's generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.

BACKGROUND AND AIM Esophageal stricture is a major complication of large areas endoscopic submucosal dissection (ESD). Until now, the critical mechanism of esophageal stricture remains unclear. We examined the role of mucosal loss versus submucosal damage in esophageal stricture formation after mucosal resection using a porcine model. MATERIALS AND METHODS Twelve swine were randomly divided into two groups, each of 6. In each group, two 5-cm-long submucosal tunnels were made to involve 1/3rd of the widths of the anterior and posterior esophageal circumference. The entire mucosal roofs of both tunnels were resected in group A. In group B, the tunnel roof mucosa was incised longitudinally along the length of the tunnel, but without excision of any mucosa. Stricture formation was evaluated by endoscopy after 1, 2, and 4 weeks, respectively. Anatomical and histological examinations were performed after euthanasia. RESULTS Healing observed on endoscopy in both groups after 1 week. Group A (mucosa resected) developed mild-to-severe esophageal stricture, dysphagia, and weight loss. In contrast, no esophageal stricture was evident in group B (mucosa incisions without resection) after 2 and 4 weeks, respectively. Macroscopic examination showed severe esophageal stricture and shortening of esophagus in only group A. Inflammation and fibrous hyperplasia of the submucosal layer was observed on histological examination in both groups. CONCLUSION The extent of loss of esophageal mucosa appears to be a critical factor for esophageal stricture. Inflammation followed by fibrosis may contribute to alteration in compliance of the esophagus but is not the main mechanism of postresection stricture.

BACKGROUND Irreversible electroporation (IRE) is an emerging tissue ablation technique, which is safe for sites where thermal-basis techniques are not suitable. The aim of this study is to evaluate the safety and efficacy of magnetic anchoring electrode (MAE)-assisted IRE for normal gastric tissue ablation in a rabbit model. METHODS IRE (500 V, 100 μs, 99 pulses, 1 Hz) of the gastric wall was performed in 24 adult New Zealand rabbits with a novel catheter-mounted MAE with fluoroscopy and a surgical approach. Procedure time, procedure-related bleeding, perforation, and other complications were recorded. Animals were sacrificed at 30 min, 1 day, 3 days, 7 days, 14 days, and 28 days post-IRE. The stomach was removed en bloc, and the diameter of each lesion was measured. Histopathological analyses by Hematoxylin-Eosin (H&E), masson trichrome, alpha-smooth muscle action (α-SMA), and terminal-deoxynucleotidyl transferase mediated nick end labeling (TUNEL) were performed. RESULTS Gastric tissue ablation with MAE-assisted IRE was successfully performed without any interruption. No perforation or bleeding was observed during IRE or throughout the follow-up period. A demarcated hemorrhage was found in the ablated area upon gross examination. H&E staining showed complete cell death with inflammatory infiltration, edema, and hemorrhaging. TUNEL presented diffuse positive cells in the ablated area. The tissue scaffold was well preserved without damage as indicated by Masson trichrome staining. Ulceration was observed starting from 3 days post-IRE. The mucosal layer was gradually recovered and regenerated within 14-28 days. No other complication was observed post-IRE. CONCLUSIONS MAE-assisted IRE is safe and effective for normal gastric tissue ablation and the gastric wall recovered in 14-28 days post-IRE.

BACKGROUND Conventional lesion-up colorectal ESD has the potential risk of iatrogenic perforation due to the knife's direction toward the muscular layer of the bowel wall. If we rotate the endoscope to the proper position, the mucosal flap is easy to be lifted down by tip attachment and the knife is easy to approach the proper dissection plane, which may prevent the perforation and facilitate difficult ESD. METHODS We aimed to retrospectively assess the safety and efficacy of this rotating technique compared with the conventional lesion-up dissection regardless of shape, location, or size of the tumor, and investigated in short- and long-term outcomes following the ESD procedure. RESULTS 41 lesions were enrolled into rotating technique group and 37 lesions in lesion-up group. The dissection speed was significantly faster in the rotating technique group (p = 0.023). R0 resection rate was significantly higher in rotating technique group (p = 0.008). The rate of perioperative complication was significantly higher in lesion-up method group (p = 0.003). Local recurrence was higher in lesion-up group (p = 0.001). Recurrence-free rate was higher in rotating technique group (p = 0.018). CONCLUSION The endoscope rotating is a useful technique for difficult colorectal ESD due to easy approaching the proper dissection plane. This technique also increases the rate of en bloc resections, R0 resections regardless of size, shape, and location and improves dissection speed without increasing the incidence of adverse events.

BACKGROUND The incidence and mortality rates of colorectal cancer (CRC) have been steadily decreasing, largely attributable to screening colonoscopies that either remove precancerous lesions or identify CRC earlier. We aimed to assess the prognostic difference between colorectal cancers diagnosed by screening (SC), diagnostic (DC), or surveillance (SU) colonoscopies. METHODS All 1809 surgically treated patients with primary CRC diagnosed through colonoscopy at our tertiary center (2004-2015) were extracted from a prospectively maintained database. Oncologic outcomes were compared, including multivariate Cox regression. RESULTS Diagnostic patients presented with more advanced disease (15.0% vs. 53.2% (SC) and 55.3% (SU) AJCC I, P < 0.001), subsequently leading to impaired survival and higher recurrence rates (P < 0.001). After adjustment for age, ASA-score and gender, oncologic outcomes remained significantly worse after DC. Hazard ratios (HR) of overall mortality (OS) compared to DC were 0.36 for SC and 0.58 for SU (P < 0.001). Adjusted HRs of disease-free survival (DFS) were 0.43 and 0.32, respectively (P < 0.001). Worse outcomes in OS withstood adjustment for stage, tumor site and (neo)adjuvant treatment (SC: HR 0.46, P < 0.001; SU: HR 0.73, P = 0.036). The benefits of SC were particularly seen in colon cancer, stages I-II and female patients. With regard to DFS, outcomes were less profound and mainly true in early stage disease and surveillance patients. CONCLUSIONS This study demonstrates the enormous impact of asymptomatic screening in CRC. Patients with CRC diagnosed through screening or surveillance had a significantly better prognosis compared to patients who presented symptomatically. This emphasizes the importance of screening.

OBJECTIVE Current literature demonstrates a lack of comparative in vivo studies regarding laparoscopic lens fogging (LLF). This randomized trial aimed to compare 3 popular methods of minimizing or reducing LLF in laparoscopic surgery by heating the lens using warm saline, applying anti-fog solution to the lens, and rubbing the lens with chlorhexidine solution. METHODS Ninety-six participants underwent randomization to be allocated in control (n = 24), warm saline (n = 24), anti-fog solution (n = 24), and chlorhexidine groups (n = 24). The primary outcome measure was the severity of LLF during the first 3 min after laparoscope insertion into the abdominal cavity. The severity of LLF was rated on a 10-point visual clarity scale ranging from 0 (clearest) to 10 (foggiest). The secondary outcome measures were (1) the severity of LLF during the remaining operative time other than the first 3 min, (2) the number of lens cleansings, and (3) the total time required to clean the lens. RESULTS Lens fogging during the first 3 min and remaining operative time other than the first 3 min was significantly decreased in the warm saline group compared to that in the other 3 groups (all, P < 0.001). In post hoc analysis, the anti-fog solution group was significantly foggier than the warm saline group, but clearer than the chlorhexidine and control groups. The number of lens cleansings and total time required to clean the lens were significantly lower in the warm saline and anti-fog solution groups than in the chlorhexidine and control groups (all, P < 0.05). CONCLUSION The use of warm saline leads to significantly fewer fogging events than the use of anti-fog solution or chlorhexidine solution, resulting in an improved continuity of surgery.

BACKGROUND We used a population-based database to: (1) compare clinical and economic outcomes between minimally invasive surgery (MIS) and open surgery (OS) for colectomy; and (2) evaluate contemporary trends in MIS rates. METHODS Retrospective Premier Healthcare Database review of patients undergoing elective inpatient colectomy between January 1, 2010 and September 30, 2017 (first = index admission). Patients were classified into MIS (laparoscopic/robotic) or OS groups, and by left or right colectomy. Propensity score matching (1:1 ratio) of MIS and OS groups was used to address potential confounding from patient/hospital/provider characteristics. Study outcomes, measured during index admission, included major perioperative complications [anastomotic leak (AL), bleeding, infection, and a composite of infection/AL], operating room time (ORT), length of stay (LOS), and total hospital costs. RESULTS Among 134,970 study-eligible patients, MIS rates increased from ~ 2% (2010) to 19-23% (2017), driven by a > tenfold increase in robotic surgery. The matched MIS and OS colectomy groups comprised 46,708 (left) and 44,560 (right) total patients. Risks of AL, bleeding, and infection were lower for MIS versus OS (all p < 0.001). In left: AL occurred in 7.9% of MIS versus 9.9% of OS; bleeding 7.8% versus 9.7%; infection 3.3% versus 5.8%; infection/AL 9.8% versus 13.3%. In right: AL 8.9% versus 11.1%; bleeding 9.8% versus 10.8%; infection 3.0% versus 5.1%; infection/AL 10.5% versus 10.4%. Although ORTs were longer with MIS (left: 240.8 vs. 216.2 min; right: 192.8 vs. 178.0 min), LOS was shorter (left: 5.4 vs. 7.1 days; right: 5.5 vs. 7.1 days), and total hospital costs were lower (left: $18,564 vs. $19,960; right: $17,375 vs. $19,417) versus OS (all p < 0.001). CONCLUSIONS Compared with OS, MIS was associated with significantly lower risk of major perioperative complications (including AL), lower LOS, and lower total hospital costs, despite longer OR times. MIS colectomy rates have increased over time; recent gains appear to be due to uptake of robotic surgery.

While short-term perioperative outcomes have been well studied in Western surgical populations, the aim of this study is to look at the one-year perioperative mortality and its associated factors in an Asian surgical population after non-cardiac surgery. A retrospective cohort study of 2163 patients aged above 45 undergoing non-cardiac surgery in a university-affiliated tertiary hospital from January to July 2015 was performed. Relevant demographic, clinical and surgical data were analysed to elicit their relationship to mortality at one year after surgery. A univariate analysis was first performed to identify significant variables with p-values ≤ 0.2, which were then analysed using Firth multiple logistic regression to calculate the adjusted odds ratio. The one-year mortality in our surgical population was 5.9%. The significant factors that increased one-year mortality include smoking (adjusted OR 2.17 (1.02–4.45), p = 0.044), anaemia (adjusted OR 1.32 (1.16–1.47), p < 0.001, for every 1 g/dL drop in haemoglobin level), lower BMI (adjusted OR 0.93 (0.87–0.98), p = 0.005, for every 1 point increase in BMI), Malay and Indian ethnicity (adjusted OR 2.68 (1.53–4.65), p = 0.001), peripheral vascular disease (adjusted OR 4.21 (1.62–10.38), p = 0.004), advanced age (adjusted OR 1.04 (1.01–1.06), p = 0.004, for every one year increase in age), emergency surgery (adjusted OR 2.26 (1.29–3.15), p = 0.005) and malignancy (adjusted OR 3.20 (1.85–5.52), p < 0.001). Our study shows that modifiable risk factors such as malnutrition, anaemia and smoking which affect short term mortality extend beyond the immediate perioperative period into longer term outcomes. Identification and optimization of this subset of patients are therefore vital. Further similar large studies should be done to develop a risk scoring system for post-operative long-term outcomes. This would aid clinicians in risk stratification, counselling and surgical planning, which will help in patients’ decision making and care planning.

Abstract Background One-lung ventilation (OLV) is the standard and widely applied ventilation approach used in video-assisted thoracoscopic surgery for esophageal cancer (VATS-e). To address the disadvantages of OLV with respect to difficulties in intubation and induction, as well as the risk of respiratory complications, two-lung ventilation (TLV) with artificial pneumothorax has been introduced for use in VATS-e. However, no studies have yet compared TLV and OLV with postoperative infection and inflammation in the prone position over time postoperatively. Here, we investigated the efficacy of TLV in patients undergoing VATS-e in the prone position. Methods Between April 2010 and December 2016, 119 patients underwent VATS-e under OLV or TLV with carbon dioxide insufflation. Clinical characteristics, surgical outcomes, and postoperative outcomes, including oxygenation and systemic inflammatory responses, were compared between patients who underwent OLV and those who underwent TLV. Results Clinical characteristics other than pT stage were comparable between groups. The TLV group had shorter thoracic operation time than the OLV group. No patients underwent conversion to open thoracotomy. The PaO2/FiO2 ratios of the TLV group on postoperative day (POD) 5 and on POD7 were significantly higher than those of the OLV group. C-reactive protein levels on POD7 were lower in the TLV group than in the OLV group. There were no significant differences with respect to postoperative complications between the OLV and TLV groups. In the TLV group, the white blood cell count on POD7 was significantly lower than that in the OLV group; body temperature showed a similar trend immediately after surgery and on POD1. Conclusions In this study, we demonstrated that, compared with OLV, TLV in the prone position provides better oxygenation and reduced inflammation in the postoperative course. Accordingly, TLV might be more useful than OLV for ventilation during esophageal cancer surgery.

Endoscopic sleeve gastroplasty (ESG) is a promising bariatric treatment. Gastric volume reduction and delayed gastric emptying are the probable mechanisms driving weight loss. However, there are concerns regarding the overtime ESG effectiveness. This study aims to evaluate the correlation between endoscopic gastroplasty integrity overtime and weight loss.

Abstract Introduction Per-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD). Patients and methods Patients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6 months. Results Ninety patients (mean age 66 years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I–II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I–II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I–II achalasia and type III achalasia, respectively (p = 0.03). Conclusion Although less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD.

Abstract Background Hepaticojejunostomy anastomotic stricture (HJS) is a rare complication after pancreatoduodenostomy. However, the rate of HJS may be increased with the expansion of operative indications, such as intraductal papillary mucinous neoplasm. Recently, the indications for EUS-guided biliary drainage to treat benign biliary disease have expanded. Recently, novel transluminal treatment protocol has been established in our hospital. The aim of this study was thus to evaluate the technical feasibility and safety of our treatment protocol. Patients and method Consecutive patients with complications of HJS between January and December 2018 were enrolled in this study. EUS-guided hepaticogastrostomy (HGS) is firstly performed. After 7 days to create the fistula, HGS stent is removed. HJS is transluminally evaluated by a cholangioscope, and antegrade balloon dilation is attempted. After 3 months, if HJS is still presence, antegrade stent deployment is performed using a covered metal stent. Also, after 1 month, antegrade stent removal is transluminally performed. Results Among total 29 patients, 14 patients were underwent antegrade metal stent deployment. The technical success rate of antegrade stent deployment was 92.9%. Median period of stent placement was 30.5 days (range 28–38 days), and transluminal stent removal was successfully performed in all patients. During follow-up (median 278 days; range 171–505 days), recurrence of HJS was seen in 2 patients. Severe adverse events were not seen in any patients during follow-up period. Conclusion Transluminal stent deployment for HJS under EUS-guidance appears feasible and safe, although further study with a larger sample size and longer follow-up is warranted.

Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery.

Abstract Background Laparoscopic liver resection (LLR) of posterosuperior segments (PSS) is still technically demanding procedure for highly selective patients. There is no long-term survival comparative estimation after LLR and open liver resection (OLR) for colorectal liver metastases (CRLM) located in PSS. We aimed to compare long-term overall (OS) and disease-free survival (DFS) after parenchyma-sparing LLR with expanding indications and open liver resection (OLR) of liver PSS in patients with CRLM. Methods Two Russian centers took part in the study. Patients with missing data, hemihepatectomy and extrahepatic tumors were excluded. One of contraindications for LLR was suspicion for tumor invasion in large hepatic vessels. Logistic regression was used for 1:1 propensity score matching (PSM). Results PSS were resected in 77 patients, which accounted for 42% of the total number of liver resections for CRLM. LLR were performed in 51 (66%) patients. Before and after matching, no differences were found between groups in the following factors: median size of the largest metastatic tumor; proximity to the large liver vessels; the rate of anatomical parenchyma sparing resection of PSS; a positive response to chemotherapy before and after surgery. Regardless of matching, the size of the largest metastases was above 50 mm in more than one-third of patients who received LLR. Before matching, intraoperative blood loss, ICU stay and hospital stay were significantly greater in the group of OLR. No 90-day mortality was observed within both groups. There were no differences in long-term oncological outcomes: 5-year OS after PSM was 78% and 63% after LLR and OLR, respectively; 4-year DFS after PSM was 27% in both groups. Conclusion Laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients who have an indication for OLR if performed in high volume specialized centers expertized in laparoscopic liver surgery.

Expanding the ventrolateral skull base corridor from the midline of lower clivus to the petroclival fissure is a challenging endonasal surgical task. Resection of lytic lesions like chondrosarcoma can cause cranial nerve morbidities and injury of ICA, necessitating accurate knowledge of correlative endoscopic anatomy with stereotactic landmarks.

Abstract Cerebral developmental venous anomalies (DVAs) are variations of venous vascular anatomy related to an underdevelopment of either the superficial or deep venous emissary system, resulting in a dilated transmedullary vein fed by multiple smaller venous radicles responsible for drainage of normal brain parenchyma. While typically benign and found incidentally on imaging studies, DVAs can rarely be symptomatic. The radiographic appearance of DVAs, as well as their symptomatic manifestations, is diverse. Herein, we will discuss the pathophysiology of symptomatic DVAs while providing illustrative case examples depicting each of their pathogenic mechanisms.

An appropriate method of anastomosis is crucial for gastric cancer patients who require gastrojejunal anastomosis. Surgeons have proposed different types of modified gastrojejunostomies in the last two decades. We focused on two types of standard anastomosis, i.e., Uncut Roux-Y and Roux-Y gastrojejunostomies, and compared the differences in immediate postoperative complications between the two types. This is a retrospective study on 236 gastric cancer patients who underwent curative distal gastrectomy with gastrojejunal Roux-Y or Uncut Roux-Y anastomosis for six consecutive years. Immediate postoperative complications were compared between the two groups. The authors discussed the causes of the significant complications and their management. There was no difference in demographics between the two groups (92 Roux-y Versus 144 Uncut Roux-y). The overall complication rate was 20.8% with 1.4% anastomotic leakage in the Uncut Roux-Y group versus 33.7% with 7.6% anastomotic failures in the Roux-Y group (p < 0.05). More abdominal infections occurred in the Roux-Y anastomosis group compared with the Uncut Roux-Y anastomosis group (p < 0.05). Duration of postoperative stay was significantly longer in patients with Roux-y anastomosis group (p < 0.05). Considering the surgical simplicity and postoperative complications, the Uncut Roux-Y is a better choice for anastomosis in patients with gastric cancer undergoing gastrojejunostomy. A well-designed large cohort in a multi-centre randomized controlled trial is necessary to support these findings and compare other aspects.

To observe if closing the mesenteric defect with absorbable sutures creates a safe adhesion compared to non-absorbable suture after Roux-en-Y gastric bypass. Rats were randomly assigned to 5 experimental groups according to the different suture materials used in closing the mesenteric defects (Peterson’s space) after Roux-en-Y gastric bypass. Group A (control group), Group B (non-absorbable suture, Prolene suture), Group C (biological glue), Group D (non-absorbable suture, polyester suture) and Group E (absorbable suture). All rats were followed up for 8 weeks postoperatively and underwent laparotomy to observe the degree of adhesion and closure of the mesenteric defect. No significant difference was found in the decrease in food intake and body weight among all groups. No internal hernia (IH) occurred in any group. The mesenteric defects of Group A remained completely visible without any closure or adhesion. Multiple gaps were found between the Prolene suture and the mesentery along the suture line in Group B. The mesenteric defects of Group C were complete closed with multiple adhesions of the small intestine and the greater omentum. The mesenteric defects in both Group D and Group E closed completely. The average adhesion scores in Group A and Group B were 0 and 0.33 ± 0.52 respectively. The average adhesion score in group C (3.83 ± 0.41) was higher than the other groups (p<0.05). The average adhesion scores in Group D and E were similar (3.17 ± 0.41 and 3.00 ± 0.00 respectively). Absorbable suture created a safe adhesion score between the mesentery which was not inferior to non-absorbable sutures.

Obesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy. The complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m2) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful. We made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

Nasolabial cysts are rare, non-odontogenic, soft-tissue cysts that develop between the upper lip and nasal vestibule with an overall incidence of 0.7% out of all maxillofacial cysts. The predominant presentation of a nasolabial cyst is a painless localized swelling with varying degrees of nasal obstruction. Several treatment modalities have described in the management of the nasolabial cyst. In this paper, we present a case of a nasolabial cyst in a 44 years old man with discussions of the treatment modalities in the lights of the literature. We present a case of a nasolabial cyst in a 44-year-old man that slowly increased in size through a period of 3 years, with associated mild pain and nasal obstruction. It had caused a mass effect upon the maxilla, resulting in scalloping. The cyst was excised entirely with no evidence of recurrence at the two months follow up. The nasolabial cyst is a rare soft-tissue cyst. Complete surgical excision using an open approach performed to our case, which considered with the complete endoscopic removal of the best treatment for the nasolabial cysts with a rare recurrence rate.

Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).

Graduating general surgery residents are required to pass the FES exam for ABS certification. Trainees and surgery educators are interested in defining the most effective methods of exam preparation. Our aim is to define trainee perceptions, performance, and the most effective preparation methods regarding the FES exam.

We report an unusual case of a young male patient who presented with severe pain and swelling of his left eyelid following an air compressor tip accident. He suffered extensive facial edema accompanied by deep tissue emphysema and an elevated intraocular pressure. On noncontrast CT scan, air was detected in the intraconal and extraconal orbital compartments, and intracranially within the subarachnoid spaces as well as in the suprasellar and perimesencephalic cisterns. There were no detectable fractures. We presume that by perforating the orbital septum, Tenon’s capsule, and the optic nerve sheath, air had managed to penetrate the cranium through the optic nerve subarachnoid space and into the intracranial subarachnoid space.