Background: The two-stage technique combining the Endoscopic Retrograde CholangioPancreatography (ERCP) with common bile duct (CBD) clearance carried out before the laparoscopic cholecystectomy represents the most common approach for CBD stones. Over time, different techniques have been proposed to manage cholecysto- choledocholithiasis (CCL) advantageously in one stage. Among these, the laparoendoscopic rendez-vous (LERV) addresses the CCL issue with a laparoscopic cholecystectomy with insertion of a guide wire performed at initial stage of the procedure, followed by the clearance of the bile duct carried out by the endoscopists. The goal of this study was to evaluate the efficacy and safeness of LERV procedure recording results and complications, also making a comparison between our results and current literature. Methods: We reviewed our experience of all consecutive patients with cholecysto-choledocholithiasis managed with LERV between January 2018 and December 2023. LERV success rate, operative time, length of hospital stay, stone recurrence, incidence of endoscopic and surgical complications were analysed. Results: A total of 120 patients underwent LERV in our facilities. We reported a 97% LERV success rate, 1.6% conversion-to-open rate, a median intraoperative time of 122 (range 95-220) min. The median hospital stay was 4 (range 2-38) days. An overall morbidity of 15% was reported (18/120): 15 Clavien-Dindo type 1/2, 2 type 3a and one type 3b. In two cases a re-operation during the hospital stay was necessary. At a median follow-up of 14 months (3-59) five patients experienced stone recurrence requiring redo-ERCP in two cases. Conclusion: LERV offers the significant advantage of a single stage procedure and hospitalisation along with a lower risk of post-ERCP pancreatitis, failed CBD cannulation and complications. Our experience confirms safety and effectiveness of the technique for CCL management.

Muscle fatigue caused by using staplers affects the surgical procedures of surgeons. Compared to manual staplers, electric staplers decrease the muscle fatigue by replacing repeated gripping and releasing with automatic model. Still powered by the battery, the electric staplers are confronted with new operation fatigue due to the extra weight of the battery. The weight and manual operation of the electric stapler can cause user's muscle fatigue. To tackle the unsettled fatigue issue, the study is to propose a new design method to offset the influence of extra weight of the battery attached to the electrical stapler by changing the opening and closing of the stapler end clamp to electric control. The purpose of this study is to verify whether the design of this electric stapler can offset the impact of weight. Experiments are set up to test the feasibility of the design on 12 male Chinese surgeons. The muscle fatigue is indicated by measuring the EMG (electromyography) signal, and the stapler's working effect is indicated by measuring the end movement of the stapler. The result shows the new-designed stapler reduce the operation fatigue, counteracting the impact of the battery weight.

Background: Laparoscopic cholecystectomy has gained popularity. The goal of this study was to evaluate outcome differences between open vs laparoscopic cholecystectomy. Method: Using a large NIS database and ICD-9 coding for open vs laparoscopic cholecystectomy, we compared inpatient outcomes for these two procedures regarding the occurrence of myocardial infarctions and mortality using uni- and multivariate analysis by studying 5 years of data from 2010 to 2015. Results: Open cholecystectomy was inferior to laparoscopic procedure with a higher occurrence of non-ST-elevation myocardial infarction (Non-STEMI), ST-elevation myocardial infarction (STEMI), and mortality in comparison to laparoscopic cholecystectomy. For example, using 2010 database, the occurrence of STEMI was 0.2 vs 0% (OR 3.1, CI 1.7-5.5, p<0.001), for Non-STEMI 1 vs 0.4% (OR 2.5 CI 2.0-3.0, p<0001) and for mortality 0.4 vs 0.4% (OR 9.2, CI 7.9-10.6, p<0001). After adjustment for age, obesity, diabetes, and hypertension, the occurrence of STEMI, Non-STEMI, and mortality remained higher in the open cholecystectomy cohort (mortality multivariate OR 6.4, CI 5.5-7.4, p<0001). Conclusion: Open cholecystectomy is associated with a higher rate of STEMI, Non-STEMI, and a markedly higher rate of mortality in comparison to the laparoscopic approach. Our study suggests that laparoscopic cholecystectomy should remain the first choice for patients needing gallbladder surgery.

The relationship between tissue effects, intensity (I), and voltage (V) of a high-frequency alternative current seems well known. However, the translation of the settings of the electrosurgical unit and their use during surgery seems not to be unanimously understood by all surgeons. This results in many variations of surgical technique and plenty of specific questions asked during live surgery. Above 200 V, the heat of the sparks results in the explosion of superficial cells and a cutting effect. With higher voltages, the associated coagulation is increasing. Voltage and amount of energy (Watt=I*V) are independent since a similar amount of energy can be obtained with a continuous current or an intermittent current half the time and a double voltage. Below 200 V, tissue is heated until the steam from boiling tissue stops the current. Therefore, slower heating with less energy or a larger contact area permits deeper coagulation. The maximal output (W) of the electrosurgical unit results in versatility of use besides being a safety measure. The current intensity increases with the area of contact. Therefore, when I*V exceeds the preset output, V has to drop. A limited maximal output thus permits using the same instrument for non-contact cutting with >200V and sparks and coagulation when the contact area is much larger. In conclusion, the tissue effects of electrosurgery vary with the device’s voltage setting (often indicated as force) and the maximal output. The sur-geon’s choice to cut or coagulate by changing the contact area adds versatility.

Advances in gastric cancer screening and endoscopic technology have made it possible to detect and treat gastric cancer at an early stage. As a result, about 40% of all gastric cancers have now been resected by endoscopic treatment in Japan. In endoscopic diagnosis, magnifying endoscopic observation using band-limited light such as narrow band imaging (NBI) has significantly improved the accuracy of gastric cancer diagnosis. At the same time, in endoscopic treatment, endoscopic submucosal dissection (ESD) has contributed to increase explosively the number of gastric cancers which could be resected endoscopically. In recent years, the construction of algorism for endoscopic diagnosis and treatment with a view to personalized medicine has been explored, and endoscopic use for gastric cancer managements is expected to develop further in the future. Keywords (5 words):

Abstract: Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percu-taneous drainage for this condition is controversial. This study compared the clinical and radio-logic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-center cohort study enrolled patients with symp-tomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n=22; combined modality approach, n=12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. After treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both the total hospital stay (55 days vs 71 days; p=0.071) and time to complete radiologic resolution were shorter (93 days vs 124 days; p=0.23) in the endoscopic approach group. Conclusion: The endoscopic step-up approach resulted in the clinical resolution of symptomatic walled-off pancreatic necrosis comparable to that of the combined modality drainage. However, the endoscopic approach alone allows higher clinical success, early clinical and radiologic resolution, and a shorter hospital stay.

We report a case in which a 74-year-old man suffering from esophageal achalasia complicated with epiphrenic esophageal diverticulum was successfully treated with a simultaneous laparoscopic surgery. The gentleman was referred with symptoms suggestive of a passage disorder in lower esophagus from 5 years. Esophagogastroduodenoscopy demonstrated an epiphrenic diverticulum at the left wall of the lower esophagus, and esophagography led to the suspicion of a combined esophageal achalasia. A simultaneous laparoscopic surgery, with an abdominal approach was performed in which, following the opening of the esophageal hiatus, the diverticular wall was separated from the mediastinal organs and diverticulectomy was performed with linear staplers. After Heller’s myotomy, Dor’s fundoplication was subsequently performed in which both incisional line of muscle layer and the suturing line of diverticulectomy were wrapped by the fornix of stomach to make up for the wall strength and avoid the suture leakage. It was theoretically considered logical and effective to reinforce this vulnerable site with Dor’s fundoplication. He had an uneventful recovery and a rapid relief from symptoms following surgery.

Background: The repeated episode of obstructive hypopnea and apnea during sleep is defined as obstructive sleep apnea (OSA) and it is a common condition in obese patients. Studies performing bariatric surgery have demonstrated a significant improvement in OSA by weight reduction. In this prospective study we aimed to explore the efficacy and safety of Laparoscopic Sleeve Gastrectomy (LSG) on OSAS among severely obese patients. Material and Methods: A total of 32 morbidly obese patients who underwent LSG for morbid obesity were included in this study. Body weight, height, body mass index (BMI) and standard overnight polysomnography (PSG) were measured at before and after LSG at the 6th month. Results: 32 patients (27 female, 5 male) who have postoperative PSG's were included in this study. The mean age was 43.22±9.87 years old. The mean preoperative and postoperative BMIs were 50.36±8.14kg/m² and 37.27±7.93kg/m², respectively. The mean Epworth sleepiness scale determined as 5.84±4.65 preoperatively and 2.19±3.55 postoperatively. The preoperative and postoperative sleep efficiency test of the patients was determined as 83.34±9.68 and 88.94±6.90 respectively. AHI average at the preoperative PSG was 31.47±26.34, while 9.35±10:34 at postoperative 6 months and found as statistically significant. Conclusion: Our data showed that LSG is an efficient and safe procedure on severely obese patients and showed a predictive remission of clinical and sleep parameters of patients with OSA by analyzing PSG data during the first 6 months.

Objective To explore the endoscopic anatomical structures of lumbar surgery. Methods A total of 290 patients who underwent lumbar endoscopic surgery due to lumbar intervertebral disc (IVD) herniation from September 2020 to September 2022 were retrospectively reviewed in our hospital,179 patients had complete surgical video recordings, including 108 males and 71 females, aged from 19 to 65 years, with an average age of 41±16 years. The endoscopic structures through the intervertebral foramen and interlaminar space were independently identified by 3 doctors with more than 3 years of related surgery experience. When there were differences of opinions, the three doctors would discuss and come to a consensus. The probability, location, and neighboring structures of each specific structures were statistically analyzed. Results The anatomical structures observed through the lumbar foramen under endoscopy include muscles and ligaments attached to the superior articular process (SAP), main blood vessels inside the intervertebral foramen, blood vessels on the surface of IVD, and blood vessels on the surface of the dural sac and nerve root. The major anatomical structures observed through interlaminar space are multifidus, the conjugated ligament of ligament flavum and capsule ligament (capsule part of flavum ligaments), edges of the lamina, specific vessel bundle to facet with exit nerve root. Conclusion The anatomical structures under spinal endoscopy have certain characteristics, which are grossly different from those under open surgery. Familiarity with these anatomical structures has important clinical significance.

Background: Rectal prolapse is usually self-limiting in early childhood. Laparoscopic rectopexy has become a safe and effective method for treating children with rectal prolapse recurrence, especially those older than 4 years of age. We present the clinical case of an infant with recurrent rectal prolapse and secondary complications. The infant required surgical intervention with laparoscopic rectopexy after the failure of conservative management. Case presentation: A 2-year- and 7-month-old infant with a 15-month history of rectal prolapse who did not respond to conservative management developed bloody diarrhea, intestinal infection and electrolyte imbalance. Laparoscopic surgical correction was performed via anterior ventral rectopexy, and the results were satisfactory. Conclusion: Infants with recurrent rectal prolapse and associated complications who do not respond to conservative measures may benefit from laparoscopic rectopexy.

Laparoscopic cholecystectomy (LC) is the gold standard of treatment for symptomatic gallstone disease. The aim of this study is to determine if postoperative opiate use is reduced with trans-versus abdominus plane (TAP) and rectus sheath (RS) regional anaesthetic blocks compared to port site local anaesthetic (LA) infiltration. A prospective, randomised cohort study was con-ducted of adult patients who underwent an emergency LC between 25 April 2022 and 25 May 2023. 40mls of 0.375% ropivacaine was infiltrated as either TAP and RS blocks or to port sites. Patient demographics, operative data and postoperative opioid use were collected from the med-ical record. 138 patients were enrolled in this study; 73 patients allocated to the LA to port sites cohort (52.9%) and 65 patients in the TAP and RS cohort (43.5%). The most common indication for surgery was acute cholecystitis. The average amount of opiate analgesia use was 115.2mg in the LA group compared to 61.2mg in the TAP and RS group (p

Background: Laparoscopic surgery produces lesser postoperative inflammation with a smaller cytokine and leptin response, and might thus reduce postoperative anorexia compared to open surgery. The aim of the present study was to determine the role of serum leptin in postoperative anorexia after laparoscopic gastric cancer surgery. Methods: Fifty-four consecutive patients with adenocarcinoma of the stomach were operated on either with open or laparoscopic surgery. Correlations were determined between the serum levels of leptin, clinico-pathological characteristics, serum haemoglobin and albumin. Results: Serum leptin levels on day seven were correlated significantly to gender (p=0.004), BMI (p=0.002) and tumour grade (p=0.033). In the patients with CRP < 100 mg/l the leptin levels on day seven were significantly lower after the laparoscopic operation (p=0.042) and in patients with lower BMI (p=0.001). The linear regression model determined a significant correlation between the relative concentration of leptin on day seven and laparoscopic surgery (Beta -0.688; p < 0.0001), gender, BMI, location of the tumour, T stage, N stage, perioperative therapy, tumour grade, perineural invasion, Lauren histological type and ulceration. In patients with CRP levels below 100 mg/ml the serum level of albumin on day seven after surgery was significantly higher in patients after laparoscopic surgery. Conclusion: Laparoscopic surgery produced significantly lower relative leptin concentrations on day seven, and higher serum albumin levels in the subgroup with CRP levels below 100 mg/l at discharge. These results suggested that laparoscopic gastric cancer surgery might reduce postoperative leptin response, leading to a better nutritional status at discharge compared to open surgery.

Background: Endoscopic sphincterotomy (EST) has been employed for the endoscopic treatment of common bile duct stones (CBDSs), and a high success rate of stone removal has been reported. However, EST is associated with the risk of bleeding, perforation, and sphincter of Oddi function disruption. To avoid these risks, endoscopic papillary balloon dilation (EPBD) is an option for CBDS. Sphincter of Oddi function preservation decreases long-term biliary infection and gallstone recurrence. EPBD may have advantages in children who require a long follow-up. However, there have been few reports on pediatric cases, particularly in infants. Methods: From September 2017 to December 2023, we performed EPBD for four pediatric CBDSs. The patients were aged from 5 months to 8 years; including two infants aged 5 and 6 months. Furthermore, we reviewed the stone removal rate and complications of 545 ESTs performed at high-volume centers and 13 EPBD-reported cases in children with CBDSs. Results: CBDSs of all patients who underwent EPBD in our institution were successfully removed. No bleeding or perforation was noted, and pancreatitis was observed in three patients. In an analysis of 545 ESTs in children, the stone removal rate was high, ranging from 83% to 100% (mean, 96%). The incidence of pancreatitis was 0%–9.6% (mean, 4.4%), and the grade of pancreatitis was almost mild. The bleeding frequency was 1.3%–5.4% (mean, 2.7%). According to the grade of bleeding, seven and four cases were mild (64%) and moderate (36%), respectively, Compared with adult cases who underwent EST, the frequency of pancreatitis and bleeding was almost similar in children.; however once bleeding occur, it has a higher risk of leading to blood transfusion in children. Stone removal by EPBD in children was 100% successful. All complications were pancreatitis, and its frequency was 46% (6/13 patients, including five mild cases and one moderate case), which is higher than that of EST and adult cases who underwent EPBD. In most children with pancreatitis, pancreatic enzyme levels returned to normal within 2–3 days following EPBD, and no severe cases caused by EPBD were reported. Conclusions: CBDS removal by EPBD in children has a high success rate with very low risk of bleeding and perforation. Although pancreatitis frequently occurs, most cases are mild. Sphincter of Oddi function preservation by EPBD is expected to prevent long-term stone recurrence and biliary tract infection, and EPBD is considered an effective method for CBDS removal in children.

Background: The cavernous sinus (CS) is a highly vulnerable anatomical space, mainly for the neurovascular structures which it contains, therefore a detailed knowledge of its anatomy is mandatory for the surgical unlocking. To compare the anatomy of this region from different endoscopic and microsurgical operative corridors, also focusing on the corresponding anatomic landmarks met along these routes. Furthermore, we tried to define the safe entry zones to this venous space from these three different operative corridors and provide indications regarding the optimal approach according to the lesion location. Methods: Five embalmed and injected adult cadaveric specimens (10 sides) separately underwent dissection and exposure of the CS via superior eyelid endoscopic transorbital (SETOA), extended endoscopic endonasal transsphenoidal-transethmoidal (EEEA) and microsurgical transcranial fronto-temporo-orbito-zygomatic (FTOZ) approaches. The anatomical landmarks and the content of this venous space have been described and compared from these surgical perspectives. Results: The SETOA allowed the exposure of the entire lateral wall of the CS without entering its neurovascular structures and part of the posterior wall; furthermore, thanks to its anteroposterior trajectory, it allowed to disclose in a minimally invasive fashion, also the posterior ascending segment of the cavernous ICA with the related sympathetic plexus through the Mullan’s triangle. Through the anterolateral triangle, the transorbital corridor allowed to expose the lateral 180 degrees of vidian nerve and artery in the homonymous canal, the anterolateral aspect of the lacerum segment of the ICA, at its the transition zone from the petrous horizontal to the ascending posterior cavernous segment, surrounded by the carotid sympathetic plexus, and the medial Meckel’s cave. Conclusion: Different regions of the cavernous sinus are better exposed by different surgical corridors. The relationship of tumor and cranial nerves in the lateral wall guides the selection of the approach to cavernous sinus lesions. The transorbital endoscopic approach can be considered a safe and minimally invasive complementary surgical corridor to the well-established transcranial and endoscopic endonasal routes in the exposure of the cavernous sinus. Nevertheless, peer knowledge of the anatomy and a surgical learning curve are required.

PurposeThe purpose of this research was the development and evaluation of an intelligent assistive classification system for the recognition of endometriosis and the improvement of the accuracy of laparoscopic imaging in diagnosis. The research was developed with the use of Deep Learning approaches. Methods Data from 4448 laparoscopy images were used in a retrospective chart analysis. The data were divided into two folders, healthy and pathological including 2157 healthy and 2291 pathological images. Based on simple clinical and imaging information and criteria such as the diagnosis of endometriosis (included in an open-source dataset GLENDA of Kaggle repository), data mining algorithms were used to improve laparoscopic imaging accuracy. Results The final developed computer system based on the ResNet50 algorithm predicted the best outcome for all participants who had laparoscopic surgical therapy. The Keras tool was used and the generated code was implemented in Python programming language providing a mean accuracy of > 95 %. Conclusion The intelligent approach revealed better performance than the commonly used imaging criteria in predicting endometriosis improving the time and the total accuracy of diagnostic approaches.

Diffuse cavernous hemangioma of the rectum (DCHR) is a rare benign lesion of vascular malformation. According to previous studies, the most reported major symptoms of DCHR are recurrent painless rectal bleeding or iron deficiency anemia[1][2][3][4][5][6]. We present a case of an 8Y11M boy who was diagnosed with DCHR by MRI. The patient underwent Laparoscopic-assisted transanal distal sigmoidectomy and sigmoido-anal anastomosis（Laparoscopic Swenson Procedure）, and recovered well. After the operation, the child had short-term fecal incontinence and loose stools, which returned to normal after half a year. Regardless of age and symptoms, early and correct diagnosis and treatment of DCHR and postoperative restoration of normal anal function are necessary. Laparoscopic Swenson procedure may be a good option for the treatment of DCHR.

Background: This study evaluates Endoscopic Sinusectomy procedures performed by young and experienced surgeons to compare outcomes achieved by young surgeons to those obtained by experienced surgeons. Methods: From a prospectively maintained database, patients with chronic non recurrent pilonidal disease who underwent Endoscopic Sinusectomy since 1 September 2011 to 31 December 2021, were enrolled. After the propensity score analysis, 200 patients were involved and divided in the group of procedures performed by young surgeons and the group performed by experienced surgeons. Results: About recurrence rate at 1-year follow up (7% vs. 10%, p=0.45) and 5-years follow-up (12.5% vs. 17.5%, p=0.53) and about time off from work (3.54±1.65 vs. 3.61±1.61, p=0.78) no significant results were found. About operative time (30.44±5.57 vs. 43.43±3.83, p=0.004), infection rate (4% vs. 14%, p = 0.013), time to healing of wound (27.89±11.06 vs. 42.22±13.63, p=0.002) and incomplete healing of wound rate (3% vs. 11%, p=0.027) statistically significant differences were found. The multivariate analysis demonstrated that being young surgeons influences the above-mentioned significant results and that the mean distance between lateral orifice and midline impacts on the recurrence rate at 1- and 5-years follow-up for both experienced surgeons’ (p=0.001 and p=0.009) and young surgeons’ procedures (p=0.001 and p=0.003). Conclusions: The recurrence rate doesn’t increase during the training but an adequate training path to perform endoscopic technique is need. A call to perform high-quality randomized controlled studies for establishing how many surgeries are required to be proficient and to outline the ideal endoscopic technique training path.

Introduction. Pituitary adenomas constitute the second most frequent neoplasm of the central nervous system and despite the often-indolent behavior of these tumors, patients affected by pituitary adenomas show higher morbidity and mortality rates. Surgery offers good results in terms of symptoms and disease control: the aim of this study was to evaluate how the neurosurgical treatment for the removal of a pituitary adenoma through a trans-sphenoidal approach can modify the patient's hormonal panel and its influence on the overall clinical outcome. Materials and methods. Between January 2018 and September 2021, 69 patients who underwent surgery for pituitary adenoma operated via the trans-sphenoidal approach were enrolled in the study. Clinical and laboratory data included pre- and post-operative hormonal status, assessed before surgery and within the following 48 hours. Results. Remission of endocrinological values outside physiological ranges and resolution of symptoms were considered as favorable outcome. Surgical treatment was statistically significant as factor to normalize the following hormones: ACTH (p = 0.014), TSH (p &lt; 0.0001), fT3 (p &lt; 0.0001), fT4 (p &lt; 0.0001), FSH (p &lt; 0.0001), LH (p = 0.001), testosterone (p = 0.001), prolactin (p &lt; 0.0001), confirming previous literature findings. Furthermore, the association between surgery and resolution of pre-operative visual disturbances was statistically significant (p &lt; 0.0001). Overall, 59% of patients experienced complete or partial remission of the pre-operative endocrinological abnormalities and in 76% their initial symptoms improved. Conclusions. This study confirms, in our experience, the excellent risk-benefit ratio supporting the use of trans-sphenoidal endoscopic surgery as an effective therapeutic approach for the removal of pituitary adenomas with improvement in the post-operative hormonal and clinical status.

Background: The advantage of a robotic assisted (RARP) over a laparoscopic (LRP) approach in radical prostatectomy (RP) remains to be demonstrated. Aim of the study is to use a homogeneous population in real life and single surgeon surgery, to analyze the oncological and functional results based on the type of the surgical approach. Methods: This is a prospective trial on non-metastatic prostate cancers (PC) patients considered after multidisciplinary decision to RP, using RARP or LRP. A real-life setting was analyzed at our Urological Departments, using homogeneous criteria for the management of PC cases and a one surgeon experience on 444 cases (284 LRP and 160 RARP) .Results: Mean operative time was significantly lower in RARP (173.33±44.3 min) than in LRP (153.21±25.1 min) (p<0.001). In cases submitted to an extended lymph node dissection (eLND), the mean number of lymph nodes removed was 15.16±7.83 and 19.83±4.78 respectively in LRP and RARP procedures (p<0.001), but positive lymph nodes (pN1) were similarly found in 15.8% of LRP patients and 13.6% of RARP patients (p=0.430). Surgical margins (SM) positivity was not significantly higher in RARP group (20.0%) when compared to LRP group (15.9%) (p=0.145). During the postoperative follow-up, a biochemical recurrence (BCR) was detected in 14.4% and 7.5% of cases in the LRP and RARP group respectively (p=0.014). Better results of PAD test at 3-month interval using RARP approach (mean pad weight 75.57±122 grams and 14±42 grams respectively in LRP and RARP (p<0.01)) were described. Conclusions: In the comparison between RARP and LRP approach, a clear advantage of the robotic approach is a significant reduction in operating times, days of hospitalization and postoperative catheterization compared to laparoscopic surgery. It is not possible to describe any certain oncological advantage both in terms of surgical margins and pathological lymph nodes removed. In RARP cases a reduction to the limit of significance is described in terms of biochemical recurrence. RARP produces a more rapid recovery of urinary continence at 3 months postoperatively without significant advantages in terms of erective potency recovery.

Objective: This prospective study investigated the feasibility performing laparoscopic pelvic surgery in spinal anesthesia and analyzed their intraoperative side effects like pain and nausea and vomitus of 915 patients. Methods: Implementation and performance of laparoscopic surgery under local anes-thesia of 915 patients out of a total of 3212, who underwent laparoscopic pelvic surgery in spinal anesthesia, were analyzed in relation to BMI (Body Mass Index), obesity, pain during surgery and amount of intraperitoneal mmHg CO2 gas pressure and surgical complications. Results: BMI > 30, intraabdominal adhesions, increased duration of the operation, bleeding and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery in spinal anesthesia. Under-weight patients, on the other hand, had less pain when intra-abdominal pressure in-creased compared to those of normal weight. The appearance of pain, nausea and vomitus occurred in 10,3% and was easy to manage and treat. It did not affect the sur-geon's work and the course of the operation. Conclusion: In view of these observations, we are proposing spinal anesthesia for lap-aroscopic surgery as the first choice in those patients, who have no contraindications. In our knowledge this clinical study constitutes the largest clinical observations and dataset that applies spinal anesthesia in laparoscopic pelvic surgery.

Background: There is ongoing debate regarding the usefulness of laparoscopic pancreaticoduodenectomy. This study aimed to analyze all the randomized control trials published including the most recent one. Material and methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and MOOSE guidelines. Heterogeneity was measured using Q tests and I2. The random-effects models were used to summarise the relative risks, odds ratios, and mean differences as appropriate.Results:4 RCTs were included consisting of 818 patients. 411 patients were in the laparoscopic group and 407 in the open pancreaticoduodenectomy group. Weighted baseline patient characteristics were similar except more patients with pancreatic adenocarcinoma and more males were there in the open pancreaticoduodenectomy group. There was no difference in-hospital stay,90 days complications rate, 90 days mortality, R1 resection, postoperative pancreatic fistula, delayed gastric emptying, post pancreatectomy hemorrhage, bile leak between the two groups. Operative time was more in the laparoscopic group. Blood loss [mean difference -132.12 ml (-172.60,-91.65)] and surgical site infection [Risk ratio 0.41 ( 0.17-1.0)] were significantly lesser in laparoscopic group.Conclusion:There was no benefit in-hospital stay or clinical outcomes after laparoscopic pancreaticoduodenectomy. Blood loss and surgical site infection were lesser in laparoscopic pancreaticoduodenectomy.

Background: To investigate the preoperative clinical and radiological factors that predict the development of a postoperative intraabdominal abscess (IAA) in patients with acute appendicitis who were treated by laparoscopic appendectomy (LA). Methods: Two hundred sixteen patients with pathologically proven acute appendicitis underwent LA between January 2013 and March 2018 in our department. Of these, 147 patients were diagnosed with complicated appendicitis (CA) (CA group), while the other 69 patients were diagnosed with simple appendicitis (SA) (SA group). We compared the perioperative clinical and radiographic factors between the two groups and investigated the predictive factors of postoperative IAA. Results: Sixteen patients developed postoperative IAA in the CA group, while no patients did in the SA group. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p <0.001), operation time more than 120 minutes (p = 0.023) and placement of a drainage tube (p <0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427). Conclusions: IAA was developed predominantly in the patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

Background/Objectives: Advancements in surgical stapling devices play a crucial role in improving outcomes for bariatric procedures. This study evaluates the performance and safety of a new endoscopic stapler (EnDrive®BelugaTM) regarding perioperative results across multiple bariatric surgery types. Methods: A retrospective analysis was conducted on 112 patients who underwent bariatric procedures using the Beluga stapler at two centres in the UAE and Kenya over 6-month period (June-December 2023). Procedures included laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), mini gastric bypass (OAGB-MGB), and revisions. Perioperative outcomes, complications, and haemoglobin changes were assessed. Results: The cohort included 29 males and 83 females, with a mean age of 32.8 years and preoperative BMI of 41.1 kg/m². Procedures performed were 88 primary LSG, three primary LRYGB, 12 primary OAGB-MGB, and nine revision surgeries. No conversions, deaths, bleeding, or leaks occurred. Minor complications were observed in 4 patients. One patient required reoperation for intestinal obstruction. The mean hospital stay was 1.5 days. Haemoglobin levels showed minimal change from preoperative (12.8 g/dL) to postoperative day 1 (12.3 g/dL). Conclusions: The new Beluga endoscopic stapler demonstrated safe and effective performance across various bariatric procedures, with low complication rates and minimal blood loss. Its enhanced articulation capabilities may offer advantages in specific cases. Further studies are warranted to compare long-term outcomes with established stapling devices.

Differential diagnosis of solid pancreatic lesions (SPLs) using B-mode endoscopic ultrasonography (EUS) is challenging. Detective flow imaging (DFI) offers the potential for detecting low-flow vessels in the pancreas, thus enhancing diagnostic accuracy. This study aimed to investigate DFI-EUS findings of SPLs and analyze their differential diagnostic accuracy for pancreatic cancer. This retrospective study included patients with pathologically confirmed SPLs who underwent EUS between April 2021 and June 2023. Expert endosonographers, blinded to the patients’ clinical data, evaluated images obtained through B-mode, eFLOW, and DFI-EUS. Frame rate and vessel detection sensitivity between eFLOW and DFI were compared, and diagnostic criteria for pancreatic cancer were established. This study included 104 patients, most diagnosed with pancreatic cancer. DFI-EUS demonstrated a significantly higher vessel visualization rate (96%) in SPLs compared to eFLOW (27%). Additionally, DFI showed a superior frame rate, sensitivity (99%), and accuracy (88%) in detecting pancreatic cancer, although with a modest specificity (43%). On DFI-EUS, characteristics such as hypovascular, peritumoral, or spotty vessel findings were suggestive of pancreatic cancer. DFI-EUS significantly improved the visualization of vascular structures within the SPLs, highlighting its efficacy as a diagnostic modality for pancreatic cancer.

Dementia is a rising public health concern. Feeding and nutritional problems increase as the disease progresses, affecting clinical course and caregiver burden. While some guidelines advise against percutaneous endoscopic gastrostomy (PEG) and tube feeding in advanced dementia, conflicting evidence exists. This study aims evaluating nutritional status and the influence of PEG-feeding on outcome and evolution of nutritional/progonosis markers of patients with severe dementia (PWSD) who underwent gastrostomy for nutritional support. We conducted a 16-year rectrospective study on 100 PEG-fed PWSD with strong familiar support. We evaluated survival PEG-feeding period, safety, and objective nutritional/progonosis data at the gastrostomy day and after 3 months: Body Mass Index (BMI), Mid Upper Arm Circumference, Tricipital Skinfold, Mid-Arm Muscle Circumference, albumin, transferrin, total cholesterol and hemoglobin. Most patients presented low values in these nutritional/progonosis parameters. No major life-threatening PEG complications were reported. The mean survival time after gastrostomy was 27.9 months (median of 17 months). Female sex, BMI recovery at 3 months, and higher baseline hemoglobin levels were associated with a reduced risk of death and increased survival time. The study concluded that, in carefully selected PWSD with strong familiar support, PEG feeding can improve nutritional status and have a positive impact on survival.

Background: Endoscopic Ultrasound (EUS) is widely used for the diagnosis of bilio-pancreatic and gastrointestinal (GI) tract diseases, for the evaluation of subepithelial lesions, and for sampling of lymph nodes and solid masses lo-cated next to the GI tract. The role of Artificial Intelligence in healthcare in growing. This review aimed to provide an overview of the current state of AI in EUS from imaging to pathological diagnosis and training. Methods: AI algorithms can assist in lesion detection and characterization in EUS by analysing EUS images and identifying suspicious areas that may require further clinical evaluation or biopsy sampling. Deep learning tech-niques, such as convolutional neural networks (CNNs), have shown great potential for tumour identification and subepithelial lesion (SEL) evaluation by extracting important features from EUS images and using them to classify or segment the images. Results: AI models with new features can increase the accuracy of diagnoses, provide faster diagnoses, identify subtle differences in disease presentation that may be missed by human eyes, and provide more information and in-sights into disease pathology. Conclusions: The integration of AI in EUS images and biopsies has the potential to improve the diagnostic accura-cy, leading to better patient outcomes and to a reduction of repeated procedures in case of non-diagnostic biopsies.

Although pancreatic neuroendocrine neoplasms (PNENs) are relatively rare tumors, their number is increasing with advances in diagnostic imaging modalities. Even small lesions that are difficult to detect using computed tomography or magnetic resonance imaging can be detected with endoscopic ultrasound (EUS). Contrast-enhanced EUS is useful, and not only diagnosis but also malignancy detection have become possible by evaluating the vascularity of tumors. Pathological diagnosis using EUS with fine-needle aspiration (EUS-FNA) is useful when diagnostic imaging is difficult. EUS-FNA can also evaluate the grade of malignancy. Pooling the data of the studies which compared the PNENs grading between EUS-FNA samples and surgical specimen, the concordance rate was 77.5% (κ-statistic: 0.65, 95% confidence interval = 0.59 - 0.71, P< 0.01). EUS is a particularly important modality for the treatment of PNENs.

Background Laparoscopic cholecystectomy constitutes the current “gold standard” treatment of symptomatic gallstone disease. In order to avoid intraoperative vasculobiliary injuries it is mandatory to establish “critical view of safety”. In case of poor identification of the cystic duct and artery leading to a missed intraoperative injury, patients present with elevated liver function tests (LFTs) or increased bilirubin postoperatively. The aim of this study is to present a series of patients of our institute with elevated liver enzymes and bilirubin after laparoscopic cholecystectomy in the absence of intraoperative injury or any other obvious etiology and to provide a possible explanation of this finding. Methods From 2019 to 2023, 200 patients underwent elective laparoscopic cholecystectomy at the Papageorgiou General Hospital and at the European Interbalcan Medical Center of Thessaloniki utilizing the “critical view of safety” method. We retrospectively collected the intraoperative reports and the pre and postoperative imaging and laboratory studies of the patients included in this series. Postoperative LFTs and bilirubin levels were extracted and the reason for their transient elevation was examined. Results From 200 cases of laparoscopic cholecystectomy, in 6 patients elevated LFTs and bilirubin were found on the first postoperative day, which is suggestive of a missed intraoperative injury. All patients were asymptomatic. During the investigatory workup, a triple-phase CT of the liver and/or an MRCP were ordered, but no pathological findings, such as biliary injury, hepatic artery injury or choledocholithiasis, were found. On postoperative day 3, LFTs and bilirubin levels decreased or normalized without any intervention. No postoperative complications were reported. Conclusion In select cases, a transient increase in LFTs and/or bilirubin may be observed in the early postoperative period after elective laparoscopic cholecystectomy in the absence of an obvious etiology. A possible interpretation of these findings could involve the pneumoperitoneum or the anesthesia regimens used intra- or perioperatively. The specific cause however remains undetermined and yet to be examined by future studies.

Purpose: To analyze the clinical efficacy of superselective renal artery embolization and retroperitoneal laparoscopic partial nephrectomy for the treatment of ruptured hemorrhagic renal angiomyolipoma and to provide a reference for the selection of treatment methods for ruptured hemorrhagic renal angiomyolipoma. Methods: A retrospective analysis was conducted on the clinical data of 24 patients who were diagnosed with ruptured hemorrhagic renal angiomyolipoma at the Second Hospital of Tianjin Medical University between January 2019 and December 2021. Among them, 10 patients were treated with superselective arterial embolization (SAE), and 14 patients were treated with retroperitoneal laparoscopic part nephrectomy (RLPN). The differences between the two treatment methods in terms of hospital stay, hospital costs, anesthesia method, operation time, intraoperative blood loss, postoperative bed rest time, antibiotic dosage, postoperative complication rate, tumor diameter changes, creatinine value changes, hemoglobin value changes, tumor recurrence rate, and reoperation rate were compared. Results: All patients completed the treatment and were discharged. There were no significant differences in length of hospital stay, hospital costs, creatinine change values, or postoperative complication rates between the two groups (P > 0.05). However, there were statistically significant differences (P < 0.05) in surgical time (85.50±19.94 min vs. 141.07±76.33 min), intraoperative blood loss (21.50±14.72 ml vs. 153.57±97.00 ml), postoperative bed rest time (22.7±1.56 h vs. 41.21±3.57 h), preoperative hemoglobin levels (94.7 ±23.62 g/L vs. 113.79 ±17.83 g/L), and hemoglobin changes (-6.60 ±10.36 g/L vs. -15.21 ±8.79 g/L) between the two groups. Both groups of patients had an average follow-up period of 22 months, and patients in the SAE group had a mean reduction of 3.33 cm in tumor diameter within the follow-up period compared with the preembolization period (P < 0.05). None of the patients in the SAE group experienced rebleeding, and there was no tumor recurrence in either group. Conclusion: SAE and RLPN are effective treatments for ruptured renal angiomyolipoma with good outcomes. Furthermore, compared to RLPN, SAE offers advantages such as simplicity of operation, minimal trauma, shorter surgical time, minimal impact on hemoglobin levels, shorter bed rest time, faster postoperative recovery, and maximal preservation of renal units.

Robotic surgery is a rapidly developing and evolving surgical technique. This literature review evaluates the advantages and disadvantages in the context of gallbladder disease comparing robotic Cholecystectomy to the well-established laparoscopic Cholecystectomy. Significant advantages are reduced operative blood loss, hospital stays and post operative pain, alongside increased patient satisfaction and improved visualization and precision compared to the laparoscopic approach. Disadvantages include lack of tactile feedback, significant cost attributed to equipment, training requirements and increased procedural time due to the set-up sequences. The implementation of robotic surgery also poses significant changes for the training of future surgeons. Whilst it can standardize training and increases opportunity for simulation, the concern is the loss of traditional skills. Currently the evidence base remains mixed however the use of robotics in the right setting, with suitably trained operatives and appropriate patients can enable improved outcomes for patients with gallbladder disease. There is a lot of scope for development including the implementation of tactile feedback to aid operative technique and artificial intelligence to aid patient safety. Likely broadening the use and potential benefit of robotic surgery not only for cholecystectomy but many surgical specialties.

Background and Objectives: The aim of this study is to investigate the diagnostic-therapeutic prob-lem of pelvic recurrence of rectum cancer, highlighting current surgical standards and the possi-ble role of the minimally invasive approach. This retrospective analysis of our surgical case study wishes to enter this debate while suggesting a possible line of action, based on the site of recur-rence. Materials and Methods: We examined, retrospectively, all the patients diagnosed, between 2008 and 2018, with cancer of the rectum at the "Pietro Valdoni" Department of Surgery and monitored their follow-up for 5 years. The sample consisted of 368 patients with rectal neoplasm, 136 females and 232 males, with an average age of 65.8 (ranging from 37 to 86). In 103 of the cases, the neo-plasm was located in the upper rectum (28%), in 119 cases in the middle rectum (32.3%), in 102 cases in the lower rectum (27.7%), in 31 cases (8.4%) at the level of the right/sigma junction and in 13 cases it was not possible to define the site with certainty (3.5%). Results: We examined all patients diagnosed with cancer of the rectum between 2008 and 2018 at the "Pietro Valdoni" Department of Surgery retrospectively and monitored their follow-up for 5 years. The sample consists of 368 patients with rectal neoplasm, 136 females and 232 males. Conclusions: The discussion remains open as to which approach is best at surgical level, whether laparoscopic, robotic or open-air. Our experience informs us that the most dangerous site remains on the anastomotic site.

Background: Laparoscopy for benign ovarian pathology is the appropriate surgical approach and it has a lot of well-known advantages. Minimal invasive gynecological surgery increases the quality of life for the patient. The learning process of laparoscopy is difficult and re-quires many interventions to acquire manual skills. The objectives of the study were to assess the learning process of laparoscopy for adnexal pathology surgery performed by beginner laparoscopists. Materials and Methods: This study included three gynecological surgeons who were beginners in laparoscopy and who were named A, B and C. We collected information about patients, diagnosis, surgical technique and complications. Results: We have analyzed the data from 159 patients. The most frequent primary diagnosis was functional ovarian cyst, and the laparoscopic cystectomy was performed in 49.1% of intervention. The need to convert a laparoscopy into laparotomy was necessary in 1.3% of patients. There were no cases of reintervention, blood transfusion or ureteral lesions. The duration of the surgical intervention varied statistically significantly according to patient's BMI and to the surgeon. After 20 laparoscopic interventions, a significant improvement was found in the time needed to perform ovarian cystectomy (operator A and B) and salpingectomy (operator C). Conclusions: The process of learning laparoscopy is laborious and difficult. We found a significant decrease in operating time after a number of twenty laparoscopic interventions.

The incidence of radiculopathy due to lumbar spinal stenosis has been on the increase in the aging population. However, patients aged 80 years hesitate to undergo conventional open surgery under general anesthesia because of the risk of postoperative morbidity and adverse events. Therefore, less invasive surgical alternatives are required for the elderly or medically handicapped patients. Transforaminal endoscopic lumbar lateral recess decompression (TELLRD) may be helpful for those patients. This study aimed to demonstrate the efficacy of TELLRD for treating radiculopathy in octogenarian patients. A total of 21 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELLRD between January 2017 and January 2021. The inclusion criterion was unilateral radiculopathy, which stemmed from lumbar lateral recess stenosis. The pain source was verified using imaging studies and selective nerve blocks. Full-scale lateral canal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. We found the pain scores and functional status improved significantly during the 24-month follow-up period. The clinical improvement rate was 95.24% (20 of 21 patients) with no systemic complication. In conclusion, endoscopic lateral recess decompression via the transforaminal approach is practical for octogenarian patients while reducing the medical risks of aggressive open surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is a routinely used therapeutic procedure for the biliary and pancreatic diseases. Population aging may increase the typical indications of ERCP and come with more complexity and difficulties, especially in cannulation. This study aimed to evaluate the incidence, causes, and management of difficult biliary cannulation during ERCP in super-aged patients and the role of difficult cannulation as a risk factor for adverse events. A total of 614 patients, underwent ERCP, were prospectively studied as a cohort and divided into two groups based on their age. There were 146 patients aged 80 years or older in group A and 468 patients aged less than 80 years in group B. The primary outcome measures were the difficulty grade of papilla cannulation, clinical outcomes, and ERCP-related complications in the two groups. The adverse events were analyzed using logistic regression for patient age, co-morbidities, indications, and cannulation difficulty grade variables. There was no difference in the incidence of difficult cannulation between the two groups (32.9% vs. 34.4%, p=0.765) though, as expected, super-aged Group A had a higher prevalence of periampullary diverticulum (29.5% vs. 16.7%, p=0.001). The technical cannulation success rate was (96.6% vs. 96.8%, p= 0.54). All used cannulation techniques in the elderly group were efficient and safe. Logistic regression showed that age ≥80 was not associated with increased adverse events; however, difficult cannulation (adjusted odds ratio [AOR]=3.478; 95% confidence interval [CI]=1.877, 6.442; p<0.001) and CCI ≥2 (AOR=1.824; 95% CI=0.993, 3.349; p=0.045) were more likely to have adverse events. Age ≤65 (AOR=3.460; 95% CI=1.511, 7.922; p=0.003), female gender (AOR=2.362; 95% CI=1.089, 5.124; p=0.030), difficult cannulation (AOR=4.527; 95% CI=2.078, 9.860; p<0.001), and patients with cholangitis (AOR=3.261; 95% CI=1.204, 8.832; p=0.020) were strongly associated with increasing Post-ERCP Pancreatitis (PEP). Advanced age has not proved to be a risk factor of difficult cannulation, and secondary cannulation techniques can be safely and efficaciously utilized for this group. CCI ≥2 and difficult cannulation are associated with increased overall adverse events rate while age ≥80 factor is not.

The oncologic merits of laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by only one surgeon in a medical institution were randomized to either laparoscopic or open treatment. During this period, total 188 patients received laparoscopic surgery and other 163 patients to open approach. The primary endpoint was cancer-free 5-year survival after operative treatment and secondary endpoint was the tumor recurrence incidence. We found there was no statistically significant difference between open and laparoscopic groups regarding average number of lymph nodes dissected, overall mortality rate, cancer recurrence rate or cancer-free 5-year survival. Nevertheless, laparoscopic approach was more effective for colorectal cancer treatment with shorter hospital stay and less blood loss despite operation time was significantly longer. Meanwhile fewer patients receiving laparoscopic approach developed postoperative urinary tract infection, wound infection, pneumonia or anastomosis leakage, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes whether in total complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free 5-year survival and tumor recurrence, we favor patients receiving laparoscopic surgery if not contraindicated.

Endoscopic medical images can suffer from uneven illumination, low contrast, and lack of texture information due to the use of point directional light sources and the presence of narrow tissue structures, posing diagnostic difficulties for physicians. In this paper, a deep learning-based su-pervised illumination enhancement network is designed for low-light endoscopic images, aiming to improve both global illumination and local details. Initially, a global illumination enhancement module is formulated utilizing a higher-order curve function to improve global illumination. Sec-ondly, a local feature extraction module incorporating dual attention is designed to capture local detailed features. Considering the significance of color fidelity in biomedical scenarios, the designed loss function prioritizes introducing color loss to alleviate image color distortion. Compared with seven state-of-the-art enhancement algorithms on Endo4IE endoscopic datasets, experimental re-sults show that the proposed method can better enhance low-light endoscopic images and avoid image color distortion. It provides an efficient method to enhance images captured by endoscopes which can effectively assist clinical diagnosis and treatment.

Background and Objectives: A novel synthetic self-assembling peptide, PuraStat, has been introduced as a hemostatic agent. This case series aimed to evaluate the clinical efficacy of PuraStat for gastrointestinal bleeding during emergency endoscopy. Cases: Twenty-five patients with gastrointestinal bleeding who had undergone emergency endoscopy with PuraStat between August 2021 and December 2022 were retrospectively examined. Six patients were receiving antithrombotic agent, and ten patients with refractory gastrointestinal bleeding had undergone at least one endoscopic hemostatic procedure. The breakdown of bleeding was gastroduodenal ulcer/erosion in 12 cases, bleeding after gastroduodenal or colorectal endoscopic resection in 4 cases, rectal ulcer in 2 cases, postoperative anastomotic ulcer in 2 cases, and gastric cancer, diffuse antral vascular ectasia, small intestinal ulcer, colonic diverticular bleeding, and radiation proctitis in each case. The method of hemostasis was only PuraStat application in six cases, and hemostasis in combination with high-frequency hemostatic forceps, hemostatic clip, argon plasma coagulation, and hemostatic agents (i.e. thrombin) in the remaining cases. Rebleeding was observed in three cases. Hemostatic efficiency was observed in 23 cases (92%). Conclusions: PuraStat has the expected hemostatic effect on gastrointestinal bleeding during emergency endoscopy. The use of PuraStat should be considered in emergency endoscopic hemostasis of gastrointestinal bleeding.

Surgeries that take place in medicine and dentistry or during any form of childbirth results in a significant amount of blood loss. The prevalent measurement methods that surgeons and anesthesiologists utilize as the “gold - standard” has several drawbacks. There are numerous other methods to measure blood loss, which, however, due to their impracticality and limitations, are not ideal either. This paper focuses on minimally invasive neurosurgery in particular, by taking into account a surgical technique known as Endoscopic Endonasal Transphenoidal surgery (EETS), which is used to treat pituitary tumors and adenomas. Along with the review of the existing literature pertaining to blood loss management, this paper proposes a modified electrode probe method along with the concept of usage, computer interface, and the system of integration. The probe is intended to measure the hematocrit count from the collected blood under all circumstances, such that the medical practitioner is assisted to improve the blood loss management technique for better patient recovery.

Aim: This study aimed to investigate the association between periampullary diverticulum (PAD) and difficult biliary cannulation, as well as to evaluate the impact of different types of PAD on the cannulation success rate and adverse events. Methods: A total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) during the study period were prospectively studied and divided into two groups based on the presence or absence of PAD. In group A, 126 patients had PAD compared with 510 patients in group B without PAD. The primary outcome measurements were ERCP procedures time, selective cannulation techniques, and cannulation difficulty in addition to cannulation success rate and ERCP-related adverse events. The difficult cannulation was analyzed using logistic regression considering age, co-morbidities, the presence of PAD types, and indications as independent factors. Results: The average cohort age was 65.30±16.67 years, and 52.7% were male. Significant higher rates of choledocholithiasis, cholangitis, and biliary pancreatitis were reported in the group of PAD (p<0.05). Successful selective cannulation was achieved in 97.6% in group A and 95.3% in group B (p>0.05). The cannulation time was significantly longer in the presence of PAD (5.1 min, vs. 4.09 min, p<0.05). There was no significant difference in the rate of overall adverse events and post ERCP pancreatic PEP. Conclusion: The presence of PAD did not affect the duration or success of the ERCP procedure. Furthermore, it was associated with longer cannulation time and increase in the cannulation difficulty, especially with PAD type 1.

Objectives: In recent years, ear endoscopy has gradually become an important tool in ear surgery. This study further explored its application in ear surgery, to establish a surgical approach for semicircular canal obstruction (SOC) via the ear canal to control vertigo in Meniere's disease. Methods: With the approval of the ethics committee, recruitment started in June 2019. ​Four patients with Meniere's disease who had been treated conservatively for more than six months received SCO via an external ear canal approach under otoendoscopy and were followed for two years after surgery to assess the safety and efficacy of the procedure. Results The control of vertigo after the operation was satisfactory (100%), and the frequency and degree of vertigo were significantly improved. Tinnitus improved in 1 case (25%) and did not progress in the other 3 cases. Hearing loss did not progress in all patients. Postoperative walking instability occurred in 1 patient (25%), and there were no obvious complications. All patients reported significant improvements in their quality of life. Conclusions: SCO via the external auditory canal approach is safe, effective, easy to accept, and an alternative to conservative treatment of Meniere's disease with no actual hearing for more than 6 months.

(1) Background: Endoscopic submucosal dissection (ESD) has been widely accepted as the standard method for treating early-stage cancer or precancerous lesions in the upper gastrointestinal tract, however it may be difficult in patients with liver cirrhosis due to coagulation dysfunction or presence of gastroesophageal varices. We aimed to demonstrate the safety and efficacy of ESD in these population. (2) Methods: We retrospectively collected the clinical data and analyzed. Patients inclusion criteria: 1) patients with liver cirrhosis; 2) patients who underwent ESD; 3) patients diagnosed of early-stage cancer or precancerous lesions in the upper gastrointestinal tract. (3) Results: Eight patients were enrolled from April 2019 to April 2023, of whom 3 were male and 5 female, with age ranging from 43 to 70 years old. Seven lesions were located in the stomach, and the other one lesion in the esophagus. ESD was performed successfully in all patients, and the resected lesion size ranged from 2 to 6 cm. Only one patient encountered postoperative complication, chest pain and fever. No recurrence of noticed during a follow-up of 6 to 36 months. (4) Conclusions: ESD is safe and effective for treating upper gastrointestinal early-stage cancer or precancerous lesions in patients with liver cirrhosis.

Background and objectives: Traditional intravenous, patient-controlled analgesia (PCA) uses a fixed-rate continuous background infusion mode. However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM), where the background injection rate varies depending on the patient's bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated into either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data of bolus demand count, total infused volume, and background infusion rate was downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (P = 0.621), decreasing with time in both groups (P < 0.001). The bolus demand count was not significantly different between groups throughout (P = 0.756). The mean cumulative infused PCA volume was lower in group OBIM [84.0 (95% confidence interval: 78.9−89.1) mL) than in group TBIM [102 (97.8−106.0) mL] (P < 0.001). The background infusion rate was significantly different between groups throughout (P < 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour, and lower from the 18th to the 48th postoperative hours. Conclusions: The OBIM combined with bolus dosing is useful in that it reduces the cumulative PCA volume compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing laparoscopic cholecystectomy.

This paper presents a system developed for the assistance with a collaborative robot in hand-assisted laparoscopic surgery (HALS). The system includes a sensing glove with piezoresistive sensors which capture continuously the flexion degree of the surgeon's fingers. These data are analyzed using an algorithm that detects and recognize the selected movements. This information is sent as commands to the collaborative robot throughout the surgical operation. The bending patterns, speed and execution times of the movements are modelled in a pre-phase in which it will extract all the necessary information for later detection during the motion execution. The results obtained with 10 different volunteers show a high degree of accuracy and a low false discovery rate.

Background and Objectives: Kidney transplantation is the preferred treatment for children with end-stage renal disease (ESRD), but its outcome can be affected by urological complications, with incidence rates of 1%-27%. The aim of this study was to evaluate the occurrence of urological complications and their management in a cohort of pediatric kidney transplant recipients. Materials and Methods: A retrospective analysis on 178 patients undergone to renal transplantation at our Pediatric Kidney Transplant Center between 2011 and 2023 was conducted. Demographic and clinical data were analyzed. Urological complications were categorized as early, intermediate, or late based on their onset time. Results: Out of 178 patients, 28 (15.7%) experienced urological complications. Most patients (61%) had a pre-existing uropathy. Early complications (7-30 days) were all obstructive, namely ureterovesical junction obstruction and perirenal collections. Intermediate complications (1-3 months) comprised ureteral stenosis, symptomatic vesicoureteral reflux (VUR), and obstructive lymphocele. Late complications (&gt;3 months) included symptomatic VUR and ureteral stenosis, with one case leading to ureteral rupture. Early complications were often detected due to acute graft dysfunction, while late ones were mainly identified during routine clinical, laboratory, or ultrasound follow-up. Urological complications requiring surgical or endoscopic therapy were 13.4%. Most ureteral stenoses were treated with initial endoscopic stents, followed by definitive surgery. VUR was treated with endoscopic correction with a high success rate (75%), while open surgery was reserved for cases where initial treatments failed, or complications recurred. No clear correlations were found between patient characteristics and risk of urological complication. Urological complications required multiple diagnostic procedures and therapeutic interventions (+2.5 admissions in mean and approximately +24,000 euros) compared to an uncomplicated post-transplant course. However, they did not significantly impact transplant outcomes, with a graft survival rate comparable to the control group. Conclusions: Regular post-transplant follow-up is crucial, especially for patients with known risk factors, to allow timely detection and treatment of urological complications, avoiding detrimental effects on graft function and improving transplantation outcomes.

Delayed Gastric Conduit Emptying (DGCE) occurs in 15-39% of patients who underwent esophagectomy. Intra-Pyloric Injection of Botulinum Toxin (IPBT), Pneumatic Balloon Dilation (PBD), and the same session combination (BTPD), represent the main endoscopic procedures, but comparative data are currently unavailable. We retrospectively analyzed prospectively collected data on all consecutive patients with DGCE treated endoscopically with IPBT, PBD, or BTPD. ISDE Diagnostic Criteria were used for DGCE diagnosis and classification. Gastric Outlet Obstruction Score was used for clinical staging. All patients undergoing IPBT received 100 UI of toxin, while those undergoing PBD were dilated up to 20mm. Clinical success (CS) was defined as the resolution of symptoms/resumption of feeding at discharge or expanding dietary intake at any rate. Recurrence was defined as symptom relapse after more than 15 days of well-being requiring endoscopic/surgical intervention. 64 patients (81.2% male, 90.6% Ivor-Lewis esophagectomy, 77.4% adenocarcinoma), median age 62 years (IQR 55-70), were enrolled: 18 (28.1%) in the IPBT group, 24 (37.5%) in the PBD group and 22 (34.4%) in the BTPD group. No statistically significant differences were found in the baseline characteristics, surgical techniques, and median follow-up among the three groups. BTPD showed a higher CS rate (100%) compared to the PD and BTPD groups (p=0.02) and Kaplan-Meier analysis with log-rank test revealed that the BTPD group was associated both with a significatively shorter mean time to refeed of 1.16 days (95% CI 0.8-1.5; p=0.001) and a shorter median time to discharge of 1 day (95% CI 1-3; p=0.0001). Endoscopic management of DGCE remains challenging. Waiting for further strong evidence, BTPD can offer patients a higher clinical efficacy rate and a shorter time to refeed and be discharged.

Endoscopic ultrasound (EUS) and intraductal ultrasound (IDUS) play very important roles in the field of biliary tract disease. Because of their excellent spatial resolution, the detection of small lesions and T-staging of tumors have become possible. Additionally, contrast-enhanced EUS and the new imaging technique of detective flow imaging are reported to be useful for differential diagnosis. Furthermore, EUS-guided tissue acquisition is used not only for pathological diagnosis, but also to collect tissue samples for cancer genome profiling. Although percutaneous transhepatic biliary drainage (PTBD) was traditionally performed in cases where endoscopic retrograde cholangiopancreatography is not feasible, treatments using EUS have recently become increasingly common, and EUS-guided biliary drainage was recently suggested to be superior to PTBD in terms of a higher success rate, less adverse events, and lower reintervention rate. This review provides an overview of diagnosis and treatment utilizing the features and techniques of EUS and IDUS.

: Optical coherence tomography is a non-invasive imaging technique that provides three-dimensional visualization of subsurface tissue structures. OCT has been proposed and explored in literature as a tool to assess oral cancer status, select biopsy sites, or identify surgical margins. Our endoscopic OCT device can generate widefield (centimeters long) imaging of lesions at any location in the oral cavity – but it is challenging for raters to quantitatively assess and score large volumes of data. Leveraging a previously developed epithelial segmentation network, this work develops quantifiable biomarkers that provide direct measurements of tissue properties in three-dimensions. We hypothesize that features related to morphology, tissue attenuation, and contrast between tissue layers will be able to provide a quantitative assessment of disease status (dysplasia through carcinoma). This work retrospectively assesses seven biomarkers on a lesion-contralateral matched OCT dataset of lateral and ventral tongue (40 patients, 70 sites). Epithelial depth and loss of epithelial-stromal boundary visualization provide the strongest discrimination between disease states. The stroma optical attenuation coefficient provides distinction of benign lesions from dysplasia and carcinoma. The stratification biomarkers visualize subsurface changes which provides potential for future utility in biopsy site selection or treatment margin delineation.

Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to pro-longed hospitalization, serious tissue inflammation, even sepsis and the need for recurrent sur-gery. Current non-surgical treatments such as self-expanding metal stents (SEMS) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GITM, a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GITM applica-tion demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal prom-ising and most importantly equally good outcomes while maintaining the possibility for sus-tained enteral nutrition and reducing stent migration risk. The VacStent GITM presents a promis-ing alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and establish its role in leak management comprehensively. Fur-ther investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GITM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma.

Endoscopic submucosal dissection (ESD) is almost always performed with a sedative because of the longer procedure times involved. The risk of post-ESD deep vein thrombosis (DVT) has been reported as relatively high, and D-dimer levels are sometimes elevated after ESD. This retrospective study evaluated factors affecting changes in D-dimer levels from before to after ESD to identify causes of elevated D-dimer levels after ESD. This retrospective analysis included 117 patients with gastrointestinal tumors resected using ESD. After excluding 8 patients with pre-ESD levels of D-dimer >1.5 μg/mL, factors correlating with changes in D-dimer from before to after ESD were analyzed using logistic regression analysis in 109 patients. Sedation was accomplished primarily using midazolam, but because the sedative effect of midazolam shows marked inter-individual variability, a “corrected midazolam dose” was determined by dividing the total midazolam dose by the initial dose to correct for inter-individual differences in the sedative effect of midazolam. This value was used as one potential explanatory variable in subgroup analysis of the 103 patients who received midazolam. In subgroup analysis using the corrected midazolam dose as an explanatory variable, only corrected midazolam dose correlated with a change in D-dimer ≥ 1.0 μg/mL in multivariate analysis (odds ratio [OR]=1.5, 95% confidence interval [CI] 0.43–0.95; P=0.030). Corrected midazolam dose correlated with increases in post-ESD D-dimer levels. This potential relationship indicates that patients undergoing ESD and requiring extended sedation may be at increased risk of DVT.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis (NC) indications has not been well studied. We compared clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (n = 8), symptomatic cholelithiasis (n = 1), gallstone pancreatitis (n = 1), choledocholithiasis (n = 1), and Mirizzi’s syndrome (n = 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (p &gt; 0.99). Clinical success rate was 94% and 100%, respectively (p &gt; 0.99). There were 4 adverse events in the AC group and 3 in the NC group (p = 0.62). Procedure duration (median 43 vs 45 minutes, p = 0.37), post-procedure length of stay (median 3 vs 3 days, p = 0.97), and total gallbladder related procedures (median 2 vs 2, p = 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC.

(1) Background: The aim of this study is to investigate the diagnostic-therapeutic problem of pelvic recurrence of rectum cancer, highlighting current surgical standards and the possible role of the minimally invasive approach. This retrospective analysis of our surgical case study wishes to enter this debate while suggesting a possible line of action, based on the site of recurrence; (2) Methods: We examined, retrospectively, all the patients diagnosed, between 2008 and 2018, with cancer of the rectum at the "Pietro Valdoni" Department of Surgery and monitored their follow-up for 5 years. The sample consisted of 368 patients with rectal neoplasm, 136 females and 232 males, with an average age of 65.8 (ranging from 37 to 86); (3) Results: In 103 of the cases, the neoplasm was located in the upper rectum (28%), in 119 cases in the middle rectum (32.3%), in 102 cases in the lower rectum (27.7%), in 31 cases (8.4%) at the level of the right/sigma junction and in 13 cases it was not possible to define the site with certainty (3.5%); (4) Conclusions: The discussion re-mains open as to which approach is best at surgical level, whether laparoscopic, robotic or open-air. Our experience informs us that the most dangerous site remains on the anastomotic site.

Surgical knots are sequences of half-knots (H) or half-hitches (S), defined by their number of throws, by an opposite or similar rotation compared with the previous one and for half-hitches, whether sliding (s) or blocking (b). Opposite rotation results in (more secure) symmetric (s) knots, similar rotation in asymmetric (a) knots, and changing active and passive ends has the same effect as changing rotation. Loop security is the force to keep tissue together after a first half-knot or sliding half-hitches. With polyfilament sutures H2, H3, SSs and SSsSsSs have a loop security of 10, 18, 28 and 48 Newton (N), respectively. With monofilament sutures, they are only 7, 16, 18 and 25N. Since many knots can reorganise, the definition of knot security as the force at which the knot opens or the suture breaks should be replaced by the clinically more relevant percentage of clinically dangerous and insecure knots. Secure knots with polyfilament sutures require a minimum of 4 or 5 throws, but the risk of destabilisation is high. With monofilament sutures, only 2 symmetric+4 asymmetric blocking half-hitches are secure. In conclusion, half-hitch sequences are recommended since mandatory for monofilament sutures, adding flexibility for loop security with less risk of destabilisation.

Flexible surgical robots are emerging as advanced tools for minimally invasive surgeries, offering greater versatility compared to traditional rigid robots. Unlike commercial endoscopes, the overtube should remain fixed to maintain stability, ensure a clear field of view, and allow surgical tools to perform tasks efficiently. While constant curvature bending of the overtube is sufficient for some lesions, certain lesions require the overtube to bend into specific shapes to achieve appropriate positioning. Various methods for creating different bending shapes have been proposed in previous research, typically involving connecting multiple segments. However, this approach complicates control and reduces both space and cost efficiency. This study proposed a conceptual method for adding a shaping tendon to control the bending shape and mathematically analyzed the effect of this shaping tendon, inserted along an arbitrary path in addition to the main driving tendons for constant curvature bending, on the bending shape of the hyper-redundant manipulator with rolling joints. The overall system was modeled and analyzed from an energy perspective, and the validity of the proposed mathematical modeling was verified through comparison with results obtained from physical experiments. In addition, it was identified that the design parameter determining the tendon path is significant element in defining bending shape of the overtube.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of isolated left anterior descending (LAD) or as multi-vessel (MV) procedure for diagonal branch (RD) or circumflex artery (RCX) region. Methods: From 2021 to 2022 91 patients underwent MIDCAB procedure in our heartcenter. 80% were male. Eighty percent of the patients had two or three vessel coronary artery disease. Mean age was 65±10 years. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending via left minithoracotomy approach in all patients. Fourteen patients received multi-vessel MIDCAB (15%) with two or three anastomoses a saphenous vein graft (as T-graft to LIMA) was anastomosed to RD or RCX. Results: Mean operation time was 2.6±0.8 hours. The 30-day mortality was 0. Mean required packed red blood cells (pRBC) was 0.4±1.2 unit. The intensive care unit stay (ICU) was 1.5±1.6 days mean. We observed two patients (2%) with wound infections postoperatively. Four patients underwent rethoracotomy because of bleeding. Mean follow-up time was 1.5±0.5 years. Seventy-eight patients (86%) were in New York Heart Association (NYHA) class 1, 11 patients (12%) were in NYHA class 2. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusion: MIDCAB is technically demanding. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible. Optimal patient selection and an experienced surgical team are mandatory.

Background and aims. Clinically significant delayed bleeding (CSDB) may complicate endoscopic colorectal submucosal dissection (ESD). Methods. We assessed the results of a prospective registry of colorectal ESD. We evaluated the effect of clip closure and PuraStat application for prevention of CSDB. Results. 40 patients with 41 colorectal ESD were included. ESD was successful in 38 lesions (92.7%), 35 with R0 resection (92.1%) and 33 with curative resection (86.8%). CSDB occurred in 3 out 38 lesions (7.9%, 95% CI [1.7 – 21.4%]), exclusively after rectal ESD (3 of 22 rectal lesions vs. 0 of 16 colonic lesions, p = 0.249). Clip closure was more frequently used after colonic ESD (12 of 16 colonic lesions vs. 2 of 22 rectal lesions, p < 0.001) and was not protective for CSDB in univariate analysis, even though no events occurred after clip closure (0 of 14 lesions with clip closure vs. 3 of 27 lesions without, p = 0.283). PuraStat was more frequently applied after ESD for rectal lesions (16 of 22 rectal lesions vs. 2 of 16 colonic le-sions, p < 0.001) and was not protective for CSDB, all three events occurring after PuraStat application (3 of 21 lesions with PuraStat application vs. 0 of 20 lesions without, p = 0.097). Conclusions. CSDB occurred exclusively after rectal ESD, and no predictive factors were identified in uni-variate analysis. Clip closure and PuraStat application were not protective for CSDB.

The aging of the population in developing and developed countries has lead to a significant increase in health burden of spinal diseases. These elderly patients often have a number of medical co-morbidities due to aging. The need for minimally invasive techniques to address spinal disorders in this elderly population group cannot be stressed enough. Minimally invasive spine surgery (MISS) has several proven benefits such as minimal muscle trauma, minimal bony resection, lesser post-operative pain, decreased infection rate and shorter hospital stay. Over the last 40 years, constant efforts are being made to develop newer techniques of spine surgery. Endoscopic spine surgery is one such subset of MISS which has all the benefits of modern MISS. Endoscopic spine surgery initially was limited only to treatment of lumbar disc herniations. With improvement in optics, endoscopes, endoscopic drills and shavers, irrigation pumps, there has been a paradigm shift. Endoscopic spine surgery can now be performed with high magnification thus allowing its application not only to lumbar spinal stenosis, but also to spinal fusion surgeries, cervical and thoracic pathology as well. There has been increasing evidence in support of these newer techniques of spine surgery. For the purpose of this review, we studied current available literature and outlined the historical evolution of endoscopic spine surgery, the various different endoscopic systems, and techniques available and the current applications of endoscopic techniques as an alternative to traditional spinal surgery.

Background: Recently, minimally invasive access via right-anterolateral mini-thoracotomy (RAMT) has been gaining popularity in cardiac surgery. This approach is also an option for sur-geons performing aortic surgery. Aim of the study is to present our surgical method highlighting the total endoscopic minimally invasive approach via RAMT for replacement of the ascending aorta (AAR) with or without involvement of the aortic root and the aortic valve. Methods: Clini-cal data of 44 patients from three participating institutions with AAR with or without involving the aortic valve or aortic root via RAMT between April 2017 and February 2024 were retrospec-tively analyzed. According to surgical procedure patients were divided in group A with only AAR and group B with concomitant valve or root replacement. Operative time, length of ventila-tion, perioperative outcome, length of intensive care unit (ICU) as well as postoperative hospital stay, and mid- and long-term results were retrospectively analyzed. Results: Mean age was 61.4 ± 10.7 years old with a frequency of male gender (63.6%). Mean cardiopulmonary bypass (CBP) time and aortic cross-clamping time was 94.9 ± 32.5 min. and 63.8 ± 25.9 min., respectively. CPB and aortic clamp time were significantly lower in group A. In the first 24 hours the mean drain-age volume was 790.3 ± 423.6 ml. Re-thoracotomy due to bleeding was zero. Sternotomy could be avoided in all patients. Patients stayed 35.9 ± 23.5 hrs at ICU and were discharged 7.8 ± 3.0 days following surgery from hospital. Mean ventilation time was 5.8 ± 7.6 hrs. All patients survived and 30-day mortality was 0.0%. At a median follow-up time of 18.2 months, all patients were alive. The results were similar in both groups. Conclusions: The full endoscopic RAMT approach with 3D visualization is a safe and feasible technique which can be transferred in the field of aor-tic surgery without compromising surgical quality, postoperative outcomes, or patient safety when performed by an experienced team in a high-volume center.

Endoscopy has made a significant and noteworthy contribution to the field of medical science and technology. Nevertheless, its potential remains constrained due to the limited availability of rigid or flexible endoscopes. This paper introduces a novel hydraulic actuator based on electrorheological fluid (ERF) as a pivotal advancement in bridging the existing gap within the realm of endoscopy. Following a comprehensive introduction that briefly outlines the electrorheological effect, the subsequent section is dedicated to the elucidation of the actuator’s development process. Challenges arise, particularly in terms of miniaturization and the realization of a hydraulically sealed system with integrated valve electrodes. An internal electrorheological valve system consisting of four valves that are controlled using a pulse-width modulated high voltage was suitable for position control of the antagonistic hydraulic actuators. High-precision stereolithography (SLA) printing has proven practical for manufacturing the actuator components. For functional testing, a test bench was set up in which the actuator follows a setpoint through a PI control loop. The control deviation ranged from 0.6 to 1 degree, with a response time between 6 and 8 seconds. The experiments have demonstrated that, through the use of ERF and integrated valve electrodes, a miniaturized functional actuator can be constructed.

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMS) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

In the diagnosis of olfactory neuroblastoma (ONB), the presence of S-100–positive sustentacular cells surrounding the tumor is important; however, these are also present in normal nasal sinus epithelium. Although ONB often has a different final diagnosis, complete resection of the tumor has a good prognosis and minimally affects the patient's treatment plan. When the tumor extends around the internal carotid artery (ICA), complete resection is difficult due to the high risk of vascular injury; revascularization using a high-flow bypass can avoid this complication. In the present case, the tumor was located in the left sphenoid sinus and extended around the ICA. Preoperative biopsy tissue was positive for neuroendocrine markers and slightly positive for S-100 protein, leading to a diagnosis of ectopic ONB. High-flow bypass revascularization with trapping of the ICA allowed complete tumor resection. The postoperative histopathological diagnosis was neuroendocrine carcinoma, showing no S-100 protein–positive cells. There was no sign of recurrence two and a half years after surgery without additional treatment. This case demonstrates that the presence of S-100 protein–positive cells in ONB may be misleading. Although misdiagnosis of ectopic ONB should be anticipated, a complete resection of the tumor is an effective treatment strategy.

There is an anecdotal impression that teenage patients report exaggerated postoperative pain scores that do not correlate with their actual level of pain. Nurse and parental perception of teenagers' pain can be complemented by knowledge of patient pain behavior, pain catastrophizing thoughts, anxiety, and mood level. Two hundred two patients completed the study: 56.4% female, 89.6% White, 5.4% Black, and 5% other race. Patient ages ranged from 11 to 17 years (mean = 13.8, SD = 1.9). The patient, the parent, and the nurse completed multiple questionnaires on day one after laparoscopic surgery to assess patient pain. Teenagers and parents (r=0.56) have a high level of agreement, and teenagers and nurses (r=0.47) have a moderate level of agreement on pain scores (p &lt;0.05). The correlation between patient APBQ (Adolescent Pain Behavior Questionnaire) and teenager VAS (Visual Analog Scale ) and between nurse APBQ and teenager VAS, while statistically significant (p &lt; 0.05), is weaker (r range = 0.14-0.17). There is a moderate correlation between teenagers' pain scores and their psychological assessments of anxiety, catastrophic thoughts, and mood (r range= 0.26 – 0.39; p &lt;0.05). A multi-modal evaluation of postoperative pain can be more informative than only assessing self-reported pain scores.

Right-sided ligamentum teres (RSLT) is a rare anatomic variant in which the fetal umbilical vein connects to the right portal vein. Patients with RSLT frequently have hepatic vasculature and bile duct anomalies, which increase the risk of complications with hepatectomy. Most patients with RSLT undergo open hepatectomy. We describe a patient with RSLT and hepatocellular carcinoma who underwent laparoscopic hepatectomy. The patient was a 69-year-old man with hepatocellular carcinoma located in the left liver based on computed tomography (CT) and magnetic resonance imaging. Imaging also demonstrated RSLT. Three-dimensional CT analysis revealed independent right lateral type anomalies of the portal vein and bile duct. Laparoscopic extended left lateral sectionectomy was performed after careful surgical planning. Ultrasonography was used frequently during surgery to avoid damaging the right hepatic vasculature. The left lateral and partial left median sections were removed as planned. The patient’s postoperative recovery was uneventful. Avoiding injury to the right hepatic vasculature is essential when performing left lobectomy, including left lateral sectionectomy, in patients with RSLT. Laparoscopic hepatectomy can be performed safely in patients with RSLT, provided that careful surgical planning is conducted using preoperative three-dimensional CT analysis and intraoperative ultrasonography is used.

There are currently no effective screening measures to detect early or occult tubo-ovarian cancers resulting in late-stage detection and high mortality. This work explores whether an optical imaging catheter can detect early-stage tubo-ovarian cancers or precursor lesions where they originate in the fallopian tubes. This device collects co-registered optical coherence tomography (OCT) and autofluorescence imaging (AFI). OCT provides three-dimensional assessment of underlying tissue structures; autofluorescence imaging provides functional contrast of endogenous fluorophores. Ex vivo fallopian tubes (n=28; n=7 cancer) are imaged; we present methods for the calculation of and analyze eleven imaging biomarkers related to fluorescence, optical attenuation, and OCT texture for their potential to detect tubo-ovarian cancers and other lesions of interest. We visualize folded plicae, vessel-like structures, tissue layering, hemosiderin deposits, and regions of fibrotic change. High grade serous ovarian carcinoma appears as reduced autofluorescence paired with homogenous OCT and reduced mean optical attenuation. Specimens containing a cancerous lesion demonstrate significant increase in median autofluorescence intensity and decrease in entropy compared specimens with no lesion. Non-cancerous specimens demonstrate an increase in optical attenuation in the fimbriae when compared to the isthmus or ampulla. We conclude that this approach shows promise and merits further investigation of diagnostic potential.

Background: This prospective study assesses the use of Rapid Remote Online Cytological Evaluation analysis for diagnosing endoscopical achieved biopsies. It focuses on its effectiveness in identifying benign and malignant conditions using digital image processing. Methods: The study was conducted between April 2021 and September 2022 and involved a total of 314 Rapid Remote Online Cytological Evaluations (17 brush, 143 fine needle aspirations and 154 imprint cytologies) analyses performed on 239 patients at the LungenClinic Grosshansdorf. During on-site evaluation via telecytology, the time requirement was determined and the findings were compared with the cyto-/histological and final diagnoses. Results: By means of Rapid Remote Online Evaluation, 86 cytological benign and 190 malignant and 38 findings of unclear diagnosis were recorded (Ø assessment time 100 sec., range 11 - 370sec.). In 27 of the 38 cases with unclear diagnosis, the final findings were malignant tumours and only 6 were benign changes. The diagnosis of another five of these 38 cases remained unclear. Excluding these 38 findings, the Rapid Remote online cytology achieved a sensitivity of 78.6% with a specificity of 99.5% and a correct classification rate of 93.1% with regard to the final diagnosis of all cases. As expected, an increase in the sensitivity rate for the cytological detection of malignant tumours (76.1% vs. 92.5%) was found especially in fine-needle aspirations. Conclusions: Rapid remote online analysis allows fast quantitative and qualitative evaluation of clinically obtained cytological specimens. With a correct classification rate of more than 93%, sampling deficiencies can be corrected promptly and diagnostic and therapeutic approaches can be derived.

Pancreatic neuroendocrine tumor (P-NET) is a rare neoplasm originating in the neuroendocrine system. Carcinoid syndrome occurs in approximately 19% of patients with functional P-NETs, typically when liver metastases occur. NETs diagnosis is frequently late, along with symptoms related to hormone hypersecretion. We described the case of a patient with a low-grade non-functional P-NET, but with a typical clinical presentation of a carcinoid syndrome; moreover, we reviewed the literature regarding this topic. An 81-year-old male was admitted to our Department of Internal Medicine at Cannizzaro Hospital (Catania, Italy) because of the onset of abdominal pain with nausea, loose stools and episodic flushing. Firstly, an abdominal contrast-enhanced CT scan showed a small pancreatic hypervascular mass; then a gallium-68 DOTATOC integrated PET/CT revealed an elevated expression of SSTR receptors. Serum Chromogranin A and urinary 5-HIAA measurements resulted negative. Given the small size of the lesion (8 mm), we preferred to perform an endoscopic ultrasonography (EUS) with fine-needle biopsy (EUS-FNB), allowing the diagnosis of low-grade (G1) non-functional P-NET (NF-P-NET). Surgery was waived, while a follow-up strategy was chosen. Early recognition of P-NETs, although rare, is necessary to improve patient’s survival. EUS-FNB should be the protocol of choice for an early characterization of these tumors.

Piriform fossa and/or esophageal injuries caused by calibration tubes are relatively rare and re-main unelucidated. Herein, we report the case of a 36-year-old woman with morbid obesity, sleep apnea, and menstrual abnormalities who was scheduled to undergo laparoscopic sleeve gastrectomy (LSG). We inserted a 36-Fr Nelaton catheter made of natural rubber as a calibration tube during the surgery. However, excessive resistance was observed. We confirmed a submuco-sal layer detachment of approximately 5 cm from the left piriform fossa to the esophagus using intraoperative endoscopy. Additionally, LSG was performed using an endoscope as the guiding calibration tube. We inserted a nasogastric tube under endoscopy with a guidewire before com-pleting the surgery, hoping for a guiding effect on saliva flow. After 17 months, the patient suc-cessfully lost weight postoperatively without complaints of neck pain or discomfort during swallowing. Therefore, if the damage is limited to the submucosal layer, as in this case, conserva-tive therapy should be considered, which is similar to the concept of not requiring suture closure in endoscopic submucosal dissection. This case highlights the risk of iatrogenic injuries to the pi-riform fossa and/or esophagus during LSG and the importance of careful calibration tube inser-tion to prevent them.

EUS–TA in unresectable pancreatic cancer requires not only a tissue diagnosis but also tissue collection in anticipation of comprehensive genomic profiling. However, the optimal puncture target remains controversial. Therefore, the Primary and Metastatic Lesions in Pancreatic Cancer (PRIMATE) study was designed to clarify the optimal target by comparing the success rates for meeting OncoGuide NCC Oncopanel (NOP) analysis criteria on pre-check primary and metastatic lesion specimens obtained during the same EUS–TA session in patients with invasive pancreatic ductal adenocarcinoma. In this ongoing prospective study, two specimens, each from primary and metastatic lesions, are obtained by EUS–TA (typically using a 19G fine-needle biopsy needle) in patients with invasive pancreatic ductal adenocarcinoma. The primary endpoint is the proportion of EUS–TA specimens that meet NOP analysis criteria during pre-check (i.e., tumor cellularity ≥ 20% and tissue area ≥ 4 mm2), which are then compared between primary and metastatic lesions. This study has been approved by the National Cancer Center Institutional Review Board (Research No. 2022-168). The results of this study will be reported at an international conference and published in an international peer-reviewed journal. The trial registration number is UMIN 000048966.

Chronic rhinosinusitis (CRS) is a complex inflammatory condition affecting the nasal and paranasal sinus mucosa. Gastroesophageal reflux disease (GERD) has been implicated as a potential exacerbating factor in CRS, but the specific endoscopic features of nasopharyngeal pathology in this context remain poorly understood. Background and Objectives: CRS is a multifactorial disease with various underlying etiologies, including inflammation, anatomical factors, and environmental triggers. While GERD has been suggested as a potential contributor to CRS, the specific endoscopic features indicative of nasopharyngeal pathology in CRS patients with GERD symptoms have not been clearly elucidated. Our aim is to identify specific endoscopic features of nasopharyngeal pathology in patients with CRS associated with GERD symptoms, and to propose a method for assessing the influence of GERD on the mucosal layer of the nose and nasopharynx. Materials and Methods: We conducted a cross-sectional observational study involving 521 adult patients presenting with symptoms suggestive of CRS. From this cohort, 95 patients with the highest scores on the Reflux Symptom Index (RSI) and Reflux Symptom Score-12 (RSS-12) questionnaires were selected as the main group. Endoscopic examinations were performed to assess the nasal and nasopharyngeal mucosa. Results: Our study revealed significant alterations in the nasopharyngeal mucosa of patients with CRS associated with GERD symptoms. Increased vascularity of the nasopharyngeal mucosa was observed in 91 patients (95.7%), while hypertrophy was noted in 83 patients (87.4%). Mucus was present in the nasopharynx of 77 patients (81.1%), exhibiting varying characteristics of color and consistency. Asymmetric hypertrophy of the oropharyngeal mucosa was noted in 62 patients (65.3%). Conclusions: We propose a method for assessing the influence of GERD on the mucosal layer of the nose and nasopharynx, which may aid in diagnostic and management decisions. Further research is warranted to explore the potential impact of GERD symptoms on the course and severity of CRS exacerbations.

This mini-review explores the comparative efficacy, safety, and clinical outcomes of high-dose proton pump inhibitor (PPI) intravenous infusion versus oral acid pump inhibitor therapy following endoscopic treatment for bleeding peptic ulcers. Recent evidence suggests that intravenous PPIs can significantly reduce the rebleeding rates within the critical first 72 hours post-intervention, with a noted rebleeding rate of 6% compared to 14% in patients receiving oral Vonoprazan (VPZ) therapy. Additionally, the rapid onset of action associated with intravenous administration leads to faster stabilization of vital signs and a reduced need for subsequent blood transfusions. Safety profiles for both intravenous and oral VPZ were favourable, with minimal adverse effects, the most common being transient headaches.However, the findings from our single-centre study with a moderate sample size prompt consideration of more extensive, multicentre trials to enhance the generalizability of the results. Current limitations include potential biases, short-term focus, missing data issues, and a need for long-term outcome data, necessitating further research. Future studies should also explore the cost-effectiveness of intravenous versus oral VPZ and the impact on patient quality of life and long-term mortality rates.This review underscores the importance of tailored PPI therapy in managing bleeding peptic ulcers post-endoscopy. It suggests a potentially pivotal role for intravenous PPIs in high-risk patient groups, advocating for a shift towards more aggressive and immediate care protocols in specific clinical settings.

Introduction: Gastric cancer (GC) is one of the most common cancers in the world. It is a very aggressive and heterogeneous tumor. GC does not cause symptoms, so it is often diagnosed in an advanced stage and associated with poor prognosis. Despite new treatment options, it still remains a therapeutic problem. An important element determining the method of treatment of locally advanced gastric cancer (LAGC) is the assessment of lymph node metastases in preoperative and postoperative imaging and/or histopathological examination.Aim: The assessment of lymphovascular invasion (LVI) in histopathological examination in patients with LAGC after gastrectomy. The groups of patients were divided into patients who received preoperative chemotherapy, patients without preoperative chemotherapy, and all patients. Additionally, we assessed the correlation between the presence of LVI and the number of lymph nodes collected during gastrectomy.Material and method: We collected patients with histologically confirmed GC after gastrectomy. The collected samples were divided into three subgroups: patients with neoadjuvant chemotherapy (NAC), patients without NAC, and all patients. Histopathological examination assessed the presence of LVI infiltration. We then assessed the correlation between the presence of LVI and the presence of lymph node metastasis in GC. Additionally, we assessed the correlation between LVI and the number of lymph nodes evaluated in patients in each group. The statistical analyses were performed using Statistica v13.3 and Microsoft Excel 2021. The significance limit was set at p<0.05.Results:The presence of LVI strongly correlated with node involvement, and the result was statistically significant in all patients and the group of patients treated with NAC. The difference was not statistically significant in the group not treated by NAC. Additionally, we did not observe a correlation between the presence of LVI and the number of metastatic lymph nodes in GC.Summary and Conclusions: The presence of LVI in a patient with GC indicates a high probability of lymph node metastasis, which should translate into therapeutic procedures. Assessment of LVI may help identify potential patients with lymph node metastases, particularly in patients undergoing endoscopic resection without planned lymphadenectomy. It is advisable to expand research on a larger scale in order to establish clear standards in this area.

This study aimed to introduce a novel machine learning (ML) model designed to predict the need of interventions during endoscopy in patients with upper gastrointestinal bleeding (UGIB). The risk stratification tools in current use, such as the Glasgow Blatchford Score (GBS) and pre-endoscopic Rockall score, have limitations in accurately predicting the need for endoscopic interventions. All patients diagnosed with UGIB from January 2013 to October 2023 who underwent endoscopy were included in the study. Variables extracted included demographics, social history ,clinical history, clinical presentation and symptoms, drug history, management prior to endoscopy, findings during endoscopy, laboratory variables and vitals, and post-endoscopic results. Three machine learning models including Random Forest Classifier (RFC), Gradient Boosting Classifier (GBC), and AdaBoost Classifier were used to evaluate the need for intervention during endoscopy in our study. A total of 1372 patients were included from three major hospitals in Jordan, of whom 242 underwent endoscopic intervention. The GBC outperformed all other models and pre-endoscopic scores in predicting the need for endoscopic intervention with an area under the curve of 0.861. Findings during endoscopy, platelet count, pulse rate and systolic blood pressure during admission were the most contributing features in predicting the need for the need of endoscopic intervention. This study highlights the potential of machine learning models in enhancing decision making for UGIB management.

Study design :Technical note. Objectives : To present a new unilateral biportal endoscopic technique for lumbar disc herniation without C-arm . Background : Lumbar disc herniation requires surgical intervention when conservative methods fail. Shifts towards minimally invasive percutaneous endoscopic lumbar discectomy, including uniportal and biportal approaches, have been hindered by challenges such as steep learning curves and reliance on radiation-intensive C-arm guidance. Our study introduces the use of standard intraoperative navigation in unilateral biportal endoscopy (UBE) to reduce radiation exposure and increase surgical acuracy. Materials and Methods : A 24-year-old man with low back and bilateral leg pain with gait disturbance was referred to our hospital. He had have conservative treatment for 12 months in another hospital before admission. However, the conservative treatment did not work for him. He had low back pain (VAS 4/10) and bilateral leg pain (VAS 8/10), muscle waekness of bilateral legs (Manual muscle testing ;MMT of extensor hullusis longs 4 4), and numbness of bilateral lower leg. Preoperative lumbar MRI showed L4/5 large central disc herniation. Results: He underwent C-arm free unilateral biportal endoscopic discectomy under the guidance of O-arm navigation. The patient was successfully treated surgically. Postoperative lumbar MRI showed good decompression of dural sac and bilateral L5 nerve roots. MMT and sensory function of both leg had recovered fully on final follow-up at one year. Conclusions/Level of Evidence: The new unilateral biportal endoscopic technique under navigation guidance is useful technique for lumbar disc herniation. This innovative technique proved to be safe, accurate, and minimized radiation exposure for surgeons for the treatment of lumbar intervertebral disc herniation. Level V.

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evalua-tion. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP, as-sessing its accuracy, timing, safety, and future technological improvement. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a cru-cial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visu-alization of the pancreas, biliary system, and adjacent structures. High accuracy of EUS is evident in detecting the actual causes of IAP such as microlithiasis, small bile duct stones, pancreas divisum, and small pancreatic tumors. Optimal timing for EUS is post-resolution of the acute phase of the disease. EUS, when conducted by experienced endoscopists, it boasts minimal safety concerns, and is crucial to prevent complications. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in cytological analy-sis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicenter prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.

The loop and knot securities of 2 braided and 2 monofilament sutures of four diameters (3.0, 2.0, 0, 1) were evaluated with a tensiometer for four 4-throw knots known to be secure with a 2.0 polyfilament suture. Loop security of monocryl 1 is low, being 14.7 + 3.0 Newton (N) for a 3-throw half-knot (H3) and 15.4 + 2.4 N and 28.3+ 10 N for 2 (SSs) and 4-throw (SSsSsSs) symmetrical sliding half-hitches. This is lower than 18, 24, and 46 N for similar knots with vicryl. Polyfilament sutures have excellent knot security for all diameters. Occasionally, some slide to open with slightly lower knot security, especially for larger diameters, although not clinically problematic. Knot se-curity of monofilament sutures was unpredictable for all 4 knots, especially for larger diameters, resulting in many clinically insecure knots. A secure monofilament knot requires a 6-throw knot with 2 symmetrical sliding half-hitches or 2 symmetrical half-knots secured with 4 asymmetric blocking half-hitches. In conclusion, with polyfilament sutures, 4 or 5-throw half-knot or half-hitch sequences result in secure knots. For monofilament sutures, loop and knot security is much less, half-knot combinations should be avoided, and secure knots require 6-throw knots with 4 asym-metric half hitches. This conclusion is valid for gynecologic laparoscopic and open surgery, and for surgery in general.

BACKGROUND: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is essential technique for sampling solid pancreatic lesions. However, the optimal needle type for achieving high histological diagnostic capability remains unclear. This study compares the histological diagnostic capabilities of the 19G FNA needle and the 22G FNB needle for solid pancreatic lesions. METHODS: This single-center, retrospective study was conducted in patients who underwent EUS-TA for solid pancreatic lesions. Patients were allocated to either Group A, utilizing the 19G FNA needle, or Group B, utilizing the 22G FNB needle. The primary outcome was the diagnostic accuracy based on histology alone. RESULTS: 143 patients were analyzed, with 61 in Group A and 82 in Group B. Diagnostic accuracy was significantly higher in Group B for both histology alone (85.4% vs. 68.9%, p=0.02) and overall diagnostic accuracy (85.4% vs. 73.8%, p=0.02). Logistic regression analysis revealed that lesion size ≥25 mm was an independent factor contributing to higher diagnostic accuracy (OR 3.32, 95% CI 1.28-8.64, p=0.01). Subgroup analysis showed that diagnostic accuracy for 15–25 mm lesions was significantly higher in Group B (90.0% vs. 63.2%, p=0.02). Additionally, trans-gastric punctures had higher accuracy in Group B (94.7% vs. 73.5%, p=0.01). CONCLUSIONS: Our study showed the overall superiority of the 22G FNB needle for EUS-TA of solid pancreatic lesions. However, 19G FNA needle remains a valuable option under specific conditions.

Ambiguity exists over treatment and surveillance strategies after endoscopic submucosal dissec-tion (ESD) for esophageal squamous cell neoplasia (ESCN) with unfavorable histologic features. This study investigated the long-term outcomes of ESD in high-risk ESCN patients. We retro-spectively included early ESCN patients treated with ESD at two medical centers in Taiwan be-tween August 2010 and December 2023. Demographic, endoscopic, and pathological data were collected. Among 146 patients (mean age 59.17 years) with 183 lesions, 73 (50%) had a history of head and neck cancer (HNC). En bloc and R0 resection were achieved in 100% and 95.6% of the lesions, respectively. The 5-year overall survival (OS), disease-specific survival (DSS) and local recurrence rates were 42.7%, 94.7% and 11%. R0 resection was significantly associated with re-currence in univariate analysis (adjusted OR: 0.23, 95% CI: 0.05-0.99, P=0.05). Alcohol abstinence was independently associated with lower recurrence (adjusted OR: 0.20, 95% CI: 0.08-0.48, P

Introduction: Lumbar radiculopathy, frequently triggered by disc herniation, affects around one in 50 young adults (30-55 ages), leading to significant impacts on quality of life. When conservative treatments fail to alleviate symptoms, surgical intervention such as discectomy is often pursued. Technological advancements have led to various minimally invasive techniques, promising improved outcomes. Our aim was to compare clinical outcomes of different techniques. Methods: We conducted a systematic search in PubMed using "lumbar disc hernia" and the meta-analysis filter. Inclusion criteria comprised meta-analyses focusing on lumbar disc herniation treatments, published in English. A rigorous selection process adhering to PRISMA guidelines ensured high-quality evidence extraction. Results: From 28,171 initial records, 31 meta-analyses involving 87,852 patients were included. Heterogeneity across the literature presented challenges, notably in study populations, surgical techniques, and research designs. Among the techniques evaluated, full-endoscopic lumbar discectomy (FELD) emerged as superior in various perioperative parameters, including Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI), operation time, and complications. Conversely, automated percutaneous discectomy (AUTD) consistently exhibited poorer outcomes, suggesting limited effectiveness compared to other techniques. Conclusion: Despite advancements, the heterogeneity observed in the literature underscores the need for standardized approaches in minimally invasive spinal surgery research. FELD stands out as a preferred technique, offering favorable outcomes across multiple parameters. Conversely, techniques like AUTD raise concerns regarding efficacy. Future research should aim for uniformity in methodologies to facilitate accurate comparisons and guide clinical decision-making.

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLNs assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is at stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: we described a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary to evolve through future IDEAL stage 2b (multi-center studies) and stage 3 (randomized controlled trials) studies.

Background. Rectal Magnetic Resonance Imaging (MRI) is a key test in advanced rectal cancer and in the preoperative staging of a lesion suitable for transanal endoscopic surgery (TES). MRI is not operator-dependent, but its results when determining anatomical landmarks are variable. Method. Observational study of inter-observer concordance regarding four diagnostic tests used to establish the anatomical characteristics of rectal lesions: colonoscopy, rectal ultrasound (EUS), rectal MRI, and intraoperative rigid rectoscopy (IRR) in patients scheduled for transanal endoscopic surgery (TES) with curative intent. This inter-observational study assessed the concordance between four expert radiologists regarding the topographic evaluation by means of rectal MRI of lesions under consideration for TES. Results. Fifty-five consecutive rectal tumors were studied. For most of the items, the correlation between IRR and colonoscopy or EUS was generally very good (intraclass correlation coefficient -ICC-)>0.75), although the correlation between MRI and IRR in relation to size by quadrants (ICC=0.092) and location by quadrants (ICC=0.292) was weak. The ICC for the other items obtained excellent correlations: Kappa index >0.80 for all items except for the distance from the peritoneal reflection to the anal verge, where it was merely good (IK=0.606). Conclusions. The anatomical description of rectal lesions that are candidates for TES provided by means of IRR, EUS, colonoscopy and MRI is reliable. The MRI is less reliable, but in the hands of expert radiologists, the anatomical study of rectal lesions is accurate and reproducible.

Direct laryngoscope and videolaryngoscope are the dominant endotracheal intubation tools. Styletubation technique (using a video-assisted intubating stylet) has shown its advantages regarding in short intubation time, high success rate, less stimulation, and operator’s satisfaction. The learning curve can be steep but easy to overcome if the technical pitfalls could be avoided. Conditions make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, and obesity, etc. In this clinical report, we present the effectiveness and efficiency of routine use of the styletubation for tracheal intubation in a super-super obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.

Regional anesthesia in postoperative pain management have developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a retrospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9, and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with ropivacaine 0.375% or 0.25%. The primary outcome was post-operative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB-group on postoperative days 0, 2, and 3 (p=0.012, p=0.016 and p=0.004). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in ESPB-group (p<0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than TAPB-group in postoperative days from 2 to 4 (1 vs 3, p>0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB-group and no block related complications were observed. We conclude that ESPB provide better postoperative pain control with less consumption of local anesthetic and less total rescue analgesic therapies.

We present here a case of complex uterine anomaly – Obstructed HemiVagina with Ipsilateral Renal Agenesis (OHVIRA), also known as Herlyn-Werner-Wunderlich syndrome in a 13-year-old girl with the history of recurrent urinary tract infections (rUTI). In emergency room, trans-abdominal sonography revealed ovarian cyst and renal agenesis, without any suspicion of vaginal obstruction. This led to delay in the diagnosis of this uncommon anomaly. Finally, MRI findings confirmed the presence of OHVIRA syndrome. As the congenital anomalies of kidney and urinary tract (CAKUT) are in almost one third of cases associated with genital malformations, urologist should carefully search for patients with rUTI. The patient underwent simultaneous laparoscopy and vaginoscopy, what was in our opinion the most appropriate therapeutic decision. In this article we are also going to discuss the role of laparoscopy in the management of OHVIRA syndrome as well as other surgical techniques described in the literature.

The main goal of our scientific study is to determine the particular characteristics of the endo-scopic image of the otorhinolaryngologic pathology of nasopharynx, which is called chronic rhinosinusitis in association with gastroesophageal acid reflux disease. Background/Objectives: to identify a specific features in the endoscopic picture of chronic rhinosinusitis associated with acid gastroesophageal reflux disease symptoms. Methods: there were selected 521 adult patients, from this sample as a main group we have selected only 95 patients with the highest scores on the Reflux Symptom Index (RSI) (>20) and Reflux Symptom Score-12 (RSS-12) (>130) questionnaires. As a control group we have selected 41 adult patients only with chronic rhinosinusitis and 10 healthy patients. Results: there were significant changes in the nasopharyngeal mucosa. In-creased vascularity of the nasopharyngeal mucosa was noted in 91 patients (95,7%). Hypertrophy of the nasopharyngeal mucosa was found in 83 patients (87,4%). In 77 (81,1%) patients, mucus was found in the nasopharynx with different characteristics of color and consistency, and no mucus or other secretions were found in the middle nasal passages in these patients. In 62 pa-tients (65,3%) asymmetric hypertrophy of the mucosa of the oropharynx was noted. Conclusions: the presence of specific features of the endoscopic picture of the nose and nasopharynx of pa-tients with chronic rhinosinusitis associated with gastroesophageal disease symptoms and pro-posed a method for assessing the degree of influence of gastroesophageal reflux disease on the mucosal layer of the nose and nasopharynx. The possible influence of symptoms of gas-tro-oesophageal reflux disease on the course and severity of clinical manifestations of exacerba-tions of chronic rhinosinusitis needs further investigation.

Background: Although endoscopic submucosal dissection (ESD) can provide a high rate of curative resection, remaining gastric mucosa after ESD is at risk of metachronous recurrence. We investigated risk factors for metachronous superficial gastric epithelial neoplasms (MSGENs) following ESD. Methods: We conducted a retrospective cohort study including 369 patients with 382 lesions that underwent ESD for adenoma/early gastric cancer. The primary endpoint was to identify clinicopathological risk factors for the occurrence of MSGENs. The secondary endpoint was to evaluate the association of Helicobacter pylori (Hp) eradication with the MSGENs. Results: Twenty-seven MSGENs were occurred. The subjects were divided into MSGEN and not-MSGEN groups. There was a significantly higher frequency of histological intestinal metaplasia (HIM) and initial neoplasm location in upper or middle part (INUM) in the MSGEN group. The HIM group and INUM group had significantly higher cumulative incidence of MSGENs. We compared the 27 patients of MSGEN group and 27 patients of matched not-MSGEN (Mnot-MSGEN) group that was matched to the MSGEN group for variables including HIM and INUM. There was a significantly higher frequency of Hp spontaneous eradication in the MSGEN group. Conclusion: HIM, INUM and Hp spontaneous eradication may be clinicopathological risk factors for developing MSGENs after ESD.

Conclusions: Our findings suggest that the NMS-E represents a valuable preoperative diagnostic tool for endometriosis, effectively correlating with the disease's severity and surgical outcomes. Incorporating the NMS-E into clinical practice could significantly enhance the management of endometriosis by addressing current diagnostic limitations and guiding surgical planning.

Surgical approaches for ovarian cancer have advanced significantly in recent years. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging technique in gyneco-logical oncology, with limited reports of its use in ovarian cancer management. This study aimed to evaluate the feasibility and safety of vNOTES for the surgical staging of early-stage adnexal malignancies. Methods: We retrospectively reviewed all cases of borderline ovarian tumors (BOTs) and early-stage ovarian cancer surgically staged using vNOTES at our institution between October 2021 and August 2024. Results: Eleven patients were included, 7 with ear-ly-stage ovarian or tubal cancer and 4 with BOTs. The median age was 47 (27 – 81) years, and the median body mass index was 28.1 (22.4 – 39.2) Kg/m². Complete vNOTES staging was achieved in all cases, including peritoneal washing, unilateral/bilateral salpingo-oophorectomy, ab-dominal cavity inspection, peritoneal biopsies, infracolic omentectomy, and total hysterectomy when required. The median operating time was 70 (35 – 138) minutes, with a median blood loss of 50 (10 – 100) mL. No intraoperative complications occurred except for one case of minor ovar-ian spillage. No conversions to laparoscopy or laparotomy were needed. Postoperative compli-cations included one surgical site infection (9.1%) and two cases of postoperative cystitis (18.2%). No severe complications graded ≥3 on the Clavien-Dindo classification were observed. Conclu-sion: vNOTES appears to be a feasible and safe approach for the surgical staging of selected pa-tients with early stage adnexal malignancies. Further studies are needed to validate its long-term safety and oncological outcomes.