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Pulmonary complications, and especially pneumonia, remain one of the most common complications after esophagectomy for esophageal cancer. These complications are reduced by minimally invasive techniques or by avoiding thoracic access through a transhiatal approach. However, a transhiatal approach does not allow for a full mediastinal lymphadenectomy. A transcervical mediastinal esophagectomy avoids thoracic access, which may contribute to a decrease in pulmonary complications after esophagectomy. In addition, this technique allows for a full mediastinal lymphadenectomy. A number of pioneering studies have been published on this topic. Here, the initial experience is presented as well as a review of the current literature concerning transcervical esophagectomy, with a focus on the robot-assisted cervical esophagectomy procedure. [ABSTRACT FROM AUTHOR]

Background: Endoscopic submucosal tunneling has evolved to allow endoscopic resection of subepithelial tumors of gastrointestinal tract without full-thickness perforation. This study aimed to investigate safety and efficacy of submucosal tunnel resection for these tumors.Method: Patients with subepithelial tumors (SET) located in esophagus, gastric cardia, lesser curvature, and antrum were recruited. The size of tumor was limited to < 40 mm. The procedures were performed under general anesthesia. A mucosal entrance was created 2 cm proximal to the SET after submucosal injection. Submucosal tunnel was then extended and the tumor was dissected and mobilized with intact overlying mucosa. After complete dissection, the tumors would be retrieved per orally and mucosal entrance closed by endoclips.Results: From June 2012 to December 2016, 51 patients with subepithelial tumors received POET. 39 patients had SET in stomach, 11 located in esophagus, and 1 in duodenum. The mean operative time was 90.46 ± 46.49 min, while the mean size of the tumors was 20.71 ± 14.05 mm. The POET was converted to endoscopic full-thickness resection (EFTR) in three patients with gastric subepithelial tumors located at greater curvature. The overall complication rate was 4.0%, and there was no bleeding, mucosal dehiscence, or leakage. The time to resume diet was 1.7 days, while the average hospital stay was 3.2 ± 1.0 days. The mean follow-up period was 19 ± 16 months, and only 1 patient developed recurrence of leiomyoma.Conclusion: Per oral endoscopic tumor resection is safe and effective treatment for esophageal and gastric SET located at cardia, lesser curvature, and antrum. Currently, POET for treatment of upper GI SET is limited by the size and location of the tumor. [ABSTRACT FROM AUTHOR]

Studies have indicated that the definitive engraftment and transdifferentiation potential of stem cells do not seem crucial for its property of tissue repair. Our previous study showed that transplantation of adipose-derived mesenchymal stem cells (ADMSCs) enhanced the healing of sutured gastric perforation. This study aimed to investigate the paracrine role of ADMSCs in the experimental gastric mucosal injury. Normoxia-conditioned medium (Nor CM) and hypoxia (HPO) CM were obtained after culturing ADMSCs in 20% O 2 and 5% O 2 for 48 h. Cell migration, proliferation, viability, and angiogenesis in vitro were significantly enhanced upon incubation with CM, especially the HPO CM. Experiments in vivo using a rodent model of gastric ulcer demonstrated that HPO CM treatment significantly accelerated wound healing by suppressing inflammation and promoting neovascularization and re-epithelization. Meanwhile, the infusion of HPO CM activated the COX 2 -PGE 2 axis both in vitro and in vivo. And the upregulation of COX 2 was further dependent on the activation of ErK1/2-MAPK pathway. In addition, vascular endothelial growth factor, tissue inhibitors of metalloproteinases-1, and chemokine (C-C motif) ligand 20 (CCL-20) were analyzed as being highly abundant factors secreted by ADMSCs under hypoxic condition. Notably, the blockade of CCL-20 abrogated the HPO CM-induced COX 2 signaling in the primary gastric mucosal epithelial cells, while incubation with recombinant CCL-20 increased the expression of COX 2 . In conclusion, the secretome from hypoxia-conditioned ADMSCs facilitates the repair of gastric mucosal injury through the enhancement of angiogenesis and re-epithelization, as well as the activation of COX 2 -PGE 2 axis with a paracrine activity involving CCL-20 factor. [ABSTRACT FROM AUTHOR]

Low-pressure endoscopy using the gel immersion method facilitates endoscopic variceal ligation of ruptured esophageal varices. Gel immersion endoscopy: Innovation in securing the visual field - Clinical experience with 265 consecutive procedures. In this issue of Endoscopy, Sekiguchi et al. describe a novel method of gel immersion endoscopy that could improve the endoscopic view for timely variceal rubber band ligation [1]. [Extracted from the article]

Developments in endoscopy and laparoscopy have made monumental changes to the way gastrointestinal diseases are being managed. Many diseases that were traditionally managed by open surgical resection could now be treated by endoscopy alone. However, there are still instances where endoscopic treatment alone is inadequate for disease control and laparoscopic surgery is required. In addition, the collaboration between laparoscopic surgery and endoscopic submucosal dissection or other endoscopic resectional techniques represents a new frontier forfurther research. The present manuscript aims to discuss the complementary role of laparoscopic surgery to endoscopic resection in the traditional context and also its future development. [ABSTRACT FROM AUTHOR]

Background Gastric intestinal metaplasia ( IM) is considered precancerous and is difficult to differentiate upon endoscopy. Endocytoscopy enables observation at a cellular level for focused biopsy. The present study examined the use of endocytoscopy for recognition of gastric IM. Patients and Methods Patients with a history of gastric IM were recruited. We first carried out narrow band imaging ( NBI) endoscopy to look for suspicious areas of gastric IM. A prototype endocytoscope with a magnification of 450× was used to re-examine these areas. Areas examined were biopsied for histological comparison. Presence of goblet cells was considered as representative of IM upon endocytoscopy. Results Twenty patients were recruited with NBI demonstrating 102 suspicious lesions of gastric IM. Mean age of patients was 53.9 ± 7.6 years. Upon histology, 72 biopsies were confirmed as gastric IM, 15 showed IM and low-grade dysplasia, whereas 15were diagnosed as chronic gastritis. Endocytoscopy image quality was significantly better for areas of IM as compared to gastritis ( P < 0.05; OR 21.7 [95% CI 4.5-105.9]). The presence of goblet cells upon endocytoscopy achieved a diagnostic accuracy of 0.86 for gastric IM. Receiver operator characteristics curve achieved an area under curve of 0.8 with the presence of goblet cells under endocytoscopy as compared to 0.64 for NBI alone. Conclusions Presence of goblet cells upon endocytoscopy indicates a diagnosis of gastric IM. Image quality of endocytoscopy, however, is suboptimal. Further developments in endocytoscopy should focus on image quality and staining methods to enhance differentiation between IM, dysplasia and early gastric cancer. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection ( SD) has emerged as one of the treatment strategies for submucosal rectal cancers. The present study reviewed the clinical outcomes of patients with rectal submucosal cancer treated by ESD. This was a retrospective review of four patients who had rectal tumor treated by ESD from 2010 to 2012 with histopathology showing T1 submucosal adenocarcinoma. The mean age ( SD) was 69.5 (7.33) and the male to female ratio was 3:1. There were no post- ESD complications. The mean ( SD) size of the tumors was 2.93 (0.87) cm. One patient with deep resection margin involvement received laparoscopic low anterior resection. Another with deep margin involvement of <1 mm refused surgery and was treated by chemoradiotherapy.There was no recurrence in all the cases with a mean follow-up duration of 461.3 (209.0) days. ESD was one of the important treatment strategies for T1sm-s rectal cancer especially when the risk of nodal metastasis was low. ESD spared the patient from colostomy when the T1 cancer was located in the lower third of the rectum. The role of adjuvant and neoadjuvant chemoradiotherapy remains controversial. [ABSTRACT FROM AUTHOR]

Aim The optimal approach for creating accesses for transgastric peritoneoscopy is still uncertain. The present study aims to assess the feasibility of carrying out transgastric submucosal tunnel ( SMT) peritoneoscopy and to determine whether this approach improves or restricts access to various sectors within the peritoneal cavity. Methods This was a randomized comparative study carried out in an in-vivo survival porcine model. Sixty-six beads in six swine were visualized and touched via gastrotomies created by either direct incision ( DI) or SMT. The influence of the type of gastrotomy on improving or restricting access to particular sites within the peritoneal cavity for natural orifice transluminal endoscopic surgery ( NOTES) peritoneoscopy was compared. The main outcome measurements were localization score of beads, overall procedural time, morbidities and mortalities. Results A significantly higher mean ( SD) localization score was observed in peritoneoscopies carried out in the DI group ( P < 0.001). Both the visualization and the touching scores were significantly better with the DI technique, and the overall yield of NOTES peritoneoscopy with DI and SMT were 72.73% and 60.6%, respectively ( P = 0.043). Significantly more beads that were not touched in the SMT group were located in the sub-phrenic area ( P = 0.013). The overall procedural time was significantly shorter in the DI group ( P = 0.004). No major morbidities or mortalities occurred in any procedures. Conclusions SMT resulted in lower visualization and touching scores for transgastric NOTES peritoneoscopy. Alternate methods to improve the diagnostic yield to the sub-phrenic area are required. [ABSTRACT FROM AUTHOR]

Background: Endoscopic submucosal dissection (ESD) is a technically demanding procedure, and exposure of the submucosa depends on the action of gravity and submucosal injection. The aim of the study was to investigate the effectiveness of the Endolifter(®) as a traction device for enhancing submucosal visualization during ESD.Methods: This was a prospective ex vivo comparative study conducted between September 2010 and March 2011 in the Prince of Wales Hospital. Consecutive ESDs were performed by four experienced endoscopists in an ex vivo ESD model with or without the Endolifter(®). The Endolifter(®) allows simultaneous grasping, retracting and lifting of the mucosa during ESD, resulting in exposure of the submucosa. Each of the procedures were recorded and reviewed later by two independent assessors. The outcome measures included the proportion of time that the submucosa was visualized during the procedures (SM ratio), procedural times, perforation rates, amount of submucosal injections, and the difficulty of the procedure.Results: Forty-eight gastric ESD procedures were performed on the model. The SM ratio was higher in the Endolifter(®) group (P = 0.007), particularly for lesions located at the antrum (P < 0.001). The time required for submucosal dissection and the total procedural time were also less in the Endolifter(®) group. The endoscopists rated the ESD procedures in the Endolifter(®) group as less difficult (P = 0.033).Conclusions: The Endolifter(®) improved submucosal visualization during gastric ESD and reduces the difficulty of performing the procedures. The device may improve the ease of performing ESD in low-volume centers or large mucosal lesions. [ABSTRACT FROM AUTHOR]

Objective: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. This article reviews the latest evidence for the timing of laparoscopic cholecystectomy in the management of acute cholecystitis. Methodology: Trials comparing early laparoscopic cholecystectomy (ELC; carried out within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (DLC; carried out at least 6 weeks after symptoms settled) for acute cholecystitis were identified from Ovid Medline, Cochrane Library and PubMed database. Only meta-analyses and randomized clinical trials were reviewed. Results: A total of seven prospective randomized trials including 670 patients and four meta-analyses were reviewed. ELC was superior to DLC in terms of a shorter hospital stay without any significant difference in perioperative mortality and morbidity. Conclusions: Current evidence supports ELC as the preferred treatment strategy for acute cholecystitis. It allows a shorter hospital stay, but shares similar operative morbidity, mortality and conversion rate as DLC. [ABSTRACT FROM AUTHOR]

Background: The approach to salvage surgery after failed endoscopic therapy for a bleeding peptic ulcer is controversial. We aimed to compare the outcomes of salvage surgery after failed endoscopic therapy for bleeding peptic ulcers over a 10-year period. Methods: Patients receiving salvage surgery for bleeding peptic ulcers were divided into 2 cohorts, the 1st from 1993 to 1998 and the 2nd from 1999 to 2004. The type of salvage surgery was defined as minimal if ulcer plication or an ulcerectomy was performed, and definitive if the patient received a vagotomy or gastrectomy. Results: One hundred and twenty-three patients received salvage surgery in the 1st cohort, while 42 patients received surgical hemostasis for the bleeding peptic ulcer in the 2nd cohort. Patients in the 2nd cohort consisted of a larger proportion of in-hospital bleeders (cohort 1: 12.2%, cohort 2: 42.9%; p < 0.005) and had a significantly higher proportion of comorbidities. A larger number of patients received minimal surgery in cohort 2 (cohort 1: 42.3%, cohort 2: 73.8%; p < 0.005). Conclusions: With advances in therapeutic endoscopy, patients who developed failed endoscopic hemostasis are likely to be poor surgical candidates with multiple comorbidities. The approach to salvage surgery has inclined towards minimal surgery to hasten surgical hemostasis among these fragile patients. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aim: There are some discrepancies as to the prognostic value of perigastric lymph node (LN) metastasis in the survival of squamous oesophageal carcinoma. The present study aimed to compare survival following standard oesophagectomy in the treatment of squamous oesophageal carcinoma with or without perigastric abdominal LN metastasis. Methods: From 1998 to 2003, 17 patients with squamous cell carcinoma of the mid or lower oesophagus who had abdominal LN metastasis upon pathological examination underwent Ivor Lewis oesophagectomy. They did not receive further adjuvant therapy. The clinical outcomes of this cohort were compared to a control of 34 patients of similar age, gender and T staging who had no perigastric nodal diseases upon oesophagectomy. Results: There was no significant difference between the two groups in terms of the demographics, tumour size, differentiation of the tumour, duration of operation, volume of blood loss, and the type of oesophagectomy. The cumulative 3-year survival rate was similar between those with abdominal LN metastasis or those without abdominal LN metastasis (52.9% vs 47.1%; log–rank test P = 0.61).There was also no significant difference in the rates of recurrence between the two groups (58.8% vs 58.8%; P = 0.1). Conclusions: Perigastric LN metastasis over the lesser curvature, left gastric artery and pericardial regions does not affect the survival of patients with squamous cell carcinoma of the oesophagus treated by two-field oesophagectomy. [ABSTRACT FROM AUTHOR]

In the past, conventional techniques of endoscopic resection, including endoscopic mucosal resection, were limited by the size of the specimen obtained, the obscurity of the resection and the uncertainty of the resection margins in piecemeal resection for early cancer of the foregut. Endoscopic submucosal dissection emerged as a novel technique of mucosal resection which can achieve a curative resection for early cancer of the foregut with a wide margin. The current article focused on a review of the application of endoscopic submucosal dissection in treating early cancer of the upper gastrointestinal tract. [ABSTRACT FROM AUTHOR]

The aim of the present systematic review is to critically appraise the current evidence from published medical trials on the role of programmed second endoscopy with appropriate therapy on peptic ulcer re-bleeding. A systematic review of five prospective randomized controlled trials comparing the effect of programmed second endoscopy against conservative management on peptic ulcer re-bleeding was carried out. From the meta-analysis of the combined results from the five trials on the effect of programmed second endoscopy in ulcer bleeding, we found that a programmed second endoscopy with appropriate therapy reduced the number of recurrent bleeding significantly (Peto odds ratio = 1.97, Mantel Haenszel-Peto P < 0.01). The number of patients needed for treatment with a programmed second endoscopy in order to prevent one recurrent bleeding ranged from four to 11. Programmed second endoscopy with appropriate therapy reduced the number of recurrent bleeding significantly in patients with bleeding peptic ulcers. Individual trials also showed a possible benefit in reduction of the number of surgical interventions. [ABSTRACT FROM AUTHOR]

Currently, there is still controversy on the issue of palliative gastrectomy for patients with advanced carcinoma of stomach in terms of safety and its benefits. From the data available in the literature, palliative gastrectomy seems to be associated with a better survival rate, better relief of symptoms and similar rates of perioperative morbidity and mortality when compared with laparotomy with or without gastrojejunostomy. However, all these studies are retrospective comparative studies or series that carried significant biases. This makes interpretation of the outcome difficult. A selective approach is advocated as palliative gastrectomy carries significant risks. Chinese Abstract. [ABSTRACT FROM AUTHOR]

In this E-Video, Hallit et al. demonstrate the performance of peroral endoscopic myotomy (POEM), using an underwater technique, for the treatment of achalasia. As the majority of cohort studies show that the commonest adverse events observed following POEM are related to insufflation causing pneumothorax, pneumomediastinum, and pneumoperitoneum, the use of an underwater technique has the potential to mitigate these effects. However, the fluid used for underwater technique should be able to conduct electrocautery and allow dissection. [Extracted from the article]

Recent literature on laparoscopic inguinal hernia repair (LIHR) has shown that laparoscopic hernioplasty is associated with reduced postoperative pain and wound infection, and an earlier return to normal daily activities. The technique of LIHR is still evolving. We descibe our technique and experience in performing laparoscopic hernioplasty using a contoured three-dimensional mesh without the application of endoscopic staples. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the current study was to compare the efficacy of partially covered duodenal stent (PCDS) vs. uncovered duodenal stent (UCDS) in patients suffering from unresectable primary malignant gastric outlet obstruction (GOO). Methods: This was a prospective international randomized controlled study conducted in 10 high‐volume institutions. Consecutive patients suffering from malignant GOO were recruited. The primary outcome measurement was the reintervention rate. Secondary outcomes included technical and clinical success, 30‐day adverse events, 30‐day mortality, causes of stent dysfunction, and the duration of stent patency. Results: Between March 2017 and October 2020, 115 patients (59 PCDS, 56 UCDS) were recruited. The 1‐year reintervention was not significantly different (PCDS vs. UDCS = 12/59, 20.3% vs. 14/56, 25%, P = 0.84). There was a trend to fewer patients with tumor ingrowth in the PCDS group (6/59 [10.2%]) vs. 13/56 [23.2%], P = 0.07). There were no significant differences in the technical success (100% vs. 100%, P = 1), clinical success (91.5% vs. 98.2%, P = 0.21), procedural time (21.5 [interquartile range [IQR] 17–30] vs. 20.0 [IQR 15–34.75], P = 0.62), hospital stay (4 [IQR 3–12] vs. 5 [IQR 3–8] days, P = 0.81), 30‐day adverse events (18.6% vs. 14.3%, P = 0.62), or 30‐day mortality (6.8% vs. 5.2%, P = 1.00). Conclusion: The use of PCDS was associated with a lower risk of tumor ingrowth but did not improve on reintervention rates or stent patency. Both kinds of stents could be used in this group of patients. [ABSTRACT FROM AUTHOR]

The article discusses a video demonstrating a technique of performing robotic D2 gastrectomy and mentions its advantages over laparoscopic surgery such as reduced blood loss, freedom of motion allowed by robotic arms, and lymph nodes retrieved in early-stage gastric cancers.

This is a review of the abstracts presented at Digestive Disease Week 2016, 21-24 May 2016 in San Diego, CA, USA, focusing on novel advances in therapeutic endoscopy of the upper gastrointestinal tract. [ABSTRACT FROM AUTHOR]

The provision of endoscopic training was significantly disrupted during the coronavirus disease (COVID‐19) pandemic. It is difficult to provide training on endoscopic submucosal dissection (ESD) due to the complexity of the procedure and the shortage of local trainers. We have designed and conducted a simulation training course with telementoring, incorporating the concept of rapid cycle deliberate practice (RCDP). After a short tutorial on basic setup and maneuvering, the participants undergo 2 h of training on a live anesthetized pig to acquire the necessary skills for ESD. Two overseas experts were involved virtually in real time as telementors. A video camera was set up at each station, and both external and endoscopic views were transmitted live between the animal laboratory and telementors via the Zoom application. The overseas experts actively engaged in the simulation by giving live feedback and instructions to participants using visual aids supported by the meeting application. The training model utilized the concept of RCDP, where repeated immediate feedback and discussion would be carried out to enhance the efficiency of learning. Eighteen trainees were invited to participate in the course, six of them instructed by overseas telementors. Four ESD procedures were performed by participants under telementoring and achieved 100% en bloc resection without perforation. The times required for each ESD were similar with telementoring than that of on‐site mentors. The establishment of telementoring has enabled knowledge and skill transfer of complex endoscopic procedures of ESD. With the limitations of international travel, this could be an alternative model allowing remote training, particularly when local experts are not readily available. [ABSTRACT FROM AUTHOR]

Objectives: The COVID‐19 pandemic has raised concerns on whether colonoscopies (CS) carry a transmission risk. The aim was to determine whether CS are aerosol‐generating procedures. Methods: This was a prospective observational trial including all patients undergoing CS at the Prince of Wales Hospital from 1 June to 31 July 2020. Three particle counters were placed 10 cm from each patient's anus and near the mouth of endoscopists and nurses. The particle counter recorded the number of particles of size 0.3, 0.5, 0.7, 1, 5, and 10 μm. Patient demographics, seniority of endoscopists, use of CO2 and water immersion technique, and air particle count (particles/cubic foot, dCF) were recorded. Multilevel modeling was used to test all the hypotheses with a post‐hoc analysis. Results: A total of 117 patients were recruited. During CS, the level of 5 μm and 10 μm were significantly higher than the baseline period (P = 0.002). Procedures performed by trainees had a higher level of aerosols when compared to specialists (0.3 μm, P < 0.001; 0.5 μm and 0.7 μm, P < 0.001). The use of CO2 and water immersion techniques had significantly lower aerosols generated when compared to air (CO2: 0.3, 0.5, and 0.7 μm: P < 0.001; water immersion: 0.3 μm: P = 0.048; 0.7 μm: P = 0.03). There were no significant increases in any particle sizes during the procedure at the endoscopists' and nurses' mouth. However, 8/117 (6.83%) particle count tracings showed a simultaneous surge of all particle sizes at the patient's anus and endoscopists' and nurses' level during rectal extubation. Conclusion: Colonoscopy generates droplet nuclei especially during rectal extubation. The use of CO2 and water immersion techniques may mitigate these risks. [ABSTRACT FROM AUTHOR]

Snake-like flexible manipulators are widely used in minimally invasive surgery (MIS), which require adequate dexterity in confined workspace. Typically, the design mechanisms of these manipulators include tendon-driven mechanism and concentric tube mechanism. Though, the workspace and dexterity of these designs are limited due to the lack of control in either the length of the bending section or the curvature of the bending section at the distal end. In this paper, we present a novel constrained wire-driven flexible mechanism (CWFM), in which both the length and the curvature of the bending section are controllable. The idea is to employ an active constraint to control the length of the bending section and use the wires to control the curvature of the bending section. Compared to the existing designs based on wire-driven flexible mechanism (WFM), CWFM has expanded workspace and enhanced dexterity while its size is not sacrificed. Additional benefits include much reduced sweeping area and controllable stiffness. Based on the computer simulation, on average, CWFM with the same size as WFM can improve the dexterity by 4.69 times and reduce the sweeping area to 20.5%. [ABSTRACT FROM AUTHOR]

Background and Aim: Esophageal squamous cell carcinoma (ESCC) is the most common histological subtype of esophageal cancer worldwide. Patients with ESCC display an altered esophageal microbiota compared with healthy individuals; however, little is known about the gut microbiota in ESCC. Methods: Here, we characterized the fecal microbiota of 15 ESCC patients and 16 healthy control subjects using 16S rRNA gene sequencing. Results: After controlling for potential confounders, significant alterations in both taxonomic and functional composition of the gut microbiota in ESCC patients were observed. By contrast, alpha diversity of the gut microbiota did not significantly differ between the cases and controls. We observed an enrichment of potentially pro‐inflammatory and/or carcinogenic bacteria, such as Butyricimonas, Veillonella, and Streptococcus, and a depletion of butyrate‐producing and/or potentially anti‐inflammatory bacteria, such as Butyricicoccus, Lachnospiraceae NK4A136 group, and Eubacterium eligens group, in the gut microbiota of ESCC patients. The log‐ratios of Streptococcus to Butyricicoccus and Streptococcus to Lachnospiraceae NK4A136 group of the gut microbiota were identified as potential diagnostic biomarkers for ESCC, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.863 (95% confidence interval: 0.707–1.000) and 0.825 (0.673–0.977), respectively. The diagnostic performance of both microbial biomarkers was validated in another ESCC cohort. Conclusions: This pilot study has revealed an altered gut microbiota in ESCC patients and has paved the way for large‐scale prospective cohort studies to examine the causative relationship between ESCC and gut dysbiosis. [ABSTRACT FROM AUTHOR]

Aim: The aim of the present study was to report our surgical technique and perioperative outcomes of endoscopic thyroid lobectomy using the bilateral axillo-breast approach (BABA). Patients and Methods: We conducted a retrospective cohort analysis of prospectively-collected data on consecutive female patients who underwent BABA endoscopic unilateral thyroid lobectomy for indeterminate thyroid nodules. Results: Between July 2012 and July 2014, 18 patients with a mean age of 37.9 ± 14.4 years received BABA endoscopic right (n = 12) and left (n = 6) thyroid lobectomy for nodules with atypia of undetermined significance (n = 7), follicular lesion of undetermined significance (n = 6) and follicular neoplasm (n = 5) in our unit. The mean nodule size was 23.6 ± 9.7 mm. All operations were successfully accomplished with no conversion to open procedures. The mean operating time was 155.9 ± 34.9 min. Intraoperative blood loss was negligible in all patients (below 10 mL). There was no postoperative haemorrhage, wound hematoma or iatrogenic parathyroid injury. Transient recurrent laryngeal nerve palsy occurred in one patient (5.6 per cent), whose condition completely recovered after 6 months. The mean hospital stay was 2.5 ± 0.7 days. At 6 months after surgery, the mean cosmetic satisfaction score was 94.4 ± 12.4 out of 100. Chronic anterior chest wall pain and chest wall paresthesia was only reported in one respective patient (5.6 per cent). Conclusion: BABA is a feasible and cosmetically-excellent technique in performing endoscopic thyroid lobectomy. It should be recommended for eligible patients who have strong desire on cosmetic outcomes. [ABSTRACT FROM AUTHOR]

Aiming at the requirements for endoscope in minimally invasive surgery, a dual neural network (DNN) controller is designed for a flexible endoscopic robot (FER) with 10 DOF. First, the FER's kinematics model with remote center of motion (RCM) constraints is established. Then, a quadratic programming control scheme involving the tracking error, joint motion, and RCM constraints of the FER is proposed. A DNN solver of the control scheme, which is activated by the sum of linear and sign-bi-power activation function with adjustable parameters (LSB-AF-AP), is designed, and its convergence rate (CR) and antinoise ability can be improved via adjusting the parameters of LSB-AF-AP. The DNN can converge rapidly in finite time and it is proved by utilizing the Lyapunov theory. Compared with the previous linear AFs applied to the DNN, theoretical analysis indicates that the DNN activated by the LSB-AF-AP has an accelerated CR. Meanwhile, it is proved that the solution obtained by using the designed DNN is the optimal solution of the control scheme. Finally, simulations using the ROS and Gazebo, and an experiment performed on a real FER are conducted. The simulative and experimental results verify that the control scheme can complete the target tracking task well, and the CR and antinoise ability of the algorithm can be further improved via adjusting the parameters of LSB-AF-AP. [ABSTRACT FROM AUTHOR]

Upper gastrointestinal (GI) hemorrhage is a common clinical emergency worldwide. Endoscopic hemostasis is the current first line treatment. Nevertheless, for patients with severe active bleeding and challenging anatomy, endoscopic management can be still difficult and usually requires a higher level of surgical expertise. A simple and effective method of endoscopic hemostasis is therefore in acute clinical demand. Herein a hemostatic hybrid hydrogel comprised of hyaluronic acid and polyethylene glycol stabilized by thiourea–catechol coupling and disulfide bonds is reported. The hybrid hydrogels exhibit enhanced mechanical properties, short gelation time, and good blood clotting ability compared with fibrin gels. The in vivo hemostatic efficacy is confirmed in a rat model of arterial bleeding, in which the rapid gelation of hybrid hydrogels after topical application effectively arrests blood loss with no rebleeding occurring during resuscitation when blood pressure approximately recovers to normal. A large animal study further demonstrates the efficacy of hybrid hydrogels to achieve endoscopic hemostasis against upper GI hemorrhage in pigs. Follow‐up observations show that the hybrid hydrogels can remain adherent at the bleeding wound for 48 h, indicating the sustained hemostatic function in vivo. Collectively, this work demonstrates a promising hemostatic hydrogel for endoscopic hemostasis in upper GI hemorrhage. [ABSTRACT FROM AUTHOR]

Background: The use of radiotherapy is frequently required in the treatment of locally advanced esophageal squamous cell carcinoma. However, the margins of the tumor are often difficult to ascertain on computed tomography. Thus, EUS-guided fiducial marker insertion can aid the localization of the margins of the tumor. However, the optimal technique of the procedure is still uncertain. Methods: This was a retrospective study of all patients that received EUS-guided fiducial marker insertion between March 2015 and December 2018. All patients suffering from esophageal squamous cell carcinoma scheduled for radiotherapy underwent the procedure within one week of the scheduled appointment. Gold fiducial markers were inserted under EUS guidance either intratumorally or within the submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, early and late migration rates, and tumor response rates. Results: During the study period, 40 patients were recruited. 10 fiducial markers were placed intratumorally and 30 markers were placed submucosally. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly more fiducials had early (40% vs 0%, RR = 0.6, 95% CI 0.36, 1.00) and late migration (60% vs 0%, RR = 0.33, 95% CI 0.13, 0.84) in the intratumoral group. The submucosal group had significantly more patients intended for curative intent (96.7% vs 70%, RR = 0.34, 95%CI 0.003, 0.361) and more patients with partial and complete response. There was no difference between the gross tumor volume, the clinical target volume, and the total radiation dose. Conclusion: In esophageal carcinomas planned for radiotherapy, fiducial markers placed in the submucosa may lead to less migration. [ABSTRACT FROM AUTHOR]

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM.Methods: Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3.Results: 150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively (P = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P = 0.47). GERDQ score was 6 (interquartile range 6 - 8; P = 0.08) in both treatment groups.Conclusions: The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up. [ABSTRACT FROM AUTHOR]

Over the past decade there has been tremendous development in the clinical application of minimally invasive esophagectomy (MIE) for the treatment of squamous esophageal carcinoma. The major challenges in the performance of MIE include limitations in visualization and manipulation within the confined, rigid thoracic cavity; the need for adequate patient positioning and anesthetic techniques to accommodate the surgical exposure; and changes in the surgical steps for achieving radical nodal dissection, especially for the superior mediastinum. The surgical procedure for MIE is more and more standardized, and there is an increasing practice of MIE worldwide. Randomized trials and meta‐analyses have confirmed the advantages of MIE over open esophagectomy, including a significantly lower rate of complications and shorter hospital stays. The recent application of robotics technologies for MIE has further enhanced the quality and safety of the surgical dissection, while intraoperative nerve monitoring has contributed to a lower rate of recurrent laryngeal nerve palsy. With the application of new technologies, we expect further improvement in surgical outcomes for MIE in the treatment of squamous esophageal cancer. [ABSTRACT FROM AUTHOR]

Objective: Untethered microrobots hold great promise for applications in biomedical field including targeted delivery, biosensing, and microsurgery. A major challenge of using microrobots to perform in vivo tasks is the real-time localization and motion control using medical imaging technologies. Here we report real-time magnetic navigation of a paramagnetic nanoparticle-based microswarm under ultrasound guidance. Methods: A three-axis Helmholtz electromagnetic coil system integrated with an ultrasound imaging system is developed for generation, actuation, and closed-loop control of the microswarm. The magnetite nanoparticle-based microswarm is generated and navigated using rotating magnetic fields. In order to localize the microswarm in real time, the dynamic imaging contrast has been analyzed and exploited in image process to increase the signal-to-noise ratio. Moreover, imaging of the microswarm at different depths are experimentally studied and analyzed, and the minimal dose of nanoparticles for localizing a microswarm at different depths is ex vivo investigated. For real-time navigating the microswarm in a confined environment, a PI control scheme is designed. Results: Image differencing-based processing increases the signal-to-noise ratio, and the microswarm can be ex vivo localized at depth of 2.2–7.8 cm. Experimental results show that the microswarm is able to be real-time navigated along a planned path in a channel, and the average steady-state error is 0.27 mm ($\sim$ 33.7% of the body length). Significance: The colloidal microswarm is real-time localized and navigated using ultrasound feedback, which shows great potential for biomedical applications that require real-time noninvasive tracking. [ABSTRACT FROM AUTHOR]

Background: Endoscope is the eye of surgeon in minimally invasive surgery (MIS). Prevailing handheld endoscopes are manually steered, which can cause endoscope-instrument fencing. Robotic endoscopes can reduce the fatigue but could not reduce collisions. Handheld endoscopes with a flexible bending tip can reduce the shaft pivoting and collisions. However, its steering is challenging. In this paper, we present a robotic flexible endoscope with auto-tracking function and compare it with the conventional rigid endoscopes.Methods: A robotic flexible endoscope (RFE) with shared autonomy is developed. The RFE could either track the instruments automatically or be controlled by a foot pedal. A mockup cholecystectomy was designed to evaluate the performance. Five surgeons were invited to perform the mockup cholecystectomy in an abdominal cavity phantom with a manual rigid endoscope (MRE), a robotic rigid endoscope (RRE), and the RFE. Space occupation, time consumption, and questionnaires based on the NASA task load index were adopted to evaluate the performances and compare the three endoscope systems. An ex vivo experiment was conducted to demonstrate the feasibility of using the RFE in a biological tissue environment.Results: All surgeons completed the mockup cholecystectomy with the RFE independently. Failure occurred in the cases involving the RRE and the MRE. Inside the body cavity, the space occupied when using the RFE is 17.28% and 23.95% (p < 0.05) of that when using the MRE and the RRE, respectively. Outside the body cavity, the space occupied when using the RFE is 14.60% and 15.53% (p < 0.05) of that by using MRE and RRE. Time consumed in the operations with MRE, RRE, and RFE are 28.3 s, 93.2 s and 34.8 s, respectively. Questionnaires reveal that the performance of the RFE is the best among the three endoscope systems.Conclusions: The RFE provides a wider field of view (FOV) and occupies less space than rigid endoscopes. [ABSTRACT FROM AUTHOR]

Fluorescent carbon dots hold great promise in biomedical real-time tracking due to their outstanding optical properties and biocompatibility. Here, we report a one-pot synthetic strategy to produce multi-doped carbon dots (MCDs) with bright and color-tunable emission. The resultant MCDs are doped by abundant biogenic elements (O, N, P), so that they contain a variety of surface functional groups. Such hetero-doping and functionalization make MCDs display strong fluorescent emission and excitation-wavelength-dependent characteristic, good aqueous solubility as well as high photo-stability and ion-stability. Moreover, the as-prepared MCDs response to the change of pH values and exhibit high selective and sensitive detection of Fe 3+ ions under blue light illumination with the limit of detection (LOD) of 15.9 nM. Such a Fe 3+ sensing ability is further demonstrated in real water samples and extended to intracellular multi-color monitoring of Fe 3+ . More interestingly, the MCDs can also sense the gastrointestinal bacteria Escherichia coli , exhibiting linear sensing dependent behavior. With low cytotoxicity and tunable emission, such MCDs hold great potential as efficient multi-color probes and imaging agents for clinical diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: A robotic laparoendoscopic single-site access surgery (R-LESS) platform that incorporates the EndoWrist function of robotic instruments may provide better triangulation and retraction during LESS. The aim of the study is to assess if R-LESS is feasible with standard robotic instruments via a single incision and whether the approach could reduce the difficulty of the procedure and confer additional benefits over conventional LESS.Methods: This was a prospective randomized controlled study investigating the workload performance, efficacy, and risks of performing R-LESS when compared with human LESS (H-LESS) in a survival porcine model for cholecystectomy and gastrojejunostomy. The primary outcome is the NASA task load index. Secondary outcomes included the difficulty of the procedures, procedural time, morbidities, and mortalities.Results: Twenty-four cholecystectomies and gastrojejunostomies using the R-LESS or H-LESS approach (12:12) were performed. None of the swine suffered from procedural adverse events and none of the procedures required conversion. In both the cholecystectomy and gastrojejunostomy groups, R-LESS was associated with significantly lower NASA task load index (P < 0.001) and reduced difficulties in various steps of the procedures. No differences in the overall procedure times of the two procedures were observed (P = 0.315).Conclusion: The R-LESS approach significantly reduced the workload and difficulties of LESS cholecystectomies and gastrojejunostomies. A dedicated single-site platform that could reduce instrument clashing while retaining the EndoWrist function is eagerly awaited. [ABSTRACT FROM AUTHOR]

The article describes the technique of laparoscopic transperitoneal paraganglioma in a 65 year old male patient who had secondary hypertension because of excessive catecholamine secretion. Topics discussed include complete surgical resection as the treatment of choice for paraganglioma, the treatment of paranglioma with either the laparoscopic transperitoneal approach or the retroperitoneoscopic approach whose surgical outcomes have proven to be promising and effective.

The article discusses the surgical technique for is oesophageal carcinoma. It mentions that oesophageal carcinoma is a cancer arising from the foodpipe known as the esophagus that runs between the throat and the stomach. It notes that oesophageal carcinoma is the leading cause of cancer death for males in Hong Kong. It notes the application of surgical robots in conducting surgical operations in patients with oesophageal carcinoma.

The article offers information on the adoption of robotic D2 subtotal gastrectomy technique for the treatment of gastric cancer. Topics include advantages of the robot system are superior views from the high definition camera, as well as the stable retraction provided by the robotic arm during operation, detection of peritoneal metastases on staging laparoscopy and Roux-en Y reconstruction.

OBJECTIVE Evaluations of upper gastrointestinal toxicity from ketamine abuse are uncommon. This study investigated the clinical pattern of upper gastrointestinal symptoms in patients inhaling ketamine. METHODS In a cross-sectional study of 611 consecutive patients who were seeking treatment for ketamine uropathy in a tertiary hospital setting between August 2008 and June 2016, their clinical pattern of upper gastrointestinal symptoms was evaluated and compared with a control population of 804 non-users. RESULTS A total of 168 (27.5%) patients abusing ketamine (mean age 26.3 years, 58.9% female) reported the presence of upper gastrointestinal symptoms. These symptoms were significantly more prevalent in patients inhaling ketamine than in those who were not (27.5% vs 5.2%, P < 0.001). Their mean duration of ketamine abuse before symptom presentation was 5.0 ± 3.1 years. The presenting symptoms included epigastric pain ( n = 155, 25.4%), recurrent vomiting ( n = 48, 7.9%), anemia ( n = 36, 5.9%) and gastrointestinal bleeding ( n = 20, 3.3%). Uropathy symptoms were preceded by upper gastrointestinal symptoms for 4.4 ± 3.0 years in 141 (83.9%) patients. Logistic regression showed that elder age (odds ratio [OR] 1.06, P = 0.04), active abuser status (OR 1.60, P = 0.04) and longer duration of ketamine abuse (OR 1.00, P = 0.04) were independent factors associated with upper gastrointestinal toxicity. CONCLUSIONS Although epigastric symptoms are unusual in the young population, upper gastrointestinal toxicity was highly prevalent in those inhaling ketamine. Enquiries about ketamine abuse are recommended when assessing young patients with epigastric symptoms. [ABSTRACT FROM AUTHOR]

Background and Study Aim: Previous studies have shown that both scheduled second-look endoscopy and high-dose continuous omeprazole infusion are effective in preventing peptic ulcer rebleeding. The aim of this noninferiority trial was to compare the efficacy of these two strategies for the prevention of rebleeding following primary endoscopic hemostasis.Patients and Methods: Consecutive patients who received endoscopic treatment for bleeding peptic ulcers (actively bleeding, with nonbleeding visible vessels) were randomized to two treatment groups following hemostasis. One group (second-look endoscopy group) received the proton pump inhibitor (PPI) omeprazole as an intravenous bolus every 12 hours for 72 hours and a second endoscopy within 16 - 24 hours with retreatment for persistent stigmata of bleeding. The other group (PPI infusion group) received continuous high-dose omeprazole infusion for 72 hours. Patients who developed rebleeding underwent surgery if repeat endoscopic therapy failed. The primary outcome was the rebleeding rate within 30 days after initial hemostasis. The margin for noninferiority was set at 5 %.Results: A total of 153 patients were randomized to the PPI infusion group and 152 to the second-look endoscopy group. Rebleeding occurred within 30 days in 10 patients (6.5 %) in the PPI infusion group and in 12 patients (7.9 %) in the second-look endoscopy group (P = 0.646). Surgery was required for rebleeding in six patients from the PPI infusion group and three patients in the second-look endoscopy group (P = 0.32). Intensive care unit stay, transfusion requirements, and mortality were not different between the groups. Patients in the second-look endoscopy group were discharged 1 day earlier than those in the PPI infusion group (P < 0.001).Conclusions: After endoscopic hemostasis, high-dose PPI infusion was not inferior to second-look endoscopy with bolus PPI in preventing peptic ulcer rebleeding.Trial Registration: ClinicalTrials.gov (NCT: 00164931). [ABSTRACT FROM AUTHOR]

Background and Aim This retrospective cohort study compared clinical outcomes and quality of life after peroral endoscopic myotomy (POEM) against laparoscopic Heller myotomy (LHM) for treatment of achalasia. Methods Patient demographics, operation time, intraoperative blood loss, hospital stay, time to resume diet and analgesic requirement were recorded. Clinical outcomes including recurrence of dysphagia, need for reintervention, and occurrence of gastroesophageal reflux disease (GERD) were recorded. Results From 2001 to 2014, 33 patients underwent POEM whereas 23 patients received LHM. Patients LHM had with longer mean operative time ( P = 0.02), more blood loss ( P = 0.001) and higher requirement for analgesics ( P = 0.009) than those treated by POEM. Hospital stay and time to resume diet were similar. Both POEM and LHM achieved similar dysphagia scores at postoperative 4 weeks, 3 months and 6 months. Twenty-six percent of LHM patients and 15.2% of POEM patients sustained gastroesophageal reflux disease (GERD) after treatment ( P = 0.311). Six patients required regular proton pump inhibitor three after POEM and three after LHM ( P = 0.639). Thirteen percent of LHM patients sustained recurrent dysphagia and one required reintervention. There was no recurrence in the POEM group. Follow-up duration (mean [SD]) for the LHM group was significantly longer (60 [42] months vs 6 [4] months; P = 0.001). There was also no difference in all four aspects of GERD-related quality of life outcomes. Conclusion Compared to LHM, POEM achieved shorter operative time, less blood loss and pain. POEM is comparable to LHM for treatment of achalasia with similar incidence of GERD after the procedure. [ABSTRACT FROM AUTHOR]

Background and Aim Patient and physician perceptions of natural orifice transluminal endoscopic surgery ( NOTES) have been reported for the Western population. However, whether Asian- Chinese patients share the same perspectives as compared to the Western population is unknown. Methods This was a cross-sectional survey carried out in the surgical outpatient's clinic at the Prince of Wales Hospital between June and September 2011. Patients were provided with an information leaflet and asked to complete a questionnaire regarding their perceptions of and preferences for NOTES cholecystectomy. Female patients attending the clinic were given an additional questionnaire regarding attitudes towards transvaginal surgery. Results Two hundred patients were recruited to complete the questionnaire(s) and the male to female ratio was 1:1. One hundred and fourteen patients (57%) preferred to undergo NOTES cholecystectomy for cosmetic reasons ( P = 0.009). Oral and anal routes were both acceptable for NOTES accesses in males andfemales. Forty-one percent of the female patients would consider transvaginal NOTES. Of these patients, significantly more patients indicated that the reason for choosing transvaginal NOTES was to minimize the risk of hernia ( P = 0.016) and to reduce pain associated with the procedure ( P = 0.017). The risk of complications (84.5%) and the cost of the procedure (58%) were considered the most important aspects when choosing a surgical approach by Asian- Chinese patients. Conclusions Asian- Chinese preferred NOTES mainly for cosmetic reasons. However, the transvaginal route was less acceptable to females. Significant differences in patient perception on NOTES were observed between Asian- Chinese and Western patients. [ABSTRACT FROM AUTHOR]

Helix-based structures have been popularly used in flexible surgical tool designs due to their large bending range. However, the helix structures also have low compressional and torsional stiffness, which results in a limited payload. In this paper, we addressed these limitations by presenting a novel helix-based structure that mimicks the DNA double helix structure. This DNA-inspired helical continuum manipulator (DHCM) contains a helix structure and a constraint structure (a slender shaft or reinforced rings) that mimicks the base pairs of the DNA structure. Simulation results revealed that the stiffness of the helix structure is improved with the constraints. At the same bending stiffness, compared to the simple helix structure, the compressional and torsional stiffness of DHCM with the shaft constraint were improved by 12.3 times and 3.2 times, respectively. The kinematics of the DHCM were derived to predicate the deformation of the DHCM based on the piecewise constant curvature assumption. The model predicted deformation of the DHCM with a mean error of 4.16 mm (6.9%). The equivalent stiffness model of the DHCM was proposed and used to derive the statics of the DHCM. The mean error of distal end between statics predictions and experiment results was 1.01 mm (1.7%). • A novel helix-based continuum manipulator with constraints was proposed. • It has high torsional and axial stiffness while preserving low bending stiffness. • Kinematic model is derived and validated by experiments. • Equivalent stiffness is derived and validated by FEA. • With the Cosserat rod theory, the static model is developed and validated. [ABSTRACT FROM AUTHOR]

Aim: This study was carried out to understand the current practice and learning of endoscopic submucosal dissection (ESD) for superficial esophageal and gastric cancers in East Asian countries. Methods: A questionnaire survey was used to investigate differences in upper gastrointestinal (GI) ESD among East Asian countries. Results: ESD is used by many endoscopists in not only tertiary centers but also secondary care hospitals in China, Korea and Japan. By contrast, it is less used by doctors in tertiary centers in Hong Kong and Taiwan. However, the general trend appears to be the same; ESD, which is a highly advanced endoscopic technique, is being transmitted from preceptors to preceptees in tertiary centers, then from doctors in tertiary centers to experienced doctors in secondary hospitals. The speed of learning and uptake in the practice of this procedure will depend on the volume of cases. Upper GI ESD can be expected to spread at a similar rate across different districts or hospitals in East Asia because of similarities in disease prevalence. Also, endoscopists in this region can easily learn from each other by attending international conferences or visiting endoscopy units to learn the procedure. Conclusion: Efforts to establish a standardized protocol for ESD practice and training are important, and may help endoscopists around the world develop this technique further. [ABSTRACT FROM AUTHOR]

Aim: Endoscopically-placed, push-type percutaneous endoscopic gastrostomies (PEG) have recently been made possible through the use of a gastropexy device. However, the safety and efficacy of the procedure in patients suffering from severe trismus or malignant obstruction due to head and neck cancers have rarely been reported. The aim of this study was thus to investigate the feasibility, safety and risk of endoscopic push-type PEG in this group of patients. Patients and Methods: Consecutive patients who were indicated for PEG and suffered from severe trismus or malignant obstruction due to head and neck cancers, precluding the introduction of a 9.8 mm oesophagogastroduodenoscope were included. Push-type PEG was performed under endoscopic control with a 5-mm endoscope and the loop fixture device. Results: Eleven patients had push-type PEG performed under conscious sedation. All procedures were successful, and minor complications occurred in one patient with a dislodged gastrostomy tube and another with wound infection. There were no mortalities or major morbidities related to the procedure. Conclusions: Push-type PEG with gastropexy inserted under endoscopic control by an ultrathin endoscope is a feasible alternative to open gastrostomy in patients with severe trismus or pharyngeal obstruction. [ABSTRACT FROM AUTHOR]

The article presents the results of a clinical trial studying the efficacy of a combination of a cyclo-oxygenase-2 (COX 2) inhibitor and proton-pump inhibitor in the prevention of recurrent ulcer bleeding in patients at very high risk. The study found that combined treatment with COX 2 inhibitors and proton-pump inhibitor esomeprazole was more effective in preventing recurring bleeding. The article concludes with a call for treatment guideline committees to review the treatment recommendations for high-risk bleeding ulcers and incorporate the results of this study.

To discuss the relationship between CO[SUB2] pneumoperitoneum and haemorrheology and the possibility of thrombosis caused by CO[SUB2]. Material and Methods: We compared indices of haemorrheology just prior to operation, 5 min after anaesthesia and 30 min after inflation or operation, and 24h after operation. The indices included low-shear and high-shear whole-blood relative viscosity; plasma relative viscosity; red cell aggregation index; red cell filtration index; haematocrit; and blood gas analysis. We analysed the relationship between a variation in haemorrheology and CO[SUB2] pneumoperitoneum. Results: After pneumoperitoneum, blood viscosity and red cell aggregation index rises markedly and red cell deformity weakens markedly. Conclusion: Carbon dioxide pneumoperitoneum can cause an increase in blood viscosity, red cell aggregation and a weakening of red cell deformity, and may lead to thrombosis after laparoscopic surgery. [ABSTRACT FROM AUTHOR]

The article discusses a study which evaluates the feasibility of using the master and slave transluminal endoscopic robot (MASTER) to perform endoscopic submucosal dissection (ESD) of the esophagus.