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BACKGROUND: Several pivotal studies and international guidelines on the perioperative management of rectal cancer have been published. However, little is known about the current state of perioperative management of rectal cancer patients in clinical practice worldwide.METHODS: An online survey including 13 questions focusing on key topics related to the perioperative management of patients with rectal cancer was conducted among colorectal surgeons registered within the database of the Research Institute Against Digestive Cancer (IRCAD).RESULTS: A total of 535 respondents from 89 countries participated in the survey. Most surgeons worked in the European region (40.9%). Two hundred and fifty-four respondents (47.5%) performed less than 25% of surgical procedures laparoscopically. The most commonly used definition of the upper limit of the rectum was a fixed distance from the anal verge (23.4%). Magnetic resonance imaging was used to define the upper limit of the rectum by 258 respondents (48.2%). During total mesorectal excision (TME), 301 respondents (56.3%) used a high-tie technique. The most commonly constructed anastomosis was an end-to-end anastomosis (68.2%) with the majority of surgeons performing a leak test intraoperatively (88.9%). A total of 355 respondents (66.4%) constructed a diverting ostomy, and the majority of these surgeons constructed an enterostomy (82%). A total of 208 respondents (39.3%) closed a stoma within 8 weeks. Lastly, 135 respondents (25.2%) introduced a solid diet on postoperative day 1.CONCLUSION: There is considerable heterogeneity in the perioperative management of rectal cancer patients worldwide with several discrepancies between current international practice and recommendations from international guidelines. To achieve worldwide standardization in rectal cancer care, further research is needed to elucidate the cause of this heterogeneity and find ways of improved implementation of best practice recommendations.

Introduction To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe. Methods All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD. Results There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC. Conclusion Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09044-w.

A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness has never been compared with higher-cost virtual reality simulators (VRSs).In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam or a validated BT-the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex vivo models. The primary endpoint was FESms improvement at 1 week. Secondary endpoints were FESms improvement at 2 weeks, FESms pass rates, ex vivo tests performance, and trainees' feedback.Seventy-seven trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16 ± 14.29 vs 25.58 ± 11.75 FESms points, respectively; p = 0.89), FESms pass rates (76.32% vs 61.54%, respectively; p = 0.16) and total ex vivo tasks completion times (365.76 ± 237.56 vs 322.68 ± 186.04 seconds, respectively; p = 0.55) after 1 week. Performances were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97 ± 1.20 vs 4.81 ± 0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p0.001).Simulation-based training is an effective means to develop competency in endoscopy, especially at the beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training.

Background: Malignant or benign biliary obstructions can be successfully managed with minimally invasive percutaneous interventions. Since percutaneous approaches are challenging, extensive trainin...

As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE). The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed ex vivo and in vivo animal models. Participants’ demographics, training, and clinical experience were recorded. Trainees’ evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees’ skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed. 162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees’ endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores; p = 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice. Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.

Although it has been proven that various volatile organic compounds (VOCs) are produced during surgery, there have been no studies focusing specifically on endoscopy. Therefore, we aimed to investigate VOCs produced during endoscopic submucosal dissection (ESD). Thirty-one patients scheduled for ESD were enrolled in this study. Sorbent tubes were installed to collect gas at two sites: one in a suction bottle and the other at the level of the endoscopists’ upper chest. Gas collections were performed for up to 30 min during submucosal dissection. Quantitative analysis of the VOCs in gas samples was performed using gas chromatography and mass spectrometry. Concentrations of fifteen VOCs were measured. The total concentration of volatile organic compounds (TVOC) was also calculated. Among the five carcinogens—benzene, ethylbenzene, formaldehyde, tetrachloroethylene, and trichloroethylene (TCE)—measured, excess life-time risks of cancer for benzene and TCE were interpreted as unacceptable based on the New Jersey Department of Environmental Protection Division of Air Quality and the Environmental Protection Agency guidelines (5 × 10–4 and 7 × 10–5, respectively). Among the non-carcinogenic VOCs, the mean concentration of toluene was much higher than the reference value (260 μg/m3) in the Japanese guidelines for indoor air quality (IAQ) (1323.7 ± 2884.0 μg/m3 from the air at the upper chest level of endoscopists and 540.9 ± 1345.4 μg/m3 from the suction bottle). Mean TVOCs were at least 10 times higher than the reference value (400 μg/m3) issued by the Japanese guidelines for IAQ. Various carcinogenic and non-carcinogenic VOCs were detected at levels higher than the reference “safe” values during the submucosal dissection step of ESD. Implementation of counter measures is essential to protect medical personnel who are involved in ESD surgeries.

This prospective study applied magnetic resonance imaging (MRI) to assess the effect of laparoscopic sleeve gastrectomy (LSG) on gastric structure and function. The impact of these changes on patient outcomes was analyzed. Obese patients without gastrointestinal symptoms referred for bariatric surgery were recruited prospectively. Pre-operative assessment included (i) high-resolution manometry and pH-impedance monitoring and (ii) magnetic resonance imaging (MRI) measurement of gastric capacity, accommodation, and emptying with the 400 ml liquid Nottingham test meal (NTM). Studies were repeated 6–7 months after LSG. Weight loss and changes in the Gastrointestinal Quality of Life Index (GIQLI) assessed patient outcomes. From 35 patients screened, 23 (66%) completed the study (17 females, age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% at follow-up. Total gastric volume (capacity) after the meal was 467 mL (455–585 ml) before and 139 mL (121–185 ml) after LSG (normal reference 534 (419–675) mL), representing a mean 70% reduction (p

The incidence of de novo gastroesophageal reflux disease (GERD) after LSG is substantial. However, an objective correlation with the structural gastric and EGJ changes has not been demonstrated yet. We aimed to prospectively evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the structure and function of the esophagogastric junction (EGJ) and stomach. Investigations were performed before and after > 50% reduction in excess body weight (6–12 months after LSG). Subjects with GERD at baseline were excluded. Magnetic Resonance Imaging (MRI), high-resolution manometry (HRM), and ambulatory pH-impedance measurements were used to assess the structure and function of the EGJ and stomach before and after LSG. From 35 patients screened, 23 (66%) completed the study (age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% after 7.1 ± 1.7-month follow-up. Esophageal acid exposure (2.4 (1.5–3.2) to 5.1 (2.8–7.3); p = 0.040 (normal 80% reduction in gastric capacity (TGV) had the highest prevalence of symptomatic GERD. LSG has multiple effects on the EGJ and stomach that facilitate reflux. In particular, EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG. : NCT01980420

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure. Endoscopic sleeve gastroplasty (ESG) is a promising new bariatric technique which is less invasive in its approach. To date no study has compared quality of life (QoL) outcomes between LSG and ESG. The aim of this study is to compare QoL after ESG and LSG using a propensity score analysis. QoL was evaluated by means of Gastrointestinal Quality of Life Index (GIQLI) questionnaire before and 6 months after the procedure. Patients were matched for age, sex, preoperative weight, and comorbidities. Propensity score matching resulted in 23 pairs of patients homogeneous for age (p = 0.3), preoperative BMI (p = 0.3), sex (p = 0.74), and comorbidities (p = 0.9). Post-ESG patients, despite a less important %EWL (39.9 (17.5–58.9)vs 54.9 (46.2–65); p = 0.01) and %TWL (13.4 (7.8–20.9) vs 18.8 (17.6–21.8); p = 0.03), presented better QoL (14 [3–24] vs 13 (− 1–23) ΔGIQLI score; p = 0.79) with clear advantage for the gastrointestinal symptoms subdomain (66.5 (61–70.5) vs 59 (55–63); p = 0.001), while post-LSG patients presented a worsening of GERD symptoms (30.7% vs 0%) and an increased use of PPI therapy (p = 0.004). Resolution or improvement of comorbidities was similar (ESG 53% vs LSG 45.8%; p = 0.79) in both groups. LSG may significantly affect QoL and results in worsening of gastrointestinal symptoms including GERD. ESG is a promising less invasive bariatric endoscopic procedure that demonstrated a positive impact on both QoL and comorbidities, which could lead to greater patient acceptance earlier in their disease or at a younger age.

A computer vision (CV) platform named EndoDigest was recently developed to facilitate the use of surgical videos. Specifically, EndoDigest automatically provides short video clips to effectively document the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). The aim of the present study is to validate EndoDigest on a multicentric dataset of LC videos.LC videos from 4 centers were manually annotated with the time of the cystic duct division and an assessment of CVS criteria. Incomplete recordings, bailout procedures and procedures with an intraoperative cholangiogram were excluded. EndoDigest leveraged predictions of deep learning models for workflow analysis in a rule-based inference system designed to estimate the time of the cystic duct division. Performance was assessed by computing the error in estimating the manually annotated time of the cystic duct division. To provide concise video documentation of CVS, EndoDigest extracted video clips showing the 2 min preceding and the 30 s following the predicted cystic duct division. The relevance of the documentation was evaluated by assessing CVS in automatically extracted 2.5-min-long video clips.144 of the 174 LC videos from 4 centers were analyzed. EndoDigest located the time of the cystic duct division with a mean error of 124.0 ± 270.6 s despite the use of fluorescent cholangiography in 27 procedures and great variations in surgical workflows across centers. The surgical evaluation found that 108 (75.0%) of the automatically extracted short video clips documented CVS effectively.EndoDigest was robust enough to reliably locate the time of the cystic duct division and efficiently video document CVS despite the highly variable workflows. Training specifically on data from each center could improve results; however, this multicentric validation shows the potential for clinical translation of this surgical data science tool to efficiently document surgical safety.

Background Paraesophageal hernias (PEHs; types II-III-IV) account for about 5% of all hiatal hernias (HHs). The peculiarity of PEHs is the presence of a herniated sac which contains a more or less important part of the stomach, along with other abdominal organs in type IV PEHs. Surgical treatment is more complex since it requires a reduction not only of the herniated content but also of the "container," namely the sac adherent to mediastinal structures. Since type III and IV PEHs are mostly grouped together as large PEHs, there is a lack of articles in the literature with regards to clear surgical outcomes, as well as management algorithms in type IV PEHs. This study aims to compare outcomes in type IV vs. type III PEHs after surgical repair. Methods A retrospective study of patients who underwent laparoscopic PEH hernia repair (LPEHR) was conducted in a single institution between 2006 and 2020. Patient baseline characteristics and surgical outcomes were analyzed. Results A total of 103 patients were included in the analysis. Patients presenting with type IV PEHs (12/103) were significantly older than patients with type III PEHs (91/104) (75.25 ± 7.15 vs. 66.91 ± 13.58 respectively (p = 0.039), and more fragile with a higher Charlson Comorbidity Index (CCI) (4.25 ± 1.48 vs. 2.96 ± 1.72, p = 0.016). Operative time was significantly longer (243 ± 101.73 vs. 133.38 ± 61.76, p = 0.002), and postoperative morbidity was significantly higher in type IV PEH repair (50% vs. 8.8% type III, p = 0.000). Conclusion Patients with type IV PEHs appear to be older and frailer. The higher incidence of postoperative complications in patients with type IV PEHs should advocate for a precise indication for surgical treatment, which should be performed in centers of expertise.

Background Laparoscopic cholecystectomy operative difficulty is highly variable and influences outcomes. This systematic review analyzes the performance and clinical value of statistical models to preoperatively predict laparoscopic cholecystectomy operative difficulty. Methods PRISMA guidelines were followed. PubMed, Embase, and the Cochrane Library were searched until June 2020. Primary studies developing or validating preoperative models predicting laparoscopic cholecystectomy operative difficulty in cohorts of >100 patients were included. Studies not reporting performance metrics or enough information for clinical implementation were excluded. Data were extracted according to CHARMS, and study quality was assessed using the PROBAST tool. Results In total, 2,654 articles were identified, and 22 met eligibility criteria. Eighteen were model development, whereas 4 were validation studies. Eighteen studies were at high risk of bias. However, 11 studies showed low concern for applicability. Identified models predict 9 definitions of laparoscopic cholecystectomy operative difficulty, the most common being conversion to open surgery and operating time. The most validated models predict an intraoperative difficulty scale and procedures >90 minutes with an area under the curve of >0.70 and >0.76, respectively. Commonly used predictors include demographic variables such as age and gender (9/18 models) and ultrasound findings such as gallbladder wall thickness (11/18). Clinical implementation was never studied. Conclusion There is a longstanding interest in estimating laparoscopic cholecystectomy operative difficulty. Models to preoperatively predict laparoscopic cholecystectomy operative difficulty have generally good performance and seem applicable. However, an unambiguous definition of operative difficulty, validations, and clinical studies are needed to implement patients’ stratification in laparoscopic cholecystectomy.

Multiple primary tumors are uncommon in patients with squamous cell esophageal cancer. Conventional imaging methods have limitations in detecting those tumors. Although 18-F-fluoro-deoxyglucose-positron emission tomography scanner increases the detection of multiple synchronous tumors in patients with other malignancies, its contribution in patients with squamous cell esophageal cancer has not been assessed as it is not systematically performed. The detection of synchronous skin squamous cell tumors in patients with squamous cell esophageal cancer presents a challenge for making diagnostic and therapeutic decisions. A metastatic tumor leads to palliative management, whereas the diagnosis of a primary skin tumor requires curative treatment of both squamous cell tumors. Pathological evaluation appears crucial in the decision.

Three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4K) monitors have recently become available for laparoscopic surgery. The aim of this study was to compare laparoscopic performance between inexperienced participants using 3-D/HD and 2-D/4K monitors and those using conventional 2-D/HD monitors.The study enrolled 66 participants with no previous surgical experience or medical training. They were randomly divided into three equal groups, each using a different type of monitor (2-D/HD, 2-D/4K, or 3-D/HD), to perform three phantom tasks using a laparoscopic simulator: Task 1, touching markers on a non-flat surface; Task 2, bimanual peg transfer; and Task 3, passing a straight rod through a loop. Each task was performed three times. The performance scores (operative time, path length of the forceps, and technical errors) were compared for each monitor type and by age group ( 30 vs. 30 years).For all three tasks, scores using the 3-D monitor were significantly better than those using either 2-D monitor, with no difference between the 2-D/4K and 2-D/HD monitors. Using the 2-D monitors, the performance of Task 3 by the participants 30 years was worse than that by the younger participants; however, there was no difference between the age groups when using the 3-D monitor.Participants with no prior experience using a 3-D monitor showed better laparoscopic performance than those using 2-D monitors, even with 4K resolution. This improvement was more marked in older participants, suggesting a greater loss of depth perception in a 2-D environment.

To evaluate the feasibility and safety of a new percutaneous image-guided surgery technique to simulate a hernia repair using hydrogel. A comparative prospective study was conducted in animals, with survival. Five pigs without any hernias were used. A hydrogel was injected at a site corresponding to the preperitoneal inguinal region. This procedure was performed bilaterally. An image-guided needle (ultrasound and computed tomography) was used, through which the material was injected. After survival, the local and systemic inflammatory reaction generated by the new material, was studied. All animals survived the procedure. No hemorrhagic or infectious complications were reported. The solidification of the material occurred as expected. In eight out of ten cases, the material was found in the planned site. No systemic inflammatory reaction secondary to the administration of hydrogel was reported. The adhesion of the material to surrounding tissues was satisfactory. The introduction of a liquid material which solidifies after injection in a short time (hydrogel) using a needle is feasible. The combined CT-scan and US image guidance allows for the percutaneous placement of the needle in the required location. The introduced hydrogel remains in this space, corresponding to the inguinal region, without moving. The placed hydrogel compresses the posterior wall composed of the transversalis fascia, supporting the potential use of hydrogel for hernia defects.

Background Laparoscopic endoscopic cooperative colorectal surgery (LECS-CR) is a promising technique to achieve full-thickness resection of colorectal tumors. This approach has shown good rates of complete resection and low local recurrence, especially for large laterally spreading tumors, which are difficult to remove via endoscopy alone. However, it is often difficult to prevent peritoneal leakage of intestinal content, causing infections and risks of cancer spreading. It was hypothesized that a robotic assistance could make the procedure easier and decrease intestinal fluid leakage. This preclinical trial aims to assess the feasibility of robotic and endoscopic cooperative colorectal surgery (RECS-CR). Methods LECS-CR was performed in five female pigs and RECS-CR was also performed in five female pigs. With the animal under general anesthesia, pseudotumors were created on the colonic mucosa at a distance comprised between 20 and 25 cm from the anal verge. Desired resection margins were marked endoscopically and two stay sutures were placed either robotically or laparoscopically. A mucosa-to-submucosa dissection was performed endoscopically along the markings. Complete full-thickness dissection was performed cooperatively. The specimen was withdrawn endoscopically. The colon was closed using a self-fixating running suture. Abdominal contaminations, operating times, complications, and complete resections were evaluated and compared between LECS-CR and RECS-CR. Results The mean number of colonies of Escherichia coli in the RECS group was significantly lower than in the LECS group (36.7 +/- 30.2 vs. 142.2 +/- 78.4, respectively, p < 0.05). Operating time was comparable (118 +/- 11.2 vs. 98.6 +/- 25.7, respectively, p = 0.22). Two stenoses occurred in the LECS group. R0 resection was achieved in all cases. Conclusion This study suggests that RECS-CR is feasible and has the potential to reduce intestinal content leakage, potentially preventing postoperative infections.

Background. New insufflators have been developed to manage leaks emanating from the working cavity during laparoscopic surgery. Little data have been published to show the performance of these insufflators. This study evaluates the performance of 2 modern continuous pressure insufflators in various leak conditions. Methods. Performance of a new continuous pressure insufflator, EVA15 (Palliare, Galway, Ireland), was compared with that of a continuous pressure insufflator, Airseal intelligent Flow System (iFS) (CONMED, Utica, NY), and a traditional intermittent pressure insufflator, Endoflator 40 (KARL STORZ, Tuttlingen, Germany). Six different leak scenarios were created in a swine model to create different dynamic leak profiles of between 5 and 15 L/min. Pressure deviation from setting was measured for each insufflator tested. The following were calculated: (a) mean absolute difference of measured insufflation pressure vs. the insufflator pressure setting for the 50 second measurement period (MAD) and (b) standard deviation of the absolute differences (SD). Results. The average mean absolute pressure difference between the EVA15 and Airseal is .27 mmHg. However, the average mean absolute pressure difference between the EVA15 and Endoflator 40 is 2.62 mmHg. Conclusions. Continuous pressure insufflators provide superior pressure delivery performance in leak situations when compared against a traditional intermittent pressure insufflator. No clinically significant performance difference was observed when comparing the EVA15 and Airseal iFS insufflators in the tested leak situations.

Objective The aim of this study was to develop a computer vision platform to automatically locate critical events in surgical videos and provide short video clips documenting the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). Background Intraoperative events are typically documented through operator-dictated reports that do not always translate the operative reality. Surgical videos provide complete information on surgical procedures, but the burden associated with storing and manually analyzing full-length videos has so far limited their effective use. Methods A computer vision platform named EndoDigest was developed and used to analyze LC videos. The mean absolute error (MAE) of the platform in automatically locating the manually annotated time of the cystic duct division in full-length videos was assessed. The relevance of the automatically extracted short video clips was evaluated by calculating the percentage of video clips in which the CVS was assessable by surgeons. Results A total of 155 LC videos were analyzed: 55 of these videos were used to develop EndoDigest, whereas the remaining 100 were used to test it. The time of the cystic duct division was automatically located with a MAE of 62.8 ± 130.4 seconds (1.95% of full-length video duration). CVS was assessable in 91% of the 2.5 minutes long video clips automatically extracted from the considered test procedures. Conclusions Deep learning models for workflow analysis can be used to reliably locate critical events in surgical videos and document CVS in LC. Further studies are needed to assess the clinical impact of surgical data science solutions for safer laparoscopic cholecystectomy.

Background: The critical view of safety (CVS) is poorly adopted in surgical practices although it is ubiquitously recommended to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aims to determine whether performing a short intraoperative time out can improve CVS implementation. Methods: Surgeons performing LCs at an academic centre were invited to perform a 5-second long time out to verify CVS before dividing the cystic duct (5-second rule). The primary endpoint was to compare the rate of CVS achievement between LCs performed in the year before and the year after the 5-second rule. The CVS achievement rate was computed using the mediated video-based assessment of two independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. Results: Three hundred and forty-three (171 before and 172 after the 5-second rule) of the 381 LCs performed over the 2-year study were analysed. After the implementation of the 5-second rule, the rate of CVS achievement increased significantly (15.9 vs 44.1 %; P, 20 pages, 3 figures, 2 tables

IMPORTANCE: The efficacy of fundoplication operations in the management of gastroesophageal reflux disease (GERD) has been documented. However, few prospective, controlled series report long-term (>10 years) efficacy and postfundoplication concerns, particularly when comparing various types of fundoplication. OBJECTIVE: To compare long-term (>15 years) results regarding mechanical complications, reflux control, and quality of life between patients undergoing posterior partial fundoplication (PF) or total fundoplication (TF) (270° vs 360°) in surgical treatment for GERD. DESIGN, SETTING, AND PARTICIPANTS: A double-blind randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from November 19, 2001, to January 24, 2006. A total of 456 patients were recruited and randomized. Data for this analysis were collected from August 1, 2019, to January 31, 2021. INTERVENTIONS: Laparoscopic 270° posterior PF vs 360° TF. MAIN OUTCOMES AND MEASURES: The main outcome was dysphagia scores for solid and liquid food items after more than 15 years. Generic (36-Item Short-Form Health Survey) and disease-specific (Gastrointestinal Symptom Rating Scale) quality of life and proton pump inhibitor consumption were also assessed. RESULTS: Among 407 available patients, relevant data were obtained from 310 (response rate, 76%; mean [SD] age, 66 [11.2] years; 184 [59%] men). A total of 159 were allocated to a PF and 151 to a TF. The mean (SD) follow-up time was 16 (1.3) years. At 15 years after surgery, mean (SD) dysphagia scores were low for both liquids (PF, 1.2 [0.5]; TF, 1.2 [0.5]; P = .58) and solids (PF, 1.3 [0.6]; TF, 1.3 [0.5]; P = .97), without statistically significant differences between the groups. Reflux symptoms were equally well controlled by the 2 types of fundoplications as were the improvements of quality-of-life scores. CONCLUSIONS AND RELEVANCE: The long-term findings of this randomized clinical trial indicate that PF and TF are equally effective for controlling GERD and quality of life in the long term. Although PF was superior in the first years after surgery in terms of less dysphagia recorded, this difference did not prevail when assessed a decade later. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04182178

Objective: To develop consensus definitions of image-guided surgery, computer-assisted surgery, hybrid operating room, and surgical navigation systems. Summary Background Data: The use of minimally invasive procedures has increased tremendously over the past 2 decades, but terminology related to image-guided minimally invasive procedures has not been standardized, which is a barrier to clear communication. Methods: Experts in image-guided techniques and specialized engineers were invited to engage in a systematic process to develop consensus definitions of the key terms listed above. The process was designed following review of common consensus-development methodologies and included participation in 4 online surveys and a post-surveys face-to-face panel meeting held in Strasbourg, France. Results: The experts settled on the terms computer-assisted surgery and intervention, image-guided surgery and intervention, hybrid operating room, and guidance systems and agreed-upon definitions of these terms, with rates of consensus of more than 80% for each term. The methodology used proved to be a compelling strategy to overcome the current difficulties related to data growth rates and technological convergence in this field. Conclusions: Our multidisciplinary collaborative approach resulted in consensus definitions that may improve communication, knowledge transfer, collaboration, and research in the rapidly changing field of image-guided minimally invasive techniques., This study gathered experts with multiple backgrounds and used common consensus-development methodologies in 2 phases (online and panel meeting). It resulted in definitions that may improve communication, knowledge transfer, collaboration, and research in the field of image-guided minimally invasive techniques.

Objective To develop a deep learning model to automatically segment hepatocystic anatomy and assess the criteria defining the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). Background Poor implementation and subjective interpretation of CVS contributes to the stable rates of bile duct injuries in LC. As CVS is assessed visually, this task can be automated by using computer vision, an area of artificial intelligence aimed at interpreting images. Methods Still images from LC videos were annotated with CVS criteria and hepatocystic anatomy segmentation. A deep neural network comprising a segmentation model to highlight hepatocystic anatomy and a classification model to predict CVS criteria achievement was trained and tested using 5-fold cross validation. Intersection over union, average precision, and balanced accuracy were computed to evaluate the model performance versus the annotated ground truth. Results A total of 2854 images from 201 LC videos were annotated and 402 images were further segmented. Mean intersection over union for segmentation was 66.6%. The model assessed the achievement of CVS criteria with a mean average precision and balanced accuracy of 71.9% and 71.4%, respectively. Conclusions Deep learning algorithms can be trained to reliably segment hepatocystic anatomy and assess CVS criteria in still laparoscopic images. Surgical-technical partnerships should be encouraged to develop and evaluate deep learning models to improve surgical safety.

This prospective study applied magnetic resonance imaging (MRI) to assess the effect of laparoscopic sleeve gastrectomy (LSG) on gastric structure and function. The impact of these changes on patient outcomes was analyzed.Obese patients without gastrointestinal symptoms referred for bariatric surgery were recruited prospectively. Pre-operative assessment included (i) high-resolution manometry and pH-impedance monitoring and (ii) magnetic resonance imaging (MRI) measurement of gastric capacity, accommodation, and emptying with the 400 ml liquid Nottingham test meal (NTM). Studies were repeated 6-7 months after LSG. Weight loss and changes in the Gastrointestinal Quality of Life Index (GIQLI) assessed patient outcomes.From 35 patients screened, 23 (66%) completed the study (17 females, age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% at follow-up. Total gastric volume (capacity) after the meal was 467 mL (455-585 ml) before and 139 mL (121-185 ml) after LSG (normal reference 534 (419-675) mL), representing a mean 70% reduction (p 0.0001). Similar findings were present for gastric content volume indicating rapid early-phase gastric emptying (GE) post-LSG. Conversely, late-phase GE was slower post-LSG (2.5 ± 1.0 vs. 1.4 ± 0.6 mL/min; p 0.0001; (reference 1.5(1.4-4.9) mL/min)). Patients with ≥ 80% reduction in gastric capacity had greater weight loss (p = 0.008), but worse gastrointestinal outcomes (p = 0.023).MRI studies quantified the marked reduction in gastric capacity after LSG. The reduction in capacity was associated with rapid early- but slow late-phase GE after surgery. These changes were associated with weight loss; however, reductions in gastric capacity ≥ 80% were linked to increased acid reflux and impacted on gastrointestinal quality of life.

The current unprecedented coronavirus 2019 (COVID-19) crisis has accelerated and enhanced e-learning solutions. During the so-called transition phase, efforts were made to reorganize surgical services, reschedule elective surgical procedures, surgical research, academic education, and careers to optimize results. The intention to switch to e-learning medical education is not a new concern. However, the current crisis triggered an alarm to accelerate the transition. Efforts to consider e-learning as a teaching and training method for medical education have proven to be efficient. For image-guided therapies, the challenge requires more effort since surgical skills training is combined with image interpretation training, thus the challenge is to cover quality educational content with a balanced combination of blended courses (online/onsite). Several e-resources are currently available in the surgical scenario; however, further efforts to enhance the current system are required by accelerating the creation of new learning solutions to optimize complex surgical education needs in the current disrupted environment.

International audience; When detected early, colorectal cancer can be treated with minimally invasive flexible endoscopy. However, since only specialized experts can delineate margins and perform endoscopic resections of lesions, patients still often undergo colon resections. To better assist in the performance of surgical tasks, a robotized flexible interventional endoscope was previously developed, having two additional side channels for surgical instrument. We propose to enhance the imaging capabilities of this device by combining it with optical coherence tomography (OCT). For this purpose, we have developed a new steerable OCT instrument with an outer diameter of 3.5 mm. The steerable instrument is terminated with a 2 cm long transparent sheath to allow three-dimensional OCT imaging using a side-focusing optical probe with two external scanning actuators. The instrument is connected to an OCT imaging system built around the OCT Axsun engine, with a 1310 nm center wavelength swept source laser and 100 kHz A-line rate. Once inserted in one of the side channels of the robotized endoscope, bending, rotation and translation of the steerable OCT instrument can be controlled by a physician using a joystick. Ex vivo and in vivo tests show that the novel, steerable and teleoperated OCT device enhances dexterity, allowing for inspection of the surgical field without the need for changing the position of the main endoscope.

We aimed to assess the feasibility of a novel hybrid endoscopic/laparoscopic non-exposed, full-thickness, single-wall gastric resection technique guided by a fluorescence lymphangiography to identify the lymphatic pathway and the sentinel node basin. Eight large white pigs (4 acute and 4 survival models) were included. Indocyanine green was injected submucosally around a pseudo-tumor at four points (1 ml, 0.1 mg/ml). The lymphatic spreading pathway was identified by the means of near-infrared (NIR) laparoscopic camera, and the resection line was planned outside of the fluorescent signals, to include all the potential lymphatic channels. Lymph node (LN) dissection was performed at greater curvature side and the infrapyloric area preserving the infragastric artery for all pigs. At the lesser curvature, 3–4 branches of the gastric artery were preserved in all acute and in two survival (group A), while in the remaining animals, 1–2 branches were preserved (group B). Perfusion of the remaining stomach was examined by NIR angiography. The gastric motility and function were evaluated by the means of a dynamic MRI immediately after the procedure and repeated after 1 week in surviving animals. The hybrid full-thickness resection with bilateral sentinel LN basin dissection were successfully performed with no intra-operative or post-operative complications. The removed specimen was including all the area with florescent signal. The remaining stomach demonstrated a good perfusion at the NIR angiography. The dynamic MRI revealed a preserved emptying function in the acute animals and in the group A, and a loss of function in the group B. Fluorescence-lymphangiography guided hybrid resection was feasible to remove a relatively large part of the stomach including the lymphatic spreading pathway and sentinel basin. The extent of dissection in the lesser curvature side can affect the post-operative function and further researches are warranted to optimize the concept.

Objective: Minimally invasive surgical interventions in the gastrointestinal tract, such as endoscopic submucosal dissection (ESD), are very difficult for surgeons when performed with standard flexible endoscopes. Robotic flexible systems have been identified as a solution to improve manipulation. However, only a few such systems have been brought to preclinical trials as of now. As a result, novel robotic tools are required. Methods: We developed a telemanipulated robotic device, called STRAS, which aims to assist surgeons during intraluminal surgical endoscopy. This is a modular system, based on a flexible endoscope and flexible instruments, which provides 10 degrees of freedom (DoFs). The modularity allows the user to easily set up the robot and to navigate toward the operating area. The robot can then be teleoperated using master interfaces specifically designed to intuitively control all available DoFs. STRAS capabilities have been tested in laboratory conditions and during preclinical experiments. Results: We report 12 colorectal ESDs performed in pigs, in which large lesions were successfully removed. Dissection speeds are compared with those obtained in similar conditions with the manual Anubiscope platform from Karl Storz. We show significant improvements ( $\mathbf {p= 0.01}$ ). Conclusion: These experiments show that STRAS (v2) provides sufficient DoFs, workspace, and force to perform ESD, that it allows a single surgeon to perform all the surgical tasks and those performances are improved with respect to manual systems. Significance: The concepts developed for STRAS are validated and could bring new tools for surgeons to improve comfort, ease, and performances for intraluminal surgical endoscopy.

Background Stereotactic navigation could improve the quality of surgery for rectal cancer. Critical challenges related to soft tissue stereotactic pelvic navigation include the potential difference in patient anatomy between intraoperative lithotomy and preoperative supine position for imaging. The objective of this study was to determine the difference in patient anatomy, sacral tilt, and skin fiducial position between these different patient positions and to investigate the feasibility and optimal set-up for stereotactic pelvic navigation. Methods Four consecutive human anatomical specimens were submitted to repeated CT-scans in a supine and several degrees of lithotomy position. Patient anatomy, sacral tilt, and skin fiducial position were compared by means of an image computing platform. In two specimens, a 10-degree wedge was introduced to reduce the natural tilt of the sacrum during the shift from supine to lithotomy position. A simulation of laparoscopic and transanal surgical procedures was performed to assess the accuracy of the stereotactic navigation. Results An up-to-supracentimetric change in patient anatomy was noted between different patient positions. This observation was minimized through the application of a wedge. When switching from supine to another position, sacral retroversion occurred independent of the use of a wedge. There was considerable skin fiducial motion between different positions. Accurate stereotactic navigation was obtained with the least registration error (1.9 mm) when the position of the anatomical specimen was registered in a supine position with straight legs, without pneumoperitoneum, using a conventional CT-scan with an identical specimen positioning. Conclusion The change in patient anatomy is small during the sacral tilt induced by positional changes when using a 10-degree wedge, allowing for an accurate stereotactic surgical navigation. This opens up new promising opportunities to increase the quality of surgery for rectal cancer cases where it is difficult or impossible to identify and dissect along the anatomical planes. Electronic supplementary material The online version of this article (10.1007/s00464-017-5968-0) contains supplementary material, which is available to authorized users.

Giant paraesophageal hernias (GPEH) are relatively uncommon and account for less than 5% of all primary hiatal hernias. Giant Secondary GPEH can be observed after surgery involving hiatal orifice opening, such as esophagectomy, antireflux surgery, and hiatal hernia repair. Surgical treatment is challenging, and there are still residual controversies regarding the laparoscopic approach, even though a reduced morbidity and mortality, as well as a shorter hospital stay have been demonstrated. A Pubmed electronic search of the literature including articles published between 1992 and 2016 was conducted using the following key words: hiatal hernia, paraesophageal hernias, mesh, laparoscopy, intrathoracic stomach, gastric volvulus, diaphragmatic hernia. Given the risks of non-operative management, GPEH surgical repair is indicated in symptomatic patients. Technical steps for primary hernia repair include hernia reduction and sac excision, correct repositioning of the gastroesophageal junction, crural repair, and fundoplication. For secondary hernias, the surgical technique varies according to hernia type and components and according to the approach used during the first surgery. There is an ongoing debate regarding the best and safest method to close the hiatal orifice. The laparoscopic approach has demonstrated a lower postoperative morbidity and mortality, and a shorter hospital stay as compared to the open approach. A high recurrence rate has been reported for primary GPEH repair. However, recent studies suggest that recurrence does not reduce symptomatic outcomes. The laparoscopic treatment of primary and secondary GPEH is safe and feasible in elective and emergency settings, especially in high-volume centers. The procedure is still challenging. The main steps are well defined. However, there is still room for improvement to lower the recurrence rate.

Near-infrared (NIR) fluorescence cholangiography by systemic administration of indocyanine green (ICG) enhances the visualization of the biliary tree anatomy. However, the simultaneous enhancement of liver parenchyma can disturb the visualization of critical details. We herein proposed a new technique of NIR cholecystocholangiography by intragallbladder ICG injection to increase the safety during laparoscopic cholecystectomy. A total of 46 patients scheduled for laparoscopic cholecystectomy for symptomatic lithiasis (n = 21) or cholecystitis (n = 25) were enrolled. A fluorescence cholangiography by direct gallbladder injection of ICG was performed in all cases. Of them, the ICG was injected through a previously placed percutaneous transhepatic gallbladder drainage catheter (n = 18) or by intraoperative, percutaneous needle puncture of the gallbladder (n = 28). Visualization of biliary structures, including the cystic duct (CD), the common bile and hepatic ducts (CBD and CHD), the gallbladder neck, and the Hartmann’s pouch (HP), was performed using White Light (served as control modality) and by NIR enhancement. Cholecystocholangiography provided a significantly higher rate of visualization of the CD in case of cholecystitis with mild adhesions, and an improved visualization of the HP, CBD, and CHD in case of severe inflammation, when compared to White Light observation. There were no benefits of NIR in case of non-inflamed lithiasis. Clinical translation of NIR cholecystocholangiography has been successful with a noise-free visualization of biliary anatomy. It can be considered in difficult cases to increase the safety of laparoscopic cholecystectomy.