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Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

Aim: Anastomotic leakage represents the most fearful complication in colorectal surgery. Important risk factors for leakage are low anastomoses and preoperative radiotherapy. Many surgeons often unnecessarily perform a protective ileostomy, increasing costs and necessitating a second operation for recanalization. The aim of this study was to evaluate the role of indocyanine green in assessing bowel perfusion, even in cases of a low anastomosis on tissue treated with radiotherapy., Patients and Methods: Two groups of patients were selected: Group A (risky group) with only low extraperitoneal rectal tumors (<8 cm) previously treated with neoadjuvant chemo-radiotherapy; group B (no risk group) with only intraperitoneal rectal tumors (>8 cm), not previously treated with neoadjuvant therapy. Clinical postoperative outcome, morbidity, mortality and anastomotic leakage were compared between these two groups., Results: In group A, comprised of 35 patients, the overall complication rate was 8.6%, with two patients developing anastomotic leakage (5.7%). In group B, comprised of 53 patients, the overall complication rate was 17% with four cases with anastomotic leakage (7.5%). No statistical difference was observed for conversion rate, general complications, or anastomotic leakage. No statistical differences were observed in clinical variables except for American Society of Anesthesiologist score (p=0.04). Patients who developed complications during radiotherapy had no significant differences in postoperative outcomes compared with other patients., Conclusion: Indocyanine green appears to be safe and effective in assessing the perfusion of colorectal anastomoses, even in the highest-risk cases, potentially reducing the rate of ileostomy. The main limitation remains the lack of a universally replicable standard assessment., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, digestive surgery potentially exposes both health-care professionals and vulnerable patients to COVID-19. A survey was conducted with aim to determine the digestive surgery services provided during the COVID-19 pandemic, optimize safety for patients and clinicians, and safeguard health-care services., Methods: An online survey was conceived and circulated to members of the Indonesian Society of Digestive Surgeons. The survey was conducted in two phases, in April 2020 and July 2020, to evaluate changes in response to the COVID-19 pandemic., Results: Early in the pandemic (April 2020), the median number of major digestive surgeries performed monthly declined from 20 cases (range. 3-100 cases) to 1 case (range. 0-10 cases) (P < .001; Wilcoxon signed-rank test). Most of the cases in April 2020 addressed emergency problems, but more definitive surgeries were performed during the later period of the survey. The importance of screening for COVID-19 with polymerase chain reaction has increased over time, and a more comprehensive screening methodology incorporating real-time polymerase chain reaction, chest CT, and rapid antibody test were evident in 31.37% of July 2020 responses., Conclusion: Our survey has shown that surgeons adapted to the evolving pandemic and continue to do so only with appropriate safety assurances., (© 2020 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Background: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries., Methods: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care., Results: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916)., Conclusion: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

Background: We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes., Methods: Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness., Results: Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m -2 ; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min -1  m -2 ; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant)., Conclusions: The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups., Clinical Trial Registration: ACTRN12615000125527., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

The National Clinical Database (NCD) of Japan was established in 2010 with the board certification system. A joint committee of 16 gastroenterological surgery database-affiliated organizations has been nurturing this nationwide database and utilizing its data for various analyses. Stepwise board certification systems have been validated by the NCD and are used to improve the surgical outcomes of patients. The use of risk calculators based on risk models can be particularly helpful for establishing appropriate and less invasive surgical treatments for individual patients. Data obtained from the NCD reflect current developments in the surgical approaches used in hospitals, which have progressed from open surgery to endoscopic and robot-assisted procedures. An investigation of the data acquired by the NCD could answer some relevant clinical questions and lead to better surgical management of patients. Furthermore, excellent surgical outcomes can be achieved through international comparisons of the national databases worldwide. This review examines what we have learned from the NCD of gastroenterological surgery and discusses what future developments we can expect.

In the past 30 years, minimally invasive surgery has been greatly improved with the development of the energy platform, instrument platform, and imaging platform. Taking colorectal cancer surgery as an example, the five elements of surgical procedure have developed to a certain extent. The surgical approach has undergone a process from large to small. The range of resection ranges from simple bowel resection to radical resection/extended radical resection, and then to surgery that focuses on preserving organ function. With the recognition of the direction of normal lymphatic drainage and the characteristics of tumor lymphatic metastasis, lymph node dissection has been gradually standardized. The reconstruction of the digestive tract has changed from manual sutures to full endoscopic anastomosis, and then to the concept of functional anastomosis. The removal of the specimen has improved from large incision through the abdominal wall, to small laparoscopic incision, and then to the natural cavity. The evolution of these procedures depends on the advancement of technology platforms and equipment, and the recognition of new concepts. The development of minimally invasive platform must be in the direction of ensuring the implementation of the most optimized surgical approach. The platform is more secure, integrated, multifunctional, and intelligent. In the future, minimally invasive procedures must be aimed at maximizing the benefits of patients. The procedures are more scientific, functional, comfortable and diverse. Surgical innovation has promoted the development of the platform. The platform and the surgical procedure promote each other's development.

Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: The aim of this study was to clarify the surgical supply situation of oncological colorectal patients in Germany during limitations of the OR caseload due to the COVID-19 pandemic., Methods: Between 11th and 19th April 2020, all members of a consortium of German colorectal cancer centers were invited to participate in a web-based survey on the current status of surgical care situation of colorectal cancer patients in Germany., Results: A total of 112 colorectal surgeons of 101 German hospitals participated in the survey. Eighty-seven percent of the participating hospitals had to reduce their total surgical caseload and 34% their surgical volume for oncological colorectal patients during COVID-19 pandemic. Restrictions of the surgical caseload were independent of the size of the hospital and the number of cases of COVID-19 in the federal state of the hospital. Sixteen percent of colorectal surgeons consider surgical limitations to be not justified and 78% to be justified only if the care of oncological patients is ensured. Ninety-five percent of the colorectal surgeons interviewed stated that all oncological colorectal patients with an indication for surgery should be operated in time, despite the current reservations for COVID-19 patients. For the majority of the respondents (63% and 51%, respectively), an extended waiting time for surgery of up to 2 weeks was acceptable for non-metastatic and metastatic patients, respectively., Conclusion: In Germany, there is a temporarily relevant reduction of surgical volume in oncological colorectal patients. Most colorectal surgeons stated that oncological colorectal surgery should not be compromised despite the measures taken during the COVID-19 pandemic.

Gastroesophageal reflux disease (GERD) is a multifaceted disorder encompassing a family of syndromes attributable to, or exacerbated by, gastroesophageal reflux that impart morbidity, mainly through troublesome symptoms. Major GERD phenotypes are non-erosive reflux disease, GERD hypersensitivity, low or high grade esophagitis, Barrett's esophagus, reflux chest pain, laryngopharyngeal reflux, and regurgitation dominant reflux. GERD is common throughout the world, and its epidemiology is linked to the Western lifestyle, obesity, and the demise of Helicobacter pylori. Because of its prevalence and chronicity, GERD is a substantial economic burden measured in physician visits, diagnostics, cancer surveillance protocols, and therapeutics. An individual with typical symptoms has a fivefold risk of developing esophageal adenocarcinoma, but mortality from GERD is otherwise rare. The principles of management are to provide symptomatic relief and to minimize potential health risks through some combination of lifestyle modifications, diagnostic testing, pharmaceuticals (mainly to suppress or counteract gastric acid secretion), and surgery. However, it is usually a chronic recurring condition and management needs to be personalized to each case. While escalating proton pump inhibitor therapy may be pertinent to healing high grade esophagitis, its applicability to other GERD phenotypes wherein the modulating effects of anxiety, motility, hypersensitivity, and non-esophageal factors may dominate is highly questionable., Competing Interests: Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: PJK has advised Ironwood on drug development for GERD, and Bayer on drug development to treat chronic cough, and received grants from the US National Institute of Health and Ironwood Pharmaceuticals outside the scope of this article. DAK is a member of the governing board for the American Gastroenterological Association (no relation to this article), undertook research (unpaid) for Shire and Celgene, and gave a lecture on eosinophilic esophagitis to Celgene. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests, (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Many Crohn's disease (CD) patients will undergo surgery over the course of their life. It is thought that with the introduction of disease-modifying agents like anti-TNF therapy, there would be a population-level decrease in the need for surgery. This time-trend study aimed to assess the changes in surgical rates following the induction of anti-TNF therapy., Methods: Adult CD patients who underwent abdominal surgery (identified by administrative coding) between January of 1996 and December of 2013 at 1 of the 4 Edmonton-area hospitals were included. Patient charts were manually reviewed to confirm diagnosis and gather demographic and disease-related data. Population-adjusted annual incidence rates for IBD surgery were calculated by dividing the number of surgeries by estimates for total population of CD patients in Edmonton. Time-trend analysis was conducted to identify change points, calculate annual percent change (APC), and associated 95% confidence intervals (CIs)., Results: A total of 1410 patients with Crohn's disease underwent surgery for their disease. The surgical rate decreased by 8.4% each year (95% CI, -9.6% to -7.3%). There was a 36.2% increase in the use of anti-TNF therapy per year (95% CI, 31.3% to 41.5%). Changes in modifiable risk factors for surgery were also seen, including the proportion of active smokers decreasing by 2.2% per year (95% CI, -3.7% to -0.6%)., Conclusions: Although anti-TNF therapy seems to play a role, the decrease in surgical trends is likely multifactorial, owing to a decline in smoking trends, earlier diagnosis, earlier treatment, improved patient education, and changes in clinical practice., (© 2020 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The omission of surgery via nonoperative management (NOM) for rectal cancer may be increasing, and this strategy could be particularly attractive for younger patients, whose incidence of rectal cancer has been rising. We sought to assess trends in NOM in young (younger than 55 y) versus older adult (55 y and older) rectal cancer cohorts., Methods: The National Cancer Database was used to identify patients diagnosed with stage II to III rectal cancer between 2010 and 2015. Multivariable logistic regression defined the association between sociodemographic variables and odds of NOM, including an age (18 to 54 vs. 55+ y)×surgery (surgery vs. NOM) interaction term. Adjusted Cox regression models compared overall survival between NOM versus surgery., Results: Among 22,561 patients with a median follow-up of 37.5 months, the utilization rate of NOM increased from 10.7% (2010) to 15.2% (2015). Older patients were more likely to receive NOM, although rates also increased among young (7.1% to 10.6%). Black patients were also more likely to receive NOM (P<0.001). Among the entire cohort, NOM was associated with worse overall survival (adjusted hazard ratio [AHR]=2.90, 95% confidence interval [CI]: 2.67-3.15) and there was a statistically significant age×NOM interaction (P=0.01) such that the effect of NOM on survival was worse for younger (AHR=3.37, 95% CI: 2.82-4.02) as compared with older patients (AHR=2.49, 95% CI: 2.27-2.74)., Conclusions: The increasing trend for NOM in stage II to III rectal cancer may be driven by disparities in treatment. Management with NOM appears to be associated with poorer survival, particularly in younger patients and could worsen outcomes for groups already at risk for suboptimal cancer care.

Background: The use of biologic therapy for Crohn's disease [CD] continues to evolve, however, the effect of this on the requirement for surgery remains unclear. We assessed changes in biologic prescription and surgery over time in a population-based cohort., Methods: We performed a retrospective cohort study of all 1753 patients diagnosed with CD in Lothian, Scotland, between January 1, 2000 and December 31, 2017, reviewing the electronic health record of each patient to identify all CD-related surgery and biologic prescription. Cumulative probability and hazard ratios for surgery and biologic prescription from diagnosis were calculated and compared using the log-rank test and Cox regression analysis stratified by year of diagnosis into cohorts., Results: The 5-year cumulative risk of surgery was 20.4% in cohort 1 [2000-2004],18.3% in cohort 2 [2005-2008], 14.7% in cohort 3 [2009-2013], and 13.0% in cohort 4 [2014-2017] p <0.001. The 5-year cumulative risk of biologic prescription was 5.7% in cohort 1, 12.2% in cohort 2, 22.0% in cohort 3, and 44.9% in cohort 4 p <0.001., Conclusions: The increased and earlier use of biologic therapy in CD patients corresponded with a decreasing requirement for surgery over time within our cohort. This could mean that adopting a top-down or accelerated step-up treatment strategy may be effective at reducing the requirement for surgery in newly diagnosed CD., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Since the 21st century, with the development of minimally invasive surgical technology, the update of comprehensive treatment strategies and the progress of clinical research, colorectal surgery has developed rapidly. However, in recent years, some disputable issues still exist in colorectal surgery, such as transanal total mesorectal excision, pelvic cavity lateral lymph node dissection, the "wait and observe" strategy for clinical complete remission of rectal cancer after neoadjuvant therapy, and robotic colorectal surgical operation. In addition, the application of three dimensions imaging, 4K resolution, 5th generation wireless systems, virtual reality, artificial intelligence and other new techniques may provide extensive space and new opportunity for the development of colorectal surgery. The therapic outcome could be optimized by more relevant clinical research and evidence, which contribute to the standardization of surgical treatment of colorectal cancer.

Objectives: In the United States, trends in the initial treatment approach for ovarian cancer reflect a shift in paradigm toward the increased use of neoadjuvant chemotherapy and interval cytoreductive surgery. The aim of this study was to evaluate the trends in surgical cytoreductive procedures in ovarian cancer patients who underwent either primary or interval cytoreductive surgery., Methods: This retrospective, population-based study examined patients with stage III/IV ovarian cancer diagnosed between January 2000 and December 2013 identified using SEER-Medicare. Small or large bowel resection, ostomy creation, and upper abdominal procedures were identified using relevant billing codes and compared over time. A 1:1 primary and interval cytoreductive propensity matched cohort was created using demographic and clinical variables. 30-day complications and the use of acute care services were compared., Results: A total of 5417 women were identified. 34% underwent bowel resections, 16% ostomy creation, and 8% upper abdominal procedures. There was an increase in bowel resections and upper abdominal procedures from 2000 to 2013 in patients who underwent primary cytoreductive surgery. Compared with patients who received primary cytoreduction, patients who underwent interval cytoreductive surgery were less likely to undergo bowel resection (OR=0.50; 95% CI [0.41, 0.61]) or ostomy creation (OR=0.48; 95% CI [0.42, 0.56]). Upper abdominal procedures did not differ between groups. For patients who underwent primary cytoreductive surgery, these procedures were associated with intensive care unit stay (4.6% vs <2%, P<0.01). In both primary and interval cytoreductive surgery patients, the receipt of bowel and upper abdominal procedures was associated with multiple 30-day postoperative complications and higher rates of readmission and emergency room visits., Conclusions: The performance of upper abdominal procedures in ovarian cancer patients increased from 2000 to 2013. Interval cytoreductive surgery was associated with decreased likelihood of bowel surgery. In matched primary and interval cytoreductive surgery cohorts, the receipt of these procedures were associated with the increased likelihood of postoperative complications and use of acute care services., Competing Interests: Competing interests: LAM: received research funding from AstraZeneca for unrelated research, and has participated in an advisory board for Clovis Oncology in 2016. CCS: received research funding from AstraZeneca for unrelated research., (© IGCS and ESGO 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The definition of true esophagogastric junction (EGJ) adenocarcinoma and its surgical treatment are debatable. We review the basis for the current definition and the Japanese surgical strategy in managing true EGJ adenocarcinoma. The Siewert classification is a well-known anatomical classification system for EGJ adenocarcinomas: type II tumors in the region 1 cm above and 2 cm below the EGJ are described as "true carcinoma of the cardia". Coincidentally, this range matches gastric cardiac gland distribution. Conversely, Nishi's classification is generally used to describe EGJ carcinomas, defined as tumors with the center located within 2 cm above and 2 cm below the EGJ, regardless of their histological subtype. This range coincides with the extent of the lower esophageal sphincter combined with gastric cardiac gland distribution. The current Japanese surgical strategy focuses on the tumor range from the EGJ to the esophagus and stomach. According to previous studies, the strategy can be roughly classified into three types. The optimal surgical procedure for true EGJ adenocarcinoma is controversial. However, an ongoing Japanese nationwide prospective trial will help confirm the appropriate standard surgery, including the optimal extent of lymph node dissection.

Malignant colon and rectal disorders must be identified and treated. Timing and indication for diagnostic and screening colonoscopy are extremely important. A high index of suspicion to exclude malignancy is imperative. This paper will focus on the screening for and treatment of colorectal and anal cancers., (Copyright 2020 by the Missouri State Medical Association.)

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

Medical artificial intelligence is a deeply integrated field of production-university-research. The collaborative innovation system of "industry, education and research" has broken down the barriers between various disciplines and has shown great impetus in scientific and technological innovation and achievement transformation. The Affiliated Hospital of Qingdao University where the authors work, relying on Shandong Key Laboratory of Digital Medicine and Computer-Assisted Surgery and Institute of Digital Medicine and Computer-Assisted Surgery of Qingdao University, has jointly established a close "industry-university-research" cooperation mechanism with the State Key Laboratory of Virtual Reality Technology and Systems of Beijing University of Aeronautics and Astronautics and Qingdao Hisense Medical Equipment Co., Ltd., which lasted for 10 years and carried out a series of useful explorations in scientific and technological innovation and achievement transformation in the field of gastrointestinal surgery of artificial intelligence with fruitful results. It mainly comprises of the following: (1) The research and development (R&D) of Hisense computer-assisted surgery (CAS) system has important clinical significance for laparoscopic gastrointestinal surgery guided by surrounding blood vessels that grasps globally the movement and variation of blood vessels in order to accurately select surgical strategies. (2) R&D of an automatic identification system for gastrointestinal diseases (namely image-assisted diagnosis system of artificial intelligence) initially applies deep neural network of artificial intelligence to the identification of lymph node metastases in rectal cancer, which has achieved accurate clinical diagnosis. (3) The virtual endoscopy platform for the gastrointestinal tract developed can successfully provide a new virtual endoscopy view of the intestinal wall eversion and realize the one-way navigation of the intestinal wall. (4) A localized platform of laparoscopic surgery simulation training is established with completely independent intellectual property rights. We realize that clinical requirement is the source of research and development, clinical practice is the source of innovation, and clinicians are practitioners of transformation of achievements. The establishment of artificial intelligence models often requires the support of massive and high-quality clinical data. Therefore, the effectiveness of its promotion and application can only be ensured by adopting a multi-center research approach. In the whole process of scientific and technological innovation and achievement transformation, the issues of medical ethics and intellectual property rights cannot be ignored.

Introduction: Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP., Area Covered: This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions., Expert Opinion: The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.

Ulcerative colitis (UC) is a chronic inflammatory disorder of poorly understood aetiology. While medical treatment is first-line management, approximately 10% of patients with UC will require a colectomy either as an emergency or elective procedure. There are multiple surgical options available in the current era and the choice of operation(s) is highly dependent on the clinical presentation, patient preference and individual surgeon or institutional practice. We present a review of modern surgical practices in ulcerative colitis, addressing some current controversies and diversities.

Colon and rectal disorders can be functional and inflammatory. This is the second paper of a three-part series14 and will focus on the diagnosis and treatment of rectal prolapse, fecal incontinence and inflammatory bowel disease., (Copyright 2020 by the Missouri State Medical Association.)

Since its introduction in China, the rapid development of robotic surgical system has brought a new trend in gastrointestinal surgery. Although clinical trials have proven its safety and effectiveness compared with traditional laparoscopic surgery, robotic gastrointestinal surgery has no obvious advantages in either short-term efficacy or long-term survival after surgery. Significantly increased costs have not brought corresponding clinical benefits, and that has limited robotic surgery to become the mainstream option for gastrointestinal surgery. In this paper, the clinical findings of robotic gastrointestinal surgery were reviewed, and the application of robotic surgical system in gastrointestinal surgery should be viewed rationally. The majority of gastrointestinal surgeons should not take the so-called "advanced equipment" as a monopolized asset, but choose surgery methods that the patients can benefit from, doctors are satisfied with, and can reflect the best socioeconomic benefits for the patients. With the development of a new generation of robotic surgical system and the support of more high-quality evidence-based medicine, it is believed that robotic gastrointestinal surgery will go towards a better future along a rational and objective track.

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field., Competing Interests: There are no conflicts of interest to declare.

Background: Lifetime risk of surgery in patients with Crohn's disease remains high., Aim: To assess population-level markers of Crohn's disease (CD) in the era of biological therapy., Methods: Population-based cohort study using administrative data from Ontario, Canada including 45 235 prevalent patients in the Ontario Crohn's and Colitis Cohort (OCCC) from 1 April 2003 to 31 March 2014., Results: CD-related hospitalisations declined 32.4% from 2003 to 2014 from 154/1000 (95% confidence interval (CI) [150, 159]) patients to 104/1000 (95% CI [101, 107]) (P < .001). There was a 39.6% decline in in-patient surgeries from 53/1000 (95% CI [50, 55]) to 32/1000 (95% CI [30, 34]) from 2003 to 2014 (P < .001). In-patient surgeries were mostly bowel resections. Out-patient surgeries increased from 8/1000 (95% CI [7, 9]) patients to 12/1000 (95% CI [10, 13]) (P < .001). Out-patient surgeries were largely related to fistulas and perianal disease and for stricture dilations/stricturoplasty. CD-related emergency department (ED) visits declined 28.4% from 141/1000 (95% CI [137, 146]) cases to 101/1000 (95% CI [99, 104]) from 2003 to 2014 (P < .001). Over the same time, patients receiving government drug benefits received infliximab or adalimumab at a combined rate of 2.2% in 2003 which increased to 18.8% of eligible patients by 2014., Conclusions: Rates of hospitalisations, ED visits and in-patient surgeries markedly declined in Ontario over the study period, while rates of biologic medication use increased markedly for those receiving public drug benefits., (© 2019 John Wiley & Sons Ltd.)

Background & Aims: Gastrointestinal (GI) surgery is an important part of the treatment algorithm for patients with Crohn's disease (CD) that is complicated or does not respond to medical therapy. Cohort studies from Denmark and Canada have shown that the risk of primary surgery is decreasing but there is a lack of contemporary data on subsequent resections. We examined trends in first and second GI resections in patients with CD., Methods: We performed a retrospective cohort study using the United Kingdom primary care database ResearchOne, collecting data from patients with Crohn's disease from 1994 through 2013. We compared rates of first and second GI resections with etiological factors., Results: Among 3059 incident cases of CD, 13%, 21%, and 26% of the patients underwent surgical resections after 1, 5, and 10 years, respectively. Of patients with an initial resection, 20% required an additional operation when followed for 10 years after the initial resection. We found a significant reduction in first surgery, from 44% to 21% after 10 years of disease, from 1994 to 2003 (χ 2 for trend, P < .05). There was a significant reduction in second resections, in a 10-year follow-up period, from 40% in 1994 to 17% in 2003 (χ 2 for trend, P < .05). Duration of disease, younger age at diagnosis, smoking, and immunomodulator use were positively associated with first surgeries. Duration of disease was significantly associated with the risk of undergoing a second resection., Conclusion: In a retrospective analysis of a United Kingdom primary care database, we observed a significant reduction in first and subsequent GI surgeries among patients with CD over the past 20 years in England., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Robotic surgery is offered at most major medical institutions. The extent of its use within general surgical oncology, however, is poorly understood. We hypothesized that robotic surgery adoption in surgical oncology is increasing annually, that is occurring in all surgical sites, and all regions of the US., Study Design: We identified patients with site-specific malignancies treated with surgical resection from the National Inpatient Sample 2010-2014 databases. Operations were considered robotic if any ICD-9-CM robotic procedure code was used., Results: We identified 147,259 patients representing the following sites: esophageal (3%), stomach (5%), small bowel (5%), pancreas (7%), liver (5%), and colorectal (75%). Most operations were open (71%), followed by laparoscopic (26%), and robotic (3%). In 2010, only 1.1% of operations were robotic; over the 5-year study period, there was a 5.0-fold increase in robotic surgery, compared to 1.1-fold increase in laparoscopy and 1.2-fold decrease in open surgery (< 0.001). These trends were observed for all surgical sites and in all regions of the US, they were strongest for esophageal and colorectal operations, and in the Northeast. Adjusting for age and comorbidities, odds of having a robotic operation increased annually (5.6 times more likely by 2014), with similar length of stay (6.9 ± 6.5 vs 7.0 ± 6.5, p = 0.52) and rate of complications (OR 0.91, 95% CI 0.83-1.01, p = 0.08) compared to laparoscopy., Conclusions: Robotic surgery as a platform for minimally invasive surgery is increasing over time for oncologic operations. The growing use of robotic surgery will affect surgical oncology practice in the future, warranting further study of its impact on cost, outcomes, and surgical training.

Background: Laparoscopy and more recently robotics are increasingly used for colorectal cancer surgery in the United States. We examined the current trends of minimally invasive surgical resections for colorectal cancer in Florida. Methods: The Florida Inpatient Discharge Dataset was used to examine the clinical data of patients who underwent elective surgery for colorectal cancer during 2013-2015. Multivariate analyses were performed to compare patient characteristics associated with the use of open and minimally invasive surgeries. Results: A total of 10,513 patients were analyzed; 5451 (52%) had open surgery, 4403 (42%) laparoscopy, and 659 (6%) robotic surgery. The rates of minimally invasive surgery (MIS) increased from 46.95% in 2013 to 48.72% in 2015. Among minimally invasive surgical procedures, the use of robotics increased from 9.82% in 2013 to 15.48% in 2015. Metastatic cancer (odds ratio [OR] 0.61, confidence interval [CI] 0.55-0.67), Elixhauser score of 3-5 (OR 0.85, CI 0.76-0.95) or more than 5 (OR 0.78, CI 0.63-0.97), Medicaid insurance (OR 0.73, CI 0.6-0.89), Black race (OR 0.88, CI 0.77-0.99), and rural residence (OR 0.83, CI 0.69-0.99) were associated with lower odds of MIS than open surgery. Conclusions: This study demonstrates that the overall rates of MIS for colorectal cancer in Florida increased from 2013 to 2015. Socially deprived and very sick patient populations with colorectal cancer are less likely to undergo MIS.

Purpose: The purpose of this study was to describe the effect of rigid or flexible stoma bridges used for loop ostomy diversions on peristomal skin integrity. Additional aims were to describe surgeon practices related to stoma bridges, and determine the availability of an ostomy nurse specialist., Design: Retrospective chart review and cross-sectional survey., Sample and Setting: The sample used to address the first aim (effect of stoma bridges) comprised 93 adult patients cared for at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, an acute care facility. Data provided by 355 colorectal surgeons from 30 countries were used to describe surgeon practice in this area and determine the availability of an ostomy nurse specialist. Respondents were invited from an international roster of colorectal surgeons obtained with permission from the American Society of Colon and Rectal Surgeons (ASCRS)., Methods: In order to accomplish the initial aim, we retrospectively reviewed medical records of patients who underwent ostomy surgery from 2008 to 2015 and met inclusion criteria. In order to meet our additional aims, analyzed data were obtained from a survey of colorectal surgeons that queried practices related to stoma bridges, and availability of an ostomy nurse specialist., Results: Patients managed with a rigid bridge were significantly more likely to experience leakage beneath the pouching system faceplate than were patients managed by a flexible bridge (42% vs 11%, P < .001). Slightly less than one quarter of patients who developed leakage (n = 22, 24%) experienced pressure and moisture-related peristomal skin complications. Peristomal wounds, inflammation, and infection were significantly higher when a rigid bridge was used (χ test, P < .003). The surgeon's survey (N = 355) showed variability in the use of bridges. Ninety-three percent of all surgeons indicated an ostomy nurse specialist was part of their health care team., Conclusions: Rigid ostomy bridges were associated with a higher likelihood of leakage from underneath the faceplate of the pouching system and impaired peristomal skin integrity. Analysis of colorectal surgeon responses to a survey indicated no clear consensus related to bridge use in patients undergoing loop ostomies.

Total mesorectal excision (TME) is the gold standard surgical treatment for mid- and low rectal cancer; however, it is associated with specific technical hurdles. Transanal TME (TaTME) is a new procedure developed to overcome these difficulties, through an enhanced visualization of the dissection plane. This potentially could result in a more accurate distal dissection with a lower rate of positive circumferential resection margins, increasing the rate of sphincter-saving procedures. The indications for TaTME are currently expanding, despite not being yet standardized, and structured training programs are ongoing to help overcome the steep learning curve related to the technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates when compared with conventional open or laparoscopic TME. Favorable short-term oncologic results have been reported: in particular, TaTME is associated with mesorectal specimen of a better quality and a longer distal resection margin that is established at the beginning of the procedure under direct view. Robotics, when available, will probably overcome the steep learning curve related to the complexity of TaTME. Long-term follow-up and ongoing RCT trials data are awaited regarding functional results, local recurrence and survival, and to facilitate the comparison with standard laparoscopic or robotic rectal resections. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, its indications, short- and long-term results and future direction in the application of TaTME.

Aim:  Surgical expertise and advances in technical equipment and perioperative management have led to enormous progress in survival and morbidity of patients with esophageal atresia (EA) in the last decades. We aimed to analyze the available literature on surgical outcome of EA for the past 80 years., Materials and Methods:  A PubMed literature search was conducted for the years 1944 to 2017 using the keywords "esophageal/oesophageal atresia," "outcome," "experience," "management," and "follow-up/follow up." Reports on long-gap EA only, non-English articles, case reports, and reviews without original patient data were excluded. We focused on mortality and rates of recurrent fistula, leakage, and stricture., Results:  Literature search identified 747 articles, 118 manuscripts met the inclusion criteria. The first open end-to-end anastomosis and fistula ligation was reported in 1941. Thoracoscopic fistula ligation and primary anastomosis was performed first in 2000. Reported mortality rate decreased from 100% before 1941 to 54% in 1950 to 1959, 28% in 1970 to 1979, 16% in 1990 to 1999, and 9% nowadays. Rates of recurrent fistula varied over time between 4 and 9%. Leakage rate remained stable between 11 and 16%. However, stricture rate increased from 25 to 38%., Conclusion:  Including a full range of articles reflecting the heterogeneity of EA, mortality rate significantly decreased during the course of 80 years. Along with the decrease in mortality, there is a shift to the importance of major postoperative complications and long-term morbidity regardless of surgical technique., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: High perianal fistulas require sphincter-preserving surgery because of the risk of faecal incontinence. The ligation of the intersphincteric fistula tract (LIFT) procedure preserves anal sphincter function and is an alternative to the endorectal advancement flap (AF). The aim of this study was to evaluate outcomes of these procedures in patients with cryptoglandular and Crohn's perianal fistulas., Methods: A systematic literature search was performed using MEDLINE, Embase and the Cochrane Library. All RCTs, cohort studies and case series (more than 5 patients) describing one or both techniques were included. Main outcomes were overall success rate, recurrence and incontinence following either technique. A proportional meta-analysis was performed using a random-effects model., Results: Some 30 studies comprising 1295 patients were included (AF, 797; LIFT, 498). For cryptoglandular fistula (1098 patients), there was no significant difference between AF and LIFT for weighted overall success (74·6 (95 per cent c.i. 65·6 to 83·7) versus 69·1 (53·9 to 84·3) per cent respectively) and recurrence (25·6 (4·7 to 46·4) versus 21·9 (14·8 to 29·0) per cent) rates. For Crohn's perianal fistula (64 patients), no significant differences were observed between AF and LIFT for overall success rate (61 (45 to 76) versus 53 per cent respectively), but data on recurrence were limited. Incontinence rates were significantly higher after AF compared with LIFT (7·8 (3·3 to 12·4) versus 1·6 (0·4 to 2·8) per cent)., Conclusion: Overall success and recurrence rates were not significantly different between the AF and LIFT procedure, but continence was better preserved after LIFT.

"Modern" rectal cancer treatment began in the 18th century. However, initial results of the pioneer surgeons were very poor. During the next several decades, significant progress was made towards the cure of rectal cancer. Improvements have included lowering mortality, reducing recurrence, and optimizing functional outcomes. This article reviews the individuals and their advancements in rectal cancer treatment. It describes the changes in the surgical approach for tumor resection, the study of the lymphatic spread of rectal cancer and the advances in sphincter preservation procedures from the era of blunt dissection until the paradigm changing revolution of total mesorectal excision.

Introduction: Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries., Materials and Methods: The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications., Results: One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively)., Conclusion: We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The term "midlife crisis" was first described in the 1930s by the Swiss psychologist Jung Carl Gustav. He found that although many middle-aged people already had a successful career and a stable family, the crisis of values and beliefs started to appear. If the minimally invasive surgery was a person, he would be 30 years old since 1987 when the first laparoscopic cholecystectomy was successfully performed in the world, and he would be gradually entering the "middle-aged phase", of which the "midlife crisis" is shown as follows: the surgical technique is basically established. Although there are continuous improvements and innovations of surgical techniques, they are only gradual innovations essentially. How can we recognize ourselves and overcome this crisis successfully? Technological change is always spiraling upward, irreversibly, and getting better. Minimally invasive surgical techniques may continue for more than one hundred years. But in the process of the pursuit of minimally invasive surgical techniques development, we should never forget to remain true to our original aspiration, from beyond the technical level to examine the development of technology, because the need of diagnosis and treatment and the quality of life of patients is our ultimate concern. No matter how technology evolves, the patient is always the first. Only with such an original intention can we move forward bravely and overcome the "midlife crisis" in technology.