Endoscopic full-thickness resection versus endoscopic submucosal dissection for challenging colorectal lesions: a randomized trial.

BACKGROUND AND AIMS: The optimal endoscopic resection method of challenging colorectal lesions (ie, adenomatous recurrences, nongranular laterally spreading tumors [LST-NGs], lesions without lifting sign <30 mm) is still under debate. The aim of this study was to directly compare endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) for the resection of challenging colorectal lesions in a randomized trial. METHODS: A multicenter, prospective, randomized study was performed in 4 Italian referral centers. Consecutive patients referred for endoscopic resection of challenging lesions were randomly assigned to undergo EFTR or ESD. Primary outcomes were complete (R0) resection and en bloc resection of lesions. Technical success, procedure time, procedure speed, area of the resected specimen, adverse event rate, and local recurrence rate at 6 months were also compared. RESULTS: Overall, 90 patients were included in the study, equally representing the 3 challenging lesion types. Age and sex were comparable in the 2 groups. En bloc resection was obtained in 95.5% of the EFTR group and in 93.3% of the ESD group. R0 resection rate was comparable in the 2 groups (EFTR vs ESD, 42 [93.3%] vs 36 [80%]; P = .06). The EFTR group exhibited a significantly shorter total procedure time (25.6 ± 10.6 minutes vs 76.7 ± 26.4 minutes, P ≤ .01), as well as overall procedure speed (16.8 ± 11.8 mm2/min vs 11.9 ± 9.2 mm2/min, P = .03). The EFTR group had a significantly smaller mean lesion size (21.6 ± 8.3 mm vs 28.7 ± 7.7 mm, P ≤ .01). Adverse events were reported less frequently in patients in the EFTR group (4.44% vs 15.5%, P = .04). CONCLUSIONS: EFTR is comparable to ESD in the treatment of challenging colorectal lesions in terms of safety and efficacy. EFTR is considerably faster than ESD in the treatment of nonlifting lesions and adenoma recurrences. (Clinical trial registration number: NCT05502276.).

End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience.

BACKGROUND: Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage. METHODS: In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ. RESULTS: The mean operative time to perform the EIPJ was 21.57 ± 3.32 min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery). CONCLUSION: The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.

One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients.

BACKGROUND: Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures. METHODS: All consecutive patients undergoing LERV for CCL between January 2014 and December 2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed. RESULTS: 181 patients were included (61 elective LERVs, 120 emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35 min, and LOS of 4.00 ± 2.82 days. POC included 7 Clavien-Dindo type 1, 11 type 2, and 3 type 3 cases. Seven patients presented with CBD stone recurrence: 2 within 30 days after discharge, 3 within 6 months after discharge, and 2 patients at 1 year. No statistically significant difference was found between elective and emergency patients. CONCLUSION: LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.

Impact of surgical repair on type IV paraesophageal hernias (PEHs).

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.

Intraoperative bowel perfusion quantification with hyperspectral imaging: a guidance tool for precision colorectal surgery.

BACKGROUND: Poor anastomotic perfusion can cause anastomotic leaks (AL). Hyperspectral imaging (HSI), previously validated experimentally, provides accurate, real-time, contrast-free intestinal perfusion quantification. Clinical experience with HSI is limited. In this study, HSI was used to evaluate bowel perfusion intraoperatively. METHODS: Fifty-two patients undergoing elective colorectal surgeries for neoplasia (n = 40) or diverticular disease (n = 12), were enrolled. Intestinal perfusion was assessed with HSI (TIVITA®, Diaspective Vision, Am Salzhaff, Germany). This device generates a perfusion heat map reflecting the tissue oxygen saturation (StO2) amount. Prior to anastomose creation, the clinical transection line (CTL) was highlighted on the proximal bowel and imaged with HSI. Upon StO2 heat map evaluation, the hyperspectral transection line (HTL) was identified. In case of CTL/HTL discrepancy > 5 mm, the bowel was always resected at the HTL. HSI outcomes were compared to the clinical ones. RESULTS: AL occurred in one patient who underwent neoadjuvant radiochemotherapy and ultralow anterior resection for rectal cancer. HSI assessment was feasible in all patients, and StO2-values were significantly higher at proximal segments than distal ones. Twenty-six patients showed CTL/HTL discrepancy, and these patients had a lower mean StO2 (54.55 ± 21.30%) than patients without discrepancy (65.10 ± 21.30%, p = 0.000). Patients undergoing neoadjuvant radiochemotherapy showed a lower StO2 (51.41 ± 23.41%) than non-neoadjuvated patients (60.51 ± 24.98%, p = 0.010). CONCLUSION: HSI is useful in detecting intraoperatively marginally perfused segments, for which the clinical appreciation is unreliable. Intestinal vascular supply is lower in patients undergoing neoadjuvant radiochemotherapy, and this novel finding together with the clinical impact of HSI perfusion quantification deserves further investigation in larger trials.

Preoperative endoscopic marking of the gastrointestinal tract using fluorescence imaging: submucosal indocyanine green tattooing versus a novel fluorescent over-the-scope clip in a survival experimental study.

BACKGROUND: Intraoperative localization of endoluminal lesions is can be difficult during laparoscopy. Preoperative endoscopic marking is therefore necessary. Current methods include submucosal tattooing using visible dyes, which in case of transmural injection can impair surgical dissection. Tattooing using indocyanine green (ICG) coupled to intraoperative near-infrared (NIR) laparoscopy has been described. ICG is only visible under NIR-light, therefore, it doesn't impair the surgical workflow under white light even if there is spillage. However, ICG tattoos have rapid diffusion and short longevity. We propose fluorescent over-the-scope clips (FOSC), using a novel biocompatible fluorescent paint, as durable lesion marking. METHODS: In six pigs, gastric and colonic endoscopic tattoos using 0.05 mg/mL of ICG and markings using the fluorescent OSC were performed (T0). Simultaneously, NIR laparoscopy was executed. Follow-up laparoscopies were conducted at postoperative day (POD) 4-6 (T1) and POD 11-12 (T2). During laparoscopy, fluorescence intensity was assessed. In one human cadaver, FOSC was used to mark a site on the stomach and on the sigmoid colon, respectively. Intraoperative detection during NIR laparoscopy was assessed. RESULTS: Gastric and colonic ICG tattooing and OSC markings were easily visible using NIR laparoscopy on T0. All FOSC were visible at T1 and T2 in both stomach and colon, whereas the ICG tattooing at T1 was only visible in the stomach of 2 animals and in the colon of 3 animals. At T2, tattoos were not visible in any animal. FOSC were still visible in both stomach and colon of the human cadaver at 10 days. CONCLUSION: Endoscopic marking using FOSC can be an efficient and durable alternative to standard methods.

Quantitative serosal and mucosal optical imaging perfusion assessment in gastric conduits for esophageal surgery: an experimental study in enhanced reality.

INTRODUCTION/OBJECTIVE: Gastric conduit (GC) is used for reconstruction after esophagectomy. Anastomotic leakage (AL) incidence remains high, given the extensive disruption of the gastric circulation. Currently, there is no reliable method to intraoperatively quantify gastric perfusion. Hyperspectral imaging (HSI) has shown its potential to quantify serosal StO2. Confocal laser endomicroscopy (CLE) allows for automatic mucosal microcirculation quantification as functional capillary density area (FCD-A). The aim of this study was to quantify serosal and mucosal GC's microperfusion using HSI and CLE. Local capillary lactate (LCL) served as biomarker. METHODS: GC was formed in 5 pigs and serosal StO2% was quantified at 3 regions of interest (ROI) using HSI: fundus (ROI-F), greater curvature (ROI-C), and pylorus (ROI-P). After intravenous injection of sodium-fluorescein (0.5 g), CLE-based mucosal microperfusion was assessed at the corresponding ROIs, and LCLs were quantified via a lactate analyzer. RESULTS: StO2 and FCD-A at ROI-F (41 ± 10.6%, 3.3 ± 3.8, respectively) were significantly lower than ROI-C (68.2 ± 6.7%, p value: 0.005; 18.4 ± 7, p value: 0.01, respectively) and ROI-P (72 ± 10.4%, p value: 0.005; 15.7 ± 3.2 p value: 0.001). LCL value at ROI-F (9.6 ± 4.7 mmol/L) was significantly higher than at ROI-C (2.6 ± 1.2 mmol/L, p value: 0.04) and ROI-P (2.6 ± 1.3 mmol/L, p value: 0.04). No statistically significant difference was found in all metrics between ROI-C and ROI-P. StO2 correlated with FCD-A (Pearson's r = 0.67). The LCL correlated negatively with both FCD-A (Spearman's r = - 0.74) and StO2 (Spearman's r = - 0.54). CONCLUSIONS: GC formation causes a drop in serosal and mucosal fundic perfusion. HSI and CLE correlate well and might become useful intraoperative tools.

Percutaneous transhepatic cholangioscopy using a single-operator cholangioscope (pSOC), a retrospective, observational, multicenter study.

BACKGROUND AND AIMS: Percutaneous cholangioscopy (PC) is more complex and invasive than a transpapillary approach, with the need for a large percutaneous tract of 16 French (Fr) on average in order to advance standard percutaneous cholangioscopes. The aim of this study was to investigate whether percutaneous single-operator cholangioscopy (pSOC) using the SpyGlass™ DS system is feasible, safe, and effective in PC for diagnostic and therapeutic indications. MATERIALS AND METHODS: The data of 28 patients who underwent pSOC in 4 tertiary referral centers were retrospectively analyzed. Technical and clinical success for therapeutic procedures was assessed as well as diagnostic accuracy of pSOC-guided biopsies and visualization. Adverse events and the required number and size of dilatations were reviewed. RESULTS: 25/28 (89%) patients had a post-surgical altered anatomy. The average number of percutaneous dilatations prior to pSOC was 1.25 with a mean dilatation size of 11 French. Histopathology showed a 100% accuracy. Visual impression showed an overall accuracy of 96.4%. Technical and clinical success was achieved in 27/28 (96%) of cases. Adverse events occurred in 3/28 (10.7%) cases. CONCLUSION: pSOC is a feasible, safe, and effective technique for diagnostic and therapeutic indications. It may be considered an alternative approach in clinical cases where gastrointestinal anatomy is altered. It has the potential to reduce peri-procedural adverse events and costs. Prospective randomized-controlled trials are necessary to confirm the previously collected data.

Hyperspectral Imagery for Assessing Laser-Induced Thermal State Change in Liver.

This work presents the potential of hyperspectral imaging (HSI) to monitor the thermal outcome of laser ablation therapy used for minimally invasive tumor removal. Our main goal is the establishment of indicators of the thermal damage of living tissues, which can be used to assess the effect of the procedure. These indicators rely on the spectral variation of temperature-dependent tissue chromophores, i.e., oxyhemoglobin, deoxyhemoglobin, methemoglobin, and water. Laser treatment was performed at specific temperature thresholds (from 60 to 110 °C) on in-vivo animal liver and was assessed with a hyperspectral camera (500-995 nm) during and after the treatment. The indicators were extracted from the hyperspectral images after the following processing steps: the breathing motion compensation and the spectral and spatial filtering, the selection of spectral bands corresponding to specific tissue chromophores, and the analysis of the areas under the curves for each spectral band. Results show that properly combining spectral information related to deoxyhemoglobin, methemoglobin, lipids, and water allows for the segmenting of different zones of the laser-induced thermal damage. This preliminary investigation provides indicators for describing the thermal state of the liver, which can be employed in the future as clinical endpoints of the procedure outcome.

Prediction of In Vivo Laser-Induced Thermal Damage with Hyperspectral Imaging Using Deep Learning.

Thermal ablation is an acceptable alternative treatment for primary liver cancer, of which laser ablation (LA) is one of the least invasive approaches, especially for tumors in high-risk locations. Precise control of the LA effect is required to safely destroy the tumor. Although temperature imaging techniques provide an indirect measurement of the thermal damage, a degree of uncertainty remains about the treatment effect. Optical techniques are currently emerging as tools to directly assess tissue thermal damage. Among them, hyperspectral imaging (HSI) has shown promising results in image-guided surgery and in the thermal ablation field. The highly informative data provided by HSI, associated with deep learning, enable the implementation of non-invasive prediction models to be used intraoperatively. Here we show a novel paradigm "peak temperature prediction model" (PTPM), convolutional neural network (CNN)-based, trained with HSI and infrared imaging to predict LA-induced damage in the liver. The PTPM demonstrated an optimal agreement with tissue damage classification providing a consistent threshold (50.6 ± 1.5 °C) for the damage margins with high accuracy (~0.90). The high correlation with the histology score (r = 0.9085) and the comparison with the measured peak temperature confirmed that PTPM preserves temperature information accordingly with the histopathological assessment.

COVID-19 Efforts at the Institute of Image Guided Surgery (IHU-Strasbourg): 2020.

We submit a summary of some of the activities of the IHU-Strasbourg during the initial period of the COVID-19 pandemic. These were presented as part of the coronnavation effort coordinated by Dr Adrian Park. Three initiatives are presented as follows: Protect-Est App, healthcare worker stress, and converted diving mask for ventilation. Two of the 3 projects are still ongoing, and one (Predoict-Est) has been adopted nationally.

Does endoscopic sleeve gastroplasty stand the test of time? Objective assessment of endoscopic ESG appearance and its relation to weight loss in a large group of consecutive patients.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is a promising bariatric treatment. Gastric volume reduction and delayed gastric emptying are the probable mechanisms driving weight loss. However, there are concerns regarding the overtime ESG effectiveness. This study aims to evaluate the correlation between endoscopic gastroplasty integrity overtime and weight loss. PATIENTS AND METHODS: Patients undergoing follow-up endoscopy (6 and 12 months) after ESG were included. ESG were classified in three groups according to endoscopic appearance: open when all the stiches were loose; partially intact if at least one stitch was loose; intact if all the stitches were present and tight. Initial BMI, excess weight loss (%EWL) and total weight loss (%TWL) at 6 and 12 months were assessed against gastroplasty endoscopic appearance. RESULTS: From October 2016 to April 2019, 133 patients underwent ESG, 87 (65.4%) had a follow-up EGD at 6 months. ESG was open in six cases (6.9%), partially intact in 38 (43.7%) and intact in 43 (49.4%). The overall %EWL and %TWL was 34.5 ± 19.8 and 13.2 ± 7.4, respectively; 25.7 ± 26.9 and 11.8 ± 11.8 for the open group, 30.8 ± 20.1 and 12.4 ± 7.8 for the partially intact group; 39.1 ± 19.7 and 14.0 ± 6.4 for the intact gastroplasty. Forty-one patients underwent a 12 months endoscopy: 10 (24.4%) had an intact ESG, 24 (58.5%) had a partially intact gastroplasty, and in 7 (17.0%) cases the sutures were lost. Overall %EWL and %TWL at 12 months was 34.3 ± 21.9 and 13.1 ± 8.1: 19.3 ± 13.4 and 8.9 ± 6.1 for the open group; 36.0 ± 24.2 and 13.1 ± 8.9 for the partially intact group; 40.3 ± 17.3 and 17.2 ± 5.4 for the intact group. ESG appearance correlated with preoperative BMI (r 0.34; p 0.001) and %EWL at 6 months (r 0.22; p 0.035) and 12 months (r 0.29; p 0.065). CONCLUSION: This preliminary work shows that weight loss correlates with ESG endoscopic appearance over time. Initial BMI predicts endoscopic suture duration over time. Larger studies and longer follow-up are needed.

Hybrid fluorescent magnetic gastrojejunostomy: an experimental feasibility study in the porcine model and human cadaver.

BACKGROUND: Laparoscopic gastrojejunostomies are time consuming and require a specific training. Alternatively, sutureless anastomosis can be achieved using endoscopically delivered magnetic rings. Our aim was to assess the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using a pair of magnets coated with a near-infrared fluorescent biocompatible polymeric material. METHODS: Five pigs (3 acute and 2 survival models) and one human anatomical specimen were included. In the survival models, the distal ring was inserted into the duodenum endoscopically, and it was fixed to a thread clipped to the gastric mucosa. Twenty-four hours later, a two-port laparoscopy was performed using a near-infrared (NIR) laparoscope. The magnet position in the jejunum was detected with the transluminal fluorescence of the dye. Magnetic interaction with the metallic tip of the laparoscopic grasper allowed to capture the ring and bring the bowel loop to the future anastomotic site on the gastric wall. The proximal magnet was inserted into the stomach endoscopically and released when magnetic interaction started, allowing for a precise connection with the distal ring. The animals were followed up for 12 days and underwent control endoscopies and radiograms. In the acute animals, the anastomotic procedure was repeated 24 times. Finally, the procedure was performed in the human anatomical specimen. RESULTS: There were no technical problems, and magnetic connection could be precisely directed at both the anterior and posterior gastric walls. No complications occurred during the survival period and the anastomoses were patent on day 5. Transluminal fluorescence enabled a rapid detection of the magnet. CONCLUSIONS: Hybrid-reduced port magnetic gastrojejunostomy using a pair of fluorescently coated magnetic rings was feasible, reproducible, and easy to perform in both porcine and cadaver models.

EUS-guided trans-esophageal drainage of a mediastinal necrotic fluid collection using the axios electrocautery enhanced delivery system™.

Mediastinal collection secondary to necrotic acute pancreatitis, is an extremely rare event caused by the posterior rupture of the pancreatic duct into the retroperitoneal space with the penetration of the pancreatic fluid through the diaphragmatic orifices. Infection of the necrotic collection may occur with a consequent substantial increase of the mortality rate. Due to the rarity of this severe condition, no consensus is known about the management of infected mediastinal necrotic collections. We reported the case of a 61-year-old male who was critically unwell secondary to a large mediastinal necrotic collections after necrotic acute pancreatitis with no improvement after surgery. The patient was successfully treated by EUS-guided trans-esophageal drainage using the AXIOS Electrocautery Enhanced Delivery System™. This procedure proved in this case to be a safe and effective option for the management of infected necrotic mediastinal collections.

Feasibility of EUS-guided Nd:YAG laser ablation of unresectable pancreatic adenocarcinoma.

BACKGROUND AND AIMS: EUS has become an interventional technique in which a needle may be used as a vehicle to deliver therapeutic agents. Laser ablation (LA) has been used to treat many primary and secondary neoplasms. This study aimed to assess the feasibility of EUS-guided LA for unresectable (UR) pancreatic cancer. METHODS: Patients with stage IIb-III pancreatic cancer underwent EUS-guided LA. All patients were unresponsive to previous chemoradiotherapy. LA was performed by using a 300-µm flexible fiber preloaded onto a 22-gauge fine needle. A 1064-nm wavelength neodymium-yttrium aluminum garnet (Nd:YAG) laser light with different power settings of 2 W for 800 J, 1000 J, and 1200 J; 3 W for 800 J, 1000 J, and 1200 J; and 4 W for 800 J, 1000 J, and 1200 J was used. Each patient was treated with a single application of 1 of these settings. The application time of the power settings ranged from 200 to 600 seconds. RESULTS: Nine patients (median age, 74.7; range 55-85) underwent Nd:Yag LA. The mean size of the focal lesion was 35.4 mm (range, 21-45). The ablation area, demonstrated by 24-hour CT, ranged from .4 cm3 (for the lower power setting of 2 W/800 J) to a maximum of 6.4 cm3 (for 4 W/1000 J). The procedure was completed in all 9 patients without adverse events. CONCLUSION: In our human experience, EUS-guided LA was feasible and well tolerated in patients with UR pancreatic cancer.

Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature.

BACKGROUND AND AIM: Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting. PATIENTS AND METHOD: Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal. RESULTS: Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6-10 mm, 4-8 cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2-105) days. The median hospital stay was of 10 (4-21) days. Median time to post-operative feeding was 4 days (2-15). CONCLUSION: FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.

Endoscopic management with multiple plastic stents of anastomotic biliary stricture following liver transplantation: long-term results.

BACKGROUND AND AIMS: Anastomotic biliary stricture (ABS) is the most common biliary complication after orthotopic liver transplantation (OLT) and can be successfully managed endoscopically. The long-term results of a protocol using placement of multiple plastic stents to treat ABS following OLT were analyzed. METHODS: All patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for OLT-related biliary complications at our Endoscopy Unit between July 1994 and March 2012 were retrospectively identified from the ERCP database. Patients with an ABS treated with an increasing number of plastic stents were included in the study. Follow-up after stent removal was obtained by telephone contact with the patient and/or referring physician and by liver function tests (LFTs) evaluation. RESULTS: 56 patients, treated with an increasing number of plastic stents until resolution of the stricture, were included. Five patients were then excluded (unrelated death during treatment, n = 3; incomplete treatment because of poor compliance, n = 2), and 51/56 patients reached study end points and were included in the analysis. Resolution of ABS was obtained in 50/51 patients; 1 patient required hepaticojejunostomy because of failure to pass the stricture with the guidewire (per protocol resolution, 98 %). Mean duration of endoscopic treatment was 11.5 months, with a median 4 ERCPs per patient. Immediate ERCP-related adverse events occurred in 3/56 patients (5.4 %). After a median follow-up of 5.8 years from stent removal, 3/50 patients (6 %) had recurrence of ABS. These 3 patients were successfully treated again endoscopically and are asymptomatic after a further median follow-up of 5.6 years. CONCLUSIONS: At long-term follow-up, endoscopic treatment with multiple plastic stents of ABS following OLT appeared to be effective in most patients. Stricture recurrence is rare and can be successfully treated again endoscopically.

Inframesocolic main pancreatic vessels-first approach for minimally invasive radical antegrade modular pancreaticosplenectomy (RAMPS): technical description and first experience.

Radical modular antegrade pancreaticosplenectomy (RAMPS) improves posterior tumor-free margins during resections of pancreatic neoplasia involving the body or tail. However, minimally invasive RAMPS is technically challenging and has been reported seldom. We present for the first time a minimally invasive RAMPS technique with an innovative approach providing early dissection and control of the main peripancreatic vessels from an inframesocolic embryonal window, suitable for laparoscopy and robotics. Minimally invasive RAMPS with inframesocolic main pancreatic vessels-first approach was performed at the Tricase Hospital (Italy) from May 2017 to April 2022 in 11 consecutive patients with neoplastic lesions of the pancreas (8 laparoscopic RAMPS and 3 robotic RAMPS). Among the laparoscopic cases, 1 included a portal vein tangential resection and 1 a celiac artery resection (modified Appleby procedure). There were no conversions, no Clavien-Dindo complications > 2, all resections' margins were tumor free, and no 90-day mortality.

Democratizing Flexible Endoscopy Training: Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam.

BACKGROUND: 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). STUDY DESIGN: 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. RESULTS: 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; p < 0.001). CONCLUSIONS: 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.