An endoscopically compatible fast-gelation powder forms Janus-adhesive hydrogel barrier to prevent postoperative adhesions.

Postoperative adhesions occur widely in various tissues, bringing the risk of secondary surgery and increased medical burden. Hydrogel barriers with Janus-adhesive ability can achieve physical isolation of adjacent tissues and are therefore considered an ideal solution. However, integrating endoscopic delivery convenience and viscoelastic Janus hydrogel formation remains a great challenge. Here, we present a report of the in situ formation of Janus-adhesive hydrogel barrier using a sprayable fast-Janus-gelation (FJG) powder. We first methacrylate the polysaccharide macromolecules to break the intermolecular hydrogen bonds and impart the ability of rapid hydration. FJG powder can rapidly absorb interfacial water and crosslink through borate ester bonds, forming a toughly adhesive viscoelastic hydrogel. The Janus barrier can be simply formed by further hydrating the upper powder with cationic solution. We construct rat models to demonstrate the antiadhesions efficiency of viscoelastic FJG hydrogels in organs with different motion modalities (e.g., intestine, heart, liver). We also developed a low-cost delivery device with a standardized surgical procedure and further validated the feasibility and effectiveness of FJG powder in minimally invasive surgery using a preclinical translational porcine model. Considering the advantages in terms of therapeutic efficacy, clinical convenience, and commercialization, our results reveal the great potential of Janus-gelation powder materials as a next-generation antiadhesions barrier.

Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial.

BACKGROUND: Intracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy. METHODS: In this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0-2 at the 6-month follow-up. RESULTS: A total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000). CONCLUSIONS: Compared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02811614.

Gasless Single-Incision Endoscopic Surgery via Subclavicular Approach for Lateral Neck Dissection in Patients with Papillary Thyroid Cancer.

BACKGROUND: The technical difficulties and trauma of remote access methods in endoscopic surgery (ES) for lateral neck dissection (LND) can be daunting for most patients with papillary thyroid cancer (PTC) and surgeons. The purpose of study was to introduce gasless single-incision ES via a subclavicular approach (ESSA) and to explore its safety and efficacy for LND. METHODS: Between January 2022 and February 2023, we retrospectively reviewed 17 patients with PTC who underwent ESSA for LND. In addition, 22 patients who received video-assisted ES (VAES) and 48 patients who underwent open surgery (OP) for LND during the same period were included. Clinicopathological characteristics, complications, and efficacy of the lymph node yield (LNY) were compared between the ESSA and the other two groups (VAES and OP). RESULTS: The LNY from central and lateral neck dissection by ESSA was comparable to that by VAES (9.2 ± 8.1 vs. 9.5 ± 4.2, P = 0.986, and 33.5 ± 11.6 vs. 30.6 ± 9.2, P = 0.382, respectively) and OP (9.2 ± 8.1 vs. 11.0 ± 5.4, P = 0.420, and 33.5 ± 11.6 vs. 31.5 ± 7.9, P = 0.383, respectively). Swallowing impairment scores at 1 and 3 months were significantly lower after ESSA than those after VAES (1.8 ± 1.0 vs. 3.0 ± 1.2, P = 0.003, and 0.9 ± 0.8 vs. 1.7 ± 0.8, P = 0.006, respectively). The cosmetic satisfaction rate 1 month after surgery was significantly higher in the ESSA group than that in the VAES group (100 vs. 31.8%, P < 0.001). CONCLUSIONS: ESSA is a safe and minimally invasive procedure that provides a scarless cervical appearance and has good efficacy for LND. Therefore, ESSA may be a feasible choice for selected patients with N1b PTC with cervical cosmetic needs.

An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis.

PURPOSE: Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis. METHODS: Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%. RESULTS: The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments. CONCLUSIONS: This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis.

PURPOSE: We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors. METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design). RESULTS: A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively. CONCLUSIONS: The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

Postoperative fever and clinical outcomes after endoscopic surgery for spontaneous intracerebral hemorrhage: a retrospective database study.

BACKGROUND: Spontaneous intracerebral hemorrhage (SICH) is a severe stroke with high mortality and disability rates. Endoscopic surgery is an increasingly widely used minimally invasive method for the treatment of SICH. However, the impact of fever on patient outcomes remains unclear. METHODS: We retrospectively included patients aged 18 years or older with supratentorial SICH confirmed by CT, who underwent endoscopic hematoma evacuation within 48 h of symptom onset. The primary outcome was the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes included hospital and neurosurgical intensive care unit (NSICU) stays, and perioperative complications. We analyzed the association between postoperative fever (highest temperature within 24 h after surgery) and these outcomes using multivariate analysis, generalized additive models, and segmented regression analysis. RESULTS: Of the 56 patients, 38 had favorable outcomes (mRS ≤ 3) and 18 had unfavorable outcomes (mRS > 3) at 3 months. A threshold effect at 38.2 °C was observed between postoperative body temperature and clinical outcomes. The mean age was 56 years (SD = 9) for the > 38.2 °C group and 58 years (SD = 8) for the ≤ 38.2 °C group, with a similar proportion of male patients (63% vs. 69%, P = 0.635). Patients with postoperative fever had larger hematoma volumes (65 vs. 56 mL; P = 0.008). Other characteristics were similar between the groups. Postoperative fever (> 38.2 °C) was independently associated with a 4.99-fold increased risk of unfavorable outcomes (95% CI = [1.13 to 25.90]; P = 0.040), which remained significant after excluding patients with postoperative complications (adjusted RR = 16.03, 95% CI = [1.69 to 417.24]; P = 0.033). The association was consistent across subgroups with different Glasgow Coma Scale scores, hematoma volumes, and intraventricular extension. Postoperative fever was also associated with longer NSICU stays (3.1 vs. 2.3 days; P = 0.023), longer hospital stays (17.2 vs. 13.6 days; P = 0.010), more residual hematoma, and greater edema volume. Different antipyretic therapies did not affect outcomes. CONCLUSIONS: This study identifies a temperature threshold (38.2 °C) associated with poor outcomes in SICH patients undergoing endoscopic surgery. Further research is needed to mitigate postoperative fever and improve patient outcomes.

Development of an evaluation and treatment strategy for olfactory neuroblastoma: a review of evidence from large-scale studies, including population-based and multicenter studies, and meta-analyses.

Olfactory neuroblastoma is a rare sinonasal malignancy arising from the olfactory epithelium that is characterized by skull base involvement and a modest natural history. Because of its rarity and long course, identification of independent prognostic factors is dependent on multivariate analysis of large, long-term data. In this review, we outline evidence for the evaluation and treatment of olfactory neuroblastoma obtained from recent large-scale population-based studies, meta-analyses and multicenter studies. Hyams grade is currently the only pathological grade system for olfactory neuroblastoma. The modified Kadish staging and Dulguerov classification are available for clinical staging. The results of large-scale studies have confirmed Hyams, the modified Kadish and Dulguerov as independent prognostic factors. Surgery followed by radiotherapy provides the best overall survival and recurrence-free survival for resectable disease. The question of whether postoperative radiotherapy should be administered for all cases or only for those at risk of recurrence remains unanswered. Exclusively endoscopic resection is indicated for modified Kadish A/B cases without any increase in the risk of death or recurrence, and is also indicated for modified Kadish C cases if a negative surgical margin is ensured. For more advanced cases, such as those with extensive brain infiltration, the open approach is indicated. Elective nodal irradiation prevents late nodal recurrence of N0 patients. Chemotherapy has failed to show a benefit in survival or disease control. Current needs for olfactory neuroblastoma include the development and validation of refined staging systems suitable for current practice; expansion of indications for endoscopic surgery; less invasive surgery; definitive radiotherapy and novel systemic therapy.

Utilizing sentiment analysis of X data to document the evolution of colorectal surgical innovations: The case of transanal total mesorectal excision.

AIM: The evolution of the utility of medical social media and its global reach has led to a much greater speed of dissemination of medical innovation, such as transanal total mesorectal excision (TaTME). The acceptability and discussions surrounding such innovations can be followed online. Here, we sought to determine if online discussions over time could match known models of innovation evolution using the example of TaTME since its initial description in 2010. METHODS: Data on using the X hashtag #TaTME were analysed using the social media analytics tool Brandwatch. Trends in mentions, impressions and reach were highlighted over 13 years (1 May 2010 to 31 July 2023). Each mention's sentiment and emotional connotations were analysed using Brandwatch's natural language processing approach. RESULTS: We identified 18 525 mentions of #TaTME by healthcare professionals, reaching over 30.6 million X users. A Gartner's hype-cycle-like pattern was identified for mention volume and emotional connotation over time. The majority of mentions had a neutral (84%; n = 15 341) or positive connotation (15%, n = 2675). A peak of negatively connotated mentions was identified surrounding the temporary suspension of TaTME in 2019. CONCLUSION: This study presents a novel method of monitoring online discussions surrounding new surgical innovations by healthcare professionals based on sentiment analysis of public social media data. Mention volume and emotional connotation were the most accurate parameters closely resembling Gartner's hype cycle.

Vascular anomalies of the limb and trunk in children: a retrospective comparative study of endoscopic surgery and open surgery.

BACKGROUND: Endoscopic resection has been reported for vascular anomalies (VA) previously. However, there is no study comparing endoscopic resection surgery (ERS) with open resection surgery (ORS) in children. We aimed to compare clinical and cosmetic outcomes between two approaches in pediatric VA. METHODS: Between June 2018 and June 2023, 138 pediatric VA patients undergoing ERS or ORS were retrospectively reviewed. Propensity score matching (PSM) was performed to minimize selection bias. The Scar Cosmesis Assessment and Rating (SCAR) Scale and numerical rating scale (NRS) based on patient satisfaction were used for cosmetic assessment. RESULTS: After PSM for age, depth of lesion, size of lesion, and site of surgery, 72 patients (ERS = 24, ORS = 48) were analyzed. Patients undergoing ERS had longer operative time (164.25 ± 18.46 vs. 112.85 ± 14.26 min; P < 0.001), less estimated blood loss (5.42 ± 2.15 vs. 18.04 ± 1.62 ml; P < 0.001), and shorter median hospital stay (4.50 [3.00-5.00] vs. 6.00 [5.00-6.00] days; P < 0.001). The follow-up time was 8.04 ± 1.23 month for ERS group and 8.56 ± 1.57 month for ORS group. For aesthetic results, the median overall SCAR score in ERS was lower than that in ORS (2 [1-3] vs. 5 [4-5]; P < 0.001), and the subscales of "scar spread," "dyspigmentation," "track marks or suture marks," and "overall impression" were better. The median NRS score was higher (8 [7-8] vs. 6 [5-6]; P < 0.001) and length of scars was shorter (2.18 ± 0.30 vs. 8.75 ± 1.98 cm; P < 0.001) in ERS group than those in ORS group. The incidences of total complications and recurrence showed no significant difference between two groups. CONCLUSIONS: Endoscopic surgery can be a safe and effective option for pediatric VA in the limbs and trunk. It offers the advantages of improving aesthetic outcomes and reducing postoperative wound healing time.

Incidence of post-operative nausea and vomiting after endoscopic bariatric and metabolic therapy procedures and the role of neurokinin-1 receptor antagonists: a retrospective cohort study.

BACKGROUND: Both the transoral gastric reduction (TORe) and endoscopic sleeve gastroplasty (ESG) procedures are novel endoscopic bariatric and metabolic therapies (EBMT). Our practice has an aggressive approach to prophylaxis of postoperative nausea and vomiting (PONV) for EBMT cases, but there is divergence of practice regarding use of prophylactic neurokinin-1 receptor (NK-1) antagonists (aprepitant, fosaprepitant). Herein, we determined the incidence of PONV and its potential association with NK-1 antagonist administration following EBMT. METHODS: We identified and reviewed medical records of patients who underwent EBMT between 2018 and 2023. Patients were divided into those administered or not administered an NK-1 antagonist. We analyzed rates of PONV, which was defined as rescue antiemetics during anesthesia recovery. A propensity score was calculated, and outcomes were assessed using generalized estimating equations with inverse probability of treatment weighting (IPTW). RESULTS: We identified 404 patients undergoing EBMT (256 [63%] TORe, 148 [37%] ESG), and of these 253 patients developed PONV, (62.6% [95% CI: 57.9% to 67.3%]). NK-1 antagonists were administered to 119 (29.5%) patients. PONV was experienced by 42 (35%) and 211 (74%) of patients who were or were not administered an NK-1 antagonist, respectively (IPTW OR = 0.18, [95%CI: 0.10 to 0.31], P < 0.001). CONCLUSIONS: EBMT has a high incidence of PONV during anesthesia recovery. Administration of a NK-1 antagonist as part of a multiagent PONV prophylaxis regimen dramatically reduces risk for this common adverse event.

A snapshot audit of global flexible endoscopy practice among European Association of Endoscopic Surgeons (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) surgeons from the EAES Flexible Endoscopy Subcommittee survey.

INTRODUCTION: Endoscopy is an essential skill for all surgeons. However, endoscopic competency, training, and practice may vary widely among them. The EAES Flexible Endoscopy Subcommittee is working towards a standardized set of fundamental endoscopic knowledge and skills. To best advise on current practice patterns of flexible endoscopy among surgeons worldwide, a snapshot audit was conducted on the training, use, and limitations of flexible endoscopy in practice. METHODS: An online survey was distributed via email distribution and social media platforms for EAES, SAGES, and WebSurg members. Respondent demographics, training, and practice patterns were assessed. The main outcome measure was the annual endoscopic volume. Multivariate regression and machine learning models analyzed relationships between outcomes and independent variables of age, geographic region, laparoscopic surgery practice, and surgical specialization. RESULTS: A total of 1486 surgeons from 195 countries completed the survey. Respondents were mainly general (n = 894/1486, 60.2%), colorectal (n = 189/1486, 12.7%), bariatric (n = 117/1486, 7.9%), upper gastrointestinal (GI)/foregut (n = 108, 7.3%), hepatobiliopancreatic/HPB (n = 59/1486, 4%), and endocrine surgeons (n = 11/1486, 0.7%) in active practice. Eighty-two percent (n = 1,204) mentioned having used endoscopy in their practice, and 64.7% (n = 961/1486) received formal flexible endoscopy training. Of those performing endoscopy annually, 64.2% (n = 660/1486) performed between 0 and 20 endoscopies, 15.2% (n = 156/1486) performed between 20 and 50 endoscopies, 10.1% (n = 104/1486) performed between 50 and 100 endoscopies, and 10.5% (n = 108/1486) performed over 100 endoscopies. From the regression analysis, there was no statistical correlation between the annual endoscopy volume and age, geographic region, laparoscopic surgery practice, or surgical specialization. Performing advanced endoscopy was directly related to the bariatric subspecialty and to performing over 50% of cases in a minimally invasive fashion. CONCLUSIONS: This international snapshot audit revealed significant heterogeneity in endoscopic practices among surgeons worldwide. There was a nonindependent relationship between endoscopy volumes and other variables tested. Barriers to practicing and receiving endoscopy training were common among respondents. The EAES Flexible Endoscopy Subcommittee will consider such results when developing an equitable and effective standardized flexible endoscopy curriculum.

Changes in pituitary adenoma patient presentation and outcomes during the COVID pandemic at a Pituitary Center of Excellence.

PURPOSE: The COVID-19 pandemic caused significant disruption to the surgical care of patients. The aim of this study was to analyze the impact of the pandemic on endoscopic endonasal surgery (EES) for patients with a pituitary adenoma. METHODS: Patients from 2015 to 2022 that had EES for a pituitary adenoma were included in this study. Patients were separated into pre-COVID (January 2015-March 2020) and COVID (March 2020-September 2022) groups. Univariate analysis was done using chi-square, fisher exact tests, and t-tests to compare groups. RESULTS: This study included 492 patients that had EES for their pituitary adenoma. There were 314 patients in the pre-COVID group and 178 patients in the COVID group. Patients in the COVID group had a higher risk analysis index (RAI) frailty score (15 ± 10 pre-COVID vs. 20 ± 9 COVID, P < 0.001) and a higher American Society of Anesthesiology (ASA) physical status score (3 or 4) (72.0% pre-COVID vs. 81.9% COVID, P = 0.02). There were significantly more macroadenoma cases (87.6% pre-COVID vs. 94.4% COVID, P = 0.02) and extrasellar surgical approaches (45.2% pre-COVID vs. 61.2% COVID, P < 0.001) during COVID. There was no significant difference in length of stay (LOS) and readmission rates between groups. CONCLUSIONS: Patients that presented during the pandemic tended to be more frail, have more comorbidities, and require additional extrasellar surgical approaches. Despite changes in clinical presentation and operative management, the LOS and readmission rate remained stable during COVID, supporting the safety of this procedure during the recent pandemic.

Incidence of postoperative hyponatremia after endoscopic endonasal pituitary transposition for skull base pathologies.

PURPOSE: Pituitary transposition is a novel surgical approach to access the retroinfundibular space and interpeduncular cistern. Few studies have evaluated post-surgical outcomes, including incidence of hyponatremia, following pituitary transposition. METHODS: This is a retrospective study including 72 patients who underwent endoscopic endonasal surgery involving pituitary transposition for non-pituitary derived tumors over a decade at the University of Pittsburgh Medical Center. Anterior pituitary deficiencies and replacement therapy, tumor pathology and pre-operative serum sodium (Na) were recorded. Na was assessed at postoperative day 1, 3, 5, 7, and 10. Anatomical/surgical parameters included sellar height, sellar access angle to approach the tumor, and cranial extension of the tumor above the sellar floor (B) compared to the height of the gland (A) (B/A). T-test (normally distributed variables) and Wilcoxon rank-sum test (not-normally distributed) were applied for mean comparison. Logistic regression analyzed correlations between anatomical/surgical parameters and postoperative hyponatremia. RESULTS: 55.6% of patients developed post-operative transient hyponatremia. Two patients (5%) developed severe hyponatremia (sodium level < 120 mmol/L). Eleven (15.3%) patients required desmopressin replacement immediately post-operatively, and 2 other patients needed desmopressin after discharge and after sodium nadir developed. Hyponatremia was inversely associated with sellar access angle (p = 0.02) and the tumor cranial extension above the sellar floor showing a trend towards significance (p = 0.09). CONCLUSION: More than half of patients who had pituitary transposition developed transient hyponatremia. Hyponatremia was more common in those with narrower sellar access angle and smaller cranial extension of the tumor above the sellar floor. Anatomical/surgical parameters may allow risk-stratification for post-operative hyponatremia following pituitary transposition.

Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent Cushing's disease: safety, feasibility, and success.

PURPOSE: The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS: A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS: Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION: Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.

vNOTES versus Laparoscopic Uterosacral Ligament Suspension for Apical Pelvic Organ Prolapse: Perioperative and Short-Term Outcomes.

INTRODUCTION AND HYPOTHESIS: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel approach in gynecological surgery. This study was aimed at comparing perioperative and short-term postoperative outcomes of vNOTES versus laparoscopic approaches to uterosacral ligament suspension (USLS) for apical pelvic organ prolapse. METHODS: A retrospective cohort study included all women who underwent vNOTES versus laparoscopic USLS at two university-affiliated centers between 2017 and 2023. The relationships between variables were tested using Fisher's exact test or t test, including a sub-analysis comparing hysterectomy and hysteropexy outcomes within the groups. Logistic regression assessed the influence of baseline factors and operative factors on the primary and main secondary outcomes of interest. RESULTS: This study comprised 47 vNOTES and 54 laparoscopic USLS cases (including 11 and 15 hysteropexies respectively). Baseline demographics in the two groups were similar. There were no differences in operative outcomes and no instances of ureteral injury. The vNOTES technique allowed for the use of significantly more sutures per side (2.0 [2.0-4.0] vs 1.0 [1.0-1.0], p = 0.001). Postoperative complications within 6 weeks demonstrated no significant differences. Both groups exhibited comparable rates of baseline subjective POP symptoms (100% vs 96.2%, p = 1.00) which improved significantly at 6 weeks (4.3% vs 11.1%, p = 0.282). At 6 weeks, anatomical success was achieved by significantly more patients with vNOTES (93.5% vs 78.6%, p = 0.042). Baseline and 6-week POP symptoms in the hysterectomy and hysteropexy subgroups were similar. CONCLUSION: Both vNOTES and laparoscopic USLS demonstrated comparable subjective success rates at 6 weeks postoperatively. The vNOTES approach demonstrated improved anatomical success at 6 weeks, but the difference was not significant after adjusting for operative factors.

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery.

INTRODUCTION: Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years. MATERIAL AND METHODS: To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024. RESULTS: Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy. CONCLUSIONS: The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic surgery in treating ovarian cysts: a retrospective cohort study.

BACKGROUND: Transvaginal Natural Orifice Transluminal Endoscopy (vNOTES) is regarded as a challenging surgical technique to learn but is promising in reducing perioperative pain and significantly improves the cosmetic outcomes. Previous studies on the learning curve analysis of vNOTES mainly focuses on the hysterectomy approach, while the vNOTES ovarian cystectomy's learning curve was merely reported though more frequently performed than vNOTES hysterectomy. Therefore, this study seeks to analyze the learning curve of three surgeons with varying levels of experience in performing endoscopic surgery and vaginal surgeries for the treatment of ovarian cysts using vNOTES. METHODS: A total of 127 patients with ovarian cysts of a variety of pathological types were treated by ovarian vNOTES performed by three surgeons of different levels of endoscopic and transvaginal surgical experience. Each surgeon's learning curve was plotted using the Cumulative Sum method and divided into three or four phases of technique learning at the turning point of the learning curve. The sociodemographic and clinical features of patients in each phase were then compared and factors potentially associated with operation time were also screened. RESULTS: The learning curve was presented in four phases. The operation time (OT) was significantly shorter in phases II (53.66 ± 16.55 min) and IV (54.39 ± 23.45 min) as compared with phases I (68.74 ± 15.85) and III (75.93 ± 30.55) (p < 0.001). More cases of serve pelvic adhesion and endometrioma were assigned in the later phases. The OT of endometriotic cysts had much longer than that of non-endometriotic cysts(62.57 ± 18.64 min vs. 49.88 ± 14.26 min, p = 0.15) The presence of pelvic adhesion [adjusted odds ratio (OR) 7.149 (0.506, 13.792), p = 0.035] and bilateral cyst [adjusted OR 16.996 (2.155, 31.837), p = 0.025], max diameter of cyst[adjusted OR 2.799 (0.174, 5.425), p = 0.037], and individual surgeon [adjusted OR -6.118 (-11.814, -0.423), p = 0.035] were significantly associated with OT. CONCLUSION: There learning curve of ovarian vNOTES has four phases. ovarian vNOTES could be mastered after performing seven, nine, and 16 cases by surgeons #1, 2 and 3 respectively, in gynecologic endoscopic surgeries. TRIAL REGISTRATION: ChiCTR2200059282 (Registered on April 28th, 2022).

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) for benign ovarian cysts is safe and feasible in same-day discharge: a retrospective cohort study.

BACKGROUND: Advances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established. OBJECTIVE: This study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes. MATERIALS AND METHODS: The study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient's demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson's chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method's quick recovery nature. RESULTS: Upon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185-0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158-0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071-679.859, P = 0.045). CONCLUSION: In this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.

Transperineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer could improve short-term outcomes: A single-institution retrospective cohort study.

PURPOSE: Transperineal minimally invasive surgery (TpMIS) during laparoscopic abdominoperineal resection (APR) is an emerging approach that allows for the precise treatment of lower rectal cancer. However, evidence regarding the efficacy of TpMIS is insufficient. This study evaluated the efficacy of TpMIS during laparoscopic APR for patients with lower rectal cancer. METHODS: Patients who underwent laparoscopic APR with TpMIS (TpMIS group; n = 12) and those who underwent conventional laparoscopic APR for low rectal cancer (conventional group; n = 13) were enrolled consecutively in this retrospective study. Standardized TpMIS was performed at our institution. Patient and tumor characteristics and intraoperative, postoperative, and pathological outcomes were compared between groups. The primary outcome was postoperative perineal wound infection. RESULTS: No patients in the TpMIS group experienced postoperative perineal wound infection; however, five (38.5%) patients in the conventional group experienced postoperative perineal wound infection (significant difference; p = 0.016). The estimated blood loss (median, 81 mL vs. 463 mL) and incidence of postoperative urinary dysfunction (8.3% vs. 46.1%) were significantly lower in the TpMIS group than in the conventional group. The postoperative hospital stay (median, 13 vs. 20 days) of the TpMIS group was significantly shorter than that of the conventional group. Pathological outcomes did not differ between groups. The positive circumferential resection margin rates of the TpMIS and conventional groups were 8.3% and 15.4%, respectively. CONCLUSION: TpMIS during laparoscopic APR was associated with significant improvements in the postoperative outcomes of patients with low rectal cancer.

Endoscopic and exoscopic surgery for brain tumors.

Nerves and blood vessels must be protected during brain tumor surgery, which has traditionally relied on microscopes. In the 2000s, endoscopes and related equipment were developed for neurosurgery. In this review, we aim to outline the role of endoscopes in brain tumor surgery and discuss the emerging use of exoscopes. The primary use of endoscopes in brain tumor surgery is in endoscopic endonasal surgery for pituitary tumors. By using the space within the sphenoid sinus, surgeons can insert an endoscope and instruments such as forceps or scissors through the nose to access and remove the tumor. Compared to microscopes, endoscopes can get closer to tumors, nerves, and blood vessels. They enable wide-angle observation of the skull base, making them valuable for skull base tumors as well as pituitary tumors. Endoscopes are also used in cases where a brain tumor is associated with hydrocephalus, allowing surgeons to correct obstructive hydrocephalus and perform tumor biopsies simultaneously. Exoscopy, a newer technique introduced in recent years, involves surgeons wearing special glasses and removing the tumor while viewing a three-dimensional monitor. This approach reduces surgeon fatigue and allows for more natural positioning during lengthy brain tumor surgeries. Future brain tumor surgeries will likely involve robotic surgery, which is already used for other organs. This is expected to make brain tumor removal safer and more accurate.