Endoscopic Gastric Plication: A Flexible and Tailored Alternative to Bariatric Surgery.

INTRODUCTION: Endoscopic procedures are expanding and have been evolving in recent years, increasing their volume along with the development of new devices. This is due to the low morbidity and complication rate, the reversibility of the procedures, and the positive impact on patients. Among the endoscopic procedures gaining interest is sleeve gastroplasty. It emerged as a feasible and safe alternative to traditional bariatric surgery. There are no guidelines available on the indications and use of endoscopic gastroplasty. The aim of this study is to present preliminary results of a case series of endoscopic gastric plication procedures performed for different options: as a primary endoscopic sleeve, as revision for sleeve gastrectomy, and as revision for gastric bypass. MATERIALS AND METHODS: A retrospective analysis was performed on a prospective database collecting data on all patients with obesity treated with endoscopic gastroplasty with the Overstitch™ (Apollo Endosurgery, Inc., Austin, Texas) device from 2022 to 2023 in the bariatric surgery unit. RESULTS: Twenty-three patients were treated from May 2022 to July 2023 with endoscopic gastric plication. Ten patients (43%) were submitted to primary endoscopic sleeve gastroplasty, three patients to revision of sleeve gastrectomy, one patient to revision of one anastomosis gastric bypass, and eight patients received a revision of Roux-en-Y gastric bypass. The body mass index (BMI) of patients submitted to primary ESG ranged from 33 to 42kg/m2, with a mean BMI of 37kg/m2. The age of the patients ranged from 22 to 70 years, with a mean age of 45. In one case, we registered a Clavien-Dindo 2 complication-an inflammatory perigastric reaction without a collection occurred 15 days after a primary ESG. CONCLUSION: Endoscopic gastric plication is emerging as a safe, mini-invasive, and effective procedure alternative to sleeve gastrectomy in patients with I or II class obesity or for those unfit for bariatric surgery. The endoscopic suturing device can be used both as a primary procedure or as a revisional option after failure of the primary surgery, thus proving to be a versatile option to provide to bariatric patients.

Laparoscopic vs Open Treatment for Gastric and Non-Gastric Gastrointestinal Stromal Tumors: a Two-Center Experience.

We retrospectively reviewed the medical records of 109 patients who underwent curative laparoscopic or open resection for different types of gastrointestinal stromal tumors (GIST). Only primary GIST patients who did not receive preoperative chemotherapy or oral imatinib treatment were included in the analysis. We divided the patients into 2 groups according to the surgical approach:a laparoscopic group (LAP) and a laparotomic group (OPEN). Our aim was to confirm the feasibility and safety of laparoscopic surgery for GISTs that differed in size and location, and to assess its long-term oncologic outcome in terms of overall survival (OS) and disease-free survival (DFS). Furthermore, we performed a surgical short-term outcome analysis. The two groups did not differ with respect to age at operation, gender, BMI or comorbidities. Even the NIH and AFIP risk classifications were not significantly different between the two groups. Furthermore, in our analysis, there was no significant difference in mean tumor size or location between the two groups. Wedge resection was the most frequently performed procedure. The conversion rate was 7.8%. The operative time was 194.75 (60- 350) min for the open group and 181.70 (57-480) min for the laparoscopic group. Our data clearly indicated that the long-term oncologic outcome and DFS of laparoscopic resection were not inferior to those of traditional open operations and laparoscopic resection was still feasible in cases with large tumors: the median size of the tumor was 4.5 cm (3-25) and the tumor was larger than 4.5 cm in 47.7% of the cases in the LAP group. With regard to short-term outcomes, our study demonstrated that the LAP group had fewer complications, faster gastrointestinal recovery, reduced use of analgesic drugs and shorter postoperative hospital stay (each p<0.05). In conclusion, our experience confirms that GISTs are very uncommon cancers for which the prognosis is closely related to size, localization and class of risk. In light of our clinical data, laparoscopic resection for gastric and non-gastric GISTs is a safe, feasible and oncologically correct procedure. The most important advantage of this technique is that it ensures a better postoperative outcome compared with open surgery, without worsening the prognosis.

Use of Indocyanine Green Fluorescence During Total Thyroidectomy to Identify Parathyroid Glands and Prevent Hypoparathyroidism.

INTRODUCTION: Total thyroidectomy is associated with a high rate of transient or permanent hypoparathyroidism. During surgery, indocyanine green (ICG) fluorescein angiography can be used to detect and preserve well-vascularized parathyroid glands. This technique has been introduced as an intraoperative support to prevent postoperative hypoparathyroidism. MATERIAL AND METHODS: One-hundred consecutive patients who had undergone total thyroidectomy were included in this study. Autofluoroscopy was used on the first dominant side of thyroidectomy and to identify the contralateral parathyroid glands. An intravenous bolus of 5 mg ICG (VERDYE, Diagnostic Green GmbH, Aschheim-Dornacht, Germany) was administered once. ICG fluorescein angiography was used as a "bridge" at the end of the first dominant hemithyroidectomy and after exposure of the parathyroid glands on the second side. This allowed us to (i) determine the vascularization of the first two parathyroid glands and (ii) define the blood vessels and thus the line of dissection of the parathyroid glands of the second resection side. Finally, autofluoroscopy was then applied outside the surgical area on the surgical specimen to assess forgotten parathyroid glands, which should therefore be re-implanted. Autofluoroscopy and ICG fluorescein angiography were evaluated in real time using the same technology, i.e., FLUOBEAM® LX (EUROPE - Fluoptics Grenoble, France; USA - Fluoptics Imaging Inc., Cambridge, MA, USA). The study was approved by the local ethics committee. RESULTS: Autofluorescence and ICG fluorescein angiography were performed without any problems in all cases. A total of 370 parathyroid glands were detected in this series. ICG changed the surgical strategy for the first-side parathyroid glands in 5% of cases, i.e,. they were not well-vascularized and were re-implanted. The rate of transient hypoparathyroidism was 19%. The percentage of parathyroids in the surgical specimen was 3.5% and all were re-implanted during the same surgery. There was no case of postoperative definitive hypoparathyroidism when at least one parathyroid gland with a high fluorescence intensity was preserved on the first side of resection. CONCLUSION: Use of ICG fluorescein angiography may contribute to predicting and thus preventing postoperative definitive hypoparathyroidism after total thyroidectomy. The results of this case series confirm recent studies. Caution is advised when weakly perfused parathyroid glands are discovered.

3D Transoral Endoscopic Thyroid.

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a feasible new surgical procedure that does not require visible incisions. We describe our experience with three-dimensional (3D) TOETVA. We recruited 98 patients who were willing to undergo 3D TOETVA. Inclusion criteria were: (a) patients with a neck ultrasound (US) with an estimated thyroid diameter of 10cm or less; (b) estimated US gland volume ≤45ml; (c) nodule size ≤50mm; (d) benign tumor, such as thyroid cyst, goiter with one nodule, or goiter with multiple nodules; (e) follicular neoplasia; and (f) papillary microcarcinoma without evidence of metastases. The procedure is performed using a three-port technique at the oral vestibule, a 10mm port for the 30° endoscope, and two additional 5mm ports for dissecting and coagulation instruments. The CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule to the sternal notch and laterally to the sternocleidomastoid muscle. Thyroidectomy is performed entirely 3D endoscopically with conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. Ninety-eight 3D TOETVA procedures were successfully performed without any conversions. The mean operative time was 87.6 minutes (59-118 minutes) for lobectomy and 107.6 minutes (99-135 minutes) for bilateral surgery. We observed one case of transient postoperative hypocalcemia. Paralysis of the recurrent laryngeal nerve did not occur. The cosmetic outcome was excellent in all patients. This is the first case series of 3D TOETVA.

Conventional Total Thyroidectomy Using a Novel Single Retractor: Technical Note for Apollo®.

Despite the increasingly innovative techniques developed in thyroid surgery to offer patients minimally invasive and scarless interventions, conventional open procedures still account for most of the interventions performed in this field. The surgical incision length has been significantly reduced, from 6-9 cm to 3 cm, and therefore patients perceive the scar to be highly acceptable. In this technical note, we present the use of a new single retractor (APOLLO®; AFS MEDICAL GmbH, Teesdorf, Austria) for conventional open thyroidectomies with intraoperative neuromonitoring. This device offers several advantages: a) better exposure of the surgical field; b) less traction on skin flaps and neck muscles; and c) protection of the skin edges from the heat generated by energy-based devices/coagulating instruments, with consequent better healing.

Use of Vivostat® Autologous Fibrin Sealant in Thyroid Surgery.

INTRODUCTION: Post-thyroidectomy hemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. Therefore, intraoperative bleeding control and hemostasis are crucial. However, the most efficient, cost-effective, and standardized way to achieve this is not clear. This study aimed to evaluate the outcome of total thyroidectomy (TT) and partial thyroidectomy (PT) performed using the Vivostat® hemostatic system (Vivostat A/S, Lillerød, Denmark). METHODS: Patients underwent TT and PT for benign and malignant diseases (multinodular goiter, Graves' disease, differentiated thyroid carcinoma). The primary endpoint was 1st-day postoperative drain output and bleeding that required reintervention. Secondary endpoints included surgery duration and postsurgical complications (vocal fold palsy, hypocalcemia, seroma, wound infection). RESULTS: Between October 2020 and December 2020, 56 patients were enrolled; 69.6% female; mean age 49.5 years. The mean 24-h drain output was 40 ml. No redo surgery was needed. Seroma was present in 5.3% of cases; no permanent vocal palsy or hypocalcemia was observed. CONCLUSION: This study shows that the Vivostat® system is both safe and effective for hemostasis during thyroid surgery.

C2 Xplore® for Intermittent and Continuous Laryngeal Nerve Monitoring: Technical Note.

Due to the direct anatomical relationship between the recurrent laryngeal nerve (RLN) and the thyroid gland, the function and anatomical integrity of the RLN is fundamentally at risk in every thyroid operation. While a RLN morbidity rate of less than 5% is achieved in specialized clinics, the morbidity rates are significantly higher in non-specialized centers. Thus, the aim is to reduce the complication rate by establishing standardized interventions. Exact knowledge of the anatomical course of the RLN, the nerve-sparing dissection technique and the supportive use of intraoperative neuro-monitoring (IONM) to identify anatomical variations are the basis for nerve-sparing surgery. We tested the new C2 Xplore® system (inomed Medizintechnik GmbH, Emmendingen, Germany) as a tool for performing intermittent and continuous laryngeal nerve monitoring during thyroid surgery. The C2 Xplore® helps to enhance surgeon-IONM interaction, and provides comprehensive digital EMG documentation with EMG quantification. EMG artifacts are removed. Image quality and EMG feedback are highly acceptable for intraoperative monitoring. The C2 Xplore® system does not have a deleterious impact on the proper function of other surgical instruments. C2 Xplore® is effective for intraoperative monitoring, optimizing RLN dissection, and supporting surgical deliberations, and for forensic use and research. A step-by-step C2 Xplore® procedure is described.

Energy-Based Devices Affect the Aesthetic Outcome of Cervical Thyroidectomy and Parathyroidectomy. A Retrospective Study.

INTRODUCTION: Thyroid and parathyroid diseases are very common. Most of these cases are in women and may be amenable to surgery. The patient's perception that these are not life-threatening diseases leads them to expect an excellent aesthetic result, since the surgical incision area is clearly visible. OBJECTIVE: To evaluate different scarring outcomes using three different energy-based devices (Harmonic Focus®, Johnson & Johnson, New Brunswick, NJ; Thunderbeat Open Fine Jaw®, Olympus Medical, Tokyo, Japan; LigaSure Small Jaw®, Medtronic, Dublin, Ireland) and to determine the impact of post-thyroidectomy/parathyroidectomy scars on the patient's quality of life. METHODS: One hundred female patients who underwent thyroidectomy or parathyroidectomy between September 2017 and September 2019 at the Endocrine and Minimally Invasive Surgery Department of Messina University Hospital were recruited. A retrospective analysis assessed the thickness of the cervical scar via ultrasound imaging, and the patient's degree of satisfaction through the Patient and Observer Scar Assessment Scale (POSAS) and the Body Dysmorphic Disorder Questionnaire (BDDQ). RESULTS: The patients were divided into three groups according to the energy-device used: group A (LigaSure SJ (n=38), group B (Harmonic F, n=32) and group C (Thunderbeat OFJ, n=30). The three groups were homogeneous with respect to number of patients, age and surgical procedures. The best aesthetic result, which correlated with the lowest scar thickness, was observed in group A; these patients were more satisfied than those in the other two groups. Moreover, correlations between scar thickness and quantitative variables (such as age or BMI) were not found in any of the groups. CONCLUSIONS: Based on the data collected and our experience, the LigaSure Small Jaw® (Medtronic) seems to offer the best aesthetic outcome in patients who undergo transverse cervicotomy for thyroid and parathyroid diseases. However, further prospective studies involving a greater number of cases are needed.

Status of Alternative Approaches for Thyroidectomy: Is There Any Evidence to Substitute in Place of Conventional Surgery?

Over the past 20 years, various alternative cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed. All of these alternative access methods aim at optimizing the cosmetic results. In principle, the indication for the use of alternative access procedures does not differ from that for conventional surgery. Nonetheless, appropriate experience in traditional thyroid surgery and suitable patient selection, taking into account thyroid volumes and the underlying pathology, are important prerequisites. General contraindications for an alternative approach are large goiter with symptoms of compression, advanced thyroid carcinoma, recurrent interventions or previous radiotherapy in the operating area. The alternative surgical approaches to the thyroid can be divided into cervical minimally invasive, extracervical endoscopic (robot-assisted) and transoral procedures. This article gives an overview of the clinically used alternative approaches in thyroid surgery. The desire for an optimal cosmetic result should not be prioritized over patient safety. Only a few alternative procedures (minimally invasive video-assisted thyroidectomy, transaxillary robot-assisted thyroidectomy) can currently be viewed as a useful addition to conventional thyroid surgery, even when in responsible, experienced hands for a selected group of patients.

An Improved Recurrent Laryngeal Nerve-Monitoring Device: Technical Note for Nim Vital™.

A new device for monitoring the laryngeal nerves during thyroid surgery has been developed. NIM Vital™ (Medtronic Xomed, Inc., Jacksonville, FL, USA) incorporates (a) a new wireless design, (b) NIM NerveTrendTM (Medtronic Xomed) EMG reporting, (c) intelligent noise-reduction technology that suppresses artifacts, (d) smart troubleshooting pop-up alerts, and (e) NIM Nervassure ™ (Medtronic Xomed) for continuous monitoring. This device offers enhanced stability and flexibility for both intermittent and continuous laryngeal nerve monitoring. The new NIM NerveTrend ™ EMG reporting makes it possible to track the recurrent laryngeal nerve condition throughout a procedure, even when using intermittent nerve monitoring. During both continuous and intermittent monitoring, green, yellow and red status bars provide visual information and associated tones provide audible cues, making it easy to monitor nerve function and interpret EMG trends. This new tool for laryngeal nerve monitoring has the potential to augment nerve dissection during surgery. Measurements of long-term outcome are needed to establish their efficacy.

Negative Pressure Therapy (NPWT) for Management of Surgical Wounds: Effects on Wound Healing and Analysis of Devices Evolution.

Infection and wound dehiscence are common complications after surgery and open surgical wounds are difficult to manage. Usually surgical incisions are closed by fixing the edges together. However, in case of significant tissue loss, infected surgical field, or particular cases, wounds may be left open. In recent years, negative pressure wound therapy (NPWT) has been widely used for management of various complicated wounds and to support postoperative tissue healing. Another emerging indication for NPWT, applied directly to the closed incisions, is to prevent infections or dehiscences in patients with increased risk of surgical-site complications (iNPWT). Furthermore, the combination of negative pressure with intermittent instillation of solution (NPWTi) seems to be effective in the treatment of a variety of complex wounds. Even if the role of NPWT in promoting wound healing has been largely accepted, there is a lack of evidence (few high-level clinical studies) regarding its effectiveness and further research is needed to better understand the mechanisms of action. This article contains a review of recent scientific and clinical research related to indications, contraindications, and mechanisms of action of NPWT to clarify current knowledge, technological evolutions, and future perspectives of devices.

Early Versus Delayed Source Control in Open Abdomen Management for Severe Intra-abdominal Infections: A Retrospective Analysis on 111 Cases.

BACKGROUND: Time to source control plays a determinant prognostic role in patients having severe intra-abdominal infections (IAIs). Open abdomen (OA) management became an effective treatment option for peritonitis. Aim of this study was to analyze the correlation between time to source control and outcome in patients presenting with abdominal sepsis and treated by OA. METHODS: We retrospectively analyzed 111 patients affected by abdominal sepsis and treated with OA from May 2007 to May 2015. Patients were classified according to time interval from first patient evaluation to source control. The end points were intra-hospital mortality and primary fascial closure rate. RESULTS: The in-hospital mortality rate was 21.6% (24/111), and the primary fascial closure rate was 90.9% (101/111). A time to source control ≥6 h resulted significantly associated with a poor prognosis and a lower fascial closure rate (mortality 27.0 vs 9.0%, p = 0.04; primary fascial closure 86 vs 100%, p = 0.02). We observed a direct increase in mortality (and a reduction in closure rate) for each 6-h delay in surgery to source control. CONCLUSION: Early source control using OA management significantly improves outcome of patients with severe IAIs. This damage control approach well fits to the treatment of time-related conditions, particularly in case of critically ill patients.

Gastric Leaks after Sleeve Gastrectomy: Focus on Pathogenetic Factors.

As reported by The International Federation for the Surgery of Obesity (IFSO) worldwide survey on bariatric surgery, sleeve gastrectomy has become the second most performed bariatric/metabolic procedure in the world just after gastric bypass. If we consider complications, despite a recent systematic review and meta-analysis that reported a substantial decrease in sleeve gastrectomy complication rates, leaks after sleeve gastrectomy still rate between 0 and 18%. Unlike the leaks of other types of gastrointestinal surgery, leaks after sleeve gastrectomy are challenging in diagnosis and treatment and can lead to sepsis, multiple organ failure, and even death. A standardized algorithm of diagnosis and management is still lacking. Current classification of gastric leaks is based on the time of onset and clinico-pathological aspects. Nonetheless, none of the largest series in literature report the pathogenesis of gastric leaks. Given this paucity of evidence-based data and the lack of defined guidelines, we try to examine and consider the pathogenetic factors of gastric leak to implement better treatments and predict outcomes.

Right-Sided versus Left-Sided Colectomies for Cancer: Surgical Outcomes and Novel Considerations.

INTRODUCTION: The aim of this study is to compare short-term outcomes of right versus left colectomies performed as a form of cancer treatment. MATERIALS AND METHODS: This study includes 305 consecutive patients with adenocarcinoma treated by laparoscopic or open colectomy. Right colectomy has been compared with left colectomy. The study endpoints were the first flatus day, the first evacuation day, the first day of postoperative solid oral diet intake, and the postoperative hospital stay length. RESULTS: There were 140 (45.9%) right colectomies and 165 (54.1%) left colectomies performed. The cut-off values for the considered (median) endpoints were three, five, four, and eight days, respectively. The first day of postoperative solid oral diet intake and the length of postoperative hospital stay are significantly associated with the type of resection. CONCLUSIONS: The colon cancer patients treated by right-sided colectomy assumed a solid oral diet and presented a longer postoperative hospital stay compared with the patients treated by left-sided colectomy.

Hemostatic agents for bleeding: recombinant-activated factor VII and beyond.

A rapid restoration of hemostasis should be regarded as a primary goal for management of critical bleeding, which often represents a life-threatening condition. Among the various therapeutic strategies available in this clinical setting, we aim to summarize in this narrative review the current status on the use of recombinant-activated factor VII and prothrombin complex concentrates. The safety and effectiveness of these hemostatic agents in reversal of the anticoagulant effects of vitamin K antagonists will be also explored. In addition, their role in the management of acute bleeding associated with the newer direct oral anticoagulants dabigatran, rivaroxaban, and apixaban will be analyzed in a dedicated section.

Recombinant activated factor VII in clinical practice: a 2014 update.

Recombinant activated factor VII (rFVIIa) was initially developed to treat bleeding episodes in patients with congenital hemophilia and inhibitors. Due to the initial success in this clinical setting, its use has been extended to other coagulopathies characterized by impaired thrombin generation, i.e. acquired hemophilia, inherited factor VII deficiency and Glanzmann's thrombasthenia, for which it is currently licensed. Extensive research in the last decade has increased our knowledge of the mechanisms utilized by rFVIIa to restore normal hemostasis. This paper reviews current understanding of the mechanisms of action of rFVIIa before summarizing the clinical experience, in terms of safety and efficacy, to date in its licensed indications.

Current Developments and Unusual Aspects in Gastrointestinal Surgical Stapling.

Stapling devices are used in gastrointestinal, gynecologic, thoracic, and many other surgeries to resect organs, transect tissues, and anastomose different structures. These devices became widely accepted standard practice in many gastrointestinal operations, especially since the successful advent of minimally invasive surgery. Despite the relevant advantages related to the use of a surgical stapler, we must also consider that these instruments may be at risk of failure. When any component fails, the patient is at risk of operative morbidity. Gastrointestinal surgical stapling technique still needs refinement in order to increase its reliability. Staple line reinforcement has been widely used and seems to effectively reduce anastomotic complications. Literature provides us with examples of studies supporting both bleeding and leakage reduction after staple line reinforcement, but high-quality evidence is not available to date. Semi-absorbable and nonabsorbable materials have been the earliest available. The use of bioabsorbable staple line reinforcement materials has recently become more widespread, and these materials are more widely used these days. Powered staplers were made available to the market some time ago and represent a rather unheard of aspect of endosurgical stapling. Despite powered staples being supposedly convenient compared with manual ones only one relevant article was found when searching the U.S. National Library of Medicine for "powered stapler." New surgical stapling devices are constantly developed and introduced on the market. Results with such devices depend on the stapler features but also surely vary according to the surgeon experience.

Self-Retaining Retractor Widox® for Thyroid Surgeries: Technical Note.

During a thyroidectomy, perfect exposure of the vascular nerve structures, parathyroid gland, trachea, larynx, esophagus, and lymphnodes is crucial to facilitate the surgeon in the meticulous dissection. WIDOX® (MOSS Spa, Lesa, Italy) is an atraumatic self-retaining thyroidectomy retractor specifically designed for thyroid surgeries with an octagonal shape and six retractors (Fig. 1). It is a sterile, single-use device which keeps the surgical wound and the neck muscles retracted allowing the proper exposure of the operatory field. The device substitutes the manual retractors held by the surgeon's assistants. In our institute, we started using the self-retaining retractor WIDOX® from May 2015 for a total of 50 patients. From our preliminary experience, the self-retaining retractor WIDOX® is simple and practical and can be adapted to each patient. The use of energy-based devices and the neuromonitoring is not prevented by the presence of this retractor.

Continuous Intraoperative Neuromonitoring (C-IONM) Technique with the Automatic Periodic Stimulating (APS) Accessory for Conventional and Endoscopic Thyroid Surgery.

One of the most important trends in intraoperative neural monitoring (IONM) in thyroid surgery is currently the real-time monitoring of the vagus nerve (VN) in order to prevent recurrent laryngeal nerve (RLN) iatrogenic damages. Notably, continuous intraoperative neuromonitoring (C-IONM) seems to be superior to intermitted intraoperative neural monitoring (I-IONM) because it enhances standardization by permanent vagus nerve (VN) stimulation, and it provides entire and constant RLN function monitoring as the surgeon dissects and removes the thyroid gland. It also has to be highlighted that the surgical maneuvers for the automatic periodic stimulating (APS) placement must be accurate and standardized in order to avoid a potential iatrogenic morbidity on the VN function. We recommend the experienced surgeon be very careful in each step, with cautious dissection. With this review article we provide a comprehensive analyses of C-IONM technique with the APS accessory for conventional and endoscopic thyroid surgery.