Evaluation of a novel disposable endoscope for retroflexed endoscopic rubber band ligation of internal hemorrhoids: a randomized pilot study.

PURPOSE: Retroflexed endoscopic rubber band ligation (ERBL) for treating Grade II and III internal hemorrhoids using disposable endoscopes has not been previously assessed. We therefore compared the safety and effectiveness of ERBL for internal hemorrhoids using novel disposable endoscopes versus traditional reusable endoscopes. METHODS: This prospective randomized controlled trial involved 42 patients who underwent ERBL for Grade II and III internal hemorrhoids using either a disposable endoscope (n = 21) or a reusable endoscope (n = 21). Safety was assessed by the incidence of equipment failure, device-related adverse events, and in-procedure stability of vital signs. Effectiveness was assessed by the postoperative therapeutic effect, feasibility of retroflexed ERBL, and incidence of complications. RESULTS: In terms of safety, no life-threatening events, equipment failure, or device-related adverse effects occurred during the procedures in either group. The rate of diastolic blood pressure stability was significantly different between the two groups (P = .049), but the rates of systolic blood pressure and heart rate stability were similar. In terms of effectiveness, the therapeutic effects on postoperative Day 30 were similar in both groups. Image clarity and endoscopic flexibility in the disposable endoscope group were mildly inferior to those in the reusable endoscope group, but without statistical significance. Matching between the endoscope and ligating device was 100% in both groups. The incidence of complications on postoperative Days 1 and 10 was not significantly different between the two groups. CONCLUSION: Compared with reusable endoscopes, disposable endoscopes are equally safe, feasible, and reliable in ERBL for internal hemorrhoids.

Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review.

OBJECTIVES: To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION: Randomised and non-randomised comparative studies. OUTCOMES: Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS: All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS: The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT: Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Cumulative evidence for reducing recurrence of colonic diverticular bleeding using endoscopic clipping versus band ligation: Systematic review and meta-analysis.

BACKGROUND AND AIM: Either clipping or band ligation will become the most common endoscopic treatment for colonic diverticular bleeding (CDB). Rebleeding is a significant clinical outcome of CDB, but there is no cumulative evidence comparing reduction of short-term and long-term rebleeding between them. Thus, we conducted a systematic review and meta-analysis to determine which endoscopic treatment is more effective to reduce recurrence of CDB. METHODS: A comprehensive search of the databases PubMed/MEDLINE and Embase was performed through December 2019. Main outcomes were early and late rebleeding rates, defined as bleeding within 30 days and 1 year of endoscopic therapy for CDB. Initial hemostasis, need for transcatheter arterial embolization, or surgery were also assessed. Overall pooled estimates were calculated. RESULTS: Sixteen studies fulfilled the eligibility criteria, and a total of 790 participants were included. The pooled prevalence of early rebleeding was significantly lower for band ligation than clipping (0.08 vs 0.19; heterogeneity test, P = 0.012). The pooled prevalence of late rebleeding was significantly lower for band ligation than clipping (0.09 vs 0.29; heterogeneity test, P = 0.024). No significant difference of initial hemostasis rate was noted between the two groups. Pooled prevalence of need for transcatheter arterial embolization or surgery was significantly lower for band ligation than clipping (0.01 vs 0.02; heterogeneity test, P = 0.031). There were two cases with colonic diverticulitis due to band ligation but none in clipping. CONCLUSION: Band ligation therapy was more effective compared with clipping to reduce recurrence of colonic diverticular hemorrhage over short-term and long-term durations.

Endoscopic Detachable Snare Ligation Improves the Treatment for Colonic Diverticular Hemorrhage.

BACKGROUND/AIMS: Recently, endoscopic detachable snare ligation (EDSL) has become increasingly common as treatment for colonic diverticular hemorrhage. This study aimed to evaluate the efficacy and safety of EDSL in comparison with endoscopic clipping (EC) as treatment for colonic diverticular hemorrhage. METHODS: From April 2013 to September 2017, 131 patients were treated with EDSL or EC at the Tokyo Metropolitan Bokutoh Hospital. We retrospectively evaluated patient characteristics and clinical outcomes, including early rebleeding rates (rebleeding within 30 days after initial hemostasis) and complications for each procedure. RESULTS: Of 131 patients, 44 and 87 were treated with EDSL and EC respectively. We initially achieved endoscopic hemostasis in all patients. The early rebleeding rate was significantly lower for EDSL (6.8%, 3 patients) than for EC (23.0%, 20 patients). There were no differences in the total procedure time (43 vs. 45 min, p = 0.84) or time to hemostasis after identification of bleeding site (12 vs. 10 min, p = 0.23). There were no severe complications following EDSL. CONCLUSION: The results of this study suggest that EDSL is superior to EC as treatment for colonic diverticular hemorrhage. EDSL may provide improvements in the clinical course of patients with colonic diverticular hemorrhage.

A novel method of bilateral patent processus vaginalis ligation in transumbilical single-site multiport laparoscopic orchiopexy.

Objective: To evaluate safety and efficacy of a novel method of bilateral patent processus vaginalis ligation in transumbilical single-site multiport laparoscopic orchiopexy for children. Methods: A retrospective study was carried out comparing the novel ligation and conventional ligation performed by a single surgeon between July, 2017-July, 2018. The patients were divided into the novel group (42 cases) and the conventional group (59 cases). In the novel group, transumbilical single-site multiport laparoscopic orchiopexy was performed and the bilateral internal rings was stitched with "8" pattern suture. In the conventional group, the conventional TriPort laparoscopic orchiopexy was performed and purse string suture was used to fix the internal rings. The parameters of operative duration time, postoperative hospital stay; postoperative complications were compared between 2 groups. Results: All operations were successful. No Perioperative period complications were found and all patients were discharged within 4-6 days after operation. There is no statistic difference in the surgery time and hospitalization day. However, there is significant difference in the Pain face scale scores after day 2(1.60±0.73 VS 2.02±0.86). And there is no scar and the satisfactory cosmetic could be seen in scrotum and inguinal area in the novel group. Conclusion: The novel ligation was safety and efficacy. It is relatively easy to perform with smaller scar and less pain. We propose the novel ligation as a more viable treatment option for pediatric cryptorchidism with bilateral patent processus vaginalis.

Ligating the rectum with cable tie facilitates rectum transection in laparoscopic anterior resection of rectal cancer.

PURPOSE: Proper transection of the distal rectum is important for reconstruction of bowel continuity in rectal cancer surgery. In this study, we introduced a modified technique for ligation of the distal rectum, and investigated its safety and efficiency to facilitate the rectum transection. METHODS: After complete mobilization and transection of the mesorectum, a cable tie was carefully positioned distal to the tumor, followed by washout and transecting the rectum with a linear stapler. From September 2017 to June 2018, consecutive 67 mid-low rectal cancer patients with laparoscopic anterior resection underwent this technique. Clinical data of these patients, including number of firings, pathological and operative variables, and postoperative outcomes, were compared with those of 132 consecutive patients who underwent traditional surgery from January 2016 to August 2017. RESULTS: Compared with the traditional method, cable tie ligation significantly reduced the number of firings (1.1 ± 0.32 vs. 1.3 ± 0.52, p < 0.001). A very high ratio of one firing transection of rectum was observed in the cable tie group (94.0% vs. 68.9%, p < 0.001), even in patients with tumor at or below the peritoneal reflection (90.2% vs. 54.4%, p < 0.001), in male patients (95.5% vs. 65.8%, p < 0.001), and in obese patients (93.8% vs. 64.9%, p = 0.005). The mean distal margin was longer in the cable tie group (3.19 ± 1.77 cm vs. 2.54 ± 1.36 cm, p = 0.005), with no positive distal margin observed. The operation time, quality of mesorectum, and morbidity between two groups were comparable. Two leaks (3.0%) in the cable tie group were observed, similar to 3.8% in the control. CONCLUSIONS: Ligation of the rectum with a cable tie reduces the number of cartridges, and increases the rate of one stapler firing for rectal transection, even in those difficult cases like male, overweight, and low rectal cancer patients. It is also useful for occlusion of the rectum before washout. It is safe, feasible, and worthwhile for popularization. TRIAL REGISTRATION: Registered at ClinicalTrial.gov, number NCT03570684.

Temporary Ligation of the Uterine Artery at Its Origin Using a Removable "Shoelace" Knot.

STUDY OBJECTIVE: To demonstrate a technique of temporary ligation of the uterine artery at its origin. DESIGN: A step-by-step demonstration of the surgery in an instructional video. SETTING: A private hospital in Mumbai, India. INTERVENTION: The peritoneum over the pelvic side wall was dissected bilaterally to expose the uterine arteries at their origins. Using a polyglactin absorbable suture, a double thread loop was used to create a removable "shoelace" knot (Video 1). Both uterine arteries were ligated in this manner. The myomectomy was completed uneventfully, and the myoma bed was sutured in 2 layers using polyglactin sutures. Once suturing was completed, the shoelace knot was untied by simply pulling one end of the thread to restore blood supply to the uterus. Intraoperative blood loss was 30 mL, and the total operation time was 120 minutes. CONCLUSION: Laparoscopic ligation of the uterine arteries at their origin is known to reduce intraoperative blood loss [1,2]. However, in patients desiring future fertility, the effect of permanent ligation of these vessels bilaterally remains under study [3-5]. The removable "shoelace" knot is a low-cost, readily available alternative to metallic titanium clips that requires no special surgical expertise to implement.

Clinical Outcomes of Patients with Small Rectal Neuroendocrine Tumors Treated Using Endoscopic Submucosal Resection with a Ligation Device.

BACKGROUND/AIMS: The therapeutic strategies for small rectal neuroendocrine tumors (NETs) have not been standardized. We examined the efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) and the long-term outcomes after endoscopic treatment. METHODS: A total of 181 patients with rectal NETs <10 mm who were treated between May 2002 and May 2017 were retrospectively enrolled. All the lesions had been resected using ESMR-L, and the follow-up strategies were determined according to the pathological examinations. The long-term outcomes after a 53-month follow-up period were also evaluated. RESULTS: R0 resection was achieved in 180 cases (99.4%). Lymphovascular invasion was confirmed in 67 cases (37.0%), while a curative resection was achieved in 114 cases (63.0%). One perforation (0.6%) and 11 cases with delayed bleeding (6.1%) were observed. A multivariate logistic regression analysis revealed that a tumor size > 5 mm (OR 2.06; 95% CI 1.04-4.08, p = 0.04) was a significant independent predictor of the presence of lymphovascular invasion. Of the 67 patients with non-curative resections, 11 patients underwent additional surgery; lymph node metastasis was confirmed in 2 cases (18.2%). No local or distant metastases were observed during the follow-up period in 77 patients with a curative resection, 9 patients who received additional surgery, and 50 patients with non-curative resections. CONCLUSION: ESMR-L is an easy, safe and effective treatment for rectal NETs <10 mm in diameter, and the prognosis of patients seems to be good, despite a relatively high rate of lymphovascular invasion.

Endoscopic submucosal resection using a ligation device without injection for duodenal neuroendocrine tumors.

BACKGROUND: Duodenal neuroendocrine tumors (NETs) measuring ≤ 10 mm in diameter that are confined to the submucosal layer without metastasis are suitable for endoscopic treatment. We previously reported the efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) for duodenal NETs. In order to make the procedure simpler, we attempted ESMR-L without submucosal injection. The aim of this study was to evaluate the efficacy of ESMR-L without injection for duodenal NETs. METHODS: A total of 12 patients with small (≤ 10 mm) sporadic duodenal NETs were treated via endoscopic resection at the National Cancer Center Hospital East between December 2010 and May 2018. All patients were evaluated via endoscopy and endoscopic ultrasound, and abdominal computed tomography was performed to rule out metastatic lesions. The patients' characteristics, clinical courses, and complications, such as perforation and bleeding, were retrospectively assessed. We examined the correlation between ESMR-L with or without submucosal saline injection and clinicopathological parameters. RESULTS: The median procedural time for ESMR-L was 13 min. All lesions invaded the submucosal layer, and the histological diagnoses were classified as NET G1 in 11 lesions and NET G2 in one lesion. En bloc resection and complete resection were achieved in 12 and 11 lesions, respectively. The postoperative duration of hospital stay was 4 days. At the median follow-up of 17 months, there was no incidence of local recurrence or distant metastasis. Perforation and intraoperative bleeding were not observed. However, delayed bleeding was found in one patient. ESMR-L without submucosal injection required a significantly shorter procedural time than ESMR-L with submucosal saline injection (10 min vs. 15 min, respectively; p = 0.007). CONCLUSIONS: ESMR-L is safe and effective. Particularly, ESMR-L without submucosal injection could be used to treat these NETs safely within a short period of time.

Novel clip applicator for minimally invasive surgery.

BACKGROUND: Ligation clips are used ubiquitously throughout minimally invasive surgery for apposition of tissues. Their size limits their application beyond ligation of small tubular structures. A novel clip and clip applicator that allows for broad-area clamping and rotation has been developed by our team. The primary aim of this study is to provide preliminary data assessing tensile strength of the clip across apposed segments of bowel. METHODS: A comparative study evaluating the maximum load (N) held across two apposed tissues by (a) our novel broad-area clip and (b) a conventional commercial clip was performed. Two sections of porcine bowel were clamped together and the maximum load (N) was measured using a tensile strength material testing machine. A preliminary experiment comparing staple line leak pressures in a porcine model ± clip enforcement of staple line was also conducted. p < 0.05 determined statistical significance. RESULTS: Twenty-four samples (intervention = 15; control = 9) of porcine bowel annealed by surgical clips were tested. The mean maximum force withheld by the bowel and staples was greater for our novel clip design (2.043 ± 0.831 N) than the control clip (1.080 ± 0.466 N, p = 0.004). Ten staple line (intervention = 5; control = 5) pressures of porcine bowel were measured. There was no statistically significant difference between the leak pressures with clip reinforcement (84.8 mmHg; range 71.8-109.8 mmHg), or without (54.1 mmHg; range 26.3-98.9 mmHg). CONCLUSION: These preliminary results suggest that our novel clip is able to withstand higher tensile force across tissues compared to a leading commercial clip. A small preliminary trial of effect on leak pressures demonstrated no statistical significance; however, increasing reliability of staple line deformation may be a clinically important finding. Whilst further iteration of product design and clinical testing is required, this product may occupy an important clinical niche through staple line reinforcement, enterotomy closure and other applications.

Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices.

BACKGROUND: The presence of oesophageal varices is associated with the risk of upper gastrointestinal bleeding. Endoscopic variceal ligation is used to prevent this occurrence but the ligation procedure may be associated with complications. OBJECTIVES: To assess the beneficial and harmful effects of band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. SEARCH METHODS: We combined searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and Science Citation Index with manual searches. The last search update was 9 February 2019. SELECTION CRITERIA: We included randomised clinical trials comparing band ligation verus no intervention regardless of publication status, blinding, or language in the analyses of benefits and harms, and observational studies in the assessment of harms. Included participants had cirrhosis and oesophageal varices with no previous history of variceal bleeding. DATA COLLECTION AND ANALYSIS: Three review authors extracted data independently. The primary outcome measures were all-cause mortality, upper gastrointestinal bleeding, and serious adverse events. We undertook meta-analyses and presented results using risk ratios (RRs) with 95% confidence intervals (CIs) and I2 values as a marker of heterogeneity. In addition, we calculated the number needed to treat to benefit (NNTTB) for the primary outcomes . We assessed bias control using the Cochrane Hepato-Biliary domains; determined the certainty of the evidence using GRADE; and conducted sensitivity analyses including Trial Sequential Analysis. MAIN RESULTS: Six randomised clinical trials involving 637 participants fulfilled our inclusion criteria. One of the trials included an additional small number of participants (< 10% of the total) with non-cirrhotic portal hypertension/portal vein block. We classified one trial as at low risk of bias for the outcome, mortality and high risk of bias for the remaining outcomes; the five remaining trials were at high risk of bias for all outcomes. We downgraded the evidence to moderate certainty due to the bias risk. We gathered data on all primary outcomes from all trials. Seventy-one of 320 participants allocated to band ligation compared to 129 of 317 participants allocated to no intervention died (RR 0.55, 95% CI 0.43 to 0.70; I2 = 0%; NNTTB = 6 persons). In addition, band ligation was associated with reduced risks of upper gastrointestinal bleeding (RR 0.44, 95% CI 0.28 to 0.72; 6 trials, 637 participants; I2 = 61%; NNTTB = 5 persons), serious adverse events (RR 0.55, 95% CI 0.43 to 0.70; 6 trials, 637 participants; I2 = 44%; NNTTB = 4 persons), and variceal bleeding (RR 0.43, 95% CI 0.27 to 0.69; 6 trials, 637 participants; I² = 56%; NNTTB = 5 persons). The non-serious adverse events reported in association with band ligation included oesophageal ulceration, dysphagia, odynophagia, retrosternal and throat pain, heartburn, and fever, and in the one trial involving participants with either small or large varices, the incidence of non-serious side effects in the banding group was much higher in those with small varices, namely ulcers: small versus large varices 30.5% versus 8.7%; heartburn 39.2% versus 17.4%. No trials reported on health-related quality of life.Two trials did not receive support from pharmaceutical companies; the remaining four trials did not provide information on this issue. AUTHORS' CONCLUSIONS: This review found moderate-certainty evidence that, in patients with cirrhosis, band ligation of oesophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared to no intervention. It is unlikely that further trials of band ligation versus no intervention would be considered ethical.

Over-the-scope clip for acute esophageal variceal bleeding.

Over-the-scope clip (OTSC) has been reported to control non-variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC 'type a' with a cap of 11 mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child-Pugh score ≤8) and portal hypertension (hepatic venous pressure gradient, mean 14.4 ± 1.3 mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip-related adverse events during a 30-day follow-up period. Two patients developed solid food dysphagia after 3 months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.

Evaluation of a resorbable self-locking ligation device for performing peripheral lung biopsies in a caprine cadaveric model.

OBJECTIVE: To compare airway leak pressures after sealing peripheral lung biopsy sites with a resorbable ligation device (LigaTie) or thoracoabdominal (TA) staples. STUDY DESIGN: Ex vivo study. ANIMALS: Four normal caprine cadavers. METHODS: Twelve lung lobes were harvested from 4 goats immediately after euthanasia. Each lobe was inflated to 20 cm H2 O to test for leaks prior to biopsy. Pressure was then maintained at 10 cm H2 O. Biopsy samples were obtained 3 cm from the periphery with a resorbable ligation device or a TA stapler (n = 6 per group). After biopsy, inflation pressure was slowly increased to 40 cm H2 O while lungs were submerged in water. The pressure at which bubbles were first seen was recorded as the airway leak pressure. The length, width, volume, and weight were recorded for each biopsy sample. RESULTS: Five of 6 LigaTie biopsy sites sustained the maximum pressure of 40 cm H2 O without leaking. One site leaked at 24 cm H2 O. The TA-stapled sites sustained airway pressure to median 25.5 cm H2 O (interquartile range, 23.5-26 cm H2 O), and none of them reached the maximum pressure (P = .015). There were no differences in biopsy length, volume, or weight between groups. CONCLUSION: Biopsy sites sealed with LigaTie withstood higher airway pressure without leaking compared with TA-stapled biopsy sites in normal cadaveric specimens. CLINICAL SIGNIFICANCE: The LigaTie may be an alternative technique for sealing peripheral lung biopsy sites.

Evaluation of a pre-tied ligature loop for canine total lung lobectomy.

OBJECTIVE: To determine the ability of a pre-tied ligature loop (PLL) to create a seal against physiological airway pressures after total lung lobectomy and report outcomes in dogs requiring lung lobectomy. STUDY DESIGN: Ex vivo experimental randomized study and clinical case study. SAMPLE POPULATION: Thirty cadaveric canine lung lobes and 5 client-owned dogs. METHODS: Thirty canine lung lobes from dogs weighing 22.5-35 kg were randomized to lobectomy with stapler, PLL, or suture ligation. After lobectomy, each bronchial stump was submerged in water, and the mainstem airway pressure was increased to 80 mm Hg. Leakage was compared between techniques. The PLL was subsequently used in 5 dogs (17-25 kg) with neoplastic disease requiring total lung lobectomy. RESULTS: Two stapled and 4 sutured bronchial stumps leaked at supraphysiological pressures >15 mm Hg. One stapled bronchial stump failed at a physiological airway pressure (5 mm Hg). None of the PLL lobectomies leaked. The incidence of bronchial stump failures did not differ among techniques (P = .15). Lung lobectomy was performed successfully with the PLL in 5 clinical cases with no intraoperative or postoperative complications; median follow-up time was 6 months. CONCLUSION: Bronchial ligation with the PLL reliably resisted physiological airway pressures and performed comparably to current standard techniques in cadavers. The PLL provided an adequate air and vascular seal in 5 clinical cases undergoing total lung lobectomy. CLINICAL RELEVANCE: Pre-tied ligature loops provide an alternative method for total lung lobectomy in dogs.

Thoracoscopic-assisted lung lobectomy in cat cadavers using a resorbable self-locking ligation device.

OBJECTIVE: To compare the maximum pressure sustained by airways sealed with a resorbable ligation device (LigaTie) and with thoracoabdominal (TA) staples during thoracoscopic-assisted hilar lung lobectomies. STUDY DESIGN: In situ cadaveric study. ANIMALS: Ten feline cadavers. METHODS: Twenty lung lobectomies were performed with either a LigaTie or a TA stapler (n = 10 per group) by using a thoracoscopic-assisted technique. Procedures were randomly performed on the cranial lung lobes only. The distance between the ligation and the hilus was measured on each specimen. Airway pressures were tested to a maximum pressure of 40 cmH2 O. RESULTS: All LigaTie sites reached a maximum airway pressure without leaking and were easily placed at the hilus. Four of 10 TA stapled sites leaked at a mean pressure of 22 cmH2 O (P = .010). All leaks occurred when the TA staple line was >5 mm from the hilus; no leaks occurred when the TA staple line was ≤5 mm from the hilus (P < .001). No difference was found between fresh and frozen cadavers (P = .483) or right vs left lung lobe (P = .284). CONCLUSION: Lung lobectomies were consistently performed at the hilus only when the LigaTie was used. Lung lobectomies were less likely to leak when performed with the LigaTie rather compared with TA staples. CLINICAL SIGNIFICANCE: The LigaTie may be an effective alternative for lung lobectomies at the pulmonary hilus in cats and small breed dogs. Our findings provide justification for additional clinical testing.

Evaluation of different methods of securing cellophane bands for portosystemic shunt attenuation.

OBJECTIVE: To compare mechanisms of and pressures at failure of 4 methods of securing 2 types of cellophane bands around a vein. STUDY DESIGN: Ex vivo mechanical evaluation. METHODS: Cellophane bands composed of 3 or 4 layers were applied around a cadaveric external jugular vein (EJV) to create 25% or 50% attenuation. These bands were secured with a medium or medium-large polymer locking ligation clip (PLLC), or a medium or medium-large titanium ligation clip (TLC). Sterile saline 0.9% was instilled into the lumen of the EJV until a pressure of 100 mm Hg was reached. Failure mechanism and luminal pressure at failure were compared between groups. RESULTS: Medium clips failed less often than medium-large clips (P < .001) and consistently sustained 100 mm Hg without failing. Three-layer cellophane bands were 4.1 times more likely to fail than 4-layer bands (P = .003, CI 1.6-10.2) and failed at lower pressures (28.32 ± 3.59 mm Hg and 44.81 ± 6.51 mm Hg, respectively, P = .027). Failure rates of the cellophane band constructs did not differ whether secured with PLLC or with TLC (P = .635) or with 25% vs 50% attenuation (P = .780). CONCLUSION: A single medium clip withstood physiological forces and secured a cellophane band at up to 50% attenuation. A 3-layer cellophane band was more likely to fail compared with a 4-layer cellophane band. CLINICAL SIGNIFICANCE: These ex vivo results provide evidence to support the application of a 4-layer cellophane band secured with a single medium PLLC or TLC for portosystemic shunt attenuation. A single medium PLLC should be used to eliminate computed tomography artifacts during postoperative evaluation of shunt closure.

Endoscopic management of refractory gastroesophageal reflux disease.

OBJECTIVE: Despite the therapeutic and surgical interventions for the management of gastroesophageal reflux disease (GERD), yet the high cost and the post-operative complications had led to a significant socioeconomic burden. The aim was to evaluate the safety and efficacy of endoscopic band ligation (EBL) in the management of refractory GERD. METHODS: A total of 150 patients with refractory GERD were assigned to an EBL group (banding was done at four quadrants just at the gastroesophageal junction (GEJ) (n = 75) or to a control group (optimized dose of PPI, n = 75). Follow-up for both groups by upper GI endoscopy to evaluate the site of the Z line from the incisors, the width of the GEJ and the coaptation of GEJ around the endoscope on retroflection. PH monitoring was performed every 3 months with GERD- QoL assessment monthly for 1 year. RESULTS: In EBL group; 58 patients (77.3%) needed 1 session, 17 patients (22.7%) needed 2 sessions. 4 rubber bands were utilized in 44 patients (58.7%), 3 rubber bands in 31 patients (41.3%). Follow-up for 1 year revealed a highly significant improvement of the GERD- QoL score, the site of Z line with significant reduction of reflux episodes and symptom index when compared to the medical treatment group. In EBL group; there were no major adverse events including bleeding, post band ulcers, stenosis at one year follow up. CONCLUSION: The current study provides a novel endoscopic intervention to treat refractory GERD, which is safe, cost-effective, with no major adverse effects at one year follow up.

Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach.

BACKGROUND: Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation. METHODS: Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips. RESULTS: Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86 min (range 40-135). There were no perioperative or postoperative complications. CONCLUSIONS: Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.

The influence of the different forms of appendix base closure on patient outcome in laparoscopic appendectomy: a randomized trial.

BACKGROUND: During laparoscopic appendectomy, the base of the appendix is usually secured by loop ligature or stapling device. Hem-o-lok and DS clips have been shown as alternative techniques. The aim of this study was to compare the clinical outcomes of various forms of securing the base of the appendix, in order to find the most suitable method. PATIENTS AND METHODS: The study included 120 patients with acute appendicitis randomly divided into four groups with 30 patients in each. In the first group, the base of the appendix was secured using an Endoloop, in the second group using a stapling device, in the third group using Hem-o-lok, and in the fourth group using a DS clip. The primary outcome was overall morbidity following securing the base of the appendix. Secondary outcomes were time of application and operative procedure, total length of stay, and surgical outcome. RESULTS: No morbidity was recorded in any group. The time of application was significantly longer in the Endoloop group than in the Stapler (P < 0.0001), Hem-o-lok (P < 0.0001), and DS clips (P < 0.0001) groups. The time of application in the Stapler group was significantly shorter than in the Hem-o-lok (P < 0.0001) and the DS clips (P < 0.0001) groups. The time of the operative procedure was significantly longer in the Endoloop than in the Stapler group (P < 0.0001). The time of the operative procedure in the Stapler group was significantly shorter than in the DS clips group (P < 0.0001) but did not differ significantly from the Hem-o-lok group (P = 0.199). The time of the operative procedure in the Hem-o-lok group was significantly shorter than in the DS clips group (P = 0.044). CONCLUSION: All forms of closure of the appendix base are acceptable, but Hem-o-lok and DS clips have the best potential for further development, and will probably become the method of choice in securing the base of the appendix.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices.

STUDY OBJECTIVE: To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices. DESIGN: Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I). SETTING: Division of Minimally Invasive Gynecologic Surgery in a university hospital. PATIENTS: Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively. INTERVENTIONS: Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH. MEASUREMENTS AND MAIN RESULTS: At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ2 test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups. CONCLUSIONS: The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.