Adverse Tissue Reactions to Orise Gel During Endoscopic Mucosal Resection and Dissection.

BACKGROUND: To facilitate endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), submucosal injection of lifting agents (LAs) is frequently used. ORISE™ gel, approved in 2018 by the US Food and Drug Administration (FDA), has been commonly utilized until recently. Its use grew rapidly due to its practical pre-filled syringe, prolonged lift effect, and ideal coloration. However, it has been noted to cause unexpected tissue reactions, described as "giant cell reaction" (GCR), which can obscure both macroscopic and microscopic views, potentially interfering with pathological evaluation. This study aims to describe the adverse effects of ORISE™ gel. METHODS: This retrospective study analyzed pathology specimens from all consecutive patients who received ORISE™ injections for attempted polyp removal and subsequently underwent segmental colon resection at our center between 2019 and 2022. Descriptive analysis was performed. RESULTS: A total of 45 patients were included, with 38% (n=17) being female and a median age of 66 years. The indications for surgery included adenocarcinoma in 14 patients (31%), suspected malignancy in 3 patients (7%) who had benign GCR-induced masses, and other indications in 28 patients, such as large polyps or recurrent polyps after initial endoscopic treatment. Surgical procedures included right hemicolectomy (44%), low anterior resection (13%), left colectomy (11%), sigmoidectomy (7%), and abdominoperineal resection (4%). Histologic evidence of prior LA injection was seen in 31 patients (69%), with 24 of these exhibiting GCR. At final pathology, no residual neoplasm was found in 9 patients (18%), while 14 patients (31%) had adenocarcinoma [T1 (7), T2 (3), T3 (3), T4 (1)]. CONCLUSION: ORISE™ Gel interacts with various tissue layers of the colon, frequently resulting in GCR. This reaction and the potential subsequent mass effect formation can impact decision-making in the management of complex colorectal lesions. Further study into the cause and consequences of LA tissue reactions is warranted.

Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions.

BACKGROUND: Endoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions. OBJECTIVE: This study aimed to assess patient outcomes following endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip. DESIGN: A retrospective review of a prospectively maintained database at a single tertiary care center was conducted. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Adult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded. MAIN OUTCOME MEASURES: En bloc resection rates, operative time, perioperative complications, and short-term outcomes such as length of stay and lesion recurrence on follow-up colonoscopy were evaluated. RESULTS: A total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8% with an average procedure time of 37.1 ± 29.8 min. There were two perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy. LIMITATIONS: This study was retrospective, conducted by two skilled endoscopists with experience in endoscopic resection, and had short-term follow up. CONCLUSIONS: Snare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing adoption of endoscopic resection and improving patient accessibility. See Video Abstract.

Using Remotely Operated Suction Irrigation System in da Vinci SP Submucosal Dissection.

BACKGROUND: Submucosal dissection using the da Vinci SP® system (Intuitive Surgical, Sunnyvale, CA, USA) is an emerging approach for treating premalignant lesions in the colon and rectum. The endoluminal space is tight and small, and during the procedure, this tight space is accessed by the 40 mm GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA). Most of the trocar space is occupied by the 25 mm port of the da Vinci SP® system. There is limited space for an additional trocar, and the full mobility of this trocar is restricted; hence there is a need for an effective suction irrigator during these procedures. Although the da Vinci SP® system has four instrument capabilities, it does not have a suction irrigation instrument. To address this issue, we tested a Remotely Operated Suction Irrigation System (ROSI™) (VTI, Nashua, NH, USA) in three patients undergoing da Vinci SP® submucosal dissection. IMPACT OF INNOVATION: The impact of innovation is the evaluation of a flexible suction irrigator during endorobotic submucosal dissection (ERSD), addressing space constraints and enhancing surgical precision. TECHNOLOGY MATERIALS AND METHODS: This was a single-center retrospective observational study involving three patients who underwent ERSD, between February 2023 and May 2023. ROSI™ was used selectively for rectal lesions. PRELIMINARY RESULTS: The first patient was a 67-year-old male with a 30 mm tubulovillous adenoma found in the rectum at 4 cm. The second patient was a 49-year-old female, referred after a screening colonoscopy, with a 40 mm rectal mass 12 cm from the anal verge. A biopsy revealed a tubular adenoma without dysplasia. The last patient was a 66-year-old male with a 25 mm tubulovillous adenoma with a focal high-grade dysplasia at 10 cm. There was no evidence of invasive carcinoma or lymph node metastasis on MRI in any of the patients. The patients were placed in a modified lithotomy position, and the GelPOINT® Path was inserted. A silk suture was attached at the proximal end of ROSI™ to facilitate tubing manipulation. ROSI™ was freely passed into the endoluminal space through the gel using a surgical clamp. Any bleeding during the operation was aspirated and irrigated using ROSI™ with the assistance of bipolar forceps. All surgeries were completed without complications and the patients were discharged on the same day. CONCLUSION AND FUTURE DIRECTIONS: ROSI™ is a flexible foot pedal-controlled suction irrigator that can facilitate da Vinci SP® submucosal dissection. The flexibility and controllability of ROSI in the surgeon's hand may qualify it as an essential tool for performing ERSD and possibly other TAMIS procedures.

Evaluating complete response rates and predictors in total neoadjuvant therapy for rectal cancer.

BACKGROUND: There is a paradigm shift in the management of locally advanced rectal cancer (LARC) from conventional neoadjuvant treatment to total neoadjuvant therapy (TNT). Despite its growing acceptance, there are limited studies that have examined its effects on disease presentation. In addition, it is important to determine the factors that play a role in complete response (CR). Our previous data from 119 patients revealed that the CR rate was 37%, and low rectal tumors and the absence of extramural vascular invasion (EMVI) were predictors of CR. Unfortunately, there continues to be a lack of data, and reliable markers are still needed to consistently identify the best respondents. Therefore, this study aimed to determine the factors associated with CR. Moreover, this study hypothesized that both predictive factors and the CR ratio might evolve over time because of the growing patient population. METHODS: This retrospective study included patients who completed TNT for LARC at our tertiary care center between 2015 and 2022. The primary outcome was to determine the predictors of CR. The secondary outcomes were the 2-year disease-free survival (DFS) rate and overall survival (OS) rate. CR consists of patients who sustained clinical CR (cCR) for at least 12 months under watch and wait or had pathologic CR (pCR) after surgery. RESULTS: Of 339 patients with LARC, 208 (61.3%) successfully completed TNT. Among 208 patients, 57 (27.4%) achieved cCR, and 166 (80.0%) sustained cCR without tumor regrowth after 1 year. The remaining 151 patients (72.6%) underwent surgery, and 42 patients had pCR. The final CR rate was 42.3%. The median age of the patients was 56 years (IQR, 49-66). Moreover, 132 participants (63.5%) were male, whereas 76 participants (36.5%) were female. The median tumor size was 4.95 cm (IQR, 3.60-6.43), with most tumors in the low rectum (119 [57.2%]). Based on the MRI findings, the mesorectal facia (MRF) involvement rate was 25.0% (n = 52), and EMVI was observed in 43 patients (20.7%). Low rectal tumors, the absence of MRF involvement, and the absence of EMVI were predictors of CR. With a median follow-up of 24.7 months, 2-year DFS and OS were significantly higher among patients with CR than among patients with incomplete response (91.3% vs 71.0% [P < .01] and 98.8% vs 90.2% [P = .03], respectively). CONCLUSION: An increasing CR rate was observed in our updated dataset compared with that in our previous study. In addition to previously identified predictors, low tumor location, and the absence of EMVI, the absence of MRF involvement was determined as a predictor of CR. Our findings offer valuable insights into clinical practice and help clinicians set clear expectations when counseling patients.

Ventral mesh rectopexy for recurrent rectal prolapse after Altemeier perineal proctosigmoidectomy: feasibility and outcomes.

PURPOSE: Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure. METHODS: We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier's perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy. RESULTS: Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m2 (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred. CONCLUSION: Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis.

BACKGROUND: Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years. METHODS: We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups. RESULTS: Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates. CONCLUSION: Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.

Robotic colorectal surgery and future directions.

As the adoption of robotic-assisted procedures expands across various surgical specialties, colorectal surgery stands out as a prominent beneficiary. This rise in usage can be traced back to the increased accessibility of robotic platforms and a growing institutional shift towards cutting-edge surgical methods. When compared with traditional laparoscopic methods, robotic techniques offer distinct advantages. Their true potential shines in surgeries involving complex anatomical regions, where the robot's enhanced dexterity and range of motion prove invaluable. The three-dimensional, magnified view provided by robotic systems further boosts surgical precision and clarity. These advantages render robotic assistance especially suitable for colorectal surgeries, notably in intricate areas such as the rectum and endoluminal spaces. As the medical world emphasizes minimally invasive surgical methods, there's a pressing need to evolve and optimize robotic techniques in colorectal surgery. This article traces the evolution of robotic interventions in colorectal surgeries, highlighting both its historical milestones and anticipated future trends. We'll also explore emerging robotic tools and systems set to reshape the colorectal surgical arena.

The impact of the preoperative red blood cell distribution width on weight loss prediction after sleeve gastrectomy.

AIM: We aimed to evaluate whether RDW has a predictive impact on weight loss after obesity surgery. MATERIAL AND METHODS: This was a single-institution retrospective study. Multiple linear regression analysis was used to determine the variables affecting the %EBMIL and %EWL values. Surgery of patients with %EMBIL > 50% and %EWL > 25% was considered successful. RESULTS: Hundred and ten patients were included in the study. The %EBMIL and %EWL values of patients with RDW>14.5% were lower. In the evaluation of successful surgeries, the probability of failure for those with RDW>14.5% is 10.93 times higher for %EBMIL and 21.55 times for %EWL. DISCUSSION: After the linear regression analysis, it was observed that the %EBMIL and %EWL were higher in the patients whose RDW values were 14.5 and below in the preoperative period. In these patients, it is an indication that more weight loss has occurred. Similar to our study, Wise et al. showed that weight loss was greater with a decrease in the RDW value 10. CONCLUSION: Preoperative RDW value can be used as a predictor of weight loss and surgical success. It can provide an idea about whether the patient will lose enough weight and the success of the surgery. KEY WORDS: Prediction, RDW, Sleeve Gastrectomy.

Prediction of short-term results after laparoscopic right hemicolectomy. Is sarcopenia superior to other methods?

Background: Complication treatment in colorectal cancer can be carried out quickly with the prediction and early diagnosis. However, there is no apparent predictive factor for this. Objective: We aimed to determine the factors that predict early mortality and morbidity in patients who underwent laparoscopic right hemicolectomy and their superiority over each other. Method: Demographic data, age-adjusted Charlson Comorbidity Index, American Society of Anesthesiologists Score, body mass index, modified-Glasgow Prognostic Score (mGPS), stage of disease, and sarcopenia were evaluated in patients who underwent right hemicolectomy between 2010-2022. Their superiority in predicting short-term outcomes was compared. Results: 78 patients were included in the study. The complication rate was higher in sarcopenic patients (p = 0.002). A high mGPS score was associated with increased mortality risk (p = 0.012). Other methods were not found to be related to short-term results. Conclusion: Sarcopenia is useful for the prediction of complications, and the mortality rate can be estimated by the mGPS score. These are superior to the other short-term results prediction methods. However, randomized controlled studies are needed.

Antecedentes: El tratamiento de complicaciones en el cáncer colorrectal puede llevarse a cabo rápidamente mediante la predicción y el diagnóstico temprano. Sin embargo, no existe un factor predictivo claro para esto. Objetivo: Determinar los factores que predicen la mortalidad y la morbilidad precoces en pacientes sometidos a hemicolectomía derecha laparoscópica y su superioridad entre ellos. Método: Se evaluaron datos demográficos, el índice de comorbilidad de Charlson ajustado por edad, el puntaje de la American Society of Anesthesiologists, el índice de masa corporal, el puntaje de pronóstico de Glasgow modificado (mGPS), el estadio de la enfermedad y la sarcopenia en pacientes que se sometieron a hemicolectomía derecha entre 2010 y 2022. Se comparó su superioridad en la predicción de resultados a corto plazo. Resultados: Se incluyeron en el estudio 78 pacientes. La tasa de complicaciones fue mayor en los pacientes sarcopénicos (p = 0.002). Una puntuación mGPS alta se asoció con un mayor riesgo de mortalidad (p = 0.012). No se encontró que otros métodos estuvieran relacionados con los resultados a corto plazo. Conclusiones: La sarcopenia es útil para la predicción de complicaciones y la tasa de mortalidad puede estimarse mediante la puntuación mGPS. Estos son superiores a los otros métodos de predicción de resultados a corto plazo. Sin embargo, se necesitan estudios controlados aleatorizados.

The contribution of laparoscopic distal pancreatectomy videos on YouTube to the learning curve in the COVID-19 pandemic.

There is no standardization in videos uploaded to Youtube. Were the videos capable of contributing to adequate technical quality and surgical training? We are aiming to answer these questions in this paper. It is a cross-sectional study. In January 2022, we searched the Youtube platform using the keyword "distal pancreatectomy." The substantiality, transparency, reliability, quality, popularity and educational values of the video content were evaluated after exclusion criteria. These parameters were evaluated using we the modified Journal of American Medical Association benchmark criteria, Global Quality Score (GQS), Video Power Index, modified laparoscopic pancreatectomy scoring system. The videos uploaded after the pandemic had a statistically significant higher GQS score (P < .001). Video Power Index, like GQS, had a statistically significant difference before and after the pandemic. (P = .046). There was no significant difference in the evaluation of the reliability and substantiality. Until the development of Youtube videos is completed, peer-reviewed, more reliable and content-rich online education platforms should be preferred in the first place. Care should be taken to watch selected videos on Youtube videos.

The role of basic blood parameters in determining the viability of intestinal tissue in incarcerated hernias.

OBJECTIVE: Abdominal hernia repair is a common surgery, with incarcerated hernias accounting for 15% of all cases. In these cases, early diagnosis of intestinal ischaemia and necrosis is crucial to prevent mortality and morbidity. Biomarkers that can predict ischaemic or necrotic status are of vital importance. The aim of this study was to reveal the roles of basic blood parameters in determining ischaemic or necrotic status. METHODS: Patients were divided into three groups. Group I included 24 patients with normal bowels, Group II included 31 patients with intestinal ischaemia without necrosis, and Group III included 10 patients who underwent bowel resection for necrosis. Patients' demographic characteristics and blood parameters were retrospectively analysed. RESULTS: A total of 65 patients were operated for incarcerated abdominal hernias. There was no significant difference between the groups in terms of age, sex, comorbidity or complications (P > .05). Group III had the longest length of hospital stay (P < .001). There were significant differences between the groups in terms of serum white blood cell (WBC), neutrophil, lymphocyte (LYM), neutrophil-lymphocyte ratio (NLR), urea, creatinine, total bilirubin, indirect bilirubin, lipase, C-reactive protein (CRP) and lymphocyte-to-C-reactive protein (CRP) ratio (LCR) values (P < .05). CONCLUSION: Blood parameters combining with clinical symptoms and radiological examination may contribute to predicting intestinal resection. Preoperative WBC, neutrophil, NLR, urea, creatinine and total bilirubin levels can contribute to predict the onset of intestinal ischaemia. Serum creatinine, total bilirubin, indirect bilirubin, phosphorus, lactate dehydrogenase (LDH) and lipase levels can contribute to deciding on bowel resection.

Patient-centered oncosurgical planning with cancer models in subspecialty education.

BACKGROUND: A fundamental aspect of oncosurgical planning in organ resections is the identification of feeder vessel details to preserve healthy organ tissue while fully resecting the tumors. The purpose of this study was to determine whether three-dimensional (3D) cancer case models of computed tomography (CT) images will assist resident-level trainees in making appropriate operative plans for organ resection surgery. METHODS: This study was based on the perception of surgery residents who were presented with 5 different oncosurgical scenarios. A five-station carousel including cases of liver mass, stomach mass, annular pancreas, pelvic mass and mediastinal mass was formed for the study. The residents were required to compare their perception level of the cases with their CT images, and 3D models in terms of identifying the invasion of the mass, making differential diagnosis and preoperative planning stage. RESULTS: All residents have given higher scores for models. 3D models provided better understanding of oncopathological anatomy and improved surgical planning. In all scenarios, 70-80% of the residents preferred the model for preoperative planning. For surgical choice, compared to the CT, the model provided a statistically significant difference in terms of visual assessment, such as tumor location, distal or proximal organotomy (p:0.009). In the evaluation of presacral mass, the perception of model was significantly better than the CT in terms of bone-foramen relationship of chondrosarcoma, its origin, geometric shape, localization, invasion, and surgical preference (p:0.004). The model statistically significantly provided help to evaluate and prepare the case together with the colleagues performing surgery (p:0.007). Commenting on the open-ended question, they stated that the tumor-vessel relationship was clearly demonstrated in the 3D model, which has been very useful. CONCLUSIONS: With the help of 3D printing technology in this study, it is possible to implement and evaluate a well-structured real patient scenario setup in cancer surgery training. It can be used to improve the understanding of pathoanatomical changes of multidisciplinary oncologic cases. Namely, it is used in guiding the surgical strategy and determining whether patient-specific 3D models change pre-operative planning decisions made by surgeons in complex cancer mass surgical procedures.

Surgical planning with patient-specific three-dimensional printed pancreaticobiliary disease models - Cross-sectional study.

BACKGROUND: Three-dimensional (3D) printing has been increasingly used in medical applications with the creation of accurate patient-specific 3D printed models in medical imaging data. This study has been planned based on the fact that research on 3D printing in pancreaticobiliary disease is limited due to lack of studies on validation of model accuracy. METHODS: This is an innovative study where general surgery residents are presented 5 distinct hepatopancreatobiliary disease scenarios to generate a perception and required to compare their perception level of these cases with magnetic resonance cholangiopancreatography (MRCP), 3D images and 1:1 solid models that the pathology, diverse diagnosis and presurgery diagnosis stages can be observed. This study is single-centered. RESULTS: The dilated pancreaticobiliary intervention based on scenarios for general surgery residency was more original since there was no prior study that includes both model building and the evaluation of the perception created by the model. Five scenarios provided qualitative assessment with results showing the usefulness of 3D models when used as clinical tools in preoperative planning, simulation of interventional procedures, surgical education, and training. The perception level in the 3D model, MRCP (Z: 3.854, p: 0.000) and the 3D image (Z: 2.865, p: 0.004) was higher; likewise, the 3D-STL image was higher compared to the MRCP image (Z: 3.779, p: 0.000). All subspecialists agree that 3D models provided better understanding of dilated pancreaticobiliary pathoanatomy and improved surgical planning. CONCLUSIONS: A thoroughly outlined genuine patient situation layout aimed for general surgery training can be installed and monitored with the support of 3D printing technology of this study. This can be utilized to develop the comprehension of pathoanatomical variations of complex pancreaticobiliary illness and to adopt a surgical approach.