Circumferential Incision Research Articles

New Developments in Surgical Treatment for Penile Size Preservation in Peyronie’s Disease

Peyronie's disease (PD) is associated with penile length loss due to atrophy that occurs as a result of fibrous inelastic scarring. Studies have shown diminished penile length and girth, as well as the inability to participate in sexual activity, can lead to decreased quality of life, emotional challenges, and sexual dissatisfaction in a large percentage of men. To provide a summary of the new developments in the surgical techniques available for the PD patient, with a focus on procedures that provide penile size restoration. A MEDLINE PubMed search was used to identify articles related to surgical treatments for PD, including plication procedures, penile prosthesis placement, and techniques for size restoration. Types of surgical treatments for PD and their outcomes regarding penile length and patient satisfaction. The Nesbit procedure, among other plication procedures, and penile prosthesis placement with modeling or plication are likely to decrease penile length. Although plaque incision with grafting offers restoration of penile length, it carries a risk of postoperative erectile dysfunction (ED). For men with concomitant ED and severe curvature not amenable to prosthesis with modeling or plication, options include grafting, circumferential tunical incisions, subcoronal prosthesis placement, and the sliding technique with its modifications, allowing for management of both PD and ED while restoring penile length. Adjunct procedures, such as ventral phalloplasty and suspensory ligament release, have also been shown to restore length in PD patients. Novel therapies continue to evolve with the goal of preserving length while treating curvature. There are numerous surgical options for correcting penile curvature in PD patients, with or without concomitant ED treatment. When determining the optimal procedure, it is important to consider possible preservation of penile length and to discuss possible complications to increase patient satisfaction and improve quality of life. Barrett-Harlow B, Clavell-Hernandez J, Wang R. New Developments in Surgical Treatment for Penile Size Preservation in Peyronie's Disease. Sex Med Rev 2019;7:156-166.

Preliminary Kidney Parenchymal Ligation Using Endoloop Ligatures—A Simple Method to Achieve a Trifecta in Laparoscopic Partial Nephrectomy Without Hilar Clamping for Polar Complex Tumors

To describe a novel and simple technique of preliminary kidney parenchymal ligation using Endoloop ligatures during laparoscopic partial nephrectomy (PN) without hilar clamping for polar complex tumor cases. The subjects were 17 patients who had a renal mass with a R.E.N.A.L. nephrometry score ≥7 (7/8/9/10 in 3/6/6/2 patients, respectively) located in the pole of the kidney. Patient-specific 3D reconstructed kidney images were created for preoperative planning in all cases. The renal hilar vessels were meticulously dissected and definitive tumor feeders were sacrificed when the branches directly perfused the peri-tumor area. Following the vascular microdissection, a circumferential cortex-depth incision on the kidney was made all around the tumor. Consequently, several Endoloop ligatures were placed in the incised tumor base to ligate the parenchyma preliminarily. Step-by-step Endoloop tightening facilitated effective parenchymal dissection without the urinary tract. After confirming that the tumor base parenchyma was ligated sufficiently, tumor resection was completed. Neither inner- nor outer-layer renorrhaphy sutures were placed. Perioperative outcomes were satisfactory and all patients had negative surgical margins with no damage in the tumor capsule. Urological complications and renal function lower than predicted at 3 months after surgery involved 1 and 3 cases, respectively. The rate of PN trifecta achievement was 82% (14/17) despite the complexity of the 17 tumors. The current technique helped surgeons achieve the trifecta in patients with polar complex masses treated with laparoscopic PN. Use of this technique can provide surgeons with a bloodless operative field even during PN without hilar clamping.

Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study

The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. Two 30-mm circular lesions were created in an exvivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P< .001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P< .001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P< .001). The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States.

Two Surgical Techniques for Essure Device Ablation: The Hysteroscopic Way and the Laparoscopic Way by Salpingectomy with Tubal Interstitial Resection

To describe 2 different surgical techniques for Essure removal on the same patient: the hysteroscopic and laparoscopic techniques. An educational video approved by the local institutional review board (Canadian Task Force classification III). A university hospital (University Hospital of Strasbourg, Strasbourg, France). A 46-year-old woman with many symptoms after Essure device implantation. An ultrasound found a right implant in the uterine cavity and a left intratubal implant. The first step was the hysteroscopic removal of the right implant. We viewed the 2 internal and external spirals, allowing the gripping of the whole device without risking any fragmentation or tubal lesion. The second step was bilateral salpingectomy with resection of the left interstitial tubal portion. We longitudinally incised the antimesial edge of the fallopian tube 2 to 3cm from the tubal serous to the implant contact. A circumferential incision was performed at the uterine horn to circumscribe the interstitial tubal portion. The implant was released from the surrounding tissue. It was gently pulled to completely extract it and avoid spiral fragmentation. Then, we performed a bilateral total salpingectomy. An X-ray of the implants and pelvis was performed to ensure complete removal of the device. We made an X-stitch in the uterine horn to avoid the risk of fistula. More and more patients are asking for the removal of their implants. The surgical technique has to be adapted to the location of the implants and has to allow their complete removal to avoid leaving fragments that can cause the persistence of side effects.

Sa1919 CLUTCH CUTTER KNIFE IMPROVES THE SAFETY OF ENDOSCOPIC SUBMUCOSAL DISSECTION AMONG NOVICES

Endoscopic submucosal dissection (ESD) is a method of resecting gastrointestinal lesions that allows for curative en bloc resection of large, flat lesions. However, ESD is technically challenging and difficult to learn. The risk of perforation remains a significant barrier to its widespread usage. Unlike conventional ESD knives, the Clutch Cutter knife allows for tissue grasping prior to electrosurgical incision, helping improve cut precision. We aimed to determine whether use of the Clutch Cutter improved safety among novice performers of ESD. We prospectively studied gastroenterology trainees and staff without experience in ESD. Participants performed ESD on an ex-vivo porcine stomach model. We compared the differences in ESD performance using the Clutch Cutter and a conventional knife (Hook knife). Participants were provided a brief theoretical introduction to ESD. A short hands-on session to practice using the knives in the animal model followed. Participants then performed circumferential incision and submucosal dissection of two, 2 cm (diameter) marked and submucosally lifted lesions. One excision was performed with the Clutch Cutter and the other with the conventional knife. Participants were individually randomized to use a certain knife first. We recorded adverse events (including full-thickness perforation, target sign, and unintentional incision), procedure time, and successful en bloc resection for each dissection. Continuous variables were compared using paired t-test; categorical variables were compared using Chi-squared analysis. P-values <0.05 were considered statistically significant. Seven endoscopists (5 trainees and 2 staff) participated in this study. Prior endoscopic experience ranged from 430-5000 (median 726) endoscopies, but all participants were novice to performing ESD. Compared to the conventional knife, use of the Clutch Cutter was associated with a significantly lower rate of perforation or target sign (14.3% vs. 71.4%, P=0.031), and unintentional incision (0% vs. 85.7%, P=0.001) (Table 1). All perforations and target signs in both groups were incurred during submucosal dissection. When compared to the conventional knife, use of the Clutch Cutter was associated with a trend towards longer time to completion of circumferential incision (median 18 min vs. 8 min, P=0.112), but shorter time to completion of submucosal dissection (median 3 min vs. 15 min, P=0.094). The total procedure time was not significantly different between use of the Clutch Cutter and conventional knife (median 23 min vs. 20 min, P=0.738). Among novices performing ESD on an animal model, use of the Clutch Cutter knife was associated with a significantly lower rate of adverse events without prolonging procedure time. Based on limited data, the Clutch Cutter appears to improve ESD safety, at least among learners.Tabled 1Outcomes of endoscopic submucosal dissection using the Clutch Cutter and a conventional knife.Clutch Cutter (n=7)Conventional knife (n=7)P-valueAdverse eventsPerforation14.3% (1/7)28.6% (2/7)0.094Target sign14.3% (1/7)57.1% (4/7)0.031Perforation or target sign14.3% (1/7)71.4% (5/7)0.031Unintentional incision0% (0/7)85.7% (6/7)0.001Median no. unintentional incision per resection02 (IQR 1-3)0.036Time to initial incision (sec)150 (IQR 36, 220)22 (IQR 15, 65)0.071Circumferential incision time (min)18 (IQR 11, 20)8 (IQR 2, 9)0.112Submucosal dissection time (min)3 (IQR 2, 14)15 (IQR 7, 18)0.094Total procedure time (min)23 (IQR 17, 38)20 (IQR 14, 24)0.738En bloc resection100% (7/7)71.4% (5/7)0.127IQR, interquartile range Open table in a new tab

Sa1057 THREE-DIMENSIONAL UPPER GASTROINTESTINAL ENDOSCOPY: A CLINICAL STUDY OF SAFETY AND AN EX VIVO STUDY OF UTILITY IN ENDOSCOPIC SUBMUCOSAL DISSECTION

The utility of three-dimensional (3D) endoscopy in the field of therapeutic endoscopy was investigated ex vivo using a newly developed 3D endoscope. Also, we conducted a clinical study to investigate the safety of 3D endoscopy as an upper gastrointestinal (GI) screening tool in actual clinical practice using the 3D endoscope, which had recently been approved as a medical device. To investigate the utility of this 3D endoscope in therapeutic endoscopy, an excised pig stomach with a 10-mm hypothetical lesion was attached to an endoscopic training simulator. The outcomes of endoscopic submucosal dissection (ESD) performed under two-dimensional (2D) and 3D conditions were compared based on the rate of en bloc resection, incidence of perforation, time required for circumferential incision and resection, and severity of eyestrain based on the symptoms of eyestrain, eye pain, blurred vision, heavy-headedness, and headache. Severity of eyestrain was evaluated before and after ESD using a visual analog scale (VAS; 0–100 mm). Eight endoscopists each performed ESD on 4 hypothetical lesions (2 lesions each for 2D and 3D endoscopy). A clinical study was conducted to investigate the safety of 3D endoscopy in 60 patients (36 men, 24 women; mean age 59.3 years) who had given written informed consent to participate in the study. We evaluated the severity of eyestrain in endoscopists before and after each endoscopic procedure, by using the VAS. All 32 lesions were resected en bloc. Perforation was observed in one 2D case. Circumferential incision time was significantly shorter in the 3D group than in the 2D group (102.8 ± 42.1 vs. 135.8 ± 65.7, respectively; p < 0.05), as was resection time (366.3 ± 187.6 s vs. 517.8 ± 282.3 s, respectively; p < 0.05). Intergroup comparisons revealed that the severity of eyestrain-related symptoms, except for blurred vision, was significantly higher in the 3D group than in the 2D group. In the clinical study, none of the 60 patients developed adverse events such as bleeding and perforation, demonstrating the safety of 3D endoscopy. Severity of eyestrain in the endoscopists was significantly higher for all items, except for headache, after endoscopic procedure. Resection time was significantly shorter in 3D ESD than in 2D ESD. Also, 3D ESD was performed safely, with no incidence of perforation. These findings suggest that 3D endoscopy enables rapid and stable ESD because of easy recognition of structures and acquisition of depth information. Furthermore, in the clinical study, 3D endoscopy was performed safely, with no occurrence of severe adverse events.

Su1112 EFFICACY AND SAFETY OF SNARE TRACTION FOR ENDOSCOPIC SUBMUCOSAL DISSECTION OF EARLY ESOPHAGEAL CARCINOMA AND PRECANCEROUS LESIONS

Endoscopic submucosal dissection(ESD) has been rapidly gaining popularity worldwide recently due to high en bloc resection rate, minimally invasive procedure, patient rapid recovery and reduced health-care cost. However, ESD is associated with more complications, such as bleeding and perforation, especially in esophageal cases without good visualization of the dissection layer. Therefore, the efficacy and safety of snare traction for ESD of early esophageal carcinoma (EEC) or precancerous lesions was investigated. 57 EEC or precancerous patients were enrolled in the study and randomly divided into two groups . 26 cases underwent ESD with snare traction (snare group). In snare group, a snare was clamped to the oral side of the lesion after the circumferential incision and pushed in the anal direction during ESD. 31 cases underwent routine ESD without snare traction (non-snare group). The total dissection time, en bloc resection rate , average dissection area per minute, times of muscularis propria injury and incidence of perforation were statistically analyzed. ESD was successful in all 57 cases with 100% en bloc resection and there was no perforation during ESD or after ESD in all these cases. No significant difference was found between the two groups with respect to the dissection area (17.01±8.42cm2 vs 17.41±7.08cm2, P>0.1). The total dissection time of ESD was shorter in the snare group than in the non-snare group (57.10±9.65min vs 87.12±10.24min，P<0.05) . The average dissection area per minute is higher in the snare group than in the non-snare group(29.78±7.06 mm2/min vs 18.44±6.58mm2/min, P<0.05).Moreover, the muscularis propria injuries in the snare group were obviously less than the non-snare group (1.32±1.06 vs 2.50±1.12，P<0.05). Snare traction is potential for decreasing the injury of muscularis propria layer and total dissection time during ESD for esophageal cancerous lesions with easy control. It could be recommended as a safe and effective procedure for ESD of EEC and precancerous lesions.

Sa1893 EFFICACY AND SAFETY OF A MAGNET TRACTION DEVICE FOR ENDOSCOPIC SUBMUCOSAL DISSECTION: EX-VIVO STUDY IN A PORCINE MODEL

Many traction devices have been developed for safer and easier endoscopic submucosal dissection (ESD). However, traction caused by most devices depends on the endoscopic longitudinal direction with ineffective traction attained in most cases. Magnetic anchor-guided ESD has been reported and requires both an internal and external magnet. This system allows traction to occur independent from the endoscopy. However, the strength of the magnets varied by location of the lesion and thickness of the abdominal wall. Thus, we developed a magnet traction device that consisted of two internal magnets. The aim of this study was to evaluate the efficacy and safety of an internal magnet traction device (MTD) for ESD in ex vivo porcine stomachs. The MTD consisted of a small neodymium magnet and a 2-0 suture (2cm length) attached to a hemoclip. A circumferential mucosal incision was completed around a 30mm round template that served as the target lesion. The first MTD was deployed at the edge of the lesion and the second MTD was deployed on the opposing wall to the lesion which resulted in both magnets connecting. This created traction of the target lesion towards the opposing wall facilitating resection (Figure). Submucosal dissection was performed using a needle knife. After resection of the lesion, all MTDs and hemoclips attached to the lesion were retrieved en bloc using a snare. The primary outcome measure was the comparison of submucosal dissection times between conventional ESD (C-ESD) and MTD assisted ESD (MTD-ESD). Secondary outcomes measured included rate of en bloc resection, visualization of submucosal layer during dissection, number of muscular injuries, and ease of use of the MTD. Visualization and ease of use were evaluated using a visual analog scale ranging from 1 (poor) to 5 (excellent). A total of 20 lesions were created in five porcine stomachs along the anterior wall, posterior wall or greater curvature. Ten lesions each were resected using C-ESD or MTD-ESD. En bloc resection was successfully completed without perforation in all cases. All MDTs were retrieved successfully. The submucosal dissection time in MTD-ESD was significantly shorter than C-ESD (median: 6.4minutes [IQR: 4.6 – 8.7] vs.14.4 minutes [IQR: 11.8 – 18.0], p<0.05). The visualization score of the submucosal layer during dissection in MTD-ESD was significantly higher than in C-ESD (median: 5 [IQR: 4 - 5] vs.3 [IQR: 2 - 4], p<0.05) and the number of muscular injuries was significantly lower in MTD-ESD than C-ESD (median: 0 [IQR: 0 - 0] vs.1 [IQR: 0 - 2], p<0.05). The ease of use score of MTD was excellent (median: 5 [IQR: 5-5]) (Table). The MTD-ESD was both effective and safe compared to C-ESD with significantly shorter procedure time, improved visualization of the submucosal layer and absent deep muscle-based trauma.TableMTD-ESD (n=10)C-ESD (n=10)P valueRate of en bloc resection100%100%-Submucosal dissection time (minute); medium (IQR)6.4 (4.6 – 8.7)14.4 (11.8 – 18.0)<0.05Specimen size (mm); medium (IQR)38 (36 - 40)39 (36 - 40)0.908Visualization score of submucosal layer; medium (IQR)5 (4 - 5)3 (2 - 4)<0.05Number of muscular injuries; medium (IQR)0 (0 - 0)1 (0-2)<0.05Ease of use score of MTD; medium (IQR)5 (5-5)-- Open table in a new tab

Transanal minimally invasive surgery for local excision of early rectal tumor.

Local excision (LE) is used in early rectal cancer and other pathologies for diagnostic purposes and curative treatment, as well as for palliative surgery in patients who are medically unfit for radical resection. Recently, transanal minimally invasive surgery (TAMIS) has been increasingly accepted as a means for performing LE. Here, we present a TAMIS technique for LE to which endoscopic submucosal dissection was applied. We used conventional laparoscopic instruments, including a 10-mm 30° camera. A GelPOINT Path® was introduced into the anal canal to maintain stable pneumorectum and valve-free access. After injecting MucoUp® (SI-4404) into the submucosal layer at the edge of the tumor, we marked dots on the mucosa with cautery using the point of the monopolar diathermy L-hook; we then performed circumferential mucosal incision and submucosal dissection. The remaining defects do not always have to be sutured. TAMIS for LE was performed for seven patients with no postoperative complication and mortality. One lesion required full-thickness resection, one lesion required partial full-thickness resection, and five lesions were dissected completely beneath the submucosal layer. Based on the pathological results, three patients underwent conventional radical resections. One patient had local recurrence at the 8-month follow-up and underwent endoscopic mucosal resection. TAMIS may be a promising option for LE that provides acceptable oncological outcomes and benefits to quality of life.

Entry into the anterior cul-de-sac during vaginal hysterectomy.

We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections. Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat. This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.

Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients

To describe our technique and outcomes using an autologous rectus fascia interposition graft for repair of recurrent urethrocutaneous fistulae (UCF) following metoidioplasty. A circumferential incision is made to the skin surrounding the UCF and carried to the level of the underlying subcutaneous tissues. The inner fistula skin edges are closed with a running 5-0 monofilament absorbable suture to obliterate the urethral side. The length of the urethral wound is measured and an appropriate sized rectus fascia graft harvested from a small transverse lower abdominal incision that is also used for concomitant percutaneous suprapubic tube placement. Prior to outer skin closure with a running 5-0 monofilament absorbable suture, the fascial graft is spread-fixed between the urethra and skin to avoid overlapping suture lines. A 10-French urethral catheter is removed after 10 days and the suprapubic catheter removed after 2-3 weeks. Three patients have undergone repair of recurrent UCF with this technique since February 2017. All patients had undergone metoidioplasty with a mean time to fistula occurrence of 3.2 months. Mean number of prior UCF repairs was 3.0. With a median follow-up since repair of 7.0 months (range 4-8), no patient has reported UCF recurrence. UCF following metoidioplasty is a difficult surgical complication. Fistula closure with interposition of autologous rectus fascia allows for separation of suture lines and encourages healing without extensive reconstruction.

Endoscopic full-thickness resection of a gastric subepithelial tumor.

Incidental subepithelial tumors are found in about 1 in 300 upper endoscopies. EUS-guided FNA can aid in establishing a diagnosis, but it cannot provide appropriate information about malignant potential because of the absence of a histologic mitotic count. In a small subset of patients, FNA is inconclusive. Inconclusive diagnosis and lack of prognostic histologic features can submit patients to continued endoscopic surveillance. We present a case of a full-thickness resection (FTR) of a gastric subepithelial nodule followed by endoscopic suturing to close the defect (Video 1, available online at www.VideoGIE.org). An 81-year-old man was found to have an incidental gastric body nodule during upper endoscopy for GERD (Fig. 1A). EUS revealed a 1.5-cm × 1.4-cm subepithelial tumor arising from the submucosa and muscularis propria (Fig. 1B). Cytologic analysis from FNA showed spindle cells, and immunostains were positive for CD34 and CD117, suggestive of a GI stromal tumor. The decision was made to perform endoscopic FTR after discussion with the patient about risks, benefits, and alternatives. Using an IT nanoknife (Olympus Optical Co, Tokyo, Japan), we performed a 360° circumferential mucosal incision defining the boundaries of the subepithelial nodule (Fig. 1C). The 360° incision was then extended deeper into the muscularis propria along the line of the initial incision. Finally, with an IT nanoknife, we completed the 300° full-thickness incision. We intentionally avoided the last 60° of the serosal layer to prevent migration of the resected specimen into the peritoneum. Hemostasis was achieved for bleeding vessels encountered during dissection by coagulation forceps. A 4-cm full-thickness defect was seen when the mesenteric fat was visualized endoscopically. The remaining pedicle was resected with a hot snare and retrieved with a Roth net (Fig. 1D). The defect was closed by 2 series of running nonabsorbable sutures by use of the endoscopic suturing device (Fig. 1E). A helix device was used to facilitate suturing. Pathologic examination of the nodule confirmed an FTR of the gastric subepithelial tumor. CT of the abdomen with enteric contrast material confirmed adequate closure of the resection site. The patient was discharged after a 23-hour observation period. A 2-month follow-up endoscopy showed hyperplastic tissue at the suture site without any residual nodule (Fig. 1F). This technique of endoscopic FTR for gastric subepithelial nodule and closure by use of an endoscopic suturing device can be safe and can provide a definitive diagnosis with malignant risk stratification, eliminating the need for continued endoscopic surveillance. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZTE3YjdiZDk1YWFlYTg1MzBiNzhjNmMwOTQ1ZjI4ZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4Njg4NDE1fQ.HLb7sIdJm7iiZ2xE3kOeRrGr_85vINonX9jhLHqH8jKk1DpbmKTkYfCicOMGKUie4LIvHMtEVeIgehB2_aXCLH3ENgkLHboRQp2o4lb8lIt2JOppUtAtVotXSFt04r-cGFEFi5qy2IkeP18TVDz_MJ8AOyeCYBuwgV76cR8ZiybR06afWFj2uHPjcledsq0nHh2c3foLNux4BQgbQ2L0TKWo9fjqElS-UycU3uXkjpMufg7pqWiIzvCppTFv1jTPKrP3k0dCoD_ZMy3W4kx8E47mQ6xIHaVU9jFGDFtwUQpGzFFsYd3D2lhJIzQfj3FC0LiDx-jfwAYtPSDKFa6gSA Download .mp4 (108.52 MB) Help with .mp4 files Video 1Video demonstrating endoscopic full-thickness resection (EFTR) of a gastric subepithelial nodule.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlOWNlNGMwZTczNWQ0ZjNjMzg1NzQ3ODY1MTNmMmI0YyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4Njg4NDE1fQ.isUNWZpZ3rpU1cKIn8qyW3rluqAVY4e-VjFofPMn9IqC_-m2nOan9tdEP5pfPRa9bRwvJJJL8bSuYPItx2TJHcOtqR_1jhCY8_EOAfRJTexJsxE4SRAaQsOStIHxTEPU9htpYr4wj7JoKgA8qv0EXKJWeshtq7Ks8BvT_RNzEdicwbI2m8fToFSEbmsATLjvr8JykWaC6KdCkTjjxQawcvB7NkRsPMFOeZ7jmdsetXJYThvq-PjB4msxAD3AR5qmaNnQQnGDlCUyxOBuwlu9PJfb1uWFMA13pnO9lLusuMiGvSNLaQzOdr_glBA5vQO2IkZs8fSjQUI7yfVTtIGogA Download .mp4 (167.22 MB) Help with .mp4 files Video 2 Download .docx (.01 MB) Help with docx files Video Script

Vestibulo-Rectal Pull Through in H-Fistula in Girls.

Aims and Objectives:Vestibulo-rectal pull-through (VRPT) in H-fistula in girls was first described by Chatterjee et al. We are presenting our experience with this approach in 47 cases.Materials and Methods:We have total 47 cases of which one is a recurrent fistula operated outside. A circumferential incision is made around the fistula in the vestibule; fistula tract is dissected liberally and delivered by invagination into the bowel. Then, the fistula tract is excised adequately and closed from within the bowel lumen so that no anterior outpouching of the rectum remains. The perineal body is repaired through the vestibular incision. In no cases, protective colostomy was performed. Only the recurrent fistula case had colostomy done in another institution.Results:Complete cure was obtained in 45 out of 47 cases. Two of our earlier cases had recurrences perhaps due to inadequate mobilization, but in later cases, we had no recurrence.Conclusion:VRPT yields good result without the need for colostomy. Incisions on the perineal skin or the anal verge are avoided, thus improving the cosmetic outcome.

Control of inferior vena cava injury during laparoscopic surgery using a double balloon-equipped central venous catheter: proof of concept in a live porcine model

BackgroundIatrogenic inferior vena cava (IVC) injury is a rare but potentially life-threatening complication during laparoscopic surgery. This experimental study aimed to assess the hemostatic ability of a new device, double balloon-equipped central venous (DB-CV) catheter, for IVC injury.MethodsThe DB-CV catheter comprises a triple-lumen sphincterotome combined with two dilating balloons having a diameter of 25 mm. The experimental procedures were performed in five pigs. The DB-CV catheter was inserted via the right femoral vein. For the IVC occlusion test, correct placement of the balloons was confirmed by indocyanine green fluorescence imaging, and hemodynamic data were recorded. For the IVC injury test, a 3- to 4-mm circumferential incision was created in IVC, and hemostasis was initiated using balloon inflation 5 s after the injury.ResultsHemodynamic changes were minimal, with a 20 mmHg reduction in the mean arterial pressure because of IVC occlusion. All bleeding from IVC injuries was successfully temporarily stopped by direct balloon compression, with a mean time to hemostasis of 69 s and mean blood loss of 32 ml. Subsequently, the positioning of IVC injuries between two balloons made it possible to suture the injured IVC.ConclusionsBalloon occlusion using the DB-CV catheter provides a rapid temporal hemostatic effect and can overcome the serious condition of massive hemorrhage from IVC injuries.

Endoscopic Full Thickness Resection (EFTR) of a Gastric Submucosal Tumor

Incidental submucosal tumors can be found in about one in three hundred upper endoscopies. Currently, EUS can aid in establishing diagnosis of highly malignant features of a nodule, but it cannot provide appropriate malignant potential due to absence of histological mitotic count. FNA is useful for making a definitive diagnosis, but many times it can be inconclusive which submits the patient to continued endoscopic surveillance. We present a case of a full thickness resection of a gastric submucosal nodule followed by endoscopic suturing to close the defect. We present an 81-year-old male complaining of GERD. An EGD showed an incidental gastric body nodule. An EUS revealed a 1.5 cm by 1.4 cm submucosal tumor extending into the muscularis propria. Cytology from FNA showed spindle cells, suggestive of a GIST. Using an IT nano knife, we made a 360-degree circumferential incision extending into the sub-mucosa. Hemostasis was achieved by using coagulation forceps for small vessels, and hemostatic clip for larger vessels. The incision was then extended deeper into the muscularis layers along the line of the initial incision. With the IT nano knife, we completed the 300-degree full thickness incision. We intentionally avoided the last 60 degrees of the serosal layer to prevent migration of the resected specimen into the peritoneum. A four centimeter full thickness defect was seen visualizing the mesenteric fat endoscopically. The remaining pedicle was resected using a hot snare and retrieved using a roth net. The defect was closed with interrupted sutures using an overstich device. A helix device was used to facilitate suturing. Pathology confirmed full thickness resection. CT abdomen with enteric contrast confirmed adequate closure of the resection site. Patient was discharged after 23-hour observation. A two month follow up endoscopy showed hyperplastic tissue at the suture site without any residual nodule. This technique of endoscopic full thickness resection using an overstich device for closure is technically feasible, safe and provides definitive diagnosis with malignant risk stratification eliminating the need for continued endoscopic surveillance. Watch the video: https://goo.gl/QAEuLg

Abstract: Secondary Full Abdominoplasty Following Prior Umbilical Stalk Detachment

INTRODUCTION: There are many techniques utilized in abdominoplasty surgery.1,2 For patients presenting with primarily infraumbilical laxity in addition to a small amount of laxity above the umbilicus, an umbilical “floating” maneuver can be used as a modification of a mini abdominoplasty.3 Patients with prior umbilical stalk detachment, secondary to modified mini-abdominoplasty or prior umbilical hernia repair, occasionally desire full abdominoplasty. In these patients, a circumferential incision around the umbilicus leaves a blood supply based entirely upon scar tissue, prompting concern about the viability of the umbilicus. Minimal literature exists to help guide clinical decision-making for these patients.4 METHODS: Queries were sent to Louisiana Society of Plastic Surgery members as well the Plastic Surgery Education Network (PSEN) online forum. Case information was gathered via email and telephone correspondence. Metrics obtained included patient age, time between umbilical stalk detachment and secondary full abdominoplasty, post-operative complications, and if rectus plication was performed at time of secondary surgery. RESULTS: Ten physicians reported 16 substantive cases, including twelve following mini-abdominoplasty and four after umbilical hernia repair. All patients healed without evidence of umbilical necrosis. Average patient age at time of secondary surgery was 37.5 years. Average duration between procedures was 3.8 years. 69% of patients had the umbilicus delayed prior to secondary procedure, with average delay time being 16 days. Rectus fascia was plicated at time of secondary surgery in 69% of patients. CONCLUSION: This is the largest series of patients undergoing full abdominoplasty after prior umbilical stalk detachment. It is also the first time the PSEN online forum has been used to collect research data, highlighting its potential as a valuable research tool. The data set thus allows for consideration of various solutions when this clinical scenario is encountered. Reference Citations: 1.Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty: classic principles and technique. Clinics in plastic surgery. 2014;41(4):655–672. 2.Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision making in abdominoplasty. Aesthetic plastic surgery. 2007;31(2):117–127. 3.Colwell AS, Kpodzo D, Gallico III GG. Low scar abdominoplasty with inferior positioning of the umbilicus. Annals of plastic surgery. 2010;64(5):639–644. 4.Matarasso A, Schneider LF, Barr J. The Incidence and Management of Secondary Abdominoplasty and Secondary Abdominal Contour Surgery. Plastic and reconstructive surgery. 2014;133(1):40–50.

Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: Animal study.

In Western countries, endoscopic submucosal dissection (ESD) has not prevailed as a result of training problems and a target patient population. We have previously reported a hybrid ESD technique, submucosal endoscopy with mucosal resection (SEMR), in which the submucosal dissection is carried out chiefly by blunt balloon dissection. We have also reported successful application in the porcine colon. In the present study, we compared the safety and efficacy of SEMR with ESD in the porcine esophagus and stomach. SEMR and ESD were carried out in eight domestic pigs under general anesthesia. Resection sites were marked by circumferential coagulation. After circumferential ESD knife mucosal incision, submucosal fluid cushion (SFC) was created. In the SEMR group, the balloon catheter was inserted deep into the SFC. The balloon was then inflated and pulled back toward the endoscope tip repeatedly, altering the direction, to disrupt the submucosa. Residual strands were cut with an IT-knife. Enbloc resection rates, procedure times, complications and dissection difficulty scales (DDS) were recorded prospectively. DDS were rated using a visual analog scale. Thirty-two resections (8 SEMR/8 ESD in the esophagus; 8 SEMR/8 ESD in the stomach) were done with no major adverse events. There was no statistical difference between the two techniques in either location in the above categories measured. SEMR and traditional ESD are comparable techniques in safety and effectiveness when carried out in the esophagus and stomach. SEMR may serve as a more appealing technical option for endoscopists who are unable to sustain a traditional ESD practice volume.

Comparison of endoscopic therapies for rectal carcinoid tumors: Endoscopic mucosal resection with circumferential incision versus endoscopic submucosal dissection

Although various endoscopic resection techniques have been established for rectal carcinoid tumors, there remains controversy regarding the best endoscopic treatment modality for these tumors. This study aimed to evaluate and compare the therapeutic efficacy and safety of EMR with circumferential incision (EMR-CI) and endoscopic submucosal dissection (ESD) for endoscopic resection of rectal carcinoid tumors. From March 2012 to June 2016, 66 rectal carcinoid tumors in 66 patients were resected by using EMR-CI (n=30) or ESD (n=36). The rates of both en bloc resection and complete resection, procedure time, procedure-related complications, and local or metastatic recurrence were analyzed retrospectively. The en bloc resection rate was 96.7% (29/30) and 100% (36/36) for EMR-CI and ESD groups, respectively, and the difference was not statistically significant (P=0.455). The complete resection rate of the ESD group was 97.2% (35/36) and significantly higher than 76.7% (23/30) of the EMR-CI group (P=0.030). The mean procedure time of the ESD group was 20.44±6.64minutes, which was significantly longer than that of the EMR-CI group at 8.47±3.40minutes (P<0.001). The complication rates for ESD and EMR-CI did not differ significantly (0% for EMR-CI vs. 2.8% for ESD, P=1.000). No local or metastatic recurrence was found in either group during the follow-up period. This study suggested that ESD may be a safe, effective, and feasible endoscopic technique for removing rectal carcinoid tumors. ESD showed a similar safety profile and superior efficacy to EMR-CI.

Endoscopic full-thickness resection using suture loop needle T-tag tissue anchors in the porcine stomach (with video)

Endoscopic full-thickness resection (EFTR) is still challenging, and a reliable technique is desirable. The aim of this study was to evaluate the feasibility of controlled EFTR using a pseudopolyp made from suture loop needle T-tag (SLNT) tissue anchors in exvivo porcine stomachs. Five pig stomachs were used. Two concentric circumferential border mucosal incisions were made to facilitate isolating a target lesion for full-thickness excision and pseudopolyp formation. SLNT tissue anchors were placed with a fishing line around the edges of the larger outer incision by endoscopic suturing. A suture pulley was created in the center of the targeted area and brought outside for traction. A large inverted pseudopolyp of the targeted lesion was made, visualizing apposing serosa with traction on the suture pulley while simultaneously cinching the encircling fishing line. EFTR was then performed on the isolated targeted tissue with the use of a needle-knife. Pseudopolyps were successful in all attempts. In the first attempt the encircling fishing line was cut, releasing the pseudopolyp during EFTR, with obvious leak. The remaining 4 EFTRs were performed with intact serosal apposing pseudopolyps and no air leaks. The median number of SLNT tissue anchors placed for a pseudopolyp was 5 (interquartile range, 4-5). The median size of full-thickness lesions was 37mm (interquartile range, 29-49) and the median maximum pressure for the leak testing 9mm Hg (interquartile range, 4-14) in the successful 4 attempts. This proof of principle study suggests that EFTR with SLNT-fashioned pseudopolyps is feasible.

Hemipelvectomia total em um gato com osteossarcoma osteoblástico

Background: Osteosarcoma (OSA) is a malignant neoplasm of mesenchymal tissue that exhibits various histological features and a differentiated biological clinical behavior. The combination of clinical, radiological, and histopathological features is important for diagnosis. Surgical treatment of neoplasms with pelvic involvement is a challenge. Primary bone tumors are rare in cats and are mostly reported in older animals. The objective of this paper was to report the case of a feline subjected to total hemipelvectomy as primary treatment of pelvic OSA; the surgical technique and histological analysis of the tumor are described. No signs of recurrence were seen during seven months of follow-up.Case: A 4-year-old female mixed breed cat weighing 3 kg was presented with a one year history of increased volume on the hip joint region. Palpation of the increased volume on the hip showed a firm, adhered, and painful mass. Radiographic examination of the pelvis in the dorso ventral projection exhibited a severe osteoblastic bone reaction on the proximal femur, as well as marked periosteal reaction of the hip joint with involvement of the acetabulum. A ventral approach total hemipelvectomy technique was adopted for excision of the tumor. The animal was placed on a lateral position and a circumferential skin incision was performed on the ipsilateral limb of the affected hemipelvis, on the medial portion of the femur, and was extended cranially up to the thoracolumbar region. The pubic symphysis was exposed with a periosteal elevator and a pubic symphysiotomy was performed on the midline using a Liston bone cutter; next, the sacroiliac junction was resected. No drain was used after surgery, only compressive bandages. The patient was hospitalized for post-operative monitoring which included opioids for pain management and a non-steroidal anti-inflammatory drug and a cephalosporin class antibiotic. The wound was cleaned with saline, rifamycin spray (Rifocina Spray®) was applied, and dressing was changed every 12 h. The excised bone was submitted for pathological analysis. Gross examination revealed a 4.2 cm hardened increase in volume on the area of the femoral head and acetabulum, with irregular surface; cut surface was hard and white with black and red spots. Histology revealed osteoblastic OSA with intense and solid fusiform and stellate cells distributed in a solid pattern with no capsular border, with marked infiltration of the bone tissue, marked osteolysis, moderate proliferation of osteoclasts, and moderate anisocytosis and anisokaryosis.Discussion: Bone tumors in cats are rare and develop spontaneously. They exhibit aggressive behavior and promote local bone destruction. Firm consistency and local swelling usually occur in more advanced cases when there is a delay between the onset of clinical signs and the veterinary consultation. Radiological findings such as bone destruction and bone formation are commonly seen in this type of tumor. Hemipelvectomy is considered an aggressive surgical technique, but necessary in many cases, especially when tumors are located in the pelvis and nearby tissues. In the case presented here, this surgery was the most viable and advised therapeutic option because of tumor location. No incidents (i.e. hemorrhage) occurred during the perioperative period. After surgery, the patient continued to perform all custom functions. The hind limb, which was affected in this case, is commonly reported to be affected in the literature; however, it is unusual to have involvement of both bones (pelvis and femur) since vascularization of these bones are independent. Diagnosis was confirmed by histopathology in which a characteristic malignant mesenchymal tumor of primitive bone cells was present, with production of osteoid of variable shapes and quantity with the presence of osteoclastic giant cells.