Intraoperative Perforation Research Articles

First clinical experience with esophageal ESD using a novel adjustable traction device.

Background and study aims In esophageal endoscopic submucosal dissection (ESD), the effectiveness of traction including clip-thread method has been reported, but it is difficult to adjust the direction of traction. Therefore, we developed a dedicated over-tube type traction device (ENDOTORNADO) that has a working channel and allows traction from any directions by rotating itself. We investigated the clinical feasibility and potential usefulness of this new device in esophageal ESD. Patients and methods This was a single-center, retrospective study. Six cases of esophageal ESD with ENDOTORNADO from January to March 2022 (tESD group) were compared with 23 cases of conventional esophageal ESD performed by the same operator from January 2019 to December 2021 (cESD group) in terms of clinical treatment outcomes. Results In all cases, en bloc resection was achieved without intraoperative perforation. The total procedure speed was significantly increased in tESD group (23 vs. 30 mm 2 /min, P = 0.046). In particular, the submucosal dissection time was significantly reduced to about one-quarter in tESD group (11 vs. 42 min, P = 0.004). Conclusions ENDOTORNADO creates the adjustable traction from any directions and may have the clinical feasibility. It would be an option for human esophageal ESD.

Complications of Descemet stripping endothelial keratoplasty - A retrospective interventional study at a tertiary eye care center in Southern India.

To analyze the visual outcome and complications of Descemet stripping endothelial keratoplasty (DSEK) with their management in 256 eyes at a tertiary eye care center in southern India. This is a retrospective interventional study of 62 months duration conducted at a tertiary eye care center in southern India. Two hundred and fifty-six eyes of 205 patients were included in the study after obtaining written informed consent from the patients. All cases of DSEK were performed by a single experienced surgeon. In all cases, donor dissection was performed manually. A Sheet's glide was inserted through the temporal corneal incision and donor button was placed on the Sheet's glide with the endothelial side down. The lenticule was separated and inserted into the anterior chamber by pushing the lenticule into the anterior chamber using Sinskey's hook. Any complication, either intraoperative or postoperative, was recorded and managed either medically or by appropriate surgical means. The mean best corrected visual acuity (BCVA) before surgery was CF-1 m, which improved to 6/18 after surgery. Intraoperative donor graft perforation during dissection was seen in 12 cases, thin lenticule in three eyes, and repeated artificial Anterior Chamber (AC) collapse in three eyes. Dislocation of lenticule was the most common complication seen in 21 eyes, which was managed by graft repositioning and rebubbling. Eleven cases had minimal separation of the graft and seven cases had interface haze. Pupillary block glaucoma was seen in two cases that resolved with partial release of bubble. Surface infiltrate was seen in two cases, which was managed with topical antimicrobial agents. Primary graft failure was seen in two cases. DSEK is a promising alternative to penetrating keratoplasty for corneal endothelial decompensation, but it also has its own merits and limitations, and most often, merits overweigh limitations.

A-22 | Gender Disparities in Periprocedural Complications After Percutaneous Coronary Intervention for Chronic Total Occlusions

Several studies have reported on gender differences in the risk of periprocedural complications after percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). The purpose of this meta-analysis is to evaluate differences in the risk of periprocedural complications of CTO-PCI based on gender. A literature search was conducted for studies reporting on periprocedural complications after CTO PCI based on gender. Clinical endpoints included embolic cerebral vascular accident (CVA), tamponade requiring pericardiocentesis, intra-operative coronary perforation, occurrence of major bleed, and vascular complications. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. A total of 8 studies with 7814 patients who underwent CTO PCI (1609 females, 6205 males) met inclusion criteria. Female patients had significantly higher risk for all secondary endpoints compared to male patients (CVA OR 3.67, 95% CI 1.55-8.70; p<0.01; Tamponade OR 2.70, 95% CI 1.40-5.24; p<0.01; Coronary Perforation OR 5.18, 95% CI 3.76-7.15; p<0.01; Major Bleed OR 2.43, 95% CI 1.50-3.93; p<0.01). There was no significant difference in the risk of perioperative vascular complications in females compared to males (OR 1.43, 95% CI 0.68-3.02; p=0.34). Female patients who undergo CTO PCI have similar rates of perioperative vascular complications, however significantly higher risk for CVA, tamponade requiring pericardiocentesis, coronary perforation, and major bleeding events.

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

ABSTRACT The original technique for mesh midurethral sling, which utilized a retropubic approach for sling placement, also recognized a risk of simultaneous iatrogenic bladder injury. While synthetic mesh midurethral slings have the criterion standard for SUI treatment, there is still no available technique that entirely eliminates the risk of bladder injury at the time of implantation. The retropubic approach holds a 0.7% to 34% rate of bladder injury. Some providers still opt for the transobturator approach because of a perceived decreased risk of intraoperative bladder perforation. This article describes the “C-clamp technique,” a method directly addressing the perceived key causes of bladder injury via the retropubic approach. This study aimed to determine bladder injury rates upon surgical implantation of retropubic synthetic mesh midurethral sling by 1 provider using the C-clamp technique. The article provides step-by-step instructions for this technique, as well as a link to a video (https://links.lww.com/FPMRS/A362). Briefly, the technique involves use of a deflecting catheter guide in steep Trendelenburg, “clamping” the pubis with the operator's nondominant hand to decrease the retropubic distance, and using the nondominant thumb on the inner curve of the trocar to guide the trocar passage toward the nondominant finger tips and suprapubic exit through the skin. This retrospective review identified 201 bottom-up retropubic synthetic mesh midurethral slings placed using the C-clamp technique between April 2012 and June 2022. General data collected included average age (51 years), average weight (46–139 kg), average body mass index (BMI, 15–57 kg/m2), and a range of prior surgical procedures and concomitant procedures. Approximately 15% of patients had a history of prior retropubic urethropexy or some form of midurethral sling. There were no lower urinary tract injuries in the entire cohort. Strengths of this study include its description of the C-clamp technique, the extremes and range of data points included within the study, and the 10-year range of the study. Limitations include its retrospective nature, the single surgeon provider, the vast majority of slings used produced by 1 manufacturer, and limited comprehensive data collection. Using data from 201 consecutive bottom-up synthetic mesh midurethral sling outcomes during a 10-year span, the authors argue that this technique addresses key anatomic issues contributing to bladder and urethral injury during placement of such slings, with a promising ability to eliminate bladder and urethral injury. Favorable data in a larger number of patients and by multiple providers could provide further support to this technique and support retropubic sling as a preferred method of midurethral sling.

Clinical course and management of adverse events after endoscopic resection of superficial duodenal epithelial tumors: Multicenter retrospective study.

This study aimed to elucidate the clinical course and management of adverse events (AEs) after endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs). Consecutive patients who underwent ER of SDETs between January 2008 and July 2018 at 18 Japanese institutions were retrospectively enrolled. The study outcomes included the clinical course, management, and risk of surgical conversion with perioperative AEs after ER for SDETs. Of the 226 patients with AEs, the surgical conversion rate was 8.0% (18/226), including 3.7% (4/108), 1.0% (1/99), and 50.0% (12/24) of patients with intraoperative perforation, delayed bleeding, or delayed perforation, respectively. In the multivariate logistic analysis, involvement of the major papilla (odds ratio [OR] 12.788; 95% confidence interval [CI] 2.098-77.961, P = 0.006) and delayed perforation (OR 37.054; 95% CI 10.219-134.366, P < 0.001) were significant risk factors for surgical conversion after AEs. Delayed bleeding occurred from postoperative days 1-14 or more, whereas delayed perforation occurred within 3 days in all cases. The surgical conversion rate was higher for delayed perforation than those for other AEs after ER of SDETs. Involvement of the major papilla and delayed perforation were significant risk factors for surgical conversion following AEs. In addition, reliable prevention of delayed perforation is required for 3 days after duodenal ER to prevent the need for surgical interventions.

Stapled disc excision for the repair of intraoperative rectal injury during robotic surgery for deep infiltrating endometriosis

Intraoperative rectal perforation is an uncommon complication of pelvic surgery, which can be life-threatening and often leads to high morbidity and stoma formation rate. No consensus has been reached regarding a standard of care for intraoperative iatrogenic pelvic injury. This article presents a technique for a stapled repair to completely resect a full-thickness low rectal perforation during robotic surgery for advanced endometriosis and avoid a high-risk colorectal anastomosis and the possible need for stoma formation. Stapled discoid excision is a novel and safe technique for the repair of intraoperative rectal injuries, showing multiple benefits compared to the standard colorectal resection with or without anastomosis.

Efficacy of the specialized scissor-type knife for gastric endoscopic submucosal dissection: a propensity score matched retrospective study.

Background and study aims Prevention of bleeding and perforation during gastric endoscopic submucosal dissection (ESD) is important. Scissor-type knives can accurately grasp and incise the targeted tissue using electrosurgical currents, thereby eliminating unexpected incisions. The SB Knife GX, a scissor-type knife specialized for gastric ESD, was released in June 2016 in Japan. The aim of the present study was to evaluate the efficacy and safety of gastric ESD using the SB Knife GX. Patients and methods A total of 716 patients who underwent gastric ESD at Hiroshima University Hospital between July 2016 and December 2020 were retrospectively reviewed. From these, 671 patients underwent ESD using the IT Knife 2 (IT-2 group), while 45 underwent ESD using an SB Knife GX (SB-GX group). After propensity score matching, the procedure time, specimen size, en bloc and complete resection rates, and intraoperative bleeding, delayed bleeding, and perforation rates were evaluated. Results No significant differences were observed in mean procedure time (SB-GX group: 115 ± 165 min; IT-2 group: 95 ± 61 min; P = 0.82) and en bloc and complete resection rates between the two groups. Intraoperative bleeding rates were significantly lower in the SB-GX group than in the IT-2 group (18 % vs. 40 %; P = 0.01), and there were no differences in delayed bleeding (4 % vs. 4 %) or perforation (0 % vs. 4 %) between the two groups. Conclusions The SB Knife GX was proven to be useful for control of intraoperative bleeding during gastric ESD, although the procedure time tended to be longer.

MP62-18 NEW FINDINGS REGARDING INDEPENDENT PREDICTORS OF POOR CORPORAL INTEGRITY IN A LARGE SERIES OF PENILE IMPLANT RECIPIENTS: A MULTICENTER INTERNATIONAL INVESTIGATION

You have accessJournal of UrologyCME1 Apr 2023MP62-18 NEW FINDINGS REGARDING INDEPENDENT PREDICTORS OF POOR CORPORAL INTEGRITY IN A LARGE SERIES OF PENILE IMPLANT RECIPIENTS: A MULTICENTER INTERNATIONAL INVESTIGATION Chrystal Chang, Zafardjan Dalimov, David Barham, Daniel Swerdloff, Hossein Sadeghi-Nejad, Robert Andrianne, Mike Hsieh, Martin Gross, Georgios Hatzichristodolou, Maxime Sempels, Daniar Osmonov, Aaron Lentz, Paul Perito, James Hotaling, Koenraad Van Renterghem, Sung Hun Park, Jonathan N. Warner, Faysal A. Yafi, and Jay Simhan Chrystal ChangChrystal Chang More articles by this author , Zafardjan DalimovZafardjan Dalimov More articles by this author , David BarhamDavid Barham More articles by this author , Daniel SwerdloffDaniel Swerdloff More articles by this author , Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author , Robert AndrianneRobert Andrianne More articles by this author , Mike HsiehMike Hsieh More articles by this author , Martin GrossMartin Gross More articles by this author , Georgios HatzichristodolouGeorgios Hatzichristodolou More articles by this author , Maxime SempelsMaxime Sempels More articles by this author , Daniar OsmonovDaniar Osmonov More articles by this author , Aaron LentzAaron Lentz More articles by this author , Paul PeritoPaul Perito More articles by this author , James HotalingJames Hotaling More articles by this author , Koenraad Van RenterghemKoenraad Van Renterghem More articles by this author , Sung Hun ParkSung Hun Park More articles by this author , Jonathan N. WarnerJonathan N. Warner More articles by this author , Faysal A. YafiFaysal A. Yafi More articles by this author , and Jay SimhanJay Simhan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) offers high satisfaction rates for patients, but this procedure is not without complications that can be encountered either intraoperatively or postoperatively. Particularly, predictors of intraoperative corporal perforation and delayed cylinder complications in IPP placement have not been well-delineated. We hypothesize that preoperative and intraoperative variables may impact the integrity of the corporal bodies long-term and thus implant viability. METHODS: We retrospectively reviewed a large, multi-institutional collaborative study of IPP surgeries performed by expert implanters from 2016-2021. All primary and revision cases were included. Salvage cases for infection were excluded. Demographic characteristics, intraoperative variables, and postoperative outcomes were assessed. PCI was defined as intraoperative corporal complications (proximal and/or distal perforation of the corpora, corporal crossover) or postoperative corporal complications (cylinder erosion, extrusion, impending erosion, or deformity). Risk factor analysis and multivariate analysis were performed to identify independent predictors of PCI. RESULTS: After excluding salvage cases for infection, we identified 5,153 patients undergoing IPPs, of which 149 were diagnosed with PCI. The rates of diabetes (p=0.19), immunosuppression (p=0.79), priapism (p=0.06), history of radiation (p=0.29), and prior use of intracavernosal injections (p=0.19) all had no significant effect on corporal integrity. Patients with PCI were more likely to have active coronary artery disease (CAD) or peripheral vascular disease (PVD) (p=0.02), be current smokers (p=0.003), and have a history of IPP infection (p<0.001). On multivariate analysis, predictors of PCI included older age (OR 1.02 (1.00-1.04), p=0.03), CAD/PVD (OR 1.58 (1.06-2.35), p=0.025) and history of IPP infection (OR 5.82 (3.27-10.34), p<0.001). Obesity (OR 0.582 (0.40-0.86), p=.006) and non-Caucasian race (OR 0.60 (0.41-0.88), p=0.01) were found to be protective. CONCLUSIONS: Our multicenter analysis found that CAD/PVD, current smoking, and history of IPP infection were risk factors for complications associated with poor corporal integrity. Recognizing these risk factors preoperatively can allow for improved patient-specific counseling and changes in surgical strategy to potentially promote longer term device viability. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e869 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chrystal Chang More articles by this author Zafardjan Dalimov More articles by this author David Barham More articles by this author Daniel Swerdloff More articles by this author Hossein Sadeghi-Nejad More articles by this author Robert Andrianne More articles by this author Mike Hsieh More articles by this author Martin Gross More articles by this author Georgios Hatzichristodolou More articles by this author Maxime Sempels More articles by this author Daniar Osmonov More articles by this author Aaron Lentz More articles by this author Paul Perito More articles by this author James Hotaling More articles by this author Koenraad Van Renterghem More articles by this author Sung Hun Park More articles by this author Jonathan N. Warner More articles by this author Faysal A. Yafi More articles by this author Jay Simhan More articles by this author Expand All Advertisement PDF downloadLoading ...

Are biopsies during endoscopic ultrasonography necessary for a suspected esophageal leiomyoma? Is laparoscopy always feasible?

The present letter to the editor is related to the work entitled "Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography-fine needle aspiration: A case report." Although endoscopic ultrasonography seems necessary in a suspected leiomyoma of the esophagus, the performance of biopsies via fine needle aspiration is controversial as it increases the risk of complications such as bleeding, infection, and intraoperative perforations. Laparoscopy is the best treatment strategy for small tumors. Laparotomy with tumor enucleation or esophageal resection can be considered in large leiomyomas.

Clinical and functional outcome following robotic Heller-myotomy with partial fundoplication in patients with achalasia

Robotic-assisted myotomy with partial fundoplication for patients with achalasia has been established as a safe and effective procedure with similar short-term results and lower rates of intraoperative esophageal perforations. Our aim was to investigate a defined patient cohort undergoing robotic-assisted and laparoscopic surgery providing pre- and postoperative symptom score and high-resolution manometry to evaluate the clinical and functional outcome.All patients underwent clinical, endoscopic, radiological and manometric investigation to verify the diagnosis of achalasia. High-resolution manometry was performed preoperatively and 6 months postoperatively and categorized according to the Chicago Classification (v4.0). We used the Eckardt Score to evaluate symptomatic outcome. All patients underwent either robotic-assisted or laparoscopic myotomy with partial anterior fundoplication (180° Dor) using the DaVinci Xi surgical system (Intuitive, Sunnyvale, California, USA). From a total amount of 101 patients, we analyzed the data of 78 (47 robotic and 31 laparoscopic) procedures between 2015 and 2020. All patients showed a significant decrease of the Eckardt Score in the robotic group (median 6 vs. 2) as well as in the laparoscopic group (median 7.5 vs. 3). The postoperative LESP and 4 s-IRP was significantly reduced in all patients in the robotic group [median LESP (mmHg) 34.16 vs. 16.9; median 4 s-IRP (mmHg) 28.85 vs. 14.55], as well as in the laparoscopic group [median LESP (mmHg) 35.34 vs. 17.3; median 4 s-IRP (mmHg) 25.6 vs. 15.9]. There was no significant difference for these parameters between the groups. There was no event of intraoperative esophageal perforation in the robotic cohort, whereas there were 2 in the laparoscopic group. Our data support the safe and effective robotic approach for the surgical treatment of achalasia. Not only the clinical outcome but also the functional results measured by high-resolution manometry are similar to the laparoscopic procedure. Further investigations in larger prospective multicenter studies are needed.

Endoscopic mucosal resection of gastrointestinal polyps with a novel low-temperature plasma radio frequency generator: a non-inferiority multi-center randomized control study.

To evaluate the efficacy and safety of novel plasma radio frequency generator and its single-use polypectomy snares for endoscopic mucosal resection (EMR) of gastrointestinal (GI) polyps. A total of 217 patients with 413 GI polyps were recruited from four centers in China. Patients were assigned to experimental or control groups using a central randomization method. The experimental group used the novel plasma radio frequency generator and its matched single-use polypectomy snares (Neowing, Shanghai), while the control group used the high-frequency electrosurgical unit (Erbe, Germany) and disposable electrosurgical snares (Olympus, Japan). The primary endpoint was the en bloc resection rate, and the non-inferiority margin was set at 10%. Secondary endpoint included operation time, coagulation success rate, intraoperative and postoperative bleeding rate, and perforation rate. The en bloc resection rate was 97.20% (104/107) in the experimental group and 95.45% (105/110) in the control group (P = 0.496). The operation time was 29.14 ± 20.21min in the experimental group and 30.26 ± 18.74min in the control group (P = 0.671). The average removal time of a single polyp in the experimental group was 7.52 ± 4.45min, which was slightly shorter than that in the control group 8.90 ± 6.67min, with no statistical difference (P = 0.076). The intraoperative bleeding rates of the experimental group and control group were 8.41% (9/107) and 10.00% (11/110), respectively (P = 0.686). No intraoperative perforation occurred in either group. The postoperative bleeding rates of the experimental group and the control group were 1.87% (2/107) and 4.55% (5/110), respectively (P = 0.465). No postoperative perforation occurred in the experimental group (0/107), while one case of delayed perforation occurred in the control group (1/110, 0.91%). There was no statistical difference between the two groups. Endoscopic mucosal resection of GI polyps with the novel plasma radio frequency generator is safe and effective, and non-inferior to the conventional high-frequency electrosurgical system.

The role and place of transanal endoscopic resections in rectal cancer

The aim of the work is to improve the algorithm of intraoperative diagnosis of rectal cancer metastasis in order to optimize surgical intervention and reduce the number of intraoperative and postoperative complications. Materials and methods. 184 operated patients with rectal cancer (RC) were divided into 2 groups: group 1 – patients with stage I RC (T1–2N0M0), and group 2 – stage II RC (T3N0M0), who underwent intraoperative detection and examination of sentinel lymph nodes. The volume and surgical approach depended on the stage and the presence of metastases (MTS). The average period of postoperative observation was 12–60 months, taking into account early (purulent-septic complications, bleeding, intestinal perforation) and late (recurrent rectal cancer) complications. Results. The patients of group 1 had no MTS lesions of the sentinel lymph nodes, the surgical intervention was limited to transanal microsurgery due to this fact. Among the complications were the following: bleeding – 2.2 %; intraoperative perforation of the intestinal wall – 5.6 %. No purulent-septic cases, no recurrences of rectal cancer were detected. In group 2, 36 (38.3 %) out of 94 patients had MTS detected intraoperatively in the sentinel lymph nodes which required a low anterior rectal resection with total mesorectumectomy. Among the complications was bleeding – 6.3 %. No intraoperative perforations of the intestinal wall and no purulent-septic complications were detected. Recurrence of rectal cancer was detected in 12 (12.8 %) patients. Conclusions. Performing transanal endoscopic resections in patients with stage I RC and especially stage II RC is possible only under the conditions of mandatory intraoperative staining and urgent histological examination of the sentinel lymph nodes. The extent of the surgical intervention is determined on the operating table based on urgent histological examination results. When MTS lesions of the mesorectal sentinel lymph nodes are detected, the operation should be continued with mandatory mesorectumectomy.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer.

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Elliptical deep anterior lamellar keratoplasty in severe Acanthamoeba keratitis.

Acanthamoeba keratitis (AK) is an intractable infection of the cornea. Penetrating keratoplasty is widely used for the management of severe AK but suffers from complications like graft rejection, endophthalmitis, and glaucoma. Herein, we aimed to describe the surgical technique and the results of elliptical deep anterior lamellar keratoplasty (eDALK) for the management of severe AK. In this retrospective case series, records of consecutive patients with AK poorly responsive to medical treatment who underwent eDALK from January 2012 to May 2020 were reviewed. The largest diameter of infiltration was ≥8 mm and did not involve the endothelium. The recipient bed was made by an elliptical trephine, and big bubble or wet-peeling technique was performed. Postoperative best spectacle-corrected visual acuity, endothelial cell density, corneal topographic data, and complications were evaluated. Thirteen eyes of thirteen patients (eight men and five women, 45.54 ± 11.78 years old) were included in this study. The mean follow-up interval was 21.31 ± 19.59 months (range, 12-82 months). At the last follow-up, the mean best spectacle-corrected visual acuity was 0.35 ± 0.27 logarithm of the minimum angle of resolution. The mean refractive and topographic astigmatism were - 3.21 ± 1.77 and 3.08 ± 1.14 D, respectively. Intraoperative perforation was encountered in one case and double anterior chambers occurred in two cases. One graft developed stromal rejection and one eye developed amoebic recurrence. eDALK can serve as the first-line surgical management of severe AK poorly responsive to medical treatment.

Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations.

Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close, although complete closure is recommended for better recovery. Endoscopic purse-string assisted suturing (EPSS) has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal defects. However, details regarding the efficacy of endoscopic pre-purse-string suture (P-EPSS) are unknown, especially that it offers several advantages over conventional EPSS (C-EPSS). To elucidate the outcomes of EPSS-assisted closure in different clinical situations, and evaluate the efficacy of P-EPSS. This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS (n = 63) or C-EPSS (n = 117) between July 2014 and June 2020. The P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size, location, and mor-phology, incidence of complete closure, intraoperative perforation, and delayed adverse events were evaluated. Data on the features and clinical course of cases with adverse events were collected for further analysis. Patients with lesion size larger than 3 cm, lesions located at the fundus of stomach, or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted closure. The P-EPSS group showed a sign-ificantly higher proportion of intraoperative perforation (56% vs 17%) and a much shorter procedure time (9.06 ± 6.14 min vs 14.84 ± 7.25 min). Among adverse events, the incidence of delayed perforation (5% vs 4%; P = 0.82) and delayed bleeding (3% vs 4%; P = 0.96) did not differ significantly between the groups. Multivariate analysis revealed that lesions with incomplete closure [odds ratio (OR) = 21.33; 95% confidence interval (CI): 5.45-83.45; P < 0.01] or size greater than 3 cm (OR = 3.14; 95%CI: 1.08-9.18; P = 0.039) showed a statistical tendency to result in an increase in delayed adverse events. The present study revealed that EPSS could achieve secure complete closure of mucosal defect. P-EPSS could shorten the procedure and yield complete closure of mucosal defects. Rather than closure-type selection, incomplete closure or lesion size larger than 3 cm were associated with worse outcomes.

Laparoscopic Esocardiomyotomy—Risk Factors and Implications of Intraoperative Mucosal Perforation

Mucosal perforation during laparoscopic esocardiomyotomy is quite frequent, and its consequences cannot always be neglected. The purpose of the study is to investigate the risk factors for intraoperative mucosal perforation and its implications on the postoperative outcomes and the functional results three months postoperatively. We retrospectively identified the patients with laparoscopic esocardiomyotomy performed at Sf. Maria Hospital Bucharest, in the period between January 2017-January 2022 and collected the data (preoperative-clinic, manometric and imaging, intra-and postoperative). To identify the risk factors for mucosal perforations, we used logistic regression analysis. We included 60 patients; intraoperative mucosal perforation occurred in 8.33% of patients. The risk factors were: the presence of tertiary contractions (OR = 14.00, 95%CI = [1.23, 158.84], p = 0.033206), the number of propagated waves ≤6 (OR = 14.50), 95%CI = [1.18, 153.33], p < 0.05), the length of esophageal myotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), the length of esocardiomyotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), and a protective factor-the intraoperative upper endoscopy (OR = 0.037, 95%CI = [0.003, 0.382] p < 0.05). Identifying risk factors for this adverse intraoperative event may decrease the incidence and make this surgery safer. Although mucosal perforation resulted in prolonged hospital stays, it did not lead to significant differences in functional outcomes.

Comment on: intraoperative gallbladder perforation and risk of postoperative abscess with or without antibiotics: national cohort study of more than 108 000 cholecystectomies.

Comment on: intraoperative gallbladder perforation and risk of postoperative abscess with or without antibiotics: national cohort study of more than 108 000 cholecystectomies.

Predictors of complicated course of perioperative period in patients with rectal cancer and rectosigmoid junction

Aim of the investigation. Evaluation of significance of a number of clinical predictors of complicated course of perioperative period in patients with rectal cancer and rectosigmoid junction. Materials and Methods. Retrospective analysis of 170 patients with rectal cancer or rectosigmoid junction. Patients with adenocarcinoma of rectum or rectosigmoid junction which were operated in combination to partial or total mesorectumectomy were included to the study. In all cases an anastomosis was formed. There were 54.7% of men and 45.3% of women. The mean age of the patients was 63 years. Preoperative treatment was performed in 54 patients. Influence of various factors (gender, age, BMI, anatomical risk factors, neoadjuvant therapy, type of operation, ligation level of the inferior mesenteric artery, forced mobilization of the splenic flexure of the colon, surgical access, anastomosis type, anastomosis protection, duration of operation, preventive stoma) on the risk of perioperative complications and separately inconsistent anastomosis suture was estimated. Results. Neoadjuvant chemoradiotherapy increases the risk of intraoperative complications by 3.4 times. Risk of anastomosis inconsistency is 3,35 times increased in men, 2,6 times for forced mobilization of the splenic flexure of the large intestine and 10 times for intraoperative perforation of the large intestine. Predictors of complicated course of the postoperative period are adhesions, narrow pelvis, short mesentery of the sigmoid colon, dolichosygma (p<0,05). Conclusion. Presence of the above risk factors must lead to application of measures on prevention and elimination of consequences of perioperative complications.

Anterior cortical overlap view in evaluation of anterior femoral cortical perforation and impingement during cephalomedullary nailing

Cephalomedullary nailing of the femur is a common procedure associated with many pitfalls, including anterior femoral cortical perforation and impingement. Lateral knee radiographs are often inadequate in determining the precise location of the anterior cortex because of the offset of the medial and lateral femoral condyles. Here we present a novel radiographic technique to identify the distal anterior femoral cortex more accurately with the goal of reducing intraoperative and postoperative perforation during long cephalomedullary nailing.

The outcome of 100 patients with achalasia cardia following laparoscopic Heller myotomy with blunt dissection technique.

Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique (BDT). Only a few studies have assessed long-term outcomes and relief of dysphagia following LHM. The study reviews our long-term experience following LHM by BDT. This retrospective study was analysed from a prospectively maintained database (from 2013 to 2021) of a single unit of the Department of Gastrointestinal Surgery at G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. The myotomy was performed by BDT in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered treatment failure. A total of 100 patients underwent surgery during the study period. Of them, 66 patients underwent LHM, 27 underwent LHM with Dor fundoplication and 7 underwent LHM with Toupet fundoplication. The median length of myotomy was 7 cm. The mean operative time was 77 ± 29.27 min and the mean blood loss of 28.05 ± 16.06 ml. Five patients had intraoperative oesophageal perforation. The median length of hospital stay was 2 days. There was no hospital mortality. The post-operative integrated relaxation pressure (IRP) was significantly lower than the mean pre-operative IRP (9.78 vs. 24.77). Eleven patients developed treatment failure, of which ten patients presented with recurrence of dysphagia. There was no difference in symptom-free survival amongst various types of achalasia cardia (P = 0.816). LHM performed by BDT has a 90% success rate. Complication using this technique is rare, and recurrence post-surgery can be managed with endoscopic dilatation.