Invasive Approach Research Articles

Endoscopic Ultrasound-Guided Radiofrequency Ablation as Therapeutic Approach for Pancreatic Insulinoma

Insulinoma is one of the most prevalent form of functional neuroendocrine tumor of the pancreas (PNET) that often manifests with debilitating symptomatic hypoglycemia. When conventional imaging fails to detect the lesion, endoscopic ultrasound (EUS) have proven to be of value to determine the preoperative localisation as well as with biochemical sampling via fine needle aspiration of the suspected lesion. Surgical resection has been the standard care for these pancreatic neuroendocrine tumors. However, with recent advancements, endoscopicultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a promising and less invasive therapeutic approach that carries a favourable outcome and a low risk of complications. We report eda patient with symptomatic pancreatic insulinoma who was treated with EUS-RFA.

Circumferential resection margin rates in esophageal cancer resection- oncological equivalency and comparable clinical outcomes between open versus minimally invasive techniques: A retrospective cohort study.

Radical surgery for esophageal cancer requires macroscopic and microscopic clearance of all malignant tissue. A critical element of the procedure is achieving a negative circumferential margin (CRM) to minimize local recurrence. The utility of minimally invasive surgery poses challenges in replicating techniques developed in open surgery, particularly for hiatal dissection in esophago-gastrectomy. In this study, the technical approach and clinical and oncological outcomes for open and laparoscopic esophago-gastrectomy are described with particular reference to CRM involvement. This cohort study included all patients undergoing either open or laparoscopic esophago-gastrectomy between January 2004 to June 2022 in a single tertiary center. A standard surgical technique for hiatal dissection of the esophago-gastric junction developed in open surgery was adapted for a laparoscopic approach. Clinical parameters, length of stay (LOS), post-operative complications and mortality data were collected and analyzed by a Mann-Whitney U or Fisher's exact method. Overall 447 patients underwent an esophago-gastrectomy in the study with 219 open and 228 laparoscopic procedures. The CRM involvement was 18.8% in open surgery and 13.6% in laparoscopic surgery. The 90-day-mortality for open surgery was 4.1% compared with 2.2% for laparoscopic procedures. Median Intensive care unit (ITU), inpatient LOS and 30-day readmission rates were shorter for laparoscopic compared with open esophago-gastrectomy (ITU: 5 versus 8 days, P=0.0004; LOS: 14 versus 20 days, P=0.022; 30-day re-admission 7.46% versus 10.50%). Post-operative complication rates were comparable across both cohorts. The rates of starting adjuvant chemotherapy were 51.8% after open and 74.4% in laparoscopic esophago-gastrectomy. This study presents a standardized surgical approach to hiatal dissection for esophageal cancer. We present equivalence between open and laparoscopic esophago-gastrectomy in clinical, oncological and survival outcomes with similar rates of CRM involvement. We also observe a significantly shorter hospital length of stay with the minimally invasive approach.

Transarterial embolization with bleomycin-lipiodol emulsion: a successful minimal invasive approach for giant liver hemangioma.

Hemangiomas are most common benign liver tumor. Most patients have an excellent prognosis because of the small size and benign nature of tumor. On some occasions, giant liver hemangioma may cause symptoms and significant challenges due to its complication. We report a case of giant liver hemangioma treated with minimal invasive approach by transarterial embolization (TAE). Following three TAE sessions over a specific timeframe, the patient was successfully managed, addressing that TAE may be a useful alternative to hepatic surgery in such cases.

Fully Endoscopic Minimally Invasive Trans-Eyebrow Supraorbital Translaminar Approach to Third Ventricle Craniopharyngiomas: Technical Nuances and Stepwise Illustrative Description

BackgroundTraditional microsurgical approaches for addressing intraventricular craniopharyngioma pose limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor. MethodsHerein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally-invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the approach’s application is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process. ResultsThe patient is a 44-year-old man who presented with polyuria, low urine specific gravity, hypogonadism, and hypopituitarism. Brain MRI revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A one-stage ESOTLA was indicated based on the narrow corridor between the pituitary gland and optic chiasm and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine deficit was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance MRI showed no evidence of the residual tumor. ConclusionsBy combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area and angle of freedom associated with its conventional microsurgical counterpart.

One-year postprocedural quality of life following mitral valve surgery: data from The Netherlands heart registration.

The aim of surgical treatment of mitral valve disease is to reverse heart failure and to restore life expectancy and quality of life (QoL). In mitral valve surgery, QoL has not been studied extensively, especially regarding the surgical approach. The current study aimed to evaluate QoL after mitral valve surgery through full sternotomy and a minimally invasive approach (MIMVS). All patients undergoing mitral valve surgery between 2013-2018 through sternotomy or a MIMVS approach (right anterolateral mini-thoracotomy, sternal-sparing), with or without concomitant tricuspid valve surgery, surgical ablation, or atrial septal defect closure were eligible for inclusion in this multicentre nationwide registry in the Netherlands. Quality of life was measured using the 12- and 36-item short form surveys, before surgery and postoperatively at 1 year. Independent predictors for loss of QoL were evaluated. 485 patients were included (full sternotomy: n = 276, and MIMVS: n = 209). Overall, patients experienced a significant increase in physical component score (56 [42-75] vs 74 [57-88], p < 0.001) and mental component score at 1-year (63 [52-74] vs 70 [59-86], p < 0.001). Baseline QoL scores and new onset of atrial arrhythmia were independently associated with a clinically relevant reduction in physical and mental QoL. Mitral valve surgery is associated with significant improvement in physical and mental QoL. Baseline QoL scores and new onset of atrial arrhythmia are associated with a clinically relevant reduction in postoperative QoL.

Outcomes of Endoscopic Third Ventriculostomy in Treating Obstructive Hydrocephalus

Background: Obstructive hydrocephalus poses significant treatment challenges, often necessitating innovative surgical interventions to alleviate symptoms and improve patient outcomes. Endoscopic third ventriculostomy (ETV) has emerged as a viable alternative to traditional shunting procedures, offering the promise of a less invasive approach with potentially lower complication rates. This study seeks to deepen our understanding of ETV's effectiveness and safety, shedding light on its role in the current treatment paradigm for obstructive hydrocephalus.&#x0D; Objective: The primary objective of this investigation was to evaluate the surgical outcomes of ETV in patients with obstructive hydrocephalus, focusing on changes in the severity of hydrocephalus and the presence of comorbid conditions pre- and postoperatively.&#x0D; Methods: A comprehensive retrospective analysis was conducted on 54 patients who underwent ETV for obstructive hydrocephalus. Patients were selected based on specific inclusion and exclusion criteria to ensure a homogenous study population. Preoperative and postoperative assessments included the severity of hydrocephalus and the identification of comorbid conditions, with outcomes measured at 6 and 12 months post-surgery. Statistical analyses employed included Chi-square tests for categorical variables, with a significance level set at p&lt;0.05.&#x0D; Results: Postoperative evaluations revealed a significant reduction in the severity of hydrocephalus, with 59% of patients categorized as mild post-surgery compared to 37% pre-surgery. Severe hydrocephalus was reduced from 30% to 11%. However, the presence of comorbid conditions showed no significant change postoperatively (41% pre-surgery vs. 37% post-surgery, p&gt;0.05). The complication rate was minimal, indicating the procedure's safety.&#x0D; Conclusion: ETV demonstrated a significant positive impact on reducing the severity of hydrocephalus in patients, confirming its efficacy as a treatment option. However, its effect on comorbid conditions was less pronounced, suggesting a need for integrated care strategies. These findings support the continued use and further study of ETV in the treatment of obstructive hydrocephalus.

Percutaneous Biliary Interventions in Pediatric Patients

AbstractPercutaneous biliary interventions have become standard for a variety of indications in pediatric patients. They offer a minimally invasive approach to managing biliary pathologies often associated with liver transplantation and hepatobiliary surgery. Interventions include the insertion of drainage catheters for bilomas, percutaneous transhepatic cholangiography for diagnostic purposes, and percutaneous transhepatic biliary drainage for the treatment of biliary leaks and cholestasis. Sonography, computed tomography, and fluoroscopy are used to guide the procedures. This review aims to demonstrate the indications and technical aspects of percutaneous biliary interventions in pediatric patients with a special focus on radiation protection.

The Role of Laparoscopic Surgery in the Management of Hepatocellular Carcinoma

Abstract Purpose of Review Hepatocellular carcinoma (HCC) is the most common primary liver tumor and 6th most common cancer overall. This article reviews the role of laparoscopy in the multi-disciplinary management of HCC. Recent Findings Laparoscopic surgery involves multiple approaches for diagnosis and treatment of HCC, including intraoperative ultrasound and biopsy, as well as ablative strategies for tumors in difficult locations. In comparison to catheter-based therapies, hepatic resection offers similar survival with the benefit of direct visualization to identify additional tumors. Laparoscopic liver resections further show similar oncologic outcomes with reduced hospital length of stay and reduced morbidity compared to open approaches and may even be used to treat large tumors. Summary Laparoscopic surgery may be involved in the diagnosis, treatment, and resection of HCC. Laparoscopic hepatic resections are safe with equivalent oncologic outcomes and may offer advantages over catheter-based therapies in selected patients. Advances in robotic surgery have served to expand the potential for minimally invasive approaches in the surgical treatment of HCC.

Concomitant midline ventral and inguinal hernia repair: can we create an algorithmic approach?

International guidelines exist for surgical treatment of either ventral or inguinal hernias repair (VHR; IHR). However, approach for managing both of them remains unestablished and is further complicated by newly developed surgical techniques and modalities (namely, robotic). This highlights the need for a tailored, algorithmic strategy to streamline surgical management. An algorithm was developed by the directors of the NYU Langone Abdominal Core Health program of which four treatment groups were described: Group 1: open VHR and either laparoscopic or robotic IHR; Group 2: robotic transabdominal pre-peritoneal (TAPP) approach for both VHR and IHR; Group 3: robotic retro-muscular VHR and IHR; and Group 4: open repair for both. Demographics, comorbidities, operative characteristics, and surgical outcomes from November 2021 to July 2023 were retrospectively compared. Ninety-two patients were included with a median age of 64years, 90% (n = 83) were white, 85% (n = 78) were male, median BMI was 27kg/m2, and 73% (n = 67) were ASA class II. Distribution of groups was: 48% (n = 44) in 1A, 8% (n = 7) in 1B, 8% (n = 7) in 2A, 3% (n = 3) in 2B, 23% (n = 21) in 3A, 8% (n = 7) in 3B, and 3% (n = 3) in 4. Ventral hernia size, OR time, and postoperative length of stay varied across groups. Postoperative outcomes at 30days including emergency consults, readmissions, and complications, showed no differences across groups. Access without guidance to new minimally invasive surgical approaches can be a challenge for the general surgeon. We propose an algorithm for decision-making based on our experience of incorporating robotic surgery, when available, for repair of concomitant VHR and IHR with consistent favorable outcomes within a small sample of patients.

The Use of a Simple Vaginal Speculum to Harvest Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction and Avoid any Potential Pitfalls during Harvesting Procedure

Anterior cruciate ligament reconstruction with quadriceps tendon autograft has gained popularity in recent years, while many harvesting techniques were described with the use of different harvesting systems available on the market. There are multiple techniques varying from transverse to longitudinal skin incision, from open to minimally invasive approach. Despite the preferred technique, it seems that there is a reported learning curve as with the majority of surgical procedures. The present technical note makes an effort to present a straightforward harvesting method of quadriceps tendon autograft with the use of a simple vaginal speculum and direct visualization with the scope. Our technique is minimally invasive, easily reproducible from every surgeon despite the level of experience, with short learning curve, requiring no additional cost or technical support during the procedure, while creating a stable working space with freedom of manipulation of the surgical instruments and arthroscope.&#x0D; Keywords: Anterior Cruciate Ligament; Knee; Arthroscopic Surgery; Quadriceps Muscle; Autografting.

Synthesis and Properties of Injectable Hydrogel for Tissue Filling.

Hydrogels with injectability have emerged as the focal point in tissue filling, owing to their unique properties, such as minimal adverse effects, faster recovery, good results, and negligible disruption to daily activities. These hydrogels could attain their injectability through chemical covalent crosslinking, physical crosslinking, or biological crosslinking. These reactions allow for the formation of reversible bonds or delayed gelatinization, ensuring a minimally invasive approach for tissue filling. Injectable hydrogels facilitate tissue augmentation and tissue regeneration by offering slow degradation, mechanical support, and the modulation of biological functions in host cells. This review summarizes the recent advancements in synthetic strategies for injectable hydrogels and introduces their application in tissue filling. Ultimately, we discuss the prospects and prevailing challenges in developing optimal injectable hydrogels for tissue augmentation, aiming to chart a course for future investigations.

What defines the “value” of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center

AbstractThe use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high‐level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient‐centered, value‐based healthcare models and reimbursement systems that embrace cost‐effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value‐based care, with a focus on robotic surgery for gastrointestinal cancers.

Salivary Biomarkers in the Diagnosis of Diabetic Nephropathy – An Non- Invasive Approach

Salivary Biomarkers in the Diagnosis of Diabetic Nephropathy – An Non- Invasive Approach

Microfluidic-based systems for the management of diabetes.

Diabetes currently affects approximately 500million people worldwide and is one of the most common causes of mortality in the United States. To diagnose and monitor diabetes, finger-prick blood glucose testing has long been used as the clinical gold standard. For diabetes treatment, insulin is typically delivered subcutaneously through cannula-based syringes, pens, or pumps in almost all type 1 diabetic (T1D) patients and some type 2 diabetic (T2D) patients. These painful, invasive approaches can cause non-adherence to glucose testing and insulin therapy. To address these problems, researchers have developed miniaturized blood glucose testing devices as well as microfluidic platforms for non-invasive glucose testing through other body fluids. In addition, glycated hemoglobin (HbA1c), insulin levels, and cellular biomechanics-related metrics have also been considered for microfluidic-based diabetes diagnosis. For the treatment of diabetes, insulin has been delivered transdermally through microdevices, mostly through microneedle array-based, minimally invasive injections. Researchers have also developed microfluidic platforms for oral, intraperitoneal, and inhalation-based delivery of insulin. For T2D patients, metformin, glucagon-like peptide 1 (GLP-1), and GLP-1 receptor agonists have also been delivered using microfluidic technologies. Thus far, clinical studies have been widely performed on microfluidic-based diabetes monitoring, especially glucose sensing, yet technologies for the delivery of insulin and other drugs to diabetic patients with microfluidics are still mostly in the preclinical stage. This article provides a concise review of the role of microfluidic devices in the diagnosis and monitoring of diabetes, as well as the delivery of pharmaceuticals to treat diabetes using microfluidic technologies in the recent literature.

Percutaneous interventional thrombectomy of an endovascular AV-fistula, a case report.

Dialysis access thrombosis is a common complication in the process of care. With the introduction of endovascular AV-fistulas [AVF]s the situation gained complexity with new potential thrombosis localizations. Several thrombectomy methods are available for recanalization of thrombosed AVFs ranging from invasive surgical methods to minimal invasive endovascular approaches. Early assessment, diagnosis and treatment is crucial for prolonging the life span of an AVF and preventing the need for placement of central venous catheters. To our best knowledge, we present the first case in which an obstructed antecubital communicating vein (aka perforating vein) of an endovascular created AVF was re-opened via interventional thrombectomy with the Rotarex® System (BD Interventional). The procedure was performed primarily under ultrasound guidance with fluoroscopic support. Our case report shows that this method, if done correctly and successfully, may prevent loss of the dialysis access. Additionally, we point towards the central role of ultrasound in this method.

Arthroscopic Hemitrapeziectomy and Extensor Carpis Radialis Longus Suspensioplasty With Intermetacarpal Ligament Reconstruction for Thumb Carpometacarpal Joint Osteoarthritis: Surgical Technique.

Level IV.

Salvage of brachiocephalic aneurysmatic fistulas, using ePTFE graft with a minimally invasive approach.

In this study, we evaluated our surgical approach in requiring surgical treatment of brachiocephalic arteriovenous fistula (AVF) aneurysms for salvage of AVF. Between 2012 and 2022, 20 patients (16 men, 4 women; mean age 54.5 years) who were surgically treated for a brachiocephalic AVF aneurysm in our Cardiovascular Surgery Clinic were evaluated retrospectively. These 20 patients were operated on for aneurysm thrombosis and fistula failure in 16 patients, sudden rupture and severe bleeding in 3 patients, cosmetic reasons, and anxiety in 1 patient. These aneurysms were ligated and divided from distal and proximal cephalic veins. Then, a 6 mm dialysis graft was interposed between the well-developed cephalic vein distal and proximal to the aneurysm with small skin incisions. All patients were taken to dialysis via this dialysis graft 24 h after the procedure without any problem. All patients were discharged after dialysis. After surgery, no catheterization or any other additional procedure was required for hemodialysis. No complications, such as infection, hematoma, neurological damage, or ischemia, were observed after the surgical procedure. The mean postoperative follow-up was 12 months. In brachiocephalic AVF aneurysms requiring surgical treatment, hemodialysis can be continued with a graft placed in the same arm in this technique.

Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results.

We aim to compare early surgical results between groups who underwent minimally invasive surgery (MIS) vs open first metatarsophalangeal (MTP) arthrodesis to treat end-stage hallux rigidus. We conducted a retrospective cohort review of 65 patients who underwent a first MTP fusion procedure at an academic medical center between 2015 and 2023. Success of fusion was determined radiographically. Postoperative complications were identified through medical record review. Sixty-seven first MTP fusion surgeries (41 open and 26 MIS) were performed on 65 patients with a primary diagnosis of hallux rigidus. Open surgery and MIS groups had similarly high fusion rates: 95% (39/41) and 96% (25/26), respectively (P = .84). We identified no difference in overall complication rates: 20% for open surgery and 23% for MIS (P = .73). This retrospective analysis of 67 first MTP arthrodesis procedures showed no significant differences in fusion success or complications in the short term when comparing MIS to open surgery. Further studies are needed to elucidate potential differences between MIS vs open surgery. Level III, retrospective comparative study.

Achievement of textbook outcome after hepatectomy combined with thermal ablation for colorectal liver metastases.

Hepatic resection combined with intraoperative ablation has been described as a technical solution potentially widening the resectability rate of patients with colorectal liver metastases (CRLM). Nevertheless, the perioperative and oncological benefit provided by this combined approach remains unclear. We hypothesized that textbook outcome (TO), which is a composite measure achieved for patients for whom some desired health indicators are met, may help to refine the indications of this approach. Patients submitted to hepatectomy with curative intent in combination with radiofrequency ablation or microwave ablation for CRLM≤3cm in two tertiary referral centers were included. TO was defined according to a recent definition for liver surgery based on a Delphi process including also the achievement of complete radiological response of the ablated lesion/s at 4weeks. Between 2015 and 2022, 112 patients were enrolled. Among them, 63 (56.2%) achieved a TO. According to multivariate analysis, minimally invasive (MI) approach (OR 2.72, 95% CI 0.99-7.48, p=0.050), simultaneous CR resection (OR 0.28, 95% CI 0.11-0.70, p=0.007), tumor burden score (OR 0.89, 95% CI 0.82-0.96, p=0.004), and major hepatectomy (OR 0.12, 95% CI 0.03-0.52, p=0.004) were significantly associated with the achievement of TO. Median overall survival was longer in those patients who were able to achieve a TO compared to those who did not. The combination of hepatectomy and ablation constitutes a valuable solution in patients affected by multiple CRLM and it may provide, also using a MI approach, adequate perioperative and oncological outcomes, allowing to achieve TO, however, in a selected number of patients and depending on several factors including the burden of disease.

Modified Valente Technique for Cauliflower Ear: Outcomes in Children at Two-Year Follow-Up

BackgroundCauliflower ear deformity, a common sequela of auricular trauma, presents an esthetic and reconstructive challenge. Existing surgical techniques have limitations, including complexity, donor site morbidity, and variable long-term outcomes.Materials and MethodsIn this case series, we present a novel and minimally invasive surgical approach for the correction of cauliflower ear deformity that adapts the Valente otoplasty technique; it combines cartilage debulking with helical rim release and Mustardé mattress stitches to restore ear contour and reduce the risk of recurrence. The procedural steps include bielliptic post-auricular skin and soft tissue incision, release of the cartilaginous spring, removal of excess fibrocartilaginous tissue, cartilage reshaping with suture to restore contour, and tissue redistribution to promote adherence of skin to the cartilage framework.ResultsOutcomes were evaluated in 7 patients (9 ears) with cauliflower ear deformity, assessing surgical duration, complications, patient satisfaction, and esthetic outcomes at two years after surgery. The mean surgical duration per patient was 52 ± 17 minutes, including 2 bilateral procedures. Follow-up at 24 months showed favorable esthetic outcome in all patients with sustained improvements in auricular contour and symmetry with neither loss of the shape nor recurrence of deformity. Patients reported high satisfaction and improved quality of life, with mean Glasgow Children Benefit Questionnaire scores of 99.3 ± 6.3.ConclusionsThis technique thus demonstrated lasting correction of cauliflower ear with favorable cosmetic outcomes, low risk of complications, and high patient satisfaction. Further investigations and longer-term follow-up are warranted to validate the technique's durability and expand its application to older and more diverse patient populations.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266.