Dissection Time Research Articles

The impact of modifications in cadaver dissection time on student learning outcomes in a doctor of physical therapy program.

Human anatomy is a foundational component of medical and allied health professional education. Doctor of Physical Therapy (DPT) programs are required to teach anatomy, however the pedagogies used are at the discretion of faculty and institutions. Cadaver dissection may have been the predominant instruction methodology in DPT programs in the past; new technology provides alternative interactive teaching methods. This paper describes the modifications in an anatomy curriculum over 5 years in one DPT program, and the impact on student perception and learning outcomes. This was a retrospective, quantitative study that utilized a survey to collect data on student perceptions about the anatomy pedagogy; the learning outcomes analyzed were grades and licensure exam pass rates. We report on outcomes for five cohorts within one DPT program. IRB approval was obtained for the research. Despite the decrease in cadaver laboratory time after 2016, students' final exam grades in Gross Anatomy improved and the first time pass rate for the national licensure exam increased. Most students rated cadaver laboratory and the active learning assignments that replaced traditional cadaver laboratory time as valuable to their learning; however, there were differences in opinions between cohorts. Although the outcomes might not reflect a direct result of dissection time, the study confirmed that using alternative methods for teaching anatomy did not hinder student performance. Using innovative pedagogy allows educators to achieve student success in spite of decreased gross dissection time.

Initial Multicenter Experience of Traction Wire Endoscopic Submucosal Dissection

Background and AimsEndoscopic submucosal dissection (ESD) is a technically challenging and time-consuming procedure. A major limitation of ESD is the lack of a “second hand” to provide traction. We have developed a novel retraction device, a traction wire (TW), for ESD. This study was conducted to assess the efficacy, safety, and efficiency of TW-ESD. MethodsWe initially evaluated TW-ESD in a randomized live pig study. After the device was approved for clinical use, we used it in patients undergoing ESD at 8 academic centers in the United States and Japan. Data on demographics, procedural performance, histopathology, and clinical follow-up were collected and analyzed retrospectively. ResultsPorcine study: In total, 12 ESDs were performed in random order in 3 live pigs. ESDs performed with TW had significantly shorter submucosal dissection time (7.0 ± 1.9 minutes vs 18.3 ± 3.4 minutes; P < 0.001) and shorter total ESD time (21.5 ± 4.1 minutes vs 29.5 ± 7.7 minutes; P= 0.049). TW was successfully deployed in all 103 study patients. The median device deployment time was 2 minutes (2, 3.0), and the median procedure time was 100.5 (65.50, 175.75) minutes. En-bloc and R0 resection rates were 98.1% (101/103) and 90.29% (93/103), respectively. The median ease of deployment and retrieval of the device on a 100-mm visual analog scale was 100 (80, 100). The median degree to which the device improved ease of procedure was 90 (77.5, 100). No adverse events related to the TW were seen. ConclusionThe TW device was safe and efficient to use in ESD.

Oncologic safety of axillary lymph node dissection with immediate lymphatic reconstruction.

Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates. Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed. A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9months (range 6-63months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified. Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.

Modified technique of tumor traction in endoscopic submucosal dissections in the stomach (ex vivo study)

Background : the method of endoscopic submucosal dissection (ESD) allows to remove large neoplasms of the GI tract enblock, which significantly reduces the risk of local tumor recurrence. However, ESD method is technically complicated with high risk of surgical complications. Aim : to modify ESD traction technique and evaluate its efficiency. Materials and methods: experimental comparative study on biological preparations (pig stomachs). 144 ESD with three different methods were performed: the 1 st group—standard ESD method (n-48); the 2 nd —ESD with the method of traction with the clip and thread (n-48); the 3 rd —ESD with a modified method of tumor traction (n-48). Results : the shortest time to submucosal dissection was 4.89 min [2–12] in the 3 rd group, and 13,27 [4–31] min and 9,37 [4–26] min in the 1 st and 2 nd , respectively (p = 0,05). Total operative time in the 3 rd was 21,10 [12–31] min, in the 1 st 23.85 [12–48] min, and in the 2 nd —25.56 [13–49] min, p = 0.002. The max dissection speed was 0.48 [0.20–1.27] (min/cm 2 ) in the 3 rd group, 0.94 [0.47–2.06] (min/cm 2 ) and 1.48 [0.56–4.10] (min/cm 2 ) in the 2 nd and 3 rd , respectively, p=0.003. HM0 was 89.6% [43/48] in group 1, 93.7% [45/48] in the 2 nd , and 100% [48/48] in the 3 rd , p&gt;0.05. Muscle layer damage during submucosal dissection was 25% [12/48] in the 1 st , 6.25% [3/48] in the 2 nd and 12.5% [6/48] in 3 rd , p=0.389. Conclusion : the modified traction method during endoscopic submucosal dissection allows to visualize submucosa layer better, to increase dissection speed thus reducing total time of the operation and time of submucosal dissection.

S1077 Novel Through the Scope Steerable Grasper Reduces Dissection Time and Technical Demand in Endoscopic Submucosal Dissection in Novice Endoscopists Compared to Clip and Line Traction Method: An Ex Vivo Randomized Study

Introduction: Lack of effective devices to aid in tissue traction to facilitate endoscopic submucosal dissection (ESD) leads to prolonged dissection time. Clip and line (CL) method is commonly used to provide traction and improve visualization of the submucosa. A novel through the scope dynamic steerable grasping arm (SGA) has recently been available. We aim to prospectively study the efficacy of this new device with novice endoscopists in an ex vivo setting. Methods: This is a prospective single center randomized trial. In an ex-vivo porcine stomach model, two 25mm circular lesions were marked. Submucosal injection using a lifting agent and circumferential incision was performed. Novice endoscopists with no prior experience of ESD and with one to three years of experience of performing endoscopies were randomized to either SGA (study group) or CL method (control group) first. Each endoscopists performed ESD with both methods. Primary outcome was total dissection time in minutes. Adverse events of muscle injury, perforation, mucosal injury or tissue fragmentation were noted. Participants were asked to choose their preferred traction method for future ESDs. Subsequently, NASA task load index was used to grade subjective mental and physical work load. Results: Ten subjects participated in the study and five were randomized to SGA method first. The mean dissection time was significantly shorter when using SGA compared to clip and line method (5.07 ± 2.19 mins vs 20.07 ± 8.45 mins, P< 0.001) irrespective of order of randomization. Four instances of muscle injury and one perforation were noted with CL and none with SGA. NASA task load index scores across the domains of mental demand (7.9 ± 3.1 vs 15 ± 4 , P< 0.001), physical demand (6.4 ± 2.5 vs 12.9 ± 5.6, P=0.009), temporal demand (5.6 ± 3.3 vs 13.8 ± 4.3, P< 0.001), performance (3.9 ± 3.2 vs 9.2 ± 5.0, P=0.02), effort (8.4 ± 3.5 vs 16.3 ± 2.8, P< 0.001) and frustration (3.9 ± 2.3 vs 14.3 ± 5.1, P< 0.001) were significantly lower with SGA compared to CL. All participants preferred SGA over CL method. Conclusion: With novice endoscopists performing ESD, SGA leads to faster dissection time compared to CL for traction with a reduced mental and physical work load. There was a trend towards reduced adverse events with SGA. SGA is a promising tool to improve efficiency and learning curve of ESD (Table). Table 1. - Dissection times between two methods across the two randomized groups Randomization Number of subjects Dissection time in minutes using SGA (mean +/- SD) Dissection time in minutes using CL (mean +/- SD) P value SGA first 5 5.32 + 2.21 22.6 + 11.42 0.017 CL first 5 4.82 + 2.41 17.5 + 3.70 0.002 Total 10 5.07 + 2.19 20.07 + 8.45 < 0.001 SGA: Steerable grasping arm; CL: Clip and line.

Neck Dissection Timing in Transoral Robotic or Laser Microsurgery in Oropharyngeal Cancer: A Systematic Review.

ObjectiveThis review assesses the effect on intra- and postoperative patient outcomes of the timing of neck dissection in relation to transoral surgery. Outcome measures include postoperative bleeding, intra- and postoperative fistula formation, and disease-specific and overall survival.Data SourcesA search was conducted across the MEDLINE, Embase, US National Library of Medicine, and Cochrane databases with search terms in July 2021.Review MethodsArticles that conformed with specified inclusion criteria were included. Included articles were scanned for bias with the ROBINS-I tool.ResultsNineteen articles were selected for qualitative analysis, including 546 patients who had neck dissection in conjunction with transoral robotic surgery/transoral laser microsurgery (TORS/TLM). Seventy-one (18%) patients had neck dissection prior to TORS/TLM, 39 (10%) had neck dissection performed after TORS/TLM, and 281 (72%) had concurrent procedures. In patients with neck dissection before TORS/TLM, 3% experienced major postoperative bleeding, and fistula rates were 0%. In the cohort with neck dissection after TORS/TLM, 3% experienced minor postoperative hemorrhage, and 8% had intraoperative fistulae. In the concurrent cohort of patients, 1% had major postoperative bleeds and 0.3% had minor bleeds, while 4% developed intraoperative fistulas and 0.3% developed postoperative fistulas.ConclusionCurrent evidence indicated that there appears to be no correlation between timing of neck dissection and complications. This systematic review found insufficient data to comment on whether the timing of neck dissection in relation to TORS/TLM affects the outcomes of patients.

Comparison of clinical safety and feasibility between reduced-port laparoscopic radical gastrectomy and conventional laparoscopic radical gastrectomy: A retrospective study.

BackgroundTraditional open gastric cancer surgery has evolved from porous to reduced-hole, single-hole, or even natural cavity surgery to laparoscopic surgery, due to the continuous development of minimally invasive concepts and medical technologies, as well as awareness for the concept of rapid recovery. Conventional laparoscopic radical gastrectomy is quite mature in age at the moment, but how to progress to minimally invasive surgery without increasing the difficulty of surgery while ensuring clinical safety and feasibility is worth further investigation. Therefore, the clinical safety and feasibility of reduced port laparoscopic radical gastrectomy were assessed in this study.MethodsInformation on the clinical data of patients undergoing laparoscopic radical gastric cancer surgery in a single centre between May 2020 and May 2022 was collected, and a total of 232 patients were included in this study according to the study protocol design. The clinical data of 232 patients with gastric cancer treated by two different surgical methods, namely, reduced port laparoscopic surgery (RPLS) or conventional laparoscopic surgery (CLS), were retrospectively analysed. The intraoperative indices, postoperative pathological indices, and short-term postoperative complications (within 30 days) of the two different surgical methods were evaluated, as well as the surgical methods’ feasibility and short-term postoperative recovery effect.ResultsThere was no significant difference between the general data of patients with RPLS and CLS (P > 0.05). Compared with CLSG, the operation time, digestive tract reconstruction time and lymph node dissection time of RPLSG are shorter. The intraoperative blood loss was less, and the incision was minimally invasive (P < 0.05). In the short-term postoperative effect, the level of white blood cell count on the first day, the time of getting out of bed, the time of removing drainage tube, the time of hospitalization and the VAS of pain on the first, third and fifth days after operation, RPLSG was obviously superior to CLSG (P < 0.05). There was no significant difference between RPLSG and CLSG in terms of pathological indices (P > 0.05).ConclusionsThe treatment of gastric cancer with RPLS has good safety, feasibility and short-term postoperative effects, which is in line with the implementation of the modern concept of rapid rehabilitation surgery.

A Double Suspension Technique for Laparoscopic Isolated Caudate Lobectomy.

Background: Laparoscopic isolated caudate lobectomy is still a challenging procedure for hepatobiliary surgeons because of its deep location and narrow operating space. Hilar exposure and adequate operation space play an important role during laparoscopic caudate lobectomy. Very few references are available on this technique, and in this study, we present a new suspension technique to assist laparoscopic caudate lobectomy. Materials and Methods: The data of patients with caudate hepatic tumors who underwent laparoscopic isolated caudate lobectomy with or without the double suspension technique at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. Results: A total of 25 patients underwent laparoscopic isolated caudate lobectomy at Eastern Hepatobiliary Surgery Hospital between June 2016 and March 2022. Eight patients had perioperative complications, and no patient died within 30 days after surgery. There were no significant differences between the two groups in terms of conversion rate (8.3% versus 7.7%; P = .954), complication rate (25.0% versus 38.5%; P = .480), length of stay (8.0 [6.0-11.0] days versus 9.0 [6.0-19.0] days; P = .098), and postoperative liver function changes. Patients who underwent resection in the suspension group had shorter operation time (154.9 ± 44.3 minutes versus 224 ± 86.3 minutes; P = .018), inferior vena cava dissection time (30.1 ± 5.4 minutes versus 44.8 ± 7.4 minutes; P < .001), and less bleeding (125.0 [20-800.0] mL versus 350 [80-850.0] mL, P = .011). Conclusions: This double suspension technique is a safe and feasible method to assist laparoscopic caudate lobectomy. It provides clear exposure and adequate surgical space, thereby shortening the operation time and reducing intraoperative blood loss.

Free-hand, transrectal ultrasound-guided hydrodissection of the retroprostatic space during robot-assisted radical prostatectomy: Impact on the learning curve

Aim of the current study is to describe our technique of hydrodissection (HD) of the retroprostatic space (RPS) performed between the Denonvillier's fascia (DF) and prostatic capsule (PC) and to evaluate its impact on the outcomes of nerve-sparing robot-assisted radical prostatectomy (nsRALP) during the learning-curve period. This randomized study enrolled 25 consecutive male patients with indication of nsRALP. The HD and the subsequent dissection of the seminal vesicles (SVs) and RPS was performed by a resident in learning curve for RALP; the residual portion of RALP was performed by an expert. The perioperative, oncologic and functional outcomes of 2 groups of patients (Group A: nsRALP after HD of the RPS and Group B: standard nsRALP without HD) were compared. Two analyses were performed, considering a per-protocol (PP) population regarding only randomized patients with correct HD and an Intention-To-Treat (ITT) population regarding all randomized patients. In 4/14 (29%) of patients of Group A the injected fluid was not intraoperatively identified in the expected plane. The groups were statistically homogeneous in relation to the baseline variables. A statistically significant difference was observed between the SVs/RPS dissection time and the SVs-related estimated blood loss in both analyses. A significantly higher rate of dry patients was observed in group A at 1 month after nsRALP. A statistically significant correlation was observed between the effective time of dissection of the SVs and the postoperative IIEF-5 drop. The transrectal ultrasound-guided transperineal HD seems useful for the preliminary development of the RPS during the learning curve period of nsRALP. It seems associated with less time and blood loss for the dissection of the SVs and RPS. Studies on larger cohorts are needed to draw more robust conclusions.

Novel Gerota-edge-sling technique facilitates retroperitoneal robot-assisted partial nephrectomy: a comparative study

BackgroundRetroperitoneal robotic partial nephrectomy is markedly restricted by limited space and visual field. We introduced a novel Gerota-edge-sling (GES) technique with self-designed traction devices to overcome these defects by attaching Gerota fascia to abdominal wall, and comparatively evaluated its utilization with routine technique.MethodsA retrospective analysis was performed for consecutive patients who underwent routine (control group) or GES assisted (GES group) retroperitoneal robotic partial nephrectomy for localized renal tumors in our hospital between March 2018 and June 2020. Clinical data of perioperative outcomes and complications were collected and compared. Comparison of outcomes between anterior versus posterior tumor subgroups was also conducted. Linear regression analysis was used to define the relationship between dissection time and perinephric fat status in each group.ResultsTotally 103 patients were included, 48 in control and 55 in GES group respectively. All the procedures were completed successfully without conversion or positive surgical margin. GES group had significantly decreased console time (91 ± 36 min vs. 117 ± 41 min, p < 0.01) and dissection time (67 ± 35 min vs. 93 ± 38 min, p < 0.01) than control, while ischemia time, blood loss, and nephrometry score comparable between them. No major postoperative complications occurred. Dissection time of GES group was notably shorter than that of control in both anterior/posterior subgroups. Only in control group, dissection time was positively associated with perinephric fat status.ConclusionsThe GES technique acting as an adjunct to robotic arms with space-sparing feature, notably improves surgical exposure and facilitates dissection in retroperitoneal partial nephrectomy, while having great feasibility, efficacy and safety.

Initial Experience of 4K Three-Dimensional Digital Microscope for Lymphaticovenular Anastomosis.

A digital microscope projecting the operative field onto a three-dimensional monitor has been developed and allows surgeons to perform “three-dimensional monitor–assisted microsurgery,” which is usually associated with distressful posture. A few articles in the neurosurgery field mentioned that the usability of digital microscopes was comparable to that of conventional optical microscopes.1 In the plastic surgery field, Ichikawa et al. and Piatkowski et al. reported the experience of the microvascular anastomosis with using the Vitom3D (Carl Storz, Tuttlingen, Germany),2,3 and Ahmed et al. also concluded that the usability of the ORBEYE (Olympus Corp., Tokyo, Japan) was not inferior to the optical microscope for microsurgery.4 However, there was a limitation for the usability in supermicrosurgery, defined as anastomosis of small vessels ranging from 0.3 to 0.8 mm because of the resolution under the large manipulation of the digital microscope. To support this, any articles regarding supermicrosurgery using digital microscopes have not been published. Herein, we report the initial experience of the lymphaticovenular anastomosis using a new type of digital microscope, the Hawk Sight (Mitaka, Tokyo, Japan). The lymphaticovenular anastomosis was approved by the Juntendo University Hospital Institutional Review Board in February of 2020 (approval number 19-101). In this study, lymphaticovenular anastomosis using the Hawk Sight was attempted in seven cases of cancer-related extremity lymphedema (upper limbs, n = 5; lower limbs, n = 2) and 13 anastomoses in total by two microsurgeons. The Hawk Sight was used during the dissection of lymphatic vessels and venules and microvascular anastomosis (Fig. 1). [See Video 1 (online), which demonstrates an overview of the lymphaticovenular anastomosis procedures with three-dimensional monitor–assisted microsurgery using the Hawk Sight. In this video, the principal surgeon is performing all procedures, using the 4K three-dimensional monitor.] All anastomoses between lymphatic vessels and venules were conducted in an end-to-end fashion. The average luminal diameter in the lymphatic vessel was 0.47 mm and the average anastomosis time was 31.5 minutes. The patency was confirmed by the lymph fluid flow from the lymphatic vessel to the vein by kneading and the indocyanine green angiography built into the Hawk Sight intraoperatively. (See Figure, Supplemental Digital Content 1, which shows an intraoperative view of indocyanine green angiography to check the patency of the anastomosis. The high-tech clarity enables surgeons to evaluate the patency with ease, https://links.lww.com/PRS/F393. See Video 2 (online), which demonstrates the monitor view of the anastomosis, the patency check, and the mode transition in indocyanine green angiography. The green color reflects the high density of the indocyanine green and helps assessment of the patency.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video demonstrates an overview of the lymphaticovenular anastomosis procedures with three-dimensional monitor–assisted microsurgery using the Hawk Sight. In this video, the principal surgeon is performing all procedures, using the 4K three-dimensional monitor.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_1l9advlg"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"This video demonstrates the monitor view of the anastomosis, the patency check, and the mode transition in indocyanine green angiography. The green color reflects the high density of the indocyanine green and helps assessment of the patency.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_gjkele2d"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Overview of the lymphaticovenular anastomosis under the latest digital microscope, Hawk Sight. The focal length is so short that the camera head unit does not interfere with the principal operator’s straight view and the assistant’s view. The maximum manipulation is 110× under the minimum focal length (20 cm).To date, several digital microscopes are available in the operative field, and each digital microscope has the original features for outlook, focal length, zoom function, optics, and cost. When considering supermicrosurgery using digital microscopes, the important aspect is high resolution on the monitor under the maximum manipulation without disturbance of the straight view. The Hawk Sight has an incredibly wide and short focal length (200 to 1000 mm), coherent optical zoom system (8×), and 4K three-dimensional optics, and those technologies broke the limitations and allow microsurgeons to perform supermicrosurgery with “heads-up” style, which is better for surgeon ergonomics. In addition, its resolution in indocyanine green mode is so clear that it enables projection of the duct brightly and sharply and evaluation of the patency precisely. Meanwhile, the procedures’ time for dissection and anastomosis were prolonged compared to the conventional method using an optical microscope. In our opinion, because the main reason was the nearly short focal depth under the maximum manipulation, even surgeons familiar with the lymphaticovenular anastomosis procedure might feel this is troublesome when they start lymphaticovenular anastomosis by three-dimensional monitor–assisted microsurgery at the beginning. However, we consider this issue can be overcome with experience with this method. In conclusion, there seems to be room yet for improvement of digital microscopes, but the paradigm shift from optical microscopes to digital microscopes is coming to the field not only of microsurgery but also of supermicrosurgery, including lymphaticovenular anastomosis. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Effectiveness of a novel traction device in endoscopic submucosal dissection for colorectal lesions

BackgroundAmong all types of superficial gastrointestinal (GI) neoplasms, colorectal lesions are recognized as one of the most difficult locations to operate, due to the limited operation space, physiological bends, poor visualization of the submucosal dissection plane sheltered by colorectal crinkle wall, and the thin intestinal mucosa layer which is easy to perforation. The purpose of this prospective study is to evaluate the feasibility, efficacy, and safety of a novel endoscopic traction technique in assisting the endoscopic submucosal dissection (ESD) procedure in colorectal lesions.MethodA total of 117 patients with colonic lesions who underwent endoscopic treatment were enrolled between August 2020 and January 2021 at the endoscopic center of Beijing Chao-yang Hospital of Capital Medical University. Based on whether traction device was used during the operation, 60 and 57 patients were assigned to the conventional ESD group and clips and rubber band triangle traction-assisted ESD group (CRT-ESD, in which three clips and a rubber band were used to form an elastic triangular traction device), respectively. The total procedure time (TPT), submucosal dissection time (SDT), submucosal dissection speed (SDS), and rate of adverse events of the two groups were analyzed.ResultsAfter excluding patients who did not undergo treatment (conventional ESD, 1; CRT-ESD, 4), 112 patients were included in the study (conventional ESD, 59; CRT-ESD, 53). The baseline characteristics of the patients were well balanced between the two groups. The TPT (58.71 ± 26.22 min vs 33.58 ± 9.88 min, p < 0.001) and SDT (49.24 ± 23.75 min vs 26.34 ± 8.75 min, p < 0.001) were significantly different between the conventional ESD group and CRT-ESD group. The CRT-ESD group had significantly higher SDS than that of the traditional ESD group (0.54 ± 0.42 cm2/min vs 0.89 ± 0.40 cm2/min, p < 0.001). There were 4 (6.8%) cases of perforation in the traditional ESD group, and no perforation occurred in traction-assisted ESD.ConclusionsCompared with traditional ESD, CRT-ESD with clip and rubber band is both safer and more effective in the treatment of colorectal lesions.Graphical abstract

Safety and feasibility of a modularized procedure for trans-subxiphoid robotic extended thymectomy.

The purpose of this study was to introduce an "eight-step modularized procedure (M-RET)" for trans-subxiphoid robotic extended thymectomy for patients with myasthenia gravis (MG). Its safety and feasibility were further verified in this study. This retrospective study included 87 consecutive MG patients who underwent trans-subxiphoid robotic extended thymectomy at our institution between September 2016 and August 2021. According to different resection models, patients were divided into two groups: traditional trans-subxiphoid robotic extended thymectomy group (T-RET group)and eight-step modularized technique group (M-RET group). Baseline demographic characteristics and operation-related parameters were collected and compared between the two groups. There were 41 (47.1%) patients in the M-RET group and 46 (52.9%) patients in the T-RET group. The M-RET group resected a greater amount of mediastinal adipose tissues and required more dissection time (median and interquartile range: 135.0, 125.0 to 164.0 v. 120.0, 105.0 to 153.8, P = 0.006) compared with the T-RET group. There were no statistically significant differences in terms of the intraoperative blood loss, duration of chest drainage, length of hospital stay, and postoperative complications between the two groups. There was no mortality or conversion in each of the two groups and all patients recovered well upon discharge. The eight-step modularized technique of trans-subxiphoid robotic extended thymectomy was verified to be a safe, effective, radical procedure, which offers unique superiority over ectopic thymic tissue resection.

Short-term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions.

ObjectivesEndoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short‐term outcomes after ESD in non‐selected consecutive patients.MethodsPatients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien‐Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events.ResultsA total of 330 patients (female 40%, male 60%; median 72 years; IQR 65–80 years) with colorectal lesions (median 30 mm, IQR 23–40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38–86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1–10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors.ConclusionsNo serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

Robotic spleen-preserving total gastrectomy shows better short-term advantages: a comparative study with laparoscopic surgery.

Robotic surgery may be advantageous for complex surgery. We aimed to compare the intraoperative and postoperative short-term outcomes of spleen-preserving splenic hilar lymphadenectomy (SPSHL) during robotic and laparoscopic total gastrectomy. From July 2016 to December 2020, the clinicopathological data of 115 patients who underwent robotic total gastrectomy combined with robotic SPSHL (RSPSHL) and 697 patients who underwent laparoscopic total gastrectomy combined with laparoscopic SPSHL (LSPSHL) were retrospectively analyzed. A 1:2 ratio propensity score matching (PSM) was used to balance the differences between the two groups to compare their outcomes. The Generic Error Rating Tool was used to evaluate the technical performance. After PSM, the baseline preoperative characteristics of the 115 patients in the RSPSHL and 230 patients in the LSPSHL groups were balanced. The dissection time of the region of the splenic artery trunk (5.4 ± 1.9min vs. 7.8 ± 3.6min, P < 0.001), the estimated blood loss during SPSHL (9.6 ± 4.8ml vs. 14.9 ± 7.8ml, P < 0.001), and the average number of intraoperative technical errors during SPSHL (15.1 ± 3.4 times/case vs. 20.7 ± 4.3 times/case, P < 0.001) were significantly lower in the RSPSHL group than in the LSPSHL group. The RSPSHL group showed higher dissection rates of No. 10 (78.3% vs. 70.0%, P = 0.104) and No. 11d (54.8% vs. 40.4%, P = 0.012) lymph nodes and significantly improved postoperative recovery results in terms of times to ambulation, first flatus, and first intake (P < 0.05). The splenectomy rates of the two groups were similar (1.7% vs. 0.4%, P = 0.539), and there was no significant difference in morbidity and mortality within postoperative 30days (13.0% vs. 15.2%, P = 0.589). Compared to LSPSHL, RSPSHL has more advantages in terms of surgical qualities and postoperative recovery process with similar morbidity and mortality. For complex SPSHL, robotic surgery may be a better choice.

Novel Colorectal Endoscopic Submucosal Dissection With Double-Endoscope and Snare-Based Traction.

BACKGROUND:Colorectal endoscopic submucosal dissection is technically demanding, and the traction offered by gravity, cap, or clip-with-line during conventional endoscopic submucosal dissection remains unsatisfactory. Robotic systems are still under development and are expensive. We proposed double-scope endoscopic submucosal dissection with strong and adjustable traction offered by snaring the lesion with additional scope.OBJECTIVE:This study aimed to test the novel double-scope endoscopic submucosal dissection with snare-based traction.DESIGN:This was a retrospective study that reviewed double-scope endoscopic submucosal dissection compared with matched conventional endoscopic submucosal dissection, and size, location, morphology, and pathology between groups were compared.SETTINGS:This study was conducted in a referral endoscopy center in a local hospital.PATIENTS:This study included patients with colorectal lesions receiving double-scope endoscopic submucosal dissection and matched conventional endoscopic submucosal dissection.MAIN OUTCOME MEASURES:The pathological completeness, procedure time, and complications were analyzed.RESULTS:Fifteen double-scope endoscopic submucosal dissection procedures, with 11 lesions located in the proximal colon with a median size of 40 mm, were performed. The median procedure time of double-scope endoscopic submucosal dissection was 32.45 (interquartile range, 16.03–38.20) minutes. The time required for second scope insertion was 2.57 (interquartile range, 0.95–6.75) minutes; for snaring, 3.03 (interquartile range, 2.12–6.62) minutes; and for actual endoscopic submucosal dissection, 28.23 (interquartile range, 7.90–37.00) minutes. All lesions were resected completely. No major complication was encountered. The procedure time was significantly shorter than that of 14 matched conventional endoscopic submucosal dissections (54.61 [interquartile range, 33.11–97.25] min; p = 0.021).LIMITATIONS:This was a single-center, single-operator, retrospective case-controlled study with limited cases.CONCLUSIONS:This study confirmed the feasibility of double-scope endoscopic submucosal dissection with snare-based traction to shorten procedure time and to simplify endoscopic submucosal dissection. Additional trials are required.

Relationship of Adjuvant Radiation and the Lymphedema Index: A Valuable Trend to Follow Subclinical Lymphedema in Patients After Immediate Lymphatic Reconstruction.

Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature. After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX). Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation. These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.

Diving, lifting, and horizontal dissection followed by loop-clip traction (DLH+T) can facilitate mucosal flap creation during colorectal ESD.

Colorectal ESD is difficult because of the poor maneuverability and difficulty of mucosal flap creation. Diving, Lifting and Horizontal (DLH) dissection technique and loop-clip traction are two different methods to facilitate mucosal trimming and adequate mucosal flap creation. We combined the advantages of these two techniques (DLH+T) in our daily practice colorectal ESD since July 2020. The purpose of this study was to examine the outcomes of DLH+T dissection compared with the conventional dissection. We retrospectively reviewed the clinical using DLH+T dissection compared with the conventional dissection since January 2018 at a single tertiary care institution. Postoperative short-term outcomes were investigated after the procedure including mucosal flap creation time, dissection time, dissection speed, en bloc resection rate, and perioperative complications. 28 lesions were in DLH+T dissection group and 39 lesions in the conventional dissection group. The outcomes including en bloc resection rate, dissection speed, and complication between the two groups were similar. The mean mucosal flap creation time (p = 0.035) and the mean dissection speed (p = 0.041) of the DLH+T dissection group was significantly shorter and faster. DLH dissection followed by loop-clip traction (DLH+T) technique is a useful technique for safe, efficient, and adequate mucosal flap creation, which can increase the dissection speed and may prevent complication, especially in biopsy-related submucosal fibrosis.

Inframammary Fold Banking of the Non-Dominant Superficial Epigastric Vein (SIEV) in Unilateral Autologous Breast Reconstruction: A Simple and Helpful Backup Option for Revision Surgery

Free flaps from the lower abdomen represent the workhorses of modern autologous, microvascular breast reconstruction. Rare signs of venous congestion often become evident during the primary index operation, but a secondary shift of the initially dominant drainage of the DIEV system to the SIEV system with consequent malperfusion is a feared, rare event requiring urgent decision, and complex skill using vein grafts and additional anastomosis to restore a sufficient venous outflow. For secondary anastomosis of the SIEV, especially in stacked flaps, a vein graft to the DIEV or retrograde IMV may be necessary, but this requires an additional donor site, thus prolonging procedure time during the emergency operation and resulting in additional scars of the graft’s donor site. We report on a versatile, easy technique of scheduled inframammary fold banking of the dissected, flushed, and clipped non-dominant superficial epigastric vein (SIEV) in unilateral autologous breast reconstruction during the index operation. The banked graft may service as an easy and convenient accessible vein graft in the rare event of secondary shifting of the initial dominant drainage of the DIEV to the SIEV system with the need for urgent re-operation. We retrospectively evaluated the management and outcome of all suitable patients receiving autologous breast reconstruction with a unilateral abdominal DIEP or MS-Tram flap accompanied by banking of the SIEV in the breast pocket between 2017 and 2020 in the present study. In two out of 42 patients (4.8%) receiving autologous breast reconstruction with an abdominal DIEP or MS-TRAM flap with banking of the SIEV in the breast pocket, secondary malperfusion of the flap with progressive venous congestion occurred during the first 48 h perioperatively, between 2 and 37 (mean: 19.5) hours after skin closure. In both cases malperfusion was due to secondary SIEV system dominance, and the banked vein was used as an interpositional graft to the retrograde IMV (case 1) or the DIEV (case 2). Revision surgery lasted between 95 and 121 (mean: 108) minutes without the need for further vein graft harvesting, and further healing was uneventful. Based on the limited cases, inframammary fold banking of the non-dominant SIEV is a versatile, beneficial, and feasible concept with scarce additional dissection time and can be done in all unilateral breast reconstructions to have a reliable graft for emergency re-exploration. It is a useful approach in the context of spare part surgery and tissue banking to safeguard against the rare instance of venous congestion and need for an interpositional graft.

The forgotten node: Axillary surgery mandates expertise

The therapeutic role of axillary dissection in breast cancer is gradually abandoned. However, in some cases axillary dissection is still indicated, and this mandates expertise in planning the operation according to imaging, understanding of current methods of axillary marking, and expertise in performing a more radical resection. In this comment we describe cases of gross nodal disease that was left behind at the time of axillary dissection and was later noted on a radiation planning CT.