Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography(ERCP)is the preferred modality for drainage of the obstructed biliary tree.In patients with surgically altered anatomy,ERCP using standard techniques may not be feasible.Enteroscope assisted ERCP is usually employed with variable success rate.With advent of endoscopic ultrasound(EUS),biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective.In this narrative review,we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Endoscopic approaches to biliary intervention in patients with surgically altered gastroduodenal anatomy

Over the past decade the ability of endoscopists to access the biliary tree in patients with surgically altered gastroduodenal anatomy has significantly advanced.Much of the progress has occurred as a result of the development of better tools to navigate the deep small bowel,such as single-balloon-(SBE),double-balloon-(DBE),and spiral-enteroscopy-assisted endoscopic retrograde cholangiopancreatography(ERCP).However,despite using a cap,accessing the papilla or bile duct using these forward-viewing enteroscopy platforms remains challenging,even in expert hands.In patients with Roux-en-Y gastric bypass(RYGB) anatomy,the excluded stomach is a potential point of access for either a delayed transgastric- or immediate laparoscopyassisted-ERCP approach.However,the parallel advancement of therapeutic endoscopic ultrasound(EUS) also provides alternative approaches through which the biliary system can be accessed and intervened on in patients with surgically altered anatomies.Generally speaking,in patients with short gastro-jejunal "Roux" and bilio-pancreatic limbs,ideally less than 150 cm in length,starting with a(cap-assisted) pushenteroscopy or balloon-enteroscopy approach would offer reasonable diagnostic and therapeutic ERCP suc-cess.When available,short-SBE or short-DBE scopes should be used,as they allow the use of conventional ERCP equipment,are associated with shorter procedure times,and are easier to manipulate.In patients with RYGB who have longer Roux and/or bilio-pancreatic limbs(> 150 cm in total length),or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP,transgastric laparoscopy-assisted-ERCP is associated with higher rates of diagnostic and therapeutic success as compared to deep-enteroscopy-assisted ERCP.Finally,EUS-guided biliary access for antegrade biliary intervention or for rendezvous enteroscopyassisted ERCP is possible.While percutaneous transhepatic biliary drainage and surgical bile duct exploration remain viable alternatives,these methods are not without significant morbidity and mortality and should only be considered if less invasive endoscopic interventions are not feasible or appropriate.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography(ERCP)in patients with surgically altered anatomy must be performed by a highly experienced endoscopist.The challenges are accessing the afferent limb in different types of reconstruction,cannulating a papilla with a reverse orientation,and performing therapeutic interventions with uncommon endoscopic accessories.The development of endoscopic techniques has led to higher success rates in this group of patients.Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction;however,these success rate is lower in long-limb reconstruction.ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length;however,it must be performed by a highly experienced and skilled endoscopist.Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography,but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy.Laparoscopic-assisted ERCP has an almost 100%success rate in longlimb reconstruction because of the use of a conventional side-view duodenoscope,which is compatible with standard accessories.This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy.This review focuses on the advantages,disadvantages,and outcomes of various procedures that are suitable in different situations and reconstruction types.Emerging new techniques and their outcomes are also discussed.

Innovative surgical approaches for hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the sixth most common cancer worldwide,with an increasing diffusion in Europe and the United States.The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC.In this review,we will analyze the modern concept of preoperative management,the role of laparoscopic and robotic surgery,the intraoperative use of three dimensional models and augmented reality,as well as the potential application of fluorescence.

Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage(EUS-BD) in patients with surgically altered anatomies.METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms "EUS drainage" and "altered anatomy". All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only fulltext English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth Ⅰ; group 2, Billroth Ⅱ; group 4, Rouxen-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrogradecholangiography in centers with expertise in EUS-BD procedures in a research setting.

Comparison of two surgical approaches for petroclinic lesions

Objective:to compare the methods of petrous apical bone removal and to explore the applicable scope of Kawase approach and retrosigmoid sinus-internal auditory canal approach.Methods:one group of cadaveric head specimens simulated Kawase approach to measure the data of“Kawase triangle”,the other group simulated retrosigmoid sinus-internal auditory canal approach to measure the safety range of the grinding bone window.Then we explored the clinical indications of the two surgical approaches.Result:the grinding depth of Kawase triangle was 11.6±0.14 mm,and the range of clival exposed after grinding Kawase triangle was 22.4±1.22 mm,which could effectively expose the ventrolateral brainstem,the midline of clivus and the area above the facial acoustic nerve.The diameter of the anterior and posterior of the grinding bone window in the retrosigmoid sinus-internal auditory canal approach was 21.95±2.23 mm.In front of the exposure area were the internal carotid artery,the cavernous sinus,and the upper trigeminal nerve;the lower part was the connection between the facial acoustic nerve and the abducent nerve.Conclusion:Kawase approach is suitable for lesions of ventrolateral brainstem,middle superior clivus,with or without invasion of middle cranial fossa;the retrosigmoid sinus-superior internal auditory canal approach is suitable for lesions mainly in cerebellopontine angle area and only slightly invading Meckel’s cavity.

SELECTION OF SURGICAL APPROACH TO TREAT TRAUMATIC INSTABILITY OF SUBAXIAL CERVICAL SPINE

Objective To evaluate the clinical outcomes of surgical therapy in treating traumatic instability of subaxial cervical spine through either anterior or posterior approach. Methods According to the Allen-Fergurson's classification, we retrospectively studied 42 cases of traumatic instability of subaxial cervical spine through either anterior or posterior surgical reconstruction. Patients requiring approach for either reduction or decompression were not included. Results The average follow-up interval was 3 years and 2 months. The anterior and posterior reconstructions were 24 and 18 cases, respectively. Before operation, the average scores of JOA and VAS were: 12.1 and 6.9 for anterior group, and 12.3 and 7.2 for posterior group. At the final assement, the scores of JOA and VAS improved to 16.0 and 2.2 for anterior group, and 15.7 and 2.6 for posterior group. The average ASIA motor scores of anterior and posterior group improved to 68.2 and 65.5 at the final follow-up from 58.4 and 59.7 before operation, respectively. The ASIA grade (A-E) was converted to a numeric score. The average scores before operation in the anterior and posterior group were 3.3 and 3.4, and increased to 3.8 and 3.7 at the final follow-up. After operation, there were different extent improvements of average radiological parameter, such as Cobb angle, vertebral body translation and disc height ratio. The average operation time and blood losing were 122 min and 125 mL for anterior group, and 153 min and 287 mL for posterior group. Fusion was achieved in all patients and 4 and 2 complications occurred at the anterior or posterior group. Conclusion The results showed that there were no obvious difference in parameters, such as neurological assements, functional grades, fusion rate, operation time and blood losing, between anterior and posterior group, except the virtues of anterior group in reconstruction and maintaining physiologic cervical lordosis and intervertrbal disc height occurred.

Application of virtual reality in quantified analyses for cavernous sinus surgical approach

Objective To evaluate the utility of virtual reality system in quantitative comparison for cavernous sinus surgical approach. Methods Image data of CT and MRI scan performed in five adult cadaver heads was inputted into the Destroscope virtual reality system to build 3-D model of cavernous sinus.

Clinical diagnosis and surgical approaches of vaginal hyperplasia in bitches

Objective:To describe the breed predisposition, clinical diagnosis, pathological findings and the surgical approach through excision of the hyperplasic mass from the vagina.Methods:Twenty five bitches of different breeds suffering from a protruded mass from the vulva were examined clinically, blood samples were collected to ensure the phase of estrus that were determined by evaluating the exfoliative vaginal epithelium, and a histopathological examination of the hyperplastic mass was done after its surgical excision.Results:The current work revealed that the maximum value of estradiol 17-B was in Alabai breed while the maximum value of progesterone was in Pit bull breed. And Pit bull breed showed cornification and stratification of the vaginal mucosa with abundant eosinophilic cytoplasm and regular round nuclei.Conclusions:As the vaginal hyperplasia is a crucial gynaecological problem that affects different breeds of bitches, the current work provides a comprehensive diagnosis of the case and illustrates the surgical interference for its excision.

Standardized surgical approaches to ear surgery in rats

Objective： To describe several approaches of ear surgeries for experimental studies in rats. Methods： Anesthetized rats were prepared for demonstration of various ear surgery approaches designed to optimize experimental outcomes in studies with specific goals and exposure requirements. The surgical approaches included the posterior tympanum, superior tympanum, inferior tympanum and occipital approaches. Results： The middle ear cavity and inner ear were successfully exposed from different angles via the mentioned surgical approaches. For example, electrode placement for recording of cochlear bioelectric responses was easily achieved through the posterior tympanum or inferior tympanum approach. Alternatively, drug delivery or gene transfection via round window membrane was most easily accomplished using the posterior tympanum approach. Cochlear perfusion of protective or ototoxic drugs was best performed using the inferior tympanum approach. Ossicular chain interruption to induce a prolonged conductive hearing loss was readily achieved using a superior tympanum approach. Lastly, surgical destruction of the endolymphatic sac to induce experimental endolymphatic hydrops was readily performed via an occipital surgical approach.Conclusion： These standardized surgical approaches can be applied in scientific studies of the ear with different purposes covering electro- physiology, conductive hearing loss, intra-cochlear drug perfusion and experimental studies relevant to Meniere＇s disease.

Subclavian Artery Pseudoaneurysm following Stab Injury and Its Surgical Approach: A Case Report and Literature Review

Penetrating injuries to the subclavian arteries as well as post traumatic pseudoaneurysm involving Subclavian artery (SCA) are very much uncommon. We present one case of a 21 year-old male sustained a physical assault with a post stab injury left subclavian artery pseudoaneurysm. He was referred to our facility, two days after sustaining a penetrating chest trauma over left infraclavicular area of the chest. The presentation, diagnostic procedures and surgical approach for management of this very rare injury are discussed.

Complete Anatomy软件在骨科手术入路教学中的应用

目的评价Complete Anatomy三维解剖软件在骨科住院医师手术入路教学中的作用。方法将我院骨科低年资住院医师20人随机分为两组,每组各10人。软件教学组采用Complete Anatomy三维解剖软件进行授课;书籍教学组采用骨科经典教科书和解剖图谱进行授课。两组授课内容均为膝关节、髋关节、踝关节的经典手术入路相关解剖知识。通过笔试和尸体考核,比较两组对手术入路解剖知识学习效果的差异,同时通过问卷调查比较两组教学满意度的差异。结果笔试分数和尸体考核分数,软件教学组分别为(85.6±12.4)分和(76.3±9.7)分,书籍教学组分别为(68.3±9.5)分和(63.1±13.9)分,组间各数据比较,差异均具有统计学意义(P <0.05)。对于教学满意度评分,软件教学组为(92.6±7.3)分,书籍教学组为(82.4±10.7)分,组间数据比较,差异具有统计学意义(P <0.05)。结论与采用经典书籍和图谱教学相比,采用Complete Anatomy软件教学可显著提高骨科常见手术入路的教学效果,不仅能使学员掌握更多解剖知识,同时大大增强其对真实环境下解剖结构的辨识能力,教学满意度评价也更高。

Progress in laparoscopic anatomy research: A review of the Chinese literature

The development of laparoscopic surgery has generated the new field of study, laparoscopic anatomy. This article reviews the reported literature on laparoscopic anatomy and explores how it has evolved along with advances in abdominal surgery. In addition, the principal concerns in current laparoscopic anatomy research are discussed, including: (1) types of special adjacent anatomical structures; and (2) special surgical planes and anatomical landmarks. Understanding of systematic laparoscopic anatomy can provide the junior surgeons a clear procedural approach, and would benefit laparoscopic surgeons in training.

3D Vector Reconstruction of the Typical Cervical Vertebra from Anatomical Sections of Korean Visible Human at the Laboratory of Clinical and Digital Anatomy of Paris Descartes University

Aim: To carry out a 3D vector reconstruction of the typical cervical vertebra from anatomical sections of the “Korean Visible Human” for educational purposes. Material and Methods: The anatomical subject was a 33-year-old Korean man who died of leukemia. He was 164 cm tall and weighed 55 kg. This man donated his body to science. Her body was frozen and cut into several anatomical sections after an MRI and CT scan. These anatomical sections were made using a special saw called a 0.2 mm thick cryomacrotome. Thus 8100 cuts were obtained. Only the sections numbered 940 to 1200 were used for our study. A segmentation by manual contouring of the different parts of the typical cervical vertebra was made using the software Winsurf version 3.5 on a laptop PC running Windows 7 equipped with a Ram of 8 gigas. Results: Our 3D vector model of the typical cervical vertebra is easily manipulated using the Acrobat 3DPDF interface. Each part of the vertebra accessible in a menu can be displayed, hidden or made transparent, and 3D labels are available as well as educational menus for learning anatomy. Conclusion: This original work constitutes a remarkable educational tool for the anatomical study of the typical cervical vertebra and can also be used as a 3D atlas for simulation purposes for training in therapeutic gestures.

Volumetric comparative analysis of anatomy through far-lateral approach:surgical space and exposed tissues

Background:The three-dimensional(3D)visualization model has ability to quantify the surgical anatomy of farlateral approach.This study was designed to disclose the relationship between surgical space and exposed tissues in the far-lateral approach by the volumetric analysis of 3D model.Methods:The 3D skull base models were constructed using MRI and CT data of 15 patients(30 sides)with trigeminal neuralgia.Surgical corridors of the far-lateral approach were simulated by triangular pyramids to represent two surgical spaces exposing bony and neurovascular tissues.Volumetric comparison of surgical anatomy was performed using pair t test.Results:The morphometric results were almost the same in the two surgical spaces except the vagus nerve(CN X)exposed only in one corridor,whereas the volumetric comparison represented the statistical significant differences of surgical space and bony and neurovascular tissues involved in the two corridors(P<0.001).The differences of bony and neurovascular tissues failed to equal the difference of surgical space.Conclusions:For far-lateral approach,the increase of exposure for the bony and neurovascular tissues is not necessarily matched with the increase of surgical space.The volumetric comparative analysis is helpful to provide more detailed anatomical information in the surgical design.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Direct anterior compared to posterior approach for hip hemiarthroplasty following femoral neck fractures

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood.Dislocation,a severe complication associated with increased mortality and often requiring additional surgery,may occur less frequently with the direct anterior approach compared to the posterior approach.Careful consideration of patient demographics is essential when planning the surgical approach.Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.

Anatomy and surgery of pure neuroendoscopic infratentorial supracerebellar approach for resection of pineal region tumor

Background: The pineal region tumors are surrounded by important structures. Neuroendoscopy has been increasingly used at home and abroad. This study is to simulate pure neuroendoscopic infratentorial supracerebellar approach for resection of pineal region tumor from the cadaveric head, and discuss the advantages and safety through this corridor. Methods: The anatomical structure for resection of pineal region tumor was visualized through pure neuroendoscopic infratentorial supracerebellar approach in three cadaveric heads. Three cases with pineal region tumors were retrospectively analyzed and summarized between June 2017 and December 2017. All cases were operated through pure neuroendoscopic infratentorial supracerebellar approach in the first affiliated hospital of Fujian medical university. Results: The anatomical structures of pineal region can be completely visualized by pure neuroendoscopic infratentorial supracerebellar corridor in the cadaveric head. Among the three cases, the first case was total resection, the second case was subtotal resection and the last case was partial resection. The postoperative pathology revealed cavernous hemangioma, germinoma and yolk sac tumor, respectively. The patients were followed-up for 1-6 months and had normal life.The KPS (karnofsky performance status) score was 100. Conclusion: The anatomical structure of the pineal region can be completely visualized and the tumor can be safely removed through pure neuroendoscopic infratentorial supracerebellar approach.

A new membrane anatomy-oriented classification of radical surgery for rectal cancer

For patients with different clinical stages of rectal cancer,tailored surgery is urgently needed.Over the past 10 years,our team has conducted numerous anatomical studies and proposed the“four fasciae and three spaces”theory to guide rectal cancer surgery.Enlightened by the anatomical basis of the radical hysterectomy classification system of Querleu and Morrow,we proposed a new classification system of radical surgery for rectal cancer based on membrane anatomy.This system categorizes the surgery into four types(A–D)and incorporates corresponding subtypes based on the preservation of the autonomic nerve.Our surgical classification unifies the pelvic membrane anatomical terminology,validates the feasibility of classifying rectal cancer surgery using the theory of“four fasciae and three spaces,”and lays the theoretical groundwork for the future development of unified and standardized classification of radical pelvic tumor surgery.