Two big orifices in the second duodenal portion:A case of an atypical double papilla

With the advent of endoscopic retrograde cholangiopancreatography(ERCP)in the early 1970s,anatomic anomalies of the Vaterian system were described endoscopically[1].Although the occurrence is rare,the common bile duct(CBD)and the pancreatic duct may fail to coalesce during embryologic development.This leads to double major papilla because both ducts open into the duodenum separately[1].In this way the cranial duct communicates with the CBD,while the caudal orifice communicates with the pancreatic duct[2].

Removal of a guide-wire sliding into abdominal cavity via transgastric natural orifice transluminal endoscopic surgery: A case report

BACKGROUND Guidewire slippage into the peritoneal cavity during clinical operations is extremely rare.Therefore,this paper aims to report a successful case of guidewire removal using transgastric natural orifice transluminal endoscopic surgery(NOTES).The goal is to enhance physicians'understanding of the management plan for this unique scenario and provide a valuable reference for clinical practice.CASE SUMMARY A 64-year-old man presented with abdominal distension and was diagnosed with cirrhosis combined with massive ascites.To proceed with treatment,the patient underwent ultrasound-guided peritoneal puncture and underwent catheterization and drainage.Unfortunately,a 0.035-inch guidewire slipped into the abdominal cavity during the procedure.Following a comprehensive evaluation and consultation by a multidisciplinary team,the guidewire was successfully removed using NOTES.CONCLUSION This case highlights the potential consideration of transgastric NOTES removal when encountering a foreign body,such as a guidewire,within the abdominal cavity.

Resection of polyps involving the appendiceal orifice by combined endo-laparoscopic surgery: Two case reports

BACKGROUND The management of polyps involving the appendiceal orifice(AO)presents notable challenges.Endoscopic resection is frequently hindered by operational complexities,a heightened risk of incomplete removal,and an elevated risk of procedural complications,including appendicitis.Conversely,surgical resection may entail unnecessary excision of intestinal segments,leading to potential morbidity.CASE SUMMARY Here,we reported two patients who presented with polyps deeply situated within the AO,with indistinct boundaries making it challenging to ensure completeness using traditional endoscopic resection.To overcome these challenges,we em-ployed combined endo-laparoscopic surgery(CELS),achieving curative resection without postoperative complications.CONCLUSION The application of CELS in managing polyps involving the AO is emerging as a safe and effective treatment modality.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery

BACKGROUND At present,laparoscopic cholecystectomy(LC)is the main surgical treatment for gallstones.But,after gallbladder removal,there are many complications.Therefore,it is hoped to remove stones while preserving the function of the gallbladder,and with the development of endoscopic technology,natural orifice transluminal endoscopic surgery came into being.AIM To compare the quality of life,perioperative indicators,adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery(EGPS)in patients with gallstones.METHODS Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected.We adopted propen-sity score matching(1:1)to compare EGPS and LC patients.RESULTS A total of 662 cases were collected,of which 589 cases underwent LC,and 73 cases underwent EGPS.Propensity score matching was performed,and 40 patients were included in each of the groups.In the EGPS group,except the gastr-ointestinal defecation(P=0.603),the total score,physical well-being,mental well-being,and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery(P<0.05).In the LC group,except the mental well-being,the total score,physical well-being,gastrointestinal digestion,the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery(P<0.05).When comparing between groups,gastrointestinal defecation had significantly difference(P=0.002)between the two groups,there was no statistically significant difference in the total postoperative score and the other three subscales.In the surgery duration,hospital stay and cost,LC group were lower than EGPS group.The recurrence factors of gallstones after EGPS were analyzed:and recurrence was not correlated with gender,age,body mass index,number of stones,and preoperative score.CONCLUSION Whether EGPS or LC,it can improve the patient’s symptoms,and the EGPS has less impact on the patient’s defecation.It needed to,prospective,multicenter,long-term follow-up,large-sample related studies to prove.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction(NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSEprocedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Laparoscopic total mesorectal excision with natural orifice specimen extraction

AIM:To introduce transvaginal or transanal specimen extraction in laparoscopic total mesorectal excision surgery to avoid an abdominal incision. METHODS:Between January 2009 and December 2011,21 patients with rectal cancer underwent laparoscopic radical resection and the specimen was retrieved by two different ways:transvaginal or transanal rectal removal.Transvaginal specimen extraction approach was strictly limited to elderly post-menopausal women who need hysterectomy.Patients aged between 30 and 80 years,with a body mass index of less than 30 kg/m2, underwent elective surgery.The surgical technique and the outcomes related to the specimen extraction,such as duration of surgery,length of hospital stay,and the complications were retrospectively reviewed. RESULTS:Laparoscopic resection using a natural orifice removal approach was successful in all of the 21 patients.Median operating time was 185 min(range,122-260 min)and the estimated blood loss was 48 mL. The mean length of hospital stay was 7.5 d(range,2-11 d).One patient developed postoperative ileus and had an extended hospital stay.The patient complained of minimal pain.There were no postoperative complications or surgery-associated death.The mean size of the lesion was 2.8 cm(range,1.8-6.0 cm),and the mean number of lymph nodes harvested was 18.7(range, 8-27).At a mean follow-up of 20.6 mo(range,10-37 mo),there were no functional disorders associated with the transvaginal and transanal specimen extraction. CONCLUSION:Transvaginal or transanal extraction in L-TME is a safe and effective procedure.Natural orifice specimen extraction can avoid the abdominal wall incision and its potential complications.

Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer

BACKGROUND This case-control study compared the short-term clinical efficacy of natural orifice specimen extraction surgery(NOSES) using a prolapsing technique and the conventional laparoscopic-assisted approach for low rectal cancer.AIM To further explore the application value of the transanal placement of the anvil and to evaluate the short-term efficacy of NOSES for resecting specimens of low rectal cancer, as well as to provide a theoretical basis for its extensive clinical application.METHODS From June 2015 to June 2018, 108 consecutive laparoscopic-assisted low rectal cancer resections were performed at our center. Among them, 26 specimens were resected transanally using a prolapsing technique(NOSES), and 82 specimens were resected through a conventional abdominal wall small incision(LAP). A propensity score matching method was used to select 26 pairs of matched patients, and their perioperative data were analyzed.RESULTS The baseline data were comparable between the two matched groups. All 52 patients underwent the surgery successfully. The operative time, blood loss,number of harvested lymph nodes, postoperative complication rate,circumferential margin involvement, postoperative follow-up data, and postoperative anal function were not statistically significant. The NOSES group had shorter time to gastrointestinal function recovery(2.6 ± 1.0 d vs 3.4 ± 0.9 d, P= 0.006), shorter postoperative hospital stay(7.1 ± 1.7 d vs 8.3 ± 1.1 d, P = 0.003),lower pain score(day 1: 2.7 ± 1.8 vs 4.6 ± 1.9, day 3: 2.0 ± 1.1 vs 4.1 ± 1.2, day 5: 1.7± 0.9 vs 3.3 ± 1.0, P < 0.001), a lower rate of additional analgesic use(11.5% vs61.5%, P = 0.001), and a higher satisfaction rate in terms of the aesthetic appearance of the abdominal wall after surgery(100% vs 23.1%, P < 0.001).CONCLUSION NOSES for low rectal cancer can achieve satisfactory short-term efficacy and has advantages in reducing postoperative pain, shortening the length of postoperative hospital stay, and improving patients' satisfaction in terms of a more aesthetic appearance of the abdominal wall.

Natural orifice translumenal surgery:Flexible platform review

Natural orifice translumenal surgery(NOTES) has garnished significant attention from surgeons and gastroenterologists,due to the fusion of flexible endoscopy and operative technique.Preliminary efforts suggest that NOTES holds potential for a less invasive approach with certain surgical conditions.Many of the hurdles encountered during the shift from open to laparoscopic surgery are now being revisited in the development of NOTES.Physician directed efforts,coupled with industry support,have brought about several NOTES specific devices and platforms to help address limitations with current instrumentation.This review addresses current flexible platforms and their attributes,advantages,disadvantages and limitations.

EXPERIMENTAL INVESTIGATIONS OF CAVITATION EFFECTS ON FLOW CHARACTERISTICS OF SMALL ORIFICES AND VALVES IN WATER HYDRAULICS

The flow characteristics and cavitation effects of water passing throughsmall sharp-edged cylindrical orifices and valves of different shapes in water hydraulics areinvestigated. The test results using orifices with different aspect ratios and different diametersshow that the flow coefficients in the case of non-cavitating flow are larger than that of flow inthe case of cavitation occurrence. The flow coefficients of flow with cavitation initially decreaseas Reynolds number increases and ultimately tend to be of constant values close to contractioncoefficient. Large aspect ratio has an effect of suppressing cavitation. The experimental resultsabout disc valves illustrate that the valves with sharp edge at large opening are less affected bycavitation than that at small opening. Throttle with triangle notch has better anti-cavitationability than that with square notch. The flowrate of the throttle with square notch is significantlyaffected by the flow direction or the flow passage shape.

A criterion for flow mechanisms through vertical sharp-edged orifice and model for the orifice discharge coefficient

According to the experimental data of the orifice discharge coefficient for the flow through a vertical sharp-edged orifice obtained in the previous study of this work,a theoretical criterion for flow mechanisms of small orifice（viz.thick-walled orifice and nozzle） and large orifice（viz.thin-walled orifice） was proposed based on the ratio of orifice diameter to plate thickness.It can help explain the dissipation of the mechanical energy loss in the flow process for the two flow mechanisms under different operating regimes.The main parameters such as orifice diameter,plate thickness and liquid head were correlated,and a semi-empirical model for orifice coefficient and an empirical model with high precision at the stable region were developed.

Natural orifice surgery applied for colorectal diseases

Clinical natural orifice surgery has been applied to abdominal surgery in recent years,mostly using transvaginal and transgastric access.Rectal and transcolonic natural orifice transluminal endoscopic surgery(NOTES) were tested in animal and cadaver models by a few research groups.Despite the potential advantages of transcolonic NOTES for colorectal diseases,it has not yet been clinically applied.The first successful series of human applications of transcolonic NOTES in the literature from the NOTES Research Group in Brazil provide new possibilities in the field in new transrectal procedures for rectal cancer and benign disease.Successful first human reports on Transcolonic NOTES potentially brings new frontiers and applications for minimally invasive surgery.The treatment of colorectal diseases through flexible Perirectal NOTES Access is a promising new approach alongside existing laparoscopic and open surgery to improve patient care.

Orifice plate cavitation mechanism and its influencing factors

The orifice plate energy dissipater is an economic and highly efficient dissipater. However, there is a risk of cavitaion around the orifice plate flow： In order to provide references for engineering practice, we examined the cavitation mechanism around the orifice plate and its influencing factors by utilizing mathematical analysis methods to analyze the flow conditions around the orifice plate in view of gas bubble dynamics. Through the research presented in this paper, the following can be observed： The critical radius and the critical pressure of the gas nucleus in orifice plate flow increase with its initial state parameter r0 ; the development speed of bubbles stabilizes at a certain value after experiencing a peak value and a small valley value; and the orifice plate cavitation is closely related to the distribution of the gas nucleus in flow. For computing the orifice plate cavitation number, we ought to take into account the effects of pressure fluctuation. The development time of the gas nucleus from the initial radius to the critical radius is about 107-10-5 s; therefore, the gas nucleus has sufficient time to develop into bubbles in the negative half-cycle of flow fluctuation. The orifice critical cavitation number is closely related to the orifice plate size, and especially closely related with the ratio of the orifice plate radius to the tunnel radius. The approximate formula for the critical cavitation number of the square orifice plate that only considers the main influencing factor was obtained by model experiments.

Natural orifice transluminal endoscopic surgery:Educational challenge

Natural orifice translumenal endoscopic surgery(NOTES) training is unique in that it crosses specialty lines and most practitioners do not possess both the knowledge and skill to perform the procedures in their current form.The learning process becomes even more complex because the field is in constant evolution with advances in technology and technique being introduced almost daily! The challenges of learning NOTES illustrates a larger problem in all procedurally based medical specialties today-the pace of change has become so rapid that a practicing physician's technical skills become out of date within five to ten years of completing residency or fellowship training.As a result,practicing physicians must develop a strategy to rapidly learn about a new technique or technology and introduce it safely into their practice while satisfying the concerns of their hospital's credentialing committee.This chapter will explore the options for learning new procedures and discuss the rapidly expanding armamentarium of education institutes and the developing technology to measure procedural competence.

Natural orifice transluminal endoscopic surgery:The transvaginal route moving forward from cholecystectomy

The advent of minimally invasive surgery and the advances in endoluminal flexible endoscopy have converged to generate a new concept in digestive surgery,whose acronym natural orifice transluminal endoscopic surgery(NOTES),has become a familiar term in the surgical community.NOTES has been performed through the mouth,the bladder,the rectum and the vagina.Of these four approaches,the vagina has gained most popularity for several reasons.It is not only readily accessible and easy to decontaminate but it also provides safe entry and simple closure.The transvaginal approach has been described in the experimental and the clinical setting as an option for cholecystectomy,nephrectomy,splenectomy,segmental gastrectomy,retroperitoneal exploration and bariatric surgery.However,larger series are needed to delineate the exact risks of this approach,and to transcend cultural barriers that impede its wider introduction.Prospective randomized trials will shed light on the definitive role of the vaginal approach in minimal invasive surgery of the future.

Natural orifice translumenal endoscopic surgery: Progress in humans since white paper

Since the first description of the concept of natural orifice translumenal endoscopic surgery (NOTES), a substantial number of clinical NOTES reports have appeared in the literature. This editorial reviews the available human data addressing research questions originally proposed by the white paper, including determining the optimal method of access for NOTES, developing safe methods of lumenal closure, suturing and anastomotic devices, advanced multitasking platforms, addressing the risk of infection, managing complications, addressing challenges with visualization, and training for NOTES procedures. An analysis of the literature reveals that so far transvaginal access and closure appear to be the most feasible techniques for NOTES, with a limited, but growing transgastric, transrectal, and transesophageal NOTES experience in humans. The theoretically increased risk of infection as a result of NOTES procedures has not been substantiated in transvaginal and transgastric procedures so far. Development of suturing and anastomotic devices and advanced platforms for NOTES has progressed slowly, with limited clinical data on their use so far. Data onthe optimal management and incidence of intraoperative complications remain sparse, although possible factors contributing to complications are discussed. Finally, this editorial discusses the likely direction of future NOTES development and its possible role in clinical practice.

Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors

Diagnosis of gastric subepithelial tumor(SET) has shown a rapid increase worldwide.Although,until now,endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET,the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection.However,endoscopic resection or laparoscopic wedge resection alone also has some limitations.Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large(larger than 25 mm diameter).On the other hand,gastric SET in a difficult location,such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection.The hybrid natural orifice transluminal endoscopic surgery(NOTES) technique is a combined method,including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs.This method may be performed safely with reasonable operation times,less bleeding,and adequate resection margin and regardless of tumor size.In particular,in the case of a difficult location for resection,such as the esophagogastric junction or pyloric ring,hybrid NOTES is currently believed to be an ideal treatment method.

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction (NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

The effect of multi-orifice plate configuration on bubble detachment volume

The multi-orifice plate gas sparger, mainly composed of a multi-orifice plate and a gas chamber, is one of the most common sparger facilities.The aeration performance of multi-orifice plate has a close relation with the multiorifice plate configuration.In addition, the weeping phenomenon has a considerable influence on the gas chamber condition which affects the bubble detachment volume directly.This paper conducts a set of visual experiments to study the influence of multi-orifice configuration and gas chamber condition on the aeration performance of gas sparger.For multi-orifice plate, an improved theoretical model is proposed which considers the wave effect of the previous bubbles generated from adjacent orifices and the variance of the number of active bubbling orifice.A parameter is proposed to evaluate the aeration performance in order to overcome the difficulty caused by the randomness of bubble formation process.The experimental results suggest that the gas chamber filled with water is in favor of large bubble formation.The influence of the pitch of orifice on aeration performance can only be observed in high-restricted case.According to the theoretical model and experimental results, the influences of gas flow rate and the number of open orifices on the aeration performance are analyzed and a design criterion for the number of open orifice is proposed.

Natural orifice specimen extraction with laparoscopic radical gastrectomy for distal gastric cancer: A case report

BACKGROUND This article introduces the surgical method and early experience in performing totally laparoscopic radical gastrectomy with transrectal specimen extraction for gastric cancer, and we evaluate the short-term effects and feasibility of this new procedure for gastric cancer in a 64-year-old male patient. This approach may provide new possibilities for gastric natural orifice specimen extraction(NOSE)surgery. In addition, we believe that this new procedure may further relieve pain,speed up recovery, and cause minimal physiological and psychological impact.CASE SUMMARY We performed NOSE gastrectomy in a male patient. Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically;the specimen was extracted from the natural orifice of the rectum-anus. This procedure reduced damage to the abdominal wall and decreased postoperative pain. We successfully performed radical gastrectomy without conversion and complications. Total operative time and blood loss were 176 min and 50 m L, respectively. The patient resumed normal activities of daily living on day 1 without pain, and passed flatus within 48 h. Postoperative hospital stay was 10 d. The number of resected lymph nodes was 0/43. During the follow-up, no stricture or anastomotic leakage was detected. Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture. Computed tomography and laboratory test results showed no signs of tumor recurrence. There was no visible scar on the abdominal wall.CONCLUSION It is safe and reliable to perform totally laparoscopic radical gastrectomy with transrectal specimen extraction for distal gastric cancer patients.