Present situation of minimally invasive surgical treatment for early gastric cancer

Minimally invasive surgery is a kind of surgical operation,which is performed by using professional surgical instruments and equipment to inactivate,resect,repair or reconstruct the pathological changes,deformities and wounds in human body through micro-trauma or micro-approach,in order to achieve the goal of treatment,its surgical effect is equivalent to the traditional open surgery,while avoiding the morbidity of conventional surgical wounds.In addition,it also has the advantages of less trauma,less blood loss during operation,less psychological burden and quick recovery on patients,and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients.Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer(EGC):endoscopic mucosal resection(EMR),underwater EMR(UEMR),endoscopic submucosal dissection(ESD),endoscopic full-thickness resection(EFTR),endoscopic submu-cosal excavation(ESE),submucosal tunnel endoscopic resection,laparoscopic and endoscopic cooperative surgery(LECS);Among them,EMR,EFTR and LECS technologies have a wide range of applications and different modific-ations have been derived from their respective surgical operations,such as band-assisted EMR(BA-EMR),conven-tional EMR(CEMR),over-the-scope clip-assisted EFTR,no-touch EFTR,the inverted LECS,closed LECS,and so on.These new and improved minimally invasive surgeries are more precise,specific and effective in treating different types of EGC.

Minimally invasive treatment of cholecysto-choledocal lithiasis:The point of view of the surgical endoscopist

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%,depending on the patient's age.Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones.At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include:single-stage laparoscopic treatment,perioperative endoscopic treatment and endoscopic treatment alone.Published data evidence that,associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay.However,current data does not suggest clear superiority of any one approach with regard to success,mortality,morbidity and cost-effectiveness.Considering the variety of therapeutic options available for management,a critical appraisal and decision-making is required.endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis,i.e.,in patients with acute obstructive suppurative cholangitis,severe biliary pancreatitis,ampullary stone impaction or severe comorbidity.In a setting where all facilities are available,decision in the selection of the therapeutic option depends on the patients,the number and size of choledocholithiasis stones,the anatomy of the cystic duct and common bile duct,the surgical history of patients and local expertise.

Background,techniques,applications,current trends,and future directions of minimally invasive endoscopic spine surgery:A review of literature

Across many of the surgical specialties,the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization.Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades,allowing surgeons to achieve similar or better outcomes,while reducing cost and recovery time.However,to date,the axial skeleton,with its close proximity to critical neural and vascular structures,has not adopted endoscopic techniques at as rapid of a rate.Over the past decade,increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery.In addition,there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques.There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders,many of which are evolving rapidly.Here we present a review of the field of endoscopic spine surgery,including the background,techniques,applications,current trends,and future directions,to help providers gain a better understanding of this growing modality in spine surgery.

Lack of proper reimbursement is hampering adoption of minimally invasive gastrointestinal endoscopy in North America

Endoscopic submucosal dissection(ESD)and related procedures are minimally invasive and cost-effective alternates to surgery.However,there is no approved or listed current procedural terminology(CPT)for ESD.We aimed to review the current reimbursement process hurdles for ESD procedures in private practice model in United States.We reviewed the data of two advanced endoscopists(one in New York and other in Pennsylvania State)performing ESD in their private practice set-ups.We found the reimbursement process was complex,with number of refusals varied from 0-9 for ESD procedures.It was not paid at all in 8.3%of cases by the medical insurance.Endoscopic mucosal resection,which is considered inferior as compared to ESD,but has a listed CPT,was denied in only 0.83%cases.Our data highlights the billing hurdles by the endoscopists to adopt ESD-related procedures in private practice model.

Removal of a large rectal polyp with endoscopic submucosal dissection-trans-anal rectoscopic assisted minimally invasive surgery hybrid technique:A case report

BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones.To avoid serious complications,these stones should be removed.There is no consensus about the ideal management strategy for such patients.Traditionally,open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography(ERCP) and laparoscopic cholecystectomy(LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages.Minimally invasive approach could be done in either twosession(preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session(laparoscopic common bile duct exploration or LC with intraoperative ERCP).Most recent studies have found that both options are equivalent regarding safety and efficacy but the singlesession approach is associated with shorter hospital stay,fewer procedures per patient,and less cost.Consequently,single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist.However,the management strategy should be tailored according to many variables,such as available resources,experience,patient characteristics,clinical presentations,and surgical pathology.

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

The incidence of remnant gastric cancer(RGC)is still increasing.Minimally invasive approaches including endoscopic resection,laparoscopic and robotic approaches,and function-preserving gastrectomy have been utilized as curative treatment methods for primary gastric cancer.However,adhesions and anatomical alterations due to previous gastrectomy make the use of minimally invasive approaches complicated and difficult for RGC.Application of these approaches for the treatment of RGC is still controversial.Endoscopic submucosal dissection is a favorable alternative therapy for the resection of early gastric cancer that occurs in the remnant stomach and can prevent unnecessary complications.The majority of retrospective studies have shown that endoscopic submucosal dissection is an effective and oncologically safe treatment modality for RGC.Subtotal gastrectomy could serve as a function-preserving gastrectomy for patients with early RGC and improve postoperative late-phase function.However,there are only two studies that demonstrate the feasibility and oncological efficacy of subtotal gastrectomy for RGC.The non-randomized controlled trials showed that compared to open gastrectomy,laparoscopic gastrectomy for RGC led to better short-term outcomes and similar oncologic results.Because of the rarity of RGC,future multicenter studies are required to determine the indications of minimally invasive treatment for RGC.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum:A review

Transanal minimally invasive surgery(TAMIS)was first described in 2010 as an alternative to transanal endoscopic microsurgery(TEM).The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and earlystage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery.TAMIS has a shorter learning curve,reduced device setup time,flexibility in instrument use,and versatility in application than TEM.Also,TAMIS shows similar results in a view of the operation time,conversion rate,reoperation rate,and complication to TEM.For these reasons,TAMIS is an easily accessible,technically feasible,and cost-effective alternative to TEM.Overall,TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons.As TAMIS becomes more broadly utilized such as pelvic abscess drainage,rectal stenosis,and treatment of anastomotic dehiscence,the acquisition of appropriate training must be ensured,and the continued assessment and assurance of outcome must be maintained.

Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection

With the advance of invasive interventions,the treatment model for infected necrotizing pancreatitis(INP)has shifted from open surgery to the step-up minimally invasive treatment.Late intervention,originating from the open surgery era,has been questioned in the minimally invasive period.With the emergence of new high-quality evidence about the timing for intervention,it seems to be increasingly apparent that,even in the age of minimal invasiveness,“late intervention”waiting for the necrotic collections to be encapsulated is still necessary.This opinion review mainly discusses the intervention timing for INP.

Snare-assisted flexible endoscope in trans-gastric endoscopic gallbladder-preserving surgery:A pilot animal study

BACKGROUND Natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving surgery by flexible endoscopy is an emerging technology.However,the gallbladder fails to obtain traction and positioning functions during the operation.AIM To evaluate the feasibility and safety of a new surgical method,“snare-assisted pure NOTES gallbladder-preserving surgery”.METHODS Eight miniature pigs were randomly divided into the experimental group[NOTES gallbladder-preserving surgery using the snare device,snare assisted(SA)]and the control group(NOTES gallbladder-preserving surgery without using the snare device,NC),with four cases in each group.The differences between the two groups of animals in operating time,operating workload,complications,adverse events,white blood cells,and liver function were determined.RESULTS No differences were found in the surgical success rate,gallbladder incision closure,white blood cell count,or liver function between the two groups.The total operating time,gallbladder incision blood loss,gallbladder disorientation time,gallbladder incision closure time,and workload scores on the National Aeronautics and Space Administration-Task Load Index were significantly reduced in the SA group(P<0.05).CONCLUSION These results indicated that snare-assisted pure NOTES gallbladder-preservation surgery using standard endoscopic instruments reduced the difficulty of operation,shortened operation time,and did not increase complications in pigs.A new method for pure NOTES gallbladder-preservation surgery was provided.

Endoscopic Assisted Eyebrow Craniotomy for Anterior Cranial Fossa Lesions: Clinical and Cosmetic Outcomes

Background: The eyebrow supraorbital keyhole approach could be considered a modified minimally invasive model for the classic pterional subfrontal approach in which an eyebrow incision and supraorbital mini craniotomy are performed for exposure of the anterior cranial fossa corridor. Methods: This study was retrospectively conducted on twenty four patients, age ranging from 20 to 65 years old, with anterior cranial fossa lesions who were meeting the eligibility criteria for eyebrow craniotomy in the period from August 2019 to January 2023. These patients were operated through eyebrow supraorbital approach in which microscopic endoscopic assisted technique were used. Extent of resection, clinical and cosmetic outcomes and complication incidence were assessed. Results: We included the twenty four patients who met inclusion criteria (17 females and 7 males) their ages ranged from 20 to 65 years. The most common pathology was meningioma in 19 patients. Two patients experienced supraorbital loss of sensation and only one patient experienced palsy of frontalis branch of facial nerve. Frontal sinus was breached in 3 patients with no patient experienced postoperative CSF leak. Total excision was accomplished for 23 patients. Four patients who had preoperative visual compromise, improvement of visual acuity and field defects was observed in 3 patients. No major intraoperative complications occurred. All patients filled cosmetic satisfaction questionnaire during their outpatient visits. For the eyebrow supraorbital approach, no incision related intolerable pain, no craniotomy defects or irregularities, no cosmetic complaints nor limitation of jaw opening were reported, and only minor symptoms in the form of limited eyebrow elevation, swelling and numbness in the forehead. Conclusions: The eyebrow craniotomy could be used safely as a more cosmetic and minimally invasive approach for a variety of anterior cranial fossa lesions. Endoscopic assistance has been found very useful for deeply seated lesions and hidden residuals with minimal brain retraction which couldn’t be accessed easily through microscopic field solely. Endoscopic assisted eyebrow supraorbital keyhole approach could be performed on a wider scale with great results but requires good selection of cases and more practice to expertise the needed skills.

Surgical instruments hyalinization:Occlusion removal in minimally invasive endoscopic surgery

Minimal invasion is an important trend in surgery.However,the endoscope,as one of the key devices for monitoring the process of minimally invasive surgery,is limited by its size and working space it operates in,which result in a considerably narrow field of view.In particular,when a surgical instrument enters through the tool channel,the instrument occupies most of the area in an endoscopic image.This hampers the surgeon’s field of view and has a negative impact on the surgery.This study proposes a novel method for removing the occlusion caused by surgical instruments in endoscopic images by making foreground occlusions on endoscopic images transparent using image restoration and interframe information filling.Compared with unprocessed images,this method can provide a clearer field of view that is necessary for minimally invasive endoscopic surgeries and improve the quality of surgeries.Clinical endoscopic images are used to verify the feasibility of the proposed method,and the results show that the proposed method improves the visual effect of endoscopic images by removing surgical-instrument occlusions.This demonstrates the considerable potential of the proposed method for use in clinical applications.

Endoscopic and minimally-invasive ear surgery: A path to better outcomes

The development of endoscopic ear surgery techniques promises to change the way we approach ear surgery.In this review paper,we explore the current evidence,seek to determine the advantages of endoscopic ear surgery,and see if these advantages are both measureable and meaningful.The wide field of view of the endoscope allows the surgeon to better visualize the various recesses of the middle ear cleft.Endoscopes make it possible to address the target pathology transcanal,while minimizing dissection or normal tissue done purely for exposure,leading to the evolution of minimally-invasive ear surgery and reducing morbidity.When used in chronic ear surgery,endoscopy appears to have the potential to significantly reduce cholesteatoma recidivism rates.Using endoscopes as an adjunct can increase the surgeon's confidence in total cholesteatoma removal.By doing so,endoscopes reduce the need to reopen the mastoid during second-look surgery,help preserve the canal wall,or even change post-cholesteatoma follow-up protocols by channeling more patients away from a planned second-look.

Use of transanal minimally invasive surgery for endoscopic resection of rectal tumour:a technical note

Background:The aim of this article is to report and discuss a case of lower rectal cancer undergoing endoscopic transanal resection of tumour(ETART)using a transanal minimally invasive surgery(TAMIS)approach.Methods:A technical note on a case report.An innovative approach for ETART using TAMIS.Results:This is the first-ever case report of lower rectal cancer treated by ETART using a TAMIS approach.The procedure was completed successfully without any operative or peri-operative complication.Peri-operative flexible sigmoidoscopy confirmed a wide and patent rectal lumen.Conclusion:Use of a TAMIS approach for ETART to remove lower rectal cancer for palliation can be technically very effective compared with conventional ETART,due to the potential advantages of avoiding contaminant fluid spillage,easy access,better visualization compared with conventional ETART,and being user-friendly.The results from larger cohorts of patients undergoing TAMIS ETART are required before recommending the routine use of this technique.However,until then,this approach may be considered as an alternative to conventional ETART.

Biomechanical evaluation of two fusion techniques based on finite element analysis:Percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion

As a novel minimally invasive technique,percutaneous endoscopic transforaminal lumbar interbody fusion(PETLIF)has been widely used in the treatment of lumbar degenerative diseases.The purpose of this study was to analyze these two operation types’biomechanical performances of PE-TLIF and traditional minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)using the finite element(FE)method.The intact FE models of L4-L5 were established and validated based on the CT images.On this basis,the FE models of MIS-TLIF and PETLIF were established and analyzed.It is demonstrated that for lumbar interbody fusion with the oblique asymmetrically implanted cage under bilateral pedicle screws and rods fixation,such as MIS-TLIF and PE-TLIF,different degrees of articular process resection have no significant effect on the cage subsidence,and the surgical segment can achieve similar stability.In addition,the maximum stress of the L4 inferior endplate of MIS-TLIF and PE-TLIF is greater than that of the L5 superior endplate,which indicates that MIS-TLIF and PE-TLIF can cause cage subsidence in the L4 inferior endplate.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery(LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors(GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to av-oid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according tothe concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Transumbilical endoscopic surgery:History,present situation and perspectives

Transumbilical endoscopic surgery or laparo-endoscopic single site(LESS)surgery has become an exciting area of surgical development as innovation continues to move in the 21st century to minimally invasive surgery.The history,present situation and perspectives are reviewed and the nomenclature of this technique is discussed in this article.The range of this technique has been applied in almost all abdominal diseases,surgeries for morbid obesity,hernia and so on,in recent years.It is estimated that 50%-80%of traditional laparoscopic surgery could be performed transumbilically in the next five years according to the LESSCAR consensus.Although the concept of transumbilical laparoscopic surgery is gaining traction rapidly and the instruments have been improved greatly, we should not advocate for slightly improved cosmetic value over safety.Multicenter,randomized and clinical trials are necessary to further elucidate the safety and efficiency of this new technique.Research that examines the efficacy of the new instruments on the market may be helpful to simplify the confusing landscape of new and novel products designed for this purpose.

Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions:a single centre experience

AIM To analyze the outcomes of transanal endoscopic microsurgery(TEM) in the treatment of rare rectal condition like mesenchymal tumors, condylomas, endometriosis and melanoma. METHODS We retrospectively reviewed a twenty-three years database. Fifty-two patients were enrolled in this study. The lesions were considered suitable for TEM if they were within 20 cm from the anus. All of them underwent an accurate preoperative workup consisting in clinical examination, total colonoscopy with biopsies, endoscopic ultrasonography, and pelvic computerized tomography or pelvic magnetic resonance imaging. Operative time, intraoperative complications, rate of conversion, tumor size, postoperative morbidity, mortality, the length of hospital stay, local and distant recurrence were analyzed.RESULTS Among the 1328 patients treated by TEM in our department, the 52 patients with rectal abnormalities other than adenoma or adenocarcinoma represented 4.4%. There were 30 males(57.7%) and 22 females(42.3%). Mean age was 55 years(median = 60, range = 24-78). This series included 14(26.9%) gastrointestinal stromal tumors, 21 neuroendocrine tumors(40.4%), 1 ganglioneuroma(1.9%), 2 solitary ulcers in the rectum(3.8%), 6 cases of rectal endometriosis(11.5%), 6 cases of rectal condylomatosis(11.5%) and 2 rectal melanomas(3.8%). Mean lesion diameter was 2.7 cm(median: 4, range: 0.4-8). Mean distance from the anal verge was 9.5 cm(median: 10, range: 4-15). One patient operated for rectal melanoma developed distant metastases and died two years after the operation. We experienced 2 local recurrences(3.8%) with an overall survival equal to 97.6%(95%CI: 95%-99%) at the end of follow-up and a disease free survival of 98%(95%CI: 96%-99%).CONCLUSION We could conclude that TEM is an important therapeutical option for rectal rare conditions.

Current developments in natural orifices transluminal endoscopic surgery:An evidence-based review

Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access,safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benef its of earlier recovery and improved cosmesis remains uncertain.