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.

Influence of humanistic care-based operating room nursing on safety,recovery,and satisfaction after radical surgery for colorectal carcinoma

BACKGROUND Radical surgery is a preferred treatment for colorectal carcinoma,wherein nursing intervention is essential for postoperative recovery and prevention of complications.Recently,the application of humanistic care in medical care has attracted attention.Humanistic care emphasizes comprehensive care,with importance attached to patients’physical needs as well as psychological and emotional support to provide more humane and personalized care services.However,no clinical reports have examined the use of humanistic care in patients undergoing radical surgery for colorectal carcinoma.AIM To investigate the influence of humanistic care-based operating room nursing on the safety,postoperative recovery,and nursing satisfaction of patients who have undergone radical surgery for colorectal carcinoma.METHODS In total,120 patients with rectal cancer who underwent surgery in Zhongnan Hospital of Wuhan University between August 2023 and March 2024 were selected and grouped based on the nursing methods employed.Of these patients,55 were treated with routine nursing intervention(control group)and 65 were provided humanistic care-based operating room nursing(research group).The patients’vital signs were recorded,including systolic/diastolic blood pressure(SBP/DBP)and heart beats per minute(BPM),as well as serum stress indices,including norepinephrine(NE),adrenal hormone(AD),and cortisol(Cor).Postoperative recovery and complications were also recorded.Patients’negative emotions,life hope,and nursing satisfaction were evaluated using the Self-rating Depression/Anxiety Scale(SDS/SAS),Herth Hope Index(HHI),and self-deve-loped nursing satisfaction questionnaire,respectively.RESULTS During emergence from anesthesia,SBP,DBP,and BPM levels were found to be lower in the research group than those in the control group,also serum Cor,AD,and NE levels were lower.In addition,the research group had shorter operative,awakening,anal exhaust,first postoperative ambulation,drainage tube removal,intestinal recovery,and hospital times.The total complication rate and the SDS and SAS scores were lower in the research group than those in the control group.The HHI and nursing satisfaction scores were higher in the research group.CONCLUSION Humanistic care-based operating room nursing can mitigate physiological stress responses,reduce postoperative complications,promote postoperative recovery,relieve adverse psychological emotions,and enhance life hope and nursing satisfaction in patients undergoing radical surgery for colorectal carcinoma,which can be popularized in clinical practice.

Systematic review of emergent laparoscopic colorectal surgery for benign and malignant disease

Laparoscopic surgery has become well established in the management of both and malignant colorectal disease.The last decade has seen increasing numbers of surgeons trained to a high standard in minimallyinvasive surgery.However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery.There is a perception that emergent surgery is technically more difficult and may lead to worse outcomes.The present review aims to provide a comprehensive and critical appraisal of the available literature on the use of laparoscopic colorectal surgery(LCS)in the emergency setting.The literature is broadly divided by the underlying pathology;that is,inflammatory bowel disease,diverticulitis and malignant obstruction.There were no randomized trials and the majority of the studies were case-matched series or comparative studies.The overall trend was that LCS is associated with shorter hospital stay,par or fewer complications but an increased operating time.Emergency LCS can be safely undertaken for both benign and malignant disease providing there is appropriate patient selection,the surgeon is adequately experienced and there are sufficient resources to allow for a potentially more complex operation.

Endoscopic trans-esophageal submucosal tunneling surgery:A new therapeutic approach for diseases located around the aorta ventralis

AIM To assess the efficiency of endoscopic trans-esophageal submucosal tunneling surgery(EESTS) technique for diseases located around the aorta ventralis.METHODS Nine pigs were assigned to EESTs. The procedures were as follows: First, a long esophageal submucosal tunnel was established. Second, full-thickness myotomy was created. Third, an endoscope was entered into the abdominal cavity through a muscle incision and the endoscope was around the aorta ventralis. Eventually,celiac trunk ganglion neurolysis, partial hepatectomy and splenectomy, partial tissue resection in the area of the posterior peritoneum, and endoscopic submucosal dissection(ESD) combined with lymph node dissection were performed. The animals were given antibiotics for 5 d and necropsied 7 d after surgery.RESULTS In all surgeries, one pig died from intraperitoneal hemorrhage after doing partial splenectomy, while the other pigs were alive after successfully operating other surgeries. For surgery of celiac trunk ganglion damage, at necropsy, there was no exudation in the abdominal cavity. Regarding surgery of partial hepatectomy, the wound with part healing was observed in the left hepatic lobe, and no bleeding or obvious exudation was seen. In surgery of partial splenectomy, massive hemorrhage was observed on the splenic wound surface, and the metal clips could not stop bleeding. After surgery of retroperitoneal tissue resection, mild tissue adhesion was observed in the abdominal cavity of one animal, and another one suffered from severe infection. For surgery of ESD and lymph node dissection, a moderate tissue adhesion was observed.CONCLUSION EESTS is a feasible and safe technique for diseases located around the aorta ventralis.

Role of ultrasound in colorectal diseases

Ultrasound is an undervalued non-invasive examination in the diagnosis of colonic diseases. It has been replaced by the considerably more expensive magnetic resonance imaging and computed tomography, despite the fact that, as first examination, it can usefully supplement the diagnostic process. Transabdominal ultrasound can provide quick information about bowel status and help in the choice of adequate further examinations and treatment. Ultrasonography,as a screening imaging modality in asymptomatic patients can identify several colonic diseases such as diverticulosis, inflammatory bowel disease or cancer. In addition, it is widely available, cheap, non-invasive technique without the use of ionizing radiation, therefore it is safe to use in childhood or during pregnancy, and can be repeated at any time. New ultrasound techniques such as elastography, contrast enhanced and Doppler ultrasound, miniprobes rectal and transperineal ultrasonography have broadened the indication. It gives an overview of the methodology of various ultrasound examinations, presents the morphology of normal bowel wall and the typical changes in different colonic diseases. We will pay particular attention to rectal and transperineal ultrasound because of their outstanding significance in the diagnosis of rectal and perineal disorders. This article seeks to overview the diagnostic impact and correct indications of bowel ultrasound.

Parallel pathways:A chronicle of evolution in rectal and breast cancer surgery

In this editorial,we have analyzed the historical evolution of rectal and breast cancer surgery,focusing on the progressive reduction of demolitive approaches and the increasing use of more conservative strategies,accompanied by a growing emphasis on perioperative treatments aimed at enhancing surgical outcomes.All of these changes have been made possible due to an increased awareness and understanding of oncological diseases and improved perioperative treatments.

Comparing short-term outcomes of robot-assisted and conventional laparoscopic total mesorectal excision surgery for rectal cancer in elderly patients

BACKGROUND Da Vinci Robotics-assisted total mesorectal excision(TME)surgery for rectal cancer is becoming more widely used.There is no strong evidence that roboticassisted surgery and laparoscopic surgery have similar outcomes in elderly patients with TME for rectal cancer.AIM To determine the improved oncological outcomes and short-term efficacy of robot-assisted surgery in elderly patients undergoing TME surgery.METHODS A retrospective study of the clinical pathology and follow-up of elderly patients who underwent TME surgery at the Department of Gastrointestinal Oncology at the Affiliated Hospital of Nanjing University of Chinese Medicine was conducted from March 2020 through September 2023.The patients were divided into a robotassisted group(the R-TME group)and a laparoscopic group(the L-TME group),and the short-term efficacy of the two groups was compared.RESULTS There were 45 elderly patients(≥60 years)in the R-TME group and 50 elderly patients(≥60 years)in the L-TME group.There were no differences in demographics,conversion rates,or postoperative complication rates.The L-TME group had a longer surgical time than the R-TME group[145(125,187.5)vs 180(148.75,206.25)min,P=0.005),and the first postoperative meal time in the L-TME group was longer than that in the R-TME(4 vs 3 d,P=0.048).Among the sex and body mass index(BMI)subgroups,the R-TME group had better out-comes than did the L-TME group in terms of operation time(P=0.042)and intraoperative assessment of bleeding(P=0.042).In the high BMI group,catheter removal occurred earlier in the R-TME group than in the L-TME group(3 vs 4 d,P=0.001),and autonomous voiding function was restored.CONCLUSION The curative effect and short-term efficacy of robot-assisted TME surgery for elderly patients with rectal cancer are similar to those of laparoscopic TME surgery;however,robotic-assisted surgery has better short-term outcomes for individuals with risk factors such as obesity and pelvic stenosis.Optimizing the learning curve can shorten the operation time,reduce the recovery time of gastrointestinal function,and improve the prognosis.

Congenital Heart Disease Referred for Surgery: Analysis and Epidemiological Description in the Cardiology Department of CHU Ignace Deen

Introduction: Congenital heart disease includes all cardiac and vascular malformations. It accounts for approximately one third of all congenital malformations and is a public health problem, particularly in developing countries. The aim of this study was to analyze the epidemiological, clinical and paraclinical aspects of congenital heart disease. Methods: This was a retrospective descriptive and analytical study based on the records of 135 patients referred for surgery and followed up in the cardiology department of the Ignace Deen University Hospital, collected in November 2022. Results: Hospital prevalence was 5%. The mean age was 71 months, ranging from 1 month to 19 years. The age group over 24 months was the most represented (62%). The M/F sex ratio was 1.36. Urban origin was predominant (58%). The rate of children not attending school or dropping out was high (16%). Siblings with fewer than 4 children were the most common (88%). A heart murmur was the most frequent sign (78%), followed by cyanosis (36%) and heart failure (29%). The association between heart murmurs and CHD was proven with a p-value Conclusion: CHDs represent the main indication for paediatric cardiac surgery and follow-up (95%). We stress the importance of implementing a screening and management strategy for congenital heart disease.

Beyond total mesorectal excision: The emerging role of minimally invasive surgery for locally advanced rectal cancer

Multivisceral resection and/or pelvic exenteration represents the only potential curative treatment for locally advanced rectal cancer(LARC);however,it poses significant technical challenges,which account for the high risk of morbidity and mortality associated with the procedure.As complete histopathologic resection is the most important determinant of patient outcomes,LARC often requires an extended resection beyond the total mesorectal excision plane to obtain clear re-section margins.In an era when laparoscopic surgery and robot-assisted surgery are becoming commonplace,the optimal approach to extensive pelvic inter-ventions remains controversial.However,acceptance of the suitability of mini-mally invasive surgery is slowly gaining traction.Nonetheless,there is still a lack of evidence in the literature about minimally invasive approaches in multiple and extensive surgical resections,highlighting the need for research studies to explore,validate,and develop this issue.This editorial aims to provide a critical overview of the currently available applications and challenges of minimally invasive abdo-minopelvic surgery for LARC.Furthermore,we discuss recent developments in the field of robotic surgery for LARC,with a specific focus on new innovations and emerging frontiers.

Therapeutic effect of Wendan Decoction combined with mosapride on gastroesophageal reflux disease after esophageal cancer surgery

BACKGROUND Gastroesophageal reflux disease(GERD)is a common complication of esophageal cancer surgery that can affect quality of life and increase the risk of esophageal stricture and anastomotic leakage.Wendan Decoction(WDD)is a traditional Chinese herbal formula used to treat various gastrointestinal disorders,such as gastritis,functional dyspepsia,and irritable bowel syndrome.Mosapride,a prokinetic agent,functions as a selective 5-hydroxytryptamine 4 agonist,enhancing gastrointestinal motility.AIM To evaluate the therapeutic effects of WDD combined with mosapride on GERD after esophageal cancer surgery.METHODS Eighty patients with GERD were randomly divided into treatment(receiving WDD combined with mosapride)and control(receiving mosapride alone)groups.The treatment was conducted from January 2021 to January 2023.The primary outcome was improved GERD symptoms as measured using the reflux disease questionnaire(RDQ).The secondary outcomes were improved esophageal motility(measured using esophageal manometry),gastric emptying(measured using gastric scintigraphy),and quality of life[measured via the Short Form-36(SF-36)Health Survey].RESULTS The treatment group showed a notably reduced RDQ score and improved esophageal motility parameters,such as lower esophageal sphincter pressure,peristaltic amplitude,and peristaltic velocity compared to the control group.The treatment group showed significantly higher gastric emptying rates and SF-36 scores(in both physical and mental domains)compared to the control group.No serious adverse effects were observed in either group.CONCLUSION WDD combined with mosapride is an effective and safe therapy for GERD after esophageal cancer surgery.It can improve GERD symptoms,esophageal motility,gastric emptying,and the quality of life of patients.Further studies with larger sample sizes and longer follow-up periods are required to confirm these findings.

Global geoepidemiology of gastrointestinal surgery rates in Crohn’s disease

BACKGROUND Data regarding the worldwide gastrointestinal surgery rates in patients with Crohn’s disease(CD)remains limited.AIM To systematically review the global variation in the rates of surgery in CD.METHODS A comprehensive search analysis was performed using multiple electronic databases from inception through July 1,2020,to identify all full text,randomized controlled trials and cohort studies pertaining to gastrointestinal surgery rates in adult patients with CD.Outcomes included continent based demographic data,CD surgery rates over time,as well as the geoepidemiologic variation in CD surgery rates.Statistical analyses were conducted using R.RESULTS Twenty-three studies spanning four continents were included.The median proportion of persons with CD who underwent gastrointestinal surgery in studies from North America,Europe,Asia,and Oceania were 30%(range:1.7%-62.0%),40%(range:0.6%-74.0%),17%(range:16.0%-43.0%),and 38%respectively.No clear association was found regarding the proportion of patients undergoing gastrointestinal surgery over time in North America(R^(2)=0.035)and Europe(R^(2)=0.100).A moderate,negative association was seen regarding the proportion of patients undergoing gastrointestinal surgery over time(R^(2)=0.520)in Asia.CONCLUSION There appears to be significant inter-continental variation regarding surgery rates in CD.Homogenous evidencebased guidelines accounting for the geographic differences in managing patients with CD is prudent.Moreover,as a paucity of data on surgery rates in CD exists outside the North American and European continents,future studies,particularly in less studied locales,are warranted.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diag- nostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Advances in beyond total mesorectal excision surgery: Behind the scenes

The management of locally advanced rectal cancer involving adjacent organs and extending beyond the surgical planes of total mesorectal excision has evolved over the past few decades both in terms of the effectiveness of preoperative treatments and surgical innovation.The use of a robotic platform is increasing,even in complex surgery such as pelvic exenteration together with the advantages of minimally invasive procedures.However,satisfactory surgical,oncological,and functional outcomes are achieved not only minimizing the impact of a demolitive surgery but also when a multidisciplinary specialized team focuses on experienced surgeons,mandatory rules of surgical oncology,appropriate medical treatments,accurate preoperative planning,and an acceptable quality of life.

Evaluation of Post-Operative Atrial Fibrillation after Cardiac Surgery for Adult Congenital Heart Disease

Background:Post-operative atrial fibrillation(POAF)frequently occurs after cardiac surgery.Although adult congenital heart disease(ACHD)patients have higher rates of arrhythmia than the general population,there is scant literature on POAF in ACHD patients.Objectives:Identify key risk factors associated with post-operative atrial fibrillation and evaluate the short-and mid-term significance of developing POAF.Methods:A retrospective cohort study was conducted of ACHD patients from 2013–2021 at the University of Colorado Hospital and Children’s Hospital of Colorado.The institutional Society of Thoracic Surgeons(STS)surgical registry was used to identify patients≥18-year-old with congenital heart disease who underwent cardiac surgery during the study period.Results:A total of 168 patients(48%female)were included.The median age was 36 years(IQR 28–48).Onehundred and fifty patients(90%)had moderate ACHD anatomical complexity,and 10 patients(6%)had severe ACHD anatomical complexity based on initial ACHD diagnosis.POAF occurred in 40(24%)patients.Older age,history of supraventricular tachycardia,intra-operative arrhythmia,and post-operative hypokalemia independently predicted POAF.POAF was associated with an increased length of stay(8 vs.5 days,p<0.001)and recurrence of atrial fibrillation(46%vs.21%,OR 3.35,p=0.002)but did not predict mortality,stroke,or bleeding event.Conclusion:Atrial fibrillation is a common complication after cardiac surgery in the ACHD population.Older age,history of supraventricular tachycardia,intra-operative arrhythmia,and post-operative hypokalemia independently predicted POAF.Further investigation is needed to understand the long-term impacts of POAF.

Advancing perioperative optimization in Crohn's disease surgery with machine learning predictions

This editorial offers commentary on the article which aimed to forecast the likelihood of short-term major postoperative complications(Clavien-Dindo grade≥III),including anastomotic fistula,intra-abdominal sepsis,bleeding,and intestinal obstruction within 30 days,as well as prolonged hospital stays follow-ing ileocecal resection in patients with Crohn’s disease(CD).This prediction re-lied on a machine learning(ML)model trained on a cohort that integrated a no-mogram predictive model derived from logistic regression analysis and a random forest(RF)model.Both the nomogram and RF showed good performance,with the RF model demonstrating superior predictive ability.Key variables identified as potentially critical include a preoperative CD activity index≥220,low preope-rative serum albumin levels,and prolonged operation duration.Applying ML ap-proaches to predict surgical recurrence have the potential to enhance patient risk stratification and facilitate the development of preoperative optimization strate-gies,ultimately aiming to improve post-surgical outcomes.However,there is still room for improvement,particularly by the inclusion of additional relevant clinical parameters,consideration of medical therapies,and potentially integrating mole-cular biomarkers in future research efforts.

Surgical and non-surgical risk factors affecting the insufficiency of ileocolic anastomosis after first-time surgery in Crohn’s disease patients

BACKGROUND Crohn's disease(CD)often necessitates surgical intervention,particularly when it manifests in the terminal ileum and ileocecal valve.Despite undergoing radical surgery,a subset of patients experiences recurrent inflammation at the anasto-motic site,necessitating further medical attention.AIM To investigate the risk factors associated with anastomotic insufficiency following ileocecal resection in CD patients.METHODS This study enrolled 77 patients who underwent open ileocolic resection with pri-mary stapled anastomosis.Patients were stratified into two groups:Group I co-mprised individuals without anastomotic insufficiency,while Group II included patients exhibiting advanced anastomotic destruction observed endoscopically or those requiring additional surgery during the follow-up period.Surgical and non-surgical factors potentially influencing anastomotic failure were evaluated in both cohorts.RESULTS Anastomotic insufficiency was detected in 12 patients(15.6%),with a mean time interval of 30 months between the initial surgery and recurrence.The predomi-nant reasons for re-intervention included stenosis and excessive perianastomotic lesions.Factors associated with a heightened risk of anastomotic failure encompassed prolonged postoperative obstruction,anastomotic bleeding,and clinically confirmed micro-leakage.Additionally,patients in Group II exhibited preoperative malnutrition and early recurrence of symptoms related to CD.CONCLUSION Successful surgical outcomes hinge on the attainment of a fully functional anastomosis,optimal metabolic status,and clinical remission of the underlying disease.Vigilant endoscopic surveillance following primary resection facilitates the timely identification of anastomotic failure,thereby enabling noninvasive interventions.

Current and future perspectives in the management and treatment of colorectal cancer

In this editorial,we reviewed the article by Fadlallah et al that was recently published in the World Journal of Clinical Oncology.The article provided a comprehensive and in-depth view of the management and treatment of colorectal cancer(CRC),one of the leading causes of cancer-related morbidity and mortality worldwide.The article analyzed the therapeutic modalities and their sequencing,focusing on total neoadjuvant therapy for locally advanced rectal cancer.It highlighted the role of immunotherapy in tumors with high microsatellite instability or deficient mismatch repair,addressing recent advances that have improved prognosis and therapeutic response in localized and metastatic CRC.Innovations in surgical techniques,advanced radiotherapy,and systemic agents targeting specific mutational profiles are also discussed,reflecting on how they revolutionized clinical management.Circulating tumor DNA has emerged as a promising tool for detecting minimal residual disease,prognosis,and therapeutic monitoring,solidifying its role in precision oncology.This review emphasized the importance of technological and therapeutic advancements in improving clinical outcomes and personalizing CRC treatment.

Analysis of the Effect of the Comprehensive Nursing Model on Patients with Moyamoya Disease Undergoing Intracranial and Extracranial Revascularization Surgery

Objective:To explore the effect of a comprehensive nursing model on patients with Moyamoya disease who underwent intracranial and extracranial revascularization surgery.Methods:110 cases were divided into control and observation groups with 55 cases each.The control group received routine perioperative care,and the observation group received perioperative care along with comprehensive nursing care.The two groups’disease cognition levels,anxiety,symptoms,daily living ability scores,and postoperative complication rates were compared.Results:The anxiety score and total postoperative complications of the observation group upon discharge were lower than that of the control group,and the disease cognition level and daily living ability upon discharge were higher than that of the control group(P<0.05).Conclusion:Applying the comprehensive nursing model in conjunction with perioperative care for patients undergoing surgery can effectively improve their anxiety,strengthen activities of daily living,and reduce the risk of postoperative complications.

Negation of the negation on beta-blockers in patients with cardiovascular diseases and noncardiac surgery

The best protocol of perioperative beta-blockers remains uncertain.Previous studies have demonstrated that tight heart rate control by beta-blockers reduced perioperative myocardial ischemia and improved clinical outcomes.However,the recent studies have failed to provide evidence to support perioperative beta blockers,with potential increased mortality as showed in the POISE trial.In this paper,perioperative use of beta-blockers will be discussed,especially about the evolution of their perioperative therapeutic application and current status.

Digital surgery for gastroenterological diseases

Advances in machine learning,computer vision and artificial intelligence methods,in combination with those in processing and cloud computing capability,portend the advent of true decision support during interventions in real-time and soon perhaps in automated surgical steps.Such capability,deployed alongside technology intraoperatively,is termed digital surgery and can be delivered without the need for high-end capital robotic investment.An area close to clinical usefulness right now harnesses advances in near infrared endolaparoscopy and fluorescence guidance for tissue characterisation through the use of biophysics-inspired algorithms.This represents a potential synergistic methodology for the deep learning methods currently advancing in ophthalmology,radiology,and recently gastroenterology via colonoscopy.As databanks of more general surgical videos are created,greater analytic insights can be derived across the operative spectrum of gastroenterological disease and operations(including instrumentation and operative step sequencing and recognition,followed over time by surgeon and instrument performance assessment)and linked to value-based outcomes.However,issues of legality,ethics and even morality need consideration,as do the limiting effects of monopolies,cartels and isolated data silos.Furthermore,the role of the surgeon,surgical societies and healthcare institutions in this evolving field needs active deliberation,as the default risks relegation to bystander or passive recipient.This editorial provides insight into this accelerating field by illuminating the nearfuture and next decade evolutionary steps towards widespread clinical integration for patient and societal benefit.