Introduction

Post surgical fistulas of the upper digestive tract(UDT) are associated with significant morbidity and mortality. The indication for surgery may influence outcomes.

Aims & Methods

We aimed to evaluate the clinical presentation,efficacy and safety of a primarily endoscopic approach to management of post surgical fistula of the UDT comparing oncologic versus non-oncologic indications for surgery.

Multicentre retrospective analysis involving 126 consecutive patients who underwent primarily endoscopic management of post surgical fistulas of the UDT between March2009-January2022. Clinical efficacy (fistula closure) and adverse events in patients with fistulas after oncologic and non-oncologic surgery were compared.Qualitative variables were evaluated with Chi-square test. Quantitative variables with non-normal distribution were expressed as median(min-max) and evaluated with Mann-Whitney´s test. We performed logistic regression analysis to determine factors associated with fistula closure and adverse events. A p value <0.05 was considered statistically significant (IBM SPSS28).

Results

Median age was 57(17-89) years and 73(60%) patients were female. Indications for surgery were non-oncologic in 80 patients(63.5%) ((mostly bariatric, n=73)) and cancer in 46(36.5%) patients.
Patients undergoing oncologic surgery were older and with male predominance. There were no differences regarding median time to detect fistula or fistula size between the groups. Fever, abdominal pain and abdominal collections were more frequent in non-oncologic surgery group. On laboratory analysis, only haemoglobin was significantly lower in patients undergoing oncologic surgery(Table1). We found no significant difference on leukocyte count, neutrophil percentage, C-reactive protein, AST, ALT, total bilirubin, INR or creatinine.

		Oncologic	Non-oncologic	p-value
Characterization	Median age	71(52-89),	45(17-79)	<0.001
	Female gender	21(26%)	35 (76%)	<0.001
	Median time to fistula detection(days)	8(1-83)	6(1-387)	0.08
	Fistula size(mm)	5.0(2.0-25.0)	5.0(1.0-30.0)	0.671
Clinical presentation	Fever	18(39%)	49(61%)	0.049
	Abdominal pain	13(28%)	46(58%)	0.006
	Abdominal collections	11(n=24%)	48(60%)	<0.001
	Sepsis	13(n=28)	21(26%)	0.309

Endoscopic interventions were similar in both groups and included placement of a covered metallic stent in 64(80.0%) non-oncologic patients and 34(73.9%) oncologic patients (p=0.506) and clips in 99(48.8%) oncologic patients and 19(41.3%) (p=0.461) non-oncologic patients. The frequency of early adverse events (<1 week) (8(17%) vs 14(18%), p=1.0),as well as late adverse events (10(22%)vs 21(26%), p=0.670) were similar in both groups
We documented clinical success (fistula closure) in 72(90%) of non-oncologic patients and 34(74%, p=0.023) of oncologic patients, but after a similar median duration of management (13 (1-423) weeks vs 6(1-55) weeks, p=0.11) and number of endoscopies (3(1-8) vs 2(1-13), p=0.706).
After a median follow up of 36(1-147) and 12.5(1-113) months, 6(7.5%) and 28(60.9%) patients died, respectively from the group of non-oncologic and oncologic surgery. In the oncologic surgery group, 12 patients (48%) died from progression of oncologic disease.

Conclusion

A primarily endoscopic approach is effective in >70% of patients with fistulas after UDT surgery but it´s efficacy was significantly lower in patients with fistulas after oncologic surgery compared to non-oncologic surgery and this may have been due to the higher age and male predominance.

Introduction

Rigid surgical instruments used for conventional laparoscopic surgery provide limited movement, and it is difficult to perform skillful surgery due to their long, jointless straight features. Articulated instruments could have the same advantages seen in robotic surgery, such as excellent control in smaller spaces, restoration of more intuitive and ergonomic movements, and the ability to overcome obstacles on a direct visual line. The aim of this study was to evaluate the surgical performance and clinical outcomes of patients following laparoscopic colorectal surgery with multijoint laparoscopic instruments, ArtiSential® (LivsMed, Seongnam, Korea), compared with those using conventional instruments.

Aims & Methods

Patients aged 19–80 years undergoing elective laparoscopic surgery for colorectal disease between December 2021 and November 2022, were consecutively enrolled. The first 20 cases underwent conventional laparoscopic surgery, and the latter 50 cases underwent laparoscopic surgery using ArtiSential®. Unedited operative videos were submitted to the Crowd-Sourced Assessment of Technical Skills (C-SATS) platform for evaluation using the Global Operative Assessment of Laparoscopic Skills (GOALS), which is a validated tool for technical proficiency. Each of GOALS’ four domains (bimanual dexterity, depth perception, efficiency, and tissue handling) was scored on a Likert scale between 1 and 5, scoring anchor, with a total score ranging from 4 to 20. The learning curve analysis was performed using the cumulative sum control chart (CUSUM) for GOALS grades (Registration number: KCT0006798).

Results

There was no significant difference between group with regards to type of operation, hospital stay, and 30-day postoperative complication. The GOALS’ grades were similar between the two groups (15.7 ± 0.7 vs. 15.9 ± 0.5, P = 0.190), but the scores in two domains (depth perception and tissue handling) were significantly higher in the ArtiSential® group (3.9 ± 0.3 vs. 4.0 ± 0.2, P = 0.014 and 3.9 ± 0.2 vs. 4.1 ± 0.2, P = 0.048, respectively) compared with those in the conventional group. In addition, patients in the ArtiSential® group experienced a shorter operation time (122.3 ± 58.9 vs. 88.1 ± 35.1, P = 0.022) and less intraoperative blood loss (56.5 ± 69.9 vs. 29.8 ± 1.4, P = 0.002) than those in the conventional group. According to the CUSUM learning curve analysis, the first 10 cases using ArtiSential® were in the inexperienced phase, and the remaining 40 cases were in the experienced phase. The GOALS’ score in the experienced phase of ArtiSential® was improved compared with that in the conventional group (16.0 ± 0.5 vs. 15.7 ± 0.7, P = 0.037).

Conclusion

A plateau in the learning curve of laparoscopic colorectal surgery performed with an articulated instrument was observed in approximately 10 cases, and it can be expected that surgical proficiency in the experienced phase increases without deterioration of clinical outcome as compared to that in conventional surgery.

References

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Disclosure

This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grantnumber: HI20C2092).

Introduction

Endoscopic full thickness resection (EFTR) of the colon has been described as an effective practicable method for resection of recurrent /advanced neoplastic lesions, but its performance and success may be difficult or different according to location of the lesion in the corresponding colonic segment.
The aim was to investigate the segment-specific efficacy and safety of EFTR in the colon using a full thickness resection device (FTRD) from real-world data.

Aims & Methods

EFTR was conducted in patients being referred to either of the 4 participating centers after previous colonoscopy leading to a diagnosis suitable for EFTR. The primary efficacy measure of EFTR was histologically complete resection (R0) of the lesion. Safety was investigated considering the frequency of adverse events (AE) to EFTR occurring during the procedure or afterwards.

Results

105 patients (66m/39f; median 70yrs) were included in the analysis. FTRD was technically successful in 101 patients (96.2%) with a median lesion size of 20 x 19mm (15-24).
Histologically R0 resection was obtained in 77.1% of the patients with a segment-specific range from 90% (rectum), 70.6% sigmoid, 78.6% descending colon to 62.5% (transverse colon), while in ascending colon and cecum resection rates of 76.9 and 83.3% could be achieved.
Overall, adverse event rate (AE, any) were documented in 33 patients (31.4%), with only 1 perforation in sigmoid (0.95%), while the others were minor, abdominal postsurgical pain (18.1%), hematochezia (9.5%), and haemoglobin decline (7.6%). Topographical analysis revealed that AE were most attributable to transverse colon (12.5%), while in the other segments AE were each lower or equal than 8.2%; the lowest rate of AE was found in rectum with 1.4%.

Conclusion

EFTR is efficacious for the endoscopic treatment of colorectal lesions with best outcome parameters in rectum (high R0 rate, low AE), followed by cecum. The other segments appeared to be more difficult for complete resection and showed a higher AE rate. Transverse colon was identified with lowest R0 resection rates and highest frequency of AE. While only one major complication occurred, minor complications in all other segments were below 8.2% and short-lived.

Introduction

Recently, the number of ESD cases of early gastric cancer detected after Helicobacter pylori eradication (GCAE) has been increasing. As the number of years since eradication increases, the management of metachronous carcinomas after ESD for GCAE has also become an issue. Serum gastrin level has been reported to be useful in identifying groups at high-risk of developing gastric cancer. In this study, we investigated the clinicopathological characteristics of patients with early-stage GCAE who underwent ESD at our department. Furthermore, we determined the risk of metachronous GCAE after ESD and the correlation between serum gastrin level and metachronous GCAE.

Aims & Methods

We retrospectively analyzed a total of 300 lesions in 245 patients who underwent ESD for GCAE with known period after eradication at Hiroshima University Hospital between April 2010 and December 2019 and examined their clinicopathology. We divided 220 lesions in 194 patients with initial GCAE who had no history of gastric endoscopic resection before successful eradication into the " metachronous gastric cancer (MGC) groups " and " no metachronous gastric cancer (NGC) groups ". Then, we examined the clinicopathological characteristics of metachronous gastric cancer cases. We classified 74 lesions in 63 patients of male and differentiated type cancers who have not been using PPIs into two groups: 37 lesions in 32 patients with gastrin level of less than 80 pg/ml and 37 lesions in 31 patients with gastrin level higher than 80 pg/ml.

Results

At a median follow-up of 4.0 years, 16 patients (8.2%) developed metachronous gastric cancers. Males were more predominant in the MGC group than in the NGC group (male / female; 16/0 vs. 223/74，p=0.02), which included increased cases of severe atrophy of the background gastric mucosa (mild to moderate / severe; 3/13 vs. 94/84, p=0.01), more lesions in the U and M regions of stomach (U･M / L; 19/4 vs 121/76, p=0.05), and a higher proportion of synchronous multiple lesions (synchronous tumor/ no synchronous tumor; 11/12 vs. 160/37, p=0.01). The relationship between gastrin levels and metachronous gastric cancer was examined, revealing that gastrin levels were higher in the MGC group. The group with a gastrin level of 80 pg/ml or higher had a significantly higher incidence of metachronous lesions than the group with that of less than 80 pg/ml (OR 6.88; 95% CI, 1.61–29.3; p=0.01).

Conclusion

These results that male patient with severe atrophy, the rates of localization to the U and M regions of stomach and the incidence of synchronous multiple lesions before ESD indicate should be noted and surveyed more strictly for metachronous gastric cancers developing after ESD of GCAE. Patients with gastrin 80 pg/ml or higher had increased risk of MGC, indicating that gastrin level may be a serological marker for MGC.

Introduction

Stenosis after esophageal Endoscopic Submucosal Dissection (ESD) has a high incidence of ranks, and muscular injury might be an important risk factor for esophageal stenosis.

Aims & Methods

Our study aimed to classify muscular injury degree and investigate its association with postoperative stenosis. This retrospective study included 1,033 patients with esophageal mucosal lesions treated by ESD between August 2015 and March 2021. Demographic and clinical parameters were analyzed, and stenosis risk factors were identified using multivariate logistic regression. A novel muscular injury classification system was proposed and further used to investigate the association between the different degrees of muscular injury and postoperative stenosis. Finally, a scoring system was established for the prediction of muscular injury.

Results

Of 1,033 patients, 118 (11.4%) had esophageal stenosis. The multivariate analysis demonstrated that the history of endoscopic esophageal treatment, circumferential range, and muscular injury were significant risk factors for esophageal stenosis. Patients with Type II muscular injuries tended to develop complex stenosis (n = 13, 36.1%, p < 0.05). Moreover, Type II muscular injuries were more likely to predispose patients to severe stenosis than Type I (73.3 and 92.3%, respectively). According to the scoring system for predicting muscular injury, patients with high scores (3-6) were more likely to suffer muscular injury. The score model presented good discriminatory power in the internal validation (AUC: 0.706; 95% CI: 0.645-0.767) and goodness-of-fit in the Hosmer-Lemeshow test (p = 0.865).

Conclusion

Muscular injury was an independent risk factor for esophageal stenosis. The scoring system demonstrated good performance in predicting muscular injury during ESD.

References

1. Yang D, Othman M, Draganov PV. Endoscopic Mucosal Resection vs Endoscopic Submucosal Dissection For Barrett's Esophagus and Colorectal Neoplasia. Clin Gastroenterol Hepatol. 2019;17:1019-28.
2. Chen M, Dang Y, Ding C, et al. Lesion size and circumferential range identified as independent risk factors for esophageal stricture after endoscopic submucosal dissection. Surg Endosc. 2020;34:4065-71.
3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020;32:452-93.
4. Zhang BZ, Zhang Y, Wang YD, et al. Stent placement to prevent strictures after esophageal endoscopic submucosal dissection: a systematic review and meta-analysis. Dis Esophagus. 2021;34.
5. Wu QN, Xu XY, Zhang XC, et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017;49:736-44.
6. Nagami Y, Ominami M, Shiba M, et al. Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection. Dig Endosc. 2018;30:198-205.
7. Xu Y, Lin Z, Zhong S, et al. Muscular injury was identified the risk factor of post-operative stenosis after large area but non-circumferential esophageal endoscopic submucosal dissection. Scand J Gastroenterol. 2022:1-8.

Introduction

Postoperative ileus, is one of the most common causes of prolonged hospital stays after abdominal surgery which cause from physiologic hypomotility of the gastrointestinal tract occurring immediately after abdominal surgery. Multi-modal approach to the resolution of postoperative ileus includes ERAS protocol such as opioid minimization, early ambulation, intake of prokinetic drug. Mosapride citrate (mosapride) is known to promote gastrointestinal motility. The objective of this study is to evaluate the effects of mosapride on postoperative ileus and postoperative gastrointestinal motility in patients undergoing elective open and laparoscopic colorectal surgery.

Aims & Methods

The study was approved by ethics committee of the Faculty of Medicine Ramathibodi Hospital Mahidol University (Ref. Number COA.MURA2021/328,ClinicalTrials.gov Identifier: NCT04905147). Forty-four colorectal cancer patients, undergoing open and laparoscopic colorectal surgery in Ramathibodi Hospital during July 2021-August 2022, were randomly assigned to a mosapride group or control group. The mosapride group received 15 mg of mosapride by enteric route with 50 ml of water three times a day, starting on postoperative day 1. The control group received 15 mg of placebo drug with 50 ml of water at the same time. Postoperative time to the first passage of flatus and the first bowel movement were evaluated by one investigator with triple blind study. Time to step diet, length of postoperative hospital stays, and adverse effects were also evaluated in secondary outcomes.

Results

All forty four patients were include, twenty-three in control group and twenty-one in mosapride group. There were no statistically significance differences between mean age and type of surgery (laparoscopic or open) in two group (P>0.05). Time to first bowel movement and time to passage of flatus after operation were significantly shorter in the mosapride group than the control group (26 vs 50 hours, P=0.004 and 40 vs 70 hours, P=0.003, respectively). Time to step diet (soft diet) was also shorter in the mosapride group (90 vs 132 hours, P=0.004). Time to defecate was less in mosapride group than control group (80 vs 120 hours, P <0.001). Length of hospital stay was significantly shorter in patients receiving mosapride (7 vs 10 days, P=0.004).

Conclusion

This study demonstrated the efficacy of mosapride when administered to patients who underwent elective colorectal surgery. Mosapride significantly enhance recovery of gastrointestinal motility and shorter length of hospital stay with no significant adverse effects.

References

1. Collins TC, Daley J, Henderson WH, Khuri SF. Risk factors for prolonged length of stay after major elective surgery. Ann Surg 1999;230:251–9
2. Vather R, O'Grady G, Bissett IP, Dinning PG. Postoperative ileus: mechanisms and future directions for research. Clin Exp Pharmacol Physiol. 2014;41(5):358-370.
3. Goldstein JL, Matuszewski KA, Delaney C, Senagore A, Chiao E, Shah M, et al. Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. P AND T.2007;32(2):82.
4. Venara A, Neunlist M, Slim K, Barbieux J, Colas PA, Hamy A, et al. Postoperative ileus: Pathophysiology, incidence, and prevention. J Visc Surg 2016;153:439-46.
5. Luckey A, Livingston E, Taché Y. Mechanisms and Treatment of Postoperative Ileus. Arch Surg. 2003;138(2):206–214.
6. Georgiadis, G & Markantonis, Sophia & Triantafillidis, John. (2000). Prokinetic agents: Current aspects with focus on cisapride. Annals of Gastroenterology. 13.
7. Reynolds, J.C. & Putman, P.E. (1992) Prokinetic Agents, Gastroenterol Clin of North Am, Vol.21, pp.567-596.
8. Taniyama, K., Makimoto, N., Furuichi, A. et al. Functions of peripheral 5-hydroxytryptamine receptors, especially 5-hydroxytryptamine₄ receptor, in gastrointestinal motility. J Gastroenterol 35, 575–582 (2000).

Introduction

To evaluate the utility of the unroofing technique in the diagnosis of gastrointestinal subepithelial tumors (SETs), we performed a multicenter retrospective study.

Aims & Methods

This study was conducted in 10 hospitals and involved all eligible patients who underwent unroofing techniques to gain biopsy for gastrointestinal SETs between April 2015 and March 2021. The primary endpoint was the rate of correct diagnosis with the unroofing technique, and the secondary endpoints were the incidence of adverse events and the factors contributing to the correct diagnosis.

Results

The study included 61 patients with 61 gastrointestinal SETs, a median tumor size of 20 mm, and a median procedure time of 38 minutes with 82% successful tumor exposure. The rate of tissue acquisition was 98.4%, and the rate of pathological diagnosis was 72.1%. In 44 cases with a pathological diagnosis, two showed discrepancies with the postresection pathological diagnosis. No factors, including facility experience, organ, tumor size, or tumor exposure, significantly affected the correct diagnosis. No significant differences in the correct diagnosis rate were observed between less than ten experiences and more than ten experiences (74.1 vs. 70.6%). The correct diagnosis rates for tumors <20 mm and ≥20 mm were 76.9% and 65.7%, respectively. There was one case of delayed bleeding and two cases of perforations.

Conclusion

The diagnostic yield of the unroofing technique was acceptable. The unroofing technique was beneficial regardless of institutional experience, organ, tumor size, or actual tumor exposure.