Publications by authors named "Giovanni Dapri"

81 Publications

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

Obes Surg 2021 Jul 30. Epub 2021 Jul 30.

Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK.

Background: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

Methods: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

Results: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

Conclusions: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.
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http://dx.doi.org/10.1007/s11695-021-05493-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323543PMC
July 2021

Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review.

JAMA Surg 2021 Jun 30. Epub 2021 Jun 30.

Department of Surgery, Skåne University Hospital, Malmö, Sweden.

Importance: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer.

Observations: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts.

Conclusions And Relevance: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.
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http://dx.doi.org/10.1001/jamasurg.2021.2380DOI Listing
June 2021

Technique for Reduced Trocar Decapsulation of a Giant Nonparasitic Splenic Cyst.

Surg Laparosc Endosc Percutan Tech 2021 Jun 10. Epub 2021 Jun 10.

International School Reduced Scar Laparoscopy, Brussels, Belgium.

Background: Minimally invasive surgery is adopted for patients presenting benign splenic cysts. Reduced port laparoscopy is an evolution of conventional laparoscopy, which can be applied for splenic cysts as well. In this video, a 3-trocar laparoscopic decapsulation of a giant nonparasitic splenic cyst is reported.

Case Report: A 16-year-old man, without history of trauma or abdominal surgery, suddenly presented abdominal pain in the left hypochondrium, associated to fever and hyperleukocytosis. A thoracoabdominal computed tomography scan showed a giant cyst of the upper pole of the spleen; serum tumor markers carcinoembryonic antigen and carbohydrate antigen 19-9 were negatives. Any preoperative vaccine was prescribed.

Results: Operative time was 130 minutes, and operative bleeding 10 mL. No additional trocar or conversion to laparotomy was necessary. Postoperatively, 4 g of paracetamol were used for 2 days, when the patient was discharged. Pathology confirmed the nonparasitic epidermoid splenic cyst. At 18 months, the patient is fine, without symptoms and without disease's recurrence.

Conclusions: Decapsulation of a giant nonparasitic splenic cyst is feasible to be performed by 3-trocar laparoscopy. This technique allows to improve the patient's comfort and the cosmetic results, to reduce the postoperative pain and to finally avoid a preoperative vaccine.
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http://dx.doi.org/10.1097/SLE.0000000000000958DOI Listing
June 2021

Eight different types of laparoscopic intracorporeal anastomosis during suprapubic single-incision right hemicolectomy - a video vignette.

Colorectal Dis 2021 Jul 12;23(7):1942-1944. Epub 2021 May 12.

Humanitas Research Hospital and University, Milan, Italy.

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http://dx.doi.org/10.1111/codi.15677DOI Listing
July 2021

Laparoscopic Management of Blunt and Penetrating Abdominal Trauma: A Single-Center Experience and Review of the Literature.

J Laparoendosc Adv Surg Tech A 2021 Jan 11. Epub 2021 Jan 11.

Department of Gastrointestinal Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium.

Trauma is a leading cause of death in young patients. The prevalence of blunt and penetrating trauma varies widely across the globe. Similarly, the global experience with laparoscopy in trauma patients also varies. There is a growing body of evidence to suggest that laparoscopy is feasible in trauma patients. We sought to contribute to these data by reporting our experience with laparoscopic management of blunt and penetrating trauma in a Belgian center. We retrospectively collected data on all trauma patients admitted to the Saint-Pierre University Hospital in Brussels, Belgium, over the 4-year period from January 2014 to December 2017. Hospital records for patients subjected to exploratory laparoscopy were retrospectively reviewed, and a descriptive analysis was reported. There were 26 patients at a mean age of 40 years treated with laparoscopic exploration for injuries from blunt trauma (7), stab wounds (14), and gunshot injuries (5). The median interval between the arrival at the emergency unit and diagnostic laparoscopy was 175 minutes (range: 27-1440), and the median duration of operation was 119 minutes (range: 8-300). In all patients who underwent laparoscopy for trauma, there were 27% overall morbidity, no mortality, 11% reoperation rate, 7.4% conversions, and 19% incidence of negative laparoscopy. The median intensive care unit stay was 3 days (range: 0-41), and median total hospital stay was 7 days (range: 2-78). Laparoscopy is a safe, feasible, and effective tool in the surgical armamentarium to treat hemodynamically stable patients with blunt and penetrating abdominal trauma. It allows complete and thorough evaluation of intra-abdominal viscera, reduces the incidence of nontherapeutic operations, and allows therapeutic intervention to repair a variety of injuries. However, it requires appropriate surgeon training and experience with advanced laparoscopic techniques to ensure good outcomes.
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http://dx.doi.org/10.1089/lap.2020.0552DOI Listing
January 2021

Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars.

Cureus 2020 Sep 30;12(9):e10742. Epub 2020 Sep 30.

Surgery, Medical Associates Hospital, St. Joseph, TTO.

Introduction As single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit. Methods This was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae. Results There were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected. Conclusion Even in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.
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http://dx.doi.org/10.7759/cureus.10742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599059PMC
September 2020

Laparoscopic repair of chronic staple line fistula with Roux-en-Y anastomosis that preserves the sleeve gastrectomy.

Authors:
Giovanni Dapri

Surg Obes Relat Dis 2020 Oct 8;16(10):1619-1620. Epub 2020 Jul 8.

International School Reduced Scar Laparoscopy, Brussels, Belgium; Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium. Electronic address:

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http://dx.doi.org/10.1016/j.soard.2020.06.037DOI Listing
October 2020

Changes of Laryngeal and Extralaryngeal Symptoms and Findings in Laryngopharyngeal Reflux Patients.

Laryngoscope 2021 06 5;131(6):1332-1342. Epub 2020 Aug 5.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), Paris, France.

Objectives/hypothesis: To assess the evolution of laryngeal and extralaryngeal symptoms and findings of laryngopharyngeal reflux (LPR) throughout a 3-month to 9-month treatment.

Study Design: Prospective Controlled Study.

Methods: One hundred twenty-seven LPR patients and 123 healthy individuals were enrolled from four European hospitals. Patients were managed with a 3-month personalized treatment considering the LPR characteristics at the impedance-pH monitoring. Regarding the clinical therapeutic response, treatment was adapted for 3 to 6 additional months. Symptoms and findings were assessed throughout the therapeutic course with the Reflux Symptom Score (RSS) and the short version of the Reflux Sign Assessment (sRSA). The relationship between patient and reflux characteristics, symptoms, and findings was assessed.

Results: One hundred twenty-one LPR patients completed the study. LPR patients exhibited more laryngeal and extralaryngeal symptoms and findings than healthy individuals. RSS significantly improved from baseline to 6 weeks posttreatment and continued to improve from 3 months to 6 months posttreatment. sRSA significantly improved from baseline to 3 months posttreatment. No further improvement was noted at 6 months posttreatment for pharyngeal and oral findings. Laryngeal findings continued to improve from 3 months to 6 months posttreatment. There was a significant association between patient stress level and RSS (P = .045). At 3 months posttreatment, 28.1% of patients had high or complete response, whereas 47.1% required 6 months or 9 months of treatment. Overall, 24.8% of patients had an LPR chronic course.

Conclusions: Laryngeal and extralaryngeal symptoms and findings significantly improved throughout treatment in LPR patients. The improvement of laryngeal findings was slower. Regarding the low prevalence of some digestive or otolaryngological symptoms, a short version of the RSS could be developed.

Level Of Evidence: 3 Laryngoscope, 131:1332-1342, 2021.
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http://dx.doi.org/10.1002/lary.28962DOI Listing
June 2021

Laparoscopic wedge resection of the proximal sleeve and handsewn esophago-sleeve anastomosis for repair of complicated staple line leak.

Authors:
Giovanni Dapri

Surg Obes Relat Dis 2020 Oct 27;16(10):1621-1622. Epub 2020 Jun 27.

International School Reduced Scar Laparoscopy, Brussels, Belgium; Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium. Electronic address:

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http://dx.doi.org/10.1016/j.soard.2020.06.030DOI Listing
October 2020

Bouveret's syndrome as a rare complication of cholelithiasis: Disputes in current management and report of two cases.

Int J Surg Case Rep 2020 25;71:315-318. Epub 2020 May 25.

General Surgery Department, San Salvatore Hospital, Paternò, Catania, Italy.

Introduction: Bouveret's syndrome is a rare complication of cholelithiasis that determines an unusual type of gallstone ileus, secondary to an acquired fistula between the gallbladder and either the duodenum or stomach with impaction of a large gallbladder stone. Preoperative diagnosis is difficult because of its rarity and the absence of typical symptoms. Adequate treatment consists of endoscopic or surgical removal of obstructive stone.

Presentation Of Cases: Two old females patients were admitted to the Emergency Department with a history of abdominal pain associated with bilious vomiting. Physical examination revealed abdominal distension with tympanic percussion of the upper quadrants, abdominal pain on deep palpation of all quadrants and in the first patient positive Murphy's sign. Preoperative diagnosis of gallstone impacted in the duodenum was obtained by abdominal computed tomography (CT) scan in the first patient and by esophagogastroduodenoscopy in the second one. Both patients underwent surgery with extraction of the gallstone from the stomach. Postoperative course of two patients was uneventful and they were discharged home.

Discussion: Bouveret's syndrome usually presents with signs and symptoms of gastric outlet obstruction. Preoperative radiological investigations not always are useful for its diagnosis. Appropriate treatment, endoscopic or surgical, is debated and must be tailored to each patient considering medical condition, age and comorbidities.

Conclusion: Bouveret's syndrome is a very rare complication of cholelithiasis, difficult to diagnose and suspect, because of lack of pathognomonic symptoms. Nowaday there are no guidelines for the correct management of this pathology. Endoscopic or surgical removal of obstructive stone represents the correct treatment.
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http://dx.doi.org/10.1016/j.ijscr.2020.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264957PMC
May 2020

Hypopharyngeal-Esophageal Impedance-pH Monitoring Profiles of Laryngopharyngeal Reflux Patients.

Laryngoscope 2021 02 21;131(2):268-276. Epub 2020 May 21.

Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the International Federation of Otorhinolaryngological Societies, Paris, France.

Objectives/hypothesis: To investigate the profile of patients with laryngopharyngeal reflux (LPR) at hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring and the relationship between hypopharyngeal-proximal reflux episodes (HREs) and saliva pepsin concentration.

Study Design: Prospective non-controlled.

Methods: Patients were recruited from three European hospitals from January 2018 to October 2019. Patients benefited from HEMII-pH monitoring and saliva collections to measure saliva pepsin concentration in the same time. Saliva pepsin concentration was measured in the morning (fasting), after lunch, and after dinner. The LPR profile of patients was studied through a breakdown of the HEMII-pH findings over the 24 hours of testing. The relationship between the concentrations of saliva pepsin and 24-hour HREs was studied through linear multiple regression.

Results: One hundred twenty-six patients completed the study. The HEMII-pH analyses revealed that 73.99% of HREs occurred outside 1-hour postmeal times, whereas 20.49% and 5.52% of HREs occurred during the 1-hour postmeal and nighttime, respectively. Seventy-four patients (58.73%) did not have nighttime HREs. Patients with both daytime and nighttime HREs had more severe HEMII-pH parameters and reflux symptom score compared with patients with only daytime HREs. There were no significant associations between HREs and saliva pepsin concentration.

Conclusions: Unlike gastroesophageal reflux disease, HREs occur less frequently after meals and nighttime. The analysis of the HEMII-pH profile of the LPR patients has to be considered to develop future personalized therapeutic strategies.

Level Of Evidence: 4 Laryngoscope, 131:268-276, 2021.
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http://dx.doi.org/10.1002/lary.28736DOI Listing
February 2021

Transanal Minimally Invasive Surgery: A Multi-Purpose Operation.

Authors:
Giovanni Dapri

Surg Technol Int 2020 May;36:51-61

nternational School Reduced Scar Laparoscopy, Brussels, Belgium.

Background: Minimally Invasive Colorectal Surgery (MICS) is continually evolving. The recognition of the anus as a natural orifice to perform MICS has contributed to the development of a new philosophy of treatment called TransAnal Minimally Invasive Surgery (TAMIS). Transanal total mesorectal excision (TaTME) is one of the most common forms of TAMIS. Other indications include benign diseases and early malignant rectal adenocarcinoma. This report presents the author's experience with TAMIS as a multi-purpose operation.

Patients And Methods: Between January 2015 and May 2019, 36 patients underwent TAMIS for benign and early malignant diseases (group 1) and 30 patients underwent TaTME (group 2). The mean ± SD age was 60.2 ± 13.9 years (range 28-84) (group 1) and 63.7 ± 8.6 years (47-87) (group 2). The mean ± SD BMI was 26.7 ± 5.2 kg/m2 (19.3-42.9) (group 1) and 25.7 ± 5.9 kg/m2 (17.3-50.7) (group 2). The conditions in group 1 consisted of anastomotic leakage (n=20), benign rectal stenosis (2), anastomotic exploration with lavage and drainage (2), salvage of abdominal dissection (1), rectal ulcus (1), rectal intussusception (1), and removal of early malignant rectal polyps (9). The conditions in group 2 consisted of TaTME associated with single-incision abdominal laparoscopy (19) and conventional abdominal laparoscopy (11).

Results: In group 1, the mean operative time was 38.2 ± 19.2 min (range 20-89) for immediate anastomotic leak repair, 90.2 ± 30.4 min (41-120) for early leak repair, 85 ± 67.4 min (30-180) for late leak repair, 45-163 min for rectal stenosis, 25-30 min for pelvic lavage and drainage, 180 min for difficult pelvic dissection, 57 min for rectal ulcus, 127 min for rectal intussusception, and 84.3 ± 28.0 min (50-131) for early malignant rectal polyps. In group 2, the mean operative time was 197.1 ± 63.3 min (96-399). The mean operative bleeding was 14.3 ± 24.7 ml (0-100) in group 1 and 57.0 ± 102.5 ml (0-450) in group 2. In group 1, the mean hospital stay was 11.6 ± 7.2 days (5-27) for immediate leak, 20.7 ± 14.7 days (6-42) for early leak, 2.6 ± 1.6 days (1-5) for late leak, 2-5 days for rectal stenosis, 4-7 days for pelvic lavage and drainage, 17 days for difficult pelvic dissection, 2 days for rectal ulcus, 1 day for rectal intussusception, and 1.3 ± 0.4 days (1-2) for early malignant rectal polyps. In group 2, the mean hospital stay was 11.4 ± 10.0 days (3-49). The early complication rate was 27.7% in group 1 and 40% in group 2. The late complication rate was 8.3% in group 1 and 10% in group 2.

Conclusions: TAMIS is an innovative technique that may be considered for the treatment of benign diseases like anastomotic complications, benign rectal stenosis, anastomotic explorations with lavage and drainage, rectal ulcus, and rectal intussusception. It can be used to search for a good plane of dissection, which cannot be found through the abdominal anterior approach. It can also be adopted for removal of early malignant rectal polyps and for TaTME. The technique described here allows the surgeons to work under ergonomic conditions, with completely reusable materials, and with a magnified view of the operative field, allowing intraluminal surgical sutures.
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May 2020

10-Year Experience with 1700 Single-Incision Laparoscopies.

Authors:
Giovanni Dapri

Surg Technol Int 2019 11;35:71-83

University of Brussels, Head, Digestive Clinic, American College of Surgeons Belgian Chapter, Saint-Pierre University Hospital, Brussels, Belgium.

Background: Single-incision laparoscopy (SIL) was initially reported in the mid-1900's, but remained unpopular until the arrival of Natural Orifice Transluminal Endoscopic Surgery. It was described not only for surgery involving the digestive system, but also for breast, thoracic, urologic, gynecologic and pediatric surgery. Various studies have proven its feasibility, safety and effectiveness. This report describes the 10-year experience with SIL of a single surgeon at a single institution.

Patients And Methods: From May 2009 to May 2019, 1700 abdominal SILs were performed, including: cholecystectomy (475), inguinal hernia repair (319), incisional/ventral hernia repair (293), appendectomy (226), colorectal surgery (158), fundoplication/diaphragmatic hernia repair (72), gastric surgery (54), diagnostic laparoscopy (42), liver surgery (18), small bowel resection (15), splenectomy (12), adrenalectomy (6), gynecologic surgery (6), pancreatic surgery (2), and urologic surgery (2). Three types of incision/access-site were adopted. Inclusion and exclusion criteria were considered. The following outcomes were evaluated: laparoscopic operative time, operative bleeding, supplementary scars or trocars for improved exposure of the operative field and/or control of perioperative complications, final incision length, hospital stay, postoperative pain during hospitalization and after discharge, early and late access-site complications and other early and late general complications.

Results: While there were no conversions to open surgery or conventional laparoscopy, a supplementary millimetric instrument or a 5-mm trocar was needed in 27.8% and 0.5% of cases, respectively. No operative or postoperative mortalities were registered. The mean final incision length was between 13.1 and 21.0 mm at the umbilicus, between 43.3 and 57.2 mm suprapubically, and between 21.4 and 36.3 mm in another abdominal quadrant. Postoperative pain decreased from the first hours until the end of hospitalization. The percentage of patients who required an analgesic drug for more than 5 days after discharge ranged between 0 and 16.6%. The early access-site complication rate was 7.5%, and the access-site incisional hernia rate was 1.3%. The other early general complication rate was 10.7%, and reoperation was required in 1.4%. The other late general complication rate was 0.7%, and reoperation was required in 0.5%.

Conclusion: SIL is a laparoscopic technique that can safely be offered to patients presenting abdominal diseases. The main advantages include enhanced cosmetic results and reduced abdominal trauma. The main disadvantages are patient selection, a longer operative time for some procedures, and a need to expose the operative field for some other procedures.
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November 2019

Laparoscopic left colectomy: modern technique based on key anatomical landmarks reported by giants of the past.

Minim Invasive Ther Allied Technol 2021 02 16;30(1):1-11. Epub 2019 Sep 16.

Scientific Director, Policlinico Abano, Padua, Italy.

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http://dx.doi.org/10.1080/13645706.2019.1665072DOI Listing
February 2021

Development of scores assessing the refluxogenic potential of diet of patients with laryngopharyngeal reflux.

Eur Arch Otorhinolaryngol 2019 Dec 12;276(12):3389-3404. Epub 2019 Sep 12.

Laryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), Paris, France.

Objective: To develop clinical tools assessing the refluxogenic potential of foods and beverages (F&B) consumed by patients with laryngopharyngeal reflux (LPR).

Methods: European experts of the LPR Study group of the Young-Otolaryngologists of the International Federation of Oto-rhino-laryngological societies were invited to identify the components of Western European F&B that would be associated with the development of LPR. Based on the list generated by experts, four authors conducted a systematic review to identify the F&B involved in the development of esophageal sphincter and motility dysfunctions, both mechanisms involved in the development of gastroesophageal reflux disease and LPR. Regarding the F&B components and the characteristics identified as important in the development of reflux, experts developed three rational scores for the assessment of the refluxogenic potential of F&B, a dish, or the overall diet of the patient.

Results: Twenty-six European experts participated to the study and identified the following components of F&B as important in the development of LPR: pH; lipid, carbohydrate, protein composition; fiber composition of vegetables; alcohol degree; caffeine/theine composition; and high osmolality of beverage. A total of 72 relevant studies have contributed to identifying the Western European F&B that are highly susceptible to be involved in the development of reflux. The F&B characteristics were considered for developing a Refluxogenic Diet Score (REDS), allowing a categorization of F&B into five categories ranging from 1 (low refluxogenic F&B) to 5 (high refluxogenic F&B). From REDS, experts developed the Refluxogenic Score of a Dish (RESDI) and the Global Refluxogenic Diet Score (GRES), which allow the assessment of the refluxogenic potential of dish and the overall diet of the LPR patient, respectively.

Conclusion: REDS, RESDI and GRES are proposed as objective scores for assessing the refluxogenic potential of F&B composing a dish or the overall diet of LPR patients. Future studies are needed to study the correlation between these scores and the development of LPR according to impedance-pH study.
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http://dx.doi.org/10.1007/s00405-019-05631-1DOI Listing
December 2019

Tubulo-villous adenoma of the appendix: A case report and review of the literature.

Int J Surg Case Rep 2019 16;61:60-63. Epub 2019 Jul 16.

General Surgery Department, San Salvatore Hospital, Paternò, Catania, Italy.

Introduction: Tubulo-villous adenoma is a rare benign appendiceal neoplasm often asymptomatic with the most clinical manifestation that resembles acute appendicitis. Pre-operative diagnosis is difficult by its rarity and the absence of typical symptoms. Adequate treatment is surgical resection.

Presentation Of Case: A 69-year-old male was admitted to the Emergency Department with a two-day history of abdominal pain associated with constipation. Abdominal examination revealed abdominal pain localized, at deep palpation, in the right iliac fossa and in hypogastrium without obvious muscle guarding or rebound tenderness. Laboratory tests showed a normal white blood cell count with 82.3% neutrophils and high C-reactive protein level. After a negative abdominal ecography, the patient was evaluated by abdominal computed tomography, which revealed acute appendicitis. The patient was submitted to surgery and open appendectomy was performed. The post-operative course was uneventful and the patient was discharged on the 5 post-operative day.

Discussion: Acute appendicitis may be a clinical manifestation of a benign appendiceal neoplasm. Pre-operative radiological investigations not always are useful for an early diagnosis that is mandatory because of the potential risk of malignant degeneration. Appropriate treatment of acute appendicitis is debated: some surgeons suggest operative treatment, but others advocate for non-operative management. In our case the patient was submitted to surgery avoiding the risk of diagnostic delay of neoplasm.

Conclusion: Appendiceal tubulo-villous adenoma is a rare neoplasm difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. Acute appendicitis is the most common clinical presentation. Appendectomy is the appropriate treatment.
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http://dx.doi.org/10.1016/j.ijscr.2019.06.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658925PMC
July 2019

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review.

Clin Otolaryngol 2019 09 31;44(5):784-800. Epub 2019 Jul 31.

Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.

Objective: To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients-those who do not respond to anti-reflux medical treatment.

Methods: A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated.

Results: Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non-acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy.

Conclusion: To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients.

Level Of Evidence: 2a.
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http://dx.doi.org/10.1111/coa.13395DOI Listing
September 2019

Single incision laparoscopic surgery from a caribbean perspective.

Int J Surg 2019 Dec 24;72S:13-18. Epub 2019 May 24.

Department of Surgery, Saint Pierre University Hospital, Brussels, Belgium.

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.
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http://dx.doi.org/10.1016/j.ijsu.2019.05.009DOI Listing
December 2019

Surgical Treatment for Laryngopharyngeal Reflux Disease: A Systematic Review.

JAMA Otolaryngol Head Neck Surg 2019 07;145(7):655-666

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Laryngopharyngeal reflux (LPR) is a prevalent disease that is usually treated with diet, lifestyle modifications, and proton pump inhibitor therapy. However, nearly 10% to 30% of patients do not achieve adequate acid suppression even with high doses of proton pump inhibitors. For these patients with resistant disease, fundoplication may be recommended but the success rate of fundoplication surgery on laryngopharyngeal symptoms and findings remains uncertain.

Objective: To determine whether fundoplication is associated with control of signs and symptoms in patients with LPR.

Evidence Review: A literature search was conducted on PubMed, Cochrane Library, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline to identify studies published between 1990 and 2018 about the efficacy of fundoplication on clinical outcomes of LPR. Three investigators screened publications for eligibility and exclusion based on predetermined criteria. Study design, patient characteristics, diagnostic method, exclusion criteria, treatment characteristics, follow-up, and quality of the outcome assessment were evaluated.

Findings: Of the 266 studies identified, 34 met the inclusion criteria, accounting for 2190 patients with LPR (1270 women and 920 men; mean [SD] age at the time of surgery, 49.3 [6.3] years). A weighted mean of 83.0% of patients (95% CI, 79.7%-86.3%) experienced improvement and a weighted mean of 67.0% of patients (95% CI, 64.1%-69.9%) experienced a disappearance of symptoms, but there is a high level of methodological heterogeneity among studies according to diagnostic method, exclusion criteria, and outcomes used to assess the efficacy of fundoplication. A pH study without impedance study was used in most studies but with various inclusion criteria. According to results of an a priori assessment, the clinical outcomes used were overall poor, excluding many symptoms and findings associated with LPR.

Conclusion And Relevance: The reported studies of fundoplication in LPR disease have important heterogeneity in method of diagnosis, exclusion criteria, symptoms, and signs assessed as therapeutic outcomes; therefore, this systematic review was nonconclusive regarding whether surgery for LPR disease is associated with effective control of sight and symptoms. Otolaryngologists, gastroenterologists, and surgeons must establish a diagnostic criterion standard, clear indications for surgery, and future clinical outcomes to precisely assess the effectiveness of treatment.
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http://dx.doi.org/10.1001/jamaoto.2019.0315DOI Listing
July 2019

Validity and reliability of the reflux symptom score.

Laryngoscope 2020 03 14;130(3):E98-E107. Epub 2019 Apr 14.

Research Committee of the Young Otolaryngologists of the International Federation of Oto-Rhino-Laryngological Societies (YO-IFOS), Marseille, France.

Objectives/hypothesis: To develop and validate the Reflux Symptom Score (RSS), a self-administered patient-reported outcome questionnaire for patients with laryngopharyngeal reflux (LPR).

Study Design: Prospective controlled study.

Methods: A total of 113 patients with LPR were enrolled and treated with diet and 3 months of pantoprazole, alginate, and/or magaldrate depending on the LPR characteristics (acid, nonacid, or mixed). Eighty asymptomatic individuals completed the study. Patients and controls completed the RSS twice within a 7-day period to assess test-retest reliability. Internal consistency was measured using Cronbach's α for the RSS items in patients and controls. Validity was assessed by comparing the baseline RSS with the Reflux Symptom Index (RSI) and Voice Handicap Index (VHI). Seventy-seven patients completed the RSS at baseline and after 6 and 12 weeks of treatment to assess responsiveness to change. The RSS cutoff for determining the presence and absence of LPR was examined by receiver operating characteristic analysis.

Results: Test-retest reliability (r = 0.921) and internal consistency reliability (α = 0.969) were high. RSS exhibited high external validity indicated by a significant correlation with the RSI (r = 0.831). Internal validity was excellent based on the higher RSS in patients compared with controls (P = .001). RSS, RSI, and VHI scores significantly improved from pre- to posttreatment, indicating a high responsiveness to change. RSS >13 can be considered suggestive of LPR-related symptoms. RSS was not influenced by the occurrence of gastroesophageal reflux disease, LPR subtypes, or patient characteristics.

Conclusions: RSS is a self-administered patient-reported outcome questionnaire that demonstrates high reliability and excellent criterion-based validity. RSS can be used in diagnosing and monitoring LPR disease.

Level Of Evidence: 3b Laryngoscope, 130:E98-E107, 2020.
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http://dx.doi.org/10.1002/lary.28017DOI Listing
March 2020

Three trocars laparoscopic right ileocolectomy for advanced small bowel neuroendocrine tumor.

Surg Oncol 2019 Mar 14;28:76-77. Epub 2018 Nov 14.

Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.

Background: In the last decade Reduced Port Laparoscopy (RPL) has been introduced to reduce the risks related to the trocars and abdominal wall trauma, with enhanced cosmetic outcomes. The authors report a 59 year old man with a small bowel neuroendocrine tumor, submitted to three trocars right ileocolectomy.

Video: Preoperative work-up, including endoscopic ultrasound, octreo-PET-CT and FDG PET-CT, showed a 15 mm small bowel low grade well differentiated neuroendocrine tumor with mesenteric and transverse mesocolic extension, until the muscularis propria of the 3rd duodenum. The procedure was performed using three trocars: 12-mm in the umbilicus, 5-mm in the right and left flanks. After mobilization of the right colon, the 2nd and 3rd duodenal segments were exposed, showing tumor extension to the anterior duodenal wall. After encircling the anterior aspect of the duodenal wall with a piece of cotton tape, a linear stapler was inserted through the umbilical trocar under a 5-mm scope in the left flank, and it was fired. The specimen was removed through a suprapubic access. Frozen section biopsy showed free duodenal margin, hence the procedure was finished with handsewn intracorporeal ileocolic anastomosis.

Results: Operative time was 4 hours. No added trocars were necessary. Patient was discharged on 4th day. Pathology showed a grade I, well differentiated small bowel neuroendocrine tumor, with lymphovascular emboli and perinervous infiltration; 1/20 metastatic nodes, free margins; stage (8 UICC edition): pT3N1. At 12 months of follow-up the patient is free of disease.

Conclusions: RPL offers all MIS advantages, including reduced trocar complications and enhanced cosmetic outcomes.
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http://dx.doi.org/10.1016/j.suronc.2018.11.011DOI Listing
March 2019

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

Surg Endosc 2019 04 15;33(4):996-1019. Epub 2019 Feb 15.

SJOG Hospital - PMU Teaching Hospital, Salzburg, Austria.

Background: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

Methods: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

Results: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

Conclusions: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.
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http://dx.doi.org/10.1007/s00464-019-06693-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430755PMC
April 2019

Fluorescence of Deep Infiltrating Endometriosis During Laparoscopic Surgery: A Preliminary Report on 6 Cases.

Surg Innov 2018 Oct 12;25(5):450-454. Epub 2018 Jul 12.

1 St Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium.

Background: The standard treatment of rectovaginal deep infiltrating endometriosis nodules (RVDIEN) consists in their surgical removal. RVDIEN are anatomically neovascularized. Indocyanine green (ICG) reveals vascularized structures when becoming fluorescent after exposure to near-infrared (NIR) light. This study aims to evaluate if fluorescence-guided surgery can improve the laparoscopic resection of RVDIEN, thus avoiding a rectal perforation.

Materials And Methods: Patients with a symptomatic RVDIEN, scheduled for a laparoscopic rectal shaving, were enrolled in the study. Technically, the RVDIEN was targeted and removed with the help of the NIR imager device Image 1 Spies (Karl Storz GmBH & Co KG, Tuttlingen, Germany) or Visera Elite II (Olympus Europe SE & Co KG, Hamburg, Germany), after an intraoperative, intravenous injection of ICG (0.25 mg/kg).

Results: Six patients underwent a fluorescence-guided laparoscopic shaving procedure for the treatment of a nonobstructive RVDIEN. Fluorescence of the RVDIEN was observed in all the patients. In one patient, once the main lesion was removed, the posterior vaginal fornix still appeared fluorescent and was removed. No intraoperative rectal perforation occurred. The postoperative hospital stay was 2 days. No postoperative rectovaginal fistula occurred within a median follow-up of 16 months (range = 2-23 months).

Conclusion: In this preliminary study, fluorescence-guided laparoscopy appeared to help in separating the RVDIEN from the healthy rectal tissue, without rectal perforation. Moreover, this technique was helpful in deciding if the resection needed to be enlarged to the posterior vaginal fornix.
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http://dx.doi.org/10.1177/1553350618785486DOI Listing
October 2018

Total Pharyngo-esophageal Stenosis: A New Surgical Procedure Using Modified Retrograde Transillumination Approach.

Surg Laparosc Endosc Percutan Tech 2018 Aug;28(4):e75-e77

Laboratory of Anatomy and Cell Biology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons.

We performed a modified combined anterograde-retrograde dilatation in a 60-year-old woman with complete pharyngo-esophageal stricture (PES). With a large endoscopic view from the upper (laryngoscope) and lower (pediatric gastroscope introduced via gastrostomy tube) parts of the PES, the approach consisted of a retrograde puncture of the complete PES by transillumination to take the guide coming from the pediatric endoscope. The guide was pulled through the mouth and the PES dilatation was made using successive boogies of various diameters through the guide. Finally, a salivary bypass was placed to maintain the diameter of the pharyngo-esophageal way. The surgical approach was performed in 25 minutes without short, medium, and long-term complications. The patient started oral alimentation the day after the surgery, and the salivary bypass was removed after 6 months. The subject had no recurrence of the PES at 5 years.
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http://dx.doi.org/10.1097/SLE.0000000000000540DOI Listing
August 2018

Three-trocar laparoscopic duodenal switch after sleeve gastrectomy.

Surg Obes Relat Dis 2018 06 10;14(6):869-873. Epub 2018 Mar 10.

Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Hôpital du Sacre Coeur, Montreal, Quebec, Canada.

Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG. The procedure is performed using a 12-mm trocar in the umbilicus, a 5-mm trocar in the right flank, and a 5-mm trocar in the left flank. One or more temporary percutaneous sutures are passed into the hepatic ligaments to increase the exposure of the first duodenum. The optical system is switched from 10 mm to 5 mm and introduced in the left 5-mm flank trocar at the step of the linear stapler insertion through the umbilical trocar. Classic construction with 150-cm alimentary limb and 100-cm common limb is performed. The duodeno-jejunostomy is fashioned in an end-to-side handsewn technique and the jejuno-ileostomy in the side-to-side semimechanical linear stapler technique. Both Petersen and mesenteric defects are closed. The umbilical access is finally meticulously closed, avoiding incisional hernia. Reduced port laparoscopic duodenal switch after LSG is a safe and feasible technique. Besides the enhanced cosmetic outcomes, this surgery is associated with a reduced use of painkillers, fewer trocar complications, and quick patient convalescence.
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http://dx.doi.org/10.1016/j.soard.2018.03.011DOI Listing
June 2018

Prospective randomized study comparing single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal (TEP) inguinal hernia repair at 2 years.

Surg Endosc 2018 07 23;32(7):3262-3272. Epub 2018 Jan 23.

Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, 322, Rue Haute, Brussels, Belgium.

Background: Inguinal hernia repair via multi-trocar laparoscopy (MTL) has gained an increasing popularity worldwide. Single-incision laparoscopy (SIL) has been introduced to reduce the port-related complications and to improve the cosmetic results. The authors report a prospective randomized study comparing SIL versus MTL totally extraperitoneal (TEP) inguinal hernia repair.

Methods: Between January 2013 and May 2015, 113 versus 97 patients were prospectively randomized between SILTEP and MTLTEP. Perioperative, short-term, and mid-term outcomes have been assessed. The primary endpoint was the mid-term outcomes (late postoperative complications, late inguinal hernia recurrence, surgical and cosmetic satisfactions). Secondary endpoints were perioperative outcomes (operative time, mesh fixation, operative complications, postoperative pain, and hospital stay) and short-term outcomes (early postoperative complications, early inguinal hernia recurrence, and days to return to normal activities).

Results: After a mean follow-up of 27 ± 8 months, a statistically significant difference was found between the two groups in terms of mean operative time for both unilateral and bilateral inguinal hernia repair (p = 0.016; p = 0.039) and cosmetic satisfaction (p = 0.003).

Conclusion: Perioperative, short-term, and mid-term outcomes were comparable between the two groups. At 2-year follow-up, a significant shorter operative time after MTLTEP and a greater cosmetic satisfaction after SILTEP have been found.
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http://dx.doi.org/10.1007/s00464-018-6045-zDOI Listing
July 2018

Transanal Minimally Invasive Anal Canal Polyp Resection.

Surg Laparosc Endosc Percutan Tech 2018 Apr;28(2):e59-e61

Department of Gastroenterology and Endoscopy, Saint-Pierre University Hospital, Brussels.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are operative endoscopies that have been performed since a long time. Recently, an evolution of laparoscopy called transanal minimally invasive surgery began to be popularized, and it can be adopted in the face of difficult cases for EMR/ESD. In this video, a 36-year-old woman was submitted to transanal minimally invasive surgery resection, after unsuccessful ESD, for a 2-cm polyp located anteriorly in the anal canal, just beyond the pectineal line. Preoperative workup showed a uT1m versus T1sm N0 M0 lesion. The procedure was performed with a new reusable transanal platform and a monocurved coagulating hook and grasping forceps. The operative time was 90 minutes. No perioperative complications were registered, and the patient was discharged on postoperative day 1. The pathologic report showed a villotubular adenoma with high-grade dysplasia and distant-free margins. After 1 year, the patient was going well, without any recurrent disease. Transanal minimally invasive surgery resection is a good alternative to conventional endoscopic therapies, allowing a meticulous dissection under the magnified operative field's exposure, and a mucosal-submucosal flap closure under satisfactory surgeon's ergonomics.
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http://dx.doi.org/10.1097/SLE.0000000000000503DOI Listing
April 2018

Transanal TME - really needed?

Authors:
Giovanni Dapri

Innov Surg Sci 2018 Mar 28;3(1):31-38. Epub 2017 Dec 28.

Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium.

In the last decade, thanks to natural orifice translumenal endoscopic surgery, the application of laparoscopy through the anus has gained interest from both research and clinical point of views. Therefore, an increased number of transanal procedures have been reported, from the resection of a large rectal polyp to total mesorectal excision, and for controlling perioperative complications like leak, bleeding, and stenosis. Currently, the most popular surgical trend remains transanal total mesorectal excision. In this article, the technique, advantages, and disadvantages are discussed.
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http://dx.doi.org/10.1515/iss-2017-0044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754050PMC
March 2018

Transanal minimally invasive full-thickness anterior middle rectum polyp resection - video vignette.

Colorectal Dis 2017 Dec 4. Epub 2017 Dec 4.

Department of Surgery, Khoo Teck Puat University Hospital, Singapore.

Rectal preservation is gaining popularity in the surgical treatment of degenerated rectal polyps or early rectal cancer (1,2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment by transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report a 60 year-old woman who underwent TAMIS for a large polyp located anteriorly in the middle 1/3 of the rectum, 7 cm from the dentate line and staged preoperatively as uTisN0M0. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/codi.13981DOI Listing
December 2017

Exploring the umbilical and vaginal port during minimally invasive surgery.

J Turk Ger Gynecol Assoc 2017 09;18(3):143-147

Department of Obstetrics, Gynecology and Reproductive Medicine, State University of New York at Stony Brook School of Medicine, Stony Brook, NY; Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY, USA

This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results.
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http://dx.doi.org/10.4274/jtgga.2017.0046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590211PMC
September 2017
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