Gastroenteroanastomosis using NOTES-technologies — results of an experimental study

Introduction. Transluminal endoscopic surgery performed through natural orifices can reduce the incidence of complications associated with the surgical procedure and the incidence of postoperative complications. The purpose of this study was to determine the feasibility of performing an experimental gastroenteroanastomosis in a live pig model using NOTES. Materials and methods. The experimental study was performed on living laboratory models pigs weighing from 25 to 30 kg. The studys preliminary phase allowed working out the technique using two animals removed from the experiment after its successful completion. The final phase included the implementation of gastrojejunoanastomosis in six animals with subsequent observation. In three animals, the procedure was performed with laparoscopic assistance using a single-channel video gastroscope. In the other three animals, it was performed without laparoscopy using a two-channel video gastroscope. Antibiotic therapy continued for seven days after surgery. The surviving animals were removed from the experiment after four weeks. Patency of the anastomosis was confirmed by repeated endoscopy and histological analysis of tissues. Results. All procedures were completed successfully in six animals (three males and three females). The formation of anastomosis required an average of 133.3 43.8 minutes (range, 80200 minutes). In one animal, bleeding during gastric wall incision was recorded and was stopped by electrocoagulation. One animal died because of an anastomotic leak and peritonitis, confirmed by autopsy. In the five surviving animals, repeated endoscopy demonstrated fully passable anastomoses covered by the mucosa. Conclusion. Gastrojejunal anastomosis using NOTES technology is technically possible but requires additional study.

Efficacy and safety of gastric exposed endoscopic full-thickness resection without laparoscopic assistance: a systematic review

Background and study aims Exposed endoscopic full-thickness resection (Eo-EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery (NOTES) technique that has shown promising efficacy and safety in resection of gastric submucosal tumors (G-SMTs) arising from muscularis propria (MP). However, data on the efficacy and safety of gastric Eo-EFTR mostly come from relatively small retrospective studies and concern regarding its use still exists. The aim of our systematic review was to assess the efficacy and safety of gastric Eo-EFTR without laparoscopic assistance. Methods A detailed MEDLINE and EMBASE search was performed for papers published from January 1998 to November 2019 and reporting on gastric Eo-EFTR without laparoscopic assistance. The search strategy used the terms “endoscopic full thickness resection” and “gastric” or “stomach”. The primary outcomes were complete resection and surgical conversion rates. The secondary outcomes were overall major adverse events, delayed bleeding, delayed perforation, peritonitis, abdominal abscess and/or abdominal infection and successful Eo-EFTR. Results Fifteen Asian studies were included in our final review, providing data on 750 Eo-EFTR-treated G-SMTs. The per-lesion rate of complete resection and surgical conversion were 98.8 %\0.8 %, respectively. The per-lesion rate of major adverse events, delayed bleeding, delayed perforation and peritonitis, abdominal abscess and/or abdominal infection was 1.6 %\0.5 %\0.1 %\0.9 %, respectively. The per-lesion rate of successful Eo-EFTR (i. e. complete tumor resection and effective endoscopic defect closure) was 98.3 %. Conclusions Eo-EFTR without laparoscopic assistance appears to be highly effective and safe NOTES for removing deep G-SMTs, particularly those arising from MP layer.

Evaluation of 30-day mortality for 500 patients undergoing non-emergency surgery in a COVID-19 cold site within a multicentre regional surgical network during the COVID-19 pandemic

BackgroundTwo million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems.ObjectiveTo determine whether it is feasible and safe to continue non-emergency surgery in the COVID-19 pandemicDesign, setting and participantsThis is a cohort study of 500 consecutive patients undergoing non-emergency surgery in a dedicated COVID-19 cold site following the first case of COVID-19 that was reported in the institution. The study was carried out during the peak of the pandemic in the United Kingdom, which currently has one of the highest number of cases and deaths from COVID-19 globally.We set up a hub-and-spoke surgical network amongst 14 National Health Service institutions during the pandemic. The hub was a cancer centre, which was converted into a COVID-19 cold site, performing urological, thoracic, gynaecological and general surgical operations.OutcomesThe primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days.Results500 patients underwent surgery with median age 62.5 (IQR 51-71). 65% were male and 60% had a known diagnosis of cancer. 44% of surgeries were performed with robotic or laparoscopic assistance and 61% were considered complex or major operations.None of the 500 patients undergoing surgery died from COVID-19 at 30-days. 30-day allcause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19.ConclusionIt is safe to continue non-emergency surgery during the COVID-19 pandemic with appropriate service reconfiguration.Patient summaryNo patients died from COVID-19 when undergoing non-emergency surgery during the pandemic in one of the worst affected world regions.

Laparoscopic-assisted gastrotomy for foreign body retrieval in four dogs

Four dogs with gastric foreign bodies were treated by laparoscopic-assisted gastrotomy. Techniques included two-port technique (n=two dogs), single-port with Alexis wound retractor (one) and single-port GelSeal cap with three cannulae (one). Foreign bodies retrieved included gravel (n=two dogs), trichobezoar (one) and a ball (one). All dogs had foreign bodies successfully removed, and no complications were encountered associated with the surgical procedures. These results suggest that laparoscopic-assisted gastrotomy is a feasible treatment for dogs with gastric foreign bodies via standard two-port technique, single-port with Alexis wound retractor, or single-port with GelSeal device. The benefits of minimally invasive surgery have been well-established for veterinary patients, and further investigation into additional uses is essential; the findings of this series highlight the importance of considering laparoscopic assistance for procedures such as gastrotomy.

APPLICATION OF THE ACCELERATED REHABILITATIONPROTOCOL (ERAS) IN THE PERIOPERATIVE PERIOD FROM THE POSITION OF AN ANESTHESIOLOGIST.

Introduction. Application of laparoscopic techniques corresponds to the principles of the ERAS maximally. Aim – assess the impact of the early multimodal rehabilitation concept use on the postoperative period. Material and methods. The study involved 49 patients who were randomized by method of envelopes into two groups. In the basic group (30 patients) a multimodal protocol of early rehabilitation was used. In the control group (19 patients) a traditional perioperative regimen was performed. In both groups, vaginal hysterectomy with laparoscopic support under general anesthesia combined with mechanical ventilation was carried out. Fentanyl analgesia (3–5 mcg/kg/hr), and 0,5% bupivacaine solution into epidural space (6,8 mL). The volume of the infusion in the main group was 6 ml/kg/h, in the control group – 10 ml/kg/hr. Noninvasive monitoring carried by monitor "Leon" (blood pressure, heart rate, capnogram), the hourly diuresis. Postoperatively the two groups used 24 hours prolonged epidural small boluses of 0,25% bupivacaine solution (4 ml/hour) in combination with systemic administration of dexketoprofen (100–150 mg/day) + ketorolac (60 mg/day) + paracetamol (2000 mg/day). Result. The groups were homogeneous in anamnestic (onset of menstruation, number of pregnancies, childbirth, abortion, miscarriage), anthropometric and demographic characteristics, duration of operations and the beginning levels of systolic, diastolic, mean arterial pressure and heart rate. The volume of blood loss (ml) in patients with ERAS was (282 ± 22), in patients of the control group – (347 ± 21), p˂0,05. Intraoperative gemohydrobalance (ml) in patients with ERAS was (547 ± 57), in the control group – (942 ± 62), p ˂ 0,05. The postoperative hospital stay in patients of the main group (ERAS) was significantly shorter (5,00 ± 0,26) than in the control group of patients without ERAS (7,16 ± 0,40), p ˂ 0,05. Conclusion. Optimal anesthetic tactic allows patients to be fast extubated and to eliminate postoperative pain in the first 24 hours effectively. Using the early multimodal rehabilitation protocol reduces the time of patient recovery after vaginal hysterectomy with laparoscopic assistance. Keywords: multimodal strategy, laparoscopy, vaginal hysterectomy

Transanal Endorectal Pull-Through With or Without Laparoscopic Assistance

Hirschsprung’s disease requires surgical treatment. Depending on the form of aganglionosis and severity of pathology, open or minimally invasive, transanal endorectal pull-through with or without laparoscopic assistance may be used. The objective of the research was to study the efficiency of using transanal endorectal pull-through with and without laparoscopic assistance for treating Hirschsprung’s disease in children. We compared outcomes between approaches. Materials and Methods. Over the period 2011-2016, 145 children with Hirschsprung’s disease were surgically treated using transanal endorectal pull-through (n=81) and laparoscopic-assisted transanal endorectal pull-through (n=64). A systematic literature review and meta-analysis were carried out. Results. We noticed that transanal endorectal pull-through without laparoscopic assistance could be easily used in children under 4 years of age with aganglionosis including the sigmoid colon without significant colon dilatation considering a significant mesosigmoid mobility at such age. In other cases, we used laparoscopic-assisted transanal endorectal pull-through. The advantages of laparoscopic stage included the possibility for correct planning of surgical strategy, a thorough revision of the affected colon, determination of aganglionosis level, mobilization of the mesenterium, elimination of the adhesions and ligaments holding the colon, thereby avoiding tension in coloanal anastomosis, control and prevention of pull-through colon twisting which may cause an obstruction. In older patients, the proximal end of the rectum could be dissected laparoscopically. This allowed transanal endorectal pull-through to be performed quicker and safer. In the postoperative period, patients underwent rehabilitation with good functional results. Two children developed coloanal anastomotic dehiscence which was corrected by open stage treatment. Conclusions. Age-related and anatomical features of the colon in the patients with Hirschsprung’s disease allowed performing transanal endorectal pull-through with or without laparoscopic assistance. Significant dilation of the colon, aganglionosis above the sigmoid area and the patient’s age over 4 years were indications for performing transanal endorectal pull-through with laparoscopic assistance. In other cases, transanal endorectal pull-through could be performed without laparoscopic assistance. The laparoscopic-assisted transanal endorectal pull-through procedure turned to be a safe and feasible technique for patients with Hirschsprung’s disease.