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Renal cell carcinoma is identified most often in the sixth or seventh decade of life, coinciding with the rise in incidental diagnosis of small renal masses as imaging technology has advanced. However, not all patients in this older age group are surgical candidates owing to their comorbidities. Cryoablation is a well-established minimally invasive technique for the treatment of small renal masses. The advent of less invasive ablative treatment has alleviated the surgical dilemma for certain patients who are contraindicated for extirpative procedures. With the appropriate patient selection, cryoablation is safe and effective, resulting in comparable local tumor control, fewer complications, better preservation of renal function, a faster recovery, and a shorter hospital stay. The percutaneous procedure has increased in popularity due to the advantages of reduced pain, shorter hospitalization, the ability to be performed without general anesthesia, and decreased cost relative to surgery. LESS      Full article

Small bowel capsule endoscopy (SBCE) is a tool used for Crohn’s disease (CD) diagnosis and monitorization, which aids in appropriate clinical decision-making, especially in the switch of treatment or withdrawal and influencing reclassification of unclassified inflammatory bowel disease. Compared to cross-sectional imaging, namely intestinal ultrasound and magnetic resonance enterography, SBCE has a superior diagnostic yield in proximal small bowel inflammatory activity, which has been associated with greater morbidity. The risk of capsule retention is higher in patients with established CD with suspected stenosis and those with suspected CD with obstructive symptoms, known stenosis or previous small bowel resection. In these situations, SBCE should be administered only after small bowel patency has been evaluated. There is evidence that the pan-enteric capsule (PEC) has a higher diagnostic yield than ileocolonoscopy in detecting terminal ileum mucosal defects. Future research should evaluate the PEC place in CD algorithms as it offers a non-invasive approach, which is especially important in a long-term follow-up, likely diminishing the disease burden. LESS      Full article

Aim: Minimally invasive distal pancreatectomy has become the standard of care for benign and low malignant lesions. Spleen preservation in this setting has been proposed to reduce surgical trauma and long-term sequelae. The aim of the current study is to present real-world data on indications, techniques, and outcomes of spleen-preserving distal pancreatectomy (SPDP).Methods: Patients who underwent SPDP and distal pancreatectomy with splenectomy (DPWS) were extracted from the 2019-2022 Italian National Registry for Minimally Invasive Pancreatic Surgery (IGoMIPS). Perioperative and pathological data were collected. Results: One hundred and ten patients underwent SPDP and five hundred and seventy-eight underwent DPWS. Patients undergoing SPDP were significantly younger (56 vs. 63.5 years; P < 0.001). Seventy-six percent of SPDP cases were performed in six out of thirty-four IGoMIPS centers. SPDP was performed predominantly for Neuroendocrine Tumors (43.6% vs.23.5%; P < 0.001) and for smaller lesions (T1 57.6% vs. 29.8%; P < 0.001). The conversion rate was higher in the case of DPWS (7.6% vs. 0.9%; P = 0.006), even when pancreatic cancer was ruled out (5.0% vs. 0.9%; P = 0.045). The robotic approach was most commonly used for SPDP (50.9% vs. 29.7%; P < 0.001). No difference in postoperative outcomes and length of stay was observed between the two groups, as well as between robotic and laparoscopic approaches in the SPDP group. A trend toward a lower rate of postoperative sepsis was observed after SPDP (0.9% vs. 5.2%; P = 0.056). In 84.7% of SPDP, splenic vessels were preserved (Kimura procedure) without an impact on short-term postoperative outcomes. Conclusion: In this registry analysis, SPDP was feasible and safe. The Kimura procedure was prevalent over the Warshaw procedure. The typical patient undergoing SPDP was young with a neuroendocrine tumor at an early stage. Robotic assistance was used more frequently for SPDP than for DPWS. LESS      Full article

Anastomotic leaks (ALs) after esophageal resection remain a dreaded complication and are associated with high morbidity and mortality, along with an increased cost of care and prolonged hospitalization. Management strategies include confirming conduit viability, controlling sepsis with drainage/antibiotics, and maintaining nutrition. Traditional treatment of ALs has given way to nonoperative management including endoscopic and radiological techniques, which are associated with decreased morbidity. This article aims to review novel technologies and techniques for the management of esophageal ALs, including self-expandable metal stents, endoluminal vacuum therapy, leak content drainage, and radiology-guided drain placement. LESS      Full article

Since its introduction in 1985, anatomical liver resection (AR) has been performed to treat early-stage hepatocellular carcinoma. The minimally-invasive AR (MIALR) approach can be safely performed at high-volume tertiary referral centers. The resection techniques can vary among surgeons, depending on the center’s experience, patient characteristics, hepatic segment involvement, and tumor characteristics. Profound knowledge of the liver’s surgical anatomy and a standardized inflow control approach is fundamental to performing MIALR safely. This article aims to summarize the applications of the MIALR and its outcomes, focusing on the techniques for vascular inflow control and the essential tips and tricks to standardize these techniques for laparoscopic and robotic approaches. LESS      Full article

Aim: The magnetic ring (LINX®) system was approved by the FDA in 2012 as a device to augment the lower esophageal sphincter pressure to manage reflux in the general population. It was introduced into the bariatric population in 2014 as an alternative to Roux-en-Y gastric bypass (RYGB) in managing reflux after sleeve gastrectomy (SG).Materials: Between January 2015 and December 2021, Seventeen patients had the Magnetic Ring (MR) device placement to manage their reflux after SG.Methods: The mean age was 54 ± 12 years. Their mean body mass index (BMI) was 31 ± 6 kg/m². The mean time between the SG and MR device placement was 41 ± 19 months. The mean DeMeester score was 48 ± 26 (normal < 14.72).Results: All seventeen patients underwent a successful laparoscopic placement of the MR device. Two patients had early post-operative dysphagia requiring removal of the device and one patient was lost to follow-up. The mean follow up of the remaining fourteen patients was 65 ± 31 months. Recurrent reflux occurred in 11 (79%). In three of these eleven (27%) patients the recurrent reflux was due to a broken device. None of these patients were interested in conversion to RYGB.Conclusion: The MR device is a valuable tool in treating reflux after SG in spite of its potential risk of recurrence. Our results can be interpreted as being dissatisfying if complete resolution is the goal. Larger studies, with more than 3 year follow up, are needed before a final decision is made on its value in the bariatric population. LESS      Full article

Aim: The aims of this study were to better understand the outcomes of Roux-en-Y gastric bypass (RYGB) surgery in patients across multiple hospitals in China along with patients with type 2 diabetes mellitus (T2DM) and to explore the potential preoperative predictors of diabetes outcomes after RYGB.Methods: This was a retrospective cohort study in Chinese patients who underwent laparoscopic RYGB at five Chinese hospitals from April 2009 to December 2014 and returned for follow-up approximately one-year post-surgery. The STROCSS guideline checklist was applied.Results: In total, 130 patients underwent RYGB: 85 males and 45 females; age, 43.4 ± 11.3 years; and preoperative body mass index (BMI), 33.1 ± 9.0 kg/m². Of those, 103 (79.2%) had T2DM duration of 6.6 ± 4.7 years and pre-RYGB HbA1c of 8.1 ± 1.9%. Among the patients with T2DM, glycemic control (HbA1c < 7.0%) increased from 28.7% before surgery to 79.3% at 12 months post-procedure, with a concurrent reduction in the use of anti-hyperglycemic agents, including a reduction in insulin requirement from 55.4% to 27.0%. The percentage of excess weight loss was -42.8 ± 44.2%. Among 71 patients with T2DM and data about remission status, 14 (19.7%) achieved T2DM remission at 12 months post-surgery. Age and duration of T2DM were lower in the remission group, while baseline BMI and weight were higher compared with the non-remission group.Conclusion: RYGB may be effective for weight loss and T2DM control in Chinese patients, and outcomes are consistent with the literature in Western populations. Younger patients with T2DM and with a higher BMI pre-surgery and shorter duration of T2DM were more likely to achieve T2DM remission. LESS      Full article

Aim: Greenlight photoselective vaporization of the prostate (PVP) is considered a safe alternative to transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms (LUTS) and a prostate volume of 30-80 mL for the comparable short- and mid-term results. Long-term re-treatment rate is still being debated.Methods: We retrospectively reviewed greenlight PVP procedures in a multi-institutional database from September 2011 to December 2019 collecting data on patients requiring re-intervention with a follow-up period of at least 12 months.Results: Among 867 patients with a median follow-up period of 32.5 months (interquartile range: 20.0-49.0 months), 35 patients (4%) required re-intervention. Patients requiring re-intervention had a prostate volume ≥ 100 mL in 28.6% of cases (P = 0.002). Preoperative urethral stricture and incidence of early complications were more frequent in the re-treatment group (P = 0.027 and P = 0.006). In the re-treatment group, 22 patients required an endoscopic intervention for bladder neck or prostatic fossa contracture (2.5% of the study population). The remaining 13 patients in the re-treatment group underwent TURP or PVP for LUTS relapse (1.5%). In the univariate and multivariate logistic regression models, only prostate volume ≥ 100 mL (P = 0.003 and P = 0.010), preoperative urethral stricture (P = 0.013 and P = 0.036), and occurrence of early complications (P = 0.008 and P = 0.024) correlated with re-intervention.Conclusion: Greenlight PVP has good functional long/mid-term results. The presence of preoperative urethral stricture and the occurrence of early complications correlate with the risk of late re-treatment. In patients with prostate ≥ 100 mL, the enucleation technique may be superior to vaporization in terms of lower long-term risk of re-intervention for LUTS relapse. LESS      Full article

Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall costs compared to traditional open surgery, and it is currently considered the standard approach both to elective and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials, and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing recurrence rate. LESS      Full article

Biliary tract malignancies include cancers of the intra-hepatic and extra-hepatic bile ducts. Cholangiocarcinoma is the predominant biliary tract malignancy with nearly 60% of them occurring in the peri-hilar region. They can present with biliary strictures causing jaundice but can be insidious and present late in their clinical course. Recent advances in imaging and other diagnostic modalities help in the earlier identification of these tumors. Diagnosis should be suspected in anyone presenting with jaundice with evidence of biliary ductal dilatation or in patients with primary sclerosing cholangitis with worsening clinical status. The diagnostic approach consists of obtaining tumor markers, mainly CA 19-9, imaging modalities which include computed tomography and/or magnetic resonance imaging to establish the level of biliary obstruction and presence or absence of mass. Tissue sampling is performed with endoscopic retrograde cholangiopancreatography (ERCP) guided cytology and biopsies and with endoscopic ultrasound (EUS) if a mass is visible on imaging. Indeterminate strictures after initial biopsies could be further evaluated by cholangioscopy directed biopsies. Treatment for resectable and distal bile duct cancers involves surgical referral, but palliative biliary drainage is the key for unresectable cancers. Metal stents are generally preferred for distal cancers and plastic stents for proximal cancers. EUS guided biliary drainage can be an alternative approach in patients with failed ERCP. LESS      Full article