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As a treatment option for early middle gastric cancer, pylorus-preserving gastrectomy (PPG) has been shown to exhibit good clinical efficacy in Japan and Korea and has attracted widespread attention in China. PPG has a similar surgical safety to conventional distal gastrectomy (DG). The incidence of postoperative complications (such as dumping syndrome, bile reflux gastritis, gallstones, weight loss, and malnutrition) has been shown to be lower, while that of delayed gastric emptying (DGE) was higher after PPG than after DG. However, preserving the vagus nerve, blood supply to the pylorus, and adequate antral cuff length can effectively reduce DGE after PPG. Whether or not incomplete lymphadenectomy affects tumor safety is a primary focus for concern. According to the analysis of lymph node metastasis rates in early middle gastric cancer, the metastasis rates of lymph nodes No. 5 and No. 6 were low, providing a theoretical basis for performing limited lymph node dissection. LESS      Full article

While the incidence of intrahepatic cholangiocarcinoma (ICC) is increasing, few patients are surgical candidates, and recurrence rates remain high. Surgical resection remains the only potential curative therapy for ICC, and many retrospective cohorts have demonstrated comparable short-term and long-term outcomes between open, laparoscopic, and robotic liver resection (RLR) for ICC. However, rates of lymphadenectomy remain low amongst all groups, especially in laparoscopic approaches, despite its role in prognostication and therapeutic management. RLR may offer many of the short-term benefits of laparoscopic liver resection (LLR) and facilitate adequate lymphadenectomy while also increasing the ability to access posterosuperior segments and perform major hepatectomies. LESS      Full article

Aim: The transorally inserted anvil (OrVil^TM) is often selected for esophagojejunostomy after total laparoscopic gastrectomy due to its versatility. During anastomosis with OrVil^TM, it is possible to select a double stapling technique (DST) or a hemi-double technique (HDST) by overlapping the linear stapler and the circular stapler, although there has been no report on the anastomotic strength. Thus, an animal experiment was conducted and verified this study.Methods: This experiment used 10 fresh porcine esophageal and jejunal specimens. Two models were created: a model in which the rod is placed at the center of the esophageal transection line (DST model) and a model in which the rod is placed at the lateral end of the esophageal transection line (HDST model). A pressure gage was inserted into the anastomosed intestine while continuously measuring pressure to determine the leakage site and leakage pressure.Results: The leakage site in both the DST (n = 5) and HDST models (n = 5) were at the staple overlapping with a leakage pressure of 151.2 ± 14.2 mmHg in the DST model and 148.2 ± 6.3 mmHg in the HDST model (P = 0.678). When the leakage site was repaired with hand-sewn sutures and conducted remeasuring pressure, leakage was observed from the contralateral crossing in the DST model and the leakage pressure was 155.8 ± 12.2 mmHg. In the HDST model, all models were capable of withstanding 300-mmHg pressures.Conclusion: HDST with a single staple intersection is beneficial for esophagojejunostomy, in terms of pressure resistance, and the repairing suture at the staple intersection can increase pressure resistance. LESS      Full article

Background: While well-described for hepatic and pancreatic resection, the minimally invasive (MIS) approach in the treatment of choledochal cysts (CC) has been under-reported. Due to the technical complexity and steeper learning curve of minimally invasive biliary reconstruction, the MIS approach has not been as widely adopted in biliary surgery. We herein review the use of laparoscopic and robotic-assisted surgery in the treatment of CC.Methods: A comprehensive review of the literature was performed on the use of laparoscopic and robotic-assisted surgery in the treatment of CC.Results: Similar morbidity and mortality rates were noted among patients undergoing laparoscopic choledochal cyst resection (LCCR) compared with previous data from patients in the literature who had undergone an open approach (OCCR, open choledochal cyst resection); however, LCCR was associated with longer operative times and high conversion rates, largely attributable to the learning curve given the technically challenging nature of the procedure. The robotic platform (RCCR, robotic choledochal cyst resection) has been shown to offer an advantage in the hepaticojejunostomy anastomosis portion of CC resection vs. laparoscopy while providing comparable short-term outcomes compared with the LCCR approach.Conclusion: A minimally invasive approach to CC likely has improved perioperative outcomes with shorter LOS, return to baseline function, as well as improved cosmesis vs. OCCR. Longer operative times with minimally invasive approaches to CC have been attributed to steep learning curves, which have improved over time as surgeons become more facile with this technique. Both LCCR and RCCR have demonstrated similar rates of long-term postoperative complications and overall survival when compared to OCCR. LESS      Full article

Gallbladder cancer is a lethal disease when diagnosed at later stages, and gallbladder polyps may have malignant potential or harbor cancer, especially as the polyp increases in size. Therefore, cholecystectomy has been recommended by guidelines for gallbladder polyps ≥ 10 mm, or smaller polyps with risk factors. In this article, we review minimally invasive approaches to the management of gallbladder polyps. The predominant method of cholecystectomy has been laparoscopic, which has advantages in faster recovery compared to open cholecystectomy. More recently, many surgeons have converted their minimally invasive techniques to robotic approaches. In addition, combined laparoscopic-endoscopic or purely endoscopic approaches have been reported. The ultimate goal of gallbladder polyp management using minimally invasive approaches is to minimize morbidity, given the low incidence of cancer within polyps, while preventing polyps with malignant potential from converting to cancer, or curing cancerous polyps. LESS      Full article

Surgeon technical improvements made in the 1980s significantly decreased the morbidity and mortality associated with pancreaticoduodenectomy (PD). While minimally invasive surgery (MIS) is now the standard surgical approach for many benign and malignant pathologies, the technical complexity associated with PD presents many challenges to MIS adoption. However, advancements in robotic technology have done much to ameliorate mechanical impediments. Compared to laparoscopic surgery, the robotic platform provides surgeons with enhanced visualization, greater degrees of freedom and range of motion, tremor elimination, and superior ergonomic positioning. Although cost and availability concerns persist, training programs have increasingly incorporated robotic curricula, boosting the prevalence of robotic procedures, including robotic PD (RPD). While prospective data are limited, studies evaluating RPD demonstrate safety, equivalent short-term oncological outcomes, and longer operating times compared to open PD. Furthermore, exciting avenues exist for the future of RPD, ranging from continued instrument innovations to AI-enhanced adjuncts. Robotics has the potential to improve PD for patients and surgeons alike; however, further evaluation of oncologic and surgical outcomes requires well-powered, randomized, prospective trials to confirm the results of earlier retrospective studies, given the significant biases present. In this article, we review the progression of minimally invasive PD, present outcomes from studies evaluating RPD, and discuss areas of innovation for RPD. 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