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Advances in Minimally Invasive Gastrointestinal Surgery

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "General Surgery".

Deadline for manuscript submissions: closed (20 April 2023) | Viewed by 15011

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Special Issue Editors

Prof. Dr. Matthias Biebl

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Guest Editor

Department of Surgery, Ordensklinikum Linz, 4020 Linz, Austria
Interests: surgical oncology; upper GI cancer; esophageal cancer; gastric cancer; clinical trials; minimally invasive surgery; robotic surgery
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Reinhold Függer

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Guest Editor

Department of General, Visceral, Thoracic and Transplant Surgery, Ordensklinikum Linz, 4010 Linz, Austria
Interests: surgical oncology; pancreas, liver; bile; upper GI; surgical infection
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Gastrointestinal surgery has evolved to become the major field for minimally invasive approaches over the past several decades. Given the distinct anatomical borders of the gastrointestinal tract, minimally invasive surgical procedures—both functional and oncologic—have been established as the preferred approach for almost every situation. Interestingly, no other field of surgery has seen so many ways of “trial and error” as minimally invasive approaches to the abdominal cavity and the gastrointestinal tract. Indeed, the past decade displayed the rise and fall of several techniques in this manner. However, every evolution has left its mark in the technical armamentarium of GI surgeons, and has further stipulated the ever-progressing evolution of surgical techniques. After years of innovation regarding mainly intraoperative approach and dissection techniques, recent times are still fascinating, as high-end technology at the patient side (including robotic technology as well as specialized visualization techniques), together with artificial intelligence for optimal patient selection and enlarging the knowledge of pre- and perioperative patient care outside the OR, forge the current state of the art in minimally invasive gastrointestinal surgery.

With this Special Issue, we aim to cover the current status of minimally invasive GI surgery, and to give a comprehensive overview of the current field of innovation in this fascinating surgical specialty.

Prof. Dr. Matthias Biebl
Prof. Dr. Reinhold Függer
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

minimally invasive surgery
laparoscopic surgery
robotic surgery
minimally invasive gastrointestinal surgery
endoscopy
GI surgery

Published Papers (10 papers)

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Research

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9 pages, 241 KiB

Open AccessArticle

Endoscopic Submucosal Dissection in the Upper Gastrointestinal Tract and the Need for Rescue Surgery—A Multicenter Analysis

by Philipp Pimingstorfer, Matthias Biebl, Matus Gregus, Franz Kurz, Rainer Schoefl, Andreas Shamiyeh, Georg O. Spaun, Alexander Ziachehabi and Reinhold Fuegger

J. Clin. Med. 2023, 12(21), 6940; https://doi.org/10.3390/jcm12216940 - 6 Nov 2023

Cited by 1 | Viewed by 739

Abstract

Endoscopic submucosal dissection (ESD) has become the standard treatment for early malignant lesions in the upper gastrointestinal (GI) tract. Its clinical results have been reported to be as good as surgery. The outcomes of rescue surgery after non-curative ESD have been reported to be as good as first-line surgery. The aim of this study was to evaluate the outcomes of ESD in the upper GI tract and the outcomes of rescue surgery after non-curative ESD performed in Linz, Austria, between 2009 and January 2023. A total of 193 ESDs were included and divided into 104 esophageal ESD and 89 gastric ESD procedures. The criteria for curative ESD were in line with established guidelines’ recommendations. For esophageal lesions, the mean lesion size was 40.3 mm and the rate of curative ESD was 56.7%. In the non-curative ESD, the rate of technical failure as the reason for non-curative ESD was 13.3% and the oncological failure rate was 86.7%. Only 48.7% of indicated rescue surgeries were performed. The main reason for not performing surgery was interdisciplinary consensus due to comorbidity. Perioperative complications Dindo–Clavien ≥ 3 occurred in 22.2% of cases with an in-hospital mortality rate of 0. In gastric lesions, the mean size was 39 mm and the rate of curative ESD was 69.7%. The rate of technical failure as a reason for non-curative ESD was 25.9% and the oncological failure rate was 74.1% for non-curative ESD. Rescue surgery was performed in 48.2% of indicated cases. The perioperative rate for major complications was 0. The outcome of ESD in the upper GI tract is in line with the published literature, and non-curative ESD does not worsen surgical outcomes. The available follow-up data are in line with the international published literature, showing a low rate of residual malignancy in surgical resection specimens. Therefore, the indication of rescue surgery for oncological failure remains challenging. Furthermore, the learning curve of ESD has shown a trend towards improving outcomes over time. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

11 pages, 694 KiB

Open AccessArticle

Postesophagectomy Diaphragmatic Prolapse after Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)

by Stefanie Brunner, Dolores T. Müller, Jennifer A. Eckhoff, Valentin Lange, Seung-Hun Chon, Thomas Schmidt, Wolfgang Schröder, Christiane J. Bruns and Hans F. Fuchs

J. Clin. Med. 2023, 12(18), 6046; https://doi.org/10.3390/jcm12186046 - 19 Sep 2023

Viewed by 823

Abstract

Background: Postesophagectomy diaphragmatic prolapse (PDP) is a major complication after esophagectomy with significant mortality and morbidity. However, in the current literature, treatment and outcomes are not evaluated for patients undergoing an Ivor Lewis Robot-assisted minimally invasive esophagectomy (IL-RAMIE). The aim of this study is to evaluate the incidence of PDP after IL-RAMIE. Moreover, the study aims to determine whether using a minimally invasive approach in the management of PDP after an IL-RAMIE procedure is safe and feasible. Materials and Methods: This study includes all patients who received an IL-RAMIE at our high-volume center (>200 esophagectomies/year) between April 2017 and December 2022 and developed PDP. The analysis focuses on time to prolapse, symptoms, treatment, surgical method, and recurrence rates of these patients. Results: A total of 185 patients underwent an IL-RAMIE at our hospital. Eleven patients (5.9%) developed PDP. Patients presented with PDP after a medium time of 241 days with symptoms like reflux, nausea, vomiting, and pain. One-third of these patients did not suffer from any symptoms. In all cases, a CT scan was performed in which the colon transversum always presented as the herniated organ. In one patient, prolapse of the small intestine, pancreas, and greater omentum also occurred. A total of 91% of these patients received a revisional surgery in a minimally invasive manner with a mean hospital stay of 12 days. In four patients, PDP recurred (36%) after 13, 114, 119 and 237 days, respectively. Conclusion: This study shows that a minimally invasive approach in repositioning PDP is a safe and effective option after IL-RAMIE. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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11 pages, 256 KiB

Open AccessArticle

Dietary Intervention Improves Gastrointestinal Symptoms after Treatment of Cancer in the Pelvic Organs

by Mette Borre, Janne Fassov, Jakob Lykke Poulsen, Peter Christensen, Søren Laurberg, Asbjørn Mohr Drewes and Klaus Krogh

J. Clin. Med. 2023, 12(14), 4766; https://doi.org/10.3390/jcm12144766 - 19 Jul 2023

Cited by 1 | Viewed by 1180

Abstract

Gastrointestinal (GI) symptoms are common in patients receiving radiotherapy, chemotherapy, and/or surgery for cancer in the pelvic organs. The aim of the present prospective cohort study was to report the efficacy of dietary intervention in patients with chronic GI sequelae to treatment of cancer in pelvic organs and insufficient symptomatic effect of medical treatment. Eighty-eight patients were offered specialist dietitian guidance. Gastrointestinal symptoms and quality of life were assessed before and after intervention by validated questionnaires. The main dietary interventions were low-fat diet (n = 44; 50%), modification of dietary fiber content (n = 19; 33%), dietary restrictions with a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet (n = 18; 20%), gluten-free diet (n = 1; 1%), and other dietary advice (n = 6; 7%). Compared to baseline, dietary intervention improved quality of life (EQ5D scale) (p < 0.01), bowel function for the last four weeks (p < 0.02), stool frequency (p < 0.03), constipation (p < 0.05), incomplete rectal emptying at defecation (p < 0.02), and performing usual activities (p < 0.0). In conclusion, this observational study using tailored dietary intervention showed that symptoms can be reduced and quality of life can be improved in patients with chronic GI sequelae following treatment of cancer in the pelvic organs not responding sufficiently to medical treatment. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

13 pages, 1478 KiB

Open AccessArticle

Endoscopic Transmural Therapy of Pancreatic Fistulas in an Interdisciplinary Setting—A Retrospective Data Analysis

by Clara Meierhofer, Reinhold Fuegger, Georg O. Spaun, Helwig Valentin Wundsam, Patrick Kirchweger, Matthias Biebl and Rainer Schoefl

J. Clin. Med. 2023, 12(13), 4531; https://doi.org/10.3390/jcm12134531 - 6 Jul 2023

Viewed by 3501

Abstract

Pancreatic fistulas belong to the most feared complications after surgery on or near the pancreas, abdominal trauma, or severe pancreatitis. The majority occur in the setting of operative interventions and are called postoperative pancreatic fistulas (POPF). They can lead to various complications, including abscesses, delayed gastric emptying or hemorrhages with a significant impact on morbidity and mortality. Several risk factors have been identified, including smoking, high BMI, male gender, and age. Prophylactic measures and treatment options have been explored but with limited success. This study aimed to analyze the incidence and management of pancreatic fistulas treated in a tertiary referral center, particularly focusing on an endoscopic approach. The data of 60 patients with clinically relevant pancreatic fistulas were analyzed between 2018 and 2021. Different treatment approaches, including conservative management, percutaneous drainage, transpapillary stenting, and endoscopic transmural drainage, were evaluated. An endoscopic transmural approach using lumen-apposing metal stents (LAMS) was used in almost half of this cohort showing promising results, with a high rate of fistula closure in refractory cases and a mean time until closure of 2.7 months. The findings suggest that an endoscopic approach, particularly using LAMS, can be effective in the management of pancreatic fistulas. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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18 pages, 4124 KiB

Open AccessArticle

Minimally Invasive Donors Right Hepatectomy versus Open Donors Right Hepatectomy: A Meta-Analysis

by Chunyang Mu, Chuwen Chen, Jianghong Wan, Guoxin Chen, Jing Hu and Tianfu Wen

J. Clin. Med. 2023, 12(8), 2904; https://doi.org/10.3390/jcm12082904 - 17 Apr 2023

Cited by 3 | Viewed by 1153

Abstract

Background: How to obtain a donor liver remains an open issue, especially in the choice of minimally invasive donors right hepatectomy versus open donors right hepatectomy (MIDRH versus ODRH). We conducted a meta-analysis to clarify this question. Methods: A meta-analysis was performed in PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases. Baseline characteristics and perioperative outcomes were analyzed. Results: A total of 24 retrospective studies were identified. For MIDRH vs. ODRH, the operative time was longer in the MIDRH group (mean difference [MD] = 30.77 min; p = 0.006). MIDRH resulted in significantly less intraoperative blood loss (MD = −57.86 mL; p < 0.00001), shorter length of stay (MD = −1.22 days; p < 0.00001), lower pulmonary (OR = 0.55; p = 0.002) and wound complications (OR = 0.45; p = 0.0007), lower overall complications (OR = 0.79; p = 0.02), and less self-infused morphine consumption (MD = −0.06 days; 95% CI, −1.16 to −0.05; p = 0.03). In the subgroup analysis, similar results were observed in pure laparoscopic donor right hepatectomy (PLDRH) and the propensity score matching group. In addition, there were no significant differences in post-operation liver injury, bile duct complications, Clavien–Dindo ≥ 3 III, readmission, reoperation, and postoperative transfusion between the MIDRH and ODRH groups. Discussion: We concluded that MIDRH is a safe and feasible alternative to ODRH for living donators, especially in the PLDRH group. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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11 pages, 1791 KiB

Open AccessArticle

Association of GLIM Defined Malnutrition According to Preoperative Chronic Inflammation with Long-Term Prognosis after Gastrectomy in Patients with Advanced Gastric Cancer

by Ryota Matsui, Noriyuki Inaki, Toshikatsu Tsuji and Tetsu Fukunaga

J. Clin. Med. 2023, 12(4), 1579; https://doi.org/10.3390/jcm12041579 - 16 Feb 2023

Cited by 3 | Viewed by 1276

Abstract

This study aimed to investigate the association of malnutrition, defined by the Global Leadership Initiative on Malnutrition (GLIM) according to preoperative chronic inflammation with long-term prognosis after gastrectomy in patients with advanced gastric cancer. We included patients with primary stage I-III gastric cancer who underwent gastrectomy between April 2008 and June 2018. Patients were categorized as normal, moderate malnutrition, and severe malnutrition. Preoperative chronic inflammation was defined as a C-reactive protein level of >0.5 mg/dL. The primary endpoint was overall survival (OS), compared between the inflammation and non-inflammation groups. Among the 457 patients, 74 (16.2%) and 383 (83.8%) were included in the inflammation and non-inflammation groups, respectively. The prevalence of malnutrition was similar in both groups (p = 0.208). Multivariate analyses for OS showed that moderate malnutrition (hazard ratios: 1.749, 95% concordance interval: 1.037–2.949, p = 0.036) and severe malnutrition (hazard ratios: 1.971, 95% CI: 1.130–3.439, p = 0.017) were poor prognostic factors in the non-inflammation group, but malnutrition was not a prognostic factor in the inflammation group. In conclusion, preoperative malnutrition was a poor prognostic factor in patients without inflammation, but it was not a prognostic factor in patients with inflammation. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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11 pages, 862 KiB

Open AccessArticle

The Nuts and Bolts of Implementing a Modified ERAS Protocol for Minimally Invasive Colorectal Surgery: Group Practice vs. Solo Practice

by Zhen-Hao Yu, Yih-Jong Chern, Yu-Jen Hsu, Bor-Kang Jong, Wen-Sy Tsai, Pao-Shiu Hsieh, Ching-Chung Cheng and Jeng-Fu You

J. Clin. Med. 2022, 11(23), 6992; https://doi.org/10.3390/jcm11236992 - 26 Nov 2022

Viewed by 1054

Abstract

AIM: The ERAS protocol consists of multiple items that aim to improve the outcomes of patients receiving surgery. Adhering to the protocol is difficult. We wondered whether surgeons practicing the ERAS protocol in a group would improve patient outcomes. Methods: All patients who underwent colorectal resection for benign disease or malignancy from November 2017 to December 2018 were collected and reviewed retrospectively. According to the physician’s ward round strategy, the patients were categorized into two groups, either by solo practice or group practice. Results: This study enrolled 724 patients and divided them into two groups according to the practice method: group practice (n = 256) and solo practice (n = 468). The group practice cohort had less postoperative morbidity (14.0% vs. 21.4%, p = 0.048) and shorter postoperative hospital stays (mean: 6.6 ± 3.2 vs. 8.6 ± 5.5, p < 0.05) than the solo practice cohort. Group practice (p < 0.001), natural orifice specimen extraction (NOSE) procedure (p < 0.001), and blood loss >50 mL (p = 0.039) significantly affected discharge within 5 days postoperatively in multivariate analyses. Conclusions: Group practice based on a modified ERAS protocol shortens postoperative hospital stays with fewer morbidities compared with solo practice in which patients receive elective minimally invasive colorectal surgery. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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Review

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10 pages, 215 KiB

Open AccessReview

Minimally Invasive versus Open Distal Pancreatectomy in the 2020s: Recent Institutional Experience and a Narrative Review of Current Evidence

by Saad Rehman, Ishaan Patel, David Bartlett and Darius Mirza

J. Clin. Med. 2023, 12(20), 6578; https://doi.org/10.3390/jcm12206578 - 17 Oct 2023

Viewed by 835

Abstract

(1) Background: Distal pancreatectomy is a standard treatment for tumours of the pancreatic body and tail. Minimally invasive techniques for all types of pancreatic tumours (benign and malignant) are being established, while concerns regarding oncological safety, cost effectiveness and learning curves are being explored with prospective studies. This paper presents our unit’s data in the context of the above concerns and provides a relevant narrative review of the current literature. (2) Methods: Data were collected retrospectively between 2014 and 2021 for all adult patients who underwent elective distal pancreatectomy in our tertiary care referral HPB Unit. Data on demographics, underlying pathology, perioperative variables and post-operative complications were collected and reported using descriptive statistics. On review of the Miami guidelines, four important but less validated areas regarding distal pancreatectomy are presented in light of the current evidence; these are recent randomised controlled trials, oncological safety, cost effectiveness and learning curves in minimally invasive distal pancreatectomy (MIDP). (3) Results: 207 patients underwent distal pancreatectomy in total from 2014–2021, with 114 and 93 patients undergoing open and minimally invasive techniques, respectively. 44 patients were operated on for PDAC in the open vs. 17 in the minimally invasive group. The operative time was 212 min for the open and 248 min for the minimally invasive group. The incidence of pancreatic fistula was higher in the minimally invasive group vs. the open group (16% vs. 4%). (4) Conclusions: Our unit’s data conform with the published literature, including three randomised control trials. These published studies will not only pave the way for establishing minimally invasive techniques for suitable patients, but also define their limitations and indications. Future studies will inform us about the oncological safety, cost effectiveness, overall survival and learning curves regarding patients undergoing minimally invasive distal pancreatectomy. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

12 pages, 267 KiB

Open AccessReview

Use of Near-Infrared Fluorescence Techniques in Minimally Invasive Surgery for Colorectal Liver Metastases

by Ishaan Patel, Saad Rehman, Siobhan McKay, David Bartlett and Darius Mirza

J. Clin. Med. 2023, 12(17), 5536; https://doi.org/10.3390/jcm12175536 - 25 Aug 2023

Cited by 1 | Viewed by 986

Abstract

Colorectal liver metastases (CRLM) afflict a significant proportion of patients with colorectal cancer (CRC), ranging from 25% to 30% of patients throughout the course of the disease. In recent years, there has been a surge of interest in the application of near-infrared fluorescence (NIRF) imaging as an intraoperative imaging technique for liver surgery. The utilisation of NIRF-guided liver surgery, facilitated by the administration of fluorescent dye indocyanine green (ICG), has gained traction in numerous medical institutions worldwide. This innovative approach aims to enhance lesion differentiation and provide valuable guidance for surgical margins. The use of ICG, particularly in minimally invasive surgery, has the potential to improve lesion detection rates, increase the likelihood of achieving R0 resection, and enable anatomically guided resections. However, it is important to acknowledge the limitations of ICG, such as its low specificity. Consequently, there has been a growing demand for the development of tumour-specific fluorescent probes and the advancement of camera systems, which are expected to address these concerns and further refine the accuracy and reliability of intraoperative fluorescence imaging in liver surgery. While NIRF imaging has been extensively studied in patients with CRLM, it is worth noting that a significant proportion of published research has predominantly focused on the detection of hepatocellular carcinoma (HCC). In this study, we present a comprehensive literature review of the existing literature pertaining to intraoperative fluorescence imaging in minimally invasive surgery for CRLM. Moreover, our analysis places specific emphasis on the techniques employed in liver resection using ICG, with a focus on tumour detection in minimal invasive surgery (MIS). Additionally, we delve into recent developments in this field and offer insights into future perspectives for further advancements. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

18 pages, 2285 KiB

Open AccessReview

Endoscopic Submucosal Dissection, Endoscopic Mucosal Resection, and Transanal Minimally Invasive Surgery for the Management of Rectal and Anorectal Lesions: A Narrative Review

by Pedro Moreira, Pedro Marílio Cardoso, Guilherme Macedo and João Santos-Antunes

J. Clin. Med. 2023, 12(14), 4777; https://doi.org/10.3390/jcm12144777 - 19 Jul 2023

Cited by 3 | Viewed by 2141

Abstract

Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and transanal minimally invasive surgery (TAMIS) are modern techniques that now play a crucial role in the treatment of colorectal lesions. ESD is a minimally invasive endoscopic procedure that allows for the resection of lesions of any size in a single piece, with clear advantages regarding oncological outcomes and recurrences. However, it is a complex technique, requiring high endoscopic skills, expertise, and specialized training, with higher rates of adverse events expected compared with EMR. EMR is another endoscopic technique used to remove superficial gastrointestinal tumors, particularly those that are limited to the mucosal layer. It is a faster and more accessible procedure, with fewer adverse events, although it only allows for an en-bloc resection of lesions measuring 15–20 mm. TAMIS is a minimally invasive surgical technique used to remove rectal tumors, involving the insertion of a single-port device through the anus, allowing for a better visualization and removal of the tumor with minimal disruption. This article reviews the current applications and evidence regarding these techniques, in search for the most adequate treatment for the removal of lesions in the rectum and anorectal junction, as these locations possess distinct characteristics that demand a more specific approach. Full article

(This article belongs to the Special Issue Advances in Minimally Invasive Gastrointestinal Surgery)

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