Multiple Synchronous Squamous Cell Cancers of the Skin and Esophagus: Differential Management of Primary Versus Secondary Tumor

Multiple primary tumors are uncommon in patients with squamous cell esophageal cancer. Conventional imaging methods have limitations in detecting those tumors. Although 18-F-fluoro-deoxyglucose-positron emission tomography scanner increases the detection of multiple synchronous tumors in patients with other malignancies, its contribution in patients with squamous cell esophageal cancer has not been assessed as it is not systematically performed. The detection of synchronous skin squamous cell tumors in patients with squamous cell esophageal cancer presents a challenge for making diagnostic and therapeutic decisions. A metastatic tumor leads to palliative management, whereas the diagnosis of a primary skin tumor requires curative treatment of both squamous cell tumors. Pathological evaluation appears crucial in the decision

Surgical data science for safe cholecystectomy: a protocol for segmentation of hepatocystic anatomy and assessment of the critical view of safety

Minimally invasive image-guided surgery heavily relies on vision. Deep learning models for surgical video analysis could therefore support visual tasks such as assessing the critical view of safety (CVS) in laparoscopic cholecystectomy (LC), potentially contributing to surgical safety and efficiency. However, the performance, reliability and reproducibility of such models are deeply dependent on the quality of data and annotations used in their development. Here, we present a protocol, checklists, and visual examples to promote consistent annotation of hepatocystic anatomy and CVS criteria. We believe that sharing annotation guidelines can help build trustworthy multicentric datasets for assessing generalizability of performance, thus accelerating the clinical translation of deep learning models for surgical video analysis.Comment: 24 pages, 34 figure

Image-Guided Surgical e-Learning in the Post-COVID-19 Pandemic Era: What Is Next?

The current unprecedented coronavirus 2019 (COVID-19) crisis has accelerated and enhanced e-learning solutions. During the so-called transition phase, efforts were made to reorganize surgical services, reschedule elective surgical procedures, surgical research, academic education, and careers to optimize results. The intention to switch to e-learning medical education is not a new concern. However, the current crisis triggered an alarm to accelerate the transition. Efforts to consider e-learning as a teaching and training method for medical education have proven to be efficient. For image-guided therapies, the challenge requires more effort since surgical skills training is combined with image interpretation training, thus the challenge is to cover quality educational content with a balanced combination of blended courses (online/onsite). Several e-resources are currently available in the surgical scenario; however, further efforts to enhance the current system are required by accelerating the creation of new learning solutions to optimize complex surgical education needs in the current disrupted environment

Endoluminal surgical triangulation: overcoming challenges of colonic endoscopic submucosal dissections using a novel flexible endoscopic surgical platform: feasibility study in a porcine model

Background: Colonic endoscopic submucosal dissection (ESD) is challenging as a result of the limited ability of conventional endoscopic instruments to achieve traction and exposure. The aim of this study was to evaluate the feasibility of colonic ESD in a porcine model using a novel endoscopic surgical platform, the Anubiscope (Karl Storz, Tüttlingen, Germany), equipped with two working channels for surgical instruments with four degrees of freedom offering surgical triangulation. Methods: Nine ESDs were performed by a surgeon without any ESD experience in three swine, at 25, 15, and 10cm above the anal verge with the Anubiscope. Sixteen ESDs were performed by an experienced endoscopist in five swine using conventional endoscopic instruments. Major ESD steps included the following for both groups: scoring the area, submucosal injection of glycerol, precut, and submucosal dissection. Outcomes measured were as follows: dissection time and speed, specimen size, en bloc dissection, and complications. Results: No perforations occurred in the Anubis group, while there were eight perforations (50%) in the conventional group (p=0.02). Complete and en bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for completed cases was statistically significantly shorter in the Anubis group (32.3±16.1 vs. 55.87±7.66min; p=0.0019). Mean specimen size was higher in the conventional group (1321±230 vs. 927.77±229.96mm2; p=0.003), but mean dissection speed was similar (35.95±18.93 vs. 23.98±5.02mm2/min in the Anubis and conventional groups, respectively; p=0.1). Conclusions: Colonic ESDs were feasible in pig models with the Anubiscope. This surgical endoscopic platform is promising for endoluminal surgical procedures such as ESD, as it is user-friendly, effective, and saf

A Novel Telemanipulated Robotic Assistant for Surgical Endoscopy: Preclinical Application to ESD

International audienceObjective: Minimally invasive surgical interventions in the gastrointestinal tract, such as Endoscopic Submucosal Dissection (ESD), are very difficult for surgeons when performed with standard flexible endoscopes. Robotic flexible systems have been identified as a solution to improve manipulation. However, only a few such systems have been brought to preclinical trials as of now. As a result, novel robotic tools are required.Methods: We developed a telemanipulated robotic device, called STRAS, which aims to assist surgeons during intraluminal surgical endoscopy. This is a modular system, based on a flexible endoscope and flexible instruments, which provides 10 degrees of freedom (DoFs). The modularity allows to easily set up the robot and to navigate towards the operating area. The robot can then be teleoperated using master interfaces specifically designed to intuitively control all available DoFs. STRAS capabilities have been tested in laboratory conditions and during preclinical experiments. Results: We report twelve colorectal ESDs performed in pigs, in which large lesions were successfully removed. Dissection speeds are compared with those obtained in similar conditions with the manual Anubiscope TM platform from Karl Storz. We show significant improvements (p = 0.01).Conclusion: These experiments show that STRAS (v2) provides sufficient DoFs, workspace and force to perform ESD, that it allows a single surgeon to perform all the surgical tasks and that performances are improved with respect to manual systems. Significance: The concepts developed for STRAS are validated and could bring new tools for surgeons to improve comfort, ease and performances for intraluminal surgical endoscopy

Real-time navigation by fluorescence-based enhanced reality for precise estimation of future anastomotic site in digestive surgery

Background: Fluorescence-based enhanced reality (FLER) is a technique to evaluate intestinal perfusion based on the elaboration of the Indocyanine Green fluorescence signal. The aim of the study was to assess FLER's performances in evaluating perfusion in an animal model of long-lasting intestinal ischemia. Materials and methods: An ischemic segment was created in 18 small bowel loops in 6 pigs. After 2h (n=6), 4h (n=6), and 6h (n=6), loops were evaluated clinically and by FLER to delineate five regions of interest (ROIs): ischemic zone (ROI 1), presumed viable margins (ROI 2a-2b), and vascularized areas (3a-3b). Capillary lactates were measured to compare clinical vs. FLER assessment. Basal (V 0 ) and maximal (V max) mitochondrial respiration rates were determined according to FLER. Results: Lactates (mmol/L) at clinically identified resection lines were significantly higher when compared to those identified by FLER (2.43±0.95 vs. 1.55±0.33 p=0.02) after 4h of ischemia. Lactates at 2h at ROI 1 were 5.45±2.44 vs. 1.9±0.6 (2a-2b; p<0.0001) vs. 1.2±0.3 (3a-3b; p<0.0001). At 4h, lactates were 4.36±1.32 (ROI 1) vs. 1.83±0.81 (2a-2b; p<0.0001) vs. 1.35±0.67 (3a-3b; p<0.0001). At 6h, lactates were 4.16±2.55 vs. 1.8±1.2 vs. 1.45±0.83 at ROI 1 vs. 2a--2b (p=0.013) vs. 3a-3b (p=0.0035). Mean V 0 and V max (pmolO2/second/mg of tissue) were significantly impaired after 4 and 6h at ROI 1 (V 0 4h =34.83±10.39; V max 4h =76.6±29.09; V 0 6h =44.1±12.37 and V max 6h =116.1±40.1) when compared to 2a--2b (V 0 4h =67.1±17.47 p=0.00039; V max 4h =146.8±55.47 p=0.0054; V 0 6h =63.9±28.99 p=0.03; V max 6h =167.2±56.96 p=0.01). V 0 and V max were significantly higher at 3a-3b. Conclusions: FLER may identify the future anastomotic site even after repetitive assessments and long-standing bowel ischemia

Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia

Background and aim: Surgeons currently rely on visual clues to estimate the presence of sufficient vascularity for safe anastomosis. We aimed to assess the accuracy of endoluminal confocal laser endomicroscopy (CLE) and laparoscopic fluorescence-based enhanced reality (FLER), using near-infrared imaging and fluorescence from injected Indocyanine Green, to identify the transition from ischemic to vascular areas in a porcine model of mesenteric ischemia. Methods: Six pigs underwent 1-h sigmoid segmental ischemia. The ischemic area was evaluated by clinical assessment and FLER to determine presumed viable margins. For each sigmoid colon, 5 regions of interest (ROIs) were identified: ischemic (ROI 1), presumed viable margins ROI 2a (distal) and 2b (proximal), and vascular areas 3a (distal) and 3b (proximal). After injection of fluorescein, CLE scanning of the mucosa from the ischemic area toward viable margins was performed. Capillary blood samples were obtained by puncturing the serosa at the ROIs, and capillary lactates were measured with the EDGE® analyzer. Results: Capillary lactates were significantly higher at ROI 1 (4.91mmol/L) when compared to resection margins (2.8mmol/L; mean difference: 2.11; p<0.05) identified by FLER. There was no significant difference in lactates between ROI1 and resection margins identified by clinical evaluation. In 50% of cases, ROI 2aCLINIC-2bCLINIC were considered to match (<1cm distance) with ROI 2aFLER-2bFLER. Confocal analysis revealed specific clues to identify the transition from ischemic to viable areas corresponding to those assessed by FLER in 11/12 cases versus 7/12 for those identified by clinical evaluation. Conclusions: In this experimental model, FLER and CLE were more accurate than clinical evaluation to delineate bowel vascularization

Preserving privacy in surgical video analysis using a deep learning classifier to identify out-of-body scenes in endoscopic videos

Surgical video analysis facilitates education and research. However, video recordings of endoscopic surgeries can contain privacy-sensitive information, especially if the endoscopic camera is moved out of the body of patients and out-of-body scenes are recorded. Therefore, identification of out-of-body scenes in endoscopic videos is of major importance to preserve the privacy of patients and operating room staff. This study developed and validated a deep learning model for the identification of out-of-body images in endoscopic videos. The model was trained and evaluated on an internal dataset of 12 different types of laparoscopic and robotic surgeries and was externally validated on two independent multicentric test datasets of laparoscopic gastric bypass and cholecystectomy surgeries. Model performance was evaluated compared to human ground truth annotations measuring the receiver operating characteristic area under the curve (ROC AUC). The internal dataset consisting of 356,267 images from 48 videos and the two multicentric test datasets consisting of 54,385 and 58,349 images from 10 and 20 videos, respectively, were annotated. The model identified out-of-body images with 99.97% ROC AUC on the internal test dataset. Mean +/- standard deviation ROC AUC on the multicentric gastric bypass dataset was 99.94 +/- 0.07% and 99.71 +/- 0.40% on the multicentric cholecystectomy dataset, respectively. The model can reliably identify out-of-body images in endoscopic videos and is publicly shared. This facilitates privacy preservation in surgical video analysis

Antireflux Transoral Incisionless Fundoplication Using EsophyX: 12-Month Results of a Prospective Multicenter Study

BACKGROUND: A novel transoral incisionless fundoplication (TIF) procedure using the EsophyX system with SerosaFuse fasteners was designed to reconstruct a full-thickness valve at the gastroesophageal junction through tailored delivery of multiple fasteners during a single-device insertion. The safety and efficacy of TIF for treating gastroesophageal reflux disease (GERD) were evaluated in a prospective multicenter trial. METHODS: Patients (n = 86) with chronic GERD treated with proton pump inhibitors (PPIs) were enrolled. Exclusion criteria included an irreducible hiatal hernia > 2 cm. RESULTS: The TIF procedure (n = 84) reduced all hiatal hernias (n = 49) and constructed valves measuring 4 cm (2-6 cm) and 230 degrees (160 degrees -300 degrees ). Serious adverse events consisted of two esophageal perforations upon device insertion and one case of postoperative intraluminal bleeding. Other adverse events were mild and transient. At 12 months, aggregate (n = 79) and stratified Hill grade I tight (n = 21) results showed 73% and 86% of patients with >or=50% improvement in GERD health-related quality of life (HRQL) scores, 85% discontinuation of daily PPI use, and 81% complete cessation of PPIs; 37% and 48% normalization of esophageal acid exposure; 60% and 89% hiatal hernia reduction; and 62% and 80% esophagitis reduction, respectively. More than 50% of patients with Hill grade I tight valves had a normalized cardia circumference. Resting pressure of the lower esophageal sphincter (LES) was improved significantly (p < 0.001), by 53%. EsophyX-TIF cured GERD in 56% of patients based on their symptom reduction and PPI discontinuation. CONCLUSION: The 12-month results showed that EsophyX-TIF was safe and effective in improving quality of life and for reducing symptoms, PPI use, hiatal hernia, and esophagitis, as well as increasing the LES resting pressure and normalizing esophageal pH and cardia circumference in chronic GERD patients.Journal ArticleMulticenter StudyResearch Support, Non-U.S. Gov'tinfo:eu-repo/semantics/publishe