monthly focus

video lecture

In this authoritative lecture, Professor Mariano Giménez looks into percutaneous surgery and e-mentoring and the possibilities of remote training.

Percutaneous surgery and e-mentoring: is it possible to train remotely?

Chirurgie percutanée et e-mentoring : l'apprentissage à distance est-il possible ?

Chirurgie assistée par ordinateur : la révolution du 21e siècle

In this authoritative lecture, Professor Mariano Giménez focuses on computer-assisted surgery marking the 21st century revolution.

Computer-assisted surgery: the 21st century revolution

surgical intervention video

Intraductal papillary mucinous neoplasms (IPMN) are the most common form of pancreatic cyst neoplasms, with a spectrum ranging from adenoma to cancer, with less than 25% of prevalence in autopsy studies (1). The risk of IPMN-associated carcinoma for patients with main duct IPMN (MD-IPMN) and mixed-type (MT-IPMN) may be as great as 57 to 92%, whereas the risk for patients with branch-duct type (BD-IPMN) seems to be more variable (6-46%) (2). 

European guideline recommendations on surgery for patients with MD-IPMN or MT-IPMN involve cases presenting with main pancreatic duct dilatation (MPD) >5mm (1)(2). However, accurate diagnosis remains a challenge despite diagnostic tools such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound imaging (US), endoscopic retrograde cholangiopancreatography (ERCP), and ERCP-guided brushing (2) since recurrence of IPMN is comprised between 15 and 22% due to the persistence of undetected missed lesions (1). 

With pancreatoscopy, direct visualization of the pancreatic duct is obtained, which allows for the guidance of surgical resection of MD- and MT-IPMNs, assessing areas of residual lesions and influencing surgical decision-making (2)(3)(4) despite limited data on an adverse event rate of 12% (3). This procedure is proposed to customize resection margins during pancreatic resections of IPMNs, re-evaluation of non-compromised areas, and biopsy sample acquisition (4).



Bibliography:

1. Pollini T, Wong P, Maker AV. The Landmark Series: Intraductal Papillary Mucinous Neoplasms of the Pancreas-From Prevalence to Early Cancer Detection. Ann Surg Oncol. 2023;30(3):1453-1462. doi:10.1245/s10434-022-12870-w Link: https://pubmed.ncbi.nlm.nih.gov/36600097/

2. Kaura T, Willingham FF, Chawla S. Role of pancreatoscopy in management of pancreatic disease: A systematic review. World J Gastrointest Endosc. 2019;11(2):155-167. doi:10.4253/wjge.v11.i2.155.  Link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379742/

3. Ciprani D, Frampton A, Amar H, Oppong K, Pandanaboyana S, Aroori S. The role of intraoperative pancreatoscopy in the surgical management of intraductal papillary mucinous neoplasms of the pancreas: a systematic scoping review. Surg Endosc. 2023;37(12):9043-9051. doi:10.1007/s00464-023-10518-8 Link: https://pubmed.ncbi.nlm.nih.gov/37907657/

4. de Jong DM, Stassen PMC, Groot Koerkamp B, et al. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. Endoscopy. 2023;55(1):25-35. doi:10.1055/a-1869-0180 Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9767751/



Step-by-step intraoperative pancreatoscopy technique for intraductal pancreatic biopsy

Technique de pancréatoscopie peropératoire par étapes pour biopsie pancréatique intra-canalaire

Cholangioscopy is a method that allows direct visualization of the biliary tree. The main reason for performing endoscopic retrograde cholangiopancreatography (ERCP) is usually choledocholithiasis, and 85 to 90% of bile duct stones are successfully removed during the procedure (1). However, 10 to 15% of the remaining cases involve greater difficulties and may require additional or advanced techniques. In cases of failed ERCP, especially in patients with a surgically altered anatomy, percutaneous transhepatic cholangioscopy (PTC) is used for both diagnosis and treatment of biliary disease. PTC may be considered for several reasons, such as disproportionate stone placement in the distal common bile duct (CBD), patients with a surgically altered gastrointestinal anatomy, biliary strictures, multiple stones, barrel-shaped stones, and difficult-to-access sites when intrahepatic lithiasis or Mirizzi I syndrome is involved (1)(2). 

Cholangioscopy-assisted lithotripsy techniques, including electrohydraulic lithotripsy (EHL) and laser lithotripsy, are investigated for their efficacy in breaking up stones. In EHL, the probe is directed to the stone and advanced at least 5mm from the tip of the cholangioscope, bringing it within 1 to 2mm of the stone (3). 

As compared to other endoscopic techniques for the biliopancreatic system, cholangioscopy offers a major advantage, as it allows to directly visualize the biliary lumen and mucosa. As a result, cholangioscopy complements ERCP and endoscopic ultrasound (EUS) in the evaluation of complex clinical situations (3)(4).



Bibliography:

1. Gimenez ME, Uribe Rivera AK, Montanelli J, Swanström LL, Mutter D, Seeliger B. Cholangioscopy under direct visualization: skill progress during a dedicated Image-Guided Surgery Course. Surg Endosc. 2023;37(10):8116-8122. doi:10.1007/s00464-023-10357-7 Link: https://pubmed.ncbi.nlm.nih.gov/37658199/

2. Palermo M, Fendrich I, Ronchi A, Obeid J, Gimenez M. Laparoscopic Common Bile Duct Exploration Using a Single-Operator Cholangioscope. J Laparoendosc Adv Surg Tech A. 2020;30(9):989-992. doi:10.1089/lap.2020.0534 Link: https://pubmed.ncbi.nlm.nih.gov/32707008/

3. Uribe Rivera AK, Seeliger B, Saldivar CA, et al. Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope. Surg Endosc. 2023;37(10):7774-7783. doi:10.1007/s00464-023-10337-x Link: https://pubmed.ncbi.nlm.nih.gov/37580582/

4. Gerges C, Vázquez AG, Tringali A, et al. Percutaneous transhepatic cholangioscopy using a single-operator cholangioscope (pSOC), a retrospective, observational, multicenter study. Surg Endosc. 2021;35(12):6724-6730. doi:10.1007/s00464-020-08176-1 Link: https://pubmed.ncbi.nlm.nih.gov/33398561/

Percutaneous transhepatic cholangioscopy and lithotripsy in surgically modified anatomy after bariatric surgery

Cholangioscopie transhépatique percutanée et lithotripsie pour anatomie modifiée après chirurgie bariatrique

The introduction of the single-operator percutaneous short cholangioscope allows greater maneuverability in the percutaneous and laparoscopic technique. The success rate in different diagnostic and therapeutic scenarios has led to its increased use (1)(2). Among the macroscopic characteristics that we have, benign lesions present a smooth mucosal surface, with ulceration and band stenosis, while malignant lesions are characterized by neovascularization, papillary projections, and tortuous vessels (2)(3).

The importance of cholangioscopy in cases of indeterminate biliary strictures lies in the adequate identification of the causes of biliary strictures, either benign or malignant for adequate therapeutic decision-making (1-4).



Bibliography:

1. Uribe Rivera AK, Seeliger B, Saldivar CA, et al. Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope. Surg Endosc. 2023;37(10):7774-7783. doi:10.1007/s00464-023-10337-x Link: https://pubmed.ncbi.nlm.nih.gov/37580582/

2. Ahmed S, Schlachter TR, Hong K. Percutaneous Transhepatic Cholangioscopy. Tech Vasc Interv Radiol. 2015;18(4):201-209. doi:10.1053/j.tvir.2015.07.003 Link: https://pubmed.ncbi.nlm.nih.gov/26615160/

3. Schubach A, Penmetsa A, Sharma A, Kothari S. A Unique Approach to Obtaining Tissue in a Difficult to Access Indeterminate Biliary Stricture: Percutaneous Cholangioscopy and Biopsy. ACG Case Rep J. 2023;10(7):e01095. Published 2023 Jul 8. doi:10.14309/crj.0000000000001095 Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10332834/

4. Laleman W, Verraes K, Van Steenbergen W, et al. Usefulness of the single-operator cholangioscopy system SpyGlass in biliary disease: a single-center prospective cohort study and aggregated review. Surg Endosc. 2017;31(5):2223-2232. doi:10.1007/s00464-016-5221-2 Link: https://pubmed.ncbi.nlm.nih.gov/27604370/

Percutaneous transhepatic cholangioscopy and endocanalicular bile duct biopsy

Cholangioscopie transhépatique percutanée et biopsie endocanaliculaire des voies biliaires

Nouvelles technologies en endoscopie opératoire flexible avancée

In this authoritative lecture, Prof. Silvana Perretta addresses new technologies for advanced flexible operative endoscopy. 

New technologies for advanced flexible operative endoscopy

In this authoritative lecture, Prof. Barbara Seeliger gives an overview of current and new surgical robotic systems on the horizon and their emerging applications.

Robotically assisted approaches to thoracoabdominal diseases have gained increasing momentum over the last two decades. More than 100 companies offer robotic systems for all surgical disciplines worldwide, and technological progress is driving the adoption of procedures that are challenging with standard instrumentation. Of note, progress in endoluminal surgery will be accelerated with the use of flexible robots, and the treatment of small tumors in the liver and lungs using robotic systems for percutaneous image-guided surgery. Surgical robotic systems as digital interfaces with computer assistance and image guidance will provide connectivity between experts and decision-making support, and enhance training and teaching via the integration of machine learning-based diagnostic systems and advanced telecommunications infrastructures (5G today and 6G tomorrow). As a surgical community, we can continue to shape the future of minimally invasive surgery with clinical trials, research/development projects, and Industry collaborations on an internatinal scale.

Focus on surgery of the 3rd millennium

Percutaneous surgery and e-mentoring: is it possible to train remotely?

Computer-assisted surgery: the 21st century revolution

Step-by-step intraoperative pancreatoscopy technique for intraductal pancreatic biopsy

Percutaneous transhepatic cholangioscopy and lithotripsy in surgically modified anatomy after bariatric surgery

Percutaneous transhepatic cholangioscopy and endocanalicular bile duct biopsy

New surgical robots on the horizon