An expert review from the Foundation for Interventional and Therapeutic Endoscopy examines the evolving role of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) in patients with acute cholecystitis who are considered poor candidates for laparoscopic cholecystectomy.

The review compares EUS-GBD with two established alternatives: percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. With the use of lumen-apposing metal stents, EUS-GBD creates internal drainage between the gallbladder and the gastrointestinal tract, eliminating the need for an external catheter.

Potential Advantages

EUS-GBD may offer several practical benefits in carefully selected patients:

• Internal drainage without an external tube.
• Greater patient comfort and mobility.
• Lower risk of catheter dislodgement.
• Reduced recurrence of cholecystitis.
• Shorter hospital stay in selected populations.
• Access for subsequent cholecystoscopy and stone removal.
• Potential use as definitive therapy in patients permanently unfit for surgery.

The authors stress that EUS-GBD is not suitable for every patient. Important contraindications include suspected gallbladder perforation, uncontrolled coagulopathy, large-volume ascites, inability to safely oppose the gallbladder to the stomach or duodenum, and limited availability of experienced interventional endoscopists.

Questions also remain regarding the ideal timing of stent removal, long-term stent management, delayed cholecystectomy, and the safest approach when patients later become fit for surgery.

Clinical Relevance

Laparoscopic surgeons increasingly evaluate patients after temporary or definitive gallbladder drainage. This review helps clarify whether EUS-GBD should be used as a bridge to delayed cholecystectomy, long-term destination therapy, or part of a combined endoscopic-surgical treatment pathway. Multidisciplinary planning remains essential.

Source: https://pubmed.ncbi.nlm.nih.gov/42490390/

Randomized TEP Trial Finds Self-Fixating Mesh Comparable to Limited Tack Fixation

The SELFITAC double-blind randomized clinical trial compared self-fixating mesh with limited nonabsorbable tack fixation in 112 adult men undergoing elective unilateral totally extraperitoneal laparoscopic inguinal hernia repair.

The investigators assessed postoperative pain, analgesic requirements, quality of life, operative time, surgical-site events, chronic discomfort, and recurrence.

Key Findings

The two fixation strategies produced broadly similar outcomes:

• Comparable early postoperative pain.
• Similar analgesic requirements.
• Similar Carolina Comfort Scale scores.
• No meaningful difference in long-term chronic pain.
• Comparable surgical-site outcomes.
• Low recurrence rates in both groups.

At more than five years of follow-up, chronic pain was uncommon in both arms. One recurrence occurred in the self-fixating mesh group. Deployment of self-fixating mesh initially took longer, but application time improved as surgeons became more familiar with the technique.

The self-fixating mesh group also showed a modestly lower rise in inflammatory markers, although the clinical importance of this finding remains uncertain.

Clinical Relevance

For surgeons performing TEP repair, self-fixating mesh appears to be a reasonable atraumatic fixation option without a clear disadvantage in pain, quality of life, or recurrence. The study also highlights a short learning curve related to mesh unfolding, positioning, and fixation within the preperitoneal space.

Source: https://pubmed.ncbi.nlm.nih.gov/42490014/

Successful Robotic HPB Program Development Requires Team Scale, Mentorship and Structured Growth

A tertiary cancer centre reviewed 573 robotic hepatopancreatobiliary operations performed over 15 years. Procedures included robotic distal pancreatectomy, liver resection, hepatic artery infusion pump placement, and pancreatoduodenectomy.

The programme progressed through three distinct stages:

1. Initial experience.
2. Stabilisation and standardisation.
3. Expansion of case volume and procedural complexity.

Annual robotic case volume increased substantially during the expansion phase. Although major complications rose numerically as more complex procedures were introduced, the increase was not statistically significant.

Elements Associated With Sustainable Growth

The authors identified several recurring requirements for developing a durable robotic HPB programme:

• A critical mass of trained surgeons.
• Mentorship from experienced HPB and robotic surgeons.
• Dedicated operating-room teams.
• Standardised patient selection.
• Reliable access to robotic technology.
• Progressive expansion of procedural indications.
• Continuous review of complications and outcomes.
• Institutional commitment to education and governance.

The study suggests that robotic HPB surgery should be developed as an institutional programme rather than as an isolated individual-surgeon initiative.

Clinical Relevance

Complex robotic liver and pancreatic surgery depends on far more than console skill. Hospitals planning robotic HPB services should develop formal credentialing, mentorship, operating-room staffing, case-review, simulation, and outcome-audit pathways before expanding into highly complex procedures.

Source: https://pubmed.ncbi.nlm.nih.gov/42489998/

Robotic Pancreatoduodenectomy Shows Benefits After Completion of the Learning Curve

A high-volume centre compared its most recent 50 robotic pancreatoduodenectomies with 100 propensity-matched open procedures. The investigators also used cumulative sum analysis to examine performance during the early and later phases of robotic adoption.

Comparative Outcomes

After the learning curve, robotic pancreatoduodenectomy was associated with:

• Lower estimated blood loss.
• Shorter postoperative hospital stay.
• Fewer lymphatic fistulas.
• Similar major complication rates.
• Similar pancreas-specific morbidity.
• Significantly longer operative time than open surgery.

Within the robotic cohort, operative efficiency improved considerably after the first 50 cases. Cumulative sum analysis identified performance inflection points around cases 51 to 55 for operative time, major complications, and postoperative haemorrhage.

Interpretation

The findings demonstrate that outcomes from robotic pancreatoduodenectomy are strongly influenced by experience and programme maturity. Early robotic results should not be directly compared with mature open-surgery outcomes without considering surgeon volume, team experience, procedural standardisation, and case selection.

Clinical Relevance

Robotic pancreatoduodenectomy should be introduced through structured, volume-based programmes with proctoring, gradual case escalation, standardised reconstruction, and continuous outcome monitoring. The operation remains technically demanding, and favourable results are unlikely to be reproduced without sufficient experience and institutional support.

Source: https://pubmed.ncbi.nlm.nih.gov/42489883/

Contrast-Free Spectral Imaging May Complement ICG Assessment of Gastric Conduit Perfusion

In a prospective study involving 33 patients undergoing laparoscopic Ivor Lewis oesophagectomy, investigators evaluated real-time snapshot spectral imaging for assessment of gastric conduit oxygenation.

The technique estimates tissue oxygen saturation without requiring injection of a contrast agent. Its findings were compared with quantitative indocyanine green fluorescence measurements and local capillary lactate levels.

Key Findings

Spectral imaging successfully differentiated well-perfused tissue from areas of reduced oxygenation. Tissue oxygen saturation measurements showed a strong correlation with local capillary lactate, which is a physiological marker of tissue hypoxia.

ICG fluorescence also detected impaired perfusion but demonstrated only a moderate correlation with tissue oxygenation. In one patient who later developed an anastomotic leak, both techniques identified ischaemia; however, spectral imaging suggested that the hypoxic area was more extensive.

Potential Advantages

Contrast-free spectral imaging may offer:

• Continuous or repeated assessment without additional dye.
• Direct estimation of tissue oxygenation.
• Improved identification of marginally perfused conduit tissue.
• Additional guidance when selecting the anastomotic site.
• Complementary information when ICG findings are equivocal.

Clinical Relevance

Anastomotic leakage remains one of the most serious complications after minimally invasive oesophagectomy. Objective assessment of gastric conduit perfusion may improve anastomotic planning, but larger studies are required to determine whether spectral imaging reduces leak rates or improves long-term outcomes.

Source: https://pubmed.ncbi.nlm.nih.gov/42489882/

Stepwise ICG Biliary Mapping Supports Safer Paediatric Pancreatic Head Resection

A Beijing group described a standardised seven-step indocyanine green fluorescence protocol for laparoscopic duodenum-preserving pancreatic head resection in seven children with focal congenital hyperinsulinism.

This operation is technically difficult because the intrapancreatic common bile duct must be preserved while abnormal pancreatic tissue is removed in a small operative field with limited tactile feedback.

Seven-Step Fluorescence Workflow

The protocol included:

1. Exposure of the pancreatic head and surrounding anatomy.
2. Initial ICG administration.
3. Fluorescence mapping of the biliary tract.
4. Near-infrared-guided pancreatic dissection.
5. Repeat assessment or reinjection when required.
6. Evaluation of duodenal and surrounding tissue perfusion.
7. Final fluorescence confirmation after reconstruction.

Continuous visualisation of the intrapancreatic common bile duct was achieved in all seven patients. No bile leak, clinically relevant pancreatic fistula, or duodenal ischaemia was reported in this small series.

Clinical Relevance

The study provides a reproducible fluorescence-guided workflow for duct-preserving pancreatic dissection. Although the evidence remains preliminary, similar principles may be useful in other paediatric and adult procedures where the common bile duct is difficult to identify and injury would carry major consequences.

Source: https://pubmed.ncbi.nlm.nih.gov/42489740/

Anti-Reflux Surgery in Connective Tissue Disorders Requires Careful Fundoplication Selection

A systematic review of nine studies examined 129 laparoscopic anti-reflux procedures performed in patients with connective tissue disorders, most commonly systemic sclerosis or scleroderma.

These patients frequently have severe gastro-oesophageal reflux combined with impaired oesophageal motility, creating a difficult balance between adequate reflux control and the risk of postoperative dysphagia.

Reported Outcomes

Across the included studies:

• Reflux symptoms improved or resolved in approximately 87% of patients.
• Regurgitation improved in around 74%.
• Postoperative dysphagia occurred in approximately 24% of patients with available data.
• Overall complications occurred in about 12%.
• No perioperative mortality was reported.
• Five-year satisfaction reached approximately 93% where long-term data were available.

Postoperative dysphagia appeared more common in cohorts dominated by complete Nissen fundoplication. Partial fundoplication was used more frequently and generally achieved acceptable reflux control with lower dysphagia rates.

Clinical Relevance

Patients with connective tissue disorders require detailed preoperative evaluation, including oesophageal manometry, endoscopy, reflux testing, and assessment of gastric emptying where appropriate. In the presence of poor motility, a partial wrap may offer a safer balance between symptom control and preservation of swallowing function.

Source: https://pubmed.ncbi.nlm.nih.gov/42489036/

Key Takeaway

Today’s evidence reinforces that successful minimally invasive surgery depends on appropriate patient selection, structured learning, objective intraoperative imaging, and multidisciplinary care. EUS-guided gallbladder drainage is becoming better defined for high-risk patients, self-fixating mesh appears reliable in TEP repair, and complex robotic HPB procedures require mature institutional programmes. Emerging fluorescence and spectral imaging technologies may further improve anatomical identification, perfusion assessment, and operative safety.