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BACKGROUND: Although endoscopic dacryocystorhinostomy (EDCR) has been performed successfully in primary and revision cases, there has yet to be a consensus on the best surgical approach. METHODS: Excessive granulation, adhesion, and fibrosis, the main causes of unsuccessful EDCR, should be expected more frequently in revision surgery. Anastomosis by ligating the nasal mucoperiosteum and lacrimal sac flaps with clips can minimise the surface of exposed bone, therefore, the possibility of stenosis and failure of the dacryocystorhinostomy. CONCLUSIONS: In 12 revision EDSR patients, ligating clips ensured an anatomical overlap of the mucoperiosteum and sac flap, providing a wider rhinostomy opening and straight epithelial lining.

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Background: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a complication of dual antiplatelet therapy (DAPT) and direct oral anticoagulant therapy (DOAC). There is a lack of data comparing mechanical therapy (clips) with thermal therapy in this population. Methods: We conducted a retrospective chart review of patients undergoing urgent/emergent endoscopy for NVUGIB while being on DAPT or DOAC. Patients who had DAPT/DOAC held as per American Society of Gastrointestinal Endoscopy guidelines were excluded from the study. Results: A total of 122 patients were included in the study. There was no difference in primary hemostasis, rebleeding rate, rescue hemostatic procedure, and 30-day mortality between the mechanical and thermal therapy groups. The mechanical therapy group had a significantly higher rate of prolonged length of stay (61.2% vs 38.9%, P = 0.02), serious clinical outcomes (56% vs 37.5%, P = 0.04), and intensive care unit admissions (50% vs 20.8%, P = 0.001) than the thermal therapy group. Conclusion: Patients on DAPT/DOAC presenting with NVUGIB can undergo mechanical or thermal endoscopic intervention without a significant difference in achieving primary hemostasis, rebleeding, requiring a secondary procedure, or mortality outcomes.

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The increasing use of MAUDE reports in patient safety research highlights the importance of understanding the processing and dissemination of open-access MAUDE data. However, the absence of a structured data pipeline undermines the reproducibility and transparency of studies relying on MAUDE data. In response, we conducted a comprehensive analysis of a recent study on endoscopic clips, assessing methodologies and results. We advocate for implementing an extract, transform, and load (ETL) pipeline, utilizing openFDA and integrating keyword search strategies and data visualization techniques. This approach aims to enhance the quality of MAUDE-based studies, ensuring their reproducibility and transparency. Moreover, ETL serves as a cornerstone in data engineering, enabling real-time data management and quality assurance, thus promoting the sustainability and collaboration of MAUDE-based patient safety research.

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Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

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BACKGROUND: Acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is a frequent life-threatening acute condition in gastroenterology associated with high morbidity and mortality. Over-the-scope-clip (OTSC) is a new endoscopic hemostasis technique, which is being used in ANVUGIB and is more effective. AIM: To summarize and analyze the effects of the OTSC in prevention of recurrent bleeding, clinical success rate, procedure time, hospital stay, and adverse events in the treatment of ANVUGIB, to evaluate whether OTSC can replace standard endoscopic therapy as a new generation of treatment for ANVUGIB. METHODS: The literature related to OTSC and standard therapy for ANVUGIB published before January 2023 was searched in PubMed, Web of Science, EMBASE, Cochrane, Google, and CNKI databases. Changes in recurrent bleeding (7 or 30 days), clinical results (clinical success rate, conversion rate to surgery, mortality), therapy time (procedure time, hospital stay), and adverse events in the OTSC intervention group were summarized and analyzed, and the MD or OR of 95%CI is calculated by Review Manager 5.3. RESULTS: This meta-analysis involved 11 studies with 1266 patients. Total risk of bias was moderate-to-high. For patients in the OTSC group, 7- and 30-days recurrent bleeding rates, as well as procedure time, hospital stay, and intensive care unit stay, were greatly inhibited. OTSC could significantly improve the clinical success rate of ANVUGIB. OTSC therapy did not cause serious adverse and was effective in reducing patient mortality. CONCLUSION: OTSC may provide more rapid and sustained hemostasis, and thus, promote recovery and reduce mortality in patients with ANVUGIB. In addition, the safety of OTSC is assured.

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Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

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Purse-string suture with nylon cords and metal clips under the endoscope is a novel therapeutic technique which is minimally invasive and it is particularly indicated for the closure and repair of gastrointestinal fistula or perforations such as duodenal fistulae. Duodenal fistulae are often caused by medical manipulation, disease progression or trauma. Once this occurs, it leads to a series of pathophysiologic changes and a variety of complications. In most cases, these complications will exacerbate the damage to the organism, and the complications are difficult to treat and can lead to infections, nutrient loss, multi-organ dysfunction and many other adverse effects. In this case report, the use of endoscopic nylon cords combined with purse-string suture and metal clips in the treatment of duodenal fistula is presented and discussed. The patient was treated with endoscopic purse-string suture and the duodenal fistula was significantly improved. The results indicate that endoscopic purse-string suture is an effective strategy for the treatment of duodenal fistulae.

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The anterior communicating artery (AcoA) aneurysms represent the most complex aneurysms of the anterior circulation. For years, surgical challenges including the intricate anatomy and narrow surgical corridor have been overcome using supplementary techniques including extended craniotomies, wide opening of the cisterns, gyrus rectus resection and special clips like fenestrated clips. However, imaginative solutions such as intraoperative clip modification may be inevitable in particular cases for safe clipping. We retrospectively analyzed clinical records of two patients who required clip modification intraoperatively. Case #1 underwent microsurgical clipping of a ruptured, 4-mm AcoA aneurysm. Unfortunately, given the short distance between the two A2s, it was not possible to clip the aneurysm without a compromise to the contralateral A2 with the available shortest 3mm-fenestrated clip. We then used the clip modification technique intraoperatively by shortening the clip tips with mesh-plaque cutter and smoothening the remaining sharp ends using cautery sanding. Eventually, the aneurysm was clipped successfully with the modified-fenestrated clip. Post-clipping imagings confirmed complete occlusion of the aneurysm and patency of parent arteries. Case 2# underwent microsurgical clipping for a ruptured, 1-mm AcoA aneurysm. Like Case 1#, the initial clipping attempt with the available shortest 4mm-fenestrated clip failed given the excessive length of the tips. The patient, thus, required clip modification as described above. The aneurysm was then clipped successfully using the modified-fenestrated clip, protecting bilateral A2s. Post-clipping imagings demonstrated patency of parent arteries with no residual aneurysm filling. Clip modification seems to be an effective option in clipping the AcoA aneurysms when available clips are too long to secure them safely.

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BACKGROUND: After breast conserving surgery (BCS), surgical clips indicate the tumor bed and, thereby, the most probable area for tumor relapse. The aim of this study was to investigate whether a U-Net-based deep convolutional neural network (dCNN) may be used to detect surgical clips in follow-up mammograms after BCS. METHODS: 884 mammograms and 517 tomosynthetic images depicting surgical clips and calcifications were manually segmented and classified. A U-Net-based segmentation network was trained with 922 images and validated with 394 images. An external test dataset consisting of 39 images was annotated by two radiologists with up to 7 years of experience in breast imaging. The network's performance was compared to that of human readers using accuracy and interrater agreement (Cohen's Kappa). RESULTS: The overall classification accuracy on the validation set after 45 epochs ranged between 88.2% and 92.6%, indicating that the model's performance is comparable to the decisions of a human reader. In 17.4% of cases, calcifications have been misclassified as post-operative clips. The interrater reliability of the model compared to the radiologists showed substantial agreement (κreader1 = 0.72, κreader2 = 0.78) while the readers compared to each other revealed a Cohen's Kappa of 0.84, thus showing near-perfect agreement. CONCLUSIONS: With this study, we show that surgery clips can adequately be identified by an AI technique. A potential application of the proposed technique is patient triage as well as the automatic exclusion of post-operative cases from PGMI (Perfect, Good, Moderate, Inadequate) evaluation, thus improving the quality management workflow.

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INTRODUCTION: Ligation of the renal pedicle is a crucial step in laparoscopic renal harvesting. Currently, two devices are widely used: Hem-o-Lok® clips and staplers. Each has its advantages and disadvantages. METHODS: A systematic literature review was conducted following the PRISMA methodology on PubMed, EMBASE, and Cochrane databases with no time restrictions. Registered in the PROSPERO database (CRD42023460585), the study's primary outcome measures include the failure rate of the ligation tool, conversion to open surgery, rate of severe bleeding, and device-related death. Other secondary variables are also explored. An assessment of the quality of included comparative studies was performed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. RESULTS: Out of 393 articles identified using our keywords, 32 were included. Overall, clips have a lower failure rate during application, elongate graft vessel length, and are more cost-effective. Staples are associated with a shorter warm ischemia time and lower blood loss. There is no significant difference between the two devices in terms of conversion, severe bleeding, death, and blood transfusion. CONCLUSION: There is no perfect modality for renal pedicle control during laparoscopic harvesting, as each instrument has its pros and cons. Hem-o-Lok® clips are a safe and cost-effective option, particularly suitable for right-sided harvesting or in cases of vascular variations. However, they are still associated with a risk of secondary displacement with potentially serious consequences. Certain technical tricks can mitigate this risk.

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While the endoscopic management of surgical complications like leaks, fistulas, and perforations is rapidly evolving, its core principles revolve around closure, drainage, and containment. Effectively managing these conditions relies on several factors, such as the underlying cause, chronicity of the lesion, tissue viability, co-morbidities, availability of devices, and expertise required to perform the endoscopy. In contrast to acute perforation, fistulas and leaks often demand a multimodal approach requiring more than one session to achieve the required results. Although the ultimate goal is complete resolution, these endoscopic interventions can provide clinical stability, enabling enteral feeding to lead to early hospital discharge or elective surgery. In this discussion, we emphasize the current state of knowledge and the prospective role of endoscopic interventions in managing surgical complications.

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A significant problem encountered in the resection of large, complex colonic polyps is delayed bleeding. This can occur up to two weeks after the procedure and is a significant source of comorbidity. Untreated it can prove life threatening. It is therefore a priority of modern endoscopy to develop and employ techniques to minimaize this. In this article we will review and discuss the evidence base and controversies in this field, with cold EMR technique, Post-EMR clip closure, and topical haemostatic agents.

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Severe gastrointestinal bleeding is a common presentation to the emergency department. In such settings, trans-arterial embolization (TAE) may be conducted to address the bleeding. However, in some circumstances, this treatment may fail. Over-the-scope clips (OTSCs) have also shown efficacy when the first-line treatment is unsuccessful, and in this case report, we describe what we believe is the first reported application of OTSCs after TAE with partial coil migration. The patient had initially arrived at the emergency department with severe gastrointestinal bleeding, and despite the usage of inotropes and TAE, the patient had developed severe rebleeding. She ultimately recovered well after the utilization of OTSCs. This case report highlights that this form of management may be a valuable endoscopic therapy in preventing further coil migration for patients with emergency gastrointestinal bleeding.

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INTRODUCTION: Accurate tumor localization and resection margin acquisition are essential in gastric cancer surgery. Preoperative placement of marking clips in laparoscopic gastrectomy as well as intraoperative gastroscopy can be used for gastric cancer surgery. However, these procedures are not available at all institutions. We conducted a prospective clinical trial to investigate the diagnostic performance of near-infrared fluorescent clips (ZEOCLIP FS) in laparoscopic gastrectomy. MATERIALS AND METHODS: Patients with gastric cancer or neuroendocrine tumor in whom laparoscopic distal, pylorus-preserving, or proximal gastrectomy was planned were enrolled (n = 20) in this study. Fluorescent clips were placed proximal and/or distal to the tumor via gastroscopy on the day before surgery. During surgery, the clips were detected using a fluorescent laparoscope, and suturing was performed where fluorescence was detected. The clip locations were then confirmed via gastroscopy, and the stomach was transected. The primary endpoint was the detection rate of the marking clips using fluorescence, and the secondary endpoints were complications and distance between the clips and stitches. RESULTS: Among the 20 patients enrolled, distal and pylorus-preserving gastrectomies were performed in 18 and 2 patients, respectively. All clips were detected in 15 patients, indicating a detection rate of 75.0% (90% confidence interval: 54.4%-89.6%). Furthermore, no complications related to the clips were observed. The median distance between the clips and stitches was 5 (range, 0-10) mm. CONCLUSIONS: We report the feasibility and safety of preoperative placement and intraoperative detection of near-infrared fluorescent marking clips in laparoscopic gastrectomy.

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Introducción: El varicocele es la dilatación anormal del plexopampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducirhipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones,incluyendo la recurrencia del varicocele, dependiendo de la técnica deoclusión vascular utilizada: clip y sección o sellador vascular, en latécnica de Palomo laparoscópico en nuestro centro.Material y métodos: Estudio longitudinal prospectivo que se realizade 2017 a 2021. Se crean dos grupos terapéuticos según el método deoclusión vascular utilizada durante la varicocelectomía laparoscópica:clip y sección o sellador vascular. Los pacientes son incluidos en ungrupo mediante asignación sistemática consecutiva alternante. Se realizael análisis de las variables: edad, grado de varicocele según la clasifica-ción de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento yrecurrencia del varicocele, según el método empleado.Resultados: Se intervinieron un total de 37 niños, con edad mediade 12 años (10-15 años) y una media de seguimiento de 12 meses. En20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes(45,9%), sellador vascular. El 24,3% presentaba varicocele Grado IIsintomático y el 75,7%, Grado III. El 32,4% de los niños presentó algunacomplicación postquirúrgica durante el seguimiento. El 29,7% de lospacientes presentó hidrocele tras la intervención, perteneciendo 8 niñosal grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisóreintervención por este motivo. Ningún paciente presentó recurrenciadel varicocele. Conclusiones: La técnica de Palomo laparoscópica es una técnicasegura y efectiva que presenta buenos resultados en pacientes pediátricos...(AU)

Introduction: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males.Varicocele diagnosis is important since it can induce testicular hyper-trophy and fertility issues in adulthood. The objective of this studywas to assess whether complications, including varicocele recurrence,depend on the vascular occlusion technique used –clipping + divisionvs. vascular sealer–in the laparoscopic Palomo technique used inour institution. Materials and methods: A longitudinal, prospective study wascarried out from 2017 to 2021. Two therapeutic groups were createdaccording to the vascular occlusion method used during laparoscopicvaricocelectomy –clipping + division vs. vascular sealer. Patients wererandomly allocated to the groups in a systematic alternating consecutivemanner. Variables –age, varicocele grade according to the Dubin-Amelarclassification, postoperative complications, follow-up, and varicocelerecurrence– were analyzed according to the method employed.Results: A total of 37 boys, with a mean age of 12 years (10-15years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17(45.9%), the vascular sealer was employed. 24.3% had symptomaticGrade II varicocele and 75.7% had Grade III varicocele. 32.4% of thechildren had postoperative complications during follow-up. 29.7% ofthe patients had hydrocele following surgery –8 boys from the seal-ing group and 3 boys from the clipping group–, with 13.5% requiringre-intervention as a result of this. None of the patients had varicocelerecurrence. Conclusions: The laparoscopic Palomo technique is safe and ef-fective, with good results in pediatric patients and few postoperativecomplications, regardless of the vascular occlusion device used...(AU)

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BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

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INTRODUCTION: Varicocele is the abnormal dilatation of the pampiniform plexus. It occurs in 15-20% of pre-adolescent/adult males. Varicocele diagnosis is important since it can induce testicular hypertrophy and fertility issues in adulthood. The objective of this study was to assess whether complications, including varicocele recurrence, depend on the vascular occlusion technique used -clipping + division vs. vascular sealer- in the laparoscopic Palomo technique used in our institution. MATERIALS AND METHODS: A longitudinal, prospective study was carried out from 2017 to 2021. Two therapeutic groups were created according to the vascular occlusion method used during laparoscopic varicocelectomy -clipping + division vs. vascular sealer. Patients were randomly allocated to the groups in a systematic alternating consecutive manner. Variables -age, varicocele grade according to the Dubin-Amelar classification, postoperative complications, follow-up, and varicocele recurrence- were analyzed according to the method employed. RESULTS: A total of 37 boys, with a mean age of 12 years (10-15 years) and a mean follow-up of 12 months, were studied. In 20 patients (54.1%), clipping + division was used, and in the remaining 17 (45.9%), the vascular sealer was employed. 24.3% had symptomatic Grade II varicocele and 75.7% had Grade III varicocele. 32.4% of the children had postoperative complications during follow-up. 29.7% of the patients had hydrocele following surgery -8 boys from the sealing group and 3 boys from the clipping group-, with 13.5% requiring re-intervention as a result of this. None of the patients had varicocele recurrence. CONCLUSIONS: The laparoscopic Palomo technique is safe and effective, with good results in pediatric patients and few postoperative complications, regardless of the vascular occlusion device used. In our study, no statistically significant differences regarding the use of clipping or vascular sealer in this laparoscopic technique were found. However, further studies with a larger sample size are required to find potential differences.

INTRODUCCION: El varicocele es la dilatación anormal del plexo pampiniforme. Puede afectar al 15-20% de los varones preadolescentes-adultos. La importancia de su diagnóstico radica en que puede inducir hipotrofia testicular y problemas de fertilidad en la etapa adulta. El objetivo de este estudio es evaluar si existe mayor índice de complicaciones, incluyendo la recurrencia del varicocele, dependiendo de la técnica de oclusión vascular utilizada: clip y sección o sellador vascular, en la técnica de Palomo laparoscópico en nuestro centro. MATERIAL Y METODOS: Estudio longitudinal prospectivo que se realiza de 2017 a 2021. Se crean dos grupos terapéuticos según el método de oclusión vascular utilizada durante la varicocelectomía laparoscópica: clip y sección o sellador vascular. Los pacientes son incluidos en un grupo mediante asignación sistemática consecutiva alternante. Se realiza el análisis de las variables: edad, grado de varicocele según la clasificación de Dubin-Amelar, complicaciones postquirúrgicas, seguimiento y recurrencia del varicocele, según el método empleado. RESULTADOS: Se intervinieron un total de 37 niños, con edad media de 12 años (10-15 años) y una media de seguimiento de 12 meses. En 20 pacientes (54,1%), se utilizó clip y sección, y en los 17 restantes (45,9%), sellador vascular. El 24,3% presentaba varicocele Grado II sintomático y el 75,7%, Grado III. El 32,4% de los niños presentó alguna complicación postquirúrgica durante el seguimiento. El 29,7% de los pacientes presentó hidrocele tras la intervención, perteneciendo 8 niños al grupo de sellado y 3 niños al de clipaje. El 13,5% de estos precisó reintervención por este motivo. Ningún paciente presentó recurrencia del varicocele. CONCLUSIONES: La técnica de Palomo laparoscópica es una técnica segura y efectiva que presenta buenos resultados en pacientes pediátricos, ya que presenta pocas complicaciones postquirúrgicas, independientemente del dispositivo de oclusión vascular que se utilice. En nuestro estudio, no se ha demostrado que existan diferencias estadísticamente significativas en cuanto al uso de clip o sellador vascular en esta técnica laparoscópica. No obstante, es preciso realizar más estudios con mayor tamaño muestral para hallar posibles diferencias.

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Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.

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Past research on gender-related brain asymmetries in emotions was limited and not univocal. The present study analyzed EEG alpha activity (indexing cortical de-activation) from 64 scalp sites in 20 women and 20 men during a counterbalanced block presentation of emotional slides and short video-clips. Stimuli consisted of 45 brief clips of 13 s, divided into 15 erotic (pleasant), 15 neutral and 15 fear (unpleasant) contents. Slides consisted in 45 photo shots (presented for 13 s each) extracted from the videos. As expected, women perceived fear stimuli as more arousing and more unpleasant compared to men. Alpha EEG source analysis revealed gender effects depending on stimulus. Emotional film-clips elicited in both groups a pattern of greater right than left occipital activation. Instead, emotional pictures activated opposite occipital regions, as women showed greater activation in the left, men in the right hemisphere. Men also showed greater activation to Erotic compared to Fear stimuli (i.e., pictures/clips) in the posterior parietal complex. Results point to the relevance of emotional stimulus type to reveal gender effects: clips are ecological, dynamic and engaging, and forced a unified pattern of emotional responses that reset individual differences. Emotional pictures, less engaging, allowed individual differences to emerge and interact with the stimulus category.

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