Bowers, Steven P.

Background: Operative decision-making in gastric gastrointestinal stromal tumor (GIST) surgery is strongly influenced by tumor anatomy. Although surgeons routinely consider anatomic features such as proximity to the gastroesophageal junction, posterior wall location, and endophytic growth during operative planning, their combined association with operative strategy has not been systematically evaluated. Methods: We evaluated whether commonly recognized anatomic features of gastric GISTs were associated with operative strategy in a contemporary minimally invasive surgical cohort. Tumors were characterized according to the presence of three predefined anatomic features: proximal location near the gastroesophageal junction, posterior wall involvement, and endophytic growth pattern. Cases were grouped as lower (0–1 features) or higher (2–3 features) complexity. The primary outcome was operative strategy, categorized as simple (wedge resection or enucleation) or complex (partial gastrectomy or transgastric resection). Associations between anatomic complexity and operative approach were evaluated. Results: A total of 83 patients were included, with 50 (60.2%) classified as lower complexity and 33 (39.8%) as higher complexity. Operative strategy varied significantly by complexity group. Tumors in the higher complexity group were more frequently managed with complex operative techniques, including partial gastrectomy and transgastric resection ( P = .002). This association remained significant after adjustment for tumor size (odds ratio 2.87, 95% CI: 1.12–7.65, P = .031). A graded relationship was observed, with increasing use of complex techniques as the number of anatomical features increased. The robotic platform was used more frequently in higher complexity cases ( P = .03). Perioperative outcomes were comparable between groups. Conclusions: Recognized anatomical features of gastric GISTs were associated with operative strategy and reflected real-world surgical decision-making. Systematically describing these features may facilitate preoperative assessment and improve consistency in reporting operative approaches.

Background Vascular injury is a feared complication of minimally invasive median arcuate ligament (MAL) release. The identified elements of variant anatomy that predispose to injury. Methods Between August 2018 and March 2025, 64 patients underwent laparoscopic (51) or robotic (13) median arcuate ligament release operation. Surgical anatomy was prospectively recorded with respect to variants of vascular and visceral anatomy. Results Only 17 cases (27%) had no observed anatomical variant. Visceral arterial variants occurred in 15 cases (23%), and included: Accessory left hepatic artery in 8 (requiring division in 6); common hepatic artery (CHA) variants were observed in 2 cases and included replaced CHA and early origin CHA; 5 left gastric artery (LGA) variants included early origin (N = 3) or duplicated LGA (N = 2). One or both IPA originated from the celiac artery in 32 cases (50%), of which anterior origin off the celiac was seen in 20 cases (31%). Both IPA originated separately from the anterior celiac in 2 cases, and from a common trunk in 9 cases (14%). One IPA arising from the anterior celiac was observed in 8 cases (13%). The coronary vein (CV) inserted into the portal vein superior to the CHA in 6 cases (9%), and coursed parallel to the CHA in 16 cases (25%). A high riding pancreas necessitating retraction was seen in 9 cases (14%). Conclusion Most patients undergoing median arcuate ligament release have elements of complexity that increase the difficulty of operation or increase operative risk.

Background Assessment of gastric conduit perfusion during esophagectomy is crucial to determine its viability and identify the optimal site for anastomosis. Indocyanine green (ICG) fluorescence imaging is commonly used for this purpose, but it is contraindicated in patients with hypersensitivity to ICG, iodine, or shellfish. Oxygen saturation endoscopic imaging (OXEI) is a newer, non-pharmacologic technique for assessing perfusion. We report our experience with OXEI in 3 esophagectomy patients who had contraindications to ICG. Methods All 3 patients underwent robot-assisted esophagectomies. None of the conduits had ischemic areas identified by white light. Using a 5 mm laparoscopic specialized camera (ELUXEO Vision, FUJIFILM Healthcare Americas Corp., USA), OXEI was deployed for intracorporeal assessment of gastric conduit perfusion after pull-up into the chest. Postoperative outcomes including anastomotic leaks and complications were recorded. Results In two patients, OXEI revealed ischemic zones, which were resected to ensure optimal conduit viability. In the remaining patient, OXEI indicated robust vascularity throughout the conduit. All three patients experienced uneventful postoperative courses and were discharged within 10 days. There were no instances of anastomotic leaks or other major complications. Conclusion In our experience, OXEI is a viable method for intraoperative assessment of gastric conduit perfusion in patients with contraindications to ICG. Prospective studies are needed to validate its efficacy in preventing anastomotic complications and to compare it with other methods of perfusion assessment including gross visual and ICG dye in a larger patient population.

Abstract Background and study aims Killian-Jamieson diverticulum (KJD) is a rare type of esophageal diverticulum that occurs in a specific area called the Killian-Jamieson space. Although surgery has been the conventional treatment for symptomatic KJD, minimally invasive endoscopic techniques, particularly Killian-Jamieson per-oral endoscopic myotomy (KJ-POEM), have emerged as an alternative. The aim of the study was to evaluate the effectiveness and safety of KJ-POEM in treating KJD. Patients and methods This was an international, multicenter, retrospective study that included patients who underwent KJ-POEM for symptomatic KJD from October 16, 2018 to April 12,2023. The primary outcome was clinical success, defined as complete or near-complete resolution of symptoms (i.e., post-procedure Kothari-Haber Score ≤ 2). Secondary outcomes were technical success (defined as successful completion of all procedural steps), rate and severity of adverse events (AEs), total procedure duration, and symptom recurrence during follow-up. Results A total of 13 patients (mean age 65.23 years, 6 female) with KJD and a mean pre-procedure Kothari-Haber Score of 6 (standard deviation [SD] 2.16) underwent KJ-POEM across 10 participating centers. Clinical success and technical success were achieved in all cases (100%) with a mean post-procedure Kothari-Haber Score of 0.91 (SD 0.99). There were no AEs and no cases of injury to the recurrent laryngeal nerve. Mean length of hospital stay was 1.09 days (SD 0.74). Mean follow-up time was 9.41 months (SD 10.07) post-procedure. There was no post-procedure symptom recurrence any patient. Conclusions KJ-POEM is a safe and effective alternative treatment for symptomatic KJD with excellent short/mid-term outcomes.