JSLS : Journal of the Society of Laparoendoscopic Surgeons最新文献

Background and objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure.

Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019.

Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15-95 days).

Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

Background and objectives: The multiple endoclip retraction technique (MERT) was developed based on our experience with suturing renal parenchyma in laparoscopic partial nephrectomy. In this study we prospectively evaluated the one-year results of cases treated by transperitoneal laparoscopic Burch with the MERT.

Methods: The patients were evaluated with stress test, one-hour pad test, and were requested to complete the International Continence Society Incontinence Questionnaire short form (ICIQ-SF) in the postoperative period. The follow-up periods were postoperative 3, 6, and 12 months.

Results: The primary outcome of this study was surgical success, defined as being cured of stress urinary incontinence (SUI) (no symptoms), experiencing improved symptoms of SUI in ICIQ-SF and negative stress test, and less than 2g urine leakage in a one-hour pad test.No statistically significant difference was found in terms of age, number of children, and body mass index (BMI) in patients according to the results of the 12 month postoperative stress test. We found statistically significant improvements at all control months in terms of stress test and pad weight. ICIQ-SF results showed a significant decrease at three months in patients who recovered after the operation. This rate has not changed in following control months. However, there was no statistical change in ICIQ-SF values in patients who did not recover after the operation.

Conclusion: MERT seems to be one of the safe and effective modifications in the management of SUI with good one year outcomes when performed by suitably trained experienced surgeons.

Background and objectives: This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery.

Methods: Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product.

Results: PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001).

Conclusion: These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.

Background and objectives: Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections.

Methods: We analyzed outcomes between January 1, 2016 and December31, 2018 using the Vizient® clinical database. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. For bivariate analysis, Wilcoxon rank-sum test was used for continuous variables and χ² test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses.

Results: A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings.

Conclusion: Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

Background: Robotic-assisted surgery facilitates the performance of numerous, complex procedures, namely conferring precision, flexibility, and control that is otherwise unavailable with conventional laparoscopy; and compared to open surgery, robotic-assisted surgery is ostensibly associated with fewer complications, reduced intraoperative complications, and shorter hospital stay duration. Nevertheless, the American College of Obstetricians and Gynecologists and the Food and Drug Administration have criticized the pervasive acceptance of robotic-assisted surgery, given the absence of randomized clinical trial data compared to traditional laparoscopy and open procedures, not to mention the increased surgical cost.

Conclusions: While the research data continue to be borne out, surgeons should exercise considerable discretion in selecting the surgical approach from which their patients would derive the greatest clinical benefit.

Background: Single-incision laparoscopic cholecystectomy, first introduced in 1995, features acceptable cosmetic outcomes and postoperative pain control. The outcomes of single-port cholecystectomy by laparoscopy and robots were recently examined in many studies owing to surgeon and patient preference for minimally invasive surgery. A next-level da Vinci robotic platform was recently released. This study aimed to evaluate the feasibility and efficacy of robotic cholecystectomy (RC) using the da Vinci SP® system.

Methods: In this retrospective observational single-center study, we analyzed the medical records of 304 patients who underwent RC between March 1, 2017 and May 31, 2021.

Results: Of the 304 patients, the da Vinci Xi® (Xi) was used in 159 and the da Vinci SP® (SP) was used in 145. The mean operation time was 45.7 mins in the SP group versus 49.8 mins in the Xi group. The mean docking time of the SP group was shorter than that of the Xi group (5.7 min vs 8.8 min; p = 0.024). The mean immediate postoperative numerical rating scale (NRS) score was 4.0 in the SP group and 4.3 in the Xi group, showing a significant difference (p = 0.003). A separate analysis of only patients with acute cholecystitis treated with the da Vinci SP® showed that the immediate postoperative NRS score in the acute group was higher than that in the nonacute group.

Conclusions: This study demonstrated acceptable results of single-site cholecystectomy using da Vinci SP®. Thus, pure single-port RC using the da Vinci SP® for various benign gallbladder diseases may be an excellent treatment option.

Background and objectives: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data.

Methods: Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day).

Results: During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement.

Conclusion: Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Robotic esophageal surgery is becoming more widely adopted. Several publications on the feasibility, short-term outcomes and technical aspects are available. Most of these articles used either the da Vinci® SI system or in newer series the Xi System. The da Vinci® X system is generally considered less suited for multiquadrant access like in esophageal surgery, hence only limited data is available. Here we describe our initial experience with 16 Ivor-Lewis robotic assisted minimally invasive esophagectomies (RAMIE) in patients with esophageal adenocarcinoma. The da Vinci® X system was installed in our department in 2019; the robotic program comprises colorectal, pancreatic and esophageal surgery. The first two patients were operated in the presence of a proctor. An operative standard was established including fluorescence angiography (Firefly®). Technical aspects with focus on the characteristics of the da Vinci® X system, operating room setup, and short-term outcomes are discussed.

Background: Laparoscopic appendectomy (LA) is claimed to require less analgesic and allow for a faster return to work. This study examines whether these benefits hold true in Asian patient populations.

Methods: A retrospective audit of emergency appendectomies over one year was conducted to study outcomes of postoperative pain, length of stay (LOS), duration of analgesia, and hospitalization leave (HL). A telephone questionnaire evaluated post-discharge analgesic intake, residual symptoms at follow-up, adequacy of HL and opinion on teleconsult reviews.

Results: Of the 201 patients, 187 (93%) underwent LA. Presurgery symptoms were significantly longer in the open appendectomy (OA) group (mean: OA 3.79, LA 1.81 days; p = 0.026) which also had a higher frequency of perforation (71.4%). LA patients reported less pain compared to OA (LA 3.60 vs. OA 4.14; p = 0.068) but were prescribed the same 2 weeks of analgesics as OA. LOS was significantly less for LA (mean LA 3.09, OA 6.93 days; p = 0.006). Mean HL for LA and OA were 17.9 and 21.8 days respectively (p = 0.05). Nearly 83% patients did not complete the prescribed course of analgesics and 47% patients felt that HL was more than adequate. Seventy-five percent of patients were asymptomatic at hospital follow-up and nearly 41% agreed to teleconsult reviews.

Conclusion: Majority of LA patients do not need 2 weeks of analgesics and their HL can be shortened for faster return to work thereby realizing the true benefits of minimally invasive surgery. Selected cases can be offered postoperative teleconsultation.

Background: Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients.

Method: A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 - June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted.

Results: Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC.

Conclusion: HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.