Minimally Invasive Therapy & Allied Technologies最新文献

Background: The spread of colorectal cancer screening has increased the percentage of patients with early-stage rectal cancer; at least 30% of patients are diagnosed with a clinical-stage cT1 or pT1 after endoscopic excision. In this subgroup of patients, the real advantage of total mesorectal excision (TME) over local excision (LE) is the ability to remove mesorectal nodes, which are metastatic in less than 20% of cases.

Method: To solve the unmet need for accurate nodal staging in patients with cT0/cT1, cN0 rectal cancer, we designed a pilot study that associates LE with mesorectal fluorescence-guided nodal sampling. From November 2018 to November 2023, we enrolled a total of ten patients with T1N0M0 rectal cancer. After extensive staging and adequate information, patients underwent endoscopic indocyanine green (ICG) infiltration and transanal local excision associated with laparoscopic fluorescence-guided mesorectal nodal sampling.

Results: After a median follow-up of 24 months (range 1-63 months), no case of local or nodal recurrence was observed. All patients were spared from ostomy and lower anterior resection syndrome.

Conclusions: In selected cases of cT0-1cN0 rectal cancer, transanal local excision plus ICG lymph nodal sampling is a feasible surgical option that increases the rate of organ preservation. Further studies are needed to identify the patients most likely to benefit from this minimally invasive strategy.

Background: Robotic-assisted endoluminal systems are rapidly evolving within the field of minimally invasive surgery. The IDEAL framework (Idea, Development, Exploration, Assessment, and Surveillance) can be used to evaluate novel technologies. This review provides a summary of current and emerging endoluminal systems using the IDEAL framework.

Methods: A scoping review was conducted to include all existing and developing robotic-assisted endoluminal systems. Data was collected via virtual interviews, questionnaires, biomedical databases, company websites, and peer-reviewed articles. Key metrics were reported, enabling the assignment of each system to an IDEAL stage.

Results: The review identified 17 distinct systems from 16 companies. Nine systems received regulatory approval in their respective countries. Our evaluation showed that two systems were at the pre-IDEAL Stage 0. Seven systems were in the Idea stage (Stage 1), six systems were in the Development stage (Stage 2) and two systems completed Stage 3. No system underwent long-term study evaluation (Stage 4).

Conclusions: There is a gap in long-term clinical data of robotic-assisted endoluminal systems, indicated by the absence of systems at Stage 4. Collaborative efforts amongst the medical community, regulatory bodies, and industry specialists are vital to ensure the delivery of evidence-based medicine in the discipline of robotics.

Background: Different reconstruction techniques after total mesorectal excision have been described, such as straight coloanal anastomosis, colonic J-pouch, side-to-end anastomosis and transverse coloplasty pouch. Establishing which technique is the best in functional terms is essential to improving a patient's quality of life.

Methods: We compared benefits and harms of different reconstructive techniques. The primary outcome was to compare functional results at 18 months after surgery (long-term). Secondary outcomes were the same as primary but at different time intervals (short-term and medium-term) and perioperative morbidity and mortality.

Results: Forty-one reports of 36 trials were included in the analysis. According to primary outcome, no significant difference was observed in terms of bowel frequency, while colonic J-pouch resulted in a lower incidence of faecal urgency only compared to side-to-end. Only up to 18 months after bowel restoration bowel frequency, fecal urgency and the number of individuals using anti-diarrheal medications were reduced in the colonic J-pouch group. No difference in mortality/morbidity could be assessed among the techniques, but a lower rate of anastomotic leak after side-to-end compared to straight coloanal anastomosis was observed.

Conclusions: Evidence suggests that reconstruction with colonic J-pouch offers similar long-term benefits to straight coloanal anastomosis and Transverse coloplasty pouch, while superior to side-to-end.

Background: Placental volume measurements can potentially identify high-risk pregnancies. We aimed to develop and validate a new method for placental volume measurements using tracked 2D ultrasound and automatic image segmentation.

Methods: We included 43 pregnancies at gestational week 27 and acquired placental images using a 2D ultrasound probe with position tracking, and trained a convolutional neural network (CNN) for automatic image segmentation. The automatically segmented 2D images were combined with tracking data to calculate placental volume. For 15 of the included pregnancies, placental volume was also estimated based on MRI examinations, 3D ultrasound and manually segmented 2D ultrasound images. The ultrasound methods were compared to MRI (gold standard).

Results: The CNN demonstrated good performance in automatic image segmentation (F1-score 0.84). The correlation with MRI-based placental volume was similar for tracked 2D ultrasound using automatically segmented images (absolute agreement intraclass correlation coefficient [ICC] 0.58, 95% CI 0.13-0.84) and manually segmented images (ICC 0.59, 95% CI 0.13-0.84). The 3D ultrasound method showed lower ICC (0.35, 95% CI -0.11 to 0.74) than the methods based on tracked 2D ultrasound.

Conclusions: Tracked 2D ultrasound with automatic image segmentation is a promising new method for placental volume measurements and has potential for further improvement.

Background: The indication of laparoscopic liver resection (LLR) for treating large hepatocellular carcinoma (HCC) is controversial. In this study, we compared the short-term and long-term outcomes of LLR and open liver resection (OLR) for large HCC.

Material and methods: We searched eligible articles about LLR versus OLR for large HCC in PubMed, Cochrane Library, and EMBASE and performed a meta-analysis.

Results: Eight publications involving 1,338 patients were included. Among them, 495 underwent LLR and 843 underwent OLR. The operation time was longer in the LLR group (MD: 22.23, 95% CI: 4.14-40.33, p = 0.02). but the postoperative hospital stay time was significantly shorter (MD : -4.88, CI: -5.55 to -4.23, p < 0.00001), and the incidence of total postoperative complications and major complications were significantly fewer (OR: 0.49, 95% CI:0.37-0.66, p < 0.00001; OR: 0.54, 95% CI:0.36 - 0.82, p = 0.003, respectively). Patients in the laparoscopic group had no significant difference in intraoperative blood loss, intraoperative transfusion rate, resection margin size, R0 resection rate, three-year overall survival (OS) and three-year disease-free survival (DFS).

Conclusion: LLR for large HCC is safe and feasible. This surgical strategy will not affect the long-term outcomes of patients.

Introduction: This paper presents a camera sheath that can be assembled to various minimally invasive surgical instruments and provide the localized view of the instrument tip.

Material and methods: The advanced transformable head structure (ATHS) that overcomes the trade-off between the camera resolution and the instrument size is designed for the sheath. Design solutions to maintain the alignment between the camera's line of sight and the instrument tip direction during the transformation of the ATHS are derived and applied to the prototype of the sheath.

Results: The design solution ensured proper alignment between the line of sight and the tip direction. The prototype was used with the curved micro-debrider blades in simulated functional endoscopic sinus surgery (FESS). Deep regions of the sinus that were not observable with the conventional endoscopes was accessed and observed using the prototype.

Conclusions: The presented camera sheath allows the delivery of the instrument and camera to the surgical site with minimal increase in port size. It may be applied to various surgeries to reduce invasiveness and provide additional visual information to the surgeons.

Introduction: The preservation of the bladder neck during robot-assisted radical prostatectomy (RARP) could improve urinary continence recovery and limit the risk of positive surgical margins (PSMs). We refined our lateral approach to the bladder neck technique and compared its outcomes with those of the standard anterior approach.

Material and methods: From a retrospective analysis of 599 consecutive RARPs, 171 patients treated with the lateral and 171 patients treated with the anterior approach were pair-matched 1:1 on the basis of age, grade, and pathological stage. We described our surgical technique and compared the two approaches in terms of basal PSMs, recovery of urinary continence, and complications.

Results: As compared to the anterior approach, the lateral approach had shorter operative times and comparable rates of basal PSMs and postoperative complications. The rates of urinary continence after one, three, and 12 months were comparable between the two groups and were generally higher in localized disease. At regression analysis, predictors of urinary incontinence were only age, pathological stage T3b, ISUP grade 5 and nerve-sparing surgery.

Conclusions: The lateral approach leads to an anatomical dissection of the bladder neck without increasing the risk of PSMs. However, no significant benefits in terms of continence recovery were demonstrated over the standard anterior approach.

Objective: Robotic surgery is being increasingly used for colorectal cancer surgery. However, its utility versus laparoscopic surgery in older patients is unclear. We systematically examined evidence to assess the differences in short-term outcomes of robotic versus laparoscopic surgery for colorectal cancer in older patients.

Material and methods: Comparative studies published on PubMed, Web of Science, Embase, and CENTRAL databases were searched up to August 30th, 2023.

Results: Seven studies totaling 14,043 patients were included. Meta-analysis showed no difference in the operation time between the robotic and laparoscopic groups. Meta-analysis of ClavienDindo complications showed no difference between the robotic and laparoscopic groups for grades I and II or grades III and IV complications. Similarly, conversion to open surgery, reoperation rates and length of hospital stay were not significantly different between the two groups. Readmission rates and mortality rates were significantly lower with robotic surgery.

Conclusion: This first meta-analysis comparing outcomes of robotic and laparoscopic surgery in older colorectal cancer patients shows that both approaches result in no difference in operating time, complication rates, conversion to open surgery, reoperation rates, and LOS. Scarce data shows that mortality and readmission rates may be lower with robotic surgery.

Purpose: This study aimed to assess the outcomes of percutaneous cryoablation (PCA) for renal cell carcinomas (RCCs) contacting critical organs without intervening fat tissue.

Material and methods: Twenty-three patients with 24 RCCs (mean size, 28.8 mm) contacting critical organs on preprocedural images were included. The organ displacement techniques, technical success, efficacy, and adverse events per Clavien-Dindo classification were retrospectively reviewed.

Results: The organs contacting the RCCs included the colon (n = 16), pancreas (n = 3), duodenum (n = 3), small intestine (n = 1), and stomach (n = 1). In all procedures, hydrodissection was conducted, and probe traction was additionally utilized in one to displace organs. Two procedures were terminated with an insufficient ice-ball margin (<6 mm) due to recurring proximity of the colon or thermal sink effect by renal hilar vessels, yielding a technical success rate of 91.6% (22/24). No severe adverse events were noted. All patients were alive without any metastases during a median follow-up of 34.4 months. The primary and secondary technical efficacy rates were 91.6% (22/24) and 95.8% (23/24) of tumors, respectively.

Conclusion: PCA can be a valid option for RCCs contacting critical organs with a good safety profile and sufficient technical efficacy.

Objective: To compare clinical outcomes of superior versus inferior splenic artery embolization in partial splenic embolization (PSE) and identify predictors of major complications.

Material and methods: This retrospective case-control study included 73 patients who underwent PSE between May 2005 and April 2021. They were divided into two groups: the superior and middle splenic artery embolization group (Group A, n = 37) and the inferior and middle splenic artery embolization group (Group B, n = 36). Outcome differences and major complications between the groups were assessed. Logistic regression was used to analyze potential predictors of major complications, and the optimal cutoff value for splenic embolization rates was determined using the Youden index.

Results: There were no significant differences in laboratory and radiological outcomes between the two groups. Group A had a significantly lower incidence of major complications than Group B (p = 0.049), a lower Visual Analog Scale (VAS) score for pain (p = 0.036), and a shorter hospital stay (p = 0.022). Independent risk factors for major complications included inferior and middle splenic artery embolization (odds ratio [OR] = 3.672; 95% confidence interval [CI] = 1.028-13.120; p = 0.045) and a higher spleen embolization rate (OR = 1.108; 95% CI = 1.003-1.224; p = 0.044). The optimal cutoff for spleen embolization rate to predict major complications was 59.93% (sensitivity 77.8%, specificity 63.6%).

Conclusion: Using 500-700 µm microspheres for PSE, targeting the middle and superior splenic artery yields similar effects to targeting the middle and inferior artery, but results in lower rates of major complications and shorter hospital stays. To effectively minimize the risk of major complications, the embolization rate should be kept below 59.93%, regardless of the target vessel.