Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines.

Method: Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed.

Results: Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence.

Conclusion: The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Background: To avoid anterior neck scarring, numerous remote-access techniques to approach the thyroid gland (Remote access approach) have been described, including the transaxillary approach (TA), bilateral axillo-breast approach (BABA), and transoral robotic thyroidectomy (TORT). Popular worldwide, Remote access approachs have unique characteristics, advantages, and disadvantages. Herein, we investigated the characteristics of these distinct thyroidectomy approaches to aid surgeons in selecting the most appropriate method for patients.

Patients and methods: In total, 2351 cases of patients who underwent thyroidectomy between 2019 and 2021 were reviewed, including 1973, 281, 66, and 31 patients who underwent the conventional transcervical approach (TCA), TA, BABA, and TORT, respectively. Demographic characteristics, outcomes, and complications associated with these procedures were compared. The data were analyzed using the Student t test and the χ 2 test. Kruskal-Wallis and Mann-Whitney U tests were used if normality was not found.

Results: Central lymph nodes (LNs) were retrieved mostly in patients who underwent lobectomy through TORT (mean: 9.4, P < 0.001). Metastatic central LNs were found more frequently (mean: 1.9 in lobectomy, 3.7 in total thyroidectomy) in patients who underwent lobectomy through TCA and TORT than in those who underwent lobectomy through other approaches (mean: 1.4 and 2.4, respectively, P < 0.05). BABA group patients had significantly fewer central LNs retrieved than those in other groups in lobectomy and total thyroidectomy (mean: 4.8 and 6.2, respectively, P < 0.05). Stimulated thyroglobulin levels did not differ among the 4 groups. The incidence of transient vocal cord palsy was statistically higher in the BABA group (5 cases, 7.5%) than in the other groups; however, all patients recovered. No difference was found in permanent vocal cord palsy (0.4% in TCA) or hypoparathyroidism (1.3% to 3.1%) among the 4 groups. The tumor size was significantly larger in the BABA group than in the other groups, with 10.6% of the patients having tumors larger than 4 cm. Total thyroidectomy was performed more frequently in the BABA group (51.8%) than in the other groups ( P = 0.005). The path of the external branch of the superior laryngeal nerve was more evident in TA, and the Cernea type was confirmed and preserved in 90.6% of TA cases.

Conclusions: Owing to the differences in working space and direction of the surgical field, TA was advantageous for preserving the external branch of the superior laryngeal nerve, whereas BABA was effective for total thyroidectomy and excision of large goiters. TORT was beneficial for central compartment neck dissection. These characteristics should be considered when choosing the best approach to improving cosmesis, function, and recurrence.

Background: The coronavirus disease 2019 (COVID-19) pandemic strained the health care sector, putting severe constraints on surgical departments. In this study, we evaluate the impact of the pandemic on the outcomes of patients undergoing robotic cholecystectomy (RC).

Patients and methods: Patients who underwent RC 1 year before and after March 2020 were included in this retrospective study and assigned accordingly to the pre or post-COVID group. Pre, intra, and postoperative variables were compared between groups.

Results: In total, 110 patients were assigned to the pre-COVID group versus 80 in the post-COVID group. There were no differences in the demographics, except for a higher rate of previous gallbladder disease in the pre-COVID group (35.5% vs 13.8,% P < 0.001). The post-COVID group had a higher rate of emergent RCs (62.5% vs 39.1%, P = 0.002). Operative times were greater in the post-COVID group due to the more frequent participation of clinical fellows in the cases. The median hospital length of stay for both groups was 1 day, with higher rates of same-day discharge (pre-COVID 40.9% vs post-COVID 57.5%, P = 0.028). Complications were comparable between both groups, with no recorded cases of COVID-19 contraction within the virus incubation period. The median follow-up was 10 months for the entire cohort.

Conclusion: During the COVID-19 pandemic, an increase in emergent cases, as well as higher rates of same-day discharge, were recorded, with no impact on postoperative outcomes in patients undergoing RC.

Background: Losing a needle during laparoscopic surgery may be a dramatic moment for the surgeon and potentially have clinical and medico-legal consequences. This case report aims to describe an unusual case of needle loss that occurred during laparoscopic Nissen fundoplication and how to prevent its further occurrence.

Methods: The patient is an 11-year-old boy with a body mass index of 32.4 kg/m 2 . He suffered from severe gastroesophageal reflux disease not responding to medical therapy and hiatal hernia. A laparoscopic Nissen fundoplication was performed.

Results: At the closure of the Nissen wrap, CO 2 leakage through the umbilical trocar caused the needle lost during the introduction of the thread. We attempted to find the needle by exploring the entire abdominal cavity without success. Therefore, we decided to complete the surgical procedure. Another 2/0 nonresorbable thread was inserted in the same way as before. But this suture also disappeared. Hence, we manually straightened the needle and introduced it under vision. The operation was accomplished successfully. An intraoperative x-ray was obtained, showing the 2 needles at the level of the 12th rib, near the working port used for the liver retractor. A peritoneal window was created using a monopolar hook, allowing to finally extract the 2 hidden needles.

Conclusion: The loss of needles, although a rare event, can occur during laparoscopic surgery. Based on our experience, we suggest that needle insertion during laparoscopic operations should be performed under direct vision, especially in obese patients, to reduce the likelihood of such complications.

Background: Although laparoscopic inguinal hernia repair (LIHR) is widely performed worldwide, few studies have focused on the procedure in female patients. This study investigated the characteristics and outcomes of female patients with inguinal hernias who underwent LIHR.

Materials and methods: This study retrospectively analyzed the data of 7380 patients with inguinal hernia admitted to the General Surgery Department of Ruijin Hospital and underwent LIHR from January 2001 to December 2020. The clinical characteristics, surgical outcomes, and complications were assessed.

Results: In total, 572 female patients were enrolled in this study. The proportion of femoral hernias in female patients was higher in women than in male patients (17.4% vs. 0.3%, respectively). Mesothelial cysts of the round uterine ligament (MCURL) were noted in 74 patients. The mean age of patients with MCURL was lower than that of patients without MCURL (46.4 vs. 55.6, P =0.018). Seventy cases (93.3%) of MCURL were resected laparoscopically, and 5 cases were resected through an auxiliary small incision. The round ligament was cut off in 335 patients and preserved in 237. No significant differences were observed in the number of hospitalization days, recurrence rates, or complications between the transection and preservation groups. None of the cases were converted to laparotomy, and no recurrence was noted during follow-up.

Conclusion: LIHR is safe and feasible in female patients. Treatment of femoral hernia, MCURL, and the round ligament of the uterus should be carefully considered during LIHR in female patients.

Background: Laparoscopic sleeve gastrectomy can lead to dangerous complications as leaks and hemorrhage. In addition, it can lead to gastric twist/torsion, prolonged postoperative nausea and vomiting (PONV), and de novo gastroesophageal reflux disease (GERD). We aimed to study the efficacy of omentopexy/gastropexy (OP/GP) in the prevention of these postoperative complications.

Materials and methods: PubMed and Google Scholar were queried in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data was analyzed using the Review Manager (RevMen) 5.4.1 software. Mantel-Haenszel statistical method and random effects analysis model were used in all meta-analyses. The odds ratio was used for dichotomous data. Subgroup analysis was done according to bougie size. Subgroup analysis according to the distance between the starting point of gastric transection and pylorus was not possible (limitation). Odds ratio and control event rate across studies were used to calculate the number needed to treat (NNT) with OP/GP for an additional beneficial outcome (prevention of adverse outcome) to occur.

Results: The initial search identified 442 records; 371 were found irrelevant after screening and were excluded. The remaining 71 reports were retrieved and assessed for eligibility. An additional 57 reports were excluded following an in-depth assessment. The remaining 14 studies were included in this meta-analysis; 8 were nonrandomized studies (NRSs) while 6 were randomized controlled trials. Most studies originated from a single country (limitation). A statistically significant decrease in favor of OP/GP was observed for all outcomes (bleeding, leaks, gastric twist/torsion, prolonged PONV 1 month postoperatively, and postoperative de novo GERD). Data was consistent across studies (low I2 ), and subgroup analysis according to bougie size revealed no subgroup differences. However, this study had 3 limitations that does not allow for strong conclusions.

Conclusions: Although the current literature lacks strong scientific evidence, this study suggests that omentopexy/gastropexy (OP/GP) may offer protection against bleeding and leaks as a staple line reinforcement method, as well as against gastric twist/torsion, prolonged postoperative nausea and vomiting (PONV), and de novo gastroesophageal reflux disease (GERD) as a staple line fixation method. Therefore, it is worthwhile to proceed with large-scale, multicenter, randomized controlled trials to reevaluate our findings. Furthermore, conducting a comparison between OP/GP and other staple line reinforcement techniques would be beneficial.

Background: Recently, smaller-size trocars and instruments have been developed for laparoscopic colon cancer surgery; however, their effectiveness and safety have not been elucidated. This study aimed to investigate whether 3 mm trocars and instruments have benefits compared with conventional trocars and instruments.

Patients and methods: Patients with colon cancer who underwent laparoscopic anterior resection or right hemicolectomy were included. Patients who underwent combined resections of other organs and those with conversion to open surgery were excluded. In the 3 mm group, three 5 mm trocars were replaced by 3 mm trocars. The numeric rating scale (NRS) immediately postoperatively at 24, 48, and 72 hours, respectively, after surgery and the use of additional analgesics and perioperative outcomes were analyzed. Case-control matched analysis was used to reduce bias according to the type of surgery.

Results: A total of 207 patients (conventional: n = 158, 3 mm: n = 49) were included. Before matching, NRS 48 hours postoperatively ( P = 0.049), proportion of patients using additional intravenous (IV) analgesics ( P = 0.007), postoperative hospital stay ( P < 0.001), and blood loss ( P < 0.001) were lower in the 3 mm group. In multivariable analysis, trocar type significantly impacted the proportion of patients using additional IV analgesics (odds ratio: 0.330; 95% CI: 0.153-0.712; P = 0.005). After case-control matching, NRS immediately postoperatively ( P = 0.015) and 24 hours postsurgery ( P = 0.043), patients using additional IV analgesics ( P = 0.019), postoperative hospital stay ( P = 0.010), intraoperative blood loss ( P < 0.001), and postoperative complication rate ( P = 0.028) were significantly lower in the 3 mm group compared with the 5 mm group.

Conclusions: The use of 3 mm trocars and instruments in laparoscopic colon cancer surgery can effectively reduce postoperative pain while maintaining perioperative safety.

Introduction: One anastomosis gastric bypass (OAGB) has gained popularity among bariatric surgeons due to the shorter operative time, fewer sites for anastomotic leaks and internal herniation, shorter learning curve, ease of reversibility and revision with equivalent results to Roux en Y gastric bypass in terms of weight loss and co-morbidity resolution. We present our experience in managing early postoperative bleeding after OAGB.

Patients and methods: Patients who underwent OAGB in Bariatric Surgery Unit, Ain Shams University Hospitals between January 2016 and January 2023 were followed up for 30 days for early postoperative complications. Patients were 210 females (70%) and 90 males, with a mean age of 41.3±7.1 years, and mean preoperative body mass index of 45.2±6.1 kg/m². The incidence of early postoperative bleeding, the sites of the bleeding and management strategy were reported.

Results: Fourteen of 300 patients (4.67%) developed early postoperative bleeding after OAGB. Intraluminal bleeding occurred in 4 patients, 3 of which were controlled by endoscopy and one by laparoscopic suturing. Intra-abdominal bleeding occurred in 10 patients, 7 of which were successfully managed conservatively, and 3 required laparoscopic management. Two cases had both intra-abdominal bleeding and intraluminal bleeding in the distal stomach, confirmed by intraoperative endoscopy, and controlled by laparoscopic suturing.

Conclusion: Early postoperative bleeding after OAGB is a rare complication (4.67%). Conservative treatment is more successful in controlling intra-abdominal bleeding. In case of failed conservative treatment, laparoscopy is the method of choice. Most cases of intra-luminal bleeding need early endoscopic intervention.

Background: The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients.

Materials and methods: This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020.

Results: The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP.

Conclusions: Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

Background: The perioperative and functional outcomes of patients with epiphrenic diverticula (ED) on a background of achalasia managed via a minimally invasive transabdominal approach are under-reported. We describe our center's experience over 10 years of treating such patients.

Methods: A single-center, retrospective chart of a prospectively maintained hospital database was performed. All patients with a diagnosis of ED and manometrically proven achalasia were identified. Demographic, clinical, and surgical data were extracted from the institution's medical records. Patients were stratified by whether they underwent myotomy only or myotomy plus diverticulectomy and compared in a univariate manner.

Results: There were 18 patients who met the inclusion criteria. The median age of the cohort was 67.1 years (range 53.1 to 77.8), the maximal size of the diverticula was 3.5 cm (range 2.0 to 7.0), and the distance of the proximal lip of the diverticulum to the incisors was 33.5 cm (range 28.0 to 38.0). In terms of surgical intervention, 14 patients (77.8%) underwent myotomy plus diverticulectomy, and 4 (22.2%) underwent myotomy alone. The duration of surgery was significantly longer in the former (177.5 vs. 75.0 min, P =0.031). In total, 9/18 (50.0%) of patients were discharged on the day of surgery. There was a trend to more major postoperative complications following diverticulectomy plus myotomy, with 2/13 (15.4%) patients suffering staple line leaks. Excellent long-term functional outcomes were achieved, with 81.3% of patients having sustained resolution of their symptoms.

Conclusions: Laparoscopic transabdominal approach for the treatment of ED offers an acceptable risk profile and favorable functional outcomes in patients with underlying achalasia.