Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Diastasis recti abdominis (DRA) is a prevalent postpartum condition characterized by the separation of the rectus abdominis muscles with an interrectal distance >2.5 cm, often leading to symptoms like back pain, constipation, and urinary incontinence. Preaponeurotic endoscopic repair (REPA) is a novel, minimally invasive surgical approach for DRA, offering an alternative to traditional abdominoplasty. Despite its minimally invasive nature, REPA surgery poses significant postoperative pain challenges, typically managed with opioids, which carry numerous side effects.

Materials and methods: This retrospective study evaluates the efficacy of combining 2 ultrasound-guided abdominal wall blocks, rectus sheath block (RSB) and transversus abdominis plane block (TAPB), to manage postoperative pain in 55 DRA patients who underwent REPA surgery. We performed lateral TAPB in 28 cases, whereas 27 received an association of TAPB and RSB.

Results: At 6 hours postsurgery, 61% of patients in the TAPB group reported significant pain (Numeric Rating Scale >3), compared with 19% in the TAPB-RSB group ( P = 0.001). The TAPB-RSB group also required fewer analgesic rescue doses ( P = 0.042) and showed earlier recovery, with faster initiation of oral intake and mobility.

Conclusion: The combination of TAPB and RSB significantly reduces opioid consumption, postoperative pain, and the need for rescue analgesia compared with TAPB alone. The dual-block approach, providing a multi-dermatomal sensory block, suggests a promising strategy for improving postoperative pain management in REPA surgery.

Objective: Postoperative nausea and vomiting (PONV) is a frequent adverse event after bariatric surgery and is associated with patient dissatisfaction and increased health care burden. Aggressive multimodal antiemetic prophylaxis and the use of propofol infusion during anesthesia are associated with the reduction of PONV. In this study, we examined the use of rescue antiemetics following bariatric surgery performed with 3 different anesthetic strategies designed to reduce PONV: (1) primary volatile (VOL) anesthetic and propofol (PROP) infusion (VOL+PROP), (2) volatile anesthetic with propofol and dexmedetomidine (DEX) infusions (VOL+PROP+DEX), or (3) opioid-sparing total intravenous anesthesia (PROP+DEX).

Methods: In this retrospective observational study, we included patients undergoing bariatric surgery from 2018-2022 who received 1 of 3 anesthetics: (1) VOL+PROP, (2) VOL+PROP+DEX, or (3) opioid-sparing PROP+DEX without a VOL. Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the postanesthesia care unit (PACU) and following PACU discharge.

Results: Three hundred thirty-two patients received VOL+PROP, 354 VOL+PROP+DEX, and 166 PROP+DEX, and all received prophylactic antiemetics during surgery. After surgery, the PROP+DEX patients received fewer rescue antiemetics in the PACU compared with VOL+PROP (11% vs. 24%, P =0.002), and VOL+PROP+DEX fewer compared with VOL+PROP (16% vs. 24%, P =0.023). This differential antinausea effect was limited to PACU stay only. Rescue antiemetic use increased across all anesthetic management groups following PACU discharge until midnight on the day of surgery (ranging from 38% to 46% across groups, P =0.71) and through the first postoperative day (ranging from 47% to 57% across groups, P =0.20).

Conclusions: The benefit associated with anesthetic strategies designed to reduce PONV was present but did not persist past PACU discharge. This finding suggests that aggressive perioperative multimodal antiemetic prophylaxis combined with anesthetic strategies designed to prevent PONV after bariatric surgery have only a short-lived effect, thus health care staff in hospital wards may expect to encounter high rates of PONV in these patients. There is a need for the development of novel antinausea treatments to reduce the rate of this frequent postoperative complication.

Objective: Endoscopic thyroidectomy through the bilateral axillo-breast approach (BABA) is predominantly used in cases involving low-risk thyroid malignancies and benign nodules measuring <4 cm. However, the efficacy and safety of this technique in larger goiters remain underexplored.

Methods: This retrospective study compared perioperative data and pathologic outcomes among patients who underwent endoscopic BABA thyroidectomy categorized on the basis of the size of the dominant nodule (<4 vs ≥4 cm).

Results: Among the 113 included patients, 81 (72%) had a dominant nodule measuring <4 cm (group 1) and 32 (28%) presented with a nodule measuring ≥4 cm (group 2). Group 2 experienced longer operative times, greater blood loss, and higher drainage volumes than group 1. However, pain scores and length of postoperative hospital stay were similar between the groups. None of the patients required conversion to open surgery. The incidence rates of vocal cord palsy and hypoparathyroidism did not differ significantly between groups. In group 2, three patients developed seroma (9%) and one exhibited delayed bleeding (3%). Pathologic examination revealed that 6 patients (19%) in group 2 had malignant neoplasms; 3 were identified in the dominant nodule, whereas the remaining 3 were identified in separate, smaller nodules. Throughout the mean follow-up period of 43 months, no recurrence or metastasis was reported.

Conclusions: Endoscopic BABA thyroidectomy is a viable option for patients with large thyroid nodules (≥4 cm); however, this technique requires careful execution.

Objective: To investigate the role of endoscopic ultrasonography (EUS) in the diagnosis and treatment of upper gastrointestinal bleeding of unknown origin in liver cirrhosis, focusing on patients with recurrent treatment of esophageal and gastric varices who failed to identify the bleeding site under direct endoscopy.

Background: Esophagogastric variceal bleeding is one of the severe complications of decompensated liver cirrhosis, and serial endoscopic therapy can improve the long-term quality of life of patients. Most acute bleeding can be detected under direct endoscopy with thrombus or active bleeding, but there are still some patients with recurrent bleeding after repeated treatments, and it is difficult to find the bleeding site, especially in gastric variceal bleeding. Therefore, it is of great significance to identify the bleeding site.

Patients and methods: A total of 88 patients with liver cirrhosis bleeding diagnosed and treated under EUS were collected in this study, including 26 patients who failed to identify the bleeding site under direct endoscopy. EUS was used to scan the bleeding site, and EUS-guided treatment was performed. The characteristics of the bleeding site under direct endoscopy and EUS and the follow-up results after surgery were analyzed.

Results: Among the 26 patients, 16 patients (16/26, 61.5%) showed red color signs of gastric fundus mucosa under direct endoscopy, 5 patients (5/26, 19.2%) showed punctate erosion, and the remaining 5 patients (5/26, 19.2%) showed no abnormal mucosal manifestations. All patients could find anechoic blood vessels under EUS, and blood flow signals could be detected within. Among them, 23 patients (23/26, 88.5%) chose EUS-guided treatment, and no rebleeding occurred after surgery. Another 3 patients (3/26, 11.5%) were given endoscopic variceal ligation due to small esophageal and gastric varices and inability to perform intravascular injection. The median follow-up time was 86 days. Adverse reactions included 5 cases of retrosternal pain (5/23, 21.7%), and 1 case of fever (1/23, 4.3%).

Conclusion: EUS can detect submucosal varices in the gastric mucosa, and these bleeding sites may present as red color signs or punctate erosion under direct endoscopy.

Background: Percutaneous endoscopic gastrostomy (PEG) is a safe method of choice for patients who need long-term nutritional support. However, complications and high mortality rates have been reported. Based on 8 years of experience in tertiary care hospitals, we aimed to identify risk factors associated with major complications and 30-day mortality after PEG.

Methods: Patients who underwent PEG in the General Surgery clinic of Tokat Gaziosmanpaşa University, Faculty of Medicine between January 2014 and March 2022 were included in the study. Data regarding patient demographics, comorbidities, laboratory data, drugs used together, and indications for PEG tube placement were collected.

Results: There were 429 patients. The mean age of the patients was 66.9±16.75 years, and 180 (44%) patients were female. The mean follow-up period was 8.84±6.75 months. Twenty patients (4.9%) had major complications. Female sex [Odds Ratio (OR) 0.33, 95% CI, CI=1.23-8.87, P =0.02] and diabetes mellitus (DM) (OR=0.23, 95% CI=1.93-6, P =0.002) were the independent variables associated with major complications. The all-cause 30-day mortality rate was 5.9% (n=24). Malignancy, DM, corticosteroid use, low albumin, and platelet values were associated with increased mortality in multivariate analysis as indications for PEG.

Conclusions: Female sex and patients with DM may potentially face major complications. The patients with cancer, diabetes, and corticosteroid use were associated with higher mortality. In addition, low serum albumin and platelet levels were an effective factor for survival in patients undergoing PEG, and this should be taken into account in decision-making.

Objective: Endoscopic papillary balloon dilation (EPBD), small endoscopic sphincterotomy (EST), and small EST plus EPBD are commonly used as rescue techniques to remove bile duct stones. However, we often encountered challenging cases with non-dilated distal bile ducts, especially in those undergoing EPBD. We aimed to explore the reasons by assessing whether patients without the dilated bile duct had a higher risk of early complications and whether it was impacted by the rescue techniques.

Methods: We performed a retrospective cohort study by frequency matching design in patients diagnosed with stones in non-dilated distal bile duct who received rescue techniques from July 2016 to June 2022. Besides, patients with stones and without dilatation of the distal bile duct (DDBD) were divided into 3 subgroups according to the rescue technique received. Outcomes were compared between the subgroups.

Results: The non-DDBD group was more likely to develop post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and hyperamylasemia (HP) than the DDBD group ( P < 0.05). Some cases had mild or moderate pancreatitis, but no one in either group developed severe pancreatitis. For subgroup analysis, each technique resulted in complete stone removal; the EPBD group had a higher HP rate than the other subgroups and reached statistical significance: the EPBD group versus the small EST group ( P = 0.013) and the EPBD group versus the EPBD plus small EST group ( P = 0.008). Although there was no statistical significance, PEP incidence in the EPBD group was 13.7% higher than in other subgroups ( P > 0.05/3).

Conclusion: Non-DDBD patients have a higher risk for endoscopic retrograde cholangiopancreatography-related pancreatic inflammation. EPBD should be used cautiously due to the significant association with increased rates of PEP and HP. Conversely, small EST and combination therapy are suitable for non-dilated bile duct stones because of their high safety profile and efficacy.

Background: Esophagogastrostomy is one of the reconstruction techniques after proximal gastrectomy, but reflux and esophagitis are significant concerns. We introduced a new robotic valvuloplasty technique (single-flap), taking advantage of robotic surgery to address these issues and simplify the technique, especially for tumors with esophageal invasion.

Methods: Between March 2022 and March 2024, patients who underwent robotic proximal gastrectomy with the single-flap technique were included. Based on the difficulty of the surgery, patients were divided into 2 groups: one with esophageal invasion requiring anastomosis in the mediastinum and the second group with tumors in the upper third of the stomach requiring anastomosis in the abdomen.

Results: A total of 22 patients were included: 13 in the esophageal invasion group and 9 in the upper stomach group. The median size of esophageal invasion was 2 cm (1 to 3 cm). The median operative time was 320 minutes (esophageal invasion 326 vs. upper stomach 280 min, P =0.51), with a median blood loss of 35 g (31 vs. 38 g, P =0.19). No postoperative mortality, anastomotic leaks, reflux symptoms, or pancreatic fistulas were observed. Eighteen patients underwent endoscopic evaluation, and no sign of esophagitis was detected. Five patients (22.7%) developed grade III strictures requiring endoscopic balloon dilation (esophageal invasion 32.1% vs. upper stomach 22.2%; P =0.96).

Conclusions: Robotic proximal gastrectomy with single-flap valvuloplastic esophagogastrostomy is a safe and feasible option for gastroesophageal junction tumors with up to 3 cm of esophageal invasion.

Background and aims: Several studies have hypothesized that sparing the oblique/sling fibers during posterior peroral endoscopic myotomy (POEM) may reduce the incidence of gastroesophageal reflux disease (GERD) and reflux esophagitis without compromising the established safety and efficacy of the procedure. This study compares perioperative, postoperative motility-related, and postoperative GERD-related outcomes between posterior oblique/sling fibers-sparing POEM (OFS-POEM) and conventional posterior POEM through a pairwise meta-analysis of comparative studies.

Methods: We conducted a systematic literature review following PRISMA guidelines to identify articles directly comparing posterior OFS-POEM with conventional posterior POEM. A pairwise meta-analysis was performed using a random-effects model. Effect sizes were calculated as odds ratios for dichotomous data and mean differences for continuous data.

Results: No significant differences were observed in perioperative outcomes, including mean gastric myotomy length, mean operative time, and incidence of adverse events. Similarly, no significant differences were noted in postoperative motility-related outcomes, such as mean Eckardt score and mean integrated relaxation pressure. However, a statistically significant reduction in the incidence of symptomatic GERD was observed in favor of OFS-POEM, with a number needed to treat (NNT) of 10 (95% CI: 6-49). Interestingly, no significant differences were found in the incidence of objectively diagnosed postoperative GERD, such as the number of patients with DeMeester scores >14 or the incidence of reflux esophagitis.

Conclusions: This study suggests that OFS-POEM may reduce the incidence of symptomatic GERD following POEM, without affecting the incidence of GERD diagnosed by pH studies (DeMeester score >14) or by endoscopy (reflux esophagitis). Future studies with larger sample sizes are needed to further investigate the impact of OFS-POEM on GERD incidence as determined by pH studies and endoscopic findings. Given the limitations of this study, no definitive conclusions can be drawn. Multicenter randomized controlled trials with larger sample sizes are required to reach more reliable conclusions. Furthermore, stratifying data according to the type and class of achalasia would provide valuable information on whether there are differences in outcomes among the various types and classes of achalasia.

Objective: The objective of this study is to assess the impact of a quantitative early activity program, integrated into the Enhanced Recovery After Surgery (ERAS) protocol on gastrointestinal function in patients undergoing laparoscopic pancreatoduodenectomy (LPD).

Methods: Perioperative data from 203 patients who underwent LPD at the Department of Comprehensive Treatment of Pancreatic Cancer, Fudan University Shanghai Cancer Center, between January 2021 and December 2022 were analyzed retrospectively. The patients were categorized into 2 groups based on their nursing plans. Group A received the standard perioperative ERAS nursing plan, while group B followed the ERAS plan supplemented with a quantitative early activity program. We assessed postoperative outcomes including bowel sound recovery time, time to first anal exhaust, time to first mobilization, activity compliance 1-week postsurgery, and incidence of postoperative breakthrough pain.

Result: We compared several postoperative metrics between group A and group B. Specifically, the time to bowel sound recovery was 62.39±17.89 hours in group A versus 56.45±22.85 hours in group B. The time to first anal exhaust was 78.88±71.99 hours in group A compared with 63.62±24.73 hours in group B. The time to first mobilization was 56.98±18.66 hours in group A versus 49.85±20.48 hours in group B. In addition, activity compliance 1-week postsurgery and the incidence of postoperative breakthrough pain (1.55±2.01 times in group A vs. 0.94±1.16 times in group B) were also compared. All these differences were statistically significant ( P <0.05). Conversely, the incidence of postoperative complications and the length of hospital stay (11.20±5.69 d in group A vs. 12.47±6.67 d in group B) did not reveal any significant differences ( P >0.05).

Conclusion: The quantitative early activity program for LPD, based on the ERAS protocol, enhances the adherence to postoperative activity and decreases the incidence of breakthrough pain, thereby facilitating gastrointestinal function recovery in patients. This approach merits clinical adoption.

Introduction: Pneumoperitoneum is widely used in gastrointestinal surgery, particularly for laparoscopic or robotic procedures, with suggested advantages associated with low pressure. While existing data predominantly focuses on laparoscopic cholecystectomy, the assessment of intra-abdominal pressures in other gastrointestinal surgeries remains unexplored.

Methods: This study conducted an electronic literature search for randomized control trials comparing low-pressure pneumoperitoneum to standard or high-pressure counterparts.

Results: Out of 26 articles meeting inclusion criteria, encompassing 2077 patients, 15 demonstrated positive associations with low-pressure pneumoperitoneum. No significant difference in postoperative pain was found in the remaining papers. Methodological variations, diverse outcome reporting, and a prevalent high risk of bias precluded meta-analysis.

Conclusions: The study highlights substantial outcome variability, urging cautious interpretation of aggregated results. Despite positive associations in specific cases, insufficient evidence was found to support the superiority of low-pressure pneumoperitoneum. The study recommends future research employing validated patient-reported outcome measures and standardized reporting to help guide the development of evidence-based guidelines and optimize patient care in abdominal surgeries.