Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Acute uncomplicated appendicitis has traditionally been managed surgically, but recent trials suggest nonoperative treatment with antibiotics may be effective in selected adults. This meta-analysis compares long-term outcomes of antibiotics versus surgery and evaluates predictors of treatment failure, including the presence of an appendicolith.

Methods: We systematically searched MEDLINE, Embase, CENTRAL, and clinical trial registries up to July 2024. We included randomized controlled trials (RCTs) comparing antibiotics versus appendectomy in adults with imaging-confirmed uncomplicated appendicitis. The primary outcome was 1-year treatment success. Secondary outcomes included complication rates, recurrence, and subgroup analysis by appendicolith. A meta-regression explored the relationship between appendicolith prevalence and treatment failure.

Results: Seven RCTs (n=3164) were included. The 1-year treatment success rate was significantly lower in the antibiotics group (73.8%) versus surgery (98.1%) (RR 0.78, 95% CI: 0.73-0.84). Complication rates were comparable (RR 0.57, 95% CI: 0.29-1.12). Patients with appendicolith had a significantly higher failure rate (up to 46%). Meta-regression confirmed a positive correlation between appendicolith prevalence and antibiotic failure.

Conclusions: Antibiotics can be effective in selected patients, but recurrence and treatment failure remain concerns, particularly in the presence of appendicolith. Appendectomy remains the definitive treatment. This meta-analysis, including the most recent trials and a novel meta-regression, provides timely insights for shared decision-making.

Background: Robot-assisted surgery has been widely adopted in digestive, urological, and gynecologic procedures, leading to its application in complex operations such as pelvic exenteration (PE). However, limited data are available regarding the perioperative outcomes of robotic PE compared directly to conventional laparoscopic PE in the treatment of colorectal cancer.

Methods: To assess the feasibility of robotic PE compared with laparoscopic PE for locally advanced colorectal cancer invading the anterior pelvic organs, we retrospectively reviewed patients who underwent either robotic or laparoscopic PE with curative intent (R0 resection) between May 2012 and August 2024.

Results: A total of 24 patients were included in the study (12 in the robotic group and 12 in the laparoscopic group). Patient characteristics revealed that the robotic group had an older median age and a lower prognostic nutritional index. In terms of surgical outcomes, no significant differences were observed in PE type, total operative time, estimated blood loss, or the number of retrieved lymph nodes. Conversion to open surgery occurred in 3 patients in the laparoscopic group, whereas no conversions were noted in the robotic group ( P = 0.032). The reasons for conversion in the laparoscopic group included uncontrollable bleeding and technical difficulty due to large tumor size.

Conclusions: Robotic surgery may offer greater suitability for complex procedures such as PE, compared with conventional laparoscopic surgery, particularly in challenging cases involving large tumors.

Aim: Temporary ileostomy is a valuable aid in reducing the severity of complications associated with rectal cancer surgery. The purpose of the present study was to determine the reasons for delays in ileostomy closure in patients who underwent laparoscopic rectal cancer surgery and protective loop ileostomy and to prevent delays in closure timing.

Methods: A retrospective analysis was conducted with patients who underwent loop ileostomy and its reversal in laparoscopic rectal surgery for rectal cancer at the Surgical Oncology Clinic of Tokat Gaziosmanpaşa University. Patients who had loop ileostomy closure between 2018 and 2023 were included in the study. Demographic data of the patients, neoadjuvant status, adjuvant chemotherapy, presence of comorbidities, smoking, American Society of Anesthesiologist's classification (ASA) score, primary surgical method [low anterior resection (LAR), very low anterior resection (VLAR), transanal total mesorectal excision (TaTME)], pathologic stage, anticoagulant use, presence of anastomotic leak, postoperative bleeding, presence of ileus, length of hospital stay, time from index surgery to closure, 90-day complications (Clavien-Dindo classification), unexpected 30-day readmission, reoperation status, and ileostomy closure time values were recorded, and a database was created. Multivariate regression analysis was used to identify clinically significant risk factors for delayed closure.

Results: A total of 129 patients underwent loop ileostomy closure during the study. The median time to closure in patients with rectal cancer was 5.47 months (range: 1 to 22). Thirty-nine of the 129 patients (30.2%) underwent reversal >6 months after index surgery. Anastomotic level ( P =0.004), Clavien-Dindo complication grade ( P =0.005), and hospital readmission after index surgery ( P =0.004) were associated with delayed ileostomy closure ( P <0.005).

Conclusions: Reasons for delay included factors such as degree of complication, hospital readmission, and anastomosis level. Addressing these causes would benefit patients in terms of improving their quality of life after closure.

Background: There is currently no universally accepted gold standard for the surgical treatment of hemorrhoidal disease. This study aimed to assess the efficacy and safety of the Doppler-guided hemorrhoidal artery ligation (DG-HAL) technique, with or without concomitant mucopexy, on postoperative clinical outcomes in patients with symptomatic grade II to IV hemorrhoidal disease.

Patients and methods: A retrospective analysis was conducted using a prospectively maintained database of patients who underwent DG-HAL ± mucopexy between January 2018 and January 2023 for medically refractory hemorrhoidal disease. Postoperative complications, analgesia type and duration, and time to return to daily activities were recorded. Patients were followed up by a general surgery specialist on postoperative day 1, week 1, month 1, and year 1. Treatment efficacy was evaluated based on changes in symptom severity and hemorrhoid grade across follow-up periods.

Results: A total of 94 patients (59 males, 35 females; mean age: 47.8 ± 12.4 y) underwent the procedure. Recurrence occurred in 9 patients (9.6%) during follow-up. Recurrence rates were 8.16% (4/49) in grade III and 31.25% (5/16) in grade IV hemorrhoids. Mean Visual Analogue Scale (VAS) scores for pain were 7.43 (postoperative day 1), 1.72 (week 1), and 0.37 (month 1), demonstrating significant improvement (P < 0.001). No postoperative bleeding, necrosis, or urinary retention was reported. One patient experienced early recurrence on the first postoperative day. Overall symptom resolution was achieved in 92.6% of patients, and 90.4% reported high satisfaction with the treatment.

Conclusion: DG-HAL with or without mucopexy is a safe and effective minimally invasive surgical option for grade II and III hemorrhoidal disease, with high patient satisfaction, low complication rates, and excellent symptom resolution. However, in patients with grade IV disease, the technique's higher recurrence rate necessitates careful patient selection and individualized surgical planning.

Background: Limited studies have examined cholecystectomy's impact on endoscopic retrograde cholangiopancreatography (ERCP) cannulation success and complications in patients with choledocholithiasis. This study used propensity score matching (PSM) to evaluate how cholecystectomy history affects these outcomes during ERCP for choledocholithiasis.

Methods: This retrospective study enrolled 806 choledocholithiasis patients undergoing ERCP at Bishan Hospital, Chongqing Medical University (February 2018 to July 2024). Based on cholecystectomy history, patients were stratified into cholecystectomy and noncholecystectomy groups. With difficult biliary cannulation [European Society of Gastrointestinal Endoscopy (ESGE) criteria] as the primary endpoint, 1:1 propensity score matching (PSM) balanced intergroup covariates. Univariate and multivariate logistic regression analyses systematically evaluated the impact of cholecystectomy history on difficult cannulation and postoperative complications.

Results: Before matching (Cholecystectomy: n=146; Noncholecystectomy: n=660), groups differed significantly in gender, ALT, AST, TBiL, and DBiL (all P <0.05). After PSM (n=290), covariates were balanced. Multivariate analysis revealed cholecystectomy history, age, and gender as independent predictors of cannulation success.

Conclusions: Patients with prior cholecystectomy undergoing ERCP for choledocholithiasis demonstrated significantly lower rates of difficult cannulation compared with those without cholecystectomy history, without significant increase in postoperative complications.

Background: As part of the accreditation process for bariatric surgery, patients must go through a preoperative pathway. There will inevitably be patients who are seen in the clinic but never undergo surgery. This rate of attrition is different for every practice. Our objective was to evaluate the percentage of patients who eventually undergo bariatric surgery at a community practice.

Methods: A single private practice was evaluated. Patients initially seen in the clinic were followed to surgery completion or until they dropped out. A period of 21 months was evaluated. Patients with at least a 6-month follow-up were included.

Results: There were 479 patients who underwent evaluation during that time. Forty-three percent of these patients went on to have surgery. There were 216 patients who did not have surgery, with most of those patients never progressing past the first visit. One patient became pregnant and dropped out, 2 did not achieve medical clearance, one moved out of town, and one obtained surgery at a different program. There was a significant increase in the rate of attrition if the wait period was 6 months or longer (P<0.05).

Conclusion: There are no national benchmarks as to what percentage of patients complete the preoperative process at accredited bariatric centers and undergo surgery. This solo private practice has a conversion rate of 43%. Longer waiting times appear to increase the rate of attrition. Mandated wait times function as barriers to patients undergoing surgery and should be abandoned.

Background: Iatrogenic colonic perforation (ICP) is a rare but serious complication of colonoscopy. Its incidence varies according to whether the procedure is diagnostic or therapeutic. Although surgery has traditionally been the cornerstone of treatment, advances in endoscopic techniques-particularly clip application-have provided less invasive alternatives. This study aimed to present the clinical characteristics, management strategies, and outcomes of ICP in a high-volume tertiary center, with a particular focus on the efficacy and limitations of endoscopic clip closure.

Methods: In this retrospective study, all patients diagnosed with ICP between 2019 and 2024 at Kartal Dr. Lutfi Kirdar City Hospital were evaluated. Among 87,526 colonoscopies performed during this period, 42 patients with ICP were included. Patients were classified according to whether colonoscopy was performed for diagnostic or therapeutic indications. Endoscopic clip closure was attempted in 14 patients and was successful in 8 of them (57.1%). Surgical intervention was performed in 34 patients, either after failed endoscopic management or as the primary treatment.

Results: ICP developed more frequently during diagnostic procedures (69%). The sigmoid colon (57.1%) was the most common site of perforation, and most perforations were intraperitoneal (81%). Baseline demographic and clinical characteristics did not differ significantly between the diagnostic and therapeutic indication groups ( P >0.05). Successful endoscopic clip closure was associated with early diagnosis, good bowel preparation, and perforation size <2 cm. Patients treated endoscopically had shorter times to oral intake and shorter hospital stays compared with those treated surgically.

Conclusions: Endoscopic clip application is an effective treatment option for carefully selected ICP cases with early recognition, favorable local conditions, and small, localized defects. However, surgery remains essential in large perforations, delayed diagnoses, or when clip closure fails. Our findings provide real-world data on the role and limitations of standard clip closure in a resource-limited tertiary center and support guideline-based, individualized decision-making for ICP management.

Background: Colorectal cancer is a leading global malignant tumor, and adequate lymph node (LN) examination is essential for its management.

Methods: This retrospective study, conducted from January 2018 to December 2023 at the First Medical Center of the Chinese PLA General Hospital, aimed to develop a statistical model for assessing LN count adequacy. To calculate false-negative probabilities, a new statistical model based on the β-binomial distribution and maximum likelihood method in R software was used.

Results: Among 4429 screened colorectal cancer patients, there were 2314 with colon cancer and 2115 with rectal cancer. For colon cancer, the excision of 7 LNs for pT1 and 11 LNs for pT2 was associated with a likelihood of encountering occult positive LNs remained below 5%. For pT3 and pT4, after the removal of 16 LNs and 20 LNs, respectively, the likelihood of overlooking a positive node was below 10%. For rectal cancer, the excision of 7 LNs for pT1 and 12 LNs for pT2 was associated with a likelihood of encountering occult positive LNs remained below 5%. For pT3 and pT4, after removing 15 LNs and 19 LNs, the likelihood of overlooking a positive node was below 10%.

Conclusions: Our study establishes a novel quantitative framework that links LN harvest thresholds to the risk of false-negative metastasis in colorectal cancer, supporting adopting a more personalized approach.

Background: A retrospective analysis was conducted on consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to evaluate the efficacy and safety of different techniques in difficult biliary cannulation cases after unintentional pancreatic duct access.

Methods: The patients were divided into 4 groups according to the cannulation method: the double guidewire (DGW) group, the transpancreatic sphincterotomy (TPS) group, the transpancreatic sphincterotomy combined with a pancreatic duct stent (TPS-PDS) group, and the precut over a pancreatic duct stent (PPDS) group. The baseline characteristics, biliary cannulation success rate, and postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) incidence were compared and analyzed among these groups.

Results: A total of 228 cases were enrolled, and there were no significant statistical differences among the groups in terms of the type of baseline characteristic. The final success rates for biliary cannulation ranged from 88.60% to 97.10%, and the incidence of PEP ranged from 0% to 27.50% among the 4 groups ( P =0.147 and 0.005, respectively). The incidence of severe PEP was significantly higher in the TPS group compared with the other groups ( P <0.001). Among the 156 cases that received pancreatic duct stent placement, the stents spontaneously migrated in 109 cases within 3 months. Furthermore, stents with trimmed wings had significantly higher migration rates when compared with stents without trimmed wings (88.50% vs. 22.70%, P <0.001).

Conclusions: For cases with difficult biliary cannulation after unintentional pancreatic duct access, TPS-PDS and PPDS are superior to DGW and TPS. Pancreatic duct stents with a trimmed front side wing would spontaneously migrate at a significantly higher rate.

Background: To compare the clinical outcomes of transgastric natural orifice transluminal endoscopic surgery (NOTES) using an ultrathin flexible endoscopic tunneling technique with conventional flexible endoscopic NOTES for gallbladder-preserving treatment of gallstones and polyps.

Methods: A retrospective study was conducted on 62 patients treated between January 2023 and February 2025 at the Fifth People's Hospital of Shenyang, including 23 in the ultrathin tunneling group and 39 in the conventional group. Clinical outcomes, operative time, blood loss, titanium clip usage, postoperative pain (VAS scores), time to flatus, oral intake, hospital stay, costs, complications, clinical success, and recurrence rates were compared. Follow-up was conducted for 1 to 3 months (median: 2 mo).

Results: Both procedures demonstrated a 100% clinical success rate. The ultrathin tunneling group showed significantly lower blood loss, fewer clips, lower VAS scores on postoperative days 1 to 3, earlier oral intake, and shorter hospital stays ( P <0.05). No significant differences were observed in operative time, flatus time, hospitalization costs, complication rates, or gallstone recurrence rates ( P >0.05). Operative time correlated with blood loss, and flatus time correlated with the day 1 VAS score.

Conclusions: Both NOTES techniques are effective and safe for gallbladder-preserving treatment of gallstones and polyps. The ultrathin tunneling approach offers advantages in reducing surgical trauma, enhancing recovery, and potentially lowering recurrence risk, supporting its clinical application.