Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

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.

Background: There are ∼750,000 laparoscopic cholecystectomies performed annually in the United States. Of these, at least 280,000 cases are nonelective laparoscopic cholecystectomies (LC). There is limited data on factors affecting LOS in patients undergoing nonelective LC. This study aims to determine the factors affecting LOS in patients undergoing nonelective LC.

Study design: The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent nonelective LC without concomitant procedures from 2010 to 2020 (n=115,142). A total of 55,481 patients without significant cardiopulmonary disorders, with a body mass index (BMI) of 18.5 to 60, and with LOS outcome data were included. Prolonged LOS was defined as >2 days. A sensitivity analysis was conducted with prolonged LOS defined as >1 day. All analyses were performed using SAS v9.4.

Results: A total of 18,094 patients (33%) had LOS >2 days, and 33,292 patients (60%) had LOS >1 day. On logistic regression analysis, prolonged LOS was found in 31% of patients with ASA class 1 and 2 versus 44% of patients with ASA class >2 (OR: 1.67; 95% CI: 1.58-1.76), 33% of patients with independent functional status versus 72% of patients with partially dependent functional status (OR: 3.94; 95% CI: 2.76-5.63), and 79% of patients with dependent functional status (OR: 4.45; 95% CI: 2.17-9.12). In logistic regression, age, BMI category, smoking status, and race/ethnicity were also associated with prolonged LOS.

Conclusion: This study showed that a significant percentage of female patients, patients with ASA class 1 and 2, with independent functional status, and belonging to minority ethnicities who underwent nonelective LC had prolonged LOS. Our study highlights the need to evaluate nonclinical factors with further institutional studies.

Background: The optimal endoscopic strategy for postliver transplantation anastomotic strictures remains undefined. This study aimed to evaluate an algorithmic, stepwise approach based on stricture severity over a 13-year period.

Methods: This retrospective study included 78 patients treated between 2011 and 2024. Standard endoscopic passage of the anastomotic stricture using a guidewire was attempted in all cases. When this was unsuccessful, a percutaneous-endoscopic rendezvous procedure was performed; if the stricture remained impassable, a magnetic compression anastomosis was applied.

Results: A total of 613 procedures were performed. The proximal side of the stricture was successfully traversed by standard endoscopy in 55 patients (70.5%), by rendezvous in 15 (19.2%), and by magnetic compression in 8 (10.3%). Stent-free follow-up was achieved in 55 patients (70.5%), with a mean treatment duration of 12.3 months. Recurrence occurred in 10 patients (18.2%), and complications developed in 8.2% of procedures, most commonly stent migration.

Conclusion: A structured algorithm incorporating rendezvous and magnetic compression techniques can enhance overall success in complex post-transplant biliary strictures.

Background: Delayed perforation is a serious complication after endoscopic submucosal dissection (ESD) for gastrointestinal stromal tumors (GISTs). Understanding its incidence, associated risk factors, and clinical outcomes can guide preventative measures. This study aimed to determine the incidence of delayed perforation, identify independent risk factors, and describe the clinical course and management outcomes.

Methods: We retrospectively identified 57 patients who developed delayed perforation ("cases"). Each case was matched 1:1 by key variables (eg, age, tumor location) with 57 controls who did not experience delayed perforation. Baseline characteristics and the timing of delayed perforation were collected. We compared clinical and procedural factors in univariate analysis and conducted multivariate conditional logistic regression. Clinical course and management outcomes for delayed perforation, and subgroup analyses were assessed robustness.

Results: A total of 57 patients developed delayed perforation at a median of 2 days postprocedure (IQR 1 to 7). In univariate analysis, larger tumor size (P=0.02) and operator inexperience (<80 ESDs, P=0.03) were associated with an increased risk. In multivariate analysis, tumor size (adjusted OR 1.45 per cm, 95% CI: 1.04-2.02, P=0.03) and operator inexperience (adjusted OR 2.88, 95% CI: 1.21-6.81, P=0.02) remained significant risk factors. Most patients with delayed perforation presented with abdominal pain (61.4%), and diagnosis was primarily made via CT (66.7%). Management strategies included endoscopic closure (31.6%), surgical repair (35.1%), and conservative treatment (33.3%), with a mean hospital stay of 7.5±2.3 days. Sensitivity analyses confirmed the robustness of these findings.

Conclusions: Larger tumor size and limited operator experience were independent risk factors. Endoscopic or surgical interventions resulted in satisfactory outcomes. These results highlight the need for standardized preventive measures and operator training to mitigate this complication.