Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Hand-assisted laparoscopy is an operative approach that combines the benefits of both open and laparoscopic surgery. Despite this method, many surgeons choose to perform standard laparoscopic surgery (SLS) without the use of a hand assist. Operative challenges encountered during SLS may necessitate an unplanned laparoscopic converted to open surgery (LCOS), which may increase the risk of adverse patient outcomes. Alternatively, prior studies show that hand-assisted laparoscopic surgery (HALS) may be associated with a lower risk of postoperative morbidity. In this study, we compared preoperative factors and postoperative outcomes between HALS and LCOS in patients undergoing a proctectomy.

Methods: The 2022 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Targeted Proctectomy Database was utilized to analyze patients undergoing proctectomy procedures. From this, 211 patients who underwent an LCOS (LCOS Cohort) and 801 patients who underwent a HALS (HALS Cohort) were identified and compared.

Results: Patients with more comorbidities were more likely to undergo an LCOS. LCOS patients experienced higher rates of postoperative complications, including blood transfusion (20.85% vs. 5.99%; P <0.001), postoperative renal insufficiency (17.06% vs. 7.12%; P <0.001), and mortality (1.90% vs. 0.37%; P =0.018). Multivariate logistic regression confirmed that undergoing an LCOS was independently associated with increased odds of postoperative renal insufficiency (OR=2.63; P <0.001) and the need for blood transfusion (OR=4.05; P <0.001).

Conclusion: We believe this is the first large national database study comparing HALS and LCOS approaches for proctectomies. Multivariate logistic regression confirmed that HALS was associated with better postoperative outcomes compared with LCOS. In complex cases, starting with the HALS approach may be more advantageous than the SLS method. Furthermore, hand assistance should be considered before converting to open surgery in challenging laparoscopic cases.

Background: The common postoperative complications of laparoscopic cholecystectomy (LC) are port site infection, biliary leak, hemorrhage, and pain at the surgical site, as well as at the shoulder tip. The aim of the study was to identify whether the Glisson's capsule (GC) injury during LC responsible for postoperative right shoulder tip pain (RSTP).

Material and methods: This prospective observational cross-sectional study was conducted over 18 months. We enrolled patients aged ≥18 years who underwent LC. Demographic data, preoperative investigations, and intraoperative video recordings were used to evaluate factors for postoperative RSTP.

Results: The study included 215 patients with a mean age of 42.65 years. Forty-one participants (19.1%) were male, and 174 (80.9%) were female. Our study showed that the incidence of RSTP after LC was 41.9%. Of 90 patients who had RSTP, 81 (90%) had GC injury. Among the 125 patients without RSTP, 97 (77.6%) also had Glisson's capsule injury. The difference in the presence of Glisson's capsule injury between patients with and without RSTP was statistically significant ( P =0.017).

Conclusion: Our study demonstrated an association between GC injury and post-LC RSTP.

Background: This retrospective study compares the short-term safety and feasibility-related clinical outcomes of robotic gastrectomy (RG) for remnant gastric cancer (RGC) (including various types of initial reconstruction) with those of laparoscopic gastrectomy (LG).

Methods: Forty-five patients underwent minimally invasive gastrectomy for RGC at our hospital between June 2012 and December 2024. LG was performed for 33 patients, and RG was performed for 12 patients.

Results: The median operation time was significantly longer in the RG group than in the LG group (346 min vs. 295 min, P =0.020). The RG group had significantly less blood loss than the LG group (27 mL vs. 100 mL, P =0.005). The median number of harvested lymph nodes was comparable between the two groups. Conversion to an alternative surgical approach occurred in three cases in the LG group, and not at all in the RG group. The overall incidence of postoperative complications (Clavien-Dindo grade ≥II) was comparable between the LG and RG groups (27.3% vs. 25.0%). The median postoperative hospital stay was similar between them. The median interval from the initial gastrectomy to surgery for RGC was significantly longer in the Billroth-II group than in the Billroth-I group (50 y vs. 10 y, P <0.001).

Conclusion: Robotic gastrectomy could be applied for various types of RGC without conversion to another approach. Robotic gastrectomy for RGC was considered a safe and feasible approach.

Objective: The global burden of colorectal cancer (CRC) is projected to increase by 60% by 2030. Colonoscopy plays a crucial role in CRC screening, reducing incidence and mortality. However, its limitation is the occurrence of post-colonoscopy colorectal cancers (PCCRC). This meta-analysis aimed to determine the pooled prevalence of PCCRC-3y (CRCs diagnosed within 6 to 36 mo of colonoscopy) and emphasize the importance of enhancing endoscopy quality metrics to mitigate the burden of PCCRC-3y effectively.

Methods: A systematic literature search through June 2024 identified single-center, multi-center, or population-based studies reporting PCCRC-3y prevalence. Pooled prevalence was estimated using methodologies recommended by the World Endoscopy Organization with a quantitative assessment of endoscopy quality measures.

Results: Seventeen studies reporting on 25,504 PCCRCs were included. The pooled PCCRC-3y prevalence was 5.5% (95% CI: 4.9-6.2%). The likelihood of these cancers developing in the proximal colon was 1.9 times higher (8.7%; 95% CI: 7.8-9.8%) than in the distal colon (4.6%; 95% CI: 3.9-5.4%). The prevalence of PCCRC-3y declined significantly from 6.7% (95% CI: 5.7-7.8%) in 1992 to 2015 to 4.0% (95% CI: 2.9-5.6%) in 2005 to 2021 ( P =0.01). Additionally, several endoscopy quality indicators impacting PCCRC were identified.

Conclusions: This meta-analysis found that the pooled PCCRC-3y prevalence was 4.0% (95% CI: 2.9-5.6%) from 2005 to 2021, reflecting a significant decline from previous years. Despite high heterogeneity among studies, the pooled prevalence serves as a useful benchmark for healthcare institutions in detecting and preventing CRC, as well as improving colonoscopy quality. The endoscopy quality indicators provide clear guidance for improving colonoscopy standards.

Background: Choledochoduodenostomy (CDD) has been reconsidered as an alternative to choledocholithiasis, especially in cases where endoscopic clearance is difficult. This study aimed to evaluate the use of laparoscopic CDD and compare the results with open CDD, including long-term outcomes.

Methods: The medical records of 65 patients who underwent laparoscopic or open surgery due to the difficulty of endoscopic treatment between 2011 and 2021 were retrospectively analyzed. Laparoscopic CDD was performed in 20 cases during the latter period, from April 2016, and open CDD was performed in 45 cases during the former period, before April 2016. The laparoscopic and open CDD surgical results were compared. Data on patient demographics, operative time, blood loss, hospital stay, and complications like bile leakage, reflux cholangitis, and anastomosis stenosis were evaluated.

Results: The median operative times, blood losses, and hospital stays were 187 and 125 minutes, 32 and 95 mL, and 8 and 14 days in the laparoscopic and open CDD groups, respectively. The occurrence of minor bile leakage, reflux cholangitis, and anastomosis stenosis was 2/20 (10%) and 1/45 (2.2%), 1/20 (5%) and 2/45 (4.4%), and 2/20 (10%) and 1/45 (2.2%) in the laparoscopic and open CDD groups, respectively. A comparison between the laparoscopic and open CDD groups revealed no significant difference in reflux cholangitis or anastomosis stenosis, but the operative times and incidence of minor bile leakage were higher in the laparoscopic group, and the hospital stays and amount of blood loss were lower in the laparoscopic group.

Conclusions: Laparoscopic CDD is feasible and not inferior to open CDD. The laparoscopic approach is minimally invasive and may be particularly advantageous in some patients.

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.