Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

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.

Objective: To describe a refined endoscopic Totally Extraperitoneal Release & Reinforce (TEP-RRT) technique for sportsman's hernia and athletic pubalgia (SH/AP) with structured rehabilitation program and to present descriptive long-term results from a nine-year clinical series.

Methods: Between January 2016 and April 2024, a consecutive series of 461 athletes with chronic SH/AP grade 4 to 5 underwent bilateral TEP-RRT by a single surgeon after failure of conservative treatment. The technique involves endoscopic extraperitoneal access, meticulous release of pubic bone (PB) complex adhesions and inflamed inguinal ligament (IL) responsible for neural entrapment, followed by pre-peritoneal reinforcement with a mid-weight mesh. A standardized postoperative structured rehabilitation program (PSRP) was initiated seven days postoperatively. Nine years long-term outcomes were assessed retrospectively using a standardized telephone survey conducted between September 2024 and March 2025.

Results: All 461 athletes (447 primary cases and 14 revision cases following failed SH/AP surgery performed at other centers) completed a survey-based postoperative follow-up, ranging from 6 months to 9 years. Overall, 98.5% (454/461) returned to sports activity and remained active, 75% resumed activity within 8 weeks, including all revision cases. No recurrences were reported during the follow-up period. Complications were infrequent (1.5%).

Conclusions: TEP-RRT combined with a PSRP is a feasible, safe, and durable technique for primary and revision SH/AP cases.

Background: Balloon-assisted endoscopic submucosal dissection (BA-ESD) can improve endoscopic maneuverability by stabilizing the tip of the scope. Studies have compared BA-ESD with conventional ESD (C-ESD) and reported conflicting results. We conducted a meta-analysis to compare BA-ESD with C-ESD in the management of colorectal polyps.

Methods: Several databases were reviewed from 1985 to December 16, 2024, to identify studies comparing BA-ESD with C-ESD for colorectal polyps. Our outcomes of interest were en bloc resection and R0 resection, procedure time, dissection speed, and adverse events such as perforation and bleeding. We calculated the pooled odds ratio (OR) with 95% CI for categorical variables and the standardized mean difference (SMD) with 95% CI for continuous variables.

Results: We included 8 studies with 1449 patients (BA-ESD 420 and C-ESD 1029). We found no significant difference in the rate of en bloc resection, OR (95% CI): 1.00 (0.51-1.99) and R0 resection, OR (95% CI): 1.24 (0.51-3.02) between groups. We found no significant difference in bleeding and perforation between groups. We found no significant difference in procedure time, SMD (95% CI): -0.15 (-0.56 to 0.26) and dissection speed, SMD (95% CI): 0.18 (-0.28 to 0.63) between groups. Subgroup analysis of RCTs showed that the procedure time was significantly shorter in the BA-ESD group.

Conclusions: Our meta-analysis demonstrated comparable outcomes between BA-ESD and C-ESD, although analysis of RCTs demonstrated shorter procedure time with BA-ESD. Large-scale multicenter RCTs are required to further evaluate these findings.

Background: Bariatric surgery is a prevalent and effective treatment for morbid obesity, yet its potential long-term effects on anorectal health remain an under-investigated aspect of post-operative care. This study aimed to meticulously evaluate the incidence and the degree of severity of two common anorectal conditions, anal fissures and hemorrhoids, in a substantial cohort of patients following either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB), two frequently performed bariatric procedures. Understanding these potential post-surgical morbidities is crucial for a comprehensive approach to patient management.

Methods: A retrospective cohort study at a large tertiary referral center (2015-2023) included 280 patients (200 SG, 80 RYGB). Detailed pre- and post-operative data on anorectal conditions, bowel habits, and surgical outcomes were extracted from electronic records and statistically analyzed.

Results: The overall incidence of new-onset anorectal disorders (defined as the development of at least one of the conditions) was significantly higher in the RYGB group (47.5%) compared to the SG group (32.5%) (P <0.001). Specifically, the incidence of new-onset hemorrhoids (36.5% vs. 23.5%, P=0.02) and anal fissures (29.0% vs. 16.0%, P=0.01) occurred more frequently in the RYGB group. The mean severity scores were also higher (Goligher score: 2.6±0.8 vs. 2.1±0.7, P = 0.01; fissure severity: 2.9±1.0 vs. 2.3±0.9, P = 0.02). Post-operative constipation and diarrhea were associated with higher risk, and RYGB was an independent predictor. Multivariate analysis, adjusting for age, sex, and baseline BMI, confirmed RYGB (OR 1.7, 95% CI 1.1-2.5, P=0.01) and post-operative constipation (OR 2.0, 95% CI 1.3-3.0, P=0.001) as independent predictors of new-onset anorectal disorders.

Conclusions: Our findings highlight that not all bariatric procedures carry the same risk for anorectal complications, and RYGB specifically warrants closer attention. These findings underscore the clinical importance of incorporating proactive assessment and management of anorectal health, including bowel habit regulation and symptom monitoring, into the routine post-operative care of bariatric surgery patients to optimize their overall well-being.

Background: Situs inversus totalis (SIT) is a rare congenital condition characterized by the mirror-image reversal of thoracic and abdominal organs. Its incidence is between 0.04% and 0.30%. Patients with SIT presenting with cholelithiasis pose diagnostic and technical challenges, particularly during laparoscopic cholecystectomy (LC), due to reversed anatomic landmarks and difficulties in orientation.

Methods: We conducted a retrospective review of 12 patients with SIT who underwent LC between September 2006 and April 2023 at our tertiary center. Preoperative evaluation included hematology, liver function tests, ultrasonography, cardiac, and pulmonary assessments. Surgeries were performed under general anesthesia using a modified French technique in mirror-image configuration. A harmonic scalpel (ultracision) was used for dissection in all cases.

Results: Out of 5375 LCs performed during the study period, 12 were in patients with SIT (prevalence: 0.22%). All procedures were completed laparoscopically without conversion. One case required port site modification for optimal clip application. Two patients underwent gallbladder decompression, and one developed postoperative ileus, which resolved conservatively. No intraoperative complications, bile duct injuries, or mortalities were observed.

Conclusion: Laparoscopic cholecystectomy in SIT patients is safe and feasible when performed by experienced surgeons. Modifications in surgical technique and port placement are essential to accommodate the reversed anatomy. Preoperative planning and intraoperative vigilance are key to minimizing complications and achieving outcomes comparable to anatomically normal patients.

Purpose: Obstructive defecation syndrome (ODS) significantly impairs bowel function and often requires surgical intervention. This study evaluated sex-specific differences in outcomes after robotic-assisted resection rectopexy with natural orifice specimen extraction (NOSE).

Methods: A prospective cohort of 57 patients (46 females, 11 males) undergoing robotic NOSE rectopexy for ODS was analyzed. Functional outcomes were assessed using the Wexner Constipation Score (WCS), Incontinence Score (WIS), and Altomare OD Score at baseline, 1, 3, and 12 months. To account for unequal group sizes, entropy balancing was applied and weighted analyses were performed.

Results: Descriptive data indicated that rectocele was more frequent in females (73.9% vs. 27.3%), and male patients had slightly longer hospital stays (6.0 vs. 4.6 d). Constipation, ODS, and incontinence scores improved markedly in both sexes (eg, WCS at 12 mo: 2.0 in males vs. 4.8 in females). While raw values suggested somewhat faster improvement in males, weighted analyses confirmed that no significant sex effects remained. No conversions or anastomotic leaks occurred, and overall patient satisfaction was high (96.5%).

Conclusion: Robotic NOSE rectopexy provides safe and effective treatment for ODS in both sexes. Descriptive analyses suggested a trend toward faster recovery in male patients, but after adjustment with entropy balancing no significant sex effects were found. Both sexes experienced marked functional improvement and high satisfaction, supporting robotic NOSE rectopexy as a valuable treatment option.

Background: Research on lymph node metastasis (LNM) in locally advanced rectal cancer (LARC) remains significantly underexplored. This study investigates the clinicopathological factors associated with LNM in LARC and develops a predictive nomogram for clinical application.

Methods: A retrospective analysis was performed on 1270 patients with LARC who underwent radical surgery between 2018 and 2023. Univariate and multivariate logistic regression analyses were conducted to identify independent predictors of LNM. A nomogram integrating these predictors was constructed and internally validated using bootstrap resampling. Subgroup analyses were carried out to compare stage N1 (n=333) and stage N2 (n=265) patients to determine the risk factors for advanced metastasis.

Results: The detection rate of LNM was 47.0% (598/1270). Independent risk factors included mucinous adenocarcinoma (OR=1.529, P=0.018), bowel obstruction (OR=1.418, P=0.014), poor tumor differentiation (OR=2.468, P<0.001), perineural invasion (OR=1.784, P=0.003), and lymphovascular invasion (LVI, OR=2.741, P<0.001). Conversely, a history of alcohol consumption (OR=0.721, P=0.016) and microsatellite instability-high (MSI-H) status (OR=0.241, P=0.005) appeared to exert protective effects. The nomogram demonstrated moderate predictive accuracy (C-index: 0.657, 95% CI: 0.627-0.686). In subgroup analyses, Ki-67 expression emerged as an additional independent risk factor for stage N2 patients (OR=1.016, P=0.040).

Conclusion: This study elucidated key risk factors for LNM in LARC patients and developed a nomogram for clinical use, offering valuable insights for the design and implementation of multidisciplinary perioperative treatment strategies.

Background: Barbed sutures enable knotless, continuous cruroplasty and are increasingly used in hiatal and paraesophageal hernia repairs. Despite widespread adoption, outcome data specific to the hiatus are limited and diaphragmatic application remains off-label.

Methods: A systematic search of PubMed and MEDLINE (inception-August 2025) identified adult hiatal/paraesophageal hernia repairs using barbed sutures. Data on operative approach, mesh use, operative time, recurrence, and perioperative outcomes were extracted. The FDA MAUDE database (2010 to 2025) was reviewed for device-related events.

Results: Five studies (n=741) met the inclusion criteria. In laparoscopic comparisons, barbed sutures shortened per-stitch closure time compared with interrupted silk, although total closure time was not significantly different. In pooled analysis of 4 comparative studies, the weighted mean difference in operative time was +12.8 minutes (95% CI: -4.3 to 29.8; P=0.14; I²=40%). Individual series demonstrated variable findings: operative time increased with mesh reinforcement but not when mesh was avoided (P=0.45). One study reported that barbed cruroplasty with biosynthetic mesh reinforcement significantly reduced ≥1-year anatomic recurrence (24.7% vs. 44.9%; risk difference -20.3%, 95% CI: -33.7 to -7.0) and symptomatic recurrence (17.2% vs. 42.2%, P=0.003) compared with barbed suture-only repair. Postmarket surveillance analysis of the FDA MAUDE database (2010 to 2025) identified only 2 hiatal-specific adverse events associated with barbed sutures, although underreporting is likely.

Conclusions: Barbed sutures for cruroplasty appear time-efficient and may lower recurrence when combined with mesh in larger hernias. However, current evidence is sparse, heterogeneous, and based largely on retrospective series. Given the off-label nature of diaphragmatic use, prospective studies with standardized recurrence definitions are needed to clarify safety and long-term efficacy.