Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

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: Peroral endoscopic myotomy (POEM) is a well-established endoscopic treatment for achalasia, utilizing an endoscopic knife for dissection. Recently, new knives with an integrated water-jet (WJ) function have been introduced. This study aims to compare the technical, perioperative, and late postoperative outcomes between WJ knives and conventional (C) knives, which lack the WJ function, through a pairwise meta-analysis of published comparative studies.

Methods: We conducted a systematic literature review following PRISMA guidelines to identify studies directly comparing knives with versus without a WJ function in POEM for achalasia. A random-effects model was employed, using odds ratios for dichotomous data and mean differences for continuous data as effect size metrics.

Results: The use of WJ knives demonstrated statistically significant reductions in the mean number of intraoperative instrument exchanges, mean intraoperative use of coagulation forceps, and operative times compared to the use of C knives. There were no significant differences in terms of the incidence of adverse events, subcutaneous emphysema, or mean hospital length of stay (LOS). Clinical success, defined as a postoperative Eckardt score <3, mean postoperative Eckardt scores, and the incidence of GERD requiring proton pump inhibitors (PPI) also showed no significant differences.

Conclusions: The use of water-jet (WJ) knives demonstrates comparable efficacy to conventional (C) knives, with superior efficiency reflected in reduced operative time and fewer intraoperative instrument exchanges. In addition, in terms of safety, the lower use of coagulation forceps with WJ knives suggests reduced intraoperative bleeding. However, no significant differences were observed between the groups in terms of length of stay (LOS) and adverse events, despite a trend toward reduction. A larger number of studies with greater sample sizes is required to better assess potential differences in safety between the use of WJ and C knives.

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: Laparoscopic sleeve gastrectomy (LSG) has become the most commonly performed bariatric procedure due to its technical simplicity and effectiveness. While stapler line reinforcement has significantly reduced hemorrhagic complications, postoperative bleeding remains a concern, particularly from omentum or unidentified sources. The LigaSure device, known for sealing vessels successfully up to 7 mm in diameter, may face challenges in obese patients due to excessive omental fat. This study introduces a double-sealing technique as a simple solution aimed at reducing postoperative bleeding related to patient-specific factors.

Methods: This study conducts a retrospective analysis to evaluate the double-line omental sealing technique in LSG, an intervention aimed at reducing the incidence of postoperative bleeding. We compared outcomes from 222 patients using the double-line sealing (DLS) technique and 297 patients with standard dissection. DLS technique involves creating 2 adjacent rows of seals on the omentum during dissection, aiming to minimize bleeding risks. Patient demographics, including age, sex, body mass index, and comorbidities, were examined, alongside operative time, length of hospital stay, and instances of reoperation. Special attention was given to identifying cases of severe postoperative bleeding, primarily determined by the need for blood transfusion.

Results: No demographic differences emerged between the groups. The study group, which utilized DLS, demonstrated a significantly lower incidence of intraperitoneal severe bleeding (0.45%) compared with the control group (3%). Reoperations were significantly reduced, with only 2 cases (0.67%) in the control group and none in the DLS group. It also correlates with reduced length of hospital stay but increased operative time.

Conclusions: DLS in LSG shows promise in reducing severe postoperative bleeding. Despite these positive initial findings, further studies with larger sample sizes are recommended to fully ascertain the efficacy and safety of this technique.

Objective: In this study, we investigated the factors related to abnormal liver function in patients undergoing laparoscopic esophageal hiatal hernia repair.

Methods: The clinical data of 347 patients who underwent elective laparoscopic esophageal hiatal hernia repair at Beijing Chao-yang Hospital of Capital Medical University between January 2018 and November 2023 were retrospectively collected. The patients comprised 131 males and 216 females, ranging in age from 24 to 87 years, and were assessed using the ASA grading system between grades I and III. The patients were divided into 2 groups based on the presence or absence of liver function abnormalities on the first day after surgery: a normal liver function group (NLA group) and an abnormal liver function group (LA group). Patients with elevation in any of the following indicators were included in the LA group: alanine aminotransferase >40 U/L, glutamine aminotransferase >40 U/L, γ-glutamyltransferase >49 U/L, alkaline phosphatase >135 U/L, total bilirubin >17.1 μmol/L, or direct bilirubin >6.8 μmol/L. The clinical data of the 2 groups of patients were compared, and only the indicators with a P-value <0.15 were included in a binary logistic regression model analysis.

Results: There were 238 patients (68.6%) who developed liver function abnormalities on the first postoperative day. In comparison to the NLA group, the LA group had a significantly higher proportion of patients with esophageal hiatal hernia type II, type III, and type IV, hypotension, and high PETCO2. Furthermore, the LA group had a significantly lower proportion of patients receiving blood transfusions. The maximum length and maximum cross-sectional area of the esophageal hiatal hernia were also significantly larger in the LA group. In addition, the operation time was significantly longer in the LA group. (all P-values are <0.15). The binary logistic regression analysis revealed that prolonged operation time (OR=1.017, 95% CI: 1.007-1.028) was the only risk factor associated with postoperative liver function abnormalities.

Conclusions: The sole risk factor for postoperative liver function abnormalities was prolonged surgical time.

Background: Although originally described as an open procedure, the application in the setting of minimally invasive surgery of the Pauli technique for parastomal hernia repair is gaining interest among surgeons owing to encouraging early results. We aimed at combining and analyzing the results of minimally invasive Pauli repair by assessing the available evidence.

Methods: A literature search in Pubmed, Embase, and Web of Science was undertaken to include all articles reporting on minimally invasive repair of parastomal hernias using the Pauli technique.

Results: Data regarding a total of 75 patients across 11 articles published between 2019 and 2023 were included. Patients received surgery either by a laparoscopic (27%) or robotic (73%) approach. A transabdominal route was chosen in 62 patients (83%), while an extraperitoneal technique was employed in the remaining 13 patients. The rate of postoperative morbidity was 34%, with 10% being the incidence of grade >II complications. The reported overall rate of recurrence was 7% at a median follow-up of 1 to 43 months.

Conclusions: The available evidence derived from a growing number of centers suggests that minimally invasive Pauli repair is a viable option to treat parastomal hernias. Despite robust, high-level data still lacking, preliminary experiences indicate promising results.

Background: Retained gallstones are the most common cause of postcholecystectomy pain. They may be in a long remnant cystic duct (CD), the common bile duct (CBD), or within a remnant gallbladder (GB) post subtotal cholecystectomy. Although endoscopic management is often attempted, occasionally surgical clearance is required. Rates of preoperative surgery to remove stones in a remnant GB are rising due to the increased practice of subtotal cholecystectomy during a problematic laparoscopic cholecystectomy. This study aims to review the surgical management of symptomatic retained stones at a tertiary hepatobiliary referral center in Sydney, Australia.

Patients and methods: This retrospective analysis of prospectively collected data was performed on patients who underwent an operation for retained stones after a previous cholecystectomy over 18 years (2004-2022). All of the patients with residual CBD stones had failed endoscopic retrograde cholangiopancreatogram (ERCP) attempts or could not have an ERCP because of prior foregut surgery. All patients underwent a systematic preoperative workup confirming the biliary anatomy and pathology.

Results: Fourteen patients had surgical intervention for retained stones. All cases were attempted laparoscopically and were successful in 11/14 patients (78%). Retained stones were found within a remnant GB (29%, n=4), a remnant CD (36%, n=5), or the CBD (36%, n=5). Conversion to an open procedure in 3 patients was for dense fibrosis associated with a long low-insertion of the CD, necessitating a hepatico-jejunostomy, failure to delineate the biliary anatomy, and inability to clear CBD stones, respectively. One patient developed a minor postoperative complication (superficial wound infection), and all patients were free of symptoms at a median follow-up of 33.5 months.

Conclusion: This study demonstrates favorable outcomes in patients undergoing laparoscopic intervention for retained gallstones. A systematic approach to the workup and surgical management of patients with retained stones is essential.

Background: We investigated the relationship between the length of a prophylactic closed-suction drainage tube and clinically relevant postoperative pancreatic fistula (CR-POPF) in distal pancreatectomy (DP).

Materials and methods: The clinical data of 76 patients who underwent DP using a reinforced stapler for the division of the pancreas at Ehime University Hospital between December 2017 and May 2023 were retrospectively analyzed. Laparoscopic DP was performed in 41 patients (53.9%). Closed-suction drainage was performed using a 19 Fr ExuFlow Round Drain with a vacuum bulb. The drainage tube length was defined as the distance between the peripancreatic stump site and the abdominal wall insertion site using abdominal radiography.

Results: CR-POPF was observed in 12 patients (15.8%). Univariate analyses demonstrated that male sex ( P =0.020), American Society of Anesthesiologists Physical Status ( P =0.017), current smoking ( P =0.005), and drainage tube length ( P <0.001) were significantly associated with CR-POPF. The optimal cut-off value of drainage tube length for CR-POPF was 220 mm (area under the receiver operating characteristic curve=0.80). In multivariate analyses, drainage tube length (≥220 mm) was the sole independent predictor for CR-POPF (odds ratio, 6.59; P =0.023). According to computed tomography performed ∼1 week after surgery, the median volume of peripancreatic fluid collection was significantly higher in the long drainage tube group than in the short drainage tube group ( P <0.001).

Conclusion: A drainage tube inserted at a shorter distance to the pancreatic stump may reduce the incidence of CR-POPF after DP.

Background: The effectiveness of colonoscopy in preventing colorectal cancer (CRC) within opportunistic screening programs has not been clearly established. The aim of this study was to analyze the effectiveness of colonoscopy within an opportunistic screening program using nested case-control study.

Methods: Subjects who received a diagnosis of CRC (CG) between the ages of 50 and 90 years were included and matched by age and gender in a 1:5 ratio with patients without CRC diagnosis (COG) during the period 2015 to 2023. Using conditional regression analyses, we tested the association between screening colonoscopy and CRC. Subgroup analyses were then performed for CRC location, endoscopist specialty, and colonoscopy quality.

Results: Of the 134 patients in CG, 19 (14.18%) had a colonoscopy in the preceding 5 years compared with 258 out of 670 (38.51%) in COG (AOR, 0.24; 95% CI: 0.14-0.41). Any colonoscopy was strongly associated with decreased odds for left-sided CRC (AOR, 0.09; 95% CI: 0.04-0.24) but not for right-sided CRC (AOR, 0.58; 95% CI: 0.29-1.17). Only complete colonoscopy (AOR, 0.41; 95% CI: 0.19-0.89) and colonoscopy with satisfactory bowel preparation (AOR, 0.38; 95% CI: 0.15-0.98) were associated with decreased odds for right-sided CRC. No significant differences in colonoscopy outcomes were found when stratifying by endoscopist specialty.

Conclusions: In the setting of an opportunistic screening program, exposure to any colonoscopy significantly reduced left-sided CRC incidence; however, only high-quality colonoscopy was associated with a lower incidence of right-sided CRC. Therefore, every possible effort should be made to optimize the quality and cost-effectiveness of colonoscopy within an opportunistic screening program.

Objective: This study aims to assess the effectiveness of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the endoscopic resection of colonic polyps and investigate the factors influencing polyp recurrence.

Methods: A total of 174 patients with colorectal polyps admitted to the Gastroenterology Department during the same period were included in this prospective randomized controlled study. The patients were randomly allocated to the EMR group and ESD group (72 cases in each group) using a random number table. The clinical efficacy, quality of life, adverse reactions, and 1-year postoperative recurrence rate were compared between the 2 groups. In addition, factors influencing polyp recurrence were analyzed.

Results: No significant differences were observed between the EMR and ESD groups in terms of clinical efficacy, postoperative quality of life, and postoperative complications. However, the postoperative recurrence rate in the ESD group was significantly lower than that in the EMR group. Multifactorial logistic regression analysis revealed that the number of polyps ≥3, maximum polyp diameter ≥2 cm, and family history of colorectal cancer were independent risk factors for colonic polyp recurrence.

Conclusion: ESD and EMR demonstrate similar efficacy and safety in patients with colonic polyps. However, the recurrence rate after ESD is significantly lower than after EMR. Furthermore, multifactorial analysis indicates that a larger polyp diameter, a more significant number of polyps, and a family history of colorectal cancer are independent risk factors for the recurrence of colonic polyps following resection.