Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Background: Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment for biliary obstruction, yet fails in 5% to 7% of cases, necessitating alternative therapeutic options like endoscopic ultrasound-guided biliary drainage (EUS-BD). With acute cholangitis posing significant morbidity and mortality risks, assessing the safety and efficacy of EUS-BD in these patients is vital. This is the first meta-analysis with a subgroup analysis assessing the outcomes of EUS-BD in patients with acute cholangitis secondary to biliary obstruction.

Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines, searching MEDLINE, Embase, Web of Science, Clinicaltrials.gov, and Cochrane databases until December 23, 2023. Studies involving adult patients undergoing EUS-BD for cholangitis were included. Outcomes assessed were pooled technical and clinical success rates, complications, and mortality. Standard meta-analysis methods were employed using the random-effects model, and heterogeneity was assessed using the I2 % statistics.

Results: Among the included 5 studies (109 patients), EUS-BD achieved a pooled technical success rate of 95.5% (95% CI: 91.0-98.5) and a clinical success rate of 92.1% (95% CI: 86.4-96.3), with low heterogeneity across studies ( I2 : 0.00% for both outcomes). The pooled complication rate was 12.2% (95% CI: 5.1-21.8, I2 : 37.46%), with predominantly mild and self-limiting complications.

Conclusion: EUS-BD demonstrated excellent pooled technical and clinical success rates, particularly when ERCP is not feasible in patients with acute cholangitis secondary to biliary obstruction. Most postprocedure complication rates are also mild and self-limiting making EUS-BD a possible alternative for the management of patients with cholangitis.

Background: Laparoscopic common bile duct exploration (LCBDE) is safe and efficacious. "Classic" LCBDE technique utilizes isolated choledochoscope-guided retrograde basketing; however, it is less effective than transcholedochal exploration. We report on the evolution of our LCBDE technique away from "classic" transcystic approach towards prioritizing antegrade clearance using a novel algorithm utilizing a variety of tools, which we term laparoscopic reverse cholangiopancreatography (LRCP).

Methods: We report an algorithm-driven LRCP technique for LCBDE that tailors intervention to the patient's anatomy and stone burden (size, location, number) seen on cholangiogram (IOC). For cystic ducts ≥4 mm, we use a choledochoscope-assisted technique versus a fluoroscopy-guided technique if <4 mm. For small stones, we use wire basketing (with the "classic" technique) or the "snow-plow" maneuver. For medium (≤10 mm) or multiple stones, we utilize sphincteroplasty plus "snow-plow" if needed. For large (>10 mm), we use laser or electrohydraulic lithotripsy. Fallback methods are ERCP or transcholedochal exploration.

Results: We retrospectively reviewed our 80 LCBDE cases at a single Veterans Affairs hospital: 50 cases in the "classic" phase and 30 subsequent cases using LRCP. Transcystic clearance was significantly higher for LRCP at 97% vs. 56% during the "classic" phase (χ2=15.14, P <0.001). There was zero utilization of choledochotomy during LRCP.

Conclusions: Algorithm-driven LRCP dramatically improved transcystic clearance success and reduced reliance on choledochotomy. Our algorithm serves as a decision aid, allowing surgeons to utilize a variety of available tools for LCBDE.

Introduction: Many patients with cirrhosis develop posthepatectomy liver failure (PHLF). Factors associated with clinically relevant PHLF (CRPHLF) in cirrhosis with different remnant liver volume (RLV)-to-standard liver volume (SLV) ratios are unclear.

Aim: The study aimed to determine whether an RLV/SLV value of <40% is safe for hepatectomy in patients with cirrhosis.

Material and methods: Patients with cirrhosis were divided into an RLV/SLV <40% group (28 cases) and an RLV/SLV ≥40% group (39 cases) based on their RLV/SLV ratio. The incidence of CRPHLF and surgical complications in the 2 groups were analysed, and CRPHLF was determined according to the criteria of the International Study Group of Liver Surgery. Factors associated with CRPHLF were identified using multivariate logistic regression for all patients. We further performed the Hosmer-Lemeshow test and calculated the area under the receiver operating characteristic curve (AUC) to assess the overall model fit. All analyses were performed using SPSS 19.0 software.

Results: Patients who developed CRPHLF had a higher rate of severe complications (17.1%) than those who did not. Body mass index (BMI), prothrombin time (PT), RLV/SLV value, and blood transfusion were associated with CRPHLF in all patients with cirrhosis ( P <0.05). Clinically relevant PHLF was associated with PT in patients with RLV/SLV ≥40% and with BMI in patients with RLV/SLV <40% ( P <0.05). Model diagnostics suggested satisfactory calibration (Hosmer-Lemeshow P =0.436) and moderate discrimination (AUC=0.78) in the overall cohort. Patients with cirrhosis with an RLV/SLV value of <40% (and ≥30%) had the same complications or CRPHLF as patients with an RLV/SLV value of ≥40% ( P >0.05).

Conclusion: We found that a high PT was a risk factor in patients with RLV/SLV ≥40%, while a low BMI was a risk factor in those with RLV/SLV <40%. Increased surgical complications may not be associated with low RLV/SLV ratios, and hepatectomy may be safe in some patients with cirrhosis with RLV/SLV values <40% (and ≥30%).

Background: Inadequate management of pain, anxiety, and gastrointestinal function after laparoscopic cholecystectomy can lead to an increase in the incidence of nausea and vomiting, disruption of gastric functions, delayed postoperative recovery, prolonged hospital stay, increased risk of mortality, opioid use, and unwanted side effects. To evaluate the impact of manual and machine-based hand massage following laparoscopic cholecystectomy on pain, anxiety, and gastrointestinal function.

Methods: This randomized controlled trial study was conducted with 171 patients. Patients were divided into 2 intervention (manual hand massage and machine-based hand massage) groups (n=57), and a control group (n=57). Data were collected at 0, 4, and 8 hours postoperatively using the survey form, Numerical Rating Scale, State-Trait Anxiety Inventory, and Gastrointestinal Function Monitoring Form.

Results: The severity of pain in the manual hand massage group decreased statistically significantly after massage ( P <0.05). Anxiety levels in the intervention groups were lower at all time intervals postoperatively ( P <0.001). The severity of nausea in the massage groups was lower at 8 hours ( P <0.05). The number of bowel sounds at 8 hours in the massage groups showed a greater increase ( P <0.05).

Conclusion: Both manual and machine-based hand massage positively affected pain, anxiety, nausea intensity, and bowel sounds following laparoscopic cholecystectomy. Manual hand massage was more effective than machine-based hand massage in reducing pain intensity and increasing bowel sounds.

Objective: This study aimed to evaluate the clinical efficacy, technical characteristics, and impact on postoperative recurrence of the transabdominal preperitoneal (TAPP) approach combined with internal ring constriction for the treatment of giant inguinal hernias.

Materials and methods: Conducted as a single-blinded, single-center randomized controlled trial, the study compared TAPP with and without internal ring constriction. A total of 962 patients with inguinal hernias were recruited from January 2020 to October 2023. Based on the European Hernia Society classification, 779 patients with type I or II hernias were excluded, leaving 183 patients with type III inguinal hernias (inner ring defect ≥3 cm) for analysis. The experimental group (n=93) received TAPP combined with internal ring constriction, while the control group (n=90) underwent standard TAPP. Key outcomes assessed included operation time, intraoperative bleeding, postoperative pain, hospital stay duration, postoperative complications, and the 2-year recurrence rate.

Results: The experimental group had a significantly longer operation time than the control group (P<0.001). However, no significant differences were observed between the groups regarding intraoperative bleeding, hospital stay length, postoperative pain (measured by the visual analog scale on the first postoperative day), surgical site infection, seroma, scrotal edema, or vascular injury (all P values >0.05). Notably, neither group experienced scrotal hematoma or hydrocele. The experimental group demonstrated a significant reduction in the 2-year recurrence rate compared with the control group (P<0.05).

Conclusions: These findings suggest that TAPP combined with internal ring constriction is a valuable technique in managing giant inguinal hernias, offering a lower postoperative recurrence rate without increasing perioperative complications, postoperative pain, or hospital stay duration.

Background: Bougie is critical for achieving the optimal sleeve size or pouch creation in metabolic and bariatric surgery (MBS). This study investigates the clinical application and challenges of specialized bougie in MBS within China, aims to identify targeted solutions, and seeks to guide clinical practice.

Methods: A survey questionnaire, developed in collaboration with MBS experts through a webinar, was distributed online to MBS centers across China from March 9 to 15, 2023. Statistical analysis was used to evaluate the survey responses.

Results: The survey collected 183 valid responses from 28 provinces, including autonomous regions and municipalities. Of these, 86.34% of centers reported using specialized bougie for MBS, with 79.23% using it frequently. Among those frequently using bougie, 40.51% reused bougie postdisinfection due to the high costs of new bougies. The most common bougie sizes used were 36Fr for laparoscopic sleeve gastrectomy and laparoscopic gastric bypass, with other sizes ranging from 30Fr to 38Fr. However, 41.53% of centers reported complications related to bougie use, with tension rupture and esophageal injury being the most frequent.

Conclusions: This nationwide survey offers insights into the clinical application and challenges of specialized bougie in Chinese MBS centers. There is a need for enhanced education, standardization, and training to mitigate complications and improve patient outcomes.

Background: Consuming only low-fiber food on the day before the procedure is recommended as standard practice for bowel cleansing in patients using polyethylene glycol (PEG). However, there have been few studies to date investigating the optimal dietary regimen for patients using the more cost-effective Sennoside A+B calcium before colonoscopy. The present study compares the quality of bowel preparation of patients following a clear diet and those following a low-fiber diet on the day before colonoscopy among patients using Sennoside A+B calcium.

Methods: This prospective, randomized, and investigator-blinded study was conducted between November 2023 and February 2024. Included in the study were 150 patients aged 18 years and over with a mean age of 55.6±14 years, with 75 patients assigned to the clear diet group and 75 patients to the low-fiber diet group. The assessment of colonoscopy cleanliness before colonoscopy was conducted using the Boston Bowel Preparation Scale (BBPS).

Results: None of the patients experienced intolerance. The mean overall total cleanliness score, measured using the BBPS, was 7.24±2.1, with 7.48 ± 2.1 in the low-fiber diet group and 7.0 ±2.1 in the clear liquid diet group. No significant difference in cleanliness was found between the 2 groups ( P =0.096).

Conclusion: Patients using cost-effective Senna for bowel cleansing before colonoscopy can safely consume low-fiber foods on the day before the procedure. In the present study, a clear diet offered no benefit over a more comfortable and better-tolerated diet in terms of colon cleanliness.

Purpose: Point-of-care (POC) diagnostic tools can support timely and efficient clinical decision-making. The introduction of a POC digital rectoscope has the potential to enhance colorectal surgical practice by enabling immediate bedside endoscopic evaluation in different settings.

Methods: This case series describes 5 cases, with video documentation illustrating the potential benefits of using a portable digital rectoscope in outpatient follow-up, inpatient postoperative care, and emergency settings.

Results: In a tertiary referral center, POC rectoscopy effectively supported the detection of anastomotic leakage and rectal perforation, response evaluation after neoadjuvant treatment for rectal cancer, and facilitated follow-up after treatment for anastomotic leakage.

Conclusions: POC digital rectoscopy shows promise in enhancing the diagnostic efficiency of colorectal care. Further studies are warranted to evaluate its clinical impact and cost-effectiveness for the illustrated indications.

Objective: The prevalence of gallbladder polyps is 0.3% to 9.5%. Gallbladder polyps are divided into polyps and pseudo polyps. We aim to determine the rate of polyps after histopathologic examination in patients who were operated on for gallbladder polyps and to choose the factors affecting the diagnosis of polyps.

Patients and methods: Patients who underwent cholecystectomy between January 2012 and January 2022 were analyzed retrospectively. Demographic data of the patients, anthropometric measurements, preoperative radiologic imaging methods, characteristics (size and number of polyps), and histopathologic results of the gallbladder after cholecystectomy were recorded. After histopathologic examination, the patients were grouped as gallbladder polyp and pseudo polyp and compared.

Result: A total of 162 (4.7%) patients were included in the study. 109 (67.3%) of the patients were in the polyp group, and 53 (32.7%) were in the pseudo polyp group. Polyp size and number were larger in the polyp group than in the pseudo polyp group and were odd in number ( P = 0.03, P < 0.001). The radiologic polyp size cut-off value to identify the polyp was >8 mm (sensitivity: 84.2%, specificity: 66.0%).

Conclusion: Gallbladder polyps are a common pathology. The distinction between true and pseudo polyp is critical. Therefore, it is essential to distinguish between polyps and pseudo polyps for cholecystectomy.

Introduction: Studies analyzing the factors associated with reintervention after endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) are limited. We aimed to analyze the incidence and predictors of reintervention in patients with malignant biliary obstruction undergoing EUS-CDS.

Methods: We retrospectively analyzed the data of patients with malignant distal biliary obstruction undergoing EUS-CDS from 8 tertiary care centers in India. The study's primary outcome was reintervention due to stent migration or blockage. The secondary outcomes included clinical success and adverse events. Multivariate analysis using the logistic regression model was used to identify the independent predictors of reintervention.

Results: A total of 134 patients were included in the study. The technical and clinical success rates were 97.8% (131/134) and 93.9% (123/131), respectively. Periprocedural adverse events (AE) were seen in 6% (8/134) cases. Over a median follow-up of 20 weeks, reintervention was required in 8.4% of the cases after a median interval of 11 weeks. On multivariate analysis, cholangitis at presentation (odds ratio [OR] 6.26) and the absence of coaxial stent with concomitant duodenal stent (OR: 7.41) were independent predictors of reintervention in the overall cohort. On subgroup analysis of patients undergoing EUS-CDS with self-expanding metallic stent (SEMS), the absence of a coaxial stent with concomitant duodenal stent (OR: 10.15) was an independent predictor of reintervention.

Conclusion: Reintervention on follow-up after EUS-CDS is required in around 8.4% of cases. The absence of coaxial stent with concomitant duodenal stent was an independent predictor of reintervention in the overall cohort as well as in those undergoing EUS-CDS with SEMS.