Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

Objective: This study aimed to assess the outcomes of minimally invasive surgery (MIS) for colon cancer and analyze the impact of tumor localization on survival.

Patients and methods: A retrospective analysis was conducted on 842 consecutive patients who underwent curative MIS (laparoscopic and robotic) for stage I to III colon adenocarcinoma between 2001 and 2024. The surgical technique adhered to oncological principles, ensuring adequate resection margins and proper lymph node dissection. Patient characteristics, operative data, perioperative outcomes, histopathologic findings, and oncological outcomes were analyzed.

Results: The study included 842 patients (59.4% male, 40.6% female) with a median age of 60.3 years. Tumor localization was right colon in 29.5%, transverse colon in 6.5%, and left colon in 64% of cases. In our study, 814 cases (96.7%) were performed using laparoscopic surgery, while 28 cases (3.3%) were performed using robotic surgery. The mean operative time was 135 minutes, with a mean hospital stay of 6 days. Conversion to open surgery occurred in 3% of cases. The mean number of lymph nodes removed was 35 (range: 8 to 72). Pathologic examination revealed that 65% of cases were node-positive stage III. During a mean follow-up of 10 years, local recurrence (LR) was observed in 2.8% of patients, with no significant difference based on tumor localization. Distant metastases (DM) occurred in 12.7% of patients. The 10-year disease-free survival (DFS) rate for all patients was 75%, and the overall survival (OS) rate was 78.7%. The 10-year DFS rates for right colon, transverse colon, and left colon cancers were 74%, 71%, and 76%, respectively. Similarly, the OS rates for the same groups were 78.9%, 75%, and 79%, respectively. Statistical analysis revealed no significant differences in DFS ( P =0.851) or OS ( P =0.789) among the 3 tumor localization groups.

Conclusion: Our study demonstrated that MIS is a promising approach for achieving favorable long-term oncological outcomes in colon cancer patients. Consequently, MIS is established as the standard approach in colon cancer surgery. Although right colon tumors are often associated with poorer disease-free and overall survival rates, this study found no significant differences in DFS or OS among left, transverse, and right colon tumors.

Introduction: The WIRELESS trial compared the postoperative analgesic effect of the bilateral transversus abdominis plane patient-controlled analgesia (TAP-PCA) with that of epidural patient-controlled analgesia (E-PCA) using ropivacaine 0.25%.

Methodology: A hundred patients aged between 18 and 85 years and planned for upper midline laparotomy (Class I and II wounds) under general anesthesia were randomized into TAP-PCA (50) and E-PCA (50) groups. The PCA pump used for the study was designed to deliver a baseline infusion rate of 5 mL/hour (0.25%). The patients were instructed to press the PCA button, as and when required to deliver an additional dose of 2 mL, with 15-minutes lockout period. Both groups received 1 g of paracetamol infusion every 8 hours. The pain score was evaluated at 3, 6, 12, and 24 hours and then every 12 hours till 72 hours postoperatively. The requirements of rescue analgesia (injection tramadol), out-of-bed mobilization, and recovery of bowel function were recorded. Drug-related side effects and catheter-related complications were also noted.

Results: Five (10%) patients in the TAP arm and 17 (34%) patients in the epidural arm could not complete the study due to complications/failure. The intention-to-treat analysis indicates that VAS scores were similar in both groups (47 in the epidural PCA group and 48 in the TAP-PCA group) at 3, 12, 24, 36, 48, 60, and 72 hours. Rescue analgesia (tramadol) was similar in both groups (0.21, 0.58 vs. 0.13, 0.44). There were no significant differences observed between the 2 groups in terms of out-of-bed mobilization and pulmonary complications. Nonetheless, the TAP arm showed the earlier passage of the first flatus and a shorter hospital stay compared with the epidural arm.

Conclusion: PCA through the TAP route is not inferior to the epidural route for managing postoperative pain. Because of fewer contraindications and complications, TAP-PCA can be considered an alternative to epidural PCA.

Background: An increasing number of medical professionals are choosing to use totally laparoscopic total gastrectomy (TLTG) as a treatment option for gastric cancer. However, the optimal reconstruction method is still under debate. The objective of this study is to evaluate the immediate results of 2 intracorporeal esophagojejunostomy techniques: overlap (isoperistaltic side-to-side) (O) and pi-shaped (π) (anisoperistaltic side-to-side) anastomosis.

Methods: Hospital records of 110 patients who underwent esophagojejunostomy (group O, n=65 or group π, n=45) after TLTG from January 2016 to December 2019 were retrospectively reviewed. The demographic and clinicopathologic characteristics, along with the surgical and pathologic results, were recorded, compared, and evaluated for immediate impacts.

Results: The demographic characteristics of the 2 groups exhibited no significant disparities. Moreover, there were no statistically notable differences in tumor size, lymph node count, or TNM stage between the 2 groups. All surgeries were successfully completed without any complications or need for conversion to laparotomy, and there were no occurrences of postoperative mortality. In addition, there were no statistically significant variances between the 2 groups in terms of total operation time, estimated blood loss, time to first flatus, or length of postoperative hospital stay. Time for esophagojejunostomy, however, was statistically significantly shorter in group π than in group O (27.4±5.2 vs. 36.7±5.0 min) ( P <0.001). No statistically significant difference was found between the 2 groups with regard to postoperative complications: 5 grade I, 6 grade II, and 1 grade IIIa in group O (n=12) versus 5 grade I, 3 grade II, 2 grade IIIa, and 1 grade IIIb in group π (n=11). At 6-month endoscopy and oral water-soluble contrast medium follow-up, no anastomotic complication was noted.

Conclusions: The π anastomosis is feasible, safe, with the need for fewer cartridges and is eventually a time-saving procedure for esophagojejunostomy with no hand-sewing involved. In this study, both methods have shown favorable short-term results in the treatment of gastric cancer.

Introduction: Endoscopic resection of colorectal polyps offers several advantages, including ease of performance, reduced surgical time, and preservation of anatomic structures. However, bleeding remains a common complication of the endoscopic treatment of colorectal polyps, particularly with a higher incidence of postprocedural bleeding in pedunculated colorectal polyps. Currently, there is no optimal method for the resection of pedunculated colorectal polyps. The aim of this study was to compare the postresection bleeding outcomes of 3 different techniques for the removal of pedunculated colorectal polyps.

Methods: A retrospective analysis of postresection bleeding following the use of 3 techniques-endoscopic mucosal resection, endoscopic submucosal dissection (ESD), and prophylactic clips was conducted on pedunculated colorectal polyps.

Results: The incidence of delayed hemorrhage after endoscopic mucosal resection resection of pedunculated colorectal polyps was highest (18.9%). In contrast, the incidence rates of delayed bleeding in the ESD and prophylactic clip groups were 4.3% and 5.9%, respectively ( P <0.05). The intraoperative bleeding rate was highest in the ESD group (6.5%), while no intraoperative bleeding occurred in the other 2 groups, indicating a statistically significant difference among the 3 groups ( P <0.05). However, the need for endoscopic hemostasis due to delayed bleeding was not significantly different among the groups ( P >0.05).

Conclusion: Employing endoscopic submucosal dissection (ESD) and clamping the stalk of pedunculated polyps before removal can effectively reduce the risk of postpolypectomy bleeding. Furthermore, ESD offers distinct advantages for the removal of larger polyps, both at the stalk and the head.

Purpose: This study aimed to compare extraperitoneal colostomy (EPC) with transperitoneal colostomy (TPC) after laparoscopic abdominoperineal resection (APR) for rectal cancer regarding postoperative complications.

Method: A literature search was performed on PubMed, Ovid, and Cochrane Databases for studies comparing EPC with TPC after laparoscopic APR for rectal cancer. The last search was performed on June 4, 2024. The primary outcome was the incidence of parastomal hernia. The Review Manager (version 5.3) was used for data analysis.

Results: A total of 9 studies with 1002 patients were included in this meta-analysis. Among the enrolled literatures, one was randomized clinical trials, and others were retrospectively case-control designed. EPC showed significant efficiency in preventing parastomal hernia ( P <0.001, OR=0.16, 95% CI: 0.09-0.28, I2 =0%). Besides, the results indicated that the EPC group was associated with significantly less incidence of stoma retraction ( P =0.02, OR=0.23, 95% CI: 0.06-0.81, I2 =0%), stoma prolapse ( P =0.002, OR=0.18, 95% CI: 0.06-0.54, I2 =0%), and total stoma-related complications ( P <0.001, OR=0.50, 95% CI: 0.33-0.74, I2 =26%). In addition, no significant difference was observed between the 2 groups in terms of the total operative time or the time for colostomy creation.

Conclusion: Current data demonstrated the significant efficiency of EPC in preventing parastomal hernia after laparoscopic APR for rectal cancer. Besides, the clinical safety and feasibility of EPC were also indicated. The EPC procedure could be widely recommended for permanent colostomy in clinical practice.

Background: Transcystic laparoscopic common bile duct exploration (LCBDE) is a procedure considered in the management of common bile duct stones. In many ways it is superior to alternatives such as endoscopic retrograde cholangiopancreatography (ERCP); however, surgeons who have limited experience in CBDE are often reluctant to persist in difficult cases with concerns regarding increasing complication rates and waste of theater time. This study aims to provide an evidence-based approach to identify points to aid early abandonment ("bail").

Methods: Review of all LCBDE performed in a single center from September 2008 to September 2022 was performed. Statistical analysis was performed on success and failure groups, with relevant undesirable outcomes chosen for further analysis to identify factors to be used as a guide to bail.

Results: A total of 952 patients were identified for analysis. Females represented 63.8% (609) of the cohort. Success was reported in 89.2% (849) of procedures. Those in whom the cystic duct could not be cannulated with the choledochoscope, those that progressed to choledochotomy, those with a prolonged operative time, and those who had adverse outcomes were selected as undesired outcomes. Factors of age, higher ASA, preoperative ERCP, and those with preoperatively identified stones or larger stones at operation were associated with higher rates of an undesired outcome.

Conclusion: Older and more comorbid patients, those who underwent preoperative ERCP, and those with preoperatively or operatively identified large stones are factors that should prompt those surgeons who are developing their LCBDE experience to consider bailing early.

Background: Early and effective management of choledocholithiasis is imperative to decrease patient morbidity. Despite the widespread use of ERCP, advancements in laparoscopy and choledochoscopy have renewed interest in laparoscopic CBD exploration (LCBDE). This meta-analysis compares outcomes of 2-stage ERCP followed by laparoscopic cholecystectomy (LC) versus one-stage transcystic LCBDE plus LC.

Methods: A comprehensive literature search was performed in PubMed, CENTRAL, and Embase databases according to PRISMA guidelines. Studies were selected based on specific criteria. Data on stone clearance, postoperative pancreatitis, bleeding, mortality, and length of stay were extracted.

Results: Seven comparative non-randomized studies enrolling 669 "one-stage LCBDE patients" and 724 "two-stage ERCP patients" were included. Overall, there were no statistically significant differences regarding the rates of stone clearance, pancreatitis, bleeding, and mortality between the 2 groups.

Conclusion: One-stage transcystic LCBDE is noninferior to the 2-stage ERCP + LC approach, supporting its use as a first-line treatment for choledocholithiasis.

Background: Resections performed using the commonly applied minimally invasive transperitoneal approach for extra-adrenal paragangliomas (ePGLs) require a broader dissection area compared with the posterior retroperitoneoscopic approach (PRA) due to the location of the masses, which can elongate the operative time and increase the risk of injury to the adjacent structures. The aim of this case series was to evaluate the feasibility and safety of the PRA method, which has very few examples reported in the literature, for the treatment of abdominal paragangliomas.

Methods: Eight patients who underwent ePGL resection with PRA in a tertiary center between April 2018 and August 2024 were included. Demographic data, localization relative to the renal vein, operative time, tumor size, perioperative and postoperative complications, and length of hospital stay were assessed.

Results: Of the patients, 4 were male, and 4 were female. The mean age was 49±10.3 years, and the mean body mass index was 27±2.7 kg/m². Tumors were located on the left side in 6 patients and on the right side in 2 patients. Relative to the renal vein, 6 tumors were located superiorly and 2 inferiorly. One patient who had previously undergone surgery through an open anterior approach underwent PRA due to recurrence. The mean operative time was 108.4±20.5 minutes, with perioperative hypotensive episodes observed in 2 patients. No complications were noted during the postoperative follow-up. The mean length of hospital stay was 3.6±1.4 days. The mean tumor size was 34.9±18.6 mm, and the mean follow-up period was 30.5±25.5 months. Disease-related mortality was observed in 1 patient.

Conclusion: PRA is a safe and feasible minimally invasive method for the treatment of ePGLs.

Background: The risk of gallstone formation is greater in obese patients; paradoxically, the rapid weight loss after bariatric surgery (BS) is also a great contributor to cholelithiasis and biliary disease. While concomitant cholecystectomy has been used to mitigate this issue, the demand for a less invasive prophylaxis was met by ursodeoxycholic acid (UDCA). This study aims to evaluate the impact of UDCA on the incidence of cholecystectomies after BS.

Methods: This retrospective chart review included all primary and revisional bariatric procedures. Patients were divided into 2 groups based on the postoperative use of daily 600 mg UDCA for 6 months (group 2) or no UDCA use (group 1) to assess its impact on the incidence of cholecystectomy. A subanalysis compared baseline demographics, weight loss performance, and the number of cholecystectomies between groups.

Results: In a cohort of 8433 patients, 5061 were in group 1, and 3372 were in group 2 who received UDCA. The total number of cholecystectomies after BS was 164 (1.9% of the cohort): 146 in group 1 (2.9%) and 18 in group 2 (0.5%) ( P <0.00). A subanalysis revealed no significant differences in preoperative weight, body mass index (BMI), and postoperative total body weight loss (TBWL%) between the groups. Nonetheless, incidences of cholecystectomy after biliopancreatic diversion with duodenal switch (BPD-DS), Roux-en-Y Gastric Bypass (RYGB), and sleeve gastrectomy (SG) were greater in group 1, 8% versus 1.4%, 4.4% versus 0.1%, and 1.7% versus 0.4%, respectively (all P <0.05).

Conclusion: UDCA is associated with lower incidence rates of cholecystectomy after BS.

Background: After laparoscopic cholecystectomy surgery, an increase in stress hormones and moderate-to-severe pain occur in the postoperative period. The aim is to compare the effects of unilateral erector spinae plane block (ESPB) and port site local anesthetic (LA) infiltration methods on stress hormone response and postoperative pain in laparoscopic cholecystectomy operations.

Methods: This study was a prospective, randomized controlled, single-blind trial that divided laparoscopic cholecystectomy patients into 3 groups. In group I, local anesthetic infiltration was administered at 4 trocar sites; group E underwent unilateral ESPB guided by ultrasound; and group C was the control group with no intervention. Stress hormones were measured preoperatively and postoperatively, and postoperative VAS scores were recorded. The primary outcome was to compare the effects of LA infiltration and ESPB on stress hormone response, while the secondary outcome was the efficacy of postoperative analgesia.

Results: A total of 90 patients were included in the study. The duration of analgesia was significantly longer in group I compared with group C ( P <0.05). Postoperative VAS scores were significantly lower in group E and group I than in group C ( P <0.05). Group E significantly suppressed prolactin levels compared with the other 2 groups ( P <0.05). In addition, group E significantly reduced glucose levels compared with group C ( P <0.05).

Conclusion: Unilateral ESPB and infiltration have similar effects on pain and stress hormones after laparoscopic cholecystectomy. Infiltration may be preferred due to its easier application.