Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

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: The objective of this study is to assess the impact of a quantitative early activity program, integrated into the Enhanced Recovery After Surgery (ERAS) protocol on gastrointestinal function in patients undergoing laparoscopic pancreatoduodenectomy (LPD).

Methods: Perioperative data from 203 patients who underwent LPD at the Department of Comprehensive Treatment of Pancreatic Cancer, Fudan University Shanghai Cancer Center, between January 2021 and December 2022 were analyzed retrospectively. The patients were categorized into 2 groups based on their nursing plans. Group A received the standard perioperative ERAS nursing plan, while group B followed the ERAS plan supplemented with a quantitative early activity program. We assessed postoperative outcomes including bowel sound recovery time, time to first anal exhaust, time to first mobilization, activity compliance 1-week postsurgery, and incidence of postoperative breakthrough pain.

Result: We compared several postoperative metrics between group A and group B. Specifically, the time to bowel sound recovery was 62.39±17.89 hours in group A versus 56.45±22.85 hours in group B. The time to first anal exhaust was 78.88±71.99 hours in group A compared with 63.62±24.73 hours in group B. The time to first mobilization was 56.98±18.66 hours in group A versus 49.85±20.48 hours in group B. In addition, activity compliance 1-week postsurgery and the incidence of postoperative breakthrough pain (1.55±2.01 times in group A vs. 0.94±1.16 times in group B) were also compared. All these differences were statistically significant ( P <0.05). Conversely, the incidence of postoperative complications and the length of hospital stay (11.20±5.69 d in group A vs. 12.47±6.67 d in group B) did not reveal any significant differences ( P >0.05).

Conclusion: The quantitative early activity program for LPD, based on the ERAS protocol, enhances the adherence to postoperative activity and decreases the incidence of breakthrough pain, thereby facilitating gastrointestinal function recovery in patients. This approach merits clinical adoption.

Introduction: Pneumoperitoneum is widely used in gastrointestinal surgery, particularly for laparoscopic or robotic procedures, with suggested advantages associated with low pressure. While existing data predominantly focuses on laparoscopic cholecystectomy, the assessment of intra-abdominal pressures in other gastrointestinal surgeries remains unexplored.

Methods: This study conducted an electronic literature search for randomized control trials comparing low-pressure pneumoperitoneum to standard or high-pressure counterparts.

Results: Out of 26 articles meeting inclusion criteria, encompassing 2077 patients, 15 demonstrated positive associations with low-pressure pneumoperitoneum. No significant difference in postoperative pain was found in the remaining papers. Methodological variations, diverse outcome reporting, and a prevalent high risk of bias precluded meta-analysis.

Conclusions: The study highlights substantial outcome variability, urging cautious interpretation of aggregated results. Despite positive associations in specific cases, insufficient evidence was found to support the superiority of low-pressure pneumoperitoneum. The study recommends future research employing validated patient-reported outcome measures and standardized reporting to help guide the development of evidence-based guidelines and optimize patient care in abdominal surgeries.

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 objectives: Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as a minimally invasive therapeutic option for patients who cannot undergo traditional retrograde access to the pancreatic duct due to difficulties in cannulation or surgically altered anatomy. This meta-analysis aimed to evaluate the overall outcomes and safety of EUS-PD.

Methods: We conducted a comprehensive search of major databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, up until October 2023. The meta-analysis focused on technical and clinical success rates, as well as the overall adverse event (AE) rate.

Results: A total of 27 trials involving 902 patients were included in the study. The cumulative rate of technical success is 89%, and the clinical success is 88%, whereas the AE rate was 17%. The most common AE observed was post-EUS-PD acute pancreatitis, with a rate of 3%. In addition, the cumulative rates of bleeding, perforation, pancreatic leak, and infection were 2%, 2%, 1%, and 1%, respectively.

Conclusion: EUS-PD demonstrates highly favorable technical and clinical success rates, alongside acceptable AE rates, making it a highly effective procedure.

Purpose: To investigate the benefits of utilizing autologous flap-supported loop stomas in comparison to conventional rod-supported loop stomas regarding feasibility, safety, convenience, and satisfaction among doctors and patients.

Methods: A retrospective analysis was conducted on the clinical data of 98 patients who underwent ileostomy at the Gastrointestinal Department of Shanxi Bethune Hospital Affiliated to Shanxi Medical University from July 2017 to January 2021. On the basis of the ileostomy methods used, the patients were categorized into 2 groups: the autologous flap loop ileostomy group (intervention group, 48 cases) and the traditional loop ileostomy group (traditional group, 50 cases). The analysis focused on assessing the quality of the stoma, short-term and long-term complications associated with postoperative stoma, and differences in feasibility, safety, convenience, and economic factors between the 2 groups.

Results: The intervention group exhibited lower rates of short-term postoperative complications compared with the traditional group, especially in peristomal dermatitis ( P =0.002) and stoma leakage ( P =0.001). In addition, the frequency of stoma appliance replacement and the average cost within a 2-week period were also superior to those of the traditional group (all P <0.001). Long-term complications were not significantly different between the 2 groups ( P ≥ 0.05). Moreover, the intervention group had a shorter operating time ( P =0.01) and less blood loss ( P =0.006) than the traditional group for the ostomy closure surgery.

Conclusions: Autologous flap-supported loop stoma shows a notable decrease in postoperative stoma-related short-term complications, offering superior feasibility, safety, convenience, with favorable economic aspects as well.

Background: Percutaneous transhepatic biliary drainage (PTBD) is a common procedure for biliary obstruction jaundice caused by biliary tract obstruction. PTBD can be performed using external or external-internal methods, by the right or left lobe approach. However, differences in both the method used and the hepatic approach may affect success rates and complications. Therefore, this study aimed to examine the outcomes and complications of PTBD and compare them according to different methods and hepatic approaches.

Methods: Patients who underwent PTBD procedures in our interventional radiology department due to benign or malignant pathologies between March 2021 and March 2024 were included in the study. The diagnoses of the patients, and total and direct bilirubin values before and after the procedure were recorded. The clinical results and the complications of PTBD were compared statistically according to the hepatic approach and method. Univariate logistic regression analysis was performed to determine significant factors associated with PTBD success and complications.

Results: Sixty patients were included in our study (32 men, 28 women; mean age: 67.14±13.61 y). The most common indication was malignant bile duct obstruction (90%). The obstruction was mostly at the level of the common bile duct (46.7%). The success rate of PTBD was the highest with the left-side external biliary drainage approach (left-side external biliary drainage, 81.2%; right-side internal-external biliary drainage, 77.8%; right-side external biliary drainage, 69.2%; P =0.596). The complication rate was higher for right-side access (right side 15.9%, left side 12.5%, P =0.744). Univariate logistic regression analysis revealed that PTBD success in females was 5 times higher than in males [Exp( B ): 5.000, β: 1.609, P <0.05]. Univariate logistic regression analysis revealed that methods used, entry lobes, and entry levels did not significantly affect PTBD success and complication incidence ( P >0.05).

Conclusion: All approaches and methods used during PTBD were associated with low complications and high success rates. Nevertheless, external biliary drainage with right hepatic access has the lowest clinical success rate and a higher complication rate than the left-lobe approach. We observed that left-sided external biliary drainage was the most successful method and had fewer complications.

Background: Data consistently supports a surgery-first approach to common bile duct (CBD) stones in patients with a gallbladder via laparoscopic CBD exploration (LCBDE). LCBDE has equivalent efficacy and decreased cost as compared with cholecystectomy plus endoscopic retrograde cholangiopancreatography (ERCP). However, adoption has been low due to the technical limitations of laparoscopy. We describe a straightforward and highly reproducible robotic CBDE (RBCDE) technique.

Methods: A cystic ductotomy is made after obtaining a critical view of safety. Through a 5 mm port, a wire-ready cholangiogram catheter is secured in the cystic duct and intraoperative cholangiogram performed. Based on stone burden, small versus large, either an antegrade balloon snowplow (push stones forward) or sphincteroplasty is performed over a wire under fluoroscopy. If concern persists for retained stones, choledochoscopy is performed.

Conclusions: Our simplified antegrade-only RCBDE technique allows surgeons to consistently offer a surgery-first, single-stage approach to CBD stones in patients with a gallbladder.

Objective: Pancreatic stump closure in minimally invasive distal pancreatectomy (DP) commonly utilizes staplers due to its simplicity; however, postoperative pancreatic fistula (POPF) remains the most frequent complication. We have developed a novel stump closure technique using a transpancreatic mattress suture with a polyglycolic acid sheet (TP method) under robotic DP. This study aims to evaluate the efficacy of the TP method.

Materials and methods: This study included 145 cases of pure minimally invasive DP performed between February 2011 and July 2024: 34 robotic (R) and 97 laparoscopic (Lap). Surgical outcomes were compared across 3 groups based on the stump closure method: 18 cases using the TP method (TP group; R: 18), 22 with hand-sewn closure in a fish-mouth manner (FM group; Lap: 22), and 91 with a reinforced stapler (S group; R: 16, Lap: 75). Logistic regression analysis was employed to identify risk factors for POPF.

Results: POPF occurred in 20 of 131 cases (grade B: 19, C: 1, 15.3%). The TP group exhibited the lowest POPF rate (TP vs FM vs S: 5.6% vs 27.3% vs 14.3%). Multivariate analysis identified pancreatic thickness ≥12 mm as an independent risk factor. For thickness <12 mm, no significant differences in POPF rates were observed (TP vs FM vs S: 0% vs 25.0% vs 5.6%). However, for thickness ≥12 mm, the TP group had a significantly lower POPF rate compared with the S group (TP vs FM vs S: 7.7% vs 28.6% vs 47.4%).

Conclusion: The TP method is superior to stapler closure in preventing POPF, especially in cases with pancreatic thickness of ≥12 mm.

Objective: The objective of this investigation was to ascertain the effectiveness of an ultrasound-guided erector spinae plane block (ESPB) administered to patients diagnosed with hepatocellular carcinoma who were subjected to laparoscopic left hemihepatectomy.

Methods: A retrospective analysis was conducted on 172 patients, comparing 2 groups: one comprising 90 individuals who were administered intravenous patient-controlled analgesia (PCA) simultaneously with ESPB, and a second group of 82 patients who received PCA monotherapy. To equilibrate covariates across the groups, propensity score matching was executed, yielding 25 matched pairs as a result.

Results: At 12 and 24 hours postprocedure, visual analog scale (VAS) pain scores, both at rest and during movement, were significantly reduced in the group receiving PCA in conjunction with ESPB. Furthermore, this group exhibited a substantially lower incidence of rescue analgesia utilization, a significantly abbreviated duration to ambulation, a reduced hospitalization period, and a significantly elevated level of patient satisfaction.

Conclusion: ESPB serves as an efficacious ancillary analgesic for laparoscopic left hemihepatectomy, offering superior pain management and recuperation relative to the administration of intravenous analgesia in isolation. The implementation of ESPB as an adjunct to PCA in patients with hepatocellular carcinoma undergoing laparoscopic left hemihepatectomy proved to be both safe and efficacious. Notably, PCA augmented with ESPB demonstrated greater efficacy in mitigating postoperative pain compared with PCA as a standalone therapy.