Surgical Laparoscopy, Endoscopy & Percutaneous Techniques最新文献

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.

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.

Introduction: Gastroesophageal reflux disease (GERD) symptoms and the use of proton pump inhibitors (PPIs) remain prevalent after Roux-en-Y Gastric Bypass (RYGB), despite it being known to alleviate reflux. The physiological changes behind long-term GERD and hiatal hernia (HH) prevalence post-RYGB are not commonly investigated.

Methods: In this consecutive cohort study, we examined patients who underwent RYGB and subsequent upper endoscopy, conducted by an expert bariatric endoscopist. The primary focus was on pouch endoscopic retrosflexion to evaluate the antireflux barrier (ARB). We gathered data encompassing patient demographics, anthropometrics, comorbidities, and findings from esophagogastroduodenoscopy (EGD) at the time of surgery and during follow-up EGD.

Results: Our study included a total of 42 patients, predominantly female (97.5%) and White (100%), with an average age of 53.6±10.6 years and a body mass index (BMI) of 32.9±9.4 kg/m 2 . In our findings, all EGDs revealed the presence of a HH of varying sizes. The average HH size was 2.07±0.87 cm. The esophagogastric junction (EGJ) flap was also effaced in all patients with the majority (90.4%, 38 patients) classified as Hill grade IV and a smaller proportion (9.6%, 4 patients) as Hill grade III. Notably, PPI usage increased from the time of surgery to the time of EGD (69.0% vs. 42.9%, P =0.06).

Conclusion: This research highlights the high incidence of HH and EGJ flap effacement in patients after RYGB, potentially elucidating the persistence of reflux symptoms, including weakly acidic or alkaline reflux, post-RYGB.

Objectives: To evaluate the comparative efficacy and safety of robotic thyroidectomy techniques, including the robotic bilateral axillo-breast approach (BABA) and the robotic gasless axillary approach (GAA).

Data sources: A comprehensive literature search was conducted across 5 major electronic databases (PubMed, Embase, Cochrane Library, Web of Science, and Scopus) to identify relevant studies published until May 2024.

Review methods: Analysis was conducted using RevMan 5.4 software with pooled mean and rate ratios calculated with 95% CIs.

Results: A total of 73 studies, comprising 70 eligible for meta-analysis, were included. Compared with robotic GAA, robotic BABA was associated with significantly longer operative time (pooled mean: 64.65 min, 95% CI: 51.77-77.53, P <0.00001), increased hospital stay (pooled mean: 1.24 d, 95% CI: 0.92-1.56, P <0.00001), and higher intraoperative bleeding (pooled mean: 44.90 mL, 95% CI: 26.99-62.81, P <0.00001). While no significant differences were observed in the rates of hypoparathyroidism, recurrent laryngeal nerve palsy, chyle leakage, seroma, hematoma, or infection, the incidence of Horner syndrome was significantly higher in the BABA group (pooled risk ratio: 0.01, 95% CI: 0.00-0.05, P =0.003).

Conclusions: Robotic BABA was associated with longer operative times, increased hospital stays, and higher intraoperative bleeding compared with Robotic GAA, although both techniques demonstrated comparable safety profiles for most outcomes. The higher incidence of Horner syndrome with BABA should be considered when selecting the optimal surgical approach for thyroidectomy.

Aim: The da Vinci Surgical System (Intuitive Surgical) currently dominates robotic gastrectomy for gastric cancer. The hinotori Surgical Robot System (Medicaroid Corporation) is a newly developed, Japan-made surgical assist robot. This study aimed to introduce the initial experience of robotic gastrectomy using the hinotori and discuss key techniques and challenges.

Methods: This single-center retrospective study involved 10 eligible patients who underwent curative robotic distal gastrectomy using the hinotori for primary Stage I to III gastric cancer. Short-term surgical outcomes were evaluated. Lymph node dissection was mainly performed using the conventional double bipolar technique, left-handed double bipolar technique, or laparoscopic coagulation shears from the assist port.

Results: No patients developed intraoperative complications, and all procedures were successfully completed without conversion to open or laparoscopic surgery. All patients achieved R0 resection. The median operation time was 275 minutes (range, 252 to 336 min), and the estimated blood loss was 5 mL (range, 3 to 20 mL). The drain amylase content on postoperative day 1 was 220.5 IU/L (range, 66 to 1207 IU/L). The median number of retrieved lymph nodes was 29.5 (range, 11 to 58). No patients developed postoperative Clavien-Dindo grade ≥IIIa complications, and there was no mortality.

Conclusion: Robotic gastrectomy using the hinotori shows potential benefits for gastric cancer. Further studies are needed to validate these advantages.

Purpose: The extended totally extraperitoneal (eTEP) approach is a novel repair method for ventral hernias. This study evaluated the feasibility and initial outcomes of a down-to-top eTEP repair technique for upper midline ventral hernias, addressing the challenges of subxiphoid midline crossing.

Materials and methods: The clinical data of 14 patients who underwent down-to-top eTEP surgery for upper midline ventral hernias at Seoul National University Hospital between January 2018 and December 2022 were retrospectively studied. Patients with M1 or M2 components according to the European Hernia Society classification were included.

Results: The mean age was 55.9 ± 13.6 years, and mean BMI was 25.9 ± 3.5 kg/m2. The mean defect area was 41.1 ± 22.5 cm2. Five patients underwent transversus abdominis release (TAR). Mean operative time was 178.3 ± 50.3 minutes in the non-TAR group and 288 ± 89.7 minutes in the TAR group. Mean hospital stay was comparable between non-TAR (5.2 ± 2.5 d) and TAR (4.8 ± 1.3 d) groups. Mean postoperative pain scores (VAS) were 3.8 on day one and 2.6 on day 3. The hernia sac was preserved in 5 patients (33.3%). No major postoperative complications occurred. No hernia recurrence was observed during the mean follow-up of 20.4 months.

Conclusion: The down-to-top eTEP approach for upper midline ventral hernia repair appears feasible and safe. This technique can be performed with TAR when necessary and is effective for repairing defects in all cases. Hernia sac preservation may reduce the need for TAR. This approach may be particularly beneficial when subxiphoid midline crossing is challenging.

Background: Endoscopic gastroplasty (EG) is a less invasive method for managing obesity compared with bariatric surgery. However, evidence on the use of EG is still scarce. This study aims to review existing evidence comparing EG with lifestyle modifications (LM) in terms of weight loss and improvement in metabolic syndrome.

Materials and methods: A systematic search was performed on PubMed, Embase, and the Cochrane Library from inception to August 2023. Exclusion criteria were patients who received concomitant pharmacological therapy for weight loss, the use of other endoscopic interventions apart from EG, and patients with prior bariatric surgery. Based on the heterogeneity of included studies, meta-analysis was performed using either a fixed-effect model or a random-effect model.

Results: There were 5 studies (4 RCTs and 1 retrospective study) with 1007 patients included in the pooled analysis. Only a minority were males (n=199, 19.8%), and only 1 study included a Sham procedure in the LM group. Six-month percentage total body weight loss (%TBWL) (n=3 studies, MD: 6.34, 95% CI: 2.89, 9.78, P <0.01) and 12-month %TBWL (n=4 studies, MD: 6.43, 95% CI: 2.62, 10.25, P <0.01) were significantly higher in EG compared with LM. Patients in the EG group also had significant improvement in control of diabetes mellitus (n=2 studies, OR: 29.10, 95% CI: 5.84, 145.08) and hypertension (n=2 studies, OR: 2.35, 95% CI: 1.18, 4.70) compared with LM. Incidence of serious adverse events ranged from 2% to 5%.

Conclusion: EG is effective for weight loss and improvement in metabolic comorbidities compared with LM alone but is suboptimal based on the Food and Drug Administration thresholds.

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 P ET CO 2 . 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.