Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Whether left upper division segmentectomy (LUDS) is a simple procedure remains controversial. This study aimed to compare the outcomes of LUDS with those of simple segmentectomy (SS) (excluding LUDS) and complex segmentectomy (CS) at two high-volume centers.

Methods: We retrospectively reviewed 1565 patients who underwent thoracoscopic segmentectomy for early-stage lung cancer between February 2015 and February 2020. Patients were categorized into three groups: LUDS (n = 189), SS (n = 317), and CS (n = 1059). The primary endpoint was defined as the occurrence of any following events: intraoperative complications, postoperative complications, 30-day readmission, and local recurrence.

Results: The rate of the primary endpoint was significantly higher in the LUDS group (14.3%) than in the SS group (7.6%) (P = 0.046) but was comparable between the LUDS and CS groups (14.4%) (P = 1.000). The median operative time in the LUDS group was 135 min, compared to 120 min in the SS group (P < 0.001) and 140 min in the CS group (P = 0.180). The median blood loss and rate of vascular injury in the LUDS group were significantly higher than those in the SS and CS groups (all P < 0.05). Subgroup analysis of the LUDS group demonstrated that the high-experience group had lower rates of primary endpoint and vascular injury, shorter operative time, and reduced blood loss.

Conclusions: LUDS is an efficient but complex procedure characterized by a long operative time, considerable blood loss, and a potential risk of vascular injury. Performance by experienced surgeons should be considered, as surgical expertise tends to result in improved outcomes.

Objective: This study aims to preliminarily investigate the therapeutic effect of cyanoacrylate glue (CG) on Forrest IIa and IIb peptic ulcer hemorrhage (PCH).

Methods: From January 2020 to May 2024, we retrospectively collected data on patients with Forrest IIa and IIb PCH treated with CG using emergency endoscopic hemostasis at a single center and subsequently evaluated and compared the efficacy of CG with respect to ulcer location, Forrest staging, and ulcer size.

Results: A total of 93 patients were enrolled, achieving 100% technical success without 24-h rebleeding. The rebleeding rate at 72 h was 1.1% (95% confidence interval [CI]: 0.2-5.9%), and the rebleeding rate at 7 days was 2.2% (95% CI: 0.6-7.6%). The median age of the patients was 43.0 years. There were 42 patients (45.2%) with Forrest IIa ulcers and 51 patients (54.8%) with Forrest IIb ulcers. Sixty patients (64.5%) had ulcers ranging in size from 1.0 to 2.0 cm, while 33 patients (35.5%) had ulcers larger than 2.0 cm. The ulcers were located in the antrum (19 cases), angulus (38 cases), gastric body (11 cases), and duodenal bulb (25 cases). Median procedure time was 12.0 min, with duodenal PCH requiring significantly less time than stomach PCH (P < 0.05). CG treatment efficacy was comparable between Forrest IIa/IIb ulcers as well as across ulcer sizes (P > 0.05).

Conclusions: CG is particularly effective and safe for PCH located in the duodenal bulb, as well as for both Forrest IIa and IIb PCH.

Background: Difficulty scoring systems (DSS) have been developed to quantify the surgical complexity of laparoscopic distal pancreatectomy (LDP). However, few studies have validated these systems in the context of robotic distal pancreatectomy (RDP). Moreover, the impact of body composition on RDP outcomes remains unexplored. This study aimed to investigate the risk factors of surgical difficulty in RDP, including body composition.

Methods: This retrospective study included 72 consecutive patients who underwent RDP at our institution between April 2021 and October 2024. Using a modified DSS for LDP, patients were divided into three difficulty index groups. The association between the difficulty index and outcomes was investigated. Multivariate analyses were performed to identify risk factors associated with surgical difficulty (prolonged operative time) in RDP.

Results: Patients were classified into three difficulty index groups: low (n = 28), intermediate (n = 25), and high (n = 19). Operative time was significantly associated with the surgical index (P = 0.01). Moreover, visceral fat area (VFA) was significantly correlated with operative time (r² = 0.10, P = 0.008). The multivariate analyses found that VFA (≥ 100 cm²) (odds ratio [OR] 5.03, 95% confidence interval [CI] 1.32-22.4, P = 0.02), malignancy (OR 4.92, 95% CI 1.50-18.9, P = 0.01), and pancreatic resection on the portal vein (OR 4.14, 95% CI 1.24-15.9, P = 0.02) were significant risk factors associated with surgical difficulty.

Conclusion: VFA could be a novel and useful factor for assessing the surgical difficulty associated with RDP.

Introduction: Robotic pancreaticoduodenectomy (RPD) is associated with technical challenges that may result in intraoperative and postoperative complications. Some previous reports and the recently published PD-ROBOSCORE describe several factors associated with an increased difficulty. The aim of this study is to investigate whether difficult RPD patients have a better outcome when operated by open approach (OPD).

Methods: All patients undergoing robotic and open PD from January 2020 to June 2024 with high PD-ROBOSCORE were included. Preoperative pancreatitis and/or cholangitis, and tumor contact with PV-SMV were also analysed. Outcomes of RPD vs OPD were compared.

Results: 45 RPD and 57 OPD patients with high PD-ROBOSCORE were considered for this study. Median age was 68.5 years (68 RPD vs 65 OPD; p = 0.25), median BMI was 27 kg/m² (27 RPD vs 28 OPD; p = 0.13), 65.6% of patients were male (60.0% RPD vs 70.2% OPD; p = 0.15) and median PD-ROBOSCORE was 10 (10 RPD vs 9 OPD, p = 0.145). POPF occurred in 37.2% (40.0% RPD vs 35.1% OPD; p = 0.668), CD ≥ 3 was 25.4% (28.8% RPD vs 22.8% OPD; p = 0.477), median CCI was 20.9 (20.5 RPD vs 20.9 OPD; p = 0.752), reoperation rate was 17.6% (15.5% RPD vs 19.3% OPD; p = 0.496). Hospital stay was 15 days (16 RPD vs 13 OPD; p = 0.583). Of patients developing POPF; 76.3% had soft pancreas, 84.2% had pancreatic duct ≤ 2 mm and 97.2% had BMI ≥ 25.

Conclusion: RPD seems to be non-inferior to OPD in patients with increased technical complexity. Most of these complications are related to fistula risk factors (high BMI, soft pancreas and small pancreatic duct) and not directly related with other technical difficulty factors.

Background: There is no consensus on the level of vascular ligation and the extent of lymphadenectomy in the treatment of ileal tumors. This study aims to define lymphovascular bundles of the terminal ileal artery (TIA) and subsequent ileal arteries. It also aims to extrapolate results from two distinct methodologies to define the level of arterial ligation and the dissection area for radical and bowel-sparing surgery.

Methods: Analysis of 3D-CT mesenteric vascular reconstructions of 104 operated patients. The second dataset consisted of 5 human cadavers for anatomical dissection. In one case, harvested viscera underwent the superior mesenteric artery (SMA) perfusion after ligation of the TIA.

Results: The calibers of the first three ileal arteries were: 2.67 ± 0.98 mm, 2.22 ± 0.78 mm, 2.31 ± 1.24 mm. The distances from the first three ileal arteries to the ileocolic artery (ICA) origin were: 12.45 ± 8.79 mm, 27.45 ± 13.47 mm, and 43.04 ± 16.94 mm. The SMA trifurcated in 61 (59%) of cases and bifurcated in 43 (41%). In 89 cases, the combined ICA + first jejunal artery caliber (6.7 ± 1.6 mm) was greater than the TIA caliber (4.84 ± 1.42 mm). The ileal artery lymphatic clearances were 0.85 mm to the preceding vessel. In the D3 volume at the ICA origin, 3-8 lymph nodes were observed. Internal calibers of the small bowel marginal artery, after selective TIA ligation and the SMA perfusion, were: proximal jejunal part 0.417 mm and distal ileal part 0.291 mm.

Conclusions: Ileal tumors are irrigated through the TIA, which can be ligated without consequences. Lymphadenectomy should encompass the adjacent vessels (1st jejunal artery, ICA) and can include the central nodes (D3 volume) at the surgeon's preference. Preserving the adjacent vessels and the marginal artery is paramount for bowel-sparing surgery.

Background: Acute appendicitis is a common emergency in rural Kenya. While open appendectomy is widely used, minimally invasive approaches may improve postoperative recovery and superficial surgical site infection rates. However, adoption in resource-limited settings is hindered by cost and availability, with fewer than 1% of operations involving laparoscopy. This study evaluates the effectiveness and costs of laparoscopic versus open appendectomy to inform practices in similar settings.

Methods: A retrospective study at Tenwek Hospital, Kenya (2015-2019), compared laparoscopic and open appendectomy using a bottom-up micro-costing method for true healthcare costs, adjusted for inflation and expressed in international dollars using purchasing power parity (I$PPP). Outcomes, including operating room turnaround time, hospital length of stay, superficial surgical site infections, and financial impact, were analyzed with Pearson's chi-squared, Wilcoxon rank-sum tests, and a multilevel generalized linear model to adjust for patient comorbidities and severity.

Results: Among 168 patients, median age was 34 years (IQR: 26-44), with 71% men, and perforation in 45%. Laparoscopic surgery was performed on 31 patients, with one conversion, versus open surgery in 137. The laparoscopic group had longer operating room turnaround times (115 vs. 75 min, p < 0.001) but shorter hospital stays (2 vs. 4 days, p = 0.002). Total costs were lower for laparoscopy cases (1527 vs. 1816 I$PPP, p = 0.049), with surgical site infections (3.2% vs. 16.7%, p = 0.026).

Conclusions: Despite longer surgery times, laparoscopic appendectomy significantly reduces hospital stays, total costs, and surgical site infections compared to open surgery in rural Kenya.

Background: Recently, the application of double band ligation-assisted endoscopic submucosal resection (ESMR-DL) in the resection of rectal endocrine tumors ≤ 10 mm has shown promising prospects. However, the use of ESMR-DL has not been reported for gastric gastrointestinal stromal tumors (gGISTs). In this study, we aimed to compare the application of modified ESMR-DL with ESD in gGISTs (≤ 1.5 cm).

Methods: Data were retrospectively collected from 472 patients who underwent modified ESMR-DL or endoscopic submucosal dissection (ESD) for resection of gGISTs (≤ 1.5 cm). To overcome selection bias, a propensity score matching method was applied using four covariates for 1:1 matching: sex, age, tumor size, and tumor location. Clinical data, surgical status, and postoperative outcomes were compared between the two groups.

Results: Of the 472 patients, 78 (16.5%) received modified ESMR-DL and 394 (83.5%) received ESD; after matching, there were 78 patients in each group. There was no statistical difference in the baseline characteristics between the two groups after matching (p > 0.05). Compared to ESD, modified ESMR-DL resulted in shorter operation time, time to a liquid diet and postoperative hospitalization time, but had a higher incidence of intraoperative perforation (p < 0.05). There was no significant difference in the R0 resection rate of tumors, incidence of postoperative complications, and average hospitalization costs between the two groups after matching (p > 0.05). Univariate and multivariate analyses showed that the maximum dimension of the lesion (7 mm increments) and the surgical method were factors affecting procedure time, and the maximum dimension of the lesion (7 mm increments) and operator (novice vs instructor) were factors affecting intraoperative perforation in modified ESMR-DL (P < 0.05). During the follow-up, there were no recurrences or metastases of gGISTs in either group.

Conclusions: Modified ESMR-DL is noninferior to ESD with a similar complete resection rate. In addition, modified ESMR-DL had shorter procedure time and hospitalization time.

Background: The purpose of this study was to evaluate the surgical and oncological outcomes of robotic-assisted beyond-TME surgery for locally advanced rectal cancer.

Methods: Consecutive adult (≥ 18 years old) patients who underwent a robotic-assisted proctectomy beyond-TME planes for primary or recurrent rectal cancer at three Mayo Clinic (USA) hospitals from 2017-2023 were included. Patient demographics and tumor and disease characteristics were obtained by review of the electronic health record. Outcomes of interest included postoperative complications, hospital length of stay, and pathologic and oncologic outcomes.

Results: In total, 72 patients were included in the final cohort. Thirty-five (48.6%) patients underwent an extended resection without exenteration, while 22 (30.6%) underwent a multi-visceral en bloc exenteration; 20 (36.1%) patients underwent a lateral pelvic lymph node dissection, with or without a concomitant extended resection. Most cases had an advanced T-stage and an involved mesorectal fascia on pre-treatment MRI. The median operative time was 425.0 min (340.5-504.0) and the median estimated blood loss was 150.0 mL (75.0-277.5). Conversion to open surgery was needed in two (2.8%) cases. Nearly half the cohort (48.3%) experienced a postoperative complication and the median postoperative length of stay was 3.5 (3.0-7.0) days. Five cases had a positive margin, resulting in an R0 rate of 93.1%. None of the exenteration cases had a positive margin. After a median follow-up of 22.0 (13.0-45.7) months, 10 patients experienced a local recurrence (13.8%).

Conclusion: Robotic-assisted beyond-TME surgery can be performed safely with favorable postoperative clinical and oncologic outcomes.

Background: To analyze the effects of different intubation and ventilation modes on left recurrent laryngeal nerve lymph node dissection and postoperative complications in patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE).

Methods: Overall, 339 patients with esophageal cancer who underwent RAMIE at Tianjin Medical University Cancer Hospital between June 2017 and December 2021 were selected for this retrospective study. The effects of CO₂ artificial pneumothorax and bronchial blockers on the number of lymph nodes dissected and the incidence of postoperative complications were compared.

Results: Among 339 patients, 111 underwent surgery using CO₂ artificial pneumothorax, while 228 used bronchial occlusion devices. There were no significant differences in baseline characteristics between the two groups (p > 0.05). The total number of lymph nodes dissected (31.11 ± 13.00 vs. 24.42 ± 11.10, p < 0.001), the number of thoracic lymph nodes dissected (19.53 ± 9.80 vs. 15.00 ± 7.85, p < 0.001), and the number of lymph nodes dissected around the left recurrent laryngeal nerve (3.62 ± 3.19 vs. 2.72 ± 3.18, p = 0.015) were significantly higher in the bronchial occlusion group than in compared to the CO₂ pneumothorax ventilation group. There were no significant differences in the number of right recurrent laryngeal lymph node dissection between the two groups (3.15 ± 2.89 vs. 2.68 ± 2.25, p = 0.132). The incidence of recurrent laryngeal nerve injury was significantly lower in the bronchoclusive single-lung ventilation group than in the CO₂ artificial pneumothorax group (15 [6.57%] vs. 17 [15.31%], p = 0.010). There were no significant differences in the incidence of overall postoperative complications, including pulmonary complications, anastomotic fistula, chylothorax, incision infection, or cardiovascular complications (all p > 0.05). However, a significant difference was noted in the Clavien-Dindo grading of postoperative complications (p = 0.016) and the number of days of hospitalization between the two groups (17.93 ± 9.98 vs. 14.48 ± 10.45, p = 0.004).

Conclusions: The bronchial blocker, one-lung ventilation mode was found to be more advantageous in lymphadenectomies than the CO₂ artificial pneumothorax, two-lung ventilation mode, given the reduced occurrence of related complications and length of hospitalization.

Introduction: Minimally invasive esophagectomy (MIE) has emerged as the preferred surgical method for esophageal cancer resulting from lower morbidity rates for MIE compared to open surgery. However, post-esophagectomy hiatal hernia (PEHH), also known as paraconduit hernia, once rare, is now increasingly observed as a late complication. This study aims to ascertain the prevalence, predictive factors, and surgical management of PEHH following MIE in esophageal cancer patients.

Methods: We retrospectively reviewed esophageal cancer patients who underwent MIE between 2013 and 2023. Patients with PEHH were identified through clinical presentation and CT scans and compared to those without PEHH using statistical tests. Variables with p-values less than 0.2 were subjected to multivariate analysis.

Results: Among 371 patients, predominantly male with locally advanced disease (stages 2-4, 90.8%), 25 (6.7%) developed PEHH after a median interval of 24 months post-MIE. The PEHH group exhibited significantly lower BMI and shorter ICU stays. On multivariate analysis BMI < 25 kg/m2 (OR 2.96, CI 1.22-7.20, p = 0.02) and ICU stays (OR 0.67, CI 0.47-0.96, p = 0.03) were independent predictors of PEHH. Surgical repair was performed in 84% of PEHH cases, with 60% symptomatic and 48% emergency surgery. The minimally invasive approach was implemented in 15 patients (71.4%). Primary repair was successfully conducted in 14 cases (66.7%), while mesh was used in one-third of patients.

Conclusion: The increasing prevalence of PEHH with MIE warrants attention. A lower BMI and shorter ICU stay was associated with PEHH. Most cases are symptomatic and effectively managed through minimally invasive techniques.