Surgical Endoscopy And Other Interventional Techniques最新文献

Introduction: The robotic approach in hepatectomy is becoming increasingly prevalent, necessitating a dedicated difficulty scoring system tailored for robotic operations. The Tampa Robotic Difficulty Score serves this purpose by offering a novel robotic-specific scoring system designed to enhance preoperative surgical planning and predict potential technical challenges in robotic hepatectomies. Following its conceptualization, we sought to internally validate the Tampa Difficulty Score by correlating it with financial variables based on our recent cohort of patients, extending the score's applicability beyond clinical outcomes alone to encompass economic or financial factors.

Methods: We retrospectively applied the Tampa Difficulty Score to our latest cohort of 124 patients who underwent robotic hepatectomy. Patients were stratified into four technical difficulty levels: Group 1 (1-8, n = 16), Group 2 (9-24, n = 86), Group 3 (25-32, n = 17), and Group 4 (33-49, n = 5). We then examined the association between the groups and various financial metrics, including total hospital charges, variable costs, fixed costs, and hospital reimbursements. A one-way ANOVA was utilized for comparisons among the groups. Data are presented as median (mean ± standard deviation). Statistical significance was accepted at p ≤ 0.05.

Results: Analysis revealed a significant association between the Tampa Difficulty Score and financial metrics. With an increase in difficulty score, there was a significant increase in total hospital charges (p < 0.001), variable costs (p < 0.001), and fixed direct (p < 0.001) and indirect costs (p = 0.017). In contrast, hospital reimbursements did not linearly increase with the procedural complexity, leading to a non-proportionate financial burden on healthcare facilities, specifically seen in the most complex cases (Group 4).

Conclusions: The Tampa Difficulty Score has demonstrated its utility not only in predicting perioperative clinical outcomes in patients undergoing robotic hepatectomy but also in projecting the financial impacts of robotic hepatectomy to payors and providing institution. This dual predictive capacity is valuable in preoperative surgical planning, resource allocation, and financial risk assessment. External validation of the Tampa Difficulty Score is an important next step to confirm its effectiveness in other healthcare settings and economic structures.

Background: The role of minimally invasive surgery (MIS) in advanced pancreatic ductal adenocarcinoma (PDAC) remains controversial, particularly after neoadjuvant chemotherapy. Most previous studies have excluded such patients, and evidence supporting MIS in this context is limited. We evaluated the safety, technical feasibility, and oncologic outcomes of minimally invasive distal pancreatectomy (MIDP) following neoadjuvant chemotherapy in patients with advanced pancreatic cancer.

Methods: We retrospectively reviewed 105 patients who underwent distal pancreatectomy with splenectomy for advanced PDAC following neoadjuvant chemotherapy at a single institution between January 2005 and August 2024. Patients were categorized into open (ODP, n = 37) and minimally invasive (MIDP, n = 68) groups. Perioperative outcomes, pathologic features, and long-term survival were compared before and after propensity score matching. Subgroup and multivariable analyses were performed.

Results: MIDP was associated with significantly lower estimated blood loss compared with ODP (166.8 vs. 269.7 mL, p = 0.020), and no patient in the MIDP group required intraoperative transfusion. Other perioperative outcomes, including operation time, postoperative morbidity, and length of hospital stay, were comparable between groups. R0 resection rates, lymph node yield, and pathologic staging did not differ significantly. Long-term disease-free and overall survival were similar between groups, including in patients who received FOLFIRINOX-based neoadjuvant and adjuvant chemotherapy. After propensity score matching, survival outcomes remained comparable. Multivariable analysis identified estimated blood loss and N2 nodal status as independent predictors of recurrence, while N2 nodal status was the only independent predictor of overall survival. The surgical approach was not associated with oncologic outcomes.

Conclusions: Minimally invasive distal pancreatectomy is a safe and oncologically sound option for selected patients with advanced PDAC after neoadjuvant chemotherapy. With careful patient selection, MIS may be effectively applied even in technically challenging cases.

Background: Pregnancy beyond the first trimester increases the risk of small bowel obstruction after Roux-en-Y gastric bypass, most often due to internal hernia. Surgical exploration can be challenging because of limited space and anatomical changes. Data on surgical and obstetrical outcomes are scarce.

Methods: We identified 32 pregnant women who underwent surgery for small bowel obstruction following bariatric surgery at our institution between January 2014 and December 2024. Data were collected on bariatric surgery history, operative details, postoperative complications, and obstetric outcomes.

Results: All patients had a history of Roux-en-Y gastric bypass. Median gestational age at surgery was 23 weeks 0 days (IQR 17 + 3-29 + 6 weeks). The most common symptom was postprandial exacerbation of abdominal pain (74%, n = 29); vomiting occurred in 51% (n = 20). Intraoperative findings included chylous fluid (53%, n = 18) and venous small bowel congestion (26%, n = 9). Serosal tears occurred in 9% (n = 3), with one case requiring conversion to laparotomy. There were no ischemia-related bowel resections. No maternal or fetal deaths occurred. Median gestational age at delivery was 39 weeks 0 days (IQR 38 + 2-39 + 3 weeks), with a mean interval from surgery to delivery of 13 weeks 6 days (IQR 8 + 1-19 + 2 weeks).

Conclusion: Laparoscopy is a suitable therapeutic approach for pregnant patients with suspected small bowel obstruction following bariatric surgery. Surgical intervention during pregnancy did not negatively impact outcomes. Early recognition of atypical presentations by clinicians, together with patient education on warning signs, is essential to prevent diagnostic delays and improve outcomes.

Background: Mediastinal lymphadenectomy represents an integral component of anatomic lung resection in the surgical treatment of non-small-cell lung cancer. These procedures are now routinely undertaken utilising minimally invasive approaches. The present study aimed to compare the radicality of mediastinal lymphadenectomy during uniportal video-assisted thoracoscopic surgery (uVATS) and robotic-assisted thoracoscopic surgery (RATS) for anatomical pulmonary resection.

Methods: This comparative study was undertaken at a university hospital between January 2020 and August 2025. We evaluated the radicality of mediastinal lymphadenectomy in two patient cohorts: those undergoing uniportal thoracoscopic resection and those undergoing robotic-assisted thoracoscopic resection. Radicality was assessed based on the number of lymph node stations retrieved from the eight stations corresponding to each hemithorax, enabling determination of the extent and completeness of lymphadenectomy.

Results: Two hundred patients were included in the analysis: 100 underwent uniportal thoracoscopic anatomic lung resection and 100 underwent robotic-assisted lung resection. A statistically significant difference was demonstrated in the number of lymph node stations retrieved between the groups, favouring RATS over uVATS in both hemithoraces-left: 7.2 versus 6.6 (p = 0.0035); right: 7.3 versus 6.4 (p < 0.0001). The 30-day postoperative morbidity rate was 28% in the uVATS group and 32% in the RATS group, demonstrating no statistically significant difference (p = 0.5370). Overall mortality in the study population was 1.5%, with no significant difference between techniques (1.0% for uVATS versus 2.0% for RATS).

Conclusions: Robotic-assisted thoracoscopy enables a higher yield of mediastinal lymphadenectomy compared with uniportal video-assisted thoracoscopy, while maintaining comparable postoperative morbidity and mortality rates.

Background: Barbed sutures have become increasingly popular across multiple surgical specialties due to their self-anchoring design, which eliminates the need for knot tying and reduces operative time. However, concerns persist that exposed barbs may cause postoperative intestinal obstruction by entangling adjacent bowel loops or mesentery. The true incidence of such events in large surgical populations remains unclear.

Methods: A retrospective analysis was conducted using an institutional database encompassing all intra-abdominal surgeries performed with barbed sutures from August 2017 to April 2024 at Mayo Clinic facilities. Patient records were screened to identify readmissions and reoperations for intestinal obstruction. Operative notes were reviewed to determine whether barbed sutures were implicated. The primary outcome was barbed suture-related intestinal obstruction; secondary outcomes included all-cause readmission and abdominal exploration for any reason.

Results: Among 20,260 patients (mean age 58.2 ± 14.7 years; 56.9% female) who underwent intra-abdominal surgery using barbed sutures, 2496 (12.3%) were readmitted. Intestinal obstruction was diagnosed in 264 patients (1.3%), and 102 (0.5%) underwent reoperation for obstruction. An additional 177 patients (0.9%) underwent abdominal exploration for other indications. Across all 279 reoperations, no case of obstruction was attributable to barbed suture use. Alternative etiologies included adhesions, anastomotic leaks, abscesses, bleeding, or hernias.

Conclusions: In this large single-institution cohort of over 20,000 patients, barbed sutures were not associated with intestinal obstruction due to small bowel entrapment. Despite over 260 readmissions for obstruction and nearly 300 abdominal re-explorations, no case was linked to suture entrapment. These findings support the safety of barbed sutures for intra-abdominal use across multiple surgical disciplines and challenge the perception that they predispose to intestinal obstruction.

Background: Endoscopic diagnosis of Ampulla of Vater (AoV) lesions remains challenging owing to complex morphology and limited representative images, particularly for high-risk dysplastic lesions. This study aimed to develop a hierarchical deep learning framework for the stepwise classification of ampullary lesions using white-light (WL) and narrow-band endoscopic images (NBI).

Methods: The framework employs three sequential binary classifications: (1) normal vs. abnormal, (2) adenoma vs. cancer, and (3) high-grade dysplasia (HGD) vs. low-grade dysplasia (LGD) within adenomas. Each stage uses EfficientNet-B4 classifiers trained independently on WL and NBI. Predictions are integrated using confidence-based voting. To overcome data scarcity and class imbalance, for HGD and cancer, we used StyleGAN2-ADA to generate synthetic images. The hierarchical model was developed using 4244 endoscopic images from 464 patients collected at Seoul National University Hospital (2693/833/718 for train/validation/test).

Results: The hierarchical model achieved stage-specific accuracies of 95.6% (normal vs. abnormal), 94.4% (adenoma vs. cancer), and 92.7% (LGD vs. HGD), resulting in overall diagnostic accuracy of 92.2%. The model demonstrated excellent sensitivity of 83.3% for HGD and 87.5% for cancer, with specificities exceeding 98%. The confidence-based dual-modality approach (AUROC: 0.921) significantly outperformed single-modality approaches using WL alone (AUROC: 0.866) or NBI alone (AUROC: 0.895), by integrating their complementary diagnostic strengths. Generative adversarial network-based augmentation substantially improved sensitivity for cancer (from 87.5% to 91.7%) and HGD (from 83.3% to 86.5%), while overall accuracy increased from 94.5% to 95.1%.

Conclusions: A hierarchical deep learning approach integrating dual-modality imaging and synthetic data augmentation significantly improves diagnostic performance for ampullary lesions.

Background and aims: Colorectal endoscopic submucosal dissection (ESD) presents persistent challenges such as limited visualization and prolonged procedure time. Single-point traction (ST) enhances dissection efficiency, but has limitations including diminished traction efficacy over time and the need for repositioning. We developed a novel multi-point traction (MT) device to provide stable and convergent traction. This study aimed to compare the efficacy and safety of non-traction (NT), ST, and MT for colorectal ESD.

Methods: This retrospective study analyzed colorectal ESD procedures performed at Nagasaki Harbor Medical Center between January 2019 and December 2024. The patients were categorized into three groups: NT, ST (S-O clip), and MT (novel multi-point traction device). The primary outcome was resection speed (mm²/min). Secondary outcomes included total resection time, local injection volume per unit area, en bloc resection rate, R0 resection rate, and the incidence of complications.

Results: A total of 172 patients were eligible (NT 62, ST 67, MT 43), and after applying the exclusion criteria, 129 remained (NT 43, ST 51, MT 35) for the analyses of procedural parameters. The MT group achieved the highest resection speed (23.8 [IQR 18.9-33.2] mm²/min), exceeding ST by 5.2 mm²/min (95% CI 1.2-10.1) and NT by 5.8 mm²/min (95% CI 0.8-10.9). MT also demonstrated the lowest injection volume per resection area (p = 0.0057). Complications-perforation and postoperative bleeding-were comparable between groups.

Conclusions: Multi-point traction may improve resection efficiency, while maintaining safety during colorectal ESD. Future prospective multicenter trials are required to validate these findings and optimize the traction strategies.

Background: Artificial intelligence (AI)-assisted endoscopy facilitates upper gastrointestinal lesion detection. Whether Helicobacter pylori (H. pylori) infection influences its diagnostic performance remains unclear. This study evaluated the effect of H. pylori infection on an AI model's accuracy for diagnosing gastric neoplasms.

Methods: A deep convolutional neural network-based AI system was evaluated for gastric neoplasm detection (low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN), and early gastric cancer (EGC)) in a retrospective cohort study. White light endoscopy (WLE) images (n = 2347) were collected from 563 patients who underwent imaging from November 2019 to August 2024 at Taizhou Hospital of Zhejiang Province to assess H. pylori infection's impact on diagnostic performance. Additional WLE images (n = 447) from 117 patients (September 2024-June 2025) were used to compare the AI system's performance with that of expert and non-expert endoscopists.

Results: The AI system achieved 85.0% accuracy, 82.0% sensitivity, 87.6% specificity, 85.2% positive predictive value (PPV), and 84.8% negative predictive value (NPV). The accuracy (87.1% vs. 80.2%), specificity (89.9% vs. 76.6%), and NPV (89.7% vs. 65.4%) were significantly higher in the H. pylori-negative group than in the H. pylori-positive group (all P < 0.001), whereas the PPV was lower (82.7% vs. 88.5%, P = 0.008), with a comparable sensitivity (82.3% vs. 81.6%, P = 0.790). Within the H. pylori-negative cohort, further stratification into never-infected and eradicated subgroups showed that the eradicated group had significantly higher accuracy, sensitivity, and NPV than the H. pylori-positive group (all P < 0.05). It exhibited significantly higher accuracy for detecting non-neoplastic lesions and LGIN in the H. pylori-negative group (P < 0.05), but not for HGIN or EGC (P > 0.05). Its diagnostic accuracy was comparable to the expert endoscopists' (84.8% vs. 81.9%, P = 0.247) and significantly higher than the non-expert endoscopists' (84.8% vs. 72.1%, P < 0.001).

Conclusion: This AI system exhibited excellent performance for gastric neoplasm detection, which was significantly affected by H. pylori infection (particularly for non-neoplastic lesions and LGIN). Eradication of H. pylori appeared to restore the diagnostic performance of the AI system. Its diagnostic accuracy in still image classification was comparable to expert endoscopists and superior to non-experts, supporting its potential as an adjunctive clinical endoscopy tool.

Background and aims: With the rapid development of endoscopic technology, endoscopic resection (ER) of gastrointestinal stromal tumors (GISTs) has been an alternative therapeutic strategy. However, endoscopic full-thickness resection (EFTR) for GISTs still presents certain technical difficulties and challenges. The study aimed to evaluate the efficacy, safety, and long-term outcomes of EFTR for GISTs in the upper gastrointestinal (UGI) tract.

Methods: 238 patients with UGI GISTs who underwent EFTR from October 2016 to September 2024 were retrospectively enrolled into this study. Clinicopathologic characteristics, procedure-related outcomes, postoperative adverse events, and follow-up results were collected and analyzed.

Results: The endoscopic complete resection (ER0) and histological complete resection (R0) rates were 99.58% and 95.80%, respectively. The mean tumor size measured under endoscopic evaluation was 17.22 ± 8.36 mm (range 4-50 mm). The average procedure time was 52.96 ± 38.21 min, comprising a resection time of 33.46 ± 26.50 min and a wound closure time of 19.50 ± 18.59 min. Ten patients (4.20%) experienced major adverse events, including delayed bleeding in one case (0.42%), delayed perforation in one case (0.42%), peritonitis in four cases (1.68%), hydrothorax in three cases (1.26%), and aspiration pneumonia in four cases (1.68%). Besides, thirty-six procedures (15.13%) experienced technical difficulty. The multivariate analysis revealed that procedures performed by non-experts, tumors presenting predominantly extraluminal growth, and tumors with diameters of 20-30 mm and ≥ 30 mm were independent risk factors for technical difficulty. No patients encountered recurrence and metastasis during the mean follow-up times of 44.15 ± 24.83 months.

Conclusion: EFTR is a safe and effective technique for treating UGI GISTs. Further prospective studies are needed to determine the role of EFTR in treating GISTs.

Background: The optimal management approach for suspected or confirmed bile duct stones (BDS) in patients with symptomatic gallstones remains unclear. This study evaluates outcomes and safety profile of laparoscopic common bile duct exploration and cholecystectomy (LCBDE) from a UK-wide multi-centre study.

Methods: The "Retrospective Audit of Laparoscopic Common Bile Duct Exploration (R-ALiCE)", study involved 18 centres across the UK. Adult patients undergoing LCBDE for BDS between 01/01/2015 and 31/12/2019 were included. Patients who underwent LCBDE for non-stone disease and as part of another operation were excluded from the study.

Results: 1,689 patients (68.2% female, median age: 59 years) were included. The open conversion rate was 5% (n = 84). Trans-cystic LCBDE (TC-LCBDE) was attempted in 71.5% (n = 1207) (success rate, 77.6%, n = 937). Trans-choledochal-LCBDE (TD-LCBDE) was performed in 41% (694), with 28.5% being direct-to-trans-ductal explorations. The TD-LCBDE success rate was 93.4% (n = 648). The bile leak rate was 4.4% (n = 75) (61, 8.8% in TD-LCBDE vs. 14,1.5% in the TC-LCBDE, Odds Ratio = 6.76; 95% CI 3.75-12.19; P < 0.001). The retained stone rate was 4.4% (n = 74) (4.1% in TC-LCBDE vs. 4.8% in TD-LCBDE; P = 0.53). Postoperative pancreatitis occurred in 0.9% (n = 15) (0.8% for TC-LCBDE vs. 1% for TD-LCBDE; P = 0.65). The bile duct stricture rate was 0 at 90-day follow-up. The 30-day readmission rate was 7.5% (n = 127). The median length of stay was 3 days (range 2-7). Overall morbidity and Clavien-Dindo grade ≥ III complications rate were 18.7% (n = 316) and 8.8% (n = 149), respectively. The 30-day mortality rate was 0.4% (n = 7).

Conclusion: LCBDE is a safe and effective approach for managing BDS, with low rates of severe complications, including bile leak, postoperative pancreatitis, and retained stones. The trans-cystic approach is associated with a lower bile leak rate than the trans-ductal approach.