Surgical Endoscopy And Other Interventional Techniques最新文献

Background: The transition from medical student to surgical resident involves a significant shift in responsibility, learning style, and hands-on training complexity. Navigating all these professional hurdles can be a challenge, and residents may struggle with various aspects of these throughout their training, which can lead to the need for remediation. Residency programs must facilitate efforts to identify and address both technical and non-technical deficiencies through targeted remediation.

Materials and methods: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a review of technical and non-technical components of resident remediation.

Results: The two primary components of remediation in a residency program are technical and non-technical skill competencies. The role of the program director is essential to guiding and facilitating the remediation process for residents. Additionally, efforts to prevent remediation are important to implement within a residency program's structure. Current resources focus on technical and non-technical skills remediation. Program design and video-based assessments play crucial roles in technical skills remediation. For non-technical skills remediation, these address resident deficiencies in professionalism, interpersonal skills and communication.

Conclusion: Resident remediation is a complex yet essential responsibility for surgical training programs. It requires structured strategies tailored to both technical and non-technical skills, grounded in timely identification and consistent support. Effective remediation begins with early recognition of deficits and the development of clear, personalized improvement plans. These plans must outline specific goals, measurable outcomes, and mechanisms for progress assessment.

Choledocholithiasis remains a common disease process to treat in modern medicine, but few are aware of its fascinating history. Starting with the preliminary understandings of ancient civilizations, significant strides in anatomic and pathologic characterization were made during the 16-18th centuries. In the latter half of the nineteenth century, the first cholecystectomy was performed, crossing an important surgical milestone that opened the door to further biliary intervention. Diagnostic advances were made and imaging techniques improved in the twentieth century, notably with Dr. George Berci's groundbreaking advancement of cholangiography and performance of the first endoscopic common bile duct exploration. The development of endoscopic cholangiopancreatography (ERCP) in the 1970s and the introduction of laparoscopy brought the management of biliary disease into the modern era. In the future, we look towards improvements in safety, imaging techniques, instrumentation, and teaching strategies, among others, to further the field. In this article, we review the history of choledocholithiasis and the medical pioneers, importantly Dr. George Berci, who revolutionized the endoscopic and surgical treatment of this disease.

Objective: Numerous auxiliary traction techniques have been devised, but their effectiveness and applicability in endoscopic submucosal dissection (ESD) remain underexplored. Our systematic review and meta-analysis aimed to compare the efficacy and safety of traction-assisted ESD (TA-ESD) and conventional ESD (C-ESD) in treating early gastric cancer (EGC) and precancerous lesions (PCL).

Methods: We identified and selected randomized controlled trials (RCTs) and cohort studies published up to February 2025 contrasting the efficacy of TA-ESD with C-ESD. The primary outcome was procedure time. Secondary outcomes encompassed the en bloc resection rate, complete resection rate, perforation, and delayed bleeding. Pooled standardized mean difference (SMD) and risk ratio (RR) were calculated. Subgroup analysis and meta-regression were implemented by the type of traction technique, operator experience, lesion size, lesion location, and lesion position.

Results: Seven RCTs and thirteen cohort studies were included. The TA-ESD group had significantly shorter procedure time relative to the C-ESD group (SMD: - 0.49, 95% CI: - 0.64 ~  - 0.33, P < 0.001, I² = 72.7%, P < 0.001). Subgroup analysis exhibited that the double-clip traction method had significantly shorter procedure time than C-ESD (SMD: - 0.62, 95% CI: - 0.78 ~  - 0.45, P < 0.001, I² = 0.0%, P = 0.857). Both experts and trainees could shorten the procedure time with TA-ESD on gastric lesions across various sizes and locations. The TA-ESD group had a higher complete resection rate (RR: 1.02, 95% CI: 1.01 ~ 1.03, P = 0.008, I² = 45.6%, P = 0.024) and lower perforation incidence (RR: 0.59, 95% CI: 0.37 ~ 0.96, P = 0.032, I² = 0.0%, P = 0.999). The en bloc resection rate and incidence of delayed bleeding were similar between the two groups.

Conclusion: Both experts and trainees may benefit from the use of auxiliary traction techniques when performing ESD on gastric lesions of varying sizes and locations. Among various auxiliary traction techniques, the double-clip traction method is relatively effective.

Prospero registration: The trial is registered with ClinicalTrials.gov CRD420251010671.

Background and aims: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an emerging alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with a malignant biliary obstruction, in case of technical failure of endoscopic retrograde cholangiopancreatography (ERCP). However, this procedure is technically challenging, and dedicated stents have only recently become available. This study prospectively evaluated the safety and feasibility of EUS-HGS with a dedicated stent.

Methods: This prospective single-center study included patients with inoperable malignant biliary obstruction that underwent an EUS-HGS. The primary outcome was safety. Technical and clinical success were evaluated as secondary endpoints. We used a partially covered self-expandable metal stent (pcSEMS) (30% uncovered and 70% covered) with anti-migration features.

Results: EUS-HGS was attempted in 28 patients, achieving technical and clinical success rates of 89% (25/28) and 96% (22/23), respectively. Three patients (11%) experienced grade IIIA adverse events (AEs) (all cholangitis) within 30 days: two with undrained right-sided bile ducts requiring percutaneous drainage, and one patient due to blockage of a side branch at the level of the covered part of the stent for which an endoscopic stent exchange was successfully performed. Five patients died < 30 days due to disease progression, none of these patients experienced procedure-related AEs. Six out of the 22 patients with clinical success developed recurrent biliary obstruction after a median of 78 days (IQR 45-108). Obstruction was caused by hyperplasia at the uncovered portion of the stent (n = 3) and due to sludge obstructing the stent (n = 3). Successful re-intervention was performed in all patients.

Conclusions: This prospective study shows that EUS-HGS with a dedicated pcSEMS is feasible and safe. Tissue hyperplasia in the uncovered part of the stent and sludge obstruction may compromise long-term stent patency. Larger, comparative prospective studies are needed to assess optimal stent design and timing of EUS-HGS within the therapeutic algorithm.

Backgound: The effects of bariatric surgery on kidney function remain controversial. This study aims to assess changes in kidney function, with a specific focus on structural biomarkers, in individuals with obesity but without evident kidney disease following bariatric surgery.

Methods: Fifty-two patients with obesity and an estimated glomerular filtration rate from creatinine and cystatin C (eGFRcr-cyc) of at least 90 mL/min/1.73 m² underwent sleeve gastrectomy (SG). Serum levels of kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) were measured at baseline, one month, and one year postoperatively to assess structural injury.

Results: eGFRcr-cyc decreased one month postoperatively (117.4 [103.2,133.2] to 105.8 [97.0,122.7] mL/min/1.73 m²), but restored to near baseline levels by one year (112.2 [107.2,122.4] mL/min/1.73 m²). KIM-1 levels showed no significant change at one month (53.4 [35.6,73.9] to 38.2 [21.6,68.5] pg/mL), while NGAL levels increased (56.2 [47.0,67.0] to 70.9 [52.6,88.0] ng/mL). At one year, both KIM-1 (56.7 [32.0,105.3] pg/mL) and NGAL (77.4 [57.4,96.0] ng/mL) levels remained elevated compared to baseline. Ten individuals who achieved normal weight postoperatively had lower KIM-1 (29.8 [27.1,43.4] vs. 73.3 [39.5,113.6] pg/mL) and NGAL (61.5 [52.3,71.1] vs. 84.0 [59.9,97.3] ng/mL) levels at one year compared to those who remained overweight or obese.

Conclusion: Although the kidney functional biomarker, eGFRcr-cyc, did not change, structural injury biomarkers, including KIM-1 and NGAL, increased one year post-SG. These findings underscore the importance of weight management and highlight the necessity for continued, long-term monitoring of kidney function in this patient population to mitigate potential subclinical kidney injury.

Background: Minimally invasive surgery (MIS) has transformed abdominal surgery by improving recovery times and maintaining comparable outcomes to open surgery. However, the loss of three-dimensional (3D) visualization remains a limitation. Robotic platforms have facilitated the adoption of 3D systems. Despite these developments, the advantages of 3D over two-dimensional (2D) visualization in MIS and robotic surgery remain controversial.

Methods: A systematic review was conducted including studies published between January 2015 and May 2024. Studies comparing 2D and 3D visualization in MIS and robotic surgery were included. Primary outcomes assessed were operative time, intraoperative blood loss, length of stay, conversion and complication rates.

Results: Regarding MIS, three studies demonstrated a statistically significant reduction in blood loss favoring 3D visualization, with median reductions from 60 mL (IQR 20-60) to 20 mL (IQR 5-40) (p = 0.008). Operative time was significantly reduced in 15 studies, notably in hernia repairs, bariatric, gastric, and colorectal surgeries. Two studies reported marginally significant reductions in hospital stay. Complication rates showed isolated improvements. In robotic surgery, 14 studies showed 3D visualization enhanced task performance, with tasks completed up to 88% faster among novice surgeons.

Conclusion: 3D visualization consistently reduces operative time in selected MIS procedures and improves robotic task performance, whereas effects on blood loss, complications, and length of stay are inconsistent. Standardized, procedure-specific trials-especially against 2D-4K-and reporting of clinical outcomes in robotic surgery are needed.

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is often associated with extensive surgical resection and has traditionally been performed via laparotomy. Data on minimally invasive robotic approaches remain limited. We evaluated surgical safety and survival outcomes of robotic CRS/HIPEC for peritoneal surface malignancies (PSM).

Methods: A single-center propensity score-matched study was conducted using a prospectively collected database (2018-2025). PSM patients treated with robotic CRS/HIPEC were matched 1:1 to open CRS/HIPEC controls using propensity scores based on age, sex, BMI, histology, and PCI.

Results: Of 99 cases, 15 robotic and 71 open CRS/HIPECs were identified. After matching, 15 robotic and 15 open cases were balanced by age, sex, BMI, diagnosis, prior surgical score, and PCI. CC-0/1 rate was 100.0% in robotic and 93.3% in open CRS/HIPEC (p = 1.00). Median blood loss was lower in the robotic group (100 mL vs 250 mL, p = 0.04). Median hospital stay was shorter after robotic CRS/HIPEC (6 vs 9 days, p = 0.05). No differences were observed in major complications (26.7% vs 33.3%, p = 1.00) and reoperation (0.0% vs 6.7%, p = 1.00). No 90-day mortality was observed in either group. Median follow-up was 58 months. Median overall survival (not reached vs 52 months, p = 0.20) and progression-free survival (not reached vs 42 months, p = 0.19) did not differ between robotic and open CRS/HIPEC.

Conclusion: In PSM patients with low tumor burden, robotic CRS/HIPEC is not associated with increased morbidity or worse survival. It may offer benefits such as reduced blood loss and shorter hospitalization. Multicenter studies are warranted to optimize patient selection.

Background: Postoperative hypoparathyroidism remains a common complication following total thyroidectomy. Although anatomical preservation of the parathyroid glands (PGs) is routinely attempted, functional outcomes are often unpredictable. To address this gap, we developed a novel physiology-based model to predict postoperative parathyroid hormone (PTH) levels by incorporating preoperative hormonal status and intraoperative perfusion assessment using indocyanine green (ICG) angiography.

Methods: This retrospective study included 37 patients who underwent bilateral axillo-breast approach robotic total thyroidectomy between July 2024 and February 2025. Intraoperative ICG angiography was used to classify each PG as well-perfused, poorly perfused, or unidentifiable. Based on our hypotheses that each PG contributes to total PTH levels equally under normal physiology and that PG's functional viability can be evaluated by ICG angiography, postoperative PTH levels were calculated using the following formula: Calculated PTH = (Preoperative PTH ÷ 4 × n_well) + (1 × n_poor), where n_well and n_poor represent the number of well- and poorly perfused PGs, respectively.

Results: Postoperative-to-preoperative PTH ratios exhibited distinct clustering at 0.25, 0.50, and 0.75, consistent with the hypothesis that each PG contributes approximately one-quarter to overall PTH production. Calculated PTH values were strongly correlated with measured postoperative levels (Spearman's ρ = 0.60, p < 0.001), and 73.0% of patients had calculated values within ± 5 pg/mL of the actual result. Transient hypoparathyroidism occurred in 13 patients (35.1%) and was associated with significantly lower actual and calculated postoperative PTH levels compared to those without hypoparathyroidism.

Conclusions: Our physiology-based model enables accurate intraoperative estimation of postoperative PTH levels by incorporating preoperative PTH values and ICG angiography-based perfusion status. This approach may serve as a rapid and effective indicator of post-thyroidectomy hypoparathyroidism, particularly in day surgery settings or in institutions where routine postoperative laboratory monitoring is not feasible.

Background: Recurrent benign biliary strictures after failed hepaticojejunostomy remain a major surgical challenge, particularly in East Asia. This study aimed to evaluate the feasibility and mid-term outcomes of a structured, risk-adapted protocol for redo laparoscopic Roux-en-Y hepaticojejunostomy (RYHJ).

Methods: Between June 2019 and December 2024, 26 consecutive patients underwent redo laparoscopic RYHJ performed by a single surgeon. Patients were preoperatively stratified according to the Hobson adhesion grade (I-V) into low-risk (I-II), moderate-risk (III), and high-risk (IV-V) groups. In patients classified as high risk, a standardized intraoperative strategy incorporating indocyanine green (ICG) fluorescence cholangiography via pre-established percutaneous transhepatic cholangiodrainage and refined anastomotic techniques was applied. Key operative steps were prospectively video documented. Primary and secondary endpoints included technical success, perioperative outcomes, and biliary patency during follow-up.

Results: Redo laparoscopic reconstruction was successfully completed in all patients. The median operative time was 210 min (range 150-378) and median blood loss was 55 mL (range 10-200).Patients with higher Hobson grades demonstrated increased technical complexity and a higher incidence of early postoperative bile leakage. In the final six high-risk cases, no bile leaks or anastomotic strictures were observed during a median follow-up of 36 months, despite increased operative complexity.

Conclusions: Redo laparoscopic RYHJ using Hobson-guided protocols yielded durable mid-term outcomes with acceptble morbidity. In high-risk patients, the standardized use of ICG fluorescence and refined anastomotic techniques contributed to improved safety, representing a reproducible and clinically practical technical refinement for complex redo biliary surgery.

Background: This study aimed to summarize the current clinical evidence, technical advances, and practical insights related to robotic thyroidectomy using the da Vinci SP (Single-Port) surgical system, with an emphasis on the evolution of surgical approaches and outcomes based on the author's institutional experience and literature review.

Methods: A focused narrative review of studies published between 2019 and 2025 was conducted to evaluate the safety, feasibility, and clinical performance of single-port robotic thyroidectomy. Five representative SP approaches (single-port transoral robotic thyroidectomy [SP-TORT], single-port transaxillary robotic thyroidectomy [SP-TART/START], retroauricular approach using the da Vinci SP system [RA-SP], single-port robotic areolar approach [SPRA], and gas-insufflation one-step single-port transaxillary [GOSTA]) were compared in terms of operative technique, ergonomics, and postoperative outcomes.

Results: Across multiple institutions, SP robotic thyroidectomy demonstrated operative times, complication rates, and lymph node yields comparable to those of conventional multi-port or open surgery while providing distinct cosmetic and ergonomic advantages. Transient recurrent laryngeal nerve palsy and hypocalcemia were the most common complications, with low overall morbidity. Recent reports have extended the SP technology to modified radical neck dissection (MRND) through the START, SPRA, and GOSTA approaches, confirming the oncologic feasibility of comprehensive nodal dissection within a confined workspace.

Conclusion: The da Vinci SP system represents a meaningful advancement in minimally invasive endocrine surgery by enabling single-port robotic thyroidectomy through various remote-access approaches. Current evidence supports its safety, feasibility, and favorable cosmetic outcomes when applied to appropriately selected patients. However, further refinement of instrumentation, optimization of surgical techniques, and accumulation of long-term clinical data are required to expand its indications and to define its role in advanced thyroid diseases more clearly.