Surgical Endoscopy And Other Interventional Techniques最新文献

Remote robotic surgery represents a transformative and unique approach to surgical care, offering the potential to expand access to healthcare to underserved areas, improve patient outcomes, and enhance surgical technologies. However, it is not without significant challenges, including technical limitations, ethical concerns, and financial implications. These hurdles must be carefully addressed to ensure safe and equitable integration into mainstream healthcare. Following initial excitement over 20 years ago regarding its potential as a remote tool in arenas, such as combat zones, its mainstream adoption faced challenges in terms of technological infrastructure, regulatory compliance, and ethical considerations. With the widespread adoption of robotic surgery and improvements in both the technology and the communications infrastructure, the potential for remote robotic telesurgery is experiencing a resurgence. While surgery in austere environments is intriguing, this article aims to explore the roadmap for potentially integrating remote robotic surgery into mainstream healthcare, as well as the feasibility of remote robotic surgery in the current clinical climate.

Background: Laparoscopic inguinal hernia surgery leads to rapid recovery and low complication rates. An alternative to fixate the mesh is using a self-fixated mesh.

Methods: From April 2021 to June 2024, we conducted a randomized controlled trial comparing self-adhesive mesh (Adhesix™) with self-gripping mesh (Progrip™) in laparoscopic inguinal hernia surgery (TAPP and TEP). Adult patients scheduled for day surgery were included in the study with a 1-year follow up. The primary endpoint was the number of analgesics (Paracetamol or Ibuprofen) used during the first post-operative week. Secondary outcomes were pain-related issues, complications, and recurrence rate.

Results: A total of 174 patients participated; 90 received Adhesix™ (group A) and 84 Progrip™ (Group P). Forty-six (26.4%) patients had recurrent hernia, 68 (39.1%) had unilateral and 60 (34.5%) had bilateral primary hernias. A total of 156 (90%) patients completed follow up. The number of analgesics during the first post-operative week was comparable between groups (P 22.9, A 21.2 tablets, p = 0.461). Group P used more analgesics during day 1, after which no difference was observed. In general, all participants used analgesics after surgery regularly for 10.8 days (SD 10.6) and occasionally for 15.9 days (SD 16.9). Time to return to work and normal activities was 16.1 days (SD 10.8) and 16.6 days (SD 9.6), respectively. More patients in group P reported moderate or severe pain (numeric rating scale > 3) during exercise 3 months after surgery (P 15.4%, A 3.1%, p = 0.035), although no difference was observed at 1 year after surgery. Both groups had significantly improved quality of life measures in physical aspects of the RAND-36 Item Health Survey after 3 months. Two recurrences, one in each group (1.1%) occurred.

Conclusion: The use of Adhesix was non-inferior to Progrip in laparoscopic surgery. Surgery using either mesh led to rapid recovery and improved quality of life. This trial was registered in ClinicalTrials.gov (NCT05091853).

Background: There is limited data on pouch outcomes after minimally invasive (MIS) proctectomy during ileal pouch-anal anastomosis (IPAA). This study aimed to determine if MIS proctectomy is associated with differences in pouch complications compared to open.

Methods: We performed a retrospective cohort study of patients from two academic institutions (2010-2022) who underwent restorative proctectomy with IPAA for inflammatory bowel disease, excluding those with Crohn's disease or Crohn's-like disease of the pouch. Patients were categorized into Open and MIS groups based on surgical approach. Perioperative outcomes and rates of pouchitis, cuffitis, and pouch failure were compared. Patient, disease, and operative factors associated with risk of pouch complications were identified using multivariable regression.

Results: 117 patients were included: 36 MIS and 81 Open. Median age at colectomy was 35 years, and 60% were male. Demographics, preoperative symptoms, medications, and surgical indications were comparable between groups. Rates of pouchitis (MIS 37% vs. Open 45%; p = 0.4), cuffitis (32% vs. 27%; p = 0.5), and pouch failure (5.6% vs. 6.2%; p > 0.9) were similar. MIS was associated with lower estimated blood loss (median 75 cc vs. 150 cc; p < 0.001). There were no differences in length of stay (MIS: 5 days vs. Open: 6 days; p = 0.2), operative time, or 30-day postoperative complications (HR 1.41; p = 0.5). There was a trend toward fewer anastomotic leaks in the MIS group (2.1% vs. 9.7%; p-0.2). On multivariable analysis, only initial colectomy for an indication of acute severe ulcerative colitis (HR 6.21; p = 0.044) and $\ge$ 5 bowel movements per day preoperatively (HR 3.58; 95% CI 1.10-13.1; p-0.041) were significantly associated with risk of pouchitis or cuffitis.

Conclusions: MIS proctectomy is associated with equivalent long-term pouch outcomes compared to open proctectomy. There may be a reduced risk of anastomotic leak with MIS and other perioperative outcomes were similar between groups. Patient and disease factors, but not operative factors, were associated with risk of pouch complications.

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: Laparoscopic procedures have nowadays become the gold standard in multiple abdominal diseases, but in the emergency setting, especially in major surgery, laparoscopy still represents an obstacle for most surgeons. This multicentric study aims to define the surgical approach for emergency resective surgery in left colonic perforation peritonitis, determine the factors influencing the choice between MIS and open surgery, and identify factors associated with laparotomic conversion.

Methods: Retrospective data from 516 patients treated for left colonic perforation between January 2019 and December 2023 across six Italian centers was collected. Variables analyzed included patient demographics, disease and surgical characteristics, post-operative complications, and long-term outcomes. Univariate and multivariate regression models were performed to identify factors associated with surgical choice and likelihood of conversion.

Results: Only 24.5% of patients underwent laparoscopic approach, with a conversion rate of 52.8%. MIS was associated to lower CCI and MPI and less severe septic status at arrival. MIS was mostly performed by colorectal surgeons, compared to acute care surgeons. The post-operative outcome, considering LOS, ICU admission, post-operative complications and mortality rate, was better in the MIS group. The multivariate regression model revealed that CCI, MPI, and night-time surgery were negatively associated with MIS while colorectal surgeons had a positive association. Laparotomic conversion more commonly occurred in older patients with a higher MPI and CCI and more severe septic status; these patients had a worse post-operative outcome. MPI was the only factor with statistical significance in the univariate analysis, associated with conversion.

Conclusion: Although MIS is associated with better post-operative outcomes, it is underutilized in the emergency setting. Patients requiring laparotomic conversion had higher morbidity and mortality compared to those who underwent successful laparoscopy. Limiting factors for MIS include logistic factors, patient severity, and surgical skills, therefore careful patient selection and surgical training is crucial.

Background: Colonic signet-ring cell carcinoma (SRCC) is a rare pathological subtype of colonic tumors. This study aims to comprehensively analyze the clinicopathological characteristics and long-term prognosis of colonic SRCC from multiple perspectives.

Methods: Patients diagnosed with colonic SRCC and mucinous adenocarcinoma (MA) between 2000 and 2021 were retrieved from the surveillance, epidemiology, and end results database. Clinicopathological characteristics were compared using Chi-square tests. Overall survival (OS) and cancer-specific survival (CSS) were assessed using Kaplan-Meier curves and Cox regression analysis.

Results: A total of 29,495 patients were enrolled, including 4000 with SRCC and 25,495 with MA. Compared to MA patients, the SRCC cohort was younger, had more males, less differentiation, and higher risks of lymph node (51.2%) and distant (36.6%) metastases. Age, T stage, and M stage were identified as risk factors for lymph node metastasis in SRCC, while age, T stage, and N stage were associated with distant metastasis. SRCC patients demonstrated significantly poorer OS and CSS compared to MA patients (P < 0.001). The 1-, 3-, 5-, and 10-year OS rates for SRCC patients were 57.8, 33.3, 26.0, and 17.1%, respectively, with corresponding CSS rates of 62.8, 39.7, 34.3, and 29.3%. Multivariate Cox regression analysis revealed that age, gender, grade, TNM stage, surgical intervention, chemotherapy, and marital status were predictive of OS, while age, gender, TNM stage, surgery, and marital status were significantly associated with CSS. Notably, female SRCC patients were younger and had a lower incidence of distant metastasis compared to males. Additionally, elderly patients had a higher proportion of females and Caucasians, and a lower incidence of lymph node and distant metastases compared to non-elderly patients.

Conclusion: Compared to colonic MA, SRCC demonstrates unique clinicopathological features and inferior prognosis, with variations observed across age and gender. Hence, individualized treatment strategies are essential.

Introduction: Former stoma-site incisional hernia (FSH) is a common complication after ostomy reversal, with a variable reported incidence of up to 50%. Current literature suggests that FSH is underreported due to the lack of a definitive understanding of the timeline of its occurrence and recurrence, making FSH prevention a clinical dilemma. This study identifies FSH risk factors and diagnostic timeline to aid surgeons' clinical decision-making.

Methods: A retrospective chart review was conducted on 340 patients who underwent ostomy reversal between January 1, 2016, and December 31, 2021. Data collected include demographics, medical history, course of ostomy treatment, and hernia diagnosis. Logistic regression and Kaplan-Meier analysis were used to identify risk factors and understand the timeline of hernia occurrence.

Results: The total incidence of hernia, including patients who had a parastomal hernia before ostomy reversal, FSH after reversal, or both, was 38.8%. The incidence of former stoma-site hernia alone was 24.4%. Significant risk factors identified were elevated BMI, presence of parastomal hernia, hypertension, diabetes, immunosuppression, and the emergency nature of the case. Kaplan-Meier analysis showed that patients with either parastomal hernia prior to ostomy reversal or obesity had a greater than 35% likelihood of being diagnosed with FSH within the first 2 years following reversal. Other risk factors, including chemotherapy, radiation therapy, ostomy history, hernia history, smoking, and type of ostomy, lacked significance. The median time between ostomy reversal and the first FSH diagnosis was 295 days, and 84.3% of the cases were diagnosed within the first 2 years.

Conclusion: Patients with ostomy are at substantial risk of developing FSH throughout the entire span of ostomy treatment. Patients with a high BMI, a parastomal hernia before ostomy closure, diabetes, and hypertension are at even higher risk of developing FSH.

Objective: This retrospective study was performed to evaluate the efficiency and safety of a new modular robotic system, the Carina™ Platform (Ronovo Surgical, Shanghai, China), in gynecological surgery.

Methods: All patients underwent robotic hysterectomies (RH) using the Carina performed by a single gynecologist experienced in laparoscopic and robotic surgery from November to December 2023. Patients were evaluated for estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, conversion rate, as well as console and docking times.

Results: Two separate populations were involved: 10 cervical cancer patients (group 1) and six endometrial cancer patients (group 2). There were no conversions to laparotomies or laparoscopies. The mean docking time was 5.75 ± 2.38 min. The mean console time and mean operative time were 154.60 ± 26.01 min and 211.90 ± 53.65 min in group 1, respectively. The mean console time and mean operative time were 98.67 ± 26.71 min and 153.33 ± 22.77 min in group 2, respectively. The median estimated blood loss for group 1 and group 2 were 30 ml (20, 50) and 20 ml (7.5, 20), respectively. No intraoperative or postoperative complications related to the device were recorded.

Conclusion: Our experience allows us to state that the modular Carina Platform is safe and efficient in complex gynecologic surgery.

Clinical trial registration: researchregistry10353  https://www.researchregistry.com/browse-the-registry#home/registrationdetails/665c1a398a97c302739cce06/.

Background: Antireflux surgery (ARS) has been found to be an effective treatment of gastro-esophageal reflux disease (GERD); however, the long-term effects are uncertain. This study aimed to evaluate the long-term efficacy of ARS on quality of life, symptom severity, and use of proton pump inhibitors (PPIs).

Methods: A validated GERD Health-Related Quality of Life (GERD-HRQL) Questionnaire was sent to 419 patients who underwent ARS at Aarhus University Hospital from January 2012 to April 2020. Patient records were reviewed retrospectively. The Danish National Prescription Registry was used to collect data on the use of PPIs before and after ARS.

Results: A response rate of 71% resulted in a total of 164 patients included in the study with a median follow-up time of 4.8 years (interquartile range: 2.5-6.7). The total GERD-HRQL median score at follow-up was 11.5 (IQR: 4-22). The proportion of patients experiencing daily symptoms of heartburn and regurgitation was significantly reduced pre- to postoperatively from 90 to 70% to 32% and 29%, respectively. Five years after surgery, 47% of patients had completely ceased PPI usage, while 44% were long-term users.

Conclusion: A lasting long-term effect of ARS on GERD symptoms was found, although almost a third of patients still experience heartburn and/or regurgitation daily. Almost half of patients were not taking PPIs 5 years after ARS, but 44% became long-term users. Patients should be made aware that long-term PPI therapy often is necessary following ARS.

Background: Symptomatic postoperative collections (PCs) frequently complicate surgery with significant morbidity and mortality. In contrast with pancreatic inflammatory collections, little is known about endoscopic ultrasound-guided drainage of PCs (EUS-PCD). The aim of this study is to evaluate the safety and efficacy of EUS-PCD using lumen-apposing metal stent (LAMS) as the first-line drainage approach for PCs of any kind.

Methods: This is a monocentric retrospective study. We retrieved all consecutive symptomatic PCs treated at our center between February 2019 and September 2024. All cases were considered suitable for EUS-PCD after multidisciplinary discussion. Rates of technical success, clinical success, and AEs were calculated.

Results: We retrieved 66 PCs, mainly resulting from pancreatic and lower gastrointestinal tract surgery. The median size of collections was 7.6 cm and infection occurred in 54 of the cases. The median time from surgery to drainage was 19 days (IQR 13-29); in 10 cases, this occurred ≤ 7 days after surgery. 51 drainages were performed from the gastric/duodenal window, 15 transrectally. LAMS were removed after a median time of 18.5 days (IQR 12-27). After removal, double-pigtail stents were placed in 25 PCs and at least one necrosectomy session was performed in 13. Technical success was achieved in 97.0% of cases. Clinical success was achieved in 95.2%; in 3 cases, collection recurrence occurred and retreatment with LAMS was successful. Overall AEs rate was 9.1%, but only one was severe, requiring surgery. Rates of technical and clinical failure and AEs were not affected by surgery type (pancreatic, non-pancreatic), timing of drainage (≤ 7, 7-10, > 10 days), size of collections (≤ 4, 4-10, > 10 cm), and access window (transgastric/duodenal/rectal). Necrosectomy performance was the only predictor of AEs occurrence (OR 6.9, C.I.: 1.1-46.9, p = 0.048) at univariable analysis.

Conclusion: First-intention EUS-PCD seems to be a safe and effective treatment, regardless of the origin and size of the collection and drainage timing.