Surgical Endoscopy And Other Interventional Techniques最新文献

Introduction: Necrotizing pancreatitis (NP), a severe form of acute pancreatitis (AP), is linked to lower survival rates. Treatment strategies have shifted towards less invasive, step-up approaches, favoring minimally invasive procedures. In this study, we report on the potential of combining the minimally invasive surgical approach with endoscopic necrosectomy as a novel treatment strategy, termed serial percutaneous endoscopic necrosectomy (SPEN), for patients with therapy-refractory NP.

Material and methods: A cohort of 19 patients suffering from therapy-refractory NP, defined as persistent necroses after drainage treatment and subsequent video-assisted retroperitoneal debridement (VARD), was treated with SPEN upon failure of the above stated. In contrast to surgery, SPEN does not require general anesthesia or an operating theater. The results were compared with the current data on alternative treatments.

Results: The investigated cohort consisted of severely ill patients as most patients experienced organ failure as well as severe disease progression in need of intensive-care unit admission. SPEN was performed 4.3 ± 3.8 times, ranging from 1 to 14 procedures per individual. According to the current Clavien-Dindo classification, only "mild" and no major SPEN procedure-associated complications can be observed.

Conclusion: In this report, we present our experience with a novel treatment approach combining surgery and endoscopic interventions for the treatment of NP. While sparing resources, SPEN was shown to be safe and effective. Favorable implications are implied owing to the combination of the best of two worlds: surgery, with its capacity for extensive necrosectomy and endoscopic necrosectomy, which is valued for its applicability as a flexible, low-grade invasive but effective tool that may be dynamically employed depending on individual disease progression.

Background: Peritoneal opening (PO) during transanal endoscopic microsurgery (TEM) can cause the pneumorectum to collapse and complicate the procedure. As indications expand to larger, more proximal rectal lesions, understanding the real-world frequency, predictors, and consequences of PO is clinically important.

Methods: We analysed a prospectively maintained single-centre database (January 1993-August 2025) of consecutive TEM/TEO resections. The primary exposure was PO; outcomes included abdominal conversion, complications, and length of stay (LOS). Multivariable logistic regression evaluated factors such as distal distance from the anal verge, maximal diameter, excision plane, and simplified lesion location (anterior, posterior, lateral, circumferential). The prone/supine position was examined overall and within the PO subgroup.

Results: Of 1077 resections, PO occurred in 81/1,077 (7.5%). PO was more common with increasing distance from the anal verge: distal edge < 7 cm 2.3% (13/570) versus ≥ 7 cm 13.5% (68/502). Independent predictors included greater distance (OR 1.49 per cm; 95%CI 1.35-1.65; p < 0.001), larger diameter (OR 1.19 per cm; 95%CI 1.03-1.38; p = 0.022), full-thickness compared to submucosal excision (OR 4.03; 95%CI 1.39-11.66; p = 0.010), and circumferential versus anterior location (OR 4.78; 95%CI 1.61-14.19; p = 0.0049). Posterior location was protective (OR 0.26; 95%CI 0.13-0.53; p = 0.0002). Conversion occurred more frequently with PO (6.2%, 5/81) than without (0.1%, 1/992). LOS was longer with PO (median 5 [IQR 4-6] days) compared to without PO (median 4 [3-5] days; p < 0.001). The rate of complications did not differ significantly (any Dindo ≥ 1: 11.1% vs 7.3%; p = 0.19). Position was prone in 560/1,077 (52.2%) and supine in 513/1,077 (47.8%); PO was more common in prone (11.1%) than in supine (3.7%; p < 0.0001). Within the PO group, conversion was higher in the supine position (4/19, 21.1%) versus prone (1/62, 1.6%; p = 0.007), and laparoscopic-only conversions showed a borderline excess in the supine position (2/19 vs 0/62; p = 0.049).

Conclusions: PO during TEM/TEO is infrequent, anatomically driven, and usually manageable with secure endoluminal repair. Careful surgical planning-considering distance, orientation, and size-and matching platform/position can reduce risk, with no evident increase in short-term morbidity.

Background: Recurrent common bile duct stone (CBDS) following laparoscopic bile duct exploration (LCBDE) represents a clinically significant long-term complication, with implications for patient morbidity, healthcare utilization, and procedural outcomes. This study aims to quantify the incidence of recurrent CBDS and identify potentially modifiable risk factors in a high-volume referral center METHODS: A 30-year prospectively maintained database of LCBDE was analyzed. Recurrences were defined by clinical and biochemical suspicion, with or without radiological confirmation, and included non-intervention cases. Electronic records were reviewed in 2020 and 2023 to identify additional episodes not captured in the original database.

Results: Among 1447 patients undergoing LCBDE, 56 (3.8%) developed recurrent choledocholithiasis after a median interval of 24 months (range: 5-220). Twelve patients (21.4%) experienced spontaneous resolution, while 44 patients (78.6%) had 61 confirmed recurrence episodes. Eight resolved with conservative management, while 53 episodes required 65 ERCPs. Multiple recurrences occurred in 13 patients (23.2%). Patients with recurrence were significantly older (median age 72 vs 60 years, p < 0.001), had larger stones (median diameter 10 mm vs 8 mm, p < 0.001), were more likely to have had a difficult LCBDE (64.3% vs 27.8%, p < 0.001), via a choledochotomy (55.4% vs 30.5%, p < 0.001), or required T-tube drainage (37.7% vs 15.1%, p < 0.001).

Conclusions: Recurrent CBDS occurred in 3.8% of patients who underwent LCBDE (3% confirmed), a rate notably lower than the 4-30% reported after sphincterotomy. Glucagon may aid the spontaneous passage of small stones in suspected recurrence episodes. Multiple recurrences affected 23.2% of patients, warranting consideration of bile acid dissolution therapy. Two modifiable factors significantly reduce recurrence risk: avoiding preoperative sphincterotomy and favoring transcystic over choledochotomy exploration.

Background: Postoperative recurrent laryngeal nerve paralysis (RLNP) is a major complication following radical esophagectomy with superior mediastinal lymph node dissection for esophageal cancer. We evaluated whether intraoperative nerve integrity monitoring (NIM) reduces the incidence of RLNP. To our knowledge, this is one of the largest studies reported to date.

Methods: We retrospectively reviewed patients with esophageal cancer who underwent minimally invasive or robot-assisted esophagectomy at our institution between January 2013 and December 2024. NIM was introduced in January 2018 and applied to all patients thereafter. Propensity score matching was performed using logistic regression model to balance baseline characteristics.

Results: After propensity score matching, 125 patients were included in each group. The NIM group had significantly shorter operation times (442 vs. 470 min, P = 0.027) and less blood loss (55 vs. 90 mL, P = 0.003) than the earlier group without NIM. RLNP (Clavien-Dindo grade ≥ I) occurred significantly less frequently in the NIM group than in the non-NIM group (12.8% vs. 24.0%, P = 0.033). Multivariate analysis identified R1 resection (odds ratio: 8.957; 95% CI 2.502-32.065) and lack of NIM (odds ratio: 1.903; 95% CI 1.098-3.296) as independent risk factors for RLNP. However, NIM did not mitigate the severity of RLNP once it developed.

Conclusion: Intraoperative NIM significantly reduced the incidence of postoperative RLNP but it did not affect the severity. Meticulous surgical technique (especially avoiding excessive nerve traction) and vigilant intraoperative nerve identification remain essential in the prevention of RLNP.

Background: As peroral endoscopic myotomy (POEM) indications expand, proactive identification and management of technically challenging cases are critically important. This study comprehensively evaluated characteristics, perioperative outcomes, and predictors of technically difficult POEM.

Methods: In this retrospective cohort study (2011-2023), consecutive POEM procedures for esophageal motility disorders at a tertiary center were analyzed. Technically difficult POEM was defined as procedure time ≥ 90 min or aborted POEM. Characteristics and operation parameters were compared between the technically difficult and non-difficult groups. Weighted logistic regression, with stabilized inverse probability of treatment weighting controlled for operator- and technique-related confounders, was used to identify predictors of technically difficult POEM.

Results: The final cohort included 676 POEM procedures, comprising 34 (5.0%) technically difficult POEM (3 aborted) and 642 (95.0%) non-difficult POEM. Technically difficult POEM demonstrated significantly higher hemostatic forceps utilization (79.4% vs. 48.8%), prolonged postoperative stays (4 vs. 3 days), and increased hospital costs (¥21,542 vs. ¥19,490) (P < 0.01). Clinically significant adverse events were more frequent in the technically difficult group (17.7% vs. 1.6%, P < 0.001). Weighted multivariable analysis identified prior pneumatic dilation, prior POEM, and prolonged disease duration as independent risk factors for technically difficult POEM (P < 0.05).

Conclusion: Technically difficult POEM was associated with higher incidence of perioperative adverse events, increased healthcare utilization, and significant financial burdens. Prior pneumatic dilation, prior POEM, and prolonged disease duration were the independent risk factors for technically difficult POEM. Centralized referral of high-risk patients to expert centers may optimize patient outcomes and enhance procedural safety.

Background: Hepatic caudate lobe hemangiomas present unique surgical challenges due to the segment's deep location amidst critical vasculature (IVC, portal vein, hepatic veins). The literature on hepatic caudate lobe hemangiomas remains limited, resulting in a lack of comprehensive understanding and standardized treatment protocols for this condition. By comparing the surgical and perioperative outcomes of robotic versus open complete isolated caudate lobectomy for hemangiomas, this study aims to advance our understanding and management of this disease.

Methods: This single-center study included 83 patients who underwent complete isolated caudate lobe hemangioma resection. Patients were allocated to two groups: the robotic liver resection group (RLR, n = 33) and the open liver resection group (OLR, n = 50). Demographic characteristics and perioperative outcomes were compared between the two cohorts. Additionally, we explored the risk factors for intraoperative bleeding and conducted a subgroup analysis of patients with BMI ≥ 25 kg/m².

Results: RLR demonstrated superior outcomes vs OLR: shorter median operative time (median 105.0 vs. 192.5 min, p < 0.001), reduced blood loss (50 vs 300 mL; p  < 0.001), lower transfusion rates (3.0% vs 20.0%; p < 0.05), abbreviated hospital stay (9 vs 16 days; p < 0.001), and faster recovery (postoperative stay: 5 vs 8 days; p  < 0.001). Univariate analysis revealed that increased blood loss was significantly associated with surgical approach, platelet count, POD (postoperative days), operation time, and ALT level. Multivariate analysis confirmed that longer operation time was an independent predictor of increased intraoperative blood loss. High-BMI RLR patients had significantly reduced operative time (105.0 vs 231.0 min; p = 0.001), blood loss (30.0 vs 400.0 mL; p < 0.001).

Conclusion: Robotic isolated caudate lobectomy for hemangioma is feasible and safe, offering significant perioperative advantages over open surgery-including reduced blood loss, shorter hospitalization, and accelerated recovery-even in high-BMI patients. Robotic resection represents a viable surgical option for selected patients with hepatic caudate lobe hemangiomas.

Introduction: Dysphagia is one of the most common complications following anti-reflux surgery (ARS). The factors affecting the development of new onset or worsening dysphagia are not well understood. This study aimed to investigate how lower esophageal sphincter distensibility impacts the development of new onset or worsening dysphagia after ARS.

Method: A review of patients who underwent robotic ARS was conducted. All patients had intra-operative EndoFLIP monitoring at two-time points, pre-repair, and post-wrap. Dysphagia was assessed pre-operatively and at 3-6 months after surgery.

Results: Out of 168 patients (63.8%) with 3- to 6-month follow-up, 24 patients (14.2%) developed new onset or worsening post-operative dysphagia. Among these, 13 patients reported mild symptoms, and 11 patients experienced moderate-to-severe dysphagia. Patients with new onset or worsening post-operative dysphagia had lower DI values compared to those without [0.9 IQR (0.7-1.5) mm²/mmHg vs 1.3 IQR (0.9-1.8) mm²/mmHg, p = 0.04]. No significant differences were observed in post-wrap high pressure zone length (HPZ) between groups [3.5 IQR (3-4) cm vs 3.5 IQR (3-3.8) cm, p = 0.71]. A post-wrap DI value of ( $\le$ 0.9 mm²/mmHg) was associated with increased risk of new onset/worsening dysphagia [4.1 95% CI (1.3-13), p = 0.02].

Conclusion: Patients who developed new onset or worsening dysphagia after ARS had lower post-wrap LES DI values compared to those who did not. A post-wrap DI value of ( $\le$ 0.9 mm²/mmHg) was associated with increased risk of new onset/worsening dysphagia. While clinicians should consider optimizing post-wrap DI values during ARS to reduce the risk of post-operative new onset/worsening dysphagia, larger scale prospective studies are needed to validate the application of this cutoff and determine its role in tailoring fundoplication, given the single-center design and the limited sample size of our cohort.

Objectives: Endoscopic transmural drainage and necrosectomy (ETDN) is a well-established technique for managing walled-off pancreatic necrosis (WON). However, ETDN may be insufficient in some cases, necessitating adjunctive techniques such as video-assisted retroperitoneal debridement (VARD) or endoscopic ultrasound-guided transcolonic drainage and necrosectomy (EUS-TC). The optimal step-up strategy in these patients remains unclear. We aimed to assess management of WON beyond the reach of ETDN.

Methods: Patients with WON undergoing EUS-TC or VARD were identified from a prospectively maintained database between 2017 and 2024.

Results: Forty-five consecutive patients (median age 53 years; median WON size 24 cm) were included, with a median follow-up of 19 months. Thirty-three patients (73%) underwent VARD, and 12 patients (27%) underwent EUS-TC. The median length of stay (LOS) was 85 days (IQR 48-126) for the VARD group and 74 days (IQR 40-152) for the EUS-TC group, and did not differ significantly (p = 0.818). In-hospital mortality was 18% (n = 8), all due to organ failure, with no difference between the two groups, p = 0.661. Thirty-seven (82%) patients achieved complete resolution (28 VARD, 9 EUS-TC). Overall, 10 (27%) patients (eight in VARD group and 3 in EUS-TC group, one patient was treated with both VARD and EUS-TC) developed 12 external fistulas (10 enterocutaneous (six colo-cutaneous, four small bowel) and two pancreatico-cutaneous. All pancreatico-cutaneous fistulas were managed conservatively, whereas all six patients with colo-cutaneous fistulas necessitated intervention.

Conclusions: EUS-TC and VARD are both viable options for managing transgastrically inaccessible WON, although management remains associated with substantial LOS and external fistula formation.

Background and aim: In clinical practice, endoscopic resection of submucosal tumors (SMTs) in the gastric fundus is extremely difficult. The aim of our study was to compare the efficiency and safety of the double-bending method (DBM) and conventional endoscopic submucosal dissection (ESD) for the treatment of SMTs in the gastric fundus.

Methods: The clinical data of 190 patients who underwent resection of SMTs in the gastric fundus were retrospectively analyzed.

Results: In all, 190 patients with an average age of 53 years were included in this study: 100 patients in the DBM-ESD group and 90 patients in the ESD group. The average operation time was 54.2 min in the DBM-ESD group and 101.6 min in the ESD group (P < 0.001), which indicates that the resection speed was significantly faster in the DBM-ESD group. Subgroup analysis revealed that the larger the tumor volume was, the greater the difference in operation time between the two groups. No significant difference was observed in intraoperative or postoperative complications.

Conclusions: DBM-ESD can be safely and effectively performed to resect SMTs in the gastric fundus and is especially suitable for patients with very large tumor diameters.