Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Hepaticojejunostomy after biliary tract tumors resection represents the main limitation to minimally invasive approaches application in this field. Robotic surgery is emerging as an attractive option, offering enhanced three-dimensional visualization and articulated instruments that allow for precise intracorporeal suturing. We present our series of robotic hepaticojejunostomy with Witzel-style transanastomotic stenting.

Methods: This dynamic manuscript provides a comprehensive overview of the robotic Witzel technique hepaticojejunostomies, focusing on technical aspects and postoperative outcomes.

Results: Nine patients underwent a robotic Witzel-hepaticojejunostomy, eight for oncologic diseases. Surgical procedures included four bile duct resections alone and four associated with major hepatectomies. All hepaticojejunostomy were built upon a Roux-an-Y jejunal loop, with an antecolic path in seven cases. The prevalent suturing technique was a mixed technique, combining continuous barbed suture for one wall with an interrupted suture for the other. The median operative time was 630 min (593-705), median blood loss was 100 ml (100-350), and no intraoperative blood transfusions were required. Postoperative complications occurred in 3 patients (Clavien-Dindo 3a), without any post-hepatectomy liver failure nor biliary complications. R0 was achieved in 6 out of 8 curative resections and median retrieved nodes were 8.5 (4.5-16.3). After a mean follow-up of 12.6 ± 8 months, 4 (50%) patients developed recurrence within 3 and 27.5 months after surgery.

Conclusion: Robotic Witzel-technique hepaticojejunostomy is feasible even in complex anatomical contexts, and safe, as demonstrated by the absence of biliary complications in the present series.

Background: The PROSPECT guidelines provide GRADE A recommendations for paracetamol, non-steroidal anti-inflammatories, and port site infiltration (PSI) with local anaesthetic following laparoscopic cholecystectomy. Despite varying practice, the optimal method of delivering additional local anesthetic is unclear.

Aim: To perform a randomised clinical trial (RCT) evaluating the value of laparoscopic-delivered transversus abdominal plane block (L-TAP) compared to intraperitoneal infiltration (IP) in addition to PSI in patients undergoing laparoscopic cholecystectomy.

Methods: A multicentre RCT was performed during a 7-month recruitment period (March-October 2025) across 6 hospitals. Patients were randomised on a 1:1 basis to L-TAP or IP. The primary outcome was postoperative visual analogue scores (VAS). Descriptive statistics and regression analyses were performed.

Results: 147 patients were recruited, of whom, 135 underwent final analysis. Of these, 49.6% were allocated to IP (67/135) and 50.1% to L-TAP (68/135). A non-significant difference was observed in baseline clinical information between groups (P > 0.050). A significant reduction in mean VAS was observed in favour of L-TAP at 6-h (IP: 3.3 (standard deviation (SD): 0.3) vs. L-TAP: 2.3 (SD: 0.3), P = 0.014) and 24-h (IP: 3.1 (SD: 0.4) vs. L-TAP: 1.6 (SD: 0.4), P = 0.008), with a trend towards significance at 12-h (IP: 3.5 (SD: 0.4) vs. L-TAP: 2.5 (SD: 0.4), P = 0.063). Moreover, regression analysis demonstrated a significant reduction in VAS following TAP (beta-coefficient: -0.681, standard error: 0.281, P = 0.015), however, a non-significant difference in 'breakthrough' opioid and morphine equivalent consumption was noted between groups (P > 0.050). There was a non-significant difference in surgical data, postoperative outcomes, and quality of life metrics between groups (P > 0.050).

Conclusion: This study demonstrates the superiority of L-TAP compared to IP in reducing postoperative pain, as measured VAS scores, in patients undergoing laparoscopic cholecystectomy.

Background: Laparoscopic liver surgery offers several benefits, yet the adoption of laparoscopic right hemihepatectomy (RH) is slow, owing to its high degree of technical complexity. It is uncertain whether the general benefits of laparoscopy also extend to RH. This study evaluates perioperative outcomes of laparoscopic vs open RH, and illustrates differences in laparoscopic RH and left hemihepatectomy (LH) within the international, multicentre, double-blinded ORANGE-II-PLUS randomized trial.

Methods: Patients were randomly assigned to open (n = 166) or laparoscopic hemihepatectomy (n = 166). The present post-hoc subgroup analysis compares perioperative and oncological outcomes of laparoscopic RH (n = 105) vs open RH (n = 108). In addition, interaction between surgical approach (open or laparoscopic) and hemihepatectomy laterality (RH; n = 213 vs LH; n = 119) was assessed.

Results: There was a higher proportion of malignancy, including more colorectal liver metastases, and more preoperative portal vein embolization in patients undergoing RH compared to LH, other characteristics were well-balanced. The laparoscopic approach was associated with shorter time to functional recovery compared to open surgery for RH (median 5 vs 5 days, p = .004) and shorter length of hospital stay (median 5 vs 6 days, p = .014). Except for longer operating times in laparoscopy (332 vs 263 min, p < .001), no differences were found in other perioperative and oncological outcomes between laparoscopic and open RH. For all outcomes, interaction testing between surgical approach and laterality did not reach significance, suggesting that approach did not affect RH and LH differently. Though patients requiring laparoscopic RH needed longer operating time (332 vs 225 min) and time to functional recovery (median 5 vs 3 days) than patients requiring laparoscopic LH.

Conclusion: Patients undergoing RH showed modest, population-level, benefits from a laparoscopic approach with regard to time to functional recovery and hospital length of stay, despite higher technical complexity and a more pronounced postoperative impact on the patient. Interaction testing between RH and LH did not reach significance, suggesting the effect of the approach on outcomes were consistent regardless of resection laterality. These results support the implementation of the laparoscopic approach for RH if surgeons are experienced.

Clinical trial information: NCT01441856.

Objective: The objective of this study is to evaluate the efficacy and safety of laparoscopic ultrasonography (LUS) when applied during emergency laparoscopic cholecystectomy (LC) in patients diagnosed with severe calculous cholecystitis, and to compare its outcomes with those of standard LC performed after preoperative magnetic resonance cholangiopancreatography (MRCP).

Methods: Between January 2022 and June 2024, sixty patients with severe calculous cholecystitis were retrospectively identified and grouped based on their treatment approach. The Emergency Group (Group E, n = 30) comprised patients who underwent emergency LC with intraoperative LUS shortly after admission. The Routine Group (Group R, n = 30) included patients who underwent routine LC following MRCP confirmation of the absence of bile duct stones. Variables evaluated included demographic characteristics, operative details, intraoperative blood loss, time to bowel function recovery, length of hospital stay, hospitalization costs, and blood parameters (white blood cell count [WBC], C-reactive protein [CRP], total bilirubin [TBIL], direct bilirubin [DBIL], indirect bilirubin [IBIL], alanine aminotransferase [ALT], and aspartate aminotransferase [AST]) at baseline and on postoperative days 1 and 3.

Results: No statistically significant differences were observed between the two groups regarding operative duration, intraoperative blood loss, time to first bowel movement, or trends in laboratory parameters (p > 0.05). However, patients in Group E demonstrated a significantly shorter overall hospital stay and reduced hospitalization costs compared with those in Group R (p < 0.05).

Conclusion: The application of LUS during emergency LC was found to be a safe, effective, and practical therapeutic approach for patients with severe calculous cholecystitis. Its use was associated with shorter hospitalization duration and lower healthcare costs without an increased risk of perioperative complications.

Background: Paraesophageal hernia (PEH) repair is usually performed with fundoplication. Historically, hiatal hernia repair without fundoplication was proposed but abandoned due to high anatomical recurrence and gastroesophageal reflux disease (GERD) rates. Modern comparisons are limited among dissimilar groups with mixed conclusions. We compared objective and symptomatic outcomes of hiatal hernia repair with gastropexy (HH-G) to a matched group of hiatal hernia repair with fundoplication (HH-F) for patients with large PEH without significant reflux.

Methods: We conducted a propensity matched analysis of patients undergoing minimally invasive HH-G to patients undergoing HH-F between 1/2010 and 12/2022. We included all patients with PEH ≥ 5 cm with non-reflux dominant symptomology excluding those with objective GERD. The 63 HH-G were matched 1:1 for age, BMI, and hernia type to 225 HH-F. The primary outcomes were recurrence (> 2 cm) and GERD health-related quality of life (GERD-HRQL).

Results: Patient demographics, hernia type, and size were similar except HH-G were slightly older. HH-G was used more during urgent repairs with less Collis gastroplasty and relaxing incision use. Median imaging follow-up was 22 (IQR:11-38) months. Anatomical recurrence (HH-G: 7/39 [14.6%] vs. HH-F: 8/48 [20.5%], p = 0.467) and symptomatic recurrences (1/36 [3%] vs. 3/42 [6%], p = 0.625) were similar between the groups. Post-operative GERD-HRQL scores were similarly low (2.0 [IQR:1.0-9.0] vs. 2.0 [IQR: 0.0-4.0], p = 0.289).

Conclusion: Hiatal hernia repair with gastropexy results in seemingly similar quality of life and recurrence to a matched group of fundoplication for patients with large PEH without significant reflux, suggesting that this approach may be a treatment alternative in selected patients during PEH repair.

Background: Optimal reconstruction after laparoscopic proximal gastrectomy (LPG) remains debated. This study compared perioperative outcomes and long-term quality of life (QoL) between tubular esophagogastric (TEG) and double-tract (DT) anastomosis, with attention to age-dependent effects.

Methods: This retrospective cohort study included 284 patients undergoing LPG with TEG or DT. Exploratory age-stratified analyses were performed. QoL was evaluated using GerdQ, dysphagia scores, and the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45).

Results: DT was associated with longer operative time than TEG (232.1 vs 217.6 min, P = 0.016), primarily due to prolonged reconstruction time (90.3 vs 66.0 min, P < 0.001). In an exploratory analysis of patients aged ≥ 70 years, TEG was associated with fewer overall complications than DT (25.9% vs 50.0%, P = 0.049), while complication severity by Clavien-Dindo grade was comparable between groups. This divergence was primarily attributable to non-anastomosis-related complications rather than anastomotic events. In multivariable analysis within the ≥ 70-year subgroup, DT (vs TEG) remained independently associated with postoperative complications (OR 3.57, 95% CI 1.03-12.41; P = 0.045). Conversely, DT demonstrated superior anti-reflux outcomes, including lower GerdQ scores and lower reflux esophagitis rates at 12 and 24 months (all P < 0.05). DT also showed lower anastomotic stenosis at 3 months (4.0% vs 11.4%, P = 0.038) and better long-term QoL regarding food intake and meal-related distress.

Conclusions: DT offers superior reflux control and long-term QoL outcomes. However, in patients aged ≥ 70 years, TEG demonstrated a perioperative safety advantage, driven mainly by a lower rate of non-anastomosis-related complications. Reconstruction choice in older patients should be individualized by balancing perioperative risks and long-term functional benefits.

Background: Activities of daily living (ADL) are an important outcome of surgery for elderly patients. As life expectancy increases, interest in minimally invasive surgery (MIS) is increasing. However, there is limited evidence regarding the effect of MIS on ADL, especially in the very elderly patients (≥ 80 years).

Methods: A total of 1009 consecutive patients (80-99 years) undergoing elective surgery for gastrointestinal and hepatobiliary-pancreatic tumors between 2010 and 2025 were enrolled. Propensity score matching (PSM, 1:1) was performed in 869 patients after excluding those with benign tumors or missing data. A comparison was made between MIS (laparoscopic/robotic, n = 284) and open surgery (n = 284). The primary outcome was postoperative ADL decline. Severe postoperative ADL decline was defined as a decline of ≥ 30 points in the Barthel Index total score.

Results: Postoperative ADL decline was observed in 128 patients (14.7%) in the entire cohort. After PSM, postoperative ADL decline occurred in 17.3% and 19.4% of patients in the open and MIS groups, respectively (P = 0.59). Severe postoperative ADL decline was lower in the MIS than in the open groups (5.7% vs. 9.5%, P = 0.11). The 90-day readmission rate was also lower in the MIS groups (16.6% vs. 22.3%, P = 0.11). Intraoperative blood loss, ICU and hospital length of stay, and severe postoperative complications were significantly better in the MIS group. In high-risk or frail subgroups, such as those with poor performance status, care needs, and severe complications, MIS consistently demonstrated lower rates of severe postoperative ADL decline compared with open surgery.

Conclusions: Compared with open surgery, MIS reduced the incidence of severe postoperative ADL decline and 90-day readmission. Subgroup analysis indicated that this trend was strongest in high-risk or frail patients. These results suggest that MIS may help maintain postoperative independence and prevent functional frailty in the very elderly patients.

Background: Gastric gastrointestinal stromal tumours (gGISTs) are among the predominant subtypes of gastric submucosal tumors (SMTs) with malignant potential. Accurate differentiation between gGISTs and non-gastric gastrointestinal stromal tumours (non-gGISTs) using current imaging tools, especially for small-diameter lesions (< 2.0 cm), remains challenging. The aim of this study was to established a diagnostic nomogram model utilising endoscopic ultrasound (EUS) images to effectively distinguish small gGISTs from non-gGISTs.

Methods: We conducted a multicentre retrospective study of consecutive patients who underwent endoscopic resection (ER) for gastric SMTs at two centres from March 2020 to June 2025. Clinical data, EUS characteristics and pathological features were collected and analysed. A nomogram model for the diagnosis of small gGISTs was established, followed by internal and external validation.

Results: A total of 496 patients were included in this study. The independent predictors of gGIST diagnosis were age ≥ 60 years (OR (95% CI) 2.30 (1.20-4.44), P = 0.013), gastric cardia-fundus/body location (OR (95% CI) 6.09 (1.55-23.98), P = 0.010), and muscularis propria/submucosa origin (OR (95% CI) 6.71 (2.24-20.04), P < 0.001). The AUCs for the nomogram were 0.83 (95% CI 0.78-0.88), 0.81 (95% CI 0.73-0.89), and 0.87 (95% CI 0.81-0.92) in the training, internal validation, and external validation cohorts, respectively. Calibration curves showed excellent agreement between the predicted and actual probabilities for differentiating between small gGISTs and non-gGISTs. Decision curve analysis (DCA) demonstrated favourable clinical applications of the model. The external validation yielded an accuracy of 0.78, a sensitivity of 0.91, and a specificity of 0.71. A subgroup analysis between gGISTs and leiomyomas revealed that the AUC was 0.73 (95% CI 0.63-0.83), with an accuracy of 0.67, a sensitivity of 0.65, and a specificity of 0.74 in the external validation cohort.

Conclusion: Patient age, lesion location, and origin layer were independent diagnostic factors for small gGISTs. The proposed nomogram served as a valuable tool for differentiating between small gGISTs and non-gGISTs.

Introduction: Minimally invasive surgery (MIS) is widely considered to be the standard of care for paraesophageal hernia (PEH) repairs, yet a subset of cases still require unplanned conversion to open surgery due to factors such as poor visualization and intraoperative complications. Although both laparoscopic and robotic approaches are routinely used, few studies have compared conversion rates as a primary outcome. This study aims to evaluate conversion to open surgery and associated short-term outcomes between surgical approaches for PEH repairs.

Methods: This retrospective cohort study used the 2022-2023 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) registry to identify elective laparoscopic and robotic PEH repairs in patients aged 18-90 years. Concomitant procedures were excluded and 1:1 propensity score matching was performed to control for baseline characteristics and comorbidities. The primary outcome was unplanned conversion to open surgery. Secondary outcomes included 30-day postoperative complications, return to OR, readmission, and hospital length of stay.

Results: A total of 8325 patients met inclusion criteria, of which 40% (n=3364) underwent robotic repair. After matching, 3335 patients were included in each group with balanced covariates (standardized mean difference < 0.05). The robotic group had zero conversions to open, while the laparoscopic group had a conversion rate of 0.2% (p = 0.031). Operative times were longer in the robotic group (133 vs 115 minutes, p < 0.001). No differences were observed in 30-day postoperative complications, readmission, return to OR, or median length of stay. Rates of specific complications including infections, thromboembolic events, and cardiopulmonary issues were comparable between groups.

Conclusion: In this large national cohort, there was a growing trend of robot usage for elective PEH repair. Additionally, robotic repairs were associated with fewer conversions to open but longer operative time. Further studies are needed.