Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Moments of intraoperative struggling, termed as surgical struggle, are common yet variably labeled and poorly defined. Existing literature substitutes proxy terms, but no standardized definitions or metrics of struggle exist despite clear implications for patient safety, outcomes, and training.

Methods: A narrative review was undertaken to map how "surgical struggle" has been conceptualized and measured in the literature. The literature was screened using concept-adjacent proxies and parallels (e.g., operative difficulty, prolonged operative time, workflow disruptions, hesitancy, intraoperative kinematics, physiologic stress) identified through searches in PubMed and Google Scholar.

Results: Existing measures each capture facets of struggle but not the moment itself. Operative difficulty, technical complexity, and surgical complexity are widely used terms that represent struggle. Prolonged operative time is objective but nonspecific. Robotic kinematic data (eg, idle bursts, path length, jerk, speed peaks) differentiates expertise and correlates with adverse intraoperative events, offering granular, real-time signals. Surgical workflow disruptions increase cognitive load and are associated with moments of struggle, while surgical hesitation represents pauses in operative period potentially highlighting struggling. Physiologic markers of struggling moments (eg, heart rate variability, galvanic skin response) are not routinely captured. Evidence supports a multilevel framework (micro, meso, macro) for surrogate measures of surgical struggle.

Conclusion: A standardized working definition of surgical struggle will establish the framework for identifying intraoperative struggle. This will enable video annotation and machine-learning pipelines for real-time detection of surgical struggle. A formal consensus process is warranted to establish a terminology, definition, thresholds, and reporting standards and to catalyze clinical adoption.

Background: Although laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) show comparable short- and long-term efficacy for treating locally advanced gastric cancer (LAGC), evidence on the cost-effectiveness of LDG versus ODG remains limited. This study aimed to evaluate the long-term cost-effectiveness of LDG versus ODG in patients with LAGC at different stages from a societal perspective in China.

Methods: A Markov model incorporating three health states (stable disease, disease progression, and death) was constructed based on data from the CLASS-01 trial. The outcome measures included incremental cost-effectiveness ratio (ICER) and quality-adjusted life years (QALYs). Cost-effectiveness was assessed by comparing the ICER to the willingness-to-pay (WTP) threshold. Sensitivity analyses were conducted to evaluate model uncertainty.

Results: In stage I patients, the model projected that LDG provided 0.29 incremental QALYs at an incremental cost of $819.33, yielding an ICER of $2829.98/QALY-below the WTP threshold, indicating potential cost-effectiveness conditional on the model parameters. Conversely, in stage II and III patients, ODG was associated with higher QALY gains than LDG (simulated incremental QALYs of - 0.14 and - 0.22, respectively), and the ICERs were negative (stage II: ICER - $7692.45 per QALY, incremental cost $1073.62; stage III: ICER - $4232 per QALY, incremental cost $913.41), suggesting that ODG was the cost-effective strategy within the simulation framework. Sensitivity analyses indicated that base-case findings were robust to parameter uncertainty.

Conclusion: Based on the model's assumptions and parameterization, the simulated results indicate that LDG is likely cost-effective in stage I patients, while ODG appears more advantageous in stage II and III patients.

Background: Achalasia is definitively treated with peroral endoscopic myotomy (POEM) or laparoscopic Heller myotomy with fundoplication (LHM + PF), but reflux after POEM remains a key concern. We compared the safety and GERD outcomes of POEM and LHM + PF using randomized controlled trials and prospective comparative studies in treatment-naïve adults.

Methods: We searched the MEDLINE, Embase, CENTRAL, Web of Science, and Scopus databases on October 18, 2025. Eligible studies directly compared POEM and LHM + PF in adults. The primary outcome was adverse events, and the secondary outcomes were endoscopic reflux esophagitis, abnormal 24-h pH, procedure time, and length of hospital stay. Random-effects meta-analyses were used to generate risk ratios (RRs) and mean differences (MDs). Certainty was graded using the GRADE system, and sensitivity and subgroup analyses were performed.

Results: Four studies (three RCTs and one propensity-matched cohort; n = 590) met the inclusion criteria. Adverse events were similar (RR 1.15, 95% CI 0.38-3.44). POEM was associated with higher rates of endoscopic esophagitis (RR 3.10, 95% CI 2.17-4.41) and abnormal pH (RR 1.94, 95% CI 1.07-3.53) compared to LHM + PF. Procedure time did not differ significantly between groups (MD =  - 62.05 min, 95% CI - 180.78 to 56.67) with wide confidence intervals indicating imprecision. The length of hospital stay was comparable (MD = 0.32 days, 95% CI - 0.21 to 0.85).

Conclusion: In treatment-naïve adults, POEM and LHM + PF had comparable safety profiles and hospital stays. POEM is associated with higher reflux rates than LHM + PF. Both are viable options, and the selection should be individualized based on the patient's phenotype and institutional expertise.

Background: Enhanced recovery after surgery (ERAS) pathways have reduced hospital stays after bariatric surgery, yet a subset of patients still require prolonged hospitalization. We aimed to identify predictors of delayed discharge and develop a validated clinical nomogram to estimate the likelihood of > 1 day postoperative stay.

Methods: We performed a retrospective cohort study of consecutive adults undergoing primary or revisional minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass at a single military treatment facility from 01/01/2022 to 12/31/2024. Demographic, comorbidity, operative, and perioperative data were abstracted. The 2023 cohort served as the development set for univariable and multivariable logistic regression to identify predictors of delayed discharge (> 1 day). A clinical nomogram was constructed from independent predictors and internally validated via bootstrap resampling (200 iterations). Temporal validation was performed on 2022 and 2024 cohorts.

Results: Among 281 patients (mean age 47.2 ± 11.3 years; mean BMI 40.5 ± 6.0 kg/m²; 26.7% male), 141 (50.2%) experienced delayed discharge. Independent predictors included operative time > 150 min (OR 3.00, 95% CI 1.14-8.09), overnight hydromorphone use (OR 3.78, 95% CI 1.40-11.0), ≥ 1 overnight antiemetic dose (OR 2.55, 95% CI 1.04-6.27), postoperative day (POD) 0 oral intake < 200 mL (OR 2.43, 95% CI 1.01-6.01), and POD 1 hemoglobin decrease ≥ 2 g/dL (OR 4.16, 95% CI 1.25-15.3). The final five-variable model demonstrated strong discrimination (AUC 0.77; bias-corrected C-index 0.74) and calibration (Hosmer-Lemeshow p = 0.17). Temporal validation confirmed robust performance (AUC 0.77-0.87). In sensitivity analysis, model discrimination remained high for both primary (AUC 0.79) and revisional cases (AUC 0.88). A web-based Shiny risk calculator was developed for bedside use ( https://michaeltolson.shinyapps.io/bariatric-delayed-discharge-2023/ ).

Conclusions: A five-variable nomogram accurately predicts delayed discharge following bariatric surgery and demonstrated strong temporal validation. This tool may aid individualized discharge planning.

Background & aims: Endoscopic retrograde pancreatography (ERP) with pancreatic duct stenting is a recognized intervention for pancreatic fistulas. However, its application as a salvage therapy for refractory postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains less defined, particularly when guided by the hypothesis that duodenal papilla obstruction perpetuates the fistula. This study evaluated the efficacy of ERP with stenting for refractory POPF after DP and investigated the role of papilla morphology.

Methods: Five patients with refractory Grade B POPF after DP were included. Refractoriness was defined as persistent high-output (> 100 mL/day) for > 3 weeks despite percutaneous drainage and medical therapy or newly developed pseudocysts. All patients underwent ERP. The key procedural goal was to traverse the papilla and place a stent into the pancreatic duct of the remnant to bypass any potential obstruction and achieve internal decompression.

Results: ERP with trans-papillary stent placement was technically successful in all five patients (100%). Clinical success, defined as a dramatic reduction in fistula output (> 75%) within 72 h and complete fistula closure within 4 weeks, was achieved in all 5 patients (100%). No procedure-related complications occurred.

Conclusion: In this case series, ERP with pancreatic duct stenting is a highly effective and minimally invasive salvage therapy for refractory POPF after DP. Its consistent success provides strong clinical support for the pathophysiological role of duodenal papilla obstruction. We propose that ERP should be considered early in the management algorithm for high-output POPF that fails to resolve with standard measures.

Background: Laparoscopic Cholecystectomy (LC) is the standard surgical treatment for symptomatic benign gallbladder diseases. Bile Duct Injury (BDI) is a common and serious complication of LC. Critical View of Safety (CVS) has been proven crucial in preventing BDI. However, current attainment rate of CVS remains low. Recent advancements in AI offer an efficient method for this gap. This study aims to develop an intelligent surgical platform (SurgSmart) enabling real-time assessment of the Critical View of Safety (CVS), integrate it into routine surgical practice, and evaluate its performance and user acceptance based on intraoperative and post-operative feedback.

Materials and methods: A total of 377 LC videos from 17 hospitals were retrospectively collected for training, validation, and testing of the AI algorithm. The model's effectiveness was evaluated using accuracy, precision, recall, F1-score, and macro-average F1-score. Our platform was deployed in the operating rooms of three hospitals. From May to October 2024, we collected LC videos and surgical reports and assessing variations in CVS scores. Surgeons were surveyed to evaluate user satisfaction, surgical confidence and to gather suggestions.

Results: For CVS I, II, and III the overall accuracy and macro-average F1-score are 0.91 and 0.72, 0.86 and 0.67, 0.73 and 0.70, respectively. The overall CVS scores for the three hospitals showed significant improvement after the deployment of platform (P < 0.01). Fifteen out of the eighteen surgeons who used our platform demonstrated overall improvement (P < 0.05). Surgeons' satisfaction was high, with recommendations including more adequate training and guidance as well as further improvements in model performance.

Conclusion: This platform has demonstrated its feasibility for real-time and automated CVS assessment. Most surgeons improved after using our platform. Surgeons reported positive feedback and expressed hope for more adequate guidance and continuous improvements in model performance.

Background: Despite advances in minimally invasive surgery, pain after appendectomy remains common. The transversus abdominis plane (TAP) block has been proposed as an alternative to port site local anesthetic. We aimed to synthesize randomized controlled trials (RCTs) comparing the efficacy and safety of 1) TAP block versus port site local anesthetic, and 2) ultrasound to laparoscope-guided TAP blocks following adult minimally invasive appendectomy.

Methods: Relevant databases were searched for RCTs until December 2024. Two authors independently identified trials, extracted data, assessed risk of bias (ROB 2), and evaluated evidence certainty (GRADE).

Results: Four RCTs (233 patients) were included comparing TAP block to port site anesthetic in laparoscopic appendectomy. No studies examined robotic surgery, and none compared ultrasound to laparoscope-guided technique. TAP block led to decreased total opioid consumption (mean difference: - 4.50 mg morphine equivalents, 95%CI - 6.51, - 2.50, 3 RCTs, 153 patients, low certainty), and reduced pain scores at 4, 6 and 12 h postoperatively, but not at 1 and 2 h, or when pooled across the first 24 h postoperatively (very low certainty). There was no difference in hospital length of stay (mean difference: - 0.03 days, 95%CI: - 0.40, 0.33, 3 RCTs, 177 patients, very low certainty) or postoperative nausea and vomiting (risk ratio: 1.15, 95%CI: 0.77, 1.71, 3 RCTs, 153 patients, low certainty). Patient satisfaction was measured in one study, which favored TAP block. No adverse reactions were reported.

Conclusions: Compared to port site injection, TAP block may result in a small improvement in opioid consumption, postoperative pain scores, and patient satisfaction following laparoscopic appendectomy. There appears to be no difference in postoperative nausea and vomiting. The impact on length of stay is unclear and may have limited clinical significance. Evidence certainty was low to very low and based on a small number of RCTs, indicating a need for further research.

Background: Nerve-sparing robot-assisted radical prostatectomy (NS-RARP) requires precise prostatic capsule identification to balance oncological control with functional preservation. Artificial intelligence (AI)-based intraoperative navigation could provide real-time anatomical guidance, but clinical feasibility remains unvalidated.

Methods: We conducted a human-in-the-loop feasibility study evaluating a convolutional neural network system for real-time fluorescence-like navigation (FLN) prostatic capsule identification. A total of 285 frames from 12 NS-RARP procedures have been used to establish the AI model. The validation and clinical acceptance assessment were performed on 23 representative frames from 3 NS-RARP procedures by four surgical scenarios: initial lateral dissection (Phase I), visual interference from bleeding/smoke (Phase II), limited capsule exposure (Phase III), and distant field view (Phase IV). 6 experienced urologic surgeons independently evaluated AI output using structured 10-point scales across 6 clinical domains. Quantitative assessment employed standard segmentation metrics comparing AI output to surgeon-annotated ground truth.

Results: The AI system achieved consistently high clinical acceptance (surgeon ratings 8.21-9.01/10) despite moderate segmentation performance (Dice 0.533 ± 0.098). Boundary positioning accuracy received the highest rating and significantly exceeding other domains (8.63 ± 0.61). Performance varied across surgical scenarios with mean Dice scores of 0.622 in Phase I, 0.489 in Phase II, 0.616 in Phase III, and 0.390 in Phase IV, yet surgeon reliability ratings remained high across all phases (8.39-9.10/10). Weak positive correlation between Dice scores and clinical ratings was observed (r = 0.42, p = 0.048). The system demonstrated high recall of 79.7% with moderate precision of 40.9%, a pattern preferred by surgeons for safety.

Conclusions: AI-driven real-time prostatic capsule navigation demonstrates clinical feasibility for pilot trials despite moderate technical performance. Surgeons exhibited well-calibrated trust across varying conditions, prioritizing anatomically correct positioning over pixel-perfect segmentation.

Background: Robot-assisted esophagectomy (RE) has been increasingly adopted as an alternative to thoracoscopic esophagectomy (TE) for esophageal cancer. While RE has shown perioperative advantages, its long-term oncological and functional outcomes remain unclear. This study compared short- and long-term outcomes, as well as postoperative changes in body composition and pulmonary function.

Methods: We retrospectively reviewed 639 patients who underwent esophagectomy for thoracic esophageal cancer between 2018 and 2022. After excluding non-standard procedures, 205 underwent RE and 434 TE. Propensity score matching was performed based on demographic, nutritional, functional, and oncological factors, yielding 122 matched pairs. Surgical outcomes, complications, overall survival (OS), relapse-free survival (RFS), skeletal muscle index (SMI), and pulmonary function (FEV1) were compared.

Results: In the matched cohort, RE was associated with reduced blood loss, lower inflammatory response, and shorter ICU stay, with comparable complication rates to TE. The 3-year OS was higher in RE than TE (78.1% vs 68.1%, p = 0.01), particularly in cStage III (71.8% vs 57.5%, p = 0.044), whereas RFS was similar. Univariate analysis identified TE, pT > 3, pStage > III, and lymphovascular invasion as adverse prognostic factors, while multivariate analysis confirmed pStage > III as the only independent predictor (HR 5.20, 95% CI 2.54-10.40, p < 0.001). SMI remained above the sarcopenia threshold (7 kg/m²) in RE but consistently below in TE, despite no statistical difference. The decline in FEV1 at 4 months was smaller in RE (-3.6% vs -8.4%, p = 0.004). Survival analysis stratified by early FEV1 decline (ΔFEV) showed superior outcomes in patients with preserved function, with the RE ΔFEV low group showing the most favorable prognosis compared with the TE ΔFEV high group (3-year OS: 81.8% vs 58.5%, p = 0.005).

Conclusions: RE was associated with improved perioperative recovery and early functional preservation compared with TE. The observed differences in OS were not confirmed in multivariable analysis.

Background: Endorobotic submucosal dissection (ERSD) using the da Vinci single-port (SP) platform offers high-definition visualization and enhanced precision for the resection of distal colorectal lesions. In contrast, conventional endoscopic submucosal dissection is technically demanding and associated with a steep learning curve. This study aims to evaluate the efficacy, broader applicability, and long-term outcomes of ERSD in a large patient cohort.

Methods: We retrospectively analyzed 101 patients who underwent ERSD using the da Vinci SP platform between March 2020 and May 2025. Patient demographics, lesion characteristics, procedural details, pathological findings, and long-term follow-up data were reviewed. The primary objectives were to assess intraoperative and postoperative complications, evaluate the feasibility of en-bloc submucosal dissection, and examine the oncological outcomes associated with the ERSD procedure.

Results: The median age of the cohort was 62.5 years (IQR: 52-70 years), with 56.4% male patients. The median distance from the anal verge was 8 cm (IQR: 6-11 cm, range: 1-24 cm). En-bloc resection was achieved in 96.0% of the cases, with a median procedure time of 73 min (IQR: 53-97). The median length of hospital stay was 0 days. The median specimen size was 19 cm² (IQR: 11-28), with a median greatest dimension of 5 cm (range: 1-18 cm). Final pathology revealed tubulovillous adenoma in 57.4% of the cases, tubular adenoma in 16.7%, and serrated adenoma in 6.0%, adenocarcinoma in 12.9%, neuroendocrine tumor in 1.0%, villous adenoma in 1.0%, and colonic mucosa/scar in 5.0%. No metastases or malignant recurrences were observed during the median follow-up of 22 months in patients with adenocarcinoma. Across the entire cohort, three non-cancer-related deaths occurred during follow-up.

Conclusion: Our experience demonstrates that ERSD is not only safe and feasible but also provides durable results with minimal long-term complications and high rates of en-bloc resection in distal colorectal lesions. These findings support the broader application of ERSD as a viable alternative to the traditional transanal approaches for selected colorectal lesions.