Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Patients requiring cholecystectomy or appendectomy may present with concomitant COVID infection in both the inpatient and outpatient scenarios. It is unclear whether these patients benefit more from operative or nonoperative management in the setting of active COVID infection. These guidelines seek to address urgent and elective clinical scenarios.

Methods: A systematic review was conducted to address these questions. These results were then presented to an interdisciplinary panel that formulated recommendations based on the best available evidence or utilized expert opinion when the evidence base was lacking.

Results: Conditional recommendations were made in favor of (1) either operative or nonoperative management of COVID-positive patients with appendicitis or cholecystitis and (2) delaying operations by more than six weeks in patients who test positive for COVID in the elective setting.

Conclusions: These recommendations should provide guidance regarding the management of surgical patients with concomitant COVID infection. This guideline also identifies important areas where future research should focus to strengthen the evidence base.

Background: HPB surgery is being increasingly performed robotically worldwide. However, there is no consensus on what constitutes adequate training or an established curriculum. We evaluate the existing literature on formal education in robotic hepatopancreaticobiliary (HPB) surgery and propose a curriculum using Kern's six-step curriculum development model.

Methods: A systematic search was performed across major databases and the methodology of the Joanna Briggs Institute was followed. The PRISMA-ScR was conformed in reporting. Evidence pertaining to cholecystectomy alone was excluded and studies that described formal training pathways were included.

Results: Fifteen curricula were included with predilection towards the pancreas (n = 7, liver: n = 5, combination: n = 3). Almost all studies proposed initial robot system training through online modules, observership and console simulation exercises. Following this, six curricula described procedure-specific anastomosis training. Almost all studies described mentorship and proctorship. The assessment for implementation commonly described includes objective structured assessment of technical skill (OSATS) and cumulative sum technique (CUSUM) for operation time, conversion-to-open rate and postoperative complications.

Discussion: This study has summarised the formal curricula for learning robotic HPB surgery. The majority share similar implementation tools. A comprehensive curriculum based on validated educational principles has been proposed which incorporates these elements.

Background: Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

Methods: Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

Results: Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

Conclusions: Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

Background: Endoscopic onlay repair (ENDOR) approach is gaining traction as a promising technique for the treatment of diastasis recti and associated ventral hernia. However, comprehensive evidence regarding its perioperative and short-term outcomes remains scarce. The objective of this meta-analysis is to provide a comprehensive summary of the existing evidence concerning perioperative and short-term postoperative outcomes.

Methods: A systematic literature review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL until August 1st, 2024. Articles reporting outcomes of ENDOR in adult population diagnosed with diastasis recti associated or not with primary or incisional ventral hernia were included. Primary outcomes were evaluated based on safety and short-term measures, including intraoperative and short-term postoperative characteristics. A fixed effects model was used for meta-analysis. The methodological quality of the studies was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria.

Results: A total of 12 studies (480 patients) were identified. Minimally invasive ENDOR resulted in an intraoperative complications and conversion rate of 1.0% [95% CI 0.0-2.0%]. The rate of seroma was 25% [95% CI 12.0-39.0%], the one of surgical site infection was 1% [95% CI 0.0-2.0%] and the rate of hematoma was 2% [95% CI 1.0-3.0%]. After a median follow-up of 16 months (1.8-39), the rate of recurrence was 2% [95% CI 0.0-3.0%].

Conclusions: The minimally invasive ENDOR approach stands out as a safe and effective method for diastasis recti and associated ventral hernia repair in selected patients, exhibiting low rates of intraoperative complications and yielding favorable outcomes. Prospero registry Registration number: CRD42024573235.

Background: Mesenteric-related internal hernia after left hemicolectomy is rare. However, it can cause serious consequences, including upper gastrointestinal obstruction and acute intestinal necrosis. This study aimed to explore the potential risk factors of symptomatic internal hernia (SIH) after a left hemicolectomy.

Materials and methods: We retrospectively reviewed the data of patients who underwent a left hemicolectomy at 10 tertiary hospitals between January 2018 and June 2024. Their baseline information, surgical procedures, and early postoperative complications (within 3 months after surgery) were recorded and analyzed.

Results: Overall, 468 patients were included in this study, the majority of patients underwent laparoscopic surgery (76.9%). SIH was detected using postoperative imaging (computed tomography/upper gastrointestinal contrast). Six patients (1.28%) developed SIH (SIH group) and underwent re-operation. Compared with the 462 patients who did not develop SIH (non-SIH group) (with comparable baseline data between groups), the SIH group did not undergo surgery to close the mesenteric defect (0 vs. 56.1%; p = 0.008) and had longer durations of postoperative hospital stay (50.5 ± 37.1 days vs. 14.6 ± 6.4 days; p < 0.001). Relative to the patients without mesenteric defect closure, those who had closure of the mesenteric defects did not have significantly increased duration of surgery (β = - 0.40, 95% CI = - 12.60 to 11.81, p = 0.949) or incidence of postoperative complications other than SIH (β = 0.79, 95% CI = 0.43 to 1.45, p = 0.443).

Conclusion: The risk of SIH after left hemicolectomy may increase if closure of the mesenteric defect is not performed. We recommend appropriate management of the mesenteric defect after left hemicolectomy to prevent SIH.

Background: Acute appendicitis is a common emergency in rural Kenya. While open appendectomy is widely used, minimally invasive approaches may improve postoperative recovery and superficial surgical site infection rates. However, adoption in resource-limited settings is hindered by cost and availability, with fewer than 1% of operations involving laparoscopy. This study evaluates the effectiveness and costs of laparoscopic versus open appendectomy to inform practices in similar settings.

Methods: A retrospective study at Tenwek Hospital, Kenya (2015-2019), compared laparoscopic and open appendectomy using a bottom-up micro-costing method for true healthcare costs, adjusted for inflation and expressed in international dollars using purchasing power parity (I$PPP). Outcomes, including operating room turnaround time, hospital length of stay, superficial surgical site infections, and financial impact, were analyzed with Pearson's chi-squared, Wilcoxon rank-sum tests, and a multilevel generalized linear model to adjust for patient comorbidities and severity.

Results: Among 168 patients, median age was 34 years (IQR: 26-44), with 71% men, and perforation in 45%. Laparoscopic surgery was performed on 31 patients, with one conversion, versus open surgery in 137. The laparoscopic group had longer operating room turnaround times (115 vs. 75 min, p < 0.001) but shorter hospital stays (2 vs. 4 days, p = 0.002). Total costs were lower for laparoscopy cases (1527 vs. 1816 I$PPP, p = 0.049), with surgical site infections (3.2% vs. 16.7%, p = 0.026).

Conclusions: Despite longer surgery times, laparoscopic appendectomy significantly reduces hospital stays, total costs, and surgical site infections compared to open surgery in rural Kenya.

Objectives: The efficacy and safety of different surgical approaches to thyroidectomy with lateral neck dissection remain unclear. This study aims to evaluate five endoscopic and open techniques for thyroidectomy with lateral neck dissection and identify the most effective method.

Methods: A systematic search was conducted in PubMed, Web of Science, Embase, and the Cochrane Library for studies comparing different surgical approaches across multiple outcome indicators. The risk of bias was analyzed, and publication bias was assessed using funnel plot asymmetry tests. Both global and local inconsistency tests were performed to evaluate the agreement between direct and indirect comparisons. Pairwise and network meta-analyses were conducted for each outcome, with approaches ranked using Surface Under the Cumulative Ranking (SUCRA) values and curves.

Results: A total of 1251 patients across 13 clinical studies were included in the analysis. No significant statistical differences were found among the approaches for lymph node dissection and postoperative recurrence rates. The bilateral axillary breast approach yielded the highest number of lymph nodes (SUCRA value: 0.762). The suprasternal fossa approach had the lowest postoperative recurrence rate (SUCRA: 0.657) and performed well in metastatic lymph node dissection (SUCRA: 0.679). The bilateral axillary breast approach significantly reduced postoperative complication rates compared to the open and transaxillary approaches (mean differences: - 1.88 and - 0.23; 95% confidence intervals: - 3.87 to - 0.46 and - 0.62 to 0.29, respectively) and was the most effective in minimizing complications (SUCRA: 0.910). Open surgery demonstrated a significantly shorter operative duration.

Conclusion: Endoscopic approaches are viable and safe alternatives to open surgery, with fewer postoperative complications, albeit at the cost of longer operative durations.

Background: Gallstone disease is common after gastric surgery and especially after weight loss from bariatric surgery. In patients with normal gastroduodenal anatomy, treatment of common bile duct stones (CBS) generally consists of, endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES), followed by cholecystectomy in a second stage. However, after gastric surgery the papilla may not be easily accessible endoscopically. The aim of our study was to evaluate the therapeutic success of single-stage laparoscopic cholecystectomy and common bile duct exploration (LCBDE) after previous gastric surgery.

Methods: In this observational cohort study, all LCBDE in patients with previous gastric surgery between January 2014 and July 2022 were retrospectively reviewed. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction. Outcomes of interest consisted of successful duct clearance, postoperative adverse events and CBS recurrence.

Results: Forty-four patients (M/F: 22/22) underwent LCBDE after previous gastric surgery, in which simultaneous cholecystectomy was performed in 38 cases. Median (range) age 68 (25-90) years. Presence of CBS was confirmed in 38 patients (85%), a choledochal polyp in one patient (2%) and recurrence of gastric cancer in another (2%). Duct clearance was successful in 37 out of 38 patients (97%). Median (range) length of stay after LCBDE was 1 (0-12) day(s). Eight patients developed a postoperative adverse event, of which three Clavien-Dindo > 3a complications. Three patients were readmitted. At a median (range) follow-up of 60 (24-120) months, no CBS recurrences were observed.

Conclusions: LCBDE is a safe technique, with a high rate of successful duct clearance after previous gastric surgery, even after previous cholecystectomy. In experienced centers, LCBDE provides a valid alternative for complex interventional endoscopy, omitting the need for the creation of a gastro-gastric fistula.

Background: Robotic (RLR) and laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) provide similar short-term outcomes, but data focused on recurrence and survival are still lacking. We hypothesized non-inferior oncologic results of RLR compared to LLR for HCC of stage BCLC 0-A.

Methods: RLRs and LLRs on patients with HCC of stage BCLC 0-A and preserved liver function (Child A or B if cirrhosis) were retrospectively reviewed. Propensity score matching (PSM) was used to mitigate selection bias. The primary endpoints were recurrence-free (RFS) and overall survival (OS); secondary endpoints were incidence, pattern, and treatment of recurrences.

Results: After 1:1 PSM, two groups (RLR = 68; LLR = 68) of patients with similar characteristics, liver function and HCC features were obtained: median age 71-years, males 73.5%, underlying cirrhosis 91.2% (Child A, 96.8%, MELD ≤ 9, 96.0%), portal hypertension 22.1%, single-HCC 90.4%. Two- and 5-year RFS were 78.0 vs 59.0% and 54.0 vs 53.0% (p = 0.107), while OS was 97.0 vs 90.0% and 87.0 vs 90.0% (p = 0.951) for RLR vs LLR, respectively. Incidence of HCC recurrence was similar (35.3 vs 39.7%; p = 0.723). Recurrences developed mostly within the liver (29.4 vs 30.9%; p = 1.000) and within 2 years after hepatectomy (19.1 vs 32.4%, p = 0.116) in RLR vs LLRs. Curative-intent treatment of recurrences did not differ (liver transplantation 19.6%, redo-resection 15.7%, locoregional treatments 52.9%) except for a tendency toward more redo-resections for recurrences after RLR.

Conclusions: Oncologic outcomes of RLR were not inferior to those of LLR in selected HCC patients of stage BCLC 0-A with underlying cirrhosis. Both techniques guaranteed similar salvageability in case of HCC recurrence.