Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Temporary diverting ostomies have become the predominant approach to reduce anastomotic leakage (AL) after anterior resection. Colovac Device is an anastomosis protection device designed to divert feces from the anastomosis. This study evaluated a new version of the Colovac Device (Colovac 2), used with the novel SmartVac Vacuum Management Device, which is used to anchor the device in the colon.

Methods: The SAFE-2023 Study was a prospective, multicenter single-arm study that enrolled patients undergoing low anterior resection (LAR) and Colovac placement. The primary performance endpoint was to assess the clinically significant (CS) migration rate of the device through device retrieval. The other performance endpoints were ostomy avoidance rate at Day 10 visit, and fecal diversion success as assessed by cleanliness of the colon immediately prior to device retrieval.

Results: A total of 24 patients were enrolled. 100% (24/24) of the Colovac devices were successfully placed in the intended location, and 100% were successfully removed endoscopically without complications. CS migration occurred in 2 patients (8.3%) on POD8 and POD9, respectively. In both cases, the device was successfully retrieved without complications, good anastomotic healing was confirmed, and no ostomy conversion was performed. The ostomy avoidance rate was 87.5% (21/24) at Day 10 and 83% (20/24) at Day 30 post-device placement. Fecal diversion success assessed immediately prior to device retrieval was 95.8% (23/24).

Conclusions: The SAFE-2023 study demonstrated a low CS migration rate for the Colovac. The Colovac Device provides a minimally invasive option to protect the anastomosis during the healing process by avoiding the need for a diverting ostomy in 87.5% of patients at Day 10.

Trial registration: SAFE-2023: NCT06540807.

Background: Lymphadenectomy along the left recurrent laryngeal nerve (RLN) is essential for curative esophagectomy but carries a high risk of RLN palsy, which impairs postoperative quality of life. Despite advances in robot-assisted minimally invasive esophagectomy (RAMIE), safe and radical dissection around the left RLN remains technically demanding. To achieve both oncological completeness and nerve preservation, we developed a novel Visceral sheath targeted approach (VISTA) based on precise anatomical understanding of the visceral and alar fasciae.

Methods: This retrospective observational study included 20 consecutive patients who underwent RAMIE with upper mediastinal lymphadenectomy using the VISTA approach for thoracic esophageal cancer between March 2024 and May 2025 at the Wakayama Medical University Hospital. RLN palsy was evaluated via bronchoscopy on postoperative day 1.

Results: No postoperative RLN palsy (Clavien-Dindo ≥ I) was observed. The median number of dissected lymph nodes along the left RLN was four. Anastomotic leakage was observed in two patients (10%), and no other severe complications classified as Clavien-Dindo grade ≥ IIIa were observed.

Conclusion: The VISTA approach has enabled anatomically guided, safe, and radical left RLN lymphadenectomy by stabilizing the nerve through the visceral sheath and expanding the operative field without traction. This technique may reduce RLN palsy while maintaining oncological precision, thereby offering a promising and reproducible procedure for upper mediastinal dissection in RAMIE.

Background: Psychological resilience-the ability to adapt positively to adversity-has emerged as a key factor influencing cancer recovery and prognosis. In gastric cancer, reduced resilience is often accompanied by sleep disturbances and elevated systemic inflammation, impairing postoperative recovery and survival. However, the efficacy of targeted psychosocial interventions remains underexplored. Reporting follows CONSORT/EQUATOR (including TIDieR) guidance.

Methods: In this single-center randomized controlled trial, 280 patients with stage I-III gastric cancer undergoing curative gastrectomy were assigned to either standard perioperative care or an integrated intervention combining cognitive behavioral therapy, resilience training, and sleep hygiene education. The intervention was initiated perioperatively and continued for 3 months. Primary outcomes included psychological resilience (CD-RISC), sleep quality (PSQI), and emotional status (HADS). Secondary endpoints comprised inflammatory markers (CRP, IL-6, TNF-α), postoperative recovery metrics, and two-year disease-free (DFS) and overall survival (OS).

Results: Compared to controls, the intervention group showed significantly greater improvements in CD-RISC, PSQI, and HADS scores (all p < 0.001; large effect sizes, d > 0.8), and reduced inflammatory markers. Enhanced recovery was reflected by shorter hospital stays and fewer major complications. Two-year survival outcomes favored the intervention: DFS 78.6% vs 64.3% (log-rank p = 0.006; HR = 0.58, 95% CI 0.37-0.91) and OS 84.3% vs 70.7% (log-rank p = 0.004; HR = 0.52, 95% CI 0.31-0.87).

Conclusions: A structured perioperative psychosocial program targeting resilience and sleep improved psychological outcomes, reduced inflammation, and enhanced recovery and survival after gastrectomy. Integration into ERAS pathways is supported, though the single-center design is a limitation.

Background: Stage IA pancreatic ductal adenocarcinoma (PDAC) is an early-stage disease where curative resection is feasible. While minimally invasive surgery (MIS) is increasingly used and adjuvant chemotherapy is standard for resected PDAC, their roles in stage IA patients remain unclear. This study evaluated the oncologic and perioperative outcomes of surgical approach and adjuvant chemotherapy in stage IA PDAC patients.

Methods: We retrospectively analyzed patients with histologically confirmed stage IA PDAC who underwent curative-intent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) at Severance Hospital (2005-2022). Those receiving neoadjuvant therapy or other procedures were excluded. Survival was assessed with Kaplan-Meier estimates and Cox models.

Results: Among 102 patients, 48 (47.1%) underwent MIS and 78 (76.5%) received adjuvant chemotherapy. The mean tumor size was 1.62 cm; 49 patients had right-sided tumors and 53 had left-sided tumors. MIS was more common in the DP group than the PD group (67.9 vs. 24.5%, p < 0.001). 12 patients (11.8%) had pathologic margin involvement of the tumor in final pathology. 59 patients (57.8%) experienced complications postoperatively and 78 patients (76.5%) received adjuvant chemotherapy. The 5-year overall and disease-free survival rates were 58.2% and 48.6%, respectively. On multivariable analysis, age (HR 1.05, p = 0.027), female sex (HR 0.32, p = 0.006), and adjuvant chemotherapy (HR 0.24, p = 0.001) were independently associated with overall survival. Age and adjuvant chemotherapy were also independently associated with recurrence-free survival.

Conclusion: Adjuvant chemotherapy was associated with improved outcomes in stage IA PDAC overall, but did not confer an overall survival benefit in left-sided tumors, underscoring the need for larger studies to define its role in this subgroup.

Background and aims: Esophagogastric variceal bleeding (EGVB) remains life-threatening in portal hypertension. This real-world cohort documents stepwise EUS-guided glue embolization evolution for secondary prophylaxis of GOV-type EGVB, comparing sequential approaches: conventional ESVD (Endoscopic selective variceal devascularization), EUS-PCSS-D/P (EUS-guided variceal puncture with cyanoacrylate selective seal targeting the distal segment of the source vessel or perforating branch vessels), and EUS-PCSS-T (targeting the source vascular trunk). We aimed to evaluate the impact of these technical iterations on clinical outcomes.

Methods: Retrospective analysis of 89 patients undergoing secondary prophylaxis: ESVD (n = 30), EUS-PCSS-D/P (n = 29), EUS-PCSS-T (n = 30). Outcomes included rebleeding rates, variceal eradication efficiency, adverse events, and survival at 1/3/6 months post-procedure.

Results: Baseline characteristics comparable (mean age 55-58 years; 50-70% male). No significant differences in EGV-related rebleeding (ESVD 23.3% vs. D/P 24.1% vs. T 13.3%), early (0-6.9%) or late rebleeding (13.3-17.2%), or all-cause GI rebleeding (13.3-33.3%). Rebleeding-free survival showed no intergroup differences overall (P = 0.221), within 180-day synchronized window (P = 0.567), or post-210-day landmark (P = 0.271). EGV eradication efficiency was superior with EUS-PCSS-T vs. ESVD or D/P (P < 0.001). Mild-moderate adverse events decreased in EUS-PCSS groups (3.5-6.7% vs. ESVD 23.3%; P = 0.033), with reduced glue use and punctures (P < 0.01).

Conclusions: EUS-PCSS-T demonstrated superior variceal eradication, reduced procedural burden, and improved safety versus earlier techniques. While rebleeding/survival differences were non-significant, it represents a technically optimized approach for GOV-type EGVB secondary prophylaxis. Prospective validation warranted.

Background: Epidural analgesia has been the gold standard for pain management in minimally invasive esophagectomy (MIE), with paravertebral analgesia as a safe alternative. This cost-effectiveness analysis, conducted alongside a randomized controlled trial, evaluates the cost-effectiveness of paravertebral analgesia compared to epidural analgesia.

Methods: This multicenter randomized controlled trial across four Dutch hospitals, including 192 patients, compared epidural and paravertebral analgesia in patients undergoing MIE. Cost-effectiveness was evaluated from a healthcare perspective, including in-hospital costs only, with time horizons from initial hospital stay and 90 days postoperatively. Procedural costs were calculated with a bottom-up approach, and analgesia costs with data from the electronic case report form (eCRF). Other hospital costs were calculated using insurance claim data from hospital registries. Effectiveness was displayed as Quality of Recovery (QoR-40) scores. Bootstrapping was used to estimate uncertainty.

Results: Mean initial surgery costs were €10,469 for the epidural and €10,051 for the paravertebral group, primarily due to a shorter mean operating room time (mean difference 19 min; 95% CI - 7 to 45). Mean postoperative (day 1-3) medication costs were €116 and €125, respectively. During the initial hospital stay, mean total in-hospital costs for uncomplicated patients were €8557 and €8646, and for complicated patients €28,244 and €28,387, respectively. When excluding complications, bootstrapping showed that 47.9% of iterations had lower costs and lower effectiveness for paravertebral analgesia, with the other iterations across all other quadrants.

Conclusions: Cost differences between paravertebral and epidural analgesia were minimal, with cost-effectiveness primarily influenced by the slightly lower effectiveness of paravertebral analgesia.

Background: Lymphocele formation is a frequent complication after kidney transplantation, occurring in up to 26% of recipients. It results mainly from lymphatic injury during dissection of the iliac vessels and can impair graft function by compressing the renal graft, vascular structures, or ureter. Improved intraoperative visualization of lymphatic vessels may reduce this risk. Indocyanine green (ICG) fluorescence technology enables real-time lymphatic mapping. This study evaluated the feasibility and clinical utility of ICG fluorescence-guided lymphography during kidney transplantation.

Methods: In a prospective single-center study, ICG lymphography was performed in 21 consecutive living-donor kidney transplantations. Under ultrasound guidance, ICG was injected into the subcutaneous tissue of the ipsilateral femoral triangle one hour before surgery. Lymphatic structures were visualized intraoperatively using a handheld fluorescence imaging system (Spy-Phi, Stryker) at four procedural time points. Identified lymphatic vessels were preserved, and any visualized lymphatic leakage was clipped. Postoperative surveillance included weekly ultrasonography in the early postoperative phase and MRI at 6 months.

Results: ICG injection enabled clear visualization of retroperitoneal lymphatic vessels in all 21 cases. Lymphatic structures were successfully preserved during dissection. In two cases, intraoperative lymphatic leakage was detected and controlled. Postoperative ultrasound showed no perirenal fluid collections in any patient. MRI performed in 15/21 patients at 6 months confirmed absence of lymphocele formation.

Conclusion: ICG-guided lymphography is a safe, feasible technique for intraoperative visualization of lymphatic vessels during kidney transplantation and may help prevent lymphocele formation.

Background: The comparative advantages of robot-assisted distal pancreatectomy (R-DP) over laparoscopic distal pancreatectomy (L-DP) remain to be fully established. This study aimed to evaluate the achievement of textbook outcomes (TO), a composite metric reflecting optimal perioperative results, in patients undergoing R-DP versus L-DP.

Methods: A retrospective analysis was conducted in 180 patients who underwent minimally invasive distal pancreatectomy between February 2011 and July 2025, including 116 L-DP and 64 R-DP cases. TO was defined as the absence of conversion to open surgery, clinically relevant pancreatic fistula (CR-POPF), postpancreatectomy hemorrhage, Clavien-Dindo ≥ IIIa complications, and readmission. Logistic regression analyses were conducted to identify factors associated with TO and CR-POPF.

Results: R-DP demonstrated a significantly lower conversion rate than L-DP (L-DP vs. R-DP: 10.3 vs. 1.6%, p = 0.034). Overall TO achievement was comparable between the two groups (L-DP vs. R-DP: 65.5 vs. 75.0%, p = 0.184), with a trend favoring R-DP was observed in spleen-preserving procedures (51.8 vs. 77.3%, p = 0.082). The robotic transpancreatic mattress suture for stump closure (TP method) significantly improved TO achievement (TP method vs. other procedures: 85.7 vs. 64.8%, p = 0.016) and reduced both conversion and CR-POPF rates. Multivariate analysis identified pancreatic thickness at the transection site ≥ 12 mm (OR 4.6) and conversion to open surgery (OR 4.9) as independent risk factors for CR-POPF. Among patients with pancreatic thickness ≥ 12 mm, R-DP significantly improved TO achievement compared with L-DP (L-DP vs. R-DP: 44.7 vs. 75.0%, p = 0.005).

Conclusions: R-DP significantly reduces conversion to open surgery while maintaining perioperative safety comparable to L-DP. Incorporation of the TP method into R-DP substantially improves TO achievement by reducing both conversion and CR-POPF, particularly in patients with a thick pancreas (≥ 12 mm). These findings support the clinical value of R-DP as an advantageous surgical strategy for optimizing perioperative outcomes in technically challenging cases.

Introduction: Recurrent dysphagia after myotomy is multifactorial and challenging to classify. Although high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and contrast studies are widely used, no standardized framework integrates anatomic and physiologic findings in the post-myotomy setting. The Atlanta Consortium for Targeted Interventions in Oesophageal and Foregut Non-Malignant Disorders (ACTION) conducted a two-part study to evaluate inter-rater agreement among experts on mechanisms of recurrent dysphagia and develop early consensus using a modified Delphi process.

Methods: In Part 1, six achalasia experts independently reviewed 42 anonymized cases of recurrent post-myotomy dysphagia and assigned a primary failure mechanism from eight prespecified categories. Inter-rater agreement was measured using Fleiss' kappa. Physiologic measures including integrated relaxation pressure (IRP), distensibility index (DI), and maximum intra-bag FLIP pressure were compared across agreement tiers. Findings informed consensus statement development for Part 2, during which an expanded panel of 13 experts completed a two-round modified Delphi process. Round 1 involved rating 12 statements on a 5-point Likert scale. Consensus required a mean ≥ 4 with ≥ 80% agreement. Round 2 included structured discussion, revision, and re-rating of statements.

Results: Among 42 cases (mean age 53.7 years; 57% female), the index intervention was Heller myotomy in 76%, POEM in 10%, and pneumatic dilation in 14% of cases. Diagnostic agreement was fair (Fleiss' κ = 0.25). Although high-agreement cases showed slightly lower median IRP and DI, distributions were broad and not statistically different, indicating that physiologic thresholds alone do not determine expert interpretation. After two rounds, the Delphi process resulted in 13 of 15 statements achieving consensus, emphasizing an anatomy-first framework with physiologic data interpreted in structural context.

Conclusion: Significant variability exists in expert assessment of post-myotomy dysphagia. This study establishes early consensus on key failure mechanisms of myotomy failure and provides reproducible anatomic subtypes to support standardized diagnostic pathways.

Background: Neoadjuvant chemoradiotherapy (NCRT) followed by surgery is the standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). Pathological complete response (pCR) is a key prognostic indicator, yet clinical outcomes and recurrence patterns in ESCC patients achieving pCR warrant further investigation.

Methods: We retrospectively analyzed patients with cT2-4aN0-3 ESCC who underwent NCRT followed by esophagectomy between 2014 and 2022. Patients were stratified into pCR (ypT0N0) and non-pCR groups. Survival and recurrence outcomes were assessed using Kaplan-Meier and Cox regression analyses.

Results: Among 136 patients (mean age 59.1 ± 7.2 years, 90.4% male), 39 (28.7%) achieved pCR. With a median follow-up of 30 months, the 5-year overall survival (OS) rate was 81.6% in the pCR group versus 39.2% in the non-pCR group (p < 0.001), and the 5-year disease-free survival (DFS) rate was 70.1 vs. 31.0%, respectively (p < 0.001). Recurrence occurred in 26.3% of pCR patients, significantly lower than the 65.9% in non-pCR patients (p < 0.001). Multivariate analysis identified pCR as an independent favorable prognostic factor for OS (HR 0.351, 95% CI 0.121-0.980, p = 0.040) and ypTNM stage for both OS (HR 1.516, 95% CI 1.114-2.063, p = 0.006) and DFS (HR 1.733, 95% CI 1.381-2.174, p = 0.001).

Conclusion: Achieving pCR after NCRT is associated with significantly improved survival in ESCC patients. However, recurrence still occurs in a notable proportion of pCR patients, underscoring the need for further risk stratification and exploration of adjuvant strategies even in this favorable response group.