Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Surgical resection (SR) has been recommended for T1 rectal cancer, but concerns about postoperative morbidity and impaired quality of life continue to pose a significant burden for patients. Endoscopic resection (ER) offers a minimally invasive alternative; however, its oncologic sufficiency compared to SR remains unclear. We conducted a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of ER versus SR in patients with T1 rectal cancer.

Methods: We systematically searched MEDLINE, EMBASE, Cochrane Library, and KMBASE up to October 2024 for studies comparing ER and SR in patients with T1 rectal cancer. Thirty-one non-randomized observational studies involving 63,443 patients were included. Outcomes of interest were overall survival (OS), disease-free survival (DFS), recurrence, and adverse events. Risk of bias was assessed using the ROBINS-I tool, and the certainty of evidence was evaluated with the GRADE framework.

Results: Compared with SR, ER was associated with a higher risk of death and tumor recurrence, along with a non-significant trend toward higher hazards for OS and DFS. It also carried an increased risk of delayed bleeding and perforation. However, ER demonstrated significantly fewer postoperative complications, including intra-abdominal leakage, wound infection, and minor adverse events. The certainty of evidence was rated as low to very low due to confounding, selection bias, and imprecision. While many patients favored curability and recurrence prevention, others valued reduced invasiveness and faster recovery.

Conclusion: In patients with T1 rectal cancer, ER is associated with a lower incidence of postoperative complications compared to SR. However, current evidence does not support the superiority of ER in terms of long-term oncologic outcomes. ER may be considered a reasonable option in carefully selected patients-particularly older adults or those at high surgical risk-through shared decision-making that incorporates clinical factors and individual preferences.

Introduction: Laparoscopic gastrectomy is increasingly adopted worldwide, but data in Western populations remain scarce. Bariatric experience may ease its implementation, yet oncologic safety requires validation.

Methods: We retrospectively analyzed 113 consecutive laparoscopic D2 gastrectomies (2019-2024) performed by a bariatric-experienced team at a tertiary center. Patient demographics, surgical outcomes, and oncologic variables were collected. Textbook outcome, operative time, complications, hospital stay, and lymph node yield were assessed. Learning curves were evaluated using Moving Average and CUSUM analyses.

Results: A total of 113 laparoscopic D2 gastrectomies were performed (60 total, 53 subtotal). Textbook outcome was achieved in 68% overall, increasing to 83% in the final group (p = 0.21). Mean operative time decreased significantly from 333 min in the first group to 263-272 min after 45 cases (p = 0.001). Lymph node yield improved from 20.1 to > 37 nodes after 32 cases (p = 0.001). Hospital stay remained stable across groups (median 4-6 days, p = 0.92). Major complications decreased from 30.4 to 12.5% without statistical significance (p = 0.66). According to learning curve assessment, textbook outcome plateaued after 71 cases (Cusum (C)), surgical time plateaued after 45 (Moving Average (MA))/29 (C), complications and hospital stay after 53 (C), and lymph node yield after 23 (MA)/32 (C).

Conclusion: Laparoscopic D2 gastrectomy is feasible and safe in Western centers with bariatric surgery expertise, but approximately 70 cases are required to achieve optimal textbook outcomes. Structured training and high-volume practice are essential to ensure oncologic and surgical quality.

Background: Indocyanine green (ICG) fluorescence enables validated clinical assessment of both global splanchnic perfusion, via specialised peripheral pulse spectrophotometry, and local intestinal perfusion, via near-infrared fluorescence angiography (ICGFA). This exploratory study investigated perioperative variations and correlations in measurements by these technologies, including their possible relevance with outcomes, in patients undergoing colorectal surgery.

Methods: In consenting patients, plasma disappearance rate (PDR) and percentage of residual ICG at 15 min (ICGR15) were measured preoperatively, intraoperatively and on postoperative day four using ICG-pulse spectrophotometry (LiMON, Getinge). ICGFA (Pinpoint, Stryker) was visually judged by an experienced surgeon concurrently with LiMON assessment intraoperatively and with quantitative analysis of fluorescence intensity-time curves in a subgroup of recorded procedures.

Results: Twenty-eight patients were included, of whom 22 (79%) underwent segmental colorectal resection with primary anastomosis in 19 (68%). While no significant within-subject variation in LiMON-derived perfusion indices evidenced across measurement time points, there was substantial inter-subject variation (notably with age > 65 years and distal resections), especially intraoperatively. Patients having distal resections tended towards greater postoperative rebound. Although patients who developed complications exhibited relatively reduced ICGR15 intraoperatively (p = 0.041), there was no significant association with severe complications. Exploratory regression analyses found a modest association between spectrophotometric PDR values and fluorescence-derived parameters, including maximum intensity and time to peak intensity.

Conclusion: Intraoperative splanchnic perfusion varies substantially, particularly during distal colorectal resections. Although qualitative ICGFA may not reflect global hypoperfusion, quantitative fluorescence analysis shows concordance with spectrophotometric findings, supporting its potential as a complementary intraoperative perfusion-monitoring tool in colorectal surgery.

Introduction: Our study has two objectives: (1) to evaluate the incidence and severity of food retention observed during esophagogastroduodenoscopies (EGDs) in patients with and without history of glucagon-like peptide-1 receptor agonist (GLP-1 RA) use and (2) to create a grading scale to standardize the language regarding food retention. GLP-1 RAs have gained attention for treating obesity and type 2 diabetes (T2DM), largely due to their ability to reduce gastric motility. We aim to evaluate if this reduction leads to increased gastric food retention, raising the risk of aspiration.

Methods & procedures: A retrospective cross-sectional study was performed on patients who underwent an EGD from 2022 to 2024. The chi-square test was used to evaluate associations between categorical variables, including sex, gastroparesis diagnosis, T2DM diagnosis, and the presence of retained gastric contents (categorized by grade). Fisher's exact test was employed in cases where expected cell counts were less than five.

Results: The study consisted of 150 patients, with 73 GLP-1 RA users in the experimental group and 77 non-users in the control group. Most patients in both groups had no significant gastric retention at the time of EGD. When retention grades were grouped into a binary classification (None/A vs. B/C/D), there was no significant association between GLP-1 RA use and gastric retention (p = 0.67). Patients in the experimental group were significantly more likely to have a documented diagnosis of gastroparesis (p < 0.001) and T2DM (p < 0.001) as compared to the control group.

Conclusions: Our initial data suggest that GLP-1 RA use does not lead to substantial gastric food retention as observed in EGDs. We propose using this study's grading scale as the standard for quantifying gastric food retention. By defining stages from no residue to severe obstruction, it enhances study comparisons and procedure planning while promoting a shared understanding among providers.

Background: Current post-polypectomy guidelines classified 3-4 non-advanced adenomas (NAAs) as carrying an intermediate risk of metachronous advanced colorectal neoplasia (ACRN), positioned between that of 1-2 NAAs and > 4 NAAs. However, emerging evidence suggested that individuals with 3-4 NAAs may have a risk comparable to those with 1-2 NAAs. This study aimed to compare the risk of metachronous ACRN between individuals with 1-2 NAAs and 3-4 NAAs.

Methods: A two-center retrospective cohort study of individuals with NAAs and subsequent surveillance colonoscopy was conducted. Cox regression models were used to compare the risk of metachronous colorectal neoplasia (CRN) and ACRN between individuals with 1-2 and 3-4 NAAs.

Results: 2955 individuals who had NAAs removed during baseline colonoscopy were included. The risk of metachronous CRN in individuals with 1-2 NAAs was significantly lower than that in those with 3-4 NAAs (adjusted HR (95% CI), 1.28(1.04-1.57)) and those with > 4 NAAs (adjusted HR (95% CI), 1.52(1.10-2.10)), while the cumulative incidence and risk of metachronous ACRN in individuals with 1-2 NAAs was comparable with that in those with 3-4 NAAs (adjusted HR (95% CI), 0.64(0.18-2.23)) and significantly lower than that in those with > 4 NAAs (adjusted HR (95% CI), 4.69(1.51-14.6)).

Conclusions: In this observational study, the risk of metachronous ACRN after removal of 1-2 and 3-4 NAAs was comparable and lower than that observed after removal of > 4 NAAs. These findings suggest that individuals with 3-4 NAAs may have a similar risk profile to those with 1-2 NAAs. Further prospective studies are warranted to determine the optimal surveillance interval for this subgroup.

Introduction: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with lumen-apposing metal stents (LAMS) is an effective strategy for high-risk surgical patients. The optimal access route-transgastric (TG) versus transduodenal (TD)-remains uncertain. We compared outcomes of TG versus TD EUS-GBD at a high-volume tertiary center.

Methods: We included patients who underwent EUS-GBD between January 2020 and December 2024. Baseline demographics, clinical variables, and outcomes data were collected. The primary outcome was clinical success, defined as resolution of cholecystitis or relief of biliary obstruction. Secondary outcomes included stent misdeployment, adverse events (AEs), and need for endoscopic reintervention. Comparisons were performed using the unpaired T-test, Mann-Whitney U test, and Fisher's exact test, with significance at p < 0.05.

Results: We included 82 patients (mean age 72 years, 48% female). The indication for drainage was cholecystitis for 45 (55%) patients and MDBO with a patent cystic duct and prior failed ERCP for 37 (45%) patients. Sixty-four (78%) patients underwent transduodenal (TD) EUS-GBD and 18 (22%) underwent transgastric (TG) EUS-GBD. There was no difference between the two groups for clinical success (TD 89% vs. TG 94%, p = 0.68) overall nor when evaluated by procedural indication. There were five (8%) cases of stent misdeployment in the TD EUS-GBD group and zero cases in the TG EUS-GBD group (p = 0.58), all of which were salvaged endoscopically. There were no significant differences between groups for AEs (20% vs. 17%, p =  > 0.99) or unplanned endoscopic reintervention (16% vs. 11%, p =  > 0.99).

Conclusions: Both TG and TD EUS-GBD are effective and relatively safe, supporting an individualized approach based on technical feasibility and future surgical candidacy. A potential trend toward more misdeployments in the TD EUS-GBD group warrants further study.

Background: Bariatric surgery is the most effective treatment for obesity and related comorbidities, but a substantial proportion of patients develop chronic abdominal pain (CAP), defined as persistent or recurrent pain lasting more than three months. CAP significantly impairs quality of life, is reported in 30-50% of patients, and represents one of the leading causes of emergency visits and readmissions. This systematic review aims to summarize the multifactorial etiologies of CAP following bariatric surgery, highlight diagnostic challenges, and propose a multidisciplinary framework for effective management.

Methods: A comprehensive literature search (PubMed and Scopus) was conducted from inception to March 15, 2025. Eligible studies included original research, case series, case reports, observational studies, and clinical trials evaluating CAP in adult patients after primary bariatric surgery. Data on prevalence, etiology, diagnostic modalities, and therapeutic interventions were extracted and synthesized.

Results: Of the 2,111 identified articles, 51 studies met the inclusion criteria. CAP was found to have diverse etiologies, including anatomical, functional, nutritional deficiencies, biliary disorders, abdominal wall conditions, and psychological contributors. Diagnostic strategies emphasized a stepwise approach integrating history, physical examination, targeted imaging, endoscopy, laboratory studies, and psychological screening. Treatment requires etiology-specific management combining surgical, endoscopic, medical, dietary, behavioral, and psychological interventions.

Conclusion: CAP after bariatric surgery is common, multifactorial, and underrecognized, leading to significant patient morbidity and healthcare burden. A systematic, multidisciplinary diagnostic and treatment approach is essential to optimize patient outcomes, reduce readmissions, and enhance the long-term success of metabolic surgery.

Background: Operative coaching (OC) involves an expert observer rating a resident's case performance to improve surgical competency and practice readiness. To optimize the OC process, we conducted a retrospective study to investigate gender and race differences in OC evaluations.

Methods: We extracted 693 OC evaluations scored by 36 surgeons and 66 PGY2-5 general surgery residents from 7/2017 to 6/2024. Each case was evaluated by the surgeon, coach, and resident with the Surgical Entrustable Professional Activities instrument. Gender was classified as male or female; race as White, Black, or Other.

Results: Half of residents (48%, n = 32) were female; 57% were White, 17% were Black, and 26% were Other. 25% of attendings were female; 81% were White, 19% were Other. In resident self-evaluations, male residents reported higher scores across measures of operative performance, autonomy, and prospective entrustment (p < 0.05). Faculty (surgeon and coach) scored all residents higher than resident self-assessments, with minimal difference by resident gender. Male faculty evaluating female residents had the highest positive difference in median scores (p < 0.05). Residents in all three racial categories self-evaluated similarly (p > 0.05), but faculty gave the highest scores to White residents and the lowest scores to Black residents in technical skill and prospective entrustment. The median positive difference between faculty and resident scores were the lowest for Other faculty-Black resident pairs.

Conclusion: Gender and race are associated with differences in faculty grading and trainee self-evaluation of operative performance and prospective entrustment in OC cases. Awareness of potential bias should be openly discussed as a component of reflective practice.

Background: Minimally invasive surgery is the gold standard for cholecystectomy and robotic-assisted cholecystectomy has been shown to be comparable if not better than the laparoscopic technique, in terms of postoperative outcomes. We aim to compare outcomes of different robotic approaches for cholecystectomy in a high-volume Center with a large experience in robotic surgery in using robotic multiport (MP), robotic single-site (SS) and robotic single-port approach (SP).

Methods: Data from 611 patients who underwent elective robotic cholecystectomy with MP, SS or SP technique were retrospectively collected between 2012 and 2024. All surgeries were performed by the same surgeon. Urgent cholecystectomies were excluded. A propensity score weighted analysis were used to balance the three groups and short-term outcomes were compared.

Results: After the weighting using general characteristics (age, gender, BMI, ASA scale, comorbidity, and previous abdominal surgery), three groups of patients were obtained: MP n = 128; SP n = 116; SS n = 118. The three groups were homogenous for the above-mentioned characteristics. Based on linear regression analysis, the SP group had shorter overall operative time (OT), length of stay (LOS) and lower estimated blood loss (EBL), although the latter in a non-clinically significant manner (5 mL). No differences between groups in 30-day Clavien-Dindo complications, conversion rate, 30-day reinterventions, 30-day readmission and 30-day mortality (p > 0.05).

Conclusion: The analysis between robotic cholecystectomy methods showed that the SP technique results in lower LOS and EBL than the multiport technique. Regarding the duration of surgery, the SP technique was faster than the other two methods compared. SP robotic cholecystectomy is a safe and feasible alternative to multiport and single-site robotic surgery with promising results.