Surgical Endoscopy And Other Interventional Techniques最新文献

Background: Intraoperative neuromonitoring (IONM) has been increasingly used in thyroid surgery, yet its clinical value remains controversial.

Objectives: This randomized controlled trial aimed to evaluate the efficacy and safety of IONM in thyroid cancer surgery.

Methods: The standardized four-step monitoring protocol was used in the IONM group. Primary endpoints included RLN injury rates and postoperative voice function recovery. Secondary endpoints included surgical parameters (operation time, blood loss), complication rates, and oncological outcomes. Voice function was assessed using VHI-10 scoring and maximum phonation time (MPT). Patients were followed up for a median of 6 months.

Results: The IONM group demonstrated significantly lower rates of temporary vocal cord paralysis (2.0% vs 10.0%, P = 0.038) and higher nerve identification rates (100% vs 96.0%) compared to the control group. Voice function recovery was notably faster in the IONM group, with smaller changes in VHI-10 scores (Δ = 4.2 ± 1.5 vs 7.6 ± 2.1, P < 0.001) and shorter MPT recovery time (14.2 ± 3.5 vs 25.6 ± 5.2 days, P < 0.001). Although operation time was longer in the IONM group (125.6 ± 18.3 vs 108.4 ± 15.7 min, P < 0.001), no significant differences were found in blood loss (45.3 ± 12.6 ml vs 48.7 ± 13.2 ml, P = 0.183), complication rates, or oncological outcomes between the groups.

Conclusion: IONM technology greatly lowers the risk of temporary recurrent laryngeal nerve injury and speeds up voice function recovery in thyroid cancer surgery. Although operation times are slightly extended, the technique is safe and preserves oncological integrity.

Background: Hepatic adenomas (HA) are benign neoplasms of the liver that have small risks of hemorrhage and malignant transformation. While the association between obesity and the development of HAs is increasingly recognized, the impact of bariatric surgery on HA regression is poorly understood.

Methods: All patients with a pre-operative diagnosis of HA who underwent primary bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass) at a single quaternary academic medical center from 2012 to 2024 were retrospectively queried and combined with all previously reported cases obtained via a systematic review of the literature. Patient clinical characteristics, including pre-operative and post-operative body mass index (BMI) and HA size, were extracted. Kendall's Tau-b correlation and fractional probit regression were used to assess the relationship between weight loss and HA size change.

Results: The institutional review identified three patients, and the systematic review yielded five studies totaling seven patients. In the combined cohort (mean age 34.8 years), the average pre-operative BMI was 44.48 kg/m² and decreased to 32.19 kg/m² post-operatively, representing 68.18% excess weight loss (%EWL). Mean HA size decreased from 4.49 cm to 1.55 cm (56.46% reduction, SD 43.68), with 40% of patients experiencing complete regression. %EWL was significantly associated with HA size reduction (Kendall's Tau-b: 0.5528; p = 0.047). Marginal effects following fractional probit regression analysis showed that each additional percentage increase in %EWL was associated with 0.76% HA size reduction (95% CI: -1.18, -0.34; p < 0.001).

Conclusions: In this combined case series and systematic review of the literature, bariatric surgery was associated with high rates of HA regression. Given the additional benefits of weight loss from bariatric surgery and the significant morbidity associated with liver resection, bariatric surgery could be considered as an initial management option for obese patients with HA.

Background: The role of antibiotics in the preoperative and perioperative management of patients with benign biliary pathology is still not clear. This study aims to develop a predictive model for identifying patients with benign biliary disease who are at low risk of positive bile cultures, optimizing antibiotic administration.

Methods: Prospective cohort study conducted between April and October 2024 in a single center from a hospital network with two locations. Consecutive adult patients (aged ≥ 18 years) diagnosed with benign biliary disease who underwent cholecystectomy with intraoperative bile culture sampling. The primary validation outcome was positive bile cultures; predictors included demographic, clinical, and paraclinical variables.

Results: Overall, 703 patients were included in the study. The incidence of positive cultures was 32.1%. The rate of major complications (Clavien-Dindo ≥ 3), comorbidities, age, and higher cholecystitis severity was significantly higher in patients with positive bile cultures. The multivariable prediction model for positive cultures included age, ERCP, and time from admission to procedure, showing fair discrimination (c-statistic 0.75, 95% CI 0.70-0.80) with no evidence of poor calibration. Patients classified as low risk for positive bile cultures had a sensitivity of 92% and a negative likelihood ratio of 0.21, indicating that classification in the low-risk group effectively rules out the possibility of a positive bile culture.

Conclusion: This study found our predictive model useful in assessing bile culture positivity during cholecystectomy to rule out the need for antibiotic initiation in low-risk patients, both preoperatively while awaiting surgery (in cases of acute cholecystitis) and perioperatively (prophylaxis).

Purpose: This study aimed to compare perioperative and long-term outcomes between laparoscopic (LLR) and open liver resection (OLR) in elderly patients with solitary hepatocellular carcinoma (HCC).

Methods: The study consecutively included patients aged ≥ 70 years who underwent curative liver resection for single HCC at four tertiary centers between January 2015 and December 2021. Perioperative short-term and long-term survival outcomes were compared between the LLR and OLR groups. Propensity score matching (PSM) was performed in a 1:1 ratio to balance baseline characteristics between the two groups. Univariate and multivariate Cox regression analyses were conducted to identify independent risk factors associated with overall survival (OS) and recurrence-free survival (RFS).

Results: Of the 180 patients, 94 and 86 were included in the LLR and OLR groups, respectively. After PSM, 65 patients were included in each group. Intraoperative blood loss (p = 0.010), operative time (p = 0.021), length of hospital stay (p = 0.021) and 90-day readmission rate (p = 0.048) were significantly lower in the matched LLR than the matched OLR group. Moreover, postoperative ascites complication was less frequent in the matched LLR group (p = 0.046). Long-term survival outcomes were better in the LLR group compared with the OLR group both before and after PSM (for OS: p = 0.019 and 0.003; for RFS: p = 0.023 and 0.012). Multivariate Cox regression analysis found that open hepatectomy was an independent risk factor of OS and RFS for elderly HCC patients compared to laparoscopic approach.

Conclusion: For selected elderly patients with solitary HCC, particularly those with tumors in locations amenable to a minimally invasive approach, LLR was associated with superior perioperative and long-term survival outcomes compared to OLR.

Clinical trials registration: Not applicable because this is a retrospective observational study.

Background: Many studies demonstrated the feasibility of laparoscopic liver resection (LLR). However, its short-term outcomes for liver malignancies located in involving Couinaud's segment 7 have not been appraised compared to open liver resection (OLR). In addition, the impact of the LLR learning curve on surgical outcomes at these sites remains unclear.

Methods: This single-institution, retrospective study included 216 patients who underwent liver resection for malignancies involving segment 7 between 2010 and 2024. Propensity score matching balanced LLR (n = 65) and OLR (n = 65) cohorts. Surgical outcomes were compared and the LLR learning curve for conversions was plotted via risk-adjusted cumulative sum (RA-CUSUM) analysis.

Results: LLR showed shorter postoperative hospital stays and a trend towards less blood loss. Despite longer operative times, LLR had lower postoperative white blood cell counts and similar alanine aminotransferase levels. There were no significant differences between the groups in the overall or severe complications. Moreover, RA-CUSUM analysis showed that after the surgeon completed around 30 patients, the conversion rate stabilized and improved, leading to enhanced safety.

Conclusions: LLR could act as a safe alternative to OLR in patients harboring malignancies involving segment 7, with accumulated experience contributing to improved outcomes.

Background: To optimize surgical procedures and prevent retained surgical instruments, precise identification of required instruments during surgical treatment is essential. However, establishing ground truth data can be a labor-intensive barrier for researchers. Therefore, we developed and evaluated a novel system for detecting laparoscopic surgical instruments during laparoscopic cholecystectomy through virtual image creation.

Methods: Virtual images were created by synthesizing laparoscopic instrument photos with surgical video backgrounds. The 311 instrument images and 1610 background images from 52 patients were augmented through random brightness, contrast, crop, rotation, scaling, flipping, and perspective transformations, resulting in 6023 composite images. These data were split into training, tuning, and internal test sets. Based on synthetic data, we developed a system comprising two-step processes. The first model is a unified instrument localization model that detects surgical instruments, and the second model is an instrument-type classification model that categorizes the detected surgical instruments. External and public datasets were used to evaluate generalizability.

Results: The unified instrument localization model achieved average precision (AP) values with intersection over union (IoU) of 0.5 of 0.981, 0.882, and 0.689 for internal, external, and public datasets, respectively. The instrument-type classification model demonstrated area under the curve (AUC) values of 0.959 for seven instrument types in the external dataset and 0.749 for four instrument types in the public dataset. The final two-step instrument detection model demonstrated an AUC of 0.848 for the external dataset and 0.688 for the public dataset, which showed significantly superior performance compared to conventional multi-class instrument models.

Conclusions: This validated deep learning model using synthetically generated data provides a reliable framework for surgical instrument detection. Our approach demonstrates strong performance and generalizability, suggesting its potential for improving operative workflow efficiency and surgical education across various minimally invasive procedures.

Background & aims: Cirrhosis with unexplained upper gastrointestinal bleeding (CUUGB) remains a persistent diagnostic and therapeutic challenge in the management of patients with cirrhosis. It is worth investigating whether EUS-guided cyanoacrylate injection (EUS-CYA) provides greater efficacy in the diagnosis and treatment of CUUGB compared to cyanoacrylate injection under direct endoscopy (DEI-CYA).

Methods: This study enrolled 116 patients with CUUGB and employed a single-blind, prospective, parallel-group randomized design to assign participants into two arms: the DEI-CYA group (n = 58) and the EUS-CYA group (n = 58). Both groups of patients were followed up at 1, 3, and 6 months postoperatively. In cases of rebleeding during this period, endoscopy was promptly repeated. The primary outcome was the comparison of rebleeding rates between the two groups of patients with CUUGB. Secondary outcomes included technical success rate, rate of vascular obliteration, Occurrence of complications during follow-up, and liver function status.

Results: Among the 116 enrolled patients, direct endoscopy revealed 47 cases (40.51%) with gastric fundal red-color signs (RCS) and 27 cases (23.30%) with punctate erosions. Post-treatment, the EUS-CYA group demonstrated a significantly higher GV obliteration rate (82.76% vs. 65.52%, p = 0.035) and a lower long-term rebleeding rate (22.41% vs. 60.34%, p < 0.01) compared to the DEI-CYA group. The cumulative incidence of rebleeding was lower in the EUS-CYA group (p = 0.003). Liver function improved following EUS-CYA, with significant increases in albumin (p = 0.038) and prothrombin time (PT, p = 0.009), whereas DEI-CYA improved only PT (p = 0.002). Multivariate analysis identified diabetes mellitus as an independent predictor of rebleeding (OR = 0.19; 95% CI: 0.06-0.65; p = 0.008). Notably, DEI-CYA was associated with significantly higher odds of rebleeding compared to EUS-CYA (OR = 0.23; 95% CI: 0.10-0.56; p = 0.001).

Conclusions: Compared with DEI-CYA, EUS-CYA demonstrates a significantly higher detection rate of bleeding etiology, superior vascular obliteration rates, and a lower incidence of rebleeding in patients with CUUGB. Chinese Clinical Trial Registry (ChiCTR) website ( https://www.chictr.org.cn/ ), Number ChiCTR2200058888.

Background: Indocyanine green (ICG) fluorescence imaging-guided laparoscopic lymphadenectomy has been proven to be safe and effective, not only in improving the number of lymph nodes (LNs) but also in prolonging survival in patients with gastric cancer (GC) compared with conventional laparoscopic lymphadenectomy. However, a cost‑effectiveness analysis of this technology has been lacking. This study aims to evaluate the cost-effectiveness of ICG fluorescence imaging-guided laparoscopic lymphadenectomy in GC patients.

Methods: Based on FUGES-012 trial, we developed a two-step decision analytic model, including a decision tree model and a partitioned survival model (PSM) with a cycle of 1 month and a 20-year time horizon, to evaluate the cost-effectiveness of ICG fluorescence imaging-guided laparoscopic lymphadenectomy from the perspective of China healthcare system. The primary outcomes included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). The economic feasibility of the intervention was determined by comparing the ICER against a willingness-to-pay (WTP) threshold set at 3 times China's 2024 per capita GDP. To assess the robustness of the model results, we conducted one-way deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA). A survival benefit threshold analysis was performed to address the uncertainty in the survival benefit.

Results: In the base-case analysis, ICG fluorescence imaging-guided laparoscopic lymphadenectomy yielded an ICER of $ 886.30 per additional QALY gained, below the WTP threshold. The DSA reveals that the ICER is most sensitive to discount, cost of progressive disease (PD), additional cost of fluorescence imaging, and utility of progression-free survival (PFS). The PSA demonstrates that ICG fluorescence imaging-guided laparoscopic lymphadenectomy has a probability of 99.30% being cost-effective at WTP. The threshold analysis demonstrated that the cost-effectiveness conclusion is robust to uncertainty in the survival benefit estimate.

Conclusions: Compared to conventional laparoscopic lymphadenectomy, ICG fluorescence imaging-guided laparoscopic lymphadenectomy for GC appears to be a cost-effective option in China.

Background: Single Anastomosis Sleeve Ileal (SASI) bypass combines sleeve gastrectomy with a single anastomosis to the ileum, preserving digestive continuity to reduce deficiencies while treating obesity-related conditions.

Methods: This study systematically reviewed SASI bypass outcomes and conducted a single-arm meta-analysis to assess its efficacy and safety. A comprehensive literature search across PubMed, Scopus, Embase, and Cochrane databases initially identified 387 articles, with 38 studies meeting inclusion criteria, contributing data on a maximum of 2,555 patients. Follow-up ranged from 6 to 60 months.

Results: Meta-analysis showed significant weight loss, with pooled Excess Weight Loss Percentage (EWL%) of 63.07% at 6 months, 82.44% at 12 months, and 93.21% at 24 months. The procedure demonstrated high remission rates for obesity-related conditions, including diabetes (92.67%), hypertension (79.06%), dyslipidemia (82.64%), gastroesophageal reflux disease (GERD) (81.63%), and obstructive sleep apnea (OSA) (81.04%). Postoperative complications were classified using the Clavien-Dindo grading system, with an overall mean complication rate of 13.70%. Mild complications (Grades I-II) accounted for 7.74%, while severe complications (Grades III-IV) had a mean rate of 5.18%. No deaths were reported.

Conclusions: These findings suggest SASI bypass is a highly effective metabolic and bariatric procedure, achieving substantial weight loss and high remission rates for multiple obesity-related conditions. Given its efficacy, SASI may benefit patients with higher body mass index (BMI) and multiple obesity-associated medical conditions. While most complications are mild and severe ones infrequent, further comparative studies are needed to establish its advantages over other bariatric techniques.

Background: Current Artificial Intelligence (AI) models for detecting gastric Helicobacter pylori (HP) infection rely on single-images, lacking integration of multi-regional stomach data. We developed a multi-region, multi-image Convolutional Neural Network (CNN) model to enhance diagnostic accuracy.

Methods: From Nanfang Hospital of Southern Medical University, 5,169 cases (104,437 images) were split into training (80%) and test (20%) sets. The models-single-image CNN and our multi-region CNN-were trained and tested for HP infection diagnosis. External validation used 696 cases (20,948 images) from three non-training hospitals (Baiyun Branch of Nanfang Hospital of Southern Medical University, Shunde Hospital of Southern Medical University, Shenzhen Second People's Hospital).

Results: (1) Validation results of multi-region and multi-image CNN model and single-image CNN model on the test set of Nanfang Hospital of Southern Medical University are given as follows: The accuracies are 95.1% vs. 93.3%, P < 0.05. The sensitivities are 96.5% vs. 94.4%, P < 0.05. The specificities are 93.4% vs. 92.2%, P > 0.05. The AUC are 99.0% vs. 98.1%. (2) The validation results of the multi-region multi-image CNN model and the single-image CNN model in the data set of non-training data source hospitals (Baiyun Branch of Nanfang Hospital of Southern Medical University, Shunde Hospital of Southern Medical University and Shenzhen Second People's Hospital) are given as follows. The accuracies are 89.7% vs. 77.6%, P < 0.01. The sensitivities are 90.2% vs. 82.4%, P < 0.01. The specificities are 89.1% vs. 72.9%, P < 0.01. The AUC are 92.5% vs. 82.4%.

Conclusion: The multi-region, multi-image CNN significantly improves AI's accuracy, sensitivity, specificity, and generalizability in diagnosing gastric HP infection.