Laparoscopic Endoscopic and Robotic Surgery最新文献

Objective

The role of selective decontamination with oral antibiotics (OABs) and mechanical bowel preparation (MBP) prior to elective colorectal surgery is still widely debated. The objective of this study was to compare the outcomes of selective decontamination with neomycin, metronidazole and MBP compared to those of decontamination with MBP alone or with no preparation.

Methods

Selective decontamination with neomycin and metronidazole combined with bowel preparation was introduced prior to elective colorectal surgery as part of an enhanced recovery after surgery program at Westmead Hospital, a major Australian tertiary referral hospital, between June 2017 and January 2023. Comparisons between short-term outcomes of OAB + MBP and MBP/no preparation were made using prospectively collected data on length of stay (LOS), readmission, mortality within 30 days, anastomotic leakage (AL), surgical site infection (SSI), urinary tract infection, deep venous thrombosis and/or pulmonary embolism, pneumonia, and ileus. Follow-up was limited to hospital stays and subsequent presentations within the health district within thirty days of surgery. The Mann–Whitney U test was used to analyse continuous data, and the chi-square test was used for categorical data. Univariate and multivariate regression modelling was performed to identify risk factors associated with an increased likelihood of SSI and AL.

Results

Patients with oral neomycin and metronidazole combined with bowel preparation had reduced superficial SSI (2.7% vs. 7.6%, p = 0.043) and overall complications (32.7% vs. 44.6%, p = 0.020), particularly Clavien–Dindo 1 complications (7.3% vs. 16.5%, p = 0.009). However, the differences in AL (2.7% vs. 4.5%, p = 0.369) and organ/space SSI (1.3% vs. 3.7%, p = 0.327) were not statistically significant. The median LOS (6 d vs. 6 d, p = 0.370) was not different between the groups.

Conclusion

Selective decontamination with neomycin and metronidazole reduces the risk of SSIs and overall complications. There was a trend to toward a lower AL, but this difference was not statistically significant.

Objective

Esophageal and gastric lesions are effectively managed with minimally invasive upper endoscopic procedures such as endoscopic mucosa resection (EMR) and endoscopic submucosal dissection (ESD), offering patients alternatives to invasive interventions. While ESD is well established in Eastern Asia, its adoption in Denmark for superficial esophageal cancer is recent. This study presents real-world data on the feasibility, safety, and hospitalization duration associated with ESD and EMR for esophageal and gastric lesions.

Methods

A retrospective analysis was conducted on patients who underwent ESD or EMR at a specialized center in Denmark from October 2016 to June 2022. Data on treatment, indication, lesion location, hospitalization duration, procedure duration, specimen size, complications, recurrence, and one-year overall survival were collected. Statistical comparisons utilized the Mann–Whitney U test, independent sample median test, and chi-squared test.

Results

The study included 130 patients (144 procedures): 72 underwent ESD and 58 underwent EMR. Compared with EMR, ESD resulted in greater percentages of en bloc and R0 resections (98.8% vs. 64.1%, p < 0.001; and 83.9% vs. 23.8%, p < 0.001), greater complication rates (28.7% vs. 3.1%, p < 0.001) and longer procedure times (119.5 min vs. 37.0 min, p < 0.001). The ESD procedure time significantly decreased over time (p = 0.01). The local recurrence rates were 14.5% for ESD and 23.8% for EMR (p = 0.767). The one-year overall survival rates were similar between the groups (95.8% vs. 94.8%, p = 0.553).

Conclusion

Both ESD and EMR are safe and viable for treating esophageal and gastric lesions. ESD offers advantages but requires more time and skill. These findings support the literature, emphasizing the importance of considering patient-specific factors and surgeon proficiency in selecting the appropriate procedure.

Objective

Robotic-assisted surgery (RAS) is continuing to expand in use in surgical specialties, including foregut surgery. The available data on its use in large hiatal hernia (HH) repair are limited and conflicting. This study sought to determine whether there are significant differences in adverse outcomes following HH repair performed with a robotic approach vs. a laparoscopic approach. This study was limited to outcomes in patients with type II, III, and IV HHs, as these hernias are typically more challenging to repair.

Methods

A retrospective analysis was performed from data obtained from TriNetX, a large deidentified clinical database, over a 10-year period. Adult patients who underwent type II, III, or IV HH repair were included in the study. HH with robotic repair was compared to laparoscopic repair. Cohorts were propensity score matched for demographic information and comorbidities. Risk ratios, risk differences (RDs) with 95% confidence intervals (CIs), and t test for each examined adverse outcome were used to estimate the effects of robotic repair vs. laparoscopic repair.

Results

In total, 20,016 patients who met the inclusion criteria were identified; 1,515 patients utilized RAS, and 18,501 used laparoscopy. Prior to matching, there were significant differences in age, sex, comorbidity, and BMI between the two cohorts. After 1:1 propensity score matching, analyses of 1,514 well-matched patient pairs revealed no significant differences in demographics or comorbidities. Patients who underwent robotic repair were more likely to experience major complications, including venous thromboembolism (RD: 0.007, 95% CI: 0.003, 0.011; p = 0.002), critical care (RD: 0.023, 95% CI: 0.007, 0.039; p = 0.004), urinary/renal complications (RD: 0.027, 95% CI: 0.014, 0.041; p < 0.001), and respiratory complications (RD: 0.046, 95% CI: 0.028, 0.064; p < 0.001). RAS was associated with a significantly shorter length of stay (32.4 ± 27.5 h vs. 35.7 ± 50.1 h, p = 0.031), although this finding indicated a reduction in the length of stay of less than 4 hours. No statistically significant differences in risk of esophageal perforation, infection, postprocedural shock, bleeding, mortality, additional emergency room visits, cardiac complications, or wound disruption were found.

Conclusions

Patients who undergo robotic-assisted large HH repair are at increased risk of venous thromboembolism, need critical care, urinary or renal complications and respiratory complications. Due to variations in RAS technique, experience, and surgical volumes, further study of this surgical approach and complication rates is warranted.

Robotic surgery systems, as emerging minimally invasive approaches, have been increasingly applied for the treatment of esophageal cancer because they provide a high-definition three-dimensional surgical view and mechanical rotating arms that surpass the limitations of human hands, greatly enhancing the accuracy and flexibility of surgical methods. Robot-assisted McKeown esophagectomy (RAME), a common type of robotic esophagectomy, has been gradually implemented with the aim of reducing postoperative complications, improving postoperative recovery and achieving better long-term survival. Multiple centers worldwide have reported and summarized their experiences with the RAME, and some have also discussed and analyzed its perioperative effects and survival prognosis compared with those of video-assisted minimally invasive esophagectomy. Compared to traditional surgery, the RAME has significant advantages in terms of lymph node dissection although there seems to be no difference in overall survival or disease-free survival. With the continuous advancement of technology and the development of robotic technology, further development and innovation are expected in the RAME field. This review elaborates on the prospects of the application and advancement of the RAME to provide a useful reference for clinical practice.

Objective

Some patients exhibit septic symptoms following laparoscopic surgery, leading to a poor prognosis. Effective clinical subphenotyping is critical for guiding tailored therapeutic strategies in these cases. By identifying predisposing factors for postoperative sepsis, clinicians can implement targeted interventions, potentially improving outcomes. This study outlines a workflow for the subphenotype methodology in the context of laparoscopic surgery, along with its practical application.

Methods

This study utilized data routinely available in clinical case systems, enhancing the applicability of our findings. The data included vital signs, such as respiratory rate, and laboratory measures, such as blood sodium levels. The process of categorizing clinical routine data involved technical complexities. A correlation heatmap was used to visually depict the relationships between variables. Ordering points were used to identify the clustering structure and combined with Consensus K clustering methods to determine the optimal categorization.

Results

Our study highlighted the intricacies of identifying clinical subphenotypes following laparoscopic surgery, and could thus serve as a valuable resource for clinicians and researchers seeking to explore disease heterogeneity in clinical settings. By simplifying complex methodologies, we aimed to bridge the gap between technical expertise and clinical application, fostering an environment where professional medical knowledge is effectively utilized in subphenotyping research.

Conclusion

This tutorial could primarily serve as a guide for beginners. A variety of clustering approaches were explored, and each step in the process contributed to a comprehensive understanding of clinical subphenotypes.

Objective

Some studies have found that cholecystectomy may increase the risk of colorectal cancer (CRC), while others have reached inconsistent conclusions. We thus performed a systematic review and meta-analysis to assess the incidence rate of CRC after cholecystectomy for patients with gallstones or gallbladder diseases, and whether the geographical location of the patients affected the results.

Methods

We systematically searched PubMed, Embase, and Cochrane for studies reporting changes in the incidence rate of CRC after cholecystectomy published before January 12, 2023. Our main endpoint was the occurrence of CRC. Data were extracted and pooled, and the relative risk (RR) and 95% confidence interval (CI) were calculated. We assessed pooled data using a random-effects model.

Results

In total, 477 articles were identified, and 6 articles were eligible, including 7 studies that included 797,917 participants. Overall, the summarized research results showed that the risk of CRC was reduced in patients with gallbladder diseases who underwent cholecystectomy (RR: 0.80, 95% CI: 0.65 to 0.99, p = 0.040; I² = 85.0%). In the subgroup analysis based on different geographical locations, cholecystectomy was not associated with the risk of CRC in the Western population (RR: 0.90, 95% CI: 0.65 to 1.25, p = 0.522; I² = 86.5%), but there was a negative correlation between cholecystectomy and the risk of CRC (RR: 0.66, 95% CI: 0.60 to 0.73, p = 0.000) in the Chinese population.

Conclusions

Our findings support that for patients with gallstones or gallbladder diseases, the incidence of CRC after cholecystectomy is lower than that of patients who do not undergo cholecystectomy.

Objective

Single-incision laparoscopic surgery has emerged as a safe and less invasive approach to conventional multi-port laparoscopy. The present meta-analysis aimed to assess the collective outcomes of single-incision laparoscopic gastrectomy (SILG) compared to multi-port laparoscopic gastrectomy (MLG) for gastric cancer.

Methods

A PRISMA-compliant systematic review of randomized controlled trials (RCTs) that compared SILG and MLG for gastric cancer in PubMed and Scopus through January 2023 was conducted. The main outcomes of the review were complications, postoperative pain, conversion to open surgery, hospital stay, and recovery.

Results

Three RCTs including 301 patients (61.8% male) were included. A total of 151 patients underwent SILG, and 150 underwent MLG. SILG was associated with a shorter operative time (WMD = −16.39, 95% CI: −27.38 to −5.40, p = 0.003; I² = 0%) and lower pain scores at postoperative day 3 (WMD = −1.18, 95% CI: −2.27 to −0.091, p = 0.033; I² = 99%) than MLG. There were no statistically significant differences between the two groups in estimated blood loss (WMD = –16.95, 95% CI: −35.84 to 1.95, p = 0.078; I² = 82%), complications (OR = 0.71, 95% CI: 0.36 to 1.42, p = 0.337; I² = 0%), conversion to open surgery (OR = 0.33, 95% CI: 0.01 to 8.38, p = 0.504), hospital stay (WMD = 0.72, 95% CI: −0.92 to 2.36, p = 0.056; I² = 84%), time to first flatus (WMD = 0.06, 95% CI: −0.14 to 0.26, p = 0.566; I² = 0%), time to first defecation (WMD = −0.14, 95% CI: −0.46 to 0.18, p = 0.392; I² = 0%), or time to first oral intake (WMD = 0.37, 95% CI: −0.75 to 1.49, p = 0.520; I² = 94%).

Conclusions

SILG is associated with shorter operative times and less early postoperative pain than MLG. The odds of complications, blood loss, hospital stay, and gastrointestinal recovery were similar between the two procedures.

Objective

Robotic-assisted spine surgeries (RASS) have been shown to enhance precision, reduce operative time, prevent complications, facilitate minimally invasive spinal surgery, and decrease revision surgery rates, leading to improved patient outcomes. This study aimed to compare the cost-effectiveness of RASS and non-robotic-assisted surgery for degenerative spine disease at a single center.

Methods

This retrospective study, including 122 patients, was conducted at a single center from March 2015 to February 2022. Patients who underwent robot-assisted surgery were assigned to the robot group, and patients who underwent non-robotic-assisted surgery were assigned to the non-robot group. Various data, including demographic information, surgical details, outcomes, and cost-effectiveness, were collected for both groups. The cost-effectiveness was determined using the incremental cost-effectiveness ratio (ICER), and subgroup analysis was conducted for patients with 1 or 2 levels of spinal instrumentation. The analysis was performed using STATA SE version 15 and TreeAge Pro 2020, with Monte Carlo simulations for the cost-effectiveness acceptability curve.

Results

The overall ICER was $22,572, but it decreased to $16,980 when considering cases with only 1 or 2 levels of instrumentation. RASS is deemed cost-effective when the willingness to pay is $3000–$4000 if less than 2 levels of the spine are instrumented.

Conclusions

The cost-effectiveness of robotic assistance becomes apparent when there is a reduced need for open surgeries, leading to decreased revision rates caused by complications such as misplaced screws or infections. Therefore, it is advisable to allocate healthcare budget resources to spine robots, as RASS proves to be cost-effective, particularly when only two or fewer spinal levels require instrumentation.