Laparoscopic Endoscopic and Robotic Surgery最新文献

Surgery for lesions of the proximal part of the pancreatic body or neck can be challenging, and when enucleation is not possible, central pancreatectomy is an option. Laparoscopic central pancreatic resection is rarely described worldwide; it is considered a difficult procedure mainly because of the risk of double pancreatic fistula developing at two sites of resection. However, it seems to be an excellent alternative to distal pancreatectomy or pancreaticoduodenectomy, with the advantages of preserving functioning parenchyma and reducing endocrine and exocrine failure. Nevertheless, patients with pancreatic lesions requiring central resection are often managed with the open approach in many hospitals due to the complexity of total laparoscopic central pancreatectomy, which requires advanced laparoscopic skills, expertise and experience. Here, we report a case of a 29-year-old female who underwent total laparoscopic central pancreatic resection with gastro-pancreatic anastomosis for symptomatic serous cystadenoma. We discuss the details of case management and review the relevant literature.

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

Laparoscopic cholecystectomy is currently the gold standard for treating symptomatic gallstone disease. Despite its success, approximately 10% of patients may experience persistent biliary symptoms, leading to the post-cholecystectomy syndrome. A remnant gallbladder with cystic duct or bile duct stones is one of the causes of this syndrome. The objective of this study was to shed light on the clinical manifestations, evaluation, therapeutic strategies, and outcomes associated with laparoscopic management of symptomatic remnant gallbladders.

Methods

This was a retrospective study, conducted over a five-year period (January 2017 to December 2022) at Apollo Hospitals in South India. All patients who underwent laparoscopic completion cholecystectomy for a remnant gall bladder were included. The following data were collected: patient demographics, symptoms, preoperative investigations, intraoperative details and post operative outcomes.

Results

In total, 36 patients were included and analysed. The majority of patients were male (25, 69.4%), with a mean age of 50.7 ± 12.1 years. The most common presentation was pain in the upper abdomen or right upper quadrant region (24, 66.7%). The laparoscopic approach was attempted in all patients, with a success rate of 94.4%. Two patients required conversion to open surgery. Cholecystoenteric fistula to the colon was observed in one patient. Choledocholithiasis was observed in 7 patients (19.4%), and stone clearance was successfully achieved using endoscopic retrograde cholangiopancreatography in all patients preoperatively.

Conclusion

Incomplete gall bladder removal either intentionally or unintentionally leaves a remnant gall bladder that is at risk for stone formation and infection. Patients who have this clinical entity with symptoms require a redo or complete cholecystectomy, a complex procedure associated with certain risks. This study highlights the feasibility and safety of laparoscopic completion cholecystectomy for the management of remnant gallbladder with cystic duct or bile duct stones.

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.

Objectives

Anastomotic leakage (AL) stands out as a prevalent and severe complication following gastric cancer surgery. It frequently precipitates additional serious complications, significantly influencing the overall survival time of patients. This study aims to enhance the risk-assessment strategy for AL following gastrectomy for gastric cancer.

Methods

This study included a derivation cohort and validation cohort. The derivation cohort included patients who underwent radical gastrectomy at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, from January 1, 2015 to December 31, 2020. An evidence-based predictor questionnaire was crafted through extensive literature review and panel discussions. Based on the questionnaire, inpatient data were collected to form a model-derivation cohort. This cohort underwent both univariate and multivariate analyses to identify factors associated with AL events, and a logistic regression model with stepwise regression was developed. A 5-fold cross-validation ensured model reliability. The validation cohort included patients from August 1, 2021 to December 31, 2021 at the same hospital. Using the same imputation method, we organized the validation-queue data. We then employed the risk-prediction model constructed in the earlier phase of the study to predict the risk of AL in the subjects included in the validation queue. We compared the predictions with the actual occurrence, and evaluated the external validation performance of the model using model-evaluation indicators such as the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration curve.

Results

The derivation cohort included 1377 patients, and the validation cohort included 131 patients. The independent predictors of AL after radical gastrectomy included age ≥65 y, preoperative albumin <35 g/L, resection extent, operative time ≥240 min, and intraoperative blood loss ≥90 mL. The predictive model exhibited a solid AUROC of 0.750 (95% CI: 0.694–0.806; p < 0.001) with a Brier score of 0.049. The 5-fold cross-validation confirmed these findings with a calibrated C-index of 0.749 and an average Brier score of 0.052. External validation showed an AUROC of 0.723 (95% CI: 0.564–0.882; p = 0.006) and a Brier score of 0.055, confirming reliability in different clinical settings.

Conclusions

We successfully developed a risk-prediction model for AL following radical gastrectomy. This tool will aid healthcare professionals in anticipating AL, potentially reducing unnecessary interventions.