Journal of Laparoendoscopic & Advanced Surgical Techniques最新文献

Purpose: There has been a longstanding debate regarding whether lower pole renal crossing vessels on the pelvi-ureteric junction preclude the need for a dismembered pyeloplasty. A retroperitoneoscopic technique for a transposition of these vessels has not yet been described in the literature. We report our early experience of the retroperitoneoscopic vascular hitch procedure for transposition of lower pole renal crossing vessels, including technique and outcomes. Methods: Single-center retrospective review of all children who had a retroperitoneoscopic vascular hitch procedure for pelvi-ureteric junction obstruction from March 2022 to April 2024. Data on symptom resolution, change in sonographic anterior-posterior diameter (APD), MAG-3 (mercaptoacetyltriglycine) renogram curves, postoperative length of stay, complications, and further surgical interventions were collected. Results are reported as median and interquartile range. Results: Ten patients (70% male, median age 11.7 years, range 8-13 years) with preoperative APD of 34 mm (23-40) over the 2-year period were included. One patient received an on-table diuretic stress test. Seven out of 10 patients had day-case surgery, and 3 patients had an overnight stay. The follow-up period was 343 days (122-456). Postoperative APD was 13 mm (6-23), and the change in APD was -18 mm (-25 to -10). No loss of function or uptake areas on MAG-3 scans were observed. Two patients received antibiotics for a presumed urinary tract infection in the postoperative period. Symptom resolution was achieved in 90% of patients, and 1 patient underwent robotic-assisted dismembered pyeloplasty 10 months later. Conclusion: Retroperitoneoscopic vascular hitch for lower pole renal crossing vessels is an acceptable alternative to dismembered pyeloplasty in selected pediatric cases.

Background: Early rectal tumors can be effectively managed using transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD). This study aimed to compare ESD and TEM in the resection of early rectal tumors concerning en bloc resection rates, R0 resection rates, mean procedural times, perforation rates, bleeding rates, adverse events/complication rates, and mean length of stay (LOS). Methods: We conducted a systematic literature review in accordance with PRISMA guidelines to identify studies directly comparing ESD and TEM for the resection of early rectal tumors. A pairwise meta-analysis was performed using a random-effects model, reporting odds ratios and mean differences. Results: The R0 resection rate was lower in the ESD group. Subgroup analysis indicated that the reduced R0 resection rate in ESD remained significant in the subepithelial subgroup but not in the epithelial subgroup, with the subgroup difference reaching statistical significance (P = .05) but didn't meet conventional statistical significance (P < .05). The number needed to treat with ESD to result in one additional missed R0 resection (harmful event) compared to TEM was 10 (95% CI 4-162). The ESD group demonstrated significantly shorter mean procedural times and LOS, with no significant subgroup differences between epithelial and subepithelial tumors. Conclusions: This study suggests that ESD is associated with a lower R0 resection rate compared to TEM, but offers a shorter mean LOS and procedural time. To date, no randomized controlled trials (RCTs) have been published. Large-scale RCTs that also involve operators who have achieved technical mastery in ESD and TEM are necessary to reach more definitive conclusions. Until such RCTs are published, strong recommendations cannot be made. Additionally, further studies are required to assess whether tumor origin (epithelial versus subepithelial) impacts the R0 resection rate in ESD.

Purpose: In refractory Crohn's disease, the terminal ileum is a common site requiring excision. Laparoscopic ileocecectomy is the procedure of choice and we use a single-incision laparoscopic technique (SILS). We have previously reported our experience with SILS ileocecectomy with a sizeable cohort compared to other series. This project aims to expand on our single-institutional experience and evaluate the impact of operative experience. Methods: We completed a single-institution retrospective review of patients who underwent SILS ileocecectomy for Crohn's disease from January 1, 2009 to March 31, 2024. Operative and inpatient characteristics were collected to determine complication rates. Subgroup analysis was completed comparing previously studied patients (January 1, 2009 to February 1, 2013) to our updated cohort. Results: Seventy-eight patients underwent SILS ileocecectomy for Crohn's disease and had a median age of 16.5 years (interquartile range: 15.0, 17.8). The median length of stay (LOS) was 96 hours (72, 186). The overall complication rate was 17%. On subgroup analysis, patients operated on after 2013 were older (P = .012), had a longer disease length before operating room (OR) (P = .051) and were more likely to be on anti-tumor necrosis factor therapy (P = .014). Mean operative time was significantly lower in the newer cohort (70 mins versus 85 mins, P = .007). The patients in the newer cohort had a shorter median LOS (72 hours compared to 108 hours, P = .149) and had a lower complication (13% versus 23%, P = .283) and re-operation rate (4% versus 15%, P = .159). Conclusions: SILS ileocecectomy is effective and safe in pediatric patients with Crohn's disease. As operative experience increases, we have observed a clinically significant decrease in operative time and complication rates. Level of Evidence: III, Retrospective study.

Background: Robotic-assisted proctectomy (RAP) has been reportedly associated with lower rates of conversion to laparotomy than laparoscopy in several cohort studies. This st0udy aimed to assess the temporal trends in conversion from RAP to laparotomy stratified by patient and treatment-related factors. Methods: This retrospective observational study was undertaken to analyse the temporal trends in unplanned conversion from RAP to laparotomy. Changes in the rates of conversion over time were plotted as line graphs, and the significance of each trend was calculated with the Cochran-Armitage trend test. A case-control analysis of factors associated with conversion to open surgery was conducted. Results: The study included 23,644 patients (62.3% male, median age: 60 years). 1280 (5.4%) patients were converted to laparotomy. There was a significant linear trend of decreased conversion over time (3.9% in 2021 compared with 10.4% in 2010; P < .001). The reduction in conversion rates was significant in all patients except in patients <50 years (P = .838), Black patients (P = .358), patients with a Charlson comorbidity index score >1 (P = .053), patients with governmental insurance other than Medicaid and Medicare (P = .629), and patients undergoing abdominoperineal resection (APR) (P = .129) or pelvic exenteration (PE) (P = .326). The independent predictors for increased conversion were male sex, higher Charlson scores, community cancer programs, comprehensive community cancer programs, household income of <$63,000, tumors ≥5 cm, and PE. Conclusions: Unplanned conversion from RAP to laparotomy showed a linear trend of reduction over time, which was statistically significant except in young patients, Black patients, patients with significant comorbidities, and patients undergoing APR or PE.

Background: Appendiceal stump closure is critical in laparoscopic appendectomy (LA) to prevent complications such as stump leakage and intra-abdominal abscess formation. This study aims to evaluate the safety and effectiveness of LigaSure™ versus Endoloop for appendiceal stump closure in pediatric LA. Methods: This prospective multicenter comparative study included 199 pediatric patients who underwent LA between May 2021 and October 2023 at two pediatric surgery clinics. Patients were allocated to the LigaSure group (n = 74) or Endoloop group (n = 125) based on the surgeon's intraoperative preference. Data collected included demographic characteristics, laboratory and radiological findings, intraoperative details, postoperative complications, and histopathological measurements of appendiceal and lumen diameters. Statistical analyses were performed using the independent samples t-test and chi-square test, with significance at P < .05. Results: No significant differences were observed between groups regarding age (P = .670), gender (P = .439), leukocyte count (P = .072), or C-reactive protein levels (P = .368). Complicated appendicitis was more prevalent in the LigaSure group (12.2%) compared to the Endoloop group (5.6%). No intra-abdominal abscesses or stump leakage were reported in either group. Histopathological analysis revealed no significant difference in mean appendiceal diameter (LigaSure: 8.9 ± 0.2 mm; Endoloop: 8.9 ± 0.1 mm; P = .743) or lumen diameter (P = .096). The largest lumen diameter measured in appendix specimens was 5113 μm, while the smallest was 255.6 μm (P = .096). No cases of intra-abdominal abscess or stump leakage were reported. The mean hospital stay was comparable (LigaSure: 2 ± 0.2 days; Endoloop: 2 ± 0.1 days; P = .068). Conclusion: LigaSure™ is a safe and effective alternative to Endoloop for appendiceal stump closure in pediatric LA. The device's ability to provide a secure seal makes it a reliable option, even in cases of complicated appendicitis.

Background: Various methods for gastrostomy tube (GT) placement have been described, including open, endoscopic, and laparoscopic. We present the results of the basic laparoscopic Stamm gastrostomy (LSG) method that we recently described. Methods: Data of patients who underwent gastrostomy with the LSG method between 2016 and 2024 were retrospectively analyzed. The patients were divided into two groups as those who had only LSG and those who had fundoplication in the same session. Primary endpoints included demographic and clinical characteristics, operative findings, and minor and major postoperative complications. Results: During the study period, LSG was performed in 122 patients (M/F: 68/54, median age: 2.5 years), only gastrostomy in 9 patients and with concomitant fundoplication in 113 patients. Both age and weight were significantly lower in the LSG group (P < 0.05). Most of patients have neurological impairment (79%). The gastrostomy indications were failure to thrive (53%) and gastroesophageal reflux symptoms (38%). There were no conversions to open surgery and no complications. The median duration of the procedure in gastrostomy, and with fundoplication was 30 and 95 minutes, respectively, the difference was significant (P < 0.05). The mean follow-up period was 63 months. Minor complications such as granulation, leakage, and dislocation were developed in 63 patients (52%), and adhesive bowel obstruction or peritonitis as major complications in 4 patients (4%). Conclusion: The LSG method is a safe, effective, and durable minimally invasive method with satisfactory midterm follow-up results and a low complication rate in patients with neurological disorders and those requiring gastrostomy due to other pathologies.

Introduction: The learning curve for a laparoscopic Roux-en-Y gastric bypass (LRYGB) requires between 50 and 150 cases to reach competency and over 500 cases to significantly reduce morbidity. Our team has developed and validated a simulation-based training program focused on LRYGB-related skills, but its impact on surgeons' clinical development has not been assessed. Objectives: This study aims to evaluate the perceptions of participants after a bariatric-metabolic surgery simulation-based training course (BSC), exploring potential effects on their surgical exposure and development. Methods: A cohort study was conducted among trainees from the 2018-2023 simulation course who were surveyed to evaluate its impact on surgical experience, proficiency, case exposure, confidence, and clinical outcomes. Results: From 2018 to 2023, 110 trainees completed the BSC, and 27% responded to a follow-up survey. Pre-course, 76% were practicing surgeons and 13% residents; 33% had performed >200 laparoscopic cases and 13% none. At follow-up, 57% reported very advanced experience; 97% affirmed enhancements in technique and outcomes; 90% noted increased confidence and deemed simulation essential. Procedure-specific relevance was rated 63% for exploratory laparoscopy, 66% for bypass, and 70% for sleeve gastrectomy. Conclusions: Feedback from trainees highlights a simulation course's role in enhancing surgical skills, confidence, and exposure to complex cases. While it is recognized that attaining surgical competency is influenced by multiple factors, this study contributes valuable trainee-centered evidence supporting the positive impact that structured simulation-based training can have in a surgical career.

Background: Incidental gallbladder cancer (IGBC) is often diagnosed unexpectedly during or after cholecystectomy performed for presumed benign gallbladder disease. Accurate preoperative prediction of lymph node (LN) metastasis is critical for guiding surgical re-resection strategies but remains challenging. This study aimed to develop and validate a nomogram to predict LN metastasis in IGBC patients prior to re-resection. Methods: We retrospectively analyzed 745 IGBC patients who underwent re-resection between August 2019 and October 2024. Clinical data, including demographics, comorbidities, laboratory tests, imaging findings, and histopathological features, were collected. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for LN metastasis. A nomogram was constructed based on these factors. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curve analysis, calibration plots, and decision curve analysis (DCA). Results: Multivariate analysis identified tumor size > 1 cm, advanced T stage, poor differentiation, positive LN status on preoperative computed tomography imaging, and elevated serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 as independent predictors of LN metastasis. The nomogram demonstrated good discriminative ability, with an area under the ROC curve (AUC) of 0.827. Calibration plots showed good agreement between predicted probabilities and observed outcomes. DCA indicated the clinical usefulness of the nomogram. Conclusions: The nomogram based on preoperative clinical, imaging, and pathological factors provides an effective tool for predicting LN metastasis in IGBC patients before re-resection. It can assist clinicians in risk stratification and optimizing surgical strategies, potentially improving patient outcomes.

Introduction: We aimed to compare the safety and efficacy of gradual dilatation (GD) and balloon dilatation (BD) in supine percutaneous nephrolithotomy (PNL) in patients with obesity. Methods: The study was performed on 164 patients with a body mass index (BMI) ≥30 kg/m² who underwent supine PNL in the Galdakao-modified Valdivia position. Sixty patients who underwent tract creation with BD were defined as Group 1, and 104 patients who underwent tract creation with GD were defined as Group 2. Demographic characteristics, preoperative, intraoperative, and postoperative data were compared between the two groups. Then, binary logistic regression analysis was performed to predict stone-free status and complications, and parameters predicting success and safety were investigated. Results: There was no statistically significant difference between the two groups regarding stone-free status, transfusion rate, and the Clavien-Dindo complication grades. Fluoroscopy time and operation time were significantly lower in Group 1 than in Group 2 (P < .001 and P = .002). When the factors predicting success were analyzed, multiple stones and staghorn stones were associated with lower success in multivariate analysis. Long operation times were found to be significant in predicting the development of complications in multivariate analysis. Conclusions: BD and GD have similar success and complication rates as dilatation methods in patients with obesity. BD method may provide less X-ray exposure with shorter fluoroscopy and operation time, but both methods can be used safely in supine PNL in patients with obesity.