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OBJECTIVE: As achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia Trial comparing endoscopic pneumodilation (PD) with laparoscopic Heller myotomy (LHM). DESIGN: A total of 201 newly diagnosed patients with achalasia were randomised to either a series of PDs (n=96) or LHM (n=105). Patients completed symptom (Eckardt score) and quality-of-life questionnaires, underwent functional tests and upper endoscopy. Primary outcome was therapeutic success defined as Eckardt score <3 at yearly follow-up. Secondary outcomes were the need for retreatment, lower oesophageal sphincter pressure, oesophageal emptying, gastro-oesophageal reflux and the rate of complications. RESULTS: After 10 years of follow-up, LHM (n=40) and PD (n=36) were equally effective in both the full analysis set (74% vs 74%, p=0.84) and the per protocol set (74% vs 86%, respectively, p=0.07). Subgroup analysis revealed that PD was superior to LHM for type 2 achalasia (p=0.03) while there was a trend, although not significant (p=0.05), that LHM performed better for type 3 achalasia. Barium column height after 5 min at timed barium oesophagram was significantly higher for patients treated with PD compared with LHM, while other parameters, including gastro-oesophageal reflux, were not different. CONCLUSIONS: PD and LHM are equally effective even after 10 years of follow-up with limited risk to develop gastro-oesophageal reflux. Based on these data, we conclude that PD and LHM can both be proposed as initial treatment of achalasia.
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Acalasia del Esófago , Esofagitis Péptica , Reflujo Gastroesofágico , Miotomía de Heller , Laparoscopía , Humanos , Acalasia del Esófago/cirugía , Esfínter Esofágico Inferior/cirugía , Miotomía de Heller/efectos adversos , Estudios de Seguimiento , Dilatación/efectos adversos , Bario , Resultado del Tratamiento , Laparoscopía/métodosRESUMEN
BACKGROUND: Minimally invasive caudate lobectomy, or even paracaval caudate resection, can be associated with significant bleeding due to its abutment of inferior vena cava (IVC), portal pedicle and hepatic veins.1-3 This risk can be magnified by cirrhosis as well as response to neoadjuvant therapy (a common phenomenon after excellent response to neoadjuvant chemotherapy), leading to obliteration or even fusion of the hepato-caval space.4-7 PATIENT: A 68-year-old female with stage IVa colorectal adenocarcinoma was found to have a single liver metastasis (3.8 × 3.1 cm) in the paracaval caudate lobe. The patient received four cycles of neoadjuvant chemotherapy, leading to inflammatory fusion of the hepato-caval space. Despite this, the patient underwent a safe laparoscopic Spiegel process resection. TECHNIQUE: Prior to surgery, three-dimensional liver and port site modeling was performed to optimize the understanding of the spatial relationship between the tumor, IVC, and portal-hepatic veins. Following inflow control of portal veinous branches, the fused hepato-caval space was dissected. The adhesions were then sharply dissected to mobilize the paracaval caudate lobe off the IVC. Using scissors rather than an energy device reduced the risk of inadvertent thermal injury to the IVC. CONCLUSION: Preoperative virtual hepatectomy facilitates surgical planning, increasing the understanding of the tumor/vessel relationship and port placement. In case of a fused hepato-caval space, low central venous pressure and judicious management of short hepatic vein branches are the key for a successful dissection. Moreover, anticipation of a fused hepato-caval space and its strategic management are paramount when performing a minimally invasive caudate resection.
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Laparoscopía , Neoplasias Hepáticas , Femenino , Humanos , Anciano , Vena Cava Inferior/cirugía , Neoplasias Hepáticas/secundario , Hepatectomía/métodos , Laparoscopía/métodosRESUMEN
BACKGROUND: Ileal neuroendocrine tumors (i-NETs) are characterized by their multifocality and bulky mesenteric mass. Having shown that minimally invasive surgery (MIS) utilizing a hand-access port device has favorable short-term outcomes and achieves the goals of surgery for i-NETs, we sought to analyze long-term survival outcomes of MIS. METHODS: One hundred and sixty-eight patients who underwent resection of primary i-NETs at a single institution between January 2007 and February 2023 were retrospectively studied. Patients were categorized into the MIS or open surgery cohorts on an intention-to-treat basis. Open surgery was selected mainly based on the need for hepatectomy or bulky mesenteric mass resection. Overall survival was analyzed using log-rank tests with propensity score matching (PSM) and Cox proportional hazards regression. PSM was performed to reduce standardized mean differences of the variables to <0.2. RESULTS: Overall, 129 (77%) patients underwent MIS and 39 (23%) underwent open surgery. Twenty-seven MIS patients were converted to an open procedure. The median follow-up time was 49 months (interquartile range 23-87 months). In the PSM cohorts, overall survival did not differ significantly between the MIS and open surgery cohorts {median 99 months (95% confidence interval [CI] 91-not applicable [NA]) vs. 103 months (95% CI 86-NA), p = 0.77; hazard ratio 0.87 (95% CI 0.33-2.2), p = 0.77}. CONCLUSIONS: MIS is an alternative to open surgery for i-NETs, achieving similar short- and long-term oncological outcomes. Bulky mesenteric mass and a plan for concurrent liver resection are potential criteria for open surgery.
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Neoplasias del Íleon , Procedimientos Quirúrgicos Mínimamente Invasivos , Tumores Neuroendocrinos , Humanos , Masculino , Femenino , Tumores Neuroendocrinos/cirugía , Tumores Neuroendocrinos/patología , Tumores Neuroendocrinos/mortalidad , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Estudios de Seguimiento , Neoplasias del Íleon/cirugía , Neoplasias del Íleon/mortalidad , Neoplasias del Íleon/patología , Procedimientos Quirúrgicos Mínimamente Invasivos/mortalidad , Anciano , Pronóstico , Hepatectomía/mortalidad , Hepatectomía/métodos , AdultoRESUMEN
PURPOSE: The recently introduced tethered DROP-IN gamma probe has revolutionized the way robotic radioguided surgery is performed, fully exploiting the nature of steerable robotic instruments. Given this success, the current first-in-human study investigates if the DROP-IN can also provide benefit in combination with steerable non-robotic instruments during conventional laparoscopic surgery, showing equivalence or even benefit over a traditional rigid gamma probe. METHODS: The evaluation was performed in ten patients during laparoscopic cervical (n = 4) and endometrial (n = 6) cancer sentinel lymph node (SLN) procedures. Surgical guidance was provided using the hybrid, or bi-modal, SLN tracer ICG-99mTc-nanocolloid. SLN detection was compared between the traditional rigid laparoscopic gamma probe, the combination of a DROP-IN gamma probe and a steerable laparoscopic instrument (LaproFlex), and fluorescence imaging. RESULTS: The gynecologists experienced an enlarged freedom of movement when using the DROP-IN + LaproFlex combination compared to the rigid laparoscopic probe, making it possible to better isolate the SLN signal from background signals. This did not translate into a change in the SLN find rate yet. In both cervical and endometrial cancer combined, the rigid probe and DROP-IN + LaproFlex combination provided an equivalent detection rate of 96%, while fluorescence provided 85%. CONCLUSION: We have successfully demonstrated the in-human use of steerable DROP-IN radioguidance during laparoscopic cervical and endometrial cancer SLN procedures, expanding the utility beyond robotic procedures. Indicating an improved surgical experience, these findings encourage further investigation and consideration on a path towards routine clinical practice and improved patient outcome. TRIAL REGISTRATION: HCB/2021/0777 and NCT04492995; https://clinicaltrials.gov/study/NCT04492995.
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Neoplasias Endometriales , Ganglio Linfático Centinela , Neoplasias del Cuello Uterino , Humanos , Femenino , Neoplasias del Cuello Uterino/diagnóstico por imagen , Neoplasias del Cuello Uterino/cirugía , Ganglio Linfático Centinela/diagnóstico por imagen , Ganglio Linfático Centinela/cirugía , Persona de Mediana Edad , Neoplasias Endometriales/diagnóstico por imagen , Neoplasias Endometriales/cirugía , Neoplasias Endometriales/patología , Biopsia del Ganglio Linfático Centinela/métodos , Biopsia del Ganglio Linfático Centinela/instrumentación , Laparoscopía , Anciano , Adulto , Cirugía Asistida por Computador/métodos , Cirugía Asistida por Computador/instrumentaciónRESUMEN
BACKGROUND: Owing to the lack of evidence-based medical studies with large sample sizes, the surgical approach for the radical resection of rectal neuroendocrine tumors remains controversial. METHODS: We retrospectively collected the medical records of patients with rectal neuroendocrine tumors who underwent radical resection at 17 large tertiary care hospitals in China between January 1, 2010, and April 30, 2022. All patients were divided into laparoscopic and open surgery groups. After propensity score matching to reduce confounders, the postoperative and oncologic outcomes were compared between the groups. RESULTS: We enrolled 174 patients with rectal neuroendocrine tumors who underwent radical surgery. After random matching, 124 patients were included in the comparison (62, laparoscopic surgery group; 62, open surgery group). The laparoscopic surgery group had fewer complications (14.5% vs. 35.5%, P = 0.007) and superior relapse-free survival (P = 0.048). Subgroup analysis revealed that the laparoscopic surgery group had fewer complications (10.9% vs. 34.7%, P = 0.004), shorter postoperative hospital stays (9.56 ± 5.21 days vs. 12.31 ± 8.61 days, P = 0.049) and superior relapse-free survival (P = 0.025) in the rectal neuroendocrine tumors ≤ 4 cm subgroup. CONCLUSIONS: Laparoscopic surgery was associated with improved postoperative outcomes and oncologic prognosis for patients with rectal neuroendocrine tumors ≤ 4 cm; it can serve as a safe and feasible option for radical surgery of rectal neuroendocrine tumors.
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Laparoscopía , Tumores Neuroendocrinos , Neoplasias del Recto , Humanos , Neoplasias del Recto/cirugía , Neoplasias del Recto/patología , Neoplasias del Recto/mortalidad , Laparoscopía/métodos , Laparoscopía/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Tumores Neuroendocrinos/cirugía , Tumores Neuroendocrinos/mortalidad , Tumores Neuroendocrinos/patología , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Anciano , Resultado del Tratamiento , Adulto , China/epidemiología , Puntaje de Propensión , Tiempo de Internación/estadística & datos numéricosRESUMEN
BACKGROUND: Recently, with the advancement of medical technology, the postoperative morbidity of pelvic exenteration (PE) has gradually decreased, and it has become a curative treatment option for some patients with recurrent gynecological malignancies. However, more evidence is still needed to support its efficacy. This study aimed to explore the safety and long-term survival outcome of PE and the feasibility of umbilical single-port laparoscopic PE for gynecologic malignancies in a single medical center in China. PATIENTS AND METHODS: PE for gynecological cancers except for ovarian cancer conducted by a single surgical team in Sun Yat-sen University Cancer Center between July 2014 and December 2019 were included and the data were retrospectively analyzed. RESULTS: Forty-one cases were included and median age at diagnosis was 53 years. Cervical cancer accounted for 87.8% of all cases, and most of them received prior treatment (95.1%). Sixteen procedures were performed in 2016 and before, and 25 after 2016. Three anterior PE were performed by umbilical single-site laparoscopy. The median operation time was 460 min, and the median estimated blood loss was 600 ml. There was no perioperative death. The years of the operations was significantly associated with the length of the operation time (P = 0.0018). The overall morbidity was 52.4%, while the severe complications rate was 19.0%. The most common complication was pelvic and abdominal infection. The years of surgery was also significantly associated with the occurrence of severe complication (P = 0.040). The median follow-up time was 55.8 months. The median disease-free survival (DFS) was 17.9 months, and the median overall survival (OS) was 25.3 months. The 5-year DFS was 28.5%, and the 5-year OS was 30.8%. CONCLUSION: PE is safe for patient who is selected by a multi-disciplinary treatment, and can be a curative treatment for some patients. PE demands a high level of experience from the surgical team. Umbilical single-port laparoscopy was a technically feasible approach for APE, meriting further investigation.
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Neoplasias de los Genitales Femeninos , Neoplasias Ováricas , Exenteración Pélvica , Neoplasias del Cuello Uterino , Humanos , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Exenteración Pélvica/efectos adversos , Exenteración Pélvica/métodos , Neoplasias del Cuello Uterino/cirugía , Neoplasias del Cuello Uterino/etiología , Neoplasias Ováricas/cirugía , Neoplasias Ováricas/etiología , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/cirugía , Recurrencia Local de Neoplasia/etiologíaRESUMEN
BACKGROUND: Recent studies have demonstrated that accelerated enhanced recovery after colorectal surgery is feasible for specific patient populations. The accelerated enhanced recovery protocols (ERP) tend to vary, and the majority of studies included a small study population. This hampers defining the optimal protocol and establishing the potential benefits. This systematic review aimed to determine the effect of accelerated ERPs with intended discharge within one day after surgery. METHODS: PubMed (MEDLINE), Embase, Cochrane and Web of Science databases were searched using the following search terms: colon cancer, colon surgery, accelerated recovery, fast track recovery, enhanced recovery after surgery. Clinical trials published between January 2005 - February 2023, written in English or Dutch comparing accelerated ERPs to Enhanced Recovery After Surgery (ERAS) care for adult patients undergoing elective laparoscopic or robotic surgery for colon cancer were eligible for inclusion. RESULTS: Thirteen studies, including one RCT were included. Accelerated ERPs after colorectal surgery was possible as LOS was shorter; 14 h to 3.4 days, and complication rate varied from 0-35.7% and readmission rate was 0-17% in the accelerated ERP groups. Risk of bias was serious or critical in most of the included studies. CONCLUSIONS: Accelerated ERPs may not yet be considered the new standard of care as the current data is heterogenous, and data on important outcome measures is scarce. Nonetheless, the decreased LOS suggests that accelerated recovery is possible for selected patients. In addition, the complication and readmission rates were comparable to ERAS care, suggesting that accelerated recovery could be safe.
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Neoplasias del Colon , Procedimientos Quirúrgicos del Sistema Digestivo , Recuperación Mejorada Después de la Cirugía , Laparoscopía , Adulto , Humanos , Alta del Paciente , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Neoplasias del Colon/cirugía , Neoplasias del Colon/complicaciones , Laparoscopía/efectos adversos , Laparoscopía/métodos , Tiempo de Internación , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
INTRODUCTION: Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery. MATERIALS AND METHODS: All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index. RESULTS: Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index). CONCLUSIONS: This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.
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Cirugía Bariátrica , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Robótica , Cirujanos , Humanos , ErgonomíaRESUMEN
INTRODUCTION: Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve. MATERIAL AND METHODS: One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA). RESULTS: Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA. CONCLUSIONS: RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Humanos , Neoplasias de las Glándulas Suprarrenales/cirugía , Espacio Retroperitoneal/cirugía , Espacio Retroperitoneal/patología , Adrenalectomía/efectos adversos , Adrenalectomía/métodos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Estudios Retrospectivos , Tiempo de Internación , Tempo Operativo , Resultado del TratamientoRESUMEN
INTRODUCTION: Despite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer. METHODS: Patients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest. RESULTS: Among the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1). CONCLUSIONS: In patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques.
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Adenocarcinoma , Laparoscopía , Márgenes de Escisión , Proctectomía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Neoplasias del Recto/cirugía , Neoplasias del Recto/patología , Neoplasias del Recto/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Anciano , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Laparoscopía/métodos , Adenocarcinoma/cirugía , Adenocarcinoma/patología , Adenocarcinoma/mortalidad , Proctectomía/métodos , Proctectomía/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Recto/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , AdultoRESUMEN
OBJECTIVE: To examine if peritoneal conditioning with an altered insufflation gas mixture is associated with reduced postoperative pain intensity compared to the standard insufflation gas (i.e., 100% CO2). DESIGN: A prospective, single-centre, randomized, double-blind, superiority trial was performed. SETTING: This study was conducted between 4 April 2019 and 10 February 2022 at the Jessa Hospital, Hasselt, Belgium. POPULATION: Patients scheduled for elective gynaecologic laparoscopic surgery. METHODS: Seventy-four patients scheduled for elective gynaecologic laparoscopic surgery were randomised to receive either the standard insufflation gas with 100 CO2 (n = 37; control group) or the altered gas mixture of 86% CO2, 10% N2O and 4% O2 (n = 37; experimental group). MAIN OUTCOME MEASURES: Postoperative pain was assessed at 4, 8 and 24 hours after surgery and on postoperative day (POD) 7 by an 11-point Numeric Rating Scale, with 0 indicating no pain and 10 indicating worst imaginable pain. RESULTS: No significant differences were found between the control and experimental groups regarding postoperative pain at 4, 8 and 24 h after surgery, as well as on POD7. In addition, the median (25% and 75%) total amount of IV piritramide consumption during the first 24 h after surgery was not significantly different between groups (control group: 18.0 [10.0, 27.0] mg vs. experimental group: 17.0 [10.0, 34.0] mg, p = 0.62). CONCLUSION: The alternative insufflation gas mixture comprising 86% CO2, 10% N2O and 4% O2 used for the pneumoperitoneum during gynaecologic laparoscopic surgery does not appear to reduce postoperative pain compared to the standard insufflation gas of 100% CO2.
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PURPOSE: Sigmoid diverticulitis is a disease with a high socioeconomic burden, accounting for a high number of left-sided colonic resections worldwide. Modern surgical scheduling relies on accurate prediction of operation times to enhance patient care and optimize healthcare resources. This study aims to develop a predictive model for surgery duration in laparoscopic sigmoid resections, based on preoperative CT biometric and demographic patient data. METHODS: This retrospective single-center cohort study included 85 patients who underwent laparoscopic sigmoid resection for diverticular disease. Potentially relevant procedure-specific anatomical parameters recommended by a surgical expert were measured in preoperative CT imaging. After random split into training and test set (75% / 25%) multiclass logistic regression was performed and a Random Forest classifier was trained on CT imaging parameters, patient age, and sex in the training cohort to predict categorized surgery duration. The models were evaluated in the test cohort using established performance metrics including receiver operating characteristics area under the curve (AUROC). RESULTS: The Random Forest model achieved a good average AUROC of 0.78. It allowed a very good prediction of long (AUROC = 0.89; specificity 0.71; sensitivity 1.0) and short (AUROC = 0.81; specificity 0.77; sensitivity 0.56) procedures. It clearly outperformed the multiclass logistic regression model (AUROC: average = 0.33; short = 0.31; long = 0.22). CONCLUSION: A Random Forest classifier trained on demographic and CT imaging biometric patient data could predict procedure duration outliers of laparoscopic sigmoid resections. Pending validation in a multicenter study, this approach could potentially improve procedure scheduling in visceral surgery and be scaled to other procedures.
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Laparoscopía , Bosques Aleatorios , Humanos , Estudios de Cohortes , Laparoscopía/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Carbon ion radiotherapy (CIRT) has received attention for the treatment of locally recurrent rectal cancer. When the surrounding primary organs are close to the irradiation site, a spacer is required to ensure safe irradiation. This work describes a novel technique using a bioabsorbable polyglycolic acid spacer placed laparoscopically and presents a technical report with five case studies. The short-term surgical outcomes were as follows: mean operating time 235 min with blood loss of 38 mL. CIRT was planned, and the patients underwent irradiation within 2 months of surgery. No pelvic infections occurred, and all procedures were performed safely. Herein, were present a technical report with reference to a video of the surgical procedure.
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Implantes Absorbibles , Laparoscopía , Recurrencia Local de Neoplasia , Ácido Poliglicólico , Neoplasias del Recto , Humanos , Neoplasias del Recto/cirugía , Neoplasias del Recto/radioterapia , Laparoscopía/métodos , Recurrencia Local de Neoplasia/cirugía , Persona de Mediana Edad , Femenino , Masculino , Anciano , Resultado del Tratamiento , Tempo OperativoRESUMEN
The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.
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Colectomía , Procedimientos Quirúrgicos Robotizados , Humanos , Colectomía/métodos , Colon/cirugía , Cirugía Colorrectal/métodos , Laparoscopía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
BACKGROUND: Maintenance of normothermia is a crucial part of enhanced recovery after colorectal surgery. Dry-cold carbon dioxide (CO2 ) traditionally used for insufflation in laparoscopic surgery and negative pressure operating theatres has been associated with intraoperative hypothermia. Studies suggest that use of warmed-humidified CO2 may promote normothermia. However, due to a scarcity of high-quality studies demonstrating a proven benefit on intraoperative core body temperature, its use in colorectal surgery remains limited. Therefore, the aim of this review was to evaluate the effects of warmed-humidified CO2 compared to traditional dry-cold CO2 , or ambient air in operating theatres, during colorectal surgery. METHODS: A search of Medline, EMBASE, and CENTRAL was performed. Randomised controlled trials (RCTs) that compared patients receiving warmed-humidified CO2 with either dry-cold CO2 insufflation in laparoscopic procedures or no insufflation during open surgery were included. The primary outcome was change in intraoperative core body temperature. Secondary outcomes included length of stay, operating time, return of gastrointestinal function, wound infection, and postoperative pain. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS: Among the six RCTs included, 208 patients received warmed-humidified CO2 (42.3% female, mean age: 65.8 years) and 210 patients received either dry-cold CO2 in laparoscopic procedures or no gas insufflation during open procedures (46.2% female, mean age: 66.1 years). No significant difference was found for change in intraoperative core body temperature (MD = 0.01, 95% CI: -0.1, 0.11, p = 0.90, very low certainty). Patients in the warmed-humidified CO2 group had significantly higher pain scores on postoperative day 1 (MD = 1.61, 95% CI: 0.91, 2.31, p < 0.05, very low certainty). No significant differences were found in any of the other secondary outcomes studied. CONCLUSION: Patients undergoing colorectal surgery receiving warmed-humidified CO2 do not experience any clinically meaningful difference in core body temperature change compared to their counterparts receiving dry-cold CO2 insufflation or no insufflation. However, patients may report greater pain scores on postoperative day 1 with warmed-humidified CO2 . There is likely no clinically important difference between warmed-humidified CO2 and dry-cold CO2 for patients undergoing colorectal surgery. Patient, clinician, and institution factors should be considered when deciding between these two insufflation modalities.
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Cirugía Colorrectal , Insuflación , Laparoscopía , Femenino , Humanos , Anciano , Masculino , Dióxido de Carbono , Insuflación/métodos , Humedad , Laparoscopía/métodos , Dolor Postoperatorio/etiologíaRESUMEN
BACKGROUND: Laparoscopic subtotal cholecystectomy (LSC) is a recognised alternative to laparoscopic cholecystectomy (LC) when it is unsafe to achieve the "critical view of safety". Although LSC reduces the risk of bile duct injury, it is associated with increased morbidity, primarily due to bile leak. LSC can be classified as fenestrating (F-LSC) or reconstituting (R-LSC), with the latter being more complex. The objective of this study was to evaluate the two LSC techniques, their complications, and overall outcomes. METHODS: We conducted a retrospective analysis of all adult patients who underwent LSC between January 2015 and December 2021 using our electronic database. Data collected included patient demographics, prior acute biliary presentations, operative details/techniques, length of stay (LOS), 30-day complications, 30-day mortality, readmissions, and follow-up investigations/procedures. Descriptive statistics, Chi-squared tests, and relative risk were employed for data analysis. RESULTS: In the study period, LSC was performed on 170 patients, showing an increasing trend over time. Most procedures (76%) were performed in the acute setting, and 37.1% of patients had a history of previous acute biliary presentations. Fenestrating LSC was the most performed technique (115 [67.6%] vs. 55 [32.4%]). Complications occurred in 80 (47.1%) patients; 60 patients (35.3%) had a bile leak. 16 patients (9.4%) required reoperation, and readmission was observed in 14 patients (8.2%). F-LSC was associated with more complications [p = 0.03 RR 2.46 (95% CI 1.5-4)], more bile leaks [p < 0.01, RR 2.1 (95% CI 1.2-3.7)], greater need for rescue postoperative endoscopic retrograde cholangiopancreatography (ERCP) [p < 0.01, RR 3.8 (95% CI 1.4-10.2)], and longer LOS (6 vs. 4 days p < 0.01). CONCLUSION: Although LSC is seen as a safe alternative to open conversion, our findings demonstrate a high morbidity, including reoperation/reintervention, readmissions, and complications, associated with LSC especially with F-LSC. We suggest that if LSC is performed, the reconstituted technique should be chosen, if feasible.
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Enfermedades de las Vías Biliares , Colecistectomía Laparoscópica , Adulto , Humanos , Colecistectomía Laparoscópica/métodos , Estudios Retrospectivos , Colangiopancreatografia Retrógrada Endoscópica , Tiempo de InternaciónRESUMEN
BACKGROUND: The appropriateness of laparoscopic gastrectomy (LG) for super-geriatric patients with locally advanced gastric cancer (LAGC) is inconclusive, and the prognostic factors are also yet to be elucidated. Herein, we aimed to investigate the surgical and oncological outcomes of LG versus open gastrectomy (OG) for geriatric patients with LAGC who have outlived the average lifespan of the Chinese population (≥ 78 years). METHODS: This is a monocentric, retrospective, comparative study. A 1:1 propensity score matching (PSM) was performed to minimize selection bias and ensure well-balanced characteristics. The primary endpoint of interest was 3-year overall survival, while secondary endpoints included procedure-related variables, postoperative recovery indices, and complications. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify unfavorable prognostic factors. RESULTS: Of 196 eligible individuals, 107 underwent LG and 89 underwent OG, with a median age (interquartile range [IQR]) of 82 [79, 84] years. PSM yielded 61 matched pairs, with comparable demographic and tumor characteristics. The LG group had a significantly lower overall complication rate than the OG group (31.1% vs. 49.2%, P = 0.042), as well as shorter duration of postoperative hospital stay [12 (11, 13) vs. 13 (12, 15.5) d, P < 0. 001], less intraoperative blood loss [95 (75, 150) vs. 230 (195, 290) mL, P < 0.001], but a longer operative time [228 (210, 255.5) vs. 196 (180, 219.5) min, P < 0.001]. The times to first aerofluxus, defecation, liquid diet, and half-liquid diet were comparable. Kaplan-Meier analyses revealed no significant difference in 3-year overall survival between the groups, either in the entire cohort or in subgroups with different TNM staging. Moreover, Age-adjusted Charlson Comorbidity Index scores of > 6 [hazard ratio (HR) 4.003; P = 0.021] and pathologic TNM stage III (HR 3.816, P = 0.023) were independent unfavorable prognostic factors for long-term survival. CONCLUSIONS: LG performed by experienced surgeons offers the benefits of comparable or better surgical and oncological safety profiles than OG for super-geriatric patients with LAGC.
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Gastrectomía , Laparoscopía , Puntaje de Propensión , Neoplasias Gástricas , Humanos , Neoplasias Gástricas/cirugía , Neoplasias Gástricas/patología , Neoplasias Gástricas/mortalidad , Masculino , Gastrectomía/métodos , Femenino , Estudios Retrospectivos , Anciano de 80 o más Años , Pronóstico , Laparoscopía/métodos , Anciano , Tasa de Supervivencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Tiempo de Internación/estadística & datos numéricosRESUMEN
BACKGROUND: There is no optimal reconstruction method after proximal gastrectomy. The valvuloplastic esophagogastrostomy can reduce postoperative reflux esophagitis, but it is technically complex with a long operation time. The gastric tube anastomosis is technically simple, but the incidences of reflux esophagitis and anastomotic stricture are higher. METHODS: We have devised a modified valvuloplastic esophagogastrostomy after laparoscopy-assisted proximal gastrectomy (LAPG), the arch-bridge anastomosis. After reviewing our prospectively maintained gastric cancer database, 43 patients who underwent LAPG from November 2021 to April 2023 were included in this cohort study, with 25 patients received the arch-bridge anastomosis and 18 patients received gastric tube anastomosis. The short-term outcomes were compared between the two groups to evaluate the efficacy of the arch-bridge anastomosis. Reporting was consistent with the STROCSS 2021 guideline. RESULTS: The median operation time was 180 min in the arch-bridge group, significantly shorter than the gastric tube group (p = 0.003). In the arch-bridge group, none of the 25 patients experienced anastomotic leakage, while one patient (4%) experienced anastomotic stricture requiring endoscopic balloon dilation. The postoperative length of stay was shorter in the arch-bridge group (9 vs. 11, p = 0.034). None of the patients in the arch-bridge group experienced gastroesophageal reflux and used proton pump inhibitor (PPI), while four (22.2%) patients in the gastric tube group used PPI (p = 0.025). The incidence of reflux esophagitis (Los Angeles grade B or more severe) by endoscopy was lower in the arch-bridge group (0% vs. 25.0%). CONCLUSION: The arch-bridge anastomosis is a safe, time-saving, and feasible reconstruction method. It can reduce postoperative reflux and anastomotic stricture incidences in a selected cohort of patients undergoing laparoscopy-assisted proximal gastrectomy.
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Esofagitis Péptica , Reflujo Gastroesofágico , Laparoscopía , Neoplasias Gástricas , Humanos , Esofagitis Péptica/etiología , Esofagitis Péptica/prevención & control , Estudios de Cohortes , Estudios Retrospectivos , Constricción Patológica/cirugía , Laparoscopía/efectos adversos , Laparoscopía/métodos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Reflujo Gastroesofágico/cirugía , Neoplasias Gástricas/cirugía , Neoplasias Gástricas/complicaciones , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
BACKGROUND: The KangDuo surgical robot (KD-SR-01) was recently developed in China. This study aims to evaluate the short-term outcomes of KD-SR-01 for colorectal cancer surgery. METHODS: This is a multicentre randomised controlled noninferiority trial conducted in three centers in China. Enrolled patients were randomly assigned at a 1:1 ratio to receive surgery using the KD-SR-01 system (KD group) or the da Vinci Xi (DV) robotic system (DV group). The primary endpoint was the success rate of operation. The second endpoints were surgical outcomes, pathological outcomes, and postoperative outcomes. RESULTS: Between July 2022 and May 2023. A total of 100 patients were included in the trial and randomly assigned to the KD group (50 patients) and the DV group (50 patients). All cases were completed successfully without conversion to laparoscopic surgery. The time to flatus and the incidence of postoperative complications of Clavien-Dindo grade II or higher grade were comparable between the two groups. Surgeons reported a high level of comfort with the KD-SR-01 system. In the subgroup analysis of different operative procedures, there were no significant differences in docking time, console time, blood loss, and the length of the incision for extraction between the two groups. There were no differences in pathological outcomes including maximum tumor diameter, circumferential resection margin, distal resection margin, and number of harvested lymph nodes. CONCLUSIONS: The KD-SR-01 system was a viable option for colorectal cancer robotic surgery, with acceptable short-term outcomes comparable to the da Vinci Xi robotic system.
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Neoplasias Colorrectales , Procedimientos Quirúrgicos del Sistema Digestivo , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Márgenes de Escisión , Laparoscopía/métodos , Neoplasias Colorrectales/cirugía , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
INTRODUCTION: A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS: We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS: Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION: The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.