Achalasia Treatment. Robotic Approach or Laparoscopy?

Background: Nowadays the question persists whether to choose the endoscopic or surgical method as the first treatment of choice for achalasia. Another debate topic is about the differences between the outcomes of the two approaches of minimally invasive surgical treatment and their feasibility. Material and Methods: This retrospective observational study included 193 patients with achalasia treated between 2008 and 2021. The patients were divided into 2 groups (A and B): 152 with minimally invasive heller myotomy (HM), and 41 with pneumatic dilation (PD). Patients surgically treated were then subdivided into robotic group (RG) and laparoscopic group (LG). Results: The recurrence rate was significantly higher in PD group (Ã?2 = 16.81, DF = 1, p 0.0001), with a success rate of 63,4%, comparing with 92,7% in HM group. No significant difference was obtained between the 2 groups concerning symptom relief on patients successfully treated. The success rate was comparable between the robotic and laparoscopic groups (p = 1). Significant difference was obtained in length of hospital stay between the 2 groups, with a mean of 4.78 +-1.59 days in the RG and, respectively, 5.52 +-2.1 days in the LG (t = 2.40, DF = 124.34, p = 0.0177). Postprocedural esophagitis rates were higher in patients with no fundoplication (6 out of 37 - 16.2%) and in patients treated with pneumatic dilation (4 out of 26 - 15.4%) than in patients with fundoplication (4 out of 46 - 8.5%). Conclusion: The present study indicates that surgery may be a better choice in fit patients for the treatment of achalasia. The procedure has a better success rate, even if the long-term outcomes are comparable in patients successfully treated. The success rate and long-term results were comparable between laparoscopy and robotic surgery.

Long-Term Evaluation of the Outcomes of Subtotal Laparoscopic and Robotic Splenectomy in Hereditary Spherocytosis.

BACKGROUND: Hereditary spherocytosis (HS) is a common inherited disease affecting the erythrocyte membrane. Total splenectomy (TS) is effective in reducing hemolysis and decreasing the need of transfusions, but total removal of the spleen represents a potential risk factor for infectious and non-infectious complications. On the other hand, subtotal splenectomy (STS) could be an alternative therapy for HS. The aim of this study is to establish which surgical approach has the best outcome in HS. METHODS: All patients (n = 63) receiving splenectomy for HS between 2002 and 2016 from one institution were retrospectively reviewed. Hemoglobin and reticulocytes levels during preoperative and postoperative follow-up periods were compared. Additionally, a meta-analysis was performed analyzing data regarding hemoglobin and reticulocytes levels from several available studies. RESULT: At 1-year follow-up, our clinical data showed that mean hemoglobin levels increased after TS from (mean ± SD) 9.77 ± 1.82 to 11.88 ± 2.08 g/dl, while after STS from 8.98 ± 1.66 to 11.87 ± 1.38 g/dl. At 3-year and 5-year follow-up after TS, we observed an increase from 9.77 ± 1.82 to 13.59 ± 2.03 and 13.46 ± 1.64 g/dl, respectively. At 3-year and 5-year follow-up after STS in our cohort, we observed an increase from 8.98 ± 1.66 to 13.21 ± 1.95 and 13.68 ± 1.65 g/dl, respectively. The meta-analysis (for a follow-up period of 1 year) showed that the hemoglobin levels increased with 2.61 g/dl (95% CI 2.15-3.08 g/dl; p < 0.001) after TS, and with 1.67 g/dl (95% CI 1.25-2.10 g/dl; p < 0.001) after STS. CONCLUSION: We conclude that subtotal and minimally invasive splenectomy could be considered as the first line of treatment in severe HS cases, especially in children.

Transanal Total Mesorectal Excision - A Case Report.

Transanal total mesorectal excision (TaTME), first introduced in 2010, represents a relatively new approach in the surgical treatment of rectal cancer. A case of a 65-years-old patient diagnosed with moderately differentiated adenocarcinoma of the middle rectum (cT2N0M0) is presented. Taking into consideration patient's characteristics and tumour features, the surgical team decided to use transanal total mesorectal excision technique. The surgical technique, as well as potential postoperative complications and oncological issues are discussed in the article. Patient selection and extensive experience in minimally invasive colorectal surgery are the bases for an optimal technique implementation. Although further studies are required in order to confirm its superiority over the laparoscopic total mesorectal excision, TaTME seems to be a safe and feasible option in the surgical approach of rectal cancer.

Splenic Cysts: A Strong Indication for a Minimally Invasive Partial Splenectomy. Could the Splenic Hilar Vasculature Type Hold a Defining Role?

BACKGROUND: The aim of the study is to assess the impact of the splenic hilar vasculature configuration on the amount of remnant splenic parenchyma volume after partial splenectomy for splenic cysts. METHODS: The data of all patients receiving a splenectomy for a splenic cyst from 2002 to 2016 at the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute were retrospectively reviewed. The size and location in the splenic parenchyma of the cyst and the splenic hilar vasculature type were assessed for each patient with a splenectomy. RESULTS: Thirty-one patients with non-parasitic and 32 patients with hydatid cysts were recorded. In cases of centrally located cysts, a total splenectomy was performed for the majority of cases, while in peripheral cysts a spleen-preserving surgery was feasible for most of the patients (p = 0.001). The size of the cyst was significantly higher in the group of patients with a total splenectomy, compared with the group with a partial splenectomy (p = 0.003). In the subgroup with a distributed arterial pattern, preservation of more than 50% of the initial parenchyma was achieved in a significantly higher proportion of patients, compared with the subgroup of patients with a magistral pattern (p = 0.012). CONCLUSION: Besides cyst size or peripheral location in the splenic parenchyma, the vascular pattern is also considered another decisive factor that associates with successful conservative or minimally invasive approach.

Hereditary Spherocytosis - Diagnosis, Surgical Treatment and Outcomes. A Literature Review.

Hereditary spherocytosis (HS) is a disease affecting the red blood cells membrane and belongs to the congenital hemolytic anemias. The clinical spectrum ranges from asymptomatic patients to severe forms requiring transfusions in early childhood. The diagnosis can be based on the physical examination, complete red blood cell count, reticulocytes count, medical history and specific tests, preferentially the EMA test (eosin-5-maleimide binding) test and AGLT (Acidified Glycerol Lysis Time). Splenectomy is considered the standard surgical treatment in moderate and severe forms of hereditary spherocytosis. Total splenectomy exposes the patient to a life - long risk of potentially lethal infections and thus, its usage was reconsidered. Because of this reason, a feasible alternative is the partial splenectomy. The use of partial splenectomy aims to retain splenic immunologic function, while at the same time to decrease the rate of hemolysis. The long - term outcomes of patients with total or subtotal splenectomy for congenital hemolytic anemia, still remain unclear, but the majority of the studies showed a qualitative resolution of anemia and reduction of transfusion rate. Despite the well known advantages of conservative surgery, the optimal choice of treatment and outcomes should be confirmed with the patient.

Robotic Surgery: A Solution in Search of a Problem-A Bayesian Analysis of 343 Robotic Procedures Performed by a Single Surgical Team.

BACKGROUND: Despite the obvious technical advantages, the value of robotic surgery is highly debated and its cost-effectiveness has been questioned. The aim of this article is to provide an evaluation of the outcomes of robotic surgery in comparison to conventional laparoscopy. METHODS: A decision analysis based on the Bayes' theorem and the decision tree was used. The robotic approach was compared with the laparoscopic approach for each of the pathologies discussed in this study. The data on robotic surgeries were obtained from a retrospective study conducted between January 2008, when the da Vinci system became available in our institution, and December 2014. During this period, 343 consecutive robotic operations were performed by a single surgical team. RESULTS: There were statistically significant differences in the likelihood of an optimal patient outcome when the robotic approach was used for hysterectomies to remove malignant tumors, difficult splenectomies, gastrectomies, and rectal resections. The results did not show important differences between the two techniques for easy splenectomies and hysterectomies for benign cases. CONCLUSIONS: The results of our study confirm the value of robotic surgery, as an alternative and complex surgical tool, for hysterectomies to remove malignant tumors, difficult splenectomies, gastrectomies, and rectal resections. Laparoscopy was preferred for easy splenectomies and hysterectomies for benign cases, because of the lack of improved outcome with robotic surgery and the high cost of robotic surgery.

[Subfascial endoscopic perforating veins section]. / Ligatura endoscopica subfasciala a venelor perforante insuficiente.

AIM: Subfascial endoscopic perforating veins section (SEPS) is a modern surgical method used in the treatment of chronic venous insufficiency. The paper presents the postoperative results using SEPS technique at the patients with chronic venous insufficiency of the inferior limbs of different etiologies. MATERIAL AND METHOD: We followed 26 patients, 16 women and 10 men, with ages between 16-75 years, with chronic venous insufficiency at the inferior legs. 20 patients had only one inferior limb affected by the disease and 6 patients had both limbs involved. They were, after CEAP clinical criterion, in C4, C5 and C6 classes and they had three different etiologies as primary varices with an evolutive period of 20 years, postthrombotic syndrome and congenital varices. We performed 32 SEPS operations in the 1-rst Clinic of Surgery, University of Medicine and Pharmacy "Victor Babes" Timisoara. RESULTS: The time of healing and postoperative complications were reduced after SEPS procedures. The healing is 100% at three months after surgery. The check up after 12 months showed a rate of 87.5% of healing. We recorded 4 unilateral relapses at patients that had postthrombotic syndrome. DISCUSSIONS: The study realized in our clinic comparing with other studies from the literature, shows that our results are similar to that recorded in medical centers from other countries demonstrating the superiority of SEPS methods comparing with the classical Linton or Felder methods of perforating veins ligation.