Comparative Analysis of Transoral Endoscopic Parathyroidectomy Vestibular Approach and Focused Open Surgery for Primary Hyperparathyroidism Treatment: A Single Center Experience.

BACKGROUND Primary hyperparathyroidism is one of the most common endocrine disorders, for which the definitive treatment is surgical parathyroidectomy. Generally, surgical exploration is performed as open focused neck surgery. The vestibular route is a new approach to minimally invasive endoscopic parathyroidectomy. This retrospective study from a single center in Turkey aimed to compare surgical outcomes from the transoral endoscopic vestibular approach (TOEPVA) vs direct open parathyroidectomy in 57 patients. MATERIAL AND METHODS Our study included data from 57 patients. TOEPVA was performed in 20 of these patients who did not want a cervical scar, and focused surgery was performed in the remaining 37 patients. The variables we analyzed were size, volume, and localization of the adenoma, operative time, presence of bleeding, presence of the recurrent laryngeal nerve damage, preoperative, short-term, and long-term postoperative PTH levels, use of drain, presence of postoperative hypocalcemia, and short-term and long-term calcium levels. RESULTS No laryngeal nerve and mental nerve damage was observed in either group. The mean operative time in focused open surgery was 80.54±33.1 min, while the mean operative time in TOEPVA was 128.21±30.88 (p: 0.794) min. The mean hospitalization period of patients who underwent open surgery was 3.29±1.9 days, while the mean discharge days of patients who underwent endoscopic surgery was 2.40±1.2. (p>0.05). CONCLUSIONS TOEPVA is a safe method in patients who underwent parthyroid surgery to avoid cervical scarring.

Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage.

BACKGROUND: Trials of surgical evacuation of supratentorial intracerebral hemorrhages have generally shown no functional benefit. Whether early minimally invasive surgical removal would result in better outcomes than medical management is not known. METHODS: In this multicenter, randomized trial involving patients with an acute intracerebral hemorrhage, we assessed surgical removal of the hematoma as compared with medical management. Patients who had a lobar or anterior basal ganglia hemorrhage with a hematoma volume of 30 to 80 ml were assigned, in a 1:1 ratio, within 24 hours after the time that they were last known to be well, to minimally invasive surgical removal of the hematoma plus guideline-based medical management (surgery group) or to guideline-based medical management alone (control group). The primary efficacy end point was the mean score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes, according to patients' assessment) at 180 days, with a prespecified threshold for posterior probability of superiority of 0.975 or higher. The trial included rules for adaptation of enrollment criteria on the basis of hemorrhage location. A primary safety end point was death within 30 days after enrollment. RESULTS: A total of 300 patients were enrolled, of whom 30.7% had anterior basal ganglia hemorrhages and 69.3% had lobar hemorrhages. After 175 patients had been enrolled, an adaptation rule was triggered, and only persons with lobar hemorrhages were enrolled. The mean score on the utility-weighted modified Rankin scale at 180 days was 0.458 in the surgery group and 0.374 in the control group (difference, 0.084; 95% Bayesian credible interval, 0.005 to 0.163; posterior probability of superiority of surgery, 0.981). The mean between-group difference was 0.127 (95% Bayesian credible interval, 0.035 to 0.219) among patients with lobar hemorrhages and -0.013 (95% Bayesian credible interval, -0.147 to 0.116) among those with anterior basal ganglia hemorrhages. The percentage of patients who had died by 30 days was 9.3% in the surgery group and 18.0% in the control group. Five patients (3.3%) in the surgery group had postoperative rebleeding and neurologic deterioration. CONCLUSIONS: Among patients in whom surgery could be performed within 24 hours after an acute intracerebral hemorrhage, minimally invasive hematoma evacuation resulted in better functional outcomes at 180 days than those with guideline-based medical management. The effect of surgery appeared to be attributable to intervention for lobar hemorrhages. (Funded by Nico; ENRICH ClinicalTrials.gov number, NCT02880878.).

[Mitral valve surgery via minimally invasive and conventional access]. / Mitral'naya khirurgiya iz mini- i traditsionnogo dostupov.

OBJECTIVE: To compare the immediate results of mini-thoracotomy and sternotomy in patients with mitral valve disease. MATERIAL AND METHODS: The study included 52 patients who underwent mitral valve surgery (25 cases - mini-thoracotomy, 27 cases - sternotomy). RESULTS: Aortic cross-clamping time was significantly longer in sternotomy compared to mini-thoracotomy group - 110 vs 94 min (p=0.03). Ventilation time was also significantly longer in the sternotomy group (12 vs. 8 hours, p=0.01). Postoperative morbidity was similar (postoperative wound infection, neurological complications, coronavirus disease, overall in-hospital mortality). CONCLUSION: In addition to cosmetic effect, minimally invasive approach in mitral valve surgery has some other advantages including less duration of aortic cross-clamping and mechanical ventilation, availability of reconstructive interventions due to better exposition of the mitral valve and subvalvular structures.

[Direct transfistulous ultrasound in minimally invasive surgical treatment of infected pancreatic necrosis]. / Pryamoe chresfistul'noe ul'trazvukovoe issledovanie pri minimal'no invazivnom khirurgicheskom lechenii patsientov s infitsirovannym pankreonekrozom.

OBJECTIVE: To develop a method for direct transfistulous ultrasound in minimally invasive treatment of infected pancreatic necrosis. MATERIAL AND METHODS: There were 148 patients with infected pancreatic necrosis between 2015 and 2019 at the Krasnodar City Clinical Hospital No. 2. Drainage with 28-32 Fr tubes was carried out at the first stage, endoscopic transfistulous sequestrectomy - at the second stage (19 (12.8%) patients). In 84 (56.8%) patients, we applied original diagnostic method (transfistulous ultrasonic assessment of inflammatory focus). RESULTS: There were 3 accesses to omental bursa in 93 (62.8%) patients and 2 in 43 (29.1%) patients. We also performed 2 access to retroperitoneal space in 63 (42.6%) patients and 1 access in 38 (25.8%) cases. Transfistulous ultrasound was used once in 19 (22.6%) patients, twice in 28 (33.3%) and 3 times in 37 (44.1%) patients. Examination was not performed in 18 (12.2%) patients due to the following reasons: migration of drainage catheters - 5, non-rectilinear fistulous tract - 13. No complications were observed. CONCLUSION: Transfistulous ultrasound makes it possible to diagnose pathological changes in the pancreas and parapancreatic tissue at various stages of surgical treatment.

Complications after Nuss bar removal procedure for pectus excavatum. Analysis and proposal of a safety protocol. / Complicaciones tras retirada de barra de Nuss en pectus excavatum. Análisis y propuesta de un protocolo de seguridad.

OBJECTIVE: The Nuss bar removal procedure may bring about different complications. Some are mild while others can be life-threatening. An adequate surgery setup and the fulfilment of some security steps may reduce their incidence. This study aims to analyze our experience with the complications that occurred during bar removal and our safety protocol for the prevention and management of these complications. MATERIALS AND METHODS: Observational cohort study from a retrospective chart review of all patients who underwent Nuss bar removal from November 2013 to March 2022 at a University hospital. Variables analyzed include patients' demographics; presence of comorbidities; time elapsed from bar placement to removal, and the occurrence of operative and postoperative complications. Study written under the 'PROCESS Guideline'. RESULTS: Fourty (40) patients were included in the study; 37 were male. One bar was removed in 17 patients and two in 22 patients. Median age at surgery: 17.5 years (Percentile 25-75%: 16.75-19.25). Time elapsed from placement to removal: 26 months (Percentile 25-75%: 23.75-30.25). Complications: 10 in 9 patients (22.5%); 6 Clavien-Dindo class I (67%); 2 class II (22%); 1 class IIIb, 1 class IV. The hemorrhagic complication motivated the development of a safety protocol to reduce incidence of complications. CONCLUSION: Nuss bar removal is a safe procedure with usually scant complications. Nonetheless, these may be serious sometimes. To prevent them, a protocol for a safe procedure is important.

OBJETIVO: La retirada de la barra de Nuss puede provocar diversas complicaciones, algunas leves y otras potencialmente mortales. Su incidencia puede verse reducida con una preparación quirúrgica adecuada y siguiendo ciertos pasos de seguridad. El presente estudio tiene por objeto analizar nuestra experiencia con las complicaciones acontecidas durante la retirada de la barra, así como nuestro protocolo de seguridad para la prevención y el manejo de dichas complicaciones. MATERIAL Y METODOS: Estudio de cohortes observacional llevado a cabo a partir del análisis retrospectivo de todos los pacientes sometidos a cirugía de retirada de barra de Nuss entre noviembre de 2013 y marzo de 2022 en un hospital universitario. Se analizaron las siguientes variables: demografía de los pacientes, presencia de comorbilidades, tiempo desde la colocación de la barra hasta su retirada, y complicaciones operatorias y postoperatorias. El estudio se realizó conforme a las directrices de la PROCESS Guideline. RESULTADOS: Se incluyó a 40 pacientes, 37 de ellos varones. En 17 pacientes se retiró una barra, y en 22, dos. La edad media en el momento de la cirugía fue de 17,5 años (percentil 25-75%: 16,75 - 19,25). El tiempo transcurrido desde la colocación hasta la retirada fue de 26 meses (percentil 25-75%: 23,75 - 30,25). Se registraron 10 complicaciones en 9 pacientes (22,5%), 6 de clase I según la clasificación de Clavien-Dindo (67%), 2 de clase II (22%), 1 de clase IIIb y 1 de clase IV. La complicación hemorrágica motivó la creación de un protocolo de seguridad para disminuir la incidencia de las complicaciones. CONCLUSION: La retirada de la barra de Nuss es un procedimiento seguro, habitualmente con escasas complicaciones, aunque en ocasiones pueden ser graves. Para evitarlas, es importante contar con un protocolo que garantice la seguridad.

Da Vinci Robotic Surgical System: Early Experience from Pakistan.

OBJECTIVE: To determine the outcomes of robotic surgeries using the Da Vinci robotic surgical system (DVSS) at Pakistan's largest urological tertiary healthcare system. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Minimally Invasive and Robotic Surgery, Division of Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 2017 to December 2021. METHODOLOGY: Hospital records of patients who underwent robotic urological surgeries were assessed for their outcomes in terms of blood loss, mortality, system malfunction, and conversion to open surgery. Descriptive statistics were determined. RESULTS: A total of 550 procedures were performed. The mean age recorded was 39.58±16.83 years. The mean blood loss recorded was 255.611±353.57 ml; there were 3 cases of malfunction. Forty cases were converted to open surgery, and the mortality rate was 1.1%. CONCLUSION: Minimally invasive surgical techniques have high precision, fewer complications, and lower morbidity rates. Using DVSS for surgical interventions is both effective and safe. KEY WORDS: Minimally invasive surgery, Da Vinci robotic surgical system, Robotic surgery.

Evaluation of the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion: cumulative sum analysis and risk-adjusted cumulative sum analysis.

PURPOSE: To evaluate the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF) using the Cumulative Sum (CUSUM) analysis and Risk-adjusted Cumulative Sum (RA-CUSUM) analysis. METHODS: This study retrospectively analyzed 184 consecutive patients who received ULIF in our hospital, including 104 males and 80 females. CUSUM analysis and RA-CUSUM analysis were used to evaluate the learning curve of ULIF based on the operation time and surgical failure rate, respectively. All postoperative complications were defined as surgical failure. Variables of different phases were compared based on the learning curve. RESULTS: The CUSUM analysis showed the cutoff point for ULIF was 29 cases, and the RA-CUSUM analysis showed the cutoff point for ULIF was 41 cases. Operating time and hospital stay were significantly decreased as the learning curve progressed (P < 0.05). Visual analogue score (VAS) and Oswestry disability index (ODI) at the last follow-up were significantly lower than preoperatively. At the last follow-up, a total of 171 patients reached intervertebral fusion, with a fusion rate of 92.9% (171/184). A total of eleven complications were observed, and RA-CUSUM analysis showed that the incidence of complications in the early phase was 17.07% and in the late phase was 2.6%, with a significant difference (P < 0.05). CONCLUSION: ULIF is an effective minimally invasive lumbar fusion surgical technique. But a learning curve of at least 29 cases will be required to master ULIF, while 41 cases will be required to achieve a stable surgical success rate.

Is pregnancy safe with an implanted pectus bar? An uneventful pregnancy with implanted pectus bar following correction of pectus excavatum.

Limited data are available on the implications on pregnancy following pectus bar implantation for correction of pectus excavatum (Nuss procedure), while the pectus bars are in place. Limited data is also available on long-term reproductive implications following pectus bar removal.Providers at times need to consider the necessity to counsel a woman desiring pectus excavatum correction and pregnancy whether to postpone one of the two in favour of the other.We present the case of a woman of reproductive age with an uneventful pregnancy and delivery while carrying an implanted pectus bar and subsequent uneventful pregnancy and delivery after bar removal.

Develop of endocavitary suction device for MiECC on minimally invasive mitral valve surgery.

The minimally invasive extracorporeal circulation (MiECC) system was developed to minimize the contact of blood with air and foreign surfaces during conventional cardiopulmonary bypass (CPB). It is also aimed to reduce the inflammatory response by further increasing the biocompatibility of the components that make up the MiECC circuits. The Minithoracotomy (MTH) approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in intensive care unit (ICU) and in hospitalization, with finally a reduction in global cost. Combining the use of the MiECC technique with minimally invasive mitral valve surgery (MIMVS) could open up new research scenarios. Although considerable progress has been made in the standardization of the surgical technique, limitations remain to be filled in the setting of Endo-cavitary aspiration for the association of MiECC with MIMVS. In this paper we introduce invention refers to a device and an air-closed endocavitary aspiration system for cardiac chamber surgery, as well as a method aimed at eliminating gaseous micro-embolic activity, hemolysis and CO2 aspiration and alteration of carbon dioxide production (VCO2) the parameters for goal directed perfusion. The system allows the surgery of the cardiac chambers to be associated with a minimally invasive extra-corporeal circulation circuit.

Impact of delayed removal of pectus bar on outcomes following Nuss repair: a retrospective analysis.

BACKGROUND: Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. METHODS: Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. RESULTS: Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0-16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P = 0.026), higher callus formation rates (68.8% vs. 46.9%; P = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P = 0.017) than group A [median duration: 4.2 (3.0-5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P = 0.308). CONCLUSIONS: Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.

[Minimally invasive removal of dumbbell shaped schwannomas with transforaminal lumbar fusion: a retrospective study with a minimum 3-year follow-up]. / Minimal'no invazivnoe udalenie ganteleobraznykh shvannom s transforaminal'nym poyasnichnym spondilodezom: retrospektivnoe issledovanie s minimal'nym 3-letnim katamnezom.

Currently, there are no standards in surgical treatment of dumbbell-shaped tumors of lumbo-foraminal region. OBJECTIVE: To evaluate the effectiveness and long-term results of minimally invasive resection of dumbbell-shaped lumbar schwannomas Eden type 2 and 3 combined with transforaminal lumbar interbody fusion and transpedicular stabilization. MATERIAL AND METHODS: A retrospective study included 13 patients (8 men and 5 women) with lumbar dumbbell tumors Eden type 2 and 3 who underwent minimally invasive facetectomy through posterolateral anatomical corridor, microsurgical tumor resection and MI TLIF. We analyzed intraoperative parameters, neurological functions (ASIA scale), clinical characteristics (ODI, SF-36), and complications. Resection quality and area of the multifidus muscle were assessed according to MRI data. All patients were followed-up throughout at least 3-year. RESULTS: Surgery time was 147 min, blood loss - 118 ml, hospital-stay - 7 days. Clinical parameters significantly improved in the follow-up period: ODI score decreased from 72 to 12 (p=0.004), SF-36 PCS increased from 26.24 to 48.51 (p=0.006) and MCS score increased from 29.13 to 53.68 (p=0.002). According to MRI data, no tumor recurrences and severe muscle atrophy (>30%) were observed after 3 years in all cases. Superficial wound infection occurred in 1 (7.7%) case. There were normal neurological functions (ASIA type E) in all patients. CONCLUSION: Minimally invasive facetectomy through posterolateral approach with MI TLIF technology can be used for safe and effective resection of dumbbell-shaped schwannomas Eden type 2 and 3.

Early result of percutaneous full-endoscopic transforaminal lumbar interbody fusion in the treatment of single-level lumbar degenerative diseases: a retrospective study.

OBJECTIVE: The study aimed to evaluate the short-term clinical efficacy of percutaneous full-endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) for lumbar degenerative diseases (LDD). METHODS: From July 2020 to July 2021, 93 patients who underwent single-level lumbar fusion procedure were retrospective analysis. The patients were divided into Endo-TLIF group and transforaminal lumbar interbody fusion (TLIF) group. General demographic and perioperative data were recorded, the clinical outcomes were evaluated using visual analogue scale (VAS) and oswestry disability index (ODI). The disk height (DH) was compared between the two groups. RESULTS: All of the surgical procedures were successfully completed, and the patients were followed for a minimum of 2 years. Intraoperative blood loss, drainage volume, time to independent ambulation and hospital length of stay in the Endo-TLIF group were significantly decreased in comparison with the open TLIF group (p < 0.05). The VAS for back pain on postoperative 7 day and ODI on postoperative 1 month were lower in the Endo-TLIF group than in the open TLIF group (P < 0.05), but no significant difference at 1 year and 2 years postoperatively (P > 0.05). The VAS score of leg pain had no demographic statistically significant differences between the groups (P > 0.05). The DH were significantly heightened after surgery compared to the preoperative height (p < 0.05). CONCLUSION: Endo-TLIF is a minimally invasive, safety surgery which can achieve comparable short-term effects as open TLIF. It may be a promising option for the treatment of LDD.

Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients.

The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.

Propensity matched analysis of minimally invasive and open radical resection for rectal cancer: comparison of short-term outcomes in elderly/frail patients.

Although minimally invasive surgery (MIS), such as robotic and laparoscopic procedures, is sometimes a better option than open surgery for patients with rectal cancer, it can present challenges for some elderly or frail patients who have a higher risk of chronic illnesses and poor surgical tolerance. On the basis of several pathophysiological characteristics, the patients were grouped according to their age. The time nodes, which are 65 and 80 years old, can clarify the goal of the study and offer some therapeutic benefit. These subgroups stand to gain a great deal from MIS because of its superior arm of machinery and imagery. The short-term oncological outcomes and postoperative conditions of robotic surgery, laparoscopic surgery, and conventional open surgery were compared in this study using a propensity-matched analysis. In this retrospective study, a total of 2049 consecutive patients who underwent proctectomy between September 2017 and June 2023 were chosen. We then carried out a propensity matching analysis based on inclusion criteria. Patients were split into two age groups: 65-80 and > 80. While the secondary objective was to further investigate the similar characteristics between RS and LS, the major objective was to compare oncological outcomes and postoperative conditions between MIS and OS. K-M survival curves were used to represent oncological outcomes and survival conditions. Complication rate and mFI score were used to assess postoperative conditions. Regarding the functional outcomes, the LARS scale was applied to create questionnaires that calculated the anal function of the patients. 110 cases from the group of patients aged 65-80 were successfully merged after matching 1: 1 by propensity score, whereas 73 instances from patients aged > 80 were incorporated while examining the primary objective between OS and MIS. Regarding the secondary goal, each group contained 45 cases for patients above 80 and 65 cases for patients aged 65-80, respectively. Faster recovery from MIS included quicker first flatus passage, earlier switch to liquid nutrition, and shorter hospital stay. In the meantime, MIS also showed benefits in terms of the proportion of low mFI scores and the rates of wound complications in the two age groups. Less blood loss and shorter operational time are further MIS features. On the other hand, MIS experienced more pulmonary complications than OS. Robotic surgery was statistically no different from laparoscopic surgery in patients aged 65-80, although it was superior in terms of operative time and recovery. Comparable and satisfactory oncological and survival results were obtained with all three treatments. For elderly/frail patients with rectal cancer, MIS could be recognized as an effective procedure with favorable outcomes of recovery that are accompanied by better postoperative conditions. While, robotic surgery is slightly better than laparoscopic surgery in some aspects. However, to further demonstrate the effectiveness of three surgical modalities in treating certain groups, multi-center prospective studies are required.

Long-term outcomes of robot-assisted versus minimally invasive esophagectomy in patients with thoracic esophageal cancer: a propensity score-matched study.

BACKGROUND: Recently, robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity worldwide. Some studies have compared the long-term results of RAMIE and minimally invasive esophagectomy (MIE). However, there are no reports on the long-term outcomes of RAMIE in Japan. This study compared the long-term outcomes of RAMIE and MIE. METHODS: This retrospective study included 86 patients with thoracic esophageal cancer who underwent RAMIE or MIE at our hospital from June 2010 to December 2016. Propensity score matching (PSM) was employed, incorporating co-variables such as confounders or risk factors derived from the literature and clinical practice. These variables included age, sex, body mass index, alcohol consumption, smoking history, American Society of Anesthesiologists stage, comorbidities, tumor location, histology, clinical TNM stage, and preoperative therapy. The primary endpoint was 5-year overall survival (OS), and the secondary endpoints were 5-year disease-free survival (DFS) and recurrence rates. RESULTS: Before PSM, the RAMIE group had a longer operation time (min) than the MIE group (P = 0.019). RAMIE also exhibited significantly lower blood loss volume (mL) (P < 0.001) and fewer three-field lymph node dissections (P = 0.028). Postoperative complications (Clavien-Dindo: CD ≥ 2) were significantly lower in the RAMIE group (P = 0.04), and postoperative hospital stay was significantly shorter than the MIE group (P < 0.001). After PSM, the RAMIE and MIE groups consisted of 26 patients each. Blood loss volume was significantly smaller (P = 0.012), postoperative complications (Clavien-Dindo ≥ 2) were significantly lower (P = 0.021), and postoperative hospital stay was significantly shorter (P < 0.001) in the RAMIE group than those in the MIE group. The median observation period was 63 months. The 5-year OS rates were 73.1% and 80.8% in the RAMIE and MIE groups, respectively (P = 0.360); the 5-year DFS rates were 76.9% and 76.9% in the RAMIE and MIE groups, respectively (P = 0.749). Six of 26 patients (23.1%) in each group experienced recurrence, with a median recurrence period of 41.5 months in the RAMIE group and 22.5 months in the MIE group. CONCLUSIONS: Compared with MIE, RAMIE led to no differences in long-term results, suggesting that RAMIE is a comparable technique.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis.

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial).

INTRODUCTION: Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS: This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION: This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER: NCT05731973.

Pre- and intra-operative risk factors predict postoperative respiratory failure after minimally invasive oesophagectomy.

OBJECTIVES: Severe pulmonary complications such as postoperative respiratory failure can occur after minimally invasive oesophagectomy. However, the risk factors have not been well identified. The goal of this study was to develop a predictive model for the occurrence of postoperative respiratory failure with a large sample. METHODS: We collected data from patients with oesophageal cancer who had a minimally invasive oesophagectomy at Shanghai Chest Hospital from 2019 to 2022. Univariable and backward stepwise logistic regression analysis of 19 pre- and intra-operative factors was used before model fitting, and its performance was evaluated with the receiver operating characteristic curve. Internal validation was assessed with a calibration plot, decision curve analysis and area under the curve with 95% confidence intervals, obtained from 1000 resamples set by the bootstrap method. RESULTS: This study enrolled 2,386 patients, 57 (2.4%) of whom developed postoperative respiratory failure. Backward stepwise logistic regression analysis revealed that age, body mass index, cardiovascular disease, diabetes, diffusion capacity of the lungs for carbon monoxide, tumour location and duration of chest surgery ≥101.5 min were predictive factors. A predictive model was constructed and showed acceptable performance (area under the curve: 0.755). The internal validation with the bootstrap method proves the good agreement for prediction and reality. CONCLUSIONS: Obesity, severe diffusion dysfunction and upper segment oesophageal cancer were strong predictive factors. The established predictive model has acceptable predictive validity for postoperative respiratory failure after minimally invasive oesophagectomy, which may improve the identification of high-risk patients and enable health-care professionals to perform risk assessment for postoperative respiratory failure at the initial consultation.

Laparoscopic necrosectomy for acute necrotizing pancreatitis: mesocolon-preserving approach and outcomes.

The surgical treatment of acute necrotizing pancreatitis has significantly evolved in recent years with the advent of enhanced imaging techniques and minimally invasive surgery. Various minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD) and endoscopic transmural necrosectomy (ETN), have been employed in the management of acute necrotizing pancreatitis and are often part of step-up approaches. However, almost all reported step-up approaches only employ a fixed minimally invasive technique prior to open surgery. In contrast, we implemented different minimally invasive techniques during the treatment of acute pancreatitis based on the extent of pancreatic necrosis. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, we performed mesocolon-preserving laparoscopic necrosectomy for debridment. The quantitative indication for pancreatic debridment in our institute has been described previously. For acute necrotizing pancreatitis of the pancreatic bed with or without extension into the left retroperitoneum, mesocolon-preserving laparoscopic necrosectomy was performed for debridment. To safeguard the mesocolon, the pancreatic bed was entered via the gastrocolic ligament, and the left retroperitoneum was accessed via the lateral peritoneal attachments of the descending colon. Of the 77 patients requiring pancreatic debridment, 41 patients were deemed suitable for mesocolon-preserving laparoscopic necrosectomy by multiple disciplinary team and informed consent was acquired. Of these 41 patients, 27 underwent percutaneous drainage, 10 underwent transluminal drainage, and 2 underwent transluminal necrosectomy prior to laparoscopic necrosectomy. Two patients (4.88%) died of sepsis, three patients (7.32%) required further laparotomic necrosectomy, and five patients (12.20%) required additional percutaneous drainage for residual infection. Three patients (7.32%) experienced duodenal fistula, all of which were cured through non-surgical treatments. Nineteen patients (46.34%) developed pancreatic fistula that persisted for over 3 weeks, with 17 being successfully treated non-surgically. The remaining two patients had pancreatic fistulas that lasted over 3 months; an internal drainage procedure has been planned for them. No patient developed colonic fistula. Mesocolon-preserving laparoscopic necrosectomy proved to be safe and effective in selected patients. It can serve as a supplementary procedure for step-up approaches or as an alternative to other debridment procedures such as VARD, ETN, and laparotomic necrosectomy.