Showing papers in "Surgical Laparoscopy Endoscopy & Percutaneous Techniques in 2020"

Laparoscopic Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients With Morbid Obesity: Technical Description and Short-term Outcomes.

Abstract: BACKGROUND Morbid obesity has been recognized as a public health crisis, particularly in developed countries. Single anastomosis sleeve ileal (SASI) bypass has been introduced as a novel bariatric and metabolic procedure. The present study aimed to describe the technical steps and assess the short-term outcomes of SASI bypass in patients with super morbid obesity. PATIENTS AND METHODS Adult patients of both sexes with body mass index (BMI) ≥50 kg/m underwent SASI bypass and were followed for 12 months postoperatively. Changes in BMI, excess weight loss (EWL), and improvement in comorbidities were recorded on follow-up. RESULTS Twenty patients (17 female) of the mean age of 35.4 years were included in the study. The mean preoperative BMI (53.7±5.9) showed a significant decrease at 6 months (39.9±5.2) and then at 12 months (33.6±6) postoperatively. The mean %EWL was 44.3±7.8 at 6 months and 65.2±12.6 at 12 months. All patients with diabetes mellitus, osteoarthritis, and reflux esophagitis showed resolution at 12 months after the SASI bypass. Complications were recorded in 2 patients and no mortality was reported. CONCLUSIONS SASI bypass is an effective and safe bariatric procedure that confers significant loss of weight and improvement in medical comorbidities. As compared with previous studies on patients with lower BMI, patients with super morbid obesity attained lower %EWL but similar resolution of diabetes mellitus at 12 months after SASI bypass.

Transoral Endoscopic Thyroidectomy Vestibular Approach: An Initial Experience in Vietnam.

Abstract: Background Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be applied to many health facilities worldwide, even in places whose medical facilities have not developed yet. To that end, our hospital is the first hospital to deploy this novel technique in Vietnam. In the study, the authors will evaluate the safety and efficacy of TOETVA, which was initially performed on patients in Vietnam. Materials and methods A TOETVA research was conducted on 28 patients in hospital K from January 1, 2018 to May 31, 2019. The surgical outcomes, cosmetic results, and complications were evaluated. Results The mean operative time was 91 minutes (70 to 130 min). There were no cases with temporary and permanent hypoparathyroidism in the patients. One patient had temporary mental nerve injury recovered completely after 14-day surgery. No case used drains in patients. All patients were highly satisfied with the surgical outcome, especially, cosmetic results. Conclusions TOETVA is a safe and feasible technique with acceptable complication rates and good outcomes. The authors will carry on this procedure for selected patients. TOETVA should not only be performed in some countries with well-developed health care systems but also be done in other developing countries worldwide.

SARS-Cov-2 Was Not Found in the Peritoneal Fluid of an Asymptomatic Patient Undergoing Laparoscopic Appendectomy.

Abstract: Background The safety of laparoscopic surgery in SARS-CoV-2 positive patients remains unclear. The presence of the virus within peritoneal fluid and the peritoneal tissues is not known. We report an asymptomatic COVID-19 positive patient who underwent laparoscopic appendectomy with negative peritoneal sampling for SARS-CoV-2. Materials and methods During a standard 3 port laparoscopic surgery samples peritoneal fluid, peritoneal brushings, and surgical smoke plum were collected. Specific real-time reverse transcriptase-polymerase chain reaction targeting SARS-CoV-2 were used to detect the presence of the virus in the samples. Results SARS-CoV-2 was not detected on multiple samples of the peritoneum in an asymptomatic patient. Conclusions SARS-CoV-2 was not found in the peritoneum of a single patient with asymptomatic infection. Further studies comparing SARS-CoV-2 surgical candidates are needed to address safety concerns.

Short-term Results After Totally Robotic Restorative Total Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Abstract: In this study, we aimed to present our initial experience on totally robotic total restorative proctocolectomy in ulcerative colitis (UC) patients. Patients undergoing a totally robotic restorative total proctocolectomy with ileal J-pouch anal anastomosis for UC between January 2015 and November 2017 were included. The da Vinci Xi was used for the operations. Patient demographics, perioperative and short-term operative outcomes were evaluated. Ten patients were included. The median operative time was 380 minutes(range, 300 to 480 min). The median blood loss was 65 mL (range, 5 to 400 mL). No conversion to open surgery was needed. The median time to flatus was 1 day (range, 1 to 2) and length of stay was 6 (4 to 12) days. Short-term complications (≤30 d) were superficial wound infection (n=3), anal bleeding (n=1), pouchitis (n=1). No mortality was observed during the study period. Our study, which is the largest series so far, reveals that totally robotic restorative proctocolectomy is a safe and feasible option for the surgical treatment of UC.

Robotic-assisted Pancreaticoduodenectomy: Technique Description and Performance Evaluation After 60 Cases.

Abstract: Purpose Robotic pancreaticoduodenectomy (RPD) remains one of the most challenging abdominal operations. During the implementation of new surgical technologies, safety and efficacy outcomes must be rigorously monitored and the learning curve clearly identified. Materials and methods The authors investigated their experience during the adoption of RPD, analyzing the outcomes of our first 60 consecutive cases, divided into group A (1 to 30) and group B (31 to 60). The cumulative sum (CUSUM) analysis was used to define the learning curve. Results The authors observed a reduction in operative time (125 min) and estimated blood loss (185 mL) between the firsts 1 to 30 and the latest 30 cases. The overall rate of complications showed the tendency to decrease during the experience (46.7% vs. 23.3%, P=0.02), conversely, severe complications and the rate of clinically relevant postoperative pancreatic fistula did not show a significant reduction in the incidence (P=0.37 and P=0.67, respectively). The mean number of lymph nodes harvested improved significantly after 30 cases (P=0.004). Conclusion Surgical performance improved significantly after the first 30 cases.

The First Report of Robotic Bilateral Modified Radical Neck Dissection Through the Bilateral Axillo-breast Approach for Papillary Thyroid Carcinoma With Bilateral Lateral Neck Metastasis.

Abstract: BACKGROUND Robotic unilateral modified radical neck dissection (MRND) has been reported to be safe and achieves good oncologic results. However, there is no report of successful robotic bilateral MRND to date. We report the first case series of robotic bilateral MRND through the bilateral axillo-breast approach (BABA). METHODS AND RESULTS We reviewed 4 patients who presented with papillary thyroid cancer and metastasis to both lateral neck compartments. BABA robotic total thyroidectomy with bilateral MRND was performed. There were no incidences of vocal cord palsy, permanent hypoparathyroidism, or chyle leakage. All patients underwent high-dose radioiodine ablation. At last follow-up, imaging tests showed no recurrence and thyroglobulin levels remained low. CONCLUSIONS BABA allows complete compartment-oriented neck dissection with outcomes that may be comparable with open bilateral MRND. BABA robotic surgery could be a good alternative for patients with papillary thyroid cancer and bilateral neck metastasis who wish to avoid long neck scar.

Thoracoscopic Repair of Esophageal Atresia With Distal Tracheoesophageal Fistula (Type C): Systematic Review.

Abstract: AIM This systematic review analyzed outcomes in thoracoscopic "primary" repair of type-C esophageal atresia. MATERIALS AND METHODS The Healthcare Database Advance Search, Embase, Medline, and Cochrane databases in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were researched by 2 independent reviewers. Non-English, mixed procedures (open/thoracoscopic) and staged-repair articles were excluded. RESULTS Between 2000 and 2018, 173 articles were identified of which 14 met the inclusion criteria and 382 neonates analyzed. Lowest reported age and weight were 28 gestational weeks and 830 g, respectively (gestational weeks: 28 to 41 wk; birth weight: 830 to 3960 g), with 136/382 (36%) having associated comorbidities. All procedures were performed in Cuschieri modified decubitus position with 3 ports (3.5 to 5 mm) and 30-degree scopes. Azygos vein sparing approach was reported in 4/14 (28.5%) articles; and if divided 70% preferred sealing/diathermy devices. Preferences for fistula ligation were sutures in 5/13 (38%) articles, clips or hemlock in 4/13 (30.7%), sutures with clips in 4/13 (30.7%) and no data in 1/14. Transanastomotic tubes placement was reported in 9/14 articles (others no data). Chest tube placement was preferred in 9/12 (75%) articles; 3/12 no chest tubes; and 2/14 no data. Intraoperative complications were reported in 9/382 (2.3%) neonates-respiratory instability (5/9), endoclip displacement (2/9), and anastomotic leak requiring conversion (2/9). Conversion to open thoracotomy was reported in 12/14 articles in 37/382 (9.6%) neonates. Postoperative complications were reported in 94/382 (25%); 79/94 (84%) anastomotic strictures, 40/94 (42.5%) anastomotic leaks and 5/94 (5.3%) recurrent fistulation. There were 17/382 (4.4%) lethal outcomes (cardiopulmonary failure, sepsis, and 1 intraoperative tracheal rupture). CONCLUSIONS Thoracoscopic "primary" repair of type-C esophageal atresia is feasible in premature/term neonates with a 1:10 conversion rate. Around one third surgeons prefer azygous sparing approach and three fourth placement of chest tubes, but there is no unanimity on the fistula ligation technique. The procedure has morbidity in one fourth patients and 5% mortality.

Meta-Analysis of Spinal Anesthesia Versus General Anesthesia During Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia

Abstract: OBJECTIVES To evaluate comparative outcomes of spinal anesthesia (SA) and general anesthesia (GA) during laparoscopic total extraperitoneal (TEP) repair of inguinal hernia. METHODS We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Postoperative pain assessed by visual analogue scale (VAS), individual and overall perioperative morbidity, procedure time and time taken to normal activities, were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. RESULTS We identified 5 comparative studies reporting a total of 1518 patients (2134 hernia) evaluating outcomes of laparoscopic TEP inguinal hernia repair under SA (n=1277 patients, 1877 hernia) or GA (n=241 patients, 257 hernia). SA was associated with significantly lower post-operative pain assessed by VAS at 12 hours [mean difference (MD): -0.32; 95% confidence interval (CI), -0.45 to -0.20; P<0.0001] and shorter time to normal activities (MD: -0.30; 95% CI, -0.48 to -0.11; P=0.002) compared with GA. However, it significantly increased risk of urinary retention [odds ratio (OR): 4.02; 95% CI, 1.32-12.24; P=0.01], hypotension (OR: 3.97; 95% CI, 1.57-10.39; P=0.004), headache (OR: 7.65; 95% CI, 1.98-29.48, P=0.003), and procedure time (MD: 3.82; 95% CI, 1.22-6.42; P=0.004). There was no significant difference in VAS at 24 hours (MD: 0.06; 95% CI, -0.06 to 0.17; P=0.34), seroma (OR: 1.54; 95% CI, 0.73-3.26; P=0.26), wound infection (OR: 1.03; 95% CI, 0.45-2.37; P=0.94), and vomiting (OR: 0.84; 95% CI, 0.39-1.83; P=0.66) between the 2 groups. There was a nonsignificant decrease in overall morbidity in favor of GA (OR: 1.84; 95% CI, 0.77-4.40; P=0.17) which became significant following sensitivity analysis (OR: 2.59; 95% CI, 1.23-5.49; P=0.01). CONCLUSIONS Although TEP inguinal hernia repair under SA may reduce pain in early postoperative period, it seems to be associated with increased postoperative morbidity and longer procedure time. It may be an appropriate anesthetic modality in selected patients who are considered high risk for GA. Higher level of evidence is needed.

Reliability and Educational Features of YouTube Videos About Hernia Operations Performed Using Laparoscopic TEP Method

Abstract: PURPOSE The purpose of this study was to assess the reliability, educational features, and popularity of YouTube videos on inguinal hernia operations using the laparoscopic total extraperitoneal (TEP) method on the basis of objective scoring criteria. MATERIALS AND METHODS We reviewed the first 50 videos on TEP. To assess the reliability and educational features of the videos, we used the DISCERN questionnaire score (DISCERN), Journal of the American Medical Association Benchmark criteria (JAMAS), and Global Quality Scores (GQS). We then used Video Power Index (VPI) to assess the videos' power on YouTube, and total extraperitoneal scoring (TEPS) to assess their conformity with the medical technique and also the accuracy, quantity, and quality of the information contained therein. RESULTS In the analysis of the source and contents of videos, the VPI, DISCERN, JAMAS, GQS, and TEPS values of all videos were found to be low. A positive correlation-at a level of 0.988-was found to exist between their number of views and VPI values (r: 0.988, P<0.001). Furthermore, we also observed a positive correlation-at a level of 0.811-between the video's likes and DISCERN scores (r: 0.811, P: 0.004). There was no other statistically significant relationship between other scores and the quantitative features of videos. A positive correlation-at a level of 0.709-was found between the videos' GQS and TEPS (r: 0.709, P: 0.022). No correlation was found among other scores. CONCLUSION Depending on the scoring criteria, the lower scores obtained by those videos show that they do not provide a sufficient level of reliability and quality information.

Cost-Effective Filtrating Suction to Evacuate Surgical Smoke in Laparoscopic and Robotic Surgery During the COVID-19 Pandemic.

Abstract: The wide and fast spread of COVID-19 around the world has led to a dramatic increase in the need for protection products both for carers and for populations. Surgical team protection includes a systematic screening of patients, wearing protection devices by all the operating staff, and adequate management of aerosols. The risk of aerosol dispersal is particularly high during laparoscopic and robotic surgeries due to the interaction between circulating CO2 and surgical smoke that may contain small viral particles. To decrease the risk of virus transmission, many recommendations have been implemented including the use of integrated insufflation devices comprising smoke evacuation and filtration mode. Such devices are lacking in many centers around the world and to overcome this urgent unmet need, we designed a cost-effective filtrating suction as a more readily available alternative.

Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

Abstract: BACKGROUND/PURPOSE To compare the changes in hepatic enzymes and comfort level of the surgeon in low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPPLC, 7 mm Hg) with that of normal pressure pneumoperitoneum laparoscopic cholecystectomy (NPPLC, 14 mm Hg). METHODS Eighty-two patients were randomly divided into 2 groups (LPPLC and NPPLC). Serum levels of bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and lactate dehydrogenase were measured before the operation, at the time of reversal from anesthesia, 24 hours after the operation, and on day 7. Serious adverse events, intra-operative complications, surgeon's comfort level of dissection, operative time, conversion rates to an open procedure, or normal pressure pneumoperitoneum were recorded. RESULTS Of the 41 patients randomized for LPPLC, 8 patients were converted to NPPLC due to difficulty in dissection and 1 converted to open in each group. There was statistically significant fall in mean serum bilirubin level in both the groups in the immediate postoperative period (P<0.05). Statistically significant increase in its level was observed after 24 hours in the NPPLC group only (P<0.05). Levels of mean serum serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactate dehydrogenase increased significantly (P<0.05) in immediate postoperative period and a further increase was observed after 24 hours (P<0.05) in the NPPLC group only. The comfort level of surgeon was found to be significantly better in the NPPLC group. CONCLUSIONS LPPLC is a safe procedure, especially in the hands of an experienced surgeon with clinically insignificant systemic effects. But the comfort level of surgeon is better in normal pressure when compared with low pressure. In patients with deranged hepatic functions undergoing advanced laparoscopic procedures, it is advisable to start the surgery with low-pressure pneumoperitoneum. Pressure may be escalated further as per the surgeon's comfort.

Laparoscopic Pancreaticodudenectomy for Periampullary Tumor: Should it be a Routine? A Propensity Score-matched Study.

Abstract: Introduction Laparoscopic pancreaticoduodenectomy (LPD) is a complex and challenging procedure even with experienced surgeons. The aim of this study is to evaluate the feasibility and surgical and oncological outcomes of LPD compared with open pancreaticoduodenectomy (OPD). Patients and method This is a propensity score-matched analysis for patients with periampullary tumors who underwent PD. Patients underwent LPD and matched group underwent OPD included in the study. The primary outcome measure was the rate of total postoperative morbidities. Secondary outcomes included operative times, hospital stay, wound length and cosmosis, oncological outcomes, recurrence rate, and survival rate. Results A total of 111 patients were included in the study (37 LPD and 74 OPD). The conversion rate from LPD to OPD was 4 cases (10.8%). LPD provides significantly shorter hospital stay (7 vs. 10 d; P=0.004), less blood loss (250 vs. 450 mL, P=0.001), less postoperative pain, early oral intake, and better cosmosis. The length of the wound is significantly shorter in LPD. The operative time needed for dissection and reconstruction was significantly longer in LPD group (420 vs. 300 min; P=0.0001). Both groups were comparable as regards lymph node retrieved (15 vs. 14; P=0.21) and R0 rate (86.5% vs. 83.8%; P=0.6). No significant difference was seen as regards postoperative morbidities, re-exploration, readmission, recurrence, and survival rate. Conclusions LPD is a feasible procedure; it provided a shorter hospital stay, less blood loss, earlier oral intake, and better cosmosis than OPD. It had the same postoperative complications and oncological outcomes as OPD.

A Novel Technique for Performing Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): A Single-port Platform.

Abstract: During transoral endoscopic thyroidectomy vestibular approach (TOETVA), the mental nerve can be injured by the lateral ports. Mental nerve injury is a worrisome complication, which can be minimized by using the single-port platform. A 56-year-old woman was diagnosed with a 5-mm sized papillary thyroid carcinoma on the isthmus. A horizontal 21-mm incision was made on the mucosa at the lower lip, followed by vertical dissection from the mentalis muscles down to the mandibular area. Subsequent hydrodissection widened the working space. For the single-port procedure, the KeyPort system was applied. After inserting the endoscopic instruments, the thyroid isthmus was resected as usual. The patient was discharged without any complications. To our knowledge, this is the first report of single-port TOETVA. Although the indications are limited, a single-port platform can be utilized for TOETVA. This will minimize the risk of mental nerve injury.

The Efficacy of Over-the-Scope Clip Closure for Gastrointestinal Iatrogenic Perforation During Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for Pancreaticobiliary Diseases.

Abstract: BACKGROUND Intestinal perforation is a severe adverse event during pancreaticobiliary endoscopy. The use of over-the-scope clip (OTSC) has recently increased; however, the efficacy of OTSC during pancreaticobiliary endoscopy has not been well studied. AIMS To evaluate the efficacy of OTSC for the closure of gastrointestinal iatrogenic perforation during pancreaticobiliary endoscopy. PATIENTS AND METHODS This was a retrospective multicenter cohort study conducted at 3 tertiary care centers. The inclusion criteria were patients who had gastrointestinal perforation during endoscopic procedures for pancreaticobiliary diseases and underwent perforation closure using OTSC. The primary outcome was the clinical success rate. Secondary outcomes were technical success rates, adverse event rates, and the duration until the start of oral intake after OTSC. RESULTS Ten patients were treated by OTSC from January 2013 to December 2017. In 2 out of 10, the perforations could not be closed completely. In the remaining 8, perforations were closed completely, but intestinal obstruction caused by OTSC occurred in 1 patient. The clinical success rate was 80% (8/10). The technical and adverse event rates were 80% (8/10) and 10% (1/10), respectively. A median resumption timing of oral intake was 5 days (range, 3 to 10 d). CONCLUSION OTSC is considered as effective management for perforations during pancreaticobiliary endoscopy, although careful consideration is required for the indication of OTSC.

Evolution From the U-shaped to Keyhole-shaped Mesh Configuration in the Repair of Paraesophageal and Recurrent Hiatal Hernia.

Abstract: Background Paraesophageal hernia (PEH) and recurrent hiatal hernia (RHH) are prone to recurrences. One adjunct used to reduce recurrences is mesh reinforcement. The optimal configuration is yet to be determined. We present our evolution from the U-shaped to the keyhole pattern. Methods All patients undergoing PEH/RHH repair with mesh between 2013 and 2019 were reviewed for demographic information, perioperative/intraoperative details, postoperative complications, and recurrences. Results Of patients undergoing PEH/RHH repair between 2013 and 2019, 138 were repaired using mesh. Of these, 88 were repaired using the U-shaped configuration and 50 using the keyhole configuration. The U-shaped configuration was used for PEH in 72% and RHH in 28%, while the keyhole configuration was used for PEH in 66% and RHH in 34%. Thirty patients suffered postoperative complications, although there was no difference between the groups. Overall, 28 patients in the U-shaped configuration group (31.8%) had a recurrence of their hiatal hernia identified, compared with 7 patients (14.6%) in the keyhole group (P=0.039). The median time to last follow-up was 21 months (range: 1 to 85) in the U-shaped group and 8 months (range: 1 to 23) in the keyhole group. There was no difference in median time to recurrence, postoperative dysphagia, dilations, or strictures. Conclusions The keyhole pattern mesh was not associated with a higher complication rate compared with the U-shape pattern. Although this study was not a direct comparison between the configurations, it does suggest that the keyhole pattern may lead to fewer recurrences.

Pharmacological Methods of Postoperative Pain Management After Laparoscopic Cholecystectomy: A Review of Meta-analyses.

Abstract: BACKGROUND Laparoscopic cholecystectomy (LC) is the optimal approach for patients with symptomatic cholecystolithiasis. Although LC has some advantages, many patients experience postoperative pain. METHODS In this review, we aimed to study the available information and meta-analyses of pharmacological methods of postoperative pain management in patients undergoing LC. Two researchers conducted a literature search in multiple databases (PubMed, Web of Science, Science Direct, Scopus, EMBASE, and Cochrane Library). Papers on pharmacological management of postoperative pain for patients undergoing LC were considered eligible. All meta-analyses, with or without a systematic search, were included in our review. The researchers read the study titles and abstracts to identify relevant articles and appraise the full-text manuscripts. Of 145 papers, the full-text of 11 articles, which met the inclusion criteria, was studied. Information, including the authors' names, publication data, type of review, patients' characteristics, interventions, outcomes, sample size, pooled effect size, publication bias, and statistical and methodological heterogeneity, was extracted. The collected data were presented descriptively, without further statistical analysis. RESULTS AND CONCLUSIONS Very low to low-quality evidence indicated that pharmacological agents, such as nonsteroidal anti-inflammatory drugs, lidocaine, parecoxib, nefopam, dexamethasone, and magnesium sulfate, could decrease pain intensity in patients undergoing LC. Moreover, moderate to high-quality evidence showed that intravenous infusion of ketamine and opioids, as well as pregabalin, was effective in pain control. Further, robust clinical trials are needed with several arms (eg, pharmacological agents) to compare the efficacy and safety of analgesics under similar clinical conditions and to find optimal regimens for pain management in patients undergoing LC.

An Important Gallbladder Pathology Mimicking Gallbladder Carcinoma: Xanthogranulomatous Cholecystitis: A Single Tertiary Center Experience.

Abstract: Background Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal, or diffuse destructive inflammatory disease of the gallbladder mimicking or being together with the gallbladder carcinoma. This study aimed to evaluate the diagnosis, treatment, and outcomes of patients with XGC as a single tertiary center experience in the light of literature. Materials and methods Data about 34 patients with XGC identified after evaluating 2212 cholecystectomy specimens between January 2013 and December 2018 in a single tertiary center were documented to determine demographics (sex, age), clinical symptoms and findings, biochemical and imaging clues and operative findings, duration of hospitalization, postoperative complications, and histopathologic results. Results Thirty-four patients with XGC were evaluated (17 male and 17 female patients with a mean age of 53; range, 25 to 78). Preoperative diagnosis was chronic calculous cholecystitis in 5 patients, cholelithiasis in 12 cases, acute calculous cholecystitis in 16 and emphysematous cholecystitis in 1 patient. Ultrasound was performed in all patients, computerized tomography in 11, contrast-enhanced magnetic resonance imaging in 9, and magnetic resonance cholangiopancreatography in 7 patients. None of the patients were diagnosed preoperatively. All patients received laparoscopic cholecystectomy, among whom 9 were converted to open. Partial cholecystectomy was performed in 1 patient. One patient with gallbladder adenocarcinoma was treated with radical cholecystectomy. XGC has nonspecific clinical and radiologic findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum. Preoperative imaging studies (ultrasound or computerized tomography) of 34 patients showed a gallbladder stone in 18 patients, microlithiazis in 12 patients, sludge in 10 patients, and gallbladder sclerosis in 5 patients. Conclusions Diagnosis of XGC and differentiation from gallbladder carcinoma may be difficult through preoperative or peroperative studies, even imaging is useful; the definitive diagnosis depends exclusively on pathologic examination. The surgeon should be prepared for every possibility.

Efficacy of Hand and Foot Massage in Anxiety and Pain Management Following Laparoscopic Cholecystectomy: A Controlled Randomized Study.

Abstract: This study was planned and performed to evaluate the effect of foot and hand massage on pain and anxiety management, which is one of the nonpharmacological pain relief methods in patients who undergo laparoscopic cholecystectomy. The present study was designed and conducted in the randomized controlled manner to determine the impacts of foot and hand massage on postoperative pain and anxiety scores of patients who receive laparoscopic cholecystectomy. The universe of the study consisted of the patients who received laparoscopic cholecystectomy between April 2018 and January 2019. The study was completed with 196 patients as 63 patients in the foot massage group, 65 patients in the hand massage group, and 68 patients in the control group. To collect the data, the "Descriptive Characteristics Form," "Visual Analog Scale," and "State-Trait Anxiety Inventory" were used. The pain intensity of patients in the foot massage group and hand massage group were less than in the control group at 90 and 150 minutes after intervention (P<0.05). A significant reduction was determined in the need for analgesics for the patients in the foot massage group and hand massage group compared with the control group (P<0.05). A significant positive relationship was found between pain intensity and state anxiety levels in patients of the foot massage group and hand massage group. Foot and hand massage are influential in decreasing pain and anxiety levels after surgeries for patients who undergo laparoscopic cholecystectomy.

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis.

Abstract: OBJECTIVE The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. METHODS We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. RESULTS We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25). CONCLUSIONS Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.

Retrospective Analysis of Primary Suturing of the Internal Orifice of Perianal Fistula During FiLaC Procedure.

Abstract: Purpose We aimed to evaluate the results of the fistula-tract laser closure associated with primary closure of internal orifice. Materials and methods The surgical objective was to seal the fistula tract using laser energy and closing internal orifice with purse-string suture. Between January 2017 and December 2018, 35 consecutive patients who underwent the laser closure plus internal orifice suturing included. In all 35 patients, the laser procedure was applied then internal orifice was primarily closed with 2-0 polyglactin suture after the debridement of necrotic tissue. Results Among 35 patients (11 female, 24 male), mean age was 43.9±12.9 years. Median follow-up was 11 months (6.0 to 17.6 mo). According to the Park classification; 21 patients (60%) had intersphincteric fistula, 12 (34%) had transsphincteric fistula, 2 (6%) had suprasphincteric or extrasphincteric fistula. There were low/simple and high/complex fistula in 21 (60%) and 14 patients (40%), respectively. Overall, 15/35 (42.9%) patients showed complete healing, 12/35 (34%) had slight drainage with minimal symptoms, 8/35 (22%) patients had persistent symptomatic drainage, and there was no patient with painful symptomatic drainage. On the basis of the Jorge-Wexner continence score, there was no significant difference in patients before and after the procedure. The perfect continence rate was achieved in 32 patients (91%). Conclusion Although the absence of major and minor complications after Fistula Laser Closure (FiLaC) procedure seemed to be a major advantage, we thought that closure of the internal opening by primary suturing has no positive effect on the healing of the perianal fistula.

Long-term Outcomes of Endoscopic Resection for Gastric Subepithelial Tumors.

Abstract: OBJECTIVE The purpose of the current study was to analyze the safety and efficacy of endoscopic resection for gastric subepithelial tumors (SETs) using long-term patient outcome data. PATIENTS AND METHODS A retrospective analysis of 73 consecutive patients with gastric SETs was performed from June 2014 to December 2016. The treatment methods included submucosal dissection, submucosal excavation or endoscopic full-thickness resection (EFTR). In addition to epidemiological data (sex and age), tumor size, surgical parameters, length of stay, complications, costs, and endoscopic, clinicopathologic, and follow-up data were analyzed to compare treatments. RESULTS The complete resection rate was 97.3% (71/73). Three patients experienced complications (4.1%), including 2 with delayed perforation and 1 with perioperative infection. The median postoperative feeding time was 3 days, and the median postoperative hospital stay was 5 days. The median follow-up period was 19 months, with no patient death or tumor recurrence. Among the 38 patients with gastrointestinal stromal tumors, the complete resection rate was 97.4% (37/38). The complete resection and complication rates between the endoscopic submucosal excavation (ESE) group and the EFTR group were not statistically significant. There was no recurrence or metastasis detected among either group; however, the ESE group had earlier postoperative feeding, a shorter postoperative hospital stay, and less hospitalization expenses. CONCLUSIONS Endoscopic resection for gastric SETs (<3 cm) is safe and feasible concerning medium-term and long-term effects. Compared with the EFTR group, the ESE group had earlier postoperative feeding, a shorter postoperative hospital stay, and less hospitalization expenses. Even so, gastric SETs with malignant potential are at risk of recurrence. Larger prospective multicenter studies are warranted.

Laparoscopic Versus Robotic-assisted Suturing Performance Among Novice Surgeons: A Blinded, Cross-Over Study.

Abstract: Robotic-assisted laparoscopy (RAL) presents several advantages over 3-dimensional conventional laparoscopy (3D-CL) that may facilitate laparoscopic suturing especially with novice surgeons. This study compares novice surgeons' suturing performance by 3D-CL and RAL using Objective Structured Assessment of Technical Skill (OSATS), an objective, validated scoring tool. Twenty-two surgeons with no robotic experience completed a standardized suturing task in an experimental setup by both 3D-CL and RAL in a randomized, cross-over design. Two experienced surgeons blindly assessed their performance using OSATS. Median (interquartile range) OSATS scores for 3D-CL and RAL were, respectively, 22.8 (17.4 to 25.8) versus 25.0 (21.9 to 26.5), P=0.032. There was no association between laparoscopic experience and robotic-assisted suturing performance. Thus, this study is, to our knowledge, the first to compare novice surgeons' suturing performance by 3D-CL and RAL using an objective, validated scoring tool and to show better suturing performance when assisted by the robot regardless of experience level.

Postoperative Dysphagia Following Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease.

Abstract: The addition of posterior cruroplasty to magnetic sphincter augmentation (MSA-PC) has been shown to be effective in treating gastroesophageal reflux disease (GERD). This study evaluates the predictors of persistent postoperative dysphagia, one of the major complaints after MSA-PC. From August 2015 to February 2018 the medical records of 118 patients (male=59, female=59) receiving MSA-PC for GERD were reviewed. Postoperative dysphagia was present in 80 patients (67.8%), with 20 (16.9%) requiring dilation for persistent dysphagia. Three patients (2.5%) had the magnetic sphincter augmentation device removed for persistent dysphagia, one was converted to a Nissen fundoplication. The median number of dilations was 1, mean time from surgery to dilation was 5.6 months, and 15/20 (75%) had symptom resolution after 1 to 2 dilations. Dilated patients were more likely than nondilated patients to have atypical GERD symptoms preoperatively (70% vs. 44.7%, P=0.042). After dilation, 93.3% of patients reported a good quality of life.

The Impact of Intraperitoneal Levobupivacaine on Pain Relief After Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Studies.

Abstract: INTRODUCTION The influence of intraperitoneal levobupivacaine on pain relief after laparoscopic cholecystectomy remains controversial. We conducted a systematic review and meta-analysis to explore the impact of intraperitoneal levobupivacaine versus placebo on pain intensity after laparoscopic cholecystectomy. MATERIALS AND METHODS We searched the PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through March 2019 for randomized controlled trials assessing the effect of intraperitoneal levobupivacaine versus placebo on pain intensity after laparoscopic cholecystectomy. This meta-analysis is performed using the random-effect model. RESULTS Six randomized controlled trials are included in the meta-analysis. Overall, compared with the control group after laparoscopic cholecystectomy, intraperitoneal levobupivacaine is associated with substantially reduced pain scores at 2 hours [standard mean difference (SMD)=-0.70; 95% confidence interval (CI)=-1.04 to -0.37; P<0.0001], 4 hours (SMD=-0.61; 95% CI=-0.90 to -0.32; P<0.0001), and 12 hours postoperatively (SMD=-0.31; 95% CI=-0.60 to -0.03; P=0.03), and analgesic requirement (SMD=-0.83; 95% CI=-1.48 to -0.19; P=0.01), but reveals no obvious impact on pain scores at 24 hours postoperatively (SMD=0.09; 95% CI=-0.64 to 0.83; P=0.80) and the incidence of nausea or vomiting (risk ratio=0.69; 95% CI=0.40-1.20; P=0.19). Total adverse events in the levobupivacaine group seem to be lower than that in the control group (risk ratio=0.57; 95% CI=0.38-0.85; P=0.006). CONCLUSION Intraperitoneal levobupivacaine provides additional benefits for pain relief after laparoscopic cholecystectomy.

Five-year weight loss outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) procedures: a systematic review and meta-analysis of randomized controlled trials

Abstract: Background: Laparoscopic vertical sleeve gastrectomy (LVSG) has overtaken the laparoscopic Roux-en-Y gastric bypass (LRYGB) as the most frequently performed bariatric surgical procedure. To date little has been reported on the long-term outcomes of the LVSG procedure comparative to the traditionally favoured LRYGB. We undertook a systematic review and meta-analysis to review the 5-year outcomes of comparing LVSG and LRYGB. We undertook a systematic review and meta-analysis to compare 5-year weight loss outcomes of randomized controlled trials comparing LVSG to LRYGB. Materials and Methods: Searches of electronic databases (PubMed, Embase, CINAHL, Cochrane) were undertaken for randomized controlled trials describing weight loss outcomes in adults at 5 years postoperatively. Where sufficient data was available to undertake meta-analysis, the Hartung-Knapp-Sidik-Jonkman estimation method for random effects model was utilized. The review was registered with PROSPERO and reported following in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Five studies met the inclusion criteria totaling 1028 patients (LVSG=520, LRYGB=508). Moderate but comparable levels of bias were observed within studies. Statistically significant body mass index loss ranged from −11.37 kg/m2 (range: −6.3 to −15.7 kg/m2) in the LVSG group and −12.6 kg/m2 (range: −9.5 to −15.4 kg/m2) for LRYGB at 5 years (P<0.001). Systematic review suggested that LRYGB produced a greater weight loss expressed as percent excess weight and percent excess body mass index loss than LVSG: this was not corroborated in the meta-analysis. Conclusions: Five year weight loss outcomes suggest both LRYGB and LVSG are effective in achieving significant weight loss at 5 years postoperatively, however, differences in reporting parameters limit the ability to reliably compare the outcomes using statistical methods. Furthermore, results may be impacted by large dropout rates and per protocol analysis of the 2 largest included studies. Further long-term studies are required to contradict or validate the results of this meta-analysis.

Laparoscopic Lavage Versus Aspiration Alone in Perforated Acute Appendicitis: A Prospective Randomized Controlled Study.

Abstract: The optimal method for preventing abscesses in perforated appendicitis is unclear. We compared the efficacy of lavage versus aspiration for periappendicular collections/abscesses in perforated appendicitis. Our study included 286 patients. After the removal of the appendectomy material, those who underwent aspiration without prior lavage were assigned to Group I, whereas those who underwent aspiration after lavage with 500 mL physiological saline were assigned to Group II. The primary outcome measure was postoperative complications. Secondary outcome measures were intraoperative complications, morbidity, and mortality. Group I comprised 174 patients (60 female and 114 male; mean age 34.47±17.40 y), whereas Group II comprised 112 patients (39 female and 73 male; mean age 36.22±18.60 y). The 2 groups were not significantly different in age, hospitalization duration, sex, abscess formation, morbidity, or mortality. Our results demonstrate that aspiration of the surgery area without prior lavage is sufficient and can be safely applied in perforated appendicitis.

Long-term Voiding and Sexual Function in Male Patients After Robotic Total Mesorectal Excision With Autonomic Nerve Preservation for Rectal Cancer: A Cross-Sectional Study.

Abstract: Background Robotic surgery can help to identify and preserve the autonomic nerves during total mesorectal excision (TME) compared with open surgery or laparoscopy due to the 3-dimensional image and high dexterity of the robotic system. Therefore, this study aimed to assess voiding and sexual function after robotic TME with autonomic nerve preservation. In particular, we focused on the long-term results in male patients operated by a single experienced surgeon. Materials and methods We surveyed male patients aged 50 years and below at the time of robotic rectal cancer surgery between November 2011 and July 2018. Patients who died and those who had a recurrence and underwent abdominoperineal resection were excluded. The questionnaire covered the International Prostate Symptom Score (IPSS) and the 5-item version of the International Index of Erectile Function (IIEF-5) for voiding and sexual function, respectively. Results Thirty-nine patients (median age, 44 y) were surveyed. IPSS and IIEF-5 scores were 5.7±5.3 and 14.7±8.4, respectively. Only 6 patients (15.4%) complained of poor quality of life due to their urinary symptoms. In sexual function, 10 patients (25.6%) complained severe reduction compared with their preoperative status. The average of postoperative days defined from surgery to the questionnaire was 37.8 months. A significant change in the IIEF-5 score was observed between 1 and 2 years postoperatively (5.8±6.9 vs. 16.5±8.8; P=0.027). Conclusions As we only included male patients who were operated by a single experienced surgeon, the results of robotic TME with pelvic autonomic nerve preservation showed acceptable data in preserving both voiding and sexual functions. Although related clinical factors for poor functional outcomes was not statistically significant due to the small sample size, we could observe an improvement in sexual function between 1 and 2 years after surgery with long-term functional results.

A Randomized Comparison of Carbon Nanoparticles in Endoscopic Lymph Node Dissection Via the Bilateral Areola Approach for Papillary Thyroid Cancer.

Abstract: Objective We assess the value of carbon nanoparticles (CNP) staining in patients undergoing endoscopic thyroidectomy and central compartment lymph node (CLN) dissection via the bilateral areola approach [endoscopic thyroidectomy via bilateral areola approach (ETBAA)]. Methods This was a prospective randomized study. Three hundred two consecutive early-stage thyroid cancer patients eligible for ETBAA were recruited at the Division of Thyroid Surgery, China-Japan Union Hospital, Jilin University, China. CLN were mapped and retrieved under the guidance of stained or unstained CNP. The location, detection rates, positive nodes, and number of stained lymph nodes were compared. Results ETBAA patients were randomly divided into a CNP group (n=152) and a control group (n=150). In the CNP group, the imaging of lymphatic flow could be observed in 1016 (95.9%) lymph nodes, whereas 43 (4.1%) were unstained. The mean number of stained lymph nodes in each procedure was 6.68 (range, 3 to 12). The total number of dissected lymph nodes was 1059 in the CNP group and 872 in the control group (P=0.00). There was a significant difference of inadvertent parathyroidectomy between the 2 groups: 0.5% versus 3.9% in lobectomy (P=0.035) and 0.6% versus 5.2% in total thyroidectomy (P=0.012). However, the rates of hypoparathyroidism were not significantly different (P>0.05). There were no cases of CNP-related adverse effects. Conclusions The lymphatic navigation by CNP increases the number of detected CLN without the involvement of radioactive isotopes. However, CNP did not lower hypocalcemia, did not improve parathyroid hormone range, and there was no significant difference in the percentage of metastatic lymph nodes between the 2 groups.

The Safety and Feasibility of Laparoscopic Technology in Right Posterior Sectionectomy.

Abstract: Background Laparoscopic hepatectomy has been accepted widely due to its advantages as a minimally invasive surgery, but laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to explore the safety and feasibility of LRPS by comparing it with open surgical approaches. Materials and methods Between January 2014 and July 2019, 51 patients who underwent right posterior sectionectomy were enrolled in this study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between 2 groups. Results There were no statistically significant differences in the preoperative data. LRPS showed significantly less blood loss (P=0.001) and shorter hospital stay (P=0.002) than open right posterior sectionectomy, but hospital expenses (P=0.382), operative time (P=0.196), surgical margin (P=0.311), the rate of other complications, and the postoperative white blood cell count, alanine aminotransferase, aspartate aminotransferase, and total bilirubin showed no statistically significant differences between the 2 groups (P>0.05). For hepatocellular carcinoma, the results showed there were no differences in both disease-free survival (P=0.220) and overall survival (P=0.417) between the 2 groups. Conclusions Our research suggests that LRPS is a safe and feasible surgical procedure that is efficient from an oncological point of view. It may be the preferred choice for lesions in the right posterior hepatic lobe.

Role and Outcome of Laparoscopic/Minimally Invasive Surgery for Variety of Colorectal Emergencies.

Abstract: Background Recently, the laparoscopic or minimally invasive approach has become common practice for planned colorectal malignancies. Its use in the emergency setting is limited by various factors, including resource availability and surgical expertise. However, more recent evidence suggests a laparoscopic approach to colorectal emergencies, which is comparable with laparoscopic routine work, and often promising. In this study, authors have investigated the outcome of the laparoscopic approach in both benign and malignant colorectal emergencies. Method Retrospective analysis of prospectively collected data (theater records, histology database, and discharge records) over the course of 9 years. The standard surgical approach included conventional laparoscopic and single-port technique (single-incision laparoscopic surgery). The outcome variables included in the final analysis were: success of the minimally invasive approach, conversion rate, postoperative complications, return to theater, and mortality. Results A total of 202 (males, 110 and females, 92) emergency patients with a median age of 59 years underwent surgery between December 2009 and 2019. The mean operating time was 169 minutes and median American Society of Anesthesiology grade III. Single-incision laparoscopic surgery was used in 19 patients (9.4%). The conversion to open surgery was 12.3% (n=25). The majority of them had primary anastomosis (n= 132, 65.3%).The complications from most to least frequent were: CONCLUSION:: The favorable results obtained in this study underline the theme that with the availability of resources and expertise, it is possible to offer minimal invasive approach to emergency colonic pathology.