Search

Background: Laparoscopic ELAPE surgery has been carried out in our center for a long time, and some modifications have been made in clinical practice. In this study, we compared conventional ELAPE operation with modified ELAPE operation to investigate the efficacy and safety of modified ELAPE operation. Methods: We retrospectively analyzed the data from 339 patients with low rectal cancer undergoing abdominoperineal resection from 2017 to 2021 in the Department of General Surgery, Qilu Hospital of Shandong University. Patients were classified into modified ELAPE groups (199 patients) and conventional ELAPE groups (140 patients). Total operation time, reconstruction time, postoperative hospital stay, total cost, intraoperative data, postoperative short-term and long-term complications and tumor recurrence were compared. Results: The baseline characteristics were comparable between the two groups. Total operation time was less with modified ELAPE group compared to conventional ELAPE group (190.6 ± 33.1 min vs 230.1 ± 51.6 min, P = 0.022). Pelvic floor reconstruction time was also less with modified ELAPE group compared to conventional ELAPE group (4.3 ± 1.2 min vs 11.9 ± 1.7 min, P = 0.004). Positive CRM was observed in 11 and 9 patients in modified ELAPE groups and conventional ELAPE groups (P = 0.744). IOP occurred in 12 and 7 patients in modified ELAPE group and conventional ELAPE group (P = 0.701). Total cost was also less with modified ELAPE group compared to conventional ELAPE group (9004 ± 1146 USD vs 10,336 ± 2047 USD, P = 0.031). The incidence of parastomal hernia was less with modified ELAPE group compared to conventional ELAPE group (7/199 vs 22/140, P < 0.001). Three-year follow-up data did not show any difference in overall survival rate or local occurrence between the two groups. Conclusion: Modified ELAPE surgery is technically safe and feasible, and oncologically comparable to that of conventional ELAPE surgery, which can be considered for popularization and application. [ABSTRACT FROM AUTHOR]

Background: Robotic retro-muscular mesh repair of parastomal hernia (PH) is possible with transversus abdominis release. The aim of this study is to report mid-term results with this method. Methods: Patients who underwent surgery for PH were enrolled in a prospective study. Patients with concomitant midline hernia also underwent Rives repair. Polypropylene meshes with an absorbable buffer mesh were used in the retro-muscular pocket—except PTFE was chosen for inflammatory bowel disease patients. Follow-up was by telephone and physical examination and CT if suspicion of complication. Results: Of the 56 included ostomy patients, 44 had colostomies, 10 had ileostomies, and two had urostomies. Thirty-nine percent had a concomitant hernia, and 25% had recurrent PH. The mean operating time without accessory repair was 156 min (SD 37), and with accessory repairs 220 min (SD 62). One bowel lesion and one vascular injury to the stoma occurred, prompting intraoperative stoma revision without postoperative morbidity. Postoperative complications ensued in 12 patients (23%). One patient had stoma necrosis after 3 weeks and the stoma was relocated. One patient had a mesh infection, 3 patients temporary ileus, one patient hypovolemic renal failure, and two patients experienced a flare-up of their Crohn's Disease. One parastomal abscess was drained percutaneously. The median postoperative stay was 3 days (1–21; mean 3.7 days), and the readmission rate was 8.9%. The recurrence rate at mean and median 24 months follow-up is 5.4%, two in ileostomy patients and one colostomy patient with unaltered bulging where CT shows a relatively large prolapse and recorded as a failure. Conclusion: Robotic Pauli repair has shown promising results. However, repair fails of PH at small bowel ostomies with short mesentery. ePauli/TAR is now the preliminary choice for eligible patients at our site. Comparative studies with the intraperitoneal mesh standard are needed. [ABSTRACT FROM AUTHOR]

Background: Since robotic pancreaticoduodenectomy (R-PD) has emerged as a promising technique for treating periampullary tumors, optimal surgical views across various stages of the surgery are vital. This study aimed to describe the evolution and optimization of the multiple scope transition (MST) method using comprehensive videos and illustrations, particularly from the perspective of the patient-side assistants, to enhance the efficiency and safety of R-PD through its different phases. Methods: We retrospectively analyzed 61 patients who underwent R-PD from April 2021 to May 2023. Results: The median total operation duration was 599 min (415–840 min). The median scope transition times for redocking from the left to central lower position, transition from the central lower to upper position, and port-hopping from the central to right position were 169 s (53–725 s), 55 s (26–165 s), and 120 s (41–260 s), respectively. Owing to the advancements in the scope transition procedures, these scope transition times became shorter with an increase in the number of experiences. No intraoperative complications relevant to scope transition was reported, and the incidence of significant postoperative complications greater than Grade IIIa of the Clavien–Dindo classification was 8.2%. Conclusion: We reported the established role and evolution of the MST method from the standpoint of the patient-side assistants. The comfortable surgical field expansion provided by the MST method can ensure the safe and widespread application of R-PD. [ABSTRACT FROM AUTHOR]

Background: Since the introduction of powered circular staplers in colorectal surgery, there has been growing interest in their impact on reducing complications, particularly anastomotic leakage. This study compared short-term postoperative outcomes between powered and manual circular staplers. Methods: This retrospective study included colorectal cancer patients at the tertiary referral center from April to October 2023 who underwent anterior or low anterior resection (LAR) using a circular stapler. According to energy source, patients were divided into powered and manual groups, which used two powered and four types of manual staplers, respectively. All open, laparoscopic, and robotic approaches were included. Propensity score matching (PSM) analysis was used to reduce selection bias. Postoperative complications within 30 days, especially for anastomosis-related complications, were compared between the groups. Results: Among 511 patients, the powered group was 161 (32%). After PSM, 143 pairs of 286 patients were analyzed. The proportions of LAR were 53.8% and 51.0%, and initial diverting stoma rates were 23.1% and 22.4% for the Powered and Manual groups, respectively. Comprehensive complication rates were similar between the Powered group and the Manual group, without statistical significance (13.3% vs. 21.0%, P = 0.063). Anastomotic leakage was not different between the Powered and Manual groups (4.2% vs. 4.9%, P = 0.782). There was no significant difference in other complications, including anastomotic bleeding, ileus, surgical site infection, and intra-abdominal hematoma. Conclusions: The study implies that powered circular staplers may not significantly reduce postoperative complications, including anastomotic leakages, compared to manual staplers in colorectal surgery of high-volume centers. [ABSTRACT FROM AUTHOR]

Background: Ureteral injury occurs in 0.3–1.5% of colorectal cancer surgeries. Devices to visualize the ureteral course and avoid ureteral injury are required for minimally invasive surgery (MIS). The NIRC™ fluorescent ureteral catheter (FUC) is a versatile ureteral visualization device currently available in Japan that can be used in combination with a variety of laparoscopic and robotic systems. In this study, we examined the outcomes of high-risk patients who underwent colorectal cancer surgery with FUC insertion. Methods: One hundred forty-one patients who underwent MIS for colorectal cancer and colorectal cancer recurrence at our institute between January 2021 and May 2024 underwent preoperative FUC insertion because of the high risk of ureteral injury and surgical difficulty. For these patients, patient background data and short-term outcomes were examined. The results are expressed as the median and interquartile range. Results: Age, 70 [60–78]; M:F(n), 84:57; BMI, 22.1 [19.7–24.7]; T4 (TNM classification), 52 cases (36.9%); preoperative intestinal obstruction, 45 cases (31.9%); abscess formation, 30 cases (21%); surgical history, 70 cases (50%); recurrent cancer, 14 cases (9.9%); preoperative chemo-radiotherapy, 28 cases (19.9%); time required for FUC insertion, 12 [9–19] minutes; operation time, 412 [309–552] minutes; blood loss, 10 [5–30] ml; open conversion, 0 cases; postoperative hospitalization, 12 [9–17.5]; circumferential resection margins < 1 mm (rectal surgery), 4/87 cases (4.6%); comorbidities, 0 ureteral injury, 1 urethral injury during FUC insertion (0.7%) and 16 CD Grade 3 or higher cases (11%). Conclusions: FUC may improve the safety of MIS and reduce blood loss in addition to preventing ureteral injury and is expected to have oncological advantages for ensuring the margin of the tumor without fear of ureteral injury. However, the time required for and complications associated with FUC are challenging. New methods for less invasive and easier ureteral visualization may be needed. [ABSTRACT FROM AUTHOR]

Aim: The literature indicates that patients with prior pelvic surgery, particularly radical prostatectomy, pose challenges in minimally invasive inguinal hernia repair (IHR). However, there is no conclusive evidence regarding the impact of pelvic surgery on postoperative complications. To address this gap, we conducted a systematic review and meta-analysis to evaluate the influence of previous prostatectomy in men undergoing MIS IHR. Materials and methods: We searched Cochrane Central, Scopus, SciELO, Lilacs, and PubMed/MEDLINE for studies comparing men undergoing MIS IHR after prostatectomy with men without previous pelvic surgery. Key outcomes evaluated included recurrence, overall postoperative complications, seroma, hematoma, surgical site infection (SSI), conversion rates, and operative time. Results: Out of 402 screened studies, 9 met the inclusion criteria. Among the included studies, three analyzed totally extraperitoneal (TEP) technique, while four analyzed transabdominal preperitoneal (TAPP) and two presented both techniques together. The analysis comprised 189,183 patients, of which 4551 (2.4%) had a history of prostatectomy. The analysis revealed that post-prostatectomy patients presented higher postoperative complications (3.7% vs. 1.9%; RR 1.9; 95% CI [1.23; 2.94]; P = 0.004) and seroma (1.6% vs. 0.9%; RR 1.58; 95% CI [1.23; 2.04]; P < 0.001) following MIS IHR. Additionally, patients with a previous prostatectomy presented an increased operative time (MD 21.25 min; 95% CI [19.1; 23.4]; P < 0.001). No significant differences were observed in recurrence (0.98% vs. 0.92%; RR 1.1; 95% CI [0.8; 1.53]; P = 0.54), SSI (0.07% VS. 0.07%; RR 0.99; 95% CI [0.34; 2.9]; P = 0.98), hematoma (3.6% vs. 1.2%; RR 3.18; 95% CI [0.84; 12.1]; P = 0.09), and conversion rates (1.1% vs. 0.9%; RR 1.26; 95% CI [0.91; 1.72]; P = 0.16). However, subgroup analysis of TEP technique in patients with previous prostatectomy showed higher conversion rates (2.4% vs. 0%; RR 20; 95% CI [2.9; 138.2]; P < 0.01). Analysis using funnel plots showed the absence of publication bias in the study outcomes. Conclusion: This comprehensive analysis indicates that patients with a history of prostatectomy undergoing MIS IHR may present higher postoperative complications and an increased operative time. Further comparative studies are needed to evaluate the cumulative impact of MIS IHR in patients with previous prostatectomy. [ABSTRACT FROM AUTHOR]

Background: A bridge to surgery (BTS) after self-expandable metallic stent (SEMS) placement is a widely recognized treatment strategy for obstructive colorectal cancer. However, there is still a lack of evidence for the efficacy and safety of laparoscopic surgery following SEMS placement. The aim of this systematic review and meta-analysis was to compare the short-term and long-term outcomes of laparoscopic surgery with those of open surgery following SEMS placement in patients with obstructive colorectal cancer. Methods: An electronic literature search through to December 2022 was performed to identify studies comparing short-term and long-term outcomes between laparoscopic and open surgery following SEMS placement for obstructive colorectal cancer. The main outcome measures were postoperative complication rates and mortality. Secondary outcome measures were the 3-year recurrence-free survival (RFS) and 3-year overall survival (OS) rates. The meta-analysis was performed using fixed-effect or random-effects methods to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: The meta-analysis included 15 studies and 883 patients, of whom 467 (52.9%) underwent laparoscopic surgery and 416 (47.1%) underwent open surgery following SEMS placement. The postoperative complication rate was significantly lower in the laparoscopic surgery group than in the open surgery group (OR 0.47, 95% CI 0.32–0.67, P < 0.001). There was no significant difference in the 3-year RFS rate or 3-year OS rate between the laparoscopic and open surgery groups (3-year RFS, OR 0.78, 95% CI 0.50–1.24, P = 0.30; 3-year OS, OR 0.68, 95% CI 0.41–1.12, P = 0.13). Conclusion: This meta-analysis found that the short-term outcome was better in patients who underwent laparoscopic surgery following SEMS placement than in those who underwent open surgery. Furthermore, there was no significant difference in long-term outcomes between the two groups. Laparoscopic surgery following SEMS placement may be a safe and effective treatment option for obstructive colorectal cancer. [ABSTRACT FROM AUTHOR]

Background: Transcervical mediastinoscopic esophagectomy for esophageal and esophagogastric junction cancer is indicated in select institutions because of the complex surgical technique required and the unfamiliar surgical view compared with the standard transthoracic esophagectomy approach. This study was performed to compare the feasibility and efficacy of bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) with thoracolaparoscopic esophagectomy (TLE) for esophageal cancer. Methods: This study involved 392 consecutive patients with esophageal cancer who underwent curative minimally invasive esophagectomy with R0 resection (excluding salvage, conversion, and two-stage operations and open thoracotomy) at the National Cancer Center Hospital from 2017 to 2022. The patients underwent either BTC-MATLE or TE (32 and 360 consecutive patients, respectively). Propensity score-matching analysis was used to balance the baseline differences by covariates of age, performance status, and clinical stage. Results: There were statistically significant differences in age, performance status, cT factor, cN factor, cStage, preoperative treatment, and surgical history for respiratory disease. After propensity score-matching, these significant differences (excluding a surgical history of respiratory disease) were no longer statistically significant, and 27 patients were assigned to each group. The total operation time and the postoperative intensive care unit stay were significantly shorter in the BTC-MATLE than TLE group. There were no significant differences in overall postoperative complications or the three major postoperative complications of recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia, even for patients whose preoperative pulmonary function indices (vital capacity and forced expiratory volume in 1 s) were significantly lower in the BTC-MATLE than TLE group. The numbers of total and thoracic harvested lymph nodes were significantly higher in the TLE than BTC-MATLE group; however, there was no significant difference in the recurrence rate between the two groups. Conclusion: BTC-MATLE may provide the same feasibility and oncological outcomes as TLE even for patients with significantly lower pulmonary function. [ABSTRACT FROM AUTHOR]

Background: There are limited data on the effect of different sutures and surgical approaches on the quality of pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy (MIPD). This study compares the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between the use of barbed sutures (BSs) and conventional sutures (CSs). Methods: A retrospective cohort study was conducted on 253 consecutive patients who had undergone MIPD from July 2016 to April 2023. Patients were excluded if conversion to open surgery or open anastomosis was necessary. 220 patients were enrolled and divided into BS (n = 148) and CS (n = 72) groups. After 1:1 propensity score matching (PSM), 67 cases remained in each group. Univariate and multivariate analyses identified factors associated with CR-POPF. Comparisons were also made between laparoscopic (LPD) and robotic (RPD) pancreaticoduodenectomy. Results: After PSM, BSs were associated with significantly lower rates of CR-POPF (7.5 vs. 22.4%, P = 0.015) and severe complications (Clavien–Dindo ≥ III) (7.5vs. 19.4%, P = 0.043). No significant differences were found in operative time, length of postoperative hospital stay, or other major morbidities. Multivariate analyses revealed BMI ≥ 22 kg/m2 (OR = 5.048, 95% CI: 1.256–20.287, P = 0.023) and the use of BSs (OR = 0.196, 95% CI: 0.059–0.653, P = 0.008) as the independent predictors of CR-POPF. There were no significant differences in postoperative outcomes between the LPD and RPD groups, but RPD was associated with significantly shorter operative time (402.8 min vs. 429.4 min, P = 0.015). Conclusions: In conclusion, using BSs for PJ during MIPD is feasible and has the potential to reduce CR-POPF and severe complications. [ABSTRACT FROM AUTHOR]

Background: Studies comparing outcomes between robotic and laparoscopic paraesophageal hernia repairs have yielded conflicting results. We sought to analyze early postoperative complications between these approaches using a newly available NSQIP variable indicating robot use. Methods: We queried the 2022 ACS NSQIP database for adult patients undergoing elective minimally invasive hiatal hernia repair. Chi-squared and Kruskal–Wallis tests were used to compare cohort characteristics. Logistic, linear, and Cox proportional hazards regression analyses were used to compare perioperative outcomes between the laparoscopic and robotic groups. Results: We identified 4345 patients who underwent repair using a laparoscopic (2778 patients; 63.9%) or robotic (1567 patients; 36.1%) approach. Most (73.1%) were female, and the median age was 65 (IQR 55, 73). Patients who underwent robotic repair were younger (median age 64 vs 66), had a slightly higher body mass index (BMI; median 30.2 vs 29.9), and were more likely to have hypertension (53.0% vs 48.5%), all p < 0.01. On unadjusted analysis the robotic approach was associated with decreased 30-day mortality (0.0% vs 0.4%, p < 0.01). After adjusting for age, gender, race, BMI, and hypertension, the robotic approach was not associated with increased major complications (5.6% vs 5.1%, AOR 1.13, 95% CI 0.86, 1.49), minor complications (0.9% vs 1.5%, AOR 1.20, 95% CI 0.74, 1.93), or unplanned readmission (6.5% vs 5.5%, AHR 1.17, 95% CI 0.89, 1.54), all p ≥ 0.26. After adjusting for age and hypertension, the robotic cohort had an increased risk of myocardial infarction (AOR 2.53, 95% CI 1.01, 6.33, p = 0.048) and pulmonary embolism (AOR 2.76, 95% CI 1.17, 6.49, p = 0.02), although none resulted in 30-day mortality. Conclusions: Robotic and laparoscopic paraesophageal hernia repairs had similar overall complication and readmission rates. The robotic cohort had an increased risk of myocardial infarction and pulmonary embolism but no 30-day mortality. Current data support the use of both robotic and laparoscopic approaches for paraesophageal hernia repair. [ABSTRACT FROM AUTHOR]

Background: Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24 h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. Methods: A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24 h were excluded. Results: A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25 days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. Conclusion: A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital. [ABSTRACT FROM AUTHOR]

Background: Proximal gastrectomy (PG) is recommended for upper-third gastric cancer and esophagogastric junction (EGJ) cancer, preserving organ function while reducing postoperative symptoms. The double-flap technique (DFT) is one approach to minimize reflux after PG. However, laparoscopic PG with DFT (LPG-DFT) has drawbacks of increased complexity, such as hand sutures for anastomosis. Robotic surgery offers potential advantages for DFT reconstruction, but the safety of robotic DFT following PG (RPG-DFT) in the introductory phase is unknown. Methods: This retrospective study compared the outcomes of RPG-DFT with LPG-DFT. Data from 402 patients (321 LPG-DFT, 81 RPG-DFT) between 2009 and 2023 were analyzed. Propensity score matching balanced patient demographics and tumor characteristics. Surgical parameters, complications, and long-term outcomes were assessed. Results: The surgery time of LPG-DFT has stabilized in patients since 2016. Thus, LPG-DFT from 2016 was defined as a stable procedure. RPG-DFT was started in 2019, after minimally invasive DFT reconstruction had been mastered at our center. Therefore, we compared the surgical outcomes of introductory RPG-DFT with stable LPG-DFT. Matched analysis revealed that RPG-DFT in the introductory phase had significantly longer surgery times but less bleeding and shorter reconstruction times and hospital stays than stable LPG-DFT. Frequencies of short-term complications and reflux esophagitis were comparable in both groups. Although RPG-DFT in the introductory phase exhibited higher incidence of anastomotic stenosis than stable LPG-DFT, the incidence of anastomotic stenosis decreased over time. Conclusions: This study demonstrated the safety of RPG-DFT in the introductory phase for EGJ and upper-third stomach tumors, with outcomes comparable to stable LPG-DFT. RPG-DFT offers shorter reconstruction time and less blood loss compared with LPG-DFT. However, anastomotic stenosis is a complication to monitor in early robotic surgery. [ABSTRACT FROM AUTHOR]

Background: Subtotal cholecystectomy is advocated in patients with severe inflammation and distorted anatomy preventing safe removal of the entire gallbladder. Not well documented in this surgically complex population is the feasibility of intraoperative imaging and management of common bile duct (CBD) stones. We evaluated these operative maneuvers in our subtotal cholecystectomy patients. Methods: We retrospectively reviewed all cholecystectomy cases from 2014 to 2023 at a single Veterans Affairs (VA) Medical Center using VASQIP (VA Surgical Quality Improvement Program), selecting subtotal cholecystectomy cases for detailed analysis. We reviewed operative reports, imaging and laboratory studies, and clinical notes to understand biliary imaging, stone management, complications, and late outcomes including retained stones (within 6 months), and recurrent stones (beyond 6 months). Results: 419 laparoscopic (n = 406) and open (n = 13) cholecystectomies were performed, including 40 subtotal cholecystectomies (36 laparoscopic, 4 laparoscopic converted to open). Among these 40 patients IOC was attempted in 35 and completed in 26, with successful stone management in 11 (9 common bile duct exploration [CBDE], 2 intraoperative endoscopic retrograde cholangiopancreatography [ERCP]). In follow-up, 3 additional patients had CBD stones managed by ERCP, including 1 with a negative IOC and 2 without IOC. Thus, 14 (35%) of 40 patients had CBD stones. Of note, IOC permitted identification and oversewing or closure of the cystic duct in 32 patients. There were no major bile duct injuries and one cystic duct stump leak (2.5%) that resolved spontaneously. Conclusions: Subtotal cholecystectomy patients had a high incidence of bile duct stones, with most detected and managed intraoperatively with CBDE, making a strong argument for routine IOC and single-stage care. When intraoperative imaging is not possible, postoperative imaging should be considered. Routine imaging, biliary clearance, and cystic duct closure during subtotal cholecystectomy is feasible in most patients with low rates of retained stones and bile leaks. [ABSTRACT FROM AUTHOR]

Background: Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics. Methods: We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18–64, 65–74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics. Results: Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8–51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13–18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51–2.93), higher BMI (aOR = 1.18, 95% CI 1.03–1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96–5.04), previous repair (aOR = 1.44, 95% CI 1.02–2.05), and component separation (aOR = 1.98, 95% CI 1.28–3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09–1.34), black (aOR = 1.30, 95% CI 1.12–1.52), with larger hernias: 2–5.9 cm (aOR = 1.76, 95% CI 1.57–1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68–17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14–2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46–3.11) variation. Conclusions: Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR. [ABSTRACT FROM AUTHOR]

Background: The association between surgical performance ratings and clinical outcomes in robotic surgery is poorly understood. Additionally, no studies have reported on the relationship between the surgeon's initial case-skill evaluation and the learning curve in robot-assisted surgery. We evaluated whether an objective surgical technique evaluation score for initial robot-assisted radical prostatectomy (RARP) was associated with clinical outcomes and surgeons' learning curves. Methods: Six surgeons who were trained in and started to perform RARP at our institution were included. Anonymized, unedited videos of each surgeon's 10th RARP case were evaluated by three reviewers, using modified Objective Structured Assessment of Technical Skill (OSATS) scores. We then divided the surgeons into two groups on the basis of these OSATS scores. We retrospectively compared the clinical outcomes and learning curves of the console time of the two groups for consecutive RARPs, performed from March 2018 to July 2023. Results: We analyzed 258 RARPs (43 cases/surgeon), including 129 cases performed by high-OSATS score surgeons (18.2–19.3 points) and 129 cases performed by low-OSATS score surgeons (11.9–16.0 points). Overall, the high-OSATS score group had significantly shorter operation and console times than the low-OSATS score group did (both P < 0.01) and their patients' rate of continence recovery by 3 months post-RARP was significantly higher (P = 0.03). However, complications, blood loss, and positive margins did not differ between the groups (P = 0.08, P = 0.51, and P = 0.90, respectively). The high-OSATS score group had a significantly shorter console time than the low-OSATS score group did after the 11–20 cases. Conclusions: The OSATS score in early RARP cases can predict subsequent surgical outcomes and surgeons' learning curves. [ABSTRACT FROM AUTHOR]

Background: Ablation is an effective, parenchymal-sparing treatment for primary liver cancer and liver metastases. The purpose of this study was to report our initial experience with laparoscopic microwave ablation regarding postoperative complications, rate of conversions to open procedure, and technical efficacy. Methods: This was a quality improvement project carried out at a tertiary care center in Denmark. Patients ≥ 18 years old with liver malignancies, not available for percutaneous ablation, and treated with ultrasound-guided laparoscopic ablation were included. Results: From March 2023 to December 2023, 39 patients were referred for laparoscopic ablation after a multidisciplinary team conference. Of these, two procedures were converted to open procedures due to adhesion and tumor progression. Three patients rejected the sharing of medical information, two procedures were canceled and in one case the strategy was changed perioperatively. Therefore, 32 procedures in 31 patients were available for analysis. Complete ablation was evaluated after 1 month and was achieved in 100% of the procedures. None of the patients died, and no complications were reported in 21 cases (65.6%). Most patients with complications had a grade 1 complication based on the Clavien–Dindo classification, which among others included abdominal and shoulder pain, atrial fibrillation, and subcutaneous hematoma. Two patients had a complication grade 2 (wound infection and decompensated cirrhosis) and one had a grade 4b (sepsis due to pneumonia and urinary tract infection). The median Comprehensive Complication Index was 12.2 (interquartile range 8.7–24.2). Furthermore, univariable logistic regression showed that ≥ 2 tumors treated were associated with a higher risk of complications (odds ratio 6.37, 95% confidence interval [1.20;33.85], p-value = 0.0297). Conclusion: Ultrasound-guided laparoscopic microwave ablation of liver malignancies is feasible and safe with little risk for complications, a high technical efficacy, and a low rate of conversions to open procedures. [ABSTRACT FROM AUTHOR]

Background: The effect of tumor budding (TB) on the prognosis of patients with esophageal squamous cell carcinoma (ESCC) after endoscopic submucosal dissection (ESD) remains unclear. We evaluated the long-term outcomes of patients with superficial ESCC after ESD and the risk factors of TB for the long-term prognosis. Methods: We conducted a retrospective study in a Chinese hospital. All patients with ESCC treated by ESD and reported TB were included consecutively. Comparative analyses were conducted in three parts: specimen analysis, follow-up analyses of unmatched patients, and propensity score-matched (PSM) patients. Cox proportional hazard regression models were constructed to identify risk factors for overall survival and recurrence-free survival (RFS). Results: A total of 437 patients were enrolled [154 TB and 283 no tumor budding (NTB)], and 258 patients (52 TB and 206 NTB) were included in the follow-up analysis. Results showed that the invasion depth, differentiation type, and positive vascular invasion (all p < 0.001) of the TB group were significantly different from the NTB group. The all-cause mortality and the median RFS time between the two groups were comparable. RFS rate at 5 years were 84.6% and 80.6%, respectively (p = 0.43). Cox analyses identified that having other cancers but not TB, as a risk factor independently associated with overall survival and RFS after ESD. Conclusion: TB tends to be associated with invasion depth, differentiation type, and positive vascular invasion. However, it might not affect the long-term outcomes of patients with superficial ESCC after ESD when other high-risk factors are negative. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is a standard procedure for achalasia, an esophageal motility disorder, characterized by a thickened lower esophageal sphincter muscularis propria (LEMP). Visualization of this anatomical stratification has been made possible by the advent of endoscopic ultrasound (EUS). However, the effect of LEMP thickness on treatment outcomes remains unclear. The objective of this study was to investigate whether LEMP thickness affects treatment response post-POEM. Methods: This was a single-center, prospective cohort study of patients who underwent POEM between 2014 and 2021. Patients who underwent EUS to evaluate the LEMP before POEM were included in the study. We divided the patients into two groups according to muscle thickness measured by EUS (≥ 2.80 mm; group 1, < 2.80 mm; group 2). The pre- and post-procedural clinical parameters were compared between the two groups. Results: Among 278 patients, 189 were enrolled. There were no significant differences in the pre- and post-Eckardt scores, integrated relaxation pressure, and distensibility index between the two groups divided by muscle thickness. Furthermore, there was no statistically significant difference in symptom recurrence, as measured by an Eckardt score > 3, post-procedural complications, or post-POEM GERD symptoms. However, patients with thicker lower esophageal sphincter muscle showed a greater decrease in Eckardt scores (ΔES ≥ 3) which was statistically significant (P = 0.002). Conclusion: POEM is an effective and safe treatment method for achalasia, regardless of LES muscle thickness. There was a statistically significant difference in the decrease of Eckardt scores of 3 or greater (ΔES ≥ 3) after POEM in the thicker LEMP group suggesting greater alleviation of symptoms in POEM patients with thicker lower esophageal muscle. [ABSTRACT FROM AUTHOR]

Introduction: There is a paucity of literature comparing safety outcomes between formal fundoplication and gastric fixation procedures for hiatal hernia repairs, especially in the emergency setting. The objective of this study was to evaluate 30-day clinical outcomes between fundoplication and gastric fixation performed in emergency hiatal hernia repairs. Methods: A retrospective cohort study using the National Surgery Quality Improvement Program (NSQIP) database from 2011 to 2021 was conducted. The study population was determined using ICD9/10 codes describing diaphragmatic hernia without obstruction or gangrene, with obstruction, and with gangrene. Elective cases were excluded. CPT codes were used to group fundoplication procedures and gastric fixation procedures. The primary outcome was the 30-day complication rate. Secondary outcomes included 30-day readmission, reoperation and mortality rates. A multivariable logistic regression analysis was used to adjust for clinically relevant confounding variables. Results: A total of 971 and 346 were in the fundoplication and gastric fixation groups, respectively. Fundoplication was associated with a significantly lower (p < 0.05) 30-day complication, reoperation and mortality rates. There was no statistically significant difference with respect to readmission. After adjustment, fundoplication was significantly associated with a decrease in odds of 30-day complications (OR 0.53, p < 0.001 95% CI 0.40–0.71) and mortality (OR 0.55, p = 0.033 95% CI 0.32–0.95). However, there was no significant difference with respect to 30-day readmission (OR 0.86, p = 0.449 95% CI 0.59–1.27) and reoperation (OR 0.66, p = 0.063 95% CI 0.42–1.02). Conclusion: Patients with hiatal hernias that underwent emergent repair with fundoplication had a significantly lower 30-day complication and mortality rates compared to those who underwent gastric fixation procedures. Fundoplication is a safe and feasible approach to manage hiatal hernias in the emergency setting for select patients. [ABSTRACT FROM AUTHOR]

Objective: Textbook outcome (TO) is widely recognized as a comprehensive prognostic indication for patients with gastric cancer (GC). This study aims to develop a modified TO (mTO) for elderly patients with GC. Methods: Data from the elderly patients (aged ≥ 65 years) in two Chinese tertiary referral hospitals were analyzed. 1389 patients from Fujian Medical University Union Hospital were assigned as the training cohort and 185 patients from Affiliated Hospital of Putian University as the validation cohort. Nomogram was developed by the independent prognostic factors of Overall Survival (OS) based on Cox regression. Results: In the training cohort, laparoscopic surgery was significantly correlated with higher TO rate (P < 0.05). Cox regression analysis revealed that surgical approach was also an independent factor of OS (P < 0.001), distinct from the traditional TO. In light of these findings, TO parameters were enhanced by the inclusion of surgical approach, rendering a modified TO (mTO). Further analysis showed that mTO, tumor size, pTNM staging, and adjuvant chemotherapy were independent prognostic factors associated with OS (all P < 0.05). Additionally, the nomogram incorporating these four indicators accurately predicted 1-, 3-, and 5-year OS in the training cohort, with AUC values of 0.793, 0.814, and 0.807, respectively, and exhibited outstanding predictive performance within the validation cohort. Conclusion: mTO holds a robust association with the prognosis of elderly patients with GC, meriting intensified attention in efforts aimed at enhancing surgical quality. Furthermore, the predictive model incorporating mTO demonstrates excellent predictive performance for elderly patients with GC. [ABSTRACT FROM AUTHOR]

Introduction: Dysphagia after anti-reflux surgery (ARS) is one of the most common indications for re-operative anti-reflux surgery and a leading cause of patient dissatisfaction. Unfortunately, the factors affecting its development are poorly understood. We investigated the correlation between pre-operative manometric and the intra-operative impedance planimetry (EndoFLIP™) measurements and development of post-operative dysphagia. Methods: A review of patients who underwent index robotic ARS in our institution. Patients who underwent pre-operative manometry and intra-operative EndoFLIP™ were included in our study. Dysphagia was assessed pre-operatively and at 3-month after surgery. Results: Fifty-five patients (26.9%) reported post-operative dysphagia, and 34 (16.6%) reported new or worsening dysphagia. On pre-operative manometry, patients with post-operative dysphagia had a lower distal contractile integral [868.7 (IQR 402.2–1447) mmHg s cm vs 1207 (IQR 612.1–2111) mmHg s cm, p = 0.006) and lower esophageal sphincter (LES) pressure [14.7 IQR (8.9–23.6) mmHg vs 20.7 IQR (10.2–32.6) mmHg, p = 0.01] compared to those without post-operative dysphagia. They were also found to have higher pre-operative cross-sectional surface area (CSA) [83 IQR (44.5–112) mm2 vs 66 IQR (42–93) mm2, p = 0.02], and distensibility index (DI) [4.2 IQR (2.2–5.5) mm2/mmHg vs 2.9 IQR (1.6–4.6) mm2/mmHg, p = 0.003] compared to patients without post-operative dysphagia. Additionally, the decrease in CSA [− 34 (− 18.5, − 74.5) mm2 vs − 26.5 (− 10.5, − 53.7) mm2, p = 0.03] and DI [− 2.3 (− 1.2, − 3.7) mm2/mmHg vs − 1.6 (− 0.7, − 3.3) mm2/mmHg, p = 0.03] measurements were greater in patients with post-operative dysphagia. Conclusion: Patients who developed dysphagia post-operatively had poorer pre-operative motility and a greater change in LES characteristics intra-operatively. This finding suggests the utility of pre-operative manometry and intra-operative EndoFLIP in identifying patients at risk of developing dysphagia post-operatively. [ABSTRACT FROM AUTHOR]

Background: Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy. Methods: Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal. Results: During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03–6.94, p = 0.044). Conclusion: Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy. [ABSTRACT FROM AUTHOR]

Objective: The Surgical Apgar Score quantifies three intraoperative parameters: lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL). This scoring system predicts postoperative complications based on these measured factors. The aim of this study was to investigate the value of modified Surgical Apgar Score (mSAS) in predicting postoperative complications in patients with rectal cancer treated with robotic surgery in order to improve the survival and quality of life of rectal cancer patients. Methods: The study included patients with rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to December 2023. In minimally invasive surgery, we developed a modified Surgical Apgar Score (mSAS) tailored for robotic rectal cancer surgery, incorporating an adjusted threshold for EBL. This threshold was derived from quartile analysis of a cohort of 524 patients, with a median EBL of 100 mL (IQR 80–130 mL). We analyzed the association of postoperative complications with low mSAS. Results: This study included 524 patients, of which 91 (17.4%) experienced complications and 22 (4.2%) suffered severe complications. mSAS of 6 provided maximal Youden index and were determined as the cut-off values. The area under the ROC curve for predicting complications using the mSAS was 0.740. Univariate and multivariate analyses indicated that an older age, lower tumor localization, longer operation time, radiotherapy alone, combined chemoradiotherapy, and lower mSAS as independent risk factors for complications. The AUC of the prediction nomogram was 0.834 (95% CI 0.774–0.867). The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve ft the diagonal well. Conclusion: This study suggests that mSAS might be a valuable predictive indicator for postoperative complications following robotic rectal cancer surgery, with potentially higher clinical utility. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery has been proven safe in end-stage kidney disease (ESKD); however, few studies have evaluated whether a history of bariatric surgery impacts transplant-specific outcomes. We hypothesize that a history of bariatric surgery at the time of transplant does not adversely impact transplant-specific outcomes. Methods: The IBM MarketScan Commercial Claims and Encounters database was queried for patients with a history of kidney transplant between 2000 and 2021. Patients were stratified into three groups based on bariatric surgery status and body mass index (BMI) at the time of transplant: patients with obesity (O), patients without obesity (NO), and patients with a history of bariatric surgery (BS). Inverse probability of treatment weighting was used to control for confounding. Adjusted hazard ratios (aHRs) describing the risk of transplant-specific and postoperative outcomes were estimated using weighted Kaplan–Meier curves. Primary outcomes included 30-day and 1-year risk of transplant-specific outcomes. Secondary outcomes included 30-day and 1-year postoperative complications and 30-day and 1-year risk of wound-related complications. Results: We identified 14,806 patients; 128 in the BS group, 1572 in the O group, and 13,106 in the NO group. There was no difference in 30-day or 1-year risk of transplant-specific complications between the BS and NO group or the O and NO group. Patients with obesity (O) were more likely to experience wound infection (aHR 1.49, 95% CI 1.12–1.99), wound dehiscence (aHR 2.2, 95% CI 1.5–3.2), and minor reoperation (aHR 1.52, 95% CI 1.23–1.89) at 1 year. BS patients had increased risk of wound infection at 1 year (aHR 2.79, 95% CI 1.26–6.16), but were without increase in risk of minor or major reoperation. Conclusion: A history of bariatric surgery does not adversely affect transplant-specific outcomes after kidney transplant. Bariatric surgery can be safely utilized to improve the transplant candidacy of patients with obesity with CKD and ESKD. [ABSTRACT FROM AUTHOR]

Background: This study presents a case series of "de novo" paraesophageal hernia (dnPEH) in post-Roux-en-Y gastric bypass (RYGB) patients and analyzes the predisposing factors, symptoms, and outcomes after repair. This is a lesser known complication after RYGB and when symptomatic, may warrant surgery. Methods: A retrospective review of data from a single academic institution from 2002 to 2022 was performed identifying patients who developed dnPEH after RYGB and compared them to patients with primary RYGB without post-operative symptomatic dnPEH. Patient characteristics from initial RYGB were analyzed to identify predisposing factors for dnPEH development. Additional information analyzed included time to dnPEH repair, indications for surgery, types of herniation, type of surgical repair, and symptom resolution. Results: There were 6975 RYGB in the study period of which 6619 underwent RYGB alone at index surgery, with 31 of those patients developing late stage PEH requiring repair. Patients with older age (51.8 years with dnPEH vs 45.2 years without, p = 0.001) and increased weight loss at 1 year (33.4% vs 30.5%, p = 0.048) from index RYGB were more likely to develop dnPEH. The incidence of dnPEH was 31/6619 (0.47%). Late dnPEH after RYGB took an average of 74 months (45–102 months IQR) to develop symptoms and undergo repair. The most common symptoms were heartburn/reflux 19/31 (61.3%) and epigastric pain 13/31 (41.9%). Symptom resolution rate after repair was highest with 100% for globus and 89.5% heartburn/reflux. The most common form of dnPEH was pouch herniation in 25/31. Surgical repair most commonly included primary cruroplasty alone in 25/31 with additional mesh in 1 case. Recurrence rate was 2/31 (6.54%). Conclusion: Late dnPEH after RYGB is an emerging entity typically occurring years after index RYGB. Symptomatic patients with dnPEH warrant hernia repair and responded well to surgical repair in this case series. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to compare the anastomotic leak rates between powered and manual circular staplers in elective left-sided colorectal resections. Methods: A retrospective cohort study of elective left-sided colorectal resections before and after implementation of a powered circular stapler at a tertiary care center was conducted. The manual stapler group consisted of consecutive resections performed between January 2016 to December 2016 and the powered stapler group, between September 2021 and December 2022. Primary outcome was 30-day anastomotic leak rate. A chi-squared analysis was performed to compare anastomotic leak rates. Factors associated with anastomotic leak were examined. Results: Two-hundred forty-seven patients were included: 154 in the manual stapler group and 93 in the powered stapler group. Mean (SD) age was 60 (15) years old, 37.7% were female and 72.9% of resections were performed for malignancy. Both groups had similar patient characteristics and surgical technique. Overall leak rate was 2.0% in the manual stapler group and 10.8% in the powered stapler group. The powered staplers were found to have 6.06 times the odds of leak compared to manual staplers (95% CI, 1.62–22.65; p = 0.01). None of the other factors were found to be associated with anastomotic leak. Conclusions: Patients who had left-sided colorectal anastomosis had higher anastomotic leak rates with powered compared to manual circular staplers. This finding is contrary to previous retrospective studies that found lower leak rates with powered staplers. [ABSTRACT FROM AUTHOR]

Background: The opioid crisis caused a huge health concern in the United States. Despite this, few studies have examined the influence of opioid-related disorders (OD) on outcomes after bariatric surgery. The major goal of this study is to determine the impact of OD on in-hospital outcomes for patients undergoing bariatric surgery. Method: The National Inpatient Sample (NIS) database from 2016 to 2020 was used to evaluate patients with OD who underwent bariatric operations including sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. The non-OD comparison group was created using a propensity score match (1:1). Weighted analysis was carried out utilizing NIS-provided weights. The odds ratios were obtained using multivariate logistic regression. Results: A total of 159,455 patients who underwent bariatric surgery were evaluated. Propensity score matching and weighted analysis were used to compare 11,025 in the OD group and 11,025 in the non-OD group. OD was an independent predictor for postoperative complications (odds ratio: 1.29, 95% confidence interval: 1.19–1.39, p < 0.001). Among complications, OD was a predictor for bleeding complications, postoperative nausea and vomiting, anastomotic leak, and mechanical ventilation. In addition, the OD group experienced significantly longer lengths of stay (LOS) and a higher total hospital charges. Conclusion: In patients undergoing bariatric surgery, OD is associated with a significantly higher risk of postoperative complications, as well as increased LOS and total hospital charges. These patients may benefit from further preoperative optimization, including decreasing the opioid dose and closer postoperative monitoring. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery offers effective treatment for morbid obesity and associated medical comorbidities, with excellent short- and long-term outcomes. Although it has been well documented that racial minority bariatric patients have worse outcomes than White patients, it remains unclear whether this recognition has led to improvement. Herein, we assess recent trends in bariatric surgery among Black and White patients and compare early postoperative outcomes by race. Methods: Primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients from 2015 to 2021 reported to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program were studied. Bariatric patients were stratified by race (Black and White) and perioperative outcomes were compared between matched Black and White patients. Primary outcome was 30-day mortality. Secondary outcomes included hospital readmissions, hospital length of stay (LOS), reoperation, and postoperative complications. Results: Overall, there were 193,071 Black and 645,224 White primary bariatric patients, with a higher volume of SG and RGYB performed among White patients. A total of 219,566 Black and White bariatric patients were matched and included in the case–control. Black patients were found to have higher rates of 30-day mortality (0.02% vs. 0.01%; p = 0.03) and readmissions (3.68% vs. 2.65%; p < 0.001). There were no significant differences in LOS, reoperations, or overall postoperative complications. However, there was a higher postoperative pulmonary thromboembolism rate (0.16% vs 0.08%; p < 0.001).). The differences in perioperative outcomes stratified by race persisted over the study period (Fig. 1). Conclusion: Black bariatric surgery patients continue to have worse perioperative outcomes compared with their White counterparts. Further work must be done to determine contributing factors in order to effect improvement in outcomes in bariatric surgical care for racial minority patients. [ABSTRACT FROM AUTHOR]

Background: To define the incidence and independent predictive factors of intraoperative adverse events (IOAEs) after minimally invasive radical nephrectomy and thrombectomy (RNAT) and to determine the impact of intraoperative adverse events on oncological outcomes. Patients and methods: A total of 294 patients underwent minimally invasive RNAT from January 2010 to December 2023 in our center were included. IOAEs are defined as any deviation from the normal surgical procedure during the operation course. Multivariate logistic regression analysis was performed to identify the independent predictive factors of IOAEs. The Kaplan–Meier curves was used to compare overall survival and cancer-specific survival between patients with IOAEs or not. Results: Seventy-four IOAEs occurred in 57 of 294 patients (19.4%) and the most frequent IOAEs were conversion to open surgery (42/74, 56.7%), followed by excessive hemorrhage (20/74, 27.0%). In multivariate logistic analysis, side (OR 0.0929; 95%Cl 0.0367–0.2160; p < 0.001), operation approach (OR 0.1762; 95%Cl 0.06828–0.4109; p < 0.001), and Mayo grade (OR 6.321; 95%Cl 3.846–11.13; p < 0.001) were independent predictive predictors of IOAEs during minimally invasive RNAT. IOAEs (OR 2.713; 95%Cl 1.242–5.897; p = 0.012) was an independent risk factor of the occurrence of postoperative complications. Between the patients with IOAEs or not, neither overall survival (OS) nor cancer-specific survival (CSS) showed statistical differences. Patients with postoperative complications show shorter OS and CSS. Conclusion: We found that the independent predictive factors of minimally invasive RNAT were side, operation approach and Mayo grade, and it is a risk factor of the occurrence of postoperative complications. In addition, the occurrence of IOAEs had no effect on long-term oncological outcomes. [ABSTRACT FROM AUTHOR]

Background: Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms and quality of life. As this procedure has only been performed in the United States for the past 4 years, safety and efficacy have not been well established. Methods: This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data, operative intervention, 90-day complications, and response to treatment. Quality of life and patient satisfaction data were collected by phone survey. Results: Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65 years and median ASA was 3, with 38.5% female patients. POPE was performed with 2–6 plication sutures in an average of 75 min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. Conclusions: POPE is an endoscopic procedure that is efficacious in relieving emptying difficulties for the end-stage esophagus and gastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk. [ABSTRACT FROM AUTHOR]

Background: This study aimed to analyze the results, feasibility and safety of the thoracoscopic approach for patients with esophageal atresia with tracheoesophageal fistula (EA/TEF) depending on the patient's birth weight. Methods: The study involved only type C and D EA/TEF. Among the analyzed parameters were the patients' characteristics, surgical treatment and post-operative complications: early mortality, anastomosis leakage, anastomosis strictures, chylothorax, TEF recurrence, and the need for fundoplication or gastrostomy. Results: 145 consecutive newborns underwent thoracoscopic EA with TEF repair. They were divided into three groups—A (N = 12 with a birth weight < 1500 g), B (N = 23 with a birth weight ≥ 1500 g but < 2000 g), and C—control group (N = 110 with a birth weight ≥ 2000 g). Primary one-stage anastomosis was performed in 11/12 (91.7%) patients—group A, 19/23 (82.6%)—group B and 110 (100%)—group C. Early mortality was 3/12 (25%)—group A, 2/23 (8.7%)—group B, and 2/110 (1.8%)—group C and was not directly related to the surgical repair. There were no significant differences in operative time and the following complications: anastomotic leakage, recurrent TEF, esophageal strictures, and chylothorax. There were no conversions to an open surgery. Fundoplication was required in 0%—group A, 4/21 (19.0%)—group B, and 2/108 (1.9%)—group C survivors. Gastrostomy was performed in 1/9 (11.1%)—group A, 3/21 (14.3%)—group B and 0%—group C. Conclusion: In an experienced surgeon's hands, even in the smallest newborns, the thoracoscopic approach may be safe, feasible, and worthy of consideration. Birth weight seems to be not a direct contraindication to the thoracoscopic approach. [ABSTRACT FROM AUTHOR]

Introduction: Management of gastroesophageal reflux disease after bariatric procedures can be challenging. There are very few long-term studies in this arena. This study aims to evaluate the long-term outcomes of the magnetic sphincter augmentation (MSA) reflux management system in a cohort of bariatric patients who had previously undergone sleeve gastrectomy and Roux-en-Y gastric bypass, with a focus on assessing gastroesophageal reflux disease (GERD) scores, medication use, and patient-reported symptoms. Methods: We conducted a retrospective chart review of 16 consecutive bariatric patients who received MSA implants following sleeve gastrectomy (n = 14) or gastric bypass (n = 2) surgeries. Data were collected regarding BMI, GERD quality of life assessments (GERD-HRQL), reflux symptoms, and use of PPIs in the sleeve/RGB patients through an extended period with a mean follow-up of 48 months. Results: Patients were followed up for a range of.5–84 months. Preoperative assessments included upper gastrointestinal imaging (UGI), high-resolution manometry, Bravo pH studies, and esophagogastroduodenoscopy (EGD). Three patients exhibited reflux on UGI, and 13/13 patients had positive Bravo studies preoperatively. Sixteen patients had a lower esophageal sphincter (LES) pressure under 18 mmHg, and eight patients had biopsy-proven esophagitis. Long-term outcomes are as follows. Daily PPI use fell from 88 to 25% at greater than three years. GERD-HRQL scores fell from 50.6 at baseline (range 27–70) and normalized at long-term follow-up. GERD symptom of regurgitation completely resolved. At long term, two patients had dysphagia and two patients had ongoing reflux. No adverse events were noted. Conclusion: This is the first long-term outcomes study of magnetic sphincter augmentation placement after bariatric surgery. Our study showed the majority of patients had long-term improvement in GERD-HRQL scores and resolution/ relief of their reflux symptoms, with decreased use of PPIs. MSA is a safe, effective and durable management tool for reflux after bariatric surgery in carefully selected patients. [ABSTRACT FROM AUTHOR]

Background: Gastric endoscopic submucosal dissection (ESD) for lesions located on the greater curvature of the upper and middle (U/M) third of the stomach remains challenging, even for experienced endoscopists. Accordingly, we have developed a novel traction technique, termed the outside-lesion clip-thread method (O-CTM). In this method, a clip thread is attached to the healthy mucosa outside the circumferential incision line, and traction is applied to bring the scope and lesion into proximity for ESD. Here, we assessed the efficacy of ESD using the O-CTM compared to ESD without the O-CTM. Methods: We retrospectively reviewed data from 63 consecutive patients who underwent gastric ESD for 63 lesions located on the greater curvature of the U/M third of the stomach between September 2015 and April 2024. The primary outcome was the operation time, and secondary outcomes were resection speed, en bloc resection, R0 resection and complications in the O-CTM and without O-CTM ESD groups. Results: Of the 63 included lesions, 37 were resected without the O-CTM between September 2015 and June 2022 (without O-CTM group), and 26 lesions were resected using the O-CTM between July 2022 and April 2024 (O-CTM group). The O-CTM group had significantly shorter operation times (40 min vs. 77 min, p = 0.01) than the without O-CTM group. The resection speed was also significantly faster (20.1 mm2/min vs. 11.3 mm2/min, p = 0.02). No significant differences in en bloc resection rate, R0 resection rate, and complications were observed. Conclusions: Gastric ESD using O-CTM is beneficial when compared with the ESD without O-CTM in reducing operation time and improving resection speeds for treating lesions located on the greater curvature of the U/M region. [ABSTRACT FROM AUTHOR]

Introduction: Minimally invasive oncological resections have become increasingly widespread in the surgical management of cancers. However, the role of minimally invasive surgery (MIS) for gallbladder cancer (GBC) remains unclear. We aim to perform a systematic review and network meta-analysis of existing literature to evaluate the safety and feasibility of laparoscopic and robotic surgery in the management of GBC compared to open surgery (OS) by comparing outcomes. Methods: A literature search of the PubMed/MEDLINE (2000 to December 2021) and EMBASE (2000 to December 2021) databases was conducted. The primary outcome studied was overall survival, and secondary outcomes studied were postoperative morbidity, severe complications, incidence of bile leak, length of hospital stay, operation time, R0 resection rate, local recurrence and lymph node yield. Results: Thirty-two full-text articles met the eligibility criteria and were included in the final analysis with a total of 5883 patients undergoing either OS or MIS (laparoscopic or robotic) for GBC. 1- and 2-stage meta-analyses did not reveal any significant differences between OS, laparoscopic and robotic surgery in terms of overall survival, R0 resection, lymph node harvest, local recurrence and post-operative complications. Patients who underwent OS had significantly longer hospitalization stay and intra-operative blood loss compared to those who underwent laparoscopic or robotic surgery. Network meta-analysis did not reveal any significant differences between post-operative and survival outcomes of laparoscopic vs robotic surgery groups. Conclusion: This network meta-analysis suggests that both laparoscopic and robotic surgery are safe and effective approaches in the surgical management of GBC, with post-operative and survival outcomes comparable to OS. An MIS approach may also lead to shorter hospitalization stay, less intraoperative blood loss and post-operative complications compared to OS. There was no obvious benefit of either MIS approach (laparoscopic versus robotic) over the other. [ABSTRACT FROM AUTHOR]

Introduction: There is uncertainty regarding the method of mesh fixation and peritoneal closure during transabdominal preperitoneal (TAPP) repair for inguinal hernias, with no definitive guidelines to guide surgeon choice. Methods: MEDLINE, Cochrane, Central Register of Clinical Trials, and Web of Science were searched for RCTs published until November 2023. Risk ratios (RRs) and mean differences (MD) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p values inferior to 0.10 and I2 > 25% considered significant. Statistical analyses were conducted using Review Manager version 5.4 and RStudio version 4.1.2 (R Foundation for Statistical Computing). Results: Eight randomized controlled trials (RCTs) were included, comprising 624 patients, of whom 309 (49.5%) patients were submitted to TAPP with the use of tacks, and 315 (50.5%) received suture fixation. The use of tacker fixation was associated with a significant increase in postoperative pain at 24 h (MD 0.79 [VAS score]; 95% CI 0.38 to 1.19; p < 0.0002; I2 = 87%) and one week (MD 0.42 [VAS score]; 95% CI 0.05 to 0.79; p < 0.03, I2 = 84%). The use of tacks was associated with shorter operative time (MD—25.80 [min]; 95% − 34.31– − 17.28; P < 0.00001; I2 = 94%). No significant differences were found in overall complications, chronic pain, seromas, hematomas, and urinary retention rates. Conclusion: In patients who underwent TAPP hernia repair, tacks are associated with decreased operative time but increased postoperative pain at 24 h and one week. [ABSTRACT FROM AUTHOR]

Background: There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations. Methods: The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies. Results: 7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports. Conclusion: These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic. [ABSTRACT FROM AUTHOR]

Background and aim: In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD). Methods: This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected. Results: 133 patients were included (80 M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20 months (IQR 6–40.1). Conclusion: Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up. [ABSTRACT FROM AUTHOR]

Background: The sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. However, insufficient weight loss or weight recidivism is frequent, which may require effective and safe revisional procedures. Objective: To determine the technical feasibility and safety of a minimally invasive, duodeno-ileal side-to-side anastomosis using a Sutureless Neodymium Anastomosis Procedure (SNAP) for patients with weight recidivism or inadequate weight loss following SG. Methods: This is a prospective, single-arm, open-label pilot study that enrolled patients with obesity to assist in weight reduction following an SG performed > 12 months prior. For the SNAP, self-assembling magnets were deployed into the ileum (laparoscopically) and duodenum (per-oral endoscopy). Magnets were coupled under laparoscopic and fluoroscopic guidance to create a compression anastomosis. The primary endpoints were technical feasibility, weight loss, and rate of serious adverse events (SAEs). Results: Successful duodeno-ileal diversions were created with SNAP in 27 participants (mean age: 50.6 ± 9.1, mean BMI: 38.1 ± 4.6 kg/m2) with no device-related serious adverse events. Upper endoscopy at 3 months confirmed patent, healthy anastomoses in all patients. At 9 months, patients (n = 24) experienced 11.9 ± 6.2%, 14.5 ± 10.8%, and 17.0 ± 13.9% TBWL at 3, 6, and 9 months, respectively. There were no device-related SAEs. Conclusion: The SNAP is technically feasible and relatively safe, with all patients presenting widely patent anastomosis at 3 months. Patients experienced a progressive, clinically meaningful weight loss. Further studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to retrospectively compare the short-term outcomes of robotic- (RAD) and laparoscopic-assisted duodenal diamond-shaped anastomosis (LAD) in neonates. Methods: Neonates who underwent RAD (n = 30) or LAD (n = 38) between January 2019 and December 2022 were analyzed retrospectively. Major patient data were collected, including preoperative, intraoperative, and postoperative information. Results: All patients were neonates below the age of 30 days weighing 4 kg. Thirty (44.1%) neonates underwent RAD and 38 neonates (55.9%) underwent LAD. Compared to the LAD group, the RAD group had a shorter intra-abdominal operation time (RAD, 60.0(50.0 ~ 70.0) min; LAD, 79.9(69.0 ~ 95.3) min; p < 0.001). There were no significant differences in immediate and 30-day complications between the two groups. Conclusions: RAD is safe and effective in neonates. Compared to traditional LAD, RAD showed comparable results. [ABSTRACT FROM AUTHOR]

Background: Ambulatory bariatric surgery has recently gained interest especially as a potential way to improve access for eligible patients with severe obesity. Building on our previously published research, this follow-up study delves deeper in the evolving landscape of ambulatory bariatric surgery over a 3-year period, focusing on predictors of success/failure. Methods: In a prospective single-center follow-up study, we conducted a descriptive assessment of all eligible patients as per our established protocol, who underwent a planned same-day discharge (SDD) primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 03/01/2021 and 02/29/2024. Trends in SDD surgeries over time were assessed over six discrete 6 month intervals. Primary endpoint was defined as a successful discharge on the day of surgery without emergency department visit or readmission within 24 h. Secondary outcomes included 30-day postoperative morbidity. Results: A total of 811 primary SG and 325 RYGB procedures were performed during the study period. Among them, 30% (n = 244) were SDD-SGs and 6% (n = 21) were SDD-RYGBs, respectively. At baseline, median age of the entire SDD cohort was 43 years old, 81% were females, and body mass index (BMI) was 44.5 kg/m2. The planned SDD approach was successful in 89% after SG (n = 218/244) and in 90% after RYGB (n = 19/21). Nausea/vomiting was the main reason for a failed SDD approach after SG (46%). The 30-day readmission rate was 1.5% (n = 4) for the entire SDD cohort including only one readmission in the first 24 h. The percentage of SDD-SGs performed as a proportion of total SGs increased over the initial five consecutive six-month intervals (14%, 25%, 24%, 38%, and 49%). Conclusion: Our SDD protocol for bariatric surgery demonstrates a favorable safety profile, marked by high success rate and low postoperative morbidity. These outcomes have led to a continued increase in ambulatory procedures performed over time especially SG. [ABSTRACT FROM AUTHOR]

Objective: While sleeve gastrectomy (SG) results in sustained weight loss for the majority of patients, some will experience inadequate weight loss or weight regain requiring revision. The objective of this study was to evaluate differences in weight loss over time between patients undergoing Roux-en-Y gastric bypass (RYGB) or single anastomosis duodenoileostomy (SADI) after SG. Methods: We queried a single institution's bariatrics registry to identify patients who underwent RYGB or SADI after previous SG over a three-year period. Demographics, operative characteristics, and post-operative complications were evaluated. Interval total body weight loss (TBWL) and excess body weight loss (EBWL) were calculated from available follow-ups within 2 years. Results: We identified 124 patients who underwent conversion to RYGB (n = 61) or SADI (n = 63) following previous SG. There were no differences in sex, age, or medical comorbidities between groups. The median initial BMI was higher in the SADI group (44.9 vs. 41.9 for RYGB, p = 0.03) with greater excess body weight (56.7 vs. 64.3 kg, p = 0.04). The SADI group had a shorter median operative duration (157 vs. 182 min for RYGB, p < 0.01) and lower readmission rates (0 vs. 14.75%, p < 0.01). There was no difference in post-operative complications or need for rehydration therapy between the groups. Among 122 patients (98.4%) that had follow-up weights available, there were no differences in TBWL between groups. RYGB patients had a higher EBWL at 2, 3, and 6 months (p < 0.05 for all comparisons), but there were no differences between RYGB and SADI at 1 or 2 years. Conclusions: Both RYGB and SADI conversions proved effective for further weight loss following failed SG at our academic center. While neither demonstrated clear superiority in long-term (> 1 year) weight loss, RYGB's restrictive gastric pouch may explain its early weight loss advantage. [ABSTRACT FROM AUTHOR]

Background: Sleeve gastrectomy is the most common bariatric procedure and its long-term complications include inadequate weight loss, weight regain, and de novo GERD, often requiring revisional surgery. Revisions, notably re-sleeve and conversion to Roux-en-Y gastric bypass (RYGB), are frequently performed, but safety data is limited. Herein, we used the MBSAQIP database to compare 30 day outcomes of primary sleeve gastrectomy (SG) with re-sleeve (RS) and SG to RYGB conversion. Methods: Patients who underwent primary SG, RS, and SG to RYGB conversion within the MBSAQIP data registry from January 1, 2020 to December 31, 2022 were included in this study. Using Propensity Score Matching analysis, the cohorts were matched for 23 preoperative characteristics. We then compared 30 day postoperative outcomes and bariatric-specific complications between primary SG and RS (analysis 1) and between RS and SG to RYGB conversion (analysis 2). Results: A total of 302,961 were included. The matched cohorts in analysis 1 (n = 1630) and analysis 2 (n = 1633) had similar pre-operative characteristics. Propensity-matched outcomes in analysis 1 showed that patients in the RS group had significantly higher staple line leak (1.3% vs. 0.1%, p < 0.001) when compared to primary SG. Similarly, longer operative times (90.16 ± 51.90 min vs. 68.32 ± 37.54 min, p < 0.001) and higher rates of readmissions (5.5% vs. 2.1%, p < 0.001), reoperations (2.3% vs. 0.6%, p < 0.001), interventions (2.5% vs. 0.4%, p < 0.001) were found in those who underwent RS. In analysis 2, RS showed higher leak rates (1.3% vs. 0.5%, p = 0.015) when compared to conversion from SG to RYGB. Conclusion: The RS group has a higher risk of staple line leaks compared to primary SG and conversion from SG to RYGB. In our study, there was a 2.6-fold increase in staple line leak after re-sleeve compared to RYGB conversion and a 13-fold increase compared to primary SG. [ABSTRACT FROM AUTHOR]

Introduction: Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications. Objective: The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions. Methods: A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups. Results: Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19 months, versus 9 months in the non bougie group. There was no difference between early (3 weeks) and late dysphagia scores (6 months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year. Conclusion: There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation. [ABSTRACT FROM AUTHOR]

Background: The safety and efficacy of robotic liver resection (RLR) for patients with hepatocellular carcinoma (HCC) have been reported worldwide. However, the exact role of RLR in HCC patients with liver cirrhosis is not sufficiently determined. Methods: We conducted a retrospective study on consecutive patients with cirrhosis or non-cirrhosis who received RLR for HCC from 2018 to 2023. Data on patients' demographics and perioperative outcomes were collected and analyzed. Propensity score matching (PSM) analysis was performed. Multivariate logistic regression analysis was performed to determine the risk factors of prolonged postoperative length of stay (LOS) and morbidity. Results: Of the 571 patients included, 364 (64%) had cirrhosis. Among the cirrhotic patients, 48 (13%) were classified as Child–Pugh B. After PSM, the cirrhosis and non-cirrhosis group (n = 183) had similar operative time, estimated blood loss, postoperative blood transfusion, LOS, overall morbidity (p > 0.05). In addition, the intraoperative and postoperative outcomes were similar between the two groups in the subgroup analyses of patients with tumor size ≥ 5 cm, major hepatectomy, and high/expert IWATE difficulty grade. However, patients with Child–Pugh B cirrhosis had longer LOS and more overall morbidity than that of Child–Pugh A. Child–Pugh B cirrhosis, ASA score > 2, longer operative time, and multiple tumors were risk factors of prolonged LOS or morbidity in patients with cirrhosis. Conclusion: The presence of Child–Pugh A cirrhosis didn't significantly influence the difficulty and perioperative outcomes of RLR for selected patients with HCC. However, even in high-volume center, Child–Pugh B cirrhosis was a risk factor for poor postoperative outcomes. [ABSTRACT FROM AUTHOR]

Introduction: As our population ages, older adults are being considered for anti-reflux surgery (ARS). Geriatric patients typically have heightened surgical risk, and literature has shown mixed results regarding postoperative outcomes. We sought to evaluate the safety and efficacy of robotic ARS in the geriatric population. Methods: We conducted a single-institution review of ARS procedures performed between 2009 and 2023. Patients ≥ 65 were assigned to the geriatric cohort. We compared operative details, lengths of stay (LOS), readmissions, reoperations, and complications between the two cohorts. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL) survey and review of clinic notes were used to evaluate ARS efficacy. Results: 628 patients were included, with 190 in the geriatric cohort. This cohort had a higher frequency of diabetes (16.3% vs 5.9% p < 0.0001), hypertension (50.0% vs 21.5% p < 0.0001), and heart disease (17.9% vs 2.3% p < 0.0001). Geriatric patients were more likely to exhibit hiatal hernias on imaging (51.6% vs 34.2% p < 0.0001) and were more likely to have large hernias (30.0% vs 7.1% p < 0.0001). Older adults were more likely to undergo Toupet fundoplications (58.4% vs 41.3%, p < 0.0001), Collis gastroplasties (9.5% vs 2.7% p < 0.0001), and relaxing incisions (11.6% vs 1.4% p < 0.0001). Operative time was longer for geriatric patients (132.0 min vs 104.5 min p < 0.0001). There were no significant differences in LOS, readmissions, or reoperations between cohorts. Geriatric patients exhibited lower rates of complications (7.4% vs. 14.6%, p = 0.011), but similar complication grades. Both groups had significant reduction in symptom scores from preoperative values. There were no significant differences in the reported symptoms between cohorts at any follow-up timepoint. Conclusion: Geriatric robotic ARS patients tend to do as well as younger adults regarding postoperative and symptomatic outcomes, despite presenting with larger hiatal hernias and shorter esophagi. Clinicians should be aware of possible need for lengthening procedures or relaxing incisions in this population. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications. Methods: Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics. Results: Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3–14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9–15.7) and without PPDS, 16.6% (CI 13.4–20.4), RR 0.8 (CI 0.51–1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3–81.1) and 25.1% (CI 19–32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively. Conclusions: Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Background: Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population. Methods: The ACS-NSQIP (2016–2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves. Results: We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152). Conclusions: Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization. [ABSTRACT FROM AUTHOR]

Introduction and objectives: Laparoscopic splenectomy and esophagogastric devascularization (LSED) are minimally invasive, effective, and safe in treating esophageal-fundic variceal bleeding with portal hypertension (PHT). The study aimed to assess the learning curve of LSED by cumulative summation (CUSUM) analysis. The 10-year follow-up data for LSED and open surgery were also examined. Patients and methods: Five hundred and ninety-four patients were retrospectively analyzed. Operation time, intraoperative blood loss, open operation conversion, and postoperative complications were selected as the evaluation indicators of surgical ability. The learning curve of LESD was assessed by the CUSUM approach. Patient features, perioperative indices, and 10-year follow-up data were examined. Results: Totally 236 patients underwent open surgery, and 358 underwent LSED. Patient characteristics were similar between groups. The LSED patients experienced less intraoperative blood loss, fewer complications, and faster recovery compared to the open surgery cohort. The learning curve of LESD was maximal for a case number of 50. Preoperative general characteristics were comparable for both stages. But the skilled stage had decreased operation time, reduced blood loss, less postoperative complications, and better recovery compared to the learning stage. The LSED group had higher recurrent hemorrhage-free survival rate and increased overall survival in comparison with cases administered open surgery in the 10-year follow-up. Free-liver cancer rates were similar between two groups. Conclusions: About 50 cases are needed to master the LSED procedure. Compared to open surgery, LSED is a safer, feasible, and safe procedure for PHT patients, correlating with decreased rebleeding rate and better overall survival. [ABSTRACT FROM AUTHOR]

Background: Hepatic arterial infusion pump (HAIP) treatment is a technique used to treat liver localized malignancy with intra-arterial chemotherapy. Methylene blue is generally administered to verify hepatic perfusion and exclude inadvertent extrahepatic perfusion. The use of indocyanine green dye (ICG) combined with near-infrared (NIR) fluorescence imaging during robot-assisted HAIP placement may be an attractive alternative by providing high contrast without blue discoloration of the operative field. Methods: Data was collected retrospectively from 2 centers in the Netherlands. Intraoperative perfusion of the liver segments and extrahepatic perfusion were assessed using ICG/NIR as well as methylene blue on video imaging and correlated to postoperative 99 m-Tc perfusion scintigraphy. Results: 13 patients underwent robot-assisted surgery for HAIP placement; median length of stay was 4 days, complications occurred in 4 patients. Hepatic perfusion showed identical patterns when ICG was compared with methylene blue. In 1 patient, additional extrahepatic perfusion was found using ICG, leading to further vessel ligation. Intraoperative ICG perfusion was concordant with 99 m-Tc perfusion scintigraphy. Discussion: Liver and extrahepatic perfusion determined by ICG fluorescence imaging is concordant with blue dye perfusion and 99 m-Tc perfusion scintigraphy. Therefore, ICG fluorescence imaging is deemed a safe and reliable technique for perfusion testing during robot-assisted HAIP placement. [ABSTRACT FROM AUTHOR]