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  • Correction to: Transoral endoscopic thyroidectomy for thyroid carcinoma: outcomes and surgical completeness in 150 single-surgeon cases.
    Surg. Endosc. Pub Date : 2019-06-07
    Jong-Hyuk Ahn,Jin Wook Yi

    The Acknowledgment was omitted from this article and appears below.

    更新日期:2020-01-14
  • Correction to: Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.
    Surg. Endosc. Pub Date : 2019-06-07
    Samantha L Margulies,Maria V Vargas,Kathryn Denny,Andrew D Sparks,Cherie Q Marfori,Gaby Moawad,Richard L Amdur

    The original article was updated to correct the author listing: the last five author names were reversed.

    更新日期:2020-01-14
  • Clinical outcomes of upper gastrointestinal bleeding in patients with gastric gastrointestinal stromal tumor.
    Surg. Endosc. Pub Date : null
    Gyu Young Pih,Sung Jin Jeon,Ji Yong Ahn,Hee Kyong Na,Jeong Hoon Lee,Kee Wook Jung,Do Hoon Kim,Kee Don Choi,Ho June Song,Gin Hyug Lee,Hwoon-Yong Jung,Seon-Ok Kim

    BACKGROUND Upper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods. METHODS Total 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively. RESULTS Of 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients. CONCLUSIONS Bleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.

    更新日期:2020-01-14
  • Outcomes and impact of laparoscopic inguinal hernia repair versus open inguinal hernia repair on healthcare spending and employee absenteeism.
    Surg. Endosc. Pub Date : null
    Gurteshwar Rana,Priscila Rodrigues Armijo,Shariq Khan,Nathan Bills,Marsha Morien,Jianying Zhang,Dmitry Oleynikov

    BACKGROUND This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes. METHODS The TRUVEN database was queried using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with α = 0.05. RESULTS 66,116 patients were included (LIHR: N = 23,010; OIHR: N = 43,106). Robotic-assisted procedures were excluded due to small sample size (N = 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%, p = 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%; p < 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h, p = 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%; p < 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014), p < 0.001. CONCLUSIONS The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.

    更新日期:2020-01-14
  • Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis.
    Surg. Endosc. Pub Date : null
    Alexandros Andreou,David I Watson,Dimitrios Mavridis,Nader K Francis,Stavros A Antoniou

    BACKGROUND Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease. METHODS Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease. RESULTS Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence. CONCLUSION Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective. REGISTRATION NO CRD42017074783.

    更新日期:2020-01-14
  • Self-directed training with e-learning using the first-person perspective for laparoscopic suturing and knot tying: a randomised controlled trial : Learning from the surgeon's real perspective.
    Surg. Endosc. Pub Date : null
    Mona W Schmidt,Karl-Friedrich Kowalewski,Sarah M Trent,Laura Benner,Beat P Müller-Stich,Felix Nickel

    BACKGROUND Laparoscopic suturing and knot tying is essential for advanced laparoscopic procedures and requires training outside of the operating room. However, personal instruction by experienced surgeons is limitedly available. To address this, the concept of combining e-learning with practical training has become of interest. This study aims to investigate the influence of the first-person perspective in instructional videos, as well as the feasibility of a completely self-directed training curriculum for laparoscopic suturing and knot tying. MATERIALS AND METHODS Ninety-one laparoscopically naïve medical students were randomised into two groups training with e-learning videos in either the first-person perspective (combining endoscopic view and view of hands/instruments/forearm motion) or the endoscopic view only. Both groups trained laparoscopic suturing and knot tying in teams of two until reaching predefined proficiency levels. Blinded, trained raters regularly assessed the participants' performance by using validated checklists. After training, participants filled out questionnaires regarding training experience and personal characteristics. RESULTS Average training time to reach proficiency did not differ between groups [first-person perspective (min): 112 ± 44; endoscopic view only (min): 109 ± 47; p = 0.746]. However, participants from both groups perceived the first-person perspective as useful for learning new laparoscopic skills. Both groups showed similar baseline performances and improved significantly after training [Objective Structured Assessment of Technical Skills (OSATS) (max. 37 points): first-person perspective: 30.3 ± 2.3; endoscopic view only: 30.8 ± 2.3]. All participants managed to reach proficiency, needing 8-43 attempts without differences between groups. Visuospatial abilities (mental rotation) seemed to enhance the learning curve. CONCLUSION Modifying instructional videos to the first-person perspective did not translate into a better performance in this setting but was welcomed by participants. Completely self-directed training with the use of e-learning can be a feasible training approach to achieve technical proficiency in laparoscopic suturing and knot tying in a training setting.

    更新日期:2020-01-14
  • Video-based coaching in surgical education: a systematic review and meta-analysis.
    Surg. Endosc. Pub Date : null
    Knut Magne Augestad,Khayam Butt,Dejan Ignjatovic,Deborah S Keller,Ravi Kiran

    BACKGROUND In the era of competency-based surgical education, VBC has gained increased attention and may enhance the efficacy of surgical education. The objective of this systematic review was to summarize the existing evidence of video-based coaching (VBC) and compare VBC to traditional master-apprentice-based surgical education. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCT) assessing VBC according to the PRISMA and Cochrane guidelines. The MEDLINE, EMBASE, and COCHRANE and Researchgate databases were searched for eligible manuscripts. Standard mean difference (SMD) of performance scoring scales was used to assess the effect of VBC versus traditional training without VBC (control). RESULTS Of 627 studies identified, 24 RCTs were eligible and evaluated. The studies included 778 surgical trainees (n = 386 VBC vs. n = 392 control). 13 performance scoring scales were used to assess technical competence; OSATS-GRS was the most common (n = 15). VBC was provided preoperative (n = 11), intraoperative (n = 1), postoperative (n = 10), and perioperative (n = 2). The majority of studies were unstructured, where identified coaching frameworks were PRACTICE (n = 1), GROW (n = 2) and Wisconsin Coaching Framework (n = 1). There was an effect on performance scoring scales in favor of VBC coaching (SMD 0.87, p < 0.001). In subgroup analyses, the residents had a larger relative effect (SMD 1.13; 0.61-1.65, p < 0.001) of VBC compared to medical students (SMD 0.43, 0.06-0.81, p < 0.001). The greatest source of potential bias was absence of blinding of the participants and personnel (n = 20). CONCLUSION Video-based coaching increases technical performance of medical students and surgical residents. There exist significant study and intervention heterogeneity that warrants further exploration, showing the need to structure and standardize video-based coaching tools.

    更新日期:2020-01-14
  • Incisionless fluorescent cholangiography (IFC): a pilot survey of surgeons on procedural familiarity, practices, and perceptions.
    Surg. Endosc. Pub Date : null
    Fernando Dip,Luis Sarotto,Mayank Roy,Aaron Lee,Emanuelle LoMenzo,Matthew Walsh,Thomas Carus,Sylke Schneider,Luigi Boni,Takeaki Ishizawa,Nohiro Kokudo,Kevin White,Raul J Rosenthal

    BACKGROUND Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. METHODS An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. RESULTS Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. CONCLUSIONS Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

    更新日期:2020-01-14
  • The hidden cost of an extensive preoperative work-up: predictors of attrition after referral for bariatric surgery in a universal healthcare system.
    Surg. Endosc. Pub Date : 2019-06-14
    Aristithes G Doumouras,Yung Lee,Glenda Babe,Scott Gmora,Jean-Eric Tarride,Dennis Hong,Mehran Anvari

    BACKGROUND Bariatric surgery is in high demand and patients generally undergo an extensive work-up process to maximize the success of surgery, especially in universal healthcare systems. Although valuable, this work-up process can lead to attrition before surgery. Therefore, we aim to assess patient and health system factors associated with attrition after bariatric surgery referral in a universal healthcare system. METHODS This was a population-based study of all patients aged ≥ 18 referred for bariatric surgery in Ontario, Canada from 2009 to 2015. Primary outcome was patients who dropped out of bariatric surgery after referral. Predictors of attrition after referral included patient demographics, clinical, institutional, and socioeconomic variables. Odds ratios and 95% CIs were estimated by multilevel logistic regression models. RESULTS From 17,703 patients that were referred for bariatric surgery, 4122 patients dropped after the initial referral. Male patients, increasing age, and longer wait times for surgery were significantly (P < 0.0001) associated with higher odds of attrition. Additionally, smoker status, immigration status, unemployment, and disability were significant factors (P < 0.0001) predicting attrition. Patients who lived in lowest income quintile neighborhoods, when compared to those from the richest neighborhoods, had significantly higher odds of attrition (P = 0.02). Sleep apnea was associated with lower odds of attrition while diabetes and heart failure both with higher odds of attrition. CONCLUSION Even in a universal healthcare system, there are various factors that could lead to increased odds of attrition before bariatric surgery. Clear disparities exist for certain marginalized populations. Further studies are warranted to ensure equitable utilization of bariatric surgery for all patients.

    更新日期:2020-01-14
  • Clinical efficacy of per-oral endoscopic myotomy (POEM) for spastic esophageal disorders: a systematic review and meta-analysis.
    Surg. Endosc. Pub Date : null
    Saurabh Chandan,Babu Pappu Mohan,Ojasvini Choudhry Chandan,Lokesh Kumar Jha,Harmeet Singh Mashiana,Alexander Todd Hewlett,Mouen A Khashab

    BACKGROUND POEM has been successfully performed in patients with spastic esophageal disorders (SED), such as diffuse esophageal spasm, jackhammer esophagus, and type 3 achalasia. We performed a systematic review and meta-analysis to evaluate its efficacy in these patients and if total average myotomy length and prior medical or endoscopic treatments affected clinical success. METHODS PubMed, EMBASE, Google-Scholar, Scopus, and Cochrane Review were searched for studies on POEM in SED from 2008 to September 2018. Clinical success was determined by Eckardt score (≤ 3) at follow-up. Sub-group analysis was performed based on myotomy length and evaluates the effect of prior treatments on clinical success. RESULTS 9 studies with 210 patients were included in the final analysis. We found that the pooled rate of clinical success for POEM was 89.6% (95% CI 83.5-93.1, 95% PI 83.4-93.7, I2 = 0%). In three studies (50 patients), where total myotomy length was < 10 cm, the pooled rate of clinical success was 91.1% (95% CI 79.5-96.4, I2 = 0%). In six studies (160 patients), the length was > 10 cms and the pooled rate of clinical success was 89.1% (95% CI 83.0-93.2, I2 = 0%). The difference between these results was not statistically significant (p = 0.69). Additionally, a meta-regression analysis showed that prior treatment status did not significantly affect the primary outcome (p = 0.43). CONCLUSIONS While it is well known that POEM is a safe and effective treatment for spastic esophageal disorders, we conclude that variation in total myotomy length and prior endoscopic or medical treatments did not have a significant effect on clinical success.

    更新日期:2020-01-14
  • Lower rate of conversion using robotic-assisted surgery compared to laparoscopy in completion total gastrectomy for remnant gastric cancer.
    Surg. Endosc. Pub Date : null
    Rana M Alhossaini,Abdulaziz A Altamran,Minah Cho,Chul Kyu Roh,Won Jun Seo,Seohee Choi,Taeil Son,Hyoung-Il Kim,Woo Jin Hyung

    BACKGROUND Completion total gastrectomy with radical lymphadenectomy for remnant gastric cancer is a technically demanding procedure. No previous studies have compared laparoscopic to robotic-assisted completion gastrectomy, whereas a few small case series have reported benefits of minimally invasive surgery over open surgery. The aim of this study is to assess the effectiveness and feasibility of robotic-assisted compared with laparoscopic completion gastrectomy for the treatment of remnant gastric cancer. METHODS We retrospectively reviewed data from 55 patients who underwent minimally invasive completion gastrectomy for remnant gastric cancer at the Severance Hospital of Yonsei University Health System from April 2005 to July 2017. Of the 55 patients, 30 patients underwent laparoscopic and 25 underwent robotic-assisted completion total gastrectomy. We compared the patients' demographics, operative outcomes, and postoperative outcomes. RESULTS Operation time was longer in the robotic-assisted surgery group (225 vs 292 min, P < 0.001), but both groups had similar estimated blood loss. The laparoscopic surgery group had a 13.3% (four patients) rate of conversion to open surgery because of severe adhesions, whereas no patients in the robotic group underwent conversion to laparoscopic or open surgery (P = 0.058). Mean hospital stay, postoperative complications, and recovery were similar in both groups. Pathology results, including the number of retrieved lymph nodes, did not differ between groups. CONCLUSION Laparoscopic and robotic approaches are both feasible and safe for remnant gastric cancer, with comparable short-term outcomes. However, the robotic approach demonstrated a lower conversion rate than laparoscopy, although the statistical difference was marginal.

    更新日期:2020-01-14
  • Pre-clinical study on a telemetric gastric sensor for recognition of acute upper gastrointestinal bleeding: the "HemoPill monitor".
    Surg. Endosc. Pub Date : null
    Sebastian Schostek,Melanie Zimmermann,Jan Keller,Mario Fode,Michael Melbert,Ruediger L Prosst,Thomas Gottwald,Marc O Schurr

    BACKGROUND Acute upper gastrointestinal bleeding is a life-threatening medical condition with a relevant risk of re-bleeding even after initial endoscopic hemostasis. The implantable HemoPill monitor contains a novel telemetric sensor to optically detect blood in the stomach allowing the surveillance of high-risk patients for re-bleedings. METHODS In this pre-clinical porcine study, bleeding has been simulated by injecting porcine blood into the stomach of a pig through an implanted catheter using a syringe pump. The effect of the sensor position in the stomach, the gastric food content, and the bleeding intensity was investigated. RESULTS Sensitivity and specificity of the sensor reached more than 87.5% when the sensor was positioned close to the source of bleeding. Solid food had a higher negative impact on sensitivity than liquid food but a positive impact on specificity. A heavy bleeding was more likely to be detected by the sensor but was also associated with a lower likelihood for true-negative results than weaker bleedings. CONCLUSIONS The study clearly demonstrated the capability of the HemoPill sensor prototype to detect clinically relevant bleedings with high sensitivity and specificity (> 80%) when the sensor was positioned close to the bleeding site. The sensors proved to be robust against artefact effects from stomach content. These are favorable findings that underline the potential benefit for the use of the HemoPill sensor in monitoring patients with a risk of re-bleeding in the upper gastrointestinal tract.

    更新日期:2020-01-14
  • Laparoscopic liver resection for segment VII lesion using a combination of rubber band retraction method and flexible laparoscope.
    Surg. Endosc. Pub Date : null
    Jin Woo Lee,Sung Hoon Choi,Seungki Kim,Sung Won Kwon

    INTRODUCTION Laparoscopic liver resection (LLR) for tumors involving segment VII has been considered a contraindication. Herein, our proposed laparoscopic technique for segment VII lesions using a rubber band retraction method and flexible laparoscope is introduced. METHODS A combination of elastic rubber band retraction method and flexible laparoscope was applied to access segment VII lesion. The perioperative outcomes and pathologic results were compared between patients with segment VII lesions (group 1) and patients with tumors in other segments (group 2) to evaluate feasibility and safety of the proposed laparoscopic approach for segment VII lesions. RESULTS Among 167 patients who underwent LLR from May 2014 to October 2017, the study population included 17 patients with tumors in segment VII (group 1) and 66 patients with tumors in other segments (group 2). The demographics of the two groups were comparable. One open conversion occurred in group 2 due to bleeding. The mean tumor size was 2.6 ± 1.0 and 2.5 ± 1.5 cm (p = 0.392) and surgical margin was 1.2 ± 0.7 and 1.3 ± 1.2 cm (p = 0.344) in group 1 and group 2, respectively. The mean operation time was 151 ± 63 and 131 ± 57 min (p = 0.596) and estimated mean blood loss was 294 ± 281 and 306 ± 405 mL (p = 0.610), in group 1 and group 2, respectively. The mean postoperative hospital stay was 6.1 ± 1.5 and 6.4 ± 2.7 days (p = 0.064) in group 1 and group 2. Two postoperative complications in both groups and no postoperative mortality occurred. CONCLUSION The combination technique of rubber band retraction and flexible laparoscopic camera allowed feasible and safe LLR for segment VII lesions that showed postoperative outcomes comparable to other segment lesions.

    更新日期:2020-01-14
  • The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias.
    Surg. Endosc. Pub Date : null
    Sean R Maloney,Kathryn A Schlosser,Tanushree Prasad,Paul D Colavita,Kent W Kercher,Vedra A Augenstein,B Todd Heniford

    BACKGROUND Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR). METHODS A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case-control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale. RESULTS The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16-4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL. CONCLUSION The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST's generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term.

    更新日期:2020-01-14
  • Mucosal loss as a critical factor in esophageal stricture formation after mucosal resection: a pilot experiment in a porcine model.
    Surg. Endosc. Pub Date : null
    Bing-Rong Liu,Dan Liu,Wenyi Yang,Saif Ullah,Zhen Cao,Dezhi He,Xuehui Zhang,Yang Shi,Yangyang Zhou,Yong Chen,Donghai He,Lixia Zhao,Yulian Yuan,Deliang Li

    BACKGROUND AND AIM Esophageal stricture is a major complication of large areas endoscopic submucosal dissection (ESD). Until now, the critical mechanism of esophageal stricture remains unclear. We examined the role of mucosal loss versus submucosal damage in esophageal stricture formation after mucosal resection using a porcine model. MATERIALS AND METHODS Twelve swine were randomly divided into two groups, each of 6. In each group, two 5-cm-long submucosal tunnels were made to involve 1/3rd of the widths of the anterior and posterior esophageal circumference. The entire mucosal roofs of both tunnels were resected in group A. In group B, the tunnel roof mucosa was incised longitudinally along the length of the tunnel, but without excision of any mucosa. Stricture formation was evaluated by endoscopy after 1, 2, and 4 weeks, respectively. Anatomical and histological examinations were performed after euthanasia. RESULTS Healing observed on endoscopy in both groups after 1 week. Group A (mucosa resected) developed mild-to-severe esophageal stricture, dysphagia, and weight loss. In contrast, no esophageal stricture was evident in group B (mucosa incisions without resection) after 2 and 4 weeks, respectively. Macroscopic examination showed severe esophageal stricture and shortening of esophagus in only group A. Inflammation and fibrous hyperplasia of the submucosal layer was observed on histological examination in both groups. CONCLUSION The extent of loss of esophageal mucosa appears to be a critical factor for esophageal stricture. Inflammation followed by fibrosis may contribute to alteration in compliance of the esophagus but is not the main mechanism of postresection stricture.

    更新日期:2020-01-14
  • Safety and efficacy of magnetic anchoring electrode-assisted irreversible electroporation for gastric tissue ablation.
    Surg. Endosc. Pub Date : null
    Fenggang Ren,Qingshan Li,Liangshuo Hu,Xiaopeng Yan,Zhongyang Gao,Jing Zhang,Weiman Gao,Zhe Zhang,Pengkang Chang,Xue Chen,Dake Chu,Rongqian Wu,Yi Lv

    BACKGROUND Irreversible electroporation (IRE) is an emerging tissue ablation technique, which is safe for sites where thermal-basis techniques are not suitable. The aim of this study is to evaluate the safety and efficacy of magnetic anchoring electrode (MAE)-assisted IRE for normal gastric tissue ablation in a rabbit model. METHODS IRE (500 V, 100 μs, 99 pulses, 1 Hz) of the gastric wall was performed in 24 adult New Zealand rabbits with a novel catheter-mounted MAE with fluoroscopy and a surgical approach. Procedure time, procedure-related bleeding, perforation, and other complications were recorded. Animals were sacrificed at 30 min, 1 day, 3 days, 7 days, 14 days, and 28 days post-IRE. The stomach was removed en bloc, and the diameter of each lesion was measured. Histopathological analyses by Hematoxylin-Eosin (H&E), masson trichrome, alpha-smooth muscle action (α-SMA), and terminal-deoxynucleotidyl transferase mediated nick end labeling (TUNEL) were performed. RESULTS Gastric tissue ablation with MAE-assisted IRE was successfully performed without any interruption. No perforation or bleeding was observed during IRE or throughout the follow-up period. A demarcated hemorrhage was found in the ablated area upon gross examination. H&E staining showed complete cell death with inflammatory infiltration, edema, and hemorrhaging. TUNEL presented diffuse positive cells in the ablated area. The tissue scaffold was well preserved without damage as indicated by Masson trichrome staining. Ulceration was observed starting from 3 days post-IRE. The mucosal layer was gradually recovered and regenerated within 14-28 days. No other complication was observed post-IRE. CONCLUSIONS MAE-assisted IRE is safe and effective for normal gastric tissue ablation and the gastric wall recovered in 14-28 days post-IRE.

    更新日期:2020-01-14
  • Endoscope rotating technique is useful for difficult colorectal endoscopic submucosal dissection.
    Surg. Endosc. Pub Date : null
    Chao-Wen Hsu,Chih-Chien Wu,Min-Hung Lee,Jui-Ho Wang,Yu-Hsun Chen,Min-Chi Chang

    BACKGROUND Conventional lesion-up colorectal ESD has the potential risk of iatrogenic perforation due to the knife's direction toward the muscular layer of the bowel wall. If we rotate the endoscope to the proper position, the mucosal flap is easy to be lifted down by tip attachment and the knife is easy to approach the proper dissection plane, which may prevent the perforation and facilitate difficult ESD. METHODS We aimed to retrospectively assess the safety and efficacy of this rotating technique compared with the conventional lesion-up dissection regardless of shape, location, or size of the tumor, and investigated in short- and long-term outcomes following the ESD procedure. RESULTS 41 lesions were enrolled into rotating technique group and 37 lesions in lesion-up group. The dissection speed was significantly faster in the rotating technique group (p = 0.023). R0 resection rate was significantly higher in rotating technique group (p = 0.008). The rate of perioperative complication was significantly higher in lesion-up method group (p = 0.003). Local recurrence was higher in lesion-up group (p = 0.001). Recurrence-free rate was higher in rotating technique group (p = 0.018). CONCLUSION The endoscope rotating is a useful technique for difficult colorectal ESD due to easy approaching the proper dissection plane. This technique also increases the rate of en bloc resections, R0 resections regardless of size, shape, and location and improves dissection speed without increasing the incidence of adverse events.

    更新日期:2020-01-14
  • Detrimental impact of symptom-detected colorectal cancer.
    Surg. Endosc. Pub Date : null
    Lieve G J Leijssen,Anne M Dinaux,Hiroko Kunitake,Liliana G Bordeianou,David L Berger

    BACKGROUND The incidence and mortality rates of colorectal cancer (CRC) have been steadily decreasing, largely attributable to screening colonoscopies that either remove precancerous lesions or identify CRC earlier. We aimed to assess the prognostic difference between colorectal cancers diagnosed by screening (SC), diagnostic (DC), or surveillance (SU) colonoscopies. METHODS All 1809 surgically treated patients with primary CRC diagnosed through colonoscopy at our tertiary center (2004-2015) were extracted from a prospectively maintained database. Oncologic outcomes were compared, including multivariate Cox regression. RESULTS Diagnostic patients presented with more advanced disease (15.0% vs. 53.2% (SC) and 55.3% (SU) AJCC I, P < 0.001), subsequently leading to impaired survival and higher recurrence rates (P < 0.001). After adjustment for age, ASA-score and gender, oncologic outcomes remained significantly worse after DC. Hazard ratios (HR) of overall mortality (OS) compared to DC were 0.36 for SC and 0.58 for SU (P < 0.001). Adjusted HRs of disease-free survival (DFS) were 0.43 and 0.32, respectively (P < 0.001). Worse outcomes in OS withstood adjustment for stage, tumor site and (neo)adjuvant treatment (SC: HR 0.46, P < 0.001; SU: HR 0.73, P = 0.036). The benefits of SC were particularly seen in colon cancer, stages I-II and female patients. With regard to DFS, outcomes were less profound and mainly true in early stage disease and surveillance patients. CONCLUSIONS This study demonstrates the enormous impact of asymptomatic screening in CRC. Patients with CRC diagnosed through screening or surveillance had a significantly better prognosis compared to patients who presented symptomatically. This emphasizes the importance of screening.

    更新日期:2020-01-14
  • A randomized Comparison of laparoscopic LEns defogging using Anti-fog solution, waRm saline, and chlorhexidine solution (CLEAR).
    Surg. Endosc. Pub Date : null
    Taejong Song,Dong Hee Lee

    OBJECTIVE Current literature demonstrates a lack of comparative in vivo studies regarding laparoscopic lens fogging (LLF). This randomized trial aimed to compare 3 popular methods of minimizing or reducing LLF in laparoscopic surgery by heating the lens using warm saline, applying anti-fog solution to the lens, and rubbing the lens with chlorhexidine solution. METHODS Ninety-six participants underwent randomization to be allocated in control (n = 24), warm saline (n = 24), anti-fog solution (n = 24), and chlorhexidine groups (n = 24). The primary outcome measure was the severity of LLF during the first 3 min after laparoscope insertion into the abdominal cavity. The severity of LLF was rated on a 10-point visual clarity scale ranging from 0 (clearest) to 10 (foggiest). The secondary outcome measures were (1) the severity of LLF during the remaining operative time other than the first 3 min, (2) the number of lens cleansings, and (3) the total time required to clean the lens. RESULTS Lens fogging during the first 3 min and remaining operative time other than the first 3 min was significantly decreased in the warm saline group compared to that in the other 3 groups (all, P < 0.001). In post hoc analysis, the anti-fog solution group was significantly foggier than the warm saline group, but clearer than the chlorhexidine and control groups. The number of lens cleansings and total time required to clean the lens were significantly lower in the warm saline and anti-fog solution groups than in the chlorhexidine and control groups (all, P < 0.05). CONCLUSION The use of warm saline leads to significantly fewer fogging events than the use of anti-fog solution or chlorhexidine solution, resulting in an improved continuity of surgery.

    更新日期:2020-01-14
  • Minimally invasive colectomy is associated with reduced risk of anastomotic leak and other major perioperative complications and reduced hospital resource utilization as compared with open surgery: a retrospective population-based study of comparative effectiveness and trends of surgical approach.
    Surg. Endosc. Pub Date : null
    David Wei,Stephen Johnston,Laura Goldstein,Deborah Nagle

    BACKGROUND We used a population-based database to: (1) compare clinical and economic outcomes between minimally invasive surgery (MIS) and open surgery (OS) for colectomy; and (2) evaluate contemporary trends in MIS rates. METHODS Retrospective Premier Healthcare Database review of patients undergoing elective inpatient colectomy between January 1, 2010 and September 30, 2017 (first = index admission). Patients were classified into MIS (laparoscopic/robotic) or OS groups, and by left or right colectomy. Propensity score matching (1:1 ratio) of MIS and OS groups was used to address potential confounding from patient/hospital/provider characteristics. Study outcomes, measured during index admission, included major perioperative complications [anastomotic leak (AL), bleeding, infection, and a composite of infection/AL], operating room time (ORT), length of stay (LOS), and total hospital costs. RESULTS Among 134,970 study-eligible patients, MIS rates increased from ~ 2% (2010) to 19-23% (2017), driven by a > tenfold increase in robotic surgery. The matched MIS and OS colectomy groups comprised 46,708 (left) and 44,560 (right) total patients. Risks of AL, bleeding, and infection were lower for MIS versus OS (all p < 0.001). In left: AL occurred in 7.9% of MIS versus 9.9% of OS; bleeding 7.8% versus 9.7%; infection 3.3% versus 5.8%; infection/AL 9.8% versus 13.3%. In right: AL 8.9% versus 11.1%; bleeding 9.8% versus 10.8%; infection 3.0% versus 5.1%; infection/AL 10.5% versus 10.4%. Although ORTs were longer with MIS (left: 240.8 vs. 216.2 min; right: 192.8 vs. 178.0 min), LOS was shorter (left: 5.4 vs. 7.1 days; right: 5.5 vs. 7.1 days), and total hospital costs were lower (left: $18,564 vs. $19,960; right: $17,375 vs. $19,417) versus OS (all p < 0.001). CONCLUSIONS Compared with OS, MIS was associated with significantly lower risk of major perioperative complications (including AL), lower LOS, and lower total hospital costs, despite longer OR times. MIS colectomy rates have increased over time; recent gains appear to be due to uptake of robotic surgery.

    更新日期:2020-01-14
  • Efficacy of artificial pneumothorax under two-lung ventilation in video-assisted thoracoscopic surgery for esophageal cancer
    Surg. Endosc. Pub Date : 2020-01-13
    Shinsuke Nomura, Hironori Tsujimoto, Yusuke Ishibashi, Seiichiro Fujishima, Keita Kouzu, Manabu Harada, Nozomi Ito, Yoshihisa Yaguchi, Daizoh Saitoh, Takehiko Ikeda, Kazuo Hase, Yoji Kishi, Hideki Ueno

    Abstract Background One-lung ventilation (OLV) is the standard and widely applied ventilation approach used in video-assisted thoracoscopic surgery for esophageal cancer (VATS-e). To address the disadvantages of OLV with respect to difficulties in intubation and induction, as well as the risk of respiratory complications, two-lung ventilation (TLV) with artificial pneumothorax has been introduced for use in VATS-e. However, no studies have yet compared TLV and OLV with postoperative infection and inflammation in the prone position over time postoperatively. Here, we investigated the efficacy of TLV in patients undergoing VATS-e in the prone position. Methods Between April 2010 and December 2016, 119 patients underwent VATS-e under OLV or TLV with carbon dioxide insufflation. Clinical characteristics, surgical outcomes, and postoperative outcomes, including oxygenation and systemic inflammatory responses, were compared between patients who underwent OLV and those who underwent TLV. Results Clinical characteristics other than pT stage were comparable between groups. The TLV group had shorter thoracic operation time than the OLV group. No patients underwent conversion to open thoracotomy. The PaO2/FiO2 ratios of the TLV group on postoperative day (POD) 5 and on POD7 were significantly higher than those of the OLV group. C-reactive protein levels on POD7 were lower in the TLV group than in the OLV group. There were no significant differences with respect to postoperative complications between the OLV and TLV groups. In the TLV group, the white blood cell count on POD7 was significantly lower than that in the OLV group; body temperature showed a similar trend immediately after surgery and on POD1. Conclusions In this study, we demonstrated that, compared with OLV, TLV in the prone position provides better oxygenation and reduced inflammation in the postoperative course. Accordingly, TLV might be more useful than OLV for ventilation during esophageal cancer surgery.

    更新日期:2020-01-13
  • Does endoscopic sleeve gastroplasty stand the test of time? Objective assessment of endoscopic ESG appearance and its relation to weight loss in a large group of consecutive patients
    Surg. Endosc. Pub Date : 2020-01-13
    Margherita Pizzicannella, Alfonso Lapergola, Claudio Fiorillo, Andrea Spota, Pietro Mascagni, Michel Vix, Didier Mutter, Guido Costamagna, Jacques Marescaux, Lee Swanström, Silvana Perretta

    Endoscopic sleeve gastroplasty (ESG) is a promising bariatric treatment. Gastric volume reduction and delayed gastric emptying are the probable mechanisms driving weight loss. However, there are concerns regarding the overtime ESG effectiveness. This study aims to evaluate the correlation between endoscopic gastroplasty integrity overtime and weight loss.

    更新日期:2020-01-13
  • Efficacy of per-oral endoscopic myotomy for the treatment of non-achalasia esophageal motor disorders
    Surg. Endosc. Pub Date : 2020-01-13
    Lucie Bernardot, Sabine Roman, Maximilien Barret, Véronique Vitton, Timothée Wallenhorst, Mathieu Pioche, Stanislas Chaussade, Jean-Michel Gonzalez, Thierry Ponchon, Frédéric Prat, Marc Barthet, Julien Vergniol, Edouard Chabrun, Frank Zerbib

    Abstract Introduction Per-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD). Patients and methods Patients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6 months. Results Ninety patients (mean age 66 years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I–II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I–II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I–II achalasia and type III achalasia, respectively (p = 0.03). Conclusion Although less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD.

    更新日期:2020-01-13
  • Novel transluminal treatment protocol for hepaticojejunostomy stricture using covered self-expandable metal stent
    Surg. Endosc. Pub Date : 2020-01-13
    Takeshi Ogura, Nobu Nishioka, Masanori Yamada, Tadahiro Yamada, Saori Ueno, Jyun Matsuno, Kazuya Ueshima, Yoshitaro Yamamoto, Atsushi Okuda, Kazuhide Higuchi

    Abstract Background Hepaticojejunostomy anastomotic stricture (HJS) is a rare complication after pancreatoduodenostomy. However, the rate of HJS may be increased with the expansion of operative indications, such as intraductal papillary mucinous neoplasm. Recently, the indications for EUS-guided biliary drainage to treat benign biliary disease have expanded. Recently, novel transluminal treatment protocol has been established in our hospital. The aim of this study was thus to evaluate the technical feasibility and safety of our treatment protocol. Patients and method Consecutive patients with complications of HJS between January and December 2018 were enrolled in this study. EUS-guided hepaticogastrostomy (HGS) is firstly performed. After 7 days to create the fistula, HGS stent is removed. HJS is transluminally evaluated by a cholangioscope, and antegrade balloon dilation is attempted. After 3 months, if HJS is still presence, antegrade stent deployment is performed using a covered metal stent. Also, after 1 month, antegrade stent removal is transluminally performed. Results Among total 29 patients, 14 patients were underwent antegrade metal stent deployment. The technical success rate of antegrade stent deployment was 92.9%. Median period of stent placement was 30.5 days (range 28–38 days), and transluminal stent removal was successfully performed in all patients. During follow-up (median 278 days; range 171–505 days), recurrence of HJS was seen in 2 patients. Severe adverse events were not seen in any patients during follow-up period. Conclusion Transluminal stent deployment for HJS under EUS-guidance appears feasible and safe, although further study with a larger sample size and longer follow-up is warranted.

    更新日期:2020-01-13
  • Augmented fluoroscopic bronchoscopy (AFB) versus percutaneous computed tomography-guided dye localization for thoracoscopic resection of small lung nodules: a propensity-matched study
    Surg. Endosc. Pub Date : 2020-01-13
    Shun-Mao Yang, Yi-Chang Chen, Wei-Chun Ko, Hsin-Chieh Huang, Kai-Lun Yu, Huan-Jang Ko, Pei-Ming Huang, Yeun-Chung Chang

    Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery.

    更新日期:2020-01-13
  • Expanding indications for laparoscopic parenchyma-sparing resection of posterosuperior liver segments in patients with colorectal metastases: comparison with open hepatectomy for immediate and long-term outcomes
    Surg. Endosc. Pub Date : 2020-01-13
    M. Efanov, D. Granov, R. Alikhanov, I. Rutkin, V. Tsvirkun, I. Kazakov, A. Vankovich, A. Koroleva, D. Kovalenko

    Abstract Background Laparoscopic liver resection (LLR) of posterosuperior segments (PSS) is still technically demanding procedure for highly selective patients. There is no long-term survival comparative estimation after LLR and open liver resection (OLR) for colorectal liver metastases (CRLM) located in PSS. We aimed to compare long-term overall (OS) and disease-free survival (DFS) after parenchyma-sparing LLR with expanding indications and open liver resection (OLR) of liver PSS in patients with CRLM. Methods Two Russian centers took part in the study. Patients with missing data, hemihepatectomy and extrahepatic tumors were excluded. One of contraindications for LLR was suspicion for tumor invasion in large hepatic vessels. Logistic regression was used for 1:1 propensity score matching (PSM). Results PSS were resected in 77 patients, which accounted for 42% of the total number of liver resections for CRLM. LLR were performed in 51 (66%) patients. Before and after matching, no differences were found between groups in the following factors: median size of the largest metastatic tumor; proximity to the large liver vessels; the rate of anatomical parenchyma sparing resection of PSS; a positive response to chemotherapy before and after surgery. Regardless of matching, the size of the largest metastases was above 50 mm in more than one-third of patients who received LLR. Before matching, intraoperative blood loss, ICU stay and hospital stay were significantly greater in the group of OLR. No 90-day mortality was observed within both groups. There were no differences in long-term oncological outcomes: 5-year OS after PSM was 78% and 63% after LLR and OLR, respectively; 4-year DFS after PSM was 27% in both groups. Conclusion Laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients who have an indication for OLR if performed in high volume specialized centers expertized in laparoscopic liver surgery.

    更新日期:2020-01-13
  • Transoral robotic thyroidectomy versus conventional open thyroidectomy: comparative analysis of surgical outcomes using propensity score matching
    Surg. Endosc. Pub Date : 2020-01-10
    Ji Young You, Hoon Yub Kim, Da Won Park, Hsien Wen Yang, Hong Kyu Kim, Gianlorenzo Dionigi, Ralph P. Tufano

    Various approaches for thyroid surgery became possible with the use of robotic systems. Transoral robotic thyroidectomy (TORT) is one of the newest approaches and draws attention because of its cosmetic excellence. In this study, we compared the surgical outcomes of TORT and conventional open thyroidectomy (OT).

    更新日期:2020-01-11
  • Resident perception of fundamental endoscopic skills exam: a single institution’s experience
    Surg. Endosc. Pub Date : 2020-01-10
    Jacqueline J. Blank, Theresa B. Krausert, Lisa R. Olson, Matthew I. Goldblatt, Brian D. Lewis, Philip N. Redlich, Robert Treat, Andrew S. Kastenmeier

    Graduating general surgery residents are required to pass the FES exam for ABS certification. Trainees and surgery educators are interested in defining the most effective methods of exam preparation. Our aim is to define trainee perceptions, performance, and the most effective preparation methods regarding the FES exam.

    更新日期:2020-01-11
  • Comparison of indocyanine green and carbon nanoparticles in endoscopic techniques for central lymph nodes dissection in patients with papillary thyroid cancer
    Surg. Endosc. Pub Date : 2020-01-06
    Xing Zhang, Jia-gen Li, Song-ze Zhang, Gun Chen

    Abstract Background Injection of carbon nanoparticle (CN) into the thyroid gland is used to stain CLNs in endoscopic surgery of patients with papillary thyroid cancer (PTC). The black-dye technique facilitates the central lymph nodes (CLNs) harvest and parathyroid protection, but improper handling of CN during injection leads to unwanted staining of surrounding tissues and increases the difficulty in anatomical identification. Therefore, a new method is needed to overcome this problem. Methods Forty-eight patients with PTC underwent endoscopic thyroidectomy via breast approach. Patients were randomized into the indocyanine green (ICG) group (Group ICG; n = 23) and CN group (Group CN; n = 25). After thyroid gland exposure, ICG was injected into the thyroid lobes. Fluorescent CLNs were identified and dissected in Group ICG. In Group CN, CN was used instead. Black dyed CLNs were harvested. The following was compared between groups: demographic characteristics, surgical time, drainage amount, hospital stay duration, number of CLNs harvested, frequency of postoperative hoarseness and hypothyroidism, and surgical cost. Results Group ICG showed decreased hypoparathyroidism frequency than Group CN (1/23 vs. 7/25, p = 0.028) and more harvested CLNs (4.6 ± 1.0 vs. 3.8 ± 1.2, p = 0.020). There was no difference between drainage amount, hospital stay duration, and frequency of postoperative hoarseness. The cost of Group ICG was less than that of Group CN (p = 0). Conclusion Injection of ICG into the thyroid gland using fluorescence imaging in endoscopic surgery in patients with PTC is safer and more effective in identifying CLNs than injection with CN. This novel method can lead to improved identification and subsequent harvesting of CLNs.

    更新日期:2020-01-06
  • Real-time ureteral identification with novel, versatile, and inexpensive catheter
    Surg. Endosc. Pub Date : 2020-01-06
    Yuki Ushimaru, Atsushi Ohigawa, Kotaro Yamashita, Takuro Saito, Koji Tanaka, Tomoki Makino, Tsuyoshi Takahashi, Yukinori Kurokawa, Makoto Yamasaki, Masaki Mori, Yuichiro Doki, Kiyokazu Nakajima

    Abstract Background Although ureteral catheters and ureteral fluorescence methods have been investigated to avoid ureteral injury, they have not been standardized for procedural complexity and safety to the living body. A near-infrared (NIR) fluorescence ureteral catheter made of fluorescent resin was jointly developed for non-invasive detection of ureters. The aims of this study were to (1) evaluate its bench-top performance and (2) assert its safety and potential usefulness in a series of animal models. Methods [Bench-top study]: Confirmed stimulation of NIR fluorescence catheter by NIR light was investigated with the use of a laparoscopic fluorescence imaging system. Additionally, the influence of imaging distance and shielding objects, such as 1.5-mm sliced pig loin with multiple sheets, was also evaluated. [Performance study]: The safety and potential usefulness of fluorescence catheter was evaluated in five pigs. Non-fluorescence and fluorescence ureteral catheters were alternatively placed in the animals’ left and right ureters. The ImageJ software was used in all experiments to quantify fluorescence signal and the signal-to-background ratio. Results [Bench-top study]: The fluorescence ureteral catheter was successfully identified at all distances. Its fluorescence decreased in inverse proportion to distance and to the intervening shield thickness (p < 0.01). When shields were present, catheter position could not be recognized with non-fluorescence catheters, but with fluorescence catheters they could be recognized. [Performance study]: Fluorescence catheter’s ability to fluoresce at all distances was confirmed (p < 0.01). No individual differences (p = 0.21) or left/right ureter differences (p  = 0.79) were observed. The fluorescence of the fluorescence catheter decreased in inverse proportion to distance (p  < 0.01). Conclusions The new fluorescence ureter catheter investigated shows promising performance in providing ureteral identification with high specificity during laparoscopic surgery.

    更新日期:2020-01-06
  • The GAMMA concept (gastrointestinal activity manipulation to modulate appetite) preliminary proofs of the concept of local vibrational gastric mechanical stimulation
    Surg. Endosc. Pub Date : 2020-01-06
    Andras Legner, Seong-Ho Kong, Yu-Yin Liu, Galyna Shabat, Peter Halvax, Alend Saadi, Marc Worreth, Jacques Marescaux, Lee Swanström, Michele Diana

    Abstract Background Mechanical stimulation of the stretch receptors of the gastric wall can simulate the presence of indigested food leading to reduced food intake. We report the preliminary experimental results of an innovative concept of localized mechanical gastric stimulation. Methods In a first survival study, a biocompatible bulking agent was injected either in the greater curvature (n = 8) or in the cardia wall (n = 8) of Wistar rats. Six animals served as sham. Changes of bulking volume, leptin levels and weight gain were monitored for 3 months. In a second acute study, a micro-motor (n = 10; MM) or a size-paired inactive device (n = 10; ID) where applied on the cardia, while 10 additional rats served as sham. Serum ghrelin and leptin were measured at baseline and every hour (T0–T1–T2–T3), during 3 h. In a third study, 24 implants of various shapes and sizes were introduced into the gastric subserosa of 6 Yucatan pigs. Monthly CT scans and gastroscopies were done for 6 months. Results Weight gain in the CW group was significant lower after 2 weeks and 3 months when compared to the shame and GC (p = 0.01/p = 0.01 and p = 0.048/p = 0.038 respectively). Significant lower increase of leptin production occurred at 2 weeks (p = 0.01) and 3 months (p = 0.008) in CW vs. SG. In the MM group significant reduction of the serum ghrelin was seen after 3 h. Leptin was significantly increased in both MM and ID groups after 3 h, while it was significantly reduced in sham rats. The global device retention was 43.5%. Devices with lower profile and with a biocompatible coating remained more likely in place without complications. Conclusions Gastric mechanical stimulation induced a reduced weight gain and hormonal changes. Low profile and coated devices inserted within the gastric wall are more likely to be integrated.

    更新日期:2020-01-06
  • Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer
    Surg. Endosc. Pub Date : 2019-12-19
    Yimei Jiang, Zijia Song, Xi Cheng, Kun Liu, Yiqing Shi, Changgang Wang, You Li, Xiaopin Ji, Ren Zhao

    Abstract Background To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery. Methods This was a retrospective case–control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM). Results Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively. Conclusions Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.

    更新日期:2020-01-04
  • Cholelithiasis after bariatric surgery, incidence, and prophylaxis: randomized controlled trial
    Surg. Endosc. Pub Date : 2019-12-19
    Ahmed Talha, Tamer Abdelbaki, Ayman Farouk, Ehab Hasouna, Eman Azzam, Gihan Shehata

    Rapid weight loss is associated with a high incidence of cholelithiasis.

    更新日期:2020-01-04
  • Feasibility and efficacy of repeat laparoscopic liver resection for recurrent hepatocellular carcinoma
    Surg. Endosc. Pub Date : 2019-12-18
    Takashi Onoe, Megumi Yamaguchi, Toshimitsu Irei, Kohei Ishiyama, Takeshi Sudo, Naoto Hadano, Masato Kojima, Haruna Kubota, Ryuta Ide, Hirofumi Tazawa, Wataru Shimizu, Takahisa Suzuki, Yosuke Shimizu, Takao Hinoi, Hirotaka Tashiro

    Abstract Background Repeat hepatectomy is an acceptable treatment for recurrent hepatocellular carcinoma (HCC). However, repeat laparoscopic liver resection (LLR) has not been widely adopted due to its technical difficulty. This study aimed to assess the feasibility and efficacy of repeat LLR compared with repeat open liver resection (OLR) for recurrent HCC. Methods We performed 42 repeat OLR and 30 repeat LLR for cases of recurrent HCC between January 2007 and March 2018. This study retrospectively compared the patients’ clinicopathological characteristics and operative and short-term outcomes including surgical time, intraoperative blood loss, duration of hospital stay, and postoperative complications between the two groups. Results There were no significant differences in patient characteristics between the two groups except in terms of Child–Pugh grade. The repeat LLR group had lower median intraoperative blood loss (100 mL vs. 435 mL; P = 0.001) and shorter median postoperative hospital stay (10 days vs. 14.5 days; P = 0.002). The other results including postoperative complications were comparable between the two groups. Further, comparison of two subpopulations of the repeat LLR group stratified by previous hepatectomy type (open or laparoscopic) or tumor location (segments 7 and 8 or other) revealed no significant differences in the postoperative clinical characteristics between them, although the morbidity rate tended to be higher in patients who underwent open hepatectomy for primary HCC than in patients who underwent laparoscopic hepatectomy. Conclusions Repeat LLR for recurrent HCC is feasible and useful with good short-term outcomes although an appropriate patient selection seems to be necessary.

    更新日期:2020-01-04
  • A prospective, randomized controlled study of the safety and efficacy of gasless bilateral axillo-breast approach (BABA) robotic thyroidectomy
    Surg. Endosc. Pub Date : 2019-12-17
    Ik Beom Shin, Do Hoon Koo, Myoung Jin Ko, Se Hoon Kim, Dong Sik Bae

    During bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT), carbon dioxide (CO2) gas is insufflated into the operative cavity, not only triggering hemodynamic and metabolic changes, but also inducing postoperative pain and gas embolism. Here, we explored whether the new gasless BABA RoT approach was as safe and efficacious as conventional robotic surgery using CO2 insufflation.

    更新日期:2020-01-04
  • Robotic versus open pancreaticoduodenectomy: a meta-analysis of short-term outcomes
    Surg. Endosc. Pub Date : 2019-12-17
    Qing Yan, Lei-bo Xu, Ze-fang Ren, Chao Liu

    Abstract Background Although robotic surgery is popular around the world, its safety and efficacy over classical open surgery is still controversial. The purpose of this article is to compare the safety and efficacy of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). Methods A literature search of PubMed, Web of Science, and the Cochrane Library database up to July 29, 2018 was performed and the meta-analysis was performed using RevMan 5.2 software with Fixed and random effects models applied. The IRB approval and written consent were not needed for this paper. Results Twelve non-randomized retrospective studies and 1 non-randomized prospective study consisting of 2403 patients were included in this meta-analysis. There were 788 (33%) patients in the RPD group and 1615 (67%) patients in the OPD group. Although RPD was associated with a longer operative time (weighted mean difference [WMD]: 71.74 min; 95% CI 23.37–120.12; p = 0.004), patient might benefit from less blood loss (WMD: − 374.03 ml; 95% CI − 506.84 to − 241.21; p < 0.00001), shorter length of stay (WMD: − 5.19 day; 95% CI − 8.42 to − 1.97; p = 0.002), and lower wound infection rate (odds ratio: 0.17; 95% CI 0.04–0.80; p = 0.02). No statistically significant difference was observed in positive margin rate, lymph nodes harvested, postoperative complications, reoperation or readmission rate, and mortality rate. Conclusions Robotic pancreaticoduodenectomy is a safe and feasible alternative to open pancreaticoduodenectomy with regard to short-term outcomes. Further studies on the long-term outcomes of these surgical techniques are needed.

    更新日期:2020-01-04
  • Cost containment: an experience with surgeon education and universal preference cards at two institutions
    Surg. Endosc. Pub Date : 2019-12-16
    Elizabeth Embick, Michael Bieri, Tracy J. Koehler, Amanda Yang

    Abstract Background As the cost of health care increases in the US, focus has been placed upon efficiency, cost reduction, and containment of spending. Operating room costs play a significant role in this spending. We investigated whether surgeon education and universal preference cards can have an impact on reducing the disposable supply costs for common laparoscopic general surgery procedures. Methods General surgeons at two institutions participated in an educational session about the costs of the operative supplies used to perform laparoscopic appendectomies and cholecystectomies. All the surgeons at one institution agreed upon a universal preference card, with other supplies opened only by request. At the other, no universal preference cards were created, and surgeons were free to modify their own existing preference cards. Case cost data for these procedures were collected for each institution pre- (July 2014-December 2014) and post-intervention (February 2015–November 2017). Results At the institution with an education only program, there was no statistically significant change in supply costs after the intervention. At the institution that intervened with the combined education and universal preference card program, there was a statistically significant supply cost decrease for these common laparoscopic procedures combined. This significant cost decrease persisted for each appendectomies and cholecystectomies when analyzed independently as well (p = 0.001 and p < 0.001 respectively). Conclusions In this study, surgeon education alone was not effective in reducing operating room disposable supply costs. Surgeon education, combined with the implementation of universal preference cards, significantly maintains reductions in operating room supply costs. As health care costs continue to increase in the US and internationally, universal preference cards can be an effective tool to contain cost for common laparoscopic general surgery procedures.

    更新日期:2020-01-04
  • Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection
    Surg. Endosc. Pub Date : 2019-12-16
    Grace C. Lee, Liliana G. Bordeianou, Todd D. Francone, Lawrence S. Blaszkowsky, Robert N. Goldstone, Rocco Ricciardi, Hiroko Kunitake, Motaz Qadan

    While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer.

    更新日期:2020-01-04
  • Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer
    Surg. Endosc. Pub Date : 2019-12-13
    Ji-Ho Park, Sang-Ho Jeong, Young-Joon Lee, Tae Han Kim, Jong-Man Kim, Dong-Hwan Kim, Seung-Jin Kwag, Ju-Yeon Kim, Taejin Park, Chi-Young Jeong, Young-tae Ju, Eun-Jung Jung, Soon-Chan Hong

    Anastomotic complications such as leaks, bleeding, and stricture remain the most serious complications of surgery for gastric cancer. No perfect method exists for an accurate and reliable prevention of these complications. This study investigated the safety and efficacy of post-anastomotic intraoperative endoscopy (PAIOE) for avoidance of early anastomotic complications during gastrectomy in gastric cancer.

    更新日期:2020-01-04
  • Transoral endoscopic selective lateral neck dissection for papillary thyroid carcinoma: a pilot study
    Surg. Endosc. Pub Date : 2019-12-13
    YuYan Tan, BoMin Guo, XianZhao Deng, Zheng Ding, Bo Wu, YiQi Niu, JianZhong Hou, YinChao Zhang, YouBen Fan

    Abstract Background Transoral endoscopic thyroid surgery via the vestibular approach (TOETVA) has been gradually accepted worldwide due to its scar-free effect on the neck. Even central cervical lymphadenectomy has been performed in some cases of papillary thyroid carcinoma (PTC). However, there are few reports involving lateral neck dissection with TOETVA. In this study, we attempted to perform selective lateral neck dissection (SLND) for PTC via a transoral vestibular approach. Methods This prospective study was conducted from January 2016 to December 2018 in twenty PTC patients with unilateral T1 tumors without capsular invasion and patients with abnormal level III and IV lymph nodes who underwent SLND via a transoral vestibular approach. Results Endoscopic surgery was successfully accomplished in all 20 PTC patients. The mean age was 29.2 ± 5.5 (20–41) years. The mean operation time was 146.0 ± 18.7 (114–193) min. The average postoperative hospital stay was 6.8 ± 1.3 (5–10) days. The mean number of removed nodes was 7.4 ± 2.5 (4–12) in the central neck and 10.9 ± 2.8 (6–16) in the lateral neck, and the positive yield amounts were 2.0 ± 1.2 (0–4) and 2.7 ± 1.9 (0–6), respectively. No major complications occurred except for 1 case of transient unilateral recurrent laryngeal nerve palsy and two cases of effusion in the operative area. No evidence of persistent or recurrent disease was observed in these patients during a mean follow-up of 24.3 ± 9.1 (6–36) months. The cosmetic results and protection of personal privacy of this procedure were excellent. Conclusion Endoscopic SLND via the transoral vestibular approach is feasible, safe, and effective for selected PTCs. A multicenter large comparative study is necessary.

    更新日期:2020-01-04
  • Anatomical study of the left colic artery in laparoscopic-assisted colorectal surgery
    Surg. Endosc. Pub Date : 2019-12-13
    Wei Zhang, Wei-Tang Yuan, Gui-xian Wang, Jun-Min Song

    Abstract Background It is important for lymph node dissection around the inferior mesenteric artery (IMA) with preservation of the left colic artery (LCA) to be aware of the track and the length of the LCA. We aimed to investigate the branching pattern and trajectory of LCA and measure the distances from the root of the IMA to the origin of the LCA (D mm) and from the origin of LCA to intersection of LCA and IMV (d mm) during laparoscopic left-sided colorectal operations. Methods We analyzed 106 patients who underwent laparoscope-assisted left-side colorectal surgery during laparoscopic surgery. The branching patterns among the IMA, LCA, and sigmoidal trunk were evaluated; the trajectory of LCA was examined; the D mm and d mm were measured using a length of silk in the surgical operation. Results In 59.5% patients, the LCA arose independently from the sigmoidal trunk (type A); in 8.5% patients, the LCA and sigmoidal trunk arose from the IMA at the same point (type B); in 29.2% patients, the LCA and sigmoidal trunk had a common trunk (type C); the LCA did not exist in 2.8% (type D).The D mm and d mm for all cases ranged from 15.0 to 65.3 mm (median, 43.1 mm) and from 20.3 to 46.2 mm (median, 34.8 mm), respectively. 74.8% of the LCA went straight upper left and upward to proximal part of descending colon (type I), 25.2% went to the lower left at first, then turned to travel straight upward to proximal part of descending colon (type II). Conclusion This study showed the anatomic variations of LCA during laparoscopic left-sided colorectal operation, which would help surgeons safely perform laparoscopic surgery in the left-side colon and rectum.

    更新日期:2020-01-04
  • What affects the prognosis of NOMI patients? Analysis of clinical data and CT findings
    Surg. Endosc. Pub Date : 2019-12-12
    Ryo Miyazawa, Minobu Kamo

    Abstract Background Non-occlusive mesenteric ischemia (NOMI) is a mesenteric ischemic disease with considerably high mortality rate, although little has been known about what factors affect the patients’ prognosis. The purpose of this study was to investigate prognostic factors of clinical data and computed tomography (CT) findings in patients with NOMI. Methods This was a single institutional, retrospective study, reviewing 21 consecutive patients diagnosed with NOMI on angiography. Patients were divided into either ‘‘survivor’’ group or ‘‘non-survivor’’ group based on their clinical courses 1 month after diagnosis. Clinical information such as laboratory data, Charlson Comorbidity Index, and time from CT to injecting vasodilator was obtained from patients’ medical records. Contrast-enhanced CT images were assessed in following items: defect of mural enhancement, pneumatosis intestinalis, hepatic portal venous gas, paralytic bowel dilatation, bowel wall thinning, and diameters of the relevant vessels. Results Eight patients belonged to ‘‘survivor’’ group, whereas eleven were allocated to ‘‘non-survivor’’ group. None of CT findings showed significant difference between survivor group and non-survivor group [defect of mural enhancement: 75% and 100% (p = 0.16), pneumatosis intestinalis: 50% and 45.5% (p = 1.00), hepatic portal venous gas: 37.5% and 45.5% (p = 1.00), paralytic bowel dilatation: 12.5% and 63.6% (p = 0.06), and bowel wall thinning: 50% and 45.5% (p = 1.00)]. The diameters of the relevant vessels did not have significant difference either. Time from CT to injecting vasodilator was revealed to be significantly shorter in survivor group [187.5 (122.5–294) min and 310 (187–925.5)] (p = 0.048). None of the other clinical information had significant difference between each group. Conclusion Prompt angiography may be a key to improve the prognosis of NOMI patients.

    更新日期:2020-01-04
  • Correction to: Laparoscopic right hemicolectomy: the SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) network prospectivetrial on 1225 cases comparing intra corporeal versus extra corporeal ileo‑colic side‑to‑side anastomosis
    Surg. Endosc. Pub Date : 2019-12-12
    Gabriele Anania, Ferdinando Agresta, Elena Artioli, Serena Rubino, Giuseppe Resta, Nereo Vettoretto, Wanda Luisa Petz, Carlo Bergamini, Alberto Arezzo, Giorgia Valpiani, Chiara Morotti, Gianfranco Silecchia, SICE CoDIG (Colon Dx Italian Group)

    Due to an error in production the members of SICE CoDIG (Colon Dx Italian Group) listed in the Acknowledgments were not tagged correctly as authors in the XML of this article. This listing is presented again here:

    更新日期:2020-01-04
  • The impact of internet-based patient self-education of surgical mesh on patient attitudes and healthcare decisions prior to hernia surgery
    Surg. Endosc. Pub Date : 2019-12-12
    Matthew P. Miller, Saeed Arefanian, Jeffrey A. Blatnik

    As internet access improves, patient self-education continues to increase. However, patient surgical background, e-literacy, and media exposure potentially influence what information patients search online. This impacts patient concern, healthcare decisions, and subsequent patient-physician interactions. The purpose of this pilot study is to characterize hernia patients’ use and the impact of internet self-education regarding surgical mesh.

    更新日期:2020-01-04
  • Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO)
    Surg. Endosc. Pub Date : 2019-12-11
    Masateru Yamamoto, Tsuyoshi Kobayashi, Akihiko Oshita, Tomoyuki Abe, Toshihiko Kohashi, Takashi Onoe, Saburo Fukuda, Ichiro Omori, Yasuhiro Imaoka, Naruhiko Honmyo, Hideki Ohdan

    Abstract Background Laparoscopic liver resection (LLR) has evolved as a safe and effective alternative to conventional open liver resection (OLR) for malignant lesions. However, LLR in cirrhotic patients remains challenging. This study analyzed the perioperative and oncological outcomes of LLR for hepatocellular carcinoma (HCC) with cirrhosis compared with OLR using propensity score matching. Methods A multicenter retrospective analysis of records of patients who underwent limited liver resection for HCC and were histologically diagnosed with liver cirrhosis between January 2009 and December 2017 in the eight institutions belonging to the Hiroshima Surgical study group of Clinical Oncology was performed. The patients were divided into two groups: the LLR and OLR groups. After propensity score matching, we compared clinicopathological features and outcomes. Results In total 256 patients with histological liver cirrhosis who underwent limited liver resection for HCC were included in this study; 58 patients had undergone LLR, and the remaining 198 patients OLR. The number of tumors was higher, tumor size was larger, and difficulty score was significantly higher in the OLR group before propensity matching. After the matching, the data of the well-matched 58 patients in each group were evaluated; the intraoperative blood loss was lower in the LLR group (p = 0.004), and incidence of the postoperative complications was significantly higher in the OLR group (p = 0.019). The duration of the postoperative hospital stay was significantly shorter in the LLR group (p < 0.001). There were no differences between two groups in overall survival and recurrent-free survival. Conclusions LLR decreased the incidences of postoperative complications, shortened the duration of postoperative hospital stay. Thus, LLR is a safe and feasible procedure even in patients with cirrhosis.

    更新日期:2020-01-04
  • Are right-sided colectomies for neoplastic disease at increased risk of primary postoperative ileus compared to left-sided colectomies? A coarsened exact matched analysis
    Surg. Endosc. Pub Date : 2019-12-11
    Richard Garfinkle, Faisal Al-Rashid, Nancy Morin, Gabriela Ghitulescu, Julio Faria, Carol-Ann Vasilevsky, Marylise Boutros

    The objective of this study was to determine whether right-sided colectomies (RC) were associated with a higher incidence of primary postoperative ileus (pPOI) compared to left-sided colectomies (LC).

    更新日期:2020-01-04
  • Short- and long-term outcomes of prophylactic thoracic duct ligation during thoracoscopic–laparoscopic McKeown esophagectomy for cancer: a propensity score matching analysis
    Surg. Endosc. Pub Date : 2019-12-11
    Tao Bao, Ying-Jian Wang, Kun-Kun Li, Xue-Hai Liu, Wei Guo

    Abstract Background Chylothorax remains a challenging and potentially life-threatening postoperative complication after minimally invasive esophagectomy (MIE). The effect of intraoperative prophylactic thoracic duct ligation on preventing postoperative chylothorax still remains controversial. Moreover, the potential impact of thoracic duct ligation on long-term outcome after MIE has not been well established. Methods From September 2009 to July 2018, a total of 600 consecutive patients suffering from thoracic esophageal cancer who underwent thoracoscopic–laparoscopic McKeown esophagectomy in the Department of Thoracic surgery at Daping hospital were eligible. Among them, 559 patients received esophagectomy with preventive thoracic duct ligation and 41 patients did not. Propensity score matching (PSM) was performed to improve comparability between the two groups. Log-rank test was used to assess the survival differences between groups. Results Postoperative chylothorax occurred in five patients in the preservation group (PG) and in seven patients in the ligation group (LG) (12.2% vs. 1.3%, P = 0.001). The median age of the patients in the preservation group (PG) was 57.78 (range, 37–76) years, while the median age in the ligation group (LG) was 62.75 (range, 39–87) years. The PG had more patients with tumor located in middle thoracic esophagus and stage T3 than LG, 82.9% vs. 55.6%, 70.7% vs. 45.6%, respectively. After PSM (40 matched patients in PG and 134 in LG), there was no significant between-group difference with respect to age, tumor location, and T stage. The median survival times for patients in the PG and LG were 69.5 months (95% interval confidence, CI 54.6–84.3) and 65.2 months (95% CI 56.3–74.1), respectively (P = 0.977). The 5-year survival rates were comparable between PG and LG (54.9% vs. 54.4%, P = 0.977). Conclusion On the basis of the present results, routine thoracic duct ligation during minimally invasive McKeown esophagectomy for cancer is an effective and safe method for prevention of postoperative chylothorax, and does not exert unfavourable effect on long-term survival.

    更新日期:2020-01-04
  • Different cognitive styles can affect performance in laparoscopic surgery skill training
    Surg. Endosc. Pub Date : 2019-12-10
    Armin Paul Mathias, Peter Vogel, Markus Knauff

    The lack of depth cues and haptic feedback makes minimally invasive surgery a cognitive challenge. It is therefore important to know which individuals are expected to perform well in minimally invasive surgery. In cognitive psychology, methods are available with which one can measure different cognitive thinking styles. It is well known that these cognitive styles correlate with many different tasks. We investigated whether this method can also predict performance on a box trainer (Lübeck Toolbox®), a device for training laparoscopic surgery. If so, the method might help to select and train those people who will most likely develop high skills in minimally invasive surgery.

    更新日期:2020-01-04
  • Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center
    Surg. Endosc. Pub Date : 2019-12-10
    Benefsha Mohammad, Michele N. Richard, Amrita Pandit, Keith Zuccala, Steven Brandwein

    Abstract Background Obesity is a prevalent issue in today’s society, increasing the number of gastric weight loss surgeries (Bowman et al. in Surg Endosc. https://doi.org/10.1007/s00464-016-4746-8, 2016; Choi et al. in Surg Endosc. https://doi.org/10.1007/s00464-013-2850-6, 2013; Paranandi et al. in Frontline Gastroenterol. https://doi.org/10.1136/flgastro-2015-100556, 2015; Richardson et al. in http://www.ingentaconnect.com/content/sesc/tas, 2012). This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP) as the traditional is technically difficult, requiring a longer endoscope with a reported success rate of less than 70% (Roberts et al. in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016032/, 2008). A solution is laparoscopic-assisted ERCP (LA-ERCP) via gastrostomy. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients. Methods An IRB-approved retrospective chart review was performed on patients with prior gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure involved two bariatric surgeons and one gastroenterologist. The gastric remnant was secured to the abdominal wall with a purse-string suture and transfascial stay sutures. After gastrostomy creation of a duodenoscope was inserted to perform ERCP. Biliary sphincterotomy, dilation, and stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital readmission, and bile leak. Results Thirty-two patients met inclusion criteria. The majority of indications for LA-ERCP was choledocholithiasis (16/32). The remainder of cases included indications such as abnormal LFTs with biliary dilation (11/32), acute pancreatitis (2/32), cholangitis (2/32), and bile leak (1/32). LA-ERCP was successfully performed in all patients. Biliary sphincterotomy and stone extraction were performed on 31/32 patients. One patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved on POD2. The median length of stay was 2 days. Conclusion LA-ERCP is a safe and feasible alternative to open surgery and can be safely implemented at community hospitals with adequately trained providers. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.

    更新日期:2020-01-04
  • Are we ready for bundled payments for major bowel surgery?
    Surg. Endosc. Pub Date : 2019-12-10
    Udai S. Sibia, Justin J. Turcotte, John R. Klune, Glen R. Gibson

    Abstract Background The Centers for Medicare & Medicaid Services (CMS) recently announced a new voluntary episode payment model for major bowel surgery. The purpose of this study was to examine the financial impact of bundled payments for major bowel surgery. Methods An institutional database was retrospectively queried for all patients who underwent major bowel surgery between July 2016 and June 2018. Procedures were categorized using MS-DRG coding: MS-DRG 329 (with MCC, major complications and comorbidity), MS-DRG 330 (with CC, complications and comorbidity), and MS-DRG 331 (without CC/MCC). Results A total of 745 patients underwent 798 procedures, with mean age 62.1 years and BMI 29.2 kg/m2. The median LOS was 4.0 days, with 12.5% of patients being discharged to a post-acute care facility for an average of 38.5 days. The mean hospital cost was $18,525. The mean payment to a post-acute care facility was $423 per day. The 90-day readmission rate was 8.6% at an average cost of $12,859 per readmission. Patients with major complications and comorbidity (MS-DRG 329) had higher CMS Hierarchical Condition Categories scores, longer LOS, higher costs, more required home health services or post-acute care facilities, and had higher 90-day readmissions. In a fee-for-service model, hospital reimbursements resulted in a negative margin of − 8.2% for MS-DRG 329, − 2.6% for MS-DRG 330, but a positive margin of 2.8% for MS-DRG 331. In a bundled payment model, the hospital would incur a loss of − 13.1%, − 11.1%, and − 1.9% for MS-DRG 329, 330, and 331, respectively. Conclusions Patients undergoing major bowel surgery are often a heterogeneous population with varied pre-existing comorbid conditions who require a high level of complex care and utilize greater hospital resources. Further study is needed to identify areas of cost containment without compromising the overall quality of care.

    更新日期:2020-01-04
  • Safety and feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection for locally advanced upper third gastric cancer: a prospective, multicenter clinical trial
    Surg. Endosc. Pub Date : 2019-12-10
    Chao-Hui Zheng, Yan-Chang Xu, Gang Zhao, Li-Sheng Cai, Guo-Xin Li, Ze-Kuan Xu, Su Yan, Zu-Guang Wu, Fang-Qin Xue, Yi-Hong Sun, Dong-Bo Xu, Wen-Bin Zhang, Jin-Wan, Pei-Wu Yu, Jian-Kun Hu, Xiang-Qian Su, Jia-Fu Ji, Zi-Yu Li, Jun You, Yong Li, Lin-Fan, Jun-Lu, Ping-Li, Chang-Ming Huang, for the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group

    Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter study to evaluate the technical safety and feasibility of LSTG for patients with AUTGC.

    更新日期:2020-01-04
  • Long-term results of laparoscopic cytoreductive surgery and HIPEC for the curative treatment of low-grade pseudomyxoma peritonei and multicystic mesothelioma.
    Surg. Endosc. Pub Date : null
    Frederic Mercier,Guedj Jeremie,Mohammad Alyami,Vaudoyer Delphine,Kepenekian Vahan,Rousset Pascal,Isaac Sylvie,Passot Guillaume,Glehen Olivier

    BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide long-term survival for low-grade pseudomyxoma peritonei (PMP) and multicystic peritoneal mesothelioma (MM). Feasibility of laparoscopic CRS-HIPEC has been reported for selected patients but data regarding long-term outcomes are missing to assess the oncological interest. This study aimed to report long-term outcomes for low-grade PMP and MM treated by laparoscopic approach. METHODS From a prospectively maintained CRS-HIPEC database, all patients who underwent laparoscopic CRS-HIPEC with curative intent were analyzed. Selection criteria for laparoscopic approach were low-grade PMP or MM, with pathological confirmation prior to CRS-HIPEC, ASA 2, age < 75 years, no extrap-eritoneal disease, Peritoneal Cancer Index (PCI) < 10, and a limited history of abdominal surgery. RESULTS Between March 2009 and June 2017, 43 patients were scheduled for laparoscopic CRS and HIPEC. Laparoscopic CRS and HIPEC was completed (LSC) in 32 patients and 11 patients were converted to open surgery (CONV). Median age was 44.5 years (17.13-71.4) in the LSC group and 54.9 years (22.5-70.5) in the CONV group (p = 0.086). Median BMI was not different between groups, 21.2 and 23.9 for LSC and CONV groups, respectively (p = 0.267). There were 21 and 11 patients in the LSC group, and 8 and 3 in the CONV group, with PMP and MM, respectively (p = 0.794). Median PCI was 2.5 (0-9) and 7 (1-15) in the LSC and CONV groups, respectively (p = 0.004). There was no difference in the completeness of cytoreduction score (p = 0.256). After a median follow-up of 31.6 months (95% CI 19.3-36.4), 2 patients in the LSC group and 2 patients in the CONV group presented with peritoneal recurrence. CONCLUSION For selected patients with low aggressive peritoneal disease, laparoscopic CRS-HIPEC provides interesting long-term outcomes.

    更新日期:2019-11-01
  • Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease.
    Surg. Endosc. Pub Date : null
    Marc A Ward,Ahmed Ebrahim,Jeffrey Kopita,Lindsay Arviso,Gerald O Ogola,Brittany Buckmaster,Steven G Leeds

    BACKGROUND The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown. METHODS A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires. RESULTS There were 86 patients (38 males; 48 females) with a median age of 51.5 years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1 year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively. CONCLUSION MSA is an effective treatment for typical and atypical GERD symptoms.

    更新日期:2019-11-01
  • Laparoscopic resection is better than endoscopic dissection for gastric gastrointestinal stromal tumor between 2 and 5 cm in size: a case-matched study in a gastrointestinal center.
    Surg. Endosc. Pub Date : null
    Xiaoyu Dong,Weisheng Chen,Ziming Cui,Tao Chen,Xiumin Liu,Dexin Chen,Wei Jiang,Kai Li,Shumin Dong,Mingyuan Feng,Jixiang Zheng,Zhiming Li,Meiting Fu,Ying Lin,Jiaying Liao,Huijuan Le,Jun Yan

    BACKGROUND The feasibility of endoscopic dissection for gastric gastrointestinal stromal tumor (gGIST) between 2 and 5 cm in size has been demonstrated. However, its impact on short-term and long-term outcomes, compared with laparoscopic resection, is unknown. The purpose of this study was to compare short-term and long-term outcomes between laparoscopic resection and endoscopic dissection for 2-5-cm gGIST. METHODS A case-matched study was performed using the propensity score. To overcome selection bias, we performed a 1:1 match using six covariates, including age, sex, BMI, ASA score, tumor size, and tumor location. Short-term and long-term outcomes between laparoscopic resection and endoscopic dissection were compared. RESULTS A total of 210 patients with 2-5-cm gGIST were enrolled between 2006 and 2017 in our gastrointestinal center. According to the intention-to-treat approach, 165 patients underwent laparoscopic resection, and 45 patients underwent endoscopic dissection. After the propensity score, 45 pairs were balanced and analyzed. There was no significant difference in the baseline characteristics between the laparoscopic and endoscopic groups after matching. The rate of complications was significantly higher in the endoscopic group compared with the laparoscopic group (P < 0.001). Perforations occurred in 16 patients in the endoscopic group (16/45, 35.6%). The postoperative hospital stay was significantly longer in the endoscopic group compared with the laparoscopic group (P < 0.001). There was no significant difference between the two groups in disease-free survival or overall survival. CONCLUSION Laparoscopic resection is better than endoscopic dissection for 2-5-cm gGIST because of the lower complication rate and shorter hospital stay.

    更新日期:2019-11-01
  • Effect of preoperative computed tomography parameters and obesity on surgical outcomes of laparoendoscopic single-site adrenalectomy.
    Surg. Endosc. Pub Date : null
    Yu-Chen Chen,Hsiang-Ying Lee,Ming-Chen Paul Shih,Yung-Shun Juan,Hao-Wei Chen,Wen-Jeng Wu,Yu-Tsang Wang,Ching-Chia Li

    BACKGROUND The aims of the present study were to (1) analyse preoperative computed tomography (CT) parameters, (2) investigate whether obesity and CT parameters affect surgical outcomes in patients undergoing LESS lateral retroperitoneal adrenalectomy, and (3) further establish the optimal cutoff point of CT parameters for tolerable operating time. METHODS Between January 2010 and August 2016, patients who underwent LESS adrenalectomy through the retroperitoneal approach in our hospitals were included. Patients' demographic data, preoperatively measured CT parameters (the depth and horizontal width to the adrenal gland in the axial view of abdominal CT, the vertical height in the coronal view of CT, and the angle of the depth and horizontal width), and intraoperative (operative time and blood loss) and postoperative (hospital stay and complications) parameters were retrospectively reviewed. Linear regression was performed to determine factors that potentially affect surgical outcomes. RESULTS In 116 patients, depth was the only CT parameter associated with surgical outcomes. Large depth (P = 0.005; 95% CI 1.739-9.256) and high BMI (P = 0.012; 95% CI 0.357-2.851) were factors significantly associated with longer operative time. The area under the ROC curve for the depth was 0.69 (P = 0.002), and the cutoff point 10.48 cm may be the tolerable operating time. CONCLUSIONS Our results suggest a depth limit of 10.48 cm for the optimal prediction of operating time less than 90 min; although obese patients and deeper adrenal glands had longer operative time, LESS adrenalectomy could be performed in the obese patients without increased blood loss, prolonged hospital stay, or increased pain.

    更新日期:2019-11-01
  • Postoperative rendezvous endoscopic retrograde cholangiopancreaticography as an option in the management of choledocholithiasis.
    Surg. Endosc. Pub Date : null
    Eva-Lena Syrén,Gabriel Sandblom,Staffan Eriksson,Arne Eklund,Bengt Isaksson,Lars Enochsson

    BACKGROUND Rendezvous endoscopic retrograde cholangiopancreaticography (ERCP) is a well-established method for treatment of choledocholithiasis. The primary aim of this study was to determine how different techniques for management of common bile duct stone (CBDS) clearance in patients undergoing cholecystectomy have changed over time at tertiary referral hospitals (TRH) and county/community hospitals (CH). The secondary aim was to see if postoperative rendezvous ERCP is a safe, effective and feasible alternative to intraoperative rendezvous ERCP in the management of CBDS. METHODS Data were retrieved from the Swedish registry for cholecystectomy and ERCP (GallRiks) 2006-2016. All cholecystectomies, where CBDS were found at intraoperative cholangiography, and with complete 30-day follow-up (n = 10,386) were identified. Data concerning intraoperative and postoperative complications, readmission and reoperation within 30 days were retrieved for patients where intraoperative ERCP (n = 2290) and preparation for postoperative ERCP were performed (n = 2283). RESULTS Intraoperative ERCP increased (7.5% 2006; 43.1% 2016) whereas preparation for postoperative ERCP decreased (21.2% 2006; 17.2% 2016) during 2006-2016. CBDS management differed between TRHs and CHs. Complications were higher in the postoperative rendezvous ERCP group: Odds Ratio [OR] 1.69 (95% confidence interval [CI] 1.16-2.45) for intraoperative complications and OR 1.50 (CI 1.29-1.75) for postoperative complications. Intraoperative bleeding OR 2.46 (CI 1.17-5.16), postoperative bile leakage OR 1.89 (CI 1.23-2.90) and postoperative infection with abscess OR 1.55 (CI 1.05-2.29) were higher in the postoperative group. Neither post-ERCP pancreatitis, postoperative bleeding, cholangitis, percutaneous drainage, antibiotic treatment, ICU stay, readmission/reoperation within 30 days nor 30-day mortality differed between groups. CONCLUSIONS Techniques for management of CBDS found at cholecystectomy have changed over time and differ between TRH and CH. Rendezvous ERCP is a safe and effective method. Even though intraoperative rendezvous ERCP is the preferred method, postoperative rendezvous ERCP constitutes an acceptable alternative where ERCP resources are lacking or limited.

    更新日期:2019-11-01
  • The impossible gallbladder: aspiration as an alternative to conversion.
    Surg. Endosc. Pub Date : null
    Natallia Kharytaniuk,Gary A Bass,Bogdan D Dumbrava,Paul P Healy,Dylan Viani-Walsh,Tej N Tiwary,Tahir Abassi,Matthew P Murphy,Emma Griffin,Thomas N Walsh

    BACKGROUND Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible. METHODS A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon's care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution. RESULTS Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p < 0.001), with attendant cost savings. CONCLUSION Laparoscopic gallbladder aspiration is a safe alternative to conversion when inflammation makes cholecystectomy impossible laparoscopically, especially in the sickest patients and for surgeons with limited open surgery experience. This approach minimises morbidity and permits laparoscopic cholecystectomy in the majority after a suitable interval or referral of predicted difficult cases to specialist hepatobiliary centres.

    更新日期:2019-11-01
  • Endoscopic full-thickness resection of duodenal lesions (with video).
    Surg. Endosc. Pub Date : null
    Gianluca Andrisani,Francesco Maria Di Matteo

    BACKGROUND AND AIM The endoscopic treatment of non-lifting or submucosal duodenal lesions is associated with a high risk of incomplete resection and adverse events. Clip-assisted endoscopic full-thickness resection (EFTR) is a new approach for en bloc removal of neoplastic lesions in the GI tract. The aim of this study was to investigate its efficacy and safety in the duodenum. MATERIALS AND METHODS We retrospectively collected all consecutive patients with duodenal lesions who underwent EFTR with OTSC (Ovesco Endoscopy, Tübingen, Germany) or the new full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany). Complete resection rate was defined as histologically-verified R0 resection. Main endoscopic and clinical outcomes (technical success, rate of EFTR, adverse events) were systematically assessed at 3 and 6 months. RESULTS Between May 2017 and January 2019, 10 patients with duodenal lesions underwent EFTR (5 non-lifting adenomas, 2 adenomas recurrence/relapse and 3 subepithelial tumours). Technical success was overall achieved in 8/10 cases (80%). The two FTRD failed cases were completed with snare resection. The complete full-thickness resection rate was achieved in 8/10 (80%), while in two cases it was limited to mucosal or submucosal layer. R0 resection rate was achieved in 8/10 (80%) patients. The mean procedure time was 75 min (range 53-120 min). There were no major adverse events. At 3 and 6-month follow-up, no recurrence was observed. CONCLUSIONS Clip-assisted EFTR is a feasible and effective technique for en bloc resection of "difficult" superficial neoplasia and submucosal lesions in the duodenum, representing another technique that must be part of the endoscopist's armamentarium.

    更新日期:2019-11-01
  • Simulator training and residents' first laparoscopic hysterectomy: a randomized controlled trial.
    Surg. Endosc. Pub Date : null
    Ewa Jokinen,Tomi S Mikkola,Päivi Härkki

    BACKGROUND Hysterectomy rates are decreasing in many countries, and virtual reality simulators bring new opportunities into residents' surgical education. The objective of this study was to evaluate the effect of training in laparoscopic hysterectomy module with virtual reality simulator on surgical outcomes among residents performing their first laparoscopic hysterectomy. METHODS This randomized study was carried out at the Department of Obstetrics and Gynecology in Helsinki University Hospital and Hyvinkää Hospital. We recruited twenty residents and randomly signed half of them to train ten times with the laparoscopic hysterectomy module on a virtual reality simulator, while the rest represented the control group. Their first laparoscopic hysterectomy was video recorded and assessed later by using the Objective Structured Assessment of Technical Skills (OSATS) forms and Visual Analog Scale (VAS). The scores and surgical outcomes were compared between the groups. RESULTS The mean OSATS score for the Global Rating Scale (GRS) was 17.0 (SD 3.1) in the intervention group and 11.2 (SD 2.4) in the control group (p = 0.002). The mean procedure-specific OSATS score was 20.0 (SD 3.3) and 16.0 (SD 2.8) (p = 0.012), and the mean VAS score was 55.0 (SD 14.8) and 29.9 (SD 14.9) (p = 0.001). Operative time was 144 min in the intervention group and 165 min in the control group, but the difference did not reach statistical significance (p = 0.205). There were no differences between the groups in blood loss or direct complications. CONCLUSION Residents training with a virtual reality simulator prior to the first laparoscopic hysterectomy seem to perform better in the actual live operation. Thus, a virtual reality simulator hysterectomy module could be considered as a part of laparoscopic training curriculum.

    更新日期:2019-11-01
  • Correction to: Risk factors and impact of conversion from VATS to open lobectomy: analysis from a national database.
    Surg. Endosc. Pub Date : 2019-06-06
    Stefano Bongiolatti,Alessandro Gonfiotti,Domenico Viggiano,Sara Borgianni,Leonardo Politi,Roberto Crisci,Carlo Curcio,Luca Voltolini,

    In the "Results" section of the Abstract, the sentence: "The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and the hospitalisation rate (p < 0.01) were higher for patients converted." should read: "The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and length of stay (p < 0.01) were higher for patients converted."

    更新日期:2019-11-01
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