ObjectiveTo explore the causes of colon-anal anastomotic stenosis in patients with low rectal cancer after prophylactic ileostomy under complete laparoscopy. MethodsA total of 194 patients with low rectal cancer who received complete laparoscopic radical resection of rectal cancer combined with preventive ileostomy in our hospital from January 2020 to December 2020 were selected as the study objects, and were divided into non-stenosis group (n=136) and stenosis group (n=58) according to postoperative colon-anal anastomosis stenosis. The clinical data of the two groups were compared. Univariate and multivariate logistic regression were used to analyze the factors affecting postoperative colon-anal anastomotic stenosis, and stepwise regression was used to evaluate the importance of each factor. The risk prediction model of postoperative colon-anal anastomotic stenosis was constructed and evaluated. ResultsIn the stenosis group, the proportion of males, tumor diameter ＞3 cm, NRS2002 score >3 points, manual anastomosis, left colic artery not preserved, anastomotic leakage, pelvic infection and patients undergoing neoadjuvant radiotherapy and neoadjuvant chemotherapy were higher than those in the non-stenosis group (P<0.05). The results of univariate logistic analysis showed that female and preserving the left colonic artery were the protective factors for postoperative colon-anal anastomotic stenosis (P<0.05), and the tumor diameter >3 cm, NRS2002 score >3 points, manual anastomosis, anastomotic leakage, pelvic infection, neoadjuvant radiotherapy and neoadjuvant chemotherapy were the risk factors for postoperative colon-anal anastomotic stenosis (P<0.05). Multivariate logistic regression analysis showed that gender, tumor diameter, NRS 2002 score, anastomotic mode, anastomotic leakage, and pelvic infection were independent influencing factors for postoperative colon-anal anastomotic stenosis (P<0.05). Stepwise regression analysis showed that the top three factors affecting postoperative colon-anal anastomotic stenosis were NRS 2002 score, gender and anastomotic leakage. Multivariate Cox risk proportional model analysis showed that the multivariate model composed of NRS 2002 score, gender and anastomotic leakage had a good consistency in the risk assessment of postoperative colon-anal anastomotic stenosis. Based on this, a risk prediction model for postoperative colon-anal anastomotic stenosis was constructed. The results of strong influence point analysis show that there are no data points in the modeling data that have a strong influence on the model parameter estimation (Cook distance <1). Receiver operating characteristic curve results showed that the model had good differentiation ability, the area under curve was 0.917, 95%CI was (0.891, 0.942). The calibration curve was approximately a diagonal line, showing that the model has good predictive power (Brier value was 0.097). The results of the clinical decision curve showed that better clinical benefits can be obtained by using the predictive model to identify the corresponding risk population and implement clinical intervention. ConclusionThe prediction model based on NRS 2002 score, gender and anastomotic fistula can effectively evaluate the risk of colon-anal anastomotic stenosis after preventive ileostomy in patients with low rectal cancer under complete laparoscopy.
From December 1995 to December 1997, 1 500 patients with gallstones or together with biliary duct stones accepted laparoscopic cholesystectomy (LC) or LC+laparoscopic common bile duct exploration (LCDE). There were 9 had serious complications (0.6%) occured . While the mean age was 54.9 years old. The sex ratio (female∶male) was 1∶1.25. Three cases had major biliary duct disruption, 1 case had stomach perforation, 2 cases had duodenal injuries, 1 bleeding case because cystic artery fail to clip, 1 case had postoperative cystic duct leak, and 1 case with T-tube dislodgement. All complications had been discovered during or shortly after operations. The injuries on the extrahepatic biliary duct with lengths of 0.2-0.4cm, and the gastrodenal injuries sized 0.5-1.0cm. All of the injuries had been sutured laparoscopically without sequela. The one who had postoperative cystic duct leak and jaundice accepted LCDE, proved to have a common bile duct stone. The bleeding cystic artery had been clipped well, and the dislodged T-tube replaced well. The results show if the complications which may be very serious or complex had been discovered shortly after or during the operations, its can be managed with laparoscopic technique safely by experienced operators.
ObjectiveTo explore the risk factors of perioperative severe complications (Clavien-Dindo grade Ⅲ and above) after laparoscopic radical resection of colorectal cancer (CRC). MethodsThe clinicopathologic data of CRC patients who met the inclusion and exclusion criteria treated in the Shaanxi Provincial People’s Hospital from January 2018 to December 2020 were retrospectively analyzed. The univariate and multivariate logistic analyses were used to explore the risk factors of perioperative severe complications after the laparoscopic radical resection of CRC. ResultsAtotal of 170 eligible patients were included in this study, and the postoperative complications occurred in 45 patients, 24 of whom were severe complications. The univariate analysis results showed that the age (P<0.001), body mass index (BMI, P=0.047), age adjusted Charlson complication index (aCCI) score (P=0.002), American Association of Anesthesiologists (ASA) classification (P<0.001), prognostic nutritional index (PNI, P=0.011), preoperative anemia (P=0.011), operation numbers of surgeon (P=0.003), and operation time (P=0.026) were related to the perioperative severe complications in the patients underwent the laparoscopic radical resection of CRC. The statistic indexes of univariate analysis (P<0.05) combined with indexes of clinical significance were included in the multivariate analysis, the results showed that the ASA classification Ⅲ– Ⅳ (OR=3.536, P=0.027), BMI ≥25 kg/m2 (OR=3.228, P=0.031), preoperative anemia (OR=2.876, P=0.049), operation numbers of surgeon <300 (OR=0.324, P=0.046), and the operation time ≥300 min (OR=3.480, P=0.020) increased the probability of perioperative severe complications in the patients underwent the laparoscopic radical resection of CRC. ConclusionsThe results of this study suggest that clinicians should pay attention to the perioperative management of patients with CRC, such as adequately evaluating the preoperative status of patients by ASA classification, PNI, and aCCI to adjust the malnutrition of patients; after operation, the patients with BMI ≥25 kg/m2 and operation time more than 300 min should be paid more attention. At the same time, the surgeon should continuously accumulate the operation numbers and improve the operation proficiency so as to reduce the occurrence of perioperative severe complications after laparoscopic radical resection of CRC.
Objective This study aimed to explore the experience of secondary excision for retrorectal cystic lesions. Method We retrospectively reviewed the medical records of patients who underwent secondary laparoscopic excision of retrorectal cystic lesions at the Department of General Surgery at our hospital between August 2012 and August 2021. Results Twelve patients [male: 5; female: 7; age: (31.8±11.5) years old (18–60 years old)] were evaluated. The lesions ranged from 5.8 to 15.0 cm in diameter [(10.0±3.5) cm]. Seven patients had epidermoid cysts, three patients had mature teratoma, one patient had mature teratoma with low-grade mucinous neoplasm and one patient had cyst with mucinous carcinoma. Laparoscopic excision of retrorectal cystic lesions was performed in ten patients, and laparoscopy combined transsacrococcygeal approach was performed in two patients. The median operative time was 137.5 min (80–240 min), and the median blood loss was 30 mL (10–200 mL). No patient experienced complications of Clavien-Dindo grade Ⅲa or worse, one patient experienced complications of Clavien-Dindo grade Ⅱa after operation. The mean duration of hospitalization was (5.9±1.4) d (3–7 d). The follow-up period ranged from 3 to 108 months, and the median follow-up time was 43-month, and one patient recurred during the follow-up period. Conclusions Attention should be paid to the initial diagnosis and treatment of retrorectal cystic lesions, particularly in children. Routine evaluation using preoperative pelvic MRI and the adoption of an appropriate surgical approach are recommended to reduce secondary operations. Surgery should be performed by surgeons experienced in rectal andpelvic surgeries.
ObjectiveTo evaluate the cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional laparoscopic surgery (CLS) for early-stage endometrial cancer (EC) from a societal perspective. MethodsA decision-tree model was constructed to conduct cost-utility analysis, simulating the short-term intraoperative to postoperative clinical progression of patients. Primary evaluation metrics included cumulative costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). The willingness-to-pay (WTP) threshold was set at three times the 2024 per capita gross domestic product (GDP) of China. The sensitivity analyses were performed to assess robustness of the model. ResultsThe base-case analysis revealed that patients in the RALS group gained 0.09 more QALYs at an additional cost of ￥39 079.52 compared with CLS group, the derived ICER was ￥437 157.36/QALYs, exceeding the predefined WTP threshold. The results suggested that RALS does not demonstrate superior cost-effectiveness compared with CLS in the management of early-stage EC. Univariate sensitivity analysis indicated that, when the annual surgical volume per robotic device reaches 809 cases, or the cost of Endowrist consumables per robotic surgery drops below ￥6 568.46, RALS will emerge as a more cost-effective surgical strategy. The probabilistic sensitivity analysis revealed that that RALS becomes more cost-effective when the WTP threshold exceeds ￥402 145.80. Conclusion From a Chinese societal perspective, robotic-assisted laparoscopic surgery for early-stage endometrial cancer is not cost-effective compared with conventional laparoscopic surgery at the current WTP threshold of three times per capita GDP.
Objective To investigate safety, feasibility, and future direction of laparoscopic splenectomy. Method The latest progress and new achievements of laparoscopic splenectomy in the world were analyzed and summarized. Results At present, the laparoscopic splenectomy mainly included the completely laparoscopic splenectomy, hand assisted laparoscopic splenectomy, gasless laparoscopic splenectomy, single hole laparoscopic splenectomy, or robot assisted laparoscopic splenectomy. The completely laparoscopic total splenectomy had become the most common surgical procedure in the clinical treatment due to the reliable curative effect, less injury, and rapid recovery, the partial splenectomy was one of the precise treatments for the benign splenic lesions. The hand assisted laparoscopic splenectomy was widely used in the giant spleen, it could reduce the exposure difficulty, effectively deal with the intraoperative hemorrhage, and reduce the risk of surgery. The robot assisted laparoscopic splenectomy was one of the minimally invasive operations, the system with three-dimensional high definition vision and flexible robotic arm overcame the limitations of traditional laparoscopic two-dimensional display, could precisely complete the operation and achieve the accurate treatment. Conclusions Laparoscopic splenectomy has some advantages of less operative injury, less pain, and rapid recovery, it’s safety and feasibility have been proved. We should strictly grasp indications and contraindications for laparoscopic splenectomy, appropriate surgical methods should be selected for specific splenic diseases to achieve the best curative effect. Remote control and precision operation will be a direction of development in future.
Objective To explore the risk factors of postoperative portal vein system thrombus (PVST) after laparoscopic splenectomy in treatment of portal hypertension and hypersplenism. Methods Clinical data of 76 patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy in the Sichuan Provincial People’s Hospital from January 2012 to January 2017 were analyzed. Results There were 31 patients suffered from PVST (PVST group), and other 45 patients enrolled in non-PVST group.There were significant differences on age, diameter of splenic vein, diameter of portal vein, blood flow velocity of portal vein, level of D-dimer, and platelet count between the PVST group and the non-PVST group (P<0.05), but there were no significant difference on gender, Child-Pugh classification, etiology of cirrhosis, operation time, intraoperative blood loss, postoperative complications, and prothrombin time between the two groups (P>0.05). Multivariate logistic regression analysis showed that, patients with age >50 years (RR=1.31, P=0.02), splenic vein diameter >12 mm ( RR=1.29, P<0.01), portal vein diameter >13 mm (RR=1.55, P=0.01), blood flow velocity of portal vein <18 cm/s ( RR=1.47, P<0.01), increases level of D-dimer (RR=2.89, P=0.03), and elevated platelet count (RR=1.82 P=0.02) had higher risk of postoperative PVST than those patients with age ≤50 years, splenic vein diameter ≤12 mm, portal vein diameter ≤13 mm, blood flow velocity of portal vein ≥18 cm/s, normal level of D-dimer and platelet count. Conclusion For patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy, we should pay more attention to the risk factor, such as D-dimer and so on, to avoid the occurrence of postoperative PVST.
ObjectiveTo investigate the clinical value of laparoscopic cholecystectomy following “A-B-D” approach applied in the operation of acute suppurative or gangrenous cholecystitis.MethodsWe sought out 45 patients diagnosed as acute suppurative or gangrenous cholecystitis and treated by laparoscopic cholecystectomy following the “A-B-D” approach in People’s Hospital of Leshan from Sep. 2019 to Dec. 2020 as the observation group (ABD observation group), and sought out 50 patients with the same diseases but treated by conventional laparoscopic cholecystectomy from Jun. 2018 to Aug. 2019 as the matched group (conventional matched group). We analyzed and compared the parameters related to safety and efficacy of the two groups retrospectively.ResultsA total of 95 patients were included, including 45 patients in the ABD observation group (26 cases of acute suppurative cholecystitis, 19 cases of acute gangrenous cholecystitis) and 50 patients in the conventional matched group (24 cases of acute suppurative cholecystitis, 26 cases of acute gangrenous cholecystitis). There were no significant differences in age, gender, body mass index, disease composition, gallbladder condition, and preoperative complications between the two groups (P>0.05). There was no bile duct injury case in the ABD observation group (0), while there were 4 cases (8.0%) in the conventional matched group, but the statistical results showed no statistical significance between the two groups (P=0.054). One case (2.2%) in the ABD observation group converted to laparotomy, which was significantly lower than the 10 cases (20.0%) in the conventional matched group, and the difference was statistically significant (P=0.017). In addition, there were no significant differences for other parameters including operative time, postoperative hospital stay, incidences of intraoperative bleeding and postoperative bleeding between the two groups (P>0.05).ConclusionsThe laparoscopic cholecystectomy following the “A-B-D” approach can help distinguish the anatomical structure of cystic duct and extrahepatic bile duct clearly, and it can help prevent biliary tract injury effectively and reduce the probability of conversion to laparotomy. It is worthy of clinical application and promotion, especially in the majority of county hospitals.
A lot of evidence-based medical evidence has shown that laparoscopic Roux-en-Y gastric bypass (LRYGB) is a durable and effective method for obesity and diabetes, and can significantly improve a series of obesity-related metabolic complications. This guideline provides a detailed description of the main operating steps and technical points of the symmetric three-port LRYGB, including posture layout, trocar position selection, liver suspension, gauze exposure, production of small gastric sacs, gastrojejunal anastomosis and production of biliary pancreatic branches, entero-enteric side to side anastomosis, closure of gastrointestinal anastomosis and mesenteric hiatus, greater omentum coverage, and closure of incisions. The purpose is to standardize the operating process of the symmetrical three hole method of LRYGB, providing standardized surgical operation references for clinical doctors in the field of obesity metabolic surgery.
ObjectiveTo review and summarize the research progress of adenocarcinoma of esophagogastric junction (AEG) in staging, surgical treatment, endoscopic treatment and adjuvant therapy in recent years, so as to provide reference and help for the follow-up research and treatment of this disease.MethodLiterature review was used to review the literatures on AEG treatment in various databases.ResultsThe incidence of AEG had increased rapidly in recent years, with high malignancy and poor prognosis. Siewert typing had allowed researchers to gain insight into the disease, and treatments were increasingly diversified. At present, the main treatment was still radical surgery. Because AEG was adjacent to the esophagus and stomach, there were many controversies about its staging, surgical approach, resection range, digestive tract reconstruction, adjuvant treatment and so on, especially Siewert type Ⅱ.ConclusionsThe surgical approach, resection range, and laparoscopic surgery of Siewert typeⅡcan choose according to esophageal involvement distance judgment, pathological staging is uncertain, still need several studies to reach a consensus. With the application of laparoscopy and adjuvant therapy, how to select individualized treatment options that require multidisciplinary collaboration for further study.