BACKGROUND AND AIMS:Esophageal foreign body (FB) impaction demands timely gastroscopic extraction, yet the need for preoperative radiographic imaging (PORI) varies by patient. To date, no validated risk-stratification tools exist to guide clinicians in determining the necessity of PORI before gastroscopic FB extraction. This study aims to fill this gap by developing a novel esophageal FB symptom score (EFBSS) to stratify patients at risk of severe complications, thereby providing a personalized approach to PORI decision-making. METHODS:Patients with suspected FBs were retrospectively categorized into PORI or non-PORI groups. Gastroscopic success rate, complications, and survival prognosis were compared and analyzed between the 2 groups. Logistic regression was used to identify risk factors for FB-related perforation or surgical complications. A risk stratification system (low-risk: 0 to 3; moderate-risk: 4 to 6; high-risk: 7 to 9 points) was then built based on the likelihood of such complications to guide PORI decision-making. RESULTS:There was no statistically significant difference between the PORI group (n=749) and the non-PORI group (n=1751) in the main outcome indicators, such as disease characteristics, FB types, incidence of complications, gastroscopic success rate, and survival prognosis (P>0.05). However, the PORI group had a longer duration of FB impaction and higher outpatient costs than the non-PORI group (P<0.05). The EFBSS includes swallowing FBs with pain, intentional ingestion of FBs, and cervical/chest/abdominal pain, with good discriminative power. The total score had an area under the receiver operating characteristic curve (AUC) of 0.822 (95% CI: 0.736-0.908), while the AUCs for the 3 components were 0.716, 0.699, and 0.894, respectively. The EFBSS system stratified the risk of FB-related perforation or surgical complications into 3 tiers: low (0.41%), moderate (2.95%), and high (39.29%). A significantly increasing risk trend was observed across tiers (P<0.001). CONCLUSIONS:We developed a risk scoring system incorporating swallowing FBs with pain, intentional ingestion of FBs, and cervical/chest/abdominal pain. This system preoperatively stratifies patients by the risk of FB-related perforation or surgical complications to facilitate PORI decision-making and maximize benefits.
BACKGROUND:In minimally invasive surgery for upper gastric and esophagogastric junction cancers, linear staplers are commonly used, and reports of circular‑stapled reconstruction have declined in parallel with the decrease in open surgery. Lower mediastinal reconstruction during robot‑assisted gastrectomy also remains technically challenging. This study describes our surgical technique and preliminary experience with transhiatal lower mediastinal anastomosis using a circular stapler. METHODS:Twelve patients who underwent robot‑assisted total or proximal gastrectomy with lower mediastinal reconstruction between March 2023 and December 2025 were included. Total operative time, blood loss, reconstruction time, length of hospital stay, postoperative complications, and esophageal transection length were evaluated separately for robot‑assisted total gastrectomy (RTG) and robot‑assisted proximal gastrectomy (RPG). RESULTS:No patient required conversion to open surgery.In the RTG group (n=6), the operative time, reconstruction time, blood loss, and hospital stay were 498.0 ± 61.1 minutes, 36.2 ± 8.4 minutes, 175 ± 117.3 g, and 14.3 ± 2.7 days, respectively.In the RPG group (n=6), these values were 345.8 ± 51.5 minutes, 75.6 ± 14.0 minutes, 75.0 ± 98.7 g, and 14.3 ± 2.7 days.Postoperative complications included one anastomotic stricture and one Grade B pancreatic fistula, both in the RPG group. No anastomotic leakage occurred in either group. The esophageal transection length was 35.2 ± 14.0 mm in the RTG group and 25.5 ± 7.9 mm in the RPG group, and all resection margins were negative. CONCLUSION:Circular staplers are feasible and safe for lower mediastinal reconstruction in robot‑assisted total and proximal gastrectomy.
BACKGROUND:The standard laparoscopic hiatoplasty with Toupet fundoplication is widely regarded as a safe treatment for giant hiatal hernia; however, it is often associated with a high incidence of posterior mediastinal seroma. To address this issue, a modified approach combining sac excision and negative pressure posterior mediastinal drainage has recently been introduced. This study compares clinical outcomes between the conventional and modified techniques to identify the optimal surgical strategy for managing giant hiatal hernia. METHODS:Patients who underwent laparoscopic hiatoplasty with sac excision and posterior mediastinal drainage between January 2013 and September 2020 were included. Demographic information, operative time, intraoperative blood loss, complication rates, length of hospital stay, and treatment outcomes were prospectively collected and assessed during follow-up. RESULTS:A total of 68 patients with giant hiatal hernia underwent the modified procedure without any conversions to open surgery or intraoperative complications. Compared with a historical cohort of 66 patients treated with the conventional approach (laparoscopic hiatoplasty with Toupet fundoplication), the modified group had significantly lower rates of postoperative posterior mediastinal seroma, as well as shorter overall and postoperative hospital stays. No significant differences were observed between the 2 groups regarding operative time, blood loss, ICU transfers, or incidence of postoperative pulmonary atelectasis. Median duration of long-term follow-up was comparable between the groups. There were no significant differences in the rates of early satiety, anatomic recurrence, diarrhea, acid regurgitation, or proton pump inhibitor (PPI) usage. In addition, no cases of dysphagia or reoperation occurred in either group. CONCLUSIONS:Laparoscopic hiatoplasty with sac excision and posterior mediastinal drainage is a safe and effective minimally invasive technique for treating giant hiatal hernia. This approach significantly reduces the risk of mediastinal seroma without increasing complication rates.
Introduction:Postoperative pancreatic fistula (POPF) is a serious complication that can lead to potentially fatal outcomes; therefore, early intervention with drainage is warranted whenever clinically feasible. Endoscopic ultrasound-guided transmural drainage (EUS-TD) is becoming an alternative to percutaneous drainage for managing POPF. While EUS-TD is increasingly used, there is no consensus on stent type or the need for external drainage in early postoperative EUS-TD for POPF. This study aimed to evaluate the feasibility of EUS-TD using multiple plastic stents (PSs) without external drainage for managing POPF within postoperative day 15.Methods:This retrospective case series included 11 patients who developed POPF and underwent EUS-TD within postoperative day 15 between January 2021 and June 2024. The primary outcome was clinical success of EUS-TD with multiple PSs without external drainage. Secondary outcomes included technical success, complications, length of hospital stay, and recurrence rate.Results:Eleven POPF patients underwent EUS-TD. Two or more PSs were successfully placed in all cases, with clinical success achieved in 10 of 11 cases. One case required additional percutaneous drainage. A pseudoaneurysm rupture occurred in one case and was successfully managed with interventional radiology. The mean length of hospital stay was 19.1 days. No recurrences were observed during a median follow-up period of 26.0 months. Stents were removed after 6 months or later.Conclusions:EUS-TD using multiple PSs without external drainage may be a feasible approach for managing POPF within postoperative day 15. Further prospective studies are needed to validate these findings and optimize early postoperative management strategies for POPF.
Background:Single-incision laparoscopic cholecystectomy (SILC) offers excellent cosmetic results but is technically challenging. Robotic systems can overcome these limitations, and although the da Vinci Xi is designed for multiport surgery, it can be adapted for single-port procedures. This study reports our experience performing single-port robotic cholecystectomy (SPRC) with straight instruments, emphasizing technical optimization and perioperative outcomes.Methods:SPRC was performed using an optimized umbilical port configuration and docking technique. Surgical steps were standardized to ensure stable traction and precise dissection, with a crossover method applied in difficult cases to improve exposure (see Supplemental Videos 1, Supplemental Digital Content 1, http://links.lww.com/SLE/A507, and 2, Supplemental Digital Content 2, http://links.lww.com/SLE/A508). Eleven patients underwent SPRC, and demographic, operative, and perioperative data were analyzed.Results:All procedures were completed without conversion to open or multiport surgery. The mean operative time was 116.7 +/- 22.2 minutes, with minimal blood loss (13.8 +/- 7.5 mL). No intraoperative complications or gallbladder perforations occurred, and only one patient required temporary drainage for minor oozing. Postoperative VAS scores averaged 3.1 +/- 1.0 on day 0 and 1.6 +/- 0.5 on day 1, with a mean hospital stay of 2.2 +/- 1.1 days. No readmissions or port-site complications were observed.Conclusions:SPRC with the da Vinci Xi system using straight instruments is feasible and safe. Optimized port placement and instrument coordination yield outcomes comparable to those reported for the SP system or single-site platform, providing an accessible alternative for centers without these platforms.
BACKGROUND:Reoperative metabolic and bariatric surgery (MBS), consisting of revision and conversion surgery, carries higher morbidity and mortality compared with primary procedures, yet robust long-term data are limited. METHODS:A retrospective review was conducted of all patients 18 years of age or older who underwent first-time reoperative MBS between 2000 and 2024 at a single large quaternary referral center. Data were stored securely and analyzed in R (v4.4.2) using standard descriptive statistics and group tests ( t tests/Wilcoxon/Kruskal-Wallis; χ²/Fisher). Sparse late-complication data precluded pairwise tests. RESULTS:Three hundred sixty patients, 86% female, mean age 50 years, underwent reoperative MBS. Conversion to Roux-en-Y gastric bypass (49%) was the most common surgery. The majority were performed for weight recidivism (37%). Length of stay, estimated blood loss, length of surgery, complication rates, readmission rates, and reintervention rates varied by type of reoperative MBS performed and indication. Most early complications were Clavien-Dindo 2, and most late complications were Clavien-Dindo 3b for all approaches. There was one procedure-related death in the study following an open conversion. CONCLUSION:In this 24-year single-center cohort, weight recidivism was the most frequent indication for reoperation and was associated with improved perioperative outcomes and durable long-term weight loss. As the landscape of bariatric surgery continues to evolve, we recommend early referral to centers with reoperative MBS expertise.
BACKGROUND:Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) helps to clarify the biliary anatomy, detect common bile duct (CBD) stones, and prevent or promptly detect bile duct injuries (BDI). However, the indication for routine or selective cholangiography remains controversial. We aimed to compare the results of a routine versus selective IOC policy during LC in an urban teaching hospital. METHODS:A prospective cohort study was designed, including a consecutive series of patients undergoing LC with either routine IOC (RC) or selective IOC (SC). SC was performed in emergent LC for cholecystitis and in patients with preoperative risk factors for CBD stones. The primary outcomes of interest were CBD stones, BDI, and anatomic variations of the biliary tract rates. Secondary outcomes of interest were the IOC success rate and readmission for residual CBD stones. RESULTS:A total of 1506 patients were analyzed: 1003 (66.6%) with RC and 503 (33.4%) with SC. Demographic variables were comparable between groups. Emergent LC was more frequent in SC (RC: 29.7% vs. SC: 36.2%, P =0.01). The IOC success rate was higher in RC (RC: 93.5% vs. SC: 82.6%, P <0.001). LC with SC had higher rates of positive IOC (RC: 6.7% vs. SC: 11%, P =0.04) and CBD stones detection (RC: 6.3% vs. SC: 10.4%, P =0.05). BDI was comparable between groups (RC: 0.5% vs. SC: 0%, P =0.3%), and none of them were detected by IOC. Residual CBD stones were similar between groups (RC: 0.4% vs. SC: 0.2%, P =0.5). Overall morbidity (RC: 4.5% vs. SC: 4.9%, P =0.6), readmissions (RC: 1.2% vs. SC: 1.7%, P =0.4), and reoperations (RC: 0.7% vs. SC: 0.2%, P =0.3) were comparable between groups. CONCLUSION:Selective use of IOC appears to be a safe and effective strategy with comparable BDI and residual CBD stone rates, compared with routine IOC. However, as selective IOC was associated with a lower success rate of IOC, surgical training for its performance should not be neglected.
BACKGROUND:Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive malignancy that predominantly affects young male patients. Its nonspecific clinical presentation and low diagnostic yield from ascitic fluid cytology pose a significant diagnostic challenge, particularly when presenting as ascites of unknown origin. CASE PRESENTATION:A 30-year-old previously healthy young man presented with a 4-week history of progressive abdominal distention, intermittent fullness, unexplained weight gain, and bloody ascites. Cytology from paracentesis and tumor markers were nondiagnostic. Imaging revealed omental caking and multiple peritoneal nodules, suggestive of peritoneal carcinomatosis. Diagnostic laparoscopy identified extensive tumor seeding, and biopsy confirmed DSRCT based on histopathology, immunohistochemistry, and the presence of an EWS-WT1 fusion transcript on cytogenetic analysis, establishing the diagnosis of DSRCT. Chemotherapy was recommended; however, the patient's condition deteriorated rapidly, and he died within a few weeks before receiving treatment. CONCLUSIONS:DSRCT, although rare, is noted for aggressiveness and rapid progression and therefore should ideally be considered in the differential diagnosis of bloody ascites in young male patients, even when initial cytology is negative. Early application of diagnostic laparoscopy and biopsy may facilitate timely tissue diagnosis, particularly when imaging mimics peritoneal carcinomatosis.
BACKGROUND:Achalasia is a rare esophageal motility disorder that causes dysphagia owing to impaired lower esophageal sphincter (LES) relaxation. This study aimed to evaluate a modified dissection and radial myotomy technique during peroral endoscopic myotomy (POEM) and to compare its outcomes with those of the standard approach. METHODS:This prospective, single-center study was conducted between February 2022 and December 2022. Eighty total with 80 achalasia patients undergoing POEM were divided into 2 groups: Group A (n=40), treated with the novel technique, and Group B (n=40), treated with the standard approach. Demographics, Eckardt score (ES), submucosal tunnel (ST), myotomy length, intervention duration, and adverse events were recorded. The follow-up period ranged from 3 to 20 months. RESULTS:Patients who underwent the novel radial myotomy technique (Group A) had significantly longer myotomy lengths (11.8±2.4 vs. 8.1±2.0 cm, P <0.001), greater myotomy extension beyond the esophagogastric junction (4.2±0.8 vs. 2.7±0.6 cm, P <0.001), and improved postoperative Eckardt scores (median 1 [0-1] vs. 2, 1-3P =0.006) compared with the conventional POEM group (Group B). Subgroup analysis revealed that in Type III achalasia patients, the novel approach yielded longer submucosal tunnel lengths (15.6±0.8 cm, P =0.038) and favorable symptom relief. Despite extended dissection, there was no increase in gastroesophageal reflux disease (GERD)-related symptoms. CONCLUSION:The novel dissection and radial myotomy technique demonstrated superior outcomes in reducing dysphagia symptoms and LES resistance compared with the standard approach. Tailoring ST and myotomy lengths based on the achalasia type and EGJ involvement may optimize outcomes without increasing the risk of GERD.
AIM:Obesity is a well-known risk factor for surgical complications. Laparoscopic adrenalectomy is now preferred over open surgery for adrenal masses of <6 cm without high malignancy suspicion. This study evaluates the impact of obesity on surgical complication rates in laparoscopic adrenalectomy. MATERIALS AND METHODS:Patients who underwent laparoscopic transabdominal adrenalectomy between 2013 and 2024 were retrospectively analyzed. They were divided into two groups: obese (BMI ≥30 kg/m 2 ) and nonobese (BMI <30 kg/m 2 ). Demographic data, perioperative, and postoperative outcomes were compared. RESULTS:A total of 110 patients (75 females, 35 males) were included, with 40 in the obese group and 70 in the nonobese group. The mean age was 46.6±12.4 years, and the mean BMI was 28.7±5.5 kg/m 2 . Surgery was performed on the right side in 58 patients (52.7%), left side in 51 (46.4%), and bilaterally in 1 (0.9%). The most common indications were Cushing syndrome (38 patients), pheochromocytoma (31), Conn syndrome (11), and incidentaloma (28). There were no significant differences between groups in terms of operative time, blood loss, tumor size, pathology, and hospital stay. Postoperative complications occurred in 6/40 obese (15.0%) and 3/70 nonobese (4.3%) patients, without a statistically significant difference ( P =0.07). Complications in the obese group included wound infection (4 cases), toxic hepatitis (1), atrial fibrillation (1), and respiratory infection (1). CONCLUSION:Obesity was associated with a trend toward higher postoperative complication rates, while operative time and length of stay were not significantly different. These findings emphasize the importance of surgical expertise and careful perioperative planning in obese patients.
OBJECTIVE:To investigate the impact of preoperative nasopancreatic duct stent placement on local resection of benign pancreatic tumors, particularly its efficacy in reducing secondary surgeries due to postoperative pancreatic fistula. METHODS:The clinical data of 306 patients with benign pancreatic tumors larger than 2 cm who underwent local resection at the Department of Pancreatic Surgery, Hubei Provincial People's Hospital, over the past 6 years were retrospectively analyzed. Propensity score matching was used to minimize the selection bias. RESULTS:The incidence of grade C pancreatic fistula in the nasopancreatic duct placement group was 5% (2/40), significantly lower than the 20% (32/160) observed in the non-nasopancreatic duct placement group, with a statistically significant difference (Fisher exact test, P =0.02). In addition, the rate of secondary surgery in the nasopancreatic duct placement group was 5% (2/40), significantly lower than the 16% (29/160) in the non-nasopancreatic duct placement group (Fisher exact test, P =0.04). However, there was no significant difference in the incidence of postoperative complications such as septic shock, overall pancreatic fistula, and postoperative mortality between the 2 groups. CONCLUSION:Preoperative nasopancreatic duct stent placement is a safe and effective procedure that significantly reduces the incidence of grade C pancreatic fistula following surgery for benign pancreatic tumors. Consequently, this decreases the necessity for secondary interventions related to grade C pancreatic fistula, ultimately enhancing patient prognosis and quality of life.
BACKGROUND:Postoperative intra-abdominal abscess (IAA) is the most feared complication after laparoscopic appendectomy (LA). The management of IAA measuring 2 to 4 cm remains controversial. We aimed to compare the effectiveness of antibiotic treatment versus percutaneous drainage for the treatment of IAA measuring 2 to 4 cm following LA. METHODS:A consecutive series of patients with post-appendectomy IAA measuring 2 to 4 cm from January 2006 to April 2024 was included for analysis. The patient cohort was divided into 2 groups according to the treatment modality: antibiotic therapy alone (ATB) versus computed tomography-guided percutaneous drainage (PERC). The primary outcome was to compare the success rate between groups. Secondary endpoints included overall and major complications, length of stay (LOS), readmissions, and mortality. RESULTS:During the study period, 2700 LA were performed, and 123 (4.5%) patients developed an IAA. Of these, 47 (38%) measured 2 to 4 cm: 25 (53%) received antibiotics only (ATB), and 22 (47%) underwent percutaneous drainage (PERC). The success rates were comparable between groups (ATB: 92% vs. PERC: 95.4%, P=0.6). Patients who failed conservative management in both groups underwent laparoscopic lavage without further complications. No readmissions, morbidity or mortality were observed. The mean LOS was longer in the PERC group (ATB: 2.0 vs. PERC: 3.5 d, P=0.03). CONCLUSIONS:Antibiotic therapy and percutaneous drainage are both highly effective for treating IAA measuring 2 to 4 cm following LA. Given the less invasive nature of antibiotic therapy with shorter length of stay, it should be considered the initial treatment of choice.
BACKGROUND:There is currently no universally accepted gold standard for the surgical treatment of hemorrhoidal disease. This study aimed to assess the efficacy and safety of the Doppler-guided hemorrhoidal artery ligation (DG-HAL) technique, with or without concomitant mucopexy, on postoperative clinical outcomes in patients with symptomatic grade II to IV hemorrhoidal disease. PATIENTS AND METHODS:A retrospective analysis was conducted using a prospectively maintained database of patients who underwent DG-HAL ± mucopexy between January 2018 and January 2023 for medically refractory hemorrhoidal disease. Postoperative complications, analgesia type and duration, and time to return to daily activities were recorded. Patients were followed up by a general surgery specialist on postoperative day 1, week 1, month 1, and year 1. Treatment efficacy was evaluated based on changes in symptom severity and hemorrhoid grade across follow-up periods. RESULTS:A total of 94 patients (59 males, 35 females; mean age: 47.8 ± 12.4 y) underwent the procedure. Recurrence occurred in 9 patients (9.6%) during follow-up. Recurrence rates were 8.16% (4/49) in grade III and 31.25% (5/16) in grade IV hemorrhoids. Mean Visual Analogue Scale (VAS) scores for pain were 7.43 (postoperative day 1), 1.72 (week 1), and 0.37 (month 1), demonstrating significant improvement (P < 0.001). No postoperative bleeding, necrosis, or urinary retention was reported. One patient experienced early recurrence on the first postoperative day. Overall symptom resolution was achieved in 92.6% of patients, and 90.4% reported high satisfaction with the treatment. CONCLUSION:DG-HAL with or without mucopexy is a safe and effective minimally invasive surgical option for grade II and III hemorrhoidal disease, with high patient satisfaction, low complication rates, and excellent symptom resolution. However, in patients with grade IV disease, the technique's higher recurrence rate necessitates careful patient selection and individualized surgical planning.
INTRODUCTION:Virtual reality simulation is a fundamental adjunct to robotic surgery training. It is not clear if individual performance at the simulator can be affected by predisposing factors such as gender, video gaming, and instrument playing. METHODS:Sixty-three volunteering medical students performed five times the same exercise at the DaVinci Simulator, and performance scores were collected for each participant (Overall Score, Time to Complete, Economy of Motion, Penalty Score) along with their demographics. Data were collected and analyzed within an electronic database. The difference (delta) between the highest score obtained in tests 2 to 5 and the score obtained in test 1 was calculated for each of the 4 scores and for each participant. RESULTS:All participants showed a significant improvement in their scores with practice (deltas were always positive). Median PS was significantly lower in women, but PSdelta was significantly higher in women than in men. Median TC and median PS were significantly lower in non-video game users. No significant difference of performance scores was found between music players and non-music players. Multivariable analysis confirmed that female gender was an independent prognostic variable towards PSdelta, that is, women showed a steeper improvement in their performance. CONCLUSION:Repeated simulation improves the performance of surgically naïve medical students. Women and non-video gamers had higher penalty scores, but women tend to improve their skills quickly. As videogaming is much more frequent within the group of men, it is possible that videogaming itself, and not gender, can have a positive effect by enhancing eye-hand coordination.
BACKGROUND:As part of the accreditation process for bariatric surgery, patients must go through a preoperative pathway. There will inevitably be patients who are seen in the clinic but never undergo surgery. This rate of attrition is different for every practice. Our objective was to evaluate the percentage of patients who eventually undergo bariatric surgery at a community practice. METHODS:A single private practice was evaluated. Patients initially seen in the clinic were followed to surgery completion or until they dropped out. A period of 21 months was evaluated. Patients with at least a 6-month follow-up were included. RESULTS:There were 479 patients who underwent evaluation during that time. Forty-three percent of these patients went on to have surgery. There were 216 patients who did not have surgery, with most of those patients never progressing past the first visit. One patient became pregnant and dropped out, 2 did not achieve medical clearance, one moved out of town, and one obtained surgery at a different program. There was a significant increase in the rate of attrition if the wait period was 6 months or longer ( P <0.05). CONCLUSION:There are no national benchmarks as to what percentage of patients complete the preoperative process at accredited bariatric centers and undergo surgery. This solo private practice has a conversion rate of 43%. Longer waiting times appear to increase the rate of attrition. Mandated wait times function as barriers to patients undergoing surgery and should be abandoned.
BACKGROUND:Colorectal cancer is a leading global malignant tumor, and adequate lymph node (LN) examination is essential for its management. METHODS:This retrospective study, conducted from January 2018 to December 2023 at the First Medical Center of the Chinese PLA General Hospital, aimed to develop a statistical model for assessing LN count adequacy. To calculate false-negative probabilities, a new statistical model based on the β-binomial distribution and maximum likelihood method in R software was used. RESULTS:Among 4429 screened colorectal cancer patients, there were 2314 with colon cancer and 2115 with rectal cancer. For colon cancer, the excision of 7 LNs for pT1 and 11 LNs for pT2 was associated with a likelihood of encountering occult positive LNs remained below 5%. For pT3 and pT4, after the removal of 16 LNs and 20 LNs, respectively, the likelihood of overlooking a positive node was below 10%. For rectal cancer, the excision of 7 LNs for pT1 and 12 LNs for pT2 was associated with a likelihood of encountering occult positive LNs remained below 5%. For pT3 and pT4, after removing 15 LNs and 19 LNs, the likelihood of overlooking a positive node was below 10%. CONCLUSIONS:Our study establishes a novel quantitative framework that links LN harvest thresholds to the risk of false-negative metastasis in colorectal cancer, supporting adopting a more personalized approach.
BACKGROUND:Iatrogenic colonic perforation (ICP) is a rare but serious complication of colonoscopy. Its incidence varies according to whether the procedure is diagnostic or therapeutic. Although surgery has traditionally been the cornerstone of treatment, advances in endoscopic techniques-particularly clip application-have provided less invasive alternatives. This study aimed to present the clinical characteristics, management strategies, and outcomes of ICP in a high-volume tertiary center, with a particular focus on the efficacy and limitations of endoscopic clip closure. METHODS:In this retrospective study, all patients diagnosed with ICP between 2019 and 2024 at Kartal Dr. Lutfi Kirdar City Hospital were evaluated. Among 87,526 colonoscopies performed during this period, 42 patients with ICP were included. Patients were classified according to whether colonoscopy was performed for diagnostic or therapeutic indications. Endoscopic clip closure was attempted in 14 patients and was successful in 8 of them (57.1%). Surgical intervention was performed in 34 patients, either after failed endoscopic management or as the primary treatment. RESULTS:ICP developed more frequently during diagnostic procedures (69%). The sigmoid colon (57.1%) was the most common site of perforation, and most perforations were intraperitoneal (81%). Baseline demographic and clinical characteristics did not differ significantly between the diagnostic and therapeutic indication groups ( P >0.05). Successful endoscopic clip closure was associated with early diagnosis, good bowel preparation, and perforation size <2 cm. Patients treated endoscopically had shorter times to oral intake and shorter hospital stays compared with those treated surgically. CONCLUSIONS:Endoscopic clip application is an effective treatment option for carefully selected ICP cases with early recognition, favorable local conditions, and small, localized defects. However, surgery remains essential in large perforations, delayed diagnoses, or when clip closure fails. Our findings provide real-world data on the role and limitations of standard clip closure in a resource-limited tertiary center and support guideline-based, individualized decision-making for ICP management.
Background:A retrospective analysis was conducted on consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to evaluate the efficacy and safety of different techniques in difficult biliary cannulation cases after unintentional pancreatic duct access. Methods:The patients were divided into 4 groups according to the cannulation method: the double guidewire (DGW) group, the transpancreatic sphincterotomy (TPS) group, the transpancreatic sphincterotomy combined with a pancreatic duct stent (TPS-PDS) group, and the precut over a pancreatic duct stent (PPDS) group. The baseline characteristics, biliary cannulation success rate, and postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) incidence were compared and analyzed among these groups. Results:A total of 228 cases were enrolled, and there were no significant statistical differences among the groups in terms of the type of baseline characteristic. The final success rates for biliary cannulation ranged from 88.60% to 97.10%, and the incidence of PEP ranged from 0% to 27.50% among the 4 groups (P=0.147 and 0.005, respectively). The incidence of severe PEP was significantly higher in the TPS group compared with the other groups (P<0.001). Among the 156 cases that received pancreatic duct stent placement, the stents spontaneously migrated in 109 cases within 3 months. Furthermore, stents with trimmed wings had significantly higher migration rates when compared with stents without trimmed wings (88.50% vs. 22.70%, P<0.001). Conclusions:For cases with difficult biliary cannulation after unintentional pancreatic duct access, TPS-PDS and PPDS are superior to DGW and TPS. Pancreatic duct stents with a trimmed front side wing would spontaneously migrate at a significantly higher rate.
BACKGROUND:To compare the clinical outcomes of transgastric natural orifice transluminal endoscopic surgery (NOTES) using an ultrathin flexible endoscopic tunneling technique with conventional flexible endoscopic NOTES for gallbladder-preserving treatment of gallstones and polyps. METHODS:A retrospective study was conducted on 62 patients treated between January 2023 and February 2025 at the Fifth People's Hospital of Shenyang, including 23 in the ultrathin tunneling group and 39 in the conventional group. Clinical outcomes, operative time, blood loss, titanium clip usage, postoperative pain (VAS scores), time to flatus, oral intake, hospital stay, costs, complications, clinical success, and recurrence rates were compared. Follow-up was conducted for 1 to 3 months (median: 2 mo). RESULTS:Both procedures demonstrated a 100% clinical success rate. The ultrathin tunneling group showed significantly lower blood loss, fewer clips, lower VAS scores on postoperative days 1 to 3, earlier oral intake, and shorter hospital stays ( P <0.05). No significant differences were observed in operative time, flatus time, hospitalization costs, complication rates, or gallstone recurrence rates ( P >0.05). Operative time correlated with blood loss, and flatus time correlated with the day 1 VAS score. CONCLUSIONS:Both NOTES techniques are effective and safe for gallbladder-preserving treatment of gallstones and polyps. The ultrathin tunneling approach offers advantages in reducing surgical trauma, enhancing recovery, and potentially lowering recurrence risk, supporting its clinical application.
BACKGROUND:There are ∼750,000 laparoscopic cholecystectomies performed annually in the United States. Of these, at least 280,000 cases are nonelective laparoscopic cholecystectomies (LC). There is limited data on factors affecting LOS in patients undergoing nonelective LC. This study aims to determine the factors affecting LOS in patients undergoing nonelective LC. STUDY DESIGN:The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent nonelective LC without concomitant procedures from 2010 to 2020 (n=115,142). A total of 55,481 patients without significant cardiopulmonary disorders, with a body mass index (BMI) of 18.5 to 60, and with LOS outcome data were included. Prolonged LOS was defined as >2 days. A sensitivity analysis was conducted with prolonged LOS defined as >1 day. All analyses were performed using SAS v9.4. RESULTS:A total of 18,094 patients (33%) had LOS >2 days, and 33,292 patients (60%) had LOS >1 day. On logistic regression analysis, prolonged LOS was found in 31% of patients with ASA class 1 and 2 versus 44% of patients with ASA class >2 (OR: 1.67; 95% CI: 1.58-1.76), 33% of patients with independent functional status versus 72% of patients with partially dependent functional status (OR: 3.94; 95% CI: 2.76-5.63), and 79% of patients with dependent functional status (OR: 4.45; 95% CI: 2.17-9.12). In logistic regression, age, BMI category, smoking status, and race/ethnicity were also associated with prolonged LOS. CONCLUSION:This study showed that a significant percentage of female patients, patients with ASA class 1 and 2, with independent functional status, and belonging to minority ethnicities who underwent nonelective LC had prolonged LOS. Our study highlights the need to evaluate nonclinical factors with further institutional studies.
