Prediction and stratification for the surgical adverse events after minimally invasive esophagectomy:A two-center retrospective study

BACKGROUND Minimally invasive esophagectomy(MIE)is a widely accepted treatment for esophageal cancer,yet it is associated with a significant risk of surgical adverse events(SAEs),which can compromise patient recovery and long-term survival.Accurate preoperative identification of high-risk patients is critical for improving outcomes.AIM To establish and validate a risk prediction and stratification model for the risk of SAEs in patients with MIE.METHODS This retrospective study included 747 patients who underwent MIE at two centers from January 2019 to February 2024.Patients were separated into a train set(n=549)and a validation set(n=198).After screening by least absolute shrinkage and selection operator regression,multivariate logistic regression analyzed clinical and intraoperative variables to identify independent risk factors for SAEs.A risk stratification model was constructed and validated to predict the probability of SAEs.RESULTS SAEs occurred in 10.2%of patients in train set and 13.6%in the validation set.Patients with SAE had significantly higher complication rate and a longer hospital stay after surgery.The key independent risk factors identified included chronic obstructive pulmonary disease,a history of alcohol consumption,low forced expiratory volume in the first second,and low albumin levels.The stratification model has excellent prediction accuracy,with an area under the curve of 0.889 for the training set and an area under the curve of 0.793 for the validation set.CONCLUSION The developed risk stratification model effectively predicts the risk of SAEs in patients undergoing MIE,facilitating targeted preoperative interventions and improving perioperative management.

Beyond statistical significance:Embracing minimal clinically important difference for better patient care

The minimal clinically important difference(MCID)represents a pivotal metric in bridging the gap between statistical significance and clinical relevance,addressing the direct impact of medical interventions from the patient's perspective.This comprehensive review analyzes the evolution,applications,and challenges of MCID across medical specialties,emphasizing its necessity in ensuring that clinical outcomes not only demonstrate statistical significance but also offer genuine clinical utility that aligns with patient expectations and needs.We discuss the evolution of MCID since its inception in the 1980s,its current applications across various medical specialties,and the methodologies used in its calculation,highlighting both anchor-based and distribution-based approaches.Furthermore,the paper delves into the challenges associated with the application of MCID,such as methodological variability and the interpretation difficulties that arise in clinical settings.Recommendations for the future include standardizing MCID calculation methods,enhancing patient involvement in setting MCID thresholds,and extending research to incorporate diverse global perspectives.These steps are critical to refining the role of MCID in patient-centered healthcare,addressing existing gaps in methodology and interpretation,and ensuring that medical interventions lead to significant,patient-perceived improvements.

New direction for surgery:Super minimally invasive surgery

The top goal of modern medicine is treating disease without destroying organ structures and making patients as healthy as they were before their sickness.Minimally invasive surgery(MIS)has dominated the surgical realm because of its lesser invasiveness.However,changes in anatomical structures of the body and reconstruction of internal organs or different organs are common after traditional surgery or MIS,decreasing the quality of life of patients post-operation.Thus,I propose a new treatment mode,super MIS(SMIS),which is defined as“curing a disease or lesion which used to be treated by MIS while preserving the integrity of the organs”.In this study,I describe the origin,definition,operative channels,advantages,and future perspectives of SMIS.

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review

BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide.About 5%-10%of patients are diagnosed with locally advanced rectal cancer(LARC)on presentation.For LARC invading into other structures(i.e.T4b),multivisceral resection(MVR)and/or pelvic ex-enteration(PE)remains the only potential curative surgical treatment.MVR and/or PE is a major and complex surgery with high post-operative morbidity.Minimally invasive surgery(MIS)has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies,but there is little evi-dence on its use in MVR,especially so for robotic MVR.This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023.Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR,or stage 4 disease with resectable systemic metastases.Pa-tients who underwent curative MVR for locally recurrent rectal cancer,or me-tachronous rectal cancer were also included.Exclusion criteria were patients with systemic metastases with non-resectable disease.All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery.Complex sur-gery was defined based on technical difficulty of surgery(i.e.total PE,bladder-sparing prostatectomy,pelvic lymph node dissection or need for flap creation).Our primary outcomes were the margin status,and complication rates.Cate-gorical values were described as percentages and analysed by the chi-square test.Continuous variables were expressed as median(range)and analysed by Mann-Whitney U test.Cumulative overall survival(OS)and recurrence-free survival(RFS)were analysed using Kaplan-Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.RESULTS A total of 46 patients were included in this study[open MVR(oMVR):12(26.1%),miMVR:36(73.9%)].Patients’American Society of Anesthesiologists score,body mass index and co-morbidities were comparable between oMVR and miMVR.There is an increasing trend towards robotic MVR from 2015 to 2023.MiMVR was associated with lower estimated blood loss(EBL)(median 450 vs 1200 mL,P=0.008),major morbidity(14.7%vs 50.0%,P=0.014),post-operative intra-abdominal collections(11.8%vs 50.0%,P=0.006),post-operative ileus(32.4%vs 66.7%,P=0.04)and surgical site infection(11.8%vs 50.0%,P=0.006)compared with oMVR.Length of stay was also shorter for miMVR compared with oMVR(median 10 vs 30 d,P=0.001).Oncological outcomes-R0 resection,recurrence,OS and RFS were comparable between miMVR and oMVR.There was no 30-d mortality.More patients underwent robotic compared with laparoscopic MVR for complex cases(robotic 57.1%vs laparoscopic 7.7%,P=0.004).The operating time was longer for robotic compared with laparoscopic MVR[robotic:602(400-900)min,laparoscopic:Median 455(275-675)min,P<0.001].Incidence of R0 resection was similar(laparoscopic:84.6%vs robotic:76.2%,P=0.555).Overall complication rates,major morbidity rates and 30-d readmission rates were similar between la-paroscopic and robotic MVR.Interestingly,3-year OS(robotic 83.1%vs 58.6%,P=0.008)and RFS(robotic 72.9%vs 34.3%,P=0.002)was superior for robotic compared with laparoscopic MVR.CONCLUSION MiMVR had lower post-operative complications compared to oMVR.Robotic MVR was also safe,with acceptable post-operative complication rates.Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Efficacy and safety of minimally invasive laparoscopic surgery under general anesthesia for ovarian cancer

BACKGROUND Ovarian cancer is one of the most common malignant tumors in female reproductive system in the world,and the choice of its treatment is very important for the survival rate and prognosis of patients.Traditional open surgery is the main treatment for ovarian cancer,but it has the disadvantages of big trauma and slow recovery.With the continuous development of minimally invasive technology,minimally invasive laparoscopic surgery under general anesthesia has been gradually applied to the treatment of ovarian cancer because of its advantages of less trauma and quick recovery.However,the efficacy and safety of minimally invasive laparoscopic surgery under general anesthesia in the treatment of ovarian cancer are still controversial.AIM To explore the efficacy and safety of general anesthesia minimally invasive surgery in the treatment of ovarian cancer.METHODS The clinical data of 90 patients with early ovarian cancer in our hospital were analyzed retrospectively.According to the different surgical treatment methods,patients were divided into study group and control group(45 cases in each group).The study group received minimally invasive laparoscopic surgery under general anesthesia for ovarian cancer,while the control group received traditional open surgery for ovarian cancer.The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire(EORTC QLQ-C30),clinical efficacy and safety of the two groups were compared.RESULTS The intraoperative blood loss,length of hospital stay,postoperative gas evacuation time,and postoperative EORTC QLQ-C30 score of the study group were significantly better than those of the control group(P<0.05).The incidence of postoperative complications in the study group was significantly lower than in the control group(P<0.05).The two groups had no significant differences in the preoperative adrenocorticotropic hormone(ACTH),androstenedione(AD),cortisol(Cor),cluster of differentiation 3 positive(CD3+),and cluster of differentiation 4 positive(CD4+)indexes(P>0.05).In contrast,postoperatively,the study group's ACTH,AD,and Cor indexes were lower,and the CD3+and CD4+indexes were higher than those in the control group(P<0.05).CONCLUSION Minimally invasive laparoscopic surgery under general anesthesia in patients with early ovarian cancer can significantly improve the efficacy and safety,improve the short-term prognosis and quality of life of patients,and is worth popularizing.

Endoscopic diagnosis and management of gallbladder carcinoma in minimally invasive era:New needs,new models

Gallbladder cancer(GBC)is a rare and lethal malignancy;however,it represents the most common type of biliary tract cancer.Patients with GBC are often diagnosed at an advanced stage,thus,unfortunately,losing the opportunity for curative surgical intervention.This situation leads to lower quality of life and higher mortality rates.In recent years,the rapid development of endoscopic equipment and techniques has provided new avenues and possibilities for the early and minimally invasive diagnosis and treatment of GBC.This editorial comments on the article by Pavlidis et al.Building upon their work,we explore the new needs and corresponding models for managing GBC from the endoscopic diagnosis and treatment perspective.

Minimally invasive reconstruction of extensive mid-lower ureteral strictures using a bilateral Boari flap

Objective:To describe and evaluate the technique using bilateral Boari flap ureteroneocystostomy(BBFUNC)for bilateral mid-lower ureteral strictures.Methods:We retrospectively reviewed five patients who underwent minimally invasive BBFUNC in our institution(Union Hospital,Wuhan,China)between July 2019 and December 2021.The bilateral ureters were mobilized and transected above the stenotic segments.The bladder was isolated and incised longitudinally from the middle of the anterior wall.Then,an inverted U-shaped bladder flap was created on both sides,fixed onto the psoas tendon,and anastomosed to the ipsilateral distal normal ureter.Following double-J stenting,the Boari flaps were tubularized,and the bladder was closed with continuous sutures.The patients’perioperative data and follow-up outcomes were collected,and a descriptive statistical analysis was performed.Results:No case converted to open surgery,and no intraoperative complication occurred.The median surgical time was 230(range 203-294)min.The median length of the bladder flaps was 6.2(range 4.3-10.0)cm on the left and 5.5(range 4.7-10.5)cm on the right side.All patients had not developed recurrent ureteral stenosis during the median follow-up time of 17(range 16-45)months and had a normal maximum flow rate after surgery.The median post-void residual was 7(range 0-19)mL.The maximal bladder capacity was decreased in one(20%)patient.Conclusion:The present study demonstrates that minimally invasive BBFUNC is feasible and safe in treating is limited.

Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions

Minimally invasive surgery(MI)has become the standard of care for many surgical procedures aimed at reducing the burden on patients.However,its adoption in pancreatic surgery(PS)has been limited by the pancreas’s unique location and the complexity of the dissection and reconstruction phases.These factors continue to contribute to PS having one of the highest morbidity and mortality rates in general surgery.Despite a rough start,MIPS has gained widespread acceptance in clinical practice recently.Robust evidence supports MI distal pancreatectomy safety,even in oncological cases,indicating its potential superiority over open surgery.However,definitive evidence of MI pancre-aticoduodenectomy(MIPD)feasibility and safety,particularly for malignant lesions,is still lacking.Nonetheless,reports from high-volume centers are emer-ging,suggesting outcomes comparable to those of the open approach.The robotic PS increasing adoption,facilitated by the wider availability of robotic platforms,may further facilitate the transition to MIPD by overcoming the technical con-straints associated with laparoscopy and accelerating the learning curve.Alth-ough the MIPS implementation process cannot be stopped in this evolving world,ensuring patient safety through strict outcome monitoring is critical.Investing in younger surgeons with structured and recognized training programs can promote safe expansion.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus:A systematic review

BACKGROUND Cheilectomy of the 1^(st)metatarsophalangeal joint(MTPJ)is one of the most common procedures for the management of hallux rigidus.However,there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy(MIDC)for the management of hallux rigidus.AIM To evaluate outcomes following MIDC for the management of hallux rigidus.METHODS During November 2023,the PubMed,EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.RESULTS Six studies were included.In total,348 patients(370 feet)underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9±16.5 months.The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows:Ⅰ(58 patients,27.1%),Ⅱ(112 patients,52.3%),Ⅲ(44 patients,20.6%).Three studies performed an additional 1^(st)MTPJ arthroscopy and debridement following MIDC.Retained intra-articular bone debris was observed in 100%of patients in 1 study.The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9±3.2 to a postoperative score of 87.1.The complication rate was 8.4%,the most common of which was persistent joint pain and stiffness.Thirty-two failures(8.7%)were observed.Thirty-three secondary procedures(8.9%)were performed at a weighted mean time of 8.6±3.2 months following the index procedure.CONCLUSION This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up.A moderate reoperation rate at short-term follow-up was recorded.The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

Application Research of PETD Combined with MRI Nerve Root Water Imaging in the Minimally Invasive Treatment of LDH

Objective: This study aims to evaluate the safety and efficacy of PETD combined with nerve root water imaging of MRI for the treatment of lumbar disc herniation. Methods: A retrospective review was performed on 62 patients with lumbar disc herniation from March 2019 to March 2021. The study included an experimental group of 30 patients and a control group of 32 patients. The experimental group underwent PETD combined with nerve root water imaging of MRI, while the control group received traditional PETD treatment. The visual analogue scoring method (VAS score), and JOA lumbar spine function score before and after surgery were compared between the two groups, and efficacy was assessed and compared using the MacNab score. Results: The mean operation time was significantly reduced in the experimental group (56.43 &#177;10.40 minutes) compared to the control group (65.69 &#177;14.12 minutes). The VAS score was compared between the two groups with preoperative (p = 0.624), one month after surgery (p = 0.325), three months after surgery (p = 0.676), one year after surgery (p = 0.341);The JOA score was compared between the two groups with preoperative (p = 0.961), one month after the surgery (p = 0.266), three months after surgery (p = 0.185), one year after surgery (p = 0.870), they were no significant statistical difference;The efficacy evaluation of the last follow-up Macnab showed that all the 30 patients in the experimental group were excellent, 31 of 32 patients in the control group were excellent, 1 case was good;There was no statistical difference in the comparison between the two groups (p > 0.05). Conclusion: The study concludes that the combined approach of PETD with nerve root water imaging of MRI is a safe, effective, and more efficient alternative to conventional PETD for treating lumbar disc herniation.

Potential value of detection of minimal residual disease in colorectal cancer following radical resection

Although there has been significant advancement in the identification and management of colorectal cancer(CRC)in recent years,there is still room for improvement in the current standard treatment regimen.One area of concern is the lack of reliable tumor markers to predict treatment efficacy and guide tailored care.Due to its dynamic,effective,and non-invasive benefits over tissue biopsy,the detection of minimal or molecular residual lesions(MRD)based on circulating tumor DNA(ctDNA)is beneficial to the clinical development of drugs for patients with CRC after radical treatment,as well as for continuous monitoring of tumor recurrence and malignancy molecular gene evolution.The detection of ctDNA can currently be used to guide individual postoperative auxiliary treatment decisions(upgrade or downgrade treatment)in CRC,stratify the risk of clinical recurrence more precisely,and predict the risk of recurrence in advance of imaging examination,according to a large number of observational or prospective clinical studies.With increasing clarity comes the possibility of selecting a regimen of treatment based on postoperative ctDNA,which also improves the accuracy of clinical recurrence risk assessment for CRC.Therefore,it is anticipated that the identification of ctDNA would alter the current framework for dealing with CRC and lead to individualized,stratified precision therapy;however,additional confirmation will require subsequent high-quality,prospective,large-scale randomized controlled studies.This article will provide an overview of the definition and clinical significance of MRD,the primary indications and technological challenges for MRD detection,along with the advancement in clinical research about ctDNA detection following radical resection of the CRC.

Exploring the Implications of the Deformation Parameter and Minimal Length in the Generalized Uncertainty Principle

The breakdown of the Heisenberg Uncertainty Principle occurs when energies approach the Planck scale, and the corresponding Schwarzschild radius becomes similar to the Compton wavelength. Both of these quantities are approximately equal to the Planck length. In this context, we have introduced a model that utilizes a combination of Schwarzschild’s radius and Compton length to quantify the gravitational length of an object. This model has provided a novel perspective in generalizing the uncertainty principle. Furthermore, it has elucidated the significance of the deforming linear parameter β and its range of variation from unity to its maximum value.

Symmetry of upper eyelid after unilateral blepharoptosis repair with minimally invasive conjoint fascial sheath suspension technique

AIM:To investigate the symmetry of upper eyelid in patients with unilateral mild and moderate blepharoptosis who underwent unilateral minimally invasive combined fascia sheath(CFS)suspension.METHODS:A retrospective study of patients who underwent unilateral minimally invasive CFS suspension surgery between January 2018 and December 2021.Inclusion criteria included unilateral mild and moderate ptosis,good levator muscle function(>9 mm)and follow-up of at least 6mo.Pre-and post-operative symmetry was graded subjectively for marginal reflex distance 1(MRD1),tarsal platform show(TPS)and eyebrow fat span(BFS).A t-test was used to evaluate MRD1,TPS and BFS asymmetry by calculating delta values.The Bézier curve tool of the Image J software was used to extract the upper eyelid contours,where the symmetry was measured by the percentage of overlapping curvatures(POC).RESULTS:Totally 105 patients(105 eyelids)were included(mild group,n=84;moderate group,n=21).Postoperatively,all patients increased MRD1 and decreased TPS in the ptotic eye while maintaining unchanged BFS.The asymmetric delta value for MRD1 was measured to be 1.48±0.86 preoperatively,and it decreased to 0.58±0.67 postoperatively in all cases(P=0.0004).In patients with mild ptosis,the asymmetry value of TPS fell significantly from 1.15±0.62 to 0.68±0.38(P=0.0187).The symmetry of the upper eyelid contour increased in all subgroups of patients,with a POC of 59.39%±13.45%preoperatively and POC of 78.29%±13.80%postoperatively.CONCLUSION:Minimally invasive CFS suspension is proved to be an effective means of improving the symmetry of unilateral ptosis in terms of MRD1(all subgroups),POC(all subgroups)and TPS(only mild group),whereas BFS is unaffected.

The clinical application and advancement of robot-assisted McKeown minimally invasive esophagectomy for esophageal cancer

Robotic surgery systems,as emerging minimally invasive approaches,have been increasingly applied for the treatment of esophageal cancer because they provide a high-definition three-dimensional surgical view and mechanical rotating arms that surpass the limitations of human hands,greatly enhancing the accuracy and flexibility of surgical methods.Robot-assisted McKeown esophagectomy(RAME),a common type of robotic esophagectomy,has been gradually implemented with the aim of reducing postoperative complications,improving postoperative recovery and achieving better long-term survival.Multiple centers worldwide have reported and summarized their experiences with the RAME,and some have also discussed and analyzed its perioperative effects and survival prognosis compared with those of video-assisted minimally invasive esophagectomy.Compared to traditional surgery,the RAME has significant advantages in terms of lymph node dissection although there seems to be no difference in overall survival or disease-free survival.With the continuous advancement of technology and the development of robotic technology,further development and innovation are expected in the RAME field.This review elaborates on the prospects of the application and advancement of the RAME to provide a useful reference for clinical practice.

Minimally Invasive Total Arterial Coronary Artery Bypass Grafting in Left Main Stem Disease

Objective: The aim was to show that Minimally Invasive total arterial revascularization for left main stem coronary artery disease, via a left anterior Mini thoracotomy using bilateral internal thoracic arteries is feasible, reproducible and safe. Further, there has been no exclusive data or experience with minimally invasive coronary artery bypass grafting in left main stem disease. Methods: From April 2019 to March 2024, 41 patients with left main stem stenosis, left main equivalent disease and unprotected left main with triple vessel disease underwent off pump minimally invasive multivessel coronary artery bypass grafting using either in situ pedicled Bilateral Internal Thoracic arteries or Left and Right Internal Thoracic artery Y composite conduits at three centers. Bilateral Internal Thoracic arteries were harvested under direct vision. All patients had an Intra-Aortic Balloon Pump inserted via the femoral artery prior to induction of anesthesia, to prevent any hemodynamic instability, arrhythmias, and was removed following completion of the procedure in the operating room without any complications. Efficacy and outcomes were evaluated by i) Primary (MACCE)-Major Adverse Cardiac and Cardiovascular events and ii) Secondary outcome measures including total length of stay, return to full physical activity and quality of life. Mean follow-up was 1.4 years (Maximum was 2.5 years). Results: 41 patients with left main stem coronary artery stenosis, underwent total arterial revascularization using bilateral internal thoracic arteries. Left main stem stenosis was present in 29 patients, Unprotected left main stem stenosis with triple vessel disease in 7 and left main equivalence in 5 patients. In this cohort, 29 patients with only left main stem stenosis had 2 grafts each, 7 patients with left main and triple vessel disease had 3 grafts and 5 patients with left main equivalent disease had 2 grafts respectively. The average number of grafts was 2.2. One patient was converted to open sternotomy as an emergency because of hemodynamic instability and myocardial revascularization was done on cardiopulmonary bypass (2.2%). The average hospital stay was 3.7 days. Ejection fraction was 45% ± 5%. There was one mortality (2.2%) but no major morbidity. The average ICU and hospital stay was 24 ± 4 hours and 3.7 days. All patients were free from major adverse cardiac and cerebrovascular events at follow-up. Conclusions: Multivessel total arterial revascularization using left and right internal thoracic arteries, was performed via a left anterior Mini thoracotomy on patients with left main stem disease and showed that it was safe, reproducible and will help extend the armamentarium of the surgeon in minimally invasive Coronary artery bypass grafting. Concomitantly it helped enhance the potential for shorter hospital stay, increased survival, decreased morbidity, and earlier return to full activity. Furthermore, the safety, efficacy, and outcomes of minimally invasive coronary artery bypass grafting in this high-risk group evaluated by primary and secondary outcome measures have been good in this study.

A novel triple periodic minimal surface-like plate lattice and its data-driven optimization method for superior mechanical properties

Lattice structures can be designed to achieve unique mechanical properties and have attracted increasing attention for applications in high-end industrial equipment,along with the advances in additive manufacturing(AM)technologies.In this work,a novel design of plate lattice structures described by a parametric model is proposed to enrich the design space of plate lattice structures with high connectivity suitable for AM processes.The parametric model takes the basic unit of the triple periodic minimal surface(TPMS)lattice as a skeleton and adopts a set of generation parameters to determine the plate lattice structure with different topologies,which takes the advantages of both plate lattices for superior specific mechanical properties and TPMS lattices for high connectivity,and therefore is referred to as a TPMS-like plate lattice(TLPL).Furthermore,a data-driven shape optimization method is proposed to optimize the TLPL structure for maximum mechanical properties with or without the isotropic constraints.In this method,the genetic algorithm for the optimization is utilized for global search capability,and an artificial neural network(ANN)model for individual fitness estimation is integrated for high efficiency.A set of optimized TLPLs at different relative densities are experimentally validated by the selective laser melting(SLM)fabricated samples.It is confirmed that the optimized TLPLs could achieve elastic isotropy and have superior stiffness over other isotropic lattice structures.

Incidence of surgical site infection in minimally invasive colorectal surgery

BACKGROUND Surgical site infection(SSI)is a common complication of colorectal surgery.Minimally invasive surgery notably reduces the incidence of SSI.This study aimed to compare the incidences of SSI after robot-assisted colorectal surgery(RACS)vs that after laparoscopic assisted colorectal surgery(LACS)and to analyze associated risk factors for SSI in minimally invasive colorectal surgery.AIM To compare the incidences of SSI after RACS and LACS,and to analyze the risk factors associated with SSI after minimally invasive colorectal surgery.METHODS Clinical data derived from patients who underwent minimally invasive colorectal surgery between October 2020 and October 2022 at the First Affiliated Hospital of Soochow University were collated.Differences in clinical characteristics and surgeryrelated information associated with RACS and LACS were compared,and possible risk factors for SSI were identified.RESULTS A total of 246 patients(112 LACS and 134 RACS)were included in the study.Fortythree(17.5%)developed SSI.The proportions of patients who developed SSI were similar in the two groups(17.9%vs 17.2%,P=0.887).Diabetes mellitus,intraoperative blood loss≥100 mL,and incision length were independent risk factors for SSI.Possible additional risk factors included neoadjuvant therapy,lesion site,and operation time.CONCLUSION There was no difference in SSI incidence in the RACS and LACS groups.Diabetes mellitus,intraoperative blood loss≥100 mL,and incision length were independent risk factors for postoperative SSI.

External validation of EncephalApp Stroop test to screen minimal hepatic encephalopathy patients with nonalcoholic cirrhosis

BACKGROUND Neurocognitive impairment,including minimal hepatic encephalopathy(MHE)and overt hepatic encephalopathy,is one of the most common complications of all types of primary liver diseases,such as hepatitis B,biliary cholangitis,and autoi-mmune hepatitis.The EncephalApp Stroop test is a smartphone application-based test that is time-saving for MHE screening.However,neurocognitive impairment is different between alcoholic cirrhosis patients and nonalcoholic cirrhosis pa-tients,so the cutoff value for MHE diagnosis might be inflated.AIM To validate the Stroop test in nonalcoholic cirrhosis patients.METHODS This external validation was performed at the National Center for Infectious Diseases(Beijing).Liver cirrhosis patients aged between 18 and 65 years who voluntarily enrolled in the study and provided signed informed consent were included.The Psychometric Hepatic Encephalopathy Score(PHES)test was used as the standard diagnostic criterion for MHE.The EncephalApp Stroop test was then performed on the iPad,including two sessions of tests(“off”and“on”)to measure patients’ability to differentiate between numbers and letters.We assessed the performance of the EncephalApp Stroop test in terms of the area under the curve(AUC),sensitivity,specificity,positive predictive value,and negative predictive value,with the PHES as the standard criterion.RESULTS A total of 160 nonalcoholic cirrhosis patients were included in this validation study,including 87(54.4%)patients without MHE and 73(45.6%)patients with MHE.Taking the PHES as the gold standard,the EncephalApp Stroop test performed well for nonalcoholic liver cirrhosis patients in terms of“off”time[AUC:0.85,95%confidence interval(CI):0.79-0.91]and“on+off”time(AUC:0.85,95%CI:0.80-0.91);however,total runs of“off”session(AUC:0.61,95%CI:0.52-0.69),total runs of“on”session(AUC:0.57,95%CI:0.48-0.65),and“on–off”time(AUC:0.54,95%CI:0.44-0.63)were comparatively low.The optimal cutoff points were“off”time>101.93 seconds and“on+off”time>205.86 seconds,with sensitivities of 0.84 and 0.90,specificities of 0.77 and 0.71,positive predictive values of 0.75 and 0.72,and false-positive values of 0.85 and 0.89,respectively.CONCLUSION Our results suggest that different cutoffs should be used for the EncephalApp Stroop tool for MHE screening between alcoholic and nonalcoholic living patients,which is a critical check before generalization to screen for neurocognitive impairment among the whole population of chronic liver diseases.

Minimally invasive multivisceral resection in rectal cancer:Preparation or Precipitation?

Rectal cancer is a malignant neoplasm that constitutes a significant public health challenge due to its high incidence and associated mortality.In this editorial,we comment on the article by Chan et al.In recent years,there has been progress in the development of new treatments for initial and metastatic rectal cancer due to introduction of techniques of innovative and minimally-invasive surgery(MIS)such as laparoscopy and robotic surgery.However,only a few studies have ana-lyzed the feasibility,safety,and results of MIS in relation to open surgery,thereby highlighting the promising and superior results of MIS in functional and oncolo-gical terms.The findings were corroborated by the comparative study of Chan et al which evaluated the feasibility and safety of minimally invasive multivisceral resection(miMVR).A comparison of postoperative outcomes between open MVR and miMVR showed that miMVR presented less blood loss,fewer postoperative complications,and less morbidity.This editorial article is focused specifically on analysis of the characteristics of new minimally-invasive surgical techniques in rectal cancer,particularly in advanced stages.The importance of future research is emphasized by progress in knowledge,training,and clinical practice in the appli-cation of these surgical procedures for the treatment of advanced colorectal cancer.

Enhanced recovery after surgery protocols for minimally invasive treatment of Achilles tendon rupture:Prospective single-center randomized study

BACKGROUND Achilles tendon rupture is a common orthopedic injury,with an annual incidence of 11-37 per 100000 people,significantly impacting daily life.Minimally invasive surgery,increasingly favored for its reduced risks and comparable fixation strength to open surgery,addresses these challenges.Despite advantages like accelerated recovery,perioperative care poses emotional support,pain management,and rehabilitation challenges,impacting treatment efficacy and patient experience.To address these gaps,this study investigated the efficacy of a rapid rehabilitation protocol in enhancing recovery outcomes for minimally invasive Achilles tendon surgery,aiming to develop personalized,standardized care guidelines for broader implementation.AIM To evaluate a nursing-led rapid rehabilitation program for minimally invasive Achilles tendon repair surgery,providing evidence-based early recovery indicators.METHODS This study enrolled 160 patients undergoing channel-assisted minimally invasive Achilles tendon repair randomized into experimental and control groups.The experimental group received perioperative rapid rehabilitation nursing care,while the control group received standard care.The primary outcome measure was the Oswestry disability index score,with secondary outcomes including quality of life,Barthel index,patient satisfaction with nursing,incidence of complications,and rehabilitation adherence.Statistical analysis included appropriate methods to compare outcomes between groups.The study was conducted in a specific setting,utilizing a randomized controlled trial design.RESULTS All 160 patients completed the follow-up.The experimental group showed significantly greater improvements in key efficacy indicators:Postoperative Oswestry disability index score(8.688 vs 18.88,P<0.0001),quality of life score(53.25 vs 38.99,P<0.0001),and Barthel index(70.44 vs 51.63,P<0.0001).The experimental group had a lower incidence of deep vein thrombosis(1.25%vs 10.00%,P=0.0339)with a relative risk of 0.1250(95%confidence interval:0.02050-0.7421).Infection rates were lower in the experimental group(2.50%vs 11.25%,P=0.0564).Hospital stay(5.40 days vs 7.26 days,P<0.0001)and postoperative bed rest(3.34 days vs 5.42 days,P<0.0001)were significantly shorter.Patient satisfaction was 100%in the experimental group vs 87.50%in the control group(P=0.0031).CONCLUSION The rapid rehabilitation intervention significantly reduced pain,shortened hospital stays,and lowered complication rates,improving joint function and patient satisfaction.