Exploration of teaching model of laparoscopic surgery skills for medical interns / 中华医学教育探索杂志

Objective:To investigate the teaching mode of laparoscopic surgery skills for medical interns and its effect.Method:s New interns were randomly divided into experimental group and control group. The experimental group received the laparoscopic surgery skill training by learning Pick and Place (PP), Scrip Shear (SS), Suture and Knot tying (SK) and Tissue Isolation (TI), and they also received additional training of basic surgery skills before the training of laparoscopic surgery skills, while the control group did not receive the pre-training. Examines and questionnaires were conducted after the training.Result:s There were no significant differences in laparoscopic skills between the two groups at the beginning of the training, but they all had obvious improvement after training ( P<0.01). Compared with the control group, the experimental group did better in PP and SK ( P<0.01), but no differences in SS and TI. The satisfaction rate of training model and skill improvement was 95% and 85% in the experimental group and control group. Conclusion:Short-term program of laparoscopic surgery skill training could effectively improve intern's laparoscopic surgery skills, and the master of basic surgery skills is conducive to the learning of laparoscopic surgery skills.

Prognostic value of combining preoperative serum tumor markers and peripheral blood routine indexes in patients with colorectal cancer / 中华胃肠外科杂志

OBJECTIVE@#To investigate the prognostic value of preoperative serum tumor markers combined with peripheral blood routine indexes in colorectal cancer patients.@*METHODS@#From January 2010 to March 2013, clinicopathological data of colorectal cancer patients receiving surgery treatment at the Third Affiliated Hospital of Sun Yat-sen University were collected.@*INCLUSION CRITERIA@#(1) histologically confirmed adenocarcinoma; (2) primary cancer resected; (3) intact clinical data; (4) no signs of clinical infection. Patients with intestinal perforation or obstruction, hematological diseases or other malignant tumors were excluded. Informations were recorded containing sex, age, tumor location, degree of differentiation, tumor size, vascular tumor thrombus, nerve invasion, depth of infiltration, lymph node metastasis, distant metastasis, TNM stage, peripheral serum CEA, CA199, number of neutrophil, monocyte, platelet and lymphocyte. Positive CEA was defined as ≥5 μg/L, CA199 as ≥35 U/L; while NLR (neutrophil-to-lymphocyte ratio), MLR (monocyte-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio) greater than their cut-off values were defined as positive. ROC curve was used to determine the cut-off values (with greatest area under curve) of NLR, MLR and PLR. The prognostic values of these indexes were analyzed using Kaplan-Meier regression and log-rank test. COX regression was used to perform risk factor analysis.@*RESULTS@#A total of 312 colorectal cancer patients were enrolled, including 192 males and 120 females with median age of 61 (15-85) years. Till March 11, 2018, during median follow-up period of 65 months(2-96), the follow-up rate was 90.4% with loss of 30 cases and the mortality was 37.2% with 116 death. Univariate analysis found that colorectal cancer patients with positive CEA, CA199, NLR (>2.32), MLR (>0.24) and PLR (>164.1) had poor prognosis (all P<0.01). When combining CEA, CA199 with NLR, MLR, PLR, the survival analysis showed that patients with both negative indexes had the best prognosis, one positive the worse and both positive were the worst (all P<0.01). COX regression revealed that CEA(HR= 1.702,95%CI:1.148-2.522, P<0.01), combination of CA199 and MLR (HR=2.292, 95%CI:1.426-3.683, P<0.01) were independent risk factors for colorectal cancer.@*CONCLUSION@#Combination of preoperative serum tumor markers and peripheral blood routine indexes can provide prognostic information for the patients with colorectal cancer.

Comparative study of outcomes after laparoscopic versus open pancreaticoduodenectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the surgical and oncological outcomes after laparoscopic pancreaticoduodenectomy (LPD), and compare its efficacy with open pancreaticoduodenectomy (OPD).</p><p><b>METHODS</b>Clinical data of 40 patients with malignant tumor undergoing pancreaticoduodenectomy between January 2012 and January 2013 in our department were retrospectively analyzed. Patients were divided into LPD and OPD group according to operative procedure. Operative time, blood loss, harvested lymph nodes, drainage on first postoperative day (POD1), first flatus day, time to liquid diet, postoperative period of fever, postoperative hospital stay, postoperative complications, and 1-year cumulative survival rate and recurrence rate were compared between the two groups.</p><p><b>RESULTS</b>There were no significant differences between the two groups in operative time, harvested lymph nodes, TNM stages, postoperative period of fever, time to drain removal, postoperative complications, 1-year cumulative survival rate and recurrence rate (all P>0.05). As compared to OPD group, LPD group showed less blood loss [(168.2±87.4) ml vs.(353.5±140.1) ml, P<0.001], drainage on POD1 [(157.7±69.7) ml vs. (289.1±197.0) ml, P=0.039], earlier flatus [(4.1±0.9) d vs. (6.6±3.4) d, P=0.024], shorter time to liquid diet [(5.8±1.3) d vs. (8.2±3.5) d, P=0.040], earlier ambulation [(3.6±1.4) d vs.(6.2±1.5) d, P<0.001], and shorter postoperative hospital stay [(17.0±2.2) d vs.(25.7±13.8) d, P=0.047].</p><p><b>CONCLUSION</b>LPD confers similar surgical and oncological outcomes and is superior to OPD in terms of decreased blood loss and rapid postoperative recovery.</p>

Perioperative safety of minimally invasive and open pancreaticoduodenectomy: a Meta analysis / 中华消化外科杂志

Objective To evaluate the perioperative safety of minimally invasive and open pancreaticoduodenectomy (PD).Methods The China National Knowledge Infrastructure,VIP,PubMed,The Cochrane Library and EMBASE were searched with the key words of laparoscopic,laparoscopy,robotic,da Vinci,minimally invasive,pancreaticoduodenectomy,微创,腹腔境,机器人,胰十二指肠切除术 to retrieve literatures on minimally invasive and open pancreaticoduodenectomy.All the patients were divided into the minimally invasive PD group and the open PD group,and the patients in the minimally invasive PD group were further divided into the robotic PD group and the laparoscopic PD group.A meta analysis was carried out using the RevMan 5.2 software.The count data were represented by the odds ratio (OR) and 95％ confidence interval (95％ CI),and the measurement data were represented by the weighted mean difference (WMD) and 95 ％ CI.Heterogeneity of the publication was analyzed using chi-square test,and the publication bias was analyzed using the funnel plots.The stability of results was analyzed using the sensitivity analysis.Results Ten literatures including 690 patients were selected.There were 235 patients in the minimally invasive PD group,and 455 in the open PD group; 107 patients were in the robotic PD group and 128 in the laparoscopic PD group.There were no significant difference in the incidence of postoperative complications,pancreatic fistula,delayed gastric emptying,postoperative hemorrhage,bile leakage,reoperation,mortality and number of lymph nodes dissected between the minimally invasive PD group and the open PD group (OR =0.75,1.01,0.98,1.50,0.94,0.56,1.06,WMD =2.29,95％ CI:0.40-1.41,0.67-1.53,0.55-1.77,0.76-2.94,0.37-2.38,0.26-1.20,0.48-2.32,-0.55-5.13,P ＞ 0.05).Although the operation time of the minimally invasive PD group was significantly longer than the open PD group,lesser volume of blood loss,shorter duration of postoperative hospital stay and higher R0 resection rate was detected in the minimally invasive PD group (WMD =99.57,-355.70,-3.30,OR =0.49,95％ CI:36.99-162.15,-608.38--103.01,-6.58-0.03,0.26-0.92,P ＜ 0.05).The operation time of the laparoscopic PD group was significantly longer than that of the open PD group (WMD =93.17,95％ CI:55.98-130.37,P ＜ 0.05).The operation time of the robotic PD group was comparable to that of the open PD group (WMD =122.96,95％ CI:-48.48-294.40,P ＞ 0.05).There was no significant difference in the duration of postoperative hospital stay between the laparoscopic PD group and the open PD group (WMD =-0.81,95％ CI:-5.08-3.45,P ＞ 0.05).The operation time of the robotic PD group was significantly shorter than that of the open PD group (WMD=-6.82,95％CI:-13.21--0.44,P＜0.05).Conclusions The perioperative safety of minimally invasive PD was comparable to open PD.Minimally invasive PD has the advantages of lesser blood loss and quick recovery of patients.Robotic PD could significantly decrease the operation time.Minimally invasive PD could be a reasonable alternative when the requirement of indications is fulfilled.

A comparative study of the laparoscopic appearance and anatomy of the autonomic nervous in normal males / 中华外科杂志

<p><b>OBJECTIVE</b>To further understand the anatomical basis of pelvic autonomic nerve preservation.</p><p><b>METHODS</b>Autopsy of five adult male donated cadavers was performed. Meanwhile, ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied. Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance.</p><p><b>RESULTS</b>Autopsy observations indicated that:the abdominal aortic plexus was situated upon the sides and front of the aorta, between the origins of the superior and inferior mesenteric arteries. The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second, third, and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers, emerged from the sympathetic trunk, were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that:abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint, the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus, situated under the loose connective tissue, and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra;left hypogastric nerve was closed to posterior of mesorectum;denonvilliers fascia was thin, reflective fascial structure, and easily removed together with mesorectum excision because of anterior loose structure.</p><p><b>CONCLUSIONS</b>Ligation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum, could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly, and protect the inferior hypogastric plexues while cutting lateral ligament laterally. The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.</p>

Reconstruction methods of digestive tract after pancreaticodudenectomy: a systematic review and meta-analysis of RCTs / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate different types of anastomosis and reconstruction techniques after pancreaticodudenectomy with meat-analysis.</p><p><b>METHODS</b>Systematically literature search was performed through Wanfang, PubMed, EMBASE, Web of Science and Cochrane Library database without restriction to regions, publication types, or languages. A total of 17 randomized controlled trials met the criteria and were evaluated by Jadad scale. Fixed and random-effects models were used to measure the pooled estimates, including pancreatic fistula, bile leakage, hemorrhage, delay gastric emptying(DGE), mortality, reoperation.</p><p><b>RESULTS</b>Meta analysis revealed that patients undergoing pancreaticogastrostomy had a lower incidence of pancreatic fistula and bile leakage(OR=0.60, 95%CI:0.44-0.82, P=0.001; OR=0.33, 95%CI:0.13-0.82, P=0.02) as compared to pancreaticojejunostomy. In pancreaticoenterostomy group, pancreatic duct-mucosa pancreaticoenterostomy had no significant differences with traditional end-to-end anastomosis in terms of overall postoperative morbidity, and development of postoperative pancreatic fistula, reoperation, perioperative death. External stent placement drainage group had a lower postoperative overall complication rate and incidence of pancreatic fistula, especially the II(-III( grade pancreatic fistula, and a shorter hospital stay than non-stent drainage group(all P<0.05).</p><p><b>CONCLUSIONS</b>Pancreaticogastrostomy should be recommended as digestive tract reconstruction after pancreaticodudenectomy and assistant external stent drainage is also necessary.</p>

Effects of hyperlipidemia on postoperative complications in patients of rectal cancer, open vs laparoscopic surgery / 中华普通外科杂志

Objective To study the effect of hyperlipidemia on postoperative complications in patients of colorectal cancer (CRC) undergoing open or laparoscopic surgery. Methods Clinical data of 382 CRC patients who received either traditional or laparoscopic operation from Mar. 2005 to Sep. 2009 were reviewed. By preoperative blood lipid levels, patients were divided into hyperlipidemia group and normal blood lipid group. Data were analyzed by Chi-square test and T test. Results In hyperlipidemia group of 201 CRC cases, volume of blood loss ( t = 11.318, P ＜ 0.01 ), time to resume oral intake( t =5.956, P ＜ 0.01 ), drainage tube removing (t = 4.781, P ＜ 0.01 ), hospital stay( t = 2.449, P ＜ 0.05 ), and incidence of wound liquefaction( x2 =3.988 ,P ＜0.05) were inferior to the other 181 cases in normal blood lipid group, while no difference was observed in operation time ( t = 0.374, P ＞ 0.05 ) and incidence of anastomotic leakage( x2 = 0.239, P ＞ 0.05 ). Patients who received laparoscopic operation had less blood loss (t=10.078 ,P ＜0.01 ), less time to resume oral intake(t =6.366,P ＜0.01 ) and earlier drainage tube removing ( t = 7.654, P ＜ 0.01 ), shorter hospital stay ( t = 4.241, P ＜ 0.01 ) and lower incidence of wound liquefaction ( x2 = 5. 203, P ＜ 0.05 ), though longer operation time ( t = 8.456, P ＜ 0.01 ) comparing with those receiving traditional operation. Among patients who received laparoscopic operation, there was no difference observed postoperatively in time to resume oral intake ( t = 0.356, P ＞ 0.05 ) and drainage tube removing (t = 0.261, P ＞ 0.05 ), and hospital stay (t = 0.248, P ＞ 0.05 ) between the hyperlipidemia group and normal blood lipid group, though the former suffered from more blood loss (t =8.784,P ＜0.01).Conclusions Hyperlipidemia impacts adversely on hemorrhage, delayed recovery and increasing rate of wound liquefaction on rectal cancer surgery. Laparoscopic surgery effectively eliminates prolonged postoperative recovery caused by hyperlipidemia.

Enteral and parenteral nutritional support for gastric cancer patients undergoing laparoscopic radical gastrectomy / 中华消化外科杂志

Objective To compare the effect and safety of enteral and parenteral nutritional support for gastric cancer patients undergoing laparoscopic radical gastrectomy(LRG). Methods Sixty gastric cancer patients received nutritional support after LRG at The Third Affiliated Hospital of Sun Yat-sen University from December 2007 to April 2010. All patients were randomly divided into the enteral nutrition(EN) group (n = 30)and parenteral nutrition (PN) group (n = 30) according to the random number table. Anthropometry, nutritional indexes, complications and expenses of the two groups were compared after treatment. All data were analysed by using the t test and chi-square test. Results Body mass index, triceps skin fold, mid-upper arm muscle circumference, hemoglobin levels, transferrin levels, and albumin levels were ( 16.9 ± 2.4) kg/m2, ( 10.6 ± 2.5 ) mm,(24.2 ±2.5) cm, (106 ± 15) g/L, (2.2 ±0.4) g/L and (39 ±3) g/Lin the EN group, and they were (16.6 ±2.1) kg/m2, (9.2 ± 1.3) mm, (24.0 ±3.4) cm, (102 ± 18) g/L, (2.0 ±0.4) g/L and (38 ±3) g/L in the PN group, respectively, with no significant differences between the two groups (t =0. 52, 1.72, 0.05, 0.93, 1.94,1.29, P ＞ 0.05). Prealbumin levels, nitrogen balance, time of first flatus, and daily expenses in the EN group were (0.30 ±0.10) g/L,0.8 ±0.3, (29 ± 10) hours and (210 ±30) yuan, while they were (0.25 ±0.09) g/L,0. 4 ± 0.2, (38±6) hours and ( 700 ± 50) yuan in the PN group, respectively, with a significant difference between the two groups ( t = 2. 03, 6. 08, 2. 25, 10. 38, P ＜ 0.05 ). One patient had dysbacteriosis, two were glycometabolic and two had a hepatic disorder in the EN group, while the corresponding numbers in the PN group were 9, 12 and 15 patients, respectively, with a significant difference between the two groups ( x2 =7.68, 9.32,13.87, P ＜ 0.05). Conclusions Nutritional support can promote the recovery of gastric cancer patients undergoing LRG. The efficacy of EN is superior to that of PN, and EN is the method of choice for nutritional support.