Safety evaluation on initial 100 consecutive procedures of self-pulling and latter transected esophagojejunostomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the feasibility and the short-term safety of self-pulling and latter transected esophagojejunostomy(SPLT) in totally laparoscopic total gastrectomy (TLTG).</p><p><b>METHODS</b>One hundred patients with gastric cancer received TLTG-SPLT at General Surgery Department of Huashan Hospital (Fudan University) from June 2014 to January 2017(SPLT group). The clinicopathologic characteristics, surgical and postoperative outcomes were collected retrospectively and compared with the conventional group undergoing TLTG plus overlap or functional end-to-end anastomosis from October 2013 to December 2015. D2 lymph node dissection was regularly performed for all the patients. In SPLT group, a sterile hemp rope was held to ligate and drag down the esophagus to maintain "self-pulling" after the duodenum was transected by the first stapler, allowing the detachment of the posterior mediastinum. Then a hole 2-3 cm above the ligature rope was made on the right-posterior wall of the esophagus. When the mesenteric tension was checked, another hole was made at the anti-mesenteric border of the jejunum 20 cm distal to the ligament of Treitz. A side-to-side esophagojejunostomy (E-J) was then performed between the right-posterior wall of esophagus and the anti-mesenteric wall of the jejunum with the second linear stapler, forming an entry hole. The "latter transection" was applied with the third stapler inserted from the assistant's Trocar, which facilitated the esophagus and the afferent loop jejunum to be simultaneously transected above the level of the entry hole. After that, a side-to-side jejunojejunostomy(J-J) with another 2 staplers was carried out between the afferent loop stump and the Roux limb 40 cm below E-J, in which the E-J entry hole could also work as the entrance for the stapler. The TLTG-SPLT was therefore completed and the specimen was removed through the incision from the umbilical Trocar site.</p><p><b>RESULTS</b>There were 66 male and 34 female patients in the SPLT group with median age of 64 years. The clinicopathologic baseline data of two groups were comparable(all P>0.05). All the patients underwent operations successfully, and none was converted to open surgery. No positive margin was found in either group. Mean operation duration was (178.2±35.9) minute in SPLT group, including (22.9±7.1) minute of reconstruction, which both were significantly shorter than those in conventional group [(204.4±55.8) minute, P=0.003; (30.5±7.2) minute, P=0.000]. Less blood loss [(74.3±72.5) ml vs. (104.2±71.6) ml, P=0.017] and earlier time to the first flatus [(1.9±1.6) days vs. (2.7±1.3) days, P=0.001] were observed in SPLT group. There were no significant differences in postoperative hospital stay and pathological findings between the two groups(all P>0.05). Postoperative operation-associated complications were found in 7 cases of SPLT group. Of these 7 patients, 1 case developed gastrointestinal bleeding, 3 pancreatic leakage, 2 chyle leakage, who all were discovered within postoperative 1 week and were cured by conservative treatment, while the other 1 case developed anastomotic fistula complicated with peritoneal infection who received laparoscopic exploration and peritoneal scavenge and drainage, then discharged 34 days later. Six patients in conventional group developed postoperative operation-associated complications, including 1 case of anastomotic bleeding, 3 cases of pancreatic leakage, 1 case of chyle leakage and 1 case of peritoneal infection. Morbidity of postoperative operation-associated complication was not significantly different between two groups [7.0%(7/100) vs. 11.5%(6/52), χ=0.414, P=0.520]. Fifty patients from two groups underwent endoscopic examination at postoperative 6-month and 12-month, and no obvious anastomotic stenosis and esophageal reflux were observed.</p><p><b>CONCLUSION</b>SPLT is a safe procedure with feasibibility in intracorporeal esophagojejunostomy.</p>

Clinical risk factors for central compartment lymph node metastasis in papillary thyroid cancer(cN0) / 中华普通外科杂志

Objective To analyze the risk factors of central compartment lymph node (CCLN)metastasis in papillary thyroid carcinoma(PTC) without clinically suspected cervical lymph node metastasis (cN0).Methods Clinical data of 272 PTC (cN0) patients who underwent radical thyroidectomy and CCLN dissection between January 2008 and December 2012 in Huashan hospital were retrospectively analyzed.Patients were divided into CCLN positive group (115 cases)and CCLN negative group(157 cases) according to postoperative pathology.Chi-square test,wilcoxon test and multivariate logistic regression analysis were used to analyze risk factors.Results CCLN metastasis of papillary micro thyroid cancer (PMTC) and papillary thyroid cancer (PTC) was 34.9％ and 48.3％,respectively.Tumor size (x2 =10.26,P ＜ 0.01),position(x2 =13.87,P ＜ 0.01),capsular invasion(x2 =20.19,P ＜ 0.01),multifocal PTC(x2 =7.42,P ＜ 0.01) and unmicro-carcinoma (x2 =5.12,P ＜ 0.05) were significantly correlated to lymph node metastasis.Middle area or lower pole of thyroid carcinoma,capsular invasion and multifocal PTC were independent risk factors of CCLN metastasis in PTC.Conclusions The cN0 PTC has a high rate of pathological CCLN metastasis,it is imperative to conduct thyroidectomy with ipsilateral level CCLN dissection in PTC patients.

Experimental and clinical study on intra-tumor injection of slow-release 5-FU to treat pancreatic carcinoma / 中国普通外科杂志

Objective To study the effect of intra-tumor injection of slow-release 5-FU on pancreatic carcinoma cells in nude mice,and on changes in serum tumor markers and cellular immunity of patients with pancreatic carcinoma.Methods (1) In vitro experiments, the releasing action and anti-tumor effect of slow-release 5-FU were studied. Measurement of the concentration of effused fluid,calculation of amount of drug released,and observation of the inhibitory effects of effused fluid on PC3 strains of pancreatic cancer cellswere perfomed.(2) Human pancreatic carcinoma strain PC-3 cells were cultured and inoculated into 60 nude mice,and were randomly divided into 5 groups according to various treatments received: NS injection as control group(A group), 5-FU (10 mg/kg)IV injection group(B group), stroma implant group(C group), intra-tumor injection of high dose slow-release 5-FU (4mg/kg) group(D group) and intra-tumor injection of low dose slow-release 5-FU (1mg/kg) group(E group). Tumor size were measured before and 14 days after treatment. On week 2, histological changes of the tumors were examined. The apoptotic index (AI) of the tumor cells was detected by terminal-deoxynucleotide transferase mediated d-UTP nick end labeling(TUNEL) and expression of bcl-2 and Bax by immunohistochemistry.(3) 69 cases of unresectable pancreatic carcinoma were divided into 3 groups randomly:intra-tumor injection of slow-release 5-FU treated group(treatment group), intra-venous injection of 5-FU group( chemotherapy group), and control group. The serum values of CD3+, CD4+, CD8+, CD4+/ CD8+, NK cells, CEA, CA50, CA19-9, CA125 and CA242 were measured in all patients 1 day before and 14 days after operation. Results (1) There was 0.85 mg 5-FU released in the 1st day and 0.45 mg 5-FU released in the 3rd day. The release remained constant at 0.25 mg and continued for about 14 days. (2) The tumor growth suppression rate on the 1st day by effusion fluid of slow-release 5-FU was 60.27% and on the 3rd day was 34.25%. Later, it remained at about 25.00%. The tumor growth rate was slower in D and E group than in other groups (P