Future of innovation and development of minimally invasive surgical technology and instruments / 中华消化外科杂志

The application of minimally invasive surgery has experienced rapid develop-ment for more than 30 years. The continuous development of minimally invasive technology and instru-ments in the fields of energy platform and imaging equipment has promoted the progress of laparos-copic surgery to be more accurate and secure, and the development of laparoscopic surgery itself has also continuously fed back the innovation of technology and instruments. In recent years, the innovative development of minimally invasive technology and instruments has been more closely combined with the current scientific and technological frontier, leading to the innovative achievements in the fields of robotic surgery, screenless surgery, artificial intelligence, electronic instrument, virtualization and so on. In the new era, surgeons should always keep an eye on the forefront of science and technology, the combination of surgery and technology, application of advanced technology to solve the key problems of current surgery, so as to inject new vitality into the next development of minimally invasive surgery.

Research Improvements and Related Hot Issues of Surgical Treatment on Locally Advanced Rectal Cancer / 肿瘤防治研究

Surgical resection is one of the main steps in the treatment of locally advanced rectal cancer. With the popularization of total mesorectal resection and laparoscopic minimally invasive techniques, related current research on surgical treatment has now entered a relatively high-level stage. In this article, we review the research frontiers of surgical treatment on rectal cancer, including reduction of trocars, specimen retrieval through natural orifices, robotic surgery, high definition/3D/indocyanine fluorescence green surgery, surgical approach and key surgery technology. Based on the current environment of evidence-based medicine, colorectal surgeons should adapt to the changes of the times, actively absorb cutting-edge scientific concepts and technologies and integrate them with surgical equipment and instruments, and carry out rigorous and innovative large-scale prospective clinical trials.

Clinical analysis of 3D printed total hip arthroplasty in elderly patients with acetabular fracture / 中国医师杂志

Objective:To study the clinical efficacy of 3D total hip arthroplasty in elderly patients with acetabular fracture.Methods:A total of 43 patients with non-obsolete acetabular fractures admitted to Xining First People's Hospital from May 2016 to December 2018 were randomly divided into the control group (22 cases) and the observation group (21 cases) for a perspective study. The control group received routine surgery and the observation group was treated with total hip arthroplasty combined with 3D printing. The patient's operation time, intraoperative blood loss, and hospitalization time were recorded. The hip function was assessed by Harris Hip Scale (HHS) after 6 months of follow-up. The patient's quality of life was assessed using the short form 36 item health survey questionnaire (SF-36) before and 6 months after surgery. The complications of the patients during operation and follow-up were recorded.Results:The operation time, hospital stay and intraoperative blood loss were significantly lower in the observation group than those in the control group ( P<0.05). At 6 months after operation, the hip joint function of the observation group was significantly better than that of the control group ( P<0.05); the quality of life scores were significantly higher than the control group ( P<0.05). There was no significant difference in the incidence of adverse reactions between the two groups ( P<0.05). Conclusions:3D printed total hip arthroplasty can effectively improve the operation and hip function of elderly patients with non-obsolete acetabular fracture and the quality of life of patients without increasing adverse reactions.

Clinical efficacy of gastrojejunal bypass surgery combined with radical gastrectomy following conversion therapy for gastric cancer with outlet obstruction / 中华消化外科杂志

Objective:To investigate the clinical efficacy of gastrojejunal bypass surgery combined with radical gastrectomy following conversion therapy for gastric cancer with outlet obstruction.Methods:The retrospective and descriptive study was conducted. The clinicopatho-logical data of 10 initially unresectable gastric cancer patients with outlet obstruction who were admitted to Ruijin Hospital of Shanghai Jiao Tong University School of Medicine from October 2019 to July 2020 were collected. There were 8 males and 2 females, aged from 41 to 59 years, with a median age of 53 years. Patients underwent 'sandwich therapy' of gastrojejunal bypass surgery combined with gastrectomy following conversion therapy. Observation indicators: (1) gastrojejunal bypass surgery and postoperative situations; (2) conversion therapy and complications; (3) radical gastrectomy and postoperative situations; (4) follow-up. Follow-up using outpatient examinations or telephone interview was conducted to detect postoperative complications, progress-free survival, tumor recurrence and metastasis up to March 2019. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:(1) Gastrojejunal bypass surgery and postoperative situations: 10 patients received modified gastrojejunal bypass surgery combined with No.4sb lymph node dissection, without intraoperative serious complications, conversion to laparotomy or death. The operation time, volume of intraoperative blood loss, time to postoperative first flatus, time to liquid diet intake were 73 minutes(range, 60-87 minutes), 33 mL(range,20-110 mL), 3 days(range, 2-6 days), 4 days(range, 4-9 days). One patient had post-operative Clavien-Dindo grade Ⅱ complication of anastomotic bleeding, and was improved after transfusion of blood products. (2) Conversion therapy and complications: of 10 patients, 9 cases received 4 cycles of FLOT regimen. One of the 9 cases was suspended chemotherapy due to Clavien-Dindo grade Ⅱ anastomotic edema after 2 cycles of FLOT regimen. Of 10 patients, there were 6 cases with partial response and 4 cases with stable disease. Of 6 patients with partial response, 4 cases with preoperative cT4b stage were down stage to T4a stage, showing the relationship of tumor with transverse mesentery and pancreatic capsule clearer than the first exploration, 2 cases with preoperative lymph nodes fusion had shrank obviously. Of 4 patients with stable disease, 3 cases were negative for lymph nodes shranking, and the rest 1 case with tumor peritoneal metastasis diagnosed by initial laparoscopy can not be evaluated by imaging examination after chemotherapy. Two of 10 patients had Clavien-Dindo grade I complication of elevated blood glucose during the chemotherapy, which were improved after insulin therapy. (3) Radical gastrectomy and post-operative situations: 10 patients underwent radical resection after conversion therapy. Of 4 cases with stable disease, 3 cases with preoperative lymph nodes fusion showed obvious space between lymph nodes and surrounding tissues at resurgical exploration and received radical resection, 1 case with peritoneal metastasis showed abdominal wall nodelus and omental tuberosity as fibrous scars at resurgical exploration and received radical resection. The operation time, volume of intra-operative blood loss, time to postoperative first flatus, time to initial liquid diet intake, duration of total hospital stay, duration of postoperative hospital stay of 10 patients were 148 minutes(range, 95-195 minutes), 108 mL(range, 100-180 mL), 3 days(range, 2-7 days), 4 days(range, 3-9 days), 11 days(range, 10-21 days), 8 days(range, 7-16 days). Two of 10 patients had perioperative complications. Results of pathological examination of 10 patients showed the number of dissected lymph nodes as 25±6. There were 1 case of stage T1, 5 cases of stage T3, 4 cases of stage T4a. There were 1 case of stage N0, 2 cases of stage N1, 3 cases of stage N2, 4 cases of stage N3. There were 3 cases of tumor regression grade 1a, 1 case of grade 1b, 4 cases of grade 2, 2 cases of grade 3. (4) Follow-up: 10 patients were followed up for 3.9-13.0 months, with a median follow-up time of 6.0 months. The median progression-free survival time of 10 patients was 6.0 months. During the follow-up, 1 case underwent postoperative Clavien-Dindo grade Ⅱ complication of delayed gastric emptying and was improved after symptomatic treatment.Conclusion:The gastrojejunal bypass surgery combined with gastrectomy following conversion therapy for gastric cancer with outlet obstruction is safe and effective.

A primary investigation on application value of glasses-free three-dimensional laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors / 中华消化外科杂志

Objective:To primarily investigate the application value of glasses-free three-dimensional (3D) laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors.Methods:The retrospective cohort study was conducted. The clinical data of 165 patients with gastrointestinal malignant tumors who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between October 2018 and May 2019 were collected. There were 99 males and 66 females, aged from 28 to 86 years, with a median age of 63 years. There were 68 of 165 patients with gastric cancer and 97 with colorectal cancer. Sixteen patients with gastric cancer who underwent laparoscopic radical gastrectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D gastric cancer group, and 52 patients with gastric cancer who underwent laparoscopic radical gastrectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D gastric cancer group. Nineteen patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D colorectal cancer group, and 78 patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D colorectal cancer group. Observation indicators: (1) operative situations of patients with gastric cancer; (2) postoperative recovery of patients with gastric cancer; (3) postoperative pathological examination results of patients with gastric cancer; (4) operative situations of patients with colorectal cancer; (5) postoperative recovery of patients with colorectal cancer; (6) postoperative pathological examination results of patients with colorectal cancer; (7) follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect complications and survival of patients up to the postoperative 30th day. Measurement data with skewed distribution were represented as M ( P25, P75) or M (range), and comparison between groups was analyzed by the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Operative situations of patients with gastric cancer: all the 68 gastric cancer patients received successfully laparoscopic radical gastrectomy, without intraoperative complication or conversion to laparotomy. Cases with distal gastrectomy or total gastrectomy(surgical methods) , operation time, volume of intraoperative blood loss were 11, 5, 195 minutes(169 minutes, 214 minutes), 20 mL (10 mL, 90 mL) in patients of the glasses-free 3D gastric cancer group, and 31, 21, 196 minutes(173 minutes, 222 minutes), 40 mL(20 mL, 100 mL) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( χ2=0.432, Z=-0.362, -1.065, P>0.05). (2) Postoperative recovery of patients with gastric cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(2 days, 3 days), 6 days(5 days, 7 days), 10 days(9 days, 14 days) in patients of the glasses-free 3D gastric cancer group, and 2 days(2 days, 3 days), 6 days(5 days, 6 days), 11 days(9 days, 14 days) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( Z=-0.163, -1.870, -0.570, P>0.05). The postoperative complication incidence of the glasses-free 3D gastric cancer group was 12.5%(2/16), including 1 case with duodenal stump fistula, 1 case with anastomotic bleeding. The postoperative complication incidence of the polarized glasses 3D gastric cancer group was 17.3%(9/52), including 2 cases with duodenal stump fistula, 2 cases with delayed gastric emptying, 1 case with pulmonary infection, 1 case with abdominal bleeding, 1 case with anastomotic leakage, 1 case with chylous fistula, 1 case with intestinal obstruction. All the patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.209, P>0.05). (3) Postoperative pathological examination results of patients with gastric cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1, N2, N3 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 3.0 cm(2.0 cm, 5.0 cm), 5, 3, 1, 7, 8, 5, 2, 3, 2, 4, 7, 6(1, 15), 28(22, 43), 15, 4, 3, 9, 0 in patients of the glasses-free 3D gastric cancer group, and 3.5 cm(2.0 cm, 6.0 cm), 13, 10, 4, 25, 19, 23, 2, 26, 6, 7, 13, 1(0, 7), 29(21, 39), 43, 21, 10, 20, 1 in patients of the polarized glasses 3D gastric cancer group. There was no significant difference in the tumor diameter, tumor T staging, cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, the number of lymph node dissected, cases with qualified lymph node dissected, TNM clinical staging between the two groups ( Z=-0.570, -0.434, χ2 =0.926, 0.851, 1.655, Z=-0.579, χ2=1.193, Z=-1.134, P>0.05). There were significant differences in the tumor N staging and the number of positive lymph node between the two groups ( Z=-2.167, -2.283, P<0.05). (4) Operative situations of patients with colorectal cancer: all the 97 colorectal cancer patients received successfully laparoscopic radical colectomy or proctectomy, without intraoperative complications or conversion to laparotomy. Cases with radical colectomy or proctectomy (surgical methods), operation time, volume of intraoperative blood loss were 7, 12, 132 minutes(97 minutes, 156 minutes), 20 mL(10 mL, 50 mL) in patients of the glasses-free 3D colorectal cancer group, and 40, 38, 124 minutes(110 minutes, 159 minutes), 25 mL(15 mL, 65 mL) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( χ2 =1.276, Z=-0.141, -0.863, P>0.05). (5) Postoperative recovery of patients with colorectal cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(1 days, 3 days), 5 days(5 days, 6 days), 8 days(7 days, 10 days) in patients of the glasses-free 3D colorectal cancer group, and 2 days(1 days, 3 days), 5 days(4 days, 6 days), 8 days(6 days, 10 days) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.678, -1.751, -1.674, P>0.05). The complication incidence of the glasses-free 3D colorectal cancer group was 15.8%(3/19), including 1 case with anastomotic leakage after low anterior proctectomy, 1 case with incision infection, 1 case with urinary tract infection. The complication incidence of the polarized glasses 3D colorectal cancer group was 14.1%(11/78), including 3 cases with anastomotic leakage after low anterior proctectomy, 2 cases with intestinal obstruction, 2 cases with urinary tract infection, 2 cases with incision infection, 1 case with anastomotic bleeding, 1 case with pulmonary infection. One of the 3 cases with anastomotic leakage after low anterior proctectomy in the polarized glasses 3D colorectal cancer group was cured after remedial terminal ileostomy. The other patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.035, P>0.05). (6) Postoperative pathological examination results of patients with colorectal cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1-N2 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 5.0 cm(3.0 cm, 6.0 cm), 3, 2, 7, 7, 3, 2, 1, 8, 11, 0(0, 4), 17(14, 23), 18, 2, 3, 12, 2 in patients of the glasses-free 3D colorectal cancer group, and 4.0 cm(3.0 cm, 5.0 cm), 7, 16, 43, 12, 14, 12, 7, 46, 32, 0(0, 1), 16(13, 19), 74, 14, 17, 40, 7 in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.768, -1.135, χ2 =0.049, 0.292, 0.278, 1.762, Z=-0.694, -1.349, χ2=0.001, Z=-1.011, P>0.05). (7) Follow-up: 165 patients received follow-up, with out short-term reoperation or postoperative death in the postoperative 30 days. Conclusion:There is no significant difference in the efficacy between glasses-free 3D laparoscopic surgery and polarized glasses 3D laparoscopic surgery for radical resection of gastrointestinal malignant tumors, of which the clinical value requires further study.

Concept renovation: a new perspective of minimally invasive surgery / 中华消化外科杂志

The development and innovation of laparoscopic vision platform has promoted the innovation of surgical concept and technology from laparotomy to minimally invasive surgery. From the initial use of reflector device with candlelight to observe the interior of the human body cavity, to the high-definition and ultra-high-definition laparoscopic vision system, from laparoscopic cholecystectomy, to the popularization and promotion of various laparoscopic surgery for malignant tumor, surgery has undergone great changes due to minimally invasive technology. In the new era, the application of three-dimensional and 4K laparoscope brings a new perspective to minimally invasive surgery, so as to promote the development of surgery in the direction of accurate anatomy and functional protection. In the future, stimulated by concept renovation in post-epidemic era of COVID-19, virtual reality technology and robotic surgery supported by the fifth generation wireless systems, as well as tele-surgery and distance training and teaching based on it, will become a new perspective for the development of minimally invasive surgery.

Concept renovation: a new perspective of minimally invasive surgery / 中华消化外科杂志

The development and innovation of laparoscopic vision platform has promoted the innovation of surgical concept and technology from laparotomy to minimally invasive surgery. From the initial use of reflector device with candlelight to observe the interior of the human body cavity, to the high-definition and ultra-high-definition laparoscopic vision system, from laparoscopic cholecystectomy, to the popularization and promotion of various laparoscopic surgery for malignant tumor, surgery has undergone great changes due to minimally invasive technology. In the new era, the application of three-dimensional and 4K laparoscope brings a new perspective to minimally invasive surgery, so as to promote the development of surgery in the direction of accurate anatomy and functional protection. In the future, stimulated by concept renovation in post-epidemic era of COVID-19, virtual reality technology and robotic surgery supported by the fifth generation wireless systems, as well as tele-surgery and distance training and teaching based on it, will become a new perspective for the development of minimally invasive surgery.

Application value of 3D laparoscope in transanal total mesorectal excision / 中华消化外科杂志

Objective:To investigate the application value of three-dimensional (3D) laparoscope in the transanal total mesorectal excision (TaTME).Methods:The retrospective cohort study was conducted. The clinicopathological data of 20 patients with middle and low rectal cancer who underwent TaTME in the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2018 to October 2019 were collected. There were 15 males and 5 females, aged from 28 to 81 years, with a median age of 64 years. Of the 20 patients, 10 patients using 3D laparoscopic system for transanal approach of TaTME were divided into 3D group, and 10 patients using two-dimensional (2D) laparoscopic system for transanal approach of TaTME were divided into 2D group. Observation indicators: (1) intraoperative situations and postoperative recovery; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted by outpatient examination and telephone interview to detect survival of patients and recurrence and metastasis of tumors in patients up to April 2020. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the Fisher exact propability. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Results:(1) Intraoperative situations and postoperative recovery: patients in the two groups completed surgeries successfully, without tranversion to laparostomy from laparoscopic surgery, transversion to transabdominal surgery from transanal surgery, or intraoperative death. The cases with terminal ileostomy, cases with manual anstomosis or mechanical anastomosis (anastomotic methods), operation time, volume of intra-operative blood loss, duration of postoperative hospital stay, cases with anastomotic leakage or anastomotic hemorrahge (postoperative short-term complications), cases with anastomotic stenosis of the 3D group were 7, 4, 6, 150 minutes (range, 100-220 minutes), 50 mL (range, 30-100 mL), 8.5 days (range, 7.0-16.0 days), 2, 0, 1, respectively, versus 8, 5, 5, 180 minutes (range, 120-250 minutes), 100 mL (range, 30-200 mL), 9.5 days (range, 6.0-17.0 days), 1, 1, 1 of the 2D group. There was no significant difference in the terminal ileostomy, anastomotic methods, postoperative short-term complications, or anastomotic stenosis between the two groups ( P>0.05). There was no significant difference in the operation time, volume of intraoperative blood loss, or duration of postoperative hospital stay between the two groups ( Z=1.909, 1.827, 0.687, P>0.05). Patients with short-term complications in the two groups were improved after conservative treatments. There was 1 patient with anastomotic stenosis in either group, and they were improved after endoscopic balloon dilatation. (2) Postoperative pathological examination: the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, cases with cancer nodes in the mesentery, cases with complete mesentery or median complete mesentery (the integrity of mesentery), cases in stage Ⅰ, Ⅱ, Ⅲ (postoperative pathological stage) of the 3D group were 3.8 cm (range, 1.8-5.0 cm), 1.0 cm (range, 0.5-2.5 cm), 14.5 (range, 6.0-19.0), 1, 9, 1, 4, 2, 4, respectively, versus 4.8 cm (range, 1.0-8.5 cm), 0.8 cm (range, 0.3-1.5 cm), 15.5 (range, 8.0-18.0), 1, 8, 2, 2, 4, 4 of the 2D group. There was no significant difference in the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, the integrity of mesentery, or postoperative pathological stage between the two groups ( Z=1.673, 1.772, 0.038, 0.610, 0.482, P>0.05). There was no significant difference in the cases with cancer nodes in the mesentery between the two groups ( P>0.05). Patients in the two groups had negative distal margin and circumferential margin. (3) Follow-up: patients in the 3D group and 2D group were followed up for 11 months (range, 6-16 months) and 13 months (range, 6-21 months), respectively. During the follow-up, there was no local recurrence, distal metastasis, or tumor-related death. Conclusions:3D laparoscope applied in the TaTME can achieve similar clinical efficacy with 2D laparoscope, which may have a positive impact on the operation time and volume of intraoperative blood loss.

Enlightenment and reflection of clinical research results on oncological minimally invasive surgery: how to improve the quality control of minimally invasive surgery / 中华消化外科杂志

The oncological minimally invasive surgery,represented by laparoscopic surgery,has been developed in the past three decades.Despite the techniques and procedures have been improved,the oncological outcomes of radical surgery by minimally invasive approach in several cancer types are still controversial according to the results of recent clinical researches.Whatever the truth is,the key point of tumor radical surgery is the quality control of minimally invasive surgery.Grasping the surgical indications strictly and providing the most suitable treatment modality for cancer patients will be helpful to ensure quality control and minimize risks.In addition,with standardizing minimally invasive surgical procedures by constructing a systematic training system,the quality of minimally invasive tumor surgery can be guaranteed perioperatively.For novel minimally invasive surgical techniques,rigorous and prudent attitude is particularly proposed for the quality control.In the context of highly developed minimally invasive surgery,not only " maintaining speed",but also better "guaranteeing quality" can minimally invasive surgery bring real benefits to more cancer patients.

Enlightenment and reflection of clinical research results on oncological minimally invasive surgery: how to improve the quality control of minimally invasive surgery / 中华消化外科杂志

The oncological minimally invasive surgery, represented by laparoscopic surgery, has been developed in the past three decades. Despite the techniques and procedures have been improved, the oncological outcomes of radical surgery by minimally invasive approach in several cancer types are still controversial according to the results of recent clinical researches. Whatever the truth is, the key point of tumor radical surgery is the quality control of minimally invasive surgery. Grasping the surgical indications strictly and providing the most suitable treatment modality for cancer patients will be helpful to ensure quality control and minimize risks. In addition, with standardizing minimally invasive surgical procedures by constructing a systematic training system, the quality of minimally invasive tumor surgery can be guaranteed perioperatively. For novel minimally invasive surgical techniques, rigorous and prudent attitude is particularly proposed for the quality control. In the context of highly developed minimally invasive surgery, not only "maintaining speed" , but also better "guaranteeing quality" can minimally invasive surgery bring real benefits to more cancer patients.

Transanal total mesorectal excision in laparoscopic surgery for lower rectal cancer: leading actor or supporting actor / 中华胃肠外科杂志

Transanal total mesorectal excision (taTME) is a hot topic currently in colorectal surgery. It has several advantages for lower rectal cancer, especially for male obese patients with narrow pelvis. But the indication of taTME which can really achieve the completeness of TME is limited. In terms of management and regulation, it is necessary to strictly control the indications for surgery. In the initial stage of development, patients with lower rectal cancer, with early stage and real difficulties in laparoscopy should be selected. TaTME is still premature in terms of technique, devices and instruments, with relative higher morbidity in its current form. We should pay more attentions to the safety of taTME to avoid the complications. Also, we should pay more attentions to indication and standardization of techniques, the improvement of instruments and training program of the technique. TaTME should be operated in large teaching hospitals for research purpose in the initial stage. Only with the high-quality evidence of clinical trials, can the technique be spread widely. Now, taTME is still a complementary technique to traditional abdominal surgery for lower rectal cancer. With the accumulation of standardized technique and high-quality of clinical evidence, the value of taTME will be assessed fairly.

Laparoscopic peritoneal dialysis catheter implantation in peritoneal chemotherapy for gastric cancer with peritoneal metastasis / 中华胃肠外科杂志

Objective@#To investigate the clinical value of laparoscopic peritoneal dialysis catheter implantation in peritoneal chemotherapy for gastric cancer with peritoneal metastasis.@*Methods@#From January 2019 to June 2019, the clinical data of 6 patients diagnosed as gastric cancer with peritoneal metastasis were retrospectively analyzed in the Gastrointestinal Surgery Department of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine. Five were male and 1 was female. The median age was 69.5 (28-77) years. The median body mass index (BMI) was 22.8 (19.6-23.5). All procedures were performed under general anesthesia with endotracheal intubation. The patient′s body position and facility layout in the operating room were consistent with those of laparoscopic gastrectomy. The operator′s position: the main surgeon was located on the right side of the patient, the first assistant stood on the left side of the patient, and the scopist stood between the patient′s legs. Surgical procedure: (1) trocar location: three abdominal trocars was adopted, with one 12 mm umbilical port for the 30° laparoscope (point A). Location of the other two trocars was dependent on the procedure of exploration or biopsy as well as the two polyester cuff position of the peritoneal dialysis catheter: Usually one 5 mm port in the anterior midline 5 cm inferior to the umbilicus point was selected as point B to ensure that the distal end of the catheter could reach the Douglas pouch. The other 5 mm port was located in the right lower quadrant lateral to the umbilicus to establish the subcutaneous tunnel tract, and the proximal cuff was situated 2 cm away from the desired exit site (point C).(2) exploration of the abdominal cavity: a 30° laparoscope was inserted from 12 mm trocar below the umbilicus to explore the entire peritoneal cavity. The uterus and adnexa should be explored additionally for women. Once peritoneal metastasis was investigated and identified, primary laparoscopic peritoneal dialysis catheter implantation was performed so as to facilitate subsequent peritoneal chemotherapy. Ascites were collected for cytology in patients with ascites. (3) peritoneal dialysis catheter placement: the peritoneal dialysis catheter was introduced into the abdominal cavity from point A. Under the direct vision of laparoscopy, 2-0 absorbable ligature was reserved at the expected fixation point of the proximal cuff (point B) for the final knot closure. Non-traumatic graspers were used to pull the distal cuff of peritoneal dialysis catheter out of the abdominal cavity through point B. The 5-mm trocar was removed simultaneously, and the distal cuff was fixed between bilateral rectus sheaths at the anterior midline port site preperitoneally. To prevent subsequent ascites and chemotherapy fluid extravasation, the reserved crocheted wire was knotted. From point C the subcutaneous tunnel tract was created before the peritoneal steath towards the port site lateral to the umbilicus. Satisfactory catheter irrigation and outflow were then confirmed. Chemotherapy regimen after peritoneal dialysis catheterization: all patients began intraperitoneal chemotherapy on the second day after surgery. On the 1st and 8th day of each 3-weeks cycle, paclitaxel (20 mg/m2) was administered through peritoneal dialysis catheter, and paclitaxel (50 mg/m2) was injected intravenously. Meanwhile, S-1 was orally administered twice daily at a dose of 80 mg·m-2·d-1 for 14 consecutive days followed by 7-days rest. To observe the patients′ intraoperative and postoperative conditions.@*Results@#All the procedures were performed successfully without intraoperative complications or conversion to laparotomy. No 30 day postoperative complications were observed. The median operative time was 33.5 (23-38) min. The median time to first flatus was 1(1-2) days, and the median postoperative hospital stay was 3 (3-4) days, without short-term complications within 30 days postoperatively. The last follow-up was up to July 10, 2019, and the patients were followed for 4(1-6) months. No ascites extravasation was observed and no death occurred in the 6 patients. There was no catheter obstruction or peritoneal fluid extravasation during and after chemotherapy.@*Conclusion@#Laparoscopic peritoneal dialysis catheter implantation was safe and feasible for patients with peritoneal metastasis of gastric cancer. The abdominal exploration, tumor staging and the abdominal chemotherapy device implantation can be completed simultaneously, which could simplify the surgical approach, improve the quality of life for patients and further propose a new direction for the development of abdominal chemotherapy.

Prime of life for minimally invasive gastrointestinal and colorectal surgery / 中华胃肠外科杂志

With the development in the past 20 years, minimally invasive gastrointestinal and colorectal surgery is now in its prime of life, with a high level in terms of surgical technique, surgical standardization, innovative technology and technical training. However, in the prime of life, in order to avoid the decline, we must meet new challenges. With the advent of the era of 5G and artificial intelligence, plus a series of changes in the internal and external environment, minimally invasive surgery, and even the entire surgery will have a major impact, including changes in treatment patterns, emphasis of multidisciplinary comprehensive treatment, changes in disease spectrum, and except neoplasms, more benign and functional diseases may require minimally invasive surgery. The gastrointestinal surgery specialist relying on "craft" will likely be replaced by an artificial intelligence surgical system. In the face of challenges, we should not forget our initial intentions, and should diligently reflect on ourselves, keeping the patient-centered minimally invasive treatment concept. Meanwhile, we should go to the basic hospitals to further establish a standardized training system, continue to maintain innovative thinking and keep pace with the times, so that we can grasp the prime of life for minimally invasive gastrointestinal and colorectal surgery.

Dorsal-and-medial hybrid approach versus medial-to-lateral approach in laparoscopic right hemicolectomy with complete mesocolic excision:A prospective comparative study / 中国实用外科杂志

OBJECTIVE: To compare dorsal-and-medial hybrid approach and medial-to-lateral approach in laparoscopic right hemicolectomy with complete mesocolic excision(CME). METHODS: Patients undergone laparoscopic right hemicolectomy in Department of Gastrointestinal Surgery in Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from July 2017 to April 2018 were prospectively included.Patients were divided into two groups:dorsal group and medial group. Clinical and pathological data were collected and compared between the two groups. RESULTS: There were 35 patients in medial group and 40 patients in dorsal group. No significant differences were found between the two groups in baseline characteristics,perioperative outcomes and pathological results. No significant difference was found between the two groups in length of bowel(24 cm vs. 22 cm),A line distance(9.8 cm vs.9.4 cm),B line distance(9.0 cm vs. 8.5 cm),area of mesentery(112.4 cm~2 vs. 109.0 cm~2),total lymph node count(19 vs.19),lymph node adequate ratio(97.1% vs. 97.5%)and CME ratio(80% vs. 85%). Obesity was found to be an independent risk factor of CME ratio(P=0.019). CONCLUSION: Dorsal-and-medial hybrid approach and medial-to-lateral approach are comparable in safety,feasibility and effectiveness in laparoscopic right hemicolectomy with complete mesocolic excision. Randomized clinical trials with larger sample size are needed.

Development and innovation of international minimally invasive gastrointestinal surgery / 中华消化外科杂志

Minimally invasive surgery has got a great development in the past 30 years.Currently,a series of new technique and novel technology have been introduced,which bring us a new prospect and also new challenges.In surgery methods,Adenocarcinoma of esophagogastric junction (AEG) is also a hot topic recently,especially the gastrointestinal tract reconstruction of AEG in total laparoscopic surgery.Transanal total mesorectal excision has several advantages in difficult cases of lower rectal cancer,but is still under debate for oncological safety.3D laparoscopic surgery,glass-free 3D laparoscopic surgery,4K laparoscopic surgery and laparoscopic indocyanine green fluorescence imaging are innovative technology in minimally invasive surgery at home and abroad.The fusion and hybrid of the new technique and novel technology might be the future of the minimally invasive surgery.

Safety and short-term outcomes of laparoscopic abdominoperineal resection with pelvic peritoneum closure for low rectal cancer / 中华消化外科杂志

Objective To investigate the safety and short-term outcomes of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LARP-PPC) for low rectal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 132 patients with low rectal cancer who were admitted to Ruijin Hospital of Shanghai JiaoTong University School of Medicine from January 2014 to December 2017 were collected.There were 81 males and 51 females,aged from 45 to 83 years,with an average age of 62 years.Among the 132 patients,60 undergoing LARP-PPC were allocated into LARP-PPC group,and 72 patients undergoing conventional LARP were allocated into LARP group.All the patients received standardized preoperative and postoperative treatments.Observation indicators:(1) surgical and postoperative conditions;(2) postoperative pathological examination;(3) postoperative complications.The measurement data with normal distribution were expressed as Mean±SD,and the t test was used for comparison between groups.The measurement data with skewed distribution were expressed as M (range),and the Mann-Whitney U test was used for comparison between groups.The count data were expressed as absolute numbers,and the chi-square test or the Fisher exact probability was used for comparison between groups.Mann-Whitney U test was used for comparison of ordinal data between groups.Results (1) Surgery and postoperative conditions:all the patients in the two groups underwent successful surgery without conversion to open surgery.The operation time,volume of intraoperative blood loss,time to first flatus,and time to first liquid intake of the LARP-PPC group were (163±45) minutes,168 mL(range,85-280 mL),2 days(range,1-5 days),3 days(range,2-6 days),versus (155±39) minutes,160 mL(range,100-305 mL),3 days(range,1-7 days),4 days(range,2-7 days) of the LARP group;there was no differencebetween the two group (t =1.113,Z =-1.623,-1.468,-0.321,P＞0.05).The duration of postoperative hospital stay in the LARP-PPC group and the LARP group were 16 days (range,11-21 days) and 19 days (14-24 days),respectively,with a significant difference between the two groups (Z =-5.888,P＜0.05)].In the LARP-PPC group,time of PPC was (13± 3) minutes.(2) Postoperative pathological examination:the length of specimen,the number of lymph node dissection,tumor diameter,cases with high-,middle-,and low-differentiated tumor in the LARP-PPC group was (18±4)cm,16±t5,(3.7±1.4)cm,10,34,16 in the LARP-PPC group,and (18±4)cm,16±5,(3.9±1.5) cm,13,41,18 in the LARP group,showing no significant difference between the two groups (t =0.779,0.390,0.703,Z=-0.267,P＞0.05).(3) Postoperative complications:cases with perineal wound infection,delayed perineal wound healing,intestinal obstruction,and perineal hernia were 2,1,1,0 in the LARP-PPC group,and 12,10,8,6 in the LARP group,showing significant differences between the two groups (x2 =6.137,6.400,P＜0.05).There were 2 and 4 patients with urinary tract infection in the LARP-PPC group and the LARP group,respectively,showing no significant difference between the two groups (P ＞ 0.05).Conclusion LARP-PPC is safe and feasible for the treatment of low rectal cancer,which can significantly reduce postoperative perineal-related complications and consequently shorten postoperative hospital stay.

Technology innovation in minimally invasive surgery for gastrointestinal and colorectal surgery / 中华消化外科杂志

Minimally invasive surgery is worldwide adopted.The technology of minimally invasive surgery plays an important role in improvement of diagnosis and treatment of diseases.In recent years,new technology of minimally invasive surgery,such as 4K laparoscopy,glasses-free 3D laparoscopy,virtual reality with 5G technology,and fluorescence imaging guided laparoscopic surgery improve the procedure,standardization and training of laparoscopic surgery for gastrointestinal and colorectal diseases.The authors hope that with the great improvement of economy technology,we can also lead the innovation of technology and standardization of technique in minimally invasive surgery in near future.

Application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy / 中华消化外科杂志

Objective To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected.The main points of the modified Overlap method:surgeons stood on the right of patients when digestive tract reconstruction,suspension of left half liver and clockwise rotation before esophageal transection were performed,regulating esophageal opening position and building jejunal loop,and then closing openings using 45.0 mm Endo-GIA and barbed wire.Patients who were diagnosed as Ⅰ A stage by postoperative pathological examination were followed up;patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in Ⅰ B and Ⅱ stages without lymph node metastases underwent oral S-1 single agent.Observation indicators:(1) surgical and postoperative recovery situations;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy,long-term complications and survival up to March 2018.Measurement data with normal distribution were represented as x±s,and measurement data with skewed distribution were described as M(range).Results (1) Surgical and postoperative recovery situations:all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy.The operation time,esophagojejunostomy time,volume of intraoperative blood loss,time to initial anal exsufflation,time for initial fluid diet intake,time for initial semifluid diet intake and time of postoperative drainage-tube removal were respectively (227 ± 19) minutes,(22 ±7)minutes,(69±11)mL,(2.1±0.5) days,(3.4±0.4) days,(4.9±0.6) days and (7.5±1.7) days.There was no anastomotic stoma-related complication in 32 patients.One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous three-cavity irrigation and conservative treatment.Results of postoperative pathological examination:number of lymph node dissected in 32 patients was 32±4.TNM staging:1,5,7,11,6,1 and 1 patients were detected respectively in Ⅰ A,Ⅰ B,Ⅱ A,Ⅱ B,ⅢA,ⅢB and ⅢC.Duration of postoperative hospital stay of 32 patients was (8.1 ±2.1)days.(2) Follow-up and survival situations:32 patients were followed up for 3-38 months,with a median time of 18 months.During the follow-up,in addition to 1 patient in IA stage,31 patients underwent postoperative adjuvant therapy;patients can take the common soft food,without symptoms of choking and burning feelings,and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency.One patient died of malignant tumor of maxillary sinus at 9 months postoperatively,1 was detected liver metastasis at 20 months postopeartively and survived with tumor,the other patients had no tumor recurrence or metastasis.Conlusion The modified Overlap esophagojejunostomy is safe and feasible in TLTG,with good short-term outcomes.

Innovation and development of minimally invasive gastrointestinal and colorectal surgery in China / 中华消化外科杂志

Laparoscopic surgery has got a brilliant progress in the past 30 years,especially in the field of gastrointestinal and colorectal surgery,which has a continuous increase in volume and frequency.However,for minimally invasive surgery,innovation is the only way to get further development.The innovation of minimally invasive gastrointestinal and colorectal surgery includes devices and techniques.The innovative devices include vision system of minimally invasive surgery such as 3D laparoscopy,4K/6K high definition displayer or VR system,all dimensions surgical arms,robotic surgery system,and therapeutic endoscopy.The innovative techniques include new approaches of laparoscopic surgery for gastrointestinal and colorectal diseases,transanal total mesorectal excision and reconstruction of gastrointestinal tract in laparoscopic surgery.The rapid progress of innovation and development in devices and techniques implies more challenges and opportunities for the minimally invasive gastrointestinal and colorectal surgery in the near future.

Long-term outcomes and prognostic factors analysis of laparoscopic gastrectomy for stage T4a gastric cancer / 中华消化外科杂志

Objective To explore the long-term outcomes and prognostic factors of laparoscopic gastrectomy for stage T4a gastric cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 224 patients who underwent laparoscopic gastrectomy of gastric cancer and D2 lymph node dissection in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between February 2004 and December 2014 were collected.Lymph node dissection followed the Japanese Gastric Cancer Treatment Guidelines (13th edition).Anastomotic methods included Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophagojejunostomy.Patients who were diagnosed in stage T4a by postoperative pathological examination underwent 5-fluorouracil chemotherapy.Observation indicators:(1) treatment;(2) postoperative pathological examination;(3) follow-up;(4) prognostic factors analysis.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence or metastases up to death (end of follow-up) or July 31,2016.Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using Student-t test.Measurement data with skewed distribution were described as M (Q).Comparisons of count data were analyzed using the chi-square test.The overall and disease-free survival curves,overall and disease-free survival rates were respectively drawn and calculated using the Kaplan-Meier method.The survival analysis was done by the Log-rank method.The univariate analysis was done by the chisquare test,and COX regression model which included affecting factors (P＜0.10) in the univariate analysis was used for the multivariate analysis.Results (1) Treatment:all the 244 patients underwent successful operation,without conversion to open surgery.Surgical method:laparoscopic-assisted distal gastrectomy (4 combined with cholecystectomy,1 with splenectomy and 1 with transverse colectomy) were detected in 125 patients and laparoscopic-assisted total gastrectomy in 99 patients (3 combined with cholecystectomy and 2 with splenectomy).Anastomotic method:Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophago-jejunostomy were respectively applied to 85,29 and 110 patients.Operation time and volume of intraoperative blood loss were (229±50)minutes and (229 ± 146)mL.All patients underwent 6 or 8 cycles 5-fluorouracil chemotherapy.(2)Postoperative pathological examination:numbers of lymph node dissected and positive lymph nodes were 25± 11 per case and 13 (8,25),with R0 resection.Tumor pathological diagnosis of 224 patients:tumor diameter was (4.5±2.3)cm.Tumors in 29,64,122 and 9 patients respectively located in 1/3 proximal stomach,1/3 middle segment of stomach,1/3 distal stomach and involving 2/3 or total stomach.Tumor differentiation:moderate-and high-differentiated tumors and low-and un-differentiated tumors were detected in 82 and 142 patients,respectively.Postoperative N staging:53,46,55 and 70 patients were detected in staging N0,N1,N2 and N3,respectively.Lymph node metastasis rates of 51,58,53 and 62 patients were 0,1％-15％,16％-40％ and ＞40％,respectively.Postoperative staging was T4a staging.(3) Follow-up:212 of 224 patients were followed up for 7-120 months,with a median time of 32 months.Of 212 follow-up patients,118 were survived and 94 died.Of 118 survived patients,13 and 105 were respectively survived with tumors and without tumor.Of 94 deaths,causes of 8 and 86 were respectively non-tumor and tumor-related deaths.The 5-year overall and disease-free survival rates of 224 patients were respectively 47.2％ and 43.6％.(4) Prognostic factors analysis:results of univariate analysis showed that tumor location,tumor diameter,N staging and lymph node metastasis rate were related factors affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (x2 =6.365,3.740,32.232,48.977,P＜0.10;x2 =9.919,8.818,34.277,45.612,P＜ 0.10).Results of multivariate analysis showed that lymph node metastasis rate was an independent factor affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (HR =1.828,1.197,95％ confidence interval:1.353-2.469,0.945-1.516,P＜0.05).Postoperative 5-year overall and disease-free survival rates were respectively 72.5％,57.0％,41.6％,23.3％ and 70.0％,53.9％,37.0％,32.4％in staging N0,N1,N2 and N3 patients,with statistically significant differences in different staging (x2 =32.232,34.277,P＜0.05).Conclusion There are good long-term outcomes in laparoscopic gastrectomy for stage T4a gastric cancer,and lymph node metastasis rate is an independent factor affecting postoperative overall and disease-free survival of patients.