Feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure / 中华胃肠外科杂志

Objective@#To investigate the feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure.@*Methods@#A retrospective cohort study was performed. Clinical data of 157 colorectal cancer patients undergoing the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure at Gastrointestinal Surgical Department of Guangdong Provincial People′s Hospital from July 2015 to June 2018 were retrospectively analyzed. Of 157 cases, 17 were transverse colon cancer, 94 were descending colon cancer, 25 were sigmoid cancer and 21 were rectal cancer; 89 were male and 68 were female; mean age was (61.8±10.3) years and mean body mass index was (23.2±3.7) kg/m2. The medial approach "four-step method" in the laparoscopic mobilization of splenic flexure was performed as follows: (1) The root vessels were treated with the "provocation" technique to expand the Toldt′s gap. This expansion was extended from the lateral side to the peritoneum reflex of left colonic sulcus, from the caudal side to the posterior rectal space, and from the cephalad side to the lower edge of pancreas. (2) The left colonic sulcus was mobilized, converging with the posterior Toldt′s gap. Mobilization was carried out from cephalad side to descending colon flexure, freeing and cutting phrenicocolic ligament and splenocolic ligament, and from caudal side to peritoneal reflex. (3) Gastrocolic ligament was moblized. Whether to enter the great curvature of stomach omentum arch when the gastrocolic ligament was cut, that was, whether to clean the fourth group of lymph nodes, should be according to the tumor site and whether serosal layer was invaded. (4) Transverse mesocolon was moblized and transected at the lower edge of the pancreatic surface, merging with the posterior Toldt′s gap, and from lateral side to lower edge of the pancreatic body, merging with the lateral left paracolonic sulcus. Safety and short-term clinical efficacy of this surgical procedure was summarized.@*Results@#All the patients completed this procedure. During operation, 3 cases were complicated with organ injury, including 1 case of colon injury, 1 case of spleen injury and 1 case of pancreas injury. No operative death and conversion to open surgery was found. The average operation time was (147.5±35.1) minutes, the average intra-operative blood loss was (40.8±32.7) ml and the average number of harvested lymph node was (16.1±5.8), including (4.0±2.3) of positive lymph nodes. The first exhaust time after surgery was (41.3±20.6) hours, the fluid intake time was (1.5±1.3) days, the postoperative hospital stay was (5.2±2.3) days. Eight (5.1%) cases developed postoperative complications, and all were improved and discharged after conservative treatments. According to the TNM classification system, postoperative pathology revealed that 31 patients were stage I, 51 were stage II, 53 were stage III, 22 were stage IV.@*Conclusion@#The medial approach "four-step method" is safe and feasible, which can effectively decrease the operation difficulty of the laparoscopic mobilization of the splenic flexure.

Expression of HER-2 in colorectal cancer and its relationship with clinicopathological features and prognosis / 中华普通外科杂志

Objective To investigate the correlation between the expression of (epidermal growth factor receptor-2,HER-2) and clinicopathological features and survival of colorectal cancer.Methods From Jan 2005 to Dec 2015,all colorectal cancer cases were enrolled that the expression levels of HER-2 were detected in Guangdong Provincial People's Hospital.Clinicopathological features of the tumors and survival of the patients were analyzed.Results A total of 1 463 cases were collected in 10 years,including 711 cases (48.6％) of HER-2 (-),470 cases (32.1％) of HER-2 (+),249 cases (17％) of HER-2 (+ +),and 33 cases (2.3％) of HER-2 (+ + +).Correlation analysis shows that the expression levels of HER-2 were significantly correlated with tumor differentiation and the depth of tumor invasion(T stage),but not correlated with gender,age,tumor location,N stage,M stage,TNM stage and overall survival,and disease-free survival.Conclusion The expression of HER-2 may be related to tumor differentiation and growth infiltration,but it cannot be used as a predictor of prognosis in patients with colorectal cancer.

Effect analysis of laparoscopy-assisted and open D2 radical gastrectomy for gastric cancer / 中华消化外科杂志

Objective To compare the effect of laparoscopy-assisted gastrectomy (LAG) and open D2 radical gastrectomy (OG) for gastric cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 117 patients who underwent D2 radical gastrectomy at the Guangdong General Hospital from January 2014 to December 2014 were collected.Of 117 patients,60 undergoing LAG and 57 undergoing OG were respectively allocated into the LAG group and OG group.Total gastrectomy,distal subtotal gastrectomy and proximal subtotal gastrectomy were performed according to the location of the tumor.The perigastric lymph nodes dissection was performed according to the Japanese " Gastric cancer treatment protocol" (the 14th edition).Eligible patients received the adjuvant chemotherapy of XELOX regimen according to the Guideline published by National Comprehensive Cancer Network (NCCN).Observation indicators:(1) comparison of intra-and postoperative recovery between groups;(2) stratified analysis of number of lymph node dissected;(3) relationship among surgical method,number of lymph node dissected and postoperative complication;(4) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative adjuvant chemotherapy,tumor-free survival and tumor recurrence or metastasis up to December 2016.Measurement data with normal distribution were represented as (x)± s and comparison between groups was analyzed using the independent-sample t test.Count data were analyzed using the chi-square test or Fisher exact probability.The relationship between number of lymph node dissected and postoperative complication was done using the Logistic regression model.Results (1) Comparison of intra-and post-operative recovery between groups:all the patients completed the operation successfully.Volume of intraoperative blood loss,time to postoperative anal exsufflation and duration of postoperative hospital stay were (113±36) mL,(4.3±2.1) days,(9.7±2.9) days in the LAG group and (209 ± 77) mL,(5.3 ± 2.2) days,(11.2 ± 3.9) days in the OG group,respectively,with statistically significant differences between groups (t =6.850,-2.604,-2.405,P＜0.05).Number of lymph node dissected,numbers of patients with overall complication,incisional infection,intestinal obstruction,digestive tract fistula,intra-abdominal bleeding,cardiovascular accident,pulmonary infection,urinary tract infection and death within postoperative 30 days were respectively 31±7,6,1,0,4,0,0,1,0,0 in the LAG group and 34±6,12,0,1,2,2,1,4,1,1 in the OG group,with no statistically significant difference between groups (t=0.177,x2=2.743,0.126,0.563,0.837,P＞0.05).All the patients with complications received symptomatic treatment,1 patient with abdominal bleeding in the OG group died and other patients recovered smoothly.(2) Stratified analysis of number of lymph node dissected:number of lymph node dissected in patients with total gastrectomy,distal subtotal gastrectomy and proximal subtotal gastrectomy were 35±8,29±5,27±4 in the LAG group and 34± 5,34±6,29±6 in the OG group,respectively,with no statistically significant difference between groups (t =0.846,1.052,0.934,P＞0.05).Number of lymph node dissected in patients with stage Ⅰ,Ⅱ and Ⅲ of TNM staging were respectively 31±5,32±9,31±6 in the LAG group and 34±7,32±4,35±6 in the OG group,with no statistically significant difference between groups (t =0.494,1.657,0.136,P＞0.05).(3) Relationship among surgical method,number of lymph node dissected and postoperative complication:surgical method (LAG and OG) and number of lymph node dissected were used as the independent variable and postoperative complication between groups was used as the dependent variable,the Logistic regression model showed that surgical method and number of lymph node dissected were not related factors affecting the postoperative complication (OR =1.062,2.049,95％ confidence interval:0.998-1.140,0.695-6.042,P＞0.05).(4) Follow-up and survival:108 of 117 patients (54 in each group) were followed up for 2-35 months,with a median time of 28 months.During the follow-up,numbers of patients undergoing postoperative adjuvant chemotherapy,with tumor-free survival and with tumor recurrence were 45,43,10 in the LAG group and 42,42,10 in the OG group,respectively,with no statistically significant difference in the tumor-free survival and tumor recurrence between groups (x2 =0.055,0.002,P＞0.05).Conclusion Laparoscopy-assisted D2 radical gastrectomy is safe and feasible,which equivalent to clinical effect of open radical gastrectomy,meanwhile,it also can reduce volume of intraoperative blood loss and duration of postoperative hospital stay,and accelerate recovery of postoperative gastrointestinal function.

The value of apparent diffusion coefficient values of cerebellar and the middle cerebellar peduncles in differential diagnosis of multiple system atrophy and Parkinson disease / 中华放射学杂志

Objective To evaluate the apparant diffusion coefficient (ADC) values of cerebellar and the middle cerebellar peduncles in the differential diagnosis of multiple system atrophy (MSA) and Parkinson disease (PD). Methods Conventional MRI and DWI were performed in 18 clinically proved MSA patients with 7 cases of early cases (early-stage MSA group), 19 PD patients (PD group) and 18 agematched normal controls (the control group). DWI was performed using a single shot-spin echo-echo planar imaging sequences, and ADC values were measured in the ROIs (0. 16 cm2) of the bilateral cerebellum, the middle cerebellar peduncles and cerebral white matter. Then one way ANOVA test was used for statistical analysis. Results Of the 18 MSA patients, 11 had MR abnormalities, 8 had hot-cross bun sign in the pens on T2-weighted images, 11 patients had pontine, cerebellar and medulla oblongata atrophy, 10 patients had atrophy of the middle cerebellar peduncles, 2 patients had hyperintense rim of the putamen and putaminal atrophy on T2-weighted images. The ADC values in the middle cerebellar peduncles were significantly increased in the MSA group[ (0. 98 ±0. 07) × 103 mm2/s] and early-stnge MSA group [ (0. 95 ±0. 05) ×103 mm2/s] as compared to PD group [ (0. 77 ±0. 04) × 103 mm2/s] and control group[ (0. 78 ±0. 04) ×103 mm2/s]. There was statistical significant difference among them (F = 91.049,55. 301, P ＜ 0.01 ).There was no overlap in the distribution of ADC values of the middle cerebellar peduncles among the MSA group [ (0.86-1.13 ) × 103 mm2/s ], early-stage MSA group [ (0. 86-1.02 ) × 103 mm2/s ] and PD group [ (0. 68-0. 84) × 103 mm2/s] and the control group [ (0. 69-0. 82) × 103 mm2/s]. The ADC values in the cerebellum were significantly increased in the MSA group[ (0. 95 ±0. 09) × 103 mm2/s] and early-stage MSA group [ (0. 92 ±0. 07) × 103 mm2/s] as compared to PD group [ (0. 78 ±0. 05) × 103 mm2/s] and control group[ (0. 79 ± 0. 05 ) × 103 mm2/s ]. Statistically significant difference was found among them (F =39. 274,18. 623 ,P ＜0. 01 ). There was overlap in the distribution of ADC values of the cerebellum [ MSAgroup(0. 80-1.10) × 103 mm2/s,early stage MSA group (0. 80-0. 99) × 103 mm2/s,PD group(0. 72-0. 90) × 103 mm2/s,control group (0. 71-0. 87) × 103 mm2/s]. There was no significant difference among the ADC values of MSA group, MSA group(early stages) and PD group and the control group in the cerebral white matter( P ＞ 0. 05 ). Conclusions ADC values in the cerebellum and the middle cerebellar peduncles have very important significance in differential diagnosis between MSA and PD.

MRI comparative study of the progressive supranuclear palsy, striatonigral degeneration and Parkinson disease / 中华放射学杂志

Objective To provide a reliable differential diagnosis among the progressive supranuclear palsy ( PSP), striatonigral degeneration ( SND ) and Parkinson disease ( PD ) . Methods Conventional MRI data in clinically proved PSP(8 cases), SND(9 cases), PI)( 12 cases)and 12 normal controls were retrospectively analyzed. Midbrain area, pons area, ports diameter and middle eerebellar peduncles width were measured. The ratio of pons area over midbrain area (pons area/midbrain area) was calculated in all patients and normal controls. Then one way ANOVA and a Kruskal-Wallis H test were used for statistical analysis. Results Midbrain area of the PSP group [ (85. 8±12. 0) mm2 ] was the smallest, and there was statistically significant difference ( P < 0. 05 ) comparing with the SND group [ ( 133.2± 8. 4) nun2 ], PD group[ ( 133. 5±10. 8) mm2 ] and the control group [ ( 135.9±7.5 ) mm2 ]. There was no overlapping in the distribution of midbrain area between the PSP group(66.0-98. 2 mm2 ) and SND, PD and normal groups( 116. 2-142. 1, 110. 8-146. 2 and 121.7-145.8 mm2 ). The pons area-midbrain area ratio (P/M) of the PSP group (5.9±0. 8) was the largest in four groups, and there was statistically significant difference ( P < 0. 05 ) comparing with the SN D group ( 2. 9±0. 5 ), PD group ( 3.8±0. 3 ) and the control group (3. 8±0. 3 ). There was no overlapping in the distribution of P/M between the PSP group(5.0-7.2) and SND,PD and normal groups(2. 2-3.5, 3. 3-4. 6 and 3. 2-4. 2). SND group had the smallest P/M, pens area, pons diameter and middle cerebellar peduncles width [ 2.9±0. 5, ( 384. 8±62. 6) mm2 , ( 18. 6±2. 0) nun and( 12. 9±2. 4) mm ] in all groups, and significant difference ( P < 0. 05 ) was found comparing with the PSP group[5.9±0. 8, (500.1±21.8)mm2, (22. 7±1.7)mm and( 16. 3±1. 1) nun],PD group[3.8±0.3, (500.2±25.8)mm2, (23.7±1.0)mm and(16.8±1. 1)mm]and the control group [3. 8±0. 3, ( 508. 8±20. 6 ) mm2, ( 23.2±1.2) nun and ( 16. 4±0. 9 ) mm]. But the PD group and control group had no statistically significant difference in the midbrain area, pans area, pons diameter, P/M and middle cerebellar peduncles width ( P > 0. 05 ). Conclusion MRI measurements helps in the differential diagnosis among PSP, SND and PD.

Study of MRI characteristics of newborn bilirubin encephalopathy / 中华放射学杂志

Objeetive To explore routine magnetic resonance imaging characteristics of newborn bilirubin encephalopathy(NBE).Methods MRI features and clinical data of 17 patients with Newbern bilirubin encephalopathy were retrospectively analyzed, globus pallidus (GP)and subthalamic signal intensity was evaluated.The increase of GP signal intensity and serum total bilirubin peak value were analyzed using pearson correlation analysis.Serum total bilimbin peak value between patients with high signal in the subthalamic nuclei on T1 WI and patients without high signal in the subthalamic nuclei were compared statistically.Results The main MRI presentation in the NBE group Was abnormally increased signal intensity in the GP on T1 WI,which was not apparent on T2 WI One patient showed abnormal high signal intensity in the postemmedial part of GP.Nine patients had high signal in the subthalamic nuclei on T1 WI and normal signal on T2 WI Four patients showed hiigh signal in the brainstem with sparing of dorsal pontine.The increase in value of GP signal intensity was 249.0-423.8 in 12 patients and their serum total bilirubin peak values were 366.0-983.3μmol/L A positive correlation Was found between increase of GP signal intensity and serum total bilirubin peak value.The serum total bilirubin level of abnormal subthalamic group and normal subthalamic group were 660.7±192.4 μmol/L and 513.3±107.5μmol/L respectively.The difference between the two groups was not statistically significant(t=1.914,P＞0.05).Conclusion The routine MRI has some characteristics and is useful in the diagnosis of newborn bilirubin encephalopathy.