Application of en-bloc Holmium laser enucleation of the prostate with an early apical mucosa dissection / 国际外科学杂志

Objective:To investigate the efficacy and safety of en-bloc Holmium laser enucleation of the prostate (HoLEP) with an early apical mucosa dissection technique for the treatment of benign prostate hyperplasia (BPH).Methods:The clinical data of 215 patients treated with HoLEP for BPH from January 2020 to January 2023 in the Department of Urology, Beijing Friendship Hospital, Capital Medical University were retrospectively analyzed. According to different treatment methods, the patients were divided into study group ( n=112) and control group ( n=103). Patients in the study group were treated by the en-bloc HoLEP with an early apical mucosa dissection technique, while patients in the control group were treated by the classical two or three-lobes HoLEP. The primary endpoints included the rates of urinary incontinence at 1-month, 3-month, and 6-month after surgery in two groups of patients. The secondary endpoints included operative time, hemoglobin decrease, dissected prostate weight, postoperative indwelling catheter time, postoperative hospital stay, and international prostate symptom score (IPSS), quality of life (QoL), Qmax, and postvoid residual urine (PVR) at 3-month and 6-month after surgery. The measurement data were tested by Shapiro-Wilk normality test. The normal distribution of the measurement data were expressed as mean ± standard deviation ( ± s), and independent sample t-test was used for comparison between two groups. Measurement data of skewness distribution were expressed as median (interquartile distance) [ M( Q1, Q3)], and Wilcoxon or Mann-Whitney U test were used for comparison between two groups. The count data in the two groups were compared by the Chi-square test. Results:The incidence of urinary incontinence in the study group was 9.0% (10/112) and 3.6% (4/112) at 1-month and 3-month after surgery, which was significantly lower than those in the control group [18.5% (19/103) and 11.7% (12/103)], and the differences were statistically significant ( P< 0.05). Urinary incontinence in two groups recovered completely 6-month after surgery. The operation time of the study group was (68.74±23.71) min, which was lower than that of the control group [(88.04±25.43) min], and the difference was statistically significant ( P<0.05). There were no significant differences in hemoglobin decrease, dissected prostate weight, postoperative indwelling catheter time, postoperative hospital stay in the two groups ( P> 0.05). The IPSS, QoL, Qmax and PVR of the two groups were significantly improved at 3-month and 6-month after surgery ( P< 0.05), but there was no significant difference between the two groups ( P> 0.05). Conclusion:En-bloc HoLEP with an early apical mucosa dissection technique is safe and reliable in treating BPH, and has advantages over classic HoLEP in terms of short-term urinary continence rates, shortening operation time.

Effectiveness analysis of hybrid endoscopic submucosal dissection in patients with colorectal epithelium-derived tumors / 中华内科杂志

Objective:To compare the clinical benefits of classic endoscopic submucosal dissection (ESD) and hybrid ESD for the treatment of colorectal epithelium-derived tumors.Methods:The current investigation was a retrospective multicenter study of 418 patients who underwent ESD between January 2015 and April 2021 at Beijing Jishuitan Hospital. The patients were assigned to one of two groups based on the surgical procedure they underwent; a classic ESD group or a hybrid ESD group. The primary outcome was the rate of en bloc resection and complete resection. SPSS 26.0 was used for statistical analysis. Homogeneity of variance was assessed via Cochran′s test. Normally distributed data with homogeneity of variance were analyzed via the t-test for independent samples. Non-normally distributed data and data with unequal variance were analyzed via the Kruskal-Wallis non-parametric test. Categorical data were analyzed via the Chi-square test or Fisher′s exact test. Multivariable assessment was performed via logistic regression analysis. Results:The en bloc resection rates [89.4% (84/94) vs. 87.0% (194/223), χ2=0.34, P=0.558] and complete resection rates [85.1% (80/94) vs. 82.1% (183/223), χ2=0.33, P=0.510] were similar. Compared with classic ESD, procedures were shorter in the hybrid ESD group [22(7, 213) vs. 47(12, 680) min, Z=0.23, P<0.001], dissection was completed more rapidly [0.14(0.02, 0.32) vs. 0.10(0.02, 0.41) cm 2/min, Z=0.08, P<0.001], and there was a higher rate of perforation (9.6% vs. 2.2%, χ2=2.67, P=0.006). Laterally spreading tumor granular type nodular mixed, non-granular type pseudo-depressed, flat-elevated type (odds ratio 2.826, P=0.012), and tumor location (odds ratio 6.970, P=0.005) were independently associated with complete resection in the hybrid ESD group. Conclusion:Classic ESD and hybrid ESD had similar en bloc and complete resection rates for colorectal epithelium-derived tumors, but hybrid ESD had shorter operation times. With respect to hybrid ESD, factors associated with failure of complete resection included lesion type and crossing tissue boundaries.

Experimental study of en-bloc resection of bladder tumors by transurethral single-port laparoscopy in vivo animal models / 现代泌尿外科杂志

【Objective】 To explore the feasibility of en-bloc resection of bladder tumors by flexible cystoscope combined with laparoscopic instruments through urethra and to provide reference for the clinical application of this technique. 【Methods】 Self-designed and processed transurethral single-hole PORT and Olympus electronic cystoscope were used as observation mirror; Φ1.8 mm soft grasper, tissue scissors, electric hook, and ultrasonic scalpel were used as instruments; the porcine bladder was used as a model.The PORT was placed through the urethra, and the cystoscope was inserted to observe the inner wall of the bladder and the condition of the mucosa.After the lesion site was identified in the bladder cavity, the soft grasper was inserted to pull the mucosa to be removed, which was then fixed with tension at the target position to maintain a satisfactory feild of view.The surgeon held the cystoscope in the left hand, and operated the laparoscopic instruments into the bladder cavity through the PORT with the right hand.Observing with the cystoscope and lifting and pulling the mucosa with the grasper, the surgeon simulated the cutting and pushing actions to realize the en-bloc resection of the lesioned mucosa. 【Results】 The mucosa at 4 different locations were successfully resected on 2 in vitro porcine bladder models. 【Conclusion】 The in vitro experiments show that the combination of flexible electronic cystoscope and laparoscopic instruments achieves synergistic effects in en-bloc resection of bladder tumor by transurethral single-hole laparoscope without additional iatrogenic bladder injury caused by percutaneous bladder incision.This method is feasible in the treatment of bladder tumors, and has the potential of clinical application after further optimization.

En bloc prostatectomy combined with abdominoperineal resection on locally advanced rectal adenocarcinoma involving the prostate: A case series

Abstract@#The genitourinary tract is known to be infiltrated in 3–10% of cases of advanced rectal adenocarcinoma. It is usually managed with total pelvic exenteration with urinary diversion. Complications are encountered because of this diversion. This case series aims to present four cases of locally advanced rectal adenocarcinoma involving the prostate who underwent en bloc prostatectomy in Jose Reyes Memorial Medical Center.@*Methods@#This case series consists of review of records of hospital charts, documentation of specimens from the database of the department.@*Results@#The study consists of four (4) male patients in their 50s presenting with primary rectal adenocarcinoma with invasion to the prostate, bladder or seminal vesicle. Two out of 4 patients had shorter hospital days (6 days) while 2 patients spent 14 and 28 days. Two out of 4 patients have anastomotic leakage, 1 had nosocomial pneumonia and no one had urinary tract infection, postoperatively. All 4 patients had a histopathologic diagnosis of rectal adenocarcinoma with a tumor size of 3.5 to 7.0 cm. Two patients are positive for lymphovascular space invasion while 1 patient has a positive line of resection margin. Two patients had neoadjuvant chemotherapy and radiotherapy while 1 patient had 1 adjuvant chemotherapy and radiotherapy. One patient was lost to follow-up.@*Conclusion@#En bloc prostatectomy combined with abdominoperineal resection to treat locally advanced rectal adenocarcinoma provides good local control with the risk of having less postoperative complications. Since there is only one stoma, there is less chance of infection and better quality of life. Complete resection of the tumor can be obtain but can also cause urologic morbidity even after chemotherapy and radiotherapy.

Perioperative complications and risk factors of en bloc resection for thoracic and lumbar spinal tu-mors / 中国脊柱脊髓杂志

Objectives:To investigate the incidence and risk factors of perioperative complications after en bloc resection for thoracic and lumbar spinal tumors.Methods:The data of patients with thoracic and lumbar spinal tumors treated in our department with en bloc resection and anterior column reconstruction were retro-spectively analyzed.Between May 2016 and October 2022,90 consecutive patients underwent en bloc resec-tion on the basis of Weinstein-Boriani-Biagini surgical staging system,and anterior reconstruction was per-formed using 3D-printed artificial vertebral bodies.The demographic,oncological,and operative data of the patients were collected prospectively,and the intraoperative and postoperative complications occurring within three months were categorized into major and minor complications according to their impacts on the recovery process(Major complications were considered as any complication that appeared to substantially alter an other-wise full and expected course of recovery,and other complications were regarded as minor).All the patients were divided into the primary group(n=67)and revision group(n=23)based on their previous surgical history.Differences between the two groups in terms of age,gender,pathological type,tumor-involved segments,oper-ative time,intraoperative blood loss,and perioperative complications were compared.The predictive factors for major and minor complications were explored.Results:En bloc resection was achieved in all the patients,in-cluding total en bloc spondylectomy in 77 cases,sagittal resection in 12 cases,and vertebrectomy in one case.The mean operative time was 553.4min(210-1208min),and the mean intraoperative blood loss was 1534.1mL(260-5500mL).A total of 129 complications were observed in 65(72.2%)patients,including 29 ma-jor complications in 21(23.3%)patients.Two patients(2.2%)died as a result of complications.The revision group was more than primary group in tumor-involved segments(P=0.000)and incidence rate of major compli-cations(P=0.038).In univariate regression analysis,the combined approach[odds ratio(OR)=14.778,P=0.001],total blood loss(OR=1.004,P=0.004),staged surgery(OR=5.250,P=0.008),previous surgical history(OR=2.946,P=0.043),number of tumor-involved vertebrae(OR=1.607,P=0.023)and lumbar tumor(OR=3.509,P=0.015)were statistically significant risk factors for major complication occurrence,while the combined approach(OR= 6.375,P=0.036)was the independent risk factor.Conclusions:En bloc resection and anterior column recon-struction is associated with high risks of complications,especially when a combined approach is needed.

Efficacy and safety of blue laser en bloc enucleation in the treatment of non-muscle invasive bladder cancer: report of 50 cases from a single center / 现代泌尿外科杂志

【Objective】 To compare the efficacy and safety of blue laser en bloc enucleation and traditional plasmakinetic electrocautery in the treatment of non-muscle invasive bladder cancer (NMIBC). 【Methods】 A total of 50 NMIBC patients treated in our hospital during Oct.2018 and Dec.2019 were enrolled. A randomized, incomplete blinding, parallel control design and non-inferior test method was adopted. The control group (electrocautery group) used plasmakinetic electrocautery for transurethral resection, and the experimental group (blue laser group) used semiconductor blue laser for transurethral en bloc enucleation. The effective resection rate, operation time, postoperative catheter indwelling time, length of hospital stay, perioperative hemoglobin changes and obturator nerve reflex were compared. 【Results】 There were 24 patients in the blue laser group and 26 in the electrocautery group. The effective dissection rate and hemostasis rate in both groups reached 100%. The blue laser group had slightly longer operation time than the electrocautery group (55 min vs.42 min, P=0.009), but lesser hemoglobin decrease (5.7 g/L vs. 10.4 g/L, P=0.007). There were no significant differences in urinary catheter indwelling time, length of hospital stay and reoperation rate between the two groups. The electrocautery group had 3 cases of obturator nerve reflex, while the blue laser group had none. 【Conclusion】 Compared with the traditional electrocautery, blue laser has good vaporization cutting and coagulation hemostatic effects on bladder tumor tissue, and can completely enucleate tumors in a front-firing model with less bleeding and no obturator nerve reflex, which can be used as a new, efficient, safe and easy-to-learn method for NMIBC surgery. However, its effects on postoperative recurrence rate and progression rate still need further studies.

Feasibility study of transurethral en-bloc resection of bladder tumor under electronic flexible cystoscopy combined with adjuvant therapy for bladder-preservation-therapy in T 2 stage bladder cancer / 中华泌尿外科杂志

Objective:To investigate the feasibility of combination of en-bloc resection of bladder tumor (ERBT) with the NBI(narrow band imaging) flexible cystoscopy, immunotherapy and chemotherapy in bladder-preserving treatments(called as TMT) for patients with stage T 2 bladder carcinoma. Methods:We retrospectively reviewed and analyzed a series of 16 patients with pT 2N 0M 0 pathologically confirmed. All patients are male with a median age of 63yr(56, 73yr). The American Association of Anesthesiologists scored ≤Ⅱ in 12 cases and Ⅲ in 4 cases. There were 9 cases with smoking history, 5 cases with hypertension, 3 cases with diabetes, and 2 cases with heart disease. The results of preoperative tissue biopsy were all urothelial carcinoma. All patients were taken lithotomy position and performed ERBT with NBI imaging technique and thulium-laser energy platform under general anesthesia. The tumor was brown and the surrounding normal mucosa was cyan in color. The procedure was ensured with a minimal tumor margin of 1cm and minimal rection depth to the deep musculi, and with the acquirement for the en-bloc specimen of which the basal site was marked afterwards, the patients all took a full length of chemoimmunotherapy (four cycles of Tislelizumab combined with Gemcitabine and cisplatin regimens) followed by a secondary ERBT. The perioperative data from sequential operations including complications were comprehensively analyzed for evaluating the therapeutic outcome and safety. All patients received a follow-up to detect efficacy and safety of the treatment with the primary end point of pCR, downgrading rate and objective response rate. Results:All operations were successfully completed. There was no obturator reflex, severe bleeding or grade Ⅱ bladder perforation, only 4 patients got a grade Ⅰ bladder perforation. The postoperative 30-day complication occured in 2 cases(1 pt with hematuresis, 1 pt with bladder irritation). The pathologic complete response rate and tumor downstaging rate were 100%. One patient recurred during a median follow-up of 13.0 months (6, 36 months).Conclusions:The En Bloc Resection of Bladder Tumor with the narrow band imaging (NBI) flexible cystoscopy has several remarkable advantages, including a better intra-operative visual, a lower complication rate and tumor residual. The combination of ERBT with immunotherapy and chemotherapy lead to affirmative curative effect and the feasibility for clinical application is relatively high.

Factors Associated With Non-en bloc Resection of Endoscopic Submucosal Dissection for Colorectal Neoplasms / 中国微创外科杂志

Objective To explore factors influencing non-en bloc resection of endoscopic submucosal dissection(ESD)for colorectal neoplasms.Methods A retrospective analysis was conducted on clinical and pathological data of 1251 patients(1312 lesions)who underwent colorectal ESD from January 2011 to December 2022 and were pathologically confirmed as adenoma,serrated lesion,or early colorectal cancer.Clinical and pathological characteristics were compared between the en bloc resection group and the non-en bloc resection group.Univariate and multivariate logistic regression analyses were performed to identify factors influencing en bloc resection in ESD.Results The average size of the1312 lesions was(25.8±16.3)mm.Among the included lesions,there were728 adenomas(55.5%),193 serrated lesions(14.7%),and 391 early colorectal cancers(29.8%).ESD was completed in 1306 lesions and stopped due to perforation or technical difficulties in6 cases.The en bloc resection rate was89.5%(1174/1312),the complete resection rate was 73.8%(968/1312),and the curative resection rate was 70.6%(926/1312).Multivariate logistic regression analysis revealed that diameter of the lesions≥40 mm(OR =6.329,95%CI:4.278-9.384,P<0.001),negative lifting sign(OR =2.384,95%CI:1.424-3.903,P =0.005),scar location lesions(OR =2.997,95%CI:1.310-6.484,P = 0.023),protruded lesions(OR =8.458,95%CI:2.678-40.453,P =0.008),lateral spreading lesions(OR =5.898,95%CI:1.917-27.796,P =0.025),and hybrid ESD(OR =10.162,95%CI:5.705-19.692,P<0.001)were independent factors influencing en bloc resection of ESD for early colorectal cancer and precancerous lesions.Conclusions Diameter of the lesions≥40 mm,negative lifting sign,scar location lesions,protruded lesions,lateral spreading lesions,and hybrid ESD were significantly associated with non-en bloc resection of ESD for colorectal neoplasms.Strict evaluation should be conducted preoperatively to improve the efficacy of ESD.

Application of en-bloc lymph node dissection in laparoscopic radical resection for gallbladder cancer / 中华肝胆外科杂志

Objective:To study the safety and feasibility of en-bloc lymph node dissection in laparoscopic radical resection for gallbladder cancer(GBC).Methods:The clinical data of 87 patients who underwent laparoscopic radical resection for GBC at Zhejiang Provincial People's Hospital from January 2014 to February 2022 were retrospectively analyzed. There were 26 males and 61 females, aged 67.0 (59.0, 72.0) years old. The patients were divided into the en-bloc dissection group ( n=29) and the non-en-bloc dissection group ( n=58) based on whether en-bloc lymph node dissection was carried out. Differences in general data, tumor characteristics, operation, recurrence and survival were compared between the two groups. Postoperative survival status of these patients was followed-up by telephone. Results:The number of lymph nodes dissected in the en-bloc dissection group was 9.0(8.0, 12.0), which was significantly higher than the 8.0(4.8, 11.0) in the non-en-bloc dissection group ( Z=-2.39, P=0.017). There were no significant differences in age, gender, preoperative blood biochemical indexes, tumor carbohydrate antigen 19-9, tumor stage, nerve and vascular invasion, operation time, intraoperative blood loss, postoperative drainage tube retention time, postoperative hospital stay, and incidences of postoperative complications (biliary fistula, abdominal hemorrhage and abdominal infection) between the two groups (all P>0.05). The median survival was longer in the en-bloc group than in the non-en-bloc group (21 vs. 15 months), and the median relapse-free survival time was 18 months in the en-bloc group compared with 10 months in the non-en-bloc group. However, there were no significant differences in postoperative cumulative survival and recurrence-free survival between the two groups (all P>0.05). Conclusion:En-bloc lymphadenectomy was safe and feasible in laparoscopic radical GBC surgery, with more lymph nodes being removed than the non-en-bloc lymphadenectomy group.

Commentary on relevant issues in surgical treatment of spinal metastatic tumors / 中国骨伤

The multidisciplinary treatment model led by surgery has become a comprehensive strategy and overall concept for the treatment of spinal metastatic tumors. But the surgical treatment of spinal metastatic tumors is different from primary malignant tumors of the spine. Surgery is only a part of the multidisciplinary comprehensive treatment. Therefore, the following aspects need to be evaluated comprehensively based on the survival assessment, evaluation of spinal stability damage, nerve dysfunction, and oncological characteristics of the metastatic tumors with a reasonable surgical intervention. The attention should be paid to the minimally invasive treatment of spinal metastases, progress of new radiotherapy technology, neoadjuvant chemotherapy, targeted drug therapy and other medical treatment to make a comprehensive and individualization decision which is benefit to relieve patients ' pain, reconstruct spinal stability and avoid paralysis. While improving patient survival, increasing local tumor control rate and possibly prolonging survival time, avoiding excessive surgery as much as possible.

Clinical effect analysis of en-bloc low-power holmium laser enucleation of prostate in the treatment of benign prostatic hyperplasia / 国际外科学杂志

Objective:To investigate the efficacy and safety of en-bloc low-power (22.5 W) holmium laser for enucleation of prostate (LP-HoLEP) in the treatment of benign prostatic hyperplasia (BPH).Methods:The clinical data of 98 patients with BPH who underwent surgical treatment in the Department of Urology, Beijing Friendship Hospital, Capital Medical University from January 2020 to October 2022 were retrospectively analyzed. They were divided into LP-HoLEP group ( n=53) and TURP group ( n=45) according to different treatment methods. Patients in the LP-HoLEP group were treated with en-bloc holmium laser enucleation of prostate, and patients in the TURP group were treated with transurethral resection of prostate (TURP). Perioperative indexes of the two groups were compared, including operation time, postoperative hemoglobin changes, tissue resection amount, postoperative catheter indentation time, postoperative hospital stay, complications, and international prostate symptom score (IPSS), quality of life (Qol) score, maximum urine flow rate (Qmax), postvoid residual volume (PVR) and other indicators were obtained at 3 and 6 months after surgery. The measurement data were tested by Shapiro-Wilk normality test. The measurement data conforming to normal distribution were expressed as mean ± standard deviation ( ± s), independent sample t-test was used for comparison between groups, measurement data of skewness distribution were expressed as median (interquartile distance)[ M( Q1, Q3)], and Mann-Whitney U test was used for comparison between groups. The Chi-square test was used to compare the count data between groups. Results:In the LP-HoLEP group, the operative time was (65.74±22.82) min, the hemoglobin decreased 5.71(3.97, 9.01) g/L, the tissue resection volume was (60.59±24.40) g, and the catheter indinduration time was (3.03±0.91) d. The length of postoperative hospitalization was (4.14±1.05) d. TURP group was (77.04±27.33) min, 11.02(8.89, 16.51) g/L, (39.49±11.32) g, (4.80±0.91) d, (5.98±1.03) d, respectively. All the indexes of LP-HoLEP group were better than TURP group. The differences were statistically significant ( P<0.05). Compared with preoperative, IPSS, Qol score, Qmax and PVR of two groups were significantly improved at 3 months after surgery, but there were no statistical significance between groups ( P>0.05). Conclusion:En-bloc LP-HoLEP is safe and reliable in the treatment of BPH, and has advantages over TURP in terms of tissue resection volume, shortening hospitalization and indwelling catheter time, and reducing intraoperative bleeding.

Artery stenosis in renal grafts from infantile donors to adult recipients / 中华器官移植杂志

Objective:To explore the clinical characteristics, causes, diagnosis and treatment of transplant renal artery stenosis after pediatric-to-adult kidney transplantation.Methods:Between July 2014 and March 2019, clinical data were retrospectively reviewed for 25 en-bloc and 27 single kidney transplant cases.Results:One en-bloc(4.0%)and two single kidney recipients(7.4%)were diagnosed as renal artery stenosis at Month 13-23 months post-transplantation.It was higher than the rate of stenosis in adult-to-adult transplant cases(1.1%)during the same period.As compared with recipients without stenosis, stenotic ones had younger pediatric donors( P<0.05)and yet similar body weight of donors as well as recipients( P>0.05). The inner diameters of stenonotic sites were(1.40-1.63)mm and predominant stenotic site was proximal renal artery rather than anastomotic site.The remaining parts of major renal arteries varied from 2.31 to 4.93 mm in diameter.It was normal in children with a corresponding age.All three cases responded well to percutaneous transluminal angioplasty and stenting. Conclusions:The cause of stenosis may be an undeveloped local artery diameter due to extensive tissue dissection around artery.Therefore cautious selections of infantile single renal graft for adult recipients and preserving surrounding tissue of renal artery assist in the prevention of graft arterial stenosis.

Functional outcome in patient with giant cell tumour distal radius after reconstruction by en-bloc resection and non-vascularized fibular bone graft: a case report

Giant cell tumor (GCT) is a relatively common benign primary bone tumor, commonly seen in end of long bones. Treatment goals for GCT of the distal radius are complete excision of the tumor and preservation of wrist function. Usually it can be treated by en-bloc resection and reconstruction using autogenous non vascularized ipsilateral proximal fibular graft. Authors present a case of twenty two years old female complaining of pain and lump in left wrist since two years ago. The pain worsened since 1 month before consultation, but did not radiate elsewhere. Pain was aggravated by movement and decreased with rest. Physical examination revealed a 3 cm mass with tenderness over left wrist. With clinical suspicion of benign bone tumor on left wrist, further evaluation was needed. Plain radiograph revealed an expansile, lytic lesion and soap bubble appearance on her left distal radius like a GCT. Open biopsy result revealed similar morphology with GCT. Reconstruction by en-bloc surgical excision, followed with non-vascularized fibular bone graft fixed with dynamic compression plate (DCP) and wrist ligament reconstruction and fixation of the head of the fibula with carpal bones and distal end of the ulna using K-wires along with palmaris longus tendon were performed. En-bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft, internal fixation with DCP with trans fixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.

Trasplante renal en bloque: a propósito de un caso / En bloc kidney transplantation: case report

En México la enfermedad renal crónica en la población pediátrica es un grave problema de salud pública. Las alternativas terapéuticas en niños con enfermedad renal crónica (ERC) son la diálisis y el trasplante renal (TxR), siendo esta última, la mejor opción terapéutica actual en niños con estadios terminal de la función renal. El objetivo de este manuscrito, fue reportar nuestra experiencia en el tratamiento perioperatorio de pacientes pediátricos sometidos a trasplante renal en bloque. Paciente de sexo femenino, 12 años de edad, originaria de Veracruz, México. Portadora de ERC estadio IV de KDOQI, secundaria a glomerulopatía. Fue programada para TxR en bloque de donante cadavérico pediátrico; el que se realizó bajo anestesia general balanceada, con ventilación mecánica controlada, isquemia fría de 17 hs, isquemia caliente de 30 min y un tiempo quirúrgico de 5 hs y 10 min. El tiempo anestésico total, fue de 6 hs. La paciente fue trasladada a la Unidad de Terapia Intensiva Pediátrica, con adecuada aceptación del injerto renal. Durante los siguientes siete meses, el curso clínico ha sido satisfactorio, con estudios ecotomográficos renales normales. En esta paciente la glomerulonefritis, le ocasionó que debutara a muy corta edad con una enfermedad renal crónica con terapia sustitutiva de hemodiálisis. El trasplante renal en bloque realizado, fue exitoso debido al manejo multidisciplinario que participa en el programa de trasplante renal

In Mexico, chronic kidney disease is a major public health problem in pediatric patients. The therapeutic options for chronic kidney disease (CKD) in children are dialysis and kidney transplant (KT); the latter constitutes the current treatment of choice for children suffering from end-stage renal disease. The aim of this study was to describe our experience of perioperative treatment of pediatric patients undergoing en bloc kidney transplant. Female patient, 12 years old, from Veracruz, Mexico, suffering from stage 4 CKD according to KDOQI criteria, secondary to glomerulonephritis. An en bloc kidney transplantarion from a pediatric deceased donor was performed; balanced general anesthesia with mechanical ventilation was used. Cold ischemia time was 17 hours and warm ischemia time was 30 minutes. The surgery lasted 5 hours and 10 minutes and the total anesthesia time was 6 hours. The patient was taken to the pediatric intensive care unit and showed an adequate renal graft acceptance. During the following seven months the clinical course was satisfactory and kidney echotomography showed normal results. Glomerulonephritis made this patient undergo hemodialysis replacement therapy due to CKD at a very early age. The en bloc kidney transplantation performed was successful thanks to the multidisciplinary management involved in the Kidney Transplant Program

Practical membrane anatomy of en bloc mesogastrium excision in lymph node dissection of gastric cancer / 中华胃肠外科杂志

Gastric cancer is a common malignant tumor of digestive system. D2 procedure is recognized as the standard operation for advanced gastric cancer at present. However, controversies still exist in the standardization and quality control of surgical procedures. Total mesorectal excision (TME) and complete mesocolic excision (CME) based on the membrane anatomy perfectly solve these problems in the treatment for colorectal cancer. However, the complexity of mesogastrium determines that TME and CME cannot be easily transplanted to the treatment of gastric cancer. The practical membrane anatomy in gastric cancer surgery is just emerging and its impact on the treatment of gastric cancer is immeasurable. By reviewing the evolution and embryonic development of digestive system, and combining with actual operation, this paper analyzes and redefines several key issues such as traditional Toldt space, Gerota fascia and complete mesenteric excision. On this basis, we propose a novel and feasible surgical procedure named regional en bloc mesogastrium excision (rEME) for distal gastric cancer. The concept of en bloc mesogastrium excision (EME) based on membrane anatomy may have some influences on the lymph node grouping from the 'Japanese Classification of Gastric Carcinoma’. Performance of EME may reduce the controversies about the group of lymph nodes and their borders. EME in the infra-pyloric region weakens the significance of subdivision of No.6 lymph nodes into No.6a, No.6v and No.6i. More studies are needed in the construction of a mature theoretical system for practical membrane anatomy in gastric surgery.

Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

STUDY DESIGN: A retrospective multi-center study.OBJECTIVES: To analyze oncological outcomes according to the resection type and surgical margin following surgical treatment for primary spinal sarcoma.SUMMARY OF LITERATURE REVIEW: Previous studies using registry databases have shown that surgery and negative margins were associated with improved survival for primary spinal sarcoma. However, few studies have comprehensively analyzed the clinical significance of the resection type and surgical margin for the oncological outcomes of this rare malignancy.MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who underwent surgical resection for primary spinal sarcoma between 1997 and 2016 at two tertiary medical centers. Overall survival and the occurrence of local recurrence and distant metastasis were compared between the groups using Kaplan-Meier curve analysis and the log-rank test.RESULTS: Thirty-three patients (21 males,12 females) with a mean age of 45.1 years and a median follow-up of 36 months were included. There were 13 (39.4%) chondrosarcomas, 12 (36.4%) osteosarcomas, and eight different histological diagnoses. The cohort was categorized into four groups: 1) total en bloc resection with a negative margin (n=12; 36.4%), 2) total en bloc resection with a positive margin: (n=5; 15.2%), 3) total piecemeal resection (n=12; 36.4%), and 4) subtotal resection (n=4; 12.1%). Total en bloc resection with a negative margin was associated with improved overall survival (p=0.030) and less distant metastasis (p=0.025) and local recurrence (p=0.004).CONCLUSIONS: Achieving a negative margin through total en bloc resection, although technically demanding, improves oncological outcomes in primary spinal sarcoma.

Research progress of distal pancreatectomy with en bloc celiac axis resection / 中华消化外科杂志

Carcinoma of pancreatic body and tail is a high invasive disease with a low resectability rate.It was once believed that celiac axis infiltration usually contraindicated resection.Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is described as a new treatment method of this disease.In recent years,more and more literatures have reported this operation,but they were case reports or small sample retrospective study,the results of which differed according to the different treatments and perioperative managements in different centers.The advantages and disadvantages of DP-CAR are still controversial.Research progress of DP-CAR is reviewed in this article.

Endoscopic submucosal dissection of colonic lesions: first 50 cases at a local institution

INTRODUCTION@#Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution.@*METHODS@#This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity.@*RESULTS@#51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported.@*CONCLUSION@#Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

Clinical significance of standardized pathological examination of specimens for en bloc transurethral resection technique with Hybrid Knife to treat NMIBC / 中华泌尿外科杂志

Objective To evaluate the pathological stage,the presence of detrusor muscle and the clinical significance for standardized examination of specimens for en bloc transurethral resection technique with Hybrid Knife to treat NMIBC (ERBT) compared with conventional TURBT.Methods This was prospective randomized controlled study.This study was approved by the Ethics Committee of Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology (TJ-IRB20180604),and patients all signed informed consent.The clinical study registration number of this study:NCT03221062.The margin of the tumor was recognized and marked by with Hybrid Knife (0.5 cm away from the normal mucosa).Then water was injected into the submucosa and form a water pad,with a circular cutting layer by layer (0.5 cm away from the marked position),reaching the detrusor muscle in depth.After complete resection,the tumor was removed by specimen bag.Specimens for ERBT cohort were given standard handling.Resected specimen of ERBT stretched with pins on foam and its margin was stained.The basement of specimen was also stained.Total specimen sectioned into appropriate pieces for histological assessment in the department of pathology.TURBT cohort performed traditional surgical methods and pathological examination.All patients received postoperative intravesical instillation according to their pathology.Imaging and cystoscopy were performed every 3 months.The primary study end-point was the quality of resection,including the pathological stage and the presence of DM.Secondary outcomes were:short-term tumour recurrence rate (18 month),feasibility,and safety.Results From January 2017 to October 2017,109 patients were enrolled.51 patients underwent ERBT,and 58 patients underwent TURBT.The clinical characteristics of the patients in each cohort,such as average age,gender,average BMI,smoking history,the mean number of lesions and tumour size had no significant differences (P ＞ 0.05).The operation of 109 cases was completed successfully.There was no statistical difference between the operative time and the postoperative bladder irrigation time.Major intraoperative or postoperative complications (Clavien ≥ Ⅱ) did not occur in all of the patients.The percentage of T1 staging was higher in the ERBT cohort vs.TURBT cohort [21/51 (41.2％) vs.13/58 (22.4％),P =0.035],of which ERBT cohort accurately detected 9 cases (42.8％) of T1b patients,significantly higher than TURBT cohort (2 cases,15.4％) (P =0.096).All the ERBT samples showed the presence of DM (100.0％),while there was only 77.4％ in TURBT cohort (P ＜ 0.05).Mean follow-up (20.3 ± 3.1) months (ranged from 18 to 24 months).Recurrence rate were 8.9％ (4/45) in ERBT cohort vs.22.2％ (12/54) in TURBT cohort (P=0.059).Conclusions ERBT with Hybrid Knife for treatment NMIBC is a safe,effective,and provides high-quality specimens compared to TURBT.More high-risk NMIBC patients,especially T1 b patients,can be detected obviously by pathologist with the standardized treatment of specimens.

Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report

@#Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.