Prevention, diagnosis and treatment of perioperative complications of bariatric and metabolic surgery / 中华胃肠外科杂志

Surgical operation in treating obesity and type 2 diabetes is popularizing rapidly in China. Correct prevention and recognition of perioperation-related operative complications is the premise of ensuring surgical safety. Familiar complications of the operation include deep venous thrombosis, pulmonary artery embolism, anastomotic bleeding, anastomotic fistula and marginal ulcer. The prevention of deep venous thrombosis is better than treatment. The concrete measures contain physical prophylaxis (graduated compression stocking and intermittent pneumatic compression leg sleeves) and drug prophylaxis (unfractionated heparin and low molecular heparin), and the treatment is mainly thrombolysis or operative thrombectomy. The treatment of pulmonary artery embolism includes remittance of pulmonary arterial hypertension, anticoagulation, thrombolysis, operative thrombectomy, interventional therapy and extracorporeal membrane oxygenation (ECMO). Hemorrhage is a rarely occurred but relatively serious complication after bariatric surgery. The primary cause of anastomotic bleeding after laparoscopic gastric bypass is incomplete hemostasis or weak laparoscopic repair. The common bleeding site in laparoscopic sleeve gastrectomy is gastric stump and close to partes pylorica, and the bleeding may be induced by malformation and weak repair technique. Patients with hemodynamic instability caused by active bleeding or excessive bleeding should timely received surgical treatment. Anastomotic fistula in gastric bypass can be divided into gastrointestinal anastomotic fistula and jejunum-jejunum anastomotic fistula. The treatment of postoperative anastomotic fistula should vary with each individual, and conservative treatment or operative treatment should be adopted. Anastomotic stenosis is mainly related to the operative techniques. Stenosis after sleeve gastrectomy often occurs in gastric angle, and the treatment methods include balloon dilatation and stent implantation, and surgical treatment should be performed when necessary. Marginal ulcer after gastric bypass is a kind of peptic ulcer occurring close to small intestine mucosa in the junction point of stomach and jejunum. Ulcer will also occur in the vestige stomach after laparoscopic sleeve gastrectomy, and the occurrence site locates mostly in the gastric antrum incisal margin. Preoperative anti-HP (helicobacter pylorus) therapy and postoperative continuous administration of proton pump inhibitor (PPI) for six months is the main means to prevent and treat marginal ulcer. For patients on whom conservative treatment is invalid, endoscopic repair or surgical repair should be considered. Different surgical procedures will generate different related operative complications. Fully understanding and effectively dealing with the complications of various surgical procedures through multidisciplinary cooperation is a guarantee for successful operation.

Efficacy of laparoscopic or open surgery for gastrointestinal stromal tumors and effects of different risk level on prognosis / 中华消化外科杂志

Objective To compare the efficacy of laparoscopic or open surgery for gastrointestinal stromal tumors (GISTs) and investigate effects of different risk level on prognosis.Methods The retrospective cohort study was adopted.The clinical data of 192 patients with GISTs who were admitted to Zhongshan Hospital of Fudan University from January 2008 to December 2013 were collected.Among the 192 patients,88 undergoing laparoscopic surgeries were allocated into the laparoscopic surgery group,104 patients undergoing open surgeries were allocated into the open surgery group.The following indicators were observed:(1) operative status:surgical procedure,operation time,volume of intraoperative blood loss.(2) Status of postoperative recovery:time of gastrointestinal function recovery,time of drainage tube removal,complications and duration of hospital stay.(3) Follow-up status.(4) Prognosis of patients in different risk level.The follow-up using outpatient examination and telephone interview was performed to assess patients' survival,tumor recurrence and metastasis until June 2015.Measurement data with normal distribution were presented as (x) ± s and comparison between groups was evaluated by the t test.Comparison of count data was analyzed by the chi-square test.The Kaplan-Meier method was used to draw survival curve and calculate the overall survival rate and relapse-free survival rate.Results (1) Operative status:of the 88 patients in the laparoscopic surgery group,1 underwent laparoscopic wedge gastrectomy + cholecystectomy + appendectomy,6 underwent laparoscopic wedge gastrectomy + cholecystectomy,14 underwent laparoscopic assisted partial gastrectomy,67 underwent laparoscopic wedge gastrectomy.Of the 104 patients in the open surgery group,1 underwent partial gastrectomy + splenectomy,2 underwent partial gastrectomy combined with distal pancreatectomy + splenectomy,2 underwent total gastrectomy,7 underwent distal subtotal gastrectomy,7 underwent wedge gastrectomy + partial or total adjacent organ resection,8 underwent proximal subtotal gastrectomy,8 underwent wedge gastrectomy + cholecystectomy,69 underwent wedge gastrectomy.The operation time and volume of intraoperative blood loss were (105 ± 33)minutes and (43 ± 16)mL in the laparoscopic surgery group,(121 ± 52)minutes and (199 ± 81) mL in the open group,respectively,with statistically significant differences between the 2 groups (t =-2.104,2.632,P ＜ 0.05).(2) Status of postoperative recovery:the time of gastrointestinal function recovery,time of drainage tube removal and duration of hospital stay were (4.6 ± 1.8) days,(5.8 ± 2.2) days,(7.1 ± 2.9) days in the laparoscopic surgery group and (5.2 ± 1.6) days,(7.1 ± 2.8) days,(8.7 ± 4.3) days in the open surgery group,respectively,with statistically significant differences between the 2 groups (t =-2.783,-3.891,-3.078,P ＜ 0.05).Wound infection,gastric emptying delay,anastomotic leakage,lung infection and bleeding were detected in 1,3,0,0,0 patients in the laparoscopic surgery group and in 0,2,2,2,1 patients in the open surgery group,respectively,with no statistically significant difference between the 2 groups (x2=0.421,P ＞ 0.05).(3) Follow-up status:Of the 192 patients,149 received follow-ups.Of 88 patients in the laparoscopic surgery group,68 were followed up for an average time of 39 months.Of 104 patients in the open surgery group,81 were followed up for an average time of 51 months.During the follow-up,tumor recurrence rate in the laparoscopic surgery group and open surgery group was respectively 8.8％ (6/68) and 21.0％ (17/81),with no statistically significant difference between the 2 groups (x2=1.888,P ＞0.05).Postoperative 1-,3-,5 year survival rates were 98.5％,92.9％,87.4％ and 91.7％,85.2％,76.9％ in the laparoscopic surgery group and open surgery group,respectively,with no statistically significant difference between the 2 groups (x2 =1.967,P ＞ 0.05).(4) Prognosis of patients in different risk level:of the 149 who received the follow-up,the tumor recurrence rate of patients in low,intermediate and high recurrence risk was 7.0％ (5/71),13.6％ (6/44) and 35.3％ (12/34),respectively,with a statistically significant difference among the above indexes (x2 =14.637,P ＜ 0.05),showing statistically significant differences between low risk and high risk patients and between intermediate risk and high risk patients (x2=13.263,6.279,P ＜ 0.05),while no statistically significant difference between low risk and intermediate risk patients (x2 =0.894,P ＞ 0.05).Five-year relapse-free survival rate of low,intermediate and high risk patients was 94.2％,80.0％ and 61.8％ respectively,with a statistically significant difference (x2=13.547,P ＜ 0.05),showing statistically significant differences between low risk and high risk patients,intermediate risk and high risk patients (x2 =4.357,12.336,P ＜ 0.05),while no statistically significant difference between low risk and intermediate risk patients (x2 =0.696,P ＞ 0.05).Conclusions Compared to open resection,laparoscopic GISTs resection offers better short-term outcomes,however,the two surgical techniques offer equal long-term outcomes.Patients of high risk have poor prognosis.

Outcome of patients with colorectal liver metastasis: analysis of 1,613 consecutive cases.

OBJECTIVE: This study was designed to evaluate the long-time outcome of patients with colorectal liver metastasis (CRLM) undergoing different types of therapy and identify prognosis factors. METHODS: From 2000 to 2010, 1,613 consecutive patients with CRLM were identified. Clinicopathological and outcome data were collected and analyzed by univariate and multivariate analyses. RESULTS: Synchronous liver metastasis (SLM), female, grade III-IV, T4 and N positive of primary tumor, bilobar disease, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, serum CEA level ≥ 5 ng/ml, and CA19-9 level ≥ 37 u/ml were the predictors of adverse outcome using univariate analysis. The median survival and 5-year survival rate for patients after resection of liver metastases was 49.8 months and 47%, better than that for those after other therapy. In addition, patients without treatment had the poorest survival. Sixty-four initially unresectable patients underwent surgery after conversion therapy with a median survival of 36.9 months and a 5-year survival of 30%. By multivariate analysis, SLM, poorly differentiated primary tumor, number of liver metastases ≥ 4, size of largest liver metastases ≥ 5 cm, and no surgical treatment of liver metastases were found to be independent predictors of poor survival. CONCLUSIONS: Patients with CRLM could get long-term survival benefit from different types of therapy, and resection of liver metastases was the optimal strategy. A predictive model using these above five factors may be of use in stratifying patients who may benefit from intensive surveillance and adjuvant therapy.

Laparoscopic splenectomy: a single-center clinical study on 55 patients / 中华肝胆外科杂志

Objective To study the safety and efficacy of laparoscopic splenectomy for splenic diseases.Method We retrospectively studied the outcomes of 55 patients who underwent laparoscopic splenectomy from May 2007 to December 2009.Splenic diseases included idiopathic thrombocytopenia purpura (n=11),autoimmune hemolytic anemia (n=6),hereditary spherocytosis (n=1),splenic lymphoma (n =1),splenic cyst (n=10),splenic angioma (n=5),vascular tumor of spleen (n=2),cirrhosis,portal hypertension and hypersplenism (n=9),cirrhosis and hyperplenism (n=9),and idiopathic splenomegaly (n=1).Results All patients underwent laparoscopic splenectomy,and there was no conversion to open surgery.The operation time (mean±S.D.) was (119.7±33.0) min.The intraoperative blood loss (mean± S.D.) was (83.8± 65.2) ml,and the postoperative hospital stay (mean±S.D.) was (5.7±1.1) days.One patient developed postoperative ascites,and 7 patients had drain fluid rich in amylase.There was no perioperatively death.Conclusion Laparoscopic splenectomy was safe and efficacious for splenic diseases.

Indications and contra-indications of antibiotic lock technique in central venous catheter / 肠外与肠内营养

Objectives:To study indications and contra indications of antibiotic lock technique in central venous catheter. Methods:Fifty patients with sepsis during use of central venous catheter were studied prospectively.The drug of ceftazidine(0.5 g) was instilled into the central line as a transient “lock”, together with mixed solution(5 ml) of normal saline and heparin sodium. Results:Twenty nine cases were proved to be catheter related sepsis.5 cases were treated by removal of infected catheter.Twenty four cases were treated by antibiotic lock technique.Out of 24,only 13 cases wee successful. Conclusions:Indications of antibiotic lock technique are as follows:① transient use when looking for source of infection, ② in patients with late stage tumor, ③inpatients with steady state of illness and ④patients receiving home parenteral nutrition.The contra indications include:①inpatients in unsteady state of illness,②for short term transfusion or parenteral nutrition, ③patients with compromised immune responsiveness,and ④with deteriorated state of an illness or the infections not controlled.

~(15)N-glycine absorption in the colon of the short bowel rats / 中国普通外科杂志

Objective To investigate 15 N glycine absorption in the colon of the short bowel rats. Methods Rats undergoing resection of 80% small intestine and were treated by enteral nutrition for 21 days. The concentration of 15 N glycine in perfusate samples was measured by the technique of HPLC. The atom percent enrichment of 15 N glycine in blood plasma was measured by the technique of isotopic dilution method Results fter 3 hours, the colonic water absorption was 1?0 5 ml, 15 N glycine absorption was zero, and the atom percent enrichment was near zero in normal group, vs. (2 6?0 82) ml ( P

Sixteen years′ home parenteral nutrition for a patient with total small bowel resection / 中国普通外科杂志

ObjectiveTo study the metabolic changes and complications of a patient on long term home parenteral nutrition (HPN). MethodsClinical data were summarized on a female patient with total small bowel plus right colon resection receiving home parenteral nutrition support for 16 years. ResultsThe patient became pregnant on the 5th year of HPN, and gave birth to a healthy baby. Her liver function remains almost normal during the 16 years. Each central vein catheter averagely lasted for 240 days, with the longest one more than 26 months. Catheter related sepsis rate was very low. Several complications occurred during the 16 years, including anaemia, zinc deficiency and increased serum iron level. Lipid peroxidation increased significantly. ConclusionsLong-term HPN support patient could suffer many metabolic abnormalities complications. Catheter related sepsis and occlusion should be prevented. The HPN formula should be adjusted according to the patient′s condition.