Machine learning techniques based on 18F-FDG PET radiomics features of temporal regions for the classification of temporal lobe epilepsy patients from healthy controls.

Background: This study aimed to investigate the clinical application of 18F-FDG PET radiomics features for temporal lobe epilepsy and to create PET radiomics-based machine learning models for differentiating temporal lobe epilepsy (TLE) patients from healthy controls. Methods: A total of 347 subjects who underwent 18F-FDG PET scans from March 2014 to January 2020 (234 TLE patients: 25.50 ± 8.89 years, 141 male patients and 93 female patients; and 113 controls: 27.59 ± 6.94 years, 48 male individuals and 65 female individuals) were allocated to the training (n = 248) and test (n = 99) sets. All 3D PET images were registered to the Montreal Neurological Institute template. PyRadiomics was used to extract radiomics features from the temporal regions segmented according to the Automated Anatomical Labeling (AAL) atlas. The least absolute shrinkage and selection operator (LASSO) and Boruta algorithms were applied to select the radiomics features significantly associated with TLE. Eleven machine-learning algorithms were used to establish models and to select the best model in the training set. Results: The final radiomics features (n = 7) used for model training were selected through the combinations of the LASSO and the Boruta algorithms with cross-validation. All data were randomly divided into a training set (n = 248) and a testing set (n = 99). Among 11 machine-learning algorithms, the logistic regression (AUC 0.984, F1-Score 0.959) model performed the best in the training set. Then, we deployed the corresponding online website version (https://wane199.shinyapps.io/TLE_Classification/), showing the details of the LR model for convenience. The AUCs of the tuned logistic regression model in the training and test sets were 0.981 and 0.957, respectively. Furthermore, the calibration curves demonstrated satisfactory alignment (visually assessed) for identifying the TLE patients. Conclusion: The radiomics model from temporal regions can be a potential method for distinguishing TLE. Machine learning-based diagnosis of TLE from preoperative FDG PET images could serve as a useful preoperative diagnostic tool.

GINS1 promotes ZEB1-mediated epithelial-mesenchymal transition and tumor metastasis via ß-catenin signaling in hepatocellular carcinoma.

GINS1 regulates DNA replication in the initiation and elongation phases and plays an important role in the progression of various malignant tumors. However, the role of GINS1 in hepatocellular carcinoma (HCC) remains largely unclear. In this study, we investigated the role and underlying mechanisms of GINS1 in contributing to HCC metastasis. We found that GINS1 was significantly upregulated in HCC tissues and cell lines, especially in HCC tissues with vascular invasion and HCC cell lines with highly metastatic properties. Additionally, high expression of GINS1 was positively correlated with the progressive clinical features of HCC patients, including tumor number (multiple), tumor size (>5 cm), advanced tumor stage, vascular invasion and early recurrence, suggesting that GINS1 upregulation was greatly involved in HCC metastasis. Moreover, Kaplan-Meier survival analysis revealed that high GINS1 expression predicted a poor prognosis. Both in vitro and in vivo, silencing of GINS1 inhibited proliferation, migration, invasion and metastasis, while overexpression of GINS1 induced opposite effects. Mechanistically, we found that ZEB1 was a crucial regulator of GINS1-induced epithelial-mesenchymal transition (EMT), and GINS1 promoted EMT and tumor metastasis through ß-catenin signaling. Overall, the present study demonstrated that GINS1 promoted ZEB1-mediated EMT and tumor metastasis via ß-catenin signaling in HCC.

A novel prognostic biomarker: GINS3 is correlated with methylation and immune escape in liver hepatocellular carcinoma.

Background: Liver cancer remains one of the tricky malignancies nowadays. GINS complex subunit 3 (GINS3), part of the GINS tetrameric complex, is significantly upregulated in many cancers, including liver hepatocellular carcinoma (LIHC). With the development of liver cancer treatment, immune and molecular targeted therapy gradually becomes a promising treatment. However, the key target for liver cancer is still indistinct. Herein, the underneath mechanism of GINS3 was investigated to verify its role as a biomarker in LIHC. Methods: Genomic expression, genetic alteration, and methylation analyses were obtained from The Cancer Genome Atlas (TCGA), Clinical Proteomic Tumor Analysis Consortium (CPTAC), The University of Alabama at Birmingham CANcer (UALCN), and Human Protein Atlas (HPA), cBioPortal, and MethSurv databases. Subsequently, the diagnostic and prognostic role of GINS3 in LIHC were analyzed based on data from receiver operating characteristic (ROC), Kaplan-Meier plotter (KM-plotter), and univariate and multivariate cox regression analyses. The functional analyses were conducted with GeneMANIA and STRING databases, gene-gene, and protein-protein interaction (PPI) networks, Gene Ontology (GO) term, and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Tumor Immune Estimation Resource (TIMER), Tumor-Immune System Interaction Database (TISIDB), and Gene Expression Profiling Interactive Analysis (GEPIA) were utilized to explore the internal connection with the immune escape. Results: Through the analyses of genomic expression, GINS3 was significantly upregulated in LIHC and positively correlated with higher T classification. ROC analysis indicated GINS3 as a potential biomarker in the diagnosis of LIHC. KM-plotter, univariate and multivariate cox regression analyses both associated GINS3 with poor prognosis in LIHC patients. GINS3 genetic alteration, gene-gene interaction, PPI networks, and enrichment analysis further revealed that GINS3 played a pivotal role in the progression of LIHC. Furthermore, hypermethylation of GINS3 at different cytosine-guanine (CpG) sites was correlated with better or worse overall survival (OS) in LIHC and GINS3 was also closely correlated with m6A modification. Moreover, results supported that GINS3 could influence the tumor microenvironment and relate to the immune checkpoints. Conclusions: Taken together, comprehensive analyses from this study supported GINS3 as a novel targeted biomarker in LIHC.

Noninvasive Strategies for the Treatment of Tiny Liver Cancer: Integrating Photothermal Therapy and Multimodality Imaging EpCAM-Guided Nanoparticles.

Surgical resection and ablation therapy have been shown to achieve the purpose of a radical cure for liver cancer with a size of less than 3 cm; however, tiny liver cancer lesions of diameters smaller than 2 cm remain challenging to diagnose and cure due to the failure of the generation of new blood vessels within tumors. Emerging evidence has revealed that optical molecular imaging combined with nanoprobes can detect tiny cancer from the perspective of molecular and cellular levels and kill cancer cells by the photothermal effect of nanoparticles in real time, thereby achieving radical goals. In the present study, we designed and synthesized multicomponent and multifunctional ICG-CuS-Gd@BSA-EpCAM nanoparticles (NPs) with a potent antineoplastic effect on tiny liver cancer. Using subcutaneous and orthotopic liver cancer xenograft mouse models, we found that the components of the NPs, including ICG and CuS-Gd@BSA, showed synergistic photothermal effects on the eradication of tiny liver cancer. We also found that the ICG-CuS-Gd@BSA-EpCAM NPs exhibited triple-modal functions of fluorescence imaging, magnetic resonance imaging, and photoacoustic imaging, with targeted detection and photothermal treatment of tiny liver cancer under near-infrared light irradiation. Together, our study demonstrates that the ICG-CuS-Gd@BSA-EpCAM NPs in combination with optical imaging technique might be a potential approach for detecting and noninvasively and radically curing tiny liver cancer by the photothermal effect.

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery.

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma.

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic capsule to infiltrate surrounding tissues. In conventional distal pancreatosplenectomy (DPS), tumor cells are prone to spread along the direction of blood and lymphatic reflux due to surgical compression. Additionally, inflammation makes it challenging to achieve R0 resection, leading to a lower patient survival rate. To address these limitations, radical antegrade modular pancreatosplenectomy (RAMPS) was developed, emphasizing deeper excision, including the left anterior renal fascia, the left anterior renal adipose sac, and even the left adrenal gland, to improve the R0 resection rate. With the advancement of minimally invasive surgical techniques, laparoscopic RAMPS (L-RAMPS) is being considered technically safe and feasible in oncology. However, due to technical difficulties and a lack of supporting evidence for clinical application, only a few institutions are currently conducting L-RAMPS. In this context, this article presents detailed techniques for laparoscopic posterior radical antegrade modular pancreatosplenectomy (L-pRAMPS), offering promise for future clinical applications.

Clinical Applied Anatomy in Trans-Areolar Endoscopic Thyroidectomy: Crucial Anatomical Landmarks.

Introduction: Endoscopic thyroidectomy (ET) has been successfully established as an excellent surgical approach. This study summarizes and describes the crucial anatomical landmarks for clinical applied anatomy in trans-areolar ET, which may help further improve the quality and safety of trans-areolar ET. Materials and Methods: Five hundred forty patients who underwent trans-areolar ET from January 2015 to June 2018 at our institution were evaluated. Several crucial anatomical landmarks were described during the surgical procedures. The surgical outcomes, including the operative time, conversion, intraoperative blood loss, postoperative complications, and postoperative stay, were collected. Results: All patients successfully underwent trans-areolar ET without conversion. The mean operative time was 142.18 ± 49.91 minutes (150.84 ± 50.32 minutes for total thyroidectomy and 110.20 ± 32.4 for lobectomy with isthmusectomy). The mean intraoperative blood loss was 20.45 ± 10.89 mL. The postoperative stay was 5.42 ± 1.49 days. The postoperative complication rate was 7.78%, including transient hypocalcemia in 30 patients, transient recurrent laryngeal nerve palsy in 3 patients, and skin ecchymosis in 9 patients. Conclusions: An understanding of crucial anatomical landmarks for clinical applied anatomy may improve the quality and safety of trans-areolar ET and subsequently help promote the development of ET.

Learning curve for endoscope holder in endoscopic thyroidectomy via complete areola approach: a prospective study.

BACKGROUND: Endoscopic thyroidectomy via complete areola approach (ETCAA) is becoming the preferred choice of some patients due to the perfect cosmetic result. Endoscope holder plays an important role in the procedures. Research on the learning curve is helpful in training of endoscope holder and improvement of the whole procedure. METHODS: This prospective study investigated 100 consecutive patients who underwent ETCAA performed by a single experienced surgeon and a single inexperienced endoscope holder. Patients were equally divided into ten groups chronologically. One-way analysis of variance, Student-Newman-Keuls test, and Pearson Chi square test were used to analyze statistical significance for clinical data. The correlativity between the operative time and the case number, the endoscope holding score and the case number, the operative time and the interval of neighboring procedures, the endoscope holding score and the interval of neighboring procedures were analyzed with linear regression analysis. RESULTS: The mean operative time was 96.30 ± 13.10 min, and the mean endoscope holding score was 74.65 ± 14.08. There were significant differences among the mean operative time (P < 0.0001) and the mean endoscope holding score (P < 0.0001). Multiple comparison revealed that the mean operative time of group 7, 8, 9, 10 were shorter than group 4, 5, 6, meanwhile the mean operative time of group 4, 5, 6 were shorter than group 1, 2, 3. Moreover, the mean endoscope holding score of group 7, 8, 9, 10 were higher than group 4, 5, 6, and the mean endoscope holding score of group 4, 5, 6 were higher than group 1, 2, 3. Linear regression analysis showed negative correlation between the operative time and the case number (r = -0.746, P < 0.0001), positive correlation between the endoscope holding score and the case number (r = 0.765, P < 0.0001), positive correlation between the operative time and the interval of neighboring procedures (r = 0.777, P = 0.008), and negative correlation between the endoscope holding score and the interval of neighboring procedures (r = -0.809, P = 0.005). CONCLUSION: A specific learning curve for endoscope holder in ETCAA does exist. The initial 30 cases composed the infancy of the learning curve, and the endoscope holder could expect a learning curve of approximately 60 cases in order to achieve proficiency. Increasing the operating frequency would help shorten the learning curve.

Endoscopic thyroidectomy via areola approach: summary of 1,250 cases in a single institution.

BACKGROUND: The aim of this study was to evaluate the effect and cosmetic results of endoscopic thyroidectomy (ETE) via the areola approach for patients with thyroid diseases. METHODS: A total of 1,250 patients with thyroid diseases underwent ETE via the areola approach between April 2005 and January 2011. Of these, 898 were benign goiters, 260 were Graves' disease, 28 were secondary hyperthyroidism, and 64 were papillary carcinomas. RESULTS: The surgery was successfully completed in 1,249 cases, and 1 case was converted to open surgery. The mean operation time, estimated blood loss, and hospital stay after surgery for patients with a goiter, hyperthyroidism, and papillary carcinoma were 94.4 min, 15.2 ml, 5.0 days, 97.9 min, 16.1 ml, 5.5 days, and 134.3 min, 18.6 ml, 6.4 days, respectively. Complications included 4 cases of postoperative bleeding, 1 case of transection of the recurrent laryngeal nerve (RLN) on one side, 7 cases of temporary RLN injury, 34 cases of transient hypocalcemia, 5 cases of skin bruising on the chest wall, and 1 case of subcutaneous infection in the neck. At 4.6-year (2.5-8 years) follow-up of 1,185 (94.8 %) patients, 3 patients with Graves' disease had recurrence of hyperthyroidism, and 4 patients with nodular goiter had recurrence of small nodules. Four patients had discomfort on swallowing, 4 patients had an abnormal sensation of skin traction on the neck and the chest, and 1 patient with scar diathesis had mild scar hyperplasia. A total of 876 patients were satisfied, 4 equivocal, and 0 unsatisfied with the cosmetic results. CONCLUSION: ETE via the areola approach for patients with benign goiters, Graves' disease, secondary hyperthyroidism, and papillary carcinomas without metastasis to lateral cervical lymph nodes is an effective and safe procedure with excellent cosmetic results.

Thyroidectomy: a novel endoscopic oral vestibular approach.

BACKGROUND: To date, no report has discussed endoscopic thyroidectomy using the oral vestibular approach (ETOVA). The objective of this study was to evaluate the feasibility, safety, efficacy, and cosmetic results of endoscopic thyroidectomy involving this surgical approach. METHODS: Twenty-four patients with benign thyroid nodules were randomized into the ETOVA (n = 12) and the endoscopic thyroidectomy by areola approach (ETAA) groups (n = 12). Therapeutic effects were assessed at follow-up by physical examination. All patients were followed to evaluate thyroid function and scar formation from endoscopic treatment. RESULTS: Complete resection of all the lesions was performed endoscopically, and no conversion to open surgery was needed. There was no difference between the 2 groups with respect to surgical time (60.4 vs 59.6 min), blood loss (10.8 vs 13.8 mL), postoperative hospital stay (4.9 vs 4.6 d), or cost of surgery (17.6 vs 17.4 thousand yuan). Patients who underwent the areola approach had 3 scars, 10 × 2 mm, 5 × 1 mm, and 5 × 1 mm in size, all of which were visible at the 6-month follow-up. Patients in the ETOVA group did not have any scars. Follow-up showed a significant difference (P = .019) in the satisfaction score between the ETOVA (2.33 ± 0.65) and the ETAA group (1.58 ± 0.79). Imaging showed that all patients had complete resection and no residual disease. Severe complications such as subcutaneous accumulation of blood and fluid, superior or recurrent laryngeal nerve injury, and parathyroid dysfunction were not observed. CONCLUSION: ETOVA was found to be safe and feasible and did not leave any scars; however, large-scale, randomized clinical trials are necessary for confirmation.

[Three-port transumbilical endoscopic cholecystectomy performed using conventional laparoscopic instruments].

OBJECTIVE: To evaluate the clinical efficacy and safety of three-port transumbilical endoscopic cholecystectomy performed using conventional laparoscopic instruments. METHODS: Thirty-two patients undergoing three-port transumbilical endoscopic cholecystectomy using conventional laparoscopic instruments (group A) with 3 ports around the umbilicus were compared with 96 patients (group B) receiving the conventional 4-port routine endoscopic cholecystectomy. RESULTS: All the procedures were successfully completed without conversion to open laparotomy. In group A, the procedures were completed smoothly in 30 cases while 2 cases required another port (5 mm) punctured below the xyphoid due to severe adhesion around the cyst. The median operating time was 39.7∓5.2 min in group A, significantly longer than that in group B (25.3∓3.3 min, P<0.001), but the patients in group A obtained better cosmetic results (P<0.001); the median blood loss, recovery time of postoperative intestine function, length of postoperative hospital stay, and the rate of use of postoperative painkillers were comparable between the two groups. Bile leakage or other postoperative complications occurred in none of cases in the two groups. CONCLUSION: In cases without severe adhesion around the cyst, three-port transumbilical endoscopic cholecystectomy using conventional laparoscopic instruments is a safe and feasible alternative to routine endoscopic cholecystectomy with better cosmetic results.

[Treatment of super obesity by laparoscopic Roux-en-Y gastric bypass: experience of 42 cases].

OBJECTIVE: To investigate the feasibility and efficacy of laparoscopic Roux-en-Y gastric bypass(LRYGB) for super obesity(BMI≥50 kg/m(2)). METHOD: Clinical data of 42 patients undergoing LRYGB in the First Affiliated Hospital of Jinan University between 2004 and 2008 were analyzed retrospectively. RESULTS: All the LRYGB procedures were successfully performed with no conversion to open surgery. Average operation time was 145.1 minutes, volume of blood loss during the surgery was 25.0 ml, and length of postoperative hospital stay was 9.9 days. The cases were followed up for 1 month to 30 months. Body weight and BMI decreased significantly 1 month after the operation and reached a minimum level after 2 years then became stable while excess body weight loss rate(EWL) increased(P<0.05). All the obese-related symptoms were relieved significantly. Four cases(9.5%) showed complications during perioperative period including 1 case of respiratory failure, 2 cases of gastrojejunal anastomotic bleeding, 1 case of umbilical wound infection, and 11 developed long-term complications. All of them were cured by conservative treatment. CONCLUSIONS: Treatment of super obesity by LRYGB is feasible with significant short-term results. But due to the difficulty of the operation and postoperative complications, comprehensive treatment from experienced bariatric surgical team is needed. The long-term outcome needs for further observation.

[Antecolic versus retrocolic gastroenteric anastomosis for laparoscopic Roux-en-Y gastric bypass: a prospective randomized control trial].

OBJECTIVE: To compare short-term postoperative outcomes between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass(LRYGB). METHODS: Forty obesity patients were admitted into The First Affiliated Hospital of Jinan University from March 2008 to July 2010. All patients were randomly assigned to undergo antecolic (group A, 20 cases) and retrocolic (group B, 20 cases) gastroenteric anastomosis. Short-term outcomes were compared. RESULTS: LRYGB procedures were successfully performed in all the 40 patients. There were no significant differences between the two groups in estimated blood loss during surgery, time to flatus passage, time to resumption of oral intake, or length of postoperative hospital stay. The operation time was longer in group B than that in group A [(163.4±28.1) min vs.(131.8±22.7) min, P<0.05]. There were no patients developed internal hernia or anastomotic leakage in either group. Comparison of short-term gastrointestinal symptoms after surgery showed no statistical significance. CONCLUSIONS: Although retrocolic procedure may be closer to anatomical structure, antecolic and retrocolic anastomosis have comparable short-term outcomes after surgery. Further study is warranted to investigate long-term outcomes.

[Treatment of obesity and type 2 diabetes mellitus by laparoscopic Roux-en-Y gastric bypass].

OBJECTIVE: To investigate the efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in the treatment for obesity and type 2 diabetes mellitus (DM). METHODS: Twenty-one cases of obesity and 9 cases of type 2 DM received the LRYGB. Weigh changes, excess body weight lose rate (EWL%) and blood glucose level were measured after surgery and occurrence of complications was observed postoperatively. RESULTS: LRYGB procedures in all the 30 cases were successfully performed with no conversion to open surgery. Average operation time was 168 minutes (110-270 mins), volume of blood loss during the surgery was 24.0 ml (10-75 ml). Twenty-one cases of simple obesity received follow-up from 2 months to 5 years. Body weight and BMI decreased significantly in one month [(85.1+/-10.1) kg vs (97.2+/-15.0) kg, 31.2+/-2.2 vs 35.3+/-3.5, both P<0.01] and to a minimal level in 2 to 3 years [(66.8+/-9.2) kg, 24.3+/-1.1], and then maintained at this level. EWL% was correspondingly higher (all P<0.05). Nine type 2 DM patients were followed up for 3 to 8 months, fasting blood glucose and blood glucose OGTT2 hours decreased significantly [(5.9+/-1.4) mmol/L vs (12.6+/-2.6) mmol/L, (7.8+/-1.4) mmol/L vs (17.8+/-4.1) mmol/L, both P<0.05], of whom 4 patients with obesity decreased in BMI significantly (P<0.05), and 5 patients without obesity had no significant changes in BMI (P>0.05). Five cases (16.7%) had postoperative complications, including 1 case of death due to acute fulminant pancreatitis, 1 case of mesenteric hiatal hernia with obstruction in line for reoperation, and the other 3 cases of healing by conservative therapy. CONCLUSIONS: Treatment of obesity and type 2 DM by LRYGB surgery is feasible with significant short term result. Long term outcome needs further observation.

[Laparoscopic Roux-en-Y gastric bypass surgery for treatment of type 2 diabetes mellitus].

OBJECTIVE: To investigate the surgical approach, feasibility and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery for treating type 2 diabetes mellitus. METHODS: Seven obese patients with type 2 diabetes and 5 type 2 diabetic patients without obesity received LRYGB surgery. The changes of the body mass, fasting blood glucose (FBG), 2-hour postprandial blood glucose (2 h PBG), C peptide (C-P) and HbA1c% were observed postoperatively. RESULTS: LRYGB procedures were successfully performed in all the 12 patients with no conversion to open surgery. The resolution rate was 85.7% in the obese group and 80% in the non-obese diabetic group. CONCLUSION: LRYGB surgery is feasible for treatment of type 2 diabetes with good short-term result, but the long-term outcome awaits further observation.

[Endoscopic thyroidectomy via the areola of breast approach].

OBJECTIVE: To investigate the feasibility and safety of endoscopic thyroidectomy via the areola of breast approach. METHODS: Between April 2005 to September 2008, endoscopic thyroidectomy via the areola of breast approach was performed in 28 female patients. Of the patients, 25 cases presented with nodular goiter, 2 cases with Grave's disease and 1 case with minimum papillary carcinoma. The average age was 22.5 years (range, 18-38 years). A 10 mm trocar was placed on the medial border of the areola of the right breast for the video-endoscopy and removing specimens, and a 5 mm trocar was placed on the lateral border of the areola of the same breast as the assisted operation hole. Another 5 mm trocar was placed on the medial border of the areola of left breast as the main operation hole. The operation data was recorded and analyzed. RESULTS: All the 28 operations were successful. The procedures included one lobe total thyroidectomy in 5 cases, one lobe subtotal thyroidectomy in 15 cases, subtotal thyroidectomy in 3 cases, one lobe near total thyroidectomy + the other lobe subtotal thyroidectomy in 4 cases, and one lobe total thyroidectomy + the central group lymph node resection + the other lobe subtotal thyroidectomy in 1 case. The average operation time was 60.7 minutes (range, 40-125 minutes), the average operation blood loss was 5.8 ml (range, 2-15 ml), the average length of post-operative hospital stay was 3.1 days (range, 2-5 days). No adverse effects was found after the operation, such as damage to the parathyroid gland and the laryngeal nerve. The patients were followed-up for 1 to 40 months with satisfactory results. All 28 patients were satisfied with the cosmetic effects of the operation. CONCLUSIONS: Endoscopic thyroidectomy via the areola of breast approach produces an outstanding cosmetic effect, it is safe and feasible.

Fatal fulminant pancreatitis after laparoscopic gastric bypass surgery.

Current widespread application of laparoscopic techniques in Roux-en-Y gastric bypass (RYGBP) is making surgical safety an increasingly important issue. We report one case that resulted in death due to postoperative fulminant acute pancreatitis after laparoscopic RYGBP was performed when this procedure was still relatively new in China. The patient was a chronically obese 19-year-old male. Weight loss medications had been ineffective, and preoperative body mass index was 40.7. Preoperative examination revealed moderate steatohepatitis. Laparoscopic RYGBP (LRYGBP) was performed. Early manifestations of clinical shock appeared 13 h after the laparoscopic surgery. A second laparoscopic examination showed small-vessel hemorrhage at the posterior wall of the jejunojejunal anastomosis, with blood clot formation resulting in Roux limb and afferent loop obstruction. Fulminant acute pancreatitis developed in the patient 18 h after the second surgery. The patient died 15 days later from systemic multiorgan insufficiency. LRYGBP (postcolon) is a technically demanding procedure for surgeons who are not experienced in this operation. In addition, surgical tolerance is reduced in morbidly obese patients. Therefore, special care should be taken during surgery, and hemostasis must be achieved at all bleeding sites. Increased perioperative surveillance allows for early detection and management of severe complications.

[Treatment for severe rectal prolapse by laparoscopic rectopexy].

OBJECTIVE: To evaluate the clinical practice of laparoscopic rectopexy in the treatment of severe rectal prolapse. METHODS: From March 1998 to February 2007, 4 cases of complete rectal prolapse, including 1 male and 3 female,ranged 21-82 years old, were treated by laparoscopic rectopexy. In one case, the posterior wall of rectum was freed and elevated, and pre-rectal introcession was closed by silk suture, then the posterior wall was suspended and fixed on sacral promontory fascia, finally the sigmoid colon was fixed by sutures on the fascia of left psoas major. In other three cases, insertion of mesh was performed. Rectum was freed and elevated to the level of levalor ani. A sheet of T-shape polypropylene mesh was placed posterior to the rectum, whose lower margin was at the level of levator ani and wrapped around the rectum covering except the anterior wall. The free margin of the mesh was sutured on the muscular layer of rectum, then the mesh was put posterior to the rectum and fixed on the sacral promontory fascia by clipping to repair hernia. After that, the pelvic peritoneum was closed, and finally the sigmoid colon was fixed by sutures on the fascia of left psoas major. RESULTS: Four operation procedures were completed successfully. There was no conversion operation. The time was consumed 92.5 (80-100) min, and the bleeding amount was 6.5 (5-10) ml. No post-operative complications were found. Urine incontinence and encopresis were relieved. No recurrence and constipation was found after 2 months to 3 years follow up postoperatively. CONCLUSION: Laparoscopic rectopexy is a safe, workable and effective procedure, which can reduce operative trauma and shorten hospitalization time.

[Endoscopic thyroidectomy via chest and breasts approach in 500 cases].

OBJECTIVE: To discuss the method, the safety, the advantages and disadvantages of endoscopic thyroidectomy via chest and breasts. METHODS: From Mar. 2002 to Dec. 2006, endoscopic thyroidectomy via anterior chest and breast approach was performed in 500 patients, including 76 cases of Grave's disease (1 case had an opened operation history), 111 cases of thyroid adenoma, 291 cases of nodular goiter (10 cases have 1-2 opened thyroidectomy history, 2 cases secondary of hyperthyroidism), and 22 cases of thyroid carcinoma. RESULTS: The endoscopic thyroidectomy was successfully carried out in 492 cases, including tumor enucleation in 50 cases, partial lobectomy in 210 cases, subtotal thyroidectomy in 212 cases (including 73 cases of Graves' disease), and lobectomy in 16 cases of thyroid carcinoma. The operative time length ranged from 40 to 270 min (mean 74.5 min). Mean operative blood loss was 5.5 ml (3-250 ml), no cases underwent blood transfusion. The drainage was taken out in the second or third days postoperatively. Postoperative hospital stay ranged from 3 to 8 days (mean 4.2 days). There were some complications including subcutaneous bleeding (3 cases), burn of the epidermal (1 case), inflammation of the incision (2 cases), subcutaneous bruising (3 cases), subcutaneous effusion (6 cases), thyroid crisis (1 case), and temporarily hoarseness of 2 cases. There were no complications such as permanence damage to recurrent laryngeal nerve or parathyroid glands. The complication rate was 3.6% (18/492). The hospital charges ranged from 7600 to 13,500 RM yuan. The average cost of endoscopic thyroidectomy was 10,510 RM yuan, in contrast to 5700 RM yuan for the open thyroidectomy patients. The post-operative following-up was 3 to 57 months (mean 27 months). All the patients were satisfied with the cosmetic results and the same curative effects as conventional surgery were obtained. However, 3 cases of nodular goiter, 1 case of thyroid carcinoma, and 1 case of Grave's disease were recurrence. The operations were converted into open surgery in 8 cases. The 22 cases with carcinoma were survival until now. CONCLUSIONS: Endoscopic thyroidectomy is a safe and effective method of thyroid surgery. Since all the minimal incisions are on concealed parts of the body, the obvious cosmetic effect of this method is guaranteed. Some disadvantages such as complications and more costs are needed to be improve.

[Endoscopic thyroidectomy with 150 cases].

OBJECTIVE: To discuss the method, the advantages and disadvantages of endoscopic thyroidectomy. METHODS: Endoscopic thyroidectomy via areola of breasts approach was performed in 150 patients, including 41 cases of thyroid adenoma, 64 cases of nodular goiter, 40 cases of Graves' disease, and 5 cases of thyroid carcinoma. RESULTS: The endoscopic thyroidectomy was successfully carried out in 144 cases, including tumor dissection in 32 cases, one lobe partial thyroidectomy in 54 cases, two lobe partial thyroidectomy in 19 cases, subtotal thyroidectomy in 37 cases of Graves' disease, and radical thyroidectomy in 2 cases of thyroid carcinoma. The operative time length ranged from 50 to 270 min (mean 80 min). There were no complications such as damage to recurrent laryngeal nerve or parathyroid glands. Postoperative hospital stay ranged from 3 to 7 days (mean 4 days). The post-operative following-up for 1 approximately 13 months indicated that all the patients were satisfied with the cosmetic results and the same curative effects as conventional surgery were obtained. However, the operations were converted into open surgery in 6 cases. CONCLUSIONS: Endoscopic thyroidectomy is a safe and effective method of thyroid surgery. Since all the minimal incisions are on concealed parts of the body, the obvious cosmetic effect of this method is guaranteed.