Endoscopic submucosal dissection as a staging measure may not lead to worse prognosis in early gastric cancer patients with additional gastrectomy

BACKGROUND: Endoscopic submucosal dissection is a novel endoluminal technique that enables resection of early stage gastrointestinal malignancies in an en bloc fashion. AIM: To assess whether preceding endoscopic submucosal dissection affected the prognoses of patients who underwent additional gastrectomy with lymph node dissection due to suspicion of nodal metastasis from endoscopic submucosal dissection specimens. PATIENTS AND METHODS: Thirty-one patients with early gastric cancer who underwent gastrectomy after endoscopic submucosal dissection were retrospectively investigated in terms of their survival and tumour recurrence. Additional gastrectomy was performed when histology of the endoscopic submucosal dissection specimens revealed that the tumours did not meet the criteria for node-negative cancers. RESULTS: Twenty-three (74%) and eight (26%) patients had undergone endoscopic submucosal dissection previously due to clinical diagnoses of node-negative cancers and possible node-positive cancers, respectively. Histology of the resected stomachs and lymph nodes revealed residual carcinoma of the stomach in two (6.5%) patients and nodal metastases in four (13%) patients. All patients remain alive without recurrence (median follow-up, 3.4 years; range, 0.6-5.2 years). CONCLUSIONS: Based on the histology of endoscopic submucosal dissection specimens, preceding endoscopic submucosal dissection itself had no negative influence on a patient's prognosis when additional gastrectomy was performed. It may be permissible to resect some early gastric cancers by endoscopic submucosal dissection as a first step to prevent unnecessary gastrectomy, if technically resectable.     

肝癌手术的非接触分离技术研究进展

为了避免手术时肿瘤细胞的播散,在切除肿瘤部分前先将肿瘤区域的淋巴、血管结扎、离断,这种技术称之为"非接触分离技术".对于肝癌的手术,传统的方法是在离断肝实质之前,充分游离预切除的肝叶,并旋转肝脏托至切口的前面,以便在肝外对肝静脉和第三肝门进行控制.这种手术可能会导致肝脏的缺血再灌注损伤,诱导休眠期肿瘤细胞释放前血管生成刺激因子促进VEGF水平的上升,加快其微小灶转移的进展,而肝脏手术旋转过程中对肿瘤的挤压可能会加重肿瘤细胞随血循环播散或在肝内门静脉系统播散的机率.肝癌手术的非接触分离技术是一项减少肝脏损害,防止术中转移和术后复发,值得深入探讨的新策略.     

Coronary vein graft disease: Pathogenesis and prevention

Not long after coronary artery bypass grafting surgery was described, several reports presented follow-up angiographic data on large cohorts of patients, demonstrating that approximately one-half of saphenous vein grafts fail within 10 to 15 years of surgery and that graft failure is associated with worse clinical outcomes. Three processes are responsible for vein graft failure. Thrombosis, intimal hyperplasia and accelerated atherosclerosis contribute to graft failure in the acute, subacute and late postoperative periods, respectively. Studies have shown that perioperative antiplatelet therapy can reduce early thrombosis and graft failure. As in native coronaries, intensive lipid lowering can attenuate the process of atherosclerosis in vein grafts. Intimal hyperplasia in the vein graft is thought to be an adaptation of the vein to higher pressures in the arterial circulation. This process is further promoted by the loss of inhibition from the endothelial layer, which is injured during surgery. A new ‘no-touch’ technique for harvesting grafts may be effective in preventing disruption to the endothelial layer, and subsequent intimal hyperplasia and graft loss. Off-pump surgery and endoscopic vein harvesting, which are known to reduce surgical morbidity, have been shown to be no worse than on-pump surgery and open vein harvesting, respectively, in terms of vein graft patency. Various gene therapies can prevent intimal hyperplasia in animal models, but human data obtained so far have been disappointing. Placing an external stent around a vein graft may reduce tangential wall stress and subsequent intimal hyperplasia.     

The Dural Dark-Side Approach for falcine and tentorial meningioma: A surgical series of five patients

IntroductionFalcine or tentorial meningioma can be complex to resect. When large meningiomas are located in eloquent areas, a direct ipsilateral surgical approach may cause brain injury and postoperative neurological deficits. In this series, 5 patients were surgically treated using a contralateral transfalcine or transtentorial approach to minimize brain retraction. This strategy was called the Dural Dark-Side Approach (DDSA). The aim was to analyze the quality of tumor resection and postoperative outcome.Material and methodsIn our department, from June 2018 to January 2020, 5 patients underwent microsurgical DDSA for resection of 4 falcine and 1 tentorial meningioma. All tumors were selected on the following two criteria: large > 40 mm diameter tumor, with surrounding functional cortex. Clinical and radiologic data were retrospectively analyzed.Results and discussionMean follow-up was 20 months. No patients required use of a rigid retractor during surgery. Gross total resection was performed in 3 patients and near-total resection in 2. All patients had favorable neurologic outcome. Postoperative MRI showed no ipsilateral or contralateral brain lesions.ConclusionThis series suggested that meticulous DDSA allows excellent resection in selected large falcine or tentorial meningioma. The approach offered a safe and effective surgical corridor without injuring the surrounding healthy parenchyma.     

Pancreatoduodenectomy using a no-touch isolation technique

Background

Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.

Methods

From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.

Results

We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.

Conclusions

No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.     

No-Touch Technique for Autologous Fat Harvesting

A new technique for autologous fat harvesting is presented. It is termed the no-touch technique because the concentrated fat graft is obtained with no handling of fatty tissue. With the no-touch technique, fat aspiration is performed under tourniquet. There is no need for any mechanical manipulations such as centrifugation, washing, whisking, filtering, or straining. The medial aspect of the knee is used as the donor area. Fat is aspirated through a disposable 10-ml syringe and a 14-gauge microcannula, which consists of a curved, semiblunted tip such as that of the Tuohy needle. What remains in the syringe is the concentrated fat without blood, serum, or lidocaine. The authors report their experience with 30 patients.This study was presented at the XVI Congress of ISAPS at Istanbul in 2002.     

腹腔镜胃癌手术不应忽视肿瘤治疗的原则

自1994年Kitano报道首例腹腔镜辅助远端胃切除联合淋巴结清扫手术以来,近年在日本和韩国,腹腔镜手术已被广泛应用于淋巴结转移风险低的早期胃癌.腹腔镜胃癌手术的目的在于最大限度地减少手术创伤,提高患者生活质量,但要以保证手术的根治性为前提.随着腹腔镜手术经验的不断积累,目前腹腔镜胃切除术的指征已逐渐从早期胃癌扩大到进展期胃癌.但是由于缺乏长期疗效的循证医学证据支持,腹腔镜手术在进展期胃癌中的运用尚存争议.因此,为保证腹腔镜胃癌手术获得与传统开腹手术相似的临床疗效,必须严格遵循肿瘤治疗的基本原则,诸如合适的病例选择,充分的手术切缘,规范的D2淋巴结清扫及符合无瘤原则等.     

No-touch获取大隐静脉桥血管在CABG中的应用及近中期桥血管通畅率观察

［摘要］ 目的观察非接触性（即No-touch）获取大隐静脉桥血管在冠状动脉旁路移植术(coronary artery bypass graftingCABG)中的应用效果及近中期血管通畅率。 方法将105例CABG患者随机分为No-touch组65例和常规手术组40例。No-touch组使用No-touch技术获取大隐静脉,常规手术组采用常规切口采集大隐静脉桥血管。比较2组手术效果和近中期桥血管通畅率。 结果2组均无死亡病例。No-touch组获取大隐静脉时间和手术时间均长于常规手术组（P＜0.05）。2组输注红细胞、输注血浆、术中出血量和再血管化数目差异均无统计学意义（P＞0.05）。2组24 h引流量、24 h血肌钙蛋白、呼吸机辅助通气时间、ICU停留时间、住院费用、引流管保留时间差异均无统计学意义（P＞0.05）。No-touch组双下肢麻木及疼痛发生率高于常规手术组（P＜0.05）。2组双下肢切口血肿、下肢水肿发生率和切口愈合不良发生率差异均无统计学意义（P＞0.05）。No-touch组术后3个月和12个月桥血管通畅率均高于常规手术组（P＜0.05）。 结论在CABG中应用No-touch获取大隐静脉桥血管能降低对静脉桥血管的损伤、延长桥血管通畅率、No-touch方法和常规切开法具有同样的安全性。     

No-Touch vs. Conventional Radiofrequency Ablation Using Twin Internally Cooled Wet Electrodes for Small Hepatocellular Carcinomas: A Randomized Prospective Comparative Study

ObjectiveThis study aimed to compare the efficacy between no-touch (NT) radiofrequency ablation (RFA) and conventional RFA using twin internally cooled wet (TICW) electrodes in the bipolar mode for the treatment of small hepatocellular carcinomas (HCC).Materials and MethodsIn this single-center, two-arm, parallel-group, prospective randomized controlled study, we performed a 1:1 random allocation of eligible patients with HCCs to receive NT-RFA or conventional RFA between October 2016 and September 2018. The primary endpoint was the cumulative local tumor progression (LTP) rate after RFA. Secondary endpoints included technical conversion rates of NT-RFA, intrahepatic distance recurrence, extrahepatic metastasis, technical parameters, technical efficacy, and rates of complications. Cumulative LTP rates were analyzed using Kaplan-Meier analysis and the Cox proportional hazard regression model. Considering conversion cases from NT-RFA to conventional RFA, intention-to-treat and as-treated analyses were performed.ResultsEnrolled patients were randomly assigned to the NT-RFA group (37 patients with 38 HCCs) or the conventional RFA group (36 patients with 38 HCCs). Among the NT-RFA group patients, conversion to conventional RFA occurred in four patients (10.8%, 4/37). According to intention-to-treat analysis, both 1- and 3-year cumulative LTP rates were 5.6%, in the NT-RFA group, and they were 11.8% and 21.3%, respectively, in the conventional RFA group (p = 0.073, log-rank). In the as-treated analysis, LTP rates at 1 year and 3 years were 0% and 0%, respectively, in the NT-RFA group sand 15.6% and 24.5%, respectively, in the conventional RFA group (p = 0.004, log-rank). In as-treated analysis using multivariable Cox regression analysis, RFA type was the only significant predictive factor for LTP (hazard ratio = 0.061 with conventional RFA as the reference, 95% confidence interval = 0.000–0.497; p = 0.004). There were no significant differences in the procedure characteristics between the two groups. No procedure-related deaths or major complications were observed.ConclusionNT-RFA using TICW electrodes in bipolar mode demonstrated significantly lower cumulative LTP rates than conventional RFA for small HCCs, which warrants a larger study for further confirmation.     

A novel technique of coronary revascularization in porcelain aorta: Report of two cases

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.