Laparoscopic pancreatoduodenectomy for a metastatic tumor in a portal annular pancreas

BackgroundPortal annular pancreas (PAP), also called circumportal pancreas, is a congenital pancreatic anomaly in which the portal and/or mesenteric veins are surrounded by pancreatic parenchyma [1,2]. Joseph et al. classified PAP into three types (according to the fusion pattern of the pancreatic parenchyma and ductal system [1]), each of which they subdivided (based on the relation to the portal confluence) into the suprasplenic, infrasplenic, and mixed type [1,3]. The most common type is IIIa [1,4], where the portal vein (suprasplenic) is encased by the uncinate process with an anteportal main pancreatic duct.MethodsThe patient was a 78-year-old woman who had undergone left nephrectomy for renal cell carcinoma five years prior. We performed laparoscopic pancreatoduodenectomy for a metastatic tumor of the head of a type IIIa PAP (Fig. 1). The anteportal pancreas was transected, and dissection was performed around the superior mesenteric artery using a right approach. The retroportal pancreas was transected using a linear stapler with bioabsorbable polyglycolic acid felt. We performed pancreatojejunostomy for the anteportal stump of the pancreas containing a main pancreatic duct; the retroportal stump was not reconstructed, because it had no major pancreatic ducts on preoperative imaging.ResultsThe operative time was 505 minutes, and the blood loss was 70 ml. The postoperative course was uneventful, and the patients was discharged on postoperative day 12.ConclusionLaparoscopic pancreatoduodenectomy was performed successfully in a patient with a type IIIa PAP. The retroportal pancreas can be transected using a linear stapler, without reconstruction.     

Laparoscopic anatomic combined subsegmentectomy of segment 8 via the tailored strategy using digital intelligent technology

IntroductionSegment 8 is considered the largest liver segment, and its portal vein branches are generally divided into four parts, including ventral, dorsal, dorsolateral and medial branches (Shindoh et al., 2010; Takayasu et al., 1985) [1,2]. An anatomic combined subsegmentectomy could satisfy both the oncological quality of anatomical resection and the safety of parenchyma sparing principle if a small hepatocellular carcinoma is located between the hepatic subsegments (Berardi et al., 2021) [3]. Yet, laparoscopic anatomic combined subsegmentectomy of segment 8 is still technically challenging. The development of digital intelligent technology has made it possible to tailored preoperative planning and accurate intraoperative navigation in laparoscopic surgery.VideoA 57-year-old man underwent a routine CT scan and was found to have a mass occupation in segment 8 of the liver. Three-dimensional reconstruction was performed to evaluate liver anatomy, vascular variations, and volume of each vascular unit as well as the location of the tumor, its relationship with the liver anatomy, and the Glissonian pedicles feeding the tumor-bearing area. Based on the reconstructed model, resection was planned aiming to the narrowest but oncologically safe anatomical tumor-bearing area. Upon evaluation, anatomic combined subsegmentectomy of segment 8 (ventral and medial subsegments) was confirmed. The operation was performed precisely under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) (Yang et al., 2020) [4].ResultsThe operation lasted 200 min with 50 ml intraoperative blood loss. There were no postoperative complications, and the patient was discharged after 6 days.ConclusionDigital intelligent technology could provide tailored strategy for laparoscopic liver surgery, which makes laparoscopic anatomic combined subsegmentectomy of segment 8 feasible and effective.     

Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique) for extremely advanced perihilar cholangiocarcinoma

BackgroundIn an increasing number of patients undergoing radical surgery for perihilar cholangiocarcinoma [[1], [2], [3]], the intrahepatic bile duct is conventionally transected after the vessels to be preserved or reconstructed are confirmed [3,4]. In patients with extremely advanced perihilar cholangiocarcinoma having massive vascular involvement, it is sometimes difficult to confirm the vessels for reconstruction because of restricted working space and/or anatomical variants, even after liver parenchymal dissection [4]. When the vessels cannot be confirmed, the tumor is usually unresectable [4].MethodsWe developed a novel technique named “Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique)”, in which we directly cut the bile duct in the Glissonean sheath under 5x loupe until the vessels to be reconstructed are secured.ResultsThis video demonstrates the case of a 62-year-old man post-gastrectomy with a 47 × 36-mm perihilar cholangiocarcinoma with massive vascular involvement. Trisectionectomy was neither indicated left nor right due to excessively small remnant liver volume estimated even with portal vein embolization; thus, extended left hemihepatectomy with caudate lobectomy was applied using the ABC technique. Using the ABC technique after liver parenchymal dissection enabled us to identify and secure RAHA, RPHA, and RPV in favorable positions, and V5, RPV, RAHA, and RPHA were reconstructed. Finally, hepaticojejunostomy was performed. The operative time and blood transfusion were 1170 min and 1240 ml, respectively. R0 resection was achieved and the postoperative course was uneventful.ConclusionABC technique was technically feasible and useful for extremely advanced perihilar cholangiocarcinoma with massive vascular involvement.     

胰十二指肠切除联合血管重建治疗胰头、十二指肠恶性肿瘤

背景与目的：胰头癌、十二指肠癌的治疗，手术切除仍是唯一可能根治的有效方法。但临床确诊时，多数为晚期，常累及门静脉／肠系膜上静脉、下腔静脉即属手术禁忌症。本研究旨在探讨累及门静彬肠系膜上静脉、下腔静脉的胰头癌、十二指肠癌切除的处理方法，以提高切除率及生存率。方法：总结2002年2月-2005年6月5例联合血管重建胰十二指肠切除术的临床资料及经验，其中胰头癌合并门静脉／肠系膜上静脉切除人工血管重建3例，十二指肠癌合并下腔静脉切除人工血管重建2例。结果：本组病例无围手术期死亡。无人工血管感染、阻塞并发症。随访10个月死亡1例，24个月死亡1例，术后存活超过3年2例，超过4年1例。结论：对累及门静彬肠系膜上静脉、下腔静脉的胰头癌、十二指肠癌行胰十二指肠切除联合血管重建手术是安全的，可提高肿瘤切除率，延长患者生存时间。     

A case of curatively resected locally advanced pancreatic cancer after chemoradiation therapy

A 68-year-old man admitted for pancreatic tumor detected by US was found by computed tomography(CT)to have locally advanced pancreatic cancer invading the portal vein and neural plexus of the superior mesenteric artery without distant metastasis. We conducted preoperative chemoradiation therapy containing S-1 and hyperfractionated accelerated radiation therapy (50 Gy). Reevaluation of CT after chemoradiation therapy showed that the primary tumor reduced 52% without distant metastasis. Based on these findings, we conducted subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection. Pathological examination revealed moderately-differentiated adenocarcinoma. Extensive fibrosis with a small amount of cancer cells was observed in the marginal area of the tumor. The portal vein was surrounded with extensive fibrosis and free from cancer cells. Extrapancreatic nerve plexus invasion and lymph node metastasis were not observed. There were no residual cancer cells (R0). The postoperative course was uneventful, and adjuvant chemotherapy (S-1) was started. The patient remains well without recurrence 12 months after surgery.     

Long-term survival after radical resection of advanced pancreatic cancer

A 65-yr-old man who underwent pancreaticoduodenectomy with portal vein resection for pancreatic cancer is alive 8 yr after surgery. Originally, computed tomography (CT) revealed an 8-cm tumor in the pancreatic head. The tumor had infiltrated the portal vein, but grew expansively, so there was neither biliary obstruction nor jaundice. Pancreaticoduodenectomy with resection of the portal vein was performed for pancreatic cancer. Many tumor-infiltrating lymphocytes were seen within cancer cell nests on routine histopathology. We performed immunostaining for CD8, and found that a large number of the lymphocytes were CD8⁺ T cells. The patient’s prognosis was considered poor because the tumor was large and had infiltrated the portal vein. We suspect that long-term survival may be related to the response of CD8⁺ T cells to the cancer.     

多层螺旋CT血管成像在肝癌化疗栓塞中的临床指导作用

背景与目的：多层螺旋CT血管成像具有扫描速度快、覆盖范围大、肝脏血管图像清晰．多角度三维显示等特点,对肝脏病变的诊断和治疗已显示出重要价值。目前对于多层螺旋CT肝脏血管三维成像的研究主要集中在肝脏肿瘤、肝移植术前评价及肝脏血管系统解剖,对于指导肝癌动脉化疗栓塞的研究仍然有限。本研究通过对比分析肝癌患者肝脏多层螺旋CT血管成像（muhislice CT angiography,MSCTA）与数字减影血管造影（digital subtraction angiography,DSA）图像．探讨MSCTA在肝癌肝动脉化疗栓塞治疗中的临床指导作用。方法：本组50例肝癌患者行多层螺旋CT肝脏双期增强扫描。采用最大密度投影（maximal intensitypmjection,MIP）和容积再现（volume rendering technique,VRT）重建技术行肝动脉、门静脉血管成像,再经股动脉插管分别行腹腔动脉、肠系膜上动脉、肾动脉、膈动脉DSA造影及TACE治疗,对比分析肝癌MSCTA与DSA图像。结果：肝动脉解剖分型和肿瘤供血动脉来源的DSA与MSCT的MIP、VRT血管成像显示符合率达到100％,χ^2检验,两者间差异无统计学意义（P=1．00）,而对肝动门脉瘘及门脉癌栓的显示MSCTA比DSA更有优势。结论：MSCTA检查无创、简单易行,其图像的三维重建立体感强,可准确提供肝动脉、门静脉及肿瘤供血来源等信息,对指导肝癌经肝动脉化疗栓塞有很好的临床指导作用。     

Digital intelligent technology assisted three-dimensional laparoscopic extended left hepatectomy with resection of the middle hepatic vein(Video)

IntroductionDigital intelligent technology represented by three-dimensional (3D) visualization technology and surgical navigation system may provide preoperative and intraoperative anatomical information more accurately than CT and MRI [1]. Besides, the fusion of 3D model with surgical visual field through surgical navigation system may also compensate for the defects of visual fields and tactile sense to some extent in laparoscopic liver surgery [2].VideoA 49-year-old male patient with a tumor mainly located at the left inner area of liver and oppressing the middle hepatic vein (MHV). We formulated preoperative planning by using the Medical Image 3D Visualization System (MI3DVS, software copyright No: 2008SR18798) [3]. It was acknowledged that the right hepatic vein (RHV) was strong enough to drain the right anterior hepatic sector. Ultimately, 3D laparoscopic extended left hepatectomy with resection of the MHV was selected as the optimal operation scheme for the patient due to the RHV would avoid hepatic venous congestion in segment V and VIII after resection of the MHV, and more liver parenchyma than left trisegmentectomy would be retained. The operation was performed under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) [4].ResultsThe total operation time was 180 min, estimated blood loss of 200 ml. The final histopathological diagnosis showed an 8*6*6-cm-sized hepatocellular carcinoma. And the patient was discharged on postoperative day 6 without any complications.ConclusionDigital intelligent technology may be helpful to formulate preoperative planning and identify intraoperative important anatomical structures in 3D laparoscopic extended left hepatectomy with resection of the MHV.     

Lateral approach toward hepatoduodenal ligament during laparoscopic radical cholecystectomy for Gallbladder cancer

BackgroundThe common approach of Lymph node dissection (LND) during laparoscopic radical cholecystectomy (LRC) is an anterior approach [1,2], which emulates the view of open surgery. However, isolating the post-pancreatic nodes and retro-portal nodes completely without any damage to neighboring organs can be difficult in laparoscopic surgery because the dorsal structures of hepatoduodenal ligament are embedded and it is difficult for a surgeon to expose them [3]. On the other hand, the lateral approach offers the better way to expose and dissect dorsal part of hepatoduodenal ligament and it can be useful for dissecting hilar during laparoscopic right hepatectomy without injury of left side vascular structures.MethodsWe performed retrospective analysis of consecutive 10 patients submitted to LRC for Gallbladder (GB) cancer and described a technical aspect regarding LND for those series of cases. Among them, we introduced a patient with 71 years old man in a surgical video clip. He had no symptom and was his lesion was detected during a regular health care screening. The preoperative computed tomography showed T2 cancer with suspicious involvement in liver. His liver function was normal and tumor marker level was in normal range. LRC with liver wedge resection were contemplated for his treatment.ResultsIn the video clip, the patient was laid on an operating table in supine position. A zero degrees flexible laparoscope was used through the port on right subcostal angle. After identifying the common hepatic artery, #8 nodes were dissected and a 360-degree surrounding loop was applied to it for gentle retraction. Then gastroduodenal artery was identified with same manner. Cystic duct was isolated and frozen biopsy of its stump was done. After completing the isolation of common bile duct, another 360-degree loop was placed around it. The main trunk of the portal vein was exposed and followed superiorly up to the area of its bifurcation. Camera moved to lateral side of patient, to provide the better view of posterior and dorsal part of hepatoduodenal ligament. Careful dissection of retro-portal area with node dissection was then performed and portal vein was surrounded in 360°. Then, surgeon paid attention to dissecting retro-pancreatic #13 nodes, which was clearly identified and dissected. LRC was performed successfully by using lateral laparoscopic approach. Then liver wedge resection under laparoscopy was performed without any problem. This approach was not a great invention or innovation. Rather, this approach is commonly used technique in “liver and pancreatic minimally invasive procedures” including robotic procedures. However, this simple procedure can be useful for a surgeon to perform LRC. During last 20 years, we performed radical cholecystectomy for treating GB cancer in our institution. Since 2014, we changed the policy to treat early GB cancer (in the stage of T1b and T2) with “minimally invasive procedure”. We performed only LND without liver resection for peritoneal side tumor. Most of all patients were diagnosed in preoperative manner. Only two cases of incidental cancer underwent additional operation of LND and liver resection. Half of cases went through the process of dissection of lymph nodes only and 5 liver resections were done. None of patients undergoing LRC required conversion to another view during hilar dissection. The retro-portal vein and pancreas head LND could be reached expeditiously and safely prior to parenchymal transection. Majority of them revealed T2 and T1b finally. Number of retrieved nodes were in between 1 and 17 and median was 7. There was one complication of small bowel perforation during adhesiolysis.ConclusionLateral approach during LRC appears to offer better way to visualize, expose and dissect the dorsal part of hepatoduodenal ligament and LND #12,13s.     

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.     

Patient-centered oncosurgical planning with cancer models in subspecialty education

BackgroundA fundamental aspect of oncosurgical planning in organ resections is the identification of feeder vessel details to preserve healthy organ tissue while fully resecting the tumors. The purpose of this study was to determine whether three-dimensional (3D) cancer case models of computed tomography (CT) images will assist resident-level trainees in making appropriate operative plans for organ resection surgery.MethodsThis study was based on the perception of surgery residents who were presented with 5 different oncosurgical scenarios. A five-station carousel including cases of liver mass, stomach mass, annular pancreas, pelvic mass and mediastinal mass was formed for the study. The residents were required to compare their perception level of the cases with their CT images, and 3D models in terms of identifying the invasion of the mass, making differential diagnosis and preoperative planning stage.ResultsAll residents have given higher scores for models. 3D models provided better understanding of oncopathological anatomy and improved surgical planning. In all scenarios, 70–80% of the residents preferred the model for preoperative planning. For surgical choice, compared to the CT, the model provided a statistically significant difference in terms of visual assessment, such as tumor location, distal or proximal organotomy (p:0.009). In the evaluation of presacral mass, the perception of model was significantly better than the CT in terms of bone-foramen relationship of chondrosarcoma, its origin, geometric shape, localization, invasion, and surgical preference (p:0.004). The model statistically significantly provided help to evaluate and prepare the case together with the colleagues performing surgery (p:0.007). Commenting on the open-ended question, they stated that the tumor-vessel relationship was clearly demonstrated in the 3D model, which has been very useful.ConclusionsWith the help of 3D printing technology in this study, it is possible to implement and evaluate a well-structured real patient scenario setup in cancer surgery training. It can be used to improve the understanding of pathoanatomical changes of multidisciplinary oncologic cases. Namely, it is used in guiding the surgical strategy and determining whether patient-specific 3D models change pre-operative planning decisions made by surgeons in complex cancer mass surgical procedures.     

Value of multiphase contrast-enhanced CT with three-dimensional reconstruction in detecting depth of infiltration,lymph node metastasis,and extramural vascular invasion of gastric cancer

BackgroundMultiphase contrast-enhanced computed tomography (CECT) can reveal the location, morphology, size, and enhancement pattern of gastric cancer (GC), whereas the three-dimensional reconstruction (3DR) technique can better display the relationships of the lesions with surrounding structures, the feeding vessels, and lymph node metastasis. Here, we investigated the value of multi-phase CECT with 3DR in detecting depth of infiltration, lymph node metastasis, and extramural vascular invasion (EMVI) of GC.MethodsThe clinical and imaging data of 132 GC patients admitted to the Chongqing Hospital of Traditional Chinese Medicine and the Third Affiliated Hospital of Chongqing Medical University during the period from January 2012 to October 2019 were collected. All patients received plain and multiphase contrast-enhanced CT scans. The agreement between the results of preoperative CT evaluation and the surgical/pathological findings was compared.Results(I) CT findings of GC of 3 differentiation levels: on the multiphase CECT, the peak enhancement percentage was highest in the portal venous phase. The CT values significantly differed among the arterial, portal venous, and equilibrium phases (P<0.05); the differences in the arterial, portal venous, and equilibrium phases were statistically significant among the well-, moderately, and poorly differentiated groups (all P<0.05); finally, the difference in the equilibrium phase was statistically significant between the well- and moderately differentiated groups (P<0.05). (II) Preoperative CT and postoperative pathology had good consistency in T staging (Kappa =0.667). (III) The Kappa values between the preoperative CT-diagnosed lymph node metastasis and postoperative pathologically showing an increasing consistency with the increase of CT enhancement differences. (IV) Preoperative CT and postoperative pathology had good consistency in N staging (Kappa =0.779). (V) Preoperative CT in displaying arterial supply to the stomach. The rate of positive EMVI was 32.6% (43/132) on preoperative CT. The positive EMVI diagnosed by preoperative CT was correlated with tumor size, growth pattern, tissue differentiation degree, T stage, and N stage (all P<0.05).ConclusionsMultiphase CECT combined with 3DR has high diagnostic performance in detecting the depth of infiltration, lymph node metastasis, and EMVI of GC.     

Simultaneous,single-docking robotic resection for right colon cancer with synchronous liver metastases

BackgroundHow best to manage colorectal cancer patients presenting resectable synchronous liver metastasis is still a matter of debate. A number of different available therapeutic strategies exist, with significant differences in terms of optimal timing and/or sequence of resection of the primary tumor and liver disease [1]. Over the last years, simultaneous resections are increasingly adopted for properly selected patients [[1], [2], [3]]. However, the application of minimally invasive surgery to combined colorectal and liver surgery is still controversial, especially in the case of liver disease requiring technically demanding resections [2,3].VideoThe presented video illustrates the details of a single-docking robotic right colectomy combined with ultrasound-guided, parenchymal-sparing resection of liver segments 6 and 7, as performed to treat a patient with locally advanced colorectal cancer and metastatic disease isolated to the right liver. Port placement strategy and main instrumentation employed are illustrated in Fig. 1, and Fig. 2, respectively. The total duration of surgery was 380 minutes. The hepatic hilum was encircled to allow extracorporeal Pringle maneuver during liver resection, though no clamping was eventually required. Right colectomy with central vascular ligation was thus carried out and an intracorporeal ileocolic anastomosis performed. The patient had an uneventful postoperative course.ConclusionsWhen feasible, minimally invasive simultaneous resection may offer distinct advantages over conventional surgery while respecting the tenets of appropriate oncological resection [2,3]. The well-known benefits of minimally invasive surgery, including shorter overall hospital length of stay, reduced morbidity, and lower blood loss, are combined with the need to recover from a single major surgery. Robotic resection may be particularly suited for technically challenging procedures, such as colectomy combined with liver metastasectomies with unfavorable anatomical accessibility [3,4].     

Cranio-caudal approach to hepatic veins in laparoscopic central bisectionectomy (with Video)

BackgroundLaparoscopic central bisectionectomy (Couinaud's segment IV, V, and VIII) needs exposure of the RHV and MHV on the surface of the remnant and the resecting side, respectively. Avoiding venous injury is mandatory and laparoscopy-specific cranio-caudal approach to hepatic veins might be helpful [1]. We present this procedure in performing laparoscopic central bisectionectomy.PatientA 45-year-old female was admitted to our hospital with a 6 cm HCC in the segment VIII and IV. Her comorbid disease was non-cirrhotic HBV hepatitis (Child-Pugh grade A) and diabetes (untreated).MethodAfter cholecystectomy, G₄ branches were dissected and cut by extra- or intra-hepatic approach. Hilar plate was dissected and the G_ant was encircled and occluded by a vascular clip. Afterwards, exposure of the MHV was started at its root on IVC [2,3] and extended in cranio-caudal direction [1]. After sufficient space was obtained around the G_ant, the G_ant and the MHV were cut. Parenchymal transection between right anterior and right posterior sections was also started form the root of the RHV to its cranio-caudal direction. Liver resection was finished with full exposure of the RHV.ResultsThe operating time was 380 minutes, and the blood loss volume was 30 ml. Postoperative CT image showed exposure of the RHV and umbilical portion of Glissonean branch, and no fluid retention.ConclusionLaparoscopy-specific cranio-caudal approach to hepatic veins may be useful to avoid split injury of venous branches [4], especially if the hepatectomy requires complete exposure of hepatic vein, such as central bisectionectomy.     

Comparison of (11)C-choline PET/CT and enhanced CT in the evaluation of patients with pulmonary abnormalities and locoregional lymph node involvement in lung cancer

BackgroundThis study compares the diagnostic abilities of integrated ¹¹C-choline PET/CT imaging and contrast-enhanced helical CT imaging in pulmonary lesions and locoregional lymph node metastases in patients with lung cancer.Patients and MethodsOne hundred eight patients with proven or suspected lung cancer underwent integrated ¹¹C-choline PET/CT and contrast-enhanced CT, followed by surgical resection and nodal staging.ResultsThe ¹¹C-choline PET/CT and CT diagnoses of pulmonary lesions and locoregional lymph node metastases were compared with pathologic findings, which revealed benign lesions in 26 patients (tuberculoma [8 patients], inflammatory pseudotumor [7 patients], hamartoma [6 patients], sclerosing hemangioma [4 patients], and pulmonary sequestration [1 patient]) and lung cancers in 82 patients (adenocarcinoma [39 patients], squamous cell carcinoma [23 patients], carcinoid [7 patients], small-cell lung cancer [5 patients], adenosquamous carcinoma [5 patients], and large-cell lung cancer [3 patients]). The accuracy, sensitivity, and specificity of ¹¹C-choline PET/CT for diagnosing lung cancer were 82.4%, 85.4%, and 73.1%, respectively, compared with 73.1%, 76.8%, and 61.5%, respectively, for CT. Differences between ¹¹C-choline PET/CT and CT in diagnosing lung cancer were not statistically significant (p = .503, .118, and .375, respectively). We used receiver operating characteristic (ROC) curve for analysis, finding the ROC of standard uptake value (SUV_max) for diagnosing lung cancer. The cutoff value of SUV_max was 3.54. Preoperative nodal staging was compared with postoperative histopathologic staging. ¹¹C-choline PET/CT correctly staged 80.5% of patients, 12.2% were overstaged, and 7.3% were understaged; for CT these values were 58.5%, 24.4%, and 17.1%, respectively. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ¹¹C-choline PET/CT for lymph nodes were 83.8%, 82.4%, 84.1%, 50.3%, and 96.1%, respectively, compared with 69.3%, 63.7%, 71.2%, 30.2%, 91.0%, respectively, for CT.ConclusionDifferences in the accuracy, sensitivity, specificity, PPV, and NPV between ¹¹C-choline PET/CT and CT are thus statistically significant for nodal staging (p = .003, .007, .000, .000, and .004, respectively). Although ¹¹C-choline PET/CT is not significantly better at diagnosing pulmonary lesions than is enhanced CT, ¹¹C-choline PET/CT has improved sensitivity, specificity, accuracy, PPV, and NPV relative to enhanced CT in the evaluation of locoregional lymph nodes.     

Preoperative evaluation and preparation in pancreatic carcinoma

The preoperative evaluation in patients with pancreatic carcinoma includes ultrasonography or CT to diagnose and localize the tumour, to rule out metastases and to guide biopsy for cytological and/or histological verification. In patients with jaundice direct cholangiography, either transhepatic (PTC) or endoscopic (ERC), is necessary to give exact anatomical delineation of the tumour. Further, these procedures may be used to establish preoperative biliary drainage or to insert an endoprosthesis for permanent biliary drainage in inoperable cases. In patients without jaundice endoscopic pancreaticography (ERP) may delineate the pathology. Selective arteriography, both of the coeliac and superior mesenteric artery, visualize possible variations in arterial anatomy and tumour invasion. Stricture of one of the main arteries is usually a sign of inoperability. As venous phase portography only in some cases gives precise visualization of both the splenic, superior mesenteric and portal vein, transhepatic portography with selective catheterization of the splenic and superior mesenteric vein should be performed to diagnose strictures or invasion of the portal venous system. Only a few cases with invasion of these veins will be operable. The preoperative preparation in patients with pancreatic carcinoma includes correction of electrolytes, hypoalbuminemia, anemia, and, in patients with jaundice, treatment of K-vitamin deficiency. All patients should have prophylactic anti-thromboembolic treatment. Whether preoperative biliary drainage in jaundiced patients is of any benefit is still controversial, but may be indicated in patients with heavy jaundice and/or septic cholangitis.     

Feasible laparoscopic left trisectionectomy by Arantius' ligament approach (with video)

BackgroundLaparoscopic trisectionectomy is a technically challenging procedure with high rate of postoperative morbidity [1,2]. Arantius' ligament approach is useful to expose the root of middle hepatic vein, which is required in left trisectionectomy [3].MethodsThis video illustrates laparoscopic left trisectionectomy using Arantius' ligament approach. A 63-year-old man, with chronic kidney disease, had intrahepatic cholangiocarcinoma with a diameter of 8 cm, located in the segment 4 and anterior section of the liver. The tumor was close to the umbilical portion of the left portal vein and future liver remnant was 770 ml (49.5% of the whole liver) after left trisectionectomy.VideoAfter the pneumoperitoneum and the mobilization of the left lateral segment, the root of left and middle hepatic vein was exposed by division of Arantius’ ligament and parenchymal transection of dorsal surface around the root of left hepatic vein. Next, the left Glissonian pedicle was controlled and divided. The Glissonean pedicle for the anterior section was then isolated and divided. Demarcation line was then observed using indocyanine green negative counterstaining. Parenchymal transection was completed followed by the division of the common trunk of the left and middle hepatic veins.ResultsThe operation time was 294 min, and the blood loss was 400 g. The patient was discharged on postoperative day 16 after conservative treatment for temporary kidney injury. Pathological examination revealed intrahepatic cholangiocarcinoma with negative surgical margin.ConclusionThe Arantius’ ligament approach could be a feasible procedure for left trisectionectomy.     

Intragastric single-port surgery (IGS) for gastric endophytic gastrointestinal stromal tumor (GIST): A novel surgical treatment

BackgroundIntragastric surgery with a single incision has been performed for several diseases, such as gastric tumors[1] and pancreatic pseudocyst[2], safety, feasibility and potential benefits of which have been reported in previous relevant studies[3].MethodsThe video shows a 65-year-old man with upper gastrointestinal hemorrhage, preoperative abdominal CT scan and endoscopy suggested an endophytic tumor located in gastric corpus, suggesting gastrointestinal stromal tumor (GIST). Intragastric single-port surgery (IGS) was indicated.ResultsUnder general anesthesia, patient was placed in supine position. Surgeons stood on the right side of the patient. After a 2.5cm transverse incision was made on left upper abdominal wall, gastric anterior wall was exteriorized and fixed to the skin incision. Single-port device was inserted inside the stomach after anterior gastric wall was opened. Next, laparoscope was introduced into gastric cavity and identified the location of tumor. Full thickness resection of the tumor was performed by using linear stapler, then stapler line was embedded with continuous sutures. Finally, after specimen and single-port device removal, the stomach incision was closed extracorporeally. The operation time was 112 minutes. Final pathology confirmed GIST (4.5cm) with negative margins and patient discharged after 4 days, without postoperative complications. In 1-year follow-up time, without recurrence or death.ConclusionIGS is safe and effective for gastric endophytic GIST resection, which not only preserves all advantages of conventional laparoscopic operation, but also includes other benefits like obviating the need of abdominal cavity exploration, potential reduction of risk of neoplasm seeding, and offering good postoperative cosmetic result.     

胰腺癌放疗分次间解剖变化及自适应放疗研究

目的 定量描述胰腺癌放疗分次间解剖位置变化及自适应放疗剂量优势。方法 回顾分析图像引导放疗的 10例胰腺癌患者的226套治疗当天CT图像,自动勾画软件勾画靶器官和危及器官轮廓后由经验丰富的医师修改。应用质心距离、最大重叠率和Dice系数定量分析分次间器官移位和变形。应用自适应放疗技术处理治疗当天CT图像,比较自适应治疗计划和校位治疗计划的剂量参数。结果 胰腺癌放疗过程中胰头分次间解剖变化显著,经骨性或软组织对齐配准后胰头质心距离、最大重叠率和Dice系数分别为(7.8±1.3) mm、(87.2±8.4)%和(77.2±7.9)%。自适应治疗计划靶体积(PTV)包绕和危及器官保护方面均优于校位治疗计划,自适应治疗计划将校位治疗计划PTV的 V₁₀₀从(93.32±2.89)%提高至(96.03±1.42)%(t=2.79,P=0.008),同时将校位治疗计划的十二指肠 V_50.4从(43.4±12.71)%降至(15.6±6.25)%(t=3.52,P=0.000)。结论 自适应放疗能有效应对胰腺癌放疗中分次间的解剖变化,可提高胰腺癌放疗剂量,这为提高胰腺癌局部控制率带来了希望。     

Gene polymorphisms in antioxidant enzymes correlate with the efficacy of androgen-deprivation therapy for prostate cancer with implications of oxidative stress

BackgroundOxidative stress mitigated by antioxidant enzymes is thought to be involved in the progression to castration-resistant prostate cancer (CRPC) during androgen-deprivation therapy (ADT). This study investigated the association between genetic variations in antioxidant enzymes and the efficacy of ADT as well as its biological background.Patients and methodsThe non-synonymous or promoter-locating polymorphisms of antioxidant enzymes were examined as well as the time to CRPC progression and overall survival in 104 and 92 patients treated with ADT for metastatic and non-metastatic prostate cancer, respectively. In addition, intracellular reactive oxygen species and expression levels of antioxidant enzymes were examined in castration-resistant and enzalutamide-resistant cells.ResultsIn metastatic prostate cancer, the AG/GG allele inGSTM3 rs7483 and CT/TT allele inCAT rs564250 were associated with a significantly lower risk of progression to CRPC and all-cause death compared with homozygotes of the major AA allele (hazard ratio [HR]; [95% confidence interval (CI)], 0.55 [0.34–0.86],P = 0.0086) and CC allele (HR; [95% CI], 0.48 [0.24–0.88],P = 0.016), respectively. On multivariate analyses, onlyGSTM3 rs7483 was associated with significant progression risk (AG/GG versus AA; HR; [95% CI], 0.45 [0.25–0.79],P = 0.0047) even after Bonferroni adjustment. In non-metastatic prostate cancer, the AG/GG allele inGSTM3 rs7483 was associated with a significantly lower risk of progression to CRPC (HR; [95% CI], 0.35 [0.10–0.93],P = 0.034) and all-cause death (HR; [95% CI], 0.26 [0.041–0.96],P = 0.043) compared with the AA allele. Intracellular reactive oxygen species levels were increased, accompanied with augmentedGSTM3 expression in both castration-resistant and enzalutamide-resistant cells.ConclusionsDifferential activity of antioxidant enzymes caused by the polymorphism inGSTM3 may contribute to resistance to hormonal therapy through oxidative stress. TheGSTM3 rs7483 polymorphism may be a promising biomarker for prostate cancer patients treated with ADT.