External pancreatic juice drainage through a percutaneous endoscopic drainage tube for the patient with a postoperative pancreatic juice leakage

Percutaneous endoscopic gastrostomy (PEG) has been widely accepted for patients who have no swallowing ability but have an intact gut. Its clinical application is mainly for nutritional support and decompression of the intestine in patients with bowel obstruction. In this paper, we report external pancreatic juice drainage through a percutaneous endoscopic drainage tube in a patient with postoperative pancreatic juice leakage. Soon after this procedure, pancreatic juice leakage subsided. This procedure was minimally invasive for the patient and may be a new application of PEG to maintain the good quality of life (QOL) in a patient with pancreatic juice leakage.     

Transcervical approach to percutaneous endoscopic gastrostomy tube insertion in a patient with head and neck cancer

This is the case of a 48‐year‐old woman with recurrent head and neck cancer. Six years before presenting at our institution, she was diagnosed with a moderately differentiated squamous cell carcinoma involving the right maxilla and underwent surgical resection followed by chemoradiation. More recently, she presented at our institution with oral bleeding and pain. Examination revealed severe trismus, and biopsy demonstrated recurrent squamous cell carcinoma. She underwent surgical resection with a plan for simultaneous placement of a feeding gastrostomy tube. Owing to the near non‐existent mouth opening, traditional per‐oral placement of a percutaneous endoscopic gastrostomy (PEG) tube was impossible. Intraoperatively, following tumor resection, endoscopy was performed via direct pharyngeal access through a right cervical incision. The PEG tube was then placed uneventfully. Numerous studies have shown the superiority of PEG tubes over either radiologically or surgically placed gastrostomy tubes. This report describes an approach to PEG placement in a patient in whom per‐oral placement was not feasible.     

同期微创经皮肾穿刺取石术治疗双侧上尿路结石的疗效观察

【目的】探讨同期微创经皮肾穿刺取石术治疗双侧上尿路结石的临床疗效。【方法】回顾分析本院2006年3月至2011年12月住院的960例上尿路结石患者中65例双侧上尿路结石的临床资料,所有病例均应用同期微创经皮肾穿刺取石术治疗。【结果]59例一次取石成功,结石清除率为91．5％（54／59）。平均手术时间62．3min,术中血红蛋白平均下降2．1g／L,平均住院时间7d,术后发热8例,肾造瘘管疼痛需镇痛治疗4例。【结论】同期微创经皮肾穿刺取石术治疗双侧上尿路结石安全、有效。     

Recent advances in thoracoscopic esophagectomy for esophageal cancer

Technical advances and developments in endoscopic equipment and thoracoscopic surgery have increased the popularity of minimally invasive esophagectomy (MIE). However, there is currently no established scientific evidence supporting the use of MIE as an alternative to open esophagectomy (OE). To date, a number of single‐institution studies and several meta‐analyses have demonstrated acceptable short‐term outcomes of thoracoscopic esophagectomy for esophageal cancer, and we recently reported one of the largest propensity score‐matched comparison studies between MIE and OE for esophageal cancer, based on a nationwide Japanese database. We found that, in general, MIE had a longer operative time and less blood loss than OE. Moreover, compared to OE, MIE was associated with a lower rate of pulmonary complications such as pneumonia, and both methods had similar mortality rates. Although MIE may reduce the occurrence of postoperative respiratory complications, MIE and OE seem to have comparable short‐term outcomes. However, the oncological benefit to patients undergoing MIE remains to be scientifically proven, as no randomized controlled trials have been conducted to verify each method's impact on the long‐term survival of cancer patients. An ongoing randomized phase III study (JCOG1409) is expected to determine the impact of each method with regard to short‐ and long‐term outcomes.     

Robotic surgery for the upper gastrointestinal tract: Current status and future perspectives

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.     

Laparoscopy assisted middle‐segment–preserving pancreatectomy for multiple pancreatic neuroendocrine tumors: Report of a case

For multiple low‐grade malignant tumors located in the pancreatic head and tail, middle‐segment–preserving pancreatectomy (MSPP) is sometimes indicated. However, MSPP has rarely been performed laparoscopically. Here we report the first case of laparoscopic MSPP for multiple pancreatic neuroendocrine tumors diagnosed preoperatively under an endoscopic ultrasound‐guided fine‐needle aspiration biopsy. A 70‐year‐old man had multiple small tumors located in the pancreatic head, body and tail. Endoscopic ultrasound‐guided fine‐needle aspiration biopsy with immunohistochemical staining made a definitive diagnosis of a pancreatic neuroendocrine tumor (G1). To preserve the 5‐cm pancreas body, we successfully performed laparoscopic MSPP: subtotal stomach‐preserving pancreaticoduodenectomy followed by distal pancreatosplenectomy. Pathological examination revealed negative surgical margin after resection. Postoperative course was uneventful, and at 14 months after the operation, the patient remains tumor‐free. The patient has discontinued insulin supplement therapy but does use an oral hypoglycemic agent. Laparoscopy‐assisted MSPP, with reconstruction through a 6‐cm transverse incision, can be safely performed for selected cases of borderline and malignant lesions.     

Transmediastinal approach for esophageal cancer: A new trend toward radical surgery

Esophageal squamous cell carcinoma (ESCC), the most common histology of esophageal cancer in Japan and Asia, shows extensive mediastinal spread from an early stage. Therefore, transthoracic esophagectomy with extensive mediastinal lymphadenectomy, including in the upper mediastinum along the recurrent laryngeal nerves, is the gold standard of radical surgery for ESCC. Minimally invasive thoracoscopic esophagectomy has now become a standard option for ESCC. However, transhiatal esophagectomy is regarded as less invasive because it avoids thoracotomy. Yet, it is also considered less curative because it offers a limited surgical view and insufficient mediastinal lymphadenectomy even when conventional specialized mediastinoscopy is used. Recent clinical studies on radical esophagectomy without thoracotomy for ESCC have been reported from Japan. The introduction of novel minimally invasive techniques for the transcervical or transhiatal approach, such as single‐port or robotic surgical devices, have enabled transmediastinal radical esophagectomy for ESCC. This review focuses on the transmediastinal approach for esophageal cancer surgery, which employs minimally invasive techniques to reduce morbidity, and its application to radical surgery for ESCC.     

食管悬吊法清扫左喉返神经旁淋巴结在微创食管手术中的回顾性研究

目的:分析微创食管癌手术中食管悬吊法对左喉返神经旁淋巴结清扫情况、手术时间和相关并发症的影响。方法:回顾分析2015年1月-12月复旦大学附属中山医院微创手术治疗的145例食管癌患者的临床资料,其中71例术中用食管悬吊法清扫左喉返神经旁淋巴结,另74例术中用常规方法清扫左喉返神经旁淋巴结。结果:与常规方法组相比,食管悬吊组的左喉返神经旁淋巴结清扫数量显著增加[(2.55±0.20)枚vs(1.46±0.22)枚,P<0.05],手术时间[(262.60±6.44)min vs(265.60±6.17)min]和左喉返神经旁淋巴结清扫时间[(9.90±0.34)min vs(9.60±0.36)min]无明显差异,喉返神经不可逆损伤、胸导管损伤等并发症无明显差异。结论:微创食管癌根治术中采用食管悬吊法可更彻底地清扫左喉返神经旁淋巴结,且不增加手术时间和围手术期并发症。     

经皮内镜下胃造口在重型颅脑损伤患者营养治疗中的应用

目的探讨重型颅脑损伤患者早期经皮内镜下胃造口（percutaneous endoscopic gastrostomy,PEG）置管肠内营养的可行性及疗效。方法 2010年4月至2011年5月对32例重型颅脑损伤患者采用早期经皮PEG置管行肠内营养治疗。结果 32例患者均在颅脑损伤或开颅手术后第3～7天内实施PEG;全部置管成功,无操作死亡病例。并发症包括造口区皮肤渗血2例,红肿5例,感染1例,吸入性肺炎2例,上消化道出血1例。胃造口营养管保留时间7～185天,平均31.6天;32例中成活27例,死亡5例。结论重型颅脑损伤患者早期经皮PEG置管肠内营养有利于减少并发症,改善生存质量,且操作安全、舒适,值得推广应用。     

腹腔镜胆肠吻合术的动物实验和临床应用研究

目的探讨腹腔镜胆囊空肠吻合术的技术可行性和临床应用的治疗效果。方法选取中型猪10只,在腹腔镜下或腹腔镜辅助下行胆囊空肠吻合术。术前术后监测肝功能,术后监测体重变化;术后半个月处死动物,了解吻合口的大小及愈合情况。5例晚期胰腺癌经腹腔镜和腹腔镜超声探查分期后行腹腔镜胆囊空肠吻合及胃空肠吻合术,其中3例采用吻合器、2例行手工缝合完成手术。选取1998~2003年对不能手术切除的胰腺癌或壶腹周围癌开腹行胆肠吻合术16例,内镜stent组12例,PTCD及内支架组12例等作为对照组。比较本实验组同对照组间术前术后肝功能指标的变化、并发症及以术后恢复情况等。以判断术式的优劣。结果动物实验组2例在腹腔镜辅助下行胆囊空肠吻合术及空肠Braun's吻合术。第1例因术中未行气管插管而致术中缺氧,手术完成后4h死亡。8例行腹腔镜胆囊空肠吻合术,手术历时120~180 min,平均150 min。存活动物术前术后肝功能各项指标无明显变化(P>0.05),术后猪只的体重增加与正常猪相仿。处死动物后检查胆肠吻合直径介于(17±3.5)mm,空肠Braun's吻合口直径为(22±4.2)mm,吻合口生长良好,未见吻合瘘。5例病人腹腔镜手术均顺利完成,平均手术时间120 min,平均住院7 d,无腹腔镜手术并发症,平均随访8个月生存良好。与内镜stent组、开腹     

经皮内镜引导下胰周坏死组织清理术治疗重症急性胰腺炎合并胰周组织坏死感染的护理

目的：探讨胰周脓肿微创治疗和护理方法,提高急性重症胰腺炎合并胰周组织坏死感染患者治愈率。方法：4例重型急性胰腺炎后期胰周脓肿感染患者,均予经皮内镜引导下胰周坏死组织清除术,内镜引导下清除坏死组织、脓苔,术后严密监护并反复负压进行冲洗,至病灶无可见异物、内壁有新鲜肉芽组织生长止。结果：治愈4例,治愈率100%;1例患者经皮内镜引导下胰腺坏死感染组织清理术后,炎症感染症状迅速控制,3例患者因术中清理不净进行二次手术后成功。结论：经皮内镜引导下胰周坏死组织清除术对治疗重型急性胰腺炎后期胰周脓肿感染患者安全可靠,通过有效治疗和护理,并发症少,治愈率高。     

Operating gastrostomy tubes: Insertion and removal for minimally invasive transgastric ulcer surgery

Summary

Some patients with bleeding peptic ulcer either continue to bleed or rebleed following endoscopic interventional therapy. Open surgery may be the only method capable of arresting haemorrhage. This requires a general anaesthetic and laparotomy. Many patients are elderly and have concomitant medical problems placing them at increased risk from surgery. A less invasive method for gaining access to the gastric cavity may benefit these patients.

Operating gastrostomy tubes (a laparoscopic port attached to a gastrostomy tube) were placed through the anterior abdominal wall directly into a porcine stomach. This allowed both visual and operative access anywhere in the stomach, apart from the pyloric canal. 20 experimental bleeding ulcers were created and complete haemostasis was achieved by under-running with laparoscopic equipment. Operating gastrostomy ports were removed and the resulting gastrostomy closed using a new percutaneous method. No infection or fistula formation occurred following gastrostomy removal.

This is a minimally invasive method for gaining access to the gastric cavity with laparoscopic equipment, enabling surgical procedures to be performed. Insertion and removal of operating gastrostomy ports may be able to be performed under a local anaesthetic and sedation, which may allow some transgastric surgical procedures to be performed without a general anaesthetic.     

Nasogastric and Percutaneous Endoscopic Gastrostomy Tube Use in Advanced Head and Neck Cancer Patients: A Comparative Study

ABSTRACT

To compare the efficacy of percutaneous endoscopic gastrostomy (PEG) and nasogastric (NGT) tube administration of enteral nutrition in head and neck cancer patients undergoing curative treatment, the authors conducted a prospective study to compare nutritional outcomes, complications, and patient satisfaction. PEG patients sustained significantly less reduction in nutritional parameters, measured at 6 weeks post insertion, as compared with NGT patients. There was also a statistically significant difference between the two groups in patient's quality of life scores and complications. Comparison could not be done at 6 months because all patients were converted to PEG feeding due to the earlier findings. The authors conclude that PEG is more efficacious than NGT as a channel for nutrition in advanced head and neck cancer patients over a short duration.     

2 419例17 530颗胆囊息肉内镜微创保胆手术后病理结果分析

目的 通过对胆囊息肉保胆手术后病理结果分析,评估内镜微创保胆手术对胆囊息肉的治疗价值。方法 收集2007年1月－2020年12月行内镜微创保胆手术的2 419例17 530颗胆囊息肉患者的病理资料,纳入回顾性研究,以内镜微创保胆手术的手术适应证作为入组标准,分析其术后病理结果。结果 胆囊良性息肉占99.68%,均行保胆取息肉手术,0.20%的患者息肉为恶性,且为早期,均行胆囊癌根治术,0.12%的患者为腺瘤高级别上皮内瘤变,行胆囊切除术。结论 胆囊息肉中恶性肿瘤占比较低,内镜微创保胆手术是治疗胆囊息肉的首选手术方法,既可以去除胆囊良性病变,又能保留胆囊功能,还可以早期发现胆囊癌。因此,胆囊息肉应早期行微创保胆手术以明确诊断,防止恶变。     

经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症的近期疗效

目的探讨经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症（1umbar disc herniation,LDH）的近期疗效。方法对29例LDH患者采用经皮椎间孔镜下髓核摘除术治疗。疗效按视觉模拟评分法（visual analogue scales,VAS）进行评定。结果29例患者术前VAS评分为（6.89±0.80）分,术后1d VAS评分为（0.50±0.29）分。术后3dVAS评分为（0.90＋0.65）分、术后1周VAS评分为（1.05＋0.70）分、术后3个月VAS评分为（0.90±0.60）分;术后l、3d,1周及3个月的VAS评分值均较术前显著降低（均P〈0.01）。结论经皮椎间孔镜下髓核摘除术治疗LDH的近期疗效较好。是一种较理想的微创手术方法。     

Synchronous rectal and esophageal cancer treated with chemotherapy followed by two-stage resection

We report a case of 61-year-old male who had synchronous advanced rectal cancer involving the urinary bladder massively associated with multiple liver metastases, and esophageal cancer successfully treated by neoadjuvant chemotherapy followed by two-stage resection. Although complete resection of each of the lesions was considered possible by performing anterior pelvic exenteration, liver resection, and esophagectomy, it might be impossible for the patient to endure the stress of all of these operative procedures at once. Therefore, we planned to perform staged treatment with prioritizing consideration. First, we instituted chemotherapy with the FOLFOX (oxaliplatin + fluorouracil + leucovorin) plus cetuximab regimen, which could adequately control both rectal and esophageal cancer. After 6 cycles of chemotherapy, high anterior resection combined with cystoprostatectomy and lateral segmentectomy plus partial hepatectomy was performed followed by staged esophagectomy with three-field lymph node dissection. It was possible to use oxaliplatin and cetuximab safely as neoadjuvant therapy not only for advanced rectal cancer but for esophageal cancer, and it was effective.     

Percutaneous radiologic and endoscopic gastrostomy: A two-year evaluation

Summary

There are two methods of minimally invasive gastrostomy placement: radiologic (RG) and endoscopic (PEG). In order to investigate the effectiveness of these two methods, this study examined those patients undergoing percutaneous gastrostomy at our institution from 1 July 1993 to 30 June 1995 (44 RG, 69 PEG). Compared to PEG, RG was a shorter procedure (33.5 min vs 41.2 min) and required less conscious sedation. RG also had a higher rate of technical success (100% vs 95.7%) and a lower rate of major complications (11.4% vs 16.7%). Thirty-day mortality was similar after both procedures. These results are consistent with those from a recent meta-analysis of the literature and suggest that radiologic gastrostomy may have advantages over PEG.     

经左胸小切口微创治疗食管、贲门癌

目的探索一种不使用胸腔镜辅助,单纯经开胸小切口微创治疗食管癌及贲门癌的手术方法。方法采用保留胸肌、不切断肋骨的微创开胸小切口技术,使用普通加长手术器械操作加单手入胸辅助的方法根治性治疗食管、贲门癌126例（研究组）。其中贲门癌29例,胸中、上段食管癌76例,胸下段食管癌21例。选取同期行常规开胸手术治疗的食管、贲门癌患者98例作为对照组。结果研究组的平均手术时间（167.4±29.4）min,切口长度平均（14.1±1.3）cm,开胸失血量小于30ml,手术中撑开肋骨（9.0±1.0）cm,全部未使用电视胸腔镜辅助,均获得满意的暴露效果。术后并发声音嘶哑2例,颈部吻合口瘘4例,胸部切口脂肪液化6例。全组无手术死亡。患者术后1～2d可下床活动,疼痛轻微,术侧上肢无明显运动受限,自然下垂可遮蔽全部或部分瘢痕,外形美观。结论不使用胸腔镜辅助,单纯经胸小切口单手辅助器械操作微创治疗食管癌是可行的,和电视胸腔镜一样具有损伤小、出血少、恢复快,不影响美观等优点;同时较电视胸腔镜手术时间短,适应证广,费用低廉等,值得推广。     

Case report. Laparoscopic pancreatic cystogastrostomy

Summary

Definitive management of pancreatic pseudocysts has traditionally involved surgical drainage via laparotomy. Minimally invasive percutaneous and endoscopic techniques for pseudocyst treatment have recently been described. The advantages of minimally invasive surgical techniques have led to the identification of new therapeutic applications of laparoscopy. We describe the technique we used to perform laparoscopic pancreatic cystogastrostomy. Although long-term predictions of morbidity, mortality and recurrence rates cannot be made based on a single case report, a laparoscopic approach to pancreatic pseudocyst is possible and may become an attractive treatment option.     

Two emergency cases of spontaneous esophageal perforation treated using a minimally invasive abdominal and left thoracic approach

Boerhaave's syndrome is a rare life‐threatening disease that requires prompt intervention. Thoracotomy has traditionally been considered the gold standard approach for treatment, but other minimally invasive approaches have recently been reported. Our institute reported the efficacy of minimally invasive abdominal and left thoracic approach in the treatment of patients with esophagogastric junction cancer and introduced it for the treatment of two patients with Boerhaave's syndrome. We intraoperatively sutured the rupture sites and irrigated the pleural cavity using thoracoscopy. Then, after confirming the absence of intraabdominal contamination, we performed jejunostomy or gastrostomy using laparoscopy. Patients' vital signs remained stable intraoperatively, and their postoperative periods were uneventful with no leakage or stricture. The minimally invasive abdominal and left thoracic approach for Boerhaave's syndrome is convenient and useful as it provides excellent visualization of the thoracic and abdominal cavities with the possibility of quickly switching between views.