Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

Purpose: Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection. Methods: Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy. Results: The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed. Conclusion: The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.     

腹腔镜胃间质瘤切除术23例

目的:探讨腹腔镜下胃间质瘤切除术的可行性及临床应用价值。方法:回顾分析23例腹腔镜下胃间质瘤切除术的手术方式、术中处理原则以及术后相关指标。结果:23例手术全部成功,平均手术时间(133±68)min,平均出血量40mL,术后平均肠道功能恢复时间(36.6±16.2)h,平均住院(8.1±3.0)d。结论:腹腔镜下胃切除术治疗胃间质瘤是安全、可行的,不同位置手术难易程度相差较大,位于后壁及近贲门部较大的间质瘤应格外慎重。     

Surgical Indication for Non-curative Endoscopic Resection in Early Gastric Cancer

Background Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without lymph node metastasis. However, after ER additional surgery may be needed to manage the risks presented by residual cancer or lymph node metastasis. Methods ER was performed on 344 gastric adenocarcinomas between November 2001 and April 2006 at the Korean National Cancer Center under the strict pre-procedural indication. The authors performed operations in 43 patients due to: residual mucosal cancer, a mucosal cancer larger than 3 cm, or a submucosal cancer regardless of size or margin involvement. ER and surgical specimens were reviewed and analyzed for residual cancer and lymph node metastasis. Results Based on examinations of ER specimens, cancer was confined to the mucosal layer in 15 patients (34.9%) and invaded the submucosal layer in 28 patients (65.1%). Surgical specimens showed residual cancer in 17 patients (39.5%) and lymph node metastasis in four (9.3%). Neither residual cancer nor lymph node metastasis was found in patients with less than 500 μm submucosal invasion without margin involvement in ER specimens. In three of four patients with lymph node metastasis, the depth of submucosal invasion was 500 μm or more; the remaining patient had a 4-cm-sized differentiated mucosal cancer. Conclusions When a pathologic evaluation of an ER specimen reveals more than 500 μm of submucosal invasion or a mucosal cancer of larger than 3 cm, surgery should be considered due to the risk of lymph node metastasis.     

全小肠切除术后残留肠道组织形态学代偿实验研究

目的 :研究全小肠切除术后 ,大鼠残留肠道的形态学代偿能力。方法 :建立全小肠切除大鼠模型 ,术后 12周处死 10只模型大鼠为实验组 ,10只正常大鼠为对照组。测量盲肠、结肠和十二指肠形态学指标。结果 :实验组结肠、盲肠及十二指肠的长度、直径、湿重、腺窝深度、皱襞 (绒毛 )高度及黏膜厚度明显增加 ,差别有极显著统计学意义 (P     

Additional Effect of Visceral Fat Resection in an Obese Rat Model of Gastric Banding

Background  There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgeries performed worldwide has increased in recent years. Although the function of visceral fat has gradually become clear, the effect of visceral fat resection is still unknown. The aim of this study was to clarify the additional effect of visceral fat resection in an obese rat model of gastric banding. Methods  Forty male Zucker fatty rats were divided into four groups: the control group, visceral fat resection group, gastric banding group, and gastric banding with visceral fat resection group. They were followed for 8 weeks after surgery, and their body weight change, cumulative food intake, metabolic parameters, and adipocytokines were measured. Results  The gastric banding rats either with or without visceral fat resection showed significant decreases in weight gain, cumulative food intake, and levels of metabolic parameters compared to the control rats. There were no significant differences in weight gain and cumulative food intake between gastric banding with and without visceral fat resection. However, gastric banding with visceral fat resection resulted in lower plasma levels of free fatty acid and TNF-alpha compared to gastric banding alone, and expression of adiponectin mRNA in the adipose tissue was significantly decreased with the addition of visceral fat resection compared with banding alone. There were no significant differences in any parameters between controls and rats receiving visceral fat resection alone. Conclusion  Visceral fat resection may improve adipocytokines and free fatty acid in an obese rat model of gastric banding. However, further studies are necessary before the procedure can be considered an option on bariatric surgery.     

腹腔镜进展期胃癌根治术66例报告

目的探讨腹腔镜进展期胃癌根治术的安全性及可行性。方法 2006年4月-2010年6月对66例进展期胃癌行腹腔镜胃癌根治术,其中远端胃癌根治性切除术41例;近端胃癌根治性切除术22例,全胃癌根治性切除术3例。结果 66例手术均获成功。手术时间：远端胃癌根治术平均280 min（220-340 min）;近端胃癌根治术平均269 min（215-325min）;3例根治性全胃切除术手术时间分别为340、370、410 min。平均切口长度6.0 cm（5.2-9.0 cm）。术中出血量：腹腔镜远端胃癌根治术平均160 ml（100-250 ml）,腹腔镜近端胃癌根治术平均200 ml（90-320 ml）,3例腹腔镜根治性全胃切除术出血量分别为200、350、400 ml。清扫淋巴结：远端胃癌根治术平均21枚（15-31枚）,近端胃癌根治术平均22枚（17-28枚）,3例根治性全胃切除术分别为25、29、35枚。65例术后随访3-48个月,平均20个月（〈1年21例,1-2年19例,〉2年25例）,均未见切口及戳孔肿瘤种植转移;1例ⅢB期术后1年出现腹腔种植转移后死亡,1例ⅢB期术后1年出现肝转移后死亡,其余患者均健在。结论腹腔镜进展期胃癌根治术安全可行,能够取得良好的近期疗效。     

进展期近端胃癌根治术联合脾脏切除术适应证的选择

目的探讨进展期近端胃癌根治术联合脾脏切除术的合理适应证。方法选取我院自2005年3月至2008年2月期间50例进展期近端胃癌行全胃切除患者为研究对象,根据脾脏是否切除分为切脾组(n=18)和保脾组(n=32),比较2组患者间手术时间、住院时间、术后并发症以及脾门淋巴结转移情况。结果切脾组手术时间、住院时间和膈下感染发生率均明显高于保脾组(P0.05)。切脾组与保脾组术后病理检查出的第10、11组淋巴结转移率的差异无统计学意义(P0.05)。结论进展期近端胃癌根治术时,脾脏和脾血管受侵是联合脾脏切除的合理适应证。     

Phase II Study of Limited Surgery for Early Gastric Cancer: Segmental Gastric Resection

Background: Endoscopic resection for treatment of early gastric cancer (EGC) is widely performed. Recently, however, surgeons began performing a limited operation for EGC when endoscopic resection was not indicated. This report discusses the surgical technique and the results of the limited operation, which is generally referred to as segmental resection (SR).Methods: Since 1990, a total of 50 patients with intramucosal invasive EGC of the middle stomach underwent SR. The procedure included a limited gastrectomy, limited lymph node dissection, and preservation of the vagal nerve. We examined the surgical risk, postoperative complications, and patient survival rates and compared the results for the SR-treated patients (group A) with results for patients with EGC who underwent subtotal gastrectomy and systemic lymph node dissection (group B).Results: Blood loss was less in group A (239±180 ml) than in group B (342±176 ml) (P<.05). The incidence of postoperative complications was also lower in group A (2.0%) than in group B (14.0%) (P<.05). The incidence of postoperative cholelithiasis was lower in group A (4.0%) than in group B (18.0%) (P<.05). All patients in both groups are alive without recurrence.Conclusions: Compared with distal gastrectomy, SR for EGC of the middle stomach decreased the surgical risk and postoperative complications without increasing the recurrence rate.Supported by a Grant-in-Aid for Cancer Research (9–3) from the Ministry of Health and Welfare, Japan.     

炎性细胞因子对大鼠肝细胞胆汁酸分泌的影响

目的探讨炎性细胞因子对肝脏胆汁酸分泌机制的影响.方法利用体外原代培养大鼠肝细胞、枯否细胞(Kupffer cell,KC)的方法和反向高效液相色谱(RP-HPLC)技术,观察部分炎性细胞因子(IL-I、IL6、TNFa)以及被内毒素(LPS)活化的KC上清液对肝细胞胆汁酸分泌的影响.结果(1)炎性细胞因子和活化的KC上清液刺激后,肝细胞培养上清液中GCDCA、GCA和TGA三种结合胆汁酸含量均较对照组明显降低(P＜0.01);(2)实验组(GCA±GDCA)/TGA(G/T)的比值较对照组G/T的比值明显升高(P＜0.05).结论炎性细胞因子可以改变大鼠肝细胞胆汁酸的分泌机制,导致胆汁酸分泌含量的减低,并引起胆汁酸比例的变化.     

Outcome of Patients With Proximal Gastric Cancer Depends on Extent of Resection and Number of Resected Lymph Nodes

Background: Studies have shown that the survival of patients with gastric adenocarcinoma is related to the number of regional lymph nodes with metastases. The probability of identifying node-positive cancers increases with the number of lymph nodes resected and examined. It has been recommended that at least 15 lymph nodes be removed and examined for adequate staging. Prospective randomized studies have shown the lymph node yield is much greater with the D2 resection than the D1. This study evaluated the relative contribution of both the number of resected lymph nodes and the extent of gastric resection (D1/D2) on the outcome of patients with proximal gastric cancer.Methods: The medical records of 114 patients with adenocarcinoma of the proximal stomach, who underwent a curative gastric resection, were reviewed. Patients were stratified into four groups, i.e., two groups, D1/D1.5 and D2/D2.5, based on the extent of resection, and two groups based on the number of lymph nodes removed, fewer than 15 lymph nodes and 15 or more lymph nodes. Survival was determined by the method of Kaplan-Meier and differences compared by the log-rank test. Multivariate analysis was performed by using the Cox model.Results: The number of resected lymph nodes had no effect on the survival of the group as a whole. A significant improvement in survival was noted for patients with a D2 or greater resection. The median survival of patients with 15 or more lymph nodes resected improved from 25 months to 42 months when treated with an extended resection, (D2 or D2.5). Resection of 15 or more lymph nodes alone, or combined with an extended resection, resulted in a statistically significant improvement in survival for patients in American Joint Committee on Cancer Staging (AJCC) stage II.Conclusions: Both resection of 15 or more lymph nodes and extended lymphadenectomy contributed to the survival advantage observed in patients with AJCC stage II gastric cancer. The D2 gastric resection prolonged the median survival time and improved the 5-year survival rate for patients with 15 or more resected lymph nodes.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Small Bowel Obstruction After Laparoscopic Gastric Bypass with Nonclosure of Mesenteric Defects

Methods:This is a retrospective review of a series of consecutive LGBs over a 3-year period. All procedures were performed by the same surgeon using the same technique. In no case was the mesenteric defect closed. A prospectively maintained database was used for data collection. Patients who returned with an SBO were the study group, and those who underwent revisional bariatric surgery or conversion to open operation were excluded.Results:There were 249 primary LGBs performed during the study period; 15 of the operations were followed by SBO, for an incidence of 6.0%. Four cases were caused by an internal hernia (IH), for an incidence of 1.6%, and 11 were caused by adhesions, which accounted for 73% of the SBOs.Conclusions:SBO after LGB is a relatively common complication. The incidence of SBO from IH with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed. Regardless of the cause of the SBO, operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed.     

Laparoscopic Local Resection Based on Sentinel Node Evaluation for Early Gastric Cancer: A Preliminary Report

We previously reported that lymphatic mapping using isosulfan blue can be used to identify sentinel nodes (SNs). This study was undertaken to evaluate the feasibility of using the SN technique in treating early gastric cancer and to explore its usefulness for minimal invasive surgery. Twenty-three patients with early gastric cancer who underwent SN biopsy were retrospectively evaluated. Based on SN evaluation, individualized surgery was performed in five patients with T1N0M0 gastric cancer. When pathological examination of frozen sections revealed metastasis in SNs, we performed a standard D2 gastrectomy. Laparoscopic local resection was applied when the SN biopsy was negative. Our results showed that the success rate with SN biopsy in early gastric cancer was 100%, as were the accuracy, sensitivity, and specificity. All five patients with early gastric cancer had SNs negative for metastases both by frozen section and by postoperative pathology. Thus, all these patients underwent laparoscopic local resection without extended lymphadenectomy. We conclude that SN biopsy is a useful tool to individualize the operative procedure, and laparoscopic local resection can be safely performed using SN guidance in selected patients with early gastric cancer.     

Laparoscopic Bowel Resection in the Setting of Metastatic Colorectal Cancer

Background This study aimed to review the outcomes of laparoscopic colorectal resection for patients with stage IV colorectal cancer. Methods From the prospectively collected database for patients who underwent surgery for colorectal cancer in our institution, those with stage IV colorectal cancer who underwent elective resection of tumor during the period from January 2000 to June 2006 were included. The outcomes of those with laparoscopic resection were reviewed and comparison was made between patients with laparoscopic and open resection. Results A total of 200 patients (127 men) with median age of 69 years (range: 25–91 years) were included, and 77 underwent laparoscopic resection. Conversion was required in ten patients (13.0%) and all except one conversion were due to fixed or bulky tumors. There was no operative mortality in the laparoscopic group. The complication rate was 14% and the median postoperative hospital stay was 7 days. When patients with laparoscopic resection were compared with those with open operations, there was no difference in age, gender, comorbidity, or tumor size between the two groups. However, the complication rate was significantly lower in those with laparoscopic resection (14% versus 32%, P = 0.007) and the median hospital stay was significantly shorter (7 days versus 8 days, P = 0.005).The operative mortalities and the survivals were similar in the two groups. Conclusions Colorectal resection can be performed safely in patients with stage IV colorectal cancer. The operative outcomes in terms of complication rate and hospital stay compare favorably with patients with open resection. Presented in the Scientific Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons on 18–22 April 2007 in Las Vegas, Nevada, USA.     

慢性前列腺炎患者前列腺液中尿酸检测及临床意义

目的:检测慢性前列腺炎患者EPS中的尿酸(UA)水平并探讨其临床意义。方法:按NIH诊断标准确诊的91例慢性前列腺炎患者分为2组,ⅢA组(n=48)和ⅢB组(n=43)。对照组(n=22)为无慢性前列腺炎的健康志愿者。分别进行CPSI评分,EPS中WBC计数、pH值及UA浓度测定。结果:ⅢB组的EPS中UA浓度[(257.02±144.84)μmol/L]显著高于ⅢA组[(159.73±121.49)μmol/L,P<0.01]和对照组[(78.55±44.53)μmol/L,P<0.01]。EPS中UA水平与pH值之间呈负显著相关(r=-0.398,P<0.01),而与CPSI疼痛症状评分(CPSI-P)、排尿症状评分(CPSI-U)以及CPSI总分(CPSI-T)之间均呈显著正相关(r分别为0.436、0.316、0.403,P均<0.01)。结论:前列腺内的UA浓度升高可能会导致化学性炎症反应。EPS中的UA水平与慢性前列腺炎的症状相关。检测EPS中的UA水平对慢性前列腺炎的诊断和治疗具有重要意义。     

Small Bowel Obstruction Secondary to Intragastric Erosion and Migration of A Gastric Band

We describe what we believe to be the first reported case of intragastric erosion and migration to the jejenum of a laparoscopically inserted gastric band, 3 months after the original bariatric surgery was performed. This had caused ulceration and necrosis of the small bowel as the tension in the port tubing had caused the bowel to become concertinaed over it and resulted in a cheese-wire effect through the jejunal convolutions. As bariatric surgery becomes more common, patients with complications of their procedure may present to the general surgeon as an emergency. We recommend early intervention in patients with gastric erosion.     

The Impact of Small Bowel Resection on the Incidence of Stomal Stenosis and Marginal Ulcer After Gastric Bypass

Background: Stomal stenosis (SS) and marginal ulcer (MU) are reported to occur in 9-20% and 2-13%, respectively, of patients undergoing gastric bypass for morbid obesity. It is hypothesized that decreasing tension on the gastrojejunostomy by performing limited small bowel resection (SBR) would decrease ischemia, thereby decreasing the likelihood of SS and MU. Methods: A retrospective review of 150 consecutive gastric bypass patients operated by one surgeon from 1993 to 1996 was performed. The incidence of SS and MU was compared in patients with and without SBR. Results: The overall rate of SS was 24.0% and that of MU was 9.3%: the incidence of both was 2.0%. The incidence of SS in patients without SBR was 26.9% and with SBR was 19.6%. The incidence of MU in patients without SBR was 8.9% and with SBR was 9.8%. Neither result was statistically significant by Fisher's exact test. Conclusion: There is a trend towards a decrease in the incidence of SS in gastric bypass patients with concomitant SBR although this did not reach clinical significance.     

Intussusception: An Uncommon Cause of Postoperative Small Bowel Obstruction after Gastric Bypass

Intussusception of the jejuno-jejunal anastomosis is a rare complication of the Roux-en-Y gastric bypass (RYGBP).There are only 3 previous cases reported in the surgical literature. We describe 2 adults who developed jejuno-jejunal intussusception requiring emergent laparotomy several months after RYGBP. Both patients underwent exploratory laparotomy after the diagnosis was made with abdominal CT scan. Each patient had an uneventful postoperative course after bowel resection and revision of the enteroenterostomy. Small bowel obstruction due to intussusception may occur many months after RYGBP and may present with non-specific symptoms such as crampy abdominal pain, nausea, and vomiting. The diagnosis of this rare entity is typically made via abdominal CT scan. Treatment mandates urgent abdominal exploration with reduction.     

急性胆道感染大鼠肝细胞原胆汁分泌的改变

目的:观察急性胆道感染大鼠肝细胞原胆汁分泌的变化.方法:制作急性胆道感染大鼠动物模型,取其肝细胞进行原代培养,利用反向高效液相色谱(RP-HPLC)技术,检测肝细胞培养上清液中胆汁酸和UCB含量.结果:急性胆道感染大鼠肝细胞培养上清液中均可检出一定量的非结合胆红素(UCB),同时三种主要结合胆汁酸(GCA,GCDCA,TCA)分泌减少,与对照组比较,有显著性差异(P＜0.01).结论:急性胆道感染大鼠肝细胞分泌会发生明显改变,原胆汁分泌胆汁酸减少,胆色素代谢发生改变,对胆色素结石的形成具有一定的影响.