BackgroundDespite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern.AimThe aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS).MethodsRandomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search.ResultsThere were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR=0.605; 95% CI 0.382-0.958; p=0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR=1.425; 95% CI 1.002-2.028; p=0.049). BTS stent significantly increased the risk of systemic recurrence (RR=1.627; 95% CI 1.009-2.621; p=0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival.ConclusionBTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.
BackgroundAlthough laparoscopic liver resection (LLR) has advanced into a safe and effective alternative to conventional open liver resection (OLR), it has not been widely accepted by surgeons. This article aimed to investigate the perioperative and long-term benefits of LLR versus OLR for hepatocellular carcinoma (HCC) in selected patients with well-preserved liver function and cirrhotic background.MethodsA retrospective study was conducted on 1085 patients with HCC who underwent liver resection at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from July 2010 to July 2015, and 346 patients with well-preserved liver function and cirrhotic background were selected. A 1:1 propensity score matching (PSM), which is the best option to overcome selection bias, was conducted to compare the surgical outcomes and long-term prognosis between LLR and OLR. After PSM, a logistic regression analysis was used to identify the predictive risk factors of posthepatectomy liver failure (PHLF).ResultsBy using PSM, the two groups were well balanced with 86 patients in each group. In the LLR group, only the median operation time was significantly longer than the OLR group, but the hospital stay, overall morbidity, and the incidence of PHLF were significantly decreased compared to OLR. There were no significant differences in the overall survival and disease-free survival rates between the two groups. On multivariate analysis, OLR was identified to be the only independent risk factor for PHLF.ConclusionsIn selected HCC patients with well-preserved liver function and cirrhotic background, LLR could be a better option compared to OLR.
BackgroundMany studies have shown that robotic gastrectomy requires a longer operation time than laparoscopic gastrectomy. However, no study has analyzed the exact reason for this difference in detail. We therefore investigated the reasons why more time is needed in robotic gastrectomy.MethodsTen consecutive cases of robotic distal gastrectomy (RDG) performed in our institution were selected to measure the operation time in detail. Ten cases of laparoscopic distal gastrectomy (LDG) performed during the same period were chosen for comparison. The operation videos and electronic medical records of these 20 patients were retrospectively reviewed. The overall operation time, operation time in each step, and time required for instrument changes were measured. The number of intraoperative instrument changes and camera cleanings were also counted.ResultsThe overall operation time (including effective time and junk time) was 56.8min longer for RDG than LDG (273.7 vs. 216.9min, respectively; p=0.000). The effective time was only 15.3min longer for RDG than LDG (145.9 vs. 130.6min, respectively; p=0.094). The time needed for the six technical steps was also not significantly different between the two groups. However, the junk time (instrument setup and docking or positioning of surgical arms) was 41.5min longer for RDG than LDG (127.8 vs. 86.2min, respectively; p=0.001). The number of instrument changes was not different between RDG and LDG (p=0.277), but the time required for each was longer for RDG than LDG (p=0.000). The number of camera cleanings was lower for RDG than LDG (10.7 vs. 15.5 times, respectively; p=0.005).ConclusionsTo reduce the operation time in RDG, a smarter and simpler system for setup should be developed to reduce the junk time. Additionally, a system for swifter instrument changes and more sophisticated energy devices are warranted to reduce the effective time.
BackgroundControl of bleeding is extremely important for laparoscopic liver resection. We introduce a new and operationally simple laparoscopic hepatic inflow occlusion apparatus (LHIOA) and its successful application in laparoscopic surgery for patients with cirrhosis.MethodsThe self-designed LHIOA was constructed using a tracheal catheter (7.5#) and infusion set. The tracheal catheter and infusion set were trimmed to 30 and 70cm, to serve as an occlusion tube and occlusion tape, respectively. After establishment of pneumoperitoneum, the occlusion tape was inserted to encircle the hepatoduodenal ligament. The occlusion tube was then introduced and the ends of the occlusion tape were pulled out of it to occlude the hepatic inflow. Under intermittent vascular occlusion with the LHIOA, the liver parenchyma was transected using an ultrasonic scalpel and monopolar electrocoagulation. Outcomes of the application of the LHIOA in hepatocellular carcinoma patients with cirrhosis (LHIOA group, n=46) were compared with patients undergoing laparoscopic hepatectomy without LHIOA (non-LHIOA group, n=46), using one-to-one propensity case-matched analysis.ResultsThe LHIOA effectively occluded the hepatic inflow while showing no damage to the hepatoduodenal ligament. The time required for presetting the LHIOA is 6.80.6min. The conversion rate in the non-LHIOA group was 13.0% while there was no conversion in the occlusion group (P<0.001). The median blood loss of patients in the LHIOA group (60ml, range 50-200ml) was significantly less than that of patients in the non-LHIOA group (250ml, range 100-800) (P<0.001). Transfusion was required in 8 patients in the non-LHIOA group while no transfusion was required in the LHIOA group. The median operative time in the LHIOA group (157min, range 80-217min) was significantly shorter than that in the non-LHIOA group (204min, range 105-278min) (P<0.001).Conclusions The new LHIOA is effective, safe, and simple. It can significantly reduce conversion rate, blood loss, and operative time. It facilitates laparoscopic liver resection and is recommended for use.
BackgroundLaparoscopy-assisted distal gastrectomy (LADG) for gastric cancer has been widely applied; however, its oncologic efficacy has yet been well established. The study aimed to compare the long-term oncologic outcomes of LADG versus open distal gastrectomy (ODG) on gastric cancer.MethodsThe clinicopathologic data of gastric cancer patients who underwent distal gastrectomy with curative intent from October 2004 through September 2014 were included and analyzed in a retrospective cohort. The last follow-up was September 2016.Results769 eligible patients (LADG 414 vs. ODG 355) were included in the study. No significant difference was observed between the groups in 5-year DFS (LADG 61.2% vs. ODG 59.1%; p=0.384) and OS rates (LADG 65.8% vs. ODG 66.3%; p=0.750). During surgery, though LADG group had longer operating time, the blood loss was less than ODG group. LADG group had faster postoperative recovery course including shorter time to oral intake, ambulation, and discharge time. Postoperative complication rate within 30days showed no significant difference between the groups (LADG 15.7% vs. ODG 13.0%; p=0.281). Age over 65years old, blood loss>200ml, postoperative complication, and advanced T and N stage were identified as independent risk factors for DFS and OS.ConclusionsLADG could yield similar oncologic outcomes compared with ODG in treating distal gastric cancer. However, the findings need to be further confirmed through ongoing prospective randomized controlled trials.
BackgroundTo determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer.MethodsThe clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had1 of the following conditions were defined as high-risk patients: (1) age80 years; (2) BMI30kg/m(2); (3) ASA (American Society of Anesthesiologists) grade3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer.ResultsA total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n=341) and the OG group (n=341). The operative time (181.70 vs. 266.71min, p<0.001) and blood loss during the operation (68.11 vs. 225.54ml, p<0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p=0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p=0.019). The number of risk factors was an independent risk factor for postoperative complications (p=0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p=0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p>0.05).ConclusionsFor high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG.
BackgroundAlthough laparoscopic surgery has been recommended as an optional therapy for patients with early gastric cancer, whether patients with locally advanced gastric cancer (AGC) could benefit from laparoscopy-assisted distal gastrectomy (LADG) with D2 lymphadenectomy remains elusive due to a lack of comprehensive clinical data. To evaluate the efficacy of LADG, we conducted a multi-institutional randomized controlled trial to compare laparoscopy-assisted versus open distal gastrectomy (ODG) for AGC in North China.MethodsIn this RCT, after patients were enrolled according to the eligibility criteria, they were preoperatively assigned to LADG or ODG arm randomly with a 1:1 allocation ratio. The primary endpoint was the morbidity and mortality within 30 postoperative days to evaluate the surgical safety of LADG. The secondary endpoint was 3-year disease-free survival. This trial was registered at ClinicalTrial.gov as NCT02464215.ResultsBetween March 2014 and August 2017, a total of 446 patients with cT2-4aN0-3M0 (AJCC 7th staging system) were enrolled. Of these, 222 patients underwent LADG and 220 patients underwent ODG were included in the modified intention-to-treat analysis. The compliance rate of D2 lymph node dissection was identical between the LADG and ODG arms (99.5%, P=1.000). No significant difference was observed regarding the overall postoperative complication rate in two groups (LADG 13.1%, ODG 17.7%, P=0.174). No operation-related death occurred in both arms.ConclusionsThis trial confirmed that LADG performed by credentialed surgeons was safe and feasible for patients with AGC compared with conventional ODG.
BackgroundDuodenum-preserving total pancreatic head resection (DPPHRt) is an accepted alternative surgical procedure for benign or low-grade malignant tumors of the pancreatic head by preserving the duodenum with its intact blood supply from the pancreatic duodenal arterial arcade. This study describes our experience in laparoscopic DPPHRt (LDPPHRt). To our knowledge, this is the first description of this novel minimally invasive operation.MethodsFrom August 2016 to May 2017, all consecutive patients who underwent LDPPHRt for pancreatic head lesions at the HPB Surgery Department, Sun Yat-Sen Memorial Hospital in Guangzhou, China were enrolled into this retrospective study.ResultsThere were ten women and two men. The average age was 37.3years (range 8-61years). The average diameter of the pancreatic head lesions on pre-operative CT/MR was 3.7cm (range 2-4.8cm). All the LDPPHRt procedures were performed successfully. There was no peri-operative death. The average operative time was 272.5min (range 210-320min). The average blood loss was 215ml (range 50-450ml). Post-operative complications included pancreatic fistula grade B (two patients, or 16.7%) and biliary fistula (two patients, or 16.7%). All the complications responded well to conservative treatment. The mean post-operative hospital stay was 11.5days (range 6-25days).ConclusionsLDPPHRt provided a minimally invasive approach with good organ-preservation for benign or low-grade malignant tumors of the pancreatic head. The long-term oncological outcomes, and the exocrine and endocrine pancreatic functions after this operation require further studies.
AimTo establish the clinical value of endoscopic papillectomy for duodenal papillary tumor based on endoscopic and clinical characteristics.Patients and methodsThis single-center, retrospective study included 110 patients with duodenal papillary tumor who underwent endoscopic papillectomy between January 2006 and April 2017at the gastrointestinal endoscopic center of the Chinese PLA General Hospital. Clinical data, postoperative pathology, procedure-related complications, and therapeutic outcomes were analyzed.ResultsEndoscopic papillectomy was technically feasible in all patients, and was mainly performed by four experienced endoscopists. The primary success rate of endoscopic papillectomy for ampullary neoplasms was 78.2%. A total of 13 patients experienced recurrence during a mean follow-up period of 16.28 months (range 6-132months), the predictive factors that were related to recurrence were complete resection (53.8% vs. 94.2%; P=0.001), and final pathology findings (P=0.001). Delayed hemorrhage, the most common procedure-related complication, occurred in 20% (22/110) of patients and was significantly related to intraoperative bleeding (P=0.042). Pancreatitis was the second most common complication, which was closely related to intraoperative bleeding requiring intervention (P=0.040) and larger tumor size (P=0.044). Histology, type of resection, stent placement, sphincterotomy, and duration of procedure were not related to post-procedure hemorrhage or pancreatitis. Older age (63.713.5 vs. 57.4 +/- 12.2; P=0.033), jaundice (47.8% vs. 13.8%; P=0.001), endoscopic forceps biopsy diagnosis of high-grade intraepithelial neoplasia (82.6% vs. 14.9%; P=0.001), tumor size2cm (60.9% vs. 34.5%; P=0.022), and dilation of the bile duct (34.8% vs. 9.2%; P=0.006) were clinical features for ampullary carcinoma. The rate of complete resection (52.2% vs. 92.0%; P=0.001) and recurrence (34.8% vs. 6.8%; P=0.001) were also related to the diagnosis of ampullary carcinoma at final pathology.Conclusions Endoscopic papillectomy is a feasible and reasonable option for both diagnosis and treatment of tumors of the duodenal papilla in properly selected patients.
BackgroundEmerging evidence has demonstrated that either laparoscopic-assisted gastrectomy (LAG) or robotic-assisted gastrectomy (RAG) could be adopted as standard treatment for early gastric cancer. However, the long-term survival and recurrence rate after LAG or RAG for locally advanced gastric cancer (AGC) has seldom been reported.MethodsWe retrospectively analyzed the data from 339 patients who underwent LAG and 163 patients who underwent RAG from a prospectively established database in the Chinese People's Liberation Army General Hospital. We compared the short- and long-term oncological outcomes of the RAG group versus the LAG group in the entire cohort, and in a propensity score-matched cohort.ResultsBefore propensity score matching (PSM), the two groups revealed comparable 3-year overall survival rates (OS, RAG vs. LAG: 76.1 vs. 81.7%, p=0.118), and recurrence-free survival rates (RFS, RAG vs. LAG: 73.0 vs. 67.6%, p=0.297). Similar results were obtained in the propensity score-matched cohort; the respective overall survival rates in the propensity score-matched RAG and LAG groups were 76.1 and 79.8% (p=0.552), and the respective RFS rates were 73.0 and 68.7% (p=0.386). After PSM, RAG was still associated with a significantly longer mean operating time (249.4663.26 vs. 232.17 +/- 65.39min, p=0.008) and higher total costs (133.38 +/- 41.62 vs. 95.34 +/- 29.39 10(3) RMB, p<0.001) than LAG; the two groups did not significantly differ in other surgical and oncological characteristics.Conclusion Although there were some differences in the outcomes of RAG versus LAG in AGC patients, both RAG and LAG were similar in short-term recovery and long-term oncological outcomes.
Background and aimsSurgical planning in liver resection depends on the precise understanding of the three-dimensional (3D) relation of tumors to the intrahepatic vascular trees. This study aimed to investigate the impact of 3D printing (3DP) technology on the understanding of surgical liver anatomy.MethodsWe selected four hepatic tumors that were previously resected. For each tumor, a virtual 3D reconstruction (VIR) model was created from multi-detector computed tomography (MDCT) and was prototyped using a 3D printer. Forty-five surgical residents were evenly assigned to each group (3DP, VIR, and MDCT groups). After evaluation of the MDCT scans, VIR model, or 3DP model of each tumor, surgical residents were asked to assign hepatic tumor locations and state surgical resection proposals. The time used to specify the tumor location was recorded. The correct responses and time spent were compared between the three groups.ResultsThe assignment of tumor location improved steadily from MDCT, to VIR, and to 3DP, with a mean score of 34.50, 55.25, and 80.92, respectively. These scores were out of 100 points. The 3DP group had significantly higher scores compared with other groups (p<0.001). Furthermore, 3DP significantly improved the accuracy of surgical resection proposal (p<0.001). The mean accuracy of the surgical resection proposal for 3DP, VIR, and MDCT was 57, 25, and 25%, respectively. The 3DP group took significantly less time, compared with other groups (p<0.005). The mean time spent on assessing the tumor location for 3DP, VIR, and MDCT groups was 93, 223, and 286s, respectively.Conclusions3D printing improves the understanding of surgical liver anatomy for surgical residents. The improved comprehension of liver anatomy may facilitate laparoscopy or open liver resection.
BackgroundHemorrhage during the liver transection is the major hazard for laparoscopic hepatectomy (LH). We aimed to evaluate the feasibility and safety of a 915-MHz microwave device used in LH.MethodsData were retrospectively analyzed regarding 60 patients who underwent LH with or without 915-MHz microwave coagulation at our center from January 2016 to June 2016. 30 patients underwent the 915-MHz microwave-assisted LH (MW group), and 30 patients otherwise were considered as control group.ResultsNo perioperative mortality was observed. Intraoperative blood loss amounts in microwave group and control group were 26.83ml and 186.33ml, respectively (P<0.001). The durations of parenchyma transaction (55.17 vs. 70.83min, P<0.001), blood occlusion (2.17 vs. 25.33min, P<0.001), and operation (120.67 vs. 148.00min, P<0.001) were much shorter in microwave group compared with control group. Lower incidence of postoperative complications (0.0 vs. 14.3%, P=0.038) and shorter length of postoperative hospital stay (6.00 vs. 7.23 days, P=0.027) were also noted in the microwave group, compared with the control group.Conclusion915-MHz microwave-assisted LH was found to be safe and efficient.
Objective Middle pancreatectomy (MP) is safe and feasible in patients with benign or low-grade malignant tumors located at the neck or proximal body of the pancreas. As a tissue-sparing operation, MP can preserve normal pancreatic function and reduce the risk of postoperative endocrine and exocrine insufficiency. However, the morbidity, especially the postoperative pancreatic fistula (POPF) rate, remains high. A robot-assisted surgical system may provide patients with less trauma; however, there are few reports on robot-assisted middle pancreatectomy (RMP). We describe the experience of RMP at our center to illustrate the learning curve (LC). Methods From August 2010 to July 2017, 100 patients underwent RMP in the Pancreatic Disease Center of Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine. Patient characteristics, operative outcomes, and oncological outcomes were collected and analyzed. The CUSUM curve was analyzed according to operative time and estimated blood loss (EBL) and was used to describe the LC and identify the flexion points. Results Among the 100 patients who underwent RMP in our hospital, the mean age was 47.5 +/- 14.2 years, and 69 patients were female. From the CUSUM curve, we found two flexion points: cases 12 and 44. After 44 cases, the rate of improvement was much faster. We separated the patients into two groups based on the LC (cases 1-44 and cases 45-100). There were significant improvements in operative time (173.1 +/- 44.7 min vs. 137.3 +/- 30.1 min, p < 0.001) and EBL (103.4 +/- 90.0 ml vs. 69.3 +/- 53.9 ml, p = 0.021). The overall POPF rate was 32% (32/100), while the incidence rate of biochemical leakage was 14% (14/100). However, there was no significant difference in the risk of POPF or other complications between the two groups. The postoperative length of stay (LOS) was also not different. The 90-day mortality rate was 1%. From our long-term follow-up, pancreatic function was preserved in most patients, with only three cases of endocrine insufficiency and two cases of exocrine insufficiency. Conclusion RMP was helpful and a good choice for the selected patients. PF was the main complication and has not been improved until now. There were two flexion points in the LC at cases 12 and 44. More cases are needed to gain more experience. A larger sample size and prospective studies are needed to verify the advantage of RMP.
Background and objectivesTransanal total mesorectal excision (TaTME) is positioned at the cutting edge of minimally invasive approach to mid- and low rectal cancer. This meta-analysis was to compare the short- and long-term outcomes of TaTME versus laparoscopic total mesorectal excision (LTME) and to evaluate the safety, efficacy, and possible superiority of TaTME.MethodsA comprehensive search was conducted for randomized controlled trials (RCTs) and non-RCTs (NRCTs) comparing TaTME with LTME. Inter-group differences were evaluated via standardized mean differences and relative risks (RRs). All outcomes were analyzed using fixed effects or random effects models according to the heterogeneity. Statistical analysis was performed using Stata/SE 12.0 software.ResultsEleven studies (1 RCT and 10 NRCTs) with involving 757 patients were included. Among which, 361 patients underwent TaTME and 396 patients underwent LTME. Comparing the surgical and oncological quality of resection of TaTME with that of LTME, reports of TaTME indicated favorable outcomes considering mesorectal resection quality, circumferential resection margin involvement, intraoperative blood loss, conversions, and postoperative complications, while the differences between the two groups had no statistical significance in terms of distal resection margin, harvested lymph node, operation time, hospital stay, recurrence, 2-year overall survival (OS), and 2-year disease-free survival.ConclusionTaTME is a promising surgical technique and is fully a safe, efficacious, and diffusible alternative to LTME in managing mid- and distal rectal cancer. Larger scale, national, multicentric RCTs are warranted to further verify these results and the possible superiority of TaTME.
BackgroundTo investigate the safety and feasibility of the completely medial access by page-turning approach (CMAP) for laparoscopic right hemi-colectomy.MethodsIn this retrospective study, the data from 72 patients who underwent laparoscopic right hemi-colectomy with CMAP were analyzed and compared with data from 124 patients who underwent the conventional medial approach performed by the same surgical team from September 2011 to March 2017.ResultComplete mesocolic excision (CME) was achieved in 67 of 72 patients (93.1%) with laparoscopic CMAP. The average operation time, blood loss, and specimen length was 135.928.3min, 63.2 +/- 32.2ml, and 23.9 +/- 4.7cm, respectively. The number of lymph nodes harvested was 20.6 +/- 7.7, the time-to-flatus was 2.5 +/- 0.8 days, the time-to-fluid intake was 3.2 +/- 0.8 days, and the average hospital stay was 8.9 +/- 4.7 days. No intra-operative complications occurred in this study. The vessel-related complication and total post-operative complication rate was 2.78% (2/72) and 6.94% (5/72), respectively.Conclusions Laparoscopic CMAP was an alternative approach for CME in laparoscopic right hemi-colectomy, which was proved safe and feasible for right colon cancer.