Pros and cons of the gasless laparoscopic transhiatal esophagectomy for upper esophageal carcinoma.

BACKGROUND: Controversies on how to treat upper esophageal carcinoma have existed for several decades. With the application of minimally invasive techniques, surgical treatment to upper esophageal carcinoma tends to show more advantages and attract more patients. Up to now, most hospitals adopted the combined thoracoscopic and laparoscopic esophagectomy (CTLE) as the way of minimally invasive surgery for upper esophageal carcinoma. But CTLE to treat upper esophageal carcinoma has its drawbacks, such as demanding certain pulmonary function and severe postoperative regurgitation. In 2011, we developed the gasless laparoscopic transhiatal esophagectomy (LTE) to treat upper esophageal carcinoma, which showed some advantages. The aim of this article was to compare LTE with CTLE in treating upper thoracic or cervical esophageal carcinoma and assess the value of LTE. METHODS: From 2009 to 2014, esophagectomy has been performed by the introduction of minimally invasive surgery in a total of 83 patients with upper thoracic or cervical esophageal carcinoma. Among these patients, LTE was performed in 27 cases (Group 1), while CTLE was performed in the other 56 (Group 2). Neoadjuvant chemotherapy was done in patients of Group 1. RESULTS: There were no operation-related deaths and conversion to open procedure. There was no significant difference in postoperative complications, ventilation time, ICU stay, hospital stay, and anastomotic leak rates between the two groups. But LTE was associated with shorter operative time and less intraoperative blood loss. In Group 2, 21 (37.5 %) patients had postoperative pulmonary complications, while in Group 1, there were 6 (22.2 %) patients having pulmonary complications at least one time. Results of 24-h pH monitoring and manometry showed that postoperative laryngo-pharyngeal reflux (PLPR) was more severe in Group 2 patients than in Group 1; for Group 1, PLPR mainly occurred on sleep stage, while for Group 2, PLPR might exist all the day with short intervals and last longer at night. The median overall survival was 27.2 months after CTLE and 30.8 months after LTE (P = 0.962). There was no significant difference in survival at 2, 3 and 4 years between the two groups. CONCLUSIONS: Compared with CTLE, LTE is a more minimally invasive approach to effectively treat patients with upper esophageal carcinoma. Laryngo-pharyngeal reflux after LTE was less severe than that after CTLE, which might lower incidence of pulmonary complications. For the elderly patients, LTE seems more suitable.

Gasless laparoscopically assisted transhiatal esophagectomy for upper esophageal carcinoma.

BACKGROUND: Transhiatal esophagectomy frequently is thought to achieve lower morbidity by sacrificing long-term survival at 5 years. With the introduction of the isobaric laparoscopy using abdominal wall lifting, the authors explore gasless laparoscopically assisted transhiatal surgical treatment of upper thoracic or cervical esophageal carcinoma after neoadjuvant chemotherapy. They wish it not only lower morbidity but also similarity to transthoracic esophagectomy, with extended en bloc lymphadenectomy in aspects of median overall, disease-free, and quality-adjusted survival. METHODS: Between 2011 and 2013, 11 patients with upper thoracic or cervical esophageal carcinoma were treated at the authors' department. Neoadjuvant chemotherapy was administered to these patients. Their clinical data were retrospectively analyzed. The tumor originated from the cervical esophagus in eight of these patients and from upper thoracic esophagus in three of them. None of the patients were receiving preoperation radiotherapy. RESULTS: No operation-related deaths or conversion to open procedure occurred. The mean operative time was 146.0 ± 22.2 min, and the mean intraoperative blood loss was 192.7 ± 25.5 ml. Anastomotic leakage occurred in three cases, pulmonary complications in one case, cardiac complications in two cases, and herniation of part of the colon into the right thorax in one case. Two patients received postoperative auxiliary radiotherapy. All the patients were followed up for 6 months to 3.5 years. During the follow-up period, three patients experienced pulmonary complications at least once. All the patients reported heartburn and regurgitation from time to time after surgery. The survival rate was 63.6%. CONCLUSION: With neoadjuvant chemotherapy, gasless laparoscopically assisted transhiatal esophagectomy provides a minimally invasive surgical treatment for upper thoracic or cervical esophageal carcinoma. But it seems that the postoperative complications are relatively high. Further study is needed to determine whether it can improve long-term survival.

(Z)-N-{3-[(2-Chloro-1,3-thia-zol-5-yl)meth-yl]-1,3-thia-zolidin-2-yl-idene}cyanamide.

In the title compound, C(8)H(7)ClN(4)S(2), the thia-zole ring is essentially planar [r.m.s. deviation = 0.0011 (2) Å] and conformation of the thia-zolidine ring is twisted on the C-C bond. The C=N bond has a Z configuration.

Differentiating Glioblastoma from Primary Central Nervous System Lymphoma: The Value of Shaping and Nonenhancing Peritumoral Hyperintense Gyral Lesion on FLAIR Imaging.

BACKGROUND: This study describes a distinct magnetic resonance imaging (MRI) feature, placing emphasis on fluid-attenuation inversion recovery (FLAIR) and contrast-enhanced T1-weighted (T1C) images for the preoperative differentiation of glioblastoma (GBM) from primary central nervous system lymphoma (PCNSL). METHODS: The preoperative MRI findings of 116 pathologically confirmed glioblastoma (n = 72) and PCNSL (n = 44) were retrospectively reviewed. Two neuroimaging specialists analyzed the MRIs, and image analysis was focused on the presence or absence of a shaping and nonenhancing peritumoral hyperintense gyral lesion on FLAIR imaging (SNEPGF, i.e., hyperintense lesion in a shaping and nonenhancing peritumoral gyral area on FLAIR imaging). The gyral area adjacent to and within 3 cm of the enhanced tumor was defined as the peritumoral gyrus region. The FLAIR hyperintensity lesion were termed as the signal intensity ratio ≥30% compared with contralateral normal gray matter. Then, the differential diagnostic efficacy of SNEFPG sign for GBM and PCNSL was analyzed. RESULTS: The SNEPGF sign was found in 33 GBM cases (33 of 72, 45.8%), and the FLAIR signal intensity and apparent diffusion coefficient value of these area were lower than the peritumoral edema area (P < 0.0001). In 44 PCNSL cases, no SNEPGF sign was found. A slightly higher FLAIR signal intensity was seen in 9 PCNSLs, but uniform and marked enhancement was seen in these areas. The sensitivity, specificity, positive predictive value, and negative predictive value of the differential diagnosis of GBM and PCNSL with SNEPGF sign were 45.8%, 100%, 100%, and 53.0%, respectively. CONCLUSIONS: The SNEPGF sign is effective in identifying GBM from PCNSL, especially with high specificity.

2-Isopropyl-3-methyl-quinoxaline 1,4-dioxide.

In the title compound, C(12)H(14)N(2)O(2), the quinoxaline ring system and the C atoms of the methylene and methyl substituents lie on a mirror plane. The crystal packing is stabilized by weak π-π inter-actions [centroid-centroid distance = 3.680 (7) Å].

[Long-term results of esophageal motor dysmotility after Heller's myotomy for achalasia].

OBJECTIVE: To investigate the long-term characteristics of both clinical manifestation and esophageal motor disturbance in achalasia patients after Heller's myotomy. METHODS: After 3 to 10 years' follow-up, clinical manifestation, esophageal motor function and 24-hour continuous esophageal pH monitoring in 72 post-operative cases of achalasia were recorded. RESULTS: The mean LES pressure decreased from 44 + or - 12 mm Hg to 10 + or - 5 mm Hg, and the rate of L ES relaxation rised from 49% + or - 20% to 84% + or - 15% (paired t test, P < 0.05). Of 24 cases with choking feeling, 11 had the high LES pressure and dysfunction in two directions and 7 in three. During swallowing, incomplete lower esophageal sphincter relaxation and aperistalsis were detected in all patients. CONCLUSIONS: The long-term characteristics of esophageal function following successfully surgical treatment to patients with Achalasia are: (1) After Heller's myotomy, LESP in at least one direction is lower than the normal standard, while higher in at least one direction. (2) During swallowing, the esophageal rear wall is lack of complete LES relaxation. For patients with choking feeling, complete LES relaxation occurs in 2-3 directions. (3) Due to lack of esophageal peristalsis, food goes through esophagus by gravitation.

[The comparative analysis of video-assisted thoracoscopic versus transsternal thymectomy for myasthenia gravis].

OBJECTIVE: To investigate different characteristics of the video-assisted thoracoscopic (VATS) versus transsternal thymectomy for myasthenia gravis (MG). METHODS: The clinical data of 106 patients who underwent VATS thymectomy for MG between February 2002 and May 2007, and 108 patients who underwent transsternal thymectomy between March 1998 and August 2003 were analyzed retrospectively. In VATS group, there were 64 male and 42 female patients, and the mean age was 38-years-old. In the transsternal group, 68 patients were male and 40 were female, and the mean age was 36-years-old. Analysis of conditions related to the surgical procedure between two groups was made, such as length of surgery, operative bleeding, postoperative drainage, hospital stay, hospitalization expenses and complications. The mean time of follow-up was 38.5 months (ranging from 10 to 67 months). All patients were classified according to the MGFA clinical classification. RESULTS: Intraoperative bleeding in VATS group was (34 +/- 5) ml, significantly less than (150 +/- 23) ml in the transsternal group. Postoperative drainage in VATS group was (42 +/- 18) ml, significantly less than (168 +/- 31) ml in the transsternal group. Complications and hospital stay in VATS group were also significantly lower than those in the transsternal group. There was no significantly different in the long-term outcome between two groups. CONCLUSION: Although both thoracoscopic and transsternal approaches to thymectomy in patients with MG are effective after the long-term follow-up, VATS thymectomy has its specific advantages of minimal invasion, less complications, and rapid recovery.

[Intraoperative esophageal manometry employed in the course of Heller's cardia-myotomies].

OBJECTIVE: To study the changes of lower esophageal sphincter (LES) high-pressure zone, and to determine the accurate length of myotomy on the esophageal and gastric sides. METHODS: There were 15 patients undergoing the Heller's cardia-myotomies and Toupet fundoplications from May 2006 to December 2007. Among them, 9 patients were female and 6 was male. The age ranged from 28 to 61 years old, and the disease duration ranged from 6 months to 9 years. The intraoperative oesophageal manometry underwent in the surgical procedures to investigate the changes of the lower esophageal sphincter pressure and the length of myotomy. RESULTS: There was no postoperative death. After (5.3 +/- 1.5) cm of esophageal side myotomy and (0.8 +/- 0.4) cm of gastric side myotomy, the mean LES pressure decreased from (33.6 +/- 13.3) mm Hg (1 mm Hg = 0.133 kPa) to (9.7 +/- 4.6) mm Hg and (4.8 +/- 3.1) mm Hg respectively (P < 0.05). The lower esophageal sphincter length ranged from 5 to 8 cm. CONCLUSION: Intraoperative esophageal manometry helps determine the accurate myotomy length of myotomy on the esophageal and gastric sides of the gastroesophageal junction and provides valuable information for the Heller's myotomy.

[Mid-, and long-term effects of video-assisted thoracoscopic and transsternal thymectomy in treatment of non-thymomatous myasthenia gravis: analysis of 204 cases].

OBJECTIVE: To evaluate the mid-, and long-term effects of video-assisted thoracoscopic thymectomy and transsternal thymectomy in treatment of myasthenia gravis (MG) and to identify the prognostic factors for thymectomy success. METHODS: 161 patients with non-thymomatous MS, 84 males and 120 females, aged 33, underwent transsternal thymectomy and were followed up for 5 years; and 43 patients with non-thymomatous MS A retrospective, 1 male and 25 females, 21 being aged >40 during operation, underwent thoracoscopic thymectomy and were followed up for 3 years. RESULTS: The mean operating time of the thoracoscopic group was (132 +/- 32) min minutes, significantly longer than that of the transsternal thymectomy group [(96 +/- 18) min, P = 0.000]. Four patients in the transsternal thymectomy group and 41 in the transsternal thymectomy group developed myasthenic crises (P = 0.023). The complete stable remission (CSR) rates 1, 2, and 3 years after operation of the thoracoscopic thymectomy group were 34.9%, 41.9%, and 46.5% respectively; and CSR rates 1, 2, 3, and 5 years after operation of the transsternal thymectomy group were 26.7%, 31.7%, 35.4%, and 40.4% respectively, without significant differences between these 2 groups. CONCLUSION: Both thoracoscopic and transsternal approaches to thymectomy in patients with MG are effective in terms of remission. The authors advocate adopting the thoracoscopic approach early.

[Outcome of Nissen fundoplication using intraoperative manometry].

OBJECTIVE: Through reviewing the surgical experience in the treatment of sliding hiatus hernia, the effectiveness of Nissen fundoplication using intraoperative oesophageal manometry has been evaluated. METHODS: There were 84 undergoing the transabdominal surgery who have been divided into three groups: 27 patients were in the Nissen group, 39 in the floppy Nissen group, 18 in the intraoperative-oesophageal-manometry group. RESULTS: There is no postoperative death. Complications occurred in 5 patients within one month after operation: in the Nissen group, 2 patients suffered from severe dysphagia and 1 from regurgitation; In the floppy Nissen group, 2 patients had regurgitation; In the intraoperative-oesophageal-manometry group, there were no one suffering severe dysphagia or regurgitation. During the long-term follow-up, excellent functional results were also observed in the intraoperative-oesophageal-manometry group, whereas 2 patients suffered from severe dysphagia and 1 from nausea in the Nissen group and 1 patient recurred in the floppy Nissen group. CONCLUSIONS: The Nissen fundoplication (NF) should be suitable to be done in patients with sliding hiatus hernia. But if there are possibilities to perform intraoperative oesophageal manometry during the operation of anti-reflux, side effects can be decreased to the least. Intraoperative manometry is useful in standardizing the tightness of the wrap in NF. And it will contribute to reducing or avoiding the happening of complications.

Gasless laparoscopic surgery plus abdominal wall lifting for giant hiatal hernia-our single-center experience.

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.

Oleanolic acid suppresses the proliferation of human bladder cancer by Akt/mTOR/S6K and ERK1/2 signaling.

Oleanolic acid has significant pharmacological activities, such as anti-tumor, regulating blood sugar level and liver protection, which are more effective compared with free aglyconeoleanolic acid. However, it is still unknown if oleanolic acid affects the proliferation of human bladder cancer. We utilized T24 cells to study the effect of oleanolic acid on the proliferation and apoptosis of human bladder cancer. In this study, we found that the anti-cancer effect of oleanolic acid significantly suppressed cell proliferation and increased apoptosis and caspase-3 activity of T24 cells. Furthermore, Akt, mTOR and S6K protein expression was greatly inhibited in T24 cells under oleanolic acid treatment. Meanwhile, ERK1/2 of phosphorylation protein expression was significantly promoted by oleanolic acid treatment. Taken together, we provided evidences that oleanolic acid was Akt/mTOR/S6K and ERK1/2 signaling-targeting anti-tumor agent. These findings represent new evidences that oleanolic acid suppresses the proliferation of human bladder cancer by Akt/mTOR/S6K and ERK1/2 signaling, and oleanolic acid may be used to prevent human bladder cancer.

Up-regulation of microRNA-302a inhibited the proliferation and invasion of colorectal cancer cells by regulation of the MAPK and PI3K/Akt signaling pathways.

Aberrant expression of microRNA-302a (miR-302a) has been frequently reported in some cancers excluding colorectal cancer (CRC). However, the role of miR-302a in CRC has not been reported. In this paper, we examined the effect of miR-302a overexpression on proliferation and invasion in CRC cells. The mRNA level of miR-302a in CRC cell lines was determined by real-time PCR. The miR-302a mimic was transiently transfected into CRC cells using Lipofectamine™ 2000 reagent. Subsequently, cell proliferation and invasion were assessed by MTT and Transwell assays. Western blot and ELISA assay were used to detect the expressions and secretions of matrix metalloproteinases (MMPs). Moreover, the expressions of epithelial marker, mesenchymal markers and transcription factors were also determined by Western blot. In addition, the effects of miR-302a overexpression on the MAPK and PI3K/Akt signaling pathways were investigated by Western blot. Our results showed that the mRNA level of miR-302a was remarkably decreased in CRC cell lines compared with normal colon epithelium cells. Up-regulation of miR-302a inhibited the proliferation and invasion of CRC cells. The expressions and secretions of MMP-9 and -2 were evidently reduced by increasing miR-302a. Besides, we found a decrease of ß-catenin, fibronection, vimentin, Snail, Slug, ZEB1 and ZEB2 expressions and an increase of E-cadherin expression. We also found that miR-302a overexpression might decrease the phosphorylation of Erk1/2 and Akt. Altogether, our results indicated that miR-302a overexpression was shown to inhibit proliferation and invasion of CRC cells by reducing the expressions of related proteins through suppressing the MAPK and PI3K/Akt signaling pathways.

[Surgical treatment with sliding esophageal hiatal hernia].

OBJECTIVE: To study the effect and method of surgical treatment in patients with sliding esophageal hiatal hernia. METHODS: To divide into two groups: fifty-two patients with sliding esophageal hiatal hernia diagnosed with gastroscopy and X-ray barium meal examination accepted operation. Forty-seven cases were treated by Nissen's operation. Three cases were treated by Hill's operation. One case was treated by Boerema's operation. One case was treated by Rampal's operation. 24-hour esophageal pH and esophageal motility were also monitored before and after operation. Thirty healthy volunteer were performed control group and were monitored by 24-hour esophageal pH and esophageal motility. RESULTS: The patients in operation group had lower esophageal sphincter relaxation and acid reflux before operation. They became significantly ameliorative after operation. Forty-seven cases (90%) had the satisfactory effect. Two cases (4%) recrudesced. CONCLUSION: Comprehensive examination and perfect surgical choice may play an important role in the treatment of sliding esophageal hiatal hernia; The better method for sliding esophageal hiatal hernia is Nissen's operation.

Long-term follow-up on the effects of sigmoid-rectal pouch for urinary diversion.

PURPOSE: The aim of this study was to investigate the long-term clinical effects of sigmoidrectal pouch for urinary diversion. MATERIALS AND METHODS: A total of 45 patients, including 40 males and 5 females, underwent sigmoid-rectal pouch procedure. The patients aged from 38 to 70 years with a mean age of 59 years. The postoperative follow-up ranged from 6 months to 19 years with an average of 6 years. Postoperative continence and voiding were analyzed, urinary reservoir pressure was measured and the complications of upper urinary tract were determined. The index of quality of life (QoL) in the International Prostate Symptom Score (IPSS) was used to evaluate the degree of satisfaction to urinate. RESULTS: Forty patients had slight incontinence in the early postoperative stage and could control urination well 30 days postoperatively. The volume of pouch was 270-600 mL with an average of 375 mL. The basic pressure during filling period was 6-20 cmH2O with an average 15 cmH2O, the maximum filling pressure was 15-30 cmH2O with an average 26 cmH2O. The compliance of sigmoid-rectal pouch was fine with an average of 30 (range 18-40) mL/ cmH2O. There were no severe complications such as hyperchloremic acidosis or retrograde pyelonephritis. Six patients had slight hydronephrosis. The index of QoL were 0-2 in 20 patients, 3 in five patients and 4 in two patients. CONCLUSION: The sigmoid-rectal pouch operation was simple and acceptable by surgeons and patients. It may be an ideal urinary diversion for patients with muscle-invasive bladder cancer, especially for patients on whom urethrectomy should be done.

Crystal structure of a new cyclomaltoheptaose hydrate: beta-cyclodextrin.7.5H2O.

The crystallographic study of a partially hydrated form of cyclomaltoheptaose (beta-cyclodextrin, betaCD) is reported. C(42)H(70)O(35).7.5H(2)O; space group P2(1) with unit cell constants a=15.1667(5), b=10.1850(3), c=20.9694(7)A, beta=110.993(2) degrees ; final discrepancy index R=0.0760 for the 6181 observed reflections and 784 refined parameters. One water molecule is included in the cavity and distributed over two partially occupied positions, the other 6.5 waters distributed over eight positions are located as space-filler between the macrocycles. The crystal structure belongs to the cage-type, like that observed in Form I (betaCD.12H(2)O; Lindner, K; Saenger, W. Carbohydr. Res. 1982, 99, 103-115) and Form II (betaCD.11H(2)O; Betzel, C., et al. J. Am. Chem. Soc., 1984, 106, 7545-7567).

New cyclodextrin derivative 6-O-(2-hydroxybutyl)-beta-cyclodextrin: preparation and its application in molecular binding and recognition.

A new soluble cyclodextrin derivative 6-O-(2-hydroxybutyl)-beta-cyclodextrin (6-HB-beta-CD) was prepared. Its molecular binding and recognition ability were investigated with the comparison of beta-cyclodextrin (beta-CD), 2-O-(2-hydroxypropyl)-beta-cyclodextrin (2-HP-beta-CD), 6-O-(2-hydroxypropyl)-beta-cyclodextrin (6-HP-beta-CD), and 2-O-(2-hydroxybutyl)-beta-cyclodextrin (2-HB-beta-CD). The relationship between the complex stability constants and the possible structures of inclusion compounds was discussed with the interaction of hosts and guests, including the weak hydrophobic interactions, the size/shape matching, the steric hindrance, and the hydrophilic property.