Characterization of tongue coating microbiome from patients with colorectal cancer.

Background: Tongue coating microbiota has aroused particular interest in profiling oral and digestive system cancers. However, little is known on the relationship between tongue coating microbiome and colorectal cancer (CRC). Methods: Metagenomic shotgun sequencing was performed on tongue coating samples collected from 30 patients with CRC, 30 patients with colorectal polyps (CP), and 30 healthy controls (HC). We further validated the potential of the tongue coating microbiota to predict the CRC by a random forest model. Results: We found a greater species diversity in CRC samples, and the nucleoside and nucleotide biosynthesis pathway was more apparent in the CRC group. Importantly, various species across participants jointly shaped three distinguishable fur types.The tongue coating microbiome profiling data gave an area under the receiver operating characteristic curve (AUC) of 0.915 in discriminating CRC patients from control participants; species such as Atopobium rimae, Streptococcus sanguinis, and Prevotella oris aided differentiation of CRC patients from healthy participants. Conclusion: These results elucidate the use of tongue coating microbiome in CRC patients firstly, and the fur-types observed contribute to a better understanding of the microbial community in human. Furthermore, the tongue coating microbiota-based biomarkers provide a valuable reference for CRC prediction and diagnosis.

The value of ICG-guided left colon vascular variation and anatomical rules for the radical resection of proctosigmoid colon cancer.

Objective: During laparoscopic radical resection for proctosigmoid colon cancer (PCC), surgeons could inadvertently damage the arteries when following the operation path.This study investigated the variations in left colon blood vessels in order to guide the scientific protection of the marginal artery (MA) during laparoscopic surgery for PCC. Methods: Data from seven patients who underwent inferior mesenteric artery (IMA) angiography were included as imaging references to preliminarily explore the vascular structure and variation in the left colon. The clinical video data of 183 PCC patients were retrospectively analyzed to observe intraoperative MA injury. Meanwhile, a prospective cohort of 96 patients with the same disease underwent intraoperative indocyanine green (ICG) fluorescence imaging of the peripheral sigmoid artery network, the variation of marginal arteries was summarized, and the distance between vessels and the bowel was measured at different levels. Patients were divided into 'ICG group' and 'non-ICG group' according to whether ICG guidance was performed, and perioperative conditions were compared between the two groups. Taking the integrity of lymph node dissection into consideration, 18 patients underwent carbon nanonode tracing. This study was conducted under the standard consent and ethical approval of the Ethics Committee of our center. Results: 7 patients with IMA angiography shared some vascular structures, defined as 'Dangerous Triangle' and 'Secure Window'. Through intraoperative observation, the primary arch was typically located 4.2 (2.3-6.0) cm away from the intestinal canal, and 5.21% (5/96) patients had poor anastomosis at the primary arch. Moreover, secondary vascular arches (6.4 (4.6-10.0) cm from the intestinal wall) were observed in 38.54% of patients. MA injury was identified in 2 of 183 cases, and the ischemic bowel was timely dissected, whereas no such injury occurred during ICG fluorescenceguided surgery. Guided by carbon nanoparticles, the integrity of lymph node dissection can be maintained while preserving the secondary arch in all patients. Conclusions: This study demonstrated the benefits of ICG guidance in protecting the intestinal blood supply in laparoscopic PCC surgery. By enhancing the understanding of primary and secondary vascular arches, secure windows, and dangerous triangles, surgeons can safely optimize the surgical path during surgery.

Excessive bowel volume loss during anus-preserving surgery for rectal cancer affects the bowel function after operation: A prospective observational cohort study (Bas-1611).

Background: Bowel volume loss during anus-preserving surgery (APS) may result in low anterior resection syndrome (LARS). We conducted this prospective observational cohort study to measure the incidence of LARS after surgery and evaluate the relationship between bowel volume loss and bowel function. Methods: Patients with R0 resectable rectal cancer who consented to several bowel function surveys through telephone interviews after the operation were included. Enrolled patients underwent standard APS for rectal cancer, and three length indexes, viz. length of excised bowel, length of the distal margin and length of the proximal margin (LPM) of fresh bowel specimens, were measured in vitro. Results: The three measured variables of the specimens showed a positively skewed distribution. Patient interviews revealed a trend of gradual improvement in bowel function. Univariate analyses revealed that longer LPM was associated with a significantly negative impact on bowel function at all time points. In multivariate analysis, LPM was found to be a significant risk factorstatistically significant, but its impact was not as strong as that of radiotherapy and low-middle tumour. Furthermore, there was no significant difference in the lymph node detection rate between <10-cm and ≥10-cm LPM groups. Conclusion: In APS for rectal cancer, bowel volume loss is an important factor causing postoperative bowel dysfunction. Controlling LPM to <10 cm may help improve postoperative bowel function.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis.

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Primary extra-gastrointestinal stromal tumor of retroperitoneum: Clinicopathologic characteristics and prognosis of six cases.

Aim: This study investigates the clinicopathological features and prognostic genic biomarker factors of primary retroperitoneal extra-gastrointestinal stromal tumors (EGISTs). Methods: The clinicopathological data of six patients with primary retroperitoneal EGIST were analyzed, including cell type (epithelioid or spindle), mitoses, and the presence of intratumoral necrosis and hemorrhage. Mitoses were counted and summed from 50 high power fields (HPFs). Mutations of exons 9, 10, 11, 13, 14, and 17 of the C-kit genes and those of exons 12 and 18 of the PDGFRA gene were examined. Follow-up was performed via telephone, and all outpatient records were reviewed. The last follow-up date was February 2022, the median follow-up was 27.5m and the postoperative status, medication, and survival of the patients were recorded. Result: The patients were treated with radical intent. Four cases (patients 3, 4, 5, and 6) underwent multivisceral resection for encroachment on the adjacent viscera. The postoperative pathological results demonstrated that all biopsy specimens were negative for S-100 and desmin, and positive for DOG1 and CD117. Additionally, four patients (case 1, 2, 4, and 5) were positive for CD34, four (case 1, 3, 5, and 6) were positive for SMA, four (case 1, 4, 5, and 6) had >5/50 HPFs, and three (case 1, 4, and 5) had Ki67 >5%. According to the modified National Institutes of Health (NIH) guidelines, all patients were graded as high-risk cases. By exome sequencing, exon11 mutations were detected in the six patients, while exon10 mutations were detected in two cases (patients 4 and 5). The median follow-up time was 30.5 (11-109) months, with only one fatality at 11 months. Conclusion: Retroperitoneal EGIST is a rare mesenchymal tumor that is difficult to distinguish from other retroperitoneal tumors. To diagnose this highly malignant tumor, low-threshold suspicion is necessary, and Kit and PDGFRA gene mutations should be routinely tested to confirm the diagnosis and guide subsequent treatment.

Anatomic patterns and clinical significance of gastrocolic trunk of Henlé in laparoscopic right colectomy for colon cancer: Results of the HeLaRC trial.

BACKGROUND: Recent interest in laparoscopic right colectomy with D3 lymphadenectomy for right colon cancer, has raised renewed attention to the anatomic variations of the gastrocolic trunk of Henlé (GTH). Understanding the vascular structure of the GTH region for individual patients should improve surgical outcomes. The goal of this nationwide multicenter study (Anatomical Classification of Henlé's Trunk in Laparoscopic Right Hemi-colectomy (HeLaRC) trial) was to study the anatomic patterns of the GTH region, to clarify the implications of GTH in laparoscopic right colectomy with D3 lymphadenectomy (D3-RC) and analyze their clinical significance. METHODS: We enrolled 583 patients from 26 centers across China who underwent D3-RC. The number of tributaries, length and types of GTH constitutions and their influence on intra-operative data were investigated. A nomogram score (based on the length of GTH, body mass index (BMI), tumor location, T stage and type of GTH (type I vs. non-type I) was established to assess the potential hazard of bleeding. RESULTS: The GTH was found in 567 patients (97.3%). The distribution of GTH types was 0 (14.1%, n = 80), I (53.3%, n = 302), II (27.0%, n = 153), III (5.6%, n = 32). Of note, the type I GTH, T1 stage and tumor location at ileocecal or ascending colon were correlated with shorter exposure time of the GTH region (P < 0.0001). Short length of GTH (P = 0.002) and tumor location (transverse colon vs. non transverse colon) (P = 0.003) were correlated with the amount of GTH bleeding during the surgery. Nomogram discrimination was good (C-index: 0.72 (95% CI: 0.64, 0.80)). The dissection plane was better in patients with type I GTH than with other types (P = 0.023). CONCLUSION: GTH pattern variations may affect surgical outcomes in patients undergoing D3-RC. Better recognition of GTH anatomy might lead to a safer operation with better oncologic quality.

Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer.

BACKGROUND: Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis. METHODS: The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis. RESULTS: The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254). CONCLUSIONS: Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.

An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area.

Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.

Effect of Wuda granule on gastrointestinal function recovery after laparoscopic intestinal resection: a randomized-controlled trial.

BACKGROUND: Previous studies have suggested that the Wuda granule (WDG) could promote the recovery of gastrointestinal (GI) function after gynecologic abdominal surgery. This trial aimed to investigate the efficacy and safety of WDG in the rapid recovery of GI function in patients after laparoscopic intestinal resection in the setting of enhanced recovery after surgery (ERAS)-based perioperative care. METHODS: We performed a randomized, double-blind, placebo-controlled pilot trial. Thirty patients who met the inclusion criteria were randomly assigned to either the WDG group or the placebo group in a 1:1 ratio. The patients received WDG or placebo twice a day in addition to ERAS-based perioperative care, starting on post-operative Day 1 until Day 3. The primary outcomes were time to first bowel movement and time to first tolerance of solid food. The secondary outcomes were time to first flatus, length of hospital stay (LOS), and post-operative ileus-related morbidity. Adverse events were also recorded. RESULTS: There were no statistically significant differences in baseline characteristics between the two groups. The median time to first bowel movement was significantly decreased in the WDG group compared with the control group (27.6 vs 50.1 h; P < 0.001), but the median times to first flatus (22.9 vs 25.1 h; P > 0.05) and LOS (5.0 vs 5.0 days; P > 0.05) were not statistically different. The occurrence rates of post-operative nausea, vomiting, abdominal distension, and abdominal pain were similar in the two groups. No adverse events occurred in any patients. CONCLUSIONS: The addition of WDG to ERAS post-operative care after laparoscopic intestinal resection can safely promote the rapid recovery of GI function.

Acupuncture for Quality of Life in Gastric Cancer Patients Undergoing Adjuvant Chemotherapy.

CONTEXT: Patients with gastric cancer experience health-related quality of life (HRQOL) decline during adjuvant chemotherapy following gastrectomy. OBJECTIVES: This pilot study aimed to evaluate the preliminary effect and feasibility of electro-acupuncture (EA) for HRQOL and symptom burden in these patients. METHODS: In this open-label, multicenter, parallel controlled trial, gastric cancer patients who planned to receive adjuvant chemotherapy were randomly assigned to receive high-dose EA (seven times each chemotherapy cycle for three cycles), low-dose EA (three times each chemotherapy cycle), or usual care only. The acupoints prescription consisted of bilateral ST36, PC6, SP4, and DU20, EX-HN3, and selected Back-shu points. Patients completed the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) weekly, and the Edmonton Symptom Assessment System (ESAS). The primary outcome was the difference among the groups on the gastric cancer subscale (GaCS) of the FACT-Ga. RESULTS: Of the 66 randomized patients, 58 were analyzed according to intention-to-treat principle, and 45 were in the per-protocol set (PPS). The average scores in PPS of GaCS were 52.12±9.71, 51.85±12.36, and 45.37±8.61 in high-dose EA, low-dose EA, and control groups, respectively. EA was significantly associated with improved average GaCS scores when compared with control group (51.98±10.91 vs. 45.37±8.61, P = 0.039). EA treatment also produced ESAS relief at the end of intervention (14.36 ± 12.28 vs. 23.91 ± 15.52, P = 0.027). Participants in EA groups had fewer grade ≥3 leukopenia (0% vs. 15.79%, P = 0.031) and neutropenia (2.56% vs. 26.31%, P = 0.012). CONCLUSION: EA showed promising effects in improving HRQOL, controlling symptom burden, and reducing toxicity during adjuvant chemotherapy in gastric cancer patients. Future adequately powered trials are feasible and needed to confirm the specific effect of EA.

The Medial Border of Laparoscopic D3 Lymphadenectomy for Right Colon Cancer: Results from an Exploratory Pilot Study.

BACKGROUND: Opinions vary on the medial border of D3 lymphadenectomy for right colon cancer. Most surgeons place the medial border along the left side of the superior mesenteric vein, but some consider the left side of the superior mesenteric artery as the medial border. OBJECTIVES: This study investigated the clinical outcomes of laparoscopic D3 lymphadenectomy for right colon cancer with the medial border along the left side of superior mesenteric artery. DESIGN: This was a retrospective study. SETTINGS: The study was conducted in specialized colorectal cancer department of 5 tertiary hospitals. PATIENTS: Patients receiving laparoscopic D3 lymphadenectomy for right colon cancer from January 2013 to December 2018 were included. MAIN OUTCOME MEASURES: After propensity score matching, 307 patients receiving laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery were assigned to the superior mesenteric artery group and 614 patients were assigned to the superior mesenteric vein group. Univariate, multivariate, and Kaplan-Meier analyses were performed to assess the clinical data. RESULTS: The short-term outcomes were similar between the 2 groups; however, the superior mesenteric artery group had a higher rate of chylous leakage (p < 0.001). More lymph nodes were harvested from the superior mesenteric artery group than from the superior mesenteric vein group (p = 0.001). The number (p = 0.005) of metastatic lymph nodes and the lymph node ratio (p = 0.041) in main nodes were both higher in the superior mesenteric artery group. The 2 groups had similar long-term survival, but the superior mesenteric artery group tended to show better disease-free survival in patients with stage disease III (p = 0.056). LIMITATIONS: This was a retrospective, nonrandomized study. CONCLUSION: Laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery, except for a higher rate of chylous leakage, had short-term outcomes comparable to the superior mesenteric vein group. The superior mesenteric artery group tended to achieve better disease-free survival in patients with stage III disease, but further study is required to better elucidate differences in these approaches because risks/benefits do exist.

Regional lymph nodes distribution pattern in central area of right-sided colon cancer: in-vivo detection and the update on the clinical exploration.

Distribution of regional lymph nodes (LNs) is decisive for the lymphadenectomy boundary in radical resection of right-sided colon cancer (RCC). Currently, the data of LNs in central area remains ambiguous and scarce. Herein we aim to provide a more detailed anatomical research on LNs surrounding the superior mesenteric vessels for RCC and investigated the metastasis rate. In this study, Carbon Nanoparticles (CNs) and Indocyanine Green (ICG) were used for regional LNs mapping by preoperative colonoscopic tattooing (PCT) and we laparoscopically observed the stained LNs distribution pattern. Lastly, 143 RCC patients who received a "superior mesenteric artery (SMA)-oriented" hemicolectomy were included to calculate the probability of LNs metastasis in our target area. 27 patients diagnosed as RCC (mean age 58.04 years, 17 male) were included. 14 patients underwent CNs injection and 13 patients consented to the ICG, while 4 cases suffered from imaging failure. The unequal number of the regional LNs located between SMV and SMA was detected in 22 cases (81.48%), posterior to SMV area in 6 cases (22.22%), and anterior to SMA in 16 cases (59.26%), respectively. The presence of LNs posterior to SMV was associated with the crossing pattern of ileocolic artery (χ2 = 4.24, P = 0.039). The probability of LNs metastasis in the above areas (target areas) was 2.10% (3/143). In conclusion, right-hemi colon-draining lymphatic vessels anteriorly/posteriorly traversed the SMV and arrived at the surface of SMA near the middle colonic artery (MCA) level, which highlights the potential need of removing mesenteric tissue in our target area on lymphatic resection.

Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic.

The whole world is going through an unprecedented period during the pandemic of COVID-19. This pandemic has affected all aspects of daily life with far-reaching implications, especially in most aspects of healthcare. Practice of surgery across the globe is in a standstill as of now. When we restart surgical practices across world, we have to bring new protocols and practices in place to combat the transmission. This article discusses the major changes in surgical practice, which need to be brought in. This article is based on scientific information about transmission of virus and experiences of some of the authors from China, a country which successfully dealt with and contained the virus outbreak.

"Caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery for the treatment of right colon cancer: is it more in line with the principle of oncology?

OBJECTIVE: To explore the feasibility and application value of a "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery (SMA) for the treatment of right colon cancer METHODS: Clinical data consisting of 168 right colon cancer cases under going laparoscopic D3 radical resection, including 84 cases of "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA (CC + SMA group) and 84 cases of conventional medial approach plus dissection around the superior mesenteric vein (MA + SMV group), from January 2017 to March 2018 were retrospectively analyzed. For CC + SMA group, our surgical method was to isolate the mesocolon using a caudal-to-cranial pathway and ligate blood vessels along the midline of the SMA. RESULTS: The baseline data was not significantly different between the two groups (all p > 0.05). The mean operation time and intraoperative blood loss in the CC + SMA and the MA + SMV groups were 170.04 ± 43.10 versus 172.33 ± 41.84 min and 91.07 ± 55.12 versus 77.38 ± 40.21 ml, respectively, which has no significant difference (p > 0.05). The mean number of total and positive harvested lymph nodes in the two groups were 29.44 ± 5.90 versus 26.21 ± 6.64 (p < 0.05) and 2.57 ± 1.93 versus 2.51 ± 1.05, respectively (p > 0.05). Compared with the MA + SMV group, there was no significant difference in total postoperative complication rate in the CC + SMA group. The time to pull out drainage tube in the CC + SMA group was longer than MA + SMV group (4.05 ± 1.79 versus 3.38 ± 1.99 day; p = 0.022). CONCLUSION: It is safe and feasible for the "caudal-to-cranial" plus "artery first" technique with beyond D3 lymph node dissection on the right midline of the SMA in right colon cancer. It may have some advantages in the number of lymph nodes dissection, and the long-term prognosis remains to be expected.

Anatomical characteristics and classifications of gastrocolic trunk of Henle in laparoscopic right colectomy: preliminary results of multicenter observational study.

BACKGROUND: As a key landmark during laparoscopic right colectomy, the classification and variation of the gastrocolic trunk of Henle (GTH) remains to be clarified. The aim of this nationwide multicenter study was to describe the characteristics of the GTH intra-operatively during laparoscopic right colectomies. METHODS: Three hundred seventy-one patients who underwent laparoscopic right colectomies from January 2018 to March 2019 in 25 hospitals across China were enrolled in the study. The length of the GTH, the classification with a precise description of confluent tributaries, and other variations were analyzed. RESULTS: Of the 371 patients, 363 had a GTH. The proportion of type-0, type-I, type-II, and type-III was 15.2% (n = 55), 54.8% (n = 199), 25.3% (n = 92), and 4.7% (n = 17), respectively. The average length of the GTH was 8.5 mm, ranging from 2 to 30 mm. CONCLUSIONS: This is the first multicenter study with a large sample by which the GTH was classified based on laparoscopic intraoperative observation. Variations in the GTH were classified into four types based on the number of colic drainage veins (right colic, superior right colic, middle colic, accessory middle colic, and ileocolic veins), among which the right colic vein was the most common. The length of the GTH was relatively short, and thus might carry a risk of bleeding. Further clinical data should be correlated with the characteristics of the GTH.

Feasibility and efficacy of laparoscopic radical right hemicolectomy with complete mesocolic excision using an 'artery-first' approach.

BACKGROUND: According to previous guidelines, the lymph nodes around the right side of the superior mesenteric artery (SMA) should be dissected and removed en bloc. However, due to the technical challenge and the risk of complications, most surgeons perform the dissection along the axis of the superior mesenteric vein (SMV). Herein, we described an 'artery-first' approach for laparoscopic radical extended right hemicolectomy with complete mesocolic excision (CME). METHODS: A total of 22 cases were collected from January to October 2016. The right side of the SMA and SMV were exposed and separated, and the No. 203, No. 213 and No. 223 lymph nodes were dissected en bloc. Toldt's fascia was dissected and expanded laterally to the ascending colon, cranial to the pancreas head. The caudal root of the mesentery and lateral attachments of the ascending colon were completely mobilized. RESULTS: There were 9 male and 13 female patients, with a mean age of 63.1 (range, 39-83) years and the mean body mass index was 24.6 (range, 18.3-37.7) kg/m2. The mean operative time was 192.5 (range, 145-240) minutes and the mean intra-operative blood loss was 55.0 (range, 10-300) ml. The mean number of harvested lymph nodes was 27.0 (range, 13-55) and the time to flatus and hospital stay were 35.0 (range, 26-120) hours and 7.5 (range, 5-20) days, respectively. Minor complications occurred in two patients and no post-operative death was observed. CONCLUSIONS: The preliminary results suggest that the reported approach may be a feasible and safe procedure that is more in accordance with the principles of CME.

[Feasibility and application value of autonomic nerve-preserving D3 radical resection for right-sided colon cancer under laparoscope].

OBJECTIVE: To explore the feasibility and application value of the preservation of vegetative nervous functions in radical resection for right-sided colon cancer. METHODS: Clinical data of 55 cases with right-sided colon cancer undergoing laparoscopic D3+ complete mesocolic excision (CME) radical resection from January 2016 to July 2017 at Department of Gastrointestinal Surgery of Guangdong Province Hospital of Traditional Chinese Medicine were retrospectively analyzed. Exclusion criteria included emergency surgery for various reasons, intestinal obstruction or perforation, distant metastasis or locally advanced cancer, previous history of abdominal surgery and preoperative neoadjuvant chemoradiotherapy. Twenty-nine cases underwent lymphadenectomy with intrathecal dissection of superior mesenteric artery (SMA) and part of superior mesenteric plexus was resected (nerve partial resection group, NPR group). Twenty-six cases received lymphadenectomy with the clearance of lymphatic adipose tissue on the right side of SMA by sharp or obtuse method outside the sheath; the sheath of superior mesenteric vein (SMV) was entered at the junction of SMA and SMV; the SMV was naked in the sheath; the third station lymph node dissection was completed with preservation of superior mesenteric plexus (nerve preserved group, NP group). Intra-operative and postoperative complications were compared between two groups. RESULTS: The baseline data were not significantly different between two groups (all P>0.05). The operation time in NP group was significantly shorter than that in NPR group [(164.0±19.8) minutes vs. (176.0±19.7) minutes, t=2.249, P=0.029]. No significant differences in operative blood loss, operative vessel damage, postoperative time to flatus, postoperative hospital stay and abdominal pain were observed between two groups(all P>0.05). The number of harvested lymph node in two groups was 28.5±7.8 and 27.6±6.5 respectively without significant difference(P>0.05). As compared to NPR group, NP group had lower incidence of chylous leakage[3.8%(1/26) vs. 37.9%(11/29), χ²=9.337, P=0.002] and postoperative diarrhea [15.4%(4/26) vs. 41.4%(12/29), χ²=4.491, P=0.034]. CONCLUSION: Autonomic nerve-preserving D3+ CME radical resection for right-sided colon cancer is safe and feasible, and can prevent the postoperative gastrointestinal dysfunction caused by nerve injury and decrease the risk of chylous leakage.

Laparoscopic resection for gastrointestinal stromal tumors in esophagogastric junction (EGJ): how to protect the EGJ.

BACKGROUND: Laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) is now widely performed. However, laparoscopic resection of GIST in the esophagogastric junction (EGJ) is technically difficult and rarely reported. Herein, we introduce four fashions of laparoscopic resection for EGJ-GIST. METHODS: A retrospective review of 42 consecutive patients with EGJ-GIST who underwent attempted laparoscopic surgery was conducted. EGJ-GIST was defined as GIST with an upper border of less than 5 cm from the esophagogastric line. Four fashions of laparoscopic resection were performed: fashion A, laparoscopic wedge resection using linear stapler; fashion B, laparoscopic complete resection by opening the stomach wall and closing with suture or linear stapler; fashion C, laparoscopic mucosa-preserving resection; and fashion D, laparoscopic proximal gastrectomy with pyloroplasty and gastric plication. Clinicopathologic characteristics, operative course, and short-term and long-term outcomes were analyzed. RESULTS: All procedures were completed successfully without operative complications. In 24 of 42 (57.1%) patients, tumors were located in the fundus or greater curvature. Out of those, 70.8% (17/24) received fashion A and 29.2% (7/24) received fashion B. Tumors in 16 of 42 (38.1%) patients were located in the lesser curvature. Of those, 81.3% (13/16) underwent fashion B and 18.7% (3/16) underwent fashion D. One tumor in the anterior stomach wall and one in the posterior wall received fashion C. The mean operative time was 103.8 ± 22.1 min and the mean estimated blood loss was 22.4 ± 13.5 ml. The mean time to flatus was 40.3 ± 12.9 h and the time to fluid intake was 43.2 ± 14.3 h. The mean hospital stay was 4.8 ± 2.1 days. CONCLUSIONS: Laparoscopic surgery for EGJ-GIST is safe and feasible. The selection of various laparoscopic resection fashions should be chosen based on tumor location and the surgeon's experience.

A Systematic Review and Meta-Analysis of Laparoscopic and Open Distal Pancreatectomy of Nonductal Adenocarcinomatous Pancreatic Tumor (NDACPT) in the Pancreatic Body and Tail.

BACKGROUND: Currently, laparoscopic distal pancreatectomy is regarded as a safe and effective surgical approach for lesions in the body and tail of the pancreas. This review examined the evidence from published data of comparative studies of laparoscopic versus open distal pancreatectomy of nonductal adenocarcinomatous pancreatic tumor in pancreatic body and tail. METHODS: A systematic review of the studies comparing laparoscopic and open distal pancreatectomy was conducted. Comparative studies published between January 1996 and June 2016 were included. Studies were selected on the basis of specific inclusion and exclusion criteria. These 2 techniques were compared regarding several outcomes of interest, which were divided into preoperative, operative, postoperative, and pathologic characteristics, postoperative biomarker, and hospital stay cost. Sensitivity and subgroup analysis partially confirmed the robustness of these data. RESULTS: Ten comparative case-control studies involving 712 patients (53.7% laparoscopic and 46.3% open), who underwent a distal pancreatectomy were included. The results favored laparoscopy with regard to intraoperative blood loss (P=0.0001), the rate of blood transfusion (P=0.02), total hospital stay (P=0.004), postoperative hospital stay (P<0.0001), overall morbidity (P=0.0002), the rate of wound infection (P=0.05), time to initial feeds (P<0.0001), first flatus time (P=0.008), duration of pain-killer intake (P=0.0003), and C-reactive protein on postoperative day 1 (P=<0.0001). In the subgroup analysis, excluding western country studies, operation time changed to have a statistically significant difference between these 2 groups (P=0.02). CONCLUSIONS: Laparoscopic resection results in improved operative and postoperative outcomes compared with open surgery according to the results of the present meta-analysis. It may be a safe and feasible option for nonductal adenocarcinomatous pancreatic tumor patients in pancreatic body and tail. However, randomized controlled trials should be undertaken to confirm the relevance of these findings.

Clinical significance of No. 10 and 11 lymph nodes posterior to the splenic vessel in D2 radical total gastrectomy: An observational study.

D2 lymphadenectomy is widely performed for advanced proximal gastric cancer, but complete dissection of No. 10 and 11 lymph nodes (LNs) is technically challenging, especially for those posterior to the splenic vessel. This study aimed to investigate the clinical significance of removing No. 10 and 11 LNs posterior to the splenic vessel in radical total gastrectomy. Between January 2013 and February 2015, 53 patients who underwent spleen-preserving D2 radical total gastrectomy were enrolled. While dissecting No. 10 and 11 LNs, we divided them into 2 parts, namely LNs anterosuperior and posterior to the splenic vessel, and the pathological data were reviewed. Sixteen patients underwent laparoscopy and 37 underwent laparotomy. No mortality was recorded. According to the pathological results, the TNM stages of the tumor were IIA in 11 patients (20.8%), IIB in 5 (9.4%), IIIA in 7 (13.2%), IIIB in 10 (18.9%), and IIIC in 20 (18.9%). The mean number of LNs retrieved was 30.3 ±â€Š12.3. The sum of No. 10 and 11 LNs posterior to the splenic vessel was 59 and the mean number was 1.11 ±â€Š1.47. One LN with metastasis was found in the special 59 regional LNs, and the metastasis rate was 1.9% (1/53). Concerning the low metastasis rate (1.9%) and difficult complete dissection of No. 10 and 11 LNs posterior to the splenic vessel, our initial analysis suggests that the rate of No. 10 and 11 LNs posterior to the splenic vessel metastasis was 1.9%, but further studies are needed to reveal its clinical significance in D2 radical total gastrectomy for advanced proximal gastric cancer.