Cav-1 regulates the bile salt export pump on the canalicular membrane of hepatocytes by PKCα-associated signalling under cholesterol stimulation.

BACKGROUND AND AIMS: The secretion of bile salts transported by the bile salt export pump (BSEP) is the primary driving force for the generation of bile flow; thus, it is closely related to the formation of cholesterol stones. Caveolin-1 (Cav-1), an essential player in cell signalling and endocytosis, is known to co-localize with cholesterol-rich membrane domains. This study illustrates the role of Cav-1 and BSEP in cholesterol stone formation. METHODS: Adult male C57BL/6 mice were used as an animal model. HepG2 cells were cultured under different cholesterol concentrations and BSEP, Cav-1, p-PKCα and Hax-1 expression levels were determined via Western blotting. Expression levels of BSEP and Cav-1 mRNA were detected using real-time PCR. Immunofluorescence and immunoprecipitation assays were performed to study BSEP and Hax-1 distribution. Finally, an ATPase activity assay was performed to detect BSEP transport activity under different cholesterol concentrations in cells. RESULTS: Under low-concentration stimulation with cholesterol, Cav-1 and BSEP protein and mRNA expression levels significantly increased, PKCα phosphorylation significantly decreased, BSEP binding capacity to Hax-1 weakened, and BSEP function increased. Under high-concentration stimulation with cholesterol, Cav-1 and BSEP protein and mRNA expression levels decreased, PKCα phosphorylation increased, BSEP binding capacity to Hax-1 rose, and BSEP function decreased. CONCLUSION: Cav-1 regulates the bile salt export pump on the canalicular membrane of hepatocytes via PKCα-associated signalling under cholesterol stimulation.

Comparison of Efficacy and Safety between Endoscopic Retrograde Cholangiopancreatography and Percutaneous Transhepatic Cholangial Drainage for the Treatment of Malignant Obstructive Jaundice: A Systematic Review and Meta-Analysis.

BACKGROUND: At present, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) are frequently used for reducing malignant obstructive jaundice (MOJ). However, it is controversial as to which method is superior in terms of efficacy and safety. OBJECTIVES: The aim of this study was to compare the safety, feasibility, and clinical benefits of ERCP and PTCD in matched cases of MOJ. METHODS: The Web of Science, Cochrane, PubMed, and CNKI databases were searched systematically to identify studies published between January 2000 and December 2019, without language restrictions, that compared ERCP and PTCD in patients with MOJ. The primary outcome was the success rate for each procedure. The secondary outcomes were the technical success rate, serum total bilirubin level, length of hospital stay, hospital expense, complication rate, and survival. This meta-analysis was performed using Review Manager 5.3. RESULTS: Sixteen studies met the inclusion criteria, including 1,143 cases of ERCP and 854 cases of PTCD. The analysis demonstrated that jaundice remission in PTCD was equal to that in ERCP (mean difference [MD], 1.19; 95% confidence interval [CI]: -0.56 to -2.93; p = 0.18). However, the length of hospital stay in the ERCP group was 3.03 days shorter than that in the PTCD group (MD, -2.41; 95% CI: -4.61 to -0.22; p = 0.03). ERCP had a lower rate of postoperative complications (odds ratio, 0.66; 95% CI: 0.42-1.05); however, the difference was not significant (p = 0.08). ERCP was also more cost-efficient (MD, -5.42; 95% CI: -5.52 to -5.32; p < 0.01). Further, we calculated the absolute mean of hospital stay (ERCP:PTCD = 8.73:12.95 days), hospital expenses (ERCP:PTCD = 5,104.13:5,866.75 RMB), and postoperative complications (ERCP:PTCD = 11.2%:9.1%) in both groups. CONCLUSION: For remission of MOJ, PTCD and ERCP had similar clinical efficacy. Each method has its own strengths and weaknesses. Considering that ERCP had a lower rate of postoperative complications, shorter hospital stay, and higher cost efficiency, ERCP may be a superior initial treatment choice for MOJ.

Role of caveolin-1 in human organ function and disease: friend or foe?

Caveolin-1 (Cav-1) is a structural protein component of caveolae, which are invaginations of the plasma membrane involved in various cellular processes, including endocytosis, extracellular matrix organization, cholesterol distribution, cell migration and signaling. Mounting evidence over the last 10-15 years has demonstrated a central role of Cav-1 in many diseases, such as cancer, diabetes and fibrosis. Cav-1 plays positive and negative roles in various diseases through its different regulation pathways. Here, we review the current knowledge on Cav-1 in different diseases and discuss the role of this protein in human organs and diseases.

Endoscopic nasobiliary drainage-based saline-injection ultrasound: an imaging technique for remnant stone detection after retrograde cholangiopancreatography.

BACKGROUND: The purpose of this retrospective study aimed to assess the accuracy of detection of remnant common bile duct (CBD) stones by injecting saline through endoscopic nasobiliary drainage (ENBD) tubes under transabdominal ultrasound (US) guidance. METHOD: Stone extraction and ENBD are regularly achieved through endoscopic retrograde cholangiopancreatography (ERCP) in patients with CBD stones. At 1-3  days thereafter, routine US studies were performed and repeated, using ENBD tubal saline injections (20-100  mL). RESULTS: A total of 302 patients underwent standard ERCP stone extractions in conjunction with occlusion cholangiograms, routine US testing, and ENBD-based saline-injection US exams. By occlusion cholangiogram, remnant stones were suspected in 31 (10.3%) patients in total of 302, and 26 (83.8%) were verified as true positives (sensitivity, 50.9%; specificity, 98.0%). Routine US studies proved suspicious in 13 (4.3%) patients in total of 302, and 12 (92.3%) were verified as true positives (sensitivity, 23.5%; specificity, 99.6%). Using ENBD-based saline-injection US, suspected stones were identified in 50 (16.6%) patients in total of 302, and 46 (92%) were verified as true positives (sensitivity, 90.1%; specificity, 98.4%). The sensitivity of ENBD-based saline-injection US significantly surpassed that of occlusion cholangiogram (p < 0.001) and routine US (p < 0.001). CONCLUSION: Detection of remnant CBD stones via ENBD-based saline-injection US is a valid, inexpensive, and repeatable means of patient screening that is non-invasive, radiation-free, and dynamically informative. This may help improve the accuracy of detecting remnant CBD stones after ERCP.

Advances in the Study of Acute Acalculous Cholecystitis: A Comprehensive Review.

BACKGROUND: Acute acalculous cholecystitis (AAC) is characterized by acute necrotizing inflammation with no calculi and is diagnosed based on imaging, intraoperative, and pathological examinations. KEY MESSAGE: Although AAC has been studied clinically for a long time, it remains difficult to diagnose and treat. The pathogenesis of AAC is still not fully understood, and it is often regarded as a relatively independent clinical disease that is different from acute calculous cholecystitis (ACC). Pathological studies suggest that AAC is the manifestation of a critical systemic disease, while ACC is a local disease of the gallbladder. SUMMARY: Concerning the pathogenesis, diagnosis, and treatment of AAC, we reviewed the research progress of AAC, which will enhance the understanding of the early diagnosis and treatment of AAC.

Dilemma of the differential diagnosis of hilar cholangiocarcinoma and benign diseases: a single-center retrospective study.

Hilar cholangiocarcinoma (HCCA), which lacks specific clinical manifestations, remains very difficult to distinguish from benign disease. This distinction is further complicated by the complex hilar anatomy. We conducted the present study to evaluate the differential diagnosis of these conditions. Sixty-five patients underwent resection surgery for suspected HCCA between January 2011 and October 2018. Institutional Review Board of Shengjing hospital agreed this study and all participants sign an informed consent document prior to participation in a research study. Following a postoperative pathology analysis, all patients were divided into two groups: malignant group (54 patients with HCCA) and benign group (11 cases with benign lesions). Compared with the benign group, the malignant group had a significantly higher median age and serum CA19-9, CEA, ALT, BILT and BILD levels (P < 0.05). In contrast, the groups did not differ significantly in terms of the sex distribution, clinical manifestations, serum levels of AST and ALKP, and imaging findings. In a receiver operating characteristic curve analysis, we identified a CA19-9 cutoff point of 233.15 U/ml for the differential diagnosis and CEA cutoff point of 2.98 ng/ml for the differential diagnosis. The differential diagnosis of HCCA and benign hilar lesions remains difficult. However, we found that patients with HCCA tended to have an older age at onset and higher serum levels of CA19-9, CEA, BILT, ALT and BILD. Furthermore, patients with a serum CA19-9 level >233.15 U/ml and CEA level >2.98 ng/ml are more likely to have malignant disease.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review.

BACKGROUND: Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility. METHODS: We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed. RESULTS: From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5 min to 270.5 ± 65.5 min, and the mean intraoperative bleeding varied from 21.1 ± 15.9 ml to 162.81 ± 40.83 ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61 days. Postoperative complications occurred in 27 patients. CONCLUSIONS: Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis: a cohort study.

BACKGROUND: In elderly patients with calculous acute cholecystitis, the risk of emergency surgery is high, and percutaneous cholecystostomy tube drainage (PC) combined with delayed laparoscopic cholecystectomy (DLC) may be a good choice. We retrospectively compared laparoscopic cholecystectomy (LC) to DLC after PC to determine which is the better treatment strategy. METHOD: We performed a retrospective cohort analysis of 752 patients with acute calculous cholecystitis. Patients with the following conditions were included: (1) age > 65 years old; (2) patients with a grade 2 or 3 severity of cholecystitis according to the 2013 Tokyo Guidelines (TG13); (3) the surgeons who performed the LC were professors or associate professors and (4) the DLC was performed in our hospital after PC. Patients who missed their 30-day follow-up; were diagnosed with bile duct stones, cholangitis or gallstone pancreatitis or were pregnant were excluded from the study. A total of 51 of 314 patients who underwent LC and 73 of 438 patients who underwent PC + DLC were assessed. PC + DLC and LC patients were matched by cholecystitis severity grade according to the TG13, and the National Surgical Quality Improvement Program (NSQIP) calculator was used to predict mortality (n = 21/group). Preoperative characteristics and postoperative outcomes were analysed. RESULTS: Compared to the matched LC group, the DLC group had less intraoperative bleeding (42.2 vs 75.3 mL, p = 0.014), shorter hospital stays (4.9 vs 7.4 days, p = 0.010) and lower rates of type A bile duct injury (4.8% vs 14.3%, p = 0.035) and type D (0 vs 9.5%, p = 0.002) according to Strasberg classification, residual stones (4.8 vs 14.3%, p = 0.035) and gastrointestinal organ injury (0 vs 3.6%, p < 0.001). Patients in the DLC group had lower incidences of ICU admission and death and a significantly lower incidence of repeat surgery. CONCLUSION: In elderly patients treated for acute calculous cholecystitis, the 30-day mortality and complication rates were lower for PC + DLC than for LC. However, the total hospitalisation time was significantly prolonged and the costs were significantly higher for PC + DLC.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy.

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

Hepatic hilar mass in an adolescent: a rare case of hepatobiliary tuberculosis.

BACKGROUND: Hepatobiliary tuberculosis is a rare manifestation of Mycobacterium tuberculosis infection, especially in younger patients. The non-specific symptoms and signs as well as the lack of definite imaging characteristics often impedes diagnosis. Definite diagnosis of tuberculosiscan be obtained through histopathological examination; conventional anti-tuberculosis drugs and surgery are the most commonly recommended treatments. CASE PRESENTATION: A previously healthy 15-year-old rural adolescent male presented with a 2-month history of weight loss and fatigue. We strongly suspected a Klatskin tumor; therefore, exploratory laparotomy was performed. However, the microscopical findings revealed a granuloma consisting of epithelioid cells, caseous necrosis, and lymphocytic infiltration, indicating caseating granulomatous inflammation and yielding a final diagnosis of hepatic hilar tuberculosis. CONCLUSION: Hepatic hilar tuberculosis is an extremely rare case; few physicians may have actually treated a case. This report therefore aims to improve the overall understanding of lymphatic tuberculosis of the hepatic hilum.

Cholecystectomy as a risk factor of metabolic syndrome: from epidemiologic clues to biochemical mechanisms.

Cholecystectomy has long been regarded as a safe procedure with no deleterious influence on the body. However, recent studies provide clues that link cholecystectomy to a high risk for metabolic syndrome (MetS). In the present review, we describe the epidemiologic evidence that links cholecystectomy to MetS. Various components of MetS are investigated, including visceral obesity, dyslipidemia, elevated blood pressure, impaired fasting glucose, and insulin resistance. The possible mechanisms that associate cholecystectomy with MetS are discussed on the basis of experimental studies.

Epigallocatechin gallate suppresses hepatic cholesterol synthesis by targeting SREBP-2 through SIRT1/FOXO1 signaling pathway.

This study aims to explore the effect of epigallocatechin gallate (EGCG) on blood lipids, liver lipids, and cholesterol synthesis in hyperlipidemic rats. SREBP-2 transgenic rats were used to investigate the transcriptional level of SREBP-2 regulated by SIRT-1/FOXO1 and the molecular mechanism of rate-limiting enzyme HMGCR that affects cholesterol synthesis. Rat models of hyperlipidemia were established and administered EGCG. Cholesterol synthesis was observed. Enzyme linked immunosorbent assay was used to determine serum triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), free fatty acid (FFA), superoxide dismutase (SOD), malondialdehyde (MDA), and T-AOC contents. Hematoxylin-eosin staining and oil red O staining were utilized to observe the histological changes in the liver. Biochemical method was applied to measure serum ALT and AST changes. Western blot assay and qRT-PCR were employed to detect the changes in SIRT1/FOXO1 pathway-related proteins, cholesterol synthesis-related genes, and SREBP-2. EGCG 50 mg/kg could obviously decrease the liver weight and liver coefficient, reduce serum TG, TC, LDL-C, and FFA levels (P < 0.05), and increase serum HDL-C levels in hyperlipidemic rats. EGCG could diminish hyperlipidemia-induced liver injury and reduce serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Oil red O staining results demonstrated that the number of red lipid droplets in hepatocytes reduced to varying degrees, especially high-dose EGCG. EGCG remarkably diminished MDA content in the liver with hypercholesterolemia and increased T-AOC and SOD activity. In the model group, SIRT1 expression increased, and FOXO1 expression decreased. EGCG activated SIRT1 and increased FOXO1 expression, whose expression trend was consistent with the fenofibrate group. HMGCR, FDPS, SS, and ABCA1 expression increased, and ACAT2 expression noticeably reduced in SREBP-2+/+ transgenic rats. EGCG could reverse the expression trend of each gene. Simultaneously, EGCG increased FOXO1 expression, and decrease SREBP-2 expression; however, no significant changes in these expression were found in SREBP-2-/- rats. EGCG can alleviate liver injury and oxidative stress in hyperlipidemic rats. EGCG can activate SIRT1, activate FOXO1 protein, regulate SREBP-2 protein, and inhibit hepatic cholesterol synthesis.

Lipopolysaccharide stimulates endogenous ß-glucuronidase via PKC/NF-κB/c-myc signaling cascade: a possible factor in hepatolithiasis formation.

Hepatolithiasis is commonly encountered in Southeastern and Eastern Asian countries, but the pathogenesis mechanism of stone formation is still not well understood. Now, the role of endogenous ß-glucuronidase in pigment stones formation is being gradually recognized. In this study, the mechanism of increased expression and secretion of endogenous ß-glucuronidase during hepatolithiasis formation was investigated. We assessed the endogenous ß-glucuronidase, c-myc, p-p65, and p-PKC expression in liver specimens with hepatolithiasis by immunohistochemical staining, and found that compared with that in normal liver samples, the expression of endogenous ß-glucuronidase, c-myc, p-p65, and p-PKC in liver specimens with hepatolithiasis significantly increased, and their expressions were positively correlated with each other. Lipopolysaccharide (LPS) induced increased expression of endogenous ß-glucuronidase and c-myc in hepatocytes and intrahepatic biliary epithelial cells in a dose- and time-dependent manner, and endogenous ß-glucuronidase secretion increased, correspondingly. C-myc siRNA transfection effectively inhibited the LPS-induced expression of endogenous ß-glucuronidase. Furthermore, NF-κB inhibitor pyrrolidine dithiocarbamate or PKC inhibitor chelerythrine could effectively inhibit the LPS-induced expression of c-myc and endogenous ß-glucuronidase, and the expression of p-p65 was also partly inhibited by chelerythrine. Our clinical observations and experimental data indicate that LPS could induce the increased expression and secretion of endogenous ß-glucuronidase via a signaling cascade of PKC/NF-κB/c-myc in hepatocytes and intrahepatic biliary epithelial cells, and endogenous ß-glucuronidase might play a possible role in the formation of hepatolithiasis.

Transumbilical single-incision laparoscopic cholecystectomy: long-term review from a single center.

BACKGROUND: Currently, researches about single-incision laparoscopic cholecystectomy (SILC) are various, but long-term reviews assessing relevant complications after SILC with considerable amount of case series are rare. STUDY DESIGN: We retrospectively reviewed a large series of 529 patients undergoing SILC to assess the long-term postoperative recovery, including postoperative complications, retained symptoms, and quality of life. Finally, we assessed its associated risk factors related to SILC patients' recovery in the long term. RESULTS: During a mean follow-up period of 36.8 ± 8.8 months after SILC, 402 (76.0 %) patients underwent complete resolution. Frequent diarrhea (12.1 %) and recurrent omphalitis (5.9 %) were most commonly seen among other complications and retained symptoms within overall the patients. We identified 1 (0.3 %) incision hernia and 1 (0.3 %) intra-abdominal abscess among overall the patients, while 3 (0.8 %) common bile duct stones and 1 (0.3 %) biliary pancreatitis among the patients with symptomatic cholelithiasis during long-term review period. No significant differences were identified between patients with symptomatic cholelithiasis and gallbladder polyps when considering other incidences (all p > 0.05). Patients undergoing SILC with older age (p = 0.023) or female gender (p = 0.020) contributed to complete resolution. CONCLUSIONS: SILC via traditional devices is feasible and safe with acceptable postoperative incidence rate in the long run. Patients with older age or female gender, who have no severe systemic diseases, tend to benefit more from the surgical intervention.

Single-incision laparoscopic-assisted ileal resection for adult intussusception.

Adult intussusception is rare and laparotomy is required in most of the cases due to the potential pathologic underlying reasons. Although it is technically challenging, single-incision laparoscopic surgery can work as an alternative to laparotomy. Here we report the case of a 45-year-old man with intermittent right lower quadrant abdominal pain for 1 month. Abdominal enhanced computed tomography (CT) scan was performed and ileo-ileal intussusception was found, with lipoma as a likely leading point. Ileal resection was performed using the single-incision laparoscopic-assisted technique. Multiple trocars in the umbilical incision technique and conventional instruments were used. After identification of the ileo-ileal intussusception, the involved small bowel was extracted from the umbilical incision, and resection and anastomosis were performed extracoporeally. The operation time was 65 min and the post-operative hospital stay was 2 days. The patient recovered uneventfully, with better cosmetic results.

Cholesterol gallstone disease: focusing on the role of gallbladder.

Gallstone disease (GSD) is one of the most common biliary tract diseases worldwide in which both genetic and environmental factors have roles in its pathogenesis. Biliary cholesterol supersaturation from metabolic defects in the liver is traditionally seen as the main pathogenic factor. Recently, there have been renewed investigative interests in the downstream events that occur in gallbladder lithogenesis. This article focuses on the role of the gallbladder in the pathogenesis of cholesterol GSD (CGD). Various conditions affecting the crystallization process are discussed, such as gallbladder motility, concentrating function, lipid transport, and an imbalance between pro-nucleating and nucleation inhibiting proteins.

Combination of curcumin and piperine prevents formation of gallstones in C57BL6 mice fed on lithogenic diet: whether NPC1L1/SREBP2 participates in this process?

BACKGROUND: A disruption of cholesterol homeostasis characterized by the physical-chemical imbalance of cholesterol solubility in bile often results in formation of cholesterol gallstones. Our earlier studies revealed that curcumin (1000 mg/kg) could prevent formation of gallstones. It has been proved that curcumin is poorly absorbed while piperine is a bioavailability-enhancer. Nevertheless, whether curcumin combined with piperine could enhance the effect of curcumin in preventing gallstones is still awaited. METHOD: C57BL6 mice were fed on a lithogenic diet concomitant with curcumin at 500 or 1000 mg/kg and/or piperine at 20 mg/kg for 4 weeks. The ratio of gallbladder stone formation was recorded and samples of blood, bile, gallbladder, liver and small intestine were also collected. The volume of gallbladder and weight of liver were calculated, and blood and bile samples were analyzed through biochemical methods. Intestinal NPC1L1 and SREBP2 mRNA and protein expression were detected by real-time PCR and Western blot. RESULT: Combining with piperine can significantly enhance the effect of curcumin, thus preventing the development of gallbladder stones, lowering the saturation of blood lipids and cholesterol in bile, as well as decreasing the expression of NPC1L1 and SREBP2 in both mRNA and protein levels. CONCLUSION: Curcumin can prevent the formation of cholesterol gallstones induced by high fat diet in mice and SREBP2 and NPC1L1 may participate in this process. Piperine can increase curcumin's bioavailability, thereby enhancing the effect of curcumin.

LPS stimulates MUC5AC expression in human biliary epithelial cells: whether there exists a possible pathway of PKC/NADPH/ROS?

Previous studies have shown that lipopolysaccharide (LPS) can upregulate MUC5AC in airway epithelial cells. However, the relationship and mechanism between bacterial infection and altered mucus secretion in the biliary tract remains unclear. Human biliary epithelial cells were induced by LPS, H2O2 production in the cell supernatants were detected by specific kit and expression of MUC5AC were detected by real-time PCR, Western blot, and immunohistochemistry. H2O2 production increased in a dose-dependent manner, LPS upregulate MUC5AC expression in both mRNA and protein level while specific inhibitors can reduce this high expression. Reactive oxygen species participates in the process of LPS by upregulating MUC5AC secretion. Moreover, PKC and NADPH oxidase regulate MUC5AC production in LPS-challenged human biliary epithelial cells.

Transumbilical single-incision laparoscopic subtotal gastrectomy and total intracorporeal reconstruction of the digestive tract in the treatment of benign peptic ulcers.

BACKGROUND: Single-incision laparoscopic surgery is being applied increasingly in many surgical specialties. However, few reports are available regarding its use in the treatment of benign peptic ulcer disease. METHODS: We report here on nine patients with gastric or duodenal ulcers who underwent transumbilical single-incision laparoscopic subtotal gastrectomy (SILSG) between November 2010 and June 2013. All procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus. Total intracorporeal gastrojejunostomy or gastroduodenostomy was then performed for reconstruction of the digestive tract. RESULTS: Only one case required conversion from single-incision to multiple-incision surgery. Among the eight patients who successfully underwent SILSG, total intracorporeal gastroduodenostomy was performed in two and gastrojejunostomy in six. The mean operation time was 290 ± 50 min (range 230-360 min), and blood loss was 200 ± 66 mL (range 100-300 mL). The patients recovered fully, and the single umbilical scars healed well. CONCLUSIONS: We believe this is the first report of SILSG with total intracorporeal gastrojejunostomy or gastroduodenostomy in the treatment of benign peptic ulcers. On the basis of this initial experience, SILSG for this indication in the hands of experienced surgeons appears to be feasible and safe.

Pure NOTES transvaginal appendectomy with gasless laparoscopy.

BACKGROUND: The vagina is the most widely used approach to natural orifice transluminal endoscopic surgery. However, a gas leak can significantly affect transvaginal operations during pneumoperitoneum laparoscopy. We tried to establish the proper technique for transvaginal appendectomy under gasless laparoscopy. MATERIALS AND METHODS: Five patients with chronic appendicitis were selected to receive gasless laparoscopic transvaginal appendectomy with concurrent vaginal hysterectomy. An abdominal wall-lifting device was applied after removal of the uterus, and the appendix was removed transvaginally. Clinical data such as operative duration, bleeding volume, morbidity, and hospital stay duration were analyzed. RESULTS: All procedures were performed successfully, without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 20-30 minutes, with minimal blood loss. All patients were discharged, scar-free, 3 d after surgery. CONCLUSIONS: Transvaginal appendectomy with gasless laparoscopy after vaginal hysterectomy appears to be a feasible and safe modification of established techniques, with acceptable outcomes.