A new method of spermatic cord mobilization in herniorrhaphy.

Spermatic cord mobilization is a routine part of inguinal hernia repair, but the method of cord mobilization varies among surgeons. This study establishes an anatomic plane for spermatic cord mobilization. We studied the anatomy of the superficial cremasteric fascia in 105 male patients during herniorrhaphy for primary inguinal hernias. The mean patient age was 44.8 (18-71) years and mean body mass index was 24.1 kg/m(2) (21.5-27.1 kg/m(2)). The two layers of the superficial cremasteric fascia between the spermatic cord and the inguinal falx were incised to mobilize the cord. We found that spermatic cord mobilization during herniorrhaphy can be easily approached through an anatomic plane between the spermatic cord and the conjoined tendon with subsequent division of the superficial cremasteric fascia. None of the patients experienced any hemorrhage or nerve injury during cord mobilization. We found this method to be both safe and easy to learn.

Laparoscopic versus open appendectomy: a prospective randomized comparison.

BACKGROUND: Whether laparoscopy offers a benefit over open surgery in the management of acute appendicitis or not remains a subject of controversy despite the publication of numerous randomized studies. This study aimed to compare laparoscopic appendectomy (LA) with open appendectomy (OA) and to ascertain its therapeutic benefit. METHODS: Adult patients older than 14 years presenting with signs and symptoms suggestive of acute appendicitis were randomized to undergo either LA or OA from January 2006 to December 2007. Comparisons were based on operating time, time until return to a general diet, time until return to normal activity and work, length of hospital stay, billed charges, and postoperative complications. RESULTS: The study enrolled 220 patients: 108 to undergo OA and 112 to undergo LA. The groups were similar in terms of clinicopathologic characteristics. The operating time seemed to be shorter for the OA patients than for the LA patients, but the difference was not significant (LA, 30 +/- 15.2 min vs. OA, 28.7 +/- 16.3 min; p > 0.05). The hospital stay of 4.1 +/- 1.5 days for the LA group and 7.2 +/- 1.7 days for the OA group, and the difference was statistically significant (p < 0.05). Laparoscopic appendectomy remained associated with a shorter time until return to a general diet (LA, 20.2 +/- 12.4 h vs. OA, 36.5 +/- 10 h; p < 0.05), to normal activity (LA, 9.1 +/- 4.2 days vs. OA, 13.7 +/- 5.8 days; p < 0.05), and to work (LA, 21.2 +/- 3.5 days vs. OA, 27.7 +/- 4.9 days; p < 0.05). The billed charges appeared to be higher for LA (LA, 5,720.3 +/- 115.7 yuan vs. OA, 5,310 +/- 575.4 yuan), but this difference failed to be clinically important or statistically significant (p > 0.05). Wound infections were more common after OA (n = 14) than after LA (n = 0) (p < 0.05). Intraabdominal abscesses occurred for two patients in the LA group and nine patients in the OA group (p < 0.05). Postoperative ileus occurred with frequencies of 0% in the LA group and 7.4% in the OA group (p < 0.05). The rate for overall complications was significantly lower in the LA group. CONCLUSION: Laparoscopic appendectomy is a useful tool in the treatment of acute appendicitis. Its advantages lie in its minimal invasiveness, its better cosmetic outcome, its lower rate of complications based on surgical expertise and state-of-the-art equipment. It can be recommended as an adoptable method for the routine patient with appendicitis.

Association of serum vascular endothelial growth factor-C and lymphatic vessel density with lymph node metastasis and prognosis of patients with gastric cancer.

AIM: To investigate whether serum vascular endothelial growth factor-C (SVEGF-C), VEGF-C, and lymphatic vessel density (LVD) in tumor tissues are related to lymph node metastasis (LNM) and prognosis in gastric cancer. METHODS: SVEGF-C levels of 80 gastric cancer patients and 20 healthy donors were examined using ELISA. VEGF-C expression and LVD were examined using immunohistochemical staining. Kaplan-Meier survival analysis was performed to determine their influence on the prognosis of the patients. RESULTS: The SVEGF-C level in gastric cancer patients (595.9 +/- 201.0 ng/L) was significantly higher (P = 0.000) than controls (360.0 +/- 97.4 ng/L). Both SVEGF-C and LVD were significantly higher in poorly differentiated adenocarcinomas, T3 and T4, LNM, distant metastasis, and pTNM groups III and IV (P = 0.000). The sensitivity and specificity of SVEGF-C for predicting LNM were 82.8% and 81.8%, respectively (cut-off = 542.5 ng/L). The positive expression rate of VEGF-C was significantly higher in cancerous than in normal tissues (65% vs 20%; P = 0.001). VEGF-C expression up-regulation was significantly related to differentiation, depth of invasion, LNM, distant metastasis, and pTNM stage (P = 0.000). LVD was 10.7 +/- 3.1/200 HP in the experimental group vs 4.9 +/- 1.3/200 HP in controls (P = 0.000); LVD in cancerous tissues with and without LNM was 12.0 +/- 2.7/200 HP vs 7.6 +/- 0.5/200 HP, respectively (P = 0.000). SVEGF-C and LVD were significantly higher in VEGF-C positive than in negative patients (P = 0.000); SVEGF-C level was related to LVD (P = 0.000). Kaplan-Meier survival analysis factors predicating poor prognosis were: SVEGF-C level (P = 0.001), VEGF-C expression and LVD (both P = 0.000). CONCLUSION: SVEGF-C level, VEGF-C and LVD are related to LNM and poor prognosis of patients with gastric cancer. SVEGF-C may be a biomarker for LNM in gastric cancer.

[Treatment of portal hypertension by endoscopic esophageal ligation of varicose veins combined with partial splenic embolization].

OBJECTIVE: To evaluate the feasibility and efficacy of a new method of endoscopic esophageal variceal ligation combined with partial splenic embolization (EVL-PSE) for the patients with portal hypertension. METHODS: From May 1999 to February 2003, sixty-eight patients with portal hypertension underwent EVL-PSE, and hemodynamics of the portal trunk (PT), the left gastric vein and azygos vein, including maximum velocity, flow volume, vein diameter, were assessed using color ultrasound Doppler. RESULTS: The esophageal varices and hypersplenism were greatly ameliorated after operation in patients who had undergone EVL-PSE. Postoperative portal trunk flow volume and velocity were significantly reduced (P < 0.05), and flow volume of the left gastric vein as well as the azygos vein were also reduced after operation. During 2 - 24-month follow-up, no recurrent bleeding was found. CONCLUSIONS: EVL-PSE is less traumatic with less complications, and results in marked eradication of esophageal varices, it can be carried out safely in the clinical treatment for patients with portal hypertension.

A novel method for creating working space during endoscopic thyroidectomy via bilateral areolar approach.

BACKGROUND: Endoscopic thyroidectomy (ET) can be performed through the bilateral areolar approach (BAA). A working space (WS) is typically created on the surface of the pectoral fascia in the chest wall and in the subplatysmal space in the neck. There are several limitations of using this WS. The aim of this study was to establish a new WS for ET. SUBJECTS AND METHODS: A retrospective review was performed on 85 patients with benign thyroid nodules who had undergone ET through a BAA. A WS was created between the anterior and poster layers of the superficial pectoral fascia (SPF) in the chest and underneath the deep layer of the investing layer (IL) in the neck. RESULTS: The time for creating the WS was 7.2 ± 2.1 (range, 5-12) minutes. No hemorrhage occurred during the procedure. Fat liquefaction occurred in 2 patients. Edema of the neck skin flap presented as lack of a suprasternal notch. No skin numbness occurred. No patient required postoperative pain medication. All patients were extremely satisfied with the cosmetic results. CONCLUSIONS: This new method of establishing a WS between the two layers of the SPF and underneath the IL is simple and fast, provides good exposure, yields less postoperative pain, and has a lower risk of skin burn.

Comparative study on three types of alimentary reconstruction after total gastrectomy.

BACKGROUND: More than 70 alimentary reconstruction procedures after total gastrectomy have been proposed to reduce the postoperative syndromes such as dumping syndrome, reflux esophagitis, and malnutrition. However, the optimal alimentary reconstruction method is still a matter of debate. The aim of the current study was to investigate the rationality of different alimentary tract reconstruction methods after total gastrectomy for gastric malignancy. METHODS: Three types of digestive reconstruction methods were performed after total gastrectomy in 285 cases of gastric malignancy from May 1996 to December 2006, including Orr-type Roux-en-Y reconstruction (Orr-type), P-type Roux-en-Y reconstruction (P-type), and Moynihan-type reconstruction (Moynihan-type) methods. The operative time, early postoperative complications and mortality, food intake, alimentary symptoms, Visick scores, nutritional status at 1 and 3years after surgery, and cumulative survival at 1, 3, and 5years were comparatively analyzed. RESULTS: There were no significant differences among the three methods in early postoperative complications and mortality, postoperative food intake and nutritional status (hemoglobin, total proteins and albumin), and incidence of diarrhea and dumping syndrome at 1 and 3years (p > 0.05). The overall 1-, 3-, and 5-year cumulative survival rate were 75.30%, 39.86%, and 21.48%, respectively, without significant differences among the three groups (p > 0.05). However, the average operative time used in the Orr-type reconstruction method (2.9 +/- 0.1h) was comparatively shorter than that used in the P-type (3.4 +/- 0.2h) and the Moynihan-type (3.2 +/- 0.1h). The incidences of reflux esophagitis after the gastric reconstruction with the Moynihan-type method at 1 and 3years (72% and 65%) were significantly higher than that with the Orr-type (3% and 0%) and P-type (5% and 0%; p < 0.01). Constituent ratio of Visick scores I-II of the Moynihan-type method at 1 and 3years (54% and 73%) were smaller than that of the Orr-type (94% and 96%) and the P-type (93% and 96%) methods (p < 0.01). CONCLUSION: Orr-type Roux-en-Y reconstruction method can avoid reflux esophagitis, and the procedure is simpler than the other two methods. Therefore, Orr-type Roux-en-Y reconstruction can be recommended as an adoptable method of digestive reconstruction after total gastrectomy for gastric cancer.

[Comparative study on three types of digestive reconstruction after total gastrectomy].

OBJECTIVE: To investigate the rational digestive reconstruction after total gastrectomy for gastric malignancy. METHODS: Three types of digestive reconstruction were performed after total gastrectomy in 189 cases with gastric carcinoma. The operating time, morbidity and mortality, food intake, digestive tract symptoms, nutritional status at 1 and 3 years after surgery and 1-, 3-, 5-year cumulative survival were compared. RESULTS: There were no significant differences among the three procedures in operative morbidity and mortality, postoperative food intake, nutritional status (Hemoglobin, total protein and labium), and incidences of diarrhea and dumping syndrome (P > 0.05). The overall 1-, 3-, 5-year survival rates were 75.3%, 38.2% and 20.5% respectively, and there were no significant differences among the three groups (P > 0.05). Orr-type and P-type esophagojejunostomy had an advantage of anti-esophageal reflux, and were obviously superior to Moynihan-type anastomosis (P< 0.01). Compared with P-type reconstruction, Orr-type reconstruction was simpler with shorter operating time, and less complications. CONCLUSIONS: Orr-type Roux-en-Y esophagojejunostomy can be recommended as an adaptable method of digestive reconstruction after total gastrectomy for gastric cancer because of its avoiding reflux esophagitis, maintaining better nutritional status and quality of life, and simpler procedure.