Prognostic impact of different tumor invasion patterns in the surgical treatment of T3 glottic laryngeal cancer / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the prognostic impact of different tumor invasion patterns in the surgical treatment of T3 glottic laryngeal cancer. Methods:A retrospective analysis was conducted on the clinical data of 91 patients with T3 glottic laryngeal cancer. Results:Among the 91 patients, 58 cases （63.7%） had anterior invasion and 33 cases （36.3%） had posterior invasion. The posterior invasion was significantly correlated with invasions of the dorsal plate of cricoid cartilage （P<0.001）, arytenoid cartilage （P= 0.001）, and subglottic region（P = 0.001）. There was no statistical difference in survival outcomes between the total laryngectomy group and the partial laryngectomy group. But in the partial laryngectomy group, the 5-year disease-free survival（DFS） of patients with anterior invasive tumors was better than that of patients with posterior invasion tumors （HR: 4.681, 95%CI 1.337-16.393, P=0.016）, and subglottic invasion was associated with worse loco-regional recurrence-free survival（LRRFS）（HR: 3.931, 95%CI 1.054-14.658, P=0.041）. At the same time, we found that involvement of the dorsal plate of cricoid cartilage was an independent risk factor for postoperative laryngeal stenosis in partial laryngectomy patients （HR:11.67, 95%CI 1.89-71.98,P=0.008）. Conclusion:Compared with total laryngectomy, selected partial laryngectomy can also achieve favorable oncological outcomes. Posterior invasion and subglottic extension are independent prognostic factors for recurrence of partial laryngectomy in T3 glottic laryngeal cancer, and the involvement of the dorsal plate of cricoid cartilage is associated with postoperative laryngeal stenosis. The tumor invasion pattern of laryngeal cancer should be further subdivided in order to select a more individualized treatment plan.

Unusual case of a free anterolateral thigh flap partial necrosis in a COVID-19 positive young male following extremity reconstruction / 中华创伤杂志(英文版)

Free flap procedure provides an overall success rate of 97%, which decreases to 85% in hypercoagulable states. COVID-19, as a pro-thrombotic disorder, therefore seems detrimental to free flap survival. We encountered a case of unique pattern of free flap partial failure in a young male who underwent extremity reconstruction. The patient was diagnosed as COVID-19 positive on the 3rd day post-reconstruction. The flap survived well for the first 7 days post-operatively, but gradually the skin got necrosed and the subcutaneous fat layer was preserved when debriding. To our knowledge, this is the only case in which the skin of the free flap of a COVID-19 positive patient was necrosed almost entirely subsequently, while the subcutaneous fat was relatively preserved.

Ultrasound-guided continuous fascia iliaca compartment block for perioperative pain management in elderly patients undergoing hip fracture surgery / 中国骨伤

OBJECTIVE@#To study the effect of ultrasound-guided fascia iliaca compartment block on perioperative analgesia and postoperative complications in geriatric patients with hip fractures.@*METHODS@#A total of 127 elderly patients undergoing hip fracture surgery from January 2021 to September 2021 were randomized to receive ultrasound-guided continuous fascia iliaca compartment block(group F) either intravenous analgesia control group(group C). There were 62 cases in group F, including 19 males and 43 females with an average age of (82.4±7.2) years old ranging from 66 to 95 years old, involving 25 femoral neck fractures and 37 femoral intertrochanteric fractures. There were 65 cases in control group, including 18 males and 47 females, with an average age of (81.4±8.7) years old ranging from 65 to 94 years old, involving 29 femoral neck fractures and 36 femoral intertrochanteric fractures. The visual analogue scale(VAS), minimental state examination (MMSE), observer's assessment of alertness/sedation(OAA/S) scale, modified Bromage score, postoperative complications and general conditions during hospitalization in two groups were observed.@*RESULTS@#The resting and exercise VAS at 30 min after block, anesthesia placement and 6, 24 and 48 h after surgery were lower than those in group C(P<0.05). In group F, MMSE scores at 12 h before surgery, and 1, 3 d after surgery and OAA/S scores at 3 d after surgery were higher than those in group C(P<0.05). The incidence of adverse effects and the number requiring additional analgesia were lower than those in group C(P<0.05). Group F had better perioperative analgesia satisfaction and hospital stay than group C(P<0.05). But there was no significant difference regarding Bromage score and 30-day mortality between two group(P>0.05).@*CONCLUSION@#Ultrasound-guided continuous fascia iliacus space block was safe and effective for elderly patients with hip fracture, and could significantly reduce perioperative pain, improve postoperative cognitive function, and reduce postoperative complications, thereby shortening hospital stay and improving the quality of life during hospitalization.

Predictive value of PTH level on day 1 after surgery for papillary thyroid carcinoma in patients with permanent hypoparathyroidism / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the relationship between parathyroid hormone（PTH） level and permanent hypoparathyroidism（PHPP） on the first day after radical papillary thyroidectomy, and its predictive value. Methods:A total of 80 patients with papillary thyroid cancer who underwent total thyroid resection and central lymph node dissection were collected and analyzed from January 2021 to January 2022. According to whether PHPP occurred after surgery, the patients were divided into hypoparathyroidism group and normal parathyroid function group, and univariate and binary logistics regression were used to analyze the correlation between PTH and serum calcium levels and PHPP on the first day after surgery in two groups. The dynamic changes of PTH at different time points after operation were analyzed. The area under the receiver operating characteristic was used to evaluate the predictive power of PTH on the development of PHPP after surgery. Results:Among the 80 patients with papillary thyroid cancer, 10 cases developed PHPP, with an incidence rate of 12.5%. Binary logistics regression analysis showed that PTH on the first postoperative day（OR=14.534, 95%CI: 2.377-88.858, P=0.004） was an independent predictive risk factor for postoperative PHPP. Taking PTH=8.75 ng/L on the first postoperative day as the cut-off value, the AUC of the area under the curve was 0.874（95%CI: 0.790-0.958, P<0.001）, the sensitivity was 71.4%, the specificity was 100%, and the Yoden index was 0.714. Conclusion:PTH level on the first day after total thyroid papillary carcinoma surgery is closely related to PHPP, and is an independent predictor of PHPP.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair

INTRODUCTION@#The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population.@*METHODS@#This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups.@*RESULTS@#There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable.@*CONCLUSION@#Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Feasibility study of immediate breast reconstruction with fusion fascia combined with implants / 中华肿瘤杂志

Objective: To investigate the oncologic and surgical safety of the fused fascia method for immediate breast reconstruction with implants. Methods: The clinical data of 343 patients with immediate breast reconstruction with implants in Tianjin Medical University Cancer Hospital from 2014-2017 were retrospectively analyzed to compare the 5-year local recurrence-free survival, 5-year disease-free survival and 5-year overall survival of patients with breast reconstruction by fusion fascia and other methods, and to analyze the complication incidences of implant removal between different implant groups. Results: Of the 343 patients with breast reconstruction, 95 were in the fused fascia group (fascia group) and 248 were in the non-fascia group (25 in the bovine pericardial patch group and 223 in the muscle flap group). At a median follow-up of 49 months, the differences in 5-year local recurrence-free survival (90.1% and 94.9%, respectively), 5-year disease-free survival (89.2% and 87.6%, respectively), and 5-year overall survival (95.2% and 95.1%, respectively) between patients in the fascial and non-fascial groups were not statistically significant (P>0.05). The complication incidence of implant removal was 24.0% (6/25) in the patch group and 2.1% (2/95) and 2.2% (5/223) in the fascia and muscle flap groups, respectively. Conclusion: Immediate breast reconstruction with fused fascial combined with implant is safe and feasible, less invasive than muscle flaps, more economical and with fewer complications than patches.

Comparison of Quality of Life of the Patients Three Months after Uniportal and Multiportal Thoracoscopic Lobectomy / 中国肺癌杂志

BACKGROUND@#The relationship between quality of life at three months after lung cancer surgery and different surgical approaches is remains unclear. This study aimed to compare the quality of life of patients three months after uniportal and multiportal thoracoscopic lobectomy.@*METHODS@#Data from patients who underwent lung surgery at the Department of Thoracic Surgery, Sichuan Cancer Hospital between April 2021 and October 2021 were collected. The European Organization for Research and Treatment of Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and Quality of Life Questionnaire-Lung Cancer 29 (EORTC QLQ-LC29) were used to collect quality of life data of the patients. Potential confounding factors in the baseline data were included in a multivariate regression model for adjustment, and the quality of life of the two groups three months postoperatively was compared with traditional clinical outcomes.@*RESULTS@#A total of 130 lung cancer patients were included, with 57 males (43.8%) and 73 females (56.2%), and an average age of (57.1±9.5) yr. In the baseline data of the two groups, there was a statistical difference in the number of chest drainage tubes placed (P<0.001). After adjustment with the regression model, at three months postoperatively, there were no significant differences in all symptoms and functional status scores between the two groups (all P>0.05). The multiportal group had longer surgery time (120.0 min vs 85.0 min, P=0.001), postoperative hospital stay (6.0 d vs 4.0 d, P=0.020), and a higher incidence of early ≥ grade 2 complications (39.0% vs 10.1%, P=0.011) compared to the uniportal group.@*CONCLUSIONS@#Patients undergoing uniportal and multiportal thoracoscopic lobectomy have similar quality of life at three months postoperatively. The uniportal group may have certain advantages in terms of traditional clinical outcome indicators such as operation time, postoperative hospital stay, and early postoperative complications.

Membrana de circulación extracorpórea veno-arterial para ablación de tormenta eléctrica en shock cardiogénico: caso clínico / Veno-arterial extracorporeal membrane oxygenation (ECMO) used for support during ablation of ventricular electrical storm: case report

RESUMEN: Se presenta el caso clínico de un paciente que presenta un infarto del miocardio con trombolisis no exitosa y posterior implantación de 2 stents coronarios quien desarrolla, algunos días después, una tormenta eléctrica ventricular. Una ablación de la taquicardia se realizó bajo ECMO, con buen resultado. Se detalla la descripción del caso, revisa y discute el tema.

ABSTRAC: A patient with a myocardial infarction whom, following a failed thrombolisis and implantion of 2 stents developed a ventricular electrical storm and hemodynamic instability. A successful ablation of the tachycardia with the use of ECMO was performed. A full description is included, along with a discussion of the subject.

Retropharyngeal lymph node dissection in head and neck cancers treated with transoral robotic surgery / 中华肿瘤杂志

Objective: To evaluate the indications, safety, feasibility, and surgical technique for patients with head and neck cancers undergoing transoral robotic retropharyngeal lymph node (RPLN) dissection. Methods: The current study enrolled 12 consecutive head and neck cancer patients (seven males and four females) who underwent transoral robotic RPLN dissection with the da Vinci surgical robotic system at the Sun Yat-sen University Cancer Center from May 2019 to July 2020. Seven patients were diagnosed as nasopharyngeal carcinoma with RPLN metastasis after initial treatments, 4 patients were diagnosed as thyroid carcinoma with RPLN metastasis after initial treatments, and one patient was diagnosed as oropharyngeal carcinoma with RPLN metastasis before initial treatments. The operation procedure and duration time, intraoperative blood loss volume and complications, nasogastric feeding tube dependence, tracheostomy dependence, postoperative complications, and hospitalization time were recorded and analyzed. Results: All patients were successfully treated by transoral robotic dissection of the metastatic RPLNs, none of which was converted to open surgery. RPLNs were completely resected in 10 patients, and partly resected in 2 patients (both were nasopharyngeal carcinoma patients). The mean number of RPLN dissected was 1.7. The operation duration time and intraoperative blood loss volume were (191.3±101.1) min and (150.0±86.6) ml, respectively. There was no severe intraoperative complication such as massive haemorrhage or adjacent organ injury during surgery. Nasogastric tube use was required in all patients with (17.1±10.6) days of dependence, while tracheotomy was performed in 8 patients with (11.6±10.7) days of dependence. The postoperative hospitalization stay was (8.5±5.7) days. Postoperative complications occurred in 4 patients, including 2 of retropharyngeal incision and 2 of dysphagia. During a follow-up of (6.5±5.1) months, disease-free progression was observed in all patients, 10 patients were disease-free survival and other 2 patients were survival with tumor burden. Conclusions: The transoral robotic RPLN dissection is safety and feasible. Compared with the traditional open surgical approach, it is less traumatic and safer, has fewer complications and good clinical application potentiality. The indications for transoral robotic RPLN dissection include thyroid carcinoma, oropharyngeal carcinoma, and some selected nasopharyngeal carcinoma and other head and neck cancers. Metastatic RPLNs from some nasopharyngeal carcinoma with incomplete capsule, unclear border and adhesion to the surrounding vessels are not suitable for transoral robotic RPLN dissection.

Comparison between laparoscopic-assisted natural orifice specimen extraction surgery and conventional laparoscopic surgery for left colorectal cancer: a randomized controlled study with 3-year follow-up results / 中华胃肠外科杂志

Objective: To evaluate the mid-term efficacy of laparoscopic-assisted natural orifice specimen extraction surgery (NOSES) colectomy using the Cai tube in the treatment of left colorectal cancer. Methods: A prospective randomized control trial (China Clinical Trials Registration Number: ChiCTR-OOR-15007060) was performed. Sixty patients with left colorectal cancer at Department of Gastrointestinal Surgery of Zhongshan Hospital from September 2015 to August 2017 were prospectively enrolled. Case inclusion criteria: (1) left colorectal adenocarcinoma (rectal cancer with distance ≥ 8 cm from tumor low margin to anal edge, sigmoid colon cancer, descending colon cancer and left transverse colon cancer) confirmed by preoperative pathology; (2) satisfactory conditions of conventional laparoscopic surgery; (3) maximum diameter of the tumor < 4.5 cm confirmed by preoperative abdominal and pelvic CT or MRI; (4) BMI < 30 kg/m2. Case exclusion criteria: (1) benign lesions, mucinous adenocarcinoma, signet-ring cell carcinoma and other special pathological types of tumors confirmed by preoperative pathological examination; (2) multiple or recurrent cancers; (3) with a history of neoadjuvant chemoradiotherapy; (4) obvious regional infiltration or distant metastasis indicated by preoperative imaging examination; (5) intestinal obstruction, intestinal perforation, etc. Participants were randomly assigned to NOSES group (using the Cai tube) and conventional laparoscopy (CL) group by random number table method. Clinical data between two groups were compared and analyzed, including perioperative conditions, tumor exfoliation cell detection and bacterial culture results of intraperitoneal lavage fluid, postoperative complications (Clavien-Dindo grading), postoperative pain [visual simulation scoring (VAS) assessment], anal function (Kirwan anal function grading assessment), and postoperative 3-year disease-free survival (DFS), overall survival (OS), overall recurrence rate, and local recurrence rate. Results: A total of 60 patients were enrolled, with 30 in the NOSES group and 30 in the CL group. All the patients in the NOSES group successfully completed operation with Cai tube. Baseline data between the two groups were not significantly different (all P>0.05). There were no statistically significant differences between two groups in conversion rate to open surgery, number of lymph node harivested, proximal and distal resection margin of tumor, negative rate of circumferential margin, operation time, blood loss, inflammatory indexes, postoperative anal function, postoperative hospital stay, hospitalization cost, morbidity of postoperative complications (Clavien-Dindo grade II or above) (all P>0.05). Compared to the CL group, the NOSES group had lower maximum postoperative VAS score (2.5±0.3 vs. 5.1±0.4, t=3.187, P<0.01), and fewer use of additional postoperative analgesia [6.7% (2/30) vs. 33.3% (10/30),χ2=6.670, P=0.02]. The postoperative time to gas passage was shorter in the NOSES group [(2.2±1.4) days vs. (3.1±1.2) days,P=0.026]. No tumor cells and bacterial contamination were found in abdominal lavage fluid before and after operation in either group. The anal function at postoperative 3-month of all the patients in the NOSES group was Kirwan grade I to II, while in the CL group, anal function of 2 cases (6.7%) was Kirwan grade III, and of 28 cases was also Kirwan grade I to II, whose difference was not statistically significant (P>0.05). In the NOSES group and the CL group, 3-year DFS was 96.7% and 83.3% (P=0.090), OS was 100% and 90% (P=0.096), overall recurrence rate was 3.3% and 10.0% (P=0.166), and local recurrence rate was 3.3% and 3.3% (P=0.999), respectively, whose differences were not statistically significant (all P>0.05). Conclusions: In the treatment of left colorectal cancer, compared with conventional laparoscopic colectomy, NOSES colectomy using Cai tube exhibits less scar, less postoperative pain, shorter recovery of gastrointestinal function, and similar mid-term outcomes. Given proper surgical indications, the surgical procedure is safe and feasible.

Patient experience in the implementation of enhanced recovery after surgery strategy after radical gastric cancer surgery / 中华胃肠外科杂志

Objective: To investigate the experience of patients in the implementation of enhanced recovery after surgery (ERAS) strategy after radical gastrectomy and the factors affecting the treatment experience. Methods: A prospective cohort study was carried out. Patients who were diagnosed with gastric cancer by pathology and underwent radical gastrectomy at the Xijing Digestive Disease Hospital from December 2019 to December 2020 were consecutively enrolled. Those who received emergency surgery, residual gastric cancer surgery, preoperative neoadjuvant chemotherapy, non-curative tumor resection, intraperitoneal metastasis, or other malignant tumors were excluded. Patients' expectation and experience during implementation were investigated by questionnaires. The questionnaire included three main parts: patients' expectation for ERAS, patients' experience during the ERAS implementation, and patients' outcomes within 30 days after discharge. The items on the expectation and experience were ranked from 0 to 10 by patients, which indicated to be unsatisfied/unimportant and satisfied/important respectively. According to their attitudes towards the ERAS strategy, patients were divided into the support group and the reject group. Patients' expectation and experience of hospital stay, and the clinical outcomes within 30 days after discharge were compared between the two groups. Categorical data were reported as number with percentage and the quantitative data were reported as mean with standard deviation, or where appropriate, as the median with interquartile range (Q1, Q3). Categorical data were compared using the Chi-squared test or Fisher's exact test, where appropriate. For continuous data, Student's t test or Mann-Whitney U test were used. Complication was classified according to Clavien-Dindo classification. Results: Of the included 112 patients (88 males and 24 females), aged (57.8±10.0) years, 35 patients (31.3%) were in the support group and 77 (68.7%) in the reject group. Anxiety was detected in 56.2% (63/112) of the patients with score >8. The admission education during the ERAS implementation improved the patients' cognitions of the ERAS strategy [M(Q1, Q3) score: 8 (4, 10) vs. 2 (0, 5), Z=-7.130, P<0.001]. The expected hospital stay of patients was longer than the actual stay [7 (7, 10) days vs. 6 (6, 7) days, Z=-4.800, P<0.001]. During the ERAS implementation, patients had low score in early mobilization [3 (1, 6)] and early oral intake [5 (2.25, 8)]. Fifty-eight (51.8%) patients planned the ERAS implementation at home after discharge, while 32.1% (36/112) preferred to stay in hospital until they felt totally recovered. Compared with the reject group, the support group had shorter expected hospital stay [7 (6, 10) days vs. 10 (7, 15) days, Z=-2.607, P=0.009], and higher expected recovery-efficiency score [9 (8, 10) vs. 7(5, 9), Z=-3.078, P=0.002], lower expected less-pain score [8 (6, 10) vs. 6 (5, 9) days, Z=-1.996, P=0.046], expected faster recovery of physical strength score [8 (6, 10) vs. 6 (4, 9), Z=-2.200, P=0.028] and expected less drainage tube score [8 (8, 10) vs. 8 (5, 10), Z=-2.075, P=0.038]. Worrying about complications (49.1%) and self-recognition of not recovery (46.4%) were the major concerns when assessing the experience toward ERAS. During the follow-up, 105 patients received follow-up calls. There were 57.1% (60/105) of patients who experienced a variety of discomforts after discharge, including pain (28.6%), bloating (20.0%), nausea (12.4%), fatigue (7.6%), and fever (2.9%). Within 30 days after discharge, 6.7% (7/105) of patients developed Clavien-Dindo level I and II operation-associated complications, including poor wound healing, intestinal obstruction, intraperitoneal bleeding, and wound infection, all of which were cured by conservative treatment. There were no complications of level III or above in the whole group after surgery. Compared with the support group, more patients in the reject group reported that they had not yet achieved self-expected recovery when discharged [57.1% (44/77) vs. 22.9% (8/35), χ2=11.372, P<0.001], and expected to return to their daily lives [39.0% (30/77) vs. 8.6% (3/35), χ2=10.693, P<0.001], with statistically significant differences (all P<0.05). Only 52.4% (55/105) of patients returned home to continue rehabilitation, and the remaining patients chose to go to other hospitals to continue their hospitalization after discharge, with a median length of stay of 7 (7, 9) days. Compared with the reject group, the support group had a higher proportion of home rehabilitation [59.7% (12/33) vs. 36.4% (43/72), χ2=4.950, P=0.026], and shorter time of self-perceived postoperative full recovery [14 (10, 20) days vs. 15 (14, 20) days, Z=2.100, P=0.036], with statistically significant differences (all P<0.05). Conclusions: Although ERAS has promoted postoperative rehabilitation while ensuring surgical safety, it has not been unanimously recognized by patients. Adequate rehabilitation education, good analgesia, good physical recovery, and early removal of drainage tubes may improve the patient's experience of ERAS.

Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction / 北京大学学报(医学版)

OBJECTIVE@#To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment.@*METHODS@#Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients' demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed.@*RESULTS@#The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death.@*CONCLUSION@#Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

Comparison of the outcomes between open and hybrid approaches in the treatment of thoracoabdominal aortic aneurysms repair / 北京大学学报(医学版)

OBJECTIVE@#Thoracoabdominal aortic aneurysm is one of the most challenging aortic diseases. Open surgical repair remains constrained with considerable perioperative morbidity and mortality. The emergence of a hybrid approach utilizing visceral debranching with endovascular aneurysm repair has brought an alternative for high-risk patients. This study aimed to compare the short- and long-term outcomes between hybrid and open repairs in the treatment of thoracoabdominal aortic aneurysms.@*METHODS@#In this retrospectively observational study, patients with thoracoabdominal aortic aneurysm treated in a single center between January 2008 and December 2019 were reviewed, of whom 11 patients with hybrid repair, and 18 patients with open repair were identified. Demographic characteristic, operative data, perioperative morbidity and mortality, freedom from reintervention, and long-term survival were compared between the two groups.@*RESULTS@#In the hybrid repair group, the patients with dissection aneurysm, preoperative combined renal insufficiency, and American Society of Anesthesiologists (ASA) score of 3 or more were significantly overwhelming than in the open repair group. The operation time of debranching hybrid repair was (445±85) min, and the intraoperative blood loss was (955±599) mL. There were 2 cases of complications in the early 30 days after surgery, without paraplegia, and 1 case died. The 30-day complication rate was 18.2%, and the 30-day mortality was 9.1%. The operation time of the patients with open repair was (560±245) min, and the intraoperative blood loss was (6 100±4 536) mL. Twelve patients had complications in the early 30 days after surgery, including 1 paraplegia and 4 deaths within 30 days. The 30-day complication rate was 66.7%, and the 30-day mortality was 22.2%. The bleeding volume in hybrid repair was significantly reduced compared with open repair (P < 0.001). Besides, the incidence of 30-day complications in hybrid surgery was significantly reduced (P=0.011). During the follow-up period, there were 4 reinterventions and 3 deaths in hybrid repair group. The 1-year, 5-year, and 10-year all-cause survival rates were 72%, 54%, and 29%, respectively. In open repair group, reintervention was performed in 1 case and 5 cases died, and the 1-year, 5-year, and 10-year all-cause survival rates were 81%, 71%, and 35%, respectively. There was no significant difference between hybrid repair and open repair in all-cause survival and aneurysm-specific survival.@*CONCLUSION@#Hybrid approach utilizing visceral debranching with endovascular aneurysm repair is a safe and effective surgical method for high-risk patients with thoracoabdominal aortic aneurysms. The incidence of early postoperative complications and mortality is significantly reduced compared with traditional surgery, but the efficacy in the medium and long term still needs to be improved.

Safety and effectiveness of esophagojejunostomy through extracorporeal versus intracorporeal methods after laparoscopic total gastrectomy / 中华胃肠外科杂志

Objective: To compare the safety and effectiveness of esophagojejunostomy (EJS) through extracorporeal and intracorporeal methods after laparoscopic total gastrectomy (LTG). Methods: A retrospective cohort study was carried out. Clinicopathological data of 261 gastric cancer patients who underwent LTG, D2 lymphadenectomy, and Roux-en-Y EJS with complete postoperative 6-month follow-up data at the General Surgery Department of Nanfang Hospital from October 2018 to June 2021 were collected. Among these 261 patients, 139 underwent EJS with a circular stapler via mini-laparotomy (extracorporeal group), while 122 underwent intracorporeal EJS (intracorporeal group), including 43 with OrVil(TM) anastomosis (OrVil(TM) subgroup) and 79 with Overlap anastomosis (Overlap subgroup). Compared with the extracorporeal group, the intracorporeal group had higher body mass index, smaller tumor size, earlier T stage and M stage (all P<0.05). Compared with the Overlap subgroup, the Orvil(TM) subgroup had higher proportions of upper gastrointestinal obstruction and esophagus involvement, and more advanced T stage (all P<0.05). No other significant differences in the baseline data were found (all P>0.05). The primary outcome was complications at postoperative 6-month. The secondary outcomes were operative status, intraoperative complication and postoperative recovery. Continuous variables with a skewed distribution are expressed as the median (interquartile range), and were compared using Mann-Whitney U test. Categorical variables are expressed as the number and percentage and were compared with the Pearson chi-square, continuity correction or Fisher's exact test. Results: Compared with the extracorporeal group, the intracorporeal group had smaller incision [5.0 (1.0) cm vs. 8.0 (1.0) cm, Z=-10.931, P=0.001], lower rate of combined organ resection [0.8% (1/122) vs. 7.9% (11/139), χ(2)=7.454, P=0.006] and higher rate of R0 resection [94.3% (115/122) vs. 84.9 (118/139), χ(2)=5.957, P=0.015]. The morbidity of intraoperative complication in the extracorporeal group and intracorporeal group was 2.9% (4/139) and 4.1% (5/122), respectively (χ(2)=0.040, P=0.842). In terms of postoperative recovery, the extracorporeal group had shorter time to liquid diet [(5.1±2.4) days vs. (5.9±3.6) days, t=-2.268, P=0.024] and soft diet [(7.3±3.7) days vs. (8.8±6.5) days, t=-2.227, P=0.027], and shorter postoperative hospital stay [(10.5±5.1) days vs. (12.2±7.7) days, t=-2.108, P=0.036]. The morbidity of postoperative complication within 6 months in the extracorporeal group and intracorporeal group was 25.9% (36/139) and 31.1%, (38/122) respectively (P=0.348). Furthermore, there was also no significant difference in the morbidity of postoperative EJS complications [extracorporeal group vs. intracorporeal group: 5.0% (7/139) vs. 82.% (10/122), P=0.302]. The severity of postoperative complications between the two groups was not statistically significant (P=0.289). In the intracorporeal group, the Orvil(TM) subgroup had more estimated blood loss [100.0 (100.0) ml vs.50.0 (50.0) ml, Z=-2.992, P=0.003] and larger incision [6.0 (1.0) cm vs. 5.0 (1.0) cm, Z=-3.428, P=0.001] than the Overlap subgroup, seemed to have higher morbidity of intraoperative complication [7.0% (3/43) vs. 2.5% (2/79),P=0.480] and postoperative complications [37.2% (16/43) vs. 27.8% (22/79), P=0.286], and more severe classification of complication (P=0.289). Conclusions: The intracorporeal EJS after LTG has similar safety to extracorporeal EJS. As for intracorporeal EJS, the Overlap method is safer and has more potential advantages than Orvil(TM) method, and is worthy of further exploration and optimization.

A prospective cohort study on the clinical value of pelvic peritoneal reconstruction in laparoscopic anterior resection for middle and low rectal cancer / 中华胃肠外科杂志

Objective: To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer. Methods: A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups. Results: A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant (t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences (Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ(2)=15.537, P<0.001). Conclusion: Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

Related factors of postoperative complications of radical resection for adenocarcinoma of esophagogastric junction / 中华胃肠外科杂志

Adenocarcinoma of esophagogastric junction (AEG) is at a special anatomic site with obviously higher morbidity of postoperative complication than gastric cancers at other sites. Postoperative quality of life and survival rate are influenced by the occurrence of complications. Moreover, the perioperative complications are associated with multiple factors such as patient factors (advanced age, obesity and preoperative nutritional status), surgical factors (surgical route, surgical procedure, resection range and prophylactic multivisceral resection), tumor factors (size, stage) etc. Optimizing perioperative management and formulating standardized surgical methods are the key points to prevent postoperative complications of AEG. In conclusion, we should strive to ensure the radical resection and reduce the occurrence of postoperative complications in order to truly benefit patients.

Exposed Implant after Immediate Breast Reconstruction - Presentation and Analysis of a Clinical Management Protocol / Exposição de prótese após reconstrução imediata da mama: apresentação e análise de protocolo clínico

Abstract Objective Infection and exposure of the implant are some of the most common and concerning complications after implant-based breast reconstruction. Currently, there is no consensus on the management of these complications. The aim of the present study was to review our cases and to present a clinical protocol. Methods We conducted a retrospective review of consecutive patients submitted to implant-based breast reconstruction between 2014 and 2016. All patients were managed according to a specific and structured protocol. Results Implant exposure occurred in 33 out of 277 (11.9%) implant-based reconstructions. Among these, two patients had history of radiotherapy and had their implant removed; Delayed reconstruction with a myocutaneous flap was performed in both cases. Signs of severe local infection were observed in 12 patients, and another 5 presented with extensive tissue necrosis, and they were all submitted to implant removal; of them, 8 underwent reconstruction with a tissue expander, and 2, with a myocutaneous flap. The remaining 14 patients had no signs of severe infection, previous irradiation or extensive tissue necrosis, and were submitted to primary suture as an attempt to salvage the implant. Of these, 8 cases (57.1%) managed to keep the Conclusion Our clinical protocol is based on three key points: history of radiotherapy, severe infection, and extensive tissue necrosis. It is a practical and potentially-reproducible method of managing one of the most common complications of implant-based breast reconstruction.

Resumo Objectivo Infecção e exposição da prótese são algumas das complicações mais comuns e preocupantes após reconstrução da mama com implantes. Atualmente, ainda não há consenso quanto ao manejo destas complicações. O objetivo deste estudo foi o de revisar os casos da nossa instituição e apresentar um protocolo clínico. Métodos Realizou-se uma revisão retrospectiva de todos os casos consecutivos submetidos a reconstrução mamária imediata com prótese entre 2014 e 2016. Todos os casos foram conduzidos de acordo com um protocolo específico e estruturado. Resultados A exposição do implante ocorreu em 33 de 227 reconstruções (11,9%). Dentre estas, duas pacientes tinham histórico de radioterapia, e foram submetidas a remoção da prótese e posterior reconstrução com retalho miocutâneo. Sinais de infecção local grave foram observados em 12 pacientes, e, em 5, necrose extensa de tecido, e todas foram submetidas a remoção dos implantes; destas, 8 foram recons truídas com expansor, e 2, com retalho miocutâneo. As 14 pacientes remanecentes não haviam sido submetidas previamente à radioterapia, não tinham sinais de infecção, nem necrose extensa; portanto, foram submetidas a sutura primária em uma tentativa de salvar a prótese. Dessas, 8 pacientes (57,1%) conseguiram manter os implantes originais. Conclusão Nosso protocolo clínico é baseado em três pontos principais: histórico de radioterapia, infecção grave, e necrose extensa de tecido. Ele constitui um método prático e potencialmente reprodutível de manejo de uma das complicações mais comuns da reconstrução mamária com implantes.

Arritmia ventricular maligna asociada a un gossypiboma: reporte de un caso / Malignant ventricular arrhythmia associated to gossypiboma: clinical case report / Arritmia ventricular maligna vinculada a gossypiboma: reporte de um caso clínico

Un gossypiboma, oblitoma o textiloma se define como todo cuerpo extraño olvidado en el interior de un paciente durante una intervención quirúrgica. Representa una complicación posquirúrgica poco frecuente pero de consecuencias potencialmente graves. En general, se manifiesta con cuadros clínicos variables: una masa o pseudotumor, sangrados, fiebre, dolor, varios meses o años después de la cirugía original. También puede ser un hallazgo accidental. Describimos el caso clínico de una paciente con un gossypiboma vinculado a una cirugía cardíaca que se realizó 40 años antes al cuadro clínico actual, que se presenta con arritmia ventricular maligna.

A gossypiboma, oblitoma or textiloma is defined as a surgical object left in the interior of the body after surgery. It represents an uncommon but potentially life threatening post-surgery complication. Clinical manifestations are variable and depend on location, relations and size, from pseudo-tumoral masses, bleeding, fever, pain and other nonspecific presentations. The onset of symptoms is unpredictable, occurring from months or years after surgery. Patients may course asymptomatically and be diagnosed incidentally as an imaging finding. We describe a case of a patient with gossypiboma diagnosed 40 years after undergoing cardiac surgery, who presented with a malignant ventricular arrhythmia.

Um gossypiboma, oblitoma ou textiloma está definido como todo corpo estranho esquecido no interior de um paciente durante um procedimento cirúrgico, representando uma complicação pos cirúrgica pouco frequente, mas com consequências potencialmente graves. Geralmente, se manifesta com quadros clínicos variáveis: uma massa ou pseudotumor, sangramentos, febre, dor, varios meses ou anos após a cirurgia original ou ser um hachado acidental. Descrevemos o caso clínico de uma paciente com um gossypiboma vinculado a uma cirurgia cardíaca realizada 40 anos antes do quadro clínico atual, que se apresenta com arritmia ventricular maligna.

Esfincterotomia isolada versus esfincterotomia associada a passagem de prótese biliar no tratamento de fístulas biliares: 10 anos de experiência de um hospital quaternário / Sphincterotomy alone versus sphincterotomy and biliary stent placement in the treatment of bile leaks: 10 year experience at a quaternary hospital

ABSTRACT BACKGROUND: Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear. OBJECTIVE: The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks. METHODS: We retrospectively analyzed 31 patients with the final ERCP diagnosis of "bile leak". Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP. RESULTS: A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005). CONCLUSION: ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

RESUMO CONTEXTO: Cirurgia hepatobiliar e trauma hepático são causas frequentes de fístulas biliares, e esta temida complicação pode ser manejada de forma segura através da colangiopancreatografia retrógrada endoscópica (CPRE). O procedimento consiste em esfincterotomia isolada, passagem de prótese biliar ou combinação das duas técnicas, porém a forma ideal permanece incerta. OBJETIVO: O objetivo desse estudo é comparar a realização de esfincterotomia isolada versus locação de prótese biliar no tratamento de fístulas pós-cirúrgicas e traumáticas. MÉTODOS: Foram analisados de forma retrospectiva 31 CPREs com diagnóstico final de "fístula biliar". A informação colhida incluía dados demográficos dos pacientes, etiologia das fístulas e detalhes dos procedimentos. As técnicas de tratamentos foram divididas em dois grupos: esfincterotomia isolada vs esfincterotomia associada a locação de prótese biliar. Foram analisados os volumes dos drenos abdominais cirúrgicos antes e depois de cada procedimento e o número de dias necessários para que ocorresse cessação da drenagem pelo dreno abdominal cirúrgico após a CPRE. RESULTADOS: Um total de 31 pacientes (18 homens e 3 mulheres; idade média de 51 anos) com fístulas biliares foram avaliados. Colecistectomia laparoscópica foi a etiologia da fístula em 14 (45%) casos, seguida de colecistectomia convenvional em 9 (29%) pacientes, trauma hepático em 5 (16%) pacientes, e hepatectomia secundária a neoplasia em 3 (9,7%) pacientes. As localizações mais frequentes das fístulas foram: coto do ducto císticos com 12 (38,6%) casos, seguido de ducto hepático comum em 10 (32%) casos, ducto colédoco em 7 (22%) cases e leito hepático em 2 (6,5%) casos. 71% dos pacientes foram tratados com esfincterotomia associada a passagem de prótese biliar e 29% com esfincterotomia isolada. Houve diferença estatística em relação ao volume drenado antes e depois de ambos os procedimentos (P<0,05). Entretanto, quando comparada esfincterotomia isolada e esfincterotomia associada a passagem de prótese biliar, em relação ao volume drenado e ao número de dias necessários para cessação da drenagem, não houve diferença estatística em ambos os casos (P>0,005). CONCLUSÃO: A CPRE permanece como tratamento de primeira linha no tratamento de fístulas biliares, sem diferença entra a esfincterotomia isolada versus esfincterotomia associada a passagem de prótese biliar.

Are there benefits in performing gastro-omentopexy in laparoscopic vertical gastrectomy? / Há benefícios em realizar gastro-omentopexia na gastrectomia vertical laparoscópica?

ABSTRACT Background: Gastro-omentopexy promotes the reconnection of the stomach to the gastroesplenic and gastrocolic ligaments and constitutes an alternative for the prevention of complications in laparoscopic vertical gastrectomy. Aim: To demonstrate the benefits of the gastro-omentopexy technique in patients undergoing sleeve gastrectomy, with possible reduction in postoperative complications. Methods: Prospective, non-randomized, case series type study, consisting of a clinical population of 179 patients who underwent the technique in 2018, with follow-up between 6-12 months in the postoperative period. Results: From the participants 71.5% were women, aged between 30-40 years (36.3%). As for the prevalence of complications in the postoperative period, the low prevalence was evident, with emphasis on readmission (1.1%); reoperation (1.1%); wound infection (1.1%); bleeding hemorrhage (0.5%); and stricture (1.1%). However, temporary symptoms were present such as nausea/vomiting, food intolerance, epigastric pain and feeling of fullness, right after surgery. Conclusion: The technique promoted a significant improvement in quality of life and control of comorbidities. In addition, it was associated with a low prevalence of stenosis, and with no fistula, making the method safer.

RESUMO Racional: A gastro-omentopexia promove a reconexão do estômago aos ligamentos gastroesplênico e gastrocólico e pode constituir alternativa para prevenção de complicações na gastrectomia vertical laparoscópica. Objetivo: Demonstrar os benefícios da gastro-omentopexia em pacientes submetidos à gastrectomia vertical laparoscópica com redução de complicações. Métodos: Estudo prospectivo, não randomizado, do tipo série de casos, constituído por população de 179 pacientes que realizaram a técnica, com acompanhamento entre 6-12 meses no pós-operatório. Resultados: Dos participantes 71,5% eram mulheres, com faixa etária entre 30-40 anos (36,3%). Quanto às complicações no pós-operatório evidenciou-se baixa prevalência delas com destaque para reinternação (1,1%); reoperação (1,1%); infecção de ferida (1,1%); sangramento/hemorragia (0,5%); e estenose gástrica (1,1%). Entretanto, surgiram sintomas temporários como náusea/vômito, intolerância alimentar, dor epigástrica e sensação de plenitude, logo após a operação. Houve melhora nas variáveis de qualidade de vida analisadas. Conclusão: A técnica promoveu melhora na qualidade de vida e no controle das comorbidades. Além disso, esteve associada à baixa prevalência de estenose, e sem ocorrência de fístula, tornando o método mais seguro.