Laparoscopic-Assisted Transhiatal Esophagogastrectomy Without Thoracic or Cervical Access: A Series of One Hundred Three Consecutive Cases.

AIM: To evaluate short-term and long-term outcomes of laparoscopic-assisted transhiatal esophagogastrectomy (LTEG) for treatment of adenocarcinoma of the esophagogastric junction (AEG). METHODS: Patients with AEG who underwent laparoscopic or open surgery at our department from October 2008 to December 2012 were enrolled in this retrospective study. Patients' demographics, perioperative outcomes, and survival data were collected. RESULTS: A total of 136 patients with AEG were enrolled (103 patients underwent laparoscopic surgery and 33 patients underwent open surgery). Patient characteristics were comparable between two groups in terms of age, gender, tumor-node-metastasis stage, tumor size, preoperative complications, and type of surgery. The median operative time was longer in laparoscopic group (240 versus 210 minutes, P = .048). However, the estimated blood loss was less, and the rate of pleural rupture was lower in laparoscopic group (20 versus 70 mL, P < .001 and 18.4% versus 36.4%, P = .033, respectively). The rate of patients with pleural rupture requiring prolonged use of mechanical ventilation longer than 12 hours (6/31, 19.4%) was higher than that of patients without pleural rupture (6/105, 5.7%) (P = .019). The incidence of reflux symptoms at postoperative month six was similar in two groups (18.4% in laparoscopic group versus 24.2% in open group, P = .468), as well as the use of proton pump inhibitors (12.6% versus 15.2%, P = .709). Furthermore, the number of lymph nodes harvested (22 versus 25), 2-year cumulative overall survival rates (80.4% versus 57.5%), and the median survival times (51.52 months versus 24.24 months) were similar between two groups (P > .05). CONCLUSION: LTEG is a safe, feasible, and oncologically effective procedure for AEG when performed by an experienced surgeon. Laparoscopic surgery is associated with a lower risk of pleural rupture, but pleural rupture in laparoscopic surgery may cause an adverse effect on the recovery of pulmonary function presumably due to tension pneumothorax.

Prognostic analysis of schistosomal rectal cancer.

BACKGROUND: Schistosomiasis is an infectious disease that affects more than 230 million people worldwide, according to conservative estimates. Some studies published from China and Japan reported that schistosomiasis is a risk factor for colorectal cancer in Asia where the infective species is S. japonicum. However, there have been only few reports of prognosis of patients with schistosomal rectal cancer SRC. OBJECTIVES: This study aimed to analyze differences in prognosis between SRC and non-schistosomal rectal cancer(NSRC) with current treatments. MATERIALS AND METHODS: A retrospective review of 30 patients with schistosomal rectal cancer who underwent laparoscopic total mesorectal excision operation (TME) was performed. For each patient with schistosomal rectal cancer, a control group who underwent laparoscopic TME with non-schistosomal rectal cancer was matched for age, gender and tumor stage, resulting in 60 cases and controls. RESULTS: Univariate analysis showed pathologic N stage (P=0.006) and pathologic TNM stage (P=0.047) statistically significantly correlated with disease-free survival (DFS). Pathologic N stage (P=0.014), pathologic TNM stage (P=0.002), and with/without schistosomiasis (P=0.026) were statistically significantly correlated with overall survival (OS). Schistosomiasis was the only independent prognostic factor for DFS and OS in multivariate analysis. CONCLUSIONS: The prognosis of patients with schistosomal rectal cancer is poorer than with non-schistosomal rectal cancer.

Prognostic significance of the mucin component in stage III rectal carcinoma patients.

BACKGROUND: Although mucinous adenocarcinoma has been recognized for a long time, whether it is associated with a poorer prognosis in colorectal cancer patients is still controversial. Many studies put emphasis on mucinous adenocarcinoma containing mucin component ≥50%. Only a few studies have analyzed cases with a mucin component <50%. OBJECTIVES: This study aimed to analyze the prognostic value of different mucin component proportions in patients with stage III rectal cancer. MATERIALS AND METHODS: Clinical, pathological and follow-up data of 136 patients with the stage III rectal cancer were collected. Every variable was analyzed by univariate analysis, then multivariate analysis and survival analysis were further performed. RESULTS: Univariate analysis showed pathologic T stage, lymphovascular invasion, and histological subtype were statistically significant for DFS. Pathologic T stage was significant for OS. Histological subtype and lymphovascular invasion were independent prognostic factors in multivariate analysis for DFS, and histological subtype was the only independent prognostic factor for OS. Survival curves showed the survival time of mucinous adenocarcinoma (MUC) was shorter than non-MUC (adenocarcinomas with a mucin component <50% and without mucin component). CONCLUSIONS: Histological subtype (tumor with different mucin component) was an independent prognostic factor for both DFS and OS. Patients with MUC had a worse prognosis than their non-MUC counterparts with stage III rectal carcinoma.

Transthoracic vs transhiatal surgery for cancer of the esophagogastric junction: a meta-analysis.

AIM: To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction. METHODS: An electronic and manual search of the literature was conducted in PubMed, EmBase and the Cochrane Library for articles published between March 1998 and January 2013. The pooled data included the following parameters: duration of surgical time, blood loss, dissected lymph nodes, hospital stay time, anastomotic leakage, pulmonary complications, cardiovascular complications, 30-d hospital mortality, and long-term survival. Sensitivity analysis was performed by excluding single studies. RESULTS: Eight studies including 1155 patients with cancer of the esophagogastric junction, with 639 patients in the transthoracic group and 516 in the transhiatal group, were pooled for this study. There were no significant differences between two groups concerning surgical time, blood loss, anastomotic leakage, or cardiovascular complications. Dissected lymph nodes also showed no significant differences between two groups in randomized controlled trials (RCTs) and non-RCTs. However, we did observe a shorter hospital stay (WMD = 1.92, 95%CI: 1.63-2.22, P < 0.00001), lower 30-d hospital mortality (OR = 3.21, 95%CI: 1.13-9.12, P = 0.03), and decreased pulmonary complications (OR = 2.95, 95%CI: 1.95-4.45, P < 0.00001) in the transhiatal group. For overall survival, a potential survival benefit was achieved for type III tumors with the transhiatal approach. CONCLUSION: The transhiatal approach for cancers of the esophagogastric junction, especially types III, should be recommended, and its long-term outcome benefits should be further evaluated.

NBS1 Glu185Gln polymorphism and cancer risk: update on current evidence.

A number of studies have investigated the association between NBS1 Glu185Gln (rs1805794, E185Q) polymorphism and cancer risk, but the results remained controversial. Previous meta-analysis found a borderline significant impact of this polymorphism on cancer risk; however, the result might be relatively unreliable due to absence of numerous newly published studies. Thus, we conducted an updated meta-analysis. A systematic search was performed in PubMed and Embase databases until April 9, 2013. The odds ratios were pooled by the fixed-effects/random-effects model in STATA 12.0 software. As a result, a total of 48 case-control studies with 17,159 cases and 22,002 controls were included. No significant association was detected between the Glu185Gln polymorphism and overall cancer risk. As to subgroup analysis by cancer site, the results showed that this polymorphism could increase the risk for leukemia and nasopharyngeal cancer. Notably, the Glu185Gln polymorphism was found to be related to increased risk for urinary system cancer, but decreased risk for digestive system cancer. No significant associations were obtained for other subgroup analyses such as ethnicity, sample size and smoking status. In conclusion, current evidence did not suggest that the NBS1 Glu185Gln polymorphism was associated with overall cancer risk, but this polymorphism might contribute to the risk for some specific cancer sites due to potential different mechanisms. More well-designed studies are imperative to identify the exact function of this polymorphism in carcinogenesis.

Association between RAD51 gene polymorphism (-135G/C) and susceptibility of myelodysplastic syndrome and acute leukemia: evidence based on a meta-analysis.

Study results on the association between RAD51 gene -135G/C polymorphism and risk of myelodysplastic syndrome (MDS) or acute leukemia are inconsistent. A meta-analysis was conducted to identify the association. A systematic search was performed in PubMed, Embase, CNKI, VIP, Wanfang databases to collect all relevant studies until January 2013. Meta-analysis was carried out using fixed/random model by Review Manager 5.1 and STATA10.0. A total of 10 eligible studies with 2,656 patients and 3,725 controls were included in meta-analysis. Significant association was detected between -135G/C polymorphism and increased MDS risk (CC + GC vs. GG: OR = 1.46, 95% CI = 1.11-1.92; CC vs. GC + GG: OR = 2.45, 95% CI = 1.23-4.89), while no association was observed for acute leukemia. Subgroup analysis by subtypes of acute leukemia and ethnicity showed no significant results either. Our meta-analysis indicated that the -135G/C polymorphism might be associated with increased susceptibility of MDS. However, lack of evidence supported association of this polymorphism with acute leukemia. Additional well-designed studies with larger samples are required to verify our results.

Is Dor fundoplication optimum after laparoscopic Heller myotomy for achalasia? A meta-analysis.

AIM: To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy (LHM) for achalasia. METHODS: Electronic database PubMed, Ovid (Evidence-Based Medicine Reviews, EmBase and Ovid MEDLINE) and Cochrane Library were searched between January 1995 and September 2012. Bibliographic citation management software (EndNote X3) was used for extracted literature management. Quality assessment of random controlled studies (RCTs) and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 and a modification of the Newcastle-Ottawa Scale, respectively. The data were analyzed using Review Manager (Version 5.1), and sensitivity analysis was performed by sequentially omitting each study. RESULTS: Finally, 6 studies, including a total of 523 achalasia patients, compared Dor fundoplication with other types of fundoplication after LHM (Dor-other group), and 8 studies, including a total of 528 achalasia patients, compared Dor fundoplication with no fundoplication after LHM (Dor-no group). Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group (OR = 7.16, 95%CI: 1.25-40.93, P = 0.03, and OR = 3.79, 95%CI: 1.23-11.72, P = 0.02, respectively). In addition, there were no significant differences between Dor fundoplication and no fundoplication in all subjects. Other outcomes, including complications, dysphagia, postoperative physiologic testing, and operation-related data displayed no significant differences in the two comparison groups. CONCLUSION: Dor fundoplication is not the optimum procedure after LHM for achalasia. We suggest more attention should be paid on quality of life among different fundoplications.

[Transabdominal and transhiatal esophagogastrostomy or esophagojejunostomy using novel double stapling technique].

OBJECTIVE: To explore the techniques of esophagogastrostomy or esophagojejunostomy in the mediastinum through the abdomen and hiatus after extended proximal gastrectomy or total gastrectomy. METHODS: From May 2010 to January 2012, 15 patients with esophagogastric junction carcinoma underwent open transhiatal extended gastrostomy or total gastrectomy. After full mobilization, the anvil was reversely introduced into the esophagus and the esophagus was transected with curved stapler. The rod of the anvil was then pulled out with a stitch to complete esophagogastrostomy after proximal gastrectomy(n=9) or esophagojejunostomy after total gastrectomy(n=6). RESULTS: The anastomosis was successfully performed in all the patients. The mean operation time was(185.5±13.1) min. The mean operation time for anastomosis was(42.0±8.6) min. The mean estimated blood loss was (106.7±34.9) ml. The proximal resection margin was(4.4±1.2) cm. All the margins were negative for residual cancer. There was no postoperative death or fistula. During the follow up, there was one case of anastomotic stenosis which was successfully managed by endoscopic balloon dilatation. CONCLUSIONS: Esophagogastrostomy or esophagojejunostomy can be safely performed with double stapling technique including reverse anvil introduction and curved stapling transection of the esophagus. It is an ideal technique for anastomosis after extended gastrectomy for esophagogastric junction carcinoma.

Features of time-intensity curve parameters of colorectal adenocarcinomas evaluated by double-contrast enhanced ultrasonography: initial observation.

PURPOSE: This study is to investigate the value of double contrast-enhanced ultrasonography (DCEU) in assessing microcirculation of colorectal adenocarcinomas and to describe the perfusion features of the tumours. MATERIAL AND METHODS: DCEUS was performed in 42 patients with adenocarcinoma. The time-intensity curve parameters (arrival time (AT), time-to-peak (TTP), peak intensity (PI) and area under the curve (AUC)) within the tumours were extracted. The parameters were compared among the tumours with different CEUS features and stages. RESULTS: The mean values of AT, TTP, PI and AUC of the colorectal adenocarcinomas were 13.68±13.36s, 32.61±19.56s, 19.82±16.54dB and 271.10±159.19dBs, respectively. In the adenocarcinomas with necrosis, the mean values of AUC was significantly lower than that of the adenocarcinomas without (231.10±219.27dBs, 278.10±123.20dBs, p=0.004). In the adenocarcinomas with necrosis, the AUC and PI of the non-necrotic part were significantly higher than that of the necrotic part (p=0.007, 0.0025, respectively). AUC increased progressively in the subgroups of T2, T3 and T4 and the difference of AUC between T2 and T4 subgroup was significant (p=0.008). CONCLUSIONS: Double contrast-enhanced ultrasonography is a valuable technique for quantifying tumour vascularity of colorectal adenocarcinomas. AUC was significantly different in the subgroups of different T stage. AUC and PI could reflect the different perfusion status of tumours with or without necrosis.

Better functional outcome provided by short-armed sigmoid colon-rectal side-to-end anastomosis after laparoscopic low anterior resection: a match-paired retrospective study from China.

PURPOSE: Side-to-end anastomosis using the descending colon has been proved to be as effective as J pouch in alleviating low anterior resection syndrome. However, using the sigmoid colon, which is less compliant for reconstruction after rectal cancer surgery, is common in China due to less prevalence of diverticulosis. The effectiveness of using the sigmoid colon for a side-to-end colorectal anastomosis in improving bowel dysfunction after laparoscopic low anterior resection of rectal cancer has not been investigated. This study was designed to compare the functional and surgical outcomes between the two anastomoses. METHODS: From October 2007 to December 2008, 16 rectal cancer patients underwent laparoscopic low anterior resection with short-armed (length of side limb 2-4 cm) side-to-end sigmoidorectal anastomosis at our department. The bowel functional results of these patients at 6 months and 1 year postoperatively were recorded and compared with that of another 1:2 matched 30 patients undergoing straight anastomosis. RESULTS: Bowel movement frequency in the side-to-end group was obviously less than that in the straight group 6 months postoperatively. Patients in the side-to-end group also had an improved incontinence score, a better ability to defer defecation, and less repeated evacuation. No differences were found between two groups 1 year after surgery. CONCLUSION: The study shows that the short-armed side-to-end colorectal anastomosis using the sigmoid colon can also improve the short-term bowel function in patients undergoing laparoscopic low anterior resection.

[Laparoscopic transhiatal extended gastrectomy for type II, III esophagogastric junction cancer: a preliminary report of 55 cases].

OBJECTIVE: To explore the feasibility and safety of laparoscopic extended gastrectomy through the transhiatal approach in patients with esophagogastric junction cancer. METHODS: From Feb 2008 to May 2010, 55 cases with Siewert type II or III esophagogastric junction cancer underwent laparoscopic transhiatal extended gastrectomy at the West China hospital. Clinical data were analyzed retrospectively. RESULTS: Esophagogastric junction cancer was Siewert type II in 36 patients and Siewert type III in 19. Thirty-five cases underwent proximal gastrectomy, 20 total gastrectomy. There were 53 D2 lymph node excisions and 2 palliative resections. Fifty patients underwent laparoscopic extended gastrectomy successfully, with 5 converted to open operations. A safe anastomosis between inferior pulmonary vein and pulmonary hilum was achieved in the majority of patients. The mean operative time was(236.2±35.5) min and the mean estimated blood loss was(60.6±33.9) ml. There were no postoperative mortalities or anastomotic leakage/stenosis. No reoperations were required. Pleural laceration occurred in 11 cases during operation, of whom 10 were repaired intraoperatively and one was managed with drainage postoperatively. There were 3 patients developed pulmonary infection and one wound infection. Postoperative recovery was uneventful in other patients. CONCLUSION: Laparoscopic transhiatal extended gastrectomy is feasible and safe for patients with esophagogastric junction cancer.