Transumbilical Single-Incision Laparoscopic Surgery in Children with Conventional Instruments: Our Early Experience.

OBJECTIVE: Laparoscopic surgery is the current accepted approach in most pediatric surgical centers. In an attempt to further minimize the surgical trauma and improve cosmetic outcome, new techniques with a single incision through the umbilicus have been proposed and we believe they will become the standard choices for pediatric surgery. This report describes our initial experience with transumbilical single-incision laparoscopic surgery (TSILS) in children with conventional instruments. MATERIALS AND METHODS: A retrospective review of 82 pediatric patients who underwent TSILS in children with conventional instruments from January 2011 to June 2015 was performed. The operations included 56 appendectomies, 9 cholecystectomies, and 17 spermatic vein ligations. RESULTS: The average age by procedure was 6.2 years for appendectomy (range of 3-14 years); 12.4 years for cholecystectomy (range of 10-14 years); and 12.8 years for spermatic vein ligation (range of 11-14 years). The average operative time was 32 minutes for appendectomy (range of 25-56 minutes); 54 minutes for cholecystectomy (range of 35-95 minutes); and 23 minutes for spermatic vein ligation (range of 17-41 minutes). The average length of staying in hospital was 3 days (range of 2-5 days). All of the operations in 82 cases were successful. None required conversion to open or conventional laparoscopic surgery. There was no obvious wound pain. In addition, there were no wound infections on umbilicus and any other intraoperative complications. There was no obvious scar at patients' umbilicus after postoperative follow-up for 2-4 weeks. CONCLUSIONS: TSILS is a safe and viable technique that may be used successfully in pediatric surgery. Additionally, excellent cosmetic results are obtained as evidenced by imperceptible umbilical scarring.

Latexin inhibits the proliferation of CD133+ miapaca-2 pancreatic cancer stem-like cells.

BACKGROUND: An increasing number of evidence suggests that pancreatic cancer contains cancer stem cells (CSCs), which may be relevant to the resistance of chemotherapy. Latexin (Lxn) is a negative regulator of stem cell proliferation and we investigate the effects of Lxn on CD133+ pancreatic cancer stem-like cells. METHODS: CD133+ miapaca-2 cells, a human pancreatic carcinoma cell line, were isolated and sorted by magnetic activated cell sorting and flow cytometry. The capacity for self-renewal, proliferation, and tumorigenicity of CD133+ miapaca-2 cells was determined by the floating spheres test and tumor xenograft assays. Protein and mRNA expression of Lxn in CD133+ and CD133- miapaca-2 cells were detected by Western blotting and qRT-PCR, respectively. After CD133+ miapaca-2 cells were treated with Lxn in serum-free medium (SFM), cell proliferation was assayed with a Cell Counting Kit 8 (CCK-8) and apoptosis was analyzed by flow cytometry. The protein and mRNA expression levels of Bcl-2, bax, and c-myc were also analyzed. RESULTS: We successfully isolated CD133+ miapaca-2 cells that exhibited the capacity for self-renewal in SFM, a proliferation potential in DMEM supplemented with FBS, and high tumorigenicity in nude mice. Lxn protein and mRNA expression levels in CD133+ miapaca-2 cells were significantly lower than those in CD133- cells. Lxn-treated CD133+ miapaca-2 cells exhibited increased apoptosis and low proliferation activity, down-regulation of Bcl-2 and c-myc expression, and up-regulation of Bax expression in a dose-dependent manner. CONCLUSIONS: Lxn induces apoptosis and inhibits the proliferation of CD133+ miapaca-2 cells. These changes are associated with down-regulation of Bcl-2 and c-myc and up-regulation of Bax.

[Effect of gastric bypass surgery on mRNA expression level of hepatic phosphoenolpyruvate carboxykinase in type 2 diabetic Goto-Kakizaki rats].

OBJECTIVE: To investigate the effects of gastric bypass surgery(GBP) on hepatic phosphoenolpyruvate carboxykinase(PEPCK) mRNA expression in type 2 diabetic Goto-Kakizaki rats. METHODS: Male GK rats were randomized into three groups: gastric bypass surgery(n=10), sham operation with diet restriction(n=10), and sham operation alone(n=10). Liver specimens of GK rats were collected during the intraoperative period for self-control study and 8 weeks after surgery. Fasting blood glucose, food intake, and body weight were recorded before surgery and 1, 2, 4, 8 weeks after surgery. The expression of PEPCK mRNA was measured by real-time PCR. RESULTS: The fasting plasma glucose level decreased from(17.6±2.1) mmol/L before surgery to(7.5±0.9) mmol/L 8 weeks after surgery in GBP group. The level of PEPCK mRNA decreased from 1.08±0.38 before surgery to 0.41±0.10 8 weeks after surgery, significantly lower than that in sham operation alone group(1.04±0.12)(P<0.01). The level of PEPCK mRNA in diet restriction group increased from 1.15±0.16 before surgery to 2.54±0.82 8 weeks after surgery(P<0.01). The expression of PEPCK mRNA in diet restriction was significantly higher than that in CBP group(P<0.01). CONCLUSIONS: GBP can significantly improve hyperglycemia in type 2 diabetic GK rat models, which may be associated with the decrease of hepatic PEPCK mRNA level.

[Impact of techniques for gastrointestinal tract reconstruction following gastrectomy on pancreatic ß-cell function in patients with type 2 diabetes mellitus].

OBJECTIVE: To evaluate the impact of different techniques for gastrointestinal tract reconstruction on postoperative pancreatic ß-cell function in patients with type 2 diabetes mellitus (T2DM). METHODS: Twenty-three patients with gastric cancer and T2DM were studied. Techniques for reconstruction included Billroth I (n=13) and bypass procedures(Billroth II n=4 and Roux-en-Y anastomosis n=6). Pancreatic ß-cell function was evaluated by oral glucose tolerance test (OGTT). Serum insulin was measured by electrochemiluminescence immunoassay and blood glucose by glucose oxidase method. HOMA-IR and HOMA-ß were assessed. RESULTS: T2DM remission rate was 90% (9/10) in the bypass group, and 23% (3/13) in Billroth I group (P<0.01). Glycosylated hemoglobin A1c and glycated hemoglobin HbA1 were improved significantly in patients after bypass procedures(P<0.05), but the difference in Billroth I group was not statistically significant (P>0.05). OGTT showed that fasting and post-glucose load plasma glucose at each time point were significantly lower in the bypass group compared to the Billroth I group. At 30 minutes and 60 minutes after glucose load, insulin levels and insulin release index were significantly higher in the bypass group compared to Billroth I( group, as were levels of HOMA-ß and ΔI30/ΔG30 in the bypass group(P<0.05). CONCLUSION: Gastrointestinal bypass following gastrectomy may induce resolution of T2DM and improve ß-cells function.

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases.

BACKGROUND: Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. METHODS: Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. RESULTS: All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. CONCLUSION: ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.

Extraluminal laparoscopic wedge-resection of submucosal tumors on the posterior wall of the gastric fundus close to the esophagocardiac junction.

PURPOSE: Laparoscopic resection of submucosal tumors in the gastric fundus, especially in the posterior wall near the esophagocardiac junction (ECJ), is difficult and time consuming and is and likely to cause esophageal stenosis and splenic injury. In this article, we report an extraluminal laparoscopic wedge-resection (ELWR) that minimizes these problems. METHODS: Thirty-seven patients with submucosal tumors in the posterior wall of the gastric fundus received ELWR. The operation consisted of four steps: 1) localization of the tumor, 2) dissection of the omentum, 3) mobilization of the gastric fundus/upper pole of the spleen and exposure of the ECJ, and 4) resection of the gastric fundus with a linear endoscopic gastrointestinal anastomosis stapler. RESULTS: None of the cases needed conversion to open surgery. Mean postoperative hospital stay was 5.5 +/- 1.0 days. The distance between the tumor and the incision margin ranged from 0.7 to 2.5 cm toward the ECJ. Pathologic examination revealed 7 cases of leiomyomas, 29 cases of stromal tumors (4 were low-grade malignant tumors), and 1 case of neurofibroma. There was no recurrence, metastasis, esophageal stenosis, or any other severe adverse event during the follow-up period (52 +/- 3.1 months). CONCLUSIONS: ELWR is a safe, effective treatment for submucosal tumors in the posterior wall of the gastric fundus.

[Laparoscopic resection of submucosal tumors in gastric fundus].

OBJECTIVE: To investigate the feasibility and safety of extraluminal laparoscopic wedge resection (ELWR) in treating submucosal tumors in the gastric fundus. METHODS: Clinical data of 84 patients underwent ELWR for submucosal tumors in the gastric fundus between September 2000 and December 2006 were reviewed and analyzed retrospectively. The four-portal operation procedures were carried out as follows: localization of the tumor, dissection of the omentum, mobilization of the gastric fundus and the upper polar of spleen, exposure of ECJ, and resection of the gastric fundus with Endo GIA. RESULTS: The patients included 53 males and 31 females, age ranged from 32 to 78 years (mean, 59 years). The mean tumor diameter was (4.2 +/- 1.3) cm. The distance from the tumor edge to the ECJ was 1.1 - 3.0 cm. The operations were successful in all the 84 patients, with a mean operation time of (62.6 +/- 8.9) min and mean operative blood loss of (86.2 +/- 8.1) ml. No apparent tumor focus was left. No operation was converted to open surgery, and no significant postoperative complications occurred. The mean post-operative hospital stay was (5.6 +/- 0.5) days. The gastrointestinal function recovered within 36 h after operation in 66 cases (78.6%), and the patients returned to normal activity and restored oral feeding. The distance between the tumor and the resection margin was 0.7 - 2.5 cm from the ECJ [mean, (1.4 +/- 0.5) cm], and 2.5 - 6.0 cm from the other three sides [mean, (4.1 +/- 1.0) cm]. Of the 84 cases, 29 cases were diagnosed with leiomyoma, 51 cases different types of stromal tumor and 4 cases neurofibroma. The mean follow-up duration was (51.0 +/- 4.3) months, no recurrence or metastasis was found in the mean time. CONCLUSIONS: ELWR is a safe, simple and beneficial procedure for submucosal tumors in the gastric fundus, especially in the posterior wall near the ECJ. It avoids intraperitoneal infection, possible splenic injury and postoperative esophageal stenosis. In addition, the resection scope is not limited.

[Efficacy of sleeve gastrectomy plus gastric remnant banding on weight reduction and remnant gastric dilatation: an animal experimental study].

OBJECTIVE: To investigate the efficacy of sleeve gastrectomy plus gastric remnant banding on weight reduction and remnant gastric dilatation in SD rat model. METHODS: Sleeve gastrectomy plus gastric remnant banding was performed in 20 male SD rats as the study group; sleeve gastrectomy was performed in 20 SD male rats as the control group, and laparotomy was performed in 10 SD male rats as the blank control group. Body weight was measured before the experiment, at day 1 and at 2-week intervals within 16 weeks after operation. RESULTS: The number of survival rats was 15 in the study group (15/20), 13 in the control group (13/20), and 10 in the blank control group (10/10). Postoperative body weight increased markedly in the blank control group, returned to the pre-operative level two weeks after operation in the control group, and four weeks after operation in the study group. Weight increase of the study group was significantly slower than that of the other two groups (P<0.01). Postoperative gastric dilation of the control group was more obvious as compared to the study group. CONCLUSION: Sleeve gastrectomy plus gastric remnant banding is safe and effective because of the restriction of postoperative gastric dilation.

[Application of laparoscopic compression anastomosis clip for laparoscopic gastrointestinal anastomosis].

OBJECTIVE: To evaluate the safety and efficacy of laparoscopic compression anastomosis clip (LapCAC) for laparoscopic gastrointestinal anastomosis. METHODS: In March, 2007, three gastric cancer patients undergone total gastrectomy (1 case) and distal gastrectomy (2 cases) received laparoscopic gastrointestinal anastomosis with LapCAC. The gastrointestinal anastomotic complications, first post-operational flatus, bowel movement and extrusion of clip device were observed. RESULTS: No anastomotic complications such as leakage or obstruction were found. The clip was expelled with stool within 12-18 days. All the patients had good results in recovery of bowel function. CONCLUSION: LapCAC is safe and simple for laparoscopic gastrointestinal anastomosis.

[Effect of immune-enhanced enteral diet on postoperative immunological function in patients with colorectal cancer].

OBJECTIVE: To explore the influence of immune-enhanced enteral diet on postoperative metabolism and immunological function in colorectal tumor patient. METHODS: Seventy-two patients with colorectal cancer were enrolled in this study. Immune-enhanced enteral diet was administrated in 36 cases (study group), while regular enteral nutrition (EN) was given in 36 cases (control group). The immunological function, inflammatory function and nutrition index were evaluated before operation and on postoperative day 1 and day 8. RESULTS: Serum levels of glutamine, asparagines, CD4 (+), NK, IgG, IgM were higher in the study group than those in the control group. The levels of IL- 6, TNF-alpha in the study group were lower than those in the control group. The difference was statistically significant (P< 0.05). CONCLUSIONS: Immune-enhanced enteral diet can ameliorate the cell immunological and fluid immunological function in the patients with colorectal cancer after the procedures.

A study evaluating the safety of laparoscopic radical operation for colorectal cancer.

AIM: This study aimed to assess the safety and feasibility of laparoscopic curative resection for colorectal cancer through the clinical practice and basic research. MATERIAL AND METHODS: From September 2001 to September 2002, 47 patients with colorectal cancer were treated using laparoscopic approach, compared with 113 patients underwent traditional operation. The length of intestinal segment excised, size of tumour, clearance of lymph nodes, local recurrence and distant metastasis rate during the period of follow-up in both groups were compared. The other part of the study involved the detection of exfoliated tumour cells in the peritoneal washing before and after surgery; flushing of the instruments was performed in both groups and the results compared. For the laparoscopic cases, the filtrated liquid of CO(2) pneumoperitoneum was also checked for tumour cells. RESULTS: No significant differences existed in tumour size, operative site and manner between the two groups. The exfoliated tumour cell was not detected in the CO(2) filtrated liquid. Between both groups there was no difference in the incidence of exfoliated tumour cells in peritoneal washing before and after surgery as well as in the fluid used for flushing the instruments. The total number of lymph nodes harvested was 13.71±9.57 for the laparoscopic group and 12.10±9.74 for the traditional procedure. Similar length of colon was excised in both groups; this was (19.38±7.47) cm in the laparoscopic and (18.60±8.40) cm in the traditional groups. The distal margins of resection for rectal cancer were (4.19±2.52) cm and (4.16±2.00) cm respectively. The local recurrence rate was 2.13% (1/47) and 1.77% (2/113) with the distant metastasis rate 6.38% (3/47) and 6.19% (7/113) respectively. Both the statistics were comparable between the laparoscopic and traditional surgery for the colorectal cancer. CONCLUSION: Laparoscopic curative resection for colorectal cancer can be performed safely and effectively. In the treatment of colorectal malignancy, laparoscopic resection can achieve similar radicalilty as compared to the traditional laparotomy.