[Efficacy observation of the caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy].

Objective: To investigate the safety and feasibility of caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy. Methods: A descriptive cohort study was conducted. Clinical data of 35 patients who underwent laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy at Department of Gastrointestinal Surgery, Guangdong Hospital of Chinese Medicine from April 2018 to May 2020 were retrospectively analyzed. All operations were performed consecutively by the same surgeon. The caudal-medial approach was used to dissect the right Toldt's fascia and the anterior pancreaticoduodenal space in a caudal-to-cranial and medial-to-lateral manner guided by the duodenum. The "page-turning" middle lymphadenectomy was used to dissect the mesocolon along the superior mesenteric vein with ileocolic vein, Henle's trunk and pancreas exposed preferentially. Results: All the 35 patients completed the operation successfully, and there was no damage and bleeding of superior mesenteric vessels and their branches. The operative time was (186.9±46.2) minutes, and the blood loss was 50 (10-200) ml. The first time to flatus was (2.1±0.6) days, and the time to fluid intake was (2.5±0.8) days. The postoperative hospital stay was 6 (3-18) d. The overall morbidity of postoperative complication was 8.6% (3/35), including grade II in 1 cases (2.8%) and grade IIIa in 2 case (5.7%) according to the Clavien-Dindo grading standard. The total number of lymph node dissected was 30.2±5.6, and the positive lymph node was 0 (0-7). Tumor staging revealed 5 cases of stage I, 18 cases of stage II, 11 cases of stage III, and 1 case of stage IVA. In this study, the median follow-up time was 15 (4-29) months. One patient died due to cerebrovascular accident 12 months after surgery, and no tumor recurrence or metastasis was observed in all other patients. Conclusions: Laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy is safe and feasible. The anterior pancreaticoduodenal space is preferentially mobilized, which reduces the difficulty of central vascular dissection.

[Comparison of clinical efficacy between bursa omentalis approach and medial-to-lateral approach in laparoscopic left hemicolectomy: a propensity score matching analysis].

Objective: Splenic flexure mobilization is technically difficult during the resection of left hemicolon cancer. This study aims to compare the safety and effectiveness between the bursa omentalis approach (BOA) and medial-to-lateral approach (MTLA) in laparoscopic radical resection of left-sided colon cancer. Methods: A retrospective cohort study was conducted. Inclusion criteria: (1) patients underwent radical resection of left hemicolon cancer; (2) the postoperative pathological result was adenocarcinoma; (3) patients aged 18-80 years old; (4) no liver, peritoneal or other distant metastasis. Exclusion criteria: (1) poor physical condition with serious heart, brain, lung, liver, kidney and hematopoietic system diseases; (2) unable to tolerate laparoscopic surgery; (3) history of other malignancies simultaneously, or multisource tumors; (4) emergency operation due to bleeding, obstruction, perforation, etc. Clinical data of 189 patients who underwent laparoscopic left hemicolectomy in the Guangdong Provincial Hospital of Chinese Medicine from 2014 to 2020 were retrospectively analyzed. According to surgical approaches, patients were divided into the BOA group (52 cases) and MTLA group (137 cases). The whole group of patients were matched by propensity score matching (PSM) according to the nearest neighbor matching method. The caliper value was 0.01. The matching variables included gender, age, American Society of Anesthesiologists (ASA) score, body mass index, tumor location and tumor stage. After PSM, 47 patients were included in the BOA group and MTLA group, respectively. There were no significant differences in baseline data between the two groups after PSM (all P>0.05). Paired t-test, paired rank sum test and paired Chi-square test were used to compare intraoperative and postoperative paramether between the two groups. Kaplan-Meier method was used to draw the survival curve, and log rank test was used for inter group comparison. When the two survival curves intersect, the two-stage method and restricted mean survival time (RMST) were further performed. Results: Both groups of patients successfully completed the operation without conversion to laparotomy or intraoperative death. No combined splenectomy or pancreatectomy were performed in the two groups. There were also no significant differences in intraoperative blood loss, number of harvested lymph nodes, time to the first flatus and the length of hospital stay between the two groups (all P>0.05). However, the median laparoscopic dissection time in the BOA group was shorter than that in the MTLA group, and the difference was statistically significant (median: 56 minutes vs. 65 minutes, P=0.032). No entry to posterior pancreatic space was recorded in the BOA group but wrong entry to posterior pancreatic space happened to 6.4% (3/47) of patients (body mass index >25 kg/m(2)) when dissecting left Toldt's fascia in the MTLA group. The 3-year disease-free survival rate in BOA group and MTLA group was 90.2% and 86.1%, respectively (P=0.909) and the 3-year overall survival rate was 85.6% and 94.4%, respectively (P=0.532). Conclusions: BOA is safe and feasible in laparoscopic left hemicolectomy, especially for inexperienced surgeons. For obese patients, BOA facilitates the entrance into the correct anatomical level and avoid entering the retropancreatic space.

[Safety and feasibility of laparoscopic double-flap technique in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction tumors larger than 5 cm].

Objective: To investigate the safety and feasibility of laparoscopic double-flap technique (Kamikawa) in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction (EGJ) leiomyoma and gastrointestinal stromal tumor (GIST) with the maximum diameter >5 cm. Methods: A descriptive case-series study was used to retrospectively analyze the data of patients with EGJ leiomyoma and GIST undergoing laparoscopic-assisted proximal gastrectomy and double-flap technique (Kamikawa) at the Department of Gastrointestinal Surgery, Guangdong Hospital of Traditional Chinese Medicine from September 2017 to March 2019. All the tumors invaded the cardia dentate line, and the maximum diameter was >5 cm. After the exclusion of patients requiring emergency surgery and complicating with severe cardiopulmonary diseases, a total of 4 patients, including 3 males and 1 female with age of 29-49 years, were included in this study. After laparoscopic-assisted proximal gastrectomy, the residual stomach was pulled out of the abdominal cavity and marked with methylene blue at the proximal end 3~4 cm from the anterior wall of the residual stomach in the shape of "H". The gastric wall plasma muscular layer was cut along the "H" shape, and the space between the submucosa and the muscular layer was separated to both sides along the longitudinal incision line to make the seromuscular flap. The residual stomach was put back into the abdominal cavity. Under laparoscopy, 4 stitches were intermittently sutured at the upside of "H" shape and 4-5 cm from the posterior wall of the esophageal stump. The stump of the esophagus was cut open, and the submucosa and mucosa were cut under the "H" shape to enter the gastric cavity. The posterior wall of the esophageal stump was sutured continuously with the gastric stump mucosa and submucosa under laparoscopy. The anterior wall of the esophageal stump was sutured continuously with the whole layer of the residual stomach. The anterior wall of the stomach was sutured to cover the esophagus. The anterior gastric muscle flap was sutured and embedded in the esophagus to complete the reconstruction of digestive tract. The morbidity of intraoperative complications and postoperative reflux esophagitis and anastomosis-related complications were observed. Results: All the 4 patients completed the operation successfully, and there was no conversion to laparotomy. The median operative time was 239 (192-261) minutes, the median Kamikawa anastomosis time was 149 (102-163) minutes, and the median intraoperative blood loss was 35 (20-200) ml. The abdominal drainage tube and gastric tube were removed, and the fluid diet was resumed on the first day after surgery in all the 4 patients. The median postoperative hospitalization time was 6 (6-8) days. Postoperative pathology revealed 3 leiomyomas and 1 GIST. There were no postoperative complications such as anastomotic leakage or stenosis, and no reflux symptoms were observed. The median follow-up time was 22 (11-29) months after the operation, and no reflux esophagitis occurred in any of the 4 patients by gastroscopy. Conclusion: For >5 cm EGJ leiomyoma or GIST, double-flap technique (Kamikawa) used for digestive tract reconstruction after proximal gastrectomy is safe and feasible.

IL-10 and trichosanthin inhibited surface molecule expression of antigen processing cells and T-cell proliferation.

AIM: To study immunoinhibitory effects and preliminary mechanism of IL-10 and trichosanthin. METHODS: Surface molecule expression on antigen processing cells (APC) was stained with fluorescence and analyzed by FACScan. B7-1 mRNA expression was detected with nested RT-PCR. RESULTS: IL-10 2 mg.L-1 and trichosanthin 10 mg.L-1 inhibited B7-1 molecule expression. By contrast, they had not the same effects on ICAM-1. IL-10 and trichosanthin down-regulated LFA-1 expression, but had no regulatory effect on CD40. IL-10 and trichosanthin dramatically inhibited T-cell proliferation and IL-2 production. B7-1 mRNA expression was undetectable in APC treated with IL-10 and trichosanthin. CONCLUSION: IL-10 and trichosanthin inhibit surface molecule expression on APC. They exert multiple immunoinhibitory effects.