Duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲ a hilar cholangiocarcinoma

At present, radical resection remains the only effective treatment for patients with hilar cholangiocarcinoma. The surgical approach for R0 resection of hilar cholangiocarcinoma is complex and diverse, but for the biliary reconstruction after resection, almost all surgeons use Roux-en-Y hepaticojejunostomy. A viable alternative to Roux-en-Y reconstruction after radical resection of hilar cholangiocarcinoma has not yet been proposed. We report a case of performing duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲa hilar cholangiocarcinoma. End-to-end anastomosis between the left hepatic duct and the distal common bile duct was used for the biliary reconstruction, and a singlelayer continuous suture was performed along the bile duct using 5-0 prolene. The patient was discharged favorably without biliary fistula 2 wk later. Evidence for tumor recurrence was not found after an 18 mo follow- up. Performing bile duct end-to-end anastomosis in hilar cholangiocarcinoma can simplify the complex digestive tract reconstruction process.

Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases

Objective： To evaluate the feasibility and safety of total mesopancreas excision （TMpE） in the treatment of pancreatic head cancer. Methods： The clinical and pathological data of 120 patients with pancreatic head cancer who had undergone TMpE in our center from May 2010 to January 2014 were retrospectively analyzed. Results： The mean operative time was （275.0±50.2） min and the average intra-operative blood loss was （390.0±160.5） mL. Post-operative complications were reported in 45 patients, while no peri-operative death was noted. The specimen margins were measured in three dimensions, and 86 patients （71.6%） achieved R0 resection. Conclusions： TMpE is safe and feasible for pancreatic head cancer and is particularly helpful to increase the R0 resection rate.

Long-term outcomes after radical gastrectomy in gastric cancer patients with overt bleeding

AIM: To investigate the difference in long-term outcomes between gastric cancer patients with and without a primary symptom of overt bleeding(OB).METHODS: Consecutive patients between January 1, 2007 and March 1, 2012 were identified retrospectively by reviewing a gastric cancer database at Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. A follow-up examination was performed on patients who underwent a radical gastrectomy. OB due to gastric cancer included hematemesis, melena or hematochezia, and gastric cancer was confirmed as the source of bleeding by endoscopy. Patients without OB were defined as cases with occult bleeding and those with other initial presentations, including epigastric pain, weakness, weight loss and obstruction. The 3-year overall survival(OS) rate, age, gender, AJCC T stage, AJCC N stage, overall AJCC stage, tumor size, histological type, macroscopic(Borrmann) type, lymphovascular invasion and R status were compared between patients with and without OB. Moreover, we carried out a subgroup analysis based on tumor location(upper, middle and lower).RESULTS: We identified 939 patients. Of these, 695(74.0%) were hospitalized for potential radical gastrectomy and another 244 received palliative resection, rerouting of the gastrointestinal tract, chemotherapy, radiotherapy or no treatment due to the presence of unresectable tumors. Notably, there was no significant difference in the percentage of OB patients between resectable cases and unresectable cases(20.3 % vs 22.1 %, P = 0.541). Fo l l o w- u p examination was performed on 653 patients(94%) who underwent radical gastrectomy. We found no significant difference in 3-year OS rate(68.2% vs 61.2%, P = 0.143) or clinicopathological characteristics(P > 0.05) between these patients with and without OB. Subgroup analysis based on tumor location showed that the 3-year OS rate of upper gastric cancer was significantly higher in patients with OB(84.6%) than in those without OB(48.1%, P < 0.01) and that AJCC stagesⅠ-Ⅱ(56.4% vs 35.1%, P = 0.017) and T1-T2 category tumors(30.8% vs 13%, P = 0.010) were more frequent in patients with OB than in those without OB. There was no significant difference in 3-year OS rate or clinicopathological characteristics between patients with and without OB(P > 0.05) for middle or lower gastric cancer.CONCLUSION: Upper gastric cancer patients with OB exhibited tumors at less advanced pathological stages and had a better prognosis than upper gastric cancer patients without OB.

Surgical management of patients with bowel obstructions secondary to gastric cancer

AIM: To assess whole-body fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the management of small bowel obstructions (SBOs) secondary to gastric cancer and its role in treatment strategies. METHODS: The medical records of all of the patients who were admitted for an intestinal obstruction after curative resection for gastric cancer were retrospectively reviewed. PET/CT was performed before a clinical treatment strategy was established for each patient. The patients were divided into 2 groups: patients with no evidence of a tumor recurrence and patients with evidence of a tumor recurrence. Tumor recurrences included a local recurrence, peritoneal carcinomatosis or distant metastases. The primary endpoint was the 1-year survival rate, and other variables included patient demographics, the length of hospital stay, complications, and mortality. RESULTS: The median time between a diagnosis of gastric cancer and the detection of a SBO was 1.4 years. Overall, 31 of 65 patients (47.7%) had evidence of a tumor recurrence on the PET/CT scan, which was the only factor that was associated with poor survival. Open and close surgery was the main type of surgical procedure reported for the patients with tumor recurrences. R0 resections were performed in 2 patients, including 1 who underwent combined adjacent organ resection. In the group with no evidence of a tumor recurrence on PET/CT, bowel resections were performed in 7 patients, adhesiolysis was performed in 7 patients, and a bypass was performed in 1 patient. The 1-year survival curves according to PET/CT evidence of a tumor recurrence vs no PET/CT evidence of a tumor recurrence were significantly different, and the 1-year survival rates were 8.8% vs 93.5%, respectively. There were no significant differences (P = 0.71) in the 1-year survival rates based on surgical vs nonsurgical management (0% with nonoperative treatment vs 20% after exploratory laparotomy). CONCLUSION: 18 F-FDG PET/CT can be used to identify the causes of bowel obstructions in patients with a history of gastric cancer, and this method is useful for planning the surgical management of these patients.

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown. AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China. METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated. RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60 (93.8%) cases and successful diagnosis in 59 (92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation, and no post-ERCP pancreatitis occurred. CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.

Effect of isoflurane on expression of NR4A1 in hypoxic pulmonary artery

Objective: To investigate the effects of emulsified isoflurane on hypoxic pulmonary artery endothelial cells (HPAECs) injury and orphan nuclear receptor subfamily 4A1 (NR4A1) expression. Methods: HPAECs were divided into normal control group, model group and test group. Normal control group was cultured under normoxia. Cells in model group and test group were treated in a hypoxic chamber with oxygen concentration of about 3% (95% N2+ 5% CO2) for 2 h. The final concentration of 1 mmol·L-1 emulsified isoflurane was added to the test group, and 30% Intralipid? was added to the normal control group and the model group. MTT method was used to detect cell proliferation, Hoechst 33258 nuclear staining was used to detect cell apoptosis, Griess method was used to detect the production of NO in cell supernatant, and real-time fluorescence quantitative PCR (q-RT-PCR) was used to detect the expression of NR4A1 in cells. Results: After 12 h of intervention, the cell viability of normal control group, model group and test group were (98.45±2.41)%, (15.46±2.69)%, (79.52±4.16)%, the apoptosis rate were (2.51±0.36)%, (50.12±3.36)%, (22.15±3.42)%respectively, the concentration of NO in the culture supernatant were (59.52±4.1) μmol·L^-1, (25.16±4.85) μmol·L^-1, (43.58±6.19) μmol·L^-1, and the relative expression of NR4A1 were 1.00±0.09, 5.89±0.41, 2.39±0.24, respectively. The difference was statistically significant (P<0.05). Conclusion: Emulsified isoflurane can promote the proliferation, inhibit apoptosis and increase NO production of hypoxic HPAECs. NR4A1 may be involved in the endogenous protective mechanism of endothelial cell injury after hypoxia.

Safety of high-carbohydrate fluid diet 2 h versus overnight fasting before non-emergency endoscopic retrograde cholangiopancreatography:A single-blind,multicenter,randomized controlled trial

Background:Although overnight fasting is recommended prior to endoscopic retrograde cholangiopancreatography(ERCP),the benefits and safety of high-carbohydrate fluid diet(CFD)intake 2 h before ERCP remain unclear.This study aimed to analyze whether high-CFD intake 2 h before ERCP can be safe and accelerate patients’recovery.Methods:This prospective,multicenter,randomized controlled trial involved 15 tertiary ERCP centers.A total of 1330 patients were randomized into CFD group(n=665)and fasting group(n=665).The CFD group received 400 mL of maltodextrin orally 2 h before ERCP,while the control group abstained from food/water overnight(>6 h)before ERCP.All ERCP procedures were performed using deep sedation with intravenous propofol.The investigators were blinded but not the patients.The primary outcomes included postoperative fatigue and abdominal pain score,and the secondary outcomes included complications and changes in metabolic indicators.The outcomes were analyzed according to a modified intention-to-treat principle.Results:The post-ERCP fatigue scores were significantly lower at 4 h(4.1±2.6 vs.4.8±2.8,t=4.23,P<0.001)and 20 h(2.4±2.1 vs.3.4±2.4,t=7.94,P<0.001)in the CFD group,with least-squares mean differences of 0.48(95%confidence interval[CI]:0.26-0.71,P<0.001)and 0.76(95%CI:0.57-0.95,P<0.001),respectively.The 4-h pain scores(2.1±1.7 vs.2.2±1.7,t=2.60,P=0.009,with a least-squares mean difference of 0.21[95%CI:0.05-0.37])and positive urine ketone levels(7.7%[39/509]vs.15.4%[82/533],χ^(2)=15.13,P<0.001)were lower in the CFD group.The CFD group had significantly less cholangitis(2.1%[13/634]vs.4.0%[26/658],χ^(2)=3.99,P=0.046)but not pancreatitis(5.5%[35/634]vs.6.5%[43/658],χ^(2)=0.59,P=0.444).Subgroup analysis revealed that CFD reduced the incidence of complications in patients with native papilla(odds ratio[OR]:0.61,95%CI:0.39-0.95,P=0.028)in the multivariable models.Conclusion:Ingesting 400 mL of CFD 2 h before ERCP is safe,with a reduction in post-ERCP fatigue,abdominal pain,and cholangitis during recovery.Trail Registration:ClinicalTrials.gov,No.NCT03075280.