Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendici

BACKGROUND Enhanced recovery after surgery(ERAS)protocol is a comprehensive manage-ment modality that promotes patient recovery,especially in the patients undergo-ing digestive tumor surgeries.However,it is less commonly used in the appen-dectomy.AIM To study the application value of ERAS in laparoscopic surgery for acute appen-dicitis.METHODS A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method,including 63 patients in the experimental group and 57 patients in the control group.Patients in the experimental group were managed with the ERAS protocol,and those in the control group were received the tra-ditional treatment.The exhaust time,the hospitalization duration,the hospita-lization expense and the pain score between the two groups were compared.RESULTS There was no significant difference in age,gender,body mass index and Sunshine Appendicitis Grading System score between the experimental group and the con-trol group(P>0.05).Compared to the control group,the patients in the expe-rimental group had earlier exhaust time,shorter hospitalization time,less hospi-talization cost and lower degree of pain sensation.The differences were statis-tically significant(P<0.01).CONCLUSION ERAS could significantly accelerate the recovery of patients who underwent la-paroscopic appendectomy for acute appendicitis,shorten the hospitalization time and reduce hospitalization costs.It is a safe and effective approach.

CXCR4/SDF-1 axis is involved in lymph node metastasis of gastric carcinoma

AIM:To investigate the role of CXC chemokine receptor-4 (CXCR4) and stromal cell-derived factor-1 (SDF-1) in lymph node metastasis of gastric carcinoma.METHODS:In 40 cases of gastric cancer,expression of CXCR4 mRNA in cancer and normal mucous membrane and SDF-1 mRNA in lymph nodes around the stomach was detected using quantitative polymerase chain reaction (PCR) (TaqMan) and immunohistochemistric assay.SGC-7901 and MGC80-3 cancer cells were used to investigate the effect of SDF-1 on cell proliferation and migration.RESULTS:Quantitative reverse transcription PCR and immunohistochemistry revealed that the expression level of CXCR4 in gastric cancer was significantly higher than that in normal mucous membrane (1.6244 ± 1.3801 vs 1.0715 ± 0.5243,P < 0.05).The expression level of CXCR4 mRNA in gastric cancer with lymph node metastasis was also significantly higher than that without lymph node metastasis (0.823 ± 0.551 vs 0.392 ± 0.338,P < 0.05).CXCR4 expression was significantly related to poorly differentiated,high tumor stage and lymph node metastasis.Significant differences in the expression level of SDF-1 mRNA were found between lymph nodes in metastatic gastric cancer and normal nodes (0.5432 ± 0.4907 vs 0.2640 ± 0.2601,P < 0.05).The positive expression of SDF-1 mRNA in lymph nodes of metastatic gastric cancer was consistent with the positive expression of CXCR4 mRNA in gastric cancer (r=0.776,P < 0.01).Additionally,human gastric cancer cell lines expressed CXCR4 and showed vigorous proliferation and migratory responses to SDF-1.AMD3100 (a specific CXCR4 antagonist) was also found to effectively reduce the migration of gastric cancer cells.CONCLUSION:The CXCR4/SDF-1 axis is involved in the lymph node metastasis of gastric cancer.CXCR4 is considered as a potential therapeutic target in the treatment of gastric cancer.

Inflammatory myofibroblastic tumor successfully treated with chemotherapy and nonsteroidals:A case report

Inflammatory myofibroblastic tumor(IMT) occurring at retroperitoneal sites has rarely been reported.We report the case of a previously well 14-year-old girl with no history of abdominal disease whose past medical history and family tumor history were unremarkable.She complained of intermittent abdominal pain for one month.An abdominal mass was found on physical examination and abdominal contrast-enhanced computed tomography(CT) showed a hypodense soft mass,the size and location of which suggested a well delineated retroperitoneal tumor surrounding the superior mesenteric vessels measuring 3.3 cm × 4.5 cm × 4.5 cm with enlarged lymph nodes.The patient underwent an exploratory laparotomy followed by biopsy and was subsequently diagnosed with retroperitoneal IMT.She was successfully treated with postoperative chemotherapy and oral diclofenac sodium.Following completion of therapy the mass was no longer palpable and no longer visible on CT scanning.The use of methotrexate and cisplatin for aggressive myofibroblastic tumors is also reviewed.

Extralevator abdominoperineal excision for advanced low rectal cancer:Where to go

Since its introduction,extralevator abdominoperineal excision(ELAPE)in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer.Most studies suggest that because of adequate resection and precise anatomy,ELAPE could decrease the rate of positive circumferential resection margins,intraoperative perforation,and may further decrease local recurrence rate and improve survival.Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction.Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position,which has advantages of excellent operative view,precise dissection and reduced postoperative complications.Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization.The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain.The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors,which is a milestone operation for the treatment of advanced low rectal cancer.

Changes in extracellular matrix in different stages of colorectal cancer and their effects on proliferation of cancer cells

BACKGROUND The extracellular matrix is the main component of the tumor microenvironment.Extracellular matrix remodels with the oncogenesis and development of tumors.Previous studies usually focused on the changes of proteins in normal colorectal tissues and colorectal cancers.Little is known about the changes in the extracellular matrix in different stages of colorectal cancer and the effects of these changes on the development of this cancer.AIM To test the changes of type I collagen,type IV collagen,matrix metalloproteinase-2(MMP-2),matrix metalloproteinase-9(MMP-9),and tissue inhibitor of metalloproteinase-3(TIMP-3)in different stages of colorectal cancer and the effects of these changes on the proliferation of cancer cells.METHODS The extracellular matrix from various stages of colorectal cancer and normal colon tissue was obtained by using acellular technology.We used proteomics to detect the differential expression of proteins between normal colon tissues and colorectal cancer tissues,and then we used Western blot to observe their expression in each stage of colorectal cancer and in normal colon tissue.By coculturing the extracellular matrix and HT29 colon cancer cells in vivo and in vitro,we tested the cancer cell proliferation rate in vitro by methyl thiazolyl tetrazolium(MTT)assay and in vivo by measuring the tumor volume.RESULTS The expression of type I collagen and MMP-2 increased with increased tumor stage.The expression of MMP-9 was higher in colorectal cancer tissues and was highest in stage III cancer.The expression of type IV collagen and TIMP-3 decreased with increased tumor stage.The proliferation rate of cancer cells in the extracellular matrix of colorectal cancer was higher than that in the extracellular matrix of the normal colon.CONCLUSION These data suggest that the extracellular matrix structure and composition become disorganized during the development of tumors,which is more conducive for the growth of cancer cells.

Successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy: A case report

BACKGROUND Surgery 5-10 d after stent insertion was recommended by the European Society of Gastrointestinal Endoscopy for obstructing colonic cancer. For some obstructive patients, this may be not a good choice. Here, we report the successful treatment of obstructing colonic cancer by combining self-expandable stent and neoadjuvant chemotherapy.CASE SUMMARY The patient was a 72-year-old man who was admitted with a chief complaint of abdominal pain for more than 1 mo. Computed tomography(CT) scanning revealed that there was a mass in the descending colon, which led to intestinal obstruction. On admission, a series of therapeutic measures, such as fasting and water deprivation, gastrointestinal decompression, total parenteral nutrition, and octreotide acetate, were taken to improve the obstructive symptoms. At the same time, a self-expandable metal stent was successfully placed across the stenosis,and a biopsy was obtained and diagnosed as adenocarcinoma. CT scanning 14 d after insertion of the stent revealed that the intestine was swollen significantly.Systemic chemotherapy with modified FOLFOX6(mFOLFOX6) was administered. After two courses of mFOLFOX6, CT scanning showed clearly that swelling of the intestine was improved. Subsequently, the patient underwent left hemi-colectomy without stoma placement. The postoperative course was uneventful, and he has been disease-free for 6 mo after surgery.CONCLUSION This modified treatment strategy may provide an alternative therapy for patients with obstructing colonic cancers.

Ileal bronchogenic cyst: A case report and review of literature

We herein report a rare case of ileal bronchogenic cyst that was found in a 39-year-old Chinese man. He had no symptoms and the physical examination was normal. Tumor markers were within the normal range. Abdominopelvic enhanced computed tomography showed a mass in the lower abdominal cavity and the tumor had a complete capsule. Diagnostic laparoscopy was then performed, which showed that a spheroid mass with a complete capsule was located at the antimesenteric border of the distal ileum 20 cm from the ileocecal valve, measuring 6.0 cm × 6.0 cm × 5.0 cm. Considering that the malignancy of the tumor cannot be ruled out, and there is a risk of rupture during laparoscopic surgery, the patient was conver-ted to an open surgery. Partial resection of the ileum with the tumor was performed, followed by a side-to-side anastomosis. The tumor was gray-red in color,filled with grayish yellow mucus and had no septum. The postoperative pathology revealed that the cystic wall was lined by pseudostratified ciliated columnar epithelium without cellular atypia. The wall consisted of bronchial mucous glands and smooth muscle fbers, and no abnormalities were found in adjacent ileumtissues. Thus, a diagnosis of bronchogenic cyst of the ileum was made.

Idiopathic chronic ulcerative enteritis with perforation and recurrent bleeding: A case report

Idiopathic chronic ulcerative enteritis (ICUE) is a distinct entity without a defined etiology and is rarely seen in the clinic. Patients with ICUE mainly present with insidious abdominal symptoms such as chronic abdominal pain and intermittent gastrointestinal hemorrhage and symptoms of malnourishment in the early stages of the disease. ICUE is always difficult to diagnose. However, as the disease progresses, patients have a variety of acute abdominal complications such as hemorrhage, perforation, or ileus. Surgical intervention is always needed, and the condition can recur and require repeat laparotomy. When diffuse ulceration of the small bowel is present in the absence of recognizable causes, it is classified as nonspecific or idiopathic. The histological examination always demonstrates an acute, chronic inflammatory infiltration without giant cells, granulomas, or villous atrophy. The etiology of ICUE has not been identified, and its pathogenesis is poorly understood; therefore, radical surgical resection is considered the best available treatment. Here, we report a case of ICUE characterized by nonspecific, multiple, small intestinal ulcers resulting in perforation and recurrent bleeding. The differential diagnosis and the treatment are also discussed.

Peritoneal cavernous hemangiomatosis:A case report

BACKGROUND Cavernous hemangiomatosis in the liver and spleen has been reported, but it occurs less commonly in the peritoneum. Here we report a case of peritoneal cavernous hemangiomatosis and share some valuable information about this disease.CASE SUMMARY A 57-year-old Chinese man had a huge abdominal mass with abdominal distention and a significant reduction of food consumption. An enhanced abdominal and pelvic computed tomography and positron emission tomography–computed tomography revealed multiple cystic masses on the peritoneum, greater omentum, small intestinal mesentery and the surface of the spleen, and a high maximum standardized uptake value of the largest cystic lesion. Exploratory laparotomy was performed, and multiple cystic masses were found on the surface of the peritoneum, greater omentum, mesentery of the small intestine, and surface of the liver and spleen. Dark red bloody cystic fluid was present in the cystic tumor. Pathological examination showed that in the stromal components, the irregular vascular wall was thin. The vessel lumen was interlinked, and the lumen was lined with flat endothelium. According to the intraoperative findings and pathologic results, the patient was diagnosed with peritoneal cavernous hemangiomatosis.CONCLUSION The possibility of peritoneal cavernous hemangiomatosis should be considered when multiple cystic masses are found in the abdominal cavity by preoperative examination.

Successful diagnosis and treatment of jejunal diverticular haemorrhage by full-thickness enterotomy: A case report

BACKGROUND Jejunal diverticula are the rarest of all small bowel diverticula and usually have no classic clinical symptoms.Jejunal diverticular haemorrhage(JDH)is a rare complication and can be difficult to identify and manage,hence it always resulting in a diagnostic delay and unsatisfactory clinical outcomes.Although with the advances in endoscopic technology,no consensus have been reached on the diagnosis and management of JDH,the conventional surgical intervention still remains the mainstream for the management of JDH.We report an unique case of a 63-year-old male who presented with massive haemorrhage from jejunal diverticula,which was successfully managed by initial resuscitation and definitive surgery.CASE SUMMARY A 63-year-old male was admitted as an emergency with 6 h history of haematemesis and melena.The haematemesis appeared to be bright red,with volume exceeding 100 mL.The amount of melena was estimated to be 200 mL.Initially,the patient received fluid resuscitation and three unit blood transfusion.Then,in order to localize the bleeding sites,colonoscopy,upper gastrointestinal endoscopy,and mesenteric angiography were utilized but failed to identify the source of haemorrhage.Informed consent form was obtained for further treatment,and he was treated with an exploratory laparotomy and the bleeding site was successfully located during the procedure.He was diagnosed with JDH.The postoperative period was uneventful,and he was discharged on day 18 after surgery.No rebleeding occurred at the 1-year follow-up.CONCLUSION In patients with gastrointestinal bleeding,if various techniques fail to identify the cause of haemorrhage in small bowel and haemodynamic instability is sustained with continuous resuscitation,we recommend surgical intervention should be the ultimate treatment of choice.

Successful management of tubular colonic duplication using a laparoscopic approach: A case report and review of the literature

BACKGROUND Alimentary duplication is a rare congenital disease with a reported incidence of 1 per 4500 persons,although the exact incidence has been difficult to ascertain.According to previous reports,the most common site of duplication is the ileum,and colonic duplication is rare.Due to different types and locations of the duplication,the manifestations are varied,which makes establishing an accurate diagnosis before surgery a challenge.CASE SUMMARY A 17-year-old female patient sought evaluation in our department with constipation and chronic abdominal pain for 12 years;she had difficulty defecating and had dry stools since she was a child.An abdominal computed tomography revealed two extremely enlarged loops of bowel full of stool-like intestinal contents in the left lower abdomen,which led us to consider the possibility of colonic duplication.A laparoscopic exploration was performed,which revealed a tubular duplicated colon that shared a common opening with the transverse colon.A left hemi-colectomy was performed with a side-to-side anastomosis.The pathologic results confirmed the diagnosis.At the 6-mo followup,the patient was doing well without constipation or abdominal pain.CONCLUSION Colonic duplication is a rare alimentary abnormality in adults.Due to the nonspecific manifestations and low incidence,it is usually difficult to make an accurate diagnosis pre-operatively.Surgery is the mainstay of treatment,even though some patients are asymptomatic.

Preliminary Outcome of Individualized Abdominoperineal Excision for Locally Advanced Low Rectal Cancer

Background： The introduction of individualized abdominoperineal excision （APE） may minimize operative trauma and reduce the rate of complications. The purpose of this study was to evaluate the safety and efficacy of individualized APE for low rectal cancer. Methods： Fifty-six patients who underwent individualized APE from June 2011 to June 2015 were evaluated retrospectively in Beijing Chaoyang Hospital, Capital Medical University. The main outcome measures were circumferential resection margin （CRM） involvement, intraoperative perforation, postoperative complications, and local recurrence. Statistical analysis was performed using SPSS version 16.0. Results： Fifty （89%） patients received preoperative chemoradiotherapy： 51 （91%） patients were treated with the sacrococcyx preserved; 27 （48%） patients with the levator ani muscle partially preserved bilaterally; 20 （36%） patients with the levator ani muscle partially preserved unilaterally and the muscle on the opposite side totally preserved; 7 （13%） patients with intact levator ani muscle and part of the ischioanal fat bilaterally dissected; and 2 （4%） patients with part of the ischioanal fat and intact lavator ani muscle dissected unilaterally and the muscle on the opposite side partially preserved. The most common complications included sexual dysfunction （12%）, perineal wound complications （13%）, urinary retention （7%）, and chronic perineal pain （5%）. A positive CRM was demonstrated in 3 （5%） patients, and intraoperative perforations occurred in 2 （4%） patients. On multiple logistic regression analysis, longer operative time （P = 0.032） and more intraoperative blood loss （P = 0.006） were significantly associated with perineal procedure-related complications. The local recurrence was 4% at a median follow-up of 53 months （range： 30–74 months）. Conclusion： With preoperative chemoradiotherapy, individualized APE may be a relatively safe and feasible approach for low rectal cancer with acceptable oncological outcomes.