Advances,breakthroughs,and challenges in gastric cancer surgery

Gastric cancer(GC)remains a substantial health burden worldwide,ranking fifth in incidence and third in mortality among all cancer types.Surgeons have persistently attempted to address this growing burden through surgical management of GC encompassing various aspects of surgery,including advances in surgical techniques and tools for minimally invasive surgery,novel technology for real-time image-guided surgery,and function-preserving and oncometabolic surgeries,aimed at improving patients’quality of life.The current perspective discusses the five most critical dimensions of the recent technical improvements and conceptual changes in GC surgery.We recommend further exploration of long-term benefits of these advancements,identification of breakthrough solutions to address current challenges,and delivery of the best quality of care.

Current status of function-preserving surgery for gastric cancer

Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer(GC)at an early stage.Due to the low incidence of lymph node metastasis and favorable prognosis in early GC,function-preserving surgery which improves postoperative quality of life may be possible.Pylorus-preserving gastrectomy(PPG)is one such function-preserving procedure,which is expected to offer advantages with regards to dumping syndrome,bile reflux gastritis,and the frequency of flatus,although PPG may induce delayed gastric emptying.Proximal gastrectomy(PG)is another functionpreserving procedure,which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach,although the incidence of heartburn or gastric fullness associated with this procedure is high.However,these disadvantages may be overcome by the reconstruction method used.The other important problem after PG is remnant GC,which was reported to occur in approximately 5%of patients.Therefore,the reconstruction technique used with PG should facilitate postoperativeendoscopic examinations for early detection and treatment of remnant gastric carcinoma.Oncologic safety seems to be assured in both procedures,if the preoperative diagnosis is accurate.Patient selection should be carefully considered.Although many retrospective studies have demonstrated the utility of function-preserving surgery,no consensus on whether to adopt functionpreserving surgery as the standard of care has been reached.Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.

Life prognosis of sentinel node navigation surgery for early-stage gastric cancer:Outcome of lymphatic basin dissection

BACKGROUND Lymphatic basin dissection is a sentinel node biopsy method that is specific for gastric cancer.In this method,the dyed lymphatic system is dissected en bloc,and sentinel nodes are identified at the back table(ex vivo).Even with lymphatic basin dissection,blood flow to the residual stomach can be preserved,and functionpreserving curative gastrectomy can be performed.The oncological safety of function-preserving curative gastrectomy combined with lymphatic basin dissection has not yet been fully investigated.We hypothesized that the oncological safety of sentinel node navigation surgery(SNNS)is not inferior to that of the guidelines.AIM To investigate the life prognosis of SNNS for gastric cancer in comparison with guidelines surgery.METHODS This was a retrospective cohort study.Patients were selected from gastric cancer patients who underwent sentinel node biopsy from April 1999 to March 2016.Patients from April 1999 to August 2008 were from the Department of Surgery II,Kanazawa University Hospital,and patients from August 2009 to March 2016 were from the Department of Surgical Oncology,Kanazawa Medical University Hospital.Patients who were diagnosed with gastric cancer,which was preoperatively diagnosed as superficial type(type 0),5 cm or less in length,clinical T1-2 and node negative,and underwent various gastrectomies guided by sentinel node navigation were retrospectively collected.The overall survival(OS)and relapsefree survival(RFS)of these patients(SNNS group)were investigated.Patients with gastric cancer of the same stage and who underwent guidelines gastrectomy with standard nodal dissection were also selected as the control group.RESULTS A total of 239 patients in the SNNS group and 423 patients in the control group were included.Pathological nodal metastasis was observed in 10.5%and 10.4%of the SNNS and control groups,respectively.The diagnostic abilities of sentinel node biopsy were 84%and 98.6%for sensitivity and accuracy,respectively.In the SNNS group,81.6%of patients underwent modified gastrectomy or functionpreserving curative gastrectomy with lymphatic basin dissection,in which the extent of nodal dissection was further reduced compared to the guidelines.The OS rate in the SNNS group was 96.8%at 5 years and was significantly better than 91.3%in the control group(P=0.0014).The RFS rates were equal in both groups.After propensity score matching,there were 231 patients in both groups,and the cumulative recurrence rate was 0.43%at 5 years in the SNNS group and 1.30%in the control group,which was not statistically different.CONCLUSION The oncological safety of patients who undergo gastrectomy guided by sentinel node navigation is not inferior to that of the guidelines surgery.

Visual function alterations in cavernous hemangioma of the orbital apex after surgery

Dear Editor,I am Dr.Kang Xue,from the Department of Ophthalmology at the Eye,Ear,Nose and Throat Hospital of Fudan University in Shanghai,China.I am writing to present three case reports of the removal of visual function alterations in cavernous hemangioma of the orbital apex after surgery.Cavernous hemangioma is a relatively common primary benign orbital tumor in adults.

RELEASE OF SERUM TROPONIN I AND ITS RELATIONSHIP TO MULTIFACTORS FOLLOWING OPEN HEART SURGERY IN CHILDREN

Objective To be released specifically after myocardial damage. The goal of this study was to measure serum cardiac troponin I levels after open heart surgery in children, and to evaluate relevance between TnTi and perioperative multi-factors. Methods Fifty-seven consecutive pediatric patients undergoing elective correction of congenital heart diseases were divided into group A （ TOF, n =31 ） and group B （ VSD, n =26）. Blood sampies were drawn preoperatively, 5min（ T0 ） , 6h（ T6 ） , 12h（ T12 ） , 24h（ T24 ） , 48h（ T48 ） , 72h（ T72 ） after removal of aortic cross clamping. Myocardial protection consisted of moderate systemic hypothermia （ 30℃- 32℃ ）, cold crystalloid cardioplegia and topical cooling. Demographic information, cardiac defect, repair procedure, duration of bypass （ CPBT） , cross-clamping time （ CCT） , clinical score for cardiac function, electrocardiographic changes and outcomes were recorded. Results Compared with the baseline value, serum concentration of troponin I peaked at T0 （ P 〈 0. 01 ）, and fell to normal level at T72 （ P 〉 0. 05 ）. Peak CTnI was 118 and 55 times higher than the baseline value, respectively in group A and group B. There was a positive correlation between peak CTnI and CPBT, CCT （ r = 0. 51 ; P 〈 0. 01 ）, myocardial operative injury after ventriculotomy and muscle resection （ r = 0. 35, P 〈0. 01 ）. Also the peak CTnl value was correlated to the clinical score for cardiac function （r = -0. 52; P 〈0. 01）. 2.3μg/L was a cutoff value which was highly predictive for postoperative recovery and inotropic support. Conclusion Postoperative serum troponin I is a highly specific and sensitive marker for myocardial ischemia and injury; therefore, its measurement may contribute to the assessment of recovery and outcome after open heart surgery.

Effect of lung volume reduction surgery on early function of lung and pulmonary hemodynamics in COPD

Objective To evaluate the effects of lung volume reduction surgery (LVRS) on early lung function and pulmonary hemodynamics in severe chronic obstructive pulmonary disease (COPD). Methods 31 patients with severe COPD underwent LVRS, bilateral LVRS in 11 patients and unilateral in 20 patients. The results of lung function (FEV1, RV, TLC), arterial blood gas analysis (PAO2, PACO2 ) and color Doppler echocardiography (CD,CI,FS,EF,PAP) were analyzed before and 3 month after LVRS in 26 cases. Results FEV1, RV and TLC were improved significantly after surgery ( P 【 0. 01). PaO2 increased (P 【 0. 05 ) and PaCO2, decreased postoperatively (P 【 0. 01). According to the Doppler echocardiography, there were no statistic differences in cardiac functions (CO, CI, FS, EF, and PAP) between pre- and post-operation. The 6-minute-walk-distance in 26 patients was (227 ± 88) m, significantly increased after surgery. Conclusion LVRS is effective in the treatment of patients with severe COPD. 3 months after operation, the

Effects of lornoxicam combining with fentanyl on postoperative arrhythmia and platelet function in patients with coronary artery disease after abdominal surgery

To investigate the effects of patient-controlled intravenous analgesia (PCIA) with lornoxicam and fentanyl on arrhythmia and the expression of platelet membrane glycoproteins in patients with coronary artery disease (CAD) after abdominal surgery.Methods Eighty ASA Ⅱ or Ⅲ patients with CAD aged 51～66 yrs weighing 59～68 kg presenting for abdominal surgery participated in this study.CAD was diagnosed by clinical symptoms and ischemic changes on ECG.The patients were premedicated with intramuscular henobarbital 0.1 g and scopolamine 0.3 mg.Anesthesia was induced with fentanyl,droperidol,propofol and vecuronium and maintained with propofol,fentanyl and vecuronium.The patients received PCIA after operation.The PCIA solution contained fentanyl 0.9 mg and droperidol 5 mg in 100 ml of normal saline (N.S.) in group A (n=40) or lornoxicam 56 mg,fentanyl 0.2 mg and droperidol 5 mg in 100 ml N.S. in group B (n=40).In group A the loading dose was fentanyl 0.05 mg and group B lornoxicam 4 mg.PCIA included a background infusion at 2 ml·h -1 and a bolus of 0.5 ml with a 15 min lock-out.VAS(0=no pain,10= worst pain) was used to measure pain intensity.In addition to BP,HR and SpO2 monitoring ECG was continuously monitored with a Holter monitor after operation.Blood samples were taken from peripheral vein before and 6 h after operation and on the 1st,2nd,7th and 8th postoperative days for determination of the expression of CD 62p ,CD 63 and CD 41 /CD 61 on the platelet membrane,platelet count,prothrombin time (PT) thrombin time (TT) and partial thromboplastin time (PTT).Results The two groups were comparable with respect to sex,age,body weight,severity of CAD,duration of operation and intraoperative blood loss.The patients received no blood transfusion during operation.There was no significant difference in VAS score,platelet count,PT,TT and PTT between the two groups.The incidence of atrial and ventricular premature beat on ECG and the expression of CD 41 /CD 61 ,CD 62p and CD 63 on the platelet membrane were significantly lower in group B than in group A on the 7th and 8th postoperative days(P<0.05 or 0.01).Conclusion Postoperative PCIA with lornoxicam and fentanyl can more effectively reduce the incidence of postoperative arrhythmia in patients with CAD.Suppression of activation of platelets by lornoxicam may contribute to the mechanism.10 refs,3 tabs.

A randomized controlled trial on triamcinolone versus saline impregnated merocel post endoscopic sinus surgery:Our experience in a tertiary care centre

Purpose:To assess the potential benefit of impregnating Merocel(a non-absorbable nasal dressing)with a topical steroid solution,for use as a direct and slow local delivery system of steroids after sinus surgery to improve postoperative wound healing.Methods:In this randomized controlled trial,40 patients with bilateral chronic rhinosinusitis with nasal polyposis were subjected to functional endoscopic sinus surgery.Following the completion of the surgery,Merocel packs were inserted in the bilateral nasal cavities and infiltrated with 4 mL triamcinolone(40 mg/mL)in one nasal cavity(treatment group)and 4 mL normal saline in the other(control group).Nasal packs were removed on the third postoperative day and postoperative healing assessment was done on postoperative Weeks 1,2,4,and 12.The findings were noted as per Lund Kennedy(LKES)and perioperative sinus endoscopy(POSE)scores and compared on both sides.Results:Significant(P<0.05)improvement was noted in Lund Kennedy score for crusting and polyp at Week 12,for edema at Week 1,and nasal discharge at Weeks 1 and 12,but there was no significant improvement in scarring at any week.Overall,the difference between the treatment and control arms was statistically significant at all postoperative visits except at Week 4.Also,there was a significant improvement in POSE scores at Weeks 1,2,and 12 but not at Week 4.Conclusion:This study positively concludes that the nasal cavity packed with drug-soaked packs had less scarring and edema in the postoperative period and the overall wound healing was much better as compared to saline-soaked packs.

Open label,interventional,single arm multicentric clinical study to analyze the potency of VELNEZ nasal pack,post-nasal surgery

Background:Nasal packs are central to nasal surgeries.Primarily,these packs function by controlling bleeding,modulating pain and reducing adhesions post-surgery.However,the major setback of the currently used conventional nasal packs is the unbearable pain the patient undergoes upon removal of these packs.To overcome this shortcoming a variety of biodegradable packs have emerged.This study was aimed at evaluating the safety,efficacy and tolerability of VELNEZ nasal packs.VELNEZ,a patented Datt Mediproducts Pvt.Ltd.nasal pack,is one of its kind biodegradable composite that fragments within a few days of application.Methods:Eighty patients were included in an open label,interventional,single arm clinical study using clinical endpoints to investigate the safety and efficacy of nasal pack VELNEZ.The patients were questioned using a visual analog scale from discharge day to 28th postoperative day(9 follow-up visits)at regular intervals.The standardized questionnaires for hemorrhage control,relief from postoperative pain,moderate obstruction,and pain were used.Results:A total of 76 patients were enrolled in the study and 74 patients completed the study.VELNEZ nasal pack played a significant role in controlling hemorrhage and reducing postoperative pain.The average hemorrhage control time was 7.49±3.90 min with only 34.24%of population complaining of pain on the sixth day of surgery(follow-up 4).Forteen days postsurgery only 10.95%of subject population complained of postoperative pain.This biodegradable composite has an average fragmentation time of 4.7 days in the nasal cavity.In addition,this study did not observe any postoperative adverse events or serious adverse events.Conclusion:VELNEZ,a fragmentable nasal pack,is comfortable,safe,and effective against postsurgery bleeding and pain.

Effect of Zhu-yuan decoction in patients with chronic rhinosinusitis after functional endoscopic sinus surgery

OBJECTIVE: To investigate the effectiveness and safety of Zhu-yuan decoction(ZYD) in patients after functional endoscopic sinus surgery(FESS).METHODS: A total of 85 patients were randomized into two groups: 44 were treated with intranasal corticosteroids(INC), and 41 were given Chinese herbal medicine(CHM). Patients with chronic rhinosinusitis(CRS) who underwent FESS were prospectively enrolled in the study. Before surgery, they were evaluated by visual analog scale(VAS), nasal endoscopy, computed tomography(CT), and routine blood test. After surgery, they were randomized to take ZYD or INC for 12 weeks and revaluated by VAS; nasal endoscopy at 4, 8, and 12 weeks;and CT at 12 weeks after surgery.RESULTS: In the both groups, VAS and endoscopyscores decreased significantly at 4, 8, and 12 weeks,and CT scores after treatment declined at 12 weeks compared with baseline scores. No significant differences were observed with regard to postoperative VAS, endoscopy, or CT scores between groups.ZYD, combined with surgery, can reduce VAS, nasal endoscopy, and CT scores and has the same efficacy and safety profile as INC in post-FESS management.No fatalities or major adverse events occurred in either group.CONCLUSION: Our findings suggest that ZYD has similar effects and safety profiles in patients after FESS compared with INC.

The effect of functional endoscopic sinus surgery on nasal resonance

Background and objective: Functional endoscopic sinus surgery (FESS) increases the nasal volume, and thereby it can alter the nasal resonance. The objectives were to measure the percentage of nasal resonance following FESS and compare it with healthy individuals with normal nasal findings.Methods: The nasometric analysis of voice was done using n/p/m consonant sounds in 72 individuals with healthy post FESS cavities (group 1) and 72 healthy individuals with normal nasal findings without any nasal pathology (group 2). The scores of nasal resonances were expressed in percentages and were compared between the two groups. Both in group 1 and group 2, 32 (44.4%) were females, and 40(55.6%) were males. In group 1, 51 participants had bilateral FESS cavities, and 21 had unilateral FESS cavities. Kannada was the mother tongue in 30 (41.7%) participants in group 1 and 36 (50.0%) in group 2. Malayalam was the mother tongue in 42(58.3%) participants in group 1 and 36 (50.0%) in group 2.Results: In both cases and control groups, more than 80% of the participants were showing less than 20% of nasal resonance. In group 1, the mean values of/n/p/m sounds were 11.23%, 10.23% and 11.42% respectively, and in group 2 the mean values were 8.27%, 8.58% and 8.58% respectively. But theP value was not statistically significant. Individuals with unilateral FESS cavities had more nasal resonance values compared to bilateral FESS cavities. Similarly, Kannada speaking people had more values compared to Malayam speaking individua.Conclusion: Changes in nasal resonance after FESS is minimal, and it is unnoticed. But it may affect the speech quality in professional voice users, depending on their language. Though the nasometer is considered as the most validated instrument to record nasal resonance, we feel that further standardization is needed to evaluate the nasalance.

Surgical management of genital lymphoedema:experience and critical considerations from a tricenter study

Aim:Genital lymphoedema(GL)is a chronic and debilitating disease,which can severely affect the patient’s quality of life with significant socio-economic impact.Nowadays,no gold standard algorithm exists for GL from diagnosis to treatment.This study proposes our therapeutic flowchart based on the three senior consultants’experience in lymphatic surgery.Methods:A retrospective investigation was conducted on a prospectively maintained database(2018-2022).Inclusion criteria involved all patients who underwent surgical procedures for treating GL in three plastic surgery departments(Lausanne,Bari,and Genova).Outcomes were assessed in terms of oedema reduction,stage regression,and functional reported outcomes.Results:16 patients with GL were included:50%underwent debulking surgery,18.8%microsurgery,and 31.2%debulking+microsurgery.We recorded a significant regression of the GL stage:62.5%shifted from stage II/III to postoperative stage I.Similarly,we found an infection recurrency resolution in 50%,a scrotal oedema reduction in 62.5%,and a scrotal oedema resolution in 37.5%of the patients treated.While almost half of the patients(53.3%)with associated penile oedema described persistent postoperative penile oedema,only two patients complained of persistent lymphorrhea.Conclusion:According to our clinical experience,preoperative and postoperative physical functional therapy is always recommended.For stages I and IIA,after the failure of the conservative treatment,lymph-venous shunts and lymph node transplantation surgery are proposed at the early time.When GL is already diagnosed at stages IIB and III,the debulking surgery,together with functional procedures,represents our first approach.

Evaluation and management of acquired ptosis

Periorbital rejuvenation is a common aesthetic goal sought by patients presenting to the plastic or oculoplastic surgeon.For this reason,it is critical that the surgeon understand the functional considerations,such as preexisting blepharoptosis,which will contribute to the ultimate aesthetic outcome.This article will review the anatomy of the normal and ptotic lid and will discuss the approach to diagnosing and characterizing the type and degree of lid ptosis.High-yield surgical techniques for ptosis correction will then be described,including the indications for and steps of each procedure.Finally,the diagnosis and management of common complications that follow ptosis surgery will be discussed.Our main objective is to arm the surgeon with the preoperative and operative planning tools to successfully manage comorbid ptosis and thereby improve blepharoplasty outcomes.