Risk factors for lymph node metastasis and evaluation of reasonable surgery for early gastric cancer

AIM: To give the evidence for rationalizing surgical therapy for early gastric cancer with different lymph node status. METHODS: A series of 322 early gastric cancer patients who underwent gastrectomy with more than 15 lymph nodes retrieved were reviewed in this study. The rate of lymph node metastasis was calculated. Univariate and multivariate analyses were performed to evaluate the independent factors for predicting lymph node metastasis. RESULTS: No metastasis was detected in No.5, 6 lymph nodes (LN) during proximal gastric cancer total gastrectomy, and in No.10, 11p, 11d during for combined resection of spleen and splenic artery and in No.15 LN during combined resection of transverse colon mesentery. No.11p, 12a, 14v LN were proved negative for metastasis. The global metastastic rate was 14.6% for LN, 5.9% for mucosa, and 22.4% for submucosa carcinoma, respectively. The metastasis in group Ⅱ?was almost limited in No.7, 8a LN. Multivariate analysis identified that the depth of invasion, histological type and lymphatic invasion were independent risk factors for LN metastasis. No metastasis from distal cancer (≤ 1.0 cm in diameter) was detected in group Ⅱ?LN. The metastasis rate increased significantly when the diameter exceeded 3.0 cm. All tumors (≤ 1.0 cm in diameter) with LN metastasis and mucosa invasion showed a depressed macroscopic type, and all protruded carcinomas were > 3.0 cm in diameter. CONCLUSION: Segmental/subtotal gastrectomy plus D1/D1 + No.7 should be performed for carcinoma (≤ 1.0 cm in diameter, protruded type and mucosa invasion).Subtotal gastrectomy plus D2 or D1 + No.7, 8a, 9 is the most rational operation, whereas No.11p, 12a, 14v lymphadenectomy should not be recommended routinely for poorly differentiated and depressed type of submucosa carcinoma (> 3.0 cm in diameter). Total gastrectomy should not be performed in proximal, so does combined resection or D2+/D3 lymphadenectomy.

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy? A multicentre rural experience from a developing world country

AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.

Surgical Treatment of Intralobar Pulmonary Sequestration

Objective To evaluate the clinical features,diagnosis,treatment,and outcome of intralobar pulmonary sequestration (ILS). Methods Patients who were diagnosed with ILS in our hospital between January 1988 and January 2009 were retrospectively reviewed. We recorded the clinical symptoms,imaging findings,operative technique,complications,and outcome of these patients. Results Forty-seven patients (25 men and 22 women) with an average age of 32.3 years were enrolled. Forty-two patients had symptoms including cough and hemoptysis. Chest X-ray,computed tomography (CT),magnetic resonance imaging (MRI),and angiography were performed. Thoracotomy was performed in 45 patients,while thoracoscopy was performed in 2 patients. Lobectomy was the most common treatment procedure. Massive bleeding developed in 2 patients due to injury of aberrant supplying artery intraoperatively,1 patient had atrial fibrillation,1 patient had thrombosis of upper extremity postoperatively. All patients were confirmed the diagnosis pathologically,4 accompanied with bronchogenic cyst,15 with bronchiectasis,8 with infection,2 with aspergilloma,and 1 with carcinoid. No late complications occurred. Conclusions ILS is rare,surgery is recommended because some patients may have potential severe complications. Contrast enhanced CT and three-dimensional reconstruction is the best diagnostic method. Both thoracotomy and thoracoscopy are appropriate for the selected candidates.

Double-balloon enteroscopy reliably directs surgical intervention for patients with small intestinal bleeding

AIM: To evaluate preoperative double-balloon enteroscopy for determining bleeding lesions of small intestine, thus directing selective surgical intervention. METHODS: We retrospectively reviewed 56 patients who underwent double-balloon enteroscopy to localize intestinal bleeding prior to surgical intervention, and compared enteroscopic findings with those of intraoperation to determine the accuracy of enteroscopy in identifying and localizing the sites of small intestinal bleeding. RESULTS: Double-balloon enteroscopy was performed in all 56 patients in a 30-mo period. A possible site of blood loss was identified in 54 (96%) patients. Enteroscopy provided accurate localization of the bleeding in 53 (95%) of 56 patients, but failed to disclose the cause of bleeding in 4 (7%). There was one case with negative intraoperative finding (2%). Resection of the affected bowel was carried out except one patient who experienced rebleeding after operation. Gastrointestinal stromal tumor (GIST) was most frequently diagnosed (55%). CONCLUSION: Double-balloon enteroscopy is a safe, reliable modality for determining bleeding lesion of small intestine. This technique can be used to direct selective surgical intervention.

Safety control strategy for vertebral lamina milling task

Vertebral lamina milling task is one of the high-risk operations in spinal surgeries. The operation is to remove part of vertebral lamina and release the pressure on the spinal nerve. Because many important vessels and nerves are under the vertebral lamina, any incorrect operation may cause irreparable damage to patients. To improve the safety of lamina milling task, a fuzzy force control strategy is proposed in this paper. Primary experiments have been conducted on bone samples from different animals. The results show that, with the fuzzy force control strategy, the bone milling system can recognize all surgery states and halt the tool at the proper location, achieving satisfactory surgery performance.

Surgery of pineal region meningioma combining obstructive hydrocephelus

Objective:The aim of our study was to find out the best operative therapeutic regimen by reviewing the comprehension of operation,the improvement of operative method and the selection of operative approach concerning pineal region meningioma combining obstructive hydrocephalus.Methods:We retrospected the clinic data,comprehension of operation and prognosis of 6 cases of pineal region meningioma.Results:Six tumors were all removed,after that the back wall of the third ventricle was cut open.The 6 tumors were defined as meningioma by pathological examination.After 4-48 months follow-up,the manifestation of hydrocephalus disappeared,other symptoms were relieved more or less without any complication with one patient dismissing.The regular MRI examination indicated that the lesions had not reoccur and the cerebral ventricles had been normal.Conclusion:We identify the nourish arteries of the tumor and anatomy relationship between the tumor and its peripheral blood vessels through modern imaging devices,to select reasonable operative method are the premier therapy of pineal region meningioma.The back wall of the third ventricle becomes thin and the suprapineal recess develops shallow and wide,so the third ventricle-quadrigeminal cistern fistulation can effectively eliminate the obstructive hydrocephalus due to the long-term compression on the aqueduct after removing the tumor.

Application of posterior Moss-Miami transpedicular system for the treatment of adolescent idiopathic scoliosis

Objective： To determine the effectiveness of posterior Moss-Miami transpedicular system for the treatment of adolescent idiopathic scoliosis in 24 patients with a 2-year minimum follow-up. Methods： 24 patients who underwent operations between September 2002 and November 2003 were evaluated for curve correction, spinal balance, and complications. Age at surgery averaged 13.8 years （range from 10 to 20）. The spinal deformities were evaluated by Cobb method with anteroposterior and lateral bending radiographs. All patients were right thoracic curves. Posterior instrumentation （Moss-Miami transpedicular system） was used. The transpedicular screws were placed between T2 and L2. All the patients were assessed both clinically and radiographically. Follow-up averaged 2.8 years. Results： There was an average correction of 72% of the primary curve （pre-operation standing average 54 degrees （range from 40 to 67 degrees）, post-operation average 15.2 degrees （range from 2 to 27 degrees）, at last examination average 16.1 degrees （range from 2 to 30 degrees）. Infection and neurological complications were not noted. No major complications were observed. Conclusions： Frontal and sagittal thoracic curve correction of thoracic scoliosis can be satisfactorily obtained using Moss Miami transpedicular instrumentation. It seems that control of the three columns of the spine by the transpedicular screws offers sufficient apical translation and coronal realignment.

Surgical treatment of locally advanced anal cancer after male-to-female sex reassignment surgery

We present a case of a transsexual patient who underwent a partial pelvectomy and genital reconstruction for anal cancer after chemoradiation. This is the first case in literature reporting on the occurrence of anal cancer after male-to-female sex reassignment surgery. We describe the surgical approach presenting our technique to avoid postoperative complications and preserve the sexual reassignment.

Application of minimally invasive surgery in traumatic brain injury

This article aims to expound the essence of minimally invasive surgery as well as when and how to use it in craniocerebral trauma surgery according to the characteristics of the disease. In neurosurgery, the importance of tissue protection should be from the inside to the outside, i.e. brain→dura→skull→scalp. In this article, I want to share my opinion and our team＇s experience in terms of selecting surgical approaches and incision, surgical treatment of the skull, dura handling, intracranial operation and placement of drainage based on the above theory. I hope this will be helpful for trauma surgeons.

Surgical treatment of complicated traumatic aneurysm and arteriovenous fistula

Objective: To evaluate the surgical methods and the outcome of management for traumatic arterial aneurysm (TAA) and traumatic arterioveneus fistula (TAVF).Methods: A total of 121 patients with TAA or TAVF were treated by surgery. Clinical, operative and postoperative data were collected and analyzed retrospectively.Results: The surgical techniques includedaneurysmectomy and arterial end-to-end anastomosis or vascular grafting or artery ligation, aneurysm ligation and bypass, vascular repair, fistula excision and vascular ligation or vascular grafting or repair and so on. One patient died (0.83%). The follow-up rates of TAA and TAVF were 65.7% and 60% respectively.Conclusions: Complicated TAA and TAVF in different sites should be treated with different methods.