用SilsPort行单一切口腹腔镜胃内手术的可行性研究

目的探讨SilsPort行单一切口胃内手术的可行性、安全性与有效性。方法 6头家猪作为实验对象,将SilsPort经腹壁切口置入胃内。3头猪用超声刀切开胃后壁黏膜层,切开长度3 cm,3-0可吸收线间断缝合;另3头猪用抓钳抓取胃后壁组织,用直线切割吻合器切除。结果所有模拟操作均顺利完成,无明显术中出血与并发症。放置SilsPort所用时间为8~40 min,（16.2±12.2）min。3头猪用直线切割吻合器行模拟切除总手术时间分别为75、45、38 min;另3头猪用超声刀模拟切除缝合所用时间分别为80、85、70 min。术后活检见胃前壁缝合良好,胃内模拟切除部位缝合（或钉合）满意,局部无出血。结论用SilsPort进行胃内手术可行、安全,提供了将腹腔镜与器械置入胃内进行手术操作简便、稳定的平台。

腹腔镜胃内手术及其在早期胃癌中的改良法:一种腹腔镜外科新技术

近年来,腹腔镜外科不仅用于胆囊切除,还广泛应用于胃肠手术。本文旨在描述我们治疗胃部疾病的独特方法,称为“腹腔镜胃内外科(laparoscopic intragastic surgery,LIGS)”。在LIGS手术中,所有套管和手术器械均直接置人胃腔内,行胃粘膜切除术。除LIGS外,我们还作了其改良技术,即利用腹内胃造口行粘膜切除术。

腹腔镜联合胃镜胃腔内手术13例报告

本文报道2011年11月～2015年4月腹腔镜联合胃镜胃腔内手术治疗贲门部黏膜下病变13例。在胃镜及腹腔镜监视下,穿刺胃前壁建立胃腔内操作空间,应用腹腔镜器械进行胃腔内手术。11例完成腹腔镜联合胃镜胃腔内手术,2例中转腹腔镜胃壁楔形切除。手术时间40～130 min,平均105 min,出血10～150 ml,平均20 ml。术后当日下床活动,第2天进食流质饮食,无并发症发生。腹腔镜联合胃镜胃腔内手术治疗贲门部黏膜下病变安全、简便、可行。

完全腹腔镜胃腔内手术治疗胃黏膜下肿瘤的应用体会

目的:评估完全腹腔镜胃腔内胃手术治疗胃黏膜下肿瘤的可行性、安全性及临床应用价值。方法:回顾分析2017年9月至2018年12月为15例胃黏膜下肿瘤患者行完全腹腔镜胃腔内手术切除术的临床资料。结果:15例手术均顺利完成,术中术野稳定、清晰,无一例需要内镜干预,术后病理报告示切缘阴性。中位手术时间64(48~92)min,中位失血量25(5~80)mL,术后中位住院时间4(2~5)d。术后1例患者发现经胃管出血,经对症治疗后治愈。术后随访12个月,无局部复发病例,无一例发生胃出血、胃瘘、胃穿孔等相关并发症。结论:利用专用腹腔镜装置施行完全腹腔镜胃内手术安全、可行,经济实惠,临床应用价值较高。

改良完全腹腔镜胃腔内手术治疗贲门或幽门周围黏膜下肿瘤的临床疗效

目的探讨改良完全腹腔镜胃腔内手术治疗贲门或幽门周围黏膜下肿瘤的临床疗效。方法采用回顾性横断面研究。收集2014年9月至2018年3月吉林大学第二医院收治的48例贲门或幽门周围胃黏膜下肿瘤患者的临床病理资料;男22例,女26例;平均年龄为58岁,年龄范围为38~78岁。根据患者情况选择多孔或单孔改良完全腹腔镜胃腔内手术。观察指标:(1)手术情况。(2)术后恢复情况。(3)术后病理学检查情况。(4)随访情况。采用门诊和电话方式进行随访。了解患者术后并发症及肿瘤转移、复发情况。随访时间截至2018年6月。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示;计数资料以绝对数或百分比表示。结果(1)手术情况:48例患者均顺利完成改良完全腹腔镜胃腔内手术,其中1例联合行近端胃切除术,无中转开放手术患者;其中多孔改良腹腔镜胃腔内手术43例,单孔改良腹腔镜胃腔内手术5例。48例患者手术时间为68 min(45~110 min),术中出血量为20 mL(5~100 mL)。48例患者术中肿瘤学评估:完整切除48例,无肿瘤破裂,肿瘤直径为32 mm(20~40 mm),切缘距肿瘤距离为6mm(5~10mm)。(2)术后恢复情况:48例患者术后首次经口进食时间为2.8d(1.0~5.0 d)。48例患者中手术部位感染4例、胃排空障碍3例、膈下积液1例、消化道漏1例;术后住院时间为5.3d(3.0~11.0d)。(3)术后病理学检查情况:48例患者肿瘤边缘距离贲门或幽门距离为15 mm(0~30 mm),肿瘤直径为24 mm(10~65mm),环周切缘为6 mm(5~10mm)。48例患者肿瘤生长方式:腔内型27例、壁间型12例、混杂型9例。48例患者肿瘤病理学类型:平滑肌瘤26例、胃肠道间质瘤9例、其他少见肿瘤4例、类癌2例、黏膜相关组织淋巴瘤2例、炎性纤维性息肉2例、深在性囊性胃炎2例、异位胰腺1例。(4)随访情况:48例患者中,41例获得术后随访,随访时间为3~48个月,中位随访时间为22个月。41例患者中,37例经术后3次胃镜检查未见肿瘤复发,39例经术后2次上消化道造影检查提示无贲门或幽门狭窄及机能障碍(1例患者可行两种检测);随访期间无手术相关远期并发症发生,无肿瘤特异性死亡。结论改良完全腹腔镜胃腔内手术治疗胃贲门或幽门周围黏膜下肿瘤安全可行。

腹腔镜手术的新概念——腹腔镜胃腔内手术

目的介绍一种全新概念的腹腔镜手术方式———腹腔镜胃腔内手术(LIGS术)。方法采用LIGS术治疗2例患者,分别为胃窦后壁胃黏膜病变局部切除及胰腺假性囊肿胃内引流术。手术主要步骤:根据病灶部位,胃镜引导下经腹壁及胃前壁将3个气囊Trocar直接穿刺入胃腔后,按传统腹腔镜方式进行手术。结果手术时间分别为130min及110min,术中出血均少于20ml。术后患者恢复平稳,疼痛轻微,均可早期恢复饮食及活动。结论临床结果显示LIGS术是一种新型的简单、安全的微创外科手术。

完全腹腔镜胃腔内手术治疗胃黏膜下肿瘤11例

目的：探讨完全腹腔镜胃腔内手术治疗胃黏膜下肿瘤的安全性及疗效。方法回顾性分析2014年9月至2015年6月于吉林大学第二医院胃肠营养及疝外科行完全腹腔镜胃腔内手术治疗的11例胃黏膜下肿瘤患者的临床资料。结果全组患者均顺利完成手术，无术中求助于胃镜及中转其他方式腹腔镜或开腹手术者，手术时间35-110（73．2±24．6） min，术中出血量3-20（6．6±5．1） ml，无术中并发症的发生。切除的胃黏膜下肿瘤标本直径20-40（31．8±6．8） mm，切缘距肿瘤5-10（6．4±2．3） mm。术后2-5（3．2±1．3） d恢复经口进食，1例术后发生胃排空障碍，1例术后发生手术部位感染。术后5-11（6．6±1．8） d出院。随访3-9（6．0±2．3）月，无肿瘤复发和贲门狭窄出现。结论完全腹腔镜胃腔内手术是一种安全、有效的微创外科手术。

腹腔镜经胃壁胃腔内手术治疗胃底近贲门处胃肠间质瘤

胃肠间质瘤（gastrointestinal stromal tumor，GIST）外科治疗的关键在于肿瘤的完整切除。腹腔镜手术因其术中出血少、术后胃肠功能恢复快以及住院时间短等优势，已被广泛应用于胃GIST的治疗。2013年11月11日，北京大学第三医院普通外科采用腹腔镜经胃壁胃腔内手术方式对1例47岁女性胃底近贲门处GIST患者进行治疗，疗效满意．现报道如下。

腹腔镜下胃壁切开胃腔内手术治疗胃间质瘤1例

病人女性，83岁。上腹不适5个月余。胃镜检查示：胃底可见巨大隆起型病变，表面黏膜充血糜烂溃疡形成，可见血痂．有黏膜桥形成，考虑胃底隆起性病变，间质瘤？上消化道造影检查示：胃轮廓光滑，胃体上部后壁可见6．0cm×5．5cm巨大类圆形占位性病变，病变光滑、规则，向胃腔内突出（图1-①）。腹部CT报告：胃体上部后壁占位性病变，最大长径约5．8cm×4．7cm，考虑为胃间质瘤，肿瘤质地均匀，明显向腔内突出，无明显胃壁外侵犯，腹腔未见肿大淋巴结（图1-②）。术前诊断为胃体后壁间质瘤。

腹腔镜胃腔内手术治疗早期胃癌(附8例报告)

目的 设计一种全新的治疗胃粘膜或粘膜下病变的腹腔镜手术方法。方法 三个穿刺套管均通过腹壁及胃壁穿刺置入胃腔 ,在胃腔内采用腹腔镜器械通过监视器图像进行手术。结果 8例中 ,6例早期胃癌 ,1例粘膜下平滑肌瘤 ,1例巨大息肉 ,均未出现并发症 ,亦无中转开腹。结论 对于纤维胃镜无法治疗的胃粘膜或粘膜下病变 ,采用腹腔镜胃腔内手术其方法简便、安全。

Gastrointestinal bezoars: A retrospective analysis of 34 cases

AIM: Bezoars (BZ) are the most common foreign bodies of gastrointestinal tract. Clinical manifestations vary depending on the location of BZ from no symptoms to acute abdominal syndrome. When located in small bowel, they frequently cause small bowel obstruction (SBO). We aimed to present our experience by reviewing literature.METHODS: Thirty-four patients with gastrointestinal BZ were presented. The data were collected from hospital records and analyzed retrospectively. Morbidity and mortality rates were statistically analyzed between the subgroups according to SBO and endoscopic or surgical treatment modalities.RESULTS: The 34 patients had phytobezoars (PBZ). Two patients with mental retardation and trichotillomania had trichobezoars (TBZ). More than half of them (55.88%) had previous gastric surgery. Also most of them had small bowel bezoars resulting in obstruction. Surgical and endoscopic morbidity rates were 32.14% and 14.28% respectively.The total morbidity rate of this study was 29.41%. Four patients in surgically treated group died. There was no death in endoscopically treated group. The total and surgical mortality rates were 11.76% and 14.28% respectively. The differences in morbidity and mortality rates between the subgroups were not statistically significant.CONCLUSION: BZ are commonly seen in stomach and small intestine. SBO is the most common complication.When uncomplicated, endoscopic or surgical removal can be applied easily.

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Postoperative bleeding in patients on antithrombotic therapy after gastric endoscopic submucosal dissection

To investigated the relationship between postoperative bleeding following gastric endoscopic submucosal dissection (ESD) and individual antithrombotic agents. METHODSA total of 2488 gastric neoplasms in 2148 consecutive patients treated between May 2001 and June 2016 were studied. The antithrombotic agents were categorized into antiplatelet agents, anticoagulants, and other antithrombotic agents, and we included combination therapies [e.g., dual antiplatelet therapy (DAPT)]. The risk factors associated with post-ESD bleeding, namely, antithrombotic agents overall, individual antithrombotic agents, withdrawal or continuation of antithrombotic agents, and bleeding onset period (during the first six days or thereafter), were analyzed using univariate and multivariate analyses. RESULTSThe en bloc resection and complete curative resection rates were 99.2% and 91.9%, respectively. Postoperative bleeding occurred in 5.1% cases. Bleeding occurred in 10.3% of the patients administered antithrombotic agents. Being male (P = 0.007), specimen size (P < 0.001), and antithrombotic agent used (P < 0.001) were independent risk factors for postoperative bleeding. Heparin bridging therapy (HBT) (P = 0.002) and DAPT/multidrug combinations (P < 0.001) were independent risk factors associated with postoperative bleeding. The bleeding rate of the antithrombotic agent continuation group was significantly higher than that of the withdrawal group (P < 0.01). Bleeding within postoperative day (POD) 6 was significantly higher in warfarin (P = 0.015), and bleeding after POD 7 was significantly higher in DAPT/multidrug combinations (P = 0.007). No thromboembolic events were reported. CONCLUSIONWe must closely monitor patients administered HBT and DAPT/multidrug combinations after gastric ESD, particularly those administered multidrug combinations after discharge.

Endoscopic submucosal dissection for early gastric cancer:Quo vadis?

The diagnosis of early gastric cancer(EGC) is of great interest because its endoscopic and surgical treatment presents the best chance for a cure.With technical development,endoscopic submucosal dissection(ESD) has been widely performed for the curative treatment of EGC in Korea.Multinational studies of ESD for EGC will be the next missions that overcome these limitations and global guidelines will be processed for ESD for EGC.

InIncidence and clinical features of endoscopic ulcers developing after gastrectomy

AIM： To determine the precise incidence and clinica features of endoscopic ulcers following gastrectomy. METHODS： A consecutive series of patients who un- derwent endoscopic examination following gastrectomy between 2005 and 2010 was retrospectively analyzed. A total of 78 patients with endoscopic ulcers and 759 without ulcers following gastrectomy were enrolled. We analyzed differences in patient age, sex, size of the le- sions, method of operation, indications for gastric resec- tion, and infection rates of Helicobacterpylor/（H. pylor/~ between the nonulcer and ulcer groups. RESULTS： The incidence of endoscopic ulcers after gastrectomy was 9.3% and that of marginal ulcers was 8.6%. Ulcers were more common in patients with Billroth l] anastomosis and pre-existing conditions forpeptic ulcer disease （PUD）. Infection rates of H. pylori- did not differ significantly between the two groups. The patients who underwent operations to treat PUD had lower initial levels of hemoglobin and higher rates of hospital admission. CONCLUSION： H. pylori was not an important factor in ulcerogenesis following gastrectomy. For patients who underwent surgery for PUD, clinical course of mar- ginal ulcers was more severe.

Biochemically curative surgery for gastrinoma in multiple endocrine neoplasia type 1 patients

AIM： To search for the optimal surgery for gastrinoma and duodenopancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1. METHODS： Sixteen patients with genetically confirmed multiple endocrine neoplasia type 1 （MEN 1） and Zollinger-Ellison syndrome （ZES） underwent resection of both gastrinomas and duodenopancreatic neuroendocrine tumors （NETs） between 1991 and 2009. For localization of gastrinoma, selective arterial secretagogue injection test （SASI test） with secretin or calcium solution was performed as well as somatostatin receptor scintigraphy （SRS） and other imaging methods such as computed tomography （CT） or magnetic resonance imaging （MRI）. The modus of surgery for gastrinoma has been changed over time, searching for the optimal surgery： pancreaticoduodenectomy （PD） was first performed guided by localization with the SAST test, then local resection of duodenal gastrinomas with dissection of regional lymph nodes （LR）, and recently pancreas-preserving total duodenectomy （PPTD） has been performed for multiple duodenal gastrinomas. RESULTS： Among various types of preoperative localizing methods for gastrinoma, the SASI test was the most useful method. Imaging methods such as SRS or CT made it essentially impossible to differentiate functioning gastrinoma among various kinds of NETs. However, recent imaging methods including SRS or CT were useful for detecting both distant metastases and ectopic NETs; therefore they are indispensable for staging of NETs. Biochemical cure of gastrinoma was achieved in 14 of 16 patients （87.5%）; that is, 100% in 3 patients who underwent PD, 100% in 6 patients who underwent LR （although in 2 patients （33.3%） second LR was performed for recurrence of duodenal gastri- noma）, and 71.4% in 7 patients who underwent PPTD. Pancreatic NETs more than 1 cm in diameter were resected either by distal pancreatectomy or enucleations, and no hepatic metastases have developed postoperatively. Pathological study of the resected specimens revealed co-existence of pancreatic gastrinoma with duodenal gastrinoma in 2 of 16 patients （13%）, and G cell hyperplasia and/or microgastrinoma in the duodenal Brunner＇s gland was revealed in all of 7 duodenal specimens after PPTD. CONCLUSION： Aggressive resection surgery based on accurate localization with the SASI test was useful for biochemical cure of gastrinoma in patients with MEN 1.Imamura Metal. Curative resection of gastrinoma in MEN-1

Treatment of Zollinger-Ellison Syndrome

In this article, we have reviewed the main therapeutic measures for the treatment of Zollinger-Ellison syndrome （ZES）. Review of the literature was based on computer searches （Pub-Med, Index Medicus） and personal experiences. We have evaluated all the measures now available for treating patients with sporadic gastrinomas or gastrinomas associated with Multiple Endocrine Neoplasia Type 1, （MEN 1） including medical therapy such as antisecretory drugs and somatostatin analogs （SST）, chemotherapy and chemoembolization, and surgical procedures. In ZES patients, the best therapeutic procedure is surgery which, if radical, can be curative. Medical treatment can be the best palliative therapy and should be used, when possible, in association with surgery, in a multimodal therapeutic approach.

胃造口缝合法腹腔镜下胃后壁间质瘤切除术

目前，腹腔镜治疗胃间质瘤（gastrointestinal stromal tumors，GIST）手术方式主要有3种，即腹腔镜胃腔外手术、腹腔镜胃镜联合胃腔内手术和腹腔镜经胃前壁造口手术。我院2006年10月至2008年7月．共施行胃造口缝合法腹腔镜下胃后壁间质瘤切除术12例，效果满意。现报道如下。

The role of visceral adipose tissue on improvement in insulin sensitivity following Roux-en-Y gastric bypass:a study in Chinese diabetic patients with mild and central obesity

Background:Most Chinese patients with type 2 diabetes mellitus(T2DM)have mild obesity and central obesity.Central obesity is combined with insulin resistance.The aim of this study was to assess the effect of abdominal adipose tissue on insulin-sensitivity improvement after Roux-en-Y gastric bypass(RYGB)in Chinese diabetic patients with mild and central obesity.Methods:Seventeen T2DM patients with a mean body mass index of 30.3 kg/m^(2) were scheduled for laparoscopic RYGB.A hyperinsulinemic-euglycemic clamp and dual-energy X-ray absorptiometry were performed prior to surgery and 3 months after RYGB.The primary end points were the correlations between insulin sensitivity and abdominal adipose tissue,including visceral adipose tissue(VAT)and subcutaneous adipose tissue(SAT),before and 3 months after RYGB.Results:Indices of peripheral insulin sensitivity,including glucose-disposal rate(M value)and glucose infusion rate,were significantly increased after RYGB.Body-fat mass,VAT and SAT were significantly reduced after RYGB.The pre-operative M value was significantly correlated with VAT mass(r=–0.57,P=0.02),but not correlated with SAT mass.M value changes after RYGB were highly correlated with changes in VAT mass(r=–0.59,P=0.01),percentage of VAT mass(r=–0.66,P<0.01),VAT area(r=–0.56,P=0.02)and percentage of VAT area(r=–0.57,P=0.02).Conclusions:A significant correlation was observed between increased peripheral insulin sensitivity and decreased VAT following RYGB in Chinese patients with mild and central obesity.VAT and SAT were significantly decreased with improved insulin sensitivity after RYGB.VAT mass may be considered as an indication for gastric bypass during patient selection.