Exploration and optimization of surgical techniques for laparoscopic transhiatal lower mediastinal lymph node dissection for adenocarcinoma of esophagogastric junction: A prospective IDEAL 2a study with qualitative design

Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction （AEGs） have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

Junctional Pacemaker May Replace the Sinoatrial Node

Junctional rhythm is usually seen in the clinic with different causes.We report a case of bicuspid aortic valve accompa-nied by sinoatrial node dysfunction.The junctional escape beat could accelerate with physiological needs and provided for the normal needs of daily life when dysfunction of the sinoatrial node occurred,which provides a new way for the treatment of sinoatrial node dysfunction.Our fi ndings could be potentially signifi cant for identifying causes and choos-ing appropriate treatment strategies by using ECG monitoring in the clinic in the future.

围术期应用华蟾素对食管胃结合部腺癌患者行纳米碳淋巴结示踪根治术预后及HKDC1、ANXA13蛋白表达的影响

目的:围术期应用华蟾素对食管胃结合部腺癌患者行纳米碳淋巴结示踪根治术预后及HKDC1、ANXA13蛋白表达的影响。方法:选取2018年1月—2020年12月在浙江中医药大学附属江南医院和延安大学附属医院接受食管胃结合部根治术治疗的80例患者,依据治疗手段的不同分为纳米组和蟾蜍素组,每组40例。纳米组患者给予切除术+纳米碳示踪淋巴结清扫术治疗,蟾蜍素组围术期应用华蟾素注射液结合切除术+纳米碳示踪淋巴结清扫术治疗。比较两组患者淋巴结检出数、肿瘤标志物水平、凝血功能、术后病理分期及HKDC1、ANXA13蛋白表达情况。结果:蟾蜍素组患者总淋巴结数、靶区淋巴数、周围淋巴数均低于纳米组(P<0.05)。蟾蜍素组糖类抗原19-9(CA19-9)、癌胚抗原(CEA)、糖类抗原125(CA125)、神经元特异性烯醇化酶(NSE)水平均低于纳米组(P<0.05)。蟾蜍素组凝血功能优于纳米组(P<0.05)。与治疗前比,治疗后两组患者胰岛素样生长因子结合蛋白(IGFBP)-3均升高,circAGFG1降低,且蟾蜍素组改善幅度更大(P<0.05)。术后T分期方面,蟾蜍素组pT0~2期18例,pT3~4期22例;纳米组pT0~2期1例,pT3~4期39例,两组比较存在明显差异(χ^(2)=19.948,P<0.001),术后N分期无明显差异(P>0.05);蟾蜍素组和纳米组的HKDC1阳性表达率分别为42.5%(19/40)、70.0%(28/40),蟾蜍素组低于纳米组(χ^(2)=4.718,P=0.040);两组ANXA13的阳性表达率无明显差异(P>0.05)。结论:华蟾素可在不影响其他各项手术指标的情况下有效提高食管胃结合部腺癌患者给予纳米碳淋巴结示踪技术联合根治术的淋巴结清扫数,降低肿瘤标志物水平和HKDC1蛋白阳性表达率,改善患者凝血功能,降低分期作用明显,可提高手术质量。

Optimal treatment for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction: A retrospective cohort study with long-term follow-up

AIM To determine the optimal treatment strategy for Siewert type Ⅱ and?Ⅲ?adenocarcinoma of the esophagogastric junction.METHODS We retrospectively reviewed the medical records of 83 patients with Siewert type?Ⅱ?and?Ⅲ?adenocarcinoma of the esophagogastric junction and calculated both an index of estimated benefit from lymph node dissection for each lymph node(LN) station and a lymph node ratio(LNR: ratio of number of positive lymph nodes to the total number of dissected lymph nodes). We used Cox proportional hazard models to clarify independent poor prognostic factors. The median duration of observation was 73 mo.RESULTS Indices of estimated benefit from LN dissection were as follows, in descending order: lymph nodes(LN) along the lesser curvature, 26.5; right paracardial LN, 22.8; left paracardial LN, 11.6; LN along the left gastric artery, 10.6. The 5-year overall survival(OS) rate was 58%. Cox regression analysis revealed that vigorous venous invasion(v2, v3)(HR = 5.99; 95%CI: 1.71-24.90) and LNR of > 0.16(HR = 4.29, 95%CI: 1.79-10.89) were independent poor prognostic factors for OS.CONCLUSION LN along the lesser curvature, right and left paracardial LN, and LN along the left gastric artery should be dissected in patients with Siewert type?Ⅱ?or?Ⅲ?adenoca rcinoma of the esophagogastric junction. Patients with vigorous venous invasion and LNR of > 0.16 should be treated with aggressive adjuvant chemotherapy to improve survival outcomes.

Current surgical treatment of esophagogastric junction adenocarcinoma

The incidence of esophagogastric junction(EGJ)adenocarcinoma has shown an upward trend over the past several decades worldwide.In this article,we review previous studies and aimed to provide an update on the factors related to the surgical treatment of EGJ adenocarcinoma.The Siewert classification has implications for lymph node spread and is the most commonly used classification.Different types of EGJ cancer have different incidences of mediastinal and abdominal lymph node metastases,and different surgical approaches have unique advantages and disadvantages.Minimally invasive surgeries have been increasingly applied in clinical practice and show comparable oncologic outcomes.Endoscopic resection may be a good therapy for early EGJ cancer.Additionally,there is still a great need for well-designed,large RCTs to forward our knowledge on the surgical treatment of EGJ cancer.

Adenocarcinoma of esophagogastric junction:controversial classification,surgical management,and clinicopathology

In recent years the world is witnessing an increasing incidence of adenocarcinoma of esophagogastric junction （AEG）, which originates from epithelial tissue of esophagogastric junction （EGJ）, and mainly derives from Barrett＇s esophagus. It＇s now gaining more and more attention due to the controversial etiology, classification and treatment.

Laparoscopic vs.open lower mediastinal lymphadenectomy for Siewert typeⅡ/Ⅲadenocarcinoma of esophagogastric junction:An exploratory,observational,prospective,IDEAL stage2b cohort study(CLASS-10 study)

Objective:This study aims to verify the feasibility and efficacy of laparoscopic lower mediastinal lymphadenectomy for Siewert typeⅡ/Ⅲadenocarcinoma of esophagogastric junction(AEG).Setting:An exploratory,observational,prospective,cohort study will be carried out under the Idea,Development,Exploration,Assessment and Long-term Follow-up(IDEAL)framework(stage 2 b).Paritcipants:The study will recruit 1,036 patients with cases of locally advanced AEG(Siewert typeⅡ/Ⅲ,clinical stage cT2-4 aN0-3 M0),and 518 will be assigned to either the laparoscopy group or the open group.Interventions:Patients will receive lower mediastinal lymphadenectomy along with either total or proximal gastrectomy.Primary and secondary outcome measures:The primary endpoint is the number of lower mediastinal lymph nodes retrieved,and the secondary endpoints are the surgical safety and prognosis,including intraoperative and postoperative lower-mediastinal-lymphadenectomy-related morbidity and mortality,rate of rehospitalization,R0 resection rate,3-year local recurrence rate,and 3-year overall survival.Conclusions:The study will provide data for the guidance and development of surgical treatment strategies for AEG.Trial registration number:The study has been registered in ClinicalTrials.gov(No.NCT04443478).

Thoracoscopic esophagectomy is related to better outcomes in early adenocarcinoma of esophagogastric junction tumors

BACKGROUND Thoracoscopic esophagectomy is related to an extended lymphadenectomy,and a high number of retrieved lymph nodes,compared to the transhiatal approach;however,its association with an improvement in overall survival(OS)is debatable.AIM To compare thoracoscopic esophagectomy with transhiatal esophagectomy in patients with adenocarcinoma of the esophagogastric junction(AEGJ)in terms of survival,number of lymph nodes,and complications.METHODS In total,147 patients with AEGJ were selected retrospectively from 2002 to 2019,and divided into Group A for thoracoscopic esophagectomy,and group B for transhiatal esophagectomy.OS,disease-free survival,postoperative complications,and number of nodes,were similarly evaluated.RESULTS One hundred and thirty(88%)were male;the mean age was 64 years.Group A had a mean age of 61.1 years and group B 65.7 years(P=0.009).Concerning the extent of lymphadenectomy,group A showed a higher number of retrieved lymph nodes(mean of 31.89±8.2 vs 20.73±7;P<0.001),with more perioperative complications,such as hoarseness,surgical site infections,and respiratory complications.Although both groups had similar OS rates,subgroup analysis showed better survival of transthoracic esophagectomy in patients with earlier diseases.CONCLUSION Both methods are safe,having similar morbidity and mortality rates.Transthoracic thoracoscopic esophagectomy allows a more extensive resection of the lymph nodes and may have better oncological outcomes during earlier stages of the disease.Prospective studies are warranted to better evaluate these findings.

食管胃交界处肿瘤纵隔淋巴结转移发生率的Meta分析

目的探讨食管胃交界处肿瘤(EGJ)纵隔淋巴结转移发生率情况,为临床手术淋巴结清扫范围提供依据。方法按纳入和排除条件筛选文献,对EGJ肿瘤的纵隔淋巴结转移情况进行Meta分析,建立EGJ肿瘤纵隔淋巴结的转移图谱。结果检索文献608篇,筛选出10项文献,1714例患者入组,行纵隔淋巴结切除的1445例。EGJ上纵隔淋巴结转移率超过5.8%,中纵隔淋巴结转移率超过7.7%,下纵隔淋巴结转移率超过17.8%。纵隔淋巴结中转移发生率前3依次为110站(8.9%),106recR站(8.4%),109L站(6.6%)。转移发生率较低的是106tbL站(0)以及105站(2.8%)。结论EGJ患者第110站转移率最高,第106站淋巴结转移率次之。对于SiewertⅡ型患者,建议常规行第110站淋巴结清扫,选择性第106站淋巴结采样。

全球有缆海底观测网概述

近期有缆海底观测网发展迅猛,世界各国包括加拿大、美国、日本和欧洲国家都依据自己的科学目标,建立了相应的有缆海底观测网。文章针对不同国家有缆海底观测网系统的组成和建设分别做了概述和评论。从1978年开始到现在,日本成功建设了10条有缆海底地震观测网,从早期同轴电缆作为主干电缆,发展到使用光电缆连接水下设施。加拿大成功建成近岸尺度和区域尺度两条有缆海底观测网。美国2012年成功建成目前世界上最长的一条区域海底观测网(约900km)。欧洲国家也正在开展在10个海区建立有缆观测网。跟随国外的步伐,我国和我国台湾地区也建立了自己的海底观测站(东海小衢山)和有缆观测网(中国台湾妈祖)。文章依据世界上已经建立的有缆海底观测网,分析认为与全球有缆观测网布设有关的遥控水下机器人是关键技术,并探讨了海底观测网今后的发展和面临的挑战。

河网非恒定水沙数学模型研究

建立了能够适用于多种情况的河网非恒定流水沙数学模型。推导提出了河网泥沙方程组的分级解法,提出了适用于河网计算的汊点分沙模式,分析和对比了多种分沙模式的适用性,对河网区域中可蓄水汊点也提出了相应的处理办法。采用汉江杜家台分蓄洪区的资料作了模型的验证和应用。

家兔房室交界区及其心房传导通路的形态学研究

目的 :探讨射频消融改良房室交界区的形态学基础。方法 :健康成年家兔 10只 ,分别做房室交界区的额状面、矢状面及水平面连续切片 ,在HE、Masson及磷钨酸苏木素染色下观察其形态学特征。结果 :家兔房室结位于房室隔内中心纤维体的右侧 ,主要由P细胞和T细胞组成 ,以P细胞为主 ,其向后形成的延伸部同射频消融慢径的部位吻合 ,且细胞分布明显较房室结稀疏 ,内有胶原纤维分隔。同时有四条过渡细胞带分别从心房的不同部位到达房室结及后延伸部 ,分别称为左房结束、右房结束、后房结束及上房结束。另外 ,在冠状窦前壁有P细胞成团分布。结论 :①房室交界区的概念应当扩大 ,分布范围从房室隔内中心纤维体的右侧一直向后接近冠状窦口 ,前部可能为快传导区 ,后部可能为慢传导区。②房内传导通路确有存在 ,并且可能参与了房内折返性心律失常的形成。③冠状窦是一个重要的结外潜在起搏点 ,可能与某些房性自律性心律失常的发生有关。目的 :探讨射频消融改良房室交界区的形态学基础。方法 :健康成年家兔 10只 ,分别做房室交界区的额状面、矢状面及水平面连续切片 ,在HE、Masson及磷钨酸苏木素染色下观察其形态学特征。结果 :家兔房室结位于房室隔内中心纤维体的右侧 ,主要由P细胞和T细胞组成 ,以P细胞为主 。

淋巴结转移对胸段食管癌及食管胃交界部癌预后的影响

目的:分析胸段食管癌和食管胃交界部癌不同淋巴结转移状况及清扫范围对预后的影响。方法:随访资料完整的906例胸段食管癌及食管胃交界部癌患者,分析淋巴结转移及清扫范围对其预后的影响。结果:食管癌组:阳性淋巴结个数在0、1-3、>3个三个级别的预后差异显著(P<0.01);淋巴结转移度在0、>0-20%、>20%三个级别的3年、5年生存率差异显著(P=0.000);淋巴结胸腹部联合清扫、单纯胸部清扫、单纯腹部清扫的生存曲线无显著差异(P>0.05);隆突下淋巴结阴性的N1M0期、T2N1M0期、T3N1M0期胸段食管癌预后明显优于阳性组(P<0.01)。食管胃交界部癌组:N0期病例预后优于N1、N2、N3期病例(P<0.05);淋巴结转移度在0、>0-50%、>50%三个级别的生存曲线预后差异显著(P<0.05);胸腹部联合淋巴结清扫、单纯胸部清扫、单纯腹部清扫的生存曲线无显著差异(P>0.05)。结论:淋巴结转移数量、转移度、转移范围均是影响食管癌预后的重要因素。隆突下淋巴结转移影响食管癌的预后,应重视该区的清扫。淋巴结转移度是食管胃交界部癌预后的重要指标。食管癌、食管胃交界部癌淋巴结清扫不同范围的各组生存曲线无显著差异。

力竭运动对大鼠心脏窦房结、房室交界区组织结构及连接蛋白40的影响

目的:探讨一次力竭和反复力竭运动后大鼠心传导组织窦房结(SAN)、房室交界区(AJ)的组织结构及连接蛋白40(Connexin 40,Cx40)表达的时相性变化和规律。方法:健康成年雄性SD大鼠90只,分为一次力竭游泳组、反复力竭游泳组及安静对照组。游泳组分别于力竭后即刻、6小时、12小时、24小时取材。采用HE、Msson及免疫组织化学染色和图像分析法,观察大鼠SAN、AJ组织结构及其Cx40的表达。结果:一次力竭和反复力竭两种力竭运动后大鼠SAN、AJ组织出现缺血缺氧和胶原纤维增生等改变;Cx40在力竭运动后失去原有的规律分布,由胞膜转移至胞浆,Cx40积分光密度值有所降低,6小时时降低最为显著(P<0.01)。结论:一次力竭运动和反复力竭运动可导致心脏窦房结、房室交界区组织结构缺血缺氧性改变,Cx40不仅表达减少,其分布模式等缝隙连接结构功能也发生异常改变,是急性大强度运动后心律失常与心肌微损伤发生的重要机制。

淋巴结清扫数目对淋巴结转移阴性SiewertⅡ型食管胃交界部癌的影响

目的:无淋巴结转移的SiewertⅡ型食管胃交界部癌的淋巴结清扫数目对患者预后的影响。方法:选取食管胃交界部癌根治术患者224例。对年龄、性别、肿瘤直径、肿瘤浸润深度、肿瘤分化程度、淋巴结清扫数目等因素做单因素及多因素回归分析,分析淋巴结清扫数目与患者生存率关系。结果:对各因素运用Cox回归模型分析,肿瘤分化程度和淋巴结清扫数目有统计学差异(P<0.05)。相同分化程度患者生存率随淋巴结清扫数目的增加而升高,差异有统计学意义(P<0.05)。结论:应在术中尽可能的提高淋巴结的清扫个数,从而提高患者远期生存率。

食管-胃结合部腺癌淋巴管侵犯与相关病理学因素关系研究

目的:探讨食管-胃结合部腺癌淋巴管侵犯与相关病理学因素之间的关系。方法:对156例根治性手术切除的食管-胃结合部腺癌的病理资料进行分析,按照有无淋巴管侵犯分为两组(LV(I+)组89例,LV(I-)组67例),比较不同N分期、T分期、肿瘤大体类型、组织学类型、分化程度、肿瘤大小及淋巴结转移个数等情况下,淋巴管侵犯的发生情况(采用卡方检验,P<0.05差异具有统计学意义),并比较LV(I+)组与LV(I-)组肿瘤分化程度的差别(采用非参数Mann-WhitneyU检验)以及肿瘤大小和淋巴结转移个数的情况(采用两个独立样本的t检验,P<0.05差异具有统计学意义)。结果:1)LV(I-)组与LV(I+)组,LN(+)发生率分别为61.2%和95.5%,LV(I+)者淋巴结转移率高,差异具有统计学意义;LN(-)者与LN(+)者,LVI(+)发生率分别为13.3%和67.5%,LN(+)者发生淋巴管侵犯的几率较大,差异具有统计学意义。2)T1期均为LVI(-);T2及T3期LVI发生率无统计学差异;T4期LV(I+)者显著高于LVI(-)者。3)分化好组与分化差组的LVI发生率有统计学差异,分化差组中低分化腺癌LVI(+)明显高于LV(I-)。4)LV(I+)组平均肿瘤大小和平均淋巴结转移个数分别为(6.09+3.40)cm和(9.75+7.82)枚,LV(I-)组分别为(4.34+2.07)cm和(2.63+2.00)枚,两组间差异具有统计学意义。结论:食管-胃结合部腺癌的淋巴管侵犯发生与N分期、T分期、组织学类型、分化程度、肿瘤大小及淋巴结转移个数等多种病理学因素显著相关。

三种食管胃交界部癌手术入路比较

目的分析食管胃交界部癌手术三种入路方式的围手术期差异,为临床制定手术策略提供参考。方法回顾性分析144例食管胃交界部癌手术切除病例的临床资料,以手术入路方式分为经腹组(A组)96例,经上腹右胸组(B组)36例,经左胸组(C组)12例。主要分析手术时间、失血量、术后并发症发生率、肿瘤上切缘距肿瘤上缘长度、淋巴结清扫程度和平均住院时间等方面的差异。结果手术时间:A组[(196.9±53.3)min]<C组[(205.0±73.1)min]<B组[(309.2±65.9)min],上切缘距肿瘤上缘距离:A组[(3.19±0.49)cm]<B组[(4.60±0.61)cm]及C组[(4.47±0.68)cm],隆突淋巴结总数:A组(0个)<B组[(1.33±0.23)个]及C组[(1.00±0.0)个],隆突淋巴结转移程度:A组(0.0%)<B组(16.6%)及C组(16.7%),术后引流量:B组[(364.1±295.3)ml)]>C组[(165.0±141.0)ml]>A组[(162.8±119.2)ml],术后胸腔积液发生率:B组(22.2%)>A组(5.2%)及C组(8.3%),平均住院时间:B组[(24.1±3.9)d]>A组[(21.7±2.6)d]及C组[(22.7±3.3)d],差异均有统计学意义(P<0.05)。各组肿瘤长度、淋巴结清扫总数、淋巴结转移程度、吻合方法、术后肺部感染发生率、术后吻合口瘘发生率、术后呼吸肌支持时间、术后血浆白蛋白水平和术后乳糜胸或乳糜腹发生率等差异均无统计学意义(P>0.05)。结论虽然经上腹右胸联合手术增加了围手术期创伤及术后并发症,但与其他入路方式无实质性差异,而且能充分地进行清扫淋巴结,尤其是隆突部位以上的纵膈淋巴结,肿瘤学根治方面更适合于食管胃交界部肿瘤手术治疗。

ZD型减速器整体结构有限元模态分析

建立了某ZD型减速器主要零部件及整体结构的有限元模型,采用Lanczos法对减速器整体结构的自由模态进行了计算,通过计算找到了整体振动的薄弱部位,为减速器结构的改进设计及整体的动态响应分析提供了可靠的依据。

洪泛区河网非恒定水沙数学模型的研究

鉴于江河流域中下游地区交错复杂的河网体系 ,本文建立了适应性强的复杂河网区非恒定水沙数学模型。模型中采用汊点分组方法求解水流方程组 ;选用了与实际情况较为吻合的汊点分沙求解方法 ,建立了分洪口门修正模式 ,采用适合于复杂流动状态下泥沙方程组的求解方法。同时为了提高模拟精度和扩展模拟功能 ,对河网中蓄水汊点和分蓄洪区的水流运动模拟等环节提出了合理可行的数值处理方法 ,并提出了河网水沙运动模拟中进一步需要研究的问题。