Clinical characteristics and risk factors of post-operative intestinal flora disorder following laparoscopic colonic surgery:A propensityscore-matching analysis

BACKGROUND Intestinal flora disorder(IFD)poses a significant challenge after laparoscopic colonic surgery,and no standard criteria exists for its diagnosis and treatment.AIM To analyze the clinical features and risk factors of IFD.METHODS Patients with colon cancer receiving laparoscopic surgery were included using propensity-score-matching(PSM)methods.Based on the occurrence of IFD,patients were categorized into IFD and non-IFD groups.The clinical characteristics and treatment approaches for patients with IFD were analyzed.Multivariate regression analysis was performed to identify the risk factors of IFD.RESULTS The IFD incidence after laparoscopic surgery was 9.0%(97 of 1073 patients).After PSM,97 and 194 patients were identified in the IFD and non-IFD groups,respectively.The most common symptoms of IFD were diarrhea and abdominal,typically occurring on post-operative days 3 and 4.All patients were managed conservatively,including modulation of the intestinal flora(90.7%),oral/intravenous application of vancomycin(74.2%),and insertion of a gastric/ileus tube for decompression(23.7%).Multivariate regression analysis identified that preoperative intestinal obstruction[odds ratio(OR)=2.79,95%CI:1.04–7.47,P=0.041]and post-operative antibiotics(OR=8.57,95%CI:3.31–23.49,P<0.001)were independent risk factors for IFD,whereas pre-operative parenteral nutrition(OR=0.12,95%CI:0.06–0.26,P<0.001)emerged as a protective factor.CONCLUSION A stepwise approach of probiotics,vancomycin,and decompression could be an alternative treatment for IFD.Special attention is warranted post-operatively for patients with pre-operative obstruction or early use of antibiotics.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma(GC)is a rare type of cancer of the digestive system,with an incidence that varies by region.Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure.Compared with traditional open surgery,laparoscopic surgery has the advantages of convenient operation and magnified field of view.Laparoscopic surgery has been successful in many fields,including gastrointestinal medicine and gynecology.The gallbladder was one of the first organs to be treated by laparoscopic surgery,and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases.However,the safety and feasibility of laparoscopic surgery for patients with GC remain controversial.Over the past several decades,research has focused on laparoscopic surgery for GC.The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation,possible port site metastasis,and potential tumor seeding.The advantages of laparoscopic surgery include less intraoperative blood loss,shorter postoperative hospital stay,and fewer complications.Nevertheless,studies have provided contrasting conclusions over time.In general,recent research has tended to support laparoscopic surgery.However,the application of laparoscopic surgery in GC is still in the exploratory stage.Here,we provide an overview of previous studies,with the aim of introducing the application of laparoscopy in GC.

Laparoscopic spleen-preserving total pancreatectomy for the treatment of low-grade malignant pancreatic tumors:Two case reports and review of literature

BACKGROUND Function-preserving pancreatectomy can improve the long-term quality of life of patients with benign or low-grade malignant tumors,such as intraductal papillary mucinous neoplasms(IPMNs)and mucinous cystic neoplasms.However,there is limited literature on laparoscopic spleen-preserving total pancreatectomy(LSpTP)due to technical difficulties.CASE SUMMARY Patient 1 was a 51-year-old male diagnosed with IPMN based on preoperative imaging,showing solid nodules in the pancreatic head and diffuse dilation of the main pancreatic duct with atrophy of the distal pancreas.We performed L-SpTP with preservation of the splenic vessels,and the postoperative pathology report revealed IPMN with invasive carcinoma.Patient 2 was a 60-year-old male with multiple cystic lesions in the pancreatic head and body.L-SpTP was performed,and intraoperatively,the splenic vein was injured and required ligation.Postoperative pathology revealed a mucinous cystic tumor of the pancreas with low-grade dysplasia.Both patients were discharged on postoperative day 7,and there were no major complications during the perioperative period.CONCLUSION We believe that L-SpTP is a safe and feasible treatment for low-grade malignant pancreatic tumors,but more case studies are needed to evaluate its safety,efficacy,and long-term outcomes.

Extrathyroidal Implantation of Thyroid Hyperplastic/neoplastic Cells after Endoscopic Thyroid Surgery

Objective To report a case of the implantation of thyroid hyperplastic or neoplastic tissue after endoscopic thyroidectomy and discuss this complication in aspects of prevalence, pathogenesis, protection, and therapies. Methods A systematic search of literature from the PubMed database was conducted for identifying eligible studies on implantation of thyroid hyperplastic or neoplastic cells after endoscopic thyroid surgery. Results Overall, 5 reported cases on patients suffering from endoscopic thyroid surgery with implantation of thyroid hyperplastic or neoplastic cells were included in the systematic review. Conclusions Unskilled surgeons, rough intraoperative surgical treatment, scarification or rupture of tumor, contamination of instruments, chimney effect, aerosolization of tumor cells may be associated with the implantation after endoscopic thyroidectomy. To minimize the risk of such complication, we should be more meticulous and strict the endoscopic surgery indications.

Resection of multiple rectal carcinoids with transanal endoscopic microsurgery:Case report

Multiple rectal carcinoids are rare.Due to the unreliability of endoscopic polypectomy in treating these submucosal lesions,a laparotomy is usually performed.We present a case report on multiple rectal carcinoids with three carcinoid foci<10 mm in diameter located in the midrectum.Preoperative examination showed the lesions to be confined to the submucosal layer with no perirectal nodal involvement.A transanal endoscopic microsurgerywas successfully performed to remove the three lesions with accurate full-thickness resection followed by secured suture closure.The postoperative pathology revealed neuroendocrine tumors G1(carcinoids)located within the submucosal layer without lymphatic or vessel infiltration.Both the deep and lateral surgical margins were completely free of tumor cells.The patient recovered quickly and uneventfully.No tumor recurrence was observed at the six-month follow-up.For the multiple small rectal carcinoids without muscularis propria or lymphatic invasion,transanal endoscopic microsurgery offers a reliable and efficient alternative approach to traditional laparotomy for select patients,with the added advantages of minimally invasive surgery.

Current status of minimally invasive surgery for pancreatic cancer

Pancreatic cancer(PC)is the most lethal cancer among digestive system cancers.Although the only way to radically cure PC is surgical resection,complex surgical procedures and severe post-operative complications lead to high mortality.In recent years,minimally invasive surgery has become more common for PC.Minimally invasive pancreatic resection(MIPR)with the laparoscopic or robotic method has shown its superiority compared with traditional surgery.However,increasing evidence indicates that the long-term or even short-term outcomes of MIPR for PC patients remain controversial.Moreover,the indications and learning curve of MIPR require further assessment.This review aims to discuss the progress in current MIPR,analyze the specific problems and obstacles in the development of MIPR,and try to standardize MIPR procedures and improve the outcomes of MIPR.

Epidemiology of pancreatic cancer:New version,new vision

Pancreatic cancer(PC)is a devastating malignancy with an extremely high mortality rate and poses significant challenges to healthcare systems worldwide.The prevalence of PC risk factors spiked over the years,leading to a global increase in PC incidence rates.The contribution of different risk factors,however,varied from region to region due to genetic predisposition,environmental,social,and political factors underlying disease prevalence in addition to public health strategies.This comprehensive review aims to provide a thorough analysis of the epidemiology of PC,discussing its incidence,risk factors,screening strategies and socioeconomic burden.We compiled a wide range of seminal studies as well as epidemiological investigations to serve this review as a comprehensive guide for researchers,healthcare professionals,and policymakers keen for a more profound understanding of PC epidemiology.This review highlights the essentiality of persistent research efforts,interdisciplinary collaboration,and public health initiatives to address the expanding burden of this malignancy.

Comprehensive treatment of deep frostbite of multiple fingers after trauma:A case report

BACKGROUND Frostbite is becoming increasingly common in urban environments,and severe cases can lead to tissue loss.The treatment goal is to preserve tissue and function;the sooner appropriate treatment is administered,the more tissue can be saved.However,not every patient with deep frostbite seeks medical care promptly.CASE SUMMARY We report the case of a 73-year-old male patient who was lost in the wilderness for 2 d due to trauma and confusion.He experienced deep frostbite on multiple fingers.Treatment should not be discontinued for patients with deep frostbite who present after the optimum treatment timing.Bullae that no longer form(bloody)blisters within 24 h of aspiration should be removed.Mucopolysaccharide polysulfate cream has clinical value in frostbite treatment.The patient was transferred to Chinese Academy of Medical Sciences and Peking Union Medical College Hospital 12 h after being rescued.The patient had contraindications for thrombolysis,the most effective treatment,due to intracranial hemorrhage and presenting past the optimum treatment timing.We devised a comprehensive treatment plan,which involved delayed use vasodilators and high-pressure oxygen therapy at day 49 post-injury.We experimented with mucopolysaccharide polysulfate cream to treat the frostbite.The aim of the treatment was to safeguard as much tissue as possible.In the end,the fingers that suffered from frostbite were able to be partially preserved.CONCLUSION The case indicated that patients with severe frostbite who missed the optimal treatment time and had contraindications for thrombolysis could still partially preserve the affected limbs through comprehensive treatment.

Percutaneous transhepatic stenting for acute superior mesenteric vein stenosis after pancreaticoduodenectomy with portal vein reconstruction:A case report

BACKGROUND Percutaneous transhepatic stent placement has become a common strategy for the postoperative treatment of portal vein(PV)/superior mesenteric veins(SMV)stenosis/occlusion.It has been widely used after liver transplantation surgery;however,reports on stent placement for acute PV/SMV stenosis after pancreatic surgery within postoperative 3 d are rare.CASE SUMMARY Herein,we reported a case of intestinal edema and SMV stenosis 2 d after pancreatic surgery.The patient was successfully treated using stent grafts.Although the stenosis resolved after stent placement,complications,including bleeding,pancreatic fistula,bile leakage,and infection,made the treatment highly challenging.The use of anticoagulants was adjusted multiple times to prevent venous thromboembolism and the risk of bleeding.After careful treatment,the patient stabilized,and stent placement effectively managed postoperative PV/SMV stenosis.CONCLUSION Stent placement is effective and feasible for treating acute PV/SMV stenosis after pancreatic surgery even within postoperative 3 d.

Factors associated with early recurrence after curative surgery for gastric cancer

AIM: To characterize patterns of gastric cancer recurrence and patient survival and to identify predictors of early recurrence after surgery.METHODS: Clinicopathological data for 417 consecutive patients who underwent curative resection for gastric cancer were retrospectively analyzed. Tumor and node status was reclassified according to the 7th edition of the American Joint Committee on Cancer tumor-node-metastasis classification for carcinoma of the stomach. Survival data came from both the patients' follow-up records and telephone followups.Recurrent gastric cancer was diagnosed based on clinical imaging, gastroscopy with biopsy, and/or cytological examination of ascites, or intraoperative findings in patients who underwent reoperation.Predictors of early recurrence were compared in patients with pT1 and pT2-4a stage tumors. Pearson's χ 2 test and Fisher's exact test were used to compare differences between categorical variables. Survival curves were constructed using the Kaplan-Meier method and compared via the log-rank test. Variables identified as potentially important for early recurrence using univariate analysis were determined by multivariate logistic regression analysis.RESULTS: Of 417 gastric cancer patients, 80(19.2%)were diagnosed with early gastric cancer and the remaining 337(80.8%) were diagnosed with locally advanced gastric cancer. After a median follow-up period of 56 mo, 194 patients(46.5%) experiencedrecurrence. The mean time from curative surgery to recurrence in these 194 patients was 24 ± 18 mo(range, 1-84 mo). Additionally, of these 194 patients,129(66.5%) experienced recurrence within 2 years after surgery. There was no significant difference in recurrence patterns between early and late recurrence(P < 0.05 each). For pT1 stage gastric cancer, tumor size(P = 0.011) and pN stage(P = 0.048) were associated with early recurrence of gastric tumors.Patient age, pT stage, pN stage, Lauren histotype,lymphovascular invasion, intraoperative chemotherapy,and postoperative chemotherapy were independent predictors of early recurrence in patients with pT2-4a stage gastric cancer(P < 0.05 each).CONCLUSION: Age, pT stage, pN stage, Lauren histotype, lymphovascular invasion, intraoperative chemotherapy, and postoperative chemotherapy are independent factors influencing early recurrence of pT2-4a stage gastric cancer.

Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors

AIM:To assess the feasibility,safety,and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery(LECS)for gastric submucosal tumors(SMT).METHODS:We retrospectively analyzed 101 consecutive patients,who had undergone partial,proximal,or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006to April 2013.All patients were followed up by visit or telephone.Clinical data,surgical approach,pathological features such as the size,location,and pathological type of each tumor;and follow-up results were analyzed.The feasibility,safety and effectiveness of LECS for gastric SMT were evaluated,especially for patients with tumors located near the cardia or pylorus.RESULTS:The 101 patients included 43(42.6%)menand 58(57.4%)women,with mean age of 51.2±13.1 years(range,14-76 years).The most common symptom was belching.Almost all(n=97)patients underwent surgery with preservation of the cardia and pylorus,with the other four patients undergoing proximal or distal gastrectomy.The mean distance from the lesion to the cardia or pylorus was 3.4±1.3 cm,and the minimum distance from the tumor edge to the cardia was 1.5 cm.Tumor pathology included gastrointestinal stromal tumor in 78 patients,leiomyoma in 13,carcinoid tumors in three,ectopic pancreas in three,lipoma in two,glomus tumor in one,and inflammatory pseudotumor in one.Tumor size ranged from 1 to8.2 cm,with 65(64.4%)lesions<2 cm,32(31.7%)>2 cm,and four>5 cm.Sixty-six lesions(65.3%)were located in the fundus,21(20.8%)in the body,10(9.9%)in the antrum,three(3.0%)in the cardia,and one(1.0%)in the pylorus.During a median follow-up of 28 mo(range,1-69 mo),none of these patients experienced recurrence or metastasis.The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.CONCLUSION:Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor.Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.

Prognostic impact of the red cell distribution width in esophageal cancer patients: A systematic review and meta-analysis

AIM To clarify the previous discrepant conclusions, we performed a meta-analysis to evaluate the prognostic value of red cell distribution width(RDW) in esophageal cancer(EC). METHODS We searched the PubM ed, EMBASE, Web of Science and Cochrane Library databases to identify clinical studies, followed by using STATA version 12.0 for statistical analysis. Studies that met the following criteria were considered eligible:(1) Studies including EC patients who underwent radical esophagectomy;(2) studies including patients with localized disease without distant metastasis;(3) studies including patients without preoperative neoadjuvant therapy;(4) studies including patients without previous antiinflammatory therapies and with available preoperative laboratory outcomes;(5) studies reporting association between the preoperative RDW and overall survival(OS)/disease-free survival(DFS)/cancer-specific survival(CSS); and(6) studies published in English.RESULTS A total of six articles, published between 2015 and 2017, fulfilled the selection criteria in the end. Statistical analysis showed that RDW was not associated with the prognosis of EC patients, irrespective of OS/CSS [hazard ratio(HR) = 1.27, 95% confidence interval(CI): 0.97-1.57, P = 0.000] or DFS(HR = 1.42, 95%CI: 0.96-1.88, P = 0.000). Subgroup analysis indicated that elevated RDW was significantly associated with worse OS/CSS of EC patients when RDW > 13%(HR = 1.45, 95%CI: 1.13-1.76, P = 0.000), when the patient number ≤ 400(HR = 1.45, 95%CI: 1.13-1.76, P = 0.000) and when the study type was retrospective(HR = 1.42, 95%CI : 1.16-1.69, P = 0.000).CONCLUSION Contrary to our general understanding, this meta-analysis revealed that RDW cannot serve as an indicator of poor prognosis in patients with EC. However, it may still be a useful predictor of unfavorable prognosis using an appropriate cut-off value.

Effect of Neoadjuvant Chemotherapy Treatment on Prognosis of Patients with Advanced Gastric Cancer:a Retrospective Study

Objective To evaluate the prognostic effects of neoadjuvant chemotherapy(NAC) in patients with local advanced gastric cancer. Methods We retrospectively analyzed prognosis in 191 patients with advanced gastric cancer, of whom 71 were treated with NAC and 120 received surgery only between February 2007 and July 2013. Postoperative complication rate was recorded. Survival by clinicopathological features, pathological T and N stages, and histopathological tumor regression was retrospectively compared between the two groups. Results According to Response Evaluation Criteria in Solid Tumors, none of the 71 patients in the NAC followed by surgery group showed complete response, 36 showed partial response, 25 had stable disease, and 10 had progressive disease. The chemotherapy response rate was 50.7%; the disease control rate was 85.9%. Grade 3/4 adverse events were seen in less than 20% patients, with acceptable toxicities. No difference was found in the overall postoperative complication rates between the two groups(7 versus 22 cases, P=0.18). Median survival time was significantly different, at 54 months in the NAC combined with surgery group and 25 months in the surgery-only group(P=0.025). Conclusion In patients with operable gastric adenocarcinomas, NAC can significantly improve overall survival without increasing surgical complications.

Risk factors of poor prognosis and portal vein tumor thrombosis after curative resection of solitary hepatocellular carcinoma

BACKGROUND:Predictors of poor prognosis of solitary hepatocellular carcinoma(SHCC),a subgroup encompassing most patients with the malignancy,are still controversial.Hence,risk factors for portal vein tumor thrombosis(PVTT) in SHCC are obscure.The present study was designed to address this issue.METHOD:Clinicopathological and follow-up data for 156 consecutive patients with SHCC following curative hepatic resection were analyzed using uni-and multi-variate analyses.RESULTS:Univariate analysis showed that PVTT,tumornode-metastasis(TNM) stage,Edmondson-Steiner grade and preoperative serum alpha-fetoprotein(AFP) level were associated with the overall and disease-free survival,whereas tumor size only influenced the overall survival.In multivariate Cox regression tests,Edmondson-Steiner grade and TNM stage were independent prognostic markers for both overall and diseasefree survival.In addition,the Chi-square test showed that AFP level and Edmondson-Steiner grade were correlated with PVTT.Among them,only Edmondson-Steiner grade was shown to be of independent significance for PVTT in multi-variate logistic regression analysis.Additionally,AFP,the sole preoperative factor for PVTT,was not adequately sensitive and specific.CONCLUSIONS:Factors relating to post-surgical prognosis and PVTT in SHCC are all tumor-related.Of these,EdmondsonSteiner grade and TNM stage might be of particular importance in survival analysis.In addition,accurate prediction of PVTT by clinicopathological parameters before surgery remains difficult.

Comparison of short-and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors

AIM To compare the short-and long-term outcomes of laparoscopic(LR) vs open resection(OR) for gastric gastrointestinal stromal tumors(g GISTs).METHODS In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed g GISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled(122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.RESULTS After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. TheLR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay(P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups(P > 0.05). No significant difference was found in postoperative adjuvant therapy(P = 0.587). The mean follow-up time was 35.30 ± 26.02(range, 4-102) mo in the LR group and 40.99 ± 25.07(range, 4-122) mo in the OR group with no significant difference(P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups(P > 0.05).CONCLUSION Laparoscopic surgery for g GISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising longterm oncological outcomes.

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.

Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital

Objective To retrospectively evaluate the diagnosis and treatment of Mirizzi syndrome(MS).Methods Patients who received elective or emergency cholecystectomies in our center during 23 years were retrospectively evaluated.The data reviewed included demography,clinical presentations,diagnostic methods,surgical procedures,postoperative complications,and follow-up.Results There were 27 patients diagnosed with MS among 8697 cholecystectomies performed during that period.The preoperative diagnostic modalities included ultrasonography,computed tomography,magnetic resonance cholangiopancreatography,and endoscopic retrograde cholangiopancreatography.The incidence of MS Type I(12/27,44.4%)had the dominance in the four types,the incidence of MS Type II and III were 33.3%(9/27)and 22.2%(6/27),and there were no MS Type IV patients.Laparoscopic cholecystectomy was performed in 15(55.6%)patients,but only 3(11.1%)patients with MS Type I had a successful surgery,and the other 12 were converted to open cholecystectomy.The remaining 12 patients directly underwent open cholecystectomy.The surgical procedures except laparoscopic cholecystectomy included simply open cholecystectomy(including laparoscopic cholecystectomy converted to open cholecystectomy)(6/27,22.2%),open cholecystectomy,T-tube placement with choledochotomy(9/27,33.3%),open cholecystectomy,closure of the fistula with gallbladder cuff,T-tube placement(3/27,11.1%),and open cholecystectomy with excision of the external bile ducts,and Roux-en-Y hepatico-jejunostomy(6/27,22.2%).Of them,88.9%(24/27)patients recovered uneventfully and were discharged in good condition without any operation related mortality.Conclusions Endoscopic retrograde cholangiopancreatography is a good method with diagnostic and therapeutic purposes.Total or partial cholecystectomy is generally adequate for MS Type I.For MS Type II-IV,paritial cholecystectomy,choledochoplasty,or if impossible,Roux-en-Y hepatico-jejunostomy may be performed.Laparoscopic cholecystectomy may be successful in selected preoperatively diagnosed MS Type I patients,and open cholecystectomy is the standard therapeutic method.

Surgical management of Zollinger-Ellison syndrome: Classical considerations and current controversies

Zollinger-Ellison syndrome(ZES)is characterized by gastric acid hypersecretion causing severe recurrent acid-related peptic disease.Excessive secretion of gastrin can now be effectively controlled with powerful proton pump inhibitors,but surgical management to control gastrinoma itself remains controversial.Based on a thorough literature review,we design a surgical algorithm for ZES and list some significant consensus findings and recommendations:(1)For sporadic ZES,surgery should be routinely undertaken as early as possible not only for patients with a precisely localized diagnosis but also for those with negative imaging findings.The surgical approach for sporadic ZES depends on the lesion location(including the duodenum,pancreas,lymph nodes,hepatobiliary tract,stomach,and some extremely rare sites such as the ovaries,heart,omentum,and jejunum).Intraoperative liver exploration and lymphadenectomy should be routinely performed;(2)For multiple endocrine neoplasia type 1-related ZES(MEN1/ZES),surgery should not be performed routinely except for lesions>2 cm.An attempt to perform radical resection(pancreaticoduodenectomy followed by lymphadenectomy)can be made.The ameliorating effect of parathyroid surgery should be considered,and parathyroidectomy should be performed first before any abdominal surgery for ZES;and(3)For hepatic metastatic disease,hepatic resection should be routinely performed.Currently,liver transplantation is still considered an investigational therapeutic approach for ZES.Well-designed prospective studies are desperately needed to further verify and modify the current considerations.

EFFECTS OF ENTERAL AND PARENTERAL NUTRITION ON GASTROENTERIC HORMONES AND GASTRIC MOTILITY AFTER SUBTOTAL GASTRECTOMY

Objective To investigate the effects of enteral nutrition(EN)and parenteral nutrition(PN)on gastric motility and gastroenteric hormones after subtotal gastrectomy.Methods Forty-one patients underwent gastrectomy were randomly divided into EN group(n=20)and PN group(n=21).From the first postoperative day to the seventh day,patients received either EN(EN group)or PN(PN group)with isocaloric(84.9 kJ·kg-1·d-1)and isonitrogenous(0.11 g·kg-1·d-1)intake.Serum gastrin(GAS),plasma motilin(MTL),and plasma cholecystokinin(CCK)were measured on preoperative day,the first and seventh postoperative day.Electrogastrography(EGG)was measured on preoperative day and the seventh postoperative day.Results Compared with preoperation,blood GAS,MTL,and CCK levels of 41 patients decreased significantly on the first day after subtotal gastrectomy(P<0.001),but returned to the preoperative levels one week later.EGG after gastrectomy showed that gastric basal electrical rhythm was significantly restrained(P<0.001).On the seventh day after subtotal gastrectomy,plasma MTL and CCK levels in EN group were higher than those in PN group(P<0.05).There was no difference in GAS level between two groups.EGG in EN group was better than that in PN group postoperatively.Conclusions The levels of gastroenteritic hormones and the gastric motility decrease significantly after subtotal gastrectomy.In contrast with PN,EN can accelerate the recovery of MTL,CCK,and gastric motility after subtotal gastrectomy.

Diagnostic accuracy of K-ras mutation for pancreatic carcinoma:a meta-analysis

BACKGROUND:The conventional tests for the diagnosis of early stage pancreatic carcinoma are not acceptable.This metaanalysis is to evaluate the accuracy of K-ras mutation for the diagnosis of pancreatic carcinoma.DATA SOURCES:A systemic search of all relevant literature was performed in Web of Science,EMBASE,Cochrane Database,and MEDLINE(PubMed as the search engine) prior to June 1,2011.Thirty-four studies fulfilled the inclusion criteria and data were pooled for analysis.RESULTS:The pooled estimates for K-ras mutation in diagnosis of pancreatic carcinoma were as follows:sensitivity 0.68(95% CI:0.66-0.71),specificity 0.87(95% CI:0.85-0.88),positive likelihood ratio 4.54(95% CI:3.47-5.94),negative likelihood ratio 0.37(95% CI:0.30-0.44) and diagnostic odds ratio 14.90(95% CI:10.02-22.15).Summary receiver operating characteristic analysis demonstrated that the maximum joint sensitivity and specificity was 0.79,and the overall area under the curve was 0.86.CONCLUSIONS:Diagnostic accuracy of K-ras mutation was not superior to that of conventional tests.Therefore,K-ras mutation analysis alone is not recommended for the diagnosis of pancreatic carcinoma.