Objective:To evaluate a transhiatal tunnel flap designed to reconstruct the cardiac functional structure in proximal gastric cancer patients in our center.Methods:A descriptive case study method was used to select the data of 11 patients undergoing surgery for upper gastric cancer from Jan to Jul 2024. After laparoscopic dissection is completed, the esophagus is transected 2 cm from the upper edge of the tumor and the specimen is removed. The distance from the lower edge of the tumor is 5 cm. The cutting width is 4 cm, and the length of sleeve distal stump stomach is 20 cm. A seromuscular flap tunnel was made with a length of 2 cm and a width of 2 cm, 2 cm away from the top of the remnant stomach. The digestive tract was reconstructed using the Overlap hybridization method.Results:The median operation time was 175 (139-285) minutes. The median muscle flap production time and reconstruction time was 10.5 (5.5-21.0) minutes and 15.0 (11.8-33.6) minutes, respectively. The median blood loss is 50 (20-100) ml. The median postoperative hospitalization was 8 (6-25) days. The median tumor size was 2.5 (1.0-4.0) cm, and 31 (15-52) lymph nodes were dissected. The median follow-up after surgery was 3.5 (0.7-6.0) months, and no tumor recurrence or metastasis was found. Postoperative anastomotic leakage (Clavien-Dindo grade Ⅱ) occurred in one case, and there was no perioperative death. The Visick score of the whole group was 1 point in 8 cases and 2 points in 3 cases, and there was no anastomotic stenosis. Reflux esophagitis (Los Angeles classification grade B) was found in 1 case after gastroscopy, and the symptoms were relieved by conservative treatment.Conclusion:The transhiatal tunnel flap arthroplasty method has high surgical safety, low reconstruction difficulty, and an reliable anti-reflux effect.

Objective:To investigate the treatment and prognosis of esophageal cancer patients with pulmonary resection history.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 58 esophageal cancer patients with pulmonary resection history who were admitted to Chest Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Jiangxi Provincial People's Hospital from May 2019 to April 2024 were collected. There were 52 males and 6 females, aged (69±3)years. Observation indicators: (1) surgical and postopera-tive conditions; (2) postoperative pathological examination results; (3) follow-up; (4) stratified analysis. Comparison of measurement data with normal distribution between groups was conducted using the independent sample t test. Comparison of count data between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data between groups was conducted using the non-parametric rank sum test. The Kaplan-Meier method was used to plot survival curve and calculate survival rate, and the Log-rank test was used for survival analysis. Results:(1) Surgical and postoperative conditions. Of the 58 esophageal cancer patients, 49 patients underwent transthoracic approach (26 cases of ipsilateral approach and 23 cases of contralateral approach of pulmonary resection history), and 9 patients underwent mediastinoscopic-laparoscopic approach. There were 57 cases with R 0 resection and 1 case with R 2 resection because of tumor invading carina. The total operation time of 58 patients was (246±27)minutes, and the volume of intraoperative blood loss was (114±29)mL. There was no unplanned reoperation or perioperative death for all patients. The duration of postoperative hospital stay of 58 patients was (10.4±4.6)days, and time for intensive care unit stay was (1.4±0.5)days, and no patient readmitted to intensive care unit due to changes in conditions. The postoperative total incidence of complications of 58 patients was 41.4%(24/58). The Clavien-Dindo grading of complications for all patients was 1-2 grade. (2) Postoperative pathological examination results. Results of postoperative pathological examination showed there were 51 cases of squamous cell carcinoma, 6 cases of adenocarcinoma, and 1 case of melanoma. Number of lymph node dissected of 58 patients was 27±6. The ratio of patient with positive lymph node was 37.9%(22/58). One patient may experience more than 1 region of positive lymph node metastasis. Results of postoperative pathological staging showed 5 cases of ⅠA stage, 2 cases of ⅠB stage, 13 cases of ⅡA stage, 15 cases of ⅡB stage, 4 cases of ⅢA stage, 16 cases of ⅢB stage, and 3 cases of ⅣA stage. Thirteen of the 58 patients underwent neoadjuvant therapy, with the pathological staging as 6 cases of Ⅰ stage, 4 cases of Ⅱ stage, 3 cases of ⅢB stage after therapy. Results of postoperative tumor regression grade for the 13 patients with neoadjuvant therapy showed 4 cases of grad 0, 3 cases of grade 1, 6 cases of grade 2. (3) Follow-up. All 58 patients were followed for 24 (4, 50)months, and no patient died within 90 days after surgery. During the follow-up period, 19 patients experienced tumor recurrence and metastasis and 17 patients died. Twenty-one patients underwent postoperative adjuvant therapy, including 7 cases with chemoradiotherapy, 7 cases with chemotherapy, 3 cases with chemotherapy and immunotherapy, 2 cases with immuno-therapy, 2 cases with radiotherapy. The postoperative 1-, 2-year overall survival rates of the 58 patients were 91.3%, 78.7%, respectively, of whom undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery with postoperative 1-, 2-year overall survival rates as 89.2%, 83.1% and 85.7%, 53.6%, respectively. The postoperative 1-, 2-year esophageal cancer specific survival rates for patients undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery were 94.4%, 87.9% and 85.7%, 71.4%, respectively. There was no significant difference in postoperative 1-, 2-year overall survival rates and postoperative 1-, 2-year esophageal cancer specific survival rates between patients undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery ( P>0.05). (4) Stratified analysis. Of the 49 patients underwent transthoracic approach for esophageal cancer, there were significant differences in surgical method, surgical type, time of chest surgery, cases with upper mediastinal lymph node dissection, and duration of postoperative hospital stay between patients with pulmonary resection history as ipsilateral approach and contralateral approach ( χ2=11.74, 11.68, t=-2.25, χ2=8.45, t=-2.17, P<0.05), and there was no significant difference in total operation time, volume of intraoperative blood loss, the number of lymph node dissected, post-operative total complications, and postoperative pathological TNM staging ( P>0.05). For patients with pulmonary resection history as ipsilateral approach and contralateral approach, the postopera-tive 1-, 2-year esophageal cancer specific survival rates were 95.5%, 95.5% and 81.4%, 71.1%, showing a significant difference between them ( χ2=5.63, P<0.05). Conclusions:The transthoracic approach and mediastinoscopic-laparoscopic approach are safe and feasible for esophageal cancer patients with pulmonary resection history. Compared with patients with pulmonary resection history as contralateral approach, patients with pulmonary resection history as ipsilateral approach have a higher ratio of McKeown surgery, minimally invasive surgery and upper mediastinal lymph node dissection, shorter time of chest surgery and duration of postoperative hospital stay, better esophageal cancer specific survival rate. And there is no increase in perioperative risk.

Objective:To investigate the treatment and prognosis of esophageal cancer patients with pulmonary resection history.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 58 esophageal cancer patients with pulmonary resection history who were admitted to Chest Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Jiangxi Provincial People's Hospital from May 2019 to April 2024 were collected. There were 52 males and 6 females, aged (69±3)years. Observation indicators: (1) surgical and postopera-tive conditions; (2) postoperative pathological examination results; (3) follow-up; (4) stratified analysis. Comparison of measurement data with normal distribution between groups was conducted using the independent sample t test. Comparison of count data between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data between groups was conducted using the non-parametric rank sum test. The Kaplan-Meier method was used to plot survival curve and calculate survival rate, and the Log-rank test was used for survival analysis. Results:(1) Surgical and postoperative conditions. Of the 58 esophageal cancer patients, 49 patients underwent transthoracic approach (26 cases of ipsilateral approach and 23 cases of contralateral approach of pulmonary resection history), and 9 patients underwent mediastinoscopic-laparoscopic approach. There were 57 cases with R 0 resection and 1 case with R 2 resection because of tumor invading carina. The total operation time of 58 patients was (246±27)minutes, and the volume of intraoperative blood loss was (114±29)mL. There was no unplanned reoperation or perioperative death for all patients. The duration of postoperative hospital stay of 58 patients was (10.4±4.6)days, and time for intensive care unit stay was (1.4±0.5)days, and no patient readmitted to intensive care unit due to changes in conditions. The postoperative total incidence of complications of 58 patients was 41.4%(24/58). The Clavien-Dindo grading of complications for all patients was 1-2 grade. (2) Postoperative pathological examination results. Results of postoperative pathological examination showed there were 51 cases of squamous cell carcinoma, 6 cases of adenocarcinoma, and 1 case of melanoma. Number of lymph node dissected of 58 patients was 27±6. The ratio of patient with positive lymph node was 37.9%(22/58). One patient may experience more than 1 region of positive lymph node metastasis. Results of postoperative pathological staging showed 5 cases of ⅠA stage, 2 cases of ⅠB stage, 13 cases of ⅡA stage, 15 cases of ⅡB stage, 4 cases of ⅢA stage, 16 cases of ⅢB stage, and 3 cases of ⅣA stage. Thirteen of the 58 patients underwent neoadjuvant therapy, with the pathological staging as 6 cases of Ⅰ stage, 4 cases of Ⅱ stage, 3 cases of ⅢB stage after therapy. Results of postoperative tumor regression grade for the 13 patients with neoadjuvant therapy showed 4 cases of grad 0, 3 cases of grade 1, 6 cases of grade 2. (3) Follow-up. All 58 patients were followed for 24 (4, 50)months, and no patient died within 90 days after surgery. During the follow-up period, 19 patients experienced tumor recurrence and metastasis and 17 patients died. Twenty-one patients underwent postoperative adjuvant therapy, including 7 cases with chemoradiotherapy, 7 cases with chemotherapy, 3 cases with chemotherapy and immunotherapy, 2 cases with immuno-therapy, 2 cases with radiotherapy. The postoperative 1-, 2-year overall survival rates of the 58 patients were 91.3%, 78.7%, respectively, of whom undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery with postoperative 1-, 2-year overall survival rates as 89.2%, 83.1% and 85.7%, 53.6%, respectively. The postoperative 1-, 2-year esophageal cancer specific survival rates for patients undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery were 94.4%, 87.9% and 85.7%, 71.4%, respectively. There was no significant difference in postoperative 1-, 2-year overall survival rates and postoperative 1-, 2-year esophageal cancer specific survival rates between patients undergoing McKeown surgery and mediastinoscopic-laparoscopic surgery ( P>0.05). (4) Stratified analysis. Of the 49 patients underwent transthoracic approach for esophageal cancer, there were significant differences in surgical method, surgical type, time of chest surgery, cases with upper mediastinal lymph node dissection, and duration of postoperative hospital stay between patients with pulmonary resection history as ipsilateral approach and contralateral approach ( χ2=11.74, 11.68, t=-2.25, χ2=8.45, t=-2.17, P<0.05), and there was no significant difference in total operation time, volume of intraoperative blood loss, the number of lymph node dissected, post-operative total complications, and postoperative pathological TNM staging ( P>0.05). For patients with pulmonary resection history as ipsilateral approach and contralateral approach, the postopera-tive 1-, 2-year esophageal cancer specific survival rates were 95.5%, 95.5% and 81.4%, 71.1%, showing a significant difference between them ( χ2=5.63, P<0.05). Conclusions:The transthoracic approach and mediastinoscopic-laparoscopic approach are safe and feasible for esophageal cancer patients with pulmonary resection history. Compared with patients with pulmonary resection history as contralateral approach, patients with pulmonary resection history as ipsilateral approach have a higher ratio of McKeown surgery, minimally invasive surgery and upper mediastinal lymph node dissection, shorter time of chest surgery and duration of postoperative hospital stay, better esophageal cancer specific survival rate. And there is no increase in perioperative risk.

Objective:To evaluate a transhiatal tunnel flap designed to reconstruct the cardiac functional structure in proximal gastric cancer patients in our center.Methods:A descriptive case study method was used to select the data of 11 patients undergoing surgery for upper gastric cancer from Jan to Jul 2024. After laparoscopic dissection is completed, the esophagus is transected 2 cm from the upper edge of the tumor and the specimen is removed. The distance from the lower edge of the tumor is 5 cm. The cutting width is 4 cm, and the length of sleeve distal stump stomach is 20 cm. A seromuscular flap tunnel was made with a length of 2 cm and a width of 2 cm, 2 cm away from the top of the remnant stomach. The digestive tract was reconstructed using the Overlap hybridization method.Results:The median operation time was 175 (139-285) minutes. The median muscle flap production time and reconstruction time was 10.5 (5.5-21.0) minutes and 15.0 (11.8-33.6) minutes, respectively. The median blood loss is 50 (20-100) ml. The median postoperative hospitalization was 8 (6-25) days. The median tumor size was 2.5 (1.0-4.0) cm, and 31 (15-52) lymph nodes were dissected. The median follow-up after surgery was 3.5 (0.7-6.0) months, and no tumor recurrence or metastasis was found. Postoperative anastomotic leakage (Clavien-Dindo grade Ⅱ) occurred in one case, and there was no perioperative death. The Visick score of the whole group was 1 point in 8 cases and 2 points in 3 cases, and there was no anastomotic stenosis. Reflux esophagitis (Los Angeles classification grade B) was found in 1 case after gastroscopy, and the symptoms were relieved by conservative treatment.Conclusion:The transhiatal tunnel flap arthroplasty method has high surgical safety, low reconstruction difficulty, and an reliable anti-reflux effect.

Objective:To evaluate the safety and feasibility of the laparoscopic indocyanine green (ICG) fluorescence imaging during the sentinel node navigational surgery for the early gastric cancer.Methods:Patients with <4 cm early gastric cancer were chosen. 0.5 ml ICG (2.5 mg/ml) was preoperatively injected into submucosa around the lesion in four points by the endoscopy. The sentinel lymph node basin including the stained tissue and lymph node (LN) were completely resected guided by the fluorescence mapping under ICG laparoscopy. The specimen was inspected by frozen pathology section. The radical gastrectomy was dependent on the pathology result.Result:Between 2019 and 2021, a total of 18 patients were included in the final analysis. Most tumors (16/18) located in the middle or distal stomach. Median tumor size was 2.0 cm. Lymph vessel invasion was revealed in five cases and perineural invasion in three cases. According to AJCC tumor grading system, tumor depth was classified as Tis in 2 cases, T1a in 5 cases and T1b in 11 cases. Lymph node metastasis (LNM) was revealed in four patients (4/18, 22%). Median sentinel lymph node basins per patient were 2 (range, 1-5). An average 6 (range, 2-13) LNs were harvested in each case, including 6 (1-13) ICG stained LNs and 1 (0-5) non stained LNs. All of four LNM patients were detected by sentinel node navigational surgery. The rate of the sensitivity and accuracy were 100% and 100%, respectively. The median follow-up for the entire group was 58.3 months (0.3-59.9 months), with no recurrence or metastasis observed in any patient.Conclusion:The sensitivity and accuracy of the laparoscopic indocyanine green fluorescence imaging during the sentinel node navigational surgery were satisfactory.

Objective:To explore long-term outcome and risk factors of recurrence in stage Ⅲ gastric cancer patients who underwent radical gastrectomy and adjuvant chemotherapy.Methods:The clinical and pathological data of patients with stage Ⅲ (AJCC V8) gastric adenocarcinoma were analyzed retrospectively. All patients received radical gastrectomy and adjuvant chemotherapy consisting of oxaliplatin, fluoropyrimidines with or without docetaxel in our center during 2006 and 2011.Results:A total of 324 patients were enrolled into the study. With a median follow-up time of 108 months, 175 (54%) patients developed tumor recurrence. One hundred and eighty-three (56.5%) patients died, including 169 (52.2%) dying of gastric cancer recurrence. The median disease-free survival (DFS) was 35 months, and the median overall survival (OS) was 64 months. The 5-year OS rates were 58.2%, 51.5% and 25.6% in patients with stage ⅢA, ⅢB and ⅢC diseases, respectively ( P<0.01). Multivariate analysis revealed that T4b cancers ( P=0.02), higher lymph meta node ratio (LNR) ( P<0.01) and perineural invasion ( P=0.01) were independent negative prognostic factors, while more than 12 weeks of adjuvant chemotherapy may improve survival. Higher LNR was correlated with locoregional ( P<0.01), distant lymph node metastases ( P<0.01), and peritoneal metastases ( P=0.038). Perineural invasion ( P=0.047) was prone to peritoneal metastases. More than 12 weeks of adjuvant chemotherapy could reduce the risk of haematogenous metastases ( P=0.023). Conclusions:Outcomes were significantly different in subgroups of patients with stage Ⅲ gastric cancers after radical gastrectomy. Higher LNR and perineural invasion could predict poor prognosis and different recurrence patterns.

Objective:To investigate the clinical effects of the modified posteromedial approach combined with the anterolateral approach in the treatment of posterior pilon fractures in the supine position.Methods:A retrospective was conducted to analyze the clinical data of 54 patients [45 males and 9 females with an age of (47.7 ± 13.1) years] who had been treated surgically for posterior pilon fractures from January 2016 to December 2020 at Department of Orthopedics, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were divided into 2 groups according to their surgical positions: a supine group of 24 patients (the modified posteromedial approach combined with the anterolateral approach in the supine position) and a prone group of 30 patients (the posteromedial approach combined with the anterolateral approach in the prone position). The 2 groups were compared in terms of operation time, hospitalization time, radiographic outcomes (bone union time and ratio of congruent articular reduction), range of ankle motion, and postoperative complications. The post-operative function was evaluated using the Manchester Oxford Foot Questionnaire (MOXFQ) and the visual analogue scale (VAS).Results:There was no statistically significant difference between the 2 groups in the general clinical data before operation, showing comparability ( P>0.05). The mean follow-up time was (19.4 ± 4.4) months for the supine group and (17.8 ± 4.2) months for the prone group. The operation time, hospitalization time, bone union time, rate of fixation of syndesmosis and ratio of congruent articular reduction were (90.8 ± 9.9) min, (9.5 ± 2.4) d, (8.4 ± 1.4) weeks, 33.3% (8/24) and 95.8% (23/24) in the supine group, and (89.1 ± 10.8) min, (9.5 ± 2.5) d, (8.1 ± 1.4) weeks, 53.3% (16/30) and 96.6% (29/30) in the prone group, showing no significant differences (all P>0.05). At the last follow-up, the dorsiflexion and plantar flexion of the ankle, VAS, and MOXFQ scores for pain, walking and social capability were, respectively, 15.0° ± 2.1°, 26.1° ± 4.2°, (1.0 ± 0.5) points, 20.0(0, 30.0) points, (16.5 ± 13.2) points and 12.5(0, 18.8) points in the supine group, and 15.7° ± 1.6°, 27° ± 4.0°, (1.3 ± 0.7) points, 12.5(10.0, 30.0) points, (19.0 ± 11.5) points and 15.6(6.3, 25.0) points in the prone group, showing no significant differences ( P>0.05). The total incidence of complications was 8.3% (2/24) in the supine group and 3.3% (1/30) in the prone group, showing no significant difference either ( P>0.05). Conclusion:In the treatment of posterior pilon fractures, as the modified posteromedial approach combined with the anterolateral approach in the supine position is equivalent to the posteromedial and the posterolateral approaches in the prone position in terms of reduction quality, bone union time, functional outcomes and complications, it can be used as an alternative choice.

Objective:To evaluate salvage surgery in patients with early gastric cancer after noncurative endoscopic resection .Method:A total of 56 cases with early gastric cancer receiving salvage surgery after noncurative endoscopic resection were enrolled and the clinicopathological and follow-up information were analyzed to evaluate the necessity and safety of salvage surgery.Results:Among the 44(79%)patients with submucosal invasion, 38 (68%) were with SM2 (invasion submucosal invasion≥500 μm) according to the pathological results after endoscopic resection. 33 (59%)cases had positive margin. The rate of lymph node metastasis and positive residual tumor as found by salvage gastrectomy were 11% (6/56) and 25% (14/56) . In the multivariate analysis, deeper submucosal invasion resulted as independent risk factor for residual tumor( OR=1.001, 95% CI=1.000-1.002, P=0.036). Among the 12(21%)cases with postoperative complications, 3 (5%)underwent unplanned reoperations because of anastomotic or intra-abdominal bleeding. There was no difference in the number of retrieved lymph nodes and rate of postoperative complications between laparoscopic and open surgery(all P>0.05). Conclusion:For patients with the risk factors of lymph node metastasis after noncurative endoscopic resection, salvage surgery was necessary and laparoscopic approach was safe and feasible.

Objective: To investigate the therapeutic strategy in patients with early gastric cancer after noncurative endoscopic submucosal dissection (ESD). Methods: A total of 107 cases with early gastric cancer receiving noncurative endoscopic submucosal dissection were collected and the patients were classified into an additional gastrectomy group (n=41) and a simple follow-up group (n=66) according to the therapeutic method used after noncurative ESD. The clinicopathological information, short- and long-term clinical outcomes between the two groups were analyzed and compared. Results: The mean age of the patients in the gastrectomy group and follow-up group was(59.2±8.7)years old and(64.7±8.8)years old, respectively. The depth of submucosal invasion was (1445.83±803.12) and (794.71±815.79) μm, respectively. The difference between the two groups was statistically significant (P=0.020 for age and P=0.010 for depth of submucosal invasion). Compared with follow-up group, the patients with undifferentiated histologic type, deep invasion of submucosa (SM2), diffuse type, lymphovascular invasion and neural invasion were more common in the gastrectomy group (P<0.05). The R0 resection rate of ESD in the gastrectomy group was significantly lower than the follow-up group(26.8% vs 65.2%, P<0.001). The positive residual tumor rate and LNM rate of additional gastrectomy group were 31.7%(13/41)and 9.76%(4/41)according to the pathological results after gastrectomy. The gastrectomy group had 2 cases of local recurrence (2/41, 4.9%), while 5(5/66, 7.6%)in the follow-up group(4.9% vs 7.6%, P=0.883). There was no significant difference in overall survival (OS) and disease-free survival (DFS) between the two study groups (P=0.066 and 0.938, respectively). Conclusions Assessment of LNM risk should be performed in patients with noncurative endoscopic resection. For patients with low risk of LNM who are intolerance of additional gastrectomy due to old age and comorbidities, close follow-up with endoscopy can be considered as an alternative.

Objective: To compare the efficacy of femoral triangle versus adductor canal approach to saphenous nerve block for postoperative analgesia in the patients undergoing knee arthroplasty. Methods: Sixty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 53-68 yr, scheduled for elective total knee arthroplasty under general anesthesia, were assigned into 2 groups (n=30 each) using a random number table method: femoral triangle approach to saphenous nerve block group (group F) and adductor canal approach to saphenous nerve block group (group A). Femoral triangle and adductor canal approach to saphenous nerve block was performed by injecting 0.5% ropivacaine 20 ml in group F and group A, respectively.Patient-controlled saphenous nerve block analgesia was used in two groups, and the analgesic pump solution contained 1% ropivacaine 400 mg diluted to 160 ml in 0.9% sodium chloride injection.The analgesic pump was set up with a 5 ml bolus dose, a 30-min lockout interval and background infusion at a rate of 5 ml/h, and analgesia lasted until 72 h after operation.When visual analog scale score > 4 and pain was not relived after 30-min pressing by patients, pethidine hydrochloride 100 mg was intramuscularly injected as rescue analgesic.The muscle strength of quadriceps femoris was assessed by manual muscle test at 4, 8, 24, 48 and 72 h after operation.The patient′s satisfaction score was assessed and recorded at 72 h after operation.Rescue analgesia and development of adverse reactions (local anesthetic intoxication, itching, dizziness, urinary retention, nausea and vomiting) were recorded within 72 h after operation. Results: Compared with group F, the muscle strength of quadriceps femoris was significantly increased at 4, 8 and 24 h after operation, the rate of postoperative rescue analgesia was decreased (P<0.05), and no significant change was found in patient′s satisfaction score or incidence of adverse reactions in group A (P>0.05). Conclusion Adductor canal approach to saphenous nerve block provides better efficacy for postoperative analgesia than femoral triangle approach to saphenous nerve block in the patients undergoing knee arthroplasty.