Objective To explore the effectiveness of an integrated laparoscopic simulation training course (best essential surgical technique training, BEST) in enhancing laparoscopic peritoneal suturing techniques in surgical residents.Methods As an integrated two-stage program, the BEST course applied basic laparoscopic training system with simple molds in phase Ⅰ training, and then adopted advanced laparoscopic training system, 3D Laparoscope and ex-vivo animal models in phase Ⅱ training. The laparoscopic suturing techniques were practiced in phase Ⅱ training. From August 2021 to July 2024, surgical residents in the second year of the national standardized training program were divided into pilot and control groups based on whether they had undergone the BEST course. Two cases of laparoscopic peritoneal suture were performed by the surgical residents under supervision in the department of gastrointestinal surgery. The operative time, quality of suture, and independent completion rate were compared between the two groups.Results A total of 33 surgical residents (19 in pilot group and 14 in control group) were included in this study, and a total of 66 cases of laparoscopic peritoneal suture were performed (38 in pilot group and 28 in control group). The operative time was significantly shorter in pilot group than that in control group (15.7 min vs. 17.5 min, P=0.025). The quality of suture was significantly better in pilot group compared to control group (P=0.023). In pilot group, all peritoneal sutures were performed by residents independently, whereas in control group, 3 cases (10.7%) were assisted by the supervisor, and the independent completion rate was different significantly (P=0.039).Conclusions The BEST course can help improve surgical residents′ laparoscopic peritoneal suturing techniques and could be promoted in the national standardized training program for surgical residents.

Hip surgery is often associated with moderate to severe postoperative pain due to exten-sive invasion.A safe and effective postoperative pain treatment can promote patients'recovering activities and facilitate the early functional recovery of the hip after the surgery.Although the routinely used intrave-nous self-controlled analgesia has an exquisite analgesic effect,it carries the risks of postoperative nausea and emesis,excessive sedation,intestinal paralysis,and even respiratory depression.As an alternative to transversus abdominis plane block(TAPB),lumbar quadratus block(QLB)has been gradually applied to the hip joint surgery.In this paper,we review the anatomical basis and characteristics of QLB and its clini-cal application in hip surgery,in order to provide the postoperative analgesia application of QLB.

Objective:To investigate the clinical value of magnetic resonance imaging (MRI) based integrated deep learning model for predicting the times of linear staplers used in double stapling technique for middle-low rectal cancer resection.Methods:The retrospective cohort study was conducted. The clinicopathological data of 263 patients who underwent low anterior resection (LAR) for middle-low rectal cancer in Ruijin Hospital of Shanghai Jiaotong University School of Medicine from January 2018 to December 2022 were collected as training dataset. There were 183 males and 80 females, aged 63(55,68)years. The clinicopathological data of 128 patients with middle-low rectal cancer were collected as validation dataset, including 83 males and 45 females, with age as 65(57,70)years. The training dataset was used to construct the prediction model, and the validation dataset was used to validate the prediction model. Observation indicators: (1) clinicopathological features of patients in the training dataset; (2) influencing factors for ≥3 times using of linear staplers in the operation; (3) prediction model construction; (4) efficiency evaluation of prediction model; (5) validation of prediction model. Measurement data with skewed distribution were represented as M( Q1, Q3), and Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers, and comparison between groups was conducted using the chi-square test. Wilcoxon rank sum test was used for non-parametric data analysis. Univariate analysis was conducted using the Logistic regression model, and multivariate analysis was conducted using the Logistic stepwise regression model. The receiver operating characteristic (ROC) curve was draw and the area under the curve (AUC) was calculated. The AUC of the ROC curve >0.75 indicated the prediction model as acceptable. Comparison of AUC was conducted using the Delong test. Results:(1) Clinicopathological features of patients in the training dataset. Of the 263 patients, there were 48 cases with linear staplers used in the operation ≥3 times and 215 cases with linear staplers used in the operation ≤2 times. Cases with preoperative serum carcinoembryonic antigen (CEA) >5 μg/L, cases with anastomotic leakage, cases with tumor diameter ≥5 cm were 20, 12, 13 in the 48 cases with linear staplers used ≥3 times in the operation, versus 56, 26, 21 in the 215 cases with linear staplers used ≤2 times in the operation, showing significant differences in the above indicators between them ( χ2=4.66, 5.29, 10.45, P<0.05). (2) Influencing factors for ≥3 times using of linear staplers in the operation. Results of multivariate analysis showed that preoperative serum CEA >5 μg/L and tumor diameter ≥5 cm were independent risk factors for ≥3 times using of linear staplers in the operation ( odds ratio=2.26, 3.39, 95% confidence interval as 1.15-4.43, 1.50-7.65, P<0.05). (3) Prediction model construction. According to the results of multivariate analysis, the clinical prediction model was established as Logit(P)=-2.018+0.814×preoperative serum CEA (>5 μg/L as 1, ≤5 μg/L as 0)+ 1.222×tumor diameter (≥5 cm as 1, <5 cm as 0). The image data segmented by the Mask region convolutional neural network (MASK R-CNN) was input into the three-dimensional convolutional neural network (C3D), and the image prediction model was constructed by training. The image data segmented by the MASK R-CNN and the clinical independent risk factors were input into the C3D, and the integrated prediction model was constructed by training. (4) Efficiency evaluation of prediction model. The sensitivity, specificity and accuracy of the clinical prediction model was 70.0%, 81.0% and 79.4%, respectively, with the Yoden index as 0.51. The sensitivity, specificity and accuracy of the image prediction model was 50.0%, 98.3% and 91.2%, respectively, with the Yoden index as 0.48. The sensitivity, specificity and accuracy of the integrated prediction model was 70.0%, 98.3% and 94.1%, respectively, with the Yoden index as 0.68. The AUC of clinical prediction model, image prediction model and integrated prediction model was 0.72(95% confidence interval as 0.61-0.83), 0.81(95% confidence interval as 0.71-0.91) and 0.88(95% confidence interval as 0.81-0.95), respectively. There were significant differences in the efficacy between the integrated prediction model and the image prediction model or the clinical prediction model ( Z=2.98, 2.48, P<0.05). (5) Validation of prediction model. The three prediction models were externally validated by validation dataset. The sensitivity, specificity and accuracy of the clinical prediction model was 62.5%, 66.1% and 65.6%, respectively, with the Yoden index as 0.29. The sensitivity, specificity and accuracy of the image prediction model was 58.8%, 95.5% and 92.1%, respectively, with the Yoden index as 0.64. The sensitivity, specificity and accuracy of the integrated prediction model was 68.8%, 97.3% and 93.8%, respectively, with the Yoden index as 0.66. The AUC of clinical prediction model, image prediction model and integrated prediction model was 0.65(95% confidence interval as 0.55-0.75), 0.75(95% confidence interval as 0.66-0.84) and 0.84(95% confidence interval as 0.74-0.93), respec-tively. There was significant differences in the efficacy between the clinical prediction model and the integrated prediction model ( Z=3.24, P<0.05). Conclusion:The MRI-based deep-learning model can help predicting the high-risk population with ≥3 times using of linear staplers in resection of middle-low rectal cancer with double stapling technique.

As the populations are aging, concerns about cognitive decline are becoming a common topic in medical consultations. The occurrence of postoperative cognitive change involves many factors such as their own situation and perioperative period. Alzheimer′s disease (AD) is the main concern about postoperative cognitive change. For years it was widely believed that cognitive dysfunction caused by anesthesia, some studies suggest that anesthetics may cause mitochondrial damage, while most studies suggest that mitochondrial dysfunction may affect AD. But it is rarely noticed, that cells can maintain the stability following mitochondrial stress by a series of integrated stress responses (ISR) and alleviate mitochondrial stress in progeny. We reviewed the research progress of mitochondrial stress in AD.

Objective:To evaluate the effects of sevoflurane combined with propofol anesthesia on the synaptic plasticity in the hippocampus after operation in rats with mild cognitive impairment (MCI) and the relationship with potassium-chloride cotransporter-2 (KCC2)/sodium-potassium-chloride cotransporter 1 (NKCC1).Methods:Clean-grade healthy male Sprague-Dawley rats, aged 16-18 months, weighing 440-540 g, in which MCI was induced by severe bilateral common carotid artery stenosis (BCAS). Forty-eight rats with MCI were divided into 4 groups ( n=12 each) using a random number table method: sham operation group (group Sham), sevoflurane anesthesia group (group S), propofol anesthesia group (group P), and sevoflurane and propofol anesthesia group (group SP). After disappearance of eyelash reflex, open reduction and internal fixation was performed after tibial fracture was induced in S, P and SP groups.Anesthesia method was as follows: 1.7% sevoflurane was inhaled and propofol 20 mg·kg -1·h -1 was intravenously infused for 3 h in group SP, 3% sevoflurane was inhaled for 3 h in group S, and propofol was intravenously infused at rate of 40 mg·kg -1·h -1 for 3 h in group P. The novel object recognition (NOR) test was performed at 14 days after operation, and the discrimination index in NOR test was calculated.The in vivo electrophysiological experiment was performed on 19 days after operation to measure long-term potentiation and amplitude of the field excitatory postsynaptic potential (fEPSP). The expression of KCC2 and NKCC1 was determined by Western blot, and the ratio of KCC2/NKCC1 was calculated.The density of dendritic spines in the hippocampal CA1 region was determined by Golgi-COX staining performed at 30 days after operation. Results:Compared with Sham group, the discrimination index in NOR test, hippocampal KCC2/NKCC1 ratio, density of dendritic spines in hippocampal CA1 region, and amplitude of fEPSP were significantly decreased in S and P groups ( P<0.05), and no significant change was found in the parameters mentioned above in group SP ( P>0.05). Compared with group S or group P, the discrimination index in NOR test, hippocampal KCC2/NKCC1 ratio, density of dendritic spines in hippocampal CA1 region, and amplitude of fEPSP were significantly increased in group SP ( P<0.05). Conclusion:Sevoflurane combined with propofol anesthesia does not aggravate postoperative cognitive dysfunction in the rats with MCI, which may be related to maintaining the balance of hippocampal KCC2/NKCC1 and protecting the synaptic plasticity in hippocampi.

Objective:To investigate the application value of three-dimensional (3D) laparoscope in the transanal total mesorectal excision (TaTME).Methods:The retrospective cohort study was conducted. The clinicopathological data of 20 patients with middle and low rectal cancer who underwent TaTME in the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2018 to October 2019 were collected. There were 15 males and 5 females, aged from 28 to 81 years, with a median age of 64 years. Of the 20 patients, 10 patients using 3D laparoscopic system for transanal approach of TaTME were divided into 3D group, and 10 patients using two-dimensional (2D) laparoscopic system for transanal approach of TaTME were divided into 2D group. Observation indicators: (1) intraoperative situations and postoperative recovery; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted by outpatient examination and telephone interview to detect survival of patients and recurrence and metastasis of tumors in patients up to April 2020. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the Fisher exact propability. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Results:(1) Intraoperative situations and postoperative recovery: patients in the two groups completed surgeries successfully, without tranversion to laparostomy from laparoscopic surgery, transversion to transabdominal surgery from transanal surgery, or intraoperative death. The cases with terminal ileostomy, cases with manual anstomosis or mechanical anastomosis (anastomotic methods), operation time, volume of intra-operative blood loss, duration of postoperative hospital stay, cases with anastomotic leakage or anastomotic hemorrahge (postoperative short-term complications), cases with anastomotic stenosis of the 3D group were 7, 4, 6, 150 minutes (range, 100-220 minutes), 50 mL (range, 30-100 mL), 8.5 days (range, 7.0-16.0 days), 2, 0, 1, respectively, versus 8, 5, 5, 180 minutes (range, 120-250 minutes), 100 mL (range, 30-200 mL), 9.5 days (range, 6.0-17.0 days), 1, 1, 1 of the 2D group. There was no significant difference in the terminal ileostomy, anastomotic methods, postoperative short-term complications, or anastomotic stenosis between the two groups ( P>0.05). There was no significant difference in the operation time, volume of intraoperative blood loss, or duration of postoperative hospital stay between the two groups ( Z=1.909, 1.827, 0.687, P>0.05). Patients with short-term complications in the two groups were improved after conservative treatments. There was 1 patient with anastomotic stenosis in either group, and they were improved after endoscopic balloon dilatation. (2) Postoperative pathological examination: the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, cases with cancer nodes in the mesentery, cases with complete mesentery or median complete mesentery (the integrity of mesentery), cases in stage Ⅰ, Ⅱ, Ⅲ (postoperative pathological stage) of the 3D group were 3.8 cm (range, 1.8-5.0 cm), 1.0 cm (range, 0.5-2.5 cm), 14.5 (range, 6.0-19.0), 1, 9, 1, 4, 2, 4, respectively, versus 4.8 cm (range, 1.0-8.5 cm), 0.8 cm (range, 0.3-1.5 cm), 15.5 (range, 8.0-18.0), 1, 8, 2, 2, 4, 4 of the 2D group. There was no significant difference in the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, the integrity of mesentery, or postoperative pathological stage between the two groups ( Z=1.673, 1.772, 0.038, 0.610, 0.482, P>0.05). There was no significant difference in the cases with cancer nodes in the mesentery between the two groups ( P>0.05). Patients in the two groups had negative distal margin and circumferential margin. (3) Follow-up: patients in the 3D group and 2D group were followed up for 11 months (range, 6-16 months) and 13 months (range, 6-21 months), respectively. During the follow-up, there was no local recurrence, distal metastasis, or tumor-related death. Conclusions:3D laparoscope applied in the TaTME can achieve similar clinical efficacy with 2D laparoscope, which may have a positive impact on the operation time and volume of intraoperative blood loss.

Objective:To primarily investigate the application value of glasses-free three-dimensional (3D) laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors.Methods:The retrospective cohort study was conducted. The clinical data of 165 patients with gastrointestinal malignant tumors who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between October 2018 and May 2019 were collected. There were 99 males and 66 females, aged from 28 to 86 years, with a median age of 63 years. There were 68 of 165 patients with gastric cancer and 97 with colorectal cancer. Sixteen patients with gastric cancer who underwent laparoscopic radical gastrectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D gastric cancer group, and 52 patients with gastric cancer who underwent laparoscopic radical gastrectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D gastric cancer group. Nineteen patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D colorectal cancer group, and 78 patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D colorectal cancer group. Observation indicators: (1) operative situations of patients with gastric cancer; (2) postoperative recovery of patients with gastric cancer; (3) postoperative pathological examination results of patients with gastric cancer; (4) operative situations of patients with colorectal cancer; (5) postoperative recovery of patients with colorectal cancer; (6) postoperative pathological examination results of patients with colorectal cancer; (7) follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect complications and survival of patients up to the postoperative 30th day. Measurement data with skewed distribution were represented as M ( P25, P75) or M (range), and comparison between groups was analyzed by the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Operative situations of patients with gastric cancer: all the 68 gastric cancer patients received successfully laparoscopic radical gastrectomy, without intraoperative complication or conversion to laparotomy. Cases with distal gastrectomy or total gastrectomy(surgical methods) , operation time, volume of intraoperative blood loss were 11, 5, 195 minutes(169 minutes, 214 minutes), 20 mL (10 mL, 90 mL) in patients of the glasses-free 3D gastric cancer group, and 31, 21, 196 minutes(173 minutes, 222 minutes), 40 mL(20 mL, 100 mL) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( χ2=0.432, Z=-0.362, -1.065, P>0.05). (2) Postoperative recovery of patients with gastric cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(2 days, 3 days), 6 days(5 days, 7 days), 10 days(9 days, 14 days) in patients of the glasses-free 3D gastric cancer group, and 2 days(2 days, 3 days), 6 days(5 days, 6 days), 11 days(9 days, 14 days) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( Z=-0.163, -1.870, -0.570, P>0.05). The postoperative complication incidence of the glasses-free 3D gastric cancer group was 12.5%(2/16), including 1 case with duodenal stump fistula, 1 case with anastomotic bleeding. The postoperative complication incidence of the polarized glasses 3D gastric cancer group was 17.3%(9/52), including 2 cases with duodenal stump fistula, 2 cases with delayed gastric emptying, 1 case with pulmonary infection, 1 case with abdominal bleeding, 1 case with anastomotic leakage, 1 case with chylous fistula, 1 case with intestinal obstruction. All the patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.209, P>0.05). (3) Postoperative pathological examination results of patients with gastric cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1, N2, N3 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 3.0 cm(2.0 cm, 5.0 cm), 5, 3, 1, 7, 8, 5, 2, 3, 2, 4, 7, 6(1, 15), 28(22, 43), 15, 4, 3, 9, 0 in patients of the glasses-free 3D gastric cancer group, and 3.5 cm(2.0 cm, 6.0 cm), 13, 10, 4, 25, 19, 23, 2, 26, 6, 7, 13, 1(0, 7), 29(21, 39), 43, 21, 10, 20, 1 in patients of the polarized glasses 3D gastric cancer group. There was no significant difference in the tumor diameter, tumor T staging, cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, the number of lymph node dissected, cases with qualified lymph node dissected, TNM clinical staging between the two groups ( Z=-0.570, -0.434, χ2 =0.926, 0.851, 1.655, Z=-0.579, χ2=1.193, Z=-1.134, P>0.05). There were significant differences in the tumor N staging and the number of positive lymph node between the two groups ( Z=-2.167, -2.283, P<0.05). (4) Operative situations of patients with colorectal cancer: all the 97 colorectal cancer patients received successfully laparoscopic radical colectomy or proctectomy, without intraoperative complications or conversion to laparotomy. Cases with radical colectomy or proctectomy (surgical methods), operation time, volume of intraoperative blood loss were 7, 12, 132 minutes(97 minutes, 156 minutes), 20 mL(10 mL, 50 mL) in patients of the glasses-free 3D colorectal cancer group, and 40, 38, 124 minutes(110 minutes, 159 minutes), 25 mL(15 mL, 65 mL) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( χ2 =1.276, Z=-0.141, -0.863, P>0.05). (5) Postoperative recovery of patients with colorectal cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(1 days, 3 days), 5 days(5 days, 6 days), 8 days(7 days, 10 days) in patients of the glasses-free 3D colorectal cancer group, and 2 days(1 days, 3 days), 5 days(4 days, 6 days), 8 days(6 days, 10 days) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.678, -1.751, -1.674, P>0.05). The complication incidence of the glasses-free 3D colorectal cancer group was 15.8%(3/19), including 1 case with anastomotic leakage after low anterior proctectomy, 1 case with incision infection, 1 case with urinary tract infection. The complication incidence of the polarized glasses 3D colorectal cancer group was 14.1%(11/78), including 3 cases with anastomotic leakage after low anterior proctectomy, 2 cases with intestinal obstruction, 2 cases with urinary tract infection, 2 cases with incision infection, 1 case with anastomotic bleeding, 1 case with pulmonary infection. One of the 3 cases with anastomotic leakage after low anterior proctectomy in the polarized glasses 3D colorectal cancer group was cured after remedial terminal ileostomy. The other patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.035, P>0.05). (6) Postoperative pathological examination results of patients with colorectal cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1-N2 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 5.0 cm(3.0 cm, 6.0 cm), 3, 2, 7, 7, 3, 2, 1, 8, 11, 0(0, 4), 17(14, 23), 18, 2, 3, 12, 2 in patients of the glasses-free 3D colorectal cancer group, and 4.0 cm(3.0 cm, 5.0 cm), 7, 16, 43, 12, 14, 12, 7, 46, 32, 0(0, 1), 16(13, 19), 74, 14, 17, 40, 7 in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.768, -1.135, χ2 =0.049, 0.292, 0.278, 1.762, Z=-0.694, -1.349, χ2=0.001, Z=-1.011, P>0.05). (7) Follow-up: 165 patients received follow-up, with out short-term reoperation or postoperative death in the postoperative 30 days. Conclusion:There is no significant difference in the efficacy between glasses-free 3D laparoscopic surgery and polarized glasses 3D laparoscopic surgery for radical resection of gastrointestinal malignant tumors, of which the clinical value requires further study.

Objective To detect the expressions of Matrix Metalloprotein-11 ( MMP-11 ) and Cathepsin-D(Cath-D),and investigate their relationship and prognostic significance. Methods The study included 95 cases′ clinical date and postoperative specimens of gastric adenocarcinoma ( North China University of Science and Technology Affiliated Hospital,2010. 01-2013. 12) as observation group,70 cases of normal gastric tissue(from observation group) as control group. Expressions of MMP-11 and Cath-D were detected by IHC methods in two groups. Results The positive rate of MMP-11 was 51. 6%( 49/95) in observation group,5. 7%(4/70)in control group(χ2＝38. 884,P＜0. 05). The positive rate of Cath-D was 73. 7%(70/95) in observation group,28. 6%(20/70) in control group(χ2＝33. 082,P＜0. 05). The positive rate of MMP-11 was correlated with metastasis and vascular invasion(χ2＝7. 193、15. 566,P＜0. 05). The positive rate of Cath-D was correlated with maximal diameter,lymph node metastasis,vascular invasion and proliferation index(χ2＝7.431、5.654、6.569、6.801,P＜0.05).There was positive relationship between MMP-11 and Cath-D in observation group(r＝0. 46,P＜0. 05). The expressions of MMP-11 and Cath-D were correlated with prognosis in gastric adenocarcinoma ( P＜0. 05) . Conclusion The higher expressions and synergistic effect of MMP-11 and Cath-D may promote the occurrence and development in gastric adenocarcinoma. The joint detection of MMP-11 and Cath-D may be helpful to predict the prognosis of gastric adenocarcinoma.

Objective To explore the long-term outcomes and prognostic factors of laparoscopic gastrectomy for stage T4a gastric cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 224 patients who underwent laparoscopic gastrectomy of gastric cancer and D2 lymph node dissection in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between February 2004 and December 2014 were collected.Lymph node dissection followed the Japanese Gastric Cancer Treatment Guidelines (13th edition).Anastomotic methods included Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophagojejunostomy.Patients who were diagnosed in stage T4a by postoperative pathological examination underwent 5-fluorouracil chemotherapy.Observation indicators:(1) treatment;(2) postoperative pathological examination;(3) follow-up;(4) prognostic factors analysis.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence or metastases up to death (end of follow-up) or July 31,2016.Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using Student-t test.Measurement data with skewed distribution were described as M (Q).Comparisons of count data were analyzed using the chi-square test.The overall and disease-free survival curves,overall and disease-free survival rates were respectively drawn and calculated using the Kaplan-Meier method.The survival analysis was done by the Log-rank method.The univariate analysis was done by the chisquare test,and COX regression model which included affecting factors (P＜0.10) in the univariate analysis was used for the multivariate analysis.Results (1) Treatment:all the 244 patients underwent successful operation,without conversion to open surgery.Surgical method:laparoscopic-assisted distal gastrectomy (4 combined with cholecystectomy,1 with splenectomy and 1 with transverse colectomy) were detected in 125 patients and laparoscopic-assisted total gastrectomy in 99 patients (3 combined with cholecystectomy and 2 with splenectomy).Anastomotic method:Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophago-jejunostomy were respectively applied to 85,29 and 110 patients.Operation time and volume of intraoperative blood loss were (229±50)minutes and (229 ± 146)mL.All patients underwent 6 or 8 cycles 5-fluorouracil chemotherapy.(2)Postoperative pathological examination:numbers of lymph node dissected and positive lymph nodes were 25± 11 per case and 13 (8,25),with R0 resection.Tumor pathological diagnosis of 224 patients:tumor diameter was (4.5±2.3)cm.Tumors in 29,64,122 and 9 patients respectively located in 1/3 proximal stomach,1/3 middle segment of stomach,1/3 distal stomach and involving 2/3 or total stomach.Tumor differentiation:moderate-and high-differentiated tumors and low-and un-differentiated tumors were detected in 82 and 142 patients,respectively.Postoperative N staging:53,46,55 and 70 patients were detected in staging N0,N1,N2 and N3,respectively.Lymph node metastasis rates of 51,58,53 and 62 patients were 0,1％-15％,16％-40％ and ＞40％,respectively.Postoperative staging was T4a staging.(3) Follow-up:212 of 224 patients were followed up for 7-120 months,with a median time of 32 months.Of 212 follow-up patients,118 were survived and 94 died.Of 118 survived patients,13 and 105 were respectively survived with tumors and without tumor.Of 94 deaths,causes of 8 and 86 were respectively non-tumor and tumor-related deaths.The 5-year overall and disease-free survival rates of 224 patients were respectively 47.2％ and 43.6％.(4) Prognostic factors analysis:results of univariate analysis showed that tumor location,tumor diameter,N staging and lymph node metastasis rate were related factors affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (x2 =6.365,3.740,32.232,48.977,P＜0.10;x2 =9.919,8.818,34.277,45.612,P＜ 0.10).Results of multivariate analysis showed that lymph node metastasis rate was an independent factor affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (HR =1.828,1.197,95％ confidence interval:1.353-2.469,0.945-1.516,P＜0.05).Postoperative 5-year overall and disease-free survival rates were respectively 72.5％,57.0％,41.6％,23.3％ and 70.0％,53.9％,37.0％,32.4％in staging N0,N1,N2 and N3 patients,with statistically significant differences in different staging (x2 =32.232,34.277,P＜0.05).Conclusion There are good long-term outcomes in laparoscopic gastrectomy for stage T4a gastric cancer,and lymph node metastasis rate is an independent factor affecting postoperative overall and disease-free survival of patients.

OBJECTIVETo evaluate the clinical significance of low ligation of inferior mesenteric artery (IMA) and preservation of left colic artery in laparoscopic radical operation for rectal cancer.

METHODSClinical data of 103 rectal cancer patients undergoing laparoscopic radical operation in Ruijin Hospital from May 2015 to January 2016 were retrospectively analyzed, including 61 cases with preservation of left colic artery (low ligation group, LL group) and 42 cases without preservation of left colic artery (high ligation group, HL group). Clinical conditions during operation and after operation were compared between the two groups.

RESULTSAll the patients underwent operation successfully without transferring to laparotomy, intra-operative or post-operative death, and severe intra-operative or anesthetic complications. Age, gender, BMI, ASA score, tumor size and tumor location were not significantly different between the two groups. Four cases(9.5%) in HL group presented ischemic changes in colonic stump during operation, receiving additional colonic resection and no such ischemic changes were found in LL group (P=0.025). The number of harvested lymph node was 16.1±6.8 in HL group and 15.5±7.2 in LL group, number of harvest lymph node in the root of IMA was 4.2±1.7 in HL group with positive rate of 9.5%(4/42) and 4.3±1.7 in LL group with positive rate of 4.9%(3/61), both were not significantly different between the two groups. Lower margin was (2.2±1.4) cm in LL group and (2.8±1.7) cm in HL group, and difference was not significant as well(all P>0.05). There were no significant differences in terms of operation time, blood loss, post-operative complication, recovery of bowel movement and hospital stay. Median follow-up time was 4.5 months(2 to 10 months) and no long-term complications and local recurrence were found.

CONCLUSIONLow ligation of IMA with preservation of left colic artery in laparoscopic radical operation for rectal cancer can provide better blood supply for proximal colon and anastomosis, and can achieve same radical clearance of lymph nodes as high ligation without prolonged operation time, which is worth clinical promotion.

Colon ; Female ; Humans ; Laparoscopy ; Length of Stay ; Ligation ; Lymph Node Excision ; Lymph Nodes ; Male ; Mesenteric Artery, Inferior ; Mesenteric Artery, Superior ; Neoplasm Recurrence, Local ; Operative Time ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Retrospective Studies