Comparison of a new gasless method and the conventional CO2 pneumoperitoneum method in laparoendoscopic single-site cholecystectomy: a prospective randomized clinical trial

To avoid CO2 pneumoperitoneum-associated cardiopulmonary side-effects during conventional laparoscopic surgeries, we have developed a gasless laparoscopic operation field formation (LOFF) device for laparoendoscopic single-site surgery. The aim of this study is to analyze the safety and efficacy of the LOFF device for laparoendoscopic single-site cholecystectomy and to verify its advantage of avoiding CO2 pneumoperitoneum-associated complications. In this prospective, randomized, observer-blinded clinical trial, eligible participants were randomized in a 1:1 ratio to undergo either conventional CO2 pneumoperitoneum assisted laparoendoscopic single-site cholecystectomy (LESS) or the new gasless LOFF device assisted laparoendoscopic single-site cholecystectomy (LOFF-LESS). Outcomes including intra-operative respiratory and hemodynamic parameters, operation time, conversion rate, complication rate, et al were compared between the two groups. A total of 100 patients were randomized to the LESS group [n = 50; mean (SD) age, 49.5 (13.9) years; 24 (48.0%) women] and the LOFF-LESS group [n = 50, mean (SD) age, 47.4 (13.3) years; 27 (54.0%) women]. Compared with the LOFF-LESS group, the LESS group witnessed significant fluctuations in intra-operative respiratory and hemodynamic parameters. The tracheal extubation time of the LESS group was significantly longer (P = 0.001). The gasless LOFF device is safe and feasible for simple laparoscopic cholecystectomy and has a predominance of avoiding CO2 pneumoperitoneum-associated cardiopulmonary side-effects. Trial registration number: ChiCTR2000033702 Graphic abstract

Causes, diagnosis, and treatment of postoperative obstructive jaundice

AIM: This study aimed to analyze the causes, diagnosis, and clinical treatment of postoperative obstructive jaundice (POOJ) in routine surgical practice. MATERIALS AND METHODS: Twenty-four patients with POOJ that developed in the organs of the hepatobiliary system after surgical interventions were included in this study. The patients were subjected to the following procedures to diagnose the causes of POOJ and choose the treatment methods: general clinical examination, biochemical blood tests, dynamic postoperative ultrasound examination of the abdominal organs, video laparoscopy, computed tomography, magnetic resonance imaging, fistulocholangiography, endoscopic retrograde cholagiopancreatography, and percutaneous transhepatic cholangiostomy. RESULTS: POOJ occurred in 18 cases after they had different variants of surgical interventions on the biliary tract after traditional (n = 6) and video laparoscopic cholecystectomy (n = 12). POOJ also developed in 6 cases after they underwent surgery on the liver: atypical (n = 2) and anatomical (n = 2) resection of the liver. This condition manifested after the opening and draining of liver abscesses under US control (n = 2). POOJ was treated with different methods to alleviate the developed complications. After surgical interventions on the liver and biliary tract in 6 cases, relaparotomy, sequestrectomy with sanation, drainage of the abdominal cavity (n = 4), and right-sided hemihepatectomy (n = 2) were performed. In 6 other cases, on days 34 of the development of POOJ after laparoscopic operation (n = 2), relaparotomy was performed, clips and ligature were removed from the choledoch with the formation of Roux-en-Y hepaticojejunostomy. Minimally invasive methods of POOJ correction were applied to 12 cases. Of the 12 cases, 5, 2, and 1 were subjected to endoscopic papillosphincterotomy with lithoextraction, endoscopic papillosphincterotomy with lithoextraction coupled with nasobiliary drainage, and relaparoscopy and redrainage of the common bile duct, respectively. In 4 cases, percutaneous transhepatic cholangiostomy was performed at the first stage. At the second stage, after POOJ resolution, the following procedures were implemented: redrainage of the common bile duct (n = 2) and dilatation of the orifice of the right hepatic duct with reconstruction of hepaticojejunostomy on the hidden transhepatic drainage. CONCLUSION: POOJ is still encountered in clinical practice in a sufficient number of cases. Treatment results largely depend on the time of diagnosis and the choice of optimal surgical strategies. The main causes of POOJ are tactical and technical diagnostic and treatment errors. POOJ is diagnosed on the basis of the data of modern radiation and laboratory and instrumental examination methods. Surgical tactics for POOJ are individually active and dependent on the severity, time, and causes of development. They also depend on the general condition of patients. Along with minimally invasive interventions for POOJ, early relaparotomy is less dangerous than passive expectation tactics.

Successful Case of Treatment the Patient with Synchronous Rectal and Sigmoid Cancers and Synchronous Lung Metastasis

Colorectal cancers (CRC) takes the leading position in the incidence of morbidity and mortality worldwide. Metastatic CRC in the primary diagnosis ranges from 15 to 35 %. Lung metastasis are the most frequent extraperitoneal manifestation of the metastatic process. Such patients are relatively rare and there are no clear recommendations for their treatment tactics to date. This clinical case describes a successful strategy of using preoperative prolonged chemoradiotherapy on a primary tumor and stereotactic irradiation of lung metastasis, with courses of chemotherapy, with further radical laparoscopic operation, in a patient with disseminated primary multiple rectal cancer, synchronous sigmoid colon cancer and 2 metastatic focuses in both lungs.

Laparoscopic Radical Hysterectomy Results in Higher Recurrence Rate Versus Open Abdominal Surgery for Stage IB1 Cervical Cancer Patients With Tumor Size Less Than 2 Centimeter: A Retrospective Propensity Score-Matched Study

ObjectiveTo compare the oncologic outcomes between laparoscopic and open radical hysterectomy in patients with stage IB1 cervical cancer lesion less than 2 cm.MethodsPatients diagnosed FIGO (2009) stage IB1 (tumor diameter <2 cm) and underwent radical hysterectomy in our hospital between March 2008 and November 2018 were studied. A propensity-matched comparison (1:2) was conducted to minimize selection biases. Demographic and baseline oncologic characteristics were balanced between groups. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan–Meier model, along with univariable and multivariable regression analysis.ResultsA total of 261 patients were enrolled in this study after propensity-matching, with 174 in the open group and 87 in the laparoscopic group. Disease relapsed in seven patients in laparoscopy group, and the recurrence rate was 8.0% (7/87). There were eight patients underwent abdominal radical hysterectomy experienced recurrence, and the recurrence rate was 4.6% (8/174). The multivariate analysis model revealed that laparoscopic operation was associated with higher risk of recurrence than abdominal radical hysterectomy (HR, 3.789; 95% CI, 1.143–12.559; p = 0.029). There were five patients or 2.9% (5/174) died in open surgery group and the corresponding percentage in laparoscopy group was 2.3% (2/87). No difference was found in OS between the two groups (HR, 1.823; 95% CI, 0.2673–12.44; log-rank p = 0.5398). All the recurrence occurred within two years after operation in the laparoscopy group, among which pelvic recurrence (85.7%) was dominant.ConclusionTraditional laparotomy radical hysterectomy has a lower recurrence rate when compared with laparoscopic operation in those cervical cancer patients with a foci diameter less than 2 cm. However, no detrimental effect on survival was found in minimal invasive operation group. Further multi-center prospective trials are needed to confirm our results on a large scale.

Laparoscopic excision of congenital choledochal cyst in children and modified hepaticojejunostomy with an unequal length of the jejunal loop

Introduction: Complete excision biliary-enteric reconstruction is necessary for a congenital choledochal cyst (CC) to prevent recurrent cholangitis, acute pancreatitis, and cholangiocarcinoma. Among various reconstructions, this study aims to evaluate the therapeutic effect of unequal length jejunal loop for the biliary reconstruction of congenital choledochal cyst. Method: The clinical data of 56 cases of congenital choledochal cyst treated in the pediatric surgery department of Children's Hospital Affiliated to Zheng Zhou University were retrospectively analyzed. All cases were treated with choledochal cyst resection and unequal length jejunal loop biliary reconstruction, including 51 cases with laparoscopic surgery and 5 cases with traditional surgery. Result: Choledochal cyst resection and unequal length jejunal loop biliary reconstruction were successfully completed in all cases. One case of laparoscopic operation developed biliary fistula on the 3rd day after the operation, and the biliary fistula healed after conservative treatment for 8 days. The other cases recovered smoothly without obvious complications. No contrast agent bile loop reflux was found in upper gastrointestinal angiography. Conclusion: The modified jejunal loop biliary reconstruction has many advantages over the traditional biliary reconstruction, which is worthy of clinical application.

Analysis of Intestinal Flora and Levels of Epidermal Growth Factor Receptor, Interleukin-32, and Gastrin 17 in Patients with Gastric Cancer via Carbon Nanoparticle Laparoscopy

In order to explore the changes of intestinal flora and serum levels of relevant substances in patients with gastric cancer before and after surgery with carbon nanoparticle laparoscopy, a total of 180 patients with early distal gastric cancer who adopted laparoscopic radical gastrectomy for distal gastric cancer in the general surgery department of TCM Hospital of Shi Jia Zhuang City from January 2018 to January 2020 were selected and randomly divided into two groups: traditional laparoscopic operation (control group) and carbon nanoparticle laparoscopic operation (experimental group) were adopted for treatment for the two groups, respectively. Postoperative evaluation included the difference between the two groups in the operative time, the efficiency of intraoperative lymph node dissection, and the number of lymph node detection. The adverse reactions, changes of intestinal flora before and after surgery in the two groups, and the serum levels of epidermal growth factor receptor (EGFR), interleukin-32 (IL-32), and gastrin 17 were evaluated. In the experimental group, the success rate of carbon nanoparticle tracer black staining reached 100%, and the operation time of the experimental group was significantly shorter than that of the control group ( P < 0.05 ). The lymph node detection rate of the experimental group was higher than that of the control group ( P < 0.05 ), but there was no significant difference in the lymph node metastasis rate between the two groups ( P > 0.05 ). The sentinel lymph node sensitivity of the experimental group reached 92.3%, and the specificity, accuracy, and positive and negative prediction rates reached 100%; the experimental group patients were with an obviously higher incidence of level I-II gastrointestinal reaction ( P < 0.05 ). Postoperative increases in Bifidobacteria and Lactobacillus were observed in both groups, while decreases in Enterococcus and Escherichia coli were observed in both groups ( P < 0.05 ). Moreover, the degree of increase and decrease in the experimental group was greater than that in the control group ( P < 0.05 ). The serum levels of EGFR, IL-32, and gastrin 17 in the two groups were significantly lower than those in the control group on 3 d, 7 d, and 15 d after surgery ( P < 0.05 ). In the radical gastrectomy for distal gastric cancer, carbon nanoparticle laparoscopy was not only helpful for the localization of small tumors but also for the thorough dissection of lymph nodes after the surgery, and the postoperative adverse reactions of carbon nanoparticle laparoscopy were also less, which was of great significance for the improvement of intestinal flora and the reduction of serum levels of EGFR, IL-32, and gastrin 17 in gastric cancer patients.

P581 Pre-operative prolonged antibiotic treatment in ileocecal Crohn’s disease: single center non-randomized prospective study

Background Patients with complicated Crohn’s disease are the most difficult cohort to make right decision in treatment and timing surgery. These patients are at risk for the long duration of operations, length of hospital stay, repeated urgent interventions because of complications and the need for a temporary stoma. In literature there is lack of information concerning the usage of prolonged antibiotics in such cases and results are conflicting in some studies. Single center non-randomized prospective study was held. Methods 120 patients were evaluated from 2012 to 2017. All patients had a complicated Crohn’s disease with abdominal mass, fistulas and stricture of the terminal ileum and all of them were operated on. In the first group there were 48 patients who received preoperative treatment with ciprofloxacin and metronidazole for at least 2.5 (1–4) months. In the second group patients also received the same treatment for the median time of 13 (1–33) days. Our hypothesis has been that prolonged treatment allows to reduce postoperative complications and the risk of stoma formation. To prove this statement, we did Chi-squared and Fisher’s exact test, univariant and multivariant analyses. The following criteria were included: prolonged treatment, gender, age, perianal lesion, laparoscopic operation, blood loss and duration of surgery. Results In the first group the complication rate was 4 (8.3%) and in 27 (56.2%) patients there was the need for stoma formation. In the second group – 18 (25%) and 58 (80.5%), respectively. First, we used Fisher’s test to see some correlations between the treatment and complications and the need of stoma formation. Prolonged treatment reduces the rate of complications in 4-fold (OR 0.25; x2= 5.34; p=0.02) and the need of stoma in 3-fold (OR 0.3; x2=8.24; p=0.004). In uni- and multivariant analyses prolonged treatment significantly reduces the complication rate and the risk for stoma creation (OR 2.73 CI 0.037–0.86; p= 0.02 and OR 0.310 CI 0.02–0.72 p=0.004, respectively). Gender, age, perianal lesion, laparoscopic operation, blood loss and duration of surgery were not statistically significant in multivariant analysis. Conclusion preoperative prolonged antibiotic treatment in complicated Crohn’s disease significantly reduced complications rate and the risk of stoma creation.