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Journal of Thoracic Disease Apr 2024Esophageal malignancies have a high morbidity rate worldwide, and minimally invasive surgery has emerged as the primary approach for treating esophageal cancer. In...
BACKGROUND
Esophageal malignancies have a high morbidity rate worldwide, and minimally invasive surgery has emerged as the primary approach for treating esophageal cancer. In recent years, there has been increasing discussion about the potential of employing inflatable mediastinoscopic and laparoscopic approaches as an option for esophagectomy. Building on the primary modification of the inflatable mediastinoscopic technique, we introduced a secondary modification to further minimize surgical trauma.
METHODS
We conducted a retrospective analysis of patients who underwent inflatable mediastinoscopy combined with laparoscopic esophagectomy at the Second Affiliated Hospital of Naval Medical University from March 2020 to March 2023. The patients were allocated to the following two groups: the traditional (primary modification) group, and the secondary modification group. Operation times, intraoperative bleeding, and postoperative complications were compared between the groups.
RESULTS
The procedure was successfully performed in all patients, and conversion to open surgery was not required in any case. There were no statistically significant differences in the surgical operation time, intraoperative bleeding, number of dissected lymph nodes, and rate of postoperative anastomotic leakage between the two groups. However, a statistically significant difference was observed in the length of the mobilized esophagus between the two groups. The mobilization of esophagus to the level of diaphragmatic hiatus via the cervical incision was successfully achieved in more patients in the secondary modification group than the primary modification group.
CONCLUSIONS
Inflatable mediastinoscopy combined with single-incision plus one-port laparoscopic esophagectomy is a safe and effective surgical procedure. The use of a 5-mm flexible endoscope, ultra-long five-leaf forceps, and LigaSure Maryland forceps facilitates esophageal mobilization and lymph node dissection through a single cervical incision.
PubMed: 38738243
DOI: 10.21037/jtd-24-309 -
Frontiers in Oncology 2024Colorectal cancer is among the most common cancers in the world, and splenic flexure colon cancer accounts for about 2-5% of them. There is still no consensus on the...
Short- and long-term outcomes after surgical treatment of 5918 patients with splenic flexure colon cancer by extended right colectomy, segmental colectomy and left colectomy: a systematic review and meta-analysis.
BACKGROUND
Colorectal cancer is among the most common cancers in the world, and splenic flexure colon cancer accounts for about 2-5% of them. There is still no consensus on the surgical treatment of splenic flexure colon cancer (SFCC), and the extent of surgical resection and lymph node dissection for SFCC is still controversial.
AIM
To compare the postoperative and long-term oncologic outcomes of extended right colectomy (ERC), segmental colectomy (SC) and left colectomy (LC) for SFCC.
METHOD
Up to March 2024, retrospective and prospective studies of ERC, SC, and LC for SFCC were searched through databases. Pooled weighted/standardized mean difference (WMD/SMD), odds ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated using a fixed effects model or random effects model, and meta-analysis was performed using Stata.
RESULTS
This meta-analysis includes 5,918 patients from 13 studies with more lymph node harvest (OR:6.29; 95%Cl: 3.66-8.91; Z=4.69, P=0), more operation time (WMD: 22.53; 95%Cl: 18.75-26.31; Z=11.68, P=0), more blood loss (WMD:58.44; 95%Cl: 20.20-96.68; Z=2.99, P=0.003), longer hospital stay (WMD:1.74; 95%Cl: 0.20-3.29; Z=2.21, P=0.03), longer time to return to regular diet (WMD:3.17; 95%Cl: 2.05-4.30; Z=5.53, P=0), longer first flatus time (WMD:1.66; 95%Cl: 0.96-2.37; Z=4.61, P=0) in ERC versus SC. More lymph node harvest (WMD: 3.52; 95% Cl: 1.59-5.44; Z=3.58, P=0) in ERC versus LC and LC versus SC (WMD: 1.97; 95% CI: 0.53-3.41; Z=2.68, P=0.007), respectively. There is no significant difference between anastomotic leakage, postoperative ileus, total postoperative complication, severe postoperative complication, wound infection, reoperations, R0 resection, postoperative mortality, 5-year overall survival (OS), 5-year disease-free survival (DFS) in three group of patients. In LC versus SC and ERC versus LC, there is no difference between operation time, blood loss, hospital stay, return to regular diet, and first flatus.
CONCLUSION
In the included studies, SC and LC may be more advantageous, with fewer postoperative complications and faster recovery. ERC harvests more lymph nodes, but there is no significant difference in long-term OS and DFS between the three surgical approaches. Given that the included studies were retrospective, more randomized controlled trials are needed to validate this conclusion.
PubMed: 38686198
DOI: 10.3389/fonc.2024.1244693 -
International Journal of Colorectal... Apr 2024The efficacy of single-incision plus one-port laparoscopic surgery (SILS + 1) versus conventional laparoscopic surgery (CLS) for colorectal cancer treatment remains... (Meta-Analysis)
Meta-Analysis Comparative Study Review
OBJECTIVE
The efficacy of single-incision plus one-port laparoscopic surgery (SILS + 1) versus conventional laparoscopic surgery (CLS) for colorectal cancer treatment remains unclear. This study compares the short-term and long-term outcomes of SILS + 1 and CLS using a high-quality systematic review and meta-analysis.
METHOD
Literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, drawing from PubMed, Embase, Web of Science, and the Cochrane Library until December 10, 2023. Statistical analysis was conducted using RevMan and Stata.
RESULT
The review and meta-analysis included seven studies with 1740 colorectal cancer patients. Compared to CLS, SILS + 1 showed significant improvements in operation time (WMD = - 18.33, P < 0.00001), blood loss (WMD = - 21.31, P < 0.00001), incision length (WMD = - 2.07, P < 0.00001), time to first defecation (WMD = - 14.91, P = 0.009), time to oral intake (WMD = - 11.46, P = 0.04), and time to ambulation (WMD = - 11.52, P = 0.01). There were no significant differences in lymph node harvest, resection margins, complications, anastomotic leakage, hospital stay, disease-free survival, overall survival, and postoperative recurrence.
CONCLUSIONS
Compared to CLS, SILS + 1 demonstrates superiority in shortening the surgical incision and promoting postoperative recovery. SILS + 1 can provide a safe and feasible alternative to CLS.
Topics: Humans; Laparoscopy; Colorectal Neoplasms; Treatment Outcome; Operative Time; Postoperative Complications; Length of Stay; Female; Male; Neoplasm Recurrence, Local; Middle Aged
PubMed: 38684561
DOI: 10.1007/s00384-024-04630-x -
Asian Journal of Surgery Apr 2024This study is aimed to explore the safety and feasibility of indocyanine green (ICG) fluorescence imaging guidance in laparoscopic para-aortic lymph node (PALN)...
Safety and efficacy of indocyanine green fluorescence imaging-guided laparoscopic para-aortic lymphadenectomy for left-sided colorectal cancer:A preliminary case-matched study.
AIM
This study is aimed to explore the safety and feasibility of indocyanine green (ICG) fluorescence imaging guidance in laparoscopic para-aortic lymph node (PALN) dissection for left-sided colorectal cancer (CRC) patients with clinically suspected PALN metastasis.
METHOD
A total of 151 patients who underwent primary tumor resection and laparoscopic PALN dissection for left-sided CRC were included, with 20 patients in the ICG group and 131 patients in the non-ICG group. The surgical outcomes, postoperative complications, and pathological results, such as the number of harvested and metastatic lymph nodes were compared between groups after propensity score matching.
RESULTS
Following propensity score matching, the ICG group had 20 patients, and the non-ICG group had 53 patients, and the two groups were similar in baseline characteristics. No significant differences were observed in overall intraoperative and postoperative complications between groups, except for chylous leakage, where the ICG group had a longer time to a normal diet. The number of harvested pericolic/perirectal and intermediate lymph nodes were comparable between the two groups, while the ICG group had a significantly higher number of total harvested lymph nodes (39 [14-78] vs. 29 [11-70], P = 0.001), inferior mesenteric artery lymph nodes (IMALN, 6 [0-17] vs. 3 [0-11], P = 0.006), and PALNs (9 [3-29] vs. 5 [1-37], P = 0.001).
CONCLUSION
ICG fluorescence imaging could increase the retrieval of IMALN, PALN, and total lymph nodes, and potentially improve the completeness of laparoscopic PALN dissection in patients with left-sided CRC.
PubMed: 38664189
DOI: 10.1016/j.asjsur.2024.04.027 -
JAMA Network Open Apr 2024Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this...
IMPORTANCE
Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes.
OBJECTIVE
To investigate associations between surgical performance and postoperative outcomes after MIE.
DESIGN, SETTING, AND PARTICIPANTS
In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes.
EXPOSURE
Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction.
MAIN OUTCOME AND MEASURE
The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes.
RESULTS
In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31).
CONCLUSIONS AND RELEVANCE
These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.
Topics: Male; Humans; Aged; Cohort Studies; Treatment Outcome; Esophagectomy; Minimally Invasive Surgical Procedures; Postoperative Complications; Esophageal Neoplasms
PubMed: 38639938
DOI: 10.1001/jamanetworkopen.2024.6556 -
Surgery Open Science Jun 2024The purpose of this study is to evaluate the potential of a novel surgical procedure, the Total Sealing Technique (TST), using the latest bipolar vessel sealing system...
BACKGROUND
The purpose of this study is to evaluate the potential of a novel surgical procedure, the Total Sealing Technique (TST), using the latest bipolar vessel sealing system (BVSS; LigaSure™ Exact Dissector) to reduce lymphatic leakage and seroma formation after electrocautery axillary lymph node dissection (ALND) in breast cancer surgery. Prolonged drainage is a common occurrence after ALND, primarily due to lymphatic leakage. In addition, the presence of seroma often leads to delays in the administration of postoperative adjuvant chemotherapy even after drain removal.
METHODS
We conducted a comparative analysis of 36 patients who underwent total mastectomy with ALND using conventional electrocautery technique (CONV) during the first 3 years, and 35 patients who underwent the same procedure using TST during the subsequent 3 years. The following factors were compared to assess the impact of TST: operation time, blood loss, total drainage volume, mean time to drain removal, postoperative hospital stay, mean time to initiation of postoperative chemotherapy, and postoperative complications in each group.
RESULTS
TST significantly reduced drainage volume (360.5 vs. 820.6 mL, < 0.001), days to drain removal (4.8 vs. 6.8 days, < 0.001), postoperative hospital stay (5.9 vs. 9.6 days, p < 0.001), the incidence of seroma (28.6 % vs. 65.9 %, = 0.001), and time to chemotherapy initiation (33.1 vs. 61.4 days, < 0.001) compared to CONV.
CONCLUSIONS
TST in total mastectomy with ALND effectively decreases the incidence of lymphorrhea and seroma formation; thus, it can be recommended for total mastectomy with ALND.
PubMed: 38590584
DOI: 10.1016/j.sopen.2024.01.011 -
World Journal of Gastrointestinal... Mar 2024In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the W. The authors present an interesting review on the use of...
In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the W. The authors present an interesting review on the use of indocyanine green fluorescence in different aspects of abdominal surgery. They also highlight future perspectives of the use of indocyanine green in mini-invasive surgery. Indocyanine green, used for fluorescence imaging, has been approved by the Food and Drug Administration and is safe for use in humans. It can be administered intravenously or intra-arterially. Since its advent, there have been several advancements in the applications of indocyanine green, especially in the surgical field, such as intraoperative mapping and biopsy of sentinel lymph node, measurement of hepatic function prior to resection, in neurosurgical cases to detect vascular anomalies, in cardiovascular cases for patency and assessment of vascular abnormalities, in predicting healing following amputations, in helping visualization of hepatobiliary anatomy and blood vessels, in reconstructive surgery, to assess flap viability and for the evaluation of tissue perfusion following major trauma and burns. For these reasons, the intraoperative use of indocyanine green has become common in a variety of surgical specialties and transplant surgery. Colorectal surgery has just lately begun to adopt this technique, particularly for perfusion visualization to prevent anastomotic leakage. The regular use of indocyanine green coupled with fluorescence angiography has recently been proposed as a feasible tool to help improve patient outcomes. Using the best available data, it has been shown that routine use of indocyanine green in colorectal surgery reduces the rates of anastomotic leak. The use of indocyanine green is proven to be safe, feasible, and effective in both elective and emergency scenarios. However, additional robust evidence from larger-scale, high-quality studies is essential before incorporating indocyanine green guided surgery into standard practice.
PubMed: 38577071
DOI: 10.4240/wjgs.v16.i3.641 -
Molecular Therapy : the Journal of the... May 2024Carrier-free naked mRNA vaccines may reduce the reactogenicity associated with delivery carriers; however, their effectiveness against infectious diseases has been...
Carrier-free naked mRNA vaccines may reduce the reactogenicity associated with delivery carriers; however, their effectiveness against infectious diseases has been suboptimal. To boost efficacy, we targeted the skin layer rich in antigen-presenting cells (APCs) and utilized a jet injector. The jet injection efficiently introduced naked mRNA into skin cells, including APCs in mice. Further analyses indicated that APCs, after taking up antigen mRNA in the skin, migrated to the lymph nodes (LNs) for antigen presentation. Additionally, the jet injection provoked localized lymphocyte infiltration in the skin, serving as a physical adjuvant for vaccination. Without a delivery carrier, our approach confined mRNA distribution to the injection site, preventing systemic mRNA leakage and associated systemic proinflammatory reactions. In mouse vaccination, the naked mRNA jet injection elicited robust antigen-specific antibody production over 6 months, along with germinal center formation in LNs and the induction of both CD4- and CD8-positive T cells. By targeting the SARS-CoV-2 spike protein, this approach provided protection against viral challenge. Furthermore, our approach generated neutralizing antibodies against SARS-CoV-2 in non-human primates at levels comparable to those observed in mice. In conclusion, our approach offers a safe and effective option for mRNA vaccines targeting infectious diseases.
Topics: Animals; Mice; SARS-CoV-2; COVID-19 Vaccines; mRNA Vaccines; COVID-19; Spike Glycoprotein, Coronavirus; Antibodies, Viral; Female; Antigen-Presenting Cells; RNA, Messenger; CD8-Positive T-Lymphocytes; Antibodies, Neutralizing; Humans; Vaccination
PubMed: 38569556
DOI: 10.1016/j.ymthe.2024.03.022 -
Clinical and Experimental Medicine Mar 2024To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients...
To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.
Topics: Humans; Male; Aged; Treatment Outcome; Chylothorax; Chylous Ascites; Lymphoproliferative Disorders; Lymphatic Abnormalities
PubMed: 38554229
DOI: 10.1007/s10238-024-01312-4 -
BMC Anesthesiology Mar 2024Kinetic analysis of crystalloid fluid yields a central distribution volume (V) of the same size as the expected plasma volume (approximately 3 L) except during general...
BACKGROUND
Kinetic analysis of crystalloid fluid yields a central distribution volume (V) of the same size as the expected plasma volume (approximately 3 L) except during general anesthesia during which V might be only half as large. The present study examined whether this difference is due to influence of the intravascular albumin balance.
METHODS
A population volume kinetic analysis according to a three-compartment model was performed based on retrospective data from 160 infusion experiments during which 1-2.5 L of crystalloid fluid had been infused intravenously over 20-30 min. The plasma dilution based on blood hemoglobin (Hb) and plasma albumin (Alb) was measured on 2,408 occasions and the urine output on 454 occasions. One-third of the infusions were performed on anesthetized patients while two-thirds were given to awake healthy volunteers.
RESULTS
The Hb-Alb dilution difference was four times greater during general anesthesia than in the awake state (+ 0.024 ± 0.060 versus - 0.008 ± 0.050; mean ± SD; P < 0.001) which shows that more albumin entered the plasma than was lost by capillary leakage. The Hb-Alb dilution difference correlated strongly and positively with the kinetic parameters governing the rate of fluid transfer through the fast-exchange interstitial fluid compartment (k and k) and inversely with the size of V. Simulations suggest that approximately 200 mL of fluid might be translocated from the interstitial space to the plasma despite ongoing fluid administration.
CONCLUSIONS
Pronounced plasma volume expansion early during general anesthesia is associated with a positive intravascular albumin balance that is due to accelerated lymphatic flow. This phenomenon probably represents adjustment of the body fluid volumes to anesthesia-induced vasodilatation.
Topics: Humans; Crystalloid Solutions; Isotonic Solutions; Retrospective Studies; Kinetics; Anesthesia, General; Hemoglobins; Albumins
PubMed: 38539087
DOI: 10.1186/s12871-024-02494-w