Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays ...Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.展开更多
Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has...Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has emerged as a cost-effective strategy for obese diabetic individuals; it has low complication rates and results in durable weight loss, glycemic control and improvements in the quality of life, obesity-related co-morbidity and overall survival. The finding that glucose homeostasis can be achieved with a weight loss-independent mechanism immediately after bariatric surgery, especially gastric bypass, has led to the paradigm of metabolic surgery. However, the primary focus of metabolic surgery is the alteration of the physio-anatomy of the gastrointestinal tract to achieve glycemic control, metabolic control and cardio-metabolic risk reduction. To date, metabolic surgery is still not well defined, as it is used most frequently for less obese patients with poorly controlled diabetes. The mechanism of glycemic control is still incompletely understood. Published research findings on metabolic surgery are promising, but many aspects still need to be defined. This paper examines the proposed mechanism of diabetes remission, the efficacy of different types of metabolic procedures, the durability of glucose control, and the risks and complications associated with this procedure. We propose a tailored approach for the selection of the ideal metabolic procedure for different groups of patients, considering the indications and prognostic factors for diabetes remission.展开更多
Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resectio...Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resection margin(PRM) and its related issues.Thus,the objective of this article is to review several studies on PRM and to summarize the current evidence on the subject.Although there is some discrepancy in the recommended values for PRM between authors,a PRM of more than 2-3 cm for early gastric cancer and 5-6 cm for advanced gastric cancer is thought to be acceptable.Once the margin is confirmed to be clear,however,the length of PRM measured in postoperative pathologic examination does not affect the patient's survival,even when it is shorter than the recommended values.Hence,the recommendations for PRM length should be applied only to intraoperative decision-making to prevent positive margins on the final pathology.Given that a negative resection margin is the ultimate goal of determining an adequate PRM,development and improvement of reliable methods to confirm a negative resection margin intraoperatively would minimize the extent of surgery and offer a better quality of life to more patients.In the same context,special attention has to be paid to patients who have advanced stage or diffuse-type gastric cancer,because they are more likely to have a positive margin.Therefore,a wider excision with intraoperative frozen section(IFS) examination of the resection margin is necessary.Despite all the attempts to avoid positive margins,there is still a certain rate of positive-margin cases.Since the negative impact of a positive margin on prognosis is mostly obvious in low N stage patients,aggressive further management,such as extensive re-operation,is required for these patients.In conclusion,every possible preoperative and intraoperative evaluation should be thoroughly carried out to identify in advance the patients with a high risk of having positive margins;these patients need careful management with a wider excision or an IFS examination to confirm a negative margin during surgery.展开更多
Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can r...Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary(16%-50%), bile duct(5%-39%), and duodenal cancer(3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival(29-47 mo and 22-54 mo) compared to pancreatic cancer(13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.展开更多
Laparoscopic surgery has many advantages over open surgery.At the same time,it is not without its risks.In this review,we discuss steps that could enhance the safety of laparoscopic surgery.Some of the important safet...Laparoscopic surgery has many advantages over open surgery.At the same time,it is not without its risks.In this review,we discuss steps that could enhance the safety of laparoscopic surgery.Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group;advanced discussion with the patient regarding unexpected intraoperative situations,and ensuring appropriate equipment is available.Important perioperative safety considerations include thromboprophylaxis;antibiotic prophylaxis;patient allergies;proper positioning of the patient,stack,and monitor(s);patient appropriate pneumoperitoneum;ergonomic port placement;use of lowest possible intra-abdominal pressure;use of additional five-millimetre(mm)ports as needed;safe use of energy devices and laparoscopic staplers;low threshold for a second opinion;backing out if unsafe to proceed;avoiding hand-over in the middle of the procedure;ensuring all planned procedures have been performed;inclusion of laparoscopic retrieval bags and specimens in the operating count;avoiding 10-15 mm ports for placement of drains;appropriate port closures;and use of long-acting local anaesthetic agents for analgesia.Important postoperative considerations include adequate analgesia;early ambulation;careful attention to early warning scores;and appropriate discharge advice.展开更多
In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic...In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects.Although the current study was limited by its small number of patients and retrospective nature,robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons.Most studies have reported satisfactory results for postoperative short-term coutcomes,such as:postoperative oral feeding,gas out,hospital stay and complications,compared with laparoscopic surgery;the difference is a longer operation time.However,robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery;after the accumulation of several cases,robotic surgery could be expected to result in a similar operation time.Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy.Moreover," total" robotic gastrectomy can be facilitated using a robotsewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique.In conclusion,robotassisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer,provided that long-term oncologic outcomes can be confirmed.展开更多
Objective: While interest in elective robotic surgery is growing, use in emergency setting remainslimited due to challenges posed by sicker patients, advanced pathology and logistical issues. During theCOVID-19 pandem...Objective: While interest in elective robotic surgery is growing, use in emergency setting remainslimited due to challenges posed by sicker patients, advanced pathology and logistical issues. During theCOVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from thebedside and reducing the number of directly exposed medical staff. The objective of this study was toreport patient outcomes and initial learning experience of emergency robotic colorectal surgery duringthe COVID-19 pandemic.Methods: A case series study was conducted, including patients undergoing emergency robotic colorectalsurgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK.Patient data were collected from an ethics approved prospective database. Patient demographics,operative time, conversions and postoperative complications were recorded. In addition, readmissions,length of stay and short-term oncological outcomes were analyzed.Results: Ten patients with median age 64 y (range, 36-83 y) were included. Four patients had roboticcomplete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease inemergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was249 ± 117 min, the median length of stay was 9.4 d (range, 5-22 d). Only one patient was given atemporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality.Conclusions: Provided an experienced team and peri-operative planning, emergency robotic colorectalsurgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncologicalcases and avoidance of diverting stoma.展开更多
Metabolic dysfunction-associated steatotic liver disease is increasingly understood to be closely linked with skeletal muscle alterations,such as sarcopenia,myoste-atosis,and metabolic dysregulation,which play a key r...Metabolic dysfunction-associated steatotic liver disease is increasingly understood to be closely linked with skeletal muscle alterations,such as sarcopenia,myoste-atosis,and metabolic dysregulation,which play a key role in its pathogenesis and progression.Recent literature,including an article by Isakov,highlights the bidirectional interactions between muscle and liver,underscoring shared mechanisms such as insulin resistance,inflammation,and myokine imbalance.This letter reflects on key findings from the review,noting strengths such as its integration of mechanistic insights,discussion of emerging biomarkers,and emphasis on lifestyle and pharmacological interventions.It also identifies areas for further development,including standardization of diagnostic criteria and more rigorous evaluation of translational data.As muscle health gains promi-nence in metabolic dysfunction-associated steatotic liver disease research,multidisciplinary strategies that target both hepatic and muscular systems may offer more effective avenues for prevention and treatment.展开更多
Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States ...Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1<sup>+</sup> or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.展开更多
Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign,solitary,and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hyp...Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign,solitary,and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple's triad,along with corroborating measurements of blood glucose,insulin,proinsulin,C-peptide,β-hydroxybutyrate,and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this,careful preoperative planning is required,with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound,which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings,but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit,laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore,this approach confers equivalent safety and efficacy rates to open resection,while improving cosmesis and reducing hospital stay. As such,laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.展开更多
BACKGROUND Mediastinal leakage(ML)is one of the most feared complications of esophagectomy.A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their i...BACKGROUND Mediastinal leakage(ML)is one of the most feared complications of esophagectomy.A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence,predictive factors,treatment,and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume,two low-volume)affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n=501)with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded,yielding an overall incidence of 11.8%(95%CI:9.1%-14.9%).The surgical approach significantly influenced the occurrence of ML:the proportion of leakage was 10.5%and 9%after open and hybrid esophagectomy(HE),respectively,and doubled(20%)after totally minimally invasive esophagectomy(TMIE)(P=0.016).No other predictive factors were found.The 30-and 90-d overall mortality rates were 1.4%and 3.2%,respectively;the 30-and 90-d leak-related mortality rates were 5.1%and 10.2%,respectively;the 90-d mortality rates for TMIE and HE were 5.9%and 1.8%,respectively.Endoscopy was the first-line treatment in 49%of ML cases,with the need for retreatment in 17.2%of cases.Surgery was needed in 44.1%of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%).Removal of the gastric tube with stoma formation was necessary in 8(13.6%)cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However,the general and specific(leak-related)mortality rates were low.Early treatment(surgical or endoscopic)of severe leaks is mandatory to limit related mortality.展开更多
BACKGROUND Neoadjuvant chemotherapy(NACT)and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas.Survival outcomes following resection have been improving over time while NACT remain larg...BACKGROUND Neoadjuvant chemotherapy(NACT)and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas.Survival outcomes following resection have been improving over time while NACT remain largely unchanged.Indeed,a recent meta-analysis of randomized control trials did not demonstrate a survival benefit in adding NACT,raising the possibility that improved surgical techniques may be reducing the perceived effectiveness of NACT.AIM To compare the effect of addition of NACT to a standardized surgery and lymphadenectomy on overall and disease-free survival in patients undergoing curative oesophagectomy for oesophageal adenocarcinoma.METHODS Patient data were analysed from a prospectively maintained surgical survival database.Demographic,surgical,and survival outcomes were compared between groups according to treatment and nodal count.RESULTS The data of 243 consecutive patients were identified.79 patients were given NACT and 162 had surgery only.The NACT group were younger,and there was less frequent stage I adenocarcinoma.Overall survival was similar between NACT and surgery only groups(5YS:48.7%vs 42.5%;P=0.113),as was diseasefree survival(5YS:40.6%vs 39.9%;P=0.635).There were≥30 nodes removed in 46 patients,and<30 in 197 patients,but were otherwise similar.There was improved survival in patients with≥30 nodes removed than those with<30 nodes(5YS:64.4%vs 40.7%;P=0.015),and a better disease-free survival that neared significance(5YS:54.9%vs 36.6%;P=0.078).CONCLUSION NACT did not appear to affect overall or disease-free survival.However,an overall survival benefit was observed in patients with≥30 lymph nodes removed,and a benefit in disease-free survival which was not significant.展开更多
BACKGROUND The United Kingdom government introduced lockdown restrictions for the first time on 23 March 2020 due to coronavirus disease 2019(COVID-19)pandemic.These were partially lifted on 15 June and further eased ...BACKGROUND The United Kingdom government introduced lockdown restrictions for the first time on 23 March 2020 due to coronavirus disease 2019(COVID-19)pandemic.These were partially lifted on 15 June and further eased on 4 July.Changes in social behaviour,including increased alcohol consumption were described at the time.However,there were no data available to consider the impact of these changes on the number of alcohol-related disease admissions,specifically alcoholrelated acute pancreatitis(AP).This study evaluated the trend of alcohol-related AP admissions at a single centre during the initial COVID-19 lockdown.AIM To evaluate the trend in alcohol-related AP admissions at a single centre during the initial COVID-19 lockdown in the United Kingdom.METHODS All patients admitted with alcohol-related AP from March to September 2016 to 2020 were considered in this study.Patient demographics,their initial presentation with AP,any recurrent admissions,disease severity and length of stay,were evaluated using ANOVA andχ^(2)and Kruskal–Wallis tests.RESULTS One hundred and thirty-six patients were included in the study.The highest total number of AP admissions was seen in March–September 2019 and the highest single-month period was in March–May 2020.Admissions for first-time presentations of AP were highest in 2020 compared to other year groups and were significantly higher compared to previous years,for example,2016(P<0.05).Furthermore,the rate of admissions decreased by 38.89%between March–May 2020 and June–September 2020(P<0.05),coinciding with the easing of lockdown restrictions.This significant decrease was not observed in the previous year groups during those same time periods.Admissions for recurrent AP were highest in 2019.The median length of hospital stay did not differ between patients from each of the year groups.CONCLUSION An increased number of admissions for alcohol-related AP were observed during months when lockdown restrictions were enforced;a fall in figures was noted when restrictions were eased.展开更多
Clostridium difficile is a gram-positive,spore-forming,obligate anaerobic bacillus that was originally isolated from the stool of a healthy neonate in 1935.In high-income countries,C.difficile is the most common cause...Clostridium difficile is a gram-positive,spore-forming,obligate anaerobic bacillus that was originally isolated from the stool of a healthy neonate in 1935.In high-income countries,C.difficile is the most common cause of infectious diarrhoea in hospitalized patients.The incidence of C.difficile infection in the USA has increased markedly since 2000,with hospitalizations for C.difficile infections in non-pregnant adults doubling between 2000 and 2010.Between 20%and 35%of patients with C.difficile infection will fail initial antibiotic treatment and,of these,40–60%will have a second recurrence.Recurrence of C.difficile infection after initial treatment causes substantial morbidity and is a major burden on health care systems.In this article,current treatments for recurrent C.difficile infection are reviewed and future directions explored.These include the use of antibiotics,probiotics,donor faecal transplants,anion resins,secondary bile acids or anti-toxin antibodies.展开更多
文摘Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.
文摘Medical therapy for type 2 diabetes mellitus is ineffective in the long term due to the progressive nature of the disease, which requires increasing medication doses and polypharmacy. Conversely, bariatric surgery has emerged as a cost-effective strategy for obese diabetic individuals; it has low complication rates and results in durable weight loss, glycemic control and improvements in the quality of life, obesity-related co-morbidity and overall survival. The finding that glucose homeostasis can be achieved with a weight loss-independent mechanism immediately after bariatric surgery, especially gastric bypass, has led to the paradigm of metabolic surgery. However, the primary focus of metabolic surgery is the alteration of the physio-anatomy of the gastrointestinal tract to achieve glycemic control, metabolic control and cardio-metabolic risk reduction. To date, metabolic surgery is still not well defined, as it is used most frequently for less obese patients with poorly controlled diabetes. The mechanism of glycemic control is still incompletely understood. Published research findings on metabolic surgery are promising, but many aspects still need to be defined. This paper examines the proposed mechanism of diabetes remission, the efficacy of different types of metabolic procedures, the durability of glucose control, and the risks and complications associated with this procedure. We propose a tailored approach for the selection of the ideal metabolic procedure for different groups of patients, considering the indications and prognostic factors for diabetes remission.
基金Supported by National Research Foundation of Korea Grant funded by the Korean Government,No. 2010-0024825
文摘Because of the intramural spread of gastric cancer,a sufficient length of a resection margin has to be attained to ensure complete excision of the tumor.There has been debate on an adequate length of proximal resection margin(PRM) and its related issues.Thus,the objective of this article is to review several studies on PRM and to summarize the current evidence on the subject.Although there is some discrepancy in the recommended values for PRM between authors,a PRM of more than 2-3 cm for early gastric cancer and 5-6 cm for advanced gastric cancer is thought to be acceptable.Once the margin is confirmed to be clear,however,the length of PRM measured in postoperative pathologic examination does not affect the patient's survival,even when it is shorter than the recommended values.Hence,the recommendations for PRM length should be applied only to intraoperative decision-making to prevent positive margins on the final pathology.Given that a negative resection margin is the ultimate goal of determining an adequate PRM,development and improvement of reliable methods to confirm a negative resection margin intraoperatively would minimize the extent of surgery and offer a better quality of life to more patients.In the same context,special attention has to be paid to patients who have advanced stage or diffuse-type gastric cancer,because they are more likely to have a positive margin.Therefore,a wider excision with intraoperative frozen section(IFS) examination of the resection margin is necessary.Despite all the attempts to avoid positive margins,there is still a certain rate of positive-margin cases.Since the negative impact of a positive margin on prognosis is mostly obvious in low N stage patients,aggressive further management,such as extensive re-operation,is required for these patients.In conclusion,every possible preoperative and intraoperative evaluation should be thoroughly carried out to identify in advance the patients with a high risk of having positive margins;these patients need careful management with a wider excision or an IFS examination to confirm a negative margin during surgery.
文摘Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary(16%-50%), bile duct(5%-39%), and duodenal cancer(3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival(29-47 mo and 22-54 mo) compared to pancreatic cancer(13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.
文摘Laparoscopic surgery has many advantages over open surgery.At the same time,it is not without its risks.In this review,we discuss steps that could enhance the safety of laparoscopic surgery.Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group;advanced discussion with the patient regarding unexpected intraoperative situations,and ensuring appropriate equipment is available.Important perioperative safety considerations include thromboprophylaxis;antibiotic prophylaxis;patient allergies;proper positioning of the patient,stack,and monitor(s);patient appropriate pneumoperitoneum;ergonomic port placement;use of lowest possible intra-abdominal pressure;use of additional five-millimetre(mm)ports as needed;safe use of energy devices and laparoscopic staplers;low threshold for a second opinion;backing out if unsafe to proceed;avoiding hand-over in the middle of the procedure;ensuring all planned procedures have been performed;inclusion of laparoscopic retrieval bags and specimens in the operating count;avoiding 10-15 mm ports for placement of drains;appropriate port closures;and use of long-acting local anaesthetic agents for analgesia.Important postoperative considerations include adequate analgesia;early ambulation;careful attention to early warning scores;and appropriate discharge advice.
基金Supported by A grant from the National R & D Program for Cancer Control,Ministry of Health and Welfare,Republic of Korea(1020410)
文摘In an effort to minimize the limitations of laparoscopy,a robotic surgery system was introduced,but its role for gastric cancer is still unclear.The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects.Although the current study was limited by its small number of patients and retrospective nature,robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons.Most studies have reported satisfactory results for postoperative short-term coutcomes,such as:postoperative oral feeding,gas out,hospital stay and complications,compared with laparoscopic surgery;the difference is a longer operation time.However,robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery;after the accumulation of several cases,robotic surgery could be expected to result in a similar operation time.Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy.Moreover," total" robotic gastrectomy can be facilitated using a robotsewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique.In conclusion,robotassisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer,provided that long-term oncologic outcomes can be confirmed.
文摘Objective: While interest in elective robotic surgery is growing, use in emergency setting remainslimited due to challenges posed by sicker patients, advanced pathology and logistical issues. During theCOVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from thebedside and reducing the number of directly exposed medical staff. The objective of this study was toreport patient outcomes and initial learning experience of emergency robotic colorectal surgery duringthe COVID-19 pandemic.Methods: A case series study was conducted, including patients undergoing emergency robotic colorectalsurgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK.Patient data were collected from an ethics approved prospective database. Patient demographics,operative time, conversions and postoperative complications were recorded. In addition, readmissions,length of stay and short-term oncological outcomes were analyzed.Results: Ten patients with median age 64 y (range, 36-83 y) were included. Four patients had roboticcomplete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease inemergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was249 ± 117 min, the median length of stay was 9.4 d (range, 5-22 d). Only one patient was given atemporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality.Conclusions: Provided an experienced team and peri-operative planning, emergency robotic colorectalsurgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncologicalcases and avoidance of diverting stoma.
文摘Metabolic dysfunction-associated steatotic liver disease is increasingly understood to be closely linked with skeletal muscle alterations,such as sarcopenia,myoste-atosis,and metabolic dysregulation,which play a key role in its pathogenesis and progression.Recent literature,including an article by Isakov,highlights the bidirectional interactions between muscle and liver,underscoring shared mechanisms such as insulin resistance,inflammation,and myokine imbalance.This letter reflects on key findings from the review,noting strengths such as its integration of mechanistic insights,discussion of emerging biomarkers,and emphasis on lifestyle and pharmacological interventions.It also identifies areas for further development,including standardization of diagnostic criteria and more rigorous evaluation of translational data.As muscle health gains promi-nence in metabolic dysfunction-associated steatotic liver disease research,multidisciplinary strategies that target both hepatic and muscular systems may offer more effective avenues for prevention and treatment.
文摘Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1<sup>+</sup> or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.
文摘Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign,solitary,and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple's triad,along with corroborating measurements of blood glucose,insulin,proinsulin,C-peptide,β-hydroxybutyrate,and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this,careful preoperative planning is required,with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound,which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings,but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit,laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore,this approach confers equivalent safety and efficacy rates to open resection,while improving cosmesis and reducing hospital stay. As such,laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.
文摘BACKGROUND Mediastinal leakage(ML)is one of the most feared complications of esophagectomy.A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence,predictive factors,treatment,and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume,two low-volume)affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n=501)with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded,yielding an overall incidence of 11.8%(95%CI:9.1%-14.9%).The surgical approach significantly influenced the occurrence of ML:the proportion of leakage was 10.5%and 9%after open and hybrid esophagectomy(HE),respectively,and doubled(20%)after totally minimally invasive esophagectomy(TMIE)(P=0.016).No other predictive factors were found.The 30-and 90-d overall mortality rates were 1.4%and 3.2%,respectively;the 30-and 90-d leak-related mortality rates were 5.1%and 10.2%,respectively;the 90-d mortality rates for TMIE and HE were 5.9%and 1.8%,respectively.Endoscopy was the first-line treatment in 49%of ML cases,with the need for retreatment in 17.2%of cases.Surgery was needed in 44.1%of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%).Removal of the gastric tube with stoma formation was necessary in 8(13.6%)cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However,the general and specific(leak-related)mortality rates were low.Early treatment(surgical or endoscopic)of severe leaks is mandatory to limit related mortality.
文摘BACKGROUND Neoadjuvant chemotherapy(NACT)and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas.Survival outcomes following resection have been improving over time while NACT remain largely unchanged.Indeed,a recent meta-analysis of randomized control trials did not demonstrate a survival benefit in adding NACT,raising the possibility that improved surgical techniques may be reducing the perceived effectiveness of NACT.AIM To compare the effect of addition of NACT to a standardized surgery and lymphadenectomy on overall and disease-free survival in patients undergoing curative oesophagectomy for oesophageal adenocarcinoma.METHODS Patient data were analysed from a prospectively maintained surgical survival database.Demographic,surgical,and survival outcomes were compared between groups according to treatment and nodal count.RESULTS The data of 243 consecutive patients were identified.79 patients were given NACT and 162 had surgery only.The NACT group were younger,and there was less frequent stage I adenocarcinoma.Overall survival was similar between NACT and surgery only groups(5YS:48.7%vs 42.5%;P=0.113),as was diseasefree survival(5YS:40.6%vs 39.9%;P=0.635).There were≥30 nodes removed in 46 patients,and<30 in 197 patients,but were otherwise similar.There was improved survival in patients with≥30 nodes removed than those with<30 nodes(5YS:64.4%vs 40.7%;P=0.015),and a better disease-free survival that neared significance(5YS:54.9%vs 36.6%;P=0.078).CONCLUSION NACT did not appear to affect overall or disease-free survival.However,an overall survival benefit was observed in patients with≥30 lymph nodes removed,and a benefit in disease-free survival which was not significant.
文摘BACKGROUND The United Kingdom government introduced lockdown restrictions for the first time on 23 March 2020 due to coronavirus disease 2019(COVID-19)pandemic.These were partially lifted on 15 June and further eased on 4 July.Changes in social behaviour,including increased alcohol consumption were described at the time.However,there were no data available to consider the impact of these changes on the number of alcohol-related disease admissions,specifically alcoholrelated acute pancreatitis(AP).This study evaluated the trend of alcohol-related AP admissions at a single centre during the initial COVID-19 lockdown.AIM To evaluate the trend in alcohol-related AP admissions at a single centre during the initial COVID-19 lockdown in the United Kingdom.METHODS All patients admitted with alcohol-related AP from March to September 2016 to 2020 were considered in this study.Patient demographics,their initial presentation with AP,any recurrent admissions,disease severity and length of stay,were evaluated using ANOVA andχ^(2)and Kruskal–Wallis tests.RESULTS One hundred and thirty-six patients were included in the study.The highest total number of AP admissions was seen in March–September 2019 and the highest single-month period was in March–May 2020.Admissions for first-time presentations of AP were highest in 2020 compared to other year groups and were significantly higher compared to previous years,for example,2016(P<0.05).Furthermore,the rate of admissions decreased by 38.89%between March–May 2020 and June–September 2020(P<0.05),coinciding with the easing of lockdown restrictions.This significant decrease was not observed in the previous year groups during those same time periods.Admissions for recurrent AP were highest in 2019.The median length of hospital stay did not differ between patients from each of the year groups.CONCLUSION An increased number of admissions for alcohol-related AP were observed during months when lockdown restrictions were enforced;a fall in figures was noted when restrictions were eased.
文摘Clostridium difficile is a gram-positive,spore-forming,obligate anaerobic bacillus that was originally isolated from the stool of a healthy neonate in 1935.In high-income countries,C.difficile is the most common cause of infectious diarrhoea in hospitalized patients.The incidence of C.difficile infection in the USA has increased markedly since 2000,with hospitalizations for C.difficile infections in non-pregnant adults doubling between 2000 and 2010.Between 20%and 35%of patients with C.difficile infection will fail initial antibiotic treatment and,of these,40–60%will have a second recurrence.Recurrence of C.difficile infection after initial treatment causes substantial morbidity and is a major burden on health care systems.In this article,current treatments for recurrent C.difficile infection are reviewed and future directions explored.These include the use of antibiotics,probiotics,donor faecal transplants,anion resins,secondary bile acids or anti-toxin antibodies.
