Robot surgery is an important trend in contemporary colorectal cancer surgical treatment. The Robotic Surgery Group, Colorectal Cancer Committee of Chinese Medical Doctor Association organized experts in relevant fields across the country to update and revise the application standards of robotic colorectal cancer surgery based on the Expert consensus on robotic surgery for colorectal cancer (2015 edition) and the revised version in 2020, in accordance with the development of robotic surgery concepts, technologies, and equipment in recent years, in order to promote the application and promotion of robotic surgery.
Objective To assess the impact of preoperative nutritional prehabilitation with total parenteral nutrition(TPN)versus enteral combined parenteral nutrition(EN+PN)on the outcomes of surgical patients with Crohn's disease(CD)complicated with intestinal obstruction or intestinal fistula.Methods The clinical data of 200 patients who underwent surgery after nutritional prehabilitation with TPN or EN+PN for CD combined with intestinal obstruction or intestinal fistula at the Inflammatory Bowel Disease Treatment Centre of General Surgery Department,Affiliated Hospital of Medical School,Nanjing University,from 2012-12-01 to 2021-12-01 were retrospectively analyzed.The patients were divided into the TPN group(137 cases)and,the EN+PN group(63 cases)according to the different ways of nutritional prehabilitation used.The propensity score matching(PSM)method was used to compare the effects of nutritional treatment and the incidence of complications at 30 d postoperatively between the TPN group and the EN+PN group.Results Before PSM,patients in the TPN and EN+PN groups had higher albumin levels and hemoglobin levels after nutritional pre-rehabilitation therapy compared with those before nutritional pre-rehabilitation therapy,and the albumin level in the EN+PN group was higher than that in the TPN group(35.7±4.4 g/L vs.33.5±5.4 g/L,t=-2.79,P=0.003);C-reactive protein in the EN+PN group was lower than that in the TPN group,but the difference was not statistically significant,6.3(1.1,20.5)mg/Lvs.9.9(2.3,30.0)mg/L,Z=-1.27,P=0.201;hemoglobin levels were higher in the EN+PN group than in the TPN group,112.5+15.5 g/L vs.105.3±18.8 g/L,t=-2.6,P=0.005.After PSM with hemoglobin and albumin as matching variables in a 1:2 ratio,there were 96 cases in the TPN group and 60 cases in the EN+PN group,respectively,and there was no statistically significant difference in the comparison of the albumin level and hemoglobin level between the two groups(both P＞0.05).After surgical treatment,the incidence of enterostomy(50.0％vs.30.0％,x2=6.1,P=0.022),superficial wound infection(27.1％vs.10.0％,x2=6.6,P=0.018),ileus(58.3％vs.33.3％,x2=9.2,P=0.004),and overall postoperative complications(70.8％vs.41.7％,x2=13.1,P=0.001)were higher in the TPN group compared with the EN+PN group.In addition,the TPN group had a longer hospital stay than the EN+PN group,11.0(7.0,16.0)d vs.8.0(6.7,11.0)d,Z=-2.4,P=0.013.Conclusions Both TPN and EN+PN can be used for nutritional prehabilitation and both can achieve satisfactory results,but nutritional prehabilitation with EN+PN may be better in terms of nutritional treatment effects and surgical outcomes,which deserves further research to validate.
一、概述 根据中国国家癌症中心发布的数据,2022年全国原发性肝癌发病人数36.77万,位列各种癌症新发病人数第4位(肺、结直肠、甲状腺、肝),发病率位列第5位(肺、女性乳腺、甲状腺、结直肠、肝);2022年因原发性肝癌死亡人数31.65万,死亡人数和死亡率均位列第2位(肺、肝)[1-2].原发性肝癌主要包括肝细胞癌(hepatocellular carcinoma,HCC)、肝内胆管癌(intrahepatic cholangiocarcinoma,ICC)和混合型肝细胞癌-胆管癌(combined hepatocellular-cholangiocarcinoma,cHCC-CCA)3 种不同病理学类型,三者在发病机制、生物学行为、病理组织学、治疗方法以及预后等方面差异较大,其中HCC占75％～85％、ICC占10％～15％[3-4].本指南中的"肝癌"仅指HCC.
膜解剖主要研究与外科手术相关的人体各种膜结构，如腹膜（peritoneum）、系膜（mesentery）、筋膜（fascia）、浆膜（serosa），及其衍生的韧带（ligament）、板（lamina）、隔（sep-tum）、束（bundle）、间隙（space）、鞘（sheath）等，在临床上强调通过筋膜间的平面来完成系膜的完整切除，因而膜解剖以系膜解剖为目的，以筋膜解剖为手段，二者共同组成了膜解剖的理论体系[1]。由于盆腔膜解剖理论和实践的迅速发展，迫切需要对现有的膜解剖名词进行修正和更新，
1单吻合口胃旁路术 单吻合口 胃旁路术(one anastomosis gastric bypass,OAGB)是在 Roux-en-Y 胃旁路术(Roux-en-Y gastric by-pass,RYGB)基础上简化的术式,通过建立狭长的胃囊及旷置十二指肠与部分空肠达到减重目的.此术式仅建立一个胃空肠吻合口,手术时间与学习曲线短,操作简捷易于掌握.
减重与代谢外科在我国快速发展,虽然目前我国主流术式源于西方国家,但中国减重与代谢外科医生也在不停的探索更适合我国病人的新术式.探索新术式初衷虽好,但是新术式在开展前要对手术的规范性、安全性、有效性进行严格评估,不可直接大范围推广.减重与代谢外科的相关行业学术组织也应发挥正面引导作用,提升经济效益与社会效益,助力我国减重与代谢外科更快更好发展.
The prognosis of gallbladder cancer（GBC）is very dismal and surgical resection renders little help for those at advanced stages. Whether neoadjuvant therapy can improve the outcome of GBC has become a hot topic of concern.However, there are still concerns regarding how to achieve effective new adjuvant therapy because of a lack of high-quality evidence-based data and misapprehension in clinical settings. In addition, three core issues need to be clarified,including the criteria of indication of applicable patientss, the specific treatment regimens, and the evaluation of therapeutic effect. The application of novel technological breakthroughs such as artificial intelligence, an organoid and liquid biopsy may shed light on neoadjuvant therapy for gallbladder cancer.
随着减重代谢外科不断发展,以胃袖状切除术(SG)为基础的多种创新术式不断涌现.目前的临床证据表明,胃袖状切除术附加手术(SG plus)能增强减重降糖效果,减少手术并发症.由于没有旷置的胃囊,因此术后可以容易施行胃镜检查.近期研究数据显示,胃袖状切除术联合十二指肠-空肠旁路术(SG-DJB)在1年和3年的随访中,多余体重减少百分比(％EWL)分别为95.77％和83.84％,总体重减少百分比(％TWL)分别为34.64％和30.32％,降糖效果和Roux-en-Y胃旁路术(RYGB)类似,胃袖状切除术联合近端空肠旁路术(SG-PJB)研究表明减重效果优于单纯的SG,减重降糖效果类似于RYGB,并发症远低于RYGB.治疗2型糖尿病为 目的的手术推荐SG-DJB,对于以减重为主要目的的病人,优先选择SG-PJB,对于有合并反流性食管炎者可以考虑RYGB.SG plus未来仍然需要高质量的研究.
肥胖是重要的全球性健康问题.肥胖不仅影响个体健康,还增加社会卫生保健负担和劳动力损失.减重与代谢手术是治疗肥胖最有效的方法.胃袖状切除术联合单吻合口十二指肠-回肠旁路术、单吻合口胃旁路术、胃内球囊置入和内镜胃袖状成形术等减重与代谢手术新术式使减重代谢治疗策略更加丰富多样.在此基础上,未来的减重代谢术式创新关键在于通过各种手术策略重塑多巴胺介导的"食物成瘾"和"享乐饥饿",而限制摄入仍然是最直接有效的切入点.
Hemorrhoid disease（HD） is one of the most common clinical benign diseases,which prevalence rates vary from4%～55% over the world.Treatment of HD increases,the financial burden.For those patients who do not.respond to conservative treatment,outpatient clinic procedure or surgical treatment would be necessary.Comparation of the recent practice guidelines（or consensus） of 11 countries shows high consistency in the classification,diagnosis and treatment of hemorrhoid disease.While there are still some differences due to different cultural and insurance factors.In Asian countries like China and Japan,there are more conservative treatment methods.Meanwhile,there are more office treatment methods in western countries.
Radiologic metrics are reliable biomarkers for evaluating the efficacy of neoadjuvant therapy in the context of digestive system cancer. Radiomics is an emerging field that combines artificial intelligence with medical images.Radiomics models could be built to support clinical decision-making by extracting and combining the vast amount of information embedded in the images, such as morphologic features, texture features, and high-dimensional features of the region of interest. It has great potential for evaluating responses precisely. Some encouraging radionics research results have been published. Affected by inter-model heterogeneity and complexity factors, as well as the lack of high-level evidence studies required for clinical application,clear clinical translation has not yet been achieved. The application of radiomics in evaluating the efficacy of neoadjuvant therapy for gastrointestinal cancer needs rigorously designed multi-center,large-sample clinical studies and prospective verification to provide effective evidence for the routine clinical application of this innovative method.
Infected pancreatic necrosis（IPN） is a bottleneck problem in the treatment of severe acute pancreatitis（SAP）.In recent years, minimally invasive drainage has become the primary choice of treatment for IPN, but open surgery remains an important part of the new "step-up" treatment strategy.Under the new treatment strategy, not only the indications and timing of open surgery should be understood and changed, but also the operation process of open surgery should keep pace with the Times.Therefore, we summarized the key points of open-surgery under the new treatment strategy, and suggested following the three "not-to-do" s:（1） Not to involve the infracolonic compartment in the surgery;（2） No add-on surgery when doing open surgery, simplify the surgery;（3） Not to pursue complete necrosectomy during the first surgery.
作为胆胰分流并十二指肠转位术(BPD-DS)的改良术式,胃袖状切除术联合单吻合口十二指肠-回肠旁路术(SADI-S)对肥胖及代谢病的疗效非常显著,且远大于胃袖状切除术和Roux-en-Y胃旁路术,且较后者具有更低的操作难度和更少的手术并发症.应充分肯定SADI-S在治疗肥胖及代谢病中的价值.然而,SADI-S术后仍有少数病人发生营养不良性肝病、低蛋白血症、胆汁反流等问题,是SADI-S术后行修正手术的主要原因,正视这些问题有利于更好地将这一术式服务于肥胖病人的治疗.术前严格筛查病人、术中精确测量肠道并制定"个性化"共同通道参数及术后严密随访是减少SADI-S术后发生营养不良和反流的有效措施.
Objective To investigate the safety and effectiveness of establishing a transaxillary lumpectomy space for lumpectomy thyroid surgery without inflatable posterior approach based on the deep cervical fascial anatomy.Methods The clinical data of 276 consecutive patients admitted to the Department of Thyroid Hernia Surgery,Southern Hospital of Southern Medical University from June to December 2021 who underwent transaxillary lumpectomy thyroid surgery were retrospectively analyzed,and the surgical space was established based on fascial anatomy.Intraoperative and postoperative conditions were observed and recorded,and follow-up was performed on the second day after surgery and at 3 and 6months after surgery.Results The operative time was 80.5（60-115） min and the operative space was established in 18（12-26） min.Intraoperative bleeding was 5（1-15） mL.There were 2 cases of intraoperative extra-jugular venous and genera expenditure blood and 1 case of intraoperative anterior jugular vein bleeding.The postoperative hospital stay was 2.5（1-4） d.Sensory recovery scores in the clavicular region were assessed on the second postoperative day:221（80.1%） S3,55（19.9%） S2,no S4,S3+,S1 or S0 cases;3 months postoperatively:245（88.8%） S3+/S4,30（10.9%） S3 and 1（0.4%） S2;6 months postoperatively:270（97.8%） S3+/S4,6（2.2%） S2,no postoperative flap area effusion.Follow-up was completed in all cases.Two patients had temporary hoarseness after surgery and voice was restored at the 3-month postoperative follow-up.There were no postoperative lymphatic fistulas,Horner’s syndrome,postoperative bleeding or swelling of the sternocleidomastoid muscle,and no recurrent cases.Conclusion The fascial anatomy-based method of transaxillary uninflated lumpectomy thyroid surgery space creation is safe and effective and can be used as a routine method.
With the concept evolution and technological development of pancreatic head cancer, the status of comprehensive treatment has become increasingly prominent.In the context of the comprehensive treatment mode of pancreatic head cancer, biliary drainage, as an important part of comprehensive treatment, not only reduces jaundice before surgery, but also ensures the effective development of comprehensive treatment. Attaching importance to endoscopic biliary drainage and selecting appropriate biliary drainage to better coordinate with chemotherapy, targeted therapy, surgery and other therapeutic means, which will help improve the quality of life, nutritional status, and long-term survival rate of patients.
胆道恶性肿瘤包括肝内胆管癌(intrahepatic cholangio-carcinoma)、肝外胆管癌(extrahepatic cholangiocarcinoma)及胆囊癌(gallbladder cancer),约占所有消化道恶性肿瘤的3％,近年来发病率呈上升趋势.50％的胆道恶性肿瘤病人在确诊时已为进展期,生存期＜1年.仅有10％左右的病人就诊时具有手术机会,术后1年内的转移复发率高达67％,5年生存率为5％～15％[1-2].
Objective To explore the safety and efficacy of donafenib as adjuvant therapy of patients with hepatocellular carcinoma at a high risk of recurrence after hepatectomy.Methods The clinical data of 27 patients with hepatocellular carcinoma who underwent radical hepatectomy admitted to the Department of Hepatobiliary Surgery of the First Affiliated Hospital of University of Science and Technology of China from April 2021 to April 2022 were retrospectively analyzed.All patients received Donafenil adjuvant therapy after surgery（initial dose 100 mg bid）.Imaging examination was performed to determine whether the patients had tumor recurrence,and the severity of adverse events were determined according to the NCICTCAE 5.0.Results Up to 2023-02-15,the median follow-up time of the study was 13.6 months（4.3-21.2）,and the 1-year RFS was 83.3%.No patient had died during the treatment.The median treatment time of patients was 12.0 months（2.2-17.5）,and the treatment period of 26 patients（96.3%） was more than 6 months.In terms of safety,adverse events occurred in 24 patients（88.9%）,the severity of which was mainly grade Ⅰ-Ⅱ（81.5%）,and no fatal adverse events occurred.Common adverse events included hand-foot syndrome,decreased platelet count,bleeding gums,alopecia,and diarrhea.Conclusion Donafenib as adjuvant therapy of patients with hepatocellular carcinoma at high risk of recurrence after hepatectomy has potential application value,and shows good safety and effectiveness.
目的 探讨腹腔镜肝切除术中转开放手术危险因素及构建中转开放手术的风险预测模型.方法 回顾性分析2019年6月至2022年5月南方医科大学南方医院肝胆外科收治的938例行腹腔镜肝切除术病人的临床病例信息,依据是否中转开放手术分为腹腔镜组(836例)和中转组(102例),收集所有纳入病人基本信息和临床病例资料,分析两组组间差异及因素,基于多因素分析结果构建中转开放手术列线图预测模型.结果 单因素分析结果显示,在有无腹部手术史、有无血管性介入治疗史、是否首次行肝切除、有无腹腔积液、肝肿瘤最大直径、是否为困难肝段切除、切除范围等,差异具有统计学意义(P＜0.05).多因素分析结果显示,有腹部手术史(OR=1.716,95％CI 为 1.023-2.878)、非首次行肝切除(OR=3.585,95％CI 为 1.705-7.538)、肝肿瘤最大直径≥5cm(OR=2.680,95％CI 为 1.646-4.363)、困难肝段切除(OR=2.953,95％CI为 1.755-4.967)、肝段切除范围≥3 个肝段(OR=1.901,95％CI为1.099-3.290)为腹腔镜肝切除术中转开放手术的独立危险因素(P均＜0.05).依据多因素分析结果,纳入5个独立危险因素变量,构建腹腔镜肝切除术中转开放手术的列线图模型.模型的C-index为0.746(95％CI为 0.692-0.800),Hosmer-Lemeshow拟合优度检验结果P=0.541＞0.05,绘制 ROC 曲线,曲线下面积(AUC)为0.746(95％CI为0.692-0.800,P＜0.001).绘制的临床决策曲线(DCA)结果示在阈值概率范围0.05～0.70内模型具有临床效用.结论 有腹部手术史,非首次行肝切除,肝肿瘤最大直径≥5 cm,困难肝段切除,肝段切除范围≥3个肝段是腹腔镜肝切除术中转开放手术的独立危险因素.基于此构建的列线图模型的校准曲线拟合程度理想,在预测的中转开放手术率与实际的中转开放手术率有较好的一致性,模型具有良好预测能力,但仍有待行外部验证来进一步证实.
Immune checkpoint inhibitors（ICIs） continue to advance in gastric cancer,which bringing new options for the neoadjuvant treatment.Through out the current research on neoadjuvant immunotherapy for locally advanced gastric cancer,ICIs in combination with chemotherapy/radiotherapy neoadjuvant therapy have shown good therapeutic efficacy and may further enhance the efficacy on the existing basis.For specific populations,immunotherapy combined with targeted therapy or dual-immune neoadjuvant therapy may show advantages.Due to immune-related toxicity,the use of immune checkpoint inhibitors should be cautious,and it remains a great challenge to screen the beneficiaries of immunotherapy and select the best treatment options.It is expected that the subsequent phase Ⅲ clinical studies will reveal the true effect of ICIs in neoadjuvant treatment of gastric cancer,leading to a new breakthrough in immunotherapy in gastric cancer and further improving the survival of gastric cancer patients.
