中华胃肠外科杂志最新文献

Objective: To explore the feasibility and preliminary clinical experience of robot-assisted pelvic exenteration (PE) in the treatment of locally advanced (LARC) and recurrent (LRRC) rectal cancer. Method: A descriptive case series research method was adopted. Inclusion criteria included: (1) Age 18-80 years old; (2) Preoperative puncture biopsy performed through endoscopy, and a pathological diagnosis of rectal malignant tumor; (3) Preoperative imaging examinations confirming locally advanced (cT4b stage) or locally recurrent rectal cancer, with tumor location in the pelvic cavity; (4) Physical condition: ECOG score ≤1 point, and radical resection being feasible after assessment. The data for five patients with LARC or LRRC who underwent pelvic exenteration (PE) using the da Vinci robotic surgical system in the Department of Anorectal Surgery, the Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital) from January, 2024 to January, 2025 were collected retrospectively. The mean age was (46.8±7.7) years, with 3 males and 2 females, who comprised 2 cases of LARC and 3 cases of LRRC. Two patients received preoperative radiotherapy, and 4 patients received preoperative chemotherapy. The average body mass index was (21.5±2.7) kg/m². According to the American Society of Anesthesiologists (ASA) classification, 2 cases were grade II and 3 cases were grade III. Results: All patients with LARC or LRRC successfully underwent robot-assisted PE. The average operation time was (496.4±139.5) minutes; the average intraoperative blood loss was (72.0±29.5) ml; the average postoperative exhaust time was (50.0 ±13.6) hours; and the average postoperative defecation time was(64.2±15.3) hours. Mean early postoperative VAS pain scores was (3.6±1.5) points. Three patients underwent primary intestinal anastomosis, and 2 patients underwent colonic single-lumen ostomy. All 5 patients underwent urinary system reconstruction, among which 2 underwent ureterovesical reimplantation, 1 underwent percutaneous ureterostomy, 1 underwent ileal conduit replacement of bladder, and 1 underwent direct bladder suture. After surgery, except for 1 case of pelvic infection with effusion (Clavien-Dindo grade IIIa), there were no obvious postoperative complications. Postoperative pathological results showed that all patients achieved R0 resection, including 1 case of T4a stage and 4 cases of T4b stage (all involving urogenital organs or tissues), and 3 cases of N0 stage and 2 cases of N1 stage, with a maximum tumor diameter of (4.7±1.9) cm. The median postoperative follow-up time was 11 (range 7 to 17) months, and no patient experienced local recurrence. Conclusion: The above short-term preliminary results of robot-assisted PE in the treatment of LARC or LRRC within the pelvic cavity indicate that it is both safe and feasible.

Robotic gastrointestinal surgery performed by domestic surgical robot started relatively late but has developed rapidly, gradually transitioning from a follower to a strong competitor and local leader, particularly in fields such as single-port and remote surgery, where it has taken the lead internationally. However, it also faces challenges such as low levels of localization of core technologies, insufficient high-level evidence-based medical evidence, an incomplete training system, and a need for standardized procedures. In the future, driven by breakthroughs in core technologies, integration of artificial intelligence, policy support, and clinical demand, domestically produced robotic gastrointestinal surgery will enter a phase of comprehensive development. By overcoming key technologies such as force feedback and precision transmission, reliance on imported components can be reduced, thereby lowering production costs and addressing clinical practical concerns; conducting high-quality clinical research to provide high-level evidence-based medical evidence for surgeries; establishing standard operating procedures and improving training systems to achieve standardized surgical practices; and deeply integrating artificial intelligence technology to enable functions such as intraoperative navigation and enhanced diagnosis, significantly improving surgical precision. Additionally, establishing standardized protocols and ethical regulations for remote surgeries will also help domestic remote robotic surgeries become an important medical tool.

Robot-assisted surgery with its advantages such as three-dimensional high-definition vision, dexterous robotic arms, and tremor filtration, is increasingly being applied to complex radical gastrectomy. However, the role of the surgical assistant remains crucial during the procedure. The assistant is responsible for tasks outside the console, including adjusting robotic arms, changing instruments, exposing the surgical field, and addressing unexpected situations. The technical proficiency of the assistant and their collaboration efficiency with the primary surgeon directly impact the smoothness of surgery and patients' outcomes. With the expansion of robot-assisted surgical indications, the establishment of a standardized training system and the optimization of team collaboration models have become urgent challenges to address. This article draws on the author's practical experience as an assistant in robot-assisted gastric cancer surgeries, conducting an in-depth analysis of the responsibilities and operational skills of surgical assistants in robot-assisted procedures. The aim is to develop a relatively comprehensive set of operational guidelines for surgical assistants in robot-assisted radical gastrectomy, providing valuable references for enhancing the overall efficiency of surgical teams and improving surgical outcomes.

Objective: To investigate the feasibility and safety of laparoscopic purse- string suture clamps combined with multi-functional seal caps for esophagojejunal Roux-en-Y anastomosis during total laparoscopic radical total gastrectomy (TLTG). Methods: This was a retrospective descriptive study of 42 patients with primary gastric malignancies who underwent TLTG at the First Affiliated Hospital of Nanjing Medical University that utilized laparoscopic purse-string suture clamps and multi-functional seal caps for esophagojejunal anastomosis between May, 2024 and January, 2025. The cohort included 33 males and 9 females, with a mean age of (67.7 ±9.5) years and a mean body mass index (BMI) of (23.9±2.9) kg/m². The American Society of Anesthesiologists (ASA) physical status classifications were I - II in 40 patients and III in 2 patients, and all patients were definitively diagnosed preoperatively via gastroscopy, dual-energy CT, and/or MRI. Tumor locations included the gastroesophageal junction (GEJ) in 28 cases (Siewert type II - III), the upper third of the stomach in 12 cases, and the middle third in 2 cases. The median distance of esophageal invasion was 1.3 cm, though in 10 cases this was ≥2 cm. Preoperative TNM staging was I-II in 17 patients and III in 25 patients. Surgical outcomes including operative time, anastomosis time, intraoperative blood loss, pathological results, and postoperative recovery were retrospectively analyzed. Results: All 42 operations were successful. The mean operative time was(212.5±26.4) minutes, and the average time from multi-functional seal cap placement to completion of the esophagojejunal anastomosis was (54.2±7.5) minutes. Mean intraoperative blood loss was (79.9±21.3) ml. Postoperative pathology confirmed R0 resection in all specimens, with a mean proximal esophageal margin distance of (2.1±1.6) cm. Furthermore, (51.9±15.1) lymph nodes on average were harvested from each patient; the mean time to oral intake was (149.5±41.4) hours; and the mean hospital stay was (11.3±5.4) days. Postoperative complications occurred in 6 patients: anastomotic leakage (n=2), residual intra-abdominal infection (n=1), pulmonary infection (n=3), and Clavien-Dindo grade III or higher complications occurred in 2 patients. No recurrence, mortality, or anastomosis-related complications were observed within a median follow-up of 5.8 months (range 3.5-11.2). Conclusion: We find the application of the laparoscopic purse-string suture clamps and multi-functional seal caps for esophagojejunal anastomosis in TLTG to be safe and feasible, with satisfactory short-term outcomes.

Over the past two decades, the surgical treatment of gastric cancer has witnessed remarkable transformations. It has evolved from traditional open - surgery to laparoscopic minimally - invasive surgery, and subsequently to robot - assisted surgery. The robotic surgical system, owing to its distinctive advantages, has been gradually applied and popularized in gastric cancer surgeries. Nevertheless, it inevitably gives rise to specific technical blind spots and operational challenges.This paper systematically reviews the classification of intraoperative errors in robotic gastric cancer surgery and their clinical implications. It proposes a grading standard for bleeding, explores the identification and prevention strategies of hazard zones, and underscores the core values of meticulous preoperative planning, the standardized operation, and teamwork. Simultaneously, in light of the impact of tissue edema and fibrosis following neoadjuvant therapy on surgery, corresponding grading standards are established. The objective is to offer a valuable reference for clinical practice and facilitate the standardized and precise development of robotic gastric cancer surgery.

Objective: To evaluate the efficacy of vacuum sealing drainage (VSD) in the comprehensive management of full-thickness perineal wound dehiscence following pelvic exenteration (PE). Methods: This study employed a descriptive case series design. We retrospectively analyzed the clinical data of 29 patients who developed postoperative perineal wound infections with full-thickness dehiscence after PE. These cases included 16 patients from the Department of General Surgery at Jiangyin People's Hospital (Jiangsu Province) and 13 patients from the Department of Colorectal Surgery at the Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital). VSD was applied to manage the dehisced wounds, with outcomes assessed based on wound healing time, complications, and follow-up data. Results: A total of 29 patients were included in the study. The operative time for PE was (498 ± 83) minutes. Among them, 23 patients underwent combined sacrococcygeal resection. The median number of VSD devices used was 28 (22, 39). The postoperative perineal wound healing time was 95 (82, 110) days in patients who underwent combined sacrococcygeal resection, 74 (63, 89) days in those without sacrococcygeal resection, 93 (79, 102) days in those treated with simple pelvic-abdominal isolation using a biological basement membrane mesh and 76 (60, 91) days in those who received combined pelvic packing with a pedicled omental flap. All patients uniformly developed Clavien-Dindo grade III complications at 2 weeks postoperatively, manifesting as perineal wound infection and dehiscence, which were successfully managed with VSD therapy. Subsequent evaluation identified delayed (>30 days) grade III complications, including enterocutaneous (3 cases) and urinary (2 cases) fistulae, all requiring surgical revision. All patients completed the follow-up at 6 months postoperatively. Three patients still presented with minimal exudate from the perineal wound, which resolved after standardized wound care and packing with alginate silver ion dressings. Four cases (13.8%) developed stoma high-output syndrome, which improved after oral medication. Eight patients (27.6%) developed adhesive intestinal obstruction, which improved with conservative treatment. Conclusions: VSD demonstrates unique advantages in managing complex wounds. For full-thickness perineal wound dehiscence after PE, VSD is a safe and effective therapeutic strategy.

Total mesorectal excision (total mesorectal excision, TME) has currently become the standard procedure for the treatment of rectal cancer. However, whether to preserve the left colic artery (LCA) during TME surgery remains controversial. The debates mainly focus on whether preserving the LCA can achieve complete dissection of No. 253 lymph nodes and its impacts on patients' defecation, urination, and sexual functions, and prognosis. This article systematically reviews the recent research progress necessity surgical techniques for LCA preservation by combining the anatomical characteristics of the inferior mesenteric artery (IMA) and LCA with clinical experience.

Total pelvic exenteration (TPE) is widely regarded as the most effective intervention for the management of primary locally advanced rectal cancer and locally recurrent rectal cancer. However, TPE presents several challenges, including the potential for failing to achieve R0 resection, high incidence of complication, decreased postoperative quality of life, and the possible overtreatment in patients without carcinomatous adhesions or with only inflammatory adhesions, as well as in those who achieve pathological complete response after neoadjuvant therapy. In the context of precision medicine, further investigation is necessary to enhance the accuracy of preoperative diagnoses of extrarectal cancer invasion and to explore the comprehensive application of genetic molecular typing methods alongside innovative neoadjuvant treatment strategies. Such research should aim to enhance the R0 resection rate of TPE, minimize surgical complications and mortality, improve postoperative quality of life, and achieve an optimal balance between radical resection and the preservation of organ function.

Objective: Summarize the clinical efficacy of using a disposable decomposed soft injection probe under propofol induced local infiltration anesthesia for the treatment of complex anal fistula. Methods: This technology is applied to patients with complex anal fistulas with clear diagnosis and no surgical contraindications. Using propofol to induce local infiltration anesthesia, a disposable decomposed soft injection probe (invention patent number: ZL 2014 1 0173127.3) soft catheter is gently introduced from the outer opening, passing through a cord like hard structure that can be touched on the surface of the body, and exiting through the rectum and anal canal. According to preoperative identification, each probe is explored one by one. If the inner opening and fistula are below the anorectal ring, a "V" - shaped incision is made to the skin and mucosal transition area between the inner and outer openings, and the fistula and inner opening are removed; If the exploration of the internal opening and fistula is above the anorectal ring, the internal opening should be enlarged and trimmed, and the skin of the external opening should be cut off in a shuttle shape. A soft catheter should be used to pull out a rubber strip for loose floating drainage. The two ends of the drainage rubber strip should be tied and fixed with 1 # silk thread. Connect a disposable decomposed soft injection probe with extracted methylene blue mixture (methylene blue 0.5 ml+0.9% sodium chloride 9.5 ml), press the external opening of the anal fistula to form a blind tube that seals the external opening, inject methylene blue mixture, implant an anal hook, explore the remaining blue anal sinus area, and inject methylene blue mixture again to determine the accurate position of the internal opening. Trim and enlarge the inner openings that have been accurately detected one by one. For the main fistula that runs below the anorectal ring, perform a "V" incision to cut open the soft tissue in the skin and mucosal transition area between the inner and outer openings, and remove the inner opening and fistula at once; For anal fistulas with fistulas above the anorectal ring, internal incision trimming and enlargement, sinus scraping, and floating bridge drainage surgery should be performed; For a complex anal fistula with multiple internal and external openings, the main lesion should be incised and treated with branch drainage. Record the successful time of internal port exploration, intraoperative and postoperative pain score (VAS), degree of fecal incontinence (Wexner incontinence score), wound healing time, and 3-month postoperative recurrence rate. Results: From January 2020 to December 2023, the Proctology Department of Zaozhuang Fourth Hospital and the Proctology Department of Tengzhou Traditional Chinese Medicine Hospital (Workers' Hospital) treated 54 patients with complex anal fistula using a disposable decomposed soft injection probe under propofol