中华胃肠外科杂志最新文献

Objective: To evaluate the functional outcomes and postoperative complications associated with modified Toupet-like (mToupet-like) anastomosis following proximal gastrectomy for patients with gastric tumors. Methods: After proximal gastrectomy, barbed sutures (2-3 stitches) in the seromuscular layer were used to secure the anterior wall of the stomach at a distance of 1-2 cm from the closure line and the posterior wall of the esophagus at a distance of 5.0 cm from the closure line. The remnant stomach was then positioned posterior to the esophagus on the greater curvature side. Esophagogastric anterior wall anastomosis (manual or circular stapling) was performed at the greater curvature of the remnant stomach, 3 cm distal to the gastroesophageal fixation point. A Toupet-like folding procedure was conducted by folding the reconstructed gastric fundus and wall anteriorly from behind the esophagus and embedding the esophagus within a 270° wrap at the site of stomach-esophagus fixation. Results: Twelve patients with gastric tumors underwent proximal partial gastrectomy with mToupet-like anastomosis in the Department of Gastric Surgery at Zhejiang Cancer Hospital from January to March 2024. Among them, 10 diagnosed as upper gastric adenocarcinoma, and 2 diagnosed as gastric gastrointestinal stromal tumors. The cohort included nine male patients and three female patients, aged 46 to 77 years old, with a body mass index (BMI) ranging from 19.7 to 27.3 kg/m². The maximum tumor diameter was less than 4 cm, and the predicted residual gastric volume exceeded one-half. Laparoscopic surgery was performed in 11 patients, while only 1 patient underwent open surgery. The mean duration of mToupet-like anastomosis was 48.3±8.7 minutes with an estimated intraoperative blood loss was 53.0±11.2 ml. All the 12 patients successfully achieved R0 resection. Among these patietns, the median postoperative hospital stay was 8.5 (7.0, 11.0) days, and the average hospitalization cost was 5.0±0.2 ten thousand yuan. No Clavien-Dindo grade II or higher complications were observed during the perioperative period. Patients were followed up for 6 to 8 months after operation, and no cases of reflux esophagitis were detected by gastroscopy, and no patient required long-term oral proton pump inhibitors. Conclusions: mToupet-like anastomosis for digestive tract reconstruction after proximal gastrectomy is a safe and feasible technique, demonstrating favorable preliminary efficacy.

Total pelvic exenteration (TPE) is a critical surgical procedure for treating locally advanced rectal cancer (LARC) at stage T4b and locally recurrent rectal cancer (LRRC), where the resectability of pelvic tumors depends on precise preoperative imaging evaluation. Laparotomy primarily aims to exclude abdominopelvic peritoneal metastases. Preoperative assessment involves contrast-enhanced chest/abdominal CT, contrast-enhanced liver MRI (as a supplement when CT findings are unclear), contrast-enhanced pelvic MRI (the preferred modality for evaluating soft tissue planes, organ involvement, and resection scope), and PET-CT (useful for systemic metastasis detection and differentiating scar/fibrosis from tumor). Key focuses include identifying invasion of pelvic wall structures (vascular, neural, muscular planes in lateral, posterior, and floor regions) and the "high-risk zone for major hemorrhage" at the confluence of internal iliac veins. Multidisciplinary team discussions involving radiology, surgery, oncology, and other specialties are essential. These discussions emphasize "en bloc resection" principles, using imaging to define resection planes layer-by-layer to assess R0 resection feasibility, reconstructive strategies, and neoadjuvant therapy. The "Changzheng Surgical Classification" proposed by our center categorizes PE into intra-pelvic exenteration (resecting ≥50% of tissues from ≥2 systems within the bony pelvis) and combined pelvic wall exenteration (involving ≥50% tissues from ≥1 pelvic system plus ≥1 of the 5 pelvic wall regions or ≥2 pelvic wall regions). Preoperative planning based on detailed pelvic anatomical zoning ensures standardized resection and reconstruction, promoting procedural consistency and improving R0 resection rates.

The invasion of pelvic tumors into multiple organs frequently necessitates the concurrent resection of the rectum, bladder, sacrococcygeal bone, uterus and its accessories, as well as other organs. This complex surgical procedure stands as a pivotal treatment for locally advanced pelvic tumors, offering patients the potential for long-term survival and improved quality of life. However, the narrow confines of the pelvic cavity, its intricate anatomical structure, limited visual exposure, and the inherent challenges of the operation itself, contribute to a surgery that is highly demanding, risky, traumatic, time-consuming, and prone to causing life-threatening hemorrhage. Despite these challenges, a safe and effective strategy for specimen removal, coupled with precise and comprehensive organ function reconstruction techniques, are paramount in reducing operative time, minimizing perioperative risks, enhancing postoperative quality of life, and mitigating complications. Currently, there exists no universally standardized evaluation framework to guide the swift removal of specimens and the meticulous reconstruction of organs and pelvic floor functions within safe boundaries. Drawing from our team's decade-long experience in pelvic tumor resection and referencing recent literature, this paper aims to provide a comprehensive overview of pelvic tumor resection involving multiple organs. We focus on safe and efficient surgical strategies, as well as the essential aspects of functional reconstruction.

Emergency surgery has always been an important component of general surgery, with major diseases including acute abdomen and trauma. With the differentiation and development of general surgery sub specialties, department of emergency surgery has begun to emerge, but its development faces various challenges, such as insufficient medical staff, inadequate treatment capabilities, and poor treatment outcomes. To change this situation, about 20 years ago, a new treatment model began to emerge in the United States, establishing a department of acute care surgery that integrates trauma, emergency general surgery, and surgical critical care. This model quickly spread worldwide and achieved remarkable achievements. In recent years, colleagues in the field of surgery in China have gradually recognized the advantages of this model and established acute care surgery. This article aims to elaborate on its development process, current situation, and future trends, providing reference for the prosperous development of acute care surgery in China.

Tianhe procedure^® is a functional sphincter-preserving surgical approach developed for rectal cancer patients following radiotherapy. This technique involves extended proximal resection of the colon beyond the pelvic cavity, followed by anastomosis of the non-irradiated proximal colon to the distal rectum or anal canal. This strategy aims to reduce the incidence of anastomotic complications and postoperative bowel dysfunction. However, there is currently a lack of standardized practice guideline for implementing Tianhe procedure^® in China. Therefore, the Chinese Radiation Intestinal Injury Research Group, the Colorectal Surgery Group of Surgery Branch of the Chinese Medical Association, the Anorectal Branch of Chinese Medical Doctor Association, the Colorectal Cancer Committee of the Chinese Medical Doctor Association, and the Colorectal Cancer Committee of China Anti-cancer Association, and the Gastrointestinal Surgical Branch of Guangdong Medical Doctor Association, have jointly convened a panel of national experts to discuss and establish this standardized surgical procedure. This standard, based on the latest evidence from literature, research advancements, and expert experience, focuses on key aspects of the Tianhe procedure^®, including its precise definition, indications, critical procedural steps, postoperative complications, and functional rehabilitation strategies. It aims to promote standardized implementation and broader clinical adoption of this innovative surgical technique.

Locally advanced colorectal cancer patients are characterized by poor prognosis and high recurrence rates, with peritoneal metastasis rates as high as 20%-30%. Despite curative resection and chemotherapy being the main treatment methods, challenges remain in preventing peritoneal metastasis. Neoadjuvant therapy and immunotherapy are hot topics of research, and hyperthermic intraperitoneal chemotherapy (HIPEC) is one of the new approaches for preventing peritoneal metastasis, yet its value and safety are still controversial. HIPEC can directly target free tumor cells in the abdominal cavity through hyperthermic effects and high concentrations of chemotherapeutic drugs, but its prophylactic use requires further exploration regarding effectiveness and risks. Early intervention and identification of high-risk factors are crucial for improving therapeutic outcomes, and tests such as circulating tumor DNA and free peritoneal cell DNA provide new avenues for early screening. The value of prophylactic HIPEC varies across different studies, and its complications and risks should not be overlooked. The selection of chemotherapy drugs, dosage, and personalized treatment plans are key factors affecting therapeutic efficacy. Other prevention strategies, such as pressurized intraperitoneal aerosol chemotherapy and neoadjuvant chemotherapy, are also being explored. In summary, prophylactic HIPEC shows some potential in controlling peritoneal metastasis, but its application requires individualized assessment and optimization.