Laparoscopic versus open hysterectomy in type I endometrial cancer – a tertiary referral center experience

Introduction/BackgroundSurgery had been considered the cornerstone in the management of endometrial cancer especially in early stages. The use of minimally invasive surgeries in patients with endometrial cancers has been widely...

Objective To explore the effects of emergent laparoscopic appendectomy on pancreatic endocrine function of patients with acute suppurative appendicitis combined with type 2 diabetes mellitus. Methods The clinical data of 76 patients with suppurative appendicitis combined with type 2 diabetes mellitus who were admitted to the Yongchuan Hospital of Chongqing Medical University between October 2012 and October 2014 were retrospectively analyzed. Among the 76 patients receiving emergent appendectomy, 41 patients receiving laparoscopic appendectomy were allocated to the laparoscopy group and 35 patients receiving open appendectomy were allocated to the open surgery group. The intraoperative conditions of patients were observed. The levels of serum C-peptide, insulin and blood glucose at preoperative minute 15 (t1) , intraoperative minute 15 (t2) , intraoperative minute 30 (t3) and postoperative minute 30 (t4) were detected by enzyme-linked immunosorbent assay (ELISA) . The recovery indicators of patients were analyzed. The patients were followed up by telephone interview till December 2014. Measurement data with normal distribution were presented as ±s. Comparison between groups was analyzed by the independent samples t-test and repeated measures ANOVA. Count data were compared by the Fisher exact probability. Results All the patients underwent successfully the operations. The operation time and the volume of intraoperative blood loss in the laparoscopy group were (50 ±7) minutes and (8. 4 ±3.4) mL, which were not significantly different from (52 ±7) minutes and (7.7 ±2. 9) mL in the open surgery group (t =1.291, 1.042, P >0.05) . Serious adhesions of tissues around the appendix in the laparoscopy group were detected in 8 patients, which was not significantly different from 11 patients in the open surgery group (P >0.05) . The results of the serologic test showed that the levels of serum C-peptide between t1 and t4 were (62. 5 ±3.3) μg/ L, (70. 7 ± 2. 9) μg/ L, (86. 5 ± 3.4) μg/ L and (68.1 ± 2.6) μg/ L in the laparoscopy group and (63.8 ± 2. 8 ) μg/ L, (95.6 ±5. 1) μg/ L, (106. 6 ±2.3) μg/ L and (67.5 ±4.9) μg/ L in the open surgery group, respectively. The levels of insulin between t1 and t4 were (13.1 ± 1.0) mU/ L, (14.0 ±1.1) mU/ L, (15.1 ± 1. 2) mU/ L and (13. 5 ± 1. 1) mU/ L in the laparoscopy group and (13. 3 ±0. 4) mU/ L, (15. 4 ±0. 6) mU/ L, (18. 2 ±0.7) mU/ L and (13.5 ±0. 4) mU/ L in the open surgery group, respectively. The levels of blood glucose between t1 and t4 were (7.8 ±1.0) mmol/ L, (8.3 ± 1.0) mmol/ L, (8.9 ± 1.0) mmol/ L and (8.1 ± 1.0) mmol/ L in the laparoscopy group and (7.8 ± 0.4) mmol/ L, (8.7 ± 0.5) mmol/ L, (10.1 ± 0.4) mmol/ L and (7.9 ± 0. 5 )mmol/ L in the open surgery group, respectively. There were significant differences in the changing trends of serum C-peptide, insulin and blood glucose between the 2 groups (F =378.917, 286.602, 118.199, P 0.05) . The duration of postoperative abdominal pain in the laparoscopy group was(1. 5 ±0.6) days ,which was significantly different from (2.5 ±0. 7) days in the open surgery group (t =-6.367, P <0.05) . The wound infection and fever in the laparoscopy group were detected in 6 and 10 patients, which were significantly different from 14 and 22 patients in the open surgery group (P <0.05) . The duration of hospital stay in the laparoscopy group and in the open surgery group were (5.2 ± 0.4) days and (6.3 ± 0.8) days, respectively, showing a significant difference between the 2 groups (t =7.796, P <0.05) . All the patients were followed up for a median time of 8 months (range, 2- 18 months) , without adhesive intestinal obstruction, abdominal pain, abdominal distension and appendix stump inflammation. Conclusion The emergency laparoscopic appendectomy compared with the open surgery would be less affected on pancreatic endocrine function of patients with acute suppurative appendicitis combined with type 2 diabetes mellitus, with an advantage of better postoperative recovery. Key words: Appendicitis; Diabetes mellitus, type 2; Laparoscopy

Objective To compare the feasibility and safety of laparoscopic versus open hepatectomy.Methods The data of 165 patients who underwent laparoscopic hepatectomy were compared with 170 patients who underwent open hepatectomy in our hospital from November 2002 to December 2010.Results Laparoscopic hepatectomy was successfully carried out in 159 patients and 6 patients were converted to open operation because of intra-operative hemorrhage.The 170 patients in the open operative group had open hepatectomy successfully carried out.The hospital stay and cost in the laparoscopic group(7.6±1.3 d,31767.4±220.1(￥))were less than the open operation group(14.6±3.3 d,35127.3±392.2(￥))(t=-12.657,P＜0.001; t=-78.859,P＜0.001).There was no significant difference in Pringle's manoeuvre time,blood loss and postoperative complications(20.6 ±8.5vs.18.6±6.5 min,t=2.108,P=0.068),(420.8±76.5 vs.395.9±96.1 ml,t=2.157,P=0.063),(0 vs.4 cases,t=2.011,P=0.156))between the 2 groups.The operative time in the laparoscopic group was significantly longer than the open group(59.6 ± 12.2 vs.42.7 ± 22.6 min)(t=6.941,P＜0.001).Conclusions Laparoscopic hepatectomy is feasible and safe.It has the advantages of having less trauma and quicker recovery for tumors which were located superficially in the left liver and in the inferior part of the right liver.The operative time was longer than open hepatectomy,but there was no significant difference between the 2 groups in Pringle's manoeuvre time,blood loss and postoperative complications.The hospital stay and total hospital cost in the open operation group were higher than the laparoscopic hepatectomy group. Key words: Laparoscopic; Open operation; Hepatectomy

Objective: To evaluate the short-term and long-term outcomes after laparoscopic surgery compared with traditional laparotomy in cases of stage ⅠA2-ⅡA2 cervical cancer. Methods: We conducted a retrospective study on the clinical data of 1 863 patients diagnosed as FIGO stages ⅠA2-ⅡA2 cervical cancer in 6 third-grade class-A hospitals in Guangxi province between January 2007 and May 2014. One thousand and seventy-one received laparoscopy, and 792 received laparotomy. T-test, U-test and χ(2) test were used to compare the short-term and long-term outcomes. The short-term outcomes included surgical related outcomes and operative complications, and the long-term outcomes included quality of life (pelvic floor functions and sexual functions), survival and recurrence. Pelvic floor function and sexual function were assessed with the International Consultation on Incontinence Quesonnaire Female Lower Urinary tract(ICIQ-FLUTS) and the Female Sexual Function Inventory (FSFI), respectively. Survival rates were estimated by Kaplan-Meier analysis. The survival curves were compared with Log-rank test. Cox regression analysis was used to evaluaterisk factors for prognosis. Results: (1)The short-term outcomes : There were significant difference in operative time([(257±69) vs(238±56)min], estimated blood loss[(358±314) vs(707±431)ml], anus exhausting time[(2.5±0.9) vs (2.9±0.8)d], preserved days of catheter[(15±7) vs(18±9)d], and post-operative length of stay[(19±16) vs (30±21)d] between the laparoscopic surgery group and the opensurgery group(P<0.05). There was no significant difference in lymph nodes yielded[(21±9) vs (21±11)], left parametrial width[(2.5±0.8) vs (2.7±0.7)cm], right parametrial width [(2.6±0.3) vs (2.7±0.2)cm], vaginal cuff length[(2.4±0.7) vs (2.2±0.7)cm] between the laparoscopic surgery group and the opensurgery group(P>0.05). The intra-operative complications occurred in 8.1%(87/1 071)in the laparoscopic surgery group and in 10.7%(85/792)in the open surgery group(P>0.05). However, the complications of vascular injury in the laparoscopic surgery group[2.6%(28/1 071)]was lower than that in the open surgery group[7.7%(61/792), P<0.001]. The laparoscopic surgery exhibited lower post- operative complication rate [33.8%(362/1 071)vs 40.2%(318/792), P<0.05] and poorer wound healing rate [0.7%(7/1 071)vs 4.0%(32/792), P<0.05]. (2)The long-term outcomes(Hierarchical analysis): The overall incontinence in ICIQ-FLUTS questionnaire in nerve-sparing laparoscopic group [28.4%(67/236)] was lower than that in the open surgery group [35.9%(71/198), P=0.004] . However, There was no significant difference in degree of incontinence between the two groups(P>0.05). The overall sexual dysfunction in FSFI questionnaire after 12 months of postoperative in the nerve-sparing laparoscopic group [47.0%(111/236)]was lower than that in the open surgery group [58.6%(116/198), P=0.001], and the six different dimension scores in the laparoscopic surgery group were higher than that in the open surgery group (P<0.05). The recurrence rate was 3.5%(35/1 007)in the laparoscopicsurgery group and 4.7%(35/740)in the open surgery group(P>0.05). The 5-year OS was 94.0% for the laparoscopic surgery group and 90.2% for the open surgery group(P>0.05), and the 5-year DFS was 93.9% for the laparoscopic surgery group and 89.1% for the open surgery group(P>0.05). (3) Prognostic fators: In univariate analysis, tumor dimension, clinical stage, deep stromal invasion, LVSI, and retroperitoneal lymph node metastasis signficantly affected 5-year OS and 5-year DFS(P<0.05); In multivariate analyses, LVSI, deep stromal invasion and LN metastasis were independent prognostic factors(P<0.05). Conclusions: Laparoscopy can reduceestimated blood loss, accelerate postoperative recovery and improve the quality of life after surgery compared to laparotomy, and it ensures the same oncological results as open surgery. Laparoscopic approach is a safe and effective treatment for early-stage cervical cancer.

Objective To compare the efficacy of laparoscopic or open surgery for gastrointestinal stromal tumors (GISTs) and investigate effects of different risk level on prognosis. Methods The retrospective cohort study was adopted. The clinical data of 192 patients with GISTs who were admitted to Zhongshan Hospital of Fudan University from January 2008 to December 2013 were collected. Among the 192 patients, 88 undergoing laparoscopic surgeries were allocated into the laparoscopic surgery group, 104 patients undergoing open surgeries were allocated into the open surgery group. The following indicators were observed: (1) operative status: surgical procedure, operation time, volume of intraoperative blood loss. (2) Status of postoperative recovery: time of gastrointestinal function recovery, time of drainage tube removal, complications and duration of hospital stay. (3) Follow-up status. (4) Prognosis of patients in different risk level. The follow-up using outpatient examination and telephone interview was performed to assess patients′ survival, tumor recurrence and metastasis until June 2015. Measurement data with normal distribution were presented as ±s and comparison between groups was evaluated by the t test. Comparison of count data was analyzed by the chi-square test. The Kaplan-Meier method was used to draw survival curve and calculate the overall survival rate and relapse-free survival rate. Results (1) Operative status: of the 88 patients in the laparoscopic surgery group, 1 underwent laparoscopic wedge gastrectomy+ cholecystectomy+ appendectomy, 6 underwent laparoscopic wedge gastrectomy+ cholecystectomy, 14 underwent laparoscopic assisted partial gastrectomy, 67 underwent laparoscopic wedge gastrectomy. Of the 104 patients in the open surgery group, 1 underwent partial gastrectomy+ splenectomy, 2 underwent partial gastrectomy combined with distal pancreatectomy+ splenectomy, 2 underwent total gastrectomy, 7 underwent distal subtotal gastrectomy, 7 underwent wedge gastrectomy+ partial or total adjacent organ resection, 8 underwent proximal subtotal gastrectomy, 8 underwent wedge gastrectomy+ cholecystectomy, 69 underwent wedge gastrectomy. The operation time and volume of intraoperative blood loss were (105±33)minutes and (43±16)mL in the laparoscopic surgery group, (121±52)minutes and (199±81) mL in the open group, respectively, with statistically significant differences between the 2 groups (t=-2.104, 2.632, P 0.05). (3) Follow-up status: Of the 192 patients, 149 received follow-ups. Of 88 patients in the laparoscopic surgery group, 68 were followed up for an average time of 39 months. Of 104 patients in the open surgery group, 81 were followed up for an average time of 51 months. During the follow-up, tumor recurrence rate in the laparoscopic surgery group and open surgery group was respectively 8.8%(6/68) and 21.0%(17/81), with no statistically significant difference between the 2 groups (χ2=1.888, P>0.05 ). Postoperative 1-, 3-, 5 year survival rates were 98.5%, 92.9%, 87.4% and 91.7%, 85.2%, 76.9% in the laparoscopic surgery group and open surgery group, respectively, with no statistically significant difference between the 2 groups (χ2=1.967, P>0.05). (4) Prognosis of patients in different risk level: of the 149 who received the follow-up, the tumor recurrence rate of patients in low, intermediate and high recurrence risk was 7.0%(5/71), 13.6%(6/44) and 35.3%(12/34), respectively, with a statistically significant difference among the above indexes (χ2=14.637, P 0.05). Five-year relapse-free survival rate of low, intermediate and high risk patients was 94.2%, 80.0% and 61.8% respectively, with a statistically significant difference (χ2=13.547, P 0.05). Conclusions Compared to open resection, laparoscopic GISTs resection offers better short-term outcomes, however, the two surgical techniques offer equal long-term outcomes. Patients of high risk have poor prognosis. Key words: Gastrointestinal stromal tumors; Gastrectomy; Open surgery; Laparoscopy; Prognosis

<h3>Introduction/Background*</h3> After minimally invasive surgery gained popularity in gynecology oncology, laparoscopic operations became widespread among oncologic operations, however more studies evaluating safety and morbidity of laparoscopic surgery during the learning period of laparoscopy are needed. <h3>Methodology</h3> A prospective study of 895 consecutive patients diagnosed with clinical stage I endometrial cancer managed between January 2005 and December 2016 in a Department of Gynaecology Oncology in a tertiary center in the Canary Islands. The open surgery group was compared to the minimally invasive surgery group over these years. Both groups were compared for epidemiological and clinical characteristics, surgery outcomes, pathologic findings, hospital stay and intraoperative and postoperative complications. <h3>Result(s)*</h3> There were no differences between both groups in terms of median age, percentage of previous laparotomies and median BMI. Median operating time was longer for the laparoscopic group, although the observed differences were not significant. The estimated blood loss was significantly less for the laparoscopic group. There were no differences in intraoperative complications although postoperative adverse events were significant lower in the laparoscopic group. Hospital stay was significantly longer in the laparotomic arm. There were no significant differences in the percentage of readmissions, reoperations and death related to treatment between both groups. <h3>Conclusion*</h3> Laparoscopic surgery in early-stage endometrial cancer is a safe and effective surgical approach applicable in any center with appropriate training. It is possible to change drastically the surgical management of endometrial cancer thus reducing significantly morbidity: less blood loss, less postoperative adverse events and shorter duration of hospital stays, compared to laparotomic surgery.

Laparoscopy or conventional open surgery for patients with ileocolonic Crohn’s disease? A prospective study

Objective To compare the clinical effect of three different nephron-sparing surgical methods including peritoneal laparoscopy, retroperitoneal laparoscopy and open surgery for localized renal carcinoma. Methods The clinical data of 139 patients with localized renal carcinoma was retrospectively analyzed from March 2008 to March 2015. According to the methods of operation, they were divided into three groups, peritoneal laparoscopic excision group (35 cases), retroperitoneal laparoscopic excision group (60 cases) and open surgery group (42 cases). The operating time, renal warm ischemia time, blood loss, hospital stay, postoperative recurrence and metastasis were compared among the three groups and were statistically analyzed. Results One case in the abdominal group and the retroperitoneum group were transferred to open surgery because of extensive adhesion around the tumor, except for this study, and 137 cases were eventually included. Operation time of three groups was(145.3±32.4)min, (126.4±33.1)min and(114.0±31.3)min respectively. There was no significant difference in operative time between the abdominal laparoscopy group and the laparoscopic group. The operative time in the two groups was higher than that in the open operation group(P 0.05). The indwelling time of abdominal drainage tube was (7.1±3.2)d, (5.4±2.4)d and (5.3±1.6)d, respectively, and there was no significant difference among the three groups(P>0.05). The hospitalization time of the three groups was (11.6±4.3)d, (10.1±3.6)d and (13.8±3.2)d, respectively. The time of hospitalization in the abdominal laparoscopy group and the retroperitoneoscope group was significantly lower than that in the open operation group, with statistical significance(P 0.05). Follow-up for 2 to 3 years, there was no significant difference in mortality, recurrence and metastasis between the three groups, and there was no significant difference in postoperative complications(P>0.05). Postoperative pathological types suggested clear cell carcinoma in 122 cases, papillary cell carcinoma in 10 cases, chromophobe cell carcinoma in 4 cases, and collecting duct carcinoma in 1 cases. The R. E.N.A.L scoring system was significantly associated with renal ischemia time, operation time, and affected glomerular filtration rate (P 0.05). Conclusions Peritoneal laparoscopic and retroperitoneal laparoscopic nephron-sparing surgery for localized renal carcinoma have the advantages of minimal invasion, quick recovery and equal clinical effect with open surgery, and can substitute for open surgery. Key words: Carcinoma, Renal Cell; Laparoscopy; Urologic Surgical Procedures

The upper two-thirds of the uterus above the level of the internal cervical os is called the corpus. The fallopian tubes enter at the upper lateral corners of a pear-shaped body. The portion of the muscular organ that is above a line joining the tubo-uterine orifices is often referred to as the fundus. The major lymphatic trunks are the utero-ovarian (infundibulopelvic), parametrial, and presacral, which drain into the hypogastric, external iliac, common iliac, presacral, and para-aortic nodes. Although a direct route of lymphatic spread from the corpus uteri to the para-aortic nodes through the infundibulopelvic ligament has been suggested from anatomical and sentinel lymph node studies, direct metastases to the para-aortic lymph nodes are uncommon. The vagina and lungs are the common metastatic sites. The FIGO Committee on Gynecologic Oncology, following its meeting in 1988, recommended that endometrial cancer be surgically staged. There should be histologic verification of grading and extent of the tumor. All tumors are to be microscopically verified. Endometrioid carcinoma: adenocarcinoma; adenoacanthoma (adenocarcinoma with squamous metaplasia); and adenosquamous carcinoma (mixed adenocarcinoma and squamous cell carcinoma). Mucinous adenocarcinoma. Serous adenocarcinoma. Clear cell adenocarcinoma. Undifferentiated carcinoma. Mixed carcinoma (carcinoma composed of more than one type, with at least 10% of each component). Type 1 (grade 1 and 2 endometrioid carcinoma) may arise from complex atypical hyperplasia and is linked to unopposed estrogenic stimulation. Type 2 includes grade 3 endometrioid tumors as well as tumors of non-endometrioid histology and develops from atrophic endometrium. GX: Grade cannot be assessed. G1: Well differentiated. G2: Moderately differentiated. G3: Poorly or undifferentiated. G1: less than 5% of a nonsquamous or nonmorular solid growth pattern. G2: 6%–50% of a nonsquamous or nonmorular solid growth pattern. G3: greater than 50% of a nonsquamous or nonmorular solid growth pattern. Notable nuclear atypia (pleomorphism and prominent nucleoli), inappropriate for the architectural grade, raises the grade of a grade 1 or grade 2 tumor by 1. In serous and clear cell adenocarcinomas, nuclear grading takes precedent. Most authors consider serous and clear cell carcinomas high grade by definition. Adenocarcinomas with squamous differentiation are graded according to the nuclear grade of the glandular component. The current FIGO staging classification for cancer of the corpus uteri is given in Table 1. Comparison of the stage groupings with the TNM classification is given in Table 2. NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis. N1: Regional lymph node metastasis to pelvic lymph nodes. N2: Regional lymph node metastasis to para-aortic lymph nodes, with or without positive pelvic lymph nodes. MX: Distant metastasis cannot be assessed. M0: No distant metastasis. M1: Distant metastasis (includes metastasis to inguinal lymph nodes or intraperitoneal disease). Corpus cancer is surgically staged, therefore procedures previously used for determination of stage are no longer applicable (e.g. the findings of fractional curettage to differentiate between Stage I and Stage II). There may be a small number of patients with corpus cancer who will be treated primarily with radiation therapy. In these cases, the clinical staging adopted by FIGO in 1971 would still apply, but designation of that staging system should be noted. Ideally, distance from tumor to serosa should be measured. The presence of lymphovascular space invasion (LVSI) should also be reported in the pathological report of the hysterectomy specimen. A LVSI-positive status has a significantly worse prognosis, especially if extensive LVSI is found [1]. The distinction by LVSI status could be more relevant than the distinction between Stages IA and IB for predicting survival in Stage I endometrial cancer [2]. As a minimum, any enlarged or suspicious lymph nodes should be removed in all patients. For high-risk patients (grade 3, deep myometrial invasion, cervical extension, serous or clear cell histology), complete pelvic lymphadenectomy and resection of any enlarged para-aortic nodes is recommended. Worldwide, endometrial cancer is the sixth most common malignant disorder with approximately 290 000 new cases annually. The incidence is higher in high-income countries (5.5%) compared with low-income countries (4.2%), although specific mortality is higher in the latter. The cumulative risk of endometrial cancer up to the age of 75 years has been estimated as 1.6% for high-income regions and 0.7% for low-income countries [3]. This difference has been associated with an epidemic of obesity and physical inactivity, two important risk factors, in high-income countries. Moreover, endometrial cancer patients with obesity also tend to have a poorer outcome [4]. On the other hand, physical activity and long-term use of continuous combined estrogen–progestin therapy is associated with a reduced risk of endometrial cancer [4,5]. Obesity is associated with earlier age at diagnosis, and with endometrioid-type endometrial cancers. Similar associations were not observed with nonendometrioid cancers, consistent with different pathways of tumorigenesis [6]. In North America and Europe, endometrial cancer is the most frequent cancer of the female genital tract and the fourth most common site after breast, lung, and colorectal cancer [3]. The incidence is rising as life expectancy increases. Furthermore, an estimated 23 700 European women died of endometrial cancer in 2012, which is the eighth most common cause of death from cancer in women [7]. Importantly, the corrected corpus uteri cancer mortality rates showed a decrease in most European Union member states among women born before 1940 [8]. In North America, it is the seventh most frequent cause of death, with approximately 55 000 new cases and 10 000 estimated new deaths each year [3]. The increase in endometrial cancer incidence rates after 2002 may be related to the widespread decrease in estrogen plus progestin menopausal hormone therapy use, which has been reported to lower endometrial cancer risk in overweight and obese women [9]. However, the main reasons underlying the increase in endometrial cancer incidence in high-income countries remain the increasing prevalence of obesity in postmenopausal as well as the increased life expectancy. Endometrioid adenocarcinoma progresses through a premalignant phase of intraepithelial endometrial neoplasia in a large proportion of cases [10]. Other forms such as serous and clear cell carcinoma arise as a result of a sequence of genetic mutations. In serous endometrial cancer, the mutant p53 plays a pivotal role [11]. Endometrial cancer research has gained some momentum in recent years and now provides better information for clinical practice. Its early presentation following postmenopausal bleeding results in a generally good prognosis, but it should be treated using evidence-based protocols, and where appropriate, by expert multidisciplinary teams. The role of population screening for endometrial cancer remains low [12], although certain high-risk groups such as those with Lynch type 2 syndrome can undergo endometrial surveillance by biopsy, or transvaginal ultrasonography if post menopausal. Transvaginal ultrasound is reasonably sensitive and specific but screening of asymptomatic women has in general been recommended only for those with Lynch syndrome [13]. Following presentation, ultrasound is an effective first test with a high negative predictive value when the endometrial thickness is less than 5 mm. In one of the largest studies undertaken, there was a negative predictive value of 96% among 1168 women in whom the results of transvaginal ultrasound were correlated with an endometrial biopsy obtained by curettage [14]. When a biopsy is required, this can be obtained usually as an office procedure using a number of disposable instruments developed for this purpose. In certain cases, hysteroscopy may be helpful, and with flexible instruments can also be done without recourse to general anesthesia. However, the biological role of cells that are transtubally flushed during hysteroscopy remains uncertain. If cervical stenosis or patient tolerance does not permit an office procedure, hysteroscopy and curettage under anesthesia may be necessary. Individuals whose pelvic examination is unsatisfactory may also be evaluated with transvaginal or abdominal ultrasound to rule out concomitant adnexal pathology. Following a histopathologic diagnosis of endometrial adenocarcinoma, the local extent of the tumor, and evidence of metastatic disease should be determined. In addition, the perioperative risk should be assessed. As a minimum, the pathology report from endometrial sampling should indicate the tumor type and grade of the lesion. A chest X-ray, full biochemistry (renal and liver function tests), and blood count are routine. A serum CA125 may be of value in advanced disease for follow-up. Evaluation for metastasis is indicated particularly in patients with abnormal liver function tests, and clinical findings such as parametrial or vaginal tumor extension. In high-risk patients, imaging of the abdomen and lymph nodes may help determine the surgical approach. In certain situations, cystoscopy and/or proctoscopy/barium enema may be helpful if direct extension to the bladder or rectum is suspected. Tumor grade 3 (poorly differentiated). More than 50% of myometrial invasion. Lymphovascular space invasion. Non-endometrioid histology (serous, clear cell, undifferentiated, small cell, anaplastic, etc.). Cervical stromal involvement. The most accurate means of assessing both depth of myometrial invasion and cervical involvement is MRI scanning and intraoperative frozen section [15–17]. CT and MRI are equivalent in terms of evaluating nodal metastases, but neither is good enough to replace surgical lymph node assessment, which provides histological confirmation [18,19]. The role of PET-CT and PET-MRI is currently being investigated. Nonsurgical staging for endometrial cancer, where extrauterine disease exists, is inherently inaccurate, particularly in respect to small nodal involvement, intraperitoneal implants, and adnexal metastasis. In 1988, the FIGO Cancer Committee changed the official FIGO staging from clinical to surgical for endometrial cancer. Since that recommendation, considerable debate has ensued as to what constitutes an internationally acceptable approach. A generally recommended protocol would be that the abdomen should be opened with a vertical midline abdominal incision and peritoneal washings taken immediately from the pelvis and abdomen, followed by careful exploration of the intra-abdominal contents. The omentum, liver, peritoneal cul-de-sac, and adnexal surfaces should be examined and palpated for any possible metastases, followed by careful palpation for suspicious or enlarged nodes in the aortic and pelvic areas. The standard surgical procedure should be an extrafascial total hysterectomy with bilateral salpingo-oophorectomy. Adnexal removal is recommended even if the tubes and ovaries appear normal, as they may contain micrometastases. Vaginal cuff removal is not necessary, nor is there any benefit from excising parametrial tissue in the usual case. Where obvious cervical stromal involvement is demonstrated preoperatively, a modified radical hysterectomy has been historically performed. However, there is consensus (ESMO-ESGO-ESTRO) that simple hysterectomy with free-margins together with pelvic lymphadenectomy can be sufficient. There has also been considerable debate on the safety of endoscopic surgery for the treatment of endometrial cancer. Recent studies have demonstrated that laparoscopic removal of the uterus and adnexae (in experienced hands) appears to be safe. Whereas there is no difference in terms of major complications between abdominal hysterectomy and laparoscopically assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH), the laparoscopic approach is associated with a significantly decreased risk of major surgical adverse event, a shorter hospital stay, less pain, and quicker resumption of daily activities [20–22]. Since the oncological safety of the laparoscopic approach has now been demonstrated in several randomized studies [23,24], hysterectomy and bilateral salpingo-oophorectomy should be performed with laparoscopy in those patients with no contraindications to laparoscopy (e.g. large-volume uterus). This approach can be accompanied by a laparoscopic lymphadenectomy, if surgical staging is to be undertaken. Robotic surgery for the surgical management of the morbidly obese patient is an option only in experienced hands. In such cases, the surgical management using robotics has been reported to be safe and have less perioperative complications compared with open surgery [25]. Retrospective studies have suggested equivalent oncologic outcomes compared with traditional laparoscopic surgery [26,27]. Although mandated through the staging system, lymphadenectomy of the pelvic and para-aortic areas remains controversial. Selective node sampling is of dubious value as a routine and complete lymphadenectomy should be reserved for cases with high-risk features. Many individuals with endometrial cancer are obese or elderly, with other medical problems, and clinical judgment is required to determine if additional surgery is warranted. Any deeply invasive tumor or radiological suggestion of positive nodes is an indication for retroperitoneal lymph node evaluation, with removal of any enlarged or suspicious nodes. Documentation of positive nodes identifies a high-risk population and helps to tailor adjuvant treatment, since patients with Stage III disease appear to benefit from chemotherapy [28]. Indications for aortic node sampling would include suspicious aortic or common iliac nodes, grossly positive adnexae, grossly positive pelvic nodes, and high-grade tumors showing full thickness myometrial invasion. Patients with clear cell, papillary serous, or carcinosarcoma histologic subtypes are also candidates for aortic node sampling. Low-risk tumors will have positive nodes in less than 5% of cases (well differentiated and < 1/2 myometrial invasion) and do not require full surgical staging. These women can be safely operated on by a general gynecologist, but those at greater risk of extrauterine disease, who may require lymphadenectomy, should be referred to a gynecological oncologist since care provided by gynecologic oncologists has been associated with better survival in high-risk cancers [29]. Moreover, primary management by gynecologic oncologists has been suggested to result in an efficient use of health care resources and minimization of the potential morbidity associated with adjuvant radiation [30]. This triaging of women can be done most effectively by a thorough preoperative assessment, paying particular attention to the pathology and to radiological features. Triaging for lymphadenectomy is also possible during surgery. Intraoperative assessment mainly involves assessment of myometrial invasion [15,17,27]. Grading on frozen section is possible, though suboptimal compared with preoperative grading [17]. The effect of waiting time for surgical staging on survival outcome of endometrial cancer is controversial. A recent population-based study concluded that a longer waiting time for surgical staging was associated with worse survival outcomes in uterine cancer [31]. However, when focusing on type I endometrial cancer only, the waiting time for surgical staging was not associated with decreased survival outcome, presumably due to its excellent prognosis anyway [32]. Although required for accurate staging, a therapeutic benefit for lymphadenectomy is controversial. Historically, one case–control study suggested that it may be therapeutic [33] and another showed a good prognosis even in node-positive women [34]. Another retrospective study showed a survival benefit of complete lymphadenectomy for patients with grade 3 tumors [35]. In the UK, the MRC ASTEC trial, however, which randomized 1400 women undergoing surgery for presumed Stage I endometrial cancer to pelvic lymphadenectomy or no lymphadenectomy, showed no therapeutic benefit [36]. An Italian randomized trial of pelvic (and in 30% para-aortic) lymphadenectomy versus no lymphadenectomy in 540 women also did not show any difference in rates of relapse or survival [37]. Both studies have been criticized because of a limited effort with respect to the extent of dissection and lymph node evaluation, because of the high proportion of low-risk patients, and because no direct decision on adjuvant therapy based on lymphadenectomy was part of the protocols. Lymphadenectomy is primarily used for staging and should be considered in women with high-risk factors [38]. Although a direct survival benefit of lymphadenectomy has not been documented, the procedure identifies node-positive patients that may benefit from adjuvant treatment. An international trial of the role of lymphadenectomy to direct adjuvant therapy for high-risk endometrial cancer (STATEC) is planned. The ongoing ENGOT-EN2-DGCG/EORCT 55102 trial aims to answer this question by comparing survival in patients with Stage I grade 3 endometrioid endometrial cancer, Stage I and II type 2 endometrial cancer or Stage II endometrioid endometrial cancer and without metastatic node after randomization for adjuvant chemotherapy. In a retrospective study, para-aortic lymphadenectomy resulted in an improved outcome in intermediate and high-risk patients when compared with pelvic lymphadenectomy alone [39]. However, adjuvant therapy was not comparable in the two groups. In patients who underwent both pelvic and para-aortic lymphadenectomy, 77% received chemotherapy whereas this was given to only 45% of patients who underwent pelvic lymphadenectomy alone. This study suggests both pelvic and para-aortic lymphadenectomy are beneficial in comparison with patients who undergo pelvic lymphadenectomy alone, but it does not imply that extensive lymphadenectomy improves survival in comparison with no lymphadenectomy. Risk factors are used to determine the indication for adjuvant radiation therapy, as the majority of patients are at low risk of recurrence. Low-risk disease (Stage I, grade 1 or 2 with no or superficial myometrial invasion) does not require adjuvant radiation therapy, as demonstrated in a Danish cohort study of low-risk women, with 96% five-year survival after surgery alone [40]. A seminal Norwegian trial [41], which included 621 women treated after surgery with vaginal brachytherapy, indicated that overall survival was not improved by additional external beam radiation therapy (EBRT), although it did reduce the risk of pelvic recurrence. Three large randomized trials of pelvic radiation therapy versus no further treatment after surgery have determined the role of radiation therapy based on risk factors, and have led to reduced indications for adjuvant radiation therapy: the PORTEC trial [42], the US GOG#99 trial [43], and the UK MRC ASTEC trial [44]. All of these trials reported a significant reduction in the rates of vaginal and pelvic recurrence with EBRT, but without survival benefit. EBRT added to the risk of long-term morbidity. PORTEC and ASTEC trials had similar recurrence and survival rates without lymphadenectomy, compared with GOG#99 that included patients with documented node-negative disease. PORTEC-1 showed that most pelvic relapses were located in the vaginal vault (75%), and that salvage rates were high in women who had not had previous radiation therapy [45]. The PORTEC-2 trial randomized 427 women with high–intermediate risk factors to EBRT or vaginal brachytherapy alone [46]. This trial showed that vaginal brachytherapy had excellent vaginal control rates (< at 5 years for both EBRT and vaginal brachytherapy with adverse and significantly better of of life of patients in the brachytherapy the as those of an population Vaginal brachytherapy has EBRT as standard adjuvant treatment for patients with high–intermediate risk of any EBRT or vaginal brachytherapy for risk disease recurrence rates for intermediate risk disease, of which but without a difference in survival has been by a Danish population study A patient study showed that are to a treatment relapse The seminal trial the use of both EBRT and adjuvant chemotherapy compared with EBRT alone for patients with risk factors (grade 3 or deep invasion or adverse This trial was in a with the Italian trial trials comparing adjuvant EBRT alone with adjuvant chemotherapy alone have not any difference in overall or survival the and trial reported a significant in survival at 5 with the of chemotherapy to EBRT, and a for a in five-year overall survival and trials are currently the of EBRT or chemotherapy alone or combined EBRT and chemotherapy for patients with high-risk or advanced stage disease results of the trial patients with Stage I II endometrial cancer with high intermediate or high-risk factors, comparing vaginal brachytherapy plus of with pelvic showed no in survival or overall survival between the at a of 50% of the trial population had grade disease with a five-year survival of In the trial, patients with high-risk Stage I II or with Stage III endometrial cancer were randomized to pelvic EBRT alone or EBRT with two of followed by of and patients in and results are in In the ongoing patients with node-negative endometrial cancer with high-risk are randomized to adjuvant chemotherapy of or with or without brachytherapy in both These trials will answer of the use and of adjuvant therapy for women with high-risk endometrial cancer. In adjuvant radiation therapy is not indicated for patients with grade tumors and no more than 50% myometrial invasion, or for those with only a risk For patients with high–intermediate risk factors least two of the age deep myometrial invasion, grade 3, serous or clear cell vaginal brachytherapy alone is to EBRT, excellent vaginal control without on of In patients with disease or more risk factors, Stages II and the role of adjuvant with or without radiation therapy, is currently being investigated. This has been in the but a of randomized trials a total of women has no survival benefit for adjuvant therapy in endometrial cancer A randomized trial of women also to any survival benefit Patients with Stage II disease are generally in a similar to patients with Stage I disease. Historically, radical bilateral bilateral pelvic lymphadenectomy, and aortic node dissection can be used as primary treatment for cervical involvement. However, this is by the medical from one of the retrospective studies could not any survival benefit from radical hysterectomy for patients with cervical involvement in comparison with simple or modified radical hysterectomy Since radical hysterectomy the risk of adverse surgical treatment in patients with cervical involvement further MRI scanning is to bladder involvement and local indicate excellent results for this with no benefit from the of radiation for patients with negative nodes is usually reserved for patients with nodes and/or or surgical However, therapy followed by a less extensive simple hysterectomy can an The for adjuvant has not been in a randomized trial, but a study reported improved survival for patients with Stage II endometrial cancer when adjuvant was used after radical and simple hysterectomy If surgery is not considered because of tumor extension, full pelvic and brachytherapy, as in cervical cancer, may be Most patients with Stage III endometrial cancer are by complete surgical resection of all metastatic disease, followed by EBRT and/or chemotherapy. The randomized trial included patients with Stages III and disease and tumor up to 2 and compared abdominal radiation with adjuvant chemotherapy of and showed a survival benefit for chemotherapy estimated five-year although rates were high in both [28]. chemotherapy and is used to reduce the risk of Retrospective studies have pelvic recurrence rates when EBRT was when using chemotherapy and current ongoing trials are the of and of chemotherapy and radiation therapy. A recent randomized trials women with primary FIGO Stage endometrial cancer who received primary surgery showed that chemotherapy survival time after primary surgery by approximately to evaluating women, mainly Stage III compared adjuvant chemotherapy with adjuvant one trial evaluating women mainly Stage III compared two chemotherapy versus in women who had all adjuvant and one trial no and were longer with adjuvant chemotherapy compared with adjuvant In the on survival in of chemotherapy were not different for Stage III and or Stage and This evidence was of from one trial showed that women adjuvant chemotherapy were more to and adverse and and more to treatment, than those adjuvant There was no significant difference in deaths between the chemotherapy and treatment There was no clear difference in survival between groups in the one trial that compared versus A large trial evaluating adjuvant chemotherapy alone of compared with chemotherapy during and after radiation therapy as used in for Stage III endometrial cancer has and results are in Patients with presumed Stage III disease because of adnexal involvement should have full surgical staging and expert examination of the as primary tumors of both the and the may be should be and based on the stage of each tumor. Patients with clinical Stage III endometrial carcinoma that is not to be by of vaginal or parametrial extension are treated primarily by pelvic with or without chemotherapy therapy has been should be considered for those patients whose disease now appears to be Patients with Stage disease based on intraperitoneal spread benefit from surgery only if there is no tumor chemotherapy is an particularly if is and/or morbidity is considered chemotherapy should be based on the trial above [28]. Patients with evidence of metastases are usually with or therapy if grade 1 and/or chemotherapy is the treatment of in disease as well as in disease. The of and and

Scores and Misses With New Technology—Walking the Narrow Path of Evidence

Objective To analyze laparoscopic lymphadenectomy and the safety of gastrectomy for gastroesophageal junction cancer. Methods From Jan 2011 to Dec 2012 72 gastroesophageal junction cancer patients were enrolled, including 46 patients in laparoscopic group, and 26 in open surgery group. Results There was no significant difference in the numgbers of lymph node dissection between the two groups and nor difference in the number of positive lymph node dissection. Esophagus resection length in open group was (2.0±1.0)cm, while that was (3.0±0.8)cm in laparoscopic group (t=0.471, P<0.001). 5 (19%) patients in open group had positive margins compared to six in laparoscopic group (13%), χ2=0.491, P=0.483. 7 patients in the open group underwent thoracoabdominal resection, while in laparoscopic group 3 patients did, χ2=5.781, P=0.016. Laparoscopic splenic hilar lymphnodes dissection harvested more lymph nodes (t=0.260, P=0.011). Laparoscopic gastrectomy used less operation time (t=0.237, P=0.021) experinced less blood loss (t=0.451, P<0.01) than open group. There was no difference in major complications between the two groups. Conclusions Laparoscopic splenic hilar lymphnodes dissection in gastroesophageal junction cancer surgery is superior to open surgery, with more lymph nodes harvested, longer esophageal cutting distances, lower incidence of thoracoabdominal surgery, shorter operation time, and less blood loss. Key words: Stomach neoplasms; Lymph node dissection; Laparoscopy

Introduction/BackgroundFor treatment of low-risk endometrial cancer, laparoscopic hysterectomy is the standard surgery approach. On the other hand, oncologic safety of minimally invasive technique in high risk disease has not yet...

Objective To compare the clinical efficacy of laparoscope and open operation in treatment of adrenal pheochromocytoma.Methods 52 cases with adrenal pheochromocytoma were randomly divided into two groups,they were treated with laparoscope or open operation.Intraoperative blood loss,intraoperative blood pressure and heart rate fluctuations,operation time,drainage,hospitalization and postoperative complications were compared between two groups.Results Intraoperative comparison:In laparoscope group,operative blood loss was (65.7 ± 50.2) ml,blood pressure fluctuations in 1 case (3.8％),heart rate variability was (18.7 ± 6.1)/min and the operation time was (93.7 ± 21.7) min; in the open operation group,amount of bleeding during the operation was (240.4 ± 150.5) ml,blood pressure fluctuations in 7 cases(26.9％),heart rate variability was (25.6 ± 6.3)/min and the operation time was (137.7 ± 30.5) min,the differences between the two groups was significant (t =3.15,x2 =5.32,t =3.65,t =4.16,all P＜0.05).The maximum tumor diameter of open operation group was (7.3 ± 1.4) cm,which was bigger than that of the laparoscope group (6.6 ± 1.2) cm,but no significant difference between two groups (P ＞ 0.05).Postoperative comparison:in the laparoscope group,postoperative drainage was (174.3 ± 121.3)ml,drainage time was (4.3 ± 1.3) d and time of hospitalization was (8.4 ± 1.2) d,which were significantly less than those in open operation group(318.5 ± 132.6)ml,(8.7 ±2.3)d and (11.4 ±3.2)d(t =2.54 3.13,2.12,all P ＜0.05).No serious complications were observed in two groups,laparoscope group 1 case,open operation group 5 cases had postoperative pain,after the corresponding symptomatic treatment was improved.After 3 months of follow-up,clinical symptoms were significantly improved or disappeared,ultrasound or CT reexamination found no recurrence.Conclusion Laparoscope in treatment of adrenal pheochromocytoma not only has definite curative effect,but also has small trauma,shorter operation time and less complications,it is worth clinical application. Key words: Laparoscopy; Open surgery; Adrenal pheochromocytoma

Objective To investigate the clinical effect and security of laparoscopic total mesopancreas excision in the treatment of pancreatic head carcinoma. Methods 46 cases of pancreatic head carcinoma were collected from April 2013 to April 2016 in our hospital and conducted a retrospective analysis. According to the different surgical methods, the patients were divided into laparoscope group (25 cases) and open surgery group (21cases), the laparoscope group was given laparoscopic total mesopancreas excision surgery, the open surgery group was given open pancreaticoduodenectomy. Statistical analysis were performed by using SPSS 19.0 software, preoperative and postoperative related indicators were presented as and examined by using t test; enumeration data (excision rate of R0, the incidence of the complications after operation) was examined by chi square test. A P<0.05 was considered as significant difference. Results The excision rate of R0 in laparoscope group was 88.0%, the excision rate of R0 in open surgery group was 61.9% (P<0.05). Compared with the open surgery group, the operation time of the laparoscope group was significantly increased, but the intraoperative blood loss and intraoperative transfusion were significantly decreased (P<0.05); Compared with the open surgery group, the postoperative anal exhaust time, eat liquid food time and hospital stays of the laparoscope group were significantly shortened (P<0.05). The incidence of postoperative complications of the laparoscope group was 16.0%, the incidence of postoperative complications of the open surgery group was 42.9%, the difference was statistically significant (P<0.05). Conclusion Laparoscopic total mesopancreas excision in the treatment of pancreatic head carcinoma has good clinical effect and security, it is worth promoting the application in clinic. Key words: Pancreatic neoplasms; Laparoscopes; Pancreatectomy; Treatment outcome

The aim of this study was to report our single-center experience of the da Vinci robotic surgery system in the management of endometrial cancer (EC) patients during 2019-2023. We descriptively summarized the preoperative, intraoperative, and postoperative outcomes. Moreover, we conducted subgroup analyses based on obesity (BMI ≥ 30kg/m2) and the intraoperative use of indocyanine green dye (ICG). Overall, 100 patients were analyzed. Eighty-five patients (85%) were obese. The mean operative time and estimated blood loss (EBL) were 240.84 ± 70.08min (range: 110-720) and 104.2 ± 80.3ml (range: 20-500), respectively. The mean number of retrieved pelvic LNs was 3.01 ± 3.06 (range: 0-15). The use of ICG was employed in 58 (58%). Only a single patient (1%) underwent conversion to laparotomy. Besides, only three (3%) patients experienced vaginal laceration intraoperatively, respectively. The mean hospital stay was 1.34 ± 0.69days (range: 1-5). No patient experienced postoperative complications. Most tumors had endometrioid histology (82%), grade-1 tumor (49%), and stage-1A disease (67%). At 3-year follow-up, only two patients (2%) developed recurrence. Patients who received the ICG had significantly lower operative time (225.86 vs. 261.52min, p = 0.011), estimated blood loss (90 vs. 123.81ml, p = 0.037), and hospital stay (1.12 vs. 1.64days, p < 0.001) compared with patients who did not receive it. However, there was no significant difference between both groups regarding the number of retrieved pelvic LNs. Obesity had no significant impact on the rates of intraoperative complications, postoperative complications, and 3-year recurrence incidence. In conclusion, robotic surgery was technically feasible and safe. The use of ICG was statistically linked to favorable outcomes, in terms of decreased operative time, EBL, and hospital stay. Obesity did not impact the perioperative surgical outcomes.