Surgery For Gastrointestinal Tumors Research Articles

Laparoscopic vs. open surgery for gastrointestinal stromal tumors of esophagogastric junction: A multicenter, retrospective cohort analysis with propensity score weighting.

ObjectiveLaparoscopic resection is increasingly performed for gastrointestinal stromal tumors (GISTs). However, the laparoscopic approach for GISTs located in the esophagogastric junction (EGJ-GIST) is surgically challenging. This study compares the efficacy of laparoscopic surgery and the open procedure for EGJ-GIST through the propensity score weighting (PSW) method.MethodsBetween April 2006 and April 2018, 1,824 surgical patients were diagnosed with primary gastric GIST at four medical centers in South China. Of these patients, 228 were identified as EGJ-GISTs and retrospectively reviewed clinicopathological characteristics, operative information, and long-term outcomes. PSW was used to create the balanced cohorts.ResultsPSW was carried out in laparoscopic and open-surgery cohorts according to year of surgery, sex, age, body mass index (BMI), tumor size, mitotic rates and recurrence risk. After PSW, 438 patients consisting of 213 laparoscopic (L group) and 225 open surgery (O group) patients were enrolled. After PSW, the following measures in the L group were superior to those in the O group: median operative time [interquartile range (IQR)]: 100.0 (64.5−141.5)vs. 149.0 (104.0−197.5) min, P<0.001; median blood loss (IQR): 30.0 (10.0−50.0)vs. 50.0 (20.0−100.0) mL, P=0.002; median time to liquid intake (IQR): 3.0 (2.0−4.0)vs. 4.0 (3.0−5.0) d, P<0.001; median hospital stay (IQR): 6.0 (4.0−8.0)vs. 7.0 (5.0−12.0) d, P<0.001; and postoperative complications (10.3%vs. 22.7%, P=0.001). The median follow-up was 55 (range, 2−153) months in the entire cohort. No significant differences were detected in either relapse-free survival (RFS) [hazard ratio (HR): 0.372, 95% confidence interval (95% CI): 0.072−1.910, P=0.236) or overall survival (OS) (HR: 0.400, 95% CI: 0.119−1.343, P=0.138) between the two groups. ConclusionsLaparoscopic surgery for EGJ-GIST is associated with the advantages of shorter operative time, reduced blood loss, shorter time to liquid intake, and shorter length of stay, all without compromising postoperative outcomes and long-term survival.

Feasibility of laparoscopic surgery for large gastric gastrointestinal stromal tumors: systematic review and meta-analysis

Feasibility of laparoscopic surgery for large gastric gastrointestinal stromal tumors: systematic review and meta-analysis

Impact of perioperative intravenous lidocaine infusion on postoperative pain and rapid recovery of patients undergoing gastrointestinal tumor surgery: a randomized, double-blind trial

To explore the effect of perioperative intravenous lidocaine infusion on postoperative pain and the rapid recovery of patients undergoing gastrointestinal tumor surgery. The patients who underwent gastrointestinal tumor surgery from May to July 2020 were selected. The patients were randomly divided into the lidocaine group (group L) and control group (group C) by the random number table method, with 60 patients in each group. Both groups of patients received an intravenous drug infusion immediately after induction of tracheal intubation under general anesthesia. In group L, 1.5 mg/kg lidocaine was slowly injected intravenously at a rate of 1.5 mg·kg-1·h-1 to the surgical suture, and intravenous inhalation was used to maintain the depth of anesthesia. Group C patients were given the same volume of normal saline. The 2-, 4-, 7-, 14-, 30-, and 90-day numerical rating scale (NRS) and the proportion of chronic post-surgical pain (CPSP) after 3 months for both groups after surgery were recorded. Each patient's postoperative comfort score, requiring analgesia, return of flatus, bowl movement, hospitalization days, hospitalization expenses, and adverse events were also recorded. One hundred and twenty patients were enrolled but 5 of them failed to complete the treatment process. Therefore, 58 and 57 patients in group L and C were included into the final analysis. The NRS of patients in group L was significantly lower than that of group C at all time points after surgery (P<0.05), and the proportion of CPSP in group L was significantly lower than that of group C (P<0.05). The percentage of patients requiring analgesia and postoperative comfort score of group L was significantly higher than that of group C (P<0.01), patient's return of flatus, bowl movement, hospitalization days, and hospitalization expenses in group L were significantly lower than those in group C (P<0.05). There were no difference of adverse events between the 2 groups (P>0.05). During the perioperative period of radical gastrointestinal tumor surgery, intravenous lidocaine infusion can reduce acute postoperative pain, promote postoperative gastrointestinal function recovery, and improve postoperative comfort.

Meta-Analysis on the Efficacy and Safety of Laparoscopic Surgery for Large Gastric Gastrointestinal Stromal Tumors

The aim of this study was to conduct a meta-analysis comparing the safety and feasibility of laparoscopic versus open resection for gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm. We searched the Cochrane Library, PubMed, and Embase for relevant articles. Randomized and nonrandomized clinical trials were identified and included in this study. Searching for related articles on large GIST (>5 cm) for laparoscopic resection (laparoscopic group [LAPG]) and open resection (open group [OG]), RevMan 5.3 was used for data analysis, comparing 2 groups of operation time, intraoperative blood loss, complications, length of hospital stay, recurrence rate, disease-free survival, and overall survival. Seven studies including 440 patients were identified for the meta-analysis. Meta-analysis revealed that LAPG had less bleeding, shorter postoperative hospital stay, and a better 5-year disease-free survival. There was no significant difference between LAPG and OG in operation time, postoperative complications, recurrence rate, and overall survival. Laparoscopic resection of large (>5 cm) GIST is safe and feasible and has the advantages of less intraoperative blood loss and fast postoperative recovery, with a good outcome in the recent oncology.

Health economic evaluation of patients with sepsis after gastrointestinal tumor surgery-a cost consequences analysis in China.

The purpose of this study was to evaluate the health economics of patients with sepsis after gastrointestinal tumor operation in ICU. This case-control study used 1:1 propensity-score (PS) matched method and patients were matched according to tumor type, age and gender. The study group was composed of 181 patients with sepsis after operation of gastrointestinal tumor in ICU, while the control group was composed of 181 patients without sepsis after operation of gastrointestinal tumor. The medical expenses and length of stay in the hospital of these patients were analyzed. The median of the total hospitalization cost for the study group was $26,038, which was 1.7 times of the control group (P<0.001). The costs of drugs, laboratory test, examination, treatment, operation, anesthesia, materials, ward and other costs in the study group were higher than those in the control group (P<0.001). The median length of stay in the hospital in the study group was 26 days, which were 12 days longer than that of the control group (P<0.001). However, there was no significant difference in daily average cost between the two groups (P=0.103). In ICU, patients with sepsis after operation of gastrointestinal tumor increased the cost of hospitalization and prolonged the length of stay in the hospital than those without sepsis.

1634P The efficacy of continuous circulatory hyperthermic intraperitoneal chemotherapy (C-HIPEC) following cytoreductive surgery for metastatic gastrointestinal stromal tumors (GISTs)

Early reports discussed the prognostic factors of patients with metastatic GIST treated with cytoreductive surgery (CRS). However, the role of C-HIPEC, after CRS, for the treatment of peritoneal metastatic GIST remains unknown. A retrospective analysis of patients with peritoneal metastatic GIST treated with CRS + C-HIPEC combined with targeted therapy from a single institution was performed. C-HIPEC was introduced 1 or more days after CRS, with mitoxantrone, or doxorubicin with cisplatin. Overall survival (OS), and progression free survival (PFS) from time of surgery was determined. One-to-one propensity score matching (PSM) analyses were conducted to balance selection bias. Univariate and multivariate analysis were performed using a Cox proportional-hazards model. Between 2007 and 2018, we performed 104 operations on 87 patients with peritoneal metastatic GIST. C-HIPEC was conducted following 35 operations. After a median follow up of 23 months, the median OS and PFS were 40 months and 16 months. After PSM, both C-HIPEC group and non-C-HIPEC group had 28 operations. Either the median OS or PFS was not significantly difference in both groups, with 35 months of C-HIPEC vs 37 months of non-C-HIPEC (HR = 1.22 [95%CI: 0.56-2.67], P = 0.6187)，and 13 months in both groups( HR = 0.99 [95%CI: 0.53-1.85], P = 0.9865). Among all patients, 30 days post-operative grade III-IV morbidity rate was 16.3% (C-HIPEC 14.3% and non-C-HIPEC 17.4%, respectively, [P = 0.901]). Multifocal progression, with liver and/or extra-abdominal metastasis, tumor rupture and diameter of resected tumors ≥ 6.5cm were prognostic of worse OS. Multifocal progression, with liver and/or extra-abdominal metastasis and mitotic index >5/50 HPF were associated with worse PFS. C-HIPEC is safe to perform after CRS for metastatic GISTs. However, lacking of infusional regimen of targeted therapy, C-HIPEC using traditional chemotherapy medications did not increase survival benefits compared to CRS alone.

Glycan-Based Near-infrared Fluorescent (NIRF) Imaging of Gastrointestinal Tumors: a Preclinical Proof-of-Concept In Vivo Study

PurposeAberrantly expressed glycans in cancer are of particular interest for tumor targeting. This proof-of-concept in vivo study aims to validate the use of aberrant Lewis glycans as target for antibody-based, real-time imaging of gastrointestinal cancers.ProceduresImmunohistochemical (IHC) staining with monoclonal antibody FG88.2, targeting Lewisa/c/x, was performed on gastrointestinal tumors and their healthy counterparts. Then, FG88.2 and its chimeric human/mouse variant CH88.2 were conjugated with near-infrared fluorescent (NIRF) IRDye 800CW for real-time imaging. Specific binding was evaluated in vitro on human gastrointestinal cancer cell lines with cell-based plate assays, flow cytometry, and immune-fluorescence microscopy. Subsequently, mice bearing human colon and pancreatic subcutaneous tumors were imaged in vivo after intravenous administration of 1 nmol (150 μg) CH88.2-800CW with the clinical Artemis NIRF imaging system using the Pearl Trilogy small animal imager as reference. One week post-injection of the tracer, tumors and organs were resected and tracer uptake was analyzed ex vivo.ResultsIHC analysis showed strong FG88.2 staining on colonic, gastric, and pancreatic tumors, while staining on their normal tissue counterparts was limited. Next, human cancer cell lines HT-29 (colon) and BxPC-3 and PANC-1 (both pancreatic) were identified as respectively high, moderate, and low Lewisa/c/x-expressing. Using the clinical NIRF camera system for tumor-bearing mice, a mean tumor-to-background ratio (TBR) of 2.2 ± 0.3 (Pearl: 3.1 ± 0.8) was observed in the HT-29 tumors and a TBR of 1.8 ± 0.3 (Pearl: 1.9 ± 0.5) was achieved in the moderate expression BxPC-3 model. In both models, tumors could be adequately localized and delineated by NIRF for up to 1 week. Ex vivo analysis confirmed full tumor penetration of the tracer and low fluorescence signals in other organs.ConclusionsUsing a novel chimeric Lewisa/c/x-targeting tracer in combination with a clinical NIRF imager, we demonstrate the potential of targeting Lewis glycans for fluorescence-guided surgery of gastrointestinal tumors.

Efficacy and safety of neoadjuvant immunotherapy in patients with microsatellite instability-high gastrointestinal malignancies: A case series

IntroductionImmune checkpoint inhibitors (ICIs) have been approved for the late-line treatment of unresectable gastrointestinal tumors, but their efficacy and safety in the neoadjuvant setting have not been described. Whether dMMR/MSI-H populations benefit from preoperative ICIs plus surgery remains undefined. Materials and methodsSix consecutive patients managed at our institution received neoadjuvant ICIs and surgery for advanced, resectable, and MSI-H gastrointestinal tumors. All patients underwent thorough clinical evaluations and radiographic investigations before and during treatment. Next-generation sequencing (NGS), immunohistochemical (IHC) staining, and in situ hybridization (ISH) were also performed for each patient’ s biopsy section to generate their molecular profiling. ResultsNeoadjuvant immunotherapy was efficient and well-tolerated in patients with dMMR/MSI-H gastrointestinal tumors. Pathologic responses were observed in 6/6 (100%) dMMR/MSI-H tumors, with 5/6 (83%) complete responses. The other patient was also confirmed to demonstrate a TNM downstaging after treated with ICIs. Three patients (50%) developed grade I/II adverse events. All enrolled patients underwent timely operations without the occurrence of unexpected perioperative or postoperative complications. No disease recurrence was identified during the follow-up so far. ConclusionsNeoadjuvant immunotherapy results in favorable pathologic responses and minor adverse effects among patients with MSI-H gastrointestinal tumors. This pre-operative measure does not compromise subsequent surgery. There is an urgent need to warrant large-cohort clinical trials to examine the utility of neoadjuvant ICIs in resectable, dMMR/MSI-H gastrointestinal malignancies.

Effect of continuous intraoperative infusion of methoxamine on renal function in elderly patients undergoing gastrointestinal tumor surgery: a randomized controlled trial

BackgroundAcute renal injury (AKI) caused by hypotension often occurs in elderly patients after gastrointestinal tumor surgery. Although vasoactive drugs can increase effective filtration pressure, they may increase renal vascular resistance and reduce renal blood flow. The effect of methoxamine on renal function is not clear.MethodsAfter obtaining written informed consent, 180 elderly patients undergoing elective gastrointestinal tumor surgery were randomly allocated into two groups: M group (continuous infusion of methoxamine at 2 μg/kg/min) and N group (continuous infusion of normal saline). The patients’ mean arterial pressure was maintained within 20% of baseline by a continuous infusion of methoxamine or normal saline. Maintenance fluid was kept at 5 mL/kg/h. According to Kidney disease improve global outcome (KDIGO) guidelines, creatinine was measured at 1, 2 and 7 days after operation, and urine volume at 6, 12 and 24 h after operation was measured to evaluate the occurrence of AKI. 162 patients were included in the final data analysis.ResultsSignificant differences in the incidence of postoperative Acute kidney injury (M group: 7.5%; N group: 18.3%; P < 0.05), the frequency of hypotension (M group: 1 [1–3]; N group: 3 [1–5]; P < 0.05), and the duration of intraoperative hypotension (M group: 2[0–10]; N group: 10 [5–16]; P < 0.05) were identified between the groups. Multivariate logistic regression analyses demonstrated that preoperative creatinine and the frequency of intraoperative hypotension were the common factors leading to the occurrence of postoperative AKI. The results of Cox multivariate analysis showed that age and AKI were independent risk factors for 30-day death.ConclusionCompared with the intraoperative continuous infusion of placebo and methoxamine, continuous infusion of 2 μg/kg/min methoxamine reduced the incidence of postoperative AKI and other clinical complications in elderly patients undergoing gastrointestinal surgery by raising blood pressure and improved the prognosis of patients.Trial registrationTrial registration: Chinese Clinical Trial Registry, ChiCTR1900020536, registered 7 January, 2019,

Robotic surgery for gastric gastrointestinal stromal tumors: A single center case series.

The aim of surgical treatment of gastrointestinal stromal tumors (GIST) is a microscopically complete resection. Initial indications for laparoscopic surgery were limited to smaller tumors, in favorable locations. Over time, indications for minimal invasive surgery (MIS) have expanded, however concerns remain when considering resection of larger GISTs. Our aims were to assess the utility of robotic resection of gastric GISTs for challenging tumors. GIST resections, in this study were performed using the Intuitive Da Vinci Surgical Xi System. GIST's were considered challenging if tumor size was >50 mm at the time of surgery and/or the location of the tumor was type II, III, or IV using Privette/Al-Thanai classification. Robotic resections were performed on 12 consecutive patients, 83% were considered challenging cases, 6 out of 12 for location and 5 out of 12 for size. Initial median tumor size on imaging was 53.7 mm, and post-imatinib was 45.8 mm. All tumors were removed with clear margins (R0) via wedge resections, with no complications. Median operative time was 192 minutes (95-250). Length of hospital stay was 2 days (2-6). Robotic resection of gastric GIST's appears oncologically safe, and may expand the benefits of MIS to a greater cohort of complex cases.

Laparoscopic versus open surgery for gastrointestinal stromal tumor in esophagogastric junction: A multi-center, retrospective cohort analysis with propensity score matching.

11534 Background: Laparoscopic resection is increasingly performed for Gastrointestinal stromal tumor (GIST). Nevertheless, laparoscopic approach for the GIST located in the esophagogastric junction (EGJ-GIST) represent a surgical challenge. This study aims to investigate the efficacy of laparoscopic surgery and open procedure for EGJ-GIST through the propensity score matching (PSM) method. Methods: Between April 2006 and April 2018, 1824 patients underwent surgery were finally diagnosed with primary gastric GIST at four medical centers in South China. EGJ-GIST was defined as a GIST with an upper border of less than 5 cm from the EG line. Among them, 228 patients were identified and retrospectively reviewed with regard to clinicopathological characteristics, operative information and long-term outcomes. The PSM methods was used to eliminate the selection bias. Results: After PSM, 102 cases, consisted of 51 laparoscopic (LA) and 51 open surgery (OP), were enrolled. The match factors contained year of surgery, gender, age, BMI, tumor size, mitotic rate, recurrence risk and adjuvant tyrosine kinase inhibitors treatment. The LA group was superior to the OP group in operative time (108.5±56.5 vs. 169.3±79.0 min, P &lt;0.001), blood loss (54.6±81.9 vs. 104.9±156.4 ml, P = 0.042), time to liquid intake (3.1±1.8 vs. 4.3±2.2 d, P = 0.003), hospital stay (6.0±2.3 vs. 9.9±8.1, P = 0.001), and postoperative complication (5.9% vs. 25.5%, P = 0.006). The median follow-up was 55 (range, 2-153) months in the entire cohort. No significant differences were detected in either the relapse-free survival (RFS, P = 0.109) or overall survival (OS, P = 0.113) between two groups. The 1-, 3-, and 5-year RFS in the LA and OP groups were 100.0%, 95.5%, 91.0% and 100.0%, 90.8%, 85.7%, respectively. The 1-, 3-, and 5-year OS in the LA and OP group were 100%, 95.6%, 91.3% and 100.0%, 91.1%, 85.4%, respectively. Conclusions: Laparoscopic surgery for EGJ-GIST is associated with the advantages of shorter operative time, reduced blood loss, shorter time to liquid intake and shorter length of stay, all without compromising post-operative outcomes and long-term survival.

Risk factors and the utility of three different kinds of prediction models for postoperative fatigue after gastrointestinal tumor surgery

Postoperative fatigue (POF) is a common complication after gastrointestinal tumor surgery, and it also brings negative effect on prognosis and life quality. However, there are no prediction models for POF, and studies of risk factors are not comprehensive. Therefore, the aim of this study is to investigate the risk factors and pick out the best prediction model for POF and to validate it. A prospective study was conducted for patients undergoing elective gastrointestinal tumor surgery. Physiological, psychological, and socioeconomic factors were collected. Logistic regression, back-propagation artificial neural networks (BP-ANNs), and classification and regression tree (CART) were constructed and compared. A total of 598 patients consisting of 463 derivation sample and 135 validation sample were included. The incidence of POF in derivation sample, validation sample, and total were 58.3%, 57.0%, and 58.7%, respectively. Logistic regression results showed age, higher degree of education, lower personal monthly income, advanced cancer, hypoproteinemia, preoperative anxiety or depression, and limited social support were risk factors for POF. Receiver operating characteristic curve (ROC) and performance indices were used to test three models. BP-ANN was the best by the comparison of models, and its strong predictive performance was also validated. More attention should be paid on specific patients after gastrointestinal tumor surgery. BP-ANN is a powerful mathematical tool that could predict POF exactly. It may be used as a noninvasive screening tool to guide clinicians for early identification of high-risk patients and grading interventions.

Magnetic marking clip for easier laparoscopic localization of small gastrointestinal tumors.

386 Background: Laparoscopic surgery for gastrointestinal tumors requires fast and precise tumor localization. As tumor palpation is not possible during laparoscopic surgery, tumor identification is often difficult for some cases. Despite various methods, such as tattooing or endo-clipping, have been introduced for the localization of tumors, these methods own clear limitations. To overcome the drawbacks of these conventional marking methods, we designed a magnetic marking device linked to an endo-clip(MMC, Magnetic Marking Clip) for endoscopy. We performed preoperative endoscopic clipping with MMC and analyzed the intraoperative localization efficacy and safety during laparoscopic surgery. Methods: Study enrolled 30 patients with gastric and colorectal neoplasms scheduled to undergo endoscopic clipping before laparoscopic surgery at the Korea University Medical Center, Korea, between August 2017 and June 2019. A silicone-coated high-power neodymium marking device (ring or rod type) was fixed together with an endo-clip and applied on the center of the lesion during preoperative endoscopy. During laparoscopic surgery, a detecting magnetic body was inserted through a laparoscopic trocar and was used to localize the tumor that is marked with MMC. The time needed for endoscopists to place MMC at the lesion, laparoscopic clip detection time and success rate were studied. Results: Endoscopists placed MMC within 30 seconds. It was possible to find MMC in all cases of laparoscopic surgery. Time needed to find the MMC laparoscopically was relatively shorter than the time conventionally taken just with an endo-clip itself. There was no reported dislodgement of the clip before the surgery or any other adverse events associated with the MMC procedure. Conclusions: The MMC method enabled simple and fast tumor localization and showed excellent outcomes in efficacy of tumor localization. The MMC method may help surgeons localize GI tumor lesions easily and safely during laparoscopic surgery.

Relation of PTEN and Ki67 expression with prognosis in gastrointestinal stromal tumors

Aim: The purpose of the present study of ours was to examine the relation of Ki67 and PTEN expression with the prognosis in the pathologies of patients who undergo gastrointestinal stromal tumor surgery in our clinic. Gastrointestinal stromal tumors; In addition to being small incidental tumors; can be tumors with large size and malignant behavior. For this reason, the relation of a great number of macroscopic and microscopic parameters with prognosis was examined. The diameter, location and mitotic index of the tumor rank the first among these parameters; however, several pathological parameters like PTEN and Ki67 expression are also important.Material and Methods: The present study was conducted between January 2005 and April 2015 with patients diagnosed with gastrointestinal stromal tumors. The demographic data (age and gender), tumor localizations, tumor sizes, mitotic activities, prognostic risk classification, follow-up times, PTEN expressions, Ki67 proliferation indices, relapse and metastasis status, andsurvival data of the patients were examined retrospectively.Results: A total of 76 patients were included in the present study. A total of 33 (43.4%) of the participants were women, and the average age was 59.7±11.7 years. The relations of PTEN with risk scores (p=0.330), tumor diameter (p=0.360), location (p=0.169), and mitosis count (p=0.579) were not significant. The relation of PTEN staining rate with relapse (p=0.832), metastasis (p=0.626) and survival (p=0.069) was not found to be statistically significant. The relation of Ki67 expression with risk scoring (p=0.018) and mitosis count (p=0.003) was significant. Although the relation between Ki67 and relapse (p=0.019) and metastasis (p=0.003) was significant, the relation between survival (p=0.655) was not significant at a statistical level.Conclusion: The Ki67 expression was a prognosis-indicating index for relapse and metastasis when the baseline value was taken as 5%; however, no relation was detected between PTEN expression and prognosis.

Exploration and development of indocyanine green fluorescence applied in laparoscopic splenic hilum lymph node dissection for gastric cancer

With the continuous development of laparoscopic techniques and the concept of individualized treatment, laparoscopic surgery is also moving from "minimally invasive" to "minimally invasive plus precision" . Lymph node metastasis is one of the most important risk factors affecting the prognosis of gastric cancer (GC). Reasonable lymph node dissection has always been an important exploration direction in the field of GC surgery. In recent years, domestic and foreign studies have found that the new tracer, indocyanine green (ICG), can detect the lymphatic vasculature non-invasively, and more accurately display the perigastric lymph nodes, providing a new perspective in laparoscopic lymph node dissection for GC. Alternatively, since the application of ICG in laparoscopic gastrointestinal tumor surgery, especially in gastric cancer surgery is still in the early stage of exploration and experience accumulation, more high-level medical evidences are needed to evaluate its clinical value.

The application of multi-mode anesthesia monitoring and management in the operation of elderly patients with gastrointestinal tumor and fragile brain function

Objective To observe the effect of multimode anesthesia monitoring and management in the operation of elderly patients with gastrointestinal tumor and fragile brain function. Methods One hundred and nine cases of patients with fragile brain function who underwent elective total intravenous anesthesia for gastrointestinal tumor surgery were divided into observation group (58 cases) and control group (51 cases). The control group received routine anesthesia monitoring management during operation, while the observation group received multi-mode anesthesia monitoring management during operation, including cardiac inde (CI), stroke volume variation(SVV), bispectral index(BIS), train-of-four stimulation(TOF) and regional cerebral oxygen saturation(rScO2). The following indexes were observed and compared between the two groups: ① Intraoperative dosage of related anesthetics. ② Ramsay sedation score and Visual Analogue Scale(VAS) score at 10 min and 1 h, 6 h, 24 h, 48 h, 72 h after operation. ③ Heart rate(HR) and mean artery pressure (MAP) at admission (T0), infusion load of dexmedetomidine (T1), 1 min after intubation (T2), after skin incision (T3), after operation(T4), 1 min after extubation(T5). ④ Postoperative recovery, the relevant indicators are the opening time from the end of operation to the call, the time from the end of operation to extubation, the time of postanesthesia care unit(PACU) residence, the time of gastrointestinal function recovery and hospitalization. ⑤ Postoperative delirium (POD) and the occurrence of postoperative cognitive dysfunction(POCD). Results The dosage used of propofol and cisatracurium besylate in the observation group were significantly less than the dosage used in control group(P<0.05). The postoperative Ramsay sedation scores of observation group at 1, 6, 24, 72 h were significantly higher than the score of the control group(P<0.05), the postoperative VAS at 10 min, 1 h, 6 h, 24 h, 48 h were significantly lower than the control group(P<0.05). The HR at T1-T5 time and MAP at T2-T5 time of observation group were significantly lower than the HR and MAP of control group(P<0.05). Postoperative observation group and called the open end of the operation time, extubation time, PACU dwell time and hospitalization time were significantly shorter than the values of control group (P<0.05). The total POD incidence rate in patients of the observation group in were significantly lower than the rate of the control group(P<0.05). Conclusions The application of multi-mode anesthesia monitoring and management in the operation of elderly patients with gastrointestinal cancer and fragile brain function is satisfactory. Key words: Multimode anesthesia monitoring and management; Fragile brain function; Gastrointestinal tumor; Aged

Laparoscopic and Endoscopic Cooperative Dissection for Small Gastric Gastrointestinal Stromal Tumor without Causing Injury to the Mucosa.

Objective To investigate the feasibility of laparoscopic and endoscopic cooperative dissection (LECD) for small gastric gastrointestinal stromal tumors (GISTs) without causing injury to the mucosa, compared with ESD surgery which is widely used now. Methods A total of 25 patients with small gastric GISTs who underwent LECD and 20 patients with small gastric GISTs who underwent ESD between October 2014 and June 2016 were included in this study. All patients underwent curative resection for pathologically diagnosed small gastric GISTs. Patients' clinical data were retrospectively analyzed. Results In LECD group, the operation was successfully performed in all patients. However, in the ESD group, three patients were transferred to laparoscopic surgery due to intraoperative massive bleeding or intraoperative perforation. No additional targeted chemotherapy drugs for interstitial tumors were prescribed in two groups. There was no difference in the complete tumor capsule rate (100% vs. 90%, p = 0.11), operation time (80.76 ± 13.86 ml vs. 84.05 ± 15.33 ml, p = 0.45), major intraoperative bleeding (0 vs. 5%, p = 0.26), postoperative bleeding (0 vs. 10%, p = 0.11), and postoperative infection (0 vs. 10%, p = 0.11) between the two groups. Compared to ESD (endoscopic submucosal dissection), LECS patients had shorter postoperative indwelling gastric tube (1.04 ± 0.98 d vs. 2.85 ± 0.24 d, p < 0.01), earlier postoperative eating (1.96 ± 0.98 d vs. 3.50 ± 1.15 d, p < 0.01), shorter average postoperative hospital stay (3.44 ± 1.00 d vs. 7.85 ± 1.18 d, p < 0.01), smaller perforation rate (0 vs. 25%, p < 0.05), and fewer surgical supplies. No recurrence or metastasis cases were found between the two groups during the follow-up period, and there were no cases of death due to gastric GISTs. Conclusion LECD is a novel surgery for small gastric gastrointestinal stromal tumors that leads to satisfactory short-term outcomes and meets the idea of minimally invasive surgery and rapid recovery; compared with ESD, LECD surgery has some advantages in clinical practice. However, further follow-up is needed to confirm.

Minimally invasive surgery for gastrointestinal stromal tumors--pursuing the trivial, or striving for perfection

Complete surgical resection is the main treatment for gastrointestinal stromal tumor (GIST). However, GIST is crisp with rich blood supply, and prone to rupture with improper handling, leading to intra-abdominal hemorrhage and tumor cell dissemination. With the development of technology and equipment, minimally invasive surgery is getting mature. However, according to a phase III, multicenter, randomized controlled trial published in the New England Journal of Medicine in November 2018, open surgery was superior to minimally invasive surgery for early cervical cancer, which warned us that the application of minimally invasive surgery in GIST should be understood dialectically. The general principle of minimally invasive surgery of GIST is avoiding tumor rupture, despite the different location and decision-making according to tumor location. For gastric GIST, minimally invasive surgery should be performed with tumor locating at the greater curvature or anterior wall of the stomach, and with a diameter less than 5 cm. Small intestinal GIST is more malignant and not recommended to undergo minimally invasive surgery, but the technique can be used to expose and locate the tumor. Colorectal GIST is rare but highly malignant, therefore open surgery should be the first choice. In fact, minimally invasive surgery for rectal GIST has certain advantages such as better visualization compared to open surgery. GIST in non-appropriate location, such as the esophagogastric junction, pylorus, and duodenum, should be treated with caution because of its close relationship with organ function. The general principle of GIST treatment is to completely remove the tumor while retaining organ function. The application of minimally invasive surgery should not cause extra damage to organ function or increase the risk of tumor rupture. Endoscopic treatment of GIST still lacks high-quality evidence-based studies. The application of minimally invasive surgery should be conservative. The purpose of performing minimally invasive surgery is not the technique itself, but to minimize the injuries to tissue and organs. In conclusion, we should perform minimally invasive surgery for appropriate patients cautiously on the basis of complete resection and function preservation.

Hepatic pleomorphic leiomyosarcoma after surgery for gastric gastrointestinal stromal tumor: a case report

BackgroundPleomorphic leiomyosarcomas (PLMSs) are extremely rare tumors. We present the first case of hepatic primary PLMS after surgery for gastric gastrointestinal stromal tumor (GIST).Case presentationThe patient was a 62-year-old man who was referred to our hospital for resection of a hepatic tumor arising after gastric GIST surgery that was resistant to imatinib and sunitinib. A 40-mm tumor in the left lobe of the liver and three small nodules in the right lobe were detected. We performed hepatic left lobectomy and partial resections for three lesions. According to the histopathological and immunohistochemical findings and c-kit gene mutations analysis, the main tumor was diagnosed as a PLMS.ConclusionIt is necessary to consider the possibility that imatinib-resistant GIST recurrence lesions are a different kind of soft-tissue sarcoma. Accurate diagnosis is required to not miss the opportunity for radical excision of PLMS.

Pazopanib use preceding curative surgery in low rectal gastrointestinal stromal tumors after imatinib failure: A case report.

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