25 May 2023, Volume 28 Issue 03 Previous Issue   
Laparoscopic colorectal surgery 30 years in China: what we learned
ZHENG Minhua, MA Junjun
2023, 28 (03):  181-185.  DOI: 10.16139/j.1007-9610.2023.03.001
Abstract ( 40 )   HTML ( 6 )   PDF (882KB) ( 45 )  

Since 1993, the first laparoscopic radical surgery for colon cancer was carried out in China, laparoscopic colorectal surgery in China has embarked on a new journey, and has now entered its 30th year. Looking back on the 30 years history of laparoscopic colorectal surgery, it is hoped that through the window of laparoscopic colorectal surgery, from the establishment of a series of key technologies in its initial stage, to the development of training systems, and even the further development of innovative technologies and technology platforms, to review the trajectory in the development of laparoscopic surgery in China, and to think from multiple dimensions, so as to gain experience, guide current practice, and look forward to the future development.

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Influence of neoadjuvant radiotherapy combined with immunotherapy on minimally invasive surgeries for rectal cancer
YANG Yingchi, PANG Kai, ZHANG Zhongtao
2023, 28 (03):  186-189.  DOI: 10.16139/j.1007-9610.2023.03.002
Abstract ( 36 )   HTML ( 3 )   PDF (870KB) ( 12 )  

The current domestic and international guidelines recommend neoadjuvant chemoradiation or total neoadjuvant therapy followed by radical surgery for mid-low locally advanced rectal cancer. In recent years, the significant efficacy of immune checkpoint inhibitors has been recognized for patients with microsatellite instability-high/mismatch repair deficiency. The latest researchs show that in the neoadjuvant therapy of microsatellite stability/mismatch repair proficient rectal cancers, combining immune checkpoint inhibitors with radiotherapy can also achieve significant tumor regression, which is expected to usher in a new era of neoadjuvant therapy for rectal cancer. Even so, surgery remains pivotal in the current multidisciplinary diagnosis and treatment modelity for rectal cancer. However, it can be foreseen that a more significant preoperative tumor regression will greatly promote the widespread use of minimally invasive surgery. The minimally invasive surgery for rectal cancer represented by transanal endoscopic microsurgery, transanal total mesorectal excision, laparoscopic total mesorectal excision plus removal of specimens through natural cavity is hopeful to be further promoted and become the standard surgery in the era of radiotherapy combined with immunotherapy for rectal cancer.

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Experts forum
Function-preserving laparoscopic resection of pancreatic head and duodenal papilla tumors
GAO Pan, CAI Yunqiang, PENG Bing
2023, 28 (03):  190-196.  DOI: 10.16139/j.1007-9610.2023.03.003
Abstract ( 47 )   HTML ( 4 )   PDF (7136KB) ( 18 )  

In recent years, with the development of minimally invasive instruments,equipment and the progress of surgical techniques, minimally invasive pancreatic surgery has entered an era of rapid development. Function-preserving laparoscopic resection of pancreatic head and duodenal papilla tumors including laparoscopic duodenum-preserving pancreatic head resection (LDPPHR), laparoscopic pancreatic head tumor enucleation and laparoscopic transduodenal ampullary resection(LTDAR) have also been used in clinical practice. However, the anatomy and surgical procedures are extremely complicated. Many surgeons lack the experience in this field. So far, these procedures have rarely used in clinical practice. In this article, we introduced the current status, problems and countermeasures of these surgical procedures, to promote the development of function-preserving laparoscopic pancreatic head and duodenal papilla tumor resection surgery.

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Meticulous surgical techniques for endoscopic thyroid surgery
WANG Bin, QIU Ming
2023, 28 (03):  197-201.  DOI: 10.16139/j.1007-9610.2023.03.004
Abstract ( 29 )   HTML ( 4 )   PDF (876KB) ( 11 )  

The refinement of thyroid surgery has become a standardized requirement and a symbol of improved technical level in thyroid surgery. Endoscopic equipment magnifies the surgical field of view in high definition, making it more conducive to perform the surgery meticulously. Here we explored the key points of refined surgery based on the technical points of endoscopic thyroid surgery. We also focused on the establishment of endoscopic operation space, exposure of thyroid tumors, and protection of key organs and tissues. With regard to the establishment of endoscopic operation space, the separation of subcutaneous layer should show the view of “red sky and yellow ground”, which means the gap between the platysma muscle and the deep layer of the superficial fascia. The subcutaneous dissection area should be present as “long tunnel, small cavity”, and the shape from the bilateral sternoclavicular joints to the bilateral areola, which seems like the fan-shape with “thin neck and wide bottom”. With regard to the exposure of thyroid tumors, the key technical points include the dissociating and traction of anterior cervical muscles. Three spaces [the median space (the white line space of the neck), the inner space (the space between the thyroid surgical capsule and the anterior cervical muscles) and the outer space (the space between the anterior cervical muscles and the sternocleidomastoid muscle)] need to be fully dissociated. Furthermore, the assistant with special sutures or hooks to fully dissociate the anterior cervical space and the use of a reasonable grasping method as well as a suitable energy platform to prevent thyroid bleeding. With regard to the protection of key organs and tissues, nerve monitoring technology helps to find and locate the recurrent laryngeal nerve. In addition, careful manipulation at the entrance to the larynx is the key to avoid the damage of recurrent laryngeal nerve. Lymph negative imaging techno-logy helps to identify the parathyroid gland. Accurate identification of the anatomical type of the parathyroid gland and meticulous dissection of the intermembrane space of the parathyroid gland is benefit to protect the blood supply of the parathyroid gland in situ. To achieve the refinement and minimally invasive surgery, it is necessary to improve the surgical instruments and materials. What is more important, surgeons should update their surgical concepts, be well acquainted with anatomical relationships and constantly improve surgical techniques.

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Controversy over the medial border of lymph node dissection during CME/D3 surgery of right colon cancer
SUN Yueming, ZHANG Dongsheng
2023, 28 (03):  202-207.  DOI: 10.16139/j.1007-9610.2023.03.005
Abstract ( 33 )   HTML ( 3 )   PDF (929KB) ( 7 )  

Radical surgery is the most important treatment for colon cancer. The development and application of complete mesentery excision (CME)/D3 lymph node dissection has promoted the standardization of surgical techniques for colon cancer. Right colon cancer surgery is relatively complicated, and is a research hotspot currently. The issues involved the range of lymph node dissection, the range of bowel resection, and the method of bowel reconstruction. The medial border of lymph node dissection for right colon cancer is one of the controversies. The left side of the superior mesenteric vein is generally considered to be the medial border of CME/D3 dissection in right colon cancer surgery. However, with the in-depth development of related research, some scholars believed that the left side of the superior mesenteric artery should be used as the medial border for lymph node dissection. This approach is more consistent with the principle of CME, and can achieve complete lymph node dissection. However, its clinical significance still needs to be evaluated with further research. This article discusses the selection of medial border of lymph node dissection for right colon cancer, hoping to provide reference for clinical practice.

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Current status of minimally invasive surgery of gastroesophageal reflux disease
Aikebaier·Aili , Yusujiang·Tusuntuoheti , Kelimu·Abudureyimu
2023, 28 (03):  208-214.  DOI: 10.16139/j.1007-9610.2023.03.006
Abstract ( 35 )   HTML ( 2 )   PDF (865KB) ( 10 )  

Gastroesophageal reflux disease (GERD) is one of the common gastrointestinal diseases. The treatment options for GERD includes lifestyle changes, medication, and surgery. With the development of surgical technology, minimally invasive surgery has become more and more widely used in clinical practice due to its advantages such as less trauma and rapid postoperative recovery. Laparoscopic fundoplication is the standard surgical treatment for GERD. Due to the postoperative complications of laparoscopic fundoplication, a variety of new alternative minimally invasive surgery methods, which are expected to provide new treatment options for GERD patients, have emerged recently. Surgical minimally invasive procedures include magnetic sphincter augmentation (MSA), bariatric surgery, and lower esophageal sphincter electric stimulating therapy (LES-EST). Endoscopic minimally invasive procedures include transoral incisionless fundoplication (TIF), Stretta radiofrequency ablation, and anti-reflux mucosectomy (ARMS). This article mainly describes the current status of minimally invasive surgical treatment of GERD.

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Minimally invasive surgery facilitates surgical treatment of obesity and metabolic diseases
HUANG Xianjue, YAO Qiyuan
2023, 28 (03):  215-219.  DOI: 10.16139/j.1007-9610.2023.03.007
Abstract ( 31 )   HTML ( 2 )   PDF (884KB) ( 9 )  

The prevalence and social burden of obesity and metabolic diseases are increasing. Multidisciplinary diagnosis and treatment, including surgical treatment, can effectively improve the condition of obesity and metabolic diseases. With the developing and updating of minimally invasive surgical techniques and concepts, traditional open transabdominal bariatric surgery has been replaced by laparoscopic surgery. The emergence of new technologies such as 4K high-definition laparoscopy, single-port bariatric surgery, robot-assisted surgery, and endoscopic bariatric surgery has further contributed to the safe, effective, and individualized treatment of obesity and metabolic diseases.

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Prevention and treatment of anastomotic leakage after laparoscopic anterior resection of low rectal cancer
LUO Yang, ZHONG Ming
2023, 28 (03):  220-225.  DOI: 10.16139/j.1007-9610.2023.03.008
Abstract ( 37 )   HTML ( 3 )   PDF (9613KB) ( 3 )  

Anastomotic leakage (AL) is one of the inevitable and severe complications after laparoscopic-assisted anterior resection of low rectal cancer. With the improvement of surgical technology and cognitive concept, the position of sigmoid-rectal anastomosis is becoming lower and lower, and the problem of AL is more challenging. Preventive stoma is currently a common method to deal with AL, but over-reliance on stoma and the stoma-related complications have also troubled surgeons. Based on years of practical experience, we summarized how to avoid unnecessary stoma through the risk assessment scale, and how to detect and deal with AL in the early stage of laparoscopic-assisted anterior resection of low rectal cancer.

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Current status of high-positioned digestive tract reconstruction after laparoscopic proximal stomach and lower esophagus resection through the abdominal-left diaphragmatic approach for adenocarcinoma of esophagogastric junction
HU Wenqing, YANG Yinhao, CUI Peng, WEI Wei
2023, 28 (03):  226-232.  DOI: 10.16139/j.1007-9610.2023.03.009
Abstract ( 29 )   HTML ( 6 )   PDF (857KB) ( 13 )  

In recent years, the rising incidence of adenocarcinoma of esophagogastric junction (AEG) and the subsequent surge in early detections have transformed the surgical treatment of AEG into a topic of substantial interest. The anatomical positioning of AEG, combined with the unique nature of its tumor biology, which encompasses two distinct surgical domains, the thoracic and abdominal cavities, has sparked numerous debates regarding the selection of treatment strategies. The comprehensiveness of lymph node dissection and the safety of digestive tract reconstruction are instrumental in shaping these strategies. The laparoscopic abdominal transhiatal (TH) approach offers a balance of addressing both these conside-rations. It ensures the oncological safety of inferior mediastinal lymph node dissection, while simultaneously performing abdominal lymph node dissection. This approach becomes a prime choice for AEG when the esophageal invasion length is ≤ 4 cm.When implementing the TH approach, surgeons have the ability to either augment the inferior mediastinal space or establish a direct connection between the abdomen and the left thoracic cavity by performing a strategic opening of the left diaphragm. Such a maneuver circumvents the need for traditional thoracotomy, thus enlarging the operating space and enhancing the surgical field of view. This method reduces chest trauma and enables a clearer and more comprehensive removal of inferior mediastinal lymph nodes. Moreover, ample operating space and sufficient esophageal dissection make high digestive tract reconstruction in the mediastinum or left thoracic cavity safer and more feasible. Our center has dubbed this approach the abdominal-left diaphragmatic (ALD) approach. Functional digestive tract reconstructions such as side overlap esophagogastrostomy (SOFY) anastomosis and double-flap technique can be progressively applied to a higher anastomosis plane through the ALD approach. Consequently, the ALD approach expands the indications for digestive tract reconstruction, ensures operational safety, and maintains an effective anti-reflux effect simultaneously.

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Practice of single-port and reduced-port laparoscopic gastric cancer surgery in China
YAN Su, ZHENG Minhua
2023, 28 (03):  233-239.  DOI: 10.16139/j.1007-9610.2023.03.010
Abstract ( 34 )   HTML ( 2 )   PDF (8152KB) ( 4 )  

The application and development of laparoscopic surgery for gastric cancer has experienced a history of more than two decades, from exploratory development to clinical validation, and then to large-scale clinical studies. Gra-dually, laparoscopic gastric cancer surgery has been supported by high-level evidence. Laparoscopic surgery is progressively recommended as one of the alternative treatment for gastric cancer and is widely performed in gastric cancer surgery worldwide, especially in East Asia, such as Japan, Korea and China. Single-port and reduced-port laparoscopic surgery was first performed for cholecystectomy and appendectomy, is becoming more popular among gastrointestinal surgeons due to its minimally invasive outcomes and better cosmetic effects. However, the clinical application of single-port and reduced-port laparoscopic surgery for gastric cancer is still in the exploratory stage. The results of initially observational studies have shown that single-port and reduced-port laparoscopic surgery have potential advantages in terms of cosmetic results and enhanced recovery after surgery compared with the conventional five-port laparoscopic surgery for gastric cancer. But its surgical safety and feasibility are still not confirmed by high-level evidence of evidence-based medicine.

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Original article
Incidence, mortality and survival analysis of small intestine cancer in Shanghai population-based study from 2002 to 2016
WU Chunxiao, GU Kai, PANG Yi, WANG Chunfang, SHI Liang, XIANG Yongmei, GONG Yangming, DOU Jianming, SHI Yan, FU Chen
2023, 28 (03):  240-248.  DOI: 10.16139/j.1007-9610.2023.03.011
Abstract ( 29 )   HTML ( 2 )   PDF (998KB) ( 7 )  

Objective: To investigate the incidence, mortality and survival of small intestine cancer in Shanghai from 2002 to 2016. Methods: Data of new small intestine cancer cases and deaths from 2002 to 2016 were obtained from the population-based cancer registry and Vital Statistics System of Shanghai Municipal Center for Disease Control and Prevention. The incidence and mortality of small intestine cancer stratified by year of diagnosis or death, gender and age-group were analyzed. Cases or deaths, proportion, crude rate, age-specific rate, age-standardized rate and others were calculated. Trends of cases or deaths, crude rate, age-specific rate and age-standardized rate of incidence and mortality with follow-up information were estimated. The annual percent change (APC) of age-standardized rates of incidence and mortality was estimated by Joinpoint analysis. The new cases and proportions with selected diagnostic character of small intestine cancer in different diagnosis years were also calculated. Age-standardized rates were calculated using Segi’s 1960 world standard population. The 1- to 5-year observed survival rates were calculated based on the life table. The probabilities of surviving from 0 to 99 years old were estimated according to the Elandt-Johnson model, and then the cumulative expected survival rates were calculated according to the Ederer Ⅱ method. Finally, the 1- to 5-year relative survival rates were calculated. Results: The age-standardized rates of incidence and mortality of small intestine cancer were stable in Shanghai from 2002 to 2016. The new average cases and deaths of small intestine cancer were 280 and 174 per year in Shanghai. The crude rate of incidence was 2.02/105, and the age-standardized rate was 0.96/105. The crude rate of mortality was 1.25/105, and the age-standardized rate was 0.54/105. The age-standardized rates of incidence and mortality in males were higher than those in females. The age-specific cases or deaths and rates of incidence and mortality increased with aging. Duodenum cancer was the dominant anatomical site. Adenocarcinoma was the most histopathological type, and the proportion of gastrointestinal stromal tumors was increasing. The 5-year observed survival rate of small intestine cancer diagnosed from 2002 to 2013 was 36.34% in Shanghai, and the 5-year relative survival rate was 39.98%. All survival rates of male were lower than those of female. The 5-year observed and relative survival rates were stable. And those decreased with the increase of diagnostic years and stages. Relative to other sites, the rates of the duodenum cancer were the lowest. Relative to other histopathological types, those of gastrointestinal stromal tumors were the highest. Conclusions: The diagnostic level of small intestine cancer has been improved in Shanghai, continuously. But the survival rates have not been improved with the times. The proportion of stage Ⅰ was low and without improvement for a long time. This study provides useful information to further research, control and prevention of small intestine cancer. Improvement of the surveillance and research on small intestine cancer will help to promote more efficient control and prevention strategies then decrease cancer burden.

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Efficacy of intraoperative indocyanine green fluorescence imaging evaluation for preventing anastomotic leakage after laparoscopic rectal cancer surgery
LUO Yang, YU Minhao, YE Guangyao, LIN Haiping, GONG Tingyue, LI Hao, ZHONG Ming
2023, 28 (03):  249-253.  DOI: 10.16139/j.1007-9610.2023.03.012
Abstract ( 35 )   HTML ( 3 )   PDF (3438KB) ( 14 )  

Objective To investigate the effect of indocyanine green(ICG) fluorescence imaging to indicate blood supply of sigmoid-rectal anastomosis in laparoscopic anterior resection of rectal cancer. Methods Here a retrospective cohort study including 175 consecutive patients with rectal cancer scheduled for laparoscopic surgery in Department of Gastrointestinal Surgery of Renji Hospital between January 2019 and December 2022 was analysed. These patients were classified into two groups, according to using ICG or not within surgery: the ICG group (n=65) and the control group (n=110). Operation situations and complications were compared between the two groups. Results The operation time of ICG group was longer than that of control group [(151.6±4.8) min vs (139.5±3.7) min, P=0.04], and the preventive ileostomy rate was lower than that of control group (12.3% vs 34.6%, P=0.01), while the other operation data (intraoperative blood loss, number of lymph node dissection), were similar between the two groups (P>0.05). The rate of anastomotic leakage in ICG group were lower than that in control group (4.6% vs 14.6%, P=0.04), and there was no significant differences in wound infection, urinary retention and intestinal obstruction between the two groups (P>0.05). Conclusions The ICG displays that the blood supply in laparoscopic anterior resection of rectal cancer can reduce the incidence of anastomotic leakage, which improves the surgical safety and the quality of postoperative life.

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Effects of silencing Ki-67 gene on doxorubicin resistance of breast cancer MCF-7/DOX cells
DONG Jun, CUI Fengming, LIU Jun
2023, 28 (03):  254-259.  DOI: 10.16139/j.1007-9610.2023.03.013
Abstract ( 32 )   HTML ( 2 )   PDF (3009KB) ( 10 )  

Objective To study the effect of Ki-67 gene silencing on doxorubicin (DOX) resistance in breast cancer MCF-7 cells. Methods Liposome transient transfection method and breast cancer MCF-7 cells cultured in vitro were used combined with the transfection of small interfering RNA (siRNA) and negative control (NC) siRNA. The expression of Ki-67 mRNA was detected by RT-PCR after 48 h of transfection. Ki-67 siRNA with the highest interference efficiency was used in subsequent experiments including three groups: control (CON) group without transfection, NC group transfected with MCF-7 negative control siRNA and siRNA group with MCF-7 transfected with Ki-67 siRNA. The expression of Ki-67 mRNA and related proteins in three groups were detected by RT-PCR and Western blot. MCF-7/DOX cells were treated with DOX at different concentrations. Proliferation of MCF-7/DOX cells was detected by MTT assay. Results After the specific siRNA was successfully transfected into MCF-7 /DOX cells, it was observed under fluorescence microscope that siRNA was evenly distributed in the cytoplasm, and transfection efficiency was more than 85%. Results of transfection of MCF-7 siRNA cells showed that Ki-67 mRNA expression in MCF-7 cells reduced Ki-67 at varying degrees. The expression of Ki-67 protein reduced significantly with the inhibition of 78.51% and the statistically significant difference compared with that in NC group and CON group (P < 0.05). MTT showed that the proliferation ability of MCF-7/DOX cells in vitro was inhibited significantly after Ki-67 mRNA expression interfered by siRNA. The half maximal inhibitory concentration (IC50) of DOX to MCF-7/DOX cells in siRNA group was (7.45±0.18) μmol/L, lower significantly than (55.19±2.86) μmol/L in NC group and (56.43±4.22) μmol/L in CON group. The reversal of drug resistance was 7.69 times compared with that in CON group (P < 0.05). The inhibitory effect of DOX at different concentrations on the cells in siRNA group was significantly higher than that in NC group and CON group with statistically significant difference (P < 0.05). Conclusions It was indicated that siKi-67 could inhibit both the expression of Ki-67 gene effectively and the proliferation of MCF-7/DOX cells, and partially reverse the DOX resistance of MCF-7/DOX cells.

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Study on effects of percutaneous transhepatic gallbladder drainage in treatment of acute biliary pancreatitis
ZHANG Zhen, HAN Jinyan, YU Xiaopeng, DENG Tianlin, WU Xiaodong, WU Shuodong
2023, 28 (03):  260-266.  DOI: 10.16139/j.1007-9610.2023.03.014
Abstract ( 35 )   HTML ( 2 )   PDF (926KB) ( 11 )  

Objective To evaluate retrospectively the clinical efficacy of percutaneous transhepatic gallbladder drainage (PTGBD) in the patients with acute biliary pancreatitis (ABP). Methods A total of 244 patients with ABP recei-ving treatment in our department from January 2014 to November 2021 were included in this study. There were 76 cases in study group using PTGBD treatment, among them, 41 cases with performed endoscopic retrograde cholangiopancreatography (ERCP) after symptoms remission, and 168 cases without PTGBD in control group with 49 cases using ERCP and 119 cases with conservative treatment. The rate of post-ERCP pancreatitis (PEP) and postoperative adverse events were compared between two groups. Results The rate of PEP was significantly lower in study group (11/41) than in control group (23/49), 26.8% vs.46.9%, P=0.008. The patients in both groups were performed cholecystectomy or cholecystectomy with bile duct drainage in late stage (73 cases in study group and 152 cases in control group). The shorter operative time [(76.3±28.3) min vs.(121.6±34.9) min, P=0.011], less intraoperative blood loss [(65.7±27.6) mL vs. (99.2±60.3) mL, P=0.028], shorter abdominal drainage duration [(3.6±2.5) d vs. (8.9±4.9) d, P=0.016] in study group than in control group. The rate of postoperative sepsis [2.7% (2 cases) vs. 5.3% (8 cases), P=0.003], rate of reoperation [1.4%(1 case) vs. 3.9%(6 cases), P<0.001], rate of admission to intensive care unit [4.1%(3 cases) vs. 7.2%(11 cases), P=0.028], and mortality [0 vs. 1.3% (2 cases), P<0.001] in study group were lower than those in control group. Conclusions PTGBD could be simple and effective in the treatment of ABP and consistent with treatment of damage control surgery which should be worthy clinical application.

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Emerging developments in immune checkpoint inhibitor therapy for gastroenteropancreatic neuroendocrine neoplasm
HAN Xu, WANG Wenquan, LOU Wenhui, LIU Liang
2023, 28 (03):  267-272.  DOI: 10.16139/j.1007-9610.2023.03.015
Abstract ( 37 )   HTML ( 3 )   PDF (1784KB) ( 11 )  

Immunotherapies targeting immune checkpoints have undergone rapid evolution, and have been preliminary explored in treatment of gastroenteropancreatic neuroendocrine neoplasm (GEP-NEN) in recent years. However, their potential to deliver tangible clinical benefits remains uncertain. In this article, we systematically reviewed the current status and efficacy of clinical trials, which evaluated immune checkpoint inhibitor (ICI) as monotherapy or in dual-ICI therapy for GEP-NEN. Despite lacking substantial breakthroughs in GEP-NEN treatment, ICI demonstrated some antitumor activity and safety in treating recurrent or metastatic GEP-NEN, albeit with a generally low objective response rate (ORR). The ORR of ICI in GEP-NEN treatment exhibited a negative correlation with tumor differentiation, suggesting that poorly diffe-rentiated gastroenteropancreatic neuroendocrine carcinoma (GEP-NEC) might achieve better clinical responses. Disease control rate of dual-ICI therapy was higher than that of monotherapy. However, dual-ICI also got more severe side effects. Given the rarity of mismatch repair gene defects and high microsatellite instability (dMMR/MSI-H) in GEP-NEN, patients with high tumor mutational burden (TMB-H≥10 muts/Mb) could get potentially benefit from ICI therapy. In the future, it is expected to further explore the synergistic combined application of ICI with chemotherapy, radiotherapy, and antiangiogenic drugs in GEP-NEN, which may enhance its antitumor efficacy. Clinically, the benefit groups of ICI immunotherapy should be evaluated comprehensively according to pathological grading, immune markers, disease progression, and patient's physical condition.

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Progress of minimally invasive thyroid surgery
LI Jiamin, KANG Jie, WU Bo, FAN Youben
2023, 28 (03):  273-277.  DOI: 10.16139/j.1007-9610.2023.03.016
Abstract ( 23 )   HTML ( 2 )   PDF (817KB) ( 5 )  

The incidence of thyroid cancer has increased in recent years. The desire for aesthetics and quality of life, combined with the development of energy devices and robotics make surgeons introduction of minimally invasive procedures both more refined and difficult techniques, resulting less painful and better aesthetic results. Thyroidectomy has been expanded to include minimally invasive video-assisted thyroidectomy, multi-approach to endoscopic thyroidectomy, thermal ablation, chemical ablation and robot-assisted thyroidectomy.

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