Hualiang DENG Epatectomia sinistra con fluorescenza

Thank you. Welcome to the 36th Congress of Digestive System Surgery in Rome.

I'm truly... it's a great pleasure for me to introduce Professor Waliang Deng,

President of the Affiliated Hospital of Shandong University of Chinese Medicine

and all of the surgeons that in this session will perform the procedures. Welcome.

technologies and we are the only TCM traditional Chinese medicine hospital invited for the

recorded session and for that we feel deeply honored and our teams of GI surgery HPP surgery

and other departments would feel very honored to show our technology and the cases that we've done

and we will try to learn from our counterparts from Italy in terms of the technologies

so in our hospital we have always placed very high emphasis on the laparoscopic surgery and

endoscopic procedures focusing very much on a complex HPV procedures and also on the

microscopic surgeries. And we also focus very much attention on the preservation of functions.

And in our hospital, we have always upholded the principle of integrating Chinese medicine

with Western medicine. Our hospital has a 70-year history. And at its founding time,

it has been established as a traditional Chinese hospital.

We have carried on the legacy from Chinese medicine,

but also we have integrated the latest advancement from Western medicine as well.

So we have never lost the legacy from the traditional Chinese medicine,

and we really adopt an integrative approach for the surgeries.

Before the surgery, we would use traditional Chinese method and approach

to improve patients' status of function and improve the tolerability of the surgery.

And during the surgery, we would leverage the modern medicine in terms of precision and surgical techniques.

And after the surgery, we would manage the patients with our traditional Chinese medicine approach as well,

including we would use traditional methods to maybe cover the acupuncture sites

and adopt the yin and yang concept in managing the patients in terms of recovery and the functional recovery,

recovery and also manage the pain and the GI function and improve patients' status as a whole.

And we also learned from our Western counterparts and we integrate these two concepts and achieve

additional benefits to our patients. And this concept of integration would be our further

direction as well. And thirdly, we have always carried on the traditional Chinese medicine

legacy. And also we focus on efficiency, advancement and cultural integration.

We have leveraged the most advanced technologies in the GI surgery, HPV surgery, and so on.

And we have always maintained an open mindset and try to learn from the latest updates from our international counterparts.

So in the future, we really look forward to maintain that principle at the spirit of being very open and integrative and also try to make breakthroughs together with the collaboration with our international counterparts.

We hope to make new breakthroughs and make contribution to humankind as a whole and we really look forward to

All the discussion today and hope to learn from the extra suggestions and your experiences. Thank you very much

Thanks. Thanks professor Dan and

I want to welcome professor also professor you deputy director that the affiliated hospital of Shandong University

of Chinese medicine

so I also

Also, for me, it's also a pleasure to welcome Professor Shi, Professor Niu, and Professor Sun, the operator and the moderator of this fantastic session.

So, I think we can start, and welcome to everybody that are online in this session.

谢谢副院长以及我们今天的述者史学伦教授以及孙真教授,非常感谢大家的参与,孙芳教授,抱歉,非常感谢大家的参与,那么我们现在就可以开始。

Thank you very much. And we're very happy to have you here as well. And thank you for the platform. Thank you for the invitation. The hospital actually places very high importance on this opportunity. So since we got the invitation, Professor Deng, our president, has organized the selection of the cases.

and today we'll have three teams sharing their cases with us including the colorectal surgery

department which has always carried on the legacy from traditional Chinese medicine

and also HPP team which upgraded the spirit of modern medicine as well as we have the

GI endoscopic department which has always been integrating traditional Chinese medicine and

the modern medicine. Welcome for sharing your cases. Thank you. Thank you. Thank you. And now

we will introduce the first case. The first case would be done by Professor Xu Xiuwen from the

colorectal surgery department of our department. And this is the laparoscopically assisted left

hemocolectomy for colon cancer. And this is the brief introduction of the case.

This patient was found to have a mass in a descending colon seven days ago, and the patient had a mass in the anal verge.

It's an irregular circumferential mass protruding into the lumen, and it's about 60 centimeters with the laparoscopic in the colon.

And on the CT, as we can see, there's focal wall thickening with luminal narrowing and marked enhancement.

And the diagnosis would be adenocarcinoma of descending colon.

And our surgical plan is, because the tumor is located in the mid-descending colon,

the surgical approach will follow a central to lateral to cephaloid sequence

to accomplish a complete mesocollic excision for left hemicolectomy.

And in this case, we have also invited Professor Sun Feng from Guangdong Traditional Chinese Medical University No. 1 Hospital as the commentator.

Professor Sun is the chief director of the colorectal and anal surgery department of the hospital from Guangzhou.

And he is also a doctor of surgery and a doctor supervisor.

He's also the member of multiple societies and associations.

Welcome all.

And for the second case, second case surgeon is Professor Sun Zhen.

He is from our hospital and he is the chief of the GI laparoscopic surgery.

surgery. And this is a brief introduction of the case. The patient had a, actually the second case

is endoscopic submucosal dissection of duodenal submucosal lesion. And the diagnosis for the

patient was, so we have done a lot of tests for the patient. The patient was a male, 52 years old,

admitted in 2020, March 24th. So they have discovered a little protrusion in the duodenal

bulb during physical examination. The patient did not have symptoms and we have done the tests and

then we see that there is a lesion in the submucosal layer in the bulb of the duodenum

and there's no enlarged lymph nodes. So the procedure was a general anesthesia and endotracheal

intubation and then we did endoscopic resection of the submucosal lesion. And for this case,

we have invited Professor Yan Hua, Deputy Chief Physician from the Shandong Traditional Chinese Medical University Hospital,

to be the commentator. And here is a brief introduction of Professor Yan.

And for our third case, we're very happy to have Professor Niu.

Professor Niu Xiufeng is the Chief of HPP Surgery Department from our hospital.

And this case is fluorescence laparoscopy guided anatomical left hemohepatotomy.

And this patient diagnoses HHCC, and the tumor is with a very close proximity to the left hepatic vein and the left hepatic pedicle.

So the case, we would do the left hemohepatectomy under the laparoscopic guidance.

And for this case, we have invited Professor Wang Kai to be our commentator.

He is from Nanchang University No. 2 Hospital.

He's a medical doctor, chief physician, and doctoral supervisor.

He is also a postdoc supervisor, and he is the chief of the QC Center of Jiangxi.

Thank you very much.

With that, we will move on to the court session of today,

playing the recordings and have a discussion over the cases.

All the cases we have selected are very representative for the current stage of our hospital.

We hope that this case sharing would be referential to all of you.

And we hope that the experts here would share your valuable opinions and suggestions with us.

And I also hope the students here can listen attentively and learn from the surgical techniques.

And let's work together to really improve together, improve the surgical techniques to a new height.

Thank you very much. And with that, we'll start.

Thanks, Professor Yu.

I think we can start.

尊敬的卡玛拉塔教授,尊敬的孙芬教授,我们今天这是探查着肿瘤位于交接场的这个中断。

The tumor is in the mid part of the descending column, and we are going in from the medial side.

我们这个手术的戳卡的方针也是无孔法。

戳卡 is a five-site method with the戳卡。

Our plan is because this tumor is at the middle part segment of descending colon,

so our surgical site would be 10 centimeters on either side, the cephalic and in the colon side.

Our surgical access is from the medial side, from the common iliac artery, and we went

in through the mesocollum.

And now we are dissecting the lymph nodes at the root of the mesocollum, the 2, 3, 5

lymph nodes.

现在显露出来的是我们的左结肠动脉根部。

Now we're exposing the root of the left colon artery.

因为是降结肠中段的肿瘤,所以说清扫的范围就是从长性膜下动脉根部到左结肠动脉之间的这个二五三淋巴结。

Since the tumor is located in the middle segment of the descending colon, so the dissection scope would be starting from the root of the SMA to the left colic artery, the 253 lymph nodes.

因为下结肠中段血管的供应呢,主要是左结肠动脉,所以说呢,这个地方的淋巴的清脏是非常重要的。

Since the left colic artery is the main supplying vessel for the descending colon, so this dissection in this area is very important.

现在呢是长须门下静脉的分离。

Here, we are dissecting the inferior vein, the IMB.

At this site, we need to pay attention to preserving the ureter as well as the vessels here.

这是我们把这个伸直血管和输尿管向背侧游离。

Here we are dissecting the ureter and the vessels to the dorsal part in order to preserve them.

这是我们在直肠上动脉和左肌肠动脉之间分离TOT间隙。

So here we are separating the TOT space between the left colic artery and the superior rectum artery.

这个地方一直要分离到外侧的融合基础的间隙,也就是我们经常说的到这个黄白交界线。

Here we go up until the edge of the fascia, the joint part between the yellowish and the whitish tissue.

我们现在分离的这个血管里面有长细膜下动脉和长细膜下静脉,共同走形。

Now we're trying to dissect the IMA and IMV.

They follow the same track.

The surgical team is actually sitting behind Professor Shi right now.

They did the surgery together.

因为我们测量肿瘤的肛门侧,10公分的地方大概是在胰状结肠的中段。

胰状结肠的第一只呢,离左结肠也是比较远。

The first branch of the sigmoid colon is actually quite far away from the left colon.

So we did not plan to dissect the lymph nodes here at the first branch of the sigmoid colon.

Because the vessels here are not supplying the tumor.

This patient is young, 33-year-old female, so we saw 253 lymph node dissection, and it

was not done completely or sufficiently, so we are going further into the right side of

the aorta.

这样我们认为根治的效果会更好。

We think if we do that, we would have a better curing effect.

现在是和左结肠半性的长细膜虾静脉的分离。

Now we are dissecting the IMV on the left side.

Dr. Camerata, please feel free to comment anytime you want.

我们试图寻找这个乙状结肠的第一只。

We are trying to find the first branch of sigmoid colon.

Yeah, nice dissection.

The first branch of the segment colon is far away from the tumor, more than 15 cm away.

One question, do you have some concerns about the conservation of the nervous plexus

near the aortic plane when you dissect the SMA so near the region.

腰腹的神经要做一个保护,同时也要保护数量管和神经血管。

Yes, actually, as is shown here, we have taken extra caution in preserving the nerve plexus here.

We have moved them aside, and also we have taken caution to preserve the ureter and the vessels.

There's a question regarding the lymph node dissection of 253.

As we can see, there are two parts of dissection.

So first of all, dissection and removal, and then there is additional dissection or removal of the lymph nodes.

So do you worry about the dissemination of the tumor in this process?

This patient is quite thin.

Her BMI was 24.

So when we dissect the lymph nodes, we were a little worried about the nerve plexus.

So our dissection scope was relatively small and superficial.

And then later, as we can see from the video, we try to protect the nerve and the vessels.

We did not cut into the left colic artery and lymph nodes and the vessels are still connected in this way.

I think it's preservative and more protective.

This is a lumbar nerve trunk.

We try to preserve it here.

This is the medial side.

We went up here and we tried to protect the nerve.

Yes, we are seeing a perfect left,

laparoscopic left hemicolectomy.

Do you think that there is a real necessity

for the using of the robotic platform for this type of surgery,

this type of surgical procedure, with this expertise, clearly.

We saw that the left half of the long-term treatment was done very well.

Is it still necessary to use this robot-assisted technology?

Because the surgical technique is already very good.

Because we are a Chinese hospital,

This is under laparoscopic assistance, actually, without the robot.

They are a TCM hospital.

They don't have a robotic system yet.

But our president is trying to get one.

Do you have any additional comments?

My question is, I saw that this procedure is laparoscopic, but with this expertise, do you think that the use of the robotic platform are really necessary?

肯定我们将来的技术更好,患者会更受益,这是一个趋势。

Yes, because robotic surgery is probably the major trend for the future,

so probably we want to start doing that as soon as we can,

improve our surgical proficiency so we can benefit our patients.

特别是我们现在国产的机器人,

然后很快就中国制造大国,

很快国产的机器人就能够成功地运用临床了,

到时候我估计价格各方面可能都会非常的优秀,有优势,我们就能运得起来,能开展起来了。

Especially with the local manufacturers also developing their surgical robots,

and they may have a lot of advantages in terms of localization and costs,

and in the future they may play a main role in this area.

施主任,现在进入到手术当中的一个长期膜下静脉的一个包录,

The first question is how to protect the IMV and the pancreas when we're doing this stage.

And the answer from the doctor is when we are going from lower to upper,

we try to avoid going to the back or the dorsal part of the pancreas.

And here, we are preserving IMV.

And the assistant is very important in exposing the mesocolon.

And as we can see, he was retracting the mesocolon.

And the chief surgeon, he can elevate the IMV to the ventral side so we can expose the

taut space.

And here, we are very close to the anterior space, anterior to the pancreas.

So in this way, we not only go from the contralateral side.

we can avoid going to the back of the pancreas.

The dissection of the left colon is done very well, but how to go into the anterior space of the pancreas instead of going to the back is quite challenging, especially for new doctors, and also especially challenging for obese patients.

But it's good that this case, the patient is quite thin.

And Professor Sun also shared some experience.

Professor Shi made a very good point in maintaining a good tension in order to go to the right space.

and the professor Sun's experience is

on the dorsal part of the mesocolon

we can see some small vessels there

and they can mark the right space for us.

And now we can see from the medial side

we can see a little bit of the spleen

so we are going from the lateral side.

Here we can see severe adhesions

in the splenocolonic ligament

and the gastric and colon ligament.

Normally, if there's not so severe adhesion,

we would be able to go into the capsule inside the omentum,

But for this case, not possible because there is adhesion.

So here we would try to go into the capsule, but normally we'll go from the root of the IMV.

Because this case, the tumor is in the middle segment of the descending colon.

In this way, the edges would be very clean and easier for us to close.

Some surgeons in Italy close the IMD only with the energy device.

What do you think about it?

Without clips, but only with the device.

Are you talking about ultrasound knife?

He had seen some doctors doing ultrasound knife only without the clips, but he think

it's safer to play some clips there yeah

其实来讲,对于确保手术的安全性,可能会更多一个保障。

所以我跟史教授的做法是一样的。

Professor Sun said he agrees with Professor Shi,

because in China there is an old saying that if you are cautious enough,

your boat, your ship can be sailed for tens of thousands of years.

So we always take caution,

because we want to avoid major hemorrhagic shock after the surgery.

So he also does the same, also plays some clips during the surgery.

Me too, just a disclosure.

He will also put some clip on himself.

He is just asking everyone's thoughts.

When I first learned about this,

my teacher sometimes didn't put clip on here.

He just cut it with a knife.

I was very worried.

But later I found that it was nothing.

There was no bleeding.

But actually, Professor Shi said

when he learned from his mentor about laparoscopic surgery,

his mentor actually did not put any clips.

He was very worried, but nothing happened.

But still, he would put some clips himself.

So we would like to ask Dr. Camerata, in Italy, how do you choose the three accesses?

What are the sequence or how do you deal with the three accesses?

It depends on the institutional policy, obviously.

So different surgeons have a different approach.

But in our institution, we have a similar approach with this order to approach this section of the steps of the surgery.

So we have the same approach.

So do you routinely use ECG?

ECG, you mean induction in green?

大家传统就是常规都会用那个引渡净滤标记吗?

我们是不常规用引渡净滤标记的,因为我们医院没有这个显影机,但是我们的机子可以显示。

就是这个机器是可以搭配它使用的,对吧?

对。

No, they don't routinely perform the endocyanin marking

because they don't have the conscious agent available.

But this system can work with endocyanin marking.

And Dr. Sun, what do you think about it?

What's your practice?

Sorry?

I want to know about the same topic to Dr. Sun Feng.

Please, Dr. Sun.

如果有印度心率的这种手术

这个术中的这种影像显影的话

我觉得是一种非常好的技术

但是在中国呢

可能面临着医保结算的问题

这个可能在意大利

我不知道有没有这种挑战

就是涉及到医保费用的支付的问题

可能会增加我们的这个

这个医保的这种支付的压力

Dr. Sun thinks the endocyanin is very good for the intraoperative imaging.

It's a good technology, but in China, there's always a consideration of medical insurance.

They may add additional burden for the hospital in terms of payment and medical insurance.

But if we worry about the vessels, before the surgery, we would perform angiography.

In Italy, we use ECG for maybe better visualization of the left ureter or to test the anastomosis

after the staplet to assess the vitality of the tissue that may be could are unvital.

In Italy, they are commonly used. They usually use the Indian gold mark to mark the leaf,

mainly to check the condition of my mouth, and then to organize the vitality, etc. They are commonly used.

And do you perform some air leak test after the anastomosis?

Usually for the rectum,

we would do a leak test.

But this for left colon,

we don't routinely test it.

But this is extra-vival anastomosis.

I would do the anastomosis outside of the cavity,

and then we also do an enhanced suturing.

So it should be very safe.

Okay. So do you perform an extracorporeal anastomosis?

Yes, yes.

体外缓和,对吧?

对,体外缓和。

And what's about, what is your idea about intracorporeal analysis?

Why not intra and why extra?

那为什么是选择体外的缓和而不是在体内缓和呢?

因为我觉得这个最后呢,因为这个标本你要拿出来的话还得切个口在腹壁上。

那么我觉得就在这样之后呢,一样要切口,所以说我觉得在体外缓和呢,这样感觉呢,更加的安全。

Because Professor Shi believes that in this way

there is a better curing effect

reducing the infection risk and contamination

since we need to take the specimen out.

We need to make an incision on the abdominal wall.

So if we do extracorporeal anastomosis

it's safer reducing the contamination and infection.

Yeah, and where do you perform the incision, the abdominal incision?

So it's in the paraumbilical, about six centimeters.

Yeah, and don't you have any tension?

It's okay for this case because the patient is quite thin

and we have cut off quite a lot of the mesocolon

allowing us to drag the specimen out.

那么这样一来的话呢

腹壁是没有切口的

你请先翻译这部分

In China, there are two major ways of taking out the specimen

First, Professor Wang in China has started this way of taking the specimen through the natural lumen

So we can either use the gastrointestinal tract

Or for the female cases, we can leverage the vagina to take out the specimen

In this way, we don't need to make an incision

那么第二个的话呢我们也少减少一个腹壁的这种切口的数量

The second way is we can leverage the port for the left upper abdomen

We use that port, the assistant is there

And in that way we can reduce the tension

And also we can avoid making the extension on the abdominal wall

我想请教一下卡玛拉塔教授您是怎么取标本的

he also wants to ask

Dr. Camerata how do you do

the specimen

for the extraction of the

specimen

we usually perform

a funnest incision

in the inferior

abdominal wall

but

we perform

routinely

an intracorporeal anastomosis

a staplet intracorporeal anastomosis

So, we resect the colon, we perform the anastomosis, and then we extract the specimen from the

funnest intrusion.

But the reason to perform an extracorporeal

anastomosis is very interesting. Do you have any data, I ask to you, about the rate of infection

performing on extracorporeal versus intracorporeal anastomosis?

We haven't seen data or literature regarding a comparison

between extracorporeal and intracorporeal in terms of infection.

Maybe we can look afterwards.

It could be an interesting topic of research

because obviously it's an area of interest

那么这样一来的话可以比较好的帮助我们明确这个长段的切除的这种范围。

因为我不清楚这个史教授说会常规游离脊梁中血管,

涉及到这个如果没有必要的话是否这个就是我们切除的范围可以更小一点。

He was asking whether we would do 3D imaging before the surgery

so we can have a better idea of the scope of resection

on the intestine, on the colon part.

Because we don't know whether you would routinely

dissect or free or move or separate the middle colic artery.

If that's the case, maybe the resection scope could be even smaller.

our principal for this case because this is a young lady so we would like to resect more in

order to achieve a definitive treatment result and also normally we wouldn't perform dissection

of the left nodes in the middle colic artery root but this is a young patient so we also

dissected the lymph nodes here uh 15 centimeters and also we have heard from japan that they have

this principle of 10 plus 5. so we did a 15 centimeters uh dissection of the lymph nodes

The last question for Dr. Camerata,

how do you decide how much colon to reset for your surgery?

Good question.

Because it depends, obviously, from the location of the tumor.

In Italy, we usually mark the lesion endoscopically.

early first the surgery so intraperitoneally we can decide how much extend the resection in

without the risk to involve the margin when you with a oncologically radicality so it's

It's an intraoperative decision, I mean, for the tension of the anastomosis and for the location of the tumor.

还有肿瘤的位置,然后还有风险,切缘的一个风险等等,我们会做一个相应的考虑,然后做具体的决定。

好,谢谢。

Thank you.

And in the interest of time, we're moving on to the second case, and we're not showing the extracorporeal anastomosis and closure for the first case.

非常感谢史教授的分享以及孙教授的点评。

那接下来我们就进入第二个病例,

有请孙真教授分享

以及严华教授参与讨论

最近的凯尔马克教授

高专家同档

晚上好

我们这是晚上

意大利可能是下午了

我们这个病例

是一个十二上求顾的

年末下的病变

Thank you

Hello everyone

Good afternoon to Dr. Kamarada

Good evening to the Chinese participants

This case is an endoscopic submucosal dissection

Of duodenal submucosal lesion

这个视频可以播放了,没播放视频。

We can start playing the recording.

视频是没播放吗?

我们可能要点一下那个播放。

会想要视频在播放吗?

我看我这儿是不动的。

出了一点问题。

好,好。

We have a little technical glitch.

We're waiting for the video to play.

I'm sorry.

老师呢,全在这儿,最好。

哦,好嘞。

这个播放有点延迟,

大家稍微等一下。

And there's a little bit of a delay, so please bear with us.

Now we're marking the lesion under the endoscope.

This is a very small cavity, the duodenal bulb,

but we try to stabilize the endoscope and mark the lesion here.

For neuroendocrine tumors, we usually have different strategies at different sites.

And for this type of neuroendocrine tumors in the duodenal bulb site,

our surgical indication would be if it's less than two centimeters,

if it's limited to just submucosal area,

if there's no metastasis in the lymph nodes,

we can treat with an endoscopic procedure.

Do you have the evaluation?

Yes.

So do you have evaluated the biological state of the tumor?

we didn't have a clear biological staging for the tumor,

but we did the evaluation under the endoscopic evaluation.

The lesion is almost all restricted to submucosal layer,

but there is a little bit of a border in the muscle.

We're not very clear whether it has invaded muscle or not,

But there is no enlargement in lymph nodes, and the tumor is 1 cm, so it fits the indication to treat with endoscope.

normally it is safest to perform the incision when the lancet is parallel to the surface

but because this is the general bulb it's impossible to do so so as we can see the

lancet where the scalpel is a perpendicular to the surface it's a circumferential incision there

And what do you think about the indication or not to perform a PET scan with gallium

to assess the biological activity of the tumor, to assess eventually localization of disease?

Do you think that is a good indication in this case or in general for the never-endocrine tumor?

He said, actually, for this case,

we should have done a PET-CT with a gadolinium enhancement

Because neuroendocrine tumors, its biological activity is very susceptible for lymph nodes or distal metastasis.

He also says we should do the PET-CT for all the neuroendocrine tumors.

He says in theory, he would do the PET-CT for all cases for neuroendocrine tumors, but

for this case, we didn't do because we have done enhanced CT and ultrasound evaluation

for this tumor, which is one centimeter large, and we have evaluated lymph node metastasis.

大概一到两毫米,所以说我们在切尸过程中非常小心,不然一刀可能就伸,伸了就可能发生穿孔。

The wall of the dodeno bulb is very thin, around one to two millimeters, so they have to be very, very cautious, otherwise it may cause a perforation.

And in this case, the surgeons, it's necessary.

手术医生的技巧非常的精湛。

你想在我们做镜子的时候,对于这种控制能力,有时候是怎么去提高形势?

The question is regarding how to improve the control of laparoscope or endoscope.

So how can surgeons improve their techniques controlling the endoscope?

Because as we can see, this is a very small space for procedure.

This is very nicely done, of course, but as we can see, he has to go back and forth,

and sometimes the endoscope would go through the pylorus but there is a back and forth procedure

so how can we improve the capability of controlling the endoscope

Dr. Sun says when they learned about the endoscopic procedure,

they were taught to really control it very tight with the upper arm.

So when you hold the endoscope with your left hand,

to always maintain a tension in order to be stable.

And always to maintain that tension in order to avoid the drop-off of the endoscope.

But because there's a peristalsis of the stomach, so sometimes we would see a movement of the endoscope.

So I think that this case will go good.

But have you experience of duodenal wall perforation during the ESD?

And how do you deal it?

Perforation?

Yeah, perforation.

您这个病例做得非常漂亮,但是想问问之前有没有出现过就是十二指肠这里窗孔的情况?

就是ESD的时候出现十二指肠窗孔,如果出现的话怎么处理呢?

这个病例就出现了,我们最终这个病例就做了一个全层的切除。

其实实际上球部,这个病变呢,其实它在刚才我们做成发现,

其实病变呢,它和基层分界不是很清楚的,

因为我们知道生生生肿瘤啊,它往往起来黏在下层,

So it's very easy for it to grow deep into the mucous membranes.

So the way it grows is very easy for it to grow deep into the mucous membranes of the muscle layer.

In this case, we found that the muscle layer and the muscle layer are inseparable.

So we ended up with a full layer of tissue in this case.

Actually, for this case, they did a whole layer resection in the end

because as we said before the margin between the tumor and the muscular layer was not very clear

and we were worried about the invasion into muscle because we know for neuroendocrine tumors they

always start from deep mucosal layer and then go to submucosal layer and then will go to the

muscular layer so they did a whole layer resection in the end my question is about the

Actually, he's going to show in the following video

because in the end they did a whole layer resection

there was a hole and then they managed

it's actually a perforation case

and they managed to suture it

actually to resect the lesion is not the most challenging part

the most important or challenging part

would be the pre-op evaluation

evaluation, and the management of perforation.

So there are many suturing techniques they can use to manage perforation if it happens.

我想问一下卡玛拉教授,他们那里这种神经的内流,无论是直肠的,

十二肠的,他们的切除方式一般是选择什么方式?

Dr. Kamarata, he would like to ask you, so for the neuroendocrine tumors in the rectum or

dodenum, how would you choose the surgical type? How would you perform the surgery?

It depends on the location of the tumour, because if the tumour is in the

first or second branch of the dodenum, we have to perform a pancreatic dodenectomy.

mean maybe if the tumor is located at the the hand of the the dodenum we can try to perform a

segmental resection of the dodenal but the risk of involvement of the incident process of the

pancreas is psych so it's a bad location for indolent tumor because we sometimes we have we

we have to perform a radical resection for a tumor

that at the end of the histopathological analysis

maybe has an indolent biological and pathological behavior.

Sorry, you said for the first and second segment of duodenum,

which surgical type?

Pancreatic duodenectomy.

First and second branch in the duodenal C, I mean.

But I believe in a potentially endoscopic approach, but the surgeon and the endoscopist and the gastroenterologist had to be near and conjured for the decision.

So, Dr. Camerata, did you mean that you mostly do surgical dodenectomy instead of endoscopic?

No. We have to assess the neuroendocrine tumor. A way to assess the aggressivity and the

The biological behavior of the tumor is with the endoscopy

and mainly with the endoscopic submucal dissection.

But if we can't, we have to perform a Whipple.

So we have to assess very well all of the factors that affect this type of tumor.

对于后续的一个操作就造成了很大的困难。

Actually, the early steps of the procedure is the major part of this video

because for this dodenal bulb lesion,

this kind of circumferential incision is the most challenging part.

If you create a perforation at the stage,

the following steps would be very complicated.

这是因为我们其实我们在做EAD,

在确实的过程中,

we will try to create a mucosal flap and then we send our camera inside so we could have

a good surgical view. But here he has tried to extend that surface by putting a clip,

a titanium clip on it, but it did not work out very well.

neuroendocrine tumor. What's your opinion and maybe indication for this type of tumor

out of this context but with professors and soon expertise can be an interesting topic to discuss.

Professor Sun says in his center,

the radiofrequency cryoablation or microwave ablation

is done in probably in other departments, interventional radiology or surgical department,

so it does not belong to their department. In our institutional the endoscopic team

perform a radio frequency ablation for small tumor maybe or tumor away from the main pancreatic duct

that could be ablated with this type of energy but also yeah also the interventional radiologic

So for the radiofrequency ablation, which type of tumor would you do?

Is it inside the duct or far away from the main pancreatic duct or in the parenchyma?

One of the contraindications of the trial that my colleagues are performing is the main indication is tumor away from the main pancreatic duct, far away.

以总管远的小肿瘤是可以用消融来做的。

好,这个我们没做过这类似的东西。

Thank you, but it's not done in their department.

我们刚才那次打了个太佳,

想延长我们半膜作用,其实效果不好,

所以说我们又打了个用牙线牵引的方法,

希望能找到我们玻璃的一个层次。

Just now he has put a clip in order to extend the flap

lab he has created on the mucosa, but it did not work very well, so he is trying with retraction

to try to find the space for dissection.

As we can see here, the submucosal layer is still very superficial.

When we inject the liquid inside, it did not elevate very well.

So it did not give us a very good dissection space.

Yes, a comment from Professor Yan is this location at the dodenum is a very challenging

location for endoscopy doctors because once there is a perforation, they can do a clipping,

but if the clipping does not work well, the patient needs to be referred to laparoscopic

surgery or open surgery and these surgeries will be very risky and these

kind of cases this kind of locations are very demanding for the doctors in order

for them to control the endoscope very well and also they need to have a strong

mindset a strong mind in order to do this kind of case well

As we can see here, the lesion, the yellowish tissue, is actually connected with the muscular

layer here, and as we can see, there is a perforation.

And we have decided to do a whole-layer resection for this case.

Sorry, can you repeat, please?

Yes, as we can see, the lesion is connected to the muscle, and there is a perforation here.

So we decided to take the anterior wall of the duodenum bulb, a whole-layer resection.

Oh, okay.

That's the first case we did the full thickness resection in the adrenal bulb site.

So we were a little worried at that time for whether we can close it well.

包括外科医生也是,你做了这个病变,我们能很好的结束这个整个的过程,其实非常关键。

As a doctor, it's very important for us not only to remove the lesion, but also to close the wound very well. That's important for us.

Do you have experience with the combined approach, maybe not for the duodenal lesion, but for, I mean, gastric gist?

So experience with the combined approach surgical and endoscopic, maybe the demolitive step approach endoscopically and the reconstruction step performed surgically.

这个问题非常好,就是也是将来一个趋势,就是我们也尝试在这样做,就是外科和内科联合对于一些导致的病变,淋巴结转移风险不是特别高的,所以也可以做一个这样的尝试。

Yes, a very good point. Actually, it's a very good way to combine endoscopic procedure and

surgical procedure. Actually, 10 years ago, we started thinking about this. Maybe for some

early stage GI tumor, we can combine these two techniques. Because as we know, surgical techniques

will remove a large mass of the tissue, also including some normal tissue. So there is an

impact of on the quality of life but the endoscopic procedure can remove just the local regional tissue

but it cannot remove the lymph nodes so i think he thinks this is a major trend in the future we

can combine these two techniques together for the early stage with a lower risk of lymph

metastasis maybe we can try combining i totally agree

Yeah, as we can see from the video, the dissection step was very difficult.

We have dissected the majority of it, and then we decided to use a snare to remove the lesion.

This is after removal of the lesion, the remaining tissue and the organs.

We used a clip and suture to do the purse string suture for the wound.

there are several factors that are quite challenging for endoscopy surgeries for the

doctor. First is it's very difficult to stabilize the endoscope in the adrenal bulb. Second is the

mucosa layer is very thin, so there's a high risk for perforation. So the doctor needs to have a

very good control of the endoscope, and also we need to know when perforation does happen,

do we know how to close it, how to suture it with a very good suturing technique.

And also, the suturing technique is not only for perforation, but also for the GI bleeding.

If we have the bleeding cases, we can always use excellent suturing technique to close it.

And do you perform any imaging after this procedure or do you deal the patients like a normal endoscopic analysis?

so they do not perform imaging routinely after the procedure they would put a gastric tube

and the patient would fast for 24 hours and we would observe the patient's symptoms and signs

if there's no pain no fever then 48 hours later the patient can start drinking and eating

because we know that purse string suture is good for this type of wound but the most important

thing is to observe the patients so there's no routine imaging clear

Sorry, we can't listen to anything.

Dr. Yan is talking.

She's making a comment for the case.

Okay.

Okay, so one last word for this case.

The reason why we chose this case is because it's quite challenging.

The site is at the bulb of the denim, and also the mucosal layer is very thin, so it's challenging.

And also, we would like to have a discussion over the suturing technique after the wound closure.

So thank you very much.

That would be all for the second case.

Thanks, Professor Zhen Sun and Professor Wai Yang.

And I welcome Professor Xufeng Niu and Professor K. Wang

for commenting on this interesting left hemipotectomy.

也有请各位专家的

也有请王教授来做点评

我们现场的各位老师

我们这边好像听不到现场的发言

I only hear the interpreter

I'm checking with them

Okay, okay

I can hear you

现场的老师麻烦用一下话筒

我们还是听不到现场的声音

老师您再试一下

Hello

现在可以了

Now we can hear you

As we can see, this patient is an HCC patient with a tumor in the liver.

This tumor is very close to the left hepatic vein and left hepatic pedicle.

So we decided to do a hemi-hypotectomy.

The goal is for an R0 resection.

The residue liver FLR would be 71%.

The liver function is grade A.

So it is safe to perform the hemohepotectomy.

So we also did a test for the remaining liver function.

It's 9.6%.

Here we are doing the dissection.

And as we can see, there are some adhesion between the omentum and the gallbladder.

So we are releasing that adhesion.

Ask the patient, said the previous surgery.

We lost again.

应该是没有,从那个病历介绍上和我了解的情况,应该是以前是没有作用。

We lost the signal from the meeting room, but Dr. Wang commented that from the history or introduction of the case,

seems not, seems the patient did not have surgery before.

我们请技术老师来调整一下现场的话筒好吗?

Hello, Professor Camerata.

Hello, Professor Wang.

Yeah.

Nice to meet you.

It's a great honor to be a commentator for Professor Niu's surgical demonstration.

And Professor Niu presented a case of surgical treatment for HCC.

The preoperative diagnosis was hepatocellular carcinoma as CNLC stage 1B and the BCLC stage

stage B. The procedure performed was a classic laparoscopic left hepatotomy.

As we are aware, there are significant differences in the treatment approaches for patients with

BCS stage B between Eastern and Western sclerosis.

in east asia surgeons often opt for surgical resection when liver function permits whereas

western approaches more frequently involve interventional or systemical therapies

that's right yeah absolutely yes and i want to ask you um in

In China, there are some transplant criteria for ACC.

And what's your experience in this way?

Yeah, for liver transplant, we refer to the Milan criteria, but also in China, we have

the Fudan criteria and Hangzhou criteria.

Clear. And in case of a resectable and ineligibility for transplant, what do you prefer to the way to approach these patients? Maybe local regional therapy, clinical trials, systemic therapy? I don't know.

在西方好像这个转化手术的这个理念

好像并不是特别受推荐

是不是这样

In China, for patients who are not eligible for surgery or transplant

Our first consideration would be to enroll into the clinical trial

And also we have local regional therapy combined with targeted or immunotherapy

And also we would consider conversion to surgery if possible

But Dr. Wang is asking, is it not popular to do conversion therapy in your country?

Absolutely, yes.

The conversion therapy is a great topic, a hard topic in Europe for liver surgery, for colorectal surgery,

maybe not for pancreatic surgery because conversion in this file is too hard to gain.

But yes, it's a good point and a good topic.

He was asking whether you don't routinely do conversion therapy.

Is it not a popular concept to do conversion therapy?

Sorry, can you repeat, please?

Yes, he was asking, did you not like the concept of conversion therapy in Europe?

Because it's quite routine in China.

But he has heard in the Western countries, people don't like conversion therapy concept.

In Europe, we like this concept, obviously, not for all type of surgery, I mean, but for liver, for colorectal, it's a good point of view, this type of disease.

Dr. Wang was asking for BCLC stage B patients,

what is your preferred option?

If the patient is eligible for surgery, would you go to surgery first or would you do intervention

therapy plus targeted therapy or immunotherapy first to reduce the tumor size and then go

on to surgery?

What is your preferred choice?

For resectable, potentially resectable one?

Yes, for resectable.

yeah clearly if the patient's it's it's rejectable we perform first a resection

approach maybe if the patient at the same time have a big burden of disease

and it's eligibility for the Trump but the transplant we we send it to a

This patient had quite a lot of fat tissue in the hilum of the liver,

So we chose an atrocycal kind of dissection of the blockage.

During the operation, we used ultrasound and fluorescence staining to get our surgery.

We start from the caudal to the cranial direction.

Do you perform this type of surgery robotically?

Professor Niu has done robotic surgery before,

But now in this center, since the hospital does not have robotic system yet, he hasn't done in this center.

But from an economic point of view, he says it's most cost-effective to do laparoscopically.

Yes, I totally agree.

Very agreeable.

In Italy, the cost of robotic surgery is covered by medical insurance?

Dr. Wang was asking, is the expense of robotic surgery covered by insurance in Italy?

only for the people that have an insurance but the public system in italy cover also robotic

procedure but at the same time the the single institution had too much attention of the cost

of that effect in the effectiveness of the operation so people that have insurance can

pay this type of platform at people that doesn't have it's depend of the institutional policy okay

Okay, so this insurance you're mentioning is a commercial insurance?

Sorry?

Commercial, commercial insurance.

Yeah, yeah.

He said it's commercial insurance, commercial insurance can be paid.

And then he said this is the public medical insurance,

it can be paid a part,

but the institution will have some cost pressure,

so it's mainly paid by commercial insurance.

I want to ask, Professor,

in Italy, is this kind of giant liver cancer

the first choice of a gun or a surgery?

So in Italy, this type of large tumors in the liver, would you prefer to choose open surgery or endoscopic?

It depends. In Italy, by the way, it depends on the hospital policy and expertise.

But today, I think that most of the Italian surgeons approach this type of tumor laparoscopically with the high risk for conversion if it's impossible to complete the resection in a secure way.

这个医院本身枪镜手术的能力

一般来说的话

目前的情况

大多数手术应该是在枪镜下做

但是如果是

就是风险比较高的话

才会采取别的方法

OK, thank you

And do you have experience

with the Cavitron Ultrasonic Surgical Aspirator

for the transaction, the KUSA?

我们这边有没有使用KUSA的经验?

没有,因为这个设备我们医院还没有

They don't have this system in the hospital yet.

Okay.

We have a licorice.

They have licorice, the ultrasound knife.

They use that very frequently.

Yeah, yeah, yeah.

Now we are exposing the left hepatic vein.

没有沿着肝组静脉传承线路,是根据这个萤光染色的一个范围,一个界线来进行引导的,所以界面不是很规整。

In this case, they are not following the middle hepatic vessels, instead they are following the fluorescence marking, staining here, so it looks not like a straight line.

这样我们用闭合器把这个肝组静脉断掉之后,肿瘤就切除了肝组静脉。

Here we have almost removed all the lesion of the tumor after we have blocked the left

hepatic vein and we removed the lesion.

In Italy and in Europe, when they do liver and liver or liver and liver removal, do they

use this light-guided tumor?

Is it common or is there a choice?

What is the choice?

One question from Dr. Wang is, do you routinely perform the fluorescence marking for

hypotectomy or hemihypotectomy in Italy? In Italy, it depends obviously for the

institution policy and we prefer to date to use ultrasound guided surgery for planning

in general generally the resection but it's a it's a diffuse policy in italy

so only for selected cases depending on the policy

yeah depend it depends on for the policy our institute to use ultrasound guided surgery