[Modified reverse puncture technique for esophagojejunostomy during totally laparoscopic total gastrectomy for gastric cancer]

Objective: To evaluate the value of implementing a modified reverse puncture procedure for esophagojejunostomy during totally laparoscopic total gastrectomy. Methods: This was a descriptive case series. Relevant clinical data, including the operative procedure, recovery, and pathological findings of 35 patients with gastric cancer who had undergone esophagojejunostomy with a modified reverse puncture technique during totally laparoscopic total gastrectomy in the Department of Gastrointestinal Surgery, Fujian Provincial Hospital, from June 2022 to January 2023, were prospectively collected and retrospectively analyzed. The age of all patients in the group was (64.9±8.0) years old, with 22 males (62.9%) and a body mass index of (23.2±2.4) kg/m2. The tumors were located in the upper and middle parts of the stomach in 24 cases (68.6%) and in the junction of the esophagus and stomach in 11 cases (31.4%). Important technical aspects of the modified reverse puncture procedure are as follows. (1) Site of the esophageal incision: a transverse incision is made across the right lateral wall of the esophagus at the expected site of esophageal disjunction. (2) Technique for inserting an anvil: after threading a silk thread through the tip of anvil, the end of the thread is knotted and fixed as the traction thread, after which an anvil is inserted into the esophagus through the esophageal incision, leaving the end of the traction line exposed. Next, a 60-mm linear cutter is placed through the right midclavicular trocar to straighten the opened esophagus vertically, after which the rod of the anvil is pulled out of a small incision that has been made in the esophagus by pulling the traction thread, thus completing anvil placement. (3) Jejunal binding: the jejunum on the central bar of the stapler is fastened with silk thread to the stump of the jejunum, and then tied to the output loop of the jejunum with a gauze strip. Results: All 35 surgeries were successful, with no mortality or conversion to laparotomy. The operation time, anvil insertion time, and digestive tract reconstruction time were (232.7±34.4), (8.5±1.4), and (40.5±4.8) minutes, respectively. The intraoperative blood loss was 100 (20-250) mL and the incision was (5.3±0.9) cm long. The upper surgical margin was negative in all patients and the mean distance between the upper and tumor margins was (3.5±1.2) cm. The mean number of lymph nodes dissected per patient was 33.9±7.1. The times to initial ambulation, initial passage of flatus , postoperative fluid intake, and length of postoperative hospital stay were (3.2±1.1), (3.7±1.5), (4.6±2.3), and (9.8±3.2) days, respectively. Postoperative complications occurred in five patients: one case of anastomotic leak, two of anastomotic stenosis, one of pulmonary infection, and one of incomplete intestinal obstruction, all of which were successfully managed conservatively. Conclusion: Esophagojejunostomy using a modified reverse puncture technique during totally laparoscopic total gastrectomy is safe and feasible for gastric cancer, requiring only a small incision and achieving higher upper esophageal resection margins and good postoperative recovery, and therefore warrants further implementation.

Involvement of T helper type 17 and regulatory T cell activity in tumour immunology of bladder carcinoma

T helper type 17 (Th17) and regulatory T cells (T(reg) ) play an important role in the pathogenesis of inflammation and autoimmune disorders. Recent studies have suggested that they also had an impact on tumour immunology. However, the relationship between Th17 and T(reg) cells in the pathogenesis of bladder carcinoma is still unclear. Flow cytometry was used to analyse the numbers, phenotype and cytokine production of Th17 cells in peripheral blood and tumour tissue from bladder carcinoma patients, in parallel with analysis of T(reg) cells. The suppressor capacity of T(reg) and the potential effects of interleukin (IL)-2 on the differentiation of Th17 and T(reg) cells in vitro were studied in a T cell stimulation and suppression assays. The results were as follows: Th17 cells were enriched in the tumours of patients with bladder carcinoma compared with the peripheral blood of patients and controls; patients with bladder carcinoma had a higher proportion of T(reg) cells in peripheral blood compared with healthy controls and nearly all patients examined showed a relative enrichment of tumour-infiltrating T(reg) with respect to peripheral blood; there appeared to be an inverse relationship between tumour-infiltrating Th17 and T(reg) cells; IL-2 could convert tumour-infiltrating T(reg) cells cultured in the presence of the autologous irradiated CD3(-) fraction into Th17 cells, down-regulate forkhead box P2 expression and suppressive capacity of T(reg) cells. This study is the first to define the frequency and characteristics of Th17 cells in bladder carcinoma. We suggest that the balance between Th17 and T(reg) cells may be involved in the development or progression of bladder carcinoma.

Reduced circulating CD4+CD25+ cell populations in haemorrhagic fever with renal syndrome

Immunopathological mechanisms are speculated to underlie haemorrhagic fever with renal syndrome (HFRS) caused by Hantaviruses. CD4+CD25+ T regulatory cells (T(regs)), a subset of CD4+ T cells, expressed high levels of CD25 and the forkhead box transcription factor P3 (FoxP3), plays an important role in the down-regulation of various immune responses. Therefore, we hypothesized that in patients with HFRS the immunopathology could be, at least in part, the result of an inefficient control of pathogenic effector T cells by T(regs). The number of T(regs) was determined by flow cytometry according to their characteristic CD4+CD25(high) membrane phenotype. The functional characterization of T(regs) was analysed by suppression of proliferation and secretion of cytokines by co-cultured effector CD4+CD25(-) T cells. FoxP3 mRNA level was assessed by quantitative real-time polymerase chain reaction. We observed that CD4+CD25(high) cells of patients with HFRS showed a conventional phenotype. Furthermore, acute-stage patients with HFRS exhibited significantly reduced numbers of peripheral T(regs) compared with healthy donors, and marked improvement was observed in convalescent-phase patients. The frequency of T(regs) was correlated positively with platelet count, and was correlated negatively with blood urea nitrogen, serum creatinine and serum aspartate aminotransferase. On the other hand, T(regs) from both healthy individuals and patients with HFRS exhibited equal FoxP3 expression of mRNA, and their ability to suppress the proliferation and cytokine secretion of CD4+ effector T cells was unimpaired in HFRS patients.