ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.

BackgroundAs an important means to tackle the worldwide shortage of liver grafts, adult-adult living donor liver transplantation (A-ALDLT) is the most massive operation a healthy person could undergo, so donor safety is of prime importance. However, most previous research focused on recipients, while complications in donors have not been fully described or investigated.Material/MethodsTo investigate donor safety in terms of postoperative complications, the clinical data of 356 A-ALDLT donors in our center from January 2002 to September 2015 were retrospectively analyzed. These patients were divided into a pre-2008 group (before January 2008) and a post-2008 group (after January 2008). Donor safety was evaluated with regard to the type, frequency, and severity of postoperative complications.ResultsThere were no donor deaths in our center during this period. The overall complication rate was 23.0% (82/356). The proportion of Clavien I, II, III, and IV complications was 51.2% (42/82), 25.6% (21/82), 22.0% (18/82), and 1.2% (1/82), respectively. In all the donors, the incidence of Clavien I, II, III, and IV complications was 11.8% (42/356), 5.9% (21/356), 5.1% (18/356), and 0.3% (1/356), respectively. The overall complication rate in the post-2008 group was significantly lower than that in the pre-2008 group (18.1% (41/227) vs. 32.6% (42/129), P<0.01). Biliary complications were the most common, with an incidence of 8.4% (30/356).ConclusionsThe risk to A-ALDLT donors is controllable and acceptable with improvement in preoperative assessment and liver surgery.

For locally advanced right colon cancer (LARCC) invading duodenum, multivisceral resection is a curative surgical treatment, which is technically challenging when performed in a total laparoscopic approach. Herein, we report the first case of LARCC treated by total laparoscopic en bloc right hemicolectomy and pancreaticoduodenectomy with transvaginal specimen extraction. The patient was a 37-year-old female suffering from upper abdominal pain who was diagnosed with LARCC invading the duodenum by preoperative examination. The en bloc resection and digestive tract reconstruction were completed laparoscopically without an assisted abdominal incision. Then the specimen was extracted transvaginally through a 6 cm transverse incision made in the posterior vaginal fornix and the vaginal incision was closed by a continuous suture intracorporeally. The operative time was 470 min and intraoperative blood loss was 130 mL. The postoperative pathological examination showed T4bN0M0 adenocarcinoma of the hepatic flexure of colon with infiltration of duodenal serosa, and all the margins were negative. The patient recovered uneventfully with minimal postoperative pain and was discharged from hospital on postoperative day 7. After 3 years of follow-up, the patient was alive with no recurrence. To the best of our knowledge, this is the most extensive multivisceral resection with natural orifice specimen extraction (NOSE) ever reported.We believe that NOSE surgery, with advantages of minimal invasiveness and enhanced recovery, is a feasible and promising option for LARCC.

Background Despite increasing acceptance in colorectal surgery, natural orifice specimen extraction (NOSE) surgery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the first case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions. Case presentation A 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathological examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improvements. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques. Conclusions Proctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions.

Objective: To explore the possibility of LPD with transanal specimen extraction for periampullary tumors. Background: Natural orifice specimen extraction has been widely performed in colorectal surgery. But so far there is no report regarding natural orifice specimen extraction in LPD. Methods: Data of 3 patients who underwent LPD with transanal specimen extraction by the same surgeon between July 2018 and March 2019 due to periampullary tumors were evaluated retrospectively. Results: All patients underwent LPD with no conversion to open surgery. Specimens were all extracted transanally. No complications occurred except for delayed gastric emptying in 1 patient. The patients' anorectal function was intact and no opioids were required postoperatively. After a follow-up of 17-25 months, all patients were alive with no tumor recurrence. Conclusion: Treatment of periampullary tumors by LPD with transanal specimen extraction is feasible and safe.