Magnetic compression anastomosis for esophagoenterostomy after total gastrectomy in rats / 西安交通大学学报(医学版)

【Objective】 Digestive tract reconstruction after total gastrectomy is complicated and causes many complications. This study aimed to investigate the feasibility, safety and effectiveness of magnetic compression anastomosis (MCA) for sutureless reconstruction after total gastrectomy in rats. 【Methods】 Twenty-four rats were randomly apportioned to two groups. Reconstruction was performed with MCA in the experimental group or hand-sewn in the control group, and the construction time was recorded. The animals were followed up for 30 days. The survival rate and complications were monitored. At each time point, the rats were euthanized to study the gross/histological morphology and mechanical strength of the anastomoses. 【Results】 The reconstruction time was (12.9±2.7)min in the experimental group and (23.8±4.1)min in the control group (P=0.036). In the experimental group, there was no anastomotic complication. Four control rats developed anastomotic leakage or hemorrhage, and all died within 4 postoperative days. Compared with the control group, burst pressure in the experimental group was similar. Both groups’ anastomoses had smooth gross appearance and histologically good alignment of tissue layers. 【Conclusion】 MCA is a safe and effective choice for reconstruction after total gastrectomy, with better postoperative outcomes than hand-sewn.

The methods of anastomosis in totally laparoscopic total gastrectomy esophagojejunostomy-the collision and fusion of hand suturing and stapled anastomosis / 中华消化外科杂志

Totally laparoscopic total gastrectomy is the most comlex procedure in gastric surgery, which involves the entire stomach removal, lymph node dissection and digestive tract recons-truction through minimally invasive techniques, among which laparoscopic esophagojejunostomy is a technological difficulty. Currently, three types of anastomoses are widely used, including stapled anastomosis with circular staplers or linear staplers, and hand suturing, but which is the best and safe anastomosis remains controversial. Based on team experience, the authors review the progress of esophagojejunostomy on stapled anastomosis or hand suturing, promote that how to select an appropriate esophagojejunostomy according to surgeon′s individual technical capabilities, operating habits and patient conditions, strive to achieve the precise and minimally invasive effect with the least trauma for patients.

Comparative study of different anastomosis methods in laparoscopic total gastrectomy esophagus jejunum anastomosis reconstruction / 中国内镜杂志

Objective To investigate the safety and short-term efficacy of π-shaped anastomosis and circular anastomosis(reverse puncture device)in reconstruction of esophagojejunostomy after laparoscopic total gastrectomy.Methods A retrospective study was used to collect the clinical and pathological data of 75 cases of gastric cancer from January 2019 to March 2021.According to the different reconstruction methods of esophagojejunal anastomosis,the patients were divided into a linear cutting obturator group(π-shaped anastomosis group,n = 27)and a circular anastomat anastomosis group(reverse puncture device group,n = 48).The general information of the two groups,operation time,esophagojejunostomy time,intraoperative bleeding volume,number of intraoperative lymph node dissection,intraoperative complications,and postoperative complications were compared and analyzed.Results The operation time and esophagojejunostomy time in the π-shaped anastomosis group were(221.5±8.8)and(34.7±3.7)min,and the reverse puncture device group were and(246.9±5.6)and(47.2±4.6)min,respectively,the differences were statistically significant(t = 15.19,t = 11.81,P＜0.05).There were no statistical significance in the comparison of intraoperative bleeding volume and number of intraoperative lymph node dissection between the two groups(P＞0.05).In the reverse puncture device group,there were two intraoperative complications,including one case of esophageal jejunal anastomosis atresia and one case of anastomosis tear,postoperative complications occurred in 3 cases,postoperative anastomotic stenosis occurred in 2 case,and anastomotic bleeding occurred in 1 case.Conclusion Laparoscopic total esophagojejunostomy with π-shaped anastomosis and reverse puncture device are safe and feasible.In terms of esophagojejunostomy time,π-shaped anastomosis reconstruction time is shorter.When the small intestine diameter is relatively small and it is difficult to extend into the 25 mm stapler,the advantage of π-shaped anastomosis is more obvious.When the tumor is Siewert type Ⅰ and type Ⅱ adenocarcinoma of gastroesophageal junction,which infiltrates into above the dentate line,reverse puncture device method is recommended for reconstruction.

Clinical value of esophageal-jejunal Orvil TM anastomosis and Overlap anastomosis in laparos-copic radical total gastrectomy of adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the clinical value of esophageal-jejunal OrVil TM anas-tomosis and Overlap anastomosis in laparoscopic radical total gastrectomy of adenocarcinoma of esophagogastric junction (AEG). Methods:The retrospective cohort study was conducted. The clinicopathological data of 112 patients with AEG who were admitted to the First Hospital of Jilin University from July 2017 to August 2022 were collected. There were 87 males and 25 females, aged (64±8)years. All 112 patients underwent laparoscopic total gastrectomy and D 2 lymphadenectomy, in which 61 cases with esophageal-jejunal OrVil TM anastomosis were divided into the OrVil TM group, 51 cases with esophageal-jejunal Overlap anastomosis were divided into the Overlap group. Observa-tion indicators: (1) surgical situations; (2) postoperative complications; (3) influencing factors for patients undergoing esophageal-jejunal OrVil TM anastomosis. Measurement data with normal distri-bution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the non-parameter test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Logistic regression model was used for multivariate analysis. Results:(1) Surgical situations. The esophageal invasion length and tumor diameter was 1.0(0.7,2.0)cm and (6.3±2.7)cm in patients of the OrVil TM group, versus 0.2(0.1,0.5)cm and (4.7±2.2)cm, respectively, in patients of the Overlap group, showing significant differences in the above indicators between the two groups ( Z=?6.14, t=3.26, P<0.05). (2) Postoperative complications. Cases with complications ≥Ⅲa grade of Clavien-Dindo classification, cases with respiratory system complications, cases with hydrothorax were 13, 17, 13 in the OrVil TM group, versus 4, 5, 4 in the Overlap group, showing significant differences in the above indicators between the two groups ( χ2=3.91, 5.74, 3.91, P<0.05). Cases underwent readmission within postoperative 30 days were 3 and 1 in the OrVil TM group and the Overlap group, respectively, and all patients recovered after symptomatic treatment. There were 2 cases died after operation in the OrVil TM group and none of patients died after operation in the Overlap group. (3) Influencing factors for patients undergoing esophageal-jejunal OrVil TM anastomosis. Results of multivariate analysis showed that esophageal invasion length was an independent factor influencing for patients undergoing esophageal-jejunal OrVil TM anastomosis ( odds ratio=8.25, 95% confidence interval as 3.41?19.96, P<0.05). Conclusions:Compared with esophageal-jejunal Overlap anastomosis, choosing the esophageal-jejunal Orvil TM anastomosis during laparoscopic radical total gastrectomy can take benefit to the proximal margin of patients with AEG. However, the ratios of complications ≥ Ⅲa grade of Clavien-Dindo classification, respiratory system complications and hydrothorax associated to OrVil TM anastomosis are relatively increased. Esophageal invasion length is an independent influencing factor for patients undergoing esophageal-jejunal OrVil TM anastomosis.

Colangiopancreatografía retrógrada endoscópica asistida por enteroscopia de doble balón en un paciente con gastrectomía total y reconstrucción en Y-de-Roux: reporte de caso / Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in a patient with total gastrectomy and roux-en-y reconstruction: A case report

Resumen La colangiopancreatografía retrógrada endoscópica (CPRE) es un procedimiento útil en el manejo de enfermedades biliopancreáticas. Los pacientes con alteración anatómica del tracto gastrointestinal representan un desafío técnico por múltiples razones. Con técnicas como la enteroscopia de doble balón (EDB) es posible realizar una CPRE en estos pacientes. El caso que se presenta es el primero de este tipo publicado en Colombia sobre una paciente con gastrectomía total con reconstrucción en Y-de-Roux y coledocolitiasis.

Abstract Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable procedure in managing biliopancreatic diseases. Patients with anatomical alteration of the gastrointestinal tract represent a technical challenge for multiple reasons. With techniques such as double-balloon enteroscopy (DBE), it is possible to perform ERCP in these patients. The case was first published in Colombia on a female patient with total gastrectomy with Roux-en-Y reconstruction and choledocholithiasis.

Calidad de vida posterior a gastrectomía total laparoscópica versus abierta en cáncer gástrico / Quality of life after -laparoscopic versus open total gastrectomy in gastric cancer

Resumen Introducción: En los últimos años, la gastrectomía laparoscópica ha aparecido como una técnica quirúrgica con resultados oncológicos comparables a la técnica abierta, pero existe poca evidencia en cuanto a la calidad de vida posoperatoria de estos pacientes. Objetivo: Evaluar la calidad de vida posoperatoria de pacientes sometidos a gastrectomía total laparoscópica (GTL) en comparación a gastrectomia total abierta (GTA) en cáncer gástrico. Materiales y Método: Estudio retrospectivo, observacional en Hospital Militar de Santiago, entre enero de 2015 y junio de 2020. Se les aplicó 2 encuestas validadas para Chile: EORTC QLQ-30 y EORTC QLQ-OG25. Resultados: Se obtuvieron 60 pacientes; 30 sometidos a GTL y 30 a GTA. Promedio edad fue 66,3 ± 11 años para GTL y 68,2 ± 11 años en GTA (p = 0,5). Se obtuvo un score en GTL versus GTA: global 83,3 y 80,2 (p = 0,6), sintomático 17,1 y 25,5 (p = 0,2) y score funcional 87,9 y 70,9 (p = 0,03). Posterior a eso obtuvimos en funcionalidad GTL versus GTA; física 92,2 versus GTA 73,1 (p = 0,04), emocional 84,1 versus 78,5 (p = 0,6), cognitiva 84,9 versus 79,0 (p = 0,3) y social 80,9 versus 72,2 (p = 0,4). Al analizar síntomas destaco; fatiga 14,6 versus 33,1 (p = 0,04) y dolor 13,4 versus 24,3 (p = 0,05). Finalmente, en síntomas digestivos altos obtuvimos en disfagia 0,84 GTL versus 17,3 GTA (p = 0,04). Conclusión: La GTL logra resultados comparables a GTA en calidad de vida e incluso ofrece ventajas significativas en funcionalidad física como también en síntomas como dolor, fatiga y disfagia.

Introduction: In recent years, laparoscopic gastrectomy has appeared as a surgical technique with oncological results comparable to the open technique, but there is little evidence regarding the postoperative quality of life of these patients. Objective: To evaluate the postoperative quality of life of patients undergoing laparoscopic total gastrectomy (LTG) compared to open total gastrectomy (OTG) in gastric cancer. Materials and Method: Prospective, observational study at Hospital Militar of Santiago, between January 2015 and June 2020. Two surveys validated for Chile were applied: EORTC QLQ-30 and EORTC QLQ-OG25. Results: 60 patients were obtained; 30 subjected to LTG and 30 to OTG. Average age was 66.3 ± 11 years for LTG and 68.2 ± 11 years for OTG (p = 0.5). A score was obtained in LTG versus OTG: global 83.3 and 80.2 (p = 0.6), symptomatic 17.1 and 25.5 (p = 0.2) and functional score 87.9 and 70.9 (p = 0.03). After that we got LTG versus OTG functionality; physical 92.2 versus 73.1 (p = 0.04), emotional 84.1 versus 78.5 (p = 0.6), cognitive 84.9 versus 79.0 (p = 0.3) and social 80.9 versus 72.2 (p = 0.4). When analyzing symptoms I highlight; fatigue 14.6 versus 33.1 (p = 0.04) and pain 13.4 versus 24.3 (p = 0.05). Finally, in upper digestive symptoms, we obtained 0.84 LTG versus 17.3 OTG in dysphagia (p = 0.04). Conclusion: LTG achieves results comparable to OTG in quality of life and even offers significant advantages in physical functionality as well as symptoms such as pain, fatigue and dysphagia.

Application value of Overlap guiding tube in Overlap esophagojejunostomy of laparoscopic total gastrectomy / 中华消化外科杂志

Objective:To investigate the application value of Overlap guiding tube (OGT) in Overlap esophagojejunostomy of laparoscopic total gastrectomy.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 5 patients with gastric cancer who were admitted to Nanfang Hospital of Southern Medical University from June to July in 2021 were collected. There were 3 males and 2 females, aged from 48 to 61 years, with a median age of 54 years. Patients underwent laparoscopic total gastrectomy combined with OGT-assisted Overlap esophagojejunostomy. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted by outpatient examination and telephone interview to detect postoperative anastomotic stenosis and esophageal reflux up to September 2021. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(IQR) or M(range). Count data were represented as absolute numbers. Results:(1) Surgical situations: 5 patients underwent laparoscopic total gastrectomy combined with OGT-assisted Overlap esophagojejunostomy and D 2 lymph node dissection success-fully, achieving R 0 resection. There was no combined organ resection, intraoperative conversion to laparotomy or combined thoracotomy. There was no intraoperative conversion to other esophagoje-junostomy method either. The tumor diameter, length of surgical incision, the number of lymph nodes dissected, time of esophagojejunal anastomosis, time of digestive reconstruction, operation time, volume of intraoperative blood loss of 5 patients were 3.0(2.8)cm, 5.0(2.0)cm, 47.0(21.0), 21.0(5.0)minutes, 62.0(23.0)minutes, 295.0(75.0)minutes, and 50.0(60.0)mL, respectively. The anvil fork of linear stapler was successfully inserted into esophageal lumen by once operation in 4 cases of 5 patients and by twice operation in 1 case to complete the esophagojejunostomy. (2) Post-operative situations: the time to first out-of-bed activities, time to postoperative first anal flatus, time to postoperative initial liquid diet intake, time to postoperative initial semi-liquid diet intake, time to abdominal drainage tube removal, duration of postoperative hospital stay of 5 patients were 2.0(1.0)days, 3.0(2.0)days, 4.0(3.0)days, 6.0(3.0)days, 7.0(4.0)days, and 9.0(6.0)days, respectively. Results of postoperative pathological examination of 5 patients showed gastric adenocar-cinoma in all the 5 patients, with the TNM staging as stage pT2-4aN0M0. The esophageal surgical margin was negative in all cases, and the length of proximal margin from esophagus was 5.0(4.0)cm. None of the 5 patients developed anastomotic leakage, anastomotic bleeding or anastomotic stenosis. Two cases with mild pneumonia (Clavien-Dindo grade Ⅱ) were cured by conservative treatment such as anti-infection and expectoration promotion. There was no unplanned secondary surgery or perioperative death occurred to the 5 patients. (3) Follow-up: 5 patients were followed up for 3 months. None of the 5 patients developed anastomotic stenosis or esophageal reflux during the follow-up. Conclusion:OGT-assisted Overlap esophagojejunostomy of laparoscopic total gas-trectomy is safe and feasible, with good short-term effects.

Clinical efficacy of proximal gastrectomy and total gastrectomy in the treatment of Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the clinical efficacy of proximal gastrectomy and total gastrectomy in the treatment of Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective cohort study was conducted. The clinicopathological data of 170 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to Guangdong Provincial People′s Hospital from January 2010 to December 2018 were collected. There were 125 males and 45 females, aged from 30 to 85 years, with a median age of 64 years. Of the 170 patients, 82 cases undergoing proximal gastrectomy were allocated into the proximal gastrectomy group and 88 cases undergoing total gastrectomy were allocated into the total gastrectomy group. Observation indica-tors: (1) surgical and postoperative situations; (2) follow-up and survival; (3) analysis of prognostic factors. Follow-up was conducted using telephone interview and outpatient examination to detect survival of patients up to December 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measure-ment data with skewed distribution were represented as M( Q1, Q3) or M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the rank sum test. Kaplan-Meier method was used to draw survival curves, and Log-Rank test was used for survival analysis. COX proportional hazard model was used for univariate and multivariate analyses. Variables with P<0.1 in univariate analysis were included for multivariate analysis. Results:(1) Surgical and postoperative situations. Cases with surgical approach as transthoracic or thoraco-abdominal approach, transabdominal approach, the operation time, cases with volume of intra-operative blood loss ≤100 mL or >100 mL, cases with length of proximal margin ≤1.5 cm or >1.5 cm, cases with radical surgery outcome as R 0, R 1, R 2, the number of lymph nodes harvest, cases with anastomotic leakage, cases with anastomotic stricture, cases with incision infection, cases with pleural infection or effusion, cases with abdominal infection or ascites were 61, 21, (211±18)minutes, 46, 36, 44, 38, 73, 6, 3, 15(9,22), 5, 2, 2, 4, 2 in the proximal gastrectomy group, respec-tively. The above indicators were 12, 76, (263±15)minutes, 27, 61, 45, 43, 82, 4, 2, 23(18,32), 4, 1, 3, 1, 4 in the total gastrectomy group, respectively. There were significant differences in the surgical approach, operation time, volume of intraoperative blood loss and the number of lymph nodes harvest between the two groups ( χ2=63.94, t=-25.50, χ2=11.19, Z=-5.62, P<0.05). There was no significant difference in the length of proximal margin or radical surgery outcome between the two groups ( χ2=0.11, Z=-0.95, P>0.05) and there was no significant difference in the anastomotic leakage, anastomotic stricture, incision infection, pleural infection or effusion, abdominal infection or ascites between the two groups ( P>0.05). (2) Follow-up and survival. All the 170 patients were followed up for 89(64,106)months. Of the 170 patients, the 5-year overall survival rates were 43.8% and 35.5% of the Siewert type Ⅱ and Ⅲ AEG patients, respectively, showing no significant difference between them ( χ2=0.87, P>0.05). Of the patients with Siewert type Ⅱ AEG, the 5-year overall survival rates were 41.7% and 54.3% in the patients with proximal gastrectomy and the total gastrectomy, respectively, showing no significant difference between them ( χ2=1.05, P>0.05). Of the patients with Siewert type Ⅲ AEG, the 5-year overall survival rates were 31.3% and 37.5% in the patients with proximal gastrectomy and the total gastrectomy, respectively, showing no significant difference between them ( χ2=0.33, P>0.05). The 5-year overall survival rates were 39.0% and 44.2% in the proximal gastrectomy group and the total gastrectomy group, respectively, showing no significant difference between the two groups ( χ2=0.63, P>0.05). Of the patients in TNM stage Ⅰ, stage Ⅱ, stage Ⅲ, the 5-year overall survival rates were 65.3%, 36.3%, 27.1% in the proximal gastrectomy group, versus 83.3%, 48.0%, 39.7% in the total gastrectomy group, showing no signifi-cant difference between the two groups ( χ2=0.02, 1.50, 1.21, P>0.05). (3) Analysis of prognostic factors. Results of univariate analysis showed that pathological N staging, degree of tumor differen-tiation and radical surgery outcome were related factors influencing prognosis of AEG patients ( hazard ratio=1.71, 1.70, 2.85, 95% confidence interval as 1.16-2.60, 1.15-2.50, 1.58-5.14, P<0.05). Results of multivariate analysis showed that pathological N staging and radical surgery outcome were independent factors influencing prognosis of AEG patients ( hazard ratio=1.55, 2.18, 95% confidence interval as 1.05-2.31, 1.18-4.02, P<0.05). Conclusions:There is no significant difference in the prognosis of Siewert type Ⅱ and Ⅲ AEG patients undergoing proximal gastrectomy or total gastrectomy. Proximal gastrectomy can be used for the treatment of advanced Siewert type Ⅱ and Ⅲ AEG.

Influences of age-adjusted Charlson comorbidity index on prognosis of patients undergoing laparoscopic radical gastrectomy: a multicenter retrospective study / 中华消化外科杂志

Objective:To investigate the influences of age-adjusted Charlson comorbidity index (ACCI) on prognosis of patients undergoing laparoscopic radical gastrectomy.Methods:The retrospective cohort study was conducted. The clinicopathological data of 242 gastric cancer patients who underwent laparoscopic radical gastrectomy in 19 hospitals of the Chinese Laparoscopic Gastrointestinal Surgery Study Group-04 study, including 54 patients in Fujian Medical University Union Hospital, 32 patients in the First Hospital of Putian City, 32 patients in Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 31 patients in Zhangzhou Affiliated Hospital of Fujian Medical University, 17 patients in Nanfang Hospital of Southern Medical University, 11 patients in the First Affiliated Hospital with Nanjing Medical University, 8 patients in Qinghai University Affiliated Hospital, 8 patients in Meizhou People′s Hospital, 7 patients in Fujian Provincial Hospital, 6 patients in Zhongshan Hospital of Fudan University, 6 patients in Longyan First Hospital, 5 patients in the First Affiliated Hospital of Xinjiang Medical University, 5 patients in the First Hospital Affiliated to Army Medical University, 4 patients in the Second Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, 4 patients in West China Hospital of Sichuan University, 4 patients in Beijing University Cancer Hospital, 3 patients in the First Affiliated Hospital of Xiamen University, 3 patients in Guangdong Provincial People′s Hospital, 2 patients in the First Affiliated Hospital of Xi′an Jiaotong University, from September 2016 to October 2017 were collected. There were 193 males and 49 females, aged 62(range, 23?74)years. Observation indicators: (1) age distribution, comorbidities and ACCI status of patients; (2) the grouping of ACCI and comparison of clinicopathological characteristics of patients in each group; (3) incidence of postoperative early complications and analysis of factors affecting postoperative early complications; (4) follow-up; (5) analysis of factors affecting the 3-year recurrence-free survival rate of patients. Follow-up was conducted using outpatient examination or telephone interview to detect postoperative survival of patients up to December 2020. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( Q1, Q3) or M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was conducted using the nonparametric rank sum test. The X-Tile software (version 3.6.1) was used to analyze the best ACCI grouping threshold. The Kaplan-Meier method was used to calculate survival rates and draw survival curves. The Log-Rank test was used for survival analysis. The Logistic regression model was used to analyze the factors affecting postoperative early complications. The COX proportional hazard model was used for univariate and multivariate analyses of factors affecting the 3-year recurrence-free survival rate of patients. Multivariate analysis used stepwise regression to include variables with P<0.05 in univariate analysis and variables clinically closely related to prognosis. Results:(1) Age distribution, comor-bidities and ACCI status of patients. Of the 242 patients, there were 28 cases with age <50 years, 68 cases with age of 50 to 59 years, 113 cases with age of 60 to 69 years, 33 cases with age of 70 to 79 years. There was 1 patient combined with mild liver disease, 1 patient combined with diabetes of end-organ damage, 2 patients combined with peripheral vascular diseases, 2 patients combined with peptic ulcer, 6 patients combined with congestive heart failure, 8 patients combined with chronic pulmonary diseases, 9 patients with diabetes without end-organ damage. The ACCI of 242 patients was 2 (range, 0-4). (2) The grouping of ACCI and comparison of clinicopathological characteristics of patients in each group. Results of X-Tile software analysis showed that ACCI=3 was the best grouping threshold. Of the 242 patients, 194 cases with ACCI <3 were set as the low ACCI group and 48 cases with ACCI ≥3 were set as the high ACCI group, respectively. Age, body mass index, cases with preoperative comorbidities, cases of American Society of Anesthesiologists classification as stage Ⅰ, stage Ⅱ, stage Ⅲ, tumor diameter, cases with tumor histological type as signet ring cell or poorly differentiated adenocarcinoma and cases with tumor type as moderately or well differentiated adenocarcinoma, cases with tumor pathological T staging as stage T1, stage T2, stage T3, stage T4, chemotherapy cycles were (58±9)years, (22.6±2.9)kg/m 2, 31, 106, 85, 3, (4.0±1.9)cm, 104, 90, 16, 29, 72, 77, 6(4,6) in the low ACCI group, versus (70±4) years, (21.7±2.7)kg/m 2, 23, 14, 33, 1, (5.4±3.1)cm, 36, 12, 3, 4, 13, 28, 4(2,5) in the high ACCI group, showing significant differences in the above indicators between the two groups ( t=-14.37, 1.98, χ2=22.64, Z=-3.11, t=-2.91, χ2=7.22, Z=-2.21, -3.61, P<0.05). (3) Incidence of postoperative early complications and analysis of factors affecting postoperative early complications. Of the 242 patients, 33 cases had postoperative early complications, including 20 cases with local complications and 16 cases with systemic complica-tions. Some patients had multiple complications at the same time. Of the 20 patients with local complications, 12 cases had abdominal infection, 7 cases had anastomotic leakage, 2 cases had incision infection, 2 cases had abdominal hemorrhage, 2 cases had anastomotic hemorrhage and 1 case had lymphatic leakage. Of the 16 patients with systemic complications, 11 cases had pulmonary infection, 2 cases had arrhythmias, 2 cases had sepsis, 1 case had liver failure, 1 case had renal failure, 1 case had pulmonary embolism, 1 case had deep vein thrombosis, 1 case had urinary infection and 1 case had urine retention. Of the 33 cases with postoperative early complications, there were 3 cases with grade Ⅰ complications, 22 cases with grade Ⅱ complications, 5 cases with grade Ⅲa complications, 2 cases with grade Ⅲb complications and 1 case with grade Ⅳ complica-tions of Clavien-Dindo classification. Cases with postoperative early complications, cases with local complications, cases with systemic complications were 22, 13, 9 in the low ACCI group, versus 11, 7, 7 in the high ACCI group, respectively. There were significant differences in cases with postoperative early complications and cases with systemic complications between the two groups ( χ2=4.38, 4.66, P<0.05), and there was no significant difference in cases with local complications between the two groups ( χ2=2.20, P>0.05). Results of Logistic regression analysis showed that ACCI was a related factor for postoperative early complications of gastric cancer patients undergoing laparoscopic radical gastrectomy [ odds ratio=2.32, 95% confidence interval ( CI) as 1.04-5.21, P<0.05]. (4) Follow-up. All the 242 patients were followed up for 36(range,1?46)months. During the follow-up, 53 patients died and 13 patients survived with tumor. The 3-year recurrence-free survival rate of the 242 patients was 73.5%. The follow-up time, cases died and cases survived with tumor during follow-up, the 3-year recurrence-free survival rate were 36(range, 2-46)months, 29, 10, 80.0% for the low ACCI group, versus 35(range, 1-42)months, 24, 3, 47.4% for the high ACCI group. There was a significant difference in the 3-year recurrence-free survival rate between the two groups ( χ2=30.49, P<0.05). (5) Analysis of factors affecting the 3-year recurrence-free survival rate of patients. Results of univariate analysis showed that preoperative comorbidities, ACCI, tumor diameter, histological type, vascular invasion, lymphatic invasion, neural invasion, tumor pathological TNM staging, postoperative early complications were related factors for postoperative 3-year recurrence-free survival rate of gastric cancer patients undergoing laparoscopic radical gastrectomy [ hazard ratio ( HR)=2.52, 3.64, 2.62, 0.47, 2.87, 1.90, 1.86, 21.77, 1.97, 95% CI as 1.52-4.17, 2.22-5.95, 1.54-4.46, 0.27-0.80, 1.76-4.70, 1.15-3.12, 1.10-3.14, 3.01-157.52, 1.11-3.50, P<0.05]. Results of multivariate analysis showed that ACCI, tumor pathological TNM staging, adjuvant chemotherapy were indepen-dent influencing factors for postoperative 3-year recurrence-free survival rate of gastric cancer patients undergoing laparoscopic radical gastrectomy ( HR=3.65, 11.00, 40.66, 0.39, 95% CI as 2.21-6.02, 1.40-86.73, 5.41-305.69, 0.22-0.68, P<0.05). Conclusions:ACCI is a related factor for post-operative early complications of gastric cancer patients undergoing laparos-copic radical gastrectomy. ACCI, tumor pathological TNM staging, adjuvant chemotherapy are indepen-dent influencing factors for postoperative 3-year recurrence-free survival rate of gastric cancer patients undergoing laparoscopic radical gastrectomy.

Short-term efficacy of laparoscopic total gastrectomy with hand-sewn esophagojejunostomy versus Roux-en-Y anastomosis using propensity score matching / 中华消化外科杂志

Objective:To investigate the short-term efficacy of laparoscopic total gastrec-tomy with hand-sewn esophagojejunostomy versus Roux-en-Y anastomosis.Methods:The propen-sity score matching and retrospective cohort study was conducted. The clinicopathological data of 159 patients who underwent laparoscopic total gastrectomy in Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from October 2014 to July 2021 were collected. There were 107 males and 52 females, aged 63(range, 28?79)years. Of 159 patients, 71 cases undergoing totally laparoscopic total gastrectomy with hand-sewn esophagojejunostomy were allocated into totally laparoscopic group and 88 cases undergoing laparoscopic-assisted total gastrectomy with Roux-en-Y anastomosis were allocated into laparoscopic-assisted group, respectively. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) intraoperative and postoperative conditions; (3) perioperative complications. Propensity score matching was done by the 1:1 nearest neighbor matching method. Measurement data with normal distribution were expressed as Mean± SD, and t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M(range), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher's exact probability method. The rank sum test was used for comparison of ordinal data. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of 159 patients, 112 cases were successfully matched, including 56 cases in the totally laparoscopic group and 56 cases in the laparoscopic-assisted group. Before propensity score matching, age, cases with tumor located in cardia or gastric body in the totally laparoscopic group were 61(range, 30?76)years, 26, 45, respectively. The above indicators in the laparoscopic-assisted group were 65(range, 28?79)years, 50, 38, respectively. There were significant differences in the above indicators between the two groups ( Z=?2.89, χ2=6.43, P<0.05). After propensity score matching, the males and females, age, body mass index, cases of American Society of Anesthesiologists classification Ⅰ, Ⅱ, Ⅲ and Ⅳ, tumor diameter, cases with tumor located in cardia or gastric body, cases in TNM stage Ⅰ, Ⅱ and Ⅲ of patients in the totally laparoscopic group were 40, 16, (62±9)years, (22.7±2.8)kg/m 2, 22, 26, 7, 1, 3.5(range, 0.6?17.0)cm, 24, 32, 22, 9, 25. The above indicators of patients in the laparoscopic-assisted group were 38, 18, (62±10)years, (22.7±3.2)kg/m 2, 19, 32, 5, 0, 4.0(range, 0.6?15.0)cm, 23, 33, 21, 7, 28, respectively. There was no significant difference in the above indicators between the two groups ( χ2=0.17, t=?0.09, ?0.04, Z=?0.12, ?0.82, χ2=0.04, Z=?0.42, P>0.05). The elimination of age and tumor location confounding bias ensured comparability between the two groups. (2) Intraoperative and postoperative conditions: after propensity score matching, the total operation time, time of esophagojejunostomy, postopera-tive 24-hour pain numerical score and time to first out-off bed activities were (310±49)minutes, (37±10)minutes, 2.3±0.8 and (2.4±0.7)days for patients in the totally laparoscopic group, versus (344±77)minutes, (44±12)minutes, 3.1±1.2 and (2.9±1.0)days in the laparoscopic-assisted group, showing significant differences between the two groups ( t=?2.85, ?3.05, ?4.20, ?3.10, P<0.05). (3) Perioperative complications: after propensity score matching, 6 cases of the patients in the totally laparoscopic group had Clavien-Dindo grade 2 or higher complications, including 2 cases of anas-tomotic leak, 1 case of anastomotic stenosis, 1 case of pleural effusion, 1 case of abdominal infection and 1 case of intestinal obstruction. The incidence of Clavien-Dindo grade 2 or higher complications was 10.7%(6/56). In the laparoscopic-assisted group, 5 patients had Clavien-Dindo grade 2 or higher complications, including 2 cases of anastomotic leak, 1 case of abdominal infection, 1 case of intestinal obstruction and 1 case of cholangitis. The incidence of Clavien-Dindo grade 2 or higher complications was 8.9%(5/56). There was no significant difference in the incidence of Clavien-Dindo grade 2 or higher complications between the two groups ( χ2=0.10, P>0.05). Patients with anas-tomotic leak were improved after puncture and drainage, secondary surgery and conservative treat-ment, and other complications were improved after symptomatic treatment. Conclusions:Com-pared with Roux-en-Y anastomosis in laparoscopic total gastrectomy, the time of hand-sewn esophagojejunostomy and esophago-jejunal anastomosis are shorter, patients have less postopera-tive pain and faster postoperative recovery. Both methods have good peri-operative safety.

A comparative study on short-term outcomes and quality of life for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic-assisted total gastrectomy using a circular stapler / 中华胃肠外科杂志

Objective: To explore the differences of short-term outcomes and quality of life (QoL) for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic-assisted total gastrectomy using a circular stapler. Methods: A retrospective cohort study was conducted. Clinicopathological data of patients with stage I to III gastric adenocarcinoma who underwent laparoscopic total gastrectomy from January 2017 to January 2020 were retrospectively collected. Those who were ≥80 years old, had serious complications that could affect the quality of life, underwent multi-organ resections, palliative surgery, emergency surgery due to gastrointestinal perforation, obstruction, bleeding, died or lost to follow-up within 1 year after surgery were excluded. A total of 130 patients were enrolled and divided into circular stapler group (CS group, 77 cases) and linear stapler group (LS group, 53 cases) according to the surgical method. The differences of age, gender, body mass index, number of comorbidities, history of abdominal surgery, ASA, tumor location, degree of differentiation, tumor length, tumor T stage, tumor N stage, tumor pathological stage and preoperative quality of life between the two groups were not statistically significant (all P>0.05). The observation indicators: (1) Surgery and postoperative conditions. (2) Postoperative complications: Any adverse conditions that require conservative treatment or surgical intervention after surgery were defined as postoperative complications, of which, complications occurring within 30 days after surgery were defined as early complications; complications occurring within 30 days to 1 year after surgery were defined as late complications. (3) Postoperative quality of life was assessed by the quality of life core scale (QLQ-C30) and gastric cancer specific module scale (QLQ-STO22). The higher the scores of functional scales and global health status, the better the corresponding quality of life. The higher the scores of symptoms scales, the worse the corresponding quality of life. Results: (1) Surgery and postoperative conditions: Compared with the CS group, the LS group presented less intraoperative blood loss [50.0 (50.0-100.0) ml vs. 100.0 (100.0-100.0) ml, Z=-3.111, P=0.002] and earlier time to flatus [(3.1±0.8) days vs. (3.5±1.1) days, t=-2.490, P=0.014]. However, there were no statistically significant differences between two groups of patients in terms of operation time, time to start a liquid diet and postoperative hospital stay (all P>0.05). (2) Postoperative complications: The early complication rates of the CS group and the LS group were 22.1% (17/77) and 18.9% (10/53), respectively, while the late complication rate were 18.2% (14/77) and 15.1% (8/53), respectively, whose differences were not statistically significant (all P>0.05). (3) Postoperative quality of life: After 1-year follow-up, 7 (5.4%) patients were lost, including 5 in CS group and 2 in LS group. One year after operation, the QLQ-C30 scale showed that the score of financial difficulty of the LS group was significantly higher than that of the CS group [33.3 (0 to 33.3) vs.0 (0 to 33.3), Z=-1.972, P=0.049] with statistically significant difference, and there were no statistically significant differences in the scores of other functional fields and symptom fields between the two groups (all P>0.05). The QLQ-STO22 scale showed that the scores of dysphagia [0 (0 to 5.6) vs. 0 (0 to 11.1), Z=-2.094, P=0.036] and eating restriction were significantly lower [0 (0 to 4.2) vs. 0 (0 to 8.3), Z=-2.011, P=0.044] in patients of the LS group than those of the CS group. There were no significant differences in scores of other symptoms between two groups (all P>0.05). Conclusions: Compared with the circular stapler, the esophagojejunostomy with linear stapler for gastric cancer patients can reduce intraoperative blood loss, shorten the time to flatus after operation, alleviate the symptoms of dysphagia and eating restriction but increase the economic burden to a certain degree.

Technical details of gastrointestinal reconstruction using linear stapler in totally laparoscopic total gastrectomy / 中华胃肠外科杂志

With the development of instrument, equipment and surgical skills, especially the emergence of a series of high-level medical evidence, the laparoscopic techniques in the field of gastric surgery has been further expanded. Totally laparoscopic total gastrectomy (TLTG) has certain technical difficulties, and more challenges are reflected in the digestive tract reconstruction. The use of linear staplers has reduced the difficulty of digestive tract reconstruction to a certain extent and has strongly promoted the transition from laparoscopic-assisted total gastrectomy to TLTG. However, for TLTG, there are still many details that should be carefully concerned, so as to effectively avoid the surgical pitfalls and ensure the fluency and safety of the procedure. In this article, we discuss the surgical details based on our own experiences, including how to obtain surgical field exposure well, how to manage specific accidents when using linear stapler for esophagojejunostomy, how to prevent intra-abdominal hernias and Roux stasis syndrome, and how to prevent the stapled lines of the esophageal or jejunal stumps from direct contact with aorta.

Choice of digestive tract reconstruction in upper gastric cancer / 中华胃肠外科杂志

With the increasing incidence of upper gastric cancer and early gastric cancer, surgeons have gradually paid attention to the selection of appropriate digestive tract reconstruction methods. At present, the safety of surgery is no longer the main aim pursued by surgeons, and the focus of surgery has gradually changed to postoperative quality of life. Surgical procedures for upper gastric cancer include total gastrectomy (TG) and proximal gastrectomy (PG). Roux-en-Y anastomosis is recommended for digestive tract reconstruction after TG. The classic method of digestive tract reconstruction after PG is distal residual stomach and esophageal anastomosis. However, to prevent esophageal reflux caused by PG, a lot of explorations have been carried out over the years, including tubular gastroesophageal anastomosis, double-flap technique (Kamikawa anastomosis), interposition jejunum, double-tract reconstruction and so on. But the appropriate method of digestive tract reconstruction for upper gastric cancer is still controversial. In this paper, based on literatures and our clinical experience, the selection, surgical difficulties and techniques of digestive tract reconstruction after PG are discussed.

Efficacy of laparoscopic proximal gastrectomy with double-tract reconstruction versus laparoscopic total gastrectomy with Roux-en-Y reconstruction for early upper gastric cancer / 中华胃肠外科杂志

Objective: To compare clinical efficacy between laparoscopic radical proximal gastrectomy with double-tract reconstruction (LPG-DTR) and laparoscopic radical total gastrectomy with Roux-en-Y reconstruction (LTG-RY) in patients with early upper gastric cancer, and to provide a reference for the selection of surgical methods in early upper gastric cancer. Methods: A retrospective cohort study method was carried out. Clinical data of 80 patients with early upper gastric cancer who underwent LPG-DTR or LTG-RY by the same surgical team at the Department of General Surgery, the First Affiliated Hospital of Xi'an Jiaotong University from January 2018 to January 2021 were retrospectively analyzed. Patients were divided into the DTR group (32 cases) and R-Y group (48 cases) according to surgical procedures and digestive tract reconstruction methods. Surgical and pathological characteristics, postoperative complications (short-term complications within 30 days after surgery and long-term complications after postoperative 30 days), survival time and nutritinal status were compared between the two groups. For nutritional status, reduction rate was used to represent the changes in total protein, albumin, total cholesterol, body mass, hemoglobin and vitamin B12 levels at postoperative 1-year and 2-year. Non-normally distributed continuous data were presented as median (interquartile range), and the Mann-Whitney U test was used for comparison between groups. The χ(2) test or Fisher's exact test was used for comparison of data between groups. The Mann-Whitney U test was used to compare the ranked data between groups. The survival rate was calculated by Kaplan-Meier method categorical, and compared by using the log-rank test. Results: There were no statistically significant differences in baseline data betweeen the two groups, except that patients in the R-Y group were oldere and had larger tumor. Patients of both groups successfully completed the operation without conversion to laparotomy, combined organ resection, or perioperative death. There were no significant differences in the distance from proximal resection margin to superior margin of tumor, postoperative hospital stay, time to flatus and food-taking, hospitalization cost, short- and long-term complications between the two groups (all P>0.05). Compared with the R-Y group, the DTR group had shorter distal margins [(3.2±0.5) cm vs. (11.7±2.0) cm, t=-23.033, P<0.001], longer surgery time [232.5 (63.7) minutes vs. 185.0 (63.0) minutes, Z=-3.238, P=0.001], longer anastomosis time [62.5 (17.5) minutes vs. 40.0 (10.0) minutes, Z=-6.321, P<0.001], less intraoperative blood loss [(138.1±51.6) ml vs. (184.3±62.1) ml, t=-3.477, P=0.001], with significant differences (all P<0.05). The median follow-up of the whole group was 18 months, and the 2-year cancer-specific survival rate was 97.5%, with 100% in the DTR group and 95.8% in the R-Y group (P=0.373). Compared with R-Y group at postoperative 1 year, the reduction rate of weight, hemoglobin and vitamin B12 were lower in DTR group with significant differences (all P<0.05); at postoperative 2-year, the reduction rate of vitamin B12 was still lower with significant differences (P<0.001), but the reduction rates of total protein, albumin, total cholesterol, body weight and hemoglobin were similar between the two groups (all P>0.05). Conclusions: LPG-DTR is safe and feasible in the treatment of early upper gastric cancer. The short-term postoperative nutritional status and long-term vitamin B12 levels of patients undergoing LPG-DTR are superior to those undergoing LTG-RY.

Safety and effectiveness of esophagojejunostomy through extracorporeal versus intracorporeal methods after laparoscopic total gastrectomy / 中华胃肠外科杂志

Objective: To compare the safety and effectiveness of esophagojejunostomy (EJS) through extracorporeal and intracorporeal methods after laparoscopic total gastrectomy (LTG). Methods: A retrospective cohort study was carried out. Clinicopathological data of 261 gastric cancer patients who underwent LTG, D2 lymphadenectomy, and Roux-en-Y EJS with complete postoperative 6-month follow-up data at the General Surgery Department of Nanfang Hospital from October 2018 to June 2021 were collected. Among these 261 patients, 139 underwent EJS with a circular stapler via mini-laparotomy (extracorporeal group), while 122 underwent intracorporeal EJS (intracorporeal group), including 43 with OrVil(TM) anastomosis (OrVil(TM) subgroup) and 79 with Overlap anastomosis (Overlap subgroup). Compared with the extracorporeal group, the intracorporeal group had higher body mass index, smaller tumor size, earlier T stage and M stage (all P<0.05). Compared with the Overlap subgroup, the Orvil(TM) subgroup had higher proportions of upper gastrointestinal obstruction and esophagus involvement, and more advanced T stage (all P<0.05). No other significant differences in the baseline data were found (all P>0.05). The primary outcome was complications at postoperative 6-month. The secondary outcomes were operative status, intraoperative complication and postoperative recovery. Continuous variables with a skewed distribution are expressed as the median (interquartile range), and were compared using Mann-Whitney U test. Categorical variables are expressed as the number and percentage and were compared with the Pearson chi-square, continuity correction or Fisher's exact test. Results: Compared with the extracorporeal group, the intracorporeal group had smaller incision [5.0 (1.0) cm vs. 8.0 (1.0) cm, Z=-10.931, P=0.001], lower rate of combined organ resection [0.8% (1/122) vs. 7.9% (11/139), χ(2)=7.454, P=0.006] and higher rate of R0 resection [94.3% (115/122) vs. 84.9 (118/139), χ(2)=5.957, P=0.015]. The morbidity of intraoperative complication in the extracorporeal group and intracorporeal group was 2.9% (4/139) and 4.1% (5/122), respectively (χ(2)=0.040, P=0.842). In terms of postoperative recovery, the extracorporeal group had shorter time to liquid diet [(5.1±2.4) days vs. (5.9±3.6) days, t=-2.268, P=0.024] and soft diet [(7.3±3.7) days vs. (8.8±6.5) days, t=-2.227, P=0.027], and shorter postoperative hospital stay [(10.5±5.1) days vs. (12.2±7.7) days, t=-2.108, P=0.036]. The morbidity of postoperative complication within 6 months in the extracorporeal group and intracorporeal group was 25.9% (36/139) and 31.1%, (38/122) respectively (P=0.348). Furthermore, there was also no significant difference in the morbidity of postoperative EJS complications [extracorporeal group vs. intracorporeal group: 5.0% (7/139) vs. 82.% (10/122), P=0.302]. The severity of postoperative complications between the two groups was not statistically significant (P=0.289). In the intracorporeal group, the Orvil(TM) subgroup had more estimated blood loss [100.0 (100.0) ml vs.50.0 (50.0) ml, Z=-2.992, P=0.003] and larger incision [6.0 (1.0) cm vs. 5.0 (1.0) cm, Z=-3.428, P=0.001] than the Overlap subgroup, seemed to have higher morbidity of intraoperative complication [7.0% (3/43) vs. 2.5% (2/79),P=0.480] and postoperative complications [37.2% (16/43) vs. 27.8% (22/79), P=0.286], and more severe classification of complication (P=0.289). Conclusions: The intracorporeal EJS after LTG has similar safety to extracorporeal EJS. As for intracorporeal EJS, the Overlap method is safer and has more potential advantages than Orvil(TM) method, and is worthy of further exploration and optimization.

Choice and consideration of digestive tract reconstruction after total gastrectomy and proximal gastrectomy / 中华消化外科杂志

At present, the surgical treatment of upper gastric cancer, including esophago-gastric junction cancer, mainly includes the total gastrectomy and proximal gastrectomy. After total gastrectomy, the reconstruction of digestive tract is completed through the anastomosis of esophagus and jejunum. Patients undergoing total gastrectomy often face the risk of poor eating effect and malnutrition. Compared with total gastrectomy, the proximal gastrectomy can preserve part of the gastric tissue, but due to the loss of the normal physiological structure of the cardia, patients have a higher risk of postoperative reflux. In order to solve the problem of reflux, there are many improved operation methods of digestive tract reconstruction after proximal gastrectomy. At present, the choice of total gastrectomy or proximal gastrectomy and the operation methods of digestive tract reconstruction is still controversial. Because of the lack of sufficient theoretical research support. The authors comb the research progress and consider the concept and method of digestive tract reconstruction after total gastrectomy and proximal gastrectomy, in order to provide theoretical basis for clinical work.

Risk factors of postoperative complication after total gastrectomy in advanced gastric cancer patients receiving neoadjuvant chemotherapy / 中华胃肠外科杂志

Objective: At present, there are few studies focusing on the factors short-term complications after total gastrectomy in patients with advanced gastric cancer receiving neoadjuvant chemotherapy (NACT). The purpose of this study is to provide a reference for clinical prevention of complications in these patients. Methods: A retrospective case-control study was conducted. Case inclusion criteria: (1) clinical stage II-III gastric cancer diagnosed by preoperative gastroscopy, pathology, abdominal CT, EUS or PET-CT; (2) evaluated suitable for NACT by MDT discussion; (3) no previous history of other malignant tumors and no concurrent tumor; (4) undergoing total gastrectomy+ D2 lymphadenectomy after NACT. Exclusion criteria: (1) age <18 or >80 years old; (2) severe concurrent diseases, and ASA classification>grade III; (3) stump gastric cancer or history of gastric surgery; (4) incomplete clinicopathological data. According to the above criteria, clinicopathological data of 140 advanced gastric cancer patients who underwent total gastrectomy after NACT in Chinese PLA General Hospital between June 2012 and June 2019 were collected, including 109 males and 31 females with mean age of (56.9±11.4) years and body mass indey (BMI) of (23.3±3.1) kg/m(2). Logistic analysis was used to analyze the relationship between postoperative complication and clinicopathological data. Factors in univariate analysis with P<0.05 were included in the multivariate analysis. Results: Postoperative complications (Clavien-Dindo classification ≥ II) occurred in 35 cases (25.0%) and severe complications (Clavien-Dindo classification ≥ IIIa) occurred in 4 cases (2.9%), including 1 case of esophago-jejunal anastomotic leakage, 1 case of vena cava thrombosis, 1 case of pleural effusion, 1 case of septic shock during perioperative days resulting in death. Univariate analysis showed that BMI (P=0.011), cycle of NACT (P=0.027), tumor diameter (P=0.021), and vascular invasion (P=0.033) were associated with postoperative complication within 30 days, while open/laparoscopic total gastrectomy were not associated with postoperative complication (P=0.926). Multivariate analysis revealed that BMI ≥ 25 kg/m(2) (OR=3.294, 95% CI: 1.343-8.079, P=0.009) and < 4 cycles of NACT (OR=2.922, 95% CI: 1.217-7.016, P=0.016) were independent risk factors for postoperative complication. The 3-year overall survival rates of patients with or without complication were 54.4% and 64.0%, respectively (P=0.395), and 3-year disease-free survival rates were 47.4% and 52.9%, respectively (P=0.587). Conclusions: Higher BMI and fewer cycles of NACT are independent risk factors of postoperative complication in advanced gastric cancer patients undergoing total gastrectomy after NACT. No obvious association is found between postoperative complication and surgical approaches.

Application of 3D-CT simulation image in the description of gastric artery variation to guide laparoscopic total gastrectomy / 中华胃肠外科杂志

Objective: Anatomic variations in the perigastric vessels during laparoscopic radical gastrectomy often affect the operator's judgment and prolong the operation time, and even cause accidental injury and surgical complications, and hence the safety and quality of the operation cannot be ensured. In this study, multiple slice CT was reconstructed by 3-dimensional CT simulation software (3D-CT), and 3D-CT images were used to describe the variation of celiac trunk and splenic artery before surgery. The guiding role of the different variation of vessels was analyzed for laparoscopic total gastrectomy+D2 lymph node dissection (LTG+D2LD). Methods: A retrospective cohort study was conducted. Case inclusion criteria: (1) Gastric cancer was at an advanced stage. All the patients were preoperatively examined by digestive endoscopy and 64-row enhanced CT scan, and were histopathologically diagnosed with gastric adenocarcinoma. (2) 3D-CT simulation images were reconstructed to guide the operation. (3) LTG+D2LD surgery was performed by the same surgical team. (4) Clinical data were complete, and all the patients had signed the informed consent. From 2014 to 2018, 98 patients with gastric cancer at the Gastrointestinal Surgery Department of Henan Provincial People's Hospital were enrolled. According to the Adachi classification, celiac trunk variation was divided into common type (Adachi type I) and rare type (Adachi type II-VI). According to the Natsume classification, splenic artery was classified into "flat type" and "curved type". Based on 3D-CT simulation images, variation of celiac trunk and splenic artery was described, and the differences in operation time, intraoperative blood loss and the number of postoperative retrieved lymph nodes were compared between groups with different types of arterial variation. Results: For celiac trunk, common type was found in 84 cases (86%) and rare type was found in 14 cases, including 6 cases (6%) of type II, 2 cases (2%) of type III, 2 cases (2%) of type IV, 3 cases (3%) of type V, 1 case (1%) of type VI. No other types were found. There were no statistically significant differences in clinical characteristics and number of retrieved lymph nodes between patients of the common type group and rare type group (all P>0.05). Compared with common type patients, those of rare type had longer operative time [(321.1±29.0) minutes vs. (295.1±46.5) minutes, t=2.081, P=0.040] and more intraoperative blood loss (median: 66.0 ml vs. 32.0 ml, Z=-4.974, P=0.001). For splenic artery, 41 patients (42%) were flat type and 57 patients (58%) were curved type. There were no statistically significant differences between the two groups in terms of clinical characteristics, intraoperative blood loss, operative time and number of retrieved lymph nodes (all P>0.05). Conclusions: The method of describing the variation in the perigastric vessels by 3D-CT simulation has certain clinical value in laparoscopic radical gastrectomy. The duration of LTG+D2LD is prolonged and the intraoperative blood loss is increased with the variation of celiac trunk, while the variation of splenic artery has no effect on LTG+D2LD.

Clinical observation of total laparoscopic radical gastrectomy for locally advanced esophagogastric junction carcinoma / 肿瘤研究与临床

Objective:To investigate the efficacy of total laparoscopic radical gastrectomy for locally advanced esophagogastric junction carcinoma and its effect on patient's immune function and levels of tumor markers.Methods:A total of 106 patients who underwent total laparoscopic radical gastrectomy (total endoscopic group) in the Affiliated Cancer Hospital of Shanxi Medical University from January 2016 to April 2020 were collected, and 98 patients who underwent open radical gastrectomy (open group) in the same period were selected. The short-term efficacy, preoperative and postoperative immune function and tumor markers were compared between the two groups.Results:The operative time of the total endoscopic group was longer than that of the open group [(214±49) min vs. (165±32) min, t = 8.87, P < 0.01], the intraoperative blood loss was less than that of the open group [(86±50) ml vs. (113±53) ml, t = 3.59, P < 0.01], the postoperative first exhaust time was shorter than that of the open group [3.0 d (3.0 d, 4.0 d) vs. 3.5 d (3.0 d, 4.5 d), Z = 2.89, P < 0.01], and the incision length was shorter than that of the open group [(4.6±0.6) cm vs. (17.6±2.0) cm, t = 68.63, P < 0.01]. The postoperative proportion of CD4 + T cells, CD4 +/CD8 + and proportion of NK cells in the total endoscopic group were higher than those in the open group [(41±8)% vs.(36±8)%, t = 4.710, P < 0.01; 1.63 (1.19, 2.30) vs. 1.15 (0.87, 1.63), Z = 4.165, P < 0.01; 24.60 % (17.77 %, 32.50 %) vs. 19.25 % (13.35 %, 25.80 %), Z = 3.440, P < 0.01], while the postoperative proportions of CD8 + T cells and regulatory T cells in the total endoscopic group were lower than those in the open group [(26±11)% vs. (30±10)%, t = 2.375, P = 0.018; 3.37% (5.00%, 6.70%) vs. 4.48% (5.70%, 7.20%), Z = 3.057, P = 0.002]. Postoperative carcinoembryonic antigen (CEA) and carbohydrate antigen 199 (CA199) in the total endoscopy were lower than those in the open group group [0.96 μg/L (0.54 μg/L, 1.50 μg/L) vs. 1.27 μg/L (0.70 μg/L, 2.98 μg/L), Z = 2.745, P = 0.036; 8.07 U/ml (5.48 U/ml, 13.07 U/ml) vs. 10.80 U/ml (6.54 U/ml, 19.93 U/ml), Z = 2.690, P = 0.043]. Conclusion:Compared with open surgery, total laparoscopic radical gastrectomy has less trauma and stress response, and has less impact on the gastrointestinal and immune function of patients, and the levels of tumor markers CEA and CA199 are low.

Technical tips and pitfalls of total laparoscopic esophagojejunostomy / 肿瘤研究与临床

With the development of laparoscopic technology and the accumulation of experience, total laparoscopic total gastrectomy has been gradually popularized and applied. Among them, laparoscopic esophagojejunostomy is the biggest challenge in this surgery because of its high difficulty. More and more surgeons have been trying to find a more feasible anastomosis method. So far, there have been many kinds of esophagojejunostomy, and they are constantly being improved. The purpose of this article is to review the technical tips and pitfalls of common laparoscopic esophagojejunostomy.