The safety and short-term efficacy of laparoscopic proximal gastrectomy for proximal gastric cancer and adenocarcinoma of esophagogastric junction: a multicenter study / 中华消化外科杂志

Objective:To investigate the safety and short-term efficacy of laparoscopic pro-ximal gastrectomy (LPG) for proximal gastric cancer and adenocarcinoma of esophagogastric junction.Methods:The retrospective cohort study was conducted. The clinicopathological data of 385 patients with proximal gastric cancer and adenocarcinoma of esophagogastric junction who underwent LPG in the 15 medical centers, including the First Affiliated Hospital of Xiamen University et al, from January 2014 to March 2022 were collected. There were 304 males and 81 females, aged (63±9)years. Of the 385 patients, 335 cases undergoing LPG were divided into the laparoscopic group and 50 cases undergoing open proximal gastrectomy were divided into the open group. Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up; (3) stratified analysis. 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(range), and comparison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Repeated measurement data were analyzed using the repeated ANOVA. Results:(1) Intraoperative and postoperative situations. The operation time, cases with reconstruction of digestive tract as esophagogastric anastomosis and esophageal-jejunal anastomosis, cases with postoperative pathological staging as stage 0?Ⅰ and stage Ⅱ?Ⅲ, duration of postoperative hospital stay, cases with postoperative early complications were (212±96)minutes, 270, 65, 177, 107, 10(range, 8?14)days, 40 in patients of the laparoscopic group, with 51 cases missing the data of postoperative pathological staging. The above indicators were (174±90)minutes, 39, 11, 22, 28, 10(range, 8?18)days, 10 in patients of the open group. There were significant differences in the opera-tion time and postoperative pathological staging between the two groups ( t=2.62, χ2=5.93, P<0.05), and there was no significant difference in the reconstruction of digestive tract, duration of post-operative hospital stay, postoperative early complications between the two groups ( χ2=0.19, Z=0.40, χ2=2.50, P>0.05). (2) Follow-up. Of the 385 patients,202 cases were followed up during the post-operative 12 months, including 187 cases in the laparoscopic group and 15 cases in the open group. Cases with reflux esophagitis, cases with esophageal anastomotic stenosis were 48, 11 in patients of the laparoscopic group, versus 5, 2 in patients of the open group, showing no significant difference in the above indicators between the two groups ( P>0.05). The body mass index (BMI), hemoglobin (Hb), albumin (Alb) at postoperative 6 months and 12 months were (21±3)kg/m 2, (130±15)g/L, (40±4)g/L and (21±3)kg/m 2, (132±14)g/L, (41±4)g/L in patients of the laparoscopic group, versus (21±3)kg/m 2, (121±19)g/L, (37±5)g/L and (21±3)kg/m 2, (125±21)g/L, (43±6)g/L in patients of the open group. There were significant differences in postoperative Hb between the two groups ( Fgroup=5.88, Ftime=5.49, Finteraction=19.95, P<0.05) and there were significant differences in time effect of postopera-tive BMI and Alb between the two groups ( Ftime=9.53, 49.88, P<0.05). (3) Stratified analysis. ① Incidence of postoperative of reflux esophagitis and esophageal anastomotic stenosis in patients with different reconstruction of digestive tract. Of the 202 patients, cases with reconstruction of digestive tract as esophagogastric anastomosis and esophageal-jejunal anastomosis were 168 and 34, respectively. The incidence rates of postoperative of reflux esophagitis were 26.79%(45/168)and 23.53%(8/34)in cases with reconstruction of digestive tract as esophagogastric anastomosis and esophageal-jejunal anastomosis, showing no significant difference between them ( χ2=0.16, P>0.05). Cases undergoing esophageal anastomotic stenosis were 13 in patients with reconstruction of diges-tive tract as esophagogastric anastomosis. ② The BMI, Hb, Alb in patients with different reconstruc-tion of digestive tract. The BMI, Hb, Alb were (24±3)kg/m 2, (135±20)g/L, (41±5)g/L in the 168 patients with reconstruction of digestive tract as esophagogastric anastomosis before the operation, versus (23±3)kg/m 2, (130±19)g/L, (40±4)g/L in the 34 patients with reconstruction of digestive tract as esophageal-jejunal anastomosis before the operation, showing no significant difference between them ( t=1.44, 1.77, 1.33, P>0.05). The BMI, Hb, Alb at postoperative 6 months and 12 months were (21±3)kg/m 2, (128±16)g/L, (39±4)g/L and (21±3)kg/m 2, (131±16)g/L, (41±4)g/L in the 168 patients with reconstruction of digestive tract as esophagogastric anastomosis, versus (20±4)kg/m 2, (133±13)g/L, (43±3)g/L and (21±3)kg/m 2, (135±12)g/L, (44±3)g/L in the 34 patients with reconstruction of digestive tract as esophageal-jejunal anastomosis. There were significant differences in the group effect and time effect of postoperative Alb between patients with different reconstruction of diges-tive tract ( Fgroup=15.82, Ftime=5.43, P<0.05), and there was also a significant difference in the time effect of postoperative BMI between them ( Ftime=4.22 , P<0.05). Conclusion:LPG can be used to the treatment of proximal gastric cancer and adenocarcinoma of esophagogastric junction, with a good safety and short-term efficacy.

Technical practice and development direction of minimally invasive gastric surgery in digital medicine era / 中华消化外科杂志

After nearly 30 years of high-speed development of minimally invasive gastric surgery in China, the surgical techniques are well developed. The concept of gastric cancer treatment is constantly changing as the deepening understanding of gastric cancer. Minimally invasiveness and precision is an inevitable trend in gastric surgery. At the same time, science and technology are fast-evolving, which greatly improved the performance of both soft- and hardware. In the future, surgical technology, real-time data and artificial intelligence will be further integrated to facilitate the evolution of minimally invasive surgery to digital surgery era. Therefore, in this article, the authors elaborate on the technical practice and future directions of minimally invasive surgery in this digital medicine era from technology and scientific progress.

Digestive tract reconstruction after laparoscopic proximal gastrectomy for adenocarcinoma of esophagogastric junction / 中华胃肠外科杂志

The incidence of adenocarcinoma of esophagogastric junction (AEG) is increasing in recent years. Its diagnosis, lymph node metastasis and digestive tract reconstruction are all different from those of upper gastric cancer. With the development of the concept of function preserving surgery for gastric cancer, the clinical application of laparoscopic proximal gastrectomy in AEG is increasing. In this kind of operation, in addition to ensuring sufficient radical cure of tumor, the short-term smooth recovery and long-term quality of life of patients are also important. The reconstruction of digestive tract after proximal stomach operation is of great significance. According to the author's own practical experience, in clinical work, the author selects different surgical resection scope and digestive tract reconstruction methods according to Siewert classification of AEG. For Siewert Ⅱ AEG, laparoscopic PG is mostly used, and laparoscopic esophageal tubular gastric side-to-side anastomosis or double channel anastomosis is mostly used for digestive tract reconstruction. It is believed that with the emergence of long-term follow-up results and the development of multicenter randomized controlled research, some controversial questions will be better answered. We should pay attention to the individual differences of patients. For different individuals, combined with the operator's experience, on the basis of ensuring the radical cure of tumor, we should adopt appropriate surgical resection scope and digestive tract reconstruction, so as to bring better long-term quality of life for patients.

Safety and effectiveness of oxaliplatin combined with capecitabine or oxaliplatin combined with S-1 neoadjuvant chemotherapy in the treatment of advanced gastric cancer / 中华胃肠外科杂志

Objective: To explore the safety and efficacy of oxaliplatin plus capecitabine (CapeOX) or oxaliplatin plus S-1 (SOX) regimen neoadjuvant chemotherapy in the treatment of advanced gastric cancer. Methods: A retrospective cohort study was performed. Clinical data of patients diagnosed as advanced gastric cancer undergoing CapeOX/SOX neoadjuvant chemotherapy and standard laparoscopic radical operation for gastric cancer in Ruijin Hospital of Shanghai Jiaotong University School of Medicine from April 2016 to April 2019 were retrospectively collected. Inclusion criteria were as follows: (1) age≥18 years; (2) gastric adenocarcinoma was confirmed by histopathology and the clinical stage was T3-4aN+M0; (3) tumor could be resectable; (4) preoperative neoadjuvant chemotherapy was CapeOX or SOX regimen without radiotherapy or other regimen chemotherapy; (5) no other concurrent malignant tumor; (6) the Eastern Cooperative Oncology Group (ECOG) score ≤ 1; (7) no bone marrow suppression; (8) normal liver and kidney function. Exclusion criteria were as follows: (1) patients with recurrent gastric cancer; (2) patients receiving emergency surgery due to tumor perforation, bleeding, obstruction, etc.; (3) allergy to oxaliplatin, S-1, capecitabine or any drug excipients; (4) diagnosed with coronary heart disease, cardiomyopathy, or the New York Heart Association class III or IV; (5) pregnant or lactating women. A total of 118 patients were enrolled as the neoadjuvant chemotherapy group, and 379 patients with locally advanced gastric cancer who received surgery combined with postoperative adjuvant chemotherapy over the same period simultaneously were included as the adjuvant chemotherapy group. After propensity score matching was performed including gender, age, ECOG score, tumor site, clinical stage, chemotherapy regimen and other factors by 1:1 ratio, there were 40 cases in each group. The differences between the two groups in general conditions, efficacy of neoadjuvant chemotherapy, intraoperative conditions, postoperative conditions, histopathological results, chemotherapy-related adverse events, and survival status were compared and analyzed. Results: Comparison of baseline demographics between the two groups showed no statistically significant difference (all P>0.05). In the neoadjuvant chemotherapy group, 5.0% (2/40) of patients achieved clinical complete response, 57.5% (23/40) achieved partial response, 32.5% (13/40) remained stable disease, and 5.0% (2/40) had disease progression before surgery. Objective response rate was 62.5% (25/40), and disease control rate was 95.0% (38/40). There were no statistically significant differences between neoadjuvant chemotherapy group and adjuvant chemotherapy group in terms of operation time, intraoperative blood loss, number of lymph node harvested, length of postoperative hospital stay, and postoperative mortality and morbidity (all P>0.05). Postoperative complications were well managed with conservative treatment. No Clavien-Dindo IV or V complications were observed in both groups. Pathological results showed that the proportion of patients with pathological stage T1 in the neoadjuvant chemotherapy group was significantly higher than that in the adjuvant chemotherapy group [27.5% (11/40) vs. 5.0% (2/40)], while the proportion of patients with pathological stage T3 was significantly lower than that in the adjuvant chemotherapy group [20.0% (8/40) vs. 45.0% (18/40)], with statistically significant difference (χ(2)=15.432, P=0.001). In the neoadjuvant chemotherapy group, there were 4 cases of tumor regression grade 0, 8 cases of grade 1, 16 cases of grade 2, and 12 cases of grade 3. The pathological complete response rate was 10% (4/40), the overall pathological response rate was 70.0% (28/40). There was no statistically significant difference in the incidence of chemotherapy-related adverse events between neoadjuvant chemotherapy group and adjuvant chemotherapy group [40% (16/40) vs. 37.5% (15/40), P>0.05). There were no statistically significant differences in OS (43 months vs. 40 months) and 3-year OS rate (66.1% vs. 59.8%) between neoadjuvant chemotherapy group and adjuvant chemotherapy group (P=0.428). The disease-free survival (DFS) and 3-year DFS rates of the neoadjuvant chemotherapy group were significantly superior to those of the adjuvant chemotherapy group (36 months vs. 28 months, 51.4% vs. 35.8%, P=0.048). Conclusion: CapeOX or SOX regimen neoadjuvant chemotherapy is a safe, effective and feasible treatment mode for advanced gastric cancer without increasing surgical risk and can improve the DFS of patients.

Clinical efficacy of gastrojejunal bypass surgery combined with radical gastrectomy following conversion therapy for gastric cancer with outlet obstruction / 中华消化外科杂志

Objective:To investigate the clinical efficacy of gastrojejunal bypass surgery combined with radical gastrectomy following conversion therapy for gastric cancer with outlet obstruction.Methods:The retrospective and descriptive study was conducted. The clinicopatho-logical data of 10 initially unresectable gastric cancer patients with outlet obstruction who were admitted to Ruijin Hospital of Shanghai Jiao Tong University School of Medicine from October 2019 to July 2020 were collected. There were 8 males and 2 females, aged from 41 to 59 years, with a median age of 53 years. Patients underwent 'sandwich therapy' of gastrojejunal bypass surgery combined with gastrectomy following conversion therapy. Observation indicators: (1) gastrojejunal bypass surgery and postoperative situations; (2) conversion therapy and complications; (3) radical gastrectomy and postoperative situations; (4) follow-up. Follow-up using outpatient examinations or telephone interview was conducted to detect postoperative complications, progress-free survival, tumor recurrence and metastasis up to March 2019. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:(1) Gastrojejunal bypass surgery and postoperative situations: 10 patients received modified gastrojejunal bypass surgery combined with No.4sb lymph node dissection, without intraoperative serious complications, conversion to laparotomy or death. The operation time, volume of intraoperative blood loss, time to postoperative first flatus, time to liquid diet intake were 73 minutes(range, 60-87 minutes), 33 mL(range,20-110 mL), 3 days(range, 2-6 days), 4 days(range, 4-9 days). One patient had post-operative Clavien-Dindo grade Ⅱ complication of anastomotic bleeding, and was improved after transfusion of blood products. (2) Conversion therapy and complications: of 10 patients, 9 cases received 4 cycles of FLOT regimen. One of the 9 cases was suspended chemotherapy due to Clavien-Dindo grade Ⅱ anastomotic edema after 2 cycles of FLOT regimen. Of 10 patients, there were 6 cases with partial response and 4 cases with stable disease. Of 6 patients with partial response, 4 cases with preoperative cT4b stage were down stage to T4a stage, showing the relationship of tumor with transverse mesentery and pancreatic capsule clearer than the first exploration, 2 cases with preoperative lymph nodes fusion had shrank obviously. Of 4 patients with stable disease, 3 cases were negative for lymph nodes shranking, and the rest 1 case with tumor peritoneal metastasis diagnosed by initial laparoscopy can not be evaluated by imaging examination after chemotherapy. Two of 10 patients had Clavien-Dindo grade I complication of elevated blood glucose during the chemotherapy, which were improved after insulin therapy. (3) Radical gastrectomy and post-operative situations: 10 patients underwent radical resection after conversion therapy. Of 4 cases with stable disease, 3 cases with preoperative lymph nodes fusion showed obvious space between lymph nodes and surrounding tissues at resurgical exploration and received radical resection, 1 case with peritoneal metastasis showed abdominal wall nodelus and omental tuberosity as fibrous scars at resurgical exploration and received radical resection. The operation time, volume of intra-operative blood loss, time to postoperative first flatus, time to initial liquid diet intake, duration of total hospital stay, duration of postoperative hospital stay of 10 patients were 148 minutes(range, 95-195 minutes), 108 mL(range, 100-180 mL), 3 days(range, 2-7 days), 4 days(range, 3-9 days), 11 days(range, 10-21 days), 8 days(range, 7-16 days). Two of 10 patients had perioperative complications. Results of pathological examination of 10 patients showed the number of dissected lymph nodes as 25±6. There were 1 case of stage T1, 5 cases of stage T3, 4 cases of stage T4a. There were 1 case of stage N0, 2 cases of stage N1, 3 cases of stage N2, 4 cases of stage N3. There were 3 cases of tumor regression grade 1a, 1 case of grade 1b, 4 cases of grade 2, 2 cases of grade 3. (4) Follow-up: 10 patients were followed up for 3.9-13.0 months, with a median follow-up time of 6.0 months. The median progression-free survival time of 10 patients was 6.0 months. During the follow-up, 1 case underwent postoperative Clavien-Dindo grade Ⅱ complication of delayed gastric emptying and was improved after symptomatic treatment.Conclusion:The gastrojejunal bypass surgery combined with gastrectomy following conversion therapy for gastric cancer with outlet obstruction is safe and effective.

Application of minimally invasive intelligent diagnosis and treatment technology in gastric cancer / 中华消化外科杂志

Gastric cancer is one of the most common malignant tumors in China, with a high incidence and poor prognosis. It is still the focus of current work to improve the diagnosis rate and investigate the new treatment for gastric cancer. In recent years, intelligent medicine represented by artificial intelligence has been gradually applied in gastric cancer diagnosis and treatment, especially in gastroscopy examination, imaging examination, pathological diagnosis and so on. In terms of minimally invasive surgery for gastric cancer, the emergence of new technologies such as 4K and 3D have further improved the accuracy of surgery. At the same time, laparoscopic fluorescence imaging technology represented by indocyanine green imaging is gradually becoming a new direction for the development of minimally invasive surgery. Combined with the literature at home and abroad, the authors expound the application of minimally invasive intelligent technology in the process of diagnosis and treatment of gastric cancer to fully understand the opportunities and challenges faced by gastric cancer intelligent diagnosis and treatment, break the boundaries of disciplines, and carry out a wide range of 'medical-engineering integration′ research. This will finally benefit patients with gastric cancer.

A primary investigation on application value of glasses-free three-dimensional laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors / 中华消化外科杂志

Objective:To primarily investigate the application value of glasses-free three-dimensional (3D) laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors.Methods:The retrospective cohort study was conducted. The clinical data of 165 patients with gastrointestinal malignant tumors who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between October 2018 and May 2019 were collected. There were 99 males and 66 females, aged from 28 to 86 years, with a median age of 63 years. There were 68 of 165 patients with gastric cancer and 97 with colorectal cancer. Sixteen patients with gastric cancer who underwent laparoscopic radical gastrectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D gastric cancer group, and 52 patients with gastric cancer who underwent laparoscopic radical gastrectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D gastric cancer group. Nineteen patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the glasses-free 3D laparoscopy system were divided into glasses-free 3D colorectal cancer group, and 78 patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D colorectal cancer group. Observation indicators: (1) operative situations of patients with gastric cancer; (2) postoperative recovery of patients with gastric cancer; (3) postoperative pathological examination results of patients with gastric cancer; (4) operative situations of patients with colorectal cancer; (5) postoperative recovery of patients with colorectal cancer; (6) postoperative pathological examination results of patients with colorectal cancer; (7) follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect complications and survival of patients up to the postoperative 30th day. Measurement data with skewed distribution were represented as M ( P25, P75) or M (range), and comparison between groups was analyzed by the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Operative situations of patients with gastric cancer: all the 68 gastric cancer patients received successfully laparoscopic radical gastrectomy, without intraoperative complication or conversion to laparotomy. Cases with distal gastrectomy or total gastrectomy(surgical methods) , operation time, volume of intraoperative blood loss were 11, 5, 195 minutes(169 minutes, 214 minutes), 20 mL (10 mL, 90 mL) in patients of the glasses-free 3D gastric cancer group, and 31, 21, 196 minutes(173 minutes, 222 minutes), 40 mL(20 mL, 100 mL) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( χ2=0.432, Z=-0.362, -1.065, P>0.05). (2) Postoperative recovery of patients with gastric cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(2 days, 3 days), 6 days(5 days, 7 days), 10 days(9 days, 14 days) in patients of the glasses-free 3D gastric cancer group, and 2 days(2 days, 3 days), 6 days(5 days, 6 days), 11 days(9 days, 14 days) in patients of the polarized glasses 3D gastric cancer group, with no significant difference between the two groups ( Z=-0.163, -1.870, -0.570, P>0.05). The postoperative complication incidence of the glasses-free 3D gastric cancer group was 12.5%(2/16), including 1 case with duodenal stump fistula, 1 case with anastomotic bleeding. The postoperative complication incidence of the polarized glasses 3D gastric cancer group was 17.3%(9/52), including 2 cases with duodenal stump fistula, 2 cases with delayed gastric emptying, 1 case with pulmonary infection, 1 case with abdominal bleeding, 1 case with anastomotic leakage, 1 case with chylous fistula, 1 case with intestinal obstruction. All the patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.209, P>0.05). (3) Postoperative pathological examination results of patients with gastric cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1, N2, N3 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 3.0 cm(2.0 cm, 5.0 cm), 5, 3, 1, 7, 8, 5, 2, 3, 2, 4, 7, 6(1, 15), 28(22, 43), 15, 4, 3, 9, 0 in patients of the glasses-free 3D gastric cancer group, and 3.5 cm(2.0 cm, 6.0 cm), 13, 10, 4, 25, 19, 23, 2, 26, 6, 7, 13, 1(0, 7), 29(21, 39), 43, 21, 10, 20, 1 in patients of the polarized glasses 3D gastric cancer group. There was no significant difference in the tumor diameter, tumor T staging, cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, the number of lymph node dissected, cases with qualified lymph node dissected, TNM clinical staging between the two groups ( Z=-0.570, -0.434, χ2 =0.926, 0.851, 1.655, Z=-0.579, χ2=1.193, Z=-1.134, P>0.05). There were significant differences in the tumor N staging and the number of positive lymph node between the two groups ( Z=-2.167, -2.283, P<0.05). (4) Operative situations of patients with colorectal cancer: all the 97 colorectal cancer patients received successfully laparoscopic radical colectomy or proctectomy, without intraoperative complications or conversion to laparotomy. Cases with radical colectomy or proctectomy (surgical methods), operation time, volume of intraoperative blood loss were 7, 12, 132 minutes(97 minutes, 156 minutes), 20 mL(10 mL, 50 mL) in patients of the glasses-free 3D colorectal cancer group, and 40, 38, 124 minutes(110 minutes, 159 minutes), 25 mL(15 mL, 65 mL) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( χ2 =1.276, Z=-0.141, -0.863, P>0.05). (5) Postoperative recovery of patients with colorectal cancer: the time to first flatus, time to initial semi-fluid diet intake, duration of postoperative hospital stay were 2 days(1 days, 3 days), 5 days(5 days, 6 days), 8 days(7 days, 10 days) in patients of the glasses-free 3D colorectal cancer group, and 2 days(1 days, 3 days), 5 days(4 days, 6 days), 8 days(6 days, 10 days) in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.678, -1.751, -1.674, P>0.05). The complication incidence of the glasses-free 3D colorectal cancer group was 15.8%(3/19), including 1 case with anastomotic leakage after low anterior proctectomy, 1 case with incision infection, 1 case with urinary tract infection. The complication incidence of the polarized glasses 3D colorectal cancer group was 14.1%(11/78), including 3 cases with anastomotic leakage after low anterior proctectomy, 2 cases with intestinal obstruction, 2 cases with urinary tract infection, 2 cases with incision infection, 1 case with anastomotic bleeding, 1 case with pulmonary infection. One of the 3 cases with anastomotic leakage after low anterior proctectomy in the polarized glasses 3D colorectal cancer group was cured after remedial terminal ileostomy. The other patients with complications were cured after symptomatic supportive treatment. There was no significant difference in the complication incidence between the two groups ( χ2=0.035, P>0.05). (6) Postoperative pathological examination results of patients with colorectal cancer: the tumor diameter, cases in stage T1, T2, T3, T4 (tumor T staging), cases with vascular invasion, cases with nerve invasion, cases with tumor nodule, cases in stage N0, N1-N2 (tumor N staging), the number of positive lymph node, the number of lymph node dissected, cases with qualified lymph node dissected, cases in stage Ⅰ, Ⅱ, Ⅲ, Ⅳ (TNM clinical staging) were 5.0 cm(3.0 cm, 6.0 cm), 3, 2, 7, 7, 3, 2, 1, 8, 11, 0(0, 4), 17(14, 23), 18, 2, 3, 12, 2 in patients of the glasses-free 3D colorectal cancer group, and 4.0 cm(3.0 cm, 5.0 cm), 7, 16, 43, 12, 14, 12, 7, 46, 32, 0(0, 1), 16(13, 19), 74, 14, 17, 40, 7 in patients of the polarized glasses 3D colorectal cancer group, with no significant difference between the two groups ( Z=-0.768, -1.135, χ2 =0.049, 0.292, 0.278, 1.762, Z=-0.694, -1.349, χ2=0.001, Z=-1.011, P>0.05). (7) Follow-up: 165 patients received follow-up, with out short-term reoperation or postoperative death in the postoperative 30 days. Conclusion:There is no significant difference in the efficacy between glasses-free 3D laparoscopic surgery and polarized glasses 3D laparoscopic surgery for radical resection of gastrointestinal malignant tumors, of which the clinical value requires further study.

Application value of 3D laparoscope in transanal total mesorectal excision / 中华消化外科杂志

Objective:To investigate the application value of three-dimensional (3D) laparoscope in the transanal total mesorectal excision (TaTME).Methods:The retrospective cohort study was conducted. The clinicopathological data of 20 patients with middle and low rectal cancer who underwent TaTME in the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2018 to October 2019 were collected. There were 15 males and 5 females, aged from 28 to 81 years, with a median age of 64 years. Of the 20 patients, 10 patients using 3D laparoscopic system for transanal approach of TaTME were divided into 3D group, and 10 patients using two-dimensional (2D) laparoscopic system for transanal approach of TaTME were divided into 2D group. Observation indicators: (1) intraoperative situations and postoperative recovery; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted by outpatient examination and telephone interview to detect survival of patients and recurrence and metastasis of tumors in patients up to April 2020. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the Fisher exact propability. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Results:(1) Intraoperative situations and postoperative recovery: patients in the two groups completed surgeries successfully, without tranversion to laparostomy from laparoscopic surgery, transversion to transabdominal surgery from transanal surgery, or intraoperative death. The cases with terminal ileostomy, cases with manual anstomosis or mechanical anastomosis (anastomotic methods), operation time, volume of intra-operative blood loss, duration of postoperative hospital stay, cases with anastomotic leakage or anastomotic hemorrahge (postoperative short-term complications), cases with anastomotic stenosis of the 3D group were 7, 4, 6, 150 minutes (range, 100-220 minutes), 50 mL (range, 30-100 mL), 8.5 days (range, 7.0-16.0 days), 2, 0, 1, respectively, versus 8, 5, 5, 180 minutes (range, 120-250 minutes), 100 mL (range, 30-200 mL), 9.5 days (range, 6.0-17.0 days), 1, 1, 1 of the 2D group. There was no significant difference in the terminal ileostomy, anastomotic methods, postoperative short-term complications, or anastomotic stenosis between the two groups ( P>0.05). There was no significant difference in the operation time, volume of intraoperative blood loss, or duration of postoperative hospital stay between the two groups ( Z=1.909, 1.827, 0.687, P>0.05). Patients with short-term complications in the two groups were improved after conservative treatments. There was 1 patient with anastomotic stenosis in either group, and they were improved after endoscopic balloon dilatation. (2) Postoperative pathological examination: the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, cases with cancer nodes in the mesentery, cases with complete mesentery or median complete mesentery (the integrity of mesentery), cases in stage Ⅰ, Ⅱ, Ⅲ (postoperative pathological stage) of the 3D group were 3.8 cm (range, 1.8-5.0 cm), 1.0 cm (range, 0.5-2.5 cm), 14.5 (range, 6.0-19.0), 1, 9, 1, 4, 2, 4, respectively, versus 4.8 cm (range, 1.0-8.5 cm), 0.8 cm (range, 0.3-1.5 cm), 15.5 (range, 8.0-18.0), 1, 8, 2, 2, 4, 4 of the 2D group. There was no significant difference in the maximum tumor diameter, distal margin of the tumor, the number of lymph nodes harvested, the integrity of mesentery, or postoperative pathological stage between the two groups ( Z=1.673, 1.772, 0.038, 0.610, 0.482, P>0.05). There was no significant difference in the cases with cancer nodes in the mesentery between the two groups ( P>0.05). Patients in the two groups had negative distal margin and circumferential margin. (3) Follow-up: patients in the 3D group and 2D group were followed up for 11 months (range, 6-16 months) and 13 months (range, 6-21 months), respectively. During the follow-up, there was no local recurrence, distal metastasis, or tumor-related death. Conclusions:3D laparoscope applied in the TaTME can achieve similar clinical efficacy with 2D laparoscope, which may have a positive impact on the operation time and volume of intraoperative blood loss.

A multicenter prospective study on incidence and risk factors of postoperative pancreatic fistula after radical gastrectomy: a report of 2 089 cases / 中华消化外科杂志

Objective To investigate the incidence of postoperative pancreatic fistula (POPF) and its risk factors after radical gastrectomy.Methods The prospective study was conducted.The clinicopathological data of 2 089 patients who underwent radical gastrectomy in 22 medical centers between December 2017 and November 2018 were collected,including 380 in the Zhongshan Hospital of Fudan University,351 in the Renji Hospital of Shanghai Jiaotong University School of Medicine,130 in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine,139 in the Peking University Cancer Hospital,128 in the Fujian Provincial Cancer Hospital,114 in the First Hospital Affiliated to Army Medical University,104 in the First Affiliated Hospital of Nanchang University,104 in the Affiliated Hospital of Qinghai University,103 in the Weifang People's Hospital,102 in the Fujian Medical University Union Hospital,99 in the First Affiliated Hospital of Air Force Medical University,97 in the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine,60 in the Hangzhou First People's Hospital Affiliated to Zhejiang University School of Medicine,48 in the Fudan University Shanghai Cancer Center,29 in the First Affiliated Hospital of Xi'an Jiaotong University,26 in the Lishui Municipal Central Hospital,26 in the Guangdong Provincial People's Hospital,23 in the Jiangsu Province Hospital,13 in the First Affiliated Hospital of Sun Yat-Sen University,7 in the Second Hospital of Jilin University,4 in the First Affiliated Hospital of Xinjiang Medical University,2 in the Beijing Chao-Yang Hospital of Capital Medical University.Observation indicators:(1) the incidence of POPF after radical gastrectomy;(2) treatment of grade B POPF after radical gastrectomy;(3) analysis of clinicopathological data;(4) analysis of surgical data;(5) risk factors for grade B POPF after radical gastrectomy.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using ANOVA.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test.Univariate analysis was conducted using the t test or chi-square test based on data excluding missing data of clinicopathological and surgical data.Multivariate analysis was conducted using the Logistic regression model based on factors with P＜0.20 in univariate analysis.Results There were 2 089 patients screened for eligibility,including 1 512 males,576 females and 1 without sex information,aged (62± 11)years.The body mass index (BMI) was (23±3) kg/m2.(1) The incidence of POPF after radical gastrectomy:the total incidence rate of POPF in the 2 089 patients was 20.728％(433/2 089).The incidence rates of biochemical fistula,grade B pancreatic fistula,and grade C pancreatic fistula were 19.627％(410/2 089),1.101％(23/2 089),0,respectively.(2) Treatment of grade B POPF after radical gastrectomy:2 of 23 patients with grade B POPF after radical gastrectomy had drainage tube placed for more than 21 days and received anti-infective therapy.Four of 23 patients with grade B POPF after radical gastrectomy had ascites detected by imaging examination,of which 2 received peritoneal drainage guided by ultrasound,1 received failed puncture drainage,1 received no puncture drainage,and they were given anti-infective therapy.Eleven of 23 patients with grade B POPF after radical gastrectomy had no ascites detected by imaging examinations,and they were given anti-infective therapy and inhibitors of pancreas secretion for clinical manifestation as fever or elevated white blood cells.Six patients with no typical clinical manifestations were given somatostatin to inhibite pancreas secretion and prolonged duration of abdominal drainage tube placement (with a median time of 7 days).All the 23 patients recovered well after treatment,without reoperation.(3) Analysis of clinicopathological data:for the 2 089 patients,BMI,cases with or without neoadjuvant therapy were (23±3) kg/m2,1 487,160 of patients without pancreatic fistula,(23±3)kg/m2,386,22 of patients with biochemical fistula,and (24±3)kg/m2,22,1 of patents with grade B pancreatic fistula,showing significant differences between the three groups (F=5.787,x2 =8.269,P＜0.05).(4) Analysis of surgical data:for the 2 089 patients,cases with open surgery,laparoscopic assisted surgery,totally laparoscopic surgery (surgical method),cases with D1 lymph lode dissection,D2 lymph lode dissection,and other lymph lode dissection (range of lymph lode dissection),cases with no omentectomy,partial omentectomy,and total omentectomy (range of omentectomy),cases with no usage of energy facility,usage of CUSA,LigaSure,LigaSure+CUSA as energy facility,cases with or without biological glue,the number of lymph node dissection were 737,624,292,24,1 580,51,418,834,381,63,1 530,23,16,1 431,201,33±14 of patients without pancreatic fistula,146,189,74,11,389,9,110,171,128,35,359,6,9,378,31,31± 14 of patients with biochemical fistula,and 14,5,4,0,20,3,6,13,4,2,18,1,2,22,1,37±16 of patients with grade B pancreatic fistula,showing significant differences between the three groups (x2=15.578,9.397,15.023,28.245,8.359,F=4.945,P＜ 0.05).(5) Risk factors for grade B POPF after radical gastrectomy:results of univariate analysis showed that usage of energy facility was a related factor for grade B POPF after radical gastrectomy (x2=9.914,P＜0.05).Results of multivariate analysis showed that laparoscopic assisted surgery,combined evisceration,application of LigaSure + CUSA,the number of lymph lode dissection were independent factors for for grade B POPF after radical gastrectomy (odds ratio=0.168,3.922,9.250,1.030,95％ confidence interval:0.036-0.789,1.031-14.919,1.036-82.602,1.001-1.059,P＜0.05).Conclusions The incidence of grade B POPF after radical gastrectomy is relatively low.Laparoscopic assisted surgery,combined evisceration,application of LigaSure + CUSA,and the number of lymph lode dissection are independent risk factors for grade B POPF.Trial Registration:This study was registrated at ClinicalTrial.gov in United States with the registration number of NCT03391687.

A multicenter prospective study on incidence and risk factors of postoperative pancreatic fistula after radical gastrectomy: a report of 2 089 cases / 中华消化外科杂志

Objective@#To investigate the incidence of postoperative pancreatic fistula (POPF) and its risk factors after radical gastrectomy.@*Methods@#The prospective study was conducted. The clinicopathological data of 2 089 patients who underwent radical gastrectomy in 22 medical centers between December 2017 and November 2018 were collected, including 380 in the Zhongshan Hospital of Fudan University, 351 in the Renji Hospital of Shanghai Jiaotong University School of Medicine, 130 in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine, 139 in the Peking University Cancer Hospital, 128 in the Fujian Provincial Cancer Hospital, 114 in the First Hospital Affiliated to Army Medical University, 104 in the First Affiliated Hospital of Nanchang University, 104 in the Affiliated Hospital of Qinghai University, 103 in the Weifang People′s Hospital, 102 in the Fujian Medical University Union Hospital, 99 in the First Affiliated Hospital of Air Force Medical University, 97 in the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, 60 in the Hangzhou First People′s Hospital Affiliated to Zhejiang University School of Medicine, 48 in the Fudan University Shanghai Cancer Center, 29 in the First Affiliated Hospital of Xi′an Jiaotong University, 26 in the Lishui Municipal Central Hospital, 26 in the Guangdong Provincial People′s Hospital, 23 in the Jiangsu Province Hospital, 13 in the First Affiliated Hospital of Sun Yat-Sen University, 7 in the Second Hospital of Jilin University, 4 in the First Affiliated Hospital of Xinjiang Medical University, 2 in the Beijing Chao-Yang Hospital of Capital Medical University. Observation indicators: (1) the incidence of POPF after radical gastrectomy; (2) treatment of grade B POPF after radical gastrectomy; (3) analysis of clinicopathological data; (4) analysis of surgical data; (5) risk factors for grade B POPF after radical gastrectomy. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using ANOVA. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the t test or chi-square test based on data excluding missing data of clinico-pathological and surgical data. Multivariate analysis was conducted using the Logistic regression model based on factors with P<0.20 in univariate analysis.@*Results@#There were 2 089 patients screened for eligibility, including 1 512 males, 576 females and 1 without sex information, aged (62±11)years. The body mass index (BMI) was (23±3)kg/m2. (1) The incidence of POPF after radical gastrectomy: the total incidence rate of POPF in the 2 089 patients was 20.728%(433/2 089). The incidence rates of biochemical fistula, grade B pancreatic fistula, and grade C pancreatic fistula were 19.627%(410/2 089), 1.101%(23/2 089), 0, respectively. (2) Treatment of grade B POPF after radical gastrectomy: 2 of 23 patients with grade B POPF after radical gastrectomy had drainage tube placed for more than 21 days and received anti-infective therapy. Four of 23 patients with grade B POPF after radical gastrectomy had ascites detected by imaging examination, of which 2 received peritoneal drainage guided by ultrasound, 1 received failed puncture drainage, 1 received no puncture drainage, and they were given anti-infective therapy. Eleven of 23 patients with grade B POPF after radical gastrectomy had no ascites detected by imaging examinations, and they were given anti-infective therapy and inhibitors of pancreas secretion for clinical manifestation as fever or elevated white blood cells. Six patients with no typical clinical manifestations were given somatostatin to inhibite pancreas secretion and prolonged duration of abdominal drainage tube placement (with a median time of 7 days). All the 23 patients recovered well after treatment, without reoperation. (3) Analysis of clinicopathological data: for the 2 089 patients, BMI, cases with or without neoadjuvant therapy were (23±3)kg/m2, 1 487, 160 of patients without pancreatic fistula, (23±3)kg/m2, 386, 22 of patients with biochemical fistula, and (24±3)kg/m2, 22, 1 of patents with grade B pancreatic fistula, showing significant differences between the three groups (F=5.787, χ2=8.269, P<0.05). (4) Analysis of surgical data: for the 2 089 patients, cases with open surgery, laparoscopic assisted surgery, totally laparoscopic surgery (surgical method), cases with D1 lymph lode dissection, D2 lymph lode dissection, and other lymph lode dissection (range of lymph lode dissection), cases with no omentectomy, partial omentectomy, and total omentectomy (range of omentectomy), cases with no usage of energy facility, usage of CUSA, LigaSure, LigaSure+ CUSA as energy facility, cases with or without biological glue, the number of lymph node dissection were 737, 624, 292, 24, 1 580, 51, 418, 834, 381, 63, 1 530, 23, 16, 1 431, 201, 33±14 of patients without pancreatic fistula, 146, 189, 74, 11, 389, 9, 110, 171, 128, 35, 359, 6, 9, 378, 31, 31±14 of patients with biochemical fistula, and 14, 5, 4, 0, 20, 3, 6, 13, 4, 2, 18, 1, 2, 22, 1, 37±16 of patients with grade B pancreatic fistula, showing significant differences between the three groups (χ2=15.578, 9.397, 15.023, 28.245, 8.359, F=4.945, P<0.05). (5) Risk factors for grade B POPF after radical gastrectomy: results of univariate analysis showed that usage of energy facility was a related factor for grade B POPF after radical gastrectomy (χ2=9.914, P<0.05). Results of multivariate analysis showed that laparoscopic assisted surgery, combined evisceration, application of LigaSure + CUSA, the number of lymph lode dissection were independent factors for for grade B POPF after radical gastrectomy (odds ratio=0.168, 3.922, 9.250, 1.030, 95% confidence interval: 0.036-0.789, 1.031-14.919, 1.036-82.602, 1.001-1.059, P<0.05).@*Conclusions@#The incidence of grade B POPF after radical gastrectomy is relatively low. Laparoscopic assisted surgery, combined evisceration, application of LigaSure + CUSA, and the number of lymph lode dissection are independent risk factors for grade B POPF. Trial Registration: This study was registrated at ClinicalTrial.gov in United States with the registration number of NCT03391687.

Metastasis and dissection of infrapyloric lymph node in the colon cancer of hepatic flexure / 中华胃肠外科杂志

Colon cancer is one of the most common malignancies of the alimentary tract, and one main metastatic route is lymph node metastasis. Thorough dissections of regional lymph nodes is one of the core surgical treatment of right colon cancer. D3 lymphadenectomy and complete mesocolic excision (CME) are generally accepted surgical methods for right colon cancer, which can improve the standardization of surgery, improve the quality of tumor resection, and provide more lymph nodes dissectal. Colon cancer of hepatic flexure is likely to have metastasis of the infrapyloric lymph nodes (No.206), which are not regional lymph nodes. Lymph node dissection of No.206 group belongs to extended right hemicolectomy, which involves many vascular variations and complicated peripheral anatomical structure. The theory of fascial surgery provides surgeons with anatomic basis and a clear understanding of the anatomical structure of the infrapyloric region, which is an important theoretical basis for the thorough dissection of lymph nodes in No.206 group, and can completely remove the mass, regional lymph nodes and adipose connective tissue, so as to achieve the goal of non-bleeding surgery. Lymph nodes in No.206 group were dissected, not just the visible lymph nodes, but the entire lymph nodes and lymphatic vessels in the region, including adipose tissue. Extended right hemicolectomy requires higher surgical techniques. The survival benefits of extended right hemicolectomy are not supported by high-level evidence. It is still controversial whether the infrapyloric lymph node dissection should become routine for colon cancer of hepatic flexure. In this article, the metastasis and dissection of infrapyloric lymph node in colon cancer of hepatic flexure is elucidated.

Laparoscopic peritoneal dialysis catheter implantation in peritoneal chemotherapy for gastric cancer with peritoneal metastasis / 中华胃肠外科杂志

Objective@#To investigate the clinical value of laparoscopic peritoneal dialysis catheter implantation in peritoneal chemotherapy for gastric cancer with peritoneal metastasis.@*Methods@#From January 2019 to June 2019, the clinical data of 6 patients diagnosed as gastric cancer with peritoneal metastasis were retrospectively analyzed in the Gastrointestinal Surgery Department of Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine. Five were male and 1 was female. The median age was 69.5 (28-77) years. The median body mass index (BMI) was 22.8 (19.6-23.5). All procedures were performed under general anesthesia with endotracheal intubation. The patient′s body position and facility layout in the operating room were consistent with those of laparoscopic gastrectomy. The operator′s position: the main surgeon was located on the right side of the patient, the first assistant stood on the left side of the patient, and the scopist stood between the patient′s legs. Surgical procedure: (1) trocar location: three abdominal trocars was adopted, with one 12 mm umbilical port for the 30° laparoscope (point A). Location of the other two trocars was dependent on the procedure of exploration or biopsy as well as the two polyester cuff position of the peritoneal dialysis catheter: Usually one 5 mm port in the anterior midline 5 cm inferior to the umbilicus point was selected as point B to ensure that the distal end of the catheter could reach the Douglas pouch. The other 5 mm port was located in the right lower quadrant lateral to the umbilicus to establish the subcutaneous tunnel tract, and the proximal cuff was situated 2 cm away from the desired exit site (point C).(2) exploration of the abdominal cavity: a 30° laparoscope was inserted from 12 mm trocar below the umbilicus to explore the entire peritoneal cavity. The uterus and adnexa should be explored additionally for women. Once peritoneal metastasis was investigated and identified, primary laparoscopic peritoneal dialysis catheter implantation was performed so as to facilitate subsequent peritoneal chemotherapy. Ascites were collected for cytology in patients with ascites. (3) peritoneal dialysis catheter placement: the peritoneal dialysis catheter was introduced into the abdominal cavity from point A. Under the direct vision of laparoscopy, 2-0 absorbable ligature was reserved at the expected fixation point of the proximal cuff (point B) for the final knot closure. Non-traumatic graspers were used to pull the distal cuff of peritoneal dialysis catheter out of the abdominal cavity through point B. The 5-mm trocar was removed simultaneously, and the distal cuff was fixed between bilateral rectus sheaths at the anterior midline port site preperitoneally. To prevent subsequent ascites and chemotherapy fluid extravasation, the reserved crocheted wire was knotted. From point C the subcutaneous tunnel tract was created before the peritoneal steath towards the port site lateral to the umbilicus. Satisfactory catheter irrigation and outflow were then confirmed. Chemotherapy regimen after peritoneal dialysis catheterization: all patients began intraperitoneal chemotherapy on the second day after surgery. On the 1st and 8th day of each 3-weeks cycle, paclitaxel (20 mg/m2) was administered through peritoneal dialysis catheter, and paclitaxel (50 mg/m2) was injected intravenously. Meanwhile, S-1 was orally administered twice daily at a dose of 80 mg·m-2·d-1 for 14 consecutive days followed by 7-days rest. To observe the patients′ intraoperative and postoperative conditions.@*Results@#All the procedures were performed successfully without intraoperative complications or conversion to laparotomy. No 30 day postoperative complications were observed. The median operative time was 33.5 (23-38) min. The median time to first flatus was 1(1-2) days, and the median postoperative hospital stay was 3 (3-4) days, without short-term complications within 30 days postoperatively. The last follow-up was up to July 10, 2019, and the patients were followed for 4(1-6) months. No ascites extravasation was observed and no death occurred in the 6 patients. There was no catheter obstruction or peritoneal fluid extravasation during and after chemotherapy.@*Conclusion@#Laparoscopic peritoneal dialysis catheter implantation was safe and feasible for patients with peritoneal metastasis of gastric cancer. The abdominal exploration, tumor staging and the abdominal chemotherapy device implantation can be completed simultaneously, which could simplify the surgical approach, improve the quality of life for patients and further propose a new direction for the development of abdominal chemotherapy.

Metastasis and dissection of infrapyloric lymph node in the colon cancer of hepatic flexure / 中华胃肠外科杂志

Colon cancer is one of the most common malignancies of the alimentary tract, and one main metastatic route is lymph node metastasis. Thorough dissections of regional lymph nodes is one of the core surgical treatment of right colon cancer. D3 lymphadenectomy and complete mesocolic excision (CME) are generally accepted surgical methods for right colon cancer, which can improve the standardization of surgery, improve the quality of tumor resection, and provide more lymph nodes dissectal. Colon cancer of hepatic flexure is likely to have metastasis of the infrapyloric lymph nodes (No.206), which are not regional lymph nodes. Lymph node dissection of No.206 group belongs to extended right hemicolectomy, which involves many vascular variations and complicated peripheral anatomical structure. The theory of fascial surgery provides surgeons with anatomic basis and a clear understanding of the anatomical structure of the infrapyloric region, which is an important theoretical basis for the thorough dissection of lymph nodes in No.206 group, and can completely remove the mass, regional lymph nodes and adipose connective tissue, so as to achieve the goal of non-bleeding surgery. Lymph nodes in No.206 group were dissected, not just the visible lymph nodes, but the entire lymph nodes and lymphatic vessels in the region, including adipose tissue. Extended right hemicolectomy requires higher surgical techniques. The survival benefits of extended right hemicolectomy are not supported by high-level evidence. It is still controversial whether the infrapyloric lymph node dissection should become routine for colon cancer of hepatic flexure. In this article, the metastasis and dissection of infrapyloric lymph node in colon cancer of hepatic flexure is elucidated.

Application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy / 中华消化外科杂志

Objective To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected.The main points of the modified Overlap method:surgeons stood on the right of patients when digestive tract reconstruction,suspension of left half liver and clockwise rotation before esophageal transection were performed,regulating esophageal opening position and building jejunal loop,and then closing openings using 45.0 mm Endo-GIA and barbed wire.Patients who were diagnosed as Ⅰ A stage by postoperative pathological examination were followed up;patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in Ⅰ B and Ⅱ stages without lymph node metastases underwent oral S-1 single agent.Observation indicators:(1) surgical and postoperative recovery situations;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy,long-term complications and survival up to March 2018.Measurement data with normal distribution were represented as x±s,and measurement data with skewed distribution were described as M(range).Results (1) Surgical and postoperative recovery situations:all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy.The operation time,esophagojejunostomy time,volume of intraoperative blood loss,time to initial anal exsufflation,time for initial fluid diet intake,time for initial semifluid diet intake and time of postoperative drainage-tube removal were respectively (227 ± 19) minutes,(22 ±7)minutes,(69±11)mL,(2.1±0.5) days,(3.4±0.4) days,(4.9±0.6) days and (7.5±1.7) days.There was no anastomotic stoma-related complication in 32 patients.One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous three-cavity irrigation and conservative treatment.Results of postoperative pathological examination:number of lymph node dissected in 32 patients was 32±4.TNM staging:1,5,7,11,6,1 and 1 patients were detected respectively in Ⅰ A,Ⅰ B,Ⅱ A,Ⅱ B,ⅢA,ⅢB and ⅢC.Duration of postoperative hospital stay of 32 patients was (8.1 ±2.1)days.(2) Follow-up and survival situations:32 patients were followed up for 3-38 months,with a median time of 18 months.During the follow-up,in addition to 1 patient in IA stage,31 patients underwent postoperative adjuvant therapy;patients can take the common soft food,without symptoms of choking and burning feelings,and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency.One patient died of malignant tumor of maxillary sinus at 9 months postoperatively,1 was detected liver metastasis at 20 months postopeartively and survived with tumor,the other patients had no tumor recurrence or metastasis.Conlusion The modified Overlap esophagojejunostomy is safe and feasible in TLTG,with good short-term outcomes.

Minimally invasive surgery in adenocarcinoma of esophagogastric junction / 中华胃肠外科杂志

Adenocarcinoma of esophagogastric junction (AEG) is the adenocarcinoma locating in the boundary of esophagus and cardia. Because of its increasing incidence, it has drawn attention widely around the world. In the 11th edition of Japanese Classification of Esophageal Cancer, the diagnosis of AEG should integrate endoscopy, upper gastrointestinal barium contrast and pathology. There are two classifications for AEG, Siewert classification and Nishi classification. In the 8th TNM staging manual, cancer crossing the esophagogastric junction (EGJ) with their epicenter within the proximal 2 cm of the stomach is incorporated into the esophagus chapter, whereas cancer crossing the EGJ with their epicenter in the proximal 2 to 5 cm of the stomach is addressed in the stomach chapter. All the tumors in stomach that do not cross the EGJ are classified as stomach cancer. The surgical approach of AEG remains controversial. Previous researches have suggested that abdominal transhiatal approach should be applied to Siewert type II and III. With respect to minimally invasive surgery, for Siewert I, the mediastinal and abdominal lymphadenectomy is conducted by thoracoscopy and laparoscopy respectively. After that a gastric tube is placed and the reconstruction is performed in the cervix. For Siewert type II, the whole procedure is accessed by laparotomy, and the lower mediastinum is accessed transhiatally. After lymphadenectomy the anastomosis can be laparoscopy-assisted or totally laparoscopic. As for Siewert type III, both circular and linear stapler can be used to perform reconstruction. With the development of surgical technology and continuous renovation of equipment, laparoscopic resection for AEG will be more and more popular.

Research advance in Billroth II with Braun anastomosis after distal gastrectomy / 中华胃肠外科杂志

Methods of digestive tract reconstruction after distal gastrectomy include Billroth I, Billroth II and Roux-en-Y. Each of them has advantages and disadvantages respectively. Alkaline reflux gastritis (ARG) is one of the complications after distal gastrectomy, which is common after Billroth II. In the past 100 years, the ways of digestive tract reconstruction have been continuously improved and developed to prevent the occurrence of alkaline reflux gastritis, and Roux-en-Y is one of them. Still, there is a high incidence of Roux stasis syndrome resulting from Roux-en-Y, with impact on quality of life. Therefore, the appropriate reconstruction is needed urgently. Braun anastomosis was proposed in 1892 to lower the incidence of afferent syndrome. Because of its effect of diverting some alkaline digestive juice, it was applied to pancreaticoduodenectomy and distal gastrectomy. Some studies have proved its effect of diverting some alkaline digestive juice, but the diverted quantity was rarely shown. Besides, compared with Roux-en-Y, Billroth II with Braun anastomosis is safer and more convenient. Meantime it is likely to have benefits in aspect of preventing anemia and malnutrition. In order to provide evidence to clinical practice, this article summarizes the history and research advance of Billroth II with Braun anastomosis by reviewing previous reports.

Long-term outcomes and prognostic factors analysis of laparoscopic gastrectomy for stage T4a gastric cancer / 中华消化外科杂志

Objective To explore the long-term outcomes and prognostic factors of laparoscopic gastrectomy for stage T4a gastric cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 224 patients who underwent laparoscopic gastrectomy of gastric cancer and D2 lymph node dissection in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between February 2004 and December 2014 were collected.Lymph node dissection followed the Japanese Gastric Cancer Treatment Guidelines (13th edition).Anastomotic methods included Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophagojejunostomy.Patients who were diagnosed in stage T4a by postoperative pathological examination underwent 5-fluorouracil chemotherapy.Observation indicators:(1) treatment;(2) postoperative pathological examination;(3) follow-up;(4) prognostic factors analysis.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence or metastases up to death (end of follow-up) or July 31,2016.Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed using Student-t test.Measurement data with skewed distribution were described as M (Q).Comparisons of count data were analyzed using the chi-square test.The overall and disease-free survival curves,overall and disease-free survival rates were respectively drawn and calculated using the Kaplan-Meier method.The survival analysis was done by the Log-rank method.The univariate analysis was done by the chisquare test,and COX regression model which included affecting factors (P＜0.10) in the univariate analysis was used for the multivariate analysis.Results (1) Treatment:all the 244 patients underwent successful operation,without conversion to open surgery.Surgical method:laparoscopic-assisted distal gastrectomy (4 combined with cholecystectomy,1 with splenectomy and 1 with transverse colectomy) were detected in 125 patients and laparoscopic-assisted total gastrectomy in 99 patients (3 combined with cholecystectomy and 2 with splenectomy).Anastomotic method:Billroth Ⅰ,Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophago-jejunostomy were respectively applied to 85,29 and 110 patients.Operation time and volume of intraoperative blood loss were (229±50)minutes and (229 ± 146)mL.All patients underwent 6 or 8 cycles 5-fluorouracil chemotherapy.(2)Postoperative pathological examination:numbers of lymph node dissected and positive lymph nodes were 25± 11 per case and 13 (8,25),with R0 resection.Tumor pathological diagnosis of 224 patients:tumor diameter was (4.5±2.3)cm.Tumors in 29,64,122 and 9 patients respectively located in 1/3 proximal stomach,1/3 middle segment of stomach,1/3 distal stomach and involving 2/3 or total stomach.Tumor differentiation:moderate-and high-differentiated tumors and low-and un-differentiated tumors were detected in 82 and 142 patients,respectively.Postoperative N staging:53,46,55 and 70 patients were detected in staging N0,N1,N2 and N3,respectively.Lymph node metastasis rates of 51,58,53 and 62 patients were 0,1％-15％,16％-40％ and ＞40％,respectively.Postoperative staging was T4a staging.(3) Follow-up:212 of 224 patients were followed up for 7-120 months,with a median time of 32 months.Of 212 follow-up patients,118 were survived and 94 died.Of 118 survived patients,13 and 105 were respectively survived with tumors and without tumor.Of 94 deaths,causes of 8 and 86 were respectively non-tumor and tumor-related deaths.The 5-year overall and disease-free survival rates of 224 patients were respectively 47.2％ and 43.6％.(4) Prognostic factors analysis:results of univariate analysis showed that tumor location,tumor diameter,N staging and lymph node metastasis rate were related factors affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (x2 =6.365,3.740,32.232,48.977,P＜0.10;x2 =9.919,8.818,34.277,45.612,P＜ 0.10).Results of multivariate analysis showed that lymph node metastasis rate was an independent factor affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer (HR =1.828,1.197,95％ confidence interval:1.353-2.469,0.945-1.516,P＜0.05).Postoperative 5-year overall and disease-free survival rates were respectively 72.5％,57.0％,41.6％,23.3％ and 70.0％,53.9％,37.0％,32.4％in staging N0,N1,N2 and N3 patients,with statistically significant differences in different staging (x2 =32.232,34.277,P＜0.05).Conclusion There are good long-term outcomes in laparoscopic gastrectomy for stage T4a gastric cancer,and lymph node metastasis rate is an independent factor affecting postoperative overall and disease-free survival of patients.

Current application and prospect of three-dimensional laparoscopic radical resection of colorectal cancer / 中华消化外科杂志

Most colorectal surgeries now are carried out as minimally invasive surgery along with the development and application of laparoscopy.However,the surgical imaging system does not meet the progressing requirement of laparoscopic surgeons.Thanks to the advent of three-dimensional (3D) laparoscopy,a more sophisticated surgical scene with realer images of anatomy is provided to surgeons.It makes identification and manipulation easier,so that to shorten the learning curve.Meanwhile,the 3D laparoscopy is not perfect.But authors believe it will finally be used broadly in colorectal surgery with the improvement of the technology.

Reconsideration of hot topics on laparoscopic radical gastrectomy / 中华胃肠外科杂志

Laparoscopic radical gastrectomy(LRG) has been popularized with the development of laparoscopic surgical techniques. As a result of the requirement of surgical skill of LRG, the evidence is always highly demanded. The surgical safety and radical resection of tumor is one of the most important principles. Based on published studies and authors' own experience, this article discusses the following topics on laparoscopic gastrectomy: (1)Indications of surgery: Laparoscopic gastrectomy for early gastric cancer is accepted all over the world. For locally advanced gastric cancer, laparoscopic gastrectomy with D2 dissection is considered to be safe and feasible based on domestic studies, especially the CLASS research. (2)Positions and approaches: Classic approaches of laparoscopic gastrectomy include left-side approach, right-side approach, anterior approach and posterior approach. Left-side position is the first choice in China, which is suitable for most laparoscopic gastrectomy. Meanwhile, right-side position is most recommended in Japan and Korea. The selection of approach could be varied by the feature of the tumor, the anatomy of the tumor and the habit of surgeons. (3) Lymphadenectomy of the superior area of pancreas: Based on Japanese Classification of Gastric Carcinoma (14th edition), Chinese Expert Consensus on Quality Control of Laparoscopic Radical Gastrectomy for Gastric Cancer (2017 edition) and authors' own experience, we define the lymph node dissection margin of the superior area of pancreas in laparoscopic distal gastrectomy with D2 dissection as follows: right side is the left wall of portal vein; left side is the posterior gastric artery; upper side is the commissure of diaphragmatic crura; lower side is the anterosuperior side of common hepatic artery and splenic artery; posterior side (on the right side of coeliac trunk) is the plane composed of portal vein, common hepatic artery and the root of coeliac trunk; posterior side (on the left side of coeliac trunk) is the Gerota's fascia. (4) Bursectomy or not: Bursectomy is not recommended as standard procedure in cT3 or cT4a gastric cancer based on the results of JCOG1001. However, to achieve a better surgical plane, dissection of anterior lobe of transverse mesocolon and pancreatic capsule in some area is accepted. (5) Totally laparoscopic reconstruction of digestive tract: along with the development of equipment and modification of anastomosis, the totally laparoscopic reconstruction of digestive tract becomes more and more welcome in laparoscopic gastrectomy as it provides a better and larger surgical scene compared to small incision assisted surgery. The whole procedure of anastomosis is overlooked by laparoscopy, without any over traction of tissue.

Effect of preserving left colic artery during radical operation of rectal cancer on anastomotic leakage and operation time / 中华胃肠外科杂志

Surgical treatment for rectal cancer has changed radically in recent years since the introduction of the principle of total mesorectal excision (TME) and technique of laparoscopic approach. The emphasis of management for vessels in laparoscopic TME surgery for rectal cancer is mainly focused on the inferior mesenteric artery (IMA) and its branches. Two alternatives of the level to execute the IMA are high ligation(without preservation of left colic artery, LCA) and low ligation (with preservation of LCA). In this article, we review the latest literature from China and foreign countries concerning this issue, and combine with our own experience to investigate the effect of LCA preserving on anastomotic leakage and operation time, which may provide a reference for proper choice of the management of IMA in rectal cancer surgery.