Research progress of function-preserving gastrectomy in radical gastrectomy for gastric cancer / 中华消化外科杂志

With the popularization of health awareness and the progress of gastroscopy, the proportion of early gastric cancer is increasing year by year in China. Early gastric cancer has a good prognosis and long-term survival time. Improving postoperative life quality of patients with early gastric cancer will become one of the key directions of gastric cancer research. Therefore, on the premise of ensuring radical tumor treatment, function-preserving gastrectomy for the purpose of improving patients′ quality of life has become a hot topic in early gastric cancer. In recent years, with the deep study on the rule of lymph node metastasis in gastric cancer, the application extent of function-preserving gastrectomy has gradually expanded to advanced gastric cancer. Function-pre-serving gastrectomy includes segmental gastrectomy, proximal gastrectomy and local gastrectomy. The authors summarize important research progress of function-preserving gastrectomy at home and abroad and their own practical experience in recent years, aiming to provide references for clinical surgeons to carry out function-preserving gastrectomy.

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.

Comprehensive treatment of gastric cancer / 中华消化外科杂志

With the deep understanding of gastric cancer and the development of new technology, various comprehensive treatment modes for different stages of gastric cancer have been widely recognized. Endoscopic technology represented by endoscopic submucosal dissection is an important method for diagnosis of gastric cancer and treatment for early gastric cancer. Surgical operation is the preferred treatment for locally advanced gastric cancer, mainly including total gastrectomy, distal gastrectomy, pylorus preserving gastrectomy, proximal gastrectomy and the corresponding regional lymph node dissection. Neoadjuvant chemotherapy, adjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy play important roles in preoperative and post-operative adjuvant therapy of gastric cancer, while the role of radiotherapy needs to be further observed. In recent years, targeted therapy represented by trastuzumab which is positive for human epidermal growth factor receptor-2 and immunotherapy represented by programmed death-1 inhibitors have made important progress in the treatment of gastric cancer. However, they need to be further proved to become the first-line treatment for gastric cancer. The authors believe that with more research results of gastric cancer, the comprehensive treatment of gastric cancer will be more diversified, which will make the treatment of gastric cancer individualized and accurate and finally benefit more patients.

Lymph node dissection strategy of adenocarcinoma of esophagogastric junction / 中华消化外科杂志

The incidence of adenocarcinoma of esophagogastric junction (AEG) is on the rise. Due to its special lesion location and biological behavior, AEG is considered as a relatively independent disease by more and more scholars, which is different from esophageal cancer or gastric cancer. AEG is anatomically located at the junction of esophagus and stomach. The lymph node metastasis of AEG can be directed to the mediastinal and abdominal. At present, the rule of lymph node metastasis of AEG is not completely clear, and the scope of lymph node dissection has not reached a consensus. The authors summarize the hot issues and clinical evidence of lymph node dissection for AEG, in order to provide references for more reasonable lymph node dissection of AEG.

Short-term efficacy of totally laparoscopic distal gastrectomy after endoscopic submucosal dissec-tion versus totally laparoscopic distal gastrectomy for early gastric cancer / 中华消化外科杂志

Objective:To investigate the short-term efficacy of totally laparoscopic distal gastrectomy (TLDG) after endoscopic submucosal dissection (ESD) versus direct TLDG for early gastric cancer.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 623 patients with early gastric cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from March 2014 to December 2019 were collected. There were 405 males and 218 females, aged from 26 to 86 years, with a median age of 62 years. Of 623 patients, 25 cases undergoing TLDG after ESD were divided into ESD+TLDG group and 598 cases undergoing TLDG directly were divided into TLDG group. Observation indicators: (1) the propensity score matching conditions and comparison of general data between the two groups after propensity score matching; (2) intraoperative and postoperative situations of TLDG; (3) stratification analysis of the ESD+TLDG group. The propensity score matching was conducted by 1∶2 matching using the nearest neighbor method. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the t test. Measurement data with skewed distribution were represented as M (range) and comparison between groups was done using the Mann-Whitney U test. Count data were represented as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data between groups was analyzed using the Mann-Whitney U test. Results:(1) The propensity score matching conditions and comparison of general data between the two groups after propensity score matching: 75 of 623 patients had successful matching, including 25 in the ESD+TLDG group and 50 in the TLDG group. Before propensity score matching, the body mass index (BMI), cases with tumor diameter ≤20 mm, 21 to 30 mm or>30 mm, cases with tumor classified as stage Ⅰ, stage Ⅱ or stage Ⅲ of clinical staging were (22.3±3.6)kg/m 2, 16, 6, 3, 24, 1, 0 of the ESD+TLDG group, respectively, versus (24.3±2.7)kg/m 2, 238, 125, 235, 312, 126, 160 of the TLDG group, showing significant differences in the above indicators between the two groups ( t=2.744, Z=?2.834, ?4.209, P<0.05). After propensity score matching, the BMI, cases with tumor diameter ≤20 mm, 21 to 30 mm or >30 mm, cases with tumor classified as stage Ⅰ or stage Ⅱ of clinical staging were (22.3±3.6)kg/m 2, 16, 6, 3, 24, 1 of the ESD+TLDG group, versus (23.6±2.9)kg/m 2, 29, 12, 9, 48, 2 of the TLDG group, showing no significant difference between the two groups ( t=1.542, Z=?0.597, 0.000, P>0.05). (2) Intraoperative and postoperative situations of TLDG: after propensity score matching, the operation time and time to postoperative drainage tube removal were 180 minutes(range, 124 to 289 minutes) and 6 days(range, 4 to 13 days) of the ESD+TLDG group,respectively,versus 170 minutes(range, 106 to 250 minutes) and 6 days (range, 4 to 9 days) of the TLDG group, showing significant differences between the two groups ( Z=-2.396, -3.039, P<0.05). Cases with the volume of intraoperative blood loss <50 mL, 50 to 100 mL or >100 mL, the number of lymph node dissected, duration of postoperative hospital stay, cases with perioperative complications as incision fat liquefaction, delayed gastric emptying, anastomotic bleeding or pulmonary infection were 7, 9, 9,34(range, 16 to 58), 8 days(range, 6 to 31 days), 1, 1, 0, 0 of the ESD+TLDG group,respectively,versus 18, 26, 6, 39 (range, 22 to 68), 8 days (range, 6 to 29 days), 0, 0, 1, 1 of the TLDG group, showing no significant difference between the two groups ( Z=-1.703, -1.958, -1.139, χ2=0.033, P>0.05). Cases with anastomotic bleeding were recovered after hemostasis under endoscopy and cases with other perioperative complications were recovered after conservative treatment. (3) Stratification analysis of the ESD+TLDG group. ① For 5 cases undergoing TLDG ≤14 days after ESD and 20 cases undergoing TLDG >14 days after ESD, the operation time of TLDG, cases with the volume of intraoperative blood loss <50 mL, 50 to 100 mL or >100 mL during TLDG, the number of lymph node dissected, time to postoperative drainage tube removal, duration of postoperative hospital stay, cases with perioperative complications were 200 minutes(range, 170 to 289 minutes), 0, 3, 2, 36(range, 9 to 57), 7 days(range, 5 to 9 days), 8 days(range, 7 to 9 days), 1 and 180 minutes (range, 124 to 253 minutes), 8, 6, 6, 34(range, 8 to 78), 6 days(range, 4 to 13 days), 8 days(range, 6 to 31 days), 1, respectively, showing no significant difference in the operation time of TLDG, volume of intraoperative blood loss during TLDG, the number of lymph node dissected, time to postoperative tube removal and duration of postoperative hospital stay between the two groups ( Z=?1.536, ?1.993, ?0.238, ?0.932, ?0.589, P>0.05), and no significant difference in cases with perioperative complications between the two groups ( P>0.05). ② For 13 cases undergoing TLDG ≤21 days after ESD and cases undergoing TLDG >21 days after ESD, the operation time of TLDG, cases with the volume of intraoperative blood loss as <50 mL, 50 to 100 mL or >100 mL during TLDG, the number of lymph node dissected, time to postoperative drainage tube removal, duration of postoperative hospital stay, cases with perioperative complications were 200 minutes(range, 145 to 289 minutes), 2, 6, 5, 34(range, 8 to 57), 6 days(range, 4 to 11 days), 8 days(range, 6 to 11 days), 1 and 179 minutes(range, 124 to 240 minutes), 6, 3, 3, 34(range, 16 to 78), 6 days(range, 5 to 13 days), 8 days(range, 6 to 31 days), 1, respectively, showing a significant difference in the operation time of TLDG between the two groups ( Z=?2.241, P<0.05), while showing no significant difference in the volume of intraoperative blood loss during TLDG, the number of lymph node dissected, time to postoperative drainage tube removal, duration of postoperative hospital stay between the two groups ( Z=?1.471, ?0.163, ?0.084, ?0.194, P>0.05) and no significant difference in cases with perioperative complications between the two groups ( P>0.05). ③ For 15 cases undergoing TLDG ≤28 days after ESD and 10 cases undergoing TLDG >28 days after ESD, the operation time of TLDG, cases with the volume of intraoperative blood loss <50 mL, 50 to 100 mL or >100 mL during TLDG, the number of lymph node dissected, time to postoperative drainage tube removal, duration of postoperative hospital stay, cases with perioperative complications were 190 minutes (range, 145 to 289 minutes), 2, 7, 6, 33(range, 8 to 57), 6 days(range, 4 to 11 days), 8 days(range, 6 to 31 days), 1 and 179 minutes(range, 124 to 240 minutes), 6, 2, 2, 37(range, 16 to 78), 6 days (range, 5 to 13 days), 8 days(range, 6 to 14 days), 1, respectively, showing no significant difference in the operation time of TLDG, volume of intraoperative blood loss during TLDG, the number of lymph node dissected, time to postoperative tube removal and duration of postoperative hospital stay between the two groups ( Z=?1.619, ?2.000, ?0.667, ?0.370, ?0.057, P>0.05), and no significant difference in cases with perioperative complications between the two groups ( P>0.05). Conclusions:Compared with cases undergoing TLDG directly, the operation time to TLDG and time to drainage tube removal after TLDG for cases undergoing ESD+TLDG are prolonged, but there is no difference in the short-term efficacy. For cases undergoing TLDG ≤21 days after ESD and cases undergoing TLDG >21 days after ESD, there is a significant difference in the operation time of TLDG.

Option of anti-reflux digestive tract reconstruction after proximal gastrectomy / 中华消化外科杂志

The incidence of proximal gastric cancer and esophagogastric junction cancer have increased gradually worldwide. At present, total gastrectomy is still the most commonly used method for the treatment of proximal gastric cancer and esophagogastric junction cancer. However, total gastrectomy inevitably leads to postoperative nutritional and metabolic disorders. The nutritional status of patients after proximal gastrectomy is better than that of total gastrectomy due to the preservation of partial gastric function. With the increase in the detection rates of early gastric cancer and esophagogastric junction cancer and the deepening understanding of lymph node metastasis, proximal gastrectomy has been received more attention and applied in more and more cases. Traditional esophagogastrostomy may cause severe reflux esophagitis. To overcome it, various kinds of anti-reflux digestive tract reconstructions after proximal gastrectomy have been created. Based on the relevant literature and combined with their practical experience, the authors summarize the progress in anti-reflux digestive tract reconstruction after proximal gastrectomy, in order to provide reference for choosing optimal reconstruction methods.

Indications for total laparoscopic proximal gastrectomy and the following selection of gastrointestinal reconstruction methods / 中国肿瘤临床

In recent years, the incidence of upper gastric cancer has increased annually worldwide. Upper gastric cancer has become a huge threat to human health. Until now, total and proximal gastrectomies are still the most commonly used surgeries for upper gastric cancer. More attention has been paid to proximal gastrectomy because it retains the function of the stomach and has little effect on nutrient absorption. Patients who received proximal gastrectomy achieved better nutritional status. With the development of laparo-scopic techniques, laparoscopic radical gastrectomy has been largely performed in gastric cancer treatment. Total laparoscopic surgery has been applied in the treatment of upper gastric cancer in recent years. However, this surgical procedure is still controversial in terms of the range of radical treatment and reconstruction of the digestive tract. Combining our own experiences, we will focus on the indications of total laparoscopic proximal gastrectomy and the guidelines for choosing the most reasonable procedure for digestive tract reconstruction.

Progress in surgical treatment for esophagogastric junction cancer / 中华消化外科杂志

The incidence of the esophagogastric junction (EGJ) cancer tends to increasing in recent years.Comprehensive treatment based on surgical treatment is currently a general strategy for the treatment of EGJ cancer.Because of the particularity of the anatomy and pathology of EGJ cancer,there were difficulties and controversies existing in the surgical treatment of EGJ cancer.Medical researchers have attached great importance to the treatment of EGJ cancer and made remarkable progress in it.Therefore,the authors summarize the progress of surgical treatment of EGJ cancer,and present it in four aspects of surgical approach lymph,node dissection,esophagogastric resection and digestive tract reconstruction.

Feasibility and efficacy of laparoscopic treatment for advanced gastric cancer from LOC-A study / 中华胃肠外科杂志

With the progression of surgical techniques, laparoscopic equipment and treatment concepts, laparoscopic radical gastrectomy has been widely used in clinical practice. However, whether laparoscopic surgery can be used for the treatment of locally advanced gastric cancer is still controversial. Recent results from the Korean KLASS-02 study, the Japanese JCOG-0901 study, and the Chinese CLASS-01 study suggest that there is no significant difference in the short-term efficacy between laparoscopic surgery and open surgery in the treatment of locally advanced gastric cancer. The long-term results have not been published. The LOC-A study was a multicenter, large sample size retrospective analysis that enrolled 1948 laparoscopic and open surgery cases with stage II to III locally advanced gastric cancer in 8 Japanese hospitals between 2008 and 2014. As a result, after removal of confounding factors by propensity score matching (PSM), the analysis showed no significant difference in long-term efficacy between laparoscopic surgery and open surgery for locally advanced gastric cancer. However, some bias still remain after the bias-control. Therefore, due to insufficiency of the high-level evidence-based medical evidence, we believe that the all-round promotion of laparoscopic surgery of locally advanced gastric cancer is too early, nevertheless, we should also recognize that the minimally invasive treatment of gastric cancer is the current development trend, and we should be confident in laparoscopic treatment of locally advanced gastric cancer.

Laparoscopic surgery strategies for adenocarcinoma of the esophagogastric junction / 中华消化外科杂志

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been raised in recently years.Comprehensive treatment based on surgical treatment is currently a general strategy for the treatment of AEG.As a minimally invasive treatment,laparoscopic surgery has been gradually applied to the treatment of AEG.Because of the particularity of the anatomy and pathology of AEG,laparoscopic radical resection still has many difficulties and controversies.Up to now,there are a few high-level evidences for the range of lymph node dissection and gastrectomy and the selection of digestive tract reconstruction,and the treatment strategy of total laparoscopic surgery for AEG has not reached a consensus.Therefore,laparoscopic surgery for AEG has gradually become a hot topic in clinical research.Here,combined with the experience of laparoscopic surgery for AEG and the latest guidelines and literatures,authors presented the general strategies for the laparoscopic treatment of AEG in our center.

Application value of the π-shaped esophagojejunostomy in totally laparoscopic total gastrectomy / 中华消化外科杂志

Objective To explore the safety and feasibility of the π-shaped esophagojeunostomy in totally laparoscopic total gastrectomy.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 6 patients with gastric cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University between May 2016 and August 2016 were collected.All the 6 patients underwent totally laparoscopic total gastrectomy,operation procedures included esophagus and stomach mobilization,lymph node dissection,π-shaped esophagojejunostomy,and then laparoscopic digestive tract reconstruction after jejunojejunal anastomosis.Observation indicators included:(1) surgical situations:conversion to open surgery,operation time,time of π-shaped esophagojejunostomy,volume of intraoperative blood loss,number of lymph node dissected;(2) postoperative situations:time for initial out-of-bed activity,time of initial anal exsufflation,time of initial liquid diet intake,time of abdominal drainage tube removal,postoperative complications and duration of postoperative hospital stay;(3) postoperative pathological examination;(4) follow-up and survival situations.Follow-up using outpatient examination was performed to detect the anastomotic stenosis,patients' survival and tumor metastasis and recurrence up to November 2016.The measurement data with normal distribution were represented as (x)±s.Results (1) Surgical situations:all the 6 patients underwent successful totally laparoscopic total gastrectomy using the π-shaped esophagojejunostomy,without conversion to open surgery and perioperative death.Operation time,time of π-shaped esophagojejunostomy,volume of intraoperative blood loss and number of lymph node dissected were respectively (282 ± 49) minutes,(37 ± 9) minutes,(37 ± 8) mL and 39 9.(2) Postoperative situations:time for initial out-of-bed activity,time of initial anal exsufflation,time of initial liquid-diet intake,time of abdominal drainage tube removal and duration of postoperative hospital stay of 6 patients were (44± 38)hours,(72±21)hours,(6.5±l.1)days,(11±7) days and (15±7) days,respectively.Six patients were not complicated with postoperative hemorrhage,duodenal stump fistula and death.One patient with anastomotic fistula was cured by abdominal puncture drainage under guidance of computed tomography (CT),enteral nutrition and antibiotic therapy,and then was discharged from hospital.(3) Postoperative pathological examination:pTNM staging showed that stage Ⅰ A,Ⅱ A,ⅡB and ⅢA were detected in 3,1,1 and 1 patients,respectively.(4) Follow-up and survival situations:6 patients were followed up for 3-6 months,with a median time of 4 months.During follow-up,results of compound meglumine diatrizoate gastrointestinal radiography showed that there were smooth anastomoses,and no tumor recurrence or metastasis and death.Conclusion The π-shaped esophagojejunostomy is safe and feasible in totally laparoscopic total gastrectomy.

Analysis of clinicopathologic factors affecting formation of lymphovascular invasion in 1 260 patients with gastric cancer / 中华消化外科杂志

Objective To analyze the clinicopathologic factors affecting the formation of lymphovascular invasion (LⅥ) in patients with gastric cancer.Methods The retrospective case-control study was conduted.The clinicopathologic data of 1 260 patients with gastric cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University between January 2014 and December 2015 were collected.All the surgical specimens of patients were detected by hematoxylin-eosin (HE) stain and diagnosed by pathological experts.Stages of patients were evaluated by the seventh TNM staging system for gastric cancer of American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC).Observation indicators:(1) pathologica features:histological differentiation,invasive depth,lymph node metastasis and TNM staging;(2) follow-up situations;(3) influenced factors of the positive LⅥ:sex,age,histological differentiation,invasive depth,number of lymph node metastasis and TNM staging affecting positive LⅥ were analyzed.Follow-up using outpatient examination and telephone interview were performed to detect survival of patients up to June 2016.Univariate analysis was done using the chi-square test,and multivariate analysis was done using the trend chi-square test,and binary Logistic regression model.Results (1) Pathological features:1 260 patients with gastric cancer were diagnosed by postoperative pathological examinations,including 355 with positive LⅥ and 905 with negative LⅥ.Histological differentiation:high-differentiated tumor was detected in 13 patients,moderate-differentiated tumor in 232 patients and low-differentiated tumor in 775 patients.There were 95 patients with mucinous adenocarcinoma and 145 with signet-ring cell carcinoma.Invasive depth:tumor invasion into mucosal layer or submucosal layer (T1 stage) was detected in 242 patients,muscular layer (T2 stage) in 160 patients,gastric wall layer and no invasion into serosal layer (T3 stage) in 37 patients and subserosal layer (T4 stage) in 821 patients.Lymph node metastasis:no regional lymph node metastasis (N0 stage) was detected in 461 patients,1-2 lymph nodes metastases (N1 stage)in 164 patients,3-6 lymph nodes metastases (N2 stage) in 245 patients and more than 7 lymph nodes metastases (N3 stage) in 390 patients.TNM staging:there were respectively 191 patients in Ⅰ A stage,114 in Ⅰ B stage,62 in ⅡA stage,202 in ⅡB stage,132 in ⅢA stage,80 in ⅢB stage,476 in ⅢC stage and 3 in Ⅳ stage.(2)Follow-up situations:1 142 patients (320 with positive LⅥ and 822 with negative LⅥ) were followed up for 4.0-24.0 months,with a meidan time of 11.0 months and a follow-up rate of 90.635％ (1 142/1 260).During the follow-up,154 patients died,including 41 with positive LⅥ and 113 with negative LⅥ.(3) Influenced factors of the positive LⅥ:① results of univariate analysis showed that histological differentiation,invasive depth,number of lymph node metastasis and TNM staging were factors affecting positive LⅥ of patients with gastric cancer (X2=16.930,29.190,64.463,46.539,P＜0.05).② Results of the trend chi-square test showed that histological differentiation,invasive depth,number of lymph node metastasis and TNM staging were factors affecting positive LⅥ of patients with gastric cancer,with a linear correlation (X2 =54.883,69.130,164.618,119.594,r=0.211,0.243,0.365,0.316,P＜0.05).There was a greater correlation between number of lymph node metastasis and formation of lymphovascular invasion.③ Results of the binary Logistic regression model showed that moderate-and low-differentiated tumor and N1-N3 stage of lymph node metastasis were independent risk factors affecting positive LⅥ of patients with gastric cancer (OR=2.572,1.782,95％ confidence interval:0.495-1.494,0.386-0.781,P＜0.05).Conclusion Patients with lower tumor differentiation and / or greater number of lymph node metastasis may have a higher risk of forming LⅥ.

Selection and appraisal of digestive tract reconstruction after totally laparoscopic gastrectomy for gastric cancer / 中华胃肠外科杂志

In recent years, with the development of laparoscopic technology, more and more totally laparoscopic gastrectomy has been applied. The reconstruction of digestive tract is the key procedure of laparoscopic gastrectomy and is associated with the postoperative quality of life. Each method of digestive tract reconstruction has its own characteristic, however, unified consensus on how to choose the optimal method for digestive tract reconstruction has not yet been reached till today. In this article, we will discuss and evaluate the advantages, disadvantages and indications of these reconstruction methods after totally laparoscopic distal gastrectomy, total gastrectomy and proximal gastrectomy combined with relative literatures and our practical experience in order to provide the reference to choose the reasonable reconstruction method at the premise of radical resection, which may decrease the morbidity of postoperative complication, increase the quality of life, and bring benefits to patients definitely.

The key points of prevention for special surgical complications after radical operation of gastric cancer / 中华胃肠外科杂志

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.

Selection and technical points of digestive tract reconstruction after total laparoscopic gastrectomy for gastric cancer / 中华消化外科杂志

Gastric cancer is the second most common malignancy in China.In recent years,with the development of laparoscopic technology and improved skills of gastrointestinal surgeons,total laparoscopic radical gastrectomy for gastric cancer has been developed rapidly.The digestive tract reconstruction is the key procedure and one of the difficulties of total laparoscopic radical gastrectomy.Each method of digestive tract reconstruction has its own characteristic,however,there has not yet reached a unified consensus until today.In this article,the advantages and disadvantages of these reconstruction methods and technical points were reviewed based on relative literatures and our application experiences.

A Chinese multi-center study on the significance of monitoring imatinib plasma concentration in patients with gastrointestinal stromal tumor before and after administration / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the factors which may influence the imatinib plasma concentration in Chinese patients with gastrointestinal stromal tumor(GIST), and to illuminate the significance of monitoring imatinib plasma concentration in adjuvant therapy for patients with GIST.</p><p><b>METHODS</b>A cross-sectional study with 60 GIST patients who accepted the imatinib therapy after surgery was conducted. They were respectively administrated in 10 domestic hospitals from December 2014 to April 2016, including The First Affiliated Hospital of Nanjing Medical University(n=28), The Affiliated Hospital of Nantong University(n=9), The Affiliated Hospital of Xuzhou Medical College(n=6), Nanjing Drum Tower Hospital(n=5), The Second Affiliated Hospital of Nanjing Medical University (n=2), Jingling Hospital (n=2), The Second People's Hospital of Lianyungang(n=2), Shandong Provincial Hospital(n=2), Jiangsu Province Tumor Hospital(n=2), and The First Affiliated Hospital of Zhejiang University(n=2). Some specific time points for collecting blood sample before and after taking imatinib were determined, then liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was used for monitoring imatinib plasma concentration in patients with GIST. Linear regression analysis was used for the correlation analysis of imatinib plasma concentration with dosage, clinicopathologic feature and side effect.</p><p><b>RESULTS</b>Patients who could not tolerate 400 mg imatinib per day(n=3) received 300 mg per day. There was no significant difference in imatinib plasma concentration between patients with 300 mg and those with 400 mg imatinib(n=53)(P=0.527). However, the imatinib plasma concentration in patients with 600 mg imatinib per day (n=4) was significantly higher as compared to those with 400 mg(P=0.000). Linear regression analysis indicated a negative correlation between the imatinib plasma concentration in patients with 400mg imatinib per day for 90 days continuously and body surface area(R=0.074, P=0.035), but no significant correlations of with age, creatinine clearance and serum albumin concentration were observed (all P>0.05). The differences in imatinib plasma concentration were not statistically significant between patients of different gender and those taking proton-pump inhibitor (PPI) or not (both P>0.05). Difference in imatinib plasma concentration between patients with different surgery was significant (P=0.026). Compared to patients who underwent wedge resection, enterectomy and other surgeries, the imatinib plasma concentration of patients with subtotal gastrectomy or total gastrectomy decreased significantly (all P<0.05). After 90 days of taking imatinib continuously, linear regression analysis revealed a negative correlation between imatinib plasma concentration in patients with 400 mg imatinib per day and white blood cell count (R=0.103, P=0.013), and a positive correlation with serum alanine aminotransferase (ALT) concentration (R=0.076, P=0.033).</p><p><b>CONCLUSIONS</b>The imatinib plasma concentration in patients with larger body surface area, subtotal gastrectomy or total gastrectomy may be lower. For these patients, dosage of imatinib should be considered to increase in order to achieve effective plasma concentration. Excessive imatinib plasma concentration can result in some side effects, such as decrease of white blood cells and liver damage. Therefore, it is significant for receiving optimal clinical therapeutic efficacy to monitor imatinib plasma concentration, adjust imatinib dosage timely and keep imatinib plasma concentration in effective and safe range.</p>

Clinical value of three-dimensional laparoscopic radical gastrectomy for gastric cancer / 中华消化外科杂志

Objective To investigate the clinical value of three-dimensional (3D) laparoscopic radical gastrectomy for gastric cancer.Methods The retrospective and descriptive study was adopted.The clinical data of 28 patients who underwent 3D laparoscopic radical gastrectomy for gastric cancer at the First Affiliated Hospital of Nanjing Medical University from October 2014 to March 2016 were collected.Trocar placement and surgical procedures were the same as 2D laparoscopic radical gastrectomy.Observation indicators included (1) surgical situations:operation time,volume of intraoperative blood loss,number of lymph node dissected,(2) postoperative situations:time for out-of-bed activity,time to anal exsufflation,time for fluid diet intake,occurrence of complications and duration of hospital stay,(3) follow-up situations.The follow-up was performed to detect postoperative survival of patients and tumor recurrence and metastasis by outpatient examination and telephone interview up to May 1st,2016.Measurement data with normal distribution were presented as x ± s.Results (1) Surgical situations:all the 28 patients underwent successful 3D laparoscopic radical gastrectomy,without conversion to open surgery and perioperative death.Seven patients received 3D laparoscopy assisted total gastrectomy with Roux-en-Y esophagojejunostomy,with operation time of (214 ± 47)minutes.Twenty-one patients underwent 3D laparoscopic distal gastrectomy with uncut Roux-en-Y gastrojejunostomy,with operation time of (181 ± 27) minutes.Volume of intraoperative blood loss and number of lymph node dissected in 28 patients were (53 ± 29)mL and 34 ± 10.(2) Postoperative situations:time for out-of-bed activity,time to anal exsufflation and time for fluid diet intake were (54 ± 17) hours,(77 ± 16) hours and (5.0 ± 1.1) days,respectively.Of 28 patients,1 complicated with gastrointestinal hemorrhage was cured by conservative treatment,and other patients had no complications.Duration of postoperative hospital stay was (8.8 ± 1.6) days.(3) Follow-up situations:all the 28 patients were followed up for 2-18 months with a median time of 10 months,without occurrence of tumor recurrence and metastasis.One patient undergoing 3D laparoscopic distal gastrectomy with uncut Roux-en-Y gastrojejunostomy was complicated with afferent recanalization,without obvious discomfort,and received regular gastroscopy reexaminations to detect bile reflux.Conclusion 3D laparoscopic radical gastrectomy for gastric cancer is safe and feasible,with good short-term outcomes.

Co-inhibition effect of 17-DMAG and oxaliplatin on proliferation and invasion of colorectal cancer cells / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the effect of heat shock protein 90 (HSP90) inhibitor (17-DMAG) and oxaliplatin on the proliferation and invasion of colorectal cancer.</p><p><b>METHODS</b>After 17-DMAG, oxaliplatin and half-dose combination of 2 drugs processing colorectal cancer SW480 and HCT116 cell lines, CCK8 assay was applied to detect cell viability. RT-PCR and Western blot were used to detect the expression level of the apoptosis-related molecules. Transwell chemokine axis experiment and Western blot were employed to detect cell invasion ability and the expression level of tumor metastasis-associated protein.</p><p><b>RESULTS</b>The growth of SW480 and HCT116 cells was inhibited after the administration of 17-DMAG and oxaliplatin(P<0.05) in dose- and time-dependent manner. Processed by 17-DMAG 100 nmol/L, oxaliplatin 50 mg/L and half-dose combination of 2 drugs, transcription level of the apoptosis inhibitory gene (Bcl-2) in SW480 and HCT116 cells was decreased, the level of apoptosis promoting gene (Bax) transcription and protein PARP-1 spliceosome expression was increased, and the above trend was more obvious when using half-dose combination of 2 drugs. Transwell chemokine axis experiments showed the penetrating relative percentage and expression level of MMP9 and integrin β3 decreased, especially for half-dose combination of 2 drugs.</p><p><b>CONCLUSION</b>17-DMAG and oxaliplatin can co-inhibit the proliferation and invasion of colorectal cancer.</p>

Effects of levator ani muscle exposure in abdominal perineal resection for rectal cancer / 中华消化外科杂志

Objective To investigate the effects of levator ani muscle exposure in abdominal periueal resection for rectal cancer.Methods The clinical data of 109 patients with rectal cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2001 to January 2008 were retrospectively analyzed.There were 55 patients received traditional procedure (conventional method group) and 54 patients received modified procedure with levator ani muscle exposure (levator ani muscle exposure group).The mesorectum was sharply dissected according to the total mesorectal excision principle.It is essential to remove the rectum along with the mesorectum up to the level of the levators.Preoperative bowel preparation,anesthesia,body position,abdominal incision,perineal incision and suture of the 2 groups were the same as Miles procedure.In the conventional method group,the superficial dissection was carried out with electrocautery or ultracision harmonic scalpel.The presacral space was entered by dividing the rectococcygeus muscle,commencing at the level of the tip of the coccygeus.The levators were then divided near the pelvic wall attachments and next procedures were performed without levator ani muscle exposure.In levator ani muscle exposure group,once the ischiorectal fat was cleared by electrocautery,the planes of levator ani muscle were identified and exposed after dividing the rectococcygeus muscle and next procedures were performed.The patients in stage Ⅰ only needed to follow-up; the patients in stage Ⅱ had to receive chemotherapy with following situation:poor differentiation,T4 stage,blood vessel or lymphatic invasion,number of lymph nodcs detected ＜ 12.Patients in stage Ⅲ or Ⅳ needed adjuvant chemotherapy.The follow-up evaluation included blood routine examination,hepatic and renal function examination,chest radiography,hepatobiliary ultrasonographic evaluation and determination of CEA levels (once every 3 months in the first year after operation,and once every 6 months after one year).Abdominal CT scan and colonoscopy should be employed every year.All the patients were followed up till December of 2012.All data were analyzed using the chi-square test or t test.The survival curve was drawn using the Kaplan-Meier method,and the prognosis was analyzed using the Log-rank test.Results The operation time were (60 ± 15)minutes and (30 ± 10) minutes in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =3.936,P ＜ 0.05).The intraoperative blood loss were (300 ± 60) mL and (30±20) mL in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =5.687,P ＜ 0.05).Three patients were with rectal injury,1 with urethral injury,1 with vaginal injury,and 10 with incision infection in the conventional method group.There were 9 patients with incision infection in the levator ani muscle exposure group.The course of chemotherapy was under 12 in 30 patients,and above 6 in 41 patients.The median time of follow-up of the patients was 56 months (range,15-95 months).Of the 109 patients,10 missed the follow-up,15 patients had local recurrence,30 had distal metastasis,and 35 patients died.The 1-,3-,5-year cumulative survival rates were 93.4％,76.0％ and 65.6％.The 5-year survival rates were 65.2％ and 66.3％ for patients in the conventional method group and the levator ani muscle exposure group,with no significant difference between the 2 groups (x2=4.210,P ＞0.05).Conclusion Levator ani muscle exposure method provides clearer vision of operational field,shorter operation time,less blood loss and less injury to the rectum or urinary tract (vagina).

Effects of the dominant negative form of protein phosphatase 2A catalytic subunit α driven by alpha-fetoprotein enhancer/phosphoglycerate kinase promoter on hepatoma cell xenografts / 中华肝胆外科杂志

Objective To investigate the effects of AFP enhancer/pgk promoter driven expression of the dominant negative form of the PP2A catalytic subunit α (DN-PP2Acα) in vivo.Methods The previously constructed AFpg promoter-driven DN-PP2Acα was recombined into an adenovirus,and the expression of PP2Ac was tested using Western blot.Cell growth was tested using the MTT and flat plate clone formation assays.In vivo studies were performed in tumor xenograft models.Results AFpg promoter-driven expression of DN-PP2Acα exerted cytotoxic effects against the AFP-positive human hepatoma cell line HepG2,but did not affect AFP-negative human hepatoma cells (SKHEP-1) or normal human liver cells (L-02).Moreover,AFP enhancer/pgk promoter driven expression of DN-PP2Acα inhibited the growth of AFP-positive HepG2 tumors in nude mice bearing solid tumor xenografts,but did not affect AFP-negative SK-HEP-1 tumors.Conclusion The recombinant AFP enhancer/pgk promoter-driven DN-PP2Acα expression adenovirus presented selective cytotoxicity against AFP-positive hepatoma cells and provides a useful gene therapy strategy to selectively target hepatocellular carcinoma.