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Due to the unique position and biological behaviors of adenocarcinoma of esophagogastric junction (AEG), the pattern of treatment has gradually changed from surgery alone leading by surgeons to comprehensive treatment by multidisciplinary teams including thoracic surgeons, oncologists, radiotherapy physicians, anesthetists and so on. The development of laparoscopic surgery makes the jointed operation possible by laparoscopy and thoracoscopy. The concept of enhanced recovery after surgery could further promote minimally invasive surgery in AEG. Meanwhile, with the continuous innovation of neoadjuvant chemotherapy, popularization of neoadjuvant radiotherapy and bold attempt of targeted therapy and immunotherapy, the resection rate, pathologic release rate and long-term survival of AEG have already achieved inspiring effects.
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Objective:To investigate the application value of hand-sewn esophagojejunal anastomosis (EJA) in totally laparoscopic total gastrectomy (TLTG).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 35 patients with early or advanced upper gastric cancer who were admitted to Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine between July 2018 and December 2019 were collected. There were 24 males and 11 females, aged (60±10)years, with a range of 35-75 years. All the 35 patients underwent TLTG combined with hand-sewn EJA. Observation indicators: (1) intraoperative situations; (2) postoperative situations; (3) postoperative pathological examination; (4) follow-up and survival. Follow-up was conducted using telephone interview, outpatient examination, short message service and WeChat to detect tumor recurrence, metastasis and survival of patients up to January 2020.Measurement data with normal distribution were repressented as Mean± SD. Measurement data with skewed distribution were represented as M (range). Count data were expressed as absoulte numbers or persentages. Results:(1) Intraoperative situations: all the 35 patients underwent TLTG combined with hand-sewn EJA successfully. The operation time, volume of intraoperative blood loss, time of hand-sewn EJA, costs of consumables used in the intraoperative resection and reconstruction, and costs of consumables used in EJA of the 35 patients were 305 minutes(range, 232-406 minutes), 94 mL(range, 50-300 mL), 37 minutes(range, 20-65 minutes), 13 674 yuan(range, 11 929-15 255 yuan) and 491 yuan(range, 223-1 044 yuan), respectively. Of the 35 patients, 4 received intraoperative blood transfusion. (2) Postoperative situations: time to first out-of-bed activity, postoperative indwelling time of gastric tube, time to initial liquid diet intake, the time to abdominal drainage tube removal and duration of postoperative hospital stay of the 35 patients were 2 days(range, 1-3 days), 4 days(range, 2-11 days), 5 days(range, 4-12 days), 8 days(range, 5-15 days) and 9 days(range, 7-16 days), respectively. Of the 35 patients, 3 had perioperative complications. One patient had inflammation and infection in the pancreatic tail and was discharged at postoperative 16 days after conservative treatment of fasting, somatostatin to reduce the pancreatic secretion, adequate drainage, anti-infection and nutritional support. One had postoperative intestinal incomplete obstruction and was discharged at postoperative 12 days after treatment with gastrointestinal decompression and enema for relief of obstruction. One had pulmonary infection who was discharged at postoperative 9 days after symptomatic and supportive treatment. None of the 35 patients had perioperative anastomotic leakage or bleeding. Of the 35 patients, 1 was diagnosed with esophagojejunostomy stenosis at postoperative 2 months and was improved after endoscopic dilatation. The incidence of long-term anastomosis-related complications of the 35 patients was 2.9%(1/35). (3) Postoperative pathological examination: the pathological examination of the upper margin of intraoperative frozen section and postoperative paraffin section showed negative in the 35 patients. Of the 35 patients, 16 had tumor located at cardia including 4 cases with tumor involving in lower esophagus, 19 had tumor located at stomach; 21 had tumor pathological type as highly or moderately differentiated adenocarcinoma, 11 had poorly differentiated adenocarcinoma, 3 had signed-ring cell carcinoma; 14 had early gastric cancer, 21 had advanced gastric cancer; 7 had tumor invaded at mucosa lamina propria and muscularis, 7 had tumor invaded at submucosa, 1 had tumor invaded at muscularis, 1 had tumor invaded at subserosal, 17 had tumor invaded at serosal, 2 had tumor invaded at extra-serosal adipose tissue. The TNM staging of the 35 patients: 14 were in stage ⅠA , 2 in stage ⅠB, 4 in stage ⅡB, 3 in stage ⅢA, 4 in stage ⅢB and 8 in stage ⅢC. Of the 35 patients, 15 had vascular invasion and 16 had nerve invasion. The tumor diameter, the number of lymph nodes dissected and the number of positive lymph nodes of the 35 patients were 3.9 cm(range, 0.6-12.0 cm), 24(range, 10-40) and 2(range, 0-11). (4) Follow-up and survival: all the 35 patients were followed up for 1-18 months, with a median time of 5 months. Of the 35 patients, tumor recurrence or metastasis was not found in 34 patients, and the other 1 patient was diagnosed with liver metastases of tumor at postoperative 6 months and survived with tumor.Conclusion:Hand-sewn EJA in TLTG is safe and feasible.
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The incidence of adenocarcinoma of esophagogastric junction (AEG) is increasing worldwide annually. Surgical resection still plays the most important role in multi-modality therapy for AEG. However, due to the specialities of tumor location and biological features, general surgeons and thoracic surgeons do not reach an agreement on regional lymph-adenectomy, extents of resection, surgical approaches, etc. The development of minimally invasive surgery makes it possible to operate by laparoscopy and thoracoscopy. With the promotion of neoadjuvant therapy, a multidisciplinary team will be essential for optimal diagnosis and treatment in the near future. From the developmental perspective of a general surgeon, the authors summarize current status and controversies of the diagnosis and treatment of AEG, and inspect its research advances.
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Surgical approaches for adenocarcinoma of esophagogastric junction have become controversial issues in recent years,including complete resection of tumors,negative proximal margin,complete lymph node dissection,safety of digestive tract reconstruction and reduction of perioperative complications.JCOG9502 trial in Japan is a well-known clinical trial on the surgical approach for adenocarcinoma of esophagogastric junction,which provides evidence-based medicine results for the transabdominal or transthoracic approach.However,due to the differences between the left and right thoracic approaches,the choice of a reasonable surgical approach has also become the focus of discussion between eastern and western scholars.With the development of minimally invasive surgery,it is possible to perform the operations combining laparoscopy and thoracoscopy in the future.
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Gastric cancer is one of the malignant tumors with high morbidity and high mortality in China.Research has shown that viral infection is closely related to the occurrence of gastric cancer.EpsteinBarr virus-associated gastric cancer characterized by EB virus infection has been classified as a subtype of gastric cancer,whose epidemiology,pathogenesis,clinical and histopathologic features have been studied in detail.At the same time,oncolytic viruses reveal the inhibitory effect of the virus on tumors,and their ability to target and kill tumor cells is used in the treatment of some advanced cancers.This article will review the research advances about relevance to gastric cancer of several viruses that have been reported and the latest progress in anticancer mechanisms and combined therapies for oncolytic viruses.
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The world-wide incidence of adenocarcinoma of the esophagogastric junction has been on a rise in recent years.Surgical resection plays the most important role in the multimodal management for adenocarcinoma of esophagogastric junction.However,due to distinct anatomical position,biological features,epidemiology and surgical teams,many controversies and different cognitions exist among surgeons from the East and the West,including tumor staging and classification,regional lymphadenectomy,surgical approaches and extents of esophageal and gastric resection.A new TNM classification has renewed the staging system,while traditional Siewert classification still decides clinical surgical strategies.With the development of minimally invasive surgery and early detection for the lesion,it is possible to perform the operations combining laparoscopy and thoracoscopy in the future.A multidisciplinary team from digestive surgery,oncology,radiology and anesthesiology will be essential for optimal diagnosis and management.
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As a new medical concept and medical model,precision medicine has been increasingly showing its benefits in the clinical diagnosis and treatment. With the development and progress of cancer genomics,imaging diagnosis and surgical techniques,the diagnosis and treatment of malignant tumors is gradually moving towards the era of precision medicine. The precision surgical treatment for gastric cancer is the use of modern molecular and imaging diagnostic technologies,on the basis of molecular classification and clinical staging,to develop accurate and individualized surgical plan with the concept of minimally invasive surgery and functional preservation. For the advanced gastric cancer, comprehensive treatments including chemoradiotherapy,molecular targeted therapy and immunotherapy are used to further improve the prognosis of patients.
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In the past few years, the early detection of gastric cancer has increased in China. The surgical treatment for early gastric cancer has gradually transformed from conventional gastrectomy with D2 lymphadenectomy to function-preserving gastrectomy which maximally preserves the anatomy and physiology of stomach to maintain the quality of life of the patient. Driven by minimally invasive techniques, function-preserving gastrectomies, including pylorus-preserving gastrectomy, proximal gastrectomy, sentinel node navigation surgery, etc. have already gained great attention especially in Japan and Korea. Although there are still many unsolved problems that need to be further discussed and explored, understanding of the clinical features of early gastric cancer and definition of gastric function preservation, launching clinical trials for solving practical problems, and emphasis of individualized and precision treatment will be the best strategies to improve the efficacy of early gastric cancer.
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The incidence of gastric cancer in East Asia is highest in the world. Level of screening and inspection in high risk population, diagnosis and treatment in early stage, standardized surgery, minimally invasive techniques and clinical research always reach the international lead. In the past few years, the surgeons and researchers from China have already made considerable progress by learning the experience from Japan and Korea. The early detection of gastric cancer increases annually, the minimally invasive surgeries including endoscopic or laparoscopic operations are widely used, the standard surgical procedure and lymphadenectomy are popularized, meanwhile the clinical research for gastric cancer has also started. In the future, as long as following this way, we will definitely achieve better improvement in diagnosis and treatment of gastric cancer in China.
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The incidence of adenocarcinoma of esophagogastric junction is increasing worldwide during recent decades.The therapeutic strategies have been transformed from surgery alone to multimodal treatments involing also perioperative chemoradiotherapy.Although there are still many problems on preoperative staging,surgical approach,excisional extent and perioperative chemoradiotherapy regimen,multidisciplinary team collaboration can provide an optimal diagnosis and treatment to achieve the principles of standardization and individualization in malignant tumor,which will prolong the survival and improve the quality of life for every patient.
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<p><b>OBJECTIVE</b>To discuss the safety and feasibility in the preservation to hepatic branch of vagus nerve by the side-to-side tubular gastroesophageal anastomosis within the laparoscopic radical proximal gastrectomy for early gastric cancer(EGC).</p><p><b>METHODS</b>Retrospective analysis on the intraoperative and postoperative data of 7 EGC patients receiving laparoscopic radical proximal gastrectomy from January 2014 to January 2015 was carried out. All the patients underwent the preservation of hepatic branch of the vagus nerve by side-to-side tubular gastroesophagreal anastomosis.</p><p><b>RESULTS</b>All the 7 patients completed operations successfully without conversion to open surgery. The mean operative time was (213.1 ± 22.1) minute, the mean reconstruction time was (56.9 ± 11.6) minute, and the mean blood loss was (38.6 ± 28.1) ml. Postoperative time to flatus was (2.4 ± 0.5) day, and postoperative hospital stay was (9.3 ± 0.9) day. No operation-related complications were observed. No severe malnutrition, no recurrence or death, and no severe esophageal reflux during follow-up period were found.</p><p><b>CONCLUSION</b>The preservation of hepatic branch of the vagus nerve by side-to-side tubular gastroesophagreal anastomosis within laparoscopic radical proximal gastrectomy for ECG is safe and feasible.</p>
Subject(s)
Humans , Anastomosis, Surgical , Feasibility Studies , Gastrectomy , Methods , Laparoscopy , Length of Stay , Neoplasm Recurrence, Local , Operative Time , Organ Sparing Treatments , Postoperative Period , Retrospective Studies , Stomach Neoplasms , General Surgery , Vagus Nerve , General SurgeryABSTRACT
Under the premise of radical resection in the treatment, it is of great significance to preserve partial gastric function so that the early gastric cancer (EGC) patients' postoperative quality of life (QOL) can be improved. In the patients with EGC in the upper third of the stomach, the emphasis is on the prevention of reflux esophagitis caused by bile and gastric juice reflux. Pylorus-preserving gastrectomy (PPG) is applicable to the patients with EGC in the middle third of the stomach. In the patients with EGC in the lower third of the stomach, distal gastrectomy (DG) is performed in general. Various anastomosis ways are applied to reduce the negative impact of pylorus resection after DG. Furthermore, it should also be considered that reasonable vagal nerves preservation and lymph node dissection are both important for function preserving gastrectomy of EGC. Rational use of laparoscopy-assisted gastrectomy has advantages of lower invasiveness, faster recovery, etc. And the amplification effect of laparoscope can contribute to preserving nerves and gastric function.
Subject(s)
Humans , Esophagitis, Peptic , Gastrectomy , Methods , Gastroenterostomy , Gastroesophageal Reflux , Laparoscopy , Lymph Node Excision , Organ Sparing Treatments , Postoperative Period , Pylorus , General Surgery , Quality of Life , Stomach Neoplasms , General Surgery , Vagus NerveABSTRACT
ObjectiveTo investigate rational surgical approaches for Siewert type Ⅰ adenocarcinoma of the esophagogastric junction (AEG),and analyze the prognostic factors.MethodsThe clinical data of 103 patients with Siewert type Ⅰ AEG who were admitted to the Renji Hospital from January 2005 to December 2009 were retrospectively analyzed.All patients were divided into transthoracic approach group (61 patients) and thoracoabdominal approach group (42 patients).The incidences of numbers of lymph node dissected and postoperative complications of the 2 groups were compared using the chi-square test,Fisher exact probability or the t test.The survival curve was drawn by the Kaplan-Meier method and the survival was analyzed using the Log-rank test.Prognostic factors were analyzed using the one-way analysis of variance and Cox regression model.ResultsNo perioperative death was observed in the 2 groups.There were significant differences in the number of lymph node dissected and number of metastatic lymph node between the 2 groups (t =2.18,2.29,P ＜ 0.05 ).There was no significant difference in splenic injury between the 2 groups (P ＞ 0.05 ).There were no significant differences in postoperative bleeding,anastomotic fistula and stricture,esophagogastric reflux,pulmonary infection and esteomyelitis between the 2 groups (x2 =0.07,0.94,0.22,1.41,0.17,P＞0.05).Of the 103 patients,97(94.2％) were followed up.The mean postoperative survival time was 26 months.The median survival time was 26 months,and the 3-yearsurvival rate was 35.9％.The 3-year survival rates of transthoracic approach group and thoracoabdominal approach group were 32.8％ and 40.2％,with no significant difference between the 2 groups ( x2 =0.37,P ＞ 0.05).The results of univariate analysis showed that radical or palliative resection,TNM stage,lymph node metastasis stage,tumor diameter and metastasis rate,degree of radical resection were independent factors influencing the prognosis of patients with Siewert type Ⅰ AEG (x2 =21.07,26.04,22.42,6.26,32.20,20.80,P＜0.05).The results of multivariate analysis showed that degree of TNM stage,lymph node metastasis rate and radical resection were independent factors influencing the prognosis of patients ( Wald =12.01,8.75,10.03,P ＜ 0.05 ).Conclusions Thoracoabdominal approach is a reasonable selection for patients with Siewert type I AEG.Degree of TNM stage,lymph node metastasis rate and radical resection were independent risk factors influencing the prognosis of patients.
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Objective To investigate the preopera ti ve diagnosis and the surgical treatment of primary retroperitoneal tumor(PRT). Methods The clinical dat a of 71 patients with PRT were retrospectively analyzed including clinical manif estation, radiologic studies, pathologic examination and surgical procedures. Results There were 32 cases of benign tumor, 38 cases of malignant tumor and 1 case of borderline tumor. Of the 32 patients with benign tumor, 31 underwent complete surgical resection. Of the 38 patients with malignant tumor, 29 underwent complete resection. One patie nt with borderline tumor underwent total resection. The 5-year survival rate of benign PRT was 89.29%, the 5-year survival rate of malignant PRT was 20.80%. Four cases of recurrent benign PRT underwent complete resection. Ten cases of r ecurrent malignant PRT underwent complete resection and 3 underwent partial rese ction. ConclusionsRadiolog ical study is crucial for the diagnosis. Complete resection is the key for the t reatment of PRT.
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Objective To explore the diagnosis and re-operation of the recurrent retroperitoneal soft tissue sarcoma(RPS).Methods Clinical data of 25 patients with recurrent RPS were retrospectively analyzed.Results All of 25 cases of recurrent RPS were diagnosed by operation and postoperative pathologic examination.They underwent a total of 42 time operations,with mean time of re-operations was 1.68.Of the 42 time operations,26 time were complete resection,11 time partial resection and 5 time only biopsy.A total of 19 cases underwent removal of contiguous intra-abdominal organs and 5 underwent resection of major invaded blood vessel.The 1-,3-and 5-year survival rate of recurrent RPS was 52.0%,40.0% and 28.0% respectively.The rate of complete resection in recurrent RPS with major blood vessel invasion was 35.7%.In contrast,the complete resection rate in recurrent RPS without major blood vessel invasion was 75%(P=0.013).On the other hand,there was no significant difference in complete resection rate between the recurrent RPS with adjacent organs invasion and the recurrent RPS with no adjacent organs invasion(P=0.462).Conclusions Preoperative imaging results are crucial factor for assessment of operative resectability.Unless there are obvious comtraindications,recurrent RPS should undergo aggressive surgical excision.