The short-term outcomes of totally robotic surgical system and robotic surgical system assisted radical gastrectomy for gastric cancer / 中华消化外科杂志

Objective:To investigate the short-term outcomes of totally robotic surgical system and robotic surgical system assisted radical gastrectomy for gastric cancer.Methods:The retrospective cohort study was conducted. The clinicopathological data of 290 patients who under-went robotic surgical system radical gastrectomy for gastric cancer in the First Affiliated Hospital of Army Medical University from January 2018 to November 2021 were collected. There were 208 males and 82 females, aged 58 (range, 24?84)years. Of the 290 patients, 125 patients undergoing totally robotic surgical system radical gastrectomy combined with reconstruction of digestive tract were divided into the totally robot group, and 165 patients undergoing robotic surgical system radical gastrectomy combined with a small midline incision-assisted reconstruction of digestive tract were divided into the robotic-assisted group. Observation indicators: (1) surgical and postoperative situations; (2) postoperative complications. 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 Mann-Whitney U test. Comparison of ordinal data was conducted using the non-parameter 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. Results:(1) Surgical and postoperative situations. The operation time, volume of intraoperative blood loss, length of incision, duration of postoperative analgesic using, time to postoperative gastric tube removal, time to postoperative initial water intake, time to postoperative first anal flatus, duration of post-operative hospital stay were (246±43)minutes, (104±51)mL, 4(range, 3?6)cm, (2.2±0.5)days, 36(range, 10?112)hours, 62(range, 32?205)hours, 63(range, 18?138)hours, 8(range, 6?50)days in patients of the totally robot group, versus (296±59)minutes, (143±87)mL, 6(range, 3?13)cm, (3.6±0.7)days, 42(range, 12?262)hours, 90(range, 18?262)hours, 80(range, 16?295)hours, 9(range, 6?63)days in patients of the robotic-assisted group, showing significant differences in the above indicators between the two groups ( t=8.04, 4.42, Z=?13.98, t=18.46, Z=?5.47, ?5.87, ?6.14, ?4.04, P<0.05). (2) Post-operative complications. Cases with systemic related complications and cases with pulmonary infection were 7 and 4 in patients of the totally robot group, versus 31 and 16 in patients of the robotic-assisted group, showing significant differences in the above indicators between the two groups ( χ2=10.86, 4.68, P<0.05). Further analysis showed that there were significant differences in age ≥60 years, body mass index ≥25 kg/m 2, tumor diameter ≥3 cm, TNM staging as stage Ⅲ of cases with postoperative complications between the totally robot group and the robotic-assisted group ( odds ratio=0.44, 0.17, 0.40, 0.31, 95 confidence interval as 0.20?1.00, 0.03?0.88, 0.18?0.89, 0.11?0.84, P<0.05). Conclusion:Totally robotic surgical system radical gastrectomy for gastric cancer is safe and feasible with advantages of minimal trauma and quick recovery, especially for patients as age ≥60 years, body mass index ≥25 kg/cm 2, tumor diameter ≥3 cm and TNM stage Ⅲ in complication controlling.

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.

The 10-year outcome and prognostic factors of laparoscopic D 2 radical distal gastrectomy for locally advanced gastric cancer: a CLASS multicenter study / 中华消化外科杂志

Objective:To investigate the 10-year outcome and prognostic factors of laparo-scopic D 2 radical distal gastrectomy for locally advanced gastric cancer. Methods:The retrospec-tive cohort study was conducted. The clinicopathological data of 652 patients with locally advanced gastric cancer who were admitted to 16 hospitals from the multicenter database of laparoscopic gastric cancer surgery in the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group, including 214 cases in the First Affiliated Hospital of Army Medical University, 191 cases in Fujian Medical University Union Hospital, 52 cases in Nanfang Hospital of Southern Medical University, 49 cases in West China Hospital of Sichuan University, 43 cases in Xijing Hospital of Air Force Medical University, 25 cases in Jiangsu Province Hospital of Chinese Medicine, 14 cases in the First Medical Center of the Chinese PLA General Hospital, 12 cases in No.989 Hospital of PLA, 12 cases in the Third Affiliated Hospital of Sun Yat-Sen University, 10 cases in the First Affiliated Hospital of Nanchang University, 9 cases in the First People's Hospital of Foshan, 7 cases in Zhujiang Hospital of Southern Medical University, 7 cases in Fujian Medical University Cancer Hospital, 3 cases in Zhongshan Hospital of Fudan University, 2 cases in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 2 cases in Peking University Cancer Hospital & Institute, from February 2004 to December 2010 were collected. There were 442 males and 210 females, aged (57±12)years. All patients underwent laparoscopic D 2 radical distal gastrectomy. Observation indicators: (1) surgical situations; (2) postoperative pathological examination; (3) postoperative recovery and complications; (4) follow-up; (5) prognostic factors analysis. Follow-up was conducted by outpatient examination and telephone interview to detect the tumor recurrence and metastasis, postoperative survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers or percen-tages, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was analyzed using the rank sum test. The life table method was used to calculate survival rates and the Kaplan-Meier method was used to draw survival curves. Log-Rank test was used for survival analysis. Univariate and multivariate analyses were analyzed using the COX hazard regression model. Results:(1) Surgical situations: among 652 patients, 617 cases underwent D 2 lymph node dissection and 35 cases underwent D 2+ lymph node dissection. There were 348 cases with Billroth Ⅱ anastomosis, 218 cases with Billroth Ⅰ anastomosis, 25 cases with Roux-en-Y anastomosis and 61 cases with other digestive tract reconstruction methods. Twelve patients had combined visceral resection. There were 569 patients with intraoperative blood transfusion and 83 cases without blood transfusion. The operation time of 652 patients was 187(155,240)minutes and volume of intraoperative blood loss was 100(50,150)mL. (2) Postoperative pathological examina-tion: the maximum diameter of tumor was (4.5±2.0)cm of 652 patients. The number of lymph node dissected of 652 patients was 26(19,35), in which the number of lymph node dissected was >15 of 570 cases and ≤15 of 82 cases. The number of metastatic lymph node was 4(1,9). The proximal tumor margin was (4.8±1.6)cm and the distal tumor margin was (4.5±1.5)cm. Among 652 patients, 255 cases were classified as Borrmann type Ⅰ-Ⅱ, 334 cases were classified as Borrmann type Ⅲ-Ⅳ, and 63 cases had missing Borrmann classification data. The degree of tumor differentiation was high or medium in 171 cases, low or undifferentiated in 430 cases, and the tumor differentiation data was missing in 51 cases. There were 123, 253 and 276 cases in pathological stage T2, T3 and T4a, respectively. There were 116, 131, 214 and 191 cases in pathological stage N0, N1, N2 and N3, respectively. There were 260 and 392 cases in pathological TNM stage Ⅱ and Ⅲ, respectively. (3) Postoperative recovery and complications: the time to postoperative first out-of-bed activities, time to postoperative first flatus, time to the initial liquid food intake, duration of postoperative hospital stay of 652 patients were 3(2,4)days, 4(3,5)days, 5(4,6)days, 10(9,13)days, respectively. Among 652 patients, 69 cases had postoperative complications. Clavien-Dindo grade Ⅰ-Ⅱ, grade Ⅲa, grade Ⅲb, and grade Ⅳa complications occurred in 60, 3, 5 and 1 cases, respectively (some patients could have multiple complications). The duodenal stump leakage was the most common surgical complication, with the incidence of 3.07%(20/652). Respiratory complication was the most common systemic complication, with the incidence of 2.91%(19/652). All the 69 patients were recovered and discharged successfully after treatment. (4) Follow-up: 652 patients were followed up for 110-193 months, with a median follow-up time of 124 months. There were 298 cases with postoperative recurrence and metastasis. Of the 255 patients with the time to postoperative recurrence and metastasis ≤5 years, there were 21 cases with distant metastasis, 69 cases with peritoneal metastasis, 37 cases with local recurrence, 52 cases with multiple recurrence and metastasis, 76 cases with recurrence and metastasis at other locations. The above indicators were 5, 9, 10, 4, 15 of the 43 patients with the time to postoperative recurrence and metastasis >5 years. There was no significant difference in the type of recurrence and metastasis between them ( χ2=5.52, P>0.05). Cases in pathological TNM stage Ⅱ and Ⅲ were 62 and 193 of the patients with the time to postoperative recurrence and metastasis ≤5 years, versus 23 and 20 of the patients with the time to postoperative recurrence and metastasis >5 years, showing a significant difference in pathological TNM staging between them ( χ2=15.36, P<0.05). Cases in pathological stage T2, T3, T4a were 42, 95, 118 of the patients with the time to postoperative recurrence and metastasis ≤5 years, versus 9, 21, 13 of the patients with the time to postoperative recurrence and metastasis >5 years, showing no significant difference in pathological T staging between them ( Z=-1.80, P>0.05). Further analysis showed no significant difference in cases in pathological stage T2 or T3 ( χ2=0.52, 2.08, P>0.05) but a significant difference in cases in pathological stage T4a between them ( χ2=3.84, P<0.05). Cases in pathological stage N0, N1, N2, N3 were 19, 44, 85, 107 of the patients with the time to postoperative recurrence and metastasis ≤5 years, versus 12, 5, 18, 8 of the patients with the time to postoperative recurrence and metastasis >5 years, showing a significant difference in pathological N staging between them ( Z=-3.34, P<0.05). Further analysis showed significant differences in cases in pathological stage N0 and N3 ( χ2=16.52, 8.47, P<0.05) but no significant difference in cases in pathological stage N1 or N2 ( χ2=0.85, 1.18, P>0.05). The median overall survival time was 81 months after surgery and 10-year overall survival rate was 46.1% of 652 patients. The 10-year overall survival rates of patients in TNM stage Ⅱ and Ⅲ were 59.6% and 37.5%, respectively, showing a significant difference between them ( χ2=35.29, P<0.05). In further analysis, the 10-year overall survival rates of patients in pathological TNM stage ⅡA, ⅡB, ⅢA, ⅢB and ⅢC were 65.6%, 55.8%, 46.9%, 37.1% and 24.0%, respectively, showing a significant difference between them ( χ2=55.06, P<0.05). The 10-year overall survival rates of patients in patholo-gical stage T2, T3 and T4a were 55.2%, 46.5% and 41.5%, respectively, showing a significant difference between them ( χ2=8.39, P<0.05). The 10-year overall survival rates of patients in patholo-gical stage N0, N1, N2 and N3 were 63.7%, 56.2%, 48.5% and 26.4%, respectively, showing a signifi-cant difference between them ( χ2=54.89, P<0.05). (5) Prognostic factors analysis: results of univariate analysis showed that age, maximum diameter of tumor, degree of tumor differentiation as low or undifferentiated, pathological TNM staging, pathological T staging, pathological stage N2 or N3, post-operative chemotherapy were related factors for the 10-year overall survival rate of locally advanced gastric cancer patients undergoing laparoscopic D 2 radical distal gastrectomy ( hazard ratio=1.45, 1.64, 1.37, 2.05, 1.30, 1.68, 3.08, 0.56, 95% confidence interval as 1.15-1.84, 1.32-2.03, 1.05-1.77, 1.62-2.59, 1.05-1.61, 1.17-2.42, 2.15-4.41, 0.44-0.70, P<0.05). Results of multivariate analysis showed that maximum diameter of tumor >4 cm, low-differentiated or undifferentiated tumor, pathological TNM stage Ⅲ were independent risk factors for the 10-year overall survival rate of locally advanced gastric cancer patients undergoing laparoscopic D 2 radical distal gastrectomy ( hazard ratio=1.48,1.44, 1.81, 95% confidence interval as 1.19-1.84, 1.11-1.88, 1.42-2.30, P<0.05) and postoperative chemotherapy was a independent protective factor for the 10-year overall survi-val rate of locally advanced gastric cancer patients undergoing laparoscopic D 2 radical distal gastrec-tomy ( hazard ratio=0.57, 95% confidence interval as 045-0.73, P<0.05). Conclusions:Laparoscopic assisted D 2 radical distal gastrectomy for locally advanced gastric cancer has satisfactory 10-year oncologic outcomes. A high proportion of patients in pathological TNM stage Ⅲ, pathological stage T4a, pathological stage N3 have the time to postoperative recurrence and metastasis ≤5 years, whereas a high proportion of patients in pathological TNM stage Ⅱ or pathological stage N0 have the time to postoperative recurrence and metastasis >5 years. Maximum diameter of tumor >4 cm, low-differentiated or undifferentiated tumor, pathological TNM stage Ⅲ are independent risk factors for the 10-year overall survival rate of locally advanced gastric cancer patients undergoing laparos-copic D 2 radical distal gastrectomy. Postoperative chemotherapy is a independent protective factor for the 10-year overall survival rate of locally advanced gastric cancer patients undergoing laparos-copic D 2 radical distal gastrectomy.

Technical points of 4K laparoscopic intersphincteric resection of low rectal cancer / 中华消化外科杂志

Intersphincteric resection (ISR) is a limited sphincter preserving surgery for low rectal cancer. The 4K laparoscopic system has the advantage of enhancing the accurate recognition of anatomical structures for operators. The authors investigate the imaging evaluation and technical standard of 4K laparoscopic ISR of low rectal cancer through surgical examples.

Short-term efficacy of laparoscopic gastrectomy versus open gastrectomy for advanced gastric cancer after neoadjuvant chemotherapy: a Meta-analysis / 中华消化外科杂志

Laparoscopic gastrectomy (LG) has been proven to be safe and feasible and widely used in surgical treatment of early and advanced gastric cancer (AGC), which has advantages over open gastrectomy in intraoperative bleeding and postoperative recovery. Neoadjuvant chemo-therapy (NACT) could achieve the effect of tumor downstaging and provide more surgical treatment chances for patients with AGC, thus improving their prognosis. Feasibility of LG for patients with AGC after NACT is a crucial problem for surgeons. The authors review the relevant studies and conducte a Meta-analysis to evaluate the short-term efficacy of laparoscopic versus open gastrec-tomy in the treatment of AGC after NACT.

Lymph node dissection along the left gastroepiploic vessels region in 4K laparoscopic radical gastrectomy with the surgeon on left position / 中华消化外科杂志

Minimally invasive surgery experienced a rapid development in the past thirty years, of which the laparoscopy has been widely used in gastrointestinal surgery. Lymph node dissection is one of the difficulties of laparoscopic radical resection of gastric cancer. The lymph node dissection along the left gastroepiploic vessels is a difficult part, which usually causes bleeding and splenic injury. This article mainly introduce the indications, contraindications, surgical preparations, the difficulties and techniques during the lymph nodes dissection when the operator stood on the left side of the patients, and perioperative complications of lymph nodes dissection along the left gastroepiploic vessels.

Extent of lymph node dissection and interpretation of technical standards for 4K laparoscopic radical total gastrectomy / 中华消化外科杂志

The technique of lymph node dissection in laparoscopic radical total gastrectomy is very difficult. The surgeons should strictly grasp the operation indications, cooperate closely with the team during the operation, standardize the extent of lymph node dissection according to the radical resection stan-dards, and realize standardized and accurate operation with the help of 4K laparoscopic system, so as to reduce the occurrence of complications.

Clinical value of semi-end-to-end esophagojejunal anastomosis versus side-to-side esophagojejunal anastomosis in laparoscopic total gastrectomy for adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the clinical value of semi-end-to-end esophagojejunal anastomosis versus side-to-side esophagojejunal anastomosis in laparoscopic total radical gastrectomy for adenocarcinoma of esophagogastric junction.Methods:The retrospective cohort study was conducted. The clinical data of 85 patients with adenocarcinoma of esophagogastric junction who were admitted to the First Hospital Affiliated to Army Medical University from January 2016 to January 2019 were collected. There were 65 males and 20 females, aged (58±10)years, with a range of 36 to 84 years. Of the 85 patients, 46 patients undergoing laparoscopic total gastrectomy+ D 2 lymphadenectomy+ semi-end-to-end esophagojejunal anastomosis were allocated into semi-end-to-end anastomosis group, and 39 patients undergoing laparoscopic radical total gastrectomy+ D 2 lymphadenectomy+ side-to-side esophagojejunal anastomosis were allocated into side-to-side anastomosis group. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was performed by outpatient examination and telephone interview to detect the survival, anastomotic stenosis and tumor recurrence at postoperative one year up to January 2020. Measurement data with normal distribution were expressed as Mean± SD, and comparison between groups was analyzed using the t test. Count data were expressed as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ranked data was analyzed using the nonparametric rank sum test. Results:(1) Surgical situations: patients of two groups successfully underwent laparoscopic total gastrectomy with D 2 lymph node dissection, without conversion to open surgery or perioperative death. The proximal length between tumor and surgical margin, time of esophagojejunal anastomosis, length of auxiliary incision were (2.3±0.9)cm, (32±3)minutes, (7.5±1.6)cm for the semi-end-to-end anastomosis group, respectively, versus (1.6±1.0)cm, (42±5)minutes, (4.8±1.2)cm for the side-to-side anastomosis group, showing significant differences between the two groups ( t=3.334, 10.177, 8.734, P<0.05). During the esophageal jejunal anastomosis, one patient in the side-to-side anastomosis group had proximal jejunum punctured by a linear cutting stapler resulting in jejunal rupture. The ruptured segment of jejunum was resected and the mesojejunum was freed to perform side-to-side anastomosis. (2) Postoperative situations: there was 1 and 7 patients with postoperative anastomotic bleeding in the semi-end-to-end anastomosis group and side-to-side anastomosis group, respectively, showing a significant difference ( χ2=4.449, P<0.05). Patients with postoperative anastomotic bleeding in the semi-end-to-end anastomosis group and side-to-side anastomosis group were cured after conservative treatment including blood transfusion and endoscopic hemostasis. One patient with esophagojejunal fistula in the side-to-side anastomosis group was cured after conservative treatment including puncture drainage and anti-infective treatment. Two patients with duodenal stump fistula in side-to-side anastomosis group were cured by anti-infection, puncture drainage and nutritional support. Eight patients with pulmonary infection (5 cases in semi-end-to-end anastomosis group and 3 cases in side-to-side anastomosis group) were cured by anti-infection, atomization and expectorant therapy. Three patients with abdominal infection (2 cases in semi-end-to-end anastomosis group and 1 case in side-to-side anastomosis group) were cured by anti-infection and abdominal puncture drainage. One case with incisional infection in semi-end-to-end anastomosis group was cured by dressing change and anti-infective treatment. (3) Follow-up: all the 85 patients were followed up for 1 year. During the follow-up, 3 and 2 patients died in semi-end-to-end anastomosis group and side-to-side anastomosis group, 0 and 2 patients had anastomotic stricture. There was no anastomotic recurrence. Conclusion:In laparoscopic total gastrectomy of adenocarcinoma of esophagogastric junction, semi-end-to-end esophagojejunal anastomosis has the advantages of higher proximal surgical magin from the tumor, shorter anastomosis time, less postoperative anastomotic bleeding, while side-to-side anastomosis anastomosis has shorter length of auxiliary incision.

A comparative study on short-term outcomes of Da Vinci robotic versus laparoscopic and open surgery for locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the short-term outcomes of Da Vinci robotic versus laparoscopic and open surgery for locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 404 patients with locally advanced Siewert type Ⅱ and Ⅲ AEG who underwent radical gastrectomy in the First Hospital Affiliated to Army Medical University from January 2009 to April 2019 were collected. There were 331 males and 73 females, aged from 34 to 90 years, with a median age of 62 years. Of the 404 patients, 104 undergoing Da Vinci robotic radical gastrectomy were allocated into robotic group, 205 undergoing laparoscopic radical gastrectomy were allocated into laparoscopic group, and 95 undergoing open radical gastrectomy were allocated into open group. Observation indicators: (1) the propensity score matching conditions and comparison of general data among the three groups after propensity score matching; (2) surgical situations; (3) intraoperative lymph node dissection; (4) postoperative situations; (5) postoperative complications; (6) follow-up. Patients were followed up at postoperative 1 month by outpatient examination and telephone interview to detect survival and severe complications up to June 2019. The propensity score matching was used to perform 1∶2∶1 nearest neighbor matching by SPSS 23.0 and R software 3.6.1 Matchit among the robotic group, laparoscopic group and open group. Measurement data with normal distribution were represented as Mean± SD, and comparison among groups was done using one-way ANOVA analysis. Measurement data with skewed distribution were represented as M (range), and comparison was done using the Kruskal-Wallis H test. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison among groups was done using the chi-square test. Results:(1) The propensity score matching conditions and comparison of general data among the three groups after propensity score matching: 312 of 404 patients had successful matching, including 78 in the robotic group, 156 in the laparoscopic group, and 78 in the open group. The age, cases in G1, G2, G3 (histopathological classification) and cases with proximal gastrectomy or total gastrectomy (surgical resection range) before matching were (62.2±1.0)years, 0, 37, 67, 13, 91 in the robotic group, (60.9±8.1)years, 0, 98, 107, 31, 174 in the laparoscopic group, and (58.5±9.8)years, 1, 32, 62, 27, 68 in the open group, showing significant differences among the three groups ( F=4.269, 6.356, χ2=10.416, P<0.05). The above indicators after matching were (61.2±10.8)years, 0, 28, 50, 12, 66 in the robotic group, (60.7±8.0)years, 0, 56, 100, 25, 131 in the laparoscopic group, and (60.7±8.4)years, 0, 25, 53, 18, 60 in the open group, showing no significant difference among the three groups ( F=0.074, 0.379, χ2=2.141, P>0.05). (2) Surgical situations: the surgical time, volume of intraoperative blood loss, length of surgical incision, length of proximal margin after matching were 300.0 minutes(range, 188.0-420.0 minutes), 137.5 mL(range, 50.0-400.0 mL), 6.0 cm(range, 3.0-12.0 cm), 2.5 cm(range, 1.5-5.5 cm) in the robotic group, 276.0 minutes(range, 180.0-400.0 minutes), 150.0 mL(range, 40.0-800.0 mL), 6.0 cm(range, 3.0-12.0 cm), 3.0 cm(range, 1.0-5.0 cm) in the laparoscopic group, and 244.5 minutes(range, 125.0-461.0 minutes), 200.0 mL(range, 55.0-800.0 mL), 20.0 cm(range, 18.0-25.0 cm), 2.0 cm(range, 1.0-5.5 cm) in the open group, showing significant differences among the three groups ( χ2=27.619, 30.069, 179.367, 11.560, P<0.05). (3) Intraoperative lymph node dissection: the number of lymph node dissected, the number of lymph node dissected in the first station, the number of diaphragmatic and periesophageal lymph node dissected were 30.5(range, 10.0-70.0), 18.0(range, 6.0-42.0), 4.0(range, 0-13.0) in the robotic group, 29.0(range, 12.0-79.0), 19.0(range, 6.0-47.0), 5.0(range, 0-15.0) in the laparoscopic group, and 29.0(range, 18.0-58.0), 18.0(range, 12.0-38.0), 5.0(range, 0-8.0) in the open group, showing no significant difference among the three groups ( χ2=3.676, 1.014, 0.827, P>0.05). The number of lymph node dissected in the second station, the number of lymph node dissected in the superior pancreatic region, the number of No.110 lymph node dissected, the number of No.111 lymph node dissected after matching were 9.0(range, 2.0-30.0), 9.0(range, 2.0-30.0), 1.0(range, 0-4.0), 0(range, 0-3.0) in the robotic group, 6.5(range, 0-25.0), 7.0(range, 0-25.0), 0(range, 0-3.0), 0(range, 0-4.0) in the laparoscopic group, and 6.5(range, 0-19.0), 6.5(range, 0-19.0), 0(range, 0-1.0), 0(range, 0-1.0) in the open group, showing significant differences among the three groups ( χ2=19.027, 24.368, 19.236, 11.147, P<0.05). (4) Postoperative situations: the time to first flatus, time to initial out-of-bed activities, duration of postoperative hospital stay, treatment expenses after matching were 3 days(range, 2-5 days), 2 days(range, 1-4 days), 9 days(range, 5-20 days), 10.6×10 4 yuan [range, (5.4-18.0)×10 4 yuan] in the robotic group, 3 days(range, 2-8 days), 2 days(range, 1-7 days), 9 days(range, 6-56 days), 8.6×10 4 yuan[range, (5.7-40.8)×10 4 yuan] in the laparoscopic group, and 4 days(range, 2-10 days), 4 days(range, 2-10 days), 11 days(range, 8-41 days), 8.4×10 4 yuan[range, (5.8-15.2)×10 4 yuan] in the open group, showing significant differences among the three groups ( χ2=28.487, 95.069, 39.443, 83.899, P<0.05). (5) Postoperative complications: the incidence of overall complications, incidence of severe complications (Clavien-Dindo classification ≥grade 3), incidence of gastrointestinal complications, incidence of incisional complications, incidence of respiratory complications, incidence of infection were 21.8%(17/78), 5.1%(4/78), 10.3%(8/78), 1.3%(1/78), 7.7%(6/78), 2.6%(2/78) in the robotic group, 21.8%(34/156), 7.1%(11/156), 5.1%(8/156), 1.3%(2/156), 11.5%(18/156), 3.8%(6/156) in the laparoscopic group, and 29.5%(23/78), 6.4%(5/78), 9.0%(7/78), 2.6%(2/78), 14.1%(11/78), 2.6%(2/78) in the open group, showing no significant difference among the three groups ( χ2=1.913, 0.321, 2.394, 0.866, 1.641, 0.335, P>0.05). (6) Follow-up: 312 patients after propensity score matching were follow up at postoperative 1 month. During the follow-up, 2 cases with severe complications died after discharge. No severe complication such as obstruction of input or output loop, dumping syndrome was found in the other 310 patients. Conclusions:The Da Vinci robotic radical gastrectomy is safe and feasible for locally advanced Siewert type Ⅱ and Ⅲ AEG. Compared with laparoscopic and open radical gastrectomy, Da Vinci robotic radical gastrectomy has more advantages in the number of lymph node dissected in the second station (especially in the superior pancreatic region).

Lymph node dissection along the left gastroepiploic vessels region in 4K laparoscopic radical gastrectomy with the surgeon on left position / 中华消化外科杂志

Minimally invasive surgery experienced a rapid development in the past thirty years, of which the laparoscopy has been widely used in gastrointestinal surgery. Lymph node dissection is one of the difficulties of laparoscopic radical resection of gastric cancer. The lymph node dissection along the left gastroepiploic vessels is a difficult part, which usually causes bleeding and splenic injury. This article mainly introduce the indications, contraindications, surgical preparations, the difficulties and techniques during the lymph nodes dissection when the operator stood on the left side of the patients, and perioperative complications of lymph nodes dissection along the left gastroepiploic vessels.

Extent of lymph node dissection and interpretation of technical standards for 4K laparoscopic radical total gastrectomy / 中华消化外科杂志

The technique of lymph node dissection in laparoscopic radical total gastrectomy is very difficult. The surgeons should strictly grasp the operation indications, cooperate closely with the team during the operation, standardize the extent of lymph node dissection according to the radical resection stan-dards, and realize standardized and accurate operation with the help of 4K laparoscopic system, so as to reduce the occurrence of complications.

Analysis of postoperative complications and risk factors of Da Vinci robotic total gastrectomy for gastric cancer / 中华消化外科杂志

Objective@#To analyze the postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer, and explore the risk factors for postoperative complications.@*Methods@#The retrospective case-control study was conducted. The clinicopathological data of 173 patients with gastric cancer who were admitted to the First Affiliated Hospital of Army Medical University from March 2010 to March 2019 were collected. There were 138 males and 35 females, aged from 34 to 76 years, with an average age of 60 years. All the 173 patients underwent Da Vinci robotic total gastrectomy for gastric cancer. Observation indicators: (1) postoperative complications; (2) analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer. Count data were expressed as absolute numbers or percentages. Univariate analysis was performed using the chi-square test or Fisher exact probability. Indicators with P<0.1 were included into multivariate analysis, and multivariate analysis was performed using logistic regression model.@*Results@#(1) Postoperative complications: of the 173 patients, 45 had postoperative complications, with a incidence rate of 26.0%(45/173). Among the 45 patients, 5 had gradeⅠpostoperative complications, 31 had grade Ⅱ postoperative complications, 2 had grade Ⅲa postoperative complications, 3 had grade Ⅲb postoperative complications, 1 had grade Ⅳa postoperative complications, 1 had grade Ⅳb postoperative complications, and 2 had grade Ⅴ postoperative complications. The incidence of serious complications was 5.2%(9/173). Of the 5 patients with gradeⅠcomplications, 1 of fever was improved after antipyretic treatment, 2 of incisional fat liquefaction were improved after dressing change, 1 of vomiting was improved after being given antiemetic, and 1 of delayed recovery of gastrointestinal function was improved after symptomatic treatment. Among 31 patients with gradeⅡcomplications, 12 patients had pulmonary infection, including 6 of pulmonary infection alone, 3 combined with pleural effusion, 1 combined with abdominal infection, 2 combined with intestinal obstruction, and all were improved after conservative treatment; 7 of fever were improved after anti-infection treatment; 4 patients had deep venous catheter infection including 1 combined with bilateral pleural effusion, and were improved after removing catheter and anti-infection treatment; 3 patients had anastomotic leakage including 1 with pulmonary infection and abdominal infection, and were improved after conservative treatment; 2 patients had duodenal stump leakage (1 combined with pulmonary infection, 1 combined with pulmonary infection and pleural effusion) , and were improved after conservative treatment; 1 patient had abdominal hemorrhage, and was improved after conservative treatment; 1 patient had intestinal obstruction, and was improved after conservative treatment; 1 patient had abdominal infection, and was improved after conservative treatment. Of the 2 patients with grade Ⅲa complications, 1 had duodenal stump leakage combined with abdominal abscess, and was improved after puncture and drainage; 1 had pleural effusion combined with pulmonary infection, and was improved after puncture and drainage. Among the 3 patients with grade Ⅲb complications, 1 of abdominal hemorrhage was improved after reoperation, 2 of anastomotic leakage were improved after being placed jejunal nutrition tube under painless gastroscopy. Of the 2 cases, 1 combined with abdominal infection and 1 combined with pleural effusion and abdominal infection were improved after puncture and drainage. Among the 2 patients with grade Ⅳ complications, 1 of Ⅳa encountering respiratory failure was improved after treatment due to misinhalation of anesthesia, and 1 of Ⅳb suffered from multiple organ failure and was improved after treatment due to anastomotic leakage. Two patients with grade V complication died, including one with anastomotic leakage, abdominal hemorrhage, and multiple organ failure, and the other with respiratory failure and cardiac insufficiency. In the 173 patients, the incidence of comprehensive complication index (CCI) ≥ 25.2 was 11.0%(19/173). (2) Analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer: univariate analysis showed that body mass index (BMI), volume of intraoperative blood loss, and operation time were the related factors affecting the postoperative complications (χ2=4.275, 5.057, 5.463, P<0.05). BMI and volume of intraoperative blood loss were the related factors affecting the postoperative serious complications (χ2=7.517, 5.537, P<0.05). Age, BMI and Charlson Comorbidity Index were the related factors affecting CCI ≥25.2 (χ2=8.946, 7.890, 4.062, P<0.05). Multivariate analysis showed that tumor diameter ≥ 3 cm and tumor located at esophagogastric junction were independent risk factors for postoperative complications [odds ratio (OR) =4.350, 2.175, 95% confidence interval (CI): 1.352-14.000, 1.018-4.647, P<0.05)]. BMI ≥25 kg/m2 was an independent risk factor for serious complications after operation (OR=5.156, 95%CI: 1.120-23.738, P<0.05). Age ≥60 years, BMI ≥25 kg/m2, and history of abdominal surgery were independent risk factors for CCI≥25.2 (OR=30.928, 3.557, 6.009, 95%CI: 1.485-644.19, 1.082-11.691, 1.358-26.592, P<0.05).@*Conclusions@#The Clavien-Dindo classification of patients after Da Vinci robotic total gastrectomy for gastric cancer is mostly gradeⅡ. The main complications are pulmonary-related complications. CCI can better predict the risk factors for serious complications after operation. Tumor diameter ≥ 3 cm and tumor located at esophagogastric junction are independent risk factors for postoperative complications; BMI ≥25 kg/m2 is an independent risk factor for serious complications; age ≥60 years, BMI ≥25 kg/m2, and history of abdominal surgery are independent risk factors for CCI≥25.2.

Analysis of postoperative complications and risk factors of Da Vinci robotic total gastrectomy for gastric cancer / 中华消化外科杂志

Objective To analyze the postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer,and explore the risk factors for postoperative complications.Methods The retrospective casecontrol study was conducted.The clinicopathological data of 173 patients with gastric cancer who were admitted to the First Affiliated Hospital of Army Medical University from March 2010 to March 2019 were collected.There were 138 males and 35 females,aged from 34 to 76 years,with an average age of 60 years.All the 173 patients underwent Da Vinci robotic total gastrectomy for gastric cancer.Observation indicators:(1) postoperative complications;(2) analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer.Count data were expressed as absolute numbers or percentages.Univariate analysis was perform7d using the chi-square test or Fisher exact probability.Indicators with P ＜ 0.l were included into multivariate analysis,and multivariate analysis was performed using logistic regression model.Results (1) Postoperative complications:of the 173 patients,45 had postoperative complications,with a incidence rate of 26.0％ (45/173).Among the 45 patients,5 had grade Ⅰ postoperative complications,31 had grade Ⅱ postoperative complications,2 had grade Ⅲ a postoperative complications,3 had grade Ⅲ b postoperative complications,1 had grade Ⅳ a postoperative complications,1 had grade Ⅳ b postoperative complications,and 2 had grade Ⅴ postoperative complications.The incidence of serious complications was 5.2％ (9/173).Of the 5 patients with grade Ⅰ complications,1 of fever was improved after antipyretic treatment,2 of incisional fat liquefaction were improved after dressing change,1 of vomiting was improved after being given antiemetic,and 1 of delayed recovery of gastrointestinal function was improved after symptomatic treatment.Among 31 patients with grade Ⅱ complications,12 patients had pulmonary infection,including 6 of pulmonary infection alone,3 combined with pleural effusion,1 combined with abdominal infection,2 combined with intestinal obstruction,and all were improved after conservative treatment;7 of fever were improved after anti-infection treatment;4 patients had deep venous catheter infection including 1 combined with bilateral pleural effusion,and were improved after removing catheter and antiinfection treatment;3 patients had anastomotic leakage including 1 with pulmonary infection and abdominal infection,and were improved after conservative treatment;2 patients had duodenal stump leakage (1 combined with pulmonary infection,1 combined with pulmonary infection and pleural effusion),and were improved after conservative treatment;1 patient had abdominal hemorrhage,and was improved after conservative treatment;1 patient had intestinal obstruction,and was improved after conservative treatment;1 patient had abdominal infection,and was improved after conservative treatment.Of the 2 patients with grade Ⅲ a complications,1 had duodenal stump leakage combined with abdominal abscess,and was improved after puncture and drainage;1 had pleural effusion combined with pulmonary infection,and was improved after puncture and drainage.Among the 3 patients with grade Ⅲ b complications,1 of abdominal hemorrhage was improved after reoperation,2 of anastomotic leakage were improved after being placed jejunal nutrition tube under painless gastroscopy.Of the 2 cases,1 combined with abdominal infection and 1 combined with pleural effusion and abdominal infection were improved after puncture and drainage.Among the 2 patients with grade Ⅳ complications,1 of Ⅳa encountering respiratory failure was improved after treatment due to misinhalation of anesthesia,and 1 of Ⅳb suffered from multiple organ failure and was improved after treatment due to anastomotic leakage.Two patients with grade Ⅴ complication died,including one with anastomotic leakage,abdominal hemorrhage,and multiple organ failure,and the other with respiratory failure and cardiac insufficiency.In the 173 patients,the incidence of comprehensive complication index (CCI) ≥ 25.2 was 11.0％ (19/173).(2) Analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer:univariate analysis showed that body mass index (BMI),volume of intraoperative blood loss,and operation time were the related factors affecting the postoperative complications (x2=4.275,5.057,5.463,P＜ 0.05).BMI and volume of intraoper.ative blood loss were the related factors affecting the postoperative serious complications (x2 =7.517,5.537,P ＜ 0.05).Age,BMI and Charlson Comorbidity Index were the related factors affecting CCI ≥ 25.2 (.x2 =8.946,7.890,4.062,P＜ 0.05).Multivariate analysis showed that tumor diameter ≥ 3 cm and tumor located at esophagogastric junction were independent risk factors for postoperative complications [odds ratio (OR) =4.350,2.175,95％ confidence interval (CI):1.352-14.000,1.018-4.647,P＜0.05)].BMI ≥25 kg/m2 was an independent risk factor for serious complications after operation (OR=5.156,95％CI:1.120-23.738,P＜0.05).Age ≥60 years,BMI ≥ 25 kg/m2,and history of abdominal surgery were independent risk factors for CCI ≥25.2 (OR =30.928,3.557,6.009,95％CI:1.485-644.19,1.082-11.691,1.358-26.592,P＜0.05).Conclusions The Clavien-Dindo classification of patients after Da Vinci robotic total gastrectomy for gastric cancer is mostly grade IⅡ.The main complications are pulmonary-related complications.CCI can better predict the risk factors for serious complications after operation.Tumor diameter ≥ 3 cm and tumor located at esophagogastric junction are independent risk factors for postoperative complications;BMI ≥ 25 kg/m2 is an independent risk factor for serious complications;age ≥ 60 years,BMI ≥25 kg/m2,and history of abdominal surgery are independent risk factors for CCI≥25.2.

Problems and strategies in the Da Vinci robotic surgery for gastric cancer / 中华消化外科杂志

Da Vinci robotic surgery for gastric cancer has been performed and accepted gradually in domestic and abroad,due to the advantages of defibrillation,three dimensional (3D) view and flexible,precise,stable operation.However,its indication is controversy,surgical process,lymphadenectomy,digestive reconstruction need to be further regulated.There is lack of prospective case-control study of large sample on short and long term efficacy.Therefore,problems and strategies in the Da Vinci robotic surgery for gastric cancer should be analyzed and evidence-based researches should be strengthened to provide tangible and credible evidence for the Da Vinci robotic surgery for gastric cancer.

Clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer / 中华消化外科杂志

Objective To investigate the clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer.Methods The retrospective cross-sectional study was conducted.The clinical data of 85 patients with right colon cancer who were admitted to the First Hospital Affiliated to Army Medical University from August 2013 to February 2019 were collected.There were 56 males and 29 females,aged from 29 to 84 years,with an average age of 60 years.All patients underwent Da Vinci robot-assisted radical resection of right colon cancer,named right hemicolon D3 + complete mesocolic excision,and received infection prevention and total parenteral nutrition treatment after surgery.According to clinical pathological staging of guideline issued by National Comprehensive Cancer Network,patients underwent postoperative chemotherapy within 1 year after surgery.Observation indicators:(1) treatment status;(2) postoperative pathological examination;(3) follow-up.Follow-up was conducted using outpatient examination,telephone interview and mail every 3 months within 1 year after surgery,every 6 months from 1 to 3 years after surgery,and once a year from 3 to 5 years after surgery up to March 2019.The postoperative tumor metastasis and survival of patients were obtained.Measurement data with normal distribution were represented as Mean±SD,and measurement data with skewed distribution were described as M (range).Count data were expressed as absolute number.Survival rates were calculated using life-table method.Results (1) Treatment status:85 patients underwent Da Vinci robot-assisted right hemicolon D3 + complete mesocolic excision successfully.The operation time,volume of intraoperative blood loss,time for postoperative outof-bed activities,time to recovery of gastrointestinal function,time to liquid diet intake were (178±28) minutes,(85±33) mL,(2.9± 1.8) days,(3.1 ± 2.7) days,(3.9± 1.9) days,respectively.There was no perioperative death.Eleven patients had postoperative complications including 5 of anastomotic leakage,2 of anastomotic bleeding,2 of pulmonary infection,1 of gastric emptying disorder and 1 of incomplete intestinal obstruction;they were cured and discharged after conservative treatment.All the 85 patients received postoperative infection prevention and total parenteral nutrition support,including 64 receiving systemic intravenous chemotherapy with 6 -8 cycles of FOLFOX or XELOX,7 receiving 6-8 cycles of oral capecitabine,and 14 receiving no chemotherapy.(2) Postoperative pathological examination:the number of harvested lymph nodes was 20± 11 and 25 had lymph node metastasis.The length of proximal and distal cutting edge of the specimens was (16±5) cm and (9±5)cm,respectively.There was no cancerous cell on the cutting edge.High-differentiated adenocarcinoma,moderatedifferentiated adenocarcinoma,moderate-differentiated tubular adenocarcinoma,low-differentiated adenocarcinoma,mucinous adenocarcinoma,tubular combined with mucinous adenocarcinoma were detected in 2,40,14,16,9,4 patients,respectively.There were 8,28,24,5,12,8 patients in Ⅰ stage,Ⅱ A stage,Ⅱ B stage,Ⅱ C stage,ⅢB stage,Ⅲ C stage of TNM staging,respectively.(3) Follow-up:85 patients were followed up for 1-67 months,with a median follow-up time of 19 months.During the follow-up,1 of 85 patients had liver metastasis at 14 months after surgery and had survived after radiofrequency ablation treatment up to the end of follow-up.Three cases died of abdominal tumor metastases,1 of which in Ⅱ C stage died at 32 months after surgery,1 in Ⅲ B stage died at 4 months after surgery and 1 in Ⅲ B stage died at 16 months after surgery.The 1-,3-year overall survival rates were 97.1％ and 94.0％,respectively.Conclusion Da Vinci robot-assisted radical resection of right colon cancer is safe and feasible,with good short-and long-term outcomes.

Comparison of clinical efficacy between proximal gastrectomy with double tract reconstruction and total gastrectomy with Roux-en-Y reconstruction for proximal gastric cancer / 中华胃肠外科杂志

Objective@#To compare the clinical efficacy of proximal gastrectomy with double tract reconstruction (PG-DT) and total gastrectomy with Roux-en-Y reconstruction (TG-RY) for proximal gastric cancer.@*Methods@#The retrospective study was conducted. Clinicopathological data of 132 patients with proximal gastric cancer confirmed by pathology who underwent PG-DT (n=51) or TG-RY (n=81) by the same surgeon team in Southwest Hospital of Army Military Medical University between January 2006 and December 2016 were collected. Patients with preoperative neoadjuvant therapy, non-R0 resection and non-adenocarcinoma confirmed by pathology were excluded. Observation indicators included intraoperative (operation time and blood loss); postoperative (time to flatus, hospital stay, total complications, metastasis of lymph nodes around distal side of stomach from cases undergoing TG-RY), follow-up (long-term hemoglobin level, incidence of anemia, and survival) parameters. Survival analysis was conducted using the Kaplan-Meier method, and Log-rank test was used to compare survival difference between two groups.@*Results@#No statistically significant differences were found between two groups in the baseline data, including age, gender, BMI, hemoglobin level before operation, postoperative TNM stage, tumor size and histological differentiation between two groups (all P>0.05). There were no significant differences between PG-DT and TG-RY in intraoperative blood loss [200 (200) ml vs. 200 (195) ml, Z=-1.860, P=0.063], time to flatus [(2.7±1.0) days vs. (2.6±1.1) days, t=0.225, P=0.823], postoperative hospital stay [10(3) days vs. 10 (4) days, Z=-0.449, P=0.654] and morbidity of perioperative complications [5.9% (3/51) vs. 8.6% (7/81), χ2=0.081, P=0.775]. Compared with the TG-RY group, PG-DT group had longer total operative time [294 (97) minutes vs. 255 (71) minutes, Z=–3.148, P=0.002]. The hemoglobin data of 42 patients with PG-DT and 56 patients with TG-RY were collected 1 year after operation. The incidence of anemia in PG-DT group was lower than that of TG-RY group [64.2%(27/42) vs. 82.1% (46/56), χ2=4.072, P=0.045], and PG-DT group had higher level of hemoglobin than TG-RY group [(114.4±16.3) g/L vs. (106.6±15.0) g/L, t=2.435, P=0.017]. There were 4 cases (4/81, 4.9%) with metastasis of lymph nodes around distal side of stomach in TG-RY group. All of these 4 tumors were T4 in depth and were more than 5 cm in diameter. The median follow-up period was 26 (1 to 110) months. One-year, 3-year and 5-year survival rates were 93.2%, 65.3% and 55.0% in PG-DT group, and 85.8%, 63.8% and 47.2% in TG-RY group, respectively without significant difference (χ2=0.890, P=0.345).@*Conclusions@#Compared with TG-RY, PG-DT has the same safety and feasibility for proximal gastric cancer. Although the operative time is a little longer than TG-RY, PG-DT has advantages in improving the postoperative hemoglobin level.

Analysis on the technical characteristics and clinical efficacy of robotic-assisted intersphincteric resection for patients with low rectal cancer / 中华胃肠外科杂志

Objective@#To explore the technical characteristics and short-term clinical efficacy of robotic-assisted intersphincteric resection (ISR) for patients with low rectal cancer.@*Methods@#A retrospective cohort study was used. Inclusion criteria: (1) rigid colonoscopy showed lower margin of the tumor ≤5 cm from the anal verge; (2) preoperative rectal MRI or endorectal ultrasound revealed staging T1-2, or T3 patients receiving concurrent chemoradiotherapy; (3) patients less than 70 years old with good function of anal sphincter before surgery; (4) no synchronous multiple primary carcinoma, and no distant metastasis; (5) the method of operation was agreed by the patient. Exclusion criteria: (1) T4 stage tumors; (2) sphincter dysfunction before operation; (3) recurrent tumors; (4) lower edge of tumors beyond the dentate line; (5) death due to non-rectal cancer during follow-up and unsatisfactory follow-up data. The clinical data of 21 patients with low rectal cancer meeting inclusion criteria undergoing robotic-assisted ISR at our department from January 2015 to June 2018 were collected. Parameters during and after operation were observed. Anorectal manometry was performed at 3, 6, and 12 months after the operation, and anal function was evaluated at 3, 6, and 12 months after the closure of the stoma by Kirwan classification and Wexner fecal incontinence score. The key steps of the operation are as follows: according to the principle of total mesorectal excision, the robot continued to enter into the levator ani hiatusdistally, and dissectin the sphincter space; according to the scope of sphincter resection, ISRwas divided into partial ISR, subtotal ISR, and total ISR; subtotal and total ISR usually needed to be combined with transanal pathway. The reconstruction of digestive tract was performed by double stapler anastomosis under laparoscope orhand-sewnanastomosis under direct vision, and preventive ileostomy was completed in the right lower abdomen.@*Results@#Of 21 patients, 13 were male and 8 were female with mean age of (57.5±16.3) years. All the patients successfully completed the operation without conversion to laparotomy. Fourteen cases (66.7%) adopted partial ISR through complete transabdominal approach, 6 cases (28.6%) adopted the subtotal ISR through combined transabdominal and transanal approachs, and 1 case (4.8%) adopted the total ISR through the combined transabdominal and transanal approachs. The total operation time was (213.1±56.3) minutes, including (27.3±5.4) minutes for mechanical arm installation and (175.7±51.6) minutes for robotic operation. The amount of intraoperative hemorrhage was (62.8±23.2) ml, and no blood transfusion was performed in any patient. All patients underwent prophylactic ileostomy, and the stoma was closed 3-6 months after the operation. Except one case of anastomotic leakage, all other stomas were closed successfully. The postoperative hospitalization time was (7.6±2.2) days, and time to fluid intake was (3.3±0.9) days. One case of anastomotic leakage, one case of anastomotic stenosis, one case of inflammatory external hemorrhoids and one case of urinary retention occurred after surgery,and all of them were cured by conservative treatment. The mean diameter of tumors was (2.9±1.2) cm, and the number of harvested lymph node was 12.8 ± 3.3. In the whole group, the circumcision margin was negative, the proximal margin was (12.2 ± 2.1) cm, the distal margin was (1.1 ± 0.4) with all negative, and the R0 resection rate was 100%. The results of anorectal manometry showed that the preoperative rest pressure, rectal maximum squeeze pressure, initial sensory volume and maximum tolerated volume were (45.19±8.46) mmHg, (128.18±18.80) mmHg, (44.33±10.11) ml and (119.00±19.28) ml, respectively;these parameters reduced significantly 3 months after operation and they were (23.44±5.54) mmHg, (93.72±12.15) mmHg, (17.72±5.32) ml and (70.44±10.9) ml, respectively. The differences were statistically significant (all P<0.001). The resting pressure and the rectal maximum squeeze pressure returned to preoperative levels 12 months after operation, which were (39.33±6.64) mmHg and (120.58±16.47) mmHg, respectively (both P>0.05), while the initial sensory volume and the maximum tolerated volume failed to reach the preoperative state, which were (30.67±7.45) ml and (92.25±10.32) ml, respectively (both P<0.05). The patients were followed up for (22.1±10.6) months without local recurrence and distant metastasis. Eighteen patients were evaluated for anal function: Kirwan classification was grade I for 6 cases, grade II for 7 cases, grade III for 4 cases, and grade IV for 1 case; Wexner incontinence score was 8.6±0.8; 14 cases had good defecation control.@*Conclusion@#The clinical efficacy of ISR with Da Vinci robot in the treatment of low rectal cancer is satisfactory.

Application of robotic surgery to treat carcinoma in the remnant stomach / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the surgical techniques and feasibility of robotic surgery for carcinoma in the remnant stomach(CRS).</p><p><b>METHODS</b>Clinicopathological data of 20 CRS patients undergoing robotic surgery at the Minimally Invasive Center for Gastrointestinal Surgery, Army Medical University Southwest Hospital from November 2012 to October 2017 were retrospectively collected. The surgical methods, procedures, main difficulties, and key techniques were analyzed, and the clinical efficacy was evaluated.</p><p><b>RESULTS</b>Among 20 CRS patients, 14 were male and 6 were female with mean age of 59.9 years and mean BMI of 19.7 kg/m. For the primary diseases, 17 patients underwent laparotomy, 3 underwent laparoscopic radical resection of gastric cancer; 18 cases received distal subtotal gastrectomy plus Billroth II( anastomosis, 2 received distal subtotal gastrectomy plus Billroth I( anastomosis. CRS located in anastomotic stoma in 15 cases and in the gastric fundus and cardiac part in 5 cases. Preoperative staging revealed 2 cases of T2NxM0, 1 of T3NxM0, 2 of TxNxM0 and 15 of T4aNxM0. Sixteen patients received robotic surgery with Roux-en-Y reconstruction successfully, and 4 patients were converted to laparotomy for palliative total gastrectomy, including 1 case with diaphragm invasion, 1 case with transverse colon invasion, and 2 cases with tight adhesions. The mean surgery time was (255±35) minutes, mean blood loss was (230±50) ml, mean number of dissected lymph nodes was 19.5±3.0, mean recovery time to gastrointestinal function was (2.3±1.0) days, mean time to feeding was (2.3±1.0) days, and mean time to ambulatory activity was (2.5±0.5) days. Pathological examinations revealed 12 patients with poorly differentiated adenocarcinoma, 6 patients with moderately differentiated adenocarcinoma, and 2 patients with mucinous adenocarcinoma. Postoperative pTNM staging was identified as follows: stage I(B for 1 patient, stage II(A for 2 patients, stage II(B for 5 patients, stage III(A for 5 patients, stage III(B for 4 patients, and stage III(C for 3 patients. One patient died 2 weeks after operation due to multiple organ failure. One patient received another hemostasis operation due to hemorrhage of splenic artery and recovered postoperatively. Two patients experienced anastomotic leakage, 1 patient developed duodenal stump fistula and 1 patient experienced incision site infection postoperatively, and all of them recovered after conservative treatment. During 5-60 months follow-up, 10 cases died and 10 cases survived, including 1 case for 6 years.</p><p><b>CONCLUSIONS</b>Robotic surgery for CRS is feasible with satisfactory short-term efficacy. However, the long-term efficacy requires further study.</p>

Short-term clinical efficacies of Da Vinci robotic surgical system-assisted and laparoscopy-assisted radical gastrectomy for locally advanced gastric cancer / 中华消化外科杂志

Objective To compare the short-term clinical efficacies of Da Vinci robotic surgical systemassisted and laparoscopy-assisted radical gastrectomy for locally advanced gastric cancer (GC).Methods The retrospective cohort study was conducted.The clinicopathological data of 162 patients who underwent minimally invasive radical gastrectomy for locally advanced GC in the First Affiliated Hospital of Army Medical University between September 2016 and September 2017 were collected.Of 162 patients,65 undergoing Da Vinci robotic surgical system-assisted radical gastrectomy were allocated into the robotic group and 97 undergoing laparoscopyassisted radical gastrectomy were allocated into the laparoscopic group.According to Japanese gastric cancer treatment guidelines,patients with upper GC and with middle or lower GC underwent respectively total gastrectomy + D2 lymph node dissection and distal subtotal gastrectomy + D2 lymph node dissection,and then Billroth Ⅱ or Roux-en-Y digestive tract reconstruction.Observation indicators:(1) surgical and postoperative situations;(2) detection of lymph node;(3) follow-up and survival situations.Measurement data with normal distribution were represented as x±s,and comparisons between groups were analyzed using the t test.Comparisons of count data were done using the chi-square test.Ordinal data were analyzed by the nonparametric test.Results (1) Surgical and postoperative situations:all 162 patients underwent successful surgery,without conversion to laparoscopic or open surgery,and pathological resection margins were confirmed as R0.Volume of intraoperative blood loss,levels of amylase in peritoneal drainage fluid at day 1,2 and 3 postoperatively,levels of serum amylase fluid at day 1,2 and 3 postoperatively were respectively (123±39) mL,(557± 181) U/L,(357± 127) U/L,(183±86) U/L,(181±47)U/L,(123±29)U/L,(85±22)U/L in the robotic group and (142±40)mL,(793±284)U/L,(497±199)U/L,(279±157) U/L,(218±45) U/L,(162±37) U/L,(120±31) U/L in the laparoscopic group,with statistically significant differences between groups (t =-3.015,-2.817,-2.364,-2.132,-2.372,-3.338,-3.720,P＜0.05).Cases with distal subtotal gastrectomy + D2 lymph node dissection and with total gastrectomy + D2 lymph node dissection,cases with Billroth Ⅱ and Roux-en-Y of digestive tract reconstruction,time of distal subtotal gastrectomy + D2 lymph node dissection,time of total gastrectomy + D2 lymph node dissection,cases with anastomotic leakage,pulmonary infection,wound infection or liquefaction and delayed gastric emptying,cases in grading Ⅱ,Ⅲ,Ⅳ and Ⅴ of postoperative complications,time of postoperative drainage-tube removal and duration of postoperative hospital stay were respectively 47,18,40,25,(222±37) minutes,(274±43) minutes,1,1,1,1,2,1,0,0,(6.5-± 1.5) days,(10.0±4.0) days in the robotic group and 74,23,69,28,(213±40) minutes,(262±39)minutes,2,4,1,0,4,1,0,1,(6.9±1.7)days,(10.0±5.0)days in the laparoscopic group,with no statistically significant difference between groups (x2=0.326,1.628,t =1.272,0.960,x2=2.501,Z=-1.342,t=-1.142,-0.115,P＞0.05).One and 1 patients in the robotic and laparoscopic groups who were complicated with esophagus-jejunum anastomotic leakage after total gastrectomy + Roux-en-Y anastomosis were cured by nutrition support therapy using feeding tube placement under gastroscopy,and 1 patient in the laparoscopic group who were complicated with gastrojejunal anastomosis leakage after distal subtotal gastrectomy +Billroth Ⅱ anastomosis received the second surgical exploration and jejunal feeding tube placement.Patients with pulmonary infection,wound infection or liquefaction and delayed gastric emptying were cured by conservative treatment.Levels of amylase in peritoneal drainage fluid and serum amylase fluid at day 1,2 and 3 postoperatively were not higher than 3 times of upper limit of normal,without treatment interventions.(2) Detection of lymph node:overall number of lymph nodes detected in the robotic and laparoscopic groups were respectively 36.82±13.41 and 35.21 ± 11.52,with no statistically significant difference between groups (t =0.786,P＞ 0.05).Results of further analysis showed that numbers of lymph node dissected in the 2nd station and upper region of pancreas in patients undergoing distal subtotal gastrectomy + D2 lymph node dissection were respectively 6.04±3.98,13.51±6.53 in the robotic group and 4.45±3.12,11.40±5.30 in the laparoscopic group,with statistically significant differences between groups (t=2.461,1.986,P＜0.05).Numbers of lymph node dissected in No 7 and 8 groups and upper region of pancreas in patients undergoing total gastrectomy + D2 lymph node dissection were respectively 5.44±2.63,2.92±1.87,10.81±4.78 in the robotic group and 3.11±1.82,1.62±1.33,7.76±3.34 in the laparoscopic group,with statistically significant differences between groups (t =3.340,2.689,2.522,P＜0.05).(3) Follow-up and survival situations:of 162 patients,148 were followed up for 2-14 months,with a median time of 8 months.During the follow-up,patients in the 2 groups had tumor-free survival.Conclusions Da Vinci robotic surgical system-assisted radical gastrectomy is safe and feasible.Compared with laparoscopy-assisted radical gastrectomy for locally advanced GC,it has advantages of clear vision of the local anatomy,less intraoperative bleeding,more numbers of lymph nodes dissected in the upper region of pancreas and lighter pancreatic injure,meanwhile,it has also certain operating advantages around the great vessels and in the deep and narrow spaces.

The present situation and future development for robotic gastrointestinal surgery in China / 中华外科杂志

After ten years of development in robotic gastrointestinal surgery in China, although the number of robot surgical systems is small, the growth rate of robotic gastrointestinal surgery has grown up. Robotic gastrointestinal surgeons used the advantage of robots to perform a variety of surgical procedures with high complexity and technical difficulty, and achieved satisfactory clinical results. The robotic gastrointestinal surgeons in China are also paying attention to clinical research while carrying out robotic surgery. The number of international publications on robotic gastrointestinal surgery is at the forefront. However, the development of a robotic surgical system with independent intellectual property rights, and the further standardization of robotic gastrointestinal surgery indications and operational procedures are issues that urgently need to be addressed.