Clinicopathological characteristics and prognosis of patients with small bowel tumors: A single center analysis of 220 cases / 中华胃肠外科杂志

Objective: To analyze the clinicopathological characteristics and prognosis of patients with small bowel tumors. Methods: This was a retrospective, observational study. We collected clinicopathological data of patients with primary jejunal or ileal tumors who had undergone small bowel resection in the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University between January 2012 and September 2017. The inclusion criteria included: (1) older than 18 years; (2) had undergone small bowel resection; (3) primary location at jejunum or ileum; (4) postoperative pathological examination confirmed malignancy or malignant potential; and (5) complete clinicopathological and follow-up data. Patients with a history of previous or other concomitant malignancies and those who had undergone exploratory laparotomy with biopsy but no resection were excluded. The clinicopathological characteristics and prognoses of included patients were analyzed. Results: The study cohort comprised 220 patients with small bowel tumors, 136 of which were classified as gastrointestinal stromal tumors (GISTs), 47 as adenocarcinomas, and 35 as lymphomas. The median follow-up for all patient was 81.0 months (75.9-86.1). GISTs frequently manifested as gastrointestinal bleeding (61.0%, 83/136) and abdominal pain (38.2%, 52/136). In the patients with GISTs, the rates of lymph node and distant metastasis were 0.7% (1/136) and 11.8% (16/136), respectively. The median follow-up time was 81.0 (75.9-86.1) months. The 3-year overall survival (OS) rate was 96.3%. Multivariate Cox regression-analysis results showed that distant metastasis was the only factor associated with OS of patients with GISTs (HR=23.639, 95% CI: 4.564-122.430, P<0.001). The main clinical manifestations of small bowel adenocarcinoma were abdominal pain (85.1%, 40/47), constipation/diarrhea (61.7%, 29/47), and weight loss (61.7%, 29/47). Rates of lymph node and distant metastasis in patients with small bowel adenocarcinoma were 53.2% (25/47) and 23.4% (11/47), respectively. The 3-year OS rate of patients with small bowel adenocarcinoma was 44.7%. Multivariate Cox regression-analysis results showed that distant metastasis (HR=4.018, 95%CI: 2.108-10.331, P<0.001) and adjuvant chemotherapy (HR=0.291, 95% CI: 0.140-0.609, P=0.001) were independently associated with OS of patients with small bowel adenocarcinoma. Small bowel lymphoma frequently manifested as abdominal pain (68.6%, 24/35) and constipation/diarrhea (31.4%, 11/35); 77.1% (27/35) of small bowel lymphomas were of B-cell origin. The 3-year OS rate of patients with small bowel lymphomas was 60.0%. T/NK cell lymphomas (HR= 6.598, 95% CI: 2.172-20.041, P<0.001) and adjuvant chemotherapy (HR=0.119, 95% CI: 0.015-0.925, P=0.042) were independently associated with OS of patients with small bowel lymphoma. Small bowel GISTs have a better prognosis than small intestinal adenocarcinomas (P<0.001) or lymphomas (P<0.001), and small bowel lymphomas have a better prognosis than small bowel adenocarcinomas (P=0.035). Conclusions: The clinical manifestations of small intestinal tumor are non-specific. Small bowel GISTs are relatively indolent and have a good prognosis, whereas adenocarcinomas and lymphomas (especially T/NK-cell lymphomas) are highly malignant and have a poor prognosis. Adjuvant chemotherapy would likely improve the prognosis of patients with small bowel adenocarcinomas or lymphomas.

Comparison of postoperative mid-term and long-term quality of life between Billroth-I gastroduodenostomy and Billroth-II gastrojejunostomy after radical distal gastrectomy in patients with gastric cancer: a cohort study based on a case registry database / 中华胃肠外科杂志

Objective: The pattern of digestive tract reconstruction in radical gastrectomy for gastric cancer is still inconclusive. This study aims to compare mid-term and long-term quality of life after radical gastrectomy for distal gastric cancer between Billroth-I (B-I) and Billroth-II (B-II) reconstruction. Methods: A retrospective cohort study was conducted.Clinicopathological and follow-up data of 859 gastric cancer patients were colected cellected from the surgical case registry database of Gastrointestinal Surgery Center of Sichuan University West China Hospital, who underwent radical distal gastric cancer resection between January 2016 and December 2020. Inclusion criteria: (1) gastric cancer confirmed by preoperative gastroscopy and biopsy; (2) elective radical distal major gastrectomy performed according to the Japanese Society for Gastric Cancer treatment guidelines for gastric cancer; (3) TNM staging referenced to the American Cancer Society 8th edition criteria and exclusion of patients with stage IV by postoperative pathology; (4) combined organ resection only involving the gallbladder or appendix; (5) gastrointestinal tract reconstruction modality of B-I or B-II; (6) complete clinicopathological data; (7) survivor during the last follow-up period from December 15, 2021 to January 15, 2022. Exclusion criteria: (1) poor compliance to follow-up; (2) incomplete information on questionnaire evaluation; (3) survivors with tumors; (4) concurrent malignancies in other systems; (5) concurrent psychiatric and neurological disorders that seriously affected the objectivity of the questionnaire or interfered with patient's cognition. Telephone follow-up was conducted by a single investigator from December 2021 to January 2022, and the standardized questionnaire EORTC QLQ-C30 scale (symptom domains, functional domains and general health status) and EORTC QLQ-STO22 scale (5 symptoms of dysphagia, pain, reflux, restricted eating, anxiety; 4 single items of dry mouth, taste, body image, hair loss) were applied to evaluate postoperative quality of life. In 859 patients, 271 were females and 588 were males; the median age was 57.0 (49.5, 66.0) years. The included cases were divided into the postoperative follow-up first year group (202 cases), the second year group (236 cases), the third year group (148 cases), the fourth year group (129 cases) and the fifth year group (144 cases) according to the number of years of postoperative follow-up. Each group was then divided into B-I reconstruction group and B-II reconstruction group according to procedure of digestive tract reconstruction. Except for T-stage in the fourth year group, and age, tumor T-stage and tumor TNM-stage in the fifth year group, whose differences were statistically significant between the B-I and B-II reconstruction groups (all P<0.05), the differences between the B-I and B-II reconstruction groups in terms of demographics, body mass index (BMI), tumor TNM-stage and tumor pathological grading in postoperative follow-up each year group were not statistically significant (all P>0.05), suggesting that the baseline information between B-I reconstruction group and the B-II reconstruction group in postoperative each year group was comparable. Evaluation indicators of quality of life (EORTC QLQ-C30 and EORTC QLQ-STO22 scales) and nutrition-related laboratory tests (serum hemoglobin, albumin, total protein, triglycerides) between the B-I reconstruction group and B-II reconstruction group in each year group were compared. Non-normally distributed continuous variables were presented as median (Q(1),Q(3)), and compared by using the Wilcoxon rank sum test (paired=False). The χ(2) test or Fisher's exact test was used for comparison of categorical variables between groups. Results: There were no statistically significant differences in all indexes EORTC QLQ-30 scale between the B-I reconstruction group and the B-II reconstruction group among all postoperative follow-up year groups (all P>0.05). The EORTC QLQ-STO22 scale showed that significant differences in pain and eating scores between the B-I reconstruction group and the B-II reconstruction group were found in the second year group, and significant differences in eating, body and hair loss scores between the B-I reconstruction group and the B-II reconstruction group were found in the third year group (all P<0.05), while no significant differences of other item scores between the B-I reconstruction group and the B-II reconstruction group were found in postoperative follow-up of all year groups (P>0.05). Triglyceride level was higher in the B-II reconstruction group than that in the B-I reconstruction group (W=2 060.5, P=0.038), and the proportion of patients with hyperlipidemia (triglycerides >1.85 mmol/L) was also higher in the B-II reconstruction group (19/168, 11.3%) than that in the B-I reconstruction group (0/34) (χ(2)=0.047, P=0.030) in the first year group with significant difference. Albumin level was lower in the B-II reconstruction group than that in the B-I reconstruction group (W=482.5, P=0.036), and the proportion of patients with hypoproteinemia (albumin <40 g/L) was also higher in the B-II reconstruction group (19/125, 15.2%) than that in the B-I reconstruction group (0/19) in the fifth year group, but the difference was not statistically significant (χ(2)=0.341, P=0.164). Other nutrition-related clinical laboratory tests were not statistically different between the B-I reconstruction and the B-II reconstruction in each year group (all P>0.05). Conclusions: The effects of both B-I and B-II reconstruction methods on postoperative mid-term and long-term quality of life are comparable. The choice of reconstruction method after radical resection of distal gastric cancer can be based on a combination of patients' condition, sugenos' eoperience and operational convenience.

How to master the clinical study on digestive tract reconstruction in gastric cancer surgery / 中华胃肠外科杂志

Digestive tract reconstruction is extremely important during gastric cancer surgery, which is related to long-tern quality of life of patients. The selection of reconstruction methods and the application of reconstruction techniques are major topics in the field of reconstruction-related study of gastric cancer surgery. The clinical research on digestive tract reconstruction needs to be designed and implemented scientifically to comprehensively evaluate the impact of reconstruction methods on surgical safety, long-term survival outcomes, short- and long-term changes in quality of life, endoscopic mucosal changes and postoperative nutritional status. In addition, health economic analysis is also important and should be considered in reconstruction-related studies. In brief, selection of appropriate gastrointestinal reconstruction methods based on individual characteristics of each gastric cancer patients may be an important direction of clinical trials in the future.

Clinical significance of No.11p posterior lymph nodes dissection in gastric cancer surgery / 中华胃肠外科杂志

Objective: To analyze the association of No.11p posterior lymph node metastasis with clinicopathological features and its prognostic significance in gastric cancer. Methods: A single-center retrospective cohort study was conducted. Clinicopathological data of patients with primary gastric cancers undergoing No.11p posterior lymph node dissection from January 2016 to December 2020 were retrieved from the Database of Gastric Cancer, West China Hospital, Sichuan University. Case inclusion criteria: (1) gastric cancer proved by pathology; (2) radical resection with intraoperative No.11p posterior lymph node dissection; (3) operations performed by the same surgical team; (4) no previous history of other malignant tumors and no concurrent malignant tumors. Those with stump gastric cancer, history of gastrectomy, neoadjuvant chemotherapy, incomplete clinicopathological data and lost to follow-up were excluded. During the operation, the upper edge of the pancreas was retracted forward to expose the area between the upper edge of the pancreas and the splenic vessels. The proximal segment of the splenic artery was skeletonized to remove lymphatic tissue anterior and superior to the splenic artery for No.11p lymph node dissection. For patients with lymphadenopathy in the area between the splenic artery and the splenic vein, dissection was performed. The enlarged lymph nodes were labeled with titanium clips and named as No.11p posterior lymph node. Pathological examination was performed separately after the specimen was isolated. Statistical analysis was performed using R software. Results: A total of 127 gastric cancer patients, who underwent No.11p posterior lymph nodes dissection were included in this study, of which 120 patients without No.11p posterior lymph nodes metastasis (No.11p posterior lymph nodes negative) and 7 patients with No.11p posterior lymph nodes metastasis (No.11p posterior lymph nodes positive). A total of 8 metastatic No.11p posterior lymph nodes were detected in 7 patients, metastasis rate and with a ratio of 5.5% (7/127) and 6.8% (8/127), respectively. In the subgroup analysis of T3-4 stage patients, the metastasis rate and ratio of No.11p posterior lymph nodes were 9.0% (7/78) and 10.7% (8/75), respectively. Compared to negative cases, patients with No.11p posterior lymph nodes metastasis had larger tumor (P=0.002), higher proportion of Borrmann type Ⅲ and Ⅳ tumors (P=0.005), more metastatic lymph nodes (P<0.001), more advanced T stage (P=0.043), N stage (P=0.004) and TNM stage (P=0.015). In survival analysis, patients with No.11p posterior lymph node metastasis had a significantly worse prognosis than those without metastasis after adjusting for TNM stage (hazard ratio=3.009, 95% confidence interval: 1.824-4.964, P<0.001). Conclusions: The No.11p posterior lymph node metastasis in gastric cancer is associated with worse prognosis. For patients of T3-4 stage gastric cancer, No.11p posterior lymph node dissection should be emphasized during radical operation.

Current status of diagnosis and treatment of gastric cancer peritoneal metastasis / 中华胃肠外科杂志

Peritoneal metastasis is the most common distant metastasis of gastric cancer. As an end-stage event of gastric cancer, patients with peritoneal metastasis often have lost the chance of radical resection, and even after palliative surgical resection, the long-term outcomes are still not satisfactory. In recent years, with the application and promotion of laparoscopic technology, neoadjuvant intraperitoneal and systemic chemotherapy, hyperthermic intraperitoneal chemotherapy and cytoreductive surgery, through perioperative comprehensive treatment strategies by multidisciplinary team, the quality of life and survival of patients with peritoneal metastasis have been significantly improved. Some patients with gastric cancer peritoneal metastasis diagnosed by laparoscopy even get the opportunity to have radical cytoreductive surgery and hyperthermic intraperitoneal chemotherapy after neoadjuvant intraperitoneal and systemic chemotherapy. Taking into account the progress in the treatment of gastric cancer peritoneal metastasis in recent years, this article intends to combine current clinical evidence and to discuss the key issues in the course of clinical diagnosis and treatment of gastric cancer peritoneal implantation and metastasis, including the imaging diagnosis of peritoneal metastasis, laparoscopic examination, evaluation of peritoneal metastasis and comprehensive treatment plan.

Relationship between body mass index and prognosis after radical gastrectomy / 医学研究生学报

Objective　BMI is widely accepted as a predictor of postoperative complications in gastric cancer, but it is controversial as a survival predictor. This paper studies the relationship between BMI and prognosis in different classification Criteria.Methods　We retrospectively analyzed the patients who underwent gastrectomy for gastric cancer from December 2008 to July 2013 in West China Hospital of Sichuan University. The relationship between the three different BMI standards (WHO, ASIA,CHINA) and the prognosis of gastric cancer after operation was analyzed. Cox proportional proportional risk model was used to determine independent predictors of survival.　Results　A total of 890 patients with gastric cancer radical surgery, including 460 patients with preoperative BMI data. Average survival time for obese and non-obese groups WHO, ASIA, and CHINA was 84.23±2.40 vs 75.23±1.02 months, P=0.156; 86.19±3.41 vs 76.79±1.84months, P= 0.046; 89.80±3.33 vs 77.66±1.70months, P=0.060, respectively. Univariate analysis has statistically significant indicators including, education, employment status, location perineural invasion, vascular invasion, tumor deposits, surgical method, T, N staging, adjuvant chemotherapy, lymph node metastasis positive rate, tumor diameter, BMI(Asia). These were associated with 5-year oral survival in patients(P<0.05). In multivariate analysis, adjuvant chemotherapy, T stage, N stage, employment status of statistical significance, is the independent prediction of survival.　Conclusion　　High BMI (obesity) is one of the prognostic factors affecting radical resection of gastric cancer. Asian standard BMI is more suitable for this study. Adjuvant chemotherapy, T staging, N staging, and employment status of are risk factors for independence after radical resection of gastric cancer.

The current status and causes of acute intestinal obstruction / 中国实用外科杂志

Intestinal obstruction is one of the common diseases in abdominal surgery. Various causes may result the incidence of intestinal obstruction. Over the past decades, due to changes in human living and dietary habits, changes in disease spectrum, and advances in surgical techniques, the risk factors of intestinal obstruction have also changed significantly. At present, the most common causes of intestinal obstruction are intestinal adhesion, tumor and hernia. In addition, acute intestinal obstruction caused by inflammatory bowel disease has also increased in recent years.Comprehensive understanding the etiology and trend of intestinal obstruction contribute to the early diagnosis and timely treatment of it, and can also improve the prognosis of patients.

Comparable analysis of in-hospital mortality in patients with acute myocardial infarction / 中华心血管病杂志

<p><b>OBJECTIVE</b>To investigate the change of the mortality of AMI and influence factors within 20 years.</p><p><b>METHODS</b>Clinic data of 134 AMI patients from 1980 to 1983, 354 AMI patients from 1990 to 1993 and 817 AMI patients from 2000 to 2003 were comparably analyzed.</p><p><b>RESULTS</b>In hospital mortality of AMI was 22.4% from 1980 to 1983, 14.4% from 1990 to 1993 and 9.2% from 2000 to 2003, respectively (P < 0.01). The decrease of in-hospital mortality in male was more significant than in female (P < 0.01). The corresponding factors for decrease of mortality were younger than 60 years old, first onset of AMI, successful rescue of cardiac arrest and reperfusion management of infarction relative artery. The disadvantage factor was female.</p><p><b>CONCLUSIONS</b>Improvement of medical and reperfusion management of AMI conduced in significant decreases of hospital mortality.</p>