ABSTRACT
In recent years, the detection rate of early gastric cancer in China has increased. Early gastric cancer has a good prognosis, and how to further improve the postoperative quality of life for patients has become an increasingly concerned problem in the treatment of early gastric cancer. Therefore, function preserving gastrectomy has emerged. Function preserving gastrectomy aims to reduce the resection scope and preserve part of the gastric function on the premise of radical tumor resection. As a representative of function preserving gastrectomy, pylorus-preserving gastrec-tomy is suitable for early gastric cancer in middle segment. Compared with distal gastrectomy, laparoscopic pylorus-preserving gastrectomy not only has the advantage of less trauma, but also can reduce the incidence of postoperative dumping syndrome, bile reflux gastritis and gallstones, and improve postoperative nutritional status. However, the practice of pylorus-preserving gastrectomy is still in controversial. Based on the new Japanese guidelines for the treatment of gastric cancer, and combined with the latest domestic and foreign research trends and relevant evidence-based medicine basis, the authors review the definition and indications, safety, advantages, technical points, digestive tract reconstruction methods, postoperative complications and other aspects of laparoscopic pylorus-preserving gastrectomy.
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Objective:To investigate the clinical efficacy of laparoscopic-assisted inters-phincteric resection (ISR) with different surgical approaches for low rectal cancer.Methods:The retrospective cohort study was conducted. The clinicopathological data of 90 patients with low rectal cancer who were admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to December 2020 were collected. There were 58 males and 32 females, aged (60±9)years. Of 90 patients, 60 cases underwent laparoscopic assisted ISR with transpelvic approach, 30 cases underwent laparoscopic assisted ISR with transabdominal and transanal mixed approach. Observation indicators: (1) clinicopathological characteristics of patients with transpelvic approach and mixed approach; (2) intraoperative and postoperative conditions of patients with transpelvic approach and mixed approach; (3) postoperative complications of patients with transpelvic approach and mixed approach; (4) follow-up. Follow-up was conducted by telephone interview and outpatient examination once every 3 months within postoperative 3 years, once every six months in the postoperative 3 to 5 years and once a year after postoperative 5 years to detect tumor recurrence and metastasis, and survival of patients.Follow-up was up to March 2021 or patient death. Measurement data with normal distribution were represented as Mean± SD, and the t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M(range), and comparison between groups was conducted using the non-parametric Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was performed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed by the non-parametric rank sum test. Kaplan-Meier method was used to draw survival curves and calculate survival rates, and survival analysis was performed by the Log-Rank test. Results:(1) Clinicopathological characteristics of patients with transpelvic approach and mixed approach. The sex (males, females), distance from the distal margin of tumor to anal margin were 34, 26, (4.5±0.5)cm for patients with transpelvic approach, versus 24, 6, (3.5±0.5)cm for patients with mixed approach, respectively, showing significant differences between them ( χ2=4.75, t=8.35, P<0.05). (2) Intraoperative and postoperative conditions of patients with transpelvic approach and mixed approach. The operation time, volume of intraoperative blood loss, distance from the postoperative anastomosis to anal margin were (187±9)minutes, 50(range, 20?200)mL, (3.4±0.7)cm for patients with transpelvic approach, versus (256±12)minuets, 100(range, 20?200)mL, (2.6±0.7)cm for patients with mixed approach, showing significant differences between them ( t=?26.99, Z=?2.48, t=4.67, P<0.05). None of the 90 patients had a positive distal margin. The stoma reversal rates of patients with transpelvic and mixed approach were 93.3%(56/60) and 90.0%(27/30), respectively. Of the 60 patients with transpelvic approach, 3 cases had no stoma reversal due to anastomotic complications, and 1 case was not yet to the reversal time. Of the 30 patients with mixed approach, 2 cases had no stoma reversal due to anastomotic complications, and 1 case was not yet to the reversal time. The 1-, 3-month Wexner scores after stoma reversal were 15(range, 12?17), 12(range, 10?14) for patients with transpelvic approach, versus 16(range, 14?18), 14(range, 12?16) for patients with mixed approach, showing significant differences between them ( Z=?4.97, ?5.49, P<0.05). The 6-month Wexner score after stoma reversal was 10(range, 9?12) for patients with transpelvic approach, versus 11(range, 8?12) for patients with mixed approach, showing no significant difference between them ( Z=?1.59, P>0.05). (3) Postoperative complications of patients with transpelvic approach and mixed approach. The complications occurred to 16 patients with transpelvic approach and 9 patients with mixed approach, respectively, showing no significant difference between them ( χ2=0.11, P>0.05). Cases with postoperative anastomotic fistula, cases with anastomotic bleeding, cases with anastomotic stenosis, cases with intestinal obstruction, cases with incision infection, cases with urinary retention, cases with pelvic infection, cases with pulmonary infection, cases with incisional hernia, cases with chylous fistula, cases with abdominal and pelvic abscess were 5, 2, 1, 7, 0, 1, 5, 3, 1, 1, 1 for patients with transpelvic approach, versus 6, 3, 2, 2, 2, 1, 2, 3, 1, 1, 1 for patients with mixed approach, showing no significant difference between them ( P>0.05). The same patient could have multiple postoperative complications. (4) Follow-up. All the 90 patients were followed up for 27(range, 6?62)months. The follow-up time of 60 patients with transpelvic approach was 27(range, 8?62)months. The follow-up time of 30 patients with mixed approach was 28(range, 6?53)months. Of the 60 patients with transpelvic approach, 3 cases had local recurrence, 4 cases had liver metastasis, 3 cases had lung metastasis, and all of them survived with tumor. Of the 30 patients with mixed approach, 1 case had local recurrence, 2 cases had liver metastasis, 1 case had lung metastasis, and all of them survived with tumor. There was no death. The 3-year disease-free survival rates of patients with transpelvic approach and mixed approach were 84.7% and 87.9%, respectively, showing no significant difference between them ( χ2=0.39, P>0.05). Conclusions:Lapa-roscopic assisted ISR via transpelvic approach or mixed approach for low rectal cancer are safe and feasible. Compared with transanal mixed approach, the transpelvic approach of laparoscopic-assisted ISR has shorter operation time, less volume of intraoperative blood loss and longer distance from the postoperative anastomosis to anal margin.
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Objective:To intestigate the clinical efficacy between modified Overlap anastomosis and traditional auxiliary incision anastomosis in laparoscopic total gastrectomy.Methods:The retrospective cohort study was conducted. The clinicopathological data of 115 patients with gastric cancer who were admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to December 2018 were collected. There were 62 males and 53 females, aged from 27 to 83 years, with a median age of 62 years. Of 115 patients, 51 patients undergoing totally laparoscopic total gastrectomy with modified Overlap anastomosis using linear stapler were divided into modified Overlap group and 64 patients undergoing laparoscopic assisted total gastrectomy with traditional auxiliary incision anastomosis using circular stapler were divided into traditional assisted group. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) anastomotic complications; (4) follow-up. Follow-up using outpatient examination or telephone interview was conducted to detected tumor recurrence and survival of patients up to December 2019. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ranked data was analyzed using the rank sum test. Results:(1) Surgical situations: the operation time, time of esophagojejunostomy, volume of intraoperative blood loss, the number of lymph node dissected, length of proximal incisional margin and length of auxiliary incision of the modified Overlap group were (234.0±11.0)minutes, (29.4±2.1)minutes, (53±14)mL, 42±13, (2.0±0.3)cm and (5.1±0.4)cm, respectively. The above indicators of the traditional assisted group were (231.0±11.0)minutes, (29.2±2.2)minutes, (50±13)mL, 40±10, (2.2±0.4)cm and (8.2±0.4)cm, respectively. There was significant difference in the length of auxiliary incision between the two groups ( t=-43.098, P<0.05), and there was no significant difference in the operation time, time of esophagojejunostomy, volume of intraoperative blood loss, the number of lymph node dissected, length of proximal incisional margin between the two groups ( t=1.168, 0.460, 0.990, 1.127, -1.926, P>0.05). (2) Postoperative situations: cases with mild, moderate, severe pain (postoperative pain degree), time to first flatus, time to initial fluid diet intake, duration of postoperative hospital stay of the modified Overlap group were 40, 9, 2, (2.9±1.0)days, (4.8±2.2)days, (11.7±2.8)days, respectively. The above indicators of the traditional assisted group were 31, 27, 6, (3.9±1.4)days, (6.5±2.5)days, (13.0±3.1)days, respectively. There were significant differences in the above indicators between the two groups ( Z=-3.217, t= -4.344, -3.888, -2.261, P<0.05). (3) Anastomotic complications: cases with anastomotic leakage, cases with anastomotic bleeding, cases with anastomotic stenosis of the modified Overlap group were 1, 1, 0, respectively. The above indicators of the traditional assisted group were all 1. There was no significant difference in the above indicators between the two groups ( P>0.05). Cases with anastomotic leakage were cured after the treatment of enteral nutritional support through nasogastric catheterization, which were confirmed by gastroenterography. Cases with anastomotic bleeding were improved by active hemostatic therapy. Cases with anastomotic stenosis were improved after the symptomatic treatment of anti-inflammatory and anti-swelling. (4) Follow-up: 109 of the 115 patients were followed up. Forty-eight of 51 patients in the modified Overlap group were followed up for 15.0-45.0 months, with a median follow-up time of 33.5 months. Sixty-one of 64 patients in the traditional assisted group were followed up for 16.0-46.0 months, with a median follow-up time of 27.0 months. There was no tumor recurrence in the modified Overlap group. One patient in the traditional assisted group had tumor recurrence with liver metastasis and survived with tumor. There was no significant difference in tumor recurrence rate between the two groups ( P>0.05). There was no patient died during the follow-up. Conclusion:Compared with traditional auxiliary incision anastomosis, patients undergoing total laparoscopic total gastrectomy with modified Overlap anastomosis have small incision, good postoperative recovery.
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Objective To analyze the anatomy of the right colonic vessels in the laparoscopic right hemicolectomy.Methods The retrospective cross-sectional study was conducted.The clinical data of 60 patients who underwent laparoscopic right hemicolectomies in the Second Affiliated Hospital of Fujian Medical University from March 2013 to October 2016 were collected.All the patients used central approach.Patients intraoperatively underwent complete mesocolic excision (CME),and vascular anatomies of the right colon were precisely distinguished through postoperatively observing video.The starting position,formation and relative spatial location of vessels were counted and analyzed,and video screenshots were used as a comments during analysis.Observation indicators:(1) superior mesenteric artery (SMA) and superior mesenteric vein (SMV):occurrence rate and relative spatial location;(2) ileocolic artery and vein:occurrence rate and relative spatial location;(3) right colonic artery and vein:occurrence rate and relative spatial location of right colonic artery,occurrence rate and distribution of right colonic vein flowed into superior vein;(4) gastrocolic venous trunk:occurrence rate and composition of the branches;(5) middle colonic artery and vein:occurrence rate and relative spatial location of middle colonic artery,occurrence rate and distritution of middle colonic vein flowed into superior vein.Measurement data were represented as proportion and percentage.Results (1) SMA and SMV:all the 60 patients appeared SMA and SMV,with an occurrence rate of 100.0％(60/60).Of 60 patients,95.0％(57/60) and 5.0％(3/60) patients' SMAs respectively were located on the left side and right side of SMVs.(2) Ileocolic artery and vein:of 60 patients,the occurrence rates of ileocolic artery and vein were 96.7％ (58/60) and 100.0％ (60/60).Relative spatial location:of 58 patients with ileocolic artery,8.6％ (5/58),31.0％ (18/58),10.3％ (6/58),6.9％(4/58),32.9％(19/58) and 10.3％(6/58) patients' ileocolic arteries were respectively located on the right ahead,anterosuperior,inferoanterior,right behind,upper posterior and lower posterior of ileocolic veins;50.0％(29/58) patients' ileocolic arteries crossed from the front of SMV,and 50.0％ (29/58) patients' ileocolic arteries ran behind the SMV.(3) Right colonic artery and vein:① Right colonic artery:of 60 patients,occurrence rate was 55.0％(33/60),including 93.9％(31/33) with 1 right colonic artery and 6.1％(2/33) with 2 right colonic arteries.A trunk made of right colonic artery and middle colonic artery was detected in 24.2％ (8/33) patients,and flowed into SMA,including 2/8 patients with 2 right colonic arteries and 6/8 with 1 right colonic artery.Relative spatial location:of 33 patients,90.9％ (30/33) occurred right colonic artery crossed from the front of SMV;9.1％ (3/33) occurred SMA located on the right side of SMV that led to no relative spatial location between right colonic artery and SMV.② Right colonic vein:of 60 patients,occurrence rate was 93.3％ (56/60),including 87.5％(49/56) with 1 right colonic vein (7 were accompanied by right colonic artery) and 12.5％ (7/56) with 2 right colonic veins.Distribution of right colonic vein flowed into superior vein:of 49 patients with 1 right colonic vein,right colonic vein respectively flowed into gastrocolic venous trunk and SMV were detected in 73.5％ (36/49) and 26.5％ (13/49) patients.Of 7 patients with 2 right colonic veins,right colonic vein flowed into SMV and gastrocolic venous trunk were detected respectively in 6/7 patients and 1/7 patients.(4) Gastrocolic venous trunk:occurrence rate was 88.3％ (53/60);11.7％ (7/60) patients had absence of gastrocolic venous trunk,and right gastric epiploic vein directly flowed into SMV.Composition of the branches of gastrocolic venous trunk:of 53 patients,3-branch or 4-branch stomach-pancreas-colon venous trunk in 54.7％ (29/53) patients was made up of right gastric epiploic vein,pancreaticoduodenal vein,right colonic vein and middle colonic vein;2-branch or 3-branch gastrocolic venous trunk in 35.9％ (19/53) patients was made up of right gastric epiploic vein,right colonic vein and middle colonic vein;2-branch stomach-pancreas venous trunk in 9.4％ (5/53) patients was made up of right gastric epiploic vein and pancreaticoduodenal vein.(5) Middle colonic artery and vein:① Middle colonic artery:60 patients appeared middle colonic artery,with an occurrence rate of 100.0％ (60/60) and 1.7％ (1/60) appeared 2 middle colonic arteries.Of 60 patients,13.3％ (8/60) patients' middle colonic artery shared the same trunk together with right colonic artery that flowed into 1 middle colonic artery,and 85.0％(51/60) appeared 1 middle colonic artery.Middle colonic artery ≤ 1 cm,from 1 to 2 cm (excluding 1 cm) and ＞2 cm occurred branch at running out of neck of pancreas were detected in 15.7％ (8/51),66.7％ (34/51) and 66.7％ (34/51)patients,respectively.② Middle colonic vein:56 of 60 patients appeared middle colonic vein,with an occurrence rate of 93.3％(56/60),and 80.3％(45/56),16.1％(9/56) and 3.6％(2/56) patients appeared respectively 1,2 and 3 middle colonic veins.Distribution of middle colonic vein flowed into superior vein:45 patients appeared 1 middle colonic vein,55.6％ (25/45) and 44.4％ (20/45) middle colonic veins respectively flowed into SMV and gastrocolic venous trunk;9 patients appeared 2 middle colonic veins,7/9 middle colonic veins flowed into SMV and gastrocolic venous trunk and 2/9 middle colonic veins flowed into SMV;2 patients appeared 3 middle colonic veins,1 and 2 middle colonic veins respectively flowed into gastrocolic venous trunk and SMV.Conclusion Vascular anatomical variations of the right colon are complex in the laparoscopic right hemicolectomy,and anatomies of the surgical thunk and Helen trunk are difficult and core issue in operation.