History and Current Situation of Digestive Tract Reconstruction After Laparoscopic Proximal Radical Gastrectomy / 肿瘤防治研究

The incidence of proximal gastric cancer worldwide is increasing year by year, and radical gastrectomy is still the main treatment. Partial function preserving in laparoscopic proximal gastrectomy has been continuously concerned in recent years, with the development of laparoscopic minimally invasive technology. However, the choice of digestive tract reconstruction is still controversial, due to the specificity of tumor location. This article reviews the current digestive tract reconstruction after laparoscopic proximal gastrectomy, and provides some references for clinicians to choose the digestive tract reconstruction methods rationally.

Application value of esophagogastric anastomosis with double muscle flap plasty in total laparoscopic radical resection of proximal gastric cancer / 中华消化外科杂志

Objective:To investigate the application value of esophagogastric anastomosis with double muscle flap plasty in total laparoscopic radical resection of proximal gastric cancer.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 5 patients undergoing radical resection of proximal gastric cancer in Cancer Hospital of China Medical University from January to December 2020 were collected. All 5 cases were male, aged from 57 to 72 years, with a median age of 65 years. All 5 patients underwent total laparoscopic radical resection of proximal gastric cancer combined with esophagogastric anastomosis with double muscle flap plasty. Observation indicators: (1) operative situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted using outpatient examination and telephone interview to detect postoperative anastomosis, esophageal reflux, nutritional status, quality of life, tumor recurrence and metastasis of patients up to February 2021. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:(1) Operative situations: all 5 patients underwent surgery successfully. The operation time, time of esophagogastric anastomosis with double muscle flap plasty, number of lymph node dissected, volume of intraoperative blood loss, length of surgical incision of 5 patients were (316±41)minutes,(109±11)minutes, 26±4, (48±12)mL, (3.4±0.4)cm, respectively. Results of intraoperative rapid frozen section pathological examination showed negative of esophageal margin. (2) Postoperative situations: the time to postoperative initial flatus, time to postoperative initial food intake, during of postoperative hospital stay, cost of treat-ment of 5 patients were (4.8±1.5)days, (5.8±1.5)days, (11.6±2.1)days and (5.5±0.4)×10 4 yuan, respectively. Results of postoperative pathological examination of 5 patients showed gastric adeno-carcinoma in all 5 patients including 4 cases with moderately and poorly differentiated adeno-carcinoma and 1 case with highly differentiated adenocarcinoma, with the TNM staging of pT1a-3N0-1 M0 stage. Of the 5 patients, 1 case underwent postoperative mild pneumonia and was cured by conservative treatment such as anti-infection and promotion of sputum evacuation. (3) Follow-up: all 5 patients were followed up for 2 to 12 months, with a median follow-up time of 6 months. Of the 5 patients, 4 cases underwent anastomotic patency and 1 case underwent mild anastomotic stenosis who was improved after endoscopic treatment. None of the 5 patients underwent reflux esophagitis. The body mass index, the score of nutritional risk screening 2002, the score of patient-generated subjective global assessment and the score of tumor patient quality of life of 5 patients were 21 kg/m 2(range, 19-27 kg/m 2), 2(range, 1-2), 2(range, 1-3) and 47(range, 42-52), respectively. None of the 5 patients underwent tumor recurrence or metastasis. Conclusion:Esophagogastric anas-tomosis with double muscle flap plasty can be used in total laparoscopic radical resection of proximal gastric cancer which will lead to satisfactory short-term efficacy.

Impact of neoadjuvant therapy on the number of harvested lymph nodes in D2 radical resection of the proximal locally advanced gastric cancer / 中华消化外科杂志

Objective To explore the impact of neoadjuvant therapy on the number of harvested lymph nodes in D2 radical resection of the proximal locally advanced gastric cancer (GC).Methods The retrospective cohort study was conducted.The clinicopathological data of 319 patients with proximal locally advanced GC who were admitted to the Beijing Cancer Hospital from January 2013 to September 2016 were collected.Of 319 patients,200 underwent D2 radical resection of GC and didn't undergo neoadjuvant therapy who were divided into the surgery group,88 underwent neoadjuvant chemotherapy into the chemotherapy group,and 31 underwent neoadjuvant chemoradiotherapy into the chemoradiotherapy group.Observation indicators and evaluation criteria:comparison of postoperative pathological results among 3 groups,according to tumor staging guideline of American Joint Committee on Cancer (AJCC) (8th version) Measurement data with normal distribution were represented as x±s,comparisons among groups were analyzed using the ANOVA.Measurement data with skewed distribution were described as M (range),comparisons among groups were analyzed using the ANOVA,and pairwise comparisons were analyzed using nonparametric test.Comparisons of count data among groups were analyzed using the exact chisquare test,and pairwise comparisons were analyzed using the chi-square partition method.Results Comparison of postoperative pathological results among 3 groups:stage T0,Tla,Tlb,T2,T3,T4a and T4b of T staging were respectively detected in 0,2,10,24,99,58,7 patients in the surgery group and 5,1,2,11,41,26,2 patients in the chemotherapy group and 5,1,2,8,10,4,1 patients in the chemoradiotherapy group.Stage N0,N1,N2,N3a and N3b of N staging 56,41,34,47,22 patients in the surgery group and 29,17,27,10,5 patients in the chemotherapy group and 18,10,2,1,0 in the chemoradiotherapy group.Cases with and without lymphovascular invasion were respectively 124,76 in the surgery group and 43,45 in the chemotherapy group and 6,25 in the chemoradiotherapy group.Total number of harvested lymph nodes,number of lymph node metastases and rate of lymph node metastasis in the surgery,chemotherapy and chemoradiotherapy groups were respectively 31 (range,15-87),30 (range,15-62),21 (range,15-36) and 3 (range,0-39),2 (range,0-37),0 (range,0-7) and 9.2％ (range,0-91.3％),7.7％ (range,0-78.7％),0 (range,0-30.4％).There were statistically significant differences in the T staging,N staging,with and without lymphovascular invasion,total number of harvested lymph nodes,number of lymph node metastases and rate of lymph node metastasis among groups (x2 =35.799,32.489,21.076,Z =27.120,22.088,16.947,P ＜ 0.05).There were statistically significant differences in the above indicators between surgery group and chemoradiotherapy group (x2 =28.500,20.124,19.570,P＜0.05),and no statistically significant difference in the above indicators between surgery group and chemotherapy group (x2 =11.436,12.343,4.295,P＞ 0.05).There were statistically significant differences in the N staging,with and without lymphovascular invasion,total number of harvested lymph nodes,number of lymph node metastases and rate of lymph node metastasis between chemotherapy group and chemoradiotherapy group (x2 =14.027,8.313,P＜ 0.05),and no statistically significant difference in the T staging between chemotherapy group and chemoradiotherapy group (x2=11.742,P＞ 0.05).Conclusion Neoadjuvant chemoradiotherapy could reduce the total number of harvested lymph nodes and number of lymph node metastases after radical resection of proximal locally advanced GC.

Differences of Lymph Node Metastasis Between Early Proximal and Distal Gastric Cancer and Indication of Endoscopic Resection / 胃肠病学

Background:In recent years,a rising incidence of proximal gastric cancer(PGC)has been reported,in contrast to a declining trend of distal gastric cancer(DGC). Differences in clinicopathological features between PGC and DGC have also been reported. Aims:To investigate the differences of lymph node metastasis between early PGC and DGC and the indication of endoscopic resection. Methods:The clinical data of 420 early gastric cancer patients(101 PGC patients and 319 DGC patients)who underwent curative gastrectomy from June 2013 to June 2016 at the Affiliated Drum Tower Hospital of Nanjing University Medical School were retrospectively analyzed. Clinicopathological features were compared between early PGC and DGC,and risk factors of lymph node metastasis were analyzed. Results:The differences in gender,age, histological differentiation,ulceration and lymph node metastasis were significant between early PDG and DGC patients (P<0.05). Tumor site,tumor size,depth of invasion,histological differentiation and vascular invasion were significantly correlated with lymph node metastasis by univariate analysis(P<0.05). Multivariate analysis revealed that tumor site, depth of invasion,histological differentiation and vascular invasion were independent risk factors for lymph node metastasis (P<0.05). The lymph node metastasis rate of mucosal,differentiated and vascular invasion negative PGC was 2.8%, which was lower than that of DGC(8.3%). Conclusions:The clinicopathological features of early PGC are different from those of early DGC. Patients with mucosal,differentiated and vascular invasion negative PGC are more suitable for endoscopic resection.

Expression and relativity of DKK-1 andβ-catenin in proximal gastric cancer / 中国肿瘤临床

Objective:To explore the role of DKK-1 andβ-catenin expressions in progression of proximal gastric cancer (PGC). Methods:The expression of DKK-1 andβ-catenin in 61 cases with PGC and para-neoplastic tissues and 20 cases with normal gastric mucosa was detected by immunohistochemistry. The related clinical significance in the cases was studied. Results:The positive expression rate of DKK-1 and the abnormal expression rate ofβ-catenin in the tissue sections of PGC were 34.4%(21/61) and 68.9%(42/61), respectively. The positive expression rate of DKK-1 and the abnormal expression rate ofβ-catenin in para-carcinoma tissues were 8.2%(5/61) and 6.6%(4/61) , respectively. The positive expression rate of DKK-1 and the abnormal expression rate ofβ-catenin in normal gastric mucosa were 15.0%(3/20) and 10.0%(2/20), respectively. The expression rate was significantly higher in PGC than that in the other tissues (P<0.05). The expression of DKK-1 was positively related to that ofβ-catenin in PGC (r=0.454, P<0.05), but not in the others. Conclusion:Higher expressions of DKK-1 and the abnormal expression ofβ-catenin are closely related to the occurrence of PGC.

Prognostic Factors for Patients after Curative Resection for Proximal Gastric Cancer / 华中科技大学学报（医学）（英德文版）

The factors influencing the long-term survival of patients with proximal gastric cancer(PGC)after curative resection were investigated.Data from 171 patients who underwent curative resection for PGC were retrospectively analyzed.The patients were grouped according to the clinicopathological factors and operative procedures.The tumor depth(T stage)and lymph node metastasis(pN stage)were graded according to the fifth edition of TNM Staging System published by UICC in1997.The metastatic lymph node ratio(MLR)was divided into four levels: 0%,<10%,10%-30%and >30%.The data of survival rate were analyzed by Kaplan-Meier method(log-rank test)and Cox regression model.The 5-year overall survival rate of 171 patients was 37.32%.The univariate analysis demonstrated that the survival time of the postoperative patients with PGC was related to tumor size(;(2=4.57,P=-0.0325),gross type(χ2=21.38,P<0.001),T stage(χ2=27.91,P<0.001),pN stage(χ2=44.72,P<0.001),MLR(χ2=61.12,P<0.001),TNM stage(χ2=44.91,P<0.001),and range of gastrectomy (χ2=4.36,P=0.0368).Multivariate analysis showed that MLR(χ2=10.972,P=0.001),pN stage(χ2=6.640,P=0.010),TNM stage(χ2=7.081,P=0.007),T stage(χ2=7.687,P=0.006)and gross type(χ2=6.252,P=0.012)were the independent prognostic factors.In addition,the prognosis of patients who underwent total gastrectomy(TG)was superior to that of patients who underwent proximal gastrectomy(PG)for the cases of tumor ≥5 cm(χ2=6.31,P=0.0120),Borrmann Ⅲ/Ⅳ(χ2=7.96,P=0.0050),T4(χ2=4.57,P=0.0325),pN2(χ2=5.52,P=0.0188),MLR 10%-30%(χ2=4.46,P=0.0347),MLR >30%(χ2=13.34,P=0.0003),TNM Ⅲ(χ2=14.05,P=0.0002)or TNM Ⅳ stage(χ2=4.37,P=0.0366);and combining splenectomy was beneficial to the cases of T3(χ2=5.68,P=0.0171)or MLR >30%(χ2=6.11,P=0.0134).It was concluded that MLR,pN stage,TNM stage,T stage,and gross type had advantages in providing a precise prognostic evaluation for patients undergoing curative resection for PGC,in which MLR was the most valuable index.TG and combining splenectomy were useful to improve the prognosis to patients with PGC of TNM Ⅲ/Ⅳ stage,serosa invasion,or extensive regional lymph node metastasis.

A New Laparoscopic Technique for Proximal Gastrectomy with Gastric Tube Reconstruction and Vagal Preservation for Early Gastric Cancer

PURPOSE: The reported incidence of early gastric cancer located in the upper portion of the stomach has been increasing with the recent advances in its diagnosis and screening. Recently, we have successfully performed laparoscopic assisted proximal gastrectomy and gastric tube reconstruction, without pyloroplasty, on six patients with an early gastric carcinoma located in the upper third of the stomach. Herein, we describe our modification of this procedure. METHODS: After creating a surgical pneumoperitoneum, the stomach was mobilized using laparoscopic coagulating shears. The upper half of the greater curvature and three- quarters of the lesser curvature were then dissected in conjunction with a regional D2 lymphadenectomy. This was followed by a 5 cm, longitudinal mini-laparotomy in the upper abdomen, with the construction of the exterior stomach using a 20 cm long and 4 cm wide gastric tube. Reconstruction, with an esophagogastrostomy, was performed using a circular stapler. RESULTS: No post-operative morbidity or mortality was observed in this small series of patients. The average operative time and blood loss were 230 minutes, ranging from 190~290 minutes, and 150 ml, ranging from 90-180 ml, respectively. The mean number of lymph nodes harvested during these laparoscopic proximal gastrectomies was 22.8 nodes, ranging from 19~30 lymph nodes. The average postoperative hospital stays was 8.3 days, ranging from 7~10 days. CONCLUSION: Our technique of laparoscopic assisted proximal gastrectomy and gastric tube reconstruction, without pyloroplasty, offers a minimally invasive technique, with the potential of improving the post-operative quality of life of patients with early-stage proximal gastric cancer.

Clinicopathologic Characteristics of and Prognosis for Proximal Gastric Carcinomas

PURPOSE: Many epidemiological studies have revealed an increasing tendency for proximal gastric cancer. Furthermore, proximal gastric cancer has been known to have unique characteristics and a poor prognosis in contrast to middle and distal gastric cancer, but the reason have not yet been fully explained. For that reason, we investigated changes in the incidence of proximal gastric cancer, its clinicopathologic characteristics, and its prognosis, and we compared the results with those of other reports and tried to identify the reasons for such phenomena. METHODS: After excluding linitis platisca-type cancer, double primary cancer, and gastric cancer arising from the remnant stomach, we retrospectively analyzed the case histories of 836 patients who had undergone operations for gastric cancer from 1992 to 1997. The cases were divided into a proximal gastric-cancer (PGC) group and a middle and distal gastric-cancer (DGC) group based on the location of the primary tumor. RESULTS: The PGC group included 74 patients (8.9%); 762 patients (91.1%) were in the DGC group. The incidence of proximal gastric cancer was 5.0% in 1992 and 11.6% in 1997. The PGC group has more advanced tumor stages (p=0.001) and more positive lymph-node metastases (p=0.013). The resectability of PGC was 87.8%, and that of the DGC was 92.4%, but these were not significantly different (p=0.169). The overall 5-year survival rate for PGC was 48.4% and that of DGC was 59.0%, but these were also not significantly different (p=0.5776). Comparing the survival rates of two groups for various stages revealed no differences. CONCLUSION: The increasing tendency of proximal gastric cancer was similar those in other reports even though we observed for a shorter periods and the proximal gastric cancers were diagnosed in advanced stages, and probably that was the reason for the poor prognosis. Therefore, if early diagnosis is made and adequate therapy is performed, proximal gastric cancer, in contrast to distal gastric cancer, is not a unique disease entity.

Surgical treatment of invasive proximal gastric cancer / 临床外科杂志

Objective To introduce the surgical treatment experiences of upper gastric cancer in our department in recent 10 years for improving its therapeutic level. Methods 94 patients with upper gastric cancer underwent proximal subtotal gastrectomy or total incision plus the left seventh to ninth ribs resection. Results One case developed a fistula at the anastomosis, 3 cases had residual tumor cells at the esophageal margin, and 8 cases developed pttlmonary infections. No one developed costal chondritis or hemopneumothorax followed by pleura injury. Conclusions Operations through mid-abdominal incision on patients with upper gastric cancers, which provide a well exposure, less injury and pain, and are applicable to those whose esophageal invasion is under 1 cm of length.