Application and challenge of neoadjuvant immunotherapy on perioperative treatment for locally advanced gastric cancer / 国际外科学杂志

The application of immunotherapy in advanced gastric cancer has become a research hotspot. At the same time, the combination of immunotherapy and neoadjuvant therapy is expected to further achieve tumor downstage, pathological remission, increase the proportion of R0 resection, which enhance the overall therapeutic effect of locally advanced gastric cancer (LAGC). Whether neoadjuvant immunotherapy affects perioperative complications, adverse events, tumor pathological responses, and long-term survival in LAGC is still in the initial stage of clinical exploration, which depends on large-scale prospective phase III clinical studies to demonstrate its clinical value. Meanwhile, the application of new innovative drugs and comprehensive perioperative treatment, screening high-specific biomarkers for therapeutic prediction, and weighing the selection of neoadjuvant cycle and interval of treatment-operation time are helpful to optimize and standardize the rational application of neoadjuvant immunotherapy, and ultimately bring benefits to patients.

Short-term efficacy of Billroth Ⅱ+Braun anastomosis versus Roux-en-Y anastomosis in totally three-dimensional laparoscopic distal gastrectomy / 中华消化外科杂志

Objective:To compare the short-term efficacy of Billroth Ⅱ+Braun anasto-mosis versus Roux-en-Y anastomosis in totally three-dimensional (3D) laparoscopic distal gastrectomy.Methods:The retrospective cohort study was conducted. The clinicopathological data of 140 patients with gastric cancer who were admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2020 were collected. There were 105 males and 35 females, aged from 23 to 84 years, with a median age of 55 years. Of the 140 patients, 54 patients undergoing totally 3D laparoscopic distal gastrectomy with Billroth Ⅱ+Braun anastomosis were allocated into Billroth Ⅱ+Braun group, and 86 patients undergoing totally 3D laparoscopic distal gastrectomy with Roux-en-Y anastomosis were allocated into Roux-en-Y group, respectively. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect remnant gastritis and its severity, bile reflux, reflux esophagitis in the postoperative 3 months up to April 2020. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the Mann-Whitney U test. Results:(1) Surgical situations: 140 patients underwent totally 3D laparoscopic distal gastrectomy. The operation time, cases with volume of intraoperative blood loss <50 mL, 50 to 200 mL or >200 mL, the number of lymph node dissected were (233±39)minutes,15, 35, 4, 30±13 for the Billroth Ⅱ +Braun group , respectively, versus (240±52)minutes,25, 51, 10, 27±10 for the Roux-en-Y group, showing no significant difference between the two groups ( t=0.856， χ2=0.774， t=1.518， P>0.05). (2) Postoperative situations: cases with drainage tube, time to postoperative first flatus, cases with postoperative grade Ⅱ, Ⅲ, Ⅳ, Ⅴ complications, cases with postoperative complications, cases with postoperative severe complications, duration of postoperative hospital stay, surgery cost and total hospitalization cost of the Billroth Ⅱ+Braun group were 38, (3.5±0.8)days,4, 1, 0, 0, 5, 1, (9.0±5.0)days, (3.8±1.2)×10 4 yuan and (9.7±2.1)×10 4 yuan, respectively. The above indicators of the Roux-en-Y group were 59, (3.7±1.0)days, 9, 1, 0, 1, 11, 2, (9.0±4.0)days, (4.3±1.0)×10 4 yuan and (9.2±2.1)×10 4 yuan, respectively. There was a significant difference in the surgery cost between the two groups ( t=2.453, P<0.05), while there was no significant difference in cases with drainage tube, time to postoperative first flatus, cases with postoperative grade Ⅱ, Ⅲ, Ⅳ, Ⅴ complications, cases with postoperative complications, duration of postoperative hospital stay or total hospitalization cost between the two groups ( χ2=0.049, t=?1.339, Z=0.000, χ2=0.409, t=0.197, 1.383, P>0.05). There was also no significant difference in cases with postoperative severe complications between the two groups ( P>0.05).(3) Follow-up: 134 of 140 patients received the follow-up, including 52 cases in the Billroth Ⅱ+Braun group and 82 cases in the Roux-en-Y group. Results of follow-up within postoperative 3 months showed that the incidence rates of remnant gastritis, bile reflux, reflux esophagitis were 61.5%(32/52), 38.5%(20/52), 26.9%(14/52) for the Billroth Ⅱ+Braun group, respectively, versus 41.5%(34/82), 22.0%(18/82), 12.2%(10/82) for the Roux-en-Y group, showing significant differences between the two groups ( χ2=5.131, 4.270, 4.695, P<0.05). Cases with grade 0,Ⅰ,Ⅱ, Ⅲ, Ⅳ residual food were 42, 3, 5, 2,0 for the Billroth Ⅱ+Braun group, versus 67, 9, 1, 5,0 for the Roux-en-Y group, showing no significant difference between the two groups ( Z=?0.156, P>0.05). Cases with minimal lesion, grade A, grade B gastritis (severity of gastritis) were 6, 5, 3 for the Billroth Ⅱ+Braun group, versus 8, 2, 0 for the Roux-en-Y group, showing no significant difference between the two groups ( Z=?1.468, P>0.05). Conclusions:It is safe and feasible to operate Billroth Ⅱ+Braun or Roux-en-Y anastomosis in totally 3D laparoscopic distal gastrectomy. Billroth Ⅱ+Braun anastomosis can reduce the surgical cost. Roux-en-Y anastomosis has advantages in reducing the incidence of reflux esophagitis, bile reflux and reflux gastritis.

Development of the patient-derived xenograft model for gallbladder carcinoma and gene screening for tumor associated mutations / 中华肝胆外科杂志

Objective:To establish a patient-derived xenograft (PDX) model of gallbladder carcinoma (GBC) and to screen mutated genes associated with GBC with the aim to provide an effective preclinical model with novel therapeutic targets for individualized patient treatment.Methods:The PDX model of GBC was established by transplantation of fresh GBC tissues from 10 patients into subcutaneous tissues of nude mice. In two of these mice, the PDX tumor tissues were stained with HE, Ki67 immunohistochemical staining and whole exome sequencing (WES). The biological characteristics of the PDX tumor tissues were compared with those of the primary donor tumors in histological structure and molecular pathology, and a high-throughput screening of tumor mutation genes was then carried out.Results:In this study, the success rate of the PDX model of GBC was 70% (7/10). The pathological and growth characteristics of PDX tumor tissues and donor tumors were basically similar. In the 2 modeled cases sequenced by WES, the same rates between the harmful mutant genes in the PDX model and primary donor tumor were 71.4% (15/21) and 65.2% (15/23), and the same genes accounted for 93.8% (15/16) and 71.4% (15/21) in the harmful mutant gene of the PDX model. The 22 mutated genes, including TP53, ABCC4 and AMPD1, were involved both in the two donor tumors, and the model tumor tissues. Ten genes including TP53 and ABCC4 were screened out and they might be closely related to development of GBC by bioinformatics analysis.Conclusions:The PDX model of GBC could effectively be used in patients with GBC in this preclinical study on individualized patient treatment. In addition, 10 mutated genes, including TP53 and ABCC4 and the like, may be used as new potential therapeutic targets for GBC.

Progress of diagnosis and treatment of gastric cancer surgery / 国际外科学杂志

Gastric cancer is a common malignant tumor in China, which is a serious threat to national health. It is the common demand of doctors and patients to reduce the complication rate on the basis of improving the therapeutic effect. Based on this demand, in recent years, on the basis of traditional surgery and systemic chemotherapy, gastric cancer surgery has derived many new hot areas, including artificial intelligence diagnosis and treatment technology, minimally invasive surgery technology, enhanced recovery after surgery, multi-disciplinary team (MDT) diagnosis and treatment, precision medicine, and so on, which provide more choices for gastric cancer surgeons, but also bring more challenges.

Surgical strategy for adenocarcinoma of esophagogastric junction / 中华胃肠外科杂志

The incidence of adenocarcinoma of esophagogastric junction (AEG) has been increasing. The surgical strategy for AEG remains controversial. The Siewert definition of AEG facilitates decision of surgical approach, while TNM stage for AEG contributes to prognosis evaluation and clinical decision making. Generally, transthoracic procedure is suitable for Siewert I and transhiatal is suitable for Siewert III. The lymph node drainage of AEG is characterized by simultaneous drainage to the mediastinal and abdominal lymphatic pathways. The optimal lymphadenectomy depends on the distribution of lymph node metastasis. Reconstruction of the digestive tract requires safety as a precondition, taking into account of postoperative complications and quality of life. For AEG patients undergoing total gastrectomy, Roux-en-Y anastomosis is more common. For those undergoing proximal gastrectomy, esophageal residual stomach (tubular stomach) anastomosis is more common, but the proportion of postoperative reflux esophagitis is higher. Some documents have revealed advantages of minimally invasive laparoscopic operation for AEG, but higher level evidences is needed.

Surgical teratment for gastric cancer patients with liver metastasis / 中华肿瘤杂志

Multidisciplinary therapy is considered as an acceptable option for gastric cancer patients with liver metastases currently, while the effectiveness of surgery is still controversial. Although there was no improved survival for cytoreductive surgery, some evidences showed that some selected patients with the combination surgery of gastric cancer and liver metastases could benefit from curative resection. Compared to cytoreductive surgery for gastric cancer patients with liver metastasis, curative resection did not increase the incidence of complications or mortality. Therefore, surgery-based multidisciplinary therapy would be appropriate for some seleted gastric cancer patients with liver metastasis. In highly selected patients with neoadjuvant chemotherapy, curative resection with both primary and metastatic tumor could improve long-term survival benefits. Furthermore, the long-term survival and quality of life should be considered of equal importance in future studies.

Clinicopathological characteristics and prognostic factors of 83 patients with ovarian metastasis from gastric cancer / 中国肿瘤临床

Objective: To explore the clinicopathological characteristics and prognostic factors of patients with ovarian metastasis from gastric cancer. Methods: We retrospectively analyzed the clinical data and treatment strategies of 83 patients with metastatic ovarian tumors treated at PLA General Hospital between January 2006 and December 2017. Univariate analysis using the Log-rank test and multivariate analysis using the Cox proportional-hazards model were used to identify the prognostic factors. Results: The median diam-eter of the metastatic ovarian tumors was 7.1 (1.0-24.0) cm. Of these patients, 36 (43.4%) had unilateral metastasis and 47 (56.6%) had bilateral metastasis; 35 (42.2%) patients had peritoneal metastasis. All patients received chemotherapy, including 57 (68.7%) pa-tients who underwent combined-modality resection of the metastatic tumors and 22 patients (26.5%) who received hyperthermic in-traperitoneal chemotherapy. Of these patients, 74 (89.1%) were followed up, with a median survival time of 15 [95% confidence inter-val (CI): 12.5-17.5] months. The 1-year, 3-year, and 5-year overall survival rates were 71.1%, 6.5%, and 0, respectively. Univariate analy-sis showed that risk factors including≥6 metastatic lymph nodes, metastasectomy, synchronous ovarian metastasis, peritoneal carcino-matosis, estrogen receptor (ER) positivity, and high levels of serum carcinoembryonic antigen and cancer antigen-125 (CA125) might af-fect the prognosis (P<0.05). Multivariate analysis showed that metastasectomy, synchronous ovarian metastasis, combined peritoneal carcinomatosis, and ER positivity were independent factors affecting prognosis (P<0.05). Conclusions: We found that the presence of synchronous ovarian metastasis or combined peritoneal carcinomatosis indicated a poor prognosis; in contrast, ER-positivity predicted a better prognosis than ER-negativity. Metastasectomy may prolong the survival of patients.

Multidisciplinary treatment of adenocarcinoma of esophagogastric junction / 中华消化外科杂志

The incidence of adenocarcinoma of esophagogastric junction (AEG) is increasing,but its treatment strategy is still controversial.Surgery is the main strategy of multidisciplinary treatment.Siewert classification and TNM staging play a decisive role in the choice of operative approach,clinical decision and prognosis.Perioperative chemoradiotherapy plays an important role in the multidisciplinary treatment of AEG,and more researches support neoadjuvant therapy in patients with AEG.What's more,targeted therapy has become an integral part of multidisciplinary treatment of AEG with the constantly emergence of targeted drugs.In addition,the particularity of AEG determines that its treatment requires multidisciplinary cooperation,and the multidisciplinary team is expected to improve the prognosis of AEG patients.

Potential advantages of robot-assisted gastrectomy over laparoscopy-assisted gastrec-tomy regarding lymphadenectomy for gastric cancer / 中国肿瘤临床

Objective: To investigate and compare the abilities of robot-assisted gastrectomy (RAG) and laparoscopy-assisted gastrecto-my (LAG) to remove lymph nodes in technically demanding areas. Methods: Between August 2014 and August 2015, 61 patients who underwent RAG and 235 patients who underwent LAG were enrolled in this study. Clinical characteristics, operative parameters, and pathological and oncological data were collected prospectively, and the numbers of retrieved lymph nodes for each station were ana-lyzed in accordance with the extent of surgery. Results: More lymph nodes were retrieved in the RAG group than in the LAG group (P=0.046). Similarly, the RAG group had more retrieved lymph nodes in the N2 area (P=0.038). In patients who underwent distal gastrecto- my, the numbers of retrieved lymph nodes around the splenic artery area using RAG and LAG were 2.8±1.7 and 2.2±1.2, respectively (P=0.036). In patients who underwent total gastrectomy, 2.8±1.2 and 2.1±1.0 lymph nodes were retrieved with RAG and LAG around the splenic artery area, respectively (P=0.049). The mean numbers of lymph nodes retrieved around the splenic hilum were 1.8±0.8 and 1.3±0.7, respectively (P=0.042). The intraoperative blood transfusion rate (P=0.617), postoperative hospital days (P=0.071), proxi-mal resection margin (P=0.064), and distal resection margin (P=0.667) were not significantly different between the two groups. The numbers of postoperative complications were also similar between the RAG and LAG groups (P=0.854). However, RAG had less severe complications according to the Clavien-Dindo classification (P=0.039). Conclusions: This study demonstrated that RAG had advantages over LAG regarding lymph node dissection in technically demanding areas and might contribute to radical D2 lymphadenectomy with less severe complications.

Risk factors analysis of complications after laparoscopy-assisted distal gastrectomy for gastric cancer / 中华消化外科杂志

Objective To explore the risk factors of complications after laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer (GC).Methods The retrospective case-control study was conducted.The clinicopathological data of 488 GC patients who underwent LADG in the General Hospital of the Chinese People's Liberation Army between January 2010 and May 2016 were collected.Observation indicators:(1)surgical and postoperative situations;(2) risk factors analysis of postoperative complications;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect the post-operative survival of patients up to October,2017.Measurement data with normal distribution were represented as (x)±s,and measurement data with skewed distribution were described as M (interquartile range).The univariate analysis was done using the chi-square test (count data),t test (measurement data with normal distrubution and homogeneity of variance) or t'test (measurement data with normal distribution and heterogeneity of variance) and nonparametric test (measurement data with skewed distrubution).The multivariate analysis was done using the Logistic regression model.Results (1) Surgical and postoperative situations:all the 488 patients underwent successful surgery,including 7 with conversion to open surgery due to intraoperative bleeding and difficult surgery and 481 with LADG.The operation time and volume of intraoperative blood loss of 488 patients were (233±71)minutes and 100 mL (100 mL).The postoperative complications occurred in 99 of 488 patients,some patients merged simultaneously multiple complications.The Clavien-Dindo Ⅰ,Ⅱ,Ⅲa,Ⅲb,Ⅳa,Ⅳb and Ⅴ complications were detected in 39,26,26,6,0,0 and 2 patients,respectively.The top 3 postoperative complications were delayed gastric emptying (18 patients),intestinal obstruction (14 patients) and anastomotic fistula (14 patients).Cases with delayed gastric emptying,intestinal obstruction and anastomotic fistula were respectively 12,12,6 with the Clavien-Dindo classification ＜ Ⅲ a and 6,2,8 with the Clavien-Dindo classification ≥ Ⅲ a.Of 99 patients with postoperative complications,97 were improved by symptomatic treatment and 2 died.Duration of postoperative hospital stay was (13± 12)days.(2) Risk factors analysis of postoperative complications:the results of univariate analysis showed that preoperative concomitant diseases and digestive tract reconstruction were the related factors affecting postoperative complications of patients undergoing LADG;(x2 =11.225,6.581,P＜0.05).The results of multivariate analysis showed that preoperative concomitant diseases and Billroth Ⅱ anastomosis were the independent risk factors affecting postoperative complications of patients undergoing LADG (Odds ratio=2.336,2.630,95％ confidence interval:1.475-3.687,1.369-5.053,P＜0.05).(3) Follow-up and survival situations:of 486 discharged patients,380 were followed up for 2-89 months,with a median time of 42 months.During the follow-up,289,35,48 and 8 patients had respectively tumor-free survival,tumor recurrence and/or metastasis,tumor-related death and non-tumor-related death.Conclusion The anastomotic fistula is one of the common and severe complications after LADG,and preoperative concomitant diseases and Billroth Ⅱ anastomosis are the independent risk factors affecting postoperative complications of patients undergoing LADG.

Emphasis on standardization of minimally invasive surgery for gastric cancer / 中华外科杂志

Different proficiency in minimally invasive surgery has great impact on efficacy of minimally invasive surgery. Therefore, great importance should be attached to the standardization of minimally invasive surgery. Accurate preoperative staging plays a prerequisite role which emphasizes multiple diagnostic strategies. Precise intraoperative procedure plays an essential role which should be performed according to the evidence-based expert consensus and guideline. Standardized postoperative management plays a crucial role which includes ex vivo lymph node dissection, registry of complication and follow-up and establishment of medical database. Establishing training system and improving quality standard system will promote standardized utilization of minimally invasive surgery clinically.

Comparison of the short-term and long-term outcome between robotic gastrectomy and laparoscopic gastrectomy: a propensity score matching analysis / 中华外科杂志

Objective@#To compare the short-term and long-term outcome between robotic gastrectomy and laparoscopic gastrectomy.@*Methods@#The clinical data of 517 patients who had received robotic gastectomy and laparoscopic gastrectomy between December 2011 and December 2013 at Department of General Surgery, Chinese People′s Liberation Army General Hospital was collected. After propensity score matching, 70 patients in robotic gastectomy and 70 patients in laparoscopic gastectomy were identified. Perioperative outcome and overall survival were compared between the two groups using t test, χ2 test, Kaplan-Meier curve and Log-rank test, respectively. Prognosis factors were analyzed by Cox′s proportional hazards regression.@*Results@#There were comparable baseline characteristics between patients in robotic group (RG) and those in laparoscopic group (LG). The conversion rate for RG and LG were 5.7% and 4.3% respectively (P=1.000). Compared with LG, RG had similar lymph node retrieval (25.5±7.2 vs. 24.5±8.3, t=0.770, P=0.443) and less blood loss ((147.0±96.8) ml vs. (188.0±111.2) ml, t=-2.326, P=0.021). There were also similar complications (χ2=0.233, P=0.629) and severity of complications (W=70.500, P=0.053). Although there tended to be early mobility, early flatus and less hospital stay for patients in RG group, the difference between RG and LG was not statistically significant. The 3-year survival rate was 72.9% and 60.0% for patients in RG and patients in LG (P=0.578). Multivariable analysis revealed gender (HR=2.529, 95% CI: 1.042 to 6.140, P=0.040), neoadjuvant chemotherapy (HR=0.272, 95% CI: 0.104 to 0.710, P=0.008) and vascular invasion (HR=2.135, 95% CI: 1.027 to 4.438, P=0.042) were independent prognostic factors.@*Conclusion@#Compared with laparoscopic gastrectomy, robotic gastectomy could achieve similar short-term and long-term outcomes.

Evaluation and future direction of three-dimensional laparoscopy in gastric cancer / 中华外科杂志

It has been thirty years since the three-dimensional (3D) laparoscopy was put into clinical use. The advantages of 3D laparoscopy are depth perception, high cost-efficacy, tactile feedback, education for basic procedures in laparoscopy and accurate operation. Currently, high-level of evidence for 3D laparoscopy in gastric cancer is still lacking. The advantage of 3D laparoscopy could be maximized in complicated procedures, like hilar lymphadenectomy and totally laparoscopic reconstruction in gastrectomy. In order to acquire optimal depth perception, optimal standing position and stereoacuity check should be emphasized for surgeons in 3D laparoscopic surgery. In light of the limitation of 3D laparoscopy, glass-free 3D laparoscopy and real-time navigation-assisted 3D laparoscopy may be one of the future directions. The value of 3D laparoscopy in obese patients and comparison with robot surgical system are worth further investigating.

Application of robotic and laparoscopic radical total gastrectomy to gastric cancer patients with body mass index ≥24 kg/m / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the short-term outcomes between robotic and laparoscopic radical total gastrectomy in gastric cancer patients with BMI index ≥24 kg/m.</p><p><b>METHOD</b>Clinical data of 93 gastric cancer patients who underwent robotic and laparoscopic radical total gastrectomy at PLA General Hospital from April 2016 to April 2017 were retrospectively analyzed. The retrospective cohort study was adopted.</p><p><b>INCLUSION CRITERIA</b>preoperatively definite diagnosis of primary gastric cancer by endoscopy and biopsy; preoperative BMI ≥24 kg/m; no previous abdominal surgery; no previous chemotherapy and radiotherapy; no distant metastasis or invasion into adjacent organs before operation or during operation; receiving radical gastrectomy; Roux-en-Y reconstruction of digestive tract in open procedure. According to approaches of minimally invasive surgery, 24 patients underwent robotic surgery and 69 underwent laparoscopic surgery. The intraoperative parameters (overall operative time, pneumoperitoneal time, open procedure time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes and metastatic lymph nodes) and postoperative parameters (drainage in the first postoperative day, the first defecation time, morbidity of postoperative complication and hospital stay) were compared between two groups. Correlation of the above parameters were analyzed.</p><p><b>RESULTS</b>Of 93 patients, 77 were male and 16 female with an average age of (60.0±10.6) years. The average BMI was (26.8±1.3) kg/m in whole patients, (26.9±1.6) kg/m in robotic group and (26.8±1.7) kg/m in laparoscopic group. No significant differences in age, gender, BMI, preoperative ASA class, postoperative pathological findings and clinical classification were observed between two groups, which made short-term parameters between two groups comparable. The robotic group had a significantly longer overall operative time [(301.2±68.9) minutes vs. (247.3±59.6) minutes, P=0.000], longer open procedure time [(141.5±26.3) minutes vs. (92.5±36.7) minutes, P=0.029] and higher cost than laparoscopy group[(17.5×10 ± 9.7×10) yuan vs. (10.0×10 ± 2.3×10) yuan, P=0.001]. Pneumoperitoneal operative time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes, number of harvested metastatic lymph nodes and postoperative short-term efficacy were similar between the two groups (all P>0.05). In robotic group, pneumoperitoneal operative time was positively correlated with overall operative time (r=0.708, P=0.010); total cost was positively correlated with postoperative hospital stay (r=0.493, P=0.000) and open procedure time was negatively correlated with the first defecation time (r=-0.962, P=0.038). In laparoscopy group, total cost was positively correlated with overall operative time (r=0.411, P=0.046), drainage volume in the first postoperative day was positively correlated with the number of total dissected lymph node (r=0.540, P=0.006), postoperative hospital stay was positively correlated with intraoperative blood loss (r=0.574, P=0.003), total cost was positively correlated with intraoperative blood loss and hospital stay (r=0.609, P=0.002; r=0.865, P=0.000), drainage volume in the first postoperative day was positively correlated with BMI (r=0.533, P=0.007).</p><p><b>CONCLUSION</b>For gastric cancer patients with BMI ≥24 kg/m, robotic radical total gastrectomy is associated with longer operative time and higher cost, but is less vulnerable to the change of BMI and more in favor of the realization of enhanced recovery after surgery (ERAS) than laparoscopic radical total gastectomy.</p>

Enhanced recovery after surgery for the gastrointestinal surgery / 中华外科杂志

It has already been ten years since the concept of enhanced recovery after surgery (ERAS) was introduced in China. The ERAS protocol focuses on relieving surgical stress and accelerating physiological recovery. From our perspective, besides the post hospital stay, it would be better to evaluate patient′s recovery by different indicators. It is important to improve the compliance of ERAS protocol. The guideline-related factors, administration, medical staff and patients have impact on compliance. Integrating stakeholders, strengthening communication and cooperation among multidiscipline teams, combining theory with practice would facilitate use of ERAS protocol in clinical settings.

Application of TBL and PBL in clinical teaching of laparoscopic surgery in general surgery / 中华医学教育探索杂志

Objective To explore the application of team-based learning (TBL) and problem-based learning (PBL) method in clinical teaching of laparoscopic surgery in general surgery. Methods 48 students of surgery in our department were selected as the subjects to conduct the clinical teaching study. These students were divided randomly into two groups. The experimental group (24 students) adopted the method that combined TBL and PBL method, while the control group (24 students) adopted the traditional teaching method. We compared the efficacy of two groups in term of theoretical knowledge, surgical practice, com-prehensive surgical grade, and questionnaire survey. Results The score of theoretical knowledge and sur-gical practice on clipping soybean and making suturation and instrumental tie of two groups were obviously higher than that before teaching. After finishing teaching, the score of experimental group on theoretical knowledge, making suturation and instrumental tie and comprehensive surgical grade were higher than that of control group. The score of clipping soybean was similar between two groups. In addition, in term of questionnaire survey on the consciousness of independent study, the depth and width of study, and satisfac-tions to teaching, the TBL and PBL group had a better score than the control group. Conclusion The new teaching method which combines TBL with PBL enhances the teaching effect on theoretical knowledge and laparoscopic surgery practice. It is an effective method to train medical students.

Factor analysis and method exploring for lymph nodes harvest in gastric cancer / 中华外科杂志

The number of lymph node dissection and positive lymph nodes are the necessary guarantees for patients to achieve accurate staging after gastric cancer surgery. On the basis of the minimum number of lymph nodes dissection recommended by the NCCN guidelines, as many as possible lymph node yields will be most likely to benefit patients. Many factors can influence the number of lymph node yields including surgery, patient, tumor pathology and postoperative sorting factors. Compared with traditional manual nodal dissection method, fat-clearing technique and methylene blue staining method can improve the number of lymph nodes detection, while lymphatic tracers, such as carbon nanoparticles, are conducive to show lymphatic vessels, contributing to the dissection of small lymph nodes. The initial results from People′s Liberation Army General Hospital show that lymph node packet submission after isolation by surgeon yields more lymph nodes. For the establishment of standards, lymph node retrieval-related procedures need further in-depth exploration and investigation.

Significance and contemplation of clinical diagnosis and therapy on the renewal of the eighth edition of gastric cancer TNM staging system / 中华胃肠外科杂志

TNM staging is essential for clinical decision-making and prognostic prediction for patients with gastric cancer. The 7th TNM staging manual was formulated in 2009 and implemented in 2010. However, it was published that there were some deficiencies of the 7th edition of gastric cancer TNM staging system in clinical application process, and this old staging system could not meet the clinical needs. With the cooperation and promotion of the American Joint Committee on Cancer (AJCC), the International Union for Cancer Control (UICC) and the International Gastric Cancer Association (IGCA), and through the accumulation and analysis of gastric cancer big data, the 8th TNM staging system was published at the end of 2016. The updated staging system has defined the selection of staging system for esophagogastric junction cancer. It also has divided N3 into N3a and N3b, which has been incorporated into the new staging system, leading to more accurate risk stratification. Moreover, the cTNM staging system and ypTNM staging system have been added in the new staging manual. Overall, the 8th TNM staging system can facilitate more reasonable decision-making, more accurate prognostic prediction and better evaluation of therapeutic strategy. It is of high value to promote diagnostic and therapeutic standard for gastric cancer.

Comparison of complications following open, laparoscopic and robotic gastrectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare clinically relevant postoperative complications after open, laparoscopic, and robotic gastrectomy for gastric cancer.</p><p><b>METHODS</b>Clinical data of patients with gastric cancer who underwent gastrectomy between January 1, 2014 and October 1, 2016 at Chinese People's Liberation Army General Hospital were analyzed retrospectively. All the patients were diagnosed by upper endoscopy and confirmed by biopsy without distant metastasis. They were confirmed with R0 resection by postoperative pathology. Patients with incomplete data were excluded. The complications among open group, laparoscopic group and robotic group were compared. The continuous variables were analyzed by one-way ANOVA, and categorical variables were analyzed by χtest or Fisher exact test.</p><p><b>RESULTS</b>A total of 1 791 patients (1 320 males and 471 females) were included in the study, aged from 17 to 98 (59.0±11.6) years, comprising 922 open, 673 laparoscopic and 196 robotic gastrectomies. There were no significant differences among three groups in baseline data (gender, age, BMI, comorbidity, radiochemotherapy) and some of operative or postoperative data (blood transfusion, number of lymph node dissection, combined organ resection, resection site, N stage, postoperative hospital stay). The blood loss in laparoscopic and robotic groups was significantly lower than that in open group[(185.7±139.6) ml and (194.0±187.6) ml vs. (348.2±408.5) ml, F=59.924, P=0.000]. The postoperative complication occurred in 197 of 1 791(11.0%) patients. The Clavien-Dindo II(, III(a, III(b, IIII(a, and IIIII( complications were 5.5%, 4.0%, 1.2%, 0.1%, and 0.2% respectively. The anastomotic leakage (2.4%), intestinal obstruction(1.3%) and pulmonary infection(1.2%) were the three most common complications, followed by wound infection(0.8%), cardiovascular disease(0.7%), anastomotic bleeding (0.7%), delayed gastric emptying (0.6%), duodenal stump fistula(0.5%), intraperitoneal hemorrhage (0.5%), pancreatic fistula (0.3%), intra-abdominal infection(0.2%), chylous leakage (0.1%) and other complications(1.7%). There were no significant differences among three groups as the complication rates of open, laparoscopic and robotic gastrectomy were 10.6%(98/922), 10.8%(73/673) and 13.3%(26/196) respectively (χ=1.173, P=0.566). But anastomotic leakage occurred more common after laparoscopic and robotic gastrectomy compared to open gastrectomy [3.1%(21/673) and 5.1%(10/196) vs. 1.3%(12/922), χ=12.345, P=0.002]. The rate of cardiocerebral vascular diseases was higher in open group[1.3%(12/922) vs. 0.1%(1/673) and 0, χ=8.786, P=0.012]. And the rate of anastomotic bleeding was higher in robotic group [2.0%(4/196) vs. open 0.4%(4/922) and laparoscopic 0.6%(4/673), χ=6.365, P=0.041]. In view of Clavien-Dindo classification, III(a complications occurred more common in laparoscopic group [5.5%(37/673) vs. open 3.3%(30/922) and robotic 2.6%(5/196), χ=6.308, P=0.043] and III(b complications occurred more common in robotic group [3.1%(6/196) vs. open 1.1%(10/922) and laparoscopic 0.7%(5/673), χ=7.167, P=0.028].</p><p><b>CONCLUSIONS</b>Morbidities of postoperative complications are comparable among open, laparoscopic and robotic gastrectomy for gastric cancer. However, in consideration of the high difficulty of anastomosis, the minimally invasive surgery should be performed by more experienced surgeons.</p>

Surgical treatment for metastatic gastric cancer / 中华胃肠外科杂志

The incidence of metastatic gastric cancer (MGC) is high and the prognosis is poor with 5-year survival rarely exceeding 5%. Systemic chemotherapy is the cornerstone for MGC in current treatment guidelines. Recent studies have revealed both reduction surgery and conversion surgery can improve patient's prognosis, indicating the value of surgical treatment in MGC. Based on the present therapeutic strategy, we discuss the indication, extent and timing of surgery for MGC. Our conclusions are as followings: the treatment of gastric cancer is chemotherapy-based, target-included and surgery-combined multidisciplinary therapy; patients with single non-curable factor are most likely to benefit from surgery-combined multidisciplinary therapy; the optimal timing for surgery depends on the response to chemotherapy; it is worthwhile to explore the conversion therapy combining target therapy and chemotherapy; the resection of metastasis lesion can be managed according to Japanese guideline; in order to establish high-level evidence, it is necessary to unite experts from different disciplines to conduct clinical trial according to the category of metastasis of gastric cancer.