Advances in clinical application of obstruction catheter in prevention and treatment of intestinal obstruction / 中华胃肠外科杂志

Intestinal obstruction is one of the most common diseases in abdominal surgery, and its prevention and treatment is a clinical difficulty. Although surgical operation can solve the symptoms of obstruction, there are many postoperative complications, and it is easy to develop re-obstruction due to postoperative abdominal adhesion. The internal fixation of small intestine with obstruction catheter provides a new idea for the prevention of postoperative adhesive bowel obstruction. The use of transanal ileus catheter provides the possibility of direct intestinal anastomosis after resection of malignant obstruction in the left hemicolon and can reduce the incidence of postoperative complications. However, sufficient attention should be paid to the related complications, and prevention and treatment should be planned. It is important to note that the use of obstruction catheter is only one of the conservative treatments for bowel obstruction, and it is not a complete replacement of surgery. Surgical treatment should still be considered, if the catheter fails to significantly move, if the obstructive symptoms do not significantly improve 5 days after catheterization.

A multi-center retrospective study of perioperative chemotherapy for gastric cancer based on real-world data / 中华胃肠外科杂志

Objective: To explore the effect of perioperative chemotherapy on the prognosis of gastric cancer patients under real-world condition. Methods: A retrospective cohort study was carried out. Real world data of gastric cancer patients receiving perioperative chemotherapy and surgery + adjuvant chemotherapy in 33 domestic hospitals from January 1, 2014 to January 31, 2016 were collected. Inclusion criteria: (1) gastric adenocarcinoma was confirmed by histopathology, and clinical stage was cT2-4aN0-3M0 (AJCC 8th edition); (2) D2 radical gastric cancer surgery was performed; (3) at least one cycle of neoadjuvant chemotherapy (NAC) was completed; (4) at least 4 cycles of adjuvant chemotherapy (AC) [SOX (S-1+oxaliplatin) or CapeOX (capecitabine + oxaliplatin)] were completed. Exclusion criteria: (1) complicated with other malignant tumors; (2) radiotherapy received; (3) patients with incomplete data. The enrolled patients who received neoadjuvant chemotherapy and adjuvant chemotherapy were included in the perioperative chemotherapy group, and those who received only postoperative adjuvant chemotherapy were included in the surgery + adjuvant chemotherapy group. Propensity score matching (PSM) method was used to control selection bias. The primary outcome were overall survival (OS) and progression-free survival (PFS) after PSM. OS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the last effective follow-up or death. PFS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the first imaging diagnosis of tumor progression or death. The Kaplan-Meier method was used to estimate the survival rate, and the Cox proportional hazards model was used to evaluate the independent effect of perioperative chemo therapy on OS and PFS. Results: 2 045 cases were included, including 1 293 cases in the surgery+adjuvant chemotherapy group and 752 cases in the perioperative chemotherapy group. After PSM, 492 pairs were included in the analysis. There were no statistically significant differences in gender, age, body mass index, tumor stage before treatment, and tumor location between the two groups (all P>0.05). Compared with the surgery + adjuvant chemotherapy group, patients in the perioperative chemotherapy group had higher proportion of total gastrectomy (χ(2)=40.526, P<0.001), smaller maximum tumor diameter (t=3.969, P<0.001), less number of metastatic lymph nodes (t=1.343, P<0.001), lower ratio of vessel invasion (χ(2)=11.897, P=0.001) and nerve invasion (χ(2)=12.338, P<0.001). In the perioperative chemotherapy group and surgery + adjuvant chemotherapy group, 24 cases (4.9%) and 17 cases (3.4%) developed postoperative complications, respectively, and no significant difference was found between two groups (χ(2)=0.815, P=0.367). The median OS of the perioperative chemotherapy group was longer than that of the surgery + adjuvant chemotherapy group (65 months vs. 45 months, HR: 0.74, 95% CI: 0.62-0.89, P=0.001); the median PFS of the perioperative chemotherapy group was also longer than that of the surgery+adjuvant chemotherapy group (56 months vs. 36 months, HR=0.72, 95% CI:0.61-0.85, P<0.001). The forest plot results of subgroup analysis showed that both men and women could benefit from perioperative chemotherapy (all P<0.05); patients over 45 years of age (P<0.05) and with normal body mass (P<0.01) could benefit significantly; patients with cTNM stage II and III presented a trend of benefit or could benefit significantly (P<0.05); patients with signet ring cell carcinoma benefited little (P>0.05); tumors in the gastric body and gastric antrum benefited more significantly (P<0.05). Conclusion: Perioperative chemotherapy can improve the prognosis of gastric cancer patients.

Application of totally laparoscopic anastomosis in laparoscopic gastrectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the safety and feasibility of the total laparoscopic anastomosis in laparoscopic gastrectomy.</p><p><b>METHODS</b>Clinical data of 36 patients who received totally laparoscopic anastomosis and another 47 patients who received anastomosis through small incision in our department from July 2012 to July 2013 were retrospectively analyzed. Clinical outcomes were compared between the two groups.</p><p><b>RESULTS</b>The operation was successfully carried out in all the 83 patients. The mean incision length was (7.1±0.9) cm in small incision group and (2.6±0.4) cm in totally laparoscopic group, while the mean time of anastomosis was (70.9±9.0) min and (29.1±4.9) min respectively. Six patients felt moderate pain and 41 felt severe pain in small incision group, while 29 patients felt moderate pain and 7 felt severe pain in totally laparoscopic group. Anastomotic leakage occurred in 1 case after operation in small incision group and there was no related anastomosis complication in totally laparoscopic group.</p><p><b>CONCLUSIONS</b>Total laparoscopic anastomosis is safe and feasible in laparoscopic gastrectomy for gastric cancer. Compared with small incision-assisted anastomosis, totally laparoscopic anastomosis is associated with shorter time and less pain.</p>

Interpretation of D2 radical operation and en bloc mesogastric excision in gastric cancer / 中华胃肠外科杂志

As a surgical oncology concept, complete mesenteric excision has been widely accepted. As to different organs, in addition to the rectum and the colon, the range or the criteria of the so-called complete mesenterium is not yet entirely clear. For the stomach, the mesogastric structure is so complicated, and the embryology and anatomy of the mesogastrium or the perigastric ligaments differed significantly. Even to perform a resection in accordance with the anatomy plane of mesogatrium, the mesogastric plane is still extended as compared to the current standard D2 radical resection. We therefore propose the concept of surgical mesogastrium, which means that the essence of en bloc mesogastric excision (EME) should be surgical mesogastric resection. In clinical practice, we found that a lot of symmetric similarity exists in stomach and colon, the morphological transformation from stomach to the colon can be accomplished to some extent by extension and folding of the stomach, and striking match exists in the morphology, distribution of the blood vessels, lymphatic drainage and mesenterium (mesogastrium or mesocolon). On this basis, we propose the plane of the surgical mesogastrium, which includes the gastrohepatic ligament, hepatoduodenal ligament, hepatopancreatic folds, splenicpancreatic folds, gastrophrenic ligament, gastrosplenic ligament, gastrocolic ligament (supracolic omentum) and omentum. This surgical mesogastric plane coincides with the current plane of D2 radical resection. This paper further discussed the N staging of gastric cancer. By comparative study of the stomach and the colon, we could re-classify the stomach-associated lymph nodes into three groups, the perigastric, the middle and the roots, which may resolve the long-standing controversy between the Eastern and Western regarding this issue. In addition, we also agree with the presence of lymph node metastasis in the plane outside of the surgical mesogastrium, the so-called lateral lymph node metastasis. As for the N staging of gastrointestinal cancer, we must firstly define the lymph node metastasis as mesenteric (mesogastric or mesocolic lymph node) and extra-mesenteric (later lymph node). In case of lateral lymph node metastasis, which should be considered as M1 stage (distant metastasis) unless there is evidence to suggest lateral lymph node metastasis, otherwise extended lateral lymph node dissection should be avoided. In case of mesenteric (mesogastric or mesocolic) lymph node metastasis, classification should be in accordance with the current NCCN guideline, which was divided by the number of lymph node metastasis (N1-N3).

Cosmetic outcome and surgical site infection rates of antibacterial absorbable (Polyglactin 910) suture compared to Chinese silk suture in breast cancer surgery: a randomized pilot research / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The primary objective of this multicenter post-market study was to compare the cosmetic outcome of triclosan-coated VICRYL Plus sutures with Chinese silk sutures for skin closure of modified radical mastectomy. A secondary objective was to assess the incidence of surgical site infection (SSI).</p><p><b>METHODS</b>Patients undergoing modified radical mastectomy were randomly assigned to coated VICRYL Plus antibacterial (Polyglactin 910) suture or Chinese silk suture. Cosmetic outcomes were evaluated postoperatively at days 12 (± 2) and 30 (± 5), and the evidence of SSI was assessed at days 3, 5, 7, 12 (± 2), 30 (± 5), and 90 (± 7). Cosmetic outcomes were independently assessed via visual analogue scale (VAS) score evaluations of blinded incision photographs (primary endpoint) and surgeon-assessed modified Hollander Scale (mHCS) scores (secondary endpoint). SSI assessments used both CDC criteria and ASEPSIS scores.</p><p><b>RESULTS</b>Six Chinese hospitals randomized 101 women undergoing modified radical mastectomy to closure with coated VICRYL Plus suture (n = 51) or Chinese silk suture (n = 50). Mean VAS cosmetic outcome scores for antibacterial suture (67.2) were better than for Chinese silk (45.4) at day 30 (P < 0.0001)). Mean mHCS cosmetic outcome total scores, were also higher for antibacterial suture (5.7) than for Chinese silk (5.0) at day 30 (P = 0.002).</p><p><b>CONCLUSIONS</b>Patients using coated VICRYL Plus suture had significantly better cosmetic outcomes than those with Chinese silk sutures. Patients using coated VICRYL Plus suture had a lower SSI incidence compared to the Chinese silk sutures, although the difference did not reach statistical significance.</p>

Value of radical dissection with vagus nerve preservation for proximal gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the feasibility and influence of vagus nerve preservation in radical operation for proximal gastric cancer.</p><p><b>METHODS</b>Thirty-two patients with early or T2 cardia cancer from May 2007 to May 2009 were enrolled and randomized into two groups, i.e. vagus nerve preservation group(n=16) and control group(n=16). Two groups were compared with regard to operative time, anastomotic fistula, digestive discomforts, body weight, survival rate, findings on gastroscope and abdominal ultrasonography.</p><p><b>RESULTS</b>There were no statistically significant differences between the two groups in operative time (2.8 vs. 2.5 h), postoperative complications rate (25.0% vs. 31.3%). No recurrence or mortality was observed after one-year follow-up. However, patients who underwent vagus nerve preservation had less postprandial discomforts(3 vs. 12 cases), bile reflux(3 vs. 10 cases), atrophic gastritis(1 vs. 9 cases), gallstones(1 vs. 8 cases), body mass index, and diarrhea(P<0.05).</p><p><b>CONCLUSION</b>For patients with early gastric cancer, preservation of the vagus nerve during radical gastrectomy results in less complications and does not compromise patient survival.</p>