No.12a Lymph Node Metastasis and Survival Analysis of Upper Gastric Cancer / 肿瘤防治研究

Objective To analyze the relationship between No.12a lymph node metastasis and clinicopathological features of upper gastric cancer and to discuss the indications and prognostic significance of lymph node dissection in this group. Methods A retrospective analysis was performed on the medical records of 377 patients with upper gastric cancer, to compare the relationship between No.12a lymph node metastasis and clinicopathological characteristics of patients with upper gastric cancer. Kaplan-Meier method was used to analyze the prognosis of patients with or without No.12a lymph node metastasis, and Cox regression analysis was performed to analyze the influencing factors of prognosis and survival of patients with upper gastric cancer. Results Tumor location (lesser curvature side), tumor diameter (≥5.5 cm), degree of differentiation, and T/N/TNM stage were significantly correlated with No.12a lymph node metastasis (P < 0.05). After excluding N staging, Cox regression results showed that the degree of differentiation (HR: 0.668, 95%CI: 0.48-0.931, P=0.017) and pTNM stage (HR: 6.319, 95%CI: 4.063-9.828, P < 0.001) were the independent risk factors, but No.12a lymph node metastasis (HR: 1.477, 95%CI: 0.71-3.075, P=0.297) was not an independent risk factor for survival of upper gastric cancer patients. Conclusion No.12a lymph node metastasis does not seem to be an independent risk factor for the prognosis of upper gastric cancer patients. However, the prognosis of patients with No.12a lymph node metastasis is worse than that of patients without No.12a lymph node metastasis. The No.12a lymph nodes should be actively dissected when the tumor is in the following situations: the tumor is located in the lesser curvature, the degree of differentiation is poorly differentiated, and the tumor stage is late (T4, N3, or Ⅱ-Ⅲ stage).

Progress of research and technical in minimally invasive surgery for gastric cancer / 中华消化外科杂志

Gastric cancer is one of the most common malignant tumors in the world, and its incidence and mortality are among the top of malignant tumors in China. Since Kitano et al com-plete the first laparoscopic radical gastrectomy for gastric cancer in the world in 1992, the laparos-copic technology has developed rapidly. After more than 30 years of exploration and practice, the clinical diagnosis and treatment of gastric cancer in China has also made considerable progress. A large number of clinical studies at home and abroad have confirmed that laparoscopic radical gas-trectomy is no less effective than traditional open surgery in the short and long term. Laparoscopic radical gastrectomy has the characteristics of less trauma, faster recovery of gastrointestinal func-tion, less postoperative pain, and shorter average hospital stay. It has gradually replaced open surgery as the mainstream surgical method for gastric cancer. As the concept of surgical treatment for gastric cancer continues to update, emerging minimally invasive technologies continue to emerge, including robotic surgery systems and indocyanine green tracing technology, which are increasingly used in gastric cancer surgery, making gastric cancer surgery more minimally invasive and accurate, the quality of perigastric lymph node dissection and the domestic gastric cancer surgery technology further improving. Based on the relevant research at home and abroad, the authors review and summarize the latest progress in recent years with the topic of minimally invasive surgery for gastric cancer, aiming to systematically describe the current situation and future prospects of gastric cancer surgery. It is believed that in the future, the clinical diagnosis and treatment of gastric cancer in China will be more standardized, minimally invasive and accurate, more high-quality multicenter clinical research will be carry out and the diagnosis and treatment of gastric cancer will be further improved in China.

Different Anesthesia and Sedation Depths of BIS-guided Closed-loop Target-controlled Infusion on Perioperative Th1/Th2 Balance in Elderly Patients Undergoing Laparoscopic Radical Gastrectomy / 肿瘤防治研究

Objective To investigate the effect of BIS-guided closed-loop target-controlled infusion on perioperative Th1/Th2 balance in elderly patients undergoing laparoscopic radical gastrectomy under different anesthesia and sedation depths. Methods We applied random number table method to divide 73 elderly patients undergoing elective laparoscopic radical gastrectomy into BIS closed-loop target-controlled infusion group with BIS value of 55(group H, n=36) and BIS value of 45(group L, n=37).Intravenous blood samples were collected immediately before surgery (T1), 2h after surgery (T2), 24h after surgery (T3) and 72h after surgery (T4).IL-2, IL-4, IL-6, IL-10, TNF-α and IFN-γ were determined by flow cytometry microsphere array.We compared operation duration, postoperative PACU stay time and postoperative hospitalization time between two groups. Results Compared with T1, IL-6 and IL-10 concentration in group H at T2, T3 and T4 significantly increased (P < 0.05), IL-4 and TNF-α in group H at T4 were significantly increased (P < 0.05), IL-2 and IFN-γ in group H at T2 and T4 were significantly increased (P < 0.05), the concentration of IL-6 and IL-10 in group L at T2, T3 and T4 were increased (P < 0.05), IL-2 in group L at T4 was decreased (P < 0.05), and IFN-γ/IL-6 in two groups were decreased at T2, T3 and T4(P < 0.05).Compared with group L, IL-6 and IL-10 in group H were significantly increased at T2(P < 0.05), IFN-γ/IL-6 in group H was significantly decreased (P < 0.05), IL-2 and IL-10 in group H were significantly increased at T4(P < 0.05).Operation duration, postoperative PACU stay time and postoperative hospitalization time had no statistical significance between two groups (P > 0.05). Conclusion The anesthesia and sedation depth of BIS-guided closed-loop target-controlled infusion set at 45 is better than 55 in maintaining Th1/Th2 balance in elderly patients undergoing laparoscopic radical gastrectomy, but it has no obvious effect on long-term prognosis.

Early postoperative complications and risk factors in laparoscopic D2 radical gastrectomy for gastric cancer / 中华胃肠外科杂志

Objective@#To investigate the morbidity and treatment of early postoperative complications after laparoscopic D2 radical gastrectomy for gastric cancer, and to explore the risk factors.@*Methods@#A case-control study was performed to retrospectively collect clinicopathological data of 764 patients undergoing laparoscopic D2 radical gastrectomy for gastric cancer at our department between January 2015 and December 2017. Patient inclusion criteria: (1) gastric cancer diagnosed by preoperative electronic gastroscopy and biopsy, and confirmed by postoperative pathology; (2) without invasion into adjacent organs by preoperative evaluation of tumors; (3) tumors without definite liver and distant metastasis; (4) R0 resection of gastric cancer and standard D2 lymph node dissection; (5) patients with informed consent. Exclusion criteria: (1) unperformed laparoscopic D2 radical resection; (2) other types of gastric tumor confirmed by pathology; (3) cases with incomplete clinical data. Complication occurring within two weeks after laparoscopic D2 gastrectomy was defined as early postoperative complication. Patients were divided into two groups: non-complication group (693 cases) and complication group (71 cases) according to the occurrence of complications after operation. The clinicopathological data of two groups were analyzed and compared with t test and χ2 test, and the factors of P < 0.2 were included in the multivariate logistic regression model to analyze the risk factors of postoperative complications.@*Results@#Of 764 patients, 71 (9.3%) developed early postoperative complications, with median onset time of 3 (1 to 11) days. Surgical complications accounted for 7.9% (60/764), including 13 cases (1.7%) of abdominal hemorrhage, 12 cases (1.6%) of anastomotic leakage, 10 cases (1.3%) of incision infection, 8 cases (1.0%) of anastomotic bleeding, 7 cases (0.9%) of gastric stump weakness, 4 cases (0.5%) of abdominal infection, 4 cases (0.5%) of duodenal stump leakage and 2 cases (0.3%) of small intestinal obstruction. Non-surgical complications accounted for 1.4% (11/764), including 6 cases (0.8%) of pulmonary infection and 5 cases (0.7%) of cardiovascular disease. Two cases (0.3%) died of sepsis caused by severe abdominal infection; 9 cases (1.2%) recovered after receiving the second operation, among whom 5 cases were abdominal hemorrhage, 2 cases were anastomotic leakage and 2 cases were duodenal stump leakage; the remaining patients were healed with conservative treatment. Compared with patients without complications, patients with complications had higher proportions of BMI ≥24 kg/m2 [42.3% (30/71) vs. 24.2%(168/693), χ2=10.881, P=0.001], comorbity [64.8% (46/71) vs. 33.5% (232/693), χ2=27.277, P<0.001], combined organ resection [70.4% (50/71) vs. 20.5% (142/693), χ2=85.338, P<0.001], and pTNM stage of III [70.4% (50/71) vs. 40.1% (278/693), χ2=24.196, P<0.001], meanwhile had longer time to postoperative flatus [(4.2±2.1) days vs. (2.9±1.2) days, t=4.621, P=0.023], longer hospital stay [(34.6±12.6) days vs. (14.2±6.2) days, t=9.862, P<0.001] and higher hospitalization cost [(126.8±64.5) thousand yuan vs. (85.2±35.8) thousand yuan, t=11.235, P<0.001]. Multivariate analysis showed that BMI ≥24 kg/m2 (OR=3.762, 95% CI: 1.960-8.783, P=0.035), accompanying disease (OR=8.620, 95% CI: 1.862-29.752, P<0.001), combined organ resection (OR=6.210, 95% CI: 1.357-21.568, P=0.026), and pTNM stage (OR=4.752, 95% CI: 1.214-12.658, P<0.001) were the independent risk factors of postoperative complications.@*Conclusions@#Laparoscopic D2 radical gastrectomy is a safe and effective approach for gastric cancer. Most early postoperative complications can obtain satisfactory efficacy after conservative treatment. Perioperative management should be strengthened for those patients with high BMI, accompanying diseases, combined organ resection, and advanced pTNM stage.

Effect of intraoperative lung-protective mechanical ventilation on pulmonary oxygenation function and postoperative pulmonary complications after laparoscopic radical gastrectomy

This study aimed to observe the effects of lung-protective ventilation (LPV) on oxygenation index (OI) and postoperative pulmonary complications (PPCs) after laparoscopic radical gastrectomy in middle-aged and elderly patients. A total of 120 patients who were scheduled to undergo laparoscopic radical gastrectomy with an expected time of >3 h were randomly divided into conventional ventilation (CV group) with tidal volume (TV) of 10 mL/kg without positive end-expiratory pressure (PEEP), and lung-protective ventilation (PV group) with 7 mL/kg TV and personal level of PEEP with regular recruitment maneuver every 30 min. Measurements of OI, modified clinical pulmonary infection score (mCPIS), and PPCs were assessed during the perioperative period. Fifty-seven patients in the CV group and 58 in the PV group participated in the data analysis. Patients in the PV group showed better pulmonary dynamic compliance, OI, and peripheral capillary oxygen saturation during and after surgery. The mCPIS was significantly lower in the PV group than in the CV group after surgery. The incidence rate of PPCs was lower in the PV group than in the CV group and the difference was significant in patients whose ventilation time was longer than 6 h in both groups. LPV during laparoscopic radical gastrectomy significantly improved pulmonary oxygenation function and reduced postoperative mCPIS and the incidence of PPCs during the early period after surgery of middle-aged and elderly patients, especially patients whose mechanical ventilation time was longer than 6 h.

Influence of different CO2 pneumoperitoneum pressure on intestinal mucosal injury and intestinal function recovery in patients undergoing laparoscopic radical gastrectomy / 中国现代普通外科进展

Objective:To evaluate the influence of different CO2 pneumoperitoneum pressure on intestinal mucosal injury and intestinal function recovery in patients undergoing laparoscopic radical gastrectomy.Methods:A total of 120 patients undergoing laparoscopic radical gastrectomy were randomly divided into group A,B and C.Each group included 40 patients.CO2 pneumoperitoneum pressure ingroup A,B and C were 8～10 mmHg,11～13 mmHg and 14～16 mmHg,respectively.The degree of intestinal mucosa damage,plasma D-lactate(2,24 and 48 hours after the treat-ment),intestinal function recovery and complication ration were compared between the three groups.Results:Damage degree of intestinal mucosa after operation in A,B and C groups were 0～1,1～2 and 2～3 respectively.There was significant change in intestinal mucosa injury after operation in both B and C groups.The level of D-lactic acid in group C (2,24 and 48 hours after the treat-ment) were significantly higher those in group A and group B (P＜0.05).The bowel sounds appeared time,exhaust time and intake time in group C were significantly longer than group A and group B (P＜0.05).The incidence of complications were not significantly difference during the three groups.Conclusion:The high pressure of CO2 pneumoperitoneum will cause intestinal mucosa damaged,and not conducive to the patients' intestinal rehabilitation.We suggest that the CO2 pneumoperitoneum pressure should be as low as possible under clear visualization during operation.

Research Progress of Fast Track Surgery in Laparoscopic Radical Gastrectomy for Gastric Cancer / 中国微创外科杂志

Fast track surgery(FTS) can reduce the patients' surgery stress response, maintain the physiological state of the patients, decrease the risk of postoperative complications and then accelerate recovery after surgery.At present, the FTS protocol in laparoscopic radical gastrectomy for gastric cancer is still in a preliminary stage, and its safety and validity remains to be verified.This systemic and comprehensive review focused on the concept of rapid rehabilitation surgery, the program of perioperative treatment, the economic benefit and its future outlook.

Laparoscopic radical gastrectomy in treatment of advanced gastric cancer: current status and clinical trials / 国际外科学杂志

Different from Japan and Korea,the gastric cancer cases in China are mostly advanced gastric cancer cases.Surgical radical gastrectomy,as the primary method in treating gastric cancer patients has achieved enormous development in recent years,especially laparoscopic radical gastrectomy.Whereas,laparoscopic radical gastrectomy in treatment of advanced gastric cancer remains controversial.The heated debates are mainly focusing on the indications,choosing of surgical approaches and reconstruction methods,completion of laparoscopic D2 lymphadenectomy,short-term postoperative outcomes and long-term oncologiceffectiveness.In this article,current status of laparoscopic radical gastrectomy in treatment of advanced gastric cancer and results of relevant clinical trials were reviewed.