Effect of Short-term Complications After D2 Radical Gastrectomy on Long-term Survival Rate of Gastric Cancer Patients / 肿瘤防治研究

Objective To investigate the effect of short-term complications after D2 radical gastrectomy on long-term survival rate of gastric cancer patients. Methods A retrospective case-control study was conducted on 421 patients with gastric cancer who underwent D2 radical gastrectomy. According to the short-term postoperative complications, they were divided into experimental group (complication group, n=76) and control group (without complication group, n=345). In order to reduce the selection bias, the long-term survival rate of the two groups was tested by Kaplan-Meier survival analysis method after balancing the variables by propensity score matching (PSM). Log rank method was used for univariate analysis and Cox multivariate analysis was used for prognostic factors. Results There was no significant difference in long-term survival rate between the experimental group and the control group (P > 0.05). Histological type, lymph node metastasis rate and pTNM stage were independent risk factors for long-term survival. Conclusion The short-term complications after D2 radical gastrectomy have no significant impact on the long-term survival rate of gastric cancer patients, but it has certain clinical significance to actively prevent and control complications.

[Comparison of short-term efficacy between robotic and 3D laparoscopic-assisted D2 radical distal gastrectomy for gastric cancer].

Objective: To compare short-term efficacy of robotic versus 3D laparoscopic-assisted D2 radical distal gastrectomy in gastric cancerpatients and those with different body mass index (BMI). Method: A retrospective cohort study was performed. Inclusion criteria:(1) gastric cancer proved by preoperative pathological results and tumor location was suitable for D2 radical distal gastrectomy; (2) no distal metastases such as in liver, kidney or abdominal cavity, and no direct invasion to the pancreas or colon on preoperative imaging; (3) postoperative pTNM stage ranged from I to III; (4) no conversion to open surgery or change of surgical procedure during operation; (5) complete clinicopathological data. Patients with severe chronic diseases, other malignant tumors, tumor invasion of other organs or distant metastases, benign gastric tumors, gastrointestinal stromal tumors and recurrent gastric cancer were excluded. According to the above criteria, 531 patients who underwent robotic or 3D laparoscopic-assisted distal gastrectomy at the General Surgery Department of Chinese PLA General Hospital from January 2016 to December 2019 were enrolled. Among them, 344 patients underwent 3D laparoscopic-assisted distal gastrectomy (3D-LADG group), including 250 males, 94 females, 66 cases (19.2%) with a BMI ≥ 25 kg/m(2), and 278 cases (80.8%) with a BMI < 25 kg/m(2), and 187 patients underwent robotic-assisted distal gastrectomy (RADG group), including 122 males, 65 females, 69 cases (36.9%) with a BMI≥25 kg/m(2) and 118 cases (63.1%) with a BMI < 25kg/m(2). There were no significant differences in baseline characteristics between the two groups (all P > 0.05). Operative indicators, postoperative recovery, pathological characteristics and complication rate were compared between the two groups. Subgroup analysis stratified BMI was also performed. Results: Compared with RADG group, 3D-LADG group presented more harvested lymph nodes (29.1±12.4 vs. 25.2±9.0, t=4.238, P<0.001), shorter postoperative hospital stay [8.0 (7.0 to 10.0) days vs. 10.0 (9.0 to 11.0) days, Z=-6.205, P<0.001], less operative cost [(3.6×10(4)±1.1×10(4)) yuan vs. (6.2×10(4)±3.5×10(4)) yuan, t=-9.727, P<0.001], less cost of hospitalization [8.6×10(4)(7.5×10(4) to 10.0×10(4)) yuan vs. 12.8×10(4)(11.7×10(4) to 14.1×10(4)) yuan, Z=-15.997, P<0.001] and longer first flatus time [(3.9±1.0) days vs. (3.4±1.2) days, t=4.271, P<0.001], whose differences were all statistically significant (all P<0.05). While there were no statistically significant differences in operation time, intraoperative blood loss, overall complication rate [10.8%(37/344) vs. 12.8%(24/187), χ(2)=0.515, P=0.473] and severe complications rate [2.0%(7/344) vs. 3.2%(6/187), χ(2)=0.294, P=0.588] between 3D-LADG group and RADG group (all P>0.05). In BMI<25 kg/m(2) group, propensity score matching (PSM) was used to reduce bias of baseline characteristics. After PSM, 3D-LADG group presented higher proportion of intraoperative blood loss <50 ml [26.7% (31/116) vs. 8.6% (10/116), χ(2)=13.065, P<0.001], more harvested lymph nodes [30.3±12.2 vs. 25.3±9.5, t=-3.192, P=0.002] and shorter postoperative hospital stay [9.0 (7.0 to 10.0) days vs. 10.0 (9.0 to 11.0) days, Z=-4.275, P<0.001] compared with RADG group, while other perioperative indicators showed no statistically significant differences between the two groups (all P>0.05). In BMI≥25 kg/m(2) group, 3D-LADG group presented higher proportion of intraoperative blood loss >200 ml [18.2% (12/66) vs. 1.4% (1/69), χ(2)=10.853, P=0.001] and shorter postoperative hospital stay [8.0 (6.0 to 10.0) days vs. 9.0 (8.0 to 10.5) days, Z=-3.039, P=0.002] compared with RADG group, while other perioperative indicators also showed no statistically significant differences between the two groups (all P>0.05). Conclusion: It is safe and feasible to perform 3D-LADG and RADG for patients with gastric cancer. The short-term efficacy of both is similar.

["See fine world" -copy experience and thinking of membrane anatomy in laparoscopic radical gastrectomy (D2+CME)].

Primary lesion removal and lymph node dissection are the main constituents of radical gastrectomy. However, the high recurrence rate after D2 radical gastrectomy for advanced gastric cancer has not improved. Recently, studies have found that discrete tumor deposits in the mesogastrium may be an important factor affecting the prognosis of gastric cancer after surgery. With the development of laparoscopic equipment, the ever-expanding "submicroscopic vision" makes it possible to completely remove the mesogastrium. Professor Gong Jianping advocated "membrane anatomy" to optimize the concept of radical gastrectomy: D2- based complete mesenteric resection (CME), namely D2+CME procedure. To prevent the leakage of tumor cells into the surgical field, as histological barrier, the intact mesogastrium should be located. The essential difference between D2+CME and previous D2/D2+systematic mesogastrium excision (SME), en-bloc mesogastric excision (EME) is as follow: double-factor guiding (lymph nodes and discrete tumor deposits) vs. single factor guiding (lymph nodes only). After practicing dozens of radical gastrectomy (D2+CME) authors believe that its conceptual connotation (double factor guiding) and operational extension (above mesentery bed) cover D2. In D2+CME surgery, depending on the anatomical identification under the magnified field of view, the conformal space between gastric mesentery and mesenteric beds is unique operational plane with repeatability. These findings and considerations address one problem: where is the precise boundary of en bloc principle in radical gastrectomy? In author's opinion, with laparoscopy and "sub-microsurgery" progression and detection of discrete tumor deposit metastasis, survival benefit from definition of en bloc boundary in radical gastrectomy will be widely recognized. Meanwhile, D2+CME procedure is an appropriate way for study. Although the development of the "membrane anatomy" concept for gastric cancer still requires many further clinical and basic researches, it is reasonable to foresee that D2+CME surgery will guide a concept-optimized era for gastric cancer surgery.

"See fine world" —copy experience and thinking of membrane anatomy in laparoscopic radical gastrectomy (D2+CME) / 中华胃肠外科杂志

Primary lesion removal and lymph node dissection are the main constituents of radical gastrectomy. However, the high recurrence rate after D2 radical gastrectomy for advanced gastric cancer has not improved. Recently, studies have found that discrete tumor deposits in the mesogastrium may be an important factor affecting the prognosis of gastric cancer after surgery. With the development of laparoscopic equipment, the ever-expanding "submicroscopic vision" makes it possible to completely remove the mesogastrium. Professor Gong Jianping advocated "membrane anatomy" to optimize the concept of radical gastrectomy: D2- based complete mesenteric resection (CME), namely D2+CME procedure. To prevent the leakage of tumor cells into the surgical field, as histological barrier, the intact mesogastrium should be located. The essential difference between D2+CME and previous D2/D2+systematic mesogastrium excision (SME), en-bloc mesogastric excision (EME) is as follow: double-factor guiding (lymph nodes and discrete tumor deposits) vs. single factor guiding (lymph nodes only). After practicing dozens of radical gastrectomy (D2+CME) authors believe that its conceptual connotation (double factor guiding) and operational extension (above mesentery bed) cover D2. In D2+CME surgery, depending on the anatomical identification under the magnified field of view, the conformal space between gastric mesentery and mesenteric beds is unique operational plane with repeatability. These findings and considerations address one problem: where is the precise boundary of en bloc principle in radical gastrectomy? In author′s opinion, with laparoscopy and "sub-microsurgery" progression and detection of discrete tumor deposit metastasis, survival benefit from definition of en bloc boundary in radical gastrectomy will be widely recognized. Meanwhile, D2+CME procedure is an appropriate way for study. Although the development of the "membrane anatomy" concept for gastric cancer still requires many further clinical and basic researches, it is reasonable to foresee that D2+CME surgery will guide a concept-optimized era for gastric cancer surgery.

Is the signet ring cell histological type a positive prognostic factor for gastric adenocarcinoma after D2 radical gastrectomy?

BACKGROUND: Previous studies indicated the histological type might have prognostic value in gastric adenocarcinoma patients. The aim of this study was to clarify whether the signet ring cell (SRC) histological type of gastric adenocarcinoma is associated with worse prognosis than pure gastric adenocarcinoma without any mixed histological component (PGA) for patients underwent D2 radical gastrectomy. METHOD: By the database of 6205 surgical patients with gastric adenocarcinoma at our department between September 2008 and May 2015, we investigated 133 SRC patients and 2847 PGA patients who underwent D2 radical gastrectomy. The clinic and pathologic data, especially tumor and pathology molecular markers, and 5-year overall survival rate were compared between SRC and PGA. The univariate and multivariate analysis were used to testify the prognosis significance of SRC. RESULTS: SRC was more frequently found in younger (<50), female patients, lower part of stomach and easy to metastasize lymph nodes. And more positive CA19-9 and less positive EGFR were obtained in SRC. The 5-year survival rate was not different between SRC and PGA after D2 radical gastrectomy, even assessed by T stage. Multivariate analysis showed age, T and N stage, CEA, CA19-9 and CA125 were the independent prognostic factors, not included the SRC histological type. CONCLUSION: Although SRC histological type of gastric adenocarcinoma after D2 radical gastrectomy had its own clinic-pathologic characters, especially in molecular tumor and pathological markers, the histological type of SRC was a negative prognostic factor in gastric adenocarcinoma patients after D2 radical gastrectomy.

Comparison of laparoscopy-assisted gastrectomy versus open gastrectomy with D2 lymphadenectomy in the treatment of advanced gastric cancer / 中国综合临床

Objective To investigate the safety and efficacy of laparoscopy-assisted D2 radical gastrectomy in the treatment of advanced gastric cancer.Methods From March 2011 to March 2016,one hundred and four cases treated with LAG for advanced gastric cancer in the general surgery department of Gaochun District People Hospital of Nanjing and the 251st Hospital of PLA were collected in the laparoscope group,104)and 101 cases undergoing gastric cancer surgery from the same period were selected as the control group(open surgery group).A retrospective analysis was performed between the two groups in operation time, intraoperative blood loss, postoperative eating time, ambulation time, exhaust time, postoperative fever, postoperative analgesic use,hospitalization time,postoperative complications,the proximal and distal margins and the number of lymph node dissection.Results The operation time was significantly longer in the LAG group than in the open surgery group(311.2 ± 28.9)min vs.(157.38 ± 11.9)min,t=2.899,P<0.01).The intraoperative blood loss in the laparoscope group was less than that in the open surgery group((100.3±12.1) ml vs.(200.6±16.3)ml,t=3.014,P<0.01).In addition,the frequency of postoperative analgesia,the first postoperative exhaust time,the first postoperative eating time and the postoperative hospital stay in the laparoscopic group were better than those in the open surgery group(P<0.05).There was no significant difference in the number of lymph node dissection and postoperative complication between the two groups(P=0.264,P=0.575).The survival analysis showed that the overall survival rate in the two groups was equivalent at 6 years after surgery(P=0.623).Conclusion Laparoscopy-assisted radical gastrectomy for advanced gastric cancer is safe and feasible,with acceptable long-term results,and shows better performance in the near future.

Application value of programmed D2 radical gastrectomy for advanced gastric cancer / 中华消化外科杂志

Gastric cancer is one of the high incidence of malignant tumors in China,the incidence of which is in the second among the world and is only inferior to Japan.But the mortality of gastric cancer in China is 2 times of world's average level,which is often associated with low early diagnostic rate,big regional differentials in the surgical quantity of gastric cancer (especially D2 radical gastrectomy) and prognosis of patients influenced by surgical quantity.Therefore,a standardized treatment of gastric cancer is the current development trend and hotspot.The correct and programmed staging,evaluation,operation methods,approaches,lymph node dissection and digestive tract reconstruction are selected,thus improving the long-term survival of patients with advanced gastric cancer and reducing mortality in China.

Comparison of laparoscopy-assisted gastrectomy versus open gastrectomy with D2 lymphadenectomy in the treatment of advanced gastric cancer / 中国综合临床

Objective To investigate the safety and efficacy of laparoscopy-assisted D2 radical gastrectomy in the treatment of advanced gastric cancer.Methods From March 2011 to March 2016,one hundred and four cases treated with LAG for advanced gastric cancer in the general surgery department of Gaochun District People Hospital of Nanjing and the 251st Hospital of PLA were collected in the laparoscope group,104)and 101 cases undergoing gastric cancer surgery from the same period were selected as the control group(open surgery group).A retrospective analysis was performed between the two groups in operation time, intraoperative blood loss, postoperative eating time, ambulation time, exhaust time, postoperative fever, postoperative analgesic use,hospitalization time,postoperative complications,the proximal and distal margins and the number of lymph node dissection.Results The operation time was significantly longer in the LAG group than in the open surgery group(311.2 ± 28.9)min vs.(157.38 ± 11.9)min,t=2.899,P<0.01).The intraoperative blood loss in the laparoscope group was less than that in the open surgery group((100.3±12.1) ml vs.(200.6±16.3)ml,t=3.014,P<0.01).In addition,the frequency of postoperative analgesia,the first postoperative exhaust time,the first postoperative eating time and the postoperative hospital stay in the laparoscopic group were better than those in the open surgery group(P<0.05).There was no significant difference in the number of lymph node dissection and postoperative complication between the two groups(P=0.264,P=0.575).The survival analysis showed that the overall survival rate in the two groups was equivalent at 6 years after surgery(P=0.623).Conclusion Laparoscopy-assisted radical gastrectomy for advanced gastric cancer is safe and feasible,with acceptable long-term results,and shows better performance in the near future.

Learning curve for hand-assisted laparoscopic D2 radical gastrectomy.

AIM: To describe the learning curves of hand-assisted laparoscopic D2 radical gastrectomy (HALG) for the treatment of gastric cancer. METHODS: The HALG surgical procedure consists of three stages: surgery under direct vision via the port for hand assistance, hand-assisted laparoscopic surgery, and gastrointestinal tract reconstruction. According to the order of the date of surgery, patients were divided into 6 groups (A-F) with 20 cases in each group. All surgeries were performed by the same group of surgeons. We performed a comprehensive and in-depth retrospective comparative analysis of the clinical data of all patients, with the clinical data including general patient information and intraoperative and postoperative observation indicators. RESULTS: There were no differences in the basic information among the patient groups (P > 0.05). The operative time of the hand-assisted surgery stage in group A was 8-10 min longer than the other groups, with the difference being statistically significant (P = 0.01). There were no differences in total operative time between the groups (P = 0.30). Postoperative intestinal function recovery time in group A was longer than that of other groups (P = 0.02). Lengths of hospital stay and surgical quality indicators (such as intraoperative blood loss, numbers of detected lymph nodes, intraoperative side injury, postoperative complications, reoperation rate, and readmission rate 30 d after surgery) were not significantly different among the groups. CONCLUSION: HALG is a surgical procedure that can be easily mastered, with a learning curve closely related to the operative time of the hand-assisted laparoscopic surgery stage.

Three-step hand-assisted laparoscopic d2 radical gastrectomy for chinese obese patients: a highly efficient and feasible surgical approach.

Three-step hand-assisted laparoscopic D2 radical gastrectomy (HALG) is a modified surgical procedure that has achieved satisfactory results for obese patients in our surgical center. To fully elucidate the advantages of this procedure, in this study, comprehensive and in-depth comparative analyses were performed to assess clinical data from obese gastric cancer patients who underwent HALG, laparoscopic-assisted D2 radical gastrectomy (LAG), and open D2 radical gastrectomy (OG) in our surgical center during a specific time period. For the 3 groups, incision length was 1.25 cm longer for the HALG group than for the LAG group but was significantly shorter for the HALG group than for the OG group (P =0.00). The rate of conversion to laparotomy , the pneumoperitoneum time and the number of recovered lymph nodes were significantly better for the HALG group than for the LAG group (P <0.05). The pain score at day 2 after surgery, intestinal function recovery time, and duration of postoperative hospital stay were not significantly different for the HALG and LAG groups ( P >0.05) but were significantly better for the HALG group than for the OG group (P <0.05). There were significantly fewer postoperative complications for the HALG group than for the LAG and OG groups (P =0.049). According to the results, the "three-step HALG method" incorporates both the thoroughness of the radical OG approach and the minimal invasiveness of the LAG approach for obese patients. Thus, the HALG approach is a relatively safe and extremely feasible surgical procedure for the treatment of these patients.

Three-step hand-assisted laparoscopic surgery for radical distal gastrectomy: an effective surgical approach.

OBJECTIVE: Three-step hand-assisted laparoscopic D2 radical gastrectomy (HALG) is a modified surgical technique based on hand-assisted laparoscopic surgery (HALS) for the treatment of gastric cancer. This surgical approach is particularly easy and convenient for radical distal gastrectomy. In order to thoroughly understand the advantages of applying "three-step HALG" in distal gastrectomy, our center conducted a retrospective study to analyze data from patients who underwent HALG and laparoscopic-assisted D2 radical gastrectomy (LAG) during the corresponding time period. METHODS: The HALG procedure is performed in three steps, namely the operation performed through an auxiliary incision under direct vision, hand-assisted laparoscopic operation, and gastrointestinal tract reconstruction through the auxiliary incision under direct vision. This study performed comprehensive, in-depth comparative analyses on the clinical data of two groups of patients who underwent HALG and LAG. RESULTS: The auxiliary incision under the xiphoid was maximally utilized in the HALG procedure. The rate of conversion to open surgery in HALG group patients was significantly lower than in the LAG group (P = 0.03), and the operating time was significantly shorter in the HALG group than in the LAG group (P = 0.00). There was no significant difference in the pain rate score on postoperative day 2 and on the day of discharge between the HALG and LAG groups (P > 0.05). No statistically significant difference was found in the time to recovery of bowel function, postoperative hospital stay, or postoperative complications (P > 0.05), although the values were all lower in the HALG group than in the LAG group. CONCLUSION: "Three-step HALG" is a highly feasible surgical approach for radical distal gastrectomy.