Consequence alimentary reconstruction in nutritional status after total gastrectomy for gastric cancer

ＮＴＯＤＵＣＴＩＯＮＴｏｉｎｖｅｓｔｉｇａｔｅｔｈｅｎｕｔｒｉｔｉｏｎａｌｃｏｎｓｅｑｕｅｎｃｅｓｏｆｇａｓｔｒｏｅｎｔｅｒｉｃｒｅｃｏｎｓｔｒｕｃｔｉｏｎｉｎｐａｔｉｅｎｔｓｗｉｔｈｇａｓｔｒｉｃｃａｎｃｅｒａｆｔｅｒｔｏｔａｌｇａｓｔｒｅｃｔｏ...     

Clinical application of immune-enhanced enteral nutrition in patients with advanced gastric cancer after total gastrectomy

OBJECTIVE: To determine whether immune‐enhanced enteral nutrition (EN) was effective on nutritional status, immune function, surgical outcomes and days of hospitalization after total gastrectomy for patients with advanced gastric cancer (AGC). METHODS: From August 2005 to May 2011, 78 patients with AGC who underwent a total gastrectomy were enrolled and divided randomly into three groups: immune‐enhanced EN (EN + glutamine [Gln]) group, standard EN group and control group. Serum parameters including total protein, albumin, proalbumin and transferrin were examined on preoperative day 1, postoperative day 2 and day 12. Levels of immunoglobulin M (IgM), immunoglobulin G (IgG), natural killer (NK) cells, CD4⁺ and CD8⁺ T cells were also compared. RESULTS: The formulas were tolerated well in all the patients except 5 with mild complications. The EN + Gln and EN groups showed a faster onset of flatus and shorter hospitalization duration than the control group. On postoperative day 12, serum total protein, albumin, proalbumin and transferrin levels of the EN + Gln and EN groups were significantly higher than those of the control group (P < 0.05). CD4⁺ T cells, NK cells, IgM and IgG levels of the EN + Gln group increased prominently, and were significantly higher than those before the operation as well as those in the EN and control groups. CONCLUSION: Immune‐enhanced EN can improve nutritional status and immune function for the patients with AGC after total gastrectomy.     

Laparoscopic vs open total gastrectomy for gastric cancer:A meta-analysis

AIM:To conduct a meta-analysis comparing laparoscopic total gastrectomy(LTG)with open total gastrectomy(OTG)for the treatment of gastric cancer.METHODS:Major databases such as Medline(PubMed),Embase,Academic Search Premier(EBSCO),Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials(CENTRAL)in The Cochrane Library were searched for studies comparing LTG and OTG from January 1994 to May 2013.Evaluated endpoints were operative,postoperative and oncological outcomes.Operative outcomes included operative time and intraoperative blood loss.Postoperative recovery included time to first fatus,time to first oral intake,hospital stay and analgesics use.Postoperative complications comprised morbidity,anastomotic leakage,anastomotic stenosis,ileus,bleeding,abdominal abscess,wound problems and mortality.Oncological outcomes included positive resection margins,number of retrieved lymph nodes,and proximal and distal resection margins.The pooled effect was calculated using either a fixed effects or a random effects model.RESULTS:Fifteen non-randomized comparative studies with 2022 patients were included(LTG-811,OTG-1211).Both groups had similar short-term oncological outcomes,analgesic use(WMD-0.09;95%CI:-2.39-2.20;P=0.94)and mortality(OR=0.74;95%CI:0.24-2.31;P=0.61).However,LTG was associated with a lower intraoperative blood loss(WMD-201.19 mL;95%CI:-296.50--105.87 mL;P<0.0001)and overall complication rate(OR=0.73;95%CI:0.57-0.92;P=0.009);fewer wound-related complications(OR=0.39;95%CI:0.21-0.72;P=0.002);a quicker recovery of gastrointestinal motility with shorter time to frst fatus(WMD-0.82;95%CI:-1.18--0.45;P<0.0001)and oral intake(WMD-1.30;95%CI:-1.84--0.75;P<0.00001);and a shorter hospital stay(WMD-3.55;95%CI:-5.13--1.96;P<0.0001),albeit with a longer operation time(WMD 48.25 min;95%CI:31.15-65.35;P<0.00001),as compared with OTG.CONCLUSION:LTG is safe and effective,and may offer some advantages over OTG in the treatment of gastric cancer.     

Ataxic gait following total gastrectomy for gastric cancer

A 58-year-old woman, who had undergone total gastrectomy for early gastric cancer 9 years previously, visited the outpatient clinic complaining of progressive difficulty in walking for 15 d. Laboratory examinations showed macrocytic anemia and a decreased serum vitamin B12 concentration and increased serum concentrations of folate, vitamin E and copper. Magnetic resonance imaging showed multifocal high signal intensities along the posterior column of the cervical and thoracic spinal cord. Treatment consisted of intramuscular injections of vitamin B12 for 7 d, which increased her serum level of vitamin B12 to normal. This was followed by weekly intramuscular injections of vitamin B12 for another 2 wk and oral administration of vitamin B12 three times per day. After comprehensive rehabilitation for 4 wk, she showed sufficient improvements in strength and ataxic gait, enabling her to return to her normal daily activities.     

Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance

AIM: To evaluate the factors associated with liver function alterations after laparoscopy-assisted gastrectomy (LAG) for gastric cancer. METHODS: We collected the data of gastrectomy patients with gastric cancer and divided them into 2 groups: open gastrectomy (OG) and LAG. We also collected the data of patients with colon cancer to evaluate the effect of liver manipulations during surgery on liver function alterations. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin,...     

Roux-en-Y改良P袢吻合术对减轻胃癌全胃切除术后胃食管反流病的临床价值

目的评价Roux-en-Y改良P袢吻合术对减轻胃癌全胃切除术后胃食管反流病（GERD）的临床价值。 方法选择2015年10月至2017年3月吉林大学中日联谊医院收治的行全胃切除术的胃癌患者40例。其中19例患者采用常规Roux-en-Y吻合术（常规Roux-en-Y吻合术组）,21例患者采用改良P袢吻合术（改良P袢吻合术组）。采用GerdQ量表评估所有患者术后1年出现GERD的情况。采用χ²检验比较2组患者GERD发生率差异。 结果所有患者手术均获得成功,无一例患者死亡。改良P袢吻合术组患者术后1年GERD发生率为4.8% （1/21）,低于常规Roux-en-Y吻合术组的42.1% （8/19）,且差异有统计学意义（χ²=7.98,P<0.05）。 结论Roux-en-Y改良P袢吻合术能显著减少胃癌全胃切除术后GERD的发生。     

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

Background:The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).Methods:A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.Results:Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.Conclusion:This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.     

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM:To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy(LATG)and open total gastrectomy(OTG)for gastric cancer.METHODS:A comprehensive search of PubMed,Cochrane Library,Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG.The following factors were checked:operating time,blood loss,harvested lymph nodes,flatus time,hospital stay,mortality and morbidity.Data synthesis and statistical analysis were carried out using RevMan 5.1 software.RESULTS:Nine studies with 1221 participants were included(436 LATG and 785 OTG).Compared to OTG,LATG involved a longer operating time[weighted mean difference(WMD)=57.68 min,95%CI:30.48-84.88;P<0.001];less blood loss[standard mean difference(SMD)=-1.71;95%CI:-2.48--0.49;P<0.001];earlier time to flatus(WMD=-0.76 d;95%CI:-1.22--0.30;P<0.001);shorter hospital stay(WMD=-2.67d;95%CI:-3.96--1.38,P<0.001);and a decrease in medical complications(RR=0.41,95%CI:0.19-0.90,P=0.03).The number of harvested lymph nodes,mortality,surgical complications,cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.CONCLUSION:Despite a longer operation,LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.     

胃癌根治术对单细胞入血转移的影响

目的在胃癌手术过程中，对门静脉血进行连续检测，检查是否存在有脱落的癌细胞，以此来证明手术对单细胞血行转移的影响．方法胃癌根治手术１２６例，男８９例，女３７例．年龄３２岁～７８岁．术中抽门静脉血检测有无癌细胞，并观察挤压肿瘤的影响．对所抽取的标本用ＥＭＡ单抗，ＡＢＣ免疫法染色，检测癌细胞．结果在受检组的６５例中有３９例阳性（６００％），对照组６１例中有１３例阳性（２７１％）．两组间有非常显著性差异（χ２＝２８２８，Ｐ＜０００５）．结论对肿瘤区的手术操作有促使肿瘤细胞脱落的高度危险性．而首先阻断有关的静脉汇流途径可减少医源性血行转移     

Uncut Roux-en-Y reconstruction after distal gastrectomy for gastric cancer

Introduction: Uncut Roux-en-Y gastrojejunostomy is a modification of the Billroth II procedure with Braun anastomosis, in which a jejunal occlusion is fashioned to avoid the Roux Stasis Syndrome. This review aimed to summarize the current knowledge about the uncut Roux-en-Y anastomosis operation, so that surgeons may be able to make informed decisions about its clinical application. Additionally, we hope that our findings will guide future research on this topic.

Areas covered: The original uncut technique was associated with dehiscence or recanalization of the jejunal occlusion, and was therefore not widely applied. However, with recent improvements in the method of jejunal occlusion, the uncut Roux-en-Y reconstruction may be an appropriate alternative for digestive tract reconstruction after distal gastrectomy. This review summarizes the basic research on and clinical applications of uncut Roux-en-Y gastrojejunostomy from the following several aspects: origin of the uncut reconstruction technique, rationale for uncut reconstruction based on data from animal experiments, clinical results of the uncut reconstruction, recanalization and its countermeasures, and so on.

Expert commentary: The uncut Roux-en-Y gastrojejunostomy is a controversial yet promising method of gastrointestinal reconstruction after distal gastrectomy. Prospective randomized controlled trials and long-term follow-up outcomes are required to support the modified technique in the future.     

Risk factors for operative morbidity and mortality in gastric cancer patients undergoing total gastrectomy

AIM： To study the risk factors for morbidity and mortality following total gastrectomy. METHODS： We retrospectively reviewed the records of 125 consecutive patients who underwent total gastrectomy for gastric cancer at the Second Affiliated Hospital of Zhejiang University School of Medicine between January 2003 and March 2008. RESULTS： The overall morbidity rate was 20.8% （27 patients） and the mortality rate was 3.2% （4 patients）. Morbidity rates were higher in patients aged over 60 [odds ratio （OR） 4.23 （95% confidence interval （CI） 1.09 to 12.05）], with preoperative comorbidity [with vs without, OR 1.25 （95% CI 1.13 to 8.12）], when the combined resection was performed [combined resection vs total gastrectomy only, OR 2.67 （95% CI 1.58 to 5.06）]. CONCLUSION： Age, preoperative comorbidity and combined resection were with the rate of morbidity gastric cancer. independently associated after total gastrectomy for     

胃癌根治术后复发转移临床相关因素分析

目的 探讨胃癌术后复发转移时间及危险因素.方法 回顾性分析2001年1月至2004年l 2月间天津医科大学附属肿瘤医院收治的141例行胃癌根治术后发生复发转移患者的临床病理资料,分析可能影响胃癌术后复发的临床病理因素.结果 术后1、2、3、5年的累积复发率分别为58.2%(82/141)、80.1%(113/141)、89.4%(126/141)、97.9%(138/141).多因素分析显示:肿瘤大小、浸润深度、淋巴结转移是影响胃癌根治术后复发转移发生的独立因素(P值分别=0.017、0.003、0.000),浸润深度、淋巴结转移、肿瘤分化程度是影响胃癌根治术后早期复发转移的独立危险因素(P值分别=0.042、0.000、0.039).结论 肿瘤大小、浸润深度、淋巴结转移是预测胃癌根治术后复发转移发生的独立危险因素;胃癌术后复发转移大部分发生在术后2年内,浸润深度、淋巴结转移及肿瘤分化程度是预测胃癌根治术后早期复发转移的独立危险因素.

Abstract：

Objective To explore the occurance and risk factors of recurrence and metastasis of gastric cancer after gastrectomy.Methods From January 2001 to December 2004, the clinic pathological data of 141 patients with recurrence and metastasis after radical gastrectomy in Tianjin Medical University Cancer Institute and Hospital were analyzed retrospectively.The possible clinic pathological factors which may affect tumor recurrence were analyzed.Results After the surgery, the 1, 2, 3 and 5-year cumulative recurrence rates were 58.2%(82/141) 、80.1%(113/141)、89.4%(126/141) 、97.9 % (138/141)respectively.The results of multivariate analysis indicated that the tumor size,invasive depth, lymph node metastasis were independent factors which affected recurrence and metastasis after radical gastrectomy (P = 0.017, 0.003, 0.000).Invasive depth, lymph node metastasis and tumor differentiation degree were independent factors which affected early recurrence and metastasis after radical gastrectomy (P=0.042, 0.000, 0.039).Conclusions The tumor size,invasive depth, lymph node metastasis are the independent risk factors to predict the recurrence and metastasis after radical gastrectomy.Most of the recurrences and metastasis is found within 2 years after radical gastrectomy.Invasive depth, lymph node metastasis and tumor differentiation degree are the independent factors to predict early recurrence after radical gastrectomy.     

Esophagojejunostomy after total gastrectomy for caustic injuries

The objective of the study was to compare outcomes of emergency esophagogastrectomy (EGT) and total gastrectomy with immediate esophagojejunostomy (EJ) in patients with full‐thickness caustic necrosis of the stomach and mild esophageal injuries. After caustic ingestion, optimal management of the esophageal remnant following removal of the necrotic stomach remains a matter of debate. Between 1987 and 2012, 26 patients (men 38%, median age 44 years) with isolated transmural gastric necrosis underwent EGT (n = 14) or EJ (n = 12). Early and long‐term outcomes of both groups were compared. The groups were similar regarding age (P = 0.66), gender (0.24), and severity of esophageal involvement. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Emergency morbidity (67% vs. 64%, P = 0.80), mortality (17% vs. 7%, P = 0.58), and reoperation rates (25% vs.14%, P = 0.63) were similar after EJ and EGT. One patient (8%) experienced EJ leakage. One patient in the EJ group and 13 patients in the EGT group underwent esophageal reconstruction (P < 0.0001). Aggregate in hospital length of stay was significantly longer in patients who underwent EGT (median 83 [33–201] vs. 36 [10–82] days, P = 0.001). Functional success after EJ and EGT was similar (90% vs.69%, P = 0.34). Immediate EJ can be safely performed after total gastrectomy for caustic injuries and reduces the need of further esophageal reconstruction.     

Clinicopathological analysis of patients with gastric cancer in 1200 cases

INTRODUCTION Gastric cancer is one of the most common fatal malignancies in the world. The prognosis is generally poor in advanced gastric cancer .The low survival is related to delayed diagnosis, metastasis and recurrence after operation .The aim of this paper was to find correlation between clinical factors was to find correlation between clinical factors and biologic behavior of gastric cancer in a series of 1200 patients undergoing surgical resection.     

胃癌病人全胃切除、代胃及人工幽门括约肌重建术的远期疗效观察

目的 观察胃癌病人行全胃切除、代胃及人工幽门括约肌重建术的远期疗效。方法 连续5年对应用此法治疗的106例胃癌患者的营养状况、生存率、术后并发症发生率以及术后生活质量等情况进行定期随访。结果 本组患者5年生存率42．5％，碱性反流性食管炎的发生率为0．9％，术后5年胆石症发生率为5．66％，生活质量优良率为89．6％。结论 全胃切除、代胃及人工幽门括约肌重建术治疗进展期胃癌有较好的远期疗效。     

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

R a d i c a l g a s t r e c t o m y w i t h a n a d e q u a t e l y m p h-adenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer(GC). A number of randomized controlled trials and meta-analysis provide phase Ⅲ evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomyfor cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.     

全胃联合脾切除治疗进展期胃癌的系统评价

目的: 系统评价全胃联合脾切除治疗进展期胃癌的有效性及安全性.方法: 计算机检索PubMed、EMBase、Cochrane Library、中国生物医学文献数据库、中国期刊全文数据库及中文科技期刊全文数据库,手工检索相关杂志搜集有关全胃联合脾切除(TGS)与全胃切除(TG)两种不同术式治疗进展期胃癌的随机对照试验.按照Cochrane系统评价方法对纳入研究的方法学质量进行评价,用RevMan 4.2.10软件进行统计分析.结果: 纳入2个随机对照试验共394例患者,各研究基线资料具有可比性,均报道随机方法但未提及盲法和分配隐藏.Meta分析显示,两组1、3、5年生存率和并发症发生率的差异均无统计学意义[ OR = 0.98、1.41、1.29、1.79,95%CI: (0.61,1.58)、(0.95,2.10)、(0.86,1.29)、(0.98,3.25),P＞0.05],但感染性并发症的差异有统计学意义( P＜0.05).结论: 除非脾脏癌转移或为彻底清扫脾门和脾动脉干阳性淋巴结,应避免在进展期胃癌全胃切除术中联合脾切除.     

Laparoscopic splenic hilum lymph node dissection for advanced proximal gastric cancer:A modified approach for pancreasand spleen-preserving total gastrectomy

AIM:To investigate the feasibility and optimal approach for laparoscopic pancreasand spleen-preserving splenic hilum lymph node dissection in advanced proximal gastric cancer.METHODS:Between August 2009 and August 2012,12 patients with advanced proximal gastric cancer treated in Nanfang Hospital,Southern Medical University,Guangzhou,China were enrolled and subsequently underwent laparoscopic total gastrectomy with pancreasand spleen-preserving splenic hilum lymph node(LN)dissection.The clinicopathological characteristics,surgical outcomes,postoperative course and followup data of these patients were retrospectively collected and analyzed in the study.RESULTS:Based on our anatomical understanding of peripancreatic structures,we combined the characteristics of laparoscopic surgery and developed a modified approach(combined supraand infra-pancreatic approaches)for laparoscopic pancreasand spleenpreserving splenic hilum LN dissection.Surgery was completed in all 12 patients laparoscopically without conversion.Only one patient experienced intraoperative bleeding when dissecting LNs along the splenic artery and was handled with laparoscopic hemostasis.The mean operating time was 268.4 min and mean number of retrieved splenic hilum LNs was 4.8.One patient had splenic hilum LN metastasis(8.3%).Neither postoperative morbidity nor mortality was observed.Peritoneal metastasis occurred in one patient and none of the other patients died or experienced recurrent disease during the follow-up period.CONCLUSION:Laparoscopic total gastrectomy with pancreasand spleen-preserving splenic hilum LN dissection using the modified approach for advanced proximal gastric cancer could be safely achieved.