经自然腔道取出标本的全腹腔镜远端胃癌根治术（Uncut Roux-en-Y吻合）七例报告

目的探讨经自然腔道取出标本的全腹腔镜远端胃癌根治术（Uncut Roux-en-Y吻合）的安全性、可行性及近期效果。 方法回顾性分析2017年1月至2017年5月淄博市临淄区人民医院实施的全腹腔镜远端胃癌D2根治术（胃空肠Uncut Roux-en-Y吻合）7例的临床资料。 结果7例病例均在全腹腔镜下成功完成,经自然腔道（阴道或直肠）取标本,无中转开腹,无术中并发症,无手术相关死亡。手术中位时间为280（260~320）min,其中消化道重建时间为45（35~55）min,术中中位失血为90（30~120）ml。术后中位排气时间2（1~3）d,手术后中位住院天数8（7~13）d。无吻合口漏、Roux滞留综合征（RSS）和直肠狭窄等相关并发症发生。 结论腹部无辅助切口经自然腔道取标本的全腹腔镜远端胃癌根治术（胃空肠Uncut Roux-en-Y吻合）安全、可行,既避免术后胆汁反流性胃炎,又避免了Roux-en-Y吻合的Roux滞留综合征;经自然腔道标本取出,进一步减少创伤,减轻术后疼痛,手术时间无明显延长。     

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

AIM: To evaluate the nature of the "learning curve" for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer. METHODS: The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated. RESULTS: After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (<200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups. CONCLUSION: Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.     

腹腔镜早期胃癌根治术的临床研究

目的:探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用。方法:回顾性分析2004年10月至2009年12月间79例接受腹腔镜胃癌根治术的早期胃癌患者的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理和随访等。结果:除1例中转开腹手术外,其余78例均在腹腔镜下完成胃切除和淋巴结清扫,其中腹腔镜远端胃切除术74例,近端胃切除术2例,全胃切除术2例;腹腔镜下D1+α式淋巴结清扫34例,D1+β式淋巴结清扫15例,D2式淋巴结清扫29例。手术时间为(202.9±45.6)min,术中失血(144.5±146.5)mL,术后排气时间(2.8±1.0)d,术后住院天数为(11.3±5.6)d,8例(10.1%)患者出现腹腔内出血、吻合口漏、小肠梗阻等,经手术和非手术治疗后痊愈。手术上、下切缘距离肿瘤为(4.0±1.9)cm和(3.6±1.7)cm,手术平均清扫淋巴结(13.1±6.5)枚,其中有3例(3.8%)发现淋巴结转移。术后随访2～64个月,均无肿瘤复发和远处转移。结论:腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的手术方法。     

Meta-analysis of the efficacy of Da Vinci robotic or laparoscopic distal subtotal gastrectomy in patients with gastric cancer

Background:Robotic-assisted gastrectomy has been used for treating gastric cancer since 2002. This meta-analysis was conducted to systematically evaluate the efficacy of Da Vinci robotic distal subtotal gastrectomy (RDG) or laparoscopic distal subtotal gastrectomy (LDG) in patients with gastric cancer.Methods:We conducted searches in domestic and foreign databases, and collected literature in Chinese and English on the efficacy of RDG and LDG for gastric cancer that have been published since the inception of the database. RevMan 5.4.1 was used for meta-analysis and drawing and Stata14.0 was used for publication bias analysis.Results:A total of 3293 patients in 15 studies were included, including 1193 patients in the RDG group and 2100 patients in the LDG groups respectively. The meta-analysis showed that intraoperative blood loss was significantly lower and the number of resected lymph nodes was higher in the RDG group compared to that in the LDG group. In addition, the times to first postoperative food intake and postoperative hospital stay were shortened, and there was a longer length of distal resection margin and prolonged duration of operation. No significant differences were found between the 2 groups with respect to the first postoperative anal exhaust time, length of proximal resection margin, total postoperative complication rate, postoperative anastomotic leakage rate, incidence of postoperative gastric emptying disorder, pancreatic fistula rate, recurrence rate, and mortality rate.Conclusion:RDG is a safe and feasible treatment option for gastric cancer, and it is non-inferior or even superior to LDG with respect to therapeutic efficacy and radical treatment.     

左半结肠癌腹腔镜和开腹根治术临床对照研究

目的评价腹腔镜辅助下左半结肠癌根治术与同期开腹手术在短期疗效方面的差异。 方法回顾性分析江苏省人民医院结直肠外科2013年1月至2014年12月实施的72例左半结肠癌根治术的临床资料,其中腹腔镜组（Laparoscopic, LAP）38例,开腹组（open suryery, OS）34例,对两组患者术中、术后结果进行比较。 结果两组手术时间差异无统计学意义（P>0.05）;腹腔镜组术中平均出血量（88.16±65.18）ml明显少于开腹组（132.35±82.46）ml（P<0.05）;腹腔镜组淋巴结清扫数量（16.16±2.14）枚,较开腹组多（14.50±2.43）枚（P<0.01）;与开腹组相比较,腹腔镜组病例术后进食时间、下床时间和平均住院天数均明显缩短（P<0.05）。两组术后并发症差异无统计学意义（P>0.05）。 结论腹腔镜辅助下左半结肠切除术技术上安全可行,与传统开腹手术相比具有出血少、术后恢复快、住院时间短等优点。     

Technique of Vagus‐Nerve Sparing Laparoscopy‐Assisted Distal Gastrectomy

Vagus‐nerve sparing distal gastrectomy (Vs‐DG) is a procedure that has been introduced to improve the quality of life for patients with early gastric cancer. We successfully performed this novel procedure for 40 consecutive patients with early gastric lesions located in the middle or lower thirds of the stomach between January 1999 and April 2001 using laparoscopic techniques (Vagus‐nerve sparing laparoscopy‐assisted distal gastrectomy). Vagus‐nerve sparing distal gastrectomy involves preserving the hepatic and celiac branches of the vagus, preservation that is expected to be beneficial in lowering the incidence of post–gastrectomy syndromes compared with standard distal gastrectomy. The mean operating time was 247 min. None of the patients had a postoperative complication. The mean postoperative hospital stay was 14 days, and all patients were alive without recurrence after the median follow‐up of 14 months. Thus, this procedure is technically feasible and safe, and might be one of the better treatments for early gastric cancer.     

65岁以上老年人胃癌332例临床分析

目的 探讨老年胃癌患者的临床特点及其外科治疗方法的选择及预后。方法 回顾性分析1990年1月至2003年6月收治的332例65岁以上老年人胃癌的临床资料和生存资料。结果 本组临床好转率为97．0％，围手术期病死率为3．0％，手术并发症发生率为24．7％。根治性胃切除组术后1、3、5年生存率分别为89.6％、63.2％和40.6％，姑息性胃切除组分别为68.6％、15．7％和0，未切除组平均生存10个月。各组术后生存率比较差异有显著性(P＜0．05)。结论 老年人胃癌术后并发症较多，围手术期处理至关重要。术中应尽量采用硬膜外麻醉，缩短手术时间。手术方式应视患者全身情况、癌肿所在部位、大小及侵犯范围而定，对早中期患者力争行根治性胃切除术(D1或D2)。     

腹腔镜尾侧入路右半结肠癌根治性切除的安全性、可行性及临床应用价值

目的探讨尾侧入路法腹腔镜右半结肠癌根治性切除术的安全性、可行性及临床应用价值。 方法回顾性分析2014年1月至2015年12月广东省中医院胃肠外科右半结肠癌病例90例,接受尾侧入路法腹腔镜右半结肠癌根治性切除术。 结果90例患者均完成手术,无死亡。手术总体并发症11.1%,其中1例（1.1%）患者因术中助手暴力撕裂回结肠静脉汇入SMV处出血,经开腹小切口修补血管后继续在腹腔镜下成功完成手术。术后并发症发生率为10%,其中包括3例（3.3%）肺部感染、2例（2.2%）泌尿系感染、1例（1.1%）切口感染、2例（2.2%）炎性肠梗阻和1例（1.1%）淋巴瘘,均经保守治疗后痊愈出院。手术时间为146.8±30.5 min,术中失血量为68.4±37.9 ml,首次排气时间为49.7±21.5 h,恢复流质饮食时间为58.1±13.2 h,术后住院时间为7.8±3.2 d,平均淋巴结清扫数目为29.8±9.9枚,其中淋巴结阳性数目为4.1±2.1枚。 结论尾侧入路法腹腔镜右半结肠癌根治性切除术是安全、可行的,符合肿瘤学根治原则,在缩短外科医生腹腔镜右半结肠切除术的学习曲线和保障手术安全方面会提供有益的帮助。     

Laparoscopy-assisted and open distal gastrectomies for early gastric cancer at a general hospital in Japan

BACKGROUND/AIMS: At general hospitals in Japan, laparoscopic surgery for early gastric cancer is not yet popular. The benefits and feasibility of this procedure remain to be established. The aim of this study was to evaluate the surgical outcome of laparoscopy-assisted distal gastrectomy (LADG) in comparison with open distal gastrectomy (ODG) in a general hospital. METHODOLOGY: We performed LADG in 20 patients with early gastric cancer between 2000 and 2001. Clinicopathologic data, blood analyses, clinical course and financial cost of treating patients with LADG were compared with 22 patients treated with ODG between 1998 and 1999. RESULTS: All patients were treated successfully by LADG. Neither reduced operative curability nor increased complications were found with this procedure. Although LADG required a significantly longer operation time than ODG, blood loss was lower in LADG than in ODG. The leukocyte count on day 1 and day 3, and serum C-reactive protein levels on day 1 were significantly lower after LADG than after ODG. There was no significant difference between LADG and ODG in the period and volume of analgesics required. High body temperature continued longer after ODG than after LADG. The first walking, passage of flatus and oral diet initiation were significantly earlier in patients with LADG than in those with ODG. LADG required a significantly shorter hospital stay and less total hospital charge than ODG. CONCLUSIONS: Laparoscopy-assisted distal gastrectomy offered faster recovery of gastrointestinal function, a shorter hospital stay, and consequently less financial cost when compared with open surgery. Therefore, LADG may be a safe and recommendable procedure for patients with early gastric cancer at general hospitals in Japan.     

Is prophylactic placement of drains necessary after subtotal gastrectomy？

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.
METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.
RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）.
CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.     

Novel method for esophagojejunal anastomosis after laparoscopic total gastrectomy: Semi-end-to-end anastomosis

AIM: To test a new safe and simple technique for circular-stapled esophagojejunostomy in laparoscopic total gastrectomy (LATG).METHODS: We selected 26 patients with gastric cancer who underwent LATG and Roux-en-Y gastrointestinal reconstruction with semi-end-to-end esophagojejunal anastomosis.RESULTS: LATG with semi-end-to-end esophagojejunal anastomosis was successfully performed in all 26 patients. The average operation time was 257 ± 36 min, with an average anastomosis time of 51 ± 17 min and an average intraoperative blood loss of 88 ± 46 mL. The average postoperative hospital stay was 8 ± 3 d. There were no complications and no mortality in this series.CONCLUSION: The application of semi-end-to-end esophagojejunal anastomosis after LATG is a safe and feasible procedure, which can be easily performed and has a short operation time in terms of anastomosis.     

Reevaluation of routine gastrointestinal decompression after gastrectomy for gastric cancer

BACKGROUND/AIMS: We reviewed postoperative courses of patients with gastric cancer who underwent gastrectomy to evaluate the need for routine postoperative gastrointestinal decompression. METHODOLOGY: Three hundred patients who underwent gastrectomy during 1998 and 1999 were enrolled in this study. A nasogastric tube was placed in all patients just after induction of the anesthesia. The patients were divided into two groups, 150 patients for each. In group 1, the nasogastric tube was maintained until the passage of flatus per rectum. In group 2, the nasogastric tube was removed immediately after the operation. RESULTS: The return of bowel function, return to a diet and postoperative length of hospital stay were similar in both groups. In group 1, only one patient (0.7%) had abdominal distension and no patient vomited, while four patients (2.7%) had abdominal distension and one patient (0.7%) vomited in group 2. There were no significant differences in the incidence of respiratory complications, anastomotic leakage and wound complications between the two groups. Postoperative death was rare, with the incidence of 0.7% in each group. There was a significantly high incidence of patient's discomfort in group 1. The major complaint was sore throat and it caused sleep disturbance when severe. CONCLUSIONS: It is desirable to insert a nasogastric tube while the patient is in the anesthetized state and keep it during operation and remove it immediately after operation, when no active bleeding is detected.     

Meta-Analysis of Randomized Controlled Trials on Laparoscopic Gastrectomy vs. Open Gastrectomy for Distal Gastric Cancer

Background/Aims: To evaluate the safety and practicability of laparoscopic gastrectomy (LG) by comparing the short-term and long-term outcomes of LG and open gastrectomy (OG) for gastric cancer. Methodology: According to the criterion, randomized clinical trials (RCTs) were searched in MEDLINE, EMBASE, CNKI (in Chinese), WANFANG DATA (in Chinese), and Cochrane Controlled Trials Register from January 2000 to January 2012. The RCTs were prepared in accordance with the quality of reporting of meta-analyses statement. Intraoperative and early postoperative parameters, as well as long-term tumor recurrence were analyzed. Random effect meta-analyses were performed using odds ratios (ORs) and weighted mean differences (WMDs). Results: Up to 8 RCTs with 782 patients were enrolled in the present meta-analysis (402 patients underwent LG (LG group) and 380 underwent OG (OG group)). The LG group had shorter wound lengths, less blood loss, more rapid bowel function recovery: first flatus and first food intake, lower overall complication rate and shorter hospital stay, whereas the LG group had longer operation times and less harvested lymph nodes. The tumor recurrence between the two groups had no significant difference. Conclusions: Considering its lower morbidity and enhanced postoperative recovery, LG is a safe technical alternative to OG for distal gastric cancer.     

Intracorporeal esophagojejunostomy after totally laparoscopic total gastrectomy: A single-center 7-year experience

AIM: To assess the efficacy and safety of intracorporeal esophagojejunostomy in patients undergoing laparoscopic total gastrectomy(LTG) for gastric cancer.METHODS: A retrospective review of 81 consecutive patients who underwent LTG with the same surgical team between November 2007 and July 2014 was performed. Four types of intracorporeal esophagojejunostomy using staplers or hand-sewn suturing were performed after LTG. Data on clinicopatholgoical characteristics, occurrence of complications, postoperative recovery, anastomotic time, and operation time among the surgical groups were obtained through medical records.RESULTS: The average operation time was 288.7 min, the average anastomotic time was 54.3 min, and the average estimated blood loss was 82.7 m L. There were no cases of conversion to open surgery. The first flatus was observed around 3.7 d, while the liquid diet was started, on average, from 4.9 d. The average postoperative hospital stay was 10.1 d. Postoperative complications occurred in 14 patients, nearly 17.3%.However, there were no cases of postoperative death.CONCLUSION: LTG performed with intracorporeal esophagojejunostomy using laparoscopic staplers or hand-sewn suturing is feasible and safe. The surgical results were acceptable from the perspective of minimal invasiveness.     

老年胃癌根治术病人术后肺部感染的影响因素分析

目的探讨老年胃癌根治术病人的临床病理特征及术后肺部感染的影响因素。方法回顾性分析2016年1月至2019年6月我院收治的120例行根治性手术治疗的老年胃癌病人的临床资料,根据病人术后是否发生肺部感染将其分为研究组(n=26)和对照组(n=94)。比较2组病人的临床病理资料,并采用多因素Logistic回归分析老年胃癌根治术病人并发术后肺部感染的独立危险因素。结果年龄(OR=3.570,95%CI1.150~9.875)、低白蛋白血症(OR=3.003,95%CI2.851~4.623)、胃肠减压(OR=7.538,95%CI3.101~18.203)、围术期输血(OR=6.813,95%CI5.323~8.303)、伤口疼痛(OR=3.417,95%CI1.546~7.537)、吸烟史(OR=3.662,95%CI1.680~7.992)是老年胃癌根治术病人并发术后肺部感染的独立危险因素。结论老年胃癌根治术病人并发术后肺部感染的独立危险因素主要为高龄、低白蛋白血症、胃肠减压、围术期输血、伤口疼痛、吸烟史,建议针对上述因素加强干预措施。     

Gastrointestinal decompression after excision and anastomosis of lower digestive tract

AIM: To discuss the clinical significance of postoperative gastrointestinal decompression in operation on lower digestive tract. METHODS: Three hundred and sixty-eight patients with excision and anastomosis of lower digestive tract were divided into two groups, i.e. the group with postoperative gastrointestinal decompression and the group without postoperative gastrointestinal decompression. Clinical therapeutic outcome and incidence of complication were compared between two groups. Furthermore, an investigation on application of gastrointestinal decompression was carried out among 200 general surgeons. RESULTS: The volume of gastric juice in decompression group was about 200 mL every day after operation. Both groups had a lower girth before operation than every day after operation. No difference in length of the first passage of gas by anus and defecation after operation was found between two groups. The overall incidence of complications was obviously higher in decompression group than in non-decompression group (28% vs 8.2%, P<0.001). The incidence of pharyngolaryngitis was up to 23.1%. There was also no difference between two groups regarding the length of hospitalization after operation. The majority (97.5%) of general surgeons held that gastrointestinal decompression should be placed till passage of gas by anus, and only 2.5% of surgeons thought that gastrointestinal decompression should be placed for 2-3 d before passage of gas by anus. Nobody (0%) deemed it unnecessary for placing gastrointestinal compression after operation. CONCLUSION: Application of gastrointestinal decompression after excision and anastomosis of lower digestive tract cannot effectively reduce gastrointestinal tract pressure and has no obvious effect on preventing postoperative complications. On the contrary, it may increase the incidence of pharyngolaryngitis and other complications. Therefore, it is more beneficial to the recovery of patients without undergoing gastrointestinal decompression.     

Early experience of the compression anastomosis ring （CAR~（TM） 27） in left-sided colon resection

AIM: To evaluate clinical validity of the compression anastomosis ring (CAR™ 27) anastomosis in left-sided colonic resection.METHODS: A non-randomized prospective data collection was performed for patients undergoing an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27 between November 2009 and January 2011. Eligibility criteria of the use of the CAR™ 27 were anastomoses between the colon and at or above the intraperitoneal rectum. The primary short-term clinical endpoint, rate of anastomotic leakage, and other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the ring elimination time were evaluated.RESULTS: A total of 79 patients (male, 43; median age, 64 years) underwent an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27. Colectomy was performed laparoscopically in 70 patients, in whom two patients converted to open procedure (2.9%). There was no surgical mortality. As an intraoperative complication, total disruption of the anastomosis occurred by premature enforced tension on the proximal segment of the anastomosis in one patient. The ring was removed and another new CAR™ 27 anastomosis was constructed. One patient with sigmoid colon cancer showed postoperative anastomotic leakage after 6 d postoperatively and temporary diverting ileostomy was performed. Exact date of expulsion of the ring could not be recorded because most patients were not aware that the ring had been expelled. No patients manifested clinical symptoms of anastomotic stricture.CONCLUSION: Short-term evaluation of the CAR™ 27 anastomosis in elective left colectomy suggested it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.     

Evaluation of intraoperative radiotherapy for gastric carcinoma with D2 and D3 surgical resection

INTRODUCTION The fate of patients after surgical removal of a gastric carcinoma is determined to a large degree by regional failure of the operation (e.g. tumor recurrence in the tumor bed or in an adjacent structure). This is true for palliative resectio…     

Jejunal interposition helps prevent reflux gastritis

BACKGROUND/AIMS: Jejunal interposition after distal gastrectomy is reported to prevent both duodenogastric reflux and rapid gastric emptying. However, comparing primary reconstruction with this procedure and Billroth-I in terms of clinical evaluation by the same surgeon is rare. In this study, the benefit of this procedure was retrospectively evaluated as compared to the Billroth-I method. METHODOLOGY: Of 30 patients with early gastric cancer located at the middle third of the stomach, 15 underwent distal gastrectomy with jejunal interposition and the other 15 underwent Billroth-I gastrectomy by the same surgeon. Isoperistaltic jejunal interposition measuring 10-12 cm was used. All the anastomoses without jejunojejunostomy were performed using auto-suture staplers. Assessment of postoperative symptoms and functions was performed one year after surgery. RESULTS: The mean operation time was significantly longer after jejunal interposition (p < 0.01). No serious complications occurred in either group, and the hospital stay after operation was also similar. There were no significant differences in terms of postoperative symptoms, food intake, and recovery of body weight. The incidence of bile regurgitation and reflux gastritis was very low or zero in the jejunal interposition group, which indicated differences (p < 0.05, p < 0.01, respectively). Reflux esophagitis was not found in jejunal interposition, but two patients after Billroth I showed grade B esophagitis. As regards gastric emptying, the retention capacity was very poor and there was no significant difference between the two groups. CONCLUSIONS: Jejunal interposition after distal gastrectomy was superior to the Billroth-I procedure in terms of reflux gastritis prevention. However, dumping syndrome and rapid gastric emptying were not prevented.     

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 laparoscopicsurgery,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 indepth 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.