腹腔镜下乙状结肠癌根治术经自然腔道（阴道）取出标本

术者简介
　　陈创奇教授,男,1969年5月出生,广东省普宁市人,医学博士学位,硕士生导师。2002年～2005年在美国宾夕法尼亚大学从事博士后研究工作,2009年 1～2月在瑞典林雪萍大学医院进修学习胃肠胰外科。现担任中山大学灾难医学教研室主任,中山大学附属第一医院普通外科副主任和结直肠外科常务副主任,中国医师协会外科医师分会结直肠外科医师委员会第一届委员会委员和肛肠外科医师委员会第一届委员会委员,广东省医师协会加速康复外科分会主任委员,广东省医学会结直肠肛门外科学分会常务委员、胃肠外科学分会委员和医学教育与信息技术学分会第三届委员会委员。担任《中华生物医学工程杂志》《中华临床医师杂志（电子版）》《中华现代临床医学杂志》《中山大学学报医学版》《消化肿瘤杂志（电子版）》《手术》等杂志编委或常务编委。目前已经发表第一作者或通讯作者的论文49篇（包括SCI 论文）;主编教材三部,即《外科学临床见习精要》《现代灾难医学》和《实习医生临床技能手册》;副主编教材《医科实习生临床技能手册》和《临床技能模拟训练教程》,副主译《消化道肿瘤诊断与治疗》1部,参编专著7部。获得专利1项。获得各级基金31项。已培养的硕士生有6名。     

腹腔镜下钉座反穿吻合法联合经自然腔道取标本对低位直肠癌患者疗效及生活质量的影响

目的 探究腹腔镜下钉座反穿吻合法联合经自然腔道取标本对低位直肠癌患者治疗效果及生活质量的影响。方法 选取承德医学院附属医院2018年4月至2021年6月收治的低位直肠癌患者86例,随机分为研究组和对照组,各43例。两组患者于腹腔镜下行直肠癌根治术并经自然腔道取标本,对照组联合传统荷包式缝合固定,研究组联合钉座反穿吻合法固定。比较两组患者手术情况(术中出血量、手术时间、术后初次排气时间及住院时间);于术前及术后3周,采用酶联免疫吸附试验检测血清炎性因子[C-反应蛋白(CRP)、肿瘤坏死因子(TNF)-α]、免疫因子[免疫球蛋白G(IgG)]、氧化应激指标[丙二醛(MDA)、超氧化物歧化酶(SOD)]水平;记录患者术后3个月术后并发症发生情况;于术前及术后3个月评估患者生活质量(GIQLI)评分。结果 研究组术中出血量、手术时间及住院时间均低于对照组(P<0.05)。术后,两组血清CRP、TNF-α水平及对照组IgG水平均高于术前(P<0.05);研究组术后血清CRP、TNF-α水平均低于对照组,IgG水平高于对照组(P<0.05)。与术前相比,术后两组血清MDA水平升高...     

免腹部辅助切口经自然腔道取标本完全腹腔镜下直肠癌根治术对第三间隙效应的影响

目的探讨免腹部辅助切口经自然腔道取标本(NOSE)法完全腹腔镜下直肠癌根治术对第三间隙效应的影响。方法选取2016年1月至2018年6月在东南大学附属中大医院江北院区普外科住院并行根治性切除术的直肠癌患者120例,随机分为观察组与对照组,每组60例。对照组行常规腹腔镜直肠癌根治术,观察组行免腹部辅助切口NOSE法完全腹腔镜下直肠癌根治术,比较两组手术相关指标,分别于术前及术后24、48、72 h测定血清白蛋白(ALB)、前白蛋白(PAB)、总蛋白(TP)、Na~+、K~+、Ca~(2+)、一氧化氮(NO)、超氧化物歧化酶(SOD)、丙二醛(MDA)、C反应蛋白(CRP)、肿瘤坏死因子α(TNF-α)及白介素-6(IL-6)水平。结果两组患者的手术时间、淋巴结清扫数及术后并发症发生率比较差异均无统计学意义(P0.05),但观察组的切口长度、术中出血量、术后首次排气时间、术后首次下床时间、术后住院时间均低于对照组,差异有统计学意义(P0.05)。两组术后血清ALB、PAB、TP、Na~+、K~+、Ca~(2+)水平比较差异无统计学意义(P0.05);观察组术后24、48、72 h的血清SOD水平高于对照组,血清MDA、CRP、TNF-α、IL-6水平低于对照组,差异均有统计学意义(P0.05)。结论免腹部辅助切口NOSE法完全腹腔镜下直肠癌根治术安全可行,可减轻手术创伤及对第三间隙效应的影响,有利于术后康复。     

免腹部辅助切口经自然腔道取标本完全腹腔镜下直肠癌根治术对第三间隙效应的影响

目的探讨免腹部辅助切口经自然腔道取标本(NOSE)法完全腹腔镜下直肠癌根治术对第三间隙效应的影响。方法选取2016年1月至2018年6月在东南大学附属中大医院江北院区普外科住院并行根治性切除术的直肠癌患者120例,随机分为观察组与对照组,每组60例。对照组行常规腹腔镜直肠癌根治术,观察组行免腹部辅助切口NOSE法完全腹腔镜下直肠癌根治术,比较两组手术相关指标,分别于术前及术后24、48、72 h测定血清白蛋白(ALB)、前白蛋白(PAB)、总蛋白(TP)、Na+、K+、Ca2+、一氧化氮(NO)、超氧化物歧化酶(SOD)、丙二醛(MDA)、C反应蛋白(CRP)、肿瘤坏死因子α(TNF α)及白介素 6(IL 6)水平。结果两组患者的手术时间、淋巴结清扫数及术后并发症发生率比较差异均无统计学意义(P>005),但观察组的切口长度、术中出血量、术后首次排气时间、术后首次下床时间、术后住院时间均低于对照组,差异有统计学意义(P<005)。两组术后血清ALB、PAB、TP、Na+、K+、Ca2+水平比较差异无统计学意义(P>005);观察组术后24、48、72 h的血清SOD水平高于对照组,血清MDA、CRP、TNF α、IL 6水平低于对照组,差异均有统计学意义(P<005)。结论免腹部辅助切口NOSE法完全腹腔镜下直肠癌根治术安全可行,可减轻手术创伤及对第三间隙效应的影响,有利于术后康复。     

经自然腔道取标本手术在右半结肠癌根治术中的应用优势与技术要点

随着微创外科理念的发展,经自然腔道取标本手术(NOSES)逐步在右半结肠癌根治术中被广泛应用.经阴道或直肠取标本的方式避免了腹部切口,使患者术后疼痛减轻,减少术后住院康复时间,并取得良好的美容效果.但右半结肠解剖结构复杂,对全腔镜下重建消化道的技术要求较高,经阴道或直肠取标本的方式也遭受了很多争议,对普遍开展造成了困难...     

全腹腔镜下三角吻合与腹腔镜辅助Brillroth Ⅰ式吻合在远端胃癌根治术中的近期效果对比

目的 分析比较远端胃癌根治术中分别采用全腹腔镜下三角吻合与腹腔镜辅助Brillroth Ⅰ式吻合的近期治疗效果.方法 选取确诊为远端胃癌的80例患者.采用随机数字表将其随机分为的A、B两组,每组各40例.A组采用全腹腔镜下三角吻合术进行治疗,B组采用腹腔镜辅助Brillroth Ⅰ式吻合术进行治疗.对两组患者的术中总出血量、手术时间、术后排气时间、淋巴结清扫数目、拆线时间、住院时间、术后并发症状况以及死亡状况进行比较.结果 与A组相比B组手术时间明显缩短(P＜0.05);两组在术后住院时间方面差异无明显统计学意义(P＞0.05);与B组相比A组的术中出血量明显减少(P＜0.05),术后拆线时间以及排气时间均明显短于B组,淋巴结清扫数目较B组明显增多(P＜0.05);两组患者术后并发症发生率比较无明显差异(P＞0.05);并且两组患者术中无死亡病例.结论 对于远端胃癌根治术中采用全腹腔镜下三角吻合手术方式其效果明显优于腹腔镜辅助Brillroth Ⅰ式吻合手术,临床实践过程中可以根据患者的自身的特点选择手术方式,可优先选择全腹腔镜下三角吻合术.     

三角吻合与管状吻合在腹腔镜远端胃癌根治术中的对照研究

目的 比较三角吻合与管状吻合在腹腔镜远端胃癌根治术中的价值.方法 回顾性分析218例在腹腔镜辅助下行远端胃癌根治+毕Ⅰ式吻合术患者的临床资料,根据吻合方式不同分为观察组116例(三角吻合)和对照组102例(管状吻合).比较两组患者术中、术后相关指标及3年生存率.结果 观察组患者的手术时间、吻合时间分别为(166.8±55.6)min、(21.5±8.6)min,均明显短于对照组的(189.1±65.1)min、(29.2±9.5)min;观察组患者的术中出血量为(86.1±28.6)ml,明显少于对照组的(106.2±39.3)ml,差异均有统计学意义(P﹤0.01).观察组患者术后1、3天视觉模拟评分(VAS)和盐酸哌替啶使用剂量分别为(3.6±1.3)分、(1.9±0.8)分和(152.3±48.9)mg,均明显低于对照组的(5.1±1.8)分、(3.2±1.4)分、(221.2±86.7)mg,差异均有统计学意义(P﹤0.01).两组患者术后切口感染、吻合口瘘、出血的发生率和3年总生存率比较,差异均无统计学意义(P﹥0.05).结论 在腹腔镜远端胃癌根治术中,三角吻合患者与管状吻合患者的远期疗效无明显差异,但三角吻合可以明显缩短手术时间,减少术中出血量,减轻术后疼痛程度.     

直肠癌腹腔镜根治术经自然腔道取标本对患者术后恢复、胃肠激素、机体体液和细胞免疫的影响

目的 研究直肠癌腹腔镜根治术经自然腔道取标本对患者术后恢复、胃肠激素、机体体液和细胞免疫的影响。方法 选取86例直肠癌患者为试验对象,随机分为2组,其中观察组41例,实施腹腔镜手术经自然腔道取标本,对照组45例实施常规腹腔镜手术治疗。比较2组患者的胃肠道恢复、围术期指标、胃肠激素、机体体液和细胞免疫之间的差异。结果 观察组患者的肠鸣音具体的恢复时间、排气所需要的时间以及开始进食所需的时间较对照组更短(P<0.05); 2组患者的切除病灶的长度、手术时间、术中出血量和总的淋巴结清扫量间的对比并无差异(P>0.05)。2组患者治疗结束后补体C3、补体C4、IgA、IgG、IgM均显著升高,且观察组患者的补体C3、补体C4、IgA、IgG、IgM显著高于对照组。2组患者的胃动力素以及胃泌素均发生显著改变,且观察组患者的胃动力素较对照组患者更高,而胃泌素较对照组更低。观察组患者出现肠梗阻、切口感染等总的并发症发生概率较对照组更低。观察组患者的术后首次下床的时间和手术结束后使用止痛药的次数较对照组更低,差异明显(P<0.05)。结论 对直肠癌患者实施腹腔镜手术,并在此手术中经自...     

腹腔镜结直肠癌标本经自然腔道取出术与传统腹腔镜结直肠癌根治术对患者术后康复的影响

目的:比较腹腔镜结直肠癌标本经自然腔道取出术（NOSE）与常规腹腔镜结直肠癌根治术（LCR）对患者术后康复的影响。方法:将本院收治的116例结直肠癌患者作为研究对象,随机分为对照组采取常规LCR术,研究组采取腹腔镜结直肠癌标本NOSE术,两组各58例。比较两组患者手术相关指标包括手术时间、术中出血量、术后住院天数和术后排气时间;比较两组患者术前、术后3 d时氧化应激指标、免疫学指标和炎症因子的水平。结果:两组患者手术时间和术中出血量的比较,均无明显差异（均P＞0.05）;但研究组术后住院天数和术后排气时间较对照组明显缩短（均P＜0.05）。两组患者术后3 d时超氧化物歧化酶（SOD）水平较术前均明显降低,且研究组降低幅度较对照组小（均P＜0.05）;两组患者术后3 d时丙二醛（MDA）水平较术前均明显升高,且研究组升高幅度较对照组小（均P＜0.05）。两组患者术后3 d时免疫球蛋白A（IgA）和免疫球蛋白M（IgM）的水平较术前均显著降低,且研究组IgM降低幅度较对照组小（均P＜0.05）;而两组术后3 d时IgA水平的比较,并无明显差异（P＞0.05）。两组患者术后3 d时肿瘤坏死因子-α（TNF-α）、C反应蛋白（CRP）和白介素-6（IL-6）的水平较术前均显著升高,且研究组升高幅度较对照组小（均P＜0.05）;两组患者术后3 d时白介素-10（IL-10）的水平较术前显著降低,且研究组降低幅度较对照组小（均P＜0.05）。结论:腹腔镜结直肠癌标本NOSE术较常规LCR术能够明显缓解结直肠癌患者氧化应激反应,抑制炎症因子的释放,减少对机体免疫功能的影响,因此具有良好的临床应用价值。     

腹腔镜根治术联合三角吻合术治疗早期胃癌的安全性

目的 分析腹腔镜根治术联合三角吻合术治疗早期胃癌的安全性.方法 将80例早期胃癌患者分为根治术组、联合手术组,每组40例.根治术组采用腹腔镜根治术进行治疗,联合手术组在根治术组基础上增加三角吻合术进行治疗.观察并比较两组患者手术指标、视觉模拟评分法(VAS)评分、消化系统疾病生存质量指数表(GLQL)评分及术后并发症发...     

腹腔镜根治术在老年胃癌患者中的应用效果

目的 探讨腹腔镜根治术在老年胃癌患者中的应用效果.方法 依据治疗方法的不同将106例老年胃癌患者分为观察组和对照组,每组53例,对照组患者实施传统开腹根治术,观察组患者实施腹腔镜根治术.比较两组患者的手术相关指标、炎性因子[C反应蛋白(CRP)和肿瘤坏死因子-α(TNF-α)]水平、免疫因子(CD3+、CD4+、CD8...     

腹腔镜与开腹胃癌根治术后患者生存质量分析

目的 调查胃癌根治术后患者生存质量变化情况,研究原发胃癌根治术后患者生存质量的影响因素.方法 采用消化病生存质量指数( GLQI)测定45例原发胃癌根治术后患者的生存质量,分析其影响因素并比较腔镜手术与开腹手术生存质量的不同.结果 患者术后GLQI评分与患者年龄无相关性.随病理分期增高,患者GLQI总分、心理情绪状态、生理功能状态及主观症状评分显著降低(P＜0.05),而社会活动状态评分无显著变化(P＞0.05).男性患者在GLQI总分及生理功能状态上均优于女性患者(P＜0.05),而在心理情绪状态、社会活动状态及主观症状评分无明显差异(P＞0.05).手术后2周腹腔镜组在GLQI总分、生理功能状态及主观症状方面优于开腹组(P＜0.05),而在心理情绪状态及社会活动状态评分无明显差异(P＞0.05).手术3个月以后,腹腔镜组在GLQI总分及主观症状优于开腹组(P＜0.05),而在心理情绪状态、生理功能状态及社会活动状态评分无显著性差异(P＞0.05).结论 胃癌根治术后患者的肿瘤病理分期、性别及手术方式是患者术后生存质量的影响因素,其中病理分期早优于分期晚的患者,男性优于女性,腹腔镜手术优于开腹手术.     

腹部无切口经肛门取标本腹腔镜下直肠癌根治术治疗早期直肠癌的近期疗效及安全性观察

目的 观察腹部无切口经肛门取标本(NOSES)腹腔镜下直肠癌根治术治疗早期直肠癌的疗效及安全性.方法 将420例早期直肠癌患者按取标本途径不同分为传统腹腔镜直肠癌根治术(LACR)组(320例)和NOSES组(100例).观察两组患者手术一般情况、应激指标、术后肛门功能、并发症发生情况以及生活质量的差异.结果 NOSE...     

腹腔镜胃癌D2根治术治疗进展期胃癌的效果及对炎症因子和免疫功能的影响

目的:探讨腹腔镜胃癌D2根治术治疗进展期胃癌的效果及对炎症因子和免疫功能的影响。方法:选择进展期胃癌患者110例,随机分为观察组和对照组各55例,分别采用腹腔镜胃癌D2根治术与开腹胃癌D2根治术治疗,比较两组治疗效果及炎症因子水平和免疫功能指标变化情况。结果:观察组手术切口长度、手术时间、术中出血量、腹腔引流时间、住院时间及肛门排气时间均明显优于对照组（P<0.05）;两组清扫淋巴结数量比较差异不显著（P>0.05）。术后两组白细胞介素（IL）-6、IL-8、IL-12、IL-16及肿瘤坏死因子-α（TNF-α）水平均较术前明显升高（P<0.05）,且与观察组比较,对照组炎症因子水平升高更为显著（P<0.05）。观察组免疫球蛋白IgA、IgM、IgG水平与术前比较差异不显著（P>0.05）,对照组IgA、IgM、IgG水平较术前明显下降且下降幅度明显大于观察组（P均<0.05）,术后两组补体C3水平均较术前明显升高（P<0.05）,且对照组升高幅度显著大于观察组（P<0.05）。结论:相比于传统开腹术式,腹腔镜胃癌D2根治术治疗进展期胃癌的效果更为理想,同时可明显减轻术后炎症反应且对患者的免疫功能影响相对较小。     

中间入路法腹腔镜辅助结肠癌根治术的临床分析

目的：探讨腹腔镜辅助结肠癌根治术采用中间入路法治疗结肠癌的方法及效果。方法选取50例结肠癌患者进行随机分组,其中研究组25例采用中间入路法进行腹腔镜辅助下结肠癌根治手术,对照组25例采用常规开腹手术。结果研究组患者术中出血量（93.2±28.2）ml,明显低于对照组（128.3±32.8）ml;研究组患者手术时间（132.8±32.8）min,明显少于对照组（167.9±38.2）min,差异均具有统计学意义（均 P＜0.01）。研究组淋巴结清扫（16.2±5.3）枚,标本切除长度（24.3±7.2）cm,对照组患者淋巴结清扫（15.4±3.2）枚,标本切除长度（22.8±7.6）cm,两组数据差异无统计学意义（均 P＞0.05）。研究组患者术后排气时间、饮食恢复时间和住院时间分别为（2.2±0.3）天、（3.0±0.5）天和（9.8±2.2）天,均少于对照组的（4.2±0.6）天、（5.3±0.4）天和（15.5±3.6）天,差异均有统计学意义（均 P＜0.01）。研究组患者并发症发生率为12%,明显高于对照组的36%,差异有统计学意义（P＜0.05）。结论腹腔镜辅助下进行结肠癌根治手术可大大提高手术的效率,提高治疗安全性,促进患者早期康复,并可减轻痛苦,提高生存质量。     

D2 plus radical resection combined with perioperative chemotherapy for advanced gastric cancer with pyloric obstruction

A patient with advanced gastric cancer complicated with pyloric obstruction was treated using D2 + radical resection combined with perioperative chemotherapy, and had satisfying outcomes. The perioperative chemotherapy regimen was Taxol and S1 (tegafur, gimeracil, and oteracil). Three cycles of neoadjuvant chemotherapy were delivered before surgery, and three cycles of adjuvant therapy after surgery. PR was achieved after chemotherapy. D2 + dissection of stations 8p, 12b, 12p, 13 and 14v lymph nodes was performed on September 10, 2012.Key Words: Advanced gastric cancer, pyloric obstruction, D2 + lymph node dissection, perioperative chemotherapyD2 lymph node dissection has become the standard surgical approach for advanced gastric cancer (1-3). However, in the case of lower stomach cancer complicated by pyloric obstruction, the lymphatic drainage and pattern of metastases are different due to the anatomical restriction, and a higher rate of metastases into the hepatoduodenal ligament and the posterior area of the pancreatic head are often seen (4). Perioperative chemotherapy can significantly improve the survival of patients (5,6). This video describes the procedure of D2 + radical resection combined with perioperative chemotherapy for a patient with lower gastric cancer complicated by pyloric obstruction, as follows. The treatment was successful.A 53-year-old woman was admitted on June 3, 2012 due to “upper abdominal fullness with dull pain for 3 months, with intermittent nausea and vomiting for 10 days.” Gastroscopy suggested a huge, solid ulcer at the antrum close to the pylorus, involving the pylorus and resulting in pyloric stenosis. Endoscopic biopsies suggested poorly differentiated adenocarcinoma of the gastric antrum. CT: huge tumor in the antrum, considered as gastric antral carcinoma, infiltrating through the serosa with metastases to multiple lymph nodes surrounding the stomach and superior area of the pancreas. Tumor markers: CA199 402.15 U/mL. Clinical diagnoses: cancer of the gastric antrum involving the pylorus, complicated by partial pyloric obstruction, staging T4aN2M0. Three cycles of preoperative chemotherapy were delivered on June 9, July 2 and July 28, 2012, using the regimen of Taxol 240 mg/dL and S1 60 mg bid po d1-14, repeated for three weeks. After the chemotherapy courses, the CT scan suggested significantly reduced volume of the antral tumor, and lymph nodes around the stomach and the pancreas were not as obvious as before. PR was achieved following chemotherapy. Radical gastrectomy with D2 + lymph dissection was performed under general anesthesia for the distal gastric cancer resection on September 10, 2012.During the surgery (Video 1), the patient was placed in a supine position. Following general anesthesia, a middle upper abdominal incision of 3 cm was made from the xiphoid down to the umbilicus. The wound was well protected, and abdominal exploration was conducted to confirm that there were no peritoneal and liver metastases. A piece of gauze was gently padded posterior to the pancreas to prevent tearing. Kocher’s separation: the peritoneum was divided at the lateral border of the duodenum and the duodenum was freed. The incision continued downwards to the hepatic flexure of the colon to expand the surgical field. Sharp dissection was performed along the posterior region of the duodenum and the pancreas to reveal the inferior vena cava, the beginning part of the left renal vein, and the right ovarian vein. The anterior lobe of the transverse mesocolon and the pancreatic capsule were completely separated to the hepatic flexure of colon on the right side and to the lower pole of the spleen on the left side, so that the omental bursa could be completely removed.Open in a separate windowVideo 1D2 plus radical resection combined with perioperative chemotherapy for advanced gastric cancer with pyloric obstructionThe lymph nodes in the inferior area to the pylorus were dissected along the course of the middle colon vein towards its root, and the superior mesenteric vein (SMV) anatomy, as well as the gastrointestinal vein trunk and accessory right colic vein, was freed from the inferior region of the pancreatic neck. The station 14v lymph nodes were dissected around the SMV. The separation continued towards the pylorus to free the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein. The structure of the gastrointestinal vein trunk formed jointly by the right gastroepiploic vein, anterior superior pancreaticoduodenal vein and accessory right colic vein was clearly visible. The right gastroepiploic vein was ligated and cut before its junction with the pancreaticoduodenal vein. The gastroduodenal artery was isolated at the junction of the duodenum and the pancreatic head. The separation continued towards the pylorus to free the right gastroepiploic artery, which was then ligated and cut at the root. The inferior pyloric artery from the gastroduodenal artery was then separated. The inferior pyloric artery was ligated and cut, and the lower edge of the duodenum and the pylorus was completely denuded to for the complete dissection of the station number 6 lymph nodes.The left gastroepiploic artery was separated, ligated and cut from the lower pole of the spleen, followed by dissection of the station number 4sb lymph nodes. The fascia over the upper edge of the pancreas was opened to reveal the splenic artery, for the dissection of the station number 11p lymph nodes. It should be noted that there were several curves along the splenic artery to the splenic hilum, especially the largest one of 3 to 4 cm to the root, which was hidden behind the pancreas with lymph nodes inside that should not be omitted. After dissection of the station number 11p lymph nodes, the separation was continued towards the left diaphragmatic muscle to dissect the lymph nodes to the left of the celiac artery.The stomach was flipped down to the inferior side, and the anterior peritoneum of the hepatoduodenal ligament was opened. The proper hepatic artery and the right gastric artery were divided, and the latter was ligated and cut at the root. The station number 5 lymph nodes were dissected. The supraduodenal vessels were transected, and the upper edge of the duodenal bulb was completely denuded. The duodenum was transected 3 cm below the pylorus (with a Tyco 60 mm linear stapler), with the duodenal stumps closed with reinforced stitching.Denuding and dissection of the hepatoduodenal ligament: the lymph nodes surrounding the proper hepatic artery (number 12a) were dissected, and the artery was retracted with retraction bands to divide the left and right hepatic arteries. Since the hepatic branch and plexus of the vagus nerve were completely removed, there would be an extremely high risk of cholecystitis and gallstones after surgery, so gallbladder was removed as well. The common bile duct was separated, and the surrounding lymph nodes were dissected (number 12b). Caution was made to protect the supplying vessels to the common bile duct. The portal vein to the posterior area was separated, and the surrounding lymph nodes (number 12p) were dissected.Dissection of lymph nodes posterior to the pancreatic head (number 13): these lymph nodes often attached closely to the pancreatic head in a flat shape. An electrocautery was required in the sharp separation, with caution to avoid the retroduodenal artery. In some cases, these lymph nodes would be closely adhesive to that small artery, so it could be separated first to prevent bleeding. The stations number 13, 12b and 12p were pushed to the right through the Winslow’s hole and retracted from the left side of the hepatoduodenal ligament. These lymph nodes were then separated along the common hepatic artery and the upper edge of the splenic vein towards the celiac trunk. The stations number 8a and 8p were dissected en bloc. The coronary vein was divided from the posterior region close to the root of the common hepatic artery, and then ligated and transected. The lymph nodes to the right of the celiac artery (number 9) were then dissected along the plane of the right crus of the diaphragm. The left gastric artery was denuded from the periphery, ligated and cut at the root, and station number 7 lymph nodes were dissected. The separation was continued along the right crus of the diaphragm towards the cardia to dissect the lymph nodes on its right and posterior side (number 1). The greater and lesser curvatures of the stomach were denuded using Ligasure (Tyco, energy platform), and the stations number 3 and 4d lymph nodes were dissected. The stomach was then transected 5 cm from the upper edge of the tumor with a Tyco 100 mm linear stapler, and 2/3 of the distal stomach was removed together with the lymph nodes.Reconstruction: Billroth II gastrojejunostomy (Tyco 25 mm circular stapler) was performed in combination with Braun’s anastomosis.The whole operation lasted 2 hours and 50 minutes, with intraoperative blood loss of 100 mL and no blood transfusion. The patient was able to ambulate four days after surgery. Liquid diet was prescribed on the 5th day, and semi-liquid diet was prescribed on the 7th day. The patient was discharged eight days after surgery. Postoperative pathology: chronic inflammation with ulceration in the mucosa of the posterior wall of the antrum, with a small amount of degenerated adenocarcinoma with interstitial fibrosis in the mucosal and serosal layers; lymph nodes 0/36 (subcomplete remission).Three cycles of adjuvant chemotherapy were delivered on October 26, November 22 and December 16, 2012 after surgery, using the regimen of Taxol 240 mg/dL and S1 60 mg bid po d1-14, repeated for three weeks. No sign of recurrence was observed during the nine months of postoperative follow-up. The tumor marker CA199 has remained at a low level.