Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer

BACKGROUND AND OBJECTIVES: Laparoscopy-assisted gastrectomy with lymph node dissection for gastric cancer is considered technically more complicated than the open method. Moreover, the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection in patients with gastric cancer have not been established yet. To evaluate short-term surgical validity, surgical outcome of the laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection was compared with that of the conventional open distal gastrectomy (CODG) in patients with early gastric cancer. METHODS: One hundred and forty-seven patients with early gastric cancer received radical distal gastrectomy during 2002 and 2003, where LADG was undergone in 71 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between the two groups. Data were retrieved from the stomach cancer database at Dong-A University Medical center. RESULTS: Baseline characteristics, including sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, tumor size, T stage, and lymph node metastasis were similar between the two groups. No significant differences were found between these groups in terms of the number of retrieved lymph nodes with respect to D1 + alpha (D1 + no. 7) and D1 + beta (D1 + no. 7, 8a, and 9) lymphadenectomy. In the LADG group, wound size was smaller (P < 0.0001), but operation time was longer (P = 0.0001) than in the CODG group. Perioperative recovery was faster in the LADG group than in the CODG group, as reflected by a shorter hospital stay (P = 0.0176) and less times of additional analgesics (P = 0.0370). Serum albumin level in LADG was higher (P = 0.0002) on day 7 than that in CODG, and the leukocyte count in LADG lower (P = 0.0445) on day 1 than that in CODG. Postoperative morbidities and mortalities were not significantly different between the two groups. CONCLUSIONS: Our data confirmed that LADG with extraperigastric (no. 7, 8, and 9) lymph node dissection proved to be feasible and acceptable surgical technique for early gastric cancer. At least taking a surgical point of view, LADG with extraperigastric lymph node dissection is suggested to be a preferred surgical option for patients with early gastric cancer. Its oncologic validity awaits larger and prospective multicenter trials.     

腹腔镜与开腹全胃切除术治疗Ⅰ期胃癌的近期疗效对比CSCD

目的探讨腹腔镜全胃切除术与传统开腹全胃切除术对Ⅰ期胃癌的近期疗效。方法回顾性分析89例肿瘤位于近端胃的Ⅰ期胃癌,并且行全胃切除术的患者。按照手术方式不同分为腹腔镜组(47例)和开腹组(42例)。通过观察两组患者手术时间、出血量、术后病理相关指标、术后并发症、术后首次进食流质饮食时间及术后住院天数,比较两种手术方式的近期疗效。结果两组患者基线资料对比差异无统计学意义,具有可比性。与开腹组相比,腹腔镜组患者手术时间更长,但术中出血量、术后首次进食流质饮食时间、术后住院天数、术后并发症发生率及并发症等级均低于开腹组(P<0.05)。结论腹腔镜全胃切除术能够在保证Ⅰ期的近端胃癌患者手术安全性的同时,降低患者术中出血量、进食流质饮食时间、术后住院时间及术后并发症。     

Laparoscopic assisted distal gastrectomy for early gastric cancer: Is it an alternative to the open approach?

ObjectiveThis study aims to compare short term outcomes and oncological value of laparoscopy assisted (LADG) and open distal gastrectomy (ODG) in the treatment of early gastric cancer.MethodsMeta-analysis of 12 studies, including three randomized controlled trials, published between 2000 and 2007, comparing laparoscopy assisted and open distal gastrectomy in 951 patients with early gastric cancer, was done. Outcomes of interest were operative data, lymph node clearance, postoperative recovery complications.ResultsOverall morbidity rate was significantly less with LADG (10.5% versus 20.1%, P = 0.003, OR 0.52, CI 0.34–0.8). A mean of 4.61 less number of lymph nodes dissected than ODG (CI ?5.96, ?3.26 P < 0.001) when all studies are included. There was no difference between the two groups in number of lymph nodes dissected when less than D2 lymphadenectomy was done (2.44 nodes less in LADG group, CI ?5.52, 0.63; P = 0.12). LADG patients had less operative blood loss (mean of 151 ml, P < 0.001), less time to walking, oral intake and flatus. LADG patients had less length of hospital stay (5.7 days, P < 0.001), postoperative fever and pain. ODG group showed significantly less operative time. There was no significant difference between the two groups in the incidence of anastomotic complications and wound infection.ConclusionLADG is a safe technical alternative to ODG for early gastric cancer with a lower overall complication rate and enhanced postoperative recovery. Endorsing LADG as a better alternative to ODG requires data on long term survival, quality of life and cost effectiveness.     

腹腔镜胃癌根治术与开放性胃癌根治术的对比研究

目的　通过比较腹腔镜下胃癌根治术与开放性胃癌根治术的差异,探讨腹腔镜下胃癌根治性的可行性。方法 选取２００８年５月至２００９年１０月行腹腔镜下胃癌根治性切除术８１例,其中根治性远端胃癌根治术４８例,根治性近端胃癌根治术１９例,根治性全胃切除术１４例,与开放性胃癌根治术（相同分期）８０例的病例资料作回顾性分析。结果　８１例均在腹腔镜辅助下完成手术,Ｄ１淋巴结清扫６例,Ｄ２淋巴结清扫７５例。腹腔镜手术和开放性手术的平均手术时间分别为２５８ｍｉｎ和１９３ｍｉｎ（Ｐ＜０.０５）,术中平均出血量分别为２９２ｍｌ和３８９ｍｌ（Ｐ＜０.０５）,清扫淋巴结平均数分别为１６.５枚和１７.８枚（Ｐ＞０.０５）;术后平均胃肠功能恢复时间分别为２.９天和３.９天（Ｐ＜０.０５）;腹腔镜手术组术中无脏器损伤,术后无出血、吻合口漏及肺部感染等并发症,无手术死亡病例。结论　腹腔镜下胃癌根治术安全、可行,与开放性胃癌根治术具有相同的淋巴结清扫范围。     

Results of total gastrectomy with extended lymphadenectomy for gastric cancer in elderly patients

BACKGROUND AND OBJECTIVES: The incidence of gastric cancer, in people over 70 years of age, has increased remarkably. Aggressive lymphadenectomy with gastrectomy has been reported to improve survival in patients with gastric cancer. Because complication rates following gastrectomy increase with advancing age, we sought to determine whether this procedure was merited in elderly patients with gastric cancer. METHODS: We performed a retrospective analysis of 202 patients who underwent total gastrectomy with extended lymphadenectomy for gastric carcinoma. Postoperative complication rates were compared between patients over and under 70 years of age. RESULTS: The 10-year survival rates of patients under and over 70 years of age following total gastrectomy with extended lymphadenectomy were not significantly different. Although medical comorbidities in each group were similar, pulmonary dysfunction was significantly more common following total gastrectomy in patients over 70 years than in patients under 70 years. Moreover, logistic regression analysis revealed that patient's age was the only variable that independently correlated with the presence of postoperative complications. CONCLUSIONS: The prognosis of the gastric cancer patients over 70 years of age was similar to that of younger patients after total gastrectomy with extensive lymphadenectomy. However, pulmonary dysfunction was significantly more common in patients over 70 years old.     

腹腔镜辅助下远端胃大部切除术治疗早期胃癌的系统评价

目的:评价腹腔镜辅助下远端胃大部切除术(laparoscopy-assisted distal gastrectomy,LADG)治疗早期胃癌的安全性及有效性。方法:本研究从MEDLINE、EMBASE、中国生物医学数据库(CBM)及Cochrane试验注册中心检索并纳入了在1991年-2007年3月间发表的LADG治疗早期胃癌的随机对照试验,并对纳入研究的方法学质量(随机、双盲和对照)进行评价,最后用Revman4.2.9软件进行分析。结果:共纳入4个随机对照试验(randomized controlled trials,RCT),包括123例患者。与开腹远端胃大部切除术(open distal gastrectomy,ODG)相比,LADG术后并发症少[OR(odd ratio)0.32,95%CI(confidenceinterval)(0.14,0.71)]、术中出血少[WMD(weight mean difference)-85.72,95%CI(-166.87,-4.58)]、止痛剂的使用次数少[WMD-1.69,95%CI(-2.18,-1.21)]、术后第1次排气时间早[WMD-0.68,95%CI(-1.26,-0.09)];住院时间、切口或吻合口并发症、复发率、转移、死亡率和生存率无明显差异。淋巴结清扫数少于或与ODG相当。但是,LADG手术时间长于ODG。结论:LADG治疗早期胃癌的近期效果优于ODG,远期效果和ODG相当。     

Evaluation of Intraoperative Radiotherapy for Gastric Carcinoma

OBJECTIVE To study the proper sites and doses of intraoperative radiotherapy (IORT) for gastric carcinoma and the effects of this treatment.METHODS A total of 106 cases of stage Ⅰ- Ⅳ gastric carcinoma who received a D2 or D3 radical resection operation combined with IORT were analyzed. Sixty-seven patients with gastric cancer of the antrum and body received distal gastrectomy. The sites of irradiation were at the celiac artery and hepatoduodenal ligament area. Another 39 patients with carcinoma of the cardia and upper part of the gastric body and whole stomach received proximal gastrectomy or total gastrectomy. The sites of irradiation for this group were the upper margin of the pancreas and the regional paraaorta.The therapeutic effects (including survival and complications) of these 106cases who received a combined operation IORT (IORT group) were compared with 441 cases treated during the same time period by a radical resection operation alone (operation group).RESULTS The radiation dose below 30 Gy was safe. The therapeutic method of the operation combined with IORT did not prolong the survival time of patients with stage Ⅱ and Ⅳ gastric cancer, but the 5-year survival rates of patients with stage Ⅱ and Ⅲ gastric cancers were significantly improved.While the 5-year survival rates of the stage Ⅲ cancer patients receiving D2 resection combined with IORT had marked improvement, for those receiving a D3 radical resection, only the postoperative survival rates at 3 and 4 years of those cases in stages Ⅲ cancers were improved (P＜0.005-0.001). The 5-year survival rate for those patients was raised only 4.7%(P＞0.05).CONCLUSION The 5-year survival rates of patients with stages Ⅱ and Ⅲ gastric carcinoma who received a D2 lymphadenectomy combined with IORT were improved and had no influence on the postoperative complications and mortality.     

Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy--Japan Clinical Oncology Group study 9501.

PURPOSE: Radical gastrectomy with regional lymphadenectomy is the only curative treatment option for gastric cancer. The extent of lymphadenectomy, however, is controversial. The two European randomized trials only reported an increase in operative morbidity and mortality, but failed to show survival benefit, in the D2 lymphadenectomy group. We conducted a randomized controlled trial to compare the Japanese standard D2 and D2 + para-aortic nodal dissection. PATIENTS AND METHODS: Only experienced surgeons in both procedures from 24 Japanese institutions participated in the study. Patients with potentially curable gastric adenocarcinoma (T2-subserosa, T3, or T4) who were surgically fit were intraoperatively randomized. Postoperative morbidity and hospital mortality were recorded prospectively in a fixed format and were compared between the two groups in this study. RESULTS: A total of 523 patients were randomized between July 1995 and April 2001. Postoperative complications were reported in 24.5% of all patients. Although the morbidity for the extended surgery group (28.1%) was slightly higher than the standard group (20.9%), there was no difference in the incidence of four major complications (anastomotic leak, pancreatic fistula, abdominal abscess, pneumonia) between the two groups. Hospital mortality was reported at 0.80%: one patient in each group died of operative complications, while one from each group died of rapid progressive cancer while inpatient. CONCLUSION: Specialized surgeons could safely perform gastrectomy with D2 lymphadenectomy in patients with low operative risks. Para-aortic lymphadenectomy could be added without increasing major surgical complications in this setting.     

Feasibility of laparoscopy-assisted total gastrectomy in patients with clinical stage I gastric cancer

Background

Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer is not yet widespread because of the technical difficulty of reconstruction. We have performed LATG on 100 patients with clinical stage I gastric cancer. This study investigated the short-term outcomes of LATG.

Methods

Between September 2001 and September 2012, 100 patients with clinical stage I gastric cancer underwent LATG with D1 plus beta or D2 lymphadenectomy. Roux-en-Y esophagojejunostomy was performed intracorporeally using end-to-side anastomosis with a circular stapler (the purse-string suture method). The primary endpoint was the proportion of postoperative complications during hospitalization.

Results

Mean operation time was 249 min; mean blood loss was 182 ml. There were no conversions to open surgery. According to the Clavien–Dindo classification, there were 8 grade II (8 %) and 10 grade IIIa/b (10 %) complications. There were no treatment-related deaths or grade IV complications. The most frequent complication was anastomotic or stump leakage (6 %), followed by pancreatic fistula (5 %). Reoperations were required in two patients with leakage.

Conclusions

The short-term outcomes of LATG in our study involving 100 patients were outlined. LATG for gastric cancer patients should be attempted preferably in a clinical trial setting by surgeons with sufficient experience in laparoscopic gastrectomy.     

充气式保温毯对腹腔镜胃癌根治术患者术中体温及围术期预后的影响

目的:探讨充气式保温毯对腹腔镜胃癌根治术患者术中体温、低体温发生率、麻醉苏醒期气管插管拔管时间、并发症发生率以及住院时间的影响。方法:采取横断面整群抽样的方法选取西安市某三甲医院手术室行腹腔镜胃癌根治术的患者98例,根据随机数字表法将试验对象分为试验组与对照组,每组49例。比较两组患者术中体温、低体温发生率、麻醉苏醒期气管插管拔管时间、并发症发生率以及住院时间。结果:试验组患者术中体温、低体温发生率、麻醉苏醒期气管插管拔管时间、并发症发生率以及住院时间均优于对照组,两组间有统计学差异（P＜0.05）。结论:充气式保温毯可减轻腹腔镜胃癌根治术患者术中体温降低、降低低体温发生率、缩短麻醉苏醒期气管插管拔管时间、减少并发症发生率以及缩短住院时间,为保障患者围术期安全及预后提供参考依据。     

完全腹腔镜全胃切除治疗家族性胃癌与普通胃癌的预后疗效对比

目的 对比完全腹腔镜全胃切除治疗家族性胃癌与普通胃癌的预后疗效。方法 2012年8月—2014年8月选择在我院进行诊治的普通胃癌患者60例作为对照组,同期选择收治的家族性胃癌患者40例作为观察组,都给予腹腔镜辅助下根治性全胃切除术。结果 两组手术时间、术中出血量、术后排气时间对比差异无统计学意义(P＞0.05),但观察组的术后住院时间与淋巴结清扫个数明显多于对照组(P＜0.001)。观察组术后发生并发症如腹腔感染、肺部感染、肠梗阻、手术吻合处出血等情况均明显少于对照组(P＜0.001)。术后1个月进行调查,观察组的吞咽困难、疼痛、焦虑、躯体外观和口干等评分明显高于对照组(P＜0.001)。结论 家族性胃癌具有独特的临床病理特点,相对于普通胃癌,完全腹腔镜全胃切除治疗家族性胃癌需要清扫更多的淋巴结,能造成更多的并发症,对于患者生活质量也有一定的影响。     

Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy

Background

The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications.

Methods

The study included 189 patients aged 70 years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien–Dindo classification, and risk factors related to postoperative complications were analyzed.

Results

The overall complication rate was 24.9 % (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8 %). Severe complications classified as grade III or above in the Clavien–Dindo grading system were found in 20 (10.6 %) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95 % CI, 1.706–15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95 % CI, 1.103–11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95 % CI, 1.378–18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients.

Conclusion

The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0 g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.     

The impact of obesity on LADG for early gastric cancer

Background Laparoscopy-assisted distal gastrectomy (LADG) has become a viable alternative treatment for patients suffering with early gastric cancer. Surgeons have long thought that obesity might increase the rate of intraoperative or postoperative complications. We set out to clarify the effect that obesity has on performing LADG for the treatment of early gastric cancer. Methods We retrospectively reviewed 97 patients who had undergone LADG for early gastric cancer between May 1998 and March 2004. We measured the degree of obesity by using the body mass index (BMI; kg/m²), and we compared the surgical outcomes between the normal BMI group (BMI < 23 kg/m²) and the high BMI group (BMI ≥ 23 kg/m²). We further subdivided the patients into four groups: normal BMI males and normal BMI females, and high BMI males and high BMI females, and we analyzed them in terms of operation times, numbers of retrieved lymph nodes, and rates of postoperative complications. Results There were no significant differences between the normal and high BMI groups in terms of the patients' characteristics, surgical outcomes, postoperative courses, postoperative complications, and operation times. There were no statistically significant differences in the number of retrieved lymph nodes or in the rate of postoperative complications among the four groups (P = 0.5030 and P = 0.3489, respectively). However, there was a statistically significant difference in operation times among the four groups (P = 0.004). Specifically, the males in the high BMI group required a longer operation time than did the females with a normal BMI (P = 0.006) and the females with a high BMI (P = 0.019). Conclusions For LADG in patients with early gastric cancer, obesity may affect the operation time, and men with high BMI require a longer operation time than do women with normal or high BMI.     

A prospective feasibility and safety study of laparoscopy-assisted distal gastrectomy for clinical stage I gastric cancer initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery

Background

The aim of this prospective study was to evaluate the feasibility and safety of laparoscopy-assisted distal gastrectomy (LADG) initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery.

Methods

Three surgeons who each had experience with more than 300 cases of open gastrectomy, more than 100 cases of laparoscopic cholecystectomy, more than 5 cases of laparoscopic colectomy, and more than 5 cases of laparoscopic partial gastrectomy were nominated as LADG operators. All three operators received training for LADG with study materials including videotapes, a box simulator, and an animal laboratory, with lectures and assistance from LADG instructors who each had experience of more than 50 LADG operations. Then the nominated LADG operators performed LADG with the instructors, in which their skills were evaluated and certified. Thereafter, they performed LADG without assistance from the instructors. The target of this study was clinical stage I gastric cancer that was resectable by distal gastrectomy. D1 + alpha, D1 + beta, or D2 dissection was performed laparoscopically. Basically reconstruction was done extracorporeally with a Billroth-I gastroduodenostomy. An extramural review board checked the surgical quality of the operations performed by the three surgeons. The primary endpoint was morbidity and mortality.

Results

A total of 193 patients were enrolled in this study between August 2004 and July 2009. The median blood loss was 35 ml and the median operation time was 250 min. Conversion to open surgery was seen in 6 patients; 4 due to bleeding and 2 due to advanced disease. Overall morbidity was 1.6 %, including grade 2 anastomotic leakage in 0.5 % and grade 2 pancreatic fistula in 0.5 %. No mortality was observed. The number of cases required until the LADG operators acted as LADG surgeons without an instructor was 3 for each of the three surgeons. When comparing the data between that in the training period (n = 9) and the operators’ data (n = 174), the median operation time was significantly longer in the training period (355 min) than in the latter period (247.5 min) (p = 0.015). Median blood loss was also greater in the training period (150 ml) than the latter period (32.5 ml), but the difference did not reach statistical significance (p = 0.084). During the training period, no patient developed any complications of ≥grade 2.

Conclusion

These results suggested that LADG could be initiated and performed feasibly and safely if surgeons with much experience of open gastrectomy and laparoscopic surgery received adequate training for LADG.     

Improvements in quality of life and survival of patients with T4 gastric cancer which invaded organs after multivisceral resections through the extension of palliative gastrectomy and post-operative chemotherapy

For patients with a locally advanced gastric cancer, palliative gastrectomy could improve local complications, such as bleeding or obstruction, but had no impact on prognosis. This study was designed to evaluate improvements in quality of life and survival of patients with T4 gastric cancer which invaded organs exhibiting bleeding or obstruction, after multivisceral resections of these organs through the extension of palliative gastrectomy and postoperative chemotherapy. Multivisceral resections were performed on 6 patients with T4 gastric cancer with local complications, such as bleeding or obstruction, at the Department of Surgery of Fujisaki hospital from 2003-2005. The sites of the organs invaded were the pancreas in five cases, and transverse colon and gallbladder in one case. The invaded organs were resected completely in five cases, and partially in one case. Surgical margins were microscopically negative in four cases. Anatomical leakage (sutured failure) occurred to none of the patients. All in all, the oral ingestion after the surgery went well. Chemotherapy (TS-1 plus CDDP) was started with 3 patients during their stay in the hospital. In addition, post-operative chemotherapy (TS-1) at the outpatient clinic was performed on 5 of the 6 patients. More than 1 year of the performance test (PS 0 or 1 in ECOG) went well for 4 patients. Two of the 4 patients could resume their work. The median survival time was more than 419.5 days. In conclusion, we consider that multivisceral resections through the extension of palliative gastrectomy and postoperative chemotherapy for patients with T4 gastric cancer could improve quality of life and prognosis.     

Systemic Analysis on Laparoscope-Assisted Gastrectomy for Patients with Gastric Cancer

Background: Laparoscope-assisted gastrectomy in treating patients with gastric cancers developed witha background of highly invasive traditional surgery and is being increasingly performed in the Asian Pacificarea. This study systemically investigated the technique and clinical results for comparison with traditionalradical subtotal gastrectomy for gastric cancers. Methods: Clinical studies evaluating the effectiveness andside effects of laparoscope-assisted gastrectomy in treating patients with gastric cancers were identified using apredefined search strategy. Summary rates of effectiveness and side effects of laparoscope-assisted gastrectomywere calculated. Results: Thirteen clinical studies which including 1,412 patients with gastric cancer treated bylaparoscope-assisted gastrectomy were considered eligible for inclusion. Systemic analysis showed that, for allpatients, the pooled resection rate was 100%. Major adverse effects were anastomotic stenosis, abdominal abscess,abdominal bleeding, postoperative ileus. Treatment related death occurred in 0. 71% (10/1412). Conclusion:This systemic analysis suggests that laparoscope-assisted gastrectomy in treating patients with gastric cancersis associated with good curative rate and acceptable complications.     

Feasibility and Safety of Robotic Surgery for Gynecologic Cancers

Background: To determine surgical outcomes, perioperative complications, and patient outcomes in gynecologic cancer patients undergoing robotic surgery. Materials and Methods: Surgical outcomes, including docking time, total operative time, console time, estimated blood loss (EBL), conversion rate and perioperativecomplications were retrospectively reviewed in 30 gynecologic cancer patients undergoing robotic surgery. Patient outcomes included recovery time and patient satisfaction, as scored by a visual analogue scale (VAS) from 0-10. Results: The operations included 24 hysterectomies with pelvic lymphadenectomy (PLD) and/or para-aortic lymphadenectomy, four radical hysterectomies with PLD, and two radical trachelectomies with PLD. Mean docking time was 12.8±9.7 min, total operative time was 345.5±85.0 min, and console time was 281.9±78.6 min. These times were decreased in the second half of the cases. There was no conversion rate. Three intraoperative complications, including one external iliac artery injury, one bladder injury, and one massive bleeding requiring blood transfusion were reported. Postoperative complications occurred in eight patients, most were minor. Only one patient had port herniation that required reoperation. Mean hospital stay was 3.5±1.7 days, and recovery time was 14.2±8.1 days. Two-thirds of patients felt very satisfied and one-third felt satisfied; the mean satisfaction score was 9.4 +0.9. Two patients with stage III endometrial cancer developed isolated port site metastasis at five and 13 months postoperatively. Conclusions: Robotic surgery for gynecologic cancer appears to be feasible, withacceptable perioperative complication rate, fast recovery time and high patient satisfaction.     

进展期胃癌术中腹腔化疗临床疗效及安全性Meta分析

目的:探讨术中腹腔化疗在进展期胃癌手术治疗中的安全性及对生存率的影响。方法:检索中国期刊全文数据库(CNKI)、万方数据库、PubMed等数据库,发表时间为建库以来至2018年9月1日,文献的语种为中文和英文,应用Meta分析的方法,对纳入研究的10篇文献进行研究,以单纯胃癌手术为对照组,以胃癌手术联合术中腹腔化疗为治疗组,比较两组患者在术后并发症及术后生存率,以判断进展期胃癌术中腹腔化疗的安全性及临床疗效。结果:纳入10篇文献,共有921例进展期胃癌患者,其中506名患者接受了胃癌根治术,415名患者在接受胃癌根治术的基础上行术中的腹腔化疗。与对照组相比,腹腔化疗在术后出血、术后感染、术后吻合口瘘及术后肠梗阻方面,差异无统计学意义（P=0.95、P=0.26、P=0.41,P=0.11）;在术后1年、2年、3年、5年生存率区别较明显,差异有统计学意义（P=0.003、P＜0.000 01、P＜0.000 01、P＜0.000 01）。结论:进展期胃癌术中应用腹腔化疗可提高患者术后生存率,并不增加术后并发症的发生率,临床有效且安全。     

Meta-analysis and systematic review on laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer: Preliminary study for a multicenter prospective KLASS07 trial

BackgroundThe curative surgical treatment of gastric cancer in the current laparoscopic surgical era relies on the surgeon's preference, technical difficulties, and concerns regarding outcome have led to the availability of totally laparoscopic distal gastrectomy (TLDG) and laparoscopic-assisted distal gastrectomy (LADG). A consensus on which of the two procedures is preferable is necessary. Therefore, the aim of this study was to evaluate the differences between LADG and TLDG in terms of surgical outcomes, postoperative recovery, pain, and complications.MethodsPubMed, Google Scholar, Medline, Embase, and Cochrane databases were explored up to 2017 to evaluate TLDG and LADG. Parameters including surgical outcomes, postoperative recovery, and postoperative complications were subjected to meta-analysis to calculate the odds ratio and weighted mean difference with 95% confidence intervals (c.i.).ResultsTwenty-five studies (24 non-RCT and 1 RCT) with a total of 4562 gastric cancer patients were included in the meta-analysis. Under reconstruction-matched analysis, overall complications and anastomotic complications were similar for TLDG and LADG. Nevertheless, short-term outcomes such as blood loss, time to first soft diet, hospital stay, analgesic use, and CRP level were favourable for TLDG, while all other surgical outcomes showed no difference.ConclusionsTLDG and LADG did not show significant differences in surgical outcomes and postoperative complications, including anastomotic-related morbidity. Therefore, decisive factors in selecting surgical procedures, which previously consisted of surgical outcomes, have been superseded by extra-surgical values such as cosmesis, economics, and patient's quality of life. These factors will be explored in a future multicentre prospective study (KLASS07 trial).     

A novel procedure for Roux-en-Y reconstruction following laparoscopy-assisted distal gastrectomy: transoral placement of anvil and intracorporeal gastrojejunostomy via umbilical mini-laparotomy

We describe herein our procedures for Roux-en-Y reconstruction using a transoral anvil following laparoscopy-assisted distal gastrectomy (LADG). The procedure consists of three technical processes: transoral placement of the anvil with the head pre-tilted, extracorporeal preparation of the Roux-en-Y limb, and intracorporeal gastrojejunostomy with a circular stapler introduced via an umbilical mini-laparotomy. We applied the procedure to 33 patients with early gastric cancer between December 2008 and June 2010. None of the patients suffered from surgical complications related either to the transoral placement of the anvil or the anastomoses. The postoperative wound appearance was much less conspicuous than that of conventional laparoscopic distal gastrectomy, because our procedure needed only a 4-cm mini-laparotomy on the umbilicus, except for the trocar ports. This technique involving transoral anvil placement enables intracorporeal anastomosis for gastrojejunostomy via an umbilical mini-laparotomy, and may be one of the surgical choices for anastomosis and Roux-en-Y reconstruction following LADG.