Postoperative Situations Research Articles

Application value of the fusiform tube stomach in the digestive tract reconstruction after thoracoscopic and laparoscopic radical resection of esophageal carcinoma

Objective To explore the application value of the fusiform tube stomach in the digestive tract reconstruction after thoracoscopic and laparoscopic radical resection of esophageal carcinoma. Methods The retrospective cohort study was conducted. The clinicopathological data of 96 patients with thoracic esophageal cancer who were admitted to the First Affiliated Hospital of Zhengzhou University between November 2016 and May 2017 were collected. All the patients underwent thoracoscopic and laparoscopic radical resection of esophageal carcinoma, 45 using thin tubular stomach and 51 using fusiform tube stomach for digestive tract reconstruction were respectively allocated into the tubular stomach group and fusiform stomach group. Observation indicators: (1) intra- and post-operative situations; (2) postoperative complications; (3) detection of gastric hemodynamics; (4) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect patients′ survival up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M (range) and comparison between groups was analyzed using the rank sum test. Ordinal data and categorical variables were respectively done using the independent-sample Wilcoxon rank-sum test and chi-square test. Paired experimental data were analyzed by the Friedman test and Wilcoxon test. Results (1) Intra- and post-operative situations: 96 patients underwent successful thoracoscopic and laparoscopic radical resection of esophageal carcinoma. The number of closers, time of postoperative mediastinal tube removal, thoracic stomach anteroposterior diameter by postoperative CT examination, number of slices at maximal width of thoracic stomach by postoperative CT examination and duration of hospital stay were respectively 4 (range, 3-5), 14 days (range, 11-45 days), 28.35 mm (range, 9.96-75.70 mm), 0.56 (range, 0.33-2.13), 16 days (range, 12-62 days) in the tubular stomach group and 4 (range, 2-4), 12 days (range, 10-16 days), 45.80 mm (range, 17.36-89.77 mm), 1.10 (range, 0.47-2.15), 14 days (range, 12-61 days) in the fusiform stomach group, with statistically significant differences between groups (Z=4.525, 4.240, -3.796, -4.604, 2.154, P 0.05). Conclusion Compared with the thin tubular stomach, the fusiform tube stomach can reduce the incidences of postoperative fistula and pulmonary complications and shorten duration of hospital stay after the thoracoscopic and laparoscopic radical resection of esophageal carcinoma, and hemodynamics of the fusiform tube stomach is superior to that of thin tubular stomach. Key words: Esophageal neoplasms; Radical resection; Thoracoscopy; Laparoscopy; Fusiform tube stomach; Complications

Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type II and III adenocarcinoma of the esophagogastric junction: a prospective randomized controlled study

Objective To investigate the clinical efficacy of jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG). Methods The prospective study was conducted. The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected. All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table, including patients using single-tract jejunal interposition reconstruction in the single-tract group and patients using double-tract jejunal interposition reconstruction in the double-tract group. Digestive tract reconstruction: after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum, single-tract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma, and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the single-tract group. Patients in the double-tract group used the same digestive tract reconstruction, but jejunum was not ligated. The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy. Observation indicators: (1) intra- and post-operative situations; (2) follow-up situations. Follow-up using telephone interview was performed to detect postoperative complication, gastrointestinal function and body mass index (BMI) up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the nonparametric test. Repeated measurement data were analyzed by the repeated measures ANOVA. Comparisons of count data were done using chi-square test. Ordinal data were analyzed by the Kruskal Wallis H test. Results One hundred and eight patients were screened for eligibility, including 55 in the single-tract group and 53 in the double-tract group. (1) Intra- and post-operative situations: total operation time, digestive tract reconstruction time, volume of intraoperative blood loss, time to initial anal exsufflation, postoperative complications, cases with gastroesophageal reflux, intestinal obstruction and Visick grading > Ⅱ and duration of postoperative hospital stay were respectively (145±26)minutes, (30±6)minutes, (181±37)mL, (53±16)hours, 1, 1, 1, (10.0±2.4)days in the single-tract group and (139±29)minutes, (26±3)minutes, (176±31)mL, (50±17)hours, 3, 0, 3, (9.4±1.4)days in the double-tract group, with no statistically significant difference between groups (t=0.725, 0.219, 0.162, -0.576, χ2=2.960, 5.830, t=-0.993, P>0.05). Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks, and were improved by symptomatic treatment such as increasing the solid food intake. One patient in the single-tract group had internal hernia-induced intestinal obstruction and was cured by reoperation. There was no anastomotic leakage, bleeding, infection, dumping syndrome and gallstone between groups. Of 108 patients, 71 underwent 6-cycle SOX chemotherapy, including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall. (2) Follow-up situations: 108 patients were followed up for 12.0-48.0 months, with a median time of 28.6 months. During the follow-up, bowel sound in the double-tract group and single-tract group was 8 times / minute (range, 5-12 times / minute) and 3 times / minute (range, 2-5 times / minute), with a statistically significant difference between groups (Z=-0.692, P 0.05). There was a statistically significant difference in changing trend of BMI between groups (F=24.930, P<0.05). Conclusion Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don′t affect secretion function of gastric remnant, but there are frequent bowel sounds and obvious weight loss. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Proximal gastrectomy; Siewert type Ⅱ; Siewert type Ⅲ; Digestive tract reconstruction; Single-tract; Double-tract

Application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric carcinoma

Objective To investigate the application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 6 patients with esophageal and gastric cancer who were admitted to the General Hospital of Jinan Military Area of PLA between January 2013 and December 2016 were collected. Among 6 patients, 2 and 4 were respectively confirmed as mid-thoracic and low esophageal cancers; tumors of 4 and 3 patients were respectively located in the gastric antrum and gastric body at lesser curvature side, including 1 with tumor in the gastric antrum and body. Esophageal cancer and gastric tumor were simultaneous resected, and proximal stomach replaced esophagus resected, with a blood-supply through right gastroepiploic vessels. There was an anastomosis between proximal tubular stomach and esoghagus. According to resection extent of resection extent, distal anastomosis included: (1) tubular stomach-duodenum BillrothⅠ anastomosis in case 1; (2) tubular stomach-jejunum Billroth Ⅱ anastomosis in case 2, 3 and 4; (3) tubular stomach-jejunum Billroth Ⅱ anastomosis + jejunum-jejunum side-to-side anastomosis in case 5 and 6. Observation indicators: (1) intra- and post-operative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and quality of life up to May 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative recovery situations: 6 patients underwent successful operation. The operation time, volume of intraoperative blood loss, gastrointestinal function recovery time, drainage-tube removal time and duration of hospital stay were respectively (206±50)minutes, (106±24)mL, (3.8±2.1)days, (6.8±5.0)days and (12.5±4.2)days. Of 6 patients, 1 with postoperative aspiration pneumonia and 1 with incomplete intestinal obstruction were cured by medical treatment. There was no anastomotic complication. (2) Postoperative pathological examination: number of lymph node dissectted of 6 patients was 13±3. Case 2 had intra-abdominal lymph node metastasis. Pathological type: esophageal cancers were comfirmed as squamous cell carcinomas, gastric tumor were comfirmed as adenocarcinomas in 5 patients and stromal tumor were in 1 patient. (3) Follow-up and survival situations: 6 patients were followed up for 5-28 months, with a median time of 14 months. During the follow-up, case 1 had severe symptom of reflux, and other 5 patients didn′t have symptoms of reflux. Case 2 died of abdominal metastasis at 11 months postoperatively, and other 5 patients had survival. Conclusion Tubular gastric interposition replacing esophagus resected is safe and feasible in esophageal and gastric cancer, easy to operate and consistent with the physiological characteristics, meanwhile, it will provide opportunities and options of radical resection. Key words: Esophageal neoplasms; Gastric neoplasms; Radical resection; Tubular stomach; Interposition; Digestive tract reconstruction

Clinical efficacy of endoscopic resection versus laparoscopic resection and open resection for gastric stromal tumor

Objective To investigate the clinical efficacy of endoscopic resection, laparoscopic resection and open resection in the treatment of gastric stromal tumor (GIST). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 254 GIST patients who were admitted to the First Affiliated Hospital of Army Medical University between January 2007 and June 2017 were collected. The endoscopic submucosal dissection (ESD) and laparoscopic or open wedge resection of GIST were performed according to the patients′ conditions. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy and survival up to June 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery situations: of 254 patients, 112 underwent ESD, including 111 with successful operation and 1 with intraoperative conversion to open surgery due to excessive bleeding-induced blurred operating view, 93 underwent successful laparoscopic wedge resection of GIST and 49 underwent successful open wedge resection of GIST. The operation time, volume of intraoperative blood loss, time for initial fluid diet intake, duration of hospital stay and hospital expenses were respectively (75±21) minutes, (6.9±0.5)mL, (2.8±0.9)days, (5.5 ± 0.2)days, (22 167±1 364)yuan in patients with ESD and (137±65)minutes, (48.1±2.6)mL, (3.9±1.4)days, (8.3 ± 2.2)days, (32 937±1 823)yuan in patients with laparoscopic operation and (168±60)minutes, (157.2±10.3)mL, (5.8±1.7)days, (11.3±3.5)days, (38 462±1 961) yuan in patients with open operation. Two patients with ESD had subcutaneous emphysema and didn′t receive special treatment, and then emphysema disappeared after 2 days. No complication was detected in patients with laparoscopic or open operations. (2) Postoperative pathological examination: tumor diameter in patients with ESD, laparoscopic operation and open operation was respectively (2.6±1.6)cm, (6.1±2.2)cm and (6.4±2.3)cm. The cases with positive CD117, discovered on GIST-1 (DOG1), CD34 and smooth muscle actin (SMA) were 106, 105, 86, 17 with ESD and 89, 87, 59, 11 with laparoscopic operation and 46, 47, 30, 8 with open operation, respectively. The extremely low risk, low risk, medium risk and high risk were respectively detected in 67, 42, 3, 0 patients with ESD and 16, 36, 23, 18 patients with laparoscopic operation and 7, 20, 14, 8 in patients with open operation. (3) Follow-up and survival situations: 210 of 254 patients were followed up for 6.0-120.0 months, with an average time of 36.0 months, including 86 with ESD, 82 with laparoscopic operation and 42 with open operation. During the follow-up, of patients with ESD, 3 patients with medium risk respectively received imatinib therapy for 7.0 months, 1.5 years and 2.0 years, and postoperative gastroscopy reexaminations every 6 months, without tumor recurrence; 81 with extremely low risk and low risk received postoperative gastroscopy reexaminations every 6 months and didn′t receive targeted therapy, without tumor recurrence; 2 died of non-stromal tumor. The postoperative average survival time, 1-, 3- and 5-year survival rates were respectively 56.3 months, 98.8%(81/82), 91.5%(75/82), 74.4% (61/82) in patients with laparoscopic surgery and 52.4 months, 97.6%(41/42), 85.7% (36/42), 81.0%(34/42) in patients with open surgery. Conclusions According to patients′ conditions, endoscopic resection, laparoscopic resection and open resection are safe and feasible in the treatment of GIST. Endoscopic resection of GIST should be selectively applied to patients with smaller diameter, with advantages of lower hospitalization expenses and better long-term prognosis. Key words: Gastric neoplasms; Stromal neoplasms; Endoscopic submucosal dissection; Surgical procedures, operative; Open resection; Laparoscopy

Analysis of therapeutic effects between minimally invasive esophagectomy and open triple-incision esopha-gectomy

Objective To investigate the clinical efficacy of minimally invasive esophagectomy and open triple-incision esophagectomy for esophageal cancer (EC). Methods The retrospective cohort study was conducted. The clinicopathological data of 454 EC patients who were admitted to the Tianjin Medical University Cancer Institute and Hospital from January 2012 to September 2016 were collected. Of 454 patients, 229 undergoing thoracoscopic esophagectomy (194) or combined thoracoscopic + laparoscopic esophagectomy (35) were allocated into the minimally invasive group, and 225 undergoing open triple-incision esophagectomy in the left cervical, right chest and epigastric regions were allocated into the open group. Observation indicators: (1) intraoperative situations; (2) postoperative recovery situations; (3) stratified analysis; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative survival up to October 2017. Measurement data with normal distribution were represented as ±s, and t test was used for comparison between groups. Measurement data with skewed distribution were described as M (range), non-parametric test was used for comparison between groups. Count data were expressed as percentage, and the chi-square test or fisher exact probability method were used to test comparison between groups. Kaplan-Meier method was used to calculate survival rate and draw survival curve. Log-rank test was used for survival analysis. Results (1) Intraoperative situations: operation time, numbers of upper mediastina lymph node dissected and right laryngeal nerve lymph node dissected in stage 0-Ⅱ of TNM staging and numbers of neck lymph nodes dissected in stage Ⅲ of TNM staging were respectively (307±70)minutes, 4 (range, 0-18), 2 (range, 0-10), 0 (range, 0-24) in the minimally invasive group and (267±49)minutes, 3 (range, 0-15), 1 (range, 0-7), 0 (range, 0-46) in the open group, with statistically significant differences between groups (t=7.071, Z=-2.207, -2.717, -1.969, P 0.05). (4) Follow-up and survival situations: of 454 patients, 415 were followed up for 1-62 months, with a median time of 28 months. Among the 415 patients, operation time ≥ 3 years was detected in 162 patients, (77 in the minimally invasive group and 85 in the open group), and 3-year cumulative survival rates of the minimally invasive and open groups were 68.1% and 53.8%, showing no statistically significant difference between groups (χ2=3.293, P>0.05). Further subgroup analysis showed that postoperative 3-year cumulative survival rates of patients with the stage Ⅰ-Ⅱ and Ⅲ of TNM staging were respectively 82.1%, 53.7% in the minimally invasive group and 62.6%, 48.6% in the open group, showing no statistically significant difference between groups (χ2=2.664, 0.382, P>0.05). Conclusion Minimally invasive esophagectomy has some characteristics of less surgical trauma postoperative complications, and its resection effect is comparable to open esophagectomy. Key words: Esophageal neoplasms; Lymph node dissection; Survival rate; Thoracoscopy; Laparoscopy

Short-term outcome analysis of laparoscopic and open pancreaticoduodenectomy for pancreatic head cancer

Objective To explore the short-term outcome of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for pancreatic head cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 108 patients with pancreatic head cancer who were admitted to the Affiliated Tongji Hospital of Huazhong University of Science and Technology between July 2014 and July 2015 were collected. Among 108 patients, 47 and 61 who respectively underwent LPD and OPD were allocated into LPD and OPD groups. Observation indicators: (1) intraoperative situations; (2) postoperative situations; (3) postoperative pathological situations; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect chemotherapy and postoperative survival situations at 1 and 3 years postoperatively up to June 2018. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparison between groups of count data was analyzed using the chi-square test. Results (1) Intraoperative situations: operation time in the LPD and OPD groups was respectively (288±24)minutes and (265±29)minutes, with no statistically significant difference between groups (t=5.138, P>0.05). Volume of intraoperative blood loss in the LPD and OPD groups was respectively (136±14)mL and (388±21)mL, with a statistically significant difference between groups (t=-7.297, P 0.05). (2) Postoperative situations: of 47 patients in the LPD group, 16 with postoperative complications were improved by conservative treatment, including 7 with pancreatic fistula (5 with biochemical pancreatic fistula and 2 with grading B and C of pancreatic fistula); 4 with delayed gastric emptying were cured by gastrointestinal decompression and gastric motility promoting treatment; 2 with postoperative bleeding were improved by conservative treatment; 2 with intra-abdominal infection were improved by enhanced antibiotic therapy and transabdominal percutaneous drainage; 1 with biliary fistula was improved by transabdominal percutaneous drainage; there was no wound infection and perioperative death. Of 61 patients in the OPD group, 28 with postoperative complications were improved by conservative treatment, including 12 with pancreatic fistula (9 with biochemical pancreatic fistula and 3 with grading B and C of pancreatic fistula); 8 with delayed gastric emptying were cured by gastrointestinal decompression and gastric motility promoting treatment; 3 with intra-abdominal infection were improved by enhanced antibiotic therapy and transabdominal percutaneous drainage; 2 with postoperative bleeding were improved by conservative treatment; 2 with wound infection were cured by conservative treatment; 1 with biliary fistula was improved by transabdominal percutaneous drainage; there was no perioperative death. There was no statistically significant difference in the cases with postoperative complications between groups (χ2=1.546, P>0.05). Duration of hospital stay in the LPD and OPD groups was (13.6±2.1)days and (19.3±4.4)days, respectively, with a statistically significant difference (t=-4.354, P 0.05), and there was 1 patient with R1 resection in the OPD group. The total number of lymph node dissected in the LPD and OPD groups was respectively 19±4 and 13±4, with a statistically significant difference (t=-4.126, P 0.05). (4) Follow-up and survival situations: 44 and 55 patients in the LPD and OPD group respectively underwent postoperative adjuvant therapy during the follow-up, with no statistically significant difference (χ2=0, P>0.05). The postoperative 1-year follow-up: 47 patients in the LPD group were followed up, 37 survived and 10 died; of 61 patients in the OPD group, 3 lost to follow-up, and 58 were followed up (43 survived and 15 died); there was no statistically significant difference in survival between groups (χ2=0.301, P>0.05). The postoperative 3-year follow-up: of 47 patients in the LPD group, 3 lost to follow-up, and 44 were followed up (21 survived and 23 died); of 61 patients in the OPD group, 6 lost to follow-up, and 55 were followed up (23 survived and 32 died); there was no statistically significant difference in survival between groups (χ2=0.346, P>0.05). Conclusion LPD is safe and feasible for pancreatic head cancer, with advantages of less bleeding, shorter duration of hospital stay and more total number of lymph node dissected, and its survival effect is equivalent to that of OPD. Key words: Pancreatic neoplasms; Pancreatic head cancer; Pancreaticoduodenectomy; Short-term outcomes; Laparoscopy

Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected. The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements), and tumors of 13 patients were BR-A type (SMV, celiac trunk and / or hepatic artery involvements). The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection, the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway. Observation indicators: (1) intraoperative and postoperative situations; (2) results of postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018. Measurement data with skewed distribution were described as M (range). The survival curve was drawn by the Kaplan-Meir method, and Log-rank test was used for survival analysis. Results (1) Intraoperative and postoperative situations: 38 patients underwent intraoperative segmental resection of PV and / or SMV, including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis. Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ. There was no intraoperative celiac trunk resection. The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range, 280-520 minutes) and 530 mL (range, 420-650 mL). The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4%(7/38), and some patients were combined with multiple complications, including 6 with pulmonary infection, 4 with pancreatic fistula (B and C grade), 4 with intra-abdominal infection, 3 with delayed gastric emptying, 2 with postoperative bleeding and 2 with venous thrombosis. Five patients were cured by postoperative symptomatic treatment, and 2 with postoperative bleeding died of worsened condition after reoperation. The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3%(2/38) and 12 days (range, 9-52 days). (2) Results of postoperative pathological examination: the R0 resection rate of 38 patients was 81.6%(31/38). The R0 resection rate of 25 patients in BR-PV type was 92.0%(23/25), and resection margin of pancreatic leading edge < 1 mm was in 2 patients without R0 resection; R0 resection rate of 13 patients in BR-A type was 8/13, and resection margin of pancreatic leading edge < 1 mm was in 2 patients and resection margin of SMV < 1 mm was in 4 patients (1 margined with resection margin of multiple sites < 1 mm) of patients without R0 resection. The resection margins of pancreatic trailing edge, venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm. The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0%(25/25) and 9/13. (3) Follow-up and survival situations: 38 patients were followed up for 6-40 months, with a median time of 15 months, and survival time was 18 months (range, 6-40 months). The survival time and 1-, 2- and 3-year cumulative survival rates were respectively 23 months (range, 8-40 months), 89.5%, 33.1%, 22.1% in 25 patients with BR-PV type and 16 months (range, 6-25 months), 83.9%, 16.8%, 0 in 13 patients with BR-A type. The tumor-free survival time and 1- and 2-year cumulative tumor-free survival rates were respectively 15 months (range, 5-30 months), 63.0%, 7.5% in patients with BR-PV type and 9 months (range, 4-18 months), 11.5%, 0 in patients with BR-A type. Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements, pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV, and increase negative rates of venous and pancreatic resection margins. Key words: Pancreatic neoplasms; Borderline resectable pancreatic cancer; Resectable pancreatic neoplasms; Pancreaticoduodenectomy; Combined venous resection; Inferior mesenteric vein pathway

Clinical value of uncinate process resection combined with portal-superior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy

Objective To explore the clinical value of uncinate process resection combined with portal-superior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 11 patients who underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis in the Peking University Cancer Hospital (8 patients) and Jilin Guowen Hospital (3 patients) between January 2014 to April 2018 were collected. During the vascular reconstruction, uncinate process of the pancreas was first resected for reducing anastomotic tension, and then end-to-end anastomosis was done after portal-superior mesenteric vein resection. Observation indicators: (1) intraoperative situations; (2) postoperative recovery situations; (3) postoperative pathological examination situations; (4) follow-up and survival situations. Follow-up using outpatient examination and imaging examination was performed to detect patients′ postoperative survival, tumor recurrence and metastasis and postoperative venous anastomotic patency up to May 2018. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The non-recurrence and non-metastasis survival curve, overall survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method. Results (1) Intraoperative situations: 11 patients received uncinate process resection of the pancreas, and successfully underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis. Eight patients underwent distal pancreatectomy + Appleby combined with celiac axis resection due to pancreatic tumor involving common hepatic artery, including 2 undergoing combined total gastrectomy due to gastric ischemia; 2 patients underwent distal pancreatectomy; 1 patient underwent distal pancreatectomy + distal gastrectomy due to blood supply obstacle of distal stomach. Operation time and volume of intraoperative blood loss of 11 patients were (5.8±1.1)hours and 800 mL (range, 200-2 500 mL). (2) Postoperative recovery situations: there was no grade C of pancreatic fistula of 11 patients. Four patients had grade B of pancreatic fistula, including 2 were cured by drainage-tube indwelling of pancreatic wound > 3 weeks, 1 was cured by continous washing due to pancreatic fistula combined with infection, and 1 was cured by the second abdominal puncture drainage due to pancreatic fistula with fever; 1 of 4 patients was combined with grade C of delayed gastric emptying and cured by conservative treatment, and other 3 patients didn′t occur postoperative complications. Of 5 patients diagnosed as biochemical fistula, 1 had esophagus-jejunum anastomotic leakage, and 1 had changes of hepatic ischemia in S2, S3 and S4b segments by CT examination and recovered normal liver function at 2 weeks postoperatively, with long-term hepatatrophia in S2 and S3 segments. There was no postoperative death and reoperation in 11 patients. Duration of postoperative hospital stay of 11 patients was (22±5)days. (3) Postoperative pathological examination results: tumors of 11 patients were located in neck and body of the pancreas, with a maximum diameter of (4.8±1.7)cm. Among 11 patients, 10 were confirmed with moderate- or low-differentiated ductal adenocarcinoma and 1 with anaplastic carcinoma. The length of portal-superior mesenteric vein resection of 11 patients was (2.6±0.8)cm. Seven of 11 patients occurred different degrees of tumor infiltration in the portal-superior mesenteric vein, and other 4 patients occurred inflammatory adhesion, without tumor infiltration. (4) Follow-up and survival situations: 11 patients were followed up for 3.0-37.6 months, with a median time of 15.7 months. During the follow-up, 8 patients died of tumor recurrence and / or metastasis, and 3 survived; the non-recurrence and non-metastais survival time and overall survival time were respectively 9.0 months (range, 3.0-37.6 months) and 24.6 months (range, 3.0-37.6 months). One patient was complicated with anastomotic stenosis and surrounding varices of portal-superior mesenteric vein by postoperative half-year reexamination, anastomotic vein anomalies and venous thrombosis were not found in other patients before local tumor recurrence and / or death. Conclusion The combined uncinate process resection of the pancreas cannot increase the risk of postoperative pancreatic fistula, and it could effectively reduce the anastomotic tension in the distal pancreatectomy combined with portal-superior mesenteric vein resection and reconstruction, meanwhile, it can also achieve end-to-end anastomosis after longer vein resection. Key words: Pancreatic neoplasms; Distal pancreatectomy; Vascular resection; End-to-end anastomosis; Uncinate process resection of the pancreas

Short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy: a multicentre retrospective study (A report of 239 cases)

Objective To investigate the short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy (LADG). Methods The retrospective cohort study was conducted. The clinicopathological data of 239 gastric cancer (GC) patients undergoing LADG in the 5 medical centers between March 2016 and March 2018 were collected, including 104 in the First Affiliated Hospital of Xiamen University, 45 in Zhangzhou Affiliated Hospital of Fujian Medical University, 35 in Quanzhou Affiliated Hospital of Fujian Medical University, 30 in the Second Affiliated Hospital of Xiamen Medical College, 25 in Zhongshan Hospital of Xiamen University. Of 239 patients undergoing LADG + D2 lymph node dissection, 107 receiving duodenal transection and then lymph node dissection in the upper region of pancreas after lymph node dissection in the lower region of pylorus and 132 receiving lymph node dissection in the upper region of pancreas and then duodenal transection were respectively divided into anterior approach group and posterior approach group. Sixty-four, 8, 16, 14 and 5 patients in the anterior approach group and 40, 37, 19, 16 and 20 patients in the posterior group respectively came from the First Affiliated Hospital of Xiamen University, Zhangzhou Affiliated Hospital of Fujian Medical University, Quanzhou Affiliated Hospital of Fujian Medical University, Second Affiliated Hospital of Xiamen Medical College and Zhongshan Hospital of Xiamen University. Observation indicators: (1) surgical and postoperative situations; (2) postoperative complications; (3) stratified analyses of surgical and postoperative situations in patients with different TNM staging, body mass index (BMI) and maximum tumor dimension; (4) follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival and tumor recurrence or metastasis up to April 2018. Measurement data with normal distribution were represented as ±s, and comparison between groups was analyzed using the independent-samples t test. Measurement data with skewed distribution were described as M (Q), and comparison between groups was analyzed using the nonparametric test. Comparisons of count data were analyzed using chi-square test or Fisher exact probability. Comparison of ordinal data was done by the rank-sum test. Results (1) Surgical and postoperative situations: all the patients underwent successful operation, without perioperative death. Number of lymph node dissection in the upper region of pylorus in the anterior and posterior approach groups were respectively 3.9±2.6 and 3.0±2.5, with a statistically significant difference between groups (t=2.778, P 0.05). (2) Postoperative complications: cases with overall complications, anastomotic leakage, anastomotic stenosis, anastomotic bleeding, pancreatic fistula, postoperative gastroparesis, intra-abdominal hemorrhage, incision infection, pneumonia, intra-abdominal infection, bacteremia, intestinal obstruction, endolymphatic leakage, Clavien-Dindo grade Ⅰ, Ⅱ, Ⅲa, Ⅲb and Ⅳa of postoperative complications were respectively 15, 1, 1, 1, 0, 3, 1, 2, 3, 0, 1, 3, 0, 3, 9, 1, 2, 0 in the anterior approach group and 25, 3, 0, 1, 2, 2, 2, 5, 7, 3, 2, 3, 1, 6, 14, 1, 2, 2 in the posterior approach group, with no statistically significant difference between groups (χ2=1.027, 0.643, 0.022, 0.479, 0.161, 0.765, 0.921, 0.161, 0.063, Z=-1.055, P>0.05). Patients in 2 groups with complications were cured by symptomatic treatment. (3) Stratified analyses of surgical and postoperative situations in patients with different TNM staging, BMI and maximum tumor dimension: operation time, dissected times of lymph nodes in upper region of pancreas, cases with visible port vein, number of overall lymph node dissection, numbers of lymph node dissection in upper region of pylorus and upper region of pancreas were respectively (236.0±41.0)minutes, (33.9±6.2)minutes, 32, 36.0±12.0, 3.8±3.0, 13.4±5.5 in patients of the anterior approach group with Ⅲ stage of TNM staging and (253.0±45.0)minutes, (36.5±7.0)minutes, 29, 31.0±9.0, 2.5±2.0, 11.4±4.6 in patients of the posterior approach group with Ⅲ stage of TNM staging, with statistically significant differences between groups (t=-1.988, -2.066, χ2=4.686, t=2.472, 2.757, 2.016, P 0.05). Conclusions Both of anterior approach and posterior approach are safe and feasible in LADG, with equivalent short-term efficacies. The anterior approach in LADG has an advantage of the lymph node dissection in the upper region of pylorus compared with posterior approach, and it also is better for patients with later tumor staging, higher BMI and bigger tumor. Key words: Gastric neoplasms, distal; Radical resection; Duodenal transection timing; Surgical approach; Laparoscopy; Multicenters; Retrospective researches

Differences and comparison of prognostic evaluation between AJCC staging system 7th edition and 8th edition for gastric cancer(A report of 1 383 cases)

Objective To compare the differences and clinical value of prognostic evaluation between American Joint Committee on Cancer (AJCC) TNM staging system 7th edition and 8th edition for gastric cancer (GC). Methods The retrospective case-control study was conducted. The clinicopathological data of 1 383 GC patients who were admitted to the First People′s Hospital of Changzhou between January 2008 and August 2012 were collected. Distal gastrectomy, proximal gastrectomy + pyloroplasty or total gastrectomy were performed according to preoperative evaluation and intraoperative exploration. Observation indicators: (1) surgical and postoperative situations; (2) follow-up and survival situations; (3) T staging comparison between AJCC TNM staging system 7th edition and 8th edition; (4) N staging comparison of AJCC TNM staging system 8th edition; (5) prognostic analysis in N staging of AJCC TNM staging system 8th edition; (6) TNM staging comparison between AJCC TNM staging system 7th edition and 8th edition; (7) prognostic analysis in different TNM staging between AJCC TNM staging system 7th edition and 8th edition. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to October 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method, and the Log-rank test was used for survival analysis. Results (1) Surgical and postoperative situations: 1 383 GC patients underwent successful radical gastrectomy, including 923 with distal gastrectomy, 165 with proximal gastrectomy and 295 with total gastrectomy. Of 1 383 patients, 115 with postoperative complications were improved by symptomatic treatment, including 87 with surgical complications and 28 with non-surgical complications. Postoperative pathological examinations: total number of intraoperative lymph node dissection and number of lymph node metastasis were 25±12 and 7±4; 577 didn′t have lymph node metastasis and 806 had regional lymph node metastasis; 308 were in early GC and 1 075 in advanced GC. (2) Follow-up and survival situations: 1 383 patients were followed up for 1-117 months, with a median time of 34 months. The 1-, 3- and 5-year survival rates of 1 383 patients were respectively 90.5%, 71.9% and 61.1%. (3) T staging comparison between AJCC TNM staging system 7th edition and 8th edition: T staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. T staging of 1 383 patients: 308, 192, 65, 628 and 190 were respectively detected in T1, T2, T3, T4a and T4b stagings. (4) N staging comparison between AJCC TNM staging system 7th edition and 8th edition: N staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. N staging of 1 383 patients: 577, 255, 207, 230 and 114 were respectively detected in N0, N1, N2, N3a and N3b stagings. N3a and N3b were classified as N3 staging of AJCC TNM staging system 7th edition, but they were classified as independent staging of AJCC TNM staging system 8th edition. (5) Prognostic analysis in N staging of AJCC TNM staging system 8th edition: 5-year survival rate of patients in N0, N1, N2, N3a and N3b stagings was respectively 85.6%, 76.5%, 59.4%, 45.2% and 32.5% based on AJCC TNM staging system 8th edition, with a statistically significant difference in survival (χ2=394.400, P 0.05), betweenⅡA andⅡB stagings (χ2=0.265, P>0.05), and between ⅢB and ⅢC stagings (χ2=1.550, P>0.05). According to 8th edition, cases and 5-year survival rate were respectively 247, 89.5% in ⅠA staging and 147, 83.7% inⅠB staging and 77, 75.9% in ⅡA staging and 205, 70.7% in ⅡB staging and 288, 53.8% in ⅢA staging and 258, 37.3% in ⅢB staging and 161, 28.5% in ⅢC staging, with a statistically significant difference in survival among sub-stagings (χ2=234.900, P 0.05) and betweenⅡA andⅡB stagings (χ2=0.564, P>0.05). There was statistically significant differences in survival between ⅢA and ⅢB or ⅢC stagings (χ2=29.790, 43.060, P 0.05) and between T4aN3a and T4bN2 stagings (χ2=0.029, P>0.05). Conclusions Compared with AJCC TNM staging system 7th edition, N3a and N3b stagings are classified as independent staging in AJCC TNM staging system 8th edition, and 8th edition is more accurate in prognostic evaluation of GC patients in stage Ⅲ. Key words: Gastric neoplasms; American Joint Committee on Cancer; TNM staging; Survival; Prognosis

Application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy

Objective To investigate the application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy (LDG). Methods The retrospective cohort study was conducted. The clinicopathological data of 164 with early gastric cancer (GC) who were admitted to the First Affiliated Hospital of Fujian Medical University between June 2010 and April 2015 were collected. Of 164 patients undergoing LDG, 45 receiving BillrothⅠ (BⅠ) anastomosis, 39 receiving Billroth Ⅱ (BⅡ) anastomosis, 44 receiving Roux-en-Y anastomosis and 36 receiving uncut Roux-en-Y anastomosis were allocated into the BⅠ group, BⅡgroup, RY group and uncut RY group, respectively. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative short-term complications situations; (3) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative nutriology and long-term complications up to May 2017. Measurement data with normal distribution were represented as ±s. Comparison among groups was analyzed using the ANOVA, and pairwise comparisons were done by the Tukey hsd test. Count data were described as the frequency and percentage, and comparisons among groups were analyzed the chi-square test or Fisher exact probability. Ordinal data were analyzed by the Kruskal Wallis test. Results (1) Surgical and postoperative recovery situations: patients in 4 groups underwent successfully LDG. Cases undergoing total LDG and assisted LDG and digestive tract reconstruction time in the BⅠ, BⅡ, RY and uncut RY groups were respectively 0, 29, 13, 15 and 45, 10, 31, 21 and (42±7)minutes, (55±8)minutes, (64±8)minutes, (51±6)minutes, with statistically significant differences among 4 groups (χ2=21.628, F=74.441, P 0.05). (3) Follow-up situations: all patients were followed up, and follow-up time in the BⅠ, BⅡ, RY and uncut RY groups were respectively (10.8±3.5)months, (10.9±3.4)months, (11.3±3.2)months and (11.2±2.2)months, with no statistically significant difference among 4 groups (F=0.200, P>0.05). ① Comparisons of postoperative 1-year nutritional indexes: rates of changes in body mass index (BMI), hemoglobin (Hb), total protein (TP) and albumin were respectively 93%±7%, 91%±7%, 90%±7%, 90%±9% and 94%±9%, 97%±11%, 95%±9%, 97%±9% and 101%±9%, 99%±7%, 98%±7%, 99%±7% and 101%±10%, 103%±7%, 100%±10%, 103%±9% in the BⅠ, BⅡ, RY and uncut RY groups, showing no statistically significant difference among 4 groups (F=1.182, 0.724, 1.050, 0.971, P>0.05). ② Of 164 patients within 1 year postoperatively, 47 were complicated with gastric retention (27, 12, 6 and 2 with severity in grade 1, 2 , 3 and 4), 87 with residual gastritis (53, 24, 10 and 0 with severity in grade 1, 2 , 3 and 4), and 38 with bile reflux (severity in grade 1). Of 38 patients with bile reflux, 33 were combined with residual gastritis, showing a correlation between residual gastritis and bile reflux (r=0.396, P<0.05). Cases with gastric retention, residual gastritis and bile reflux within 1 year postoperatively were respectively 16, 9, 21, 1 and 35, 30, 13, 9 and 16, 18, 3, 1 in the BⅠ, BⅡ, RY and uncut RY groups, showing statistically significant differences among 4 groups (χ2=21.261, 41.103, 30.469, P<0.05). There were statistically significant differences in gastric retention occurrence between uncut RY group and BⅠgroup or BⅡgroup or RY group (χ2=12.958, 6.675, 20.065, P<0.05), and in residual gastritis occurrence between RY group and BⅠgroup or BⅡgroup (χ2=20.831, 18.587, P<0.05) and between uncut RY group and BⅠgroup or BⅡgroup (χ2=22.452, 20.220, P<0.05). There were statistically significant differences in bile reflux occurrence between RY group and BⅠgroup or BⅡgroup (χ2=10.942, 16.926, P<0.05), and between uncut RY group and BⅠgroup or BⅡgroup (χ2=12.958, 18.620, P<0.05). Conclusion Roux-en-Y and uncut Roux-en-Y anastomoses are superior to BⅠand BⅡanastomoses in improving residual gastritis and bile reflux in the postoperative digestive tract reconstruction of LDG, and uncut Roux-en-Y anastomosis can effectively reduce occurrence of postoperative gastric retention. Key words: Gastric neoplasms; Distal gastrectomy; Uncut Roux-en-Y anastomosis; Reflux gastritis; Gastric retention; Laparoscopy

Application value of π-shaped Roux-en-Y esophagojejunostomy in totally laparoscopic total gastrectomy

Objective To investigate the application value of π-shaped esophagojejunostomy in totally laparoscopic total gastrectomy. Methods The retrospective and descriptive study was conducted. The clinicopathological data of 3 patients who underwent totally laparoscopic total gastrectomy in the Beijing Friendship Hospital of Capital Medical University between October 2016 and March 2017 were collected. Patients received π-shaped Roux-en-Y esophagojejunostomy. Patients who were diagnosed with Ⅱ and above stages by pathological examination underwent postoperative adjuvant chemotherapy with oxaliplatin + tegafur gimeracil oteracil. Observation indicators: (1) surgical and postoperative recovery situations; (2) follow-up and survival situations. The follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy and survival up to March 2018. Results (1) Surgical and postoperative recovery situations: 3 patients underwent successfully totally laparoscopic total gastrectomy, and π-shaped Roux-en-Y esophagojejunostomy was also performed. Case 1 had injury of spleen vessel when No 11p lymph nodes were dissected and then received successful hemostasis, and case 2 and 3 didn′t have complication. Operation time, digestive tract reconstruction time, volume of intraoperative blood loss, time to anal exsufflation and postoperative drainage-tube removal time of case 1, 2 and 3 were respectively 376 minutes, 290 minutes, 284 minutes and 26 minutes, 30 minutes, 24 minutes and 500 mL, 100 mL, 200 mL and 2 days, 3 days, 3 days and 4 days, 4 days, 5 days. Case 3 with left pleural effusion was cured by puncture and drainage treating, and case 1 and 2 didn′t have complication. Three patients were not complicated with anastomotic stoma-related complicaions. Results of postoperative pathological examination: number of lymph node dissected and TNM staging of case 1, 2 and 3 were respectively 20, 17, 20 and T1aN0M0 staging, T3N3M0 staging, T1bN0M0 staging. Duration of hospital stay in case 1, 2 and 3 was respectively 7 days, 8 days and 11 days. (2) Follow-up and survival situations: 3 patients were followed up, and follow-up time of case 1, 2 and 3 was respectively 18 months, 16 months, 12 months. During the follow-up, case 2 received postoperative adjuvant therapy, and then underwent palliative treatment of Paclitaxel and Xeloda after the case was rechecked out multiple liver metastases at postoperative month 12. Case 1 and 3 had disease-free survival. Conclusion The π-Shaped esophagojejunostomy is safe and feasible for totally laparoscopic total gastrectomy, and it can be used as an alternative to digestive tract reconstruction. Key words: Gastric neoplasms; Total gastrectomy; Digestive tract reconstruction; Esophagojejunostomy; Laparoscopy

Application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy

Objective To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected. The main points of the modified Overlap method: surgeons stood on the right of patients when digestive tract reconstruction, suspension of left half liver and clockwise rotation before esophageal transection were performed, regulating esophageal opening position and building jejunal loop, and then closing openings using 45.0 mm Endo-GIA and barbed wire. Patients who were diagnosed as ⅠA stage by postoperative pathological examination were followed up; patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in ⅠB and Ⅱ stages without lymph node metastases underwent oral S-1 single agent. Observation indicators: (1) surgical and postoperative recovery situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy, long-term complications and survival up to March 2018. Measurement data with normal distribution were represented as ±s, and measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery situations: all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy. The operation time, esophagojejunostomy time, volume of intraoperative blood loss, time to initial anal exsufflation, time for initial fluid diet intake, time for initial semi-fluid diet intake and time of postoperative drainage-tube removal were respectively (227±19)minutes, (22±7)minutes, (69±11)mL, (2.1±0.5)days, (3.4±0.4)days, (4.9±0.6)days and (7.5±1.7)days. There was no anastomotic stoma-related complication in 32 patients. One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous three-cavity irrigation and conservative treatment. Results of postoperative pathological examination: number of lymph node dissected in 32 patients was 32±4. TNM staging: 1, 5, 7, 11, 6, 1 and 1 patients were detected respectively in ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB and ⅢC. Duration of postoperative hospital stay of 32 patients was (8.1±2.1)days. (2) Follow-up and survival situations: 32 patients were followed up for 3-38 months, with a median time of 18 months. During the follow-up, in addition to 1 patient in IA stage, 31 patients underwent postoperative adjuvant therapy; patients can take the common soft food, without symptoms of choking and burning feelings, and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency. One patient died of malignant tumor of maxillary sinus at 9 months postoperatively, 1 was detected liver metastasis at 20 months postopeartively and survived with tumor, the other patients had no tumor recurrence or metastasis. Conclusion The modified Overlap esophagojejunostomy is safe and feasible in TLTG, with good short-term outcomes. Key words: Gastric neoplasms; Gastric carcinoma, upper; Carcinoma of esophagogastric junction; Radical resection; Total gastrectomy; Digestive tract reconstruction; Esophagojejunostomy; Laparoscopy

Clinical efficacy of three-dimensional laparoscopic resection for gastric stump cancer

Objective To investigate the clinical efficacy of three-dimensional (3D) laparoscopic resection for gastric stump cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 20 patients who underwent 3D laparoscopic resection for gastric stump cancer in the Henan Provincial People′s Hospital between January 2015 and January 2018 were collected. All patients were diagnosed as malignant tumors through gastroscopy and pathological examination before operation, and underwent 3D laparoscopic resection for gastric stump cancer and lymph node dissection according to Japanese Classification of Gastric Carcinoma (ver. 14). Observation indicators: (1) intra- and post-operative recovery situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and tumor recurrence up to March 2018. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative recovery situations: of 20 patients with gastric stump cancer, 14 underwent 3D laparoscopic radical resection for gastric stump cancer (R0 resection and negative resection margin), 4 underwent 3D laparoscopic palliative resection for gastric stump cancer and 2 were converted to open palliative resection for gastric stump cancer. Operation time, volume of intraoperative blood loss, number of lymph node dissected, time for postoperative out-of-bed activity, time to initial anal exsufflation, time for postoperative semi-fluid diet intake, duration of hospital stay and treatment expenses in 18 patients were (195±60)minutes, (105±85)mL, 20±8, (1.6±0.8)days, (3.0±1.0)days, (5.5±1.8)days, (8.0±2.8)days and (5.5±1.5)×104 yuan, respectively. There was no surgery-related complication. (2) Follow-up and survival situations: of 20 patients, 18 were followed up for 2-36 months, with a median time of 18 months. During the follow-up, 6 patients died, including 2 dying of liver metastases and 4 dying of peritoneal metastases, 12 had good conditions. Conclusion 3D laparoscopic resection for gastric stump cancer is safe and effective. Key words: Gastric neoplasms; Gastric stump neoplasms; Surgical complications; Efficacy; Three-dimension; Laparoscopy

Application of ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in anatomical segmentectomy

Objective To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy. Methods The retrospective cross-sectional study was conducted. The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected. The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed, laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment, and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization, finally laparoscopic anatomical segmentectomy was performed. Observation indicators: (1) intraoperative situations: success rate of portal vein puncture, targeted hepatic segment, effect of ICG fluorescence staining, intraoperative complications, operation time, volume of intraoperative blood loss, blood transfusion, conversion to open surgery, tumor diameter, the minimum resection margin to tumor; (2) postoperative situations: postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay; (3) follow-up situations: cases with follow-up, follow-up time and postoperative tumor recurrence. Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018. Measurement data with normal distribution and count data were respectively described as average (range) and percentage. Results (1) Intraoperative situations: a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0%(26/26), and punctures in S8, S7, S2, S3, S6, S5 and S4 of the liver were respectively performed to 7, 6, 4, 3, 3, 2 and 1 patients. Of 26 patients, 22 achieved expected effect of ICG fluorescence staining, with a statisfaction of 84.6%(22/26) and 4 failed to get expected effect, including 2 with uneven dying, 1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary. All the 26 patients were not complicated with ICG injection induced to allergy. Average operation time and volume of intraoperative blood loss were 184 minutes (range, 60-315 minutes) and 97 mL (range, 10-400 mL), without intraoperative blood transfusion and conversion to open surgery. Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range, 1.2-10.0 cm) and 1.5 cm (range, 0.4-3.0 cm). (2) Postoperative situations: of 26 patients, 2 with gradeⅠ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion), no patient had grade Ⅲ and above complications, and there was no bile leakage, infection and hepatic dysfunction. Average duration of hospital stay in 26 patients was 6.9 days (range, 5.0-14.0 days). (3) Follow-up situations: 26 patients were followed up for 0.3-17.0 months, with a median time of 6.0 months. During the follow-up, 1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival. Conclusion Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach is safe and feasible, especially suitable in posterosuperior liver segments. Key words: Hepatic neoplasms; Anatomical hepatic segmentectomy; Laparoscopy; Interventional ultrasonography; Three-dimensional visualization; Portovenography; Indocyanine green

Application value of the adhesive suspension of left lateral lobe of liver in transumbilical single-port laparoscopic left upper abdominal surgery

Objective To investigate the application value of the adhesive suspension of left lateral lobe of liver in transumbilical single-port laparoscopic left upper abdominal surgery. Methods The retrospective cross-sectional study was conducted. The clinical data of 112 patients who underwent single-port laparoscopic left upper abdominal surgery in the Shengjing Hospital of China Medical University between January 2010 and October 2016 were collected. Patients underwent single-port laparoscopic left upper abdominal surgery, and intraoperative surgical fields were exposed through adhesive suspension of left lateral lobe of liver. Observation indicators: (1) intraoperative situations: surgical completion, surgical procedures, time of liver adhesive suspension, total operation time and intraoperative liver adhesive suspension-related complications; (2) postoperative situations: pre- and post-operative alanine transaminase (ALT) and aspartate transaminase (AST) levels, hospital expenses and duration of hospital stay; (3) follow-up: number of patients with follow-up, follow-up time, complications during follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Repeated measurement data were analyzed using the repeated measures ANOVA. Results (1) Intraoperative situations: 112 patients underwent successfully single-port laparoscopic left upper abdominal surgery, without conversion to multi-port surgery or open surgery. Of 112 patients, 30, 23, 13, 11, 11, 10, 3, 3, 3, 3, 1 and 1 underwent radical resection of gastric cancer, partial gastrectomy, esophageal Heller myotomy + Dor fundo-plication, subtotal gastrectomy, resection of body and tail of pancreas, paraoesophageal hiatal hernia repair + fundoplication, total gastrectomy, splenectomy, splenectomy + devascularization, pancreatic tail resection, simple fundoplication and splenic artery aneurysm resection, respectively. Time of liver adhesive suspension and total operation time in 112 patients were respectively (1.4±0.4)minutes and (192.0±91.3) minutes. There was no hepatic laceration, hepatic subcapsular hematoma and other complications. (2) Postoperative situations: of 112 patients, preoperative ALT and AST levels of 6 patients were mildly elevated, postoperative ALT and AST levels in 2 of 6 patients returned to normal, that in 1 of 6 patients were elevated at day 1 postoperatively and returned to normal at day 3 postoperatively, and that in 2 of 6 patients remained mildly elevated at week 1 postoperatively; preoperative ALT and AST levels of 106 patients were normal, ALT and AST levels in 31 of 106 patients were elevated at day 1 postoperatively (that in 28 patients returned to normal within week 1 postoperatively, and that in 3 patients remained mildly elevated), and that in 75 of 106 patients returned to normal. ALT and AST levels of 112 patients were (16±11)U/L, (18±7)U/L before operation and (31±21)U/L, (34±26)U/L at day 1 postoperatively and (19±17)U/L, (19±12)U/L at week 1 postoperatively, respectively, with statistically significant differences in ALT and AST levels before operation and at day 1 postoperatively (F=36.353, 29.792, P 0.05). Hospital expenses, surgery-related expenses and duration of hospital stay were (45 231±20 440)yuan, (23 511±9 609)yuan and (6.0±1.9)days, respectively. (3) Follow-up: 112 patients were followed up for 1.0-3.0 months, with a median time of 1.6 months. During the follow-up, there were no obvious complications. Conclusion Adhesive suspension of left lateral lobe of liver is simple and safe, with satisfactory exposure effects, and it is suitable for the better operative field exposure in single-port laparoscopic left upper abdominal surgery. Key words: Gastric neoplasms; Left lateral lobe of liver; Suspension, adhesive; Left hypochondriac region; Laparoscopy, single-port

Application value of secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail in laparoscopic partial splenectomy

Objective To investigate the application value of secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail in laparoscopic partial splenectomy. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 13 patients who underwent laparoscopic partial splenectomy in the Ningbo First Hospital from March 2016 to October 2017 were collected. After preoperative assessment using computed tomography(CT) angiography, 13 patients underwent laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail. Observation indicators: (1) intra- and post-operative recovery situations; (2) follow-up situations. Follow-up using outpatient examination was performed to detect postoperative changes of peripheral blood platelet (PLT), thrombosis of splenic vein, lesions residual or recurrence up to November 2017. Measurement data were represented as average (range). Results (1) Intra- and post-operative recovery situations: 13 patients underwent successful laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail, without conversion to open surgery, including 6 with laparoscopic partial splenectomy of inferior pole of the spleen and 7 with laparoscopic partial splenectomy of upper pole of the spleen. Operation time was 42-93 minutes, with an average of 61 minutes; volume of intraoperative blood loss was 30-260 mL, with an average of 92 mL; postoperative gastrointestinal function recovery time was 22-47 hours, with an average of 34 hours; postoperative drainage tube removal time was 3.0-6.0 days, with an average of 4.2 days. The postoperative pathological examination of 13 patients: 7, 2, 2, 1 and 1 patients were respectively confirmed with splenic cysts, splenic hemangiomas, vascular hemangiomas, splenic hamartoma and splenic lymphangioma. Of 13 patients, 1 was complicated with splenic recess effusion and fever, and was improved with B ultrasound-guided percutaneous catheter drainage. Duration of hospital stay of 13 patients was 7.0-16.0 days, with an average of 9.6 days. (2) Follow-up situations: 13 patients were followed up for 1.0-19.5 months, with a median time of 8.5 months. During the follow-up, PLT level of 13 patients was normal. Color Doppler ultrasound examination showed no venous embolism, and CT angiography showed good vascular perfusion. There was no recurrence of splenic cysts in 7 patients and no tumor residual or recurrence in 6 patients. Conclusion Laparoscopic partial splenectomy using secondary splenic pedicle separation technology through superior posterior approach of the pancreatic tail is safe and effective, and it can precisely dissect splenic hilum, preserve blood supply and function of the remnant spleen, and reduce surgical injury. Key words: Splenic neoplasms, benign; Partial splenectomy; Secondary splenic pedicle separation; Superior posterior approach of the pancreatic tail; Laparoscopy

Application value of the different lymph node staging system predicting prognosis of advanced gallbladder carcinoma

Application value of the different lymph node staging system predicting prognosis of advanced gallbladder carcinoma

Clinical effects of laparoscopic pancreaticoduodenectomy for distal cholangiocarcinoma

Objective To investigate the clinical effects of laparoscopic pancreaticoduodenectomy (LPD) for distal cholangiocarcinoma. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 37 patients who underwent LPD for distal cholangiocarcinoma in the Hunan Provincial People′s Hospital between January 2013 and November 2016 were collected. LPD for distal cholangiocarcinoma was performed using the en-block procedure. According to the principle of one axis, two planes and four zones , anatomy used posterior approach, anterior approach and medial approach, lymph node dissection was performed from carotid sheath outside, and en bloc specimens were resected. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination was performed to detect the patients′ recurrence-free survival up to November 2017. Measurement data with normal distribution were represented as ±s. The survival curve and rate were drawn and calculated by the Kaplan-Meier method. Results (1) Surgical and postoperative recovery situations: all the 37 patients underwent successful LPD, without conversion to open surgery and perioperative death. The operation time, volume of blood loss and case with intraoperative blood transfusion were (326±55)minutes, (176±39)mL and 1, respectively. The time to initial exsufflation and time for diet intake were respectively (4.5±1.6)days and (5.3±2.7)days. Of 37 patients, 14 had postoperative complications, including 8 with pancreatic fistula (6 with biochemical fistula and 2 with grade B pancreatic fistula), 1 with biliary fistula, 3 with postoperative bleeding (2 with intra-abdominal bleeding and 1 with gastrointestinal anastomosis bleeding), 2 with delayed gastric emptying (grage A), 2 with intra-abdominal infection and 2 with pulmonary infection; the same patients can merge multiple complications. Three patients were in Clavien-Dindo classification ≥Ⅲ. One patient received reoperation and other patients were improved by symptomatic treatment. Duration of hospital stay of 37 patients was 13.5 days (range, 8.0-33.0 days). Eight patients underwent adjuvant chemotherapy of 4-6 cycles by taking orally tegafur or gemcitabine with cisplatin. (2) Postoperative pathological examination: tumor diameter and pancreatic duct diameter of 37 patients were (2.1±1.1)cm and (2.5±1.2)mm, respectively . Of 37 patients, 9, 13 and 15 were respectively detected in high-differentiated, moderate-differentiated and low-differentiated adenocarcinoma. Surgical margins: 35 patients received R0 resection and 2 received R1 resection. Number of lymph node dissected, cases with lymph node metastasis and number of positive lymph nodes were respectively 18.5±4.9, 16 and 1.7±1.4. Analysis of lymph node metastasis location showed that the positive rates in 8a, 12, 13, 14 and 17 groups lymph nodes were respectively 5.4%(2/37), 18.9%(7/37), 21.6%(8/37), 8.1%(3/37) and 10.8%(4/37); Perineural invasion (PNI), lymphovascular invasion (LVI), pancreatic invasion and duodenal invasion were identified in 14, 9, 16 and 6 patients, respectively. TNM stage: stage 0, ⅠA, ⅠB, ⅡA and ⅡB were respectively detected in 1, 3, 5, 12 and 16 patients. (3) Follow-up situation: of 37 patients, 36 were followed up for 6-45 months, with a median time of 26 months. The median recurrence-free survival time, 1- and 3-year recurrence-free survival rates were respectively 28 months, 80.6% and 42.2%. Conclusion LPD is safe and effective for distal cholangiocarcinoma, and en-block resection not only helps to optimize the process of LPD for distal cholangiocarcinoma, but also has a significant effect on R0 resection and lymph node dissection. Key words: Bile duct neoplasms, distal; Pancreaticoduodenectomy; Laparoscopy; Lymph node dissection; En-block procedure

Application value of nano carbon lymph tracing technique in the radical resection of gallbladder cancer: a prospective study

Application value of nano carbon lymph tracing technique in the radical resection of gallbladder cancer: a prospective study