Objective:To evaluate the safety of double and a half layered esophagojejunal anastomosis in radical gastrectomy.Methods:This prospective, multi-center, single-arm study was initiated by the Affiliated Cancer Hospital of Zhengzhou University in June 2021 (CRAFT Study, NCT05282563). Participating institutions included Nanyang Central Hospital, Zhumadian Central Hospital, Luoyang Central Hospital, First Affiliated Hospital of Henan Polytechnic University, First Affiliated Hospital of Henan University, Luohe Central Hospital, the People's Hospital of Hebi, First People's Hospital of Shangqiu, Anyang Tumor Hospital, First People's Hospital of Pingdingshan, and Zhengzhou Central Hospital Affiliated to Zhengzhou University. Inclusion criteria were as follows: (1) gastric adenocarcinoma confirmed by preoperative gastroscopy;(2) preoperative imaging assessment indicated that R0 resection was feasible; (3) preoperative assessment showed no contraindications to surgery;(4) esophagojejunostomy planned during the procedure; (5) patients volunteered to participate in this study and gave their written informed consent; (6) ECOG score 0–1; and (7) ASA score I–III. Exclusion criteria were as follows: (1) history of upper abdominal surgery (except laparoscopic cholecystectomy);(2) history of gastric surgery (except endoscopic submucosal dissection and endoscopic mucosal resection); (3) pregnancy or lactation;(4) emergency surgery for gastric cancer-related complications (perforation, hemorrhage, obstruction); (5) other malignant tumors within 5 years or coexisting malignant tumors;(6) arterial embolism within 6 months, such as angina pectoris, myocardial infarction, and cerebrovascular accident; and (7) comorbidities or mental health abnormalities that could affect patients' participation in the study. Patients were eliminated from the study if: (1) radical gastrectomy could not be completed; (2) end-to-side esophagojejunal anastomosis was not performed during the procedure; or (3) esophagojejunal anastomosis reinforcement was not possible. Double and a half layered esophagojejunal anastomosis was performed as follows: (1) Open surgery: the full thickness of the anastomosis is continuously sutured, followed by embedding the seromuscular layer with barbed or 3-0 absorbable sutures. The anastomosis is sutured with an average of six to eight stitches. (2) Laparoscopic surgery: the anastomosis is strengthened by counterclockwise full-layer sutures. Once the anastomosis has been sutured to the right posterior aspect of the anastomosis, the jejunum stump is pulled to the right and the anastomosis turned over to continue to complete reinforcement of the posterior wall. The suture interval is approximately 5 mm. After completing the full-thickness suture, the anastomosis is embedded in the seromuscular layer. Relevant data of patients who had undergone radical gastrectomy in the above 12 centers from June 2021 were collected and analyzed. The primary outcome was safety (e.g., postoperative complications, and treatment). Other studied variables included details of surgery (e.g., surgery time, intraoperative bleeding), postoperative recovery (postoperative time to passing flatus and oral intake, length of hospital stay), and follow-up conditions (quality of life as assessed by Visick scores).Result:[1] From June 2021 to September 2022,457 patients were enrolled, including 355 men and 102 women of median age 60.8±10.1 years and BMI 23.7±3.2 kg/m2. The tumors were located in the upper stomach in 294 patients, mid stomach in 139; and lower stomach in 24. The surgical procedures comprised 48 proximal gastrectomies and 409 total gastrectomies. Neoadjuvant chemotherapy was administered to 85 patients. Other organs were resected in 85 patients. The maximum tumor diameter was 4.3±2.2 cm, number of excised lymph nodes 28.3±15.2, and number of positive lymph nodes five (range one to four. As to pathological stage,83 patients had Stage I disease, 128 Stage II, 237 Stage III, and nine Stage IV. [2] The studied surgery-related variables were as follows: The operation was successfully completed in all patients, 352 via a transabdominal approach, 25 via a transhiatus approach, and 80 via a transthoracoabdominal approach. The whole procedure was performed laparoscopically in 53 patients (11.6%), 189 (41.4%) underwent laparoscopic-assisted surgery, and 215 (47.0%) underwent open surgery. The median intraoperative blood loss was 200 (range, 10–1 350) mL, and the operating time 215.6±66.7 minutes. The anastomotic reinforcement time was 2 (7.3±3.9) minutes for laparoscopic-assisted surgery, 17.6±1.7 minutes for total laparoscopy, and 6.0±1.2 minutes for open surgery. [3] The studied postoperative variables were as follows: The median time to postoperative passage of flatus was 3.1±1.1 days and the postoperative gastrointestinal angiography time 6 (range, 4–13) days. The median time to postoperative oral intake was 7 (range, 2–14) days, and the postoperative hospitalization time 15.8±6.7 days. [4] The safety-related variables were as follows: In total, there were 184 (40.3%) postoperative complications. These comprised esophagojejunal anastomosis complications in 10 patients (2.2%), four (0.9%) being anastomotic leakage (including two cases of subclinical leakage and two of clinical leakage; all resolved with conservative treatment); and six patients (1.3%) with anastomotic stenosis (two who underwent endoscopic balloon dilation 21 and 46 days after surgery, the others improved after a change in diet). There was no anastomotic bleeding. Non-anastomotic complications occurred in 174 patients (38.1%). All patients attended for follow-up at least once, the median follow-up time being 10 (3–18) months. Visick grades were as follows: Class I, 89.1% (407/457); Class II, 7.9% (36/457); Class III, 2.6% (12/457); and Class IV 0.4% (2/457).Conclusion:Double and a half layered esophagojejunal anastomosis in radical gastrectomy is safe and feasible.

Objective:To evaluate the safety of double and a half layered esophagojejunal anastomosis in radical gastrectomy.Methods:This prospective, multi-center, single-arm study was initiated by the Affiliated Cancer Hospital of Zhengzhou University in June 2021 (CRAFT Study, NCT05282563). Participating institutions included Nanyang Central Hospital, Zhumadian Central Hospital, Luoyang Central Hospital, First Affiliated Hospital of Henan Polytechnic University, First Affiliated Hospital of Henan University, Luohe Central Hospital, the People's Hospital of Hebi, First People's Hospital of Shangqiu, Anyang Tumor Hospital, First People's Hospital of Pingdingshan, and Zhengzhou Central Hospital Affiliated to Zhengzhou University. Inclusion criteria were as follows: (1) gastric adenocarcinoma confirmed by preoperative gastroscopy;(2) preoperative imaging assessment indicated that R0 resection was feasible; (3) preoperative assessment showed no contraindications to surgery;(4) esophagojejunostomy planned during the procedure; (5) patients volunteered to participate in this study and gave their written informed consent; (6) ECOG score 0–1; and (7) ASA score I–III. Exclusion criteria were as follows: (1) history of upper abdominal surgery (except laparoscopic cholecystectomy);(2) history of gastric surgery (except endoscopic submucosal dissection and endoscopic mucosal resection); (3) pregnancy or lactation;(4) emergency surgery for gastric cancer-related complications (perforation, hemorrhage, obstruction); (5) other malignant tumors within 5 years or coexisting malignant tumors;(6) arterial embolism within 6 months, such as angina pectoris, myocardial infarction, and cerebrovascular accident; and (7) comorbidities or mental health abnormalities that could affect patients' participation in the study. Patients were eliminated from the study if: (1) radical gastrectomy could not be completed; (2) end-to-side esophagojejunal anastomosis was not performed during the procedure; or (3) esophagojejunal anastomosis reinforcement was not possible. Double and a half layered esophagojejunal anastomosis was performed as follows: (1) Open surgery: the full thickness of the anastomosis is continuously sutured, followed by embedding the seromuscular layer with barbed or 3-0 absorbable sutures. The anastomosis is sutured with an average of six to eight stitches. (2) Laparoscopic surgery: the anastomosis is strengthened by counterclockwise full-layer sutures. Once the anastomosis has been sutured to the right posterior aspect of the anastomosis, the jejunum stump is pulled to the right and the anastomosis turned over to continue to complete reinforcement of the posterior wall. The suture interval is approximately 5 mm. After completing the full-thickness suture, the anastomosis is embedded in the seromuscular layer. Relevant data of patients who had undergone radical gastrectomy in the above 12 centers from June 2021 were collected and analyzed. The primary outcome was safety (e.g., postoperative complications, and treatment). Other studied variables included details of surgery (e.g., surgery time, intraoperative bleeding), postoperative recovery (postoperative time to passing flatus and oral intake, length of hospital stay), and follow-up conditions (quality of life as assessed by Visick scores).Result:[1] From June 2021 to September 2022,457 patients were enrolled, including 355 men and 102 women of median age 60.8±10.1 years and BMI 23.7±3.2 kg/m2. The tumors were located in the upper stomach in 294 patients, mid stomach in 139; and lower stomach in 24. The surgical procedures comprised 48 proximal gastrectomies and 409 total gastrectomies. Neoadjuvant chemotherapy was administered to 85 patients. Other organs were resected in 85 patients. The maximum tumor diameter was 4.3±2.2 cm, number of excised lymph nodes 28.3±15.2, and number of positive lymph nodes five (range one to four. As to pathological stage,83 patients had Stage I disease, 128 Stage II, 237 Stage III, and nine Stage IV. [2] The studied surgery-related variables were as follows: The operation was successfully completed in all patients, 352 via a transabdominal approach, 25 via a transhiatus approach, and 80 via a transthoracoabdominal approach. The whole procedure was performed laparoscopically in 53 patients (11.6%), 189 (41.4%) underwent laparoscopic-assisted surgery, and 215 (47.0%) underwent open surgery. The median intraoperative blood loss was 200 (range, 10–1 350) mL, and the operating time 215.6±66.7 minutes. The anastomotic reinforcement time was 2 (7.3±3.9) minutes for laparoscopic-assisted surgery, 17.6±1.7 minutes for total laparoscopy, and 6.0±1.2 minutes for open surgery. [3] The studied postoperative variables were as follows: The median time to postoperative passage of flatus was 3.1±1.1 days and the postoperative gastrointestinal angiography time 6 (range, 4–13) days. The median time to postoperative oral intake was 7 (range, 2–14) days, and the postoperative hospitalization time 15.8±6.7 days. [4] The safety-related variables were as follows: In total, there were 184 (40.3%) postoperative complications. These comprised esophagojejunal anastomosis complications in 10 patients (2.2%), four (0.9%) being anastomotic leakage (including two cases of subclinical leakage and two of clinical leakage; all resolved with conservative treatment); and six patients (1.3%) with anastomotic stenosis (two who underwent endoscopic balloon dilation 21 and 46 days after surgery, the others improved after a change in diet). There was no anastomotic bleeding. Non-anastomotic complications occurred in 174 patients (38.1%). All patients attended for follow-up at least once, the median follow-up time being 10 (3–18) months. Visick grades were as follows: Class I, 89.1% (407/457); Class II, 7.9% (36/457); Class III, 2.6% (12/457); and Class IV 0.4% (2/457).Conclusion:Double and a half layered esophagojejunal anastomosis in radical gastrectomy is safe and feasible.

Object:To explore surgical treatments for duodenal fistula with intra-abdominal infection.Methods:The data of 19 patients with duodenal fistula treated at the Affiliated Tumor Hospital of Zhenzhou University between Jan 2015 and Dec 2021 were analyzed retrospectively. Surgery is performed with duodenostomy or modified duodenal shunt procedures.Result:All patients were accompanied by intra-abdominal infection, including 9 duodenal stump fistulas. All patients successfully completed the operation,11cases underwent duodenostomy, 8 case underwent modified duodenal shunt procedures. operating time was 110(60-140)min, postoperative hospitalization time was 29(9-103)d. Two patients died postoperatively. Fistula heals in other patients.Conclusion:Surgical intervention for duodenal fistula should focus on controlling the source of infection, strengthening intestinal and abdominal drainage, and reducing postoperative complications.

Objective:To investigate the effect of transorally inserted anvil (OrVil TM) in patients with relapsed or denovo carcinoma at the esophagogastric junction. Methods:The clinical data of 60 patients who underwent radical intent resection for locally relapsed or denovo esophagogastric junction adenocarcinoma at Zhengzhou University Cancer Hospital from Jan 2011 to Jun 2021 were retrospectively analyzed. The patients were divided into two groups according to whether transorally inserted anvil was used. Twenty-six patients who had used the system were assigned to the experimental group. Thirty-four patients without transorally inserted anvil were set to control group.Results:The incisor distance of the experimental group was shorter than that of the control group [36(34-40)cm vs. 39(36-41)cm, Z=-4.948, P<0.05]. Operation time in experimental group was 177 (145-260) min, compared to control group of 172 (140-225) min ( Z=-0.735, P=0.463). Intraoperative blood loss was 200 (100-900) ml in the experimental group and 300 (100-800) ml in the control group ( Z=-1.244, P=0.213). Postoperative upper margin distance of the experimental group was (3.6±1.7) cm compared to control group of (1.8±1.1) cm ( t=-0.735, P<0.01). The positive rate of margin in the experimental group was 4% vs. 15% in the control group ( χ2=1.931, P=0.165). The length of postoperative hospital stay in the experimental group was (18.6±5.2) d vs. (20.5±4.7) d ( t=-1.455, P=0.151). Surgery-related complications developed in 19% in the experimental group vs. 27% in the control group ( P>0.05). Conclusion:The application of the transorally inserted anvil in the operation of patients with locally relapsed or denovo esophagogastric junction cancer after initial operation reduces the difficulty of operation and decreases the positive rate of margin.

Object:To investigate the impact of carbon nanoparticle tracing on the number of lymph nodes harvested in obese patients during radical gastrectomy for gastric cancer.Methods:Clinical data of 127 patients undergoing D 2 radical gastrectomy in the Affiliated Tumor Hospital of Zhengzhou University from Jan 2015 to Dec 2019 were retrospectively analyzed. According to whether the patients were injected with carbon nano particles during operation, they were divided into two groups: 64 patients without carbon nano particles during operation served as control group; 63 patients with carbon nano particles were included into experimental group. Results:The operation time of the control group was (160±31) min and that of the experimental group was (168±28) min ( t=-1.521, P=0.445). Intraoperative blood lose in the control group was (234±82) ml and that in the experimental group was (238±84) ml ( t=-0.295, P=0.846). The number of lymph nodes harvested in the first station, in the second station, the number of total lymph nodes and the number of lymph nodes with diameter <5 mm in the control group were less than those in the experimental group(10.4±3.8 vs. 24.5±10.6, t=-10.054),(6.6±2.8 vs. 16.8±7.3, t=-10.381),(17.1±6.4 vs. 41.2±17.6, t=-10.293),(3.9±2.5 vs. 21.2±9.1, t=-14.662) (all P<0.05), while the number of positive lymph nodes was not statistically different between the two groups all (5.9±6.2 vs. 4.2±3.4, t=-1.963, P>0.05). Black staining of lymph nodes in nano carbon group: 1 542 black stained lymph nodes were detected in the experimental group, the black staining rate of lymph nodes was 59.44% (1 542/2 594). Conclusion:Intraoperative application of carbon nanoparticles can significantly increase the number of harvested lymph nodes in obese (BMI≥25 kg/m 2) gastric cancer patients after radical resection.

Objective:To evaluate a nano-carbon lymphatic tracing method for patients with rectal cancer after neoadjuvant radiotherapy and chemotherapy .Method:Retrospective analysis was made on 88 patients of rectal cancer undergoing neoadjuvant chemoradiation at the Department of General Surgery, He′nan Cancer Hospital from Jan 2016 to May 2020.According to whether nano-carbon lymph node was used or not, patients were divided into nanocarbon tracer group (study group) and non-nanocarbon tracer group (control group).Results:There was statistically significant in the number of havested lymph nodes between the two groups [15(11-19) vs.9(5-12), Z=5.227, P<0.001], There was no statistically significant in the number of positive lymph nodes between the two groups [0(0-0.25) vs.0(0-1), Z=1.199, P=0.231]. There were significant differences in the ratio of patients with less than 7 lymph nodes(0/34 vs.18/54, χ 2=14.248, P<0.001) and patients with less than 10 lymph nodes (4/34 vs.29/54, χ 2=15.657, P<0.001). Conclusions:The injection of nanocarbon after neoadjuvant chemoradiotherapy can increase the number of harvested postoperative lymph nodes and the ratio of patients with lymph nodes ≥7 and ≥10, which is more beneficial for prediction of the prognosis of patients.

Objective:To investigate whether adjuvant chemotherapy could be beneficial for patients with pT1N1M0 (stage ⅠB) gastric cancer.Methods:From Jan 2010 to Dec 2016, 185 patients with pT1N1M0 gastric cancer who were surgically resected at Henan Cancer Hospital were retrospectively analyzed. The patients were divided into chemotherapy group ( n=100) and non chemotherapy group ( n=85). Results:For disease-free survival (DFS) analysis, univariate survival analysis showed that age, examined lymph nodes, vascular invasion, nerve invasion and adjuvant chemotherapy were associated with DFS (all P<0.05); multivariate analysis showed that lymph node resection ≥ 16 ( HR=0.363, 95% CI: 0.160-0.827, P=0.016), vascular invasion ( HR=4.117, 95% CI: 1.796-9.436, P=0.001) and postoperative chemotherapy ( HR=4.530, 95% CI: 1.932-10.622, P=0.001) were independent risk factors for DFS. For disease-specific survival (DSS) analysis, univariate survival analysis showed that lymph node resection, vascular invasion, nerve invasion and adjuvant chemotherapy were associated with DSS; multivariate analysis showed that lymph node resection ≥ 16 ( HR=0.344, 95% CI: 0.144-0.822, P=0.016), vascular invasion ( HR=5.113, 95% CI: 2.029-12.887, P=0.001) and postoperative chemotherapy ( HR=4.694, 95% CI: 1.854-11.888, P=0.001)were independent risk factors for DSS. According to examined lymph nodes and vascular invasion , pT1N1M0 patients were divided into three risk categories (high, medium and low). DFS and DSS were significantly different among the three risk groups (all P<0.001, respectively). Conclusion:pT1N1M0 gastric cancer patients are expected to benefit from adjuvant chemotherapy. Patients with less than 16 lymph nodes and vascular invasion may be particularly suitable for adjuvant chemotherapy.

Objective:To investigate the clinical significance of MRI dynamic enhancement in defining the upper edge of adenocarcinoma of esophagogastric junction.Methods:The clinical data of 73 patients with adenocarcinoma on the esophagogastric junction operated from Jul 2018 to Aug 2019 in the Affiliated Cancer Hospital of Zhengzhou University were retrospectively analyzed. All patients underwent MRI examination within one week before surgery. First, the T 2WI, diffusion-weighted imaging and dynamic enhanced images of each patient were carefully observed to define the tumor location, size, shape, signal and enhancement mode, then the distances between the upper edge of the tumor and the cardiac incisure on MRI dynamic enhancement were measured independently, and compared with the measured distance in surgical fresh specimens. Results:The mean location of tumor upper edge measured in MRI of 73 patients was (1.75±1.98)cm, while measured in the surgical specimen was (1.72±1.97)cm. There was no significant difference between the two groups ( t=0.572, P=0.569). The intraclass correlation efficient between the two groups was excellent (ICC=0.974, 95% CI: 0.959-0.984, P<0.01). Conclusion:The measurement result of tumor upper edge in MRI is basically consistent with that of surgical specimens. MRI can be used to locate the tumor upper edge for adenocarcinoma of esophagogastric junction before operation.

Objective:To investigate the application value of one-stitch prophylactic ileostomy in late ileostomy closure.Methods:The prospective randomized control study was conducted. The clinicopathological data of 141 patients with rectal cancer who underwent low anterior resection combined with prophylactic ileostomy in the Affiliated Tumor Hospital of Zhengzhou University from January 2016 to July 2020 were selected. There were 127 patients being selected after excluding 14 cases who did not undergo ileostomy closure. Patients undergoing one-stitch prophylactic ileostomy were divided into observation group, and patients undergoing traditional ileostomy were divided into control group. Observation indicators: (1) grouping situations of the enrolled patients; (2) surgical situations of ileostomy closure; (3) postoperative situations; (4) follow-up. Follow-up was conducted using outpatient examination and telephone interview once a month after low anterior resection combined with prophylactic ileostomy to detect complication and death of patients. The end point was at 3 months after ileostomy closure. The follow-up was up to July 2020. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M( P25, P75) or M (range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data between groups was conducted using the Mann-Whitney U test. Results:(1) Grouping situations of the enrolled patients: a total of 127 patients were selected for eligibility, aged from 31 to 83 years, with a median age of 64 years. Of 127 patients, there were 66 cases in observation group and 61 cases in control group. (2) Surgical situations of ileostomy closure: all patients from the two groups underwent ileostomy closure successfully. The incision length, operation time, volume of intraoperative blood loss, cases with abdominal adhesion degree as slight adhesion or obvious adhesion were 4.25 cm(4.00 cm, 5.00 cm), 48.00 minutes(33.75 minutes, 58.00 minutes), 30 mL(20 mL, 50 mL), 34, 32 of the observation group, versus 7.50 cm(7.00 cm, 8.50 cm), 70.00 minutes(57.00 minutes, 80.00 minutes), 30 mL(30 mL, 50 mL), 13, 48 of the control group, showing significant differences between the two groups ( Z=-9.549, -6.133, -2.758, χ2=12.405, P<0.05). (3) Postoperative situations: cases with incision infection of the observation group and the control group were 5 and 13, respectively, showing a significant difference between the two groups ( χ2=4.917, P<0.05). (4) Follow-up: all the 127 patients were followed up for 6-21 months, with a median follow-up time of 10 months. During the follow-up, 3 cases of the control group had postoperative incisional hernia and were cured after conservative treatment. None of patient had anastomotic leakage related complications or died during the follow-up. Conclusion:The one-stitch preventive ileostomy has the advantage of ileostomy closure, which can reduce the operation time, volume of intraoperative blood loss and shorten the incision length effectively, so as to reduce the incidence of postoperative incision infection related complications.

Objective:To investigate the effects of preoperative endoscopic mucosal injection of carbon nanoparticle tracer and intraoperative serosa injection of carbon nanoparticle tracer on the acquisition of lymph nodes in total gastrectomy for gastric cancer.Methods:The retrospective cohort study was conducted. The clinical data of 118 patients with gastric cancer who underwent total gastrectomy in the Affiliated Tumor Hospital of Zhengzhou University between May 2017 and April 2018 were collected. There were 79 males and 39 females, aged from 26 to 81 years, with an average age of 59 years. Of 118 patients, 56 patients undergoing preoperative endoscopic mucosal injection of carbon nanoparticle tracer were divided into observation group and 62 patients undergoing intraoperative serosa injection of carbon nanoparticle tracer were divided into control group. Observation indicators: the total number of lymph node dissected, the number of positive lymph node dissected, the number of lymph node dissected at the first station and the number of lymph node dissected at the second station. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the independent-sample t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the rank sum test. Results:The total number of lymph node dissected, the number of positive lymph node dissected, the number of lymph node dissected at the first station, the number of lymph node dissected at the second station of the observation group were 48±16, 3(range, 0-25), 26±9, 23±7, respectively. The above indicators of the control group were 41±13, 4(range, 0-28), 25±8, 16±5, respectively. There were significant differences in the total number of lymph node dissected and the number of lymph node dissected at the second station between the two groups ( t=2.494, 6.588, P<0.05), and there was no significant difference in the number of positive lymph node dissected and the number of lymph node dissected at the first station between the two groups ( Z=0.747, t=1.689, P>0.05). Conclusions:Carbon nanoparticle labeled lymph node staining using preoperative endoscopic mucosal injection of carbon nanoparticle tracer or intraoperative serosa injection of carbon nanoparticle tracer is safe and effective in total gastrectomy for gastric cancer. Compared with intraoperative serosa injection of carbon nanoparticle tracer, preoperative endoscopic mucosal injection of carbon nanoparticle tracer can increase the total number of lymph node dissected, especially the number of lymph node dissected at the second station of gastric cancer.