Many breakthroughs in the field of surgical clinical researches have been achieved in China, but the overall quality is relatively limited, largely because of the insufficiency in standardization, rationality and scientificity of methodology. In consideration of the nature of surgical procedures and equipments, it is necessary to establish a set of methodological system, suitable for the high-quality clinical research in the surgical field. IDEAL collaboration has put forward a systematic methodological framework for innovation in surgical procedure and equipment. For the clinical research on surgical innovation, the IDEAL framework can be divided into five sequential stages, namely, Idea, Development, Exploration, Assessment and Long-term follow-up. In different stages, the difficulties to be faced, the problems to be solved, and the research design to be adopted are diverse and progressive. Although the IDEAL framework is not perfect, it is currently the best framework for surgical clinical research. While performing surgical clinical research, we should continue to think about how to improve the surgical clinical research methodology.

Objective:To explore the effect of standardized surgical treatment and multidisciplinary treatment strategy on the treatment outcomes of gastric cancer patients.Methods:A single-center cohort study was carried out. Clinicopathological and long-term follow up data of primary gastric cancer patients were retrieved from the database of Surgical Gastric Cancer Patient Registry (SGCPR) in West China Hospital of Sichuan University. Finally, 4516 gastric cancer patients were included and were divided into three groups according to time periods (period 1 group: exploration stage of standardized surgical treatment, 2000 to 2006, 967 cases; period 2 group: application stage of standardized surgical treatment, 2007 to 2012, 1962 cases; period 3 group: optimization stage of standardized surgical treatment and application stage of multidisciplinary treatment strategy, 2013 to 2016, 1587 cases). Differences in clinical data, pathologic features, and prognosis were compared among 3 period groups. Follow-up information was updated to January 1, 2020. The overall follow-up rate was 88.9% (4016/4516) and median follow-up duration was 51.58 months. Survival curve was drawn by Kaplan-Meire method and compared with log-rank test. Univariate and multivariate analyses were performed by Cox proportional hazards model.Results:There were significant differences among period 1, period 2 and period 3 groups in the rates of D2/D2+ lymphadenectomy [14.4%(139/967) vs. 47.2%(927/1962) vs. 75.4%(1197/1587), χ 2=907.210, P<0.001], in the ratio of proximal gastrectomy [19.8%(191/967) vs. 16.6%(325/1962) vs. 8.2%(130/1587), χ 2=100.020, P<0.001], and in the median intraoperative blood loss (300 ml vs. 100 ml vs. 100 ml, H=1126.500, P<0.001). Besides, the increasing trend and significant difference were also observed in the median number of examined lymph nodes among period 1, period 2 and period 3 groups (14 vs. 26 vs. 30, H=987.100, P<0.001). Survival analysis showed that the 5-year overall survival rate was 55.3% in period 1, 55.2% in period 2 and 62.8% in period 3, and significant difference existed between period 3 and period 1 ( P=0.004). The Cox proportional hazards model analysis showed that treatment period (period 3, HR=0.820, 95%CI: 0.708 to 0.950, P=0.008), postoperative chemotherapy (HR=0.696, 95%CI: 0.631 to 0.768, P<0.001) and mid-low gastric cancer (HR=0.884, 95%CI: 0.804 to 0.973, P=0.011) were good prognostic factors. Whereas old age (≥65 years, HR=1.189, 95%CI: 1.084 to 1.303, P<0.001), palliative resection (R1/R2, HR=1.538,95%CI: 1.333 to 1.776, P<0.001), large tumor size (≥5 cm, HR=1.377, 95%CI: 1.239 to 1.529, P<0.001), macroscopic type III to IV (HR=1.165, 95%CI: 1.063 to 1.277, P<0.001) and TNM stage II to IV(II/I: HR=1.801,95% CI:1.500~2.162, P<0.001;III/I: HR=3.588, 95% CI: 3.028~4.251, P<0.001; IV/I: HR=6.114, 95% CI: 4.973~7.516, P<0.001) were independent prognostic risk factors. Conclusion:Through the implementation of standardized surgical treatment technology and multidisciplinary treatment model, the quality of surgery treatment and overall survival increase, and prognosis of gastric cancer patients has been improved.

Objective:To explore the effect of standardized surgical treatment and multidisciplinary treatment strategy on the treatment outcomes of gastric cancer patients.Methods:A single-center cohort study was carried out. Clinicopathological and long-term follow up data of primary gastric cancer patients were retrieved from the database of Surgical Gastric Cancer Patient Registry (SGCPR) in West China Hospital of Sichuan University. Finally, 4516 gastric cancer patients were included and were divided into three groups according to time periods (period 1 group: exploration stage of standardized surgical treatment, 2000 to 2006, 967 cases; period 2 group: application stage of standardized surgical treatment, 2007 to 2012, 1962 cases; period 3 group: optimization stage of standardized surgical treatment and application stage of multidisciplinary treatment strategy, 2013 to 2016, 1587 cases). Differences in clinical data, pathologic features, and prognosis were compared among 3 period groups. Follow-up information was updated to January 1, 2020. The overall follow-up rate was 88.9% (4016/4516) and median follow-up duration was 51.58 months. Survival curve was drawn by Kaplan-Meire method and compared with log-rank test. Univariate and multivariate analyses were performed by Cox proportional hazards model.Results:There were significant differences among period 1, period 2 and period 3 groups in the rates of D2/D2+ lymphadenectomy [14.4%(139/967) vs. 47.2%(927/1962) vs. 75.4%(1197/1587), χ 2=907.210, P<0.001], in the ratio of proximal gastrectomy [19.8%(191/967) vs. 16.6%(325/1962) vs. 8.2%(130/1587), χ 2=100.020, P<0.001], and in the median intraoperative blood loss (300 ml vs. 100 ml vs. 100 ml, H=1126.500, P<0.001). Besides, the increasing trend and significant difference were also observed in the median number of examined lymph nodes among period 1, period 2 and period 3 groups (14 vs. 26 vs. 30, H=987.100, P<0.001). Survival analysis showed that the 5-year overall survival rate was 55.3% in period 1, 55.2% in period 2 and 62.8% in period 3, and significant difference existed between period 3 and period 1 ( P=0.004). The Cox proportional hazards model analysis showed that treatment period (period 3, HR=0.820, 95%CI: 0.708 to 0.950, P=0.008), postoperative chemotherapy (HR=0.696, 95%CI: 0.631 to 0.768, P<0.001) and mid-low gastric cancer (HR=0.884, 95%CI: 0.804 to 0.973, P=0.011) were good prognostic factors. Whereas old age (≥65 years, HR=1.189, 95%CI: 1.084 to 1.303, P<0.001), palliative resection (R1/R2, HR=1.538,95%CI: 1.333 to 1.776, P<0.001), large tumor size (≥5 cm, HR=1.377, 95%CI: 1.239 to 1.529, P<0.001), macroscopic type III to IV (HR=1.165, 95%CI: 1.063 to 1.277, P<0.001) and TNM stage II to IV(II/I: HR=1.801,95% CI:1.500~2.162, P<0.001;III/I: HR=3.588, 95% CI: 3.028~4.251, P<0.001; IV/I: HR=6.114, 95% CI: 4.973~7.516, P<0.001) were independent prognostic risk factors. Conclusion:Through the implementation of standardized surgical treatment technology and multidisciplinary treatment model, the quality of surgery treatment and overall survival increase, and prognosis of gastric cancer patients has been improved.

OBJECTIVE: To compare the long-term survival outcomes of Siewert II adenocarcinoma of esophagogastric junction (AEG) between transthoracic (TT) approach and transabdominal (TA) approach. METHODS: The databases of Gastrointestinal Surgery Department and Thoracic Surgery Department in West China Hospital of Sichuan University from 2006 to 2014 were integrated. Patients of Siewert II AEG who underwent resection were retrospectively collected. INCLUSION CRITERIA: (1) adenocarcinoma confirmed by gastroscopy and biopsy; (2) tumor involvement in the esophagogastric junction line; (3) tumor locating from lower 5 cm to upper 5 cm of the esophagogastric junction line, and tumor center locating from upper 1 cm to lower 2 cm of esophagogastric junction line; (4)resection performed at thoracic surgery department or gastrointestinal surgery department; (5) complete follow-up data. Patients at thoracic surgery department received trans-left thoracic, trans-right thoracic, or transabdominothoracic approach; underwent lower esophagus resection plus proximal subtotal gastrectomy; selected two-field or three-field lymph node dissection; underwent digestive tract reconstruction with esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis above or below aortic arch using hand-sewn or stapler instrument to perform anastomosis. Patients at gastrointestinal surgery department received transabdominal(transhiatal approach), or transabdominothoracic approach; underwent total gastrectomy or proximal subtotal gastrectomy; selected D1, D2 or D2 lymph node dissection; underwent digestive tract reconstruction with esophagus-single tube jejunum or esophagus-jejunal pouch Roux-en-Y anastomosis, or esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis; completed all the anastomoses with stapler instruments. The follow-up ended in January 2018. The TNM stage system of the 8th edition UICC was used for esophageal cancer staging; survival table method was applied to calculate 3-year overall survival rate and 95% cofidence interval(CI); log-rank test was used to perform survival analysis; Cox regression was applied to analyze risk factors and calculate hazard ratio (HR) and 95%CI. RESULTS: A total of 443 cases of Siewert II AEG were enrolled, including 89 cases in TT group (with 3 cases of transabdominothoracic approach) and 354 cases in TA group. Median follow-up time was 50.0 months (quartiles:26.4-70.2). The baseline data in TT and TA groups were comparable, except the length of esophageal invasion [for length <3 cm, TA group had 354 cases(100%), TT group had 44 cases (49.4%), χ²=199.23,P<0.001]. The number of harvested lymph node in thoracic surgery department and gastrointestinal surgery department were 12.0(quartiles:9.0-17.0) and 24.0(quartiles:18.0-32.5) respectively with significant difference (Z=11.29,P<0.001). The 3-year overall survival rate of TA and TT groups was 69.2%(95%CI:64.1%-73.7%) and 55.8% (95%CI:44.8%-65.4%) respectively, which was not significantly different by log-rank test (P=0.059). However, the stage III subgroup analysis showed that the survival of TA group was better [the 3-year overall survival in TA group and TT group was 78.1%(95%CI:70.5-84.0) and 46.3%(95%CI:31.0-60.3) resepectively(P=0.001)]. Multivariate Cox regression analysis revealed that the TT group had poor survival outcome (HR=2.45,95%CI:1.30-4.64, P=0.006). CONCLUSION The overall survival outcomes in the TA group are better, especially in stage III patients, which may be associated with the higher metastatic rate of abdominal lymph node and the more complete lymphadenectomy via TA approach.
Adenocarcinoma ; classification ; mortality ; pathology ; surgery ; China ; Databases, Factual ; Esophageal Neoplasms ; classification ; pathology ; surgery ; Esophagectomy ; methods ; Esophagogastric Junction ; pathology ; surgery ; Gastrectomy ; methods ; Humans ; Laparotomy ; Lymph Node Excision ; methods ; Neoplasm Staging ; Retrospective Studies ; Stomach Neoplasms ; classification ; mortality ; pathology ; surgery ; Survival Analysis ; Thoracic Surgical Procedures

The surgical treatment for adenocarcinoma of esophagogastric junction (AEG) involves thoracic and abdominal cavities. With no general consensus on the surgical treatment modality for AEG in China, the understanding and surgical practice of AEG are controversial between thoracic and gastrointestinal surgeons. Chinese expert consensus on the surgical treatment for adenocarcinoma of esophagogastric junction (2018 edition) was released in September 2018 by the Chinese expert panel including 19 thoracic surgeons and 20 gastrointestinal surgeons. The formulation and publication of this consensus has increased homogeneity of the understanding of the disease in different disciplines to a certain extent, and has facilitated standardized surgical treatment for adenocarcinoma of esophagogastric junction. The consensus was based on the best available clinical evidence and the latest national and international guidelines and consensus. Several rounds of discussion and voting were conducted. Finally, 27 statements on surgery-related recommendations and 9 issues requiring further investigation were reached in the consensus, which basically cover the fields and research hotspots of surgical treatment for adenocarcinoma of esophagogastric juncton. This review will explain in details the Chinese expert consensus on the surgical treatment for adenocarcinoma of esophagogastric junction.
Adenocarcinoma ; surgery ; China ; Consensus ; Esophageal Neoplasms ; surgery ; Esophagogastric Junction ; surgery ; Humans ; Stomach Neoplasms ; surgery

Objective: To compare the safety and efficacy between proximal gastrectomy and total gastrectomy and to ascertain the optimized procedure for patients with upper third gastric cancer through meta-analysis. Methods: The English literatures about proximal gastrectomy and total gastrectomy for upper third gastric cancer were searched from PubMed, EMBASE, the Cochrane Library and the Web of Science database and then collected. The quality of enrolled studies was independently assessed by two researchers according to the Newcastle-Ottawa Scale for retrospective studies and Jadad scale for RCT studies. The basic information of the literature and related clinical indicators were extracted. The primary endpoints were 5-year overall survival rate and recurrence rate. The secondary endpoints were operative time, intraoperative blood loss, morbidity of postoperative complication, incidence of anastomotic stenosis and incidence of reflux esophagitis. Considering the influence of tumor staging on postoperative clinicopathological features and prognosis, a subgroup analysis was performed on the literatures including cases of early gastric cancer and those including cases of tumor stage I to IV. Statistical analyses were carried out by the "metafor" and "meta" software packages from RevMan 5.3 software and R software (V3.2.4). Results: Twenty-five literatures involving 3667 patients (proximal gastrectomy for 1483, total gastrectomy for 2184) were finally enrolled for analysis, including 24 retrospective studies with ≥ 5 points and 1 RCT with 3 points, and all the literatures were of high quality. A total of 2516 cases of early gastric cancer were enrolled in 18 articles, including 1027 with proximal gastrectomy and 1489 with total gastrectomy. A total of 1151 cases with stage I to IV were enrolled in 7 articles, including 456 in proximal gastrectomy group and 695 in total gastrectomy group. Five-year survival rate was not significantly different for patients with early gastric cancer between the proximal gastrectomy group and total gastrectomy group (OR=1.16, 95% CI: 0.72 to 1.86, P=0.54). Similarly, there was no significant difference for patients with stage I to IV between the proximal gastrectomy group and the total gastrectomy group (OR=1.19, 95% CI: 0.92 to 1.53, P=0.18). Recurrence rate of early gastric cancer patients was not significantly different between the proximal gastrectomy group and the total gastrectomy group (OR=0.40, 95% CI: 0.05 to 3.16, P=0.39).However, the recurrence rate of the proximal gastrectomy group was higher than that of the total gastrectomy group in patients with stage I to IV (OR=1.55, 95% CI: 1.09 to 2.19, P<0.01), whose difference was statistically significant. There was no significant differences in postoperative complication between the groups, both in patients with early gastric cancer, and in those with stage I to IV (both P>0.05). The incidences of postoperative anastomotic stenosis (OR=3.57, 95% CI: 1.82 to 6.99, P<0.01) and reflux esophagitis (OR=2.83, 95% CI: 1.23 to 6.54, P=0.01) in the proximal gastrectomy group were significantly higher than those in the total gastrectomy group in patients with early gastric cancer. Conclusions There is no significant difference in long-term survival outcomes between total gastrectomy and proximal gastrectomy for upper gastric tumors. However,incidence of anastomotic stenosis and reflux esophagitis, and tumor recurrence rate after total gastrectomy are significantly lower. The total gastrectomy is recommended as the first choice for advanced upper gastric tumor.

Objective To compare the safety and efficacy between proximal gastrectomy and total gastrectomy and to ascertain the optimized procedure for patients with upper third gastric cancer through meta?analysis. Methods The English literatures about proximal gastrectomy and total gastrectomy for upper third gastric cancer were searched from PubMed, EMBASE, the Cochrane Library and the Web of Science database and then collected. The quality of enrolled studies was independently assessed by two researchers according to the Newcastle?Ottawa Scale for retrospective studies and Jadad scale for RCT studies. The basic information of the literature and related clinical indicators were extracted. The primary endpoints were 5?year overall survival rate and recurrence rate. The secondary endpoints were operative time, intraoperative blood loss, morbidity of postoperative complication, incidence of anastomotic stenosis and incidence of reflux esophagitis. Considering the influence of tumor staging on postoperative clinicopathological features and prognosis, a subgroup analysis was performed on the literatures including cases of early gastric cancer and those including cases of tumor stage I to IV. Statistical analyses were carried out by the"metafor"and"meta"software packages from RevMan 5.3 software and R software (V3.2.4). Results Twenty?five literatures involving 3667 patients (proximal gastrectomy for 1483, total gastrectomy for 2184) were finally enrolled for analysis, including 24 retrospective studies with≥5 points and 1 RCT with 3 points, and all the literatures were of high quality. A total of 2516 cases of early gastric cancer were enrolled in 18 articles, including 1027 with proximal gastrectomy and 1489 with total gastrectomy. A total of 1151 cases with stage I to IV were enrolled in 7 articles, including 456 in proximal gastrectomy group and 695 in total gastrectomy group. Five?year survival rate was not significantly different for patients with early gastric cancer between the proximal gastrectomy group and total gastrectomy group ( OR=1.16, 95% CI : 0.72 to 1.86, P=0.54). Similarly, there was no significant difference for patients with stage I to IV between the proximal gastrectomy group and the total gastrectomy group ( OR=1.19, 95% CI :0.92 to 1.53, P=0.18). Recurrence rate of early gastric cancer patients was not significantly different between the proximal gastrectomy group and the total gastrectomy group (OR=0.40, 95% CI: 0.05 to 3.16, P=0.39).However, the recurrence rate of the proximal gastrectomy group was higher than that of the total gastrectomy group in patients with stage I to IV ( OR=1.55, 95% CI : 1.09 to 2.19, P<0.01), whose difference was statistically significant. There was no significant differences in postoperative complication between the groups, both in patients with early gastric cancer, and in those with stage I to IV (both P>0.05). The incidences of postoperative anastomotic stenosis ( OR=3.57, 95% CI : 1.82 to 6.99, P<0.01) and reflux esophagitis ( OR=2.83, 95% CI : 1.23 to 6.54, P=0.01) in the proximal gastrectomy group were significantly higher than those in the total gastrectomy group in patients with early gastric cancer. Conclusions There is no significant difference in long?term survival outcomes between total gastrectomy and proximal gastrectomy for upper gastric tumors. However,incidence of anastomotic stenosis and reflux esophagitis, and tumor recurrence rate after total gastrectomy are significantly lower. The total gastrectomy is recommended as the first choice for advanced upper gastric tumor.

Objective To compare the safety and efficacy between proximal gastrectomy and total gastrectomy and to ascertain the optimized procedure for patients with upper third gastric cancer through meta?analysis. Methods The English literatures about proximal gastrectomy and total gastrectomy for upper third gastric cancer were searched from PubMed, EMBASE, the Cochrane Library and the Web of Science database and then collected. The quality of enrolled studies was independently assessed by two researchers according to the Newcastle?Ottawa Scale for retrospective studies and Jadad scale for RCT studies. The basic information of the literature and related clinical indicators were extracted. The primary endpoints were 5?year overall survival rate and recurrence rate. The secondary endpoints were operative time, intraoperative blood loss, morbidity of postoperative complication, incidence of anastomotic stenosis and incidence of reflux esophagitis. Considering the influence of tumor staging on postoperative clinicopathological features and prognosis, a subgroup analysis was performed on the literatures including cases of early gastric cancer and those including cases of tumor stage I to IV. Statistical analyses were carried out by the"metafor"and"meta"software packages from RevMan 5.3 software and R software (V3.2.4). Results Twenty?five literatures involving 3667 patients (proximal gastrectomy for 1483, total gastrectomy for 2184) were finally enrolled for analysis, including 24 retrospective studies with≥5 points and 1 RCT with 3 points, and all the literatures were of high quality. A total of 2516 cases of early gastric cancer were enrolled in 18 articles, including 1027 with proximal gastrectomy and 1489 with total gastrectomy. A total of 1151 cases with stage I to IV were enrolled in 7 articles, including 456 in proximal gastrectomy group and 695 in total gastrectomy group. Five?year survival rate was not significantly different for patients with early gastric cancer between the proximal gastrectomy group and total gastrectomy group ( OR=1.16, 95% CI : 0.72 to 1.86, P=0.54). Similarly, there was no significant difference for patients with stage I to IV between the proximal gastrectomy group and the total gastrectomy group ( OR=1.19, 95% CI :0.92 to 1.53, P=0.18). Recurrence rate of early gastric cancer patients was not significantly different between the proximal gastrectomy group and the total gastrectomy group (OR=0.40, 95% CI: 0.05 to 3.16, P=0.39).However, the recurrence rate of the proximal gastrectomy group was higher than that of the total gastrectomy group in patients with stage I to IV ( OR=1.55, 95% CI : 1.09 to 2.19, P<0.01), whose difference was statistically significant. There was no significant differences in postoperative complication between the groups, both in patients with early gastric cancer, and in those with stage I to IV (both P>0.05). The incidences of postoperative anastomotic stenosis ( OR=3.57, 95% CI : 1.82 to 6.99, P<0.01) and reflux esophagitis ( OR=2.83, 95% CI : 1.23 to 6.54, P=0.01) in the proximal gastrectomy group were significantly higher than those in the total gastrectomy group in patients with early gastric cancer. Conclusions There is no significant difference in long?term survival outcomes between total gastrectomy and proximal gastrectomy for upper gastric tumors. However,incidence of anastomotic stenosis and reflux esophagitis, and tumor recurrence rate after total gastrectomy are significantly lower. The total gastrectomy is recommended as the first choice for advanced upper gastric tumor.

Neoadjuvant chemotherapy combined with radical gastrectomy is one of the most important parts of the multimodality therapy strategies for locally advanced gastric cancer. With the development of laparoscopic technique in recent decades, laparoscopic technique plays a more and more important role in the surgical treatment of gastric cancer. Neoadjuvant chemotherapy, as a part of comprehensive treatment of gastric cancer, has gained more and more clinical supports and been recommended for guidelines. With the development of laparoscopic technique and clinical evidence, laparoscopic operation for advanced gastric cancer has been applied more and more widely. However, the safety and efficacy of laparoscopic resection following neoadjuvant chemotherapy, as a new treatment modality, still needs prospectively high-level researches to verify. Therefore, we will discuss some key points of laparoscopic gastrectomy after neoadjuvant chemotherapy based on the CLASS 03a trial, which is led by the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, the Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, and Chinese Laparoscopic Gastric Surgery Study Group. The CLASS 03a trial aims to confirm surgical and oncological safety of laparoscopy distal D2 radical gastrectomy for locally advanced stage gastric cancer patients (cT3~4a, N-/+, M0) who completed neoadjuvant chemotherapy. On the base of CLASS 03a trial, this article elucidates the choice of neoadjuvant chemotherapy for gastric cancer and proposes some associated problems about neoadjuvant chemotherapy combined with laparoscopic gastric cancer operation.

OBJECTIVETo establish the tissue response grading (TRG) system following neoadjuvant chemotherapy and to investigate its application in the gastric cancer patients who received neoadjuvant chemotherapy.

METHODSData of 30 cT3-4N0-3M0 gastric cancer cases who received neoadjuvant chemotherapy and operation from May 2017 to February 2018 at Department of Gastrointestinal Surgery, West China Hospital were analyzed retrospectively. The edema degree of gastrointestinal tract and perigastric tissues, intraoperative effusion, and fibrosis of tumor and lymph nodes bearing tissues which could be divided into 4 categories constituted the core parameters of the TRG system following neoadjuvant chemotherapy. Four categories of edema: grade 0, no obvious tissue edema; grade 1, slight tissue edema and swelling, no obvious effusion when dissecting the capsule of connective tissues; grade 2, moderate tissue edema and swelling, a few effusion when dissecting the capsule of connective tissues; grade 3, severe tissue edema and swelling with high tension on the capsule of connective tissues, tension blister could be observed in some patients, continuous effusion when dissecting the capsule of connective tissues. Four categories of intraoperative effusion: grade 0, no obvious effusion; grade 1, slight effusion and a few intraperitoneal exudation; grade 2, moderate effusion and continuous intraperitoneal exudation necessitating interrupted suction; grade 3, severe effusion and continuous intraperitoneal exudation necessitating constant suction. Four categories of fibrosis: grade 0, no fibrosis; grade 1, slight fibrosis with threadiness fibrous bands, clear dissecting space could be found between the fibrous tissues and adventitia/normal tissues; grade 2, moderate fibrosis with flaky fibrous tissues, the difficulty of tissue and lymph nodes dissection increased although dissecting space could be found between the fibrous tissues and adventitia/normal tissues; grade 3, severe fibrosis with hard and flaky fibrous membrane, the difficulty of tissue and lymph nodes dissection increased extremely and the fibrous tissues merges with adventitia/normal tissues without dissecting space. The relationships of TRG system with tumor response evaluation by computed tomography (CT), tumor regression score, surgical duration, number of retrieved lymph nodes, number of metastatic lymph nodes, number of enlarged lymph nodes seen in the preoperative CT scans as well as postoperative complications were analyzed using t test, χ² test and logistic regression model.

RESULTSNineteen male and 11 female patients with a mean age of(59.1±9.4) years were enrolled. There were 17 cases of grade 1, 12 cases of grade 2 and 1 case of grade 3 for tissue edema, while the corresponding number was 14, 15 and 1 for intraoperative effusion and 15, 14 and 1 for fibrosis respectively. There were no significant differences among the different degrees of tissue edema, intraoperative effusion and fibrosis in terms of the tumor response evaluation by CT and tumor regression score (all P>0.05). The results of logistics regression showed that tumor response evaluation by CT was related with the degree of tissue edema (P=0.012) and intraoperative effusion (P=0.007), rather than the degree of fibrosis (P=0.527). However, tumor regression score was not related with the degree of tissue edema(P=0.345), intraoperative effusion (P=0.159) and fibrosis (P=0.207). Surgical duration of one case with all grade 3 in tissue edema, intraoperative effusion and fibrosis was 408 minutes, which was longer than those with grade 1 and grade 2 patients [(295.9±40.1) minutes and (293.1±34.3) minutes, respectively]; the number of retrieved lymph nodes, metastatic lymph nodes, and enlarged lymph nodes seen in the preoperative CT scans of this case with all grade 3 were 25, 4 and 1, which were all less than those with grade 1 and grade 2 (42.3±11.9 and 38.5±18.2, 7.3±9.1 and 8.1±9.7, 1.8±1.6 and 2.3±1.3, respectively). There were no significant differences between grade 1 and grade 2 of tissue edema, intraoperative effusion and fibrosis in terms of surgical duration, retrieved lymph nodes, metastatic lymph nodes and enlarged lymph nodes seen in the preoperative CT scans(all P>0.05). Four patients suffered from pulmonary complications and 2 patients experienced slight lymphatic, and all leakage were cured by conservative therapies. There were no significant differences among the different grades of tissue edema, intraoperative effusion and fibrosis in terms of the operation-associated complications (all P>0.05).

CONCLUSIONThe tissue response grading system can assist the judgment of operation difficulty and reflect the effectiveness of neoadjuvant chemotherapy to some extent, which has the possibility of applications.

Aged ; China ; Female ; Humans ; Lymph Node Excision ; Lymph Nodes ; Male ; Middle Aged ; Neoadjuvant Therapy ; Retrospective Studies ; Stomach Neoplasms ; drug therapy ; surgery