Gastric cancer is one of the most common gastrointestinal malignancies in China. D2 radical gastrectomy is the main treatment for advanced gastric cancer patients. With the advancement of laparoscopic technology, laparoscopic radical gastrectomy has been gradually developed in the world, and even popularized in China. There have been a lot of literature reports on the indications, the scope of lymph node dissection and the improvement of techniques of laparoscopic radical gastrectomy for gastric cancer. Relevant guidelines or consensus for radical gastrectomy. The prevention and treatment of complications of gastrointestinal reconstruction for laparoscopic radical gastric cancer surgery is a major concern for gastrointestinal surgeons. Once complications occur in digestive tract reconstruction, it would increase the hospitalization cost, prolong the hospitalization stay of patients, delay follow-up chemotherapy, and even lead to postoperative death or other serious consequences. Therefore, it is of positive and far-reaching clinical significance to pay attention to the techniques of gastrointestinal reconstruction after laparoscopic radical gastric cancer surgery, to reduce the occurrence of gastrointestinal reconstruction complications, and to detect and reasonably manage related complications in a timely manner. The Chinese expert consensus on prevention and treatment of complications related to digestive tract reconstruction after laparoscopic radical gastrectomy for gastric cancer (2022 edition) has significance value for reducing the occurrence of gastrointestinal reconstruction complications. This manuscript mainly serves as the interpretation and supplement of this Consensus.
Humans ; Consensus ; Gastrectomy/methods* ; Laparoscopy/adverse effects* ; Lymph Node Excision ; Retrospective Studies ; Stomach Neoplasms/pathology* ; China

Surgery is the main curative treatment for gastric cancer. As surgical techniques continue to improve, the scope of radical resection and lymph node dissection has formed consensus and guidelines, so people's attention has gradually shifted to the quality of life (QOL) of patients after surgery. Postgastrectomy syndrome is a series of symptoms and signs caused by complications after gastrectomy, which can affect the quality of life of patients with gastric cancer after surgery. Gastrectomy and anastomosis are closely related to postgastrectomy syndrome. The selection of appropriate surgical methods is very important to the quality of life of patients after surgery. This article reviews the effects of gastrectomy procedures on postoperative quality of life of patients with gastric cancer and its evaluation methods.
Gastrectomy/methods* ; Humans ; Lymph Node Excision/adverse effects* ; Postgastrectomy Syndromes ; Quality of Life ; Stomach Neoplasms/complications*

Objective: To evaluate the feasibility of identification and preservation of arm lymphatics (DEPART) in axillary lymph node dissection (ALND) for breast cancer to prevent arm lymphedema. Methods: A randomized controlled study method was used. Two hundred and sixty-five patients who underwent breast cancer surgery at the Department of Thyroid and Breast Surgery, Zhongnan Hospital of Wuhan University from November 2017 to June 2018 were included, and the patients were randomly divided into ALND+ DEPART group (132 patients) and standard ALND group (133 patients) by random number table method. In the ALND+ DEPART group, indocyanine green and methylene blue were injected as tracers before surgery, and the arm sentinel nodes was visualized by staged tracing during intraoperative dissection of axillary lymph nodes. Partial frozen sections were made of arm lymph nodes >1 cm in length and hard and suspicious of metastasis, and arm lymph nodes and lymphatic vessels were selectively preserved. Patients in the standard ALND group underwent standard ALND. Objective and subjective indexes of arm lymphedema were evaluated by 5-point circumference measurement and Norman questionnaire. Results: Among 132 breast cancer patients in the ALND+ DEPART group, 121 (91.7%) completed DEPART. There were no statistically significant differences in age, body mass index, pathological type, dissection number of axillary lymph node, N stage, TNM stage, molecular typing, and regional radiotherapy between the ALND+ DEPART and standard ALND groups (P>0.05). At a median follow-up of 24 months, assessment by the 5-point circumference measurement showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.0% (6/121) and 15.8% (21/133), respectively, with statistically significant differences (P=0.005). Assessment by the Norman questionnaire showed that the incidence rates of lymphedema in the ALND+ DEPART and standard ALND groups were 5.8% (7/121) and 21.8% (29/133), respectively, with a statistically significant difference (P<0.001). No local regional recurrence was observed in either group during the follow-up period. Conclusion: For breast cancer patients with positive axillary lymph nodes, the administration of DEPART during ALND can reduce or avoid the occurrence of arm lymphedema without compromising oncology safety.
Arm/pathology* ; Axilla/pathology* ; Breast Neoplasms/pathology* ; Female ; Humans ; Lymph Node Excision/methods* ; Lymph Nodes/surgery* ; Lymphatic Vessels/pathology* ; Lymphedema/surgery* ; Sentinel Lymph Node Biopsy/adverse effects*

OBJECTIVETo systematically assess the safety and efficacy of hand-assisted laparoscopic distal gastrectomy (HALG) versus open distal gastrectomy (ODG) for gastric cancer.

METHODSChinese or English literature regarding comparison of HALG and ODG were collected by searching in databases (such as PubMed, Cochrane Library, CNKI, Wanfang database) between January 1996 and September 2016. The data of operative time, incision length, blood loss, number of harvested lymph nodes, time to flatus, hospital stay, postoperative complication morbidity and long-term outcomes were compared between the two procedures. Then funnel plot was used to evaluate publication bias and sensitivity analysis was used to evaluate the stability of the results. All these data analyses were performed using the Meta for or Meta package of R version 3.3.1.

RESULTSA total of 7 studies with 835 patients (323 cases in HALG group and 512 cases in ODG group) were included. Compared with ODG, HALG had a longer operative time (WMD=28.93 minutes, 95%CI=9.59 to 48.28, Z=2.93, P=0.000), a shorter incision length (WMD=-10.31 cm, 95%CI=-14.01 to -6.62, Z=-5.47, P=0.000), less blood loss (WMD=-140.08 ml, 95%CI=-215.07 to -65.09, Z=-3.66, P=0.000), faster gastrointestinal recovery (WMD=-1.23 days, 95%CI=-1.89 to -0.56, Z=-3.62, P=0.000), shorter postoperative hospital stay (WMD=-3.24 days, 95%CI=-5.47 to -1.02, Z=-2.85, P=0.000). In subgroup analysis, 3 studies published before 2013 vs. 4 studies published afterwards, the number of harvested lymph nodes (WMD=-0.78, 95%CI=-2.05 to 0.50, Z=-1.19, P=0.235) and postoperative complication morbidity (RR=1.02, 95%CI=0.43 to 2.44, Z=0.05, P=0.961) did not differ significantly between two groups. Compared with ODG, the RR(95%CI) of ileus of HALG was 0.43 (0.07 to 2.82), but the difference was not statistically significant (P=0.383). One study reported the 5-year overall survival rates of HALG and ODG were 81.0% vs 67.5%, and the tumor recurrence rates were 7.1% vs 22%, respectively, but the differences were not statistically significant(all P>0.05). Sensitivity analysis showed that the above results were stable. The funnel plots of the lymph nodes and postoperative complication morbidity did not present significant publication bias.

CONCLUSIONSHALG has the advantages of minimal invasiveness such as shorter incision length and quicker recovery. Furthermore, the short-term efficacy of HALG is similar to conventional open surgery. However, the long-term efficacy is lack of support from multicenter long-term follow-up results.

Blood Loss, Surgical ; statistics & numerical data ; Comparative Effectiveness Research ; Gastrectomy ; methods ; Hand-Assisted Laparoscopy ; adverse effects ; Humans ; Length of Stay ; statistics & numerical data ; Lymph Node Excision ; statistics & numerical data ; Neoplasm Recurrence, Local ; epidemiology ; Operative Time ; Postoperative Complications ; epidemiology ; Postoperative Period ; Recovery of Function ; Stomach Neoplasms ; mortality ; surgery ; Survival Rate ; Time ; Treatment Outcome

OBJECTIVETo investigate the feasibility of segmental pylorus-reservation gastrectomy in patients with early gastric cancer.

METHODA retrospective cohort study on clinical data of 6 patients strictly met the criteria of early gastric cancer locating in the middle of the stomach undergoing laparoscopic segmental gastrectomy from January 2014 to April 2016 at Department of General Surgery, Peking Union Medical College Hospital was carried out. Preoperative clinical staging revealed T1N0M0 for all the cases. One case received endoscopic mucosa resection(EMR) first, and postoperative pathology showed moderate differentiated adenocarcinoma invading substratum of mucosa, so a complementary laparoscopic segmental gastrectomy was performed. Surgical procedure was laparoscopic segmental gastrectomy with D1 or D2 lymph node dissection. Vagus nerve was not reserved during lymph node dissection in lesser curvature side. Number of resected lymph node, postoperative complication and long-term gastric function were observed.

RESULTOf 6 cases, 3 were male and 3 were female with age ranging from 55 to 59 years old. The distal resection margin was (4.6±0.5) cm away from pylorus. The average number of resected lymph node was 18.3±7.5 without metastasis. Follow-up time was 1 to 29 months for all the 6 cases and no relapse or metastasis was found during the follow-up. In 4 cases with follow-up beyond 1 year, 3 cases had slight distension in superior belly after meal and dyspepsia; another one case had vomiting nocturnal occasionally. Gastroscope examination one year after operation found food residue in all the cases. Images indicated the decrease of stomach size in all the cases. Two cases had esophagogastric reflux. All the patients had delayed gastric emptying symptoms after operations and were relieved within one year.

CONCLUSIONSIt is technically feasible to perform laparoscopic segmental gastrectomy in patients with early gastric cancer. Whether vagus nerve should be reserved requires further investigation.

Female ; Gastrectomy ; adverse effects ; methods ; Gastroesophageal Reflux ; epidemiology ; etiology ; Gastroparesis ; epidemiology ; etiology ; Humans ; Laparoscopy ; adverse effects ; methods ; Lymph Node Excision ; adverse effects ; methods ; statistics & numerical data ; Male ; Middle Aged ; Neoplasm Staging ; Postoperative Complications ; epidemiology ; etiology ; Retrospective Studies ; Stomach Neoplasms ; surgery ; Treatment Outcome ; Vagus Nerve ; surgery ; Vomiting ; epidemiology ; etiology

OBJECTIVETo compare clinically relevant postoperative complications after open, laparoscopic, and robotic gastrectomy for gastric cancer.

METHODSClinical data of patients with gastric cancer who underwent gastrectomy between January 1, 2014 and October 1, 2016 at Chinese People's Liberation Army General Hospital were analyzed retrospectively. All the patients were diagnosed by upper endoscopy and confirmed by biopsy without distant metastasis. They were confirmed with R0 resection by postoperative pathology. Patients with incomplete data were excluded. The complications among open group, laparoscopic group and robotic group were compared. The continuous variables were analyzed by one-way ANOVA, and categorical variables were analyzed by χtest or Fisher exact test.

RESULTSA total of 1 791 patients (1 320 males and 471 females) were included in the study, aged from 17 to 98 (59.0±11.6) years, comprising 922 open, 673 laparoscopic and 196 robotic gastrectomies. There were no significant differences among three groups in baseline data (gender, age, BMI, comorbidity, radiochemotherapy) and some of operative or postoperative data (blood transfusion, number of lymph node dissection, combined organ resection, resection site, N stage, postoperative hospital stay). The blood loss in laparoscopic and robotic groups was significantly lower than that in open group[(185.7±139.6) ml and (194.0±187.6) ml vs. (348.2±408.5) ml, F=59.924, P=0.000]. The postoperative complication occurred in 197 of 1 791(11.0%) patients. The Clavien-Dindo II(, III(a, III(b, IIII(a, and IIIII( complications were 5.5%, 4.0%, 1.2%, 0.1%, and 0.2% respectively. The anastomotic leakage (2.4%), intestinal obstruction(1.3%) and pulmonary infection(1.2%) were the three most common complications, followed by wound infection(0.8%), cardiovascular disease(0.7%), anastomotic bleeding (0.7%), delayed gastric emptying (0.6%), duodenal stump fistula(0.5%), intraperitoneal hemorrhage (0.5%), pancreatic fistula (0.3%), intra-abdominal infection(0.2%), chylous leakage (0.1%) and other complications(1.7%). There were no significant differences among three groups as the complication rates of open, laparoscopic and robotic gastrectomy were 10.6%(98/922), 10.8%(73/673) and 13.3%(26/196) respectively (χ=1.173, P=0.566). But anastomotic leakage occurred more common after laparoscopic and robotic gastrectomy compared to open gastrectomy [3.1%(21/673) and 5.1%(10/196) vs. 1.3%(12/922), χ=12.345, P=0.002]. The rate of cardiocerebral vascular diseases was higher in open group[1.3%(12/922) vs. 0.1%(1/673) and 0, χ=8.786, P=0.012]. And the rate of anastomotic bleeding was higher in robotic group [2.0%(4/196) vs. open 0.4%(4/922) and laparoscopic 0.6%(4/673), χ=6.365, P=0.041]. In view of Clavien-Dindo classification, III(a complications occurred more common in laparoscopic group [5.5%(37/673) vs. open 3.3%(30/922) and robotic 2.6%(5/196), χ=6.308, P=0.043] and III(b complications occurred more common in robotic group [3.1%(6/196) vs. open 1.1%(10/922) and laparoscopic 0.7%(5/673), χ=7.167, P=0.028].

CONCLUSIONSMorbidities of postoperative complications are comparable among open, laparoscopic and robotic gastrectomy for gastric cancer. However, in consideration of the high difficulty of anastomosis, the minimally invasive surgery should be performed by more experienced surgeons.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Anastomotic Leak ; epidemiology ; etiology ; Blood Loss, Surgical ; statistics & numerical data ; Cerebrovascular Disorders ; epidemiology ; etiology ; Chylous Ascites ; epidemiology ; etiology ; Comorbidity ; Comparative Effectiveness Research ; Duodenal Diseases ; epidemiology ; etiology ; Female ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; epidemiology ; etiology ; Gastroparesis ; epidemiology ; etiology ; Gastroscopy ; Hemoperitoneum ; epidemiology ; etiology ; Humans ; Intestinal Fistula ; epidemiology ; etiology ; Intraabdominal Infections ; epidemiology ; etiology ; Laparoscopy ; adverse effects ; Length of Stay ; Lymph Node Excision ; Male ; Middle Aged ; Postoperative Complications ; epidemiology ; etiology ; Postoperative Hemorrhage ; epidemiology ; etiology ; Postoperative Period ; Respiratory Tract Infections ; epidemiology ; etiology ; Retrospective Studies ; Risk Assessment ; Robotic Surgical Procedures ; adverse effects ; Stomach Neoplasms ; surgery ; Surgical Wound Infection ; epidemiology ; etiology

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.
Anastomosis, Roux-en-Y ; adverse effects ; China ; Chylous Ascites ; etiology ; prevention & control ; therapy ; Duodenum ; blood supply ; surgery ; Gastrectomy ; adverse effects ; methods ; mortality ; Gastric Outlet Obstruction ; etiology ; prevention & control ; Gastric Stump ; surgery ; Hemostatic Techniques ; Hernia ; etiology ; prevention & control ; therapy ; High-Intensity Focused Ultrasound Ablation ; instrumentation ; Humans ; Jejunum ; blood supply ; surgery ; Lymph Node Excision ; adverse effects ; instrumentation ; Lymphatic System ; injuries ; Postoperative Complications ; classification ; diagnosis ; mortality ; prevention & control ; Prognosis ; Stomach ; surgery ; Stomach Neoplasms ; complications ; surgery ; Suture Techniques ; standards ; Thoracic Duct ; injuries ; Wound Closure Techniques ; standards

D2 lymphadenectomy is currently the worldwide standard operation for locally advanced gastric cancer and D2+ is an option for some selected patients. The D2 plus lymphadenectomy includes No.8p, No.10, No.11d, No.12b, No.12p, No.13, No.14v, No.16a2 and No.16b1. Dissection of these groups of lymph nodes may cause related complications. Postoperative complications that can cause prolonged inflammation have significant impact not only on mortality but also on overall survival of patients with gastric cancer even if the tumor is resected curatively. D2 plus lymphadenectomy is recommended only in high volume medical center by experienced surgeon. The adequate exposure of the operative field, right anatomical space, use of ultrasound scalpel and operator with enough patience are proved to be pivotal to prevent the complications.
High-Intensity Focused Ultrasound Ablation ; instrumentation ; Humans ; Inflammation ; prevention & control ; Long Term Adverse Effects ; prevention & control ; Lymph Node Excision ; adverse effects ; instrumentation ; methods ; mortality ; Lymph Nodes ; Postoperative Complications ; prevention & control ; Stomach Neoplasms ; mortality ; surgery ; Surgical Instruments

Radical surgery of gastric cancer (D2 lymph node dissection) as the standard operation is widely used in clinical practice and satisfactory prognosis can be obtained in patients who receive radical gastrectomy. But surgical invasion can cause high morbidity of complications and mortality. The data of large-scale evidence-based medical clinical trials and large databases in Japan and Korea showed that anastomotic leakage, pancreatic leakage and abdominal abscess were the most common complications after gastrectomy, and the morbidity of complication was about 20% and mortality was about 1%. The risk factors such as elderly, obesity, and comorbidities may increase the morbidity of complications and mortality, and these factors were regarded as poor predictors after operation. Postoperative complications criteria of gastric cancer surgery is mainly used with Clavien-Dindo classification of surgical complications as international standard, and this criteria is also used in Korea. The postoperative complications are evaluated with the Common Terminology Criteria for Adverse Events (CTCAE v4.0) and Japanese Clinical Oncology Group(JCOG) postoperative complications criteria for grading definitions of postoperative complications after gastric surgery in Japan. These classifications of postoperative complications criteria were adopted widely in Japan with large-scale evidence-based medical clinical trials of gastric cancer. PS, ASA, POSSUM, E-PASS, APACHE-II(, Charison weighted index of comorbidities (WIC), Frailty Score was used in predicting postoperative mortality and morbidity in gastric cancer patients. These risk factors were assigned points in scoring systems to objectively evaluate risk of surgery, and surgical operation method was one of the risk factors on the basis of these scoring systems. We can use these scoring systems for choosing reasonable surgical methods and proper perioperative management.
APACHE ; Gastrectomy ; adverse effects ; methods ; Health Status Indicators ; Humans ; Japan ; Korea ; Lymph Node Excision ; adverse effects ; Patient Care Planning ; standards ; Perioperative Care ; methods ; Postoperative Complications ; classification ; diagnosis ; mortality ; prevention & control ; Prognosis ; Risk Assessment ; methods ; Risk Factors ; Stomach Neoplasms ; complications ; surgery

OBJECTIVETo compare the clinical efficacy of robotic and laparoscopic radical surgery in the treatment of middle-low rectal cancers.

METHODSFrom January 2015 to March 2016, intra-operative and postoperative follow-up data of 30 patients with middle-low rectal cancers who underwent robotic radical resection(robot group) and 32 patients with middle-low rectal cancers who underwent laparoscopic radical resection (laparoscopy group)n in our department were retrospectively collected. The distance from cancer to anal margin was less than 10 cm in both two groups and advanced rectal cancers were confirmed by preoperative colonoscopy biopsy. Associated data were compared between two groups.

RESULTSThere were 13 males and 17 females in robot group with age of 27 to 85 (mean 59.7) years, disease course of 3 to 12 (mean 6.2) months and clinical stage T2-3N0-1. There were 16 males and 16 females in laparoscopic group with age of 32 to 79 (mean 60.3) years, disease course of 2 to 10(mean 5.9) months and clinical stage T2-3N0-1. The baseline data of two groups were not significantly different (all P>0.05). All the patients in two groups completed operations successfully without conversion to open operation. Compared with laparoscopic group, the blood loss was less [(100.3±43.7) ml vs. (150.3±68.2) ml, t=3.413, P=0.001], the first flatus time [(49.3±12.4) h vs. (58.6±12.5) h, t=2.838, P=0.006] and urinary catheter removal time [(3.0±0.7) d vs. (4.8±0.9) d, t=5.491, P=0.000] were shorter, while the operation time [(217.3±57.8) min vs. (187.9±23.1) min, t=2.772, P=0.009] was longer in robot group. No cancer tissue was observed in resection margin of two groups. Number of harvested lymph node per case (15.2±7.4 vs. 13.9±4.9, t=-0.764, P=0.448), distance from anal margin to tumor distal edge [(7±3) cm vs. (6.5±3) cm, t=-1.952, P=0.056] and postoperative hospital stay [(13.6±1.3) d vs. (13.8±1.8) d, t=0.925, P=0.359] were not significantly different between two groups. No serious complications occurred in two groups during intra-operative and postoperative period. During following up of 3 to 12 (average 8.7) months, 1 case of anastomotic fistula occurred in each group and was cured by conservative treatment without significant difference [3.3%(1/30) vs. 3.1%(1/32), P=1.000]. No sexual dysfunction was found in either groups. Two cases in laparoscopic group presented relapse and metastasis, but no recurrence and metastasis was observed in robot group. There was no death in two groups.

CONCLUSIONRobotic radical surgery in the treatment of middle-low rectal cancers is safe and effective with the advantages of less trauma, less bleeding, rapid recovery of intestinal function and urinary function.

Adult ; Aged ; Blood Loss, Surgical ; Comparative Effectiveness Research ; Defecation ; Digestive System Surgical Procedures ; adverse effects ; methods ; Female ; Fistula ; etiology ; surgery ; Humans ; Laparoscopy ; adverse effects ; Length of Stay ; Lymph Node Excision ; Male ; Middle Aged ; Neoplasm Metastasis ; Neoplasm Recurrence, Local ; Operative Time ; Postoperative Period ; Recovery of Function ; Rectal Neoplasms ; surgery ; Retrospective Studies ; Robotic Surgical Procedures ; adverse effects ; Treatment Outcome ; Urination