Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: a single-center experience

AIM To evaluate the safety and efficacy of totally laparoscopic total gastrectomy(TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy(LATG) using a circular stapler in gastric cancer patients.METHODS We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed.RESULTS The TLTG group had higher mean ages at the time of operation(57.78 ± 11.20 years and 55.69 ± 11.96 years,P = 0.020) and more histories of abdominal surgery(20.2% and 12.4%,P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions,combined operations,pain scores and administration of analgesics,and complications were similar between the two groups. However,compared with the LATG group,the TLTG group required a shorter operation time(149 min vs 170 min,P < 0.001),had lower postoperative hematocrit change(3.49% vs 4.04%,P = 0.002),less intraoperative events(3.1% vs 10.2%,P < 0.001),less intraoperative anastomosis events(2.4% vs 7.1%,P = 0.003),faster postoperative recovery such as median time to first flatus(3.30 d vs 3.60 d,P < 0.001),faster median commencement of soft diet(4.30 d vs 4.60 d,P < 0.001) and shorter length of postoperative hospital stay(6.75 d vs 7.02 d,P = 0.005). CONCLUSION The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore,TLTG can be recommended as an appropriate procedure for gastric cancer.

Laparoscopic-assisted radical gastrectomy for distal gastric cancer

A 48-year-old female patient was diagnosed with a superficial depressed type early gastric cancer （type IIc） of 1.0 cm at the gastric angle as indicated by gastroscopy. Laparoscopic-assisted greater omentumpreserving D2 radical gastrectomy was performed in combination with Billroth I reconstruction under general anesthesia for the distal gastric cancer on April 5, 2013. The postoperative recovery was satisfying without complications. The patient was discharged seven days after surgery.

Efficacy of totally laparoscopic compared with laparoscopic-assisted total gastrectomy for gastric cancer: A meta-analysis

BACKGROUND Laparoscopic radical gastrectomy is currently the most common surgical approach for gastric cancer.The main difference between totally laparoscopic total gastrectomy(TLTG)and laparoscopic-assisted total gastrectomy(LATG)is the route of digestive tract reconstruction.However,TLTG is currently not widespread as the safety and feasibility of intracorporeal esophagojejunostomy is uncertain.AIM To compare the short-term efficacy of TLTG and LATG for radical gastrectomy of gastric cancer,and to determine the safety and feasibility of intracorporeal esophagojejunostomy.METHODS PubMed,EMBASE,and Web of Science databases were searched for all relevant articles regarding TLTG vs LATG for gastric cancer published up to October 1,2019.Inclusion and exclusion criteria were established.All the basic conditions of patients and important clinical data related to surgery were extracted,and a meta-analysis was performed with RevMan 5.3 software.RESULTS Eight studies involving a total of 1883 cases(869 cases in the TLTG group and 1014 cases in the LATG group)were included.Compared with the LATG group,reduced intraoperative blood loss(weighted mean difference=-35.37,95%CI:-61.69--9.06,P=0.008)and a larger number of retrieved lymph nodes(weighted mean difference=3.11,95%CI:-2.60-12.00,P=0.01)were found in the TLTG group.There were no significant differences in operating time,anastomotic time,tumor size,proximal resection margin length,postoperative pain score,time to first flatus,time to first oral intake,postoperative hospital stay,postoperative anastomosis-related complication rate and overall complication rate between the two groups(P>0.05).CONCLUSION Intracorporeal esophagojejunostomy is safe and feasible.TLTG has the advantages of being minimally invasive,reduced intraoperative blood loss and easier access to lymph nodes compared with LATG.Totally laparoscopic gastrectomy is likely to be the surgical trend for gastric cancer in the future.

Ileo-ileal intussusception caused by lymphangioma of the small bowel treated by single-incision laparoscopic-assisted ileal resection

Intraabdominal lymphangiomas are uncommon;additionally,those affecting the gastrointestinal tract are rare and account for less than 1%of cases.Intussusception caused by a cystic lymphangioma of the small bowel is extremely rare.The patient was a20-year-old woman who visited our emergency room with a complaint of abdominal pain.A computed tomography image revealed ileo-ileal intussusception with a leading hypovascular mass measuring 1 cm in a diameter.Single-incision laparoscopic-assisted ileal resection was performed.The surgical specimen consisted of a soft polycystic mass.Macroscopically,a pedunculated polyp with a convolutional pattern was found.Microscopically,the inner surfaces of the cysts were covered with a single layer of endothelial cells.On immunohistochemical examination,the endothelial cells were partially positive for D2-40 and CD34.Smooth muscle cells were also found around the cysts.The lesion was diagnosed as a cystic lymphangioma.Dozens of cases of small bowel lymphangiomas have previously been reported.Of these,cases with intussusception were very rare.This is the first case of small bowel intussusception due to lymphangioma treated by singleincision laparoscopic-assisted surgery.

Laparoscopic-assisted vs open transhiatal gastrectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: A retrospective cohort study

BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LTG with the open transhiatal gastrectomy(OTG) for patients with Siewert type Ⅱ AEG.METHODS We retrospectively evaluated a total of 578 patients with Siewert type Ⅱ AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG(n = 382) and OTG(n = 196) groups.RESULTS Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes(P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group(P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group(88.2% vs 79.2%, P = 0.011;79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage Ⅱ/Ⅲ patients(P < 0.05) but not for stage I patients.CONCLUSION For patients with Siewert type Ⅱ AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.

Observation on the Therapeutic Effect and Complication Rate of Totally Laparoscopic Total Gastrectomy and Laparoscopic-Assisted Total Gastrectomy in the Treatment of Gastric Cancer

Objective:To investigate the effect and complication rate of totally laparoscopic and laparoscopic-assisted total gastrectomy in the treatment of gastric cancer.Methods:From March 2019 to July 2021,60 patients with gastric cancer were selected as the subjects in this study;the patients in group A underwent laparoscopic-assisted total gastrectomy,whereas those in group B underwent totally laparoscopic total gastrectomy;the treatment effect and complication rate were compared between the two groups.Results:The postoperative recovery of group B was significantly better than that of group A,and the postoperative complications(10.00%)of group B were significantly lower than that of group A(33.33%)(P<0.05).Conclusion:For patients with gastric cancer,totally laparoscopic total gastrectomy has better therapeutic effect and lower postoperative complications,which is worthy of popularization.

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUND Three-dimensional(3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach(CRS), but its clinical efficacy remains controversial.AIM To compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy(3DLAG) with open gastrectomy(OG) for CRS.METHODS The clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up,we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival(OS) rates were compared between the two groups.RESULTS Among 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score,initial disease state(benign or malignant), primary surgical anastomosis method,interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss(188.33 ± 191.35 mL vs 305.83 ± 303.66 mL;P =0.045) and smaller incision(10.86 ± 3.18 cm vs 20.06 ± 5.17 cm;P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG(14.0 ± 7.17 vs 10.73 ± 6.82;P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups(1.56 ± 2.84 vs 2.35 ± 5.28;P = 0.413). The complication rate(8.3% vs 20.8%;P = 0.207) and intensive care unit admission rate(5.6% vs 14.5%;P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval(CI): 72.4%-95.6%] and 73.3%(95%CI: 60.0%-89.5%)respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3%(95%CI: 76.4%-99.8%) and 75.6%(95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups(P = 0.68).CONCLUSION Compared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.

Direct Instruction by an Experienced Surgeon Can Shorten the Learning Curve for Laparoscopic-Assisted Distal Gastrectomy

Aim: Laparoscopy-assisted distal gastrectomy (LADG) with regional lymph node dissection is a treatment option for patient with early gastric cancer. However, LADG is a technically complex and advanced procedure, which is challenging for inexperienced surgeons. In this report, we retrospectively evaluated the learning curve for LADG of a single surgeon with no previous experience in LADG and the usefulness of direct instruction by a surgeon experienced in LADG in shortening the learning curve. Patients and Methods: This study was analyzed 80 consecutive patients, who underwent LADG by a single surgeon (first assistant in 10 cases and operator in 70 cases) between January 2008 and December 2012. Patients were divided into 3 sequential groups of 10 (training period), 30 (learning period), and 40 (operating period) cases in each group. Median operation time and estimated blood loss for these 3 groups were determined. Other learning indicators, including transfusion requirement, postoperative complications, number of lymph node harvested, and rate of conversion open gastrectomy, were also evaluated. Results: During the training period, median operation time and estimated blood loss were 219.5 min and 83.0 ml, respectively. During the learning period, the operation time was significantly longer than that of training period. In the operating period, the operation time was significantly lesser than that during the learning period. However, the operation time was not different from that during the training period and reached a plateau. The estimated blood loss during the operating period was significantly lesser than that during the learning period. The difference in the number of lymph nodes retrieved between each group was not significant. Conclusions: Direct instructions by an experienced surgeon can decrease the number of cases required for learning. Because LADG is technically more complex than other laparoscopic procedures, standardization of LADG and an effective training system for performing it should be established.

Lung ultrasound score evaluation of the effect of pressure-controlled ventilation volume-guaranteed on patients undergoing laparoscopicassisted radical gastrectomy

BACKGROUND Laparoscopic-assisted radical gastrectomy(LARG)is the standard treatment for early-stage gastric carcinoma(GC).However,the negative impact of this proce-dure on respiratory function requires the optimized intraoperative management of patients in terms of ventilation.AIM To investigate the influence of pressure-controlled ventilation volume-guaranteed(PCV-VG)and volume-controlled ventilation(VCV)on blood gas analysis and pulmonary ventilation in patients undergoing LARG for GC based on the lung ultrasound score(LUS).METHODS The study included 103 patients with GC undergoing LARG from May 2020 to May 2023,with 52 cases undergoing PCV-VG(research group)and 51 cases undergoing VCV(control group).LUS were recorded at the time of entering the operating room(T0),20 minutes after anesthesia with endotracheal intubation(T1),30 minutes after artificial pneumoperitoneum(PP)establishment(T2),and 15 minutes after endotracheal tube removal(T5).For blood gas analysis,arterial partial pressure of oxygen(PaO_(2))and partial pressure of carbon dioxide(PaCO_(2))were observed.Peak airway pressure(P_(peak)),plateau pressure(Pplat),mean airway pressure(P_(mean)),and dynamic pulmonary compliance(C_(dyn))were recorded at T1 and T2,1 hour after PP establishment(T3),and at the end of the operation(T4).Postoperative pulmonary complications(PPCs)were recorded.Pre-and postoperative serum interleukin(IL)-1β,IL-6,and tumor necrosis factor-α(TNF-α)were measured by enzyme-linked immunosorbent assay.RESULTS Compared with those at T0,the whole,anterior,lateral,posterior,upper,lower,left,and right lung LUS of the research group were significantly reduced at T1,T2,and T5;in the control group,the LUS of the whole and partial lung regions(posterior,lower,and right lung)decreased significantly at T2,while at T5,the LUS of the whole and some regions(lateral,lower,and left lung)increased significantly.In comparison with the control group,the whole and regional LUS of the research group were reduced at T1,T2,and T5,with an increase in PaO_(2),decrease in PaCO_(2),reduction in P_(peak) at T1 to T4,increase in P_(mean) and C_(dyn),and decrease in Pplat at T4,all significant.The research group showed a significantly lower incidence of PPCs than the control group within 3 days postoperatively.Postoperative IL-1β,IL-6,and TNF-αsignificantly increased in both groups,with even higher levels in the control group.CONCLUSION LUS can indicate intraoperative non-uniformity and postural changes in pulmonary ventilation under PCV-VG and VCV.Under the lung protective ventilation strategy,the PCV-VG mode more significantly improved intraop-erative lung ventilation in patients undergoing LARG for GC and reduced lung injury-related cytokine production,thereby alleviating lung injury.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopicassisted total gastrectomy

BACKGROUND Natural orifice specimen extraction surgery(NOSES)has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy(LATG)for treating gastric cancer(GC).However,evidence regarding the efficacy and safety of NOSES for GC surgery is limited.This study aimed to compare the safety and feasibility,in addition to postoperative complications of NOSES and LATG.METHODS Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG,and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size≤5 cm.The study was conducted from May 2018 to September 2020,and patients were categorized into the NOSES group(n=22)and LATG group(n=29).Perioperative parameters were compared and analyzed,including patient and tumor characteristics,postoperative outcomes,and anastomosis-related complications,postoperative hospital stay,the length of abdominal incision,difference in tumor type,postoperative complications,and postoperative survival.RESULTS Postoperative exhaust time,operation duration,mean postoperative hospital stay,length of abdominal incision,number of specific staplers used,and Brief Illness Perception Questionnaire score were significant in both groups(P<0.01).In the NOSES group,the postoperative time to first flatus,mean postoperative hospital stay,and length of abdominal incision were significantly shorter than those in the LATG group.Patients in the NOSES group had faster postoperative recovery,and achieved abdominal minimally invasive incision that met aesthetic requirements.There were no significant differences in gender,age,tumor type,postoperative complications,and postoperative survival between the two groups.CONCLUSION The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient.This approach offers better short-term outcomes compared to LATG,while long-term survival rates are comparable to those of conventional laparoscopic surgery.

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children,enteral tube feeding becomes a necessity.The overall aim is to ultimately promote appropriate growth,improve the patient’s quality of life and increase carer satisfaction.Nasogastric tube feeding is considered appropriate on a short-term basis.Alternatively,gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements,and carries a lower risk of complications.Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition.Several techniques can be used to insert gastrostomies in children including endoscopic,image guided and surgical gastrostomy insertion whether open or laparoscopic.Each technique has its own advantages and disadvantages.The timing of gastrostomy insertion,device choice and method of insertion is dependent on the local expertise,patient requirements and family preference,and should be individualized with a multidisciplinary team approach.We aim to review gastrostomy insertion in children including indications,contraindications,history of gastrostomy,insertion techniques and complications.

Preservation of superior rectal artery in laparoscopically assisted subtotal colectomy with ileorectal anastomosis for slow transit constipation

BACKGROUND Slow transit constipation(STC)has traditionally been considered as a functional disorder.However,evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology.If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment,surgical intervention with subtotal colectomy may be effective.The most unwanted complication of the procedure is anastomotic leakage,however,preservation of the superior rectal artery(SRA)may reduce its incidence.AIM To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.METHODS This was a single-center retrospective observational study.STC was diagnosed after a series of examinations which included a colonic transit test,anal manometry,a balloon expulsion test,and a barium enema.Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018.The operation time,blood loss,time to first flatus,length of hospital days,and incidence of minor or major complications were recorded.RESULTS A total of 32 patients(mean age,42.6 years)who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA.All patients were diagnosed with STC after a series of examinations.The mean operative time was 151 min and the mean blood loss was 119 mL.The mean day of first time to flatus was 3.0 d,and the mean hospital stay was 10.6 d.There were no any patients conversions to laparotomy.Post-operative minor complications including 1 wound infection and 1 case of ileus.There was no surgical mortality.No anastomosis leakage was noted in any of the patients.CONCLUSION Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection.Sparing the SRA may protect against anastomosis leakage.

Clinical significance of aberrant left hepatic artery during gastrectomy:A systematic review

BACKGROUND Vascular variations are frequently encountered during surgery.Approximately thirty percent of these variations are aberrant left hepatic arteries originating from the left gastric artery.AIM To summarize the safety and feasibility of aberrant left hepatic arteries(ALHA)ligation in gastric cancer patients who underwent laparoscopic-assisted gastrectomy(LAG).METHODS The literature search was systematically performed on databases including Pub Med,Embase,and Cochrane Library.The publishing date of eligible studies was from inception to June 2021.RESULTS A total of nine studies were included according to the inclusion and exclusion criteria in this review.The variation rate of ALHA ranged from 7.00%to 20.70%,and four studies compared the differences between the ALHA ligation group and the preservation group.Only one study showed worse postoperative outcomes in the ALHA ligation group.In all the included studies,a significant difference was found between the ALHA ligation group and the preservation group in terms of postoperative liver enzymes after LAG.However,there was no significant difference in the number of retrieved lymph nodes between the two groups.CONCLUSION In conclusion,it is not always safe and feasible for surgeons to ligate the ALHA during LAG surgery,and it is necessary for gastric cancer patients to undergo preoperative examination to clarify the ALHA subtypes,measure the diameter of the ALHA,and determine whether the patients have chronic liver disease.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years,a wide range of gastrointestinal endoscopy techniques have been developed,such as endoscopic submucosal dissection(ESD)and endoscopic retrograde cholangiopancreatography(ERCP).Although ESD and ERCP have an important role in gastrointestinal and biliary diseases,each technique has its limitations.Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time.Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area.Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate.The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction,stenosis and bile duct injuries.For patients with simultaneous presence of stones in the gallbladder and the common bile duct,the laparoendoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP.Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction.The most common used approach to deliver the magnets is by percutaneous-peroral tract.Laparoscopicassisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.