Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND Laparoscopic radical gastrectomy is widely used,and perioperative complications have become a highly concerned issue.AIM To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery,guide perioperative treatment strategies for gastric cancer patients,and prevent serious complications.METHODS In total,998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model,and 398 patients were included in the validation group.The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected.Three machine learning methods,lasso regression,random forest,and artificial neural networks,were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy,and their prediction efficacy and accuracy were evaluated.RESULTS The constructed complication model,particularly the random forest model,could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy.It exhibited stable performance in external validation and is worthy of further promotion in more centers.CONCLUSION Using the risk factors identified in multicenter datasets,highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established.We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

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.

Harnessing interventions during the immediate perioperative period to improve the long-term survival of patients following radical gastrectomy

Although the incidence and mortality of gastric cancer(GC)have been decreasing steadily worldwide,especially in East Asia,the disease burden of this malignancy is still very heavy.Except for tremendous progress in the management of GC by multidisciplinary treatment,surgical excision of the primary tumor is still the cornerstone intervention in the curative-intent treatment of GC.During the relatively short perioperative period,patients undergoing radical gastrectomy will suffer from at least part of the following perioperative events:Surgery,anesthesia,pain,intraoperative blood loss,allogeneic blood transfusion,postoperative complications,and their related anxiety,depression and stress response,which have been shown to affect long-term outcomes.Therefore,in recent years,studies have been carried out to find and test interventions during the perioperative period to improve the long-term survival of patients following radical gastrectomy,which will be the aim of this review.

Influences of dexmedetomidine on stress responses and postoperative cognitive and coagulation functions in patients undergoing radical gastrectomy under general anesthesia

BACKGROUND Radical gastrectomy(RG)is commonly used in the treatment of patients with gastric cancer(GC),but this procedure may lead to stress responses,postoperative cognitive dysfunction,and blood coagulation abnormalities in patients.AIM To investigate the influences of dexmedetomidine(DEX)on stress responses and postoperative cognitive and coagulation functions in patients undergoing RG under general anesthesia(GA).METHODS One hundred and two patients undergoing RG for GC under GA from February 2020 to February 2022 were retrospectively reviewed.Of these,50 patients had received conventional anesthesia intervention[control group(CG)]and 52 patients had received DEX in addition to routine anesthesia intervention[observation group(OG)].Inflammatory factor(IFs;tumor necrosis factor-α,TNF-α;interleukin-6,IL-6),stress responses(cortisol,Cor;adrenocorticotropic hormone,ACTH),cognitive function(CF;Mini-Mental State Examination,MMSE),neurological function(neuron-specific enolase,NSE;S100 calciumbinding protein B,S100B),and coagulation function(prothrombin time,PT;thromboxane B2,TXB2;fibrinogen,FIB)were compared between the two groups before surgery(T0),as well as at 6 h(T1)and 24 h(T2)after surgery.RESULTS Compared with T0,TNF-α,IL-6,Cor,ACTH,NSE,S100B,PT,TXB2,and FIB showed a significant increase in both groups at T1 and T2,but with even lower levels in OG vs CG.Both groups showed a significant reduction in the MMSE score at T1 and T2 compared with T0,but the MMSE score was notably higher in OG compared with CG.CONCLUSION In addition to a potent inhibitory effect on postoperative IFs and stress responses in GC patients undergoing RG under GA,DEX may also alleviate the coagulation dysfunction and improve the postoperative CF of these patients.

Emergency exploratory laparotomy and radical gastrectomy in patients with gastric cancer combined with acute upper gastrointestinal bleeding

BACKGROUND Gastric cancer(GC)is a prevalent malignant tumor worldwide and ranks as the fourth leading cause of cancer-related mortality.Upper gastrointestinal bleeding(UGIB)is a frequent complication of GC.Radical gastrectomy and palliative therapy are widely used surgical procedures in the clinical management of GC.This study intends to probe the clinical efficacy and safety of radical gastrectomy and palliative therapy on the basis of exploratory laparotomy in patients with GC combined with UGIB,hoping to provide valuable information to aid patients in selecting the appropriate surgical intervention.AIM To investigate the clinical efficacy and safety of exploratory laparotomy^(+)radical gastrectomy and palliative therapy in patients with GC and UGIB combined.METHODS A total of 89 GC patients admitted to the First Affiliated Hospital of the University of South China between July 2018 and July 2020 were selected as participants for this study.The 89 patients were divided into two groups:radical resection group(n=46)treated with exploratory laparotomy^(+)radical gastrectomy and Palliative group(n=43)treated with palliative therapy.The study compared several variables between the two groups,including surgical duration,intraoperative blood transfusion volume,postoperative anal exhaust time,off-bed activity time,length of hospitalization,and incidence of complications such as duodenal stump rupture,anastomotic obstruction,and postoperative incision.Additionally,postoperative immune function indicators(including CD3^(+),CD4^(+),CD8^(+),CD4^(+)/CD8^(+),and CD3^(+)/HLADR^(+)),immunoglobulin(IgG and IgM),tumor markers(CEA,CA199,and CA125),and inflammatory factors(IL-6,IL-17,and TNF-α)were assessed.The surgical efficacy and postoperative quality of life recovery were also evaluated.The patients were monitored for survival and tumor recurrence at 6 mo,1 year,and 2 years post-surgery.RESULTS The results indicated that the duration of operation time and postoperative hospitalization did not differ between the two surgical procedures.However,patients in the radical resection group exhibited shorter intraoperative blood loss,anus exhaust time,off-bed activity time,and inpatient activity time than those in the Palliative group.Although there was no substantial difference in the occurrence of postoperative complications,such as duodenal stump rupture and anastomotic obstruction,between the radical resection group and Palliative group(P>0.05),the radical resection group exhibited higher postoperative immune function indicators(including CD3^(+),CD4^(+),CD8^(+),etc.)and immunoglobulin levels(IgG,IgM)than the Palliative group,while tumor markers and inflammatory factors levels were lower than those in the radical resection group.Additionally,surgical efficacy,postoperative quality of life,and postoperative survival rates were higher in patients who underwent radical gastrectomy than in those who underwent palliative therapy.Moreover,the probability of postoperative tumor recurrence was lower in the radical gastrectomy group compared to the palliative therapy group,and these differences were all statistically significant(P<0.05).CONCLUSION Compared to palliative therapy,exploratory laparotomy^(+)radical gastrectomy can improve immune function,reduce the levels of tumor markers and inflammatory factors,improve surgical efficacy,promote postoperative quality of life recovery,enhance survival rates,and attenuate the probability of tumor recurrence.

Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer:An academic perspective

BACKGROUND Few studies have examined the specific efficacy of deep neuromuscular blockade(NMB)combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy(LRG)in the elderly.AIM To investigate the application effect of deep neuromuscular blockade(NMB)combined with reduced pneumoperitoneum pressure in LRG for gastric cancer(GC)in elderly patients and its influence on inflammation.METHODS Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed.Among them,45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group,while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group.The two groups were compared in the changes of the Leiden-surgical rating scale score,serum tumor necrosis fact-α(TNF-α)and interleukin 6(IL-6)before and after therapy.The visual analogue scale(VAS)was adopted for evaluating the shoulder pain of patients at 8 h,24 h and 48 h after the operation.The driving pressure of the two groups at different time points was also compared.Additionally,the operation time,pneumoperitoneum time,infusion volume,blood loss,extubation time after surgery,residence time in the resuscitation room,TOF%=90%time and post-anesthetic recovery room(PACU)stay time were all recorded,and adverse PACU-associated respiratory events were also recorded.The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared.RESULTS No significant difference was found between the two groups at the time of skin incision,60 minutes since the operation and abdominal closure after surgery(P>0.05).The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery(P<0.05).Additionally,the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum(P<0.05).Additionally,the two groups were similar in terms of the operation time,pneumoperitoneum time,infusion volume,blood loss,extubation time after surgery,residence time in the resuscitation room and TOF%=90%time(P>0.05),and the observation group showed significantly lower TNF-αand IL-6 Levels than the control group at 24 h after therapy(P<0.05).Moreover,the incidence of adverse events was not significantly different between the two groups(P>0.05),and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group(P<0.05).CONCLUSION Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction,without hindering the surgical vision and increasing adverse PACU-associated respiratory events,and can thus shorten the hospitalization time and treatment cost for patient.

Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients

AIM: To assess the impact of fast-track surgery (FTS) on hospital stay, cost of hospitalization and complications after radical total gastrectomy. METHODS: A randomized, controlled clinical trial was conducted from November 2011 to August 2012 in the Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, the Fourth Military Medical University. A total of 122 gastric cancer patients who met the selection criteria were randomized into FTS and conventional care groups on the first day of hospitalization. All patients received elective standard D2 total gastrectomy. Clinical outcomes, including duration of flatus and defecation, white blood cell count, postoperative pain, duration of postoperative stay, cost of hospitalization and complications were recorded and evaluated.Two specially trained doctors who were blinded to the treatment were in charge of evaluating postoperative outcomes, discharge and follow-up. RESULTS: A total of 119 patients finished the study, including 60 patients in the conventional care group and 59 patients in the FTS group. Two patients were excluded from the FTS group due to withdrawal of consent. One patient was excluded from the conventional care group because of a non-resectable tumor. Compared with the conventional group, FTS shortened the duration of flatus (79.03 ± 20.26 hvs 60.97 ± 24.40 h, P = 0.000) and duration of defecation (93.03 ± 27.95 h vs 68.00 ± 25.42 h, P = 0.000), accelerated the decrease in white blood cell count [P < 0.05 on postoperative day (POD) 3 and 4], alleviated pain in patients after surgery (P < 0.05 on POD 1, 2 and 3), reduced complications (P < 0.05), shortened the duration of postoperative stay (7.10 ± 2.13 dvs 5.68 ± 1.22 d,P = 0.000), reduced the cost of hospitalization (43783.25 ± 8102.36 RMBvs 39597.62 ± 7529.98 RMB,P = 0.005), and promoted recovery of patients. CONCLUSION: FTS could be safely applied in radical total gastrectomy to accelerate clinical recovery of gastric cancer patients.

Laparoscopy-assisted D2 radical distal gastrectomy for gastric cancer (Billroth Ⅱ anastomosis)

Laparoscopic radical gastrectomy has been increasingly applied in China. However, how to reduce surgery-related trauma, shorten operative time and achieve the long-term prognosis equal to the conventional open surgery is still hot research topics. Along with the change in learning curve and the optimization of endoscopic techniques, laparoscopic lymph node dissection can achieve or even exceed the extent that can be achieved in open surgery. Therefore, it has gradually replaced the conventional digestive tract reconstruction using an auxiliary incision. By completing the laparoscopic digestive tract reconstruction with EndoGIA, we describe the laparoscopy-assisted D2 radical distal gastrectomy for gastric cancer （Billroth Ⅱ anastomosis）.

Effect of Subcostal Anterior Quadratus Lumborum Block vs.Oblique Subcostal Transversus Abdominis Plane Block after Laparoscopic Radical Gastrectomy

Objective:To evaluate the analgesic effect of ultrasound-guided subcostal anterior quadratus lumborum block(QLB)for laparoscopic radical gastrectomy surgery.Methods:Patients(aged 20-65 years,ASA Ⅰ-Ⅱ,and weighing 40-75 kg)scheduled for elective laparoscopic radical gastrectomy were enrolled in the current study.Sixty patients were randomly assigned to two groups by computer-generated randomization codes:an ultrasound-guided oblique subcostal transversus abdominis plane block(TAPB)group(group T,n=30)or an ultrasound-guided subcostal anterior QLB group(group Q,n=30).In both groups,bilateral ultrasound-guided oblique subcostal TAPB and subcostal anterior QLB were performed before general anesthesia with 0.25% ropivacaine 0.5 mL/kg.For postoperative management,all patients received patient-controlled intravenous analgesia(PCIA)with nalbuphine and sufentanil after surgery,maintaining visual analogue scale(VAS)scores<4 within 48 h.The intraoperative consumption of remifentanil,the requirement for sufentanil as a rescue analgesic,and the VAS scores at rest and coughing were recorded at 1,6,12,24 and 48 h after surgery.The recovery(extubation time after surgery,first ambulation time,first flatus time and length of postoperative hospital stay)and the adverse events(nausea and vomiting,skin pruritus,respiratory depression and nerve-block related complications)were observed and recorded.The primary outcome was the perioperative consumption of opioids.Results:Compared with group T,the intraoperative consumption of remifentanil,requirement for sufentanil and the frequency of PCIA were reduced in group Q.Meanwhile,VAS scores at all points of observation were significantly lower in group Q than in group T.Patients in group Q were also associated with shorter time to first out-of-bed activity and flatus,and shorter length of postoperative hospital stay than group T(P<0.05).There were no skin pruritus,respiratory depression or nerve-block related complications in both groups.Conclusion:Compared with ultrasound-guided oblique subcostal TAPB,ultrasound-guided subcostal anterior QLB provided greater opioid-sparing effect,lower visual analogue scores,and shorter postoperative hospital stay for laparoscopic radical gastrectomy.

Heterotopic ossification beneath the upper abdominal incision after radical gastrectomy:Two case reports

BACKGROUND Heterotopic ossification(HO)is a rare clinical phenomenon that refers to bone formation in nonossifying tissues.CASE SUMMARY This report presents two cases of HO beneath the upper abdominal median incision after radical gastrectomy.The first patient had postoperative pain below the incision area.There were no signs of anastomotic leakage,and the wound healed.Computed tomography(CT)findings 2 wk postoperatively were negative for HO,but the 6-wk CT showed HO beneath the incision.The patient refused reoperation,and after conservative therapy,the pain was gradually relieved after 2 wk.In the second case,postoperative recovery was uneventful,and HO was only detected on routine follow-up CT after 4 mo.An anti-adhesion membrane was applied beneath the peritoneum in both patients.Our findings suggest that HO beneath the abdominal incision might form at approximately 1 mo postoperatively.It may cause intractable pain;however,reoperation is usually not required.CONCLUSION In our cases,we suspect that HO may be related to the use of foreign materials beneath the peritoneum,which needs to be further investigated.

Radical gastrectomy for D2 distal gastric cancer

Patient＇s information The patient is a 56-year-old man who visited our hospital for ＂repeated epigastric pain for more than two months.＂ Physical examination showed nearly pale appearance; abdomen was soft and no mass palpable; left supraclavicular lymph node （-）; and digital rectal examination （-）.

Effect of enteral and parenteral nutritional diet intervention on recovery, nutritional status and immune functi on for gastric cancer patients after radical gastrectomy

Objective:To explore the effect of enteral and parenteral nutritional diet intervention on recovery, nutritional status and immune function for gastric cancer patients after radical gastrectomy.Methods:A total of 180 patients with gastric cancer treated in our hospital from January 2016 to December 2017 were selected, and randomly divided into the control group and the observation group by computer, each with 90 cases. Control group received parenteral nutrition intervention, and observation group received enteral and parenteral nutritional diet intervention. Cellular immune function, humoral immune function, nutritional status, and complications occurrence rate were compared between two groups.Results: The levels of cellular immune function between the two groups had no difference before intervention (P>0.05). After intervention, the observation group had higher levels of CD3+, CD4+, and CD4+/CD8+ as well as lower level of CD8+ than those of control group (P<0.05). The IgM, IgA, and IgG levels between the two groups had no difference before treatment (P>0.05), which were decreased after treatment (P<0.05), and were lower in the observation group than those in the control group (P<0.05). The albumin and prealbumin levels between the two groups had no difference before intervention (P>0.05), which were increased after treatment, and were higher in observation group than those in the control group (P<0.05). The incidence of complications in the observation group was significantly lower than that in the control group (P<0.05).Conclusion:The application of enteral and parenteral nutritional diet intervention can promote the recovery, improve the nutritional status and immune function for gastric cancer patients after radical gastrectomy, which has fewer complications.

Comparison of hand-assisted laparoscopic radical gastrectomy and laparoscopic-assisted radical gastrectomy:A systematic review and meta-analysis

BACKGROUND Gastrectomy is the optimal treatment for gastric cancer.Laparoscopic-assisted gastrectomy(LAG)has been extensively employed,while hand-assisted laparoscopic gastrectomy(HALG),which is similar to LAG,remains controversial.Although HALG is popular in China,some surgeons do not accept it as a minimal-access technique.AIM To assess the safety and practicability of HALG by comparing the short-term outcomes of HALG and LAG.METHODS The electronic databases of EMBASE,PubMed,China National Knowledge Infrastructure,and Cochrane Library were thoroughly searched,and randomized controlled trials(RCTs)comparing HALG and LAG were included.The study results,including surgery time,blood loss,retrieved lymphatic nodes,incision length,time to first flatus,hospitalization duration,and all postsurgical complications,were compared between the two groups.RESULTS Five RCTs,which included 302 cases with HALG and 298 cases with LAG,were considered eligible for inclusion.Meta-analysis showed that HALG significantly reduced surgery time(P<0.01),hospital duration(P<0.01),and overall postsurgical complications(P<0.01).Additionally,HALG significantly increased the number of retrieved lymphatic nodes(P=0.01)and incision length(P<0.01)compared with LAG.The blood loss and time to first flatus were similar between the two groups(P>0.05).CONCLUSION Compared with LAG,HALG is a simpler and safer technique.Additionally,HALG should be used as a minimal-access technique,especially in technologically undeveloped areas.

Effect on changes of blood coagulation function, cytokines and immune function in patients undergoing laparoscopic radical gastrectomy for gastric cancer

Objective:To explore the changes of coagulation function, cytokines and T lymphocyte in patients undergoing laparoscopic radical gastrectomy for gastric cancer and its clinical significance.Methods: 40 cases of laparoscopic radical gastrectomy for gastric cancer patients and 40 cases of open radical gastrectomy for gastric cancer patients in our hospital were selected to detect and investigate the perioperative coagulation function [APTT (activated partial thromboplastin time), FIB (fibrinogen), and PLT (platelet)], cytokines [CRP (C reactive protein), IL-6 (IL-6) and TNF-alpha (Tumor necrosis factor-alpha)] and T lymphocytes (CD4+, CD8+ and CD4+/CD8+) changes and clinical meaning of patients in the two groups.Results: The coagulation function related indicators, cytokines and T lymphocytes of the two groups before treatment did not change significantly (P>0.05). 1 d after operation, blood coagulation, TNF-alpha, CD4+ and CD4+/CD8+ levels were significantly lower than that before operation in two groups of patients (P<0.05), while IL-6, CRP and CD8+ were significantly higher than that before the operation (P<0.05), and the index change in open group was more obvious. 3 d after surgery, the APTT, IL-6, CRP, CD4+, CD8+ and PLT levels in two group patients were significantly lower than that 1 d after surgery, while FIB, TNF-alpha and CD4+/CD8+ were significantly higher than that 1 d after surgery;blood coagulation index, TNF-alpha and CD4+ and CD4+/CD8+ were significantly lower in the laparotomy group patients than in laparoscopic group, while IL-6, CRP and CD8+ were significantly higher than the laparoscopic group (P<0.05). 5 d after operation, the APTT, TNF-alpha, FIB, CD4+, CD4+/CD8+ and PLT in two groups were significantly higher than that 3 d after surgery (P<0.05), while IL-6, CRP and CD8+ levels were significantly lower than that of 3 d after surgery (P<0.05);blood coagulation index, TNF-alpha and CD4+ and CD4+/CD8+ in the laparotomy group patients were significantly lower than laparoscopic group (P<0.05), while IL-6, CRP and CD8+ were significantly higher than the laparoscopic group (P<0.05).Conclusions: Radical resection of gastric cancer can cause coagulation disorder, inhibit the immune function and inflammatory reaction, and gradually recover with the passage of time;Compared with open surgery, laparoscopic radical gastrectomy have smaller impact on patients and recovery faster.

Superior pancreatic lymphadenectomy with portal vein priority via posterior common hepatic artery approach in laparoscopic radical gastrectomy

BACKGROUND D2 lymph node dissection for advanced gastric cancer is advocated,and station 8p lymph node should be considered in selected patients,which is,however,technically difficult.AIM To introduce a new and easy-to-perform procedure for dissection of the lymph nodes superior to the pancreas.METHODS A series of patients who underwent laparoscopic gastrectomy for gastric cancer were retrospectively included with utilization of a new procedure for superior pancreatic lymphadenectomy(LND)with portal vein priority via the posterior common hepatic artery approach(SPLD-PPPH)based on a newly defined portal triangle.The surgical outcome of the patients,as well as the efficacy and safety of SPLD-PPPH are reported.RESULTS A total of 51 patients were included with most of them being male(n=34,66.7%).According to the 8th edition of AJCC TNM staging,there were four(7.8%)patients in stage I,13(25.5%)in stage II,33(64.7%)in stage III and one(2.0%)in stage IV.The average duration for LND was about 1 h(67.7±6.9 min).After surgery,four patients developed morbidities,but all were treated successfully with no perioperative mortality.Among the 51 patients included,the percentage of patients who had lymph node metastasis at station 8p was 9.8%.Of note,with a total of 14 lymph nodes harvested at station 8p,the incidence of nodal metastasis was 14.3%.CONCLUSION About one in 10 patients with advanced gastric cancer had nodal metastasis at station 8p.The new approach of SPLD-PPPH is safe and effective for D2+LND during laparoscopic radical gastrectomy.

How to examine anastomotic integrity intraoperatively in totally laparoscopic radical gastrectomy? Methylene blue testing prevents technical defect-related anastomotic leaks

BACKGROUND Intraoperative methylene blue testing(IMBT),air leak testing,or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer.Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades.However,reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.AIM To explore the effects of IMBT on the incidence of postoperative anastomotic leaks(PALs)and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.METHODS From January 2017 to December 2019,patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed.According to whether or not they experienced an IMBT,the patients were divided into an IMBT group and a control group.If the IMBT was positive,an intraoperative suture was required to reinforce the anastomosis.The difference in the incidence of PALs was compared,and the risk factors were investigated.RESULTS This study consisted of 513 patients,211 in the IMBT group and 302 in the control group.Positive IMBT was shown in seven patients(3.3%)in the IMBT group,and no PAL occurred in these patients after suture reinforcement.Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index(BMI)>25 kg/m2(hazard ratio[HR]=8.357,P=0.009),operation time>4 h(HR=55.881,P=0.002),and insufficient surgical experience(HR=15.286,P=0.010).Moreover,15 patients(2.9%)developed PALs in 513 patients,and the rates of PALs were significantly lower in the IMBT group than in the control group[2 of 211 patients(0.9%)vs 13 of 302 patients(4.3%),P=0.0026].Further analysis demonstrated that preoperative complications(HR=13.128,P=0.017),totally laparoscopic total gastrectomy(HR=9.075,P=0.043),and neoadjuvant chemotherapy(HR=7.150,P=0.008)were independent risk factors for PALs.CONCLUSION IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy,thus preventing technical defect-related anastomotic leaks.Preoperative complications,totally laparoscopic total gastrectomy,and neoadjuvant chemotherapy are independent risk factors for PALs.

Clinical observation of laparoscopic radical gastrectomy for advanced gastric cancer

Objective: To explore the clinical efficacy of laparoscopic radical gastrectomy and traditional open radical gastrectomy for advanced gastric cancer. Methods: 116 patients with advanced gastric cancer in our hospital were randomly selected, including 55 cases in the experimental group and 61 cases in the control group. The clinical effects, CEA, CA-199, AFP and postoperative complications of the two groups were compared. Results: The indexes of operation and post-operation (average operation time, incision length, exhaust time, intraoperative bleeding volume, hospital stay, enteral nutrition time), and the total number of lymph nodes dissected in the experimental group was less than that in the control group (P < 0.05). There was no difference in CEA, CA-199 and AFP before operation and 1 month after operation. The incidence of complications in laparoscopic group was 9.1% lower than that in control group (27.9%). Conclusion: Laparoscopic radical gastrectomy has many advantages in the treatment of gastric cancer, which can effectively reduce complications and is worth promoting.

Effects of different anesthetic depths on cardiovascular response, stress level and immune function in patients undergoing radical gastrectomy

Objective:To investigate the effects of different anesthesia depth on cardiovascular response, stress level and immune function in patients undergoing radical gastrectomy for gastric cancer.Methods: Ninety-two patients who underwent radical gastrectomy in our hospital from January 2017 to June 2018 were randomly divided into group A (46 cases) and group B (46 cases). Group A received deep anesthesia (BIS:35~45) and group B received shallow anesthesia (BIS:55~65). The changes of heart rate (HR), mean arterial pressure (MAP), cortisol (Cor), adrenocorticotropic hormone (ACTH), epinephrine (E), norepinephrine (NE) and T cell subsets were compared between the two groups at different time points.Results:At T2, T3, and T4, the MAP of group B was (90.37±16.34) mmHg, (105.36±13.27) mmHg, and (86.26±15.34) mmHg, which were higher than group A, and the difference was statistically significant (P<0.05);There was no significant difference in MAP between the two groups at T1, T5 and T6 (P>0.05). There was no significant difference in HR between the two groups at each time point (P>0.05). Before anesthesia, there were no significant differences in Cor, ACTH, E, and NE between the two groups (P>0.05). At the end of surgery and 24 h after surgery, Cor, ACTH, E, and NE were higher than those before anesthesia, and the difference was statistically significant (P<0.05). At the end of surgery and 24 h after surgery, Cor, ACTH, E, and NE in group B were (164.28±40.27) ng/mL, (57.85±18.66) pg/mL, (33.36±5.83) mmol/L, (301.29±41.74) mmol/L, and (156.27±44.28) ng/mL, (50.85±11.40) pg/mL, (27.65±4.78) mmol/L, (267.22±38.21) mmol/L, both higher than group A, the difference was statistically significant (P<0.05). Before anesthesia, there was no significant difference in CD3+, CD4+, CD4+/CD8+ between the two groups (P>0.05). At the end of surgery and 24 h after surgery, the CD3+, CD4+, CD4+/CD8+ levels in the two groups were lower than those before anesthesia, and the difference was statistically significant (P<0.05). At the end of surgery and 24 h after surgery, CD3+, CD4+, CD4+/CD8+ in group B were (51.00±6.10)%, (26.85±4.31)%, (1.15±0.19), and (44.41±4.21)%, (22.41±2.51)%, (1.06±0.29), all lower than group A, the difference was statistically significant (P<0.05). There was no significant difference in CD8 level between the two groups at different time points (P>0.05).Conclusion:The effect of deep anesthesia (BIS: 35~45) on cardiovascular response, stress level and immune function in patients undergoing radical gastrectomy was milder than that of light anesthesia (BIS: 55-65).

Anesthetic Effect of Sufentanil Combined with Remifentanil in Patients Undergoing Radical Gastrectomy

Objective:To explore and analyze the anesthetic effect of sufentanil combined with remifentanil in patients undergoing radical gastrectomy for gastric cancer.Methods:In this study,100 patients receiving radical gastrectomy for gastric cancer in our hospital were selected as the research subjects,and the period from June 2019 to February 2021 was divided into different anesthesia regimens.Fifty patients receiving remifentanil anesthesia were used as the control group,and 50 patients receiving remifentanil combined with sufentanil anesthesia were used as the research group.The anesthetic effect of the two groups of patients was analyzed and compared.Results:The HR and MAP of the study group at different time after intubation were lower than those of the control group(P<0.05).The changes of HR and MAP before and after intubation in two groups were significant compared with those before intubation(P<0.05).The postoperative VAS score of the study group was significantly better than that of the control group(P<0.05).Conclusions:In radical gastrectomy for gastric cancer,the choice of sufentanil and remifentanil as the anesthesia scheme can effectively stabilize the hemodynamics of patients,relieve the degree of postoperative pain,with obvious clinical value.

Enhanced recovery after surgery with laparoscopic radical gastrectomy for stomach carcinomas

AIM: To study the efficacy of the enhanced recovery after surgery(ERAS) program in laparoscopic radical gastrectomy for stomach carcinomas.METHODS: From June 2010 to December 2012, 61 gastric cancer patients who underwent laparoscopicassisted radical gastrectomy with D2 lymphadenectomy at First Hospital of Jilin University were enrolled in this randomized controlled trial.(Clinical Trials.gov, registration ID: NCT01955096). The subjects were divided into the ERAS program group and the conventional control group. The clinical characteristics, recovery variables, and complications of patients were analyzed.RESULTS: The time to first ambulation, oral food intake, and time to defecation were significantly shorter in the ERAS group(n = 30), compared to the conventional group(n = 31; P = 0.04, 0.003, and 0.01, respectively). The postoperative hospital stay was less in the ERAS group(6.8 ± 1.1 d) compared to the conventional group(7.7 ± 1.1 d)(P = 0.002). There was no significant difference in postoperative complications between the ERAS(1/30) and conventional care groups(2/31)(P = 1.00). There were no readmissions or mortality during the 30-d follow-up period.CONCLUSION: The ERAS program is associated with a shorter hospital stay in gastric cancer patients undergoing laparoscopic radical gastrectomy. The ERAS protocol is useful in the treatment of gastric cancer.