目的研究加速康复外科(enhanced recovery after surgery,ERAS)在腹腔镜胃癌患者术后肠道功能及肠道菌群变化的影响。方法选取2018年8月至2019年12月在烟台毓璜顶医院胃肠外一科、甲状腺外科接受腹腔镜胃癌根治性D2手术的患者80例。根...目的研究加速康复外科(enhanced recovery after surgery,ERAS)在腹腔镜胃癌患者术后肠道功能及肠道菌群变化的影响。方法选取2018年8月至2019年12月在烟台毓璜顶医院胃肠外一科、甲状腺外科接受腹腔镜胃癌根治性D2手术的患者80例。根据是否为ERAS处理分为2组(n=40):ERAS组和传统围手术期处理组。记录两组患者的术后肠鸣音出现时间、第1次排气及排便时间,抗生素相关性腹泻(AAD)及手术部位感染(SSI)的比例。收集术前、术后第1次、术后1、2周及1月的粪便,采用16S rRNA测序的方法进行肠道菌群多样性和种类的鉴定,比较围手术期肠道菌群多样性指数及益生菌(双歧杆菌及乳酸杆菌)比例的变化。结果ERAS组肠鸣音出现时间、第1次排气及排便时间[(16.25±6.41)h、(23.95±6.02)h、(34.95±9.34)h]显著小于传统处理组[(22.3±6.49)h、(28.45±7.12)h、(48.1±15.64)h],差异有统计学意义(P<0.05)。抗生素相关性腹泻发生比例在传统处理组(3/40)比ERAS组(1/40)高,但差异无统计学意义(P>0.05)。ERAS组和传统处理组术后手术部位感染(SSI)比例(1/10,3/40),ERAS组略高,但差异无统计学意义(P>0.05)。围手术期肠道菌群多样性指数(Chao1及shannon指数)及益生菌(嗜酸乳杆菌和双歧杆菌)所占比例,术前两组之间无明显差异(P>0.05),术后第1次、第1周、术后2周及术后1个月,ERAS组较传统组均高(P<0.05);在术后各时间点,传统组下降较ERAS组明显,术后第1次降低值最大(P<0.05);术后随着时间的推移,肠道菌群多样性和益生菌比例逐渐回升,至术后1个月,两组均未恢复至术前肠道菌群多样性的状态及比例。结论加速康复外科理念(ERAS)促进了胃癌患者术后肠道早期运动功能的恢复,没有降低抗生素相关性腹泻的发生或增加手术部位感染(SSI)的比例,维持了肠道菌群多样性的平衡和稳定。展开更多
In addition to the popularity of laparoscopic gastrectomy(LG),many reconstructive procedures after LG have been reported.Surgical resection and lymphatic dissection determine long-term survival;however,the election of...In addition to the popularity of laparoscopic gastrectomy(LG),many reconstructive procedures after LG have been reported.Surgical resection and lymphatic dissection determine long-term survival;however,the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer(GC).Presently,no consensus exists regarding the optimal reconstructive procedure.In this review,the current state of digestive tract reconstruction after LG is reviewed.According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction,we divide these reconstruction procedures into three categories consistent with the resection procedures.We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes(length of surgery and blood loss)and postoperative complications(anastomotic leakage and stricture)to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.展开更多
AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer(GC) patie...AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer(GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1%(n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 8 3. 8 8 %(n = 1 7 4 0) a n d 8 4. 3 6 %(n = 2 0 7 1), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications(n = 463, 9.7%) and the need for patient observation(n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54(1.1%). In a multivariate analysis, the intraoperative events(OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male(OR = 1.459), advanced age(OR = 1.727), total gastrectomy(OR = 2.444), combined operation(OR = 1.731), and ASA score(OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.展开更多
Surgical management of gastric cancer improves survival.However,for some time,surgeons have had diverse opinions about the extent of gastrectomy.Researchers have conducted many clinical studies,making slow but steady ...Surgical management of gastric cancer improves survival.However,for some time,surgeons have had diverse opinions about the extent of gastrectomy.Researchers have conducted many clinical studies,making slow but steady progress in determining the optimal surgical approach.The extent of lymph node dissection has been one of the major issues in surgery for gastric cancer.Many trials demonstrated that D2 dissection resulted in greater morbidity and mortality than D1 dissection.However,long-term outcomes demonstrated that D2 dissection resulted in longer survival than D1 dissection.In 2004,the Japan Clinical Oncology Group reported a pivotal trial which was performed to determine whether para-aortic lymph node dissection combined with D2 dissection was superior to D2 dissection alone and found no benefit of the additional surgery.Gastrectomy with pancreatectomy,splenectomy,and bursectomy was initially recommended as part of the D2 dissection.Now,pancreas-preserving total gastrectomy with D2 dissection is standard,and ongoing trials are addressing the role of splenectomy.Furthermore,the feasibility and safety of laparoscopic gastrectomy are well established.Survival and quality of life are increasingly recognized as the most important endpoints.In this review,we present perspectives on surgical techniques and important trials of these techniques in gastric cancer patients.展开更多
AIM:To report the incidence and potential risk factors of small-volume chylous ascites(SVCA)following laparoscopic radical gastrectomy(LAG).METHODS:A total of 1366 consecutive gastric cancer patients who underwent LAG...AIM:To report the incidence and potential risk factors of small-volume chylous ascites(SVCA)following laparoscopic radical gastrectomy(LAG).METHODS:A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study.We analyzed the patients based on the presence or absence of SVCA.RESULTS:SVCA was detected in 57(4.17%)patients,as determined by the small-volume drainage(range,30-100 m L/24 h)of triglyceride-rich fluid.Both univariate and multivariate analyses revealed that the total number of resected lymph nodes(LNs),No.8 or No.9 LN metastasis and N stage were independent risk factors for SVCA following LAG(P<0.05).Regarding hospital stay,there was a significant difference between the groups with and without SVCA(P<0.001).The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4%and 56.1%,respectively,which were similar to those of the patients without SVCA(P>0.05).CONCLUSION:SVCA following LAG developed significantly more frequently in the patients with≥32harvested LNs,≥3 metastatic LNs,or No.8 or No.9LN metastasis.SVCA,which was successfully treated with conservative management,was associated with a prolonged hospital stay but was not associated with the prognosis.展开更多
BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopat...BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD. METHODS We retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM). RESULTS Surgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%).Multivariate analysis revealed that positive horizontal margin [odds ratio (OR)=13.393, 95% confidence interval (CI): 1.435-125, P=0.023] and neural invasion (OR=14.714, 95%CI: 1.087-199, P=0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR=12.000, 95%CI: 1.197-120, P=0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 μm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications. CONCLUSION Gastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 μm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.展开更多
文摘目的研究加速康复外科(enhanced recovery after surgery,ERAS)在腹腔镜胃癌患者术后肠道功能及肠道菌群变化的影响。方法选取2018年8月至2019年12月在烟台毓璜顶医院胃肠外一科、甲状腺外科接受腹腔镜胃癌根治性D2手术的患者80例。根据是否为ERAS处理分为2组(n=40):ERAS组和传统围手术期处理组。记录两组患者的术后肠鸣音出现时间、第1次排气及排便时间,抗生素相关性腹泻(AAD)及手术部位感染(SSI)的比例。收集术前、术后第1次、术后1、2周及1月的粪便,采用16S rRNA测序的方法进行肠道菌群多样性和种类的鉴定,比较围手术期肠道菌群多样性指数及益生菌(双歧杆菌及乳酸杆菌)比例的变化。结果ERAS组肠鸣音出现时间、第1次排气及排便时间[(16.25±6.41)h、(23.95±6.02)h、(34.95±9.34)h]显著小于传统处理组[(22.3±6.49)h、(28.45±7.12)h、(48.1±15.64)h],差异有统计学意义(P<0.05)。抗生素相关性腹泻发生比例在传统处理组(3/40)比ERAS组(1/40)高,但差异无统计学意义(P>0.05)。ERAS组和传统处理组术后手术部位感染(SSI)比例(1/10,3/40),ERAS组略高,但差异无统计学意义(P>0.05)。围手术期肠道菌群多样性指数(Chao1及shannon指数)及益生菌(嗜酸乳杆菌和双歧杆菌)所占比例,术前两组之间无明显差异(P>0.05),术后第1次、第1周、术后2周及术后1个月,ERAS组较传统组均高(P<0.05);在术后各时间点,传统组下降较ERAS组明显,术后第1次降低值最大(P<0.05);术后随着时间的推移,肠道菌群多样性和益生菌比例逐渐回升,至术后1个月,两组均未恢复至术前肠道菌群多样性的状态及比例。结论加速康复外科理念(ERAS)促进了胃癌患者术后肠道早期运动功能的恢复,没有降低抗生素相关性腹泻的发生或增加手术部位感染(SSI)的比例,维持了肠道菌群多样性的平衡和稳定。
文摘In addition to the popularity of laparoscopic gastrectomy(LG),many reconstructive procedures after LG have been reported.Surgical resection and lymphatic dissection determine long-term survival;however,the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer(GC).Presently,no consensus exists regarding the optimal reconstructive procedure.In this review,the current state of digestive tract reconstruction after LG is reviewed.According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction,we divide these reconstruction procedures into three categories consistent with the resection procedures.We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes(length of surgery and blood loss)and postoperative complications(anastomotic leakage and stricture)to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.
文摘AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer(GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1%(n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 8 3. 8 8 %(n = 1 7 4 0) a n d 8 4. 3 6 %(n = 2 0 7 1), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications(n = 463, 9.7%) and the need for patient observation(n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54(1.1%). In a multivariate analysis, the intraoperative events(OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male(OR = 1.459), advanced age(OR = 1.727), total gastrectomy(OR = 2.444), combined operation(OR = 1.731), and ASA score(OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.
基金supported by multidisciplinary grants from The University of Texas MD Anderson Cancer Centersupported in part by the National Cancer Institute,National Institutes of Health(No.CAl 38671, CAl72741,and CAl50334 to JAA)the Biostatistics Resource Group(No. P30CA016672)
文摘Surgical management of gastric cancer improves survival.However,for some time,surgeons have had diverse opinions about the extent of gastrectomy.Researchers have conducted many clinical studies,making slow but steady progress in determining the optimal surgical approach.The extent of lymph node dissection has been one of the major issues in surgery for gastric cancer.Many trials demonstrated that D2 dissection resulted in greater morbidity and mortality than D1 dissection.However,long-term outcomes demonstrated that D2 dissection resulted in longer survival than D1 dissection.In 2004,the Japan Clinical Oncology Group reported a pivotal trial which was performed to determine whether para-aortic lymph node dissection combined with D2 dissection was superior to D2 dissection alone and found no benefit of the additional surgery.Gastrectomy with pancreatectomy,splenectomy,and bursectomy was initially recommended as part of the D2 dissection.Now,pancreas-preserving total gastrectomy with D2 dissection is standard,and ongoing trials are addressing the role of splenectomy.Furthermore,the feasibility and safety of laparoscopic gastrectomy are well established.Survival and quality of life are increasingly recognized as the most important endpoints.In this review,we present perspectives on surgical techniques and important trials of these techniques in gastric cancer patients.
基金Supported by Grants from National Key Clinical Specialty Discipline Construction Program of China,No.[2012]649
文摘AIM:To report the incidence and potential risk factors of small-volume chylous ascites(SVCA)following laparoscopic radical gastrectomy(LAG).METHODS:A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study.We analyzed the patients based on the presence or absence of SVCA.RESULTS:SVCA was detected in 57(4.17%)patients,as determined by the small-volume drainage(range,30-100 m L/24 h)of triglyceride-rich fluid.Both univariate and multivariate analyses revealed that the total number of resected lymph nodes(LNs),No.8 or No.9 LN metastasis and N stage were independent risk factors for SVCA following LAG(P<0.05).Regarding hospital stay,there was a significant difference between the groups with and without SVCA(P<0.001).The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4%and 56.1%,respectively,which were similar to those of the patients without SVCA(P>0.05).CONCLUSION:SVCA following LAG developed significantly more frequently in the patients with≥32harvested LNs,≥3 metastatic LNs,or No.8 or No.9LN metastasis.SVCA,which was successfully treated with conservative management,was associated with a prolonged hospital stay but was not associated with the prognosis.
基金the National Natural Science Foundation of China,No.81772642Beijing Municipal Science and Technology Commission,No.Z161100000116045Capital’s Funds for Health Improvement and Research,No.CFH 2018-2-4022
文摘BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD. METHODS We retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM). RESULTS Surgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%).Multivariate analysis revealed that positive horizontal margin [odds ratio (OR)=13.393, 95% confidence interval (CI): 1.435-125, P=0.023] and neural invasion (OR=14.714, 95%CI: 1.087-199, P=0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR=12.000, 95%CI: 1.197-120, P=0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 μm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications. CONCLUSION Gastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 μm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.
