Anatomic Basis And Retrospective Studies Of Laparoscopic Radical Gastrectomy For Gastric Cancer

Objectives:The purpose of this study was to explore the anatomical structure and histopathology of the mesogastrium to provide evidence for D2 lymphadenectomy plus complete mesogastrium excision（D2+CME）in laparoscopic gastrostomy for gastric cancer.Methods:Surgical videos of the patients who underwent laparoscopic gastrectomy（D2+CME）for gastric cancer were collected and analyzed.Surgical diagrams and the images of laparoscopic surgery were used to illustrate the relationship between mesogastrium and meso-bed and the critical techniques in laparoscopic gastrectomy（D2+CME）.The specimens of each mesogastrium were fixed and embedded.Histological slices were stained by HE and Masson.Immunohistochemical staining（Pan-ck）was performed to identify the mesothelial cells.Results:The surface of the mesogastrium and meso-bed was composed of serosa with mesothelial cells and fascia with fibrous connective tissue.The fused process was characterized by strong inhomogeneity with the different distribution of mesothelial cells in the vestigial serosa.Conclusions:This study describes the existence of mesogastrium by video reviewing and histological examination which provides more theoretical basic for D2+CME surgery in gastrectomy.Objectives:Under the concept of mesogastrium model,the D2+CME procedure could help surgeons achieve a complete and standard excision of the suprapancreatic area.Here we aim to elucidate the key technique point of suprapancreatic dissection during the procedure D2+CME and to summarize the short term results.Methods:We retrospectively reviewed 107 patients who underwent laparoscopic curative subtotal gastrectomy（D2+CME,R0）and their short term outcomes between August 28^th 2017 and December 27 th 2018.Results:107 patients were retrospectively enrolled in this study,including 67 males and 40 females.The mean age was 55.5±9.8 years;the average body mass index（BMI）was 23.0 ±3.1kg/m2.The mean number of retrieved regional lymph nodes was 33.4±13.0,23.0±9.1 of which were harvested from suprapancreatic area.The median volume of blood loss was 14 ml（IQR 6-34）.The median total operation time and the laparoscopic surgery time were 287 min（IQR 265-314）and 132 min（IQR 116-142）respectively.Postoperative morbidity rate was 9.3 %,and the mortality rate was 0%.The median follow-up was 10 months（IQR 8-13）.No patient relapsed or died and no patient was lost during follow-up.Conclusion:A laparoscopic distal gastrectomy with D2+CME procedure provides a complete and standardized en bloc excision of the suprapancreatic area dissection.Objectives: Here we aimed to assess the quality of gastric cancer surgery by greviewing surgical videos.Under the concept of mesogasrium,the completeness of dissected mesogastrium and mobilized meso-bed was considered most crucial for the assessment.We also tried to quantify the assessment by scoring each surgery to figure out the correalation between the quality of surgeries and morbidity,mortality,and survival.Methods: All laparoscopic distal gastrectomies conducted at the Department of Gastrointestinal Surgery,Tongji Hospital,between Dec 12,2013 and Dec 28,2017,were identified.All patients underwent a curative R0 excision.The videos are well preserved and were graded according to the exposure of important structures,the plane of surgical resection,the amount of tissue removed,and the ligation of the root of the vessel.A total of 855 videos were collected in this study.Univariate and multivariate models were used to ascertain whether there was an association with 3-year cumulative overall survival rates.The primary outcome measures were overall survival,which was defined as deaths that occurred from any cause,and progression-free survival,which was defined as recurrence or death.Results: A total of 1551 patients were identified and 696 patients were excluded.Among the identified patients,368 patients underwent LATG,196 patients underwent LAPG,5 patients underwent a neoadjuvant therapy,3 patients were diagnosed with a neuroendocrine carcinoma,and the surgical videos of 124 patients were considered for retrospective grading,eventually 855 patients were considered eligible for analysis.There were remarkable variations in the proportion of each surgical grade: 53%（n=453）,28.4%（n=243）and 18.6%（n=159）were assessed as good,moderate and poor,respectively.We noted an 11.7% overall survival advantage and a 15.1% progression-free survival at 3 years with the good surgery compared with the poor surgery.Furthermore,this association with overall survival was significant,both in the univariate model（HR 2.00 [95% CI 1.27–3.14],p=0.003）and in the multivariate model（HR 1.69 [95% CI 1.07–2.67],p=0.025）.The association with progression-free survival was also significant,both in the univariate model（HR 2.07 [95% CI 1.39–3.08],p<0.001）and in the multivariate model（HR 1.78 [95% CI 1.19–2.67],p=0.005）.Conclusion: In previous studies of colorectal cancer,pathologists evaluated the intergrity of mesocolon and mesorectum through histopathological manners.We evaluated the operation videos because of the complexity of the mesogastrium.The improvement of the quality of surgeries might improve overall survival and progression-free survival.The improvement of the completeness of the mesogastrium might be a new and very effective method for decreasing the morbidity and mortality in patients with gastric cancer.Background:Although laparoscopy-assisted gastrectomy with D2 lymphadenectomy has become a standard approach for the treatment of advanced gastric cancer（AGC）,patients still have a poor prognosis after operation.Previously,we proposed D2 lymphadenectomy plus complete mesogastrium excision（D2 +CME）for the treatment of advanced gastric cancer in early 2013.In this study,we aimed to investigate the feasibility and oncologic efficacy of laparoscopic total gastrectomy with D2+CME.Methods:A total of 395 patients who underwent laparoscopic total gastrectomy（LTG）from January 2014 to June 2018 were included in this study.The postoperative morbidity was stratified by the Clavien-Dindo classification.All the patients were followed until death or last follow-up in June 2019.The primary endpoints were overall survival（OS）,which was defined as the time from post-operation to death from any cause,and progression-free survival（PFS）,which was defined as the months from post-operation to recurrence or death.The patients were grouped according to the type of operation（145 in the D2+CME group and 250 in the D2 group）.The short-and long-term outcomes were compared between the two groups after propensity score matching.Results:Before matching,TNM stages were significantly different between the D2 and D2+CME groups.After propensity score matching,290 patients（145 patients in each group）were enrolled and the two groups were well balanced in clinicopathologic characteristics.A longer operation time was required for the D2+CME group,but less intraoperative bleeding was observed and a greater number of lymph nodes were dissected.Time to first flatus was similar in the two groups but duration of hospital stay was longer in D2+CME group.Furthermore,The D2+CME group had higher morbidity and mortality than D2 group,but no significant differences were found.After matching,the 3-year OS（73.3 vs.59.1 %,p = 0.058）and PFS（68.6 vs.54.2 %,p = 0.032）rates of the D2+CME group were higher than those of the D2 group even though no significant difference was found in OS.Multivariate Cox regression showed that p T stage,p N stage,and surgical procedure were independent prognostic factors.Conclusions: Laparoscopic total gastrectomy with D2 +CME is feasible and reproducible and could also attain a stable oncologic outcome for gastric cancer.