Clinical Application Study Of Intraoperative Sentinel Node Location And Detection During Laparoscope Assisted Radical Operation For Carcinoma Of Distal Stomach

Part 1.Study of feasibility and clinical effection for intraoperative sentinel node location and detection during laparoscope assisted radical operation for carcinoma of distal stomachAbstractBackgroundSenrinel lymph node is the first regional lymph node received tumour drainage, also occured the earliest tumor metastasis lynph node,whose pathology state can represent certain regonal lymph nodes state. If there has existed metastasis in sentinel node,there were likely to be metastasis in upstream drainage lymph nodes. If there has not been metastasis in sentinel node,we can infer, in theory, total regional lymph nodes were not involved by tumor. So,in theory,to detect metastasis of sentinel lymph node can predict metastasis state of tumor regional lymph nodes,further,to guide and determine operation method and lymphadenectomy scope,evaluate patient’s prognosis and offer help for postoperation comprehensive therapy. Technology of sentinel lymph node biopsy has in succession got successful application in therapy of malignant melanin,breast cnacer,thyroid cancer and head and neck squamous cell carcinoma.It has been important diagnosis and treatment for malignant melanin.In breast surgery,lymph node dissection under the guidance of sentinel lymph node biopsy has gradually replaced traditional axilary lymph nodes dissection,which was honoured as a revolution in history of treatment for breast surgery.Laparoscope technology,grown up in recent years,is a new type operation technique,which can sufficiently embody minimal invasion surgery fundamental philosophy.There are some advantages of laparoscope technology,such as little trauma,distinct view,few blood loss,light intestinal adhesion postoperation,low occurence rate of intestinal obstruction,quick postoperative recovery,light inflammation and stress reaction postoperation,gentle influence to immune and cardio-pulmonary function,which was gradually accepted by people. With the development of science and technology,application scope of laparoscopic operation has gradually extended from original benign disease such as appendicectomy, choleccystectomy to malignant tumor therapy,such as radical resection of colorectal cancer. Radical resection of colorectal carcinoma by laparoscope has become normalization operation technique for colorectal cancer.Applied research of laparoscope technology in gastric cancer is in exploratory stage now. Indications of operation gradually enlarges from early gastric cancer to early advanced gastric carcinoma. Technological security and feasibility of gastric cancer radical operation by laparoscope has been proved. Lymph node dissection is critical point and difficulty for laparoscope gastric cancer radical operation.lt always is concerned hot issue by domestic and overseas scholar,how to effectively carry out gastric cancer lymph node dissection by laparoscope,reduce complication and shrink scope of surgery.Technology of sentinel node biopsy determined metastasis state of tumor regional lymph nodes,combined with laparoscope technique in radical operation for carcinoma of stomach will allow full play to minimally invasive advantage of laparoscope technology,which can get the effection of bring out the best in each other,and provied new idea and method for surgical treatment of gastric cancer.Objective1. To analyze security and feasibility of the application of sentinel node location and detection in laparoscope assisted distal gastrectomy of stomach cancer.2.To discuss clinical effect of the application of sentinel node location and detection in laparoscope assisted distal gastrectomy of stomach cancer.Method124 patients with distal gastric cancer from october 2012 to october 2014 in Yishui Centrol Hospital were selected, all patients accepted stomachoscopy preoperation, pathology biopsy to confirm gastric adenocarcinoma,chest computed tomography, abdomen intensified computed tomography and tumor marker were convention,in oeder to screen early or early progress gastric cancer. Patients were divided into 3 groups by random,in which,open distal gastrectomy(ODG) 45 cases, laparoscopy-assisted distal gastrectomy(LADG) 43cases,sentinel lymph node biopsy(SLNB) and LADG 43 cases.Patients in ODG group accepted traditional open D2 radical operation for carcinoma of distal stomach,in LADG group accepted laparoscopy-assisted D2 radical operation for carcinoma of distal stomach,in SLNB+LADG group accepted laparoscopy-assisted radical operation for carcinoma of distal stomach under the guidance of sentinel node location and detection in operation.1.Recording preoperation 3 group patients’ gender,age,QLQ-C30 scale grade and STO-22 scale grade.2.Recording in operation 3 group patients’ length of incision,time of operation,amount of bieeding,distance from up and down incision edge to tumor edge,numbers of cleanness lymph nodes.3.Recording postoperation 3 group patients’ first down-bed activity time,first passage of gas by anus time, first time of feeding liquid food, total time postopration in hospital, short-term complication postoperation occurrence,pathological examination (T.N.M) postoperation,general expenses in hospital process,tumor recurrence,every indicative grade condition of QLQ-C30 and STO-22 scale at the time NO.1 and NO.6 month postoperation.Result1.There are no significant difference of age,gender,QLQ-C30 and STO-22 scale grade condition preoperation,size of the tumor and TNM stage postoperation (P>0.05).2.Operation time of LAND group and SLNB+LADG group apparently higher than that of ODG group (P<0.01). Operation time of SLNB+LAND group obviously higher than that of LADG group (P<0.05).Amount of bleeding of LADG group and SLNB+LADG group were obviously less than that of ODG group (P＜0.05), further,amount of bleeding of SLNB+LADG group was obviously less than that of LADG group (P<0.05).Length of incision of ODG group patients was evidently longer than that of LADG group and SLNB+LADG group patients (P＜0.01). Distance from up and down incision edge to tumor tissue of the 3 groups were not statistical difference (P>0.05).Total number of lymph nodes got from SLNB+LADG group was obviously less than that of LADG and ODG group (P<0.05).Metastasis accuracy rate of regional lymph nodes predicted by sentinel node was 90%(36/40),sensibility was 92.59% (25/27),specificity was 84.62%(11/13),false negative rate was 7.41% (2/27). 3.Comparison of the first down-beb activity time,peristalsis recovery time and first feeding time among 3 groups of SLNB+LADG group were obviously earlier than that of LADG and ODG group (P<0.05),furtherly, which of LADG group was distinctly earlier than that of ODG group (P<0.05).Average stay time postoperation in hospital of SLNB+LADG group was obviously shorter than that of LADG and ODG group (P<0.05),moreover,which of LADG group was obviously shorter than that of ODG group (P＜0.05). The average hospitalization costs of SLNB+LADG and LADG group was obviously higher than that of ODG group, and there was statistical difference.There were no complication death case,total complication occurrence rate was 35.56% of ODG group,22.22% of LADG group,22.50% of SLNB+LADG group,and the difference was no statistical significance (P>0.05). Occurrence rate of basicity regurgitation postoperation was obviously lower than that of the other two groups (P<0.05).4.Recurrence and metastasis occurrence rate was 10.00%(1/40) of ODG group,8.57% of LADG group,9.75% of SLNB+LADG group,and there were no statistical significance (P＜0.05).2 years post-oeration follow-up,Long-rank test was used to compare 3 groups’survival rate, Inspection result was P>0.05,so we can sonsider that there were no significant difference of the influence caused by 3 operation methods to patients’ survival condition.5.There were statistical difference of grade of holistic health condition,physiological function,role function,social function,pain and financial difficulty from QLQ-C30 scale at the time of NO.1 month postoperation (P＜0.05),in which of holistic health condition,physiological function,role function,social function of SLNB+LADG group were obviously superior to that of the other two groups (P<0.05),and at the aspect of appetite lose and financial difficulty, that of SLNB+LADG group was inferior to that of the other two groups (P<0.05).But, grade of the other norms from QLQ-C30 scale and indicators from STO-22 scale from 3 groups were no significant difference. There were statistical difference of grade of holistic health condition and physiological function from QLQ-C30 scale at the time of NO.6 month postoperation (P<0.05),that of SLNB+LADG group was obviously higher to that of the other two groups (P<0.05),but the other norms from QLQ-C30 scale and every norms from STO-22 scale were no significant difference among 3 groups (P>0.05).Conclusion1.It is safe,effective and feasible to apply sentinel node location and detection in operation to laparoscopy-assisted radical operation for distal stomach cancer.2.Sentinel node location and detection in operation can guide lymph node cleaness scope and operation method selection of laparoscopy-assisted radical operation for distal stomach cancer,compared to traditional open and laparoscopy-assisted radical operation for distal stomach cancer,which can get similar treatment effect and remarkably promote patients’ postoperative recovery and recent living quality enhancement.Part 2.Effectof intraoperative sentinel node location and detection during laparoscope assisted radical operation for carcinoma of distal stomach on systemicinflammatory stress and immune functionAbstractBackgroundSurgical operation is the only way to cure gastric cancer at present, as a type invasive procedure, which must necessarily cause postoperative inflammatory stress, further, leading to a series of changes, such as immune function, metabolic level and so on, ultimately influencing postoperative recovery and prognosis. Currently, the laparoscopic operation is increasingly common in radical resection for gastric cancer, which can significantly reduce postoperative inflammatory stress, decrease immune suppression, promote postoperative recovery of patients with gastric cancer and increase survival rate. Sentinel lymph node biopsy technique can determine the status of regional lymph node metastasis, in combination with laparoscope assisted radical operation for gastric cancer may maximize the benefit of minimally invasion of laparoscopic technology, reduce postoperative inflammation and stress reaction and protect immune function.Objectives:K To observe and explore the effect of intraoperative sentinel node location and detection during laparoscope assisted radical operation for carcinoma of distal stomach on inflammatory stress.2、To observe and explore the effect of intraoperative sentinel node location and detection during laparoscope assisted radical operation for carcinoma of distal stomach on immune function.MethodsBetween October 2013 and October 2014, a total of 124 patients in our hospital with preoperative histologically proven gastric cancer, were enrolled in our study. According to the reports of nonenhanced chest CT scans, enhanced abdominal CT scans and tumor markers, early or advanced gastric cancer was then screened. Patients were assigned randomly to ODG group(45 cases), LADG group(36 cases) and SLNB+LADG group(43 cases), respectively. Patients undergoing conventional open D2 resection for distal stomach were designated as the ODG group. Patients having laparoscopic assisted radical operation for carcinoma of distal stomach were designated as LADG group. Patients with SLN during laparoscopic assisted radical operation for carcinoma of distal stomach were designated as SLNB+LADG group.1^ Peripheral blood of patients on one day preoperatively(DO) was drawn tmeasure WBC count, proportion of neutrophils, CRP, IL-6, IgG, IgA, IgM, CD4+T cells, and CD8+T cells.2n Peripheral blood of patients on first day(D1), third day(D3) and sixth day(D6) postoperatively was drawn to measure WBC count, proportion of neutrophils, CRP, IL-6, IgG, IgA, IgM, CD4+T cells, and CD8+T cells.Results1. There were no significant differences among three groups in the WBC count, Proportion of neutrophils, CRP, IL-6, IgG, IgA, IgM, CD4+T cells, and CD8+T cells preoperatively(P>0.05).2. The WBC count and proportion of neutrophils among three groups began to rise and reached the peak on first day after surgery, then fell to normal level gradually. There were no significant differences among three groups in WBC count and proportion of neutrophils at each time point(P>0.05). Compared within groups, the WBC count and proportion of neutrophils on D1 and D3 were higher than those on D0(P<0.05), there were no significant differences between DO and D6(P>0.05).3. The level of CRP were variably elevated among three groups, comparing with those preoperatively, and reached a peak on the third day postoperatively, then reduced gradually, CRP still maintained at a high level on the sixth day. There were no significant differences in CRP level between D1 and D6 of ODG group(P>0.05). There were significant differences in CRP level between the other two groups(P<0.05) There were significant differences in CRP level on D3 among three groups(P<0.05). There were no significant differences among the other groups(P>0.05).4. The level of IL-6 in the three groups increased postoperatively, reached a peak on the first day after operation, then fell gradually to normal level on the sixth day. The level of IL-6 at each time point among three groups was significantly higher than those before operation(P<0.05). The rise of IL-6 in ODG group was most pronounced compared with the other two group, the second was LADG group, and the last was SLNB+LADG group(P<0.05), additionally, the trend of SLNB+LADG group was smooth relatively. There were significant differences in CRP level on D1 among three groups().There were no significant differences at each time point among three groups(P>0.05).5. The level of IgG in three groups all decreased firstly, reached the lowest point on the first day after surgery, thereafter began to return, the trend of SLNB+LADG group was more smooth than those of the other two group. And the level of IgG of three groups postoperatively was less than those preoperatively, but there were significant differences only on the first day(P<0.05). the level of IgG postoperatively in SLNB+LADG group was higher obviously than those in ODG group(P<0.01) and slightly higher than those in LADG group(P<0.05). the level of IgG postoperatively in LADG group was slightly higher than those in ODG group(P>0.05). The level of IgA in three groups reduced firstly, reached the lowest point on the first day a’fter surgery, then began to return, the trend of SLNB+LADG group was more smooth than those of the other two group. Compared within groups, the level of IgA in three groups was less than those before operation, but there were no significant differences at each time point(P>0.05). Compared among groups, there were no significant differences in level of IgA at each time point among three groups(P>0.05). The level of IgM in three groups reduced firstly, reached the lowest point on the first day after surgery, then began to return, the trend of SLNB+LADG group was more smooth than those of the other two group. Compared within groups, the level of IgM in three groups was less than those before operation, but there were significant differences only on the first day postoperatively(P<0.05).Compared among groups, the level of IgM postoperatively at each time point in SLNB+LADG group was much higher than those in ODG group and slightly higher than those in LADG group, there were no significant differences (P>0.05). the level of IgM postoperatively in LADG group was slightly higher than those in ODG group, there were no significant differences (P>0.05).6. The trend of CD4+T cells postoperatively in three groups was basically similar, and showed varying degrees of reduction, thereafter reached the lowest point on the first day after surgery, then gradually returned to almost the preoperative level on the third day, the trend of SLNB+LADG group was more smooth among three groups. Compared within groups, the level of CD4+T cells on the third day and seventh day postoperatively was much less than those preoperatively(P<0.05), there were no significant differences (P>0.05).Compared among groups, the level of CD4+T cells on the first day postoperatively SLNB+LADG group was much higher than ODG group and LADG group (P＜0.05), and there were no significant differences at other time point in three groups (P>0.05). Compared within group of CD8+T cells, there were no significant differences at each time point postoperatively in three groups (P>0.05), which maintained preoperative similar level. Compared among groups, there were no significant differences at each time point in three groups (P>0.05). The trend between CD4+/CD8+ Tcell ratio and level of CD4+Tcell was nearly identical, and showed varying degrees of reduction postoperatively, reached the lowest point on the first day after surgery, then gradually returned to the preoperative level nearly on the third day, the trend of SLNB+LADG group was more smooth among three groups. CD4+/CD8+ Tcell ratio presented varying degrees of reduction and returned to the preoperative normal level on the third day. Compared within groups, CD4+/CD8+ Tcell ratio decreased significantly on the first day postoperatively(P<0.05), there were no significant differences on the third and seventh day compared with those preoperatively(P>0.05). Compared among groups, CD4+/CD8+ Tcell ratio in SLNB+LADG group was significantly higher than ODG group and LADG group(P<0.05), there were no significant differences at other time points postoperatively in three groups(P>0.05).Conclusions1. The three operative approaches can lead to postoperative inflammation and stress reaction, but compared with conventional open operation and pure laparoscopic operation, sentinel lymph node detection during laparoscopic assisted radical operation for carcinoma of distal stomach enables reduce significantly postoperative early inflammation and stress reaction.2、The three operative approaches can cause immune suppression, but compared with conventional open operation and pure laparoscopic operation, sentinel lymph node detection during laparoscopic assisted radical operation for carcinoma of distal stomach enables reduce significantly immune suppression.