| Part1The clinical study on totally laparoscopic total gastrectomy treatment for gastric cancer.Objective:To evaluate the feasibility, safety and short-term outcomes of totally laparoscopic total gastrectomy (TLTG) for upper and middle gastric cancer by comparison with open total gastrectomy (OTG).Methods:According inclusion and exclusion criteria, the clinical data of all TLTG cases were compare with OTG cases at our institution from November2007to October2011. The major data include operation time, blood loss, number of dissected lymph nodes, proximal resection margins, first flatus time, first liquid diet time, first semiliquid diet time, post operative in-hospital days, post operative complications and the findings of laboratory test. Then compare the feasibility, safety and short-term outcomes of TLTG with OTG.Results:Under the inclusion and exclusion criteria, there were19cases in the TLTG group and72cases in the OTG group. There were no significant differences between these two groups with respect to sex, age, BMI index, ASA status and TNM stage. In the TLTG group, all operations were completed successfully without converting to open or laparoscopic-assisted surgery. Operation time was significantly longer in the TLTG group than in the OTG group (318.8±82.8min vs256.8±56.5min, P<0.05), However, the blood loss were significantly lower in the TLTG group (135.9±83.7ml vs355.7±154.7ml, P<0.05), and there were16cases (22.2%) need transfusion in OTG group and1case(5.9%)need transfusion in TLTG group. No significant difference was found between TLTG and OTG in terms of number of dissected lymph nodes (29.4±8.1vs30.1±13.1) and proximal resection margins4.3±1.5cm vs3.9±1.6cm). The post operative morbidity was similar between the TLTG and OTG group (27.8%vs26.4%). However, major complications such as anastomotic leakage, anastomotic stenosis, abdominal abscess and bleeding occurred in8patients (11.1%) in the OTG group, but only1patient (5.6%) in the TLTG group.4patients (5.6%) in the OTG group suffered laparotomy, but in none of the patients in the TLTG group. First flatus time(3.1±1.0d vs4.2±1.1d), first liquid diet time (4.3±1.2d vs6.4±3.0d), first semiliquid diet time (6.1±1.8d vs8.9±4.3d), post operative hospital stay (10.5±3.6d vs13.9±6.0d) were significantly shorter in the TLTG group than in the OTG group(P<0.05). The TLTG group had better hematologic and serum chemical profiles, including white-cell counts, total protein levels, and albumin levels. The first day white blood cell was significantly lower in the TLTG group than in the OTG group (10.6±2.7vs12.3±2.9, P<0.05). The first and third day neutrophilic-granulocyte were significantly lower in the TLTG group than in the OTG group (dl:85.2±5.3vs88.1±4.2, P<0.05; d3:80.0±5.2vs84.5±4.9, P<0.05). The first, third and fifth day albumin were significantly higher in the TLTG group than in the OTG group (d1:32.6±3.7g/L vs29.7±3.8g/L, P<0.05; d3:32.0±3.7g/L vs29.2±3.8g/L, P<0.05; d5:35.2±4.3g/L vs32.8±4.3g/L, P<0.05). The third and fifth day total protein were significantly higher in the TLTG group than in the OTG group (d3:54.8±5.4g/L vs50.2±6.4g/L, P<0.05; d5:60.0±6.0g/L vs54.5±7.2g/L, P<0.05). No significant difference was found between TLTG and OTG in terms of alanineaminotransferase, creatinine and blood urea nitrogen.Conclusions:Comparing with OTG, TLTG consume more operative time. However, TLTG has the advantage of minimal invasive, such as associated with less severe complications and better postoperative quality of life than OTG and can achieve the same cancer clearance as OTG. Besides, TLTG could reduce invasive, with less acute-phase response after surgery and leads to quick post operative recovery. We believe that TLTG is a safe, useful, and less invasive alternative for the treatment of gastric cancer located in the upper or middle third of the stomach. Part2:Totally laparoscopic radical gastrectomy for gastric stump carcinoma:report of two cases and review of literatureObjective:To investigate the feasibility, safety and short-term outcomes of totally laparoscopic radical gastrectomy for gastric stump carcinoma and analyse the techniques of the surgery.Methods:The clinical data of two patients who received totally laparoscopic radical gastrectomy for their gastric stump carcinoma were analyzed retrospectively. The way, method,difficulty and main points of the operation were analyzed. Moreover, its clinical results were evaluated. Results:The laparoscopic operative proceedure were sueeessfully accomplished in the two patients. The mean operative time was260min. The mean estimated operative blood loss was90ml. Two patients were not found to have bleeding, abdominal abscess, anastomotic leakage, gastrointestinal dysfunction or other complications, and were suceessfully discharged from the hospital on post operative day9and day7respectively. One patient died of Alzheimer’s disease19months after surgery, the other one is alive tumor free12months after surgery. According the Medline database, there are only four case reports and it also indicate that laparoscopic surgery has the adnantage of minimally invasive,but achieve the same cancer clearance with sufficient number of lymph nodes and resection margins.Conclusion:It is feasible for totally laparoscopic radical gastrectomy for gastric stump carcinoma. It is assioated with less invasivion and faster recovery. So, it has better short-term results. Part3:The necessity of routine nasogastric decompression after gastrectomy for gastric cancer:a meta-analysisObjective:To evaluate the necessity of routine nasogastric decompression after radical gastrectomy for gastric cancer with meta-analysis.Methods:The literature database before September,2011was extensively searched to retrieve the randomized controlled trials (RCT) with a relevance of study goal. The inclusion and exclusion criteria were formulated. After a quality evaluation, the data were extracted. The Cochrane collaboration RevMan5.1version software was used for meta-analysis.Results:There are7RCT studies meeting the inclusion criteria for meta-analysis. The total sample size of these studies was871cases. Those not having a nasogastric tube routinely inserted experienced a marginal earlier time to flatus [weighted mean difference(WMD)=0.10days,95%confidence interval(CI)0.00～0.30, P=0.05), a significant earlier time to oral diet[weighted mean difference(WMD)=0.43days,95%confidence interval(CI)0.25～0.61, P<0.01)], a significant shorter hospital stay[weighted mean difference (WMD)=0.60days,95%confidence interval(CI)0.15～1.18,P=0.01), and a marginal decrease in pulmonary complications[relative risk(RR)=1.30,95%confidence interval(CI)1.00～1.68, P=0.05)]. Anastomotic leakage, morbidity and mortality were similar between the two groups.Conclusion:Nasogastric tubes should not be used routinely in patients undergoing radical surgery for gastric cancer. |
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