腹腔镜远端胃癌根治术的临床研究与荟萃分析
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摘要
胃癌是最常见的消化道恶性肿瘤之一,以病灶扩大切除和区域淋巴结清扫为要求的胃癌根治术是其最主要的治疗手段。但传统的开腹手术在治疗疾病的同时也造成了巨大的创伤。1994年,Kitano首先报道运用腹腔镜技术治疗远端胃癌,其切口小、疼痛轻、患者恢复快,具有明显的徽创优势。
腹腔镜远端胃癌根治术主要包括腹腔镜辅助远端胃癌根治术(laparoscopic-assisted distal gastrectomy, LADG)和完全腹腔镜远端胃癌根治术(totally laparoscopic distal gastrectomy, TLDG)两种手术方式。LADG是指在腹腔镜下离断胃周血管,并清扫相应的淋巴结群,最后通过上腹部的辅助切口直视下切除标本并进行胃肠道重建。而TLDG则是在腹腔镜下完成所有的手术操作,最后经扩大的脐下套管孔取出标本。尽管TLDG手术更具微创优势,但由于腹腔镜下吻合难度较高,多数术者仍选择行LADG手术,TLDG手术目前仍极少开展。
本中心自2004年11月起开始运用LADG术治疗胃癌,体会到其显示胃周血管更清晰,淋巴结清扫不逊于传统开放手术,但对肥胖或病灶位置较高者辅助切口下的切除重建仍不理想。随着手术技能的提高,自2007年3月起术者开始施行TLDG手术,临床效果理想。为了全面评价TLDG手术的安全性、肿瘤治疗效果以及其在减轻患者炎症应激反应水平、降低术后免疫抑制程度、改善术后生活质量和胃肠功能等方面的优势,并评估术中长时间气腹对患者肺、肝、肾等脏器功能的影响。本研究总结分析了本中心开展的全部TLDG病例的临床资料,并在2009年12月到2011年1月间对接受TLDG与传统的开腹远端胃癌根治术(opendistal gastrectomy, ODG)的患者进行了前瞻性对照研究。此外,对现有研究报道较多的LADG手术,本研究提取其与ODG对比的随机对照研究(randomized controlled trials, RCT)和高质量的观察性研究的结果,并对其进行了荟萃分析。
第一部分：完全腹腔镜远端胃癌根治术的临床研究(附56例报道)
研究目的：1.探讨TLDG的可行性、安全性及肿瘤治疗效果并总结相关的手术经验和技巧。2.分析患者身体质量指数(body mass index, BMI)及术者手术经验对TLDG近期结果的影响。
研究方法：总结分析2007年3月到2011年1月间本中心施行的所有TLDG手术病例的临床资料。主要分析指标包括：手术时间、术中出血量、淋巴结清扫数目、近端远端切缘距离、肛门排气时间、术后进半流时间、术后住院天数、术后并发症及随访结果等。同时根据患者的BMI值将所有患者分为低体重组(BMI<20kg/m2)、正常体重组(20≤BMI<25 kg/m。)及高体重组(BMI≥25 kg/m。),通过对三组患者手术时间、出血量、淋巴结清扫数目、术后住院天数及术后并发症情况的对比研究分析患者BMI对TLDG近期结果的影响。此外,本研究还借鉴文献报道的结果,将所有患者分为早期手术组(前40例)和后期手术组(后16例),通过对比两组间的手术时间、出血量、淋巴结清扫数目、术后住院天数及术后并发症情况来分析术者手术经验对TLDG近期结果的影响。
研究结果：本组共56例,其中男性38例,女性18例；年龄34-79岁,平均58.6±10.6岁。术前BMI为15.4～27.7 kg/m。,平均22.5±2.8 kg/m2,其中低体重组10例,正常体重者31例,高体重组15例。本组手术均顺利完成,无中转开腹或腹腔镜辅助手术。手术时间175-400 min,平均269±54 min;术中出血30～600 mL,平均164±105 mL,术中输血1例。淋巴结清扫数目15-45枚,平均29.2±8.0枚；近端切缘距离3.5-8.0 cm,平均5.6±2.3 cm；远端切缘距离3.5～11.0 cm,平均5.8±2.1 cm。
术后肛门排气时间2-7 d,平均3.5±13 d；术后进半流时间3-14 d,平均5.2±2.5d；术后住院天数6～21 d,平均9.7±3.1 d。术后9例出现并发症,并发症率为16.1%,其中腹腔积液伴感染2例；短期胃排空障碍2例；肺部感染2例；吻合口漏、腹腔乳糜漏及严重低蛋白血症各1例。术后随访2～47月,平均22月,失访7人,随访率87.5%。5例患者分别于术后4m、13m、13m、15m、17m出现肿瘤复发或转移。
分组研究显示患者BMI值对手术操作并无明显影响。除低体重组术后并发症率明显高于正常体重组外(40% vs 9.7%),三组的手术时间、术中出血量、淋巴结清扫数目及术后住院天数均无显著性差异。线性回归分析也证实BMI值与患者手术时间、术中出血量、淋巴结清扫数目及术后住院天数均无相关性。但术者手术经验对手术操作有明显影响。后期手术组的手术时间(233±31 min vs 284±55min)、术中出血量(118±66mL vs 182±113mL)及术后住院天数(9.1±3.6d vs10.0±2.8 d)均显著低于早期手术组(P<0.05)。结论：1TLDG手术在技术上是完全可行的,并具有良好的近期治疗效果。2.患者的BMI值对手术近期结果并无明显影响,但术者的手术经验可以显著影响手术效果。
第二部分：完全腹腔镜与开腹远端胃癌根治术的对照研究
研究目的：1.进一步评价TLDG的手术安全性及肿瘤治疗效果。2.探讨TLDG在减轻机体炎症应激反应、降低术后免疫抑制程度、改善术后生活质量及胃肠功能等方面的优势。3.评估TLDG术中持续的长时间CO2气腹对患者肺、肝、肾等脏器功能的不良影响。
研究方法：选择本中心2009年12月至2011年1月间的远端胃癌患者。根据患者自身意愿分为TLDG组和ODG组。通过对两组患者的近期手术结果的对照分析对TLDG手术的安全性及肿瘤治疗效果进行评价。通过对两组患者术后血pH值、CO2分压、丙氨酸氨基转移酶(alanine aminotransferase, ALT)总胆红素(total bilirubin, TB)、血清白蛋白(albumin, ALB)、血清前白蛋白(prealbumin, PA)、血清肌酐(creatinine, CR)及血清尿素氮(blood urea nitrogen, BUN)等指标的对比分析来研究气腹对患者术后肺、肝、肾等脏器功能的影响。通过对两组术后白细胞(white blood cell, WBC)、中性粒细胞(neutrophilicgranulocyte, NE)数目及血浆C反应蛋白(C reactive protein, CRP)、白介素-6(interleukin-6, IL-6)、白介素-10(interleukin-10, IL-10)等炎症因子水平的对比分析来探讨TLDG手术在减少机体炎症应激反应中的作用。通过对两组术后CD3+T细胞、CD4+T细胞、CD8+T细胞、NK细胞及免疫球蛋白A (immunoglobulin A, lgA)、免疫球蛋白M (immunoglobulin M, IgM)、免疫球蛋白G (immunoglobulin G, IgG)和补体C3、C4水平的对比分析来评估TLDG手术在降低患者术后免疫抑制程度中的价值。通过对比两组术后1 m、3 m的QLQ-C30和STO-22生活质量量表评分和术后3 m的胃镜及液体核素胃动力检查结果来分析TLDG手术在改善患者术后生活质量及胃肠功能中的作用。
研究结果：两组共41例患者,其中TLDG组19例,ODG组22例。两组在性别、年龄、BMI、术前ASA分级及术后病理分期上均无显著性差异。两组手术均顺利完成,TLDG组无中转开腹或腹腔镜辅助手术。两组总的手术时间无显著性差异,但和ODG组相比,TLDG组的进腹及关腹时间明显缩短,而淋巴结清扫时间明显延长。TLDG组切口长度明显短于开腹组(4.0±0.9 cm vs 22.8±1.9 cm),且出血量明显减少(126.8±73.6 mL vs 279.6±129.7 mL),但TLDG组术中体温下降幅度明显大于ODG组,且其治疗费用显著增加(53000±8236元vs 39658±10630元)。两组在淋巴结清扫数目及近端、远端切缘距离上均无显著性差异。
在术后恢复上,TLDG组和ODG组的并发症率无明显差异(21.1% vs 22.7%)。TLDG组术后恢复较快,其术后下床时间、术后肛门排气时间、术后进流质时间、术后进半流质时间及术后住院天数均显著短于ODG组。TLDG组术后的疼痛评分及镇痛泵用量也均显著优于ODG组,显示腹腔镜手术可以明显减轻患者的手术疼痛。
在术后脏器功能的研究中,TLDG组和ODG组术后0 h、2 h、6 h及24 h的pH值和CO2分压均无显著性差异,TLDG组术后各时间点的pH值和CO2分压均位于正常范围。这表明腹腔镜气腹并未对患者的肺功能造成明显不利影响。两组术后24 h、72 h、120 h、168 h的ALT、TB、ALB、PA及CR水平均无显著性差异,提示腹腔镜气腹对患者的肝肾功能并无明显不利影响。
在对患者术后炎症应激反应水平的评估中,TLDG组术后0h的WBC和NE数目及术后24h内的CRP、IL-6、IL-10水平均显著低于ODG组,表明TLDG可以有效减轻患者术后早期的炎症应激反应。两组术后24h、72h、120h、168h的CD3+T细胞、CD4+T细胞、CD8+T细胞、NK细胞及IgA、IgM、IgG免疫球蛋白水平均无显著性差异,这表明腹腔镜手术并不能减轻患者术后的免疫抑制程度。但TLDG组术后72h、120h、168h的补体C3、C4水平均显著低于ODG组,这可能与腹腔镜手术更小的手术创伤有关。
TLDG组术后具有更佳的生活质量。在术后1m的生活质量评分上TLDG组在整体健康状况、生理功能、角色功能、社会功能及疼痛评分上均显著优于ODG组。术后3m的生活质量评分上,TLDG组除在整体健康状况及生理功能评分上仍显著高于ODG组外,其他项目均无显著性差异。术后3m的液体核素胃动力检查结果显示TLDG组和ODG组术后的线性胃半排时间和30min胃排空率无明显差异。术后3m的胃镜检查结果发现两组的吻合口胆汁反流及反流性食道炎发生率均无显著性差异。这显示TLDG组在术后远期胃肠功能上并无明显优势。
结论：1TLDG和ODG具有相同的手术安全性和相同的病灶切除与淋巴结清扫效果。TLDG在加快术后恢复、减轻机体早期炎症应激反应及提高术后生活质量上具有明显的微创优势。2.腹腔镜手术在减轻患者术后的免疫抑制程度、改善患者术后的远期胃肠功能等方面并无明显优势。3TLDG术中长时间的CO2气腹对患者术后的肺、肝及肾功能并无明显不利影响。
第三部分：腹腔镜辅助与开腹远端胃癌根治术对比研究的荟萃分析
研究目的：通过对LADG与ODG对比研究文献的荟萃分析来评估当前LADG手术的安全性和肿瘤治疗效果。
研究方法：检索1995年1月1日至2011年2月28日Pubmed、Cochrane library、Web of Science和Biosis Previews数据库有关LADG和ODG的对比性研究文献。对其中的手术时间、术中出血量、淋巴结清扫数目、近端及远端切缘距离、术后肛门排气时间、术后进流质时间、术后住院时间及术后并发症等数据进行荟萃分析。对连续性变量进行加权平均数差(weighted means difference, WMD)统计,对二分类变量进行相对危险度(relative risk, RR)统计,异质性探索使用Meta回归分析。数据分析使用STATA11.0软件。
研究结果：共13篇文献纳入本研究,其中RCT研究4篇,观察性研究9篇。病人总数为1945例,其中LADG组958例,ODG组987例。在近期手术结果上,除手术时间较长外,LADG组具有更少的术中出血量、更快的肛门排气和进食时间、更短的术后住院时间及更少的术后并发症率。在肿瘤根治效果上,LADG组和ODG组的淋巴结清扫数目和远端切缘距离无显著性差异,但LADG组的近端切缘距离显著短于ODG组。
结论：LADG具有术中出血少、并发症率低、患者术后恢复快等优势,并具有和ODG相同的淋巴清扫效果。但其近端切缘较短,值得重视。
Gastric cancer is one of the most common digestive tract cancers, and the surgery with extended resection and regional lymph node dissection is still the major treatment for it. However, severe surgical trauma is inevitable in the conventional open surgery. In 1994, Kitano reported the first case of laparoscopic distal gastrectomy (LDG) which had significant advantages of minimally invasion with small incision, light pain and
对连续性变量进行加权平均数差(weighted means difference, WMD)统计,对二分类变量进行相对危险度(relative risk, RR)统计,异质性探索使用Meta回归分析。数据分析使用STATA11.0软件。
研究结果：共13篇文献纳入本研究,其中RCT研究4篇,观察性研究9篇。病人总数为1945例,其中LADG组958例,ODG组987例。在近期手术结果上,除手术时间较长外,LADG组具有更少的术中出血量、更快的肛门排气和进食时间、更短的术后住院时间及更少的术后并发症率。在肿瘤根治效果上,LADG组和ODG组的淋巴结清扫数目和远端切缘距离无显著性差异,但LADG组的近端切缘距离显著短于ODG组。
结论：LADG具有术中出血少、并发症率低、患者术后恢复快等优势,并具有和ODG相同的淋巴清扫效果。但其近端切缘较短,值得重视。
Gastric cancer is one of the most common digestive tract cancers, and the surgery with extended resection and regional lymph node dissection is still the major treatment for it. However, severe surgical trauma is inevitable in the conventional open surgery. In 1994, Kitano reported the first case of laparoscopic distal gastrectomy (LDG) which had significant advantages of minimally invasion with small incision, light pain and rapid recovery.
LDG includes two approaches, laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG). With LADG, the perigastric devasculization and systematic lymph node dissection are carried out laparoscopically. However, the excision of the specimen and the anastomosis are performed with a direct view through a minilaparotomy in the epigastrium. On the other hand, with TLDG, all the processes are performed laparoscopically follows by removal of resected specimen through the extended U-shaped skin incision beneath the umbilicus. Most surgeons prefer LADG with extracorporeal anastomosis rather than TLDG because of the technical difficulties of intracorporeal anastomosis, although the total laparoscopic procedure appears to be less invasive.
Beginning from November 2004, LADG was introduced at our institution for the surgical treatment of gastric cancer. Comparing with conventional ODG, it has more clear view of perigastric vessles and similar effect of lymph node dissection. But the resection and reconstruction through a minilaparotomy is difficult for the fat or the high-location lesion. With the accumulation of surgical experience, we switched to TLDG approach from March 2007. To clarify the safety and oncological effect of TLDG, evaluate the advantages of TLDG in alleviating the inflammatory response, reducing the postoperative immunodepression and improving the quality of life (QOL) and gastrointestinal function and assess the negative effect of long-duration pneumoperitoneum on the patient's lung, liver and kidney functions, an analysis of the clinical data of all TLDG cases at our institution and a prospective comparative study of LADG and open distal gastrectomy (ODG) from December 2009 to January 2011 were performed. Furthermore, to evaluate the status of LADG which has been investigated in many papers, a meta-analysis of randomized controlled trials (RCT) and high quality observational studies were performed.
Part1:the clinical study of totally laparoscopic distal gastrectomy for gastric cancer (56 cases report)
Objective:1. To investigate the feasibility, safety and oncological effect of TLDG.2. To evaluate the effects of patient's body mass index (BMI) and surgeon's experience on the short-term outcomes of TLDG.
Methods:Analyzed the clinical data of all TLDG cases at our institution from March 2007 to January 2011. The major data including operation time, blood loss, first flatus time, first semiliquid diet time, postoperative hospital stay, postoperative complications, number of dissected lymph nodes, proximal and distal resection margins were all collected. Also, The operation time, blood loss, number of dissected lymph nodes, postoperative hospital stay and postoperative complications in the low-weight group (BMI<20 kg/m2), normal-weight group (20≤BMI<25 kg/m2) and high-weight group (BMI≥25kg/m2) were compared to assess the effect of patient's BMI on the short-term outcomes of TLDG. Furthermore, these data were also compared between the early stage (40 cases) and late stage (16 cases) to assess the effect of surgeon's experience on the short-term outcomes of TLDG.
Results:56 cases were analyzed in this study, including 38 men and 18 women with a mean age of 58.6±10.6 y (range,34 to 79 y). The mean BMI was 22.5±2.8 kg/m2 (range,15.4 to 27.7 kg/m2) and there were 10 cases in the low-weight group,31 cases in the normal-weight group and 15 cases in the high-weight group respectively. All operations were completed successfully without converting to open and laparosopic-assisted surgery. The mean operation time was 269±54 min (range,175 min to 400 min) and the mean blood loss was 164±105 mL (range,30 mL to 600 mL) with only one case of introperative blood transfusion. The mean number of dissected lymph nodes was 29.2±8.0 (range,15 to 45). The mean proximal and distal resection margins were 5.6±2.3 cm (range,3.5 to 8.0 cm) and 5.8±2.1 cm (range,3.5 to 11.0 cm), respectively.
The mean time to first flatus and semiliquid diet were 3.5±1.3 d (range,2 to 7 d) and 5.2±2.5 d (range,3 to 14 d), respectively. The mean postoperative hospital stay was 9.7±3.1 d (range,6 to 21 d). Postoperative complications occurred in 9 cases (16.1%) including 2 cases of delayed gastric empting,2 cases of pulmonary infection, 2 cases of abdominal abscess,1 case of anastomotic leakage which needed second open surgery,1 case of chylous leakage and 1 case of severe hypoalbuminemia. The mean follow-up period was 22 m (range,2 to 47 m), while 7 cases were lost and the follow-up rate was 87.5%. Tumor recurrence or metastasis was occurred in 5 cases at 4 m,13 m,13 m,15 m and 17 m after operation, respectively.
The patient's BMI had no obvious effect on the short-term outcomes. There were no significant difference on the operation time, blood loss, number of dissected lymph nodes, postoperative hospital stay or postoperative morbidity among these three groups except for that the postoperative morbidity of low-weight group was significantly higher than normal-weight group (40% vs 9.7%). The consequences of linear regression analysis also showed that there were no obvious correlations between the BMI and the operation time, blood loss, number of dissected lymph nodes or postoperative hospital stay. Otherwise, the surgion's experience had obvious effect on the short-term outcomes. Lower operation time (233±31 min vs 284±55 min), less blood loss (118±66 mL vs 182±113 mL) and shorter postoperative hospital stay (9.1±3.6 d vs 10.0±2.8) were observed in the late stage group than the early stage group (P<0.05).
Conclusion:1. TLDG is feasible and safe with good short-term outcomes.2. The surgeon's experience, rather than the BMI has obvious effect on the short-term outcomes of TLDG.
Part 2:comparative study of totally laparoscopic and open distal gastrectomy for gastric cancer
Objective:1. To further investigate the safety and oncological effect of TLDG.2. To evaluate the advantages of TLDG in alleviating the inflammatory response, reducing the postoperative immunodepression and improving the quality of life (QOL) and gastrointestinal function.3. To assess the negative effect of long-duration pneumoperitoneum on the patient's lung, liver and kidney functions.
Methods:From December 2009 to Januanry 2011, the distal gastric caner patients at our institution who signed the informed consents were included in this study. The operative procedure was selected by the patients and their families. The safety and oncologic effect of TLDG were investigated by comparing the short-term outcomes of two groups. The negative effect of prolonged pneumoperitoneum on the lung, liver and kidney function was assessed by comparing the values of pH, CO2 pressure, alanine aminotransferase (ALT), total bilirubin (TB), albumin (ALB), prealbumin (PA), creatinine (CR) and blood urea nitrogen (BUN) in the blood between the TLDG and ODG group. Inflammatory response was evaluated by comparing the number of white blood cell (WBC) and neutrophilicgranulocyte (NE) and the plasma levels of C reactive protein (CRP), interleukin-6 (IL-6) and interleukin-10 (IL-10) between these two groups. Postoperative immunity was evaluated by comparing the numbers of CD3+ T-cells, CD4+T-cells, CD8+T-cells and NK cells and the serum levels of immunoglobulin A (IgA), immunoglobulin M (Igm), immunoglobulin G (IgG), C3 and C4. The simplified Chinese versions of QLQ C-30 and STO-22 questionnaires were used to assess the QOL at 1 m and 3 m postoperatively and the dynamic radionuclide imaging and endoscopy were used to assess the gastrointestinal function at 3 m postoperatively, and both results were compared between these two groups.
Results:Totally,41 cases were included in this study, including 19 cases in the TLDG group and 22 cases in the ODG group. There were no significant differences between these two groups with respect to sex, age, BMI, ASA status and TMN stage. In the TLDG group, all operations were completed successfully without converting to open or laparoscopic-assisted surgery. The total operation time was similar in two groups, but the time of opening and closing abdomen were shorter and the time of lymph node dissection was longer in the TLDG group. The TLDG group was associated with shorter incision (4.0±0.9 cm vs 22.8±1.9 cm) and less blood loss (126.8±73.6 mL vs 279.6±129.7 mL), but the body temperature declined much faster and the costs was much higher (53,000±8,236 CNY vs 39,658±10,630 CNY). There were no significant differences with regard to the number of dissected lymph nodes and proximal or distal resection margins.
The postoperative morbidity was similar between the TLDG and ODG group (21.1% vs 22.7%). Patients in the TLDG group recovered much faster, Its time to out-of-bed activity, first flatus, first liquid diet, first semiliquid diet and postoperative hospital stay were significantly shorter than those in the ODG group. Moreover, the TLDG group also had lower VAS pain scores and less consumption of analgesics, indicating that the laparoscopic surgery resulted in less postoperative pain.
There were no significant differences in pH value and CO2 pressure between the TLDG and ODG group and the pH value and CO2 pressure of the TLDG group were all in the normal range at all measurement points (0 h,2 h,6 h,24 h, postoperatively). This indicated that long-duration pneumoperitoneum had no obvious negative effect on the lung function. There were also no significant differences of the value of ALT, TB, ALB, PA and CR between these two groups at all measurement points (24 h,72 h,120 h,168 h, postoperatively). These outcomes demonstrated that pneumoperitoneum during TLDG does not adversely alter postoperative liver and kidney functions to any greater extent than ODG.
The numbers of WBC and NE at 0 h postoperatively and the values of CRP, IL-6 and IL-10 within 24 h postoperatively were significantly lower in the TLDG group, which meant that TLDG resulted in less early postoperative inflammatory response. However, there were no significant differences in the numbers of CD3+T-cells, CD4+ T-cells, CD8+T-cells, NK cells and the values of IgA, IgM, IgG between these two groups, which demonstrated that TLDG did not have an immunological advantage over ODG. In addition, the values of C3 and C4 were much lower in the TLDG group at 72 h、120 h、168 h postoperatively, which implied that TLDG induced less surgical trauma than ODG.
TLDG group had better QOL than ODG group. In the assessment of QOL at 1 m postoperatively, the QOL parameters including global health, physical function, role function, social function and pain scale were significantly better in the TLDG group compared with the ODG group. However, it was also observed that the advantages of QOL in the TLDG group weakened with the passing of time. At 3 m postoperatively, only global health and physical function were still significantly better in the TLDG group. In addition, there was no advantage of long-term gastrointestinal function in the TLDG group over ODG group. The consequences of dynamic radionuclide imaging at 3 m postoperatively showed that there were no significant differences of the linear fit half empting time and the gastric empting rate within 30 min between these two groups. The endoscopic findings at 3 m postoperatively also showed there were no significant differences of the incidence of anastomotic bile reflux and reflux esophagitis between these two groups.
Conclusions:1.TLDG has similar safety and surgical results of tumor resection and lymph node dissection comparing with ODG. It has obvious mini-invasive advantages in accelerating the postoperative recovery, alleviating the early inflammatory response and improving the QOL.2. TLDG has no advantages in reducing the postoperative immunosuppression and improving the gastrointestinal function.3. Long-duration pneumoperitoneum during TLDG has no obvious negative effect on the patient's lung, liver and kidney functions.
Part3:meta-analysis of laparoscopic-assisted and open distal gastrectomy for gastric cancer
Objective:To evaluate the safety and oncologic effect of LADG by the means of meta-analysis.
Methods:Comparative studies of LADG and ODG in Pubmed, Cochrane library, Web of Science and Biosis Previews Databases from January 1,1995 to February 28,2011 were collected. The data of operation time, blood loss, number of lymph node dissection, the proximal and distal resection margins, time to flatus, time to first oral intake, postoperative hospital stay and postoperative morbidity were analyzed. The results were expressed with weighted mean difference (WMD) for continuous variable and relative risk (RR) for the dichotomous variable. Meta-regression analysis was performed to explore the sources of heterogeneity. The statistical analysis was performed by STATA11.0 software.
Results:13 articles were analyzed in this study, including 4 RCT and 9 retrospective observational articles. A total of 1945 patients with gastric cancer of whom 958 underwent LADG and 987 underwent ODG were included in this meta-analysis. Compared to ODG, LADG results in prolonged operation time, decreased blood loss, less time to flatus and oral intake, shortened postoperative hospital stay and less postoperative morbidity. On the aspect of oncological effect, there was no differences between these two groups in number of dissected lymph nodes and the distal resection margin, but the proximal resection margin was significantly shorter in the LADG group.
Conclusion:1. LADG has the advantages of less blood loss, less postoperative morbidity and faster postoperative recovery. LADG is capable of providing a quality of lymph node dissection equivalent to that of ODG, but the proximal resection margin of LADG is significantly shorter.
腹腔镜远端胃癌根治术主要包括腹腔镜辅助远端胃癌根治术(laparoscopic-assisted distal gastrectomy, LADG)和完全腹腔镜远端胃癌根治术(totally laparoscopic distal gastrectomy, TLDG)两种手术方式。LADG是指在腹腔镜下离断胃周血管,并清扫相应的淋巴结群,最后通过上腹部的辅助切口直视下切除标本并进行胃肠道重建。而TLDG则是在腹腔镜下完成所有的手术操作,最后经扩大的脐下套管孔取出标本。尽管TLDG手术更具微创优势,但由于腹腔镜下吻合难度较高,多数术者仍选择行LADG手术,TLDG手术目前仍极少开展。
本中心自2004年11月起开始运用LADG术治疗胃癌,体会到其显示胃周血管更清晰,淋巴结清扫不逊于传统开放手术,但对肥胖或病灶位置较高者辅助切口下的切除重建仍不理想。随着手术技能的提高,自2007年3月起术者开始施行TLDG手术,临床效果理想。为了全面评价TLDG手术的安全性、肿瘤治疗效果以及其在减轻患者炎症应激反应水平、降低术后免疫抑制程度、改善术后生活质量和胃肠功能等方面的优势,并评估术中长时间气腹对患者肺、肝、肾等脏器功能的影响。本研究总结分析了本中心开展的全部TLDG病例的临床资料,并在2009年12月到2011年1月间对接受TLDG与传统的开腹远端胃癌根治术(opendistal gastrectomy, ODG)的患者进行了前瞻性对照研究。此外,对现有研究报道较多的LADG手术,本研究提取其与ODG对比的随机对照研究(randomized controlled trials, RCT)和高质量的观察性研究的结果,并对其进行了荟萃分析。
第一部分：完全腹腔镜远端胃癌根治术的临床研究(附56例报道)
研究目的：1.探讨TLDG的可行性、安全性及肿瘤治疗效果并总结相关的手术经验和技巧。2.分析患者身体质量指数(body mass index, BMI)及术者手术经验对TLDG近期结果的影响。
研究方法：总结分析2007年3月到2011年1月间本中心施行的所有TLDG手术病例的临床资料。主要分析指标包括：手术时间、术中出血量、淋巴结清扫数目、近端远端切缘距离、肛门排气时间、术后进半流时间、术后住院天数、术后并发症及随访结果等。同时根据患者的BMI值将所有患者分为低体重组(BMI<20kg/m2)、正常体重组(20≤BMI<25 kg/m。)及高体重组(BMI≥25 kg/m。),通过对三组患者手术时间、出血量、淋巴结清扫数目、术后住院天数及术后并发症情况的对比研究分析患者BMI对TLDG近期结果的影响。此外,本研究还借鉴文献报道的结果,将所有患者分为早期手术组(前40例)和后期手术组(后16例),通过对比两组间的手术时间、出血量、淋巴结清扫数目、术后住院天数及术后并发症情况来分析术者手术经验对TLDG近期结果的影响。
研究结果：本组共56例,其中男性38例,女性18例；年龄34-79岁,平均58.6±10.6岁。术前BMI为15.4～27.7 kg/m。,平均22.5±2.8 kg/m2,其中低体重组10例,正常体重者31例,高体重组15例。本组手术均顺利完成,无中转开腹或腹腔镜辅助手术。手术时间175-400 min,平均269±54 min;术中出血30～600 mL,平均164±105 mL,术中输血1例。淋巴结清扫数目15-45枚,平均29.2±8.0枚；近端切缘距离3.5-8.0 cm,平均5.6±2.3 cm；远端切缘距离3.5～11.0 cm,平均5.8±2.1 cm。
术后肛门排气时间2-7 d,平均3.5±13 d；术后进半流时间3-14 d,平均5.2±2.5d；术后住院天数6～21 d,平均9.7±3.1 d。术后9例出现并发症,并发症率为16.1%,其中腹腔积液伴感染2例；短期胃排空障碍2例；肺部感染2例；吻合口漏、腹腔乳糜漏及严重低蛋白血症各1例。术后随访2～47月,平均22月,失访7人,随访率87.5%。5例患者分别于术后4m、13m、13m、15m、17m出现肿瘤复发或转移。
分组研究显示患者BMI值对手术操作并无明显影响。除低体重组术后并发症率明显高于正常体重组外(40% vs 9.7%),三组的手术时间、术中出血量、淋巴结清扫数目及术后住院天数均无显著性差异。线性回归分析也证实BMI值与患者手术时间、术中出血量、淋巴结清扫数目及术后住院天数均无相关性。但术者手术经验对手术操作有明显影响。后期手术组的手术时间(233±31 min vs 284±55min)、术中出血量(118±66mL vs 182±113mL)及术后住院天数(9.1±3.6d vs10.0±2.8 d)均显著低于早期手术组(P<0.05)。结论：1TLDG手术在技术上是完全可行的,并具有良好的近期治疗效果。2.患者的BMI值对手术近期结果并无明显影响,但术者的手术经验可以显著影响手术效果。
第二部分：完全腹腔镜与开腹远端胃癌根治术的对照研究
研究目的：1.进一步评价TLDG的手术安全性及肿瘤治疗效果。2.探讨TLDG在减轻机体炎症应激反应、降低术后免疫抑制程度、改善术后生活质量及胃肠功能等方面的优势。3.评估TLDG术中持续的长时间CO2气腹对患者肺、肝、肾等脏器功能的不良影响。
研究方法：选择本中心2009年12月至2011年1月间的远端胃癌患者。根据患者自身意愿分为TLDG组和ODG组。通过对两组患者的近期手术结果的对照分析对TLDG手术的安全性及肿瘤治疗效果进行评价。通过对两组患者术后血pH值、CO2分压、丙氨酸氨基转移酶(alanine aminotransferase, ALT)总胆红素(total bilirubin, TB)、血清白蛋白(albumin, ALB)、血清前白蛋白(prealbumin, PA)、血清肌酐(creatinine, CR)及血清尿素氮(blood urea nitrogen, BUN)等指标的对比分析来研究气腹对患者术后肺、肝、肾等脏器功能的影响。通过对两组术后白细胞(white blood cell, WBC)、中性粒细胞(neutrophilicgranulocyte, NE)数目及血浆C反应蛋白(C reactive protein, CRP)、白介素-6(interleukin-6, IL-6)、白介素-10(interleukin-10, IL-10)等炎症因子水平的对比分析来探讨TLDG手术在减少机体炎症应激反应中的作用。通过对两组术后CD3+T细胞、CD4+T细胞、CD8+T细胞、NK细胞及免疫球蛋白A (immunoglobulin A, lgA)、免疫球蛋白M (immunoglobulin M, IgM)、免疫球蛋白G (immunoglobulin G, IgG)和补体C3、C4水平的对比分析来评估TLDG手术在降低患者术后免疫抑制程度中的价值。通过对比两组术后1 m、3 m的QLQ-C30和STO-22生活质量量表评分和术后3 m的胃镜及液体核素胃动力检查结果来分析TLDG手术在改善患者术后生活质量及胃肠功能中的作用。
研究结果：两组共41例患者,其中TLDG组19例,ODG组22例。两组在性别、年龄、BMI、术前ASA分级及术后病理分期上均无显著性差异。两组手术均顺利完成,TLDG组无中转开腹或腹腔镜辅助手术。两组总的手术时间无显著性差异,但和ODG组相比,TLDG组的进腹及关腹时间明显缩短,而淋巴结清扫时间明显延长。TLDG组切口长度明显短于开腹组(4.0±0.9 cm vs 22.8±1.9 cm),且出血量明显减少(126.8±73.6 mL vs 279.6±129.7 mL),但TLDG组术中体温下降幅度明显大于ODG组,且其治疗费用显著增加(53000±8236元vs 39658±10630元)。两组在淋巴结清扫数目及近端、远端切缘距离上均无显著性差异。
在术后恢复上,TLDG组和ODG组的并发症率无明显差异(21.1% vs 22.7%)。TLDG组术后恢复较快,其术后下床时间、术后肛门排气时间、术后进流质时间、术后进半流质时间及术后住院天数均显著短于ODG组。TLDG组术后的疼痛评分及镇痛泵用量也均显著优于ODG组,显示腹腔镜手术可以明显减轻患者的手术疼痛。
在术后脏器功能的研究中,TLDG组和ODG组术后0 h、2 h、6 h及24 h的pH值和CO2分压均无显著性差异,TLDG组术后各时间点的pH值和CO2分压均位于正常范围。这表明腹腔镜气腹并未对患者的肺功能造成明显不利影响。两组术后24 h、72 h、120 h、168 h的ALT、TB、ALB、PA及CR水平均无显著性差异,提示腹腔镜气腹对患者的肝肾功能并无明显不利影响。
在对患者术后炎症应激反应水平的评估中,TLDG组术后0h的WBC和NE数目及术后24h内的CRP、IL-6、IL-10水平均显著低于ODG组,表明TLDG可以有效减轻患者术后早期的炎症应激反应。两组术后24h、72h、120h、168h的CD3+T细胞、CD4+T细胞、CD8+T细胞、NK细胞及IgA、IgM、IgG免疫球蛋白水平均无显著性差异,这表明腹腔镜手术并不能减轻患者术后的免疫抑制程度。但TLDG组术后72h、120h、168h的补体C3、C4水平均显著低于ODG组,这可能与腹腔镜手术更小的手术创伤有关。
TLDG组术后具有更佳的生活质量。在术后1m的生活质量评分上TLDG组在整体健康状况、生理功能、角色功能、社会功能及疼痛评分上均显著优于ODG组。术后3m的生活质量评分上,TLDG组除在整体健康状况及生理功能评分上仍显著高于ODG组外,其他项目均无显著性差异。术后3m的液体核素胃动力检查结果显示TLDG组和ODG组术后的线性胃半排时间和30min胃排空率无明显差异。术后3m的胃镜检查结果发现两组的吻合口胆汁反流及反流性食道炎发生率均无显著性差异。这显示TLDG组在术后远期胃肠功能上并无明显优势。
结论：1TLDG和ODG具有相同的手术安全性和相同的病灶切除与淋巴结清扫效果。TLDG在加快术后恢复、减轻机体早期炎症应激反应及提高术后生活质量上具有明显的微创优势。2.腹腔镜手术在减轻患者术后的免疫抑制程度、改善患者术后的远期胃肠功能等方面并无明显优势。3TLDG术中长时间的CO2气腹对患者术后的肺、肝及肾功能并无明显不利影响。
第三部分：腹腔镜辅助与开腹远端胃癌根治术对比研究的荟萃分析
研究目的：通过对LADG与ODG对比研究文献的荟萃分析来评估当前LADG手术的安全性和肿瘤治疗效果。
研究方法：检索1995年1月1日至2011年2月28日Pubmed、Cochrane library、Web of Science和Biosis Previews数据库有关LADG和ODG的对比性研究文献。对其中的手术时间、术中出血量、淋巴结清扫数目、近端及远端切缘距离、术后肛门排气时间、术后进流质时间、术后住院时间及术后并发症等数据进行荟萃分析。对连续性变量进行加权平均数差(weighted means difference, WMD)统计,对二分类变量进行相对危险度(relative risk, RR)统计,异质性探索使用Meta回归分析。数据分析使用STATA11.0软件。
研究结果：共13篇文献纳入本研究,其中RCT研究4篇,观察性研究9篇。病人总数为1945例,其中LADG组958例,ODG组987例。在近期手术结果上,除手术时间较长外,LADG组具有更少的术中出血量、更快的肛门排气和进食时间、更短的术后住院时间及更少的术后并发症率。在肿瘤根治效果上,LADG组和ODG组的淋巴结清扫数目和远端切缘距离无显著性差异,但LADG组的近端切缘距离显著短于ODG组。
结论：LADG具有术中出血少、并发症率低、患者术后恢复快等优势,并具有和ODG相同的淋巴清扫效果。但其近端切缘较短,值得重视。
Gastric cancer is one of the most common digestive tract cancers, and the surgery with extended resection and regional lymph node dissection is still the major treatment for it. However, severe surgical trauma is inevitable in the conventional open surgery. In 1994, Kitano reported the first case of laparoscopic distal gastrectomy (LDG) which had significant advantages of minimally invasion with small incision, light pain and
对连续性变量进行加权平均数差(weighted means difference, WMD)统计,对二分类变量进行相对危险度(relative risk, RR)统计,异质性探索使用Meta回归分析。数据分析使用STATA11.0软件。
研究结果：共13篇文献纳入本研究,其中RCT研究4篇,观察性研究9篇。病人总数为1945例,其中LADG组958例,ODG组987例。在近期手术结果上,除手术时间较长外,LADG组具有更少的术中出血量、更快的肛门排气和进食时间、更短的术后住院时间及更少的术后并发症率。在肿瘤根治效果上,LADG组和ODG组的淋巴结清扫数目和远端切缘距离无显著性差异,但LADG组的近端切缘距离显著短于ODG组。
结论：LADG具有术中出血少、并发症率低、患者术后恢复快等优势,并具有和ODG相同的淋巴清扫效果。但其近端切缘较短,值得重视。
Gastric cancer is one of the most common digestive tract cancers, and the surgery with extended resection and regional lymph node dissection is still the major treatment for it. However, severe surgical trauma is inevitable in the conventional open surgery. In 1994, Kitano reported the first case of laparoscopic distal gastrectomy (LDG) which had significant advantages of minimally invasion with small incision, light pain and rapid recovery.
LDG includes two approaches, laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG). With LADG, the perigastric devasculization and systematic lymph node dissection are carried out laparoscopically. However, the excision of the specimen and the anastomosis are performed with a direct view through a minilaparotomy in the epigastrium. On the other hand, with TLDG, all the processes are performed laparoscopically follows by removal of resected specimen through the extended U-shaped skin incision beneath the umbilicus. Most surgeons prefer LADG with extracorporeal anastomosis rather than TLDG because of the technical difficulties of intracorporeal anastomosis, although the total laparoscopic procedure appears to be less invasive.
Beginning from November 2004, LADG was introduced at our institution for the surgical treatment of gastric cancer. Comparing with conventional ODG, it has more clear view of perigastric vessles and similar effect of lymph node dissection. But the resection and reconstruction through a minilaparotomy is difficult for the fat or the high-location lesion. With the accumulation of surgical experience, we switched to TLDG approach from March 2007. To clarify the safety and oncological effect of TLDG, evaluate the advantages of TLDG in alleviating the inflammatory response, reducing the postoperative immunodepression and improving the quality of life (QOL) and gastrointestinal function and assess the negative effect of long-duration pneumoperitoneum on the patient's lung, liver and kidney functions, an analysis of the clinical data of all TLDG cases at our institution and a prospective comparative study of LADG and open distal gastrectomy (ODG) from December 2009 to January 2011 were performed. Furthermore, to evaluate the status of LADG which has been investigated in many papers, a meta-analysis of randomized controlled trials (RCT) and high quality observational studies were performed.
Part1:the clinical study of totally laparoscopic distal gastrectomy for gastric cancer (56 cases report)
Objective:1. To investigate the feasibility, safety and oncological effect of TLDG.2. To evaluate the effects of patient's body mass index (BMI) and surgeon's experience on the short-term outcomes of TLDG.
Methods:Analyzed the clinical data of all TLDG cases at our institution from March 2007 to January 2011. The major data including operation time, blood loss, first flatus time, first semiliquid diet time, postoperative hospital stay, postoperative complications, number of dissected lymph nodes, proximal and distal resection margins were all collected. Also, The operation time, blood loss, number of dissected lymph nodes, postoperative hospital stay and postoperative complications in the low-weight group (BMI<20 kg/m2), normal-weight group (20≤BMI<25 kg/m2) and high-weight group (BMI≥25kg/m2) were compared to assess the effect of patient's BMI on the short-term outcomes of TLDG. Furthermore, these data were also compared between the early stage (40 cases) and late stage (16 cases) to assess the effect of surgeon's experience on the short-term outcomes of TLDG.
Results:56 cases were analyzed in this study, including 38 men and 18 women with a mean age of 58.6±10.6 y (range,34 to 79 y). The mean BMI was 22.5±2.8 kg/m2 (range,15.4 to 27.7 kg/m2) and there were 10 cases in the low-weight group,31 cases in the normal-weight group and 15 cases in the high-weight group respectively. All operations were completed successfully without converting to open and laparosopic-assisted surgery. The mean operation time was 269±54 min (range,175 min to 400 min) and the mean blood loss was 164±105 mL (range,30 mL to 600 mL) with only one case of introperative blood transfusion. The mean number of dissected lymph nodes was 29.2±8.0 (range,15 to 45). The mean proximal and distal resection margins were 5.6±2.3 cm (range,3.5 to 8.0 cm) and 5.8±2.1 cm (range,3.5 to 11.0 cm), respectively.
The mean time to first flatus and semiliquid diet were 3.5±1.3 d (range,2 to 7 d) and 5.2±2.5 d (range,3 to 14 d), respectively. The mean postoperative hospital stay was 9.7±3.1 d (range,6 to 21 d). Postoperative complications occurred in 9 cases (16.1%) including 2 cases of delayed gastric empting,2 cases of pulmonary infection, 2 cases of abdominal abscess,1 case of anastomotic leakage which needed second open surgery,1 case of chylous leakage and 1 case of severe hypoalbuminemia. The mean follow-up period was 22 m (range,2 to 47 m), while 7 cases were lost and the follow-up rate was 87.5%. Tumor recurrence or metastasis was occurred in 5 cases at 4 m,13 m,13 m,15 m and 17 m after operation, respectively.
The patient's BMI had no obvious effect on the short-term outcomes. There were no significant difference on the operation time, blood loss, number of dissected lymph nodes, postoperative hospital stay or postoperative morbidity among these three groups except for that the postoperative morbidity of low-weight group was significantly higher than normal-weight group (40% vs 9.7%). The consequences of linear regression analysis also showed that there were no obvious correlations between the BMI and the operation time, blood loss, number of dissected lymph nodes or postoperative hospital stay. Otherwise, the surgion's experience had obvious effect on the short-term outcomes. Lower operation time (233±31 min vs 284±55 min), less blood loss (118±66 mL vs 182±113 mL) and shorter postoperative hospital stay (9.1±3.6 d vs 10.0±2.8) were observed in the late stage group than the early stage group (P<0.05).
Conclusion:1. TLDG is feasible and safe with good short-term outcomes.2. The surgeon's experience, rather than the BMI has obvious effect on the short-term outcomes of TLDG.
Part 2:comparative study of totally laparoscopic and open distal gastrectomy for gastric cancer
Objective:1. To further investigate the safety and oncological effect of TLDG.2. To evaluate the advantages of TLDG in alleviating the inflammatory response, reducing the postoperative immunodepression and improving the quality of life (QOL) and gastrointestinal function.3. To assess the negative effect of long-duration pneumoperitoneum on the patient's lung, liver and kidney functions.
Methods:From December 2009 to Januanry 2011, the distal gastric caner patients at our institution who signed the informed consents were included in this study. The operative procedure was selected by the patients and their families. The safety and oncologic effect of TLDG were investigated by comparing the short-term outcomes of two groups. The negative effect of prolonged pneumoperitoneum on the lung, liver and kidney function was assessed by comparing the values of pH, CO2 pressure, alanine aminotransferase (ALT), total bilirubin (TB), albumin (ALB), prealbumin (PA), creatinine (CR) and blood urea nitrogen (BUN) in the blood between the TLDG and ODG group. Inflammatory response was evaluated by comparing the number of white blood cell (WBC) and neutrophilicgranulocyte (NE) and the plasma levels of C reactive protein (CRP), interleukin-6 (IL-6) and interleukin-10 (IL-10) between these two groups. Postoperative immunity was evaluated by comparing the numbers of CD3+ T-cells, CD4+T-cells, CD8+T-cells and NK cells and the serum levels of immunoglobulin A (IgA), immunoglobulin M (Igm), immunoglobulin G (IgG), C3 and C4. The simplified Chinese versions of QLQ C-30 and STO-22 questionnaires were used to assess the QOL at 1 m and 3 m postoperatively and the dynamic radionuclide imaging and endoscopy were used to assess the gastrointestinal function at 3 m postoperatively, and both results were compared between these two groups.
Results:Totally,41 cases were included in this study, including 19 cases in the TLDG group and 22 cases in the ODG group. There were no significant differences between these two groups with respect to sex, age, BMI, ASA status and TMN stage. In the TLDG group, all operations were completed successfully without converting to open or laparoscopic-assisted surgery. The total operation time was similar in two groups, but the time of opening and closing abdomen were shorter and the time of lymph node dissection was longer in the TLDG group. The TLDG group was associated with shorter incision (4.0±0.9 cm vs 22.8±1.9 cm) and less blood loss (126.8±73.6 mL vs 279.6±129.7 mL), but the body temperature declined much faster and the costs was much higher (53,000±8,236 CNY vs 39,658±10,630 CNY). There were no significant differences with regard to the number of dissected lymph nodes and proximal or distal resection margins.
The postoperative morbidity was similar between the TLDG and ODG group (21.1% vs 22.7%). Patients in the TLDG group recovered much faster, Its time to out-of-bed activity, first flatus, first liquid diet, first semiliquid diet and postoperative hospital stay were significantly shorter than those in the ODG group. Moreover, the TLDG group also had lower VAS pain scores and less consumption of analgesics, indicating that the laparoscopic surgery resulted in less postoperative pain.
There were no significant differences in pH value and CO2 pressure between the TLDG and ODG group and the pH value and CO2 pressure of the TLDG group were all in the normal range at all measurement points (0 h,2 h,6 h,24 h, postoperatively). This indicated that long-duration pneumoperitoneum had no obvious negative effect on the lung function. There were also no significant differences of the value of ALT, TB, ALB, PA and CR between these two groups at all measurement points (24 h,72 h,120 h,168 h, postoperatively). These outcomes demonstrated that pneumoperitoneum during TLDG does not adversely alter postoperative liver and kidney functions to any greater extent than ODG.
The numbers of WBC and NE at 0 h postoperatively and the values of CRP, IL-6 and IL-10 within 24 h postoperatively were significantly lower in the TLDG group, which meant that TLDG resulted in less early postoperative inflammatory response. However, there were no significant differences in the numbers of CD3+T-cells, CD4+ T-cells, CD8+T-cells, NK cells and the values of IgA, IgM, IgG between these two groups, which demonstrated that TLDG did not have an immunological advantage over ODG. In addition, the values of C3 and C4 were much lower in the TLDG group at 72 h、120 h、168 h postoperatively, which implied that TLDG induced less surgical trauma than ODG.
TLDG group had better QOL than ODG group. In the assessment of QOL at 1 m postoperatively, the QOL parameters including global health, physical function, role function, social function and pain scale were significantly better in the TLDG group compared with the ODG group. However, it was also observed that the advantages of QOL in the TLDG group weakened with the passing of time. At 3 m postoperatively, only global health and physical function were still significantly better in the TLDG group. In addition, there was no advantage of long-term gastrointestinal function in the TLDG group over ODG group. The consequences of dynamic radionuclide imaging at 3 m postoperatively showed that there were no significant differences of the linear fit half empting time and the gastric empting rate within 30 min between these two groups. The endoscopic findings at 3 m postoperatively also showed there were no significant differences of the incidence of anastomotic bile reflux and reflux esophagitis between these two groups.
Conclusions:1.TLDG has similar safety and surgical results of tumor resection and lymph node dissection comparing with ODG. It has obvious mini-invasive advantages in accelerating the postoperative recovery, alleviating the early inflammatory response and improving the QOL.2. TLDG has no advantages in reducing the postoperative immunosuppression and improving the gastrointestinal function.3. Long-duration pneumoperitoneum during TLDG has no obvious negative effect on the patient's lung, liver and kidney functions.
Part3:meta-analysis of laparoscopic-assisted and open distal gastrectomy for gastric cancer
Objective:To evaluate the safety and oncologic effect of LADG by the means of meta-analysis.
Methods:Comparative studies of LADG and ODG in Pubmed, Cochrane library, Web of Science and Biosis Previews Databases from January 1,1995 to February 28,2011 were collected. The data of operation time, blood loss, number of lymph node dissection, the proximal and distal resection margins, time to flatus, time to first oral intake, postoperative hospital stay and postoperative morbidity were analyzed. The results were expressed with weighted mean difference (WMD) for continuous variable and relative risk (RR) for the dichotomous variable. Meta-regression analysis was performed to explore the sources of heterogeneity. The statistical analysis was performed by STATA11.0 software.
Results:13 articles were analyzed in this study, including 4 RCT and 9 retrospective observational articles. A total of 1945 patients with gastric cancer of whom 958 underwent LADG and 987 underwent ODG were included in this meta-analysis. Compared to ODG, LADG results in prolonged operation time, decreased blood loss, less time to flatus and oral intake, shortened postoperative hospital stay and less postoperative morbidity. On the aspect of oncological effect, there was no differences between these two groups in number of dissected lymph nodes and the distal resection margin, but the proximal resection margin was significantly shorter in the LADG group.
Conclusion:1. LADG has the advantages of less blood loss, less postoperative morbidity and faster postoperative recovery. LADG is capable of providing a quality of lymph node dissection equivalent to that of ODG, but the proximal resection margin of LADG is significantly shorter.
引文
1. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer,2001,37(8):4-66.
2. Parkin DM. International variation. Oncogene,2004,23(38):6329-40.
3. Di Martino N, Izzo G, Cosenza A, et al. Total gastrectomy for gastric cancer:can the type of lymphadenectomy condition the long-term results?. Suppl Tumori,2005, 4(3):84-5.
4. Ohgami M, Otani Y, Kumai K, et al. Laparoscopic surgery for early gastric cancer. Nippon Geka Gakkai Zasshi,1996,97(4):279-85.
5. Ohashi S. Laparoscopic Intra-gastric Surgery for Early Gastric Cancer:A New Technique in Laparoscopic Surgery. Surg Technol Int,1994,3:221-6.
6. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
7. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
8. Goh P, Tekant Y, Isaac J, et al. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc,1992,2(3):258-60.
9. Ballesta-Lopez C, Bastida-Vila X, Catarci M, et al. Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies. Am J Surg,1996,171(2):289-92.
10. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy:new technique of intraabdominal gastroduodenostomy. J Am Coll Surg,2002,195(2):284-7.
11. Kim JJ, Song KY, Chin HM, et al. Totally laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linear staplers:preliminary experience. Surg Endosc,2008,22(2):436-42.
12.徐晓武牟一平。严加费.应用腹腔镜辅助D2根治术治疗进展期胃癌的临床观察.中华医学杂志,2008,88(31)：2195-7.
13.徐晓武牟一平,严加费.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
1.徐晓武,牟一平,严加费.应用腹腔镜辅助D2根治术治疗进展期胃癌的临床观察.中华医学杂志,2008,88(31)：2195-7.
2.徐晓武,牟一平,严加费.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
3. Goh P, Tekant Y, Isaac J, et al. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc,1992,2(3):258-60.
4. Ballesta-Lopez C, Bastida-Vila X, Catarci M, et al. Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies. Am J Surg,1996,171(2):289-92.
5. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy:new technique of intraabdominal gastroduodenostomy. J Am Coll Surg,2002,195(2):284-7.
6. Kim JJ, Song KY, Chin HM, et al. Totally laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linear staplers:preliminary experience. Surg Endosc,2008,22(2):436-42.
7. Roukos DH, Katsios C. Totally intracorporeal laparoscopic gastrectomy for gastric cancer. Surg Endosc,2010,24(12):3247-8.
8. Kitano S, Shiraishi N, Uyama I, et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg,2007,245(1):68-72.
9. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
10. Hur H, Jeon HM, Kim W. Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers:three years' experience. J Surg Oncol,2008,98(7):515-9.
11. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
12. Shuang J, Qi S, Zheng J, et al. A Case-Control Study of Laparoscopy-Assisted and Open Distal Gastrectomy for Advanced Gastric Cancer. J Gastrointest Surg,2010, 15(1):57-62.
13. Kinoshita T, Shibasaki H, Oshiro T, et al. Comparison of laparoscopy-assisted and total laparoscopic Billroth-I gastrectomy for gastric cancer:a report of short-term outcomes. Surg Endosc. Epub ahead of print.
14. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
15. Lee WJ, Wang W, Chen TC, et al. Totally laparoscopic radical BII gastrectomy for the treatment of gastric cancer:a comparison with open surgery. Surg Laparosc Endosc Percutan Tech,2008,18(4):369-74.
16. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
17. Kubo M, Sano T, Fukagawa T, et al. Increasing body mass index in Japanese patients with gastric cancer. Gastric Cancer,2005,8(1):39-41.
18. Hiki N, Fukunaga T, Yamaguchi T, et al. Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer. J Gastrointest Surg,2009,13(4):626-33.
19. Kim MG, Kawada H, Kim BS, et al. A totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG) for improvement of the early surgical outcomes in high BMI patients. Surg Endos,2010,25(4):1076-82.
20. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
21. Jin SH, Kim DY, Kim H, et al. Multidimensional learning curve in laparoscopy-assisted gastrectomy for early gastric cancer. Surg Endosc,2007, 21(1):28-33.
1. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
2. Hyung WJ, Lim JS, Cheong JH, et al. Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy. Surg Endosc, 2005,19(10):1353-7.
3. Kim HI, Hyung WJ, Lee CR, et al. Intraoperative portable abdominal radiograph for tumor localization:a simple and accurate method for laparoscopic gastrectomy. Surg Endosc,2010,25(3):958-63.
4. Tokunaga M, Hiki N, Fukunaga T, et al. Does age matter in the indication for laparoscopy-assisted gastrectomy? J Gastrointest Surg,2008,12(9):1502-7.
5. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
6. Nguyen NT, Fleming NW, Singh A, et al. Evaluation of core temperature during laparoscopic and open gastric bypass. Obes Surg,2001,11(5):570-5.
7. Berber E, String A, Garland A, et al. Intraoperative thermal regulation in patients undergoing laparoscopic vs open surgical procedures. Surg Endosc,2001,15(3): 281-5.
8. Stewart BT, Stitz RW, Tuch MM, et al. Hypothermia in open and laparoscopic colorectal surgery. Dis Colon Rectum,1999,42(10):1292-5.
9. Bashirov E, Cetiner S, Emre M, et al. A randomized controlled study evaluating the effects of the temperature of insufflated CO2 on core body temperature and blood gases (an experimental study). Surg Endosc,2007,21(10):1820-5.
10. Sajid MS, Mallick AS, Rimpel J, et al. Effect of heated and humidified carbon dioxide on patients after laparoscopic procedures:a meta-analysis. Surg Laparosc Endosc Percutan Tech,2008,18(6):539-46.
11. Peng Y, Zheng M, Ye Q, et al. Heated and humidified CO2 prevents hypothermia, peritoneal injury, and intra-abdominal adhesions during prolonged laparoscopic insufflations. J Surg Res,2009,151(1):40-7.
12. Jakimowicz J, Stultiens G, Smulders F. Laparoscopic insufflation of the abdomen reduces portal venous flow. Surg Endosc,1998,12(2):129-32.
13. Etoh T, Shiraishi N, Tajima M, et al. Transient liver dysfunction after laparoscopic gastrectomy for gastric cancer patients. World J Surg,2007,31(5):1115-20.
14. Nguyen NT, Braley S, Fleming NW, et al. Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass. Am J Surg,2003,186(1): 40-4.
15. Carmona M, Lopes RI, Borba M, et al. Comparison of the effects of carbon dioxide and helium pneumoperitoneum on renal function. J Endourol,2008,22(5): 1077-82.
16. Demyttenaere S, Feldman LS, Fried GM. Effect of pneumoperitoneum on renal perfusion and function:a systematic review. Surg Endosc,2007,21(2):152-60.
17. Schietroma M, Carlei F, Franchi L, et al. A comparison of serum interleukin-6 concentrations in patients treated by cholecystectomy via laparotomy or laparoscopy. Hepatogastroenterology,2004,51(60):1595-9.
18. Veenhof AA, Sietses C, von Blomberg BM, et al. The surgical stress response and postoperative immune function after laparoscopic or conventional total mesorectal excision in rectal cancer:a randomized trial. Int J Colorectal Dis,26(1):53-9.
19. Hildebrandt U, Kessler K, Plusczyk T, et al. Comparison of surgical stress between laparoscopic and open colonic resections. Surg Endosc,2003,17(2):242-6.
20. Sammour T, Kahokehr A, Chan S, et al. The humoral response after laparoscopic versus open colorectal surgery:a meta-analysis. J Surg Res,2010,164(1):28-37.
21. Huang C, Huang R, Jiang T, et al. Laparoscopic and open resection for colorectal cancer:an evaluation of cellular immunity. BMC Gastroenterol,2010,10:127-34.
22. Yue Q, Ma R, Mao DW, et al. Effects of laparoscopically-assisted vaginal hysterectomy compared with abdominal hysterectomy on immune function. J Int Med Res,2009,37(3):855-61.
23. Wichmann MW, Huttl TP, Winter H, et al. Immunological effects of laparoscopic vs open colorectal surgery:a prospective clinical study. Arch Surg,2005,140(7): 692-7.
24. Hu JK, Zhou ZG, Chen ZX, et al. Comparative evaluation of immune response after laparoscopical and open total mesorectal excisions with anal sphincter preservation in patients with rectal cancer. World J Gastroenterol,2003,9(12): 2690-4.
25. Tang CL, Eu KW, Tai BC, et al. Randomized clinical trial of the effect of open versus laparoscopically assisted colectomy on systemic immunity in patients with colorectal cancer. Br J Surg,2001,88(6):801-7.
26. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
27. Yasuda K, Shiraishi N, Etoh T, et al. Long-term quality of life after laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2007, 21(12):2150-3.
28.张群,于健春,康维明.胃大部分切除术后胃癌患者血清胃泌素、血浆胃动素和胃动力变化.中国医学科学院学报,2008,30(3)：334-7.
29. Lee J, Hur H. Kim W. Improved long-term quality of life in patients with laparoscopy-assisted distal gastrectomy with jejunal pouch interposition for early gastric cancer. Ann Surg Oncol,2010,17(8):2024-30.
30. Sekita Y, Takeshita K, Tani M, et al. Microbiological evaluation after gastrectomy and reconstruction for gastric cancer. Int Surg,2007,92(6):355-60.
1. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
2. Chen XZ, Hu JK, Yang K, et al. Short-term evaluation of laparoscopy-assisted distal gastrectomy for predictive early gastric cancer:a meta-analysis of randomized controlled trials. Surg Laparosc Endosc Percutan Tech,2009,19(4): 277-84.
3. Ohtani H, Tamamori Y, Noguchi K, et al. A meta-analysis of randomized controlled trials that compared laparoscopy-assisted and open distal gastrectomy for early gastric cancer. J Gastrointest Surg,14(6):958-64.
4. Kodera Y, Fujiwara M, Ohashi N, et al. Laparoscopic surgery for gastric cancer:a collective review with meta-analysis of randomized trials. J Am Coll Surg,211(5): 677-86.
5. Kitano S, Shiraishi N, Fujii K, et al. A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery,2002,131(1 Suppl):S306-11.
6. Hayashi H, Ochiai T, Shimada H, et al. Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc,2005,19(9):1172-6.
7. Kim HH, Hyung WJ, Cho GS, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer:an interim report--a phase Ⅲ multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg,2010, 251(3):417-20.
8. Makino H, Kunisaki C, Izumisawa Y, et al. Effect of obesity on laparoscopy-assisted distal gastrectomy compared with open distal gastrectomy for gastric cancer. J Surg Oncol,2010,102(2):141-7.
9. Huang JL, Wei HB, Zheng ZH, et al. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer. Dig Surg,2010,27(4):291-6.
10. Lee JH, Yom CK.Han HS Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer. Surg Endosc,2009, 23(8):1759-63.
11. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
12. Du XH, Li R, Chen L, et al. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer:initial experience. Chin Med J (Engl),2009,122(12): 1404-7.
13. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
14. Kawamura H, Okada K, Isizu H, et al. Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure. Surg Endosc,2008,22(1):81-5.
15. Ziqiang W, Feng Q, Zhimin C, et al. Comparison of laparoscopically assisted and open radical distal gastrectomy with extended lymphadenectomy for gastric cancer management. Surg Endosc,2006,20(11):1738-43.
16. Kim MC, Kim KH, Kim HH, et al. Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol,2005,91(1):90-4.
17. Mochiki E, Kamiyama Y, Aihara R, et al. Laparoscopic assisted distal gastrectomy for early gastric cancer:Five years' experience. Surgery,2005,137(3):317-22.
18. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
1. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
2. Etoh T, Shiraishi N, Kitano S. Current trends of laparoscopic gastrectomy for gastric cancer in Japan. Asian J Endosc Surg,2009,2(1):18-23.
3. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
4. Kitano S, Shiraishi N, Uyama I, et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg,2007,245(1):68-72.
5. Lee JH, Yom CK, Han HS. Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer. Surg Endosc,2009, 23(8):1759-63.
6. Strong VE, Devaud N, Karpeh M. The role of laparoscopy for gastric surgery in the West. Gastric Cancer,2009,12(3):127-31.
7. Azagra JS, Goergen M, De Simone P, et al. Minimally invasive surgery for gastric cancer. Surg Endosc,1999,13(4):351-7.
8. Huscher CG, Mingoli A, Sgarzini G, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer:five-year results of a randomized prospective trial. Ann Surg,2005,241(2):232-7.
9. Orsenigo E, Di Palo S, Tamburini A, et al. Laparoscopy-assisted gastrectomy versus open gastrectomy for gastric cancer:a monoinstitutional Western center experience. Surg Endosc,25(1):140-5.
10. Huscher CG, Mingoli A, Sgarzini G, et al. Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer:early and long-term results of a 100-patient series. Am J Surg,2007,194(6): 839-44.
11.柯重伟,郑成竹,仇明,等.腹腔镜胃手术的临床应用.中华外科杂志,2000,38(9)：680-2.
12.王家镔,黄昌明,郑朝辉,等.腹腔镜胃癌D2根治术218例疗效评价.中华外科杂志,2010,48(7)：502-5.
13. Kawamura H, Okada K, Isizu H, et al. Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure. Surg Endosc,2008,22(1):81-5.
14. Jung IK, Kim MC, Kim KH, et al. Cellular and peritoneal immune response after radical laparoscopy-assisted and open gastrectomy for gastric cancer. J Surg Oncol, 2008,98(1):54-9.
15. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
16. Yasuda K, Shiraishi N, Etoh T, et al. Long-term quality of life after laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2007, 21(12):2150-3
17. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
18. Kawamura H, Homma S, Yokota R, et al. Inspection of safety and accuracy of D2 lymph node dissection in laparoscopy-assisted distal gastrectomy. World J Surg, 2008,32(11):2366-70.
19. Lee YJ, Ha WS, Park ST, et al. Port-site recurrence after laparoscopy-assisted gastrectomy:report of the first case. J Laparoendosc Adv Surg Tech A,2007,17(4): 455-7.
20. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
21. Shoup M, Brennan MF, Karpeh MS, et al. Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies:an uncommon entity. Ann Surg Oncol,2002,9(7):632-6.
22. Hao YX, Yu PW, Zhong H, et al. Comparison of laparoscopic and open gastrectomy on cancer cells exfoliating from the cancer-invaded serosa. Surg Laparosc Endosc Percutan Tech,2009,19(3):201-7.
23. Hur H, Jeon HM, Kim W. Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers:three years' experience. J Surg Oncol,2008,98(7):515-9.
24. Shuang J, Qi S, Zheng J, et al. A Case-Control Study of Laparoscopy-Assisted and Open Distal Gastrectomy for Advanced Gastric Cancer. J Gastrointest Surg,2010, 15(1):57-62.
25. Kubo M, Sano T, Fukagawa T, et al. Increasing body mass index in Japanese patients with gastric cancer. Gastric Cancer,2005,8(1):39-41.
26. Lee HJ, Kim HH, Kim MC, et al. The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer. Surg Endosc,2009,23(11): 2473-9.
27. Ojima T, Iwahashi M, Nakamori M, et al. Influence of overweight on patients with gastric cancer after undergoing curative gastrectomy:an analysis of 689 consecutive cases managed by a single center. Arch Surg,2009,144(4):351-8.
28. Hiki N, Fukunaga T, Yamaguchi T, et al. Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer. J Gastrointest Surg,2009,13(4):626-33.
29. Kunisaki C, Makino H, Takagawa R, et al. Predictive factors for surgical complications of laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(9):2085-93.
30. Tokunaga M, Hiki N, Fukunaga T, et al. Does age matter in the indication for laparoscopy-assisted gastrectomy? J Gastrointest Surg,2008,12(9):1502-7.
31. Hwang SH, Park do J, Jee YS, et al. Risk factors for operative complications in elderly patients during laparoscopy-assisted gastrectomy. J Am Coll Surg,2009, 208(2):186-92.
32. Kim MG, Kawada H, Kim BS, et al. A totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG) for improvement of the early surgical outcomes in high BMI patients. Surg Endosc,2010,25(4):1076-82.
33. Choi YY, Kim YJ. Intracorporeal Anastomosis Using a Lapra-Ty Clip in Laparoscopic Distal Gastrectomy:Initial Clinical Experiences. J Laparoendosc Adv Surg Tech A,2010,21(1):51-5.
34.徐晓武,牟一平,严加费,等.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
35. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
36. Hyung WJ, Lim JS, Cheong JH, et al. Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy. Surg Endosc, 2005,19(10):1353-7.
37. Beretvas RI, Ponsky J. Endoscopic marking:an adjunct to laparoscopic gastrointestinal surgery. Surg Endosc,2001,15(10):1202-3.
38. Kim HI, Hyung WJ, Lee CR, et al. Intraoperative portable abdominal radiograph for tumor localization:a simple and accurate method for laparoscopic gastrectomy. Surg Endosc,2010,25(3):958-63.
39. Sakuramoto S, Kikuchi S, Futawatari N, et al. Laparoscopy-assisted pancreas-and spleen-preserving total gastrectomy for gastric cancer as compared with open total gastrectomy. Surg Endosc,2009,23(11):2416-23.
40. Jeong GA, Cho GS, Kim HH, et al. Laparoscopy-assisted total gastrectomy for gastric cancer:a multicenter retrospective analysis. Surgery,2009,146(3):469-74.
41. Omori T, Oyama T, Mizutani S, et al. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg,2009,197(1):13-7.
42. Kinoshita T, Oshiro T, Ito K, et al. Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy. Surg Endosc,24(11):2908-12.
43. Sakuramoto S, Kikuchi S, Futawatari N, et al. Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer. Surgery,147(5):742-7.
44. Kunisaki C, Makino H, Oshima T, et al. Application of the transorally inserted anvil (OrVil) after laparoscopy-assisted total gastrectomy. Surg Endosc,2010, 25(4):1300-5.
45. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
46. Jin SH, Kim DY, Kim H, et al. Multidimensional learning curve in laparoscopy-assisted gastrectomy for early gastric cancer. Surg Endosc,2007,21(1):28-33.
47. Kinoshita T, Kanehira E, Matsuda M, et al. Effectiveness of a team participation training course for laparoscopy-assisted gastrectomy. Surg Endosc,24(3):561-6.
48. Hiki N, Fukunaga T, Yamaguchi T, et al. The benefits of standardizing the operative procedure for the assistant in laparoscopy-assisted gastrectomy for gastric cancer. Langenbecks Arch Surg,2008,393(6):963-71.
49. Tokunaga M, Hiki N, Fukunaga T, et al. Quality control and educational value of laparoscopy-assisted gastrectomy in a high-volume center. Surg Endosc,2009, 23(2):289-95.
50. Song J, Oh SJ, Kang WH, et al. Robot-assisted gastrectomy with lymph node dissection for gastric cancer:lessons learned from an initial 100 consecutive procedures. Ann Surg,2009,249(6):927-32.
51. Kim MC, Heo GU, Jung GJ. Robotic gastrectomy for gastric cancer:surgical techniques and clinical merits. Surg Endosc,24(3):610-5.
52. Song J, Kang WH, Oh SJ, et al. Role of robotic gastrectomy using da Vinci system compared with laparoscopic gastrectomy:initial experience of 20 consecutive cases. Surg Endosc,2009,23(6):1204-11.
53. Kodama M, Koyama K. Indications for pylorus preserving gastrectomy for early gastric cancer located in the middle third of the stomach. World J Surg,1991,15(5): 628-33.
54. Kodama M, Koyama K, Chida T, et al. Early postoperative evaluation of pylorus-preserving gastrectomy for gastric cancer. World J Surg,1995,19(3): 456-60.
55. Sawai K, Takahashi T, Fujioka T, et al. Pylorus-preserving gastrectomy with radical lymph node dissection based on anatomical variations of the infrapyloric artery. Am J Surg,1995,170(3):285-8.
56. Taniguchi S, Koga K, Ibusuki K, et al. Laparoscopic pylorus-preserving gastrectomy with intracorporeal hand-sewn anastomosis. Surg Laparosc Endosc, 1997,7(4):354-6.
57. Tanaka N, Katai H, Saka M, et al. Laparoscopy-assisted pylorus-preserving gastrectomy. a matched case-control study. Surg Endosc,25(1):114-8.
58.Nunobe S, Hiki N, Fukunaga T, et al. Laparoscopy-assisted pylorus-preserving gastrectomy:preservation of vagus nerve and infrapyloric blood flow induces less stasis. World J Surg,2007,31(12):2335-40.
59. Jiang X, Hiki N, Nunobe S, et al. Long-term outcome and survival with laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc,2010,25(4):1182-6.
60. Hiki N, Shimoyama S, Yamaguchi H, et al. Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation. J Am Coll Surg,2006,203(2):162-9.
61.Nunobe S, Sasako M, Saka M, et al. Symptom evaluation of long-term postoperative outcomes after pylorus-preserving gastrectomy for early gastric cancer. Gastric Cancer,2007,10(3):167-72.
2. Parkin DM. International variation. Oncogene,2004,23(38):6329-40.
3. Di Martino N, Izzo G, Cosenza A, et al. Total gastrectomy for gastric cancer:can the type of lymphadenectomy condition the long-term results?. Suppl Tumori,2005, 4(3):84-5.
4. Ohgami M, Otani Y, Kumai K, et al. Laparoscopic surgery for early gastric cancer. Nippon Geka Gakkai Zasshi,1996,97(4):279-85.
5. Ohashi S. Laparoscopic Intra-gastric Surgery for Early Gastric Cancer:A New Technique in Laparoscopic Surgery. Surg Technol Int,1994,3:221-6.
6. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
7. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
8. Goh P, Tekant Y, Isaac J, et al. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc,1992,2(3):258-60.
9. Ballesta-Lopez C, Bastida-Vila X, Catarci M, et al. Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies. Am J Surg,1996,171(2):289-92.
10. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy:new technique of intraabdominal gastroduodenostomy. J Am Coll Surg,2002,195(2):284-7.
11. Kim JJ, Song KY, Chin HM, et al. Totally laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linear staplers:preliminary experience. Surg Endosc,2008,22(2):436-42.
12.徐晓武牟一平。严加费.应用腹腔镜辅助D2根治术治疗进展期胃癌的临床观察.中华医学杂志,2008,88(31)：2195-7.
13.徐晓武牟一平,严加费.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
1.徐晓武,牟一平,严加费.应用腹腔镜辅助D2根治术治疗进展期胃癌的临床观察.中华医学杂志,2008,88(31)：2195-7.
2.徐晓武,牟一平,严加费.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
3. Goh P, Tekant Y, Isaac J, et al. The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc,1992,2(3):258-60.
4. Ballesta-Lopez C, Bastida-Vila X, Catarci M, et al. Laparoscopic Billroth II distal subtotal gastrectomy with gastric stump suspension for gastric malignancies. Am J Surg,1996,171(2):289-92.
5. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy:new technique of intraabdominal gastroduodenostomy. J Am Coll Surg,2002,195(2):284-7.
6. Kim JJ, Song KY, Chin HM, et al. Totally laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linear staplers:preliminary experience. Surg Endosc,2008,22(2):436-42.
7. Roukos DH, Katsios C. Totally intracorporeal laparoscopic gastrectomy for gastric cancer. Surg Endosc,2010,24(12):3247-8.
8. Kitano S, Shiraishi N, Uyama I, et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg,2007,245(1):68-72.
9. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
10. Hur H, Jeon HM, Kim W. Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers:three years' experience. J Surg Oncol,2008,98(7):515-9.
11. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
12. Shuang J, Qi S, Zheng J, et al. A Case-Control Study of Laparoscopy-Assisted and Open Distal Gastrectomy for Advanced Gastric Cancer. J Gastrointest Surg,2010, 15(1):57-62.
13. Kinoshita T, Shibasaki H, Oshiro T, et al. Comparison of laparoscopy-assisted and total laparoscopic Billroth-I gastrectomy for gastric cancer:a report of short-term outcomes. Surg Endosc. Epub ahead of print.
14. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
15. Lee WJ, Wang W, Chen TC, et al. Totally laparoscopic radical BII gastrectomy for the treatment of gastric cancer:a comparison with open surgery. Surg Laparosc Endosc Percutan Tech,2008,18(4):369-74.
16. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
17. Kubo M, Sano T, Fukagawa T, et al. Increasing body mass index in Japanese patients with gastric cancer. Gastric Cancer,2005,8(1):39-41.
18. Hiki N, Fukunaga T, Yamaguchi T, et al. Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer. J Gastrointest Surg,2009,13(4):626-33.
19. Kim MG, Kawada H, Kim BS, et al. A totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG) for improvement of the early surgical outcomes in high BMI patients. Surg Endos,2010,25(4):1076-82.
20. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
21. Jin SH, Kim DY, Kim H, et al. Multidimensional learning curve in laparoscopy-assisted gastrectomy for early gastric cancer. Surg Endosc,2007, 21(1):28-33.
1. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
2. Hyung WJ, Lim JS, Cheong JH, et al. Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy. Surg Endosc, 2005,19(10):1353-7.
3. Kim HI, Hyung WJ, Lee CR, et al. Intraoperative portable abdominal radiograph for tumor localization:a simple and accurate method for laparoscopic gastrectomy. Surg Endosc,2010,25(3):958-63.
4. Tokunaga M, Hiki N, Fukunaga T, et al. Does age matter in the indication for laparoscopy-assisted gastrectomy? J Gastrointest Surg,2008,12(9):1502-7.
5. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
6. Nguyen NT, Fleming NW, Singh A, et al. Evaluation of core temperature during laparoscopic and open gastric bypass. Obes Surg,2001,11(5):570-5.
7. Berber E, String A, Garland A, et al. Intraoperative thermal regulation in patients undergoing laparoscopic vs open surgical procedures. Surg Endosc,2001,15(3): 281-5.
8. Stewart BT, Stitz RW, Tuch MM, et al. Hypothermia in open and laparoscopic colorectal surgery. Dis Colon Rectum,1999,42(10):1292-5.
9. Bashirov E, Cetiner S, Emre M, et al. A randomized controlled study evaluating the effects of the temperature of insufflated CO2 on core body temperature and blood gases (an experimental study). Surg Endosc,2007,21(10):1820-5.
10. Sajid MS, Mallick AS, Rimpel J, et al. Effect of heated and humidified carbon dioxide on patients after laparoscopic procedures:a meta-analysis. Surg Laparosc Endosc Percutan Tech,2008,18(6):539-46.
11. Peng Y, Zheng M, Ye Q, et al. Heated and humidified CO2 prevents hypothermia, peritoneal injury, and intra-abdominal adhesions during prolonged laparoscopic insufflations. J Surg Res,2009,151(1):40-7.
12. Jakimowicz J, Stultiens G, Smulders F. Laparoscopic insufflation of the abdomen reduces portal venous flow. Surg Endosc,1998,12(2):129-32.
13. Etoh T, Shiraishi N, Tajima M, et al. Transient liver dysfunction after laparoscopic gastrectomy for gastric cancer patients. World J Surg,2007,31(5):1115-20.
14. Nguyen NT, Braley S, Fleming NW, et al. Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass. Am J Surg,2003,186(1): 40-4.
15. Carmona M, Lopes RI, Borba M, et al. Comparison of the effects of carbon dioxide and helium pneumoperitoneum on renal function. J Endourol,2008,22(5): 1077-82.
16. Demyttenaere S, Feldman LS, Fried GM. Effect of pneumoperitoneum on renal perfusion and function:a systematic review. Surg Endosc,2007,21(2):152-60.
17. Schietroma M, Carlei F, Franchi L, et al. A comparison of serum interleukin-6 concentrations in patients treated by cholecystectomy via laparotomy or laparoscopy. Hepatogastroenterology,2004,51(60):1595-9.
18. Veenhof AA, Sietses C, von Blomberg BM, et al. The surgical stress response and postoperative immune function after laparoscopic or conventional total mesorectal excision in rectal cancer:a randomized trial. Int J Colorectal Dis,26(1):53-9.
19. Hildebrandt U, Kessler K, Plusczyk T, et al. Comparison of surgical stress between laparoscopic and open colonic resections. Surg Endosc,2003,17(2):242-6.
20. Sammour T, Kahokehr A, Chan S, et al. The humoral response after laparoscopic versus open colorectal surgery:a meta-analysis. J Surg Res,2010,164(1):28-37.
21. Huang C, Huang R, Jiang T, et al. Laparoscopic and open resection for colorectal cancer:an evaluation of cellular immunity. BMC Gastroenterol,2010,10:127-34.
22. Yue Q, Ma R, Mao DW, et al. Effects of laparoscopically-assisted vaginal hysterectomy compared with abdominal hysterectomy on immune function. J Int Med Res,2009,37(3):855-61.
23. Wichmann MW, Huttl TP, Winter H, et al. Immunological effects of laparoscopic vs open colorectal surgery:a prospective clinical study. Arch Surg,2005,140(7): 692-7.
24. Hu JK, Zhou ZG, Chen ZX, et al. Comparative evaluation of immune response after laparoscopical and open total mesorectal excisions with anal sphincter preservation in patients with rectal cancer. World J Gastroenterol,2003,9(12): 2690-4.
25. Tang CL, Eu KW, Tai BC, et al. Randomized clinical trial of the effect of open versus laparoscopically assisted colectomy on systemic immunity in patients with colorectal cancer. Br J Surg,2001,88(6):801-7.
26. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
27. Yasuda K, Shiraishi N, Etoh T, et al. Long-term quality of life after laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2007, 21(12):2150-3.
28.张群,于健春,康维明.胃大部分切除术后胃癌患者血清胃泌素、血浆胃动素和胃动力变化.中国医学科学院学报,2008,30(3)：334-7.
29. Lee J, Hur H. Kim W. Improved long-term quality of life in patients with laparoscopy-assisted distal gastrectomy with jejunal pouch interposition for early gastric cancer. Ann Surg Oncol,2010,17(8):2024-30.
30. Sekita Y, Takeshita K, Tani M, et al. Microbiological evaluation after gastrectomy and reconstruction for gastric cancer. Int Surg,2007,92(6):355-60.
1. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
2. Chen XZ, Hu JK, Yang K, et al. Short-term evaluation of laparoscopy-assisted distal gastrectomy for predictive early gastric cancer:a meta-analysis of randomized controlled trials. Surg Laparosc Endosc Percutan Tech,2009,19(4): 277-84.
3. Ohtani H, Tamamori Y, Noguchi K, et al. A meta-analysis of randomized controlled trials that compared laparoscopy-assisted and open distal gastrectomy for early gastric cancer. J Gastrointest Surg,14(6):958-64.
4. Kodera Y, Fujiwara M, Ohashi N, et al. Laparoscopic surgery for gastric cancer:a collective review with meta-analysis of randomized trials. J Am Coll Surg,211(5): 677-86.
5. Kitano S, Shiraishi N, Fujii K, et al. A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery,2002,131(1 Suppl):S306-11.
6. Hayashi H, Ochiai T, Shimada H, et al. Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc,2005,19(9):1172-6.
7. Kim HH, Hyung WJ, Cho GS, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer:an interim report--a phase Ⅲ multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg,2010, 251(3):417-20.
8. Makino H, Kunisaki C, Izumisawa Y, et al. Effect of obesity on laparoscopy-assisted distal gastrectomy compared with open distal gastrectomy for gastric cancer. J Surg Oncol,2010,102(2):141-7.
9. Huang JL, Wei HB, Zheng ZH, et al. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer. Dig Surg,2010,27(4):291-6.
10. Lee JH, Yom CK.Han HS Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer. Surg Endosc,2009, 23(8):1759-63.
11. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
12. Du XH, Li R, Chen L, et al. Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer:initial experience. Chin Med J (Engl),2009,122(12): 1404-7.
13. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
14. Kawamura H, Okada K, Isizu H, et al. Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure. Surg Endosc,2008,22(1):81-5.
15. Ziqiang W, Feng Q, Zhimin C, et al. Comparison of laparoscopically assisted and open radical distal gastrectomy with extended lymphadenectomy for gastric cancer management. Surg Endosc,2006,20(11):1738-43.
16. Kim MC, Kim KH, Kim HH, et al. Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol,2005,91(1):90-4.
17. Mochiki E, Kamiyama Y, Aihara R, et al. Laparoscopic assisted distal gastrectomy for early gastric cancer:Five years' experience. Surgery,2005,137(3):317-22.
18. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
1. Kitano S, Iso Y, Moriyama M, et al. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc,1994,4(2):146-8.
2. Etoh T, Shiraishi N, Kitano S. Current trends of laparoscopic gastrectomy for gastric cancer in Japan. Asian J Endosc Surg,2009,2(1):18-23.
3. Ikeda O, Sakaguchi Y, Aoki Y, et al. Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(10):2374-9.
4. Kitano S, Shiraishi N, Uyama I, et al. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg,2007,245(1):68-72.
5. Lee JH, Yom CK, Han HS. Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer. Surg Endosc,2009, 23(8):1759-63.
6. Strong VE, Devaud N, Karpeh M. The role of laparoscopy for gastric surgery in the West. Gastric Cancer,2009,12(3):127-31.
7. Azagra JS, Goergen M, De Simone P, et al. Minimally invasive surgery for gastric cancer. Surg Endosc,1999,13(4):351-7.
8. Huscher CG, Mingoli A, Sgarzini G, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer:five-year results of a randomized prospective trial. Ann Surg,2005,241(2):232-7.
9. Orsenigo E, Di Palo S, Tamburini A, et al. Laparoscopy-assisted gastrectomy versus open gastrectomy for gastric cancer:a monoinstitutional Western center experience. Surg Endosc,25(1):140-5.
10. Huscher CG, Mingoli A, Sgarzini G, et al. Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer:early and long-term results of a 100-patient series. Am J Surg,2007,194(6): 839-44.
11.柯重伟,郑成竹,仇明,等.腹腔镜胃手术的临床应用.中华外科杂志,2000,38(9)：680-2.
12.王家镔,黄昌明,郑朝辉,等.腹腔镜胃癌D2根治术218例疗效评价.中华外科杂志,2010,48(7)：502-5.
13. Kawamura H, Okada K, Isizu H, et al. Laparoscopic gastrectomy for early gastric cancer targeting as a less invasive procedure. Surg Endosc,2008,22(1):81-5.
14. Jung IK, Kim MC, Kim KH, et al. Cellular and peritoneal immune response after radical laparoscopy-assisted and open gastrectomy for gastric cancer. J Surg Oncol, 2008,98(1):54-9.
15. Kim YW, Baik YH, Yun YH, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer:results of a prospective randomized clinical trial. Ann Surg,2008,248(5):721-7.
16. Yasuda K, Shiraishi N, Etoh T, et al. Long-term quality of life after laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2007, 21(12):2150-3
17. Song KY, Kim SN, Park CH. Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer:technical and oncologic aspects. Surg Endosc,2008,22(3):655-9.
18. Kawamura H, Homma S, Yokota R, et al. Inspection of safety and accuracy of D2 lymph node dissection in laparoscopy-assisted distal gastrectomy. World J Surg, 2008,32(11):2366-70.
19. Lee YJ, Ha WS, Park ST, et al. Port-site recurrence after laparoscopy-assisted gastrectomy:report of the first case. J Laparoendosc Adv Surg Tech A,2007,17(4): 455-7.
20. Hwang SI, Kim HO, Yoo CH, et al. Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer. Surg Endosc,2009, 23(6):1252-8.
21. Shoup M, Brennan MF, Karpeh MS, et al. Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies:an uncommon entity. Ann Surg Oncol,2002,9(7):632-6.
22. Hao YX, Yu PW, Zhong H, et al. Comparison of laparoscopic and open gastrectomy on cancer cells exfoliating from the cancer-invaded serosa. Surg Laparosc Endosc Percutan Tech,2009,19(3):201-7.
23. Hur H, Jeon HM, Kim W. Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers:three years' experience. J Surg Oncol,2008,98(7):515-9.
24. Shuang J, Qi S, Zheng J, et al. A Case-Control Study of Laparoscopy-Assisted and Open Distal Gastrectomy for Advanced Gastric Cancer. J Gastrointest Surg,2010, 15(1):57-62.
25. Kubo M, Sano T, Fukagawa T, et al. Increasing body mass index in Japanese patients with gastric cancer. Gastric Cancer,2005,8(1):39-41.
26. Lee HJ, Kim HH, Kim MC, et al. The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer. Surg Endosc,2009,23(11): 2473-9.
27. Ojima T, Iwahashi M, Nakamori M, et al. Influence of overweight on patients with gastric cancer after undergoing curative gastrectomy:an analysis of 689 consecutive cases managed by a single center. Arch Surg,2009,144(4):351-8.
28. Hiki N, Fukunaga T, Yamaguchi T, et al. Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer. J Gastrointest Surg,2009,13(4):626-33.
29. Kunisaki C, Makino H, Takagawa R, et al. Predictive factors for surgical complications of laparoscopy-assisted distal gastrectomy for gastric cancer. Surg Endosc,2009,23(9):2085-93.
30. Tokunaga M, Hiki N, Fukunaga T, et al. Does age matter in the indication for laparoscopy-assisted gastrectomy? J Gastrointest Surg,2008,12(9):1502-7.
31. Hwang SH, Park do J, Jee YS, et al. Risk factors for operative complications in elderly patients during laparoscopy-assisted gastrectomy. J Am Coll Surg,2009, 208(2):186-92.
32. Kim MG, Kawada H, Kim BS, et al. A totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG) for improvement of the early surgical outcomes in high BMI patients. Surg Endosc,2010,25(4):1076-82.
33. Choi YY, Kim YJ. Intracorporeal Anastomosis Using a Lapra-Ty Clip in Laparoscopic Distal Gastrectomy:Initial Clinical Experiences. J Laparoendosc Adv Surg Tech A,2010,21(1):51-5.
34.徐晓武,牟一平,严加费,等.完全腹腔镜胃癌根治术的临床应用.中华医学杂志,2010,90(6)：386-9.
35. Song KY, Park CH, Kang HC, et al. Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?:prospective, multicenter study. J Gastrointest Surg,2008,12(6):1015-21.
36. Hyung WJ, Lim JS, Cheong JH, et al. Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy. Surg Endosc, 2005,19(10):1353-7.
37. Beretvas RI, Ponsky J. Endoscopic marking:an adjunct to laparoscopic gastrointestinal surgery. Surg Endosc,2001,15(10):1202-3.
38. Kim HI, Hyung WJ, Lee CR, et al. Intraoperative portable abdominal radiograph for tumor localization:a simple and accurate method for laparoscopic gastrectomy. Surg Endosc,2010,25(3):958-63.
39. Sakuramoto S, Kikuchi S, Futawatari N, et al. Laparoscopy-assisted pancreas-and spleen-preserving total gastrectomy for gastric cancer as compared with open total gastrectomy. Surg Endosc,2009,23(11):2416-23.
40. Jeong GA, Cho GS, Kim HH, et al. Laparoscopy-assisted total gastrectomy for gastric cancer:a multicenter retrospective analysis. Surgery,2009,146(3):469-74.
41. Omori T, Oyama T, Mizutani S, et al. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg,2009,197(1):13-7.
42. Kinoshita T, Oshiro T, Ito K, et al. Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy. Surg Endosc,24(11):2908-12.
43. Sakuramoto S, Kikuchi S, Futawatari N, et al. Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer. Surgery,147(5):742-7.
44. Kunisaki C, Makino H, Oshima T, et al. Application of the transorally inserted anvil (OrVil) after laparoscopy-assisted total gastrectomy. Surg Endosc,2010, 25(4):1300-5.
45. Yoo CH, Kim HO, Hwang SI, et al. Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon's learning curve period. Surg Endosc,2009,23(10):2250-7.
46. Jin SH, Kim DY, Kim H, et al. Multidimensional learning curve in laparoscopy-assisted gastrectomy for early gastric cancer. Surg Endosc,2007,21(1):28-33.
47. Kinoshita T, Kanehira E, Matsuda M, et al. Effectiveness of a team participation training course for laparoscopy-assisted gastrectomy. Surg Endosc,24(3):561-6.
48. Hiki N, Fukunaga T, Yamaguchi T, et al. The benefits of standardizing the operative procedure for the assistant in laparoscopy-assisted gastrectomy for gastric cancer. Langenbecks Arch Surg,2008,393(6):963-71.
49. Tokunaga M, Hiki N, Fukunaga T, et al. Quality control and educational value of laparoscopy-assisted gastrectomy in a high-volume center. Surg Endosc,2009, 23(2):289-95.
50. Song J, Oh SJ, Kang WH, et al. Robot-assisted gastrectomy with lymph node dissection for gastric cancer:lessons learned from an initial 100 consecutive procedures. Ann Surg,2009,249(6):927-32.
51. Kim MC, Heo GU, Jung GJ. Robotic gastrectomy for gastric cancer:surgical techniques and clinical merits. Surg Endosc,24(3):610-5.
52. Song J, Kang WH, Oh SJ, et al. Role of robotic gastrectomy using da Vinci system compared with laparoscopic gastrectomy:initial experience of 20 consecutive cases. Surg Endosc,2009,23(6):1204-11.
53. Kodama M, Koyama K. Indications for pylorus preserving gastrectomy for early gastric cancer located in the middle third of the stomach. World J Surg,1991,15(5): 628-33.
54. Kodama M, Koyama K, Chida T, et al. Early postoperative evaluation of pylorus-preserving gastrectomy for gastric cancer. World J Surg,1995,19(3): 456-60.
55. Sawai K, Takahashi T, Fujioka T, et al. Pylorus-preserving gastrectomy with radical lymph node dissection based on anatomical variations of the infrapyloric artery. Am J Surg,1995,170(3):285-8.
56. Taniguchi S, Koga K, Ibusuki K, et al. Laparoscopic pylorus-preserving gastrectomy with intracorporeal hand-sewn anastomosis. Surg Laparosc Endosc, 1997,7(4):354-6.
57. Tanaka N, Katai H, Saka M, et al. Laparoscopy-assisted pylorus-preserving gastrectomy. a matched case-control study. Surg Endosc,25(1):114-8.
58.Nunobe S, Hiki N, Fukunaga T, et al. Laparoscopy-assisted pylorus-preserving gastrectomy:preservation of vagus nerve and infrapyloric blood flow induces less stasis. World J Surg,2007,31(12):2335-40.
59. Jiang X, Hiki N, Nunobe S, et al. Long-term outcome and survival with laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc,2010,25(4):1182-6.
60. Hiki N, Shimoyama S, Yamaguchi H, et al. Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation. J Am Coll Surg,2006,203(2):162-9.
61.Nunobe S, Sasako M, Saka M, et al. Symptom evaluation of long-term postoperative outcomes after pylorus-preserving gastrectomy for early gastric cancer. Gastric Cancer,2007,10(3):167-72.
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