| Research BackgroundGastric cancer is one of the most common malignant tumors in the digestive system. Its death rate ranks the top among the malignant tumors. Currently, the treatment means are mainly involved with surgical intervention. Since 1994 that Kitano first reported the laparoscopic-assisted distal gastrectomy and lymphonodus clearance operation, after many years of development, benefited from its minimally invasive advantages and low complication after operation, laparoscopic radical gastrectomy gradually becomes the main means of surgical treatment towards gastric cancer and is widely accepted by the public.Due to its clinical effects, the laparoscopic surgery to treat early gastric cancer has been widely accepted, and has become one of the operation indications to cure the early gastric cancer. Laparoscopic surgery to treat advanced gastric cancer has become the hot spot that the public pays close attention to currently; however, lots of disputes still exist in its feasibility and safety, especially that whether the laparoscopic surgery can be applied to treat the serosa-involved advanced gastric cancer is the focus of the public’s attention. The main reason for death of patients with gastric cancer after the surgery is peritoneal metastasis. As for whether the laparoscopic radical gastrectomy to treat the serosa-involved advanced gastric cancer increases the probability of peritoneal micrometastasis, the reports relevant clinical studies are not seen.Purpose of ResearchTherefore, by selecting the clinical data of the patients with serosa-involved gastric cancer in the center, in the experiment, the clinical effects of laparoscopic surgery and the clinical effects of open laparotomy to treat the serosa-involved advanced gastric cancer are compared and analyzed. In the meanwhile, by testing the presented changes of dopadecarboxylase, DDC and carcino-embryonic antigen, CEA in the peritoneal washings before and after the laparoscopic surgery towards the patients with gastric cancer with different serosa-involved areas, its relationship with the clinical effects on the patients after the surgery is analyzed. To make further discussion on the changes and significance of the peritoneal micrometastasis after conducting the laparoscopic surgery towards the patients with serosa-involved gastric cancer provide the theoretical foundation for the wide application of laparoscopic surgery to treat advanced gastric cancer.Research MethodFirstly, Comparison between the Laparoscopic Radical Gastrectomy and Open Gastrectomy in the Clinical Effects to Treat the Patients with Serosa-Involved Gastric Cancer111 patients towards whom the laparoscopic radical gastrectomy was successfully conducted from September, 2006 to December, 2008 in the center and 119 patients towards whom the open gastrectomy was successfully conducted during the same period are taken as the object of research. In the surgery, the trachea cannula and general anesthesia were adopted, and the curative resection of gastric cancer was conducted according to the tumor location. Towards all the patients, the D2 radical operation of gastric cancer is conducted according to the 2014 Version of Japanese GRGCS. The comparison and analysis are conducted in the indicators including the duration of operation, intraoperatve blood loss, length of incision, first time of anus exhaust time, first time of food taking, length of stay, and complication incidence and so on, of the patients in laparoscopic radical gastrectomy group and open gastrectomy group respectively; besides, the survival situations of the patients in the two groups are observed after five years since the surgeries were conducted.Secondly, Influence of Conducting Laparoscopic Surgery towards Patients with Serosa-Involved Gastric Cancer on Peritoneal MicrometastasisIn the meanwhile, 114 patients towards whom the laparoscopic gastric cancer surgery was conducted in the center from October, 2012 to October, 2014 are selected; besides, 82 patients who were confirmed to have serosa-involved gastric cancer by intraoperative probing are divided into the following groups after the postoperative pathology confirmation and the calculation of the serosa-involved areas by the application of Auto CAD software: Group B <5 cm2(n=30 cases), Group C 5-10 cm2(n=27 cases) and Group D >10 cm2(n= cases); in addition, it made the comparison and analysis towards the 32 patients with non-serosa-involved gastric cancer(Group A) during the same period. The presented changes of CEA m RNA and DDC m RNA in the peritoneal washings before and after the surgery were tested by adopting RT-PCR; besides, the comparison and analysis were conducted towards the different serosa-involved areas. In the meanwhile, the relationship between the above indicators and the postoperation survival conditions was observed.ResultsFirstly, Comparison between the Laparoscopic Radical Gastrectomy and Open Gastrectomy in the Clinical Effects to Treat the Patients with Serosa-Involved Gastric Cancer1, the comparison between short-term clinical efficacy of the two groups of patientsTwo groups of patients with abdominal incision length: laparoscopic group(4.8 ± 1.2) cm, open group(17.2 ± 3.4) cm(P <0.05). Two groups of patients surgery time: laparoscopic group 189 ± 57.5min, open group 201 ± 68.2min(P> 0.05). Blood loss, two groups of patients: laparoscopic group 143 ± 87.3ml, open group 223 ± 108.1ml(P <0.05). First exhaust time: laparoscopic group 2.3 ± 1.6d, open group 3.5 ± 2.0d(P <0.05). Two groups of patients first feeding time: laparoscopic group 3.1 ± 1.6d, open group 4.1 ± 2.3d(P <0.05). Two groups of patients hospitalized time: laparoscopic group 7.9 ± 3.7d, open group 9.2 ± 4.8d(P <0.05). The number of patients were lymph node dissection: laparoscopic group(35 ± 11) missiles, open group(37 ± 14) pieces(P> 0.05).2, two groups of patients after surgery complicationsAll patients had 11.3%(26/230) had postoperative complications, which occur after the laparoscopic group 8 patients complications(7.2%), bleeding in 2 cases, one case of wound infection, pulmonary infection in 2 cases, anastomosis fistula in two cases, one case of intestinal obstruction; and open surgery group, 18 patients had complications(15.1%), including two cases of bleeding, wound infection in 4 cases, 4 cases of lung infection, anastomotic leakage in 4 cases, intestinal Obstruction three cases, one case of deep vein thrombosis; postoperative complications of laparoscopic group was significantly lower than the open group(P <0.05);3. The postoperative survivalThe median follow-up time is 46.3 months(3.0~82.0 months). Laparoscopic group and open group of 5-year survival rates were 37.8% and 35.3%(P> 0.05), 5-year overall survival rates were 47.7% and 40.3%(P> 0.05). Patient 1-year, 3-year and 5-year disease-free survival for the laparoscopic group(83.8%, 67.6%, 37.8%); laparotomy group(81.5%, 65.5%, 35.3%, P> 0.05). Overall survival for the laparoscopic group(89.2%, 72.1%, 47.7%); laparotomy group(87.4%, 68.1%, 40.3%, P> 0.05).Secondly, Influence of Conducting Laparoscopic Surgery towards Patients with Serosa-Involved Gastric Cancer on Peritoneal Micrometastasis1. The Changes of the CEA m RNA Expression Quantities in Peritoneal Washings of the Four Groups of Patients with Gastric Cancer before and after the SurgeryThe CEA m RNA expression quantities in the peritoneal washings of the patients in Group A, Group B, Group C and Group D before and after the surgery are 0.198±0.032, 0.205±0.034, 0.212±0.037 and 0.453±0.046 respectively. By the comparison among the patients in Group A, Group B and Group C, there is no statistical significance in difference(P>0.05); whereas by the comparison of the patients in Group D with the patients in Group A, Group B and Group C, there difference has statistical significance(P<0.05). After the surgery, the CEA m RNA expression quantities of the patients in Group A, Group B, Group C and Group D are 0.241±0.028,0.247±0.031, 0.255±0.032 and 0.513±0.045 respectively. By the comparison among the patients in Group A, Group B and Group C, there is no statistical significance in difference(P>0.05); whereas by the comparison of the patients in Group D with the patients in Group A, Group B and Group C, the difference has statistical significance(P<0.05).2. The Changes of the DDC m RNA Expression Quantities in Peritoneal Washings of the Four Groups of Patients with Gastric Cancer before and after the SurgeryThe DDC m RNA expression quantities in the peritoneal washings of the patients in Group A, Group B, Group C and Group D before and after the surgery are 0.239±0.029, 0.245±0.031, 0.251±0.028 and 0.446±0.033 respectively. By the comparison among the patients in Group A, Group B and Group C, there is no statistical significance in difference(P>0.05); whereas by the comparison of the patients in Group D with the patients in Group A, Group B and Group C, there difference has statistical significance(P<0.05). After the surgery, the DDC m RNA expression quantities of the patients in Group A, Group B, Group C and Group D are 0.248±0.032, 0.256±0.034, 0.262±0.033 and 0.528±0.044 respectively. By the comparison among the patients in Group A, Group B and Group C, there is no statistical significance in difference(P>0.05); whereas by the comparison of the patients in Group D with the patients in Group A, Group B and Group C, the difference has statistical significance(P<0.05).3. Relationship between CEA m RNA and DDC m RNA Expression Changes of the Patients in the Four Groups and Clinical Effects104 patients received post-operation follow-up visits and the follow-up rate is 91.23%(104/114). The median follow-up time is 15.5 months(3.0~30.0 months). Among the 104 patients receiving post-operation follow-up visits, the cumulative survival rates of Group A, Group B, Group C and Group D are 90.6%, 83.3%, 77.7% and 64% respectively. When comparing the survival conditions of the Group A、Group B and Group C, there is no statistical significance in difference(P > 0.05)); and when comparing the survival conditions of Group D with those in Group A, Group B and Group C, there is the statistical significance in difference(P<0.05). The comparing the survival conditions of the patients in the four groups, the difference has the statistical significance(P<0.05).Conclusions1. When comparing the laparoscopic radical gastrectomy and open gastrectomy towards the patients with serosa-involved gastric cancer, the durations of the two kinds of surgeries are almost the same; however in the aspects of intraoperative blood loss, number of lymphonodi being cleared, time of food taking, anus exhaust time and recovery condition after operation and so on, the laparoscopic radical gastrectomy is significantly superior than open gastrectomy, and the postoperative complications of the former are low, which indicates that to treat the patients with serosa-involved gastric cancer by conducting laparoscopic radical gastrectomy is safe and feasible.2. The five-year disease free survival rates to treat the patients with serosa-involved gastric cancer by conducting laparoscopic radical gastrectomy and open gastrectomy are 37.8% and 35.3% respectively(P>0.05), The five-year survival rate values of the two groups of patients are 47.7% and 40.3% respectively(P>0.05). The clinical effects to treat the patients with serosa-involved gastric cancer by conducting laparoscopic radical gastrectomy are satisfactory and able to achieve the same operation results of open gastrectomy.3. The levels of the CEA m RNA and DDC m RNA in the peritoneal washings of the patients after the surgery is higher than those before the surgery, among which, in the groups smaller than 5 cm2 and 5-10 cm2, although the levels of CEA m RNA and DDC m RNA in the peritoneal washings of the patients after the surgery rise compared to those before the surgery, the raising degree of the non-serosa-involved group is not significant(P>0.05); however, the raising degree of the CEA m RNA and DDC m RNA in the peritoneal washings of the patients in the group larger than 10cm2 is significant compared to that in the other three groups(P<0.05). It shall be noticed that when the serosa-involved area of the patients with gastric cancer is smaller than 10cm2 the relatively low on peritoneal micrometastases.4. The overall survival rates is 79.8%, among which there is no significant difference among Group A, Group B and Group C in survival rate is 90.6%, 83.3%, and77.7% respectively.(P>0.05); however, the survival rate of Group D is significantly lower than that of Group A, Group B and Group C(P<0.05). It shall be noticed that when the serous-involved area of the patient is larger than 10cm2;,the poorer the prognosis of the patients would be, which indicates that when the serous-involved area of the patient is smaller than 10cm2 is safe and feasible. |
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