Prof. C.M. HUANG Totally Laparoscopic Total Gastrectomy

Yes, I will for this case report about the tumor location and the clinical stage after

after we are broadcasting.

Okay, so we are not broadcasting yet.

It's not easy for a man to comment for us.

I think it's a good learning opportunity.

And your English is not very good.

You have to work hard and push yourself to the limit.

I apologize.

Professor Dougal,

because we have a Chinese audience,

I think you will be five minutes left.

Yes, it's five minutes.

Five minutes, yes.

Let's take a break.

Take a break.

Take a break.

Hello, Professor Huang.

Hello.

Hello, Prof. Li Jiang.

Hello, Prof. Huang. I'm Fan Lin.

Hello, Prof. Huang.

Hello.

I'm very happy to see you perform on the international stage today.

Thank you.

Thank you for using your precious time to comment for us.

Your English is very good.

Thank you.

I remember last year, because of the pandemic, I didn't go to Fuzhou.

But online, I think it's pretty good.

Later, we'll come and enjoy your surgery

and interact with them.

Hello, Professor Yu Jiang.

Your voice is not working.

Hello, hello.

Nice to meet you, Professor Fan Lin.

How are you?

Fine, fine.

Okay.

Okay.

So, Zhen Xian,

could you please introduce the Italian professor to us because probably in the operation we can

translate some Italian professors comments to our Chinese audience okay okay and

probably we need to know Italian professors background and we can have some communication

because this this part we will broadcast to the Italian surgeons and Chinese

surgeons because I think probably thousands surgeons will be watching this

operation. Okay thank you and today we will have four professors from Italy

join this operation, and they are Professor Ducmi, Ducmi, President of Italy Society of

Surgery, and second is Professor Ducco, and he's the Director of the Agotino Gemini Polyclinical

Hospital, from Rome. And the third is Professor Giacobbo, from the Department of Digestive

Surgery, St. Mary's Hospital in Italy. And the last one is Professor Fabio, the Health

Physician of the Department of Digestive Surgery is in the hospital of Luigi Emilia from Italy.

This is for Italy professors to join the face operation.

So, one of the most relevant randomized contract trials in gastric cancer.

So, it's a great pleasure for us to see your surgery.

Giacomo, I think your voice is a little noisy, not so clear.

Yeah. So yeah, so the technique can have helps you.

Hey, Dr. Lin, introduce this patient.

Professor Wang will start the surgery, so please, Dr. Ling, introduce the patient's

background to us okay dear all professors this patient is 60 years old is is female

The BMI is 19.5 kg per meter and the chief command is abdominal pain for two weeks, no

special history and the physical examination is normal and the endoscopy sees the proximal

posterior walls of the stomach have a deep ulcer is about 2.5, multiple by 2.5 cm.

And the clinical stage for this patient is

It's called T4A-M021-M0, and it's an advanced proximal gastric cancer patient.

So today, the tumor located here, we can see the tumor located in the proximal, the upper

third of the stomach is the tumor invading the serosome.

So today, Professor Huang performed the totally laparoscopic total gastrectomy, and he also

performed the spring preserving, spring highland lymph node dissection for us.

So thank you, Professor Huang.

we already we have already ever first brief a technical question if you listen to me regarding

the position in the in the surgical field and the you know suspension of the liver in this case is

made by a single hand or an assistant are you ever using any kind of device or different system in

in order to suspend the left liver lobe?

We just one assistant surgeon,

assistant surgeon, you mean for the liver, left liver?

Yeah.

Yeah, and we just holding the liver by the scrap

and no the other equipment for the left liver.

Yeah, I think in the western countries, the patient's BMI is higher than the eastern.

So this patient, his BMI is just 19.5.

Exactly.

What you are doing now, the gastro-colic removal, the mental removal is, you know, it's just

for you a matter of minutes, and in Europe it's a matter of hours.

uh so professor uh would you uh use to use uh different uh energy uh instruments like a harmonic

or for others well i i know that there have been studies comparing different kind of energies and

we have no feelings that you know ultrasonic or or bipolar make such a huge difference

The only difference that has been sometimes highlighted is that bipolar is not coagulating

lymphatic vessels.

So in order to close and seal at best the lymphatic micro vessels, I think that the

maximum attention of the oncology surgeon today is on ultrasound devices.

Okay. Would you think the ligature should be better for the high BMI patient?

I would not mention commercial names, but the problem is not the energy. The problem is the different ability of, like in this case, traction and counter traction highlighting the vascular planes.

When the fat is so huge, highlighting the vascular planes is not easy, so it takes long time and possibly some bleeding.

It's a matter of precision surgery, and magnification and molecular vision today are helping.

With different kinds of colors, now we have the possibility of highlighting the fatty tissues and the planes.

like in this case you're looking for a plane and you know just traction and

counter traction in a in a in a you know in a skinny patient you can find the

planes in a different kind of patient this way of opening the membrane would

not have been so so wonderfully done like the exercise that professor one is

I have a question, what is the proportion of laparoscopic gastric cancer in Italy?

I guess, and are you familiar with the published results of Professor Gong from Wuhan regarding

the membrane anatomy-based dissection?

Hello, Professor Jianjian, Jianjian, can you hear me?

Yes, of course.

oh okay okay uh professor professor and uh professor professor fun and all the italian

professors uh good morning from uh it's maybe it's morning in italy right so good morning yes

okay this is okay this is dr singadi from peak university cancer hospital

and uh uh you know due to the well-known reasons so so we cannot see each other as a maybe

Maybe we only can see each other on the internet.

So it's really, it's really, I miss you.

I miss you all so much.

Miss you all so much.

So I have a question that we will perform.

We will perform a total guest track, right?

Yes.

Yes.

Okay.

I say that we will perform the slim preserving number 10

live not resection, right?

Yes.

Okay, could you give us a short introduction about what is the indication, so in your department,

what is the indication of number 11 dissection plus sleep preserving this type, this procedure?

What is the indication?

Thank you, thank you Professor Xin's question, that is a good question, and so we know the

And the number 10 thing we know is that in the Japanese guidelines, it was not as a D2

with a negative intent for the proximal gastric cancer, not invading the great curvature.

But in our center, as you know, several years ago, Professor Huang and Professor Chen has

performed a lot of splint polythermy, and we have a clinical trial this year published

published in JAMA surgery, we found for the tumor located in the proximal gastric, not

invading the great curvature, if the tumor located in the posterior side of stomach,

we found the number 10 lymph node detection will have better survival after three years

follow-up. So for this case, the tumor is located in the posterior side of the stomach

and with invasional serosome. So Professor Huang performed a lymph node dissection. That

is the indication in our center.

Okay, thank you so much.

Exactly.

The operation, the section is held by the assistant, surgical assistant by Professor Zheng,

and by his right hand. The assistant is Professor Zheng? Yes. Okay, okay, that's good.

And just now, Professor Fung has finished the infraloric area lymph node detection for

the number 10, number 6, number 6 lymph nodes.

Now he will have superior pancreatic area lymph node dissection.

And usually he will start in the left side approach.

It's the proximal of the sphenic artery.

And usually we will finish the number 11P lymph node dissection first.

Very good. Now we'll start the same.

Do you see anything? I'm sure we can see anything.

you know what i mean in this moment of the operation

when you are approaching the applicator going to the origin of the left classic

Thank you very much.

He said if this area is for people who are fatter,

it might not be easy to expose or expose.

I think he might want to talk about

whether or not to leave the 12-storey building.

Or leave the 3-storey building.

Professor Odi, do you think in this area

it's not easy to explore it.

So sometimes we probably, we can dissect the duodenal.

So this area will be very clear to exposing.

So you can do the process in this area.

Yes, ICG, we have used, usually we were used for the lymph nodes dissection, and in our

center, Professor Huang will carry out several clinical trials for ICG, and as we know, two

Two years ago, in 2020, our center's clinical child in JAMA surgery, we found the ICG for the lymph node dissection will be better without the ICG group, which we found more dissected lymph node numbers.

Are you doing this today?

And now because of the equipment, today Professor Huang was using the Stoss 3D, not ICG camera.

I remember in 2019 when Professor Huang and Professor Zeng had the operation internally,

internally we used the ICG for the live surgery.

Yes, I think ICG is a very good method to indicate the lymph node, but in China, ICG,

we have no any guideline or standard.

Yes, the ICG used in gastric cancer, we need more trials.

How about ICG used in Italy, Italian professors, is it a popular procedure or not?

Well, it's increasingly popular. It's increasingly popular, not only for angiographic, you know, verification of patients that are going towards esophageal resection and I will use operation in order to test the vascular viability of the gastric tube or conduit.

But it's increasingly popular for lymph node recognition and planning of the operation.

So if you do a preoperative ICG injection of the submucosa and you check the nodes,

it's not important in order to show what the nodes to remove are,

but just to check that your planning of a D2 was accomplished.

And I think it's increasingly popular.

Submucosal injection a few hours before the operation at 3 and 9 hours, just two small

injections and some hours before.

So after the number 11P lymph node dissection, we were from the left side to the right side.

so we can explore the common gastric artery and left gastric artery sorry to insist but as you

see very clearly here while you are working very nicely on your left gastric artery your left

liver lobe is just there and this patient permits an easy visualization i guess that in europe not

Not so many patients will be exposed like that

comparing to the fact that the left liver lobe

is hanging down on your surgical field.

So we have to use, we are forced to use some way,

some system for liver suspension.

Sometimes we use to retract the left liver,

but actually in some Chinese surgeons,

we have a very good system.

So they can help the operator to expose the field, and sometimes we think this is probably more convenient.

But anyway, different patients, we choose different ways.

For some high BMI, we would choose to retract the liver, but some patients, we would not.

Yes.

that's the right gastric artery vessels including the artery and the vein

then move anteriorly to the hepatic column in order to dissect it and you mean to

in order to clean the anterior aspect of the hepatic column at this point of depression we

usually go on the other side and we clean from the fatty tissue the anterior aspect of the hepatic

column looking at the origin the real origin of the right gastric artery but this is you know a

matter of of the technical choices and of course if you have delivered that way you cannot do it

frontierly uh usually professor uh will divide the right gastric vessels and in a poster sign

because he can reveal the root of the artery.

He will check the...

We can simply divide it, yeah.

So I think this is a very, very good question.

So how we cut the right gastric arteries

from anteriorly or posteriorly.

So usually, as you said, if this is done with patients

patients such as this patient, the BMI is less than 20, so maybe we can cut it from the posterior side.

We can simply divide the right gastroenteritis from the common hepatic arteries or proper hepatic arteries.

If this is a fatty patient, maybe we are not very clear from the common hepatic arteries,

so we may go through the anterior side.

Yes, sometimes we will reveal it in the front side.

What you're doing now is, you know, putting in my mind another question.

In Europe and in Western patients, what is extremely frequent is variation of the anatomy of the vessel

and a left hepatic artery coming differently from another location, like Hirtle artery is very frequent.

So we are forced to observe the angiographic aspect of the CT scan before operation because more than 50% of the patients have some variation.

And it's not unfrequent that a left hepatic artery is huge and it originates directly from the left gastric artery.

So it's forcing us to make a different dissection.

And when you do it from below, if you have some kind of anatomical variation, it is not so easy to dissect the origin of the left gastric artery in the way you did it right now before the section of the duodenum.

So, you know, different anatomy for different populations is changing the approach.

Yes, I think this is very, very good procedures before the surgery.

We use the anagram to find any variations of these very important vessels that is very very important procedurizing.

That is a good question. In 2017, we have a research about the assessed left hamster artery.

Usually, we divide it at the root of the left gastric artery, but we found that if they

have liver disease before operation, the liver function sometimes will be higher post operation.

But if there was no liver disease, it would not leave a function.

Now we have another question for you. While you are structuring the duodenum, that's a very tricky point for any kind of surgery,

in order to avoid the duodenal fistulas, do you advise or have you ever used the staple line reinforcement materials?

You know the stripes that are put on the jaws of the staple in order to reinforce and diminish the bleeding of the staple light.

Do you ever use it?

Maybe different doctors choose different ways.

Some doctors use the suture light reinforcement.

Maybe some doctors didn't perform this type.

So my surgery, if I think the ligation, if the cut is diodino, the stem of the diodino is very good.

So I will not perform this procedure.

Maybe some doctors have different.

Some doctors use the suture reinforcement.

Dr. Lin, you use the reinforcement?

Yes, I think Professor Huang will be sutured

for the standard of the diuretina.

Maybe it will be more safe.

But some surgeons, as Professor Xin said,

some surgeons were not sutured.

so the reason why you just put this clip on this emergency of a lymphatic is that

you are afraid that bleeding that would eventually come out of it could not be reached

since the portal vein drops down and you don't find the origin i mean there is no specific

Professor Huang just showed us the portal ring.

Yes, just here.

Professor, sometimes some patients, for this clip, it will be a voice, lymphatic, right?

Right. Yeah. Yeah. You will be more safe.

Because we work. Yeah. It's the Guangzhou speaking because we all worry about the lymph node leakage.

So this is for so this is for lymphatic leakage. This is just for that.

Yes. Yes. That's important. That's very important because I totally agree with you.

there are some specific lymphatics this one that are going directly to the liver that have a very

high fluxes so um uh you know since you are not sealing certainty vessels that are not coagulating

uh i think that you have a right choice in this specific lymphatic the last two ones

you put the clip i think it's important for for gastric cancer yes thank you for your command

And it's important, yeah.

So, super pancreatic lymph node dissection

now is finished.

Photobain.

Aortic plane.

Very perfect.

No, because I think it's, you know, in order to do it, you need a very long duodenal stump.

And the longer you leave the duodenal stump, the more it is avascular.

And this is the first point.

The second point is that there is no demonstration that if you intraflect and extraflecting mechanical suture, you're not doing a good thing.

Because you are, you know, double closing with two different systems.

so one is extraflecting, one is infraflecting. And in order to do it like you are doing now,

you need a very long stump. So if it is long, if it is without vessels. Second, you know,

we are the best surgeon in the world, but in every surgeon's hand, this maneuver, I think,

is traumatic on the duodenum. So in order to trespass these dangers in the hands of

a non-skilled surgeon i think that sometimes staple line reinforcement could be a good

a good uh you know compromise with safety yes yes i think so in our in our center uh

this procedure is not a routine work what is interesting that in in no surgical series

period worldwide, the post-operative duodenal fistula is 0%. Nobody observed 0%. But the reason

why this percentage has never been, you know, cleared out is not clear. I mean, there is no

specific explanation why this event, even if in small numbers, is always there in every single

that you have been naming have been dissected and removed unblocked, all in one single piece.

There is no lymph node removal per se. There is no cherry picking. It's just one unblocked

resection, right? Yes.

That is important. Unblocked resection and clipping of the last lymphatics going directly

Yeah, it's a momentum branch.

I have a question. It's a from Guangzhou.

What is the indication for group 10 lymph node dissection in Italy?

It is limited according to the guidelines to those extra-serosal tumor belonging to the posterior aspect of the greater curvature.

So, it's really unfrequent, and most surgeons, when it is indicated, associate this lymph node removal with splenectomy.

Okay, okay, thank you.

Well, it is interesting to express to our Chinese colleagues that the number of operations for gastric cancer in Italy every single year in all countries is 9,000.

And if you divide the number of these operations by the hospitals that perform these operations, the average is 10 cases per single surgeon.

So when your average volume for this kind of cancer is 10 cases a year, you are not entitled to do a lymph nodal dissection of the splenic hilum without removing the spleen, because it is, as you will see in a moment, a very difficult, complicated matter.

Yes, I think so. In our center, before the last month, we nearly have finished 1,000 cases for gastric cancer this year.

Just in one center?

Yeah, just in our center.

It needs a very skilled operation team, I think so.

Yes, yes, yes. So Dr. Lin, could you give us a short introduction about this famous

three-step maneuver of Professor Huang's number 10 lymph node dissection, okay?

Okay, yeah, and for the spring preserving number 10 lymph nodes dissection,

Professor Huang was separated for three steps.

The step one is we can see now we revealed the lower part of the spring

and revealed the left gastroepipoietic vessels.

So there are some lymph nodes in here, and so the first one will divide the left gas

chain at the point versus first, and then to divide the one or two short gas chain versus.

Let's finish the first step, the first step for the number 10 lymph node dissection.

And the second step is from the supranuclear trunk to the supranuclear hydra.

During this step, we will reveal two to three, two to four short gastric vessels.

And after we divided the short gastric artery or vent into the root, we will start the step

three.

Step three is the output of the spleen, and we will reveal and divide usually the last

one or two short gastric vessels.

I think there is a certain degree of damage to the organization.

The function side was in the upside.

I think we take our function side away from the T-shirt.

Yes, this is clear.

But you are very fast and you reach this point of operation after 50 minutes.

Usually, a Western surgeon arrives at this point of operation after three hours, and the instrument is dirty and very hot.

So, we try to make double attention, because sometimes, even if you touch with a protected branch, you can do terrible damages to these delicate veins.

And this is another problem that explains how most surgeons don't perform this dissection of the splenic ilum, but they prefer to remove the entire spleen.

And of course, it is not a good thing for the immune system of the patient, but this is what happens.

So, splenectomy is reserved to cases that have an extracellular cell tumor originating from the posterior aspect of the greater curvature or like the posterior aspect of the subcardial area.

Yes, I think it's difficult, especially for the high BMI Western patients.

But I also think that the spleen excretion can be done completely in the lower part of the spinal cord.

Yes.

Yes, I think so. I think the splenectomy should be a complete number 10 liminal dissection.

So this is the complexion of the so-called step one, right?

So we can see after the step one, the whole area of the spinal artery, it will be revealed clearly.

So the assistant holding the posterior side of the stomach, posterior wall of the stomach,

Now that you have shown this gauze pressing on the pancreatic tail, I was extremely interested by a trial that was coming from the East, comparing the only real big difference in a trial that was comparing robotic gastrectomy with laparoscopic gastrectomy.

And the only huge difference, the only one, was the accumulation of amylase-rich pancreatic fluid in the post-op accumulation of liquid in the abdomen.

And the explanation of the authors was that in robotics, you just pull up and divide, while in laparoscopic surgery, you have always to counter traction with an assistant pushing down on the pancreas.

And when it is done for a long time, it can create some possible, you know, pancreatic

mini leaks.

Do you think it's an interesting explanation that is, you know, possibly one day pushing

towards the indication of robotic in some kind of patient with a huge pancreas or do

you think it's just, you know, just a fake?

I mean, it is a published trial comparing laparoscopic gastrectomy with robotic gastrectomy.

The only huge difference is not the time of operation, the complication rate.

The only difference is the accumulation of pancreatic rich fluid in the postoperative

fusion.

And the explanation was this left hand pushing down on the pancreas.

And Professor Dugo, do you think the laparotic surgery for gastric cancer, what's the advantage or disadvantage?

I am absolutely sure about that. You know that I am president of the European Society of Surgical Oncology, and we organized yearly a very popular course for laparoscopic approach to gastric cancer in Utrecht, the Netherlands.

And I usually start my lectures in this course with a title that is less can be more.

I mean, mini-invasiveness is not just a fancy thing in order to give the patient a smaller trauma when he's facing a huge cancer.

Mini-invasiveness means magnification of the image, means precision surgery,

and means, you know, delicate maneuvers that with new devices like the ones that Professor

Kwan is showing us, increase, you know, the radicality of the pulperation.

It's not just a different way of doing it, but I sincerely believe that we will soon

demonstrate not only the non-inferiority of laparoscopy compared to the ordinary approaches,

but I think that in a few years, we will show the superiority only from an oncological point

take more than complicated i would say that it's never the same i mean it's uh it's the variations

are so many and the different kind of crossing that this vessel can be are so many that you

cannot you know easily attend a very specific pre-operative plan you just have to be a very

skilled surgeon like we are you know looking at now yeah and be ready to any kind of variation

Prof. Dugou, I think the CT reconstruction of the vessel may be helpful.

You mean a 3D model?

Yes, 3D model.

A few years ago, we performed the 3D model for every patient, the proximal to advanced

gastric patients so we can see the branch of the splenic vessels so it will be helpful

during the operation with this regard another possible i mean never demonstrated but possible

uh you know advantage of robotics is a robotic platform now is ready to host this

is an unsaid vision system that are able to superimpose the 3D model to your

operative field.

So you have a sort of virtual assistant during your operation showing you the

3D model while you're operating once in a while and leading your surgical

gesture.

I mean, it's not commercial by now, but it is a promise of the robotic platform

That is called augmented vision and intelligent planning of the operation by superimposition of vision to the operative field.

This is going to be the next future, I think.

Short-gassed vessels.

Short-gassed vessels.

Professor Jianxian Lin, what kind of reconstruction do you perform?

We call it a later cut. It's an overlap method.

Okay.

As for the Georgina mix chart.

So follow the instructions where Professor Huang will lift the left lever by the line.

Okay, this is in response to my question of the opening of the operation.

So you reserve a form of liver suspension to just the last part of the operation, the

operation of the anastomosis preparation.

This dinner table is made in China, it's WeGao Surgical.

so this is another very debated point there is no standard for reconstruction of the total

the giugino first we and after finished the Asperger's giugino reconstruction we

transacted the giugino. Yes several surgeons do it several surgeons do it in order to use

you know the stomach in order to make traction on the suture and not having the liver on so it's

very popular and i think it's something that can be done quite routinely not just for selected

and the GDA, and the number 5, number 12A, and number 8, 8, 8, number 7, number 9.

Yeah, it's Potovin, the proximal of the splenic chunk, the number 11P, 11D, and number 10.

For a post-advanced proxmolytic gastric cancer, our clinical trial shows that number 10 lymph nodes dissection will improve the patient's long-term survival.

Professor Huang, Professor Dugong wants to take a picture.

Yeah, my congratulations because this section is so wonderful that I wanted to take a picture

and show this to any resident in my hospital because this is the way to do it.

Unblock, unblock, then extend it to station stand and it's wonderfully made.

Now we are looking forward to observe your reconstruction technique.

Okay, let's see what we can do.

Thank you.

Professor Degu, would you think intracorporeal for the LTG is convenient for the high BMI patients,

or would you like to use the extracorporeal to do the construction?

Well, when my opinion is that, you know, what is totally different from from open procedure and laparoscopic is the reconstruction.

So we never did in times of open surgery, this kind of anastomosis before.

And so we have to be very careful about, you know, counseling these as the best method.

If you look at Western trials, the only main difference that is not enhancing laparoscopy

is in the anastomosis, especially when you go to perform this kind of anastomosis in

the thorax, there is sometimes inferiority.

I think that you can perform a lateral lateral when you have, like in this case, a huge part

at this point there is no fact every every patient is the same so it depends on how long

is the intra-abdominal esophagus my personal choice is since we have short abdominal esophagus

is to try to perform a circular anastomosis with that with the terminal lateral operation

like i usually do in open surgery so i don't want to modify my technique in order to not to modify

my leak rate but this is just very personal there is no no specific suggestion so you so you are

transacting the the the limb after the suture okay i guess it okay you know what i mean you have

a very long intra-abdominal esophagus that permits this suturing but this is extremely rare

in our patients I mean we don't have three to four centimeters of exposed

esophagus under the hiatus portion that can be visualized this way and this is a

tricky part of the operation I see actually sometimes it's very difficult

to do this one and and if you have very good technique probably you will you

You know, it's not like, yeah, less than more.

It's like you said.

Let's say less than more.

But this is important.

This is not the difference between East and West

because in this part of the body, there is no fat.

I mean, every hiatus is the same, no?

You know, you have the left liver lobe,

the diaphragm, and the hiatus, no fat.

So this is not dependent upon that kind of difference.

The difference is a matter of technical schools.

Yeah, so sometimes that, it's my opinion, sometimes I think probably the circular, you know, we can use a circular stamper to do this stamper.

That should be more safe or more convenient for some, you know, high BMI patients.

it means an anastomosis leakage yes i mean i mean that nobody has a zero percent

so what is the percentage of leakage that in your opinion is too much in order to be accepted and

what is the you know the average in the referral center and in our center

For the Asperger's, you know, anastomosis, the leakage rate usually is lower than 2%.

He said it was 2%.

Since you have a 2% leak rate, how long after the operation do you give liquid sperm out to the patient?

How many hours or days?

liquid liquid food oh and usually um two or three days post operations the patients will drink

water or liquid food and what about intraoperative control by by blue dye or post-operative

x-ray control of the patency of the anastomosis? Do you do it intraoperatively or postoperatively?

Or you just give liquids to the patient without no control if the patient is asymptomatic?

Okay, if we check the anastomosis is fine, we will remove the genital tube and patients will be discharged in seven days.

Oh, this is interesting. You leave, you know, an oral tube for six days?

Yes.

That's interesting because several studies have been conducted demonstrating that they are useless in terms of, you know.

protection of anything. Yes, but we usually have six days for the change tube.

No, I mean do you do it because it is, you know, a habit of your

technical school or because there is a demonstration that leaving the tube

inside is advantage for the patient? That is because we usually have

semi-food semi-diet in five days and so in six days we will check it check the

nasmosis you will be fine

i think about professor dugo i think the patients have a fever after the operation

or he had a heart rate increase we all worry about the leakage because as we

know not all patients will have a positive energy gram GI so in our center

intraoperative endoscopic check is helpful to prevent the leakage?

Yes, not only for the leakage, also for bleeding.

Also for?

Yeah.

Bleeding, I mean, I mean, intraluminal bleeding you mean?

Yes, but we will not perform the endoscopy yearly. If we think the anastomosis, the quality is not good, maybe we will have endoscopy yearly in operation.

intra intra uh i mean so the intra suture bleeding is another problem it's only

associated with the lateral lateral anastomosis there is no circular anastomosis that has ever

been bleeding before so this uh control is not available in any center and as i told you when

you have a short esophagus controlling the entire line for bleeding is not easy especially when

When bleeding is active, controlling the bleeding on the side of the surgeon is not easy because, you know, coagulating inside the suture there can be very tricky and sometimes dangerous on the integrity of the esophageal wall.

So these are some questions that are always raised when it comes to the discussion in superiority or inferiority regarding circular or linear anastomosis for esophageal digenome.

but you know years are passing by and the linear anastomosis is increasing popularity and circular

is decreasing popularity because patient life much longer and stenosis of the staple line is

something that is only related to the circular anastomosis so there are there are questions

there are no answers and there are personal preferences and possibly the solution is that

that we should be skilled in any kind of anastomosis

and try to personalize the choices

for the better interest of the patient.

I think he, just now I also asked about the internal box of the gun and the support cutout,

the one outside the gun, they seem to do the internal box of the gun very little, so he didn't.

I just looked at the data of our alliance, I didn't see the data that came out of our statistics,

I really don't know.

It seems to be about 4% to 10%.

Hello. So here you are using a white cartridge.

Yes, white.

So the white cartridge we think probably different surgeons would choose the different.

Sometimes we choose the blue cartridge.

But some surgeons, they think you can use the white cartridge will prevent the bleeding

because the intestinal is very thin

and the white cartilage is more safe for this part

and no bleeding.

So you don't need to worry about the bleeding.

So especially we do the intracorporeal anatomosis

because if you suture, you should use more time

and you should to do a lot of procedures for this part.

So about the linkage, I checked the data

but I did not find that one,

but we discussion about this one probably less than 6%

the whole country.

So Professor Deku.

Yes.

So, for this, for the LTG, I mean, would you leave the gastric tube, you know, for every patient, or you just select different patients to do this? I mean, like as a gastrointestinal tube or gastric tube to avoid the linkage?

Dr. No gastric tube.

Dr. What do you mean? Do you mean the alimentary limb?

Dr. I mean, if you do the total gastrectomy, you will use a gastric tube for the patient,

or you don't use that?

Dr. No, no, no, no, no. The gastric tube, the gastric conduit along the greater

curvature is just reserved to CFRT2 and CFRT1 type of cancers. And we have long discussions

on CFRT2 because sometimes it is not that helpful, especially because patients that have

gastric origin cancer that are, you know, poorly cohesive and the mucinous tumors

should not preserve any part of the stomach in order to be safe for the future.

So, the first choice for CFRT1 and CFRT2 that are highly located is leaving a gastric conduit for, you know, tumors that are CFRT3.

total gastrectomy is mandatory at all. And we are trying to improve in CIFAR-3 classification

those tumors that even if reaching the esophagogastric junction are clearly originating

from the gastric wall and are clearly related to an histotype that should include the total

removal of the stomach for the oncological safety of the patient. Okay. Okay. Thank you.

CIFAR-2 is a very debated issue, and very recently in Bordeaux, the session on upper GI of the European Society of Surgical Oncology was totally dedicated to CIFAR-2.

And again, there is a club that is the European chapter of International Gastric Cancer Association that has reunited in Italy very recently.

And CIFAR-2, the best choices for CIFAR-2 are still a huge matter for debate.

I've been listening to different kinds of presentations, and even laparoscopy for CIFAR-2 is under debate.

There are wonderful surgeons from Switzerland and from Germany that still prefer open approach.

Some are hybrid approaches, some are totally laparoscopic.

So CIFAR-2 is very, very dependent upon personal choices.

all right so thank you it's clear

so this is for centimeters how long is this blue tape and how many centimeters do you count

黄教授,那个20cm,20cm,20cm,OK,那是总共的距离应该是40,45,45, so this, the blue is 20cm, so usually Professor Huang will, the distance is 45cm, the total length.

Yeah. And how many centimeters from the trice to the esophageal anastomosis? Because this is another distance.

meters so how long should it be in your it's just a matter of vascular traction and you decide

case by case or you have a standard measure also for the esophageal dejunal anastomosis

okay

所有的病人 所有的病人 所有的病人

You're all patients.

So the professor Huang said

all the patients choose the same distance.

All of them use the same 45 centimeter.

And because he did the operation

is a lateral, you know, lateral

transected

jejunal. So sometimes

this stands, you know, I mean, that stands

for our center, we would like to use

25 centimeters. The reason

I told you that is that because

there are some surgeons, especially from Germany,

you know, where patients are very huge, very big,

that before starting the operation, check

the origin of the mesenteric root, because there are some huge patients with IBMI that have

an almost mesenteric root with short vessels. So there is a general difficulties in keeping high

limb, especially when you perform it like now, antacolic. So some patients have a so short

mesenteric root that they need to be trans mesocolic or differently reconstructed in

different ways sometimes they are very short so there is no limb that arrives up to there

different kind of anatomy it's a very different kind of patients as i totally understand because

uh i i think probably we need uh for my you know my opinion probably different patients

we choose the different distance.

Like you said, different BMI

and sometimes the mesentery is very short

and you can't put it to the upside.

And sometimes it's very tension of the mesentery.

And if you want to do the anemosis

will be very difficult, right?

So sometimes we can, sometimes 50 or 60.

I think sometimes we can sacrifice some intestinal

and make the menstrual period longer for the fighter patient

or the menstrual period is very short for the patient.

Huang Jiaozhu, he means that in Germany and Europe,

they have a lot of fat patients.

Fat patients have a very short menstrual period.

So the distance between them may still be a problem.

Yes, he says this distance may be difficult.

You can tell him that the average BMI of our team is 23 to 24.

Okay.

So Professor Huang said that due to gastric cancer surgery,

the average BMI is 23 to 26.

Professor Huang, are you going to close Peter's Gung later?

No, I'm not closing it.

No, you're not closing it?

No, it's over.

您常规是不关,是吧?

常规不关,没错。

细膜裂孔也不关吗?

都不关,就这样结束了。

是因为您做的是这个后离断的方式,是吧?

没错,是。

So, Professor Diggle, I have a question.

If you do the total gastric to me,

would you close the mesentery defect like the Peter's defector?

I mean, suture that?

Never, never do it.

Because, you know, very seldom you observe complication in terms of internal hernias.

But when you do it, we have had, you know, post-op fixations that we didn't like in patients.

So there is no evidence that closing those kind of defects would be an advantage for the patient.

there is you know a proverb that says yes three letters keep it simple so the more you do the

more you implicate that something can go wrong and if there is no evidence that you know an

adjunctive maneuver is useful for the patient you should avoid it okay you do the same with

with Professor Wang.

But in China, many surgeons, they will close that.

You know, they will suture this defect

because they worry about the hernia.

Yes, this is common to many fields of surgery

because we initially have been, you know,

studying and learning surgery from our masters.

Like, you know, an artisan is learning his mastery.

history, but now we are in the times of evidence-based surgery, and when you do it always the same,

it implicates that every patient is the same.

And this is for the surgeon, and it's not in their interest.

We should take a look at evidences and personalize choices when we have statistical evidence

that an adjunctive maneuver is useful.

I will not discard closure of the mesentery, but there could be patients when this adjunct maneuver is for sure an advantage on evidence-based measuring, and it could be body mass or other kinds of things, but it should not be a matter of individual choice.

Okay. Okay. Thank you. Right now, Professor Huang, you know, almost done the surgery. So, like almost done. Professor Huang, give us...

Thank you, thank you, the Italy professor, the interview, this operation, now today we finish the total laparoscopy, the total get to me, thank you.

So everybody on this side of the ocean is thankful for this wonderful demonstration.

Thank you very much.

Thank you. Thank you, Professor Degu.

And thank you to all the audience of Italy.

And Professor Huang gave us a very exciting surgery.

And I think this surgery will be very helpful for the young and junior surgeons.

and we hope we will have more communication in the future.

Thank you.

Thank you very much.

Thank you again.

Thank you.

Thank you all of the Italian professors.

Thank you, thank you.

Thank you, Professor Huang.

It's a perfect demonstration.