Hu WenQing M.D. Ph. D. Laparoscopic Radical Proximal Gastrectomy + Kamikawa Anastomosis

So welcome in Rome on behalf of Professor Palastine. We thank you. We are very honored to have you in this International Congress.

We're waiting for you to start with your presentation or your intervention.

Distinguished Professor Barberi and Professor Mascani and dear colleagues from Italy, good afternoon.

We are very honored to be invited to your Congress.

Our hospital is located in the central of China.

It's called Shanxi Province, Changzhi City.

Today we are presenting you with a case of patients who has tumor at the proximal stomach.

下面请允许我为大家简单的介绍一下今天手术病人的基本情况。

Good afternoon, Professor Masconi, Professor Bavieri.

We're very honored to be part of this Congress.

I am Dr. Song Dongyang from Professor Hu Wenqing's team.

And now, please allow me to introduce the patient, the case.

患者是体检发现食管胃及荷布恶性肿瘤,两天入院。

The patient presented to our hospital two days after a physical examination

that identified a tumor at the cardiac part of stomach during the physical examination.

患者两天前在我院体检实行胃镜检查提示奔门早癌,

胃痘溃疡A17,病理提示是胃痘是粘膜慢性炎,

奔门是高级别上皮内流变。

Two days ago, the patient was receiving a general physical examination

examination at our hospital, and he received a gastroscope examination, and then we identified

an early stage carcinoma at the gastrocardia part. It's a pathology A1, and also there's

chronic inflammation in the mucosa.

And also in some of the glands, we've seen some intra-epithelial neoplasia.

In order to get further care, the patient was hospitalized for further evaluation.

And since admission, the patient has been alert and well-oriented,

good mental status, adequate intake, and a good bowel and bladder function,

and no weight change in the past one month.

And also the patient used to be healthy.

So these are some of the examination notes from ultrasound and pathology.

And ultrasound shows the patient had a tumor at the GE junction.

And we suspect there is the lower layer of mucosa involvement.

and we consider the patient T1B staging.

但是呢周围没有看到阳性的增大的淋巴结

所以说我们结合超声胃镜以及腹部的增强CT呢

考虑患者术前分期是一个CT1BN0

This is the abdominal enhanced CT scan

As we can see there are some enhancement

Some thickening at the GE junction

But there is no significant lymph node enlargement

So considering the ultrasound and the abdominal CT

we consider the patient's CT1BN0 stage.

And now the treatment plan is with the diagnosis of malignant tumor of GE junction.

The staging is CT1BN0M0 and we plan to do a surgery of the laparoscopic radical proximal gastrectomy plus a D1 lymph node dissection and a kamikawa anastomosis.

And that's all about the case introduction. Thank you for your attention.

we will start from the greater curvature of the stomach since this lesion is in the early stage

so we consider preserving the omentum there's no need to resect the complete omentum that's our

plan can you hear me yes yes please no no we don't have so many gi junction tumor especially

Especially T1 like yours, we see many patients with advanced cancer T2 and T3.

And Professor Mascani is not here, he's coming.

He's slightly late.

We haven't seen Professor Mascani yet, he might be a little bit late.

Now we have Professor Barberi speaking with us.

He said that there are not many patients with gastrointestinal cancer,

especially T1, which is less common in the early stages.

They usually see T2 and T3 in the later stages.

Thank you, Professor Barberi, for commenting on our procedure today.

Be part of the meeting. Thank you.

It's an honor to have you here with us.

Now we have video, thank you.

刚刚可能就是网络突然断了一下,他说现在可以看到了。

今天的画面一直不是特别的好。

这位老师说,今天镜头不太明显,看起来有点褪色。

这是胃膜左血管。

这是胃膜左血管。

今天的镜子怎么这么不清楚啊?

All right, and now it looks better.

Just now we have identified the gastroepipelatic vein on the left side,

but now we see that it's a little bit too low maybe this plane would be a

better surgical plane so we did not break the vessel being cautious I'm

sorry but we lost your video again we have only audio now

did your screen turn black or did you not see

We see your name, Claire, interpreter, and the name of the hospital in the black screen, written in white.

那么这实际上是一个

这个应该是一个陷阱

那么从这个地方断

应该是最合适的

So as we can see

here is the splenic vein

and the gastroepipelatic vein

if we dissect from the epipelatic vein

it would be too low

the position would be too low

so that might be a pitfall

maybe on the upper right corner

it would be a better place to dissect

from this part

华贝利先生,这个地方能看清楚吧?

Professor Baberi, you can see well here, right?

Yes.

能看到的。

They are doing the dissection from here.

这个地方有个血管了。

They see a vessel here.

沙布,沙布。

They are putting some gauze.

等等来过信息。

等等,等等先别动。

好,我们开始做一线上缘。

And now they are going to work on the upper rim

with pancreatic gland.

操作放到中间。

是,今天这个不是很清晰啊。

然后让那个肩一直模模糊糊的。

我们清扫第七八九组淋巴结,

第八组清扫到这里就可以了,

因为再往前走就是第十二组。

We are doing lymph node dissection,

the group 7, 8, and 9 up to now.

We will stop here,

because if we move further on,

we will see the group 12 lymph nodes.

So we'll stop here with the lymph node dissection, 7, 8, and 9.

Now they're doing dissection of the group 8, group 8 lymph nodes.

They're trying to make the surgical field more clearer with the laparoscope.

Now it looks a little bit blurry.

would you please try swiping the screen to the other side yeah now is it okay

Yes, it is.

Yes, now it was a bleeding from the lymph node.

I'm sorry.

We can see a black screen only.

Could you try swiping to the other side?

Because in Zoom, there is on the upper right corner.

Now it's good.

Now it's good.

Now it's good.

Yeah, in the upper right corner is a view.

We can choose the view,

and there are two signals showing this procedure.

So if you lost this signal, please try, choose the other view.

Probably it will come back.

They are trying to dissect the left gastric vein.

Normally, they would put two clips on the distal part of the vein

because this vein is right in the middle of the surgical field.

Sometimes we just accidentally touch it.

So if we just give one clip, it may fall off.

So we'll put two clips.

Now, we're planning to dissect the left gastric artery.

Hello, Professor Mascani.

Yeah, yeah, yeah. I am Domenico Mascani. I'm here. I'm looking at your operation. It's a very nice operation, very clean.

To see you again.

Thank you for your encouragement.

清扫到这个地方就可以了,这第八组我们完全的把它清扫掉了。

Now we have completed the dissection of group 8 leaf node.

后面的强劲脉。

We can see the vena cava in the back.

挡住纱布挡。

挡住被撞的。

你左手往下抓一下。

OK.

不要抓破了。

上去。

OK.

We see some bleeding and now doing suction.

Now we are at the back of the stomach.

The patient has long vessels at the back of the stomach.

Professor Hu Wenqing, how many operations of this type for T1 gastric cancer you make in one year approximately?

因为首先这部分不能做ESD的病人,我们来比较偏早的,T1B的病人,比较偏早的病人,分化比较好的,每年应该有几十人。

好,like a few dozens, less than 100, a few dozens of patients every year.

We mostly do those patients who are not eligible for ESD

and those earlier stage, well-differentiated T1B patients.

A few dozens, fewer than 100 every year.

Pretty much.

我看看,这是隔下血管。

这是左隔下血管。

This is the vessel, it's the subphrenic, left subphrenic vessel.

我们现在正在往脾的上脊,从胃的后方往脾的上脊走。

Now we're moving in the direction from the back of the stomach to the upper pole of the spleen.

Using a small hemlock.

This is the approach, the access they mostly use.

they will go from the back of the stomach and then they will fully um they will do a complete

dissection and then they will go from the curvature of the stomach what do you think

what is the common approach that you would go through meaning that the route of the surgery

where would you go what direction what route would you take

Now they're adjusting the patient's position

to be higher on the left side.

If it's an advanced stage tumor,

then we'll go deeper.

But now this lesion is quite early stage.

so it's sufficient to go from here. And just now a doctor who wants to ask you

what would be your direction of surgery if you do this because they like to go

from the back of the stomach and then it will go from this plane. What would be

your choice? It's very rare in Italy to have this number of patients with

with the T1 cancer in the stomach,

but this is the plane, absolutely.

This is the section or the one section.

I want to ask to Professor Hu and King

how they do the study of the neoplasm?

How they study the gastric cancer?

to establish the correct study.

Sorry, what was your question?

So you said what is the stage of the stomach cancer?

Each exams were made in preparative diagnosis

and the study of this for the stage of this tumor.

Okay, thank you.

这个入路的方式是很好的。

另外就是有一个问题想问一下,

关于这个病人在术前做分期和检查的时候,

都做了哪些检查?

这个病人做了超声内镜,

还有增强CT。

We used ultrasound-guided endoscope examination

and enhanced CT for staging.

看这样的两边,

刚才和我刚才上面的会合了,

这就会显得非常的安全这个地方。

As we can see from here, this root has joined with the previous vein that we have dissected.

In this way, it's safer for the patient.

好,这样把这边就游离完毕了。

里面几块长不?

Now we have completed the dissection.

好,你松开,你松开,你松开。

松开,松开,去这儿。

Congratulations for this dissection.

祝贺您完成了分离,完成了这个游离。

这个时候我们的这个十二位结合部,

这个地方的游离就变得,变得视野比较好。

At this point, we can see very good visibility for the GE junction.

这是隔血管发出的这个奔门使管值。

奔门使管。

奔门,就是奔门使管值的这个动脉,

这个动脉是隔动脉发出来的,从左隔下动脉发出的这个血管。

Okay, now we can see an artery at the cardiac part.

It's actually originated from the phrenic artery.

随在下面,这个联系定位和冰冻。

我们一会儿要竖中胃经定位。

They are going to do a localization of the tumor during the surgery with a gastroscope.

And they're also contacting the pathology for the frozen section.

好,我们现在要打开尸管裂孔。

Now they're going to open the hiatal esophagus.

你来做这个事情,你来挡着我来闹的事。

来,小王子,来来来。

这有个复肝组血管,复肝组血管我们准备把它断掉。

There is a liver vein, a hepatic vein on this part,

and we are planning to dissect it.

好了,我们现在要,这个病人要保留胃往往右和胃右血管。

这只血管是胃右血管,我们要把它保留。

For this patient, we will preserve the right gastric vein

and the right gastric epiphylotic vein.

This is the right epigastric vein.

We are preserving this vein.

没错,没错。

This is the right gastric vein, we are preserving it.

We can consider preserving all these veins because it's a very early stage lesion.

This one we can dissect from here.

You mean intralisional procedure?

No, during the laparoscopic procedure, never injects any indotion in green on the tumor.

No, normally they don't use endocyanin green

because they use a pre-op and intra-op gastroscope

to localize where the tumor is.

They think this is more precise, more accurate.

Okay, thank you.

那么我们一般也不会去清扫。

那就要做转化治疗了。

Because normally for a certain type of lesion,

there will be a corresponding group of lymph nodes

that we need to dissect.

So we'll follow the guideline for that.

If the lymph node is outside of the corresponding group,

we will do conversion therapy.

We will not do dissection for anything

that's not in the corresponding group.

Okay, I agree with you.

同意您的说法。

他也同意您刚刚说的。

Medium-sized hemlock.

Now the gastroscope is here.

We have our interventional radiologist here

to use the gastroscope to do the localization of the lesion here.

They are preparing the surgical field

so the gastroscope can go in.

There's a subcardiac capsule here.

It's not in the chest cavity yet,

not the thoracic cavity.

It's the subcavity.

This patient only has a mild invasion in esophagus.

So if the inferior esophagus invasion is less than two centimeters,

there is no need to do a sub-mediastinal dissection of lymph nodes.

They are dissecting the lower part of the esophagus for the later kamikawa anastomosis.

Yeah, checking the position.

And I want to also ask you if you use a dendoscopy intraoperatively also in rectal cancer.

Yes, normally for the GE junction tumor, they would use intraoperative endoscope.

They are using it now to look for the site.

You will also use intraoperative endoscope for small rectal tumor as well.

Thank you.

So they have used the intraoperative endoscope

and also before the surgery they would use a titanium clip

to mark the upper and the lower incisional margin before the surgery

and we have used it.

Mostly it's one centimeter to the upper,

on the top part of the tumor

and three centimeter for the lower margin.

Okay.

Okay, we'll cut it from here.

I'll do the dissection here.

Take the front one.

Two pieces.

Two pieces?

Yes.

Take two pieces.

This one and that one.

So now they're retracting from the epigastric incision

and take the specimen out for frozen section.

This is where we have marked with the clip.

Yeah, we see the marker for rejection.

You can see the mark for rejection.

Cut it.

Blue nail.

Look at the time.

We need to press it for 15 seconds.

15 seconds.

15 seconds.

This kind of nail will have the best effect.

The straightening effect is good.

We will keep it on for several seconds, for 30 seconds, so that we have a better hemostasis result.

In order to prevent the bleeding at the stump, we will do some extra sutures, extra layer of sutures.

我们现在切下来的标本,他们在旁边,要进行切圆的,把切圆切下来以后,要马上送,速冻并动。

Now they are giving the specimen from the surgical margin to the first section.

大家可以看一下。

That's the specimen.

哦,OK。

Professor Hu Wenqing, in which post-operative days you will allow the patient to drink or to eat something,

and you will perform any radiological exam before this?

You mean before surgery? How long do they fast?

After the surgery, after the anastomosis, when you will allow the patient to drink or to eat something.

做完吻合手术之后

我们大概等多久才能吃饭或者是喝水

没有什么异常的话

明天就可以喝水

然后喝水喝一两天以后

然后可以进流食

So if everything is good after the surgery

Tomorrow the patient can drink some water

And one or two days later

The patient can start to take some liquid food

你说完吻合之后会用这个影像的技术

来检查那个吻合口的情况吗?

你说就是当时手术后吧?

You mean immediately after the anastomosis?

Whether he uses any imaging or radiographic

to check the anastomosis?

是的,是的。

In some case or just in case

you use radiological exam to check the anastomosis.

就是在术后当时。

Post-operative I tell.

So he would like to firstly show you the specimen.

As we can see, the two clips are both there.

And the lesion that is very small is in the middle.

And actually, right after the anastomosis, they will use endoscope to check the anastomosis.

Is that the radiographic that you are referring to?

Yes.

我们现在开始做积半。

Now they are making the musculature flap.

正常的。

他刚刚可能是想问就是术后吻合之后会不会用那个X光来检查吻合口。

这个是噪音。

In terms of radiographic, they will do it three days after the anastomosis,

together with some contrast agent.

Now they finish the muscular flap and then now they're making a small opening on top of it.

They have completed making both muscular flaps on both sides.

And in the middle, we can see the potential anastomosis site.

我现在是拿这个五厘米的线

要测量一下距离

美兰

They are using the five centimeter suture

to measure the length

我们现在就等这个结果了

等它的冰冻的结果

We are now waiting for the first

section result

现在我要去患者的右侧

And now the surgeon is moving

to the right side of the patient

什么

We're waiting for the pathologist to call us.

So if they tell us the margins are okay, we'll start anastomosis.

So now we're waiting for the result of pathology.

The surgical plane is okay.

It's not very high.

It's the right plane to choose.

Now the surgical plane is not too high,

but if in some other cases the surgical plane is too high,

then we would have to open the diaphragm and do the intramedial stinal,

and maybe we enter into the thoracic cavity and do the anastomosis in there.

But in this case, it's not too high.

Thank you very much.

Thank you.

Did you call?

Okay.

Let's see the output.

Put the output here.

No, you still have to...

No, no, no.

Let's go to the real one.

4085.

Don't worry.

Did the result come back?

He's asking if the result is reported yet.

Still waiting for the result.

电话响了。

听见了吧,这个上下气源全是阴性。

We have a negative incisional margin, both on the upper and the lower margin, so the surgical margin is okay.

Okay, so we go for anastomosis now.

好的,那所以现在我们准备开始往合了,对吗?

对的。

Yes, we're ready for the anastomosis.

不用打。

好,我们缝两针,收一次线。

We'll draw the sutures every two.

Every two sutures, we'll draw the suture line.

Excuse me, could you repeat your last statement?

你说现在就是缝两针,是吧?收一下线。

so in total

four sutures

for the fixation of the posterior wall

of the stomach

okay thank you

this is the third suture

we have marked it with the

methylene blue

we just completed the third suture

suture and about to do the fourth suture.

They're trying to wipe the endoscope,

the periscope, so they look more clear.

We have

We have completed the suture

on the posterior wall.

We will start the suture,

the anastomosis at the anterior wall.

The anastomosis would involve the mucosa.

We have to also consider the mucosa

during the suture.

We had some electricity problem where the light went down for every participant to this congress.

So you didn't see the previous part.

you can see the screen right yes thank you we're using another we're using another pc

Marco, do you know this anastomosis here? Kamikawa, do you know it too? Well, all those who have heard it do not know it, I thought it was me, I said, well, not even the professor here.

and this one here is an esophagus stomach opened first the serous and the muscular then he made us

open the mucosa and he is attacking the mucous to this thing here but I lost half of the

stomach because there was no light but the particular thing is also difficult there is challenging as

it is called so

kamikawa

I have never heard it but many people have never heard it here

What's so special about it? It's an antireflux, an antireflux esophagus-stomach.

The muscular serum opens. So it made a superior volar? Yes, it was a

joint neoplasia, T1b of the joint. It made a superior volar? Yes, it did the

opened, he did the parotomy, he sent the piece to see the distance of the margins, he prepared

this part here in the open and then he put it back in and he is doing the anastomosis.

How is the anterior blus? I don't know, because I lost half of the anastomosis with the light.

Yes, you can go to the light.

They are right now doing the anastomosis at the anterior wall.

They are sewing two extra sutures here at this location.

Next time the professor will prepare the Mac.

It looks much better. I don't know why, but it looks much better.

Maybe because of the Mac? No.

He's right now anesthetizing the two muscular flaps

from both sides.

I, by the way, have interviewed all those I know, someone said a motorbike, those things, I don't know.

So I take this away? No, wait a minute, I was trying to make it go back, it doesn't work, Chrome Error, no.

Anyway, I'll leave it now. No, no, I wanted to, but yes, now when the time passes, I'll tell you, let's see if it's here, no, no, it doesn't work at all.

No, but do it comfortably now, there is a problem, do it, do it.

Professor, who won king?

You will drain this patient.

Sorry?

You mean drain?

Put the drainage after the finish of the operation, at the end of the operation.

事后会做引流吗?

事后引流管会放一个。

Yes, he will do drainage.

So, Hu Wenjing, a lot of congratulations for your operation.

Your technique is wonderful, it's well standardized,

diced and so uh was very also deducted for young surgeons and also for a well-trained surgeon

because it's a technique very careful and we know that is a standardized technique and with a

the careful hemostasis and all the procedures are well organized and conducted. Congratulations

very much for your work.

整个吻合也做得非常的精确

每一步都做得非常好

非常祝贺你

谢谢

谢谢

谢谢巴贝尼教授

Thank you for your encouragement, professor

Your microphone is off

这位是

Dr. Maskani, your microphone is off

We couldn't hear you

这是马斯卡尼教授,是吧

是的

再来一个

Dr. Mosconi, your microphone is off, so we didn't hear you before.

We didn't hear your previous comment yet.

Yeah, do you, can you listen to me?

Yeah, I can hear now.

Just for a comment, that is a well-standardized and careful technique.

And we appreciated very much the technique

And all the phases of the procedure are clear, and we appreciate very much this work.

Thank you.

Thank you.

He repeated again that you did a great job in the whole operation, and you were very good at every step.

So when his microphone was turned off, I asked him if there was anything else he wanted to say.

He said that the whole operation was very good.

Thank you, thank you, Professor Mascani.

In this patient, the opening, the incision was a little bit big,

so we are using some extra sutures here.

But in the regular case, it would just take two barbed sutures to finish the case.

But now there are some extra sutures.

Now I'm starting anastomosis to both sides, lateral sides.

Now we are finishing at the apex of the left side, so we finish the left side.

It's very clear, we can see very well.

好,我们用这一侧的线。

And now we move on to this side, this side of suture.

我用刚才上面预留的这个线,完了把这一侧倒的缝回来。

Because we have some sutures left from the previous stage, and now we're using that suture to go backwards.

来,我去那一侧。

So, Janice is moving to the other side.

Okay.

Now, the intraoperative endoscope is here for the examination.

We're performing the intraoperative endoscope.

As we can see the anastomosis,

we can pass the anastomosis very easily.

We just performed the intraoperative endoscope examination.

The endoscope can go through the anastomosis very easily,

and there's no active bleeding in the stomach.

We'll put a nasogastric tube or not.

regularly we would we would do

do a nasogastric tube during the surgery in order to perform the surgery.

And then after the surgery, we would remove the nasogastric tube if everything is okay.

But in some cases, maybe the surgical plane is a little high and we were worried about the safety.

We may keep the nasogastric tube in for one or two days.

And then if everything is okay, we retract.

He just showed us the anastomosis. It's a Y-shaped anastomosis. We have embedded the

encephalus and the anastomosis. Thank you so much for staying with us. And with your

comments and your suggestions, we have finished this surgery completely and successfully.

Thank you, Professor Hu Wenqing. We enjoyed very much your operation and

I hope to see you very, very, very soon. Thank you and congratulations.

非常好,我们教授也说非常

期待很快再和您见面。

好的,谢谢,谢谢

马斯卡尼教授,谢谢。

希望很快能够

见面,谢谢。

Thank you, Professor Mascani, hope to see you soon.

谢谢。

Bye-bye.