Shen Xian M.D. Ph. D. Total laparoscopic radical resection of gastrc cancer

Good morning, buongiorno, and good afternoon to you, dearest friends and dearest colleagues in China.

My name is Umberto Grandi. It's my great honor to be with you during this day.

It looks like, again, we will be very crowded.

This time online, we are not in presence now.

We are in Rome. Great weather. It's hot.

I just want to thank you for staying with us today and to give us the opportunity to

see you.

I heard laparoscopic radical gastrectomy.

It looks like your curriculum vitae is so long, Professor Shen, and it's simply overwhelming.

Vice President of Bensu Medical University, President of the first affiliated hospital

medical university, national middle aged expert with exceptional contribution to health, responsible

for national key R&D program and it looks like I'm not going to read everything about

your curriculum vitae because I'm allowed to speak to you only two minutes and one minute

it's already okay so I just want to thank you on behalf of Professor Giorgio

Palazzini it's a great pleasure to lend a hand to him in Rome I'm from Ravenna

north and part of Italy on the Adriatic Sea and together with me there is also

Professor Materti that will be speaking to you during this procedure so

professor thank you very much you can go ahead whenever you want

Thank you so much.

Good morning, Professor Grandi, Professor Mappetri, and Professor Vitellola.

I'm glad to attend the 35th Annual Congress of Italy, the Digestive Surgery.

And it's my great honor to do live surgery demonstrations.

I want to introduce my teams.

Dr. Qiantong Dong is the associate professor, my first assistant, and my PhD student, Wei-Teng Zhang, and my nurse is Lei-Lei Jin.

Thank you very much.

Let me introduce my hospitals.

Wenzhou Medical University's affiliate hospital was established in 1919

As one of the first four comprehensive hospitals in Zhejiang province to pass the top tiers

evaluation, as medicals cover nearly 30 million people in South Zhejiang, North Fujian, and

Eastern Jiangxi, the hospital currencies have about 7,000 employees on staff and 4,000 hospital

beds.

The gastrointestinal surgery department currently has three wards with 139 beds.

As the largest digestive tract cancer center in southern Zhejiang and north Fujian province,

we performed over 900 stomach cancer surgeries and about 1,600 gastro-rectal cancer surgeries

Firstly, this patient is a 47-year-old female who underwent a myomectomy four years ago,

and the patient presented for admission 17 days following the diagnosis of gastric cancer.

Her psychology examination showed that this patient has very soft abdomen, no tendons,

nomasis, or organomegaly, and her bowel sound is normal without any vascular bruise.

The BMI score of this patient was 20.8, and the NRS-2002 score was 1 point, and ASA classification

was at grade 1.

The laboratory tests only showed a very gentle increase of the cancer agent, 125.

Next page.

Next page.

In the November 9 of this year, the patients received a test of gastroscopy.

It showed that a very small gastritis with erosion.

But unfortunately, four days later, the result of pathology reported that the gastric antrum

was first considered to be polydifferentiated endo-casinoma, and some of them were sick

ring cell casinoma.

Next page.

So we performed a PET-CT for this patient, and we can find there are abnormal concentration

of local imaging agents in the last curvature of the entremes, which was consistent with

gastric magnet tumor imaging.

But very luckily, there is no more high-uptake metastasis was found in the remainder abnormal.

Next page.

So, the patient's diagnosis and the treatment was as follows.

The clinical diagnosis and the stage was gastric carcinoma, and the clinical stage is T1, N021, and M0,

followed by the guideline of gastric cancer in both NCCN guideline and the Cisco guideline in 2023.

The best strategy for this patient is to do the surgery.

Next.

At last, we will do the intracorporeal line stepper toxin-wide gastrointestinal genome stormy.

That's all. Thank you so much.

Thank you. I beg your pardon, I didn't get this.

The patient was admitted to the hospital about 20 days ago.

Because of what? I didn't get it. Sorry.

for the endoscopy and find that there is a very small endo-casinoma.

Did you get it, Professor Grandy?

Yes, definitely.

Body checkup. Okay.

Okay. Yes. I thought there were some symptoms and it was only an endoscopy, previous endoscopy. Thank you.

okay let's let's begin our surgery yes please professor can you show us the position of the

talkers oh okay have a look okay thank you sir thank you okay

Now we have already done the exploration under laparoscopy.

Okay, so the device we used is the 3D device from Stultz.

The difficulty part of remove the transverse mesogastrin, not mesocolons, from the gastrin.

So we try to do that to propel it from the transverse of colon, colon, colon, gastrin.

Yes, okay, thanks.

Canadian surgeon is very lucky.

The patient is thin, not like Italian patient is very big.

so maybe the surgery will be easy yes you are definitely right yes this is a

normal joke whenever I speak it to our our dearest colleague in China we are

speaking about the BMI and these patients yes some some 20 I think the

now we can we can see the pancreas yes the images are quite clear and the

momentum is the thinness of it was easy to see the pancreas yes right

Yeah, the images are quite clear.

The Stoss 3D is very excellent.

Do you normally use 3D devices for every laparoscopic surgery?

Yes.

Let's go back to the front page of the film.

Yes, you can go back to this position.

You have to loosen this first.

You have to loosen this line first.

Okay, you can go a little further.

Okay, now we can see the right gastric apoptic veins, and the right colon veins, and the

helioskeletal tract, and the number 14 lymph node is negative, so maybe have a one lymph

node, we can remove it.

Great, great professor, thanks.

There are a few lymph nodes. Do you want to do it?

Yes, it's okay.

The number 6 lymph node.

Right.

Continue to go up.

So professor, do you discuss every single patient in an MDT and multidisciplinary team?

Does every patient do MDT discussion?

Yes.

every patient against cancer will have mdt discard this kind of discussion

i'm hoping do you plan a single laparoscopic review of the abdomen before having i mean

normally whenever you perform a operation like this but do you plan to have only laparoscopic

we can discuss again in the MDT paper.

What did he say?

He said it's only when we do the imaging

that we do the MDT discussion.

No, every patient,

every case will have MDT discussion.

Professor Granny,

every gastric cancer patient in our center

will have the discuss by MDT before the surgery.

even the open abdomen, or doing the laparoscopy.

I understand this.

My question is, do you sometimes, in some patients, do you perform,

do you plan only laparoscopy and just to check if there is any problem in the peritoneum

to be discussed again without performing?

is repeated in some patients we we plan only laparoscopy just to understand if there is any

any peritoneal problem in the patient just to speak with the oncologist and

to discuss the case with the oncologist having a probably an extra biopsy

No, we will give you the last guest at the public meeting.

Good morning, Professor Shen.

Shen Yemli is a doctor from Rome.

First of all, good morning to you and your staff.

Thanks for this excellent discussion.

Very meticulous.

I just want to ask you, apart from the meeting, the multidisciplinary meeting,

do you also send the specimen, the opposite specimen, for molecular studies?

Thank you very much, Professor Shen.

Professor Maberti wants to ask a question.

Will our standard be sent to the place where we do the molecular test?

Yes, we will do the normal by mark.

Every patient, we will do the test like a fish HER2.

If the HER2 is positive, we will sequentially do the fish for it.

And also, we will send it for the black RNA sequence.

If the patient's in need, because it costs a little expensive,

So, if a patient's ECNAMI is allowed, we will send it for the formal test of black RNA sequence.

Besides for the immunostaining, we also do the MSI test and the CPS score for the guidance.

presence, the patient and the immunotherapy, and also the Claudian 18.2, the Claudian and

the HER2, and also EGFR, such like this.

Now we can see the GDA.

Now, we can show the number six lymph node.

It's the anus tract and the right gastroepirotic veins.

Okay, now.

The number 8 lymph node is very big, but I believe maybe it's a benign.

Here, here, here.

Here, here, here.

Here, here, here.

Here, here, here.

Here, here, here.

No, we can see the colonal vein.

Apparently, the left gastric vein has been appeared.

It's a spleen artery.

It's a common hepatic artery.

Yes, thank you.

The images are really clear.

and the BMI of the patient just helped us.

Yes, that's great.

There's a joke between Professor Maberti and myself

about the hemlock.

It looks like that hemlock is the same word in Italian and in Chinese.

玩笑,就是他们团队之间会说用到的Hemlock,

我们中国也叫Hemlock,

然后他们意大利也是叫Hemlock,

都是一样的名字。

It's only a joke, of course.

Yeah, yeah, Hemlock.

有个会设的文件,

然后来,

把这个打开上来。

Professor Shen,

I want to ask you,

in the work

of the patient, of your patients,

when, in case,

Do you also use magnetic resonance and echoendoscopy, especially?

He wants to ask Professor Shen a question.

When we do the examination,

when do we use this magnetic resonance or superlative inner mirror

to examine the patient?

OK.

Our common rule is not to use magnetic resonance,

but to use superlative inner mirror to do the analysis.

If the patient is relatively early,

We usually prefer using the CT scan

other than the MR test.

If the patient was at a very early stage,

and it's better to do it by the ESD,

We will use the ultrasound and the intrascopic.

So CT scan is our best try for the TNM stage.

Yes, the small gauze is very good.

The small, a little bit of bleeding, the small gauze can stop those bleedings.

这里后面还有不少淋巴腱。

Okay, it's the corner vein.

很韧,组织很韧。

年轻青年组织韧得多呢。

Okay.

What a precise dissection, professor.

分离得非常的好。

It's a left gastric artery.

Definitely, perfectly cleaned.

Be careful, there's a foreign object behind you.

It looks very delicate.

I'll give you this little gauze.

Put it on top.

Okay.

Should I put it on first?

Yes, put it on first.

On top.

Don't move, don't move, don't move.

Okay.

So you just opened the Lesser Romantum from behind.

Yes.

Maybe it's the node, which we can see.

Now we swap the last curation of the gastric.

上午还是三台吧,上午是四台啊。

挺好的,大家做做演示对手术技术是有进步的,差不多啊。

再打点吧,再打点。

再打点。

这个人胃好像有点...

就是我这里挑了...

好,现在分离前。

maximum you can move up cut right thank you come on I'm gonna bumming to make

So Dr. Shen said he will be very careful here.

Every cut may be hurt the portal vein.

Now we can see the portal vein.

It's a portal vein.

The portal vein is up here.

And it's known.

no

this is 8p lymph node

We should be careful with the perturbing.

Yes.

Why are we using the hemlock here?

It's to avoid the lymph node leakage from here.

In this surgical passage, we can clearly understand the huge experience

the experience and the skill of the first operator.

Now we should deal with the right gastric artery.

Before we dissect the right gastric arteries, we should see the hepatic artery.

It will be safe.

Okay.

It's the right gastric artery.

Why the miss cut the hepatic arteries every time when we cut the vein and the arteries

together we cut the every time before we cut the right gastric arteries we need to see

the hepatic artery first.

Yes, number 12 lymph nodes.

It's number 12.

Yes, number 12, you reached the particular right.

OK.

This is the 12th station.

We have now reached the dry gate.

OK.

It's a compact haptic artery.

It's a haptic artery.

And it's a right gastric vessel.

OK.

Next.

Next.

Here.

Hit it a little bit.

Hit it closer.

Here.

No problem.

We can move this.

Don't move it too high.

The stomach.

The stomach's mark.

OK.

为了更好地能够做清扫工作。

The patient turned 30 degrees to the right side,

and the head of the patient also lifted for 30 degrees.

Thank you.

不要太近。

这个痕迹才很长。

这是没有做那个当孔的输出机器人,

这蛮可惜的。

刘叔,你可以介绍一下,

就是我们现在中心在开展这个,

China has done a lot of research in the field of subcutaneous surgery.

We now have a single-hole gastrointestinal surgery,

and we have done nearly 30 of them.

There are more than 40 gastrointestinal surgeries in total.

More than 40 gastrointestinal surgeries

The center of our hospital is to explore the Chinese-made robot machine for the laparoscopy.

And we have done for the 30 to 40 cases in gastric cancer and also colon cancer.

That is a so-called Chinese da Vinci robot machine.

It was a very development of this machine very rapidly.

Thanks for the information.

Again, I've heard that the amount of gastric surgery in your hospital,

I mean in your city, I've seen it's almost 10 millions of people living there.

The gastric surgery per year is about 1,000.

Did I recall right?

About 800 gastric cancer surgeries.

We have 800.

Every year.

Yes.

So 800, how many people, I mean,

how many skilled surgeons are there performing?

800, 800 surgical procedure in the stomach per year.

有多少能主刀作位的那个高级的医生,

然后大概每个人完成多少?

Six surgeons.

Six surgeons.

That means almost 150,

150, almost 150 average surgical procedures.

Yes, and every surgeon will do the colon-rectal surgery.

In my sense, about more than 1,600

colon-rectal cancer surgery.

So every surgeon's-

What did it cost?

What did it?

Yeah, we have six superior doctors, surgeon doctors.

In our department, we divided for six groups.

So each group, the charge PI, the PI personal who in charge for this group,

can handle this surgery like the gastric and the colon cancers.

So all the 1,200 cases is done by them every year.

That's amazing.

Every time I speak with my dearest colleague in China,

well, I'm always overwhelmed by this number.

Incredible.

for two surgical departments.

And it's on the Adriatic Sea in between Venice and Rimini, right on the Adriatic Sea.

It's six kilometers from the sea.

They have a population of 170,000, and the city's history is relatively long,

it's a 600-year history, and it's very close to the Roman Empire.

Welcome to Wenzhou.

Wenzhou is the south or east of Zhejiang province, close to Hanzhou and Shanghai.

Yes, professor, I've studied something last night just to understand what's going on in your city.

It's only almost 10 million people living there. It's incredible.

This patient, the transverse colon is very long.

Are you heading towards the number 10 lymph nodes?

No, no, no, no.

There are some attention with the omentums and the spleen.

Yes, you can take a look at it.

Ok, I will put one more.

One more?

Yes, put one more.

Please take a look at the outside.

Ok, good.

Can you turn it higher?

Yes, CSB.

What is it?

It is 4SB, the number 4, leaf node.

Yes, but the one in front is not the main one.

If you put it higher, it will move a little.

I will spray it.

They are trying to find the LTEV from the spring wine.

branch of the spleen, wine, and the artery.

We can see have a three, one, two, three,

sort of vessels.

So which the dissection, the sector vessel, the short.

the two to three branches of the short gastric artery.

Now they are swiping the large curvature of the gastric.

So he's going to save two over three short veins,

short gastric veins, is that okay?

Yes, now there is a great momentum.

Definitely, and she just told us that you are going to save 2 over 3 short gastric veins.

Yes, I mean that they are trying to keep 2 to 3 short gastric veins.

Now we should cut the duodenal.

Okay, cut it down a little bit.

Almost there.

Okay.

Almost there.

Okay.

We will select the lox y anastomosis.

I will help you.

Let's take a look at the whole picture.

It's okay.

Just put it there.

Let's take a look at it.

I'll give it a review for the whole view.

We can see the patient, the number six lymph node.

It's a duodenal, it's a GDA, and there's a common hepatic artery,

and the right gastric artery, and the spleen artery.

Professor Shen, I was asking earlier on whether your incision was through the pallors or above it.

Because this patient's ligament is located at the anteroom, so maybe one third of the stomach is enough.

off but this patient is early stage due to the stations stages very early and

the cancer was at his own terms so we left as a one of three part for this

gastric we decided that the cut line to remain two branches of the vessels in

in the last curvature.

How we to rebuild the digestive tract?

This is a very interesting point.

Firstly, we found the trislegment, and we counted 50 to 20 centimeters of the jejunum.

Now, the assistant helped Dr. Shen to lift the small intestinal.

About 20 centimeters.

Yeah, 20 centimeters from the chest.

20 centimeters to chest ligament.

Now the chef will using this line for mark.

Yeah, good.

Okay.

Now we pull the samples back down.

It will be easy when we open the abdomen.

It will be easy to find this back.

and also this line is the mark when we open the abdomen we will find the intestinal 20 meter 20

centimeters after the treats now we will open a small incision about two centimeters

So you know why we need to

Remind us the line here here to market was a in small intentional

So you by using this line we will be very easy to find the where is the centers 20 centimeters after the segment

I don't think it don't do it now. You don't tell us about it. It's really what the woman told you

You don't want you sure

So, it's about 5 cm.

Let's measure it again.

5 cm here, 25 cm here, 35 cm here.

It's about the same as the original.

Should I just cut it off?

Sure, sure.

Amalok.

5 cm, 25 cm, 35 cm.

Okay, that's it.

Okay, you have to present this.

Biden, one more.

Here we're using the stepper to rebuild the Y connection, the Y of Roxin-Y.

this lion stepper is 60 centimeters but we only use the top of the 45 centimeter

so the diameters of this connection is 45 centimeter

meter okay no bleeding yes now this is the sample we're cutting before we can find the gastric

where the tumor is at the at the top of this cramps yes thank you okay thank you so much

Are you going to perform an anastomosis as a single layer or a double layer?

Double layer. Great, thank you. Within an absorbable thread, I think.

the mesointestinal here to avoid the internal hernia of the other

investinals after the operation

it's not rare for the patients who receive the gastric cancer surgery

they will have the internal hernia of other

small invest small intestinals so close this gap is quite

Okay, you can sit.

I can't see clearly here.

Then push this down to the front.

Where are my glasses?

It's okay.

Okay.

Let me see.

It's long.

I'll come down.

Okay.

I'll come down.

Give me the electric stick.

Step on it.

Step on it.

Professor Grandy, I should fly to another city to have a conference, so now I should leave.

The anastomosis will be completed with my junior doctor.

Professor Dong will do the anastomosis. Thank you very much.

Thank you for staying with us. It was great to speak to you.

thank you sir thank you welcome to visit our hospitals well i would love to yes welcome

looking forward yeah i would love to thank you very much

so the remaining part will be done by dr dong and now they're trying to rebuild the

There are no bleedings inside.

Professor Dong, I wonder, do you pass through the Erasogastric tube now?

Now we regularly do not let the tube into the gastric for the ERAS.

Professor, I see that you over suture all your stapler line.

这个稳合钉线的这一个缝合,加固缝合是怎么样的缝法?

我是用一个僵基层的包埋。

We're basically using a pre-string suture with the embedment of the serosa and the muscular layer.

你把它钉高一点,这样。

轻轻拉一点,轻轻拉一点,你要松掉这个。

Professor, do you perform any tests in your anastomosis and in your stomach and ileus?

I mean, something with the glutamethylin or flourishing and so on.

Yes, we usually at the post-operative phase three,

we let the patient drink the Proust brew.

If there are any leakage of the connections,

the Proust brew will be drained from the tube.

So no intraoperative tests, I mean.

Thanks.

Here, here, here, here, here, here, here.

Give me a bigger scene.

Big scene.

Clamp it up.

Where's your clamp?

Clamp it up.

It's a little less.

Give me this.

Clamp your head up.

Yeah.

Okay.

I'll take it off.

My needle.

The needle is back.

Look at my needle.

Don't grab it.

Don't grab it.

Clamp it.

Press it down.

Clamp it.

You don't have to pull the line up.

The needle is back.

So be careful of the fine lines.

Pull the line.

Pull the line.

Yes.

Okay.

Don't pull the line.

Like this.

Okay.

Get ready.

Hold it like this.

Okay.

Hold it like this.

Okay.

Don't pull the line too tight.

Now we're going to rinse the tube.

We're going to finish the whole operation.

Rinse.

Rinse.

Rinse.

Look here.

Yes.

刘师,我们先展示一下这个吻合的情况。

We show the connection of the digestive tract for all of you.

这个是胃肠吻合口。

This one is the connection of the small intestinal and the remaining gastric.

胃肠吻合口。

下面,下面。

这个是外吻合口。

And here is the Y connection for the 20 centimeters after the tris-legment

and for the 16 centimeters after the tris-legment.

这是肾肠端,看一下。

And here is the duodenum, remaining of the duodenum.

好,那我们现在冲洗一下那个,走了吧。

Now we will clean the abdominal, flush for it, and put the drain tube, and then we will finish this surgery.

So a single drain?

Yeah, only one drain.

Only one drain.

Yes, yes, only one drain.

Sorry, Professor, when are you going to feed again this young patient?

If everything goes smoothly, the patient can be discharged post-op day 7.

It's basically 6 to 7 days after the surgery.

Professor Dong, can you hear me?

Yeah.

Okay.

First of all, congratulations for the excellent procedure,

bloodless, accurate meticulous.

and please send our regards also to Professor Shen.

One thing that I want to ask you before the surgery course,

having so huge amount of populations,

also for oncological cases,

and having so much rural people very far in the periphery,

Do you have any campaign also to prevent and to instruct the people concerning the diet to decrease the amount of...

Thank you very much for the very nice question.

I think it is true that we need to pay more attention to patient education, including the preoperative education.

education. Here in our hospital, we have very good digitalized tools to help patients. Before

they are even admitted, we can provide them with the virtual baths so that they can have very good

patient education during their waiting for the hospital baths. They also can have very good

nutritional support. Before admission, they will be given suggestions on how to keep a very good

nutritional status to prepare for surgery and after discharge patient would also have very

good patient education from our nice nurses regarding nutrition regarding a good diet

dietary habit you're right indeed we have a lot of patients from a rural area very remote area so

they they are in bigger need for this patient education regarding their nutrition and regarding

learning their dietary habit.

So we have a lot of nurse team.

We have the digital tools to help these patients

with these education campaigns.

Thank you.

Wait a minute.

There are a few questions from Professor Idarim here

that he wants to talk to you about.

Because there was a break just now.

Okay, okay.

I'm on the line.

Hi, Professor.

Hi.

I'm so sorry.

It was a technical problem with the energy.

And so I just wanted to thank you so much for the great performance.

And I really hope we can meet very soon, hopefully, in your country, in our country, in the next Professor Spallazzini Congress.

And I just want to tell you something.

I was speaking with the colleagues.

What I wanted to say is, well, it depends on the BMI.

it depends on on how many patients you are performing in a year i really don't know i

think that you are a great surgeon you're performing something it looks like it was

slow it was smooth but it was not because in less than two hours you were you were performing you

were completing a surgical procedure i mean and you have to really to you suture again every single

stapler. I really think it was really great and you were fast but you were not

in a hurry. Great performance, really. Thank you so much.

Thank you very much for really nice comments and under the guidance of

Professor Shen in our team we have done a lot of advancements recently and also

the advancements of the procedure types from laparoscopic assisted surgery to

to pure laparoscopic, to robotic surgery, and all the way to uniportal robotic surgeries.

We have done many gastric cancer and colorectal cancer cases in a minimally invasive fashion.

And we are also striving for even refinement of our surgical skills with better details of the surgery

and standardization of the surgery to benefit our patient more.

more and thank you so much for professors from Italy your nice comments and your participation

and we we hope that someday we can visit Italy visit your center to learn from you as well and

to conduct face-to-face discussions furthermore thank you thank you so much it was really

impressive thank you so much hope to see you next year at minimum thank you thank you see you see you

thank you