Nghiên cứu ứng dụng cắt bán phần dưới dạ dày nội soi hoàn toàn điều trị ung thư dạ dày ttta

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATION DEFENCE INSTITUTE OF CLINICAL MEDICAL SCIENCE 108 LUONG NGOC CUONG STUDY ON APPLICATION OF TOTALLY LAPAROSCOPIC DISTAL GASTRECTOMY FOR GASTRIC CANCER TREATMENT Speciality: Abdominal Surgery Code: 9720104 MEDICAL DOCTORAL THESIS HA NOI - 2023 THE THESIS WAS DONE IN: INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES 108 Supervisor: Ass Prof PhD Nguyen Anh Tuan Prof PhD Phạm Nhu Hiep Reviewer 1: Reviewer2: Reviewer3: The thesis is defended in front of the University Thesis AssessmentCouncil More information of the thesis could be found at: LIST OF PUBLICATIONS RELATED TO THESIS THEME Luong Ngoc Cuong, Nguyen Anh Tuan, Pham Nhu Hiep, Nguyen Van Du (2023) Study on technical characteristics of totally laparoscopic distal gastrectomy for gastric cancer treatment, Journal of Clinical Medicine, Hue Central Hospital, 88, 63-67 Luong Ngoc Cuong, Nguyen Anh Tuan, Nguyen Van Du (2023) Results of totally laparoscopic distal gastrectomy, restoring Finterer-type gastrointestinal circulation for treat gastric cancer, Journal of Clinical Medicine, Hue Central Hospital, 88, 102-106 Luong Ngoc Cuong, Nguyen Anh Tuan, Nguyen Van Du, Vu Thi Hong Anh, Bui Thi Quynh Nhung (2021) Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: Short- term results from a tertiary hospital in Vietnam Annals of Cancer Research and Therapy, (29), BACKGROUND Gastric cancer is a common gastrointestinal malignancy worldwide In 2020, according to the International Agency for Research on Cancer (IARC), the incidence of gastric cancer ranks 5th and the mortality rate ranks 4th among 10 common cancers globally In Vietnam, in 2020, the incidence rate of stomach cancer ranks th and the mortality rate ranks 3rd among 10 common cancers There are many treatment methods for gastric cancer applied such as: surgery, chemotherapy, radiation therapy, immunotherapy However, gastrectomy combined with D2 lymph node dissection is still the optimal treatment option preferred when the tumor is still resectable With the advancement of science, laparoscopic surgery was born Laparoscopic surgery is used for many diseases, including the treatment of stomach cancer Currently, in addition to laparoscopic assisted distal gastrectomy, there is also a totally laparoscopic distal gastrectomy In Vietnam, tottally laparoscopic distal gastrectomy has been implemented in a number of hospitals such as 108 Military Central Hospital, 103 Military Hospital, Viet Duc Hospital, Hue Central Hospital In totally laparoscopic distal gastrectomy, the restoration of gastrointestinal circulation is done completely intra-abdominal through laparoscopic There are many methods of tottaly laproscopic gastrointestinal circulation restoration have been applied However, up to now, methods and techniques for restoring gastrointestinal circulation in totally laparoscopic distal gastrectomy are not really unified The choice depends on the surgeon and the patient's condition Therefore, we carry out the topic: "Research on the application of tottaly laparoscopic distal gastrectomy for gastric cancer treatment" Objective of the subject Describe the technical characteristics of totally laparoscopic distal gastrectomy for gastric cancer treatment Evaluation of the results of totally laparoscopic distal gastrectomy for gastric cancer treatment 2 Urgent nature of the project Gastric cancer is a common cancer with a high mortality rate in the world as well as in Vietnam In Vietnam, the new incidence rate ranks 4th and the mortality rate ranks 3rd among 10 common cancers Treatment of gastric cancer is mainly surgical The world has applied totally laparoscopic distal gastrectomy with good results and has many advantages compared to laparoscopic assisted distal gastrectomy In Vietnam, totally laparoscopic distal gastrectomy has also been implemented in some hospitals The question posed in the totally laparoscopic distal gastrectomy for gastric cancer treatment is: how to restore gastrointestinal circulation?, is the surgery safe and meets the requirements of cancer treatment? New contributions of the thesis It should be indicated for patients with gastric carcinoma of the lower third and middle third, the tumor invasive ≤ T4a and no distant metastases (M0) Elderly patients, patients with cardiovascular, respiratory and endocrine diseases are still indicated for totally laparoscopic distal gastrectomy Using trocars, 5-step technique, restoring gastrointestinal circulation in Finsterer style, using straight staplers to perform gastrojejunostomy, side to side anastomosis Anastomosis of the free border of the jejunum with the great curvature of the stomach first, then closed the anastomosis simultaneously with gastrectomy The layout of the thesis - 132 page thesis: background are pages, overview are 35 pages, subjects and methods are 28 pages, study results are 24 pages, discussion are 38 pages, conclusions are pages and recommendations page - The thesis has 47 tables, charts and 40 images - The thesis has 122 references, including 14 Vietnamese and 108 English CHAPTER 1: OVERVIEW 1.1 Gastric Anatomy 1.1.1 Body shape, histological structure 1.1.2 Blood vessels, omentum, lymph nodes 1.1.3 Histology of gastric cancer 1.2 Totally laparoscopic gastrectomy 1.2.1 History of surgery 1.2.2 Indications for surgery 1.2.3 Pros and cons of surgery 1.3 Study on totally laparoscopic distal gastrectomy technique 1.3.1 In the world * Patient position and surgical team position: Depending on the surgeon, there are different ways to arrange the position of the surgical team and the position of the patient There are usually ways to arrange the surgical team and position the patient: (i) The patient lies supine, legs apart; the surgeon stands to the right of the patient; Assistant holds the camera and stands between the patient's legs; Second assistant stands to the left of the patient (iii) The patient lies supine with legs closed; the surgeon stands on the right side of the patient; Assistant holds the camera and stands on the same side with the surgeon, assistant stands on the left side of the patient (iii) The patient lies on his back, legs apart; the surgeon stands between the patient's legs; Assistant holds the camera to the right of the patient, assistant stands on the left of the patient * Placement of trocar and number of trocars: the number of trocars and placement of trocars in the abdomen are also different Some authors use trocars, some use trocars, some use trocars, especially some authors use only trocars * Gastric release, gastrectomy with lymph node dissection: performed like lymph node dissection in laparoscopic-assisted distal gastrectomy Lymph node dissection is performed according to the Treatment Guidelines of the Japan Gastric Cancer Society 2018 Usually, lymph node dissection is made into an “en block” block in a clockwise direction Cut and close the duodenal process: most use a line stapler to cut and close the duodenal process, without stitches to strengthen the cut Gastrectomy: most perform gastrectomy first, restore gastrointestinal circulation later Some restore gastrointestinal circulation first, gastrectomy later Remove the specimen from the abdomen: most of the time, the umbilical trocar hole is enlarged to take the specimen; some extend trocar 10 on the left; some small opening of the epigastrium; some pave the way above the pubic bone * Restoration of gastrointestinal circulation: the method of restoring gastrointestinal circulation in totally laparoscopic distal gastrectomy is not really comprehensive, the way to recover depends on the surgeon, the patient's condition and the location of the injury Normally, digestion is restored in three ways: Billroth I-type restoration of gastrointestinal circulation: this is the ideal rehabilitation method in distal gastrectomy because it has many advantages such as: uncomplicated technique, little anatomical changes, favorable physiology, The rate of intestinal adhesions and internal hernias after surgery is low However, this method has limitations because it depends on the tumor location and the size of the remaining gastric The following methods of laparoscopic Billroth I gastrointestinal rehabilitation are available: (i) Gastro-duodenal anastomosis, using a line stapler, the anastomosis closed with another line stapler (Delta anastomosis); (ii) Gastroduodenal anastomosis, using a line stapler, the anastomosis is closed with sutures, laparoscopic suture is performed; (iii) Gastro-duodenal anastomosis, using a round stapler, the junction is closed with a line stapler; (iv) Gastro-duodenal anastomosis, using sutures, manual laparoscopic suture Roux-en-Y-type restoration of gastrointestinal circulation: Roux-en-Y gastrointestinal restoration can reduce tension at the gastrojejunal junction This technique is performed regardless of the extent of gastrectomy, although the technique is more complicated and time-consuming than other types of circulation restoration, since two anastomosis is required The following types of restorations are available: (i) Gastro-jejunostomy, using a line stapler, the joint closed with another line stapler; (ii) Gastro-jejunal anastomosis, using a line stapler, the anastomosis is closed with laparoscopic sutures; (iii) Gastro-jejunostomy, using a line stapler, the joint is closed with another line stapler; (iv) Gastro-jejunal anastomosis, anastomosis using a circular stapler; (v) Roux-en-Y "uncut" (U-RY) join, which is an improvement of the Roux-en-Y method Billroth II-type restoration of gastrointestinal circulation: Billroth II gastrointestinal restoration in totally laparoscopic distal gastrectomy is easier to perform than in Billroth I or Roux-en-Y The technique is simple, the extent of resection is larger, the indications are independent of tumor location or size of the remaining gastric However, Billroth II rehabilitation has some disadvantages such as: residual gastritis and reflux esophagitis caused by reflux of food in the intestine into the gastric The following methods of restoring gastrointestinal circulation of Billroth II type are available: (i) Anterior gastro-jejunal anastomosis, using a line stapler; (ii) Gastro-jejunostomy, using a circular stapler; (iii) Posterior gastrojejunostomy, using a line stapler; (iv) Gastro-jejunostomy, using a line stapler; (v) Anastomosis of the back of the gastric - jejunum with sutures, manual suturing through endoscopy 1.3.2 In Viet Nam In Vietnam, there have not been many studies on totally laparoscopic distal gastrectomy According to Ngo Quang Duy (2018), totally laparoscopic distal gastrectomy for 33 cases Technique: enter the abdomen through trocars, restore gastrointestinal circulation with Billroth I or Billroth II anastomosis, use a line stapler to perform the anastomosis 1.4 Study on the results of totally laparoscopic distal gastrectomy 1.4.1 In the world An analysis of a total of 21 studies with 1889 cases of totally laparoscopic distal subgastrectomy The results showed that the mean age (56.6 ± 12 to 64.7 ± 10) years old; average surgical time (132.1 ± 26.6 to 263.1 ± 52) minutes; mean blood loss (37 ± 3.2 to 252.6 ± 62.8) ml; the average number of removed lymph nodes (23.4 ± 10.8 to 39.4 ± 9.8) lymph nodes; the average time to return to liquid diet (2.1± 0.8 to 3.9 ± 1.5) days; mean hospital stay (6.9 ± 2.4 to 14.3 ± 10.3) days Complications after surgery ranged from 0.2% to 12.0% Another randomized clinical trial, evaluating the results of laparoscopic distal gastrectomy for 519 cases of advanced gastric cancer from 14 centers in China The 3-year follow-up showed that the recurrence rate was 18.8% Overall survival and disease-free survival were: 83.1% and 76.5%, respectively The disease-free survival rate for stage I: 96.5%; phase II: 87.5%; stage III: 58.0% and stage IV: 20.8% Overall survival rate in stage I: 97.9%; phase II: 92.5%; stage III: 69.5% and stage IV: 20.0% [106] 1.4.2 In Viet Nam In Vietnam, there have not been many studies and evaluations of totally laparoscopic distal gastrectomy with a large enough number of reports According to Ngo Quang Duy (2018), totally laparoscopic gastrectomy for 44 cases of gastric cancer As a result, the conversion rate to open surgery was 9.1% There were no complications during surgery The mean surgical time in the total gastrectomy group was: 303.18 ± 75.54 minutes and the distal gastrectomy group was: 261.76 ± 58,326 minutes The average blood loss is about 100 ml Complication rate 20.45%, in which: bleeding, accumulation of fluid in the abdomen 11.4%; paralytic, semi-obstructive bowel 4.5%; duodenal fistula 2.3% and pneumonia 2.3% Average time to eat back 4.18 ± 1.41 days; mean time to first flatus 3.27 ± 1.08 days; average hospital stay 7.86 ± 2.96 days According to Nguyen Hoang (2022), totally laparoscopic distal gastrectomy for 39 gastric cancer cases As a result, the mean age was 61 ± 9.9 Ratio Male/Female = 1.93 The average hospital stay was 9.27 ± 3.65 days There were no complications and switched to open surgery, there was 01 case of pancreatitis, 01 case of anastomosis bleeding, which was treated conservatively There was no postoperative mortality To date, no studies on the long-term outcomes of totally laparoscopic gastrectomy have been reported in Vietnam Chapter 2: SUBJECTS AND METHODS 2.1 Research subjects Gastric cancer patient underwent totally laparoscopic distal gastrectomy, at the Department of Gastrointestinal Surgery, 108 Military Central Hospital, from January 2019 to November 2020 2.1.1 Inclusion patients - Patients with gastric carcinoma middle 1/3, lower 1/3 are identified by histopathology - The patient is indicated for totally laparoscopic distal gastrectomy - The patient consented to participate in the study - Patients are monitored and evaluated 2.1.2 Exclusion patients - Patients with a history of surgery on another organ for cancer such as thyroid cancer, breast cancer, cervical cancer, prostate cancer - Patients with metastases or invasive tumors observed during surgery - Patients with non-carcinoma pathologic results or tumor invasiveness > T4a - Patients with contraindications for laparoscopic surgery - The patient did not agree to participate in the study 108 patients underwent totally laparoscopic distal gastrectomy Objectives of the study 1: Describe the technical characteristics of totally laparoscopic distal gastrectomy for gastric cancer treatment - Gastric release and lymph node dissection techniques - The technique of cutting and closing the duodenum - Techniques to restore digestive circulation - Technique to take out the specimen, check the anatomosis Objectives of the study 2: Evaluation of the results of totally laparoscopic distal gastrectomy for gastric cancer treatment Intraoperative results - Conversion surgery - Surgery time - Blood loss - Number of dissected lymph nodes - Intraoperative death Research Diagram Proximal results - Time to first flatus - Time in hospital - Early complications - Death after surgery Distant results - Late complications - Rate of metastasis, recurrence - Overall survival rate - Disease-free survival rate 10 3.2.3 Duodenal resection and closure technique All used Endo GIA 45 mm, 3.5 mm to cut and close the duodenal process; there are no use cases of 02 Endo GIA There were 107 (99.1%) cases without duodenal enhancement stitch, 01 (0.9%) cases required duodenal enhancement stitch There were 03 (2.8%) cases of duodenal bleeding, of which: 02 (1.9%) cases of bleeding from the duodenum, 01 (0.9%) cases of bleeding from the upper border of the duodenum 3.2.4 Technique to restore gastrointestinal circulation A total of 403 Endo GIAs were used to perform anastomosis and gastrectomy, of which: 387 Endo GIA 60 mm, 3.5 mm and 15 Endo GIA 45 mm, 3.5 mm (3 rows of staples) Restoration of gastrointestinal circulation: 105 (97.2%) cases of anastomosis of the jejunum with the great curvature of the stomach and 107 (97.2%) of cases of anterior gastrojejunostomy, resection posterior gastric Anastomosis, apex closure of anastomosis: there were 02 (1.9%) cases of bleeding at the gastro-jejunal junction; 07 (6.5%) cases of apical bleeding close the opening to perform anastomosis Number of staplers used: mainly Endo GIA accounts for 67.6% 3.2.5 Technique for taking samples, checking the anastomosis Taking samples: mainly, expanding the umbilical trocar hole by cm to take samples, accounting for 75.5% Checking the anastomosis: there are 28 (25.9%) cases of gas inflating the gastric to check the gastro-jejunostomy 3.3 Result of surgery 3.3.1 Intraoperative results * Conversion to open surgery: there were no cases of conversion to open surgery, no complications in surgery * Intraoperative results -Average surgery time is: 167.64 ± 42.99 minutes (80 - 315 minutes) - Average amount of blood loss: 20.69 ± 10.36 ml (10-50 ml) - Average number of lymph nodes removed: 27.15 ± 10.39 (7-61) lymph nodes - The average number of metastatic lymph nodes is: 2.05 ± 3.76 (0 - 21) nodes * Sectional distance - The distance of the upper section, the average is: 8.60 ± 3.03 cm The shortest near-cutting distance is 3.5 cm; the longest is 14 cm - The distance of the lower section, the average is: 4.16 ± 1.55 cm The shortest far-cutting distance is 2.3 cm; the longest is 9.5 cm 3.3.2 Proximal results * Time to first flatus: time first flatus the mean after surgery is: 3.38 ± 1.25 days; day at the earliest, days at the latest 11 * Length of hospital stay: the average hospital stay after surgery was: 8.68 ± 4.12 days The shortest hospital stay was days, the longest 44 days * Early complications: (5.6%) postoperative complications, of which: 02 (1.9%) cases of gastrointestinal fistula, 01 (0.9%) cases of edema causing narrowing of the anastomosis, 03 (2.8%) cases of semi-obstruction All cases are complications grade I, II; stable medical treatment, no need for surgery There were no cases of duodenal fistula, intra-abdominal bleeding, anastomosis bleeding, fluid collection, intra-abdominal abscess, pancreatic fistula, surgical site infection * Early results: good 102 (94.4%) cases; an average of (5.6%) cases, none of which had a poor outcome * Mortality after surgery: there were no deaths after surgery 3.3.3 Distant results * Late complications: late complications 04 (3.7%) cases, of which: 02 (2.8%) cases of intestinal obstruction due to internal hernia; 01 (0.9%) case of intestinal obstruction due to food residue; 01 (0.9%) case of gastro-colic fistula (02 cases of internal hernia and 01 case of gastro-colic fistula requiring reoperation, stable patient discharged from hospital; 01 case of semi-obstruction of bowel due to food residues medical treatment, stable hospital discharge without surgery) * Metastasis, recurrence: follow-up up to March 30, 2021, the mean follow-up time was 14.84 ± 6.1 months, the longest follow-up time was 26.3 months and the shortest time was 2, months Monitored 108 (100%) cases, assessed 84 (77.8%) cases There were 24 cases that could not be assessed, of which: 06 cases of patients died during the covid epidemic, so they could not be evaluated; 18 cases of patient contact by phone were still alive, but at the end of the study, the patient could not be re-examined due to the covid epidemic, so the recurrence of metastasis could not be assessed Up to the end of the study, there were 12 (14.3%) cases of metastasis and recurrence, of which: metastasis 10 (11.9%) cases, recurrence (2.4%) cases * Survival time: follow-up up to March 30, 2021, there were 15 (13.9%) deaths, of which: 07 (6.5%) deaths due to metastasis and recurrence; 02 (1.9%) deaths were not due to metastasis or recurrence; 06 (5.6%) cases where the exact cause of death could not be determined (because the patient died during the covid epidemic, so it could not be determined) Overall survival, median 11.47 months The disease-free survival time, on average, was 10.5 months * Extra survival rate Overall survival rate: the probability of overall survival after surgery months, 12 months and 24 months, respectively: 98.8%; 95.2%; 89.3% Disease-free survival: the probability of disease-free survival after surgery months, 12 months and 24 months, respectively: 95.2%; 89.3%; 83.3% The overall survival rate of stages I, II, III after surgery months, 12 months and 24 months of stage I are: 97.4%; 97.4%; 97.4%; Phase II is: 100%; 100%; 100%; Phase III is: 100%; 87.5%; 66.7% The disease-free survival rate of stages I, II, III after surgery months, 12 months, 24 months of stage I are: 97.4%; 97.4%; 94.7%; Phase II: 100%; 100%; 95.5%; Phase III is: 87.5%; 66.7%; 54.2% 12 Chapter 4: DISCUSSION 4.1 Common characteristics 4.1.1 Gender, age, BMI Male/Female ratio: 2.37 (76/32) The mean age in the study was: 59.49 ± 12.10 years old The youngest diseased age was 26, the oldest diseased age was 86 Consistent with domestic authors Average BMI in the study: 20.95 ± 2.31 kg/m2 4.1.2 Reason for admission, medical history * Reason for admission: patients admitted to the hospital due to abdominal pain in the epigastrium accounted for 86.1% This is also the main reason why gastric cancer patients go to the doctor reported in Vietnam (66.7% - 100%) The most common symptom associated with abdominal pain was weight loss in 44 (40.7%) cases Weight loss is a common comorbidity in gastric cancer reported in Vietnam (27.8% - 68.9%) * Medical history: in the study, 26 (20.1%) cases had a history of gastrointestinal disease, consistent with domestic studies, the rate of gastric cancer with a history of peptic ulcer treatment (14.9%-62.3%) In the study, 21 (19.5%) cases had medical comorbidities According to studies in Vietnam, gastric cancer patients have medical comorbidities (10.8%-17.05) This shows that there is no contraindication to laparoscopic gastrectomy for gastric cancer cases with concomitant medical disease Contraindications are only relative and indications for surgery depend on the specific condition of each patient 4.1.3 Characteristics of lesions * Tumor location In the study, the most common cancer site was the small curvature, accounting for 42.6%; antral cancer: 29.6%; prepyloric cancer: 21.3%; pyloric cancer: 3.7% and great curve cancer: 2.8% In Vietnam, studies show that the common tumor location in cancer of the distal stomach is the small curvature, accounting for over 35% * Tumor gross lesion In the study, the most common form of gross lesion was invasive ulcer in 71 (65.7%) cases; non-invasive ulceration 35 (32.4%) cases; protruding (1.9%) cases; There were no cases of hard infiltrates According to studies in Vietnam, the gross damage of gastric cancer is mainly invasive ulcer (over 40%) * Tumor microscopic lesion There were 98 (90.7%) cases of ductal adenocarcinoma; 07 (6.5%) cases of ring cell carcinoma; 03 (2.8%) cases of mucinous cell carcinoma Studies in Vietnam show that the rate of ductal adenocarcinoma (44.2% 92.6%); ring cell cancer; mucinous cell carcinoma (3.7% - 14.1%) and papillary cancer (1.35% - 9.5%) In the study, there were 62 (63.3%) cases of lowdifferentiated adenocarcinoma; 33 (33.7%) cases of moderately differentiated adenocarcinoma and (3.1%) of highly differentiated adenocarcinomas In Vietnam: 13 low-differentiated carcinoma accounts for (37.0 - 52.0%); moderately differentiated (26.4%-41.3%); highly differentiated (3.6% -24.5%) Thus, the differentiation of ductal carcinoma in the study is the same as in Vietnam, Japan and Korea, most of the ductal carcinoma has low differentiation Moderately differentiated, highly differentiated accounts for a low percentage * Tumor size The average size of the tumor was 2.82 ± 1.50 cm; the largest size is 8.0 cm; 0.7 cm minimum The mean size of the tumor in the horizontal dimension was 3.17 ± 1.69 cm; the longest size is 11.5 cm; The shortest is 0.8 cm According to studies in Vietnam, the average size of tumors ranges (4.2 ± 1.65 to 5.38 ± 1.88) cm According to studies in Japan and Korea, the mean size of tumors ranges (2.2 ± 1.3 to 3.1 ± 2.2) cm In China, the mean tumor size (3.07 ± 1.68 to 5.38 ± 0.66) cm The average size of tumors in the studies was not the same due to the different disease stage and study subjects * Tumor invasion Tumor invasive T1 level accounted for 35.3% (T1a: 16.7%; T1b: 18.5%); T2 accounts for 17.6%; T3 accounts for 22.2%; T4a accounted for 25.0% According to studies in Vietnam, invasive tumors of T1 level account for the proportion (3.6% 31.3%); T4 invasion accounts for the rate (12.0% - 65.2%) According to studies in Japan and Korea, invasive tumors of T1 level account for the proportion (46.7% - 80.4%); T4 accounts for the proportion (4.5% - 4.8%) The above results show that, although the rate of T1-level invasive tumors in the study is higher than those reported in Vietnam, it is still low compared to Japan and Korea * Degree of lymph node metastasis In the study, 66 (61.1%) cases had no lymph node metastasis (N0); 14 (13.0%) cases of N1 lymph node metastasis; 16 (14.8%) cases of N2 lymph node metastasis; 11 (10.2%) cases of N3a metastases and (0.9%) cases of N3b metastases According to studies in Vietnam, gastric cancer without lymph node metastasis (N0) accounts for the rate (27.0% - 70.7%); N3 lymph node metastasis accounts for (1.9% - 8.0%) According to studies in Japan and Korea, gastric cancer without lymph node metastasis (N0) accounts for the rate (48.6% - 85.5%); N3 lymph node metastasis accounts for the rate (1.8% - 13.1%) According to studies in China, gastric cancer without lymph node metastasis (N0) accounts for the rate (48.0% - 50.8%); N3a lymph node metastasis (22.4% - 26.7%) Thus, the rate of gastric cancer without lymph node metastasis in the study was not lower than that of Japan, Korea and China But the number of gastric cancer patients with lymph node metastasis in the study was still quite high, accounting for 38.9% * Disease stage In the study, stage I cancer accounted for 46.3% (IA: 33.3%; IB: 13.0%) According to studies in Vietnam, stage I gastric cancer accounts for the rate (6.1% - 14 25.2%) According to studies in Japan, stage I gastric cancer accounts for the rate (50.4% - 79.7%) In Korea, stage I gastric cancer accounts for the rate (12.3% - 89.5%) The rate of gastric cancer stage IIIC in the study was very low, accounting for 0.9%, lower than the results reported in Vietnam (5.1% - 15.2%) Thus, the rate of gastric cancer stage I in the study, although higher than those reported in Vietnam, is still lower than that of Japan, Korea and China 4.2 Characteristic technique 4.2.1 Gastric release and lymphadenectomy In the study, mainly (90.7%) entered the omentum omentum through the thinnest position of the great omentum It was found that entering the omentum first and then releasing the great omentum was more convenient and easier than releasing it directly from the superior border of the transverse colon To stop bleeding and cut the artery, the left gastric omentum, mainly ligasure (83.3%) During the implementation process, it was found that using a ligsure or an ultrasound were convenient, safe, and had good hemostasis results We used the ligasure more because we found that the ligasure stopped bleeding quickly and the hemostatic area was larger When dissecting group lymph nodes, there were 82 (75.9%) cases using ligaure, 10 (9.3%) cases using ultrasound and 16 (14.8%) cases using a combination ligasure and ultrasound for lymph node dissection When performed, it was found that in the case of group lymph nodes, which are numerous, large, firm, and adherent, it is very difficult to determine the dissection boundaries Using an ultrasound to create an entrance will be more convenient ligasure due to the small ultrasonic tip and blade easier to reach the site to be dissected Hemostasis of the right gastric artery and vein omentum: mainly using Hemolock clamps (83.3%) to prevent hemostasis Only Hemolock clamps were used to clamp the proximal end of these two vessels while the distal end was stopped with a ligasure or an ultrasound There were 9.3% hemostasis of the right gastric artery and vein omentum by ligasure and 7.4% by ultrasound without using Hemolock During the implementation process, it was found that the hemostasis of the right gastric artery and vein omentum by ligasure or the ultrasound were good and safe for hemostasis However, we only perform this procedure when the size of these two vessels is < 5mm, although according to the manufacturer's recommendations, it is possible to stop bleeding for blood vessels up to 7mm in size Hemostasis of the right gastric artery and vein: when performed, these two vessels are found to be small, so stop bleeding completely with an ultrasound knife or a ligasure knife, without using a Hemolock clamp, the use of ligasure knife or ultrasound knife is safe When performing group 12 lymphadenectomy, it was found that using the ultrasound knife was more convenient and easier than the ligasure knife in opening the peritoneum anterior to the liver pedicle, so most of us used the ultrasound knife (79.7%) and less using ligasure knife (20.4%) 15 In order to remove the group 8p lymph nodes more conveniently, we actively did not remove the right gastric artery and vein immediately after removing the group lymph nodes, but left it until the group lymph node was removed When dissecting group 8p lymph nodes, leaving these two blood vessels allows the entire group 8a lymph node to be up like a hammock One end is suspended by the right gastric artery and vein, the other end by the left gastric artery and vein Just slightly lifting the group 8a lymph node up and to the left, and at the same time gently pressing the common hepatic artery downward will reveal the group 8p lymph node When performed, it was found that using an ultrasound for dissecting group lymph nodes is more convenient than a ligasure because the tip and small ultrasound blade are easier to access the lymph nodes, especially with large, firm, inflamed lymph nodes Therefore, in our study, we mainly used ultrasound (83.3%) to dissect group lymph nodes and most (70.4%) performed right gastric artery and gastric vein removal after group lymph node dissection When dissecting the lymph nodes in group 7, group and group 11p, we found that using ligasure knife or ultrasound knife to dissect, so entering this area is often convenient and not difficult The lymph nodes in this area can often be seen quite clearly, the organization around the lymph nodes is also quite loose, so removing them is quite easy When performing hemostasis of the left gastric artery and vein, it was found that these two blood vessels are often large in diameter, so hemostasis is mainly done with Hemolock clamp (78.7%), hemostasis by ligasure is less often performed 9.3%) We only use the ligasure to stop bleeding when these two vessels are not close together and the diameter is < mm During surgery, there were 85 (78.7%) cases of hemostasis of left gastric artery and vein with Hemolock forceps because these two vessels did not go close together, only 23 (21.3%) cases of coronary artery and gastric vein The left side are close together, so the hemostasis is clamped with Hemolock forceps In all the cases in the study, using only the proximal Hemolock clamp of the right gastric artery and vein, hemostasis and distal resection with ligasure knife or ultrasound knife, this can save 02 distal hemostasis clips, reduce the cost of surgery When dissecting group and group lymph nodes, there were 26 (24.1%) cases where we approached to release the small omentum from the front of the stomach, 15 (13.9%) cases approached from the back and 67 (62.0%) of cases approached from the front and back of the gasstric When performed, the small omentum release, group and lymph node dissection using ligasure or ultrasound is very convenient The use of ultrasound or ligasure depends on the surgeon and the specific injury status of each patient To release the small omentum, we found that the combined approach from the anterior and posterior sides of the gastric is more convenient and safer In the study, the average time of gastric release and lymphadenectomy: 83.04 ± 19.26 minutes, the longest was 151 minutes and the fastest was 51 minutes We found that this is the most time consuming step of the surgery 4.2.2 Duodenal resection and closure technique 16 In the study, there were 107 (99.1%) cases that did not need additional suture of the duodenal closure margin, only 01 (0.9%) cases required additional suture of the duodenal closure margin, due to damage to the sphincteric muscle duodenum occurs during duodenal clearance There were 03 (2.8%) cases of duodenal closure bleeding, of which: 02 bleeding from the duodenal closure margin, 01 bleeding from the superior duodenal artery All cases of bleeding were treated by electrocautery, no need for hemostasis When performing, we found that the cut and closure of the duodenum using Endo GIA 45 mm is very convenient, the cut edge of the duodenum is closed, there are no cases of difficulties and complications It should be noted that before performing duodenal closure, the superior duodenal vascular branch should be released wide enough to avoid bleeding from this branch after resection 4.2.3 Technique to restore gastrointestinal circulation In the study, there were 105 (97.2%) cases connecting the free border of the jejunum to the great curvature of the stomach; 02 (1.9%) cases were connected to the front of the stomach and 01 (0.9%) of the cases were connected to the back of the stomach When implementing, we found that all ways of connecting above are convenient and easy to implement We performed the technique of anastomosis of the free margin of the jejunum with the greater curvature because it was more favorable to close the anastomosis There were 03 cases where we performed gastric bypass first because these 03 patients had pyloric stenosis To perform the connection, in the study, most of the 05 Endo GIA were used, accounting for 67.6% The number of Endo GIA used the most for patient in the group performing posterior gastrectomy was 05 Endo GIA; while all cases performed anterior gastrectomy, each patient used Endo GIA Thus, anterior gastrojejunostomy and posterior gastrectomy can save 01 Endo GIA, which can reduce the cost of surgery, so in our study, most (97.2%) performed anterior gastro-jejunal junction However, a larger study is still needed for this to be convincing When performing, we found that, in cases where the lesions are not visible, it is difficult to determine the safe distance of the upper section, the anterior gastrojejunostomy and posterior gastrectomy are limited Especially when checking the distance of the upper section is not guaranteed or biopsiing immediately on the upper section and the tumor will take a lot of time and effort to overcome Therefore, in the study, only when determining the exact location of the lesion, we performed an anastomosis The average time of anastomosis in the study was 16.68 ± 5.13 minutes According to studies in China and Korea, the average time to perform anastomosis (10.8 ± 3.9 to 46.7 ± 13.2) minutes The time to create anastomosis in the study was not too long and took up too much of the surgery time, not longer than reported in Korea and China 4.2.4 Technique for taking samples, checking the anastomosis Mainly, we took samples by expanding the umbilical trocar hole by cm, 17 accounting for 75.5% Checking the connection mouth by inflating gastric gas accounts for 25.9% Through the study, we found that, taking samples through the umbilical trocar hole is convenient, the incision is small and aesthetic The size of the enlargement is highly dependent on the tumor size and the surgeon The examination of the stomach by gastric inflation does not have much meaning, so in the next 80 (74.1%) cases we did not perform gastric bypass to check the anastomosis The average time of specimen collection, lavage and closure of the abdomen: 24.67 ± 4.64 minutes (6 -40 minutes) 4.3 Result of surgery 4.3.1 Intraoperative results * Surgery time The average surgery time was: 167.64 ± 42.99 minutes The shortest surgery time is 80 minutes, the longest is 315 minutes In Vietnam, the average surgery time (261.1 ± 58.3 to 209.43 ± 41.1) minutes Average surgical time when performing complete laparoscopic distal gastrectomy according to studies: In Korea, it ranges (197.3 ± 40.1 to 222.0 ± 60.2) minutes; In Japan, ranges (92.3 ± 4.0 to 298.0 ± 57.0) minutes The above results showed that the average surgery time in the study was not longer than that of Japan, Korea and China Shorter than reports in Vietnam * Blood loss The amount of blood loss during surgery is also a factor to evaluate the safety of laparoscopic distal gastrectomy The average blood loss in the study was: 20.69 ± 10.36 ml The least amount of blood loss is: 10 ml, the maximum is: 50 ml In Vietnam, there are very few reports on the results of totally laparoscopic distal gastrectomy The mean blood loss after totally laparoscopic distal gastrectomy in some studies: In Japan ranged (36.8 ± 21.2 to 96.0 ± 72.0) ml In Korea (91.4 ± 68.4 to 185.1 ± 127.3) ml Thus, compared with reports in Vietnam, Japan, Korea and China, the average blood loss in the study was less The blood loss in the study was less than the blood loss in the studies in Vietnam, Japan, Korea and China * Lymph nodes removed Currently, totally laparoscopic distal gastrectomy for gastric cancer treatment has been widely applied Besides the technical feasibility and positive clinical results, the quality of lymph node dissection is the most important factor when performing laparoscopic complete distal gastrectomy In the study, the average number of lymph nodes removed: 27.15 ± 10.39 nodes The number of removed nodes is at least nodes, the maximum number of removed nodes is 61 nodes According to studies in Vietnam, the average number of removed lymph nodes in laparoscopic-assisted distal gastrectomy ranged from 10.9 ± 2.2 to 35.0 ± 11.0) lymph nodes The least number of removed nodes (7 - 22) lymph nodes, the maximum number of removed nodes (22 - 46) nodes According to studies in Japan, the number of removed lymph nodes fluctuated (28.6 ± 13.0 to 53.0 ± 19.0) lymph nodes; In Korea, the lymph nodes ranged (32.6 ± 18 9.2 to 46.3 ± 17.9) Thus, compared with reports in Japan and Korea, the average number of lymph nodes removed in the study was less, but the difference was not much, the number of removed lymph nodes still met the requirements for lymph node dissection for cancer and is sufficient to stage the disease after surgery This shows that laparoscopic distal gastrectomy does not affect lymph node dissection and the number of removed lymph nodes * Sectional distance One of the problems posed in the complete laparoscopic distal gastrectomy is that when performing gastrectomy, the cutting area is guaranteed to be sufficient in principle for cancer treatment and the cutting area is safe in terms of method cancer or not In the study, the average distance of the proximal section was 6.59 ± 3.04 cm; the shortest near-cutting distance is 1.5 cm; The longest is 14 cm The average distance of the distal section is 3.12 ± 1.56 cm; The shortest distance of the distal section is 0.8 cm, the longest is 9.5 cm According to studies in Korea, the mean distance of the proximal section in totally laparoscopic distal gastrectomy ranges (4.3 ± 2.6 to 6.0 ± 3.4) cm; The average distance of the distal section ranged from 5.4 ± 2.6 to 6.1 ± 3.7 cm Biopsy results after surgery 100% of the proximal and distal sections are free of cancer cells This shows that tottaly laparoscopic distal gastrectomy has a guaranteed cutout distance and a safe and safe cut in terms of cancer 4.3.2 Proximal results * Time to first flatus Median time to first flatus to assess bowel function recovery after complete laparoscopic distal gastrectomy This is a factor in evaluating the effectiveness of surgery In the study, the mean time to first flatus after surgery was: 3.38 ± 1.25 days Mean transit time after totally laparoscopic distal gastrectomy, according to studies: In Korea, ranges (2.1 ± 0.8 to 3.6 ± 1.5) days Thus, compared with reports in Vietnam, Japan, and Korea, the mean transit time in the study was not slower This shows that tatolly laparoscopic distal gastrectomy completely does not delay the patient's postoperative transit time * Length of hospital stay Post-operative hospital stay to evaluate the effectiveness of full-thickness totally laparoscopic distal gastrectomy with the advantage of being less invasive, restoring early intestinal circulation, helping to reduce hospital stay In the study, the mean hospital stay after surgery was: 8.68 ± 4.12 days Average hospital stay after totally laparoscopic distal gastrectomy, according to the following studies: In Korea, ranges (6.9 ± 2.4 to 9.4 ± 5.0) days; In Japan, it ranges from (10.6 ± 2.6 to 13.3 ± 4.5) days Thus, the average length of hospital stay in the study was not longer than that of Japan and Korea This shows that, totally laparoscopic distal gastrectomy, not only does not prolong the treatment time, but also can reduce the postoperative treatment day 19 * Early complications Post-operative complications have always been considered as one of the important criteria to evaluate the effectiveness and safety of surgery in terms of technique In the study, there were 06 (5.6%) cases of early complications, of which: 04 (3.7%) cases of early intestinal obstruction, 02 (1.9%) cases of gastrointestinal fistula All cases of early complications were treated medically, without surgery There were no cases of duodenal fistula, intra-abdominal bleeding, anastomosis bleeding, fluid collection or intra-abdominal abscess, pancreatic fistula, surgical site infection The rate of complications after totally laparoscopic distal gastrectomy, according to the following studies: In Korea, ranges (7.3% - 17.9%); In Japan it fluctuates (5.4% - 15.3%) Thus, the early complication rate in the study was not higher than that reported in Japan and Korea This shows that totally laparoscopic distal gastrectomy is safe with an acceptable rate of postoperative complications Anastomosis fistula: the gastric is nourished by many blood vessels, so when surgery only needs to preserve one branch of the artery, it is enough to supply blood to the other part of the stomach Fistula anastomosis is usually caused by suture technique or by the patient's condition (anemia, poor nutrition, infection or the patient has many underlying diseases ) rather than nutritional anemia Just like open gastrectomy or laparoscopic-assisted gastrectomy, complications of anastomosis after totally laparoscopic distal gastrectomy are also a concern In the study, there were 02 (1.9%) cases of anastomosis fistula, both cases were treated medically, not surgically The incidence of anastomotic fistula complications after totally laparoscopic distal gastrectomy reported in different studies also varies widely In Japan, Korea and China, the rate of anastomosis fistula (0.7% - 2.7%) The above results show that the rate of anastomosis in the study is not higher than that reported in Vietnam, Japan, Korea and China This shows that totally laparoscopic distal gastrectomy can safely perform laparoscopic anastomosis with a low complication rate of postoperative anastomosis, less than 3% Early intestinal obstruction: Intestinal obstruction after totally laparoscopic distal gastrectomy is also common Intestinal obstruction is caused by many different causes According to some reports in Japan and Korea, the rate of early bowel obstruction after totally laparoscopic distal gastrectomy (0.7% - 6.0%) In the study, there were (3.7%) cases of early bowel obstruction after surgery Although the rate of early bowel obstruction is higher than some domestic and foreign reports, all cases are grade II complications (according to Dindo's complication classification), all of which are treated medical and does not require surgery 20 4.3.3 Distant results * Late complications Late complications are usually those related to gastrointestinal circulation In the study, there were 04 (3.7%) cases of late complications, of which: 02 (1.9%) cases of internal hernia; 01 (0.9%) case of gastro-colic fistula and 01 (1.9%) case of intestinal obstruction due to food residue * Metastasis Recurrence The rate of metastasis after laparoscopic gastrectomy evaluates the effectiveness of the surgical approach in terms of oncology In the study, as of March 30, 2021, the average follow-up time was 14.84 ± 6,12 months, the longest follow-up time is 26.3 months and the shortest is 2.5 months (the shortest follow-up case was because the patient died after 2.5 months of discharge) Monitored 108 (100%) cases, assessed 84 (77.8%) cases There were 10 (11.9%) cases of metastasis after surgery According to studies in Japan, Korea and China, the rate of metastasis after tottaly laparoscopic distal gastrectomy varies (5.6% - 18.6%) The results of studies show that laparoscopic distal gastrectomy is safe in terms of cancer with an acceptable rate of metastasis and recurrence after surgery * Recurrence The recurrence rate after laparoscopic gastrectomy is also one of the criteria to evaluate the effectiveness of the surgical method in terms of oncology Anastomosis recurrence after laparoscopic gastrectomy is often related to resection The cut area ensures safety when the biopsy results are no longer cancerous In the study, there were (2.4%) relapse cases In Vietnam, there are not many studies evaluating the distant outcome of laparoscopic gastrectomy In some published studies, the recurrence rate after surgery (2.3% - 9.2%) According to studies in Japan, Korea and China, the recurrence rate after laparoscopic distal gastrectomy varies (1.3% - 4.4%) Thus, the results of the above studies show that laparoscopic complete resection of the distal stomach is safe in terms of cancer with an acceptable postoperative recurrence rate In the study, although 100% of the proximal and distal sections, both biopsies showed no cancerous tissue, but there were still some cases of recurrence of the anastomosis, which poses a problem to consider again the technique of taking the section for biopsy In our opinion, there should be a specific procedure to unify the intra- and post-operative biopsies between the surgeon and the pathologist In our opinion, it is best to immediately biopsy the surgical cut area in combination with a biopsy to check the postoperative area * Extra survival rate There were 15 (13.9%) deaths during follow-up Examination assessed 84 cases, of which: 07 (8.3%) cases of death due to disease (metastasis, recurrence); 02 (2.4%) non-disease deaths (stroke) Overall survival rate Overall survival rate after surgery months, 12 months, 24 months, 21 respectively: 98.8%; 95.2%; 89.3% According to studies in Vietnam, the overall survival rate after laparoscopic gastrectomy is year (94.4% - 100%), years (72.8% - 88.9%) Thus, the overall survival rate after surgery year years in the study is equivalent to that reported in Vietnam Disease-free survival The disease-free survival rate after surgery months, 12 months, 24 months, respectively: 95.2%; 89.3%; 83.3% In Vietnam, According to Vo Duy Long (2017), the 1-year, 2-year, 3-year disease-free survival rates are: 93.4%; 82.4% According to Phan Canh Duy, the 1year and 2-year disease-free survival rates are: 85.5%, respectively; 66.7% Thus, compared with studies in Vietnam, the probability of disease-free survival after surgery year, years in the study is not lower Survival rate by stage of disease The overall survival rate after surgery year, years: Stage I is: 97.4%; 97.4% Phase II is: 100%; 100% Phase III is: 87.5%; 66.7% The disease-free survival rate after surgery year, years, stage I, respectively: 97.4%; 94.7% Phase II is: 100%; 95.5% Phase III is: 66.7%; 54.2% In Vietnam, according to Vo Duy Long (2017), laparoscopic gastrectomy for 112 cases of gastric cancer, the overall survival rate after surgery year, years stage II is: 94.4, respectively: 94.4 %; 90.9% Stage III: 65.2%; 59.5% Survival rate of year, years, disease-free stage II: 92.1%; 87.9%; stage III: 56.5%; 48.6% 22 CONCLUSION - The thesis is the first study on the technical characteristics and results of totally laparoscopic distal gastrectomy for gastric cancer treatment at 108 Military Central Hospital - The results of the study on 108 patients undergoing totally laparoscopic distal gastrectomy showed that: Characteristic technique The surgery consists of steps, entering the abdomen through trocars Group 12a and lymph nodes were removed mainly by ultrasound (79.6 - 83.3%) Lymph nodes in the remaining groups were mainly removed by ligasure (51.5% - 90.7%) The group of lymph nodes that are often difficult to remove is group (29.6%), group (25.9%) and group (42.6%) Hemostasis of the left gastric artery and omental vein by ligasure accounted for 83.3%; Right gastric artery and vein by ultrasound accounted for 79.6% Using Hemolock forceps to stop the bleeding of the artery, the right gastric omental vein accounted for 83.3% and the left gastric artery and vein accounted for 90.7% Enter the posterior omentum first, then cut the greater omentum accounting for 90.7% Release of the small omentum, approaching from the front and back of the gastric accounted for 62.0% Cutting the right gastric artery and vein after lymph node dissection in group accounts for 70.4% The left gastric artery and vein were clamped to stop bleeding and cut together, accounting for 21.3% Additional suture of the duodenum 01 (0.9%) cases; bleeding at the duodenal apex in 03 (2.8%) cases (02 from the duodenal apex, 01 from the superior border of the duodenum) Performing anastomosis of the jejunal free margin with the great curvature of the stomach first, then gastrectomy accounted for 97.2% Bleeding from the mouth connecting 02 (1.9%) cases; bleeding at the anastomotic margin in 07 (6.5%) cases (04 bleeding in jejunostomy, 02 bleeding in serial margin; 01 bleeding in gastrectomy) Collect specimens by opening the umbilical trocar hole by cm, accounting for 75.5% Checking the anastomosis by inflating through the gastric tube accounted for 25.9% Result of surgery There were no cases that had to be converted to open surgery, no complications, and no deaths during surgery Average surgery time: 167.64 ± 42.99 minutes (80 - 23 315 minutes) Average blood loss: 20.69 ± 10.36 ml (10 - 50ml) The average number of lymph nodes removed: 27.15 ± 10.39 nodes (7 - 61 nodes) The average distance of the upper section is: 8.60 ± 3.03 cm (3.5 - 14 cm), the mean distance of the lower section is: 4.62 ± 1.55 cm (2.3 - 9.5 cm) Good surgical results 94.4%; average 5.6%, no poor results Average time Time to first flatus: 3.38 ± 1.25 days (1 - days) Mean hospital stay: 8.68 ± 4.12 days (5 - 44 days) Complication rate: 5.6% (semi-obstruction: 3.7%; gastrointestinal fistula: 1.9%; anastomosis edema: 0.9% Postoperative metastasis rate: 11.9%; recurrence rate: 2.4%; death rate due to metastasis, recurrence: 8.3% Rate of late complications: 3.7% (internal hernia: 1.9%; gastro-colic fistula: 0.9%; intestinal obstruction due to food residue: 0.9%) Overall survival after surgery, average 11.47 months Disease-free survival time after surgery, average 10.5 months Overall survival and disease-free survival at 12 months; 24 months respectively: 98.8%; 95.2%; 89.3% and 95.2%; 89.3%; 83.3% - The results of this study are the new contributions of the thesis, which was published for the first time on the specifications and results of totally laparoscopic distal gastrectomy for gastric cancer treatment at the Central Hospital Army 108 The results show that totally laparoscopic distal gastrectomy for gastric cancer treatment is safe and effective 24 REQUEST Through the study of totally laparoscopic lower gastrectomy for 108 gastric cancer cases, we have the following recommendations: This surgery can be applied in facilities with full laparoscopic equipment and experienced surgeons in laparoscopic-assisted gastrectomy More studies comparing laparoscopic-assisted distal gastrectomy are needed to evaluate the effectiveness of this technique more clearly and convincingly