217例早期胃癌扩大胃切除与淋巴结清除术的回顾分析

目的评价早期胃癌不同扩大手术的实际意义，以选择合理的胃切除和淋巴结清除范围。方法以临床病理资料完整、施行规范D2及扩大手术的217例早期胃癌患者为研究对象。分析施行不同扩大手术的原因、淋巴结清除的必要性及第Ⅱ站淋巴结转移与临床病理因素的相关性。结果胃上部癌行全胃切除术6例，No．5、6淋巴结均未见转移；联合脾、脾动脉切除2例，No．10、11p、11d淋巴结均未见转移；胃下部癌联合横结肠系膜切除3例，No．15淋巴结未见转移。以上病例术中多数误认为进展期胃癌而扩大了胃切除或淋巴结清除范围，手术时间长，术中失血较多。胃下部癌清除的第Ⅱ站淋巴结中No．11p、12a、14v均未见转移；黏膜下癌（sm癌）中，No．7、8a淋巴结转移率明显高于黏膜内癌（m癌）（P〈0．05）；淋巴管癌栓阳性者No．7淋巴结转移较阴性者明显增多（P〈0．001），No．1、13淋巴结转移仅出现在淋巴结转移高危病例（sm、癌灶大于3．0cm、凹陷型，淋巴管癌栓阳性）。结论早期胃癌不需施行淋巴结扩大清除术和联合脏器切除。早期胃上部癌不需施行全胃切除术。早期胃下部癌中No．11p、12a、14v淋巴结不需清除．但对胃下部癌淋巴结转移高危病例，应行标准D2淋巴结清除术。

Retrospective analysis of extended gastrectomy and lymphadenectomy in early gastric cancer patients

Objective To objectively evaluate the practical significance of different extended surgeries in early gastric cancer(EGC) patients,and to choose reasonable gastrectomies and lymphadenectomies. Methods A total of 217 EGC patients were investigated undergone normalized D2 or above extended surgery and their clinicopathological data were recorded in detail. The efficiency of the extended lymphadenectomies,complications and operation causes were analyzed,and the correlation between the group 2 lymph node metastasis (LNM) and clinicopathological factors were assessed,too. Results There was no nodal involvement in the No.5 and No.6 lymph nodes among the total gastrectomy in the upper third of the stomach,neither was in the No.10,11p and 11d lymph nodes among the combined splenectomy,and neither was in the No.15 lymph nodes among the combined transverse mesocolon resection in the lower third of the stomach. There was no distant nodal involvement in the EGC. Above all,most of them were mistaken for advanced gastric cancer preoperatively and intraoperatively,the operation time was longer and the blood loss was more during operation. Among the resected nodes of group 2 in the lower third of the stomach,metastasis was not found in the No.11p,12a and 14v lymph nodes. The rate of the No.7 and 8a nodal involvement in the submucosa cancer was higher than that in the mucosa cancer(P < 0.05) and so did the No.7 in the lymphatic penetration positive(P < 0.001). The No.1 and No.13 nodal involvement were only seen in the high risk cases,such as submucosa cancer,the lesion diameter more than 3.0 cm,depressed type and lymphatic involvement. Conclusion It is not necessary to execute total gastrectomy in the upper third of the stomach,combined organ resection (such as splenectomy,transverse mesocolon resection),and distant lymph node dissection in the EGC. In the lower third of the stomach,the No.11p 12a and 14v lymph nodes shouldn't be dissected. With respect to the high risk nodal involvement cases in the lower third of the stomach,the No.1 lymph nodes should be dissected and so does the No.13 lymph nodes if it's tumefied. It is the key point of reasonable operation to exactly diagnose the EGC before and during the surgery.