θ���ܰͽ�ת�Ƽ�����������¸���

胃癌是我国常见的恶性肿瘤，根治术后仍有部分复发和死亡病例，淋巴结转移是主要的原因之一，是影响胃癌病人预后的重要因素。胃癌现代外科治疗的进步，提高了手术切除率、根治切除率及5年生存率，降低了手术死亡率及术后并发症发生率。胃癌现代外科治疗从一般的胃大部切除术进入以清除淋巴结为目的的根治术；从解剖学为基础     

����θ����ƺϲ�֢������

晚期胃癌往往已有广泛转移 ,且多有合并幽门梗阻、癌灶穿孔、出血、腹水等状况 ,临床上已失去手术根治之机会。此类病人约占胃癌总数的 10 %～ 15 %。随着现代诊疗技术的提高 ,人们已逐渐认识到 ,对晚期胃癌的治疗亦应采用积极治疗的新观念来代替消极等待的旧意识。从外科综合治疗角度来看 ,主要内容包括 :(1)决不轻易放弃对晚期病人的手术治疗机会。目前 ,大力推荐的肿瘤去负荷手术(ｃｙｔｏｒｅｄｕｃｔｉｖｅｓｕｒｇｅｒｙ) ,强调若能积极切除原发肿瘤 ,即可明显地减少一些晚期肿瘤的相关并发症 ,亦为施行其它综合治疗创造条件。 (2 )对…     

����θ���Ļ�ѧ����

晚期胃癌是指确诊时已处于Ⅳ期者 ,非根治术后以及根治术后复发转移者 ,化学治疗成为主导姑息疗法。晚期胃癌化疗近 10年有显著进步与发展 ,化学治疗水平的提高直接影响胃癌的总体疗效。有效的晚期胃癌化疗方案可用于术前、术后及区域化疗 ,提高胃癌治疗水平。　　近 10年晚期胃癌全身化疗进步表现在近期客观有效率提高 ,单药治疗 >2 0 % ,两药 >30 % ,三联方案 >40 % ,见表 1。表 1　晚期胃癌化学治疗报告者 (年代 )药物、方案ｎＲＲ( % )Ｋｉｍ( 1995 ) 5 -ＦＵ 10 82 5 ( 2 3.0 )Ｔａｇｕｃｈｉ( 1999) Ｓ -112 96 0 ( 4 6 .0 )Ｐｒｅｕ…     

θ�����ڵı�Ǩ——ת��ҽѧ����Ҫ�ɹ�

胃癌分期经过半个世纪不断地改进、充实,使其为更精确的判定预后和选择治疗方案提供了科学依据。胃癌分期是胃癌外科进步和国际标准化、规范化治疗的极为重要的平台和基础。胃癌分期的产生、演变是在长期的临床实践、科学研究的基础上形成,特别是转化医学性质的基础和临床研究贯穿于其形成和发展的每个重要时期,尤其是胃癌预后因子T、N的确立,淋巴结转移程度分类基准评价体系的确立,以转移淋巴结个数评价系统为基础的第5版TNM分期的确立,以及2010年日本胃癌规约分期系统与UICC/AJCCTNM分期系统的统一产生的第7版TNM分期体系,无不显示出转化医学理念和转化研究成果的价值与作用。胃癌分期的演变过程是将最新研究成果快速转化为临床医学技术,解决临床问题的转化医学理念的具体体现和实践。     

��չ��θ���������󸴷�30���ٴ�����

目的　总结胃癌术后复发的临床特点并探讨复发癌切除术的临床意义。方法　回顾性分析 1994年 8月至 2 0 0 1年 5月共收治的 30例胃癌术后复发病人的临床资料 ,将其分成切除组 (7例 )和非切除组 (2 3例 ) ,比较两组的临床特点和预后。结果　首次术后平均随访 2 1个月 (3～ 4 7 5个月 ) ,平均复发时间为 11 5个月 (1 3～4 5 0个月 )。切除组复发后平均存活期为 13 4个月 ,非切除组为 4 7个月 ,两组差别明显。复发癌切除对复发后生存超过 10个月有统计学意义 (P <0 0 5 )。结论　进展期胃癌根治术后局部复发癌切除可延长病人生存期。     

胃、十二指肠

30岁以下胃癌病人45例外科治疗体会；胃底贲门癌急性穿孔的诊治体会；胃癌组织中环氧合酶2、Ki-67、微血管密度及临床病理因素对胃癌复发的影响；胃肠道间质瘤的临床诊断与治疗；连续性空肠间置在胃次全切除术消化道重建中的应用研究；淋巴结转移阴性的胃癌患者临床病理特征及生存分析；前哨淋巴结活检技术在胃癌外科中的应用     

θ�����󸴷�������������

胃癌仍然是我国病死率最高的恶性肿瘤之一 ,早期胃癌约有 5 %而进展期胃癌约有 5 0 %在 5年内死亡。导致死亡的最终原因往往是肿瘤复发。因此 ,对胃癌术后复发病例的积极治疗显得尤为重要[1] 。胃癌术后的复发率高 ,根治手术后有 30 %～ 80 %局部或远处复发。复发可分为早期 (2年内 )、中期 (2～ 5年 )与晚期 (5年以上 ) [2 ] 。早期复发 ,生物学行为较恶 ,切除率低 ,预后差 ;晚期复发 ,生物学行为较好 ,切除率高 ,预后也较好。据报道 10年以上的复发组 ,根治切除率可达 6 5 2 % ,而 2年以下复发者 ,切除率仅 2 9 7% [3 ] 。一般认为腹膜转…     

��ǰ�����Ը������ƶԸ���θ��������Ч���ٴ�����

进一步提高胃癌疗效的关键性问题中必然涉及到如何有效地克服肿瘤的转移与复发。据文献统计,进展期胃癌即使施行了根治性切除术,其术后复发率仍高达40%～65%。尽管如此,目前仍应将外科手术列为胃癌的首选治疗方法。随着各种新的辅助性治疗理论和技术的完善,有望弥补单纯手术治疗的不足,特别是针对肿瘤的转移和术后复发问题。综合治疗的观念已从传统之注重手术与术后治疗逐渐演变成首先开展术前治疗,旨在提高手术的切除率与根治率,为降低术后复发率创造有利条件,使之形成了围手术期辅助治疗与外科手术有机整合的新方案。其中,术前区域性辅助…     

��θ��28���ٴ�����

目的 分析和总结残胃癌的外科诊断和治疗情况。方法 回顾分析了28例残胃癌发病率、临床表现及治疗情况。结果 首次胃切除以胃溃疡为主，占64.3%。首次手术B-Ⅱ式22例，占84.6%。确诊残胃癌距首次手术时间平均为28.3年。残胃癌发生在吻合口占50%，残胃小弯侧42.9%，贲门部7.1%。结论 胃良性病行手术治疗时以B-I式为首选；定期胃镜检查残胃癌高危人群，早期诊断、早期治疗是提高残胃癌预后的关键。     

θ��Ѫ��θ���غ������ߵ�ԭ�����

目的 研究胃癌病人血清胃泌素（Gs）含量升高的原因。方法 应用放免法测定胃癌病人血清Cs含量,并分析其与胃癌发生部位、临床病理分期、预后的关系以及手术前后血清Gs的变化。结果 胃口地底贲门癌病人血清Gs值明显升高,而胃窦癌、胃体癌血清Gs值与正常对照组接近;随着胃癌临床病理分期的进展,血清Gs含量逐渐升高;胃癌术后2周血清Gs含量虽明显下降,但术后3个月恢复到与术前水平相当;对41例不能手术切除的胃癌病人进行随访,发现生存期超过1年者血清Gs含量与生存期未超过1年者接近。结论 胃癌病人血清Gs升高是一种继发性改变,不能作为一种肿瘤标志物,也不能作为一个预后因素。     

Early gastric cancer

Eighteen cases of 'early gastric cancer' have been managed over a 14-year period. This represents only 3.5% of all patients diagnosed as having adenocarcinoma of the stomach. The symptoms of early gastric cancer are similar to those of benign peptic ulcer disease and differ from those of invasive disease. The pathology of the lesions is described and the morphology shown to be similar to that seen in Japan. The overall 5-year survival rate is 82% but no patient has developed recurrence within 5 years of surgery, confirming the biological behaviour of the lesion to be identical to that noted by Japanese researchers.     

Early gastric cancer

Thirty patients with early gastric cancer were studied as part of a consecutive series of 308 gastric cancers, giving a proportion of 9.7%. Twenty-eight of the early gastric cancer patients were symptomatic, pain being the most common symptom. Endoscopy proved more effective than barium studies as a first investigation but the diagnosis rate at first examination was still only 69%. Seven patients with early gastric cancer had lymph node spread at the time of presentation. Five patients eventually died of cancer metastases. There was a high incidence of benign peptic ulceration (50%) and this with lymph node metastasis was an unfavourable prognostic feature. Only four of the 26 patients submitted to standard surgical resections died of cancer. This study supports the concept that early gastric cancer does indeed occur in Western man and the five year survival rate (65%) is much higher than for late gastric cancer (13%). The high incidence of metastasis at the time of presentation may account for the difference between our survival rate for early gastric cancer, and that reported from Japan.     

Early gastric cancer

From 1975 to 1985, 142 patients with early gastric cancer were operated on in our service; this group comprised 14 per cent of all patients with gastric cancer operated on during this period. Epigastric pain was the most frequent symptom (75.3 per cent). The lesions were located in the lower third in 45.8 per cent, in the middle third in 31.7 per cent, in the upper third in 20.4 per cent and in the gastric stump in 2.1 per cent. Subtotal gastrectomy was performed in 116 patients and operative mortality was limited to two patients. Macroscopically 86.6 per cent of cases were included in type III, IIc and IIc-III. The five year survival rate, excluding the operative mortality, was 93.1 per cent. Tumours located in the lower third of the stomach, limited to the mucosa and of ulcerating type, had the best prognosis.     

Early gastric cancer

Thirty-six patients with early gastric cancer were studied. In 15 patients, malignancy was restricted to the mucosa; in 21 patients, submucosal invasion was noted. Lymph node involvement was found in four patients. Kaplan-Meier estimates for 5-year survival were 92 percent for mucosal lesions and 65 percent for submucosal lesions (overall 5-year survival rate 73 percent). Mucosal lesions were significantly larger than were submucosal lesions (3.7 +/- 0.6 cm versus 2.5 +/- 0.4 cm, mean +/- SE; p less than 0.005). Associated malignancy was recorded in 13 of 36 patients. When compared with data from a large Japanese study, early gastric cancer in the United States tends to develop more distally in the stomach and in patients approximately one decade older. Survival was not as favorable as in Japan. This may be related to patient age and the high incidence of associated nongastric malignancy.     

Proximal gastric exclusion for unresectable gastric cancer

Background: Patients with unresectable distal gastric cancer causing obstruction have classically undergone palliative gastrojejunostomy, but high mortality rates and delayed return of gastric emptying have been reported. The aim of the present study was to compare gastrojejunostomy and proximal gastric exclusion in patients with unresectable distal gastric cancer. Methods: Until 1996, patients with unresectable obstructing distal gastric cancer underwent antecolic gastrojejunostomy, but since 1997 we have performed proximal gastric exclusion for these patients. Mortality, morbidity, time taken to resume oral fluids and normal diet, length of palliation and survival were compared. Results: There was no mortality in either the gastrojejunostomy group (n = 4) or the exclusion group (n = 6). A single patient in the gastrojejunostomy group developed a sacral sore and another patient had recurrent vomiting following gastrojejunostomy. Exclusion resulted in a quicker return to diet and a slightly longer survival, although these were not statistically significant. Conclusion: Proximal gastric exclusion offers a safe, quick and life‐enduring palliation for unresectable malignant gastric outlet obstruction.     

腹腔镜下残胃癌及残胃复发癌的外科治疗

目的探讨残胃癌及残胃复发癌腹腔镜手术治疗的可行性。方法对4例残胃癌和4例残胃复发癌病人行腹腔镜手术切除，分析手术的方式、方法、难点及技术要领。结果在腹腔镜下完成根治性全胃切除6例，行姑息性全胃切除1例，中转开腹1例。腹腔镜手术平均用时（310±50）min，术中平均出血量（190±80）ml，清扫淋巴结平均数量（17．5±6）枚。术后胃肠恢复时间平均（3．5±1．5）d，进食时间平均（3．5±1．5）d，下床活动时间平均（4±1．5）d。无手术并发症。随访时间4～13个月，发生肝脏转移死亡1例，余7例病人仍生存。结论残胃癌和残胃复发癌在腹腔镜行手术切除技术上是可行的，创伤比开腹手术小，恢复快。     

Early gastric cancer.

Early gastric cancer is a unique form of gastric carcinoma with an excellent prognosis. Now recognized worldwide, this tumor is most commonly diagnosed in Japan secondary to aggressive screening practices. Early detection is dependent on a low threshold for esophagogastroduodenoscopy with biopsies, because specific symptoms and physical findings or diagnostic laboratory tests are rarely present with early gastric cancer. Once the disease is diagnosed, subtotal gastrectomy achieves survival rates equivalent to those of age-matched controls. Consideration of total gastrectomy is warranted with proximal tumor location or multicentric carcinoma. Radical lymphadenectomy should be undertaken in patients with regional nodal metastasis. After operative resection, patient outcome is usually excellent. Large submucosal tumors with an aneuploid DNA pattern and nodal involvement denote a more ominous outlook. Close patient follow-up is necessary to detect both the uncommon recurrence and the more common nongastric malignancy.