胃癌全胃切除术后化疗期间饮食护理

全胃切除术是治疗胃癌的一种手术方式,术后化疗可以控制可能存在的残存病灶,防止复发和转移,提高生存率.全胃切除术后的"无胃"状态,将会导致患者消化吸收功能与营养代谢紊乱[1].使用化疗药物患者常有食欲减退、恶心、呕吐、腹泻等胃肠道反应.     

口服营养补充剂对胃癌患者辅助化疗期间营养状况及化疗相关毒副反应耐受性的影响

目的:探讨服用口服营养补充剂对胃癌术后患者辅助化疗期间营养状况及化疗相关毒副反应耐受性的影响。方法:回顾性分析中国人民解放军北部战区总医院肿瘤科2017年1月-2017年12月收治的胃癌术后首次接受辅助化疗的59名患者,其中28名患者自入院起即接受常规营养教育和口服肠内营养补充(ONS)且持续至化疗4周期以上作为ONS组, 31名患者仅接受常规营养饮食教育作为对照组。比较两组患者化疗前及4周期化疗后的营养状况及化疗相关不良反应严重程度。结果:两组患者化疗前一般情况、PG-SGA评分、体重指数（BMI）、血清白蛋白(ALB）水平无明显统计学差异（P＞0.05）。经过4周期化疗后,ONS组患者PG-SGA评分（12.61±1.93）低于对照组（14.84±2.21）（P＜0.05）;ONS组患者体重指数BMI（22.32±3.06）kg/m2高于对照组患者（20.49±2.91）kg/m2（P＜0.05);ONS组患者血清白蛋白（35.36±3.89）g/L高于对照组（31.32±3.03）g/L（P＜0.05）;ONS组化疗相关骨髓抑制及消化道不良反应严重程度低于对照组（P＜0.05）。结论:口服营养补充剂可以有效改善胃癌术后患者辅助化疗期间的营养不良状态,降低化疗毒副反应严重程度,增加化疗毒副反应的耐受性。     

胃肠重建方法对胃癌全胃切除术后营养的影响

为了解全胃切除后胃肠道重建方法对术后病人营养状态的影响。作者于１９８９～１９９４年，对１２例胃癌全胃切除、胃及幽门括约肌重建术后病人摄取和吸收食物营养的能力进行了调查，并且与７例空肠袢重建和５例Ｒｏｕｘ－ｅｎ－Ｙ重建术后病人进行了比较，采用代谢平衡实验方法，对这些病人利用和贮存所吸收食物营养成份的情况进行了对比评价。结果表明在住院期间所有病人进食量要大于病人维持标准体重所需要的食物量，直接对照发现大多数空肠袢重建和Ｒｏｕｘ－ｅｎ－Ｙ重建的病人进食量减少，其中以空肠袢重建病人最为严重。作者认为，术后营养不良最常见的机制是进食不足，在解决好返流性食管炎的基础上，保持十二指肠食物的通过性，对于减少全胃切除术后营养不良及其它并发症的发生是极其有意义的。     

老年营养风险指数对新辅助化疗后胃癌患者疗效的预测价值

目的:探讨老年营养风险指数(geriatric nutritional risk index, GNRI)对接受新辅助化疗的老年胃癌患者近远期疗效的临床价值。方法:回顾性分析2014年1月至2019年12月期间在我院接受新辅助化疗后行腹腔镜胃癌根治术的230例老年胃癌患者的临床病理资料,应用受试者工作特征(receiver operating characteristic, ROC)曲线评估新辅助化疗前后GNRI对患者近远期疗效的预测效能,分别应用Logistic回归模型和Cox回归模型分析近远期疗效的影响因素。构建各因素和GNRI的交互项并计算交互项检验P值,分析GNRI在各亚组人群中的远期预后价值。结果:与新辅助前GNRI、新辅助前后GNRI变化值相比,新辅助后GNRI预测术后并发症、3年总体生存和3年无病生存的AUC值均最高,分别为0.692、0.703和0.702;与高GNRI组的患者相比,低GNRI组的患者首次下床时间、首次排气时间、首次进食时间、术后住院天数均明显延长,且并发症发生率明显升高(33.6%vs 20.5%),差异均具有统计学意义(P<0.05)。多因素分...     

口服营养补充在肿瘤患者中的临床应用进展

肿瘤严重危害人类的生命健康,肿瘤患者自身的营养状态与肿瘤疾病的各种临床结局密切相关。由于情绪、肿瘤本身以及抗肿瘤治疗等多重因素,容易导致肿瘤患者摄入不足,存在营养风险,进而可能发生营养不良,因此对于肿瘤患者需要科学的营养治疗。口服营养补充（ONS）作为肠内营养的一种方法,是肿瘤患者最易行、最方便的医学营养治疗方式,且具有较高等级的证据支持,已被多项指南推荐为肿瘤患者肠内营养的首选应用途径。ONS是肿瘤患者营养干预重要的方式之一,无论患者处于肿瘤围手术期、放化疗期间以及恶液质或肿瘤终末期等任何肿瘤的疾病阶段,ONS均适用于营养摄入不达标的患者。选择科学合理的制剂,适当的服用方法,坚持不懈,必定能发挥改善患者的营养状态、帮助患者更好地完成抗肿瘤治疗、减少并发症、提高肿瘤患者的生活质量、优化卫生经济学指标等作用。本文将围绕ONS在肿瘤患者中的临床应用进展进行综述。     

进展期全胃癌手术的有关问题

我们对胃淋巴流向的规律及进展期胃癌生物学特性，淋巴结转移规律经过20余年的研究，得出的结论认为，进展期全胃癌（Ⅱ、Ⅲa期）采取全胃切除，选择D3手术是比较合适的，即不行所谓标准D3，D4，而采用：（1）将1，2站淋巴结群全部清降；（2）第3，4站转移率高的淋巴结群（而不是某一淋巴结）常规予以清除，转移率很低的淋巴结群，则视临床病理学因素及术中判定结果决定是否予以切除，即选择性D3手术，临床证实此种做法有一定的效果，截止1995年一共收治胃癌（Ⅱ1Ⅲa期535例），其中有完整纪录的进展期全胃癌（Ⅱ1a期）为175例，施行了全胃切除，选择性D3手术，术后5年生态率Ⅱ期55．4％，Ⅲ期30．0％。     

口服营养补充依从性的影响因素

ONS 能增加患者营养素摄入,改善其营养不良状态,然而目前研究发现 ONS 的依从性较低。本项研究旨在探 索影响ONS适口性的相关因素,对营养不良患者ONS的依从性的影响,采用关键词：适口性、口感、口味、香味、风味、 接受度、依从性、ONS、肠内营养、营养补充剂等,检索MEDLINE、Sci Search、AGRICOLA、BIOSIS Previews、CAB ABSTRACTS、Embase、Foodline、中国生物医学文献数据库、中国知网数据库,按照纳入和排除标准对搜索的文献进行分 析和总结。根据文献检索结果,最终将影响因素归纳为三大类,包括 ONS 产品本身、患者个人情况和患者环境因素;进一 步细分为：营养素、口味、能量密度、ONS 容量、黏度、个体消化机制、年龄、患者病情、摄入时间、社会疏离感、鼓 励措施。研究发现,小剂量、高能量密度的 ONS 能够促进营养摄入。患者营养状况越来越受到医疗工作者的重视,需要尽 早通过营养筛查等方法确定患者营养不良状态,借鉴 ONS 依从性的影响因素,根据不同患者对营养的需求,设计不同营养 处方、以个性化的方式提高营养摄入,增强依从性是今后增强人群营养摄入的关键方向。     

辅助化疗前基于老年营养风险指数预测老年胃癌患者预后的研究

目的：探讨辅助化疗前老年营养风险指数（geriatric nutrition risk index,GNRI）评估老年胃癌患者的复发率和死亡率。方法：收集2013年1月至2017年1月连云港市东方医院162例接受根治性手术并行规范化疗的老年胃癌患者的临床资料,计算术前和化疗前GNRI,绘制其预测患者预后的ROC曲线,比较两者的诊断精度,分析化疗前GNRI不同水平患者的临床病理特征和预后。结果：化疗前GNRI的AUC值均大于术前GNRI,差异有统计学意义（均P<0.05）。根据最佳截断值将化疗前GNRI分为高GNRI组和低GNRI组。通过Kaplan-Meier分析,高GNRI组患者5年生存率和无病生存率均高于低GNRI组患者（均P<0.05）。根据pTNM分期分层分析,在pTNMⅡ期患者中,高GNRI组患者5年生存率高于低GNRI组患者（P<0.05）。高GNRI组和低GNRI组患者的5年无病生存率无显著性差异（P>0.05）。在pTNMⅢ期患者中,高GNRI组患者5年生存率和无病生存率均高于低GNRI组患者（均P<0.05）。多因素Cox回归分析,低GN...     

进展期胃癌不同切除术式对辅助化疗耐受性的影响

目的比较不同胃癌根治术式对术后辅助化疗耐受性及完成率的影响。方法回顾性观察不同术式对进展期胃癌病例术后辅助化疗的影响,比较严重不良反应发生率、化疗终止原因、内镜下反流性食管炎发病率及吻合口病变情况。结果 327例可切除的局部进展期胃癌患者,其中全胃切除术式81例,近端胃切除85例,远端胃切除161例;术后化疗完成率分别为40.7%,21.2%及36.6%。近端胃切除组化疗严重不良反应发生率为48.2%,明显高于其他两组,差异有统计学意义(P<0.05)。导致近端胃切除组化疗不耐受的原因中,消化道不良反应所占比例为43.3%,尤其是呕吐反应的发生率为35.8%,明显高于其他两组,差异有统计学意义(P<0.05)。近端胃切除组反流性食管炎及吻合口溃疡的发生率亦明显高于其他两组,差异均具有统计学意义(均P<0.05)。结论近端胃切除组病例术后化疗不良反应发生率高,化疗完成率低,而全胃切除术后辅助化疗耐受相对好,化疗完成率高,可提高胃上部癌的治愈率并降低复发率。     

进展期胃癌新辅助化疗的现状

胃癌是常见的恶性肿瘤之一,手术切除仍是主要的治疗手段。但进展期胃癌术后复发转移率很高,术胃癌是常见的恶性肿瘤之一,手术切除仍是主要的治疗手段。但进展期胃癌术后复发转移率很高,术后辅助化疗效果不佳。近年来,临床开展的新辅助化疗采用新的化疗药物(如多西紫杉醇)和新的化疗方案(如FOLFOX方案),效果满意,提高了手术切除率。本文对进展期胃癌的新辅助化疗现状做一综述。     

Spleen-preserving lymphadenectomy versus splenectomy in laparoscopic total gastrectomy for advanced gastric cancer

Background

To investigate the optimal approach for laparoscopic splenic hilum lymph node dissection in proximal advanced gastric cancer, we compared the operative outcomes between laparoscopic spleen-preserving total gastrectomy (sp-LTG) and laparoscopic total gastrectomy with splenectomy (sr-LTG).

Comparison of laparoscopic and open radical gastrectomy for gastric cancer patients with GLIM-defined malnutrition

PurposeMalnutrition is common in the patients with gastric cancer. Radical gastrectomy remained the primary strategy of curable treatment for gastric cancer. This study is performed to explore the effect of laparoscopic radical gastrectomy on clinical outcomes in gastric cancer patients with malnutrition.MethodsGastric cancer patients with GLIM-defined malnutrition between 2014 and 2019 at our center were enrolled. The patients were divided into two groups according to the different type of surgery. Propensity score match analysis was used to balance the clinicopathologic characteristics of two groups. Postoperative outcomes and survival were compared. Multivariate analysis was used to independent risk factors of complication, overall survival (OS), and disease-free survival (DFS).ResultsCompared with patients underwent open radical gastrectomy, patients who underwent laparoscopic radical gastrectomy had lower rate of total, surgical and severe complications. They also had shorter postoperative hospital stay with better OS and DFS. Hypoalbuminemia (P = 0.003) was the independent risk factor of complications. Old age (≥75, P = 0.035) and TNM stage (III: P < 0.001, II: P = 0.015) were the independent risk factors of OS. Combined resection (P = 0.003) and TNM stage (III: P < 0.001, II: P = 0.001) posed independent risk factors of lacking DFS. Laparoscopic surgery proved to be the independent protective factor of complications (P = 0.014), OS (P < 0.001) and DFS (P < 0.001).ConclusionLaparoscopic radical gastrectomy was relative safe and showed favorable outcomes in malnourished gastric cancer patients.     

Comparison of totally laparoscopic and laparoscopic assisted gastrectomy after neoadjuvant chemotherapy in locally advanced gastric cancer

BackgroundNeoadjuvant chemotherapy (NACT) and laparoscopic surgery have been increasingly used in the treatment of gastric cancer, however, the feasibility and safety of totally laparoscopic gastrectomy after NACT still remain unknown.Materials and methodsAt the Gastrointestinal cancer center of Peking university cancer hospital and institute in Beijing, clinical and pathological data of patients who has received NACT, followed by radical laparoscopic gastrectomy was retrospectively reviewed between March 2011 and November 2019. Patients were divided into 2 groups according to whether intracorporeal anastomosis or extracorporeal anastomosis had been performed, short-term outcomes (post-operative recovery index and complications) and economic cost were compared between 2 groups.ResultAll of 139 patients underwent laparoscopic gastrectomy. 87 [62.6%] patients had totally laparoscopic gastrectomy (TLG) and 52 [37.4%] patients had laparoscopic-assisted gastrectomy (LAG). Overall complication rate was 28.8% in all patients. TLG group was significantly associated with lower overall complication rate (21.8% VS 40.4%; p = 0.019) and major complication rate (3.4% VS 13.5%; p = 0.001) compared with LAG group. Overall cost was similar (p = 0.077). In subgroup analysis, totally laparoscopic total gastrectomy (TLTG) group showed lower overall postoperative complication rate (19.0% VS 56.5%; p = 0.011), as well as marginal significant differences in major complication (0% VS 21.7%; p = 0.05) than laparoscopic-assisted total gastrectomy (LATG) group. Earlier first liquid diet (4 [3.5–5] day VS 6 [4–6.5] day; p = 0.047), earlier first aerofluxus (3 [3-4] day VS 4 [3–4.5] day; p = 0.02) and a shorter hospital stay (9 [8-12] day VS 12 [10-15] day; p = 0.004) were observed in TLTG group. Overall and major complication rate were similar in totally laparoscopic distal gastrectomy (TLDG) and laparoscopic assisted distal gastrectomy (LADG) group (22.7% VS 27.6%; p = 0.611; 4.5% VS 6.9%; p = 0.639; respectively). Significant differences were found between TLDG and LADG groups regarding time to first liquid diet (4 [3-5] day VS 6 [3.75–6] day; p = 0.006), time to first aerofluxus (3 [3–3] day VS 4 [3-6] day; p< 0.001), time to first defecation (4 [4-5] day VS 5 [4-6] day; p = 0.045), time to remove all drainage (7 [6-8] day VS 8 [6-9] day; p = 0.021), white blood cell count on postoperative Day 1 (9.54 ± 2.49 10⁹/L VS 10.91 ± 2.89 10⁹/L; p = 0.021)and postoperative hospital stay (9 [8-10] day VS 10 [9,13] day; p = 0.009).ConclusionFor patients with Locally advanced gastric cancer who received NACT, totally laparoscopic gastrectomy, including TLTG and TLDG, doesn’t increase complications and overall cost compared with LAG, and has advantages in gastrointestinal function recovery, incision length and postoperative hospital stay.     

Fully robotic total gastrectomy with D2 lymphadenectomy for gastric cancer

PurposeRobotic surgery with technical advantages was shown to make complex maneuvers easier and more precise for gastric surgery [1]. This video demonstrates our technique on robotic total gastrectomy with the da Vinci Xi platform for gastric cancer.Methods68-year-old female was presented with persistent epigastric abdominal pain and underwent upper endoscopy showed ulcerated mass extended from the cardia to the lesser curvature. Histopathology showed gastric adenocarcinoma. After patient received neoadjuvant chemotherapy, decision was made to proceed with surgery.ResultsInitially, greater curvature dissection was started by division of the gastrocolic ligament with entering the lesser sac with monopolar scissors and bipolar forceps. The right gastroomental vessels were identified and divided at their root along with lymph nodes. After ligation of the right gastric vessels, dissection was extended to retrieve lymph nodes around the left gastric vessels. Duodenum was circumferentially dissected and transected 2 cm distal to the pylorus. Subsequently, extended lymphadenectomy was started with suprapancreatic lymph node dissection to retrieve lymph nodes around the common hepatic artery and celiac axis. Spleen-preserving dissection of the lymphatic tissue of the distal splenic artery and the splenic hilum was performed. The distal esophagus was divided with robotic stapler. Fully robotic end-to-side esophagojejunal anastomosis was constructed. For the reconstruction of gastrointestinal continuity after total gastrectomy, side-to-side jejuno-jejunal anastomosis was performed. Total operative time was 5 hours and estimated blood loss was 20 cc.DiscussionTotally robotic gastrectomy with D2-lymphadenectomy is a safe technique for gastric cancer and provides intracorporeal suturing in reconstructing the anatomy.     

Current status of adjuvant chemotherapy for gastric cancer

Although radical gastrectomy is a standard treatment for advanced gastric cancer, recurrence remains high. After several large-scale controlled studies have shown the beneficial effects of adjuvant chemotherapy, that treatment emerged as a standard option for advanced gastric cancer after gastrectomy. However, various guidelines from different countries have suggested different adjuvant chemotherapies. Understanding the differences between guidelines is very important for investigating further therapeutic strategies. Fortunately, because there are many ongoing studies about new regimens for adjuvant treatment, it is expected that patients with gastric cancer after surgery will have better outcome.     

Solitary living worsens the continuation of adjuvant chemotherapy for gastric cancer

BackgroundNo studies have reported the effect of solitary living on adjuvant chemotherapy continuation in patients with gastric cancer. This study aimed to investigate the influence of solitary living on the efficacy of adjuvant chemotherapy after curative gastrectomy.MethodsWe enrolled 155 patients with pathological stage II/III gastric cancer who underwent gastrectomy and adjuvant chemotherapy between January 2013 and March 2020. The patients were divided into two groups according to their living conditions, the solitary group (n = 34) versus the non-solitary group (n = 121). Clinicopathological features, predictive factors for the continuation of adjuvant chemotherapy, and long-term survival were compared between the two groups.ResultsThe median body weight loss (BWL) at one month after surgery (8.9% vs. 7.0%, p = 0.01), and the rates of failure to continue six courses of chemotherapy were higher in the solitary group (41.2% vs. 14.9%, p = 0.002) than in the non-solitary group. Multivariate analysis revealed that solitary living was an independent predictive factor for discontinuing adjuvant chemotherapy (odds ratio 3.36, 95% confidence interval [CI; 1.32–8.58], p = 0.01) as well as 10% BWL at one month after surgery (odds ratio 3.99, 95% CI [1.57–10.2], p = 0.004). The relapse-free survival was significantly worse in the solitary group (p = 0.03).ConclusionsSolitary living may be an independent risk factor for discontinuation of adjuvant chemotherapy in patients with gastric cancer. It is necessary to examine whether social and medical support organized by medical institutes and the government improves the continuation of adjuvant chemotherapy in patients living alone.     

Cumulative total S-1 dose in adjuvant chemotherapy affects the long-term outcome following curative gastrectomy for gastric cancer

A recent JCOG1104, OPAS-1 trial revealed the significance of S-1 duration. However, the significance of cumulative total S-1 dose (CTSD) remains unclear. In this study, we designed to evaluate the prognostic effect of CTSD on adjuvant chemotherapy after curative gastrectomy. We retrospectively analyzed 77 consecutive pStage II and III gastric cancer (GC) patients, who underwent curative gastrectomy followed by adjuvant S-1 chemotherapy from 2008 through 2014. CTSD of 20000 mg was the upper-limit of cut-off value to stratify the prognosis (5-year relapse free survival (RFS); CTSD < 20000 mg vs. CTSD ≥ 20000 mg: 51.9% vs. 85.1%, P = 0.004). Compared patients with CTSD more than 20000 mg, those with CTSD less than 20000 mg had a significantly higher rate of preoperative anemia (P = 0.041), low nutrition (P = 0.008) and open gastrectomy (P = 0.012). Multivariate Cox’s proportional hazards model for RFS proved that CTSD less than 20000 mg was an independent prognostic factor [P = 0.031, HR 3.32 (95% CI: 1.11-11.1)] although S-1 intensity and duration were not independent prognostic factors. The cumulative total S-1 dose more than 20000 mg might contribute to better prognosis.     

An updated meta-analysis of adjuvant chemotherapy after curative resection for gastric cancer

Objectives

To investigate whether and how much gastric cancer patients after curative resection could benefit from chemotherapy.

Patients and methods

Meta-analysis was conducted with all the qualified clinical randomized trials which compared adjuvant chemotherapy with surgery alone. The database includes MEDLINE, EMBase and CBM disc, and the censor data were up to November 2007. Primary outcomes were relative risk (RR) on death and disease-free survival (DFS); secondary outcomes include RR of adverse reactions of the two arms. Sub-group analysis and sensitivity analysis were also performed. All the calculations and statistical tests were done with the RevMan 4.2.8 software.

Results

Finally, 23 trials which included 4919 patients (2441 in the adjuvant chemotherapy arm, 2478 in the observation arm) achieved all the criteria. Among them, 19 studies reported the survival rate at the end of follow-up, 60.6% alive among 2286 patients in the adjuvant chemotherapy arm, 53.4% alive among 2313 patients in the observation arm, with the RR on death of 0.85 (95%CI: 0.80–0.90). Eight studies reported the DFS, and the observation arm had a shorter DFS (RR: 0.88, 95%CI: 0.77–0.99). Grade 3/4 of myelosuppression and GI toxicity occurred more frequently in the treatment arm. Nine studies reported the recurrence rate and suggested that the treatment arm had a lower recurrence rate (RR: 0.78, 95%CI: 0.71∼0.86).

Conclusions

Statistically, adjuvant chemotherapy could improve the survival rate and disease-free survival rate in gastric cancer after curative resection and reduce the relapse rate. However, the clinical benefits of adjuvant chemotherapy still need to be improved. Additionally, post-operative chemotherapy could be tolerated.     

Evaluation of effectiveness of chemotherapy in patients with gastric cancer after curative resection

Background. A prospective randomized study involving gastric cancer patients was undertaken to evaluate combined adjuvant chemotherapy and the prognostic value of biologic markers. Methods. One hundred and eighty-five patients under 75 years of age who underwent a curable resection of pathologic stage II or III gastric cancer were randomly assigned to receive adjuvant chemotherapy containing either: mitomycin C (MMC) plus oral 5-fluorouracil (FU) (MF), epirubicin plus oral FU (EF), or oral FU (F). Tumor tissue collected at surgery was immunohistochemically analyzed for p53 and proliferating cell nuclear antigen, and DNA ploidy was determined. Results. All prognostic factors were equally distributed in each arm. There was no significant difference among the groups in the 5-year overall survival. When the relationship between the biologic markers and prognosis was analyzed, the overall survival of all patients and stage III patients was poorer in those with p53 positivity, but the difference did not achieve significance. For patients with positive nodes, irrespective of the treatment regimen, p53-positivity was significantly associated with poorer prognosis (P = 0.05). In stage III patients, the survival of those with p53-positivity and DNA aneuploidy was significantly worse than that for patients with any other combination (P = 0.02). Conclusion. No survival benefit was observed with the combined chemotherapeutic regimens compared with FU alone. p53 positivity was negatively correlated to survival for node-positive and stage III patients. Received: July 3, 2000 / Accepted: September 21, 2000