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目的分析比较胃癌合并肝硬化病人接受胃癌根治术D1和D2淋巴结清扫的术后并发症情况。方法回顾性分析1994年3月至2006年3月大连医科大学附属第一医院诊治54例胃癌合并肝硬化病人接受胃癌根治术的临床资料,比较D1和D2淋巴结清扫的临床疗效。结果胃癌合并肝硬化病人接受胃癌根治术的1、3、5年存活率分别为77.8%、44.4%、33.3%。行D1淋巴结清扫术(D1组)1、3、5年存活率为81.3%、37.5%、25.0%,行D2淋巴结清扫术(D2组)为76.3%、47.4%、36.8%(P>0.05),54例病人中位生存时间32个月,D1组为23个月,D2组为34个月。D1组和D2组肝功能Child-Pugh分级A级病人并发症发生率差异无统计学意义;Child-Pugh分级B、C级的病人中,D2组肝肾功能障碍发生率明显高于D1组(P<0.05)。结论胃癌合并肝硬化病人D2组较D1组的存活率差异无统计学意义。肝功能Child-Pugh分级A级病人行D2淋巴结清扫并不增加并发症发生率,Child-Pugh分级B、C级的病人应慎行D2淋巴结清扫。     

Does the extent of lymph node dissection affect the postoperative survival of patients with gastric cancer and disseminating peritoneal metastasis?

For patients with gastric cancer and either P, or P₂ peritoneal metastasis, no definite consistent policy with respect to the extent of lymph node dissection has yet been established. In palliatively gastrectomized patients, we analyzed the relationship between the extent of lymphadenectomy and postoperative survival. In patients with P₁, an R₂ or R₃ lymphadenectomy was associated with a significantly improved postoperative survival as compared to an Rl dissection, while this, however, was not the case in patients with P₂. As this study was not intended to be a prospective randomized study, a definite conclusion should be avoided. However, our findings suggest that in patients with PI, surgery should not be confined to a resection of the primary lesion, but should also include an R₂ or R₃ lymphadenectomy.     

Evaluation of extended lymph node dissection for gastric cancer

A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages of stomach cancer and end-results of the R₂ (with a conventional lymph node dissection) and the R₃-resections (with an extended lymph node dissection). R₃-resections were found to be generally associated with higher 5-year survival rates than R₂-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was considerably higher with R₃-resections than with R₂-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested from these results that the end-results might be improved more effectively by performing R₃ resection for cases without a marked serosal invasion.     

The influence of excess body weight on the surgical treatment of patients with gastric cancer

Sixty-two overweight gastric cancer patients were compared with 201 normal-weight patients to clarify the influences of excessive weight on the surgical treatment of gastric cancer. The frequencies of hypertension and diabetes mellitus were significantly higher in the overweight group (P<0.01), but no pathologic differences in the resected tumor were found between the two groups. The operative times were longer (P<0.01) and the number of lymph nodes extirpated and examined was smaller (P<0.01) in the overweight group. The incidence of postoperative complications was not higher in the overweight group. The postoperative survival rate of patients with nodal metastasis was statistically lower in the overweight group (P<0.05). Regarding the causes of death in patients with nodal metastasis, 61.1% of overweight patients and 43.8% of normal-weight patients died of recurrence of gastric cancer. In conclusion, surgical treatment of overweight patients with gastric cancer was found to be technically more difficult and the prognosis of such patients with nodal metastasis may thus be worse than that of their normal-weight counterparts.     

胃癌腹膜种植临床病理特征及手术对预后的影响

目的了解不同区域腹膜种植胃癌临床病理特征及手术治疗对预后的影响。方法中山大学附属第一医院1994年8月至2006年3月共收治107例胃癌伴单纯腹膜种植,分析其临床病理参数并评估外科治疗对预后的影响。依种植区域分为结肠上区(SC)、结肠下区(IC)、全腹膜种植(TPS)3组。结果TPS组的年龄较单区域种植组小(P<0.05),SC和TPS组发生脏器侵犯的比例高于IC组(P<0.05)。病灶全切除、病灶姑息性切除较旁路或造口手术、探查活检术的存活期明显延长(P<0.05),手术方式为独立预后因素。淋巴结清扫组较未清扫组的存活期显著延长(P<0.01)。全胃切除(TG)、部分胃切除(PG)较未切胃(NG)的存活期明显延长(P<0.05)。结论低龄胃癌病人容易发生远处腹膜种植,结肠上区和全腹腔种植者易发生局部脏器浸润,病灶全切除和姑息性切除、适度淋巴清扫可提高病人存活期,在满足病灶切除条件下,应首选部分胃切除而不是全胃切除。     

D1和D2淋巴结清扫术治疗胃癌合并失代偿性肝硬化的效果比较

目的 比较胃癌合并失代偿性肝硬化患者接受胃癌根治术D1及D2淋巴结清扫的临床效果.方法 胃癌合并失代偿性肝硬化患者50例,均采用胃癌根治术治疗,根据术中淋巴结的清扫范围分为D1组(30例)和D2组(20例),比较D1及D2淋巴结清扫的疗效.结果 D1组淋巴结清扫术1年、3年、5年存活率分别为79.3％、58.1％和28.7％,D2组分别为81.1％、57.1％和30.7％,差异无统计学意义(P＞0.05).D2组术后大量腹水、肝功能衰竭的发生率为85％和30％,D1组分别为33.3％和3.3％,两组比较差异有统计学意义(P＜0.05).结论 胃癌合并失代偿性肝硬化患者,D1淋巴结清扫术对Child-PughB级的患者更加安全有效.     

胃癌前哨淋巴结研究进展

前哨淋巴结是从原发肿瘤淋巴引流途中首先可能发生转移的部位。Cabana在阴茎癌中提出前哨淋巴结的概念后,前哨淋巴结活检技术不断在多种肿瘤中广泛应用。目前,该技术已成功用于黑色素瘤、乳腺癌等手术。但在胃癌中,由于胃淋巴引流复杂、存在跳跃转移以及假阴性率较高,前哨淋巴结活检技术应用于临床还为时过早,其可行性和适用性尚无定论。因此,前哨淋巴结活检技术应用于胃癌,还有许多问题需要回答。     

Surgery for cholelithiasis in cirrhotic patients

Although biliary tract surgery for cholelithiasis is performed frequently in Japan, cirrhotic patients require special consideration. Postoperative complications after biliary tract surgery were studied in 23 patients with liver cirrhosis and associated cholelithiasis, 9 of whom had no complications, 8 had minor complications, and 6 had severe complications. Concerning the relation between Child's classification and postoperative complications, no complications were seen in four Child's type A patients, but seven of ten (70%) Child's type B patients and seven of nine (78%) Child's type C patients developed complications. Two (20%) of the Child's type B patients and four (44%) of the Child's type C were severe, and three of the latter group died. Regarding the preoperative laboratory findings, significant differences were seen between the patients without complications and those with severe complications in serum bilirubin, albumin, and ICG R₁₅ values. Of the six patients with severe complications, five had choledocholithiasis, three of whom died of liver failure, while two developed biliary peritonitis caused by insufficient fistula formation after removal of the T-tube. Thus, for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical invasion through the use of such techniques as endoscopic papillotomy is recommended whenever possible.     

进展期胃癌淋巴结清扫范围的研究进展

一个多世纪以来,胃癌的手术治疗存在诸多争议,尤其是进展期胃癌的淋巴结清扫范围是争论的焦点问题.本文就当前国内、外有关胃癌淋巴结清扫范围的研究报道及最新进展做一综述和分析.     

The operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach

While proximal gastrectomy is often performed for early gastric cancer in Japan, it remains unclear whether or not proximal gastrectomy should be performed for advanced gastric cancer. This study was designed to determine the operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach. A total of 1691 patients with gastric cancer were reviewed retrospectively from hospital records during the period from 1969 to 1994, and the clinicopathologic characteristics of 82 patients who underwent proximal gastrectomy were compared with those of 150 patients who underwent total gastrectomy. Lymph node metastasis along the lower part of the stomach was observed in gastric cancers which had invaded beyond the muscularis propria of the stomach, but not in those confined to the muscularis propria. Three patients with gastric cancer that had invaded beyond the muscularis propria and metastasized to nodes along the lower part of the stomach were cured by total gastrectomy. However, there was no difference in the postoperative survival rates of the patients treated with proximal gastrectomy and those treated with total gastrectomy, irrespective of tumor stage and depth of invasion. Thus, proximal gastrectomy should be performed for gastric cancer when the depth of invasion is confined to the muscularis propria of the stomach.     

转移性淋巴结阳性比率对淋巴结转移胃癌患者的预后价值研究

目的 探讨转移性淋巴结阳性比率(MLNR)在预测淋巴结转移胃癌患者预后中的临床价值.方法 对2005年6月至2008年5月收治的接受D2根治术的173例淋巴结转移胃癌患者的临床病理资料进行回顾性分析.采用Kaplan-Meier法分析MLNR与5年总体生存率之间的相关性,分别采用单因素及多因素分析对MLNR的预后意义进行评估,通过绘制受试者工作特性曲线(ROC曲线)比较MLNR与淋巴结转移阳性数目在预测淋巴结转移胃癌患者预后方面的敏感性和特异性.结果 Kaplan-Meier分析表明MLNR与患者的5年总体生存率呈显著负相关(P＜0.05);单因素分析显示,MLNR、肿瘤发生部位、浸润深度、远处转移及淋巴结转移数目均为淋巴结转移胃癌患者预后的影响因素(均为P＜0.05);多因素分析表明,MLNR是淋巴结转移胃癌患者预后的一项独立、有效的预测指标(P＜0.05);MLNR分期对应的ROC曲线下面积(AUC)显著高于淋巴结转移阳性数目对应的AUC(P ＜0.05).结论 MLNR是影响淋巴结转移胃癌患者预后的一项独立、有效的预测指标,其预测效果比淋巴结转移阳性数目更为准确和客观.     

Lymphangitis carcinomatosis of the lesser omentum: A prognostic factor in gastric cancer

A series of 126 patients with gastric cancer who underwent radical gastrectomy with systemic lymph node dissection revealed 9 patients who survived for a median time of only 3 months. Of these 9 patients, 4 were classified by the UICC system as stage II and 5 as stage III, all of whom had lymphangitis carcinomatosis of the lesser omentum. These data suggest that although lymphangitis carcinomatosis of the lesser omentum is an uncommon finding, if it is present, curative surgery is impossible and an operation should therefore be limited to tumor palliation.     

乳腺癌前哨淋巴结检测的临床研究

目的通过前哨淋巴结(sentinel lymph node,SLN)活检,了解前哨淋巴结是否能反映乳腺癌腋窝淋巴结转移情况,从而决定是否行腋窝淋巴结清扫(axillary lymph node dissection,ALND). 方法 47例T1、T2、T3临床检查腋窝淋巴结无肿大的乳腺癌患者,术前30 min于乳腺肿块周围腺体注射蓝色染料,术中取蓝染的SLN病理检查,术后将病理检查结果与腋窝淋巴结转移情况进行比较分析. 结果 47例中5例未见淋巴结及淋巴管蓝染,其余42例找到腋窝淋巴结608个,阳性18例168个,阴性24例440个;SLN共78个,阳性16例29个,阴性26例49个.SLN的检出率89.4%,准确性95.2% ,特异性100%,敏感性88.9%,假阴性率11.1%,假阳性率0. 结论 SLN活检反应腋窝淋巴结的肿瘤转移状况,可以用于术中确定是否行ALND.     

早期胃癌淋巴结转移相关因素分析

目的 探讨早期胃癌病人临床病理特征及免疫病理与淋巴结转移的相关性。方法 对2006年1月至2008年l2月第二军医大学长海医院普通外科诊治的212例早期胃癌病例进行回顾性分析,采用t检验、χ2检验和Logistic回归等统计学方法对肿瘤大小、浸润深度、组织学类型等临床病理特征以及p53、Ki?67、CAM5.2等免疫组化指标与淋巴结转移进行相关性分析。结果 肿瘤大体类型、大小、浸润深度、组织分化程度与淋巴结转移存在明显的相关性（P值为0.014、0.001,0.012,0.006,相关系数R为2.213、1.779、4.737、4.15）。免疫病理指标中p53、CAM5.2与淋巴结转移也存在明显相关（P值为0.001和0.000,相关系数R为1.922、3.632）。而年龄、性别、肿瘤位置、多发肿瘤及免疫病理指标中p16、TopoⅡ、Ki?67与淋巴结转移无明显相关性。结论 早期胃癌淋巴结转移与肿瘤大小、肿瘤分化程度、浸润深度等明显相关,可参考上述因素判断淋巴结转移风险,同时根据免疫病理指标CAM5.2、P53判断是否存在微转移可能,从而决定治疗方案。     

Impact of skip metastasis in gastric cancer

BACKGROUND: Several studies have shown the features of skip metastasis in other cancers besides gastric cancer. Since minimally invasive surgery has been applied to gastric cancer, the concerns and awareness of skip metastasis have grown in the medical community. We conducted the present retrospective study to reveal the clinicopathological characteristics of patients with skip metastasis. We also wished to clarify the clinical impact of skip metastasis for gastric cancer. METHODS: Five hundred and eighty-nine patients having lymphatic metastases were enrolled in the present study. Among them, 266 patients had positive nodes extending into the N2 group. We divided these patients into the skip positive (+) and the skip negative (-) group, and we comparatively analysed clinicopathological factors and calculated the survival probabilities for the two groups. RESULTS: The skip (+) and skip (-) groups involved 14 (5.3%) and 252 (94.7%) patients, respectively. Of all the investigated factors, a significant difference between two groups was observed only in the total number of retrieved nodes. Stations of skip nodes were along left gastric (7), anterior common hepatic (8a), celiac (9), splenic (11) artery and right paracardial nodes (1). The survival curves calculated in the present study did not show any statistical differences between the groups. CONCLUSIONS: Due to problems of skip metastasis in gastric cancer, D2 lymph node dissection should be performed until sentinel node detection is feasible and reliable. The potential risk from skip metastasis is not great and skip metastasis itself should not be a major consideration in therapeutic decisions.     

Laparoscopic lymph node dissection after endoscopic submucosal dissection: a novel and minimally invasive approach to treating early-stage gastric cancer

BACKGROUND AND OBJECTIVE: Endoscopic submucosal dissection (ESD), a newly developed endoscopic mucosal resection (EMR) technique, can completely cure a differentiated mucosal gastric cancer smaller than 2 cm. For early-stage gastric cancers (EGCs) deviating from the above-mentioned criterion, gastrectomy with lymph node dissection is performed for potential risk of lymph node metastasis (LNM). However, many of surgical EGC cases actually do not have LNM, indicating this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, we have introduced laparoscopic lymph node dissection (LLND) after ESD. Standard gastrectomy with extended lymph node dissection is indicated for patients if LLND reveals LNM. We present our novel approach and the preliminary results of EGC patients having potential risk of LNM. METHODS: Five patients with EGC deviating from the EMR criterion underwent the combination of ESD and LLND. ESD was performed using a newly developed insulation-tipped diathermic knife. Lymph nodes, which were determined on the basis of the location of the primary tumor and lymphatic drainage of the stomach, were removed laparoscopically. The lymphatic drainage was visualized by submucosally injecting indocyanine green (ICG) around the post-ESD ulcerative scars during intraoperative gastroscopy. RESULTS: The ESD enabled en bloc resection without any complications. The resected margins of all the lesions were free of cancer cells vertically and horizontally. LLND was successfully performed without any complications. The mean number of the dissected lymph nodes was 15 (range 6 to 22). In 4 of the 5 patients, the dissected lymph nodes were free of cancer cells, and therefore, the combination of ESD and LLND was considered a definitive treatment. The remaining patient was found to have LNM but chose not to undergo any surgery. During follow-ups, the patients' previous quality of life was restored without any tumor recurrence. CONCLUSIONS: The combination of ESD and LLND enables the complete resection of the primary tumor and the histologic determination of lymph node status. This combination treatment is a potential, minimally invasive method, and may obviate unnecessary gastrectomy without compromising curability for EGC patients having the potential risk of LNM.     

Lymphatic routes of the stomach demonstrated by gastric carcinomas with solitary lymph node metastasis

To clarify whether or not the lymphatic routes that have long been generally accepted are indeed correct, we retrospectively examined the clinical records of patients with solitary lymph node metastasis from gastric carcinoma. From 735 patients gastrectomized with lymph node dissection (more than D1), 51 (7%) were histologically proven to have only one lymph node involved. In 44 of these 51 patients, the involved nodes were all in the perigastric region (N1). There were also 7 patients with a jumping metastasis to the N2–N3 nodes. Three of them were found along the left gastric artery (#7 according to Japanese classification) and the other 4 were found along either the common hepatic artery (#8) or the proper hepatic artery (#12). The depth of invasion was submucosal in 2, proper-muscular in 2, subserosal in 1, and serosa-exposed in 2, and the conclusive stage was II in 2, IIIa in 3, and IIIb in 2. However, 1 of these patients died of liver cirrhosis and 2 died of pneumonia, while the other 4 were still alive at the time of this report more than 5 years after surgery. These results suggest that not every sentinel node is located in the perigastric region near the primary tumor and that, if the preoperative examination indicates submucosal invasion, then a systematic regional lymph node dissection should therefore be carried out.     

Indication for endoscopic treatment based on the risk of lymph node metastasis in patients with undifferentiated early gastric cancer

BackgroundDespite the risk of lymph node metastasis (LNM), the indications of endoscopic submucosal dissection (ESD) has expanded to undifferentiated type (UD-type) early gastric cancer (EGC). There is debate as to whether the endoscopic resection can be used. This study was conducted to evaluate risk factors for LNM in undifferentiated early gastric cancer, implications for the indication of the ESD so as to providing evidence for proper clinical management for UD-type EGC.MethodWe retrospectively analyzed 203 patients with UD-type EGC who underwent gastrectomy for primary gastric adenocarcinoma between 2012 and 2017. We evaluated the relationship between the clinicopathological factors and the presence of LNM using univariable and multivariable logistic regression analyses.ResultsA total of 203 UD-type EGC patients were enrolled, and LNM was positive in 40 cases (19.7%). Multivariable logistic regression analysis identified three independent risk factors for LNM, the tumor size (≥2.0 cm, P < 0.001), depth of invasion (P < 0.001), and lymphatic vessel involvement (LVI, P < 0.001). LNM was observed in 5.9% patients without the three predictive factors in UD-type EGC, whereas 7.7% and 37.7% of patients with one and two risk factors had LNM, respectively. In contrast, the LNM rate was up to be 66.7% in patients with three factors. Of 41 patients satisfying the expanded indication of ESD, 3 patients (7.3%) showed LNM. LNM was not found in any of 12 patients with small intramucosal lesions (<1.0 cm) without LVI.ConclusionsLNM-related risk factors were tumor larger than 2.0 cm, submucosal invasion, and the presence of LVI in UD-type EGC. ESD alone may be sufficient treatment for the intramucosal UD-type EGC that is smaller than 1.0 cm in size. When endoscopically resected specimens show unexpectedly larger tumor size, unexpected submucosal and LVI than that determined at pre-ESD endoscopic diagnosis, an additional gastrectomy with lymphadenectomy should be considered.