提高早期胃癌诊断水平的几项关键点

长期以来，胃癌一直是我国发病率和病死率最高的恶性肿瘤。患者就诊晚、临床总体诊断水平欠佳等造成众多病人确诊时已属进展期，且常伴有胃周、腹腔甚至远处转移。自从证实仅浸润黏膜或黏膜下层的早期胃癌预后良好以来，30多年间我国从事胃肠病、外科学和肿瘤学的专业人员努力进取，在早期胃癌的诊断方面开展了大量研究，但因种种原因早期胃癌的诊断率依然很低，早期胃癌手术率〈10％，这与日本的早期胃癌占50％以上相比差之甚远。据统计，日本1975年早期胃癌占所有接受治疗胃癌病例的20．9％，1990年迅速升至43．4％。15年间日本TNM分期中T2的发生率无明显变化，而T4的发生率从22．3％下降至11．1％。2004年以来在日本早期胃癌检诊协会所属医疗机构中，检出的胃癌中超过70％为早期胃癌，约50％的早期胃癌患者接受了内镜下黏膜切除术（EMR）或黏膜下剥离术（ESD）。如此高的早期胃癌检出率得益于对无症状的日本人群进行胃癌筛选。     

胃癌的早期诊断

胃癌是全世界最常见的恶性肿瘤之一，居癌症病死率第二位。胃癌在全世界范围内的总体5年生存率约为20％。早期胃癌经治疗后5年生存率大于90％，总体复发率为1.5％～13.7％；而进展期胃癌术后5年生存率仅30％～40％，总体复发率高达50％～70％。因此，早期诊断是改善患者预后的关键。早期胃癌癌细胞浸润仅限于黏膜层和黏膜下层，癌肿范围及有无淋巴结转移不论。我国胃癌病例以进展期为主（约占90％），早期胃癌诊断率仅约10％。     

高龄患者行腹腔镜胃癌手术的安全性与可行性分析

<正>自1994年日本Kitano等[1]首次报道了腹腔镜早期胃癌根治手术以来,近20年腹腔镜胃癌手术得到不断发展,技术逐渐成熟,其运用范围也由最初的早期胃癌扩展到进展期胃癌。目前研究表明腹腔镜胃癌手术相对于传统开腹手术具有术中出血少、术后疼痛轻、下床活动时间早、胃肠功能恢复快、住院时间短、并发症发生率低等优点,肿瘤根治效果与传统开腹手术相当[2-3]。随着我国人口平均寿命的延长及年龄结构的老龄     

2010年上海市六家医院早期胃癌患者手术治疗情况总结及分析

长期以来,胃癌一直是全球发病率和病死率最高的恶性肿瘤之一。由于日本的早期胃癌研究较为成功,日本胃癌总的5年生存率为40％～60％,居世界之首;其他国家约为20％［1］。中国每年死于胃癌的患者约22.7万,占所有恶性肿瘤死亡患者的23％,而患者的早期胃癌诊断率不足1／10,早期胃癌手术率仅为5％～10％［2］。因此,提高我国早期胃癌检出水平刻不容缓。由于胃癌诊断主要取决于胃镜及活组织病理检查,因此提高我国胃镜检查中对胃癌的识别能力至关重要。     

早期胃癌的治疗方式探讨

早期胃癌是指无论患者是否有淋巴结的转移，其病变只限于黏膜或黏膜下层的胃癌。早期胃癌的治疗方法可以分为三大类，即内镜、腹腔镜和传统手术治疗，每种方法均有其一定治疗范围。如早期胃癌没有发生淋巴结转移，肿瘤长径≤2cm时，采用内镜黏膜切除；当肿瘤长径〉2cm时，采用缩小手术。当出现淋巴结转移时，肿瘤长径≤2cm时，采用缩小手术；肿瘤长径〉2cm时，采用标准根治术。     

内镜黏膜下剥离术治疗早期胃癌进展

早期胃癌(EGC)是指胃癌病变位于黏膜或黏膜下层,而无论病灶大小和是否有淋巴结转移.外科剖腹胃癌根治术及淋巴结清扫术是治疗EGC的一种有效手段,5年生存率达到96%以上,近年来开展的EGC内镜黏膜下剥离术(ESD)不但治疗效果与外科手术相似,而且能使大部分患者免除了传统手术治疗的风险及术后对生活质量带来的严重影响.     

早期胃癌研究必须从学科群建设抓起

胃癌是我国发病率和病死率最高的恶性肿瘤。30多年来,无数从事胃肠病、外科学和肿瘤学的专业人员前赴后继,在胃癌的诊断和治疗方面,包括中两医结合治疗进展期胃癌等项目中开展了大量研究,但我国胃癌的临床总体水平还不高,尤其是早期胃癌的诊断率较低,早期胃癌手术率<5％,这与日本的早期胃癌占50％以上相比差之甚远。而日本在早期胃癌研究方面的经验值得总结和借鉴。     

胃黏液祛除剂——链霉蛋白酶在上消化道内镜诊疗中的应用价值

早期胃癌（earlygastriccancer，EGC）定义为垂直方向的浸润不超过黏膜下层而无论有无转移的胃癌…。在日本，早期胃癌占所有胃癌患者的比例高达40％一60％，然而在我国及欧美还不足15％”0。目前多数学者认为，无论部位、大小及基因类型，EGC是可以治愈的疾病，早期切除病变部位后患者的5年生存率高达90％以上，然而，进展期胃癌患者的5年生存率仅10％一20％”’。     

早期胃癌临床病理特征和术后生存率的研究

目的：研究早期胃癌术后生存率和有关因素,提高患者就诊意识,使医师在胃癌早期作出正确诊断和手术治疗,方法：收集本院病理科1974－1997年间,病理证帝的早期胃癌193例,其中有完整随访资料152例,另41例中途失访,早期胃癌诊断依国际通用标准：切除胃标本,胃癌组织浸润限于黏膜层或黏膜下层,不管淋巴结是否有转移,结果：152例早期胃癌,其中150例术前确诊胃癌,2例因溃疡手术,152例术后病理诊断,黏膜内癌51例,浸润黏膜肌层49例,浸润黏膜下层52例,伴淋巴结转移10例,81例用5－氟尿嘧啶治疗,因胃癌复发死亡5例,其他原因死亡例,140例健在,术后5年生存率为98．1％,＞5－≤10年生存率为96．4％;＞10－≤15年生存率为93．5％,＞15－≤20年的15例患者中14例健在,1例因其他病死亡,＞20－≤25年9例均健在,＞25－≤30年1例,健在,结论：虽然本组收集研究的早期胃癌仅152例,但可以看出早期胃癌术后生存率很高,如术后15年内不复发或转移,便进入生存率的安全阶段。     

222例早期胃癌的临床病理及预后分析

胃癌在我国发病率高,居消化道恶性肿瘤之首。进展期胃癌治疗效果差,手术治疗5年生存率仅40％-60％。早期胃癌手术治疗后5年生存率可达90％以上,然而我国早期胃癌检出率一直较低。因此,提高早期胃癌诊断率是提高胃癌生存的关键。现将我院7年间经手术病理证实的222例早期胃癌的临床病理及随访资料进行分析,总结早期胃癌临床病理特点,以提高临床医师对早期胃癌的认识。     

腹部无辅助切口经阴道取标本的全腹腔镜全胃切除术（GC-NOSES Ⅷ式）（附视频）

胃癌是全球最常见的恶性肿瘤之一,腹腔镜胃癌根治术已成为治疗胃癌的重要手段。腹腔镜胃癌根治术经历了从腹腔镜辅助胃癌根治术到全腹腔镜胃癌根治术的发展过程,进一步降低了手术创伤,加快了术后恢复,目前腹腔镜胃癌手术已能达到与开腹手术相同的D2淋巴结清扫水平,消化道的重建亦能在腹腔镜下完成（即全腹腔镜胃癌手术）。进一步推动胃癌手术的微创化是当前的关注焦点,经自然腔道取标本手术（NOSES）作为一种新兴的微创手术方式,具有创伤小、操作性好及可行性强等优势,已越来越多地应用于胃、结直肠肿瘤等患者中。本手术为NOSES在根治性全胃切除术中的临床应用。     

Laparoscopic gastric surgery for cancer: Where do we stand?

Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.     

腹腔镜早期胃癌根治术的临床研究

目的:探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用。方法:回顾性分析2004年10月至2009年12月间79例接受腹腔镜胃癌根治术的早期胃癌患者的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理和随访等。结果:除1例中转开腹手术外,其余78例均在腹腔镜下完成胃切除和淋巴结清扫,其中腹腔镜远端胃切除术74例,近端胃切除术2例,全胃切除术2例;腹腔镜下D1+α式淋巴结清扫34例,D1+β式淋巴结清扫15例,D2式淋巴结清扫29例。手术时间为(202.9±45.6)min,术中失血(144.5±146.5)mL,术后排气时间(2.8±1.0)d,术后住院天数为(11.3±5.6)d,8例(10.1%)患者出现腹腔内出血、吻合口漏、小肠梗阻等,经手术和非手术治疗后痊愈。手术上、下切缘距离肿瘤为(4.0±1.9)cm和(3.6±1.7)cm,手术平均清扫淋巴结(13.1±6.5)枚,其中有3例(3.8%)发现淋巴结转移。术后随访2～64个月,均无肿瘤复发和远处转移。结论:腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的手术方法。     

65岁以上老年人胃癌332例临床分析

目的 探讨老年胃癌患者的临床特点及其外科治疗方法的选择及预后。方法 回顾性分析1990年1月至2003年6月收治的332例65岁以上老年人胃癌的临床资料和生存资料。结果 本组临床好转率为97．0％，围手术期病死率为3．0％，手术并发症发生率为24．7％。根治性胃切除组术后1、3、5年生存率分别为89.6％、63.2％和40.6％，姑息性胃切除组分别为68.6％、15．7％和0，未切除组平均生存10个月。各组术后生存率比较差异有显著性(P＜0．05)。结论 老年人胃癌术后并发症较多，围手术期处理至关重要。术中应尽量采用硬膜外麻醉，缩短手术时间。手术方式应视患者全身情况、癌肿所在部位、大小及侵犯范围而定，对早中期患者力争行根治性胃切除术(D1或D2)。     

CURRENT STATUS AND EVALUATION OF LAPAROSCOPIC SURGERY FOR GASTRIC CANCER

Laparoscopic gastrectomy for gastric cancer was developed in Japan and has been established as a treatment for early gastric cancer thanks not only to improvements in technology and medical equipment but also to great efforts made by surgeons. With increasing numbers of surgeons performing the procedure and extending its indication to some advanced gastric cancers, it has achieved an important position in the treatment of gastric cancer together with endoscopic mucosal resection and open surgery. In clinical practice, it has been accepted as a safe, minimally invasive and radical treatment for early gastric cancer through several clinical studies and case–control studies. A large‐scale randomized controlled trial to evaluate laparoscopic gastrectomy as an acceptable procedure for early gastric cancer is being prepared. In order to extend the indication to some advanced gastric cancers, first, we need to collect more cases of laparoscopic gastrectomy for advanced cancer and start a phase II study in the experienced hospitals.     

老年胃癌患者外科治疗的临床研究

目的探讨老年胃癌患者的临床特点及其外科治疗方法的选择及预后。方法回顾性分析1993年1月至2003年1月收治的443例≥65岁老年人胃癌的临床资料和生存资料。结果本组围手术期病死率为2.5%,手术并发症发生率为20.1%。根治性胃切除组术后1、3、5年生存率分别为90%、65.8%和42.1%,姑息性胃切除组分别为73.6%、13.6%和0,未切除组平均生存10月。各组术后生存率比较差异有统计学意义(P<0.05)。结论老年人胃癌术后并发症较多,围手术期处理至关重要。手术方式应视患者全身情况、癌肿所在部位、大小及侵犯范围而定,对早中期患者力争行根治性胃切除术。术后生存率和手术方式密切相关。     

达芬奇手术系统辅助腹腔镜胃癌根治术的研究进展

随着微创外科技术的发展,腹腔镜胃癌根治术逐渐成为了安全可行的手术方法。然而,复杂的手术操作、过高的技术要求限制了腹腔镜胃癌根治术的进一步发展。达芬奇手术系统的技术优势有助于解决腹腔镜手术中的这一难题。本文就近年达芬奇手术系统辅助腹腔镜胃癌根治术的研究进展作一综述。     

Spread and development of laparoscopic surgery for gastric tumors in mainland china: initial experiences

Background/Aims: To introduce the initial experience of the laparoscopic surgery for gastric tumors in mainland China. Methodology: A key Chinese full-text database was comprehensively searched for eligible reports on laparoscopic gastric surgery from 1991 to 2009. Outcomes of laparoscopic gastrectomy for gastric cancer were extracted for pooling estimate. Results: In the period 2003-2008, the amount of relevant journal papers sharply increased (p<0.001). Analysis included 67 reports (no randomized controlled trial, 4 case control studies and the remnant of case series or case reports); 74.6% of the reports were from institutions in the Eastern China region. Finally 542 patients of gastric cancer were analyzed. Early gastric cancer (TNM stage Ia/Ib) was only 30.0%. D2/D2+ lymphadenectomy was performed in 69.0% patients. The combined overall complication and mortality rates were 10.9% and 0.4%, respectively. The incidence of conversion to open surgery and reoperation were 4.1% and 1.1%, respectively. The long-term outcome of 5-year survival rate was unavailable. Conclusions: Laparoscopic gastric surgery has spread rapidly and developed in mainland China during recent several years. The initial experiences from mainland China showed that postoperative complication and mortality rates of laparoscopic gastrectomy for gastric cancer were acceptable and comparable to Japanese and Korean trials.     

Towards personalized perioperative treatment for advanced gastric cancer

Gastric cancer is one of the most frequently diagnosed cancers worldwide. Although the rate of gastric cancer has declined dramatically over the past decades in most developed Western countries, it has not declined in East Asia. Currently, a radical gastrectomy is still the only curative treatment for gastric cancer. Over the last twenty years, however, surgery alone has been replaced by a multimodal perioperative approach. To achieve the maximum benefit from the perioperative treatment, a thorough evaluation of the tumor must first be performed. A complete assessment of gastric cancer is divided into two parts: staging and histology. According to the stage and histology of the cancer, perioperative chemotherapy or radiochemotherapy can be implemented, and perioperative targeted therapies such as trastuzumab may also play a role in this field. However, perioperative treatment approaches have not been widely accepted until a series of clinical trials were performed to evaluate the value of perioperative treatment. Although multimodal perioperative treatment has been widely applied in clinical practice, personalization of perioperative treatment represents the next stage in the treatment of gastric cancer. Genomic-guided treatment and efficacy prediction using molecular biomarkers in perioperative treatment are of great importance in the evolution of treatment and may become an ideal treatment method.     

The current status and future perspectives of laparoscopic surgery for gastric cancer

The incidence of early gastric cancer (EGC) has increased to over 50% in Korea and Japan due to rapid advances in diagnostic instrumentation and increased use of mass screening. Considering the excellent prognosies of EGC patients, the quality of life of these patients after treatment has recently been emphasized. For the better quality of life, laparoscopic surgery has emerged as an alternative therapy for EGC patients. Since Kitano et al. first performed laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer in 1991, it has been performed worldwide, especially in Japan and Korea. A number of reports have presented the excellent short term outcomes; less pain, better cosmetics, faster recovery, and shorter hospital stay. However, there is little evidence of the oncological outcome of laparoscopic gastrectomy as a treatment modality for gastric cancer. Multi-center randomized controlled trials of laparoscopic versus open gastrectomy are needed to establish the future role of laparoscopic surgery in the treatment of patients with gastric cancer.