早期胃癌的腹腔镜下手术

早期胃癌的腹腔镜下手术吴涛姜波健综述涂长龄审校当今，治疗早期胃癌仍采用标准的胃切除伴Ｄ２淋巴结清扫，但术后易造成残胃运动障碍、倾倒综合征、小肠运动障碍以及残胃癌的发生。近年来，在详细分析胃癌切除标本的组织学特征和长期的随防结果后，已对如此大范围手术的...     

腹腔镜远端胃D2根治术的临床分析

<正>近年来,随着微创外科(MIS)技术的发展,腹腔镜手术越来越流行于治疗一些恶性疾病,尤其是在治疗胃肿瘤方面,特别是针对远端胃。我院自2011年1月至2013年5月行腹腔镜胃癌D2根治术远端胃切除术117例,观察其临床疗效。1临床资料1.1一般资料本组117例,男71例,女46例;年龄37⁸1〔平均(59±22)〕岁;肿瘤部位:胃窦及幽门区癌63例,胃角39     

FOLFOX、XELOX方案联合腹腔镜治疗进展期胃癌的研究

背景:单一的手术、放疗、化疗对进展期胃癌疗效均欠佳,近年来多学科协作诊治模式(MDT)越来越受重视。目的:探讨术前FOLFOX、XELOX化疗方案联合腹腔镜治疗进展期胃癌的疗效。方法:纳入2009年2月~2013年2月新疆生产建设兵团第一师医院和新疆生产建设兵团医院收治的进展期胃癌患者,给予FOLFOX或XELOX化疗方案联合腹腔镜胃癌D2根治术,对两种治疗方案的疗效进行比较分析。结果:共54例患者纳入研究,FOLFOX组29例,XELOX组25例。化疗后临床完全缓解(CR)7例,部分缓解(PR)23例,疾病稳定(SD)15例,疾病进展(PD)9例,总有效率(RR)为55.6%(30/54),FOLFOX、XELOX组间疗效差异无统计学意义(P0.05)。XELOX组患者恶心、呕吐、骨髓抑制以及腹泻的发生率显著低于FOLFOX组(P0.05),口腔黏膜炎、手足综合征的发生率显著高于FOLFOX组(P0.05)。45例患者经腹腔镜切除肿瘤,9例患者行腹腔镜探查术,未切除肿瘤,FOLFOX、XELOX组间手术切除率差异无统计学意义(P0.05)。FOLFOX、XELOX组术后病理分期均较治疗前显著降低(P0.05)。结论:术前FOLFOX、XELOX方案联合腹腔镜治疗进展期胃癌疗效相似,具有良好的有效性和安全性。     

腹腔镜在胃肠外科的应用

自1987年法国医师Mouret首次完成腹腔镜胆囊切除术以来,腹腔镜技术在世界范围内广泛普及并形成一门新的学科-腹腔镜外科学.腹腔镜是集电学、光学等高科技为一体的一门新的技术,最初用于胆囊的切除,随着对腹腔镜认识的提高、技术的改进、设备及器械的更新,目前已广泛应用于普通外科的每个领域.本文就腹腔镜在胃肠外科的应用作一概述.     

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。     

三重性早期胃癌1例

男，71岁．因厌油、纳差、乏力、消瘦1”mo入院．查体：一般情况尚可，巩股不黄，全身残表淋巴结无肿大，腹平软，肝脾助缘下未及，未触及局部包块，上腹部轻压痛．肝功能检查正常；B超提示：胆囊息肉；纤维内镜报告：距门齿50crn冒体前壁见一0．3cruX04crn大小息肉样隆起，幽门前壁见结节状隆起，活切清理报告：（胃窦）低分化腺癌；（胃体）管状腺癌；胃体、胃窦多源癌．1998－0509在气管内全麻下经胶行胃癌根治术．术中探查：冒壁光滑，鲁窦部可及一个约0．IcrnXO．scrnXlctn包块，质软，胃体部未及明显肿块，但在贲门部粘膜面可及一…     

加速康复外科理念在老年患者腹腔镜辅助胃癌根治术中的应用

目的探讨实施腹腔镜辅助胃癌根治术老年患者应用加速康复外科理念(ERAS)的效果及安全性。方法入选铜陵市人民医院胃肠外科2015年12月至2018年12月拟行腹腔镜辅助胃癌根治术患者80例,随机数表法分为ERAS组和常规组,每组40例,比较2组患者术后相关指标和并发症。应用SPSS 22.0统计软件对数据进行分析。依据数据类型,采用t检验或χ2检验进行组间比较。结果相比常规组,ERAS组术后首次通气时间[(53.77±23.53)和(64.24±22.44)h]、首次排便时间[(60.92±22.15)和(75.10±22.25)h]、首次下床活动时间[(18.77±3.27)和(26.67±4.29)h]、首次经口流质饮食时间[(22.26±9.64)和(89.47±13.39)h]、肠外营养时间[(5.43±1.57)和(7.46±1.45)d]、腹腔引流管拔除时间[(4.90±1.24)和(6.60±1.04)d]和住院时间[(8.73±1.80)和(10.83±2.07)d]短,术后住院费用[(5.35±0.58)万元和(6.06±0.65)万元]低,差异均有统计学意义(P<0.05)。ERAS组相比常规组咽喉疼痛[7.5%(3/40)和27.5%(11/40)]、切口疼痛>Ⅱ级[5.0%(2/40)和20.0%(8/40)]、术后并发症Clavien-DindoⅠ级[17.5%(7/40)和37.5%(15/40)]发生率低,差异均具有统计学意义(P<0.05)。结论ERAS在老年患者腹腔镜胃癌根治术中应用安全有效,可降低术后并发症Clavien-DindoⅠ级发生率。     

胃癌的手术治疗240例

目的探讨胃癌（GC）的诊断方法和手术治疗．方法本文对1968－08／1998－05经手术治疗的240例胃癌进行了回顾性研究．诊断方法包括临床症状、钡餐检查、纤维内镜检查和病理学诊断．手术方法计有根治性切除、姑息性切除、姑息性手术、仅限于剖腹探查和切取活检．结果临床症状最多的是胃部不适、上腹疼痛、消瘦和食欲不振，体征最多的是上腹压痛．在化验检查中，34．5％血红蛋白过低、粪潜血阳性者居多（56．2％）、血型分布中以A型居多（34．6％）．纤维内镜的诊断符合率（92．0％）高于钡餐检查（83．6％），差异无显著性（x2＝3．40，P＞0．05）．病变部位分布于鲁窦者最多（55．4％），在胃癌分期中早期胃癌仅有6例（2．5％）绝大多数为进展期．手术切除率为85．5％（206／240），其中根治性切除率为63．6％（131／206），姑息性切除率为36．4％（75／206）．治疗结果：近期治愈120例（50．0％），好转或有效78例（32．5％），无效29例（12．1％），恶化8例（3．3％），死亡5例（2．1％），治愈好转率为82．5％结论在胃癌的检查中，纤维内镜检查的诊断符合率最高；在胃癌的治疗中，手术治疗的治愈好转率最高     

中国腹腔镜外科进展

腹腔镜作为一种有效的腹内疾病诊断手段在临床已应用多年,主要是妇科应用．经过多年实践,仪器不断更新,到２０世纪８０年代,一些治疗用的剪刀、施夹器、持针器等相继问世,一些妇科简单治疗手术逐步开展．器械的补充和技术的提高为开展外科手术创造了条件．法国的Ｍｏ...     

早期胃癌的内镜治疗

早期胃癌的内镜治疗山东医科大学（２５００１２）顾晓萌目前，早期胃癌的内镜治疗技术分为两类，即组织切除术和组织破坏术（包括激光、微波、电凝电切和纯酒精注射等）。前者是内镜治疗早期胃癌的首选方法，可以达到根治的目的；后者虽能破坏癌肿组织，但无法进行病理组...     

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。     

Worldwide practice in gastric cancer surgery

AIM: To evaluate the current status of gastric cancer surgery worldwide.METHODS: An international cross-sectional survey on gastric cancer surgery was performed amongst international upper gastro-intestinal surgeons. All surgical members of the International Gastric Cancer Association were invited by e-mail to participate. An English web-based survey had to be filled in with regard to their surgical preferences. Questions asked included hospital volume, the use of neoadjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. The invitations were sent in September 2013 and the survey was closed in January 2014.RESULTS: The corresponding specific response rate was 227/615 (37%). The majority of respondents: originated from Asia (54%), performed > 21 gastrectomies per year (79%) and used neoadjuvant chemotherapy (73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer (91%) and total gastrectomy for both early and advanced cancer (52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer (65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also (63%). A D1+ lymphadenectomy was preferred in early gastric cancer (52% for distal, 54% for total gastrectomy) and a D2 lymphadenectomy was preferred in advanced gastric cancer (93% for distal, 92% for total gastrectomy)CONCLUSION: Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neoadjuvant chemotherapy, minimally invasive techniques are still not widely adapted.     

Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review

AIM: To report a systematic review,establishing the available data to an unpublished 2a strength of evidence,better handling clinical practice.METHODS: A systematic review was performed using MEDLINE,EMBASE,Cochrane,LILACS,Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants,inclusion and exclusion criteria,interventions(mainly,mucosal resection and submucosal dissection vs surgical approach) and outcomes(adverse events,different survival rates,mortality,recurrence and complete resection rates). To ascertain the validity of eligible studies,the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software Rev Man,by computingrisk differences(RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ2 and the Higgins method(I2). Sensitivity analysis was performed when heterogeneity was higher than 50%,a subsequent assay was done and other findings were compiled.RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Threeyear survival data were available for six studies(n = 1197). There were no risk differences(RD) after endoscopic and surgical treatment(RD = 0.01,95%CI:-0.02-0.05,P = 0.51). Five-year survival data(n = 2310) showed no difference between the two groups(RD = 0.01,95%CI:-0.01-0.03,P = 0.46). Recurrence data were analized in five studies(1331 patients) and there was no difference between the approaches(RD = 0.01,95%CI:-0.00-0.02,P = 0.09). Adverse event data were identified in eight studies(n = 2439). A significant difference was detected(RD =-0.08,95%CI:-0.10--0.05,P 0.05),demonstrating better results with endoscopy. Mortality data were obtained in four studies(n = 1107). There was no difference between the groups(RD =-0.01,95%CI:-0.02-0.00,P = 0.22).CONCLUSION: Three-,5-year survival,recurrence and mortality are similar for both groups. Considering complication,endoscopy is better and,analyzing complete resection data,it is worse than surgery.     

Laparoscopic vs open D2 gastrectomy for locally advanced gastric cancer: A meta-analysis

AIM:To conduct a meta-analysis comparing laparoscopic(LGD2)and open D2 gastrectomies(OGD2)for the treatment of advanced gastric cancer(AGC).METHODS:Randomized controlled trials(RCTs)and non-RCTs comparing LGD2 with OGD2 for AGC treatment,published between 1 January 2000 and 12January 2013,were identified in the Pub Med,Embase,and Cochrane Library databases.Primary endpoints included operative outcomes(operative time,intraoperative blood loss,and conversion rate),postoperative outcomes(postoperative analgesic consumption,time to first ambulation,time to first flatus,time to first oralintake,postoperative hospital stay length,postoperative morbidity,incidence of reoperation,and postoperative mortality),and oncologic outcomes(the number of lymph nodes harvested,tumor recurrence and metastasis,disease-free rates,and overall survival rates).The Cochrane Collaboration tools and the modified Newcastle-Ottawa scale were used to assess the quality and risk of bias of RCTs and non-RCTs in the study.Subgroup analyses were conducted to explore the incidence rate of various postoperative morbidities as well as recurrence and metastasis patterns.A Begg’s test was used to evaluate the publication bias.RESULTS:One RCT and 13 non-RCTs totaling 2596patients were included in the meta-analysis.LGD2 in comparison to OGD2 showed lower intraoperative blood loss[weighted mean difference(WMD)=-137.87 m L,95%CI:-164.41--111.33;P<0.01],lower analgesic consumption(WMD=-1.94,95%CI:-2.50--1.38;P<0.01),shorter times to first ambulation(WMD=-1.03d,95%CI:-1.90--0.16;P<0.05),flatus(WMD=-0.98d,95%CI:-1.30--0.66;P<0.01),and oral intake(WMD=-0.85 d,95%CI:-1.67--0.03;P<0.05),shorter hospitalization(WMD=-3.08 d,95%CI:-4.38--1.78;P<0.01),and lower postoperative morbidity(odds ratio=0.78,95%CI:0.61-0.99;P<0.05).No significant differences were observed between LGD2 and OGD2 for the following criteria:reoperation incidence,postoperative mortality,number of harvested lymph nodes,tumor recurrence/metastasis,or three-or five-year diseasefree and overall survival rates.However,LGD2 had longer operative times(WMD=57.06 min,95%CI:41.87-72.25;P<0.01).CONCLUSION:Although a technically demanding and time-consuming procedure,LGD2 may be safe and effective,and offer some advantages over OGD2 for treatment of locally AGC.     

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.     

Totally laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis of outcomes compared with open surgery

AIM: To systematically review the surgical outcomes of totally laparoscopic gastrectomy (TLG) vs open gastrectomy (OG) for gastric cancer.METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted. All original studies comparing TLG with OG were included for critical appraisal. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.RESULTS: One RCT and 13 observational studies involving 1532 patients were included (721 TLG and 811 OG). TLG was associated with longer operation time [weighted mean difference (WMD) = 58.04 min, 95%CI: 37.77-78.32, P < 0.001], less blood loss [WMD = -167.57 min, 95%CI: -208.79-(-126.34), P < 0.001], shorter hospital stay [WMD = -3.75 d, 95%CI: -4.88-(-2.63), P < 0.001] and fewer postoperative complications (RR = 0.71, 95%CI: 0.58-0.86, P < 0.001). The number of harvested lymph nodes, surgical margin, mortality and cancer recurrence rate were similar between the two groups.CONCLUSION: TLG may be a technically safe, feasible and favorable approach in terms of better cosmesis, less blood loss and faster recovery compared with OG.     

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently....     

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently....     

D2 dissection in laparoscopic and open gastrectomy for gastric cancer

AIM: To evaluate the radicalness and safety of laparoscopic D2 dissection for gastric cancer. METHODS: Clinicopathological data from 209 patients with gastric cancer, who underwent radical gastrectomy with D2 dissection between January 2007 and February 2011, were analyzed retrospectively. Among these patients, 131 patients underwent laparoscopyassisted gastrectomy (LAG) and 78 underwent open gastrectomy (OG). The parameters analyzed included operative time, blood loss, blood transfusion, morbidity, mortality, the number of harvested lymph nodes (HLNs), and pathological stage.RESULTS: There were no significant differences in sex, age, types of radical resection [radical proximal gastrectomy (PG + D2), radical distal gastrectomy (DG + D2) and radical total gastrectomy (TG + D2)], and stages between the LAG and OG groups (P 0.05). Among the two groups, 127 cases (96.9%) and 76 cases (97.4%) had 15 or more HLNs, respectively. The average number of HLNs was 26.1 ± 11.4 in the LAG group and 24.2 ± 9.3 in the OG group (P = 0.233). In the same type of radical resection, there were no signifi cant differences in the number of HLNs between the two groups (PG + D2: 21.7 ± 7.5 vs 22.4 ± 9.3; DG + D2: 25.7 ± 11.0 vs 22.3 ± 7.9; TG + D2: 30.9 ± 13.4 vs 29.3 ± 10.4; P 0.05 for all comparisons). Tumor free margins were obtained in all cases. Compared with OG group, the LAG group had signifi cantly less blood loss, but a longer operation time (P 0.001). The morbidity of the LAG group was 9.9%, which was not signifi cantly different from the OG group (7.7%) (P = 0.587). The mortality was zero in both groups. CONCLUSION: Laparoscopic D2 dissection is equivalent to OG in the number of HLNs, regardless of tumor location. Thus, this procedure can achieve the same radicalness as OG.