胃间质瘤行胃镜联合腹腔镜手术的护理配合体会

胃肠道间质瘤是胃肠道最常见的间叶组织来源的肿瘤,其中胃间质瘤约占60%[1],胃间质瘤是潜在恶性肿瘤,主要以血行传播为主,因此单纯胃间质瘤楔形切除术已成为目前外科实践中的经典术式[2],近年腹腔镜微创技术发展迅速,广泛应用于胃肠道肿瘤手术,是目前治疗胃间质瘤的最佳方式[3],由于较小的胃间质瘤在腔镜下定位困难,给单纯腹腔镜手术切除增加了难度,随着内镜技术的成熟,腹腔镜与胃镜联合胃间质瘤切除术逐渐应用于临床[4]。围术期结合加速康复外科的理念,我们将胃间质瘤胃镜联合腹腔镜切除术的护理配合进一步规范[5],现将配合经验总结如下。     

腹腔镜胃切除术治疗胃间质瘤的临床经验

胃肠道间质瘤(gastrointestinal stromal tumor,GIST)是一种由间叶组织内Cajal细胞分化而来的少见肿瘤,可发生在整个胃肠道,以胃和小肠最为常见[1].在欧洲其发病率为(1.4～2.0)/10万[2].开腹手术完整切除病灶为传统首选治疗方式.近年来随着微创技术的发展,更符合现代外科理念的腹腔镜胃间质瘤切除术得到外科医师的广泛推崇.本研究回顾性分析2009年6月至2012年9月于南方医科大学附属佛山医院普通外科微创中心行腹腔镜胃间质瘤切除术的21例患者的临床资料,旨在总结其治疗经验. 1 资料与方法 1.1 一般资料 本组GIST患者21例,男8例,女13例;年龄24～72岁,中位年龄55岁.肿瘤直径为4～9 cm,中位直径为4,2 cm.患者肿瘤位于胃体区3例、胃幽门区5例、胃底贲门区13例.患者术前均经胃镜及腹部CT检查确诊.     

˫�����ϼ�����θ���������������е�Ӧ�ü�����

近年来,内镜和腹腔镜治疗技术发展迅速。然而,单纯内镜或腹腔镜治疗均有其局限性,双镜联合治疗弥补了其不足,拓宽了微创技术的应用领域。胃肠道间质瘤(gastrointestinal stromal tumor,GIST)是消化道最常见的间叶来源肿瘤,手术切除是其首选的治疗方式。GIST的生物学特性决定了双镜联合技术应用于GIST的诊疗具有成熟的理论基础和极好的前景。     

达芬奇机器人胃间质瘤切除术的围手术期护理

<正>胃肠道间质瘤(gastrointestinal stromal tumors,GIST)是消化道最常见的间叶组织源性肿瘤,60%~70%的胃间质瘤发生于胃部~([1])。手术切除是胃间质瘤的首要治疗措施。结合加速康复外科(enhanced recovery after surgery,ERAS)的理念(旨在术前、术中及术后应用各种已经证实有效的方法减少手术应激及并发症,加速术后康复~([2]))及达芬奇机器人微创     

胃肠道间质瘤外科治疗十年回顾与展望

外科治疗是胃肠道间质瘤(GIST)的首选治疗措施.近10年来研究者对手术原则达成了共识和规范,有效地指导了GIST的规范治疗.腹腔镜技术、内镜技术作为微创治疗手段快速介入到GIST的治疗中,推动了GIST诊断与治疗共识的不断更新和发展,腹腔镜逐渐成为治疗GIST的主要手段之一,多学科团队协作诊断与治疗模式已现雏形.本文结合我们的病例资料,回顾10年来GIST外科治疗的进展,展望可预期的趋势.     

胃肠道间质瘤的手术治疗

胃肠道间质瘤(GIST)可以发生于胃肠道、网膜、肠系膜或腹膜表面,其中约60％发生于胃.GIST的手术治疗原则是尽量完整切除病灶.对于转移复发的GIST,手术仅限于解决穿孔、梗阻、出血等并发症.绝大部分胃间质瘤可以局部或楔形切除.位于贲门周围的间质瘤,如果局部切除后可能造成贲门狭窄,可以采取近端胃切除.胃窦小弯侧的间质瘤可以酌情进行远端胃切除,胃间质瘤患者极少实施全胃切除.发生于胃体大弯侧的间质瘤常需要联合脾、胰尾、横结肠切除.十二指肠间质瘤尽量采取局部切除,有经验的中心可以行胰十二指肠切除术.小肠间质瘤手术操作时避免肿瘤破裂,一旦发现肿瘤侵犯周围脏器、结构,应该果断采取联合脏器切除.直肠间质瘤原则上采取低位前切除,避免腹会阴联合手术.     

代谢综合征合并多发胃间质瘤行腹腔镜袖状胃切除术1例报告

全球肥胖人口的快速增长促进了减重外科的迅速发展,胃肠道间质瘤( gastrointestinal stromal tumors,GIST)患者行腹腔镜袖状胃切除术( laparoscopic sleeve gastrectomy,LSG)的病例报道也逐渐增加,但大部分为术后病理意外发现或联合手术切除.GIST是少见的胃...     

靶向治疗时代胃肠间质瘤的外科理念

胃肠间质瘤（GIST）是胃肠道最常见的间质肿瘤。长期以来外科治疗是首选也是惟一的治疗手段,随着GIST靶向治疗的到来,外科治疗模式也不断发展。无论是手术原则、手术技术、手术时机,还是手术联合靶向治疗为主的多学科治疗模式,都在循证医学的基础上进行了细化和发展。外科完全切除仍是原发局限可切除GIST治疗的金标准。而对于进展期GIST,靶向治疗的介入彻底改变了此类病人的预后。对伊马替尼治疗有效的进展期GIST病人,联合外科手术切除为主的综合治疗模式是目前研究的热点。     

486例胃肠道间质瘤的外科治疗

目的 根据不同部位胃肠道间质瘤(GIST)的临床特点,总结其外科手术治疗方式.方法 回顾性分析2003年1月至2012年12月北京协和医学院经过手术治疗的486例GIST患者的临床资料.原发GIST 461例,继发GIST 25例.对患者临床特征、手术方式进行分析.计数资料以百分比表示,采用x2检验.结果 本组461例原发GIST患者中,6例食管间质瘤患者均行食管部分切除术;234例胃间质瘤患者中,行胃部分切除术183例、近端胃+贲门切除术23例、远端胃切除术23例、全胃切除术2例、剖腹探查3例;51例十二指肠间质瘤患者中,行十二指肠局部切除术34例、胰十二指肠切除术9例、保留幽门胰十二指肠切除5例、姑息性手术3例;116例小肠间质瘤患者中,行小肠部分切除110例、姑息性手术6例;29例直肠间质瘤患者中,行经骶经肛门括约肌直肠肿瘤切除术13例、经肛门直肠肿瘤切除术12例、经腹会阴联合切除术4例;25例其他部位的原发GIST患者均行开腹手术.25例继发GIST患者中,肝转移患者行肝段切除10例、肝活组织检查1例;腹盆腔肿瘤切除6例;小肠或结肠部分切除5例,乙状结肠切除1例;脾切除及颅内肿瘤切除各1例.461例原发GIST患者中,联合原发部位以外脏器切除占12.58％(58/461),其中联合胆囊切除比例最高,占34.5％(20/58).最易出现联合脏器切除的GIST依次为十二指肠间质瘤、胃间质瘤、小肠间质瘤.腹腔镜手术占总手术的20.39％(94/461),其中近5年腹腔镜手术占总手术的28.52％ (77/270),与前5年的8.90％(17/191)比较,差异有统计学意义(x2=36.67,P＜0.05).结论 根据不同部位GIST的临床特点,采用包括微创手术在内的不同手术方式,完整切除肿瘤是主要目标.     

腹腔镜手术治疗胃间质瘤18例临床分析

胃肠道间质瘤（gastrointestinal stromal tumors,GIST）极少发生淋巴结转移,故治疗上无需行大范围淋巴结清扫,对〈5cm者行病灶局部切除即可。随着腹腔镜手术器械的发展和操作技术的成熟,越来越多的胃肠外科医师更乐于采用微创技术处理胃间质瘤。现就我院2005年1月～2006年1月实施的18例腹腔镜胃间质瘤切除术的临床经验,现报道如下。     

内镜治疗胃胃肠间质瘤的可行性

近年来,随着消化内镜技术的发展,以内镜黏膜下剥离术（ESD）及其衍生技术包括内镜黏膜下挖除术（ESE）、内镜下全层切除技术（EFR）、内镜经隧道肿瘤切除术（STER）和腹腔镜内镜联合手术（LECS）等的内镜切除技术可治疗绝大多数的胃GIST。本文就内镜治疗胃GIST的指征、方法和疗效评价进行评述。     

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

BACKGROUND: Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size. METHODS: Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. RESULTS: In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases. CONCLUSIONS: The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.     

��ǻ��������θθ�������������е�Ӧ�ü�ֵ������

??Application value and controversy of laparoscopic surgery in gastric GIST XU Ze-kuan, XU Hao, LI Feng-yuan. Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
Corresponding author: XU Ze-kuan, E-mail??xuzekuan@njmu.edu.cn
Abstract Gastrointestinal stromal tumor (GIST) has unique biological and clinical characteristics. Surgical treatment and molecular targeted therapy are the main means of gastric GIST. With the rapid development of laparoscopic technology in recent years, laparoscopic surgery for gastric GIST has gradually replaced the traditional open operation and has become a trend in the future. However, the laparoscopic treatment of gastric GIST for the size of gastric GIST and the special part of the stomach is still controversial. From the update of NCCN treatment guideline, the size limitation of laparoscopic treatment of gastric GIST can be broken. It depends on the location of tumor lesions, the professional level of doctors and the degree of cooperation of medical teams. For the special part of the gastric GIST, the surgeon can choose the operative method flexibly according to its particularity to achieve the purpose of complete resection of the tumor and preserve the function of the stomach.     

腹腔镜和内镜联合手术在早期胃癌治疗中应用价值

早期胃癌的手术治疗正由追求传统和标准化转向微创化、精准化和个体化发展,即从单纯强调根治转变为根治与保留功能并重。腹腔镜和内镜联合手术（LECS）是其中的重要实践,该术式既可对内镜治疗下难以处理的早期胃癌病灶进行局部精准切除,又能够对潜在的转移淋巴结进行清扫。尽管目前暂无更多大型临床试验验证此类术式的有效性和安全性,但经过近20年的实践,已证明LECS是一种具有临床可操作性并能提高病人获益的治疗手段,LECS+前哨淋巴结导航手术将是未来早期胃癌治疗的重要发展方向。     

腹腔镜技术在胃胃肠间质瘤手术中的应用价值与争议

胃肠间质瘤（GIST）具有独特的生物学行为与临床特征。外科手术治疗和分子靶向治疗是胃GIST的主要手段。近年来随着腹腔镜技术的快速发展,胃GIST的腹腔镜手术治疗逐渐替代传统开放手术,并成为未来发展的趋势。但行腹腔镜手术治疗时,对于胃GIST的大小和特殊部位的胃GIST目前仍存在争议。从美国国家综合癌症网络（NCCN）治疗指南的更新中看出,对腹腔镜手术治疗胃GIST的大小限制是可以打破的,关键取决于肿瘤病变的部位、医生专业水平和医疗团队配合的程度。对于特殊部位的胃GIST,外科医生可根据其特殊性尝试灵活选择术式以达到完整切除肿瘤和保留胃功能的目的。     

腹腔镜手术治疗胃间质瘤的现状与进展

外科手术的完整切除被视为治疗胃间质瘤的主要手段。随着手术技术和器械的发展以及微创治疗理念的流行,越来越多的腹腔镜手术切除胃间质瘤的案例和研究被报道,同时也从一定角度上描述了腹腔镜治疗的相对优势和不足之处。笔者结合近年文献拟就胃间质瘤的腹腔镜手术治疗相关问题作简要综述。     

105例胃GIST的手术治疗

目的:探讨不同部位胃胃肠间质瘤(G IST)的临床病理学特点及手术治疗方式。方法:回顾性分析2010年1月—2014年8月江苏省苏北人民医院经手术治疗的105例胃G IST患者的临床病理资料。结果:本组105例胃G IST患者中,行开放手术65例,行腹腔镜手术21例,行内镜手术12例,行腹腔镜内镜联合手术7例;行近端胃切除术26例,远端胃切除术23例,全胃切除术2例,胃楔形切除术41例,肿瘤剥除术13例。内镜、腹腔镜及双镜联合微创手术占总手术比为38.1%(40/105)。结论:胃G IST的手术治疗方案(尤其是微创手术治疗)应根据肿瘤的部位、大小以及生物学行为的不同而定。完整切除肿瘤以及尽可能多地保留功能是胃G IST手术治疗的主要目标。     

Laparoscopic Intragastric Surgery for Early Gastric Cancer and Gastrointestinal Stromal Tumors

Background

T1a gastric cancer and gastrointestinal stromal tumors (GIST) often require extensive resection despite their favorable tumor biology. This holds especially true for lesions located at the gastroesophageal junction. In this video we will demonstrate an oncologically sound technique of laparoscopic intragastric surgery that allows for safe and effective tumor resection.

Methods

The first patient has a T1a gastric adenocarcinoma with no adverse features at the gastroesophageal junction. The tumor is resected with multiple cuffed ports placed directly into the stomach. The specimen is removed via the mouth. The next video shows the use of multi-port access to resect a 6 cm GIST at the cardia. An endoloop is used to provide safe manipulation with minimal handling of the GIST itself. The third patient has a small 1.5 cm GIST, and a single incision access device is used for stapled removal of this tumor located at the gastroesophageal junction.

Results

The video shows safe and feasible techniques for intragastric surgery to remove early gastric cancer and GIST. We demonstrate the use of multiple ports and single access, as well as stapling inside the stomach.

Conclusions

The technique of intragastric laparoscopic surgery allows for safe removal of T1a gastric cancer too extensive for endoscopic resection. At this point, gastric adenocarcinomas of <4–5 cm, with no submucosal, lymphatic, or vascular invasion or ulceration and no suspicion for lymph node metastasis should undergo this treatment. Excellent visualization, the ability to perform full-thickness resection and manage perforations make this new technique an excellent treatment option for early gastric cancer and GIST.     

Gastrointestinale Stromatumoren aus chirurgischer Sicht

Gastrointestinal stromal tumors (GIST) are the most frequent soft tissue tumors of the gastrointestinal tract. The demonstration of KIT expression (CD117) defined GIST as a distinct tumor entity. Despite many improvements in the medical therapy, complete tumor resection remains the standard treatment for resectable GIST and is the precondition for cure. Data concerning the role of laparoscopic surgery are sparse, but small gastric GIST (<5 cm) could be a good indication for laparoscopic procedures. In principle laparoscopic GIST resections should be performed only by interdisciplinary teams of surgeons and gastroenterologists experienced in laparoscopy, endoscopy, and oncology.