影响胃癌术后复发及预后的相关因素分析

目的：探讨胃癌术后复发的时间规律以及远期预后评估指标。 方法：将25年间经笔者所在医院科室诊治的胃癌术后复发的447例患者按照复发间隔期（第1次手术至复发的时间）的长短分为2组：A组为术后<2年复发, B组为术后2~5年复发。用Kaplan-Meier法计算两组术后生存率,以Cox模型进行多变量分析。 结果：胃癌术后复发的患者占同期胃癌手术患者的29.3%（447/1 526）,其中312例（69.8%)于2年内复发(A组),135例（30.2%）于2~5年内的复发(B组)。单因素分析显示,无病生存期、病灶部位、肿瘤大体类型、病理分型、肿瘤分期、手术性质以及复发类型(局部,远处)等因素对胃癌术后复发患者的累计生存率有显著影响（均P<0.05）,其中病灶在胃底、Borrmann Ⅲ型、黏液腺癌、手术方式为D0、肿瘤TNM分期为Ⅳ期的患者2年内复发的构成比较其他患者明显高,在2年内复发的患者中局部复发所占的比例相对较大。多因素分析显示无病生存期、肿瘤分期和肿瘤大体类型是胃癌术后复发患者的累计生存率的独立影响因素。无病生存期和无进展生存期均与术后复发患者的生存期呈正相关。 结论：胃癌术后复查至少应持续5年,前2年每3个月复查1次,之后每3~6个月复查1次,无病生存期和无病进展生存期可作为胃癌复发患者远期治愈和预后的最佳预测指标。     

胃癌术后复发的临床分析

目的 研究胃癌术后复发的临床特点,总结处理经验.方法 回顾性分析2002年1月至2008年12月收治的78例胃癌术后复发病例的临床资料.结果 本组78例胃癌术后复发患者的中位复发时间为术后16.8个月.多因素分析显示首次手术的根治程度、切缘情况、肿瘤分化程度、TNM分期直接影响肿瘤的复发时间(P＜0.05).术后复发转移部位与首次胃癌手术方式无明显关系(P＞0.05).再手术36例,其中因单一肝转移行肝叶或肝段切除3例,因局部复发再手术33例.结论 首次手术的根治程度、切缘情况、肿瘤分化程度、TNM分期是胃癌术后复发的主要因素.应根据具体情况采取包括手术在内的综合治疗积极措施,以改善患者的生活质量及预后.     

胃癌术后复发及其相关因素分析

目的探讨胃癌术后复发的形式及影响胃癌术后复发的独立因素。方法总结分析225例胃癌患者根治性手术后肿瘤复发的情况,并采用Logistic多因素回归分析,对可能影响胃癌术后复发的15个临床病理因素和治疗措施进行分析。结果胃癌术后复发率为37.3%(84/225),其中腹膜复发47.6%(40/84),血源性转移复发33.3%(28/84),区域局部复发15.5%(13/84),远处淋巴结转移复发3.6%(3/84)。术后2年内复发者75.0%(63/84),2年后复发者25.0%(21/84)。Logistic多因素回归分析显示:影响胃癌患者术后复发的独立因素依次为T、N分级,术后早期腹腔化疗;影响术后腹膜复发的独立因素依次为T分级,肿瘤大体分型,术后早期腹腔化疗;影响术后血源性转移复发的独立因素依次为T、N分级,术前区域性动脉灌注化疗;影响术后区域局部复发的独立因素依次为病期,肿瘤部位,肿瘤大体分型。结论胃癌术后复发大部分发生在术后2年内,以腹膜复发和血源性复发常见。T、N分级和术后早期腹腔化疗是影响胃癌术后复发的独立因素。     

直肠癌根治术后局部复发多因素分析

探讨直肠癌根治术后局部复发的相关因素,为直肠癌治疗提供理论根据。回顾性分析346例直肠癌根治手术病例临床资料和随访结果,比较各临床资料与复发的关系。结果显示,直肠癌术后局部复发48例（13．9％）,其中合并远处转移复发29例（8．4％）;多因素分析表明,肿瘤部位,输血与否,分化程度,病理类型,Dukes分期,CEA水平,有无淋巴转移和是否行全直肠系膜切除术与术后局部复发相关,而性别、年龄、手术方式、术后化疗与否等与术后局部复发无关。结果表明,术后局部复发与病理分期晚、分化程度低、肿瘤位置低及复查时CEA水平高、有淋巴转移和未行全直肠系膜切除术有关。为预防复发宜做好首次手术,对复发病例力争早发现并给予再次手术为主的综合治疗,以延长生存期。     

Ⅱ、Ⅲ期胃癌病人术后治疗失败模式及危险因素分析

目的 探讨Ⅱ、Ⅲ期胃癌病人的术后治疗失败模式及其影响因素。方法 回顾性分析2010年1月至2013年12月福建医科大学附属协和医院胃外科收治的875例行根治性切除手术的Ⅱ、Ⅲ期胃癌病人的临床资料,其中术后治疗失败407例（治疗失败组）,无术后治疗失败468例（无治疗失败组）。术后治疗失败定义为手术后首次发现任何部位复发或任何原因死亡。通过Kaplan-Meier累积风险曲线、COX比例风险模型分析术后治疗失败的影响因素,并用韦恩图和核密度曲线展示术后治疗失败模式。结果 治疗失败组与无治疗失败组病人在远侧胃切除率、术前CA19-9水平、术前癌胚抗原（CEA）水平、肿瘤大小以及pN分期方面差异有统计学意义（P均＜0.05）。多因素分析发现,术前CA19-9水平≥37 kU/L、术前CEA水平≥5 μg/L、肿瘤部位、pN分期、严重并发症为影响Ⅱ、Ⅲ期胃癌病人术后治疗失败的独立危险因素,而术后辅助化疗是其独立保护因素。竞争风险分析术后治疗失败模式显示,Ⅱ、Ⅲ期胃癌病人远处器官复发、腹膜复发、局部复发和无复发死亡的3年累积发生率分别为20.4%、10.0%、7.9%和5.1%。根据3个月的时间间隔拟合所有病例的治疗失败风险曲线显示,治疗失败风险率峰值在术后第16.7个月出现,峰值为0.0143,随后逐渐下降,大部分治疗失败事件发生于术后36个月内。分层分析显示,尽管局部复发、腹膜复发和无复发死亡呈现出相似的达峰时间和风险峰值,但远处器官复发的达峰时间最早,且峰值显著高于其他失败类型（达峰时间14.5个月,风险峰值0.0074）。结论 不良的肿瘤学特征与Ⅱ、Ⅲ期胃癌病人术后治疗失败密切相关,而术后辅助化疗是其独立保护因素。对于Ⅱ、Ⅲ期胃癌病人早期随访应重视远处器官复发的筛查。     

原发性腹膜后肿瘤手术后复发因素分析

目的　探讨原发及复发腹膜后肿瘤手术治疗经验 ,并分析影响肿瘤术后复发的因素。方法　回顾性分析 1983～ 2 0 0 0年原发性腹膜后肿瘤 35 2例 ,并进行术后肿瘤复发的多因素回归分析。结果　手术 30 8例 ,恶性肿瘤 188例 ,良性肿瘤 12 0例。多因素分析显示 :男性、恶性肿瘤、肿瘤残留者、肿瘤与腹主动脉关系密切者易复发 ,脂肪肉瘤、平滑肌肉瘤、血管外皮细胞肉瘤是易复发的病理类型。结论　原发及复发性腹膜后肿瘤多数可行手术治疗 ,通过对影响复发诸因素分析可预测患者的预后。     

原发性腹膜后肉瘤的外科治疗68例临床报告

目的探讨原发性腹膜后肉瘤的诊断与治疗。方法对2000年1月至2010年1月经手术治疗的68例原发性腹膜后肉瘤的临床资料进行回顾性分析。结果原发性腹膜后肉瘤病理类型多样,本组68例中恶性纤维组织瘤9例,脂肪肉瘤33例,平滑肌肉瘤9例,未分化肉瘤7例,滑膜肉瘤4例,恶性外周神经鞘瘤6例。其中术后局部复发43例,5年存活率广泛切除为29%,局部切除的为43%。结论原发性腹膜后肉瘤的临床表现多为无症状性包块,组织学类型复杂,以脂肪肉瘤多见,预后与手术的彻底性和病理类型相关。     

直肠癌前切术后局部复发的临床分析

目的探讨直肠癌前切除术后局部复发的相关因素及防治措施。方法对我院1993年1月～2002年12月年行直肠癌前切除术412例病人作一回顾性分析。结果总共有42例患者术后局部复发;按照病理类型为印戒细胞癌、低分化粘液腺癌、低分化腺癌、中高分化腺癌,其局部复发率逐渐降低;按Dukes分期A、B、C期的局部复发率逐渐升高,统计学分析有显著性差异(P﹤0.05);肿瘤远侧切缘距离小于3cm占局部复发患者的71.1%;局部复发病例再次手术切除率为19.1%,姑息手术率为23.8%,余行保守或转院化疗。结论直肠癌前切除术后局部复发与肿瘤病理类型、Dukes分期、肿瘤远侧切缘距离等因素相关;早期诊断及再次手术是其重要处理手段;直肠癌前切除术适应症的选择及术中技巧是预防术后局部复发的关键。     

胃癌术后复发因素的分析

回顾性分析胃癌术后复发的主要因素,改进胃癌的诊治措施。方法：回顾性分析1995年1月～1999年12月我科收治的25例胃癌复发行再手术病例。结果：胃癌术后复发的主要部位是腹腔、腹膜、淋巴结和吻合口区,其根本原因是肿瘤组织的浆膜浸润、淋巴清扫术不够彻底和不规范切除(D≤N)以及切缘的潜在阳性。结论：胃癌的疾病分期和合理有效的综合治疗是影响复发的根本原因。胃癌的早诊早治是提高预后和降低术后复发的重要手段。     

直肠癌术后局部复发转移的临床病理因素分析

目的探讨可能导致直肠癌术后局部复发的临床病理因素。方法应用单因素和多因素分析方法,回顾性分析2004年1月至2011年4月期间我院收治的368例直肠癌患者完整临床及病理资料。结果局部复发73例,占同期直肠癌(368例)的19.84%。单因素分析结果显示,直肠癌患者的性别、肿瘤距肛缘距离、肿瘤周径、TNM分期、组织学类型、脉管浸润、肿瘤穿孔、吻合口漏及放化疗与术后局部复发有关(P<0.05),而与年龄、病程、大体类型、肿瘤直径及手术方式无关(P>0.05)。进一步多因素分析结果显示,肿瘤距肛缘距离、肿瘤周径、TNM分期、组织学类型、脉管浸润、肿瘤穿孔及放化疗是术后局部复发转移的危险因素(P<0.05)。结论直肠癌术后局部复发与多种因素有关,脉管浸润是最重要的危险因素。     

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??Reason and treatment of recurrent gastric cancer: an analysis of 127 cases ZHAO Cheng-gong, ZHAO Jiu-wu, WANG Shi-chen. Department of General Surgery, the 105 th Hospital of People’s Liberation Army, Hefei 230031, China Corresponding author??ZHAO Cheng-gong, E-mail??zcg105@sohu.com Abstract Objective To explore the position, intervals and risk factors of recurrent gastric cancer. And provide the basis for preventing the recurrence after gastrectomy for gastric cancer. Methods The clinical data of 127 patients with recurrent gastric cancer admitted from January 2000 to January 2006 at the 105th hospital of People’s Liberation Army were analyzed retrospectively. The recurrent position, intervals, clinicopathologic characters of the tumors and operative fashion of primary tumors were analyzed. Results Recurrence causations were correlated with clinicopathologic characters of the tumors and the operative radical cure area. Celiac were much more than outer stomach in the part recurrence. The ??, ??, ?? type were much more in Bormann classification. Low polarization tumors were much more. Part recurrence were less after complete gastrectomy except celiac recurrence. Cardia circumambience and liver-duodenum ligaments (No. 1, 12) lymph node were more in the outer stomach recurrence. Conclusion Consummate perioperative period treatment may decrease recurrence of gastric cancer. Active surgical treatment should be performed in the local recurrence cases of gastirc cancer.     

胃癌复发的类型、时间和危险因素分析

目的 探讨胃癌复发的类型、复发时间和危险因素,为预测和预防胃癌根治术后复发提供依据。方法 回顾性分析1994年8月至1999年8月我科收治的48例胃癌复发病例的复发类型、复发时间和原发胃癌的临床病理特征,并任取我科同期收治的48例无复发胃癌病例作对照。用单因素和多因素分析研究胃癌复发和短期内复发的相关因素。结果 单因素分析结果显示,复发组病例术前存在盆腔转移结节、浸润深度达浆膜或浆膜以外以及Borrmann分型Ⅲ型和Ⅳ型的比例明显增多,差异具有统计学意义（P〈0.05）。多因素Logistic回归分析表明,浸润深度和Borrmann分型是胃癌复发的高危因素。COX回归分析显示,初发胃癌的浸润深度和腹水是影响胃癌根治手术后早期复发的主要因素。结论 Borrmann分型是胃癌复发的高危因素,腹水是影响胃癌根治手术后早期复发的主要因素,而浸润深度既是胃癌复发的高危因素也是胃癌早期复发的主要因素。     

Surgical Outcomes for Gastric Cancer in the Upper Third of the Stomach

Introduction The proportion of gastric cancers affecting the upper third of the stomach has been increasing. At our surgical service we perform total and proximal gastrectomy for this condition. The purpose of this study was to investigate the surgical outcome of the two operative procedures and determine an optimal surgical approach. Methods Data from 147 patients who underwent resection for gastric cancer affecting the proximal one-third of the stomach were retrospectively analyzed. The patients were classified into a total gastrectomy (TG) group or a proximal gastrectomy (PG) group, and the clinicopathologic characteristics and surgical results were compared. We analyzed survival rates using Kaplan-Meier methods and made comparisons using a log-rank test across the same stage of the gastric cancer. Results From 1992 to 2000, a total of 104 total gastrectomies and 43 proximal gastrectomies for gastric cancer affecting the upper one-third of the stomach were performed. Our investigation revealed significantly different clinicopathologic characteristics in Borrmann type, length of the resection margin, degree of lymph node dissection, and lymph node stage. During the procedure, a combined resection of other organs was performed in 30 TG and 27 PG patients. Postoperative complications developed in 15 TG and 22 PG patients. The cancer recurrence rate was 4.8% for the TG group and 39.5% for the PG group; it was highest when the length of the proximal resection margin was < 1 cm. When we compared 5-year survival rates between the two groups, each at the same cancer stage, a significant difference was noted for stage III and IV gastric cancers. Conclusions Proximal gastrectomy may be performed during the early stage of proximal gastric cancer; but because of the high frequency of complications and cancer recurrence, an additional procedure should be expected afterward. When the cancer stage is advanced, total gastrectomy should be performed with sufficient length of the proximal resection margin.     

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.     

早期胃癌行功能保留手术的价值和关键环节

随着检出率的逐年升高，越来越多的早期胃癌病人得以长期生存。保留功能的胃切除术在确保肿瘤根治的同时，保留胃的正常解剖生理功能，并改善病人术后生活质量，是未来早期胃癌治疗的发展趋势。其最经典的保留幽门的胃切除术，及在前哨淋巴结示踪基础上的胃局部切除术是目前最受关注的保留功能胃切除术式。而以上术式是否会带来肿瘤根治性上的风险、是否会增加手术并发症的发生以及术后病人的生活质量获益程度是影响其作为常规手术开展推广的主要因素。因此，对于目前胃功能保留手术所关注的相关问题进行系统、深入研究，提供有力的循证医学依据，将有助于早期胃癌外科治疗的新一轮革新。     

早期胃癌行保留幽门胃切除术的争议与共识

保留幽门胃切除术是胃中部早期胃癌的缩小手术方式之一，也是重要的保留功能胃切除术，在确保肿瘤学安全性的前提下保留了胃的正常解剖和生理功能，对于病人长期生活质量和营养状况有较好的改善。该术式伴随着早期胃癌检出率的不断提高在日韩得以普及和推广，近年来在国内也逐步开展，其手术适应证、术前准备、手术操作步骤等细节也不断规范，但仍然存在诸多争议和焦点问题。完全腹腔镜较腹腔镜辅助更具微创优势，但对于术中病灶定位有较高的要求；幽门下区的淋巴结清扫趋于更精准，但术前分期尤为重要；而保留幽门胃切除术最主要的并发症则是胃排空障碍，通过术中保护幽门部静脉减少局部水肿，进而降低其发生率成为目前研究的热点。     

Comparison of results of surgery in the upper third and more distal stomach.

The results of surgery for gastric cancer in the upper third of the stomach and the more distal region were compared to explain the comparatively poor outcomes in the former. Characteristics and therapeutic results of 1245 patients who underwent curative gastrectomy (244 with tumors in the upper third of the stomach and 1001 with more distal cancers) were compared. Survival was significantly lower in patients with cancer of the upper third of the stomach than in patients with more distal cancers. There was a significant difference between the two groups in the survival of patients with advanced gastric cancer, particularly in those with pN1. Among patients with tumors deeper than T2 and pN1, survival was significantly reduced in those aged 相似文献   

Results of an aggressive surgical approach to gastric carcinoma during a twenty-three-year period

The early work of Dr. William Longmire with total gastrectomy for gastric carcinoma prompted us to initiate an aggressive surgical approach to gastric carcinoma in 1960: in curative resections radical total gastrectomy with hepaticoceliac-left gastric arterial node dissection was to be performed for tumors involving the entire stomach or upper two thirds and radical 80% to 90% subtotal gastrectomy with similar node dissection for tumors located in the antrum. During a 23-year period 213 patients with confirmed gastric carcinoma were studied. Celiotomy was performed in 192: advanced gastric cancer was found in 185 and seven had early gastric cancer. In only 80 patients could resections for "cure" be done. In 31 patients who underwent total or extended total gastrectomy the operative mortality rate was 9.6%, and life table survival curves show a better survival rate than in 49 patients treated by subtotal gastrectomy, with an operative mortality rate of 16.3%. The study shows the urgent need for diagnosis of early gastric cancer by gastroscopic screening of adults at risk and the meager salvage by radical resection in advanced disease.     

Long-term benefit of extended lymphadenectomy with gastrectomy in distally located early gastric carcinoma

BACKGROUND: Extended lymphadenectomy performed with gastrectomy has been reported to prolong survival of patients with early gastric cancer. However, some authors question the value of extensive lymphadenectomy in these patients, especially since much recent discussion of patient quality of life after gastrectomy has favored less invasive operations. METHODS: We retrospectively analyzed 485 patients who had undergone gastrectomy for early cancer in order to evaluate the effect of extended versus limited lymphadenectomy on postoperative survival. Various prognostic factors were examined for patients whose tumors were located in the distal third of the stomach. RESULTS: Although extended radical lymphadenectomy did not prolong postoperative survival when early gastric cancer was located in the middle or proximal third of the stomach, it did when the tumor occupied the distal third. CONCLUSIONS: Performance of extended radical lymphadenectomy was a significant prognostic factor for early gastric cancer patients when tumors were located in the distal third of the stomach.     

Clinical Significance of Tumor Location in Remnant Gastric Cancers Developed after Partial Gastrectomy for Primary Gastric Cancer

We sought to elucidate the clinical value of tumor location of the remnant gastric cancer developed after partial gastrectomy for gastric cancer to determine the disease characteristics and surgical outcome. Fifty-two patients underwent a second operation with a curative intent because of remnant gastric cancer after undergoing partial gastrectomy for gastric cancer between 1995 and 2005. The clinicopathological features of their primary and recurrent diseases, surgical results, and survivals according to tumor sites within the remnant stomach were examined. Tumors that developed at the anastomotic site (n = 27) in remnant stomach favored a female gender, younger age, and unfavorable histological characteristics of primary and recurrent diseases and were also associated with lower tumor resectability than those that developed in the non-anastomotic site (n = 25). The overall 5-year survival rates of patients that experienced an anastomotic recurrence and non-anastomotic recurrence were 36.9 and 95.8% (p = 0.001), respectively, and the overall 5-year survival rates of patients with stage I primary gastric cancer were 83.3 and 100% (p = 0.018) for anastomotic and non-anastomotic recurrence. Tumor location of remnant gastric cancer is an important factor for predicting surgical outcome, but it also reflects the characteristics of primary and recurrent diseases. It is hoped that these results will assist surgeons establishing the treatment plan for remnant gastric cancer.