全胃切除治疗胃癌56例报告

为总结全胃切除治疗胃癌的经验，作者对１９８０～１９９１年间以此术式治疗胃癌５６例临床资料进行回顾性分析。根治性全胃切除４７例，姑息性全胃切除９例。合并远侧胰、脾、横结肠、部分肝切除２３例。手术死亡率３．８％（２例），术后１，３，５年生存率分别为７１．２％，３９．７％和２０．９％。作者认为：严格掌握手术适应证，恰当的选择切口，合理确定淋巴清除范围和联合脏器切除，选用最佳的消化道重建方式，是影响全胃切除治疗胃癌疗效的重要因素     

胰腺导管癌扩大和根治性全胰切除术的探讨

目的：探讨胰腺癌根治性全胰切除的疗效。方法：１９７０￣１９９４年对２１胰腺导管癌（按Ｋｌｏｅｐｐｅｌ分期：Ｔ１－２Ｎ０Ｍ０ １０例，Ｔ１－３Ｎ０－２Ｍ０ ８例及Ｔ１－３Ｎ１－２Ｍ０ ３例）施行根治性全胰切除术，包括胰周、区域性淋巴结及后腹膜间隙组织廓清／和有侵犯的门静脉切除。结果：区域性淋巴结阳性占５２．３％，胰后血管粘连或侵犯占２６．６％，胰腺多病灶癌占１９％。本组无手术死亡率。生存期平均５６个     

近端1/3胃癌的特点与临床结果

对于胃癌的肿瘤部位与预后的关系，普遍认为贲门癌或近端１／３胃癌预后比中、远端１／３胃癌差，原因尚不清。本文比较了近端１／３胃癌（ＰＧＣ）与中１／３胃癌（ＭＧＣ）、远端１／３胃癌（ＤＧＣ）的临床特点及结果。方法　从１９８５年至１９９４年，回顾性分析了６４６例原发胃癌，排除全胃癌。肿瘤部位分近端１／３、中１／３、远端１／３。计算生存率除外手术后３０天内死亡者。结果　ＰＧＣ、ＭＧＣ、ＤＧＣ分别占２１－８％、３９－５％和３８－７％，１１４例近端胃癌中食管侵犯有３０例（２１－３％）。ＰＧＣ或ＤＧＣ患者年龄…     

胃癌胰体尾侵犯的发病因素和临床结局分析

目的探讨胃癌病人胰体尾侵犯的相关临床病理因素和手术干预的临床结局。方法回顾性分析1994年8月至2006年3月间中山大学附属第一医院胃癌数据库资料中病人的临床病理资料和随访结果。结果870例胃癌病人中有73例发生胰体尾侵犯。BorrmannⅣ型、肿瘤穿透浆膜、离胃〉3cm淋巴结转移、腹膜扩散与胃癌胰体尾侵犯相关（P〈0．05）。联合胰体尾切除根治术后，较严重的并发症发生率为2．3％（1／44），围手术期内无病人死亡。联合胰体尾切除根治术组病人1、3、5年存活率分别为63％、24％和19％，其1年内各时点存活率总体上高于胃癌姑息性切除组和姑息性手术组（P〈0．05）。结论联合胰体尾切除的根治术具有可接受的手术并发症发生率，能显著改善胃癌胰体尾侵犯病人的近期预后。     

联合脏器切除治疗进展期胃癌

目的总结联合脏器切除治疗进展期胃癌的经验。方法对１９８８～１９９３年间施行联合脏器切除的４８例进展期胃癌的临床资料进行回顾性分析。结果４８例中,根治性切除３３例,姑息性切除１５例。其中联合脾切除１４例,脾合并胰体尾切除１２例,脾、胰体尾合并横结肠切除１例,胰体尾合并横结肠切除２例,横结肠切除３例,肝左外叶切除７例,卵巢切除３例,胆囊切除５例,胰十二指肠切除１例。手术死亡率４２％。随访１,３,５年生存率分别为６５１％,３２６％,２７９％。结论作者认为,严格掌握联合脏器切除的指征,恰当的选择手术入路,同时注重病人围手术期的营养支持,是降低并发症,提高手术成功率及远期生存率的重要因素     

胃癌根治术保留胰脾功能清除脾门和脾动脉干淋巴结的临床意义

目的 探讨胃癌根治术保留胰脾功能清除脾门和脾动脉干淋巴结（即No10、No11)的合理性和可行性。方法 分析439例手术切除的胃贲门、体部和全胃癌侵入胰脾情况;对54例胃癌患者在术中从贲门和体部浆膜下注入亚甲兰观察胃的淋巴流向;63例胃癌采用保留胰脾功能性清除No10、No11淋巴结方法,与同期保胰法和胰脾切除法比较,分析No10、No11淋巴结转移率,观察术后并发症发生率和生存率。结果 439例胃贲门、体部和全胃癌侵入胰脾机会不多,分别为5．7％（25／439）和2．3％（10／439）;54例胃的美兰淋巴引流不进入脾脏和胰腺内。保留胰腺法、保胰法和胰脾切除法3组No10、11淋巴结转移率分别为17．5％（11／63）,19．1％（12／63）;20．8％（45／216）,25％（54／216）;20％（6／30）,23％（7／30）,差异无显著意义。63例保留胰脾法术后并发症发生率和病死率均较保留胰法和胰脾联合切除法低,而生存期较高,5、10年生存率分别为57．5％、52％,57．4％、47．4％和37．3％、30％。Ⅱ、Ⅲa期患者保留胰脾手术的5、10年生存率明显改善。结论 保胰脾法是一个安全、切实可行的保留脏器功能的胃癌手术,术后并发症低、生存率高。尤对Ⅱ、Ⅲa期患者应行保留胰脾手术。     

联合胰体尾脾切除并温热低渗腹腔灌洗化疗治疗进展期胃癌18例临床分析

目的 总结联合胰体尾脾切除并温热低渗腹腔灌洗化疗治疗胃癌的经验。方法 对1993—1997年施行联合胰体尾脾切除并温热低渗腹腔灌洗化疗的18例胃癌的临床资料进行回顾性分析。结果 联合胰体尾脾切除并温热低渗腹腔灌洗化疗18例胃癌，术后无严重并发症发生，无手术死亡，随访1、3、5年生存率分别为72．2％、38．9%、27．8％。结论 掌握联合脏器切除的指征，关注腹腔内脱落癌细胞的处理，提高外科手术技巧，注重病人围手术期的营养支持是降低并发症发生率、提高手术成功率和远期生存率的重要因素。     

胃癌术中放疗疗效的评估

目的：探讨胃癌术中照射部位、剂量和治疗结果。方法：对１０６例Ⅰ－Ⅳ期胃癌患者行Ｄ２或选择性Ｄ３术式,并采用不同照射剂量进行术中照射。对胃窦、体癌患者施行远侧胃大部切除术时,在腹腔动脉和肝十二指肠韧带区域进行术中照射。在胃体、贲门和全胃癌施行近侧胃大部切除或全胃切除时,将脾、胰体尾游离并翻向右侧,扩大术中照射野。此组病例的放疗结果与１９７５年至１９８９年期间４４１例胃癌单纯手术患者进行对照。结果：Ⅰ、Ⅳ期胃癌术中放疗不能提高术后生存期,Ⅱ、Ⅲ期胃癌能提高５年生存率１４．４％～２０％。其中Ⅲ期胃癌采用Ｄ２术式加术中放疗１～５年生存率有显著提高（Ｐ＜０．００１）,而采用选择性Ｄ３手术加术中放疗术后３、４年生存率较单纯选择性Ｄ３显著提高（Ｐ＜０．００５）。结论：胃癌术中放疗能提高Ⅱ、Ⅲ期胃癌术后生存率,不增加术后并发症和死亡率。     

全胃切除治疗胃癌

报告我科１９８２～１９９３年间为５５例胃癌实施的全胃切除术,并探讨外科治疗中的一些问题。１．临床资料：本组男４５例,女１０例。年龄３３～７１（平均５４．６）岁。全组病例均经胃钡餐造影和／或纤维胃镜检查确诊为胃癌。癌灶部位：C区３例,CM区１２例,M区１９例,MC区１１例,MA区４例,AM区１例,MCA区３例,MAC区２例。TNM分期：Ⅱ期８例,Ⅲ期３８例,Ⅳ期９例。手术方式：根治性全胃切除４６例,姑息性全胃切除９例。其中并行脾和胰体尾切除９例,并行脾切除６例,并行保留胰腺的脾动静脉及脾切除５例,并行肝左叶…     

615例胃癌行全胃切除术的远期疗效

目的：探讨全胃切除术治疗胃癌的意义及消化道重建的最佳术式。方法：总结分析我科615例胃癌行全胃切除术及各种消化道重建术式的临床资料。结果：本组随访580例，随访率94．3％。总的1、3、5年生存率分别为77．4％、45．3％、32．5％。其中根治性全胃切除术507例，姑息性切除术108例，其5年生存率分别为48．9％与5．9％，差异有非常显性意义（P＜0．01）。对比同期近侧胃大部切除术466例5年生存率20．2％，全胃切除术的5年生存率明显高于近侧胃大部切除术（P＜0．05）。全胃切除术后并发症发生率为11．4％，手术死亡率为2．9％。消化道重建术式采用空场原位间置代胃术，对术后生活质量方面具有较好的效果。结论：除皮革样胃癌、胃体癌、多原发癌以及残胃癌应行全胃切除术外，贲门区癌无论早、晚期，只要一般条件许可，应常规行全胃切除术，以提高生存期。消化道重建术采用空肠原位间置代胃术可取得较好的生活质量。     

保留脾胰清除脾门和脾动脉干淋巴结的胃癌手术疗效观察

目的 探讨胃癌手术保留脾脏、胰腺，清除脾门和用动脉干淋巴结方法的疗效。方法 采用保留用胰、清除脾门和脾动脉干淋巴结方法治疗61例胃癌中层得，观察其术后并发症发生率和生存率。结果 保脾胰法的术后并发症发生率、死亡率均较保胰法和胰脾联合切除法低，而生存率较高。结论 保脾胰法是一种安全、切实可行的胃癌手术疗法。     

同时发生的食管胃重复癌的外科治疗

目的探讨同时发生的食管、胃重复癌的外科治疗方法及效果.方法1985年1月至2005年1月收治同时发生的食管、胃重复癌12例,均为男性,平均年龄56.8岁.全组均行手术治疗,成功完成同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道10例,食管内翻拔脱并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道1例,手术探查1例.结果全组无围术期死亡.术后颈部吻合口瘘2例,不全肠梗阻1例,均经保守治疗后痊愈;术后腹部切口裂开1例,二期缝合治愈.9例获得随访,1、3、5年生存率分别100%、44.4%、22.2%.结论同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道是根治同时发生的食管、胃重复癌安全有效的外科治疗方法.     

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.     

根治性全胃切除术治疗进展期贲门癌的疗效评价

目的 探讨全胃切除及系统的淋巴结清扫治疗进展期贲门癌的临床价值。方法 对387例进展期贲门癌患者施行全胃切除及D2以上的淋巴结清扫，分析贲门癌浸润胃壁深度与淋巴结转移、淋巴转移及清扫淋巴结数目与术后累积生存率的关系。结果 本组贲门癌患者术后3年、5年累积生存率分别为47.3％、34．2％，pT3、pT4的贲门癌患者pN3转移率分别为4．8％、15．2％，并且随着淋巴结转移数目的增加，3年、5年累积生存率明显下降（P〈0．01、P〈0．01），清扫15或30个以上淋巴结的贲门癌患者3年、5年累积生存率明显高于清扫少于15个淋巴结者（P〈0．05、P〈0．01）。本组贲门癌患者术后并发症发生率与病死率分别为14．2％、2．52％。结论 对进展期贲门癌患者只要条件许可应施行根治性全胃切除（D2^＋术式），必要时联合脾、胰体尾整块切除，以提高生存质量和延长生存期。     

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.     

Near-total gastrectomy for gastric cancer

Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.     

Significance of extended radical surgery for stage IV gastric cancer

Forty percent of patients with gastric cancer with direct infiltration to adjacent organs survived for more than 5 years after curative resection. Favorable results were obtained in cases in which combined resection of the body of the pancreas or the liver was performed due to cancer infiltration. However, patients who had undergone gastrectomy with combined colectomy or pancreatoduodenectomy showed a poor survival rate. The postoperative 5-year survival rate was 29% for patients who had presented with group 3 lymph node metastasis and undergone potentially curative surgery. Particularly, favorable results were obtained in cases with metastases confined to lymph nodes in the hepatoduodenal ligament. In dissection of the deepest nodes, lymph nodes in the hepatoduodenal ligament is the most important to remove in surgery for stage IV gastric cancer. We have performed gastrectomy combined with dissection of group 1 and 2 lymph nodes in the treatment of patients with gastric cancer with peritoneal metastasis. Results obtained so far revealed that only patients with a lesser extent of serosal invasion survived longer after operation. We are presently conducting a trial of hyperthermia combined with anticancer chemotherapy as a possible method for prolongation of survival of patients with peritoneal metastasis of gastric cancer.     

Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer?

BACKGROUND: In Japan, wide resection with extended lymph node dissection has been performed for advanced cancer with good prognosis. Pancreaticosplenectomy with gastrectomy is performed to facilitate dissection of the lymph nodes around the splenic artery. We attempted to evaluate the effects of pancreaticosplenectomy and splenectomy with gastrectomy for advanced gastric cancer. METHODS: Gastric cancer patients underwent splenectomy with gastrectomy (78 cases), pancreaticosplenectomy with gastrectomy (105 cases), or gastrectomy alone (1,755 cases). Survival rates were compared among the three groups for each factor of the depth of invasion, stage, and curability. RESULTS: There were no significant differences among the three groups. Pancreaticosplenectomy or splenectomy with gastrectomy to dissect lymph nodes does not improve survival but is associated with severe complications. CONCLUSIONS: The spleen should be resected when a patient has clearly positive node metastasis around the splenic hilus and artery, and pancreaticosplenectomy be performed when the cancer lesion invades the pancreas.     

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.