5-氟尿嘧啶-2''''-脱氧核苷经胃左动脉介入灌注后的药代动力学实验研究

目的研究术前经胃左动脉行介入灌注后5鄄氟尿嘧啶鄄2’鄄脱氧核苷(FUDR)的药代动力学变化。方法将20头健康幼猪随机分成2组,分别于术前经胃左动脉行介入化疗(IAC)或全身性静脉化疗(SC)。标本中FUDR的浓度用高效液相色谱(HPLC)法测定。结果IAC组胃壁和胰腺中FUDR的曲线下面积(AUC0鄄49)明显高于SC组;注药后60min时部分胃周淋巴结中的FUDR平均浓度明显高于SC组;在心脏和肾脏中明显低于SC组。结论术前经胃左动脉行介入化疗后,FUDR的药代动力学变化明显优于全身性静脉化疗。本实验为在临床上术前采用经胃左动脉介入化疗治疗胃癌提供了实验性依据。     

术前区域动脉灌注化疗对进展期胃癌端粒酶活性的影响

目的：探讨手术前区域动脉灌注化疗对进展期胃癌端粒酶活性的影响。 方法：80例进展期胃癌分为2组,每组40例。灌注化疗组：术前经胃镜超声,螺旋CT术前分期,对Ⅲ期、部分Ⅳ期病变经介入方法经动脉药盒导管植入系统（PCS）行区域灌注化疗,经1～2疗程治疗再行根治切除术。对照组：术前检查同化疗组,均未行术前化疗。术后分别检测两组胃癌组织的端粒酶活性。 结果：区域动脉灌注化疗组胃癌组织端粒酶活性( TA=0.696)明显低于对照组（TA=1.216）（P<0.05）。灌注1次及2次胃癌组织端粒酶活性有明显差别（分别为TA1=0.856及TA2=0.428）;显示术前动脉灌注化疗次数越多, 胃癌组织的端粒酶活性下降越明显。 结论：进展期胃癌术前行区域灌注化疗可明显降低胃癌组织的端粒酶活性, 其活性降低程度与灌注化疗次数呈正相关。     

胃癌根治术后动脉区域灌注化疗与全身静脉化疗的临床疗效比较

目的 研究胃癌根治术后进行的动脉区域灌注化疗是否优于全身静脉化疗。方法从1997年7月至2002年7月，将行根治性切除术后的进展期胃癌患者随机分为两组，在术后3周开始化疗。全身静脉化疗组：188例，第1天氟尿嘧啶（5-Fu）750mg、吡柔比星（THP）50nag和丝裂霉素（MMC）8mg；第2天5-FU500nag；第8天5-FU 1000mg；第29天5-FU750mg、THP50nag和MMC8nag；第30天5-FU500mg；第36天5-FU 1000mg；均经外周静脉滴注完成1个疗程；间隔2周再进行1个疗程；共用2个疗程。动脉区域灌注化疗组：180例，按Seldinger法穿刺股动脉。在DSA电视荧屏监视下。将导管经股动脉、髂动脉、腹主动脉插入腹腔动脉。经导管注入5．FU1000mg、THP50mg和MMC8mg；每4周进行1次共4次。结果两组患者性别、年龄、肿瘤位置和组织学类型及TNM分期、手术类型的差异均无统计学意义（P〉0．05）。动脉区域灌注化疗组术后1、3、5年生存率分别为93．3％、72．2％和53．6％；而全身静脉化疗组则分别为87．2％、53．7％和43．1％；两组比较P〈0．01。差异有统计学意义。结论胃癌患者在根治术后进行动脉区域灌注化疗其生存率高于全身静脉化疗。     

晚期胃癌新辅助化疗的初步临床研究

目的：评价晚期胃癌新辅助化疗的近期疗效，并比较静脉化疗和介入化疗的效果。方法：取20例术前分期为Ⅲb或Ⅳ期的胃癌病人，随机分为两组，分别接受静脉化疗或介入化疗，化疗方案为LV/5-FU CDDP THP,2－4个疗程后作超声胃镜及螺旋CT等复查，重新分期和评价临床疗效，并视情况进行手术治疗。对切除的胃癌标本进行病理学研究，并与临床分期相近的10例未行化疗者进行比较。结果：20例胃癌病人中，10例化疗后TNM分期降低（50％），14例获手术切除（70％）。介入化疗组的临床疗效优于静脉化疗组，但差别无显著意义（P＞0．05）；病理学检查提示介入化疗组的组织学疗效（87．5％）明显优于静脉化疗组（33．3％）及对照组（20．0％）（P＜0．05），而后两者之间无明显差异（P＞0．05）。结论：（1）新辅助化疗在降低晚期胃癌的临床分期和提高手术切除率方面有一定作用；（2）初步结果表明，介入化疗的效果优于静脉化疗。     

腹腔区域性血流阻断动脉内介入化疗对循环系统影响的实验研究

目的：研究腹腔区域性血流阻断动脉内介入化疗对机体循环系统的影响。对象与方法：16头幼猪分为两组,每组8头,分别行腹腔区域性血流阻断（Stop-flow,SF)及区域性血流阻断动脉内介入化疗（Stop-flow-Chemotherapy,SFC,MMC 0.2mg/kg)。术中监测心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、肺动脉压（PAWP）、心排量（CO）、外周静脉阻力（SVR）及混合血氧饱和度（SvO2)。结果：两组实验动物术中的血流动力学指标均有较明显改变。血流阻断及再通后心率、心排量、血压、外周静脉阻力和混合静脉血氧饱和度（SvO2) 有显著变化,阻断开放后PAWP有一过性升高,CVP术中无明显改变,血流再通20分钟左右上述指标均基本恢复至术前水平。SF与SFC两组间无明显差异。结论：腹腔区域性血流阻断动脉内介入化疗对循环系统有一定影响,但均在可控制范围,提示在临床应用是安全可靠的。     

胃左动脉置泵灌注联合腹腔化疗治疗中晚期胃癌

目的 探讨胃癌手术后经胃左动脉灌注联合腹腔化疗和静脉化疗治疗中晚期胃癌的远期疗效。方法 病人随机分为联合化疗组（63例）和静脉化疗组（53例），对比研究患者毒副反应及生存率。结果 毒副反应中肝、肾功能损害两组差异无显著性（P＞0．05）；与静脉化疗组比较，联合化疗组的恶心呕吐、脱发及骨髓抑制症状较轻，而腹痛腹胀较严重（均P＜0．05）；联合化疗组5年生存率显著高于静脉化疗组（P＜0．05）。结论 对中晚期胃癌患者行胃左动脉灌注联合腹腔化疗，其毒副作用小，并可提高患者生存率。     

胃癌少见淋巴转移方式一例报告

病例男，62岁，因上腹部饱胀不适2月而入院。体检：锁骨上无肿大淋巴结，腹部无阳性体征。胃镜及活检病理示：贲门低分化腺癌。上消化道钡餐及胃镜见肿瘤位于胃上部小弯侧，约(3×3)cm2，但胸片提示右上纵隔增宽。进一步行CT检查示：纵隔多发淋巴结（胃癌淋巴转移），未发现肝转移及明显腹腔内淋巴结肿大，因检查结果提示胃癌（Ⅳ期），故未行手术治疗，转为FAM方案交替行股动脉置管腹腔动脉介入化疗（氟脲嘧啶1g，表阿霉素60mg，丝裂霉素10mg）与静脉化疗。讨论淋巴转移是胃癌转移的主要方式，通常经黏膜下层复杂而庞大的回流系统最终到…     

丹参及5-氟尿嘧啶胃癌术后早期腹腔化疗的临床应用

目的：探讨丹参联合5－氟尿嘧啶（5－FU）对胃癌切除术后早期腹腔化疗（EPIC）的可行性及近期疗效。方法：136例胃癌后病人分为EPIC、早期静脉化疗（EPVC）、对照3组，EPIC组胃癌切除术后2－3d丹参、5－FU腹腔注射；EPIC组胃癌切除术后2－3d丹参、5－FU静脉注射；对照组术后早期不用任何方式化疗，术后3周常规化疗，分别观察：（1）EPIC组和EPVC组消化道反应、骨髓抑制和肝肾功能损害等毒副反应；（2）EPIC组和对照组有EPVC组术后切口感染或裂开，吻合口瘘，腹腔脓肿或出血，化学性腹膜和粘连性肠梗阻等并发症发生；（3）3组术后近期生存率及腹腔复发率。结果：（1）EPVC组比较，EPIC组消化道反应，骨髓抑制和肝肾功能损害等毒副反应明显降低（P＜0．05）；（2）和对照组及EPVC组比较，EPIC组切口感染或裂开，吻合口瘘，腹腔脓肿或出血，化学性腹膜炎和粘连性肠梗阻等各项并发症无明显增加（P＞0．05），（3）EPIC组1年、2年生存率明显高于另外两组（P＜0．01）而术后2年腹腔复发率明显低于另两组（P＜0．05）。结论：丹参联合5－FU胃癌术后早期腹腔化疗不仅是安全可行的，而且较静脉化毒副反应小，腹腔复发率低，近期生存率满意，有较大治疗上的优势。     

进展期胃癌术后早期持续腹腔热灌注化疗的临床观察

目的探讨术后早期持续腹腔热灌注化疗（CHPP）对进展期胃癌的疗效。方法将70例进展期胃癌患者随机分为两组：治疗组胃癌根治术后第1—2天开始行CHPP，每131次，共4次；对照组单纯行胃癌根治术。两组术后2-3周均予以四氢叶酸钙和氟尿嘧啶（LF方案）静脉全身化疗6个疗程。观察并比较患者术后生存和肿瘤复发情况。结果治疗组和对照组术后1年生存率分别为83．3％和79．4％，两组差异无统计学意义（P〉0．05）；3年生存率分别为63．9％和39．8％，差异有统计学意义（P〈0．05）。治疗组与对照组术后1年肿瘤复发率分别为8．3％和11．7％，两组差异无统计学意义（P〉0．05）；3年复发率分别为19．4％和44．1％，两组差异有统计学意义（P〈0．05）。结论进展期胃癌患者术后早期CHPP有利于降低复发率和提高生存率。     

腹腔化疗和外周静脉化疗对晚期胃肠道恶性肿瘤患者生存质量的影响

目的比较经腹腔化疗及外周静脉化疗对晚期胃肠道恶性肿瘤患者生存质量的影响。方法对无法切除的晚期消化道肿瘤采用经腹腔化疗（60例）、外周静脉化疗（32例）两种不同的化疗方式，分别于术前和术后2、5、10、20、30周测定胃肠道生活质量(GQLI)指数。结果术前、术后2、5周两组GQLI指数差异不明显，术后10、20、30周两组GQLI指数差异有显著性意义，P<0.01；静脉化疗组患者GQLI指数明显下降。腹腔化疗组的1年生存率高于外周静脉化疗组，P<0.05。结论经腹腔化疗较外周静脉化疗能提高晚期消化道肿瘤患者的生存质量。     

腹腔镜下经前路清扫腹腔干区域淋巴结的临床体会

目的:探讨腹腔镜胃癌D2根治术中经前路清扫腹腔干区域7、8、9组淋巴结的安全性与可行性。方法:回顾分析2010年1月至2013年12月接受前路法腹腔镜下清扫7、8、9组淋巴结的21例患者的临床资料,清扫顺序:首次清扫12a(肝固有动脉周围淋巴结),其次清扫8a(肝总动脉周围淋巴结),再清扫第9组淋巴结(腹腔干淋巴结)及第7组淋巴结(胃左动脉周围淋巴结)。路径:不经胃后间隙,经胃小弯侧网膜囊间隙操作。结果:21例手术均获成功,无一例中转开腹。20例经胃前路成功行第7、8、9组淋巴结清扫,平均清扫淋巴结数量(9.7±2.4)枚,平均清扫时间(31.5±5.7)min,术中出血量极少。结论:经前路法腹腔镜清扫第7、8、9组淋巴结可降低手术配合要求、缩短手术时间,是安全、可行的。     

全腹腔镜下远端胃癌根治术三角吻合术

先确定肿瘤位置,沿横结肠边缘超声刀游离横结肠系膜前叶,向右游离至结肠肝曲,左至脾曲,离断网膜左血管,清扫4sb,4d淋巴结;沿结肠中动脉及其分支分离,向上暴露肠系膜上静脉、右结肠静脉、胃网膜右静脉,骨骼化胃网膜右动脉于根部切断;裸化十二指肠下缘,暴露胃十二指肠动脉,肝总动脉胃左脾动脉和腹腔干,切断胃左动脉清扫第7.8.9.11p组淋巴结;向下剥离裸化肝十二指肠韧带,清扫第12a组淋巴结,并向上彻底清扫第1,3,5组淋巴结,使用内镜下直线切割吻合器离断十二指肠球部,胃体。扩大脐部穿刺孔至取出标本,缝合切口。重建气腹,行胃大弯和十二指肠后壁三角吻合。     

Studies on gastric lymphatics by using activated carbon particle (CH44) and lymph node metastasis of gastric cancer

Gastric lymphatics in 200 patients of gastric cancer were studied by injection of activated carbon particles (CH44). By observing the carbon flow intraoperatively and examining stained lymph nodes, gastric lymphatics for individual regions (cardia, lesser curvature, left greater curvature and right greater curvature) were evaluated. The cardiac orifice has a main series of lymphatics along the left gastric artery and also has other lymphatics along the splenic artery, left phrenic artery, esophagus, lesser omentum and diaphragm. The left greater curvature depends on the lymph flow along the splenic artery. The lesser curvature has a main lymphatic stream along the left gastric artery. The right greater curvature has convened lymphatics around pancreatic head. Most streams gather around celiac axis, while the flow along right gastro-epiploic vein is also important. We also studied the relationship between the site of gastric cancer and metastasis is to the lymph nodes in 1097 gastrectomized patients. They had received more than R2 lymphatic dissection successfully. In the cases with lesions located in the upper part of the stomach, n4 (positive findings of metastasis to group 4 lymph nodes) is greater than n3 (positive findings of metastasis to group 3 lymph nodes). We concluded that most of gastric lymphatics run along the proper gastric vessels and gathered around celiac axis. For lymph node dissection in gastric cancer, it is important to know the direction of the gastric lymphatics based on tumor sites.     

An anatomical and pathological study of autopsy material on the metastasis of pancreatic cancer to para-aortic lymph nodes

The purpose of the present study was to clarify the anatomy of the lymphatic system of the para-aortic region with special reference to lymphatic pathways from the pancreas, and the incidence and extent of lymphatic metastases of pancreatic cancer to para-aortic lymph nodes. Lymph nodes were found mostly on the bilateral and anterior sides of the aorta, and rarely on its posterior side. Lymphatic vessels from the pancreas (peripancreatic nodes) were closely related to the para-aortic lymph nodes on the bilateral and anterior surfaces of the aorta ranging from the root of the celiac artery and that of the inferior mesenteric artery. Out of 10 autopsy cases of relatively small pancreatic cancer, 4 cases were found to have microscopic metastases in a few para-aortic lymph nodes. The localization of involved para-aortic nodes was compatible with that of anatomically related para-aortic lymph nodes. Lymph node dissection of the para-aortic region, if carried out in a patient with a possibility of radical resection of the primary pancreatic cancer, should be an en bloc resection of lymph nodes and surrounding soft tissues in the area ranging between the root of the celiac artery and that of the inferior mesenteric artery.     

Angiotensin alteration of drug uptake in an experimental model of hepatic metastases

To evaluate the use of angiotensin-II (A-II) as a means of improving results with intra-arterial infusions of hepatic tumors, 32 New Zealand white rabbits underwent perfusion of VX-2 hepatic implants. Tritium-labeled fluorodeoxyuridine [( 3H]FUDR) was administered via peripheral ear vein in 9 control rabbits (iv), via the hepatic artery in 12 rabbits (HA), and following a constant infusion of A-II in the remaining 11 rabbits (HA/A-II). Biopsies of tumor and normal hepatic parenchyma were taken and tissue levels of FUDR measured. Hepatic artery infusions, both with and without A-II, resulted in a significantly greater tumor uptake of FUDR than the iv infusions (P less than 0.001). More importantly, the tumor/liver ratio of FUDR uptake was significantly greater in the HA/A-II group (3.40) than that in the HA without A-II (0.98) group (P less than 0.001). This difference is due to the decreased FUDR uptake by normal hepatic parenchyma in rabbits undergoing A-II infusion; tumor drug uptake is similar for both groups. We conclude that the addition of angiotensin II to hepatic artery infusional chemotherapy significantly improves the tumor/liver ratio of drug uptake in this experimental model of hepatic metastases.     

全腔镜全胃切除术

切开胃结肠韧带,游离至脾脏下极,于根部离断胃网膜左血管,清扫第4组淋巴结,离断胃短血管直至脾上极。游离胃窦部,于胰腺上缘离断胃网膜右静脉,显露胃十二指肠动脉后,于根部离断胃网膜右动脉,并完成第六组淋巴结的清扫。显露胃窦后壁,离断胃右血管,清扫肝门部淋巴结。距幽门2 cm离断十二指肠。沿胰腺上缘解剖脾动脉根部,于根部离断胃左静脉。显露腹腔干及胃左动脉,向右侧清扫第8组淋巴结,于根部离断胃左动脉后,向头侧清扫第1,2组淋巴结。游离食管腹段,解剖出迷走神经左右支后离断。悬吊肝左叶后,距贲门2 cm离断食管,取上腹正中辅助切口3 cm,移除胃标本及大网膜。重建气腹后,距TREIZ韧带20 cm离断空肠,行食管左后壁与近端空肠侧侧吻合(OVERLAP法),手工缝合共同开口。距此吻合口40 cm,借助辅助切口完成小肠侧侧吻合(ROUX－Y)吻合。     

经脐小切口联合左上腹单孔腹腔镜远端胃癌根治术

首先,沿着大网膜的横结肠附着缘游离大网膜,左侧游离至脾脏下极,右侧至十二指肠降部。显露胃网膜右静脉在其根部结扎切断,完成第6v组淋巴结的清扫。显露幽门下血管和胃网膜右动脉在其根部予以结扎切断,完成第6a和6i组淋巴结的清扫。在幽门上区域开窗并离断十二指肠,根部结扎切断胃右血管蒂,完成第5组淋巴结清扫。显露并保护门静脉,在肝总动脉和肝固有动脉鞘表面清扫第8a组和12a组淋巴结。进而转向腹腔动脉根部清扫第9组淋巴结,在根部结扎并切断冠状静脉及胃左动脉,完成清扫第7组淋巴结。沿着脾动脉起始部向远心端清扫11p组淋巴结,裸化胃小弯侧,清扫第1组和第3组淋巴结。在近脾下极处显露胃网膜左血管,并于其根部结扎,清扫第4sb组淋巴结。最后,镜下完成近端残胃与空肠的Billroth II吻合及空肠间侧侧吻合。     

腹腔镜根治性全胃切除重建术

患者,59岁男性,术前诊断：胃体腺癌(cT3N1＋M0)。拟行腹腔镜根治性全胃切除术。手术思路：1.打开胃结肠韧带,游离横结肠系膜前叶2.显露并离断胃网膜右静脉根部,清扫14V组淋巴结,显露胃十二指肠动脉,于根部离断胃网膜右动脉,清扫6组淋巴结。3.游离胰腺被膜,清扫7、8、9组淋巴结。沿肝总动脉后方显露门静脉,清扫12a组淋巴结。显露胃十二指肠动脉、肝固有动脉,离断胃右动脉,清扫5组淋巴结。游离肝胃韧带至贲门右侧,清扫1组淋巴结。4.沿脾动脉游离,显露脾门血管,清扫10、11组淋巴结。游离贲门左侧,清扫2组淋巴结。5.采取腹部辅助小切口完成胃肠Roux－en－Y重建。     

Principles of surgical treatment for carcinoma of the esophagus: analysis of lymph node involvement.

Extensive lymph node dissections in the posterior mediastinum and abdomen were performed during resections of esophageal carcinomas. Analysis of lymph nodes demonstrated a widespread distribution of positive lymph nodes regardless of the location of the tumor. The distribution of positive lymph nodes was noticed in the area between the superior mediastinum and the celiac region. The studies were also made on the distribution of positive lymph nodes in the superior gastric region, particularly in the region of the lesser curvature of the stomach. The following principles should be followed when carcinoma of the esophagus is surgically treated. 1) Lymph node dissection of the whole length of the posterior mediastinum, superior gastric region, and celiac region must be performed. 2) Total thoracic and abdominal esophagectomy with resection of the proximal lesser curvature and cardia, including the first to fourth branches, and preferably the fifth branch of the left gastric artery, is mandatory in order to remove possible lymphatic and intramural spread of tumors. 3) Satisfactory esophageal replacement in one stage must follow. Of the Toranomon Hospital, 210 underwent resections and reconstructions, for a resectability rate of 59.3%. The operative mortality rate was 1.4% and the overall five-year survival rate was 34.6%.