腹腔镜在胃癌根治术的应用进展

近年来有关早期胃癌的微创治疗进展很快，并已取得国内外的共识。对进展期胃癌应用腹腔镜行胃癌根治术尽管已经取得了较好的临床效果，但仍尚待前瞻性多中心临床随机对照研究。从应用前景看，随着术者技术的完善、观念的改变、经验的积累、手术器械的不断改进，腹腔镜胃癌根治术必将在胃癌手术中扮演越来越重要的角色。     

Multicentric Oncologic Outcomes of High-Intensity Focused Ultrasound for Localized Prostate Cancer in 803 Patients

Background

High-intensity focused ultrasound (HIFU) is an emerging treatment for select patients with localized prostate cancer (PCa).

Objectives

To report the oncologic outcome of HIFU as a primary care option for localized prostate cancer from a multicenter database.

Design, setting, and participants

Patients with localized PCa treated with curative intent and presenting at least a 2-yr follow-up from February 1993 were considered in this study. Previously irradiated patients were excluded from this analysis. In case of any residual or recurrent PCa, patients were systematically offered a second session. Kaplan-Meier analysis was performed to determine disease-free survival rates (DFSR).

Measurements

Prostate-specific antigen (PSA), clinical stage, and pathologic results were measured pre- and post-HIFU.

Results and limitations

A total of 803 patients from six urologic departments met the inclusion criteria. Stratification according to d’Amico's risk group was low, intermediate, and high in 40.2%, 46.3%, and 13.5% of patients, respectively. Mean follow-up was 42 ± 33 mo. Mean PSA nadir was 1.0 ± 2.8 ng/ml with 54.3% reaching a nadir of ≤0.3 ng/ml. Control biopsies were negative in 85% of cases. The overall and cancer-specific survival rates at 8 yr were 89% and 99%, respectively. The metastasis-free survival rate at 8 yr was 97%. Initial PSA value and Gleason score value significantly influence the DFSR. The 5- and 7-yr biochemical-free survival rates (Phoenix criteria) were 83–75%, 72–63%, and 68–62% (p = 0.03) and the additional treatment-free survival rates were 84–79%, 68–61%, and 52–54% (p < 0.001) for low-, intermediate-, and high-risk patients, respectively. PSA nadir was a major predictive factor for HIFU success: negative biopsies, stable PSA, and no additional therapy.

Conclusions

Local control and DFSR achieved with HIFU were similar to those expected with conformal external-beam radiation therapy (EBRT). The excellent cancer-specific survival rate is also explained by the possibility to repeat HIFU and use salvage EBRT.     

The Additional Value of Laparoscopic Ultrasound to Staging Laparoscopy in Patients with Suspected Pancreatic Head Cancer

Background

This study aimed to evaluate the additional value of laparoscopic ultrasound (LUS) to staging laparoscopy (SL) for detecting occult liver metastases in patients with potentially resectable pancreatic head cancer.

Methods

A retrospective cohort study was performed including all patients who underwent SL and LUS between 2005 and 2016. LUS was performed during SL to detect liver metastases not found by preoperative imaging or visual inspection of the liver.

Results

Out of 197 patients, visual inspection during SL detected distant metastases in 29 (14.7%) patients. LUS was performed in 127 patients, revealing 3 additional liver metastases. The proportion of patients with unresectable disease after SL and negative LUS was 32.3%, which was similar to 36.6% of patients with unresectable disease after SL without LUS (difference 4.3%; 95% CI ??13–23%; P?=?0.61). Sensitivity, specificity, and positive and negative predictive values of LUS to detect liver metastases were 30, 100, 100, and 94%, respectively. The proportion of patients with distant metastases diagnosed at SL significantly increased over time (P?=?0.031).

Conclusion

The routine use of LUS during SL for patients with potentially resectable pancreatic head cancer cannot be recommended. Imaging should be repeated when significant delay occurs between index CT and the scheduled surgery.

     

腹腔镜胃癌手术的进展与展望

1994年日本Kitano等[1]首次报道了腹腔镜胃癌根治术,相对于传统的胃癌根治术,具有明显的微创优势。腹腔镜早期胃癌根治术经过10余年的发展,技术上已逐渐成熟,取得了与开腹手术相当的近、远期疗效[2]。1997年Goh等[3]将腹腔镜胃癌     

Clinical Risk Score Can be Used to Select Patients for Staging Laparoscopy and Laparoscopic Ultrasound for Colorectal Liver Metastases

Background

Despite advanced staging investigations, some patients with potentially resectable colorectal liver metastases (CLM) are unresectable at laparotomy. Staging laparoscopy and laparoscopic ultrasound (Lap + LUS) detects a subset of these unresectable patients before a major laparotomy. Clinical risk scoring may be helpful to identify this subgroup. The goal of our study was to evaluate the role of Lap + LUS and to assess the value of the Memorial Sloan Kettering clinical risk score (CRS) in identifying this subset.

Methods

Patients were identified from the regional multidisciplinary team (MDT) cancer database and operative records for a 5-year period. All patients whose tumors were deemed resectable proceeded to Lap + LUS. LUS findings were recorded and any change in MDT plan was noted. LUS findings were compared with resectability at open surgery. The CRS (Memorial Sloan-Kettering) based on five factors was calculated.

Results

A total of 79 patients were identified. In 15 of 74 patients, LUS prevented an unnecessary laparotomy by predicting the benign nature of lesions or demonstrating unresectability. The CRS ranged from 0 to 4. Lap + LUS prevented an operation in only 7% of patients with a CRS of ≤2. However in patients with a CRS > 2, Lap + LUS prevented an operation in 24% of patients.

Conclusions

LUS prevented an unnecessary laparotomy in 20% of patients. This may reduce inpatient stay, morbidity, and mortality, allowing some patients to proceed to palliative treatments earlier. The benefit of Lap + LUS is limited in patients with a CRS of ≤2. It is worth considering selective use of Lap + LUS for the staging of CLM.     

Clinical Correlation of Endoscopic Ultrasonography with Pathologic Stage and Outcome in Patients Undergoing Curative Resection for Gastric Cancer

Background Endoscopic ultrasonography (EUS) is considered valuable for preoperative staging of gastric cancer and defining patient eligibility for enrollment in neoadjuvant protocols. The aim of this study was to correlate EUS staging with pathologic evaluation and outcome in patients undergoing curative R0 resection for gastric cancer. Methods All patients who underwent preoperative clinical assessment of T/N stage with EUS and subsequent R0 resection for gastric adenocarcinoma between 1993 and 2003 were identified from a prospective database. Patients who received neoadjuvant chemotherapy were excluded. Clinical staging results from preoperative EUS were compared with postoperative pathologic staging results and correlated with clinical outcome. Results Two hundred twenty-five patients with gastric cancer underwent EUS followed by R0 resection, without preoperative chemotherapy. The accuracy of the individual EUS T stage was 57% (127 of 223) and was 50% for N stage (110 of 218). Although EUS was less able to predict outcome according to individual T stage, patients with lesions ≤T2 on EUS had a significantly better outcome than patients with lesions ≥T3. Preoperative assessment of risk was not predicted by EUS N stage alone. Patients identified as high risk on EUS and those with a combination of serosal invasion and nodal disease had both the highest concordance with pathology and a significantly worse outcome (P = .02). Conclusions The concordance between EUS and pathologic results was lower than expected for individual T and N stages. Patients with lesions ≤T2 had a significantly better prognosis than patients with more advanced lesions. Individual EUS N stage has limited value in preoperative risk assessment. Combined assessment of serosal invasion and nodal positivity on EUS identifies 77% of patients at risk for death from gastric cancer after curative resection.     

Indications for Staging Laparoscopy in Clinical T4M0 Gastric Cancer

Background  

This study was undertaken to determine the efficacy of the clinical indications for performing staging laparoscopy for locally advanced gastric cancer to detect peritoneal metastasis or positive cytology findings.     

Surgical Indication for Non-curative Endoscopic Resection in Early Gastric Cancer

Background Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without lymph node metastasis. However, after ER additional surgery may be needed to manage the risks presented by residual cancer or lymph node metastasis. Methods ER was performed on 344 gastric adenocarcinomas between November 2001 and April 2006 at the Korean National Cancer Center under the strict pre-procedural indication. The authors performed operations in 43 patients due to: residual mucosal cancer, a mucosal cancer larger than 3 cm, or a submucosal cancer regardless of size or margin involvement. ER and surgical specimens were reviewed and analyzed for residual cancer and lymph node metastasis. Results Based on examinations of ER specimens, cancer was confined to the mucosal layer in 15 patients (34.9%) and invaded the submucosal layer in 28 patients (65.1%). Surgical specimens showed residual cancer in 17 patients (39.5%) and lymph node metastasis in four (9.3%). Neither residual cancer nor lymph node metastasis was found in patients with less than 500 μm submucosal invasion without margin involvement in ER specimens. In three of four patients with lymph node metastasis, the depth of submucosal invasion was 500 μm or more; the remaining patient had a 4-cm-sized differentiated mucosal cancer. Conclusions When a pathologic evaluation of an ER specimen reveals more than 500 μm of submucosal invasion or a mucosal cancer of larger than 3 cm, surgery should be considered due to the risk of lymph node metastasis.     

肥胖患者的腹腔镜辅助胃癌根治术

目的探讨肥胖因素对腹腔镜辅助胃癌根治术近期疗效的影响。方法回顾性分析我科2006年3月-2011年10月412例腹腔镜辅助胃癌根治术的临床资料,其中体重指数（body mass index,BMI）92594例（肥胖组）,BMI〈25318例（非肥胖组）,比较2组患者术中情况、术后恢复、手术并发症等指标。结果肥胖组手术时间明显长于非肥胖组[（220．7±40．4）min vs．（185．5±29．1）min,t=9．365,P=0．000],术中出血量明显多于非肥胖组[（132．1±34．1）mlvs．（106．2±18．6）ml,t=9．572,P=0．000],2组肛门排气时间虽有统计学差异,但无实际临床意义[（3．6±1．0）dVB．（3．4±0．8）d,t=2．005,P=0．046]。肥胖组淋巴结清扫数目为（20．8±7．5）枚,明显少于非肥胖组（27．1±8．7）枚（t=-6．356,P=0．000）。肥胖组与非肥胖组术后并发症发生率分别为19．1％（18／94）和13．2％（42／318）,无统计学差异（χ2=2．058,P=0．151）。2组围手术期死亡率分别为2．1％（2／94）和0．3％（1／318）,无统计学差异（P=0．132）。结论肥胖会延长腹腔镜辅助胃癌根治术的手术时间,影响淋巴结清扫,但不增加术后并发症发生率,开展初期应选择BMI〈25的非肥胖病例。     

腹腔镜胃癌手术后消化道重建现状

腹腔镜胃癌手术已有20余年的历史[1],随着腹腔镜技术的进步和手术器械的发展,腹腔镜胃癌根治术的适应证已从早期胃癌逐渐扩展到较早期的进展期胃癌,胃切除范围也从远端胃大部切除术扩展到了全胃切除术[2-3]。而胃切除术后的消化道重建是手术成败的关键步骤之一,它关系到患者术后能否获得较好的恢复和生活质量。现结合笔者所在医院科室的经验及国内外文献,就腹腔镜胃癌手术后消化道重建现状做一论述。     

Comparison of Single-Port Laparoscopy,Standard Laparoscopy,and Robotic Surgery in Patients with Endometrial Cancer

Background  

The aim of this study was to evaluate single-port laparoscopy (SPL) for the surgical treatment of presumed early-stage endometrial cancer and to compare surgical outcomes to laparoscopy and robotics.     

Impact of Cosmetic Result on Selection of Surgical Treatment in Patients With Localized Prostate Cancer

Objectives:

To analyze the effect of cosmetic outcome as an isolated variable in patients undergoing surgical treatment based on the incision used in the 3 variants of radical prostatectomy: open (infraumbilical incision and Pfannestiel incision) and laparoscopic, or robotic (6 ports) surgery.

Patients and methods:

612 male patients 40 to 70 years of age with a negative history of prostate disease were invited to participate. Each patient was evaluated by questionnaire accompanied by a set of 6 photographs showing the cosmetic appearance of the 3 approaches, with and without undergarments.Participants ranked the approaches according to preference, on the basis of cosmesis. We also recorded demographic variables: age, body mass index, marital status, education level, and physical activity.

Results:

Of the 577 patients who completed the questionnaries, the 6-port minimally invasive approach represents the option preferred by 52% of the participants, followed by the Pfannestiel incision (46%), and the infraumbilical incision (11%), respectively. The univariate and multivariate analyses did not show statistically significant differences when comparing the approach preferred by the patients and the sub-analyses for demographic variables, except for patients who exercised who preferred the Pfannestiel incision (58%) instead of minimally invasive approach (42%) with statistically significant differences.

Conclusion:

The minimally invasive approach was the approach of choice for the majority of patients in the treatment of prostate cancer. The Pfannestiel incision represents an acceptable alternative. More research and investment may be necesary to improve cosmetic outcomes.     

Appraisal of Treatment Strategy by Staging Laparoscopy for Locally Advanced Gastric Cancer

More accurate preoperative staging is necessary to determine the treatment strategy for locally advanced gastric cancer. Thirty-two patients with T3 or T4 gastric cancer expected to undergo curative resection based on conventional examinations underwent staging laparoscopy. The disease stages determined were compared with those obtained by conventional methods. The discrepancy rate of disease staging was 16 of 32 (50.0%), with down-staging in 5 of 32 (15.6%) and up-staging in 11 of 32 (34.4%). Of the 32 patients, 13 (40.6%) were found to have unsuspected peritoneal dissemination. The positive predictive value for peritoneal metastasis by staging laparoscopy was 100%, whereas the negative predictive value was 89% (17/19). The accuracy rate was 94%. After laparoscopy, 15 of the 32 (46.9%) were diagnosed as candidates for curative resection. Of these 15 patients who underwent surgery, 13 (86.7%) underwent curative resection (1 R0 and 12 R1); the remaining two underwent R2 resection because of peritoneal metastasis that was undetected by staging laparoscopy. Patients with tumors judged noncurable by laparoscopy (n= 11) received neoadjuvant chemotherapy. In 7 of the 11 cases, salvage surgery was done (one R0, three R1, three R2 resections). A second staging laparoscopy was performed in four cases to determine the indication for salvage surgery. Three of the four were judged to be curable and underwent curative resection. Staging laparoscopy is an effective tool for detecting unsuspected peritoneal metastasis, and it can increase the curative resection rate and decrease unnecessary laparotomy for advanced gastric cancer. Second-look laparoscopy enables accurate assessment of the chemotherapeutic response, which can help in decisions about salvage surgery.     

Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT and Endoscopic Ultrasound

Background A standardized method for predicting unresectability in pancreatic cancer has not been defined. We propose a system using CT and endoscopic ultrasound (EUS) to assess patients for unresectable pancreatic cancers. Methods Radiologic and surgical data from 101 patients who underwent exploration/resection for pancreatic cancer were reviewed. Chi-squares were used to identify five factors significantly correlated with unresectability, which were incorporated into a scoring system (one point for each factor). Results The resectability rates were 84, 56, and 10% for patients with scores of 0, 1, and 2, respectively. All four patients with three risk factors for unresectability had unresectable tumors. The most accurate results were achieved in patients evaluated with both CT and EUS. Discussion This scoring system stratifies pancreatic cancer patients into three groups: (1) patients with a score of zero (likely to undergo successful resection), (2) patients with a score of one (likely to benefit from laparoscopic staging prior to attempting resection), and (3) patients with a score of two or higher (low probability of successful resection, who may be better served by neoadjuvant therapy). Poster presented at the Society for Surgery of the Alimentary Tract, May 22, 2006, Los Angeles, CA.