胃癌微创外科临床研究进展及展望（2000-2020）

目前临床研究已证实腹腔镜胃癌根治术治疗早期胃癌的安全性、可行性和有效性。基于此，第4版日本《胃癌治疗指南》推荐腹腔镜手术治疗临床Ⅰ期远端胃癌。然而，腹腔镜胃癌手术治疗进展期胃癌的有效性和安全性仍存争议。中国腹腔镜胃肠外科研究组（CLASS研究组）发起的CLASS-01研究顺利完成，提供了全球首个局部进展期胃癌腹腔镜手术安全性和疗效的前瞻性多中心证据。胃癌外科的主流方向在从“大切口和扩大化手术切除”逐渐向“微创、精准化手术”转变，以使手术安全性和病人术后生活质量最优化。     

腹腔镜胃癌手术的争议与共识

腹腔镜胃癌手术历经20余年的发展,手术技术日趋成熟、手术适应证逐渐扩大、手术并发症发生率不断降低。在当前腹腔镜胃癌手术不断成熟的过程中,争议与共识并存。（1）手术适应证：腹腔镜用于治疗早期胃癌已成为共识,用于治疗进展期胃癌尚存争议。（2）淋巴结清扫范围：腹腔镜远端胃癌D2根治术中,各站淋巴结清扫的镜下解剖标志已在国内专家意见下达成共识;对于网膜囊切除,根据日本 JCOG1001研究结果,不推荐作为cT3期（浆膜下层）或cT4a期（浆膜层）胃癌的标准治疗方式。（3）消化道重建：全腹腔镜重建手术较小切口辅助重建手术视野更好,操作空间更大,且原位断胃无过度牵拉,切缘更充分,主要吻合过程均在腹腔镜监视下完成,是腹腔镜胃癌手术发展的一种趋势。（4）站位和入路：左侧站位入路是国内目前应用最为广泛和成熟的腹腔镜胃癌手术入路,具有中国特色,更体现手术团队紧密协作,对于进展期胃癌行D2根治术时,须剥离大网膜和部分横结肠系膜前叶,以及进行第2站淋巴结清扫,较右侧站位入路优势明显。     

腹腔镜胃癌淋巴结清扫的策略

1994年日本Kitano等首次报道了腹腔镜胃癌根治术治疗早期胃癌，由于其相对于传统的胃癌根治术，具有明显的微创优势，因而在国内外逐步得到开展。目前，腹腔镜胃癌根治术用于早期胃癌治疗的临床报道较多。取得了与开腹手术相当的近远期疗效固，也使腹腔镜胃癌根治术的手术指征从早期胃癌扩大到较早期的进展期胃癌。1997年Goh等首次将腹腔镜胃癌D2根治术用于治疗进展期胃癌，由于该手术包括肿瘤根治切除、扩大淋巴结清扫和消化道重建三个技术环节，手术难度大，特别是腹腔镜下能否达到与开腹手术相当的淋巴结清扫范围和平均淋巴结清扫数量，这是腹腔镜胃癌根治手术开展伊始众多学者疑虑和关注的焦点。     

腹腔镜全胃切除术后消化道重建的方式

自从1991年日本Kitano等[1]实施了首例腹腔镜辅助远端胃切除术治疗早期胃癌以来,腹腔镜胃癌根治术的切除范围从远端胃扩展到全胃,淋巴结清扫范围从胃周淋巴结清扫发展到标准D2根治,手术指征从早期胃癌推广到进展期胃癌。腹腔镜下实施胃癌手术在技术上已经日趋成熟,     

胃背侧系膜近侧段的论证和意义

目前,D 2胃癌根治术治疗局部进展期胃癌,是被人们广泛接受的手术方式。其主要内容包括大网膜和网膜囊的完整切除和网膜囊外D 2范围内的淋巴结清扫。可是,在一系列的临床试验中,人们发现,无论是系统性淋巴结清扫,还是大网膜和网膜囊的完整切除,都没能为胃癌患者带来肿瘤学获益,反而徒增外科学风险。这些事实,与...     

从日本《胃癌治疗指南》（第5版）修订谈日本胃癌外科发展趋势

日本《胃癌治疗指南》自2001年3月制定以来进行了5次修订,其建立在日本大量经验性数据基础上,采用教科书形式介绍,但第5版《胃癌治疗指南》体现出从经验外科向循证医学外科的转变,包括非治愈性胃癌的减瘤手术、网膜囊外切除、近端和胃体部癌合并脾切除、胃癌侵犯食管的手术入路问题等,采纳了国际多中心临床试验（MRCT）研究结果。推荐cStageⅠ胃癌为腹腔镜手术适应证,而对于进展期胃癌正在进行MRCT（JLSSG0901）研究,有待结果发表。改变单一手术模式,注重术前新辅助化疗,对于临界可切除的高度淋巴结转移病例,进行新辅助化疗（SP方案）2~3疗程后,再行D2+No.16淋巴结清扫。对于胃癌腹膜转移的腹腔镜诊断标准以及食管胃结合部癌和残胃癌区域淋巴结定义和清扫范围,指南提出了日本标准,有待循证医学检验。     

胃癌根治术中完整切除网膜囊的临床意义

目的探讨完整切除网膜囊对胃癌的治疗意义。方法回顾分析1999年至2002年期间我科收治的56例进展期胃癌根治术患者的临床资料,其中35例接受完整切除网膜囊的胃癌根治术,同期21例接受合适范围胃部分切除加淋巴结清扫术。利用1、2、3年累积生存率和死亡率评估两种术式的疗效。结果完整切除网膜囊组的1、2、3年累积生存率分别为84.8%,62.8%和39.9%;对照组1、2、3年累积生存率分别为70.8%、47.8%和17.2%,差异有统计学意义。两组术后3年累积死亡率分别为42.9%和51.4%,差异有统计学意义。结论完整切除网膜囊的胃癌根治对于提高手术疗效、减少癌残留、降低局部复发和提高进展期胃癌患者生存率方面有明显临床意义。     

腹腔镜下胃癌根治联合结肠部分切除的实践与评价

胃癌是全球高发的恶性肿瘤,手术治疗仍是目前根治胃癌的主要手段。一般来说,胃癌根治术可选择开腹和腹腔镜两种方式;腹腔镜技术是快速发展的新技术,腹腔镜下胃癌根治术治疗早期胃癌的已经得到世界的认可,而逐渐被作为早期胃癌的标准治疗术式;但是,腹腔镜下胃癌根治术或者腹腔镜下胃癌根治术联合器官切除治疗进展期胃癌的远期效果尚不明确。国内外越来越多的的研究机构都在探索腹腔镜胃癌根治术治疗进展期胃癌的可能性。本文根据国内外研究结果和本中心实践经验,对腹腔镜下胃癌根治联合结肠部分切除的应用现状和前景做了探讨。     

腹腔镜胃癌根治术治疗进展期胃癌的现状与临床研究

不同于日、韩等国家,我国胃癌病例大多以进展期胃癌为主.手术根治作为胃癌的主要治疗手段,近年来取得了很大发展,特别是腹腔镜胃癌根治术的发展.然而针对于腹腔镜胃癌根治术应用于进展期胃癌治疗的诸多方面,在国内外仍存在较大争议,特别是在手术适应证、具体术式以及重建方法选择、镜下完成D2淋巴结清扫以及术后的近期疗效与远期肿瘤学疗...     

腹腔镜辅助远端胃癌根治术

腹腔镜辅助远端胃癌根治术（LADG）是微创外科的技术之一,是现代外科的重要发展方向之一。按照日本胃癌治疗指南．LADG的适应证应严格限定在早期胃癌中,进展期胃癌应属于探索性临床研究。LADG在早期胃癌病例中应用的短期优势已得到较普遍地认可,但全腹腔镜技术尚需进一步研究探索;而LADG在进展期胃癌中的应用仍然是目前学术争议的热点之一。虽然当前有研究显示,LADG加D2淋巴结清扫对于进展期胃癌其效果与开腹手术相当,但仍需等待中国、日本和韩国目前正在进行的大样本多中心随机对照试验的结果确认。     

Current status and evaluation of laparoscopic surgery for gastric cancer

Laparoscopic surgery for gastric cancer in Japan has been established as a treatment for early gastric cancer after technical improvements, development of instruments, and efforts of surgeons. The technigue was extended to some advanced gastric cancers and now plays an important role in the gastric cancer treatment strategy with open surgery and endoscopic mucosal resection. Laparoscopic surgery for early gastric cancer has been evaluated as less invasive, offering radical cure, and safe in several clinical trials and case-control studies. However, the accumulation of more cases and additional basic research are necessary before adapting laparoscopic surgery for advanced gastric cancer. A large-scale, randomized, controlled study will be carried out in early gastric cancer, and, as a result, scientific and objective evaluation of laparoscopic surgery for gastric cancer will be possible in the near future.     

��ǻ��θ�������������빲ʶ

??Controversies and consensus of laparoscopic surgery for gastric cancer ZANG Lu, MA Jun-jun, ZHENG Min-hua. Department of Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai 200025, China
Correspongding author??ZANG Lu, E-mail: zanglu@yeah.net
Abstract Laparoscopic gastrectomy has been popularized with the expanding indication and decreasing complication since the development of laparoscopic surgical techniques in the past 20 years. The controversies and consensus also coexist at present.(1) Indication of laparoscopic surgery for gastric cancer: Laparoscopic gastrectomy for early gastric cancer is accepted all over the world. For locally advanced gastric cancer, laparoscopic gastrectomy with D2 dissection is still under debate. (2)Lymphadenectomy and bursectomy:D2 lymph node dissection margin in laparoscopic distal gastrectomy has been defined by a Chinese expert consensus in terms of quality control of laparoscopic radical gastrectomy for gastric cancer. Bursectomy is not recommended as standard procedure in cT3 or cT4a gastric cancer based on the results of JCOG1001. (3)Totally laparoscopic reconstruction: Totally laparoscopic reconstruction provides a better and larger surgical scene compared to small incision assisted surgery. The whole procedure of anastomosis is monitored clearly by laparoscopy, without any over traction of tissue. (4)Position and approach: Left-side position is the first choice in China, which is suitable for most laparoscopic gastrectomy, and needs good teamwork. It is superior to right-side position especially in D2 dissection for local advanced gastric cancer when dissection of greater omentum and anterior lobe of transverse mesocolon is needed.     

腹腔镜胃癌根治术需关注的几个问题

微创性、安全性和肿瘤的根治性是腹腔镜胃癌手术的三大基本原则，以循证医学为基础不断更新、发展和完善。本文将现有的指南、共识及文献报道与自身经验相结合，对手术适应证的选择、不同手术入路的优劣、淋巴结清扫的顺序和质量控制以及全腹腔镜下消化道重建不同方式的特点进行探讨。在国内外广泛开展腹腔镜手术治疗早期和局部进展期胃癌的背景下，如何合理、规范的开展手术，是值得外科医生关注的问题，手术理念的进步和手术技术的发展也必将让更多的患者受益。     

腹腔镜在胃肠恶性肿瘤中的应用现状及存在问题

Laparoscopic surgery has gained wide acceptance for its use in benign gastrointestinal cancer in the past 20 years, while its use in malignant gastrointestinal cancer has been highly controversial until the recent 3-5 years. Several prospective randomized clinical trials have suggested that the long-term outcome of laparoscopic surgery for colon cancer is the same as or better than that of open surgery. As for rectal cancer, whether the principles of total mesorectal excision can be well followed in laparoscopic surgery remains. Most recently, the trial of large number of patients doesn't show any differences upon local recurrence and 3-year survival rate between rectal cancer patients in laparoscopic group and open group. Laparoscopic surgery has been widely accepted as a standard treatment regimen for early gastric cancer in many specialized centers. Meanwhile, the feasibility and effectiveness of laparoscopic D2 lymphadenectomy for gastric cancer has been proved by several scholars. The use of laparoscopic surgery for advanced gastric cancer especially for T3 gastric cancer still remains controversial. The early concern that laparoscopic surgery for malignant cancer might increase tumor dissemination is not confirmed. The system of technical training and occupational qualification, proper selection of patients and adherence to all the principles of cancer clearance will ensure a good result of laparoscopic surgery for malignant gastrointestinal cancer.     

腹腔镜胃肠肿瘤手术的进展

Since Dr.Mouret first introduced the laparoscopic technique into chokcystectomy,a new surgical era has arrived.With the rapid development of minimally invasive technique,it is now playing an important role in the surgical treatment of gastrointestinal cancers.Almost all kinds of gastric operations,such as wedge resection,distal gastrectomy,proximal gastrectomy and total gastrectomy with or without lymph node resection can be achieved with a laparoscope.In China,laparoscopic gastrectomy has been widely applied in many experienced medical centers and great progress has been achieved in the treatment of early and advanced gastric cancer.Laparoscopic colonic surgery has been recognized as one of the standard operations by NCCN.In Asian countries like China,Japan and Korea,laparoscopic rectal surgery following the TME principle has been widely applied.Because of the rapid development of laparoseopic gastrointestinal surgery in China,the Chinese Society of Laparoendoscopic Surgery has published standardized guidelines and established training centers for the development of young Surgcons.     

局部进展期胃上部癌的腹腔镜淋巴结清扫策略与应用前景

局部进展期胃上部癌行腹腔镜根治性手术必须遵循与开腹手术相同的淋巴结清扫范围。按从下至上程序化的步骤进行淋巴结清扫,不仅能使手术进程更加顺畅,而且能达到“整块切除”的要求。脾门区淋巴结清扫是腹腔镜局部进展期胃上部癌D2根治术的难点,选择正确的手术入路、熟识脾门区血管解剖类型以及整个手术团队的默契配合有助于缩短该术式的学习曲线。尽管目前对于局部进展期胃上部癌进行腹腔镜淋巴结清扫术仍处于探索性开展阶段,但相信随着更多高级别循证学证据的出现,其有望成为治疗局部进展期胃上部癌的标准清扫术式之一。     

腹腔镜远端胃癌根治术淋巴结清扫相关解剖学的临床应用研究

目的：研究腹腔镜远端胃癌根治术淋巴结清扫相关解剖学特点,探讨腹腔镜下实施淋巴结清扫的正确方法和技巧。方法：通过29例腹腔镜远端胃癌根治手术和6具人体标本解剖,观察胃癌根治术D2淋巴结清扫的镜下解剖学定位标志、可利用的解剖间隙以及与开放手术的差异。结果：25例在腹腔镜下完成手术,4例因肿瘤浸润、淋巴结融合固定而中转行姑息性切除手术,手术清扫的淋巴结数目为11～32个。腹腔镜远端胃癌D2根治术淋巴结清扫均位于韧带和系膜形成的潜在间隙内。胰腺、结肠中血管、胃左血管位置恒定而突出,在腔镜下易于识别,可作为腹腔镜下淋巴结清扫的定位标志。结论：利用镜下解剖定位标志,进入正确的解剖间隙进行清扫,更符合安全性的原则和肿瘤根治的规范。腹腔镜下的相关解剖学研究为腹腔镜胃癌根治手术提供了正确可靠的依据。     

试析腹腔镜胃癌根治术淋巴结清扫的相关问题

手术是胃癌治疗的基石,但关于淋巴结清扫的范围东西方学者一度有过争论。基于2010年Dunch研究15年随访结果,D2淋巴结清扫作为进展期胃癌治疗的标准术式方得到普遍认同。至此也为胃癌腹腔镜淋巴结清扫术的应用奠定基础,开启了胃癌外科治疗的新纪元。自从1994年日本Kitano教授进行了首例腹腔镜手术治疗早期胃癌以来,其应用于胃癌的证据越来越多,现已被日本胃癌治疗指南推荐为早期远端胃癌的标准治疗选择。在我国,依据中国胃肠肿瘤外科联盟收集2014年至2016年间3年来自全国73家中心88000余例胃癌手术病例数据来看,接受腔镜手术患者的比例已超过30%,并呈每年上升趋势。由于腹腔镜手术具有微创、视野放大、操作精细、便于沟通、交流及学习等特点,其将具有更广阔的应用前景。本文结合笔者团队既往的经验,讨论腹腔镜下胃癌淋巴结清扫的特点。希望借此文对读者有所启发。     

胃癌外科综合治疗的若干进展与展望

胃癌是国内、外常见恶性肿瘤，手术仍是治疗胃癌的主要方法。一系列临床研究改变了传统胃癌手术理念，避免盲目扩大手术切除范围。腹腔镜手术治疗早期和局部进展期胃癌的疗效并不劣于开腹手术。胃癌微创手术发展的关键是把握合理的手术指征，建立手术技术培训系统，以及优化成本与效益。理性认识胃癌扩大术脏器切除与保留脏器功能的关系。注重局部进展期胃癌围术期治疗的全程管理。并提倡晚期胃癌的术前转化治疗。对广泛转移晚期胃癌的姑息性切除术应慎之又慎，建议综合治疗，旨在延长病人生命。