早期胃癌的淋巴结廓清研究

<5 cm的黏膜内癌,淋巴结转移主要局限于第1站,但黏膜下层癌时随着肿瘤增大,第2、3站均见转移.黏膜内癌的累积5年生存率为97.3%,黏膜下层癌为87.6%(P=0.019).淋巴结廓清范围与累积5年生存率关系为:D2为93.8%,D3为91.7%(P=0.677).结论 早期胃癌中的黏膜下层癌D2或D2+程度的淋巴结廓清是必要的,但胃上部早期癌、<2 cm的黏膜内癌是缩小手术的适应证.     

Lymph node metastasis of early gastric cancer and lymph node dissection

Five hundred and four cases of early gastric cancer and their status of lymph node metastases were analyzed. The patients were classified into 4 groups by age; Group A: Younger than 50 years, Group B: 50-59, Group C: 60-69 and Group D: Over 70 years. The tumors were divided into 2 histologic groups, differentiated type and undifferentiated type. The results are as follows. 1. The incidence of lymph node metastasis was 2.4% in mucosal cancer and 17.1% in submucosal cancer. 2. The incidence of lymph node metastasis in Group D was remarkably lower compared to that in other younger groups. 3. No lymph node metastasis was found in mucosal cancer of differentiated type. 4. Positive node was usually found in the regional nodes near the tumor and in the nodes adjacent to the left gastric artery. 5. Extended lymph node dissection is not necessary for the patient over 70 years and for mucosal cancer of differentiated type.     

Detection of early lymph node metastases in prostate cancer by laparoscopic radioisotope guided sentinel lymph node dissection

PURPOSE: Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. MATERIALS AND METHODS: In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. RESULTS: Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). CONCLUSIONS: SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.     

Evaluation of extended lymph node dissection for gastric cancer

A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages of stomach cancer and end-results of the R₂ (with a conventional lymph node dissection) and the R₃-resections (with an extended lymph node dissection). R₃-resections were found to be generally associated with higher 5-year survival rates than R₂-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was considerably higher with R₃-resections than with R₂-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested from these results that the end-results might be improved more effectively by performing R₃ resection for cases without a marked serosal invasion.     

Appropriate extent of lymph node dissection in thyroid cancer]

Surgery is not always necessary for micro cancer (less than 1.0 cm in diameter). In surgery of micro cancer, we recommended to dissect only the central compartment (pretracheal [II]/paratracheal [III] area). In patient with cancer (more than 1.0 cm in diameter), lymph nodes in the central compartment, ispirateral supraclavicular area, and jugulocarotid chain (V and VI) should be dissected. Even in incomplete surgery, lymph node dissection of the central compartment is warranted in patients with papillary cancer, because recurrence in the central compartment results in dyspnea and/or hemosptum, lowering the quality of life.     

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND: A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported. METHODS: Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision. RESULTS: The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated. CONCLUSION: A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.     

Learning curve for laparoscopy-assisted distal gastrectomy with regional lymph node dissection for early gastric cancer

An assessment of the learning curve of laparoscopy-assisted distal gastrectomy (LADG) might encourage its worldwide spread among inexperienced surgeons. One hundred sixty-seven patients with early gastric cancer were enrolled in this study: 67 underwent conventional open distal gastrectomy and 100 underwent LADG after classification into 5 groups of 20 according to the surgeon's level of experience. Patient characteristics and operative findings were compared between groups. Operation time was significantly longer, time to first flatus earlier, and blood loss reduced in the LADG groups compared with the open distal gastrectomy group. Surgeons with experience of 60 cases performed operations of similar times in both groups, and blood loss decreased with experience of 20 cases. There was no operative conversion, the frequency of nonsteroidal anti-inflammatory drugs administered were significantly less, and length of hospital stay were shorter by surgeons with experience of 60 cases. LADG is a technically feasible surgical procedure, depending on the surgeon's technical proficiency. Experience of at least 60 cases of LADG seems to result in satisfactory patient outcomes.     

腹腔镜下胃癌根治术三例

目的初步探讨腹腔镜下胃癌根治术的适应证、手术方法和根治的可行性。方法对3例早、中期胃癌患者行腹腔镜下胃癌根治术的临床资料进行分析。结果3例患者均顺利完成腹腔镜下胃癌根治术,无中转开腹;平均手术时间240min,术中平均出血量177ml。术后排气时间平均60h,均于术后7d出院。术中及术后未出现并发症。随访3～10个月,患者饮食基本正常,B超、钡餐等影像检查及血液肿瘤标记物检测无异常。结论腹腔镜下胃癌根治性手术技术可行。应合理选择适应证。远期疗效有待进一步随诊观察。     

进展期胃癌行腹主动脉旁淋巴结清扫的疗效观察

目的　评价进展期胃癌患者淋巴结清扫范围与生存率的关系。　方法　共施行进展期胃癌根治术 15 8例 ,其中在D2 、D2 + 或D3 的基础上再作腹主动脉旁淋巴结清扫 (PALD组 )共 73例 ,未作腹主动脉旁淋巴结清扫 (非PALD组 )共 85例。 2组在年龄、性别、肿瘤部位、Borrmann分型、肿瘤大小、组织学类型差异无显著性意义 ,而PALD组的侵犯深度、淋巴结转移和临床病理分期均较非PALD组更晚期。　结果　PALD组手术时间为 (2 80± 93)min ,非PALD组为 (2 4 5± 91)min(P <0 0 1)。输血量PALD组为 (6 93± 32 4 )ml,非PALD组为 (46 0± 375 )ml(P <0 0 1)。 2组均无吻合口瘘、胰瘘、腹腔脓肿及肠梗阻等并发症。除PALD组腹泻发生率较高外 ,其他并发症 2组差异无显著性意义。 2组生存曲线、平均生存期、中位生存期的差异有显著性意义 (P <0 0 5 ) ,2组中淋巴结阴性、阳性患者的生存曲线、平均生存期、中位生存期差异亦有显著性意义 (P <0 0 5 )。PALD组腹主动脉旁淋巴结阴性、阳性患者的生存曲线、平均生存期、中位生存期差异有显著性意义 (P <0 0 5 )。　结论　腹主动脉旁淋巴结清扫有助提高进展期胃癌患者生存期 ,且其病死率和并发症发生率与限制性手术并无明显差别。     

"Super-extensive lymph node dissection" for advanced gastric cancer

Our "super-extensive lymph node dissection" (SELD) for gastric cancer is designed to remove the nodes as thoroughly as possible from the n4-area, i.e., para-aortic area from diaphragmatic crus to IMA, and para-superior mesenteric trunk. One hundred and sixty three cases of gastric cancer, treated with SELD is reviewed. 1) ps (+) cases had n4 metastasis in 25.8%, incidence being compatible to n1 or n2 cases. 2) Prognosis was relatively good in the cases whose cancer positive rate of the dissected n4 lymph nodes was found below 25%. 3) Recurrence was noted in the remaining lymph nodes in the cases, whose rate of lymph node metastasis had been high in preceding surgery. This fact seems to warrant SELD for advanced gastric cancer. 4) SELD however, was accompanied by the longer duration of surgery with more blood loss and by higher incidence of complications, than conventional R2, R3 dissection.     

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

Background Recent advances in surgical techniques have led to widespread acceptance of laparoscopic gastrectomy for gastric cancer. We performed distal gastrectomy with regional lymph node dissection in 235 patients with gastric cancer located in the middle and lower third of the stomach. Methods In 171 cases, reconstruction was done using the Billroth I method intracorporeally and the aid of laparoscopic linear stapling devices. The Billroth II and Roux-en-Y methods were used in the remaining 56 and eight patients, respectively, Results Patients who underwent laparoscopic distal gastrectomy had a more rapid postoperative recovery than those treated via the open approach. Postoperative complications with this technique were within a permissible range. In terms of the survival curve, there was no statistical difference between the laparoscopic group diagonesed as clinical T2N0 (c T2N0) Preoperatively and the open group. Conclusion The laparoscopic technique is not only less invasive, but is also similarly safe and curative compared to open gastrectomy.     

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been advocated, and the laparoscopic operation is noted as a technique that increases the quality of life. We performed distal gastrectomy with regional lymph node dissection on 160 cases of gastric cancer located in the middle or lower third of the stomach. In 123 cases, Billroth I reconstruction was performed intracorporeally using the quadrilateral (square) stapling technique with a laparoscopic linear stapling device to prevent postoperative anastomotic bleeding and stenosis. In the remaining 37 cases, the Billroth II method was performed with a linear stapling device [1]. This technique is not only less invasive but also as safe as open gastrectomy, which was performed on 100 gastric cancer cases of similar staging.     

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目的：探讨胃癌No16淋巴结清扫术式的可行性和意义，提出合适的No 16淋巴结清扫术指征。方法：对1998年9月至2001年9月所行的48例No16淋巴结清扫术病例资料进行分析。结果：在48例No16淋巴结清扫术中发现有第16淋巴结转移者9例，转移率为18．6％，浸润型胃癌、肿瘤直径大于5cm、肿瘤侵及浆膜以及第2、3站淋巴结受累时，No16淋巴结转移率明显增高（P＜0．05）。全组病例无手术死亡，手术并发症也未见明显增高。结论：只要严格掌握手术适应证，No16淋巴结清扫术是安全、可行、有效的。     

腹腔镜保脾的脾门淋巴结清扫在胃上部癌根治术中的应用

目的 探讨腹腔镜保脾的脾门淋巴结清扫在胃上部癌根治术中应用的可行性.方法 2010年7月至12月共对18例胃上部癌患者施行腹腔镜保脾的脾门淋巴结清扫,男性11例,女性7例;年龄28～64岁,平均(53±11)岁.所有患者均行D2淋巴结清扫加全胃切除术,术后病理学诊断为R0切除;乳头状腺癌2例、管状腺癌7例、低分化腺癌6例、黏液腺癌1例、类癌2例;TNM分期:ⅡA期7例、ⅡB期9例、ⅢA期2例.结果 按解剖学分类,所有患者的脾叶动脉分为三型:一支型1例、二支型15例、三支型2例.全组患者均成功实施手术,无一例中转开腹,手术时间215～310 min,平均(271±26)min,术中出血量55～150ml,平均(96±36)ml,脾门淋巴结清扫1～11枚,平均(3.6±2.8)枚,术后住院时间9～16 d,平均(11.3±1.8)d.术后2例患者出现并发症,无手术后死亡.全组患者术后随访2～8个月,未发现肿瘤复发及转移.结论 腹腔镜保脾的脾门淋巴结清扫治疗胃上部癌是安全可行的.

Abstract：

Objective To explore the feasibility of laparoscopic spleen-preserving splenic hilar lymph node dissection for proximal gastric cancer. Methods The clinical data of 18 patients of proximal gastric cancer underwent laparoscopic spleen-preserving splenic hilar lymph node dissection was analyzed from July to December 2010. There were 11 male and 7 female patients, with a mean age of (53 ± 11) years (range 28 to 64 years). All the patients underwent total gastrectomy with D2 lymph-node dissection. A complete macroscopic and microscopic resection (R0) was performed. Results in 18 cases, papillary adenocarcinoma was 2, tubular adenocarcinoma was 7, low differentiated adenocarcinoma was 6, mucous adenocarcinoma was 1 and carcinoid was 2. The TNM stages were distributed as follows: 7 in stage Ⅱ A, 9 in stage Ⅱ B and 2 in stage Ⅲ A. Results Splenic lobar artery which came from splenic artery in the splenic hilar area entered the spleen. According to anatomic classification,splenic lobar artery was divided into three types. In the observation of 18 patients,the splenic lobar artery showed a single lobar artery in 1 case,two lobar arteries in 15 cases,and three lobar arteries in 2 cases. Laparoscopic spleen-preserving splenic hilar lymph node dissection was successfully performed for all patients without open conversion. The mean operation time was (271 ±26)min(range 215 to 310 min) ,mean intraoperative blood loss was (96 ±36)ml (range 55 to 150 ml) ,mean number of splenic hilar lymph nodes dissected was (3.6 ±2. 8) (range 1 to 11) ,and the mean postoperative hospital stay was (11.3 ± 1.8)d (range 9 to 16 d). Two patients experienced complications postoperatively, and there was no postoperative death. The entire cohort were followed up for 2 to 8 months, none of them had recurrence or metastasis. Conclusion Laparoscopic spleen-preserving splenic hilar lymph node dissection for proximal gastric cancer is technically feasible and safe.     

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

BACKGROUND: The technique and results of laparoscopic gastrectomy in 110 patients with gastric cancer located in the upper third of the stomach are presented. METHODS: Proximal gastrectomy was performed for lesions in the upper third of the stomach, and total gastrectomy for those that spread over both the upper and middle third. D1 and D2 lymph node dissection was undertaken in patients with T1 or T2 lesions. Anastomosis of the oesophagus was performed intracorporeally using a conventional circular stapling device or a laparoscopic linear stapler. RESULTS: Median operating time was 247 min for proximal gastrectomy and 285 min for total gastrectomy; median blood loss was 207 and 334 ml respectively. A median of 23 lymph nodes was harvested from patients in the proximal gastrectomy group and 34 from those having a total gastrectomy. There was minimal morbidity and fast recovery after surgery. Postoperative recurrence occurred in only one patient, giving a recurrence rate of 0.9 per cent. CONCLUSION: Laparoscopic gastrectomy for upper gastric cancer appears to be a safe and curative procedure.     

腹腔镜胃上部癌保脾手术的脾门区淋巴结清扫技术

脾门区淋巴结是进展期胃上部癌患者行D2根治术中必须清扫的淋巴结。随着外科技术的进步和治疗理念的更新．保脾的脾门区淋巴结清扫术目前已逐渐被外科医师所接受。由于脾脏位置深在．脾血管解剖变异多,使得腹腔镜保脾的脾门区淋巴结清扫术操作难度大。术者一方面要把握手术适应证：另一方面应采取合理的手术人路和程序化的手术操作步骤．同时必须熟识腹腔镜下脾门区的血管解剖特点．以血管解剖为基础．才能更好地完成腹腔镜下保脾的脾门淋巴结清扫术。     

Standard strategy for lymph node dissection in advanced gastric cancer patients

The standard strategy for lymph node dissection in advanced gastric cancer patients is defined as D2 lymph node dissection based on the Japanese Classification of Gastric Cancer and Gastric Cancer Treatment Guidelines 2010 edited by the Japanese Gastric Cancer Association. Lymph nodes that should be dissected for D2 are also defined according to whether the surgical method is total gastrectomy or distal gastrectomy. The locations of those lymph nodes are anatomically described in the Japanese Classification of Gastric Cancer: No. 1 to 12. The efficacy of prophylactic extended lymph node dissection in the paraaortic area (No. 16) was not confirmed in a randomized clinical trial (JCOG9501). Splenectomy aiming for complete lymph node dissection at the splenic hilum is under evaluation in a clinical trial (JCOG0110). Optional dissection of the lower mediastinal lymph nodes (No. 110, 111) is recommended for junctional tumors, although the dissection of lymph nodes at the root of the supramesenteric vein (No. 14v) and behind the pancreas (No. 13) remains controversial.     

Distant lymph node metastasis of early gastric cancer

Among 601 patients with early gastric cancer (EGC), the clinicopathological findings of 5 patients (invasion of the mucosal layer in 2 and of the submucosal layer in 3) with distant lymph node metastasis according to TNM classification (third-or fourth-tier lymph node metastasis according to the Japanese classification) were investigated. The proliferating-cell nuclear antigen (PCNA) expression of EGC was also examined immunohistologically. The sites of distant metastasis were the nodes at the root of the mesentery, in the hepatoduodenal ligament, and the paraaortic nodes, while the PCNA-positive rate of EGC with distant lymph node metastasis (35.4%) was significantly higher than that of EGC without lymph node metastasis (14.7%,P=0.01), it was similar to that of EGC with perigastric lymph node metastasis. The cumulative survival rate of the EGC patients with distant lymph node metastasis (5-year survival rate 20.0%) was significantly lower than that without lymph node metastasis (88.2%,P<0.0001), first-tier lymph node metastasis (76.9%,P<0.04), or second-tier lymph node metastasis (77.1%,P<0.04). Thus, although the prognosis of EGC patients with distant lymph node metastasis was poor, a dissection of the distant lymph nodes should be performed when metastasis is suspected.