从“单打独斗”到“合作共赢”：论多学科团队在食管胃结合部腺癌诊治中的现状和展望

由于食管胃结合部腺癌特殊的肿瘤部位和生物学行为,其治疗模式也由传统的完全外科医师主导、手术治疗为先向包括胸外科、肿瘤内科、放疗科、麻醉科等在内的多学科团队合作的综合治疗发生转变。腔镜技术的发展使腹腔镜和胸腔镜共同治疗食管胃结合部腺癌将逐渐成为可能,加速康复外科理念则有望进一步推动食管胃结合部腺癌手术的微创化。同时,新辅...     

从胸外科视角看Siewert Ⅱ型食管胃结合部腺癌的治疗

Siewert Ⅱ型食管胃结合部腺癌（AEG）相比较于SiewertⅠ、Ⅲ型,存在着较大的临床诊疗争议。《中华胃肠外科杂志》于2018年发表了首版《食管胃结合部腺癌外科治疗中国专家共识》,几年来,随着胸腔镜微创技术的发展已经证实,胸腔镜微创手术能使SiewertⅡ型AEG患者受到更小的胸部创伤,经胸行远端食管切除可以实...     

食管胃结合部腺癌外科治疗现状与争议

食管胃结合部腺癌的发病率在全球范围内呈上升趋势。由于肿瘤位于食管和胃的结合部,因此,有关手术方式、淋巴结清扫、食管和胃的切除范围、微创技术应用等问题尚未达成共识,存在争议。但手术仍然应该重视术前分期和分型的准确性,遵循恶性肿瘤根治手术的基本原则,合理选择规范化和个体化治疗策略。未来食管胃结合部腺癌的诊治将需要通过多学科协作的模式来共同完成。     

Siewert Ⅱ型食管胃结合部腺癌的外科治疗现状

胃癌在全球恶性肿瘤发病率中位居第五，每年有100多万新发病例、76万死亡病例，严重威胁人们的身体健康。其中包括SiewertⅡ型食管胃结合部腺癌在内的胃上部癌近年发病率正在不断升高。目前，胃癌的治疗是以手术治疗为主的综合治疗模式，而关于SiewertⅡ型食管胃结合部腺癌的手术方式仍存在争议，主要表现在手术切除范围、淋巴结清扫及术后消化道重建方面。本文以胃肠外科医生视角，从上述几方面综述了SiewertⅡ型食管胃结合部腺癌的外科治疗策略，以期提高对此类疾病的认识，为SiewertⅡ型食管胃结合部腺癌的临床治疗方案选择提供参考。     

手辅助腹腔镜联合胸腔镜治疗侵犯食管下段食管胃结合部腺癌八例

目的 总结手辅助腹腔镜联合胸腔镜治疗侵犯食管下段Siewert Ⅱ型食管胃结合部腺癌手术流程,为该病治疗提供一种更为安全、可行的微创手术方式.方法 2016年1月至2019年2月间在广州红十字会医院普外科住院确诊为侵犯食管下段的Siewert Ⅱ型食管胃结合部腺癌并行手辅助腹腔镜联合胸腔镜治疗者8例,回顾性分析其临床资...     

《中国实用外科杂志》2012年第4期重点内容介绍 重点选题:食管胃结合部腺癌的综合治疗

理念与技术并重提高食管胃结合部腺癌综合治疗水平(秦新裕,刘凤林)食管胃结合部腺癌的规范综合治疗(季加孚,季鑫)食管胃结合部腺癌流行趋势病因及防治(陈志峰)食管胃结合部腺癌的临床病理特点(孙宇,李吉友)食管胃结合部腺癌的淋巴转移规律及其对临床的指导意义(陈凛,张士武)食管胃结合部腺癌的进展方式和临床特征(胡祥)可切除食管胃结合部腺癌的术式选择(叶颖江,王杉)     

食管胃结合部腺癌的外科治疗

食管胃结合部癌的发病率呈持续上升的趋势,尤其是在西方国家。外科手术切除仍然是治疗食管胃结合部癌的基石。由于肿瘤位于食管和胃的结合部,所以对其定义、分型、分期和手术方式都还存在一些争议。Siewert分型是目前认可程度最高的分型方法。对于进展期SiewertⅠ型食管胃结合部癌,其生物学特性和外科治疗方案更接近于食管癌;对于进展期SiewertⅡ、Ⅲ型食管胃结合部癌,外科治疗方案更接近于胃癌。而对于早期食管胃结合部癌,可以采用内镜切除或者缩小手术。     

食管胃结合部腺癌保功能手术的现状和发展

食管胃结合部腺癌是消化系统常见肿瘤,其发生率呈进行性上升。传统经腹食管裂孔路径的食管胃结合部腺癌根治手术多采用全胃切除术。随着早期病人的比例增加,保功能手术观念的发展及更多的研究数据支持,近端胃切除术在早期食管胃结合部腺癌中越来越得到重视。食管胃结合部腺癌的近端胃切除术的两个重要研究方向：一是食管胃结合部腺癌的适应证研究,主要涉及淋巴结转移、切缘要求等;二是消化道重建的术式选择研究,主要基于增加残胃的容受、重建结构屏障或压力屏障、加速胃排空三个基本原理进行重建术式的设计。笔者希望通过对两个研究方向的探讨,为食管胃结合部腺癌保功能手术的发展提供一些方向。     

胃食管结合部良性疾病的腹腔镜治疗

胃食管结合部良性疾病临床上以胃食管反流病、食管裂孔疝和贲门失弛缓症最为常见,中、重度病人通常需要外科手术治疗。传统外科的开放式手术创伤大、围手术期并发症发生率较高,随着腹腔镜技术的日臻成熟,针对上述疾病所开展的腹腔镜胃底折叠术、腹腔镜食管裂孔疝修补术、腹腔镜贲门括约肌切开术逐渐被临床应用。临床研究显示：腹腔镜微创技术在治疗胃食管结合部良性疾病方面具有手术创伤小、恢复快、操作安全、疗效可靠等优势。     

食管胃结合部腺癌的外科治疗原则

近年来,远端胃癌发病率在世界范围内均呈下降趋势,与之相反,食管胃结合部腺癌（AEG）的发病率自20世纪70年代起持续升高。由于AEG处于胸腹交界处这一特殊部位,有着相对独立的临床病理特征和治疗策略。随着微创外科技术的进展,虽然少数早期AEG病例可通过内镜黏膜下剥离术等微创手术达到治愈切除的效果,     

���굥�׸�ǻ�����ϵ�����ǻ����ʳ��θ��ϲ��ٰ������е�Ӧ��

目的探讨联合经脐单孔腹腔镜技术和单操作孔胸腔镜技术在食管胃结合部腺癌(AEG)治疗中的应用。方法 2010年3月至2011年6月间中国医科大学附属盛京医院共进行了3例AEG的微创治疗。用经脐单孔腹腔镜技术游离胃,再用单操作孔胸腔镜技术游离食管,通过使用OrVil系统完成食管和胃部的吻合。结果术后病人疼痛轻微,术后第1天均离床活动,术后4d拔除引流管,术后7d进食,病人均痊愈出院。结论微创技术有创伤小、疼痛轻、恢复快的特点,经脐单孔腹腔镜技术和单操作孔胸腔镜技术在AEG治疗中将会是一种更加微创的治疗方法。     

��ǻ��������ʳ��θ��ϲ��ٰ������е�Ӧ�ü�����

腹腔镜技术在食管胃结合部腺癌(AEG)中的运用是基于Siewert分型系统的指导进行的。经过十余年的临床实践,腹腔镜手术已经在AEG的治疗中显示出了一定的活力。其手术的安全性及对于相对早期肿瘤的疗效已经得到证实。但是由于该肿瘤部位和生物学特性,目前尚缺乏大规模、多中心的前瞻性临床研究来判断腹腔镜技术在其治疗中的价值和地位。外科医师应严格选择合适病例,严格遵循恶性肿瘤手术的根治原则,以发挥腹腔镜技术的微创优势,并取得与传统手术相当的远期疗效。     

Sentinel Node Mapping in Adenocarcinoma of the Esophagogastric Junction

Background

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing, but the surgical strategy for AEG remains controversial. We hypothesized that sentinel node (SN) mapping for AEG could be validated to avoid unnecessary lymphadenectomy and permit minimally invasive surgery. We examined the feasibility of SN mapping for AEG.

Methods

We enrolled 15 patients with preoperatively diagnosed cT1 N0 M0 primary AEG (Siewert type I, N = 3; Siewert type II, N = 12) lesions measuring <4 cm in diameter. The dual tracer method employing radioactive colloid and blue dye was used to detect SNs. The distribution of SNs was compared with that of metastatic lymph nodes in 52 patients who were surgically treated without SN mapping.

Results

SNs were successfully identified in all the patients. Two patients with lymph node metastasis had positive SNs identified via an intraoperative pathological examination, and the diagnostic sensitivity and accuracy based on the SN status were both 100 %. For Siewert type II AEG, the SNs were not detected in the lower mediastinum by intraoperative gamma probing. Thus, all surgical procedures were performed via a transhiatal approach. No patient without SN metastasis experienced cancer recurrence during a 38-month median follow-up. The distribution of SNs was similar to that of lymph node metastasis in the patients who were surgically treated without SN mapping.

Conclusions

We achieved 100 % SN detection. Our results suggested that SN mapping is feasible for AEG and highly sensitive and accurate in diagnosing lymph node metastasis. SN mapping may clarify the necessity of mediastinal lymph node dissection and individualize minimally invasive surgery.     

ʳ��θ��ϲ��ٰ����������״������

??Current status and controversy of surgical treatment for adenocarcinoma of esophagogastric junction CAO Hui ??ZHAO En-hao. Department of Gastrointestinal Surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
Corresponding author: CAO Hui, E-mail: caohuishcn@hotmail.com
Abstract The incidence of adenocarcinoma of esophagogastric junction (AEG) has been an alarming rise worldwide during recent decades. Due to the anatomic location of the tumor, there are still many controversies about surgical approaches, regional lymphadenectomy, extents of esophageal and gastric resection, efficacy of minimally invasive surgery, etc. Standard and individual therapy strategies, based on precisely pre-operative classification and staging, should be selected cautiously according to the basic principles of radical surgery in malignant tumor. A multidisciplinary team will be essential for optimal diagno.sis and management in the near future.     

食管胃结合部腺癌的手术原则

食管胃结合部腺癌（AEG）在欧美地区急剧增加,引起世界范围的高度关注。我国虽有散见的相关研究报道,但对AEG治疗现状的把握是困难的。目前对AEG的规范化治疗正在逐渐形成共识。早期AEG的治疗是以内镜下黏膜切除术（EMR）、内镜黏膜下剥离术（ESD）、腹腔镜下手术、缩小手术为主。进展期AEG的治疗,SiewertⅠ型患者作为食管癌处理,开胸手术、纵隔淋巴结清扫可获得良好的预后效果;SiewertⅡ、Ⅲ型患者行开胸手术获益少,作为胃癌手术清扫更为妥当,经腹食管裂孔扩大、下段食管切除、全胃切除、下纵隔腹腔淋巴结（D：）清扫。     

微创手术治疗牌外翻畸形的Meta分析

目的系统评价微创手术治疗腰外翻畸形的有效性和安全性。方法电子检索TheCochraneLibrary、ISIWebofscience、Pubmed、EMBASE、CNKI、CBMdisc等数据库,检索时间始于各数据库起始日期,截止至2012年3月12日,并辅以手工检索和附加检索,收集公开发表的关于微创手术治疗牌外翻畸形的研究文献,按Cochrane系统评价方法选择文献、提取资料并评价纳入研究质量后,采用RevMan5．1软件进行Meta分析。结果共纳入25篇文献,合计2391例患者,由于绝大部分文献是自身前后对照的病例系列研究,并且各研究间存在较大差异,有显著异质性,不符合Meta分析条件,故采用描述性分析。分析结果显示：多数研究提示微创手术治疗牌外翻疗效明确,2个病例对照研究显示微创手术与传统手术疗效无差异,而微创手术并发症发生率是否高于传统手术尚不明确。结论微创手术可以有效治疗牌外翻,但尚无有力证据证明其疗效优于传统开放手术。微创手术的安全性尚不明确。由于纳人研究质量不高,各研究治疗方案不统一,报告不标准和不全面,降低了该结论的可靠性,但仍应关注微创手术治疗脾外翻的益处。未来需要进一步采用一致的干预、随访方法和全面报告结果的准则,进行大样本、前瞻性对照研究。     

From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.     

人工智能时代肝胆胰外科微创技术与开放手术之争

现今从技术层面来看,腹腔镜与机器人已可以完成几乎所有的开放肝胆胰手术,并且经多项前瞻性RCT研究认为：微创胰十二指肠切除术和肝切除术的术后恢复更好,但对术后远期疗效的影响仍不明显,其学习曲线期间手术并发症发生率较开放手术高。多部指南与共识建议：仅在高流量大型专科单位由经验丰富且已度过学习曲线的专科医生施行微创肝胆胰高难度手术,同时专业学会应强化技术监管和审批,合理选择手术适应证,做好开放与微创技术的深度融合,不断改善手术质量使病人获益。     

腹腔镜手术治疗胰腺肿瘤的现状

Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use.In the past,minimally invasive techniques in pancreatic surgery were only used for diagnostic laparoscopy,staging of pancreatic cancer and palliative procedures for unresectable pancreatic cancer.A growing number of case series and multi-institutional reports on safety and efficacy of minimally invasive pancreatic resection have been published.Current knowledge on minimally invasive pancreatic resection is based mainly on short-term outcomes from a small number of centers with cohorts too small to make strong arguments for or against its use.In carefully selected patients,minimally invasive pancreatic resection is safe and feasible.However,the procedure should only be attempted by surgeons who are experienced in open pancreatic surgery and in laparoscopic surgery.The role and oncologic safety of minimally invasive approach for pancreatic resection for pancreatic cancer remain unknown.