胃癌扩大切除术的现状

现今，胃癌的手术原则是：缩小与扩大切除并存，提高疗效与保存良好的生活质量并重。胃切除2/3以上、淋巴结D2清除术，定名为标准根治术；小于或大于此范围的手术，分别叫做缩小与扩大切除术。胃癌扩大切除术是指原发癌或转移灶直接侵及胃周脏器（T4），或淋巴结转移达N2以远，尚能行根治切除。因此，扩大切除术即是联合脏器切除和／或D2^＋＋或D3淋巴结清除术。适用于ⅢAⅢa和生物学行为较好的部分Ⅳ期局限型癌患者。     

双镜联合治疗早期胃癌的临床体会

目的:探讨胃镜、腹腔镜双镜联合治疗早期胃癌的安全性与可行性。方法:回顾分析近6年双镜联合治疗78例早期胃癌患者的临床资料。胃体、远端胃肿瘤非溃疡患者行内镜黏膜下剥离术,近端胃及胃体、远端胃肿瘤合并溃疡患者行双镜联合下腹腔镜胃楔形切除术。标本送快速病理检查。结果:为早期胃癌浸润至黏膜下层及肌层、伴有脉管癌栓、肿瘤直径>20 mm、低分化腺癌(包括印戒细胞癌)的30例患者行腹腔镜胃癌D2根治术,5例近贲门或幽门部位肿瘤患者行单纯胃大部切除术,43例患者仅行内镜黏膜下剥离术或单纯胃楔形切除术。根治患者术后淋巴结转移占全部病例的11.5%,术后均无并发症发生,患者痊愈出院。结论:双镜联合治疗早期胃癌安全、患者创伤小、康复快、疗效确切,更加体现了微创优势,避免了部分患者不必要的根治切除甚至全胃切除的痛苦,值得临床推广。     

早期胃癌腹腔镜与开腹根治术的对照研究

目的评价腹腔镜胃癌根治术治疗早期胃癌的可行性、安全性、肿瘤根治性以及术后近期疗效.方法回顾性分析2004年8月至2007年8月间68例接受外科手术的早期胃癌的临床和手术资料,其中腹腔镜胃癌根治术31例,开腹胃癌根治术37例;并比较两组的手术时间、术中出血、术后胃肠道恢复、术后住院天数、术后并发症、术后病理及随访等结果.结果全部31例早期胃癌均在腹腔镜下完成胃切除和淋巴结清扫,无中转开腹,其中远端胃大部切除术28例,近端胃大部切除术2例,全胃切除术1例;D1 α式淋巴结清扫16例、D1 β式淋巴结清扫2例,D2淋巴结清扫13例.腹腔镜胃癌根治术的平均手术时间为194.8±50.8 min,与开腹组无显著性差异;术中出血量(138.7±157.3)ml,显著低于开腹组(P＜0.05).腹腔镜手术后肠道恢复功能时间1.8(1～4)d,显著少于开腹组(P＜0.01).腹腔镜组术后并发症发生率为3.2%,与开腹组无显著性差异(P＞0.05).腹腔镜组清扫淋巴结数(9.6±4.4)枚,测量胃近端和远端正常切缘(3.8±1.6)cm及(3.5±1.3)cm,与开腹组比较无显著性差异.术后中位随访15(2～35)个月,腹腔镜组无肿瘤复发或者死亡,开腹组一例因腹膜复发而死亡.结论腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的方法.     

217例早期胃癌扩大胃切除与淋巴结清除术的回顾分析

目的评价早期胃癌不同扩大手术的实际意义，以选择合理的胃切除和淋巴结清除范围。方法以临床病理资料完整、施行规范D2及扩大手术的217例早期胃癌患者为研究对象。分析施行不同扩大手术的原因、淋巴结清除的必要性及第Ⅱ站淋巴结转移与临床病理因素的相关性。结果胃上部癌行全胃切除术6例，No．5、6淋巴结均未见转移；联合脾、脾动脉切除2例，No．10、11p、11d淋巴结均未见转移；胃下部癌联合横结肠系膜切除3例，No．15淋巴结未见转移。以上病例术中多数误认为进展期胃癌而扩大了胃切除或淋巴结清除范围，手术时间长，术中失血较多。胃下部癌清除的第Ⅱ站淋巴结中No．11p、12a、14v均未见转移；黏膜下癌（sm癌）中，No．7、8a淋巴结转移率明显高于黏膜内癌（m癌）（P〈0．05）；淋巴管癌栓阳性者No．7淋巴结转移较阴性者明显增多（P〈0．001），No．1、13淋巴结转移仅出现在淋巴结转移高危病例（sm、癌灶大于3．0cm、凹陷型，淋巴管癌栓阳性）。结论早期胃癌不需施行淋巴结扩大清除术和联合脏器切除。早期胃上部癌不需施行全胃切除术。早期胃下部癌中No．11p、12a、14v淋巴结不需清除．但对胃下部癌淋巴结转移高危病例，应行标准D2淋巴结清除术。     

诊治胃癌腹膜转移的有效方法及其临床意义

近20年来,胃癌外科治疗的临床技术已取得显著进步,内镜下早期胃癌黏膜下切除术、腹腔镜胃癌根治术和机器人胃癌根治术等微创手术已逐渐普及并得到广泛应用,将胃癌D2根治术作为我国胃癌的标准术式也形成了普遍共识。规范的胃癌D2根治术和胃癌扩大根治术旨在彻底清扫转移淋巴结,其优势表现在早期胃癌或进展期胃癌术后因淋巴结转移而引起的肿瘤复发比例明显降低,改善了病人的预后。同时,微创外科手术不但能降低病     

胃镜病理活检诊断高级别上皮内瘤变的临床探讨

目的 评价胃高级别上皮内瘤变（HIN）这一概念在临床应用中的价值和不足.方法 回顾性分析经胃镜活检病理诊断为HIN的45例患者的临床和病理资料,并与术后病理诊断结果进行对比研究.结果 本组患者33例接受远端胃大部切除术,3例行近端胃大部分切除术,7例行全胃切除术,2例行内镜黏膜切除术.术后病理结果显示,15例（33.3%）维持HIN的诊断：14例（31.1%）为早期胃癌,16例（35.6%）为进展期胃癌,其中40.0%（12/30）伴有局部淋巴结转移.术前胃镜活检显示直径大于或等于3 cm、伴有溃疡或具有低分化癌特点的HIN病灶.术后多提示为癌（P〈0.05）.对于胃癌患者,具有上述特征者多为进展期胃癌,易发生淋巴结转移（P〈0.05）.结论 术前采用胃镜病理活检对HIN作出诊断应慎重;当HIN病灶直径大于或等于3 cm、伴有溃疡或具有低分化癌特点时,建议选择积极的根治性手术治疗.     

早期胃癌的诊断与外科治疗

目的总结14例早期胃癌临床特点及诊治经验，并探讨最佳诊治方法。方法对14例早期胃癌患者的资料进行回顾性分析。结果本组病例全部接受纤维胃镜或电子胃镜检查，确诊率96．8％；本组2例采用内镜粘膜切除术：2例采用保留迷走神经胃段切除术；其余10例采用D2根治术8例，Dt根治术2例。结论早期胃癌缺乏特异症状、早期误诊率高，胃镜检查是诊断早期胃癌的首选方法。D2根治术应做为根治早期胃癌的标准术式．内镜下粘膜切除术、保留迷走神经胃段切除术有利于保持患者术后生存质量。     

对胃癌扩大切除术的几点基本认识与选择

当今,胃癌的手术原则是缩小与扩大切除并存、提高疗效与保存良好的生活质量并重。胃切除2/3以上、淋巴结D2清除术,定名为标准根治术;小于或大于此范围的手术,分别叫做缩小与扩大切除术。现就胃癌扩大切除术的几点基本认识和如何正确选择术式等问题与同道商榷。一、关于胃癌扩大切除术的几点基本认识1.胃癌扩大切除术的定义:扩大切除术的定义是原发癌或转移灶直接侵及胃周脏器(T4)或淋巴结转移达N2以远,尚能行根治切除。因此扩大切除术即是联合脏器切除和(或)D2+或D3淋巴结清除术。病期属于ⅢA、ⅢB和部分Ⅳ期者,后者应是生物学行为较好的…     

胃癌联合脾 胰体尾或胰头切除的争议和趋势

胃癌的标准根治术是指D2淋巴结清扫术,胃癌的扩大根治术是指D3手术或联合脏器切除加D3淋巴结清扫术[1]。在胃癌联合脏器切除中,对于胃上部癌是否联合脾、胰体尾切除及胃下部癌是否联合胰头十二指肠切除,争论较大,结合国内外资料和本人体会谈谈有关问题。日本学者最早提出和开展     

早期胃癌手术后死亡的原因和复发

一般而言，早期胃癌的预后良好，10年无病生存率约为90％，但切除手术后仍有一部分病例出现复发。作者复习意大利7家医院于1974～1987年所手术治疗的172例早期胃癌资料，临床病理分析均按日本胃癌研究学会（JRSGC）制定的标准。28例上1／3胃癌均行全胃切除、脾切除和D2淋巴结清扫术。53例下2／3胃癌行全胃切除和D2淋巴结清扫术，其中31例还切除了脾脏。余91例下2／3胃癌行胃次全切除和D0－1淋巴结清扫术，切缘距肿瘤至少2cm。结果（一）死亡原因分析在172例手术病例中，经平均13年的随访达141例，其中7例死于手术（手术死亡率4．1％），…     

近端胃癌手术时淋巴结清扫范围、数目及转移的研究

目的研究近端胃癌手术时淋巴结切除范围、数目、转移和预后的关系。方法 行D2或D3术式的近端胃癌标本，全数摘取淋巴结，比较全胃切除和近端胃切除的淋巴结切除数目并判断预后。结果 本组31例共取淋巴结1971枚，平均63枚／例。近端胃切除57枚／例，全胃切除71枚／例，左半胰切除64枚／例，保留左半胰63枚／例。新分期N1、N2、N35年生存率分别为36％、11％、0。结论 随着癌肿侵犯范围扩大，必须扩大淋巴结切除范围；保留左半胰不影响淋巴结切除数目；新的定量N分期在评价预后方面优于旧的定性N分期。     

老年胃癌患者的外科治疗

目的探讨老年胃癌患者的外科手术治疗方法及其治疗效果。方法回顾性分析我院1999年6月至2003年6月226例65岁以上老年胃癌患者行手术治疗的临床资料。胃癌根治性切除122例(D157例,D232例,D333例),姑息性切除56例,行远端胃切除术107例,近端胃切除术51例,全胃切除术15例,联合器官(脾、胰尾、横结肠)切除5例,未切除41例。结果围手术期死亡率为3.1%,手术并发症发生率为17.3%。随访207例,平均随访时间37(12~60)个月。总体中位生存时间32.5个月;根治性切除组平均为37个月,姑息性切除组为19个月,未切除组为8个月;5年生存率根治性切除组为28.0%,姑息性切除组为2.1%,未切除组为0。根治性切除者的术后生存时间明显长于姑息性切除者,差异有显著意义(P<0.01)。结论老年胃癌术后并发症发生率高。对老年胃癌患者积极行根治性切除术,能延长生存期,改善患者生活质量,但应做好围手术期处理。     

Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis

BACKGROUND: Less invasive treatment is the current trend in many surgical fields. Most patients with early gastric cancer do not have lymph node metastasis. Thus extensive resection of the stomach and extended lymph node dissection do not appear to be necessary. METHODS: In a retrospective study, 890 consecutive patients with early gastric cancer who had undergone standard gastrectomy were assessed for depth of invasion, gross appearance, and maximum diameter of the tumor to examine the possibility of limiting the extent of lymph node dissection. A variety of limited gastrectomies have been developed and now include endoscopic mucosal resection, wedge resection, segmental gastrectomy, limited proximal gastrectomy, and distal hemigastrectomy. RESULTS: A retrospective study revealed that extensive lymph node dissection did not improve the survival of patients with early gastric cancer. Endoscopic mucosal resection was suitable for cancers of the depressed type of less than 1 cm in diameter and the elevated type of less than 2 cm in diameter. Wedge, segmental, or limited proximal gastrectomy was suitable for the elevated type of 2 to 3 cm in diameter. The elevated type of more than 3 cm in diameter and the depressed type of 1 to 3 cm in diameter sometimes involved metastasis to group 1 nodes. The depressed type of more than 3 cm in diameter sometimes involved metastasis to group 2 nodes. Thus such cases should be treated by gastrectomy with dissection of potentially metastatic lymph nodes. CONCLUSIONS: Limitation of the extent of gastrectomy and lymph node dissection may be possible, depending on the gross appearance and size of the tumor.     

残胃癌49例临床分析

目的分析和总结残胃癌的临床诊治特点。方法回顾性分析我院1994年1月~2004年3月收治的49例残胃癌病人的临床资料。按胃镜、病理检查结果和手术方式分组,采用Kap-lan-M e ier法绘制生存曲线,进行累积生存率比较。结果49例残胃癌病人中,早期残胃癌9例(18.4%),进展期残胃癌40例(81.6%),两者的5年累积生存率分别为88.9%,47.5%,早期残胃癌的5年累积生存率明显高于进展期(P<0.01)。根治性切除36例,姑息性切除11例,根治手术组,姑息性手术组的中位生存时间分别为69月和12月,两者之间差异有显著性(P<0.01)。结论定期胃镜复查和合理的根治性手术是提高残胃癌病人生存率的关键。     

双对比钡餐造影对早期胃癌的诊断价值

目的探讨早期胃癌的双对比钡餐造影的特征及其临床诊断价值。方法对我院放射科在2003年1月至2007年12月间38例经手术或胃镜取病理证实早期胃癌在术前接受双对比钡餐造影X线检查进行回顾性分析。本组患者在检查时采用多体位、多轴位观察黏膜像及充盈像，并摄片，必要时使用压迫器。结果38例早期胃癌，位于胃窦部21例，胃角8例，胃体部5例，胃底部4例，Ⅰ型11例，Ⅱc型7例，Ⅱa＋c型6例，Ⅲ型14例。高分化腺癌10例，低分化腺癌6例，粘液腺癌7例，印戒细胞癌5例，中分化管状腺癌10例。11例结节状隆起型，13例表浅型，14例凹陷型。结论优良的双对比钡餐造影法是将粘膜法、充盈法和压迫法充分结合，并利用体位进行检查，它有助于检出早期胃癌。     

Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer

Background There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. Methods Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. Results No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. Conclusions Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.     

残胃癌的临床病理特征及预后的荟萃分析

目的 总结残胃癌的临床病理特征及手术治疗效果.方法 对在青岛大学医学院附属医院已治疗过的及文献报道的共计902例残胃癌患者的年龄、性别、病理类型、TNM分期、手术治疗及预后等临床资料进行荟萃分析.结果本组残胃癌患者男女比例约为4.1∶1,中位年龄61岁(35～80岁).首次手术Billroth Ⅱ式重建术后残胃癌的发生率比Billroth Ⅰ式术后明显高(81.6%比17.1%).癌灶好发于吻合口 50.5%,其他如残胃小弯侧21.7%,贲门胃底18.5%,其余约占不到10%.残胃癌手术切除率和根治性切除率分别为81.3%和62.7%,其中有301例次(36.5%)行联合脏器切除术,根治性切除1、3、5年生存率分别为77.8%、58.2%、28.9%,姑息性切除1、3、5年生存率分别为36.4%、9.8%、3.9%,两组比较差异均有统计学意义(P＜0.01).结论 残胃癌多发生于Billroth Ⅱ式胃大部切除术后,病变主要位于吻合口,以分化型腺癌居多,就诊时以中晚期居多.联合脏器切除手术率高,早期发现,行根治性手术可提高生存率.

Abstract：

Objective To summarize the clinicopathological characteristics and effects of surgical treatment on gastric stump cancer.Methods With meta- analysis, clinical data of 902 gastric stump cancer patients who were treated in our hospital or were reported in literatures were included for analysis.Age, gender, pathological types, TNM stages, surgical treatment, prognosis were evaluated.Results Gastric stump cancer developed mostly in male patients (4.1∶1) , and the median age was 61 years.Incidence of gastric stump cancer after digestive tract reconstruction with Billroth- Ⅱ operative modality was higher than that with Billroth- Ⅰ (81.6% vs.17.1%).50.5% of the cancers were present at the anastomotic site, 21.7% at the gastric lesser curvature, 18.5% at the gastric cardia, and less than 10% at other places.Resection and radical resection rates were 81.3% and 62.7% , while operation combined organ resection was carried out (36.5% ).The 1-, 3-, 5- year survival rate of the patients with radical resection were significantly better than those with palliative resection, which was 77.8% vs.36.4% , 58.2% vs.9.8% and 28.9% vs.3.9% (P＜0.01) respectively.Conclusions Distal gastrectomy and Billroth Ⅱ GI tract reconstruction was the most common type of previous operation.Gastric stump cancer occurs more frequently at anastomotic site and the majority of histological types was well-differentiated adenocarcinoma.Most cases were at the advanced TNM-stage when diagnosed.Radical resection is an effective way to prolong the postoperative survival time in gastric stump cancer patients, especially in early stage.