胃癌扩大根治性切除术

一、胃癌扩大根治术的历史上世纪40年代研究发现,淋巴结转移在胃癌的发展中起重要作用,单纯行胃大部切除术并不能明显改善进展期胃癌的生存率。1944年Longmire就曾认为“一个包括全胃和区域性淋巴结在内的整块切除术,显然会比局部切除原发病灶或胃部分切除在内的整块切除更能达到清除全部恶性组织的目的”。Morton和Lahey等人建议应用全胃切除术来治疗胃癌。由于当时全胃切除术的并发症与死亡率相当高,胃癌扩大根治性切除术没有得到发展。加拿大的Appleby于1948年开始研究腹腔动脉的解剖,他提出在腹腔动脉根部离断血管的Appleby手术,以便…     

胃癌外科基础研究与扩大切除术的进展

为了胃癌的合理外科治疗，国内外学者对胃周淋巴结转移规律、清除方法以及临床病理分期等基础问题进行了持续地、分阶段地研究总结，并基于这些研究成果，改善了现有的外科治疗或开展了新的手术方法。但每一次进步均需众多学者长期的实践验证、不断修正，取得共识，才能成为有效的、广泛应     

胃癌扩大切除术的几点新认识

现代胃癌外科治疗的发展约经半个多世纪,上世纪60年代胃癌扩大切除术盛行,70年代基本定型。经众多学者不断研究、改进及总结经验,近年确定了胃癌扩大切除术的定义和类型,规范了各种术式的适应证、操作方法和辅助治疗等。特别对扩大切除术中兼顾提高根治性与保存无癌脏器、组织方面取得了明显成绩,使胃癌扩大切除术更趋科学化、合理化。定义:根治性扩大切除术是胃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,尚可行根治切除。切除范围是联合脏器切除和(或)D2 或D3淋巴结清除术,病期为Ⅲa、Ⅲb和部分Ⅳ期。后者多为限局型、膨…     

现代胃癌外科治疗的几点新认识

1　现代胃癌外科治疗是一种复杂手术1881年Ｂｉｌｌｒｏｔｈ首次成功施行胃癌切除术 ,迄今已12 0余年。此间 ,胃癌手术切除范围由小到大 ,到超扩大 ,再回归缩小 ,逐渐发展到当今的合理切除。这一漫长发展过程中 ,不只一次地出现过不同主张 ,甚而在一定时期内形成争论焦点。如 2 0世纪 5 0～ 6 0年代开始 ,东西方学者对胃癌根治术的淋巴结清除范围存在着明显的分歧。东方学者多主张扩大淋巴结清除术 ,然而西方一些学者做的结果却是扩大清除术不仅并发症多 ,术后病死率高 ,远期疗效也差。经过 4 0～ 5 0年的争论、研究、分析探讨和互相切磋交…     

胃癌扩大根治性切除术应用进展

胃癌扩大根治切除术自应用至今已有数10年历史，上世纪60-70年代曾盛行一时，但其后数年总结的病例资料中欠缺肯定的支持数据，于是又一度受质疑。近年来，由于进展期胃癌的比例大、手术技巧与仪器设备先进性提高、并发症率降低等原因，胃癌扩大根治切除术又渐受关注。[第一段]     

胃癌复发与原切除术式的关系

目的;探讨首次胃癌切除术的方式与胃癌复发之间的关系。方法：对1106例胃癌病人进行回顾分析。结果：853例有随访资料,按胃部部位分析,远端根治性切除效果较好。按淋巴结清扫范围,D2手术施行最多达346例,D1手术5年,10年生存率最高,结论：手术方式应根据胃癌病灶部位,淋巴结转移范围及肿瘤浸润情况选用不同的手术方式,清扫范围不盲目扩大,但为避免癌残留也可选择性采用扩大根治性切除。     

胃癌缩小手术与扩大手术的选择与评价

当今，胃癌手术可分为缩小手术（用于治疗早期胃癌）、标准根治术与扩大根治术（主要用于治疗进展期胃癌）和非治愈手术（为晚期胃癌的姑息治疗方法），本文重点介绍缩小手术与扩大手术的适应证与术式。为此，应先弄清标准根治术的定义，比其小者谓之缩小手术，比其大者谓之扩大手术。     

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。     

胃全系膜切除术治疗胃癌

胃癌根治术日趋规范化、合理化,但目前尚缺乏完全统一的概念,使评估手术疗效缺乏一致的标准。在此我们总结最新胃癌手术进展,首先提出胃全系膜切除术(mesogastrectomy)治疗胃癌,供大家商榷。胃全系膜切除必须建立在有力的科学基础上,从胚胎发生学和解剖学上深刻理解胃与其淋巴回流、腹膜反折之间的关系。胃在胚胎发生初期为矢状位的直管状,在其腹侧及背侧分别有腹侧系膜和背侧系膜与腹壁相连,腹侧系腹和背侧系膜各为两叶,系膜的两叶间有胃的血管及伴行的淋巴管、淋巴结和神经。随着胚胎发育,胃的形态和位置发生旋转,胃的背侧缘生长迅速形成…     

食管癌和贲门癌术后胸内吻合口瘘诊治分析

目的 探讨食管癌及贲门癌术后胸内吻合口瘘的诊断及治疗方法.方法 分析我院2001年1 月至2010年12月2583例行食管癌、贲门癌术后发生胸内吻合口瘘19例患者的临床资料.结果 本组吻合口瘘发生率为0.74%,死亡率15.8%.确诊时间平均术后10d.接受手术治疗9例(治愈6例),保守治疗10例(治愈8例).手术治疗组平均住院时间79.4d,保守治疗组为70.5 d.手术治疗组与保守治疗组在治愈率和平均住院时间方面差异均无统计学意义(P=0.09,P=0.63).结论胸内吻合口瘘有较高死亡率.一旦确诊或高度怀疑吻合口瘘发生,应积极根据患者情况个体化选择合理的治疗方法.无论是手术治疗还是保守治疗,充分引流、有效冲洗和营养支持治疗均很重要.     

Recurrence following curative resection for gastric carcinoma

BACKGROUND: The diagnosis and treatment of recurrent gastric cancer remains difficult. The aim of this study was to determine the risk factors for recurrence of gastric cancer and the prognosis for these patients. METHODS: Of 2328 patients who underwent curative resection for gastric cancer from 1987 to 1995, 508 whose recurrence was confirmed by clinical examination or reoperation were studied retrospectively. The risk factors that determined the recurrence patterns and timing were investigated by univariate and multivariate analysis. RESULTS: The mean time to recurrence was 21.8 months and peritoneal recurrence was the most frequent (45.9 per cent). Logistic regression analysis showed that serosal invasion and lymph node metastasis were risk factors for all recurrence patterns and early recurrence (at 24 months or less). In addition, independent risk factors involved in each recurrence pattern included younger age, infiltrative or diffuse type, undifferentiated tumour and total gastrectomy for peritoneal recurrence; older age and larger tumour size for disseminated, haematogenous recurrence; and older age, larger tumour size, infiltrative or diffuse type, proximally located tumour and subtotal gastrectomy for locoregional recurrence. Other risk factors for early recurrence were infiltrative or diffuse type and total gastrectomy. Reoperation for cure was possible in only 19 patients and the mean survival time after conservative treatment or palliative operation was less than 12 months. CONCLUSION: The risk factors for each recurrence pattern and timing of gastric cancer can be predicted by the clinicopathological features of the primary tumour. Since the results of treatment remain dismal, studies of perioperative adjuvant therapy in an attempt to reduce recurrence are warranted.     

Endoscopic mucosal resection for early gastric carcinoma]

Endoscopic mucosal resection (EMR) has made it possible to perform radical resection of early gastric cancers in resectable cases. To extend the indications for EMR, we discuss the following. 1) Three hundred fifty-seven patients with 389 lesions of early gastric cancer who were treated either with whole-block resection or partial resection were analyzed to evaluate the recurrence rate by the method. The recurrence rate was 15.1% of 139 lesions treated with whole-block resection and 8.0% of 250 lesions treated with both methods. It is considered that partial resection with the marking procedure is very important to remove the cancer completely. 2) The management of recurrent cancer recognized at follow-up examination after EMR is very important for patients because these are operable cases. Of recurrent cancers, 80.5% were diagnosed within one year after EMR, and therefore during this period careful follow-up examinations should be done. The therapy used to treat these recurrent cancers was re-EMR in 26 cases and surgical operation in 15 cases. 3) Problems still remain concerning how to manage cancer invading the submucosa diagnosed after EMR.     

扩大联合脏器切除治疗T4b期胃癌的临床分析

目的探讨扩大联合脏器切除T4b期胃癌的疗效,总结手术经验。方法对2012年1月至2015年12月在哈尔滨医科大学附属第一医院手术治疗的128例T4b期胃癌临床资料进行回顾性分析。结果 85例行扩大联合脏器切除术(extended multi-organ resection,ER组),43例行姑息性手术(non-extended multi-organ resection,NER组)。随访ER组1年、2年、3年的生存率分别为65.38%、44.87%和38.46%,均高于NER组的35.13%、16.21%和5.41%,两者之间的差异均有统计学意义(P0.05)。ER组的并发症发生率为18.82%,高于NER组的4.65%,两组之间的差异有统计学意义(P0.05);ER组的围手术期病死率为2.35%,NER组为2.33%,两者之间的差异无统计学意义(P0.05)。结论扩大联合脏器切除是安全可行的,可以延长病人生存期,改善临床症状,提高生存质量。     

局部侵犯期结直肠癌扩大切除术66例的疗效分析

目的探讨局部侵犯期结直肠癌扩大切除术的疗效。方法回顾性分析1995年1月至2002年12月960例结直肠癌手术病例的临床资料,统计局部侵犯期结直肠癌的手术并发症率、围手术期死亡率、5年生存率,并用Cox回归方法对预后因素进行分析。结果局部侵犯期结直肠癌扩大切除术66例,占6.9%(66/960),手术并发症发生率27%(18/66),较结直肠癌常规手术高(χ2=8.82,P=0.002),围手术期死亡率为0。术后病理证实联合切除脏器的肿瘤侵犯率为31%(27/88),术后5年生存率为62%;联合切除脏器的粘连性质(Wald=7.42,P=0.005)、淋巴结状态(Wald=4.55,P=0.035)是影响预后的独立因素。结论局部侵犯期结直肠癌扩大切除术有较好的术后生存率,其手术并发症较常规手术高,但仍是安全术式。     

多发胃癌胃切除范围的研究

目的明确多发胃癌的合理胃切除范围。方法应用组织病理学、免疫组织化学方法,检测多发早期胃癌及背景黏膜上分布的异型增生病变的分布状态、增殖细胞核抗原(PCNA)阳性细胞和癌抑制基因产物变异型P53蛋白的阳性率。结果分化型多发早期胃癌与其背景黏膜上的异型增生病变的分布一致,异型增生病变的PCNA阳性细胞率(30.3%)显著高于正常黏膜及肠上皮化生黏膜(7.8%,21.0%),且高度异型增生病变的PCNA阳性细胞率(38.9%)与癌(44.1%)相近。与此同时,变异型P53蛋白在异型增生病变中被发现,并随其异型程度的增加而升高。结论分化型多发胃癌及具有高度癌变潜能的异型增生病变主要分布于幽门腺、中间带领域。因此,多发胃癌切除时应将幽门腺领域、中间带领域一并切除。     

Risk of gastric stump carcinoma after gastric resection for benign ulcer disease

This follow-up study concerns 537 patients who underwent gastric resection for gastric or duodenal ulcer disease 10-13, 21-22, or 31-32 years ago. 12 (2.2%) gastric stump carcinomas were found. The development of gastric stump cancer among these patients was compared with the development of gastric cancer in a general Finnish population. In the oldest male follow-up group the observed: expected ratio for cancer was 9:3.5. This was statistically almost significant (p less than 0.05). No statistical difference could be seen in the other follow-up groups. Gastric stump carcinoma showed a strong male preponderance, with a male:female ratio of 11:1. The primary ulcer disease, whether gastric or duodenal, had no influence on the development of gastric stump carcinoma. Endoscopic screening is recommended for all male patients operated on aged 45 years or younger when 15 years have elapsed since the original gastric operation.     

胆囊癌扩大根治的联合脏器切除问题

原发性胆囊癌是肝外胆道常见的恶性肿瘤,早期缺乏特异性的临床表现,恶性程度较高,易发生肝脏直接浸润和肝门及淋巴结转移,多数病人就诊时已为中晚期,手术切除率较低,预后较差。因此,很多医生对中晚期胆囊癌持消极悲观态度,特别是在术前或手术探查时发现右半肝、胰头、横结肠和肝门部侵犯严重时,常常放弃行根治性手术。但近年来,随着现代外科综合技术不断发展和成熟、对胆囊癌转移特点的深入研究、胆囊癌扩大根治术及联合脏器切除等的开展,使胆囊癌手术切除率和术后存活率已有明显改善。胆囊癌最有效的治疗方法是行根治性切除,而采取何种术式…     

Randomized clinical trial of Ligasure versus conventional surgery for extended gastric cancer resection

BACKGROUND: The Ligasure Vessel Sealing System is a haemostatic device designed primarily for use in abdominal surgery. Randomized trials have demonstrated that it is safe and quick for haemorrhoidectomy, but there is no evidence that it confers any advantage in complicated gastrointestinal surgery. The aim of the present study was to examine the value of the Ligasure system in extended lymph node dissection (D2) during gastrectomy for cancer in a randomized clinical trial. METHODS: D2 gastric resection performed with the Ligasure system was compared with resection using conventional haemostatic methods in a prospective randomized trial. Central randomization (40 patients in each group) was performed after a staging laparotomy. The main outcome measures were operating time, intraoperative blood loss, postoperative course and complications. RESULTS: Ligasure was associated with less intraoperative blood loss (mean(s.d.) 142(73) versus 239(124) ml; P = 0.001) and a shorter operating time (mean(s.d.) 169(25) versus 222(28) min; P = 0.001) than conventional operation. Postoperative drainage fluid volumes were greater in the Ligasure group (mean(s.d.) 1577(940) versus 886(542) ml; P = 0.020). There were no differences in postoperative complications or hospital stay. CONCLUSION: The Ligasure Vessel Sealing System is safe for use in extended lymph node dissection for gastric cancer, and is associated with a shorter operating time and decreased blood loss compared with conventional haemostatic techniques.     

Is palliative resection necessary for gastric carcinoma patients?

Background and aims The benefit of palliative resection for gastric carcinoma patients remains controversial. We thus evaluated the survival benefit of palliative resection in advanced gastric carcinoma patients. Materials and methods We reviewed the hospital records of 466 gastric carcinoma patients who had palliative resection and compared the clinicopathologic findings to those of patients who underwent a bypass or exploration from 1986 to 2000. Results Cox’s proportional hazard regression model revealed only one independent statistically significant prognostic parameter, the presence of peritoneal dissemination (risk ratio, 0.739; 95% confidence interval, 0.564–0.967; P < 0.05). The 5-year survival rate of patients who had palliative resection was higher than that of patients who did not (7.03 vs 0%, P < 0.001). When the 5-year survival rates of patients with peritoneal dissemination were examined, the rate was higher for those who underwent resection (4.43 vs 0%, P < 0.001). Conclusion The results highlight the improved survivorship of gastric carcinoma patients with palliative resection compared to those who did not undergo the procedure. Although curative resection is not possible in this group of patients, we recommend performing resection aimed at palliation.