腹腔镜辅助胃癌D2根治性全胃切除术

目的 探讨腹腔镜辅助下D2淋巴结清扫全胃切除术的手术要点.方法根据我院2005年7月至2007年4月期间61例腹腔镜辅助下D2淋巴结清扫全胃切除术患者的临床资料,对腹腔镜辅助下D2淋巴结清扫全胃切除的手术要点进行归纳分析. 结果 本组61例接受腹腔镜辅助下D2淋巴结清扫全胃切除术的患者均无中转开腹,无手术死亡,无严重的手术并发症.手术中应着重遵循以下几点:(1)避免损伤横结肠;(2)避免损伤胰头下缘;(3)先离断胃左静脉,清扫完第7、8a、9、11p组淋巴结后,最后离断胃左动脉;(4)准确无误离断胃右动脉;(5)避免清扫腹腔动脉旁淋巴结时出血;(6)避免分离脾胃韧带时出血;(7)找对间隙,分离贲门及胃底.结论了解进展期腹腔镜辅助胃癌D2淋巴结清扫全胃切除的手术要点,对顺利开展腹腔镜辅助下胃癌D2淋巴结清扫全胃切除术有益.     

腹腔镜辅助胃癌根治术：附54例报告

目的 探讨腹腔镜辅助胃癌根治术的安全性和可行性.方法 对54例胃癌患者进行腹腔镜辅助下胃癌根治术,其中根治性全胃切除术12例,近端胃大部切除术18例,远端胃大部切除术24例;淋巴结清扫D1式29例,D2式25例.结果 54例均成功完成腹腔镜手术.平均手术时间全胃切除(164.4±38.7)min,近端胃切除(142.4±35.2)min,远端胃切除(149.1±35.4)min.平均术中出血量全胃切除(164.6±80.1)mL,近端胃切除(149.5±94.7)mL,远端胃切除(152.5±87.7)mL.清扫淋巴结数平均(19.1±6.2)枚/例.术后平均胃肠功能恢复时间(3.5±0.7)h.术后发生吻合口出血2例,均经非手术治疗止血;无吻合口瘘、吻合口梗阻、十二指肠残端瘘等并发症.术后住院时间平均(9.2±1.7)d.结论 腹腔镜辅助胃癌根治术安全、可行;只要严格遵守肿瘤的手术原则,腹腔镜辅助胃癌根治术能够保持肿瘤的根治性,同时能体现手术的微创性.     

手辅助腹腔镜胃癌D2根治术中淋巴结清扫模式分析

目的探讨手辅助腹腔镜胃癌D：根治术中的淋巴结清扫模式。方法回顾性分析成都军区总医院全军普通外科中心胃肠外科2010年12月至2012年9月间,采用自行设计的手术操作系统所实施的111例手辅助腹腔镜胃癌D：根治术患者的临床资料。患者均采用自左向右、伴随肿瘤一并完整切除的淋巴结清扫模式（逆向卷席式淋巴结清扫模式）,即手辅助腹腔镜下完成胃近端区域淋巴结清扫后,在预切除线切断胃或食管,将切除组织移出腹腔外,在直视下完成其他区域的淋巴结清扫．完整切除肿瘤组织,最后进行消化道重建。结果全组患者手术切口长度（6．8±0．3）em;术中出血量（238．4＋113．6）ml;手术时间（171．9±23．3）min。手术切缘残端均无癌残留,病理检获淋巴结数（17．2＋5．7）枚／例。术后并发症10例（9．0％）,围手术期死亡1例（0．9％）;术后住院时间（10．1±3．7）d。结论逆向卷席式淋巴结清扫模式可以避免开腹与腹腔镜手术模式的多次转换,有利于手辅助腹腔镜胃癌D：根治术操作流程的标准化。     

刮吸解剖法在进展期胃癌淋巴结清扫术中的应用

目的　探讨刮吸解剖法在进展期胃癌淋巴结清扫术中的应用效果。方法　回顾性总结行刮吸法淋巴结清扫术的28例进展期胃癌患者的临床资料。行远端胃切除11例,近端胃切除11例（其中3例附加脾切除）,全胃切除6例（其中1例附加左肝外叶及双侧附件切除）。淋巴结清扫标准为D219例,选择性D39例。结果　所有手术均顺利完成,未发生血管损伤等严重并发症,术中平均出血290 m l。28例共清除淋巴结609枚,平均21.7枚/例。25例随访6-24月,7例复发,6例死亡（其中3例为复发者）,15例无瘤存活。结论　刮吸法行胃癌淋巴结清扫安全性高、出血量小、并发症少,淋巴结清扫和术后恢复均较满意,值得临床进一步探索和应用。     

手术机器人系统在120例胃癌患者治疗中的应用

目的总结应用达芬奇手术机器人系统治疗胃癌的经验,并探讨其安全性及有效性。方法2010年5月至2012年4月间．应用达芬奇手术机器人系统治疗胃癌患者共计120例。综合分析这组患者的手术及近期康复结果。结果120例患者中男74例,女46例;平均年龄58．5（22-80）岁。其中远端胃次全切除62例,全胃切除35例。近端胃次全切除23例：其中55例患者采用了腹部辅助小切口完成消化道重建：65例在机器人系统下完成消化道重建。中转开腹1例（0．9％）。手术时间（245±50）min,其中装机时间（17±5）min。术中出血量（70±45）ml,获取淋巴结数为（22．5±10．7）枚／例;切除标本切缘均阴性。术后病理分期：ⅠB期24例,Ⅱ期28例,ⅢA期47例,ⅢB期21例。术后并发症发生率为5％（6／120）,分别为十二指肠残端瘘1例。食管残胃吻合口瘘2例,术后肠梗阻1例,残胃排空障碍1例和术后出血1例：通过手术或保守治疗均获得治愈。无围手术期死亡者。术后住院时间（6．3±2．6）d。结论达芬奇手术机器人系统应用于胃癌手术创伤小、出血少并安全有效。在淋巴结清扫及消化道吻合重建方面更具有独特的优越性。     

腹腔镜下胃癌根治性切除术31例报告

目的 探讨腹腔镜下胃癌根治性的可行性. 方法 2006年8月～2007年5月行腹腔镜下胃癌根治性除术31例,其中根治性远端胃癌根治术26例,根治性全胃切除术5例. 结果 中转开腹手术1例,完全腹腔镜胃癌根治术2例,腹腔镜辅助下胃癌根治术28例.D1 β淋巴结清扫2例,D2/D2 淋巴结清扫 29例,联合肝脏部分切除1例.中位手术时间5 h(4.5～7 h).术中出血量中位数为150 ml(100～600 ml).术中输血1例.术中脾损伤1例.清扫淋巴结数目的中位数为20枚(14～33枚).本组无术后死亡.术后胃肠功能恢复时间的中位数4 d (3～6 d).术后胃无力1例,经保守治疗后3周恢复;1例全胃切除,回肠储袋出血1例;环甲关节半脱位1例;无吻合瘘及肺部感染.31例随访2～8个月(中位时间5个月),无复发和转移. 结论 腹腔镜胃癌根治术可行.     

腹腔镜远端胃癌D_2根治术手术路径的临床应用研究

目的探讨腹腔镜远端胃癌D2根治术手术路径的临床效果。方法 2007年10月-2010年5月,对56例远端胃癌实施腹腔镜远端胃癌D2根治手术。手术路径：大网膜切除和横结肠系膜前叶剥离;解剖腹腔动脉、肝总动脉、脾动脉及清扫相应淋巴结;处理胃右动脉和5组淋巴结;清扫12a组淋巴结等顺序进行,淋巴清扫以4d→4sb→14v→6→7/9→11p→8a→5→12a→1→3的路径进行。结果手术时间130-375 min,（203.4±48.4）min。清扫淋巴结13-21枚,（16.2±1.2）枚。术后胃肠功能恢复时间48-120 h,（80.6±17.7）h。标本远近切缘无癌残留。无围手术期死亡病例。术后72 h吻合口出血1例,96 h输出端梗阻1例。56例术后随访2-31个月,（14.1±6.9）月,死亡8例：肿瘤广泛转移6例,心脑血管疾病2例;带瘤生存5例,无瘤生存43例,无瘤生存时间最长已31个月。结论腹腔镜远端胃癌D2根治术按照合理的路径进行手术,能够保证手术在正确的间隙和解剖层面进行,有利于在遵循肿瘤根治的原则下完成手术。     

腹腔镜与开腹胃癌根治术D2淋巴结清扫的比较研究

目的探讨腹腔镜下胃癌根治术D2淋巴结清扫的可行性。方法回顾性分析我科2007年1月～2009年3月手术治疗的110例胃癌的临床、病理资料。7例伴有远处转移,1例行腹腔镜下胃局部切除未行D2淋巴结清扫,根据排除标准予以剔除。其余102例行胃癌根治术(D2淋巴结清扫),包括近端胃大部切除+D2清扫术(PG+D2)25例,远端胃大部切除+D2清扫术(DG+D2)60例,全胃切除+D2清扫术(TG+D2)17例。102例根据手术方式分为腹腔镜组38例,开腹组64例。结果腹腔镜组清扫淋巴结数目(22.2±9.9个)与开腹组(23.4±9.4个)比较,差异无显著性(t=-0.651,P=0.514)。三种术式腹腔镜组清扫淋巴结数目与开腹组比较[PG+D2:19.4±7.3(n=8)vs21.2±8.5(n=17);DG+D2:20.9±10.8(n=22)vs22.2±8.0(n=38);TG+D2:28.3±7.5(n=8)vs32.8±12.1(n=9)],差异均无显著性(t=-0.517,-0.526,-0.913;P=0.610,0.601,0.375)。结论腹腔镜下胃癌根治D2淋巴结清扫是可行的,清扫淋巴结数目和开腹手术类似,能够符合肿瘤根治原则。     

经口置入钉砧头系统（OrVil）在机器人辅助胃癌根治术中的应用

目的 探讨经口置入钉砧头系统（OrVil）在机器人辅助胃癌根治术中的应用可行性及近期疗效.方法 回顾性分析解放军总医院2010年10月至2013年9月收治的采用经口置入钉砧头系统（OrVil）在机器人辅助下行胃癌根治术的84例患者的临床资料,用logistic模型对围手术期并发症进行多因素分析.结果 84例患者均在机器人辅助下完成手术,无中转开腹,其中近端胃切除52例,全胃切除32例.平均手术时间：219.88±48.91 min;术中平均出血量：178.57±190.48 ml.平均清扫淋巴结数：21.88±8.22枚.5例发生严重并发症,无手术死亡.多因素分析影响术后并发症的因素中,手术方式、手术时间、转移的淋巴结数以及合并症的有无与并发症的发生相关（P＜0.05）.结论OrVil在机器人辅助下行胃癌根治术中的应用是安全可行的,能够取得良好的近期疗效.     

胃癌根治术中肿大淋巴结的分析

目的　研究胃癌根治手术中肿大淋巴结实际转移状况并分析淋巴结切除范围与预后的关系。方法　查阅手术记录和术后病理报告并进行 5年随访。记录肿大淋巴结数 ,比较近端胃、远端胃和全胃切除术的淋巴结切除数目并分析其与预后的关系。结果　本组 15 5例胃癌标本中 ,共摘取淋巴结 3 3 0 5枚 (平均 2 1.3 2枚 /例 ) ;肿大淋巴结 10 3 7枚 (平均 6.69枚 /例 ) ;转移淋巴结 42 3枚 (平均 2 .73枚 /例 )。在 15 5例获 5年随访的患者中 ,行D2式手术 10 9例 ,D3式 46例 ,5年生存分别是 3 7例和 11例。结论　手术中肿大淋巴结不一定是转移淋巴结 ;胃癌根治术中淋巴结清扫范围不应盲目扩大 ,而应根据术中冰冻病检结果判断。     

Safety and application of laparoscopic gastrectomy for benign gastric disease and gastric cancer

INTRODUCTION

Laparoscopic gastrectomy is rapidly expanding despite reservations by some surgeons regarding its safety and radicality. The aim of this study was to evaluate patients undergoing laparoscopic gastrectomy for both benign and malignant disease with particular emphasis on technical feasibility, safety, effectiveness and complications.

PATIENTS AND METHODS

Review of prospectively collected data of patients who underwent laparoscopic gastrectomy from May 2005 to September 2009 under the care of one consultant surgeon.

RESULTS

A total of 61 laparoscopic gastrectomies were performed (35 men and 26 women) with a median age of 68 years (range, 41–90 years). There were 39 distal gastrectomies (19 adenocarcinoma, 6 gastrointestinal stromal tumour [GIST], 4 benign gastric outlet obstruction, 4 high-grade dysplasia in gastric adenomas, 4 non-healing ulcers, 2 gastric antral vascular ectasia [GAVE]); 15 sub-total gastrectomies (13 adenocarcinomas, 2 GIST); and 7 total gastrectomies (5 adenocarcinomas, 1 GIST, 1 carcinoid). Median follow-up was for 48 months (range, 1–72 months). There was one death, two major and six minor complications. All patients with complications made a satisfactory recovery.

CONCLUSIONS

Laparoscopic gastrectomy is associated with a low mortality (1.75%) and major morbidity (3.50%). Although technically demanding, especially when a D2 lymphadenectomy is performed, our results have shown that tailored laparoscopic resection based on tumour characteristics with either D1 or D2 lymphadenectomy results in good surgical and oncological outcomes.     

腹腔镜下胃癌全胃切除术79例的体会

目的 探讨腹腔镜下胃癌行全胃切除术的可行性及效果.方法 对2004年6月至2006年12月共行腹腔镜下根治性全胃切除术79例,其中行D1及D1+淋巴结清扫12例,D2/D2+淋巴结清扫67例.肿瘤位于胃近端者19例,位于胃体者41例,皮革胃2例,位于胃窦并浸润至胃小弯中上部者17例进行分析.结果 79例中77例成功进行腹腔镜手术,2例中转开腹,中转率为2.5%.平均手术时间(275.8±20.8) min,平均出血量(163.3±48.6) ml,平均每例清扫淋巴结(34.7±12.2) 枚,肿瘤近残端(3.8±1.2) cm,远残端(6.9±2.8) cm.术后肛门排气时间(3.6±0.9) d,下床活动时间(2.5±0.4) d.无术后死亡,无吻合口漏,术后发生并发症7例均经内科治疗痊愈.术后随访9～39个月,平均25.6个月,15例患者因肿瘤复发死亡,余64例仍生存.结论 腹腔镜下全胃切除联合胃癌标准根治术是安全可行的,能达到开腹手术的淋巴结清扫范围,且具有创伤小、出血少、恢复快、并发症率低等优点.     

Quality of Life following Radical Surgical Treatment of Gastric Carcinoma

Quality of life (QOL) in patients with gastric cancer who underwent total gastrectomy has so far not been studied using the EORTC QLQ-C30 (Quality of Life Core Questionnaire of the European Organization for Research and Treatment of Cancer) as a standardized European QOL instrument. The aim of this study was to evaluate the effect of radical procedures such as extensive lymph node resection and combined resection of adjacent organs on patients' QOL. From 1992 to 1996, 152 patients underwent total gastrectomy. All patients alive on July 1, 1996 were included in the study (77/152). For assessing QOL, the EORTC QOL questionnaire QLQ-C30 version 2.0 and a validated gastric cancer module were sent home to the patients for self-completion. The response rate was 91%. It was possible to evaluate the questionnaires of 62 patients who had undergone resection with curative intent including 13 extended gastrectomies (21%). Of the 62 resections, 50 were combined with D2 lymphadenectomy (80.6%). The global health status was not negatively influenced by D2 lymphadenectomy and extended gastrectomy. Patients with splenectomy were more affected by treatment than patients without splenectomy. Radical gastrectomy combined with D2 lymphadenectomy is the treatment of choice for gastric cancer patients, concerning not just survival but QOL as well.     

Stomach cancer: a study of 117 consecutive resected cases and results of R2-R3 gastrectomy

In a consecutive series of 175 patients with gastric carcinoma, 66.8% underwent gastric resection: 74 total gastrectomies with R3 lymphadenectomy and 43 distal subtotal gastrectomies with R2 lymphadenectomy were performed. 73% (86 cases) of resective procedures proved to be "absolute curative" according to Japanese criteria (JRSGC). Nodal involvement was present in 62 out of 117 resected patients (52.9%): 29.9% N1, 9.4% N2, 13.6% N3; a significant relationship (p = 0.012) between depth of invasion of the gastric wall and lymph node metastases was revealed. The hospital mortality after R2-R3 gastrectomy was 4.2%, major surgical complications occurred in 6.8% of cases. The actuarial 5-year survival after curative resection was 59%. The results suggest that extended lymphadenectomy (R2-R3 gastrectomy) is justified in the surgical treatment of gastric cancer; this procedure can be safely performed and permits "absolute curative" resections in a remarkable percentage of cases.     

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6-9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.     

Clinical outcome after D1 vs D2-3 gastrectomy for treatment of gastric cancer.

BACKGROUND: Clinical benefit from extended lymphadenectomy for gastric cancer remains controversial as a considerable variation exists between results of different studies. METHODS: 562 patients were treated at HUCH between 1987-2003, whereof 223 underwent gastrectomy with curative intent. Of these, 114 patients underwent subtotal/total gastrectomy with D1 (standard) lymphadenectomy and 109 patients had D2-3 (extended) lymph node dissection. The clinical outcome of these patients was analysed retrospectively. RESULTS: The incidence of surgical complications was 33.0% in D2-3 and 16.8% in D1 lymphadenectomy groups (p = 0.008). Abscess was the most common complication (11.0%) among D2-3 operated patients and haemorrhage (4.4%) in D1 group. Hospital mortality was 3.7% in D2-3 and 1.8% in D1 group (p = 0.438). The only statistically significant factor influencing the rate of complications was D2-3 lymphadenectomy (OR 2.620, 95% C.I. 1.375 to 4.991). D2-3 was associated with a longer postoperative hospital stay and operation time, greater blood loss and increased need for blood transfusions compared to D1. The 5-year survival was not statistically different between lymphadenectomy groups. CONCLUSION: It is justified to perform a D2-3 gastrectomy in Europe with a acceptable postoperative mortality but with a significant morbidity. Further studies are needed to assess the value of extended lymphadenectomy in gastric cancer.     

Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicenter Italian randomized trial. The Italian Gastrointestinal Tumor Study Group.

OBJECTIVE: The purpose of this study was to analyze postoperative morbidity and mortality of patients included in a randomized trial comparing total versus subtotal gastrectomy for gastric cancer. SUMMARY BACKGROUND DATA: There is controversy as to whether the optimal surgery for gastric cancer in the distal half of the stomach is subtotal or total gastrectomy. Although only a randomized trial can resolve this oncologic dilemma, the first step is to demonstrate whether the two procedures are penalized by different postoperative morbidity and mortality rates. METHODS: A total of 624 patients with cancer in the distal half of the stomach were randomized to subtotal gastrectomy (320) or total gastrectomy (304), both associated with a second-level lymphadenectomy, in a multicenter trial aimed at assessing the oncologic outcome after the two procedures. The end points considered were the occurrence of a postoperative event, complication, or death and length of postoperative stay. RESULTS: Nonfatal complications and death occurred in 9% and 1% of subtotal gastrectomy patients and in 13% and 2% of total gastrectomy patients, respectively. Multivariate analysis of postoperative events showed that splenectomy or resection of adjacent organs was associated with a twofold risk of postoperative complications. Random surgery and extension of surgery influenced the length of stay. The mean length of stay, adjusted for extension of surgery, was 13.8 days for subtotal gastrectomy and 15.4 days for total gastrectomy. CONCLUSIONS: Our data show that subtotal and total gastrectomies, with second-level lymphadenectomy, performed as an elective procedure have a similar postoperative complication rate and surgical outcome. A conclusive long-term evaluation of the two operations and an accurate estimate of the oncologic impact of surgery on long-term survival, not penalized by excess surgical risk of one of the two operations, are consequently feasible.     

新辅助化疗对进展期胃癌患者术后肺部感染的影响

目的探讨新辅助化疗对进展期胃癌患者术后肺部感染的影响。方法按随机数字表法将2009年1月至2011年1月间在南京军区南京总医院接受治疗的139例伴有淋巴结转移的胃癌病例（排除术前重度肺功能障碍者）,随机分为新辅助化疗组[69例,动静脉结合新辅助化疗（静脉用药：氟尿嘧啶、亚叶酸：动脉介入：奥沙利铂、表阿霉素、依托泊甙）1个半疗程后接受手术]和直接手术组（70例）,比较两组病例术后肺部感染的发生情况。结果两组病例术前一般情况的比较差异无统计学意义（均P〉0．05）。所有病例均顺利实施D2胃癌根治手术,术后新辅助化疗组和直接手术组分别有8例（11．6％）和9例（12．9％）患者出现肺部感染,差异无统计学意义（P〉0.05）。结论动静脉结合新辅助化疗不会增加胃癌患者术后肺部感染发生率,可安全应用。     

腹腔镜胃癌根治术24例报告

目的探讨无瘤技术在腹腔镜胃癌根治术中的价值。方法 2002年5月～2008年9月,实施腹腔镜胃癌根治术24例,在遵循肿瘤根治术原则下实施无瘤技术以减少或防止肿瘤细胞的脱落、种植和播散等。结果 24例均完成腹腔镜下肿瘤根治术。D1淋巴清除术3例,D2淋巴清除术21例。手术时间(149.1±35.4)min;术中出血量(152.5±87.7)ml。术后发生吻合口出血1例,非手术治疗止血。未发生吻合口瘘、吻合口梗阻、十二指肠残端瘘等并发症。24例随访3～24个月,3例(12.5%)术后复发或转移:1例Ⅱ期肝转移,2例Ⅲ期病人分别出现食管空肠吻合旁种植转移和骨转移,均为D2淋巴清除术。结论腹腔镜下胃癌根治术中严格掌握手术入选标准,术中标准的根治范围和严格遵循癌症手术的无瘤原则,可取得与开放手术相同的效果。