Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer

Background  Laparoscopic-assisted gastric surgery has become an option for the treatment of early gastric cancer. However, there are few reports of laparoscopic surgery in the management of advanced gastric cancer. In this study we describe our experience with laparoscopic-assisted distal gastrectomy (LADG) for advanced gastric cancer (AGC). Methods  Between November 2004 and June 2007, 47 patients with AGC underwent LADG at our hospital, and 45 of those patients were enrolled in this study. These patients were compared with 83 patients who had AGC and underwent conventional open distal gastrectomy (ODG) during the same period. Results  Operation time was significantly longer in the LADG group than in the ODG group. Estimated blood loss in the LADG group was significantly less than in the ODG group. Time to ambulation and first flatus and duration of analgesic medication were significantly shorter in the LADG group. The morbidity and mortality rate were also lower than in the ODG group, with no statistically significant difference. The distance of the proximal resection margin showed no significant difference compared with ODG (6.3 ± 0.9 versus 6.5 ± 0.9 cm; p = 0.228). The mean number of nodes resected with LADG was 35.6 ± 14.2, and that with ODG was 38.3 ± 11.4 (p = 0.269). The mean follow-up for the LADG group was 23.6 months (range 9–40 months). In the LADG group, recurrence was observed in six patients (13.3%). Three patients had recurrence and died after 10 (IIIB), 11 (IIIA), and 13 (IIIB) months. Conclusions  LADG with extended lymphadenectomy for AGC is a feasible and safe procedure and has several advantages. Moreover, this method can achieve a radical oncologic equivalent resection. Indications for LADG with extended lymphadenectomy could be expanded in the treatment of locally advanced gastric cancer.     

Meta-analysis of laparoscopy assisted distal gastrectomy and conventional open distal gastrectomy for EGC

In recent decades, laparoscopy assisted distal gastrectomy (LADG) has been introduced to treat early gastric cancer (EGC). This study evaluated the safety and efficacy of laparoscopy assisted and conventional open distal gastrectomy for EGC. Comprehensive searches of PubMed, EmBase, Cochrane Controlled Trials Register and Chinese Biomedical Database (CBM) were performed. Included literature was evaluated using the Newcastle-Ottawa Scale. Original data were extracted, pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using RevMan 5.0. Eight RCTs of 734 patients were included in the study. Compared to CODG, LADG increases the operation time (weighted mean difference [WMD]: 63.35; 95% confidence interval [CI]: 57.96, 68.74; P < 0.01), reduces intraoperative blood loss (WMD: ?127.95; 95% CI: ?147.97, ?107.93; P < 0.01), decreases number of harvested lymph nodes (WMD: ?4.21; 95% CI: ?6.10, ?2.31; P < 0.01), forwards oral intake time (WMD:?0.43; 95% CI: ?0.61, ?0.24; P < 0.01), and shortens hospital stay(WMD: ?1.29; 95% CI: ?1.76, ?0.83; P < 0.01). There is no significant difference in postoperative complications(OR: 0.70; 95% CI: 0.46, 1.06; P = 0.09). All these findings indicate that LADG for EGC is feasible and safe.     

远端胃切除术后的消化道重建

尽管远端胃切除术后消化道重建方式多种多样,但在我国,BillrothⅠ和BillrothⅡ式仍然是主流的重建方式。 Roux-en-Y、间置空肠、间置空肠储袋、双通道和保留幽门的重建方式以及适于腹腔镜下手术的重建和吻合技术方法,近年逐渐增加,且成为研究的热点。虽然消化道重建目前尚无统一而明确的规范,但结合患者的实际情况、经济状况、社会因素以及术者的技术水平,合理地选择与应用最佳的重建方法,是业界的共识。     

腹腔镜辅助远端胃次全切除术

目的探讨腹腔镜外科技术在胃切除手术的应用价值。方法对15例腹腔镜辅助胃手术患者的临床资料和随访情况进行回顾性分析。结果腹腔镜辅助远端胃大部分切除术13例(其中胃癌D1根治术3例、胃十二指肠溃疡手术10例),进展期胃癌腹腔镜探查术2例。无中转开腹,无手术死亡。术中皮下气肿1例、发生率6.67%(1/15),平均手术时间245.6±35min,平均出血量110±45ml,辅助切口平均长6.5±1cm,平均术后住院日10±2.5d。术后吻合口输出襻梗阻1例、发生率7.69%(1/13)。全组13例患者术后随访2～26个月,未出现远期并发症,其中3例胃癌患者未发现远处转移病灶,其trocar穿刺孔及腹壁切口无肿瘤种植。结论只要严格掌握手术适应证,正确应用腹腔镜技术,腹腔镜辅助远端胃大部分切除术是安全、可行的。     

Long-term quality of life after laparoscopy-assisted distal gastrectomy for gastric cancer

Background Laparoscopy-assisted distal gastrectomy (LAG) is gaining acceptance for treating early gastric cancer. However, the long-term quality of life after LAG for gastric cancer is unknown. This study compared the long-term quality of life after LAG versus open distal gastrectomy (ODG) for early gastric cancer. Method This study included 53 patients who underwent LAG and 37 patients who underwent ODG for treatment of early gastric cancer. Quality of life was evaluated on the basis of a 22-item questionnaire that addressed food tolerance and mental and physical conditions, scored on a scale of 1–3. Results The mean follow-up periods after LAG and ODG were 99.3 and 97.0 months, respectively. Although the majority of patients who had undergone LAG were consuming a normal diet and had weight loss of less than 5 kg, all 22 items and the total score of the LAG group were comparable to those of the ODG group. However, the incidence of postoperative intestinal obstruction was significantly lower in the LAG group than in the ODG group (1% vs. 13%, p < 0.05). Conclusions LAG is equivalent to ODG with respect to long-term quality of life and is associated with a reduced incidence of postoperative intestinal obstruction. This work was supported in part by a Grant-in-Aid for Scientific Research (No. 15390401) from the Japanese Ministry of Education, Science, and Culture     

腹腔镜与开腹远端胃癌根治术同期临床对比研究

目的比较腹腔镜辅助下远端胃癌根治及D2淋巴结清扫术的手术方法、可行性及安全性。方法对2004年3月至2005年5月行腹腔镜胃癌根治术44例及传统开腹手术58例病人的手术安全性、术后恢复及肿瘤根治性进行比较分析。结果腹腔镜组44例病人中43例成功完成腹腔镜手术,其中行D1+α淋巴结清扫6例,D1+β2例,D2及D2+手术35例,平均清扫淋巴结(30·11±16·97)枚,1例因胃左动脉根部淋巴结融合包绕血管而中转开腹手术。腹腔镜组手术平均用时长于开腹组[(282·84±32·81)vs(223·75±23·25)min]。腹腔镜组术中出血、切口长度、术后止痛剂注射次数以及术后肛门排气时间、下床时间分别为(139·30±82·67)mL,(5·61±0·81)cm,(1·02±1·03)次,(4·10±0·75)d,(3·24±0·777)d,显著低于开腹手术组。腹腔镜组肺部感染率低于开腹组,但差异无显著性,两组间其他并发症差异无显著性。腹腔镜组肿瘤近或(远)端切缘、淋巴结清扫数量、第一及二站淋巴结转移阳性率分别为(6·05±1·27)cm、(6·37±1·12)cm、(30·11±16·97)、47·7%及31·8%,与开腹组相比差异无显著性。术后近期随访效果良好。结论腹腔镜胃癌根治术较传统开腹手术耗时长,但能达到与开腹胃癌标准根治术(D2)相同的淋巴结清扫范围及肿瘤切缘,且具有创伤小、出血少、安全、术后恢复快等优点。     

腹腔镜手术对早期远端胃癌短期疗效的meta分析

目的:通过meta分析评估早期远端胃癌根治术中腹腔镜手术的短期临床疗效与安全性。方法:从Pub Med、Cochrane library等数据库中搜索2014年4月以前发表的研究对象为腹腔镜辅助远端胃大部切除术(laparoscopy-assisted distal gastrectomy,LADG)、开腹远端胃癌根治术(open distal gastrectomy,ODG)治疗早期远端胃癌患者近期疗效的随机对照试验(randomized controlled trials,RCT)文献,采用Rev Man 5.2软件对纳入的数据进行meta分析。结果:共7篇RCT纳入本研究。纳入病例数为692例,其中LADG组354例,ODG组338例,meta分析结果提示:两组患者进食时间[加权均数差(WMD)=-0.49,95%CI(-1.45,0.47)]与术后住院时间[WMD=-1.44,95%CI(-3.17,0.29)]差异无统计学意义,LADG组手术时间较长[WMD=82.91,95%CI(58.59,107.24)],淋巴结清扫数量略少[WMD=-4.62,95%CI(-6.58,-2.66)];但术中出血量[WMD=-103.58,95%CI(-140.75,-66.42)]更少,术后排气时间[WMD=-0.55,95%CI(-1.02,-0.08)]更短,术后早期并发症发生率[比值比(OR)=0.44,95%CI(0.27,0.70)]更低。结论:腹腔镜早期远端胃癌根治术后患者肠道功能恢复较快,并发症较少,短期效果优于开腹手术。     

全胃切除术后家兔营养不良的实验研究

目的通过建立家兔全胃切除和迷走神经干切断的模型,初步探讨全胃切除术后所引起的进食减少、体质量下降、营养不良的原因。方法新西兰兔24只,随机分为A组（对照组）、B组（全胃切除组）和C组（迷走神经干切断组）,观察B、C组手术后体质量比、进食量、血浆胆囊收缩素、胃动素含量、近段小肠上皮单糖转运体GLUT5和SGLT1的mRNA表达情况等指标,并和A组比较。结果与A组相比,B组术后体质量比、进食量明显下降。家兔术后血浆胃动素含量变化不大,胆囊收缩素含量分别于术后第3天和第14天升高（P〈0.05）。B组家兔十二指肠和空肠GLUT5 mRNA表达显著下降（P〈0.05和〈0.01）。在十二指肠和空肠B组家兔SGLT1 mRNA表达均无变化（P〉0.05）。C组家兔术后上述指标与对照组比较,差异均无统计学意义（P〉0.05）。结论全胃切除术后与胃动素相关的消化间期小肠蠕动和食物排空速度可能未出现改变,而胆囊收缩素含量上升可能与中枢性摄食抑制？食欲下降有关;胃切除后家兔小肠近段GLUT5 mRNA表达明显下降,SGLT1 mRNA表达无变化。迷走神经干的切断在这些病理生理变化中不起重要作用。     

Gastric remnant necrosis following splenic infarction after distal gastrectomy in a gastric cancer patient

INTRODUCTIONDistal gastrectomy with lymph node dissection is the standard treatment for gastric cancer. Remnant gastric necrosis after distal gastrectomy is very rare and fatal complication.PRESENTATION OF CASEA-78-year-old male diagnosed with advanced gastric cancer underwent distal gastrectomy with lymph node dissection. Postoperative gastric remnant necrosis occurred following splenic infarction. There was thought to be an insufficient blood supply to the gastric remnant due to the lymph node dissection along the proximal splenic artery during the initial surgery. Non-contrast abdominal computed tomography did not reveal any necrosis in the remnant stomach. An endoscopic examination confirmed this diagnosis. Total remnant gastrectomy was performed, and the patient thereafter successfully recovered.DISCUSSIONCareful management of blood vessels and lymph node dissection above the pancreas should be performed to avoid restricting the blood flow and also to prevent gastric remnant necrosis.CONCLUSIONThe knowledge of this fatal complication is crucial for management of postoperative complication. For early and accurate diagnosis, upper gastrointestinal endoscopy is necessary in case of remnant gastric necrosis.     

远端胃癌根治术后三种消化道重建方式的比较研究

目的比较远端胃癌根治术后3种不同消化道重建方式的治疗效果。方法回顾性分析2007-2010年问在贵阳医学院附属医院接受远端胃大部分切除术的169例胃癌患者的临床资料．按不同消化道重建方式分为BilkothⅠ式组（60例）、BillrothⅡ式组（41例）和胃空肠Roux-en-Y吻合组（68例）。比较3组患者术中及术后恢复情况;并通过特殊症状量表评估3组患者术后3个月的生活质量。结果与Billroth Ⅰ式组和Billroth Ⅱ式组相比,胃空肠Roux-en-Y吻合组患者手术时间更长[（266．3±70．4）min比（196．2±54.3）min和（228．5±67．7）min],术中出血量更多[（220．9±67．6）ml比（170．5±61．5）ml和（188．5±76．7）ml],但其术后拔除胃管时间更短[（2．6±1．5）d比（3．1±1-3）d和（3．6±1．2）d],术后反流和烧心症状更为轻微（特殊症状量表评分1．8±0．4比1．9±0．6和2．6±0．4）：差异均有统计学意义（均P〈0．05）。结论Roux-en-Y吻合术虽不符合生理通道,操作也较为复杂．但其能有效地防止反流性食管炎的发生,是较为理想的远端胃癌根治术后消化道重建术式。     

远端极量胃次全切除术

目的探寻远端极量胃次全切除术的可行性和安全性。方法对2005年1月至2007年4月第四军医大学西京医院普通外科远端极量胃次全切除术45例的临床资料进行分析。其中43例胃癌病人施行胃切除术,2例溃疡病行远端胃大部切除术后残胃吻合口溃疡反复出血者,将脾胃韧带内由脾下极向上的数支胃短血管分支离断,在切断胃短血管的近胃底胃大弯缘至贲门下2cm连线切除荷瘤胃。将仅由3支胃短动脉或2支胃短动脉及胃后动脉提供血运的残胃与空肠行Billroth-Ⅱ式胃空肠吻合。结果胃癌术后病理石蜡切片报告上切缘均干净,未发现肿瘤细胞。术后随访2~45个月,未出现吻合口癌及残胃癌复发,未发生胃缺血或吻合口瘘等并发症,术后残胃的功能正常。2例溃疡病行远端胃大部切除术后,残胃吻合口溃疡反复出血者术后无再出血发生。结论仅保留2支胃短动脉及胃后动脉,或3支胃短动脉的远端极量胃次全切除术是一种安全、实用的胃切除方法。     

远端胃切除术后毕Ⅰ式与Roux-en-Y消化道重建远期疗效的比较

目的：比较远端胃切除术后毕Ⅰ式与Roux-en-Y消化道重建的远期疗效。方法回顾性分析2000年6月至2010年6月间在广州医科大学附属肿瘤医院接受根治性远端胃大部分切除151例胃癌患者的临床资料,其中行毕Ⅰ式消化道重建者87例（毕Ⅰ组）,行Roux-en-Y消化道重建者64例（R-Y组）,术后均获得了至少3年的随访。比较两组患者术后远期临床症状、营养状况、胆石形成及胃肠道并发症情况。结果术后3年,毕Ⅰ组和R-Y组胃食管反流征的发生率分别为11．5％（10／87）和4．7％（3／64）,倾倒综合征的发生率分别为9．2％（8／87）和4．7％（3／64）,差异并无统计学意义（均P＞0．05）。内镜评估结果显示,R-Y组食物残留、残胃（食管）炎及胆汁反流情况均显著优于毕Ⅰ组（均P＜0．05）。体质量和血清白蛋白、总胆固醇水平两组差异均无统计学意义（均P＞0．05）。除去行胆囊切除的病例,毕Ⅰ组和R-Y组的胆石形成率分别为13．2％（10／76）和15．8％（9／57）,差异无统计学意义（P＞0．05）。两组胃肠道并发症发生率分别为8．0％（7／87）和4．7％（3／64）,差异无统计学意义（P＞0．05）。结论远端胃大部分切除术后Roux-en-Y消化道重建者比毕Ⅰ式重建者胃食管反流及胆汁反流程度更轻,远期疗效更佳。     

Laparoscopy-assisted distal gastrectomy for early gastric cancer in obese and nonobese patients

Background Conventional open gastrectomy has been reported to result in increased morbidity in obese patients. To date, there has been no study evaluating laparoscopic gastrectomy in such patients; therefore, we assessed the short-term results of this procedure in a group of obese patients.Methods The study included 99 consecutive patients who underwent laparoscopy-assisted distal gastrectomy (LDG) for the cure of early gastric cancer. The patients were divided into two groups: obese (body mass index [BMI] 25.0, n = 16) and nonobese (BMI <25.0, n = 83). Patient characteristics, operative details, and postoperative outcomes were compared and analyzed.Results Patient characteristics, including age, sex, American Society of Anesthesiologists (ASA) status, and disease stage, were not different between obese and nonobese patients. Operating time was significantly longer in obese patients than in nonobese patients (271 vs 239 min, p < 0.05). However, there was no significant difference between obese and nonobese patients in time to first flatus (3.7 vs 3.3 days), time to solid diet (6.3 vs 5.2 days), length of postoperative hospital stay (18.7 vs 17.9 days), or frequency of major (25% vs 16%) and minor (19% vs 12%) postoperative complications. There were no conversions to conventional open surgery and no perioperative deaths.Conclusion The only difference between our two study groups was that LDG required a longer operating time in obese patients; morbidity and length of hospital stay were not increased. Thus, we believe that LDG is likely to become the treatment of choice for obese patients with early gastric cancer.     

腹腔镜全胃联合胰体尾和脾切除术

Laparoscopic curative gastrectomy has been widely adopted because it is minimal invasiveness.The efficacy of laparoscopic gastrectomy is comparable to that of open gastrectomy for patients with early o...     

远端胃癌根治术后迟发性出血原因与处理

目的 分析远端胃癌根治术后迟发性腹腔出血的病因、诊断及治疗方案.方法 对广州市第一人民医院2008年1月-2013年6月远端胃癌根治术后发生出血的45例患者进行回顾性研究.结果 45例患者中有13例发生迟发性腹腔性出血,出血时间为术后1～4周.其中5例为术后1周以后出现间歇性出血,经CT、DSA诊断为胃十二指肠动脉假性动脉瘤破裂出血,经DSA栓塞止血后治愈;8例术后3～4周出现反复呕血,经胃镜检查后明确诊断为吻合溃疡出血,在内镜下止血成功.结论 远端胃癌根治术后迟发性腹腔出血病因复杂,CT、DSA及胃镜检查可帮助明确诊断,DSA及内镜具有较高的治疗价值,可避免再次开腹手术.     

Laparoscopic-assisted proximal gastrectomy for early gastric carcinomas

(Received for publication on Dec. 11, 1997; accepted on July 7, 1998)     

腹腔镜辅助胃远端癌淋巴结清扫术近期疗效

目的探讨腹腔镜辅助胃远端癌D2淋巴结清扫术的可行性及近期疗效。方法2007年1月至2008年12月,对241例胃远端癌患者施行D2淋巴结清扫术。其中腹腔镜辅助远端胃大部切除术（LADG组）93例,常规开腹远端胃大部切除术（ODG组）148例。比较两组患者的淋巴结清扫数及术中、术后恢复情况、并发症发生率和住院死亡率。结果LADG组和ODG组患者淋巴结清扫数分别为（27．5±9．1）枚和（27．3±8．5）枚,两组差异无统计学意义（P〉0．05）。按肿瘤浸润深度进行分层分析,T1、T2、T3期患者两组平均清扫淋巴结数差异均无统计学意义（P〉0．05）。LADG组手术时间显著长于ODG组,但术中出血量、输血例数、术后首次下床时间、肛门排气时间、进流质时间、住院时间和手术并发症发生率均显著少于ODG组,两者差异有统计学意义（P〈0．05）。结论腹腔镜辅助胃远端癌D2淋巴结清扫术在淋巴结清扫方面能达到与开腹手术相同的效果,且具有安全、术后恢复快和并发症少等优点。     

腹腔镜辅助下胃癌D2根治性远端胃大部切除术安全性与有效性的系统评价

目的 评价腹腔镜辅助下胃癌D2根治性远端胃大部分切除术的安全性与有效性.方法 检索Pubmed、Medline、EMBASE和中国生物医学数据库（CBM）2001年1月至2010年2月间发表的D2根治性远端胃大部分切除术治疗胃癌的对照试验研究,用Revman 5.0统计软件进行分析.结果 共纳入7个对照试验,其中1项研究为随机对照试验,6项为非随机对照研究.腹腔镜辅助远端胃大部分切除组（LADG）与开腹远端胃大部切除术（ODG组）相比,术中出血量少[加权均数差（WMD）=-132.04,95% CI：-207.32～-56.77],术后第1次排气时间早（WMD=-0.82,95% CI：-1.20～-0.45）,术后并发症发生率低[相对危险度（OR）=0.45,95%CI：0.26～0.78],术后住院时间短（WMD=-3.63,95%CI：-4.19～-3.07）,清扫的淋巴结数目多（WMD=1.93,95%CI：0.36～3.50） 但术后复发率、转移率和近期（3年内）生存率差异无统计学意义（P＞0.05）.结论 腹腔镜辅助下胃癌D2根治性远端胃大部分切除术的短期效果优于开腹手术.     

胃十二指肠三角吻合术应用于胃癌全腹腔镜下远端胃切除术的可行性研究

目的：探讨胃十二指肠三角吻合术应用于胃癌全腹腔镜下远端胃切除术的可行性。方法2013年7-11月间,上海交通大学医学院附属瑞金医院普通外科对22例胃癌患者应用直线形吻合器进行胃十二指肠三角吻合,完成全腹腔镜下远端胃切除术并D2淋巴结清扫,其中12例应用改良三角吻合术（闭合共同开口时将原十二指肠吻合线一并移去的术式）,回顾性总结分析其临床资料。结果22例胃癌患者均于全腹腔镜下完成远端胃切除及胃十二指肠三角吻合,总手术时间（194．6±38．4） min,胃十二指肠三角吻合时间（19．1±14．1） min。术中应用直线形吻合器钉匣（5．8±0．8）个／例。术中出血量（49．5±24．0） ml,淋巴结清扫数目（32．8±12．4）枚／例,上、下切缘病理检查均未见癌残留。术后患者首次肛门排气时间（2．9±0．7） d,恢复饮水时间（4．8±1．1） d,进食半流质时间（6．6±1．2） d,术后住院时间（10．1±2．3） d。全组术后并发症发生率为9．1％（2／22）,但均未出现吻合口瘘、梗阻和出血等吻合口相关并发症。结论胃十二指肠三角吻合术简易、安全、可行,是胃癌全腹腔镜下远端胃切除术消化道重建较为理想的术式。     

三角吻合在完全腹腔镜远端胃癌根治术中的应用研究

目的 对比分析远端胃癌根治术中全腹腔镜下三角吻合与腹腔镜辅助Brillroth Ⅰ式吻合的近期疗效,探讨三角吻合技术的应用价值.方法 回顾性分析2013年3月至2014年2月开展的50例全腹腔镜下远端胃癌根治术加三角吻合的临床资料（三角吻合组）,并以同期开展的43例腹腔镜辅助远端胃癌根治术加Brillroth Ⅰ吻合作为对照（BⅠ吻合组）,比较两组患者的手术相关指标和术后并发症发生情况.结果 两组手术时间、术中出血量、淋巴结清除数、术后肛门排气时间、并发症发生率和术后住院天数比较,差异均无统计学意义（均P＞0.05）;三角吻合组切口长度[（3.4±0.4）cm]和术后第1天疼痛评分[（3.1±1.0）]小于BⅠ吻合组[（6.9±0.8）cm和（4.6±1.4）],差异均有统计学意义（均P＜0.05）.结论 全腹腔镜下远端胃癌根治术三角吻合技术安全可行,在切口美观和舒适度方面较腹腔镜辅助下Brillroth Ⅰ式吻合更有优势。