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     

腹腔镜胰体尾切除术与开腹胰体尾切除术临床疗效对比分析

目的 对比腹腔镜胰体尾切除术（laparoscopic distal pancreatectomy,LDP）与开腹胰体尾切除术（open distal pancreatectomy,ODP）的疗效,探讨腹腔镜胰体尾切除术的优缺点.方法 回顾性分析2011年1月至2014年4月施行的17例腹腔镜胰体尾切除术患者与20例开腹胰体尾切除术患者的临床资料,对比两组患者的手术及术后情况.结果 腹腔镜组术中出血量少于开腹组,差异具有统计学意义（P＜ 0.05）;腹腔镜组术后肛门排气时间、禁食时间、住院时间较开腹组短,差异具有统计学意义（P＜0.05）;腹腔镜组手术时间长于开腹组,差异具有统计学意义（P＜0.05）;两组保脾率、术后并发症发生率差异无统计学意义（P＞ 0.05）,开腹组5例胰漏,1例切口感染、1例肺部感染、1例腹腔感染,腹腔镜组4例胰漏.结论 腹腔镜胰体尾切除术是安全可靠的,短期预后优于开腹组,值得临床进一步推广.     

腹腔镜与开腹胰体尾切除术的疗效比较

通过比较腹腔镜胰体尾切除术(LDP)和开腹胰体尾切除术(ODP)治疗胰体尾肿瘤的效果,探讨LDP的安全性和有效性.回顾性分析厦门医学院附属第二医院2014年3月—2019年6月61例胰体尾肿瘤患者的临床及病理资料,其中30例采用LDP,31例采用ODP,对两组患者的术中及术后情况进行比较.LDP组术中出血量明显少于OD...     

切断脾血管行保留脾脏的胰体尾切除术的实验研究与应用

切断脾血管行保留脾脏的胰体尾切除术的实验研究与应用曹金铎朱明炜唐大年苏伟王舒于治国金秀然近年来，我们在实验研究的基础上，临床采用切断脾血管行保留脾脏的胰体尾切除术疗效满意，现简要报告如下。１．动物实验：小型雄性猪８头。猪龄６～１２个月，体重１１．５～...     

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...     

根治性顺行模块化胰脾切除术治疗胰体尾癌的现状与展望

胰腺癌是致死性较高的胃肠道恶性肿瘤之一,发病率逐年上升.胰体尾癌约占胰腺癌的20％～30％,与胰头癌相比,胰体尾癌起病更加隐匿并且早期缺乏有效的诊断方法.传统的根治性手术效果较差,胰体尾癌患者术后5年生存率仅20％～30％.2003年,Strasberg团队率先开创了根治性顺行模块化胰脾切除术(radical ante...     

胰体尾切除术后的胰漏防治

胰漏是胰体尾切除术后最常见也是最严重的并发症,如何有效地减少胰漏的发生和胰漏发生之后及时的处理是临床上亟待解决的问题。本文对近年来胰体尾切除术后胰漏发生的危险因素、胰漏的预防和处理等有关方面的研究的现状和进展做一综述。     

腹腔镜辅助逆行法胰颈体尾脾切除术

目的:探讨腹腔镜辅助逆行法胰体尾脾切除术的手术方法及适应证。方法:总结分析2010年5月至2012年10月为8例胰颈体恶性肿瘤患者行腹腔镜辅助逆行胰颈体尾脾切除术的临床资料,肿瘤侵犯周围重要血管,术前经增强CT、MR充分评估,肿瘤左侧胰体尾脾界清,无远处转移。术中腹腔镜完全游离肿瘤左侧胰体尾脾,再于上腹正中做8～10 cm切口,直视下处理胰颈肿瘤与周围重要血管的侵犯、粘连,于门静脉右侧缘离断胰颈部,完整切除、取出胰体尾脾。结果:8例均顺利完成腹腔镜辅助手术,手术时间100～180 min,术中出血量100～200 ml,术后患者恢复顺利。结论:腹腔镜辅助逆行法胰颈体尾脾切除术可作为侵犯周围重要血管但左侧胰体尾界清的胰颈体肿瘤的选择术式,具有患者创伤小、康复快、安全可行等优点。     

进展期胃癌淋巴结转移与全胃联合脾胰体尾切除的相关性

目的:探讨进展期胃癌根治术的全胃切除联合脾胰体尾切除合理适应证与淋巴结转移等的相关性。方法:选取我院自1997年1月至2007年12月期间273例行全胃切除的胃癌根治术病人,比较全胃联合脾胰体尾切除组(切脾组)和单纯全胃切除(保脾组)之间在肿块大小、淋巴结转移、生长方式、Borrmann分型、癌灶距脾门距离、分化类型以及生存期等方面的差异。结果:切脾组病人5年生存率为31.8%,保脾组为35.4%,两组在5年生存率上无统计学差异(χ2=0.205,P>0.05),在生存曲线上两组间有统计学差异,保脾组明显优于切脾组(χ2=10.853,P<0.01)。切脾组和保脾组间4、10、11组淋巴结转移情况、肿块大小、分化程度、生长方式、Borrmann分型等方面差异有统计学意义(P0.05),但是第10、11组淋巴结有转移的12例病人中有11例第4组淋巴结转移。结论:胃癌根治术全胃切除时,肿块较大、分化较差、呈浸润性生长并4、10和11组淋巴结有转移应考虑联合脾胰体尾切除,但全胃联合脾胰体尾切除不一定延长胃癌病人生存期。     

The Role of Surgery After Incomplete Endoscopic Mucosal Resection for Early Gastric Cancer

Purpose Endoscopic mucosal resection (EMR) is a relatively new treatment option for early gastric cancer (EGC). However, cases of incomplete EMR resulting in a positive lateral margin or submucosal invasion (positive vertical margin) have been reported. We conducted this study to evaluate the role of surgery after incomplete EMR for EGC. Methods We analyzed 19 patients who underwent gastrectomy as a result of an incomplete EMR. The patients were divided into three groups according to the type of incomplete EMR: a positive lateral margin (LM) group (n = 9), a positive vertical margin (VM) group (n = 4), and a positive lateral and vertical margin (LM + VM) group (n = 6). Results The positive residual tumor rate and the positive lymph node rate were 44.4% (4/9) and 0% (0/9) in the LM group, 50.0% (2/4) and 25.0% (1/4) in the VM group, and 83.3% (5/6) and 16.7% (1/6), LM + VM group, respectively. Curative resection was performed in all patients and there was no recurrence in 30.8 months of follow-up. Conclusion Radical surgery is recommended for patients with a positive lateral resection margin or submucosal invasion, or both, after EMR for EGC, because of the possibility of residual tumor or lymph node metastasis. This paper was presented at the 76th Annual Meeting of the Japanese Gastric Cancer Association, Yonago, Japan, March 4–6, 2004.     

Lack of Benefit of Combined Pancreaticosplenectomy in D2 Resection for Proximal-Third Gastric Carcinoma

Of the 2790 patients with gastric carcinoma who underwent surgery between January 1978 and December 1993, there were 224 who underwent a D2 resection for cancer of the proximal third of the stomach. Survival in these patients was retrospectively analyzed with special reference to the survival benefit of pancreaticosplenectomy (PS). The D2 resection involved a splenectomy in 129 patients, a PS in 38 patients, and neither in 57 patients, with 5-year survivals of 74%, 59%, and 91%, respectively. Although these differences in survival were attributable to the apparent deviation in the incidence of prognostic variables, no significant survival benefit of PS was observed for patients with the same clinical stage disease (stages II and III) or the same nodal status (n1 and n2). Because PS was associated with a significant increase in the incidence of anastomotic dehiscence and length of hospital stay, the dismal survival benefit implies that it should not be performed routinely with the D2 resection but should be employed only for lesions with direct invasion of the pancreas.     

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。     

64排增强CT对进展期胃癌根治程度的判断价值

目的探讨64排增强CT(MDCT)对进展期胃癌(AGC)手术根治程度的判断价值。方法分析70例AGC患者MDCT增强扫描的影像学资料,判断N2(第7、8和9组)淋巴结转移及脏器受侵情况,并将CT判断结果与手术后病理结果进行比较。结果62例患者接受手术治疗,8例因手术禁忌证无法行手术治疗。MDCT术前判定N2淋巴结转移的敏感性为92.0%(46/50),特异性为75.0%(9/12),准确性为88.7%(55/62)。MDCT术前判定存在N2或以上淋巴结转移者81.6%(40/49)行D2以上扩大根治术;判定N2淋巴结无转移者92.3%(12/13)行标准D2根治术。结论MDCT对诊断AGC N2淋巴结转移及周围脏器侵犯有重要价值,对AGC手术根治程度的判定有指导作用。     

腹腔镜辅助进展期胃癌D2根治术与开腹手术近期疗效的临床对照研究

目的探讨腹腔镜辅助与传统开腹手术治疗进展期胃癌的近期疗效。方法对2010年10月至2012年10月期间因胃癌在笔者所在医院普外中心行腹腔镜辅助胃癌D2根治术（腹腔镜组,76例）和同期行传统开腹胃癌D2根治术（开腹组,104例）患者的临床资料进行回顾性分析,比较2组患者的手术相关指标、术后恢复情况和肿瘤根治程度。结果腹腔镜组的手术时间为（192．5±14．8）min,长于开腹组的（171．5±16．5）min（P〈0．05）;但腹腔镜组术中出血量、术后引流量、手术切口长度及住院时间则少于或短于开腹组（P〈0．05）。术后并发症发生率及肿瘤根治程度2组问的差异无统计学意义（P〉0．05）。2组均无切缘癌残留和手术死亡病例。结论腹腔镜辅助进展期胃癌D2根治术,能达到与开腹手术相当的临床近期疗效,且微创优势明显。     

Simultaneous Laparoscopy-Assisted Resection for Rectal and Gastric Cancer

Laparoscopy-assisted surgery for either rectal or gastric cancer has been increasingly performed. However, simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer is rarely reported in the literature. In our study, 3 cases of patients who received simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer were recorded. The results showed that all 3 patients recovered well, with only 253 minutes of mean operation time, 57 mL of intraoperative blood loss, 5 cm of assisted operation incision, 4 days to resume oral intake, 12 days'' postoperative hospital stay, and no complication or mortality. No recurrence or metastasis was found within the follow-up period of 22 months. When performed by surgeons with plentiful experience in laparoscopic technology, simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer is safe and feasible, with the benefits of minimal trauma, fast recovery, and better cosmetic results, compared with open surgery.     

腹腔镜与开腹胃间质瘤楔形切除的临床对比研究

目的探讨腹腔镜胃楔形切除治疗胃间质瘤的可行性。方法回顾性分析我院2002年9月~2009年4月腹腔镜胃间质瘤楔形切除术32例（腹腔镜组）和1999年10月~2009年1月开腹胃间质瘤楔形切除术20例（开腹组）的临床资料,比较2组围手术期的情况和预后。结果与开腹组相比,腹腔镜组手术时间短[120 min（23~210 min）vs 145 min（75~400 min）,Z=-2.960,P=0.003],术中出血量少[20 ml（5~100 ml）vs 50 ml（10~200 ml）,Z=-3.580,P=0.000],术后进食时间早[3 d（1~4 d）vs 3 d（3~21 d）,Z=-3.032,P=0.002],术后住院时间短[6 d（4~15 d）vs 8.5 d（6~26 d）,Z=-4.202,P=0.000]。腹腔镜组29例随访6~79个月（中位随访时间25个月）,开腹组16例随访9~120个月（中位随访时间58个月）,均无复发或转移。结论腹腔镜胃间质瘤楔形切除术安全、有效,具有可行性。     

关于胃癌淋巴结清扫范围的研究进展

目的：总结并分析目前胃癌外科手术中关于淋巴结清扫范围问题的不同观点及统一认识的方法和途径。方法：对当前国内、外有关胃癌淋巴结清扫范围的研究报道及最新进展进行综述和分析。结果：由于研究方法的不同、种族的差异及操作技术等原因，东、西方国家的学者之间，对胃癌淋巴结清扫范围问题的看法至今未能达成共识。结论：尽管越来越多的学者主张对进展期胃癌进行广泛性的淋巴结清扫，但精确评估其作用是困难和复杂的，需要世界范围内的胃肠外科学者互相取长补短，加强合作，进一步研究，才能得出令人信服的一致结论，最终形成临床实践的指导原则。     

Gallbladder Cancer: Defining the Indications for Primary Radical Resection and Radical Re-resection

Background The role of radical resection for gallbladder cancer is an ongoing area of debate. In this review, we present our experience managing gallbladder cancer at a tertiary center by using an aggressive surgical approach for T2 or greater disease, reserving simple cholecystectomy only for T1 lesions. Methods Seventy-six patients with histologically confirmed gallbladder cancer were identified from our cancer registry. Estimated survival distributions were calculated by the Kaplan-Meier method, and comparisons were made by using the log-rank test. The Cox proportional hazards model was used to determine the effect on survival of T stage, nodal status, age, and margins. Results Sixty-four patients were assessable for this study. Simple cholecystectomy was the only procedure performed in 10 T2 and 15 T3 cases. Radical cholecystectomy was performed as the primary procedure in two T2, two T3, and six T4 cases. Radical re-resection was accomplished in seven T2 and two T3 cases. Excluding the T4 group, there was a significant survival advantage (P = .007) for the radical resection group (n = 13; median survival not yet reached) compared with the simple cholecystectomy group (n = 25; median survival, 17 months; 95% confidence interval, 7–27 months). Analysis of the 13 T2 and T3 patients who underwent radical resections revealed that the radical re-resection group (n = 9) had an overall survival similar to that of the primarily resected group (n = 4). All T2N⁺ and T3N⁻ patients are still alive and disease free after 5 years of follow-up, whereas none of the T3N⁺ or T4 patients survived beyond 24 months. Increasing T stage and age (>65 years) were independent predictors of a poor prognosis. Conclusions Radical resection for T2 and T3 disease resulted in a significant survival advantage compared with simple cholecystectomy. Patients who undergo radical re-resection after an incidentally discovered gallbladder cancer experience the same survival benefit as primarily resected patients. Radical resection for T2N⁻, T2N⁺, and T3N0 cases can achieve long-term survival. Conversely, the prognosis for T3N⁺ and T4 patients is poor, and improved outcome for this group will likely depend on the development of multi-institutional neoadjuvant clinical trials that can identify effective systemic regimens. Presented at the 58th Annual Meeting of the Society of Surgical Oncology, Atlanta, Georgia, March 3–6, 2005.     

Outcome of Patients with Known Metastatic Gastric Cancer Undergoing Resection with Therapeutic Intent

Background Metastatic gastric cancer has a dismal prognosis. We identified a subset of patients where surgical resection with therapeutic intent was undertaken in the setting of known metastatic disease. Methods Review of a prospectively maintained database of gastric cancer patients at a single institution over a 19-year period was performed. Results Thirty-seven patients with metastatic disease known prior to resection with therapeutic intent were identified out of 3384 patients with gastric cancer (1%). Twelve patients had positive peritoneal cytology as the only evidence of metastasis, 21 had gross metastasis limited to peritoneal surfaces, one had peritoneal and ovarian metastasis, one had liver metastasis, one had retropancreatic lymph node metastasis, and one had a malignant pleural effusion. Thirty-six patients (97%) received chemotherapy prior to resection, and 30 (81%) received postoperative chemotherapy. The median time from diagnosis to resection was 4.5 months (range 1–22) in patients receiving preoperative chemotherapy. Median survival was 12 months after resection with no three-year survivors. Predictors of worse prognosis were cytologic or pathologic evidence of persistent metastatic disease at the time of resection or at laparoscopy within six weeks of resection (P < .01), N3 disease (P = .03), and total gastrectomy or additional organ resection (P = .04). Metastatic disease as evidenced by cytology only was not associated with improved prognosis. Conclusions Highly selected patients with metastatic gastric cancer undergoing surgical resection with therapeutic intent have a relatively poor prognosis. Persistent detectable metastatic disease after preoperative chemotherapy portends a particularly poor prognosis.