经腹应用吻合器治疗胃底贲门癌24例体会

胃底贲门癌手术入路常用经腹、经胸和胸腹联合3种[1]。2000年以来,我科应用管状吻合器经腹行胃底贲门癌手术24例,效果满意,现报告如下。临床资料1.一般资料:胃底贲门癌24例,其中男18例,女6例,年龄45~75岁,平均66岁。术前均经纤维胃镜及病理确诊,B超、CT和钡餐检查了解病灶位置及病期。其中贲门癌20例,胃底癌4例;低分化腺癌8例,中分化腺11例,高分化腺癌5例。TNM分期:Ⅰ期2例,Ⅱ期4例,Ⅲ期16例,Ⅳ期2例。2.手术方法:本组病例均采用气管插管麻醉,采用正中切口,链式悬吊拉钩牵开切口,充分暴露膈下区。常规扩开分离膈肌裂孔并切开膈肌脚正中弓…     

经腹纵隔内根治贲门癌56例分析

目的：探讨经腹纵隔内施行贲门癌根治术式。方法：对1998年-2003年经腹部采用管型吻合器进行纵隔内食管胃(空肠)吻合的56例进行回顾性分析。结果：根治性切除贵门癌时，在癌灶以上6-7cm切断食管，无切缘癌残留。无吻合口漏。无手术死亡。只l例吻合口狭窄。并发症低于开胸手术。结论：经腹扩大后下纵隔视野，有利于施行贲门癌根治术，纵隔内食管胃(空肠)机械吻合术，能预防并发症的发生。     

CDH园型吻合器在胃底贲门癌外科中的应用

目的:评价CDH圆形吻合器经腹食管、胃吻合中的应用。方法:用该吻合器对45例胃底贲门癌切除术后行食管胃机械吻合,对照组同期18例胃底贲门癌切除术后行手工吻合,复习1989～1994年58例胃底贲门癌切除用上海GF-1型园型吻合器行食管胃机械吻合。结果:45例用CDH圆形吻合器均一次吻合成功,无器械故障,无吻合口瘘,无吻合口狭窄,无手术死亡病例。结论:CDH圆形吻合器设计合理、安全可靠、在胃底贲门癌经腹行食管胃吻合术中应用,可缩短手术时间,减少手术创伤,降低手术难度。     

圆吻合器在贲门癌经腹切除153例中的应用体会

<正> 我科于1991年以来使用圆吻合器经腹行贲门癌根治性切除153例,现报告如下。 1 临床资料 1.1 一般资料:本组男87例,女66例,年龄30～72岁。贲门区癌肿113例,贲门胃底癌18例,贲门胃体癌(胃小弯侧或胃前后壁上端)22例。有5例尚处于早期,无吞咽困难,体检时发现;进展期148例。125例胃左动脉旁淋巴结有转移,有3例癌肿直接侵犯胰腺上缘,形成局限性肿块:,全组无远处转移或明显种植转移病例。术后病检结果:溃疡型腺癌115例,粘液癌17例,鳞腺癌21例;1例断端有癌残留,152例未见癌残留,低分化腺癌37例,中、高分化腺癌116例。     

胃肠吻合器在胃切除术中的应用

1988年5月至1992年6月,我科运用 GF-I 型吻合器行胃大部分切除术(包括全胃切除术)100例,其中胃癌16例,胃溃疡44例,十二指肠溃疡28例,复合性溃疡12例;行 Billroth-Ⅰ式36例,Billroth-Ⅱ式49例,全胃切除15例。仅1例术后0.5年出现吻合口狭窄。作者介绍了吻合器在不同胃切除术式中的使用方法,并对使用过程中应注意的事项及并发症进行了探讨。     

多种管状消化道吻合器在食管胃吻合中的应用

1986年2月至1999年1月应用沪产GF—Ⅰ型和常州产WGW—Ⅰ型弯管形两种消化道吻合器,对539例食管癌和贲门癌病人进行了食管胃吻合术,无吻合失败。术后吻合口瘘发生率1．3％(7,539),吻合口狭窄率1．8％(10／539),死亡率0．6％(3／539)。作认为：采用小切口,食管胃机械吻合操作简便,吻合可靠,价格便宜,手术时间短,术后病人痛苦小,住院时间短,节省了住院费用,减轻了病人经济负担;结合 本组病例,提出采用31号GF—Ⅰ型吻合器进行弓下吻合,26号WGW—Ⅰ型吻合器进行胸顶以上吻合,减少跨弓吻合,有助降低术后并发症的发生。     

经腹手术治疗贲门癌29例

贲门癌29例,男22例,女7例,年龄51～76岁.腺癌28例,腺鳞癌1例.肿瘤位于"Z"状线下2cm内23例,位于"Z"状线处6例,肿瘤多在2～4cm.     

食管癌和贲门癌手术中应用圆形吻合器的经验

吻合口瘘长期以来一直是食管癌和贲门癌手术中最严重的并发症，也是手术治疗成败的关键，发生率虽低，但死亡率很高。1990年至1996年，我国食管手术吻合口瘘的发生率仍在3％-5％，病死率达17％～25％。国外文献报道其发生率亦在3％-4％。1980年8月至2004年9月，我们应用消化道圆形吻合器对3322例食管癌和贲门癌切除后进行吻合，取得了良好效果。现将本组治疗经验报道如下。[第一段]     

弧形吻合器在低位直肠癌前切除术中的应用价值

为探讨弧形切割吻合器在低位直肠癌前切除术中的应用价值,回顾分析45例应用弧形切割吻合器行前切除术治疗的低位直肠癌患者资料。结果显示,本组患者无手术死亡及吻合口狭窄。术后发生吻合口漏2例（4．4％）,3例（6．7％）出现严重尿潴留需留置导尿管。3个月后排便和排尿功能基本恢复正常。结果表明,应用弧形切割吻合器行低位直肠癌前切除术安全可靠,操作简单。只要操作得当,不会增加吻合口漏的发生率。     

单吻合器与双吻合器技术在直肠癌低位前切除术中的临床应用分析

目的评价单吻合器与双吻合器技术在直肠癌低位前切除术中临床应用的效果。方法对2003年1月至2010年1月68例低位前切除加单吻合器技术及57例低位前切除加双吻合器技术患者的临床资料作分析比较。结果两组所有患者保肛手术均获成功,无手术死亡,术后病理远端切缘未见癌残留。两组手术时间、术中出血量、住院时间均无统计学意义（P〉0.05）。吻合口漏,双吻合器组1例（1.7%）,单吻合器组3例（4.4%）,两组间比较差异无统计学意义（P=0.74）。住院费用,双吻合器组为2.45万元（2.1～3.2万元）,单吻合器组为1.9万元（1.7～2.2万元）,两组间差异有统计学意义（P〈0.05）。结论单吻合器与双吻合器技术均可完成直肠癌低位超低位吻合术,具有保肛成功率高,手术时间短,并发症少等优点,安全可行。而单吻合器较双吻合器更为经济实用,适合在基层医院开展。     

国产单吻合器在低位直肠癌保肛手术中的临床应用

目的 探讨国产单吻合器在低位直肠癌保肛手术中的临床应用效果.方法 结合相关文献回顾性分析2003年1月至2007年12月期间我院收治的128例低位直肠癌中行直肠全系膜切除(TME)且应用国产管状吻合器及荷包钳进行手术的91例患者的资料.结果 全组无手术死亡病例,保肛均获成功·保舡率为71.09%(91/128),术后病理检查肿瘤远端切缘无癌残留.未发生吻合口出血及狭窄;1例(1.10%)发生吻合口漏,经保守治疗后痊愈;无大便失禁发生.全组获随访1～5年,平均3.8年,局部复发6例(6.59%);总的1年生存率为97.80%(89/91),3年生存率为80.00%(72/90),5年生存率为68.97%(60/87).结论 TME联合国产管状吻合器及荷包钳应用于低位直肠癌根治术,可提高保肛率,操作简单安全,疗效满意.     

凯途双吻合器在低位直肠癌保肛手术中的应用

目的探讨凯途（CONTOUR）双吻合器在低位直肠癌前切除术中的应用价值。方法对我院2007年3月至2012年2月期间46例低位直肠癌患者应用凯途双吻合器保肛的治疗经过进行回顾性分析。结果本组46例患者均一次吻合成功,平均手术时间180min,术中平均出血315mL,吻合口距齿状线距离平均为2.5cm。术后发生吻合口出血1例（2.17%）,吻合口漏2例（4.35%）,术后直肠阴道瘘1例（2.17%）,均经相应治疗而治愈。无吻合口狭窄及死亡病例。术后平均住院时间17.7d。术后平均随访1年均无局部复发及吻合口狭窄,无死亡病例。结论凯途弧形切割缝合器在低位直肠癌保肛手术中有着较大的优势。     

弧形切割缝合器在直肠癌低位前切除术中的应用

目的:探讨新型弧形切割缝合器(凯途TM)在直肠癌低位前切除术中的应用.方法:回顾性分析2005年11月至2006年6月收治的46例低位直肠癌应用新型弧形切割缝合器施行低位前切除的临床资料.双重器械吻合前切除术40例中,1例家族性腺瘤样息肉病行全大肠切除回肠J型贮袋肛管吻合术;39例直肠癌,其中Dukes A期 11例,Dukes B期15例,Dukes C期13例,分别行低位或超低位前切除术、或前切除术.Hartmann术6例为5例Dukes D期和1例高龄体虚Dukes B期低位直肠癌.结果:双重吻合前切除40例中,超低位吻合33例(33/40,82.5%);无吻合口瘘发生,无局部复发出现;吻合口出血3例(3/40,7.5%),直肠阴道瘘2例(2/18,11.1%).行Hartmann术6例,直肠切割闭合处平均距肛缘2.8 cm.结论:弧形切割缝合器在低位直肠癌的保肛手术中的应用与直线形切割缝合器相比有着较大的优势.     

Gastric Cancer Surgery in Elderly Patients

Background To investigate the value of individual risk-adapted therapy in geriatric patients, we performed a consecutive analysis of 363 patients undergoing potentially curative surgery for gastric cancer. Patients and Methods All patients underwent extensive preoperative workup to assess surgical risk. The following criteria were evaluated in 3 age groups (< 60 years, 60–75 years, and > 75 years): comorbidity, tumor characteristics, type of resection, postoperative morbidity and mortality, recurrence rate, overall survival, and disease-free survival. Results There was an increased rate of comorbidity in the higher age groups (51% vs 76% vs 83%; P < 0.05). Cardiovascular and pulmonary diseases were most common. There was a decrease in the rate of both total gastrectomy (74%, 54%, 46%; P < 0.05) and D2 lymphadenectomy (78%, 53%, 31%; P <0.05). The 30-day mortality in the 3 age groups was 0%, 1%, and 8%, respectively (P < 0.05). There was only a slight difference in tumor recurrence rate (35%, 37%, and 27%; P = 0.437), with no significant difference in 5-year cancer-related survival (61%, 53%, 61%; P = 0.199). Conclusions Patient selection and risk-adapted surgery in elderly patients can result in acceptable therapeutic results comparable to younger patients. Limited surgery in elderly gastric cancer patients with high comorbidity does not necessarily compromise oncological outcome.     

Palliative Resection in Noncurative Gastric Cancer Patients

Background  

Palliative resection for noncurable gastric cancer remains controversial, especially in the elderly. This retrospective study was designed to elucidate the clinicopathological factors and operative outcome in patients undergoing palliative gastric resection.     

经肛门拖出吻合器吻合法在腹腔镜直肠癌根治术中的应用

目的 探讨经肛门拖出吻合器吻合在腹腔镜直肠癌根治术中应用的可行性及临床疗效。方法 2010年6月～2013年1月,采用腹腔镜辅助经肛门拖出吻合器吻合法治疗30例中低位直肠癌。22例≤T2期,8例T3期,均为N0,M0。电子结肠镜检查显示肿瘤下缘距肛缘的距离4.0～10.0cm,（7.6±1.5）cm;肿瘤直径2～6cm,（3.8±1.3）cm。先在腹腔镜下进行直肠全系膜切除,于耻骨联合上做下腹部正中辅助切口,直视下切断近端结肠,经肛门拖出切除直肠标本,应用双荷包、单吻合器技术,以国产管型消化道吻合器（31.5mm或28.5mm）行结一直肠端端吻合。结果 30例手术均顺利完成。手术时间170～280min,（216.3±25.9）min。术中出血量50～700ml,（273.3±160.1）ml。术后肛门排气时间1～4d,（2.5±0.8）d。术后住院时间8～30d,（12.2±4.2）d。肠管远端切缘距肿瘤的距离2.0～6.0cm,（3.9±0.9）cm。远近切缘均未见癌残留。术后发生吻合口漏1例（3.3％）,腹腔积液并感染1例（3.3％）,均经非手术治疗治愈,无腹腔内出血、肠梗阻、吻合口出血等并发症。随访6～24个月,（11.8±3.9）月,术后3个月大便次数1～5次／d;1例吻合口瘢痕收缩狭窄,排便困难,予以扩肛等处理后好转;1例术后16个月局部肿瘤复发,行腹一会阴联合直肠癌根治术（Miles手术）。结论 经肛门拖出吻合器吻合联合腹腔镜手术治疗中低位直肠癌安全可行,值得推广应用。     

全胃切除术治疗胃底贲门癌的疗效

目的探讨全胃切除术治疗胃底贲门癌的治疗效果. 方法对1990年1月至2003年12月间收治的480例胃底贲门癌患者的临床资料进行回顾性分析,其中全胃切除组(A组)290例,近侧胃大部分切除术(B组)190例. 结果 A组1、3、5年生存率分别为83.8%、60.8%、38.3%,B组分别为79.2%、48.3%、23.3%,两组3、5年生存率有显著性差异(P<0.05).A组术后并发症的发生率和病死率分别为13.8%和2.4%,B组分别为11.6%和2.1%,两组无统计学差异(P>0.05). 结论全胃切除术治疗胃底贲门癌能提高疗效,不会增加术后并发症发生率和病死率,且能明显提高生存率.     

Laparoscopy-assisted Gastrectomy for Early Gastric Cancer in Young and Elderly Patients

Open gastric surgery in elderly patients is associated with higher morbidity and mortality rates than those reported among younger individuals. Therefore, minimally invasive surgery may have a larger impact on the elderly compared to the younger age group. The objective of this study was to evaluate the experience of laparoscopy-assisted distal gastrectomy (LADG) in patients with early gastric cancer and compare the results in patients 70 years of age and older to those in patients younger than 70 years of age. From January 1998 to October 2004, a total of 103 patients underwent LADG. Of these patients, 30 who were older than 70 years were compared with 73 who were younger. Preoperative co-morbidity, operative results, postoperative outcomes, and survival were analyzed. Furthermore, as a standard control of this study, we reviewed 54 distal gastrectomy cases with open surgery (open distal gastrectomy; ODG) in the same term with the same background factors, categorized into elder (n = 16) and younger (n = 38). The mean age of the elderly patients was 75 years in the LADG group. A significantly higher proportion of elderly patients had concurrent diseases in both groups. Blood loss was significantly less in the elderly than in younger patients undergoing LADG, and it was less in the LADG group than in the ODG group. The overall 5-year survival rates in the LADG group were not significantly different between elderly and younger patients. Laparoscopy-assisted distal gastrectomy is a safe and effective treatment for early gastric cancer in the elderly. Therefore, chronological age alone should not be considered a contraindication in selecting patients for LADG.     

Prognostic Impact of Microscopic Tumor Involved Resection Margin in Advanced Gastric Cancer Patients after Gastric Resection

Background

The prognosis of patients with positive surgical resection margins is dismal in gastric cancer. However, the influence of positive margin itself on prognosis is still uncertain, especially in advanced gastric cancer (AGC). The aims of the present study were to evaluate the prognostic impact of microscopic tumor involved resection margins in stage III–IV AGC after gastric resection in comparison with other well-known factors.

Methods

Among 1,536 consecutive gastric cancer patients who received intentional curative resection for stage III–IV AGC between April 2001 and December 2011 at the National Cancer Center, 35 patients (2.28 %) had positive resection margins on their final histology. A comparison of clinicopathologic characteristics, recurrence pattern, overall survival (OS), and disease-free survival (DFS) was made between positive margin (PM) patients and negative margin (NM) patients.

Results

Among the 35 PM patients, 15 (42.9 %) had proximal involved margins, 21 (60.0 %) had distal involved margins, and one (2.9 %) had both involved margins. Twenty-eight PM patients (80.0 %) were stage III, and 7 (20.0 %) were stage IV. Recurrence was significantly higher in PM than NM (63.6 % vs. 39.7 %, respectively; p = 0.005). The OS and DFS rates were significantly lower in the PM group than in the NM group (14.9 vs. 36.3 months, p < 0.001 and 11.6 vs. 27.1 months, p = 0.005, respectively). The presence of PM was an independent risk factor for both OS and DFS.

Conclusions

The presence of PM is an independent risk factor for OS and DFS. Considering the prognostic impact of PM, a sufficient resection margin should be ensured when determining the resection line in gastrectomy with curative intent. The reoperation to secure clear resection margins should be considered as a treatment of choice in the case of PM.