腹腔镜下残胃癌及残胃复发癌的外科治疗

目的探讨残胃癌及残胃复发癌腹腔镜手术治疗的可行性。方法对4例残胃癌和4例残胃复发癌病人行腹腔镜手术切除，分析手术的方式、方法、难点及技术要领。结果在腹腔镜下完成根治性全胃切除6例，行姑息性全胃切除1例，中转开腹1例。腹腔镜手术平均用时（310±50）min，术中平均出血量（190±80）ml，清扫淋巴结平均数量（17．5±6）枚。术后胃肠恢复时间平均（3．5±1．5）d，进食时间平均（3．5±1．5）d，下床活动时间平均（4±1．5）d。无手术并发症。随访时间4～13个月，发生肝脏转移死亡1例，余7例病人仍生存。结论残胃癌和残胃复发癌在腹腔镜行手术切除技术上是可行的，创伤比开腹手术小，恢复快。     

Minimally invasive surgery for gastric cancer

BACKGROUND: The use of laparoscopic surgery in the treatment of gastric cancer has not yet met with widespread acceptance; thus, it should be regarded as still in the developmental phase. Nevertheless, the laparoscopic approach appears to have some valuable advantages for the management of gastric cancer patients, and it can be expected to have a dramatic impact on public health expenditures. Herein we present the results of our experience with laparoscopic and laparoscopy-assisted gastrectomies for cancer, and we discuss the role of these procedures in current surgical practice. METHODS: Between June 1993 and November 1997, we performed a total of 13 laparoscopic procedures on 13 patients affected with gastric carcinoma. There were eight male and five female patients with a mean age of 65.4 years (range, 42-78). All patients were staged preoperatively with US and CT scan and required to sign a formal consent. RESULTS: Altogether we performed nine D1 laparoscopic total gastrectomies, seven of which were done with a laparoscopy-assisted approach; three D2 laparoscopy-assisted total gastrectomies, associated in one case with a distal pancreasectomy; and one laparoscopy-assisted distal gastrectomy performed on a morbid obese patient. The preliminary laparoscopic staging allowed for a better definition of tumor extension and identification of undetected hepatic metastases in two patients. The mean duration of the intervention was 240 min. Blood losses were as high as 300 cc on average. We recorded one major intraoperative complication, consisting of an inadvertent injury to the proper hepatic artery, which was successfully repaired by the same laparoscopic route. The postoperative course was uneventful in all patients but one, who died of acute hepatic failure on day 6. At a mean follow-up of 27.5 months, 11 patients are still alive. Two of them have hepatic metastases and nine are disease-free. CONCLUSIONS: Although they remain challenging procedures, laparoscopic gastrectomies appear to be oncologically adequate. We believe that a pure laparoscopic approach should be reserved for low-stage lesions (N0, up to T2), while a combined approach is preferable for locally advanced cancer (N1 or higher, T3 or higher). Much work still needs to be done to establish the optimal strategy in both open and laparoscopic surgery, but laparoscopy can be a valuable tool in the decision-making process for patients affected with gastric malignancies.     

早期胃癌的微创外科治疗

开腹手术一直是早期胃癌的有效治疗方式,但开腹手术创伤大,术后并发症多,如何降低早期胃癌手术的创伤、减少并发症一直是外科医师致力解决的问题.随着早期胃癌发现率的提高和微创外科技术的发展,越来越多的外科医师和患者倾向于使用微创技术治疗早期胃癌.早期胃癌微创治疗方式多样,从当前文献报道来看都取得了不错的进步,但也都存在不足....     

Minimally invasive gastric surgery

The most common indications for gastric resection remain benign ulcer disease and neoplasm. Surgery for these diseases can be performed safely with laparoscopy. As surgeons adhere to the original tenets of open gastric resections while performing laparoscopic resections, disease outcomes will remain the same with the improved surgical outcomes of less pain, a shorter hospital stay, and a lower incidence of wound complications. Laparoscopic gastric resections can be divided into the more straightforward wedge/tumor resections performed for submucosal tumors or the more formal anatomic gastric resections. This article reviews the tools and techniques for laparoscopic gastric resection.     

Minimally invasive surgery for gastric tumors

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric tumors, including gastric cancer and gastric gastro-intestinal submucosal tumor (GIST). Although laparoscopic gastric resection for gastric tumors has not been accepted worldwide, its use has definitively increased due to its reduced invasiveness. The most common procedures are laparoscopy-assisted distal gastrectomy (LADG) for cancer and laparoscopic gastric resection as a standard of care for gastric tumors, multicenter randomized controlled clinical trials are needed to evaluate its short- and long-term outcomes.     

Minimally invasive surgery in the treatment of gastric cancer

Unlike benign pathology, progress of laparoscopy in performing cancer surgery has been slow because of fear of safety and oncological adequacy. However, the initial fear has been replaced by optimism as the results from a numerous studies have shown equivalent if not superior results to open surgery. Laparoscopic gastrectomy is safe and oncologic adequate, but time consuming and technically demanding procedure. Laparoscopic surgery has gained wide acceptance in the treatment of early gastric cancer, especially of the distal stomach. The use of laparoscopic surgery for the treatment of advanced gastric cancer remains controversial. Another open question that need complete evaluation is cost-effectiveness analysis of minimally invasive and open approach.     

Minimally invasive surgery for rectal cancer

The present scarcity of literature on laparoscopic rectal cancer surgery makes it premature to determine whether laparoscopic surgery should be the standard of care for rectal cancer. Notwithstanding that, the available evidence proves its safety and adequate oncological clearance. Moreover, current data do not suggest any detrimental effect on the postoperative and early oncological outcomes. On the contrary, there is level three evidence showing that laparoscopic technique results in less blood loss, shorter length of stay, and reduced abdominal wound disorders and pulmonary complications, albeit the overall morbidity remains similar to that of open surgery. Long-term survival outcomes remain largely unclear, however. Hence, it is high time that laparoscopic technique should be further evaluated, preferably by means of large-scale randomized trials, to define its exact role in the treatment of rectal cancer.     

胃癌外科的微创技术策略

<正>国际癌症研究机构(international agency for research on cancer,IARC)提供的2018年全球癌症负担现状报告(GLOBOCAN)显示,胃癌是位列全球新发病例第五位、死亡病例第三位的恶性肿瘤[1]。我国是胃癌大国,每年新发病例67.9万例,约占全球50%,诊断时大部分处于进展期[2- 3]。腔镜手术具有独特的微创优势,近年在中国的临床实践中获得迅速发展,但是与同为胃癌高发国的日本和韩国相比,中国     

Minimally invasive surgery for posterior gastric stromal tumors

Background: Because involvement is extremely rare, surgery for gastric stromal tumors consists of local excision with clear resection margins. The aim of this study was to report the results of a consecutive series of nine patients with posterior gastric stromal tumors that were excised using a minimally invasive method. Methods: Patients received a general anesthetic before placement of three laparoscopic ports— a 10-mm (umbilical) port for the telescope and two working ports, a 12-mm port (left upper quadrant) and a 10-mm port (right upper quadrant). Grasping forceps were placed through an anteriorly placed gastrotomy to deliver the tumor through the gastrotomy into the abdominal cavity, thus allowing an endoscopic linear cutter to excise the tumor with a cuff of normal gastric tissue. Results: Nine consecutive patients with a median age of 73 years (range, 47–83) were treated. In seven patients, laparoscopic removal of the tumor was achieved. Two patients required conversion to an open operation because the tumor could not be delivered into the abdominal cavity. The median length of postoperative stay for the seven patients in whom the procedure was completed laparoscopically was 3 days (range, 2–6). Conclusions: Posterior gastric stromal tumors can be removed safely using this minimally invasive method. Delivery of the tumor through the gastrotomy is essential for success. Received: 30 April 1999/Accepted: 12 July 1999     

Minimally invasive surgery for lung cancer with coronary artery disease

We report a 69-year-old woman with lung cancer and severe stenosis in the left anterior descending coronary artery. To perform a curative operation for the lung cancer without myocardial infarction, minimally invasive direct coronary artery bypass and left lower lobectomy with video-endoscopic assistance were performed simultaneously. There was no major complication, and she was discharged at 14 days after the operation. This procedure may be useful and safe for patients with lung cancer and coronary artery disease.     

乳腺癌的微创手术

乳腺癌的微创治疗,在乳腺疾病患者术后的精神和心理康复方面具有常规手术难以达到的突出效果,可能使外科医生长期追求的创伤更小、治疗效果更好、在治愈疾病的同时兼顾患者的美观和心理效应的手术目标得以实现,这正是乳腺癌临床治疗实践的美好愿望,更是乳腺外科发展总的趋势。     

Minimally invasive surgery for gastric stromal cell tumors: intermediate follow-up results

Laparoscopic wedge resection of the stomach (LWS) has become the treatment of choice for patients with benign gastric tumors. The technical consideration and long-term follow-up data of LWS for gastrointestinal stromal tumors (GISTs) of the stomach are limited. We present our experience of 28 LWSs for gastric GISTs with a mean follow-up of 43 months. From October 1995 to December 2002, we successfully performed 28 LWSs for 29 patients with GISTs of the stomach, and one patient needed conversion to laparotomy because of suspected bowel injury when establishing pneumoperitoneum. Patient demographics, perioperative parameters, and outcomes of the 28 patients were assessed retrospectively. The tumors were located in the upper third of the stomach in 13 patients, in the middle third, in eight patients, and in the lower third, in seven patients. The mean size of tumors was 3.4 ± 1.6 cm in diameter. The duration of operation ranged from 95 to 390 minutes: 189.6 ± 79.5 minutes with the stapler method and 194.3 ± 50.5 minutes with the hand-sewn method (P = 0.8870). No blood transfusion was given in the perioperative period in all cases. Cholecystectomy in three patients and repair of hiatal hernia in one patient were performed during the same operation. The oral intake was restored at the third to fourth postoperative days. The hospital stay ranged from 3 to 11 days (mean, 6.7 ± 1.8 days). The follow-up period ranged from 12 to 95 months (mean, 43.3 ± 23.5 months, median 42 months). There has been no evidence of tumor recurrence, including one patient with microscopic invasion of section margin. LWS can be performed safely with a satisfactory remission rate for patients with gastric stromal cell tumors. Presented at the 94th Annual Meeting of the Surgical Association of Taiwan, March 27, 2005, Tao-Uan, Taiwan.     

Minimally invasive surgery for esophageal cancer: a review on sentinel node concept

Background

Lymphoadenectomy is a cornerstone of esophageal cancer treatment, and sentinel node (SN) biopsy (SNB) might provide surgeons with an extra tool to limit unnecessarily extended lymphadenectomy and to implement a minimally invasive approach. The aim of our study was to review all the available literature on the use of SNB in esophageal surgery for malignancy.

Methods

The review was conducted according to the PRISMA guidelines. A systematic search was performed in PubMed, EMBASE, and the Cochrane database to identify all original articles on the role of SNB in esophageal cancer. Data on methodologies, tumor stage and localization, and results were summarized and used to address relevant clinical questions related to the application of the SNB technique in esophageal cancer.

Results

Twelve studies were included, with a total of 492 patients. Different methods for SN identification were used (radionuclide, blue dye, computed tomography [CT] lymphography). The pooled values estimated using the random-effects model were, respectively: technetium-99 m overall detection rate (DR) 0.970 (95 % CI 0.814–0.996), accuracy (ACC) 0.902 (95 % CI 0.736–0.968); blue-dye DR 0.971 (95 % CI 0.890–0.993), ACC 0.790 (95 % CI 0.681–0.870); and CT lymphoscintigraphy DR 0.970 (95 % CI 0.814–0.996), ACC 0.902 (95 % CI 0.736–0.968).

Conclusion

Based on these results, the concept of SN in esophageal cancer is technically feasible with an acceptable DR and ACC, and it might be applicable in the event of early-stage adenocarcinoma of the gastroesophageal junction in patients with a high surgical risk or in a patient where an endoscopic resection is taken into consideration. Further studies focused on a single tumor type and localizations are needed in order to predict the correct utilization of this concept in minimally invasive treatment of esophageal cancer.