腹腔镜胃窦癌根治术13例报告

目的：探讨腹腔镜辅助下胃癌根治术的安全性及可行性。方法：对2007年11月至2008年10月期间完成的13例腹腔镜辅助胃窦癌根治术的临床资料进行回顾性分析。结果：13例患者全部在腹腔镜下成功完成手术,手术时间平均为206min。所有标本经病理检查切缘均为阴性,平均每个患者清扫淋巴结13．3枚,术后患者排气时间平均为74．6h,患者下床活动时间平均为69．2h,术后人均镇痛次数为0．77次。未出现吻合口漏、腹腔内出血、消化道出血、肺部感染、切口感染或裂开及切口种植等并发症。结论：使用腹腔镜辅以小切口完成胃癌根治手术,患者痛苦小、恢复快、疗效好。     

腹腔镜辅助下进展期胃癌根治术临床分析（附6例报告）

目的:探讨腹腔镜辅助下进展期胃癌根治术的安全性及可行性.方法:6例进展期胃癌患者均行腹腔镜辅助下根治性远端胃大部切除术.结果:6例患者均成功进行腹腔镜手术.无中转开腹.手术用时(251±24)min,术中出血量(185±65)mL,清扫淋巴结(14.5±5.7)枚/例.术后患者平均下床活动时间(1.8±0.6)d,胃肠功能恢复时间为(3.8±1.2)d,术后效果良好,没有近期并发症发生.结论:腹腔镜进展期胃癌根治术具有创伤小、术后恢复快等优点,安全、有效,可行性好.     

78例胃窦癌的治疗分析

自１９８８年２月至１９９２年８月期间手术治疗的７８例胃窦癌患者进行了回顾性分析，手术后肿瘤复发的情况，与十二指肠断端有无癌细胞残存密切相关，并发现于幽门环下切断十二指肠少于３ｃｍ者有癌细胞残存达３４％，切除十二指肠达３ｃｍ者，无论肿瘤分化程度如何，恶性程度高低，切除断端均无癌细胞残存，手术后辅以化疗，对于病人的预后有一定提高。本组随访到的５９例病人中，接受化疗的３３例，在２年３个月至６年１个月内死亡７例（２１．２％），未接受化疗的２６例，在５个月至３年８个月内死亡的２６例，在５个月至３年８个月内死亡９例（３５％）。     

急性早幼粒细胞白血病同时合并胃窦癌1例

1 病例介绍 患者,男性,61岁,因左上腹不适1个月伴消瘦15d于2002年4月9日入消化内科.1月前无明显诱因出现食欲不振,左上腹不适,轻度乏力和头昏,无发热,无鼻出血及皮肤黏膜出血,无骨和关节疼痛.查体:体温正常.轻度贫血貌,浅表淋巴结不大,巩膜无黄染,胸骨无压痛,心肺无明显异常,腹软,剑突下压痛明显,无肌紧张,肝脾肋下未触及.     

后腹腔镜下肾癌根治术60例临床观察

[目的]探讨后腹腔镜在肾癌根治术中的应用。[方法]对60例行后腹腔镜下肾癌根治术肾癌患者进行回顾性分析。[结果]60例肾癌患者,59例手术成功,1例中转开放手术。手术平均时间173．5min（95～300min）;失血量50～1500ml,中位失血量175ml;术后住院4～12d,平均7．2d。术后随访7～32个月,平均17个月。60例患者全部生存,无一例肿瘤局部复发或切口种植转移。[结论]后腹腔镜下肾癌根治术具有创伤小、恢复快等特点,是肾癌外科治疗的发展方向。     

超声显像对胃窦癌诊断价值的探讨

目的探讨超声诊断胃窦部癌诊断价值.方法检查前禁食12小时,病人饮水500～800ml后通过超声显像诊断胃窦部癌进行回顾性分析.结果超声诊断与手术病理证实为86.6%.结论超声显像诊断胃窦部癌是一种有效的、无痛苦的、简便易行的方法.     

腹腔镜治疗胃类癌35例临床分析

目的:探讨胃类癌的诊断、腹腔镜外科治疗及患者预后。方法:兰州军区兰州总医院普外科2009年10月至2014年6月收治的35例胃类癌患者行腹腔镜手术治疗,观察其疗效及预后。结果:35例患者腹腔镜手术均顺利,术后出现肺部感染、胸腔积液2例,吻合口瘘1例,积极处理后痊愈出院,术后病理结果提示符合胃类癌。结论:胃类癌具有生长缓慢、恶性程度相对较低、临床表现不典型、预后相对其他消化道肿瘤较好的特点,腹腔镜下胃类癌手术治疗,疗效满意。     

腹腔镜下保留神经宫颈癌根治术的近期疗效

目的:探讨腹腔镜下保留神经的广泛性子宫切除术(SNSRH)治疗早期宫颈癌的近期疗效.方法:选取我院从2015年12月至2016年12月收治的100例早期富颈癌患者,按照随机对照原则分为腹腔镜下保留神经的广泛性子宫切除术(SNSRH组)和腹腔镜下广泛性子宫切除术(LRH组),分析术后近期疗效.结果:两组患者手术均顺利进行,两组患者的手术时间、淋巴结清扫数目、术中出血量比较,差异无统计学意义(P＞0.05);SNSRH组患者术后排气时间、术后排便时间、拔出尿管时间、膀胱功能恢复时间、术后住院时间较LRH组患者明显缩短,差异具有统计学意义(P＜0.05);两组患者术后膀胱功能障碍比较:LRH组患者术后伴有更明显的间断排尿、腹压排尿、尿失禁、尿潴留症状(P＜0.05);对于尿频症状,无统计学差异(P＞0.05).结论:腹腔镜下保留神经的宫颈癌根治术的近期临床疗效好,值得在临床上应用和推广.     

肾细胞癌合并腔静脉癌栓诊治体会（5例报告并文献复习）

目的:探讨肾细胞癌合并腔静脉癌栓患者临床特点、诊断、综合治疗原则。方法:回顾性分析我院收治的5例肾细胞癌合并腔静脉癌栓患者临床资料并文献复习。其中3例接受开放肾癌根治性切除+癌栓取出术,1例接受腹腔镜下肾癌根治性切除+癌栓取出术,1例行靶向药物治疗。结果:4例手术均成功,手术平均时间213.7 min（135~315） min,术中平均出血量1 650.0 ml（600~3 500） ml,术后病理学诊断均为肾透明细胞癌,术中、术后未出现明显并发症,平均随访时间为12.2(5~30)个月,影像学复查未见明显复发、远处转移表现。结论:肾细胞癌合并腔静脉癌栓患者治疗上以根治性手术为主,条件合适患者可采用腹腔镜等微创手术方式,术前充分评估,术中多学科合作、严密监测、预防癌栓脱落,术前采用新辅助靶向药物治疗可能降低癌栓等级、手术难度。     

Laparoscopic gastrectomy for distal gastric cancer

This video presents a standard D2 laparoscopic-assisted gastrectomy for distal gastric cancer. The lymph node dissection of each station is performed as required in the standardized procedure of distal gastrectomy, followed by the Billroth II anastomosis through a small incision.Key Words: Laparoscopy, radical gastrectomy, lymph node dissectionLaparoscopic radical gastrectomy is indicated in patients with early gastric cancer. Laparoscopic-assisted D2 radical gastrectomy is the standard surgical approach in the management of such condition, particularly in early gastric cancer. For lymph node dissection, the second station should also be included during the treatment of early gastric cancer.The patient is a 54-year-old man admitted for “repeated epigastric pain for one year which worsened for one week”. Physical examination revealed no positive signs or palpable lymph node enlargement. Laboratory tests showed no abnormalities in the blood testing. Gastroscopy showed a 1 cm ulcer at the gastric angle, and indicated reflux esophagitis. Gastroscopic pathology showed mucosal erosion at the gastric angle complicated with high-grade intraepithelial neoplasia, and localized cancer.In this video (Video 1), as the early gastric cancer is not readily located via palpation with laparoscopic instruments, an additional astroscope is used to identify the lesion and mark it with Hemo-lock on the gastric wall. After the tumor is located, the greater omentum is separated from the middle part of the transverse colon using an ultrasonic scalpel along the left half of the transverse colon towards the splenic flexure. After the omentum at the splenic flexure is divided, the separation is continued towards the splenic hilum, and the left omental vessels are clamped at the roots with Hemo-lock clips and cut. Station number 4sb lymph nodes are dissected, and the gastrosplenic ligament is then divided with Ligasure. The first branches of the short gastric vessels are transected, and station number 4sa lymph nodes are dissected. The greater omentum is then separated along the greater curvature. Station number 4d lymph nodes are dissected. After dissection of the left side, the greater omentum and the right half of the anterior lobe of the transverse mesocolon are separated towards the right side to expose the gastrocolic trunk, and the right gastroepiploic vein at the root is transected. This process is completed with caution to avoid injury to the anterior superior pancreaticoduodenal vein. Following separation of the right omental vein, the right omental artery is divided upwards along the surface of the pancreatic head. The head of the pancreas is located at a significantly higher position in this patient, so caution is needed to avoid mistaking the pancreas for lymph nodes during dissection. Therefore, the posterior wall of the duodenum and the pancreatic capsule are first separated to expose the gastroduodenal artery before dividing the right gastroepiploic artery. The right gastric artery is transected at the root, and station number 6 lymph nodes are dissected. The division is continued towards the anterior edge of the pancreas along the surface of the gastroduodenal artery to expose the common and proper hepatic arteries. With further division in the space over the surface of the gastroduodenal artery using separation forceps, the right gastric vein is cut with an ultrasonic scalpel. The right gastric artery is then exposed at the anterior region of this space and transected. Station number 12a lymph nodes are dissected. Station number 8a lymph nodes are dissected along the surface of the common hepatic artery. The celiac trunk and the splenic artery are exposed, and stations number 9 and 10 lymph nodes are dissected. The gastric coronary vein and the left gastric artery are cut at their roots. Station number 7 lymph nodes are then dissected. Tissue in the posterior pancreatic space is divided along the upper edge of the pancreas. Fat and lymph nodes posterior to the common and proper hepatic arteries are dissected, and stations 8p and 12p are removed en bloc. After the hepatogastric ligament is separated along lower edge of the liver, the tissue over the surface of the proper hepatic artery is divided through to the upper edge of the duodenum. Stations number 5 and 12 lymph nodes are dissected. Stations 1 and 3 are then dissected along the lesser curvature. The duodenum is transected using an ENDO-GIA stapler. A central incision of 6 cm is made to the upper abdomen, and the gastric wall 5 cm away from the ulcer is transected. Billroth II anastomosis of the stomach to the jejunum is conducted.Open in a separate windowVideo 1Laparoscopic gastrectomy for distal gastric cancerPostoperative pathology showed moderately to poorly differentiated adenocarcinoma at the gastric angle (superficial depressed type), with invasion to the submucosa. No tumor tissue was present in the surgical margin. Metastases were found in lymph nodes of the lesser curvature (2/11), but not in those of the greater curvature (0/5). No metastasis was detected in the other lymph nodes (0/6). pTNM stage: (T1bN1M0, IB).The patient got off the bed after the gastric tube was removed the second day after surgery, and began normal diet from the third day. He was discharged on the sixth day after surgery.     

Laparoscopic-assisted radical gastrectomy for distal gastric cancer

A 48-year-old female patient was diagnosed with a superficial depressed type early gastric cancer (type IIc) of 1.0 cm at the gastric angle as indicated by gastroscopy. Laparoscopic-assisted greater omentum-preserving D2 radical gastrectomy was performed in combination with Billroth I reconstruction under general anesthesia for the distal gastric cancer on April 5, 2013. The postoperative recovery was satisfying without complications. The patient was discharged seven days after surgery.Key Words: Early gastric cancer, gastrectomy, laparoscopic-assisted, D2 lymph node dissectionAs a novel minimally invasive surgical technique, laparoscopic radical gastrectomy is associated with such advantages as less injury, reduced postoperative pain, lower impact on immune function, rapid recovery of gastrointestinal function, and short hospital stay. In 1997, Goh and coworkers conducted D2 radical gastrectomy for advanced gastric cancer under laparoscope, which demonstrated the safety and feasibility in terms of the technique. In their reviews, Topal (1) and Huscher (2) also confirmed the above conclusion, and they suggested that the long-term survival outcomes of laparoscopic-assisted radical gastrectomy were similar to those of open surgery. Laparoscopic-assisted radical gastrectomy has now been recognized for treating gastric cancer with an invasion depth of T2 or less, without evidence of lymph node metastases in preoperative examination (3). On April 5, 2013, we conducted laparoscopic-assisted gastrectomy for a patient with early gastric cancer (type IIc). The postoperative recovery was satisfying. The details are as follows:A 48-year-old woman was admitted to our hospital due to “upper abdominal dull pain with acid reflux for more than a month”. Gastroscopy suggested a superficial depressed type early gastric cancer of 1.0 cm at the gastric angle. Biopsies indicated adenocarcinoma at the gastric angle. Endoscopic ultrasound indicated disordered structure of the submucosal layer of the gastric lesion at the gastric angle. CT scan suggested slightly thickened gastric wall at the gastric angle, without enlargement of lymph nodes around the stomach or liver metastasis. Preoperative staging: T1bN0M0. On April 5, 2013, laparoscopic-assisted D2 radical gastrectomy was conducted under general anesthesia for the distal gastric cancer.During the surgery (Video 1), the patient was placed in a supine position with legs apart. Following general anesthesia, CO₂ pneumoperitoneum was established at 12 cm water column. Laparoscopic exploration showed no peritoneal dissemination or liver metastasis nodules, so the surgeons decided to perform D2 radical resection while preserving the greater omentum. The gastrocolic ligament was cut open 2-3 cm away from the greater curvature through to the lower pole of the spleen. The left gastroepiploic vessels were denuded, and the left gastroepiploic artery was ligated and cut at the root. The station number 4sb lymph nodes were dissected. The greater curvature was denuded, and station number 4d lymph nodes were dissected.Open in a separate windowVideo 1Laparoscopic-assisted radical gastrectomy for distal gastric cancerThe lymph nodes in the inferior area of the pylorus were then dissected. The station number 14v lymph nodes were typically not dissected in the standard D2 radical surgery. The anterior pancreaticoduodenal fascia was stripped close to the head of the pancreas to reveal the right gastroepiploic vein. During the separation, the non-working face of the ultrasonic scalpel was pointed towards the pancreas. Caution was made to avoid injury to the small vessels on the surface of the pancreas, particularly to the anterior superior pancreaticoduodenal vein. The right gastroepiploic vein was denuded, and transected before its junction with the pancreaticoduodenal vein. The right gastroepiploic artery was then denuded. The small vessels and subpyloric vessels emerging from the gastroduodenal artery and entering the posterior wall of the duodenum were treated first. This could reduce bleeding when separating the right gastroepiploic artery. After the right gastroepiploic artery was denuded, ligated and cut, the lower edge of the duodenum was denuded, and the station number 6 lymph nodes were dissected. The gastroduodenal artery was stripped to its root in an inverse direction. The common hepatic artery was dissected, and the right gastric artery was separated near the bifurcation, but was not transected for the moment.A piece of sterile gauze was placed on the lesser sac to flip the stomach downward. The pylorus and the superior region of the duodenum were denuded, then the small omentum was opened, and the gauze was clearly visible. The duodenum was first transected, and the stomach was flipped to the left side to reveal the structure more clearly from the upper edge of the pancreas to the posterior wall of the lesser sac.The anterior hepatoduodenal capsule was opened and the proper hepatic artery was divided. The right gastric artery was further denuded, ligated and cut at the root. The station number 5 lymph nodes were dissected. With the assistant gently lifting the gastropancreatic fold, the surgeon began to separate the superficial fascia on the upper edge of the pancreas. The gastropancreatic fold was dissected, and the coronary vein and the left gastric artery were denuded. After the coronary vein was denuded, a clamp was applied to the root and the vessel was transected. The left gastric artery was denuded from the periphery. An absorbable clamp was applied to 0.5 cm above its root and the vessel was transected so that the clamp would not slip off. The station number 7 lymph nodes were dissected.The lesser sac was opened until the right edge of the cardia. The peritoneal reflection was opened to the anterior part of the right crus of the diaphragm to provide an accurate anatomic plane for the subsequent dissection of the station number 9 lymph nodes. The station number 12a lymph nodes were then dissected. The proper hepatic artery was gently pulled to the right side, and the fascia to the left was separated to naturally reveal the left anterior wall of the portal vein. The separation was continued along the upper edge of the fascia from the left side of the portal vein to the celiac artery, during which the stations number 12a and 8a lymph nodes were dissected en bloc. After the dissection, the entrance of the portal vein, splenic vein and coronary vein was clearly visible. The two stations were gently retracted to the left side, and the lymph nodes to the right of the celiac artery were dissected along the plane established anterior to the crus in the above steps, and the anterior region of the celiac artery was then dissected.Afterwards, the lymph nodes proximal to the splenic artery were then dissected (number 11p). The fascia at the upper edge of the pancreas was separated towards the pancreatic tail to expose the splenic artery. It should be noted that there were several curves along the splenic artery to the splenic hilum, especially the largest one of 3 to 4 cm to the root, which was hidden behind the pancreas with lymph nodes inside that should not be omitted. Hence, we dissected the lymph nodes surrounding the splenic artery from both the anterior and the posterior directions. The dissection from posterior to anterior areas beginning from the left crus of the diaphragm would help ensure that the lymph nodes at the curves were not omitted. The supplying vessels along the lymph nodes around the splenic artery could be directly transected with the ultrasonic scalpel. After dissection, the lymph nodes were lifted to the anterior right side. The separation was then continued towards the cardia so that lymph nodes to the posterior and right of the cardia could be dissected. The right side of the cardia and the lesser curvature of the stomach were denuded, and the stations number 1 and 3 were dissected. At this point, the laparoscopic operation was is complete. An auxiliary incision of about 5 cm was made inferior to the xiphoid for the removal of the entire specimen. A Tyco 25# circular gastrointestinal stapler was used to complete the Billroth I anastomosis.The whole operation lasted 3 hours and 10 minutes, with intraoperative blood loss of 20 mL, and no blood transfusion was delivered. The patient was able to ambulate three days after surgery. Liquid diet was prescribed on the 5th day and semi-liquid diet on the 6th day. The patient was discharged seven days after surgery without postoperative complications. Postoperative pathology showed a superficial depressed type moderately to poorly differentiated adenocarcinoma with superficial ulceration at the junction of the antrum and the gastric body on the lesser curvature side (size 1 cm × 1 cm × 0.2 cm), invading the submucosa. Chronic inflammation was noted in 2 (suprapyloric), 1 (subpyloric), 5 (lesser curvature), 3 (greater curvature), 2 (close to the left gastric artery), 1 (close to the common hepatic artery), 2 (close to the splenic artery), 2 (close to the celiac artery), 1 (12a), 1 (4sb), and 2 (to the right of the cardia) lymph node. Both upper and lower margins were negative. Postoperative pathological staging was T1bN0M0.     

Two-stage radical gastrectomy for perforated gastric cancer

Introduction Perforation represents a severe complication of gastric cancer. Because it is rare, only few data are available regarding treatment and prognosis. Methods Patients with perforated gastric cancer were identified from two prospective registers of gastric cancer and of gastroduodenal ulcer. Results Between February 1982 and June 1999 23 patients with perforated gastric cancer were treated surgically. This corresponds to only 1.8% of 1273 patients presenting with gastric cancer, but to 14% of 161 patients presenting with gastric perforation during this time period. Overall, post-operative mortality was 13% (3/23). Initially, 21 patients had palliative operations. Two patients had a potentially curative procedure at the emergency operation and one of the two died post-operatively. Another six patients had potentially curative gastrectomy at a second stage and no patient died post-operatively. The 5-year overall survival was estimated at 50% for all eight curatively-treated patients. Median survival of palliatively treated patients was 6 months.Conclusions Perforation of the stomach should raise suspicion of malignancy, particularly in elderly patients. At the time of perforation radical gastrectomy with lymphadenectomy is mostly not advised, either because a diagnosis of gastric cancer is not confirmed or because the patient's condition does not allow extended surgery. In this situation it is suggested to consider a two-stage procedure and direct the primary operation at the treatment of perforation and peritonitis. Tumour staging can be completed when the patient has recovered and a radical operation with curative intent can be planned without compromising long-term prognosis. Our observations and a review of the literature confirm that perforation of gastric cancer does not preclude long-term survival per se in a substantial number of patients.     

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.     

Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer

Background

Proximal gastrectomy is not routinely performed because it is associated with increased reflux symptoms and anastomotic strictures. The purpose of this study is to describe a novel method of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) for proximal early gastric cancer (EGC), and to evaluate the technical feasibility, safety, and short-term surgical outcomes, especially reflux symptoms, after LPG.

Methods

Retrospective review of the prospective cohort data of 43 patients who presented to a single tertiary hospital from June 2009 through April 2012 and underwent LPG with DTR for proximal EGC. The data of this prospective cohort were analyzed, and the reflux symptoms, clinicopathologic characteristics, surgical outcomes, postoperative morbidities and mortalities, and follow-up findings were analyzed.

Results

The mean surgical time was 180.7 min; mean estimated blood loss, 120.4 mL; mean length of the proximal resection margin, 4.13 cm; mean number of retrieved lymph nodes, 41.2; and mean postoperative hospital stay, 7.1 days. Early complication rate was 11.6 % (n = 5); major complication (grade higher than Clavien-Dindo IIIa) occurred in 1 patient (2.3 %). Late complication rate was 11.6 % (n = 5): 2 patients had esophagojejunostomy stenosis, which was successfully treated with fluoroscopic balloon dilatations; 1, chylous ascites; and 2 had Visick grade II reflux symptoms (4.6 %), managed by medication during the mean follow-up period of 21.6 months.

Conclusion

DTR after LPG is a feasible, simple, and novel reconstruction method with excellent postoperative outcomes in terms of preventing reflux symptoms. Its clinical applicability must be validated by prospective randomized trials.     

腹腔镜辅助胃癌根治术的学习曲线

目的 探讨腹腔镜辅助胃癌根治术的学习曲线.方法 回顾性分析2007年1月至2008年11月我科开展腹腔镜辅助胃癌根治术以来150例患者的临床资料,按手术先后顺序分3组(A、B、C组),每组50例,对各组患者的手术时间、术中出血量、中转开腹率、淋巴结清扫数目、术后肛门排气时间、术后住院天数和术后并发症发生率等进行比较.结...     

注射用血凝酶在腹腔镜胃癌根治术中止血作用的临床研究

目的 探讨注射用血凝酶(巴曲亭)在腹腔镜胃癌根治术中和术后止血效果及对凝血功能的影响.方法 选取行腹腔镜手术治疗的28例胃癌患者,随机分为血凝酶组和对照组.观察两组创面止血时间、术中出血量、术后3天创面出血渗血量及对患者凝血功能的影响.结果 血凝酶组患者创面止血时间、术中出血量、术后3天创面出血及渗血量均明显少于对照组(均P＜ 0.05);两组术前和术后凝血功能差异无统计学意义(P＞0.05).结论 血凝酶在腹腔镜胃癌手术术中及术后具有良好的止血效果,对患者凝血功能无影响,临床应用安全有效.