Pancreaticoduodenectomy in combination with right hemicolectomy for surgical treatment of advanced gastric carcinoma located in the lower half of the stomach.

The results of surgical treatment of patients with gastric carcinoma infiltrating into the duodenum and the pancreas head and with N3 metastases are very poor. We have employed pancreaticoduodenectomy in combination with right hemicolectomy (PD + LH) with the aim of leaving no remnant of cancer cells in the vicinity of the primary lesion, in patients with carcinomas of the distal third of the stomach, associated with duodenal invasion, presence of fixity to the pancreas head or N3 metastases, in the last ten years. Twenty-six cases were treated with this technique (Group A). These cases were compared with 63 patients who underwent subtotal gastrectomy (Group B) in the same period. The operation time, amount of blood loss and numbers of operative complications were greater in Group A than in Group B. Operating mortality was found in 2 cases in Group B but was 0 for Group A. When the survival rates were compared, PD + LH can provide better long-term results than subtotal gastrectomy, especially in the patients with tumors infiltrating into the pancreas head or metastasizing to N3. The PD + LH is a rational and safe method for the treatment of gastric carcinoma infiltrating into the pancreas head or metastasizing to N3.     

Surgical results of pancreaticoduodenectomy for carcinoma of the distal third of the stomach.

Pancreaticoduodenectomy (PD) was performed as a radical operation on 10 patients who had stage III or IV carcinoma of the distal third of the stomach which invaded the pancreas head (T4) or had level 3 lymph node metastasis. The surgical results of the PD were compared with those of 69 patients treated with subtotal gastrectomy (SG). Although the postoperative morbidity was higher (70%) in the PD group than in the SG group (32%), no hospital death occurred. The overall postoperative survival provided by PD was as good as that provided by SG for 43 patients who had stage III or IV tumors (the 5-year survival rates, 40 versus 45%). Regarding the T4 tumors invading the pancreas, the survival of the 9 patients with PD was better than that of the 12 patients with SG (median survival time, 19 versus 9 months). Thus, PD might improve the postoperative survival of patients with carcinoma of the distal stomach invading the pancreas.     

Treatment of patients with gastric cancer and duodenal invasion

We retrospectively examined clinicopathologic features of gastric cancer with duodenal invasion to clarify the effect of surgical treatment that include pancreaticoduodenectomy (PD). Among 2504 patients with gastric cancer, 69 (2.8%) who had gastric cancer and duodenal invasion resected by surgical treatment were investigated. The mode of the duodenal invasion was grouped into three categories: mucosal type, submucosal type, and nodal type. Mucosal type is invasion of the duodenal mucosal layer, submucosal type is invasion of the submucosal layer or deeper, and nodal type is invasion from nodal metastatic lesions around the pancreatic head. The 5-year survival rates of curative PD and curative gastrectomy were 37.3% and 33.8%, respectively. Despite the incidence of adjacent tissue infiltration and significantly higher duodenal invasion average length in cases with PD than in cases with gastrectomy, there was no significant difference in the survival curves. However, the prognoses of the cases with nodal-type invasion were significantly poorer, and all these patients died within 2 years, regardless of whether curative PD had been performed. Curative PD improves the prognosis of cases with long duodenal invasion or pancreas infiltration except for nodal-type duodenal invasion.     

胃癌根治联合胰十二指肠切除治疗局部进展期胃癌疗效分析：附11例报告

目的：探讨联合行胃癌根治及胰十二指肠切除治疗局部进展期胃癌的疗效。 方法：回顾性分析2005年5月—2012年6月期间11例因侵及胰头或十二指肠而联合行胃癌根治及胰十二指肠切除术的胃癌患者的临床资料。 结果：行远端胃联合胰十二指肠切除术6例,行远端胃联合胰十二指肠切除加右半结肠切除5例,全组无手术死亡病例。术后并发症4例,其中胆瘘1例,胰瘘1例,腹腔感染1例,切口感染1例。患者术后1,3,5年生存率分别为68.2%,34.1%,22.7%。 结论：对能达到R0切除的胃癌侵犯胰头或十二指肠患者,行胰十二指肠切除术是积极有效的治疗方法。     

胃癌侵及胰头、十二指肠的根治性手术治疗

目的探讨胃癌侵犯胰头十二指肠进行根治切除术的治疗效果。方法应用胃癌根治术联合胰十二脂肠切除术治疗胃窦癌侵及胰头、十二指肠病人6例。胃窦癌侵及胰头、十二指肠为本手术的适应证,第1,2站淋巴结转移者临床疗效满意,手术安全性高;第3站淋巴结转移应视为本手术的禁忌证。结果本组无手术并发症发生,无手术死亡。术后半年随访,6例病人均存活。术后1年随访,生存5例,术后2年随访,生存4例。结论严格选择病例,联合胰十二指肠切除适用于胃癌侵犯胰头、十二指肠的根治性切除。     

胃癌腹膜转移手术治疗的探讨

目的 研究胃癌远处腹膜转移肿瘤姑息性切除的可行性问题。方法 1994年9月至2004年9月共实施胃癌腹膜转移手术治疗44例，将其分为两组，胃癌姑息切除组29例，其中远处腹膜少处转移（P2）20例，远处腹膜多处转移（P3）9例；胃癌未切除组15例，其中P24例，P311例，探讨胃癌伴腹膜转移病人的存活率和影响存活率的因素。结果 胃癌姑息切除组和未切除组的存活率差异有显著性（P=0．004），胃癌站息切除组的中位生存时间为13．6个月，而未切除组的中位生存时间为4．5个月；胃癌切除组和非切除组内P2、P3组之间的存活率差异无显著性。结论 腹膜转移的程度不是判断是否手术的标准，手术切除肿瘤病灶能提高P2和P3病人的存活率。     

Pancreatic and Duodenal Invasion in Distal Bile Duct Cancer: Paradox in the Tumor Classification of the American Joint Committee on Cancer

BACKGROUND: Distal bile duct cancer often invades the pancreas and/or duodenum. Invasion of the pancreas is defined as a T3 and that of the duodenum as a T4 tumor in the T classification of the American Joint Committee on Cancer (AJCC). The aim of this study was to assess whether this T classification is rational from the viewpoint of prognostic power. METHOD: Ninety-five patients with distal bile duct cancer were retrospectively analyzed according to the current T classification of the AJCC. RESULTS: The main determinant of pT3 (n = 32) and pT4 (n = 30) was pancreatic and duodenal invasion, respectively, and the survival rates for patients with pT3 and pT4 are similar (p = 0.595). Duodenal invasion was present in 39% of the patients with pancreatic invasion, whereas pancreatic invasion was observed in 86% of those with duodenal invasion. The survival for patients with pancreatic invasion was not significantly different (p = 0.283) whether or not there was concomitant duodenal invasion (n = 19 and n = 37, respectively). Multivariate analysis identified venous invasion, distant metastasis, histologic grade, and pancreatic invasion as independent prognostic factors. CONCLUSION: Although duodenal invasion usually occurs after pancreatic invasion, it is not a significant prognostic factor while pancreatic invasion is. The current T classification should be revised since it expresses tumor extension but does not reflect a survival in distal bile duct cancer.     

胃癌根治手术联合脾脏切除远期疗效分析

目的探讨胃癌根治手术联合脾脏切除对胃癌患者预后的影响。方法1994年6月至2004年3月完成胃癌手术692例,其中在胃癌D2、D3手术基础上联合脾脏切除45例,选择同时期完成的具有可比性的仅行胃癌根治手术的343例病例进行分析,比较淋巴结转移的临床病理学因素、淋巴结转移率、切除脾脏后5年生存率。结果胃癌联合脾脏切除No10淋巴结转移率为15．6％,其中上1／3（U）区为11．5％,中1／3（M）区为33．3％,下1／3（L）区为0％。近端胃癌和胃体部癌、低分化及未分化腺癌、BorrmannⅢ、Ⅳ型、肿瘤浸润深度在T3、T4以及Ⅲ、Ⅳ期胃癌与远端胃癌、高中分化腺癌、Borrmann Ⅰ、Ⅱ型、肿瘤浸润深达度在T1、T2以及Ⅰ、Ⅱ期胃癌比较,其淋巴结转移率的差异有统计学意义。Ⅰ、Ⅱ期胃癌切除脾脏后平均生存时间和中位生存时间与单纯胃癌根治手术组比较降低并有统计学意义差异,Ⅲ、Ⅳ期胃癌切除脾脏以后平均生存时间和中位生存时间与单纯胃癌根治手术组比较差异无统计学意义。结论Ⅰ、Ⅱ期胃癌患者不应联合脾脏切除,Ⅲ、Ⅳ期胃癌联合切除脾脏也未能提高术后生存率,胃癌直接侵犯胰腺体尾部,脾门淋巴结明显肿大转移者,才有脾切除的指征。联合脾脏切除的手术适应证需进一步研究。     

胃窦癌胃周淋巴结转移规律的探讨

目的 探讨胃窦(胃L区)癌的淋巴结转移规律与临床病理因素之间的关系及其临床意义.方法 对2006年6月至2007年12月期间于西安交通大学医学院第一附属医院进行胃窦癌根治性淋巴结清扫手术的129例患者的手术切除标本进行解剖,分组收集切除淋巴结,逐枚进行病理组织学检查,判断淋巴结是否转移并计算各组淋巴结转移率,分析其与肿瘤大小、肿瘤部位、浸润深度、组织学类型、Borrmann分型等方面的关系.结果 本组129例胃窦癌患者的淋巴结转移阳性80例(62%).共收获3295枚淋巴结,平均每例25.54枚,中位数24枚/例,转移淋巴结数889枚.胃窦癌患者No.1、No.3、No.4d、No.5、No.6、No.7、No.8a、No.9、No.11p、No.12a、No.14v各组淋巴结转移率分别为18.60%、48.84%、37.98%、38.76%、44.19%、31.01%、10.85%、14.73%、4.65%、1.55%及0.78%,其中以No3和No6组为最高.结论 在实施胃癌根治手术时,应综合考虑各临床病理因素,并结合胃窦区胃癌淋巴结分组、分站转移的特点,合理选择淋巴结清扫范围,以达到根治目的.     

Significance of extended radical surgery for stage IV gastric cancer

Forty percent of patients with gastric cancer with direct infiltration to adjacent organs survived for more than 5 years after curative resection. Favorable results were obtained in cases in which combined resection of the body of the pancreas or the liver was performed due to cancer infiltration. However, patients who had undergone gastrectomy with combined colectomy or pancreatoduodenectomy showed a poor survival rate. The postoperative 5-year survival rate was 29% for patients who had presented with group 3 lymph node metastasis and undergone potentially curative surgery. Particularly, favorable results were obtained in cases with metastases confined to lymph nodes in the hepatoduodenal ligament. In dissection of the deepest nodes, lymph nodes in the hepatoduodenal ligament is the most important to remove in surgery for stage IV gastric cancer. We have performed gastrectomy combined with dissection of group 1 and 2 lymph nodes in the treatment of patients with gastric cancer with peritoneal metastasis. Results obtained so far revealed that only patients with a lesser extent of serosal invasion survived longer after operation. We are presently conducting a trial of hyperthermia combined with anticancer chemotherapy as a possible method for prolongation of survival of patients with peritoneal metastasis of gastric cancer.     

胃癌并局限型肝转移同步切除九例报告

目的探讨同步切除治疗胃癌并局限型肝转移的临床效果。方法回顾性分析胃癌并局限型肝转移行同步切除的9例患者的临床资料。结果行根治性远端胃大部分切除术7例,根治性近端胃大部分切除术1例,根治性全胃切除1例;局部肝切除8例,左半肝切除1例。无手术死亡病例。术后生存期分别为9、12、12、13、21、24、30、37和62个月,平均生存24.3个月。术后6例再发残肝转移。死亡原因中,3例死于残肝转移,3例死于腹膜转移。结论对胃癌并局限型肝转移患者施行原发灶根治性切除和肝转移灶同步切除可有效地延长生命。     

Therapeutic significance of noncurative gastrectomy for gastric cancer with liver metastasis

The therapeutic significance of noncurative gastrectomy for gastric cancer with liver metastasis was evaluated and the histologic characteristics of such cancer examined. The mean postoperative survival time of patients with liver metastasis limited to one lobe or a few scattered metastases to both lobes without peritoneal metastasis or direct cancer invasion to other organs was significantly prolonged by noncurative gastrectomy. Differentiated adenocarcinoma, including papillary adenocarcinoma, and intravenous cancer invasion were found to be the histologic characteristics of gastric cancer with liver metastasis.     

Cancer of the gastric stump following distal gastrectomy for cancer

BACKGROUND: Cancer of the gastric stump (CGS) after distal gastrectomy for cancer has not been characterized in a large study. The aim of this study was to investigate the clinicopathological features and outcome of CGS following distal gastrectomy for cancer. METHODS: Patients with CGS following distal gastrectomy for gastric cancer diagnosed between 1970 and 2002 were reviewed retrospectively. RESULTS: A total of 108 patients was identified. The median interval between the initial gastrectomy and resection for CGS was 7.5 (range 1-41) years. The depth of tumour invasion was T1 in 67 patients, T2 in 16, T3 in eight and T4 in 17 patients. Endoscopic mucosal resection was performed in 25 patients with T1 tumours. R0 resection was achieved in 103 patients. The overall 5-year survival rate was 53.1 per cent. The 5-year survival rates for patients with T1, T2, T3 and T4 disease were 76, 40, 13 and 9 per cent respectively. CONCLUSION: The outcome for patients with non-early CGS was poor. Early detection of CGS is important following distal gastrectomy for gastric cancer and strict surveillance is recommended for at least 10 years after the initial gastrectomy.     

胃切除方式对胃中部癌患者预后的影响

目的探讨胃切除方式对胃中部癌患者预后的影响。方法回顾性分析1998年1月至2005年12月间福建医科大学附属协和医院收治的222例胃中部癌患者的临床资料,其中行开腹远端胃大部切除术66例（DG组）,行开腹全胃切除术患者156例（TG组）,比较两组患者术后5年的生存率。结果DG组和TG组术后5年生存率分别为63．9％和49．8％,差异具有统计学意义（P〈0．05）。但相比之下,TG组患者肿瘤更大、分期更晚、肿瘤位于小弯侧者居多（均P〈0．01）。按TNM分期进行分层预后分析显示,相同病期的两组患者术后5年生存率的差异均无统计学意义（均P〉0．05）。无论是以4cm、5cm还是6cm作为近切缘截点,不同近切缘距离患者5年生存率的差异均无统计学意义（均P〉0．05）。多因素预后分析显示,浸润深度、淋巴结转移和TNM分期是独立预后影响因素（均P〈0．05）;而胃切除方式并不是独立预后因素（P〉0．05）。结论胃中部癌患者如果能够达到根治手术的要求,其预后不受胃切除方式的影响,行远端胃大部切除术是可行的。     

Clinicopathological features of early gastric cancer: results of 100 cases from a rural general hospital.

OBJECTIVE: To evaluate 100 patients with early gastric cancer from the point of view of early detection, clinicopathological variables, and long term results. DESIGN: Retrospective study. SETTING: Rural general hospital, Japan. SUBJECTS: 100 patients with early gastric cancer (confined to the epithelium, lamina propria, or submucosa) out of a total of 197 who had gastric cancers resected for cure between May 1986 and April 1996. INTERVENTIONS: Subtotal gastrectomy (n = 87), total gastrectomy (n = 8), proximal gastrectomy (n = 2), and local wedge resection (n = 3). MAIN OUTCOME MEASURES: Histopathological features and outcome. RESULTS: The mean annual incidence of early gastric cancer was 51% (range 35%-70%). 16/59 patients with mucosal cancer (37%) and 18/41 with submucosal cancer (44%) presented with symptoms of the disease. The diagnosis was made in 62 by endoscopy, and in only 2 by upper gastrointestinal radiographic examination. None of the 59 with mucosal cancer had lymphatic invasion, and only 1 had a lymph node metastasis. Among the 41 with submucosal cancer, however, 15 had lymphatic invasion (37%), 13 had venous invasion (32%), and 2 had lymph node metastases (5%). 83 patients were alive with no sign of recurrence at the time of writing (median follow up 62 months, range 12-136). One patient with a tumour that produced alpha-fetoprotein died of hepatic metastases 23 months after subtotal gastrectomy. 9 patients developed second cancers, and 6 died of these with no signs of recurrence of early gastric cancer. The overall 5 and 10 year survival rates were 82% and 66%, and the corresponding disease-specific survival rates for 85 patients were both 98%. CONCLUSIONS: Excellent long term results can be achieved in the treatment of early gastric cancer, even in a non-specialist centre. Patients with early gastric cancer should have their alpha-fetoprotein concentration measured, and be examined for the presence of other malignant disease both before and after treatment of the gastric cancer.     

Selection of operative procedure for adenocarcinoma of the midstomach. Twenty years' experience with implications for future treatment strategy.

Pathoanatomic studies of the regional spread of adenocarcinoma of the middle one-third of the stomach suggested the need for extensive gastric and lymphatic resection. To seek evidence of improved results, a retrospective study was made of 213 patients curatively treated by three commonly used procedures: 1) radical high subtotal gastrectomy (SG, n = 39), 2) radical total gastrectomy (TG, n = 48), and 3) extended total gastrectomy (ETG, n = 126). The overall five-year survival rates were SG:10%, TG:16%, and ETG:19%. Advanced stage tumors (N2, N3, or M1) were highly lethal, irrespective of the type of resection. However, patients with early stage tumors (T1-4, N0 or N1) showed higher survival rates after more extensive resections (ETG:42% and TG: six of eight patients, versus SG:17%). The highest survival rate (93%) was observed in a subset of patients with early stage tumors electively treated by ETG; this was achieved despite the presence of metastasis to the juxtagastric (N1) lymph nodes or direct invasion of an adjacent organ in most of these patients. These observations confirm the merit of extensive resection for carcinoma of the midstomach.     

Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem

Many surgeons favour total gastrectomy (TG) 'de principe' in the treatment of gastric cancer, but final demonstration of its advantage over subtotal gastrectomy (SG) is still lacking. We analysed survival after curative TG or SG within groups of patients stratified according to the main prognostic variables as found in multivariate analysis, i.e., nodal status, degree of invasion of the gastric wall, patient age and sex. Our series consisted of 361 patients treated by curative SG and 41 by curative TG, admitted to the Istituto Nazionale Tumori of Milan between 1965 and 1979. In patients with lymph node involvement survival appeared to be significantly better (P = 0.0005) after SG. However, stratifying for age it was found that the benefit was limited to patients over 60 years old. No significant difference in survival was found in the group without nodal involvement (N -) and invasion of the wall to the serosa or beyond. No statistical comparison was possible in N - groups with invasion confined to mucosa, submucosa or muscularis propria because of the small number of such patients who underwent TG. We conclude that SG still represents the standard reference operation for gastric carcinoma provided that a safe proximal margin of resection is guaranteed.     

胃幽门窦癌浸润胰头联合胰十二指肠切除43例临床分析

目的探讨胃幽门窦癌浸润胰头时的手术方法。方法回顾性分析1984年6月至2004年6月收治的采用胰十二指肠切除术(PD)治疗的胃癌侵及胰头43例临床资料。结果无手术死亡。19例根治手术中联合胰十二指肠切除术15例,胰头局部切除4例;姑息切除17例;探查及胃空肠吻合7例。术后并发症发生率:PD术后为33%(5/15),胰头部分切除为25%(1/4),姑息切除为18%(3/17),探查活检为14%(1/7)。组间差异无显著性意义(P>0·05)。随访:中位生存时间PD为26个月(12~156个月),胰头部分切除为23个月(14~73个月),姑息切除为8个月(3~37个月),探查及胃空肠吻合为3个月(1·5~9·0个月)。联合PD和胰头部分切除的生存期明显长于姑息切除和探查及胃空肠吻合组(P<0·01)。结论胃幽门窦癌联合PD或胰头局部切除能够提高病人的生存期,手术指征选择恰当和肿瘤的彻底根治是取得良好临床效果的关键。     

胃底贲门癌侵及胰体尾外科治疗的预后分析

目的 探讨影响胃底贲门癌侵及胰体尾外科治疗预后的因素.方法 对135例胃底贲门癌侵及胰体尾患者进行手术.其中剖腹探查术20例,联合脾及胰体尾切除术115例.对影响手术的预后进行单因素及多因素分析,并分析术后的并发症发生率和病死率.结果 剖腹探查术和联合脾及胰体尾切除术患者的中位生存期分别为4.7个月和30.5个月,差异有统计学意义(X2=403.8,P＜0.01).联合脾及胰体尾切除术患者的3、5年生存率分别为48.3%、26.6%;肿瘤的直径、大体分型、浸润深度、淋巴结转移、No.10或No.11淋巴结转移、根治程度和受侵脏器切除数目为影响预后的相关因素:其中浸润深度、淋巴结转移分期、手术根治程度及受侵脏器切除数目为影响预后的独立因素.术后并发症发牛率和病死率分别为20.0%和3.5%.结论 对于胃底贲门癌侵及胰体尾患者.施行联合脾及胰体尾切除术能够提高疗效.如果患者无淋巴结转移、或无不可根治因素存在、或无合并其他脏器受侵.施行联合脾及胰体尾切除术疗效最好.     

Surgical Indications for Gastrectomy Combined with Distal or Partial Pancreatectomy in Patients with Gastric Cancer

Background

The purpose of this study was to clarify the surgical indications for gastrectomy combined with distal or partial pancreatectomy (GP) in patients with gastric cancer.

Methods

From January 1994 to December 2009, 29 patients with primary gastric cancer surgically invading the pancreas without distant organ metastasis underwent GP for R0 resection. The patients’ characteristics, surgical data, and clinicopathological features were used for the analysis of survival and prognostic factors.

Results

The median disease-free survival and median survival time (MST) of all patients were 15 and 30?months, respectively. Only pN3 status (characterized by 7 or more pathologically metastatic lymph nodes) according to the Japanese Classification of Gastric Carcinoma, 14th edition, was shown to be a prognostic factor in a multivariate analysis. The MST of the patients with pN3 and the other patients were 12 and 51?months, respectively (p?<?0.001).

Conclusions

We suggest that pancreas invasion should not be considered a contraindication for gastrectomy and that patients with a small number of lymph node metastases (six or fewer) might be candidates for GP in the case of gastric cancer that requires pancreatectomy for R0 resection.