Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric carcinoma

Background The outcome and quality of surgical treatment in gastric cancer are closely associated with specific postoperative morbidity and mortality, in addition to an oncosurgically adequate resection status. In this context, a preventive concept of decreasing the insufficiency rate of esophageal anastomosis may have a great impact.Method Over a time period of 12 months (from 1 January 2002 to 31 December 2002), 1,199 patients (from 80 East German hospitals) with gastric carcinoma, carcinoma of the esophagogastral junction, or gastrointestinal stroma tumor (GIST) were enrolled in this prospective multicenter observational study with the aim of evaluating their early postoperative outcome. By means of a logistic regression analysis, independent variables, which alter significantly the healing of esophagojejunal anastomosis, were determined; in addition, their clinical impact on preventive management to lower the insufficiency rate of esophageal anastomosis was investigated.Results In 1,139 patients, histological investigation revealed gastric carcinoma. Out of these patients, 1,031 subjects underwent surgical intervention (90.5%) and 891 individuals underwent resection (86.4%). In 813 patients, radical resection (subtotal resection and gastrectomy) was executed (78.9%), whereas in 726 cases, R₀ resection was achieved (81.5%). Gastrectomy was the preferred procedure in 649 patients, resulting in a gastrectomy rate of 62.9% relating to all patients who underwent operation (curative and palliative intention, 80.3% and 19.7%, respectively). The insufficiency rate of esophagojejunal anastomosis was 5.7% (37/649). Neither the comparison between the various procedures for the reconstruction of the esophagojejunal passage and anastomosing techniques after gastrectomy nor that between gastrectomies with curative and palliative intention revealed any significant difference. Dysphagia and gastric outlet syndrome due to a stenosis were determined as independent variables by a logistic regression analysis of all preoperative and intraoperative variables. In all patients with gastric carcinoma, both parameters were recorded in 9.9% (113/1,139) and 6.7% (76/1,139), respectively.Conclusion Dysphagia and gastric stenosis, which significantly influence the healing of esophagojejunal anastomosis after gastrectomy, are considered characteristics of an advanced tumor growth and a pretherapeutic lack of an adequate nutrition. This emphasizes the necessity of an early diagnosis of gastric cancer in order to lower perioperative morbidity. In addition, dysphagia is commonly associated with an obstruction of the upper gastrointestinal tract, which can lead to nutritional deficits, and thus deserves specific care during preventive management.     

关于胃癌TNM分期系统中最少淋巴结检出数目的研究

目的研究国际抗癌联盟(UICC)和美国癌症联合会(AJCC)对胃癌TNM分期系统中准确分期的最少检出淋巴结数目。方法回顾性收集436例行胃癌根治术的患者淋巴结数目、生存率等临床和病理资料,通过卡方检验和q检验方法对其进行分析。结果在pN0病例中,送检淋巴结1～4个,5～9个的病例,比10～14个和15个以上的5年生存率低且差异具有统计学意义(P<0.05)。10～14个检出淋巴结的病例与15个以上的5年生存率差别无统计学意义。在pN1,pN2患者,送检1～4个,5～9个和10～14个淋巴结者与15个以上者的生存率差别具有统计学意义(P<0.05)。Ⅱ期中检出10～19个淋巴结的患者,其5年生存率明显低于20～29个及30个以上的患者,在Ⅲ期中,检出5～9,10～19,20～29个淋巴结者生存率显著低于30个以上的生存率(P<0.05)。结论淋巴结检出数目在胃癌pN分期中显著影响预后。pN0的最少检出数目应由原来的15个减至10个。而有淋巴结转移的病例至少应送检15个以上淋巴结。Ⅱ期病例最好检出20个淋巴结,而Ⅲ、Ⅳ期最好检出30个以上淋巴结。     

Gastrectomy Performed with Noninvasive Positive Pressure Ventilation for a Patient with Severe Chronic Obstructive Pulmonary Disease: Report of a Case

We report the case of a patient with severe chronic obstructive pulmonary disease (COPD) for whom gastrectomy was successfully performed with the use of noninvasive positive pressure ventilation (NPPV). A 63-year-old man who had been suffering from chronic pulmonary emphysema for 12 years and receiving home oxygen therapy (HOT) for 9 years was diagnosed with gastric carcinoma. The patient required supplemental oxygen via nasal cannulae even at rest, and had labored breathing through pursed lips after a short conversation. The forced expiratory volume in 1 s was 400 ml. He underwent conventional gastrectomy under general anesthesia, and was extubated 90 min after surgery and given NPPV support. He was successfully weaned from NPPV on postoperative day (POD) 10 and discharged from our hospital on POD 28. Noninvasive positive pressure ventilation is useful for the perioperative management of patients with severe COPD and for extending the possibilities of surgery for patients on HOT.     

胃癌阻断新技术降低癌细胞血行转移的临床研究

目的　评价胃癌阻断技术降低胃癌门静脉血内癌细胞播散的效果。方法　 2 3例胃癌患者 ,8例术中未采用胃癌阻断技术者为常规手术组 ,15例采用胃癌阻断技术者为阻断组 ,术前、术中抽门静脉血及阻断区域胃网膜静脉弓内静脉血 ,应用RT -PCR技术测定静脉血内CK19mRNA表达情况。结果　切除胃癌病灶之前 ,门静脉血内CK19mRNA的总阳性率为 34 7% ( 8/ 2 3) ,常规组和阻断组的阳性率分别为 37 5 % ( 3/ 8)和 33 3% ( 5 / 15 ) ;术中牵拉胃癌病灶时 ,常规组门静脉血CK19mRNA的阳性率为 87 5 % ( 7/ 8) ,而阻断组的阳性率为 6 7% ( 1/ 15 ) ,两组差异有统计学意义 (P <0 0 5 ) ;阻断组 15例患者癌灶阻断区域网膜血管弓内静脉血CK19mRNA均阳性。结论　术中采用胃癌阻断技术能有效的阻断胃癌细胞播散 ,防止手术操作引致的癌细胞远处转移     

Association of Splenectomy With Postoperative Complications in Patients With Proximal Gastric and Gastroesophageal Junction Cancer

Background: Splenectomy has been associated with increased morbidity after gastrectomy for gastric cancer. Resection of proximal versus distal tumors is associated with a higher morbidity. Because splenectomy is more commonly performed in resection of proximal tumors, these analyses may be biased. The aim of this study was to describe the association of splenectomy with complications in patients undergoing resection of proximal gastric and gastroesophageal junction (GEJ) cancers.Methods: From July 1985 to August 2001, 335 patients underwent resection of proximal gastric or GEJ (type II and III) cancers. Clinical and pathologic factors were retrieved from a prospective database.Results: Overall morbidity was 59% (infectious complications, 41%; noninfectious complications, 36%), and mortality was 4.5%. Splenectomy was associated with a higher rate of infectious complications (57% vs. 33%; P < .01) but not of noninfectious complications (39% vs. 34%; not significant) or mortality (4% vs. 5%; not significant). Splenectomy was also associated with a higher rate of infectious complications on multivariate analysis (hazard ratio, 2.4; P < .01).Conclusions: Morbidity after resection of proximal gastric and GEJ cancer is significant; splenectomy is associated with increased morbidity, but not mortality, in these patients. Because these complications can be managed without an increase in mortality, splenectomy should be performed when indicated by the extent of the tumor.     

胃大部切除术后内疝的原因及预防（附2例报告及近10年国内文献复习）

目的探讨胃大部切除术后内疝发生的原因及预防方法。方法分析收治的2例及近10年国内文献报道的196例,共198例胃大部切除术后内疝的诊治资料。结果198例均为胃大部切除BillrothⅡ式吻合术,结肠前吻合156例(78.8%),输入袢>15cm106例;结肠后吻合38例(19.2%),输入袢8～12cm4例,输入袢>15cm4例。疝入肠袢与吻合方式记载完整的60例中,输入袢疝19例,其中输入袢对大弯9例,输入袢对小弯10例。输出袢疝41例,其中输入袢对大弯22例,输入袢对小弯19例。明确记载胃空肠吻合方式120例中,输入袢对大弯67例,输入袢对小弯53例。治愈174例,死亡24例(12.1%)。结论吻合口后间隙及过长的输入袢是内疝发生的主要原因,内疝及疝入肠袢与胃空肠吻合方式无明显关系。缝合吻合口后间隙,采用合适长度的输入袢是避免发生内疝的关键。     

管状吻合器及缝合器在Roux-en-Y上消化道重建术中的临床应用

目的：探讨使用管状吻合器及缝合器在Roux-en-Y上消化道重建术中的临床应用价值。方法：回顾性分析本院2000年1月~2010年1月329例应用管状吻合器及缝合器行Roux-en-Y近端胃切除和全胃切除手术患者的临床资料与并发症的发生率。结果：全组均获手术成功,无手术死亡病例,手术时间1.6～4.0h,平均2.8h,无吻合口瘘、出血及狭窄等严重并发症。术后随访0.5～2年,发生吻合口狭窄3例,经放置支架后恢复正常饮食,其余患者胃镜或钡餐示吻合口愈合良好,进食状态良好。结论：Roux-en-Y上消化道重建术中应用管状吻合器及缝合器具有操作简单、安全有效,手术时间短、并发症少等优点,有较高的临床应用价值。     

腹腔镜远端胃癌根治术21例初步体会

目的:总结腹腔镜胃癌根治术开展初期的临床资料。方法:回顾分析21例腹腔镜远端胃癌根治术的经验。D1/D1+α或β/D2淋巴结清扫18例,其中毕Ⅰ式胃肠吻合11例,毕Ⅱ式7例;中转开腹姑息性手术3例。结果:本组无手术死亡病例,手术时间150～230min,标本远近切缘均无癌细胞残留,清扫淋巴结数11～32个。术后1～3d恢复胃肠功能,无手术并发症发生。结论:腹腔镜胃癌根治术安全可行,近期疗效达到或好于开放手术。手术成功的关键是血管处理、淋巴结清扫和结肠系膜前叶剥除。     

胃癌根治术后切端癌残留的预后及化学治疗效果

目的了解胃癌根治术后切端癌残留对预后的影响及术后化疗是否能提高其生存率.方法对70例胃癌根治术后切端癌残留病例及1073例无癌残留病例回顾性分析及随访结果.结果远侧胃大部切除术后切端阳性与切端阴性者总5年生存率分别为12.5%、38.2%(P＜0.05),近端胃大部切除术后切端阳性与切端阴性5年生存率分别为13.0%、25.5%(P＜0.05).但按分期比较,则各期5年生存率切端阳性与切端阴性均无显著性差异(P＞0.05).而术后化疗者5年生存率为20.0%,未化疗者为0,二者有显著性差异(P＜0.05)     

腹腔镜胃癌根治术的临床应用

目的：探讨腹腔镜胃癌根治术的可行性和效果。方法：为20例胃癌患者行腹腔镜胃癌根治术,其中根治性远侧胃次全切除术18例;根治性全胃切除术2例。结果：1例中转开腹,1例改行经胸食管空肠吻合,余者行腹腔镜胃癌根治术均获成功。平均手术时间270min（210～380min）,平均出血量185ml（80～350ml）,平均清扫淋巴结21.5枚（13～29枚）,平均肛门排气时间2.5d（1～4d）。结论：腹腔镜胃癌根治术是安全可行的,能获得与开腹手术相当的根治效果。