贲门癌手术径路与疗效的关系研究

目的：探讨贲门癌手术径路的选择与外科治疗效果的关系。方法：随机抽取天津市肿瘤医院资料完整的贲门癌手术切除病例217例，回顾性分析其手术径路与疗效之间的关系，判定各径路的优劣。结果：腹部径路创伤小、失血少、手术时间短，易于术后恢复，但较难以切除足够长的食管及行下纵隔的淋巴结清扫。左胸径路可切除足够长的食管，有利于纵隔淋巴结的清扫，但腹腔暴露差，施行全胃切除、联合胰脾切除及5、6、8、9、12、13、14等组淋巴结的清扫有一定的难度。胸腹联合径路腹腔暴露好，便于行全胃切除及脏器联合切除，能切除足够长的食管和施行彻底的下纵隔淋巴结清扫并能进行D2淋巴结清扫，对肿瘤不能切除的患者避免了开胸探查，但是创伤大，可能引起较多的并发症和较高的死亡率。结论：3种手术径路各有其优缺点。手术径路的选择需根据病变部位、病变大小、疾病分期、患者体质以及医生的经验和技术水平等因素综合考虑而决定。单一的手术径路并非是影响预后的独立因素。

Selection of operative approaches and the efficacy in gastric cardia carcinoma

Objective:To research the relationship between the selection of operative approaches and curative effect in surgical treatment of the carcinoma of gastric cardia.Methods:A total of 217 patients with carcinoma of gastric cardia were randomized in the Cancer Hospital of Tianjin Medical University and the relationship between the operative approach and curative effect was retrospectively analyzed to determine a better approach.Results:The transabdominal approach had the advantages of less damage,less blood loss,less operation time and quicker recovery after operation,but it was sometimes difficult to resect adequate length of the esophagus and to eliminate the lymph nodes in para-esophagus and inferior mediastinum.The trans-left thoracic approach was easy to resect sufficient esophagus and to eliminate the para-esophageal lymph nodes,but it had a poor exposure of the abdominal cavity and was difficult to execute total gastrectomy,splenectomy and partial pancreatectomy and to eliminate the lymph nodes of the group 5,6,8,9,12,13 and group 14.The trans-thoracoabdominal approach had a good exposure of the thoracic and abdominal cavity at the same time,is easy to conduct the total gastectomy and the resection of multi-organs,to resect enough esophagus and eliminate the lymph nodes of inferior mediastinum,as well as to complete the elimination of lymph nodes of D2,thus avoiding exploration alone for un-resectable patients,but it did have some disadvantages,such as more serious damage,more complications and a higher mortality.Conclusion:The three approaches have their own merits and deficiencies.Some factors should be considered in the selection of the approaches,including the location of tumor,size,staging,complication,experience and skill of the surgeon.The simple operative approach is not the independent factor for prognosis.