胃癌根治术联合脾切除的Meta分析及保留脾脏脾门淋巴结清扫的临床及解剖学观察

发布时间：2018-09-16 19:42

【摘要】：在世界上引起癌症死亡的病因中,胃癌占第二位,相比所有的胃肿瘤,近端胃癌的发病率逐年升高。在大多数患者中,胃癌在发现时已经是进展期。进展期贲门或胃底部胃癌的标准化手术是清扫第二站淋巴结。而根据日本胃癌治疗指南,在进展期近端胃癌根治术中,脾门淋巴结属于第二站。所以,脾门及脾动脉周围淋巴结清扫在近端胃癌根治术中必须完成。在近端胃癌和胃食道连接部癌,脾门经常发生淋巴结转移,预示着预后较差。因此,日本胃癌指南要求在行近端胃癌和胃食道连接部癌手术时,应行全胃联合胰尾及脾脏切除或行全胃切除术时同时切除脾脏而保留胰尾。而根据最新欧洲肿瘤临床实践指南,认为脾切除是不必要的,除非肿瘤直接侵犯脾脏。他们认为脾切除不但达不到提高患者生存率的目的,反而增加患者术后的并发症与死亡率,如急性胰腺炎、术后出血、腹腔脓肿、胰瘘、术后糖尿病的发生率明显增加。关于是否在行胃癌手术时同时切除脾脏仍是有争议的。我们这篇Meta分析和系统评价的目的是想阐明胃癌手术时联合脾脏切除在短期并发症和长期生存率方面的价值。这篇Meta分析的结论是同时切除脾脏,不仅达不到提高患者生存率的目的,反而增加患者术后的并发症与死亡率。如急性胰腺炎、术后出血、腹腔脓肿、胰瘘、术后糖尿病的发生率明显增加。我们行尸体解剖及腹腔镜手术,旨在寻求一种最佳手术路径及手术方式,既可保留胰腺和脾脏的功能,减少术后并发症和死亡率,又不降低患者的5年生存率。我们在行全胃切除术时,通过胰后入路清扫脾门淋巴结、骨骼化脾动静脉,完全实现了既保留功能又完成D2淋巴结清扫的目的。第一章在根治性胃癌手术中联合脾脏切除是必要的吗?一篇系统评价和Meta分析目的:这篇系统评价和Meta分析的目的是比较在根治性胃癌手术中脾脏切除和脾脏保留的短期和长期结果。方法和材料:我们检索 PubMed、Embase、Cochrane Library 和 Web of Knowledge数据库,纳入在根治性胃癌手术中脾脏切除和脾脏保留的随机临床对照研究和非随机临床对照研究。用固定效应模型或随机效应模型检测分析短期和长期结果,统计学软件使用RevMan5.2。结果:2个随机临床对照试验以及9个非随机临床对照试验共计5431例患者被纳入本研究,相对脾保留组,脾切除组有明显高的术后并发症(OR =2.31,95%CI:1.80 to 2.96,P0.001),肺部并发症明显增加(OR=1.80,95%CI:1.22 to 2.64,P=0.003),腹腔脓肿明显增加(OR=3.71,95%CI:2.18to6.32,P0.001),胰腺炎明显增加(OR=4.56,95%CI:1.60 to 12.97,P=0.004)。术后死亡率(OR=1.18,95%CI:0.93 to 1.49,P=0.17),切口感染(OR=1.69,95%CI:0.98 to 2.92,P=0.06),吻合口瘘(OR=1.82,95%CI:1.01 to 3.29,P=0.05)和术后5年生存率(OR=0.85;95%CI,0.63 to 1.14,P=0.28)无显著性差异。结论:与脾保留组相比,脾切除组并未取得相当的长期肿瘤学疗效,而存在较差的短期效果。因而,在根治性胃癌手术中脾切除是不必要的。然而,本研究的结论仍需大样本前瞻性随机临床对照试验的进一步证实。第二章胃癌患者腹腔镜经胰后入路行保留脾脏的脾门淋巴结清扫目的:探讨近端胃癌患者在行腹腔镜手术时,在保留脾脏的前提下,经胰后入路清扫脾门淋巴结的可行性。方法:选取尸体两具和2008年5月-2013年5月10例在南方医院因近端进展期胃癌行全胃切除并保留胰腺和脾脏经胰后入路清扫脾门淋巴结的患者进行分析。结果:通过尸体解剖胰腺前后间隙,发现从胰后间隙入路完全可行。在尸体解剖的基础上,我们给10例近端胃癌患者做了全胃切除术,并在保留胰腺和脾脏的前提下,经胰后入路行脾门淋巴结清扫。10例患者无一例中转开腹,均于术后15天内好转出院。结论:腹腔镜全胃切除经胰后入路行保留脾脏的脾门淋巴结清扫是可行的,安全的。第三章胃癌根治术D2淋巴结清扫的外科间隙及入路目的:通过解剖胃周及胰周筋膜间隙,探讨行胃癌根治术D2淋巴结清扫的安全入路。方法:选取尸体两具解剖胃周及胰周筋膜间隙,并对胃癌根治术D2淋巴结清扫可能的手术入路进行分析。结果:通过尸体解剖胃周及胰周筋膜间隙,发现胃周与胰周有许多无血管及神经走行的筋膜间隙,而且胃周与胰周筋膜间隙常互相交通。熟悉这些筋膜间隙才能制定出安全的手术入路,防止术中大出血及损伤重要脏器。结论:只有熟悉胃周及胰周筋膜间隙,才能制定出安全的手术入路。
[Abstract]:Gastric cancer is the second leading cause of cancer death in the world. Compared with all gastric tumors, the incidence of proximal gastric cancer is increasing year by year. In proximal gastric cancer and gastroesophageal junction cancer, lymph node metastasis often occurs in the splenic hilum, indicating poor prognosis. Therefore, the Japanese guidelines for gastric cancer require proximal gastric cancer and gastroesophageal junction cancer. Splenectomy is not necessary unless the tumor invades the spleen directly. They believe that splenectomy is not enough to improve survival. However, the incidence of postoperative complications and mortality, such as acute pancreatitis, postoperative hemorrhage, abdominal abscess, pancreatic fistula, and diabetes mellitus, increased significantly. It is still controversial whether splenectomy should be performed simultaneously during gastric cancer surgery. The purpose of our Meta-analysis and systematic review is to clarify the association of spleen with gastric cancer surgery. This Meta-analysis concludes that simultaneous splenectomy does not achieve the goal of improving the survival rate of patients, but increases the postoperative complications and mortality of patients. For example, the incidence of acute pancreatitis, postoperative hemorrhage, abdominal abscess, pancreatic fistula, and postoperative diabetes mellitus increases significantly. We performed autopsy and laparoscopic surgery in order to find the best way to preserve the function of the pancreas and spleen, reduce postoperative complications and mortality without reducing the 5-year survival rate. Chapter 1 Is Splenectomy Necessary in Radical Gastric Cancer Surgery? A Systematic Review and Meta-analysis Purpose: The purpose of this systematic review and Meta-analysis is to compare the short-term and long-term outcomes of splenectomy and spleen preservation in radical gastric cancer surgery. MATERIALS: We searched PubMed, Embase, Cochrane Library, and Web of Knowledge databases for randomized, controlled, and non-randomized clinical trials of splenectomy and spleen preservation in radical gastric cancer surgery. RevMan 5.2. Result: Two randomized controlled trials and nine non-randomized controlled trials were conducted in 5431 patients. Compared with the spleen preservation group, the splenectomy group had significantly higher postoperative complications (OR = 2.31, 95% CI: 1.80 to 2.96, P 0.001), significantly increased pulmonary complications (OR = 1.80, 95% CI: 1.22 to 2.64, P = 0.003) and abdominal abscess. Postoperative mortality (OR = 1.18, 95% CI: 0.93 to 1.49, P = 0.49, P = 0.17), inciinfection (OR = 1.69, 95% CI: 0.98 to 2.92, P = 0.06), anastomotic fistula (OR = 1.82, 95% CI: 1.95% CI: 1.01 to 3.01 to 3.3.29, P = 0.29, P = 0.29, P = 0.05), anastomstomstomotifistula (OR = 1.82, 95% CI: 95% CI: 1.82, 95% CI: 1.01 to 3.01 to 3.01 to 3.29, P = 0.29, P = 0.29, P = 0.29, P = 0.29, P = 0.05, P = 0 0.85; 95% CI, 0.63 to 1.14, There was no significant difference between the two groups (P = 0.28). CONCLUSION: Splenectomy did not achieve significant long-term oncological outcomes compared with spleen preservation, but had poor short-term outcomes. Objective:To investigate the feasibility of retropancreatic laparoscopic splenic hilar lymph node dissection in patients with gastric cancer undergoing laparoscopic surgery with spleen preservation. Results: By autopsy of the anterior and posterior spaces of the pancreas, the retropancreatic approach was found to be completely feasible. On the basis of autopsy, we performed total gastrectomy in 10 patients with proximal gastric cancer and preserved the pancreas and spleen. Conclusion: Laparoscopic total gastrectomy via retropancreatic approach for splenic hilar lymph node dissection with spleen preservation is feasible and safe. Methods: Two cadavers were selected to dissect the perigastric and peripancreatic fascial spaces, and the possible surgical approaches of D2 lymph node dissection were analyzed. Results: The perigastric and peripancreatic fascial spaces were found by autopsy. There are many fascial spaces without blood vessels and nerves, and the perigastric and peripancreatic fascial spaces often communicate with each other. Familiar with these fascial spaces can make a safe surgical approach to prevent intraoperative bleeding and injury of important organs.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R735.2

【相似文献】