胃癌根治术中切除胰腺被膜及横结肠系膜前叶对患者远期生存的影响

发布时间：2018-07-17 09:10

【摘要】：背景：胃癌在全球各种常见恶性肿瘤中排名第四位，肿瘤相关死亡原因中排名第二位，胃癌的早期诊断和规范化、合理化的治疗是医学界的一大难题，大部分胃癌患者一经诊断明确就已经处于进展期，因此，其死亡率很大程度上取决于疾病的局部或远处复发及转移，，尽管胃癌的治疗手段在不断的进步，其治疗模式也已经从单纯的手术治疗发展到以解剖学、肿瘤生物学及免疫学为基础的联合规范化手术和围手术期辅助治疗的综合治疗模式。随着手术技术的改进、综合治疗方法的进步以及早期诊断能力的提高，胃癌的总体生存率已经得到了很大的提高，但手术治疗仍然是胃癌治疗的基础，规范化合理化的胃癌根治术仍然是提高胃癌患者生存期的关键。从医学的发展史来看，手术是治疗癌症的第一种可用的方法。1809年，EphraimMcDowell在没有用麻醉的情况下切除了一个卵巢肿瘤，提供了肿瘤肿物可通过手术治愈的证据。1881年，Billroth成功完成了第一例胃切除手术，1908年Voelcker成功施行第一例全胃切除手术。但在随后的50余年时间里，胃癌的外科治疗基本只限于胃大部切除水平。20世纪50年代后，日本学者提出了胃切除及淋巴结清扫，以切除胃2/3以上及行第二站淋巴结清扫术作为根治目的的标准胃切除手术，同时开展了受累及脏器的联合切除术，相继提出了胃癌标准根治术D2、D3手术。但胃癌根治术的合理切除范围一直是极具争议的话题，不同国家和地区的医疗工作者有着不同的观点，以往在亚洲国家，特别是东亚的中国、日本等胃癌高发国家，进展期胃癌根治术中淋巴结清扫范围的选择要来得更激进，更倾向于淋巴结扩大清扫，而西方国家则相对保守。近年来，根治Ⅱ（D2）淋巴结清扫已经成为了东亚国家胃癌根治术淋巴结清扫方式的标准，然而，胃癌D2根治术中切除胰腺被膜及横结肠系膜前叶是否能提高患者远期生存率还没有一个定论，例如，美国Memorial Sloan-Kettering Cancer Center的专家主张行横结肠系膜前叶与胰腺包膜切除，而美国Mayo Clinic和M.D.Anderson CancerCenter的专家则认为横结肠系膜前叶与胰腺包膜切除没有临床意义，一般不切除。目的：通过本前瞻性随机性研究，进一步探讨肿瘤未直接侵犯胰腺被膜及横结肠系膜前叶的胃癌患者在行胃癌根治术时是否有必要常规切除胰腺被膜及横结肠系膜前叶，为以后制定规范化、合理化、个体化的手术方案提供参考。方法：选择我胃癌治疗小组自2007年1月至2008年7月间收治的胃癌患者共计236例，将最终入组的213例患者随机分为两组：N组（108例）及R组（105例）。研究指标包括患者的性别、年龄、肿瘤的大小(cm)、部位、浸润深度、病理分级、手术方式、淋巴结清扫范围、术中出血量、手术时间、术后并发症及术后3年、5年生存率。对N组和R组临床数据采用卡方检验；术后生存率计算采用Kaplan-Meier法；两组生存率比较，应用Log-rank秩检验。所有数据采用SPSS18.0统计软件处理，双侧检验，α=0.05为检验水准，P0.05为差异有统计学意义。结果：R组105例患者术后病理中有9例检测出胰腺被膜及横结肠系膜前叶有转移癌细胞，R组术后病理阴性患者96例（定为R(-)组），胃癌胰腺被膜及横结肠系膜前叶癌转移与肿瘤浸润深度、肿瘤前后壁位置、临床分期、淋巴结转移程度有关(P0.05)；而与患者性别、年龄、肿瘤部位、大小、病理分级、Borrmann分型无关(P0.05)。而N组和R组患者术后5年生存率也无明显统计学意义(P0.05)，N组和R(-)组患者术后5年生存率也无明显统计学意义(P0.05)。结论：肿瘤浸润深度越深、临床分期越晚、淋巴结转移程度越高的患者，越容易发生胰腺被膜及横结肠系膜前叶的癌转移，但是，与N组患者相比，切除胰腺被膜及横结肠系膜前叶的R组在术后生存率方面并无明显优势，说明在胃癌根治术中，不需要对所有患者常规行胰腺被膜及横结肠系膜前叶切除。
[Abstract]:Background: gastric cancer ranks fourth in all kinds of common malignant tumors in the world, ranking second in the cause of cancer related death. Early diagnosis and normalization of gastric cancer is a difficult problem in the medical field. Most of the patients with gastric cancer have been in the period of diagnosis once the diagnosis is clear, so the death rate depends largely on the death rate. Local or distant recurrence and metastasis of the disease, despite the continuous progress of the treatment of gastric cancer, has also developed from simple surgical treatment to integrated surgical and perioperative combined therapy based on anatomy, tumor biology and immunology. The progress of treatment and the improvement of early diagnosis ability, the overall survival rate of gastric cancer has been greatly improved, but surgical treatment is still the basis for the treatment of gastric cancer. Standardized and rational radical gastrectomy is still the key to improve the survival period of gastric cancer patients.
From the history of medicine, surgery is the first available method of treatment for cancer.1809 years. EphraimMcDowell excised an ovarian tumor without anaesthesia, provided a tumor tumor that could be cured by surgery for.1881 years, and Billroth successfully completed the first gastrectomy. In 1908, Voelcker was successfully implemented first. Total gastrectomy, but in the following 50 years, the surgical treatment of gastric cancer was basically limited to the level of the gastrectomy in the 50s.20 century. The Japanese scholars proposed gastrectomy and lymph node dissection to excise more than 2/3 of the stomach and second station lymph node dissection as a standard radical gastrectomy. The standard radical gastrectomy for gastric cancer (D2, D3) has been put forward, but the rational resection range of radical gastrectomy has always been a very controversial topic. The medical workers in different countries and regions have different views. In the past, the advanced gastric cancer countries such as Asia countries, especially in East Asia, Japan, and other advanced gastric cancer countries, have a progressive stomach. The selection of lymph node dissection in radical resection should be more radical and more inclined to lymph node enlargement, while western countries are relatively conservative. In recent years, radical II (D2) lymph node dissection has become the standard of lymph node dissection in the radical operation of gastric cancer in East Asia. However, the resection of the pancreatic and transverse colon during the radical resection of gastric cancer is to remove the pancreatic and transverse colon. There is no conclusion whether the anterior mesangial leaves can improve the long-term survival of the patients. For example, the Memorial Sloan-Kettering Cancer Center experts advocated the anterior mesangial lobe and pancreatic capsule excision, while the Mayo Clinic and M.D.Anderson CancerCenter experts in the United States believed that the anterior lobe of the transverse colic mesenteric membrane was not associated with the pancreatic cyst excision. Objective: to further explore the necessity of conventional resection of the pancreatic and transverse mesangial anterior mesangial leaves during radical gastrectomy for gastric cancer patients without direct invasion of the anterior lobe of the pancreatic and transverse mesangial mesangial leaves by this prospective randomized study to establish a standardized, rational and individualized operation for the future. The scheme provides reference.
Methods: a total of 236 patients with gastric cancer treated from January 2007 to July 2008 were selected. The final 213 patients were randomly divided into two groups: group N (108 cases) and group R (105 cases). The study indexes included patients' sex, age, tumor size (CM), location, depth of invasion, pathological classification, operation mode, lymph node clearance. Scanning range, intraoperative bleeding volume, operation time, postoperative complications and 3 years, 5 year survival rate. The clinical data of group N and group R were checked by chi square test; the postoperative survival rate was calculated by Kaplan-Meier method; the two groups of survival rates were compared with Log-rank rank test. All data were treated with SPSS18.0 statistical software, bilateral test, and alpha =0.05 as test water. P0.05 is statistically significant.
Results: in group R, there were 9 cases of 105 patients after operation, 9 cases of the anterior lobe of the pancreatic membrane and the transverse colon were detected to have metastatic carcinoma cells, and 96 cases of pathological negative patients in group R (R (-) group), the metastasis of the carcinoma of the pancreas and the transverse colon mesangial anterior lobe and the depth of tumor infiltration, the position of the anterior and posterior wall of the tumor, the clinical stage and the degree of lymph node metastasis (P0. 05) and no significant difference (P0.05) with sex, age, tumor location, size, pathological grade and Borrmann typing, but there was no significant statistical significance (P0.05) for 5 years after operation in group N and group R (P0.05), and there was no significant statistical significance (P0.05) in the 5 year survival rate of group N and R (-) group.
Conclusion: the deeper the depth of the tumor, the more late the clinical stage and the higher the lymph node metastasis, the more prone to metastasis of the pancreatic membrane and the anterior lobe of the transverse colon. However, the R group excised from the group of N and the anterior lobe of the transverse mesenteric membrane has no obvious advantage in the postoperative survival rate, indicating the radical gastrectomy for gastric cancer. There is no need to remove the pancreatic capsule and transverse mesenteric anterior lobe in all patients.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R735.2

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