胃癌同时性肝转移外科治疗疗效分析

发布时间：2018-05-01 14:35

本文选题：胃癌 + 肝转移　；参考：《山东大学》2017年硕士论文

【摘要】：目的肝脏是胃癌常见的转移部位之一,同时性转移的发生率为2%-9%,常伴随淋巴结转移、腹膜播散、肝内转移及邻近脏器直接侵袭等不利因素,提示预后不良。为此,手术、化疗、介入等治疗方法均有所应用,但迄今尚缺乏统一认识。其中,手术作为目前唯一可能取得治愈效果的手段已在多个中心开展,相较大肠癌肝转移完全切除术后5-年生存率在50%以上,10-年生存率为17%-25%,其适应症、禁忌症和近远期疗效有待进一步探讨。我们将胃癌同时性肝转移患者的术前、术中和术后资料进行回顾性分析,探讨胃癌同时性肝转移外科治疗的指征及疗效。方法回顾性分析普外科2004年3月至2016年4月期间收治的21例胃癌同时性肝转移患者行胃癌D2切除术的临床资料,根据有无行肝脏R0切除分为R0切除组(11例)和非R0切除组(10例)并对两组临床病理特征和生存情况进行比较。生存期的计算为手术日起至因该病致死亡时间;删失值为随访期间因失访、退出或截至最后一次随访(2016年6月2日)患者仍存活等非疾病因素致观察终止的时间。运用SPSS21.0进行统计分析,定量资料:正态分布以x±s表示并用t检验,偏态分布以M(min-max)表示并用Mann-Whitney U检验比较;分类资料:用χ2检验(包括Fisher确切概率法)或秩和检验比较;Kaplan-Meier法计算生存率,然后用log-rank检验判别统计学差异;多因素分析使用Cox比例风险回归模型。P值0.05认为差异有统计学意义。结果术中资料显示,R0切除组和非R0切除组手术时长无明显统计学差异。术后资料显示,R0切除组有1例出现淋巴瘘,非R0切除组有2例分别出现刀口感染和吻合口瘘;术后相关死亡率均为0%;R0切除组1-,2-,3-年生存率分别为54.5%,27.3%和27.3%;非R0切除组1-,2-,3-年生存率分别为48.0%,0%和0%(P=0.044)。中位生存期分别为16.2个月和5.9个月(P=0.008)。对R0切除组生存资料进行单因素分析发现Bormann分型(P=0.004),区域淋巴结受累(P=0.010)与患者预后有关;多因素分析无明显独立预后因素,可能与Bormann分型与淋巴结受累存在交互作用(P=0.031)。结论1.胃癌同时性肝转移并非手术禁忌,在适宜的人群中基于胃癌D2切除联合肝脏R0切除的多学科辅助治疗是可行的;2.在胃癌同时性肝转移可手术治疗人群中,R0切除较非R0切除可明显延长生存期且并不增加手术时长及并发症发生率;3.关于独立预后因素,需要多中心、大样本前瞻性研究进一步证实。
[Abstract]:Objective the liver is one of the most common metastatic sites of gastric cancer. The incidence of simultaneous metastasis is 2-9. It is often associated with lymph node metastasis, peritoneal dissemination, intrahepatic metastasis and direct invasion of adjacent organs, indicating poor prognosis. Therefore, surgical, chemotherapeutic and interventional treatments have been applied, but so far there is a lack of unified understanding. Among them, surgery, as the only possible cure method, has been carried out in many centers. Compared with complete resection of liver metastasis of colorectal cancer, the 5-year survival rate is more than 50% and the 10-year survival rate is 17% -25%. Contraindications and short-and long-term outcomes need to be further explored. We retrospectively analyzed the preoperative, intraoperative and postoperative data of patients with simultaneous hepatic metastasis of gastric cancer, and discussed the indications and therapeutic effects of surgical treatment for simultaneous hepatic metastasis of gastric cancer. Methods the clinical data of 21 patients with simultaneous hepatic metastasis of gastric cancer treated in general surgery from March 2004 to April 2016 were analyzed retrospectively. According to whether the liver R0 resection was performed, the patients were divided into R0 resection group (n = 11) and non-R0 resection group (n = 10). The clinicopathological features and survival of the two groups were compared. The survival time was calculated as the time from the operation date to the death due to the disease, and the censored value was the time when the patient was observed to be terminated by non-disease factors such as loss of visit, withdrawal or survival as of the last follow-up (June 2, 2016) during the follow-up period. SPSS21.0 was used for statistical analysis and quantitative data: normal distribution was expressed by x 卤s and t test was used, and skewness distribution was expressed by Mann-Whitney U test. Classification data: the survival rate was calculated by 蠂 2 test (including Fisher exact probability method) or rank sum test. The survival rate was calculated by Kaplan-Meier method, and then the difference was distinguished by log-rank test. Multivariate analysis using Cox proportional risk regression model. P 0. 05 suggested that the difference was statistically significant. Results Intraoperative data showed that there was no significant difference in the length of operation between R0 resection group and non-R0 resection group. Postoperative data showed that 1 case had lymphatic fistula in R0 resection group and 2 cases in non-R0 resection group had incision infection and anastomotic fistula respectively. The postoperative mortality rates were 54.5% and 27.3% in the R0 resection group and 48.0% and 0.044% in the non-R0 resection group, respectively. The median survival time was 16.2 months and 5.9 months respectively. Univariate analysis of survival data of R0 excision group showed that Bormann typing and regional lymph node involvement (P0.010) were related to the prognosis of the patients, but there was no significant independent prognostic factor in multivariate analysis, and there might be an interaction between Bormann classification and lymph node involvement (P0.031). Conclusion 1. Simultaneous liver metastasis of gastric cancer is not a contraindication of surgery, and it is feasible to treat gastric cancer based on D2 resection combined with liver R0 resection in a suitable population. In the patients with simultaneous liver metastasis of gastric cancer, the survival time was significantly prolonged and the incidence of complications was not increased by R0 resection than that by non R0 resection. Independent prognostic factors need to be further confirmed by multicenter, large-sample prospective studies.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2

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