胃癌根治术流程+超声刀.ppt

分离胃左动、静脉，靠近根部切断、结扎，清扫腹腔动脉周围淋巴结 切断贲门 因食管下段无浆膜，只剩肌层，缝合时易撕裂，因此可用1号线于切线的近侧全层缝合一排缝线，将食管肌层和粘膜固定，距缝线远侧0.5cm处将食管切断，将胃管拉出食管。 重建消化道 提起横结肠，于中结肠血管左侧近屈氏韧带无血管处切开，将空肠远端拉至系膜上。 空肠食管-Roux-en-y吻合术 * * 胃癌根治术 STAGE GROUPING Stage 0 Tis N0 M0 Stage 1A T1 N0 M0 Stage IB T1 N1 M0 T2a/b N0 M0 Stage II T1 N2 M0 T2a/b N1 M0 T3 N0 M0 Stage IIIA T2a/b N2 M0 T3 N1 M0 T4 N0 M0 Stage IIIB T3 N2 M0 Stage IV T4 N1–3 M0 T1–3 N3 M0 Any T Any N M1 From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2001. Staging Staging -- T Staging -- N TNM system AJCC and UJCC N有不同的分类方法 -1997: 距肿瘤的距离：3cm: N1; 1997-: 转移淋巴结的个数(15)：6：N1，7-15：N2； 日本分类: 根据淋巴结分站 R status R0 – microscopically negative margin R1 – micro +, gross – R2 – gross residual disease AJCC: Surgical Treatment Cardia / proximal: Proximal Total gastrectomy or proximal gastric resection？ Proximal / Cardia Proximal Gastrectomy– increased morbidity / mortality Buhl, et al. Gastroesophageal Reflux ，heartburn, reduced appetite Norwegian Stomach Ca Trial Prox. gastrectomy morbid / mortal 52% 16% Total gastrectomy morbid / mortal 38% 8% Total gastrectomy considered procedure of choice for proximal gastric lesions Distal Tumors No 5-year survival difference b/n subtotal vs total gastrectomy Subtotal appropriate if negative margins Recurrence vs nonrecurrence depends on margin of 3.5 cm vs 6.5 cm Extended Lymphadenectomy Controversial Japanese system D1 – group 1 LN D2 – groups 1 2 D3 – D2 plus para-aortic LN To remove station 10 11 LN – splenectomy D2 resection + partial pancreatectomy No longer routine Used for tumor extension Removal of station 10 LN Dutch D1 vs D2 resection Increased intra-hosp mortality Japan D2 improved survival over D1 West No improvement Extended Lymphadenectomy Outcomes Recurrence After gastrectomy quite high 40–80 % Most occur in first 3 years Locoregional failure 38 – 45% Anastomosis, gastric bed and regional nodes Peritoneal dissemination – 54% 切口 探查 进入腹腔以后全面探查肝、胆、胰、脾、肠系膜、盆腔有无转移。最终探查病灶，