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首页 胃癌清扫

胃癌清扫.pdf

胃癌清扫

shuiyun120
2010-05-07 0人阅读 举报 0 0 0 暂无简介

简介:本文档为《胃癌清扫pdf》,可适用于医药卫生领域

DNodalDissectionMitsuruSasako,MDGastriccancerseldomproducesdistantmetastasesuntiltheprimarybecomesaTtumor(Table)Ontheotherhand,theincidenceoflymphnodemetastasisisalreadyevidentinearlystagesofthedisease(Table)Localcontroloflymphnodemetastasesis,therefore,essentialifcureistobeobtainedUntilrecently,operativeresectionwastheonlyeffectivemethodforlocalcontrolAdjuvantchemotherapyhasnotbeenshowntoincreasesurvivalforgastriccancerinanylargetrials,althoughradiochemotherapy,asadjuvanttreatment,demonstratedbetterresultsthansurgeryaloneinarandomizedcontrolledtrial,Intergroup(SWOG),suggestingtheimportanceoflocalcontrolofthismalignancyHowever,thesurgicaltreatmentappliedinthistrialwasgastrectomywithalimitedlymphnodedissectioninofpatients,andinaddition,retrospectiveanalysisofthistrialdemonstratedthatsurgicalundertreatmentunderminedsurvivalTherefore,itisquestionablewhetheradequatelymphnodedissectioncanbereplacedbyradiochemotherapyTheDutchGastricCancerTrialcomparingDversusDdissectiondidnotprovebeneficialeffectsofaDdissection,principallyduetoanexcessivepostoperativemortalityofThistrialhighlightedtheimportanceofsurgicalexperienceingastrectomyforcancerThusfar,notrialcomparingDversusDhasbeenperformedaftersufficientpretrialtrainingoraphaseIIfeasibilitystudyTheonlyphaseIIstudyinthehistoryofDdissectionwasthatintheItalianGastricCancerTrials,inwhichthepostoperativemortalitywasloweratFollowingthisstudy,thesamegroupofsurgeonsareconductingaphaseIIItrialcomparingDversusDresectionsSPLENECTOMYANDPANCREATECTOMYINDDISSECTIONHistorically,whenDdissectionwasinitiallyperformedinthesthroughs,manycurabletumorswereeitherTorhadlargenodalmetastasesinthesuprapancreaticareaadherenttothepancreasThebodyandtailofthepancreasandthespleenoftenhadtoberesectedenblocwiththetumortoachieveanRresection,ie,completemacroscopicclearanceofthetumorInthes,MaruyamaadvocatedtheadvantageofpancreaspreservationinDdissectionsWiththismodification,thetailofthepancreasispreservedbutthesplenicarteryandthespleenareresectedasinatraditionalpancreatiFromtheGastricSurgeryDivision,NationalCancerCenterHospital,Tokyo,JapanAddressreprintrequeststoMitsuruSasako,MD,ProfessorofSurgery,Chief,GastricSurgeryDivision,NationalCancerCenterHospital,,Tsukiji,Chuoku,Tokyo,,JapanTerminology:Ddissection,lymphnodedissectionlimitedtoperigastricareaDdissection,lymphnodedissectionincludingbothperigastricandsuprapancreaticnodes(commonhepatic,celiac,leftgastricandsplenicarterynodes)SupportedinpartbytheNewyearStrategyforCancerControloftheMinistryofHealth,LaborandWelfareofJapan©ElsevierIncAllrightsreservedX$doi:otgnTablePathologicNstageDistributionAccordingtotheTumorDepthAmongPatientsWhoUnderwentLaparotomyatNCCHBetweenDepthNNNNNTmmsmTmpssTseTsiTotalmm,mucosaandmuscularismucosasm,submucosalmp,muscularispropriass,subserosalse,serosalsi,surroundingorganinvasionReproducedwithpermissionfromSasakoM:Surgicalmanagementofgastriccancer:TheJapaneseexperienceIN:DalyJM,HennesyTPH,ReynoldsJV(eds):ManagementofUpperGastrointestinalCancerLondon,WBSaunders,,ppTableIncidenceofNodal,Hepatic,andPeritonealMetastases()AccordingtoTumorDepthAmongPatientsWhoUnderwentLaparotomyatNationalCancerCenterHospital(NCHH)BetweenDepthLymphNodeLiverPeritoneumNoofPatientsTmmsmTmpssTseTsiTotalmm,mucosaandmuscularismucosasm,submucosalmp,muscularispropriass,subserosalse,serosalsi,surroundingorganinvasionReproducedwithpermissionfromSasakoM:Surgicalmanagementofgastriccancer:TheJapaneseexperienceIN:DalyJM,HennesyTPH,ReynoldsJV(eds):ManagementofUpperGastrointestinalCancerLondon,WBSaunders,,ppOperativeTechniquesinGeneralSurgery,Vol,No(March),:ppcosplenectomyInmanyspecialistcentersinbothEuropeandJapan,pancreaspreservingtotalgastrectomyisthestandardprocedureforaDtotalgastrectomy,,,althoughdisadvantagestosplenectomyhavebeensuggestedInparticular,thetwolargeclinicaltrialscomparingDtoDdissectionstronglysuggestedanegativeeffectofsplenectomyonbothpostoperativemorbidityandmortality,Asthesetrialswerenotdesignedtocomparepatientswithorwithoutsplenectomy,anewtrialcomparingDwithorwithoutsplenectomyneedstobeperformedtoprovideadefinitiveanswertothisquestionSuchatrialhas,infact,beenstartedbytheJapaneseClinicalOncologyGroupinwiththeaccrualofpatientsplannedinanattempttoprovetheadvantagesdisadvantagesofsplenicpreservationAstheresultsofthisrandomizedcontrolledtrialarepending,apancreaspreservingtotalgastrectomywithaDnodaldissectionisdescribedasthestandardsurgicaltechniqueinthiscontributionCANDIDATESFORPANCREASPRESERVINGDTOTALGASTRECTOMYAnyTtumorrequiringatotalgastrectomyshouldbetreatedwithoutperformingasplenectomyAnycurableTtumorinvadingthetailofthepancreasshouldbetreatedbytotalgastrectomywithapancreaticosplenectomyInpatientswhohavemacroscopicallymetastaticnodesadherenttothepancreas,theinvolvedportionoftheglandandtheremainderofthedistalpancreasshouldberesectedwiththespleenOthercurableadvancedtumorsarecandidatesforthisprocedureSurgicalProcedureTheincisionofchoiceiseitheranuppermidline,orthesocalledMercedesincision,whichincludesbilateralsubcostalincisionsplusahighmidlineincisionoverthexiphoidprocess(Fig)ThexiphoidprocessshouldberesectedatthexiphisternaljunctiontoobtainclearvisualizationoftheesophagealhiatusFollowinglaparotomy,theentireperitonealsurfaceincludingthepouchofDouglasshouldbeinspectedandpalpated,afterwhichasampleforlavagecytologyistakenfromthepouchofDouglasortheleftsubphrenicspaceTheliverisinspectedandpalpatedtoexcludepreviouslyundetectedmetastasesAKochermaneuverisperformedtoaccesstheparaaorticareaIftherearesuspiciousmetastaticnodes,theyshouldberemovedandsentforfrozensectionanalysisIftheseevaluationsrevealnodistantmetastasis,acurativeoperationisinitiatedDNodalDissectionThegreateromentumisdissectedfromthetransversecolontogetherwiththeanteriorsheetofthemesocolon(lessersac)ItisunclearwhetheracompleteomentectomyandbursectomyisnecessaryforTtumors,butitisimportantforTtumorsthatmayinvadethelessersacManytumorsinvadingoradherenttotheanteriorsheetofthemesocoloncanberesectedcompletelywithresectionofthissheetonlybutwithoutatransversecolectomyThesecondassistantshouldspreadthetransversecolonsothattheoperatorcandissecttheanteriorsheetfromtheunderlyingtissueeasilyThisprocedureisstartedfromboththehepaticandthesplenicflexurestowardthemiddleofthecolon,wheredissectionisthemostdifficultDissectioniscontinuedcraniallyfromthecolontowardthepancreaticbodyandtailThedissectionshouldbestoppedclosetotheinferiorborderofthepancreasOntheright,theanteriorsheetofthemesocoloncontinuesontotheduodenumandtheheadofthepancreasMitsuruSasakoWhiledissectingthissheet,therightaccessorycolicveinisfoundandfollowedcraniallytothepointwhereitjoinsHenle’ssurgicaltrunkTheoriginofthegastroepiploicveincanthenbeidentifiedThisveinisligatedanddividedatitsoriginDNodalDissectionAsthemesocoloncontainsvesselswhichemergefrombehindthepancreas,cranialcontinuationofthedissectionoftheanteriorsheetofmesocolonleadstoaplanebehindthepancreasTherefore,thelayerofdissectionhastochangefromtheposteriortotheanteriorsurfaceofthepancreasSeveralsmallvesselspassingfrombehindthepancreasshouldbeligatedanddividedTheanteriorsheetofthemesocoloncontinuesasthepancreaticcapsule,whichisnowdissectedfromtheunderlyingpancreaticparenchymaThisdissectionisperformedfromtheinferiortothesuperiorborderofthepancreasandfromthemiddleofthepancreastowardtheduodenum,untilthegastroduodenalarteryisfoundThisarteryisfollowedcaudallytotherightgastroepiploicartery,whichisdoublyligatedanddividedatitsoriginMitsuruSasakoAfterdivisionofthegastroepiploicartery,thegastroduodenalarteryisfollowedcraniallyuntilthecommonandproperhepaticarteriesarerecognizedThereisusuallyonelargelymphnodelyinginthetriangleformedbythegastroduodenalandcommonhepaticarteriesandthesuperiorborderofthepancreasThisnodeisclassifiedasasuprapancreaticnode,butrecentstudieshaveshownthatitisoftenoneofthesentinelnodesfromtumorsinthegastricantrumThestomachispulledcaudallybytheassistantsothatthelesseromentumandtheserosacoveringtheesophagealhiatusarestretchedThelesseromentumisthendividedcmcaudaltotheattachmenttothelateralsectoroftheliverInmanycases,thereisanaccessorylefthepaticartery(occasionallyareplacedlefthepaticartery)crossingthelesseromentumtotheliver,whichrequiresspecialattentionWhetherthisarterytotheliverfromtheleftgastricarteryshouldbepreservedornotisdecidedbythestageoftumor(incidenceofmetastasistothisarea)andthesizeofthearteryWhentheintrahepaticanastomosisbetweenthebranchesoftheproperhepaticarteryandanaberrantlefthepaticarteryispoorlydeveloped,partiallivernecrosisinthelateralsegmentsmayoccurThislineofdivisionjustbelowthelivershouldbecontinuedontothehepatoduodenalligamenttothepatient’sleftsideofthehepaticductTheserosaoftheligamentisincisedcaudallytowardtheduodenumThisdefinestheareaofdissectionofthehepatoduodenalligamentSeveralsupraduodenalvessels,mostofwhichoriginatefromthegastroduodenalartery,areligatedonthefirstpartoftheduodenumAftercompletingthisstep,thegastroduodenalarteryandthesurfaceoftheneckofthepancreasareclearlyseen,astheduodenumisalreadydetachedfromthepancreasalongthegastroduodenalarteryTissueinthehepatoduodenalligamentisdissectedalongthegastroduodenalarteryandthenalongtheproperhepaticarteryfromtheduodenumtowardtheliverDNodalDissectionTheproximalendsofthesupraduodenalarteriesareligatedattheiroriginfromthegastroduodenalarteryDissectionofthehepatoduodenalligamentistothebifurcationoftheproperhepaticarterynearthehepatichilumTherightandlefthepaticarteriesarerecognizedatthislevelandtissuesaredissectedcaudallyandfromtherighttotheleftTherightgastricarteryisfoundarisingfromeitherthegastroduodenalorproperhepaticarteryinmostcasesOccasionallytherightgastricarterycanarisefromthelefthepaticarterywhenithasbifurcatedlowfromtheproperhepaticarteryMitsuruSasakoAfterligationanddivisionoftherightgastricartery,theduodenumisdividedinthefirstportionBeforestartingthedissectionofthesuprapancreaticnodes,lymphnodestotheleftandbehindtheportalveinaredissected,exposingtheleftandtheposteriorsidesoftheportalveinDissectionofthesuprapancreaticnodes,ie,commonhepatic,celiac,leftgastricandsplenicarterynodes,isnowperformedfromrighttoleft,fromtheportalveintothemiddleofthesplenicarteryTheadiposetissuecranialtothepancreascontainsmanylymphnodesThistissueislooselyattachedtothepancreaticparenchymainmostcasesandthereforecanbeseparatedfromthepancreaswithoutdifficultyHowever,inpatientswhohaveahistoryofpancreatitisorwhohavefattydegenerationofthepancreas,dissectionbetweenthepancreaticparenchymaandthesuprapancreaticadiposetissueisdifficultandoftenbloodyThepancreasis,therefore,easilydamaged,andthismayresultinpancreaticleakageDNodalDissectionTheleftgastricveincrossingoverthecommonhepaticorthesplenicarteryandenteringthesplenicveinissometimesencountered(approximatelyonethirdofcases)duringthisstageoftheprocedureThisveinshouldbeligatedanddividednearthesuperiorborderofthepancreasTheadiposetissuecontaininglymphnodesinthisareaisthencarefullydissectedfromthearteriesandsurroundingnervetissueinacranialdirectionIftherearenoobviousnodalmetastases,thenervestructuressurroundingthearteriesincludingbilateralceliacgangliashouldbepreservedTheposteriorborderofthisadiposetissueistherespectivediaphragmaticcrusoneachsideoftheceliacarteryOntheright,therearemanylymphnodesbehindthecommonhepaticartery,whichcontinuecaudallyastheparaaorticnodesWhenthesenodesaredissected,theleftgastricveinisseenenteringtheportalveinnearthesplenoportaljunction(approximatelytwothirdsofcases)showninthefigureAfterdissectionofthistissuefromtherightcrus,therightsideoftheceliacarteryandtherootoftheleftgastricarterycanberecognizedfromitsrightsideTheleftgastricarteryissurroundedbythicknervetissue,mainlyceliacbranchesofthevagalnervesTogetherwiththenerve,thearteryisligatedanddividednearitsoriginMitsuruSasakoTheadiposetissueontheleftsideoftheceliacarteryisnowdissectedfromtheleftcrussurroundingtheesophagealhiatusandfromtheleftsideofGerota’smembranemorelaterallyThistissuecontainsthesplenicarterynodesanddissectionofthesenodesiscontinuedalongtheanteriorsurfaceofthesplenicarteryuntiltheposteriorgastricvesselsareencounteredandligatedattheiroriginfromthesplenicarteryThegreatpancreaticartery(arteriapancreaticamagna)branchesoffatthesamepointfromthesplenicartery,whichisligatedanddivideddistaltothegreatpancreaticarteryIntheoriginalMaruyama’spancreaspreservingDtotalgastrectomy,thesplenicarterywasligatednearitsorigin,butinSasako’smodification,thepositionofligationisdistaltothegreatpancreaticarterytoimprovebloodsupplytothetailofthepancreasThesplenicveinshouldbepreservedasfarasthetipofthepancreasandasmanytributariesfromthepancreasaspossibleshouldbepreservedDNodalDissectionThebodyofthepancreasismobilizedfromtheretroperitoneumonToldt’sfasciaDissectionisstartednearthemiddleoftheglandfromtheinferiorborderofthepancreastowardthesuperiorborderandthenlaterallyfrommiddleparttowardthespleenCompletemobilizationofthebodyandtailofthepancreastogetherwiththespleenenablesthoroughlymphnodedissectionofsplenicarteryandsplenichilarnodesAlltheconnectivetissuesurroundingthetailofthepancreas,splenicveinandarteryisclearedAtthisstage,thestomach,thespleen,andtheomentumwithsurroundingconnectivetissue,includingmanyregionallymphnodes,arepulledupandthecardioesophagealbranchoftheinferiorphrenicvessels,branchingtotheleftsideofthecardia,isligatedanddividedatitsoriginThelymphnodesattheoriginofthephrenicvesselsareincludedintheleftpericardiacnodesintheJapaneseClassificationoftheGastricCarcinomaThevagaltrunksaredividedatasuitablelevelbasedontheproximalextensionofthetumorTheabdominalesophagusisthendividedwithasafesurgicalmarginMitsuruSasakoOurpreferredreconstructionisastapledRouxenYesophagojejunostomyTheRouxlimb(jejunum)shouldbeplacedthroughaslitofmesocolonjusttotherightofthemiddlecolicvesselsThelengthofjejunumabovethemesocolonshouldbeasshortascmtoavoidkinkingandadhesiontothedissectedsurfaceWepreferanendtosideesophagojejunostomyforsafety,beingcarefultomakethejejunalstumpsmalltoavoidablindloopandstasisoffoodTheRouxlimbisfixedtothetransversemesocolonwithclosureofthedefectWestronglyfavoraretrocolicRouxenYtechniqueDNodalDissectionPOSTOPERATIVECARETableshowstheincidenceofpostoperativecomplicationsafterDorDdissectionsintheclinicaltrialJCOGTotalanddistalsubtotalgastrectomyareincludedThemostfrequentcomplicationisintraabdominalabscess,whichisusuallysubphrenicIfthemorbidityaftersubtotalandtotalgastrectomyiscompared,pancreaticfistulaisnotablymorefrequentaftertotalgastrectomy,butthereislittledifferenceinothercomplications(Table)Anastomoticleakageattheesophagojejunostomyhasdecreasedfrommorethantotobecauseoftheuseofsurgicalstaples,ThemostfrequentlifethreateningcomplicationfollowingDtotalgastrectomyispancreaticleakage,usuallyaccompaniedbyintraabdominalabscesswhencontaminatedAsthiscontaminationoccurseveninpatientswithoutdrainagetubes,themostlikelyrouteforcontaminationisrefluxofduodenalcontentthroughthePapillaofVaterToavoidsepticcomplicationsrequiringreoperation,insertionofprophylacticdrainagetubesintotheleftsubphrenicspaceisrecommendedSeparatedrainsareplaced(laterally)inthesubphrenicspaceand(anteriorly)alongthetailofthepancreasAmylaseconcentrationofthefluidfromthesedrainagetubesismeasureddailyuntilitdecreasestolessthaninternationalunitspermilliliterIftheamylaseconcentrationremainsmorethanIUmLaftertodays,pancreaticleakageisoccurringIfthelevelismorethanIUmL,continuoussuctionisrecommendedIftheamylaselevelislessthanIUmLandthepatientdoesnothavefeaturesofsepsis,thedrainagetubesarekeptinplacefortodayswhenfistulographythroughthetubesisperformedIfthereisalargecavityoraninsufficientlydrainedspace,continuousirrigationshouldbestartedDrainageofcontaminatedpancreaticleakageisoftensoviscousthatdrainsareeasilyoccludedInsuchcases,thedrainsneedtobeaspiratedfrequentlywithlargecalibersuctioncathetersUltimatelythedrainsshouldbechangedtoalargedoublelumen(usuallyFrenchgauge)draintoalloweffectivecontinuousirrigationContaminationofpancreaticjuiceactivatespancreaticenzymesandmaycausepseudoaneurysmsofhepatic,splenic,celiacarteries,ortheirligatedstumpsAswithpatientswhodevelopanastomoticleakage,continuousaggressiveirrigationistheonlywaytopreventsuchlifethreateningoccurrencesSURVIVALRESULTSThesurvivalresultsofDgastrectomyaresummarizedi

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