【摘要】：背景：胃癌在全球各種常見惡性腫瘤中排名第四位，腫瘤相關死亡原因中排名第二位，胃癌的早期診斷和規(guī)范化、合理化的治療是醫(yī)學界的一大難題，大部分胃癌患者一經(jīng)診斷明確就已經(jīng)處于進展期，因此，其死亡率很大程度上取決于疾病的局部或遠處復發(fā)及轉(zhuǎn)移，，盡管胃癌的治療手段在不斷的進步，其治療模式也已經(jīng)從單純的手術治療發(fā)展到以解剖學、腫瘤生物學及免疫學為基礎的聯(lián)合規(guī)范化手術和圍手術期輔助治療的綜合治療模式。隨著手術技術的改進、綜合治療方法的進步以及早期診斷能力的提高，胃癌的總體生存率已經(jīng)得到了很大的提高，但手術治療仍然是胃癌治療的基礎，規(guī)范化合理化的胃癌根治術仍然是提高胃癌患者生存期的關鍵。 從醫(yī)學的發(fā)展史來看，手術是治療癌癥的第一種可用的方法。1809年，EphraimMcDowell在沒有用麻醉的情況下切除了一個卵巢腫瘤，提供了腫瘤腫物可通過手術治愈的證據(jù)。1881年，Billroth成功完成了第一例胃切除手術，1908年Voelcker成功施行第一例全胃切除手術。但在隨后的50余年時間里，胃癌的外科治療基本只限于胃大部切除水平。20世紀50年代后，日本學者提出了胃切除及淋巴結清掃，以切除胃2/3以上及行第二站淋巴結清掃術作為根治目的的標準胃切除手術，同時開展了受累及臟器的聯(lián)合切除術，相繼提出了胃癌標準根治術D2、D3手術。但胃癌根治術的合理切除范圍一直是極具爭議的話題，不同國家和地區(qū)的醫(yī)療工作者有著不同的觀點，以往在亞洲國家，特別是東亞的中國、日本等胃癌高發(fā)國家，進展期胃癌根治術中淋巴結清掃范圍的選擇要來得更激進，更傾向于淋巴結擴大清掃，而西方國家則相對保守。近年來，根治Ⅱ（D2）淋巴結清掃已經(jīng)成為了東亞國家胃癌根治術淋巴結清掃方式的標準，然而，胃癌D2根治術中切除胰腺被膜及橫結腸系膜前葉是否能提高患者遠期生存率還沒有一個定論，例如，美國Memorial Sloan-Kettering Cancer Center的專家主張行橫結腸系膜前葉與胰腺包膜切除，而美國Mayo Clinic和M.D.Anderson CancerCenter的專家則認為橫結腸系膜前葉與胰腺包膜切除沒有臨床意義，一般不切除。目的：通過本前瞻性隨機性研究，進一步探討腫瘤未直接侵犯胰腺被膜及橫結腸系膜前葉的胃癌患者在行胃癌根治術時是否有必要常規(guī)切除胰腺被膜及橫結腸系膜前葉，為以后制定規(guī)范化、合理化、個體化的手術方案提供參考。 方法：選擇我胃癌治療小組自2007年1月至2008年7月間收治的胃癌患者共計236例，將最終入組的213例患者隨機分為兩組：N組（108例）及R組（105例）。研究指標包括患者的性別、年齡、腫瘤的大小(cm)、部位、浸潤深度、病理分級、手術方式、淋巴結清掃范圍、術中出血量、手術時間、術后并發(fā)癥及術后3年、5年生存率。對N組和R組臨床數(shù)據(jù)采用卡方檢驗；術后生存率計算采用Kaplan-Meier法；兩組生存率比較，應用Log-rank秩檢驗。所有數(shù)據(jù)采用SPSS18.0統(tǒng)計軟件處理，雙側(cè)檢驗，α=0.05為檢驗水準，P0.05為差異有統(tǒng)計學意義。 結果：R組105例患者術后病理中有9例檢測出胰腺被膜及橫結腸系膜前葉有轉(zhuǎn)移癌細胞，R組術后病理陰性患者96例（定為R(-)組），胃癌胰腺被膜及橫結腸系膜前葉癌轉(zhuǎn)移與腫瘤浸潤深度、腫瘤前后壁位置、臨床分期、淋巴結轉(zhuǎn)移程度有關(P0.05)；而與患者性別、年齡、腫瘤部位、大小、病理分級、Borrmann分型無關(P0.05)。而N組和R組患者術后5年生存率也無明顯統(tǒng)計學意義(P0.05)，N組和R(-)組患者術后5年生存率也無明顯統(tǒng)計學意義(P0.05)。 結論：腫瘤浸潤深度越深、臨床分期越晚、淋巴結轉(zhuǎn)移程度越高的患者，越容易發(fā)生胰腺被膜及橫結腸系膜前葉的癌轉(zhuǎn)移，但是，與N組患者相比，切除胰腺被膜及橫結腸系膜前葉的R組在術后生存率方面并無明顯優(yōu)勢，說明在胃癌根治術中，不需要對所有患者常規(guī)行胰腺被膜及橫結腸系膜前葉切除。
[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.
【學位授予單位】：第二軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R735.2

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