贲门癌食管及胃切除范围的探讨

Study of the Suitable Extent of Resection of Esophagus and Stomach for Carcinoma of Gastric Cardia

目的 探讨贲门癌外科治疗中食管及胃的适宜切除范围。方法 回顾性分析手术切除贲门癌217例，其中近端胃＋食管下段切除186例，全胃＋食管下段切除31例。根治性切除191例，姑息性切除26例。为保证切缘距肿瘤距离的精确性，以切除后标本测量值和术中目测值双重对比判断。结果标本上切端距肿瘤上缘0—5cm；下切端距肿瘤下缘0．5～19cm。术中目测上切端距肿瘤上缘3．3cm；下切端距肿瘤下缘平均4．7cm。将实测距离转化为术中目测距离，则上切端距肿瘤为0～11．6cm．下切端距肿瘤0．65～24．7cm。上切端阳性36例，阳性率17．4％；下切端阳性6例，阳性率2．9％。上切缘最大标本距离4cm，下切缘8cm，即上切缘目测距离9．3cm，下切缘10．4cm时仍有切缘阳性的发生。术中目测距离达7cm时切缘阳性率为3．7％。结论 施行贲门癌切除术时为避免上切端阳性的发生．至少应在肿瘤上缘以上7cm处切断食管；应从病变的部位及大小、对淋巴结清扫的影响、切缘有否可能阳性、手术的并发症及死亡率、术后生存率和生活质量等因素综合考虑。在尽可能保证切缘阴性和切除彻底性的前提下尽量不作全胃切除。

Objective To study the suitable extent of resection of esophagus and stomach in the surgical treatment for carcinoma of gastric cardia. Methods To analyze retrospectively randomly 217 patients with surgical resection for carcinoma of gastric cardia,in which 186 patients were underwent partial gastrectomy and distal pancreatectomy,31 patients were treated with total gastrectomy and distal esophagectomy, 191 patients with radical resection,26 patients with palliative resection. In order to make sure the precise of the distance from tumor to cutting edge, we compare the post-operative measurements with a rule with per-operative eye-measurement for the specimens. Results The distance measuring with a rule from tumor to superior cutting edge is 0 - 5 cm, to inferior-cutting extremity is 0.5 - 19 cm. Turn the actual measurement into eye-measurement, the distance from tumor to superior and inferior margins is 0 - 11.6cm and 0.65 - 24.7cm respectively. 36 patients （ 17.4% ） with positive margins superiorly,6 patients （2.9%） with positive margins inferiorly. When the largest distance measuring with a rule from tumor to superior cutting edge is 4cm, to inferior cutting edge is 8cm, or to say, is respectively 9.3cm and 10.4cm with eye-measurement, can be positive yet. When the distance measured by per-operative eye-measurement is 7cm, the positive rate of superior cutting edge is about 3.7%. Conclusion The distance from superior margins to neoplasm must be 7cm at least in the gastrectomy for carcinoma of gastric cardia. We should synthetically consider the tumor＇ s location, size,influence of elimination for lymph nodes, possibility of positive for the cutting edge, complications, mortality, survival rate and quality of life etc. We wouldn＇ t like to suggest to perform total gastrectomy as far as possible on the precondition of making sure the positive of cutting edge and the completeness of resection.