早期胃癌淋巴转移的影响因素和缩小型手术治疗

Influencing factors of the lymph metastasis of early gastric cancer and restrictive operation

分析影响淋巴转移的高危因素，探讨剖腹缩小手术的适应证。方法对５２０例早期胃癌手术病理标本进行研究，比较粘膜内癌（ｍ癌）和粘膜下层癌（ｓｍ癌）大体分类、浸润深度、溃疡伴发和病灶大小以及病理类型与淋巴转移的关系，同时探讨剖腹缩小手术（保留大网膜的Ｄ１＋７廓清术）和Ｄ２廓清术的手术死亡率和并发症。结果在２７５例ｍ癌和２４５例ｓｍ癌中，Ⅱｃ型淋巴转移最多。小于２０ｍｍ的ｍ癌，均无淋巴转移；大于２０ｍｍ的１５３例（５５６％）中，淋巴转移有４例（Ｐ＜０．０１）。无溃疡病灶的１４６例中，仅１例（０７％）有淋巴转移；但伴有溃疡病灶的１２９例中，有３例（２３％）有淋巴转移（Ｐ＜０．０５）。Ｄ１＋７式（６６例）术后肠梗阻的发生率较Ｄ２式（２５９例）有明显下降（１５％比１５％；Ｐ＜０．０１）。而手术死亡率和长期生存率则无明显变化。结论本组结果提示ｓｍ癌较ｍ癌易发生淋巴转移，而ｓｍ癌伴有溃疡时更易发生Ｎ２淋巴转移。因此剖腹缩小手术（Ｄ１＋７廓清术）的适应证宜为２０ｍｍ以下未伴有溃疡的ｍ癌。

Objective To analysis the risky factors of lymph metastasis and study the indications of restrictive resection for EGC. Methods The relationship between lymph metastasis and the gross types, invading depth, tumor size with or without ulcer and pathological profiles were analysed in 520 cases of early gastric cancer(EGC). Meanwhile the mortalities and the complications after D 1+7 (restrictive resection or less invasive resection) and D 2 lymphodenectomy for ECG have been analysed and compared. Results In 275 cases of mucosal cancer (m Ca.) lympha node(LNM) metastsis was recognized in 4 cases (1.09%) but no LNM in the mCa which dimater was less than 20mm; in 245 cases of submucosal cancer (smCa), lympha node metasatasis was found in 54 cases (22.0%). Only one case with LNM was found in 146 cases of EGC without ulcer formation; whereas, 3 cases with LNM in 125 cases of EGC with ulcer formation ( P <0.05). Intestinal obstruction after D 1+7 lymphodenectomy was significantly lower than that in D 2 lymphodenectomy (1.5% vs 15%, P <0.01). Conclusions This study showed that LNM would more easily occurred in sm Ca than that in mCa and the sm Ca with ulcer formation would more easily result in n 2 lymph metastasis. Therefore, the indications for restrictive resection of D 1+7 lymphodenectomy should be limited in the diameter less than 20mm of m Ca and without ulcer formation. The indications and the choice of various restrictive operations depend on the correct judgment of the invading depth of cancer, and the correct pathological diagnosis intraoperatively.