残胃癌外科治疗临床分析及再认识

Clinical Analysis and Recognition on Surgical Treatment of Remnant Gastric Cancer

目的分析残胃癌的外科治疗及其临床病理特征,对当前残胃癌外科治疗进行再认识。方法回顾性总结我院2004年1月至2011年3月期间经内镜和病理学检查诊断为残胃癌并行外科治疗的26例患者的临床资料,其中首次疾病为良性的残胃癌（RGCB）者14例,胃癌根治术后残胃癌（RGCC）者12例,对其临床发病、HP感染、手术方式、组织病理学特点及预后因素进行分析。结果 RGCB距第1次胃切除术后的发病时间为15～44年（中位时间为26.3年）,RGCC距第1次胃切除术后的发病时间为1~10.5年（中位时间为4.0年）,两者间差异有统计学意义（P〈0.05）。病理检测残胃癌的HP感染率为73.1%（19/26）,其中RGCB的HP感染率为71.4%（10/14）,RGCC的HP感染率为75.0%（9/12）,两者间差异无统计学意义（P〉0.05）。26例患者均再次进行了手术治疗,其残胃癌手术根治率为46.2%（12/26）,其中RGCB根治切除率为57.1%（8/14）,RGCC根治切除率为33.3%（4/12）,两者间差异无统计学意义（P〉0.05）。在行根治性切除的12例患者中胃周淋巴结转移以小弯淋巴结转移率最高（83.3%,10/12）,其次为空肠系膜淋巴结（33.3%,4/12）和脾门淋巴结（33.3%,4/12）。26例残胃癌术后病理分期：Ⅰ期3例,Ⅱ期2例,Ⅲ期14例,Ⅳ期7例。18例手术切除者术后病理报告提示有13例（72.2%）发生淋巴结转移;明确肿瘤侵犯胰腺或横结肠或脾脏者13例（50.0%）;8例有腹膜转移（30.8%）,其中RGCB的腹膜转移率为14.3%（2/14）,明显低于RGCC的腹膜转移率（50.0%,6/12）,P〈0.05。全组病例累积1年总体生存率为54.5%,3年生存率为38.5%,生存时间为2～61个月（中位生存时间12个月）。生存分析结果表明,肿瘤的病理分期与是否接受根治性手术为残胃癌患者生存的影响因素（P〈0.01）,而患者年龄、性别、第1次疾病、病理分化程度以及HP感染均不是影响预后的相关因素（P〉0.05）;是否接受根治性手术为影响生存的独立预后因素（P〈0.05）。结论早期诊断和根治手术是改善残胃癌患者预后的关键因素,腹腔镜探查可减少不必要的外科手术创伤。胃癌术后残胃癌与良性疾病后残胃癌在临床特点上不同,临床处理仍需区别对待。

Objective To analyze surgical treatment and clinicopathologic features of remnant gastric cancer,and to recognize the strategies of treatment.Methods The clinical data of 26 cases patients with remnant gastric cancer diagnosed by endoscopy and pathological examination and underwent surgical treatment were retrospectively analyzed in our hospital between January 2004 and March 2011.In this study,14 cases of remnant gastric cancer from benign disease（RGCB） and 12 cases of remnant gastric cancer after stomach cancer operation（RGCC） were included.The clinical findings,Helicobacter pylori（HP） infection,surgical methods,histopathological features,and prognosis were analyzed.Results The patients developed a carcinoma in the gastric remnant about 15-44 years after operation for benign disease（median 26.3 years） and about 1-10.5 years after gastric cancer operation（median 4 years）,and there was significant differences of the two groups（P0.05）.HP infection of the gastric remnant was found in 73.1%（19/26） patients,and infection rate of patients was 71.4%（10/14） in RGCB and 75.0%（9/12） in RGCC,but there was no statistical different in two groups（P0.05）.All 26 patients underwent surgical procedure,and the rate of radical resection was 46.2%（12/26）,which was 57.1%（8/14） in RGCB and 33.3%（4/12） in RGCC respectively,there was no statistical different（P0.05）.Among the 12 cases underwent radical resection,the highest lymphatic metastasis rate was in No.3 group（83.3%,10/12）,which came in second in lymph node of mesojejunum or splenic hilum（33.3%,4/12）.Postoperative pathological staging was as follows：stageⅠin 3 cases,stageⅡ in 2 cases,stage Ⅲ in 14 cases and stage Ⅳ in 7 cases.In 18 patients underwent tumor excision,the metastasis of lymph node occurred in 13 cases（72.2%）,and the pancreas,transverse colon,or spleen were invaded in 13 cases according to histopathological results.Meanwhile,peritoneal metastasis were founded in 8 cases patients,and the peritoneal metastasis rate of patients with RGCB（14.3%;2/14） was significantly lower than that with RGCC（50.0%,6/12）,P0.05.The overall one-year survival rate and three-year survival rate was 54.5% and 38.5%,respectively,and the survival time was 2-61 months（median 12 months）.Survival analysis indicated that pathological stage and radical resection were significant prognostic factors for patients with remnant gastric cancer（P0.01）,and radical resection was an independent prognostic factor（P0.05）,while age,gender,disease of first operation,degree of differentiation and HP infection were not（P0.05）.Conclusions Early detection and standard radical resection are the key factor to improve the prognosis of patients with remnant gastric cancer and laparoscopic exploration may minimize unnecessary injures of surgery.Because of the different clinical characteristics,strategy of treatment for RGCC and RGCB shall be discriminatory.