进展期胃近侧癌的淋巴结转移和手术治疗

Lymph node metastasis and its surgical treatment in advanced proximal gastric cancer.

目的 通过研究进展期胃近侧癌淋巴结转移情况及相关因素 ,阐述合理的手术治疗。方法 复习 1982～ 1998年行根治性全胃切除的胃近侧癌手术的 16 8例 ,分析淋巴结的转移及有关预后。结果 淋巴结转移率为74 4%。肿瘤的大小、Borrmann分型及病理分型和浸润深度均与淋巴结转移相关 (P <0 0 1)。肿瘤侵及肌层 ,浆膜及浆膜外淋巴结转移率分别为 35 7%、81%和 10 0 %。肿瘤侵及肌层No⑤、⑥淋巴结转移分别为 2 5 %和 10 7% ,并随着外侵程度的加重向下转移率也明显增高。肿瘤侵犯肌层无脾门淋巴结转移 ,侵犯浆膜层及浆膜外分别达5 3%和 15 8% ,而No 淋巴结转移率为 0。N3 淋巴结转移率低 ,在 3%以下 ,极少数为跳跃式转移。肿瘤浸润浆膜外行联合脏器切除中 ,整块切除组预后好于浸润融合组 (P <0 0 5 )。死因中腹膜转移占 74% ,血行转移占 2 2 % ,而局部复发只占 4%。本组有 3 6 %为胃多发癌 ,发生于胃窦部。结论 (1)进展期及对术前不能确定的早期胃近侧癌行全胃切除、D2 或D2 + 清除应为标准术式。 (2 )当肿瘤侵出浆膜外伴脾门部淋巴结转移或脾脏转移应切除脾脏或行联合脏器切除的D2 或D2 + 清除。 (3)

Objective To determine the appropriate surgical treatment by studying lymph node metastasis and relative factors in gastric cancer.Methods We reviewed the data of 168 patients with proximal gastric cancer who underwent radical total gastrectomy in our hospital from 1982 to 1998;we also analyzed lymph node metastasis and prognosis.Results The lymph node metastasis rate was 74.4%,which was related to the tumor size,Borrmann type,pathological type and depth of invasion(P<0.01).The lymph node metastasis rates were 35.7%,81%and 100%,respectively when the tumor invaded depth of muscularis propria,serosa and beyond serosa.The No5,6 lymph node metastasis rates were 25% and 10.7%,respectively when the tumor invaded depth of muscularis propria,more heavy depth invasion and more frequent metastasis along the lower stomach.There was no lymph node metastasis in the splenic hilum when the depth was confined to muscularis propria and there were metastasis rates 5.3% and 15.8%,respectively when the tumor invaded the depth of serosa and beyond serosa, but it showed no lymph node involvement in NoB11.There was lower rate of metastasis in N 3(under 3%),including some jump-type metastasis.Among multiorgan resections for tumor invading depth of beyond serosa,the en-bloc resection group had a better prognosis than infiltration resection group(P<0.05).The causes of death were peritoneal recurrence(74%),hematogenous spread(22%) and local recurrence(4%).There was 3.6% of gastric multicancer occurring in pylorus.Conclusion ①The operation of TG+D 2 or D 2+ clearance should be a standard procedure for advanced or unconfirmed early proximal gastric cancer.②Spleen or multiorgan resection with D 2 or D 2+ clearance should be performed when the depth invasion beyond serosa with lymph node metastasis in splenic hilum or splenic metastasis.③Extending radical resection can not raise the survival rate when there is severe tumor infiltration.