胃癌急性穿孔的外科诊疗策略

Surgical strategy of diagnosis and treatment for acute perforated gastric cancer

胃癌急性穿孔是发生于胃癌原发灶的穿孔.是一种较少见的外科急腹症,以进展期胃癌为主,与肿瘤浸润深度有关。胃癌急性穿孔术前诊断困难,术中冰冻病理是确诊胃癌急性穿孔的主要手段和临床标准。胃癌急性穿孔的主要治疗方式是外科手术,其风险大,并发症发生率和病死率较高,在外科治疗选择上,首先应考虑患者近期安全性,根据患者全身情况、肿瘤分期及术者经验选择合适的手术方式,可采用生理学和手术严重程度评分(POSSUM)对术后并发症发生风险进行全面评估。其次应考虑患者远期生存。手术的关键是R。切除,当初次手术无法达到R。切除时,应尽量避免姑息切除手术,建议先行单纯修补术,为患者情况改善后择期行腹腔镜手术提供机会。胃癌急性穿孔修补术后二期手术时机的选择尚未有定论,笔者认为,对于进展期胃癌急性穿孔,如一期仅行穿孔修补术,建议完成新辅助治疗后,根据疗效再决定二期手术。胃癌急性穿孔病例不多,目前国内外尚缺乏相关外科治疗的高级别循证医学证据.也无统一的诊治规范和共识,因此,有待进一步去关注与探索,建立一套完善的胃癌急性穿孔外科诊治思路.帮助一线外科医师进行临床决策,提高胃癌急性穿孔患者的近期疗效及远期生存。

Acute perforated gastric cancer (GC)is defined as an acute perforation of primary GC.It is a rare surgical acute abdominal disease that is mainly caused by advanced GC.The onset of acute perforation of GC is related to the depth of invasion.Preoperative diagnosis is very difficult for GC with acute perforation.The main method to confirm malignant perforation is intraoperative frozen section, which also is the primary clinical standard at present.The primary treatment for GC with acute perforation is surgical intervention,which is associated with high morbidity and mortality.Therefore,we should first consider short-term safety and choose the surgical approach based on the patient's condition,tumor stage and surgeon's experience. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM)can provide a comprehensive assessment for patient's condition and surgical risk.Secondly,long-term survival should be considered and R0resection is the most important.When R0 resection can not be achieved in the initial treatment phase, palliative gastrectomy should be avoided.A simple perforation repair can provide an opportunity for two-stage laparoscopic surgery,but the timing of the second stage operation is controversial.We advocate that advanced GC with acute perforation undergoing initial perforation repair can receive subsequent neoadjuvant therapy.A second stage surgery should depend on the response to therapy.Cases of acute perforation of gastric cancer are few.At present,high-level evidence is absent for surgical treatment at home and abroad, and there is no guideline or consensus for diagnosis and treatment.Therefore,it is necessary to explore and establish a comprehensive process of diagnosis and surgical treatment for acute perforated GC,which may be very helpful for first-line surgeons and can also improve the short-term outcomes and long-term survival for GC with acute perforation.