晚期胃癌维持治疗中手术干预、化疗及营养治疗的作用

Surgical intervention, chemotherapy and nutritional support in the maintenance treatment of advanced gastric cancer

目的通过对温州医科大学附属第一医院3例晚期胃癌患者维持治疗全程观察,探讨手术干预(时机及方式选择)、低剂量化疗及营养治疗在晚期胃癌患者维持治疗中的作用。方法对3例确诊为胃癌晚期的患者,在病程不同阶段采取手术干预、低剂量化疗及营养治疗(以肠内免疫营养制剂方案为主)作为维持治疗措施。维持治疗的化疗药物连续应用14天,停药7天,以21天为1个周期,用药剂量为普通剂量的50%~75%。根据患者对上一轮治疗方案的胃肠道反应VAS评分变化、骨髓抑制程度(血常规)及脏器损伤程度调整本轮治疗措施(调整幅度±25%);根据患者对头一天的肠内营养耐受VAS评分调整营养方案(以肠内营养为主,不足的量用肠外营养补充);根据胃肠道梗阻是否影响患者饮食及营养状况,决定是否进行手术。结果 3例患者维持时间分别为30个月、15个月、22个月;3例患者对低剂量化疗及营养治疗依从性良好(VAS评分7分以上,总分10分)。在治疗期间均经过手术治疗,手术目的不一,例1因幽门梗阻早期行胃肠短路术,其目的是为了畅通消化道(总存活30个月,术后存活30个月);例2因原发病灶及盆腔转移病灶有所退缩,行"姑息性全胃切除术,Roux-Y吻合",目的为切除肿瘤(总存活15个月,术后存活12个月);例3因出现癌性肠梗阻行剖腹探查,行"姑息性全胃切除、食道-空肠Roux-Y吻合+全结肠切除、回肠造瘘术",目的是在减除梗阻的同时,达到减瘤的目的(总存活22个月,术后存活4个月)。结论在晚期胃癌患者中低剂量化疗及营养治疗联合应用并根据病情变化及时调整方案,可以在延长患者生存时间及改善生活质量上发挥一定作用;合适的手术时机及手术方式对延长患者生存时间有一定的作用,但过于复杂的手术不一定能达到预期目的,并且可能因手术创伤带来的不利影响缩短患者的生存时间。

Objective Discuss surgical intervention(timing and option)and the effects of maintenance therapy with low dose chemotherapy and nutritional support in patients with advanced gastric cancer by observing3cases from the first affiliated hospital of wenzhou medical university.Methods3patients with advanced gastric cancer were treated by surgical intervention,low dose chemotherapy and nutritional therapy at different stages as maintenance therapy.Maintenance treatment of chemotherapeutic drugslasted for14days,7days interval,21days for a cycle,with the50%~75%dose of the average;the dose was adjusted in next cycle(the adjusted range±25%)according to the VAS score(visual analogue scale)of gastrointestinal reaction in the previous cycle and the degree of myelosuppression(blood routine test)and organ injuries;the nutrition program was adjusted(mainly enteral nutrition,supplementally parenteral nutrition)according to the VAS score of enteral nutrition tolerance in the previous day.Results3patients lived for30months,15months,and22months respectively;3patients had a good compliance to chemotherapy and nutritional treatment(VAS score of7points or more,total score of10points)and all performed surgery with different purposes.The first patientperformed gastrointestinal short circuit operation on the early stage because of gastric intestinal obstruction,and survived total30months;the second patient,total survival of15months and the postoperative survival12months,performed the Palliative totalgastrectomy,Roux-Y operation when imaging and anal examination showed primary lesions and pelvic metastases were regressionafter a period of chemotherapy;the third patient,total survival of22months and postoperative survival of4months,performed the operation of palliative total gastrectomy and esophageal jejunal Roux-Y anastomosis,total colectomy and ileostomy for malignant obstruction in the late stage for the purpose of reducing the tumor and disengage obstruction.Conclusions Low dose chemotherapy and nutritional support,with the plan adjusted according to the condition changes,can play a certain role in prolonging the survival time and improving the life quality of the advanced gastric cancer patients;the appropriate timing of operation and operative methods have certain effect to prolong the survival time of the patients,but the excessive surgery is not always able to achieve the desired objective,and maybe bring adverse effects due to surgical trauma.