进展期胃癌围手术期治疗全程管理的若干要点

Key points of perioperative whole-process management for patients with advanced gastric cancer

进展期胃癌围手术期治疗全程管理的理念,主要针对进展期胃癌治疗过程中容易被疏忽或未得到充分重视的临床问题,提出并制定科学合理的诊疗计划,将诊断、治疗、康复等各环节有机整合,避免因多学科参与而缺乏有效衔接的状况。进展期胃癌的围手术期全程管理涉及多学科的专业工作,应始终围绕如何提高根治手术的效率、降低术后肿瘤复发、提高患者远期生存率为唯一目标。本文拟结合目前进展期胃癌患者围手术期诊疗中一些薄弱环节与问题,提出全程管理中应重视的若干要点,包括以下几个方面。(1)术前临床分期与评估:通过内镜与影像学诊断进行正确的术前分期,并制定合理的治疗计划,是实施患者围手术期治疗全程管理的必备条件。(2)腹腔镜探查的临床意义与指征:腹腔镜探查有助于发现腹腔内微小转移灶,避免不必要的剖腹探查,对于已浸润至浆膜或怀疑腹膜转移的进展期胃癌患者,应该常规施行术前腹腔镜探查。(3)应充分重视术前新辅助治疗:近年多项随机对照试验研究证实,术前新辅助化疗能使大多数进展期胃癌患者获益;因此,对于cTNMⅢ期与ⅣA期的进展期胃癌患者,应积极开展新辅助治疗。(4)有效预判新辅助化疗的疗效:内镜、多层螺旋CT扫描、PET-CT和液体活检等均有一定的预测价值,可以联合或分别应用以提高预测的准确性。(5)有效预防术后腹膜转移:术中腹腔内大量盥洗、新辅助腹腔内与全身联合化疗、腹腔内温热化疗、术后早期腹腔内化疗与常温腹腔内化疗等都被证实对于预防腹膜转移复发有一定疗效。(6)新辅助治疗患者术后病理评估与TNM再分期的重要性:关键的病理指标是肿瘤退缩程度(TRG)和ypTNM,特别是有无淋巴结转移和转移数量;对已接受新辅助化疗的进展期胃癌患者术后病理达到TRG 0级或ypN0者,其预后常可与cTNMⅠ期患者相媲美。(7)重视术后辅助治疗:术后辅助化疗是进展期胃癌患者围手术期治疗全程管理的重要部分。近来若干研究证实,与单药口服相比,两药联合化疗方案能显著降低D2胃癌根治术后肿瘤复发与死亡风险,特别是cTNMⅢ期患者。(8)强调围手术期营养支持治疗:进展期胃癌患者往往存在不同程度的营养不良,积极给予围手术期营养支持治疗不仅能减少手术并发症,同时也有助于患者完成必须的化疗疗程并最终改善预后。

Perioperative whole-process management(WPM)for patients with advanced gastric cancer(AGC)mainly focuses on some clinical issues which are easily neglected or underappreciated.WPM is helpful in making a scientific and rational therapeutic plan,and avoiding inadequate communication in multi-disciplinary participation,so that the diagnosis,treatment and rehabilitation for AGC patients can be integrated organically.Based on the current clinical practice for AGC patients,eight key issues in WPM should be emphasized.(1)Preoperative clinical staging.An accurate preoperative staging by endoscopy and imaging technique is helpful in setting up a rational therapeutic plan,and is also a prerequisite to start WPM.(2)Indications and value of diagnostic laparoscopy.Laparoscopic exploration is beneficial to find intraperitoneal micro-metastases so as to avoid unnecessary laparotomy.For cases of AGC infiltrating serosal layer or suspected of peritoneal metastasis,preoperative laparoscopic exploration should be routinely performed.(3)Neoadjuvant therapy.Multiple RCT studies have shown that neoadjuvant chemotherapy can benefit a majority of patients with AGC,improving prognosis and prolonging their overall survival.Therefore,neoadjuvant therapy should be considered first for stage III and IVA AGC patients.(4)Prediction of efficacy in neoadjuvant chemotherapy.Endoscopy,MDCT scan,PET-CT and liquid biopsy have certain predictive value individually,which can be used together or separately to improve the accuracy of prediction.(5)Effective prevention of postoperative peritoneal metastasis.Extensive intraoperative peritoneal lavage(EIPL),neoadjuvant intraperitoneal and systemic chemotherapy(NIPS),hyperthermic intraperitoneal chemotherapy(HIPEC),early postoperative intraperitoneal chemotherapy(EPIC),and normothermic intraperitoneal chemotherapy(NIPEC)have been shown to be of various efficacy in preventing peritoneal metastases.(6)Prediction of postoperative prognosis of AGC patients.The key pathological indicators are tumor regression grade(TRG)and ypTNM staging,especially if there is lymph node metastasis.Usually for AGC patients who received neoajuvant chemotherapy with TRG 0 or ypN0,their prognosis was comparable to that of patients with cTNM stage I.(7)Postoperative adjuvant chemotherapy.Postoperative adjuvant therapy is always an important part of the WPM management of AGC patients.Several recent RCT studies have shown that duplet chemotherapy can significantly reduce the risk of death after D2 radical gastrectomy compared to singlet chemotherapy,especially for stage III patients.(8)Perioperative nutritional support.Due to different degrees of malnutrition in AGC patients,enhanced nutritional treatment in the perioperative period can not only reduce surgical complications,but also enable patients to complete necessary course of chemotherapy,and ultimately further improve their survival rate.