摘要
OBJECTIVE: To study the clinical value of radical resection of gastric carcinoma with pancreas and spleen preservation (PSP) and functional cleaning of lymph nodes (LNs) of the spleen hillus and along the splenic artery. METHODS: Pancreas and spleen involvement was retrospectively reviewed among 439 cases of resectable carcinoma of the gastric cardia, gastric corpus and total stomach. During gastric surgery, 2 ml of methylene blue was injected into the subserosal space of the gastric cardia or corpus to observe the spread of lymphatic flow in 54 cases of gastric carcinoma. The metastatic rate of LNs in splenic hillus and along the trunk of the splenic artery (No10, No11), postoperative complications and survival rates were investigated in 63 gastric carcinoma patients that had received gastrectomy with pancreas and spleen preservation (PSP). These were compared with the pancreas preservation (PP) group and pancreas and spleen combined resection (PSR) group. RESULTS: Among these 439 cases, only 25 cases were observed with direct invasion to the pancreas (5.7%), and 10 cases with direct invasion to the spleen (2.3%). After pathological examination of the pancreatic body and tail, we found 22 cases with pancreas and spleen combined resection, 4 cases (18.2%, 4/22) with direct invasion of the capsule and 2 with invasion to the superficial parenchyma (9.1%, 2/22), without metastasis to the lymph nodes within the pancreas and spleen. The metastatic rate of No10, No11 lymph nodes were 17.5% (11/63) and 19.1% (12/63) in the PSP group, 20.8% (45/216) and 25% (54/216) in the PP group, and 20% (6/30) and 23.3% (7/30) in the PSR group. There were no statistically significant differences (P > 0.05). Injection of methylene blue into the subserosal space of the stomach did not diffuse into the spleen or pancreatic parenchyma. Postoperative complications, diabetes and mortality in PSP (0%, 0%, 0%) were lower than in PP (4.2%, 0.9%, 0.9%) or PSR (40%, 10%, 3.3%). The 5-year survival rate (5-YSR) and 10-YSR in PSP (57.5%, 52.0%) were higher than in PSR (37.5%, 30.0%). Those patients with stage II and III(a) treated by PSP, improved markedly. CONCLUSIONS: The surgical procedure of pancreas and spleen preservation for gastric cancer is a safe and organ function protected method. Postoperative complications were lower and survival rates were higher, the radicality was not reduced. These results indicate that PSP is preferred in patients with gastric carcinoma of stage II or III(a).
目的 观察胃癌手术保留胰脾清除脾门和脾动脉干淋巴结 (即No 10、11)合理性和可行性。方法 分析 4 39例手术切除的胃贲门、体部和全胃癌侵入胰脾情况 ;对 5 4例胃癌患者在术中从贲门和体部浆膜下注入亚甲兰观察胃的淋巴流向 ;6 3例胃癌采用保留胰脾功能性清除No 10、11淋巴结方法 ,与同期保胰法和胰脾切除法比较 ,分析No 10、11淋巴结转移率 ,观察术后并发症发生率和生存率。结果 4 39例胃贲门、体部和全胃癌侵入胰脾机会不多 ,分别为 5 7% (2 5 / 4 39)和 2 3% 910 / 4 39) ;5 4例胃的美兰淋巴引流不进入脾脏和胰腺内。保留胰脾法、保胰法和脾胰切除法 3组No 10、11淋巴结转移率分别为 17 5 %(11/ 6 3) ,19 1% (12 / 6 3) ;2 0 8% (45 / 2 16 ) ,2 5 % (5 4/ 2 16 ) ;2 0 % (6 / 30 ) ,2 3% (7/ 30 ) ,差异无显著意义。 6 3例保留胰脾法术后并发症发生率和病死率均较保留胰法和胰脾联合切除法低 ,而生存期较高 ,5年、10年生存率分别为5 7 5 %、5 2 % ,5 7 4 %、4 7 4 %和 37 3%、30 %。Ⅱ、Ⅲa期患者保留胰脾手术的 5年、10年生存率明显改善。结论 保胰脾法是一个安全、切实可行的保留脏器功能的胃癌根治手术 ,术后并发症低、生存率高。尤对Ⅱ、Ⅲa期患者应行保留胰脾手术。
