胃癌根治术-流程+超声刀课件

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1、胃癌根治术STAGEGROUPINGStage0TisN0M0Stage1AT1N0M0StageIBT1N1M0T2a/bN0M0StageIIT1N2M0T2a/bN1M0T3N0M0StageIIIAT2a/bN2M0T3N1M0T4N0M0StageIIIBT3N2M0StageIVT4N1–3M0T1–3N3M0AnyTAnyNM1FromAJCCCancerStagingManual,6thed.NewYork,Springer-Verlag,2001.StagingStaging--TStaging--NTNMsystemAJCCandUJCCN有不同的分类

2、方法-1997:距肿瘤的距离：<3cm:N1;1997-:转移淋巴结的个数(>15)：6：N1，7-15：N2；日本分类:根据淋巴结分站RstatusR0–microscopicallynegativemarginR1–micro+,gross–R2–grossresidualdiseaseAJCC:SurgicalTreatmentCardia/proximal:ProximalTotalgastrectomyorproximalgastricresection？Proximal/CardiaProximalGastrectomy–increasedmorbidity/

3、mortalityBuhl,etal.GastroesophagealReflux，heartburn,reducedappetiteNorwegianStomachCaTrialProx.gastrectomymorbid/mortal52%16%Totalgastrectomymorbid/mortal38%8%TotalgastrectomyconsideredprocedureofchoiceforproximalgastriclesionsDistalTumorsNo5-yearsurvivaldifferenceb/nsubtotalvstotalgastre

4、ctomySubtotalappropriateifnegativemarginsRecurrencevsnonrecurrencedependsonmarginof3.5cmvs6.5cmExtendedLymphadenectomyControversialJapanesesystemD1–group1LND2–groups1&2D3–D2pluspara-aorticLNToremovestation10&11LN–splenectomyD2resection+partialpancreatectomyNolongerroutineUsedfortumorexten

5、sionRemovalofstation10LNDutchD1vsD2resectionIncreasedintra-hospmortalityJapanD2improvedsurvivaloverD1WestNoimprovementExtendedLymphadenectomyOutcomesRecurrenceAftergastrectomyquitehigh40–80%Mostoccurinfirst3yearsLocoregionalfailure38–45%Anastomosis,gastricbedandregionalnodesPeritonealdiss

6、emination–54%切口探查进入腹腔以后全面探查肝、胆、胰、脾、肠系膜、盆腔有无转移。最终探查病灶，确定其位置、大小、范围及其与周围组织器官的关系，以确定是否行全胃切除。探查探查胰、横结肠系膜是否受累时，可以沿横结肠表面分离切开大网膜进入网膜囊，进一步确定胰腺、横结肠系膜和大血管有否受累及其受累的程度。分离胃网膜右血管和胃右血管显露胃底和食管下段分离胃左动、静脉，靠近根部切断、结扎，清扫腹腔动脉周围淋巴结切断贲门因食管下段无浆膜，只剩肌层，缝合时易撕裂，因此可用1号线于切线的近侧全层缝合一排缝线，将食管肌层和粘膜固定，距缝线远侧0.5cm处将食管切断，将胃管拉出食管

7、。重建消化道提起横结肠，于中结肠血管左侧近屈氏韧带无血管处切开，将空肠远端拉至系膜上。空肠食管-Roux-en-y吻合术