胃癌根治术流+超声刀.ppt

胃癌根治术,Staging,Staging - T,Staging - N,TNM system AJCC and UJCC N有不同的分类方法 -2019: 距肿瘤的距离：15)：6：N1，7-15：N2； 日本分类: 根据淋巴结分站 R status R0 microscopically negative margin R1 micro +, gross R2 gross residual disease,AJCC:,Surgical Treatment,Cardia / proximal: Proximal Total gastrectomy or proximal gastric resection？,Proximal / Cardia,Proximal Gastrectomy increased morbidity / mortality Buhl, et al. Gastroesophageal Reflux ，heartburn, reduced appetite Norwegian Stomach Ca Trial Prox. gastrectomy morbid / mortal 52% 16% Total gastrectomy morbid / mortal 38% 8% Total gastrectomy considered procedure of choice for proximal gastric lesions,Distal Tumors,No 5-year survival difference b/n subtotal vs total gastrectomy Subtotal appropriate if negative margins Recurrence vs nonrecurrence depends on margin of 3.5 cm vs 6.5 cm,Extended Lymphadenectomy,Controversial Japanese system D1 group 1 LN D2 groups 1 & 2 D3 D2 plus para-aortic LN To remove station 10 & 11 LN splenectomy D2 resection + partial pancreatectomy,No longer routine Used for tumor extension Removal of station 10 LN Dutch D1 vs D2 resection Increased intra-hosp mortality Japan D2 improved survival over D1 West No improvement,Extended Lymphadenectomy,Outcomes,Recurrence,After gastrectomy quite high 4080 % Most occur in first 3 years Locoregional failure 38 45% Anastomosis, gastric bed and regional nodes Peritoneal dissemination 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