胃癌根治术流+超声刀.ppt

胃癌根治术,Staging,Staging-T,Staging-N,TNMsystemAJCCandUJCCN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RstatusR0microscopicallynegativemarginR1micro+,grossR2grossresidualdisease,AJCC:,SurgicalTreatment,Cardia/proximal:ProximalTotalgastrectomyorproximalgastricresection？,Proximal/Cardia,ProximalGastrectomyincreasedmorbidity/mortalityBuhl,etal.GastroesophagealReflux，heartburn,reducedappetiteNorwegianStomachCaTrialProx.gastrectomymorbid/mortal52%16%Totalgastrectomymorbid/mortal38%8%Totalgastrectomyconsideredprocedureofchoiceforproximalgastriclesions,DistalTumors,No5-yearsurvivaldifferenceb/nsubtotalvstotalgastrectomySubtotalappropriateifnegativemarginsRecurrencevsnonrecurrencedependsonmarginof3.5cmvs6.5cm,ExtendedLymphadenectomy,ControversialJapanesesystemD1group1LND2groups1&2D3D2pluspara-aorticLNToremovestation10&11LNsplenectomyD2resection+partialpancreatectomy,NolongerroutineUsedfortumorextensionRemovalofstation10LNDutchD1vsD2resectionIncreasedintra-hospmortalityJapanD2improvedsurvivaloverD1WestNoimprovement,ExtendedLymphadenectomy,Outcomes,Recurrence,Aftergastrectomyquitehigh4080%Mostoccurinfirst3yearsLocoregionalfailure3845%Anastomosis,gastricbedandregionalnodesPeritonealdissemination54%,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