胃癌根治术-流程+超声刀ppt课件

1、胃癌根治术STAGE GROUPINGStage 0TisN0M0Stage 1AT1N0M0Stage IBT1N1M0T2a/bN0M0Stage IIT1N2M0T2a/bN1M0T3N0M0Stage IIIAT2a/bN2M0T3N1M0T4N0M0Stage IIIBT3N2M0Stage IVT4N13M0T13N3M0Any TAny NM1From AJCC Cancer Staging Manual, 6th ed. New York, Springer-Verlag, 2019. TNM system AJCC and UJCC N有不同的分类方法 -2019: 距肿瘤的

2、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 diseaseAJCC: Surgical Treatment Cardia / proximal: Proximal Total gastrectomy or proximal gastric resection？Proximal / Cardia Proximal Gastrectomy increased morbidity / mortality Buhl,

3、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 lesionsDistal Tumors No 5-year survival difference b/n subto

4、tal 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 resec

5、tion + 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 LymphadenectomyRecurrence After gastrectomy quite high 4080 % Most occur in first

6、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