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1、胃癌根治術(shù)STAGEGROUPINGStage0TisN0M0Stage1AT1N0M0StageIBT1N1M0T2a/bN0M0StageIIT1N2M0T2a/bN1M0T3N0M0StageIIIAT2a/bN2M0T3N1M0T4N0M0StageIIIBT3N2M0StageIVT4N1–3M0T1–3N3M0AnyTAnyNM1FromAJCCCancerStagingManual,6thed.NewYork,Springer-Verlag,2001.StagingStaging--TStaging--NTNMsystemAJCCandUJCCN有不同的分類(lèi)
2、方法-1997:距腫瘤的距離：<3cm:N1;1997-:轉(zhuǎn)移淋巴結(jié)的個(gè)數(shù)(>15)：6：N1，7-15：N2；日本分類(lèi):根據(jù)淋巴結(jié)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%切口探查進(jìn)入腹腔以后全面探查肝、膽、胰、脾、腸系膜、盆腔有無(wú)轉(zhuǎn)移。最終探查病灶，確定其位置、大小、范圍及其與周?chē)M織器官的關(guān)系，以確定是否行全胃切除。探查探查胰、橫結(jié)腸系膜是否受累時(shí)，可以沿橫結(jié)腸表面分離切開(kāi)大網(wǎng)膜進(jìn)入網(wǎng)膜囊，進(jìn)一步確定胰腺、橫結(jié)腸系膜和大血管有否受累及其受累的程度。分離胃網(wǎng)膜右血管和胃右血管顯露胃底和食管下段分離胃左動(dòng)、靜脈，靠近根部切斷、結(jié)扎，清掃腹腔動(dòng)脈周?chē)馨徒Y(jié)切斷賁門(mén)因食管下段無(wú)漿膜，只剩肌層，縫合時(shí)易撕裂，因此可用1號(hào)線(xiàn)于切線(xiàn)的近側(cè)全層縫合一排縫線(xiàn)，將食管肌層和粘膜固定，距縫線(xiàn)遠(yuǎn)側(cè)0.5cm處將食管切斷，將胃管拉出食管
7、。重建消化道提起橫結(jié)腸，于中結(jié)腸血管左側(cè)近屈氏韌帶無(wú)血管處切開(kāi)，將空腸遠(yuǎn)端拉至系膜上。空腸食管-Roux-en-y吻合術(shù)
