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目的　探讨治疗贲门癌的手术新入路及吻合方法。方法　广东省揭阳市人民医院普通外科 1997年1月至 2 0 0 3年 7月经腹切开膈肌脚入路 ,行胃浆肌瓣覆盖 食管胃黏膜吻合 10 3例。结果　全组病例无死亡、无吻合口瘘 ,亦无食管切缘癌残留。术后并发症发生率 4 82 %。结论　经腹切开膈肌脚 ,行胃浆肌瓣覆盖 食管胃黏膜吻合术 ,操作在腹腔进行 ,创伤及生理干扰较小 ;能有效地预防吻合口漏 ;既能切除足够的食管 ,又能扩大淋巴结的清除范围 ,适用于浸润食管长度 <2cm的贲门癌的手术治疗。     

经腹经后纵隔贲门癌根治术

目的 探讨经腹经后纵隔进行贲门癌根治的可行性和安全性.方法 对26例贲门癌侵及食管下段的患者进行经腹经后纵隔贲门癌根治术,其中根治性近端胃食管切除9例,根治性全胃食管切除17例.结果 本组26例均成功完成经腹经后纵隔贲门癌根治术.平均手术时间:全胃切除(189±39)min,近端胃切除(153±35)min;平均手术出血量:全胃切除(200±80)ml,近端胃切除(168±76)ml;平均清扫淋巴结数:腹腔淋巴结(23.3±7.3)枚/例,食管旁淋巴结(4.1±2.0)枚/例.术后无吻合口出血、吻合口瘘、吻合口狭窄发生,4例患者出现肺部感染,经治疗好转,所有患者恢复良好.术后随访5～51个月,4例出现肝转移,2例发生肺转移,其中1例死亡,其余患者情况良好,无吻合口癌复发.结论 经腹经后纵隔贲门癌根治术安全、可行,适用于膈肌没有受侵犯、食管受侵小于5 cm的胃上都癌.     

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目的：探讨经腹纵隔内施行贲门癌根治术式。方法；对1990－1999年经腹部采用管型吻合器进行纵隔内食管胃（空肠）吻合的87例进行回顾性分析。结果：根治性切除贲门癌时，在癌灶以上6－7cm切断食管，无切缘癌残留。无吻合口瘘。无手术死亡。只1例吻合口狭窄。并发症低于开胸手术。结论：经腹扩大后下纵隔视野，有利于施行贲门癌根治术、纵隔内食管胃（空肠）机械吻合术，能预防并发症的发生。     

经腹纵隔内根治贲门癌56例分析

目的：探讨经腹纵隔内施行贲门癌根治术式。方法：对1998年-2003年经腹部采用管型吻合器进行纵隔内食管胃(空肠)吻合的56例进行回顾性分析。结果：根治性切除贵门癌时，在癌灶以上6-7cm切断食管，无切缘癌残留。无吻合口漏。无手术死亡。只l例吻合口狭窄。并发症低于开胸手术。结论：经腹扩大后下纵隔视野，有利于施行贲门癌根治术，纵隔内食管胃(空肠)机械吻合术，能预防并发症的发生。     

经腹经裂孔纵隔内食管-胃和食管-空肠双吻合新技术的应用

目的探讨经腹经裂孔行扩大近端胃或全胃切除术后,在纵隔内完成食管-胃或食管-空肠吻合的方法。方法2010年5月至2012年1月,对15例食管胃交界部腺癌患者在施行开放经腹膈肌裂孔扩大胃切除术或全胃切除术后,采用腹段食管逆向置入抵钉座、弧形吻合器切断食管、利用缝线牵出抵钉座的方法予以双吻合技术完成食管-胃或食管-空肠吻合,其中9例为近端胃大部切除行食管-管状胃端端吻合,6例为全胃切除术行食管-空肠吻合。结果全部病例吻合过程顺利,手术时间（185．5±13．1）min,吻合耗时（42．0±8．6）min,术中出血量（106．7±34．9）ml,食管切缘距肿瘤近端（4．4±1．2）cm．残端均无癌残留。无手术死亡及吻合口瘘发生,术后随访发现1例吻合口狭窄．经扩张后缓解。结论抵钉座逆向置人食管联合弧形切割闭合器双吻合技术能简单而安全地在下后纵隔完成食管-胃或食管-空肠吻合．可能成为食管胃交界处癌行扩大胃切除术后的一种较理想的吻合方式。     

经腹食管裂孔切开在进展期胃近侧癌根治术的应用

目的探讨经腹食管裂孔切开胃近侧癌的手术入路新方法。方法对46例经腹食管裂孔切开在胃近侧癌手术中的应用回顾性分析。结果46例无手术死亡病例,无食道下端癌残留。术后并发症发生率6.52%,其中胰漏1例,吻合口狭窄2例。结论经腹食管裂孔切开操作安全简便,能切除足够长度的食道,避免开胸手术对患者的创伤。适合于食道下端浸润小于2cm者。     

贲门胃底癌根治性全胃切除的改进

经腹行贲门胃底癌的根治性切除,由于胸段食管暴露困难,食管切除长度受限及消化道膈下吻合困难,现已很少采用。我们于1988年至1992年9月,为贲门胃底癌行根治性全胃切除术30例。经腹进入后纵隔,充分暴露胸段食管远端,采用Gambee单层吻合行Lahey消     

吻合器在经腹胃上部癌切除手术中的应用

目的:降低吻合器在经腹胃上部癌切除手术中吻合口的并发症。方法:139例胃上部癌切除手术中,使用吻合器进行食管胃吻合88例,食管空肠吻合51例。结果:无手术死亡病例。术中发生吻合口出血3例,予以局部缝合而止血;术后发生吻合口出血1例,吻合口瘘2例,吻合口狭窄4例,返流性食管炎5例,均保守治愈。结论:胃上部癌经腹切除后,正确选择和使用吻合器进行消化道重建,可以有效地减少吻合口并发症的发生。     

原发食管贲门二元癌的外科治疗6例

目的探讨原发食管贲门二元癌的外科治疗及效果。方法1991年1月至2006年12月收治的原发食管贲门二元癌6例,全组均行手术治疗,5例采用消化道缝合器切除贲门病变,缝合成管状胃,完全切除食管病变,胃代食管胸腔内吻合重建消化道,1例行全胃切除,行食管-空肠端侧吻合,空肠"U"袢代胃重建消化道。结果全组无围术期死亡,无吻合瘘发生。全组均获得随访,1、3、5年生存率分别是100%、50%、33.3%。结论原发食管贲门二元癌应用消化道缝合器切除贲门病变可提高胃的利用距离,下段食管癌胃全切后,利用空肠"U"袢代胃,均可行胸腔内吻合,使手术治疗方便、安全。     

腹腔镜下经膈肌裂孔食管胃切除治疗食管胃交界癌55例

目的 探讨腹腔镜下经膈肌裂孔食管胃切除术治疗食管胃交界癌的安全性和可行性.方法 回顾性分析2008年2月至2010年5月接受腹腔镜下经膈肌裂孔食管胃切除术治疗的55例食管胃交界癌患者的临床资料.结果 本组患者中Siewert Ⅱ型者36例,Siewert Ⅲ型者19例;行近端胃大部切除35例,全胃切除术20例;行D2淋巴结清扫53例,姑息性切除2例;行下纵隔食管旁淋巴结清扫或活检33例.5例患者中转开腹,其余50例顺利完成腹腔镜手术,手术时间（236.2±35.5） min,出血量（60.6±33.9） ml,清扫淋巴结（21.2±10.4）枚,食管切缘距肿瘤近端平均（3.5±0.7） cm.无围手术期死亡病例,无吻合口狭窄或瘘发生.术中纵隔淋巴结清扫过程中11例患者出现胸膜破裂,其中6例于术中及时修补,4例于手术结束前修补,1例于术后行胸腔穿刺,均顺利恢复.术后肺部感染3例,切口感染1例.结论 腹腔镜下经膈肌裂孔食管胃切除治疗食管胃交界癌安全可行.     

Application of a suspending abdominal retractor and stapling device in resection of carcinoma of the gastric cardia using a trans diaphragm approach

The article describes the structure assemblage and Clinical application of a Suspending abdominal retractor. From the experience gained in 40 cases of cardial carcinoma operated on, it was found that the device has the following advantages: (1) there is no need for a thoracotomy, and hence the operative trauma is much reduced; (2) good exposure of the upper abdomen and lower mediastinum; (3) adequate length of the lower esophagus and as many as 110 lymph nodes can be resected. Postoperative complications were relatively few. The incidence of residual carcinoma at the esophageal Stump was 2.5%, being much lower than in cases using a single abdominal incision, and similar to those using a combined left thoracoabdominal incision. It was concluded that this operative approach, applying the device recommended, is a relatively ideal procedure for resection of carcinoma of the gastric cardia, especially in elderly patients with poor general health.     

Radical operation for carcinoma of gastric cardia--lymph node dissection by laparosternophrenotomy approach

The adequate esophago-gastric resection and lymph node dissection can be performed without the necessity of a thoracotomy, by using the laparosternophrenotomy approach. For tumors restricted to lower esophagus of 4cm in localized tumors or 3cm in invaded tumors above the EG junction, the sternotomy approach is utilized. However, if the tumor extends to more than the above criteria, the thoracoabdominal approach must be utilized. For 14 years, 85 cases with tumor of gastric cardia were performed by sternotomy approach and 76 cases were performed by thoracotomy approach. The lymph node metastatic rate in the lower thoracic cavity was 26% in total. The lymph node metastatic rate of No. 110 was 22.6%, No. 111 was 17.4% and No. 112 was 12.5%. These results show the lymph node dissection in the lower thoracic cavity is very important in tumors of gastric cardia. The five year survival rate was 41% in patients who undergone curative operation by the sternotomy approach, and 45% in patients performed by the thoracotomy approach. According to our study of the lymph fluid stream in gastric cardia tumors using carbon, the lymph node dissection around the renal vein is important. This approach has less respiratory disturbance than the thoracotomy. This procedure is one of the best approaches for carcinoma of gastric cardia according to our criteria.     

食管癌,贲门癌手术入路的探讨

为了评估食管癌，贲门癌各种手术入路的优缺点，我们总结食管贲门癌手术２１２０例，其中病变位于食管颈，胸上，中，下段及贲门者分别为２６，２８０，９３６，４０８，４７０例，经左后外侧剖胸，包括左胸，左颈两切口者１９９５例，并发症６．６％（１３３／１９５５）；经右胸－腹正中－颈三切口者５８例，并发症２４．１％，（１４／５８）颈腹二切口者２０例；胸腹联合切口者３９例，并发症７．６％（３／３９）；经上腹正中切     

进展期胃癌术前CT与手术结果的对比研究

目的探讨CT检查对进展期胃癌手术可切除性的术前评估价值。方法回顾性分析对比93例进展期胃癌的CT表现及手术治疗的相关资料。结果胃底贲门癌23例,胃体部癌59例,胃窦部癌11例。肿瘤肿块最大者直径1.5～11cm。93例胃癌均显示胃壁有不同程度的增厚,部分胃壁有软组织肿块形成,黏膜面有溃疡形成,胃腔及贲门狭窄,贲门管壁增厚,食道下段受累以及周围组织器官侵犯等。CT对进展期胃癌的定位、定性诊断与胃镜活检和/或手术病理符合率高,肿瘤检出率可达100%。手术前判断为可切除组的手术切除率达93.3%;不宜手术切除组病例的不能切除率为75.0%。结论胃癌术前CT诊断具有重要临床意义,CT对肿瘤的可切除性评估有较高的参考价值,值得推广应用。     

贲门癌根治术术中管状吻合器的使用优点及技巧探讨

目的 探讨贲门癌根治术(食管空肠吻合及残胃食管吻合)术中管状吻合器的使用优点及技巧.方法 1998年～2007年本院753例贲门癌根治术行食管空肠吻合或残胃食管吻合重建消化管,术中均使用一次性管状吻合器.结果 本组753例,无手术死亡,行胸腹联合手术6例(0.80%),无吻合口漏发生,吻合器切割不全2例(0.26%),发生吻合口狭窄4例(0.53%),腹腔感染1例(0.13%),膈疝1例(0.13%),术后标本病理检查上切缘癌累及1例,下切缘均未累及.结论 在贲门癌根治术中,管状吻合器的运用简化了手工操作程序,可靠、安全、省时,降低贲门癌进胸手术比例,手术创伤小,恢复快,能有效地预防吻合口瘘和狭窄.但吻合器吻合也不是绝对安全的,吻合口瘘、出血、狭窄等并发症仍有一定的发生率,术中技巧值得在今后的工作中进一步总结、探讨.     

Diagonal abdominothoracic incision as an approach to carcinoma of the cardia and upper gastric region

An operative technique consisting of a diagonal epigastric incision extending to the left chest wall and severing the inner side of diaphragm adjacent to the pericardium to the hiatus is introduced. This technique was successfully used in 16 cases and the present surgical approach facilitates frontal visualization of the lower esophagus without disruption of the circulatory system. Furthermore, a sufficiently large operative field is obtained and radical dissection of cardia and upper gastric region or combined resection of infiltrated adjacent organs is facilitated. Postoperative recovery of pulmonary function in terms of PaO2 and PaCO2 was similar to that of patients who had received an upper median incision. We found no postoperative complications peculiar to the operative technique introduced here in any of the 16 patients.     

Clinical Application of Layered Anastomosis During Esophagogastrostomy

The aim of this study was to compare the operative results in regard to reducing anastomotic leakage and stricture formation using a newly designed layered manual esophagogastric anastomosis versus a stapler esophagogastrostomy versus the conventional hand-sewn whole-layer anastomosis after resection for esophageal or gastric cardiac carcinoma. From January 2004 to September 2006, a total of 1024 patients with esophageal or gastric cardia carcinoma underwent a layered esophagogastric anastomosis with the assistance of a three-leaf clipper in a single university medical center. The mucosal layers of the esophagus and stomach were sutured continuously with 4/0 Vicryl plus antibacterial suture (polyglyconate). From May 2002 to December 2003, there were also 170 patients and 69 patients who underwent stapler and conventional whole-layer anastomosis, respectively; they served as control groups. The results were analyzed retrospectively. The operative mortality rate was 0.7% in the layered group compared to 5.9% and 7.2% for the stapler group and the whole-layer group (p < 0.01), The anastomotic leakage rates were 0%, 3.5%, and 5.8% for the layered group, stapler group, and whole-layer group, respectively (p < 0.01). All patients were followed postoperatively. Six patients in the layered group (0.6%) developed mild stricture formation compared to 16 patients in stapled group (9.9%) and 5 patients in the conventional whole-layer group (7.8%) (p < 0.01). The application of layered esophagogastric anastomosis could reduce the incidence of anastomotic leakage and stricture after esophagectomy compared with the stapler and whole-layer manual anastomoses. It is easy to apply and could be used as an alternative for esophagogastric anastomosis after resection for esophageal or cardiac carcinoma. This abstract was accepted as a free paper and oral presentation at International Surgical Week 2007, Abstract 320, Montreal, Canada, August 2007     

机器人下近端胃癌根治术

患者为老年男性,68岁,发现贲门巨大肿物,进行新辅助化疗,TC方案,化疗4个周期后,部分缓解后行手术治疗,术后病理诊断为鳞癌,分期ypT2N1M0。主要步骤：离断胃周血管,清扫相应部位淋巴结(D2),离断食管贲门部,经口置入Orvil吻合器,上腹部正中开口,将游离胃体提至腹腔外,距肿瘤远端约5 cm处离断胃体,移除大体标本。纵向切开残胃4 cm,置入胃肠吻合器,与吻合器抵针座衔接,旋紧,激发。置入空肠营养管,检查无出血后,逐层关腹。手术结束。     

Diagonal abdominothoracic incision as an approach to carcinoma of the cardia and upper gastric region

An operative technique consisting of a diagonal epigastric incision extending to the left chest wall and severing the inner side of diaphragm adjacent to the pericardium to the hiatus is introduced. This technique was successfully used in 16 cases and the present surgical approach facilitates frontal visualization of the lower esophagus without disruption of the circulatory system. Furthermore, a sufficiently large operative field is obtained and radical dissection of cardia and upper gastric region or combined resection of infiltrated adjacent organs is facilitated. Postoperative recovery of pulmonary function in terms of PaO₂ and PaCO₂ was similar to that of patients who had received an upper median incision. We found no postoperative complications peculiar to the operative technique introduced here in any of the 16 patients.