外科學(xué)：胃十二指腸腫瘤（英文版）完整版

GastricCancerEpidemiologyJemalA,BrayF,CenterMM,etal.Globalcancerstatistics.CACancerJClin2011;61:69.EpidemiologyJemalA,BrayF,CenterMM,etal.Globalcancerstatistics.CACancerJClin2011;61:69.RiskFactors1.NutritionLowfatorproteinconsumptionSaltedmeatorfishHighnitrateconsumptionHighcomplex-carbohydrateconsumption2.Environment

Poorfoodpreparation(smoked,salted)LackofrefrigerationPoordrinkingwater(wellwater)Smoking3.SocialLowsocioeconomicstatus(exceptinJapan)RiskFactors4.MedicalPriorgastricsurgery

HelicobacterpyloriinfectionGastricatrophyandgastritis

AdenomatouspolypsPerniciousanemiaMalegenderEtiologicalFactors(RiskFactors)Pathology1.Earlygastriccancer(EGC)Gastriccancerconfinedtothemucosaorsubmucosa,regardlessofthepresenceorabsenceoflymphnodemetastasis2.Advancedgastriccancer(AGC)

Cancercellsinfiltratetheproprialmusclelayerorserosa

EGCPathologyI:protrudedIIa:superficiallyelevatedIIc:superficiallydepressedIIb:superficiallyflatIII:excavatedEGC:EndoscopicimagesTypeITypeIITypeIIIPathologyBorrmann's

classificationofgastriccancerbasedongrossappearanceAGC:Borrmann’sclassificationLinitisplasticaTstagearedefinedbydepthofpenetrationintothegastricwallLaminapropriaT1aT1bT4aT4bT3SubserosalconnectivetissueT1bT1aT4aT4bTstageGroupingofRegionalLymphNodes(Groups1-3)byLocationofPrimaryTumorAccordingtotheJapaneseClassificationofGastricCarcinomaNstage

MetastesisDirectinvasionLyphmaticmetastesisHematogenousmetastasisSeedingmetastasisClinicalPresentation1.Vagueepigastricdiscomfort2.Epigastricpain3.Weightloss,

anorexia,fatigue,orvomiting4.Hematemesis,anemicPhysicalsigns1.Apalpableabdominalmass2.Apalpablesupraclavicularlymphnode3.Apalpablemassbyrectalexamination4.Apalpableovarianmass(Krukenberg'stumor)ExaminationEndoscopyM-SCT(multipledetector-rowspiralCT)MRIBUS&EUSDouble-contrastradiographyDL(diagnosticlaparoscopy)PET-CTClinicpathologicalStagingEUSLaprascopyBUSCTPET-CTCTisthemainlyprocedureMRIEndoscopyCarcinomainsituAdvancedcarcinomaNicheDouble-ContrastBariumUpperGIRadiographyEUSEUSTTNCTscanABCTNM1T4N2M1CTscanMRIPET-CT:T3N2BUSLivermetastasisKrukenberg’stumorleftrightTTLaparoscopyAbdominalmetastasisTreatmentforGastricCancerSurgeryEndoscopicmucosalresection(EMR)Endoscopicsubmucosaldissection(ESD)LaparoscopicSurgeryOpenSurgeryChemotherapyChemoradiotherapyTargettherapyEMRforEarliergastriccancer(EGC)CriteriaforEMRNCCN2013V2:1.TisorT1a2.Well

ormoderatelydifferentiatedhistology3.Tumorslessthan15mminsize,4.AbsenceofulcerationandnoevidenceofinvasivefindingCriteriaforEMRAbsoluteindication(EMR/ESD):DifferentiatedadenocarcinomaT1adiameteris≤2cmwithoutulcerfinding(UL-)JapaneseGastricCancerAssociationExpandedindication(ESD):TumorsclinicallydiagnosedasT1aand:(a)Differentiated,UL(-),but

>2cm(b)Differentiated-type,UL(+),and≤3cm(c)Undifferentiated-type,UL(-),and≤2cmEMREMREMR1.Difficulttoresectlargethan20mmtumorinsize2.DifficulttoresectulcerativelesionsLimitationofEMRtechniquesESDwasdevelopedESDforEarliergastriccancer(EGC)ESDOitaDigestiveOrgansHospital

ESDOitaDigestiveOrgansHospital

Principlesofradicaloperationforgastriccancer1.Negativemargin(R0resection,adequatemargins≥4cm)2.D2lymphnodedissectionforadvancegastriccancer3.Subtotalgastrectomyfordistalgastriccancer4.TotalorproximalgastrectomyforproixmalgastriccancerSurgicalTreatmentforGastricCancerLaparoscopicResection1.AsuitableprocedureforECG(Ourexperience)2.TheefficacyandsafetyofthisapproachforadvancgastriccarcinomarequiresfurtherinvestigationOpenSurgeryforAdvancedGastricCancer1.AsuitableprocedureforACG2.R0resection3.R1resection4.R2resectionPrinciplesofadvancedgastriccancersurgery

Gastrectomywithregionallymphatics:perigastriclymphnodes(D1)andthosealongthenamedvesselsoftheceliacaxis(D2),withagoalofexamining15orgreaterlymphnodesGastrectomywithD2lymphadenectomyisthestandardtreatment

forcurablegastriccancerineasternAsia

GastrectomyandD2lymphadenectomyforadvancedgastriccarcinomaGastrectomyLymphadenectomyRoux-en-YanastomosisBillrothIIanastomosisAnastomosisSubtotalgastrectomyTotalgastrectomyLeftgastricAHepaticASplenicANo.11LNPortalVeinSpleenStomachGreateromentumAdjuvantTherapyChemotherapyRadiationTherapyTargetedTherapyECF:Epirubicin,Cisplatin,5-FuFOLFOX:Oxaliplatin,5-Fu,CFSOX:S-1,OxaliplatinXELOX:Capecitabin,OxaliplatinDCF:Docetaxel,Cisplatin,5-Fu……ChemotherapyPreoperativeChemotherapy

PostoperativeChemotherapyUlcerativemassatantrumofstomach，about4*5cminsizeThelesionisabout2.0*1.0cminsizeAfter3coursesofFOLFOXBeforetheneoadjvantchemotherapyOurexperiencePreoperativechemotherapyAfter3coursesofpreoperative

chemotherapyPreoperativechemotherapyOurexperienceLymphadectomyofgroup7,8,9LiverafterChemotherapyOurexperiencefoamcellsinlaminapropria(40×10)OurexperienceTargetedTherapyHerccptin

Herb-2receptorinhibitorIressaEGFRinhibitorAvastin

VEGFRinhibitor

OtherMolecularMedicineInterventionsofGastricCancer1.Oncogeneactivationandtargetedtherapy2.Tumor-suppressor-geneinactivationandrelatedtherapy3.Apoptosistargetedtherapy4.Anti-metastasistherapy5.Telomeraseinhibitiontherapy6.Gene