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双镜联合胃间质瘤的治疗
张勇 龚伟 等近年的研究发现，胃间质瘤的良恶性生物学行为之间并无明确的界限，从良性至恶性是一个渐进的过程，随着肿瘤的生长，其恶性特征会逐渐显现。有随访发现，即使是<2cm，甚至是1cm的间质瘤也可能发生转移[1, 6-7]。因此，手术切除是治疗间质瘤的首选方法。间质瘤的主要扩散途径是血型转移，较少发生淋巴结转移，因而一般在手术时无需进行淋巴结清扫[8-10]。间质瘤的这些生物学特性使腹腔镜手术的微创优势得以充分体现。胃间质瘤的切除方式与肿瘤的大小、位置及生长方式有关。须遵循以下原则：①肿瘤完整的包膜外切除；②最大限度保留正常胃壁组织；③最低程度的手术污染；④避免手术后的胃肠管道狭窄。因此，术中对肿瘤，尤其是较小病灶的精确定位对于确定恰当的切除范围、避免过多切除正常组织而影响吻合口通畅是至关重要的。通过联合胃镜进行术中腔内定位后，能顺利明确了肿块与贲门及幽门的距离，确定了手术方式及切除范围。除此之外，对于胃后壁的肿瘤，常规的腹腔镜探查一般不能直接发现肿瘤，需进行组织分离。而胃镜不仅能起到术中定位的作用，还能协助进行胃前壁造口胃锲形切除术。对于胃后壁的间质瘤，双镜联合法更具优势。此外，切除术完成后，胃镜还能检验吻合口是否狭窄、通畅或扭曲，并可对吻合口的血供及出血情况做出直观的显示，避免了相关并发症的漏诊或延误处理。近年来我院张勇教授和龚伟医生进行了60余例接受腹腔镜胃镜双镜联合胃间质瘤切除术患者的间质瘤，均早期康复出院，没有并发症，预后良好。关于腹腔镜胃间质瘤切除术的指征，目前国内外有许多运用腹腔镜切除大于2cm，甚至大于5cm间质瘤的报道。多数研究显示开腹间质瘤切除与腹腔镜切除的死亡率、并发症发生率、住院时间及病理学诊断等均无明显差异[13-15]。因此，国内外亦有学者总结经验后提出如下腹腔镜胃间质瘤切除术的指征：①影像学检查提示肿瘤边界清楚、质地均匀；②肿瘤横径<6cm或>6cm的腔外型肿瘤（适合行胃壁楔形切除者）；③肿瘤无胃周侵犯；④胃周局部侵犯或腹腔转移，但仍可行整块肿瘤切除者[16]。我们研究的结果显示，双镜联合组在术中出血量、术后住院时间、术后开放进食时间等均显著优于开腹组，但两者在手术时间、术后并发症发生率等均相似，说明腹腔镜手术的近期效果是肯定的。关于腹腔镜胃间质瘤切除术的远期疗效，目前报道不多，且对于影响患者长期预后的相关因素仍有待探讨。有学者认为阴性切缘并不是决定预后的主要因素[17]。Yuri等[18]对1996-2005年间进行的50例腹腔镜胃间质瘤切除术患者进行了随访，肿瘤平均大小为4.4cm，结果显示3年生存率可达96%，无瘤生存率可达92%。该研究还发现，间质瘤的核分裂数、肿瘤大小、粘膜溃疡形成及坏死是提示患者预后的重要因子。新近的另一项研究对54例接受腹腔镜间质瘤切除术的进行了平均41个月的随访，肿瘤平均大小为3.5cm，统计表明无瘤生存率为77%[19]。故Otani等[20]学者认为，尽管间质瘤的恶性生物学行为较难预测，但对于体积较小的间质瘤，腹腔镜切除术仍是相对安全和有效的。我们对患者随访3-31个月，腹腔镜手术的患者在随访期内未发生复发或转移，与文献报道一致。我们将通过随访进一步评估腹腔镜胃间质瘤手术的长期疗效，为今后的治疗提供客观依据。参考文献[1] Miettinen M, Majidi M, Lasota J..Pathology and diagnostic criteria of gastrointestinal stromal tumors (GISTs): a revise. Eur J Cancer, 2002, 38(5):39-51.[2] Matthews BD, Joels CS, Kercher KW, et al. Gastrointestinal stromal tumors of the stomach, Minerva Chir, 2004; 59: 219-231.[3] Fujimoto Y, Nakanishi Y, Yoshimura K, et al. Clinicopathologic study of primary malignant gastrointestinal stromal tumor of the stomach, with special reference to prognostic factors: analysis of results in 140 surgically resected patients, Gastric Cancer, 2003; 6: 39-48.[4] Blanke CD, Corless CL. State-of-the art therapy for gastrointestinal stromal tumors, Cancer Invest, 2005; 23: 274-280.[5] Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach, Hum Pathol, 2002; 33:459-465.[6] Ballarini C, Intra M, Ceretti AP, et al. Gastrointestinal stromal tumors: a "benign" tumor with hepatic metastasis after 11 years, Tumori, 1998; 84: 78-81.[7] Tornoc zky T, Kove r E, Pa jor L. Fr equentoccurrence of low grade cases among metastaticgastrointestinal stromal tumours, J Clin Pathol, 2003; 56: 363-367.[8] Matthews BD, Walsh RM, Kercher KW, et al. Laparoscopic vs open resection of gastric stromal tumors, Surg Endosc, 2002; 16: 803-807.[9] Cuschieri A. Laparoscopic gastric resection, Surg Clin North Am, 2000; 80: 1269-1284.[10] Nishimura J, Nakajima K, Omori T,et al. Surgical strategy for gastric gastrointestinal stromal tumors: laparoscopic vs. open resection, Surg Endosc, 2007; 21(6): 875-878.[11] Blay JY, Bonvalot S, Casali P, et al. Consensus meeting for the management of gastrointestinal stromal tumors, Report of the GIST Consensus Conference of 20-21 March 2004, under the auspices of ESMO, Ann Oncol, 16:566–578.[12] Demetri G, Benjamin R, Blanke CD et al. NCCN task force report: optimal management of patients with gastrointestinal stromal tumor (GIST): expansion and update of NCCN clinical practice guidelines, J Natl Compr Cancer, Netw 2(Suppl 1):S1-S26.[13] Novitsky YW, Kercher KW, Sing RF, et al. Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors, Ann Surg, 243:738-745.[14] Lai IR, Lee WJ, Yu SC. Minimally invasive surgery for gastric stromal cell tumors: intermediate follow-up results, J Gastrointest Surg, 10:563-566.[15] Choi SM, Kim MC, Jung GJ, et al. Laparoscopic wedge resection for gastric GIST: long-term follow-up results, Eur J Surg Oncol, 33(4):444-447.[16] 郑成竹, 李际辉. 胃间质瘤的诊断和微创治疗, 中国普外基础与临床杂志, 2004, 1l(3): 19-20.[17] DeMatteo RP, Lewis JJ, Leung D et al, Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival, Ann Surg, 2000; 231(1): 51-8.[18] Yuri W. Novitsky, MD, Kent W, et al. Long-term outcomes of resection of gastric gastrointestinal stromal tumors, Ann Surg, 2006; 243(6): 738-747.[19] Tabrizian P, Nguyen SQ, Divino CM. Laparoscopic management and longterm outcomes of gastrointestinal stromal tumors. J Am Coll Surg, 2009; 208(1): 80-6.[20] Otani Y, Furukawa T, Yoshida M, et al. Operative indications for relatively small (2-5 cm) gastrointestinal stromal tumor of the stomach based on analysis of 60 operated cases, Surgery, 2006; 139(4): 484-92.
