Radical gastrectomy for gastric cancer

In recent years, scholars at home and abroad have conducted in-depth research on the basic problems of gastric cancer and its depth of invasion, lymphatic metastasis, biological characteristics, etc., combined with the development of new techniques such as endoscopy, B-ultrasound, CT, etc., to make the diagnosis rate of early gastric cancer and advanced gastric cancer. Significantly improved, the mortality rate of radical gastric partial resection and total gastrectomy was reduced to less than 5%, complications have been reduced, and the five-year survival rate has also increased significantly. Treatment of diseases: elderly gastric cancer, gastric cancer, residual gastric cancer Indication The scope and surgical style of radical resection of gastric cancer have become increasingly standardized. The indications for surgery are also increasingly clear. According to the National Gastric Cancer Cooperative Group, the gastric cancer radical surgery was divided into three basic surgical procedures: radical type I (R1), radical type II (R2), and radical type III (R3). For some early gastric cancers, that is, the lesion is confined to the mucosal layer, R1 surgery, clearing the lymph node at the first station of the stomach can meet the treatment requirements. For general stage gastric cancer, R2 surgery can be used as a basic procedure, and the second station lymph node must be removed. For some gastric cancers with lymph node metastasis at the third station, R3 radical surgery should be applied for relative cure resection. The so-called radical cure of gastric cancer is relatively radical, and its effect depends on factors such as staging, lesions, lymph node metastasis, and biological characteristics of gastric cancer. Therefore, the surgical procedure is also decided accordingly. According to recent reports at home and abroad, the expansion of radical surgery has obtained better curative effect. Therefore, R3-based radical total gastrectomy or combined organ resection has attracted more and more attention. Gastric cancer is the main indication for total gastrectomy: 1. According to the staging method of the National Gastric Cancer Cooperative Group, the upper part (C area) and the middle part (M area) and the lower part (A area) of stage II and III are invading the corpus (AM). 2. A wide range of multi-focal early gastric cancer with diffuse or scattered diffuse lymph nodes, suitable for total gastrectomy including the first and second lymph nodes. 3. Residual gastric cancer after partial gastric resection due to benign disease. 4. Gastric lymphosarcoma and gastric leiomyosarcoma. 5. Zollinger-Ellison syndrome is currently the most common indication for total gastrectomy except gastric cancer. Preoperative preparation Preoperative correction of anemia (hemoglobin up to 8g%), improvement of nutrition (plasma albumin up to 3g%), enhance patient immune function, and focus on monitoring, treatment of heart, lung, liver, renal insufficiency and diabetes . Hemostatic drugs and intestinal antibiotics were given 3 days before surgery. Preoperative night cleansing enema, morning stomach tube and indwelling catheter, preoperative chemotherapy, surgery with mitomycin 20mg preparation intraoperative intravenous drip, 5-Fu500mg preparation intraoperative gastric tube injection and terminal abdominal cavity Rinse, each 250mg Surgical procedure 1. Position, incision: supine position, under normal circumstances, total gastrectomy can be completed through the mid-abdominal incision, that is, from the xiphoid down the navel to the navel 2cm, if necessary, the xiphoid can be fully revealed . If the laparotomy reveals that the tumor is involved in the cardia or the lower esophagus, a chest and abdomen combined incision can be used. The left side is 45° high and the left intercostal space is inserted into the chest. 2. Exploration: After the laparotomy, the exploration process should adhere to the principle of no-tumor operation as well as the operation. Not in direct contact with the tumor. The order of exploration is performed by far and near according to certain procedures. First, starting from the rectal fossa of the bladder, check whether the fossa is implanted, whether the ovary is metastasized or not (Krukenberg tumor), and then the liver, the visceral surface, the hilar, the spleen, and the tail of the pancreas. Finally, focus on the stomach. Use the oval clamp to lift the stomach to minimize the spread of tumor cells. When the cancer has been leached out of the serosa, it is applied to the gauze cover to close. The extent of tumor invasion, mobility, adhesion to the pancreas and transverse mesenteric membrane, and lymph node metastasis of each group were examined to determine the extent of resection. 3. Blocking the gastric perivascular and venous blood circulation: the stomach is pulled downward, and the small omentum is close to the left and right movements of the stomach, and the root of the vein is sutured, and then the left and right movements and veins of the gastric retina are also ligated. At the same time, the door and the pylorus are blocked by thick lines to prevent the spread of cancer cells in the operation. 4. Excision of the omentum: the assistant lifts the stomach and the transverse colon is pulled downward, so that the mesenteric membrane of the transverse colon is tight. The left hand of the surgeon pulls the omentum to reveal the avascular zone, and cuts it from the transverse colon edge with an electric knife. From the middle of the colon, cut to the left side to the lower part of the spleen, and then cut to the right side, straight to the transverse colon. 5. Excision of the 14th and 15th groups of lymph nodes before resection of the anterior transverse mesenteric stenosis: lifting the omentum that has been cut, starting from the right side of the middle cerebral artery, with a sharp-edged knife and a ball-striped strip between the anterior and posterior lobe of the mesentery. Perform sharp and blunt dissection and peeling. It is easy to find the loose connective tissue gap. It is easy to clearly peel off and remove the anterior mesenteric lobe and its attached fatty lymphoid tissue. Continue to peel up to the lower edge of the pancreas, find the confluence of the colonic vein and the right vein of the gastric retina, remove the lymph nodes of the mesenteric root (group 14) and the lymph nodes around the middle of the colon (group 15). Continue to remove the pancreatic capsule along this level to the upper edge of the pancreas. 6. Cut the right movement and vein of the gastric retina and remove the lymph nodes of the sixth group: continue to dissect to the upper right, and ligature and cut the right venous root of the gastric retina at the lower edge of the pancreatic head and the duodenum. Then, the right gastric artery of the gastric duodenal artery was found. It was also ligated and cut, and the sixth group (under the pylorus) was cleared. 7. Clear the posterior pancreatic lymph nodes: cut the lateral peritoneum of the duodenum, fully separate the pancreatic head and duodenum to the inside, and cut the dorsal fascia of the dorsal head of the pancreas. In the posterior intestine artery arch, there are several lymph nodes next to the bow, that is, the thirteenth group of posterior and posterior lymph nodes. After being cleaned and resected, the anatomy of the common bile duct was dissected and the pancreatic duct of the common bile duct was removed under direct vision, that is, the lymph node of the 12th group. At this time, the common inferior vena cava, abdominal aorta, and common hepatic artery at the lower end of the duodenal ligament were clearly seen. 8. Clear the lymph nodes in the duodenal ligament: the stomach and duodenum are pulled downward, the hilar area and the small omentum are exposed, and they are cut along the avascular area under the liver. Anatomize from the hilar to the duodenum to remove the capsule and loose tissue in front of the duodenal ligament. The proper hepatic artery, common bile duct and portal vein are exposed. Find the right gastric artery and vein, and ligature and cut at the root. The lymph nodes of the gallbladder neck, the peri-hepatic arteries and the fat lymphoid tissues of the portal vein were removed, and the lymph nodes of the 12th group in the hepatoduodenal ligament were removed. 9. Cut off the duodenum: After the pyloric side is removed, the duodenum is usually cut 3 cm away from the pylorus. If the pylorus is suspected of cancer infiltration, it can be cut at a distance of 4 to 5 cm. If a Billroth II anastomosis is planned, the duodenal stump can be closed by conventional suturing. 10. Clear the common aortic lymph nodes: along the dissected hepatic artery, cut the anterior cranial artery to the medial side, and peel down the gastroduodenal artery. Continue to dissect along the arterial trunk to the center side, and cut the hepatic and pancreatic folds to the root of the common hepatic artery. During this process, the common hepatic artery trunk and its root lymph nodes (Group 8) were removed from the upper edge of the pancreas. At the same time, the gastric coronary veins that merged into the splenic vein or portal vein were noted during this anatomy, which must be cut and properly ligated. 11. Clear the lymph nodes around the celiac artery: lift the severed stomach to the upper left and lift it up along the trunk of the common hepatic artery to dissect the lymph nodes around the celiac artery. The left gastric artery was isolated on the upper left side of the celiac artery, double-ligated and cut. The splenic artery was dissected along the upper edge of the pancreas to reach the spleen. During this process, the left gastric artery trunk, the peri-peri-valvular artery, the spleen and the splenic artery (groups 7, 9, 10, 11) were removed. 12. Clear the left aortic lymph nodes of the gastric retina: on the basis of the aforementioned omental resection, separate the left arteriovenous vein along the gastric retina. As far as possible, the roots are ligated and cut off to remove the 4Sa and b lymph nodes. If the spleen and pancreatic tail resection are not combined with early gastric cancer, the second branch of the short gastric artery can be ligated and resected. . 13. If the gastric or large curved side of the stomach, the spleen can be proposed together, the spleen and kidney ligament and the gastric ligament ligament are stripped, and the pancreatic tail is completely free along the retroperitoneal space. The splenic vein was ligated and cut off on the left side of the inferior mesenteric vein. If the pancreas and the tail are to be cut, the left venous axis of the portal vein and the mesenteric vein can be cut to the left, and the pancreatic duct can be separately sutured to carefully stop the section. 14. Excision of the stomach: the left lobular ligament of the left lobe of the liver is cut, and the left outer lobe of the liver is turned to the lower right to reveal the Tuen Mun area. Incision of the peritoneum around the esophageal rupture, separation of the lower end of the esophagus, cutting the vagus nerve before and after the dry, can make the esophagus to the abdominal cavity 6 ~ 8cm, enough to match the jejunum in the abdominal cavity. The upper and lower ends of the gastrectomy should be at least 6 cm from the lesion and at least 3 cm from the pylorus at the lower end. The lower end of the esophagus can be cut off and the entire specimen can be removed under the control of a non-invasive right angle clamp. The stomach can also be pulled to the esophagus to facilitate anastomosis with the jejunum, and then the stomach is cut. 15. Digestive tract reconstruction: There are many methods for reconstruction of the digestive tract after total gastrectomy. Only commonly used esophageal jejunostomy and three-layer jejunal sacral gastroplasty are introduced as follows: (1) esophageal jejunal end-to-side anastomosis: the assistant pulls the stomach up and pulls upward, reveals the lower end of the esophagus, and sutures a needle pull line on both sides of the plane to be cut, and then selects a section about 20 cm below the duodenal suspensory ligament. The jejunum is anastomosed to the esophagus before or after the colon. The suture of the posterior wall of the esophagus and the muscle layer of the jejunum are usually sutured with 5 to 6 needles. The posterior wall of the esophagus and the jejunal wall were cut at a distance of 0.3 to 0.5 cm from the suture line of the first row. After the contents of the esophagus and jejunum were exhausted, the inner layer of the posterior wall was sutured with a full-length suture. Cut off the anterior wall of the esophagus and remove the stomach. The stomach tube was inserted into the jejunum through the anastomosis, and the anterior wall of the anastomosis was continuously sutured with a silk thread. The esophageal anterior wall muscle layer and the jejunal pulp muscle layer were sutured intermittently, and the anterior wall of the anastomosis was sutured. Finally, the jejunal muscle layer and the diaphragm of the diaphragm were sutured by 3 to 4 needles. To strengthen the front wall of the anastomosis. In order to reduce the stimulation of the duodenal contents to the anastomosis, the jejunum can be input and output between the anastomosis 5 cm below the side anastomosis of 8 to 10 cm long. This lateral side anastomosis can also receive the effect of increasing the appetite and reducing the food dumping. At this point, total gastrectomy esophageal jejunostomy is completed. (2) Y-style anastomosis at the end of the esophageal jejunum: First, a jejunum fistula is lifted 10 to 15 cm below the duodenal suspensory ligament, and the vascular arch is selected by the assistant according to the A line or the B line. The vascular arch was cut according to the A line to extend the mesangium, and two non-injured right angle clamps were clamped 10 to 15 cm below the duodenal suspensory ligament. Cut the jejunum between two right angle pliers. The distal jejunum was selected by puncture the hole in the avascular zone of the transverse mesenteric membrane. At the distal jejunum 40 ~ 50cm, the proximal jejunum and the distal jejunal end side Y-form anastomosis, and the mesenteric gap between the two is closed to prevent internal hemorrhoids. The lower end of the esophagus and the upper jejunum are placed close to each other. The first line of the esophagus and the posterior wall of the jejunum are sutured with 4 to 5 needles, and two right angle clamps are clamped together to tighten all the squat lines. Remove the right angle pliers and tie them one by one. The anterior wall was sutured with intermittent varus, and the knot was externally tied. Finally, several needles were sutured by the peritoneum of the anastomosis and the periosteal edge of the diaphragm to strengthen and peritone. After the operation is completed, the nasogastric tube is delivered to the end of the jejunal anastomosis through the esophageal jejunal anastomosis, and the early decompression is performed, and the nasal feeding is used later. The hose was treated under the anastomosis of the esophagus and the spleen of the pancreatic stump. (3) Triassic jejunal cystectomy: After total gastrectomy for esophageal jejunostomy, food emptying is accelerated, and the nutrition and weight of the patient are often difficult to maintain normal. Therefore, various colon or jejunal surgery can be added to overcome the above disadvantages. . The three-layer jejunum method between the esophagus and the duodenum: take a section of the proximal jejunum about 40 cm, and retain the blood supply in the mesangium. The upper mouth is anastomosed to the esophagus, the lower mouth is anastomosed to the duodenum, and the middle intestinal fistula is folded into 3 sections, each section is about 10 to 12 cm long; the intestinal wall is sutured with silk thread to form a triple stack of jejunal capsules instead of Stomach cavity. Then, the remaining jejunum is end-to-end anastomosis. The proximal esophageal and proximal duodenal segments of the triad of intestinal fistula are all peristaltic, while the middle part of the intestinal fistula is reverse peristalsis, which can delay the emptying of food, which is beneficial to the absorption of nutrients and the maintenance of body weight. Triassic jejunum Y-style anastomosis: For patients with duodenal stumps that are too short or have adhesions after total gastrectomy and cannot be anastomosed with the inserted jejunum, the duodenal stump can be closed in the duodenum. The jejunum was cut at 15-20 cm below the suspensory ligament, and the distal jejunum was aligned with the end of the esophagus on the premise of the colon. The jejunum below the anastomosis of the esophageal jejunum was then sutured in three segments. Finally, the proximal jejunum is anastomosed at the upper end of the distal jejunum at about 10-15 cm below the sacral sac in the jejunum sac. It can also receive the effect of delaying emptying and facilitating nutrient absorption. complication 1. Anastomotic leakage: This is a serious complication after gastrectomy, which occurs mostly around 7 days after surgery. Strict aseptic technique and meticulous operation ensure a smooth anastomosis and a good blood supply. And adequate nutritional supplement before and after surgery is the key to prevent anastomotic leakage. Signs of anastomotic leakage are signs of peritonitis and symptoms of systemic infection. The principle of treatment is timely drainage of the abdominal cavity, control of infection, fasting and intravenous supplementation. After being treated in time, it is generally possible to heal itself. 2. Reflux esophagitis: This is due to the inflammatory reaction caused by alkaline intestinal fluid, bile fluid and pancreatic juice flowing back to the lower end of the esophagus, which is characterized by burning pain after the sternum and inability to eat. The treatment method is mainly to relieve pain and reduce body fluid secretion. The jejunal input and output lateral side anastomosis or jejunal gastrostomy can also prevent this complication. 3. Anastomotic stenosis: occurs mostly in the lower end of the esophagus, in addition to technical reasons, but also related to reflux esophagitis. Mild stenosis can be treated with dilatation; patients with severe stenosis should undergo reoperation, resection of the stenosis, re-synchronization, and removal of factors of reflux of digestive juice. 4. Malnutrition and anemia: After total gastrectomy, food emptying accelerates, affecting digestion and absorption, leading to malnutrition and lack of internal factors, which is the cause of anemia, and can be supplemented with vitamin B12 and other nutrients. Prevention methods can be used as much as possible to use partial gastrectomy or gastric replacement to retain part of the stomach wall tissue.