Clinical Study Between Intraoperative Staging Of Gastric Cancer And Choose Of Operation Modality

The morbidity and mortality rate of gastric cancer is still in the first place in our country. As the mass screening of early gastric cancer has not been introduced, most inpatients are troubled in developed stage. The main surgical project is standard radical dissection and extended radical dissection,whose final treatment purpose is for the radical cure of tumor,maximum extending survival rate of patients,minimum trauma and elevating quality of life. It is a hot focus on how to choose an individualization operative project for each patient. Although it is precise to make a definite staging after examining the ex vivo specimen, the intraoperative staging is more instructive for doctors to choose reasonable operation modality. The main purpose of this passage is to approach the accuracy of intraoperative staging of gastric cancer and its influence to the selection of operation chooses.Take 86 patients from January to December in 2006 in our division in the hospital for example,64 patients are assessed as developed gastric cancer during operation (49 males and 15 females,aging from 32 to 78,averaging about 55.91 years old),in which 62 are assessed correctly. The assessment of stage-T:⑴Preoperative transabdominal ultrasonography of gastric cancer: the gastric wall is thicken or not, and abnormal echogenicity exists or not;⑵Intraoperative assessment: T2: we can touch the carcinoma during the operation,around which the wall is inflexible,and the lesion the tumor infiltrates contracts;T3:we can see the serosa of the gastric wall is affected by tumor definitely;T4:the carcinoma infiltrates liver,pancreas,spleen,duodenum,transverse colon,diaphragmatic muscle and so on. The assessment of stage-N:According to UICC,N1includes 1～6 lymph nodes,N2includes 7～15,N3 is more than 15(the number of clearance of each patient is no less than 15). (1) The result of preoperative transabdominal ultrasonography:the location and number of swell lymph nodes in the abdominal cavity;(2)The normal lymph node is soft,smooth and has a good range of motion;so we define metastases lymph node as follows:diameter≥10mm,homoround,pallor and bad range of motion;(3)If we highly suspect N2 lymph node as metastases during the operation,we should make frozen section. The assessment of stage-M:(1)Preoperative physical check to findwhether there is swell lymph node above clavicle;(2)Take a plain chess film to make sure whether there is metastases site in the lung ; (3)Preoperative transabdominal ultrasonography shows whether there is metastases in the liver and peritoneal and some other signs;(4) Intraoperative assessment:①explore the surface of liver,small bowel and its mesenterium,transverse colon and its mesenterium,cavitas pelvis and ovary to check whether there is small pallid nodule;②If we cannot find definite metastases intraoperatively,but there is obvious peritoneal fluid,we should make exfoliative cytology and it is positive;③No. 13,14,16 are suspected as metastases;④The number of lymph nodes which are suspected metastases is no less than 16. The accuracy rate of stage-T2,T3,T4 is 64.71%,89.66%,61.11%,stage-N0,N1,N2,N3 is 57.14%,47.06%,62.5%,87.5%, stage-M0,M1 is 100%,85.71%,and stage-IB,II,IIIA,IIIB,IV is 66.67%,33.33%,30%,40%,85%. Dia-x2 analysis,it is concluded that the difference among group T2/T3,T3/T4 and M0/M1 is signi- ficant(p<0.05). We also conclude that the difference among group II/IV,IIIA/IV,IIIB/IV is significant,too(p<0.01). It canbe seen that the assessment of stage T3 is more accurate than T2,T4;As the accuracy of lymph-node assessment has no significant different(p>0.05),we can exclude the error caused by subjective assessment. After analysis with postoperative patho-staging,we find that the metastases rate of No.7,8,9 is 33.9% that is merely the same with some statistics,so we advise to make frozen section in order to identify the extent of radical cure.In our data,the major operation modalities we choose are standard radical dissection and extended radical dissection. The former means to resect 2/3 of proximal and distal stomach or the whole stomach,according to the site of the tumor,plus clearance of N2 lymph nodes;it is also called D2 resection. The latter needs to resect more combined organs that are infiltrated by the carcinoma,while the tumor invades its neighborhoods. Or lymph nodes that are exceeding N2 are suspected as metastases;we must practice D2+ or D3 lymph nodes dissection in order to achieve B-grade radical resection. According to the results of intra- operative staging,we choose D2 or D2 +No.12 lymph node dissection for IB,II,IIIA,part of IIIB,and extended radical dissection for IV,part of IIIB. If it is of no sense for IV-staging patients to have radical cure, we then advise to make by-pass procedure or exploratory laparotomy. In our data, 15 cases receive D2 laparotomy, 37 extended radical operation, and 12 palliative resection. Using x2 analysis, we find the rate of complication between D2 dissection and extended radical operation has no statistical significance (p>0.05). For palliative resection, we adopt by-pass procedure and exploratory laparotomy, and no one has complications. However, according to some literature results, the survival rate between by-pass procedure and palliative resection is significantly different, so we claim to choose palliative resection first.In conclusion, we suggest: 1,the gross accuracy rate of assessment of advanced gastric cancer is relatively high;but inaccurate assessment of stage-N causes the low accuracy rate of each stage of advanced gastric cancer. 2,D2 resection can be used as the major operation style;but if No.7,8,9 lymph nodes are highly suspected as metastases during the operation, we advise to make frozen section in order to identify whether to practiceextended radical resection. 3,we recommend to selectively perform the extended radical resection. 4,We advise to apply palliative resection first.