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[中国、日本和韩国腹腔镜胃癌手术的临床研究现状]

[Clinical research status of laparoscopic gastric cancer surgery in China, Japan and South Korea].

作者信息

Li Guoxin, Chen Xinhua, Yu Jiang, Liu Hao

机构信息

Departmen of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.

出版信息

Zhonghua Wei Chang Wai Ke Za Zhi. 2018 Feb 25;21(2):126-131.

Abstract

Laparoscopic surgery has its unique minimally invasive advantages, however, taking the complex and difficult D2 lymph node dissection for advanced gastric cancer into consideration, laparoscopic gastrectomy was only applied in the treatment of early gastric cancer at its preliminary stage. With the development of more than a decade, many multicenter clinical data have confirmed the safety, feasibility and effectiveness of laparoscopic radical gastrectomy for early gastric cancer. Based on high-quality evidence-based medicine evidence, laparoscopic gastrectomy has been recommended as an optional treatment for stage I( gastric cancer by the Japanese Gastric Cancer Treatment Guidelines 2014(ver.4). However, the safety and effectiveness of laparoscopic gastrectomy for advanced gastric cancer remains controversial due to the lack of high-level evidence-based clinical evidence. Currently, China, Japan and South Korea are trying to clarify its safety and effectiveness by conducting well-designed multicenter prospective randomized controlled trials. To date, CLASS-01 trial in China, whose secondary endpoint indicated that laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer can be safely performed by experienced surgeons, has provided the highest level evidence for the controversy in the world. At ASCO 2016, the safety reports from Korea's KLASS-02 trial also presented the similar conclusion. The long-term oncologic outcomes of the both researches were particularly promising. Retrospecting the whole development of gastric cancer surgery, it is not difficult to find that its mainstream direction is gradually shifted from "extended and standardized surgical resection" to "individual and precise surgery" for the safety and postoperative quality of life. The new concept of minimally invasive surgery built on laparoscopic surgery emphasizes more than shortening the surgical incision, but minimizing tissue trauma and maximizing functional preservation. On the ground of this new minimally invasive concept, surgeons have appreciated to select the most rational treatment for an individual patient. Thus, techniques focusing on further assisting laparoscopic gastrectomy with reducing trauma and preserving function, such as sentinel node navigation surgery and related fluorescence molecular imaging techniques, are increasingly being applied in gastric cancer surgery. At present, a series of researches about the feasibility of sentinel node navigation surgery and function preserving surgery associated with gastric cancer surgery are actively conducted or prepared. Results of these researches may further promote the development of laparoscopic gastrectomy and achieve the qualitative change in minimally invasive surgery in the new era.

摘要

腹腔镜手术具有其独特的微创优势,然而,考虑到进展期胃癌复杂且困难的D2淋巴结清扫术,腹腔镜胃切除术在其初期仅应用于早期胃癌的治疗。经过十多年的发展,许多多中心临床数据已证实腹腔镜根治性胃切除术治疗早期胃癌的安全性、可行性及有效性。基于高质量的循证医学证据,腹腔镜胃切除术已被《日本胃癌治疗指南2014(第4版)》推荐为Ⅰ期胃癌的可选治疗方式。然而,由于缺乏高级别的循证临床证据,腹腔镜胃切除术治疗进展期胃癌的安全性和有效性仍存在争议。目前,中国、日本和韩国正试图通过开展精心设计的多中心前瞻性随机对照试验来阐明其安全性和有效性。迄今为止,中国的CLASS - 01试验,其次要终点表明经验丰富的外科医生可安全地实施腹腔镜D2淋巴结清扫术治疗进展期胃癌,为全球这一争议提供了最高级别的证据。在2016年美国临床肿瘤学会(ASCO)会议上,韩国KLASS - 02试验的安全性报告也得出了类似结论。这两项研究的长期肿瘤学结局都特别令人期待。回顾胃癌手术的整个发展历程,不难发现其主流方向正逐渐从“扩大化和标准化手术切除”转向“个体化和精准手术”,以保障安全性和术后生活质量。建立在腹腔镜手术基础上的微创外科新概念,不仅强调缩短手术切口,更注重将组织创伤降至最低并最大程度保留功能。基于这一新的微创理念,外科医生已开始重视为个体患者选择最合理的治疗方案。因此,诸如前哨淋巴结导航手术及相关荧光分子成像技术等旨在进一步辅助腹腔镜胃切除术以减少创伤并保留功能的技术,正越来越多地应用于胃癌手术。目前,一系列关于胃癌手术前哨淋巴结导航手术及功能保留手术可行性的研究正在积极开展或筹备中。这些研究结果可能会进一步推动腹腔镜胃切除术的发展,并实现新时代微创外科的质的转变。

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