全胃联合脾切除治疗进展期胃癌的系统评价
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摘要
目的系统评价(Meta analysissystematic review)全胃联合脾切除与脾保留两种不同术式在治疗进展期胃癌中的有效性及安全性。
方法计算机检索PubMed、EMBASE、Cochrane Library、中国生物医学文献数据库、中国期刊全文数据库、中文科技期刊全文数据库并手工检索有关全胃联合脾切除(TGS)与脾保留(TG)两种不同手术方式治疗进展期胃癌的随机对照试验(RCT)文献,按照Cochrane系统评价方法对纳入研究的方法学质量(随机、双盲和对照)进行评价,用RevMan4.2.10软件进行统计分析。结合其它半随机临床对照试验文献和回顾性研究文献对其进行描述性分析。
结果共纳入2个RCT,包括394个病例,其中TGS组194例,TG组200例,各研究基线资料均具有可比性,均报道了随机方法但未提及盲法和分配隐藏。Meta分析显示,两组的1,3,5年生存率[OR(95%CI)分别为0.98(0.61,1.58),1.41(0.95,2.10),1.29(0.86,1.29)]和并发症发生率[OR(95%CI)1.70(0.93,3.09)]的差异均无统计学意义;手术死亡率、淋巴结清扫数、肿瘤学方面、再手术次数、平均手术时间和平均住院时间两组均无明显差异。8篇半随机临床对照试验文献和数十篇回顾性研究文献大都证明进展期胃癌根治术中全胃联合脾切除疗效不优于保留脾脏的全胃切除术。
结论TGS治疗进展期胃癌不改善患者术后生存率,可能轻微增加术后感染性并发症发生率,对手术死亡率无影响,因脾脏对肿瘤有免疫调节作用,因此,除非脾脏癌转移或为彻底清扫脾门和脾动脉干阳性淋巴结,应避免在进展期胃癌根治术中联合脾切除。由于纳入文献样本量较少,本结论尚需更高质量的多中心大样本的随机对照试验进一步证实。
Objective: To assess the efficacy and safety of total gastrectomy splenectomy (TGS) versus total gastrectomy (TG) in patients with advanced gastric carcinomas.
Methods: We searched PubMed, Embase, Cochrane Library, Chinese Bio-medicine Database, China Journal Fulltext Database, Chinese Scientific Journals Fulltext Database and handsearched some related Randomized Controlled Trials about TGS and TG to cure advanced gastric carcinomas, the quality of included studies was assessed according to The Cochrane Systematic Reviews Method and statistical analysis was performed by RevMan4.2.10 software.
Results: Two Randomize controlled trials involving 394 patients met the inclusion criteria. All the studies mentioned method of randomization but didn't describe the use of blinding and allocated concealment. The baseline of the included study is comparable. The Meta-analysis showed that: there are no statistically differences between the two groups in 1,3,5-year survival rate [OR(95%CI )0.98 (0.61, 1.58 ), 1.41 (0.95, 2.10), 1.29(0.86,1.29) respectively] and complications [OR(95%CI)1.70 (0.93,3.09)]. There are no obviously differences between the two groups in operative mortality, phymatology directions, reoperation rate, mean operation time and average duration of hospital stay.
Conclusions: This study suggests TGS slightly increased infected complications and was not superior to TG on survival rate, without affecting operative mortality. So splenectomy in advanced gastric carcinomas patients who had received total gastrectomy should generally be avoided, unless cancer metastatis to spleen or in order to thoroughly clear away positive lymphoid node in hilum and arteriosus truncus of spleen. Because of literature sample size is less, they still need to be confirmed by large-sample, multicenter, randomized controlled trials.
方法计算机检索PubMed、EMBASE、Cochrane Library、中国生物医学文献数据库、中国期刊全文数据库、中文科技期刊全文数据库并手工检索有关全胃联合脾切除(TGS)与脾保留(TG)两种不同手术方式治疗进展期胃癌的随机对照试验(RCT)文献,按照Cochrane系统评价方法对纳入研究的方法学质量(随机、双盲和对照)进行评价,用RevMan4.2.10软件进行统计分析。结合其它半随机临床对照试验文献和回顾性研究文献对其进行描述性分析。
结果共纳入2个RCT,包括394个病例,其中TGS组194例,TG组200例,各研究基线资料均具有可比性,均报道了随机方法但未提及盲法和分配隐藏。Meta分析显示,两组的1,3,5年生存率[OR(95%CI)分别为0.98(0.61,1.58),1.41(0.95,2.10),1.29(0.86,1.29)]和并发症发生率[OR(95%CI)1.70(0.93,3.09)]的差异均无统计学意义;手术死亡率、淋巴结清扫数、肿瘤学方面、再手术次数、平均手术时间和平均住院时间两组均无明显差异。8篇半随机临床对照试验文献和数十篇回顾性研究文献大都证明进展期胃癌根治术中全胃联合脾切除疗效不优于保留脾脏的全胃切除术。
结论TGS治疗进展期胃癌不改善患者术后生存率,可能轻微增加术后感染性并发症发生率,对手术死亡率无影响,因脾脏对肿瘤有免疫调节作用,因此,除非脾脏癌转移或为彻底清扫脾门和脾动脉干阳性淋巴结,应避免在进展期胃癌根治术中联合脾切除。由于纳入文献样本量较少,本结论尚需更高质量的多中心大样本的随机对照试验进一步证实。
Objective: To assess the efficacy and safety of total gastrectomy splenectomy (TGS) versus total gastrectomy (TG) in patients with advanced gastric carcinomas.
Methods: We searched PubMed, Embase, Cochrane Library, Chinese Bio-medicine Database, China Journal Fulltext Database, Chinese Scientific Journals Fulltext Database and handsearched some related Randomized Controlled Trials about TGS and TG to cure advanced gastric carcinomas, the quality of included studies was assessed according to The Cochrane Systematic Reviews Method and statistical analysis was performed by RevMan4.2.10 software.
Results: Two Randomize controlled trials involving 394 patients met the inclusion criteria. All the studies mentioned method of randomization but didn't describe the use of blinding and allocated concealment. The baseline of the included study is comparable. The Meta-analysis showed that: there are no statistically differences between the two groups in 1,3,5-year survival rate [OR(95%CI )0.98 (0.61, 1.58 ), 1.41 (0.95, 2.10), 1.29(0.86,1.29) respectively] and complications [OR(95%CI)1.70 (0.93,3.09)]. There are no obviously differences between the two groups in operative mortality, phymatology directions, reoperation rate, mean operation time and average duration of hospital stay.
Conclusions: This study suggests TGS slightly increased infected complications and was not superior to TG on survival rate, without affecting operative mortality. So splenectomy in advanced gastric carcinomas patients who had received total gastrectomy should generally be avoided, unless cancer metastatis to spleen or in order to thoroughly clear away positive lymphoid node in hilum and arteriosus truncus of spleen. Because of literature sample size is less, they still need to be confirmed by large-sample, multicenter, randomized controlled trials.
引文
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1.Kamagawa H,Hamagoe R,Osak Y,Shimizu N,Maeta M,Koga S.Immunosupressive factor from the spleen in gastric cancer patients.Cancer 1985;56:1963-1966.
2.Fujita T,Matai K,Kohno S,Itsubo K.Impact of splenectomy on circulating immunoglobulin levels and the development of postoperative infection following total gastrectomy for gastric cancer.Br J Surg 1996;83:1776-1778.
3.王吉甫主编.胃肠外科学.第1版.北京:人民卫生出版社,2000;360-397.
4.Cuschieri A,Fayers P,Fielding J,Craven J,Bancewicz J,JoyPaul V,et al.Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer:preliminary results of the MRC randomized controlled surgical trial.Lancet 1996;347:995-999.
5.Kwon SJ.Prognostic impact of splenectomy on gastric cancer:results of the Korea gastric cancer study group.World J Surg 1997;21:837-844.
6.Chang-Hua Zhang,Wen-Hua Zhan,Yu-Lng He,et al.Spleen Preservation in Radical Surgery for Gastric Cardia Cancer[J].Annals of Surgical Oncology,2007;29:745-751
7.黄洁夫主编.腹部外科学.北京:人民卫生出版杜,2001;1572-1584.
8.Toge T,Kameda A,Kinai K,Seto Y,Yamada H,Hattori T.The role of spleen in immunosupression and the effects of splenectomy on prognosis in gastric cancer patients. Nippon Geka Gakkai Zasshi 1985; 86: 1120-1123.
9.Weitz J, Jaques DP, Brennan M , et al. Association of splenectomy with postoperative complications in patients with proximal gastric and gastroesophageal junction cancer[J]. Ann Surg Oncol, 2004; 11(7): 682-689.
10.Brady MS, Rogatko A, Dent LL, Shiu MH. Effect of splenectomy on morbidity and survival following curative gastrectomy for carcinoma. Arch Surg 1991; 126:359-364.
11.Maehara Y, Moriguchi S, Yoshida M, Takahashi Y, Korenaga D, Sugimachi K.Splenectomy does not correlate with length of survival in patients undergoing curative total gastrectomy for gastric carcinoma. Cancer 1991; 67: 3006-3009.
12.Kim WS, Noh SH, Yoo CH, Kim YI, Kim CB, Lee KS et al. Effectiveness of combined resection of spleen in total gastrectomy for gastric cancer. J Kor Surg Soc 1998; 54: 363-368.
13.Lee JB, Mok YJ. Significance of a splenectomy with a curative total gastrectomy for gastric cancer. J Kor Surg Soc 1998; 55: 70-75.
14.Okayima K, Isozaki H. Splenectomy for treatment of gastric cancer: Japanese experience. World J Surg 1995; 9: 537-540.
15. Maruyama K, Gunven P, Okabayashi K, Sasako M, Kinoshita T. Lymph node metastases of gastric cancer.General pattern in 1931 patients. Ann Surg 1989;210: 596-602.
16. WaneboHJ, Kennedy BJ, Winchester DP, etal. Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on longterm survival [J]. J Am Coll Surg, 1997; 185(2): 177-184.
17.Otsuji E, Yamaguchi T, Sawai K, Ohara M, Takahashi T. End results of simultaneous splenectomy in patients undergoing total gastrectomy for gastric carcinoma. Surgery 1996; 120: 40-44.
18.Takahashi M, Fojimoto S, Kabay K, et al. Indication for splenectomy combined with total gastrectomy for gastric cancer: Analysis of data on 249 gastric cancer patients.Hepatogastroenterolofty,1995;2:230.
19.M(o|¨)nig SP,Collet PH,Baldus SE,Schmackpfeffer K,Schr(o|¨)der W,Thiele J et al.Splenectomy in proximal gastric cancer:frequency of lymph node metastasis to the splenic hilus.J Surg Oncol 2001;76:89-92.
20.Meyer HJ,Jahne J,Wilke H,Pichlmayr R.Surgical treatment of gastric cancer:retrospective survey of 1704 operated cases with special reference to total gastrectomy as the operation of choice.Semin Surg Oncol 1991;7:356-364.
21.W.Yu,G.S.Choi and H.Y.Chung,Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer[J].British Journal of Surgery Society,2006;93:559-563.
22.Csendes A,Burdiles P,Rojas J.et al.A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187patients with gastric carcinoma[J].Surgery,2002;131(4):401-407.
23.Kodera Y,Yamamura Y,Shimizu Y,Toni A,Hirai T,Yasin K.Lack of benefit of combined pancreato-splenectomy in D2 resection for proximal third gastric carcinoma.World J Surg 1997;21:622-628.
24.Adachi Y,Kamakura T,Mori M,Maehara Y,Sugimachi K.Role of lymph node dissection and splenectomy in nodepositive gastric carcinoma.Surgery 1994;116:837-841.
25.韩方海,詹文华,李玉明等.胃癌根治手术联合脾脏切除远期疗效分析.中华外科杂志,2005;43(17):1114-1117.
26.陈俊强,詹文华,蔡世荣等.脾切除并中上部胃癌根治性全胃切除术对患者生存的影响.中国普通外科杂志,2005,14(3):161-164.
27.Griffth JP,Sue-Ling HM,Martin I,Dixon MF,McMahon MJ,Axon AT,et al.Preservation of the spleen improves survival after radical surgery for gastric cancer.Gut 1995;36:684-690.
28.Kinoshita T,Maruyama K,Sasako M,Okabayashi K.Lymph node dissection around the splenic artery:a comparative study of pancreatectomy and pancreas preserving operation.Nippon Geka Gakkai 1992;93:128-132.
29.Yoshino K,Yamuda Y,Asanuma F,Aizawa K.Splenectomy in cancer gastrectomy: recomendation of spleen-preserving forearly stages.Int Surg 1997;82:150-154.
30.A Cuschieri,S Weeden,J Fielding,et al.Patient survival after D1 and D2resections for gastric cancer:long-term results of the MRC randomized surgical trial British Journal of Cancer.1999;79:1522-1530
31.Shigetoyo Saji,Junichi Sakamoto,Satoshi Teramukai,et al.Impact of splenectomy and Immunochemotherapy on Survival Following Gastrectomy for Carcinoma:Covariate Interaction with Immunosuppressive Acidic Protein,A Serum Marker for the Host Immune System.Surg Today.1999;29:504-510.
32.夏穗生.关于脾功能和脾脏疾病外科治疗的若干问题.中华医学杂志,1988;68:603.
33.华积德主编.肿瘤外科学 北京:人民军医出版杜,1995;1924-2156.
34.Stipa S,DiGiorgio A,Ferri M,and Botti G.Resultst of curative gastrectomy for carcinoma.J Am Coll Surg 1994;17:567-572.
35.张启瑜主编.钱礼腹部外科学 北京:人民卫生出版杜,2006;237-278.
36.仇登波,黄韬,黄文广等.脾脏对胃癌患者免疫状态的影响.中华医学杂志.1992;72:334.
37.朱正纲,林言箴,尹浩然等.胃癌宿主脾脏免疫状态对扩大根治术的影响.中国肿瘤临床,1994;21:387.
38.Japanese Research Society for Gastric Cancer.The general rules for gastric cancer study in surgery and pathology.Tokyo:Igaku Shoin;1978;460-497.
39.Soga J,Kobayashi K,Saito J,Fujimaki M,Muto T.The role of lymphadenectomy in curative surgery for gastric cancer.World J Surg 1979;3:701-708.
40.Brady MS,Rogatko A,Dent LL,Shiu MH.Effect of splenectomy on morbidity and survival following curative gastrectomy for carcinoma.Arch Surg 1991;126:359-364.
41.Cullingford GL,Watldns DN,Watts ADJ,Mallen DF.Severe late post-splenectomy infection.Surgery 1991;78:716-721.
42.Crookes PF,Incarbone R,Peters JH,Engle S,Bremner CG,DeMeester TR.A selective therapeutic approach to gastric cancer in a large public hospital.Am J Surg 1995;170:602-605.
43..孙学军,黄风瑞,楮海波.肿瘤切除前后患者血清吞噬刺激素水平的变化,外科杂志,1997;2:120.
44.Sobin LH,Wittekind CH.International Union Against Cancer.TNM Classification of Malignant Tumors,Fifth edition.New York:John Wiley & Sons,1997;387-393.
45.Corley DA.Kubo A.Influence of site classification on cancer incidence rales:an analysis of gastric cardia carcinomas.J Natl Cancer lnst,2004;96:1383-1387.
46.Siewert J,Feith M,Werner M,et al.Adenocarcinoma of the esophagogastric junction-Results of SR cal therapy based on anatomical/topographic classification in 1002 consecutive patients.Ann Surg,2000;232:353-360.
47.Enurk S,Ersan Y,Cicek Y,et al.Effect of simultaneous splenectomy on the survival of patients undergoing curative gastrectomy for proximal gas tric carcinoma.Surg Today,2003;33:254-258.
48.傅培彬,董方中,林言箴等.胃癌扩大根治术的疗效评价.中华消化杂志,1982;12:65.
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52.杨永康.胃癌手术中的脾切除问题.普外临床.1990:4:291.
53.陈峻青.胃癌.见:王吉甫主编.胃肠外科学.第1版,北京:人民卫生出版社,2000;360-397.
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3.王吉甫主编.胃肠外科学.第1版.北京:人民卫生出版社,2000;360-397.
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5.Kwon SJ.Prognostic impact of splenectomy on gastric cancer:results of the Korea gastric cancer study group.World J Surg 1997;21:837-844.
6.Okayima K,Isozaki H.Splenectomy for treatment of gastric cancer:Japanese experience.World J Surg 1995;19:537-540.
7.Maruyama K,Gunven P,Okabayashi K,Sasako M,Kinoshita T.Lymph node metastases of gastric cancer.General pattern in 1931 patients.Ann Surg 1989;210:596-602.
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15.汪建平,詹文华主编.胃肠外科手术学.北京:人民卫生出版社, 2005;426-473.
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24.Chang-Hua Zhang,Wen-Hua Zhan,Yu-Lng He,et al.Spleen Preservation in Radical Surgery for Gastric Cardia Cancer[J].Annals of Surgical Oncology,2007;29:745-751
25.韩方海,詹文华,李玉明等.胃癌根治手术联合脾脏切除远期疗效分析.中华外科杂志,2005;43(17):1114-1117.
26.陈俊强,詹文华,蔡世荣等.脾切除并中上部胃癌根治性全胃切除术对患者生存的影响.中国普通外科杂志,2005;14(3):161-164.
27.张杰,周元明.胃癌的D3手术中脾脏的取舍(附87例分析).Antholgy of Mediline.2000;19(4):484-485.
28.Kinoshita T,Maruyama K,Sasako M,Okabayashi K.Lymph node dissection around the splenic artery:a comparative study of pancreatectomy and pancreas preserving operation.Nippon Geka Gakkai 1992;93:128-132.
29.Yoshino K,Yamuda Y,Asanuma F,Aizawa K.Splenectomy in cancer gastrectomy:recomendation of spleen-preserving forearly stages.Int Surg 1997;82:150-4.
30.A Cuschieri,S Weeden,J Fielding,et al.Patient survival after D1 and D2resections for gastric cancer:long-term results of the MRC randomized surgical trial British Journal of Cancer.1999;79:1522-1530
31.Shigetoyo Saji,Junichi Sakamoto,Satoshi Teramukai,et al.Impact of splenectomy and Immunochemotherapy on Survival Following Gastrectomy for Carcinoma:Covariate Interaction with Immunosuppressive Acidic Protein,A Serum Marker for the Host Immune System.Surg Today.1999;29:504-510.
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42.夏穗生.关于脾功能和脾脏疾病外科治疗的若干问题.中华医学杂志,1988;68:603.
43.华积德主编.肿瘤外科学 北京:人民军医出版杜,1995;1924-2156.
44.Stipa S,DiGiorgio A,Ferri M,and Botti G.Resultst of curative gastrectomy for carcinoma.J Am Coll Surg 1994;17:567-572.
45.张启瑜主编.钱礼腹部外科学 北京:人民卫生出版杜,2006:237-278.
46.杨永康.胃癌手术中的脾切除问题.普外临床,1990;4:291.
47.陈峻青.胃癌.见:王吉甫主编.胃肠外科学.第1版,北京:人民卫生出版社,2000:360-397.
48.葛依工,高瀚,孔宪涛等.脾切除在胃癌根治术中的作用.中华消化杂志.1989:9:227.
49.仇登波,黄韬,黄文广等.脾脏对胃癌患者免疫状态的影响.中华医学杂志.1992;72:334.
50.朱正纲,林言箴,尹浩然等.胃癌宿主脾脏免疫状态对扩大根治术的影响.中国肿瘤临床,1994;21:387.
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69.Siewert J,Feith M,Werner M,et al.Adenocarcinoma of the esophagogastric junction-Results of SR cal therapy based on anatomical/topographic classification in 1002 consecutive patients.Ann Surg,2000;232:353-360.
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1.Kamagawa H,Hamagoe R,Osak Y,Shimizu N,Maeta M,Koga S.Immunosupressive factor from the spleen in gastric cancer patients.Cancer 1985;56:1963-1966.
2.Fujita T,Matai K,Kohno S,Itsubo K.Impact of splenectomy on circulating immunoglobulin levels and the development of postoperative infection following total gastrectomy for gastric cancer.Br J Surg 1996;83:1776-1778.
3.王吉甫主编.胃肠外科学.第1版.北京:人民卫生出版社,2000;360-397.
4.Cuschieri A,Fayers P,Fielding J,Craven J,Bancewicz J,JoyPaul V,et al.Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer:preliminary results of the MRC randomized controlled surgical trial.Lancet 1996;347:995-999.
5.Kwon SJ.Prognostic impact of splenectomy on gastric cancer:results of the Korea gastric cancer study group.World J Surg 1997;21:837-844.
6.Chang-Hua Zhang,Wen-Hua Zhan,Yu-Lng He,et al.Spleen Preservation in Radical Surgery for Gastric Cardia Cancer[J].Annals of Surgical Oncology,2007;29:745-751
7.黄洁夫主编.腹部外科学.北京:人民卫生出版杜,2001;1572-1584.
8.Toge T,Kameda A,Kinai K,Seto Y,Yamada H,Hattori T.The role of spleen in immunosupression and the effects of splenectomy on prognosis in gastric cancer patients. Nippon Geka Gakkai Zasshi 1985; 86: 1120-1123.
9.Weitz J, Jaques DP, Brennan M , et al. Association of splenectomy with postoperative complications in patients with proximal gastric and gastroesophageal junction cancer[J]. Ann Surg Oncol, 2004; 11(7): 682-689.
10.Brady MS, Rogatko A, Dent LL, Shiu MH. Effect of splenectomy on morbidity and survival following curative gastrectomy for carcinoma. Arch Surg 1991; 126:359-364.
11.Maehara Y, Moriguchi S, Yoshida M, Takahashi Y, Korenaga D, Sugimachi K.Splenectomy does not correlate with length of survival in patients undergoing curative total gastrectomy for gastric carcinoma. Cancer 1991; 67: 3006-3009.
12.Kim WS, Noh SH, Yoo CH, Kim YI, Kim CB, Lee KS et al. Effectiveness of combined resection of spleen in total gastrectomy for gastric cancer. J Kor Surg Soc 1998; 54: 363-368.
13.Lee JB, Mok YJ. Significance of a splenectomy with a curative total gastrectomy for gastric cancer. J Kor Surg Soc 1998; 55: 70-75.
14.Okayima K, Isozaki H. Splenectomy for treatment of gastric cancer: Japanese experience. World J Surg 1995; 9: 537-540.
15. Maruyama K, Gunven P, Okabayashi K, Sasako M, Kinoshita T. Lymph node metastases of gastric cancer.General pattern in 1931 patients. Ann Surg 1989;210: 596-602.
16. WaneboHJ, Kennedy BJ, Winchester DP, etal. Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on longterm survival [J]. J Am Coll Surg, 1997; 185(2): 177-184.
17.Otsuji E, Yamaguchi T, Sawai K, Ohara M, Takahashi T. End results of simultaneous splenectomy in patients undergoing total gastrectomy for gastric carcinoma. Surgery 1996; 120: 40-44.
18.Takahashi M, Fojimoto S, Kabay K, et al. Indication for splenectomy combined with total gastrectomy for gastric cancer: Analysis of data on 249 gastric cancer patients.Hepatogastroenterolofty,1995;2:230.
19.M(o|¨)nig SP,Collet PH,Baldus SE,Schmackpfeffer K,Schr(o|¨)der W,Thiele J et al.Splenectomy in proximal gastric cancer:frequency of lymph node metastasis to the splenic hilus.J Surg Oncol 2001;76:89-92.
20.Meyer HJ,Jahne J,Wilke H,Pichlmayr R.Surgical treatment of gastric cancer:retrospective survey of 1704 operated cases with special reference to total gastrectomy as the operation of choice.Semin Surg Oncol 1991;7:356-364.
21.W.Yu,G.S.Choi and H.Y.Chung,Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer[J].British Journal of Surgery Society,2006;93:559-563.
22.Csendes A,Burdiles P,Rojas J.et al.A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187patients with gastric carcinoma[J].Surgery,2002;131(4):401-407.
23.Kodera Y,Yamamura Y,Shimizu Y,Toni A,Hirai T,Yasin K.Lack of benefit of combined pancreato-splenectomy in D2 resection for proximal third gastric carcinoma.World J Surg 1997;21:622-628.
24.Adachi Y,Kamakura T,Mori M,Maehara Y,Sugimachi K.Role of lymph node dissection and splenectomy in nodepositive gastric carcinoma.Surgery 1994;116:837-841.
25.韩方海,詹文华,李玉明等.胃癌根治手术联合脾脏切除远期疗效分析.中华外科杂志,2005;43(17):1114-1117.
26.陈俊强,詹文华,蔡世荣等.脾切除并中上部胃癌根治性全胃切除术对患者生存的影响.中国普通外科杂志,2005,14(3):161-164.
27.Griffth JP,Sue-Ling HM,Martin I,Dixon MF,McMahon MJ,Axon AT,et al.Preservation of the spleen improves survival after radical surgery for gastric cancer.Gut 1995;36:684-690.
28.Kinoshita T,Maruyama K,Sasako M,Okabayashi K.Lymph node dissection around the splenic artery:a comparative study of pancreatectomy and pancreas preserving operation.Nippon Geka Gakkai 1992;93:128-132.
29.Yoshino K,Yamuda Y,Asanuma F,Aizawa K.Splenectomy in cancer gastrectomy: recomendation of spleen-preserving forearly stages.Int Surg 1997;82:150-154.
30.A Cuschieri,S Weeden,J Fielding,et al.Patient survival after D1 and D2resections for gastric cancer:long-term results of the MRC randomized surgical trial British Journal of Cancer.1999;79:1522-1530
31.Shigetoyo Saji,Junichi Sakamoto,Satoshi Teramukai,et al.Impact of splenectomy and Immunochemotherapy on Survival Following Gastrectomy for Carcinoma:Covariate Interaction with Immunosuppressive Acidic Protein,A Serum Marker for the Host Immune System.Surg Today.1999;29:504-510.
32.夏穗生.关于脾功能和脾脏疾病外科治疗的若干问题.中华医学杂志,1988;68:603.
33.华积德主编.肿瘤外科学 北京:人民军医出版杜,1995;1924-2156.
34.Stipa S,DiGiorgio A,Ferri M,and Botti G.Resultst of curative gastrectomy for carcinoma.J Am Coll Surg 1994;17:567-572.
35.张启瑜主编.钱礼腹部外科学 北京:人民卫生出版杜,2006;237-278.
36.仇登波,黄韬,黄文广等.脾脏对胃癌患者免疫状态的影响.中华医学杂志.1992;72:334.
37.朱正纲,林言箴,尹浩然等.胃癌宿主脾脏免疫状态对扩大根治术的影响.中国肿瘤临床,1994;21:387.
38.Japanese Research Society for Gastric Cancer.The general rules for gastric cancer study in surgery and pathology.Tokyo:Igaku Shoin;1978;460-497.
39.Soga J,Kobayashi K,Saito J,Fujimaki M,Muto T.The role of lymphadenectomy in curative surgery for gastric cancer.World J Surg 1979;3:701-708.
40.Brady MS,Rogatko A,Dent LL,Shiu MH.Effect of splenectomy on morbidity and survival following curative gastrectomy for carcinoma.Arch Surg 1991;126:359-364.
41.Cullingford GL,Watldns DN,Watts ADJ,Mallen DF.Severe late post-splenectomy infection.Surgery 1991;78:716-721.
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