老年胃癌伴消化道梗阻、出血的MDT微创手术治疗

doi:10.3877/cma.j.issn.1674-6899.2026.03.009

目的

通过回顾本中心老年胃癌合并消化道梗阻、出血患者的多学科协作诊疗(multi-disciplinary treatment，MDT)全过程，总结并探讨老年胃癌患者的外科诊疗原则。

方法

基于2025年4月在哈尔滨医科大学附属第一医院肿瘤腔镜外科收治的1例因黑便、进食后剧烈呕吐，在近期检查中临床诊断胃癌合并消化道出血、幽门梗阻的患者。通过启动MDT诊治模式，对患者术前一般状态及全身脏器储备功能的评估，结合消化内镜检查、肿瘤分期评估后制定微创外科手术治疗策略。

结果

患者顺利接受腹腔镜下胃癌根治术D2(远端胃大部分切除术＋毕II式吻合＋肠间吻合)，手术用时近3 h，出血量约50 ml，术后无感染、出血、吻合口瘘、消化道功能障碍、血栓等并发症的发生，恢复顺利，术后病理检查结果为胃溃疡性中-低分化腺癌(T3N0MX)。

结论

老年胃癌患者入院后应立刻启动MDT诊治模式，对其全身脏器储备功能进行严密、全面的术前评估，制定精密的围手术期准备方案，并可以通过微创外科手术处理肿瘤及其引发的并发症，使患者最终达到最大获益。

关键词: 胃癌, 消化道出血, 老年外科, 幽门梗阻, 腹腔镜下胃癌根治术

Objective

By reviewing the whole process of multi-disciplinary treatment (MDT) for elderly patients with gastric cancer complicated with gastrointestinal obstruction and bleeding in our center, the principles of surgical diagnosis and treatment for elderly patients with gastric cancer were summarized and discussed.

Methods

Based on a patient admitted to the Department of Oncological Laparoscopic Surgery, the First Affiliated Hospital of Harbin Medical University in Apr. 2025, who was clinically diagnosed as gastric cancer with gastrointestinal bleeding and pyloric obstruction in the recent examination due to melena and severe vomiting after eating. By starting MDT diagnosis and treatment mode, the patient′s preoperative general status and systemic organ reserve function were evaluated, and the minimally invasive surgical treatment strategy was formulated after digestive endoscopy and tumor staging evaluation.

Results

The patient successfully underwent laparoscopic radical gastrectomy D2 (distal gastrectomy+ Billroth Ⅱ anastomosis+ intestinal anastomosis). The operation time was about 3 hours, and the amount of bleeding was about 50ml. There was no postoperative infection, bleeding, anastomotic leakage, gastrointestinal dysfunction, thrombosis and other complications. Postoperative pathological examination showed gastric ulcer moderately to poorly differentiated adenocarcinoma (T3N0MX).

Conclusion

Elderly patients with gastric cancer should start the MDT diagnosis and treatment mode immediately after admission, carry out rigorous and comprehensive preoperative evaluation of their systemic organ reserve function, formulate precise perioperative preparation plan, and treat the tumor and its complications through minimally invasive surgery, so that patients can finally achieve maximum benefits.

Key words: Gastric cancer, Gastrointestinal bleeding, Geriatric surgery, Pyloric obstruction, Laparoscopic radical gastrectomy for gastric cancer

图1 术前内镜检查及病理结果注：A、B.胃镜下胃小弯至胃角处可见约6 cm×7 cm巨大溃疡灶；C.内镜下溃疡病理结果

图2 术前CT检查结果注：A.腹部CT示：肝多发囊肿，胃壁增厚；B、C.肺CT示：双肺气肿、双肺炎症；D.头CT示：腔隙性脑梗死

图3 手术病理结果注：A.大体标本正面观(病灶剖开后)；B.镜下胃肿瘤病理

[1]	Takeda K, Sakayauchi T, Kubozono M, et al. Palliative radiotherapy for gastric cancer bleeding: a multi-institutional retrospective study[J]. BMC Palliat Care, 2022, 21(1): 52.
[2]	Takatsu Y, Hiki N, Nunobe S, et al. Clinicopathological features of gastric cancer in young patients[J]. Gastric Cancer, 2016, 19(2): 472-478.
[3]	Fuchs CS, Mayer RJ. Gastric Carcinoma[J]. N Engl J Med, 1995, 333(1): 32-41.
[4]	Theuer CP, de Virgilio C, Keese G, et al. Gastric adenocarcinoma in patients 40 years of age or younger[J]. Am J Surg, 1996, 172(5): 473-477.
[5]	Yang L, Ying X, Liu S, et al. Gastric cancer: epidemiology, risk factors and prevention strategies[J]. Chin J Cancer Res, 2020, 32(6): 695-704.
[6]	李勇，赵群，范立侨，等. 胃癌并发出血的危险因素分析[J]. 腹部外科，2017, 30(6): 448-451.
[7]	郑才锋. 急诊胃镜治疗胃癌急性出血的临床效果及安全性分析[J]. 实用癌症杂志，2017, 32(4): 638-640.
[8]	Nano M, Solej M. Principles of Geriatric Surgery[M]//Crucitti A. Surgical Management of Elderly Patients. Cham: Springer International Publishing, 2018: 31-46.
[9]	范中宝，荣大庆，刘严峰. 老年患者围手术期治疗[J]. 中国实用医药，2014, 9(35): 18-19.
[10]	杨芬，陈玉英，林平顺. 《老年外科患者围手术期营养支持中国专家共识(2024版)》要点解读[J]. 现代临床护理，2025, 24(12): 8-15.
[11]	Amarya S, Singh K, Sabharwal M. Changes during aging and their association with malnutrition[J]. J Clin Gerontol Geriatr, 2015, 6(3): 78-84.
[12]	Norman K, Haβ U, Pirlich M. Malnutrition in older adults: recent advances and remaining challenges[J/OL]. Nutrients, 2021, 13(8): 2764.
[13]	Srifuengfung M, Abraham J, Avidan MS, et al. Perioperative anxiety and depression in older adults: epidemiology and treatment[J]. Am J Geriatr Psychiatry, 2023, 31(11): 996-1008.
[14]	Parker MJ, Gurusamy K, Stoker M. Surgery in elderly patients[J]. Curr Orthop, 2004, 18(5): 333-344.
[15]	Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery[J]. Ann Intern Med, 2001, 135(10): 847-857.
[16]	McGill JB, White PF, Cryer PE, et al. Perioperative management of surgical patients with diabetes mellitus[J]. Anesthesiology, 1991, 74(2): 346-359.
[17]	Gavin LA. Perioperative management of the diabetic patient[J]. Endocrinol Metab Clin North Am, 1992, 21(2): 457-475.
[18]	Cheisson G, Jacqueminet S, Cosson E, et al. Perioperative management of adult diabetic patients. Preoperative period[J]. Anaesth Crit Care Pain Med, 2018, 37: S9-S19.
[19]	Kwon S, Thompson R, Dellinger P, et al. Importance of perioperative glycemic control in general surgery: a report from the surgical care and outcomes assessment program[J]. Ann Surg, 2013, 257(1): 8-14.
[20]	Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review[J]. J Am Geriatr Soc, 2006, 54(10): 1578-1589.
[21]	Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment[J]. Nat Rev Neurol, 2009, 5(4): 210-220.
[22]	Vaurio LE, Sands LP, Wang Y, et al. Postoperative delirium: the importance of pain and pain management[J]. Anesth Analg, 2006, 102(4): 1267-1273.
[23]	Smetana GW, Conde MV. Preoperative pulmonary update[J]. Clin Geriatr Med, 2008, 24(4): 607-624.
[24]	American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the american college of physicians[J]. Ann Intern Med, 2006, 144(8): 596-608.
[25]	Anders J, Heinemann A, Leffmann C, et al. Decubitus ulcers: pathophysiology and primary prevention[J]. Dtsch Arztebl Int, 2010, 107(21): 371-381.
[26]	Jaul E. Assessment and management of pressure ulcers in the elderly[J]. Drugs Aging, 2010, 27(4): 311-325.
[27]	Alhazzani W, Lim W, Jaeschke RZ, et al. Heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomized trials[J]. Crit Care Med, 2013, 41(9): 2088-2098.
[28]	Layke JC, Lopez PP. Gastric cancer: diagnosis and treatment options[J]. Am Fam Physician, 2004, 69(5): 1133-1140.
[29]	Tsendsuren T, Jun SM, Mian XH. Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer[J]. World J Gastroenterol, 2006, 12(1): 43-47.
[30]	Ma D, Zhang Y, Shao X, et al. PET/CT for predicting occult lymph node metastasis in gastric cancer[J]. Curr Oncol, 2022, 29(9): 6523-6539.
[31]	Takahashi T, Saikawa Y, Kitagawa Y. Gastric cancer: current status of diagnosis and treatment[J]. Cancers, 2013, 5(1): 48-63.
[32]	汪学非，张恒. 早期胃癌内镜切除术后追加外科手术中国专家共识(2025版)[J]. 中国实用外科杂志，2025, 45(10): 1087-1094.
[33]	Hsu JT, Lin YN, Chen YF, et al. A comprehensive overview of gastric cancer management from a surgical point of view[J]. Biomed J, 2025, 48(4): 100817.
[34]	Guerrini GP, Esposito G, Magistri P, et al. Robotic versus laparoscopic gastrectomy for gastric cancer: The largest meta-analysis[J]. Int J Surg, 2020, 82: 210-228.
[35]	Kitano S, Shiraishi N. Minimally invasive surgery for gastric tumors[J]. Surg Clin North Am, 2005, 85(1): 151-164.
[36]	王宁，崔昊，刘贵宾，等. 老年胃癌患者行机器人胃癌根治术后近期并发症的影响因素分析[J/OL]. 中华腔镜外科杂志(电子版), 2021, 14(5): 265-270.
[37]	赵春红，杨亚凯，徐帅，等. 老年患者腹腔镜与开腹胰十二指肠切除术的疗效对比[J/OL]. 中华腔镜外科杂志(电子版), 2025, 18(4): 203-210.
[38]	Kim HH, Han SU, Kim MC, et al. Effect of Laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage i gastric cancer: the KLASS-01 randomized clinical trial[J]. JAMA Oncol, 2019, 5(4): 506-513.
[39]	Sato Y, Okamoto K, Kida Y, et al. Overview of chemotherapy for gastric cancer[J]. J Clin Med, 2023, 12(4): 1336.
[40]	孟元光，王楠. 达芬奇机器人在妇科恶性肿瘤MDT手术的应用[J/OL]. 中华腔镜外科杂志(电子版), 2023, 16(5): 257-261.
[41]	Dewan SK, Zheng SB, Xia SJ. Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive[J]. Eur J Intern Med, 2012, 23(6): 487-494.

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MDT minimally invasive surgery for elderly patients with gastric cancer complicated with gastrointestinal obstruction and bleeding

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MDT minimally invasive surgery for elderly patients with gastric cancer complicated with gastrointestinal obstruction and bleeding