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2025年国际胃癌大会（IGCC）在荷兰阿姆斯特丹隆重召开，来自全球的顶尖胃癌专家齐聚一堂，共同探讨胃癌诊疗的最新进展与未来趋势。荷兰鹿特丹医学中心Bas Wijnhoven教授在大会现场接受了《肿瘤瞭望消化时讯》记者的专访，分享了其在食管胃结合部癌（GEJ癌）外科治疗领域的独到见解和丰富经验。本文整理Bas Wijnhoven教授现场访谈实录，深度解析胃癌诊疗中的几大关键议题：手术方式选择标准与微创技术应用前景、围手术期治疗模式优化策略，以及并发症防治的创新理念等。

肿瘤瞭望消化时讯：外科手术是GEJ癌治疗的核心，但手术方式（如经胸 vs. 经腹）和切除范围仍存争议。您如何看待不同术式的选择标准？微创手术在GEJ癌中的应用前景如何？

Bas Wijnhoven教授：感谢您提出这个问题。如今，选择食管胃结合部癌的最佳治疗方案仍具有重要临床意义，但这个问题并不容易回答。

在临床实践中，我们通常高度依赖内镜检查。我会通过内镜仔细评估肿瘤侵犯食管、贲门/胃部的范围，并据此决定手术方案。对于食管胃结合部周围的肿瘤，除非肿瘤已广泛浸润胃部，否则我倾向于选择食管切除术联合胃管重建术。这是因为该部位肿瘤存在近端切缘阳性的风险，而食管切除术能有效降低近端切缘阳性率。研究数据也显示，虽然两种术式的患者生存率可能相近，但食管切除术能降低近端切缘阳性率。

除术前内镜评估外，术中我们会再次评估肿瘤的侵犯范围。特别是在实施全胃切除术时，常需进行术中内镜检查（台上内镜）以确认能否获得足够的食管阴性切缘。为确保切缘阴性，有时需要扩大食管切除范围，并进行切缘冰冻病理检查。因此，手术方案往往需要在术中根据实际情况进行调整。

关于微创手术，我们总是优先采用这种方式，因其安全性与开放手术相当。但当微创手术中难以准确判断肿瘤范围或对能否获得阴性切缘存在疑虑时，我会毫不犹豫地转为开放手术，以便通过直接触诊评估来确定最佳手术方案。

Prof. Bas Wijnhoven：Thanks for the question. Choosing the best approach for GEJ cancer remains very relevant nowadays, yet it's not an easy question to answer.

What we normally do is rely heavily on endoscopy. I assess the extent to which the tumor invades the esophagus, cardia/stomach. Based on that, I decide on my surgical approach. For tumors around the GE junction, I'm more inclined to perform an esophagectomy with gastric tube reconstruction, unless the tumor invades too much of the stomach. I think the danger with junction cancers is an ir radical resection on the proximal side, which is why I'm more inclined to perform an esophagectomy for these cases. Also, data from studies show that survival is probably similar, but the rate of positive proximal margins is lower with this approach.

Besides preoperative endoscopy, during the operation, I re-assess the lenght of esophageal/gastric invasion. Sometimes, we also have to perform an intraoperative endoscopy (on-table endoscopy) to confirm whether we can achieve a clear margin on the esophagus, especially when attempting a total gastrectomy. Additional esophageal length may need to be resected to ensure a clear margin and a frozen section of the margin may be indicated .  Hence, it’s not always easy or clear-cut from the start, and sometimes we have to adapt our surgical strategy during the operation.

Regarding minimally invasive surgery, we always start with this approach as it's safe and has oncological outcomes similar to open surgery. But when it is difficult to judge the tumor extension through a minimally invasive and I'm uncertain about obtaining a clear resection margin, I convert to open surgery with a low threshold facilitating manual assessment to determine the optimal approach.

肿瘤瞭望消化时讯：围手术期治疗模式（如化疗 vs. 放化疗）的优化是提升预后的关键。从外科视角，如何平衡肿瘤降期需求与手术安全性？多学科协作中外科与内科应如何配合？

Bas Wijnhoven教授：确实，这是当前我们在各大学术会议中频繁讨论的重要议题。正如您所言，目前围手术期治疗主要存在两种治疗模式。关于最佳治疗策略的讨论应该在多学科诊疗团队(MDT)框架内进行。这正体现了肿瘤科医生和外科医生之间协作的重要性。

基于ESOPEC研究的结果，目前我们倾向于对大多数食管胃结合部癌和胃癌患者采用化疗方案。但放化疗仍然有其应用价值。我们在决策时不仅要考虑5年生存率这一关键指标，还需要评估治疗方案的毒性反应。众所周知，化疗方案的毒性相对较高。因此，对于老年患者群体，我们可能更倾向于选择放化疗方案。其次，我们在器官保留治疗策略(如新辅助放化疗后的主动监测方案)方面积累了一定经验。其他研究显示，与FLOT化疗方案相比，放化疗能带来更高的局部区域缓解率，使更多患者可能符合器官保留治疗的条件。但值得注意的是，ESOPEC研究得出了相反的结论。

综上所述，基于最新研究数据，对于年轻、淋巴结转移广泛的晚期患者（尤其需要强效全身治疗者），我们目前更倾向于按照MDT建议采用化疗方案。而对于老年患者和局部区域病变局限的患者，如果治疗目标是获得最佳局部区域缓解并保留器官功能，放化疗仍然是可行的选择。

Prof. Bas Wijnhoven：Yes, that’s a very important topic nowadays we discuss at every meeting. I think there are two options, like you say, neoadjuvant chemoradiation and chemotherapy perioperatively.

I think the discussion on optimal strategy should take place within the MDT (Multidisciplinary Team). Hence, the interaction between oncologists and surgeons is visible here. Given the results of the ESOPEC trial, we are inclined to administer chemotherapy to most patients with junctional and gastric cancer nowadays.

But still, there is a place, I think, for chemoradiation. So it’s not only looking at the possibility of achieving optimal 5-year survival, but we also should take into account the toxicity of the treatment. We know that chemotherapy is associated with a somewhat higher toxicity.

So, for elderly patients, we are more inclined probably to choose chemoradiation. Secondly, we have experience with an organ-sparing approach, such as active surveillance, and that’s been investigated after neoadjuvant chemoradiation.

We know from other studies that chemoradiation will achieve a somewhat higher locoregional response, and  more patients may be eligible for an organ-sparing approach compared to FLOT chemotherapy. However, the ESOPEC study showed opposite results.

In summary, looking at the recent data, we are now more inclined to give chemotherapy as advised by the MDT, to younger patients who have advanced nodal disease, especially those who need a strong systemic component. For elderly patients and limited locoregional disease, if the goal is to achieve the best locoregional response with the potential for an organ - sparing approach, chemoradiation remains a viable option.

肿瘤瞭望消化时讯：术后并发症（如吻合口瘘）和长期生活质量是患者关注重点。您在术中技术和术后管理中有哪些创新策略以减少风险？

Bas Wijnhoven教授：这是一个非常重要的议题。并发症管理的核心在于预防，而这与患者选择密切相关。选择合适的手术患者并非易事。尽管有研究表明术前康复训练可改善患者体能状态，但其对降低并发症发生率及严重程度的实际效果仍需更多证据支持。因此我们主要通过严格筛选患者来预防并发症。一旦出现并发症，我们会采取非常积极的处理措施。具体而言，我们会密切监测患者术后恢复情况，关注任何异常临床表现。只要出现任何异常，我们会立即进行CT检查以排查并发症。

就手术技术而言，这是一个常被低估的关键因素。我们知道，术者对食管切除术和胃切除术的熟练程度（特别是吻合技术）至关重要。在本医疗中心，我们要求所有外科医生遵循统一的吻合操作规范。通过这种标准化实践，我们积累了丰富经验，使手术流程趋于一致且安全性显著提高。此外，荷兰实行的集中化诊疗模式确保这类复杂手术仅由经验丰富的高手术量外科医生执行，这也是取得良好治疗效果的重要保障。

总的来说，我们的术后管理遵循非常明确的标准化路径。通过密切监测并发症早期征象并及时干预，从而争取最佳治疗效果。

Prof. Bas Wijnhoven：It's a very important topic. I think managing complications likely starts with prevention, which is closely related to patient selection. Choosing the right patients for surgery is no easy task. There's data about rehabilitation and its impact on lowering complication rates, but while patients may get fitter, there isn't clear evidence yet that it will truly decrease the chances of getting a complication or its severity. So we try to prevent complications by selecting the right patients. If a complication occurs, we treat it very aggressively. In other words, we closely monitor patients during their postoperative period and look for any abnormalities in the postoperatice course of the patient. If there's any abnormality, we will perform a CT scan with a very low threshold to check if there's any complication.

In terms of surgical expertise, it's an underestimated factor. We now that surgeon's proficiency with oesophagectomy and gastrectomy, especially regarding the  anastomosis, is very important. In our unit, we try to have all surgeons perform the anastomosis in the same way and stick to the same principles. By doing so, we are able to build up quite a lot of experience, making the procedures similar and very safe.

Also, I believe the second important thing is that this type of cancer surgery is centralized in the Netherlands. Only high-volume surgeons perform these operations, which I think that's also a requirement for achieving the best outcomes.

In summary, I think most of our postoperative care follows very clear standardized pathways. We carefully look for early signs of complications and try to treat them early to achieve the best results.

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