Shimoyama Shouji, Mafune Ken-ichi, Kaminishi Michio
Department of Gastrointestinal Surgery, University of Tokyo, Tokyo, Japan.
Arch Surg. 2003 Nov;138(11):1235-9. doi: 10.1001/archsurg.138.11.1235.
Our previous demonstrations of the feasibility of a pylorus-preserving gastrectomy with a wider-scope lymphadenectomy for early gastric cancer (GC) have raised the possibility of applying pylorus-preserving gastrectomy to a broader segment of GC patients, such as those having GC with invasion extending into the proper muscle layer (GCpm).
Case series.
Tertiary care center.
This study comprised 107 patients with solitary primary GCpm located in the middle or lower third of the stomach.
All patients underwent gastrectomy, using at least the former D2 dissection of the American Joint Committee on Cancer.
Patterns and sites of nodal involvement were analyzed in relationship to other clinicopathologic characteristics, including preoperative and intraoperative evaluations of tumor depth (cT), nodal involvement (cN), and serosal involvement. The conditions required were serosal negativity and measurements less than or equal to cT2 cN0 with histologic proof of node negativity, or if positive, the positive nodes had to be confined to the first or selective second tier. The selective second-tier nodes were defined as those along the left gastric, common hepatic, and celiac arteries.
The factors favoring node negativity were serosal negativity, cN0, or both. For tumors that were serosal-negative and less than or equal to cT2 cN0 to meet the above conditions, a tumor in the middle third of the stomach had to be less than or equal to 2 cm in the maximum diameter, and that in the lower third could be any size. No patients with serosal negativity and cT2 cN0 GCpm less than or equal to 2 cm in diameter died of cancer or had positive nodes beyond the selective second tier.
Considering the required distance between the pyloric ring and distal margin of the tumor to avoid a positive resection margin, pylorus-preserving gastrectomy with a selective second-tier node dissection is optimal for tumors that are serosal negative, less than or equal to cT2 cN0, and less than or equal to 2 cm in maximum diameter when located in the middle or lower third of the stomach.
我们之前已证明，对于早期胃癌（GC），行保留幽门的胃切除术并扩大范围的淋巴结清扫术是可行的，这使得将保留幽门的胃切除术应用于更广泛的GC患者群体成为可能，比如那些肿瘤侵犯至固有肌层的GC（GCpm）患者。
病例系列研究。
三级医疗中心。
本研究纳入了107例孤立性原发性GCpm患者，肿瘤位于胃中下部。
所有患者均接受胃切除术，至少采用美国癌症联合委员会先前的D2淋巴结清扫术。
分析淋巴结受累的模式和部位，并与其他临床病理特征相关联，包括术前和术中对肿瘤深度（cT）、淋巴结受累（cN）和浆膜受累情况的评估。所需条件为浆膜阴性，且测量结果小于或等于cT2 cN0，并有淋巴结阴性的组织学证据；或者如果为阳性，阳性淋巴结必须局限于第一站或选择性第二站。选择性第二站淋巴结定义为沿胃左动脉、肝总动脉和腹腔动脉的淋巴结。
有利于淋巴结阴性的因素为浆膜阴性、cN0或两者兼具。对于浆膜阴性且小于或等于cT2 cN0以满足上述条件的肿瘤，位于胃中1/3的肿瘤最大直径必须小于或等于2 cm，而位于胃下1/3的肿瘤则可以是任何大小。没有浆膜阴性且直径小于或等于2 cm的cT2 cN0 GCpm患者死于癌症或出现选择性第二站以外的阳性淋巴结。
考虑到幽门环与肿瘤远端切缘之间所需的距离以避免切缘阳性，对于浆膜阴性、小于或等于cT2 cN0且位于胃中下部时最大直径小于或等于2 cm的肿瘤，行保留幽门的胃切除术并选择性清扫第二站淋巴结是最佳选择。
