Shimoyama Shouji, Seto Yasuyuki, Yasuda Hidemitsu, Mafune Ken-ichi, Kaminishi Michio
Department of Gastrointestinal Surgery, University of Tokyo, 3-7-1, Hongo, Tokyo, Bunkyo-ku 113-8655, Japan.
World J Surg. 2005 Jan;29(1):58-65. doi: 10.1007/s00268-004-7427-z.
Previously proposed criteria of less invasive surgery for early gastric cancer (EGC) were based mainly on the pathological analyses of the resected specimens; however, preoperative and intraoperative information are also obviously essential for decision making on stage-dependent patient management. Furthermore, most indications and treatment options have not been systematically integrated or evaluated by treatment outcomes. We investigate in this report the rationality of less invasive surgery employed for EGC. Distribution analyses of positive nodes were investigated among 684 patients with primary solitary EGC (379 mucosal and 305 submucosal) who underwent curative resection between 1976 and 2000. Clinicopathological factors highlighted and analyzed included clinical (preoperative and intraoperative) and pathological (postoperative) cancer depth and nodal involvement, gross form, histological type, and maximum cancer diameter, as well as postoperative morbidity and mortality. The scope of lymphadenectomy can be reduced to a modified D1 for clinically mucosal, node-negative, nonpalpable gastric cancer, or for clinically submucosal, node-negative gastric cancer < or = 1.5 cm for intestinal type, or < or = 1.0 cm for diffuse type. Otherwise, a modified D2 lymphadenectomy is sufficient. Local resection can be recommended for clinically mucosal, node-negative gastric cancer without apparent ulceration < or = 4 cm if adjacent lymph nodes are proved cancer negative by a frozen section examination. If the gastric cancer has spread beyond the above criteria, a pylorus-preserving gastrectomy (PPG) can be recommended for tumors located in the middle or lower third of the stomach, provided the distal margin of the cancer is at least 4.5 cm from the pyloric ring. The PPG can be accompanied by a modified D1 or a modified D2 lymphadenectomy according to the respective dissection criteria. Results of these less invasive strategies showed reduced morbidity and mortality, as well as no recurrence or cancer-related deaths. These results suggest that each of our criteria for less invasive surgery for EGC is realistic, well stratified, and satisfactory.
先前提出的早期胃癌（EGC）微创外科手术标准主要基于对切除标本的病理分析；然而，术前和术中信息对于依分期进行患者管理的决策显然也至关重要。此外，大多数适应证和治疗选择尚未通过治疗结果进行系统整合或评估。在本报告中，我们研究了用于EGC的微创外科手术的合理性。对1976年至2000年间接受根治性切除的684例原发性孤立性EGC患者（379例黏膜癌和305例黏膜下癌）的阳性淋巴结分布进行了分析。重点突出并分析的临床病理因素包括临床（术前和术中）及病理（术后）癌症深度和淋巴结受累情况、大体形态、组织学类型、最大癌直径，以及术后发病率和死亡率。对于临床诊断为黏膜癌、无淋巴结转移、不可触及的胃癌，或临床诊断为黏膜下癌、无淋巴结转移且肠型癌直径≤1.5 cm或弥漫型癌直径≤1.0 cm的胃癌，淋巴结清扫范围可缩小至改良D1。否则，改良D2淋巴结清扫就足够了。对于临床诊断为黏膜癌且无淋巴结转移、无明显溃疡且直径≤4 cm的胃癌，如果冰冻切片检查证实相邻淋巴结无癌转移，则可推荐局部切除。如果胃癌超出上述标准，对于位于胃中、下三分之一的肿瘤，若癌的远端边缘距幽门环至少4.5 cm，则可推荐保留幽门的胃切除术（PPG）。PPG可根据各自的清扫标准同时进行改良D1或改良D2淋巴结清扫。这些微创策略的结果显示发病率和死亡率降低，且无复发或癌症相关死亡。这些结果表明，我们为EGC制定的每项微创外科手术标准都是现实的、分层良好且令人满意的。
