Kunisaki Chikara, Shimada Hiroshi, Nomura Masato, Matsuda Goro, Otsuka Yuichi, Ono Hidetaka, Akiyama Hirotoshi
Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
Surgery. 2005 Feb;137(2):165-71. doi: 10.1016/j.surg.2004.06.005.
The incidence of carcinoma in the cardiac area of the stomach has been increasing, but the appropriate surgical strategy for these tumors remains controversial. Here we attempt to clarify the debate by retrospectively evaluating surgical outcome.
A total of 191 patients were examined. Patients underwent potentially curative resection for gastric adenocarcinoma, primarily of the upper third of the stomach. Prognostic factors, patterns of lymph node metastasis, and the efficacy of lymphadenectomy were evaluated.
Univariate and multivariate analyses revealed lymph node metastasis as a prognostic factor in gastric cancer. Old and new indices of efficacy were the highest for lymph node removal along the lesser curvature, followed by the paracardial regions and along the left gastric and pancreatic arteries. Removal of the lateroaortic lymph node on the cranial side of the left renal vein had a relatively high efficacy index. In esophageal invasion, the efficacy of lower paraesophageal and supraphrenic lymph node removal was high, although there were discrepancies between the 2 indices.
The extent of lymphadenectomy should be tailored to tumor location. Lymphadenectomy might include the lateroaortic lymph nodes for advanced gastric cancer in the upper third of the stomach and the supradiaphragmatic and lower paraesophageal nodes for tumors extending to the esophagus. Randomized controlled trials are needed to verify these indices.
胃贲门部癌的发病率一直在上升，但针对这些肿瘤的合适手术策略仍存在争议。在此，我们试图通过回顾性评估手术结果来澄清这一争论。
共检查了191例患者。患者接受了胃腺癌的潜在根治性切除术，主要是胃上三分之一部位的腺癌。评估了预后因素、淋巴结转移模式以及淋巴结清扫的疗效。
单因素和多因素分析均显示淋巴结转移是胃癌的一个预后因素。沿小弯侧进行淋巴结清扫的新旧疗效指标最高，其次是贲门旁区域以及沿胃左动脉和胰动脉进行清扫。在左肾静脉头侧切除主动脉旁淋巴结的疗效指标相对较高。在食管侵犯方面，尽管两个指标之间存在差异，但食管旁下组和膈上淋巴结清扫的疗效较高。
淋巴结清扫范围应根据肿瘤位置进行调整。对于胃上三分之一的进展期胃癌，淋巴结清扫可能应包括主动脉旁淋巴结；对于延伸至食管的肿瘤，应包括膈上和食管旁下淋巴结。需要进行随机对照试验来验证这些指标。
