Marrelli Daniele, Pedrazzani Corrado, Neri Alessandro, Corso Giovanni, DeStefano Alfonso, Pinto Enrico, Roviello Franco
Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Siena, Italy.
Ann Surg Oncol. 2007 Jan;14(1):25-33. doi: 10.1245/s10434-006-9063-3. Epub 2006 Oct 7.
Very few studies from Western centers have compared D2 and D3 dissection in the surgical treatment of gastric cancer. The aim of the prospective observational study reported here was to analyze the postoperative outcome and potential risk factors for complications following D2 and D3 lymphadenectomy.
A total of 330 consecutive patients, of which 251 submitted to D2 lymphadenectomy and 79 were treated by D3 lymphadenectomy, were enrolled in the study. Twenty potential risk factors for morbidity and mortality were studied by means of univariate and multivariate analysis.
Overall morbidity and mortality rates were 34% (111 patients) and 4% (14 patients), respectively. Abdominal abscess, anastomotic leakage, pleuropulmonary diseases and pancreatitis were the most commonly observed complications. No differences in morbidity, surgical morbidity, mortality rates and mean hospital stay between D2 and D3 lymphadenectomy were found. Multivariate analysis revealed that American Society of Anesthesiologists' (ASA) class II/III versus class I, perioperative blood transfusions, and low albumin serum levels were independent predictors of postoperative complications. Age, surgical radicality (R1/R2 vs. R0) and low albumin serum levels independently predicted mortality. Mortality rate was .5% in the 203 patients aged 75 years or younger who underwent curative surgery. Most of deaths were observed in patients older than 75 years with low albumin serum levels or treated by non-curative surgery.
D2 lymphadenectomy represents a feasible procedure associated to acceptable morbidity and mortality rates. In specialized centers, D3 lymphadenectomy may be performed without increasing the risk of postoperative complications and associated deaths in carefully selected patients. These techniques should be avoided in subgroups of patients with a high risk of postoperative mortality.
西方中心很少有研究比较D2和D3清扫术在胃癌外科治疗中的效果。本文报道的前瞻性观察研究旨在分析D2和D3淋巴结清扫术后的结局及并发症的潜在危险因素。
本研究共纳入330例连续患者，其中251例行D2淋巴结清扫术，79例行D3淋巴结清扫术。通过单因素和多因素分析研究了20个可能导致发病和死亡的危险因素。
总体发病率和死亡率分别为34%（111例患者）和4%（14例患者）。腹腔脓肿、吻合口漏、胸膜肺部疾病和胰腺炎是最常见的并发症。D2和D3淋巴结清扫术在发病率、手术相关发病率、死亡率和平均住院时间方面未发现差异。多因素分析显示，美国麻醉医师协会（ASA）分级II/III级与I级、围手术期输血以及血清白蛋白水平低是术后并发症的独立预测因素。年龄、手术根治性（R1/R2与R0）和血清白蛋白水平低独立预测死亡率。203例年龄75岁及以下接受根治性手术的患者死亡率为0.5%。大多数死亡病例见于年龄大于75岁、血清白蛋白水平低或接受非根治性手术的患者。
D2淋巴结清扫术是一种可行的手术，发病率和死亡率可接受。在专业中心，对于精心挑选的患者，行D3淋巴结清扫术可能不会增加术后并发症和相关死亡的风险。术后死亡风险高的患者亚组应避免采用这些技术。
