Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. w.o.de_steur @ lumc.nl
Dig Surg. 2013;30(2):96-103. doi: 10.1159/000350873. Epub 2013 Jul 18.
The extent of surgery for gastric cancer has been debated since Billroth performed his first gastrectomy in 1881. This review gives an overview of the available literature on the extent of gastrectomy and lymphadenectomy for advanced resectable gastric cancer. Subtotal gastrectomy is associated with lower morbidity and mortality compared with total gastrectomy, without compromising long-term survival. However, a positive resection margin decreases the chance of curation. Frozen section examination may prevent this. For poorly differentiated singlet ring cell tumors, there may be an argument to perform a total gastrectomy in all cases. In 1981, the Japanese Research Society for the Study of Gastric Cancer provided guidelines for the standardization of surgical treatment and pathological evaluation of gastric cancer. Since then, D2 lymph node dissections have become the standard of care in Japan. Because of the superior stage-specific survival rates in Japan, a D2 dissection was evaluated in several Western randomized controlled trials, but no survival benefit was found for a D2 over a D1 dissection. This might be explained by the increased mortality in the D2 dissection groups which might be the result of a standard pancreaticosplenectomy and low experience with D2 dissections. Adding the removal of the para-aortic nodes to a D2 dissection does not further improve survival. The removal of lymph node stations 10 and 11 by splenectomy showed an increased morbidity, no survival benefit, and a very poor prognosis if lymph nodes were affected. Therefore, pancreaticosplenectomy should only be performed in cases of tumor invasion into these organs. A D2 dissection without routine splenectomy and pancreatic tail resection in experienced hands should be considered standard of care for advanced resectable gastric cancer, both in Asian and in Western patients. Centralization and auditing may further improve outcomes after gastrectomy.
自 1881 年 Billroth 首次进行胃切除术以来，胃癌手术的范围一直存在争议。本综述概述了关于可切除进展期胃癌胃切除术和淋巴结清扫术范围的现有文献。与全胃切除术相比，次全胃切除术的发病率和死亡率较低，而不会影响长期生存。但是，阳性切缘会降低治愈的机会。冷冻切片检查可能可以预防这种情况。对于分化不良的单环细胞肿瘤，可能有理由在所有情况下进行全胃切除术。1981 年，日本胃癌研究协会为胃癌的手术治疗和病理评估提供了标准化指南。从那时起，D2 淋巴结清扫术已成为日本的标准治疗方法。由于日本具有优越的特定分期生存率，因此在几项西方随机对照试验中评估了 D2 解剖术，但并未发现 D2 解剖术比 D1 解剖术具有生存优势。这可能是由于 D2 解剖组的死亡率增加所致，这可能是标准的胰脾切除术的结果，并且 D2 解剖术的经验不足。在 D2 解剖术的基础上增加主动脉旁淋巴结清扫术并不能进一步提高生存率。脾切除术切除淋巴结站 10 和 11 会增加发病率，对生存无益，如果淋巴结受到影响，则预后非常差。因此，只有在肿瘤侵犯这些器官的情况下才应进行胰脾切除术。在有经验的医生手中，无需常规进行脾切除术和胰腺尾部切除术的 D2 解剖术，应被视为可切除进展期胃癌的标准治疗方法，无论是亚洲患者还是西方患者。集中化和审核可能会进一步改善胃癌手术后的结果。
