Karavokyros Ioannis, Michalinos Adamantios
First Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece.
Front Surg. 2018 Jun 7;5:42. doi: 10.3389/fsurg.2018.00042. eCollection 2018.
The role of extended lymphadenectomy in the surgical treatment of gastric cancer has been debated for many years. So far six prospective randomized trials and a number of meta-analyses comparing D- to D-lymphadenectomy in open surgery have been published with contradicting results. The possible oncologic benefit of radical lymphadenectomy has been blurred by a number of reasons. In most of the trials the strategies under comparison were made similar after protocol violations. Imperfect design of the trials could not exclude the influence of cofounding factors. Inappropriate endpoints could not detect evidently the difference between the two surgical strategies. On the other hand radical lymphadenectomy was characterized by increased morbidity and mortality. This was mostly caused by the addition of pancreatico-splenectomy in all D-dissections, even when not indicated. A careful analysis of the available evidence indicates that D-lymphadenectomy performed by adequately trained surgeons without resection of the pancreas and/or spleen, unless otherwise indicated, decreases Gastric Cancer Related Deaths and increases Disease Specific Survival. This evidence is not compelling but cannot be ignored. D-lymphadendctomy is nowadays considered to be the standard of care for resectable gastric cancer.
扩大淋巴结清扫术在胃癌外科治疗中的作用多年来一直存在争议。到目前为止，已经发表了六项前瞻性随机试验以及一些比较开放手术中D级与D级淋巴结清扫术的荟萃分析，但结果相互矛盾。根治性淋巴结清扫术可能带来的肿瘤学益处因多种原因而变得模糊不清。在大多数试验中，在违反方案后，所比较的策略变得相似。试验设计不完善无法排除混杂因素的影响。不恰当的终点无法明显检测出两种手术策略之间的差异。另一方面，根治性淋巴结清扫术的特点是发病率和死亡率增加。这主要是由于在所有D级清扫术中都增加了胰脾切除术，即使并无必要。对现有证据的仔细分析表明，由训练有素的外科医生进行D级淋巴结清扫术，在无其他指征的情况下不切除胰腺和/或脾脏，可降低胃癌相关死亡率并提高疾病特异性生存率。这一证据虽不具有说服力，但也不能被忽视。如今，D级淋巴结清扫术被认为是可切除胃癌的标准治疗方法。
