Stipa S, Di Giorgio A, Ferri M, Botti C
First Department of Surgery, La Sapienza University, Rome, Italy.
J Am Coll Surg. 1994 Nov;179(5):567-72.
In the western literature, controversy exists regarding the operative management of carcinoma of the stomach. Still debated are the extent of gastric resection, the role of splenectomy, and the significance of lymphadenectomy.
We performed a retrospective study of 646 consecutive patients who underwent curative gastrectomy for carcinoma of the stomach from 1950 to 1989. A multivariate analysis of nine clinicopathologic and treatment-related variables, including type of gastrectomy, splenectomy, and extent of lymphadenectomy was done to assess the relative influence of these variables on survival.
The following variables emerged as independent predictors of death: serosal involvement, distant lymph node metastases, and total gastrectomy. Splenectomy and lymphadenectomy were not related to prognosis. However, a separate analysis on defined subsets of patients revealed that radical lymphadenectomy (removal of N2 nodes) provided a survival benefit in patients with T1-2 N0-1 disease.
These findings suggest that although prognosis of carcinoma of the stomach is mainly determined by the stage of disease at time of operation, the choice of the surgeon can affect survival. Total gastrectomy should be avoided when it is not necessary for proximal tumor location. Subtotal gastrectomy in distally located tumors seems to be the best option. Radical lymph node dissection should be performed when nodal involvement is expected to be limited or absent.
在西方文献中，关于胃癌的手术治疗存在争议。胃切除范围、脾切除术的作用以及淋巴结清扫的意义仍在争论中。
我们对1950年至1989年间连续646例行胃癌根治性胃切除术的患者进行了回顾性研究。对包括胃切除类型、脾切除术和淋巴结清扫范围在内的九个临床病理和治疗相关变量进行多变量分析，以评估这些变量对生存的相对影响。
以下变量成为死亡的独立预测因素：浆膜受累、远处淋巴结转移和全胃切除术。脾切除术和淋巴结清扫术与预后无关。然而，对特定患者亚组的单独分析显示，根治性淋巴结清扫术（切除N2淋巴结）对T1-2 N0-1期疾病患者有生存益处。
这些发现表明，尽管胃癌的预后主要取决于手术时的疾病分期，但外科医生的选择会影响生存。对于近端肿瘤位置，不必要时应避免全胃切除术。远端肿瘤行次全胃切除术似乎是最佳选择。当预计淋巴结受累有限或无受累时，应进行根治性淋巴结清扫。
