Verreet P R
Zentrum für Chirurgie, Klinikum Krefeld.
Praxis (Bern 1994). 1998 Mar 25;87(13):447-50.
The aim of any surgical approach to gastric carcinoma should be a complete resection with no residual tumor left behind, that is, a R0-resection according to UICC. Complete tumor resection in this respect refers to the primary tumor as well as to the lymphatic drainage and requires an adequate safety margin. The indications for surgical therapy of gastric cancer and the choice of procedure should consequently be guided by the tumor stage. This requires accurate preoperative staging, which can today be achieved with endoscopic ultrasonography and surgical laparoscopy. Gastric carcinoma stage IA (mucosa carcinoma) can be cured by local excision. In patients with tumor Stages IB (submucosa carcinoma), II, and IIIA, lymph node metastases are common. Based on the available data, this group of patients benefits from radical resection and D2 lymph node dissection. The overall 5-year survival rate of 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of extended lymphadenectomy. In patients with advanced gastric carcinoma, that is, tumor stages IIIB and IV, a complete tumor removal usually can not be achieved by surgical dissection. Neoadjuvant therapeutic modalities should consequently be assessed in these patients. Based on tumor location and growth pattern, a total gastrectomy is the procedure of choice in patients with middle and proximal third gastric cancer. A subtotal gastrectomy may be performed in patients with tumors of the distal third and "Laurens intestinal type" growth pattern. The distal site of the main lesion must be investigated carefully to ensure that incidental concomitant lesions are not overlooked. Depending on the individual tumor situation, the gastrectomy can be extended toward varying portions of the distal esophagus or the pancreas, preserving splenectomy and resection of the retroperitoneal lymph nodes. The high incidence of locoregional recurrences and distant metastases after curative surgery for gastric cancer calls for improved locoregional control and systemic adjuvant treatment.
任何胃癌手术方法的目标都应该是实现完整切除，不留残余肿瘤，即根据国际抗癌联盟（UICC）标准进行R0切除。在这方面，完整的肿瘤切除是指切除原发肿瘤以及淋巴引流区，并且需要足够的安全切缘。因此，胃癌手术治疗的适应证和手术方式的选择应以肿瘤分期为指导。这就需要准确的术前分期，如今通过内镜超声检查和手术腹腔镜检查可以实现这一点。胃癌IA期（黏膜癌）可通过局部切除治愈。在肿瘤分期为IB期（黏膜下癌）、II期和IIIA期的患者中，淋巴结转移很常见。根据现有数据，这组患者从根治性切除和D2淋巴结清扫中获益。大量接受胃癌切除手术患者的总体5年生存率为50%，这似乎令人信服地证明了扩大淋巴结清扫术的价值。对于晚期胃癌患者，即肿瘤分期为IIIB期和IV期的患者，通常无法通过手术切除实现肿瘤的完全清除。因此，应在这些患者中评估新辅助治疗方式。根据肿瘤位置和生长模式，全胃切除术是胃中、近端三分之一胃癌患者的首选手术方式。对于远端三分之一肿瘤且呈“劳伦氏肠型”生长模式的患者，可进行胃次全切除术。必须仔细检查主要病变的远端部位，以确保不遗漏偶然伴随的病变。根据个体肿瘤情况，胃切除术可向远端食管或胰腺的不同部位扩展，同时保留脾脏并切除腹膜后淋巴结。胃癌根治性手术后局部区域复发和远处转移的高发生率要求改善局部区域控制和全身辅助治疗。
