Current concepts in gastric cancer surgery

OBJECTIVE: Current problems in gastric cancer surgery concern the extent of gastric resection, the need for abdominal evisceration, the degree of lymphadenectomy, and an optimal preoperative tumor staging procedure.

METHODS: A retrospective clinical trial of 284 patients who underwent surgery at Ernst-Moritz-Arndt-University, Greifswald, Germany for gastric cancer between 1987 and 1996. Main outcome measures consist of epidemiological parameters, data on type of surgery, histopathology, postoperative complications, mortality and cancer survival. Statistical analysis between groups was performed using Chi square test (perioperative risk factors, tumor localization, and surgical treatment) and Mann Whitney U tests (Lauren classification). Survival was calculated according to the Kaplan Meier method.

RESULTS: The results are in favor of subtotal gastrectomy performed for all T stages located in the distal or middle 3rd provided that a tumor-free margin of 5 cm in intestinal type and 10 cm in diffuse Lauren's type tumor can be achieved, since this operation carries the lowest postoperative risks and provides the best postoperative quality of life. Resection of adjacent organs are indicated only if they are invaded by the primary tumor (T4). They should not be resected as part of an extended lymphadenectomy procedure. The primary tumor site should guide the degree of lymph node removal. Multimodal therapeutic approaches and high postoperative morbidity and mortality after exploratory laparotomy justify the use of diagnostic laparoscopy in T3 and T4 stage tumors and if diagnostic scans suggest tumor spread.

CONCLUSION: Even though surgery for gastric cancer is well standardized, a tailored surgical approach to different extents of gastric cancer appears justified.