Gastrectomy with D2 lymphadenectomy for gastric cancer: Morbidity, mortality and survival | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ain Shams Journal of Surgery | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Article 9, Volume 5, Issue 1, January 2012, Page 73-86 PDF (10.46 MB) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Document Type: Original Article | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
DOI: 10.21608/asjs.2012.179357 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
View on SCiNiTO | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Authors | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mohamed I Kassem; Abdel Hamid Ghazal; Magdy A Sorour; Aymen Azzam; Mohamed El-Riwini; Hassan El-Bahrawy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
GJT Surgical Unit, Department of General Surgery, University of Alexandria, Egypt. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abstract | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Background: Gastric cancer is the second leading cause of cancer death worldwide. Ninety percent of gastric cancers are adenocarcinomas. Overall, there is a decline in the incidence of gastric cancer in most countries over the past 50 years. Surgical resection is the most effective treatment for curable gastric cancer.Controversy still surrounds the value of extensive lymph node dissection in the curative treatment of gastric carcinoma.The overall 5-year survival rate among patients with resectable gastric cancer ranges from 10% to 30% in the western world. In contrast, Japanese publications report a marked improvement in survival (between 50% and 62%), largely attributed to lymph node resection known as "D2 lymphadenectomy". Methods: The study was a prospective follow-up study on 50 consecutive patients with gastric cancer (without distant metastasis) between March 2007 and February 2010 in the Upper Gastrointestinal Surgery Unit, Faculty of Medicine, Alexandria University, Egypt. Patients less than 65 years with histologically proven and potentially curable gastric cancer were eligible for the study. Preoperatively, all patients underwent upper gastrointestinal endoscopy with biopsies and histopathologic examination. Computed tomography (CT) scans were done to look for metastases. Results: Fifty patients (36 men, 14 women) underwent gastric resection with D2- lymphadenectomy for gastric adenocarcinoma in a three-year period. Mean age was 46.6 years with a range of23-65 years. Almost 44% of patients had preoperative co-morbid disease. Weight loss with epigastric pain and dyspepsia was the most common presenting symptom (80%). Fifty patients underwent D2 resection, fifteen patients with radical total gastrectomy and intra abdominal oesophagojejunostomy, and thirty five patients with a subtotal distal gastrectomy and gastrojejunostomy. The hospital mortality rate was 4% (2/50). Morbidity rate was 44% (22/50), some of them presented with more than one complication. The median time of hospital stay was 22 days (mean 22.3, range 13-40). Follow-up included clinical, laboratory and CT examinations of all patients after surgery. In addition, when relapse was suspected, endoscopy with biopsy, and CT scan were performed. During the first 2 years follow-up, locoregional relapses were observed in 2 patients (local lymph nodes relapse). One patient presented with peritoneal recurrence, and 2 patients showed distant spread. The overall actuarial one-year survival in D2 patients was 92% and 76% at two years. Conclusion: The results obtained in our series of patients submitted to gastrectomy with D2 lymphadenectomy suggest that this technique offers low morbidity, mortality and acceptable 2-year survival rates. The survival benefit with D2 is obtained when a tumor invades muscularis propria or penetrates serosa without invasion of adjacent structures. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Full Text | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gastrectomy with D2 lymphadenectomy for gastric cancer: Morbidity, mortality and survival
Mohamed I Kassem, MD; Abdel Hamid Ghazal, MD; Magdy A Sorour, MD; Aymen Azzam, MD; Mohamed El-Riwini, MD; Hassan El-Bahrawy, MD
GJT Surgical Unit, Department of General Surgery, University of Alexandria, Egypt.
Abstract Background: Gastric cancer is the second leading cause of cancer death worldwide. Ninety percent of gastric cancers are adenocarcinomas. Overall, there is a decline in the incidence of gastric cancer in most countries over the past 50 years. Surgical resection is the most effective treatment for curable gastric cancer.Controversy still surrounds the value of extensive lymph node dissection in the curative treatment of gastric carcinoma.The overall 5-year survival rate among patients with resectable gastric cancer ranges from 10% to 30% in the western world. In contrast, Japanese publications report a marked improvement in survival (between 50% and 62%), largely attributed to lymph node resection known as "D2 lymphadenectomy". Methods: The study was a prospective follow-up study on 50 consecutive patients with gastric cancer (without distant metastasis) between March 2007 and February 2010 in the Upper Gastrointestinal Surgery Unit, Faculty of Medicine, Alexandria University, Egypt. Patients less than 65 years with histologically proven and potentially curable gastric cancer were eligible for the study. Preoperatively, all patients underwent upper gastrointestinal endoscopy with biopsies and histopathologic examination. Computed tomography (CT) scans were done to look for metastases. Results: Fifty patients (36 men, 14 women) underwent gastric resection with D2- lymphadenectomy for gastric adenocarcinoma in a three-year period. Mean age was 46.6 years with a range of23-65 years. Almost 44% of patients had preoperative co-morbid disease. Weight loss with epigastric pain and dyspepsia was the most common presenting symptom (80%). Fifty patients underwent D2 resection, fifteen patients with radical total gastrectomy and intra abdominal oesophagojejunostomy, and thirty five patients with a subtotal distal gastrectomy and gastrojejunostomy. The hospital mortality rate was 4% (2/50). Morbidity rate was 44% (22/50), some of them presented with more than one complication. The median time of hospital stay was 22 days (mean 22.3, range 13-40). Follow-up included clinical, laboratory and CT examinations of all patients after surgery. In addition, when relapse was suspected, endoscopy with biopsy, and CT scan were performed. During the first 2 years follow-up, locoregional relapses were observed in 2 patients (local lymph nodes relapse). One patient presented with peritoneal recurrence, and 2 patients showed distant spread. The overall actuarial one-year survival in D2 patients was 92% and 76% at two years. Conclusion: The results obtained in our series of patients submitted to gastrectomy with D2 lymphadenectomy suggest that this technique offers low morbidity, mortality and acceptable 2-year survival rates. The survival benefit with D2 is obtained when a tumor invades muscularis propria or penetrates serosa without invasion of adjacent structures.
Introduction: Gastric cancer is the second leading cause of cancer death worldwide, although its incidence is decreasing. INinety per cent of gastric cancers are adenocarcinomas. Overall, there is a decline in the incidence of gastric cancer in most countries over the past 50 years.2-6 The reason for this decline remains unknown, but there is speculation that the eradication ofHelicobacter pylori and a change
in diet may be contributing factors.2 Gastric cancer mortality is largely attributable to relapse of the disease, manifested in different ways in more than one location simultaneously.7 Gastric cancer relapse and patient survival depend on both the stage of the disease at the time of diagnosis and on the extent of surgery.8 The overall 5-year survival rate among patients with resectable gastric cancer ranges from 10% to 30% in the western world.9 In contrast, Japanese publications report a marked improvement in survival (between 50% and 62%), largely attributed to lymph node resection known as "D2 lymphadenectomy".10 Some studies suggest that surgeon expertise not only plays an important role in reducing surgical morbidity and mortality but also contributes substantially to improving survivai.ll Surgical resection is the most effective treatment for curable gastric cancer. Controversy still surrounds the value of extensive lymph node dissection in the curative treatment of gastric carcinoma. Reports from the Gastric Cancer Registry and other retrospective studiesl2-15 have made radical gastrectomy with extended D2 removal of regional lymph nodes the standard for the treatment of curable gastric cancer in Eastern Asia and the United States.16-21 The aim of gastrectomy is to achieve an RO resection. A curative resection was defined as RO, and patients with positive microscopic margins (Rl) and evidence of gross residual disease (R2) were considered to have palliative resections. The Japanese Research Society for Gastric Cancer (JRSGC) has assigned the lymph nodes draining the stomach into 16 different lymphatic stations and this is divided into four echelons (Nl-N4).22 The extent of lymphadenectomy is defined as Dl-D4 depending on the lymph node stations dissected. In the Western World, removal of the perigastric lymph nodes along the lesser curvature and the greater curvature is a D1 resection. D2 gastrectomy, involves D1 resection plus removal of the omental bursa and the front leaf of the transverse mesocolon and the nodes along the left gastric artery, the common hepatic artery, the coeliac artery, the splenic artery and splenic hilum (N2 nodes). D3 involves D2 plus removal of nodes in the hepatoduodenalligament, inthe retropancreatic space and along the vessels of the transverse mesocolon. D4 resection involves a D3 resection and removal of the nodes around the abdominal aorta. In reality, D3 and D4 resections are rarely practiced where D2 resections are the gold standard lymphadenectomy.22 Once the gastric tumor invades the subserosa (stage T2b), the serosa (stage T3), or the adjacent structures (stage T4), metastases can spread to the para-aortic lymph nodes, which are termed N3 nodes according to the Japanese Classification of Gastric Carcinoma,23 and M1 nodes according to the International Union Against Cancer (UICC) tumor-node-metastasis (TNM) classification.24 Why should D2 lymphadenectomy be considered? Firstly; the principle, it is known that second echelon N2 nodes will be involved in a high proportion of gastric cancer cases, and most patients have node-positive disease. The excision of this echelon of nodes will increase the likelihood of an RO resection, and this may benefit a subset of patients. Secondly, the experience of centers in Japan and the West reported low operative risks and excellent outcomes.25-27 Complete locoregional tumor removal with adequate margins of clearance has been repeatedly identified and widely accepted as a major factor in reducing locoregional tumor recurrences and improving survival in patients with gastric cancer. Safe margins, by this defmition, entail no residual tumor at resection margins and gastric bed, and no lymph node with tumor in the area of lymphatic drainage.28,29 The aim of this study was to evaluate the morbidity, mortality, and survival in the surgical treatment of curable gastric cancer with radical gastrectomy and D2 lymphadenectomy and the factors that could influence them, and to evaluate whether extending the lymph node dissection to N2 level can improve the survival rate and reduce the incidence of locoregional relapse.
Patients and methods: The study was a prospective follow-up study on 50 consecutive patients with gastric cancer (without distant metastasis) between March 2007 and February 2010 in the Upper Gastrointestinal Surgery Unit, Faculty of Medicine, Alexandria University, Egypt. Patients less than 65 years with histologically proven and potentially curable gastric cancer were eligible for the study. Patients with severe cardiorespiratory, renal or metabolic disease precluding extended resections were excluded, as were those with distant metastases at preoperative staging. Preoperatively; all patients underwentupper gastrointestinal endoscopy with biopsies for histopathologic examination, and computed
Figure (1) tomography (en for staging of gastric cancer and look for metastases Figure(t,l). A total of 50 patients with gastric cancer were operated on. Patients who underwent an en bloc resection of the stomach with extended 02-lymphadenectomy were selected for this study. The lymph node dissection included compartments I (No. 1-6) and II (No. 7-15). The records: Age, gender, co-morbidity, type of gastrectomy, additional organ resection (splenectomy) and pathologic1NM stage were reviewed in the 50 D2 gastrectomies prospectively. Operative mortality and morbidity were defined as death or complications occurred within 30 days after the operation.
Figure (2)
Figure (1,2): CT evidence of cancer stomach (distal third).
Results: Fifty patients (36 men, 14 women) underwent gastric resection with D2- lymphadenectomy for gastric adenocarcinoma in a three-year period. Mean age was 46.6 years with a range of 23-65 years. Patients with a histopathological diagnosis other than adenocarcinoma were excluded, as were those with synchronous neoplasm, and those with tumors located at the oesophagogast:ric junction. There were no exclusions due to co-morbidity or age, except for those patients for whom surgery did not intend to be radical due to the extent of illness, or patients for whom surgery was exclusively palliative. Almost 44% of patients had preoperative co-morbid disease (some of patients presented with more than one co-morbidity). The factors of co-morbidity (n=29) in the 22 patients were diabetes mellitus (n=9),ischemic heart disease (n=8), hypertension (n=7),chronic obstructive pulmonary disease (n=4) and chronic cardiac and dyspepsia was 1he most common presenting symptom (80%), anorexia and dysphagia (10%), upper abdominal discomfort (6%), and haematemesis (4%). Fifty patients underwent D2 resection, fifteen patients with radical total gastrectomy and intra-abdominal oesophagojejunal anastomosis Figures(3,4), and thirty five patients with a subtotal distal gastrectomy and gastrojejunostomy Figures(S-15).Six patients underwent splenectomy,one patient underwent distal pancreatectomy, and one patient underwent transverse colectomy in an attempt to achieve RO resections inthe locally advanced tumors. Distal subtotal gastrectomy was reserved for those patients with tumors located inthe distal thirdof the stomach, corresponding to the Lauren intestinal type, and which, on macroscopic examination, appeared not to invade the gastric serosa. The remaining patients underwent total gastrectomy. Resection was extended to the neighboring
-&iiihl!fiii!ffNtiiDftJ:&II -
failure (n =1). Weight loss with epigastric pain organs when tumor invasion was suspected.
Splenectomy was performed in patients with advanced proximal tumors with suspected splenic infiltration, or with apparently invaded splenic hilar lymph nodes. In the 6 patients in whom a splenectomy was carried out, 2 were for tumors at the upper part of the stomach, 3 for the tumors of the middle part, and one for the tumors diffusely affect the stomach (3 patients had T4 tumors and 3 patients had localized tumors near the splenic hilum with
Figure (3)
suspicion of lymphatic invasion). A distal pancreatectomy was performed in patients with suspected tumor infiltration or metastatic disease in the lymph nodes of the splenic artery chain. Distal pancreatectomy was done in one patient with T3/T4 tumors and the tumor invasion was confirmed. Transverse colectomy with primary anastomosis was done in one patient with T4 tumor invasion of the transverse mesocolon.
Figure(4)
Figures (3,4): Total gastrectomy for diffuse type of cancer stomach.
Figure (5)
Figure (7) Figure(6)
Figure(8)
Figure (9)
Figure (11)
Figure (13)
Figure(10)
Figure(12)
Figure(l4)
Figure (15)
Figures(5-14):Distal gastrectomywith D2lymphadenectomy forcancerstomachof the pyloric antrum and gastrojejunostomy Figure (15). -&iiihl!*iii!ffNtiWftJ:&II -
The clinicopathological characteristics of the 50 patients, the pathologic TNM stages of the patients, and the lymph nodes in the D2 dissections are shown in Table(1). Disease staging was based on the TNM classification included in the fifth edition (2005) of the TNM atlas:illustrated guide to the TNM classification of malignant tumors, of the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC).30
Table (1): Clinicopathological characteristics of the 50 patients (gastrectomy with D1 lymphadenectomy).
NO: No positive nodes N1: One to 6 positive nodes N2: Seven to 15 positive nodes N3: More than 15 positive nodes
The hospital mortality rate was 4% (2/50). The two patients undeiWent total gastrectomy; the first one, 64 years old, was hospitalized before the gastric operation with serious gastric bleeding from the stomach cancer; after blood transfusion and correction of the general condition, he was operated on and died on the 12th postoperative day due to anastomotic dehiscence (oesophagojejuno stomy), septicemia and respiratory distress secondary to pneumonia. The second patient, 60 years old, had hypertension and chronic cardiac failure as a co-morbidity preoperatively, and despite preoperative hospitalization and control of hypertension and chronic cardiac failure, the patient died on the 25th postoperative day because of heart failure and chest infection. Morbidity rate was 44% (22/50), some of them presented with more than one complication. Chest infection (n = 12); two of these patients had respiratory failure and required intensive support at the intensive care unit (ICU) but none required artificial ventilation, wound infection (n=lO), diabetic ketoacidosis (n=3), atrial fibrillation (n=2), upper gastrointestinal hemorrhage (n=2); which resolved spontaneously, deep vein thrombosis (n=l), pulmonary embolism (n=1), and intra abdominal abscess (n=l). There were two patients with oesophagojejunalleak; one patient died postoperative because of intraabdominal abscess and respiratory failure and the other patient was treated conservatively with percutaneous drainage and medical treatment. Another patient with gastrojejunal anastomotic leak was successfully managed conservatively with percutaneous drainage and medical treatment (the anastomotic leak proved by a systematic water soluble X-ray imaging performed on the seventh postoperative day). No patient required surgical re-interventions. The statistics of the parameters according to mortality and morbidity are shown in Table(l).
Table (1): Postoperative complications (morbidity) and mortality.
The median time of hospital stay was 22 days (mean 22.3, range 13--40). Follow-up included clinical, laboratory and CT examinations of all patients during the first two years after surgery. In addition, when relapse was suspected, endoscopy with biopsy, and CT scan were performed. Tumor markers were performed; carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9. Recurrences were classified as locoregional, peritoneal, or distant metastasis. Locoregional recurrences were included (those located in the surgical bed, retroperitoneal lymph nodes of the upper abdomen, or in the site of anastomosis). Peritoneal recurrences were included [those affecting the ovaries, (Krukenberg tumor), carcinomatosis, and positive cytology]. Distant recurrences were those detected in other non-regional lymph nodes or other organs. During the first 2 years follow-up, locoregional relapses were observed in 2 patients (local lymph nodes relapse). One patient presented with peritoneal recurrence, and 2 patients showed distant spread. The survival curve following D2 resections is shown in Figures(16,17). The overall actuarial one-year survival in D2 patients was 92% and 76% at two years.
Statistical analysis: The SPSS version 12.0.1 statistical package was used for statistical analysis. Values for qualitative variables were given as percentages and those for quantitative variables were given as medians and ranges. Survival curves were calculated using the Kaplan-Meier method.
Suryjya!Function
I1!0
O.!f.i ,
ii
-0.00 ' > :J Ill E:s o.as u
D80
0 4 E 8 HI 12 14 16 18 0 -::! 4 :ze duration in months
Figure (16):Survival curve following D2lymphadenectomy and gastriccancer resection.
survivalFunction
1.0
0,8
0.2
0.0
o.oo 2.00 4.oo 6.oo a.oo 100 12.00 14.oo 1oo 1eo 2o.oo 22.00 :z /.oo 26.oo duration In months
Figure (17): The overall actuarial survivalcurve for patients after total and distal subtotal gastrectomy for gastric cancer (2-year Kaplan-Meier survival curve).
Discussion: Despite its recent decline, gastric cancer is still a common lethal disease in western countries.31 For apparently resectable cancers, surgery offers the best locoregional control; but unfortunately,average 5-year survival rates for treated patients remain low in the western world,ranging fi:om15 to 30%.32,33 The benefit of D2 gastrectomy's potential for reducing locoregional recurrence may be nullified by the significant increase of post-operative morbidity andmortality_31 There is controversy over the use ofD2 as a curative procedure for gastric cancer.Japanese surgeons have advocated its use since the 1960s and it is now the standard surgical treatment
-&iiihl!*iii!ffNtiWftJ:&II
for gastric cancer in Japan and in many centers in Hong Kong, Korea and China. Its use in Europe and the US has been limited to specialist units. This may reflect some therapeutic nihilism to gastric and other upper gastrointestinal cancers in the Western World, but in greater part it reflects the lack of supporting evidence from randomised studies which claim no survival benefit yet enhanced operative morbidity and mortality from the extended lymphadenectomy. The Medical Research Council (MRC) studied 400 patients undergoing gastrectomy (200 in both the D1 and D2 groups) in a multicentre trial and found significantly higher post-operative morbidity (33% D2 vs.21% Dl) and mortality (13% D2 vs. 6.5% Dl) following D2 resection.34 In support of this view, Wanebo et ai35 reviewed a prospectively gathered database of 18,346 cases of gastric carcinoma in the US. Among the 3,804 patients undergoing curative resection, five year survival rates for patients with N2, N1 and NO nodes removed were 26.3%, 30% and 35.6% respectively. They concluded that lymph node dissection (D2) of N2 nodes did not confer a survival advantage. Overall mortality was very low, at 0.6%. This rate is comparable to those shown by eastern authors in series from experienced centers, and is strikingly different from the rates of both arms reported in MRC and Dutch trials.36,37 Although morbidity and mortality rates of gastrectomy for gastric cancer were different, in a data analysis of 22 cancer centers; the mortality rate was reported between 3.1% and 31%.38 Inthis study, the hospital mortality rate was 4%, and the mortality rate at one year was 8% and this is in agreement with literature reports. The morbidity rate of our study was 44%, This figure is higher than the percentages reported by other authors in literature in which the morbidity has been reported as being 8- 31%.39,40 Varies studies41,42 have demonstrated that the morbidity increased with age but no significant correlation was found; however other studies emphasized that the age is a predictor factor of morbidity.43,44 In our experience; the mortality and morbidity increased with age but no significant correlation was found. The most common non-abdominal complications in our series were of a respiratory nature, in agreement with many other literature sources_34,45-54 Among the abdominal complications, anastomotic leakage rates reported in the literature ranged from 2.1% to more than 8%.34,45-52,54 The overall incidence of dehiscence in our series was 6%. It is now acceptedthat pancreatic and splenic resections are only justified in the rare situations where there is direct contiguous involvement of these organs by the gastric tumor and that a compete D2 lymphadenectomy can be effectively and safely performed with preservation of these organs.55 In our study, six patients underwent splenectomy, one patient a distal pancreatectomy, and one patient a transverse colectomy in an attempt to achieve RO resections in the locally advanced tumors. The incidence of disease relapse varies greatly among the different series published in the literature. This is due to a number of factors, including the extent of surgery and the tumor stage at the time of the operation. Accordingly, the published relapse rates range from 20% to more than 60%; this figure is higher than the percentages reported by this study (recurrence rate was 10%) and this is because it includes both RO and Rl patients, unlike many other studies that include only RO patients.56-64 It is generally accepted that most relapses occur within the first 2 years after curative surgery for gastric cancer.8,60,65 Yoo et al57 on classifying relapse into early and late groups (according to whether relapse occurred before or after 2 years), found 73% of all disease relapses to occur early. D'Angelica et al60 in turn, reported a higher relapse rate, of 79%, in the first 2 years after surgery; this figure reached 94% before the fourth year.In our series, recurrence within the first 2 years after surgery was seen in 5 patients. Gastric cancer survival according to the type of surgery performed has been the subject of many studies- including those of Bonenkamp et al66 and Cuschieri et ai34 who recommended the obviation of routine D2 gastrectomy due to its high morbidity and mortality, and because the overall 5-year survival in their group of D2 lymphadenectomized patients was not significantly different from that of the group
submitted to more conservative surgery. Other authors have also reported overall 5-year survival rates of fewer than 50%, with results in the range of 30%-47%.47,48,67-69 The 5-year survival rates show marked differences between patients from the West and East, and although the prognosis of resectable gastric carcinoma in the West remains poor, in Japan it is two-fold to three fold higher than those in the West mainly because extended lymph node dissection has been standard procedure during the last three decades_70,71 In recent years, the results of treatment in the West have also shown evidence of improvement. The 5-year survival rate after all resections has increased significantly from 21% in the series ending before 1970 to 28% in those ending before 2000, and the 5-year survival rate after curative resection has risen from 38% to 55% over the same period.72,73 In our study; the overall one-year survival in D2 patients was 92% and 76% after two years.
Conclusion: Our experience is consistent with reports from other units in Western, European and the US and indicates that the extended lymph node dissection with gastrectomy can be performed with a low risk of mortality and morbidity, and acceptable outcomes. In conclusion, the results obtained in our series of patients submitted to gastrectomy with D2 lymphadenectomy suggest that this technique offers low morbidity, mortality and acceptable 2-year survival rates of76%. We consider it essential for such surgery to be performed by specialized surgeons. In principle, the survival benefit with D2 is obtained when a tumor invades muscularis propria or penetrates serosa without invasion of adjacent structures.
References: 1- Kelley JR, Duggan JM: Gastric cancer epidemiology and risk factors. J Clin Epidemio/2003; 56: 1-9. 2- Sobin LH, Witekind C: TNM classification of malignant tumours. New York: John Wiley & Sons, Inc. (Publisher); 5th edn. 1997. 3- Ashley SW, Evoy D, Daly JM: Stomach. In:Principles of surgery.Schwartz (Editor); McGraw Hill (Publisher); 7th edn. 1999;
p. 1181-1216. 4- Nobrega FT, Sedlack JD, Sedlack RE, Dockerty MB, Ilstrup DM, Kurtland LT: A decline in carcinoma of the stomach. A diagnostic artifact? Mayo Clinical Proceedings 1983; 54 (4): 255-260. 5- Ekstrom AM, Hansson LE, Signorello LB, Lindgren A, Bergstrom R, Nyren 0: Decreasing incidence of both major histological sub-types of gastric adenocarcinoma: A population-based study inSweden.BrJCancer2000; 83 (3): 391- 396. 6- McKinney A, Sharp L, MacFarlane GJ, Muir CS: Oesophageal and gastric cancer in Scotland. Br JCancer 1995; 71(2): 411- 415. 7- Yoo CH, Noh SH, ShinDW, Choi SH, Min JS: Recurrence following curative resection for gastric carcinoma. Br J Surg 2000; 87: 236-242. 8- Roukos D, Kappas A: Limitations in controlling risk for recurrence after curative surgery for advanced gastric cancer are now well explained by molecular-based mechanisms. Ann Surg Onco/2001; 8: 620- 821. 9- Alvaro DL, Concepcion Y, Ruben A, et al: Rational for gastrectomy with D2 lymphadenectomy in the treatment of gastric cancer. Gastric cancer 2008; 11: 96-102. 10-Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM: Gastric adenocarcinoma: Review and considerations for future directions. Ann Surg 2005; 241: 27-39. 11-Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL: Surgeon volume and operative mortality in United States. N Eng/ JMed2003; 349: 2117-2127. 12-de Aretxabala X, Konishi K, Yonemura Y, et al:Node dissection in gastric cancer. Br J Surg 1987; 74: 770-773. 13-Maruyama K, Okabayashi K, Kinoshita T: Progress in gastric cancer surgery in Japan and its limits ofradicality. World J Surg 1987; 11: 418-425. 14-Sasako M, McCulloch P, Kinoshita T, Maruyama K:New method to evaluate the therapeutic value of lymph node dissection
for gastric cancer.Br JSurg 1995; 82: 346- 351. 15-Pacelli F, Doglietto GB, Bellantone R, et al: Extensive versus limited lymph node dissection for gastric cancer: a comparative study of320 patients. Br JSurg 1993; 80: 1153-1156. 16-Wu CW, Hsiung CA, LoSS, Hsieh MC, Shia LT, Whang-Peng J: Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer. Br JSurg 2004; 91: 283-287. 17-Sierra A, Regueira FM, Herruindez-Lizmlin JL, Pardo F, Martinez-Gonzalez MA, A Cienfuegos J: Role of the extended lymphadenectomy in gastric cancer surgery: Experience in a single institution.Ann Surg Onco/2003; 10: 219-226. 18-Bonenkamp JJ, Songun I, Hermans J, et al: Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients.Lancet 1995; 345: 745- 748. 19-Douglass HO Jr, Hundahl SA, Macdonald JS, Khatri VP:Gastric cancer:D2 dissection or low Maruyama Index-based surgery- a debate. Surg Oneal Clin N Am 2007; 16: 133-155. 20-Sasako M, Saka M, Fukagawa T, Katai H, Sano T: Modem surgery for gastric cancer -- Japanese perspective. Scand J Surg 2006; 95: 232-235. 21-Sano T: Tailoring treatments for curable gastric cancer. Br J Surg 2007; 94: 263- 264. 22-Japanese Research Society for Gastric Cancer. Japanese Classification of Gastric Carcinoma. 1st English Edition. Tokyo: Kanehara, 1995. 23-Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma- 2nd English Edition. Gastric Cancer 1998; 1: 10-24. 24-Sobin LH, Witekind C: TNM classification of malignant tumours. New York: John Wiley & Sons, Inc. (Publisher); 5th edn. 2002. 25-Sue-Ling HM, Johnston D, Martin IG, Dixon MF, Landsown MRJ, McMahon MJ, Axon ATR: Gastric cancer: A curable disease in Britain. Br Med J 1993; 307: 591-596. 26-Degiuli M, Sasako M, Ponti A, Soldati T, Danese F, CalvoF: Morbidity and mortality after D2 gastrectomy for gastric cancer: Results of the Italian gastric cancer study group prospective multicentre surgical study. Clin Onco/1998; 16: 1490-1493. 27-Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF: Is gastric cancer different between Japan and the United States? Cancer 2000; 89(11): 2237-2246. 28-Siewart JR, Bottcher K, Stein HJ, et al: Relevant prognostic factors in gastric cancer. Ten-year results of the German Gastric Cancer Study.Ann Surg 1998; 228: 449-461. 29-Siewart JR, Bottcher K, Stein HJ:Operative strategies. In: Surgery for gastrointestinal cancer. Wanebo HJ (Editor); Philadelphia: Lippincott-Raven (Publisher); 1997; p.305- 318. 30-Wittekind CH, Greene FL, Hutter RVP, Klimpfinger M, Sobin LH: TNM atlas: Illustrated guide to the TNM classification of malignant tumors. Heidelberg Berlin New York Tokyo: Springer (Publisher); 5th edn. 2005. 31-Degiuli M, Sasako M, Calgaro M, et al: Morbidity and mortality after D1 and D2 gastrectomy for cancer: Interim analysis of the Italian Gastric Cancer Study Group (IGCSG) randomised surgical trial. EJSO 2004; 30: 303-308. 32-Parikh D, Chagla L, Johnson M, LoweD, McCulloch P: D2 gastrectomy: Lessons from a prospective audit of the learning curve. Br J Surg 1996; 83: 1595-1599. 33-Wanebo HJ, Kennedy BJ, Chmiel J, Steele G Jr., Winchester D, Osteen R: Cancer of the stomach. A patient care study by the American College of Surgeons. Am JSurg 1993;218:583-592. 34-Cuschieri A, Payers P, Fielding J, Craven J, Bancewicz J, Joypaul V, Cook P: Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: Preliminary results of the MRC randomised controlled surgical trial. Lancet 1996; 347: 995-999. 35-Wanebo HJ, Kennedy BJ, Winchester DP, Fregmen A, Stewart AK: Gastric carcinoma: Does lymph node dissection
alter survival? JAmer Coli Surg 1996; 183: 616-624. 36-Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, Cook P: Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: Preliminary results of the MRC randomised controlled surgical trial. Lancet 1996; 347: 995-999. 37-0tsujii E, Yamaguchi T, Sawai K, Okamato T, Takahashi T: End results of simultaneous pancreatectomy, splenectomy and total gastrectomy for patients with gastric carcinoma. Br JCancer 1997; 75: 1219- 1223. 38-Damhuis RAM, Meurs CJC, Dijkhuis CM, Stassen LP, Wiggers T: Hospital volume and post-operative mortality after resection for gastric cancer. Eur JSurg Onco/2002; 28: 401-405. 39-McCullough JA, Evoy D, Sweeney KJ, Meyers C, RaviN, Keeling N, et al: D2 lymphadenectomy in the management of gastric cancer. Ir J Med Sci 2003; 172 (3): 132-135. 40-Katai H, Sasako M, Sano T, Fukagawa T: Gastric cancer surgery in the elderly without operative mortality. Surg Onco/2004; 13: 235-238. 41-Gil-Rendo A, Hernandez-Lizoain JL, Martinez-Regueira F, Sierra Martinez A, Rotellar Sastre F, Cervera Delgado M, et al: Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer. Clin Trans! Onco/2006; 8(5): 354-361. 42-McCullochP, WardJ, Tekkis PP: ASCOT group of surgeons, British Oesophago Gastric Cancer Group. Mortality and morbidity in gastro-oesophageal cancer surgery: Initial results of ASCOT multicentre prospective cohort study. Br Med J 2003; 327(7425): 1192-1197. 43-Persiani R, Antonacci V, Biondi A, Rausei S, La Greca A, Zoccali M, et al: Determinants of surgical morbidity in gastric cancer treatment. JAm Coli Surg 2008; 207: 13-19. 44-Gong DJ, Miao CF, Bao Q, Jiang M, Zhang LF, Tong XT, et al: Risk factors for operative morbidity and mortality in gastric
cancer patients undergoing total gastrectomy. World J Gastroentero/2008; 14: 6560-6563. 45-Roviello F, Marrelli D, Morgagni P, de Manzoni G, DiLeo A, Vindigni C, et al: Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study. Ann Surg 2002; 9: 894-900. 46-Siewert JR, B ttcher K, Roder JD, Busch R, Heimanek P, Meyer HJ: Prognostic relevance of systematic lymph node dissection in gastric carcinoma. Br JSurg 1993;80: 1015-1018. 47-Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F: A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery 2002; 131: 401- 407. 48-Bittner R, Butters M, Ulrich M, Uppenbrink S, Beger HG: Total gastrectomy: Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age. Ann Surg 1996; 224: 37-42. 49-Zilberstein B, da Costa Martins B, Jacob CE, Bresciani C, Lopasso FP, de Cleva R, et al: Complications of gastrectomy with lymphadenectomy in gastric cancer.Gastric Cancer 2004; 7: 254-259. 50-Lewis WG, Edwards P, Barry JD, KhanS, Dhariwal D, Hodzovic I, et al: D2 or not D2? The gastrectomy question. Gastric Cancer 2002; 5: 29-34. 51-Roder JD, Bottcher K, Siewert JR, Busch R, Hermanek P, Meyer HJ: Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992. Cancer 1993; 72: 2089-2097. 52-Dent D, Madden M, PriceS: Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma. Br JSurg 1988; 75: 110- 112. 53-Bozzetti F, Marubini E, Bonfanti G, Miceli R, Piano C, Crose N, et al: Total versus subtotal gastrectomy: Surgical morbidity and mortality rates in a multicenter Italian randomized trial.Ann Surg 1997; 226: 613-
620. 54-Sano T, Katai H, Sasako M, Maruyama K: One thousand consecutive gastrectomies without operative mortality.Br J Surg 2002; 89: 123. 55-Park DJ, Lee IU, Kim HH, Yang HK, Lee KU, Choe KJ: Predictors of operative morbidity and mortality in gastric cancer surgery. Br J Surg 2005; 92: 1099-1102. 56-Kappas A, Roukos D: Quality of surgery determinant for the outcome of patients with gastric cancer. Ann Surg Oncol2002; 9: 828-830. 57-Yoo CH, Noh SH, ShinDW, Choi SH, Min JS: Recurrence following curative resection for gastric carcinoma. Br J Surg 2000; 87: 236-242. 58-Maehara Y, Hasuda S, Koga T, Tokunaga E, Kakeji Y, Sugimachi K: Postoperative outcome and sites of recurrence in patients following curative resection of gastric cancer. Br J Surg 2000; 87: 353-357. 59-Bohner H, Zimmer T, Hopfenm)ler W, Berger G, Buhr IU:Detection and prognosis of recurrent gastric cancer. Is routine follow-up after gastrectomy worthwhile? Hepatogastroenterology 2000; 47: 1489- 1494. 60-D'Angelica M, Gonen M, Brennan MF, Turnbull AD, Bains M, Karpeh MS: Patterns of initial recurrence in completely resected gastric adenocarcinoma. Ann Surg 2004; 240: 808-816. 61-Schwarz R, Zagala-Nevarez K:Recurrence patterns after radical gastrectomy for gastric cancer: Factors and implications for postoperative adjuvant therapy. Ann Surg Onco/2002; 9: 394-400. 62-Bennett JJ, Gonen M, D'AngelicaM, Jaques DP, Brennan MF, Coit DG: Is detection of asymptomatic recurrence after curative resection associated with improved survival in patients with gastric cancer? JAm Coil Surg 2005; 201: 503-510. 63-Marrelli D, Roviello F, de Manzoni G, Morgagni P, Di Leo A, Saragoni L, et al: Different patterns of recurrence in gastric cancer depending on Lauren's histological
type: Longitudinal study. World J Surg 2002; 26: 1160-1165. 64-Marrelli D, De Stefano A, de Manzoni G, Morgagni P, Di Leo A, Roviello F: Prediction of recurrence after radical surgery for gastric cancer. A scoring system obtained from a prospective multicenter study. Ann Surg 2005; 241: 247-255. 65-Shchepotin I, Evans SR, Shabahang M, Cherny V, Buras RR, Zadorozhny A, et al: Radical treatment of locally recurrent gastric cancer. Am Surg 1995; 61: 371-376. 66-Bonenkarn.p J, Hermans J, Sasako M, van de Velde CJ, Welvaart K, Songun I, et al: Extended lymph-node dissection for gastric cancer.NEng/ JMed 1999; 340: 908-914. 67-Desai A, Pareek M, Nightingale P, Fielding J: Improving outcomes in gastric cancer over 20 years. Gastric Cancer 2004; 7: 196-203. 68-Martin R, Jaques D, Brennan M, Karpeh M: Extended local resection for advanced gastric cancer: Increased survival versus increased morbidity. Ann Surg 2002; 236: 159-165. 69-Karpeh M, Leon L, Klimstra D, Brennan M: Lymph node staging in gastric cancer: Is location more important than number? An analysis of 1038 patients. Ann Surg 2000; 232: 362-371. 70-Sue-Ling HM, Johnston D, Martin IG, et al: Gastric cancer: Acurable disease in Britain. Br Med J 1993; 307: 591-596. 71-Yildirim E, Orban C, Berberoglu U: The Turkish experience with curative gastrectomies for gastric carcinoma: Is D2 dissection worthwhile? JAm Coli Surg 2001; 192: (1) 25-37. 72-Jatzko GR, Lisborg PH, Denk H, et al: A 10-year experience with Japanese-type radical lymph node dissection for gastric cancer outside of Japan. Cancer 1995; 76: 1302-1312. 73-Akoh JA,Maclntyre IMC: Improving survival in gastric cancer: Review of 5- year survival rates in English language publications from 1970. Br J Surg 1992; 79: 293-299. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Statistics Article View: 69 PDF Download: 66 |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||