BIBLIOGRAPHIC SOURCE(S)
Society for Surgery of the Alimentary Tract (SSAT). Surgical treatment of gastric cancer. Manchester (MA): Society for Surgery of the Alimentary Tract (SSAT); 2004 May 15. 4 p. [8 references]
Treatment depends upon the clinical stage at presentation and the comorbid disease of the patient. For patients who are medically fit and who have potentially resectable disease, surgery should be performed with an effort to achieve an R0 resection that is defined as a curative en bloc resection with negative proximal, distal, and radial margins (i.e., no obvious residual tumor). The surgeon should attempt to achieve >5-cm proximal and distal margins. For distal tumors, this usually requires a distal gastrectomy. For proximal tumors, a total gastrectomy or proximal gastrectomy is acceptable. For gastric cancers that approach the gastroesophageal junction, the proximal margin should be at least 6 cm; this requirement usually mandates a formal esophagogastric resection with thoracotomy. An extended (D2) lymph node dissection (removing an average of 25 to 30 lymph nodes) can provide more complete staging than a limited (D1) lymph node dissection (removing an average of 15 lymph nodes), but there are no randomized Western trials that demonstrate a survival advantage associated with a D2 dissection yet. A large multi-center, randomized Dutch trial demonstrated that a D2 dissection was associated with increased morbidity and mortality but not with increased survival. A smaller, controlled British trial confirmed the findings of the Dutch study. Splenectomy should be avoided unless the spleen is involved by tumor and at least 15 lymph nodes should be assessed to properly stage the lymph nodes. To ensure that 15 lymph nodes are removed usually requires removal of the lesser omentum, greater omentum, common hepatic arterial lymph nodes, and the left gastric lymph nodes to the celiac axis. In most cases, this lymph node dissection approximates a D2 dissection with the important exception that the splenic hilar lymph nodes are not removed (which is an important component of most D2 dissections) to avoid removal of the spleen.
