Achieving an R0 resection in gastric cancer remains the most powerful predictor of outcomes. In the patients with clinical T4 tumors, additional organ resection is required to achieve an R0 resection. Additional organ resection in surgical therapy for gastric cancer has been associated with increased morbidity and perioperative mortality in two recent large prospective randomized control trials. Both reports published higher mortality rates, higher complication rates, and longer hospital stays in patients who have undergone a pancreaticosplenectomy in pursuit of a D2 lymphadenectomy
(1,
3,
4 ).
A large retrospective study from Japan found no survival difference when patients undergoing gastrectomy alone were compared to patients with additional organ resection, but again complication rate were greater
( 5 ).
This lack of survival disadvantage for gastrectomy with additional organ resection has been demonstrated in other retrospective studies when evaluating outcomes of patients undergoing total gastrectomy alone, with splenectomy, and with pancreaticosplenectomy
( 6 ).
Martin's study supports the more recent reports in that he found that the number and type of organs were not independent predictors of survival. Splenectomy, pancreaticosplenectomy, or any other organ resection was not found to be a poor predictor of survival on multivariate analysis.
Martin et al. found that advanced T- and N-stage had a far more influential effect on survival than the type or number of organs resected.
The overall 5-year survival rate for the 286 patients undergoing gastrectomy with additional organ resection was 32%. This is significantly less than the gastrectomy-alone group and reflects the greater incidence of nodal stage as well as depth of invasion when compared to patients with gastrectomy alone. This survival is similar to previous reports of patients treated with extended surgical resection in advanced T-stage gastric cancer
(2,
7,
8,
9 )
This study differs from the previous historical reports in the Japanese literature because the authors included only patients undergoing R0 resection, as well as patients with distal stomach lesions. The number of organs resected, as well as the spleen, and pancreas and spleen, were factors on univariate analysis, but they were not found to be predictors of poor survival on multivariate analysis
( 2,
10 ).
Martin's study continues to confirm previous reports that patients with advanced T-stage disease can benefit from aggressive en bloc surgical resection, with minimal morbidity, and should not be rendered unresectable by preoperative imaging, endoscopic ultrasound, or intraoperative assessment of adjacent organ involvement. In addition, if organ involvement is suggested on preoperative evaluation but not found on final pathologic analysis, the survival for these patients is the same, stage for stage.
Recurrence of gastric cancer after resection is not uncommon and represents an aggressive histology. Patients with polyvisceral resection (PVR) have a greater burden of disease and subsequently a greater incidence of recurrence (52%) when compared to patients with gastrectomy alone (42%). Neither the specific organ type resected nor the number of organs resected was predictive of recurrence or the pattern of recurrence. The most powerful predictors of recurrence were nodal stage, depth of invasion, and the site of the primary lesion (distal esophagus and proximal stomach)
( 2 ).
With careful patient selection, gastrectomy with additional organ resection can be done with acceptable morbidity and low mortality. Improvements in preoperative evaluation to confirm T3 and T4 disease are needed to minimize unnecessary organ resections for early-stage disease. Using a reproducible complication grading scale allows for a more accurate appraisal of surgical complications and a more specific evaluation
(1,
2 ).
Su-Shun Lo et al. affirm that total gastrectomy with pancreaticosplenectomy for gastric cancer has been proposed for facilitating lymph node dissection or for resection of direct tumor invasion to the pancreas, especially for T4 lesions. After a learning period in their series, the major complication rate of combined resection decreased from 40% to 20.7%, and mortality decreased from 17.5% to 1.1%
( 11 ).
References
1) Robert C. G. Martin II, David P. Jaques, Murray F. Brennan , and Martin Karpeh. Achieving R0 resection for locally advanced gastric cancer: is it worth the risk of multiorgan resection? J Am Coll Surg.194, 5, May 2002, Pages 568-577
2) Robert C. G. Martin II, David P. Jaques, Murray F. Brennan, Martin Karpeh. Extended Local Resection for Advanced Gastric Cancer: Increased Survival Versus Increased Morbidity. Annals of Surgery 2002; 236(2):159-165
3) J.J. Bonenkamp, I. Songun, J. Hermans et al., Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 345 (1995), pp. 745¯748.
4) A. Cuschieri, P. Fayers, J. Fielding et al., Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 347 (1996), pp. 995¯999.
5) Kasakura Y, Fujii M, Mochizuki F, et al. Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer? Am J Surg 2000; 179: 237-242.
6) Otsuji E, Yamaguchi T, Sawai K, et al. Total gastrectomy with simultaneous pancreaticosplenectomy or splenectomy in patients with advanced gastric carcinoma. Br J Cancer 1999; 79: 1789-1793.
7) Shchepotin IB, Chorny VA, Nauta RJ, et al. Extended surgical resection in T4 gastric cancer. Am J Surg 1998; 175: 123-126.
8) Korenaga D, Okamura T, Baba H, et al. Results of resection of gastric cancer extending to adjacent organs. Br J Surg 1988; 75: 12-15.
9) Yonemura Y, Ooyama S, Matumoto H, et al. Pancreaticoduodenectomy in combination with right hemicolectomy for surgical treatment of advanced gastric carcinoma located in the lower half of the stomach. Int Surg 1991; 76: 226-229.
10) Suehiro S, Nagasue N, Ogawa Y, et al. The negative effect of splenectomy on the prognosis of gastric cancer. Am J Surg 1984; 148: 645-648.
11) Su-Shun Lo, M.D., Chew-Wun Wu, M.D., King-Han Shen, M.D., Mao-Chie Hsieh, M.D., and Wing-Yiu Lui, M.D. Higher Morbidity and Mortality after Combined Total Gastrectomy and Pancreaticosplenectomy for Gastric Cancer. World Journal of Surgery, 26, 678-682, 2002.
