Br. J. Surg. 1992, Vol. 79, September, 942-944
C. Hiischer, S. Chiodini, V. Freni, A. Recher, F. Torri and F. Bozzetti lstituto Nazionale Tumori, Via Venezian 7 , 20133 Milan, Italy Correspondence to: Dr F. Bozzetti
Adequacy of paracardial dissection in subtotal versus total gast rectomy Right and left paracardial dissection represents an obligatory step in gastrectomy for gastric cancer of the lower half of the stomach because a second-level lymphadenectomy is part of the radical surgery f o r malignancy at this site. Whereas right and left paracardial dissection is easily accomplished during total gastrectomy, there is doubt as to whether subtotal gastrectomy achieves the same radical clearance of these groups of lymph nodes. This study therefore compared the number of lymph nodes dissected and the frequency of metastases in these compartments in 14 patients undergoing total gastrectomy and 22 submitted to subtotal gastrectomy. The mean number of lymph nodes dissected in the right paracardial compartment was 7.1 per patient undergoing total gastrectomy and 6.7perpatient in subtotal gastrectomy ( P = 0.7). The mean numbers of left paracardial lymph nodes dissected in total and subtotal gastrectomy were 3.4 and 4.1 per patient respectively ( P = 0.3). These data show that the same degree of radical clearance can be achieved in these nodal compartments, irrespective of the extent of gastric resection.
Current literature suggests that gastric cancer should be managed with subtotal resection rather than total gastrectomy’.’, provided that a safe proximal margin is guaranteed. This would generally require a 6-cm clearance of tissue3, although this value is somewhat dependent o n the degree of tuniour penetration into the gastric wall3, the macroscopic appearance of the tumour4,’ and the histological type according t o Lauren’s c la ~ s i f ic a t io n ~ ~ ’ . -~’ There is also evidence, from both J a p a n e ~ e ~ . ~and German’,’* investigations, that dissection of the second lymph node compartment could improve the prognosis; the potential benefit is being tested by ongoing trials in South Africa13 an d the UK4. T h e question is whether paracardial right and left dissections of lymph nodes, which represent the second- a n d third-level compartments respectively, can be performed in carcinoma of the distal third of the stomach with the same radical degree in both subtotal and total gastrectomy. T h e purpose of this investigation was t o compare the number of lymph nodes dissected in the left a n d right paracardial compartments after subtotal an d total gastrectomy for cancer of the lower third of the stomach, an d t o assess the safety of both procedures.
To dissect the left and right paracardial nodes without carrying out a total gastrectomy, the phreno-oesophageal ligament was divided, truncal vagotomy performed, and the paracardial nodes dissected by traction on the vagi and fatty tissue surrounding the cardio-oesophageal .junction (Figure 1 ). In subtotal gastrectomy it was usual to ligate and divide the first and the lowest two or three short gastric vessels, leaving the intermediate ones intact to optimize the vascular supply to the gastric stump. The stomach was then stapled just below the cardia to leave only a small fundal pouch. The gastrojejunal anastomosis along the greater curvature was carried out with an EEA stapler (US Surgical) using a 70-cm Roux-en-Y loop. The procedure was completed with dissection of the retropancreatic nodes.
Patients and methods Thirty-six patients underwent total or subtotal gastrectomy for cancer of the lower third of the stomach. Table 1 summarizes the main features of the series. There were 14 patients in the total gastrectomy group (six men, eight women; mean age 60.0 years) and 22 in the subtotal gastrectomy group (16 men, six women; mean age 64.0 years). The operative procedure consisted of an upper midline incision followed by separation of the greater omentum from the transverse colon, in continuity with the upper leaflet of transverse mesocolon and peritoneum of the lesser sac investing the anterior surface of the pancreas. The infrapyloric lymph nodes were dissected after ligation of the anteroinferior pancreatic vessels. The first part of the duodenum was mobilized and transected with a CIA stapler (US Surgical, Norwalk, Connecticut, USA). The lymph nodes of the hepaticoduodenal ligament were dissected. The right gastroepiploic vessels were ligated and divided; the lymph nodes along the common hepatic artery were dissected together with those of the coeliac axis and splenic artery. The left gastric artery was ligated and divided at its origin. Lymph node dissection was carried from the coeliac axis to the right crus of the diaphragm.
Figure 1 To perform adequate paracardial dissection, the phrenooesophageal ligament jusi beneath the hiatus was divided. The two vagal trunks were divided, traciion was applied to the vagi and all the sofr tissue surrounding the cardio-oesophageal junction wws dissected
942
0007-1323/92/090942-03
0 1992 Butterworth-Heinemann Ltd
Paracardial dissection in gastrectomy: C. Huscher et al.
Table 1 Pafient details ~~
Left
Right Histological type of adenocarcinoma
No. resected
Staging
No. involved
No. resected
No. involved
.-
Total gastrectomy 1 2 3 4 5 6 . 7 8 9 10 11 12. 13 14 Total
46 70 36 66 46 67 23 61 67 68 79 82 50 79
Subtotal gastrectomy I 79 2 45 58 3 4 52 64 5 6 67 I 54 8 70 9 62 10 73 11 65 12 61 13 25 14 75 15 54 16 65 50 17 18 71 19 76 20 79 21 82 22 82 Total
Diffuse Mucinous Diffuse Early Intestinal Diffuse Early Diffuse Mucinous Early Diffuse Intestinal Early Diffuse
Early diffuse Diffuse Diffuse Tubular Diffuse Intestinal Diffuse Mucinous Early intestinal Intestinal Diffuse Early diffuse Diffuse Diffuse Tubular Diffuse Intestinal Diffuse Diffuse Diffuse Intestinal Early diffuse
5 4 9 6 5 13 10 5 4 9 8 5 5 12 100
1 1 0 4 0 0 1 0 0
9
1
1 1
0 0 0 2 10
9 4 5 2 14 4 2 4 12 11 8 8 3 4 3 II 3
0 0 3 0 4 0 0 0 0 0 0 0 0 0 I
10
1
I 13 3 8 148
I 0 0
1
0
1 12
4 1
I 6 3 1 8 4 1
5 3 48 6 3 3 3 3 3 3 4 5 8 3 6 3 3 3 5 4 8 3 3 3 6 91
2 0 0 1
0 0 0 0 0 0 0 0 0 0 3 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0 1
0 0 0 0 2
Staging follows the tumour node metastasis ( T N M ) system All the fatty areolar tissue of the left and right paracardial regions was sent separately for pathological assessment after immersion in Bouin's solution. All fragments of yellow-stained tissue >4-5 mm in size were carefully dissected and prepared for histological examination. In this way it was possible to identify the small lymph nodes; some nodules of 4-5 mm were subsequently recognized as fatty tissue. Statistical analysis of the number of resected lymph nodes was performed using Student's t test.
Results The mean operating times for total gastrectomy and subtotal gastrectomy were 202 and 208 min respectively. There were no deaths after either procedure. Patients were discharged at a mean of 12 days after both total and subtotal operations. The mean number of lymph nodes dissected in the right paracardial compartment was 7.1 per patient for total gastrectomy and 6.7 per patient for subtotal gastrectomy (Table 1 ; P = 0.7).The mean numbers of left paracardial lymph nodes dissected at total and subtotal gastrectomy were 3.4 and 4.1 per patient respectively ( P = 0.3). Nodal involvement of right and left paracardial compartments was present in 36 and 11 per cent of patients, respectively, and in 8.9 and 3.6 per cent of removed lymph nodes respectively.
Br. J. Surg.. Vol. 79, No. 9. September 1992
Discussion There is little doubt that subtotal gastrectomy can afford the same radical clearance as total gastrectomy at lymph node Level 1 and on lymph nodes along the left gastric artery, along the common hepatic artery and around the coeliac artery. Howeyer, dissection of the right and left cardial nodes may be less radical in subtotal gastrectomy because of the fear that skeletonizing the upper part of the stomach and distal oesophagus might jeopardize the vascularization. O n the other hand, metastatic involvement of the right paracardial compartment in cancer of the lower third of the stomach is r e p ~ r t e d ~ , ' ~ , to " *be ' ~ in the range of 6-18 per cent, depending on the stage of the tumour, with a mean 5-year survival rate5 of about 21 per cent. These values are less than the 36 per cent rate of nodal involvement observed in the present study and further stress the 'radical nature of the procedure reported. Present data also show that in subtotal gastrectomy lymph node dissection of the right paracardial region, representing a second-level compartment in cancer of the lower third of the stomach, can be performed to the same radical degree obtained in total gastrectomy. Furthermore, in subtotal gastrectomy a percentage of metastatic deposits of cancer cells within these nodes has been obtained that is higher than that reported by Japanese authors, usually regarded as meticulous in their nodal
943
Paracardial dissection in gastrectomy: C. Huscher et al. dissection. Nevertheless, the choice between subtotal an d total gastrectomy should rely not o n the desired extent of nodal dissection but primarily on the site of the lesion in the stomach. This is obviously valid when a n extensive nodal a n d extranodal spread of the tumour does not exist. However, when there is such a spread, the surgeon is faced with a neoplastic lymphangitis of the perigastric tissue; this is more amenable to total gastrectomy, even though such an operation is unlikely to be curative in nature.
7.
8.
9. 10.
References 1.
2. 3. 4. 5. 6.
944
Gennari L, Bozzetti F, Bonfanti G et al. Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem. Br JSurg 1986;73: 534-8. Gouzi JL, Huguier M, Fagniez PL et al. Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. Ann Surg 1989; 209: 162-6. Bozzetti F, Bonfanti G , Bufalino R ei al. Adequacy of margins of resection in gastrectomy for cancer. Ann Surg 1982; 196: 685-90. Cuschieri A. Gastrectomy for gastric cancer: definitions and objectives. Br J Surg 1986; 73: 513- 14. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. WorldJ Surg 1987; 11: 418-25. Fass J, Schumpelick V. Principles of radical surgery in gastric
14.
carcinoma. Hepatogastroenterology 1989; 36: 13-17. Gall FP, Hermanek P. New aspects in the surgical treatment of gastric carcinoma - a comparative study of 1636 patients operated on between 1969 and 1982. Eur J Surg Oncol1985; 11: 219-25. Kodama Y, Sugimachi K, Soejima K, Matsusaka T, Inokuchi K. Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJ Surg 1981; 5: 241-8. Mine M, Majima S, Harada M, Etani S. End results of gastrectomy for gastric cancer: effect of extensive lymph node dissection. Surgery 1970; 68: 753-8. Mishima Y, Hirayama R. The role of lymph node surgery in gastric cancer. Wor/d J Surg 1987; 11: 406-11. Soga J, Kobayashi K, Saito J, Fujimaki M, Muto T. The role of lymphadenectomy in curative surgery for gastric cancer. World J Surg 1979; 3: 701-8. Siewert JR, Lange J, Boettcher K, Becker K, Stier A. Lymphadenectomy in stomach cancer. Langenbecks Arch Chir 1986; 568: 137-48 (in German). Dent DM, Madden MV, Price SK. Randomized comparison of R, and R, gastrectomy for gastric carcinoma. Br J Surg 1988; 75: 110-12. Kampschoer GHM, Maruyama K, Van de Velde CJH, Sasako M, Kinoshita T, Okabayashi K. Computer analysis in making preoperative decisions: a rational approach to lymph node dissection in gastric cancer patients. Br J Surg 1989; 76: 905-8.
Paper accepted 18 February 1992
Br. J . Surg., Vol. 79. No. 9, September 1992
C. Hiischer, S. Chiodini, V. Freni, A. Recher, F. Torri and F. Bozzetti lstituto Nazionale Tumori, Via Venezian 7 , 20133 Milan, Italy Correspondence to: Dr F. Bozzetti
Adequacy of paracardial dissection in subtotal versus total gast rectomy Right and left paracardial dissection represents an obligatory step in gastrectomy for gastric cancer of the lower half of the stomach because a second-level lymphadenectomy is part of the radical surgery f o r malignancy at this site. Whereas right and left paracardial dissection is easily accomplished during total gastrectomy, there is doubt as to whether subtotal gastrectomy achieves the same radical clearance of these groups of lymph nodes. This study therefore compared the number of lymph nodes dissected and the frequency of metastases in these compartments in 14 patients undergoing total gastrectomy and 22 submitted to subtotal gastrectomy. The mean number of lymph nodes dissected in the right paracardial compartment was 7.1 per patient undergoing total gastrectomy and 6.7perpatient in subtotal gastrectomy ( P = 0.7). The mean numbers of left paracardial lymph nodes dissected in total and subtotal gastrectomy were 3.4 and 4.1 per patient respectively ( P = 0.3). These data show that the same degree of radical clearance can be achieved in these nodal compartments, irrespective of the extent of gastric resection.
Current literature suggests that gastric cancer should be managed with subtotal resection rather than total gastrectomy’.’, provided that a safe proximal margin is guaranteed. This would generally require a 6-cm clearance of tissue3, although this value is somewhat dependent o n the degree of tuniour penetration into the gastric wall3, the macroscopic appearance of the tumour4,’ and the histological type according t o Lauren’s c la ~ s i f ic a t io n ~ ~ ’ . -~’ There is also evidence, from both J a p a n e ~ e ~ . ~and German’,’* investigations, that dissection of the second lymph node compartment could improve the prognosis; the potential benefit is being tested by ongoing trials in South Africa13 an d the UK4. T h e question is whether paracardial right and left dissections of lymph nodes, which represent the second- a n d third-level compartments respectively, can be performed in carcinoma of the distal third of the stomach with the same radical degree in both subtotal and total gastrectomy. T h e purpose of this investigation was t o compare the number of lymph nodes dissected in the left a n d right paracardial compartments after subtotal an d total gastrectomy for cancer of the lower third of the stomach, an d t o assess the safety of both procedures.
To dissect the left and right paracardial nodes without carrying out a total gastrectomy, the phreno-oesophageal ligament was divided, truncal vagotomy performed, and the paracardial nodes dissected by traction on the vagi and fatty tissue surrounding the cardio-oesophageal .junction (Figure 1 ). In subtotal gastrectomy it was usual to ligate and divide the first and the lowest two or three short gastric vessels, leaving the intermediate ones intact to optimize the vascular supply to the gastric stump. The stomach was then stapled just below the cardia to leave only a small fundal pouch. The gastrojejunal anastomosis along the greater curvature was carried out with an EEA stapler (US Surgical) using a 70-cm Roux-en-Y loop. The procedure was completed with dissection of the retropancreatic nodes.
Patients and methods Thirty-six patients underwent total or subtotal gastrectomy for cancer of the lower third of the stomach. Table 1 summarizes the main features of the series. There were 14 patients in the total gastrectomy group (six men, eight women; mean age 60.0 years) and 22 in the subtotal gastrectomy group (16 men, six women; mean age 64.0 years). The operative procedure consisted of an upper midline incision followed by separation of the greater omentum from the transverse colon, in continuity with the upper leaflet of transverse mesocolon and peritoneum of the lesser sac investing the anterior surface of the pancreas. The infrapyloric lymph nodes were dissected after ligation of the anteroinferior pancreatic vessels. The first part of the duodenum was mobilized and transected with a CIA stapler (US Surgical, Norwalk, Connecticut, USA). The lymph nodes of the hepaticoduodenal ligament were dissected. The right gastroepiploic vessels were ligated and divided; the lymph nodes along the common hepatic artery were dissected together with those of the coeliac axis and splenic artery. The left gastric artery was ligated and divided at its origin. Lymph node dissection was carried from the coeliac axis to the right crus of the diaphragm.
Figure 1 To perform adequate paracardial dissection, the phrenooesophageal ligament jusi beneath the hiatus was divided. The two vagal trunks were divided, traciion was applied to the vagi and all the sofr tissue surrounding the cardio-oesophageal junction wws dissected
942
0007-1323/92/090942-03
0 1992 Butterworth-Heinemann Ltd
Paracardial dissection in gastrectomy: C. Huscher et al.
Table 1 Pafient details ~~
Left
Right Histological type of adenocarcinoma
No. resected
Staging
No. involved
No. resected
No. involved
.-
Total gastrectomy 1 2 3 4 5 6 . 7 8 9 10 11 12. 13 14 Total
46 70 36 66 46 67 23 61 67 68 79 82 50 79
Subtotal gastrectomy I 79 2 45 58 3 4 52 64 5 6 67 I 54 8 70 9 62 10 73 11 65 12 61 13 25 14 75 15 54 16 65 50 17 18 71 19 76 20 79 21 82 22 82 Total
Diffuse Mucinous Diffuse Early Intestinal Diffuse Early Diffuse Mucinous Early Diffuse Intestinal Early Diffuse
Early diffuse Diffuse Diffuse Tubular Diffuse Intestinal Diffuse Mucinous Early intestinal Intestinal Diffuse Early diffuse Diffuse Diffuse Tubular Diffuse Intestinal Diffuse Diffuse Diffuse Intestinal Early diffuse
5 4 9 6 5 13 10 5 4 9 8 5 5 12 100
1 1 0 4 0 0 1 0 0
9
1
1 1
0 0 0 2 10
9 4 5 2 14 4 2 4 12 11 8 8 3 4 3 II 3
0 0 3 0 4 0 0 0 0 0 0 0 0 0 I
10
1
I 13 3 8 148
I 0 0
1
0
1 12
4 1
I 6 3 1 8 4 1
5 3 48 6 3 3 3 3 3 3 4 5 8 3 6 3 3 3 5 4 8 3 3 3 6 91
2 0 0 1
0 0 0 0 0 0 0 0 0 0 3 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0 1
0 0 0 0 2
Staging follows the tumour node metastasis ( T N M ) system All the fatty areolar tissue of the left and right paracardial regions was sent separately for pathological assessment after immersion in Bouin's solution. All fragments of yellow-stained tissue >4-5 mm in size were carefully dissected and prepared for histological examination. In this way it was possible to identify the small lymph nodes; some nodules of 4-5 mm were subsequently recognized as fatty tissue. Statistical analysis of the number of resected lymph nodes was performed using Student's t test.
Results The mean operating times for total gastrectomy and subtotal gastrectomy were 202 and 208 min respectively. There were no deaths after either procedure. Patients were discharged at a mean of 12 days after both total and subtotal operations. The mean number of lymph nodes dissected in the right paracardial compartment was 7.1 per patient for total gastrectomy and 6.7 per patient for subtotal gastrectomy (Table 1 ; P = 0.7).The mean numbers of left paracardial lymph nodes dissected at total and subtotal gastrectomy were 3.4 and 4.1 per patient respectively ( P = 0.3). Nodal involvement of right and left paracardial compartments was present in 36 and 11 per cent of patients, respectively, and in 8.9 and 3.6 per cent of removed lymph nodes respectively.
Br. J. Surg.. Vol. 79, No. 9. September 1992
Discussion There is little doubt that subtotal gastrectomy can afford the same radical clearance as total gastrectomy at lymph node Level 1 and on lymph nodes along the left gastric artery, along the common hepatic artery and around the coeliac artery. Howeyer, dissection of the right and left cardial nodes may be less radical in subtotal gastrectomy because of the fear that skeletonizing the upper part of the stomach and distal oesophagus might jeopardize the vascularization. O n the other hand, metastatic involvement of the right paracardial compartment in cancer of the lower third of the stomach is r e p ~ r t e d ~ , ' ~ , to " *be ' ~ in the range of 6-18 per cent, depending on the stage of the tumour, with a mean 5-year survival rate5 of about 21 per cent. These values are less than the 36 per cent rate of nodal involvement observed in the present study and further stress the 'radical nature of the procedure reported. Present data also show that in subtotal gastrectomy lymph node dissection of the right paracardial region, representing a second-level compartment in cancer of the lower third of the stomach, can be performed to the same radical degree obtained in total gastrectomy. Furthermore, in subtotal gastrectomy a percentage of metastatic deposits of cancer cells within these nodes has been obtained that is higher than that reported by Japanese authors, usually regarded as meticulous in their nodal
943
Paracardial dissection in gastrectomy: C. Huscher et al. dissection. Nevertheless, the choice between subtotal an d total gastrectomy should rely not o n the desired extent of nodal dissection but primarily on the site of the lesion in the stomach. This is obviously valid when a n extensive nodal a n d extranodal spread of the tumour does not exist. However, when there is such a spread, the surgeon is faced with a neoplastic lymphangitis of the perigastric tissue; this is more amenable to total gastrectomy, even though such an operation is unlikely to be curative in nature.
7.
8.
9. 10.
References 1.
2. 3. 4. 5. 6.
944
Gennari L, Bozzetti F, Bonfanti G et al. Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem. Br JSurg 1986;73: 534-8. Gouzi JL, Huguier M, Fagniez PL et al. Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. Ann Surg 1989; 209: 162-6. Bozzetti F, Bonfanti G , Bufalino R ei al. Adequacy of margins of resection in gastrectomy for cancer. Ann Surg 1982; 196: 685-90. Cuschieri A. Gastrectomy for gastric cancer: definitions and objectives. Br J Surg 1986; 73: 513- 14. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. WorldJ Surg 1987; 11: 418-25. Fass J, Schumpelick V. Principles of radical surgery in gastric
14.
carcinoma. Hepatogastroenterology 1989; 36: 13-17. Gall FP, Hermanek P. New aspects in the surgical treatment of gastric carcinoma - a comparative study of 1636 patients operated on between 1969 and 1982. Eur J Surg Oncol1985; 11: 219-25. Kodama Y, Sugimachi K, Soejima K, Matsusaka T, Inokuchi K. Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJ Surg 1981; 5: 241-8. Mine M, Majima S, Harada M, Etani S. End results of gastrectomy for gastric cancer: effect of extensive lymph node dissection. Surgery 1970; 68: 753-8. Mishima Y, Hirayama R. The role of lymph node surgery in gastric cancer. Wor/d J Surg 1987; 11: 406-11. Soga J, Kobayashi K, Saito J, Fujimaki M, Muto T. The role of lymphadenectomy in curative surgery for gastric cancer. World J Surg 1979; 3: 701-8. Siewert JR, Lange J, Boettcher K, Becker K, Stier A. Lymphadenectomy in stomach cancer. Langenbecks Arch Chir 1986; 568: 137-48 (in German). Dent DM, Madden MV, Price SK. Randomized comparison of R, and R, gastrectomy for gastric carcinoma. Br J Surg 1988; 75: 110-12. Kampschoer GHM, Maruyama K, Van de Velde CJH, Sasako M, Kinoshita T, Okabayashi K. Computer analysis in making preoperative decisions: a rational approach to lymph node dissection in gastric cancer patients. Br J Surg 1989; 76: 905-8.
Paper accepted 18 February 1992
Br. J . Surg., Vol. 79. No. 9, September 1992
