Seminars in Surgical Oncology 7:356-364 (1991)
Surgical Treatment of Gastric Cancer: Retrospective Survey of 1,704 Operated Cases With Special Reference to Total Gastrectomy as the Operation of Choice H.-1. MEYER, MD, J. JAHNE, MD, H.WILKE, MD, AND R. PICHLMAYR, MD From the Klinik fur Abdominal- und Transplantationschirurgie (H.-/.M., I.]., R. P.) and Klinik fur Hamatologie and Onkologie (H.W.), Medizinische Hochschule Hannover, Konstanty-Cutschow-Strasse 8, 3000 Hannover 6 1, Germany.
Total gastrectomy is discussed as the operation of choice among different surgical approaches for gastric carcinoma. We prefer the performance of an elective total gastrectomy with systematic lymphadenectomy (compartments I and 11) and obligatory splenectomy. A retrospective study of 1,704 consecutive cases of gastric carcinomas showed a better outcome following total gastrectomy in relationship to distal subtotal gastrectomy, but these results cannot be used as evidence because of the lack of a prospective study. Nevertheless, a precise analysis of our cases in regard to tumor site and tumor type could show a frequency of only 6% to maximally 30%, in which elective total gastrectomy may represent a procedure too extensive to justify for an oncological course. KEY WORDS:gastric carcinoma, surgical procedures, survival rates
INTRODUCTION The prognosis for a patient with a gastric carcinoma is poor and has not considerably changed during the past decades; in general, however, according to epidemiological investigations, the incidence of this tumor is still declining. At present, the only means of improving life expectancy for gastric cancer patients are early diagnosis and adequate surgical intervention. But even with some new diagnostic procedures, the frequency of early gastric cancer could not be increased to more than 10% or 15% in most Western countries in recent years. Furthermore, most gastric cancers are diagnosed in advanced stages of tumor development, and surgical resection must be considered the first choice of treatment [l-151. However, controversy still exists about the extent of gastric resection as well as about the value of systematic lymph node dissection or obligatory splenectomy [2,7,12,16-301. Primary arguments for total gastrectorny as the operation of choice in comparison with subtotal gastrectomy were founded on the debate of 0 1991 Wiley-Liss, Inc.
the selection of resection lines at the stomach. Without guarantee of a so-called safe margin of resection, high rates of intraluminar local recurrences could be observed following subtotal gastrectomies [5,9,10,30341. Furthermore, 50-80% of potentially curatively gastrectomized patients, but in most cases without performance of a systematic lymphadenectomy, will suffer from locoregional recurrences and/ or distant metastases within the first 2 postoperative years [4,7, 311. Therefore, it seems logical to use more extensive surgical procedures dictated by oncological requirements, with the aim to reduce recurrence rates and to improve the survival rates at the same time. The question then arises about the value of total gastrectomy as the operation of choice as well as the degree of lymph node dissection, especially since former counterarguments have become less important in Address reprint requests to Dr. Hans-Joachim Meyer, Klinik fur Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Konstanty-Gutschow-Strasse 8, 3000 Hannover 61, Germany.
Surgical Treatment of Gastric Cancer 357
view of the results obtained in recent years. In particular, the postoperative morbidity and mortality for total gastrectomy (e.g., leakage of the proximal anastomoses as the most feared complication, severe reflux esophagitis, digestive problems) could be evidently reduced [8,10,16,18,35-371. This is also true for the performance of extensive dissection of lymph nodes independent of different points of view: systematic lymphadenectomy as a basic condition for precise pathohistological staging or the direct way to improve the long-term prognosis [8,10,22,23,26,30,38,39]. Nevertheless, discussion concerning different surgical procedures in the treatment of gastric carcinoma must remain open because of the lack of multicentric or prospective studies. This crucial point is related to any surgical measures; independent of theoretical arguments as well as current individual therapeutic approaches, the decisive improvement of overall survival rates can only be achieved by the performance of an RO resection without microscopic or macroscopic residual tumor [1,8,12,22,28]. To reach this therapeutic goal, particularly in advanced stages of tumor development, efforts regarding multimodality treatments, such as surgery, chemotherapy, and/or radiation therapy, must be continued, as gastric carcinoma has been shown to be a chemosensitive tumor, even with the concept of preoperative (neoadjuvant) application of effective drug regimens [40-42]. The purpose of this study is to analyze retrospectively the results of our therapeutic strategy in the treatment of gastric cancer, including total gastrectomy as the operation of choice, as well as systematic lymphadenectomy and routine splenectomy performed since 1974.
Gastric Cancer Study in Surgery and Pathology” [45]. Perigastric and other regional lymph nodes of the stomach were divided into three compartments: compartment I (lymph node group 1-6), compartment I1 (lymph node group 7-1 1; optionally 12 and 13), and compartment 111(lymph node group 14-16). The performance of a distal subtotal or total gastrectomy enbloc lymph node dissection of compartment I and 11, including partial or total resection of the lesser and greater omentum, as well as resection of the anterior sheet of the mesocolon and capsule of the pancreas, was carried out since 1974. All total gastrectomies were combined with splenectomy independent of the tumor site. The definitions of curative gastrectomies followed the criteria of the UICC (1987) [46]: RO R1 R2
No residual tumor Microscopic residual tumor Macroscopic residual tumor
RESULTS Pathohistological Findings In one-half of cases (N = 852), the tumor involved more than one-third of the stomach; in 18% of cases (N= 308), the tumor was located in the upper third of the stomach, including the esophagogastric junction. The location of 460 cases was in the midstomach, and the distal third of the stomach, whereas in only 4.9% (n = 84), the tumor was situated in the prepyloric area. According to L a u r h [47], with regard to the histological findings, following resective procedures the incidence of the diffuse type was greater than that of the intestinal type (N = 682 vs. N = 560). In 44 cases, socalled mixed cancer was described. The degree of lymph node dissection could be invesPATIENTS AND METHODS tigated histopathologically in a prospective study From May 1968 through December 1988, among a from 1986 to 1989; among 218 different resective prototal of 2,046 malignant tumors of the stomach, 1,704 cedures, a mean number of 36 or 39 lymph nodes in patients underwent operation for early (N = 173) and the intestinal or diffuse type, respectively, were disadvanced (N = 1,531) gastric carcinomas: 151 for re- sected. No significant differences of the involved current carcinomas, 91 for gastric remnant car- lymph nodes could be found in regard to the histologicinomas and 100 patients were operated for nonepi- cal type, the intestinal type was associated with an thelial malignant tumors. There were 1,085 men and average of 13.3 lymph node metastases, the diffuse 619 women (ratio 1:0.57) with a mean age of 61.4% type with an average of 13.9 lymph node metastases, 11.7 years (range 1&86 years). The follow-up rate for and in most cases these metastases were located in the all patients operated on was 98.5%. The life-table so-called compartment I. method was used for calculating the survival rates [43], Surgical Procedures including operative mortality defined as death during Among a total of 1,704operations, 418 nonresective hospital stay. The standard error figures were achieved procedures, such as explorative laparotomy, endowith the Greenwood formula. The statistical significance of the survival rates was calculated using the prostheses, or bypass operations, and 1,286 gastrectomodified Wilcoxon test. The definitions for classifica- mies were carried out, resulting in an overall rate of tion of gastric carcinoma were taken from the UICC resectability of 75.5% (Table I). In the resective proce(1978) [44], as well as from “The General Rules for dures, 837 total gastrectomies, 331 distal subtotal, and
358 Meyer et al.
TABLE I. Gastric Carcinoma: Surgical Procedures and Clinical Mortality, 1968-1988 Clinical mortality
Total Operative procedures Resection Distal subtotal gastrectomy Proximal gastrectomy Total gastrectomy Without resection exploratory laparotomy, endoprosthesis, gastroenterostomy Total
N
Y"
N
"/u
1,286 331 118 837
75.5 19.4 6.9 49.2
126 41 19 66
9.8 12.4 16.1 7.9
418
24.5
70
16.7
1,704
(100)
196
11.5
TABLE 11. Gastric Carcinoma: Development of Resective Procedures, 1968-1988
Postoperative Mortality The postoperative mortality of all operations was 11.5%; 70 patients (16.7%) died after nonresective procedures, and 126 patients (9.8%) died following gastrectomy (Table I). A direct comparison of the clinical mortality rates after distal subtotal gastrectomy and total gastrectomy (12.4% vs. 7.9%) shows no statistically significant differences. In both groups, the postoperative mortality could be generally reduced in various time periods, but it is more evident after total gastrectomies. During the past 5 years, a mortality rate of 3.9% could be achieved (Table 111). Simultaneously, the overall frequency of leakage of the esophagojejunostomy, as well as a lethal outcome of this complication, could be decreased to 3.6% and 16.7%, respectively (Table IV).
Long-Term Morbidity Early and late postprandial symptoms, sometimes associated with different degrees of malnutrition, are Distal subtotal Proximal Total potential impairments following total gastrectomy. gastrecgastrecgastrecFollow-up investigation of those of our patients who tomy tomy tomy had no signs of tumor recurrence showed that severe Time interval N Yo N % N Yo postprandial symptoms could be present in a few of patients, as described in previous reports [37,38]. An 19.5 62 25.2 55.3 48 136 1968-1973 early or late dumping syndrome occurred in less than 197 61.2 31 9.6 1974-1978 94 29.2 248 78.5 22 6.9 46 14.6 1979-1983 of patients following total gastrectomy and re17 330 82.1 20% 55 19841988 4.2 13.7 construction with the interposed jejunal loop as well as 65.1 837 25.7 118 9.2 331 1968-1 988 with the Roux-en-Y procedure. Symptoms or serious 118 proximal gastrectomies were performed. The reflux esophagitis could be found in only 5% of paoverall incidence of total gastrectomies among the re- tients by complementary radiological and endoscopisective approaches was 65.1% and rose in various time cal investigation. Furthermore, a recent trial demonintervals from 25.2% up to 82.1% during the past 5 strated that a higher percentage of patients with a years. At the same time, the frequency of distal subto- jejunal interposition had recovered their premorbid tal gastrectomies performed decreased from 55.3% to weight in relationship to patients with a Roux-en-Y 13.7% (Table 11). Furthermore, about 90% of distal reconstruction (89O/0 vs. 78?h) [38]. subtotal gastrectomies were carried out in patients Survival Rates with markedly increased operative risk factors as well as for palliation during the past 10 years. The number The most relevant factors in evaluating the success of proximal gastrectomies decreased to about 4%, be- of surgical therapy for gastric carcinoma are the progcause of operative morbidity. This procedure repre- nosis of the patients and the survival rates. Irrespecsents an operative exception, mainly for cases with tive of surgical therapy, a 5- and 10-year survival for high seated tumors or with anatomical abnormalities all patients of 26.2% and 21.2%, respectively, could be of the mesenteric vessels. obtained. The median survival was 11.8 months. A The preferred reconstructive procedures following slightly better but statistically insignificant survival fatotal gastrectomy were the isoperistaltic interposition vored females. Patients under the age of 70 years reof a long jejunal loop, according to Longmire [48], vealed a significantly better 5- and 10-year survival with a proximal end-to-side (EIS) anastomosis than that of patients above their seventh decade of life. (N = 472), as well as the Roux-en-Y reconstruction Considering the histological type of carcinoma, it was (N = 300). The latter procedure was also preferred fol- the diffuse type that showed poorer results, with a lowing distal subtotal gastrectomy. The proximal median survival of 10.5 months (Table V). The 5- and anastomoses at the esophagus or stomach remnant 10-year survival for all resections (N = 1,286) was were almost exclusively hand-sutured. 33.7% and 27.2%, respectively (median: 22.1 months). Type of resection
Surgical Treatment of Gastric Cancer
359
TABLE 111. Comparison of Clinical Mortality Following Distal Subtotal and Total Gastrectorny, 1968-1988 Type of resection Distal subtotal gastrectomy
Total gastrectorny
Clinical mortality
N
%
N
Yo
Total Age (69 years Age 2 70 years
411331 261208 151122
12.4 12.5 12.1
661837 461672 201125
7.9 6.8 12.1
Time interval 1968-1973 19761978 1979-1983 19861989
221 136 11194 4/46 4/55
16.2 11.7 8.7 7.3
11162 191197 231248 131330
17.7 9.6 9.3 3.9
7164
10.9
21 103
1.9
Early gastric cancer
TABLE IV. Frequency of Leakages of the Proximal Anastomosis and Clinical Mortality Following 837 Total Gastrectomies, 1968-1989 Leakages of the proximal anastomosis
Time interval 1968-1 973 19741978 1978-1983 19841989 1968-1989
Clinical mortality Total
Total gastrectomy (N)
N
Yo
N
%
N
Yo
62 197 248
3 24 31
2 11 8
12
837
70
75.0 45.8 25.8 16.7 32.8
11 19 23
330
4.8 12.1 12.5 3.6 8.4
17.7 9.6 9.3 3.9 7.9
Total
Lethal course
2 23
12 66
While in early gastric carcinomas the 10-year survival was 66.9%, it decreased in cases of advanced carcinomas to 20.5%. The median survival for the advanced tumor stages was 17.8 months, but in 173 early gastric carcinomas, the median survival rate could not yet be determined. Proximal resections showed the poorest survival rates. Although the 5-year survival barely differed for distal subtotal and total gastrecto-
mies, the 10-year survival was markedly improved for total gastrectomy (Table VI). The best survival rates were obtained in cases of RO resection. Proximal resections showed again the poorest survival, while there was almost no difference in the 5-year-survival of distal subtotal and total gastrectomies. Patients with a R2 resection did not attain 10-year survival, regardless of the type of resection. In R1 resection, however, even 16.2% of the patients survived 10 years following distal subtotal gastrectomy and 12.7% after total gastrectomy (Table VII). Looking at the survival rates following total gastrectomies, the 10-year survival for these patients was 31.5%, increasing in potentially curative resections up to 47.2%. The survival rates could be improved within several time periods, particularly since 1979. The most encouraging results, however, demonstrated for curative total gastrectomies, for which the median survival for patients operated on since 1979 could not yet be determined. Irrespective of tumor stage, 55.7% of all cases survived 10 years (Table VIII). There was no significant difference in survival for all advanced tumors in regard to tumor site and histologi-
TABLE V. Survival Rates of 1,704 Gastric Carcinomas Independent of Surgical Procedures Survival rates Total N
Total Male Female Age 5 6 9 Age S70 Histological classification (Lauren) Intestinal type Diffuse type
* P
Surgical Treatment of Gastric Cancer: Retrospective Survey of 1,704 Operated Cases With Special Reference to Total Gastrectomy as the Operation of Choice H.-1. MEYER, MD, J. JAHNE, MD, H.WILKE, MD, AND R. PICHLMAYR, MD From the Klinik fur Abdominal- und Transplantationschirurgie (H.-/.M., I.]., R. P.) and Klinik fur Hamatologie and Onkologie (H.W.), Medizinische Hochschule Hannover, Konstanty-Cutschow-Strasse 8, 3000 Hannover 6 1, Germany.
Total gastrectomy is discussed as the operation of choice among different surgical approaches for gastric carcinoma. We prefer the performance of an elective total gastrectomy with systematic lymphadenectomy (compartments I and 11) and obligatory splenectomy. A retrospective study of 1,704 consecutive cases of gastric carcinomas showed a better outcome following total gastrectomy in relationship to distal subtotal gastrectomy, but these results cannot be used as evidence because of the lack of a prospective study. Nevertheless, a precise analysis of our cases in regard to tumor site and tumor type could show a frequency of only 6% to maximally 30%, in which elective total gastrectomy may represent a procedure too extensive to justify for an oncological course. KEY WORDS:gastric carcinoma, surgical procedures, survival rates
INTRODUCTION The prognosis for a patient with a gastric carcinoma is poor and has not considerably changed during the past decades; in general, however, according to epidemiological investigations, the incidence of this tumor is still declining. At present, the only means of improving life expectancy for gastric cancer patients are early diagnosis and adequate surgical intervention. But even with some new diagnostic procedures, the frequency of early gastric cancer could not be increased to more than 10% or 15% in most Western countries in recent years. Furthermore, most gastric cancers are diagnosed in advanced stages of tumor development, and surgical resection must be considered the first choice of treatment [l-151. However, controversy still exists about the extent of gastric resection as well as about the value of systematic lymph node dissection or obligatory splenectomy [2,7,12,16-301. Primary arguments for total gastrectorny as the operation of choice in comparison with subtotal gastrectomy were founded on the debate of 0 1991 Wiley-Liss, Inc.
the selection of resection lines at the stomach. Without guarantee of a so-called safe margin of resection, high rates of intraluminar local recurrences could be observed following subtotal gastrectomies [5,9,10,30341. Furthermore, 50-80% of potentially curatively gastrectomized patients, but in most cases without performance of a systematic lymphadenectomy, will suffer from locoregional recurrences and/ or distant metastases within the first 2 postoperative years [4,7, 311. Therefore, it seems logical to use more extensive surgical procedures dictated by oncological requirements, with the aim to reduce recurrence rates and to improve the survival rates at the same time. The question then arises about the value of total gastrectomy as the operation of choice as well as the degree of lymph node dissection, especially since former counterarguments have become less important in Address reprint requests to Dr. Hans-Joachim Meyer, Klinik fur Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover, Konstanty-Gutschow-Strasse 8, 3000 Hannover 61, Germany.
Surgical Treatment of Gastric Cancer 357
view of the results obtained in recent years. In particular, the postoperative morbidity and mortality for total gastrectomy (e.g., leakage of the proximal anastomoses as the most feared complication, severe reflux esophagitis, digestive problems) could be evidently reduced [8,10,16,18,35-371. This is also true for the performance of extensive dissection of lymph nodes independent of different points of view: systematic lymphadenectomy as a basic condition for precise pathohistological staging or the direct way to improve the long-term prognosis [8,10,22,23,26,30,38,39]. Nevertheless, discussion concerning different surgical procedures in the treatment of gastric carcinoma must remain open because of the lack of multicentric or prospective studies. This crucial point is related to any surgical measures; independent of theoretical arguments as well as current individual therapeutic approaches, the decisive improvement of overall survival rates can only be achieved by the performance of an RO resection without microscopic or macroscopic residual tumor [1,8,12,22,28]. To reach this therapeutic goal, particularly in advanced stages of tumor development, efforts regarding multimodality treatments, such as surgery, chemotherapy, and/or radiation therapy, must be continued, as gastric carcinoma has been shown to be a chemosensitive tumor, even with the concept of preoperative (neoadjuvant) application of effective drug regimens [40-42]. The purpose of this study is to analyze retrospectively the results of our therapeutic strategy in the treatment of gastric cancer, including total gastrectomy as the operation of choice, as well as systematic lymphadenectomy and routine splenectomy performed since 1974.
Gastric Cancer Study in Surgery and Pathology” [45]. Perigastric and other regional lymph nodes of the stomach were divided into three compartments: compartment I (lymph node group 1-6), compartment I1 (lymph node group 7-1 1; optionally 12 and 13), and compartment 111(lymph node group 14-16). The performance of a distal subtotal or total gastrectomy enbloc lymph node dissection of compartment I and 11, including partial or total resection of the lesser and greater omentum, as well as resection of the anterior sheet of the mesocolon and capsule of the pancreas, was carried out since 1974. All total gastrectomies were combined with splenectomy independent of the tumor site. The definitions of curative gastrectomies followed the criteria of the UICC (1987) [46]: RO R1 R2
No residual tumor Microscopic residual tumor Macroscopic residual tumor
RESULTS Pathohistological Findings In one-half of cases (N = 852), the tumor involved more than one-third of the stomach; in 18% of cases (N= 308), the tumor was located in the upper third of the stomach, including the esophagogastric junction. The location of 460 cases was in the midstomach, and the distal third of the stomach, whereas in only 4.9% (n = 84), the tumor was situated in the prepyloric area. According to L a u r h [47], with regard to the histological findings, following resective procedures the incidence of the diffuse type was greater than that of the intestinal type (N = 682 vs. N = 560). In 44 cases, socalled mixed cancer was described. The degree of lymph node dissection could be invesPATIENTS AND METHODS tigated histopathologically in a prospective study From May 1968 through December 1988, among a from 1986 to 1989; among 218 different resective prototal of 2,046 malignant tumors of the stomach, 1,704 cedures, a mean number of 36 or 39 lymph nodes in patients underwent operation for early (N = 173) and the intestinal or diffuse type, respectively, were disadvanced (N = 1,531) gastric carcinomas: 151 for re- sected. No significant differences of the involved current carcinomas, 91 for gastric remnant car- lymph nodes could be found in regard to the histologicinomas and 100 patients were operated for nonepi- cal type, the intestinal type was associated with an thelial malignant tumors. There were 1,085 men and average of 13.3 lymph node metastases, the diffuse 619 women (ratio 1:0.57) with a mean age of 61.4% type with an average of 13.9 lymph node metastases, 11.7 years (range 1&86 years). The follow-up rate for and in most cases these metastases were located in the all patients operated on was 98.5%. The life-table so-called compartment I. method was used for calculating the survival rates [43], Surgical Procedures including operative mortality defined as death during Among a total of 1,704operations, 418 nonresective hospital stay. The standard error figures were achieved procedures, such as explorative laparotomy, endowith the Greenwood formula. The statistical significance of the survival rates was calculated using the prostheses, or bypass operations, and 1,286 gastrectomodified Wilcoxon test. The definitions for classifica- mies were carried out, resulting in an overall rate of tion of gastric carcinoma were taken from the UICC resectability of 75.5% (Table I). In the resective proce(1978) [44], as well as from “The General Rules for dures, 837 total gastrectomies, 331 distal subtotal, and
358 Meyer et al.
TABLE I. Gastric Carcinoma: Surgical Procedures and Clinical Mortality, 1968-1988 Clinical mortality
Total Operative procedures Resection Distal subtotal gastrectomy Proximal gastrectomy Total gastrectomy Without resection exploratory laparotomy, endoprosthesis, gastroenterostomy Total
N
Y"
N
"/u
1,286 331 118 837
75.5 19.4 6.9 49.2
126 41 19 66
9.8 12.4 16.1 7.9
418
24.5
70
16.7
1,704
(100)
196
11.5
TABLE 11. Gastric Carcinoma: Development of Resective Procedures, 1968-1988
Postoperative Mortality The postoperative mortality of all operations was 11.5%; 70 patients (16.7%) died after nonresective procedures, and 126 patients (9.8%) died following gastrectomy (Table I). A direct comparison of the clinical mortality rates after distal subtotal gastrectomy and total gastrectomy (12.4% vs. 7.9%) shows no statistically significant differences. In both groups, the postoperative mortality could be generally reduced in various time periods, but it is more evident after total gastrectomies. During the past 5 years, a mortality rate of 3.9% could be achieved (Table 111). Simultaneously, the overall frequency of leakage of the esophagojejunostomy, as well as a lethal outcome of this complication, could be decreased to 3.6% and 16.7%, respectively (Table IV).
Long-Term Morbidity Early and late postprandial symptoms, sometimes associated with different degrees of malnutrition, are Distal subtotal Proximal Total potential impairments following total gastrectomy. gastrecgastrecgastrecFollow-up investigation of those of our patients who tomy tomy tomy had no signs of tumor recurrence showed that severe Time interval N Yo N % N Yo postprandial symptoms could be present in a few of patients, as described in previous reports [37,38]. An 19.5 62 25.2 55.3 48 136 1968-1973 early or late dumping syndrome occurred in less than 197 61.2 31 9.6 1974-1978 94 29.2 248 78.5 22 6.9 46 14.6 1979-1983 of patients following total gastrectomy and re17 330 82.1 20% 55 19841988 4.2 13.7 construction with the interposed jejunal loop as well as 65.1 837 25.7 118 9.2 331 1968-1 988 with the Roux-en-Y procedure. Symptoms or serious 118 proximal gastrectomies were performed. The reflux esophagitis could be found in only 5% of paoverall incidence of total gastrectomies among the re- tients by complementary radiological and endoscopisective approaches was 65.1% and rose in various time cal investigation. Furthermore, a recent trial demonintervals from 25.2% up to 82.1% during the past 5 strated that a higher percentage of patients with a years. At the same time, the frequency of distal subto- jejunal interposition had recovered their premorbid tal gastrectomies performed decreased from 55.3% to weight in relationship to patients with a Roux-en-Y 13.7% (Table 11). Furthermore, about 90% of distal reconstruction (89O/0 vs. 78?h) [38]. subtotal gastrectomies were carried out in patients Survival Rates with markedly increased operative risk factors as well as for palliation during the past 10 years. The number The most relevant factors in evaluating the success of proximal gastrectomies decreased to about 4%, be- of surgical therapy for gastric carcinoma are the progcause of operative morbidity. This procedure repre- nosis of the patients and the survival rates. Irrespecsents an operative exception, mainly for cases with tive of surgical therapy, a 5- and 10-year survival for high seated tumors or with anatomical abnormalities all patients of 26.2% and 21.2%, respectively, could be of the mesenteric vessels. obtained. The median survival was 11.8 months. A The preferred reconstructive procedures following slightly better but statistically insignificant survival fatotal gastrectomy were the isoperistaltic interposition vored females. Patients under the age of 70 years reof a long jejunal loop, according to Longmire [48], vealed a significantly better 5- and 10-year survival with a proximal end-to-side (EIS) anastomosis than that of patients above their seventh decade of life. (N = 472), as well as the Roux-en-Y reconstruction Considering the histological type of carcinoma, it was (N = 300). The latter procedure was also preferred fol- the diffuse type that showed poorer results, with a lowing distal subtotal gastrectomy. The proximal median survival of 10.5 months (Table V). The 5- and anastomoses at the esophagus or stomach remnant 10-year survival for all resections (N = 1,286) was were almost exclusively hand-sutured. 33.7% and 27.2%, respectively (median: 22.1 months). Type of resection
Surgical Treatment of Gastric Cancer
359
TABLE 111. Comparison of Clinical Mortality Following Distal Subtotal and Total Gastrectorny, 1968-1988 Type of resection Distal subtotal gastrectomy
Total gastrectorny
Clinical mortality
N
%
N
Yo
Total Age (69 years Age 2 70 years
411331 261208 151122
12.4 12.5 12.1
661837 461672 201125
7.9 6.8 12.1
Time interval 1968-1973 19761978 1979-1983 19861989
221 136 11194 4/46 4/55
16.2 11.7 8.7 7.3
11162 191197 231248 131330
17.7 9.6 9.3 3.9
7164
10.9
21 103
1.9
Early gastric cancer
TABLE IV. Frequency of Leakages of the Proximal Anastomosis and Clinical Mortality Following 837 Total Gastrectomies, 1968-1989 Leakages of the proximal anastomosis
Time interval 1968-1 973 19741978 1978-1983 19841989 1968-1989
Clinical mortality Total
Total gastrectomy (N)
N
Yo
N
%
N
Yo
62 197 248
3 24 31
2 11 8
12
837
70
75.0 45.8 25.8 16.7 32.8
11 19 23
330
4.8 12.1 12.5 3.6 8.4
17.7 9.6 9.3 3.9 7.9
Total
Lethal course
2 23
12 66
While in early gastric carcinomas the 10-year survival was 66.9%, it decreased in cases of advanced carcinomas to 20.5%. The median survival for the advanced tumor stages was 17.8 months, but in 173 early gastric carcinomas, the median survival rate could not yet be determined. Proximal resections showed the poorest survival rates. Although the 5-year survival barely differed for distal subtotal and total gastrecto-
mies, the 10-year survival was markedly improved for total gastrectomy (Table VI). The best survival rates were obtained in cases of RO resection. Proximal resections showed again the poorest survival, while there was almost no difference in the 5-year-survival of distal subtotal and total gastrectomies. Patients with a R2 resection did not attain 10-year survival, regardless of the type of resection. In R1 resection, however, even 16.2% of the patients survived 10 years following distal subtotal gastrectomy and 12.7% after total gastrectomy (Table VII). Looking at the survival rates following total gastrectomies, the 10-year survival for these patients was 31.5%, increasing in potentially curative resections up to 47.2%. The survival rates could be improved within several time periods, particularly since 1979. The most encouraging results, however, demonstrated for curative total gastrectomies, for which the median survival for patients operated on since 1979 could not yet be determined. Irrespective of tumor stage, 55.7% of all cases survived 10 years (Table VIII). There was no significant difference in survival for all advanced tumors in regard to tumor site and histologi-
TABLE V. Survival Rates of 1,704 Gastric Carcinomas Independent of Surgical Procedures Survival rates Total N
Total Male Female Age 5 6 9 Age S70 Histological classification (Lauren) Intestinal type Diffuse type
* P
