Il trattamento chirurgico del carcinoma gastrico (Esperienza personale su 706 casi)

Background. Gastric cancer is still one of the most frequent tumors in Western Countries. Until now surgery seems to be the only effective therapy and chemotherapy doesn't improve the long term survival. Extension of exeresis and lymphectomy related to localization and staging of neoplasm are still debated. Methods. From January 1989 to December 1998, 706 patients with gastric adenocarcinoma have been treated at the 1st Surgical Clinic. The males/females ratio was 1.6/1 and the average age was 67.2 years (32-91); 342 neoplasms were of intestinal type of Lauren's classification, 297 were of diffused type, 18 mixed. In 525 cases a curative intervention was performed (resecability 76.6%), with 273 total gastrectomies (248 Roux-en-Y reconstructions), 242 subtotal gastrectomies (237 Billroth 2 gastrojejunal anastomosis, 7 esophagectomies and 1 proximal gastric resection, associated to second level lymph nodes dissection (D2). Results. Mean hospital stay was 13.7 days (9-45). The mortality rate was 4% (21 patients, 14 after total gastrectomy and 7 after gastric resection respectively). Overall morbidity was 18% (95 cases) and specific morbidity was 7.2% (38 cases). Thirty-eight neoplasms (7.2%) were staged as Ia, 62 (11.8%) Ib, 110 (21%) II, 80 (15.2 %) IIIa, 72 (13.8 %) IIIb and 163 (31%) IV. In 213 patients (40.6 %) lymph nodes were not involved by neoplastic infiltration, while 158 cases (30.1%) were N1 and 154 (29.3%) N2. Overall 5 years survival was 31.8%, 87.5% for stage I, 41.3% for stage II, 25.3% for stage III and 5.2% for IV (p<0.05). We found out a statistic survival difference among patients NO (72.2 %), N1 (37.1%) and N2 (20.4 %) (p<0.05). Survivals for extension of exeresis, site and hystologic type were not significantly different. As regards the extension of exeresis and lymphectomy, a total gastrectomy was performed in body-fundus gastric cancers; in case of antral tumors, gastric resection gives the same oncologic radicality, reducing complications and postoperative stay. Conclusions. Lymph node dissection should be extended at least to second level stations in order to obtain a more accurate staging and to prevent local recurrences. Splenectomy is associated to gastric exeresis only in case of direct infiltration of splenic ilus or in case of surgical need.