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Gastric Carcinoma and Extended Surgery. - Dr Steven Dubenec ( M entor: Dr Bryan Yeo). Diffuse M:F 1:1 Onset Middle Age 5 yr surv overall <10% Aetiology Diet H. pylori. Intestinal M:F 2:1 Onset Middle Age 5 yr surv overall 20% Aetiology Unknown Blood group A association H. pylori.

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gastric carcinoma and extended surgery

Gastric Carcinoma and Extended Surgery

- Dr Steven Dubenec (Mentor: Dr Bryan Yeo)

gastric carcinoma

M:F 1:1

Onset Middle Age

5 yr surv overall <10%



H. pylori


M:F 2:1

Onset Middle Age

5 yr surv overall 20%



Blood group A association

H. pylori

Gastric Carcinoma
gastric carcinoma3
Gastric Carcinoma
  • Japanese & Chinese mortality rates for Gastric Ca ~2x southern hemisphere
  • Disease of lower socioeconomic groups
gastric carcinoma staging
Gastric Carcinoma Staging
  • JRSGC – PHNS System

P- Grade of peritoneal spread

H- Presence of Hepatic Mets

N- Extent of lymph node involvement

S- Extent serosal invasion

  • Internationally Unified TMN Staging
gastric carcinoma surgery
Gastric Carcinoma Surgery
  • Western societies when resecting stomach tend not to be as extensive as the Japanese
  • The extent of resection is described as
    • D1. Limited Lymphadenectomy. All N1 Nodes removed en bloc with the stomach
    • D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach
    • D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes
gastric carcinoma surgery8
Gastric Carcinoma Surgery
  • The case for D2 systematic lymphadenectomy is controversial
  • Japan practices this routinely
  • Western medicine tends to take a more conservative approach
indications for splenectomy
Indications for Splenectomy
  • If macroscopic disease can be resected & the operation is potentially curative then en bloc splenectomy or pancreaticosplenectomy is worthwhile.
  • If it is more palliative then this benefit must be weighed against the potential complications of splenectomy and more extensive operation
distal pancreatectomy
Distal Pancreatectomy
  • Associated with marked increase in morbidity & mortality with or without splenectomy
  • Indications for pancreatectomy:
    • Direct invasion of the tail of the pancreas
    • Likelihood of splenic artery nodal involvement

“No survival benefit from combined pancreaticosplenectomy and total gastrectomy for gastric cancer” Kitamura K, et al., Br J Surg 86:119-122; 1999

  • Gastric Carcinoma is a common fatal malignancy
  • More common in Japan c/w rest of world
  • Japan reports better survival rates
    • Stage Migration
    • Thinner Population
    • Experience with Gastric Surgery
  • Combined pancreaticosplenectomy does have increased morbidity & mortality†
  • †Cuschieri A, Fayers P, Fielding, etal. Postoperative morbidity and mortality after D1 & D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 1996; 347: 995-9
  • Does Extended Surgery for Gastric Carcinoma offer any survival benefit?
  • Retrospective Study
  • Data collected from 1969 – 1996
  • Total number of patients undergoing gastric surgery 1844
  • 190 – Total Gastrectomy + Pancreaticosplenectomy
  • 206 Total Gastrectomy + Splenectomy
  • Pathology based on Japanese Research Society for Gastric Surgery
  • Patients with direct invasion of pancreas or suspected lymph nodes along splenic artery had TG+PS
  • Patients with suspected splenic hilum nodes had TG+S
statistical analysis
Statistical Analysis
  • c2 used to assess clinicopathological difference between groups
  • Kaplan-Meier used for cumulative survival rates
  • Wilcoxon test used for survival curves
  • No differences in ages or sex between groups
  • TG+S groups had smaller tumours and were more superficial (p<0.005)
  • TG+PS groups had more frequent lymph node metastases & were more histologically advanced
  • No difference in histological type
post op survival
Post-Op Survival
  • (9/190) 5% of TG+PS died within 30/7 of Post-Operatively
  • (12/206) 6% of TG+S died within 30/7 of Post-Operatively
post op survival21
Post-Op Survival
  • Survival rates only for stage 3&4 disease looked at because of numbers
post op survival22
Post-Op Survival
  • No Statistical Significance Between Survival of Stage 3&4 Disease for TG+S & TG+PS
  • 5 Year Survival
  • 83 patients had TG+PS for direct invasion of pancreas
  • 104 patients had TG+PS when lymph node metastasis was evident or suspected
  • 46/83 had histological confirmation of direct invasion
  • 22/104 had confirmation of lymph node metastasis at histology
  • 6 of 46 lived for > 5 years
  • 2 of 22 lived > 5 years
  • Assumption that TG+PS has improved survival rate
  • TG+PS routine in Japan >30 years
  • No direct evidence
  • Of the TG+PS 6 long term survivors with direct invasion of pancreas
  • 2 patients with metastases along splenic artery survived > 5years after TG+PS
  • 20 of 22 Patients with splenic hilar nodes died before 5 years after TG+S
  • TG+S does not appear to be beneficial in patients with splenic hilar nodes
  • Extended Surgery offers some advantages for patients with direct invasion of pancreas body or tail
  • TG+PS has most morbidity
  • TG+PS mortality in Japan is about 10% c/w 1996 MRC trail in UK 16%
  • ? This due to
    • More surgical experience with this disease
    • Thinner patients
    • Case mix differences
    • Co-morbidities
  • Extended surgery for Gastric Ca not beneficial unless there is direct invasion of the pancreas body or tail
  • TG+PS not routine
  • TG+PS not useful for lymph node metastases along splenic artery
  • Purpose clearly stated
  • Good comprehensive collation of results which were well presented
  • Results collated support the conclusions derived
  • This study offer clinical significance for surgical treatment of Gastric Ca
  • Retrospective study
  • Surgical decision for TG+S or TG+PS was subjective ?
  • Anatomical position of tumour. Is it important?
  • ? Co-morbidities of the patients. Did they die of causes other than their Ca
  • No mention of the specific post-op complications that led to patients death within the 30/7