Total versus subtotal gastrectomy in cancer of the distal stomach: facts and fantasy.
The purpose of this review is to analyse critically the pros and cons of 'en principle' total gastrectomy for cancers of the distal stomach. The theoretical advantages of total gastrectomy would be the guarantee of no infiltration of the margin of proximal transection owing to multicentric cancers or to a microscopical intramural spreading of tumoral cells beyond the macroscopically detectable boundaries of the lesion. However, these expectations are not substantiated since multicentric tumours are rare, a safe margin of resection can be achieved maintaining a proximal clearance of 6 cm from the cranial edge of the tumour. Moreover, recurrences confined to the gastric stump, after subtotal gastrectomy (and originally preventable with a total gastrectomy) are extremely rare according to literature. Furthermore, current experience suggests that the extent of lymph node dissection is not affected by the extent of the resection of the stomach. Analysis of the published series of patients undergoing an en principle total gastrectomy fails to demonstrate any advantage for long-term survival compared with patients treated by subtotal gastrectomy. A recent randomized trial comparing these two procedures is in keeping with the above-mentioned conclusions. It is true, however, that the gap in surgical mortality for total and subtotal gastrectomy tends to disappear when total gastrectomy is electively performed in patients with tumours of the distal stomach. So, whereas the long-term oncological results of the two surgical procedures seem to be similar, the main disadvantage of total gastrectomy is the onset of malnutrition, which is common, but incapacitating only in a few patients. This condition is likely to be of relevance should the patients be selected for aggressive postoperative adjuvant treatments which require good general status and nutritional integrity. The main disadvantage of subtotal gastrectomy is that the patients are exposed to the risk of a gastric stump cancer. However, this risk, owing to the advanced median age of the resected patients and the actual reconstructive procedures which minimize the biliary reflux, cannot be quantified. We think that when two surgical procedures are compared, if the oncological results are the same, the operation which is associated with least discomfort and impairment of the quality of life, should be chosen.
Bozzetti
F
F
Istituto Nazionale Tumori, Milan, Italy.
D005743:Gastrectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D009364:Neoplasm Recurrence, Local; D009752:Nutritional Status; D011788:Quality of Life; D013274:Stomach Neoplasms / Q000601:surgery*; D016019:Survival Analysis; D016896:Treatment Outcome