[Gastric carcinomas of the "bare area". Their anatomo-surgical definition and proposal of an en bloc total gastrectomy].
BACKGROUND
Regarding the surgical treatment, carcinomas of the gastric proximal third and cardia are considered as an uniform problem. Particularly no difference exists between the gastric tumors of the anterior wall and those of the posterior wall. Nevertheless, cancers of the posterior wall of the proximal third are more difficult to cure and therefore less success has been achieved than with those of the anterior wall. The cause of this different behaviour must consist in an anatomical characteristic, the fact that the posterior wall of the fundus and subcardial portion is not covered by the visceral peritoneum ("bare area").


METHODS
Our study group consisted of 22 patients who presented carcinoma of the stomach risen in the area without peritoneal lining. Our treatment of this condition consisted of an operational procedure wherein we removed en bloc the stomach, left pancreas, spleen, and lymph nodes of the compartment I, II and III. In each case we considered the pathological situation, the involvement of the retroperitoneal structures and the condition of the lymph nodes in the compartment III specially, and actuarial statistics.


RESULTS
We divided the 22 patients in 4 groups based on the neoplastic involvement of the retroperitoneum. Only in 3 cases (14%) of group 1 the cancer invasion was limited to the gastric muscular layer. In all of the rest, tumor involved the retroperitoneal structures. Postoperative mortality rate was 9%. The five year survival rate was 100% in the 3 cases of group 1 only and 10.5% in all other cases.


CONCLUSIONS
The results show that carcinomas of the "bare area" cause a real jump in the degree of severity of the biological neoplastic process and hence of the prognostic evaluation. When the growth involves the gastric muscular layer, it indicates invasion of the retroperitoneum. Therefore, as with surgical treatment of esophageal carcinoma with the en bloc esophagectomy, we propose an en bloc total gastrectomy which should be performed in every carcinoma arising in the "bare area" because it allows more radical removal than can be obtained from traditional surgical procedures, without risking an increased mortality rate.
Tonelli
P
P
Scuola di Specializzazione in Chirurgia Generale Università di Firenze.
D016629:Esophagectomy; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods; D006801:Humans; D008197:Lymph Node Excision; D009361:Neoplasm Invasiveness; D010179:Pancreas / Q000601:surgery; D013154:Spleen / Q000601:surgery; D013270:Stomach / Q000473:pathology*; D013274:Stomach Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed