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Correspondence
March 16, 2009

Total Gastrectomy—Reply

Arch Surg. 2009;144(3):289-292. doi:10.1001/archsurg.2008.585

In reply

Dr Badruddoja's letter raises many questions. First, there is currently no controversy regarding the choice between TG and partial gastrectomy for gastric cancer. Total gastrectomy is actually the treatment of choice for upper gastric cancer and middle gastric cancer, in which a proximal 5-cm disease-free margin cannot be obtained.

Lower cancers and those located in the middle, where it is possible to achieve a 5-cm proximal margin, are best treated with a distal subtotal gastrectomy.1 Given its retrospective nature, our study (which encompass a long period of time) also includes a group of patients with antral cancer who underwent, during the early years of our experience, the so-called de principe TG, which was subsequently abandoned.

Second, the article by Sasako et al2 (which was performed differently from ours) includes only patients who were operated on with curative intent. Actually, the reported overall 5-year survival rate (69.2%) after D2 dissection compares with that reported in our article (61.8%), when only curative D2 TG is considered. Including patients with stage IV disease in the calculation of the overall survival may be confounding. Moreover, if only curative resections are considered, the survival reported in our article is undoubtedly higher compared with those recently reported in a Western series.3,4

Third, as far as palliative surgery is concerned, given the reported good palliations of symptoms and better survival rates in patients after resections compared with those without operations or with bypass procedures for stage IV disease, we think that, in specialized centers, TG could be considered worthwhile in upper and middle cancers, even in the palliative setting.

Fourth, regarding the extent of nodal dissection, we absolutely do not accept D1 dissection as the standard of care. This concept is mostly related to the results of the Dutch study,5 which, though it was heavily criticized because of the bias of the trial,6,7 had a negative influence on Western surgeons treating this curable disease. Indeed, it has been demonstrated that extended lymphadenectomy can be safely and effectively performed by Western surgeons.8 Moreover, the introduction of techniques that preserve the pancreas has reduced postoperative complications.9

The differences between Western and Eastern patients are not based on different behaviors of gastric cancer, but rely mostly on the different attitudes of Japanese and Eastern surgeons, especially when the extent of nodal dissection is concerned. In fact, in the ongoing Western trials on adjuvant therapies (Medical Research Council Adjuvant Gastric Infusional Chemotherapy II and Chemotherapy or Chemoradiotherapy in Resectable Gastric Cancer trials), D2 dissection is considered the standard and represents an inclusion criteria.

Finally, the report of long-term metabolic and nutritional effect of TG was beyond the purpose of our study. However, it is well demonstrated10 that the roux-en-Y reconstruction, which we routinely use, avoids alkaline reflux esophagitis and reduces postprandial symptoms to a very low rate. As a consequence, most patients can achieve an adequate caloric intake, thus overcoming the problem of relative malabsorption after TG.

Correspondence: Dr Pacelli, Digestive Surgery Unit, Istituto di Clinica Chirurgica, Catholic University–School of Medicine, Largo A. Gemelli 8, 00168 Rome, Italy (fpacelli@rm.unicatt.it).

Author Contributions:Study concept and design: Pacelli and Rosa. Acquisition of data: Pacelli and Rosa. Analysis and interpretation of data: Pacelli, Rosa, and Doglietto. Drafting of the manuscript: Pacelli. Critical revision of the manuscript for important intellectual content: Pacelli, Rosa, and Doglietto. Administrative, technical, and material support: Rosa. Study supervision: Pacelli and Doglietto.

Financial Disclosure: None reported.

References
1.
Bozzetti  FMarubini  EBonfanti  GMiceli  RPiano  CGennari  LItalian Gastrointestinal Tumor Study Group, Subtotal versus total gastrectomy for gastric cancer: five year survival rates in a multicenter randomized Italian trial.  Ann Surg 1999;230 (2) 170- 178PubMedGoogle ScholarCrossref
2.
Sasako  MSano  TYamamoto  S  et al. Japan Clinical Oncology Group, D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.  N Engl J Med 2008;359 (5) 453- 462PubMedGoogle ScholarCrossref
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Macdonald  JSSmalley  SRBenedetti  J  et al.  Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.  N Engl J Med 2001;345 (10) 725- 730PubMedGoogle ScholarCrossref
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Cunningham  DAllum  WHStenning  SP  et al. MAGIC Trial Participants, Perioperative chemotherapy versus surgery alone for respectable gastroesophageal cancer.  N Engl J Med 2006;355 (1) 11- 20PubMedGoogle ScholarCrossref
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Bonenkamp  JJHermans  JSasako  MVan de Velde  CJHfor the Dutch Gastric Cancer Group, Extended lymph-node dissection for gastric cancer.  N Engl J Med 1999;340 (12) 908- 914PubMedGoogle ScholarCrossref
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Brennan  MF Lymph-node dissection for gastric cancer.  N Engl J Med 1999;340 (12) 956- 958PubMedGoogle ScholarCrossref
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Degiuli  MSasako  MMalgaro  M  et al.  Morbidity and mortality after D1 and D2 gastrectomy for cancer: interim analysis of the Italian Gastric Cancer Study Group (ISCSG) randomised surgical trial.  Eur J Surg Oncol 2004;30 (3) 303- 308PubMedGoogle ScholarCrossref
9.
Doglietto  GBPacelli  FCaprino  PBossola  MDi Stasi  C Pancreas-preserving total gastrectomy for gastric cancer.  Arch Surg 2000;135 (1) 89- 94PubMedGoogle ScholarCrossref
10.
Crucitti  FPacelli  FBellantone  R  et al.  Roux-en-Y esophagojejunostomy in reconstruction of the alimentary tract after total gastrectomy for carcinoma of the stomach.  Nutrition 1990;6 (3) 261- 263PubMedGoogle Scholar
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