Limited gastric resection

Until recently, adjuvant therapy for gastric cancer was of little proven benefit. Thus, surgery was considered the sole mode of treatment for curative intent. This led many authors, especially in Asia, to propose radical, multivisceral resection with regional nodal dissection as a method for improving the dismal survival rates seen for patients who have adenocarcinoma of the stomach. Unfortunately, the benefit of extended gastric resection, either by total gastrectomy or with an extended D2 lymph node dissection, has never proven to be of benefit in terms of overall survival in a prospective, randomized trial from a Western center. Thus, it is the authors' current practice to perform a subtotal gastrectomy for antral lesions when a proximal margin of 5 to 6 cm can be obtained, and to perform dissection of all perigastric lymph nodes along the branches of the celiac axis. This will usually provide for the requisite 15 lymph nodes to be sampled for accurate staging, according to the 6th edition of the American Joint Committee on Cancer (AJCC) staging system. General surgeons, gastrointestinal surgeons, and surgical oncologists alike will encounter less common gastric tumors such as gastric lymphoma, gastrointestinal stromal tumors, and gastric carcinoid tumors. Such tumors are often amenable to local resection, either by laparoscopic or open means, or may be treated by nonoperative means. Thus, techniques for limited gastric resection should be in the armamentarium of all such surgeons. Finally, when faced with an unresectable tumor, it is now clear that operative intervention should be avoided to allow for early intervention with palliative or even potentially curative systemic therapy. This is true of GISTs, Stage IV adenocarcinoma, and Stage II and IV gastric lymphoma. Although palliative gastrectomy may be performed for intractable bleeding or perforation, it is almost always at the cost of a high rate of morbidity and postoperative mortality.