Альманах клинической медицины. 2019; 47: 707-711
Есть ли место мультивисцеральным резекциям в лечении рака желудка?
Смирнов А. B., Черепанин А. И., Ищенко Р. В.
https://doi.org/10.18786/2072-0505-2019-47-081Аннотация
Общеизвестно, что мультивисцеральные резекции (МВР) сопровождаются значительным числом послеоперационных осложнений. Однако до сих пор идут дискуссии об эффективности МВР в отношении увеличения продолжительности жизни больных. Оправданы ли риски операций расширенного объема? Ранее предполагалось, что удаление соседних органов может улучшить прогноз заболевания, даже в отсутствие прямой инвазии. Но в эпоху широких возможностей химио- и лучевой терапии выполнение сверхрасширенного хирургического объема без прорастания опухоли вызывает сомнения. При наличии метастазов в регионарные лимфоузлы МВР не улучшают прогноз в сравнении с паллиативными резекциями. В случае если у пациента есть отдаленные метастазы либо операция проведена заведомо нерадикально, МВР ухудшают прогноз. Если степень инвазии T4b и нет жизнеугрожающих осложнений, оптимально начать неоадъювантную химиотерапию или провести периоперационную химиотерапию. При интраоперационном подозрении на вовлечение соседних анатомических структур в отсутствие отдаленных метастазов показана резекция en bloc в сочетании с D2-лимфодиссекцией. Приблизительно в 30–60% наблюдений инвазия морфологически не подтверждается. Единственный путь улучшения результатов хирургического лечения больных раком желудка – тщательная оценка распространенности заболевания на дооперационном этапе, отбор больных и работа хирургов в команде с химиотерапевтами, радиологами и диагностами.
Список литературы
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19. Lowenfeld L, Datta J, Lewis RS Jr, McMillan MT, Mamtani R, Damjanov N, Chandrasekhara V, Karakousis GC, Drebin JA, Fraker DL, Roses RE. Multimodality Treatment of T4 Gastric Cancer in the United States: Utilization Trends and Impact on Survival. Ann Surg Oncol. 2015;22 Suppl 3:S863–72. doi: 10.1245/s10434-015-4677-y.
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Almanac of Clinical Medicine. 2019; 47: 707-711
Is there a place for multivisceral resections in the treatment of gastric cancer?
Smirnov A. V., Cherepanin A. I., Ishchenko R. V.
https://doi.org/10.18786/2072-0505-2019-47-081Abstract
It is known that multivisceral resections (MVR) are associated with significant numbers of post-operative complications. However, the effectiveness of MVR in increasing the patients' life expectancy remains a matter of debate. Are the risks of extended volume resections justified? It has been previously assumed that the removal of adjacent organs could improve the prognosis of the disease, even in the absence of direct invasion. However, in the era of the big potential of chemoand radiation therapy, the implementation of an over-extensive surgical volume in the absence of tumor invasion is doubtful. In the presence of regional lymphatic nodes metastases, MVR do not improve prognosis, compared to that after palliative resections. If the patient has distant metastases, or the operation has been obviously not radical enough, MVR worsen the prognosis. In grade T4b invasion and with the absence of life threatening complications, it is optimal to start with neoadjuvant or perioperative chemotherapy. In the case of intraoperative suspicion of adjacent anatomical structures involvement, with no distant metastases, en bloc resection in combination with D2 lymphodissection is indicated. In approximately 30–60% of cases, invasion is not confirmed by histology. The only way to improve the results of surgical treatment of gastric cancer patients is to carefully assess the extension of the disease at the preoperative stage, select patients and team work of surgeons with chemotherapists, radiologists and specialists in diagnostics.
References
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4. Furukawa H, Hiratsuka M, Iwanaga T, Imaoka S, Ishikawa O, Kabuto T, Sasaki Y, Kameyama M, Ohigashi H, Nakamori S, Yasuda T. Extended surgery – left upper abdominal exenteration plus Appleby's method – for type 4 gastric carcinoma. Ann Surg Oncol. 1997;4(3):209–14. doi: 10.1007/bf02306612.
5. Isozaki H, Tanaka N, Fujii K, Tanigawa N, Okajima K. Improvement of the prognosis of gastric cancer with extensive serosal invasion using left upper abdominal evisceration. Hepatogastroenterology. 2001;48(40):1179–82.
6. Yonemura Y, Kawamura T, Nojima N, Bandou E, Keizou T, Fujita H, Michiwa Y, Fujimura T, Fushida S, Ajisaka H, Miwa K. Postoperative results of left upper abdominal evisceration for advanced gastric cancer. Hepatogastroenterology. 2000;47(32):571–4.
7. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19. doi: 10.1007/s10120-016-0622-4.
8. Jiang L, Yang KH, Chen Y, Guan QL, Zhao P, Tian JH, Wang Q. Systematic review and meta-analysis of the effectiveness and safety of extended lymphadenectomy in patients with resectable gastric cancer. Br J Surg. 2014;101(6):595–604. doi: 10.1002/bjs.9497.
9. Kodera Y, Schwarz RE, Nakao A. Extended lymph node dissection in gastric carcinoma: where do we stand after the Dutch and British randomized trials? J Am Coll Surg. 2002;195(6): 855–64. doi: 10.1016/s1072-7515(02)01496-5.
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11. Brar SS, Seevaratnam R, Cardoso R, Yohanathan L, Law C, Helyer L, Coburn NG. Multivisceral resection for gastric cancer: a systematic review. Gastric Cancer. 2012;15 Suppl 1:S100– 7. doi: 10.1007/s10120-011-0074-9.
12. Dhar DK, Kubota H, Tachibana M, Kinugasa S, Masunaga R, Shibakita M, Kohno H, Nagasue N. Prognosis of T4 gastric carcinoma patients: an appraisal of aggressive surgical treatment. J Surg Oncol. 2001;76(4):278–82. doi: 10.1002/jso.1046.
13. Martin RC 2nd, Jaques DP, Brennan MF, Karpeh M. Extended local resection for advanced gastric cancer: increased survival versus increased morbidity. Ann Surg. 2002;236(2):159–65. doi: 10.1097/00000658200208000-00003.
14. Carboni F, Lepiane P, Santoro R, Lorusso R, Mancini P, Sperduti I, Carlini M, Santoro E. Extended multiorgan resection for T4 gastric carcinoma: 25-year experience. J Surg Oncol. 2005;90(2):95–100. doi: 10.1002/jso.20244.
15. Ozer I, Bostanci EB, Orug T, Ozogul YB, Ulas M, Ercan M, Kece C, Atalay F, Akoglu M. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg. 2009;198(1):25–30. doi: 10.1016/j.amjsurg.2008.06.031.
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