はじめに：Common Terminology Criteria for Adverse Events v30（以下，CTCAE）を用いて胃癌手術に関する合併症の評価を試み，その有用性と問題点について検討した．方法：2004年12月から2006年12月に行った胃癌手術症例154例を対象として，胃癌手術合併症を術中合併症，術後早期合併症（外科的合併症，非外科的合併症），術後晩期合併症に分類して前向きに評価した．手術内容は幽門側胃切除術93例，胃全摘術38例，吻合術10例，その他13例であった．結果：胃癌手術における周術期の合併症は全体として125例（812％），Grade 3以上は27例（175％）に認められた．術中合併症は3例（13％），術後早期合併症のうち外科的合併症は，30例（195％），非外科的合併症は121例（786％），術後晩期合併症は18例（117％）にみられた．手術死亡例，在院死亡例はなく，術後在院日数の中央値は21日であった．術後早期のGrade 1以上の外科的合併症またはGrade 2以上の非外科的合併症を生じた症例で術後在院日数が延長していた．まとめ：胃癌手術の合併症について，CTCAEを用いて詳細な評価が可能であった．Grade 1以上の外科的合併症またはGrade 2以上の非外科的合併症を手術合併症として評価するのが妥当と考えられた．

https://www.jstage.jst.go.jp/article/jjgs/42/1/42_1_10/_pdf

胃癌手術におけるCommon Terminology Criteria for Adverse Events v3.0を利用した合併症の評価

Introduction:Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) is a treatment option for peritoneal surface malignancy. Despite the survival benefits, this treatment was previously associated with a high morbidity and mortality rates and the perception of the

Morbidity and mortality outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy at a single tertiary institution: towards a new perspective of this treatment.

Short-term results of gastric cancer surgery vary remarkably worldwide, and international surgical quality criteria are urgently needed. To contribute to defining these criteria, we reviewed short-term results of gastrectomy for gastric cancer in three centers of the Italian Research Group for Gastric Cancer, with an average of 24.7, 29.5, and 18 gastrectomies per year. Between 1988 and 2002, 1,032 patients underwent gastrectomy for gastric cancer in Verona, Siena, and Padua. D1, D2, and D3 lymphadenectomy were performed, respectively, in 228, 584, and 220 cases. The median number of retrieved lymph nodes was 14 (interquartile range 9–18.75) after D1, 29 (21–38) after D2, and 46.5 (37–57) after D3. Fewer than 15 nodes were retrieved in 54.5%, 6.2%, and 1.4% of cases undergoing, respectively, D1, D2, and D3. Adjacent organ removal was rare during D1 (splenectomy: 6.1%, splenopancreasectomy: 1.8%), and quite common during D3 (11.4%, 11.4%). Forty patients (3.9%) died postoperatively. Neither postoperative morbidity nor mortality was significantly associated with extension of lymphadenectomy. We conclude that at least D2 lymphadenectomy is necessary to achieve adequate disease staging (≥15 nodes retrieved). Spleen and pancreas tail are more frequently removed during D3, but this removal is not associated with higher postoperative morbidity or mortality.

Indexes of Surgical Quality in Gastric Cancer Surgery: Experience of an Italian Network.

Background Several studies in the literature have investigated the possible role of the extent of lymphadenectomy in gastric cancer treatment failure. The current study attempted to determine the effectiveness and safety of lymphadenectomy with gastrectomy for the treatment of gastric cancer. Methods Randomized controlled trials (RCTs) were identified by means of MEDLINE, EMBASE, Cochrane Controlled Trials Register databases, and Chinese Biomedical Database, as well as by selecting references from relevant articles. Results Overall, 14 RCTs (3,432 patients) were included in the meta-analysis. Of the D1 and D2 surgery groups, the operative mortality and postoperative morbidity were higher in the D2 group than in the D1 group, but the 3- and 5-year survival rates were not statistically different. Also the operative time was shorter in D1 compared to D2. In the D2 versus the D3 surgical group, the operative mortality, percentage of postoperative complications, operative time, and hospital stay were not significantly different. Conclusions The results suggest that D2 and D3 surgery may not offer specific advantages for gastric cancer and instead may lead to disadvantages for patient outcomes.

An evidence-based medicine review of lymphadenectomy extent for gastric cancer.

Membres du groupe de travail (par ordre alphabétique) : Blay JY (Oncologue Lyon), Brouquet A (Chirurgien Boulogne), Chatelain D (Anatomopathologiste Amiens), Comy M (Chirurgien La Roche sur Yon), Delpero JR (Chirurgien Marseille), Denet C (Chirurgien Paris), Elias D (Chirurgien Villejuif), Fléjou JF (Anatomopathologiste Paris), Fourquier P (Chirurgien Nantes), Fuks D (Chirurgien Amiens), Glehen O (Chirurgien Lyon), Karoui M (Chirurgien Paris), Kohneh-Shahri N (Chirurgien Villejuif), Lesurtel M (Chirurgien Clichy), Mariette C (Chirurgien Lille), Mauvais F (Chirurgien Beauvais), Nicolet J (Chirurgien Meaux), Perniceni Th (Chirurgien Paris), Piessen G (Chirurgien Lille), Regimbeau JM (Chirurgien Amiens), Rouanet Ph (Chirurgien Montpellier), Sauvanet A (Chirurgien Clichy), Schmitt G (Chirurgien Reims), Vons C (Chirurgien Bondy).

[Digestive oncology: surgical practices].

BACKGROUND/AIMS A randomized study was performed to evaluate morbidity and mortality after D2 (level 1 and 2 lymphadenectomy) and D4 (D2 plus lymphadenectomy of para-aortic lymph nodes) dissection for advanced gastric cancer. METHODOLOGY Two hundred and fifty-six patients with advanced gastric adenocarcinoma were enrolled (128 to each group). Patients were randomly allocated into D2 (N = 128) or D4 (N = 128) group. The first and second tiers of lymph nodes are removed in D2 dissection. In D4 gastrectomy, the paraaortic lymph nodes were additionally removed. RESULTS There was no indication of significant distribution bias with regard to age, sex, T-grade, and N-grade between the two groups. Operation time of D4 gastrectomy (369 +/- 120 min) was significantly longer than that of D2 gastrectomy (273 +/- 1103 min), and blood loss of the D4 group (872 +/- 683 mL) was significantly greater than that of the D2 group 571 +/- 527 mL (P < 0.001). Five (4%) and two (2%) medical complications developed in the D2 and D4 groups, respectively. Surgical complications developed in 28 (22%) and 48 patients (38%) after D2 and D4 gastrectomy. The most common complications were anastomotic leakage, pancreatic fistula, and abdominal abscess. Pancreatic fistula developed in 6 (19%) of 32 patients after D4 plus pancreatosplenectomy, but the incidence of pancreatic fistula after D2 gastrectomy plus pancreatosplenectomy was low (6%, 1/16). Two patients died within 30 days of operation (0.8%, 2/256), and each patient belonged to the D2 and D4 group. CONCLUSIONS Although there is a significantly higher surgical complication rate in D4 dissection, D4 dissection can be done safely as D2 dissection when performed by well-trained surgeons.

Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons.

Background/aims Lymph node dissection is an essential component of curative resection for advanced gastric cancer. To improve the survival of N2 patients, Asian surgeons have been performing D2+para-aortic lymph node dissection. The current study presents the results of lymph node status from multicenter trial of D2 and D2 + para-aortic nodal (No.16) dissection (D4 dissection). Methodology Patients enrolled in the study had potentially curable gastric adenocarcinoma in an advanced stage, T2, T3 or T4/N1 or N2. Patients were randomized to undergo either D2 or D4 gastrectomy. Results Two hundred and seventy patients were registered and 136 and 134 patients were allocated into the D2 or D4 group, respectively. The average nodal yield of No.16 in D4 group was 18.4 +/- 14.1, ranging from 2 to 84. No.16 metastasis was detected in 12 (9.0%) of 134 D4 patients. One, 9 and 2 patients had simultaneous involvement in N1, N2, and N3 (No.8p, 12, 13 or 14). Namely, in 39 patients who were diagnosed as N2 from the lymph node status in N1 and N2 levels, nine (23.0%) patients had No.16 metastasis. The stage migration by D4 was found in 10 (7.5%). Logistic regression analysis revealed that the stations of No.7 and No.8 were the significant predictors of No.16 involvement. Conclusions The present study may strongly suggest that prophylactic D4 dissection may be indicated for patients with N2 involvement, and that No.7 and No.8 are the junctional nodes for D4 dissection.

Metastasis in para-aortic lymph nodes in patients with advanced gastric cancer, treated with extended lymphadenectomy.

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Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons.

Metastasis in para-aortic lymph nodes in patients with advanced gastric cancer, treated with extended lymphadenectomy.