Although a variety of novel molecular targets have been found and the targeted therapies have shown encouraging results in gastric cancer patients,[12–16] curative resection is considered to be the ideal primary choice that not only brings favorable long-term survival but also causes a low morbidity rate.[17,18] However, consideration regarding the extent of surgical resection depends on multiple factors.[19,20] Till now, there was no consensus about the surgical procedure for distal gastric cancer. A previous extensive survey of 62 centers in Europe including 16,594 patients showed that 44% surgeons would chose TG for antrum tumor of stomach. The national Cancer Data Base report of United States comprising 6400 patients showed that approximately 12.3% distal gastric cancer patients received TG. In our cohort, only 8.3% patients received TG which was obviously lower than the proportion reported previously.
Actually, TG could cause several complications such as weight loss, diarrhea, anorexia, and metabolic changes. Meanwhile, there is also some superiority of TG compared with DG; for instance, avoiding tumor local recurrence and reducing the occurrence risk of remnant gastric cancer. However, a previous randomized clinical trial demonstrated that the postoperative complications were comparable between DG and TG. At the current time, the comparison of perioperative morbidity and mortality between the 2 groups were still under debate.[22,25,26] In the present study, DG showed significant superiority to TG during the surgical procedure. The postoperative complications and hospital stay were comparable between the 2 groups. From the point of view of safety, DG instead of TG was feasible. Previous studies demonstrated that extended lymph node dissection had not shown any benefit for gastric cancer so far.[27–29] In the current study, the number of excised lymph nodes was not an independent prognostic factor either.
Long-term survival is the most important criteria when choosing the extent of resection. A French prospective controlled study including 201 patients with gastric antrum cancer indicated that TG did not increase the survival rate compared with DG. In consistent with the conclusion above, another randomized clinical trial including 618 patients with tumor of the distal stomach from 28 institutions, demonstrated that there is no superiority in extending resection, which showed familiar 5-year survival rate between DG and TG groups. The similar results were also found in the other studies.[32–34] In our study, DG brought a significantly better overall survival than TG for distal gastric cancer patients. But, the multivariate analysis showed that type of resection was not an independent prognostic factor for the entire cohort. The poor survival after TG may be due to the higher stage of tumor in the TG group.
Under this case, further clinicopathological factor-stratified survival analysis was necessary. Multivariate analysis indicated that TG was an independent risk factor for poor prognosis in subgroup of TNM stage III. Thus, patients with distal gastric cancer who received TG should be treated more carefully and followed up closely, when assessed as TNM stage III degree postoperatively by the pathologists.
There are several limitations in our present study. First, it was a retrospective study of a single center's experience. Multicenter studies are needed to verify the survival impact of these 2 types of gastrectomy. Second, the postoperative quality of life of patients who underwent either DG or TG was not analyzed. Third, the numbers of patients in the 2 groups were unbalanced.
. Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016;66:115–32.
. Billroth T. Offenes schreiben an Herrn Dr. L. Wittelshofer. Wien Med Wochenschr 1881;31:161–5.
. Schlatter K. A unique case of complete removal of the stomach-successful esophago-enterostomy recovery. Med Rec 1897;52:909–14.
. Dicken BJ, Bigam DL, Cass C, et al. Gastric adenocarcinoma: review and considerations for future directions. Ann Surg 2005;241:27–39.
. Ajani JA, D’Amico TA, Almhanna K, et al. Gastric cancer, version 3.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2016;14:1286–312.
. McNeer G, Bowden L, Booner RJ, et al. Elective total gastrectomy
for cancer of the stomach: end results. Ann Surg 1974;180:252–6.
. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinoma. an attempt at a histo-clinical classification. Acta Pathol Microbiol Scand 1965;64:31–49.
. Wanebo HJ, Kennedy BJ, Chmiel J, et al. Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 1993;218:583–92.
. Hundahl SA, Menck HR, Mansour EG, et al. The National Cancer Data Base report on gastric carcinoma. Cancer 1997;80:2333–41.
. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113–23.
. Washington K. 7th edition of the AJCC cancer staging manual: stomach. Ann Surg Oncol 2010;17:3077–9.
. Saito R, Abe H, Kunita A, et al. Overexpression and gene amplification of PD-L1 in cancer cells and PD-L1+ immune cells in Epstein–Barr virus-associated gastric cancer: the prognostic implications. Mod Pathol 2016;doi: 10.1038/modpathol.2016.202.
. Amedei A, Munari F, Bella CD, et al. Helicobacter pylori secreted peptidyl prolyl cis, trans-isomerase drives Th17 inflammation in gastric adenocarcinoma. Intern Emerg Med 2014;9:303–9.
. Iveson T, Donehower RC, Davidenko I, et al. Rilotumumab in combination with epirubicin, cisplatin, and capecitabine as first-line treatment for gastric or oesophagogastric junction adenocarcinoma: an open-label, dose de-escalation phase 1b study and a double-blind, randomised phase 2 study. Lancet Oncol 2014;15:1007–18.
. Satoh T, Lee KH, Rha SY, et al. Randomized phase II trial of nimotuzumab plus irinotecan versus irinotecan alone as second-line therapy for patients with advanced gastric cancer. Gastric Cancer 2015;18:824–32.
. Muro K, Chung HC, Shankaran V, et al. Pembrolizumab for patients with PD-L1-positive advanced gastric cancer (KEYNOTE-012): a multicentre, open-label, phase 1b trial. Lancet Oncol 2016;17:717–26.
. Stein HJ, Sendler A, Siewert JR. Site-dependent resection techniques for gastric cancer. Surg Oncol Clin N Am 2002;11:405–14.
. Clark CJ, Thirlby RC, Picozzi V Jr, et al. Current problems in surgery: gastric cancer. Curr Probl Surg 2006;43:566–670.
. Roukos DH. Current advances and changes in treatment strategy may improve survival and quality of life in patients with potentially curable gastric cancer. Ann Surg Oncol 1999;6:46–56.
. Takiguchi S, Yamamoto K, Hirao M, et al. A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distal gastrectomy
for gastric cancer: results from a multi-institutional RCT. Gastric Cancer 2012;15:198–205.
. Heberer G, Teichmann RK, Kramling HJ, et al. Results of gastric resection for carcinoma of the stomach: the European experience. World J Surg 1988;12:374–81.
. Le A, Berger D, Lau M, et al. Secular trends in the use, quality, and outcomes of gastrectomy for noncardia gastric cancer in the United States. Ann Surg Oncol 2007;14:2519–27.
. Meyer HJ, Jahne J, Wilke H, et al. Surgical treatment of gastric cancer: retrospective survey of 1,704 operated cases with special reference to total gastrectomy
as the operation of choice. Semin Surg Oncol 1991;7:356–64.
. Bozzetti F, Marubini E, Bonfanti G, et al. Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicenter Italian randomized trial. The Italian Gastrointestinal Tumor Study Group. Ann Surg 1997;226:613–20.
. Meyer C, Rohr S, Vix J, et al. Outcome of surgical treatment of cancer of the stomach. Report of 330 cases. Chir Ital 1997;49:27–33.
. Lau M, Le A, El-Serag HB. Noncardia gastric adenocarcinoma remains an important and deadly cancer in the United States: secular trends in incidence and survival. Am J Gastroenterol 2006;101:2485–92.
. Bozzetti F. Rationale for extended lymphadenectomy in gastrectomy for carcinoma. J Am Coll Surg 1995;180:505–8.
. Robertson CS, Chung SC, Woods SD, et al. A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy
for antral cancer. Ann Surg 1994;220:176–82.
. Hartgrink HH, van de Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004;22:2069–77.
. Gouzi JL, Huguier M, Fagniez PL, et al. Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study. Ann Surg 1989;209:162–6.
. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy
for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg 1999;230:170–8.
. Gockel I, Pietzka S, Gonner U, et al. Subtotal or total gastrectomy
for gastric cancer: impact of the surgical procedure on morbidity and prognosis
—analysis of a 10-year experience. Langenbecks Arch Surg 2005;390:148–55.
. Pugliese R, Maggioni D, Sansonna F, et al. Subtotal gastrectomy with D2 dissection by minimally invasive surgery for distal adenocarcinoma of the stomach: results and 5-year survival. Surg Endosc 2010;24:2594–602.
. Morgagni P, Marfisi C, Gardini A, et al. Subtotal gastrectomy as treatment for distal multifocal early gastric cancer. J Gastrointest Surg 2009;13:2239–44.