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Indications for pancreaticosplenectomy in advanced gastric cancer.

BACKGROUND/AIMS
The lymph nodes along the splenic artery (No. 11) and at the splenic hilum (No. 10) are classified in group 2 (n2) in the Japanese Classification of Gastric Carcinoma. Pancreaticosplenectomy is performed to achieve complete D2 dissection, but its efficacy remains controversial. To clarify the indications for pancreaticosplenectomy in gastric cancer, surgical results were investigated.


METHODOLOGY
This study investigated 111 gastric cancer patients who underwent potentially curative total gastrectomy with pancreaticosplenectomy accompanied by D2 or more extensive lymph node dissection. The rate of lymph node metastasis and the number of Nos. 10 and 11 lymph nodes that contained metastases were ascertained from several histopathological findings. Predictive factors for metastasis in lymph nodes Nos. 10 and 11 and prognostic factors for survival were calculated and compared using the univariate and Cox proportional hazard regression model.


RESULTS
Lymph node metastasis to No. 10 or 11 was observed in 19 patients. Of these, 8 (42.1%) had paraaortic lymph node metastases. The average number of metastatic lymph nodes in the 19 patients was 19.4 +/- 19.2. The location of the primary tumor and the number of metastatic lymph nodes were correlated to lymph node metastasis to Nos. 10 and 11. Of the regional lymph nodes, the right paracardial lymph nodes and those along the short gastric vessels frequently metastasized to No. 10 or 11. The 5-year survival rate of patients with metastases in lymph nodes No. 10 or 11 was 23.8% and that with No. 16 metastases was 24.5%, whereas that in n2 without metastasis in No. 10 or 11 was 41.4%. The independent prognostic factor was the number of metastatic lymph nodes. Of the postoperative complications, pancreatic fistula was observed in 43 patients (38.7%) and followed by anastomotic leakage in 6 (5.4%).


CONCLUSIONS
Pancreaticosplenectomy is indicated in patients with advanced gastric cancer in the upper third or the whole of the stomach and with lymph node metastasis at right paracardial or along the short gastric vessels. To obtain good surgical results, pancreaticosplenectomy with paraaortic lymph node dissection (D3) should be carried out in patients with as few metastatic lymph nodes as possible.