Stellenwert der Lymphadenektomie im Behandlungskonzept des Magenkarzinoms

Zusammenfassung

Der Stellenwert der erweiterten Lymphadenektomie kann auch nach Vorliegen eines Cochrane-Reviews nicht abschließend bewertet werden. Verschiedene nichtrandomisierte japanische und europäische Studien konnten einen Prognosevorteil nach D2-Lymphadenektomie aufzeigen. Zwei randomisierte europäische Studien berichteten über eine signifikant erhöhte Morbidität und Mortalität nach D2-Lymphadenektomie ohne Prognosegewinn in dieser Gruppe. Lediglich in der N2-Subgruppe ist eine verbesserte Prognose gegenüber der eingeschränkten Lymphadenektomie zu erwarten. Ursächlich für die schlechten Ergebnisse in der D2-Gruppe ist neben der hohen Rate von Pankreaslinksresektionen und Splenektomien die geringe Erfahrung der teilnehmenden Operateure und Kliniken. Da in Subgruppen ein Prognosegewinn zu erwarten ist und diese präoperativ nicht sicher bestimmt werden können, sollte die D2-Lymphadenektomie bei allen lokal fortgeschrittenen Karzinomen erfolgen. Die Indikation zur Splenektomie und/oder Pankreaslinksresektion muss aufgrund der Studienergebnisse sehr zurückhaltend gestellt werden.

Abstract

The appropriate extent of lymph node dissection during gastrectomy for cancer remains controversial. Even the Cochrane-Review analyzing the significance of D2-lymphadenectomy in gastric carcinoma does not come to a final evaluation. Recent studies from Japan and several Western centres have shown an improved survival rate in patients who underwent extensive lymph node dissection with curative intention. Two large European randomized trials only reported an increase in operative morbidity and mortality, but failed to show survival benefit, in the D2-lymphadenectomy group. Only for patients with N2-diseases the extended lymph node dissection may offer cure. Both randomized studies show that increased mortality in D2-lymphadenectomy is associated with high rates of spleen and pancreas resection, inexperience of the surgeon and surgery performed in centres with low case numbers. Since improvement of prognosis can be assumed for a subgroup of patients with gastric carcinoma, which can not be safely determined preoperatively, D2-lymphadenectomy should be performed in all cases of locally advanced gastric carcinoma. According to the results of recent studies, the indication for splenectomy and/or left pancreatic resection has to be applied very close.

Schlüsselwörter

Magenkarzinom - Lymphadenektomie - Morbidität - Prognose

Key words

gastric carcinoma - lymphadenectomy - surgical morbidity - prognostic factors

Literatur

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