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
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Priv.-Doz. Dr. med. Stefan P. Mönig
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