Surgical Treatment of Localized Gastric Cancer

Theodor Billroth performed the first successful gastric resection (a distal subtotal gastrectomy for stomach cancer) in 1881.1 Billroth operated on a 43-yearold woman with gastric outlet obstruction caused by pyloric carcinoma. Despite tolerating the surgical procedure well and having a benign hospital course, the patient died of recurrent gastric cancer 14 months later. Nevertheless, the new surgical technique proved to be a great success for Billroth, whose clinic would later report 257 gastric resections for stomach cancer in 1894.2 In 1889, Mikulicz began to espouse lymph node dissection in addition to gastrectomy and (if required) distal pancreatectomy for the treatment of gastric cancer.3 In 1898, Charles B. Brigham performed the first successful gastric resection in the United States, a total gastrectomy, on a 66-year-old woman using a Murphy button in the reconstruction phase of the operation, to help create an esophagoduodenal anastomosis.4 The contributions of these surgeons and others in the late nineteenth century provided the cardinal foundations for current surgical management of patients with gastric cancer. Resection remains the only potentially curative treatment for localized gastric cancer. The basic surgical approach for stomach cancer that is amenable to potential cure has essentially remained the same since Billroth’s time. In the early 1940s, Coller and colleagues recommended radical resection, including regional lymphadenectomy, for all gastric cancers since lymph node metastasis could be insidious and because identification of the correct resection plane is difficult.5 However, other contemporaries were not convinced of Coller’s assertions and found the high postoperative mortality rate associated with radical gastrectomy unacceptable.6 Since that time, there has been an ongoing discourse as to which surgical procedure is associated with the most optimal outcome and the least postoperative morbidity and mortality. Efforts to enhance the surgical cure of patients have focused on defining the appropriate extent of lymphadenectomy. The principal areas addressed in this chapter include the extent of both gastric resection and lymph node dissection, the adequacy of proximal and distal margins, the role of adjacent-organ resection and splenectomy in localized disease, and the surgical treatment of recurrent gastric cancer.