Indikationen und Ergebnisse der palliativen Magenresektion beim fortgeschrittenen Magenkarzinom

Zusammenfassung

Hintergrund: Das Magenkarzinom wird oft erst im UICC-Stadium 3 b oder 4 diagnostiziert. Eine R0-Resektion ist hier nur im Einzelfall erzielbar. Selbst bei diesen Patienten beträgt die 5-Jahre-Überlebensrate weniger als 5 %. Chirurgische Palliativoperationen sind traditionell der Behandlung therapierefraktärer, vitaler Tumorkomplikationen vorbehalten. Patienten und Methodik: Wir berichten über 21 Patienten, die im Zeitraum 2004 bis 2007 in unserer Klinik wegen eines fortgeschrittenen Magenkarzinoms eine palliative Tumorresektion erhielten, wobei bei zehn dieser Patienten die Zuordnung zur palliativen Therapieintention präoperativ und bei elf Patienten diese anhand des Operationsbefundes erfolgte. Im einzelnen wurden 17 Gastrektomien, drei proximale und eine distale Magenresektion vorgenommen. Ergebnisse: Es konnte gezeigt werden, dass die Patienten eine verbesserte Gesamtüberlebenszeit im Vergleich zu konservativ therapierten Patienten haben. Das perioperative Risiko erwies sich bei Auswahl geeigneter Patienten als vertretbar. Das mediane Überleben betrug 16 Monate für die palliativ resezierten Patienten. 80 % der Patienten waren nach sechs Monaten und rund 60 % der Patienten nach 12 Monaten noch am Leben. Die perioperative Mortalität betrug 0 % bei einer durchschnittlichen stationären Aufenthaltsdauer von 12 Tagen. Alle Patienten konnten bei regelhafter Darmpassage und bedarfsgerechter Analgetikatherapie in die häusliche Umgebung entlassen werden. Schlussfolgerungen: Nach unserer Auffassung bietet die palliative Magenresektion einen deutlichen Überlebensvorteil gegenüber allen anderen palliativen Therapieoptionen. Für die Patienten ergibt sich auch eine Verbesserung der Lebensqualität.

Abstract

Background: Gastric carcinoma is often diagnosed at UICC stage 3 b or 4. R0 resection can be achieved only in very few such cases. Even for these patients the 5-year survival rate is less than 5 %. Surgical palliation is traditionally reserved for the treatment of severe tumour complications not responding to other forms of treatment. Patients and Methods: We report on 21 patients who underwent palliative resection for gastric carcinoma at our institution between 2004 and 2007. Ten of these were assigned to palliative surgical treatment pre-operatively while this choice was made for 11 patients on the grounds of the intra-operative findings. We performed 17 gastrectomies, 3 proximal gastric resections and one distal gastric resection. Results: It has been shown that the patients have an improved overall survival time as compared to patients who received non-surgical treatment. The perioperative risk was reasonable when patients were carefully selected. Median survival for resected patients was 16 months. 80 % of patients were alive after 6 months and approximately 60 % of patients were alive after 12 months. The perioperative mortality was 0 % with a mean hospital stay of 12 days. All patients were discharged home with proper bowel passage and analgesia as individually required. Conclusions: We are convinced that palliative gastric resection provides a pronounced survival benefit over any other palliative treatment options. Patients also have an improved quality of life.

palliative Gastrektomie - fortgeschrittenes Magenkarzinom - Überleben - Lebensqualität

palliative gastrectomy - advanced gastric cancer - survival - quality of life

Literatur

• 1 Ball A B, Baum M, Breach N M. Surgical palliation. In: Derek D, Hrsg. Oxford Textbook of Palliative Medicine. Oxford: Oxford Press; 1998: 282 – 297
• 2 Bozzetti F, Bonfati G, Audisio R A et al. Prognosis of patients after palliative surgical procedures for carcinoma of the stomach.  Surg Gynecol Obstet. 1987;  164 151-154
• 3 Cheong J H, Chen J Y, Song C S et al. Early postoperative intraperitoneal chemotherapy following cytoreductive surgery in patients with very advanced gastric cancer.  Ann Surg Oncol. 2007;  14 61-68
• 4 Chu D Z, Lang N P, Thompson C et al. Peritoneal carcinomatosis in nongynecologic malignancy, a prospective study of prognostic factors.  Cancer. 1989;  63 364-367
• 5 Conroy T, Marchal F, Blazeby J M. Quality of life in patients with oesophageal and gastric cancer: an overview.  Oncology. 2006;  70 391-402
• 6 Dindo D, Demartines N, Clavien P A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6 336 patients and results of a survey.  Ann Surg. 2004;  240 214-215
• 7 Fujisaki S, Takashina M, Tomita R et al. Improvements in quality of life and survival of patients with T4 gastric cancer which invaded organs after multivisceral resections through the extension of palliative gastrectomy and postoperative chemotherapy.  Gan To Kagaku Ryoho. 2006;  33 1881-1884
• 8 Foukakis T, Lundell L, Gubanski M et al. Advances in the treatment of patients with gastric adenocarcinoma.  Acta Oncol. 2007;  46 277-285
• 9 Geoghegan J G, Keane T E, Rosenberg I L et al. Gastric cancer: the case for a selective policy in surgical management.  J R Coll Surg Edinb. 1993;  38 208-212
• 10 Hartgrink H H, Putter H, Klein-Kranenbarg E et al. Value of palliative resection in gastric cancer.  Br J Surg. 2002;  89 1438-1443
• 11 Haugstvedt T, Viste A, Eide G E et al. The survival benefit of resection in patients with advanced stomach cancer: the Norwegian multicenter experience. Norwegian stomach cancer trial.  World J Surg. 1989;  13 617-621
• 12 Hiramatsu K, Mizukami Y, Momiyama M et al. Stage IV gastric cancer patient who underwent palliative gastrectomy showing complete response to induction therapy with methotrexate plus 5-fluorouracil and secondary treatment with oral TS-1.  Gan To Kagaku Ryoho. 2005;  32 1163-1166
• 13 Jemal A, Tiwari R C, Murray T et al. American Cancer Society. Cancer statistics 2004.  CA Cancer J Clin. 2004;  54 8-29
• 14 Jeung H C, Rha S Y, Jang W I et al. Treatment of advanced gastric cancer by palliative gastrectomy, cytoreductive therapy and postoperative intraperitoneal chemotherapy.  Br J Surg. 2002;  89 460-466
• 15 Kunisaki C, Makino H, Takagawa R et al. Impact of palliative gastrectomy in patients with incurable advanced gastric cancer.  Anticancer Res. 2008;  28 1309-1315
• 16 Lawrence W, McNeer G. The effectiveness of surgery for palliation of incurable gastric cancer.  Cancer. 1958;  11 28-32
• 17 Lim S, Muhs B E, Marcus S G et al. Results following resection for stage IV gastric cancer; are better outcomes observed in selected patient subgroups?.  J Surg Oncol. 2007;  95 118-122
• 18 Lin S Z, Tong H F, You T et al. Palliative gastrectomy and chemotherapy for stage four gastric cancer.  J Cancer Res Clin Oncol. 2008;  134 187-192
• 19 Medina-Franco H, Contreras-Saldivar A, Ramos-De La Medina A et al. Surgery for stage 4 gastric cancer.  Am J Surg. 2004;  187 543-546
• 20 Meijer S, De Bakker O J, Hoitsma H F. Palliative resection in gastric cancer.  J Surg Oncol. 1983;  23 77-80
• 21 Miner T J, Jaques D P, Karpeh M S et al. Defining palliative surgery in patients receiving noncurative resections for gastric cancer.  J Am Coll Surg. 2004;  198 1013-1021
• 22 Miner T J, Brennan M F, Jaques D P. A prospective symptom related outcomes analysis of 1 022 palliative procedures for advanced cancer.  Ann Surg. 2004;  240 719-726
• 23 Mizutani S, Shioya T, Maejima K et al. Significance of gastrectomy as palliative surgery for gastric carcinoma with pyloric stenosis.  J Nippon Med Sch. 2007;  74 241-245
• 24 Moehler M, Galle P R, Gockel I et al. The multidisciplinary management of gastrointestinal cancer, multimodal treatment of cancer.  Best Pract Res Clin Gastroenterol. 2007;  21 965-981
• 25 Moesta K T, Hünerbein M, Schlag P M. Therapieverfahren für Karzinome des ösophagogastralen Überganges.  Chirurg. 2003;  74 381-393
• 26 Monson J R, Donohue J H, McIlrath D C et al. Total gastrectomy for advanced cancer. A worthwhile palliative procedure.  Cancer. 1991;  68 1863-1868
• 27 Nazli O, Yaman I, Tansug D et al. Palliative surgery for advanced stage (stage 4) gastric adenocarcinoma.  Hepatogastroenterology. 2007;  54 298-303
• 28 Onate-Ocana L F, Mendez-Cruz G, Hernandez-Ramos R et al. Experience of surgical morbiditiy after palliative surgery in patients with gastric carcinoma.  Gastric Cancer.. 2007;  10 215-220
• 29 Ouchi K, Sugawara T, Ono H et al. Therapeutic significance of palliative operations for gastric cancer for survival and quality of life.  J Surg Oncol. 1998;  69 41-44
• 30 Pech O, Günter E, Ell C. Endosonografie Ösophagus und Magen.  Z Gastroenterol. 2008;  46 564-571
• 31 Roukos D H, Kappas A M. Perspectives in the treatment of gastric cancer.  Nat Clin Pract Oncol. 2005;  2 98-107
• 32 ReMine W H. Palliative operations for incurable gastric cancer.  World J Surg. 1979;  3 721-729
• 33 Saidi R F, ReMine S G, Dudrick P S et al. Is there a role for palliative gastrectomy in patients with stage four gastric cancer?.  World J Surg. 2006;  30 21-27
• 34 Sarela A I, Miner T J, Karpeh M S et al. Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma.  Ann Surg. 2006;  243 189-195
• 35 Schein P S, Smith F P, Woolley P V et al. Current management of advanced and locally unresectable gastric carcinoma.  Cancer. 1982;  50 2590-2596
• 36 Sugarbaker P H, Yu W, Yonemura Y. Gastrectomy, peritonectomy and perioperative intraperitoneal chemotherapy: the evolution of treatment strategies for advanced gastric cancer.  Semin Surg Oncol. 2003;  21 233-248
• 37 Swan R, Miner T J. Current role of surgical therapy in gastric cancer.  World J Gastroenterol. 2006;  12 372-379
• 38 Tomimatsu H, Nakano T. Two cases of stage four gastric cancer who underwent total gastrectomy and achieved long-term survival by sequential chemotherapy.  Gan To Kagaku Ryoho. 2007;  34 2291-2295
• 39 Wada T, Iwanaga T, Koyama H et al. A case report of long-term survival in advanced gastric cancer with multiple liver metastases treated with mitomycin C and tegafur therapy after palliative gastrectomy.  Gan To Kagaku Ryoho. 1988;  15 353-356
• 40 Zittel T T. Die Therapie des Magenkarzinoms.  Viszeralchirurgie. 2002;  37 262-268