PROBLEM OF PROXIMAL 3RD GASTRIC-CARCINOMA

The prevalence of proximal third gastric carcinoma increases rapidly i n the Western world. An analysis of prognostic factors indicates that the poor prognosis usually associated with these tumors is due at leas t in part to late presentation and advanced tumor stages. The current TNM classification usually understages these tumors because it does no t take the partly retroperitoneal location of the proximal stomach int o account. After correction of the TNM classification a proximal tumor location has no influence on survival. Because these tumors benefit m ost from radical lymph node dissection, the retroperitoneal lymphatic drainage must be taken into account when performing lymphadenectomy fo r proximal third gastric cancer. To avoid pancreatic fistulas and the associated morbidity, a pancreas-preserving splenectomy and lymphadene ctomy should be adapted if an extended lymph node resection of the ret roperitoneum is performed. Because of the high prevalence of ''intesti nal type'' tumors in the proximal third of the stomach the extent of t he luminal resection margins can be limited; that is, a total gastrect omy with transhiatal resection of the distal esophagus usually suffice s to achieve complete tumor removal at the oral margin.