ROLE OF SPLENECTOMY IN GASTRIC-CANCER SURGERY - ADVERSE EFFECT OF ELECTIVE SPLENECTOMY ON LONG-TERM SURVIVAL

Background: Splenectomy, and in some cases pancreatico splenectomy, ha s been advocated by surgeons in an effort to improve clearance of meta static nodes to splenic hilum (node 10) and splenic artery (node II). Although splenectomy has known effects on increasing morbidity and eve n mortality after a variety of surgical maneuvers including gastrectom y, the longterm effect on survival is controversial. The purpose of th is study is to review and analyze the effect of splenectomy on surviva l in patients having curative gastrectomy for stomach cancer. Methods: We reviewed the role of splenectomy in patients having curative gastr ectomy in a data base of stomach cancer patients that had been collect ed in 1987 as part of an American College of Surgeons Patterns of Care Study. This analysis had involved 18,344 patients, of whom 11,252 wer e first diagnosed in 1982 as part of a longterm study, and 7,092 were first diagnosed in 1987 as part of a shortterm study. From the two dat a collection periods information was available on 12,439 patients who received cancer directed abdominal surgery; 21.2% of these patients re ceived a splenectomy. Among the 3,477 patients reported as having a cu rative gastrectomy (pathologically clear margins), 26.2% received a sp lenectomy. Results: The operative mortality was 9.8% with splenectomy and 8.6% without splenectomy. In patients having a curative gastrectom y, the 5-year observed survival rate was 20.9% in patients having sple nectomy versus 31% in patients who did not receive splenectomy (p < 0. 0001). Examination of differences in survival by stage of diagnosis sh owed significantly reduced survival outcomes among patients with stage LI and LII, but not for those diagnosed with stage I or TV disease. T he pattern of recurrence was moderately different with a larger propor tion of patients having distant metastases among the group of patients who had undergone splenectomy compared with the patients who had not, 29% and 15.5%, respectively. Whether these differences are inherent i n the splenectomy or in the associated cofactors was not determined in this study. Conclusions: The data suggest elective splenectomy should generally be avoided in patients with stage II and III gastric cancer . In patients with resectable proximal advanced (stage Iv) cancer or w ho have extension to spleen and pancreas or macroscopic nodal metastas es to splenic hilum, splenectomy might be necessary to facilitate comp lete removal of the tumor in an effort to achieve longterm tumor contr ol. The importance of surgical judgment is emphasized as the major dec iding factor in determining the need for splenectomy in the individual cancer patient. (C) 1997 by the American College of Surgeons.