expansivegrowthpattern(Types1and2)and5cmisrec- ommendedforthosewithinfiltrativegrowthpattern(Types3 and4).Whentheserulescannotbeobserved,itisadvisable toexaminetheproximalresectionmarginbyfrozensection. Fortumorsinvadingtheesophagus,a5-cmmarginisnot necessarilyrequired,butfrozensectionexaminationofthe resectionlineisdesirabletoensureanR0resection.ForT1tumors,agrossresectionmarginof2cmshould beobtained.Whenthetumorborderisunclear,preopera- tiveendoscopicmarking,byclips,ofthetumorborder basedonbiopsyresultswillbehelpfulfordecision-making regardingtheresectionline.2.2.2.2Selectionofgastrectomy Thestandardsurgical procedureforclinicallynode-positive(cN?)orT2-T4a tumorsiseithertotalordistalgastrectomy.Distalgastrectomy isselectedwhenasatisfactoryproximalresectionmargin(see above)canbeobtained.Pancreaticinvasionbytumor requiringpancreaticosplenectomynecessitatestotalgastrec- tomyregardlessofthetumorlocation.Totalgastrectomywith splenectomyshouldbeconsideredfortumorsthatarelocated alongthegreatercurvatureandharbormetastasistono.4sb lymphnodes,eveniftheprimarytumorcouldberemovedby distalgastrectomy.Foradenocarcinomalocatedontheprox- imalsideoftheesophagogastricjunction,esophagectomyand proximalgastrectomywithgastrictubereconstructionshould beconsidered,similarlytosurgeryforesophagealcancer.ForcT1cN0tumors,gastricresectioncanbemodifiedas followsaccordingtotumorlocation.– Pylorus-preservinggastrectomy(PPG) fortumorsin themiddleportionofthestomachwiththedistaltumor borderatleast4cmproximaltothepylorus.– Proximalgastrectomy forproximaltumorswheremore thanhalfofthedistalstomachcanbepreserved.
Segmentalgastrectomyandlocalresectionarestill regardedasinvestigationaltreatments.
2.3Lymphnodedissection
2.3.1Extentoflymphnodedissection
Theextentofsystematiclymphadenectomyisdefinedas followsaccordingtothetypeofgastrectomyindicated. Whenthelymphadenectomyperformeddoesnotcomply withtheDlevelcriteria(eitherwhenlymphnodesoutside therequirementfortheDcriteriaareresectedorwhen nodaldissectionisinsufficienttofulfillthecriteria),the lymphnodestationthathasbeendissectedoromitted
shouldbespecified,asinthefollowingexamples:D1 (?No.8a),D2(-No.10).Whenreportingthedatato constructaformaldatabase,onlytheDlevelthathasbeen completelyresectedshouldbeprovided.
2.3.1.1Totalgastrectomy
D0:LymphadenectomylessthanD1 D1:Nos.1–7 D1?:D1? Nos.8a,9,11p D2:D1 ? Nos.8a,9,10,11p,11d,12a.
Fortumorsinvadingtheesophagus,D1? includesNo. 1101,D2includesNos.19,20,110,and111.
4d 4sb
6 3
5 7
12a 9
1
2
4sa
8a 11p 11d 10
2.3.1.2Distalgastrectomy
Total gastrectomy
D0:LymphadenectomylessthanD1 D1:Nos.1,3,4sb,4d,5,6,7 D1?:D1? Nos.8a,9 D2:D1 ? Nos.8a,9,11p,12a.
4d 4sb
6 3
5 7
12a 9
1
8a 11p
Distal gastrectomy
1 No.110lymphnodes(lowerthoracicpara-esophagealnodes)in gastriccancerinvadingtheesophagusarethoseattachedtothelower partoftheesophagusthatisremovedtoobtainasufficientresection margin.
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