Subtotal versus total gastrectomy for T3 adenocarcinoma of the antrum

Background. The role of subtotal or total gastrectomy in the treatment of advanced gastric cancer of the antrum with serosal invasion was investigated. Methods. The investigation involved 117 patients with a cancer of the lower third of the stomach invading the serosa (pT3) who underwent R0 resection with at least D2 lymphadenectomy between 1988 and 1998 at three different Italian centers. The choice of surgical procedure (40 total gastrectomies and 77 subtotal gastrectomies) was based on the preference of the surgeon; none of the patients underwent splenectomy. The Cox regression model was used to evaluate the prognostic significance of the type of surgery (subtotal versus total gastrectomy), controlling for age, sex, histology, nodal involvement, and surgical center. Results. The morbidity and mortality rates did not vary significantly according to the type of surgery. Patients undergoing subtotal gastrectomy presented a better disease-related survival than patients undergoing total gastrectomy (P = 0.011): the median survival times were, respectively, 38 months and 23 months, and the overall cumulative 5-year survival rates (95% confidence intervals [CI]) were, respectively, 36% (22%-50%) and 22% (11%-37%). On univariate analysis, the relative risk (RR) of disease-related death was 1.84 (1.14-2.97) after total gastrectomy, with respect to subtotal gastrectomy. This difference was blunted on multivariate analysis (RR, 1.66; 0.99-2.78): in the final model, only nodal metastasis was a significant prognostic factor, while type of surgery had a borderline significance (P = 0.057). Conclusion. Survival after subtotal gastrectomy is not lower than that after total gastrectomy in patients with tumor of the antrum invading the serosa.