[Barrett and stomach carcinoma: surgical guidelines]

The aim of surgical therapy of adenocarcinoma in Barrett's esophagus and gastric carcinoma is an R0 resection of the infiltrated organ including regional lymphadenectomy. In Barrett's carcinoma these requirements can be achieved by radical transhiatal subtotal esophagectomy and lymphadenectomy of the lower mediastinum and compartment I and II. In case of adenocarcinoma of the thoracic esophagus, a transthoracic en bloc esophagectomy is indicated because of the probability of mediastinal lymph node metastasis. In gastric cancer the criteria for the luminal extent of resection are localization, depths of infiltration, and histological type according to Laurén. In carcinoma of the antrum of intestinal type and stage T1, T2 (T3) and in distal T1-carcinoma of diffuse type a subtotal gastric resection is possible. All other carcinomas require total gastrectomy which, in case of infiltration of the cardia, should be extended to the distal esophagus. A local excision of gastric carcinoma in curative intention can only be performed in mucosal carcinoma (pT1a) of intestinal type. As several studies have shown an improvement of prognosis by D2-lymphadenectomy, especially in UICC-Stages II and IIIa, a D2 lymphadenectomy is suggested in order to achieve, aside from a better staging, a possible prognostic gain for special subgroups of patients with beginning lymph-node metastasis. Principle splenectomy in case of gastrectomy increases morbidity and is more disadvantageous concerning prognosis. Therefore, splenectomy only is suggested in case of proximal gastric carcinoma because of the special type of lymph-node metastasis.