Incorporation of laparoscopic D2 dissection into the management of gastric adenocarcinoma (GCa) in a community-based setting.

Abstract

117 Background: A recent meta-analysis suggests that lymph node (LN) retrieval may be inferior when gastrectomy for GCa is performed laparoscopically rather than open. The purpose of this study was to examine the pathologic evaluation, postoperative morbidity and receipt of adjuvant treatment associated with adoption of D2 lymphadenectomy in a community setting. Methods: Routine D2 LN dissection was instituted as part of laparoscopic GCa resection at two community hospitals in Toronto in July 2008. Sequential cases up to Feb 2011 were identified and charts reviewed retrospectively. LN retrieval, margin status, morbidity, mortality and receipt of adjuvant treatment were examined. Results: Twenty-nine patients were identified; 69% were male and the median age was 69 (28-84). All patients underwent D2 lymphadenectomy, 10 with total gastrectomy (TG) and 19 with subtotal (STG). Pathologic evaluation showed that all patients underwent an R0 resection. Median number of LNs retrieved was 32 (15-62) and 93% of patients had adequate LN assessment according to AJCC 7 staging criteria. Sixty-five percent of patients had nodal metastases. There were 8 major complications in 7 patients including 3 post-operative deaths (10% mortality): one patient died in hospital from anastomotic leak and two after discharge from PE (1) and evisceration through the specimen extraction site (1). Four patients commenced neoadjuvant chemotherapy, but only 2 completed the planned pre-operative regimen. Ten additional patients started post-operative adjuvant chemo-radiotherapy, but only 5 completed it. Fifteen patients received no adjuvant treatment. Reasons for lack of adjuvant treatment were: early stage (n=4), medically unfit (2), post-operative death (2), patient declined (5) and early post-operative distant metastatic disease (2). Conclusions: Laparoscopic gastrectomy with D2 lymphadenectomy can be performed in a community setting with excellent margin status and LN retrieval results and complication rates comparable to those previously reported in prospective trials of open resection. Barriers to receipt/completion of adjuvant therapy in this setting should be explored.