D2 Lymphadenectomy In Patients Research Articles

Long-term oncologic outcome of D3 lymph node dissection for clinical stage 2/3 right-sided colon cancer.

To investigate oncologic outcomes including overall survival and disease-free survival depending on the extent of lymphadenectomy (D3 versus D2) by comparing D3 and D2 lymphadenectomy in patients with clinical stage 2/3 right colon cancer. Consecutive series of patients who underwent radical resection for right colon cancer at our three hospitals between January 2015 and June 2018 were retrospectively analyzed. Study cohorts were divided into two groups: D3 group and D2 group. Oncologic, pathologic, and perioperative outcomes of the two groups were compared. A total of 295 patients (167 in the D2 group and 128 in the D3 group) were included in this study. Patients' characteristics showed no significant difference between the two groups. The median number of harvested lymph nodes was significantly higher in the D3 group than in the D2 group. The rate of complications was not significantly different between the two groups except for chyle leakage, which was more frequent in the D3 group. Five-year disease-free survival was 90.2% (95% CI: 84.8-95.9%) in the D3 group, which was significantly (p = 0.028) higher than that (80.5%, 95% CI: 74-87.5%) in the D2 group. There was no significant difference in overall survival between the two groups. Our results indicate that D3 lymphadenectomy is associated with more favorable 5-year disease-free survival than D2 lymphadenectomy for patients with stage 2/3 right-sided colon cancer. D3 lymphadenectomy might improve oncologic outcomes in consideration of the recurrence rate.

Prognosis of Stage IV Gastric Cancer Patients

Aim. This study evaluated the survival of gastric cancer patients with metastasis to the hepatoduodenal, retropancreatic, mesenteric, and para-aortic lymph nodes. Materials and methods. We analyzed the survival rate of 435 gastric cancer patients who underwent operation from 2001 to 2010 at the Department of Surgery, Chonnam National University Hospital. There were 43, 25, 16, and 55 patients with metastasis to the hepatoduodenal, retropancreatic, mesenteric, and para-aortic nodes, respectively. Results. Based on tumor location, metastasis to the para-aortic lymph nodes was more common in upper-third cancer, and that to the hepatoduodenal lymph nodes was more common in lower-third cancer. The survival rate of patients with non-regional lymph node metastasis was better than that of patients with hepatic metastasis or peritoneal dissemination (p < 0.05). Conclusion. We recommend performing a more extended lymphadenectomy than a D2 lymphadenectomy in patients with advanced gastric cancer those having metastasis to the hepatoduodenal nodes.

Laparoscopic versus Open Total Gastrectomy for Locally Advanced Gastric Cancer: Short and Long-Term Results.

Laparoscopic gastrectomy for early gastric cancer is widely accepted and routinely performed. However, it is still debated whether the laparoscopic approach is a valid alternative to open gastrectomy in advanced gastric cancer (AGC). The aim of this study is to compare short-and long-term outcomes of laparoscopic (LG) and open (OG) total gastrectomy with D2 lymphadenectomy in patients with AGC. A retrospective comparative study was conducted on patients who underwent LG and OG for ACG between January 2015 and December 2021. Primary endpoints were the following: recurrence rate, 3-year disease-free survival, 3-year and 5-year overall survival. Univariate and multivariate analysis was conducted to compare variables influencing outcomes and survival. Ninety-two patients included: fifty-three OG and thirty-nine LG. No difference in morbidity and mortality. LG was associated with lower recurrence rates (OG 22.6% versus LG 12.8%, p = 0.048). No differences in 3-year and 5-year overall survival; 3-year disease-free survival was improved in the LG group on the univariate analysis but not after the multivariate one. LG was associated with longer operative time, lower blood loss and shorter hospital stay. Lymph node yield was higher in LG. LG for AGC seems to provide satisfactory clinical and oncological outcomes in medium volume centers, improved postoperative results and possibly lower recurrence rates.

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial. To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer. Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019. The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery. Total number of retrieved lymph nodes. Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery. Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy. ClinicalTrials.gov Identifier: NCT03050879.

Distal subtotal resection and gastrectomy in the treatment of patients with gastric cancer. A critical review of meta-analyses

The purpose of the work is to study the evidence base by comparing the results of distal subtotal resection and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer. Materials and methods. Three meta-analyses were selected during the systematic review process. Their validity assessment and critical analysis were carried out using the recommendations of the Cochrane community. Results. The greatest heterogeneity was noted in calculations of the frequency of postoperative complications. This indicator ranges from 1.1 % to 22 %. Postoperative mortality ranges from 0.6 % to 2.9 %. The overall five-year survival rate after gastrectomy is 49.6 %–53.9 %, after distal subtotal resection — 55.9 %–63.9 %. A large number of systematic biases in completed meta-analyses reduces the degree of reliability of the evidence base in this matter to the level 2 of evidence. Conclusion. Further evidence-based level 1 studies are needed to compare the results of distal subtotal resection and gastrectomy in patients with distal gastric cancer.

Enlightenment and reflection of splenic hilar lymph node dissection for advanced proximal gastric cancer

Splenic hilar lymph node (LN) is the difficulty and focus of perigastric LN dissection during radical gastrectomy for advanced proximal gastric cancer (APGC). Although the new edition of Japanese Gastric Cancer Treatment Guidelines excluded the splenic hilar LN from the D2 lymphadenectomy in patients with APGC, there are still few high-level evidences. Meanwhile, the guideline recommends that splenectomy is still necessary for patients with APGC involving the greater curvature. With the support of increasing evidences, the spleen-preserving splenic hilar LN dissection has been recognized by more and more scholars. Additionally, the technique of laparoscopy provides a new method for splenic hilar LN dissection. Our center proposed a new technique named Huang′s three-step maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy, which not only reduces the difficulty of operation, but also makes the technique easier to popularize and with a significance of minimally invasive effect. During the clinical practice, the dissection of LNs behind the splenic portal vessels is also one of the controversies. Therefore, the difficult technique of splenic hilar LN dissection not only requires us to make a technical exploration, but also requires us to explore precise indications, in order to avoid unnecessary operation in patients who do not require dissection of the No.10 LNs and to avoid missing the opportunity for radical surgery in high-risk patients because of the difficult techniques. Key words: Gastric neoplasms; Surgical procedure, operative; Splenic hilar lymph node; Lymphadenectomy; Laparoscopy

Distal subtotal gastrectomy and gastreectomy in surgical treatment of patients with gastric cancer: a systematic review and meta-analysis

Objective To analyze the randomized controlled trials (RCTs) devoted to distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer. Material and methods RCTs were searched in the electronic library, the Cochrane Community database, and PubMed database. A systematic review and meta-analysis were carried out in accordance with the recommendations of the Cochrane Community experts (Higgins et al. 2019). Mathematical calculations of a meta-analysis were made using RevMan 5.3 software package. Statistical criteria were calculated for relative risk (RR), hazard ratio (HR), 95% confidence interval (95% CI) and significance level (p). Results Seven primary RCTs were selected. A total number of 1463 surgical interventions with D2 lymphadenectomy were observed (805 patients underwent distal subtotal gastrectomy, 658 - gastrectomy). Postoperative mortality is significantly higher (6.5% and 2.6%) after gastrectomy compared to subtotal distal gastrectomy (RR 2.2, 95% CI 1.34-3.64, I2 0%, fixed effect model). Postoperative complications are also significantly more common (28% and 14%) after gastrectomy (RR 1.72, 95% CI 1.16-2.55, I2 heterogeneity 49%, random effect model). Differences in overall five-year survival after gastrectomy and subtotal distal resection (51.6% and 60.8%) are insignificant (HR 0.74, 95% CI 0.45-1.22, I2 90%, random effect model, general reverse inversion). Conclusion The choice of distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer is not regulated by evidence-based medicine. The boundaries of minimal surgical clearance from the tumor edge vary from 2.5 cm to 6 cm. An updated meta-analysis shows that postoperative mortality and morbidity are significantly higher after gastrectomy compared to distal subtotal gastrectomy while overall 5-year survival is similar.

Post-operative morbidity and mortality following D2 gastrectomy in a state funded tertiary care centre in South India

Background: Radical gastrectomy with D2 lymphadenectomy is a surgery with significant post-operative morbidity. Pre-operative malnutrition portends a poor post-operative outcome following any gastrointestinal surgery in general. This study aims at finding out whether it is feasible to perform D2 lymphadenectomy in patients presenting with significant malnutrition.Methods: In this single centre study, we retrospectively analysed the post-operative morbidity and mortality data of 46 patients who underwent D2 gastrectomy for operable gastric cancer between October 2016 to April 2019. Almost all the patients who were analysed fulfilled at least one criterion for malnutrition.Results: The morbidity rate was 39.1% and the mortality rate was 6.5% which were a little high when compared to results from other Indian centres but not prohibitive, considering the nutritional status of these patients. Almost 50% of these patients were able to complete adjuvant chemotherapy.Conclusions: D2 gastrectomy can be performed in patients with poor pre-operative nutritional status. If perioperative nutritional requirements are taken care of promptly, the post-operative outcomes can be better.

Short-Term Outcome in Patients Undergoing Gastrectomy with D2 Lymphadenectomy for Carcinoma Stomach.

The safety and feasibility of D2 lymphadenectomy for gastric cancer in Western patients have been shown by Italian Gastric Cancer Study Group (IGCSG). In our center at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), we have been doing D1 lymphadenectomy all these years. Hence, this study was taken up to assess the feasibility of gastrectomy with D2 lymphadenectomy in patients with gastric cancer at JIPMER, Puducherry, India. Of the 148 carcinoma stomach patients explored, a total of 52 patients (35.13%) underwent resection with D1 (34 patients) or D2 (18 patients) lymphadenectomy, who formed the study groups. Patients were admitted and investigated by upper gastrointestinal endoscopy (UGIE) and other appropriate investigations including contrast-enhanced computed tomography (CECT) of the abdomen. Eligible patients had no serious comorbid cardiorespiratory disease that would preclude a safe D2 procedure. Two-third of the patients in both the groups belonged to the 50-75 age group. The mean number of nodes dissected was 6.44±5.3 in the gastrectomy with D1 lymphadenectomy group versus 21.67±5.3 in the gastrectomy with D2 lymphadenectomy group. There was no difference in the intraoperative blood loss, the number of units of blood transfused and the duration of surgery between D1 and D2 lymphadenectomy in our study. There was no difference between the postoperative stay and overall stay between the D1 and D2 lymphadenectomy. There was no significant difference between the overall morbidity and mortality or when the surgical complications were analysed individually. Intraoperative blood loss, the number of units of blood required for transfusion and the duration of surgery were not increased in D2 lymphadenectomy. The number of lymph nodes harvested was significantly more in D2 lymphadenectomy that resulted in a better staging. Postoperative morbidity or mortality in patients undergoing D2 lymphadenectomy was the same as in D1 lymphadenectomy. Hence, gastrectomy with D2 lymphadenectomy could be done safely.

Role of frailty and nutritional status in predicting complications following total gastrectomy with D2 lymphadenectomy in patients with gastric cancer: a prospective study.

This study was performed to determine the association of frailty and nutritional status with postoperative complications after total gastrectomy (TG) with D2 lymphadenectomy in patients with gastric cancer. Patients undergoing TG with D2 lymphadenectomy for gastric cancer between August 2014 and February 2016 were enrolled. Frailty was evaluated by sarcopenia which was diagnosed by a combination of third lumbar vertebra muscle index (L3 MI), handgrip strength, and 6-m usual gait speed. Nutritional status was evaluated by the nutritional risk screening 2002 (NRS 2002) score. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. A total of 158 patients were analyzed, and 27.2% developed complications within 30days of surgery. One patient died within 30days of the operation. In the univariate analyses, NRS 2002 score ≥3 (OR = 2.468, P = 0.012), sarcopenia (OR = 2.764, P = 0.008), and tumor located at the cardia (OR = 2.072, P = 0.046) were associated with the postoperative complications. Multivariable analysis revealed that sarcopenia (OR = 3.084, P = 0.005) and tumor located at the cardia (OR = 2.347, P = 0.026) were independent predictors of postoperative complications. This study showed a significant relationship between postoperative complications and geriatric frailty using sarcopenia in patients with gastric cancer after TG with D2 lymphadenectomy. Frailty should be integrated into preoperative risk assessment and may have implications in preoperative decisionmaking.

Management of high-output chylous ascites after D2-lymphadenectomy in patients with gastric cancer: a multi-center study

This study aimed to propose treatment strategies for high-output chylous ascites (CA) developed after gastric cancer surgery. The data of patients with CA after gastric cancer surgery in three high volume Training and Research Hospitals between 2005 and 2015 were retrospectively evaluated. Nine patients out of 436 gastrectomies were detected with CA. The mean amount of daily fistula output was 939 mL. Treatment consisted of cessation of oral feeding, total parenteral nutrition (TPN), somatostatin analogs administration, clamping and/or removal of the drainage tube, diuretic administration and diet therapy with medium-chain triglycerides (MCTs) alone or in combination. The mean fistula closure time and length of hospital stay were 23 and 24 days respectively. Hemopneumothorax developed during right subclavian vein catheterisation for TPN implementation in one patient. There was no mortality. Combined cessation of oral feeding and TPN are usually used for treatment of CA as first-line treatment. However, TPN is no harmless. Although our data are limited they do allow us to conclude that diet with MCT's may use for medical treatment of CA as first-line.

Prognostic significance of distal subtotal gastrectomy with standard D2 and extended D2 lymphadenectomy for locally advanced gastric cancer

This study was conducted to investigate prognosis and survival of patients undergoing distal subtotal gastrectomy with D2 and D2+ lymphadenectomy for patients with locally advanced gastric cancer. Overall survival rates of 416 patients with locally advanced gastric cancer were compared between D2 and D2+ lymphadenectomy. Univariate analysis and multivariate analysis was used to identify significant prognostic factors correlated with LN metastasis and prognosis. Univariate analysis identified tumor size, lymphatic vessel invasion, pT stage, pN stage, TNM stage, locoregional recurrence, and distant recurrence, to significantly correlate with prognosis; Tumor size, LVI, and pT stage were identified as independent factors correlating with LN metastasis. Multivariate analysis demonstrated that tumor size, pT stage, pN stage, locoregional recurrence, and distant recurrence were independent prognostic factors; Tumor size and pT stage were independent prognostic factors predicting LN metastasis. When comparing 5-year survival rates of patients who underwent D2 and D2+ lymphadenectomy, as stratified by pT stage and pN stage, a significant difference was found in pN3 patients, but not for pT2–4 and pN0–2 patients, or the patient cohort as a whole. In conclusion, D2 lymphadenectomy for patients with locally advanced gastric cancer undergoing distal subtotal gastrectomy was recommended, especially in eastern Asia.

Proximal gastric cancer: lymph node metastatic patterns according to different T stages dictate surgical approach

Background As a common form of gastric cancer migration, lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer. Surgery is the fundamental curative option for gastric cancer that varies depending on different stages. The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer. Methods In our retrospective study, the data of 328 patients of proximal gastric cancer with different T stages were analyzed. By comparing the differences of lymph node metastatic rate and ratio, we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes. Also, we were especially interested in the differences in survival rates between patients with and without No. 5 and 6 group metastasis with the same TNM stage. Results The overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4% and 23.3%, respectively. The tumors of different T stages were statistically significant in size and differentiation degree (P &lt;0.05), multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer (RR, 12.025; 95% CI, 2.326 to 62.157; P=0.003). The overall survival rate of patients with No. 5, 6 group lymph node metastasis and those without was significantly different, but the differences in survival rates between patients with and without No. 5 and 6 group metastasis with the same TNM stage were not statistically significant. Conclusions Different T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis. D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare. Therefore the range of the lymph node dissection in radical gastrectomy for early gastric cancer was considered reasonable. Moreover, to meet the requirements of the lymph node dissection, total gastrectomy plus D2 lymphadenectomy or more are supposed to be applied for the advanced proximal gastric cancer patients. Precise T staging largely determines the range of gastrectomy and lymphadenectomy.

Laparoscopic gastrectomy: advances enable wide clinical application

The current trend is toward laparoscopic gastrectomy. Although no level 1 randomized evidence or cost-effective analysis exists to show the superiority of laparoscopic gastrectomy over open gastrectomy, the indications and use of laparoscopic gastrectomy in clinical practice have been expanded beyond the carefully selected older patients described in the report by Singh et al. [1] in a recent issue of this journal. A current published report shows the clinical use of laparoscopic gastrectomy for early-stage gastric cancer with a trend also toward locally advanced carcinoma [2] and for carriers of CDH1 mutations to prevent hereditary diffuse gastric cancer (HDGC) syndrome [3, 4]. As laparoscopic gastrectomy currently is being applied in an environment of strong competition within various countries and among specialized institutions worldwide to attract patients, what are the benefits and risks of the laparoscopic approach? Laparoscopic gastrectomy is unlikely to improve survival or cure rates for gastric cancer patients, but evidence supports its superiority over open gastrectomy in improving quality of life (QOL). Singh et al. [1] report on a series of 20 elderly patients who underwent laparoscopic gastrectomy procedures. These patients were at risk for high morbidity and mortality with the use of conventional gastric surgery. There were no perioperative deaths. Four patients experienced significant complications, with two patients requiring reoperation. Extended D2 lymphadenectomy should be considered for patients with gastric cancer. Lee et al. [2] recently reported on laparoscopically assisted distal gastrectomy (LADG) with extended D2 lymphadenectomy for patients with early-stages gastric cancer. Two surgeons performed the procedure for 64 patients over an 8-month period, with a postoperative complication rate of only 3% and no deaths. The high-volume surgeons who performed the procedures are the key for these excellent results. The D2 lymphadenectomy compliance rate for the LADG was similar to that for open gastrectomy. Should D2 gastrectomy be the standard procedure for localized gastric cancer? Despite a long-term debate in the West [5–8], D2 surgery is a standard approach in Eastern countries [9, 10]. High cure rates have been reported with D2 surgery for early-stage gastric malignant tumors [9, 11, 12], but there still is no level 1 evidence in favor of D2 surgery [13]. The current status of the treatment for localized gastric cancer [14] includes either D2 surgery performed by experienced surgeons [15, 16] or, if this criterion is not met, limited D1 surgery plus chemoradiotherapy [17, 18]. With the randomized evidence for the safety and efficacy of the laparoscopic approach for colorectal cancer, laparoscopic gastrectomy has been growing rapidly. The advantages of laparoscopic over open gastrectomy include quicker return of gastrointestinal function, faster ambulation, and earlier discharge from the hospital, although the operating time is longer than for open gastrectomy [19]. Another important field of laparoscopic approach is the primary prevention of gastric cancer for individuals with familial susceptibility to the disease. This patient-friendly technique may increase the number of health individuals who are carriers of germ-line mutations in the CDH1 (Ecadherin) gene. For these carriers, who face a very high T. Liakakos (&) Third Surgical Department, University of Athens, Athens, Greece e-mail: theodlia@otenet.gr

Short-term Surgical Outcomes after Laparoscopic D2 Lymphadenectomy in Patients with Distal Gastric Cancer

Short-term Surgical Outcomes after Laparoscopic D2 Lymphadenectomy in Patients with Distal Gastric Cancer

Does endoscopic ultrasound staging already allow individual treatment regimens in gastric cancer

The aim of our study was to evaluate the accuracy of preoperative TNM staging with endoscopic ultrasound (EUS) in gastric cancer patients in comparison with the pathohistological stage of the resected specimen, and to determine the possible implications of EUS for individualized treatment of gastric cancer patients at our institution. The study included 82 patients operated for resectable gastric cancer between January 1(st) 2001 and July 1(st) 2003 at the Maribor Teaching Hospital Department of Abdominal and General Surgery. The EUS stage was assessed preoperatively at the Endoscopical Unit, and the pathohistological stage in the resected specimen was determined postoperatively at the Department of Pathologic Morphology according to recommended standards. Comparison of EUS and pathohistological assessments revealed accuracy of EUS staging for locoregional tumor infiltration (category T) in 68% of patients. The accuracy of EUS staging was 68% for T1, 69% for T2, 69% for T3 and 60% for T4. Lymph nodes (category N) were correctly staged with EUS in 57% of cases. The EUS stage was correct for lymph nodes with no metastases (N-) in 40% of cases, and for lymph nodes with metastases (N+) in 90%. There was no significant difference in accuracy of EUS staging with regard to tumor site (P = 0.768) or tumor size (P = 0.766). According to our results the accuracy of EUS staging matched pathohistological staging with regard to tumor infiltration and lymph node stage in 68% and 57% of cases respectively. Underestimation of the final T2 and T3 stages as T1 stage by EUS presents a problem regarding the consistency of EUS examination at our institution, particularly with respect to individual treatment for early gastric cancer. The present uncertainty in EUS stage reliability makes it necessary to have a strategy of radical resection with D2 lymphadenectomy in patients within EUS stages T1-T3, with additional CT examinations in more advanced EUS stages in order to visualize the circumstances of tumor growth. Nevertheless, EUS provides an opportunity for the surgeon to gain more insight into the loco-regional circumstances of the gastric tumor process. For development of individual modes of treatment based on EUS staging, a more reliable assessment of EUS stage is mandatory.

Is D2 lymph node dissection necessary for early gastric cancer?

The objective of this study was to clarify a survival benefit of D2 lymphadenectomy in patients with early gastric carcinoma (GC). A retrospective study was conducted to examine the incidence of metastasis to level 2 lymph nodes, the causes of postoperative death, and the mode of recurrence in 1041 patients who had early GC and underwent D2 lymphadenectomy with curative intent. Postoperative mortality occurred in 129 (12.4%) of 1041 patients, 6 patients (.6%) died of surgical complications, 108 (10.2%) died of diseases other than cancer, and 16 (1.5%) died of recurrence. Hematogenous metastasis was the major mode of recurrence (56.3% of recurrences). The incidence of metastasis to level 2 nodes was 2.5% (26 of 1041 patients, 18 of whom were alive). Thus, the estimated survival benefit of radical lymphadenectomy for patients with early GC was calculated to be 1.7% (18 of 1041 patients). D2 lymphadenectomy in patients with early GC had little survival benefit because (1) metastasis to level 2 nodes was rare, (2) most causes of death were not related to the tumor, and (3) more than half the recurrences were hematogenous. Use of radical lymphadenectomy for early GC should be limited.

Survival benefit of D2 lympadenectomy in patients with gastric adenocarcinoma.

A definite resolution to the controversy on the optimal extension of lymph node dissection (LND) in gastric cancer has not been achieved. Surgical morbidity and survival of D1 and D2 LND are compared by multivariate analysis. A retrospective cohort study of 219 patients with gastric cancer and curative resection performed according to Japanese rules. D1 dissection was performed in 106 cases and D2 in 113. The logistic regression model was used to define risk factors for surgical morbidity and the Cox model to determine prognostic factors. Surgical morbidity occurs in 16.9% and 19.5% in D1 and D2 LND, respectively (P = .7). The morbidity determinants were operation blood loss, splenectomy, pancreaticosplenectomy, antrum location, low serum albumin, total gastrectomy, and metastatic nodal ratio (P < .0001), but not D2 LND. Five-year survival was 35.1% for D1 and 64% for D2 LND (P < .039). The prognostic factors were T stage, N stage, serum albumin level, total gastrectomy, D2 LND, and comorbidity (P < .0001). The increment of surgical morbidity and mortality rates attributed to D2 LND is largely caused by the effect of splenectomy and pancreaticosplenectomy. A significant survival benefit because of D2 LND was found. The results support the value of extended LND in the surgical treatment of gastric cancer.

Impact of D2 Lymphadenectomy on Morbidity and Long-Term Survival in Patients with Gastric Cancer

The impact of lymphadenectomy in the surgical treatment of carcinoma of the upper gastrointestinal tract remains controversial. Eastern, especially Japanese centers advocate extended forms of lymphadenectomy on the basis of their excellent results, whereas many Western authors state that its benefits do not outweigh the risks of higher operative morbidity and mortality. In our department we have been favoring systematic lymphadenectomy in gastrointestinal surgery of malignant tumors since 1978. Out of 1,500 subtotal and total gastrectomies, which have been performed in our department since 1968, there were 440 resections with a D2 lymphadenectomy in patients with gastric carcinoma between 1986 and 1994. Lymphadenectomy resulted in a specific morbidity of 3.6%. As compared to the era before systematic lymphadenectomy was performed, patient survival improved especially in UICC stage II and IIIA with reduced morbidity. On the background of this evaluation, our therapeutic concept for the treatment of gastric cancer with special regard to the extent of lymphadenectomy is presented.