D2 Procedure Research Articles

D3 Lymphadenectomy for Right Colon Cancer: Feasibility, Safety, and Early Outcomes from a District General Hospital in London.

Observational studies suggest a link between D3 lymphadenectomy and improved disease-free survival in some colon cancer patients. However, high-quality randomized controlled trials are needed to confirm its advantage over D2 lymphadenectomy. Concerns about potential complications with D3 have limited its use outside of Japan. This study examines short-term outcomes following D3 lymphadenectomy for right-sided colon cancer compared to the established D2 procedure. Materials and Methods: This retrospective cohort single center study analyzed data on patients with right-sided colon cancer who underwent curative surgery within our healthcare trust between January 2019 and November 2022. Only patients treated by surgeons who routinely perform D3 lymphadenectomy were included for a homogenous study population. The decision to perform D3 was at the discretion of the operating surgeon. Data were collected from both paper charts and electronic medical records. Non-parametric statistical tests were used for data analysis. Results: A total of 214 patients met the criteria, with 170 undergoing D2 lymphadenectomy and 44 undergoing D3 lymphadenectomy. There were no significant differences between the groups in terms of surgery duration, blood loss, postoperative hemoglobin levels, or transfusion needs. Interestingly, the D3 group had a lower complication rate (25%) compared to the D2 group (41.2%). However, the D3 group also had a higher rate of lymph node spread (45.5% vs. 30.6% for D2) and more lymph nodes removed (19 [16, 25] vs. 23 [18, 28]). Importantly, both groups achieved similar complete tumour removal rates. Conclusions: This study suggests D3 lymphadenectomy for right-sided colon cancer might be safe with potential benefits, especially for younger patients with suspected lymph node involvement. However, the limited sample size necessitates larger, randomized trials to confirm these findings and potentially establish D3 lymphadenectomy as standard care.

Convenient method to improve efficiency of lymph node examination after gastrectomy with D2 lymphadenectomy for gastric cancer

BackgroundThe D2 procedure has been accepted as the standard treatment for advanced gastric cancer (GC) in East Asia. Determination of the number of lymph nodes (LNs) after gastrectomy may influence the pathological stage assessment of lymph node metastasis, significantly influencing prognostic evaluations and formulation of chemotherapy regimens.MethodsBetween January 2020 and January 2022, the medical files of 312 patients with clinical stage T0-4aN0-3M0 gastric cancer were reviewed retrospectively, and the patients were assigned to the normal group (lymph nodes were examined roughly), manual group (lymph nodes were manually examined meticulously), and device group (lymph nodes were examined by device). The clinical and pathologic characteristics, number of lymph nodes harvested, and the time required for lymph node examination was compared.ResultsA total of 312 gastric cancer patients (mean age 65.8 ± 10.3 years, 85 females and 227 males) underwent gastrectomy with curative intent at our department. Sex, age, body mass index (BMI), tumor size, clinical TNM stage, and pathologic TNM stage in the three groups showed no statistically significant differences (P > 0.05). The mean number of harvested lymph nodes in the normal, manual, and device group was 24.2, 36.6 and 35.2, respectively, which showed significant differences (P < 0.0001). The mean number of positive lymph nodes in the normal, manual, and device group was 3.5, 3.9 and 3.9, respectively (P = 0.99). The mean time consumption in device group was 15 min while the time consumption in manual group was 52.3 min, which showed a significant difference (P < 0.0001).ConclusionThis improved lymph node examination method offers a simple approach that is worth promoting, and it can improve the number of harvested lymph nodes efficiently.

Short-term outcomes of D2 lymphadenectomy plus complete mesogastric excision for gastric cancer: a propensity score matching analysis.

Our previous study has demonstrated the surgical advantages of D2 lymphadenectomy plus complete mesogastric excision (D2 + CME) in gastric cancer surgery. To further verify the safety of D2 + CME procedure, we conducted this large-scale, observational cohort study and applied propensity score matching (PSM) approach to compare D2 + CME with conventional D2 in terms of short-term outcomes in gastric cancer patients. Data on 855 patients from Tongji Hospital who underwent laparoscopic-assisted distal gastrectomy (LADG) with R0 resection (496 in the conventional D2 cohort and 359 in the D2 + CME cohort) between Dec 12, 2013 and Dec 28, 2017 were retrieved from prospectively maintained clinical database. After PSM analysis at a 1:1 ratio, each cohort included 219-matched patients. Short-term outcomes, including surgical results, morbidity, and mortality within 30days after the operation, were collected and analyzed. In this large-scale, observational cohort study based on PSM analysis, the D2 + CME procedure showed less intra-laparoscopic blood loss, more lymph node harvest, and faster postoperative flatus than the conventional D2 procedure. However, both the overall and severe postoperative adverse events (Clavien-Dindo classification grade ≥ III a) seemed comparable between two cohorts. The present study showed that D2 + CME was associated with better short-term outcomes than conventional D2 dissection for patients with resectable gastric cancer.

D2 dissection improves disease-specific survival in advanced gastric cancer patients: 15-year follow-up results of the Italian Gastric Cancer Study Group D1 versus D2 randomised controlled trial

BackgroundThe extended lymphadenectomy (D2) was recently introduced in several guidelines as the optimal treatment for gastric cancer, based only on the 15-year follow-up results of the Dutch randomised trial, while the British Medical Research Council (MRC) study failed to demonstrate a survival benefit over the more limited D1 dissection. The Italian Gastric Cancer Study Group randomised controlled trial (RCT) was also undertaken to compare D1 versus D2 gastrectomy, and a tendency to improve survival in patients with advanced resectable disease (pT > 1N+) was documented despite negative results in the entire patient population. Now we present the 15-year follow-up results of survival and gastric cancer-related mortality. MethodsBetween June 1998 and December 2006, eligible patients with gastric cancer who signed the informed consent were randomised at 5 centres to either D1 or D2 gastrectomy. Intraoperative randomisation was implemented centrally by phone call. Primary outcome was overall survival (OS); secondary end-points were disease-specific survival, postoperative morbidity and mortality. Analyses were by intention to treat. Strict quality control measures for surgery, lymph node removal, pathology and patient follow-up were implemented and monitored. Registration number: ISRCTN11154654 (http://www.controlled-trials.com). FindingsA total of 267 eligible patients were assigned to either D1 (133 patients) or D2 (134) procedure. Median follow-up time was 16.76 years. Analyses were done both in overall patient population and in pT > 1N+. One hundred patients (38.5) were alive without recurrence. OS and disease-specific survival (DSS) were very high in both arms. In overall population, they were not different between D1 and D2 arm (51.3% vs. 46.8% and 65% vs. 67% respectively, p = 0.31 and p = 0.94). DSS was significantly higher after D2 in pT > 1N+ patients (29.4% vs. 51.4%, p = 0.035). OS and DSS were better after D1 in patients older than 70 years (p = 0.003 and p = 0.006). DSS was higher after D1 also in early stages (p = 0.01). InterpretationAfter 15-year follow up, despite no relevant difference in overall population, DSS and gastric cancer-related mortality of patients with advanced disease and lymph node metastases are improved by D2 procedure. Further data available from this trial suggest that D1 procedure should be preferably used in older patients and in early disease. As accurate detection of advanced diseases can be currently provided by adequate preoperative workup in referral centres, D2 procedure should be recommended in these cases. FundingPiedmont Regional fund for Finalized Healthy Research Project, Application 2003 for data collection.

Complete Mesogastric Excision for Locally Advanced Gastric Cancer: Safety and Efficacy Analysis of a Randomized Clinical Trial

Background: Implementation of complete mesogastric excision in gastric cancer surgery, named D2 lymphadenectomy plus complete mesogastric excision (D2+CME), has been recently proposed as an optimal procedure. However, the safety and efficacy of D2+CME remain uncertain. Methods: A prospective, randomized, parallel-controlled trial was conducted at a tertiary referral teaching hospital. Participants were randomized to undergo either D2+CME or conventional D2 procedure. Results: 338 patients were included in the modified intention-to-treat analysis, which comprised 169 patients (102 men and 67 women; mean [SD] age, 54•8 [9•5] years) in D2+CME group and 169 patients (111 men and 58 women; mean [SD] age, 54•5 [9•3] years) in D2 group. Patients in D2+CME group showed less intraoperative blood loss (median [IQR]; 15 • 0 [23 • 0] ml in D2+CME vs. 37 • 0 [33 • 5] ml in D2, p<0 • 0001), more lymph node harvesting (median [IQR]; 34 [16] lymph nodes in D2+CME vs. 27 [13] lymph nodes in D2, p<0•0001) and earlier postoperative flatus (p=0•009) than those in D2 group. The overall postoperative complication rate was comparable between two groups (20•1% in D2+CME vs. 16•0% in D2, p=0•322), however, patients in D2+CME group were less likely to have severe complications (Clavien-Dindo Classification grade ≥IIIa: 4 in D2+CME vs. 9 in D2, p=0•041). Conclusion: D2+CME is associated with better short-term outcomes and surgical safety than conventional D2 dissection for patients with advanced gastric cancer. Trial Registration: ClinicalTrials.gov; NCT01978444

Mesogastrium theory of D2 lymphadenectomy for advanced gastric cancer: cogitation and skills

D2 lymphadenectomy combined with complete mesentery excision (CME) for advanced gastric cancer in recent years was a hotspot issue in China, while its safety and effectiveness have been proved. According to the Membrane anatomy of the stomach, both surgical approach and mesogastrium interval is particularly important in Laparoscopic radical gastrectomy. We summarized and shared the following clinical experience for medical colleagues. (1) Lymph nodes of right abdominal aorta-No.7,8,9,12-should be resection as an indivisible whole. This integrity tissue above the portal vein was supposed to the end of the dorsal mesentery of stomach and the continuation of Gerota fascia. (2) No.10 (splenic hilar lymph nodes) lymphadenectomy: The surgical approach enters the Gerota fascia between the left gastric artery(LGA) and the left alongside the splenic artery. When the extent of lymphadenectomy performed to cardia and upper margin of the spleen, then the ultrasonic scalpel should excise the lymph node along the splenic artery to the splenic hilum. (3) Esophagogastric junctional cancer: There is no consensus over the type of resection and the extent of lymphadenectomy that could be a standard of care for this category.While we recommended that paraesophageal lymph node dissection and digestive tract reconstruction should be completed in 3D laparoscopy vision. (4) Infracardiac bursa(ICB): Intentional entry into the ICB provides surgeons with a landmark to identify the location of the pleura, and inferior vena cava. (5)The application of endoscopic aspirator with flushing and electrocautery. The CME concept of gastric cancer emphasizes the membrane anatomy theory rather than the regional lymph node. The precision and homogeneity of the D2 procedure therapy of gastric cancer depend on complete mesentery excision, standard the surgical process, or approach. Only in this way can we find the avascular gaps easily and perfectly cover the extent of lymph node dissection required for the D2 procedure.

Complete Mesogastric Excision Compared with Conventional D2 in Laparoscopic Gastrectomy for Locally Advanced Gastric Cancer: Safety and Efficacy Analysis of a Randomized Clinical Trial

IMPORTANCE: Implementation of complete mesogastric excision in gastric cancer surgery, named D2 lymphadenectomy plus complete mesogastric excision (D2+CME), was proposed as a novel optimal procedure. However, the safety and efficacy of D2+CME remain uncertain. OBJECTIVE: To compare short-term outcomes of patients with advanced gastric cancer after D2+CME or conventional D2 in laparoscopic gastrectomy. DESIGN, SETTING, AND PARTICIPANTS: Between September 2014 and June 2018, a prospective, randomized, parallel-controlled trial was conducted at a tertiary referral teaching hospital (Department of Gastrointestinal Surgery, Tongji Hospital, Wuhan, China). Patients between 18 to 75 years of age with locally advanced gastric cancer (cT2-4a,N0/+,M0) were enrolled and randomized. The surgical outcomes and postoperative data were compared between the groups in a modified intention-to-treat (mITT) analysis. INTERVENTIONS: Participants were randomized to undergo either D2+CME (n=243) or conventional D2 (n=243) procedure. MAIN OUTCOMES AND MEASURES: The primary end point was 3-year disease-free survival rate. The current study presented surgical outcomes, 30-day postoperative morbidity and mortality, postoperative recovery indexes. RESULTS: In total, 486 participants were randomized in this study. Among them, 243 were assigned to D2 group and 243 were assigned to D2+CME group. After postsurgical exclusions, 338 patients were included in the modified intention-to-treat analysis, which comprised 169 patients (111 men and 58 women; mean [SD] age, 54•5 [9•3] years) in the D2 group and 169 patients (102 men and 67 women; mean [SD] age, 54•8 [9•5] years) in the D2+CME group. Patients in D2+CME group showed less intraoperative blood loss (median [IQR]; 15•0 [23•0] ml in D2+CME vs. 37•0 [33•5] ml in D2, p<0•0001), more lymph node harvesting (median [IQR]; 34 [16] lymph nodes in D2+CME vs. 27 [13] lymph nodes in D2, p<0•0001) and earlier postoperative flatus (p=0•009) than those in D2 group. The overall postoperative complication rate was comparable between the two groups (20•1% in D2+CME vs. 16•0% in D2, p=0•322), however, patients in D2+CME group were less likely to have severe complications (Clavien-Dindo Classification grade ≥IIIa: 4 in D2+CME vs. 9 in D2, p=0•041). No mortality occurred in either group. CONCLUSION: D2+CME is associated with advantages in intraoperative blood loss, lymph nodes harvest and postoperative flatus duration, and could provide better surgical safety than conventional D2 in laparoscopic gastrectomy. TRIAL REGISTRATION: ClinicalTrials.gov; NCT01978444 FUNDING STATEMENT: This work was supported by grants from the National Natural Science Foundation of China, Grant numbers: 81171927, 81372324, 81874185. DECLARATION OF INTERESTS: The authors have no conflicts of interest to disclose. ETHICS APPROVAL STATEMENT: The study was approved by the Tongji Hospital Ethics Committee (TJ-C20130811). All patients signed an informed consent document to participate in this study.

Significance of nodal dissection and nodal positivity in gastric cancer.

Lymphadenectomy is a central component of surgery for gastric cancer. However, controversies over the optimal extent of lymphadenectomy in gastric cancer surgery have persisted for several decades. In Eastern countries where the incidence of gastric cancer is high, surgeons have performed extensive lymphadenectomy (D2 lymphadenectomy) with low morbidity and mortality, while most Western surgeons have advocated for more limited lymphadenectomies according to the results of Dutch trial and MRC trial. Initially, these trials had failed to show survival benefit of D2 procedure and instead, found pancreaticosplenectomy performed as part of the D2 procedure associated with high incidence of morbidity and mortality. Subsequently, superiority of D2 lymphadenectomy on survival was demonstrated based on updated results. Moreover, spleen and pancreas preserving D2 lymphadenectomy are being performed safely in Western countries. Today, there is an international consensus on performing D2 lymphadenectomy as the standard procedure for advanced gastric cancer and is widely accepted as the standard procedure for gastric cancer surgery. The significance of the extent of lymphadenectomy is intimately associated with the prognostic importance of nodal metastases as the most powerful indicator of recurrence and survival for patients after curative gastrectomy. Maruyama computer program could be used to estimate the risk of lymph node metastasis in each nodal station. The Maruyama Index could be used to assess the adequacy of lymphadenectomy in gastric cancer. Positive lymph node ratio is calculated as the ratio of positive lymph nodes to all harvested lymph nodes, which might be a more precise predictor of prognosis than the absolute number of positive lymph nodes. While D2 lymphadenectomy enables the accurate staging of the disease, reduces the incidence of locoregional recurrences and thus contribute to an improved overall survival; performing lymphadenectomy beyond D2 is unlikely to improve survival. Therapeutic D2+ lymphadenectomy for advanced gastric cancer requires further evaluations, especially for patients receiving neo-adjuvant or conversion treatments.

Morbidity and mortality of laparoscopic D2+CME versus conventional D2 procedure for locally advanced gastric adenocarcinoma (NCT01978444)

Morbidity and mortality of laparoscopic D2+CME versus conventional D2 procedure for locally advanced gastric adenocarcinoma (NCT01978444)

Comparison of laparoscopic versus open gastrectomy with D2 lymph node dissection for advanced gastric cancer: A meta-analysis

For many decades, D2 procedure has been accepted in the far-east as the standard treatment for both early (EGC) and advanced gastric cancer (AGC). In case of AGC, the debate on the extent of nodal dissection has been open for many years in order to highlight the safety and efficacy of treatment, hence this study.&#x0D; A comprehensive literature research was performed in PubMed to identify studies that compared laparoscopic- assisted gastrectomy (LAG) and open gastrectomy (OG) with D2 lymph node dissection (D2-LND) for treatment of AGC for the last five years. Data of interest were checked and subjected to meta-analysis with RevMan 5.3 software. The pooled risk ratios (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI) were calculated.&#x0D; Overall, 19 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD -2.31; 95% CI -4.09 to -0.53; P = 0.01), less blood loss (WMD -120.49; 95% CI -174.27 to -66.71; P &lt; 0.01), faster bowel recovery (WMD -0.55; 95% CI -0.86 to -0.24; P ˂ 0.01) and earlier ambulation (WMD -0.75; 95% CI -1.38 to -0.11; P = 0.02). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.94, 95% CI, -2.95 to 1.06; P=0.36), a lower complication rate [odds ratio (OR)=0.80; 95%CI, 0.68-0.97; P=0.02], and overall survival (OS) and disease-free survival (DFS) comparable to OG.&#x0D; In conclusion, for AGCs both techniques (LAG and OG) appeared comparable in short- and long-term results. More time was needed to perform LAG; nonetheless, it had some advantages in achieving faster postoperative recovery over OG. In order to clarify this controversial issue ongoing trials and future studies are needed.

Practical membrane anatomy of en bloc mesogastrium excision in lymph node dissection of gastric cancer

Gastric cancer is a common malignant tumor of digestive system. D2 procedure is recognized as the standard operation for advanced gastric cancer at present. However, controversies still exist in the standardization and quality control of surgical procedures. Total mesorectal excision (TME) and complete mesocolic excision (CME) based on the membrane anatomy perfectly solve these problems in the treatment for colorectal cancer. However, the complexity of mesogastrium determines that TME and CME cannot be easily transplanted to the treatment of gastric cancer. The practical membrane anatomy in gastric cancer surgery is just emerging and its impact on the treatment of gastric cancer is immeasurable. By reviewing the evolution and embryonic development of digestive system, and combining with actual operation, this paper analyzes and redefines several key issues such as traditional Toldt space, Gerota fascia and complete mesenteric excision. On this basis, we propose a novel and feasible surgical procedure named regional en bloc mesogastrium excision (rEME) for distal gastric cancer. The concept of en bloc mesogastrium excision (EME) based on membrane anatomy may have some influences on the lymph node grouping from the 'Japanese Classification of Gastric Carcinoma'. Performance of EME may reduce the controversies about the group of lymph nodes and their borders. EME in the infra-pyloric region weakens the significance of subdivision of No.6 lymph nodes into No.6a, No.6v and No.6i. More studies are needed in the construction of a mature theoretical system for practical membrane anatomy in gastric surgery.

The Precised Management of Surgical Treatment for Gastric Cancer: Interpretation of the 5th edition of Japanese Gastric Cancer Treatment Guideline and the 15th edition of Japanese Classification for Gastric Cancer

The 8(th) UICC gastric cancer TNM classification has international view since it was based on the follow-up data from 57 institutes of 15 countries. The number of examined lymph nodes is a determining factor for accurate staging. Dissection of No13 and No14 nodes may benefit for the selected distal advanced gastric cancer. The concept of esophagogastric junction cancer was redefined and Siewert type Ⅲ EGJ cancer will be classified according to the TNM staging of gastric cancer. The transhiatal approach has survival advantage for patient with esophageal invasion of 3 cm or less EGJ cancer. The dissection of distal lymph nodes for patients with 4 cm or less EGJ cancer is not recommended and the clinical benefit of dissection of lymph nodes in mediastinum is not clear. No10 node dissection is not recommended to the D2 procedure for total gastrectomy. Bursectormy could not bring survival benefits for cT3/4 gastric cancer, nor could palliative surgery bring improved survival to patients with metastatic gastric cancer. However, for highly selected cases of stage Ⅳ gastric cancer, conversion therapy can make some patients get the opportunity of radical operation and gain the chance for long-term survival.

Prospective randomized controlled trial to compare laparoscopic distal gastrectomy (D2 lymphadenectomy plus complete mesogastrium excision, D2\u2009+\u2009CME) with conventional D2 lymphadenectomy for locally advanced gastric adenocarcinoma: study protocol for a randomized controlled trial

BackgroundAlthough radical gastrectomy with D2 lymph node dissection has become the standard surgical approach for locally advanced gastric cancer, patients still have a poor prognosis after operation. Previously, we proposed laparoscopic distal gastrectomy (D2 lymphadenectomy plus complete mesogastrium excision [D2 + CME]) as an optimized surgical procedure for locally advanced gastric cancer. By dissection along the boundary of the mesogastrium, D2 + CME resected proximal segments of the dorsal mesogastrium completely with less blood loss, and it improved the short-term surgical outcome. However, the oncologic therapeutic effect of D2 + CME has not yet been confirmed.Methods/designA single-center, prospective, parallel-group, randomized controlled trial of laparoscopic distal gastrectomy with D2 + CME versus conventional D2 was conducted for patients with locally advanced gastric cancer at Tongji Hospital, Wuhan, China. In total, 336 patients who met the following eligibly criteria were included and were randomized to receive either the D2 + CME or D2 procedure: (1) pathologically proven adenocarcinoma; (2) 18 to 75 years old; cT2–4, N0–3, M0 at preoperative evaluation; (3) expected curative resection via laparoscopic distal gastrectomy; (4) no history of other cancer, chemotherapy, or radiotherapy; (5) no history of upper abdominal operation; and (6) perioperative American Society of Anesthesiologists class I, II, or III. The primary endpoint is 3 years of disease-free survival. The secondary endpoints are overall survival, recurrence pattern, mortality, morbidity, postoperative recovery course, and other parameters.DiscussionPrevious studies have demonstrated the safety and feasibility of D2 + CME for locally advanced gastric cancer; however, there is still a lack of evidence to support its therapeutic effect. Thus, we performed this randomized trial to investigate whether D2 + CME can improve oncologic outcomes of patients with locally advanced gastric cancer. The findings from this trial may potentially optimize the surgical procedure and may improve the prognosis of patients with locally advanced gastric cancer.Trial registrationClinicalTrials.gov, NCT01978444. Registered on October 31, 2013.

Risk factors for metastasis to No.14v lymph node and prognostic value of 14v status for gastric cancer patients after surgery.

D2 procedure has been accepted as the standard lymphadenectomy for advanced GC, while the role of No.14v lymph node (14v) dissection for distal GC is still controversial. A total of 284 GC patients receiving D2 plus 14v dissection in our center were enrolled. Patients were categorized into two groups based on 14v status: positive group (PG) and negative group (NG). Clinicopathological factors correlated with 14v metastasis and prognostic variables were respectively analyzed. Thirty-five patients (12.3%) had 14v metastasis. Metastasis to No.4d and No.6 lymph node were independent variables affecting 14v metastasis. Patients with positive 14v had a significant lower 3-year overall survival (OS) rate than those without (3-year OS: 42.9% vs. 70.3%, P < 0.001). Multivariable analysis demonstrated that 14v status was an independent prognostic factor for III stage GC (hazard ratio 1.462, 95% confident interval: 1.182-2.309, P = 0.027). The prognosis of 14v positive patients correlated with tumor size and No.6 lymph node status in univariate analysis. GC patients with No.4d and No.6 lymph node metastasis were more likely to have positive 14v. Status of 14v was an independent prognostic factor for III stage GC. Patients with 14v metastasis usually had a poorer prognosis, while survival in such patients after curative surgery was similar to that of patients staged IIIc without 14v metastasis.

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.

Precision lymphadenectomy for locally advanced gastric cancer

Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Patients with more lymph nodes harvested may have better survival. Negative node count may provide prognostic information for gastric cancer patients. The extranodal metastasis is significantly associated with the survival of gastric cancer patients and should be incorporated into N stage. In total gastrectomy for proximal gastric cancer without great curvature invasion, prophylactic splenectomy should be avoided not only for operative safety but also for survival benefit. The metastatic rate of No14v nodes for patients with distal stage III( disease is about 20%, so D2+ No.14v lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with metastasis to the No.6 nodes. According to JCOG9501, extend D2+PAND should not be used to treat curable stage T2b, T3, N1-2 (II(B-III(A) gastric cancer. But the clinical benefit of D2+PAND for patients with stage T4 and/or stage N3 (III(B, III(C) disease could not be determined. The quality control of D2 procedure is very important for the prognosis of gastric cancer patients. Base on the experience from Europe, Unite States and China, centralization of gastric cancer treatment will improve the outcome of gastric cancer operation effectively.

Gastric cancer: Current status of lymph node dissection.

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

D2 gastrectomy and complete mesentery excision based on metastasis IIIII( and membrane anatomy

D2 procedure, which includes dissection of the lymph nodes and adipose tissue in the field, has been widely accepted as a standard for curative gastric cancer surgery. However, there is no description for the boundary of these adipose resection in D2 procedure protocol so far. We found that there was a membranous tissue plane which enveloped the stomach, blood vessels, lymphatic and adipose together, and suspended them to the posterior wall of abdomen. This structure is consistent with the definition of the mesentery and we call it the mesogastrium, indicating a metastasis V in it. The precise D2 procedure should include the complete mesentery excision based on membrane anatomy, which may lead to less bleeding, more complete dissemination.

Effectiveness of D2 gastrectomy for lymph node positive and advanced gastric cancer: Survival results of the Italian Gastric Cancer Study Group (IGCSG) randomized surgical trial on D1 versus D2 dissection for gastric carcinoma.

4027 Background: It is still unclear whether D2 lymphadenectomy can significantly improve survival of gastric cancer and therefore should be applied routinely or performed in selected cases. We conducted a multicenter randomized trial to compare the efficacy of D2 and D1 lymphadenectomy for gastric cancer. Primary outcome was overall survival; secondary endpoints were disease specific survival, morbidity and in-hospital mortality. Methods: Between June 1998 and December 2006 patients with gastric adenocarcinoma were randomly assigned to either D1 or D2 lymphadenectomy. Intraoperative randomization was implemented centrally by telephone. Results: A total of 267 eligible patients were allocated to either D1 (133) or D2 group (134). Morbidity (12·0% vs 17·9%, p=0·18) and mortality (3·0% vs 2·3%; p=0·72) were similar. There was no difference in the overall 5-year survival (66·5% vs 64·2%, p = 0.70). Subgroups analyses showed a 5-years disease specific survival benefit for pT1 cases treated with D1 dissection (98.0% vs 82.9%, p = 0.01) and of pT&gt;1 LN+ patients treated with D2 resection (38·4% vs 59·5%, p = 0.05 at five years). Conclusions: In intention to treat analysis we observed no overall 5-year survival benefit from D2 resection. The trial showed a survival benefit of D1 procedure in early stages. On the opposite, despite evidence of contamination in the D1 arm, a survival advantage was documented in patients with advanced disease and lymph node metastases submitted to D2 procedure. Clinical trial information: ISRCTN11154654. [Table: see text]

D1 versus D2 dissection in gastric carcinoma: Evaluation of postoperative mortality and complications.

Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. The aim of the study was to evaluate complications, postoperative length of hospital stay and postoperative mortality after D1 or D2 lymph node dissection for gastric cancer in a non-specialized hospital. All patients who underwent surgery for pathologically confirmed gastric cancer at our 3rd General Surgery Department, Ankara Numune Training Hospital between January 1999 and 2007 were retrospectively reviewed. A consecutive series of 71 gastric cancer patients was identified. D1 resection (level 1 lymphadenectomy) was compared with D2 resection (levels 1 and 2 lymphadenectomy). The D2 group had higher postoperative mortality (16% vs. 8%; p<0.005) and morbidity (54% vs. 34%; p<0.005), and their postoperative length of stay was longer. Splenectomy did not have an effect on postoperative morbidity and mortality in either the D1 or the D2 group. The D2 procedure was associated with significantly higher postoperative mortality, morbidity, and postoperative length of hospital stay.