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Gastric cancer: Current status of lymph node dissection
#MMPMID26973384
Degiuli M
; De Manzoni G
; Di Leo A
; D'Ugo D
; Galasso E
; Marrelli D
; Petrioli R
; Polom K
; Roviello F
; Santullo F
; Morino M
World J Gastroenterol
2016[Mar]; 22
(10
): 2875-93
PMID26973384
show ga
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.
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