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DI VS D2 GASTRECTOMY The ideal lymphadenectomy for gastric cancer (GC) should accurately stage the extent of disease and

predict prognosis; in addition it should have the potential to improve survival by selectively and completely removing all metastatic lymph nodes (LN), with minimal morbidity and mortality. Unfortunately the optimal extent of lymph node dissection (LND) for GC has not been determined and is certainly not standardized.At the time of resection, the macroscopic assessment of nodal metatstases is notoriously unreliable, and the intraoperative assessment of microscopic LN metastases is costly and impractical. Furthermore the pattern of lymph node involvement depends on numerous factors, including location of the primary tumor and depth of tumor invasion. Opinion over the optimum resection for patients with gastric cancer remains divided, and the literature polarised. The impressive outcomes after D2 gastrectomy published in large retrospective series from Japan (Soga et al, 1979; Maruyama et al, 1987) have not been reproduced in randomised comparative studies from Europe (Bonenkamp et al, 19951999; Cuschieri et al, 19961999). The two largest randomised studies both report significantly greater operative morbidity and mortality associated with an extended D2 lymphadenectomy when compared with the less aggressive D1 lymphadenectomy, and have failed to demonstrate any survival advantage for a D2 resection. Many of the serious complications associated with D2 resections were associated with resections of the pancreas and spleen (Bonenkampet al, 1995; Cuschieri et al, 1996), and the best long-term survival was observed in patients undergoing D2 gastrectomy without pancreatico-splenectomy (Cuschieri et al, 1999). Although this latter report concluded than a classical D2 resection offered no survival advantage over a D1 resection, the possibility that a modified D2 resection, preserving pancreas and spleen, might be better than a D1 resection was not dismissed (Cuschieri et al, 1999). Poor outcomes after surgery for gastric cancer in Britain are due to the greater age, comorbidity, advanced stages of disease and greater body mass indices of Western patients when compared with their Japanese counterparts. Most oesophagogastric cancer surgery in Britain and much of the West, has by tradition, been performed by general surgeons. Radical lymphadenectomy is a painstaking, technically demanding procedure, which has usually remained within the province of small numbers of specialist upper gastrointestinal surgeons. D1 perigastric lymphadenectomy remains the most commonly performed operation for gastric cancer in the West. Both MRC ST01 and the Dutch trial have received criticism over the relative inexperience of many different surgeons performing D2 lymphadenectomy. Furthermore, the existence of a relationship between caseload and operative mortality remains controversial. The specialist surgical unit in Leeds has described a long learning curve during the adoption of D2 gastrectomy, with 10 years elapsing before operative mortality fell to 5%. D2 lymphadenectomy can be performed with low morbidity-mortality, and a 5-year survival of more than 50%. The procedure offers benefit in terms of survival for a certain percentage of patients with positive level N2 lymph nodes.

The rationale for extended lymphadenectomy has been enhanced local control. The clearance of the possible metastatic nodes in the region outside of the perigastric nodes is presumed to impact on overall patient survival rates. The proponents of systemic LND point to numerous anatomical/ lymphographic studies, histopathologic analyses, statistical analyses of LN metastases, clinical prognostic observations, and advances in surgical techniques to support their argument that ELND is the most effective procedure to treat the lymphatic spread to GC. Japanese surgeons have been actively performing extended lymphadenectomy (D2, removal of perigastric nodes and nodes along the left gastric, common hepatic, celiac and splenic arteries; or D3, D2 plus removal of nodes in the hepatoduodenal ligament, in the retropancreatic space and along the vessels of the transverse mesocolon). In recent years interest has expanded to superextended lymphadenectomy (D4) of nodes around abdominal aorta (para-aortic lymph nodes from aortic hiatus to aortic bifurcation). Because the therapeutic value of this D4 procedure remains controversial, Maeta et al. initiated a prospective study to compare D3 and D4 lymphadenectomy. Surgical treatment of microscopic disease in grossly normal para-aortic lymph nodes may generate occasional long-term survivors. Selecting appropriate candidates who might benefit from D4 resections needs to be refined. In the recently published Dutch trial, the cumulative risk of relapse was lower in patients with spleen preservation than in those with splenectomy, but the aim of the study was to compare D1 and D2 resections. The description D dissection for the determination of extent of lymph node dissection arises from the Japanese classification (JRSGC). D1 to D4 dissection correspondences to the anatomical site of dissection of levels N1 to N4. The rationale for extended lymph node dissection is that it achieves a R0 resection due to clearance of the metastatic extraperigastric lymph nodes that can not be removed with a limited D1 node dissection. Thus, it increases the curative resection rate, reduces the locoregional recurrence rate and may improve survival. This hypothesis for improvement of both local control and survival after D2 dissection is supported by a large number of Japanese observational studies that based on historical comparisons. Furthermore, several prospective but non-randomised studies and other observational Western series have shown encouraging long-term results with D2 dissection. However, many surgeons in the West argue against the therapeutic value of D2 dissection and are clearly against the routine use of D2 dissection for Western patients. In their opinion, D2 dissection increases postoperative morbidity and mortality rates and does not improve long-term survival. This argument has been based on retrospective studies, which have failed to demonstrate any survival benefit in favour of D2 dissection. In the Dutch trial, D2 dissection did not improve longterm survival or decrease the risk of relapse. However, the D1 and D2 groups were not well balanced. Resection of the spleen was an independent risk factor for reduced survival but splenectomy and pancreatectomy was significantly more often performed in the D2 than the D1 group.