What is the role of lymph node dissection in the management of gastric cancer?

Updated: May 21, 2019
  • Author: Elwyn C Cabebe, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Answer

The extent of the lymph node dissection is somewhat controversial. Many studies demonstrate that nodal involvement indicates a poor prognosis, and more aggressive surgical approaches to attempt to remove involved lymph nodes are gaining popularity.

Two randomized trials compared D1 (perigastric lymph nodes) with D2 (hepatic, left gastric, celiac, and splenic arteries, as well as those in the splenic hilum) lymphadenectomy in patients who were treated for curative intent. In the largest of these trials, postoperative morbidity (43% versus 25%) and mortality (10% versus 4%) were higher in the D2 group. [35, 36]

Most critics argue that these studies were underpowered and overestimated benefit. In addition, a  more recent randomized trial found a much lower rate of complications than those earlier trials. Degiuli et al reported complication rates of 17.9% and 12% with D2 and D1 dissections, respectively—a statistically insignificant difference— and postoperative mortality rates of 2.2% and 3%, respectively. [37]

D2 dissections are recommended by the National Comprehensive Cancer Network over D1 dissections. [4] A pancreas- and spleen-preserving D2 lymphadenectomy is suggested, as it provides greater staging information, and may provide a survival benefit while avoiding its excess morbidity when possible.

D1 gastrectomy is associated with less anastomotic leaks, a lower postoperative complication rate, a lower reoperation rate, decreased length of hospital stay, and a lower 30-day mortality rate. The 5-year survival rate in patients who underwent D1 gastrectomy was similar to the D2 cohort. [38]


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