Topic Highlight
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2016; 22(10): 2875-2893
Published online Mar 14, 2016. doi: 10.3748/wjg.v22.i10.2875
Gastric cancer: Current status of lymph node dissection
Maurizio Degiuli, Giovanni De Manzoni, Alberto Di Leo, Domenico D’Ugo, Erica Galasso, Daniele Marrelli, Roberto Petrioli, Karol Polom, Franco Roviello, Francesco Santullo, Mario Morino
Maurizio Degiuli, Erica Galasso, Mario Morino, Department of Surgery, University of Turin, Citta della Salute e della Scienza, 10126 Turin, Italy
Giovanni De Manzoni, Department of Surgery, University of Verona, Ospedale Borgo Trento, 37126 Verona, Italy
Alberto Di Leo, Division of Surgery, Ospedale di Arco, 38062 Arco TN, Italy
Domenico D’Ugo, Francesco Santullo, Department of Surgery, University “Cattolica del Sacro Cuore”, “A.Gemelli” University Hospital, 00168 Rome, Italy
Daniele Marrelli, Franco Roviello, Department of Surgery, University of Siena, 53100 Siena, Italy
Roberto Petrioli, Department of Oncology, University of Siena, 53100 Siena, Italy
Karol Polom, Department of Surgery, Wielkopolskie Centrum Onkologii, 61-866 Poznan, Poland
Author contributions: Degiuli M designed the article structure; Degiuli M, De Manzoni G, Di Leo A, D’Ugo D, Galasso E, Marrelli D, Petrioli R, Roviello F, Santullo F and Morino M. contributed equally to this work and wrote the paper.
Conflict-of-interest statement: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Maurizio Degiuli, MD, Chirurgia Generale Universitaria 1, Department of Surgery, University of Turin, Citta della salute e della scienza, 10126 Turin, Italy. dr.mauriziodegiuli@gmail.com
Telephone: +39-335-8111286 Fax: +39-11-6336725
Received: July 7, 2015
Peer-review started: July 8, 2015
First decision: August 26, 2015
Revised: October 9, 2015
Accepted: January 17, 2016
Article in press: January 18, 2016
Published online: March 14, 2016
Processing time: 241 Days and 4.3 Hours
Abstract

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.

Keywords: Gastric cancer; Lymph node dissection; Lymphadenectomy; D2 gastrectomy; D1 gastrectomy; D1 plus gastrectomy; Robot assisted lymphadenectomy; Laparoscopic lymphadenectomy

Core tip: Recently early gastric cancer and advanced gastric cancer (AGC) has been successfully treated endoscopically; surgery is offered only to patients not fitted for less invasive treatment and in several guidelines D1+ (open, laparoscopic, robotic) is the adequate treatment. For AGC, while D2 gastrectomy is the standard procedure in eastern countries, mostly based on retrospective studies, in the west different randomised controlled trials have been conducted to demonstrate a survival benefit of D2 over D1 with evidence based medicine, with contradictory results. As nowadays D2 gastrectomy can be done safely with pancreas and spleen preservation, it has been suggested also in several western guidelines as the recommended procedure for patients with AGC.