Published online Mar 27, 2026. doi: 10.4240/wjgs.v18.i3.114895
Revised: December 28, 2025
Accepted: January 21, 2026
Published online: March 27, 2026
Processing time: 178 Days and 3.8 Hours
Lymph node invasion stands out as the most critical prognostic factor in gastric cancer. The extent of lymph node dissection required during curative gastric cancer surgery has long been debated. Japanese Gastric Cancer Association was the first to define a classification system for regional gastric lymph node stations, numbering them from No. 1 to No. 16. This classification was later used to differentiate between different types of lymph node dissection, such as D1, D2 and D3. However, these definitions were often considered too complex to be universally adopted, resulting in wide variations of recommendations from one country to another and making it difficult to compare published studies. Moreover, the optimal extent of lymph node dissection remains uncertain, as the extensive dissections that where initially recommended are associated with significant morbidity without a clear survival benefit. Though gastrectomy with extended D2 lymphadenectomy is classified as a non-standard gastrectomy, its clinical significance has been evaluated in many studies. D2 plus superior mesenteric vein lymph node (No. 14v) dissection is recommended when metastasis to No. 6 nodes is suspected in the lower stomach, and D2 plus posterior surface of the pancreatic head (No. 13) lymph node dissection may be an option in potentially curative gastrectomy for cancer invading the duodenum. No. 14v lymph node dissection has been shown to improve overall survival in patients with distal gastric cancer, primarily in patients with clinical stage III/IV distal gastric cancer. Furthermore, D2 plus lymphadenectomy showed a significantly higher 5-year overall survival rate (55.3% vs 43.9%) and a lower recurrence rate (51.5% vs 69.5%) then D2 standard dissection. The quality of lymphadenectomy may influence prognosis in gastric cancer patients. Both hospital volume and surgeon volume were important factors for the quality of radical gastrectomy. The purpose of this review is to support the extension of lymph node dissection based on the existing literature, including a comprehensive review of current definitions of lymphadenectomy. An outcome analysis is performed to assess the need for lymphadenectomy with removal of lymph nodes not included in the standard D2 lymphadenectomy in patients with distal gastric cancer, especially if the tumor is advanced.
Core Tip: The extent of lymphadenectomy influences the prognosis in patients with distal gastric cancer. The most authoritative guidelines recommend a D2 lymphadenectomy in T2-T4 tumors, as well as T1N+, regardless of tumor location. The purpose of this review is to support the extension of lymph node dissection based on the existing literature. An analysis of the results is performed to assess the need for lymphadenectomy with removal of lymph nodes not included in the standard D2 lymphadenectomy in patients with distal gastric cancer, especially if the tumor is advanced.