- Lymphadenectomy plays an important role in staging, local control, and survival for gastric cancer patients. - The Japanese have standardized lymphadenectomy techniques since the 1960s, removing specific nodal stations (D1, D2 etc.), and achieve much higher 5-year survival rates compared to the West. - A D2 lymphadenectomy, removing more lymph nodes than just those adjacent to the tumor, significantly increases cure rates according to Japanese studies. However Western studies have difficulty reproducing these results due to lower surgery volumes, lack of standardization, and operating on older patient populations with more advanced cancers.

1. LYMPHADENECTOMY IN
CARCINOMA STOMACH
Dr.A.Joseph Stalin PG
PROF.DR.R.RAJARAMAN’S UNIT
DEPT OF SURGICAL ONCOLOGY
GOVT ROYAPETTAH HOSPITAL
CHENNAI

2. CONTENTS
• BASIC PRINCIPLES
• TECHNIQUE
• FUTURE PROSPECTIVE

3. PRINCIPLES
• Role of lymphadenectomy
STAGING
LOCO REGIONALCONTROL
SURVIVAL BENEFIT

4. Japanese concept
• Gastric cancer spreads in a orderly pattern from tier I node to
tier 2 nodes and then to tier 3 node/systemic spread .
• Removal of one nodal basin more than involved region highly
increase the chance of cure.
• T1 tumours :D1 lymphadenectomy
• T2,T3,T4 tumours :D2 lymphadenectomy

5. Western Concept
• Lymphadenectomy done mainly for staging purpose
not to improve survival.
• Survival benefit of D2 lymphadenectomy if any is
negated by high morbidity and mortality associated
with the procedure.

6. SURVIVAL
• Overall 5yr survival
EAST(Japan,Korea) : 60%
WEST(Europe,USA):20 %
Shachelford 6th Edition

7. Why this Difference?

8. PATIENT/DISEASE FACTORS
EAST (Japan,Korea)
• Incidence: 75/Lakh
• Younger age
• Lower BMI
• Higher incidence of H.Pylori
infection
• More of Distal tumours
• Detected at early stage
WEST (Europe,USA)
• Incidence:5/lakh
• Older age
• Higher body mass index
• Lower incidence of H. pylori
infection
• More of proximal tumors
• Present at advanced stage

9. SURGICAL FACTORS
EAST
• Japanese are the first to
stage gastric cancer in 1962.
• First to describe nodal
station.
• Described D2
lymphadenectomy in 1960’s
practising since then.
• High volume centre :200
gastric cancer surgery/year
WEST
• Practising D2
lymphadenectomy since
1990’s.
• Technique of
lymphadenectomy not yet
standardised.
• 20 gastric cancer
surgery/year

10. D1 Versus D2 Lymphadenectomy for Gastric Cancer
BENJAMIN SCHMIDT, MD and SAM S. YOON, MD*
J Surg Oncol. 2013 March ; 107(3): 259–264. doi:10.1002/jso.23127
• Mortality and morbidity following D2 lymphadenectomy
East :0.5 % mortality,20% morbidity.
West :4-9 % mortality,40% morbidity.
• Even after adjustment for age, sex,tumor location, Lauren
classification, number of lymph nodes resected (negative and
positive), and depth of invasion ,
Eastern patients have 30% better disease specific survival rate.

11. Japanese Gastric Cancer
Association (JGCA)
• JGCA guidelines -1963
• Upper, middle and lower portions
• 16 nodal stations
• Grouped N0-N4 according to the location and extension
of the primary tumor
• Designations changed based on the primary location of
the tumor (i.e., upperthird, middle third, and lower third)

12. LYMPH NODE STATION

13. The JGCA recently abandoned their N designation of nodal stations

14. • The N groupings have changed considerably
over time.
• Current definitions include only node levels
from N1 thorough N3 (i.e., no N4).
• 20 stations

15. Evolution of Nomenclature of
Lymphadenectomy in Japan
Originaldescription
D 1 – 3, N 1-
3 based on
location of
the growth
Japaneseguideline2001
D 0 : Incomplete D 1
D 1 : 1 – 6
D 2 : + 7 – 11, 1 4 v
D 3 : + 12 – 1 4
D 4 : + 15 , 16
Japaneseguidelines2011
D 0
D 1
D 1 +
D 2
D 2 +

16. Total gastrectomy
• D0: Lymphadenectomy less than D1
• D1: Nos. 1–7
• D1+: D1 and Nos. 8a, 9, 11p
• D2: D1 and Nos. 8a, 9, 10, 11p, 11d, 12a.
For tumors invading the esophagus,
D1+ includes No.110,
D2 includes Nos. 19, 20, 110, and 111.
Japanese gastric cancer treatment guidelines
2010 (ver. 3)

17. Distal gastrectomy
• D0: Lymphadenectomy less than D1
• D1: Nos. 1, 3, 4sb, 4d, 5, 6, 7
• D1+: D1 and Nos. 8a, 9
• D2: D1 and Nos. 8a, 9, 11p, 12a.
Japanese gastric cancer treatment guidelines
2010 (ver. 3)

18. D 2 in
Distal
Gastrectomy
8a
9
11p
1
2
3
4
5
6
7
10
11d
12a
8a
9
11p
1
2
3
4
5
6
7
10
11d
12a
Omit Stations 2,
4sa , 10 and 11d
4sa

19. INDICATION
• D1 or a D1+ lymphadenectomy : cT1N0
• D1 lymphadenectomy :T1a tumors that do not meet the criteria for
endoscopic mucosal resection (EMR)/ endoscopic submucosal resection
(ESD), and for cT1bN0 tumors that are histologically of differentiated type
and 1.5 cm or smaller in diameter.
• D1+ lymphadenectomy : cT1N0 tumors other than the above

20. INDICATION
• D2 : cN+ or cT2-T4 tumors.
• The benefit of prophylactic para-aortic lymphadenectomy
(D3)was denied by the Japanese randomized controlled trial
(RCT) JCOG 9501

21. Lymphadenectomy NOT indicated :
• T1a & < 2cm, well differentiated without
ulceration ( EMR / ESD )
• Palliative gastrectomy

22. TECHNIQUE

23. Sequence of Operative Procedures
• Mobilization of the greater curvature with bursectomy /omentectomy and division
of the left gastroepiploic artery
• Infrapyloric mobilization with ligation of the right gastroepiploic artery and vein as
it enters the gastrocolic trunk
• Suprapyloric mobilization with ligation of the right gastric artery
• Duodenal transection
• Lymphadenectomy with dissection of the porta hepatis, common hepatic artery,
left gastric artery, celiac axis, and splenic artery .
• ligation of left gastric artery
• Gastric transection
• Reconstruction by loop or Roux-en-Y gastrojejunostomy

24. Bursectomy
Omentum
Duodenum
Ant. sheet of transv. mesocolon
Post. sheet of transv. mesocolon

25. Completion of Bursectomy
Pancreatic tail

26. Exposure of the Gastro-colic Trunk
Middle colic V.
rt. colic V.
Rt. gastro-epiploic V.
Ant. sup. panc. duod. V.
Sup. mesenteric V.
Gastro-colic trunk

27. Division of the Right Gastro-epiploic
Vein

28. Exposure of the Supra-pyloric Area
Rt. gastric A.
Sup. duodenal A.
Pylorus

29. Exposure of the Right Gastric Argery
Gastroduodenal A.
Rt. gastric A.

30. Transection of the Duodenum

31. Dissection of the Upper Border of the
Pancreas

32. Identification of the Splenic Artery
Splenic A.
Gastroduodenal A.
No. 8a LN
Common hepatic A.

33. Dissection of the No. 12a Nodes
No. 12a LN
Common hepatic A.Proper hepatic A.
Portal V.

34. Taping of the Common Hepatic Artery

35. Lymphadenectomy along the Splenic
Artery
Great pancreatic A.
Splenic V.
Post. gastric A.
Splenic A.

36. Division of the Left Gastric Artery
Lt. gastric A. stump

37. Lymphadenectomy along
Esophageal Hiatus
Diaphragmatic crus
Post. wall of the cardiaPost. vagal trunk

38. DISTAL GASTRECTOMY +D2

39. DISTAL GASTRECTOMY +D2

40. DISTAL GASTRECTOMY + D2

41. Table S1. Evaluation criteria for completeness of subtotal D2 lymphadenectomy
Surgical Video Assessment Form
Video ID: ___________________________ Reviewer ID: _________________________________
Please indicate whether or not the surgeon meets the requirements of the D2 lymph node dissection in the video you are reviewing
by encircling either “yes” or “no” next to the 22 defined elements of the procedure. In cases where the surgeon fails to perform the
required dissection, please identify the reason the requirement was not met.
Procedure Station Requirement Meets the
requirement
In case of “No”
please identify the
reason
1. Total omentectomy No injury was made to the any other organ. Yes / No
2. Division of left
gastroepiploic artery
(It is not necessary to dissect
the root of left gastroepiploic
artery if the tumor is located
in lower third of the
stomach.)
4Sb The left gastroepiploic artery and left gastroepiploic vein are
divided at least below the bifurcation of the first gastric
branch.
Yes / No
No injury was made to the colon of splenic flexure. Yes / No
4d The branch of right gastroepiploic artery and vein are
retrieved.
Yes / No
3. Appropriate extent of No.
6 lymph node (LN) dissection
6 The right gastroepiploic vein is divided just above the
bifurcation of the anterior superior pancreaticoduodenal vein
and the right gastroepiploic vein.
Yes / No
The right gastroepiploic artery is divided just peripheral to
the bifurcation of the right gastroepiploic artery and the
anterior superior pancreaticoduodenal artery.
Yes / No
The lowest anterior superior pancreaticoduodenal vein is
identified and exposed.
Yes / No
The prepancreatic soft tissues above the lowest anterior
superior pancreaticoduodenal vein are completely removed.
Yes / No
The prepancreatic soft tissues above the level of the
bifurcation of the anterior superior pancreaticoduodenal vein
and right gastroepiploic vein are completely removed.
Yes / No
No injury was made to the pancreatic parenchyma. Yes / No

42. 4. Appropriate extent of
No. 5 LN dissection
5 The root of right gastric artery is identified and
exposed.
Yes / No
5. Appropriate extent of
No. 12a LN dissection
12a The lower half of the proper hepatic artery is
exposed; at least its anterior and left surfaces.
Yes / No
The left side of the portal vein is identified and
exposed and soft tissues are completely removed.
Yes / No
6 .Appropriate extent of
No. 8a LN dissection
8a The common hepatic artery is exposed; at least its
anterior and superior surfaces.
Yes / No
The soft tissues above the upper edge of the pancreas
are completely removed.
Yes / No
7. Appropriate extent of
No. 9 LN dissection
(resection of the celiac
plexus is not necessary)
9 The retroperitoneal membrane is divided along the
boundary between the right crus and the soft tissues
around the celiac trunk to completely dissect No. 9
LNs.
Yes / No
8. Appropriate extent of
No. 7 LN dissection
7 The root of the left gastric artery is exposed and
ligated.
Yes / No
9.Appropriate extent of
No. 11p LN dissection
11p The proximal half of the splenic artery is exposed,
from its root to the site where the meandering splenic
artery is in the closest vicinity to the stomach.
Yes / No
The splenic vein is identified and exposed, or at least
the dorsal side of pancreatic parenchyma is exposed.
Yes / No
10.Prevention of
pancreatic injury during
suprapancreatic LN
dissection
No pancreatic injury by heat of energy devices and/or
assistant’s forceps was caused.
Yes / No
11.Appropriate extent of
No. 1 and 3 LN dissection
1, 3 The soft tissue attached to the lesser curvature side of
gastric wall is completely removed.
Yes / No
No esophageal and/or gastric injury by heat of energy
devices and/or blind manipulation was caused.
Yes / No
General impression and comments:

44. COMPLICATIONS
%
• Pancreatitis 3.7
• Pancreatic fistula 4.6
• Abdominal abscess 4.6
• Obstruction /ileus 1.9
• Lymphorrhea 0.9
• Wound infection 1.9
• Pneumonia 5.7
• Anastamotic leak 1.9
• Cardiac 0.9
• Reoperation 2.8
• Mortality 4
• Morbidity 33
• ANNALS OF GASTROENTEROLOGY 2010, 23(3)

45. FUTURE PROSPECTIVE

46. Sentinel Lymph Node (SLN) Biopsy
• Injection of Isosulfan blue Indocyaninegreen
• Technetium 99 m - radioisotope
– Intraoperative endoscopic injection (standard)
– Intraoperative subserosal injection
• Injections are carried out in four quadrants of the tumor
48

47. SUITABLE PATIENT SUBGROUP
• Eastern studies node-negative T1 and T2
patients
• Western institutions have included T3 tumors
as well
49

48. • Authors from Asia reported an accuracy of more than 98%
in particular in early stages (T1-T2)
• Whereas other series from Western countries, the accuracy
was about 80% , with the false negative SLN rate ranging
from 15% to 20%
• Patients with sentinel nodes containing metastasis should
be treated with the D2 procedure (Miwa et al., 2001).
50

49. SNB
• Complex lymphatic drainage of the stomach
and fear of skip metastasis - make the
selection of patients difficult
• Further studies are needed before this
method can be introduced into daily practice.
51

50. CONCLUSION
• Entire concept of lymphatic spread and lymphadenectomy
first conceived and practised by Japanese.
• Lymphadenectomy classified based on the type of gastric
resection done since 2010.
• Total gastrectomy : D1 : 1-7
• D2 :D1 + 8a,9,10,11p,11d,12a.
• Distal gastrectomy : D1 :1-7 (except 2,4sa)
• D2 :D1 + 8a,9,11p,12a

51. CONCLUSION
• D2 lymphadenectomy done in Japan has low morbidity
and mortality with increased survival advantage.
• Same results are not reproduced by Western surgeons.
• D2 lymphadenectomy has to be standardised and
practised uniformly by all surgeons to come to an
meaningful conclusion about it’s efficacy

52. THANK U………