2. Gastric Cancer
Responsible for > one million new
cases in 2020
Estimated 769,000 deaths (one in
every 13 deaths globally)
Ranking fifth for incidence and
fourth for mortality globally
His/her education People who
influenced him / her
2
4. Data from
Nepal
Prevalence of gastric
cancer among patients
undergoing UGI
endoscopies was 2.4%
S. Bhattarai et al 2021
In younger age group
77.8% had poorly
differentiated
adenocarcinoma and
56% of younger
patients had stage IV
disease at.
B. Kandel et al 2016
The mean age was
59.6±12.4 yrs
Three, four and five
year survival rates
were 17.9%, 11.9%
and 8.3%,
respectively.
J. Shah et al 2015
4
5. The only treatment with
curative intent is
represented by surgery
as part of a multimodal
therapy
5
Dawn of surgery
9. Approach to
resectable
gastric cancer
Once staging investigations
completed, individualized
tailored management plan is
adopted
Staging
Laparoscopy
Peritoneal
cytology
Extent of
resection
Surgery for clinical
stage 1
Extent of
lymphadenectomy
Laparoscopic
versus open
9
12. 12
Staging Laparoscopy
Superior to radiographic studies for detecting metastatic disease
Sensitivity 86% and specificity 100%,
Detects occult disease in 9% to 50%
Spares unnecessary laparotomy and can begin chemotherapy earlier (19.5
vs 36.8 days) and shorter length of hospital stay
Leake PA et al.A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of gastric cancer.GastricCancer 2012
13. 13
Ann Gastroenterol Surg. 2019
Poorly differentiated
Bormanns >3
LN mets
Equivocal finding in
CT
Linitis plastica
14. 14
Peritoneal lavage
Positive peritoneal cytology in the absence of other metastatic disease (C1 )
correlate with a poor prognosis;
Median survival : 14.8 to 20.0 months
Selects out up to 7% patients who are C0 disease initially and receive
neoadjuvant therapy but are found to have C1 disease at the time of repeat
laparoscopy, thus sparing them an unnecessary laparotomy
Cardona K, Zhou Q, Gönen M, et al. Role of repeat staging laparoscopy in locoregionally advanced gastric or gastroesophageal cancer after neoadjuvant therapy.Ann Surg Oncol. 2013
15. Incidence of positive peritoneal cytology : 4% to 40%
26 studies
Positive cytology was associated with significantly reduced
overall survival
15
16. Staging
laparoscopy
and peritoneal
lavage
.
Performed for
T3 orT4
without mets
Indicated
locoregional
disease (other
than stage IV,
Tis orT1a)
Diagnostic lap
if considered
for
neoadjuvant
therapy
Patients with initial positive cytology
may have a good prognosis following
neo-adjuvant treatment if the
cytology results change to negative
after treatment.
16
NCCN Guidelines 2021
18. Type of Non
standard surgery
Modified surgery
The extent of gastric
resection and/or
lymphadenectomy is
reduced (D1, D1+, etc.)
compared to standard
surgery.
Extended surgery
1) Resection of
adjacent involved
organs.
2) Gastrectomy with
extended
lymphadenectomy
exceeding D2 18
19. Type of Non
Curative surgery
Palliative surgery
Bleeding or obstruction
in advanced/ metastatic
Gastrectomy or
Gastrojejunostomy
Reduction surgery
Gastrectomy in
incurable factors
such as unresectable
liver metastasis and
peritoneal
metastasis, while no
tumor-associated
symptoms
19
20. Open-label, randomised, phase 3 trial at 44 centres in Japan, South Korea, and Singapore.
Single non-curable factor confined to either the liver (H1), peritoneum (P1), or para-aortic
lymph nodes (16a1/b2) were assigned to chemotherapy alone or gastrectomy followed by
chemotherapy
Gastrectomy followed by chemotherapy did not show any survival benefit compared with
chemotherapy alone and cannot be justified for treatment of patients with these tumours.
20
Reduction surgery
21. Extent of resection
21
Total Gastrectomy
Distal
Gastrectomy
Local resection
Non resectional
surgery
PPG
Proximal Gastrectomy
Segmental Gastrectomy
Japanese Cancer Guidelines 2018
22. Selection of Gastrectomy
22
• T2-4a or cN+ : Distal orTotal
Gastrectomy
Greater curvature with 4Sa
involvement-Total Gastrectomy with
Splenectomy
• Pancreas involvement – requiring
pancreaticosplenectomy necessitates
total gastrectomy
• For cT1 No
• PPG if middle tumor with distal 4
cm margin achieved proximal to
pylorus
• Proximal Gastrectomy –if > distal
half stomach can be preserved
• Local resection – investigational
Japanese Cancer Guidelines 2018
23. 23
Stomach resection preserving the upper third of the
stomach and the pylorus along with a portion of the
antrum
Function-preserving procedure
Advantages :dumping syndrome, bile reflux
gastritis, and the frequency of flatus, although may
induce delayed gastric emptying.
Is (PPG) recommended for early
gastric cancer ?
Weak recommendation
Japanese Cancer Guidelines 2018
T. Saito et al World J Gastroenterol 2014
24. 24
Stomach resection including the cardia
(esophagogastric junction).The pylorus is
preserved.
Advantages over conventionalTG in terms of
retention of food in the remnant stomach.
Heartburn or gastric fullness due to
esophageal reflux or gastric stasis is a
potential disadvantage
Is Proximal gastrectomy recommended
for cT1N0 tumor in the upper-third
stomach when EMR or ESD is not
indicated?
weakly recommended
Japanese Cancer Guidelines 2018
T. Saito et al World J Gastroenterol 2014
25. ≥T2 or deeper tumors :
Expansive growth pattern - proximal margin of at least 3 cm
Infltrative growth pattern – proximal margin of 5cm
For T1 tumors, a gross resection margin of 2 cm should be obtained.
Resection margin
25
Japanese Cancer Guidelines 2018
26. 26
Lymph node metastasis is the most
frequent route of metastasis
For T1 lesions invading submucosa : LN
involvement around 20%
For T2 tumors invading the muscularis
propria : increase to over 50% .
If serosa or adjacent organs are invaded :
exceed to as high as 80%
.
The total number of LN resected, or
positive LN, or positive to negative ratio of
LN (nodal ratio) : predictors of gastric
cancer survival
Dissection of ≥15 lymph nodes to
adequately stage the disease
Y-X Zhang et al.Transl Gastroenterol Hepatol 2020
Lymph node dissection
27. 27
Lymph node dissection
Maruyama computer program : estimate the risk of LN metastasis in each nodal
station and adequacy of lymphadenectomy
Positive LN ratio : more precise predictor of prognosis than the absolute
number of positive lymph nodes.
A higher total harvested negative nodes or lower ratio of positive nodes,
(Maruyama index ) saw improvements in both survival and progression free
survival
Lu J, WangW, Zheng CH, FangC, Li P, Xie JW, et al. Influence of total lymph node count on staging and survival after gastrectomy for gastric cancer: an analysis from a two-institution database in China. Ann SurgOncol. 2017
Maruyama K, Kaminishi M, Hayashi K, IsobeY, Honda I, Katai H, et al.Gastric cancer treated in 1991 in Japan: data analysis of nationwide registry.GastricCancer. 2006
28. 28
Lymph node dissection
NCCN Guidelines 2021
Classified as D0, D1, D2 or D3 depending on
the extent of lymph node removal at the time of Gastrectomy.
29. 29
Lymph node dissection
Japanese Cancer Guidelines 2018
• D1 resection is done for
• cT1 a not meeting EMR/ESD criteria
• and cT1b but differentiated and <1.5cm
• D1+ : cT1N0
• D2 : cT2-4,cN+
• D2 +
• 14v if 6 involved,
• 13 if ca stomach invades duodenum else is
metastatic M1.
• 16 after neoadjuvant
• Extent of Lymphadenectomy according to type of
gastrectomy
31. 31
1ST RCT, 1988 D2 more Blood transfusion,
Hospital stay higher
reoperation rate
3 year survival similar
MRC UKTrial,1993 Similar short term
Higher morbidity and
mortality for D2
5 year survival no difference
Dutch trial, 2010 Decrease in mortality in D2 No difference in OS at 15year
follow up
British and Italian trials,
2004/2010
D2 beneficial withT3 tumors,
N0 and N1 nodal disease,
stage III cancers, cardia
tumors, and those who had
their spleen preserved
Significant 5 year survival
benefit for D2
D1 vs D2
R Seevartnam et al , Gastric cancer,2012
32. 32
Outcomes of 5 randomized trials involving 1642 patients (845 D1, 797 D2)
Subgroup analysis of recent trials and spleen/pancreas preservation
revealed no significant difference in hospital mortality between groups.
Conclusion : A trend of improved survival exists among D2 patients
who did not undergo resection of the spleen or pancreas, as well as for
patients withT3/T4 cancers.
33. 33
Lymph node dissection D2+
Japanese Cancer Guidelines 2018
• No. 10 (splenic hilar ) with or without splenectomy for
cancer of the upper stomach invading the greater
curvature
• No. 14v (superior mesenteric venous) for cancer of
the distal stomach tumor with metastasis to the No. 6
lymph nodes .
• No. 13 (posterior pancreas head ) for cancer invading
the duodenum
• No. 16 (abdominal aortic lymph) after neoadjuvant
chemotherapy for cancer with an extensive lymph
node involvement
34. 34
7 non-randomized comparisons, 3 RCT, 5 five meta-analyses
D3 compared to D2 significantly associated with more blood loss, prolonged operative
time, higher re laparotomy rates and post-procedural surgical and non-surgical
morbidity.
Phase II clinical trial from Japan reported a 3 -year survival rate of 59% in patients with
clinically involved para-aortic nodes treated with neoadjuvant chemotherapy followed
by D3 lymphadenectomy, rekindled the issue. (Kodera et al,2015)
Future multicenter randomized trials needed
GN. Douridas et al, 2018
35. 35
Omentectomy
• Removal of the greater omentum in the standard
gastrectomy forT3 or deeper tumors.
• ForT1/T2 tumors, the omentum more than 3 cm away
from thegastroepiploic artery may be preserved.
Bursectomy
• Tumors penetrating the serosa of the posterior gastric
wall
• However, no survival benefit of this procedure by a
large-scale randomized trial (JCOG1001)
Japanese Cancer Guidelines 2018
36. Reconstruction after gastrectomy
36
Japanese Cancer Guidelines 2018
Total gastrectomy
– Roux-en-Y
Esophagojejunostomy
.
– Jejunal interposition
– Double tract
method.
Distal gastrectomy
– Billroth I
– Billroth II
– Roux-en-Y GJ
– Jejunal interposition
Pylorus-preserving
gastrectomy
– Gastro-gastrostomy
Proximal gastrectomy
– Esophagogastrostomy.
– Jejunal interposition.
– Double tract method
38. 38
Esophagojejunostomy (EJS) is performed as with
the R-Y technique, and duodenojejunostomy is
added about 20 cm distal from the EJS.
Second enteroenterostomy is performed 20-25 cm
below.
Digestive and absorption functions of the
duodenum are maintained.
DT afterTG
T. Saito et al World J Gastroenterol 2014
41. 41
Evolution of laparoscopic gastrectomy
Yeon-Ju Huh et al "The Advances of Laparoscopic Gastrectomy for Gastric Cancer", Gastroenterology Research and Practice, vol. 2017
42. 42
EARLY GASTRIC CA
13 institutes, conducted a phase 3, multicenter, open-label, non inferiority, prospective randomized clinical
trial (KLASS-01) of patients with histologically proven, preoperative clinical stage I gastric
adenocarcinoma
Among the 1416 patients the 5-year overall survival rates were 94.2% in the lap group and 93.3% in the open
group .
Conclusions and Relevance
Similar overall and cancer-specific survival
Laparoscopic distal gastrectomy is an oncologically safe alternative to open surgery for stage I
gastric cancer.
49. Not covered
49
GEJ tumor Operative
steps
Complications
Robotic
surgery
Cytoreductive
surgery and
HIPEC
Sentinel node
navigation
surgery
50. Summarize
D2 gastrectomy with a
minimal lymph node
dissection of 15 for
staging purposes
remains an appropriate
surgical treatment with
curative treatment for
gastric adenocarcinoma
Laparoscopy as a
technique for
resection, provides
equivalent resections
with equivalent
lymphadenectomy
comparable to the
open approach with
no compromise in
recurrence or long-
term survival
50
56. 56
is widely accepted that gastrectomy with a modified D2
lymphadenectomy (sparing the distal pancreas and spleen)
confers adequate staging information, with the goal of obtaining
a minimum of 15 lymph nodes. As minimally-invasive
techniques continue to be developed, oncologic safety and
equivalence to the standard open gastrectomy remains to be
seen. With better efficacy of systemic chemotherapy, more
aggressive approaches to surgical resection, including
cytoreduction and HIPEC, can also be considered in selected
patients
Stomach cancer remains an important cancer worldwide and is responsible for over one million new cases in 2020 and an estimated 769,000 deaths (equating to one in every 13 deaths globally), ranking fifth for incidence and fourth for mortality globally
Cancer burden is increasing with modest improvement in
Nationwide population-based screening programmes are available in only a few countries with high incidence rates in the Asia-Pacific region. In Korea, nationwide stomach cancer screening using either upper gastrointestinal series or endoscopy is available every two years for men and women aged 40 or over (Choi et al., 2015[39]).
Five-year net survival for stomach cancer varies widely between Asia-Pacific countries. For patients diagnosed during 2010-14, five-year survival was the highest in the region in the Republic of Korea (69%) and Japan (60%), but very low in India (9%) and Thailand (13%)
A descriptive, cross-sectional study was conducted in the Department of Medicine at Manipal Teaching Hospital, Nepal, from January 2018 to June 2020. A total of 2640 subject
Despite advances in the field of oncology, where radiotherapy, neo and adjuvant chemotherapy may improve the outcome, the only treatment with curative intent is represented by surgery as part of a multimodal therapy surgery still remains the first choice of
treatment modalities for gastric cancer
Although surgery is still the primary treatment option for gastric cancer, the treatment model has undergone significant changes: the previously used simple gastrectomy has been replaced by radical approaches aiming at lymph node dissection; and anatomy-based operations are giving their place to an integrated mode that combines standardized surgery and perioperative adjuvant therapies based on anatomy, tumor biology and immunology.
Optimal therapy depends on accurate staging of the extent of the disease
wo major classifications are currently being used. The Japanese classification is more elaborate and is based on anatomic involvement, particularly the lymph node stations.12 The other staging system, developed jointly by the AJCC and the Union for International Cancer Control (UICC), is the system used in countries in the Western Hemisphere.13 A minimum of 15 examined lymph nodes is recommended for adequate staging. The 7th Edition of the AJCC Staging Manual does not include the proximal 5 cm of the stomach, which has created debates, confusion, and disagreements.
TNM Staging
Staging recommendations for gastric cancer presented in the eighth edition of the AJCC Cancer Staging Manual include clinical staging (cTNM; newly diagnosed, not-yet-treated patients), pathologic staging (pTNM; patients undergoing resection without prior treatment), and postneoadjuvant staging (ypTNM; patients receiving preoperative therapy).61 The eighth edition also introduced modifications regarding tumors located at the EGJ and within the gastric cardia. Using this system, tumors involving the EGJ with an epicenter located >2 cm into the proximal stomach are now staged as gastric carcinomas. Tumors involving the EGJ with an epicenter ≤2 cm into the proximal stomach will still be staged as esophageal carcinomas. Cancers located within the gastric cardia that do not involve the EGJ are staged as gastric carcinomas.
Optimal therapy depends on accurate staging of the extent of the disease
wo major classifications are currently being used. The Japanese classification is more elaborate and is based on anatomic involvement, particularly the lymph node stations.12 The other staging system, developed jointly by the AJCC and the Union for International Cancer Control (UICC), is the system used in countries in the Western Hemisphere.13 A minimum of 15 examined lymph nodes is recommended for adequate staging. The 7th Edition of the AJCC Staging Manual does not include the proximal 5 cm of the stomach, which has created debates, confusion, and disagreements.
TNM Staging
Staging recommendations for gastric cancer presented in the eighth edition of the AJCC Cancer Staging Manual include clinical staging (cTNM; newly diagnosed, not-yet-treated patients), pathologic staging (pTNM; patients undergoing resection without prior treatment), and postneoadjuvant staging (ypTNM; patients receiving preoperative therapy).61 The eighth edition also introduced modifications regarding tumors located at the EGJ and within the gastric cardia. Using this system, tumors involving the EGJ with an epicenter located >2 cm into the proximal stomach are now staged as gastric carcinomas. Tumors involving the EGJ with an epicenter ≤2 cm into the proximal stomach will still be staged as esophageal carcinomas. Cancers located within the gastric cardia that do not involve the EGJ are staged as gastric carcinomas.
Treatment strategies of gastric cancer according to TNM stage. Stage 0: TisN0M0; stage IA: T1N0M0; stage IB: T2N0M0; stage II: T1N2M0/T2N1M0/T3N0M0; stage IIIA: T3N1M0/T4N0M0; stage IIIB: T3N2M0; stage IV: T3N1-3M0/T1-3N3M0/T1-4N0-3M1 (Tis—the mucosa; T1—submucosa;T2—muscle layer; T3—subserosa; T4—serosa/adjacent structures/N0—(0+)LN; N1—(1–2+)LN; N2—(3–6+)LN; N3—(>7+)LN/M0—no metastasis; M1—distant metastasis or carcinomatosis); LN—lymph nodes; ST—subtotal; T—total; ChT—chemotherapy; ChRxT—chemo-radiotherapy; preop—preoperative; postop—postoperative. 2. Results and Discussion 2.1. Extent of Gastric Resection: Total Gastrectomy (TG), Subtotal Gastrectomy (SG), and Proximal Gastrectomy (PG) The extent of surgical resection required to achieve surgical margins free of malignant cells, R0, depends on the size, location, and histological type of the tumor. The optimal length for the proximal margin is often suggested to be at least 3 to 5 cm depending on the tumor histology [11]. However, recent studies suggest that resection margins of 1 cm may be comparable in terms of survival and oncological outcome [12]. Since the standard approach for gastric cancer with any localization is total gastrectomy (TG), several studies have shown that the outcomes of patients with proximal tumors who underwent TG or proximal gastrectomy (PG) were similar in terms of the overall survival interval and disease-free interval [13]. Following these studies, it is accepted today that both procedures could be accomplished safely. Some authors suggest that distal gastrectomy can be safely performed for patients with distal lesions
.
Spares unnecessary laparotomy, which has morbidity of 13% to 23% and mortality of 10% to 21% Began chemotherapy earlier (19.5 vs 36.8 days) and shorter length of hospital stay
he Japanese Gastric Cancer Association included the results of cytological examination of peritoneal lavage fluid as a key prognostic factor in their classification of gastric carcinoma [1, 3]. However, recently published guidelines suggested that cytology-positive status in the absence of other noncurative factors, that is, macroscopic disease, can be managed with D2 gastrectomy and perioperative chemo- therapy [4].
Pooled analysis demonstrated that positive cytology was associated with significantly reduced over- all survival (HR, 3.46; 95% CI, 2.77–4.31; P < 0.0001). Interestingly, negative cytology following neoadjuvant chemotherapy was associated with significantly improved overall survival (HR, 0.42; 95% CI, 0.31–0.57; P < 0.0001). The absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved overall survival (HR, 0.64; 95% CI, 0.56–0.73; P < 0.0001).
Accurate staging of gastric cancer is crucial in selecting the appropriate treatment option, whether curative or pallia- tive. The Japanese Gastric Cancer Association included the results of cytological examination of peritoneal lavage fluid as a key prognostic factor in their classification of gastric carcinoma [1, 3]. However, recently published guidelines suggested that cytology-positive status in the absence of other noncurative factors, that is, macroscopic disease, can be managed with D2 gastrectomy and perioperative chemo- therapy [4]. Initial data of those treated with surgery alone showed poor 5-year survival; however, more recent publica- tions have shown that the use of postoperative chemotherapy improves overall survival rates to 26%,
Cat 2b : low level evidence : appropriate intervention
Standard gastrectomy Standard gastrectomy is the principal surgical procedure performed with curative intent. It involves resection of at least two-thirds of the stomach with a D2 lymph node dissection (refer to the section of “lymph node dissection" and Fig. 2 and 5 for the defnition of D-categories)
. Non‑standard gastrectomy In non-standard gastrectomy, the extent of gastric resection and/or lymphadenectomy is altered according to tumor stages.
It includes modifed surgery and extended surgery. Modifed surgery The extent of gastric resection and/or lymphadenectomy is reduced (D1, D1+, etc.) compared to standard surgery. Extended surgery (1) Gastrectomy with combined resection of adjacent involved organs. (2) Gastrectomy with extended lymphadenectomy exceeding D2
Adequate gastric resection to achieve negative microscopic
margins is preferred for resectable T1b to T3 tumors, while T4 tumors
require en-bloc resection of involved structures.132 Patients with Tis or T1a
tumors may be considered for EMR in experienced centers.
The standard surgical procedure for clinically node-positive (cN+) or T2–T4a tumors is either total or distal gastrectomy. Distal gastrectomy is selected when a satisfactory proximal resection margin (see above) can be obtained. When obtaining proximal resection margin is not possible, total gastrectomy is selected. Ev
ve duration of PPG is longer than that of DG. During the procedure, the distal part of the stomach is resected, but a pyloric cuff 2-3 cm wide is preserved[6,7]. The right gastric artery and the infrapyloric artery are preserved to maintain the blood supply to the pyloric cuff. In addition, the hepatic and pyloric branches of the vagal nerves are preserved to maintain pyloric function. The celiac branch of the posterior vagal trunk is sometimes preserved. All regional nodes except the suprapyloric nodes (No. 5) should be dissected as in the standard D2 procedure
In particular, in order to maintain pyloric cuff function with PPG, lymph nodes at the suprapyloric and infrapyloric stations may be incompletely dissected due to preservation of the right gastric artery, the infrapyloric artery, and the hepatic and pyloric branches of the vagus nerves[9-11]. In general, PPG is performed in patients who are preoperatively diagnosed with cT1N0M0 primary GC in the middle third of the stomach when the distal border of the tumor is approximately 4-5 cm away from the pylorus[9-12]. This indication is based on the incidence of lymph node metastasis in patients who have undergone conventional gastrectomy[13-16].
PG is generally thought to offer advantages over conventional TG with Roux-en-Y reconstruction in terms of retention of food in the remnant stomach. On the other hand, heartburn or gastric fullness due to esophageal reflux or gastric stasis is a potential disadvantage. However, these advantages and disadvantages depend on the reconstruction method used. During the procedure, all regional nodes except the splenic hilar nodes (No. 10), the distal splenic nodes (No. 11d), the suprapyloric nodes (No. 5), and the infrapyloric nodes (No. 6) are dissected, although the dissection of the distal lesser curvature nodes (No. 3) and the right gastroepiploic artery (No. 4d) is incomplete. The hepatic and pyloric branches of the vagal nerve are preserved to
Maruyama computer program : estimate the risk of lymph node metastasis in each nodal station.
Assess adequacy of lymphadenectomy
Positive lymph node ratio : ratio of positive lymph nodes to all harvested lymph nodes, which might be a more precise predictor of prognosis than the absolute number of positive lymph nodes
dissection of ≥15 lymph nodes positively influences survival in patients
with advanced gastric cancer.
A higher total harvested negative nodes or lower ratio of positive nodes, referred to as the Maruyama index, also saw improvements in both survival and progression free survival [5, 19, 58]. The Maruyama index was created to determine unresected disease as the sum of regional nodal disease, with higher value on the index portending poorer outcome [5, 19, 58]. In 1989, the Maruyama computer program was created based on the data of 3,843 cases from Japanese National Cancer Center database (58). Eight variables including age, gender, Borrmann type, invasion depth, maximal diameter, longitudinal and circumferential tumor location as well as histological classification were used to estimate the risk of lymph node metastasis in each nodal station by matching the input variables to the database of Maruyama computer program
Lymph node dissection may be classified as D0, D1, or D2 depending on
the extent of lymph node removal at the time of gastrectomy.
D0 : incomplete resection of lymph nodes along the
lesser and greater curvature of the stomach.
D1 : removal of the greater and lesser omenta (which includes the right and left
cardiac lymph nodes along lesser and greater curvature and the
suprapyloric lymph nodes along the right gastric artery and infra-pyloric
area).
D2 involves D1 dissection plus the removal of all the lymph nodes
along the left gastric artery, common hepatic artery, celiac artery, and
splenic artery.
dissection of ≥15 lymph nodes positively influences survival in patients
with advanced gastric cancer.
Lymph node dissection may be classified as D0, D1, or D2 depending on
the extent of lymph node removal at the time of gastrectomy.
Non-regional (distant) lymph nodes • Retropancreatic, pancreaticoduodenal, peripancreatic, superior mesenteric, middle colic, para-aortic, retroperitoneal, others
D0 : incomplete resection of lymph nodes along the
lesser and greater curvature of the stomach.
D1 : removal of the greater and lesser omenta (which includes the right and left
cardiac lymph nodes along lesser and greater curvature and the
suprapyloric lymph nodes along the right gastric artery and infra-pyloric
area).
D2 involves D1 dissection plus the removal of all the lymph nodes
along the left gastric artery, common hepatic artery, celiac artery, and
splenic artery.
In principle, D2 lymphadenectomy is indicated for cN+ or ≥cT2 tumors and a D1 or D1+ for cT1N0 tumors. Since pre and intraoperative diagnoses regarding the depth of tumor invasion and nodal involvement remain unreliable, D2 lymphadenectomy should be performed whenever the possibility of nodal involvement cannot be dismissed. D1 lymphadenectomy A D1 lymphadenectomy is indicated for cT1a tumors that do not meet the criteria for EMR/ESD, and for cT1bN0 tumors that are histologically of diferentiated type and 1.5 cm or smaller in diameter. D1+ lymphadenectomy A D1+ lymphadenectomy is indicated for cT1N0 tumors other than the above. D2 lymphadenectomy A D2 lymphadenectomy is indicated for potentially curable cT2–T4 tumors as well as cT1N+ tumors. Spleen should be preserved in total gastrectomy for advanced cancer of the upper stomach provided the tumor does not involve the greater curvature [5] (CQ4). The role of splenectomy for tumors invading the greater curvature remains equivocal
In Eastern countries where the incidence of gastric cancer is high, surgeons performed extensive lymphadenectomy (D2 lymphadenectomy) with low morbidity and mortality, while most Western surgeons preferred more limited lymphadenectomies according to the results of Dutch trial and MRC trial, which failed to show survival benefit of D2 procedure and instead, found pancreaticosplenectomy associating with high incidence of morbidity and mortality
East versus west presepectives
The traditional D2 resection involves a distal pancreatectomy and splenectomy for all tumors except in the antral location, in order to adequately resect lymph node stations 10 and 11 surrounding the splenic artery and hilum. In the UK MRC trial, subset analysis of patients undergoing pancreaticosplenectomy, splenectomy alone, or preservation of both organs showed survival difference, with the poorest survival in those undergoing multi-visceral resection (35). Similarly, the Dutch trial performed a multivariate analysis and showed increased mortality associated with splenic or pancreatic resections. This likely contributed to the lack of survival difference between D1 and D2 resections
gastric cancer in the West is more commonly located in the proximal stomach and presents at a more advanced stage and has a worse prognosis than in the East, where distal gastric cancers are more common (8). Additionally, lower esophageal and proximal gastric adenocarcinoma has been steadily increasing, a phenomena not observed in the East; this has been postulated to be due to a lower incidence of reflux esophagitis and Barretts metaplasia (8). In the West, the incidence of the diffuse and signet ring histologic subtypes occurs more commonly than in the East and are associated with worse prognoses. In addition to the differences in histology, patients in the West tend to present with more advanced disease, whereas nearly half of patients in South Korea and Japan present with early stage disease, a result likely attributable to the national screening progr
However, the type of curative resection and, in particular, the extent of lymph node dissection is debated. While D2 resection is considered the standard procedure in the East, many surgeons in the West continue to perform D1 resections, as randomized controlled trial (RCT) evidence to the contrary has beenlacking. Patients with gastric cancer have a high frequency of regionalized disease with nodal metastasis; relapses after curative surgery due to local or regional lymph node metastasis are common. Local recurrence has been documented in up to 87.5% of patients presenting with relapse [2]; thus, an extended lymph node dissection is advocated by many surgeons to decrease the c
Given the apparent impact of d2 lymphadectomy on disesase specific survival , most centres performing d2
Dissection of No. 10 (splenic hilar lymph nodes) with or without splenectomy for cancer of the upper stomach invading the greater curvature (D2 + No. 10). This procedure had been defned as D2 lymphadenectomy in the previous editions of the Japanese Gastric Cancer Treatment Guidelines (CQ4). – Dissection of No. 14v (superior mesenteric venous lymph node) for cancer of the distal stomach tumor with metastasis to the No. 6 lymph nodes (D2 + No. 14v). – Dissection of No. 13 (posterior pancreas head lymph node) for cancer invading the duodenum (D2 + No. 13) [6]. Metastases to the No. 13 nodes, which are not included in the regional lymph nodes for gastric cancer, should usually be classifed as M1. However, since the No. 13 nodes are among the regional lymph nodes for cancer of the duodenum according to the TNM classifcation and the Japanese Classifcation of Gastric Carcinoma 15th edition, these should be regarded as regional lymph nodes once gastric cancer invades the duodenum. – Dissection of No. 16 (abdominal aortic lymph node) after neoadjuvant chemotherapy for cancer with an extensive lymph node involvement (D2 + No. 16) (CQ5)
w. Seven non-randomized comparisons, three randomized trials and five meta-analyses, almost exclusively of Asian origin, were identified and examined. D3 compared to D2 lymphadenectomy consistently and significantly proved to be associated with a “heavier” iatrogenic surgical trauma translated to more blood loss, prolonged operative time, higher relaparotomy rates and post-procedural surgical and non-surgical morbidity. Oddly mortality in most of these series did not reach statistical significance a fact probably attributed to Asian surgical expertise and/or methodologic drawbacks. All existing evidence and their meta-analyses, including a well-designed RCT from Japan (JCOG), failed to support a clear overall survival benefit linked to D3 dissection thus excluding the procedure from current treatment algorithms. The Italian GC research group, analyzing their database, proposed tumor histology, macroscopic type, size and location as selection criteria for D3 dissection provided surgical expertise is available. Recently, a phase II clinical trial from Japan reported a 3 -year survival rate of 59% in patients with clinically involved para-aortic nodes treated with neoadjuvant chemotherapy followed by D3 lymphadenectomy, rekindled the issue. Future multicenter randomized trials should test the extend and after effect of lymphadenectomy in gastric cancer combined with modern chemotherapeutic agents in multimodal treatments.
Available evidence cannot support D3 lymphadenectomy as advantageous practice for the surgical treatment of resectable advanced gastric cancer. D2 lymphadenectomy is for the time being the recommended extend of nodal excision in gastric cancer surgery. Non-anatomic lymphadenectomy yields an unpredictable and often imperfect number of nodes and is unacceptable in the context of oncologic surgery. Comprehension and consolidation of D2 concept lymphadenectomy in western surgical training consists a high priority. Future trials should test after effect of lymphadenectomy in conjunction with novel chemotherapies
D3 dissection is indisputably a more technically demanding and complicated procedure compared to D1 or D2 as it requires dissection around large vessels located in deep retroperitoneal
LN dissection
Micrometastatic involvement if para aortic boderlineeitehr surgey or neoadj
Bursectomy JCOG1001 trial is complete
Survival denied by this large scale RCT even in posterior tumor or T3,T4
Bursectomy is surgically removing peritoneal lining covering pancreas and anterior plane of transverse mesocolon during gastretomy
.
Djd Digestion and absorption of many substances, such as proteins, fats, fat-soluble vitamins, most water-soluble vitamins (except vitamin B12), and selected microelements (iron, potassium) takes place in the duodenum and initial part of the jejunum. Therefore, the maintenance of partial duodenal passage should in theory improve absorption,
With the increasing expertise and experience of oncologic surgeons in the minimally invasive surgery for gastric cancer, the indication for laparoscopic gastrectomy is expanding to advanced cases.
Laparoscopic surgery for EGC has become popular based on several prospective randomized controlled trials (RCTs) that generally reported improved short-term surgical outcomes with comparable oncological safety to that of open surgery
, several meta-analyses have showed that laparoscopic gastrectomy with limited lymphadenectomy for patients with EGC had non-inferior oncologic outcome relative to open surgery, and a benefit in terms of faster postoperative recovery [5-7]. Based on this evidence, most experienced surgeons have applied the laparoscopic procedure in patients with EGC.
1994, Kitano firstly described the efficacy of laparoscopy gastrectomy (LG) in the case of early stage carcinoma in the antrum of the stomach [6]. Then, the employment of LG for gastric cancer has achieved rapid development and popularities in past decades due to minimal invasion, less blood loss, less time of using analgesic requirement and quicker recovery [7–10]. Another benefit of laparoscopic surgery is the capacity to observe the surgical field in a magnified view, which could help surgeons with more meticulous dissection of lymph nodes which is important to patient’s prognos
However, previous studies showed decreased number of harvested lymph nodes for gastric patients during LG compared with OG [12, 13]. Besides, like all the laparoscopic procedure, port site metastases and seeding during LG were inevitable because of intra-abdominal hyperpressure and adherence of laparoscopic instrument [14–17
However, the use of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains controversial. Several obstacles have been considered as the reasons for this limitation. First, extended (D2) lymphadenectomy is an essential procedure for performing curative resection in AGC patients, which requires more sophisticated surgical techniques to ensure patient safety. Owing to some limitations of laparoscopic surgery such as impossible palpation, unsecure bleeding control, among others, the experience and skill of surgeons is more important in laparoscopic surgery for AGC. Second, some researchers have expressed the concern that the laparoscopic procedure for advanced malignant disease might aggravate cancer progression via the intraoperative intraperitoneal pressure and circulating gas.
Several Eastern multicenter randomized controlled trials demonstrated the safety and efficacy of laparoscopic distal gastrectomy regarding hospital stay, postoperative complications, and lymph node yield
There are no Western multicenter randomized controlled trials comparing laparoscopic with open distal gastrectomy or laparoscopic with open total gastrectomy.1
The Western population has a lower incidence of gastric cancer, more comorbidities, higher body mass index, higher age and presents with more advanced tumor stages.11 Moreover, hospital case volumes are markedly lower, total gastrectomy is more frequently performed, and perioperative chemotherapy is more frequently
Due to the lack of level-1 evidence, concerns of a reduced lymph node yield in patients with advanced gastric cancer still exist and Western guidelines do not generally consider laparoscopic gastrectomy a standard treatment option
. Laparoscopic gastrectomy resultedinlessintraoperativebloodloss andalonger operating time. This is the first multicenter trial to support the safety and efficacy of laparoscopic total and distal gastrectomy in aWestern population.10 These results supportthe use of laparoscopic gastrectomy as an alternative to open gastrectomy, but superiority could notbe demonstrated. Surgical teams trained in laparoscopic gastrectomy may offer laparoscopic gastrectomy as an alternative approach.
Follow-up should continue for no longer than 5 years after which patients should be referred to regional general physicians or should be encouraged to undergo surveillance examinations provi
D2 gastrectomy with a minimal lymph node dissection of 15 for staging purposes remains an appropriate surgical treatment for gastric adenocarcinoma
With increasing experience and expertise of oncologic surgeons in the minimally invasive approach to gastric resection for cancer, it is becoming evident that laparoscopy as a technique for resection, provides equivalent resections with equivalent lymphadenectomy comparable to the open approach with no compromise in recurrence or long-term survival
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Open gastrectomy with a minimal lymph node dissection of 15 for staging purposes remains an appropriate surgical treatment for gastric adenocarcinoma in the West. With increasing experience and expertise of oncologic surgeons in the minimally invasive approach to gastric resection for cancer, it is becoming evident that laparoscopy as a technique for resection, provides equivalent resections with equivalent lymphadenectomy comparable to the open approach with no compromise in recurrence or long-term survival based on preliminary studies. In addition, based on the known benefits of the minimally invasive approach including reduced surgical trauma, blood loss, pain and quicker recovery for the patient, we are encouraged to expand our indications for this approach. T
In accordance with the evolution of surgical instrumentation and increased laparoscopic surgical experience, its indication has been extended to advanced cases. Recent studies show that the oncologic outcomes of laparoscopic gastrectomy for EGC are comparable to those of open gastrectomy. The demonstration of a similarly optimal result regarding the safety of laparoscopic gastrectomy in AGC is awaited. The results of several ongoing multicenter RCTs are expected to establish concrete evidence of the widespread suitability of laparoscopic gastrectomy in the treatment of gastric cancer.
