title: D2 or not D2? The gastrectomy question.
abstract: BACKGROUND
  The best reported long-term survival following surgery for gastric cancer is from centers performing radical D2 gastrectomy. Yet comparative studies from European centers report higher rates of postoperative complications following D2 gastrectomy than after the less radical D1 gastrectomy, without any benefit in survival. We aimed to compare the outcome after modified D2 gastrectomy (preserving spleen and pancreas where possible), performed by specialist surgeons, with that after conventional D1 gastrectomy performed by general surgeons for gastric cancer in a large United Kingdom cancer unit.
  
  
  METHODS
  Two groups of patients were studied: a historical control group of 245 consecutive patients with gastric cancer, of whom 50 underwent a potentially curative D1 resection (median age, 69 years; 35 males) was compared with 200 consecutive patients, 72 of whom underwent a potentially curative D2 resection (median age, 71 years; 47 males).
  
  
  RESULTS
  Among the 122 patients judged to have curable cancers, patients who underwent a D2 gastrectomy had lower operative mortality (8.3% vs 12%; chi(2) = 0.48; P = 0.50) and experienced fewer complications (28% vs 36%; chi(2) = 0.93; P = 0.35) than patients who underwent a D1 gastrectomy. Cumulative survival at 5 years was 56% after D2 resections, compared with 11% after D1 resections ( P < 0.00001). In a multivariate analysis, only the stage of disease (stage I, hazard ratio [HR], 0.068; P = 0.0001; stage II, HR, 0.165; P = 0.001; stage III, HR, 0.428; P = 0.053) and the level of lymphadenectomy (HR, 0.383; P = 0.00001) were independently associated with the duration of survival.
  
  
  CONCLUSIONS
  Modified D2 gastrectomy without pancreatico-splenectomy, performed by specialist surgeons, can improve survival after R0 resections without increasing operative morbidity and mortality, when compared with D1 gastrectomy performed by general surgeons.
authors.affiliation: Department of Surgery, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, UK.
authors.forename: Wyn G
authors.initials: WG
authors.lastname: Lewis
authors.forename: Paul
authors.initials: P
authors.lastname: Edwards
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Barry
authors.forename: Saboor
authors.initials: S
authors.lastname: Khan
authors.forename: Daljit
authors.initials: D
authors.lastname: Dhariwal
authors.forename: Ilias
authors.initials: I
authors.lastname: Hodzovic
authors.forename: Miles C
authors.initials: MC
authors.lastname: Allison
authors.forename: Kenneth
authors.initials: K
authors.lastname: Shute
mesh_terms: D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000401:mortality*; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D015999:Multivariate Analysis; D010180:Pancreatectomy; D013156:Splenectomy; D013274:Stomach Neoplasms / Q000401:mortality* / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome