title: Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis.
abstract: BACKGROUND
  Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy.
  
  
  METHODS
  Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate.
  
  
  RESULTS
  Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null.
  
  
  CONCLUSIONS
  These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy. Electronic address: gennaro.galizia@unina2.it.
authors.forename: Gennaro
authors.initials: G
authors.lastname: Galizia
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Eva
authors.initials: E
authors.lastname: Lieto
authors.affiliation: Division of Medical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Ferdinando
authors.initials: F
authors.lastname: De Vita
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Castellano
authors.affiliation: Unit of Pathology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Ferraraccio
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Zamboli
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mabilia
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Annamaria
authors.initials: A
authors.lastname: Auricchio
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: De Sena
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: De Stefano
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Cardella
authors.affiliation: Division of Surgical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Barbarisi
authors.affiliation: Division of Medical Oncology, Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, School of Medicine, Naples, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Orditura
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D005260:Female; D005743:Gastrectomy; D006801:Humans; D008197:Lymph Node Excision / Q000009:adverse effects / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000209:etiology; D016016:Proportional Hazards Models; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*