Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons.

Abstract

Background/Aims: A randomized study was per formed to evaluate morbidity and mortality after D2 (level 1 and 2 lymphadenectomy) and D4 (D2 plus lymphadenectomy of para-aortic lymph nodes) dis section for advanced gastric cancer. Methodology: Two hundred and fifty-six patients with advanced gastric adenocarcinoma were enrolled (128 to each group). Patients were randomly allocat ed into D2 (N=128) or D4 (N=128) group. The first and second tiers of lymph nodes are removed in D2 dissection. In D4 gastrectomy, the paraaortic lymph nodes were additionally removed. Results: There was no indication of significant dis tribution bias with regard to age, sex, T-grade, and N-grade between the two groups. Operation time of D4 gastrectomy (369±120 min) was significantly longer than that of D2 gastrectomy (273±1103 min), and blood loss of the D4 group (872±683mL) was sig nificantly greater than that of the D2 group (571±527mL).(PcO.OOl). Five (4%) and two (2%) medical complications developed in the D2 and D4 groups, respectively. Surgical complications devel oped in 28 (22%) and 48 patients (38%) after D2 and D4 gastrectomy. The most common complications were anastomotic leakage, pancreatic fistula, and abdominal abscess. Pancreatic fistula developed in 6 (19%) of 32 patients after D4 plus pancreatosplenectomy, but the inci dence of pancreatic fistula after D2 gastrectomy plus pancreatosplenectomy was low (6%, 1/16). Two patients died within 30 days of operation (0.8%, 2/256), and each patient belonged to the D2 and D4 group. Conclusions: Although there is a significantly high er surgical complication rate in D4 dissection, D4 dis section can be done safely as D2 dissection when per formed by well-trained surgeons.