Department of General Surgery, McGill University Health Centre, Montreal, QC, Canada.
Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada.
J Gastrointest Surg. 2018 Mar;22(3):414-420. doi: 10.1007/s11605-017-3633-5. Epub 2017 Nov 9.
Despite evidence of oncologic benefits from extended (D2) lymphadenectomy in gastric cancer from many East Asian studies, there is persistent debate over its use in the West, mainly due to perceived high rates of morbidity and mortality. This study evaluates the safety and efficacy of D2 dissection in a high-volume North American center.
A prospectively entered database of all patients undergoing gastrectomy for cancer at a North American referral center from 2005 to 2016 was reviewed. Wedge resections, thoracoabdominal approach, emergency surgery, palliative operations, and non-adenocarcinoma cases were excluded.
Of 366 non-bariatric gastrectomies over this period, 175 met the inclusion criteria. Median age was 73 years and 69% were male. One hundred forty-one patients (80%) underwent D2 dissection, the rest having D1. There was no difference in postoperative complications (D1 = 44%: D2 = 42%), anastomotic leaks (D1 = 6%: D2 = 5%), and same-admission or 30-day mortality (D1 = 6%: D2 = 2%). D2 dissection was associated with higher pathological stage (72% > stage 1 vs 38% > stage 1; p < 0.05) and median lymph node yield (30 vs 14; p < 0.05), with no difference in complete resection (R0) rate (D1 = 98% vs D2 = 92%). Laparoscopic approach was employed in 34% (45/141) of D2 cases, resulting in shorter median length of stay (6 days vs 9; p < 0.05) and equivalent oncologic outcomes compared to open D2.
This study supports the use of D2 lymphadenectomy, by either open or laparoscopic approach, in high-volume North American centers as a safe and effective oncologic procedure for gastric cancer, with equivalent complication rates and superior lymph node yield to traditional D1 dissection.
尽管许多东亚研究都表明胃癌扩大（D2）淋巴结清扫术具有肿瘤学益处，但在西方，对于这种方法的使用仍存在持续争议，主要是因为人们认为其发病率和死亡率较高。本研究评估了在北美高容量中心进行 D2 解剖的安全性和有效性。
回顾了 2005 年至 2016 年期间在北美转诊中心接受胃癌胃切除术的所有患者的前瞻性输入数据库。排除楔形切除术、胸腹联合入路、急诊手术、姑息性手术和非腺癌病例。
在此期间，366 例非减肥胃切除术中，有 175 例符合纳入标准。中位年龄为 73 岁，69%为男性。141 例（80%）患者行 D2 清扫术，其余患者行 D1 清扫术。术后并发症（D1=44%：D2=42%）、吻合口漏（D1=6%：D2=5%）和同院或 30 天死亡率（D1=6%：D2=2%）无差异。D2 清扫术与较高的病理分期（72%>1 期比 38%>1 期；p<0.05）和中位淋巴结产量（30 比 14；p<0.05）相关，完全切除（R0）率无差异（D1=98%比 D2=92%）。腹腔镜方法应用于 34%（45/141）的 D2 病例，中位住院时间较短（6 天比 9 天；p<0.05），与开放 D2 相比，肿瘤学结果相当。
本研究支持在北美高容量中心采用开放或腹腔镜方法进行 D2 淋巴结清扫术，作为一种安全有效的胃癌治疗方法，并发症发生率与传统 D1 清扫术相当，但淋巴结产量更高。
