Zhang Chun-Dong, Yamashita Hiroharu, Seto Yasuyuki
Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
Ann Transl Med. 2019 Sep;7(18):493. doi: 10.21037/atm.2019.08.48.
Gastrectomy plus D2 lymphadenectomy plays a decisive role in the management of resectable gastric cancer in Japan. Before recent advances in chemotherapy, Japanese surgeons considered that extensive surgery involving extended lymphadenectomy with combined resection of neighboring organ(s) was required to eliminate any possible lymphatic cancer spread and improve patient survival. This approach differs radically from that in Western countries, which aim to improve survival outcomes by multidisciplinary approaches including perioperative chemotherapy and/or radiotherapy with limited lymph node dissection. However, a randomized controlled trial conducted in Japan found that more extensive lymphadenectomy including the para-aortic lymph nodes provided no survival benefit over D2 lymphadenectomy. Splenic hilum dissection with splenectomy also failed to show superiority over the procedure without splenectomy in patients with proximal gastric cancer, except in cases with tumor invasion of the greater curvature. Furthermore, bursectomy recently demonstrated similar outcomes to omentectomy alone. Although "D2 lymphadenectomy" as carried out in Japan contributes to low local recurrence rates and good survival outcomes, the results of randomized controlled trials have led to a decreased extent of surgical resection, with no apparent adverse effects on survival outcome. Notably, gastrectomy with D2 dissection has tended to become acceptable for advanced gastric cancer in Western countries, based on the latest results of the Dutch D1D2 trial. Differences in surgical practices between the West and Japan have thus lessened and procedures are becoming more standardized. Japanese D2 lymphadenectomy for advanced gastric cancer is evolving toward more minimally invasive approaches, while consistently striving to achieve the optimal surgical extent, thereby promoting consensus with Western counterparts.
在日本，胃切除术加D2淋巴结清扫术在可切除胃癌的治疗中起着决定性作用。在化疗取得最新进展之前，日本外科医生认为，需要进行广泛的手术，包括扩大淋巴结清扫术并联合切除邻近器官，以消除任何可能的淋巴癌扩散并提高患者生存率。这种方法与西方国家的方法截然不同，西方国家旨在通过多学科方法（包括围手术期化疗和/或放疗以及有限的淋巴结清扫术）来提高生存结果。然而，日本进行的一项随机对照试验发现，包括主动脉旁淋巴结清扫在内的更广泛的淋巴结清扫术与D2淋巴结清扫术相比，并没有生存获益。对于近端胃癌患者，脾门淋巴结清扫加脾切除术也未显示出优于未行脾切除术的手术方式，除非肿瘤侵犯大弯侧。此外，最近的研究表明，切除囊与单纯切除大网膜的结果相似。尽管日本实施的“D2淋巴结清扫术”有助于降低局部复发率并取得良好的生存结果，但随机对照试验的结果导致手术切除范围缩小，且对生存结果没有明显的不利影响。值得注意的是，基于荷兰D1D2试验的最新结果，西方国家对于进展期胃癌采用D2淋巴结清扫的胃切除术已逐渐被接受。因此，西方和日本在手术方式上的差异有所减小，手术操作也越来越标准化。日本针对进展期胃癌的D2淋巴结清扫术正在朝着更微创的方法发展，同时始终努力实现最佳的手术范围，从而促进与西方同行达成共识。
