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Systematic review and meta‐analysis of the effectiveness and safety of extended lymphadenectomy in patients with resectable gastric cancer. BJS 2014; 101: 595-604.

Published: 25th March 2014

Authors: L. Jiang, K.‐H. Yang, Y. Chen, Q.‐L. Guan, P. Zhao, J.‐H. Tian et al.

Background

The extent of lymphadenectomy in the treatment of gastric cancer has been debated for more than two decades. This meta‐analysis sought to evaluate the effectiveness and safety of extended lymphadenectomy in patients with gastric cancer.

Method

A comprehensive search was performed to identify randomized clinical trials (RCTs) comparing the outcomes of D1 and D2 dissection for gastric cancer in PubMed, EMBASE, the Cochrane Library, Science Citation Index, Web of Science and the Chinese Biomedical Literature Database in any language from inception of the database to March 2012. Meta‐analyses were performed using Review Manager software.

Results

Eight RCTs including a total of 2044 patients (D1, 1042; D2, 1002) were eligible for meta‐analysis. Five‐year survival and haemorrhage rates were similar in the two groups. There were significant differences in morbidity, anastomotic leakage, pancreatic leakage, reoperation rates, wound infection, pulmonary complications and postoperative mortality, all of which favoured D1 dissection. Subgroup analysis indicated a trend towards lower gastric cancer‐related mortality in patients undergoing D2 dissection who did not also have resection of the spleen or pancreas.

Conclusion

D2 dissection was associated with a significantly higher postoperative risk. A trend towards lower gastric cancer‐related mortality was found following D2 dissection that did not include resection of the spleen or pancreas, but further long‐term survival data are needed to determine whether there is a specific survival benefit after D2 dissection.

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1 Comment

Kirsty McFarlane

3 years ago

We carefully read the results of the meta-analysis by Jiang and colleagues comparing D1 and D2-lymphadenectomy for gastric cancer (1) and concluding that D2-dissection is associated with a higher postoperative morbidity without any sure survival benefit. We considered its study selection criteria and we appreciated the methodological rigor applied.

We read with similar interest the results of another meta-analysis by Jiang and colleagues (2), concluding that D2-lymphadenectomy offers the most survival benefit. We also verified the good methodological accuracy of this study and we retrieved all the same trials considered in the last meta-analysis.

Quid est veritas? In their meta-analyses the authors reported comparable results, but they presented some quite different discussion details, implying conclusions less (1) or more (2) supporting D2-lymphadenectomy.

Very similar convincing results and controversial conclusions can be found in other two meta-analyses published in the last three years (3,4).

The key to understanding the matter of debate on lymphadenectomy in gastric cancer is not continuing to elaborate complex although accurate meta-analyses, but by definitively admitting the previous evidence’s mistakes. As Cuschieri himself claims, the results of the MRC trial and in our view those of the Dutch trial “are no longer a sustainable argument against D2-gastrectomy in modern surgery” (5).

Most guidelines already include D2 lymphadenectomy for the cure of gastric cancer. We do not need further data confirming once again the well-know and previously reported bad outcomes for D2-dissection. Perhaps we do not need further data confirming once again the efficacy of D2-dissection.

Rausei Stefano
Mangano Alberto
Ruspi Laura
Frattini Francesco
Boni Luigi
Dionigi Gianlorenzo

Department of Surgery
University of Insubria
Viale Luigi Borri 57
Varese 21100
Italy
s.rausei@libero.it

References:
1. Jiang L, Yang K-H, Chen Y, et al. Systematic review and meta-analysis of the effectiveness and safety of extended lymphadenectomy in patients with resectable gastric cancer. Br J Surg 2014; 101: 595-604.
2. Jiang L, Yang KH, Guan QL, Zhao P, Chen Y, Tian JH. Survival and recurrence free benefits with different lymphadenectomy for resectable gastric cancer: a meta-analysis. J Surg Oncol 2013; 107: 807-814.
3. Seevaratnam R, Bocicariu A, Cardoso R, Mahar A, Kiss A, Helyer L, Law C, Coburn N. A meta-analysis of D1 versus D2 lymph node dissection. Gastric Cancer 2012; 15 Suppl 1: S60-S69.
4. Memon MA, Subramanya MS, Khan S, Hossain MB, Osland E, Memon B. Meta-analysis of D1 versus D2 gastrectomy for gastric adenocarcinoma. Ann Surg 2011; 253: 900-911.
5. Cuschieri SA, Hanna GB. Meta-Analysis of D1 Versus D2 Gastrectomy for Gastric Adenocarcinoma: Let Us Move on to Another Era. Ann Surg 2013; Dec 23.