Significance of super-extended (D3) lymphadenectomy in gastric cancer surgery

Background: The extension of lymphadenectomy is a matter of debate in gastric cancer surgery. The purpose of the present study was to analyse our experience on D3 lymphadenectomy in the treatment of gastric cancer with special reference to post-operative morbidity and mortality, incidence of para-aortic nodal metastases and long-term prognosis. Methods: The results of 201 patients who underwent potentially curative gastrectomy with D3 lymphadenectomy for non-metastatic gastric adenocarcinoma at the First Department of General Surgery, University of Verona, from January 1988 to December 2004, were analysed statistically. The analysis did not include gastric stump and linitis plastica type tumors. Results: Twenty-six out of the 201 patients (12.9%) showed para-aortic nodal metastases. Para-aortic node involvement was significantly higher in upper third tumors (29.1%) with respect to middle (6.1%) and lower third (7.5%) (P<0.001). Sixty-two patients (30.8%) developed post-operative complications with pulmonary affections (7%), pancreatic fistulas (4.5%) and abdominal abscesses (4.5%) as the most frequently observed complaints. In-hospital mortality was 1.5%. Overall 5-year survival rate for R0-patients was 53.6%. Considering survival in relation to nodal involvement, interestingly, patients with non-regional lymph node metastases (M1a) showed a slightly better prognosis with respect to pN3 patients (3-year survival: 13.9% and 19.4% for pN3 and M1a classes, respectively). Conclusions: D3 lymphadenectomy should be considered in curative surgery for advanced gastric cancer, especially for upper third tumors, with an acceptable morbidity and no increase in mortality. Further studies with a larger number of patients are required to confirm its prognostic value.