Japanese surgical results on gastric cancer seen as gold standard, however, their good results have never been matched in the West. Better Japanese outcomes might be at least partially due to the fact that gastric cancer in Japan are localised more distally (antrum versus proximal stomach), are less of diffuse type, less obese patients, more radical surgery.
Total gastrectomy mortality is similar between Tokyo and Leeds studies, however, D2 gastrectomy in the West has never achieved significant survival benefit over D1 lymphadenectomy. Stage 2 cancers are the only ones that may benefit from a D2 lymphatic dissection.
The original Dutch study (Lancet 1995) randomising D1 and D2 resections showed no survival benefit at 11 years post-surgery. MRC study shows a higher mortality for D2 but no difference in five years survival (33% D1 vs 35% D2). However, a criticism was that most Western surgeons were on their learning curve and the higher mortality was registered in the pancreatico-splenectomy group (12%T3 and 40% T4 have lymph node mets at the splenic hilum). Cochrane review of D2 shows overall no benefit for D2 lymphadenectomy. D2 is recommended only for stage 2/3 in high-volume centres. JCOG 9501: D2 vs D3 (para aortic node dissection): no survival benefit.
Summary:
1. No benefit from superextended surgery (D2 can be performed in high-volume centres)
2. No need for prophylactic pancreatico-splenectomy
3. No para-aortic node dissection
4. New field of interest: quality of life and adjuvant/neoadjuvant chemotherapy
Laparoscopic gastrectomies results
Difficult to compare East and West: In the east more laparoscopic assisted procedures and early disease, whilst in the west various procedures and less numbers. There is a benefit for quality of life for laparoscopic assisted distal gastrectomy.
Consider suitability for Siewert type III; young patients and advanced disease, multiple organ resections.