Trials in gastric cancer surgery

Presenter Dr Pankaj Kumar GargModerator Dr Sunil Kumar

Learning objectives• Extent of Gastric resection• Extent of Lymphadenectomy• Omentectomy• Bursectomy• Laparoscopic gastric cancer surgery• Nasogastric drainage• Surgical Site infection prophylaxis• Intraperitoneal drain placement

EXTENT OF GASTRECTOMY

Extent of GastrectomyTypes of Gastric resections1.Total gastrectomy2.Distal gastrectomy3.Pylorus preserving gastrectomy4.Segmental gastrectomy5.Local resections

• Resection line decided by– T1 tumors 2 cm– T2 and deep tumors 3 cm

(Type 1 and 2) – T2 and deep tumors 5 cm

(Type 3 and 4) If these rules not followed – Frozen section

• Distal tumors Distal gastrectomy• Proximal tumorsTotal gastrectomy

• Proximal tumorsNo RCT• Distal tumors Three RCTs

Distal Vs. Total gastrectomy

• Total patients randomized 201 • No difference in post operative morbidity (32 % vs 34%), No

mortality in any group• No difference in five year survival

Distal Vs. Total gastrectomy

• Total patients randomized 55 • Significant difference in post operative

morbidity and mortality in TG group• Median survival better in SG groups (1511 vs.

922 days, p < 0.05)

Distal Vs. Total gastrectomy

• Total patients randomized 618 • No difference in post operative morbidity and

mortality in any group• No difference in five year survival (65.3% vs

62.4%)

EXTENT OF LYMPHADENECTOMY

Extent of Lymphadenectomy D1 vs D2

• Total patients randomized 711• Significant difference in post operative morbidity (25%

vs. 43%, P value < 0.001) and mortality (4% vs. 10%. P value < 0.001)

• No significant difference in 5 year survival (43% vs. 47%.) and local recurrence rate (43% vs. 37%)

Extent of Lymphadenectomy D1 vs D2

• Total patients randomized 711• No significant difference in 11 year survival (30%

vs. 35%.)

Extent of Lymphadenectomy D1 vs D2

• Overall 15-year survival 21% vs. 29% (p=0.34). Gastric-cancer-related death rate (48%, vs. 37%, 123 patients),

• Local recurrence 22% vs. 12% • Regional recurrence was 19% versus 13%. • Spleen-preserving D2 resection technique the

recommended surgical approach

• Patients 400• 5-year survival rates were 35% for D1

resection and 33% for D2 resection (difference –2%, 95% CI = –12%–8%)

Flaws in the British and Dutch Trial

• No quality control surgery; Surgeon explained D2 dissection with videotapes and booklets.

• Involved many low volume centers doing a few gastric resections per year

• High non compliance• Routine splenectomy and distal splenectomy

in all D2 dissections, Also included pancreatectomy in many D2 dissections

• In specialized centres, the rate of complications following D2 dissection is much lower than in published randomized Western trials.

Extent of Lymphadenectomy D1 Vs D3

Wun wu et al, University of Taipei, Taiwan• Patients 221• The average number of lymph nodes removed was 42.7 in D2

and 68.7 in D3• Overall 5-year survival significantly higher in D3 surgery than

in D1 surgery (59·5% vs 53·6%). • 215 R0 resection patients : recurrence of 50·6% for D1 and

40·3% for D3 at 5 years

Extent of Lymphadenectomy D2 Vs D2+

• Yonemura et al, Shizuoka Cancer Center, Japan• Patients 293• The average number of lymph nodes removed was 42.7 in D2

and 68.7 in D2+• Five-year survival was 52.6% for the 135 D2 dissection and

55.0% for D2+dissection.• Prophylactic D4 dissection not recommended for patients

with potentially curable advanced gastric cancer.

• Patients 523• No significant differences between the two

groups in the frequencies of anastomotic leakage, pancreatic fistula, abdominal abscess, pneumonia, or death from any cause within 30 days after surgery

Minimally invasive gastric surgery

• Ming Cui et al. Peking University Cancer Hospital and Institute, Beijing, China

• Patients 209

Laparoscopic D2 dissection is equivalent to OG in the number of HLNs, regardless of tumor location. Thus, this procedure can achieve the same radicalness as OG.

Omentectomy

• Planned sample size: 250• AIM: To evaluate the impact of omentectomy

for advanced gastric cancer on patient survival.

• Endpoint: 3-year relapse-free survival rate

BURSECTOMY

• Imamura et al. Sakai, Japan.

• Imamura et al. Sakai, Japan.• Experienced surgeons could safely perform a

D2 gastrectomy with an additional bursectomy without increased major surgical complications.

• Fuzita et al, Osaka, Japan• Patients: 210 patients with cT2–T3• No difference in Morbidity and mortality• 3-year OS rates 85.6% in the bursectomy

group and 79.6% in the non-bursectomy group• Among 48 serosa-positive (pT3–T4), the 3-year

OS was 69.8% for the bursectomy group and 50.2% for the non-bursectomy group.

INTRAPERITONEAL DRAINAGE

Intraperitoneal drainage

• Patients 170• Procedure: Subtotal or total gastrectomy with

D2 dissection• No difference in postoperative complications

Intraperitoneal drainage

• Patients 60• Procedure: Total gastrectomy with D2

dissection• Postoperative morbidity, hospital stay

significantly higher in patients with drains

NASOJEJUNAL DECOMPRESSION

Nasojejunal decompression

• Patients: 237• Procedure Total gastrectomy• No difference in anastomotic leak, postoperative morbidity

and mortality• Major postoperative complications (25.9% and 21.5%, P=.42) • Overall postoperative mortality (0.9% and 0.8%, respectively;

P=.50

SURGICAL SITE PROPHYLAXIS

Surgical site infection prophylaxis

• Patients: 501• Procedure: Gastric cancer surgery• SSI rate was 9·5 per cent (23 of 243) and 8·6

per cent (21 of 243) • Antimicrobial prophylaxis had no major

adverse effects.

Current evidence

• Spleen preserving D2 dissection is the standard of care for T2-4 gastric cancer

• Complete bursectomy is likely to improve survival and to decrease in local recurrence in advanced gastric cancer.

• No role of routine intra-peritoneal drainage and naso-jejunal drainage.

• Single dose anti-microbial prophylaxis seems sufficient.