Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma

Abstract

The contention that the R2 radical gastrectomy for localized and potentially curable gastric carcinoma may be superior to gastrectomy without lymphadenectomy (R1) was assessed by randomized trial. Five years after commencement 403 patients have been evaluated at surgery and only 43 (11 per cent) found eligible (S0-2, P0, H0, N0-1), 22 of whom underwent R1 and 21 R2 gastrectomy. Seven patients had final histological stages in excess of the protocol. The R2 group had a longer operating time (P less than 0.005), a greater blood transfusion requirement (P less than 0.005), a longer hospital stay (0.05 greater than P greater than 0.025) and required reoperation in four cases. There were no postoperative deaths. Four patients have died from the disease in the R1 group and five in the R2 group, there being no difference in the probability of survival at a median follow-up of 3.1 years. The small proportion of patients suitable for radical R2 surgery, the high associated morbidity and the fact that survival advantage has yet to be proven in trial suggest that this procedure should not yet be performed outside of controlled clinical trials.

Adjuvant and neoadjuvant therapy for gastric cancer using epirubicin/cisplatin/5-fluorouracil (ECF) and alternative regimens before and after chemoradiation

“…Likewise, adjuvant radiotherapy alone has also failed to demonstrate any survival benefit (Hallissey et al, 1994). Recognition of the high locoregional failure rates following surgery has resulted in four separate randomised trials evaluating the role of extended lymph node dissection (Robertson et al, 1994;Dent et al, 1988;Bonenkamp et al, 1999;Cuschieri et al, 1999). All the four trials demonstrate a substantial increase in morbidity and, in some series, operative mortality with extended lymph node dissection.…”

Rationale for extensive lymphadenectomy in early gastric carcinoma

“…This relatively small survival benefit must be considered against the increased operative risks of extended lymphadenectomy. Although the operative mortality rate of 2% associated with the ELND procedure seems to be acceptable, some researchers have reported that more aggressive surgery may be related to higher operative morbidity and mortality (Diggory and Cuschieri, 1985;Heberer et al, 1988;Dent et al, 1988). In addition, the ELND procedure presents the disadvantage of longer operation time and greater blood loss, although these factors were not associated with any increase in the mortality rate (de Aretxabala et al, 1987;Smith et al, 1991;Pacelli et al, 1993).…”

“…Japanese surgeons normally perform extensive lymphadenectomy for EGC because a certain proportion of these patients have lymph nodal involvement and carcinoma recurrence is not rare. In contrast, most surgeons in Western countries do not use aggressive surgery (Cuschieri, 1986;Heberer et al, 1988;Irvin and Bridger, 1988;Heesakkers et al, 1994), perhaps because of uncertainty regarding improvement in the survival rate and the high operative risk associated with extensive lymph node dissection (Dent et al, 1988;Heberer et al, 1988;Irvin and Bridger, 1988).To evaluate the therapeutic value of extensive lymphadenectomy in EGC, we analysed retrospectively the causes of death after surgery and compared the 10 year disease-specific survival rate in patients who had received extensive lymphadenectomy with patients who had received simple gastric resection. (LLND).…”

A clinicopathological study of asymptomatic gastric cancer

“…As for the type of surgical intervention, the effect of extended lymph node dissection on survival remains somewhat controversial, especially in western countries (Dent et al, 1988;Robertson, 1994 1650 complications or rather small early cancer, which is a good candidate for conservative surgery. Early detection is unquestionably effective for improving survival (Green et al, 1988).…”