D2-Lymphadenectomy in gastric cancer: Analysis of risk factors for morbility and mortality in a single institution experience and short literature review

AIM: Lymph node metastasis is the most important prognostic factor in gastric cancer and for this reason gastrectomy with lymphoadenectomy is the only curative treatment option for this disease. The influence of D2-lymphadenectomy on morbidity, mortality and long-term survival is still controversial: the data of Western institutions generally reported a significant increase in postoperative complications after D2 resection compared to Japanese institutions. The aim of this study was to analyze the risk factors for complications after D2 dissection in a single-institution experience. METHODS: For the present retrospective study we only considered 93 patients (53 male and 40 female) that were undergoing surgical resection and D2 dissection for gastric adenocarcinoma from January 2003 to February 2009. Thirty-two total gastrectomies were performed; distal pancreatectomy was only performed in the cases of direct invasion of pancreatic tail (4 cases) and lymphadenectomy of splenic hilum (7 cases) which was always achieved by pancreas preserving splenectomy. The mean number of removed lymph nodes was 34+/-10 (Range 65-14) and in 64 pN+ patients we found a mean of 15+/-10 positive lymph nodes. The potential risk factors for morbidity and mortality were analyzed by univariate and multivariate analysis. RESULTS: Postoperative morbidity and mortality rates were 33% (31patients) and 2% (1 patient) respectively. Pancreatic fistula, abdominal abscess and pneumonia were the three most important observed complications. A univariate analysis shows that patients who underwent a splenectomy or a splenopancreasectomy, submitted to non-curative surgery, and that received perioperative blood transfusion showed a significant association with the incidence of postoperative complications. Low preoperative level of haemoglobin and high creatinine level and ASA score are also directly related to postoperative complications. Mortality rate was associated with advanced age, presence of cardiopulmonary disease, surgical radicality and, finally, with creatinine level (18%). In a multivariate analysis splenopancreasectomy, high creatinine level and ASA class II/III were independent factors related to postoperative complications. CONCLUSION: In our experience the D2 standard lymphoadenectomy, according to the results of Japanese institutions, seems to be the most attractive procedure in the surgical management of gastric cancer. In specialized centers this approach may be performed with an acceptable risk of postoperative complications and deaths: in our experience the incidence of postoperative complications do not differ from those reported in different Japanese and some European studies. Moreover the majority of the reported complications in our casuistry could be resolved favorably with a specific medical approach. The correct patient selection and the evaluation of the potential risk factors in addition to adequate surgical approach and postoperative management and care can considerably reduce the incidence of postoperative problems and deaths.