Postoperative morbidity and mortality after D-1 and D-2 resections for gastric cancer: Preliminary results of the MRC randomised controlled surgical trial

Background In Japan the surgical approach to treatment of potentially curable gastric cancer, including extended lymphadenectomy, seems in retrospective surveys to give better results than the less radical procedures favoured in Western countries. There has, however, been no evidence from randomised trials that extended lymphadenectomy (D-2 gastric resection) confers a survival advantage. This question was addressed in a trial involving thirty-two surgeons in Europe. Methods In a prospective randomised controlled trial, D-1 resection (level 1 lymphadenectomy) was compared with D-2 resection (levels 1 and 2 lymphadenectomy). Central randomisation (200 patients in each arm) followed a staging laparotomy. Findings The D-2 group had greater postoperative hospital mortality (13% vs 6.5%; p=0.04 [95% CI 9-18% for D-2, 4-11% for D-1] and higher overall postoperative morbidity (46% vs 28%; p<0.001); their postoperative stay was also longer. The excess postoperative morbidity and mortality in the D-2 group was accounted for by distal pancreatico-splenectomy and splenectomy. In the whole group (400 patients), survival beyond three years was 30% in patients whose gastrectomy included en-bloc pancreatico-splenic resection versus 50% in the remainder. Interpretation D-2 gastric resections are followed by higher morbidity and mortality than D-1 resections. These disadvantages are consequent upon additional pancreatectomies and distal splenectomies, and in long-term follow-up the higher mortality when the pancreas and spleen are resected may prove to nullify any survival benefit from D-2 procedures.