Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.

PURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years. CONCLUSION: Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

Extended lymph-node dissection for gastric cancer.

BACKGROUND: Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hospitals in which we compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery. METHODS: Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 group) underwent the randomly assigned treatment with curative intent, and 285 received palliative treatment. The procedures for quality control included instruction and supervision in the operating room and monitoring of the pathological results. RESULTS: Patients in the D2 group had a significantly higher rate of complications than did those in the D1 group (43 percent vs. 25 percent, P<0.001), more postoperative deaths (10 percent vs. 4 percent, P= 0.004), and longer hospital stays (median, 16 vs. 14 days; P<0.001). Five-year survival rates were similar in the two groups: 45 percent for the D1 group and 47 percent for the D2 group (95 percent confidence interval for the difference, -9.6 percent to +5.6 percent). The patients who had R0 resections (i.e., who had no microscopical evidence of remaining disease), excluding those who died postoperatively, had cumulative risks of relapse at five years of 43 percent with D1 dissection and 37 percent with D2 dissection (95 percent confidence interval for the difference, -2.4 percent to +14.4 percent). CONCLUSIONS: Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer.

Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients.

For patients with gastric cancer deemed curable the only treatment option is surgery, but there is disagreement about whether accompanying lymph-node dissection should be limited to the perigastric nodes (D1) or should extend to regional lymph nodes outside the perigastric area (D2). We carried out a multicentre randomised comparison of D1 and D2 dissection. 1078 patients were randomised (539 to each group). 26 allocated D1 and 56 allocated D2 were found not to satisfy eligibility criteria (histologically confirmed adenocarcinoma of the stomach without clinical evidence of distant metastasis). Each of the remainder was attended by one of eleven supervising surgeons who decided whether curative resection was possible and, if so, assisted with the allocated procedure. Among the 711 patients (380 D1, 331 D2) judged to have curable lesions, D2 patients had a higher operative mortality rate than D1 patients (10 vs 4%, p = 0.004) and experienced more complications (43 vs 25%, p < 0.001). They also needed longer postoperative hospital stays (median 25 [range 7-277] vs 18 [7-143] days, p < 0.001). Morbidity and mortality differences persisted in almost all subgroup analyses. While we await survival results, D2 dissection should not be used as standard treatment for western patients.

[Diagnostic score for acute appendicitis]. / Diagnosescore für akute Appendicitis.

Scoring systems seem to be ideal for supporting diagnosis of acute appendicitis because they are non invasive, require no special equipment and can be used in clinical routine. Several scores for appendicitis have been developed with good results in the original publications. Unfortunately these good results could not be reproduced on a German data base. Therefore we developed a new score using multivariate statistics and a quality controlled prospective data base. The score covers 8 variables: tenderness, rebound tenderness, micturition, type of pain, leucocytes, age, relocation of pain, rigidity. Independent evaluation of the score on a Dutch database resulted in a negative appendicectomy rate of 21% and a missing appendicitis rate of 2%. The results are encouraging, so that further testing and clinical application can be recommended.

A pelvic mass: bladder diverticulum with haemorrhage in Ehlers-Danlos patient.

We report on a case of haemorrhage in a large bladder diverticulum, impressing as a pelvic mass, in a patient with the Ehlers-Danlos syndrome. A review of the literature revealed 14 other cases of bladder diverticula and the Ehlers-Danlos Syndrome. Conservative treatment is first choice, unless complications occur.

Idiopathic fibrous mediastinitis--a case report.

A rare case of idiopathic fibrous mediastinitis is reported. Symptoms, etiology, diagnostic and therapeutic aspects are discussed with reference to the literature. In this case in which dysphagia and hoarseness were the presenting symptoms, a successful oesophageal myotomy was performed.

Percutaneous transluminal angioplasty during operation.

In certain cases it can be useful to perform percutaneous transluminal angioplasty (PTA) and vascular surgery in the same session. The PTA procedure has to be performed by the radiologist through an artery that has been prepared and visualized by the vascular surgeon. This combined procedure usually lessens the number of hospitalization days and offers the patient the advantage of being cured in one session.

Hematuria as a presenting symptom of an aortic-vena caval fistula from ruptured aortic aneurysm.

We describe a patient with an abdominal aortic aneurysm and gross hematuria caused by rupture of the aneurysm into the vena cava who was treated successfully.

The treatment of benign strictures in the distal portion of the oesophagus.

Oesophagocardial plasty combined with intrathoracic fundoplication (Thal-Nissen-Rosetti) appears to be efficacious in the treatment of severe achalasia and of stenosis resulting from reflux in hiatus hernia. Advanced age and moderately severe cardiorespiratory disorders do not preclude good results from this operation. The above procedure was applied to six patients, with results varying from very good to fair.