Functional outcomes after extended surgery for gastric cancer (Br J Surg 2011; 98: 239-245)

Gastric cancer surgery: historical background and perspective in Western countries versus Japan

Gastrectomy plus D2 lymphadenectomy plays a decisive role in the management of resectable gastric cancer in Japan. Before recent advances in chemotherapy, Japanese surgeons considered that extensive surgery involving extended lymphadenectomy with combined resection of neighboring organ(s) was required to eliminate any possible lymphatic cancer spread and improve patient survival. This approach differs radically from that in Western countries, which aim to improve survival outcomes by multidisciplinary approaches including perioperative chemotherapy and/or radiotherapy with limited lymph node dissection. However, a randomized controlled trial conducted in Japan found that more extensive lymphadenectomy including the para-aortic lymph nodes provided no survival benefit over D2 lymphadenectomy. Splenic hilum dissection with splenectomy also failed to show superiority over the procedure without splenectomy in patients with proximal gastric cancer, except in cases with tumor invasion of the greater curvature. Furthermore, bursectomy recently demonstrated similar outcomes to omentectomy alone. Although "D2 lymphadenectomy" as carried out in Japan contributes to low local recurrence rates and good survival outcomes, the results of randomized controlled trials have led to a decreased extent of surgical resection, with no apparent adverse effects on survival outcome. Notably, gastrectomy with D2 dissection has tended to become acceptable for advanced gastric cancer in Western countries, based on the latest results of the Dutch D1D2 trial. Differences in surgical practices between the West and Japan have thus lessened and procedures are becoming more standardized. Japanese D2 lymphadenectomy for advanced gastric cancer is evolving toward more minimally invasive approaches, while consistently striving to achieve the optimal surgical extent, thereby promoting consensus with Western counterparts.

Treatment approaches to esophagogastric junction tumors

Esophagogastric junction (EGJ) adenocarcinomas are usually classified into one of the three categories of the Siewert system. The clinicopathological features of EGJ adenocarcinomas vary according to this classification scheme. The lymphatic flow in EGJ tumors of any type is mainly toward the abdomen, and nodal metastasis to the upper or middle mediastinum from Siewert type II or III tumors is relatively uncommon. Thus, the transhiatal approach is regarded as the standard in surgery for Siewert type II or III tumors, while the transthoracic approach via a right thoracotomy is recommended for Siewert type I tumors. Chemoradiotherapy followed by surgery is regarded as the standard treatment for resectable cancer of the EGJ in Western countries, but the necessity of adding radiation therapy to preoperative chemotherapy remains unknown. In the East, postoperative adjuvant chemotherapy is the current standard of care since the survival benefit was proven in pivotal randomized trials for stage II/III gastric cancer, including adenocarcinoma of the EGJ.