Extended lymph node dissection for gastric cancer: results of a prospective, multi-centre analysis of morbidity and mortality in 118 consecutive cases

Comparison of different methods of splenic hilar lymph node dissection for advanced upper- and/or middle-third gastric cancer

BACKGROUND

Surgery for advanced gastric cancer (AGC) often includes dissection of splenic hilar lymph nodes (SHLNs). This study compared the safety and effectiveness of different approaches to SHLN dissection for upper- and/or middle-third AGC.

METHODS

We retrospectively compared and analyzed clinicopathologic and follow-up data from a prospectively collected database at the Peking University Cancer Hospital. Patients were divided into three groups: in situ spleen-preserved, ex situ spleen-preserved and splenectomy.

RESULTS

We analyzed 217 patients with upper- and/or middle-third AGC who underwent R0 total or proximal gastrectomy with splenic hilar lymphadenectomy from January 2006 to December 2011, of whom 15.2 % (33/217) had metastatic SHLNs, and from whom 11.4 % (53/466) of the dissected SHLNs were metastatic. The number of harvested SHLNs per patient was higher in the ex situ group than in the in situ group (P = 0.017). Length of postoperative hospital stay was longer in the splenectomy group than in the in situ group (P = 0.002) or the ex situ group (P < 0.001). The splenectomy group also lost more blood volume (P = 0.007) and had a higher postoperative complication rate (P = 0.005) than the ex situ group. Kaplan-Meier (log rank test) analysis showed significant survival differences among the three groups (P = 0.018). Multivariate analysis showed operation duration (P = 0.043), blood loss volume (P = 0.046), neoadjuvant chemotherapy (P = 0.005), and N stage (P < 0.001) were independent prognostic factors for survival.

CONCLUSIONS

The ex situ procedure was more effective for SHLN dissection than the in situ procedure without sacrificing safety, whereas splenectomy was not more effective, and was less safe. The SHLN dissection method was not an independent risk factor for survival in this study.

Laparoscopic spleen-preserving hilar lymph node dissection through pre-pancreatic and retro-pancreatic approach in patients with gastric cancer

BACKGROUND

The conventional radical resection of proximal gastric cancer is even more risky when performed laparoscopically, though this technique is widely used in gastrointestinal surgery and is accepted as the superior method. This paper explores the feasibility of laparoscopic spleen-preserving hilar lymph node dissection using a retro-pancreatic approach for the treatment of proximal gastric cancer.

METHODS

Two cadavers were dissected for examination of and the pre-pancreatic and retro-pancreatic spaces. Following the dissection of the cadavers, ten live patients with proximal gastric cancer from May 2008 to May 2013 at Nanfang Hospital, Guangzhou, China, were given total gastrectomy and adjuvant splenic hilar lymph node clearance through pre-pancreatic and retro-pancreatic approach on the precondition of preserving the pancreas and spleen. The clinicopathologic characteristics, as well as the intraoperative and postoperative variables affecting the procedure, were observed and analyzed.

RESULTS

Anatomy of the space anterior and posterior to the pancreas in the two cadavers demonstrated the feasibility of pre-pancreatic and retro-pancreatic approach. The surgeries were all successfully performed laparoscopically; conversion to laparotomy was not necessary for any of the ten patients. The overall mean operative time was 243.6 ± 45 min. The mean estimated blood loss was 232 ± 80 ml. At the time of follow-up (median 12 months post-surgery), there had been neither local recurrence nor mortality in any of the patients.

CONCLUSION

Laparoscopic spleen- and pancreas-preserving splenic hilar lymph node dissection during total gastrectomy, using both pre-pancreatic and retro-pancreatic approaches, is indicated as a safe and feasible method for the treatment of proximal gastric cancer.

Metastasis, risk factors and prognostic significance of splenic hilar lymph nodes in gastric adenocarcinoma

BACKGROUND

The metastatic rate and risk factors of splenic hilar (No.10) lymph nodes (LNs) in gastric adenocarcinoma were still variable and uncertain, and the prognostic significance of No.10 LNs was also controversial. The aim of this retrospective study was to analyze the metastatic rate, risk factors and prognostic significance of No.10 LNs in gastric adenocarcinoma.

METHODS

From August 2007 to December 2011, 205 patients who were diagnosed with primary gastric adenocarcinoma and underwent total or proximal gastrectomy plus No.10 LNs dissection in West China Hospital were enrolled. Clinicopathological features and survival outcomes were retrospectively analyzed.

RESULTS

Mean numbers of harvested LNs and metastatic LNs were 34.8±12.6 (15-73) and 8.7±10.8 (0-67), respectively. The proportion of cases with positive No.10 LNs was 8.8% (18/205). In all 204 dissected No.10 LNs, 47 LNs (23.0%) were metastatic. In 52.2% (107/205) patients, the dissected splenic hilar tissues were histologically determined as only fat tissues but without LNs structure. Histological evidence of LNs structure was found in 98 (47.8%) patients with 18.4% (18/98) metastatic No.10 LNs. In multivariate logistic regression analysis, metastasis of No.10 LNs was significantly correlated with No.4sa LNs (p = 0.010) and pN stage (p = 0.012). Regarding survival analysis, 199 (97.1%) patients were followed up (0.6-74.8 months). In all patients with R0 resection, metastatic No.10 LNs caused significantly worse prognosis both in Kaplan-Meier (p = 0.006) and Cox regression analysis (p = 0.031).

CONCLUSIONS

Although the metastatic rate of No.10 LNs was 8.8%, dissection of No.10 LNs might be meaningful due to the poor prognosis of positive cases. And attentions should be also paid to its correlated factors including pN stage and No.4sa LNs.

Impact of obesity on early surgical and oncologic outcomes after total gastrectomy with "over-D1" lymphadenectomy for gastric cancer

INTRODUCTION

The purpose of the present study was to assess the impact of body mass index (BMI) on perioperative and pathologic outcomes after total gastrectomy with "over-D1" dissection for gastric cancer.

METHODS

Data on 161 patients undergoing total gastrectomy between 2005 and 2011 were reviewed. Patients were grouped into three categories by BMI: BMI < 25 kg/m(2) (63 normal-weight patients; 39.1 %), BMI ≥ 25-<30 kg/m(2) (73 overweight patients; 45.3 %), and BMI ≥ 30 kg/m(2) (25 obese patients; 15.6 %) and matched for the analysis of perioperative and cancer-related outcomes.

RESULTS

Operative time was longer for obese patients. Medical (mainly pulmonary) and surgical (mainly bleeding and wound infection) complications occurred more frequently in overweight/obese subjects. However, they were mostly managed conservatively (grade I-II in the Clavien-Dindo classification). The overall postoperative mortality was 0.9 %. Multivariate analysis identified the American Society of Anesthesiologists score and splenectomy, but not obesity, as independent risk factors for postoperative complications. The median number of lymph nodes retrieved differed significantly from group to group: obese 21 (IQR 18-26), versus overweight 24, versus normal weight 28 (p = 0.031). No difference was found in lymph node ratio and cancer-related parameters.

CONCLUSIONS

Obese patients with operable gastric cancer can be candidates for standard extensive surgical resection, provided that pre-existing co-morbidities and potential intraoperative and postoperative complications are considered.

Surgical outcomes for gastric cancer of a single institute in southeast China

BACKGROUND

In recent years, with social and economic development and lifestyle changes, the incidence of gastric cancer as well as the surgical results and prognoses of patients with gastric cancer have changed significantly in southeast China.

METHODS

A total of 1,451 patients were divided into 2 groups according to admission time periods. Trends in clinicopathologic characteristics and operative outcomes of these patients were analyzed retrospectively.

RESULTS

The numbers of old and young patients were significantly increased in period 2 compared with period 1. Tumors located in the proximal stomach increased from 20.26% to 36.83%. The incidence of early gastric cancer was significantly increased from period 1 to period 2. Lymph node metastasis was seen more prevalently in period 2 than in period 1. The rate of operation-related major complications decreased from 5.23% to 1.43%. Operative mortality was .49% in period 1 and .24% in period 2. The 5-year survival rate increased from 38.40% to 53.99%.

CONCLUSIONS

Early diagnosis, standardized surgical treatment including pertinent lymph node dissection, and better perioperative care notably improve the outcomes of patients with gastric cancer.

Systematic review of D2 lymphadenectomy versus D2 with para-aortic nodal dissection for advanced gastric cancer

AIM

To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.

METHODS

Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a pre-defined search strategy. Five-year overall survival rate, post-operative mortality, and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Four RCTs (1120 patients) and 4 non-randomized studies (901 patients) were identified. Meta-analysis showed that there was no significant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI: 0.93-1.16) for RCTs and 0.96 (95% CI: 0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI: 0.44-2.24) for RCTs and 2.06 (95% CI: 0.69-6.15) for non-randomized studies]. There was a significant difference between these two groups in wound degree of surgery, operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI: 114.59-276.05) for RCTs and 126.07 min (95% CI: 22.09-230.04) for non-randomized studies] and blood loss was significantly greater [WMD 301 mL (95% CI: 151.55-450.45) for RCTs and 302.86 mL (95% CI: 127.89-477.84) for non-randomized studies] in D2 + PAND.

CONCLUSION

D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.

Prognosis of metastatic splenic hilum lymph node in patients with gastric cancer after total gastrectomy and splenectomy

AIM

To clarify the significance of combined resection of the spleen to dissect the No. 10 lymph node (LN).

METHODS

We studied 191 patients who had undergone total gastrectomy with splenectomy, excluding non-curative cases, resection of multiple gastric cancer, and those with remnant stomach cancer. Various clinicopathological factors were evaluated for any independent contributions to No. 10 LN metastasis, using χ(2) test. Significant factors were extracted for further analysis, carried out using a logistic regression method. Furthermore, lymph node metastasis was evaluated for any independent contribution to No. 10 LN metastasis, using the same methods. The cumulative survival rate was calculated using the Kaplan-Meier method. The significance of any difference between the survival curves was determined using the Cox-Mantel test, and any difference was considered significant at the 5% level.

RESULTS

From the variables considered to be potentially associated with No. 10 LN metastasis, age, depth, invasion of lymph vessel, N factor, the number of lymph node metastasis, Stage, the number of sites, and location were found to differ significantly between those with metastasis (the Positive Group) and those without (the Negative Group). A logistic regression analysis showed that the localization and Stage were significant parameters for No. 10 LN metastasis. There was no case located on the lesser curvature in the Positive Group. The numbers of No. 2, No. 3, No. 4sa, No. 4sb, No. 4d, No. 7, and No. 11 LN metastasis were each found to differ significantly between the Positive Group and the Negative Group. A logistic regression analysis showed that No. 4sa, No. 4sb, and No. 11 LN metastasis were each a significant parameter for No. 10 LN metastasis. There was no significant difference in survival curves between the Positive Group and the Negative Group.

CONCLUSION

Splenectomy should be performed to dissect No. 10 LN for cases which have No. 4sa, No. 4sb or No. 11 LN metastasis. However, in cases where the tumor is located on the lesser curvature, splenectomy can be omitted.

Upper abdominal body shape is the risk factor for postoperative pancreatic fistula after splenectomy for advanced gastric cancer: a retrospective study

Background

Postoperative pancreas fistula (POPF) is a major complication after total gastrectomy with splenectomy. We retrospectively studied the effects of upper abdominal shape on the development of POPF after gastrectomy.

Methods

Fifty patients who underwent total gastrectomy with splenectomy were studied. The maximum vertical distance measured by computed tomography (CT) between the anterior abdominal skin and the back skin (U-APD) and the maximum horizontal distance of a plane at a right angle to U-APD (U-TD) were measured at the umbilicus. The distance between the anterior abdominal skin and the root of the celiac artery (CAD) and the distance of a horizontal plane at a right angle to CAD (CATD) were measured at the root of the celiac artery. The CA depth ratio (CAD/CATD) was calculated.

Results

POPF occurred in 7 patients (14.0%) and was associated with a higher BMI, longer CAD, and higher CA depth ratio. However, CATD, U-APD, and U-TD did not differ significantly between patients with and those without POPF. Logistic-regression analysis revealed that a high BMI (≥25) and a high CA depth ratio (≥0.370) independently predicted the occurrence of POPF (odds ratio = 19.007, p = 0.002; odds ratio = 13.656, p = 0.038, respectively).

Conclusion

Surgical procedures such as total gastrectomy with splenectomy should be very carefully executed in obese patients or patients with a deep abdominal cavity to decrease the risk of postoperative pancreatic fistula. BMI and body shape can predict the risk of POPF simply by CT.

Dissection of No. 13 lymph node in radical gastrectomy for gastric carcinoma

AIM: To evaluate the feasibility and safety of No. 13 lymphadenectomy in radical gastrectomy for gastric carcinoma.

METHODS: Medical records of the patients undergone No. 13 lymph node dissection during D2 gastrectomy for gastric carcinoma, were reviewed from March 2003 to May 2007.

RESULTS: One hundred and fifty-eight patients underwent No. 13 lymph node dissection for D2 gastric carcinoma, of them, 4 (2.53%) were found to have metastasis in No. 13 lymph node. Metastasis to No. 12 lymph node was detected in 6 patients and 4 of them had positive No. 13 lymph node. The operative morbidity except for wound infection was 15.19% (24/158), and hospital death rate was 1.27% (2/158). No obstructive jaundice caused by No. 13 lymph node metastasis after No. 13 lymph node dissection in radical gastrectomy for gastric carcinoma was detected during the follow-up study to end of January 2007.

CONCLUSION: Dissection of No. 13 lymph node in D2 gastrectomy for gastric carcinoma is safe with a low morbidity and mortality rate. Further study is needed to explore its long-term effect.

Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial

BACKGROUND

A multicenter, randomized, clinical trial was initiated to evaluate the possible benefits of extended D2 (D2+) lymphadenectomy after potentially curative resection of gastric cancer.

METHODS

Standard D2 lymphadenectomy was defined according to the Japanese Gastric Cancer Association classification. D2+ lymph node dissection additionally included the removal of para-aortic nodes.

RESULTS

Of 781 patients screened, 275 were randomized to standard D2 (n = 141) or extended D2+ (n = 134) lymphadenectomy. The overall morbidity rates were comparable in D2 (27.7%; 95% confidence interval [CI], 20.3-35.1) and D2+ (21.6%; 95% CI, 13.7-29.5) groups (P = .248). Pre-existing cardiac disease, splenectomy, and excessive blood loss were identified as risk factors for overall and nonsurgical complications. Postoperative mortality rates were 4.9% (95% CI, 1.4-8.5) and 2.2% (95% CI, 0-4.7), respectively (P = .376).

CONCLUSIONS

The interim safety analysis failed to show any significant difference with regard to the extent of lymph node dissection. The surgical outcome was not different between the 2 surgeries.

Modified radical lymphadenectomy (D1.5) for T2-3 gastric cancer

BACKGROUND

The operative mortality in gastric cancer surgery has been reported to be higher with D2 lymphadenectomy than with D1 in the West. The modified radical lymphadenectomy (D1.5) may be safer than D2 under these circumstances. This study was aimed to determine whether D1.5 would deteriorate long-term survival as compared with D2.

METHOD

Since the concept of the extent of lymphadenectomy varied among the surgeons, 461 patients who underwent curative gastrectomy for T2-4 gastric adenocarcinoma were retrospectively categorized into three groups according to the surgeon: D1 with dissection along the left gastric and common hepatic arteries (D1.5); lymphadenectomy between D1.5 and D2; D2 or more extended dissection.

RESULTS

No differences were found in the survival rates among the three groups within each of the T2a, T2b, and T3 categories. According to a multivariate analysis using Cox's proportional hazard model, the classification according to the surgeons had no survival impact (p>0.8).

CONCLUSION

D1.5 lymphadenectomy resulted in a survival rate that was almost equal to that of D2. The use of D1.5 instead of D2 can be an attractive option to be compared with D1 in future trials.

Status of extended lymph node dissection: Locoregional control is the only way to survive gastric cancer

There are many factors that are of influence on gastric cancer treatment. The only way to survive is complete locoregional control. More extended dissections should lead to better outcome, but increased morbidity and mortality probably offset its long-term effect in survival in randomised studies. In this article the factors of influence on outcome of gastric cancer treatment such as the extent of lymph node dissection, splenectomy, pancreatectomy, age, volume and additional treatments are discussed. A literature review of these factors in relation to the latest results of the Dutch Gastric Cancer Trials are presented. If morbidity and mortality can be reduced there might be an advantage of extended lymph node dissection. Splenectomy and pancreatectomy should be performed only in case of direct in growth from the tumour into these organs. Centralisation of gastric cancer treatment should be achieved in order to improve results and to facilitate research. By refining selection criteria in the treatment of gastric cancer further improvements are to be expected.

Aggressive surgical treatment for T4 gastric cancer

Surgical treatment for locally advanced gastric cancer remains controversial, and many still question the benefits of extended resection. The aim of this study was to evaluate the effectiveness of combined resection of the involved organs with regard to survival in patients with gastric cancer. Between 1993 and 2000, among the 1638 patients with gastric cancer who underwent gastrectomy, 82 were found to have evidence of adjacent organ spread at laparotomy. A retrospective analysis of these patients was performed. Curative resections were carried out in 50 patients, whereas noncurative resections were performed in 32 patients. The 5-year survival rate in the group undergoing curative resection was 36.9%. The survival rate in the R0 group was significantly higher than the survival rate for patients undergoing noncurative resections. There was no significant difference in survival rates between patients with pT3 cancer and those with pT4 cancer. Seventy-one patients were pathologically proved to have lymph node metastasis, and the survival rate for patients with a lymph node ratio greater than 0.2 was lower than that in other groups. In multivariate analysis, peritoneal dissemination, lymph node ratio, and histologic findings were the predictors of survival. Patients with T4 gastric carcinoma, even with lymph node metastasis, might have benefited from aggressive surgery with curative intent.

Comparison of complications after D2 and D3 dissection for gastric cancer

BACKGROUND

D3 dissection is accepted as having higher rates of mortality and morbidity than D2 dissection. In this study, we aimed to evaluate the mortality and morbidity rates of D3 dissection in our department and to compare these with mortality and morbidity after D2 dissection.

PATIENTS AND METHODS

All patients who underwent radical gastric resection with lymph node dissection for gastric adenocarcinoma between June 1999 and June 2002 were evaluated. Clinicopathologic features of the tumour, the resection and lymphadenectomy, the postoperative mortality and morbidity were analysed.

RESULTS

There were 359 patients admitted for the treatment of gastric cancer. One hundred twenty four underwent palliative resection and 134 underwent resection with curative intent. Of 34/134 patients, underwent gastric resection with D3 dissection, and 100 underwent D2 dissection. The overall operative mortality rate of D2 and D3 dissections was 1 and 8.8%, respectively (p<0.05). The relaparotomy rate was almost doubled in D3 dissection group (11.8% vs. 6%) but this difference was not statistically significant. D3 dissection was also associated with an increase in morbidity (35.3% vs. 10%, p<0.05).

CONCLUSIONS

This study indicates that D3 dissection can be performed with reasonable safety. It may be a useful alternative procedure in advanced cases for which additional risks of surgical morbidity and mortality are felt to be outweighed by potential benefits to patients.

The difference in gastric cancer between Japan, USA and Europe: what are the facts? what are the suggestions?

In Japan the survival rate for gastric cancer has steadily improved over the last 30 years whilst that in the West has remained static and inferior. In this review three hypotheses are examined to explain the difference. There is little evidence to suggest genetic differences, which might result in a less aggressive cancer in Japan. Recently there has been a rise in the proportion of cancers of the gastro-oesophageal junction in the West and this has not been seen in Japan. The comparison of survival data from these two regions is problematic with different staging systems and a stage migration effect. The established surgical treatment of gastric cancer in Japan is radical gastrectomy and regional lymphadenectomy and this has been proposed as a superior treatment to the standard gastrectomy common in the West. The results for survival benefit however, have not been reproduced in randomized clinical trials. The heterogeneity of adjuvant and neoadjuvant treatment regimens in Japan and the West has led to difficulties in the interpretation of their effects. There is considerable scope for future collaboration between clinicians in the West and Japan.

Phase IB study on prevention of surgery-induced immunodeficiency with preoperative administration of low-dose subcutaneous interleukin-2 in gastric cancer patients

BACKGROUND AND OBJECTIVES

Low count of total and T helper lymphocytes predicts a poor prognosis in cancer patients and surgical trauma can worsen cancer-related immunodeficiency. Aim of this phase IB study is to verify toxicity and biological effects of interleukin-2 (IL-2) at 9 million IU/day subcutaneously (sc.) administered one, two or three preoperative days in patients with gastric cancer undergoing radical surgery.

METHODS

Absolute value of total and T-helper (CD4) lymphocytes were measured at baseline and at 7th, 14th, and 50th postoperative days in 12 gastric cancer patients, who preoperatively received IL-2 at 9 million IU/day sc. as follows: group A (4 pts) 1-day; group B (4 pts) 2-days; group C (4 pts) 3-days administration. T and total lymphocytes count were recorded and retrospectively analyzed in a historical control-group of 22 consecutive patients, age and stage-matched.

RESULTS

Toxicity consisted of fever grade I. In group A (1 day) T helper lymphocytes count decreased at 7th and at 14th postoperative day; in group B (2 days) and group C (3 days) no decrease of neither total nor T helper lymphocyte count occurred postoperatively, whereas in the historical group these parameters decreased significantly postoperatively and recovered only at 50th day.

CONCLUSIONS

Two- and three-day schedules of sc. IL-2 preoperative administration at 9 million IU/daily prevented postoperative lymphocytopenia, whereas one-day administration did not. Since the IL-2 dose was so tolerable, that it could be given safely as outpatient, based on the previous results on survival observed in colorectal cancer patients with 3-days schedule we suggest that a 3-day schedule of Interleukin-2 as outpatient preoperative treatment seems advisable for further studies in gastric cancer patients.

Characterization of early gastric cancer and proposal of the optimal therapeutic strategy

BACKGROUND AND AIMS

The optimal protocol of the treatment for early gastric cancer has not been fully established. The current study was designed to elucidate the relationship between the depth of tumors with or without an ulcer and the presence of lymph node metastasis and to establish the optimal and practical therapeutic strategy for patients with early gastric cancer.

PATIENTS AND METHODS

A retrospective analysis of 1051 patients with early gastric cancer treated by gastrectomy with D1 or D2 lymph node dissection was performed. The patients were divided into those with mucosal (M) tumors and those with submucosal (SM) tumors. These 2 groups were subclassified, depending on the coexistence of ulcer or the degree of submucosal invasion, and were characterized in relation to clinicopathologic factors and 5-year prognosis.

RESULTS

The incidence of lymph node metastases from SM tumors (19.8%, 85 of 430) was more frequent than that from M tumors (2.3%, 14 of 621) (P <.001). All M tumors with lymph node involvement, including tumors smaller than 1.5 cm in diameter, had ulceration or ulceration scar in the lesions. SM tumors that had invaded less than 200 microm in depth (SM1a) had significantly less lymph node involvement than those with deeper invasion. The node metastases were confined to epigastric lymph nodes (N1) in both M tumors with ulceration or ulceration scar and SM1a tumors.

CONCLUSIONS

All macroscopic M tumors without ulceration or ulceration scar should be considered for endoscopic mucosal resection. The need for reoperation for a formal gastrectomy with lymphadenectomy or a limited surgical operation will vary depending on the pathologic analysis of endoscopic mucosal resection specimens (depth of invasion, presence of ulceration).

D3 lymph node dissection in gastric cancer: evaluation of postoperative mortality and complications

Since November 1995 we have been performing a D3 lymph node dissection in patients undergoing an operation for gastric cancer with a curative intent. The aim of the present study was to evaluate whether this procedure results in an increased postoperative mortality or complication rate in a Western population. Between November 1995 and August 1997 the postoperative courses of 76 patients were retrospectively assessed (45.3 lymph nodes per patient, lymph node ratio: 0.16). The patient outcome was compared with data from a historic control group of patients (n = 383) in whom the newly established D2 dissection was studied in our department. Regarding the demographic, clinical, and tumor-pathologic data, and the choice of resection and reconstructive procedures, the two groups differed only slightly. The postoperative mortality of 1% was lower (vs 6.8%) while the overall complication rate of 34% (vs 32.1%) was identical. In particular, no anastomotic leakage (vs 9.4%) and fewer nonsurgical complications (17.1% vs 27.9%) occurred. The reoperation rate was 1% vs 9.7%. However, in 6% of the patients drainage tubes had to be inserted under computed tomographic guidance. The average hospital stay remained unchanged (21.9 vs 20.7 days). A D3 dissection was shown to be feasible while demonstrating no disadvantages in the patients when compared with the D2 procedure.

Cancer surgery: the last 25 years

Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact.