Postoperative gastrointestinal dysfunction after 2-field versus 3-field lymph node dissection in patients with esophageal cancer

Coping flexibility and associated factors after gastrectomy in patients with gastric cancer: A cross-sectional multisite study

Objective

To elucidate the current state of coping flexibility and associated factors in gastric cancer patients after gastrectomy.

Methods

A cross-sectional multisite study was conducted with 142 patients with gastric cancer who completed questionnaires on coping flexibility, postgastrectomy dysfunction, health literacy, and perceived social support. Coping flexibility was measured using the Coping Flexibility Scale-Revised, which includes three subscales: Abandonment Coping (i.e., abandoning ineffective coping strategies), Re-Coping (i.e., assessing the process of developing and implementing alternative coping strategies), and Meta-Coping (i.e., monitoring coping flexibility process). Higher scores indicate greater coping flexibility. Descriptive statistics and univariable and multivariable logistic analyses were conducted to examine factors associated with coping flexibility.

Results

The mean age of the participants was 72.6 (± 10.5) years. Limited activity due to decreased food consumption was associated with lower scores for Abandonment Coping (odds ratio [OR]: 0.4; P ​= ​0.03; 95% confidence interval [CI], 0.2-0.9) and Re-Coping (OR: 0.3; P ​= ​0.003; 95% CI, 0.1-0.6). Higher levels of communicative health literacy were associated with higher Abandonment Coping scores (OR: 1.1; P ​= ​0.04; 95% CI, 1.0-1.3), and higher levels of critical health literacy were associated with higher Re-Coping scores (OR: 1.2; P ​= ​0.03; 95% CI, 1.0-1.3).

Conclusions

Limited activity due to decreased food consumption and limited coping flexibility were significantly associated. Health literacy had an important role in facilitating coping flexibility. Nursing support may be crucial in evaluating coping strategies and developing alternatives based on new information.

Clinical value of lymph node dissection for stage T1b mid-thoracic esophageal squamous cell carcinoma

Background

Surgery remains the mainstay of treatment for esophageal squamous cell carcinoma (ESCC), during which lymph node (LN) dissection, especially recurrent laryngeal nerve (RLN) LN dissection, is particularly important and challenging. This study aimed to investigate the LN metastasis of stage T1b mid-thoracic ESCC and explore the clinical value of RLN LN dissection.

Methods

The clinicopathological data of 254 patients with stage T1b mid-thoracic ESCC who underwent the McKeown procedure ("tri-incisional esophagectomy") and three-field LN dissection (3FD) at Fujian Cancer Hospital from January 2010 to December 2015 were retrospectively analyzed. The value of LN dissection (especially RLN LNs) was evaluated by calculating the metastasis rate of each LN station. The efficacy index (EI) of the dissection was calculated by multiplying the frequency (%) of metastases to a station and the 5-year survival rate (%) of patients with metastases to that station, and then dividing by 100.

Results

The stage T1b mid-thoracic ESCC had the highest rate of metastasis in the paracardiac LNs (4.3%), followed by RLN LNs (2.8%) and the left gastric artery LNs (2.8%). The 5-year survival rate was highest in patients who received lesser gastric curvature LN dissection (100%), followed by patients who underwent right RLN LN dissection (80%), and was 50% in patients who had undergone dissection of the left RLN LNs, upper paraesophageal LNs, subcarinal LNs, and left gastric artery LNs, respectively. In addition, dissection of the right RLN LNs had the highest EI value (2.2), followed by the dissection of LNs along the lesser curvature of the stomach (1.6) and left gastric artery LNs (1.4).

Conclusions

Right RLN LNs have a metastasis rate only lower than that of the paracardiac LNs, but could be the most valuable location for performing dissection.

Photon Versus Proton Beam Therapy for T1-3 Squamous Cell Carcinoma of the Thoracic Esophagus Without Lymph Node Metastasis

Background and Purpose

We compared treatment outcomes and toxicities of photon radiotherapy versus proton beam therapy (PBT) and evaluated radiation field effects for T1–3 squamous cell carcinoma of the thoracic esophagus (EC) without lymph node metastasis.

Methods

Medical records of 77 patients with T1–3N0M0 thoracic EC treated with radiotherapy between 2011 and 2019 were retrospectively analyzed. Among these patients, 61 (79.2%) individuals had T1 EC. The initial clinical target volume encompassed the whole esophagus with or without supraclavicular and/or abdominal lymph nodes (extended-field radiotherapy; 67 patients, 87.0%) or the area 3–5 cm craniocaudally and 1–2 cm radially from the gross tumor volume (involved-field radiotherapy; 10 patients, 13.0%). The final clinical target volume included margins of at least 1 cm from the gross tumor volume, with total radiation doses of 50–66 (median, 66) cobalt gray equivalent. Three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and PBT were used in twenty-four, five, and forty-eight patients, respectively. Concurrent chemotherapy was administered to 17 (22.0%) patients overall and only five (8.0%) T1 patients.

Results

PBT showed significantly lower lung and heart radiation exposure in mean dose, V5, V10, V20, and V30 than photon radiotherapy. The median follow-up for all patients was 46 (interquartile range, 22–72) months. The 5-year progression-free survival and overall survival rates were 56.5 and 64.9%, respectively, with no significant survival difference between photon radiotherapy and PBT. In patients with T1 EC, 5-year progression-free survival and overall survival rates were 62.6 and 73.5%, respectively.

Conclusions

Extended-field radiotherapy using modern radiotherapy techniques without chemotherapy showed satisfactory clinical outcomes for lymph node-negative T1 EC.

Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy

OBJECTIVE

This prospective randomized phase-II trial examined whether gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis(RY) minimized gastroduodenal reflux and delayed gastric emptying compared with standard gastric reconstruction.

SUMMARY BACKGROUND DATA

There is no established standard surgical procedure to prevent both gastroduodenal reflux and delayed gastric emptying simultaneously.

METHODS

Sixty patients with thoracic esophageal cancer scheduled to undergo esophagectomy with retrosternal gastric tube reconstruction were randomly allocated to standard gastric reconstruction (non-RY, n = 31) or gastric reconstruction with duodenal diversion plus RY (n = 29) groups. Primary endpoint was quality of life assessed by DAUGS-32 score 1 year after surgery. Secondary endpoints were the extent of postoperative duodenal juice reflux into the gastric tube, postoperative morbidity, endoscopic findings, body weight changes, and nutritional status.

RESULTS

Preoperative clinicopathological characteristics and postoperative morbidity did not differ significantly between groups. However, operation time and blood loss volume were significantly higher in the RY group. Pancreatic amylase concentrations in the gastric conduit on postoperative days 2, 3, and 7 were higher in the non-RY group. Postoperative endoscopic examination showed residual gastric content in 7 of 17 patients in the non-RY group but in none in the RY group (P = 0.012). Quality of life was significantly favorable in the RY group with regard to reflux symptoms and food passage dysfunction. Postoperative body weight changes, serum albumin levels, and peripheral blood lymphocyte counts were not significantly different between groups.

CONCLUSION

Gastric reconstruction with duodenal diversion plus RY is effective in improving both gastroduodenal reflux and delayed gastric emptying.

The Role of Modern Radiotherapy Technology in the Treatment of Esophageal Cancer

Radiation therapy (RT) has improved patient outcomes, but treatment-related complication rates remain high. In the conventional 2-dimensional and 3-dimensional conformal RT (3D-CRT) era, there was little room for toxicity reduction because of the need to balance the estimated toxicity to organs at risk (OARs), derived from dose-volume histogram data for organs including the lung, heart, spinal cord, and liver, with the planning target volume (PTV) dose. Intensity-modulated RT (IMRT) is an advanced form of conformal RT that utilizes computer-controlled linear accelerators to deliver precise radiation doses to the PTV. The dosimetric advantages of IMRT enable better sparing of normal tissues and OARs than is possible with 3D-CRT. A major breakthrough in the treatment of esophageal cancer (EC), whether early or locally advanced, is the use of proton beam therapy (PBT). Protons deposit their highest dose of radiation at the tumor, while leaving none behind; the resulting effective dose reduction to healthy tissues and OARs considerably reduces acute and delayed RT-related toxicity. In recent studies, PBT has been found to alleviate severe lymphopenia resulting from combined chemo-radiation, opening up the possibility of reducing immune suppression, which might be associated with a poor prognosis in cases of locally advanced EC.

Comparison of short- and long-term outcomes between 3-field and modern 2-field lymph node dissections for thoracic oesophageal squamous cell carcinoma: a propensity score matching analysis

OBJECTIVES

Our goal was to compare short- and long-term outcomes between 3-field lymphadenectomy (3-FL) and modern 2-field lymphadenectomy (2-FL) in patients with thoracic oesophageal squamous cell carcinoma.

METHODS

We reviewed clinical outcomes for 298 patients with thoracic oesophageal squamous cell carcinoma who underwent 3-FL or modern 2-FL from March 2008 to December 2013 at a major cancer hospital in Guangzhou, southern China. Propensity score matching was used to balance baseline differences, and 83 pairs of cases were selected. Postoperative complications, recurrence patterns and survival outcomes were compared between the 2 groups.

RESULTS

Compared with modern 2-FL, 3-FL led to higher overall operative morbidity rates [78.3% vs 61.4%, odds ratio (OR) 2.266, 95% confidence interval (CI) 1.143-4.490; P = 0.019], with higher recurrent nerve palsy rates (47.0% vs 19.3%, OR 3.712, 95% CI 1.852-7.438; P < 0.0001), more respiratory failures (18.1% vs 6.0%, OR 3.441, 95% CI 1.189-9.963; P = 0.023) and longer postoperative hospital stays (23 vs 17 days, P = 0.002). The 5-year overall survival rate (58.5% vs 59.4%; P = 0.960) and the 5-year disease-free survival rate 50.1% vs 54.5%; P = 0.482) were comparable between the 2 groups. Multivariable analysis showed that additional cervical lymph node dissection was not associated with overall survival [hazard ratio (HR) 1.039, 95% CI 0.637-1.696; P = 0.878] and disease-free survival (HR 0.868, 95% CI 0.548-1.376; P = 0.547). The overall recurrence rate and cervical nodal recurrence rate were not significantly different between the 2 groups.

CONCLUSIONS

Additional cervical lymphadenectomy did not lead to added survival benefit when compared with modern 2-FL in patients with thoracic oesophageal squamous cell carcinoma. Recurrence was similar in patients undergoing 3-FL and modern 2-FL. 3-FL resulted in more postoperative complications.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy

PURPOSE

The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups.

RESULTS

No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis.

CONCLUSION

Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

The Impact of the Location of Esophagogastrostomy on Acid and Duodenogastroesophageal Reflux After Transthoracic Esophagectomy with Gastric Tube Reconstruction and Intrathoracic Esophagogastrostomy

BACKGROUND

The aim of this study was to evaluate the impact of the location of esophagogastrostomy on acid and duodenogastroesophageal reflux (DGER) in patients undergoing gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty patients receiving transthoracic esophagectomy without cervical lymph node dissection and gastric tube reconstruction by intrathoracic anastomosis were enrolled. All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy one year after surgery. Patients were divided into three groups according to esophagogastrostomy location: group A (n = 9), above the top of the aortic arch; group B (n = 15), between the top and bottom of the aortic arch; and group C (n = 6), below the bottom of the aortic arch. The relations among the esophagogastrostomy location, 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were investigated.

RESULTS

No acid reflux into the remnant esophagus was observed in group A, whereas it was observed in three of 15 patients (20%) in group B and in two of six patients (33%) in group C (P = 0.139). No DGER was found in group A, whereas DGER was observed in eight (53%) patients in group B and all patients in group C (P < 0.001). Reflux esophagitis was observed in one patient (11%) in group A, five patients (33%) in group B, and all patients in group C (P = 0.002).

CONCLUSION

In gastric tube reconstruction via intrathoracic anastomosis, esophagogastrostomy should be performed above the top of the aortic arch to prevent postoperative DGER and reduce the incidence of reflux esophagitis.

Three-field lymph node dissection in esophageal cancer surgery

Although multidisciplinary treatment has improved the prognosis of esophageal cancer, it is commonly associated with one of the worse prognoses. Since lymph node (LN) metastases can primarily occur from the cervical to the abdominal field, a strategy for extended LN dissection has been established. The three field LN dissection (3FD) during a transthoracic esophagectomy which is defined as a procedure for cervico-thoraco-abdominal LN dissection, was established in the 1980s' in Japan, and is currently widely accepted throughout the world. To date, various comparative trials between 3FD and two field LN dissections (2FD) have been reported and show that a transthoracic esophagectomy with 3FD is superior to 2FD for prognosis. However, in 3FD, postoperative complications, such as recurrent laryngeal nerve palsy and postoperative gastrointestinal dysfunction can be induced. Furthermore, there are few prospective trials that have compared between 2FD and 3FD. Therefore, to determine the ideal range of LN dissection, various factors (e.g., location of the primary tumor, disease progression, tumor histology, and perioperative treatment) must be considered. Recently, the efficacy of intense perioperative treatment for esophageal cancer has been reported, and the significance of minimally invasive surgical procedures are being verified. The ideal combination of perioperative treatment and feasible surgery must be established to improve the oncological outcome of esophageal cancer patients further.

Quality of life: A critical outcome for all surgical treatments of gastric cancer

Surgery represents the main curative therapeutic modality for gastric cancer, and it is occasionally considered for palliation as well as prophylaxis. Most frequently, surgical outcomes are conveyed in terms of oncological outcomes such as recurrence and survival. However, quality of life (QoL) is also important and should be considered when making treatment decisions - including the extent of and approach to surgery. Measurement of QoL usually involves the application of questionnaires. While there are multiple QoL questionnaires validated for use in oncology patients, there are very few that have been validated for use in those with gastric cancer. In this review, we discuss and compare the current status of QoL questionnaires in gastric cancer. More importantly, the impact of surgery for treatment, palliation and prophylaxis of gastric cancer on QoL will be described. These data should inform the surgeon on the optimal approach to treating gastric cancer, taking into account oncological outcomes. Knowledge gaps are also identified, providing a roadmap for future studies.

Developing core outcomes sets: methods for identifying and including patient-reported outcomes (PROs)

BACKGROUND

Synthesis of patient-reported outcome (PRO) data is hindered by the range of available PRO measures (PROMs) composed of multiple scales and single items with differing terminology and content. The use of core outcome sets, an agreed minimum set of outcomes to be measured and reported in all trials of a specific condition, may improve this issue but methods to select core PRO domains from the many available PROMs are lacking. This study examines existing PROMs and describes methods to identify health domains to inform the development of a core outcome set, illustrated with an example.

METHODS

Systematic literature searches identified validated PROMs from studies evaluating radical treatment for oesophageal cancer. PROM scale/single item names were recorded verbatim and the frequency of similar names/scales documented. PROM contents (scale components/single items) were examined for conceptual meaning by an expert clinician and methodologist and categorised into health domains. A patient advocate independently checked this categorisation.

RESULTS

Searches identified 21 generic and disease-specific PROMs containing 116 scales and 32 single items with 94 different verbatim names. Identical names for scales were repeatedly used (for example, 'physical function' in six different measures) and others were similar (overlapping face validity) although component items were not always comparable. Based on methodological, clinical and patient expertise, 606 individual items were categorised into 32 health domains.

CONCLUSION

This study outlines a methodology for identifying candidate PRO domains from existing PROMs to inform a core outcome set to use in clinical trials.

Esophageal squamous cell carcinoma with special reference to its early stage

The term 'early squamous cell carcinoma of the oesophagus', which was previously restricted to superficial carcinoma with no lymph node metastasis, now encompasses intramucosal carcinoma regardless of the nodal status. Such lesions are rare in Western countries, where the experience is limited. In recent years, the development and greater use of chromoendoscopy and narrow band imaging (NBI), both of which facilitate the evaluation of mucosal morphology, have played an important role in the detection of early esophageal squamous cell carcinoma. In addition, the techniques and indications of endoscopic resection (mucosal resection [EMR] and mucosal dissection [ESD]) are still being refined. In the present article, we will discuss the clinical and pathologic features of esophageal early squamous cell carcinoma, as well as the epidemiology and aetiology of esophageal cancer in general. In addition, we will provide a therapeutic decision tree taking into account endoscopic and surgical modalities as they apply to early esophageal squamous cell carcinoma.

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non-surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non-RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery-32 questionnaire postoperatively was significantly better in the RY group than in the non-RY group for 'decreased physical activity,''symptoms of reflux,''nausea and vomiting,' and 'pain.' The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large-scale, randomized controlled trial.

Postoperative quality of life: development and validation of the "Dysfunction After Upper Gastrointestinal Surgery" scoring system

BACKGROUND

Although postoperative quality of life is an important outcomes measure, few tools exist to evaluate patients specifically after upper gastrointestinal surgery. The previously developed Dysfunction After Upper Gastrointestinal Surgery (DAUGS)32 scoring system has been further refined to include just 20 items. This study was undertaken to validate the refined evaluation tool.

STUDY DESIGN

The study was performed as a survey, administered to patients after upper gastrointestinal resection at 3 separate institutions.

RESULTS

The DAUGS20 score after gastrectomy (n = 662) was 27.8 and that after esophagectomy (n = 221) was 36.1, showing a significant difference (p < 0.05). The score after distal gastrectomy (n = 282) was 25.4 and that after total gastrectomy (n = 149) was 32.0, showing a significant (p < 0.05) difference. The α coefficient of all items on the DAUGS20 system was 0.904 and Cronbach's α coefficients of the subscales were 0.612 to 0.856, demonstrating high reliability of this evaluation tool. In addition, 7 factors were extracted from the 20 items using definitive factor analysis, to verify validity.

CONCLUSIONS

Patient quality of life should be evaluated as an outcomes measure after surgical resection for cancer, just as overall survival is analyzed. The DAUGS20 score is reliable, has validity in the evaluation of postoperative patients, and is a valuable tool to assess patient quality of life after upper gastrointestinal surgery for cancer.

Presence and persistence of nutrition-related symptoms during the first year following esophagectomy with gastric tube reconstruction in clinically disease-free patients

BACKGROUND

Esophagectomy with gastric tube reconstruction results in a variety of postoperative nutrition-related symptoms that may influence the patient's nutritional status.

METHODS

We developed a 15-item questionnaire, focusing on the nutrition-related complaints the first year after an esophagectomy. The questionnaire was filled out the first week after discharge and 3, 6, and 12 months after surgery. The use of enteral nutrition, meal size and frequency, social aspects related to eating, defecation pattern, and body weight were recorded at the same time points. We analyzed the relationship between the baseline characteristics and the number of nutrition-related symptoms, as well as the relationship between those symptoms and body weight with linear mixed models.

RESULTS

We found no significant within-patient change for the total number of nutrition-related symptoms (P = 0.67). None of the baseline factors were identified as predictors of the complaint scores. The most frequently experienced complaints were early satiety, postprandial dumping syndrome, inhibited passage due to high viscosity, reflux, and absence of hunger. One year after surgery, meal sizes were still smaller, the social aspects of eating were influenced negatively, and patients experienced an altered stool frequency. Directly after the surgical procedure 78% of the patients lost weight, and the entire postoperative year the mean body weight remained lower (P = 0.47). We observed no association between the complaint scores and body weight (P = 0.15).

CONCLUSIONS

After an esophagectomy, most patients struggle with nutrition-related symptoms, are confronted with nutrition-related adjustments and a reduced body weight.

Extent of gastric resection impacts patient quality of life: the Dysfunction After Upper Gastrointestinal Surgery for Cancer (DAUGS32) scoring system

BACKGROUND

Quality of life is an important outcome measure in the care of patients with cancer. We developed a new scoring system specifically for the evaluation of patients with upper gastrointestinal cancer and postoperative gastrointestinal dysfunction. This study was undertaken to evaluate the scoring system's validity in comparing outcomes after gastric resection.

MATERIALS AND METHODS

Patients with gastric cancer, 3 months to 3 years postoperatively, were surveyed using the survey instrument. Postoperative dysfunction scores and the status of resuming activities of daily living were compared with the surgical procedure performed by analysis of variance and multiple-comparison techniques.

RESULTS

Of 211 patients surveyed, 165 (119 men, 46 women; mean age, 65.1 ± 10.5 years) responded. Procedures included distal gastrectomy in 100, total gastrectomy in 57, and pylorus-preserving gastrectomy in 8. The overall dysfunction score was 61.8 ± 15.5. The dysfunction score was 58.9 ± 15.0 after distal gastrectomy, 66.8 ± 14.1 after total gastrectomy, and 62.4 ± 21.6 after pylorus-preserving gastrectomy. These values differed significantly among the groups (P = .007). Dysfunction scores according to postoperative activity status were 49.1 ± 15.6 in 71 patients who resumed their activities, 56.9 ± 15.7 in 39 patients with reduced activities, 57.3 ± 8.8 in 15 patients with minimal activities, and 63.3 ± 11.8 (P < .05) in 16 patients who did not resume activities because of poor physical condition.

CONCLUSIONS

This scoring system for postoperative gastrointestinal dysfunction provides an objective measure of dysfunction related to specific surgical procedures and correlates with activities of daily living in the postoperative period.

D2 plus para-aortic lymphadenectomy versus standardized D2 lymphadenectomy in gastric cancer surgery

PURPOSE

To evaluate the survival benefits and safety of D2 plus para-aortic lymphadenectomy (D2 + PALD) for gastric carcinoma.

METHODS

Patients with gastric carcinoma, who agreed to undergo D2 + PALD between February 2001 and December 2003, were allocated to the D2 + PALD group, and compared with a control group who underwent D2 lymphadenectomy. Patients were followed up until August 2007.

RESULTS

Sixty-two patients were allocated to the D2 + PALD group, and a concurrent 55 patients were allocated to the D2 group. The mean follow-up period was 57.6 (range 43.0-77.6) months, with 11.1% lost to follow-up. The morbidity and mortality rates were 24.2% and 0% in the D2 + PALD group, and 27.3% and 1.8% in the D2 group, respectively. The overall 3- and 5-year survival rates were 77.5% and 65.8% in the D2 + PALD group, and 73.2% and 66.1% in the D2 group, respectively, without a significant difference. The frequency of metastasis to the para-aortic lymph nodes (PALN) was 8.1%. The logistic regression revealed that PALN metastasis was correlated to metastasis of No. 8a and No. 9 lymph nodes (P = 0.021 and P = 0.030, respectively).

CONCLUSION

Although D2 + PALD can be performed safely with an acceptable incidence of complications when performed by well-trained gastrointestinal surgeons, its survival benefits are not significantly greater than those of D2 lymphadenectomy. Therefore, routine D2 + PALD should not be recommended.