D2 GASTRECTOMY

Dr K Suneel Kaushik
Senior Resident
Surgical Oncology

Complete operative resection remains the

only potentially curative modality for
gastric adenocarcinoma
Assess if the patient is fit for surgery
Extent of resection?
Extent of lymphnode dissection?
Value of extended organ resection?

Extent of resection

Determined by site and extent of the primary

neoplasm

Proximal lesions and Siewert type II and III :

proximal gastrectomy with esophagectomy or
Total gastrectomy

Antral lesions: Distal subtotal gastrectomy

Midbody or more extensive lesions: Total

gastrectomy

Total vs partial
gastrectomy

Total gastrectomy for all gastric

carcinomas does not improve survival

Associated with increased morbidity and

mortality

Hence R0 resection of tumors by distal or

subtotal gastrectomy is preferred

Extended organ resection is reserved for

node negative T4 lesions involving
resection of invaded portions of
diaphragm, pancreas, spleen, adrenal,
colon etc

Extent of
lymphadenectomy
D1 vs d2 has been the focus of 6RCTs.
- British Medical research Council
Dutch Gastric cancer study group
Italian Gastric cancer study Group(IGCSG)
Wu et al (D1 vs D3)
Japanese Clinical Oncology Group (D2 vs
d2 plus)
Japanese trial (D2 vs D4)

MRC trial
D1

D2

P value

No. of patients

200

200

Operative mortality(%)

6.5

13

<.04

Postoperative
complications(%)

28

46

<0.001

5yr overall survival(%)

35

33

NS

Italian group
D1

D2

P value

No. of patients

76

86

Operative mortality(%)

1.3

NS

Postoperative complications(%)

10.5

16.3

.29

Postoperative stay(d)

12

12

NS

5y overall survival(%)

NS

NS

NS

Dutch Trial:
D1

D2

P value

No. of patients

380

331

Operative mortality(%)

10

.004

Postoperative complications(%)

25

43

<.001

Postoperative stay(d)

18

25

<.001

5y overall survival(%)

45

47

NS

11yr F/U Overall survival(%)

30

35

.53

15yr F/U overall survival(%)

21

29

.34

15yr F/U gastric cancer specific

death

48

37

.01

Initial conclusion was that there was no

role for routine use of D2 resection

It was revised after 15yr followup:

Because spleen preserving D2 resection is

safer in high volume centres it is
recommended surgical approach for
patients with potentially curable gastric
cancer.

Surgical anatomy

16 nodal stations were grouped into 4

N1 - The perigastric nodes directly attached along the
lesser curvature and greater curvatures

N2 - The removal of nodes along the left gastric artery

(station 7), common hepatic artery (station), celiac trunk
(station 9), splenic hilus, and splenic artery (station 10
and 11).
N3 Includes stations 12 through 14
N4 - stations 15 and 16 in the paraaortic and the
paracolic region

Surgical Procedure

1.

2.

3.

Principles:
Extent of the lesion is determined by CT
EUS
Diagnostic laparoscopy in selected
patients( advanced disease clinical N+ /T3
Unresectable for cure (inoperable) : Level 3
or 4 nodes, invasion or encasement of major
vascular structures, distant metastasis or
peritoneal cytology positive

4. Resectable tumors :
Tis or T1 : EMR
T1b T3 : Adequate gastric resection to
achieve negative microscopic margins
( typically 4cm from gross tumor)
T4 : require enbloc resection of involved
structures
Include regional lymphatics : D1 or D2. D2 is
the standard of care.
Goal to examine atleast 15 nodes (NCCN)
FJ in selected patients (wh may require CRT)

4-6cm margin on either side is preferred.

2cm distal if antral lesions, proximal
lesion a lesser extent of uninvolved
esophagus is acceptable.

Palliative procedures for unresectable

tumors
Palliative gastric resection
Bypass GJ
Stenting
Gastrostomy or jejunostomy

Preop evaluation and

preparation

Diagnostic evaluation
Staging evaluation and assess operability
Evaluate for tolerance for major surgery
PFT if thoracic approach is required for GE
junction tumors
Pre op antibiotic cephalosporin single
dose just before induction

Position:
- Supine with lower chest prepared in case
extension of incision is required.
- Consideration given for possibility of thoracic
approach

Incision :
Midline
Bilateral subcostal Chevron
Left thoracoabdominal incision

Distal Subtotal
gastrectomy

Distal Subtotal
Gastrectomy

Greater Curvature mobilisation :

Dissected off the transverse colon with cautery

along the avascular plane between the
omentum and appendices epiploicae

Anterior leaf of transverse mesocolon and

anterior pancreatic capsule are dissected off

Omentum is resected with the specimen along

with level 4 lymphnodes.

Dissection proceeds to the left side of

abdomen and omentum dissected off the
splenic flexure and inferior pole of spleen

Left gastroepiploic vessels are identified

and divided near their origin from Splenic
vessels

Preservation of short gastric vessels is

critical.

Dissection of pancreatic capsule :

- A standard approach
- Value is unproven, may be omitted
- May result in minor pancreatic leaks
- At the base of transverse mesocolon,
capsule is incised and dissected from
anterior surface of pancreas

Infrapyloric mobilisation :
Omentum is divided on right side upto
the duodenum
Colic branch of gastrocolic trunk(into
SMV) is identified in tranverse mesocolon
and followed to its confluence with the
right gastroepiploic vein.
The right gastroepiploic vein is divided at
its junction with the gastrocolic trunk and
inferior pancreaticoduodenal arcade.

- Right Gastroepiploic artery is divided as it

arises from the gastroduodenal artery
- Station 6 LN are dissected away from head
of pancreas and included in the specimen.

Suprapyloric mobilisation
Gastrohepatic ligament is divided
Vertically in the direction of hepatic artery
proper
Right gastric artery is ligated at its origin
from either hepatic artery proper or
gastroduodenal artery
Right gastric vein is divided close to its
junction with the portal vein
Station 5 LN are dissected with the specimen

Duodenal transection:
Duodenum transected just distal to pylorus ( or
away for negative margins in distal cancers)
using GIA-60 or straight Kocher clamps.

Staple line is inverted with Lembert sutures

using 3-0 monofilament absorbable material.

Most important factor affecting the healing of

stump is the adequate blood supply.

Allows upward and forward rotation of

stomach

And easy access to node bearing areas.

D2 lymphadenectomy:

Dividing and reflecting the peritoneum and

lymphatics in superior porta hepatis from right
to left and above downwards.

Station 8: Nodal tissue dissected from right to

left on anterior surface of common hepatic
artery(8a), hepatic artery is gently retracted to
the right side and nodal tissue between common
hepatic artery and portal vein dissected(8b)

Station 12 : Hepatoduodenal LN along the

hepatic artery proper, Bile duct and
portal vein are dissected

Left gastric vein is ligated at its entry into

portal or splenic vein

Station 11: Along the upper border of

pancreas and proximal splenic artery
dissected

Dissection continues medially into the

coeliac axis

Left gastric artery is ligated at its origin

from coeliac trunk

Adjacent nodal tissue is reflected towards

the crura of diaphragm

Dissection then proceeds proximally

along the lesser curvature

Nodal tissue along the 2-3cm of

abdominal esophagus is dissected
(Station 1)

Station 10: may not routinely be required

for distal gastrectomy

Gastric transection:
Along the line connecting about 2cm distal to the
GEJ on lesser curvature and a point 5cm proximal
to the upper border of the tumor on greater
curvature side

Straight clamps are applied for 6-8cm on greater

curvature side and divided with knife

The remaining stomach from tips of straight

clamps to chosen point on lesser curvature with
GIA stapler.

Total Gastrectomy :
The paracardial LN reflected inferiorly and
the entire stomach is lifted forward and the
GE junction is mobilised and divided using a
Satinsky atraumatic vascular clamp.
frozen for margin.

Positive microscopic margin is a negative

prognostic factor in patients who have
<6nodes positive. If >5nodes positive no
longer an independent predictor of poor
survival.

- But because nodal status is not known in

majority of patients at surgery, frozen is
usually preferred.

Reconstruction :
Roux en Y Esophagojejunostomy

Roux en Y Gastrojejunostomy

Billroth II Loop Gastrojejunostomy

(antecolic or retrocolic)

Billroth I Gastroduodenostomy

Billroth II GJ

Standard two Layer

hand Sewn anastomosis

Roux en y GJ

Following Total
gastrectomy

Postoperative care

Early mobilization and pulmonary toilet

Continuous Epidural analgesia
Prophylactic broad-spectrum antibiotics
for 24hrs
Careful fluid and electrolyte balance
Packed red blood cells if Hb <7g% or Hb ,
9g% if symptomatic.
NG tube removed with return of bowel
movements or when is output is low

Postgastrectomy diet consisting of six

small daily meals.
FJ feeds

Complications

Morbidity : 20%
Mortality : 2-3%
Pulmonary complications
Anastomotic and duodenal stump leaks
Intraabdominal abscess
Pancreatic fistula
Vit B 12, Vit D, irona nd calcium
deficiencies

Post Gastrectomy syndromes:

Alkaline reflux gastritis
Dumping syndrome
Roux Stasis Syndrome
Afferent limb Syndrome

1 Right paracardial LNs, including those

along the first branch of the ascending limb
of the left gastric artery.
2 Left paracardial LNs including those along
the esophagocardiac branch of the left
subphrenic artery
3a Lesser curvature LNs along the branches
of the left gastricvartery
3b Lesser curvature LNs along the 2nd
branch and distal part of the right gastric
artery

4sa Left greater curvature LNs along the

short gastric arteries (perigastric area)
4sb Left greater curvature LNs along the
left gastroepiploic artery (perigastric
area)
4d Rt. greater curvature LNs along the
2nd branch and distal part of the right
gastroepiploic artery

5 Suprapyloric LNs along the 1st branch and

proximal part of the right gastric artery
6 Infrapyloric LNs along the first branch and
proximal part of the right gastroepiploic
artery down to the confluence of the right
gastroepiploic vein and the anterior superior
pancreatoduodenal vein
7 LNs along the trunk of left gastric artery
between its root and the origin of its
ascending branch

8a Anterosuperior LNs along the common

hepatic artery
8p Posterior LNs along the common hepatic
artery
9 Celiac artery LNs
10 Splenic hilar LNs including those adjacent
to the splenic artery distal to the pancreatic
tail, and those on the roots of the short
gastric arteries and those along the left
gastroepiploic artery proximal to its 1st
gastric branch

11p Proximal splenic artery LNs from its origin to halfway

between its origin and the pancreatic tail end
11d Distal splenic artery LNs from halfway between its origin
and
the pancreatic tail end to the end of the pancreatic tail
12a Hepatoduodenal ligament LNs along the proper hepatic
artery,in the caudal half between the confluence of the right and
left hepatic ducts and the upper border of the pancreas
12b Hepatoduodenal ligament LNs along the bile duct, in the
caudal half between the confluence of the right and left
hepatic
ducts and the upper border of the pancreas
12p Hepatoduodenal ligament LNs along the portal vein in the
caudal half between the confluence of the right and left hepatic
ducts and the upper border of the pancreas

13 LNs on the posterior surface of the pancreatic

head cranial to the duodenal papilla
14v LNs along the superior mesenteric vein
15 LNs along the middle colic vessels
16a1 Paraaortic LNs in the diaphragmatic aortic
hiatus
16a2 Paraaortic LNs between the upper margin of
the origin of the celiac artery and the lower border
of the left renal vein
16b1 Paraaortic LNs between the lower border of
the left renal vein and the upper border of the
origin of the inferior mesenteric artery

16b2 Paraaortic LNs between the upper border

of the origin of the inferior mesenteric artery
and the aortic bifurcation
17 LNs on the anterior surface of the
pancreatic head beneath the pancreatic sheath
18 LNs along the inferior border of the
pancreatic body
19 Infradiaphragmatic LNs predominantly
along the subphrenic artery
20 Paraesophageal LNs in the diaphragmatic
esophageal hiatus

110 Paraesophageal LNs in the lower

thorax

111 Supradiaphragmatic LNs separate

from the esophagus

112 Posterior mediastinal LNs separate

from the esophagus and the esophageal
hiatus