The article by Pacelli et al highlights, once again, the role of high-volume experienced centers in performing complex operations with low morbidity and mortality. The authors are to be commended for their ability to perform TG and pancreas-preserving D2-D3 lymph node dissections with excellent long-term survival (61.8% at 5 years and 47.3% at 10 years). In this study, 95.5% (298 of 312) of patients underwent R0 resection. However, several points required careful attention.
Although TG is no longer considered the standard for gastric cancer, it may be needed in selected patients with proximal lesions or diffuse-type (linitis plastica) gastric cancer to obtain R0 resection.1 However, the extent of lymphadenectomy in gastric cancer remains controversial. The authors routinely performed pancreas-preserving D2-D3 lymphadenectomy for gastric cancer. Data from several randomized trials and meta-analysis have shown no survival benefit of extended lymphadenectomy. The Dutch Gastric Cancer Group has recently published long-term results with 11-year follow-up and confirmed no survival benefit of D2 vs D1 lymph node dissection except for N2 disease on subset analysis.1 Splenectomy and pancreatectomy were shown to be significant risk factors for morbidity and in-hospital mortality after D2 lymph node dissections in randomized trials.1,2 Recent evidence supports the use of the so-called over-D1 lymphadenectomy to obtain adequate lymph nodes for appropriate staging, with selective resection of the pancreas and spleen to obtain R0 resection.1 In addition, the role for palliative TG seems small, given a recent series showing that most patients with distant metastasis do not require any surgical interventions for symptom control.3 In the study by Pacelli et al, palliative TG by experienced surgeons carried substantial mortality of 6.8% and morbidity of 37.5%, with unclear benefits. Most patients (69.3%) undergoing palliative TG received adjuvant chemotherapy, and the authors do not address the contribution of adjuvant therapy. Gastric cancer remains a lethal disease worldwide, and future progress will depend on the addition of adjuvant and neoadjuvant regimens such as the regimen used in the recent MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) trial,1 as well as better disease stratification with the use of genetic profiles.