European Surgery

, Volume 43, Issue 5, pp 255–261

Meta-analysis of randomized controlled trials comparing D2 and D4 lymphadenectomy for gastric cancer



BACKGROUND: The aim of the study was to assess the efficacy and safety of D2 compared with D4 surgery in patients treated with curative intent. METHODS: An electronic search of the Cochrane Central Register of Controlled Trials, PubMed, Embase, ISI databases and Chinese Biomedical Literature Database was conducted till September 2010 to identify randomized controlled trials on related studies. Statistic analyses were carried out using RevMan software. RESULTS: Three randomized controlled trials with 1067 patients were included. The meta-analysis showed that D4 dissection tended to be associated with slightly higher 5-year survival rate, but there were no statistically significant differences between two groups [OR = 0.93, 95% CI (0.69–1.25)]. However, there appeared to be no statistically differences between D2 and D4 group in terms of recurrences of cancer, re-operation, hospital mortality, overall morbidity, anastomotic leakage, pancreatic fistula, operation time, though pulmonary increased in the D2 group comparing to that in the D4 group. CONCLUSIONS: Prophylactic D4 dissection is not recommended for patients with curable gastric cancer.


Gastric cancer D2 lymphadenectomy D4 lymphadenectomy Meta-analysis 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Akoh JA, Macintyre IMC. Improving survival in gastric-cancer-review of 5-year survival rates in English-language publications from 1970. Br J Surg 1992;79:293–9PubMedCrossRefGoogle Scholar
  2. Nakamura K, Ueyama T, Yao T, et al. Pathology and prognosis of gastric-carcinoma-findings in 10,000 patients who underwent primary gastrectomy. Cancer 1992;70:1030–7PubMedCrossRefGoogle Scholar
  3. Kim JP, Lee JH, Kim SJ, et al. Clinicopathologic characteristics and prognostic factors in 10783 patients with gastric cancer. Gastric Cancer 1998;1:125–33PubMedCrossRefGoogle Scholar
  4. Sun XD, Mu R, Zhou YS, et al. Analysis of mortality rate of stomach cancer and its trend in twenty years in China. Chin J Oncol 2004;26:101–5Google Scholar
  5. Sasako M. Principles of surgical treatment for curable gastric cancer. J Clin Oncol 2003;21(Suppl.):274S–5PubMedCrossRefGoogle Scholar
  6. Allum WH, Griffin SM, Watson A, et al. Guidelines for the management of oesophageal and gastric cancer. Gut 2002;50: 1–23CrossRefGoogle Scholar
  7. Douglass HO Jr, Hundahl SA, Macdonald JS, et al. Gastric cancer: D2 dissection or low Maruyama Index-based surgery – a debate. Surg Oncol Clin N Am 2007;16:133–55PubMedCrossRefGoogle Scholar
  8. Sasako M, Saka M, Fukagawa T, et al. Modern surgery for gastric cancer – Japanese perspective. Scand J Surg 2006;95:232–5PubMedGoogle Scholar
  9. Sano T. Tailoring treatments for curable gastric cancer. Br J Surg 2007;94:263–4PubMedCrossRefGoogle Scholar
  10. Takeda J, Koufuji K, Kodama I, et al. Para-aortic lymph node dissection for the treatment of advanced gastric cancer. Kurume Med J 1993;40:101–6PubMedCrossRefGoogle Scholar
  11. Yonemura Y, Katayama K, Kamata T, et al. Surgical-treatment of advanced gastric-cancer with metastasis in paraaortic lymph-node. Int Surg 1991;76:222–5PubMedGoogle Scholar
  12. Nakane Y, Okamura S, Masuya Y, et al. Incidence and prognosis of para-aortic lymph node metastasis in gastric cancer. Hepatogastroenterology 1998;45:1901–6PubMedGoogle Scholar
  13. Yonemura Y, Segawa M, Matsumoto H, et al. Surgical results of performing R4 gastrectomy for gastric cancer located in the upper third of the stomach. Jpn J Surg 1994;24:488–93CrossRefGoogle Scholar
  14. Kunisaki C, Shimada H, Yamaoka H, et al. Significance of para-aortic lymph node dissection in advanced gastric cancer. Hepatogastroenterology 1999;46:2635–42PubMedGoogle Scholar
  15. Gunji Y, Suzuki T, Kobayashi S, et al. Evaluation of D3/D4 lymph node dissection for patients with grossly N2 positive advanced gastric cancer. Hepatogastroenterology 2003;50:1178–82PubMedGoogle Scholar
  16. Sano T, Sasako M, Yamamoto S, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy – Japan Clinical Oncology Group study 9501. J Clin Oncol 2004;22:2767–73PubMedCrossRefGoogle Scholar
  17. Yonemura Y, Wu CC, Fukushima N, et al. Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons. Hepatogastroenterology 2006;53:389–94PubMedGoogle Scholar
  18. Kulig J, Popiela T, Kolodziejczyk P, et al. Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial. Am J Surg 2007;193:10–5PubMedCrossRefGoogle Scholar
  19. Yonemura Y, Wu CC, Fukushima N, et al. Randomized clinical trial of D2 and extended paraaortic lymphadenectomy in patients with gastric cancer. Int J Clin Oncol 2008;13:132–7PubMedCrossRefGoogle Scholar
  20. Sasako M, Sano T, Yamamoto S, et al. D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N Engl J Med 2008;359:453–62PubMedCrossRefGoogle Scholar
  21. Jiang BJ, Gao YF, Sun RX, et al. Clinical study on the dissection of lmyph nodes around abdominal aortic artery in advanced gastric cancer. Chin J Gener Surg 2000;9:292–5Google Scholar
  22. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. [] Accessed 10 March 2009
  23. Higgins JP, Green S (editors) Cochrane handbook for systematic reviews of interventions 4•2•6. The Cochrane Library, Issue 4. Chichester: John Wiley & Sons; 2006. pp. 1–257Google Scholar
  24. Wu CW, Hsiung CA, Lo SS, et al. Randomized clinical trial of mortality after D1 and D3 surgery for gastric cancer. Br J Surg 2004;91:283–7PubMedCrossRefGoogle Scholar
  25. Desai AM, Pareek M, Nightingale PG, et al. Improving outcomes in gastric cancer over 20 years. Gastric Cancer 2004;7:196–203PubMedCrossRefGoogle Scholar
  26. Di Leo A, Pedrazzani C, Bonfiglio M, et al. Superextended lymphadenectomy (D4) in the treatment of gastric cancer. Minerva Chir 2002;57:641–7PubMedGoogle Scholar
  27. Yu W, Choi GS, Chung HY. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006;93:559–63PubMedCrossRefGoogle Scholar
  28. Yoshikawa T, Sasako M, Sano T, et al. Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial. Br J Surg 2006;93:1526–9PubMedCrossRefGoogle Scholar
  29. Tsujinaka T, Sasako M, Yamamoto S, et al. Influence of overweight on surgical complications for gastric cancer: results from a randomized control trial comparing D2 and extended para-aortic D3 lymphadenectomy (JCOG9501). Ann Surg Oncol 2007;14:355–61PubMedCrossRefGoogle Scholar
  30. Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 2010;11:439–49PubMedCrossRefGoogle Scholar
  31. Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340: 908–14PubMedCrossRefGoogle Scholar
  32. Wu CW, Hsiung CA, Lo SS, et al. Nodal dissection for patients with gastric cancer: a randomised controlled trial. Lancet Oncol 2006;7:309–15PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Evidence-Based Medicine Center of Lanzhou UniversityLanzhouChina
  2. 2.First Affiliated Hospital of Lanzhou UniversityLanzhouChina
  3. 3.Second People Hospital of Gansu ProvinceLanzhouChina

Personalised recommendations