Overview
Definition:
D2 lymphadenectomy is an extended lymph node dissection technique performed during gastrectomy for gastric cancer, involving the removal of lymph nodes along the major gastric arteries and their surrounding tissues (stations 1-12)
This comprehensive dissection aims to achieve a more accurate locoregional staging and to resect potentially micrometastatic nodal disease, thereby improving survival outcomes.
Epidemiology:
Gastric cancer remains a significant global health concern, with a high incidence in East Asia, including India
While the incidence is decreasing in many Western countries, it still accounts for substantial morbidity and mortality
Accurate staging, particularly nodal status, is a critical determinant of prognosis and treatment strategy.
Clinical Significance:
D2 lymphadenectomy is considered the gold standard for lymph node dissection in potentially curable gastric cancer
It is crucial for accurate pathological staging, which guides adjuvant and neoadjuvant therapy decisions
Adequate nodal clearance significantly impacts long-term survival rates, making it a key component of gastric cancer surgery for DNB and NEET SS aspirants.
Indications
Surgical Resection:
Resectable gastric adenocarcinoma, including early-stage to locally advanced disease, with no distant metastases.
Patient Factors:
Good performance status, adequate cardiopulmonary function, and absence of significant comorbidities that would preclude major surgery.
Lymph Node Involvement:
Clinical or radiological suspicion of lymph node involvement, or as part of a standard radical resection for all resectable gastric cancers regardless of initial nodal suspicion.
Preoperative Preparation
Evaluation:
Comprehensive assessment of overall health, including cardiac and pulmonary function tests, nutritional status, and evaluation of comorbidities.
Staging:
Endoscopic evaluation with biopsy, endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for nodal assessment, CT scan of chest, abdomen, and pelvis for distant metastasis screening, and potentially PET-CT for equivocal findings.
Nutritional Support:
Preoperative nutritional optimization with appropriate dietary counseling or supplementation to improve surgical outcomes and reduce postoperative complications.
Informed Consent:
Detailed discussion with the patient and family regarding the procedure, potential risks, benefits, alternatives, and expected outcomes, including the rationale for D2 dissection.
Surgical Management
Surgical Approach:
Laparoscopic, robotic-assisted, or open gastrectomy with D2 lymphadenectomy
The choice depends on surgeon expertise, patient factors, and institutional resources.
Gastrectomy Type:
Subtotal gastrectomy for distal tumors or total gastrectomy for proximal tumors, ensuring adequate margins.
Lymph Node Stations Dissected:
Stations 1 (cardia), 2 (para-aortic), 3 (lesser curvature nodes), 4 (greater curvature nodes), 5 (suprapyloric nodes), 6 (infrapyloric nodes), 7 (left gastric artery nodes), 8 (common hepatic artery nodes), 9 (splenic artery nodes), 10 (splenic hilum nodes), 11 (splenocolic ligament nodes), and 11d (distal splenic artery nodes).
Reconstruction:
Esophagojejunostomy or esophagogastrostomy with Roux-en-Y reconstruction following total gastrectomy, or gastrojejunostomy following subtotal gastrectomy.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, pain control, and for signs of complications such as anastomotic leak, bleeding, or ileus.
Pain Management:
Effective multimodal pain management, including patient-controlled analgesia (PCA) or epidural analgesia.
Nutritional Support:
Early enteral nutrition via nasojejunal tube or oral feeding as tolerated, with gradual transition to oral diet
Vitamin B12 supplementation is essential after total gastrectomy.
Mobilization And Rehabilitation:
Early ambulation and physical therapy to prevent deep vein thrombosis (DVT), pulmonary complications, and promote recovery.
Complications
Early Complications:
Anastomotic leak (0-5%), bleeding (2-8%), intra-abdominal abscess (2-5%), pancreatitis (1-3%), chylous ascites (0.5-2%), pancreatic fistula, and prolonged ileus.
Late Complications:
Dumping syndrome, afferent loop syndrome, marginal ulceration, nutritional deficiencies (B12, iron, vitamin D), weight loss, and incisional hernias.
Prevention Strategies:
Meticulous surgical technique, careful handling of tissues, adequate blood supply preservation, appropriate use of drains, prompt diagnosis and management of leaks, and comprehensive postoperative care including nutritional support and early mobilization.
Prognosis
Factors Affecting Prognosis:
Stage of the disease (TNM staging), depth of tumor invasion, lymph node metastasis (number and location), presence of distant metastasis, histological type, and completeness of surgical resection (R0 status).
Outcomes:
Survival rates vary significantly with stage
For Stage I gastric cancer treated with D2 dissection, 5-year survival can exceed 80-90%
For advanced stages, outcomes are poorer but D2 dissection still offers survival benefits compared to less extensive dissections.
Follow Up:
Regular follow-up appointments with clinical examination, laboratory tests (e.g., CEA), and imaging (CT scans) to monitor for recurrence and manage long-term sequelae
Frequency and duration depend on the stage of the disease.
Key Points
Exam Focus:
Understand the anatomical boundaries of D2 dissection (stations 1-12)
Recognize indications and contraindications
Be familiar with the morbidity and mortality associated with D2 dissection versus D1
Recall the importance of R0 resection and accurate pathological staging.
Clinical Pearls:
The success of D2 lymphadenectomy relies on surgeon experience and a multidisciplinary approach
Consider adjuvant or neoadjuvant chemotherapy for advanced stage disease
Preservation of the spleen is often possible during D2 dissection for tumors not involving the splenic hilum.
Common Mistakes:
Inadequate nodal dissection (missing key stations)
Overly aggressive dissection leading to excessive morbidity
Failure to achieve negative resection margins
Incorrect staging due to insufficient lymph node sampling
Neglecting postoperative nutritional support.