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Page 6 of 9 van den Berg et al. Mini-invasive Surg 2019;3:23 I http://dx.doi.org/10.20517/2574-1225.2019.07

lymph node dissection (D2) reported that D2 lymphadenectomy is associated with lower locoregional
recurrence (D1; 22% vs. D2; 12%) and significantly reduced gastric-cancer related deaths (D1; 48% vs.
[35]
D2; 37%) . A systematic review of RCTs comparing different types of lymph node dissection in patients
[36]
with gastric cancer was reported . In this review no significant difference in OS was seen after D1
lymphadenectomy compared with D2 lymphadenectomy (n = 5; HR 0.91, 95%CI: 0.71 to 1.17). In contrast,
D2 lymphadenectomy was related to a significantly improved disease specific survival compared to D1
lymphadenectomy (HR 0.81, 95%CI: 0.71-0.92). However, the D2 lymphadenectomy was associated with
a higher postoperative mortality rate (RR 2.02, 95%CI: 1.34-3.04). The high post-operative morbidity and
mortality following D2 dissection in this study was attributed to performing a splenectomy. Therefore,
a spleen-preserving D2 lymphadenectomy is the recommend surgical approach for resectable advanced
gastric cancer.

In a meta-analysis comparing open with LG, 11 of 12 studies described lymph node resection, with no
significant differences between OTG and LTG groups . Eight of the studies individually favoured open
[12]
resection for lymph node resection. Only three studies reported resection margin status, with no difference
in proximal, distal or circumferential margin R0 resection status. Overall, lymph node yield was equal after
both methods of gastric surgery. The recently published long-term results of the CLASS-01 trial showed
a mean retrieval of lymph nodes of 36 in the laparoscopic group compared with 37 in the open group .
[6]
Overall, these numbers are higher compared with the number of lymph nodes retrieved in the West.
Therefore, the results of ongoing RCTs in Europe are needed to establish the optimal surgical approach in
patients with gastric cancer in Western countries.

Omentectomy
A Dutch prospective trial studied the presence of metastases in the greater omentum in patients
[37]
undergoing a (sub) total gastrectomy with omentectomy and D2 lymphadenectomy for gastric cancer .
Five percent of the patients had metastases in the greater omentum, however all these patients also had a
positive proximal or distal resection margin (R1 resection). In addition, another Dutch prospective trial
demonstrated that omental lymph node metastases or tumour deposits are present in 10% of the patients .
[38]
Worldwide there is no consensus on whether to perform an omentectomy or not for gastric cancer surgery.
RCTs are warranted to investigate the effect of omentectomy on long-term survival. Traditionally, an
omentectomy has been considered the standard approach to gastrectomy for gastric cancer patients. Due to
possible presence of omental lymph node metastases and difficulty in predicting presence of these nodes,
omentectomy should be performed as standard, unless proven otherwise by randomised trials.

Bursectomy
In eastern Asia, a bursectomy has been performed to remove the peritoneum covering the pancreas and the
anterior plane of the transverse mesocolon. Two Japanese RCTs compared bursectomy with omentectomy
[39]
for patients with resectable gastric cancer. First, Hirao et al. reported in patients with cT2-3 gastric
adenocarcinoma and D2 gastrectomy a 5-year survival of 77.5% in patients who underwent a bursectomy
compared with 71.3% in patients without bursectomy (P = 0.16). However, multivariate analysis that
[40]
bursectomy was an independent prognostic factor of good OS (P = 0.033). More recently, Kurokawa et al.
reported no survival advantage for bursectomy combined with omentectomy over omentectomy alone.
Five-year OS was 76.7% in the non-bursectomy group and 76.9% in the bursectomy group (HR 1.05, 95%CI:
0.81-1.37; P = 0.65). In addition, a recent meta-analysis reported that a bursectomy for advanced gastric
cancer has no positive influence on the number of harvested lymph nodes (WMD 5.86; P = 0.157) or on the
OS (HR 0.95; P = 0.647) . A study describing patients who underwent a LTG with complete bursectomy
[41]
[42]
showed that this technique is feasible and safe in experienced hands .