Total Gastrectomy with Radical Systemic Lymphadenectomy (Classic Japanese Style D2)

Abstract

Historically, total gastrectomy (TG) with radical lymphadenectomy included distal pancreatectomy and splenectomy and was favored by Brunschwig in 1948. Maruyama modified this procedure by preserving the distal pancreas, so-called pancreas-preserving radical TG. His initial report was published in Japanese in 1979. Initially he ligated both the splenic artery and vein near their origin, which often caused major congestion of the pancreas tail followed by massive necrosis. The first available English report was published in 1995 and described a modified technique of the original version. There he obtained the splenic vein up to the tip of the pancreas tail to preserve venous return.

The technique of pancreas preserving TG with radical systemic lymphadenectomy (D2) by preserving the splenic artery and vein as far as the branching-off of the major pancreatic artery (Sasako’s modification) is described. After this original text was written, results of the JCOG0110 study, a RCT comparing this type of TG and spleen preserving TG, were reported in ASCO 2014, showing that spleen should be preserved unless tumors do not involve the greater curvature of the upper body or the pancreas tail or the spleen. Therefore indication of this technique should be limited mainly for T4a tumors of the greater curvature and T4b tumors involving the pancreas or spleen.