D2 Lymphadenectomy for Gastric Cancer Advancements and Technical Considerations

Jul 16, 2026

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Lymphadenectomy (LND) is a crucial element of curative surgery for gastric cancer, providing both accurate pathologic staging and therapeutic potential. D2 LND is identified as the optimal approach for locally advanced disease, balancing survival benefit with acceptable morbidity when performed with high technical proficiency. This review synthesizes evidence on D2 LND status, anatomic borders, operative details, and key controversies such as splenic hilar dissection and omentectomy. It also reviews indocyanine green fluorescence imaging for drainage mapping and discusses surgical standardization and centralization.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

Abstract and Background

Role and rationale of D2 lymphadenectomy

Staging requirements and AJCC guidance

Definition, anatomic borders, and technical elements

Historical Perspective

Evolution from D1 vs D2 and trial evidence

Morbidity considerations and surgical modifications

Controversies and Advances

Splenic hilar dissection and omentectomy

Indocyanine green fluorescence imaging

Quality, compliance, standardization, and centralization

Ann Surg Oncol (2024) 32:2129–2140 [https://doi.org/10.1245/s10434-024-16545-6](https://doi.org/10.1245/s10434-024-16545-6) REVIEW ARTICLE – GASTROINTESTINAL ONCOLOGY D2 Lymphadenectomy for Gastric Cancer: Advancements and Technical Considerations Ahmed Dehal, MD, MPH, FSSO1, Yanghee Woo, MD2, Evan S. Glazer, MD, PhD3, Jeremy L. Davis, MD4, Vivian E. Strong, MD5, and Society of Surgical Oncology Gastrointestinal Disease Site Workgroup 1Department of General Surgery, Southern California Permanente Medical Group, Department of Clinical Sciences, Kaiser Permanente School of Medicine, Los Angeles, CA; 2Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA; 3Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; 4Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD; 5Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY ABSTRACT Lymphadenectomy (LND) is a crucial component of the curative surgical treatment of gastric cancer (GC) . The LND serves to both accurately stage the disease and offer therapeutic benefits. At the time of “curativeintent” gastrectomy, D2 LND is the optimal treatment for patients with locally advanced GC due to its survival benefits and acceptable morbidity. Mastery of the technical aspects of LND, especially D2, requires significant training, adequate case volume, and expertise. This review discusses key aspects of D2 LND, including its status as the standard treatment for locally advanced GC, definition and anatomic borders, technical details, and controversial topics such assplenic hilar dissection and omentectomy. The application of indocyanine green (ICG) fluorescence imaging to elucidate the drainage patterns of GC and to facilitate lymph node (LN) identification is briefly reviewed. Finally, GC standardization and centralization, including surgical treatment, are discussed. Keywords Lymphadenectomy · Gastric cancer · D2 · Technique · Lymph node · Dissection © Society of Surgical Oncology 2024, corrected publication 2025 First Received: 9 September 2024 Accepted: 5 November 2024 Published online: 26 November 2024 A. Dehal, MD, MPH, FSSO e-mail: [ahmed.n.dehal@kp.org](ahmed.n.dehal@kp.org) Gastric cancer (GC) is the fifth most frequently diagnosed type of cancer and the fourth leading cause of cancer-related death worldwide. 1 Gastrectomy with lymphadenectomy (LND) is the mainstay of curative multimodality treatment for GC and currently is considered the standard treatment, especially for those with locally advanced disease, resulting in a 36–45% 5-year survival rate.2–5 The American Joint Committee on Cancer (AJCC) staging system is the most accepted for determining disease prognosis and survival. The eighth-edition AJCC recommends examining at least 16 retrieved lymph nodes (LNs) and ideally 30 LNs or more for accurate staging and prognosis.6 The level of LND that ensures meeting this requirement has been described as D2 . It currently is the most widely accepted and recommended level of LND, which provides optimal locoregional control and a survival benefit.7 The D2 LND accurately stages the disease, reduces locoregional recurrences, and offers therapeutic benefits.8 The quality of D2 LND is crucial for a favorable prognosis.9 In this report, we discuss key elements of D2 LND by providing a consolidated overview of the existing literature and synthesizing evidence from relevant studies and different surgical practices. First, we present a historical overview of landmark studies that led to our current understanding of D2 LND as well as contemporary evidence. Next, we review the definition of actual anatomic borders of a complete D2 LND according to the Japanee Gastric Cancer Association (JGCA) guidelines. We also discuss the optimal number of harvested LNs and the impact of neoadjuvant chemotherapy (NAC) . Controversi

FAQs

Why is D2 lymphadenectomy considered important in curative gastric cancer surgery?

D2 LND is crucial because it accurately stages the disease and can provide therapeutic benefit alongside locoregional control, leading to survival advantages for patients with locally advanced gastric cancer.

What lymph node retrieval targets are recommended for accurate staging?

The AJCC eighth edition recommends examining at least 16 retrieved lymph nodes and ideally 30 or more to improve accuracy for staging and prognosis.

What controversial topics does the review address within D2 lymphadenectomy?

The review addresses controversies including splenic hilar dissection and omentectomy, and it also briefly discusses how these practices relate to surgical outcomes and technique.

How does indocyanine green (ICG) fluorescence imaging support D2 lymphadenectomy?

ICG fluorescence imaging is reviewed as a way to elucidate gastric cancer drainage patterns and facilitate lymph node identification during surgery.

Jul 16, 2026

Upload by Asher