Summary Controversy still exists on the optimal surgical resection for potentially curable gastric cancer. Much better long-term survival has been reported in retrospective/non-randomized studies with D 2 resections that involve a radical extended regional lymphadenectomy than with the standard D 1 resections. In this paper we report the long-term survival of patients entered into a randomized study, with follow-up to death or 3 years in 96% of patients and a median follow-up of 6.5 years. In this prospective trial D 1 resection (removal of regional perigastric nodes) was compared with D 2 resection (extended lymphadenectomy to include level 1 and 2 regional nodes). Central randomization followed a staging laparotomy.Out of 737 patients with histologically proven gastric adenocarcinoma registered, 337 patients were ineligible by staging laparotomy because of advanced disease and 400 were randomized. The 5-year survival rates were 35% for D 1 resection and 33% for D 2 resection (difference -2%, 95% CI = -12%-8%). There was no difference in the overall 5-year survival between the two arms (HR = 1.10, 95% CI 0.87-1.39, where HR > 1 implies a survival benefit to D 1 surgery). Survival based on death from gastric cancer as the event was similar in the D 1 and D 2 groups (HR = 1.05, 95% CI 0.79-1.39) as was recurrence-free survival (HR = 1.03, 95% CI 0.82-1.29). In a multivariate analysis, clinical stages II and III, old age, male sex and removal of spleen and pancreas were independently associated with poor survival. These findings indicate that the classical Japanese D 2 resection offers no survival advantage over D 1 surgery. However, the possibility that D 2 resection without pancreatico-splenectomy may be better than standard D 1 resection cannot be dismissed by the results of this trial.

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Theoretical concerns over the vasoconstrictive properties of ropivacaine may be sufficient to avoid its use where the potential for ischemia to end organs is present.

A high-efficiency hepatic cryosurgical unit has been developed and evaluated. It is capable of simultaneously driving three implantable insulated cryoneedle probes. The system has been used to treat 18 patients with secondary and 4 patients with primary liver cancer: open (n = 12), total laparoscopic (n = 6), laparoscopic assisted (n = 4). In three patient laparoscopic cryotherapy was repeated inside 6 months. Intraoperative bleeding was encountered in three patients undergoing high-volume hepatic freezing but the bleeding was easily controlled. A fall in the core body temperature was encountered in 10 out of 22 patients and averaged 0.4 degree C. There was one postoperative death from liver failure in an 80-year-old patient in whom a large hepatoma was frozen. The most consistent postoperative biochemical change was hyperbilirubinaemia (n = 3). A right-sided pleural effusion developed in two patients after freezing of lesions on the superior surface of the right lobe. A survival benefit was encountered in three patients, one with central cholangiocarcinoma and the other two with large solitary secondary deposits (melanoma, colon cancer). Seven patients with multiple metastases and two patients with large hepatomas developed recurrence at the frozen site or elsewhere in the liver inside 12 months of follow-up and no clinical benefit could be demonstrated by cryotherapy in this group. In nine patients, the follow-up has been too short (< 18 months) to permit any conclusion on outcome. The current limitations of hepatic cryotherapy are largely due to incomplete tumor destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

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