Open Access

A comparison of total versus partial omentectomy for advanced gastric cancer in laparoscopic gastrectomy

World Journal of Surgical Oncology201412:64

https://doi.org/10.1186/1477-7819-12-64

Received: 5 October 2013

Accepted: 23 February 2014

Published: 26 March 2014

Abstract

Background

Minimally invasive surgery has been slowly introduced into the field of advanced gastric cancer (AGC) surgery. However, the appropriate extent of omentectomy during laparoscopic gastrectomy for AGC is unknown.

Methods

From July 2004 to December 2011, 146 patients with serosa-negative advanced gastric cancer were divided into the total omentectomy group (TO group, n = 80) and the partial omentectomy group (PO group, n = 66). The clinicopathologic characteristics, surgical outcomes, recurrence pattern and survival were analyzed.

Results

There were no significant differences in the clinicopathologic features between the two groups, except for depth of invasion; more T3 (subserosal invasion) cases (65%) were included in total omentectomy group (P = 0.011). The mean time for PO was significantly shorter (35.1 ± 13.0 min) than TO (50.9 ± 15.3 min) (P %0.001), and there were two omentectomy-related complications in the TO group: spleen and mesocolon injuries. Recurrence occurred in 14 (17.5%) and 5 (7.6%) cases in the TO and PO group, respectively (P = 0.054). Disease-free survival (TO versus PO: 81.5% versus 89.3%, P = 0.420) and disease-specific survival (TO versus PO: 89% versus 94.7%) were not significantly different between the two groups. In the case-matched analysis using propensity score matching, there was no difference in disease-free survival (TO versus PO: 83.3% versus 90.5%, P = 0.442).

Conclusions

Partial omentectomy might be an oncologically safe procedure during laparoscopic gastrectomy for serosa-negative advanced gastric cancer, similar to early gastric cancer.

Keywords

stomach neoplasms omentum laparoscopy

Background

Laparoscopic gastrectomy for advanced gastric cancer (AGC) is not widely used, but interest in the procedure is increasing [13]. Therefore, in Korea, the KLASS-02 trial (NCT01456598) began in 2012 to compare laparoscopic and open subtotal gastrectomy in local AGC. In the surgical procedure for AGC, D2 dissection with total omentectomy is mandatory for both laparoscopic gastrectomy and open gastrectomy. Although D2 dissection has an oncologic benefit in AGC, the role of total omentectomy is still questionable, particularly for serosa-negative AGC [4, 5]. In fact, dissection through the avascular plane with proper countertraction of the transverse colon can lead to rapid and satisfactory total omentectomy during open surgery; however, in laparoscopic gastrectomy, total omentectomy is time-consuming and poses a risk of injury to the adjacent organs, particularly the spleen and colon. According to the Japanese gastric cancer treatment guidelines, partial omentectomy may be performed in cases of T1 and T2, and total omentectomy is the standard procedure for T3 or deeper tumors [6]. The main purpose of performing total omentectomy is to remove all of the potential seeding lesions in the event of serosal exposure of the tumor cells (T4a). The aim of this study was to elucidate the feasibility of partial omentectomy, based on surgical and oncologic aspects, compared with total omentectomy during laparoscopic gastrectomy for serosa-negative AGC.

Methods

Patients and variables

The data of 530 patients who had undergone laparoscopic gastrectomy from July 2004 to December 2011 were retrospectively reviewed. Among these patients, 146 with histologically confirmed serosa-negative AGC were evaluated. The patients were divided into a total omentectomy group (TO group, n = 80) and a partial omentectomy group (PO group, n = 66) based on the surgical procedure that they had undergone. The type of omentectomy was determined according to intraoperative gross findings regarding the status of serosal exposure. Total omentectomy was performed in cases of suspected serosal tumor infiltration, and partial omentectomy was performed in definitively serosa-negative cases. The omentectomy time was defined as the time from the initial division of the omentum to the completion of both sides of the gastroepiploic vessels. Clinicopathologic features; postoperative surgical outcomes, including the omentectomy time; disease-specific and disease-free survival; and the pattern of recurrence were compared between the two groups. To compensate for the selection bias, a case-matched analysis using propensity score matching was additionally performed based on T-stage and N-stage. This study was approved by institutional review board in Catholic Medical Center, Korea.

Surgical procedure

All of the patients were placed in a supine position and subjected to a 15 to 20° reverse Trendelenburg position. First, routine exploration of the abdominal cavity and tumor lesion was performed to exclude peritoneal metastasis and definite serosal invasion.

Total omentectomy was performed via the same procedure as in open gastrectomy. The assistant grasped the transverse colon with an atraumatic grasper to ensure a secure dissection plane, and division of the greater omentum along the avascular plane using ultrasonic shear (Ethicon Endo-Surgery, Cincinnati, OH, USA) was started from the middle part of the transverse colon and extended up to the lower pole of the spleen. The left gastroepiploic vessels were divided to remove lymph node number 4sb. The right side of the omentum was divided along the transverse colon and the hepatic flexure. The dissection was continued toward the inferior border of the pancreas head and neck area, and the right gastroepiploic vessels were exposed and divided at their origin with removal of lymph node number 6. In cases of partial omentectomy, the division was started from the greater omentum at the line 4 to 5 cm from the gastroepiploic arcade using an ultrasonic shear toward the origin of the left gastroepiploic vessels. The omental branch was typically identified and preserved to prevent a possible omental infarct. The procedures for the right side were same as for total omentectomy.

Statistical analysis

Clinicopathologic features and surgical outcomes were analyzed using an unpaired t-test for continuous variables and the chi-square test or Fisher’s exact test for nominal variables. In the univariate survival analysis, the Kaplan-Meier and log-rank tests were used. All statistical analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). A P value of %0.05 was considered to be statistically significant.

Results

Clinicopathologic features and surgical outcomes

There were no significant differences between the groups, including regarding lymph node status and TNM staging, except for the depth of invasion. More T3 cases (65%) underwent total omentectomy, and more T2 cases (56.1%) underwent partial omentectomy (P = 0.011; Table 1). The two groups did not significantly differ regarding other clinicopathologic findings, including sex, age, the type of resection, tumor size, histologic type, resected margins, and the number of retrieved and metastatic lymph nodes. In the surgical results, the mean time for partial omentectomy was significantly shorter (35.1 ± 13.0 min) than that for total omentectomy (50.9 ± 15.3 min) (P %0.001). There were two omentectomy-related complications in the TO group, including spleen and mesocolon injuries, requiring concurrent splenectomy and transverse colectomy (Table 2).
Table 1

The clinicopathologic features of patients with serosa-negative advanced gastric cancer (AGC) according to the type of omentectomy

Variable

Total omentectomy (n = 80)

Partial omentectomy (n = 66)

P

Age (years)a

 

60.9 ± 11.2

62.2 ± 11.0

0.483

Sex

Male

56 (70)

50 (75.8)

0.438

Female

24 (30)

16 (24.2)

 

Extent of resection

Total

19 (23.8)

12 (18.2)

0.413

Distal

61 (76.3)

54 (81.8)

 

Depth of invasion

pT2

28 (35)

37 (56.1)

0.011

pT3

52 (65)

29 (43.9)

 

Lymph node metastasis

0

40 (50)

34 (51.5)

0.419

1

14 (17.5)

8 (12.1)

 

2

13 (16.3)

16 (24.2)

 

3a

6 (7.5)

6 (9.1)

 

3b

7 (8.8)

2 (3.0)

 

Tumor stage (UICC 7th)

Ib

17 (21.3)

23 (34.8)

0.130

IIa

30 (37.5)

15 (22.7)

 

IIb

9 (11.3)

11 (16.7)

 

IIIa

13 (16.3)

12 (18.2)

 

IIIb

11 (13.8)

5 (7.6)

 

Tumor size (cm)a

 

4.8 ± 2.5

4.4 ± 2.4

0.366

Histologic type

Differentiated

37 (46.3)

24 (36.4)

0.228

Undifferentiated

43 (53.8)

42 (63.6)

 

Proximal margin (cm)a

 

4.0 ± 2.1

3.7 ± 2.2

0.357

Distal margin (cm)a

 

5.3 ± 3.4

6.4 ± 4.2

0.083

Lymphatic invasion

Absent

27 (33.8)

30 (45.5)

0.149

Present

53 (66.3)

36 (54.5)

 

Perineural invasion

Absent

39 (48.8)

40 (60.6)

0.152

Present

42 (51.3)

26 (39.4)

 

aMean ± standard deviation; nominal variables are expressed as number (%).

Table 2

Surgical outcomes in patients with serosa-negative advanced gastric cancer (AGC) according to the type of omentectomy

Variable

Total omentectomy (n = 80)

Partial omentectomy (n = 66)

P

Lymph node (LN) dissection

D1 + β

2 (2.5)

6 (7.6)

0.153

 

D2

78 (97.5)

61 (92.4)

 

Number of retrieved LNsa

 

34.6 ± 14.7

39.8 ± 14.7

0.034

Number of metastatic LNsa

 

4.3 ± 8.5

2.9 ± 5.3

0.228

Omentectomy time (min)a

 

50.9 ± 15.5

35.1 ± 13.0

%0.001

Omentectomy-related complication

 

2b

0

0.198

Recurrence

 

14 (17.5)

5 (7.6)

0.076

aMean ± standard deviation; nominal variables are expressed as number (%).

b Complications included intra-operative spleen and mesocolon injury, requiring concurrent splenectomy and transverse colectomy.

Recurrence and survival

During the follow-up period, a total of 19 recurrences were identified, including 14 (17.3%) in the TO group and 5 (7.6%) in the PO group. Among the T2 cases, 2 recurrences occurred in the 3rd-tier lymph node and bone in the TO group, and 2 recurrences occurred in the bone, with simultaneous 3rd-tier lymph node metastasis and remnant stomach cancer in the PO group. Among the T3 cases, there were 13 recurrences in the TO group: 3 carcinomatoses, 3 distant lymph node metastases, 3 remnant stomach tumors, and 4 cases of hematogenous spread (3 in the liver and 1 in the bone). Three recurrence cases, including 1 carcinomatosis, 1 liver site, and 1 port site, occurred in the PO group among T3 cases (Table 3).
Table 3

Recurrence pattern according to the type of omentectomy and the depth of invasion

Depth (n)

Omentectomy (n)

Recurrence (n)

Site (n)

pT2 (65)

Total omentectomy (28)

2

3rd-tier lymph node (LN) (1)

Bone (1)

 

Partial omentectomy (37)

2

3rd-tier LN + bone (1)

Remnant stomach (1)

pT3 (81)

Total omentectomy (52)

12

Carcinomatosis (3)a

Liver (3)

Bone (1)

3rd-tier lymph node (2)

Remnant stomach (3)

 

Partial omentectomy (29)

3

Carcinomatosis (1)a

Liver (1)

Port site (1)

aProportion of carcinomatosis in total omentectomy versus partial omentectomy: 3/80 (3.8%) versus 1/66 (1.5%), P = 0.410 (chi-square analysis).

There were no significant differences in cumulative disease-free survival (TO versus PO: 81.5% versus 89.3%, P = 0.420) or disease-specific survival (TO versus PO: 89.0% versus 94.7%, P = 0.624) between the two groups (Figure 1). In addition, there was no difference in the development of recurrence in the omentum or of carcinomatosis (TO versus PO: 3/80 (3.8%) versus 1/66 (1.5%), P = 0.410) (Table 3). To overcome the selection bias due to the T-stage discrepancy between the two groups, Cox proportional analysis was performed for recurrence with the following covariates: the type of omentectomy, tumor depth, and lymph node status (Table 4). This analysis revealed that the type of omentectomy was not a risk factor for recurrence.
Figure 1

Survival analysis. (A) Disease-free survival did not differ between the total omentectomy (TO) and the partial omentectomy (PO) groups. (B) Disease-specific overall survival did not differ between the total omentectomy and the partial omentectomy groups. (C) Disease-free survival did not differ between the matched groups.

Table 4

Univariate and multivariate analyses of the risk factors for recurrence

Variable

Univariate

Multivariate

5 yr DFSa (%)

P

Odds ratio

P

Type of omentectomy

Total

81.5

0.42

1

0.766

 

Partial

89.3

 

0.85 (0.30 to 2.43)

 

Depth of invasion

pT2

92.5

0.015

1

0.082

 

pT3

77.5

 

3.00 (0.87 to 10.39)

 

Lymph node metastasis

Absent

97.2

%0.001

1

0.003

 

Present

68.5

 

9.98 (2.06 to 39.14)

 

aDisease-free survival.

Case-matched analysis

Propensity score matching yielded 51 patients in each group. Table 5 shows the same proportions of T-stage and N-stage in the two matched groups. A comparison of disease-free survival between the two matched groups also showed no difference (TO versus PO: 83.3% versus 90.5%, P = 0.442) (Figure 1C).
Table 5

Proportions of T-stage and N-stage in matched groups

Variable

Total omentectomy (n = 51)

Partial omentectomy (n = 51)

P

Depth of invasion

pT2

22 (43.1)

22 (43.1)

1.000

pT3

29 (56.9)

29 (43.9)

 

Lymph node metastasis

0

28 (54.9)

28 (54.9)

1.000

1

8 (15.7)

8 (15.7)

 

2

11 (21.6)

11 (21.6)

 

3a

2 (3.9)

2 (3.9)

 

3b

2 (3.9)

2 (3.9)

 

Discussion

Laparoscopic gastrectomy for early gastric cancer (EGC) has been widely performed, and its advantages over open gastrectomy have been verified in many randomized clinical trials [711]. Recently, laparoscopic gastrectomy for AGC has been increasingly performed, and certain reports have outlined its feasibility from technical and oncologic perspectives [13]. In laparoscopic gastrectomy for AGC, D2 dissection and total omentectomy have been the primary troublesome issues for many laparoscopic surgeons.

Although the greater omentum is known to play a role in peritoneal defense by adhering to sites of inflammation and absorbing bacteria and other contaminants, it is a common site of both recurrent disease and primary seeding in gastrointestinal malignancies [12]. Additionally, several experimental studies have reported that cancer cells seeded in the peritoneal cavity preferentially grow on the omentum [12, 13]. For this reason, total omentectomy has been a standard operative procedure during open gastrectomy, regardless of tumor depth. However, if there is no serosal exposure, cancer cell spillage or spread through the omentum is not theoretically possible. Therefore, we hypothesized that partial omentectomy is sufficient for T2 and even T3 cases. The most important type of recurrence relevant to omentectomy may be carcinomatosis. Kim et al. and Ha et al. reported no survival difference between TO and PO in EGC [14, 15]. Kim et al.[16] reported no difference in the pattern of recurrence between TO and PO in AGC without serosal exposure during open gastrectomy. The researchers also detected no difference in the rate of peritoneal metastasis among all recurrences (35% and 25% in TO and PO, respectively). In our series, although more recurrences were noted in the TO group than in the PO group, there was no difference in survival between the two groups. In addition, there was no difference in the occurrence of carcinomatosis between the two groups. Interestingly, approximately half of the T3 cases (25 cases) in the TO group were regarded as including definite serosal invasion (T4a) intra-operatively but were finally proven to encompass subserosal invasion (T3) histologically. Despite the paucity of serosal exposure in the pathologic findings, certain investigators believe that the peritoneum can form a new surface over exposed cancer cells in clinically T4a lesions. Koji et al. reported that the width of subserosal invasion is an independent risk factor for survival in histologically confirmed T3 gastric cancer [17]. We believe that clinical serosal exposure in histologically confirmed T3 cases involves a larger width of subserosal invasion or even focal serosal penetration, which may be why the number of recurrences was much higher in the TO group.

Regarding the high incidence of remnant gastric cancer, we were unable to determine the exact reason because all of the cases had negative margins for malignancy and because remnant gastric cancer lesions were not involved in the anastomosis line. The Japanese gastric cancer treatment guidelines (2010; version 3) recommend leaving a proximal margin of at least 3 cm in the presence of an expansive growth pattern and of 5 cm in the presence of an infiltrative growth pattern or evaluating frozen sections when these factors cannot be observed [6]. Considering that the interval between the initial operation and the completion of gastrectomy was relatively short (1 year for 2 patients and 2 years for the others), there may have been undetected cancer lesions in the remnant stomach, despite preoperative gastrofiberscopy.

Moriguchi et al.[18] have reported that serosal invasion and Borrmann type 4 carcinoma are independent risk factors for the development of carcinomatosis. Although no randomized controlled trials have been performed, Fugita et al.[19] also showed that the type of omentectomy was not a risk factor for recurrence in serosa-negative AGC in a retrospective study, and they included several serosal exposure cases (T4a). The researchers also showed that the development of carcinomatosis has no relationship with the type of omentectomy. The most important factor for justifying the selection of partial omentectomy is tumor depth. The accuracy of preoperative evaluation by endoscopic ultrasonography (EUS) was reported to be 85.7%, and Kim et al. reported that the accuracy of macroscopic findings in determining whether a tumor had invaded the serosa was 87% [16]. Therefore, if we select the type of operation conservatively, with consideration of preoperative evaluations, we can avoid performing partial omentectomy in T4a cases.

In previous reports comparing total omentectomy and partial omentectomy in EGC, partial omentectomy showed several advantages over total omentectomy, including in operation time, perioperative complications, and the postoperative albumin level [14, 15]. Total omentectomy in open gastrectomy is no more difficult than partial omentectomy. With traction of the transverse colon by an assistant, the dissection of the greater omentum can be easily performed through the avascular plane. Otherwise, in laparoscopic gastrectomy, total omentectomy can be a more challenging procedure because maintaining the dissection line through the avascular plane and dividing the omental tissue from the mesocolon are not easy, particularly in patients with a high BMI. In the present study, PO demonstrated several advantages in terms of surgical outcomes. The omentectomy time was shorter, and omentectomy-related complications did not occur in the PO group. However, omental infarction may occur during PO and can appear as carcinomatosis or omental recurrence in radiologic findings [3]. It is important to differentiate between various radiological findings and omental infarcts [20], and close follow-up is required when differentiation is difficult, particularly in the immediate postoperative period.

Because the present study was retrospectively designed, it has certain limitations. Although there was no significant difference in the distribution of stages between the two groups, the TO group contained more advanced cases. These discrepancies in tumor staging may influence the recurrence rate. However, omentectomy was not risk factor for recurrence in the multivariate analysis. Despite these limitations, the present study is valuable because previous reports were based on open gastrectomy, so this is the first report to evaluate the role of the type of omentectomy in laparoscopic gastrectomy for serosa-negative AGC.

Conclusions

In conclusion, partial omentectomy can be a useful alternative method for performing laparoscopic gastrectomy for serosa-negative AGC. However, to determine long-term technical and oncologic safety, a prospective randomized controlled trial is needed.

Abbreviations

AGC: 

advanced gastric cancer

BMI: 

body mass index

EGC: 

early gastric cancer

EUS: 

endoscopic ultrasonography LN, lymph node

PO: 

partial omentectomy

TO: 

total omentectomy.

Declarations

Authors’ Affiliations

(1)
Division of GI Surgery, Department of Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea
(2)
Department of Surgery, Bucheon St. Mary’s Hospital, The Catholic University of Korea

References

  1. Hamabe A, Omori T, Tanaka K, Nishida T: Comparison of long-term results between laparoscopy-assisted gastrectomy and open gastrectomy with D2 lymph node dissection for advanced gastric cancer. Surg Endosc. 2012, 26: 1702-1709. 10.1007/s00464-011-2096-0.View ArticlePubMedGoogle Scholar
  2. Lee J, Kim W: Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: analysis of consecutive 106 experiences. J Surg Oncol. 2009, 100: 693-698. 10.1002/jso.21400.View ArticlePubMedGoogle Scholar
  3. Parkdo J, Han SU, Hyung WJ, Kim MC, Kim W, Ryu SY, Ryu SW, Song KY, Lee HJ, Cho GS, Kim HH: Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study. Surg Endosc. 2012, 26: 1548-1553. 10.1007/s00464-011-2065-7.View ArticleGoogle Scholar
  4. Lee JS, Douglass HO: D2 dissection for gastric cancer. Surg Oncol. 1997, 6: 215-225. 10.1016/S0960-7404(98)00009-7.View ArticlePubMedGoogle Scholar
  5. Oñate-Ocaña LF, Aiello-Crocifoglio V, Mondragón-Sánchez R, Ruiz-Molina JM: Survival benefit of D2 lympadenectomy in patients with gastric adenocarcinoma. Ann Surg Oncol. 2000, 7: 210-217. 10.1007/BF02523656.View ArticlePubMedGoogle Scholar
  6. Japanese Gastric Cancer A: Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011, 14: 113-123.View ArticleGoogle Scholar
  7. Hayashi H, Ochiai T, Shimada H, Gunji Y: Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc. 2005, 19: 1172-1176. 10.1007/s00464-004-8207-4.View ArticlePubMedGoogle Scholar
  8. Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, Bae JM: Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg. 2008, 248: 721-727. 10.1097/SLA.0b013e318185e62e.View ArticlePubMedGoogle Scholar
  9. Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y: A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: an interim report. Surgery. 2002, 131: S306-311. 10.1067/msy.2002.120115.View ArticlePubMedGoogle Scholar
  10. Lee JH, Han HS: A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg Endosc. 2005, 19: 168-173. 10.1007/s00464-004-8808-y.View ArticlePubMedGoogle Scholar
  11. Ohtani H, Tamamori Y, Noguchi K, Azuma T, Fujimoto S, Oba H, Aoki T, Minami M, Hirakawa K: A meta-analysis of randomized controlled trials that compared laparoscopy-assisted and open distal gastrectomy for early gastric cancer. J Gastrointest Surg. 2010, 14: 958-964. 10.1007/s11605-010-1195-x.View ArticlePubMedGoogle Scholar
  12. Oosterling SJ, van der Bij GJ, Bögels M, van der Sijp JR, Beelen RH, Meijer S, van Egmond M: Insufficient ability of omental milky spots to prevent peritoneal tumor outgrowth supports omentectomy in minimal residual disease. Cancer Immunol Immunother. 2006, 55: 1043-1051. 10.1007/s00262-005-0101-y.View ArticlePubMedGoogle Scholar
  13. Lopes Cardozo AM, Gupta A, Koppe MJ, Meijer S, van Leeuwen PA, Beelen RJ, Bleichrodt RP: Metastatic pattern of CC531 colon carcinoma cells in the abdominal cavity: an experimental model of peritoneal carcinomatosis in rats. Eur J Surg Oncol. 2001, 27: 359-363. 10.1053/ejso.2001.1117.View ArticlePubMedGoogle Scholar
  14. Ha TK, An JY, Youn HG, Noh JH, Sohn TS, Kim S: Omentum-preserving gastrectomy for early gastric cancer. World J Surg. 2008, 32: 1703-1708. 10.1007/s00268-008-9598-5.View ArticlePubMedGoogle Scholar
  15. Kim MC, Kim KH, Jung GJ, Rattner DW: Comparative study of complete and partial omentectomy in radical subtotal gastrectomy for early gastric cancer. Yonsei Med J. 2011, 52: 961-966. 10.3349/ymj.2011.52.6.961.PubMed CentralView ArticlePubMedGoogle Scholar
  16. Kim JH, Kang SH, Oh ST, Yook JH, Kim BS, Park KC: Following of the omentum preserving gastrectomy for advanced gastric cancer without serosa exposure. J Korean Surg Soc. 2009, 76: 154-158. 10.4174/jkss.2009.76.3.154.View ArticleGoogle Scholar
  17. Soga K, Ichikawa D, Yasukawa S, Kubota T, Kikuchi S, Fujiwara H, Okamoto K, Ochiai T, Sakakura C, Kokuba Y, Yanagisawa A, Otsuji E: Prognostic impact of the width of subserosal invasion in gastric cancer invading the subserosal layer. Surgery. 2010, 147: 197-203. 10.1016/j.surg.2009.06.032.View ArticlePubMedGoogle Scholar
  18. Moriguchi S, Maehara Y, Korenaga D, Sugimachi K, Nose Y: Risk factors which predict pattern of recurrence after curative surgery for patients with advanced gastric cancer. Surg Oncol. 1992, 1: 341-346. 10.1016/0960-7404(92)90034-I.View ArticlePubMedGoogle Scholar
  19. Fugita J, Tsukahara Y, Ikeda K, Akagi K, Kan K, Hata S: Evaluation of omentum preserving gastrectomy for advanced gastric cancer. Jpn J Gastroenterol Surg. 2003, 36: 1151-1158. 10.5833/jjgs.36.1151.View ArticleGoogle Scholar
  20. Oh JY, Cho JH, Kang MJ, Lee JH, Kwon HJ, Nam KJ, Kim MC, Choi H: Omental infarction caused by laparoscopy-assisted gastrectomy for gastric cancer: CT findings. Clin Radiol. 2011, 66: 966-973. 10.1016/j.crad.2011.05.006.View ArticlePubMedGoogle Scholar

Copyright

© Kim et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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