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Centre for Evidence-
Based Medicine

Harm: Clinical Scenario

You are referred a 68 year old retired company director with cancer of the proximal stomach. He has angina on moderate effort, is moderately obese (despite recent weight loss) and has a history of excessive alcohol consumption, ceasing about seven years previously. He asks you what type of surgery is available for his condition. Staging investigations including CT and laparoscopy have not shown any liver or peritoneal metastasis, nor any invasion of adjacent organs. You therefore recommend a total gastrectomy with curative intent. He has heard about the controversy over the risks and benefits of extended lymphadenectomy in the Japanese style, and has asks whether you would recommend the Japanese operation for him. You explain that a survival benefit has not been proven for this surgery, although many surgeons remain enthusiastic. He asks, very reasonably, whether the increased risk attributed to the Japanese operation is also unproven. Together, you formulate the question: Is radical lymphadenectomy more dangerous than conventional resection in patients with gastric cancer?

A Medline search (using the terms 'gastric cancer' and 'lymph node excision' yields two recent randomised controlled trials looking at this question. You choose the first of these
Lancet 1995; 345: 745-8).

Read the article and decide:

  1. Are the results of this harm study valid?
  2. Are the results of the harm study important?
  3. Should these valid, important results change the treatment of your patient?

Continue to completed worksheet