Abstract
BackgroundSurgery for advanced gastric cancer (AGC) often includes dissection of splenic hilar lymph nodes (SHLNs). This study compared the safety and effectiveness of different approaches to SHLN dissection for upper- and/or middle-third AGC.MethodsWe retrospectively compared and analyzed clinicopathologic and follow-up data from a prospectively collected database at the Peking University Cancer Hospital. Patients were divided into three groups: in situ spleen-preserved, ex situ spleen-preserved and splenectomy.ResultsWe analyzed 217 patients with upper- and/or middle-third AGC who underwent R0 total or proximal gastrectomy with splenic hilar lymphadenectomy from January 2006 to December 2011, of whom 15.2 % (33/217) had metastatic SHLNs, and from whom 11.4 % (53/466) of the dissected SHLNs were metastatic. The number of harvested SHLNs per patient was higher in the ex situ group than in the in situ group (P = 0.017). Length of postoperative hospital stay was longer in the splenectomy group than in the in situ group (P = 0.002) or the ex situ group (P < 0.001). The splenectomy group also lost more blood volume (P = 0.007) and had a higher postoperative complication rate (P = 0.005) than the ex situ group. Kaplan–Meier (log rank test) analysis showed significant survival differences among the three groups (P = 0.018). Multivariate analysis showed operation duration (P = 0.043), blood loss volume (P = 0.046), neoadjuvant chemotherapy (P = 0.005), and N stage (P < 0.001) were independent prognostic factors for survival.ConclusionsThe ex situ procedure was more effective for SHLN dissection than the in situ procedure without sacrificing safety, whereas splenectomy was not more effective, and was less safe. The SHLN dissection method was not an independent risk factor for survival in this study.
Highlights
Surgery for advanced gastric cancer (AGC) often includes dissection of splenic hilar lymph nodes (SHLNs)
Some of the patients in the splenectomy group had intended to undergo in situ or ex situ approach after abdominal exploration, but encountered unintended splenic injury resulting in splenectomy
The rates of conversion from in situ and ex situ procedures to splenectomy were 2.86 % (2/70) and 2.48 % (3/121), respectively. All of their clinicopathologic factors except the number of patients who received neoadjuvant chemotherapy (NACT) and the range of gastrectomy were comparable among the three groups; lower percentages of the in situ group underwent NACT and total gastrectomies than the ex situ and splenectomy groups (Table 2)
Summary
Surgery for advanced gastric cancer (AGC) often includes dissection of splenic hilar lymph nodes (SHLNs). The estimated incidence and mortality of gastric cancer in 2013 were 984,000 and 841,000 worldwide, respectively [1, 2]. Surgery is the primary treatment for gastric cancer, with D2 lymphadenectomy widely accepted for advanced gastric cancer (AGC) in both Eastern and Western countries [3,4,5]. The incidence of upper- and/or middle-third gastric cancer has steadily increased, especially in Asia [6]. According to the 2010 Japanese gastric cancer treatment guideline 3) published by the Japanese Gastric Cancer Association, the extent of systematic lymphadenectomy depends on the type of gastrectomy [7]. The lymph node stations surrounding the stomach have been precisely defined by the Japanese Gastric Cancer
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