Advanced Proximal Gastric Cancer Research Articles

Station 10 lymph node dissections in laparoscopic-assisted spleen-preserving radical gastrectomy for advanced proximal gastric cancer.

D2 gastric resection has been increasingly recognized as the optimal surgical treatment for advanced gastric cancer. Dissection of the station 10 splenic lymph nodes is required in the treatment of advanced proximal gastric cancer. Based on vascular anatomy and anatomical plane of fascial space, integrated with our experience in station 10 splenic lymph node dissection in open surgery and proven skills of laparoscopic operation, we have successfully mastered the surgical essentials and technical keypoints in laparoscopic-assisted station 10 lymph node dissection.

Laparoscopic splenic hilum lymph node dissection for advanced proximal gastric cancer: A modified approach for pancreas- and spleen-preserving total gastrectomy

To investigate the feasibility and optimal approach for laparoscopic pancreas- and spleen-preserving splenic hilum lymph node dissection in advanced proximal gastric cancer. Between August 2009 and August 2012, 12 patients with advanced proximal gastric cancer treated in Nanfang Hospital, Southern Medical University, Guangzhou, China were enrolled and subsequently underwent laparoscopic total gastrectomy with pancreas- and spleen-preserving splenic hilum lymph node (LN) dissection. The clinicopathological characteristics, surgical outcomes, postoperative course and follow-up data of these patients were retrospectively collected and analyzed in the study. Based on our anatomical understanding of peripancreatic structures, we combined the characteristics of laparoscopic surgery and developed a modified approach (combined supra- and infra-pancreatic approaches) for laparoscopic pancreas- and spleen-preserving splenic hilum LN dissection. Surgery was completed in all 12 patients laparoscopically without conversion. Only one patient experienced intraoperative bleeding when dissecting LNs along the splenic artery and was handled with laparoscopic hemostasis. The mean operating time was 268.4 min and mean number of retrieved splenic hilum LNs was 4.8. One patient had splenic hilum LN metastasis (8.3%). Neither postoperative morbidity nor mortality was observed. Peritoneal metastasis occurred in one patient and none of the other patients died or experienced recurrent disease during the follow-up period. Laparoscopic total gastrectomy with pancreas- and spleen-preserving splenic hilum LN dissection using the modified approach for advanced proximal gastric cancer could be safely achieved.

Laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer in left approach: a new operation procedure

BackgroundTo explore the feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection in a left-sided approach for advanced proximal gastric cancer.MethodsThe clinical data of 32 patients with advanced proximal gastric cancer who underwent laparoscopic spleen-preserving No. 10 lymph node dissection from June 2010 to December 2011 were analyzed.ResultsLaparoscopic spleen-preserving No. 10 lymph node dissection using a left-sided approach was successfully performed for all patients without open conversion. The mean operation time was 206.4±54.3 minutes, mean intraoperative blood loss was 68.2±34.1 ml, mean number of No. 10 lymph nodes dissected was 2.8±2.1, mean number of positive No. 10 lymph nodes was 0.6±1.2, and the incidence of No. 10 lymph node metastasis was 11.6%. The mean postoperative hospital stay was 11.3±1.5 days. The postoperative morbidity rate was 9.4%, and there was no postoperative death. Splenic lobar vessels of all 32 patients were anatomically classified and divided into three types: 4 patients had a single lobar vessel, 22 had two lobar vessels and 6 had three lobar vessels.ConclusionsLaparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer using a left-sided approach is technically feasible. It simplifies the complicated surgical procedure of No. 10 lymph node dissection and leads to the popularization and promotion of this technique.

Laparoscopic spleen-preserving splenic hilar lymph node dissection for proximal gastric cancer

Splenic hilar lymph node (LN) should be removed in a D2 lymph node dissection for the advanced proximal gastric cancer. After improving the surgical technology and renewing treatment concepts, spleen-preserving splenic hilar LN dissection has been accepted by more and more surgeons. Because the anatomy position of spleen is very deep, and the splenic vessel is various, laparoscopic spleen-preserving splenic hilar LN dissection may be more difficult. In order to do better in laparoscopic spleen-preserving splenic hilar LN dissection, surgeons should choose the suitable patients; take reasonable surgical approach and surgical steps. Moreover, knowing the anatomy variance well of splenic vessel is also very important too.

The Significance of Splenectomy for Advanced Proximal Gastric Cancer

Objectives. The significance of splenectomy in advanced proximal gastric cancer is examined retrospectively. Methods. From 1994 to 2004, 505 patients with advanced proximal gastric cancer underwent curative total gastrectomy with preserving spleen (T) for 264 patients and total gastrectomy with splenectomy (ST) for 241 patients. Results. Patients who underwent splenectomy showed more advanced lesions. The metastatic rate of lymph node (LN) in the splenic hilus (No. 10) in ST was 18.3%. As for the incidence of surgical complications, there was not statistically difference except for pancreatic fistula. The index of estimated benefit of (No. 10) LN was 4.2, which was similar to that of (No. 9), (No. 11p), (No. 11d), and (No. 16) LNs. 5-year survival rate of (No. 10) positive group was 22.2%. 5-year survival rates of pSE and pN2 in T group were better than that of pSE and pN2 in ST, respectively. The superiority of ST was not confirmed even in Stage II, IIIA, and IIIB. Conclusion. Splenectomy was not effective for patients with (No. 10) metastasis in long-term survival. Spleen-preserving total gastrectomy will be feasible and be enough to accomplish radical surgery for locally advanced proximal gastric cancer.

Survival benefits from splenic hilar lymph node dissection by splenectomy in gastric cancer patients: relative comparison of the benefits in subgroups of patients

The present study estimated survival benefits from lymph node dissection at the splenic hilus in advanced proximal gastric cancer patients who underwent total gastrectomy with simultaneous splenectomy, and then determined patient subgroups that received relatively high survival benefits from splenectomy. A total of 280 patients with advanced proximal gastric cancer who underwent curative total gastrectomy with simultaneous splenectomy were retrospectively analyzed. Patients with primary tumors directly invading the spleen or pancreas and those with gross metastases to the para-aortic nodes, as determined by intraoperative diagnosis, were excluded from analyses. The index of estimated benefit from lymph node dissection at the splenic hilus by splenectomy was calculated for each clinicopathological factor by multiplying the incidence of splenic hilar metastasis by the 5-year survival rate of patients with metastasis to that nodal station. Thirty patients (10.7%) showed lymph node metastasis at the splenic hilus, and the 5-year survival rate of these patients was 51.3% (overall index 5.49). The index was relatively high in patient subgroups with tumors localized on the greater curvature (19.4) and Borrmann type 4 cancers (12.9), while relatively low in subgroups with encircling tumors (1.62) and tumors invading adjacent organs other than the spleen and pancreas (0). Patients with tumors localized on the greater curvature and Borrmann type 4 cancers might obtain relatively high survival benefits from lymph node dissection at the splenic hilus by splenectomy.

The causes and management of postoperative anastomotic fistula after stapling resection of advanced proximal gastric cancer

Objective To explore the causes and management of postoperative anastomotic fistula after stapling resection of advanced proximal gastric cancer. Methods The data on 113 patients receiving stapling resection of advanced proximal gastric cancer in our hospital from January 2004 to June 2009 were retrospectively analyzed. Results Anastomotic fistula occurred in 13 patients but was cured after 2-4 weeks of treatment. No recurrence was found during 6 months to 5 years of follow-up. 4 patients developed anastomotic stenosis but could take semi-liquid foods after anastomotic dilatation. Conclusions In stapling resection of advanced proximal gastric cancer, postoperative anastomotic fistula is the most serious complication due to many reasons. By prompt management, anti-infection treatment, peritoneal drainage,and application of duodenal nutrients to enhance enteral nutrition therapy, anastomotic fistula can be cured. Key words: Proximal gastric Cancer; Anastomotic fistula; Stapling technique

Clinical characteristics of 103 lymph node metastasis in advanced proximal gastric cancer

To explore the pattern of lymph node metastasis(LNM) in advanced proximal gastric cancer in order to guide lymphadenectomy. Between September 2001 and December 2005, a total of 103 patients with advanced proximal gastric cancer underwent radical gastrectomy with D2 or>D2 lymphadenectomy. The clinical characteristics, pathologic features, and LNM were analyzed by univariate and multivariate analysis. LNM was observed in 81 of 103 cases(78.6%). The LNM was identified in 70.8% at N1, 38.3% at N2, 22.3% at N3. LNM frequency was found in groups No.3,No.1,No.2 and No.4Sa,4Sb (from the highest to the lowest) at N1, groups No.7, No.10, No.9, No.11, No.8a and No.4d at N2, and groups No.5, No.6, No.16 and No.12 at N3. Ordinal Logistic regression analysis showed that histopathological type, tumor size, depth of invasion, and distant metastasis were independent factors for lymph node metastasis in advanced proximal gastric cancer. The number of lymph node metastasis in advanced proximal gastric cancer is mainly associated with differentiation, tumor size, depth of invasion, and distant metastasis. It is essential to dissect the lymph nodes according to the risk of lymph node metastasis.

Prognostic impact of splenectomy on advanced proximal gastric cancer with No. 10 lymph node metastasis

Background This study evaluated the prognostic impact of D2 lymphadenectomy combined with splenectomy in patients with advanced proximal gastric cancer and lymph node metastasis at the splenic hilum (No. 10 lymph nodes). Methods The clinical records of 216 patients with advanced proximal gastric cancer and No. 10 lymph node metastasis who underwent D2 curative resection were retrospectively analyzed. Seventy-three patients underwent simultaneous splenectomy (splenectomy group), while 143 patients did not (spleen-preserving group). Five-year survival rates, mean numbers of dissected No. 10 lymph nodes and metastatic No. 10 lymph nodes, and operative morbidity and mortality were calculated and compared between the two groups. Potential prognostic factors were evaluated by univariate and multivariate analysis. Results The 5-year survival rate was 30.0% for the splenectomy group and 19.7% for the spleen-preserving group (χ2=14.73, P <0.05). The mean numbers of dissected No. 10 lymph nodes and metastatic No. 10 lymph nodes in the splenectomy group were significantly greater than in the spleen-preserving group (P <0.05). Multivariate analysis revealed that the depth of invasion, splenectomy, and type of gastrectomy were independent prognostic factors. The survival rate for T3 patients with and without splenectomy was 38.7% and 18.9%, respectively (χ2 =15.03, P <0.05). For patients undergoing total gastrectomy, survival rates were 33.4% and 20.7%, respectively (χ2 =13.63, P<0.05). Operative morbidity and mortality in splenectomy group was 24.7% and 4.1%, respectively, and in the spleen-preserving group was 17.5% and 3.5%, respectively. The differences were not statistically significant (P >0.05). Conclusions Splenectomy is beneficial for No. 10 lymph node dissection in patients with advanced proximal gastric cancer. To improve patient prognosis, total gastrectomy with splenectomy is recommended for patients with T3 proximal gastric cancer who have No. 10 lymph node metastasis.

Prognostic analysis of splenectomy in patients with advanced proximal gastric cancer.

To evaluated the prognostic impact of splenectomy on patients with advanced proximal gastric cancer. The clinical records of 237 patients with advanced proximal gastric cancer who underwent D2 curative resection combined with splenectomy from January 1980 to June 2003 were analyzed retrospectively. Seventy-five patients presented with No.10 lymph nodes metastasis, while 162 patients did not. Potential patient prognostic factors were evaluated by univariate and multivariate analysis. The independent prognostic factors of patients were performed subgroup analysis. The 5-year survival rate was 27.7% for patients with No.10 lymph nodes metastasis and 35.4% for patients without, the difference was statistically significant between the two groups (P < 0.05). On univariate analysis, lymph node metastasis, macroscopic appearance, depth of invasion, type of gastrectomy and No.10 lymph nodes metastasis were predictive factors of survival. The depth of invasion, type of gastrectomy and No.10 lymph nodes metastasis were independent prognostic factors. In the subgroup analysis, the survival rates of T3 patients with and without No.10 lymph nodes metastasis was 34.5% and 39.7%, respectively (P > 0.05). For patients undergoing total gastrectomy, survival rates were 31.2% and 36.7%, respectively (P > 0.05). To improve patient prognosis, total gastrectomy with splenectomy should be recommended for patients with T3 proximal gastric cancer with No.10 lymph node metastasis.

Efficacy of combined splenectomy in proximal gastric cancer with No.10 lymph node metastasis

To explore the impact on prognosis of D(2) lymphadenectomy combined with splenectomy in patients of advanced proximal gastric cancer with No.10 lymph node metastasis. Clinical data of 216 patients of advanced proximal gastric cancer with No.10 lymph node metastasis undergone D(2) curative resection in our hospital from January 1980 to December 2002 were analyzed retrospectively. Among them, 73 underwent simultaneous splenectomy (splenectomy group), while 143 without splenectomy (spleen-preserving group). The 5-year survival rate, the mean numbers of dissected No.10 lymph nodes and metastatic No.10 lymph nodes, the complication morbidity and mortality were compared between the two groups. The 5-year survival rates of splenectomy group and spleen-preserving group were 30.0% and 19.7% respectively, whose difference was significant(P<0.05). The mean numbers of dissected No.10 lymph nodes and metastatic No.10 lymph nodes in splenectomy group were significantly greater than those in spleen-preserving group(P<0.05). Splenectomy, invasion depth and gastrectomy type were independent prognostic factors. The survival rates of T(3) patients in splenectomy group and spleen-preserving group were 38.7% and 18.9% respectively, whose difference was significant (P<0.05). The survival rates of patients undergone total gastrectomy in splenectomy group and spleen-preserving group were 33.4% and 20.7% respectively, whose difference was significant (P<0.05). The complication morbidity and mortality in splenectomy group were 24.7% and 4.1%, while in spleen-preserving group were 17.5% and 3.5% respectively, whose differences were not significant(P>0.05). Splenectomy is benefit for No.10 lymph node dissection in patients with advanced proximal gastric cancer. To improve the prognosis, total gastrectomy combined with splenectomy should be recommended for patients of T(3) proximal gastric cancer with No.10 lymph node metastasis. Simultaneous splenectomy dose not increase the complication morbidity and mortality.

Pathological characteristics and clinical significance of local infiltration of advanced proximal gastric cancer

Pathological characteristics and clinical significance of local infiltration of advanced proximal gastric cancer

Splenectomy in proximal gastric cancer: frequency of lymph node metastasis to the splenic hilus.

The indication for splenectomy in proximal gastric cancer remains controversial. Splenectomy is performed because of possible lymph node metastasis of the splenic hilus or infiltration/metastasis of the spleen. The purpose of this study was to investigate the frequency of lymph node metastasis to the splenic hilus and metastasis to the spleen in proximal gastric carcinomas. In a morphologic study, the frequency of lymph node metastasis to the splenic hilus in 112 patients with proximal gastric cancer was investigated with particular emphasis on its correlation with established clinicopathological characteristics and classifications. Seventy-seven gastrectomy specimens were obtained from men and 35 from women. Patients ranged in age from 20 to 89 years (median 60 years). All patients underwent a potential curative resection (RO resection) with total gastrectomy and pancreas-preserving splenectomy. None of the patients had been treated preoperatively with cytotoxic drugs or radiation. A mean number of three lymph nodes (range 0-8) in the splenic hilus was found in each specimen. The incidence of lymph node metastasis of the splenic hilus was 9.8% (n=11). Lymph node metastasis was only observed in advanced proximal gastric cancer (UICC IIIb/IV) located at the greater curvature and in Borrmann type III/IV cancer with advanced lymph node metastasis. An infiltration of the spleen was seen only in two cases with advanced stages of gastric carcinoma (stage IV). Based on our data lymph node metastasis to the splenic hilus is rarely observed in proximal gastric cancer and only found in advanced cancer (UICC IIIb/IV) especially in tumors of the greater curvature and of Borrmann type IV cancer.

A new approach to the palliation of advanced proximal gastric cancer

Background: The operative mortality and morbidity rates of palliative total gastrectomy can be high, and survival is not extended. The quality of a foreshortened life is often marred by distressing postprandial symptoms and relentless weight loss. These problems can be attributed to the conventional manner of reconstruction after total gastrectomy, with small-bowel gastric reservoirs restricting the amount of caloric intake. Large-bowel gastric reservoirs have greater capacity and empty well if positioned upright within the chest for proper emptying. The scope of a combined palliative total gastrectomy, esophagectomy, and colon pull-through must be kept within the limits of patient tolerance. Study Design: A palliative total gastrectomy was performed in 70 patients with incurably advanced cancers of the proximal and middle third of the stomach (TNM stages: II, 4%; III, 26%; and IV, 70%) using the large bowel as a gastric substitute. The trauma of reconstruction by colon pull-through was lowered by avoiding thoracotomy and by positioning the colon within the lumen of the deepithelialized esophagus. Proximal cervical esophagocolostomy, distal duodenocolostomy, and colocolostomy reestablished gastrointestinal continuity. Followup focused on subjective gastrointestinal symptoms and nutritional maintenance. Results: The operative mortality rate was 10%, postoperative complications were not inordinately high, and autopsy findings showed no defects in the technique of reconstruction. The normal esophageal mucosa was readily cored out through the neck and the abdomen, and the remaining esophageal muscular tunnel accommodated the pulled-through segment of colon. Quantitative assessment of postoperative quality of life proved impractical, but none of 58 longterm survivors (mean of 17.1 months for combined TNM stages II, III, and IV) suffered from disabling symptoms or pronounced weight loss. The quality of life, but not its length, appeared distinctly improved. Conclusions: The frequently encountered problems of abdominal distress and weight loss after palliative total gastrectomy can be averted by safely positioning a colonic gastric substitute within the lumen of the normal esophagus from which the mucosal lining has been extracted.

A COMPARISON OF PANCREARO-SPLENECTOMY (PS) AND PANCREAS PRESERVING

In a series of operated patients with advanced gastric cancer at the center, patients undergoing pancreato-splenectomy (PS) were compared with those undergoing pancreas preserving operation (PP) for the 5-year survival rate and postoperative quality of life (QOL) according to multivariate analysis. Subjects were 99 patients undergoing PS (PS group) and 47 patients undergoing PP (PP group) excluding those with early cancer of P0, H0. According to the multivariate analysis, a significantly favorable prognosis was noted in the PP group compared with the PS group. In cases of old histological stage III, the 5-year survival rate in the PP group was 66.7% (28 cases) versus 36.4% (66 cases) in the PS group, with a significant difference. Post operative complications, dressing and hospital stay in the PS group were more frequent and longer than thsoe of in the PP group. From these results, we support PP method for advanced proximal gastric cancer.