Gastric Lymph Node Dissection Research Articles

Endoscopic treatment for early gastric cancer

Background: In Korea, the number of screening endoscopies to detect early stage gastric neoplasms has increased exponentially following the active implementation of the National Cancer Screening Program.Current Concepts: Endoscopic treatment, including endoscopic mucosal resection and endoscopic submucosal dissection, is recognized as a minimally invasive treatment method with low morbidity and mortality for gastric dysplasia or early gastric cancer. Owing to improvement in the detection of early gastric cancer and advances in techniques, cases of endoscopic resection have increased and indications have been expanded. Endoscopic resection can preserve gastric function with excellent maintenance of the patient’s quality of life, and previous studies have shown better long-term follow-up outcomes compared to those with surgery. However, the fundamental limitation of endoscopic procedures is that gastric lymph-node dissection is not possible using endoscopic resection.Discussion and Conclusion: Although the usefulness of endoscopic resection is proven for tumors with a very low risk of lymph-node metastasis, follow-up examination using endoscopy and computed tomography should be performed for at least 5 years after curative resection of early gastric cancer.

RA02.03: THERAPEUTIC STRATEGY FOR ADENOCARCINOMA OF ESOPHAGO-GASTRIC JUNCTION

Abstract Background The optimal surgical management for adenocarcinoma of the esophagogastric junction, including surgical approach, range of nodal dissection, and type of gastrectomy remains controversial. Methods In our two institutions, from January 2001 to September 2016, we retrospectively analyzed clinicopathological factors and long-term results of 72 patients who underwent radical resection and evaluated the priority of nodal dissection based on the therapeutic value index [ = the frequency of lymph node metastasis (%) x the 5-year survival rate (%)/100] and recurrence pattern. Results Median age:66 (44–94), male/female = 54/18, TG/PG = 60/12, Tumor size < 40mm/ ≥ 40mm = 32/40, pT1/2/3/4 = 14/13/28/17, pN0/1/2/3 = 32/17/8/15, intestinal/diffuse type = 39/33. pStageI/II/III = 29/17/26, 5-year survival rates were pStageI/II/III = 91.1/86.2/51.4%. Univariate analysis revealed that tumor size ≥ 40mm (vs < 40mm, P = 0.009), diffuse type (vs intestinal type, P = 0.0031) and pN2–3 (vs pN0–1, P < 0.001) patients had significantly poor prognosis, and multivariate analysis revealed that diffuse type (P = 0.018, HR 3.991, 95%CI 1.264–12.606) and pN2–3 (P = 0.040, HR 3.112, 95%CI 1.055–9.183) were independent prognostic factors. The therapeutic value index of nodal dissection was No.1/2/3/7/11d/parahiatal/lower mediastinal = 15.56/12.34/11.34/7.05/5.40/12.04/2.70, and no evidence of lymphadenectomy was observed for No.4, 5, 6, 10, 16, upper and middle mediastinum. 19 cases had disease recurrence, 3 cases were mediastinal lymph node recurrence. Conclusion Our study showed that distal gastric lymph nodes dissection is unnecessary, and gastrectomy with lower mediastinal and proximal gastric lymph node dissection is recommended for the treatment of adenocarcinoma of EGJ. Since diffuse type and pN2–3 were independent prognostic factors even after potentially curative resection, so additional chemotherapy might be required for such cases. Disclosure All authors have declared no conflicts of interest.

Gastric and Small Bowel Tumors.

The incidence of gastric adenocarcinoma has decreased in the United States over the past 70 years although it continues to have a poor prognosis. While radical resection was initially the primary treatment for adenocarcinoma of the stomach, systemic chemotherapy and radiation have been shown to play a role in prolonging survival in most patient populations. This chapter explores the evidence that guides treatment for gastric cancer today. It also discusses the treatment for gastrointestinal stromal tumors (GIST), and small bowel tumors. In addition to systemic therapies, this chapter explores the surgical management of gastric and small bowel tumors including the extent of the gastric lymph node dissection.

Comparative effectiveness in esophagogastric cancer.

Cancer of the esophagus and the gastroesophageal junction (GEJ) continues to have a dismal prognosis, with the incidence of esophageal cancer increasing in the United States. Although radical resection was initially the primary treatment for this disease process, systemic chemotherapy and radiation have been shown to play a role in prolonging survival in most patient populations. This chapter explores the evidence that guides treatment for esophageal and GEJ cancer today. Chemotherapy and radiation therapy were introduced as treatment modalities for esophageal and GEJ cancers when it became evident that surgical therapy alone provided poor long-term survival rates. A variety of treatment strategies have been explored including preoperative (neoadjuvant) and postoperative (adjuvant) chemotherapy, with and without radiation. The evidence suggests that neoadjuvant chemotherapy or chemoradiotherapy provides better outcomes compared to surgery alone for esophageal, GEJ, and gastric cancers. Studies indicate a trend towards improved survival when neoadjuvant chemoradiotherapy is compared to chemotherapy alone. When patients have undergone resection with node-positive disease without receiving neoadjuvant therapy, some form of adjuvant treatment is recommended. This chapter also explores the surgical management of esophageal, GEJ, and gastric cancers including the extent of the gastric lymph node dissection. It also includes a discussion about adherence to national guidelines in terms of gastric cancer treatment and esophageal and gastric lymph node examinations.

Laparoscopic intraoperative navigation surgery for gastric cancer using real-time rendered 3D CT images.

Recent advances in laparoscopic surgical technology have made it possible to perform advanced high-level surgery, such as lymph node dissection for malignancy. Grasping the anatomy during such procedures is important for a safe operation. We have developed a new image information system that provides three-dimensional (3D) reconstructed CT images synchronized with the motion of the laparoscope. This study assesses this new navigation system. Enhanced CT using a custom-made software program can provide 3D angiography images reconstructed as a laparoscopic view. A motion sensor mounted on the laparoscope can detect the direction angle of the laparoscope. The real-time rendered 3D CT images are synchronized with the laparoscopic video images according to the motion of the scope. These 3D CT images are projected on another monitor close to the laparoscopic video monitor. Lymph node dissection can be performed with the help of the real-time navigation system that provides a detailed 3D view of the vasculature. Ten laparoscopic gastrectomies were performed using this navigation system. Real-time intraoperative navigation of the vasculature was available, allowing for an excellent surgical outcome. No complications occurred in this series. Our intraoperative navigation system allows for safe laparoscopic gastric lymph node dissection.

Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy

Here we report the method of anastomosis based on double stapling technique (hereinafter, DST) using a trans-oral anvil delivery system (EEATM OrVilTM) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection.As a basic technique, laparoscopic total gastrectomy employed Roux-en-Y reconstruction, laparoscopic proximal gastrectomy employed double tract reconstruction, and end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum.We used EEATM OrVilTM as a device that permitted mechanical purse-string suture similarly to conventional EEA, and endo-Surgitie.After the gastric lymph node dissection, the esophagus was cut off using an automated stapler. EEATM OrVilTM was orally and slowly inserted from the valve tip, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. Yarn was cut to disconnect the anvil from a tube and the anvil head was retained in the esophagus.The end-Surgitie was inserted at the right subcostal margin, and after the looped-shaped thread was wrapped around the esophageal stump opening, assisting Maryland forceps inserted at the left subcostal and left abdomen were used to grasp the left and right esophageal stump. The surgeon inserted anvil grasping forceps into the right abdomen, and after grasping the esophagus with the forceps, tightened the end Surgitie, thereby completing the purse-string suture on the esophageal stump.The main unit of the automated stapler was inserted from the cut-off stump of the lifted jejunum, and a trocar was made to pass through. To prevent dropout of the small intestines from the automated stapler, the automated stapler and the lifted jejunum were fastened with silk thread, the abdomen was again inflated, and the lifted jejunum was led into the abdominal cavity.When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, DST-based anastomosis was completed with no dog-ear.The method may facilitate safe laparoscopic anastomosis between the esophagus and reconstructed intestine. This is also considered to serve as a useful anastomosis technique for upper levels of the esophagus in laparotomy.

Reconstruction of the Gastrointestinal Tract byHemi-DoubleStapling Method for the Esophagus andJejunum Using EEA OrVil in Laparoscopic Total Gastrectomy and Proximal Gastrectomy

We report the method of anastomosis based on a hemi-double stapling technique (hereinafter, HDST) using a trans-oral anvil delivery system (EEA OrVil) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection. As a basic technique, end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum. After the gastric lymph node dissection, the esophagus was cut off obliquely to the long axis using an automated stapler. EEA OrVil was orally, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, HDST-based anastomosis was completed. The method may safe laparoscopic anastomosis between the esophagus and reconstructed intestine.