Hilar Lymph Node Dissection Research Articles

Safety and Feasibility of Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy During Total Gastrectomy for Advanced Proximal Gastric Cancer: A Randomized Clinical Trial

Background: The splenic hilar lymph node (No. 10 LN) dissection is still controversial for patients with advanced proximal gastric cancer (APGC) not invading the greater curvature. The present study aimed to evaluate the short-term outcomes of laparoscopic spleen-preserving No. 10 lymphadenectomy (LSPL) for APGC not invading the greater curvature and the characteristic of No. 10 LN metastasis. Methods: This single-center, open-label, randomized, phase III clinical trial was done in the Department of Gastric Surgery, Fujian Medical University Union Hospital (FMUUH). Individuals aged 18 to 75 years who had histologically proven gastric adenocarcinoma in proximal stomach with clinical stage cT2-4a/N0-3/M0 not invading the greater curvature were enrolled and randomized (1:1) to receive laparoscopy-assisted total gastrectomy with either D2 lymphadenectomy (D2 group) or D2 lymphadenectomy without No. 10 LN dissection (D2- group). The main outcomes were morbidity and mortality within 30 days after surgery, number of retrieved LNs, and the metastasis rate of No. 10 LN. Analysis was based on modified intention-to-treat. Findings: From Jan 5, 2015, to Dec 10, 2018, 268 participants were randomly assigned to the D2 and D2- groups respectively. The full analysis set consisted of 263 participants in the D2 and D2- groups respectively. There were no significant differences in the intraoperative and postoperative morbidity between the D2 and D2- groups (all P>0.05). And there was no mortality in either group. There were more retrieved LNs in the D2 group than in the D2- group (45.1 vs 40.6, P=0.001). The metastasis rate of the No. 10 LN was 13.3% (35/263): 4.9% (2/41) in the early stage, and 14.9% (18/223) in the advanced stage. Pathological T (pT) stage and pN stage were related to No. 10 LN metastasis. The metastasis rates of No. 10 LN in T3-4a tumors located in the lesser curvature, posterior wall or multiple parts were all higher than 10%. Interpretation: Experienced surgeons can safely perform LSPL for APGC with more retrieved LNs. For APGC located in the lesser curvature, posterior wall or multiple parts with a clinical stage cT3-4a, dissection of the No.10 LN is necessary. Trial Registration: The study is registered with ClinicalTrials.gov, number NCT02333721; the trial has ended and this report represents the final analysis. Funding Statement: This study was supported by Scientific and Technological Innovation Joint Capital Projects of Fujian Province (2016Y9031; 2017Y9011). Construction Project of Fujian Province Minimally Invasive Medical Center (No. [2017]171). Fujian Science and Technology Innovation Joint Fund Project (2017Y9004). Joint Funds for the Innovation of Science and Technology of Fujian Province (2018Y9041). Special Fund for Clinical Research of Wu Jieping Medical Foundation (No: 320.6750.17511). Declaration of Interests: There are no conflicts of interest or financial ties to disclose from any authors. Ethics Approval Statement: The trial protocol was approved by the FMUUH Ethics Committee, and all participants provided written informed consent.

Enlightenment and reflection of splenic hilar lymph node dissection for advanced proximal gastric cancer

Splenic hilar lymph node (LN) is the difficulty and focus of perigastric LN dissection during radical gastrectomy for advanced proximal gastric cancer (APGC). Although the new edition of Japanese Gastric Cancer Treatment Guidelines excluded the splenic hilar LN from the D2 lymphadenectomy in patients with APGC, there are still few high-level evidences. Meanwhile, the guideline recommends that splenectomy is still necessary for patients with APGC involving the greater curvature. With the support of increasing evidences, the spleen-preserving splenic hilar LN dissection has been recognized by more and more scholars. Additionally, the technique of laparoscopy provides a new method for splenic hilar LN dissection. Our center proposed a new technique named Huang′s three-step maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy, which not only reduces the difficulty of operation, but also makes the technique easier to popularize and with a significance of minimally invasive effect. During the clinical practice, the dissection of LNs behind the splenic portal vessels is also one of the controversies. Therefore, the difficult technique of splenic hilar LN dissection not only requires us to make a technical exploration, but also requires us to explore precise indications, in order to avoid unnecessary operation in patients who do not require dissection of the No.10 LNs and to avoid missing the opportunity for radical surgery in high-risk patients because of the difficult techniques. Key words: Gastric neoplasms; Surgical procedure, operative; Splenic hilar lymph node; Lymphadenectomy; Laparoscopy

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review.

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

Advantages of Splenic Hilar Lymph Node Dissection in Proximal Gastric Cancer Surgery.

Gastrectomy with lymph node dissection remains the gold standard for curative treatment of gastric cancer. Dissection of splenic hilar lymph nodes has been included as a part of D2 lymph node dissection for proximal gastric cancer. Previously, pancreatico-splenectomy has been performed for dissecting splenic hilar lymph nodes, followed by pancreas-preserving splenectomy and spleen-preserving lymphadenectomy. However, the necessity of routine splenectomy or splenic hilar lymph node dissection has been under debate due to the increased morbidity caused by splenectomy and the poor prognostic feature of splenic hilar lymph node metastasis. In contrast, the relatively high incidence of splenic hilar lymph node metastasis, survival advantage, and therapeutic value of splenic hilar lymph node dissection in some patient subgroups, as well as the effective use of novel technologies, still supports the necessity and applicability of splenic hilar lymph node dissection. In this review, we aimed to evaluate the need for splenic hilar lymph node dissection and suggest the subgroup of patients with favorable outcomes.

Is video-assisted thoracoscopic surgery sufficient for lymph node dissection in pulmonary metastasectomy?

AimWe evaluated the results of patients undergoing pulmonary metastasectomy with video-assisted thoracoscopic surgery (VATS) and aimed to investigate postoperative lymph node positivity after lymph node dissection (PM-LND).Material and methodsPatients who underwent pulmonary metastasectomy and mediastinal lymph node dissection with VATS between March 2015 and March 2020 in our clinic were included in the study.ResultsThe mean age of 58 patients who underwent pulmonary metastasectomy and mediastinal lymph node dissection with VATS was 56.5. Thirty-four of the patients were female and 24 were male. A total of 61 surgical procedures, 3 of which were bilateral, were performed in 58 patients. The mean number of resected pulmonary metastases was 1.72. The total number of dissected lymph nodes was 191, with an average of 3.1 per surgical procedure. Colon carcinoma (20 patients) and breast carcinoma (16 patients) were the most common primary tumor origin. Others were thyroid, sarcoma, renal cell carcinoma and melanoma. Unexpected lymph node positivity was present in 9 of 58 patients.ConclusionsVideo-assisted thoracoscopic surgery is a technique that can be applied in pulmonary metastasectomy with its advantages such as a low complication rate and rapid recovery. In these patients, lymph node dissection, which is one of the determining factors of prognosis, can be performed effectively with VATS. Mediastinal and hilar lymph node dissection combined with pulmonary metastasectomy is effective in detecting unexpected lymph node positivity.

Exploration and development of indocyanine green fluorescence applied in laparoscopic splenic hilum lymph node dissection for gastric cancer

With the continuous development of laparoscopic techniques and the concept of individualized treatment, laparoscopic surgery is also moving from "minimally invasive" to "minimally invasive plus precision" . Lymph node metastasis is one of the most important risk factors affecting the prognosis of gastric cancer (GC). Reasonable lymph node dissection has always been an important exploration direction in the field of GC surgery. In recent years, domestic and foreign studies have found that the new tracer, indocyanine green (ICG), can detect the lymphatic vasculature non-invasively, and more accurately display the perigastric lymph nodes, providing a new perspective in laparoscopic lymph node dissection for GC. Alternatively, since the application of ICG in laparoscopic gastrointestinal tumor surgery, especially in gastric cancer surgery is still in the early stage of exploration and experience accumulation, more high-level medical evidences are needed to evaluate its clinical value.

Safety and feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection for locally advanced upper third gastric cancer: a prospective, multicenter clinical trial

Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter study to evaluate the technical safety and feasibility of LSTG for patients with AUTGC. Patients diagnosed with AUTGC (cT2-4a, N-/+, M0) underwent LSTG at 19 institutions between September 2016 and October 2017 were included. The number of No. 10 lymph node (LN) dissections, metastasis rates, intraoperative and postoperative complications were investigated. A total of 251 patients were enrolled in the study, and 242 patients were eligible for the per protocol analysis. The average numbers of No. 10 LN dissections and metastases were 2.4 and 0.1, respectively. Eighteen patients (7.4%) had No. 10 LN metastases, and among patients with advanced gastric cancer, the rate of No. 10 LN metastasis was 8.1% (18/223). pN3 status was an independent risk factor for No. 10 LN metastasis. Intraoperative complications occurred in 7 patients, but no patients required conversion to open surgery or splenectomy. The overall postoperative complication rate was 13.6% (33/242). The major complication and mortality rates were 3.3% (8/242) and 0.4% (1/242), respectively. The number of retrieved No. 10 LNs, No. 10 LN metastasis and TNM stage had no significant influence on postoperative complication rates. LSTG for AUTGC was safe and effective when performed by very experienced surgeons, this technique could be used in patients who needed splenic hilar lymph node dissection.

P2.16-16 Calf Circumference Is Associated with Postoperative Outcomes in Lung Cancer Patients Who Underwent Surgery

Sarcopenia has gained considerable attention as a poor prognostic factor in lung cancer after surgical resection. Calf circumference (CC) is an easy-to-measure, non-invasive clinical indicator that reflects body muscle mass as well as subcutaneous fat. For this property, many studies have reported that CC is capable of screening sarcopenia, aside from the assessment of nutritional status. In this study, we investigated the association between CC and postoperative outcomes in lung cancer patients. Between 2007 and 2016, 873 lung cancer patients underwent surgery in our institution. Patients who received induction therapy (n=33), with a prior history of the disease that could affect the diameter of lower limb (n=5), and with missing data (n=17) were excluded in advance, leaving 818 patients for this retrospective analysis. CC was measured prior to surgery in the occasion of hospital admission. We chose 34 cm for men and 33 cm for women as the CC cutoff value for predicting low muscle mass, following the previous report in Japan (Kawakami R et al. Geriatr Gerontol Int.). The patient characteristics, operative factors, and surgical outcomes were examined to compare the groups. The Kaplan-Meier method was used to estimate long-term survival. The mean age of all patients was 67.9 years. There were 473 men and 345 women, and each of their average CC was 34.4 cm and 32.0 cm. In the smaller CC (s-CC) group (n=427), the average age and the female proportion were significantly higher, whereas BMI, %VC, %FEV1 and %DLco, in addition to the proportion of the other cancer history were significantly lower (P<0.01 each) compared with the other group (n=391). As for operative factors, there were no significant differences in surgical approach, type of resection, operation time and intraoperative bleeding, except that the ratio of systematic hilar and mediastinal lymph node dissection was lower (P<0.01) in the s-CC group. Though overall postoperative complications were equivalent (27.2% vs. 23.0%), complications grade 3 or higher were more frequent in the s-CC group (10.5% vs. 5.9%, P=0.02). The 5-year DFS (65.1% vs. 77.9%, P=0.01) and OS (77.9% vs. 81.7%, P=0.03) were significantly poorer in the s-CC group. The smaller CC was associated with severe postoperative complications and poor DFS and OS in patients with resected lung cancer. CC was useful for assessing sarcopenia and therefore predicting postoperative outcomes.

The technique of thoracic lymph node dissection

Systematic mediastinal, hilar and interlobar lymph node dissection is required in the S3guidelines for the treatment of operable lung cancer. The lymph node involvement is considered one of the key prognostic factors. The type of lymph node resection is repeatedly the subject of controversially discussion. Lymph node dissection is essential for staging, prognosis, survival and recurrence rate. It should be standardized as a compartmental dissection with en bloc resection of lymph nodes including surrounding fat and connective tissue. Thus, exact knowledge of the anatomy of the thoracic organs with their peculiarities and high anatomical variability is necessary.

Risk evaluation of splenic hilar or splenic artery lymph node metastasis and survival analysis for patients with proximal gastric cancer after curative gastrectomy: a retrospective study

BackgroundAs splenectomy and spleen-preserving lymphadenectomy are performed only in some proximal gastric cancer patients, it is difficult to identify patients who have undergone radical gastrectomy with or without splenic hilar (No.10) or splenic artery (No.11) lymph node metastases. We aimed to determine the risk factors for No.10 and No.11 lymph node metastases and evaluate the survival significance of No.10 and No.11 lymph node dissection in advanced proximal gastric cancer patients.MethodsA total of 873 advanced proximal gastric cancer patients who underwent curative gastrectomy with or without splenectomy or pancreaticosplenectomy were analyzed retrospectively. The clinicopathological characteristics of 152 patients who underwent splenectomy or pancreaticosplenectomy were analyzed to determine the risk factors for No.10 and No.11 lymph node metastases. The survival difference between patients with No.10 and No.11 lymph node dissections and those who did not undergo these dissections were compared.ResultsPatients with No.10 and No.11 lymph node metastases had very poor prognoses. Tumor invasion of the greater curvature and No.2 and No.4 lymph node metastases were independent risk factors for No.10 and No.11 lymph node metastases. No survival differences were evident between patients with No.10 and No.11 lymph node metastases who underwent No.10 and No.11 lymph node dissections and those who did not undergo these dissections but were at high risks of No.10 and No.11 lymph node metastases.ConclusionsSplenic hilar or splenic artery lymph node dissection was not associated with increased survival, in proximal gastric cancer patients without direct cancer invasion of the spleen and pancreas, regardless of whether splenectomy, pancreaticosplenectomy, or spleen-preserving lymphadenectomy was performed.

Laparoscopic splenic hilar lymph node dissection for advanced gastric cancer: to be or not to be.

The incidence of proximal gastric cancer has increased in both the East and the West. Although some novel reconstructions like double-tract or double-flap anti-reflux procedure related to proximal gastrectomy are promising, total radical gastrectomy still accounts for a significant portion of these procedures. D2 radical gastrectomy is the globally accepted standard surgical procedure for advanced gastric cancer, and lymph node (LN) dissection is considered as the critical point of radical surgery and closely related to the prognosis. The splenic hilar LNs (No. 10) are LNs that need to be removed during standard D2 surgery for proximal and total gastrectomy. Lymphadenectomy does not only provide valuable information on the prognosis of gastric cancer, but the thoroughness of the sweep itself is directly related to postoperative survival. The incidence of splenic hilar LN (No. 10) metastasis rate is not high. Although the LN metastasis pathway around the spleen is complicated, the feasibility of laparoscopic splenic hilar LN dissection in locally advanced gastric cancer has been verified. However, these results are mostly from small volume clinical studies, and the fact is that the dissection of the splenic hilar is technique-demanding even for open surgery. The rational strategy for LN dissection for surgeons is still controversial. For splenic LN dissection in radical gastric cancer surgery, whether to select individualized splenic LN dissection for those patients highly suspected of clinical metastasis or to advocate the evidence-based strategy and neglect dissection in lower risk patients to avoid over-removing of LNs, is a vital question that needs to be clarified.

Clinicopathologic predictors of metastasis of different regional lymph nodes in patients intraoperatively diagnosed with stage-I non-small cell lung cancer

BackgroundSelection of the best lymph node for dissection is a controversial topic in clinical stage-I non-small cell lung cancer (NSCLC). Here, we sought to identify the clinicopathologic predictors of regional lymph node metastasis in patients intraoperatively diagnosed with stage-I NSCLC.MethodsA retrospective review of 595 patients intraoperatively diagnosed as stage I non-small-cell lung cancer who underwent lobectomy with complete lymph node dissection was performed. Univariate and multivariable logistic regression analysis was performed to determine the independent predictors of regional lymph node metastasis.ResultsUnivariate logistic regression and multivariable analysis revealed three independent predictors of the presence of metastatic hilar lymph nodes, five independent predictors for lobe specific mediastinal lymph nodes, two independent predictors for lobe nonspecific mediastinal lymph nodes and two independent predictors for skipping mediastinal lymph nodes.ConclusionsA complete mediastinal lymph node dissection may be considered for patients suspected of nerve invasion and albumin (> 43.1 g/L) or nerve and vascular invasions. Lobe-specific lymph node dissection should probably be performed for patients suspected of pulmonary membrane invasion, vascular invasion, CEA (> 2.21 ng/mL), and tumor (> 1.6 cm) in the right lower lobe or mixed lobes. Hilar lymph node dissection should probably be performed for patients suspected of having bronchial mucosa and cartilage invasion, vascular invasion, and CEA (> 2.21 ng/mL).

Analysis of the short- and long-term outcomes of membrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for treating advanced proximal gastric cancer

ObjectiveTo investigate the short- and long-term efficacy of membrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for the treatment of advanced proximal gastric cancer.MethodsA retrospective analysis was conducted in 186 patients with advanced proximal gastric cancer who underwent mesenteric anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer in our center from March 2013 to March 2018. The patients were divided into two groups: one group was the laparoscopic anterior splenic hilar lymph node dissection group which we named L-ASHD, n = 103), while the other group was the laparoscopic circumferential splenic hilar lymph node dissection group which we named L-CSHD, n = 83).ResultsThere was no significant difference in total operative time, intraoperative blood loss, postoperative length of hospital stay, and incidence of postoperative complications, etc. (P > 0.05). The number of harvested splenic hilar lymph nodes and the number of patients with harvested positive splenic hilar lymph nodes were both higher in the L-CSHD than in the L-ASHD (3.90 ± 2.52 vs. 3.02 ± 3.07, P < 0.05; 19 vs. 9 patients, P < 0.05). The positive rate of lymph nodes behind the splenic hilar was 8.4%. Kaplan–Meier survival curves showed that patients in the L-CSHD had similar OS and DFS compared with those of patients in the L-ASHD.ConclusionMembrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for advanced proximal gastric cancer is safe and feasible and can help avoid the incomplete dissection of positive lymph nodes.

Robotic spleen-preserving splenic hilar lymph node dissection during total gastrectomy for gastric cancer.

Robotic system may have potential advantages to facilitate the technically challenging splenic hilar lymphadenectomy during gastrectomy for gastric cancer. However, robotic spleen-preserving splenic hilar lymphadenectomy is performed infrequently not only because of the limited availability of the robot but also because of its technical difficulty. In this study, we describe our technique of performing robotic spleen-preserving splenic hilar lymphadenectomy in detail to facilitate wider application and present operative outcomes and the follow-up results of the procedure. From 2005 to 2015, 93 patients underwent robotic total gastrectomy with D2 lymphadenectomy. One patient with obvious lymph node (LN) metastasis received splenectomy and was excluded from the analysis. Intraoperative complications, operation and console time, estimated blood loss, postoperative morbidity and mortality, the number of harvested LNs in total and at the splenic hilum, and 5-year overall survival were analyzed, retrospectively. Among the 92 patients, robotic spleen-preserving splenic hilar lymphadenectomy was successfully performed in 91 patients except one who experienced intraoperative splenic artery injury which demanded splenectomy to be performed simultaneously. The overall mean operation time and console time were 287.2 ± 66.0 and 180.2 ± 47.2min, respectively. Mean estimated blood loss was 141.1 ± 227.0ml. The mortality was 1.1% (1/92). The overall postoperative morbidity rate was 16.3% (15/92). There was no case of pancreatic fistula, whole splenic infarction, or the delayed aneurysm of splenic artery. The mean numbers of harvested LNs in total and at the splenic hilum were 50.8 ± 18.1 and 1.9 ± 2.6. The 5-year overall survival was 86.3% and 5-year recurrence-free survival was 87.4%. This study suggests that robotic application for spleen-preserving splenic hilar lymphadenectomy could be a feasible and safe method.

Laparoscopic lymph nodes dissection for advanced gastric cancer: the current status and the perspective

The laparoscopic gastrectomy (LG) with D2 lymph node dissection (LND) for advanced gastric cancer (AGC) have been widely done. However, the applicability to more advanced disease is still under debate. Actually, there are a lot of technical demands against D2 LND for AGC, e.g., total omentectomy, splenic hilar node dissection, and the management for bulky lymph nodes, etc. Recently, extensive research has been gradually performed in the field of LG for AGC and demonstrated that LG for AGC is a safe and feasible procedure with better short-term outcomes compared with open gastrectomy. Also, large-scaled phase III trials are ongoing, and their long-term outcomes are awaited the publication in the near future. LG with D2 LND by expert surgeons under the cautious indications could be acceptable treatment for locally AGC. On the other hand, we should keep searching for solutions to the technical or oncological issues, and long-term outcome of phase III study should be warranted for standard treatment. Robotic surgery, LG following neoadjuvant chemotherapy, or conversion therapy using LG for several stage IV patients may help us clear the technical hurdles, and may show survival advantages in the future.

The efficacy of splenic hilar lymph node dissection in advanced gastric cancer.

112 Background: Total gastrectomy with splenectomy for splenic hilar lymph node (No.10 LN) dissection had been a standard treatment for proximal advanced gastric cancer in Japan. The efficacy of No. 10 LN dissection with splenectomy for advanced gastric cancer without the greater curvature invasion was denied by a randomized controlled trial, JCOG0110. However, JCOG0110 did not include the patients with greater curvature invasion. Therefore, we aimed to clarify the role of No. 10 LN dissection in patients with proximal advanced gastric cancer invading the greater curvature. Methods: A total of 273 patients with proximal advanced gastric cancer who underwent curative total gastrectomy with splenectomy from 2002 to 2013 were included. We reviewed esophagogastroduodenoscopy and upper gastrointestinal series for evaluation of clinical tumor localization and classified the patients into with greater curvature invasion group (G group, n = 108) or without invasion group (NG group, n = 165). The incidence and therapeutic value index (TVI) of No. 10 LN were compared between the groups. Results: Patients in the G group had more advanced T stage, undifferentiated histology, and larger tumor size than those in the NG group. However, there was no difference in survival between the groups; 5-year overall survival (5-OS) was 66.3% in the G group and 69.1% in the NG group (p = 0.570). The incidence of No.10 LN metastasis was significantly higher in the G group (10.2%) than that in the NG group (3.0%) (p = 0.028). TVI for No.10 LN dissection was higher in the G group (5.6) than that in the NG group (0.6). The survival of the patients with No.10 LN metastasis tended to be better in the G group, although it did not reach statistical significance (5-OS: 54.5% in G group vs. 20.0% in NG group, p = 0.336). Conclusions: It is suggested that splenic hilar LN dissection has a favorable effect on survival in patients with proximal gastric cancer invading the greater curvature.

Prognostic Impact of Extended Lymph Node Dissection versus Limited Lymph Node Dissection on pN0 Proximal Advanced Gastric Cancer: a Propensity Score Matching Analysis.

PurposeSplenic hilar lymph node dissection (LND) during total gastrectomy is regarded as the standard treatment for proximal advanced gastric cancer (AGC). This study aimed to investigate whether splenic hilar LND or D2 LND is essential for proximal AGC of pT2-4aN0M0 stage.Materials and MethodsData of curative total gastrectomies (n=370) performed from 2000 to 2010 for proximal AGC of pT2-4aN0 stage were retrospectively reviewed. Clinicopathological characteristics and long-term outcomes were compared using propensity score matching between patients who underwent splenectomy (n=43) and those who did not (n=327) and between patients who underwent D2 LND (n=122) and those who underwent D1+ LND (n=248).ResultsTumors of larger size and a more advanced T stage and significantly lower overall and relapse-free survival (P<0.001) were observed in the splenectomy group than in the 2 spleen-preserving groups. Before propensity score matching, worse overall and relapse-free survival (P<0.001) was observed in the splenectomy group than in the non-splenectomy group. After matching, although the overall survival became similar (P=0.123), relapse-free survival was worse in the splenectomy group (P=0.021). Compared with D1+ LND, D2 LND had no positive impact on the overall (P=0.619) and relapse-free survival (P=0.112) after propensity score matching.ConclusionsSplenic hilar LND with or without splenectomy may not have an oncological benefit for patients with pathological AGC with no LN metastasis.

Treatment of stage IIIA-N2 EGFR-mutant non-small cell lung adenocarcinoma.

Lung cancer remains the leading cause of death worldwide and is the most common cancer both in incidence and mortality (1.35 million deaths annually). Lobectomy, along with hilar and mediastinal lymph node dissection, is the standard surgical treatment for lung cancer. Roughly 20–25% of patients diagnosed with non-small cell lung cancer (NSCLC) are suitable for surgical resection with curative intent (1).

A case of pulmonary histoplasmosis diagnosed after lung lobectomy

BackgroundHistoplasmosis is considered a fairly rare imported mycosis in Japan. Here we report a case of histoplasmosis describing the preoperative findings, histopathological findings, supposed infection route, and appropriate treatment, including the postoperative management.Case presentationA healthy 65-year-old man was found at routine medical check-up to have an abnormal opacity on chest radiography. A chest computed tomography (CT) scan showed a nodular lesion in the posterior basal segment of the right lung, as well as two smaller nodules in the same lobe. This was highly suggestive of primary lung cancer with pulmonary metastases in the same lobe. We thus performed a right lower lobectomy with hilar and mediastinal lymph node dissection via thoracotomy. The lesions were diagnosed as pulmonary histoplasmosis on histopathology. At 6-month follow-up examination, the patient was free from fungal infection without any postoperative medication.ConclusionsWe describe a patient with pulmonary histoplasmosis diagnosed following surgical lobectomy. The possibility of pulmonary histoplasmosis should be considered in the differential diagnosis of pulmonary nodular lesions.

Current status of laparoscopic total gastrectomy.

In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.