Lymphadenectomy In Gastric Cancer Surgery Research Articles

ASO Author Reflections: Indocyanine Green Fluorescence to Optimize Lymphadenectomy in Gastric Cancer Surgery: Recommendations to Improve Radicality in D2 Lymphadenectomy.

ASO Author Reflections: Indocyanine Green Fluorescence to Optimize Lymphadenectomy in Gastric Cancer Surgery: Recommendations to Improve Radicality in D2 Lymphadenectomy.

Preliminary study for developing a navigation system for gastric cancer surgery using artificial intelligence.

We are attempting to develop a navigation system for safe and effective peripancreatic lymphadenectomy in gastric cancer surgery. As a preliminary study, we examined whether or not the peripancreatic dissection line could be learned by a machine learning model (MLM). Among the 41 patients with gastric cancer who underwent radical gastrectomy between April 2019 and January 2020, we selected 6 in whom the pancreatic contour was relatively easy to trace. The pancreatic contour was annotated by a trainer surgeon in 1242 images captured from the video recordings. The MLM was trained using the annotated images from five of the six patients. The pancreatic contour was then segmented by the trained MLM using images from the remaining patient. The same procedure was repeated for all six combinations. The median maximum intersection over union of each image was 0.708, which was higher than the threshold (0.5). However, the pancreatic contour was misidentified in parts where fatty tissue or thin vessels overlaid the pancreas in some cases. The contour of the pancreas could be traced relatively well using the trained MLM. Further investigations and training of the system are needed to develop a practical navigation system.

Fluorescence-guided lymphadenectomy in gastric cancer: a prospective western series.

Indocyanine green (ICG) has been recently introduced in clinical practice as a fluorescent tracer. Lymphadenectomy is particularly challenging in gastric cancer surgery, owing to the complex anatomical drainage. The primary outcomes of this study were the feasibility and usefulness of ICG-guided lymphadenectomy in gastric cancer surgery, considering both the success rate and improved understanding of the surgical anatomy of nodal basins. The secondary outcome was the diagnostic ability of ICG to predict the presence of nodal metastases. We conducted a single-center prospective trial comprising 13 patients with gastric cancer. ICG was injected the afternoon prior to surgery or intraoperatively via the submucosal or subserosal route. Standard lymphadenectomy was performed in all patients, according to patient age and tumor stage, as usual, but after standard lymphadenectomy the residual ICG + nodes were harvested and analyzed. Each nodal station and each dissected node was recorded and classified as ICG + or ICG- (both in vivo and back table evaluation was utilized for classification). After pathological analysis, each nodal station and each dissected node was recorded as metastatic or nonmetastatic (E&E staining). The feasibility rate was 84.6% (11/13). The mean number of dissected lymph nodes per patient was 37.9. Focusing on the 11 patients in whom ICG-guided nodal navigation was successfully performed, 81 lymph node stations were removed, for a total of 417 lymph nodes. Sixty-six stations (81.48%), comprising a total of 336 lymph nodes, exhibited fluorescence. No IC- node was metastatic; all 54 metastatic nodes were ICG + . A total of 282 ICG + nodes were nonmetastatic. In two cases, some nodes outside D2 areas were harvested, being ICG + (1 case of metastatic node). Fluorescence lymphography-guided lymphadenectomy is a promising new technique that combines a high feasibility rate with considerable ease of use. Regarding its diagnostic value, the key finding from this prospective series is that no metastatic nodes were found outside fluorescent lymph node stations. Further studies are needed to investigate whether this technique can help surgeons performing standard lymphadenectomy and selecting cases for D2 + lymphadenectomy.

Significance of nodal dissection and nodal positivity in gastric cancer.

Lymphadenectomy is a central component of surgery for gastric cancer. However, controversies over the optimal extent of lymphadenectomy in gastric cancer surgery have persisted for several decades. In Eastern countries where the incidence of gastric cancer is high, surgeons have performed extensive lymphadenectomy (D2 lymphadenectomy) with low morbidity and mortality, while most Western surgeons have advocated for more limited lymphadenectomies according to the results of Dutch trial and MRC trial. Initially, these trials had failed to show survival benefit of D2 procedure and instead, found pancreaticosplenectomy performed as part of the D2 procedure associated with high incidence of morbidity and mortality. Subsequently, superiority of D2 lymphadenectomy on survival was demonstrated based on updated results. Moreover, spleen and pancreas preserving D2 lymphadenectomy are being performed safely in Western countries. Today, there is an international consensus on performing D2 lymphadenectomy as the standard procedure for advanced gastric cancer and is widely accepted as the standard procedure for gastric cancer surgery. The significance of the extent of lymphadenectomy is intimately associated with the prognostic importance of nodal metastases as the most powerful indicator of recurrence and survival for patients after curative gastrectomy. Maruyama computer program could be used to estimate the risk of lymph node metastasis in each nodal station. The Maruyama Index could be used to assess the adequacy of lymphadenectomy in gastric cancer. Positive lymph node ratio is calculated as the ratio of positive lymph nodes to all harvested lymph nodes, which might be a more precise predictor of prognosis than the absolute number of positive lymph nodes. While D2 lymphadenectomy enables the accurate staging of the disease, reduces the incidence of locoregional recurrences and thus contribute to an improved overall survival; performing lymphadenectomy beyond D2 is unlikely to improve survival. Therapeutic D2+ lymphadenectomy for advanced gastric cancer requires further evaluations, especially for patients receiving neo-adjuvant or conversion treatments.

Laparoscopic modified lymphadenectomy in gastric cancer surgery using systematic mesogastric excision: a novel technique based on a concept.

Radical surgery for gastrointestinal cancer involves en bloc removal of the primary tumor and organ-specific mesenteries. However, the surgical concept and technique for lymphadenectomy during gastric cancer surgery remain unclear. We examined a novel technique for laparoscopic modified lymphadenectomy during gastric cancer surgery involving systematic mesogastric excision (SME) and focused on the topographic anatomy, surgical technique, and specimens. Our surgical technique involved the following: mesenterization by dissociating embryological planes, separating fat tissue containing lymph nodes from the pancreas and its associated vessels by tracing the intramesenteric dissectable layers, and dissecting the lymph node that is dependent on the D1+ criteria. Between October 2011 and September 2016, 227 patients underwent laparoscopic D1+ gastrectomy using SME. Of these, total gastrectomy was performed in 47 cases and distal gastrectomy was performed in 180 cases. The median operative time was 303min (range, 201-722min), and estimated blood loss was 50mL (range, 0-550mL). The median number of harvested lymph nodes was 54 (range, 18-163). There was no conversion to open surgery. SME was adapted for modified gastrectomy and is considered safe. Modified lymphadenectomy during gastrectomy is determined by the resection margin of the mesogastrium.

Role of exetended lymphadenectomy in gastric cancer surgery: A retrospective single centre experience

Role of exetended lymphadenectomy in gastric cancer surgery: A retrospective single centre experience

A three-step method for modular lymphadenectomy in gastric cancer surgery: The ability to retrieve sufficient lymph nodes and improve survival

BackgroundSystematic lymphadenectomy for the resection of sufficient lymph nodes is the most important part of curative resection in gastric cancer surgery. Here, we explore the outcomes of the three-step method for modular lymphadenectomy (TSMML) and determine its safety and efficacy, compared with the conventional method for lymphadenectomy (CML). MethodsFrom 2008 to 2011, 270 patients with gastric cancer were divided into 2 subgroups: the TSMML group and the CML group. ResultsPatients in the TSMML group had a significantly higher median number of retrieved lymph nodes (rLNs), lower median metastatic lymph node ratios (MLRs), and superior 5-year relapse-free survival (RFS) than the CML group. Moreover, the use of the TSMML procedure was an independent protective factor for RFS. No significant intergroup differences were found in morbidity or mortality in these two groups. ConclusionThe TSMML procedure is safe and effective and is easy to learn.

Management of postoperative complications of lymphadenectomy.

Gastric cancer remains a disease with poor prognosis, mainly due to its late diagnosis. Surgery remains as the only treatment with curative intent, where the goal is radical resection with free-margin gastrectomy and extended lymphadenectomy. Over the last two decades there has been an improvement on postoperative outcomes. However, complications rate is still not negligible even in high volume specialized centers and are directly related mainly to the type of gastric resection: total or subtotal, combined with adjacent organs resection and the extension of lymphadenectomy (D1, D2 and D3). The aim of this study is to analyze the complications specific-related to lymphadenectomy in gastric cancer surgery.

Volumes of lymphadenectomy in gastric cancer surgery

It is summarized an experience of 1528 resections for gastric cancer supplemented by D1-, D2-, D2,5- and D3-lymphadenectomy in 751, 241, 359 and 177 patients resrectively. Unconventional type D2.5 means D2-lymphodis section with additional lymphadenectomy along hepatoduodenal ligament and superior retropancreatic nodes as well as omental bursa removal with lymphodis section of esophageal opening crura. Analysis of immediate and remote results is presented. It is concluded that D3-lymphadenectomy is minimally preferred over D2.5-type in gastric cancer staging. D3-lymphodis section has the largest number of especially purulent and pancreatogenic postoperative complications. D2.5-lymphadenectomy significantly increases 5-year survival in comparison with D2-lymphodis section (from 51.2 ± 4.9 to 64.0 ± 4.1%; p<0.001) and may be chosen for any radical surgery for gastric cancer including early forms. Localized proximal tumors which are in distinctive for metastasis into hepatoduodenal ligament lymph nodes are exception. D3-lymphodis section did not impact on survival in comparison with D2,5-lymphadenectomy. Only patients with antral cancer after distal subtotal gastric resection had 5-year survival increasing on 8 % (from 60.6 ± 7.5 to 68.5 ± 6.3%).

Long-Term Survival After Gastrectomy for Cancer in Randomized, Controlled Oncological Trials: Comparison between West and East

The presence of mixed evidence about the value of lymphadenectomy in gastric cancer surgery coupled with the difference in patients' demographics and tumor stage between the West and East have doubted the needs to standardize surgical techniques in Western clinical practice. The purpose of this study was to compare survival rates between the West and East following gastrectomy in randomized, controlled, oncological trials with appropriate adjustment for confounding variables. Systematic search revealed 25 trials that have randomization into surgery and chemotherapy versus surgery alone between 1995 and 2012 (n = 7 (East) and n = 18 (West)). End points were 5-year survival and cancer recurrence. There was association between gastrectomy performed in the East and improved 5-year survival (pooled odds ratio (OR) 4.83; 95 % confidence interval (CI) 3.27-7.12) and reduced cancer recurrence (pooled OR 0.33; 95 % CI 0.2-0.54). Association of improved 5-year survival with surgery in the East remained when meta-regression adjusted for the effect of age, sex, chemotherapy, tumor depth and nodal status, and gastrectomy type. Association of reduced cancer recurrence also persisted with meta-regression adjusting for age, chemotherapy, nodal status, and gastrectomy type. However, when adjustment for the percentage of patients with tumor depth T1 or 2 was made statistical significance was lost. This analysis shows association between gastrectomy performed in Eastern countries and improved survival. The known difference in surgical techniques between the East and the West is one potential unexamined variable that may be responsible in part for such discrepancy in outcomes.

Three-Step Method for Lymphadenectomy in Gastric Cancer Surgery: A Single Institution Experience of 120 Patients

Gastric cancer is one of the most common malignancies and a leading cause of cancer death. Complete resection is still the only treatment to offer a cure for patients with gastric cancer. Lymphadenectomy is the most important part of curative resection, but lymphadenectomy is also very difficult in gastric cancer surgery. The aim of this study was to report our 3-step method for lymphadenectomy and clarify its safety and value in gastric cancer. A total of 120 consecutive patients underwent our 3-step method for lymphadenectomy at the Second Affiliated Hospital Zhejiang University College of Medicine between February 2006 and July 2007. The main surgical procedure was performed from right to left and from caudal to cranial. Clinical factors, surgical variables, postoperative morbidity, and hospital (30-day) mortality were analyzed retrospectively. Total gastrectomy was performed in 41 patients; combined adjacent organ resection was performed in 9 patients. The mean operation time was 201.8 minutes, and the mean blood loss was 376.7 mL. The median postoperative hospital stay was 14.9 ± 4.3 days. A total of 3,569 lymph nodes (LNs) were removed and examined, and 2,879 were negative. More than 15 LNs were examined in all 120 patients. The median number of examined LNs was 29 (range 17 to 64; mean 29.7 ± SD 9.6) per patient, and the median number of positive LNs was 5 (range 0 to 37; mean 5.8 ± SD 7.1) per patient. The overall incidence of postoperative complications was 10.8%, and the rate of hospital death was 0%. The median follow-up period for those patients was 34.3 months (range 10 to 53 months), and the overall 3-year survival rate was 40.6%. The 3-step method for lymphadenectomy is easy to perform and is a safe and useful procedure for gastric cancer surgery.

Attach importance to the methods and strategies for lymphadenectomy in gastric cancer surgery

随着医学的发展进步,胃癌综合治疗的理念深入人心,但外科手术治疗仍是治疗胃癌的最主要手段.东西方学者对淋巴清扫与否的争论基本得到平息,胃癌淋巴清扫质量将直接影响患者预后,因此外科医生应充分重视胃癌淋巴清扫的技巧与策略,达到手术根治的目的。

D2 lymphadenectomy in gastric cancer surgery

Gastric cancer is one of the most common causes of cancer death worldwide. Surgery is the most widely utilized treatment for resectable gastric cancer. Evidence indicates that lymph node involvement and depth of invasion of the primary tumor are the most important prognostic factors for gastric cancer patients. Therefore, lymph node clearance is deemed a key procedure in gastric cancer surgery for the prognostic value to patients. Although the appropriate lymphadenectomy during gastrectomy for cancer still remains controversial, extended lymph node dissection (D2 lymphadenectomy) should be recommended in high volume hospitals.

Clinical significance of sentinel lymph node detection by combining the dye-directed and radioguided methods in gastric cancer

To investigate the feasibility and accuracy of detection of sentinel lymph nodes (SLN) with combining the dye-directed and radioguided methods in gastric cancer and assess its potential role in determining the rational extent of lymphadenectomy in gastric cancer surgery. Twenty-six patients of gastric cancer diagnosed as T(1)-T(3) were enrolled in this study. Endoscopic injection submucosally of (99m)Tc labeled sulfur colloid solution was performed around the primary tumor 2 - 4 h before operation. Immediately after laparotomy, patent blue violet was injected into subserosal layer adjacent to the tumor. SLNs were defined as blue stained nodes or(and) those containing 10 times more radioactivity than surrounding tissue with a gamma probe. Standard radical gastrectomy with lymphadenectomy (D(2) or D(3)) was performed in most of the patients, however, limited surgery was performed in early gastric cancer (EGC) when a rapid frozen examination indicated negative SLNs. All resected nodes were examined postoperatively by routine HE stain and those negative SLNs were examined with further cytokeratin immunohistochemistical staining. The diagnostic accuracy, sensitivity, negative predictive value and false-negative rate of regional lymph node status on the basis of SLN status were calculated respectively. SLNs were dectected in 25 of 26 patients with a successful detection rate of 96%. The number of SLNs ranged from 1 to 6, with a mean value of 3.2 per case. The SLNs of gastric cancer were only found in N(1) area in 50% of the cases, and only in N(2) or N(3) in 12%. The incidence of metastasis was significantly higher in SLNs than in non-SLNs (35% vs 7%). The diagnostic accuracy, sensitivity, negative predictive value and false-negative rate were 96%, 94%, 7/8 and 6% respectively. Complete analysis of SLN upstaged 2/7 of patients of gastric cancer. The SLN concept is validated in gastric cancer. Combined-agent SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with gastric cancer and may indicate rational extent of lymphadenectomy for gastric cancer.

Role of the extended lymphadenectomy in gastric cancer surgery: experience in a single institution.

Although curative resection is the treatment of choice for gastric cancer, controversy exists about the adequate extent of lymph node dissection when resection is performed. We retrospectively assessed 85 patients who underwent a limited lymphadenectomy (D1) and 71 who had an extended lymph node dissection (D2) in a single institution between 1990 and 1998 (median follow-up, 37.3 months). Prognostic factors were assessed by Cox proportional hazard models adjusted for potential confounders. We found no significant difference in the length of hospital stay (median, 12.1 and 13.1 days), overall morbidity (48.2% and 53.5%), or operative mortality (2.3% and 0%) between D1 and D2, respectively. Five-year survival in the D2 group was longer (50.6%) than in the D1 group (41.4%) for tumor stages (tumor-node-metastasis) >I. In multivariate analysis, tumor-node-metastasis stage (hazard ratio for stages >I vs. 0-I, 11.6), the ratio between invaded and removed lymph nodes, the presence of distant metastases, Laurén classification, and the extent of lymphadenectomy (hazard ratio for D1 vs. D2, 2.3; 95% confidence interval, 1.25-4.30) were the only significant prognostic factors. Our experience shows that extended (D2) lymph node dissection improves survival in patients with resected gastric cancer.

D2 Lymphadenectomy Superior to D1 Lymphadenectomy in Gastric Cancer Surgery

D2 Lymphadenectomy Superior to D1 Lymphadenectomy in Gastric Cancer Surgery

Can sentinel node biopsy indicate rational extent of lymphadenectomy in gastric cancer surgery? Fundamental and new information on lymph-node dissection.

Lymph-node dissection has been regarded as an effective surgical treatment for gastric cancer in Japan. It reduces local recurrence and improves survival rate. Japanese-style systematic D2 lymphadenectomy is now being introduced in western countries for treatment of gastric cancer. This surgical procedure, however, is not simple and should be performed by experienced surgeons. And it is too early to apply sentinel node biopsy for reducing extent of lymphadenectomy because of so complicated lymphatic streams from the stomach and frequent skip- and micrometastases.