Lymph Node Dissection Procedure Research Articles

D3 Lymph Node Dissection Improves Survival Outcomes in Patients With cT2 Colorectal Non-well-differentiated Adenocarcinoma.

The extent of lymphadenectomy appropriate for patients with cT2 colorectal cancer (CRC) remains controversial. This study was conducted to compare the survival outcomes of patients with cT2 CRC after D3 or D2 lymph node dissection (LND). Qualifying subjects (N=590) had undergone radical colorectal resections for cT2 CRC and were grouped according to tumor histological type as either well-differentiated (WDA) or non-well-differentiated (nWDA) adenocarcinoma. Each group was further stratified into D3 or D2 LND according to the extent of lymph node dissection. Propensity score matching (PSM) was applied to balance potential confounding factors, and identify independent prognostic risk factors using Cox regression analysis. Primary outcome measures were overall survival (OS), cancer-specific survival, (CSS) and relapse-free survival rate (RFS). Prior to PSM, OS and CSS differed significantly (p=0.001 and p=0.021, respectively) for D3 and D2 LND subsets in the nWDA group. Estimated hazard ratios (HRs) for OS and CSS were 3 [95% confidence interval (CI)=1.3-6.8; p=0.0084] and 3.2 (95%CI=1-10; p=0.047), respectively, in the D3 LND subset. After matching, significant differences in OS (p=0.007) and CSS (p=0.012) were also observed, with corresponding estimated HRs of 4 (95%CI=1.2-14; p=0.028) and 16 (95%CI=1.2-220; p=0.034). In the WDA group, D2 and D3 LND procedures displayed similar favorable prognoses before and after matching. Postoperative complications emerged as independent risk factors for prognosis in the WDA group of patients with cT2 CRC. D3 LND improved survival outcomes in patients with non-well-differentiated cT2 CRC. In patients with well-differentiated cT2 adenocarcinoma, D3 LND was preferred to reduce perioperative complications.

Identification of the Optimal Candidates for Nodal Staging with Extended Pelvic Lymph Node Dissection Among Prostate Cancer Patients Who Underwent Preoperative Prostate-specific Membrane Antigen Positron Emission Tomography. External Validation of the Memorial Sloan Kettering Cancer Center and Briganti Nomograms and Development of a Novel Tool

BackgroundAlthough the therapeutic role of extended pelvic lymph node dissection (ePLND) in patients with prostate cancer (PCa) is still under debate, this procedure is recommended for staging purposes in selected cases. Nomograms for predicting lymph node invasion (LNI) do not account for prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging, which is characterized by a high negative predictive value for nodal metastases. ObjectiveTo externally validate models predicting LNI in patients with miN0M0 PCa at PSMA PET and to develop a novel tool in this setting. Design, setting, and participantsOverall, 458 patients with miN0M0 disease undergoing radical prostatectomy (RP) and ePLND at 12 centers between 2017 and 2022 were identified. Outcome measurements and statistical analysesAvailable tools were externally validated using calibration plots, the area under the receiver operating characteristic curve (AUC), and decision curve analyses to assess calibration, discrimination, and the net benefit. A novel coefficient-based model was developed, internally validated, and compared with available tools. Results and limitationsOverall, 53 patients (12%) had LNI. The AUC was 69% for the Briganti 2012, 64% for the Briganti 2017, 73% for the Briganti 2019, and 66% for the Memorial Sloan Kettering Cancer Center nomogram. Multiparametric magnetic resonance imaging stage, biopsy grade group 5, the diameter of the index lesion, and the percentage of positive cores at systematic biopsy were independent predictors of LNI (all p ≤ 0.04). Internal cross-validation confirmed a coefficient-based model with AUC of 78%, better calibration, and a higher net benefit in comparison to the other nomograms assessed. Use of a 5% cutoff would have spared 47% ePLND procedures (vs 13% for the Briganti 2019 nomogram) at the cost of missing only 2.1% LNI cases . The lack of central review of imaging and pathology represents the main limitation. ConclusionsTools for predicting LNI are associated with suboptimal performance for men with miN0M0 PCa. We propose a novel model for predicting LNI that outperforms available tools in this population. Patient summaryTools currently used to predict lymph node invasion (LNI) in prostate cancer are not optimal for men with negative node findings on PET (positron emission tomography) scans, leading to a high number of unnecessary extended pelvic lymph node dissection (ePLND) procedures. A novel tool should be used in clinical practice to identify candidates for ePLND to reduce the risk of unnecessary procedures without missing LNI cases.

Subcarinal lymph node dissection facilitated by applying suture passer in uniportal video-assisted thoracoscopic surgery.

With the advancement of surgical skills and instrumentation, uniportal video-assisted thoracoscopic surgery (UniVATS) has become a popular option for the treatment of early stage lung cancer surgery. However, performing subcarinal lymph node dissection remains technically challenging under UniVATS view. We introduce a novel technique that utilized a suture passer to improve the exposure of the subcarinal area and simplify lymph node dissection, which has the potential for widespread adoption in clinical practice. There were 13 lung cancer patients who underwent UniVATS lobectomy with mediastinal lymphadenectomy in our institution from July to August 2022. Clinical data of the patients were documented and reviewed. The study population consisted of nine females and four males, with an average age of 57.5 ± 9.1years. UniVATS lobectomy with mediastinal lymphadectomy was successfully performed in all patients without conversion to open surgery. The mean operation time was 90.7 ± 36.0min (53-178min), intraoperative blood loss was 73.1 ± 43.8mL (50-200mL), and postoperative hospital stay was 2.9 ± 0.3days (2-3days). No complications related to lymph node dissection, such as chylothorax, occurred. Our novel method of using a suture passer could simplify the procedure of subcarinal lymph node dissection during UniVATS in initial clinical practice. Further comparative studies are warranted in the future.

Suprapancreatic Lymph Nodes Dissection Using a Novel Multijoint Articulating Instrument and Simultaneous Near-Infrared Image in Patient with Gastric Cancer

Introduction: Optical imaging using near-infrared (NIR) fluorescence is now actively used to observe structures during real-time surgery. The advantages of NIR fluorescent light (700–900 nm) include high tissue penetration and low autofluorescence, which enable sufficient contrast.1 Lymph node dissection along the suprapancreatic area (e.g., nodes 7, 8a, 9, 11p, and 12a) during laparoscopic gastrectomy remains challenging even for an experienced surgeon. Fluorescent lymphography may be useful for performing a complete lymphadenectomy by assessing the adequacy of lymphadenectomy in real time.2 To facilitate this procedure, a sophisticated articulation device was used with NIR fluorescence imaging guidance.3 Materials and Methods: A 54-year-old man was found to have gastric adenocarcinoma located at the midbody along the lesser curvature of the stomach. An abdominal computed tomography scan revealed clinical stage T2N1M0. No metastatic lesions were found on preoperative testing. Laparoscopic distal gastrectomy was performed with a D2 lymph node dissection. The laparoscopic articulating instrument with a multijointed structure that synchronized with the surgeon's hand, wrist, and finger movements was used to facilitate the lymph node dissection. Of note, indocyanine green was injected submucosally at four sites around the cancerous tissues during intraoperative endoscopy before the lymph node dissection. Results: The operating time was 150 minutes, and the estimated blood loss was 30 mL. The patient recovered well, and he was started on a liquid diet on postoperative day 3. He was discharged on postoperative day 6 without any complications. The final pathologic report revealed that 45 lymph nodes had been retrieved and 2 were metastatic. He received adjuvant therapy and is alive at 1.6 years follow-up without recurrence. Conclusion: The suprapancreatic lymph node dissection procedure can be accomplished by using a novel multijointed articulating instrument and simultaneous NIR imaging in a patient with gastric cancer. No competing financial interests exist. Runtime of video: 7 mins 41 secs

Increase in Complications Following Vaginal Hysterectomy Compared to Laparoscopic Hysterectomy Using the ACS-NSQIP 2016 – 2019 Database

<h3>Study Objective</h3> We compare postoperative outcomes following laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) between 2016 and 2019 before and after controlling for obesity. <h3>Design</h3> A retrospective cohort study. <h3>Setting</h3> A national database study using ACS-NSQIP data from 2016 to 2019. <h3>Patients or Participants</h3> Women undergoing laparoscopic or vaginal hysterectomy between 2016 and 2019. <h3>Interventions</h3> Laparoscopic and vaginal hysterectomy. <h3>Measurements and Main Results</h3> Patient undergoing hysterectomy were identified by current procedural terminology (CPT) code. Cases with additional procedure of lymph node dissection were excluded to eliminate perioperative complications from surgeries for late-stage malignancy. Our primary outcome was a composite primary morbidity score including wound infection, sepsis, cardiovascular, thrombotic, pulmonary, and renal complications, readmission, return to the operating room, and death. Patient's undergoing LH and VH underwent propensity matching. Comparisons were made with and without matching for BMI. Multivariable logistic regression analysis was performed. After propensity matching that included BMI, we found that LH had a lower relative risk of 0.845 when compared to VH. After propensity matching that excluded BMI, we found that women with class III obesity had an increased relative risk of our composite primary morbidity of RR 1.153 (p = 0.044) and transfusion RR 1.484 (p = 0.001) when undergoing VH compared to LH. We found that these results also held true for women without class III obesity. In women with BMI <40 (non-class III obesity), there was an increased relative risk of composite primary morbidity (RR 1.178; p = 0.001), return to OR (RR 1.634; p = 0.009), and transfusion (RR 1.646; 0.004) were all significantly higher when undergoing VH compared to LH. <h3>Conclusion</h3> We found an increase in perioperative complications following VH compared to LH, regardless of BMI. To our knowledge, this is the first large database study that suggests superiority of laparoscopic approach over vaginal approach to hysterectomy. This data highlights the progress and advancements of LH.

Near-infrared fluorescent image-guided lymph node dissection compared with locoregional lymphadenectomies in dogs with mast cell tumours.

ObjectivesNear‐infrared fluorescent imaging has been described for intraoperative mapping of the draining lymph nodes in human cancer and canine oral tumours. The aim of this study was to retrospectively describe the results of lymphadenectomies in dogs with mast cell tumours treated either by standard unguided locoregional lymph node dissection or near‐infrared fluorescent image‐guided lymph node dissection.MethodsMedical records between 2012 and 2020 were reviewed for dogs that were presented for surgical resection of mast cell tumours with concurrent lymphadenectomy either with (near‐infrared fluorescent image‐guided lymph node dissection) or without near‐infrared fluorescence image guidance (lymph node dissection). The number and location of lymph nodes planned for surgical dissection and actually dissected nodes, presence of metastases and perioperative complications were recorded.ResultsThirty‐five patients underwent near‐infrared fluorescent image‐guided lymph node dissection, and 43 lymph node dissections. The number of nodes preoperatively planned for resection were 70 and 68, respectively. Fifty‐eight of those (83%) were identified during near‐infrared fluorescent image‐guided lymph node dissection procedures, compared with 50 (74%) during lymph node dissection. near‐infrared fluorescent image‐guided lymph node dissection resulted in resection of additional fluorescent nodes not corresponding to locoregional nodes in 15 of 35 dogs. Using near‐infrared fluorescent image‐guided lymph node dissection, we identified at least one metastatic node in 68% of dogs (24 of 35) compared with 33% (14 of 43) when lymph node dissection was used without imaging. No complications related to near‐infrared fluorescent imaging were reported.Clinical SignificanceThe present study suggests that near‐infrared imaging is a promising technique for intraoperative detection of the draining lymph nodes in dogs with mast cell tumours. Further validation of the technique is required to assess if near‐infrared fluorescent imaging can detect the true sentinel lymph node.

Clinical Experience of Intracorporeal Hand-sewn Anastomosis Following Totally Laparoscopic Pylorus-Preserving Gastrectomy for Middle-Third Early Gastric Cancer

IntroductionPylorus-preserving gastrectomy (PPG) has been accepted as a representative function-preserving procedure for early gastric cancer (EGC) in the middle stomach. Totally, intracorporeal laparoscopic gastrectomy can provide better aesthetics, be less invasive, and allow faster postoperative recovery. Here, we first describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy with intracorporeal hand-sewn anastomosis (TLPPG-IHSA). MethodsAfter standard procedure of lymph node dissection and middle stomach resection, we used two double-needle barbed sutures to perform a layer-to-layer manual anastomosis of the anterior and posterior walls in the abdominal cavity. Twelve patients with preoperatively diagnosed clinical EGC located in the middle third of the stomach underwent TLPPG-IHSA between August 2019 and January 2021. ResultsA total of 12 patients with EGC successfully underwent TLPPG-IHSA. Only one patient (8.3%) suffered postoperative gastric stasis. No complications or recurrence occurred in other patients during half a year after surgery. ConclusionTLPPG-IHSA is considered technically feasible to treat EGC located in the middle third of the stomach.

A standardized procedure for upper mediastinal lymph node dissection improves the safety and efficacy of robotic McKeown oesophagectomy.

Recurrent laryngeal nerve (RLN) palsy is a common complication of upper mediastinal lymph node dissection (UMLND) in the context of oesophageal cancer surgery. In an effort to reduce its occurrence, we developed a standardised surgical procedure that allows flexible suspension of the left RLN during robotic McKeown oesophagectomy. Patients who received robotic McKeown oesophagectomy for cancer were divided into two groups (pre and poststandardisation). Perioperative outcomes were retrospectively compared. The pre and poststandardisation groups consisted of 44 and 42 patients, respectively. There were no significant intergroup differences in terms of number of dissected lymph nodes. Compared with the prestandardisation group, patients treated after standardisation had a markedly lowered incidence of left RLN palsy (20.5% vs. 4.8%, respectively, p=0.029) and a reduced mean thoracic operating time (161.05 vs. 131min, respectively, p<0.001). Our standardised surgical approach is efficient and may increase the safety of UMLND.

Same Day Discharge versus Inpatient Surgery for Robot-Assisted Radical Prostatectomy: A Comparative Study.

(1) Background: no study has compared outcomes of same day discharge (SDD) versus inpatient robot-assisted radical prostatectomy (RARP) in homogenous cohorts. Our aim was to compare perioperative outcomes and urinary continence recovery between SDD and inpatient RARP in contemporary, comparable patients. (2) Methods: we included consecutive patients undergoing RARP between 2018 and 2020 (n = 376). Only patients eligible for SDD (no oral anticoagulant, distance home-hospital <150 km) and having >6-month follow-up were included (n = 180). All patients underwent RARP with or without lymph node dissection. Comparisons were performed between SDD (n = 42) and inpatient RARP (n = 138). Primary outcomes were 90-day complication and readmission rates and continence rates at 1 and 6 months. (3) Results: median patient age was 66.7 years. Median duration of surgery and blood loss was 134 min and 200 mL, respectively. Lymph node dissection and nerve-sparing procedures were performed in 76.7% and 82.2% of cases, respectively. Median follow-up was 19.5 months. No difference was seen regarding patient features, peri-operative outcomes, and pathology parameters between both groups. The proportion of SDD RARP was stable over time (23.5%). The 90-day unplanned visits, readmission and complication rates were 9.5%, 7.1%, and 19.0% in SDD patients versus 14.5% (p = 0.407), 10.1% (p = 0.560), 28.3% (p = 0.234) for inpatient RARP, respectively. Trends favoring SDD were not statistically significant. Continence rates at 1-(p = 0.589) and 6-months (p = 0.674) were comparable between SDD and inpatient RARP. The main limitation was the lack of randomization. (4) Conclusions: this multi-surgeon comparative study confirms the safety of routine SDD RARP in terms of perioperative and functional outcomes. Trends favoring SDD in terms of complications, emergency visits and readmission have to be confirmed.

Prevalence and distribution of cervical lymph node metastases in HPV-positive and HPV-negative oropharyngeal squamous cell carcinoma

ObjectiveIn oropharyngeal squamous cell carcinoma (OP-SCC), the prevalence and distribution of clinical and pathological lymph node metastasis in the neck have been extensively reported. It served as the basis for consensus recommendations on the selection of the lymph node levels in the neck requiring a treatment. The objective of the study is to compare the prevalence and distribution of neck node metastases in HPV+ and HPV− OP-SCC from a large series of patients with OP-SCC who underwent a cervical lymph-node dissection (LND) as part of their treatment. MethodsThe study concentrated on OP-SCC patients treated by various neck node dissection (LND) procedures from January 2014 to December 2018 in 3 French institutions. Patients with prior head and neck cancer, prior neck surgery, the use of induction chemotherapy, or patients with carcinoma of unknown primary were excluded. HPV-status was assessed by p16 immunohistochemistry. For each patient, the clinical and the pathological nodal status, as well as the distribution of the positive nodes in each neck level (from Ia to V) were reported. ResultsTwo-hundred and sixty-three patients were included (126 p16-negative (p16−), and 137 p16-positive (p16+). The rate of clinical positive node (cN+) reached 54% and 88.3% in the p16− and p16+ groups, respectively (p < 0.001); the corresponding rate of pathological positive node (pN+) reached 61.9% and 91.2%, respectively (p < 0.001). Regarding the clinical lymph node distribution, in p16+ patients, more positive nodes were observed in the ipsilateral level IV (p = 0.003), and less positive nodes were observed in the contralateral levels III and IV (p = 0.003 and p = 0.045, respectively). Regarding the pathologic lymph node distribution in the ipsilateral neck, in the cN0 patients, no significant difference was observed between p16− and p16+ patients (p = 0.33 to 1); in the cN+ patients, the nodes were distributed in levels Ib, II, III, IV and V without differences between the p16− and the p16+ patients. In the contralateral neck of p16− patients, nodes metastases were mainly observed in levels II, III and IV, whereas for the p16+ patients, positive nodes were only observed in level II (p = 0.03). ConclusionThis study demonstrated the higher prevalence of cN+ and pN+ in p16+ OP-SCC patients, but without meaningful difference in the distribution of the lymph node drainage between p16− and p16+ OP-SCC. It indicates that no difference should be made between p16− and p16+ patients regarding the extend of neck treatment.

Multi-Institutional Assessment of Routine Same Day Discharge Surgery for Robot-Assisted Radical Prostatectomy.

We assessed the multi-institutional safety of same day discharge for robot-assisted radical prostatectomy within a single health care system. We included 358 patients undergoing planned same day discharge for robot-assisted radical prostatectomy at 6 French centers. Primary outcomes were same day discharge failure, and 30-day complication and readmission rates. Secondary outcomes included preoperative characteristics, perioperative parameters, Chung score and pain visual analogue scale at discharge, pathological features and followup. Mean patient age was 64.7 years. Mean operative time and blood loss were 147.5 minutes and 228 ml, respectively. Concomitant lymph node dissection and nerve sparing procedures were performed in 43% and 62% of cases, respectively. No patient required transfusion or conversion. The same day discharge failure, complication and readmission rates were 4.2%, 16.8% and 2.8%, respectively. The most frequent complications were low grade complications including urinary infection (6.4%) and ileus (2.8%). Blood loss, lymph node dissection and pain visual analogue scale were significantly correlated with same day discharge failure. Same day discharge failure was reported in 7.8% of patients with pelvic lymph node dissection compared with only 1.5% of patients who did not undergo lymph node dissection (p=0.003). ASA® score was the only factor significantly associated with postoperative complications (p=0.023). The only factor correlated with readmission was the pain visual analogue scale at discharge (p=0.017). This first multi-institutional evaluation confirms the safety of same day discharge robot-assisted radical prostatectomy in a single health care system and identifies for the first time factors associated with same day discharge failure and readmission. These findings may help physicians anticipate ideal same day discharge candidates and adapt postoperative followup.

A novel procedure of thoracoscopic 4L lymph node dissection: 4L posterior first technique

Background: Left lower paratracheal (4L) lymph node dissection for left lung cancer is difficult because of the anatomic configurations of the aortic arch, pulmonary artery, and left recurrent nerve. This study aimed to describe a novel procedure of thoracoscopic 4L lymph node dissection and determine its surgical outcomes. Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared. Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs . 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs . 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%). Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.

Possibilities of performance of nonstandard operative interventions in patients, suffering early gastric cancer

Objective. To study a possibility of performance of nonstandard organ-preserving operations in patients, suffering early gastric cancer, using application of the sentinel lymph nodes visualization procedures and the lymph node dissection procedure.&#x0D; Materials and methods. There were performed operative interventions in 35 patients, suffering early gastric cancer (Stages T1 and T2). For identification of sentinel lymph nodes a procedure of luminescence, using green indocyan, was applied.&#x0D; Results. In all the patients early gastric cancer was diagnosed (T1,T2). Possibility for performance of organ-preserving operations in early gastric cancer was shown. Miniinvasive interventions in a patient with severe concurrent diseases have appeared sufficiently effective and radical. The patients’ quality of life after laparoscopic pylorus-preserving and organ-preserving operations was significantly better, than quality of life in patients, to whom gastric resection with extended D2 lymph node dissection was done.&#x0D; Conclusion. There was established, that intraoperative lymphography constitutes he informative method, which helps to estimate the disease Stage in gastric cancer and to apply the adequate scheme of combined and complex treatment. More sensitive is a procedure of luminescence, using green indocyan. Determination of the affection degree of «sentinel lymph nodes» in gastric cancer may serve as an argument for change of the selection tactics while changing the tactics for the operative intervention volume choice.

Vagus nerve and phrenic nerve guided systematic nodal dissection for lung cancer.

Systematic nodal dissection (SND), which is defined as “all the mediastinal tissues containing the lymph nodes are dissected and removed systematically within anatomical landmarks”, is vital in surgical treatment for patients with non-small cell lung cancer (NSCLC) with curative intent (1). However, for avoiding surgical complications or other reasons, a variation of SND affects the thoroughness of lymph node dissection and the accuracy of pathologic nodal (pN) staging, which are the most significant prognostic factors in resectable NSCLC (2,3). Also, reduction in the severity and incidence of postoperative complications, such as nerve injury, is of utmost importance and remains challenging (4). Although some studies reported the experience and skills in mediastinal lymph node dissection (4,5), a standard and systematic procedure for nerve protection are still lacking. Therefore, an easy-to-follow standardized approach of SND, which can not only achieve regional en bloc lymph node resection but also effectively protect the nerves, is critically needed. Based on clinical practice experience, we discovered that the hilar and mediastinal lymph nodes are distributed along with the courses of these two nerves and connected in some anatomical regions (Figure 1). Thus, we first divided the lymph nodes into three areas of each side and developed an improved approach named “duo-nerve-guided SND” for resectable lung cancer, aiming to easily achieve complete resection of hilar and mediastinal lymph nodes as well as adipose tissue without increasing the nerve-related complications. Open in a separate window Figure 1 The anatomy of the thoracic vagus nerve and phrenic nerve and the distribution of lymph nodes. (A,C) The hilar and mediastinal lymph nodes were distributed along the vagus and phrenic nerves as well as their anatomical thoracic branches (pulmonary plexus, cardiac plexus, and esophageal plexus); (B,D) the regional lymph nodes distribution. Area A (green), the posterior area of the hilum; area B (blue), the anterior area of the hilum; area C (red), the anterior mediastinal area for the left side, the superior mediastinal area for the right side. (E) The subcarinal lymph nodes in left side (station 7); (F) the station 4L lymph nodes. RVN, right vagus nerve; LVN, left vagus nerve; LRLN, left recurrent laryngeal nerve.

Impact of the surgical modality for axillary lymph node dissection on postoperative drainage and seroma formation after total mastectomy

BackgroundThe most common complications after total mastectomy with axillary lymph node treatment are prolonged drainage and seroma formation. The aim of this study was to find factors correlated with prolonged fluid discharge (prolonged drainage or seroma formation after 20th operative day or later), including surgical techniques or devices and clinical factors.Patients and methodsA total of 202 conclusive primary breast cancer patients underwent total mastectomy with axillary lymph node treatment between January 7, 2014 and June 20, 2018 at our hospital. The factors that correlated with the total fluid discharge volume and prolonged fluid discharge were examined statistically. The surgical modalities for total mastectomy with axillary treatment were classified into the following three groups:, Group A; skin flap formation by EC and axillary lymph node dissection by EC with ligation of the arteries and veins, Group B; skin flap formation by EC and axillary lymph node dissection by ultrasonic dissector (UD) without ligation of the vessels. Group D; skin flap formation by electrocautery (EC) and axillary lymph node dissection by picking up using forceps and ligation (PL).ResultsThe total fluid discharge volume and prolonged fluid discharge after total mastectomy with sentinel node retrieval (33 patients) were significantly lower than those after total mastectomy with axillary lymph node dissection (169 patients). In patients treated without drainage, a high rate of seroma formation and prolonged fluid discharge were observed, and 1 patient developed seroma infection.In the total mastectomy with axillary lymph node dissection group, logistic regression analysis revealed that body mass index, 1-week drainage volume, and surgical modality were independently correlated with prolonged fluid discharge.ConclusionsThe surgical procedure for axillary lymph node dissection should be considered to avoid prolonged fluid discharge, and the lymph vessels should be ligated in axillary lymph node dissection. An ultrasonic dissector was not effective in reducing the total fluid discharge volume. An optimal axillary lymph node dissection technique should be developed. For the patients without drainage, careful postoperative treatment should be given to avoid infectious seroma formation, even for patients who underwent total mastectomy with sentinel lymph node retrieval.

Recurrent Laryngeal Nerve Palsy (RLNP) in the Esophageal Cancer Operation: Surgical Procedure of Lymph Node Dissection Avoiding RLNP, and Usefulness of an Intraoperative Nerve Monitoring System

Recurrent Laryngeal Nerve Palsy (RLNP) in the Esophageal Cancer Operation: Surgical Procedure of Lymph Node Dissection Avoiding RLNP, and Usefulness of an Intraoperative Nerve Monitoring System

Surgical Management of Carcinoma Vulva-Case Series and Review of Literature.

The objective of this study was to study the risk factors, management protocols, and the outcome of vulvar cancer cases over a period of 2years in a tertiary care hospital. This is a case series of early-stage vulvar cancer in the Department of Surgical Oncology in BL Kapur Superspeciality Hospital from Jan 2016 to date. Five patients with histologically proven diagnosis of early-stage vulvar cancer were included. The mean age for the diagnosis of vulvar cancer was 58years and the peak incidence was seen in postmenopausal age group. All of the cases were squamous cell carcinomas in stage IB except one which was a basisquamous variant. All cases were treated primarily with surgery and vulvar flap reconstruction. Adjuvant therapy was not given in any case. Cases were followed from 6months to date, and no recurrence noted. The limitations of the study were rarity of disease and less number of cases. As all the cases in our study were in early stage of disease (stages I and II), surgical treatment in the form of modified radical vulvectomy with B/L inguinofemoral lymph node dissection and oncoplastic procedure was the treatment modality chosen for all the patients.

The Oncologic Outcomes of Inferior Mesenteric Artery-Preserving Laparoscopic Lymph Node Dissection for Upper-Rectal or Sigmoid Colon Cancer.

The standard procedure of lymph node (LN) dissection for rectal or sigmoid colon cancer remains controversial. Many laparoscopic surgeons cut the inferior mesenteric artery (IMA) at the root; however, this may cause bowel ischemia around the site of anastomosis. We performed D3 or D2 LN dissection with the preservation of the IMA. The aim of this study was to evaluate the oncologic outcomes of IMA-preserving LN dissection. We retrospectively analyzed 142 consecutive patients with upper-rectal or sigmoid colon cancer who underwent laparoscopic LN dissection with the preservation of the IMA. The number of LNs dissected and the overall and disease-free survival rates were retrospectively evaluated. Laparoscopic D3 (n = 92) or D2 (n = 50) LN dissection were performed with the preservation of the IMA. The left colic artery was preserved in all cases, the superior rectal artery was also preserved in 30 cases. The mean number of LNs dissected was 19.6 in the D3 group and 12.9 in the D2 group. The median operative time was 230 minutes, and the median volume of blood loss was 17 mL. There was no treatment-related mortality. The estimated 5-year disease-free survival rates of the stage I, II, and III patients were 93%, 83%, and 74%, respectively. No patients developed LN recurrence. Laparoscopic surgery with IMA-preserving LN dissection is an oncologically acceptable treatment strategy in patients with upper-rectal or sigmoid colon cancer.

PS02.002: EN-BLOC MEDIASTINAL LYMPH NODE DISSECTION USING A LAPAROSCOPIC TRANSHIATAL APPROACH FOR ESOPHAGEAL AND ESOPHAGOGASTRIC JUNCTION CANCERS

Abstract Background The procedure for mediastinal lymph node dissection using a laparoscopic transhiatal approach (LTHA) had not been established for esophageal and esophagogastric junction (EGJ) cancers because of the difficulties associated with surgery. We developed a novel and simple technique for their en-bloc dissection using LTHA. To date, 296 patients had undergone our method during various esophageal surgical procedures, including 39 cases with EGJ cancer. We describe our technique and evaluate the optimal range of mediastinal lymph node dissection for EGJ cancer. Methods The esophageal hiatus was opened and CO2 was introduced into the mediastinum. The posterior plane of the pericardium was extended, and the anterior side of the subcarinal, main bronchial, thoracic paraaortic and pulmonary ligament lymph nodes were separated. The posterior side of these lymph nodes was then separated. Finally, while lifting lymph nodes like a membrane, they were resected from bilateral mediastinal pleura, main bronchi and tracheal bifurcation. Results 1) Patients with EGJ cancers performed middle and lower mediastinal lymph node dissection by LTHA (n = 39) were compared with those performed by the right thoracotomy (n = 41). The total operative time and bleeding were significantly decreased by LTHA. The number of resected middle and lower mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 87.2% of patients treated by LTHA, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by LTHA (LTHA: 7.7%, thoracotomy: 17.0%). 2) Patients with EGJ cancers performed total mediastinal lymph node dissection by thoracotomy for the time before introducing LTHA were analyzed (n = 37). Upper and/or middle mediastinal lymph nodes metastasis was observed in 10 cases, and all of them had advanced tumors. All of 6 cases with upper mediastinal lymph nodes metastasis were squamous cell carcinoma. Even in adenocarcinoma, middle mediastinal lymph node metastasis was observed in 2 cases, suggesting the importance of mediastinal lymph node dissection for advanced EGJ cancers. Conclusion Our surgical procedure resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications. Disclosure All authors have declared no conflicts of interest.

Clinical outcomes and costs of robotic surgery in prostate cancer: a multiinstitutional study in Korea.

BackgroundThis study compared the surgical, functional, and oncologic outcomes of robot-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and retropubic radical prostatectomy (RRP) in Korean men.MethodsThe study population included 864 patients who underwent radical prostatectomy for prostate cancer in the departments of urology of five tertiary hospitals between 2010 and 2011. RALP, LRP, and RRP perioperative, oncological, and functional outcomes as well as complications were assessed. Medical cost data were analyzed for 682 of 864 patients.ResultsNo significant differences were found among the three groups regarding the length of stay, biochemical recurrence, complications, and metastasis. The RALP group had a significantly higher rate of pelvic lymph node dissection (64.6% vs. 35.3% or 53.3%, P value <0.0001) and bilateral nerve-sparing procedures (15.7% vs. 10.0% or 8.9%, P value <0.0001) and less blood loss (median 250 mL vs. 300 mL or 700 mL, P value <0.0001) than the LRP and RRP groups. The 12-month continence recovery rate was higher in the RALP group (92.1%) than in the LRP (86.5%) and RRP (84.4%) groups (P value <0.0001). Medical costs for RALP were approximately twofold to threefold higher than those for LRP or RRP.ConclusionsOur findings suggest that surgical and functional outcomes are better with robot-assisted surgery than with laparoscopic or open surgery in terms of estimated blood loss and urinary continence; however, no differences were found among groups in terms of biochemical recurrence and the rate of complications.