Splenic Hilar Lymph Node Dissection Research Articles

Robotic spleen‑preserving suprapancreatic and splenic hilar lymph node dissection using the preemptive retropancreatic approach in total gastrectomy for gastric cancer.

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488min (254-564min). The median intraoperative bleeding was 55mL (0-115mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered.

A clinicopathologic feature-based nomogram for preoperative estimation of splenic hilar lymph node metastasis in advanced proximal gastric cancer without invasion of the greater curvature

BackgroundThe indications for splenic hilar lymph node dissection in advanced proximal gastric cancer without invasion of the greater curvature are controversial. We aimed to develop a preoperative nomogram for individualized prediction of splenic hilar lymph node metastasis in non–greater curvature advanced proximal gastric cancer. MethodsFrom January 2014 to December 2021, 558 patients with non–greater curvature advanced proximal gastric cancer who underwent D2 lymphadenectomy (including splenic hilar lymph node) were retrospectively analyzed and divided into a training cohort (n = 361) and validation cohort (n = 197), depending on the admission time. A preoperative predictive nomogram of splenic hilar lymph node metastasis was established based on independent predictors identified by multivariate analysis, and the performance and prognostic value were confirmed. ResultsIn the training and validation cohorts, 48 (13.3%) and 24 patients (12.2%) had pathologically confirmed splenic hilar lymph node metastasis, respectively. Tumor located in the posterior wall, tumor size ≥5 cm, Borrmann type IV, and splenic hilar lymph node lymphadenectasis on computed tomography were preoperative factors independently associated with splenic hilar lymph node metastasis. The nomogram developed based on these four parameters had a high concordance index of 0.850 (95% confidence interval, 0.793–0.907) and 0.825 (95% confidence interval, 0.743–0.908) in the training and validation cohorts, respectively, with well-fitting calibration plots and better net benefits in the decision curve analysis. In addition, disease-free survival and overall survival were significantly shorter in the high-risk group, with hazard ratios of 3.660 (95% confidence interval, 2.228–6.011; log-rank P < .0001) and 3.769 (95% confidence interval, 2.279–6.231; log-rank P < .0001), respectively. ConclusionThe nomogram has good performance in predicting the risk of splenic hilar lymph node metastasis in non–greater curvature advanced proximal gastric cancer preoperatively, which can help surgeons make rational clinical decisions.

178P Survival benefit of splenic hilar lymph nodes (no.10) dissection in B4 type gastric carcinoma: An IPTW propensity score analysis of large multi-institutional data

178P Survival benefit of splenic hilar lymph nodes (no.10) dissection in B4 type gastric carcinoma: An IPTW propensity score analysis of large multi-institutional data

Splenic hilar lymph node dissection enhances survival in Bormann type 4 gastric cancer

Splenic hilar (no.10) lymph node dissection during total gastrectomy is no longer recommended for advanced proximal gastric cancer. However, the treatment efficacy of no.10 lymph node dissection in Borrmann type 4 tumors remains unclear. We enrolled 539 patients who underwent total gastrectomy for Borrmann type 4 tumors between 2006 and 2016 in four major institutions in Korea. We compared the long-term survival of the no.10 lymph node dissection (n = 309) and no-dissection groups (n = 230) using the propensity score (inverse probability of treatment weighting). The treatment effects of no.10 lymph node dissection were estimated in the weighted sample using the Cox proportional hazards regression model with a robust sandwich-type variance estimator. After inverse probability of treatment weighting, there were 540.4 patients in the no.10 lymph node dissection group and 532.7 in the no-dissection group. The two groups showed well-balanced baseline characteristics, including tumor node metastasis stage. The 5-year survival rates in the no.10 lymph node dissection and no-dissection groups were 45.7% and 38.6%, respectively (log-rank p = 0.036, hazard ratio 0.786, 95% confidence interval 0.630–0.982). Multivariate analysis revealed that no.10 lymph node dissection was an independent favorable prognostic factor (adjusted hazard ratio 0.747, 95% confidence interval 0.593–0.940) after adjusting for other prognostic factors. Sensitivity analyses in other inverse probability of treatment weighting models and the propensity score matching model showed similar results. Patients undergoing no.10 lymph node dissection showed improved survival compared to those without. No.10 lymph node dissection is recommended during total gastrectomy for patients with Borrmann type 4 gastric cancer.

Distribution of splenic artery lymph nodes and splenic hilar lymph nodes

Total gastrectomy with splenectomy is the standard treatment for advanced proximal gastric cancer with greater-curvature invasion. As an alternative to splenectomy, laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection (SPSHLD) has been developed. With SPSHLD, the posterior splenic hilar LNs are left behind.To clarify the distribution of splenic hilar (No. 10) and splenic artery (No. 11p and 11d) LNs and to verify the possibility of omitting posterior LN dissection in laparoscopic SPSHLD from an anatomical standpoint.Hematoxylin & eosin-stained specimens were prepared from six cadavers, and the distribution of LN No. 10, 11p, and 11d was evaluated. In addition, heatmaps were constructed and three-dimensional reconstructions were created to visualize the LN distribution for qualitative evaluation.There was little difference in the number of No. 10 LNs between the anterior and posterior sides. For LN No. 11p and 11d, the anterior LNs were more numerous than the posterior LNs in all cases. The number of posterior LNs increased toward the hilar side. Heatmaps and three-dimensional reconstructions showed that LN No. 11p was more abundant in the superficial area, while LN No. 11d and 10 were more abundant in the deep intervascular area.The number of posterior LNs increased toward the hilum and was not neglectable. Thus, surgeons should consider that some posterior No. 10 and No. 11d LNs may remain after SPSHLD.

Prevention and management of complications related to laparoscopic spleen-preserving hilar lymph node dissection for gastric cancer

Hilar splenic lymph node metastasis is one of the risk factors for poor prognosis in patients with proximal gastric cancer. Laparoscopic spleen-preserving splenic hilar lymph node dissection (LSPSHLD) can effectively improve the survival benefits of patients at high risk of splenic hilar lymph node metastasis. However, LSPSHLD is still a challenging surgical difficulty in radical resection of proximal gastric cancer. Moreover, improper operation can easily lead to splenic vascular injury, spleen injury and pancreatic injury and other related complications, due to the deep anatomical location of the splenic hilar region and the intricate blood vessels.Therefore, in the prevention and treatment of LSPSHLD-related complications, we should first focus on prevention, clarify the indication of surgery, and select the benefit group of LSPSHLD individually, so as to avoid the risk caused by over-dissection. Meanwhile, during the perioperative period of LSPSHLD, it is necessary to improve the cognition of related risk factors, conduct standardized and accurate operations in good surgical field exposure and correct anatomical level to avoid surrounding tissues and organs injury, and master the surgical skills and effective measures to deal with related complications, so as to improve the surgical safety of LSPSHLD.

Single-arm phase II trial to evaluate the safety of laparoscopic/robotic total gastrectomy with spleen-preserving splenic hilar dissection for locally advanced proximal gastric cancer that invades the greater curvature: JCOG1809.

TPS479 Background: The standard treatment for locally advanced proximal gastric cancer invading the greater curvature is “open total gastrectomy combined with splenectomy” (OTG+S) aiming for whole clearance of the splenic hilar lymph nodes. However, its pertinent postoperative severe complication (e.g. pancreatic fistula) is problematic. An objective of this study is to evaluate the safety of “laparoscopic or robotic total gastrectomy with spleen-preserving splenic hilar dissection” (LRSHD) as a new treatment option which has a potential to reduce surgical morbidity, subsequently to replace the current standard treatment, OTG+S. Methods: This is a multicenter single-arm phase II trial. The main eligibility criteria are as follows; clinical T2-4a resectable locally advanced proximal gastric adenocarcinoma that invades the greater curvature; without obvious lymph node metastasis at the splenic hilum nor direct invasion to the spleen/splenogastric ligament. Protocol treatment is laparoscopic or robotic total gastrectomy with splenic hilar lymph node dissection (D2 + No.10 lymphadenectomy according to the Japanese guidelines) in which the spleen is preserved with skeletonizing the splenic vessels. Quality control of surgery is assured by surgeon’s qualification and central peer review of intraoperative photo at the splenic hilum after dissection. The primary endpoint is the proportion of postoperative pancreatic fistula and/or intra-abdominal abscess formation with Clavien-Dindo Grade III or higher (within 30 days after surgery). Secondary endpoints are intraoperative blood loss, operation time, mortality, overall postoperative complication, number of yield splenic hilar nodes, number of metastatic splenic hilar nodes, conversion to splenectomy, conversion to laparotomy, relapse-free survival, and overall survival. Sample size was set as 85 patients to obtain 80% power considering that 15% of patients are judged as unresectable intraoperatively, with the hypothesis that the primary endpoint would have an expected value of 7% and a threshold value of 16% in one-sided alpha of 0.1. Planned accrual period is 5 years. The accrual began in August 2019. As of August 2022, 53 of the planned 85 patients (62.4%) have been enrolled. When the safety of LRSHD is proved by this study, a non-inferiority phase III trial will be consequently launched. Clinical trial registry number: UMIN000037580. Clinical trial information: UMIN000037580 .

Intraoperative Adverse Events, Technical Performance, and Surgical Outcomes in Laparoscopic Radical Surgery for Gastric Cancer: A Pooled Analysis From 2 Randomized Trials.

To verify an intraoperative adverse event (iAE) classification (ClassIntra grade) to evaluate quality control and to predict the prognostic performance of laparoscopic radical surgery for gastric cancer. Surgical quality control is a key factor in the evaluation of surgical treatment for tumors. And, there is no recognized iAE classification for gastric cancer. We performed a retrospective post hoc analysis of previously collected data from the FUGES-001 study (NCT02327481) and a subset of the CLASS-01 study (NCT01609309). Patients were classified into the iAE and non-iAE groups. And iAE was further classified into 5 subgrades according to the ClassIntra grade (with I-V severity categories). Technical performance was evaluated using the Objective Structured Assessment of Technical Skills tool and the Generic Error Rating Tool. Overall, 528 gastric cancer patients were included in this study, with 105 patients (19.9%) in the iAE group and 423 (80.1%) in the non-iAE group. The survival curve showed that the overall, disease-specific, and recurrence-free survival of the non-iAE group were significantly better than those of the iAE group ( P =0.001). The prognosis of patients with ClassIntra grade ≥II was significantly worse than that of patients with ClassIntra grade ≤I. A higher ClassIntra grade, lower Objective Structured Assessment of Technical Skills score, and total gastrectomy were independent risk factors for severe postoperative complications. There was a significant increase in bleeding (grade IV) and injury with splenic hilar lymph node dissection during total gastrectomy. The ClassIntra grade is an effective prognostic and surgical quality control index for laparoscopic radical surgery for gastric cancer; therefore, it could be included in routine hospital care and surgical quality control.

Ex Situ In Vivo Technique of Spleen-Preserving Splenic Hilar Lymph Node Dissection in Operable Proximal Gastric Adenocarcinoma.

D2 gastrectomy is the globally accepted standard surgical procedure for operable gastric cancer, and lymph node (LN) dissection is considered as the critical part of radical surgery and closely related to the prognosis. The splenic hilar LN (SHLN) or level 10 are to be removed during standard D2 total gastrectomy. In situ and ex situ spleen-preserving lymphadenectomies have been the most common dissection approaches for SHLNs. No study exists which compares the outcomes of these techniques in Indian population. This study is aimed to analyse the operative outcomes of ex situ in vivo technique of spleen-preserving splenic hilar lymph node dissection in patients who underwent D2 total gastrectomy for operable proximal gastric cancer in comparison with in situ in vivo technique of splenic hilar lymph node dissection. We reviewed prospectively collected data from 17 patients with operable proximal gastric cancer between September 2016 and April 2019 who underwent D2 total gastrectomy with splenic hilar lymph node dissection and studied the preoperative demographic factors, operative and postoperative outcomes comparing the different operative techniques. Patients with oesophago-gastric junction involvement, direct splenic or other adjacent organ invasion requiring multivisceral resection and gastric stump carcinoma were excluded. Overall, 17 patients underwent D2 total gastrectomy for operable gastric cancer. Mean age of presentation was 54.7 years including 13 males and 4 females. Five patients had middle third and 12 patients had upper third cancer. All patients had splenic hilar nodal clearance as follows: in situ - 14 and ex situ - 3 patients. R0 resection was achieved in all patients. Lymph node harvest tends to be higher with lower operative time and blood loss in patients with ex situ technique compared to in situ technique with similar morbidity. Ex situ in vivo technique of spleen-preserving splenic hilar lymph node dissection can be considered as both safe and feasible procedure for operable proximal gastric cancer patients in experienced centres to achieve better lymph node yield with no significant increase in morbidity.

Fluorescent lymphography during minimally invasive total gastrectomy for gastric cancer: an effective technique for splenic hilar lymph node dissection.

Fluorescent lymphography is an excellent technique for complete lymph node dissection during minimally invasive surgery for gastric cancer. This study aimed to evaluate the role of fluorescent lymphography in splenic hilar lymph node dissection during minimally invasive total gastrectomy. We retrospectively analyzed 168 gastric cancer patients who underwent minimally invasive total gastrectomy with D2 + No. 10 lymph node dissection from 2013 to 2018. Fluorescent lymphography was used whenever it is possible. However, when near-infrared imaging system and endoscopic indocyanine green injection were not available, we performed surgery without fluorescent lymphography. A total of 74 patients underwent surgery with fluorescent lymphography (FL group) and 94 underwent surgery without it (non-FL group). Perioperative and long-term outcomes including the number of retrieved lymph nodes at each nodal station were compared between groups. The median number of retrieved lymph nodes at the splenic hilum was larger in the FL group {2.5 [Interquartile range (IQR), 1-5]} than in the non-FL group [1 (IQR, 1-3); P = 0.012]. The negative predictive value of fluorescent lymphography for lymph node metastasis at the splenic hilum was 97.1%, although the sensitivity was 66.7%. The overall survival (FL: 96.9% vs. non-FL: 88.9%; P = 0.334) and relapse-free survival (FL: 90.5% vs. non-FL: 65.5%; P = 0.054) were higher in the FL group, although there were no statistical differences. However, among the patients without lymph node metastasis, the relapse-free survival was significantly higher in the FL group (100%) than in the non-FL group (67.1%; P = 0.017). Fluorescent lymphography is an effective tool for complete lymph node dissection at the splenic hilum. Moreover, it may help select patients who do not need splenic hilar lymph node dissection during a total gastrectomy.

Clinical Relevance of Splenic Hilar Lymph Node Dissection for Proximal Gastric Cancer: A Propensity Score-Matching Case-Control Study.

The application of splenic hilar lymph node (no. 10 LN) dissection (no. 10 LND) for proximal gastric cancer (PGC) remains controversial. This study aimed to investigate the clinical relevance of no. 10 LND from the perspective of long-term survival. The main study population included 995 previously untreated patients who underwent laparoscopic radical total gastrectomy between January 2008 and December 2014. Of these 995 patients, 564 underwent no. 10 LND (no. 10D+ group) and the remaining 431 patients did not (no. 10D- group). Propensity score-matching was applied to reduce the effects of confounding factors. The study end points were overall survival (OS) and disease-free survival (DFS). Additionally, 39 patients who received neoadjuvant chemotherapy during the same period also were included as a separate population for analysis. The metastasis rate for no. 10 LN was 10.5 % (59/564). No significant differences were observed in intra- and postoperative complications nor in mortality between the no. 10D+ and no. 10D- groups (all P > 0.05). After 1:1 matching, the two groups were comparable in clinicopathologic characteristics. The no. 10D+ group had significantly better survival than the no. 10D- group (5-year OS: 63.3 % vs 52.2 %, P=0.003; 5-year DFS: 60.4 % vs 48.1 %, P=0.013). For the patients who received neoadjuvant chemotherapy, the 5-year OS rates in the no. 10D+ and no. 10D- groups were respectively 50.6 % and 31.3 % (P=0.150) and the 5-year DFS rates were respectively 51.5 % and 31.3 % (P=0.123). Patients with untreated PGC may achieve the benefit of long-term survival from no. 10 LND. For patients with PGC who undergo neoadjuvant chemotherapy, no. 10 LND may not bring survival benefits. However, further validation with a large-sample study is needed.

ASO Author Reflections: Long-Term Efficacy of Splenic Hilar Lymph Node Dissection for Proximal Gastric Cancer.

ASO Author Reflections: Long-Term Efficacy of Splenic Hilar Lymph Node Dissection for Proximal Gastric Cancer.

Limited Clinical Significance of Splenectomy and Splenic Hilar Lymph Node Dissection for Type 4 Gastric Cancer.

PurposeType 4 gastric cancer (GC) has a very poor prognosis even after curative resection, and the survival benefit of splenectomy for splenic hilar lymph node (LN; #10) dissection in type 4 GC remains equivocal. This study aimed to clarify the clinical significance of splenectomy for #10 dissection in patients with type 4 GC.Materials and MethodsThe data of a total of 56 patients with type 4 GC who underwent total gastrectomy with splenectomy were retrospectively analyzed. Postoperative morbidity, state of LN metastasis, survival outcomes, and therapeutic value index (TVI) of each LN station were evaluated. TVI was calculated by multiplying the incidence of LN metastasis at each nodal station and the 5-year overall survival (OS) of patients who had metastasis to each node.ResultsOverall, the postoperative morbidity rate was 28.6%, and the incidence of #10 metastasis in the patients was 28.6%. The 5-year OS rate for all patients was 29.9%, and most patients developed peritoneal recurrence. Moreover, the 5-year OS rates with and without #10 metastasis were 6.7% and 39.1% (median survival time, 20.4 vs. 46.0 months; P=0.006). The TVI of #10 was as low as 1.92.ConclusionsThe clinical significance of splenectomy in the dissection of #10 for type 4 GC is limited and splenectomy for splenic hilar dissection alone should be omitted.

Can laparoscopic spleen-preserving splenic hilar lymph node dissection replace prophylactic splenectomy for proximal advanced gastric cancers that invade the greater curvature?

Background and objectivesProximal advanced gastric cancer that invades the greater curvature is often treated by prophylactic splenectomy because of a risk for metastasis to the splenic hilar lymph node (station No.10). We evaluated whether laparoscopic spleen-preserving splenic hilar dissection (SPSHD) could be a better approach. MethodsWe reviewed records of patients with proximal gastric cancer who underwent total gastrectomy with No.10 dissection between 2012 and 2018 using our in-house database set. We divided patients by whether they had received SPSHD or splenectomy, first to compare surgical outcomes, and subsequently to analyze survival outcomes among patients with tumors invading the greater curvature. ResultsOf 145 patients enrolled in this study, 82 had SPSHDs and 63 had splenectomies. All SPSHDs were laparoscopic; 80% of splenectomies were laparotomic. Morbidity ≥ grade III was seen in 8.5% of the SPSHD group and 11.1% of the splenectomy group. The median number of retrieved No. 10 nodes was three in each group. In multivariable analysis, SPSHD was not an independent prognostic factor among patients whose tumors invaded the greater curvature (n = 73). Among propensity-matched cohorts (n = 25 each), 5-year relapse-free survival rates were 77.6% in the SPSHD group and 49.9% in the splenectomy group. ConclusionLaparoscopic SPSHD can potentially replace prophylactic splenectomy.

129P Exploration of the best candidates for splenic hilar lymph node dissection (No.10 LND) based on long-term survival: Stage IIIA proximal gastric cancer may benefit from No.10 LND

129P Exploration of the best candidates for splenic hilar lymph node dissection (No.10 LND) based on long-term survival: Stage IIIA proximal gastric cancer may benefit from No.10 LND

The value of spleen-preserving lymphadenectomy in total gastrectomy for gastric and esophagogastric junctional adenocarcinomas: A long-term retrospective propensity score match study from a high-volume institution in China

BackgroundThe benefit of removing the splenic lymph nodes in patients with proximal gastric cancer has been controversial. The purpose of our study was to investigate the importance of performing a splenic hilar lymph node dissection without splenectomy in patients undergoing total gastrectomy for gastric cancer. MethodsFrom January 2006 to December 2015, we retrospectively reviewed patients who underwent a curative total gastrectomy for gastric cancer. Propensity score matching was used to balance any potential discrepancy of the other covariates between patients with and without splenic hilar lymph node dissection. Survival analysis, Cox univariate and multivariate analysis, and subgroups analysis were conducted to determine the value of splenic hilar lymph node dissection. After matching, 2 nomograms among patients with and without splenic hilar lymph node dissection were established respectively, the C-index, calibration curve and decision curve analysis were used to further evaluate the value of splenic hilar lymph node dissection. ResultsThe rate of metastatic splenic hilar lymph nodes in the 274 patients undergoing splenic hilar lymph node dissection was 16.4% (45/274). Patients undergoing splenic hilar lymph node dissection had better survival outcomes than those not undergoing splenic hilar lymph node dissection before (P = .003) and after (P = .003) propensity score matching. Cox multivariate analysis also confirmed that splenic hilar lymph node dissection was an independent prognostic factor both before (hazard ratio 1.284, 95% confidence interval 1.042–1.583, P = .019) and after (hazard ratio 1.480, 95% confidence interval 1.156–1.894, P = .002) propensity score matching. Subgroup analysis indicted that splenic hilar lymph node dissection offered better survival outcomes for esophagogastric junctional adenocarcinoma (P < .001, P for interaction = .018). After propensity score matching, the nomogram of patients with splenic hilar lymph node dissection (C-index 0.735, 95% confidence interval 0.695–0.774) also indicated a statistically significant advantage compared with that without splenic hilar lymph node dissection (C-index 0.708, 95% confidence interval 0.668–0.748, P < .001). ConclusionOur study suggests that spleen-preserving splenic hilar lymph node dissection should be an essential procedure among patients undergoing total gastrectomy.

Surgical selection and metastatic warning of splenic lymph node dissection in advanced gastric cancer radical surgery: a prospective, single-center, randomized controlled trial

Objective: To investigate the surgical options for splenic lymph node dissection in patients with advanced gastric cancer undergoing radical total gastrectomy, and to evaluate the sentinel effect of No. 4s lymph node on splenic lymph node metastasis. Methods: A prospective, single-center, randomized and controlled study was carried out (Trial registration, No.NCT02980861). Enrollment criteria: (1) >18 years old and <65 years old; (2) gastric adenocarcinoma locating in the proximal or corpus; (3) preoperative clinical staging as cT2-4aN0-3M0; (4) D2 radical total gastrectomy feasible judged before operation; (5) physical ability score 0 to 1; (6) I to III of ASA classification. Pregnant or lactating women, patients with severe mental illness or previous history of upper abdominal surgery, those suffered from other malignant tumors in the past 5 years, or heart and lung system diseases judged to affect surgery before operation, those receiving preoperative chemotherapy, radiotherapy or targeted therapies, and distant metastases being found during surgery were excluded. According to above criteria, 222 patients at The First Medical Center of Chinese PLA General Hospital from December 2016 to December 2017 were enrolled prospectively and were randomly divided into the laparoscopic splenic hilar lymph node dissection group (laparoscopic group, n=114) and the open splenic hilar lymph node dissection group (open group, n=108). The result of rapid frozen immunohistochemistry of harvested No.4s lymph nodes was used to evaluate the sensitivity and specificity of sentinel effect on splenic hilar lymph node metastasis. The surgical parameters, postoperative recovery parameters, and complication rates were compared between the two groups. Results: There were 80 males and 34 females in the lapascopic group with a mean age of (56.1±10.2) years, and 69 males and 39 females in the open group with a mean age of (58.4±10.9) years. There were no significant differences in baseline data between the two groups (all P>0.05). Total blood loss was less in the laparoscopic group [(96.3±82.4) ml vs. (116.6±101.9) ml, t=1.124, P<0.001], and the amount of bleeding from the splenic hilar lymph nodes dissected was also less than that in the open group [(25.3±17.8) ml vs. (59.5±36.4) ml, t=1.172, P<0.001]. However, the operation time, the time of splenic hilar lymph node, the number of lymph node dissected and number of splenic hilar lymph node dissected were not significantly different between the two groups (all P>0.05). As compared to the open group, the laparoscopic group had shorter time to the first flatus [(1.3±1.2) days vs. (1.6±1.5) days, t=1.665, P=0.021], shorter time to fluid diet [(4.6±1.4) days vs. (4.9 ± 1.6) days, t=1.436, P=0.007], shorter time to remove nasogastric tube [(3.9±2.6) days vs. (4.3±2.4) days, t=0.687, P<0.001] and shorter hospital stay [(10.3±6.6) days vs. (12.1±7.2) days, t=0.697, P<0.001]. Complication rate was 14.0% (16/114) and (12.0%) ((1)3/108) in the laparoscopic group and the open group, respectively, without significant difference (χ(2)=6.723, P=0.331). The sensitivity of the No. 4s lymph node for the prediction of splenic hilar lymph node metastasis reached 89.5%, and the specificity reached 99.6%. Conclusions: Laparoscopic technique is safe and feasible in the treatment of splenic hilar lymph node dissection in advanced gastric cancer. The No.4s lymph node examination has good sentinel effect on predicting the metastasis of splenic hilar lymph nodes.

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

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.