Splenic Hilar Nodes Research Articles

Laparoscopic spleen-preserving hilar lymph node dissection through pre-pancreatic and retro-pancreatic approach in patients with gastric cancer.

BackgroundThe conventional radical resection of proximal gastric cancer is even more risky when performed laparoscopically, though this technique is widely used in gastrointestinal surgery and is accepted as the superior method. This paper explores the feasibility of laparoscopic spleen-preserving hilar lymph node dissection using a retro-pancreatic approach for the treatment of proximal gastric cancer.MethodsTwo cadavers were dissected for examination of and the pre-pancreatic and retro-pancreatic spaces. Following the dissection of the cadavers, ten live patients with proximal gastric cancer from May 2008 to May 2013 at Nanfang Hospital, Guangzhou, China, were given total gastrectomy and adjuvant splenic hilar lymph node clearance through pre-pancreatic and retro-pancreatic approach on the precondition of preserving the pancreas and spleen. The clinicopathologic characteristics, as well as the intraoperative and postoperative variables affecting the procedure, were observed and analyzed.ResultsAnatomy of the space anterior and posterior to the pancreas in the two cadavers demonstrated the feasibility of pre-pancreatic and retro-pancreatic approach. The surgeries were all successfully performed laparoscopically; conversion to laparotomy was not necessary for any of the ten patients. The overall mean operative time was 243.6 ± 45 min. The mean estimated blood loss was 232 ± 80 ml. At the time of follow-up (median 12 months post-surgery), there had been neither local recurrence nor mortality in any of the patients.ConclusionLaparoscopic spleen- and pancreas-preserving splenic hilar lymph node dissection during total gastrectomy, using both pre-pancreatic and retro-pancreatic approaches, is indicated as a safe and feasible method for the treatment of proximal gastric cancer.

Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer.

Laparoscopic distal gastrectomy has recently become accepted as a surgical option for early gastric cancer in the distal stomach, but laparoscopic total gastrectomy (LTG) has not become widespread because of technical difficulties of esophagojejunal anastomosis and splenic hilar lymphadenectomy. Splenic hilar lymphadenectomy should be employed in the treatment of advanced proximal gastric cancer to complete D2 dissection, but laparoscopically it is technically difficult even for skilled surgeons. Based on the evidence that prophylactic combined resection of spleen in total gastrectomy increased the risk of postoperative morbidity with no survival impact, surgeons have preferred laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) for advanced tumors without metastasis to splenic hilar nodes or invasion to the greater curvature of the stomach, and reports with LSPL have been increasing rather than LTG with splenectomy. In this paper, recent reports with laparoscopic splenic hilar lymphadenectomy were reviewed.

Impact factors and effect of longer operation time of laparoscopic spleen-preserving splenic hilar lymph node dissection for upper-or middle-third gastric cancer

Objective To explore the impact factors and effect of longer operation time of laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND). Methods The method of retrospective casecontrol study was adopted.The clinicopathological data of the 317 patients with upper-or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND at the Fujian Medical University Union Hospital between January 2011 and December 2013 were collected.Median operation time was served as a cut-off point, 148 patients with operation time≥24 minutes and 169 patients with operation time <24 minutes were allocated into the long time group and short time group, respectively.Impact factors affecting the operation time of laparoscopic spleen-preserving SHLND were analyzed firstly, and then operation time affecting clinical effect of patients was explored.Measurement data with normal distribution were presented as ±s and analyzed using an independent sample t test.Count data and univariate analysis were done using the chi-square test.Multivariate analysis was done using the Logistic regression model. Results The gender, body mass index (BMI), number of splenic lobar arteries, type of splenic lobar arteries, number of short gastric arteries and experiences of surgeons were factors affecting longer operation time of SHLND in the univariate analysis (χ2=7. 268, 21. 551, 14. 960, 23. 791, 6. 987, 26. 995, P 0. 05).The mortalities were 0.68% (1/ 148)in the long time group and 0.59% (1/ 169)in the short time group, with no significant difference between the 2 groups (χ2 =0. 009, P >0.05). Conclusion Longer operation time of laparoscopic spleen-preserving SHLND is closely associated with gender, BMI, number of splenic lobar arteries, type of splenic lobar arteries and experiences of surgeons, and it should be performed selectively for inexperienced surgeons in order to reduce operation time and enhance postoperative recovery of patients. Key words: Gastric neoplasms; Spleen; Lymph node dissection; Operation time; Laparoscopy

Strategies of laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer.

For advanced proximal gastric cancer (GC), splenic hilar (No. 10) lymph nodes (LN) are crucial links in lymphatic drainage. According to the 14(th) edition of the Japanese GC treatment guidelines, a D2 lymphadenectomy is the standard surgery for advanced GC, and No. 10 LN should be dissected for advanced proximal GC. In recent years, the preservation of organ function and the use of minimally invasive technology are being accepted by an increasing number of clinicians. Laparoscopic spleen-preserving splenic hilar LN dissection has become more accepted and is gradually being used in operations. However, because of the complexity of splenic hilar anatomy, mastering the strategies for laparoscopic spleen-preserving splenic hilar LN dissection is critical for successfully completing the operation.

Laparoscopic spleen-preserving complete splenic hilum lymphadenectomy for advanced proximal gastric cancer

For advanced proximal gastric cancer, total gastrectomy with D2 lymphadenectomy is the standard surgical therapy containing splenic hilum lymph nodes (LNs) dissection. However, laparoscopic spleen-preserving complete splenic hilum LNs dissection for advanced proximal gastric cancer is technically challenging. Herein, we introduced an omnibearing method for laparoscopic spleen-preserving complete splenic hilar lymphadenectomy in racial total gastrectomy. The order of lymphadenectomy was No. 4d and 6 LNs-No. 12a, 8a, 9 and 7 LNs-No. 1, 3 and 5 LNs-No. 4sb, 4sa and 2 LNs-No. 10 and 11 (anterosuperior) LNs-No. 10 and 11 (posterior) LNs. During dissecting No. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. Laparoscopic total gastrectomy with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

A preoperatively predictive difficulty scoring system for laparoscopic spleen-preserving splenic hilar lymph node dissection for gastric cancer: experience from a large-scale single center.

The purpose of this study was to evaluate the risk factors that influence the difficulty of performing laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND) for gastric cancer and to establish a simple and effective scoring system to predict the surgical difficulty preoperatively. Between January 2011 and December 2013, we prospectively collected and retrospectively analyzed the medical records of 317 patients with upper- or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND. Univariate and multivariate analyses were performed to determine the independent predictors for surgical difficulty based on the operation time during spleen-preserving SHLND. A logistic regression model was used to identify determinant variables and construct a predictive difficulty scoring system. Multivariate analysis showed that gender, body mass index (BMI), number of splenic lobar arteries (SLAs), and type of SLA were independently predictive factors of operation time. According to these factors, we developed a predictive surgical difficulty scoring system and the difficulty levels are divided into 0, 1, 2, 3, and 4 points or more. Based on the relative risk, we stratified the surgical difficulty into the following three divisions: 0 low difficulty, 1-2 intermediate difficulty, and 3 points or more high difficulty. The patients with long operation time accounted for 19.6, 43.6, and 90.9% for the three groups, respectively (p<0.001). The area under the receiver operating characteristic curve for the logistic regression model and the simplified difficulty scoring prediction model was 0.717 and 0.715, respectively. Based on four independent risk factors, including gender, BMI, number of SLAs, and type of SLA, we developed a simple and effective scoring system to predict the difficulty of laparoscopic spleen-preserving SHLND preoperatively. This novel scoring system might aid surgeons with different experience in performing operations at different levels of difficulty.

Clinical Significance of Splenic Hilar Dissection with Splenectomy in Advanced Proximal Gastric Cancer: An Analysis at a Single Institution in Japan.

Significance of splenic hilar node dissection with splenectomy is now denied for advanced gastric cancer of upper one-third of the stomach without invasion to the greater curvature by the Japan Clinical Oncology Group 0110, a pivotal randomized study from Japan. However, a question remains for tumors which involve the greater curvature, as this study excluded such tumors. We retrospectively analyzed 421 consecutive patients with gastric cancer who underwent curative total gastrectomy with splenectomy from 1992 to 2009. The survival curves, state of lymph node (LN) metastasis, and index of the estimated benefit from LN dissection of each station were evaluated according to the tumor location. The incidence of No. 10 metastasis was 9.3 % (39/421), with 15.9 % in patients with tumors involving the greater curvature (Gre group, n = 132) and 6.2 % in those without (non-Gre group, n = 289) (P = 0.032). The 5-year overall survival (OS) of patients with and without No. 10 metastasis was 35.4 and 43.1 % (P = 0.135) in the Gre group and 32.8 and 66.5 % (P = 0.0006) in the non-Gre group, respectively. The index of No. 10 LN dissection was 5.6 and 2.0 in the Gre and non-Gre groups, respectively. In the Gre group, the index was relatively higher in patients aged < 65 years, within pT3, and with Borrmann type 4 tumors. Splenectomy may have a survival benefit when a tumor shows involvement with the greater curvature, especially in relatively young patients and those without serosal exposure.

Laparoscopic splenic hilar lymph node dissection for proximal gastric cancer using integrated three-dimensional anatomic simulation software.

Laparoscopic lymph node (LN) dissection along the distal splenic artery (Station No. 11d) and around the splenic hilum (Station No. 10) remains challenging even for skilled surgeons. The major reason for the difficulty is the complex, multifarious anatomy of the splenic vessels. The latest integrated three-dimensional (3D) simulations may facilitate this procedure. Usefulness of 3D simulation was investigated during 20 laparoscopic total gastrectomies with splenic hilar LN dissection while preserving the spleen and pancreas (LTG+PSP) or with splenectomy (LTG+S). Clinical information acquired by 3D simulation and the consistency of the virtual and real images were evaluated. Furthermore, clinical data of these patients were compared with that of the patients who underwent the same surgery before the introduction of 3D simulation (n=10), to clarify its efficacy. The vascular architecture and morphologic characteristics were clearly demonstrated in 3D simulation, with sufficient consistency. The median durations of 14 LTG+PSP and 6 LTG+S operations were 318 and 322min, respectively. The estimated blood losses were 18 and 38g, respectively. There were no deaths. One postoperative peritoneal abscess (grade II according to Clavien-Dindo) was recorded. A comparison of clinical parameters between surgeries without or with 3D simulation showed no differences in operation time, blood loss, or complication rate; however, the number of retrieved No. 10 LNs has significantly increased in cases with the use of 3D simulation (p=0.006). This kind of surgery is not easy to perform, but the latest 3D computed tomography simulation technology has made it possible to reduce the degree of difficulty and also to enhance the quality of surgery, potentially leading to widespread use of these techniques.

Dissection of splenic hilar lymph nodes for patients with gastric cancer: from the evidence-based view

There are many controversial issues in the aspects of No.10 lymphadenectomy, such as the necessity of No.10 lymphadenectomy, the value of splenectomy, the most appropriate procedure and the safety as well as feasibility of laparoscopic or robotic No.10 lymphadenectomy. These issues will be discussed in this article from the evidence-based view.

Totally laparoscopic spleen-preserving splenic hilum lymph nodes dissection in radical total gastrectomy: an omnibearing method

To investigate the feasibility and safety of laparoscopic spleen-preserving splenic hilum lymph nodes (LNs) dissection for advanced proximal gastric cancer using an omnibearing method. Between August 2013 and December 2014, 16 patients with advanced proximal gastric cancer treated in Guangdong Province Hospital of Chinese Medicine, were enrolled and subsequently underwent laparoscopic radical total gastrectomy (TG) with spleen-preserving splenic hilum LNs dissection. During dissecting Nos. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. The clinicopathological characteristics, intraoperative outcomes and postoperative courses were retrospectively collected and analyzed in the study. Laparoscopic surgery was successfully completed in all 16 patients without conversion to open surgery, and no perioperative death occurred. The mean operating time was 328.75±46.96min, and the mean estimated blood loss was 135.63±62.07ml. One patient experienced intraoperative bleeding due to the splenic vein injury which was successfully handled with laparoscopic vessel suturing, and one postoperative pulmonary infection was recorded. The mean time to first flatus was 3.56±1.03days with a mean 9.63±1.50days of postoperative hospital stay. The mean number of retrieved LNs was 28.31±5.99, in which LNs anterosuperior to splenic artery was 2.88±2.66 and LNs posterior was 1.38±1.75. Laparoscopic TG with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Primary splenic lymphoma masquerading as splenic abscess: A rare case

The incidence of primary splenic lymphoma (PSL) is <1%. Here we report a case of PSL in a 63-year-old female patient who had fever, night sweats, anorexia, and weight loss for 2 months. Abdominal contrast-enhanced computed tomography showed mild splenomegaly with multiple patchily enhancing splenic space occupying lesions (SOLs) along with multiple enlarged splenic hilar lymph nodes. A provisional diagnosis of splenic abscesses was made. Following splenectomy, histopathological examination and immunohistochemical analysis revealed this to be a case of splenic non-Hodgkin lymphoma - diffuse large B-cell - nongerminal center type. This case is significant since it was misdiagnosed as splenic abscess initially. Even though, PSL is an extremely rare tumor, this entity must be borne in mind when splenic SOL is detected radiologically. Documentation of such rare cases is of utmost importance to facilitate early diagnosis and treatment of similar cases in the future.

Updates in the research of laparoscopic splenic hilar lymphadectomy for upper-third gastric cancer

Laparoscopic surgery for upper-third gastric cancer has gradually been accepted by experienced surgeons as the mature of this technique.Different from the standardized and programmed D2 lymph node dissection in Laparoscopy-assisted Billroth Ⅰ gastrectomy,the indications and methods for laparoscopic splenic hilar lymphadectomy in the upper-third gastric cancer remains controversial.Unsolved problems include joint organs resection,appropriate surgical approach selection and variable vascular anatomy of the splenic hilum.Meanwhile,the long-term efficacy and safety of laparoscopic splenic hilar lymphadectomy for the upper-third gastric surgery need to be confirmed by evidence-based medical trials.With the advance of the theory and clinical practice,laparoscopic splenic hilar lymph node dissection will continue to progress. Key words: Gastric neoplasms ; Laparoscopy ; Lymphadectomy

Survival benefit and safety of no. 10 lymphadenectomy for gastric cancer patients with total gastrectomy.

This study was aimed to evaluate the survival benefit and safety of No. 10 lymphadenectomy for gastric cancer patients with total gastrectomy.Splenic hilar lymph nodes (LNs) are required to be dissected in total gastrectomy with D2 lymphadenectomy. However, there has still not been a consensus in aspects of survival and safety on No. 10 LN resection.From January 2006 to December 2011, 453 patients undergoing total gastrectomy for gastric cancer were retrospectively analyzed. Patients were grouped according to No. 10 lymphadenectomy (10D+/10D−). Clinicopathologic characteristics were compared between the 2 groups. These patients had undergone a follow-up until January 2014. The overall survival, morbidity, and mortality rate were analyzed. Subgroup analyses which were stratified by the sex, age, tumor location, lymphadenectomy extent, curative degree, differentiation, tumor size, and TNM staging (ie, stages of tumor) were performed.There were 220 patients in 10D+ group, whereas 233 in 10D− group. In terms of prognosis, the baseline features between the 2 groups were almost comparable. The incidence of No. 10 LN metastasis was 11.82%. There was no difference in morbidity and mortality between the 2 groups. Significantly more LNs were harvested from patients in 10D+ group (P = 0.000). The estimated overall 5-year survival rates were 46.44% and 37.43% in 10D+ group and 10D− group respectively, which is not statistically significant (P = 0.3288). Although no statistical significance was found in the estimated 5-year survival rate, these data were obviously higher in patients with age >60 years, Siewert II/ III tumors, N1 status, or IIIa/IIIc stages when No. 10 lymphadenectomies were performed.Although the differences were obvious, the 5-year survival rates between the 2 groups did not reach statistical significances, which was probably caused by too small patient samples. High-quality studies with larger sample sizes are needed before stronger statement can be done. Until then, the No. 10 LNs’ resection might be recommended in total gastrectomy with D2 lymphadenectomy with an acceptable incidence of complications.

P2-20-3 - Diffuse Large B Cell Lymphoma with Chromosome 6Q Deletion in Siblings

There was previously shown that chromosome 6q was frequently deleted in malignant lymphoma and identified TNFAIP3/A20, a negative regulator of NF- B pathways, as the primary target for 6q deletion. We report two cases of diffuse large B cell lymphoma with chromosome 6q deletion in siblings. Case 1 is a 81-year old woman diagnosed MALT lymphoma in 2008. She received triple therapy for eradication of H.pylori so her lymphoma was achieved complete remission. 4 years later, her lymphoma was relapsed and further transformed diffuse large B cell lymphoma. She had chromosome 6q deletion detected by G-banding. she was revealed para-aortic lymph nodes swelling by computed tomography,so her lymphoma diagnosed stage II2 as Lugano staging system. She was administered R-THP-COP and R-GCD regimen. In spite of long term chemotherapy, her lymphoma did not achieve remission.Case 2 is a 77-year old man received distal gastrectomy for early gastric cancer in 2003.He was revealed para-aortic and splenic hilum lymph nodes swelling by computed tomography,which has received after surgery in 2013. Therefore, he was received surgery of lymph node biopsy, and diagnosed diffuse large B cell lymphoma.We diagnosed his lymphoma stage IIIB as Ann Arbor staging system. He also had chromosome 6 deletion, and further, he was siblings of case 1 patient. He was administered R-CHOP regimen so his lymphoma achieved complete remission.Family history especially siblings are powerful marker of personal risk of NHL. We are interested that 2 cases had similar gene abnormality as chromosome 6q deletion, and we suspect the 2 cases suggest hereditary. The report,including the consideration of some here.

A 346 case analysis for laparoscopic spleen-preserving no.10 lymph node dissection for proximal gastric cancer: a single center study.

PurposeThis study was designed to formulate a model that efficiently predicts splenic hilar lymph node metastasis (SHLNM) in patients with proximal gastric cancer and to assess indications for laparoscopic spleen-preserving no.10 lymph node dissection (LSPNo.10LND) based on this model.MethodsPatients (N = 346) with proximal gastric cancer who underwent LSPNo.10LND from January 2010 to October 2013 were prospectively enrolled and retrospectively evaluated. Groups of patients with and without SHLNM were compared, and independent risk factors for SHLNM determined. An optimal predictive model of SHLNM in patients with proximal gastric cancer was well established.ResultsOf the 346 patients with proximal gastric cancer, only 35 (10.1%) were diagnosed with SHLNM. Depth of invasion, tumor location and metastases to No.7 and No.11 lymph nodes (LNs) were independent risk factors for SHLNM (p<0.0001 each). A model involving depth of invasion, tumor location and metastasis to No.7 and 11 LNs yielded a lowest Akaike’s information criterion (AIC) of −913.535 and a highest area under the ROC curve (AUC) of 0.897(95%CI:0.851–0.944). Stratification analysis showed no SHLNMs in the absence of serosal invasion of the lesser curvature and metastases at No.7 and No.11 LNs (T2-3∶0/87, 95% CI: 0.00–4.15).ConclusionsA model including depth of invasion, tumor location and metastases at No.7 and No.11 LNs was found optimal for predicting SHLNM for proximal gastric cancers. LSPNo.10LND may be avoided when tumors on the lesser curvature did not show serosal invasion or metastases at No.7 and No.11 LNs.

Metastasis, risk factors and prognostic significance of splenic hilar lymph nodes in gastric adenocarcinoma.

BackgroundThe metastatic rate and risk factors of splenic hilar (No.10) lymph nodes (LNs) in gastric adenocarcinoma were still variable and uncertain, and the prognostic significance of No.10 LNs was also controversial. The aim of this retrospective study was to analyze the metastatic rate, risk factors and prognostic significance of No.10 LNs in gastric adenocarcinoma.MethodsFrom August 2007 to December 2011, 205 patients who were diagnosed with primary gastric adenocarcinoma and underwent total or proximal gastrectomy plus No.10 LNs dissection in West China Hospital were enrolled. Clinicopathological features and survival outcomes were retrospectively analyzed.ResultsMean numbers of harvested LNs and metastatic LNs were 34.8±12.6 (15–73) and 8.7±10.8 (0–67), respectively. The proportion of cases with positive No.10 LNs was 8.8% (18/205). In all 204 dissected No.10 LNs, 47 LNs (23.0%) were metastatic. In 52.2% (107/205) patients, the dissected splenic hilar tissues were histologically determined as only fat tissues but without LNs structure. Histological evidence of LNs structure was found in 98 (47.8%) patients with 18.4% (18/98) metastatic No.10 LNs. In multivariate logistic regression analysis, metastasis of No.10 LNs was significantly correlated with No.4sa LNs (p = 0.010) and pN stage (p = 0.012). Regarding survival analysis, 199 (97.1%) patients were followed up (0.6–74.8 months). In all patients with R0 resection, metastatic No.10 LNs caused significantly worse prognosis both in Kaplan-Meier (p = 0.006) and Cox regression analysis (p = 0.031).ConclusionsAlthough the metastatic rate of No.10 LNs was 8.8%, dissection of No.10 LNs might be meaningful due to the poor prognosis of positive cases. And attentions should be also paid to its correlated factors including pN stage and No.4sa LNs.

Huang's three-step maneuver for laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer.

Due to the complexity of the splenic hilar vessels, their anatomical variation and the narrow and deep space, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding at the splenic hilum,the procedure remains challenging and technically demanding procedure for the performance of laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection. Based on our experiences, we gradually explored a set of procedural operation steps called "Huang's three-step maneuver". In this paper, we not only provide the concrete operation steps for the surgeon, but we also provide our recommended technique of pulling and exposure for assistants. This new maneuver simplifies the complicated procedure and improves the efficiency of laparoscopic spleen-preserving splenic hilar lymphadenectomy, making it easier to master and allowing for its widespread adoption.

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic surgery, especially for complex procedures. Laparoscopic spleen-preserving total gastrectomy with D2 lymph node (LN) dissection (LTGD2) is one of the most complicated procedures. We hypothesized that robotic LN dissection would be more thorough and accurate. We compared robotic spleen-preserving total gastrectomy with D2 LN dissection (RTGD2) with LTGD2 to investigate the impact of robotics. Clinicopathologic characteristics and short-term and long-term outcomes of RTGD2 (n=51) versus LTGD2 (n=58) in gastric adenocarcinoma patients were extracted from a prospectively designed database and analyzed retrospectively. There was no difference of patients' characteristics between groups. Mean operation time of RTGD2 was longer than LTGD2 (p<0.001), and no differences in tumor histology, size, location, and TNM stage were seen. Total retrieved LNs from RTGD2 was similar to LTGD2 (mean 47.2 vs. 42.8, respectively), as were retrieved LNs at splenic hilum (1.3 vs. 0.8). However, mean numbers of retrieved LNs along the splenic artery from RTGD2 was higher than LTGD2 (2.3 vs. 1.0, respectively; p=0.013), as was also the case at the splenic hilum and artery (3.6 vs. 1.9, p=0.014). Postoperative complication (16 vs. 22%, p=0.374) and overall and disease-free survival between the two groups were not significantly different (p=0.767 and p=0.666, respectively). Robotic spleen-preserving total gastrectomy with D2 LN dissection is feasible. Operation time and retrieved total LNs and splenic hilar LNs in the robotic procedure are acceptable.

Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy Performed by Following the Perigastric Fascias and the Intrafascial Space for Advanced Upper-Third Gastric Cancer

BackgroundLaparoscopic spleen-preserving Splenic hilar lymphadenectomy (LSPL) is required in laparoscopy-assisted total gastrectomy for advanced proximal gastric cancer. However, it is considerably difficult and risk in clinical practice. Thus, we explore the application of LSPL performed by following the perigastric fascias and the intrafascial space in D2 radical gastrectomy for advanced upper-third gastric cancer.MethodsFrom July 2010 to December 2012, 109 patients with T2–3 upper-third gastric cancer underwent LSPL. Of these patients, 55 underwent classic LSPL (classic group), and the remaining 54 patients underwent LSPL performed by following the fascias and intrafascial space (fascia group). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups.ResultsThere were no significant differences in clinicopathological characteristics between the two groups (P>0.05). All of the operations were successful without conversion to laparotomy. The operation time, mean splenic hilar lymph node (LN) dissection time, mean total blood loss and mean blood loss from splenic hilar LN dissection were significantly lower in the fascia group than in the classic group (P<0.05), whereas the times to first flatus, fluid diet and soft diet and the duration of hospital stay were similar in both groups. The mean number of harvested LNs (No. 10 and No. 11d) was slightly higher in the fascia group, but the difference was not significant. No significant difference in morbidity was found between the fascia group and the classic group (9.3% vs.10.9%, P>0.05). At a median follow-up of 12 months(range 5 to 35 months), none of the patients had died or experienced recurrent or metastatic disease.ConclusionLSPL performed by following the fascias and intrafascial space is an optimal and safe technique based on anatomical logic, and it reduces the difficulties associated with LSPL, making it easier to master and allowing its widespread adoption.

Laparoscopic Spleen-Preserving No. 10 Lymph Node Dissection for Advanced Proximal Gastric Cancer Using a Left Approach

We developed a novel procedure for spleen-preserving No. 10 lymph node (LN) dissection, which is difficult and advocates for patients with advanced proximal gastric cancer, except those with direct tumor extension to the spleen or definite LN metastasis at the splenic hilum. The surgeon reveals the splenic vessels (SVs), and the assistant pulls up the lymphatic fatty tissue on the surface of the lower lobar vessels of the spleen (LLVSs). The surgeon then exposes the left gastroepiploic vessels (LGEVs), completely separating the LLVSs from the LGEV roots. After tracking the SV termini, the No. 11d LNs are carefully dissected and the upper lobar vessels of the spleen are exposed from their roots to the upper pole of the spleen. During this process, 2-4 branches of the short gastric vessels are skeletonized and divided at their roots. The LNs behind the SVs in front of Gerota's fascia are then dissected. The above procedure was performed on 118 consecutive patients with stage cT2-3 disease. Mean operation time was 20.4±6.0min (range 13-41min), mean blood loss was 13.6±4.0ml (range 10-40ml), and mean times to first flatus, fluid diet, and soft diet were 3.3±1.2days (range 2-8days), 4.8±1.6days (range 3-14days), and 8.1±4.1days (range 6-20days), respectively. A mean 44.6±17.3 LNs (range 22-103) were retrieved, including a mean 3.0±2.4 (range 0-11) splenic hilar area LNs. At a median follow-up of 9months, no patients had died or experienced recurrent or metastatic disease. This procedure is feasible and simplifies complicated laparoscopic No. 10 LN dissection.