Splenic Lymph Node Dissection Research Articles

Membrane anatomy-based splenic hilar lymph node dissection for gastric cancer

There is a consensus that selectively perform splenic lymph node dissection is necessary for high-risk patients with proximal gastric cancer to achieve radical treatment. However, there are still some outstanding issues that need to be solved during the practice of splenic lymph node dissection. These include poorly defined boundaries, technical difficulties, and blurred boundaries in No. 10 and No. 11 lymph nodes, etc. Membrane anatomy has achieved successful applications in the field of gastric and colorectal surgery in recent years. The study of membrane anatomy in the splenic hilum region is controversial due to the special location of the splenic hilum, which involves multiple organs and affiliated mesentery undergoing complex rotation, folding, and fusion during embryonic development. In this manuscript, we summarize the following points based on existing research and personal experience regarding membrane anatomy. 1. There is a membrane anatomical structure that can be used for lymph node dissection in the splenic hilum region. 2. The membrane structure in the splenic hilum region can be divided into two layers: the superficial layer is composed of the dorsal mesogastrium, and the deep layer is composed of Gerota fascia, the tail of the pancreas, and the mesentery of the transverse colon (from head to tail). 3. There is a loose space between the two layers that can be used for separation during surgery. The resection of the dorsal mesogastrium belongs to D2 dissection. The No. 10 lymph node in the deeper layer belongs to the duodenal mesentery, and the resection of the No.10 lymph node exceeds D2 dissection. The complete excision of the gastric dorsal mesentery is consistent with the D2+CME surgical mode proposed by Gong Jianping's group.

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.

Spleen-preserving lymphadenectomy versus splenectomy in laparoscopic total gastrectomy for advanced gastric cancer

BackgroundTo investigate the optimal approach for laparoscopic splenic hilum lymph node dissection in proximal advanced gastric cancer, we compared the operative outcomes between laparoscopic spleen-preserving total gastrectomy (sp-LTG) and laparoscopic total gastrectomy with splenectomy (sr-LTG). MethodsA retrospective case-cohort study was conducted between February 2006 and December 2012. The operative outcomes, the number of retrieved splenic hilum lymph node, complication, and patients' survivals were analyzed. Results112 patients who underwent laparoscopic total gastrectomy with or without splenectomy for advanced gastric cancer were enrolled (68 sp-LTGs and 44 sr-LTGs). The mean operation time (227 min vs. 224 min, p = 0.762), estimated blood loss (157 ml vs. 164 ml, p = 0.817), and complication rate (17.6% vs. 13.6%, p = 0.572) were not different between two groups. Regarding splenic lymph node dissection, there were significantly differences in the mean number of retrieved lymph nodes between sp-LTG and sr-LTG (LN no.10; 1.78 vs. 3.21, p = 0.033, LN no.11d; 1.41 vs. 2.76, p = 0.004). The 5-year survivals were 77.3% in sp-LTG and 65.9% in sr-LTG (p = 0.240). The hazard ratio of splenectomy was 1.139 (95% confidence interval 0.514–2.526, p = 0.748). ConclusionIn laparoscopic total gastrectomy for proximal advanced gastric cancer, spleen-preserving hilar dissection showed comparable short-term and long-term outcomes.

Impact of splenic node dissection on short-term outcome and survival following esophagectomy

BackgroundThe purpose of this study was to investigate the impact of splenic node dissection on short-term outcomes and survival after esophagectomy in patients with thoracic esophageal squamous cell carcinoma (ESCC). MethodsWe retrospectively analyzed the clinical data of 1282 consecutive patients with thoracic ESCC who underwent esophagectomy in the First Affiliated Hospital of Zhengzhou University from January 2005 to December 2013. ResultsOf all 1282 patients, there were 964 without splenic node dissection and 318 with splenic node dissection. The average operative time in the splenic node nondissection group was significantly shorter than dissection group, and blood loss in the nondissection group was significantly less than dissection group (all p < 0.05). The comparison of overall survival curves between the splenic node nondissection group and dissection group showed no significant difference (p > 0.05). In the dissection group, there were 15 patients (4.7%) with confirmed splenic node metastasis by postoperative pathologic examination. Patients with splenic node metastasis had a worse cumulative survival compared with those without splenic node metastasis (p < 0.05). Compared with nondissection group, prophylactic splenic node dissection failed to improve the survival rate significantly (p > 0.05). ConclusionThe frequency of splenic node metastasis is low in thoracic ESCC. Splenic node metastasis indicates a worse prognosis for patients with thoracic ESCC. Splenic node dissection might be futile for patients with thoracic ESCC.

Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection.

To investigate whether computed tomography with 3D imaging (3DCT) can reduce the risks associated with laparoscopic surgery. We performed a retrospective case-control study evaluating the efficacy of preoperative 3DCT of the splenic vascular anatomy on surgical outcomes in patients undergoing laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection for upper- or middle-third gastric cancer. The clinical records of 312 patients with upper- or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection in our hospital from January 2010 to June 2013 were collected, and the patients were divided into two groups (group 3DCT vs group NO-3DCT) depending on whether they underwent 3DCT or not. Clinicopathologic characteristics, operative and postoperative measures, the number of retrieved LNs, and complications were compared between these two groups. Patients were further compared regarding operative and postoperative measures, the number of retrieved LNs, and complications when subdivided by body mass index ( ≥ 23 and < 23 kg/m(2)) and the number of operations performed by their surgeon (≤ 40 vs > 40). The mean numbers of retrieved splenic hilar LNs were similar in patients in group 3DCT and group NO-3DCT (2.85 ± 2.33 vs 2.48 ± 2.18, P > 0.05). The operation time and blood loss at the splenic hilum were lower in the patients in group 3DCT (P < 0.05 each). The postoperative recovery time and complication rates were similar between the two groups (P > 0.05 each). Subgroup analysis showed that the operation time at the splenic hilum in patients with a BMI ≥ 23 kg/m(2) was significantly shorter in patients in group 3DCT than in group NO-3DCT (20.27 ± 5.84 min vs 26.17 ± 11.01 min, P = 0.003). In patients with a BMI < 23 kg/m(2), the overall operation time (171.8 ± 26.32 min vs 188.09 ± 52.63 min, P = 0.028), operation time at the splenic hilum (19.39 ± 5.46 min vs 23.74 ± 9.56 min, P = 0.001), and blood loss at the splenic hilum (13.27 ± 4.96 mL vs 17.98 ± 8.12 mL, P = 0.000) were significantly lower in patients in group 3DCT than in group NO-3DCT. After 40 operations, the operation time (18.63 ± 4.40 min vs 23.85 ± 7.92 min, P = 0.000) and blood loss (13.10 ± 4.17 mL vs 15.10 ± 4.42 mL, P = 0.005) at the splenic hilum were significantly lower in patients who underwent 3DCT, but there were no significant between-group differences prior to 40 operations. 3DCT is critical for surgical guidance to reduce the risks of splenic LN dissection. This method may be important in safely facilitating laparoscopic spleen-preserving splenic LN dissection.

Spleen-preserving splenic lymph node dissection in radical total gastrectomy.

Radical gastrectomy has been recognized as the standard surgical treatment for advanced gastric cancer, and essentially applied in a wide variety of clinical settings. The thoroughness of lymph node dissection is an important prognostic factor for patients with advanced gastric cancer. Splenic lymph node dissection is required during D2 radical gastrectomy for upper stomach cancer. This is often accompanied by removal of the spleen in the past few decades. A growing number of investigators believe, however, that the spleen plays an important role as an immune organ, and thus they encourage the application of a spleen-preserving method for splenic hilum lymph node dissection.

Station 10 lymph node dissections in laparoscopic-assisted spleen-preserving radical gastrectomy for advanced proximal gastric cancer.

D2 gastric resection has been increasingly recognized as the optimal surgical treatment for advanced gastric cancer. Dissection of the station 10 splenic lymph nodes is required in the treatment of advanced proximal gastric cancer. Based on vascular anatomy and anatomical plane of fascial space, integrated with our experience in station 10 splenic lymph node dissection in open surgery and proven skills of laparoscopic operation, we have successfully mastered the surgical essentials and technical keypoints in laparoscopic-assisted station 10 lymph node dissection.