Suprapancreatic Node Dissection Research Articles

Pancreas-left gastric artery angle predicts difficulty of suprapancreatic lymph node dissection in gastrectomy for gastric cancer: a cross-sectional study.

Suprapancreatic lymph node dissection is one of the most challenging procedures performed in the treatment of gastric cancer. This study aimed to investigate whether the pancreas-left gastric artery angle (PLA) can be used to predict the difficulty of the procedure. This was a single-center cross-sectional study. Before gastrectomy, the patients were classified according to the size of the PLA into the small PLA (s-PLA; < 30°) and large PLA (l-PLA; ≥ 30°) groups in a surgeon-blinded manner. After gastrectomy, a surgeon evaluated suprapancreatic lymph node dissection as hard, normal, or easy to perform. Seventy-three patients were enrolled in the study. Surgeons evaluated lymph node dissection as hard in 43.8 and 8.7% of patients in the s-PLA and l-PLA groups, respectively (p = 0.002). The time taken for suprapancreatic lymph node dissection was also significantly longer in the s-PLA group than in the l-PLA group (p = 0.040). In patients who underwent laparoscopic gastrectomy, the time for node dissection in the s-PLA group was also significantly longer than that in the s-PLA group (p = 0.021), while there was no difference in those who underwent robotic surgery (p = 0.815). PLA is useful for predicting the degree of difficulty of suprapancreatic lymph node dissection during gastrectomy for gastric cancer.

Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy.

We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery. For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position. We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046). Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.

Safe suprapancreatic lymph node dissection for gastric cancer with ectopic common hepatic artery.

Suprapancreatic lymph node dissection for patients with gastric cancer in whom the common hepatic artery is located neither at the suprapancreatic margin nor in front of the portal vein is a more difficult procedure than when the common hepatic artery is in a more typical position. There is an increased risk of injury to the vessels that need to be preserved and inadequate lymph node dissection. Measures that have been reported for use in this situation are preoperative diagnosis with three-dimensional computed tomography angiography, dissection using the portal vain as a guide, and safe exposure of the portal vein with dissection to preserve the nerves at the suprapancreatic margin and in front of the portal vein. We review the literature and report our experience with a patient whose common hepatic artery was not located in the suprapancreatic margin who safely underwent suprapancreatic lymph node dissection using these methods.

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

Is the ISGPS definition of pancreatic fistula applicable after gastrectomy?

Pancreatic fistula is one of the most common and potentially fatal surgical complications after radical gastrectomy. The purpose of this study was to assess the validity of extrapolating the definition of pancreatic fistula by the International Study Group on Pancreatic Surgery to include situations surrounding gastric cancer surgery. The clinicopathological data of 443 patients who underwent elective gastrectomy with suprapancreatic lymph node dissection (D1+, D2, or D2+ dissection) without pancreatic resection were reviewed. The relationship between postoperative pancreas-related complications (PPRC) and laboratory data, including drain fluid amylase levels on postoperative day 1 (dAmy1) and day 3 (dAmy3), were investigated. Twenty-four patients (5.4%) developed PPRC of ≥ grade II according to Clavien-Dindo classification. Among them, 15 patients had dAmy3 levels ≥ 375IU/L, while all 24 patients had dAmy1 levels ≥ 375IU/L. None of the patients with dAmy1 levels < 375IU/L developed PPRC. The area under the curve of dAmy1 and dAmy3, calculated by drawing receiver operating characteristic curves, were 0.896 and 0.791, respectively. Univariate and multivariate analyses demonstrated that both dAmy1 and dAmy3 were significant predictors of PPRC; however, dAmy1 (p < 0.001) was more strongly correlated with PPRC than dAmy3 (p = 0.049). DAmy1 is more sensitive than dAmy3 as an indicator of pancreatic fistula after gastric cancer surgery.

What is necessary to shorten the operative time in initial introduction of robotic gastrectomy for gastric cancer?

Robotic gastrectomy (RG) is a good alternative to laparoscopic gastrectomy, as it improves treatment outcomes and reduces the burden of technical difficulties; however, prolonged operative time may be a disadvantage. This study aimed to identify measures to shorten the operative time during the initial introduction of RG at an institution. We assessed 33 patients with gastric cancer who underwent radical distal gastrectomy with Billroth-I reconstruction and divided them into three groups: laparoscopic distal gastrectomy (LDG), robotic distal gastrectomy in the early phase (RDG-E), and in the late phase (RDG-L). Operative time, six technical steps, and junk time, including the roll-in/roll-out, docking/undocking, and instrument exchange times, were compared among the groups. The median (range) overall operative times of LDG, RDG-E, and RDG-L were 248 (179-323), 304 (249-383), and 263 (220-367) min, respectively, but no significant differences were observed. For each surgical step of RG, RDG-L in suprapancreatic lymph node dissection was significantly shorter than that in RDG-E. The median (range) junk times of LDG, RDG-E, and RDG-L were 16.7 (12.7-26.4), 48.3 (38.6-67.7), and 42.0 (35.4-49.2) min, respectively. Junk time was significantly longer in RDG-L than in LDG (p=0.003), but not significant between RDG-E and RDG-L. The learning curve effect of overall, console, and junk times were achieved in four cases of RDG. Junk time is a major factor in prolonging RDG operative time. However, to reduce the time after initial introduction, measures to promote robot-specific standardization and more effective use of robotic instruments are essential.

Pancreas-contactless gastrectomy for gastric cancer prevents postoperative inflammation.

Pancreas-related complications after laparoscopic gastrectomy (LG) for gastric cancer can be fatal. We developed a gastrectomy procedure with no pancreas contact to prevent such complications and herein report the surgical outcomes. We retrospectively reviewed 182 consecutive patients with gastric cancer who underwent LG at Kitasato University Hospital from January 2017 to January 2020. These patients were divided into a pancreas-contact group (C group) and pancreas-contactless group (CL group) for comparison of postoperative complications, and inflammatory parameters such as body temperature (BT) and C-reactive protein (CRP). Postoperative complications of CDc grade ≧ IIIa were significantly fewer in the CL group than in the C group [0/76 (0%) vs. 6/106 (5.7%), P = 0.035]. The median drain amylase (drain-AMY) on postoperative day 1 (POD1) was significantly lower in the CL group than in the C group (641 vs. 1162IU/L, P = 0.02), as was BT at POD1 (37.4°C vs. 37.7°C, P = 0.04), the patient group with a BT above 37.5°C at POD3 [5/76 (6.5%) vs. 18/106 (17%), P = 0.037], and those showing a CRP above 20.0mg/dL at POD3 [5/76 (6.5%) vs. 20/106 (19%), P = 0.018]. Our technique to prevent pancreas contact during supra-pancreatic lymph node dissection during LG could minimize the inflammatory response and prevent further postoperative complications. Further large-scale, prospective studies are now required.

Comparison of laparoscopic gastrectomy with 3-D/HD and 2-D/4K camera system for gastric cancer: a prospective randomized control study.

We conducted a prospective clinical control study to identify the best imaging technology among three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4K) technology and confirm their effects on surgical outcomes of laparoscopic gastrectomy for gastric cancer. From April 2018 to August 2019, 50 patients were randomly classified into two groups based on the imaging technology (3-D/HD group = 25, 2-D/4K = 25). After excluding eight patients based on laparoscopic findings, 42 patients were analyzed (3-D/HD group = 21, 2-D/4K = 21). The primary endpoint was the operative time; the secondary endpoints were blood loss, postoperative infectious complications, and postoperative hospital stay. The patients' backgrounds were similar (sex, age, body mass index [BMI], stage, procedure, and extent of lymph node dissection). There were no significant differences in operative time (252 vs. 238min, P = 0.70), total blood loss, postoperative infectious complications, and postoperative hospital stay between the two groups. However, video analysis of surgeries revealed a significantly shortened median operative time (18 vs. 25min, P = 0.04) in the suturing step with 3-D/HD; the median number of camera cleaning procedures during suprapancreatic lymph node dissection was significantly lower with 2-D/4K than with 3-D/HD (n = 4.4 vs. 2.8, P = 0.02). 3-D/HD and 2-D/4K laparoscopic radical gastrectomies provide similar surgical outcomes. However, the 3-D monitor reduces suturing time during reconstruction, while the 4K monitor reduces the number of camera cleaning procedures during lymphadenectomy. Registered in the University Hospital Medical Information Network Clinical Trials Registry (identification number 000029227).

Hybrid Robotic and Laparoscopic Gastrectomy for Gastric Cancer: Comparison with Conventional Laparoscopic Gastrectomy.

PurposeThe benefits of robotic gastrectomy remain controversial. We designed this study to elucidate the advantages of a hybrid robot and laparoscopic gastrectomy over conventional laparoscopic surgery.Materials and MethodsA total of 176 patients who underwent gastrectomy for gastric cancer were included in this study. We compared 88 patients treated with hybrid robotic and laparoscopic gastrectomy (HRLG) and 88 patients who underwent conventional laparoscopic gastrectomy (CLG). In HRLG, suprapancreatic lymph node (LN) dissection was performed in a robotic setting. Clinicopathological characteristics, operative details, and short-term outcomes were analyzed for the patients.ResultsThe number of LNs retrieved from the suprapancreatic area was significantly greater in the HRLG group (11.27±5.46 vs. 9.17±5.19, P=0.010). C-reactive protein levels were greater in the CLG group on both postoperative day (POD) 1 (5.11±2.64 vs. 4.29±2.38, P=0.030) and POD 5 (9.86±6.51 vs. 7.75±5.17, P=0.019). In addition, the neutrophil-to-lymphocyte ratio was significantly greater in the CLG group on both POD 1 (7.44±4.72 vs. 6.16±2.91, P=0.031) and POD 5 (4.87±3.75 vs. 3.81±1.87, P=0.020). Pulmonary complications occurred only in the CLG group (4/88 [4.5%] vs. 0/88 [0%], P=0.043).ConclusionsHRLG is superior to CLG in terms of suprapancreatic LN dissection and postoperative inflammatory response.

Feasibility analysis on membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer

To investigate the feasibility and safety of membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer. The clinical data of 41 patients with advanced distal gastric cancer who underwent laparoscopic gastrectomy using membrane-based right-sided approach for laparoscopic suprapancreatic lymph node dissection at the Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University from January 2016 to January 2018 were retrospectively analyzed. There were 24 males and 17 females with a mean age of 56.8 years and a mean body mass index of 22.6 kg/m². Membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection contained 4 steps briefly: (1) dissection of mesenteria above the head of pancreas: the tri-junction of pancreas-duodenum was cut to expose and identify the logo of Benz;clearance of the membrane of No.5a was performed towards the left, and then expanded to the posterior layer of No.12a. (2) dissection of the V shape dorsal mesogastrium: membrane bridge at splenic artery trunk root was cut; in suprapancreatic space, clearance was performed towards to the left to the middle of the splenic artery trunk and expanded to the posterior Tolds plane upwards to the posterior phrenic angle and retroperitoneal esophagus, then the surrounding tissue of anterior abdominal aorta. (3) dissection of the U shape mesenteria:membrane bridge at common hepatic artery root was cut; mesentery was separated; the left gastric vein was freed and ligated at its root; in posterior pancreatic space, the mesentery of No.7, No.9 and No.8 was dissected in turns; the left gastric artery was high ligated and cut; the portal vein and posterior dorsal mesogastrium Toldt plane was routinely exposed; clearance was performed to right for No.8a and upward to the hepatic portal meeting at posterior mesentery No.12 plane. (4) dissection of the upper triangular area of pylorus: the trigone mesentery was cut along the upper edge of the pylorus; No.12a was swept upward along the gastric ventral mesentery; the upper boundary(No.8a) on the right side of the U-shaped membrane was joined. Intraoperative and postoperative presentations were analyzed. Laparoscopic gastrectomy for advanced distal gastric cancer with membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection was successfully carried out in all the 41 patients. Distal gastric mesenteria en bloc resection was successfully performed. The operation time was (145.2±25.4) minutes and intraoperative blood loss was (53.3±18.3) ml without massive bleeding and severe complication. Number of lymph nodes dissected was 41.1±6.4, and number of suprapancreatic lymph node dissected was 23.3±3.7 without residual cancer at cut margin by pathology. Postoperative drainage volume was (65.8±21.7) ml; time to withdraw of catheter was (7.0±1.7) days; time to fluid intake was (3.5±1.8) days; postoperative hospital stay was (10.4±2.8) days; time to postoperative anal exhaust was (3.3±1.1) days. No complications, such as chyle leakage, postoperative massive bleeding, anastomotic leakage, abdominal cavity infection or gastroplegia occurred within 30 days after surgery. Membrane-based right-sided approach of laparoscopic suprapancreatic lymph node dissection for advanced distal gastric cancer can achieve en bloc resection and conform to the radical principle of oncology, and is safe and feasible.

The anatomical configuration of the splenic artery influences suprapancreatic lymph node dissection in laparoscopic gastrectomy: analysis using a 3D volume rendering program.

The aim of this study is to categorize splenic artery and vein configurations, and examine their influence on suprapancreatic lymph node (LN) dissection in laparoscopic gastrectomy. Digital Imaging and Communications in Medicine images from 169 advanced cancer patients who underwent laparoscopic gastrectomy with D2 dissection were used to reconstruct perigastric vessels in 3D using a volume rendering program (VP Planning®). Splenic artery and vein configuration were classified depending on the relative position of their lowest part in regard to the pancreas. Number of resected LNs and surgical outcomes were analyzed. The splenic artery was categorized as superficial (36.7%), middle (49.1%), and concealed (14.2%), and the splenic vein was categorized as superior (6.5%), middle (42.0%), and inferior to the pancreas (51.5%). The number of resected LNs around the proximal half of the splenic artery (#11p) and the proportion of the splenic vein located inferiorly to the pancreas were significantly higher in splenic arteries of concealed types. LN metastasis of station #7 was an independent risk factor of LN metastasis in station #11p (p = 0.010). Concealed types showed a tendency towards longer operating times, more blood loss, longer hospital stays, and a higher postoperative morbidity. Concealed types of splenic artery are associated with an increased difficulty in the dissection of LN station #11p around the splenic artery. A 3D volume rendering program is a useful tool to rapidly and intuitively identify individual anatomical variations, to plan a tailored surgical strategy, and to predict potential challenges.

"Pancreas-Compressionless Gastrectomy": A Novel Laparoscopic Approach for Suprapancreatic Lymph Node Dissection.

In radical operations for gastric cancer, a balance between the quality of lymph node dissection and safety of surgery must be ensured. During suprapancreatic lymphadenectomy in laparoscopic gastrectomy (LG), an adequate operative field should be safely and effectively established to reduce pancreas-related complications. We present a novel approach that avoids direct compression of the pancreas in LG and describe the surgical outcomes of this method. We historically compressed the pancreas during suprapancreatic lymph node dissection in LG to obtain an adequate operative field but have since modified our operative technique. In our new method introduced in March 2016, the operative field is established by pulling and controlling the connective tissues along the inferior border of the pancreas and the nerves along the common hepatic and splenic arteries, instead of directly compressing the pancreas itself. We compared 51 patients in the compression group (January 2015-February 2016) and 45 patients in the compressionless group (March 2016-January 2017) in terms of surgical outcomes, including the amylase concentration in the drainage fluid and postoperative complications. The amylase concentrations in the compressionless group were significantly lower on postoperative days 1 and 3 (p<0.001 and p=0.013, respectively) compared with the compression group. The rates of severe postoperative pancreatic fistula and intra-abdominal infectious complications decreased from 11.8 to 2.2% (p=0.116) and from 17.6 and 2.2% (p=0.018), respectively. Our approach, termed "pancreas-compressionless gastrectomy," can be considered a safe and useful method to prevent postoperative infectious complications in LG.

Long-term outcomes of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG0703)

Laparoscopic gastrectomy has become a common surgical treatment for gastric cancer in eastern Asian countries. However, a large-scale prospective study to investigate the benefit of laparoscopy-assisted distal gastrectomy (LADG) regarding long-term outcomes has never been reported. We have already reported the short-term outcomes of this study. Here we report long-term outcomes as the secondary endpoints of this study after a 5-year follow-up period. This study comprised patients with clinical stage I gastric cancer who were able to undergo a distal gastrectomy. LADG with D1 plus suprapancreatic lymph node dissection was performed by credentialed gastric surgeons who had each conducted at least 30 LADG and 30 open gastrectomy procedures. The primary endpoint was the proportion of patients who developed either anastomotic leakage or pancreatic fistula. The secondary endpoints included overall survival and relapse-free survival. From November 2007 to September 2008, 176 eligible patients were enrolled, comprising 140 patients with pathological stage IA disease, 23 patients with pathological stage IB disease, 9 patients with pathological stage II disease, and 4 patients with pathological stage IIIA disease. No patients had recurrent disease, and three of the patients died within the follow-up period. The 5-year overall survival was 98.2% (95% confidence interval 94.4-99.4%) and the 5-year relapse-free survival was 98.2% (95% confidence interval 94.4-99.4%). The long-term outcomes of stage I gastric cancer patients undergoing LADG seem comparable to those of patients undergoing an open procedure, although this result should be confirmed by a randomized control trial. We have already completed accrual of 921 patients for a multicenter randomized phase III trial (JCOG0912) to confirm the noninferiority of LADG compared with open gastrectomy in terms of relapse-free survival.

Strategy of laparoscopic suprapancreatic lymph node dissection for advanced gastric cancer

The lymph nodes (LNs) that distribute along the celiac artery (CA) system in the suprapancreatic area include LNs around the root of the left gastric vessels (No. 7, No. 8a, No. 9 and No. 11p) and the right gastric vessels (No. 5 and No. 12a). Due to the high rate of LNs metastasis and the various vascular anatomies in this area, the suprapancreatic LN dissection is a crucial and demanding procedure for radical resection in the treatment of patients with advanced gastric cancer (AGC). Laparoscopic gastrectomy with D2 LN dissection has not yet been widely adopted for advanced stages because it is technically complicated. The initial segment of the splenic artery (SpA) approach is recommended as the ideal approach for laparoscopic suprapancreatic LN dissection in AGC.

The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy.

Postoperative pancreatic fistula (POPF) is one of the major complications after laparoscopic gastrectomy (LG). We investigated the impact of the anatomical location of the pancreas, especially in relation to the suprapancreatic lymph nodes, on the incidence of POPF after LG. We retrospectively reviewed the preoperative computed tomography (CT) images of 246 patients who underwent LG with the suprapancreatic lymph node dissection between November 2008 and November 2015. The length between the levels of the pancreatic body surface and the root of the common hepatic artery (LPC) was measured on a CT image with an axial view. A receiver operating characteristics (ROC) curve analysis was performed to determine the cutoff LPC value. A multivariate analysis was performed to determine the predictive factors for POPF. POPF occurred in 11 patients (4.5%). The median LPC was significantly longer in the patients with POPF than in those without (26mm vs. 21mm, p=0.026). The ROC curve analysis revealed that the optimal cutoff LPC value for predicting POPF was 25mm. The POPF rate was significantly higher in the long LPC group than in the short LPC group (10 vs. 1.3%, p=0.002). A multivariate analysis demonstrated that a long LPC (p=0.018) and dissection of the lymph nodes along the distal splenic artery (p=0.042) were independent predictors of POPF. The amylase level in the drainage fluid on postoperative day 1 was significantly higher in the long LPC group than in the short LPC group. The LPC is a simple and reliable predictor of POPF after LG. Surgeons should take the anatomical location of the pancreas into consideration when performing LG with suprapancreatic lymph node dissection.

Strategy of laparoscopic suprapancreatic lymph node dissection for advanced gastric cancer

Strategy of laparoscopic suprapancreatic lymph node dissection for advanced gastric cancer

OPTIMIZATION OF THE METHOD OF SUPRAPANCREATIC LYMPH NODE DISSECTION IN LAPAROSCOPY-ASSISTED GASTRECTOMY (IN THE FINAL ANALYSIS OF INTERNATIONAL CONFERENCES «SCHOOL OF STOMACH SURGERY»)

The article analyzed the methods of suprapancretic lymph node dissection in laparoscopic gastrectomy which were devel- oped and applied in Japan. The authors described the details of operation technique. There were noted the advantages of medial approach for suprapancreatic lymph node dissection.

Laparoscopic Suprapancreatic Lymph Node Dissection for Advanced Gastric Cancer Using a Left-Sided Approach.

We developed a novel procedure for laparoscopic suprapancreatic lymph node (LN) dissection, which is compulsory and quite difficult for patients with advanced gastric cancer.1 (-) 3 METHODS: We dissected suprapancreatic LNs from the left to the right side. The No. 11p LNs were dissected first, followed by the No. 9, 7, and 8a LNs. Dissection of the No. 5 and 12a LNs was completed last. The above procedure was performed on 814 consecutive patients with stage cT2-3 disease. Mean operation time was 186.9 ± 56.4 min (range 80-480 min), mean blood loss was 76.6 ± 106.8 ml (range 3-500 ml), and mean times to first flatus, fluid diet, and soft diet were 3.7 ± 1.2 days (range 1-9 days), 5.2 ± 1.7 days (range 2-14 days), and 8.3 ± 2.2 days (range 5-20 days), respectively. A mean 34.5 ± 12.9 LNs (range 22-103) were retrieved, including a mean 12.4 ± 5.7 (range 0-35) suprapancreatic area LNs. Overall postoperative morbidity rate was 14.7 % (120/814), including three cases of pancreatic fistula. All of these postoperative complications were successfully treated by conservative methods. At a median follow-up of 27 months (range 1-63), cumulative 3-year overall survival was 59.2 %. Laparoscopic suprapancreatic LN dissection using a left-sided approach could be safely achieved and is more convenient for advanced gastric cancer.

Long-term survival results of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: A multicenter phase II trial (JCOG 0703).

113 Background: Laparoscopic gastrectomy has been a common tool for gastric cancer patients in eastern Asian countries. A large-scale prospective study with a sample size sufficient to investigate the benefit of laparoscopy-assisted distal gastrectomy (LADG) has never been reported. We conducted a multi-center phase II trial (JCOG0703) to evaluate the safety of LADG with nodal dissection for clinical stage I gastric cancer patients. A short-term outcome including postoperative complications of LADG as a result of this study was already reported and a following multi-center phase III trials (JCOG0912) to confirm the non-inferiority of LADG compared with open gastrectomy in terms of overall survival (OS) was already started. Long-term outcomes as the secondary endpoints of this study are reported here after 5-year follow up period. Methods: The subjects of this study comprised patients with clinical stage I gastric cancer that were able to undergo a distal gastrectomy. LADG with D1 plus suprapancreatic lymph node dissection was performed by credentialed gastric surgeons who experienced &gt;=30 LADG and &gt;=30 open gasterctomy. The primary endpoint was the proportion of patients who developed either anastomotic leakage or a pancreatic fistula. The secondary endpoints included surgical morbidity, short-term clinical outcome, OS, and relapse free survival (RFS). Results: Between November 2007 and September 2008, 176 eligible patients were enrolled. 140/23/9/4 patients had pStage IA/IB/II/IIIA disease respectively. No patients had recurrence. 3 patients died without recurrence. 5-year OS was 98.2% (95%CI, 94.7% to 99.4%). 5-year RFS was 98.2% (95%CI, 94.4% to 99.4%). Conclusions: The long-term outcome of LADG for Stage I gastric cancer patients seem comparable to those of open procedures. However, this result should be confirmed by a randomized control trial. We have just finished an accrual of 921 patients for a multi-center phase III trial (JCOG0912) to confirm the non-inferiority of LADG compared with open gastrectomy in terms of OS. Clinical trial information: UMIN000000874.

Clinical significance of medial approach for suprapancreatic lymph node dissection during laparoscopic gastric cancer surgery

Suprapancreatic lymph node dissection is critical for gastric cancer surgery. Beginning in 2010, a medial approach was adopted for suprapancreatic lymph node dissection during laparoscopic gastrectomy for distal gastric cancer in our institution. The aim of this study was to compare surgical outcomes of the medial approach and conventional approach in laparoscopic gastric surgery. Between January 2007 and December 2012, a total of 100 patients with clinical T1 or T2 tumors underwent laparoscopic distal gastrectomy involving suprapancreatic lymph node dissection by the medial approach (n = 44) and conventional approach (n = 56) with curative intent. The comparison was based on clinicopathological characteristics and surgical outcome. The laparoscopic procedure was not converted to laparotomy in any patient. The patients' demographics and tumor characteristics did not show any statistically significant difference, except for tumor location. In the conventional approach group, the tumors were at a higher position (p = 0.037) and more frequently received Roux-en-Y reconstruction (p < 0.001). Intracorporeal anastomosis was significantly more common in the medial approach group (p < 0.001). Compared with the conventional approach, the medial approach was associated with significantly less operative blood loss (p < 0.001), more retrieved suprapancreatic lymph nodes (p = 0.019), and a shorter hospital stay (p = 0.018). The rates of complications were comparable between the two groups. This study suggests that the medial approach to suprapancreatic lymph node dissection seems to be convenient and useful in laparoscopic gastric cancer surgery.