Laparoscopic splenic hilum lymph node dissection for advanced proximal gastric cancer:A modified approach for pancreasand spleen-preserving total gastrectomy

AIM:To investigate the feasibility and optimal approach for laparoscopic pancreasand spleen-preserving splenic hilum lymph node dissection in advanced proximal gastric cancer.METHODS:Between August 2009 and August 2012,12 patients with advanced proximal gastric cancer treated in Nanfang Hospital,Southern Medical University,Guangzhou,China were enrolled and subsequently underwent laparoscopic total gastrectomy with pancreasand spleen-preserving splenic hilum lymph node(LN)dissection.The clinicopathological characteristics,surgical outcomes,postoperative course and followup data of these patients were retrospectively collected and analyzed in the study.RESULTS:Based on our anatomical understanding of peripancreatic structures,we combined the characteristics of laparoscopic surgery and developed a modified approach(combined supraand infra-pancreatic approaches)for laparoscopic pancreasand spleenpreserving splenic hilum LN dissection.Surgery was completed in all 12 patients laparoscopically without conversion.Only one patient experienced intraoperative bleeding when dissecting LNs along the splenic artery and was handled with laparoscopic hemostasis.The mean operating time was 268.4 min and mean number of retrieved splenic hilum LNs was 4.8.One patient had splenic hilum LN metastasis(8.3%).Neither postoperative morbidity nor mortality was observed.Peritoneal metastasis occurred in one patient and none of the other patients died or experienced recurrent disease during the follow-up period.CONCLUSION:Laparoscopic total gastrectomy with pancreasand spleen-preserving splenic hilum LN dissection using the modified approach for advanced proximal gastric cancer could be safely achieved.     

Indications for paraaortic lymph node dissection in gastric cancer patients with paraaortic lymph node involvement

BACKGROUND/AIMS: The surgical results for stage IVb gastric cancer remain very poor. The purpose of the current study is to reveal indications for paraaortic lymph node dissection in stage IVb gastric cancer patients with paraaortic lymph node involvement by analyzing prognostic factors for 3-year survival of stage IVb gastric cancer patients followed by curative B resection. METHODOLOGY: The 3-year survival in clinicopathologic variables were compared by univariate analysis. Using Cox proportional hazards regression model, independent prognostic factors were identified from 11 variables. RESULTS: Overall 5-year survival in stage IVb was 26.5%; mean survival was 19 months. Using univariate analysis, p53 expression significantly influenced 3-year survival. Using Cox proportional hazards regression model, the number of total positive lymph nodes, the number of positive paraaortic lymph nodes, and p53 expression were independent prognostic factors. CONCLUSIONS: In stage IVb, paraaortic lymph node dissection should be indicated in patients with < or = 10 total positive lymph nodes, and < or = 3 positive paraaortic lymph nodes or p53 expression < or = 50%. This indication can be applied according to the preoperative imaging, the staining of p53 by endoscopic biopsy specimens and the intraoperative microscopic evaluation of dissected lymph nodes.     

胃癌淋巴结转移规律及其清扫范围探讨

目的　探讨胃癌淋巴结转移规律及其清扫范围。方法　对188例接受手术治疗的胃癌患者,于术中用美蓝-胃癌单克隆抗体(MAb)3H11标记淋巴结,并对染色淋巴结进行清扫,术后统计切除标本的淋巴结转移情况及病理特征。结果 188例胃癌患者的淋巴结转移率为62.8％(118／188)。胃上1／3(U区)、中1／3(M区)、下1／3(L区)及全胃癌患者的淋巴结转移率分别为61.9％、60.0％、57.5％及95.0％。早、中、晚期胃癌患者淋巴结转移率依次呈递增趋势,P<0.05。浸润型(Ⅲ、Ⅳ型)转移率(76.1％)明显高于局限型(Ⅰ、Ⅱ型)(44.3％),P<0.05。肿瘤直径≤4cm、-7cm和≥8cm者的淋巴结转移率依次增加,差异有显著性,P均<0.01。结论 胃癌淋巴结转移率较高。尤其晚期、浸润型及直径>4cm的胃癌,其淋巴结转移率更高,术中应按胃癌的临床病理分期、部位、大小及Borrman分型,选择淋巴结清扫范围。如果根据术中美蓝-MAb3H11标记结果确定淋巴清扫范围将更准确可靠。     

Effectiveness of paraaortic lymph node dissection for advanced gastric cancer

BACKGROUND/AIMS: To evaluate the effectiveness of paraaortic lymph node dissection (D4) for gastric cancer from the viewpoint of long-term results. METHODOLOGY: Among 879 patients who underwent gastrectomy for advanced gastric cancer, 130 patients who underwent D4 lymphadenectomy were evaluated in relation to clinicopathological findings and long-term results. RESULTS: The frequency of histological paraaortic lymph node metastasis (n4) was 23.1% (30/130). The cumulative 5-year survival rate of 30 n4 patients with D4 lymphadenectomy was 16.7%, which was higher than that (4.2%) of n4 patients without D4 (sampling of paraaortic lymph nodes). Among n4 patients with D4 lymphadenectomy, the cumulative survival rate in 8 patients with 1-2 paraaortic lymph nodes involved (5-year survival rate: 50%) was significantly higher than that in 21 patients with 3 or more paraaortic lymph nodes involved (5-year survival rate: 4.6%). According to the intra-operative macroscopic extent of lymph node metastasis, the cumulative survival rate of patients who were judged as N2 was higher than that of patients judged as N4. CONCLUSIONS: Paraaortic lymph node dissection for advanced gastric cancer was effective, especially when it was done prophylactically and when the number of paraaortic lymph node metastases were 2 or less.     

Prophylactic lymph node dissection for early gastric cancer invading submucosa

BACKGROUND/AIMS: Prophylactic lymph node dissection for gastric cancer patients was considered to prolong survival time and D2 lymph node dissection was a standard treatment for early gastric cancer invading submucosa without lymph node metastasis. We investigated the possibility of minimizing the extent of prophylactic lymph node dissection for early gastric cancer invading submucosa if there was no evidence of lymph node metastasis. METHODOLOGY: We analyzed data on 404 patients with early gastric cancer invading the submucosa who underwent gastrectomy from 1979 to 1998 in the National Kyushu Medical Center, Fukuoka, Japan. The postoperative survival rate of patients with standard D2 dissection was compared with cases of those with limited D2 dissection which was defined as confined as D2 dissection dissections No.7 (lymph nodes were those along the left gastric artery), No.8 (lymph nodes along the anterosuperior common hepatic artery) and No.9 (lymph nodes along the celiac artery). RESULTS: Of the 404 patients, 52 and 17 had lymph node metastasis in group 1 and group 2 nodes, respectively. Of 17 patients with lymph node metastasis in group 2, 14 (82.4%) had metastasis confined to No.7, 8 and 9 of group 2 nodes. The 5-year survival rate of patients with submucosal cancer without lymph node metastasis was 94.4% after limited D2 dissection and 97.3% after standard D2 dissection, respectively. CONCLUSIONS: The appropriate prophylactic lymph node dissection for early gastric cancer invading the submucosa without lymph node metastasis was considered to be minimized to limited D2 dissection.     

Paraaortic lymph node dissection for gastric cancer in 244 consecutive cases

BACKGROUND/AIMS: More than 20% of patients with advanced gastric cancer show paraaortic lymph node metastasis. However, whether extensive paraaortic lymphadenectomy is beneficial remains controversial. We performed a prospective study of paraaortic lymphadenectomy for patients with advanced gastric cancer. METHODOLOGY: From January 1991 to March 2004, 244 consecutive patients with advanced gastric cancer underwent gastrectomy with paraaortic lymphadenectomy with curative intent. The patients were divided into 3 groups according to the period: Group 1 (1991-1995), Group 2 (1996-1999), and Group 3 (2000-2004). RESULTS: Overall mortality rate was 2.4%, and it fell rapidly from 7.1% in Group 1 to 0% in Group 3. Postoperative complications occurred in 35.6%. High age and postoperative complications were significant predictive factors for operative death. Preoperative comorbidity, positive distal margin, and pancreatectomy were significant predictive factors of postoperative complications. Depth of cancer invasion was correlated with paraaortic node metastasis. Ten patients with paraaortic node metastases survived for more than 5 years. Operative curability and postoperative complications were significant prognostic factors for patients who underwent this procedure. CONCLUSIONS: Paraaortic lymph node dissection for gastric cancer should be performed in patients with tumors deeper than the serosa. Pancreatectomy should be avoided, with careful management required in cases of unavoidable pancreatectomy.     

Segmental gastrectomy with radical lymph node dissection for early gastric cancer

AIM: To describe a new surgical technique and evaluate the early results of segmental gastrectomy (SG) with modified D2 lymph node (LN) dissection for early gastric cancer (EGC). METHODS: Fourteen patients with EGC underwent SG with modified D2 dissection from 2006 to 2008. Their operative results and postoperative courses were compared with those of 17 patients who had distal gastrectomy (DG) for EGC during the same period. RESULTS: Operating time, blood loss, and hospital stay were similar between the 2 g...     

Significance of para-aortic lymph node dissection in advanced gastric cancer.

BACKGROUND/AIMS: Since surgical results in advanced gastric cancer remain poor and para-aortic lymph node dissection may contribute to survival, it is useful to determine the significance of para-aortic lymph node dissection. METHODOLOGY: Para-aortic lymph node dissection was provisionally indicated for patients with invasion depth deeper than the subserosal layer. Clinicopathologic variables were retrospectively analyzed using univariate analysis and multivariate analysis to predict para-aortic lymph node metastasis. Similarly, they were analyzed using univariate analysis and the Cox's proportional hazards regression model to estimate the prognostic factor in 120 patients who underwent para-aortic lymph node dissection. Surgical results and post-operative complications were compared between para-aortic lymph node dissection and D2 dissection. RESULTS: Univariate analysis revealed that the mean diameter, the degree of lymph node metastasis, and the invasion depth were significant predictors of para-aortic lymph node metastasis. Multivariate analysis showed that n2 was the only independent predictive factor as to para-aortic lymph node metastasis. Univariate analysis revealed tumor site, tumor diameter, lymph node metastasis, number of positive lymph nodes, INF, and stage were significantly associated with 5-year survival. The Cox's proportional hazards regression model showed that the number of positive lymph nodes and the number of positive para-aortic lymph nodes were independent prognostic factors. Patients with < or = 10 positive lymph nodes in any stage or < or = 3 positive para-aortic lymph nodes in stage IVb had significantly better surgical results. Surgical results for patients who underwent para-aortic lymph node dissection with n2 or invasion depth deeper than the exposed serosa were significantly higher than those in D2. As to post-operative complications, pancreatic fistula and respiratory complications were significantly frequent after para-aortic lymph node dissection. CONCLUSIONS: n2 is helpful in predicting para-aortic lymph node metastasis. Whereas, post-operative morbidity such as pancreatic fistula and respiratory complications after para-aortic lymph node dissection were significantly higher, they were controllable. Para-aortic lymph node dissection should be indicated in advanced gastric cancer patients in which lymph node metastasis is over n2 or invasion depth is deeper than the exposed serosa. But the number of positive para-aortic lymph nodes must be less than three.     

Vascularizing lymph node dissection for advanced gastric cancer: A single-institution experience

AIM: To compare the short- and long-term outcomes of vascularizing lymph node dissection(VLND) and nonvascularizing lymph node dissection(NVLND) from a single institution.METHODS: Data of 315 patients with advanced gastric cancer who underwent standard D2 lymphadenectomy with curative intent was collected between January 1994 and December 2006. One hundred and fifty-two patients received VLND while 163 patients received NVLND. Short- and long-term clinical outcomes were compared between the two groups. RESULTS: The median followed-up time was 82 mo. The rate of postoperative complications in the VLND group was 13.2%, while that in the NVLND group was 11.7%(P = 0.686). The overall 5-year survival rate was 64% in the VLND group and 59% in the NVLND group(P = 0.047). When subgroup analyses were performed according to Bormann type, type of differentiation and lymph node status, survival benefit was demonstrated in patients with Bormann type Ⅲ or Ⅳ(59% vs 50%, P = 0.032), undifferentiated type(63% vs 49%, P = 0.021) or presence of lymph node metastasis(53% vs 38%, P = 0.010) in the VLND group. CONCLUSION: D2 VLND in advanced gastric cancer treatment allows survival benefit with acceptable morbidity and mortality. VLND for patients with potentially curable advanced gastric cancer is feasible and safe when performed by a well-trained surgical team.     

Lateral lymph node dissection for lower rectal cancer

BACKGROUND/AIMS: This study was conducted to evaluate the effects of lateral lymph node dissection (LLD) on overall survival, disease-free survival, and local recurrence for the patients with lower rectal cancer. METHODOLOGY: From 1990 through 2000, 169 consecutive patients with T2 (TNM classification) or more advanced, extended lower rectal cancer (located below the peritoneal reflection) underwent curative resection at Kanagawa Cancer Center were reviewed. One hundred and forty-three patients who underwent LLD and the 26 patients who did not were entered in this study. RESULTS: Cox's multivariate regression analysis showed T stage (TMN classification), N stage (TNM classification), and LLD were found to be significantly related to the rates of both cumulative survival and disease-free survival. That mean LLD was identified as a significant prognostic factor. But disease-free survival did not differ significantly between the patients who underwent LLD and those who did not undergo LLD in stage I, II, or III disease (p = 0.3681, p = 0.1815, and p = 0.0896, respectively). The local recurrence rate was similar in patients who received LLD (17.5 percent) and in those who did not receive LLD (23.1 percent; p = 0.498). But 7 patients with lateral lymph node metastasis (33.3 percent) remained disease free. And these patients had local lateral lymph node metastasis and benefited from LLD. CONCLUSIONS: LLD can substantially improve outcomes in selected patients at high risk for lateral lymph node metastasis. A randomized controlled clinical study is necessary to clarify the role of LLD in the treatment of rectal cancer.     

Sentinel lymph node concept in gastric cancer with solitary lymph node metastasis

AIM: To study the localization of the solitary metastases in relation to the primary gastric cancers and the feasibility of sentinel lymph node (SLN) concept in gastric cancer. METHODS: Eighty-six patients with gastric cancer, who had only one lymph node involved, were regarded retrospectively as patients with a possible sentinel node metastasis, and the distribution of these nodes were assessed. Thirteen cases with jumping metastases were further studied and followed up. RESULTS: The single nodal metastasis was found in the nearest perigastric nodal area in 65.1% (56/86) of the cases and in 19.8% (17/86) of the cases in a fairly remote perigastric area. Out of 19 middle-third gastric cancers,3 tumors at the lesser or greater curvatures had transverse metastases. There were also 15.1% (13/86) of patients with a jumping metastasis to N2-N3 nodes without N1 involved. Among them, the depth of invasion was mucosal (M) in 1 patient, submucosal (SM) in 2, proper-muscular (MP) in 4, subserosal (SS) in 5, and serosa-exposed (SE) in 1. Five of these patients died of gastric cancer recurrence at the time of this report within 3 years aftersurgery. CONCLUSION: These results suggest that nodal metastases occur in a random and multidirectional process in gastric cancer and that not every first metastatic node is located in the perigastric region near the primary tumor. The rate of “jumping metastasis” in gastric cancer is much higher than expected, which suggests that the blind examination of the nodal area close to the primary tumor can not be a reliable method to detect the SLN and that a extended lymph node dissection (ELND) should be performed if the preoperative examination indicates submucosal invasion.     

Effect of extensive lymph node dissection on the survival of early gastric cancer.

BACKGROUND/AIMS: A retrospective analysis of 628 cases of early gastric cancer was performed to evaluate prognostic significance of extensive lymph node dissection. METHODOLOGY: The patients were assigned to either D0/D1 (n=177) group or D2/D3 group (n=451) according to the extent of lymph node dissection and the survival of the two groups was compared. RESULTS: The survival rate of D2/D3 group was significantly higher than D0/D1 group in the case of both including and excluding unrelated cause of death (p<0.0001 and p<0.005, respectively). CONCLUSIONS: Though early gastric cancer is excellent prognostic disease, very few numbers of patients with recurrence really remain. Our data show extensive lymph node dissection was effective to prolong the survival of patients with early gastric cancer.     

Laparoscopy-assisted lateral pelvic lymph node dissection for advanced rectal cancer

In Japan, there has been no indication of laparoscopic surgery for advanced lower rectal cancer because of the problem about the treatment of lateral pelvic lymph node metastasis. We report a new technique which allows lateral pelvic lymph node dissection like in open surgery for advanced rectal cancer. After laparoscopic total mesorectal excision for rectal cancer, a surgical incision of approximately 8 cm is placed in the supra-pubic area. Then, the latero-vesical area of the retroperitoneum, latero-vesical space is dissected bluntly with forceps. The external iliac artery and vein are taped and lymph node dissection is performed. As the external iliac vein is pulled internally, fatty tissue including lymph nodes in the obturator space is separated from the psoas major muscle. After completing of such a procedure, the obturator nerve is indentified in the fatty tissue with surrounding lymph nodes. As the external iliac vein is pulled laterally, fatty tissue including lymph nodes in the oburator space is dissected by fat aspiration procedure (FAP) using a suction tip. FAP is helpful to confirm the vascular system, by which the obturator space is skeletonized and anatomical structures are identified clearly.     

Long-term survival is improved by an extended lymph node dissection in potentially curable gastric cancer

BACKGROUND/AIMS: This study was planned to investigate the therapeutic value of performing an extended lymphadenectomy in potentially curable gastric cancer. METHODOLOGY: A prospective gastric cancer database was used. In total 114 gastric cancer patients (85 male, 29 female) who underwent a gastrectomy for curative intent from 1992 through 1999 were included to this study. Morbidity and mortality, survival rates and factors affecting survival were evaluated. RESULTS: Sixty-six (58%) patients had limited (D1) and 48 (42%) patients had extended (D2) gastric resections. The operative mortality rates were 12% and 8% and the postoperative complication rates were 33% and 25% in the D1 and D2 lymphadenectomy patients, respectively. The mean follow-up period was 34 (range: 8-94) months. The overall mean survival was 32 months (25 months in D1 group, 46 months in D2 group) (P < 0.05). The duration of symptoms, the presence of postoperative complications, the extent of lymphadenectomy, the operative curability and the site of the tumor were all found to be independent prognostic factors based on a multivariate analysis. CONCLUSIONS: This study demonstrates that an extended lymph node dissection improves long-term survival without increasing postoperative morbidity and mortality in patients with potentially curable gastric cancer.     

Rationale for extent of lymph node dissection for right colon cancer

PURPOSE: The extent of lymph node dissection optimal for the prognosis of right colon cancer is investigated. METHODS: Between 1946 and 1991, 275 patients had curative operation for right colon cancer. A retrospective analysis of rate and degree of lymph node metastasis was performed in each of the 275 patients, and survival rate was estimated in 197 patients who could be followed over a period of three years or more. RESULTS: In most of the curative operative cases of right colon cancer, metastasis to epicolic and paracolic nodes was restricted up to 10 cm proximal or distal to the tumor margin, and metastasis in the central direction was restricted up to main nodes. When cancer metastasized to infrapyloric lymph nodes, dissection of the nodes resulted in a higher rate of long-term prognosis. The five-year cumulative survival rates showed no statistically significant difference between any two of the N0 to N3 lymph node metastasis groups. CONCLUSION: The dissection procedure for right colon cancer involved removal of 10 cm of normal bowel both proximal and distal to the lesion and, in the central direction, dissection of regional lymph nodes along the main trunk artery up to main nodes,i.e., nodes situated anterior to the surgical trunk, which was confirmed to have a therapeutically satisfactory benefit. Infrapyloric lymph nodes must be dissected when metastasis to the nodes is suspected. In cases of cecal or ascending colon cancer in which the middle colic artery is no longer the main trunk artery, a right hemicolectomy with resection of only the right branch of the middle colic artery will usually suffice.     

Predictive factors for lymph node metastasis in early gastric cancer

AIM: To analyze the predictive factors for lymph node metastasis (LNM) in early gastric cancer (EGC). METHODS: Data from patients surgically treated for gastric cancers between January 1994 and December 2007 were retrospectively collected. Clinicopathological factors were analyzed to identify predictive factors for LNM. RESULTS: Of the 2936 patients who underwent gas-trectomy and lymph node dissection, 556 were diag-nosed with EGC and included in this study. Among these, 4.1% of patients had mucosal tumors ...     

早期胃癌淋巴结转移规律的临床病理因素研究

目的探讨早期胃癌临床病理因素与淋巴结转移规律的相关性。方法回顾性分析2012年1月—2018年12月期间在陆军军医大学第一附属医院经胃镜下活检病理确诊,并实施外科根治手术的早期胃癌病例,采用单因素分析及Logistic回归多因素分析相关临床病理因素与各组淋巴结转移的关系。结果164例早期癌患者中,34例出现转移。单因素分析显示病理分化程度、浸润深度、肿瘤最大径、脉管浸润与早期胃癌淋巴结转移相关(P均<0.05)。Logistic回归多因素分析结果显示:肿瘤最大径>2 cm(OR=3.2,95%CI:2.305~4.187)、浸润至黏膜下层(OR=2.5,95%CI:2.091~3.859)、病理分化不良(OR=1.7,95%CI:1.029~2.933)及脉管侵犯(OR=2.1,95%CI:1.817~3.176)是早期胃癌淋巴结转移的独立影响因素(P均<0.05)。上部癌中转移率较高的淋巴结依次是第1组(66.7%)、第3组(33.3%);中部癌中转移率较高的淋巴结依次是第3组(75.0%)、第4组(25.0%);下部癌中转移率较高的淋巴结依次是第6组(33.3%)、第3组(25.9%)、第4组(25.9%)及第7组(14.8%)。从转移站别看,分化良好且肿瘤直径≤2 cm的黏膜内早期癌,各部位癌第1站均未见淋巴结转移。结论早期胃癌肿瘤最大径>2 cm﹑浸润至黏膜下层﹑病理分化程度低及脉管受侵犯是淋巴结转移的危险因素。上、中、下部癌均有其各自的高发区域,早期胃癌的淋巴结胃周转移基本符合由近及远的规律。     

Solitary lymph node metastasis of gastric cancer as a basis for sentinel lymph node biopsy

BACKGROUND/AIMS: In order to examine the biology of sentinel lymph node of stomach cancer, we investigated solitary lymph node metastases that were hypothesized to represent sentinel lymph node. METHODOLOGY: In the 4,620 primary gastric cancers between 1964 and 1997, 1271 cases with a localized tumor were selected and the localization of the solitary metastases in relation to the primary tumors were studied. RESULTS: Of the 130 tumors with a single basin metastasis, only 71% of the tumors in the upper third, 75% of the middle and 80% of the lower involved the node basins in the close vicinity. In the anterior wall and the greater curvature the rates of adjacent metastasis were more than 90%, while in the posterior wall and the lesser curvature they were 76% and 43%, respectively. Metastases of the remaining cases were found at more distant basins. CONCLUSIONS: In stomach cancer sensitivity of sentinel lymph node biopsy would be very low by the exploration of the adjacent basin especially for the lesions in the lesser curvature and posterior wall.