Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach

Dissection of the extraperigastric lymph nodes is necessary in most submucosal gastric cancers. Laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection via minilaparotomy has been performed, but, to our knowledge, completely laparoscopic extraperigastric lymph node dissection has never been reported. We successfully performed completely laparoscopic distal gastrectomy with extraperigastric lymph node dissection in 12 patients, of whom 11 had early gastric cancer and 1 had malignant lymphoma. This surgery is technically feasible, has an acceptable complication rate, and a curability similar to that with open surgery. Received for publication on June 15, 1999; accepted on Aug. 18, 1999     

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.     

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been developed, and this laparoscopic operation is seen as a technique that will raise quality of life for patients. Previously, we reported this technique, as well as the results of a distal gastrectomy with regional lymph node dissection using hand-assisted laparoscopic surgery (HALS) for gastric cancer located in the middle or lower third of the stomach. This paper describes total or proximal gastrectomy with regional lymph node dissection by HALS on 28 cases of gastric cancer located in the upper portion of the stomach. After the mobilization of stomach and lymph node dissection via HALS, an anastomosis of the esophagus was performed intracorporeally with a conventional circular stapling device (PCEEA), whereas jejunojejunostomy and jejunogastrostomy were carried out extracorporeally with a conventional hand-sewn procedure through a HALS wound. The operation time and the amount of blood loss in all the patients were considered to be satisfactory, and the average number of dissected lymph nodes per patient was similar to that in open surgery. The patients had minimal morbidity and quick recovery after their operation. This technique was thought to be not only less invasive, but also similarly curative compared with open gastrectomy. Received: May 2, 2002 / Accepted: September 12, 2002 Offprint requests to: S. Tanimura     

Quality control of lymph node dissection in the Dutch randomized trial of D1 and D2 lymph node dissection for gastric cancer

Background. Variability among surgeons and reduced protocol adherence threaten the conduct and outcome of surgical multicenter trials. We introduced, in the Dutch Gastric Cancer Trial of D1 and D2 (extended) lymph node dissection for gastric cancer, a novel way of managing instruction, quality control, and evaluation of protocol adherence. Methods. Of 1078 patients entered in the Dutch trial, 711 patients with potentially curative resections were evaluated. Numbers and locations of lymph nodes detected at pathological investigation were compared according to the guidelines of the Japanese Research Society for the Study of Gastric Carcer. Non-compliance indicated inadequate removal of lymph node stations, whereas contamination indicated that lymph nodes were detected outside the intended level of dissection. Protocol adherence during the course of the trial, and the impact on complications, hospital mortality, and survival were evaluated. Results. Major non-compliance was noted in 15.3% of D1 and 25.9% of D2 patients. Contamination was present in 22.9% of D1 and 23.5% of D2 patients, and was limited to one or two lymph node stations only. Intensification of quality control resulted in only a marginal improvement in protocol adherence and in the number of lymph nodes detected. There was no association between protocol adherence and the occurrence of complications or long term survival. Conclusions. Contamination proved an important parameter to substantiate protocol adherence by the surgeon, whereas non-compliance had a multifactorial cause. Non-adherence to the protocol did not lead to increased hospital morbidity and mortality, but also had no impact on long term survival. Received for publication on Aug. 17, 1998; accepted on Nov. 12, 1998     

Lymph node dissection around the splenic artery and hilum in advanced middle third gastric carcinoma

Aim

To evaluate the clinicopathological factors influencing lymph node metastasis around the splenic artery and hilum and the effect of spleen-preserved lymphadenectomy in advanced middle third gastric carcinoma.

Methods

We retrospectively studied 131 patients with advanced middle third gastric carcinoma who had received D2 lymphadenectomy and lymph node dissection around the splenic artery and hilum, from 2000 to 2004. Of these patients, 62 simultaneously underwent splenectomy and 69 underwent spleen-preserved lymphadenectomy.

Results

The incidences of Nos. 10 and 11 lymph node metastases were 21% and 15%, respectively, in advanced middle third gastric carcinoma. A tumor size larger than 5 cm, metastases of Nos. 1 and 7–9 lymph node were independent risk factors for metastasis of No. 10 and/or No. 11 lymph node. The spleen-preserved group had a slightly better survival rate and a relatively lower rate of postoperative complications than the splenectomy group. No. 10 and/or No. 11 lymph node metastasis was an independent prognostic factor, while splenectomy was not.

Conclusions

It is necessary to remove the lymph nodes around the splenic artery and hilum to achieve radical resection in advanced middle third gastric carcinoma patients with risk factors. Our results demonstrate that spleen-preserved lymphadenectomy is a good option for those patients.     

The extent of lymph node dissection for gastric cancer: a critical appraisal

The extent of lymphadenectomy during therapeutic gastrectomy for gastric cancer remains a protracted and controversial issue. While traditionally extended lymphadenectomy is performed in Eastern Asia, limited lymphadenectomy is advocated by most western surgeons. Two large western randomized trials, meta-analyses and a recent systematic review were unable to demonstrate overall benefit from extended lymphadenectomy. In this review, the currently available data on this topic are critically evaluated, while ongoing studies and future perspective are discussed.     

腹腔镜远端胃癌D2根治术在进展期胃癌中的临床应用价值

目的:对比分析完全腹腔镜与开腹远端胃癌D2根治术在进展期胃癌中的应用价值。方法:回顾性分析我院2013年1月至2014年12月收治的接受完全腹腔镜胃癌D2根治手术的进展期胃癌患者40例(腹腔镜组）及接受开腹胃癌D2根治手术的进展期胃癌患者36例（开腹组）的临床资料。对比分析两组的手术时间、术中出血量、术后肛门排气时间、术后住院时间、术后并发症、淋巴结清除数、肿瘤距远近切缘距离。结果:腹腔镜组手术时间明显较开腹组长,但术中出血量、术后肛门排气时间、术后住院时间均少于开腹组,差异均有统计学意义（P<0.05）;两组术后并发症发生率、淋巴结清扫数目及两组远、近切端距肿瘤距离比较,差异无统计学意义（P>0.05）。结论:完全腹腔镜远端胃癌D2根治术治疗进展期胃癌是安全、可行的,可以达到与开腹手术同样的根治效果。     

Laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy for advanced gastric cancer

Received on Aug. 31, 1999; accepted on Jan. 27, 2000     

胃中部癌前哨淋巴结邻近、横向和跳跃性转移的临床分析

Objective: To investigate the distribution pathway of sentinel lymph nodes (SLN) in middle third gastric carci-noma, as the foundation for rational lymphadenectomy. Methods: 52 cases of middle third tumors with solitary lymph nodes from 1852 gastric carcinomas were selected. The locations and histological types of metastatic lymph nodes were analyzed retrospectively. Results: Of 52 solitary node metastases cases, 37 were limited to perigastric nodes (N1), while 15 with skipping metastasis. In the 35 cases with tumor of lesser curvature, there were 17 cases found lymph nodes of the lesser curvature side (No. 3), 5 cases involved lymph nodes of the greater curvature (No. 4), and 8 cases with lymph nodes of the left gastric artery (No. 7). In the 17 cases with tumor of greater curvature, 7 cases spread to No. 4, while 3 metastasized to lymph nodes of the spleen hilum (No. 10). The difference of the histological types in groups N1 and over N1, were not statistically significant (P > 0.05). Conclusion: Adjacent metastasis formed the primary distribution pattern of SLN in middle third gastric carcinoma, transversal and skipping metastases being also notable.     

Extended lymph node dissection in gastrointestinal cancer

We reviewed the literature concerning the effect of extended lymph node dissection on survival in patients with gastrointestinal cancer. Most retrospective and/or prospective nonrandomized comparative studies have claimed that extended lymph node dissection significantly improves survival rate in patients with esophageal cancer, gastric cancer, and colorectal cancer. However, it is difficult to interpret these results since specialized care provided in trials may itself improve survival. In gastric cancer, several prospective randomized trials have failed to demonstrate a survival advantage of extended dissection, while there are few well-done prospective randomized trials in esophageal or colorectal cancer. Therefore, the therapeutic value of extended lymph node dissection remains to be determined in gastrointestinal cancer. Randomized prospective studies within the bounds of the ethical treatment of patients can and should be done. J. Surg. Oncol. 1997;65:57-65. © 1997 Wiley-Liss, Inc.     

On the road to standardization of D2 lymph node dissection in a European population of patients with gastric cancer

The amount of lymph node dissection (LD) required during surgical treatment of gastric cancer surgery has been quite controversial. In the 1970s and 1980s, Japanese surgeons developed a doctrine of aggressive preventive gastric cancer surgery that was based on extended (D2) LD volumes. The West has relatively lower incidence rates of gastric cancer, and in Europe and the United States the most common LD volume was D0-1. This eventually caused a scientific conflict between the Eastern and Western schools of surgical thought: Japanese surgeons determinedly used D2 LD in surgical practice, whereas European surgeons insisted on repetitive clinical trials in the European patient population. Today, however, one can observe the results of this complex evolution of views. The D2 LD is regarded as an unambiguous standard of gastric cancer surgical treatment in specialized European centers. Such a consensus of the Eastern and Western surgical schools became possible due to the longstanding scientific and practical search for methods that would help improve the results of gastric cancer surgeries using evidence-based medicine. Today, we can claim that D2 LD could improve the prognosis in European populations of patients with gastric cancer, but only when the surgical quality of LD execution is adequate.     

全腹腔镜胃癌D2根治术治疗高龄胃癌患者的安全性及生存分析

目的:评价全腹腔镜胃癌D2根治术治疗高龄胃癌患者的安全性及对患者生存的分析。方法:采用回顾性病例对照研究的方法,纳入2012年10月到2016年9月在空军军医大学附属唐都医院胃肠外科行手术治疗的70岁以上胃癌患者108例,根据手术方式差异分为腹腔镜组(n=54)和开腹组(n=54)。收集并分析两组患者的临床病理学资料和术后30天内并发症发生情况及生存状况。结果:两组术前一般特征及术后病理学特征比较未见统计学差异(P>0.05)。与开腹组相比,腹腔镜组术中出血量、围手术期输血更少(69.6±44.6 vs 234.1±110.5,P=0.000;27.8% vs 53.7%,P=0.006),术后首次通气时间早(3.0±1.1 vs 3.8±1.1,P=0.000),且术后住院时间短(7.4±3.4 vs 9.3±4.0,P=0.011)。开腹组术后30天内非腹部并发症发生率更高(29.6% vs 9.3%,P=0.007),但两组腹部并发症(18.5% vs 11.1%,P=0.302)和严重并发症比较(7.4% vs 1.9%,P=0.206)未见统计学差异。腹腔镜组1年、2年及3年累计生存率分别为87.6%、80.1%及58.6%,开腹组1年、2年及3年累计生存率分别为84.8%、68.9%和54.3%,组间比较未见统计学差异(P>0.05)。结论:全腹腔镜D2根治术治疗高龄胃癌患者安全可行,且具有术中出血少、术后首次通气时间早、术后住院时间短的优势,患者术后远期生存情况与传统开腹手术相当。     

Laparoscopic distal gastrectomy with D2 dissection for advanced gastric cancer

The successful application of the laparoscopic distal gastrectomy with D2 dissection for gastric cancer requires adequate understanding of the anatomic characteristics of peripancreatic and intrathecal spaces, the role of pancreas and vascular bifurcation as the surgical landmarks, as well as the variations of gastric vascular anatomy. The standardized surgical procedures based on distribution of regional lymph node should be clarified.Key Words: Gastric cancer, gastrectomy, laparoscopyThe D2 lymph node dissection has been widely applied in traditional open surgery for locally advanced gastric cancer with curative intent (1). However, the feasibility of this procedure in laparoscopic surgery has only been reported in a few conclusive studies around the world (2,3). That is because of the technical threshold for laparoscopic lymph node dissection derived from the perigastric anatomical complexity (4), which is an important factor of the surgical performance and the indicator of prognosis (5). Since the inception of this technique in our department in 2004, we have clinically accumulated proven experience in laparoscopic lymph node dissection for advanced gastric cancer. We believe that it is a combination of proper arrangement of surgical procedures and skilled application of laparoscopic techniques based on complete understanding of the perigastric space (6), surgical landmarks and variations in blood vessels.The key step in the radical treatment of distal gastric cancer lies in the regional lymph node dissection. The extent of D2 dissection for distal gastric cancer defined in the Japanese Gastric Cancer Surgery Guidelines and the Treatment Guideline for Gastric Cancer in Japan (7) involves stations number 1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, 11p, 12a and 14v lymph nodes, while station 14v is excluded in the latest guidelines.According to the distribution of perigastric lymph nodes and the characteristics of laparoscopic techniques, especially the perigastric anatomical features of the gastric body and antrum flipped towards the head under laparoscopy, the scope of D2 lymph nodes can be divided into five regions: (I) lower left region (stations number 4sb and 4d around the left gastroepiploic vessel); (II) lower right region (mainly including station number 6 inferior to the pylorus, and at the root of the right gastroepiploic artery; station number 14v around the superior mesenteric vein in the former version); (III) upper right region (station number 5 superior to the pylorus and number 12a in the hepatoduodenal ligament); (IV) central region posterior to the gastric body (stations number 7, 8a, 9 and 11p surrounding the celiac artery and along its three branches); and (V) hepatogastric region (stations number 1 and 3 along the lesser curvature).Based on the above classification, we have established the standard procedure for laparoscopic D2 lymphadenectomy for distal gastric cancer in our department (Video 1):Open in a separate windowVideo 1Laparoscopic distal gastrectomy with D2 dissection for advanced gastric cancer

1. The left side of the gastrocolic ligament is dissected near the transverse colon through to the lower splenic pole and the pancreatic tail. The key steps include extending and stretching the attachment of the greater omentum to the transverse colon tightly, and then separating from the greater sac into the anterior and posterior space of the transverse mesocolon near splenic flexure, until the lower edge of the tail of the pancreas is exposed;
2. The origin of the left gastroepiploic vessels are ligated. The key steps include extending and stretching the gastrosplenic ligament and fending off the posterior wall of the gastric fundus to expose the splenic hilum and the tail of the pancreas, and thereby the pancreatic capsule can be flipped from the lower edge to the upper edge of its tail. During this process, the left gastroepiploic artery and vein are ligated at the roots near the upper edge of the pancreatic tail, and division is continued from the greater curvature towards distal gastric body. The goal is the dissection of stations number 4sb and 4d lymph nodes;
3. The right side of the gastrocolic ligament is cut near the transverse ligament through to the hepatic flexure, the hepatic flexure of the colon is separated from the duodenal bulb and the surface of the pancreatic head. The key steps include cutting the mesogastrium and the mesocolon along the attachment line between the posterior wall of gastric antrum and mesocolon, and retracting the posterior wall of the sinus to the left anterior direction and the colon and its mesentery to the lower right direction to expose the underlying loose fusion fascial space. Take time to divide the vessels. In the process, the anatomical layer should be fully exposed to separate the right side of the transverse colon and its mesentery from the duodenal descending part, the surface of pancreatic head and the lower edge of pancreatic neck it is attached to. In this way, the gastrocolic trunk (variations may be present in certain patients) formed by the right gastroepiploic vein, right colic vein and their confluence has been completely revealed;
4. The right gastroepiploic vessels are transected. The key steps include fully exposing the lower edge of the pancreatic neck, the pancreatic head and the duodenum, so that the right gastroepiploic vein can be transected above the point where the anterior superior pancreaticoduodenal vein joins. Using the pancreas as a starting point, the pancreatic capsule is lifted and the tissue is separated from the lower edge of the pancreas along the anterior pancreatic space on the surface of the pancreas towards the external superior region, until the origin of the right gastroepiploic artery from the gastroduodenal artery is reached. The right gastroepiploic artery is then cut. The posterior inferior wall of duodenal bulb is denuded near the surface of the pancreatic head along the anterior pancreatic space. The goal is the dissection of stations number 6 lymph nodes;
5. The gastroduodenal artery is exposed and the right gastric artery is transected. The key steps include transecting the duodenum only after dissecting the tissue around the pancreatic head and the upper part of the pancreatic neck from inferior to superior along the gastroduodenal artery in the posterior region of the duodenal bulb on the surface of the pancreas and on the plane of the anterior pancreatic space, in which the bifurcation of the common hepatic artery is exposed at the upper edge of the pancreatic edge for the access to the inner layer of arterial sheath, and the proper hepatic artery is denuded along the adventitia through to hepatoduodenal ligament, where the right gastric artery is cut at its root. The goal is the dissection of stations number 12a and 5 lymph nodes;
6. The three branches of the celiac trunk are divided and the left gastric artery is transected. The key steps include stretching the left gastric vascular pedicle in the gastropancreatic fold and fending the gastric body towards the anterior superior region while pulling the pancreas downwards to fully expose the upper edge of the pancreas for access to the posterior pancreatic space. The three branches of the celiac trunk are denuded here and the left gastric artery is transected at the root. The division is continued upwards in the space until the crura of the diaphragm. The goal is dissection of stations number 7, 8a, 9 and 11p lymph nodes;
7. The hepatogastric ligament and the anterior lobe of the hepatoduodenal ligament are transected close to the lower edge of the liver, and the right side of the cardia and the lesser curvature are fully separated. The key steps include retracting the liver upwards and the gastric downwards to stretch the hepatogastric ligament so that the hepatogastric ligament and the anterior lobe of the hepatoduodenal ligament can be transected and the division can continue towards the right to reach the anterior surface of the proper hepatic artery, which has been separated previously, and towards the left to reach the right side of the cardia, where the lesser curvature is fully divided and denuded. Stations number 1 and 3 lymph nodes are dissected;
8. The distal subtotal gastrectomy, and reconstruction of the digestive tract were completed through minilaparotomy.

The above surgical procedure is designed to accommodate the characteristics of laparoscopic techniques by organizing the sequence of operations from proximal to distal, inferior to superior, and posterior to anterior. More importantly, it has incorporated with our understanding of the anatomical structures under laparoscopy, so that we can make full use of the advantages of visual amplification to identify the relevant anatomical landmarks based on the shape, color and other features, and always proceed at the correct surgical plane while minimizing bleeding.     

Resected gastric cancer with D2 dissection: advances in adjuvant chemoradiotherapy and radiotherapy techniques

Surgery is the main treatment option for locally advanced gastric cancer. D2 dissection has been recommended worldwide as standard lymphadenectomy for resectable gastric cancer. Furthermore, the role of peri- or postoperative chemotherapy for D2-dissected gastric cancer has been established in both Western and European countries. It has been disputed whether adding radiotherapy to chemotherapy could further benefit those patients. Until recently, studies from Korea and China may have made it clear. In North America, however, the INT-0116 trial does not rule out that chemoradiotherapy is effective in patients with D2 dissection, but the ongoing CRITICS trial will, hopefully, clarify this. In addition, literature published in the past decade supports the theory that improved radiotherapy techniques are likely to accurately deliver radiation dose and significantly reduce radiation toxicity. Finally, the status of E2F-1 and HER-2 may be associated with efficacy of radiotherapy based on retrospective studies.     

Robotic curative para-aortic lymph node dissection via INfra-mesocolon for gastric cancer: Robotic CAVING approach

BackgroundTwo major surgical complications in D2 plus para-aortic nodal dissection (PAND) for gastric cancer (GC) have been pancreatic fistula and abdominal abscess [1]. The increase in these complications is due to the excessive mobilization of the pancreas. We previously reported a laparoscopic Curative PAND Via INfra-mesocolon for GC (CAVING), which minimizes mobilization of the pancreas [2]. Robotic surgery may be more comfortable than laparoscopic surgery for the surgeon performing this CAVING approach because robotic surgery has ergonomic benefits and advantages, such as native wrist-like motion and three-dimensional vision. We initially report successful robotic CAVING approach on a 72-year-old male with GC with para-aortic nodal metastases (clinical stage IV) [3].MethodsWe apply PAND after chemotherapy to patients with resectable gastric cancer who are suspected of having metastases to the lymph nodes around the para-aorta. CAVING approach minimizes mobilization of the pancreas and maximizes the view from the caudal side, which has been likened to cave exploration, a specialty of robotic surgery. The caudal side of the root of the superior mesenteric artery (SMA) can be dissected via the infra-pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach.ResultsAfter neoadjuvant chemotherapy using trastuzumab plus S-1 and oxaliplatin, robotic subtotal gastrectomy plus D2 with PAND was performed. The operation took 491 min (105 min for PAND) with no intraoperative complications, and blood loss of 92 ml. Final pathological examination showed complete response, yp stage 0 [3]. The patient was discharged uneventfully on postoperative day 17.ConclusionsRobotic CAVING approach is feasible and safe in advanced GC with para-aortic nodal metastases, but its oncological value has yet to be determined.     

Management of lymph node metastases in breast cancer and gastric cancer

The management of regional lymph node metastases in breast cancer and gastric cancer is reviewed. Regional lymph node metastasis is a critical prognostic factor in these diseases, but there is an apparent discrepancy in the efficacy of regional lymph node dissection between them. A number of prospective randomized clinical trials have demonstrated that regional lymph node dissection improves the regional control of breast cancer, but does not improve the survival. On the other hand, only retrospective or prospective comparative studies have shown that extended lymph node dissection significantly improves the survival in gastric cancer. Although the discrepancy in the regional lymph node dissection between breast and gastric cancers has been explained by differences in their biological behaviors, caution must still be exercised in drawing conclusions from these nonrandomized studies. © 1995 Wiley-Liss, Inc.