A case of advanced gastric cancer with tumor embolus in the portal vein successfully treated with S-1 and CDDP therapy

A 50-year-old man with advanced gastric cancer and a tumor embolus in the portal vein was referred to our hospital. We diagnosed the tumor as cStage III B (cT3, cN2, cH0, P0, M0) gastric cancer, and selected neoadjuvant S-1 (80 mg/m2) and CDDP (60 mg/m2) therapy for him. After 2 courses of chemotherapy, the embolus in the portal vein disappeared. After additional chemotherapy, the primary tumor and regional lymph node revealed a partial response (PR), and judging from the results from the barium meal study, upper GI endoscopic findings and CT scan, a total gastrectomy with lymph node dissection was performed.     

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.Key Words: Gastric cancer, D2 radical resection, lymph node dissection, splenic hilumAccording to the Japanese Gastric Cancer Treatment Guidelines, the splenic hilar lymph nodes (No. 10) are the station 2 lymph nodes in gastric cancer of the upper and middle stomach (cardia, fundus, and gastric body). In a typical D2 gastrectomy, this group must be dissected. In order to achieve a thorough dissection, there has been controversy as to whether the spleen is preserved or removed.In April 2013, a 51-year-old female patient visited our department due to “upper abdominal swelling with nausea and vomiting for more than a month”. Gastroscopy and endoscopic ultrasound showed a mucosal nodular bulge at the gastric body and the fundus. The diagnosis was stomach cancer. Pathology suggested diffuse-type, poor cohesive cancer (gastric body), HP (–). Abdominal CT showed that the tumor was located at the junction of the gastric body and fundus, invading through the serosa and into the pancreatic capsule, with lymph node metastases. The cTNM staging was T4aN2M0. With adequate preoperative preparation, we performed spleen-preserving D2 radical total gastrectomy (Video 1) for the patient.Open in a separate windowVideo 1Spleen-preserving splenic lymph node dissection in radical total gastrectomyFollowing the routine procedures for D2 resection, we removed the anterior lobe of transverse mesocolon, and separated the pancreatic capsule. After the Kocher incision was made, we found lymph nodes around the inferior vena cava, so dissection of the station 16 was conducted, followed by dissection of the station 13 posterior to the pancreatic head.The gastrosplenic ligament was cut, and the spleen hilum was resected. The station 10 lymph nodes were dissected. It is much easier to resect the spleen than preserving it. Iatrogenic splenic injury can often occur during gastrectomy, especially when dissecting the lymph nodes around the splenic artery, fat and connective tissue around the spleen, and denuding the splenic artery, which is associated with a high risk of injury to the spleen and blood vessels. In this case, when major bleeding was present due to splenic vascular injury, we use 5-0 proline suture to close the vascular wounds effectively. The lesion was transected 3 cm above the cardia, and the specimen was removed. Roux-en-y esophagojejunal anastomosis was conducted.Ikeguchi and coworkers (1) reported that splenectomy was needed in advanced gastric cancer complicated by serosal invasion and local lymph node metastases. The rate of metastases to splenic hilar lymph nodes was 20.19%, and failure to dissect the lymph nodes was associated with poor prognosis, while the prognosis in patients undergoing successful dissection was comparable to those without metastasis. Zhang et al. (2) studied 108 cases with gastric cancer and the cardia and fundus to compare the prognoses with and without splenectomy. The 5-year survival rates were 38.17% in the spleen-preserving group, and 16.19% in the splenectomy group (P=0.1008), suggesting a worse prognosis in those undergoing splenectomy. Therefore, the spleen should be preserved as long as it is unaffected by the lesion.The length of operation was 153 minutes, with an estimated blood volume of 80 mL. According to the staging criteria described in the seventh edition of AJCC, the postoperative pathologic stage was T4aN3M0 (IIIc). Liquid diet was started from the 4th day after surgery, and the patient was discharged on the 8th day. No evidence of complications or tumor recurrence and metastasis has been found in the ongoing follow-up.     

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.     

Survival benefit of “D2-plus” gastrectomy in gastric cancer patients with duodenal invasion

Background

The optimal extent of lymph node (LN) dissection for gastric cancer with duodenal invasion is yet to be clarified. This study sought to evaluate the significance of gastrectomy with D2-plus lymphadenectomy including posterior LNs along the common hepatic artery (no. 8p), hepatoduodenal ligament LNs along the bile duct (no. 12b) and those behind the portal vein (no. 12p), LNs on the posterior surface of the pancreatic head (no. 13), LNs along the superior mesenteric vein (no. 14v) and para-aortic LNs around the left renal vein (nos. 16a2 and 16b1) dissection.

Methods

Patients with gastric cancer with duodenal invasion undergoing R0 gastrectomy from January 2000 to December 2015 were enrolled. The therapeutic value index (TVI) of each LN dissection was calculated by multiplying the incidence of metastasis to each LN station by the 5-year overall survival (OS) rate of the patients with metastasis to the station.

Results

In total, 117 patients were eligible. The 5-year OS rates (and TVI) of the patients with metastasis to LNs were 40.4% (7.4) in no. 12b, 25.4% (6.8) in no. 13, 32.0% (6.1) in no. 14v, 50.0% (13.0) in no. 16a2 and 40.0% (10.0) in no. 16b1. None of the patients with metastasis in no. 8p or no. 12p survived 5 years or longer.

Conclusion

In a potentially curative gastrectomy for gastric cancer with duodenal invasion, there may be some survival benefit in dissection of nos. 12b, 13, 14v, 16a2 and 16b1 LNs, while no benefit was seen in dissection of nos. 8p or 12p LNs.

     

A case of malignant lymphoma of the stomach in which preoperative chemotherapy provided a complete response

We have encountered a case of malignant lymphoma of the stomach in which a complete remission was confirmed in a resected specimen after chemotherapy. A 75-year-old woman complained of vomiting blood. A biopsy from gastric endoscopy indicated malignant lymphoma of diffuse large B-cell type. The patient was assumed to be inoperable due to enlargement of the tumor and lymph node metastasis, and THP-COP chemotherapy was carried out. After four courses of the THP-COP regimen, endoscopic examination revealed a significant tumor reduction. Total gastrectomy and splenectomy with lymph node dissection (D2) were performed after chemotherapy. No tumor cells were detected in any sections of the specimen or regional lymph nodes.     

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

Background

To 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).

Portomesenteric vein thrombosis after gastric surgery

Background

Postoperative portomesenteric venous thrombosis (PMVT) is a rare but potentially serious complication of gastric surgery. This study analyzed the incidence, characteristics, risk factors, and outcomes of PMVT following gastric surgery.

Methods

Medical records of patients who underwent gastric surgery between January 2007 and December 2012 were reviewed retrospectively. The risk factors of PMVT were analyzed by a logistic regression analysis with control group matched 1:4 by age, sex, and cancer stage and by a Poisson regression analysis with unmatched control group. The resolution rate of PMVT in 12 months was compared between the treatment group and the nontreatment group.

Results

The total incidence of PMVT after gastric surgery was 0.67 % (31/4611). Most (54.84 %) PMVT cases were detected within 1 month postoperatively. No accompanying deep vein thrombosis (DVT) was noted. Multivariate comparison with 1:4 matched control showed that combined splenectomy, synchronous malignancy, and intra-abdominal complication were independent risk factors. Advanced stage, combined splenectomy, and synchronous malignancy were independent risk factors in Poisson regression analysis using unmatched controls. The resolution rate of PMVT was not different from patients treated with anticoagulation (n = 6) or antiplatelet therapy (n = 1) and were not significantly different with those of the untreated group [85.7 % (6/7) vs. 82.3 % (14/17), p = 0.935] during 1-year follow up.

Conclusions

PMVT after gastric surgery was associated with advanced cancer stage, combined splenectomy, and synchronous malignancy, but it was not related to laparoscopy or DVT. Significant differences in the natural course of PMVT were not found between the treatment group and observation group.

     

A case of advanced gastric cancer with peritoneal dissemination responding to S-1/CDDP neoadjuvant chemotherapy

The patient was a 72-year-old male diagnosed with type III poorly-differentiated adenocarcinoma in the lesser curvature by gastric fiberscopy. An abdominal computed tomography (CT) scan showed the thickness of the gastric wall and the enlarged lymph node around the stomach and laparoscopic examination revealed peritoneal dissemination. The patient received neoadjuvant combined chemotherapy with S-1 and CDDP. S-1 (100 mg/day) was orally administered for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (100 mg/body) was administered by intravenous drip on day 8. After the third course, significant tumor reduction was obtained. Total gastrectomy, splenectomy and D2 nodal dissection were performed. Peritoneal dissemination disappeared, and the histological diagnosis revealed complete disappearance of cancer cells in the ascites and no metastasis in all lymph nodes. The patient has now been in good health with no recurrence for 22 months after surgery. The combined neoadjuvant chemotherapy with S-1 and CDDP can be an effective treatment of choice for advanced gastric carcinoma with peritoneal dissemination.     

Significance of the lymph nodes in the 7th station in rational dissection for metastasis of distal gastric cancer with different T categories

Objective： To determine the clinicopathological characteristics, and evaluate the appropriate extent of lymph node dissection in distal gastric cancer patients with comparable T category. Methods： A retrospective study was conducted on 570 distal gastric cancer patients, who underwent gastric resection with D2 nodal dissection, which was performed by the same surgical team from January 1997 to January 2011. We compared the differences in lymph node metastasis rates and metastatic lymph node ratios between different T categories. Additionally, we investigated the impact of lymph node metastasis in the 7th station on survival rate of distal gastric cancer patients with the same TNM staging. Results： Among the 570 patients, the overall lymph node metastasis rate of advanced distal gastric cancer was 78.1%, and the metastatic lymph node ratio was 27%. The lymph node metastasis rate in the 7th station was similar to that of perigastric lymph nodes. There was no statistical significance in patients with the same TNM stage （stage Ⅱ and Ⅲ）, irrespective of the metastatic status in the 7th station. Conclusions： Our results suggest that to a certain extent, it is reasonable to include lymph nodes in the 7th station in the D 1 lymph node dissection.     

Laparoscopic pancreas- and spleen-preserving D2 lymph node dissection in advanced (cT2) upper-third gastric cancer

BACKGROUND AND OBJECTIVES: Although the laparoscopic assisted total gastrectomy (LATG) has been performed in upper gastric cancer, dissection of lymph nodes No. 10 and 11d without resection of the distal pancreas and the spleen has been hard to accomplish, because of the possibilities of injury to splenic vessels and parenchyma of the spleen or pancreas. Herein, we present successful results in laparoscopic pancreas- and spleen-preserving D2 lymph node dissection in advanced upper gastric cancer. METHODS: Between March 2004 and May 2007, 18 clinical T2 patients who underwent LATG with D2 lymph node dissection for upper gastric cancer were enrolled. RESULTS: We used the technique of encircling and pulling the splenic artery with umbilical tape and that helped us complete dissection of lymph nodes No. 10 and 11d without distal pancreatectomy or splenectomy. The mean operative time was 370 min without any perioperative complications or conversion to an open procedure. CONCLUSIONS: Laparoscopic extended lymph node dissection without pancreatectomy or splenectomy can be adapted to the patients with clinical T2 upper gastric cancer. The techniques like taping of the splenic artery can be a useful tip for surgeons who wish to perform laparoscopic complete D2 lymph node dissection in advanced upper gastric cancer.     

A case of S-1-resistant recurrent gastric cancer successfully treated with weekly administration of paclitaxel

We report a case of recurrent gastric cancer with peritoneal dissemination and paraaortic lymph node metastases, successfully treated with weekly administration of paclitaxel. The patient was a 63-year-old man who underwent distal gastrectomy with lymph node dissection for advanced gastric cancer in February 2005. After the operation, adjuvant chemotherapy with S-1 was started and continued. He complained of abdominal distention, anorexia and nausea in April 2006. Therefore, paclitaxel (PTX) was administered at a dose of 60 mg/m(2)/day for 3 weeks followed by a week rest. Clinical symptoms were relieved, and abdominal X-ray findings showing intestinal obstruction disappeared after 2 courses. CT scan revealed metastatic lymph nodes were reduced after 3 courses. Grade 1 peripheral neuropathy and grade 2 leukocytopenia were noted, but no serious adverse reaction appeared. Weekly administration of PTX may be a promising regimen as second-line chemotherapy for S-1-resistant recurrent gastric cancer.     

Treatment selection for gastric cancer with portal hypertension: clinical management

Background

Treatment for gastric cancer with portal hypertension must consider the eradication of the tumor and the change of hemodynamics in portal hypertension (PHT). Few reports have described the surgical procedures and postoperative complications of surgery for gastric cancer associated with PHT.

Methods

The clinical data of 22 patients with PHT undergoing curative surgery for gastric cancer during 5 years were retrospectively analyzed. For 12 patients classified in Child’s class A, D2 lymph node (LN) dissection was performed, and 10 patients classified into Child’s class B were treated with D1 LN dissection. Surgical treatment included total gastrectomy combined with pericardial devascularization, distal subtotal gastrectomy, distal subtotal gastrectomy combined with splenectomy, and distal subtotal gastrectomy combined with pericardial devascularization with posterior gastric artery and left inferior phrenic artery preserved. A liver biopsy was analyzed in all patients.

Results

Postoperative complications developed in 50 % (11/22 patients) and the mortality rate was 9 % (2/22). The rate of postoperative ascites in patients with Child’s class A was much lower than in those with Child’s class B (P < 0.05). “Operation time,” “volume of hemorrhage,” “platelet count,” and “treatment of PHT” are all risk factors of liver function deterioration. However, there was no significant difference in liver function deterioration rate between patients with Child’s class A and Child’s class B (P > 0.05). The occurrence rate of complications in patients with PHT was much higher compared to those without with PHT (P < 0.05).

Conclusions

Individualized selection of surgical approaches is crucial for treatment of gastric carcinoma accompanied by PHT. Surgical treatment should be based on preoperative TNM stage, liver function, and degree of PHT.     

Gastric carcinoid tumors with aggressive lymphovascular invasion and lymph node metastasis

We report a patient with multiple gastric carcinoid tumors without hypergastrinemia. An abdominal computed tomography (CT) scan was performed in a 66-year-old Japanese man who had abdominal discomfort. An abnormal, round, 2.5cm mass close to the lesser curvature of the stomach was detected. Multiple small gastric carcinoid tumors were also detected by endoscopy. A total gastrectomy with lymph node dissection was performed after it was determined that the round mass was a lymph node metastasis of carcinoid tumor. Further pathological investigation of the surgical specimen revealed multiple gastric carcinoid tumors with severe lymphovascular invasion. The carcinoid tumors in the present patient were not related to hypergastrinemia. These lesions could not be grouped as any of the three types of gastric carcinoid tumors in the recent classification. Furthermore, as a simple distal gastrectomy is the standard treatment for multiple carcinoid tumors of the stomach, we recommend that a precise histopathological evaluation should be performed before an appropriate curative surgical treatment is selected.     

Effectiveness of doxifluridine (5'-DFUR)/docetaxel against advanced/recurrent gastric cancer showing resistance to various anticancer drug regimens.

A 58-year-old man was diagnosed as having type 3 gastric cancer (poorly differentiated adenocarcinoma). He underwent total gastrectomy with splenectomy, as well as D3 dissection, and received postoperative chemotherapy combining oral uracil and futrafur (UFT) with cisplatin (CDDP), but results showed recurrence of multiple abdominal lymph node metastases around the aorta. He therefore received various anticancer drug regimens (irinotecan [CPT-11]/CDDP; 1 M tegafur-0.4 M gimeracil-1 M oteracil potassium [TS-1], methotrexate (MTX)/5-fluorouracil); however, final results showed growth of lymph node metastasis and simultaneous worsening of his general condition. The patient then received combined administration of doxifluridine (5'-DFUR)/docetaxel (5'-DFUR, 1000 mg/body [666.7 mg/m(2)], given by consecutive daily administration, orally, for days 1-14; and docetaxel, 80 mg/body [60 mg/m(2)], on day 8, by venous drip, every 3 weeks). Three courses of this regimen resulted in approximately 90% reduction of the abdominal lymph node size, disappearance of the right cervical lymph node metastasis, reductions of the levels of two tumor markers (carcinoembryonic antigen [CEA] and carbohydrate antigen [CA]19-9), and improvement of his general condition. In total, seven courses of the regimen were carried out. The patient died on day 298 after starting this combined regimen and showed a response period of 126 days. The primary toxicity identified was neutropenia (grade 4), as well as other low-grade (grade 1, 2) hematological and nonhematological toxicities. In the field of gastric cancer treatment, especially for patients showing multiple resistance to anticancer drugs, an effective therapy is critically needed.     

A systematic review of spleen and pancreas preservation in extended lymphadenectomy for gastric cancer

Background

The overall prognosis and survival of patients with advanced gastric cancer are generally poor. Extended lymphadenectomy is recommended for patients with advanced gastric cancer; however, splenectomy and distal pancreatectomy performed with an extended lymph node dissection may be associated with increased morbidity and mortality.

Method

Electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1 January 1998 to 31 December 2009. Studies on gastric carcinoma investigating extended lymphadenectomy with splenectomy and/or pancreaticosplenectomy that reported data on surgical outcomes or survival were selected.

Results

Forty studies were included in this review. Decreased complication rates were demonstrated with spleen preservation in two prospective studies and three retrospective studies, and with pancreas preservation in five retrospective studies. No randomized controlled trial showed survival benefit or detriment for preservation of spleen or pancreas in extended lymphadenectomy. Improved survival was demonstrated with spleen preservation in two prospective and eight retrospective studies, and with pancreas preservation in one prospective and four retrospective studies.

Conclusions

Preservation of the spleen and pancreas during extended lymphadenectomy for gastric cancer decreases complications with no clear evidence of improvement or detriment to overall survival.

     

D2 plus radical resection combined with perioperative chemotherapy for advanced gastric cancer with pyloric obstruction

A patient with advanced gastric cancer complicated with pyloric obstruction was treated using D2 + radical resection combined with perioperative chemotherapy, and had satisfying outcomes. The perioperative chemotherapy regimen was Taxol and S1 (tegafur, gimeracil, and oteracil). Three cycles of neoadjuvant chemotherapy were delivered before surgery, and three cycles of adjuvant therapy after surgery. PR was achieved after chemotherapy. D2 + dissection of stations 8p, 12b, 12p, 13 and 14v lymph nodes was performed on September 10, 2012.Key Words: Advanced gastric cancer, pyloric obstruction, D2 + lymph node dissection, perioperative chemotherapyD2 lymph node dissection has become the standard surgical approach for advanced gastric cancer (1-3). However, in the case of lower stomach cancer complicated by pyloric obstruction, the lymphatic drainage and pattern of metastases are different due to the anatomical restriction, and a higher rate of metastases into the hepatoduodenal ligament and the posterior area of the pancreatic head are often seen (4). Perioperative chemotherapy can significantly improve the survival of patients (5,6). This video describes the procedure of D2 + radical resection combined with perioperative chemotherapy for a patient with lower gastric cancer complicated by pyloric obstruction, as follows. The treatment was successful.A 53-year-old woman was admitted on June 3, 2012 due to “upper abdominal fullness with dull pain for 3 months, with intermittent nausea and vomiting for 10 days.” Gastroscopy suggested a huge, solid ulcer at the antrum close to the pylorus, involving the pylorus and resulting in pyloric stenosis. Endoscopic biopsies suggested poorly differentiated adenocarcinoma of the gastric antrum. CT: huge tumor in the antrum, considered as gastric antral carcinoma, infiltrating through the serosa with metastases to multiple lymph nodes surrounding the stomach and superior area of the pancreas. Tumor markers: CA199 402.15 U/mL. Clinical diagnoses: cancer of the gastric antrum involving the pylorus, complicated by partial pyloric obstruction, staging T4aN2M0. Three cycles of preoperative chemotherapy were delivered on June 9, July 2 and July 28, 2012, using the regimen of Taxol 240 mg/dL and S1 60 mg bid po d1-14, repeated for three weeks. After the chemotherapy courses, the CT scan suggested significantly reduced volume of the antral tumor, and lymph nodes around the stomach and the pancreas were not as obvious as before. PR was achieved following chemotherapy. Radical gastrectomy with D2 + lymph dissection was performed under general anesthesia for the distal gastric cancer resection on September 10, 2012.During the surgery (Video 1), the patient was placed in a supine position. Following general anesthesia, a middle upper abdominal incision of 3 cm was made from the xiphoid down to the umbilicus. The wound was well protected, and abdominal exploration was conducted to confirm that there were no peritoneal and liver metastases. A piece of gauze was gently padded posterior to the pancreas to prevent tearing. Kocher’s separation: the peritoneum was divided at the lateral border of the duodenum and the duodenum was freed. The incision continued downwards to the hepatic flexure of the colon to expand the surgical field. Sharp dissection was performed along the posterior region of the duodenum and the pancreas to reveal the inferior vena cava, the beginning part of the left renal vein, and the right ovarian vein. The anterior lobe of the transverse mesocolon and the pancreatic capsule were completely separated to the hepatic flexure of colon on the right side and to the lower pole of the spleen on the left side, so that the omental bursa could be completely removed.Open in a separate windowVideo 1D2 plus radical resection combined with perioperative chemotherapy for advanced gastric cancer with pyloric obstructionThe lymph nodes in the inferior area to the pylorus were dissected along the course of the middle colon vein towards its root, and the superior mesenteric vein (SMV) anatomy, as well as the gastrointestinal vein trunk and accessory right colic vein, was freed from the inferior region of the pancreatic neck. The station 14v lymph nodes were dissected around the SMV. The separation continued towards the pylorus to free the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein. The structure of the gastrointestinal vein trunk formed jointly by the right gastroepiploic vein, anterior superior pancreaticoduodenal vein and accessory right colic vein was clearly visible. The right gastroepiploic vein was ligated and cut before its junction with the pancreaticoduodenal vein. The gastroduodenal artery was isolated at the junction of the duodenum and the pancreatic head. The separation continued towards the pylorus to free the right gastroepiploic artery, which was then ligated and cut at the root. The inferior pyloric artery from the gastroduodenal artery was then separated. The inferior pyloric artery was ligated and cut, and the lower edge of the duodenum and the pylorus was completely denuded to for the complete dissection of the station number 6 lymph nodes.The left gastroepiploic artery was separated, ligated and cut from the lower pole of the spleen, followed by dissection of the station number 4sb lymph nodes. The fascia over the upper edge of the pancreas was opened to reveal the splenic artery, for the dissection of the station number 11p lymph nodes. It should be noted that there were several curves along the splenic artery to the splenic hilum, especially the largest one of 3 to 4 cm to the root, which was hidden behind the pancreas with lymph nodes inside that should not be omitted. After dissection of the station number 11p lymph nodes, the separation was continued towards the left diaphragmatic muscle to dissect the lymph nodes to the left of the celiac artery.The stomach was flipped down to the inferior side, and the anterior peritoneum of the hepatoduodenal ligament was opened. The proper hepatic artery and the right gastric artery were divided, and the latter was ligated and cut at the root. The station number 5 lymph nodes were dissected. The supraduodenal vessels were transected, and the upper edge of the duodenal bulb was completely denuded. The duodenum was transected 3 cm below the pylorus (with a Tyco 60 mm linear stapler), with the duodenal stumps closed with reinforced stitching.Denuding and dissection of the hepatoduodenal ligament: the lymph nodes surrounding the proper hepatic artery (number 12a) were dissected, and the artery was retracted with retraction bands to divide the left and right hepatic arteries. Since the hepatic branch and plexus of the vagus nerve were completely removed, there would be an extremely high risk of cholecystitis and gallstones after surgery, so gallbladder was removed as well. The common bile duct was separated, and the surrounding lymph nodes were dissected (number 12b). Caution was made to protect the supplying vessels to the common bile duct. The portal vein to the posterior area was separated, and the surrounding lymph nodes (number 12p) were dissected.Dissection of lymph nodes posterior to the pancreatic head (number 13): these lymph nodes often attached closely to the pancreatic head in a flat shape. An electrocautery was required in the sharp separation, with caution to avoid the retroduodenal artery. In some cases, these lymph nodes would be closely adhesive to that small artery, so it could be separated first to prevent bleeding. The stations number 13, 12b and 12p were pushed to the right through the Winslow’s hole and retracted from the left side of the hepatoduodenal ligament. These lymph nodes were then separated along the common hepatic artery and the upper edge of the splenic vein towards the celiac trunk. The stations number 8a and 8p were dissected en bloc. The coronary vein was divided from the posterior region close to the root of the common hepatic artery, and then ligated and transected. The lymph nodes to the right of the celiac artery (number 9) were then dissected along the plane of the right crus of the diaphragm. The left gastric artery was denuded from the periphery, ligated and cut at the root, and station number 7 lymph nodes were dissected. The separation was continued along the right crus of the diaphragm towards the cardia to dissect the lymph nodes on its right and posterior side (number 1). The greater and lesser curvatures of the stomach were denuded using Ligasure (Tyco, energy platform), and the stations number 3 and 4d lymph nodes were dissected. The stomach was then transected 5 cm from the upper edge of the tumor with a Tyco 100 mm linear stapler, and 2/3 of the distal stomach was removed together with the lymph nodes.Reconstruction: Billroth II gastrojejunostomy (Tyco 25 mm circular stapler) was performed in combination with Braun’s anastomosis.The whole operation lasted 2 hours and 50 minutes, with intraoperative blood loss of 100 mL and no blood transfusion. The patient was able to ambulate four days after surgery. Liquid diet was prescribed on the 5th day, and semi-liquid diet was prescribed on the 7th day. The patient was discharged eight days after surgery. Postoperative pathology: chronic inflammation with ulceration in the mucosa of the posterior wall of the antrum, with a small amount of degenerated adenocarcinoma with interstitial fibrosis in the mucosal and serosal layers; lymph nodes 0/36 (subcomplete remission).Three cycles of adjuvant chemotherapy were delivered on October 26, November 22 and December 16, 2012 after surgery, using the regimen of Taxol 240 mg/dL and S1 60 mg bid po d1-14, repeated for three weeks. No sign of recurrence was observed during the nine months of postoperative follow-up. The tumor marker CA199 has remained at a low level.     

Skeletonizing en-bloc gastrectomy for adenocarcinoma in Caucasian patients

Background The prognostic relevance of a Japanese-like lymphadenectomy for gastric adenocarcinoma in Caucasian patients is not well established.Methods Skeletonizing en-bloc gastrectomy (SEBG) (including removal of the stomach, excision of the potentially involved lymph nodes, and skeletonization of the main anatomic structures in the upper abdominal floor) was attempted in 216 consecutive patients with adenocarcinoma of the stomach. Gastrectomy was total in 143 patients, and subtotal in 72. One debilitated patient had a wedge resection of the gastric wall.Results SEBG was performed in 160 patients (74%), whereas 56 patients (26%) had a palliative gastrectomy (PG) without lymph node dissection. The feasibility rate of SEBG was influenced significantly (P 0.001) by the depth of wall penetration, so that it dropped from 97% in T1 tumors to 91%, 65%, and 17% in those classified T2, T3, and T4, respectively. The 5-year survival rate, including postoperative mortality (0.9%) was 48% for the whole series, 66% after SEBG, and 0% after PG. The 5-year survival rate after SEBG was related significantly to the lymph node involvement (N0, 75% vs N+, 54%; P = 0.008) and to its magnitude (N+, 5 metastatic lymph nodes, 62% versus N+, 5 metastatic lymph nodes, 39%; P = 0.018). Considering the fact that 9 patients died of an unrelated cause before the postoperative term of 5 years, the cancer-related survival rate 5 years after SEBG was 71% in the whole group of 160 patients. This survival rate was 82% in patients with normal lymph nodes, versus 56% in those with metastatic nodes (P 0.001).Conclusions SEBG was feasible in three-quarters of a po-pulation of Caucasian patients operated on for gastric adenocarcinoma. SEBG provided a chance for a longterm favorable outcome in three-quarters of patients with normal lymph nodes and in more than half of those with metastatic lymph nodes. These results are similar to those achieved after radical gastrectomy in Japanese patients with gastric adenocarcinoma.     

Lymph node dissection for gastric cancer: Establishment of D2 and the current position of splenectomy in Europe and Japan

Two European phase III trials comparing D1 and D2 demonstrated that D2 did not improve the overall survival and was associated with a high mortality related to splenectomy. However, a long-term follow-up study showed that the gastric cancer-related death rate was significantly higher in D1 than D2. Based on these findings, the standard surgery in Europe became D2 without pancreatico-splenectomy to prevent mortality. In contrast, the JCOG9501 phase III comparing D2 and D2 plus para-aortic nodal dissection did not showed a survival efficacy of extended lymphadenectomy, but the mortality rate was quite low in both surgeries. Subsequently, the JCOG0110 phase III study comparing D2 and spleen-preserving D2 for upper gastric cancer not invading the greater curvature clearly showed the non-inferiority of spleen preservation. Thus, spleen-preserving D2 was made the standard surgery for these tumors in Japan. However, splenectomy is often selected for complete dissection of the splenic-hilar nodes, a frequent metastatic site for upper gastric tumors invading the greater curvature. Recently, an approach involving splenic hilar nodal dissection without splenectomy has been developed.     

Laparoscopic-assisted radical gastrectomy for distal gastric cancer

A 48-year-old female patient was diagnosed with a superficial depressed type early gastric cancer (type IIc) of 1.0 cm at the gastric angle as indicated by gastroscopy. Laparoscopic-assisted greater omentum-preserving D2 radical gastrectomy was performed in combination with Billroth I reconstruction under general anesthesia for the distal gastric cancer on April 5, 2013. The postoperative recovery was satisfying without complications. The patient was discharged seven days after surgery.Key Words: Early gastric cancer, gastrectomy, laparoscopic-assisted, D2 lymph node dissectionAs a novel minimally invasive surgical technique, laparoscopic radical gastrectomy is associated with such advantages as less injury, reduced postoperative pain, lower impact on immune function, rapid recovery of gastrointestinal function, and short hospital stay. In 1997, Goh and coworkers conducted D2 radical gastrectomy for advanced gastric cancer under laparoscope, which demonstrated the safety and feasibility in terms of the technique. In their reviews, Topal (1) and Huscher (2) also confirmed the above conclusion, and they suggested that the long-term survival outcomes of laparoscopic-assisted radical gastrectomy were similar to those of open surgery. Laparoscopic-assisted radical gastrectomy has now been recognized for treating gastric cancer with an invasion depth of T2 or less, without evidence of lymph node metastases in preoperative examination (3). On April 5, 2013, we conducted laparoscopic-assisted gastrectomy for a patient with early gastric cancer (type IIc). The postoperative recovery was satisfying. The details are as follows:A 48-year-old woman was admitted to our hospital due to “upper abdominal dull pain with acid reflux for more than a month”. Gastroscopy suggested a superficial depressed type early gastric cancer of 1.0 cm at the gastric angle. Biopsies indicated adenocarcinoma at the gastric angle. Endoscopic ultrasound indicated disordered structure of the submucosal layer of the gastric lesion at the gastric angle. CT scan suggested slightly thickened gastric wall at the gastric angle, without enlargement of lymph nodes around the stomach or liver metastasis. Preoperative staging: T1bN0M0. On April 5, 2013, laparoscopic-assisted D2 radical gastrectomy was conducted under general anesthesia for the distal gastric cancer.During the surgery (Video 1), the patient was placed in a supine position with legs apart. Following general anesthesia, CO₂ pneumoperitoneum was established at 12 cm water column. Laparoscopic exploration showed no peritoneal dissemination or liver metastasis nodules, so the surgeons decided to perform D2 radical resection while preserving the greater omentum. The gastrocolic ligament was cut open 2-3 cm away from the greater curvature through to the lower pole of the spleen. The left gastroepiploic vessels were denuded, and the left gastroepiploic artery was ligated and cut at the root. The station number 4sb lymph nodes were dissected. The greater curvature was denuded, and station number 4d lymph nodes were dissected.Open in a separate windowVideo 1Laparoscopic-assisted radical gastrectomy for distal gastric cancerThe lymph nodes in the inferior area of the pylorus were then dissected. The station number 14v lymph nodes were typically not dissected in the standard D2 radical surgery. The anterior pancreaticoduodenal fascia was stripped close to the head of the pancreas to reveal the right gastroepiploic vein. During the separation, the non-working face of the ultrasonic scalpel was pointed towards the pancreas. Caution was made to avoid injury to the small vessels on the surface of the pancreas, particularly to the anterior superior pancreaticoduodenal vein. The right gastroepiploic vein was denuded, and transected before its junction with the pancreaticoduodenal vein. The right gastroepiploic artery was then denuded. The small vessels and subpyloric vessels emerging from the gastroduodenal artery and entering the posterior wall of the duodenum were treated first. This could reduce bleeding when separating the right gastroepiploic artery. After the right gastroepiploic artery was denuded, ligated and cut, the lower edge of the duodenum was denuded, and the station number 6 lymph nodes were dissected. The gastroduodenal artery was stripped to its root in an inverse direction. The common hepatic artery was dissected, and the right gastric artery was separated near the bifurcation, but was not transected for the moment.A piece of sterile gauze was placed on the lesser sac to flip the stomach downward. The pylorus and the superior region of the duodenum were denuded, then the small omentum was opened, and the gauze was clearly visible. The duodenum was first transected, and the stomach was flipped to the left side to reveal the structure more clearly from the upper edge of the pancreas to the posterior wall of the lesser sac.The anterior hepatoduodenal capsule was opened and the proper hepatic artery was divided. The right gastric artery was further denuded, ligated and cut at the root. The station number 5 lymph nodes were dissected. With the assistant gently lifting the gastropancreatic fold, the surgeon began to separate the superficial fascia on the upper edge of the pancreas. The gastropancreatic fold was dissected, and the coronary vein and the left gastric artery were denuded. After the coronary vein was denuded, a clamp was applied to the root and the vessel was transected. The left gastric artery was denuded from the periphery. An absorbable clamp was applied to 0.5 cm above its root and the vessel was transected so that the clamp would not slip off. The station number 7 lymph nodes were dissected.The lesser sac was opened until the right edge of the cardia. The peritoneal reflection was opened to the anterior part of the right crus of the diaphragm to provide an accurate anatomic plane for the subsequent dissection of the station number 9 lymph nodes. The station number 12a lymph nodes were then dissected. The proper hepatic artery was gently pulled to the right side, and the fascia to the left was separated to naturally reveal the left anterior wall of the portal vein. The separation was continued along the upper edge of the fascia from the left side of the portal vein to the celiac artery, during which the stations number 12a and 8a lymph nodes were dissected en bloc. After the dissection, the entrance of the portal vein, splenic vein and coronary vein was clearly visible. The two stations were gently retracted to the left side, and the lymph nodes to the right of the celiac artery were dissected along the plane established anterior to the crus in the above steps, and the anterior region of the celiac artery was then dissected.Afterwards, the lymph nodes proximal to the splenic artery were then dissected (number 11p). The fascia at the upper edge of the pancreas was separated towards the pancreatic tail to expose the splenic artery. It should be noted that there were several curves along the splenic artery to the splenic hilum, especially the largest one of 3 to 4 cm to the root, which was hidden behind the pancreas with lymph nodes inside that should not be omitted. Hence, we dissected the lymph nodes surrounding the splenic artery from both the anterior and the posterior directions. The dissection from posterior to anterior areas beginning from the left crus of the diaphragm would help ensure that the lymph nodes at the curves were not omitted. The supplying vessels along the lymph nodes around the splenic artery could be directly transected with the ultrasonic scalpel. After dissection, the lymph nodes were lifted to the anterior right side. The separation was then continued towards the cardia so that lymph nodes to the posterior and right of the cardia could be dissected. The right side of the cardia and the lesser curvature of the stomach were denuded, and the stations number 1 and 3 were dissected. At this point, the laparoscopic operation was is complete. An auxiliary incision of about 5 cm was made inferior to the xiphoid for the removal of the entire specimen. A Tyco 25# circular gastrointestinal stapler was used to complete the Billroth I anastomosis.The whole operation lasted 3 hours and 10 minutes, with intraoperative blood loss of 20 mL, and no blood transfusion was delivered. The patient was able to ambulate three days after surgery. Liquid diet was prescribed on the 5th day and semi-liquid diet on the 6th day. The patient was discharged seven days after surgery without postoperative complications. Postoperative pathology showed a superficial depressed type moderately to poorly differentiated adenocarcinoma with superficial ulceration at the junction of the antrum and the gastric body on the lesser curvature side (size 1 cm × 1 cm × 0.2 cm), invading the submucosa. Chronic inflammation was noted in 2 (suprapyloric), 1 (subpyloric), 5 (lesser curvature), 3 (greater curvature), 2 (close to the left gastric artery), 1 (close to the common hepatic artery), 2 (close to the splenic artery), 2 (close to the celiac artery), 1 (12a), 1 (4sb), and 2 (to the right of the cardia) lymph node. Both upper and lower margins were negative. Postoperative pathological staging was T1bN0M0.     

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.