ABSTRACT
Splenic hilar lymph node (LN) is the difficulty and focus of perigastric LN dissection during radical gastrectomy for advanced proximal gastric cancer (APGC).Although the new edition of Japanese Gastric Cancer Treatment Guidelines excluded the splenic hilar LN from the D2 lymphadenectomy in patients with APGC,there are still few high-level evidences.Meanwhile,the guideline recommends that splenectomy is still necessary for patients with APGC involving the greater curvature.With the support of increasing evidences,the spleenpreserving splenic hilar LN dissection has been recognized by more and more scholars.Additionally,the technique of laparoscopy provides a new method for splenic hilar LN dissection.Our center proposed a new technique named Huang's three-step maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy,which not only reduces the difficulty of operation,but also makes the technique easier to popularize and with a significance of minimally invasive effect.During the clinical practice,the dissection of LNs behind the splenic portal vessels is also one of the controversies.Therefore,the difficult technique of splenic hilar LN dissection not only requires us to make a technical exploration,but also requires us to explore precise indications,in order to avoid unnecessary operation in patients who do not require dissection of the No.10 LNs and to avoid missing the opportunity for radical surgery in high-risk patients because of the difficult techniques.
ABSTRACT
Objective@#To investigate the surgical options for splenic lymph node dissection in patients with advanced gastric cancer undergoing radical total gastrectomy, and to evaluate the sentinel effect of No. 4s lymph node on splenic lymph node metastasis.@*Methods@#A prospective, single-center, randomized and controlled study was carried out (Trial registration, No.NCT02980861). Enrollment criteria: (1) >18 years old and <65 years old; (2) gastric adenocarcinoma locating in the proximal or corpus; (3) preoperative clinical staging as cT2-4aN0-3M0; (4) D2 radical total gastrectomy feasible judged before operation; (5) physical ability score 0 to 1; (6) I to III of ASA classification. Pregnant or lactating women, patients with severe mental illness or previous history of upper abdominal surgery, those suffered from other malignant tumors in the past 5 years, or heart and lung system diseases judged to affect surgery before operation, those receiving preoperative chemotherapy, radiotherapy or targeted therapies, and distant metastases being found during surgery were excluded. According to above criteria, 222 patients at The First Medical Center of Chinese PLA General Hospital from December 2016 to December 2017 were enrolled prospectively and were randomly divided into the laparoscopic splenic hilar lymph node dissection group (laparoscopic group, n=114) and the open splenic hilar lymph node dissection group (open group, n=108). The result of rapid frozen immunohistochemistry of harvested No.4s lymph nodes was used to evaluate the sensitivity and specificity of sentinel effect on splenic hilar lymph node metastasis. The surgical parameters, postoperative recovery parameters, and complication rates were compared between the two groups.@*Results@#There were 80 males and 34 females in the lapascopic group with a mean age of (56.1±10.2) years, and 69 males and 39 females in the open group with a mean age of (58.4±10.9) years. There were no significant differences in baseline data between the two groups (all P>0.05). Total blood loss was less in the laparoscopic group [(96.3±82.4) ml vs. (116.6±101.9) ml, t=1.124, P<0.001], and the amount of bleeding from the splenic hilar lymph nodes dissected was also less than that in the open group [(25.3±17.8) ml vs. (59.5±36.4) ml, t=1.172, P<0.001]. However, the operation time, the time of splenic hilar lymph node, the number of lymph node dissected and number of splenic hilar lymph node dissected were not significantly different between the two groups (all P>0.05). As compared to the open group, the laparoscopic group had shorter time to the first flatus [(1.3±1.2) days vs. (1.6±1.5) days, t=1.665, P=0.021], shorter time to fluid diet [(4.6±1.4) days vs. (4.9 ± 1.6) days, t=1.436, P=0.007], shorter time to remove nasogastric tube [(3.9±2.6) days vs. (4.3±2.4) days, t=0.687, P<0.001] and shorter hospital stay [(10.3±6.6) days vs. (12.1±7.2) days, t=0.697, P<0.001]. Complication rate was 14.0% (16/114) and 12.0% (13/108) in the laparoscopic group and the open group, respectively, without significant difference (χ2=6.723, P=0.331). The sensitivity of the No. 4s lymph node for the prediction of splenic hilar lymph node metastasis reached 89.5%, and the specificity reached 99.6%.@*Conclusions@#Laparoscopic technique is safe and feasible in the treatment of splenic hilar lymph node dissection in advanced gastric cancer. The No.4s lymph node examination has good sentinel effect on predicting the metastasis of splenic hilar lymph nodes.
ABSTRACT
Splenic hilar lymph node (LN) is the difficulty and focus of perigastric LN dissection during radical gastrectomy for advanced proximal gastric cancer (APGC). Although the new edition of Japanese Gastric Cancer Treatment Guidelines excluded the splenic hilar LN from the D2 lymphadenectomy in patients with APGC, there are still few high-level evidences. Meanwhile, the guideline recommends that splenectomy is still necessary for patients with APGC involving the greater curvature. With the support of increasing evidences, the spleen-preserving splenic hilar LN dissection has been recognized by more and more scholars. Additionally, the technique of laparoscopy provides a new method for splenic hilar LN dissection. Our center proposed a new technique named Huang′s three-step maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy, which not only reduces the difficulty of operation, but also makes the technique easier to popularize and with a significance of minimally invasive effect. During the clinical practice, the dissection of LNs behind the splenic portal vessels is also one of the controversies. Therefore, the difficult technique of splenic hilar LN dissection not only requires us to make a technical exploration, but also requires us to explore precise indications, in order to avoid unnecessary operation in patients who do not require dissection of the No.10 LNs and to avoid missing the opportunity for radical surgery in high-risk patients because of the difficult techniques.
ABSTRACT
Splenic hilar lymph node must be dissected in D2 dissection for advanced upper gastric cancer.With the advances of surgical technology and updated treatment concept,spleen-preserving splenic hilar lymph node dissection has been widely accepted and gradually carried out by surgeons.However,laparoscopic spleen-preserving splenic hilar lymph node dissection has become a technical difficulty of laparoscopic surgery for gastric cancer due to complex anatomy of splenic hilar vessels and exposed difficulty in splenic hilar region,especially in obese patients.Surgeons not only have skillful laparoscopic techniques but also know anatomic characteristics of splenic hilar vascular well,and reasonable surgical approach and programmed surgical procedures can guarantee successful laparoscopic spleen-preserving splenic hilar lymph node dissection.Meanwhile,with the development of laparoscopic spleen-preserving splenic hilar lymph node dissection,there is also some disputes about lymph node dissection.