Oncologic feasibility of D1+ gastrectomy for patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer.

INTRODUCTION: D2 gastrectomy has shown a survival benefit in patients with highly advanced gastric cancer; however, it remains unclear whether D2 gastrectomy is required for patients with early-stage advanced gastric cancer or early gastric cancer with limited lymph node metastasis. This analysis aimed to clarify the oncologic feasibility of D1+ gastrectomy in patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer. METHODS: This retrospective cohort analysis included 466 patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer who received curative gastrectomy with either D2 or D1+ dissection. Surgical outcomes were compared between the D2 group (n = 406) and the D1+ group (n = 60). RESULTS: The number of patients with higher age and higher comorbidity index was greater in the D1+ group than in the D2 group. Postoperative complications were significantly lower in the D1+ group than in the D2 group (10.0% vs. 26.8%, p = 0.004). No statistically significant difference in 5-year overall survival (p = 0.146) and disease-specific survival (p = 0.807) between the groups was noted. The incidence of local recurrences (p = 0.500) and that of lymph node recurrences (p = 1.000) were also similar between the groups. Multivariable analysis for overall survival identified age, clinical node-positive status, high Charlson score (≥3), advanced pathological stage (≥III), and postoperative complication (grade ≥ II) as independent prognostic factors. The propensity score-matched analysis showed very similar survival outcomes between the groups. CONCLUSION: D1+ gastrectomy may be oncologically feasible for patients with cT1N1, cT2N0-1, or cT3N0 stage gastric cancer.

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

Diagnosis and treatment of Petersen hernia after gastrectomy: report of 6 cases / 中华普通外科杂志

Objective:To explore the clinical characteristics, diagnosis and treatment of Petersen hernia after gastrectomy.Methods:The clinical data of 6 patients with Petersen hernia developed after gastrectomy in Shizuoka Cancer Center from Jan 2014 to Dec 2019 were retrospectively analyzed.Results:All 6 patients were males, with a median age of 76 years. The operative procedures for preceding gastrectomies were robotic-assisted total gastrectomy in 2 patients, laparoscopic distal gastrectomy in 2 patients, and laparoscopic proximal gastrectomy in 2 patients. Petersen′s defect was closed in all patients at previous gastrectomy. The time of onset was 1 month to 55 months after surgery. The main manifestations are acute pain in upper abdomen with nausea and vomiting. In all the cases, abdominal CT showed obstruction caused dilatation of the small intestine. The whirl sign was present in 3 patients. All the patients underwent reoperation with reduction and repair of the hernia. All the patients did not show obvious bowel necrosis. Their postoperative courses were uneventful, and all the patients were discharged. During the follow-up period, none of the patients developed complications related to the Petersen hernia.Conclusions:Petersen hernia is a rare complication of gastrectomy. It is important to conduct abdominal CT scanning as early as possible from the clinical history and physical findings, and to determine the surgical indication.