The anatomical configuration of the splenic artery influences suprapancreatic lymph node dissection in laparoscopic gastrectomy: analysis using a 3D volume rendering program

Clinical Feasibility of Vascular Navigation System During Laparoscopic Gastrectomy for Gastric Cancer: A Retrospective Comparison With Propensity-Score Matching

PURPOSE

The usability of a new surgical navigation system that provides patient-specific vascular information for robotic gastrectomy in gastric cancer remains unexplored for laparoscopic gastrectomy owing to differences in surgical environments. This study aimed to evaluate the applicability and safety of this navigation system in laparoscopic gastrectomy and to compare the post-operative outcomes between procedures with and without its use.

MATERIALS AND METHODS

Between June 2022 and July 2023, 38 patients across 2 institutions underwent laparoscopic gastrectomy using a navigation system (navigation group). The technical feasibility, safety, and accuracy of detecting variations in vascular anatomy were measured. The perioperative outcomes were compared with 114 patients who underwent laparoscopic gastrectomy without a navigation system (non-navigation group) using 1:3 propensity score matching during the same study period.

RESULTS

In all patients in the navigation group, no adverse events associated with the navigation system occurred during surgery in any patient in the navigation group. No accidental vessel injuries necessitate auxiliary procedures. All vessels encountered during the gastrectomy were successfully reconstructed and visualized. Patient demographics and operative data were comparable between the 2 groups. The navigation group exhibited a significantly lower overall complication rate (10.5%) than the non-navigation group (26.3%, P=0.043). Notably, pancreas-related complications were absent in the navigation group but occurred in eight cases in the non-navigation group (7.0%, P=0.093), although the difference was not statistically significant.

CONCLUSIONS

The patient-specific surgical navigation system demonstrated clinical feasibility and safety for laparoscopic gastrectomy for gastric cancer, potentially reducing complication rates compared with laparoscopic gastrectomy without its use.

Short-Term Outcomes Analysis Comparing Open, Laparoscopic, Laparoscopic-Assisted, and Robotic Distal Gastrectomy for Locally Advanced Gastric Cancer: A Randomized Trials Network Analysis

BACKGROUND

Minimally invasive surgery for the treatment of locally advanced gastric cancer (AGC) is debated. The aim of this study was to execute a comprehensive assessment of principal surgical treatments for resectable distal gastric cancer.

METHODS

Systematic review and randomized controlled trials (RCTs) network meta-analysis. Open (Op-DG), laparoscopic-assisted (LapAs-DG), totally laparoscopic (Lap-DG), and robotic distal gastrectomy (Rob-DG) were compared. Pooled effect-size measures were the risk ratio (RR), the weighted mean difference (WMD), and the 95% credible intervals (CrIs).

RESULTS

Ten RCTs (3823 patients) were included. Overall, 1012 (26.5%) underwent Lap-DG, 902 (23.6%) LapAs-DG, 1768 (46.2%) Op-DG, and 141 (3.7%) Rob-DG. Anastomotic leak, severe complications (Clavien-Dindo > 3), and in-hospital mortality were comparable. No differences were observed for reoperation rate, pulmonary complications, postoperative bleeding requiring transfusion, surgical-site infection, cardiovascular complications, number of harvested lymph nodes, and tumor-free resection margins. Compared to Op-DG, Lap-DG and LapAs-DG showed a significantly reduced intraoperative blood loss with a trend toward shorter time to first flatus and reduced length of stay.

CONCLUSIONS

LapAs-DG, Lap-DG, and Rob-DG performed in referral centers by dedicated surgeons have comparable short-term outcomes to Op-DG for locally AGC.

Morphological Evaluation of the Splenic Artery, Its Anatomical Variations and Irrigation Territory

BACKGROUND

Precise knowledge of the topographic features of the splenic artery and its branches in the hilum region is of practical interest due to the various interventions on the vessels of the spleen.

MATERIALS AND METHODS

The anatomy of the spleen was studied by means of macroscopic dissection on 330 organ complexes, which were carefully documented and analyzed statistically.

RESULTS

The analysis of the splenic artery trajectory led to identification of four types: straight (43.03%), sinusoidal (27.58%), serpentine (20.91%) and alternating (8.48%). To assess the relation between the trajectory of the splenic artery and its branches we performed a chi square test. Sinuous or serpentine trajectory was associated with the presence of long splenic artery branches (dorsal pancreatic artery or the great pancreatic artery), X2 (2, N = 330) = 12.85, p = 0.001. The artery was located suprapancreatic in 70.30% of cases, anteropancreatic in 4.55%, the vessel had an intrapancreatic course in 14.85% and in 10.00% of cases the artery was located retropancreatic. The presence of inferior polar arteries was associated with a longer pancreas (Spearman's correlation; r = 0.37; p = 0.037). In a multiple regression analysis, inferior polar arteries predicted the length of the pancreas although only a small number of cases could be explained by this model (R2 = 0.127, Adjusted R2 = 0.098; Betta = 0.357; t(330) = 2.091; p = 0.045). There were 30 (9.09%) cases of accessory spleens.

CONCLUSIONS

The arterial supply of the spleen is highly variable in its trajectory, terminal branches, and relation to other organs. The splenic artery tends to be sinuous or serpentine in zones when a large artery branches off (e.g., the dorsal pancreatic or greater pancreatic artery). Multiple short branches tend to stabilize the trajectory of the splenic artery. Inferior polar arteries and accessory spleens contribute to the length of the pancreas, most likely due to increased vascular supply to the tail of the gland.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review

BACKGROUND

3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research.

METHODS

A scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated.

RESULTS

A total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found.

CONCLUSION

The use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

Systematic review and updated network meta-analysis of randomized controlled trials comparing open, laparoscopic-assisted, and robotic distal gastrectomy for early and locally advanced gastric cancer

BACKGROUND

The role of minimally invasive surgery for the treatment of early and locally advanced gastric cancer remains controversial. The purpose of this study was to perform a comprehensive evaluation of major surgical approaches for operable distal gastric cancer.

METHODS

Systematic review and network meta-analyses of randomized controlled trials were performed to compare open distal gastrectomy, laparoscopic-assisted distal gastrectomy, and robotic distal gastrectomy. Risk ratio, weighted mean difference, and 95% credible intervals were used as pooled effect size measures.

RESULTS

Seventeen randomized controlled trials (5,909 patients) were included. Overall, 2,776 (46.8%) underwent open distal gastrectomy, 2,964 (50.1%) laparoscopic-assisted distal gastrectomy, and 141 (3.1%) robotic distal gastrectomy. Among these 3 groups, there were no significant differences in 30-day mortality, anastomotic leak, and overall complications. Compared to open distal gastrectomy, laparoscopic-assisted distal gastrectomy was associated with significantly reduced intraoperative blood loss, early postoperative pain, time to first flatus, and hospital length of stay. Similarly, robotic distal gastrectomy was associated with significantly reduced blood loss and time to first flatus compared to open distal gastrectomy. No differences were found in the total number of harvested lymph nodes, tumor-free resection margins, 5-year overall, and disease-free survival. The subgroup analysis in locally advanced gastric cancer showed trends toward reduced blood loss, time to first flatus, and hospital length of stay with minimally invasive approaches but similar overall and disease-free survival.

CONCLUSION

Laparoscopic-assisted distal gastrectomy and robotic distal gastrectomy performed by well-trained experienced surgeons, even in the setting of locally advanced gastric cancer, seem associated with improved short-term outcomes with similar overall and disease-free survival compared with open distal gastrectomy.

Morphometric analysis of the splenic artery using contrast-enhanced computed tomography (CT)

PURPOSE

To evaluate the morphology and course of the splenic artery, which might impact the surgical implantation of systems that stimulate the nerves surrounding the splenic artery. Experimental studies indicate that these nerves play an important part in immune modulation, and might be a potential target in the treatment of autoimmune diseases.

METHODS

This retrospective cohort study made use of contrast-enhanced CT images from 40 male and 40 female patients (age 30-69) that underwent a CT examination of the aorta, kidneys or pancreas. Anatomic features were described including total splenic artery length, calibers, tortuosity, the presence of arterial loops and the branching pattern of the splenic artery.

RESULTS

No age-gender-related differences could be found related to tortuosity or branching pattern. The length of splenic artery in contact with pancreatic tissue decreased with increasing age, but was not different between genders. Artery diameters were wider in male compared to female subjects. Loops of variable directions, that represent a part of the artery that curls out of the pancreatic tissue, were identified in each age-gender category and were present in nearly all subjects (86%).

CONCLUSION

This study suggests that although some anatomic features of the splenic artery are subject to factors as age and gender, the tortuosity of the splenic artery is not age dependent. Most subjects had one or multiple loops, which can serve as a target for neuromodulatory devices. Future studies should investigate whether splenic nerve stimulation is safe and feasible.

Significance of prediction of the dorsal landmark using three-dimensional computed tomography during laparoscopic lymph node dissection along the proximal splenic artery in gastric cancer

Objectives:

Dissection of the No. 11p lymph nodes is technically challenging because of variations in anatomical landmarks. This study aimed to determine the accuracy and efficacy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography simulation.

Methods:

Laparoscopic gastrectomy with No. 11p lymph node dissection with preoperative simulation using three-dimensional computed tomography was performed in 24 patients at our institution from October 2016 to May 2018. Initially, preoperative three-dimensional computed tomography findings with operative videos in these 24 patients were compared. The dorsal landmark was defined as an anatomical structure behind the splenic artery on preoperative three-dimensional computed tomography and operative videos. The dorsal landmark of No. 11p lymph node was divided into four types: (1) splenic vein type, (2) splenic vein and pancreas type, (3) pancreas type, and (4) unclear type. Then, to investigate the efficacy of three-dimensional computed tomography, we compared the clinical and pathological features and surgical outcomes of nine patients who underwent preoperative three-dimensional computed tomography simulation (three-dimensional computed tomography group) and 23 patients who did not undergo three-dimensional computed tomography simulation from August 2014 to September 2016 (non-three-dimensional computed tomography group). All procedures were performed by one surgeon certified by the Endoscopic Surgical Skill Qualification System in Japan.

Results:

The concordance rate between three-dimensional computed tomography and operative videos of the dorsal landmark using three-dimensional computed tomography was 79% (19/24). The operative time of No. 11p lymph node dissection was significantly shorter in the three-dimensional computed tomography group than in the non-three-dimensional computed tomography group (7.7 versus 15.8 min, P = 0.044).

Conclusion:

The accuracy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography was extremely high. Preoperative simulation with three-dimensional computed tomography was useful in shortening the operative time of No. 11p lymph node dissection.

Vascular anatomy of the splenic flexure, focusing on the accessory middle colic artery and vein

AIM

Recently, the accessory middle colic artery (AMCA) has been recognized as the vessel that supplies blood to the splenic flexure. However, the positional relationship between the AMCA and inferior mesenteric vein (IMV) has not been evaluated. Herein, we aimed to evaluate the anatomy of the AMCA and the splenic flexure vein (SFV).

METHOD

Two hundred and five patients with colorectal cancer who underwent enhanced CT preoperatively were enrolled in the present study. The locations of the AMCA and IMV were evaluated, focusing on the positional relationship between the vessels and pancreas - below the pancreas or to the dorsal side of the pancreas.

RESULTS

The AMCA was observed in 74 (36.1%) patients whereas the SFV was found in 177 (86.3%) patients. The left colic artery (LCA) was the major artery accompanying the SFV in 87 (42.4%) of patients. The AMCA accompanied the SFV in 65 (32.7%) patients. In 15 (7.8%) patients, no artery accompanied the SFV. The origin of the AMCA was located on the dorsal side of the pancreas in 15 (20.3%) of these 74 patients. Similarly, the destination of the IMV was located on the dorsal side of the pancreas in 65 (31.7%) of patients.

CONCLUSION

The SFV was observed in most patients, and the LCA or AMCA was the common accompanying artery. In some patients these vessels were located on the dorsal side of the pancreas and not below it. Preoperative evaluation of this anatomy may be beneficial for lymph node dissection during left-sided hemicolectomy.