Value of splenectomy in patients with Siewert type II adenocarcinoma of the esophagogastric junction

Mapping of lymph node dissection determined by the epicenter location and tumor extension for esophagogastric junction carcinoma

Backgrounds

Previous studies identified the extent of lymph node dissection for esophagogastric junction (EGJ) carcinoma based on the metastatic incidence. The study aimed to determine the optimal extent and priority of lymphadenectomy based on the therapeutic efficacy from each station.

Methods

The studies on the lymph node metastasis (LNM) and therapeutic efficacy index (EI) for EGJ carcinomas were identified until April 2022. The obligatory stations with the LNM rates over 5% and therapeutic EI exceeding 2% should be routinely resected for D2 dissection, whereas the optional stations with EI between 0.5% and 2% should be resected for D3 dissection in selective cases.

Results

The survey yielded 16 eligible articles including 6,350 patients with EGJ carcinoma. The metastatic rates exceeded 5% at no. 1, 2, 3, 7, 9, 11p, and 110 stations and were less than 5% in abdominal no. 4sa~6, 8a, 10, 11d, 12a, and 16a2/b1 and mediastinal no. 105~112 stations. Consequently, obligatory stations with EI over 2% were largely determined by the epicenter location and located at the upper perigastric, lower mediastinal, and suprapancreatic zones, corresponding to those with rates of LNM over 5%. Consistent with the LNM rates less than 5%, the optional stations with EI between 0.5% and 2% were largely dependent on the degree of tumor extension toward the lower perigastric, splenic hilar (grecurvature), para-aortic (less curvature of the cardia), and middle or upper mediastinal zones.

Conclusions

The obligatory stations can be resected as an “envelope-like” wrap by transhiatal proximal gastrectomy with lower esophagectomy, whereas the optional stations for dissection are indicated by the tumor extension. The extended gastrectomy is required for the lower perigastric in the stomach-predominant tumor with gastric involvement exceeding 5.0 cm, para-aortic dissection in the less curvature-predominant tumor and splenic hilar dissection in the grecurvature-predominant tumor whereas transthoracic subtotal esophagectomy is required for complete mediastinal dissection and adequate negative margin in the esophagus-predominant tumor with esophageal invasion exceeding 3.0 cm.

Optimal surgery for esophagogastric junctional cancer

Esophagogastric junctional cancer is classified into three categories according to the Siewert classification, which reflects the epidemiological and biological characteristics. Therapeutic strategies have been evaluated according to the three Siewert types. There is a consensus that types I and III should be treated as esophageal cancer and gastric cancer, respectively. On the other hand, type II is often described as true cardiac cancer, which has different clinicopathological features from the other types. Thus, there is no consensus on the surgical management of type II esophagogastric junctional cancer. The optimal surgical management should focus on the principles of cancer surgery, which take into consideration oncological curability, including an appropriate resection margin, adequate lymphadenectomy, and minimization of postoperative complications. In this review, we evaluate the current relevant literature and evidence, on the surgical treatment of esophagogastric junctional cancer, focusing on type II. Esophagectomy with a thoracic approach has the advantage of ensuring a sufficient proximal resection margin and adequate mediastinal lymphadenectomy. However, the oncological benefit is offset by a high incidence of postoperative complications. Minimally invasive esophagectomy could be a possible solution to reduce complications and improve long-term outcomes. Further development of surgical treatments for Siewert type II is required to improve the outcomes. Furthermore, the surgical team should have expertise in both gastric cancer and esophageal cancer treatment, or patients should be managed with close collaboration between thoracic surgeons and gastric cancer surgeons.

Feasibility of laparoscopic total gastrectomy with splenectomy for proximal advanced gastric cancer: A comparative study with open surgery

INTRODUCTION

Total gastrectomy with splenectomy (TGS) is sometimes performed for treatment of locally advanced gastric cancer invading the greater curvature because metastasis to splenic hilar nodes is expected. Despite the widespread use of laparoscopic procedures, the feasibility of laparoscopic TGS (LTGS) has been scarcely reported because of its technical difficulties.

METHODS

This retrospective single-institutional study included 93 consecutive patients with proximal advanced gastric cancer who underwent either LTGS or open TGS (OTGS) from 2010 to 2018. The patients who underwent LTGS (n = 12) were compared with a 1:2 ratio propensity score-matched cohort of patients who underwent OTGS (n = 20). Clinical outcomes were retrospectively reviewed and compared between the two groups.

RESULTS

The patients' baseline characteristics were well balanced between the two groups. The operating time was longer (332.5 vs 222.5 minutes, P < .01) but the blood loss volume was smaller (34.5 vs 426 mL, P < .01) in the LTGS than OTGS group. The incidence of postoperative morbidity (≥ Clavien-Dindo grade III) was much lower (0.0% vs 36.8%, P = .02) and the median postoperative hospital stay was shorter (9 vs 11 days, P < .01) in the LTGS than OTGS group. The median number of harvested No. 10 or 11 days lymph nodes was equivalent between the two groups.

CONCLUSIONS

Although TGS is not a common procedure, LTGS may be safely performed in selected patients when carried out by an experienced surgical team. The oncological safety remains unclear and needs to be further examined in future trials.

Clinical Relevance of Splenic Hilar Lymph Node Dissection for Proximal Gastric Cancer: A Propensity Score-Matching Case-Control Study

BACKGROUND

The application of splenic hilar lymph node (no. 10 LN) dissection (no. 10 LND) for proximal gastric cancer (PGC) remains controversial. This study aimed to investigate the clinical relevance of no. 10 LND from the perspective of long-term survival.

METHODS

The main study population included 995 previously untreated patients who underwent laparoscopic radical total gastrectomy between January 2008 and December 2014. Of these 995 patients, 564 underwent no. 10 LND (no. 10D+ group) and the remaining 431 patients did not (no. 10D- group). Propensity score-matching was applied to reduce the effects of confounding factors. The study end points were overall survival (OS) and disease-free survival (DFS). Additionally, 39 patients who received neoadjuvant chemotherapy during the same period also were included as a separate population for analysis.

RESULTS

The metastasis rate for no. 10 LN was 10.5 % (59/564). No significant differences were observed in intra- and postoperative complications nor in mortality between the no. 10D+ and no. 10D- groups (all P > 0.05). After 1:1 matching, the two groups were comparable in clinicopathologic characteristics. The no. 10D+ group had significantly better survival than the no. 10D- group (5-year OS: 63.3 % vs 52.2 %, P = 0.003; 5-year DFS: 60.4 % vs 48.1 %, P = 0.013). For the patients who received neoadjuvant chemotherapy, the 5-year OS rates in the no. 10D+ and no. 10D- groups were respectively 50.6 % and 31.3 % (P = 0.150) and the 5-year DFS rates were respectively 51.5 % and 31.3 % (P = 0.123).

CONCLUSIONS

Patients with untreated PGC may achieve the benefit of long-term survival from no. 10 LND. For patients with PGC who undergo neoadjuvant chemotherapy, no. 10 LND may not bring survival benefits. However, further validation with a large-sample study is needed.

Systemic Review and Meta-analysis of Impact of Splenectomy for Advanced Gastric Cancer

BACKGROUND/AIM

Prophylactic splenectomy has shown no inferiority for tumors not invading the greater curvature side. Despite this, the clinical impact of prophylactic splenectomy for proximal advanced gastric cancer is not clear. This review aimed to clarify the impact of splenectomy for advanced gastric cancer in the upper third of the stomach.

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted based on PubMed and EMBASE databases. The following search terms were used: "gastric cancer" OR "splenectomy" OR upper third of the stomach" OR preservation of the spleen.

RESULTS

Out of 765 articles, 18 studies (combined n=6,341) were included in the analysis. Four randomized controlled trials (RCT) and eight retrospective studies suggested the benefits of spleen-preserving gastrectomy. Six retrospective studies showed no significant benefit of spleen-preserving gastrectomy. Prophylactic splenectomy showed a close association with a higher incidence of postoperative morbidity (pancreatic fistula and anastomotic leakage) with no concomitant improvement in overall survival. Prophylactic splenectomy should not be routinely performed and RCTs are necessary to confirm the impact of splenectomy for cN(+) at the splenic hilum tumors and tumors invading the greater curvature.

Priority of lymph node dissection for advanced esophagogastric junction adenocarcinoma with the tumor center located below the esophagogastric junction

To clarify the priority of lymph node dissection (LND) in advanced Siewert type II and III AEG, in which the center of the tumor is located below the esophagogastric junction (EGJ).Data in 395 patients with advanced Siewert type II or III AEG was analyzed retrospectively. The index of estimated benefit from LND (IEBLD) was used to evaluate the efficacy of LND for each nodal station.The mean number of dissected LNs did not differ significantly between patients with type II and III AEG, nor did the mean number of retrieved LNs at each station significantly differ between the 2 groups. According to the IEBLD, the dissection of parahiatal LNs (No.19 and 20) and LNs along the distal portion of the stomach (No.5, 6, and 12a) seemed unlikely to be beneficial, whereas the dissection of Nos.1-3, 7, 9 and 11p yielded high therapeutic benefit (IEBLD>3.0) in both groups. The IEBLDs of No.4d, 8a, and 10 were much higher in type III than in type II AEG cases. No.10 LND may improve survival for type III AEG cases (IEBLD = 2.9), especially for subgroups with primary tumors invading the serosa layer, undifferentiated cancers, macroscopic type 3-4 tumors and tumors ≥50 mm in size (all IEBLDs > 4.0).For advanced AEG located below the EGJ, the dissection of paracardial LNs, lesser curvature LNs, and LNs around the celiac axis would promote higher survival benefits regardless of the Siewert subtype. Patients with type III AEG, especially those with serosa-invasive tumors, undifferentiated tumors, macroscopic type 3-4 tumors and tumors ≥50 mm in size may obtain relatively higher survival benefits from No. 10 lymphadenectomy.

Laparoscopic splenic hilar lymph node dissection for advanced gastric cancer: to be or not to be

The incidence of proximal gastric cancer has increased in both the East and the West. Although some novel reconstructions like double-tract or double-flap anti-reflux procedure related to proximal gastrectomy are promising, total radical gastrectomy still accounts for a significant portion of these procedures. D2 radical gastrectomy is the globally accepted standard surgical procedure for advanced gastric cancer, and lymph node (LN) dissection is considered as the critical point of radical surgery and closely related to the prognosis. The splenic hilar LNs (No. 10) are LNs that need to be removed during standard D2 surgery for proximal and total gastrectomy. Lymphadenectomy does not only provide valuable information on the prognosis of gastric cancer, but the thoroughness of the sweep itself is directly related to postoperative survival. The incidence of splenic hilar LN (No. 10) metastasis rate is not high. Although the LN metastasis pathway around the spleen is complicated, the feasibility of laparoscopic splenic hilar LN dissection in locally advanced gastric cancer has been verified. However, these results are mostly from small volume clinical studies, and the fact is that the dissection of the splenic hilar is technique-demanding even for open surgery. The rational strategy for LN dissection for surgeons is still controversial. For splenic LN dissection in radical gastric cancer surgery, whether to select individualized splenic LN dissection for those patients highly suspected of clinical metastasis or to advocate the evidence-based strategy and neglect dissection in lower risk patients to avoid over-removing of LNs, is a vital question that needs to be clarified.

Comparison of Early Postoperative Outcomes after Total Gastrectomy and D2 Lymph Node Dissection with and without Splenectomy

Background

A famous prognostic ingredient for gastric cancer is the lymph node metastasis. Previously in the therapy of gastric cancer, splenectomy was considered as a definitive part of lymph node dissection. Currently, preservation of the spleen is the accepted approach during total gastrectomy and routine splenectomy is abandoned. The aim of this study was to estimate the impression of splenectomy for D2 lymph node dissection with total gastrectomy.

Methodology

Between February 1998 and January 2012, 1531 patients underwent gastric cancer surgery. Of these 257 patients, 205 patients underwent total gastrectomy with splenectomy, and the remaining 52 underwent a spleen-preserving total gastrectomy.

Results

No statistical difference between these two groups in terms of age, gender, comorbidity, stage and American Society of Anesthesiologists score, surgical complications were detected. A significant difference was not seen in these groups with regard to postoperative mortality too.

Conclusion

Early postoperative results were similar after TG ± splenectomy. Performing splenectomy did not increase the postoperative morbidity and mortality.

How to cite this article: Oter V, Dalgic T, Ozer I, Colakoglu K, Cayci M, Ulas M, Bostanci EB, Akoglu M. Comparison of Early Postoperative Outcomes after Total Gastrectomy and D2 Lymph Node Dissection with and without Splenectomy. Euroasian J Hepatogastroenterol, 2018;8(2):108-111.

Outcomes of the Surgical Treatment for Adenocarcinoma of the Cardia - Single Institution Experience

Background

Adenocarcinomas at the cardia are biologically aggressive tumors with poor long-term survival following curative resection. For resectable adenocarcinoma of the cardia, mostly esophagus extended total gastrectomy or esophagus extended proximal gastric resection is performed; however, the surgical approach, transhiatal or transthoracic, is still under discussion. Postoperative morbidity, mortality and long-term survival were analyzed to evaluate the potential differences in clinically relevant outcomes.

Patients and methods

Of altogether 844 gastrectomies performed between January 2000 and December 2016, 166 were done for the adenocarcinoma of the gastric cardia, which we analyzed with using the Cox proportional hazards model.

Results

136 were esophagus extended total gastrectomy and 125 esophagus extended proximal gastric resection. A D2 lymphadenectomy was performed in 88.2%, splenectomy in 47.2%, and multivisceral resections in 12.4% of patients. R0 resection rate was 95.7%. The mean proximal resection margin on the esophagus was 42.45 mm. It was less than 21 mm in 9 patients. Overall morbidity regarding Clavien-Dindo classification (> 1) was altogether 28.6%. 15.5% were noted as surgical and 21.1% as medical complications. The 30-day mortality was 2.2%. The 5-year survival for R0 resections was 33.4%. Multivisceral resection, depth of tumor infiltration, nodal stage, and curability of the resection were identified as independent prognostic factors.

Conclusions

Transhiatal approach for resection of adenocarcinoma of the cardia is a safe procedure for patients with Siewert II and III regarding the postoperative morbidity and mortality; moreover, long-term survival is comparable to transthoracic approach. The complications associated with thoracoabdominal approach can therefore be avoided with no impact on the rate of local recurrence.

Prognoses of advanced esophago-gastric junction cancer may be modified by thoracotomy and splenectomy

Globally, the incidence of esophago-gastric junction (EGJ) cancer is rapidly increasing. However, the proposed strategies for the treatment of these types of cancer are so diverse that there is no established consensus on the optimal treatment. The aim of the present study was to identify independent prognostic factors to delineate the optimal strategies for the treatment of EGJ cancer. The medical records of 150 patients with EGJ cancer who underwent curative surgery at the Kitasato University were retrospectively reviewed. The median follow-up period was 48 months. The patients with tumors that were classified as post-treatment primary tumor stage 3 [(y)pT3] or higher had a 5-year disease-specific survival (DSS) rate of 53%, whereas those with tumors that were classified as (y)pT0-2 had a 5-year DSS rate of 90%. Therefore, prognostic analysis was restricted to those tumors that were designated (y)pT3 or higher. A multivariate Cox's proportional hazards model identified the following independent prognostic factors that negatively influenced the DSS: i) Presence of tumors classified as post-treatment regional lymph node stage 1-3 [(y)pN1-3] [hazard ratio (HR), 3.62; 95% confidence interval (CI), 1.39-12.36]; ii) not undergoing treatment with splenectomy (HR, 2.40; 95% CI, 1.15-5.15); and iii) undergoing treatment with thoracotomy (HR, 2.07; 95% CI, 1.02-4.23). In patients with (y)pN0 tumors, the DSS rate was significantly improved for those who underwent splenectomy than for those who did not (P=0.024). In patients with (y)pN1-3 tumors, the DSS rate was significantly worse for those who underwent thoracotomy compared with those who did not (P=0.004). Splenectomy and thoracotomy may critically affect prognosis in locally advanced EGJ cancer that are classified as (y)pN0 and (y)pN1-3, respectively. Surgical treatments require optimization in order to improve prognoses in advanced EGJ cancer.

Prognostic Impact of Splenectomy in Patients with Esophagogastric Junction Carcinoma

BACKGROUND/AIM

We evaluated the survival benefit of splenectomy in patients with esophagogastric junction (ECJ) carcinoma.

PATIENTS AND METHODS

We retrospectively examined clinicopathological and survival data for 60 surgically-treated patients with ECJ carcinoma.

RESULTS

The 5-year overall survival (OS) rate was 47%. Splenectomy was performed in 20 patients (30%). Multivariate Cox regression analysis revealed splenectomy (odds ratio (OR), 2.70; 95% confidence interval (CI)=1.06-7.17; p=0.04) and venous invasion (OR=3.03; 95%CI=1.20-9.27; p=0.02) as significant independent predictors of poorer OS. Splenic hilar lymph node metastasis was not observed. Multivariate logistic regression analysis identified perioperative blood transfusion (BTF) as a significant independent factor associated with splenectomy.

CONCLUSION

The survival benefit of splenectomy in ECJ carcinoma patients may decrease with increasing frequency of perioperative BTF for blood loss. We recommend that splenectomy should be performed carefully when indicated by the extent or invasion of EGJ carcinoma.

Optimal treatment for Siewert type II and III adenocarcinoma of the esophagogastric junction: A retrospective cohort study with long-term follow-up

AIM

To determine the optimal treatment strategy for Siewert type II and III adenocarcinoma of the esophagogastric junction.

METHODS

We retrospectively reviewed the medical records of 83 patients with Siewert type II and III adenocarcinoma of the esophagogastric junction and calculated both an index of estimated benefit from lymph node dissection for each lymph node (LN) station and a lymph node ratio (LNR: ratio of number of positive lymph nodes to the total number of dissected lymph nodes). We used Cox proportional hazard models to clarify independent poor prognostic factors. The median duration of observation was 73 mo.

RESULTS

Indices of estimated benefit from LN dissection were as follows, in descending order: lymph nodes (LN) along the lesser curvature, 26.5; right paracardial LN, 22.8; left paracardial LN, 11.6; LN along the left gastric artery, 10.6. The 5-year overall survival (OS) rate was 58%. Cox regression analysis revealed that vigorous venous invasion (v2, v3) (HR = 5.99; 95%CI: 1.71-24.90) and LNR of > 0.16 (HR = 4.29, 95%CI: 1.79-10.89) were independent poor prognostic factors for OS.

CONCLUSION

LN along the lesser curvature, right and left paracardial LN, and LN along the left gastric artery should be dissected in patients with Siewert type II or III adenocarcinoma of the esophagogastric junction. Patients with vigorous venous invasion and LNR of > 0.16 should be treated with aggressive adjuvant chemotherapy to improve survival outcomes.

The surgical management of esophago-gastric junctional cancer

The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.

The Role of No. 10 Lymphadenectomy for Advanced Proximal Gastric Cancer Patients Without Metastasis to No. 4sa and No. 4sb Lymph Nodes

BACKGROUND

There is no consensus in the impact of No. 10 lymph node dissection (LND) for advanced proximal gastric cancer (APGC) and the status of negative No. 4sa and No. 4sb lymph nodes (No. 4s LNs) is reportedly associated with no metastasis to No. 10 LN. We aimed to evaluate the role of No. 10 LND in APGC patients with negative No. 4s LNs and the diagnostic accuracy of intraoperative pathologic examination.

METHODS

We analyzed data on 727 patients with APGC who had undergone D2 lymphadenectomy with No. 10 LND (n = 380) or without No. 10 LND (n = 347) between January 2005 and December 2010. Additionally, from January to July 2014, we prospectively enrolled 48 patients with APGC and examined their No. 4s LNs intraoperatively.

RESULTS

The negative predictive efficacy of No. 4s LN status for no metastasis to No. 10 LN was 98.09 %. Operation time, blood loss, time to first solid diet, hospital stay, and postoperative complication rate differed significantly between patients with negative No. 4s LNs who underwent No. 10 LND (n = 260) and those who did not undergo No. 10 LND (n = 243). Differences between the two groups in 5-year overall and disease-free survival were not statistically significant. The sensitivity, specificity, and accuracy of intraoperative pathological examination of LNs were 93.42, 96.56, and 95.86 %, respectively.

CONCLUSIONS

The No. 10 lymphadenectomy may not be recommended in patients with APGC who are found by intraoperative pathological examination to have negative No. 4s LNs.

Should Splenic Hilar Lymph Nodes be Dissected for Siewert Type II and III Esophagogastric Junction Carcinoma Based on Tumor Diameter?: A Retrospective Database Analysis

The aim of the study is to identify the value of a spleen-preserving No. 10 lymphadenectomy (SPL) for Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG).From January 2007 to June 2014, 694 patients undergoing radical total gastrectomy for Siewert type II/III AEG were analyzed. Oncologic outcomes were compared between SPL and no SPL (No. 10D+ and No. 10D-) groups.The incidence of No. 10 lymph node metastasis (LNM) was 12.3%. No significant differences in the incidence of No. 10 LNM were found between Siewert type II AEG with tumor diameters of <4 cm and ≥4 cm (P = 0.071). However, Siewert type III AEG with a tumor diameter ≥4 cm showed a significantly higher frequency of No. 10 LNM compared with a tumor diameter <4 cm (P < 0.001). The No. 10D+ group had superior 3-year overall survival (OS) and disease-free survival (DFS) rates compared with the No. 10D- group (P = 0.030 and P = 0.005, respectively). For patients with Siewert type II and type III AEG with a tumor diameter <4 cm, the 3-year OS and DFS rates were similar between the 2 groups. However, the No. 10D+ group had better 3-year OS (66.6% vs 51.1%, P = 0.019) and DFS (63.2% vs 45.9%, P = 0.007) rates for Siewert type III AEG with a tumor diameter ≥4 cm. A multivariate Cox regression showed that SPL was an independent prognostic factor in Siewert type III AEG with a tumor diameter ≥4 cm.SPL may improve the prognosis of Siewert type III AEG with a tumor diameter ≥4 cm, whereas SPL may be omitted without decreasing survival in patients with Siewert type II or type III AEG with a tumor diameter <4 cm.

Theoretical therapeutic impact of lymph node dissection on adenocarcinoma and squamous cell carcinoma of the esophagogastric junction

BACKGROUNDS

The aim of this study was to evaluate the theoretical therapeutic impact of dissecting each lymph node station for adenocarcinoma and squamous cell carcinoma of the esophagogastric junction.

METHODS

This multicenter study included 431 junctional cancer patients (381 adenocarcinomas and 50 squamous cell carcinomas) who fulfilled the following criteria: (1) the center of the tumor was located between 1 cm above and 2 cm below the esophagogastric junction, and (2) the tumor invaded the junction. The theoretical therapeutic impact of dissecting each lymph node station was evaluated based on the therapeutic value index calculated by multiplying the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

The 5-year overall survival rates (95% confidence interval) were 60.4% (55.1-65.7) in the adenocarcinoma cases and 52.3% (35.6-69.0) in the squamous cell carcinoma cases. The nodal stations showing the first to fifth highest index were the paracardial and lesser curvature nodes (nos. 1, 2 and 3), nodes at the root of the left gastric artery (no. 7) and lower mediastinal lymph nodes, regardless of the histology.

CONCLUSIONS

Nodal dissection achieved by proximal gastrectomy and lower esophagectomy should be the minimal requirement for junctional cancer regardless of the histology, considering the therapeutic value indices for the relevant lymph node stations.

Laparoscopic lymphadenectomy around the left renal vein (16a2lat) by tunneling under the pancreas for advanced Siewert type II adenocarcinoma

The para-aortic lymph nodes around the left renal vein (16a2lat) are now considered important to target in the treatment of advanced adenocarcinoma of the esophagogastric junction. We describe a laparoscopic approach for resecting these nodes. This new tunneling approach starts from the ligament of Treitz and then enters the retroperitoneal space. The left renal vein and left adrenal vein are dissected to identify the anatomy of the 16a2lat area. After this dissection, the 16a2lat nodes are retrieved through the suprapancreatic area. Six patients with advanced type II junctional cancer underwent laparoscopic 16a2lat lymph node dissection. The median operative time and estimated blood loss were 479 (390-750) min and 250 (130-500) ml, respectively. The median hospital stay was 22 (17-54) days and there were no deaths or serious complications. Although this series was relatively small, our technique proved effective and feasible.

Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis

BACKGROUND

Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy.

METHODS

Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate.

RESULTS

Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null.

CONCLUSION

These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.

Survival benefit and safety of no. 10 lymphadenectomy for gastric cancer patients with total gastrectomy

This study was aimed to evaluate the survival benefit and safety of No. 10 lymphadenectomy for gastric cancer patients with total gastrectomy.Splenic hilar lymph nodes (LNs) are required to be dissected in total gastrectomy with D2 lymphadenectomy. However, there has still not been a consensus in aspects of survival and safety on No. 10 LN resection.From January 2006 to December 2011, 453 patients undergoing total gastrectomy for gastric cancer were retrospectively analyzed. Patients were grouped according to No. 10 lymphadenectomy (10D+/10D-). Clinicopathologic characteristics were compared between the 2 groups. These patients had undergone a follow-up until January 2014. The overall survival, morbidity, and mortality rate were analyzed. Subgroup analyses which were stratified by the sex, age, tumor location, lymphadenectomy extent, curative degree, differentiation, tumor size, and TNM staging (ie, stages of tumor) were performed.There were 220 patients in 10D+ group, whereas 233 in 10D- group. In terms of prognosis, the baseline features between the 2 groups were almost comparable. The incidence of No. 10 LN metastasis was 11.82%. There was no difference in morbidity and mortality between the 2 groups. Significantly more LNs were harvested from patients in 10D+ group (P = 0.000). The estimated overall 5-year survival rates were 46.44% and 37.43% in 10D+ group and 10D- group respectively, which is not statistically significant (P = 0.3288). Although no statistical significance was found in the estimated 5-year survival rate, these data were obviously higher in patients with age >60 years, Siewert II/ III tumors, N1 status, or IIIa/IIIc stages when No. 10 lymphadenectomies were performed.Although the differences were obvious, the 5-year survival rates between the 2 groups did not reach statistical significances, which was probably caused by too small patient samples. High-quality studies with larger sample sizes are needed before stronger statement can be done. Until then, the No. 10 LNs' resection might be recommended in total gastrectomy with D2 lymphadenectomy with an acceptable incidence of complications.

Technical feasibility of laparoscopic total gastrectomy with splenectomy for gastric cancer: clinical short-term and long-term outcomes

BACKGROUND

Since its widespread acceptance for the treatment of early gastric cancer, laparoscopic gastrectomy has been gaining popularity as a treatment option for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) with splenectomy is seldom performed, because of its difficulty of removal of station 10 lymph nodes; splenectomy is technically essential for complete removal of these lymph nodes. The purpose of this study was to describe the details of the LTG procedure and to evaluate the short- and long-term outcomes of LTG with splenectomy.

METHODS

Of 725 consecutive patients with gastric cancer who underwent laparoscopic gastrectomy with lymph node dissection in our institution from January 1996 to December 2012, 18 consecutive patients who underwent LTG with splenectomy were enrolled in this study.

RESULTS

No operative mortality occurred, and the pathological margins were free from cancer cells in all patients. The mean operation time was 388 min (range 324-566 min). The mean volume of blood loss was 45 ml (range 5-347 ml), and the mean number of dissected lymph nodes was 51 (range 40-105). Postoperative morbidity occurred in six patients (33.3%) (each with grade B postoperative pancreatic fistula, postoperative bleeding, chylous ascites, atelectasis, ileus, and intra-abdominal infection). Five patients (27.8%) developed recurrence (four in the peritoneum and one in the liver), and the overall 3- and 5-year survival rates were 83.0 and 72.6%, respectively.

CONCLUSIONS

Considering the 0% mortality rate and low rates of postoperative morbidity and locoregional recurrence, LTG with splenectomy is technically and oncologically acceptable. This procedure can be expanded to include advanced gastric cancer, which generally requires splenectomy for lymph node dissection.

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type II or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

The optimal extent of lymph node dissection for adenocarcinoma of the esophagogastric junction differs between Siewert type II and Siewert type III patients

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing worldwide. We investigated the clinicopathological characteristics of patients with Siewert type II and III AEGs and clarified the optimal intra-abdominal lymph node dissection in these patients.

METHODS

This study included 132 patients with AEG who underwent curative resection at Shizuoka Cancer Center from September 2002 to December 2012. We used the index of estimated benefit from lymph node dissection (IEBLD) to assess the efficacy of lymph node dissection of each station. The clinicopathological characteristics and IEBLDs of each station were compared between patients with Siewert type II and III AEGs.

RESULTS

We analyzed 92 patients with Siewert type II AEG and 40 patients with Siewert type III AEG. The incidence of lymph node metastasis was high in both groups (64.1 % in type II AEG and 75.0 % in type III AEG). The 5-year survival rates were similar for the patients with Siewert type II and III AEGs, at 54.0 and 53.4 %, respectively. The IEBLDs of stations located near the esophagogastric junction were generally high in both groups, while the IEBLDs of lower perigastric lymph nodes were higher in Siewert type III than in Siewert type II AEG cases.

CONCLUSIONS

The IEBLDs were similar between Siewert type II and III AEGs at all stations except for lower perigastric lymph nodes. Total gastrectomy should be selected as a standard treatment for Siewert type III AEG, whereas in Siewert type II AEG, preservation of the distal part of the stomach may be an acceptable procedure.

Priority of lymph node dissection for Siewert type II/III adenocarcinoma of the esophagogastric junction

OBJECTIVE

The purpose of this study was to clarify the priority of nodal dissection in Siewert types II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

The priority of nodal dissection was evaluated based on the therapeutic value index calculated by multiplying of the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

A total of 176 patients (95 type II and 81 type III) were examined. Among the lymph nodes that had a metastatic incidence exceeding 10 %, the stations showing the first to fourth highest index were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the node at the root of the left gastric artery (No. 7) in the total cohort, as well as in each type. The next station was the lower thoracic paraesophageal lymph node (No. 110), followed by the nodes along the proximal splenic artery (No. 11p) in type II, whereas it was the nodes along the proximal splenic artery (No. 11p) followed by the para-aortic nodes (No. 16a2), the nodes at the celiac artery (No. 9), and the nodes around the splenic hilum (No. 10) in type III.

CONCLUSIONS

These results suggest that the highest priority nodal stations to be dissected were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the nodes at the root of the left gastric artery (No. 7), regardless of the Siewert subtype, but the subsequent priority was different depending on the subtype.