Right-sided bursectomy as an access plane for aesthetic resection of the posterior leaf of the lesser sac from the head of the pancreas en block with the No. 6 and 14v lymph nodes in advanced lower third gastric cancer. Surgery. 2015;158:1742. [PMID: 25704420 DOI: 10.1016/j.surg.2014.12.008]

Laparoscopic infrapyloric lymph nodes dissection through the right bursa omentalis approach for gastric cancer

BACKGROUND

A complete dissection of infrapyloric lymph nodes is the key to a curative gastrectomy, which can be sometimes technically challenging in laparoscopic surgery.

METHODS

One hundred and eighteen patients with gastric cancer undergoing laparoscopic gastrectomy with D2 lymphadenectomy in which the infrapyloric lymph nodes were dissected through the right bursa omentalis approach were included. The clinicopathologic characteristics and surgical outcomes were analyzed retrospectively.

RESULTS

The laparoscopic gastrectomy with D2 lymphadenectomy was successful in all 118 patients with no open conversion. The mean operation time was 246.6 ± 45.7 min. The mean estimated blood loss was 87.0 ± 35.9 mL. Postoperative complications occurred in 17.8% of the patients, which were treated successfully with conservative therapy or aspiration in all. There were no No.6 lymphadenectomy-associated complications, such as injury of transverse colon, vessels of mesocolon, pancreas or duodenum, no pancreatitis, pancreatic leakage or postoperative hemorrhage. The mean postoperative hospital stay was 9.6 ± 3.7 days. On average, the total lymph nodes harvested were 36.8 ± 12.9, in which the ones from the infrapyloric area were 5.1 ± 3.1.

CONCLUSION

Laparoscopic dissection of infrapyloric lymph nodes through the right bursa omentalis approach seems to be feasible and safe, facilitating a more complete No.6 lymphadenectomy for gastric cancer.

Prognostic significance of 14v-lymph node dissection to D2 dissection for lower-third gastric cancer

BACKGROUND

Radical gastrectomy with D2 lymph node (LN) dissection is the standard surgical procedure for patients with resectable gastric cancer (GC). In the fifteenth edition of the Japanese Classification of Gastric Carcinoma, the 14v LN (LNs along the root of the superior mesenteric vein) was defined as the regional gastric LN. The efficacy of 14v LN dissection during radical distal gastrectomy for lower-third GC remains controversial.

AIM

To analyze whether the addition of 14v LN dissection improved the survival of patients with lower-third GC.

METHODS

The data from 65 patients who underwent 14v LN dissection and 65 patients treated without 14v LN dissection were selected using the propensity score-matched method from our institute database constructed between 2000 and 2012. Overall survival was compared between the groups.

RESULTS

Overall survival was similar between patients with 14v LN metastasis and those with distant metastasis (P = 0.521). Among patients with pathological stage IIIA disease, those who were treated with 14v LN dissection had a significantly higher overall survival than those treated without it (P = 0.020). Multivariate analysis showed that age < 65 years and pT2-3 stage were independent favorable prognostic factors for prolonged overall survival in patients with pathological stage IIIA disease. Patients with No. 1, No. 6, No. 8a, or No. 11p LN metastasis were at higher risk of having 14v LN metastasis.

CONCLUSION

Adding 14v LN dissection to D2 dissection during radical distal gastrectomy may improve the overall survival of patients with pathological stage IIIA lower-third GC.

Is it worthy of adding dissection of the superior mesenteric vein lymph node (14v) to standard D2 gastrectomy for distal gastric cancers with No. 6 lymph node metastasis?

PURPOSE

Radical gastrectomy with D2 lymphadenectomy has been widely recognized as standard surgical procedure for advanced gastric cancer, while the role of No. 14v lymphadenectomy in distal gastric cancer remains controversial.

METHODS

Clinicopathological data of 793 distal gastric cancer patients who underwent at least a radical D2 lymphadenectomy with No. 6 nodes metastasis were retrospectively reviewed.

RESULTS

Fifty patients received No. 14v lymphadenectomy. Patients with No. 14v nodes metastasis (21/50, 42.0%) had poor prognosis. The No. 14v nodes metastasis was not an independent prognostic factor (P = 0.075). In distal gastric cancer patients with No. 6 nodes metastasis, No. 14v lymphadenectomy deteriorated overall survival, what's more, No. 14v lymphadenectomy was an independent risk prognostic factor (hazard ratio: 1.404; 95% confidence interval 1.043-1.889; P = 0.025). There was no significant difference in overall or locoregional and other types of recurrence rate between the 14vD+ and the 14vD- groups. The proportion of complication rate was greater in 14vD+ group (P = 0.001).

CONCLUSION

Extended D2 gastrectomy including No. 14v lymphadenectomy seems to be associated with poor overall survival and increased complication rate of distal gastric cancer patients with No. 6 nodes metastasis.

Oncologic Effectiveness and Safety of Bursectomy in Patients with Advanced Gastric Cancer: A Systematic Review and Updated Meta-Analysis

Purpose/Aim: In the past few decades some researchers have questioned whether bursectomy for gastric cancer is essential from an oncological point of view and no consistent recommendations have been proposed. The aim of this systematic review with meta-analysis is to investigate the oncologic effectiveness and safety of bursectomy for the treatment of advanced gastric cancer patients.

MATERIALS AND METHODS

We planned and performed this systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and Cochrane Handbook for Systematic Reviews of Intervention.

RESULTS

Overall, four studies with a total of 1,340 patients met inclusion criteria. The pooled hazard ratio for overall survival between the bursectomy versus nonbursectomy groups was [HR = 0.85, 95% CI 0.66-1.11, p =.252]. Interestingly, the pooled HR between the two groups in serosa-positive cases subgroup, showed a significant improvement of overall survival rate in favor of bursectomy [HR = 0.72, 95% CI 0.73-0.99, p <.05].

CONCLUSIONS

Bursectomy represents a surgical procedure that might be able to improve overall survival in serosa positive gastric cancer patients. However, a definitive conclusion could not be made because of the studies' methodological limitations. This meta-analysis points to the urgent need of high quality, large-scaled, clinical trials with short- as well as long-term evaluation comparing bursectomy with non bursectomy procedures, in a controlled randomized manner, helping future researches and establishing a modern and tailored approach to gastric cancer.

Characteristics and survival outcomes related to the infra-pyloric lymph node status of gastric cancer patients

BACKGROUND

To study metastasis to the infra-pyloric (no. 6) lymph nodes and their subgroups and the related risk factors of gastric cancer patients.

METHODS

Gastric cancer patients who underwent gastrectomy with complete postoperative pathological information on the no. 6 lymph node station and its subgroups from January 1, 2008, to December 31, 2011, were included. The clinicopathological characteristics and survival outcomes were analyzed.

RESULTS

A total of 121 patients were included; they had 6.1 ± 7.7 positive lymph nodes, and 35.1 ± 14.2 lymph nodes were examined. The overall lymph node positivity rate was 67.8% (82/121) with a positivity rate of 28.1% (34/121) for the no. 6 lymph nodes. The metastasis rate was 6.6% for the no. 6a nodes, 6.6% for the no. 6b nodes, and 21.5% for the no. 6c nodes. Also, no. 8a (OR = 1.329, p = 0.017) and no. 9 (OR = 1.250, p = 0.022) nodal positivity and lower third tumor location (OR = 1.278, p = 0.001) were independent risk factors for no. 6 lymph nodal metastasis. There was a significant survival difference between patients with positive and negative no. 6 lymph nodes and patients with metastasis to other lymph node stations (p <  0.001).

CONCLUSIONS

Patients with no. 6 lymph node metastasis have poor survival outcomes. Complete infra-pyloric lymphadenectomy is necessary and crucial for gastric cancer patients.

Safety and prognostic impact of prophylactic laparoscopic superior mesenteric vein (No. 14v) lymph node dissection for lower-third gastric cancer: a propensity score-matched case-control study

AIM

To investigate oncologic efficacy of prophylactic laparoscopic superior mesenteric vein (No. 14v) lymph node (LN) dissection for lower-third gastric cancer (LTGC).

METHODS

We retrospectively collected data from 757 patients who underwent laparoscopic-assisted distal gastrectomy for LTGC. Of these patients, 102 underwent 14v LN dissection (14vD+ group), and the remaining 655 patients did not undergo 14v LN dissection (14vD- group). The outcomes were compared using a 1:1 propensity score matching method.

RESULTS

After matching, 93 patients from the 14vD+ group and 93 patients from the 14vD- group with similar clinicopathological characteristics were compared. Before matching, the overall survival (OS) was similar between the two groups (P = 0.742). After matching, the OS was greater in the 14vD+ group (P = 0.025). The status of 14v dissection was not a significant prognostic factor in the survival analyses, both before and after matching. However, a stratified analysis according to the independent factors in the OS showed that the OS in the 14vD+ group was higher than that in the 14vD- group for cT2-3 patients after matching. The forest plot of OS showed that after matching the 14vD+ group had a significantly higher 3-year OS rate than the 14vD- group in cT2-3 patients. The distribution of the therapeutic index demonstrated that the index of 14v LN was similar to those of Nos. 1, 7, 8a, 9, and 11p after matching.

CONCLUSIONS

Adding laparoscopic 14v dissection for laparoscopic-assisted radical distal gastrectomy was safe and might improve the OS for clinically advanced LTGC without serosal invasion.

Positive impact of adding No.14v lymph node to D2 dissection on survival for distal gastric cancer patients after surgery with curative intent

BACKGROUND

D2 lymphadenectomy has been increasingly regarded as standard surgical procedure for advanced gastric cancer (GC), while the necessity of No.14v lymph node (14v) dissection for distal GC is still controversial.

METHODS

A total of 920 distal GC patients receiving at least a D2 lymph node dissection in Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital were enrolled in this study, of whom, 243 patients also had the 14v dissected. Other 677 patients without 14v dissection were used for comparison.

RESULTS

Forty-five (18.5%) patients had 14v metastasis. There was no significant difference in 3-year overall survival (OS) rate between patients with and without 14v dissection. Following stratified analysis, in TNM stages I, II, IIIa and IV, 14v dissection did not affect 3-year OS; in contrast, patients with 14v dissection had a significant higher 3-year OS than those without in TNM stages IIIb and IIIc. In multivariate analysis, 14v dissection was found to be an independent prognostic factor for GC patients with TNM stage IIIb/IIIc disease [hazard ratio (HR), 1.568; 95% confidence interval (CI): 1.186-2.072; P=0.002]. GC patients with 14v dissection had a significant lower locoregional, especially lymph node, recurrence rate than those without 14v dissection (11.7% vs. 21.1%, P=0.035).

CONCLUSIONS

Adding 14v to D2 lymphadenectomy may be associated with improved 3-year OS for distal GC staged TNM IIIb/IIIc.

Bursectomy and non-bursectomy D2 gastrectomy for advanced gastric cancer, initial experience from a single institution in China

BACKGROUND

The aim of this study is to evaluate the safety and efficacy of bursectomy of D2 gastrectomy in terms of postoperative complications and short-term survival outcomes.

METHODS

From January 2012 to December 2013, data of 406 gastric cancer patients with advanced tumor stages and who underwent D2 radical gastrectomy and were grouped according to whether bursectomy was performed or not in West China Hospital, Sichuan University, were analyzed.

RESULTS

Finally, 159 patients were in bursectomy group and 247 patients in non-bursectomy group. Surgical duration was 260.1 ± 43.4 min in the bursectomy group, compared to 227.9 ± 48.6 min in the non-bursectomy group (p < 0.001). The intraoperative blood loss was comparable between the bursectomy group and the non-bursectomy group (198.9 ± 63.5 vs. 201.1 ± 53.7 ml, p = 0.729). Postoperative morbidity rate showed no significant difference between the two groups, which were 23.3 % in the bursectomy group and 17.8 % in the non-bursectomy group, p = 0.179. The overall survival outcomes of patients were compared between the two groups of all patients (p = 0.055): patients who underwent distal gastrectomy (p = 0.129) and total gastrectomy (p = 0.016) and pT2-3 stage patients (p = 0.117) and pT4a stage patients (p = 0.128). The multivariate survival analysis identified that bursectomy or not, pT stage and pN stage were independent prognostic risk factors for the overall survival.

CONCLUSIONS

The bursectomy might increase the surgical duration when the D2 gastrectomy was done. Experienced surgeons can perform it safely. However, for the survival benefits of bursectomy, long-term, large sample sized, and high-quality randomized controlled trials are expected.