The Impact of Confluence Types of the Right Gastroepiploic Vein on No. 6 Lymphadenectomy During Laparoscopic Radical Gastrectomy

OSATS scoring confirms ICG enhancement of performance in laparoscopic radical gastrectomy: a post-hoc analysis of a randomized controlled trial

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is effective in increasing the number of lymph node dissections during laparoscopic radical gastrectomy; however, no studies have attempted to explain this phenomenon.

METHODS

This study utilized the data from a previous randomized controlled trial (FUGES-012 study) investigating ICG-guided laparoscopic radical gastrectomy performed between November 2018 and July 2019. The Objective Structured Assessments of Technical Skills (OSATS) scoring system was used to grade videos from the ICG and non-ICG groups. Patients with an OSATS score greater than 29 were classified as the high-OSATS population, while those with an OSATS score less than or equal to 29 were classified as the low-OSATS population.

RESULTS

A total of 258 patients were included in the modified intention-to-treat analysis: 129 in the ICG group and 129 in the non-ICG group. The OSATS score of the ICG group was higher than that of the non-ICG group (29.6±2.6 vs. 26.6±3.6; P <0.001). The ICG group underwent a significantly higher mean total number of lymph node dissections than the non-ICG group (50.5±15.9 vs. 42.0±10.3; adjusted P <0.001). The group assigned to ICG use, better OSATS (high-OSATS) scores were observed, which correlated with greater D2 lymph node retrieval (54.1±15.0 vs. 47.2±8.7; adjusted P =0.039). Finally, the ICG group had a lower rate of lymph node noncompliance than that of the non-ICG group (31.8 vs. 57.4%; P <0.001).

CONCLUSIONS

By applying the ICG fluorescence navigation technique, better OSATS scores were observed, which correlated with greater lymph node retrieval and a lower lymph node noncompliance rate, as recommended for individualized laparoscopic radical gastrectomy.

Effect of preoperative colonoscopy combined with preservation of the right vein of the gastric omentum during radical resection of intestinal cancer on the efficacy and prognostic indicators of the procedure

BACKGROUND

The aim of this study was to investigate the clinical value of preoperative colonoscopy combined with right gastroepiploic vein preservation (RGV) in radical resection of colorectal cancer for right colon cancer.

METHODS

A total of 120 patients with right colon cancer in our hospital from February 2019 to October 2021 were selected and randomly divided into study group (RGV preserved during operation) and control group (RGV not preserved during operation), with 60 cases in each group. Perioperative parameters, intestinal fatty acid binding protein (I-FABP), Pittsburgh Sleep Quality Index (PSQI), total protein (TP), D-lactate (D-LA), quality of life scale (SF-36) scores, incidence of complications, and tumor recurrence rate were compared between the two groups.

RESULTS

Duration of hospitalization was shorter in the study group than in the control group (P<0.05). Six months after surgery, I-FABP, D-LA levels and PSQI scores were lower, and TP levels and SF-36 scores were higher in the study group than in the control group (P<0.05). The incidence of complications in the study group (11.67% vs. 33.33%) was lower than that in the control group (P<0.05). There was no significant difference in tumor recurrence rate 6 months after operation between the two groups (P>0.05).

CONCLUSIONS

Preoperative colonoscopy combined with RGV preservation in radical resection of colorectal cancer for right colon cancer can avoid surgical trauma caused by unnecessary transection, reduce gastrointestinal function damage, promote physical rehabilitation and shorten hospital stay, and reduce the risk of complications such as gastroparesis.

Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial

BACKGROUND

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.

STUDY DESIGN

We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events.

RESULTS

Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.

CONCLUSION

Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

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.

Anatomical Findings and Short-term Efficacy of Fascial Anatomy-guided Infrapyloric Lymphadenectomy in Laparoscopic Radical Gastrectomy for Gastric Cancer

OBJECTIVE

The aim was to investigate the anatomical layers of the specific fascia involved in infrapyloric lymphadenectomy in laparoscopic radical gastrectomy for gastric cancer and to analyze the short-term efficacy of an anatomy-guided surgical approach.

MATERIALS AND METHODS

On the basis of many years of clinical practice in fascial anatomy-guided laparoscopic radical gastrectomy for gastric cancer, we proposed anatomical considerations for infrapyloric lymphadenectomy in this procedure and investigated the anatomy of the mesentery and mesenteric fusion in this region, including the specific starting and ending points and the plane of the operation. We also retrospectively analyzed the clinical data of 265 patients who underwent fascial anatomy-guided infrapyloric lymphadenectomy in laparoscopic radical gastrectomy for gastric cancer from January 2015 to January 2019 and compared the short-term efficacy between the fascial anatomy-guided laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group and the laparoscopic infrapyloric lymphadenectomy group.

RESULTS

Extensive mesenteric fusion and folds exist in the infrapyloric region of the stomach, and removal of the medial fold (medial leg) and lateral fold (lateral leg) of the infrapyloric mesogastrium during surgery is easily missed, resulting in incomplete removal of the infrapyloric mesogastrium. Baseline data were comparable between the laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group and the laparoscopic infrapyloric lymphadenectomy group. The mean operative time for infrapyloric lymphadenectomy, the number of positive lymph nodes harvested in the infrapyloric region, and the number of patients with mesenteric metastasis in the infrapyloric region were not significantly different (P>0.05). The number of harvested lymph nodes was higher in the laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group than in the laparoscopic infrapyloric lymphadenectomy group (5.09±3.30 vs. 4.13±2.90, P<0.05), and intraoperative blood loss was lower in the former group than in the latter group (5.89±3.78 vs. 25.21±11.24 mL, P=0.000).

CONCLUSION

Fascial anatomy-guided laparoscopic infrapyloric lymphadenectomy enables systematic and complete removal of the lymph nodes and mesentery of the infrapyloric region with less intraoperative blood loss.

Near-infrared fluorescence-guided surgery using indocyanine green facilitates secure infrapyloric lymph node dissection during laparoscopic distal gastrectomy

PURPOSE

We aimed to investigate the usefulness of near-infrared indocyanine green (ICG)-enhanced fluorescence guidance for infrapyloric LN dissection in laparoscopic distal gastrectomy.

METHODS

This study enrolled patients with early gastric cancer scheduled for laparoscopic distal gastrectomy. After intraoperative submucosal injection of ICG (0.1 mg/mL), LN dissection was conducted under near-infrared ICG fluorescence guidance. The operation time, bleeding events during infrapyloric LN dissection were analyzed. Cases were retrospectively 1:3 propensity-score matched to patients who underwent laparoscopic distal gastrectomy without ICG injection.

RESULTS

The mean time from midline omentectomy to exposure of the right gastroepiploic vein was significantly shorter in the ICG group (n = 20) than in the non-ICG group (n = 60) (13.05 ± 5.77 vs 18.68 ± 7.92 min; p = 0.001), and the incidence of bleeding during infrapyloric LN dissection was lower in the ICG group (20% vs 68.3%, p < 0.001). The two groups did not differ significantly regarding the number of LNs retrieved from the infrapyloric area (p = 0.434).

CONCLUSIONS

Near-infrared ICG fluorescence guidance facilitates safe and fast infrapyloric LN dissection in laparoscopic distal gastrectomy.

The venous trunk of henle (gastrocolic trunk): A systematic review and meta-analysis of its prevalence, dimensions, and tributary variations

Surgeons have recognized the clinical significance of the venous trunk of Henle during multiple pancreatic, colorectal, and hepatobiliary procedures. To date, no study has followed the principles of evidence-based anatomy to characterize it. Our aim was to find, gather, and systematize available anatomical data concerning this structure. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were searched. The following data were extracted: prevalence of the trunk of Henle, its mean diameter and length, the organization of its tributaries, method of anatomical assessment (cadaveric, radiological, or intraoperative), geographical origin, study sample, and known health status. Our search identified 38 records that included data from 2,686 subjects. Overall, the prevalence of the trunk of Henle was 86.9% (95% CI, 0.81-0.92) and the mean diameter was 4.2 mm. Only one study reported the length of the trunk (10.7 mm). The most common type of venous trunk (56.1%) was a vessel comprising three tributaries: gastric (right gastro-epiploic vein), pancreatic (most commonly the anterior superior pancreaticoduodenal vein), and colic (most commonly the superior right colic vein). The trunk of Henle is a common variant in the anatomy of the portal circulation. It is a highly variable vessel, but the most common type is a gastro-pancreato-colic trunk. In surgical practice, the presence of this venous trunk poses a high risk for bleeding, but it can also be a useful landmark during various abdominal procedures. Clin. Anat. 31:1109-1121, 2018. © 2018 Wiley Periodicals, Inc.

Variations of Gastrocolic Trunk of Henle and Its Significance in Gastrocolic Surgery

Due to the increasing incidence of gastrointestinal (GI) tumors, more and more importance is attached to radical resection and patients' survival, which requires adequate extent of resection and radical lymph node dissection. Blood vessels around the gastrointestinal tract, as anatomical landmarks for tumor resection and lymph node dissection, play a key role in the successful surgery and curative treatment of gastrointestinal tumors. In the isolation of subpyloric area or hepatic flexure of the colon for gastrectomy or right hemicolectomy, lymph node dissection and ligation are often performed at the head of the pancreas and superior mesenteric vein, during which even a minor inadvertent error may lead to unwanted bleeding. Among these blood vessels, the venous system composed of Henle's trunk and its tributaries is the most complex, which has a direct influence on the outcome and postoperative recovery of the patients. There are many variations of Henle's trunk, with complicated courses and various locations, attracting more and more researchers to study it and tried to analyze the influence of its variations on gastrointestinal surgeries. We characterized various variants and tributaries of Henle's trunk using autopsy, vascular casting, 3D CT reconstruction, intraoperative anatomy, and Hisense CAS system and summarized and analyzed the tributaries of Henle's trunk, to determine its influence on GI surgeries.

Surgical Anatomy of the Superior Mesenteric Vessels Related to Colon and Pancreatic Surgery: A Systematic Review and Meta-Analysis

The surgeon dissecting the base of the mesenterium, around the superior mesenteric vein (SMV) and artery, is facing a complex tridimensional vascular anatomy and should be aware of the anatomical variants in this area. The aim of this systematic review is to propose a standardized terminology of the superior mesenteric vessels, with impact in colon and pancreatic resections. We conducted a systematic search in PubMed/MEDLINE and Google Scholar databases up to March 2017. Forty-five studies, involving a total of 6090 specimens were included in the present meta-analysis. The pooled prevalence of the ileocolic, right colic and middle colic arteries was 99.8%, 60.1%, and 94.6%, respectively. The superior right colic vein and Henle trunk were present in 73.9%, and 89.7% of specimens, respectively. In conclusion, the infra-pancreatic anatomy of the superior mesenteric vessels is widely variable. We propose the term Henle trunk to be used for any venous confluence between gastric, pancreatic and colic veins, which drains between the inferior border of the pancreas and up to 20 mm downward on the right-anterior aspect of the SMV. The term gastrocolic trunk should not be synonymous, but a subgroup of the Henle trunk, together with to gastropancreatocolic, gastropancreatic, or colopancreatic trunk.

A pilot study of lymph node mapping with indocyanine green in robotic gastrectomy for gastric cancer

OBJECTIVES

Robotic gastrectomy has become increasingly popular in the treatment of gastric cancer, especially in Asian countries. The use of indocyanine green fluorescence has been reported in lymphatic mapping for gastric cancer in laparoscopic gastrectomy; however, there have been few reports regarding the use of indocyanine green in robotic gastrectomy.

METHODS

From January 2011 to March 2016, a total of 79 patients underwent robotic gastrectomy for gastric cancer. Among them, intraoperative subserosal injection (n = 9) or preoperative submucosal injection (n = 5) of indocyanine green with near-infrared imaging was performed in 14 patients, and the other 65 patients underwent robotic gastrectomy without the use of indocyanine green.

RESULTS

There was no significant difference in the operative time, total number of retrieved lymph nodes, operative blood loss, and postoperative hospital stay between the patients who underwent robotic gastrectomy with or without indocyanine green fluorescence. For each lymph node station, there was significantly more number of retrieved lymph nodes in the indocyanine green group than in the no-indocyanine green group at the greater curvature side of the low body (#4d) to the infrapyloric region (#6) of the stomach. Five of the 14 patients who received an indocyanine green injection for lymphatic mapping had lymph node metastasis, and metastatic lymph nodes were located in the lymph node stations as detected by indocyanine green fluorescence during surgery.

CONCLUSION

Indocyanine green fluorescence with near-infrared imaging is feasible and is a promising method of lymphatic mapping in robotic gastrectomy for gastric cancer. In future studies, larger patient numbers and long-term follow-up are required.

Development of lymph node dissection in laparoscopic gastrectomy: safety and technical tips

With the accumulation of experience in laparoscopic radical gastrectomy and the progress in surgical instruments, the laparoscopic technique has been widely applied in gastric cancer. Combining previous reports with data from our center, we believe that laparoscopic surgery for gastric cancer is safe and feasible, and its surgery-related complications have an incidence that is not higher, and perhaps even lower, than that of traditional laparotomy. However, the stomach has many anatomical levels and an abundant blood supply; additionally, laparoscopic surgery is relatively difficult. Therefore, understanding the normal gastric peripheral vascular anatomy and variation, selecting an appropriate surgical approach, applying programmed surgical procedures and team cooperation, and paying attention to the details in lymph node dissection are keys to a successful laparoscopic lymph node dissection in gastric cancer.