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

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

The Impact of Perioperative Events on Cancer Recurrence and Metastasis in Patients after Radical Gastrectomy: A Review

Radical gastrectomy is a mainstay therapy for patients with locally resectable gastric cancer (GC). GC patients who are candidates for radical gastrectomy will experience at least part of the following perioperative events: surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response. Considerable clinical studies have shown that these perioperative events can promote recurrence and decrease the long-term survival of GC patients. The mechanisms include activation of neural signaling and the inflammatory response, suppression of antimetastatic immunity, increased release of cancer cells into circulation, and delayed adjuvant therapy, which are involved in every step of the invasion-metastasis cascade. Having appreciated these perioperative events and their influence on the risk of GC recurrence, we can now use this knowledge to find strategies that might substantially prevent the deleterious recurrence-promoting effects of perioperative events, potentially increasing cancer-free survival in GC patients.

Is Splenic Hilar Lymph Node Dissection Without Splenectomy Essential for Proximal Advanced Gastric Cancer?

BACKGROUND

The standard surgery for proximal advanced gastric cancer (PAGC) is total gastrectomy with D2 lymph node dissection (LND). Although prophylactic splenectomy for splenic hilar LND (No. 10) is not recommended due to any survival advantage, prophylactic LND (No. 10) without splenectomy remains controversial. Thus, we aimed to evaluate whether No. 10 LND is essential for patients' survival benefit in PAGC.

METHODS

We conducted a retrospective study of 1038 patients with PAGC who underwent total gastrectomy without splenectomy. After adjusting for confounders and propensity score matching (PSM), patients were grouped into Group 1 (D2 LND without splenic hilar LN; n = 288) or Group 2 (D2 LND with splenic hilar LN; n = 288). Variables between the two groups (5-year overall survival [OS] and disease-free survival [DFS]) were compared, as well as in patients with tumors located in the greater curvature and those with Borrmann type IV disease.

RESULTS

The 5-year OS and DFS rates after PSM were not significantly different between Groups 1 and 2 (57.3% vs. 62.1%, p = 0.300; 52.8% vs. 59.7%, p = 0.100, respectively). Furthermore, the 5-year OS and DFS rates in patients with greater curvature involvement (54.4% vs. 61.9%, p = 0.500; 50.0% vs. 57.6%, p = 0.400, respectively) and Borrmann type IV disease (23.8% vs. 38.6%, p = 0.400; 16.7% vs. 33.9%, p = 0.200, respectively) after PSM were also not significantly different between the two groups.

CONCLUSIONS

Prophylactic splenic hilar LND without splenectomy does not improve long-term survival in PAGC. Therefore, this procedure might not be essential for patients with PAGC as well greater curvature involvement and Borrmann type IV disease.