A Meta-analysis And The Clinical Practice Observation Of Extra-corporeal Splenic Hilar Lymph Nodes Dissection In Radical Gastric Surgery

Objective:The objectives of this research were to systematically compare the short-and long-term outcomes of extra-corporeal splenic hilar lymph nodes dissection versus intra-corporeal splenic hilar lymph nodes dissection in radical gastric surgery.Meanwhile,to observe the clinical practice of extracorporeal splenic hilar lymph nodes dissection in radical gastric surgery,and to statistically evaluate the metastasis situation of splenic hilar lymph nodes.Methods:A comprehensive search of CNKI、Wanfang Database、CBMdisc、Pub Med、Web of science、the Cochrane Library and other databases was performed through meta-analysis method.Comparative studies of extra-corporeal splenic hilar lymph node dissection and intra-corporeal splenic hilar lymph node dissection in radical gastrectomy were included.By using Revman 5.4 software,this meta-analysis compared and analyzed the observed indexes including operation time、intraoperative blood loss、aggregated number of harvested lymph nodes、aggregated number of harvested splenic hilar lymph nodes、positive ratios of No.10lymph nodes、postoperative complications and three/five-year survival rate,et al by fixed effect model or random effect model according to the heterogeneity test results.In the part of clinical practice observation,the patients who underwent D2 radical gastrectomy combined with extra-corporeal splenic hilar lymph node dissection in the first unit of gastrointestinal colorectal and anal surgery of the China-Japan Union Hospital of Jilin University from May 2020 to February 2021 were selected as the research objects according to established filter criteria.The aggregated number、metastasis ratio and positive ratio of splenic vascular anterior lymph nodes、splenic vascular posterior lymph nodes and all splenic hilar lymph nodes were observed.Meanwhile,metastasis rate and positive ratios of No.10 lymph nodes were observed.Results:A total of 10 retrospective studies involving 1127 patients were included in this meta-analysis.Compared with intra-corporeal splenic hilar lymph nodes dissection,the extra-corporeal splenic hilar lymph nodes dissection was significantly associated with less intraoperative blood loss(WMD=-34.98;95%CI=-55.54～-14.43;Chi~2=48.84;P<0.05)、more harvested splenic hilar lymph nodes(WMD=1.04;95%CI=0.50～1.59;Chi~2=32.42;P<0.05)、higher positive ratios of No.10lymph nodes(WMD=1.64;95%CI=1.24～2.16;Chi~2=0.21;P<0.05)and later first postoperative fart time(WMD=0.28;95%CI=0.18～0.37;Chi~2=2.14;P<0.05)。No statistical difference was noted regarding operation time(WMD=0.24;95%CI=-15.58～16.06;Chi~2=197.87;P=0.98)、total harvested lymph nodes(WMD=0.12;95%CI=-1.27～1.52;Chi~2=3.97;P=0.86)and postoperative complications(WMD=1.64;95%CI=1.24～2.16;Chi~2=0.21;P<0.05),et al.In clinical practice part,a total of 12 patients were included,containing 7 male patients and 5 female patients,aged 31-75 years.All patient underwent the operation successfully,one of which underwent combined splenectomy due to the unrepairable injury of splenic vein.The average number of harvested lymph nodes was 42.4±6.7.Only a few patients suffered from postoperative complications involving pleural effusion、ascites and Incision fat liquefaction were all cured and discharged after active conservative treatments.The total number of No.10 lymph nodes was 71 including 43 No.10a LNs and 28 No.10p LNs.The postoperative pathological stages of the included patients were all stage III.The average number of harvested No.10 lymph nodes was5.9±3.5 of which the metastasis rate and positive rate were 16.7%and8.5%;The average number of harvested No.10a lymph nodes was 3.6±2.1 of which the metastasis rate and positive rate were 8.3%and 4.7%;The average number of harvested No.10p lymph nodes was 2.3±2.1 of which the metastasis rate and positive rate were 16.7%and 14.3%.Conclusions:The following conclusions were cautiously drawn regarding the No.10 lymph node dissection in spleen-preserving radical surgery for gastric cancer:(1)Lymph nodes which were potentially metastasized could be found along both ventral and dorsal sides of splenic hilar vessels.(2)Compared with the intra-corporeal dissection,the extra-corporeal splenic hilar lymph node dissection could increase the lymph node detection rate and improve the completeness of radical surgery for gastric cancer.(3)The extra-corporeal splenic hilar lymph node dissection could be considered as a safe and feasible maneuver which is worthy of clinical application.