| Background:For all the deaths caused by cancers in the world,gastric cancer is convicted of the second largest killer.Compared with other gastric carcinomas types,proximal gastric cancer displays an annually increasingly higher incidence.And in most patients,gastric cancer usually has reached the advanced stage when detected.Standard operation for this kind of proximal gastric cancer is D2 total gastrectomy.In accordance with Japanese Gastric Cancer Treatment Guidelines,splenic hilar lymph nodes are categorized belonging to station 2 for radical resection of proximal gastric cancer,which therefore validates the necessity of dissecting lymph nodes at the splenic hilum.In proximal gastric and gastroesophageal junction cancers,lymph node metastases are found more frequently in the splenic hilum,which independently predicts poor survival.Therefore,some surgeons believe it is necessary to excise the total stomach combined with the pancreatic tail and spleen or excise the total stomach and spleen while preserving the pancreas,consistent with Japanese guidelines especially for Siewert type II esophagogastric junction adenocarcinoma.However,according to the latest European Society for Medical Oncology clinical practice guideline,splenectomy is not recommended unless the tumor is directly infiltrating the spleen.Others insist such aggressive surgeries not only fail to elevate the long-term survival rate of patients but also increase patients,postoperative complications and mortality,such as causing distinctly increased incidences of pancreatic fistula,acute pancreatitis,abdominal abscess,postoperative diabetes and postoperative hemorrhage.Whether splenectomy is mandatory still remain unclear,the aim of this study is to perform a systematic review and meta analysis to clarify the value of splenectomy in gastric cancer patients by comparing short-term complications and long-term survival and elucidate the impact of tumor stage on it.The outcome of the meta analysis show that splenectomy not only fail to elevate the long-term survival rate of patients but also increase patients'postoperative complications and mortality,such as causing distinctly increased incidences of pancreatic fistula,acute pancreatitis,abdominal abscess,postoperative diabetes and postoperative hemorrhage.Thus,we undertook anatomy of cadavers and laparoscopic operations to derive an optimal surgical approach and method,which is able to both preserve the functions of pancreas and spleen,reduce postoperative complications and mortality,and maintain or enhance five-year survival rate.Not only preserving the function of pancreas and spleen,but also finishing the cleaning of D2 lymph nodes,after cleaning the spleen door lymph nodes and skeletonizing the splenic arteriovenous through the retro-pancreatic approach.Chapter 1.Is Concomitant Splenectomy Necessary in Radical Gastric Cancer Surgery?a Systematic Review and Meta-analysis Aim:This study is a systematic review and meta-analysis that compares the short-and long-term outcomes of splenectomy(SP)versus splenic preservation(NSP)in radical gastric cancer surgery.Methods:A comprehensive search of PubMed,Embase,Cochrane Library,and Web of Knowledge was performed.Systematic review was carried out to identify studies comparing SP versus NSP in radical gastric cancer surgery.Measures evaluating short-and long-term outcomes were collected and analyzed by a fixed or random effects model according to the heterogeneity using RevMan 5.2 software.Results:A total of 5431 gastric cancer patients who underwent radical surgery(1706 with SP and 3725 with NSP)were reviewed in eleven studies included in this study.Compared with NSP,SP was significantly associated with higher rate of overall postoperative complication(odds ratio(OR)=2.31,95%confidence interval(CI):1.80 to 2.96,P<0.001),increased incidence of pulmonary complications(OR=1.80,95%CI:1.22 to 2.64,P=0.003),abdominal abcess(OR=3.71,95%CI:2.18 to 6.32,P<0.001)and pancreas complications(OR=4.56,95%CI:1.60 to 12.97,P=0.004).No statistical difference was noted regarding motality(OR=1.18,95%CI:0.93 to 1.49,P=0.17),wound infection(OR=1.69,95%CI:0.98 to 2.92,P=0.06),anastomotic leakage(OR=1.82,95%CI:1.01 to 3.29,P=0.05),and postoperative 5-year overall survival(OR=0.85;95%CI,0.63 to 1.14,P=0.28),as observed in subgroups stratified by tumor stages or by total gastrectomy.Conclusions:This meta-analysis suggested that there was no difference in long-term oncological outcome but remarkably poorer short-term outcomes in SP group than NSP group.Therefore,SP seems unnecessary in radical gastric cancer surgery.However,well-designed,multicenter,prospective,randomized controlled trials are warranted to further validate it.Chapter 2.Laparoscopic Spleen-preserving Hilar Lymph Node Dissection Through Retro-pancreatic Approach in Patients with Gastric CancerObjective:This paper aims to explore the feasibility of laparoscopic spleen-preserving hilar lymph node dissection through retro-pancreatic approach in proximal gastric cancer.Method:Two cadavers were dissected and ten cases of patients undergoing total gastrectomy and spleen-and-pancreas preserving splenic hilar lymph node dissection through retro-pancreatic approach for advanced proximal gastric cancer from May 2008 to May 10,2013 in Nanfang Hospital were included and analyzed.Results:Anatomy of the space anterior and posterior to the pancreas in the two cadavers eloquently demonstrated the feasibility of retro-pancreatic approach.Thereupon,10 cases of patients with proximal gastric cancer were given total gastrectomy and adjuvant splenic hilar lymph node clearance through retro-pancreatic approach on the precondition of preserving the pancreas and spleen.All these ten cases were spared conversion to laparotomy and discharged 15 days post to operations.Conclusion:Laparoscopic total gastrectomy and adjuvant spleen-and-pancreas preserving splenic hilar lymph node dissection through retro-pancreatic approach is proved feasible and safe.Chapter 3.The Surgical Space and Operation Approach of Radical Operation with D2 Lymphadenectomy for Gastric CarcinomaObjective:This paper aims to explore the safety of operation approach of radical operation with D2 lymphadenectomy for gastric carcinoma through dissecting the fascial spaces for stomach and pancreas.Method:Two cadavers were dissected to the fascial spaces for stomach and pancreas,and the possible operation approach of radical operation with D2 lymphadenectomy for gastric carcinoma were analyzed.Results:Anatomy of the fascial spaces for stomach and pancreas in the two cadavers eloquently demonstrated there are many fascial spaces around the stomach and pancreas with no blood vessel and nerve,which communicating each other.Formulating safe operation approach after familiaring fascial spaces around the stomach and pancreas,and preventing the massive bleeding and the injure of important intra-abdominal pelvic organ.Conclusion:Formulating safe operation approach after familiaring fascial spaces around the stomach and pancreas. |
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