| Objective:To investigate the safety,feasibility and short-term effect of membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node circumferential dissection for local advanced proximal gastric cancer.Methods:A retrospective analysis was conducted on 105 patients with local advanced proximal gastric cancer who underwent membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node dissection in the First Division of the Gastrointestinal Surgery of the First Hospital of Putian City from December 2016 to December 2019.Regarding the methods of splenic hilar lymph node dissection,they were divided into two groups: circumferential group,which represented 49 patients who underwent the anterior and posterior lymph nodes of splenic lobe vessels and anterior group,which represented 56 patients who underwent the anterior lymph nodes of splenic lobe vessels.With reference to the online medical records and the surgical videos of these patients,the author compared these two groups of patients in regard to the total number of splenic hilar lymph nodes,the number of positive splenic hilar lymph nodes,the number of patients with positive splenic hilar lymph nodes and positive rate of splenic hilar lymph nodes,the incidence of intraoperative and postoperative complications,postoperative recovery,and so on.Results:(1)The clinical baseline data of the two groups of patients were comparable.The total operative time,intraoperative blood loss,the time of first anal exhaust,the removal time of left abdominal cavity drainage tube,the time of starting fluid diet,the postoperative length of hospital stay were slightly increased in the circumferential group than in the anterior group,but there were no significant difference between the two groups(P>0.05);the time for splenic hilar lymph node dissection were higher in the circumferential group than in the anterior group(48.24±7.51 min vs.41.95±8.18 min,P<0.05).There were 3 cases of intraoperative complications in the circumferential group with an incidence of 6.12%,and 3 cases of intraoperative complications in the anterior group with an incidence of 5.36%.Both groups were pancreatic injury.There were no significant difference in the incidence of intraoperative complications between the two groups(3 cases vs.3 cases,P>0.05).At the same time,there were no adjacent organ(colon,kidney)injury,no splenic parenchyma / vascular injury,and no splenic infarction.There were 12 cases of postoperative complications in the circumferential group with an incidence of 24.49%,manifested as pulmonary infection,anastomotic hemorrhage,postoperative intestinal obstruction,and pulmonary embolism,and 12 cases of postoperativ complications in the anterior group with an incidence of 21.43%,manifested as pulmonary infection,anastomotic hemorrhage,abdominal bleeding,and chylous fistula.There were no perioperative deaths in the two groups of patients,and there were no significant difference in the incidence of postoperative complications between the two groups(12cases vs.12 cases,P>0.05).(2)The number of perigastric lymph nodes and splenic hilar lymph nodes were higher in the circumferential group than in the anterior group(51.84±18.32 vs.44.32±12.55,P<0.05;4.20±3.06 vs.2.93±2.37,P<0.05);the number of positive perigastric lymph nodes and positive splenic hilar lymph nodes were higher in the circumferential group than in the anterior group,but there were no significant difference between the two groups(P>0.05).(3)The positive rate of splenic hilar lymph nodes in 105 patients was 16.19%(17/105).The Chi-square test showed that tumor size,positive or negative lymph nodes at D2,and p TNM stage were related to positive splenic hilum lymph node(P<0.05).Among them,the positive rate of splenic hilum lymph node in patients with different states were as follows: tumor ≥4cm group 22.22%(14/63),diffuse type of Lauren classification group 30.00%(9/30),positive lymph node in D2 group 28.26%(13/46),stage T3 and T4 group 17.58%(16/91),stage III group 25.42%(15/59).(4)There were 12 patients with positive splenic hilar lymph nodes in the circumferential group,and the positive rate was 24.49%(12/49),among which the positive rate of splenic hilar lymph nodes in stage T3 and T4 patients and that in stage III patients were respectively 26.67%(12/45)and 35.48%(11/31).There were 5 patients with positive splenic hilar lymph nodes in the anterior group,and the positive rate was24.49%(12/49),among which the positive rate of splenic hilar lymph nodes in stage T3 and T4 patients and that in stage III patients were respectively 8.70%(4/46)and14.81%(4/27).The number of positive patients with splenic hilum lymph node were significantly higher in the circumferential group than in the anterior group(12 cases vs.5cases,P=0.031).(5)In the circumferential group,there were 12 patients with positive anterior splenic hilar lymph nodes,3 of whom were accompanied by positive posterior splenic hilar lymph nodes,and all 3 patients were in stage T4 and stage III.That was to say,25.00%(3/12)of patients with positive anterior splenic hilar lymph nodes had positive posterior splenic hilar lymph nodes,and the positive rate of posterior splenic hilar lymph nodes was 6.12%(3/49),and the positive rate of posterior splenic hilum lymph node in stage T4 patients was 20.00%(3/15),and the positive rate of posterior splenic hilum lymph node in stage III patients was 9.68%(3/31).Conclusion:Membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node circumferential dissection is feasible,safe and has reliable short-term efficiency.Compared with splenic hilar lymph node anterior dissection,it completely clean the anterior and posterior lymph nodes of splenic lobe vessels.Therefore,the larger access to the number of splenic hilar lymph nodes and patients with positive splenic hilum lymph nodes can help to avoid the omission of positive lymph nodes behind the splenic hilum,and enhance the effect of gastric cancer surgery,especially be suitable for patients with upper gastric cancer in T4 stage and III stage.This method is worthy of clinical popularization and application. |
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