Safety And Risk Factors Of Laparoscopic Spleen-preserving Splenic Hilar Lymph Node Dissection Via Retropancreatic Approach For Proximal Gastric Cancer

Objective:To investigate the safety and feasibility of retropancreatic approach for splenic hilar lymph node dissection in laparoscopic total gastrectomy compared with D2 lymphadenectomy,and to preliminarily explore the risk factors of splenic hilar lymph node metastasis.Methods:This study included 314 patients who underwent laparoscopic D2 radical total gastrectomy by the same group of physicians from October 2015 to December 2020,who were divided into the D2+10 group(n = 77)and the D2 group(n = 237)according to whether splenic hilar lymph node dissection via retropancreatic approach performed or not.Propensity score matching was used for 1:2 matching.The differences in intraoperative blood loss,postoperative hospital stay,intraoperative and postoperative complications between the two groups were compared.The D2+10 group was divided into the negative(n = 69)and positive(n = 8)groups according to whether the splenic hilar lymph nodes(LNs)metastasize,and univariate analysis was performed for factors such as Borrmann classification,p T stage,and p TNM stage.Results:After propensity score matching,203 patients were finally included,including 72 in the D2+10 group(n=72)and 131 in the D2 group(n=131).There were 53 in stage Ⅰ,44 in stage Ⅱ,and 106 in stage Ⅲ(52.2%).After matching,there was no significant difference between the two groups in gender,age,BMI,p T stage,p N stage,and p TNM stage.After matching,the median number of dissected LNs in the D2+10 group(n = 77)was 48,more than that in the D2 group(P<0.05).The operation time was longer than that in the D2 group(P<0.05).There was no significant difference in the total intraoperative blood loss,postoperative hospital stay and the number of lymph node metastasis(P>0.05).There was no significant difference between the two groups in intraoperative complications such as splenic vascular bleeding,pancreatic injury,and splenic injury(P >0.05).After matching,10 cases(13.9%)of postoperative complications occurred in the D2+10 group,and there was no significant difference in postoperative complications such as anastomotic bleeding,abdominal bleeding,anastomotic leakage,chylous fistula,duodenal stump fistula,intestinal obstruction,abdominal infection,and pulmonary infection compared with the D2 group(P>0.05).There were 11 in p T1-status in the 77 patients who underwent laparoscopic spleen-preserving splenic hilar lymph node dissection via retropancreatic approach.The incidence of splenic hilar lymph node metastasis in progressive proximal gastric cancer was 12.1%.There were 8 in the No.10 positive group,including 6 located in the lesser curvature,7 with Borrmann type Ⅲ-Ⅳ,all with p T3/4-status,5 with pⅢB-status,and 3 with pⅢC-status.Univariate binary logistic regression analysis showed that Borrmann classification was a risk factor for splenic hilar lymph node metastasis.(P<0.05,OR:17.150,95%CI:1.980-148.542)Conclusion:Compared with laparoscopic standard D2 lymphadenectomy,laparoscopic spleenpreserving splenic hilar lymph node dissection via retropancreatic approach for proximal gastric cancer is safe and feasible,which prolongs the operation time but increases the number of dissected LNs,with no significant difference in intraoperative blood loss,postoperative hospital stay and incidence of intraoperative and postoperative complications.Patients with splenic hilar lymph node metastasis are usually in Borrmann type Ⅲ-Ⅳ.