Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer: A comparison of short‐term outcomes

Abstract

Introduction: Splenic hilar lymph node dissection via a splenectomy for advanced proximal gastric cancer remains controversial. Recently, a laparoscopic spleen-preserving hilar lymph node dissection procedure was described in several publications. To assess the feasibility and safety of spleen-preserving laparoscopic total gastrectomy with D2 lymphadenectomy (LTG-D2), the present retrospective study compared the short-term surgical outcomes between spleen preservation and splenectomy during laparoscopic D2 total gastrectomy (LTG-D2S).Method: This study included 59 patients who underwent LTG-D2 and 19 patients who underwent LTG-D2S. Results: The mean operation time did not significantly differ between the LTG-D2 and LTG-D2S groups (339.4 ± 56.8 vs 356.8 ± 46.0 min). The mean blood loss tended to be smaller in the LTG-D2 group than in the LTG-D2S group (105.9 ± 89.7 vs 210.0 ± 149.5 mL). The mean number of retrieved lymph nodes did not significantly differ between the LTG-D2 and LTG-D2S groups (39.9 ± 17.0 vs 40.6 ± 14.9), and the mean number of retrieved lymph nodes at the splenic hilum also did not significantly differ between the LTG-D2 and LTG-D2S groups (1.3 ± 1.7 vs 2.4 ± 2.6). Mild pancreatic fistula occurred in three cases (5%) in the LTG-D2 group and in three cases (15.8%) in the LTG-D2S group. Conclusion: A LTG-D2 is feasible in terms of the short-term outcomes. However, the indications for this complicated procedure should be considered carefully.

Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer

“…Because prophylactic combined resection of spleen increased the risk of postoperative morbidity (22,23) with no survival benefit (24,25) in open total gastrectomy, the reports on LTG with splenectomy were limited (19)(20)(21). There were only small case series so far.…”

“…LDG has recently been applied to advanced gastric cancer, and several largescale randomized controlled trials comparing open and laparoscopic distal gastrectomy for advanced gastric cancer in the distal stomach have been performed in Korea and Japan (2,3) to evaluate feasibility and long-term oncologic outcome of LDG. However, the use of laparoscopic total gastrectomy (LTG) remains limited because of the high technical demands of esophagojejunostomy (4)(5)(6) and the complexity of lymphadenectomy at the splenic hilum (5,7,(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). Because of the variation of the vascular anatomy in the splenic hilum and with the concern of pancreasrelated complications, splenic hilar lymphadenectomy is technically challenging even for skilled surgeons.…”

“…Based on the evidence that prophylactic combined resection of spleen in total gastrectomy increased the risk of postoperative morbidity (22,23) or had no survival benefit (24,25), surgeons have preferred laparoscopic spleenpreserving splenic hilar lymphadenectomy (LSPL) (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) rather than LTG with splenectomy (20,21). Since the first report by Hyung et al (8) in 2008, the number of studies with acceptable feasibility of LSPL has increased (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). For further advanced cases, such as with metastasis to splenic hilar nodes or invasion to the greater curvature Review Article Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer of the stomach, or with direct invasion to distal pancreas, LTG with splenectomy, sometimes with combined resection of distal pancreas has been performed (19)(20)(21).…”

“…Since the first report by Hyung et al (8) in 2008, the number of studies with acceptable feasibility of LSPL has increased (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). For further advanced cases, such as with metastasis to splenic hilar nodes or invasion to the greater curvature Review Article Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer of the stomach, or with direct invasion to distal pancreas, LTG with splenectomy, sometimes with combined resection of distal pancreas has been performed (19)(20)(21). In this paper, the recent reports of LTG with splenic hilar lymphadenectomy were reviewed.…”

“…Longer operation time, less blood loss, and earlier postoperative recovery were found in LATG with LSPL, which was consistent with the previous results of LDG (1). Gradually this operative procedure was applied to more advanced tumors (10)(11)(12)(14)(15)(16)(17)(18)(19), unless they had definite lymph node enlargement in the splenic hilum or direct tumor invasion of the gastrosplenic ligament. Among the 13 studies with LSPL, the indication was up to T2 in three studies, and up to T3 in five and T4a in five studies, respectively.…”