Chen Rui-Fu, Huang Chang-Ming, Chen Qi-Yue, Zheng Chao-Hui, Li Ping, Xie Jian-Wei, Wang Jia-Bin, Lin Jian-Xian, Lu Jun, Cao Long-Long, Lin Mi
From the Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, Fujian Province, China.
Medicine (Baltimore). 2015 May;94(18):e832. doi: 10.1097/MD.0000000000000832.
Laparoscopic gastrectomy with D2 lymph node (LN) dissection has not yet been widely adopted for advanced gastric cancer because it is technically complicated. Due to the high suprapancreatic lymph nodes metastasis rate (LMR) and the various vascular anatomies, the suprapancreatic LN dissection is a crucial and demanding procedure for radical resection of gastric cancer.To explore the anatomical basis of the proximal splenic artery (SA) approach for laparoscopic suprapancreatic LN dissection and its application in advanced gastric cancer.Laparoscopic suprapancreatic LN dissections were performed in 1551 consecutive advanced gastric cancer patients between June 2007 and November 2013. A total of 994 consecutive patients since January 2011 were selected to compare the clinicopathological characteristics and surgical outcomes between the conventional approach group (330) and the proximal SA approach group (664). In the proximal SA approach, the No. 11p LNs are dissected first, followed by the Nos. 9, 7, and 8a LNs; dissection of the Nos. 5 and 12a LNs is performed last.In the suprapancreatic arteries, the proximal SA had the lowest anatomic variation rate (P < 0.05, each) and maximum diameter (P < 0.05, each) compared with the common hepatic artery (CHA), left gastric artery (LGA), right gastric artery (RGA), and gastroduodenal artery (GDA). In addition, the proximal SA was located closer to the suprapancreatic border than the CHA (P = 0.000). The No. 11p LMR was lower than the Nos. 9, 7, 8a, 5, and 12a LMR (P < 0.01, each). Compared with the conventional approach, the proximal SA approach was associated with less blood loss (P < 0.05), significantly more retrieved total LNs and suprapancreatic LNs (P < 0.01, each).The proximal SA exhibits the most constant and maximum diameter, is located closer to the suprapancreatic border, and exhibits the lowest LMR; therefore, the proximal SA approach is the ideal approach for laparoscopic suprapancreatic LN dissection in advanced gastric cancer.
由于技术复杂，腹腔镜胃癌根治术联合D2淋巴结清扫术尚未在进展期胃癌中广泛应用。由于胰上淋巴结转移率高以及血管解剖结构多样，胰上淋巴结清扫是进展期胃癌根治性切除的关键且具有挑战性的步骤。为探讨腹腔镜胰上淋巴结清扫近端脾动脉入路的解剖学基础及其在进展期胃癌中的应用。2007年6月至2013年11月期间，对1551例连续性进展期胃癌患者实施了腹腔镜胰上淋巴结清扫术。选取自2011年1月起的994例连续性患者，比较传统入路组（330例）和近端脾动脉入路组（664例）的临床病理特征及手术结果。在近端脾动脉入路中，先清扫第11p组淋巴结，接着清扫第9、7和8a组淋巴结；最后清扫第5和12a组淋巴结。在胰上动脉中，与肝总动脉（CHA）、胃左动脉（LGA）、胃右动脉（RGA）和胃十二指肠动脉（GDA）相比，近端脾动脉的解剖变异率最低（均P<0.05），直径最大（均P<0.05）。此外，近端脾动脉比肝总动脉更靠近胰上缘（P = 0.000）。第11p组淋巴结转移率低于第9、7、8a、5和12a组（均P<0.01）。与传统入路相比，近端脾动脉入路的术中出血量更少（P<0.05），清扫出的总淋巴结和胰上淋巴结显著更多（均P<0.01）。近端脾动脉直径最恒定且最大，位置更靠近胰上缘，转移率最低；因此，近端脾动脉入路是进展期胃癌腹腔镜胰上淋巴结清扫的理想入路。
