Hirai Kenjiro, Aoyama Taro, Hirata Wataru, Okabe Hiroshi, Mitsuyoshi Akira
Department of Surgery, Otsu City Hospital 2-9-9 Motomiya, Otsu City, Shiga, 520-0804, Japan.
Department of Surgery, Otsu City Hospital 2-9-9 Motomiya, Otsu City, Shiga, 520-0804, Japan; Department of Surgery, Graduate School of Medicine, Kyoto University 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto City, 606-8507 Japan.
Int J Surg Case Rep. 2020;77:743-747. doi: 10.1016/j.ijscr.2020.11.086. Epub 2020 Nov 24.
Due to recent advances in surgical procedures and instruments, laparoscopic gastrectomy for gastric cancer has been widely performed, and previous studies reported laparoscopic surgery for gastric cancer with Adachi type VI vascular anomaly. In Adachi type VI patients, the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA); therefore, the route of lymph flow differs from the normal route, and the supra- and infrapyloric lymph nodes (LN) may reach SMA LN. However, metastasis has not yet been reported. A case of SMA LN metastasis 3 years after laparoscopic distal gastrectomy for gastric cancer with Adachi type VI CHA anomaly, which was diagnosed using preoperative computed tomography (CT), was described herein.
The patient was a 77-year-old male. Laparoscopic distal gastrectomy and D2 + 14v LN dissection for gastric cancer with Adachi type VI vascular anomaly were performed. Three years after surgery, periodic CT revealed swelling of regional and mediastinal SMA LN, leading to a diagnosis of recurrent gastric cancer. A histopathological examination of the resected specimen showed metastases to the greater curvature right group and infrapyloric LN.
Metastasis to LN No. 6 may have reached SMA LN via the gastroduodenal artery and CHA, but not the celiac artery.
If preoperative diagnostic imaging suggests metastasis to the greater curvature right group and pyloric regions in gastric cancer patients with Adachi type VI vascular anomaly, LN dissection along CHA originating from SMA and the hepatomesenteric trunk needs to be considered.
由于外科手术和器械的最新进展，腹腔镜胃癌切除术已广泛开展，先前的研究报道了针对伴有安达achi VI型血管异常的胃癌进行腹腔镜手术。在安达achi VI型患者中，肝总动脉（CHA）起源于肠系膜上动脉（SMA）；因此，淋巴引流途径与正常途径不同，幽门上和幽门下淋巴结（LN）可能转移至SMA淋巴结。然而，尚未有转移的报道。本文描述了一例伴有安达achi VI型CHA异常的胃癌患者，在腹腔镜远端胃癌切除术后3年发生SMA淋巴结转移，该转移通过术前计算机断层扫描（CT）诊断。
患者为77岁男性。对伴有安达achi VI型血管异常的胃癌进行了腹腔镜远端胃切除术和D2 + 14v淋巴结清扫术。术后三年，定期CT显示区域和纵隔SMA淋巴结肿大，诊断为复发性胃癌。切除标本的组织病理学检查显示大弯右侧组和幽门下淋巴结有转移。
6号淋巴结转移可能通过胃十二指肠动脉和CHA到达SMA淋巴结，但未通过腹腔动脉。
如果术前诊断性影像学提示伴有安达achi VI型血管异常的胃癌患者大弯右侧组和幽门区域有转移，则需要考虑沿起源于SMA和肝肠系膜干的CHA进行淋巴结清扫。
