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Curative para-Aortic lymph node dissection Via INfra-mesocolonic approach in laparoscopic Gastrectomy (CAVING approach)

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Abstract

Purpose

Para-aortic lymph node (PAN) metastasis for gastric cancer is considered a distant lymph node metastasis. Meanwhile, multidisciplinary treatments have improved survival of patients with PAN metastases. We developed a novel technique of curative para-aortic lymph node dissection via infra-mesocolonic approach in laparoscopic gastrectomy (CAVING approach). This method minimizes the mobilization of the pancreas and the spleen and maximizes the view from the caudal side resembling cave exploration.

Methods

After laparoscopic gastrectomy, PAN dissection is performed using the same ports setup. The retroperitoneum is widely exposed to ease anatomical cognition and for troubleshooting. The inferior vena cava, the left gonadal vein, the left renal vein, and the aorta are recognized under Gerota’s fascia. The retroperitoneum is then divided into four sections. We perform PAN dissection in the order of 16blat, 16b1int, 16a2lat, and then 16a2int. Using the CAVING approach, the caudal side of the root of the superior mesenteric artery can then be dissected below the pancreas, and only the cranial side of the SMA root requires a suprapancreatic approach.

Results

In three cases, preoperative chemotherapy and laparoscopic gastrectomy plus D2 with PAN dissection were performed for gastric cancer and esophagogastric junction cancer. The median operation totaled 484 min, 142 min for the PAN dissection. The median whole blood loss was 130 ml. The median harvested number of PAN was 25.

Conclusions

The minimal mobilization of pancreas and the wide surgical fields by CAVING approach may facilitate safe and reliable PAN dissection.

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Abbreviations

PAN:

para-aortic lymph node

SMA:

superior mesenteric artery

IMV:

inferior mesenteric vein

IMA:

inferior mesenteric artery

IVC:

inferior vena cava

POD:

postoperative day

References

  1. Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D, ESMO Guidelines Committee (2016) Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 27(suppl 5):38–49

    Article  Google Scholar 

  2. Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A, Hiratsuka M, Tsujinaka T, Kinoshita T, Arai K, Yamamura Y, Okajima K (2008) Japan Clinical Oncology Group.D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N Engl J Med 359(5):453–462

  3. Edge SB, Compton CC (2010) The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 17:1471–1474

  4. Japanese Gastric Cancer Association (2011) Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 14(2):101–112

  5. Japanese Gastric Cancer Association (2021) Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 24:1–21

  6. Tokunaga M, Ohyama S, Hiki N, Fukunaga T, Aikou S, Yamaguchi T (2010) Can superextended lymph node dissection be justified for gastric cancer with pathologically positive para-aortic lymph nodes? Ann Surg Oncol 17(8):2031–2036

  7. Kunisaki C, Akiyama H, Nomura M, Matsuda G, Otsuka Y, Ono H, Nagahori Y, Hosoi H, Takahashi M, Kito F, Shimada H (2006) Comparison of surgical results of D2 versus D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric carcinoma: a multi-institutional study. Ann Surg Oncol 13(5):659–667

  8. Fujimura T, Nakamura K, Oyama K, Funaki H, Fujita H, Kinami S, Ninomiya I, Fushida S, Nishimura G, Kayahara M, Ohta T (2009) Selective lymphadenectomy of para-aortic lymph nodes for advanced gastric cancer. Oncol Rep 22(3):509–514

  9. Yoshikawa T, Sasako M, Yamamoto S, Sano T, Imamura H, Fujitani K, Oshita H, Ito S, Kawashima Y, Fukushima N (2009) Phase II study of neoadjuvant chemotherapy and extended surgery for locally advanced gastric cancer. Br J Surg 96(9):1015–22

  10. Tsuburaya A, Mizusawa J, Tanaka Y, Fukushima N, Nashimoto A, Sasako M (2014) Stomach Cancer Study Group of the Japan Clinical Oncology Group. Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis. Br J Surg 101(6):653–660

  11. Takahari D, Ito S, Mizusawa J, Katayama H, Terashima M, Sasako M, Morita S, Nomura T, Yamada M, Fujiwara Y, Kimura Y, Ikeda A, Kadokawa Y, Sano T (2020) Stomach Cancer Study Group of the Japan Clinical Oncology Group. Long-term outcomes of preoperative docetaxel with cisplatin plus S-1 therapy for gastric cancer with extensive nodal metastasis (JCOG1002). Gastric Cancer 23(2):293–299

  12. Shi Y, Xu X, Zhao Y, Qian F, Tang B, Hao Y, Luo H, Chen J, Yu P (2019) Long-term oncologic outcomes of a randomized controlled trial comparing laparoscopic versus open gastrectomy with D2 lymph node dissection for advanced gastric cancer. Surgery 165(6):1211–1216

  13. Kodera Y, Kobayashi D, Tanaka C, Fujiwara M (2015) Gastric adenocarcinoma with para-aortic lymph node metastasis: a borderline resectable cancer? Surg Today 45(9):1082–1090

  14. Li G, Dong J, Lu JS, Zu Q, Yang SX, Li HZ, Ma X, Zhang X (2011) Anatomical variation of the posterior lumbar tributaries of the left renal vein in retroperitoneoscopic left living donor nephrectomy. Int J Urol 18(7):503–509

  15. Gwon DI, Ko GY, Yoon HK, Sung KB, Lee JM, Ryu SJ, Seo MH, Shim JC, Lee GJ, Kim HK (2007) Inferior phrenic artery: anatomy, variations, pathologic conditions, and interventional management. Radiographics 27(3):687–705

  16. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

  17. Park IH, Kim SY, Kim YW, Ryu KW, Lee JH, Lee JS, Park YI, Kim NK, Park SR (2011) Clinical characteristics and treatment outcomes of gastric cancer patients with isolated para-aortic lymph node involvement. Cancer Chemother Pharmacol 67(1):127–136

  18. Ito S, Sano T, Mizusawa J, Takahari D, Katayama H, Katai H, Kawashima Y, Kinoshita T, Terashima M, Nashimoto A, Nakamori M, Onaya H, Sasako M (2017) A phase II study of preoperative chemotherapy with docetaxel, cisplatin, and S-1 followed by gastrectomy with D2 plus para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis: JCOG1002. Gastric Cancer 20(2):322–331

  19. Sano T, Sasako M, Mizusawa J, Yamamoto S, Katai H, Yoshikawa T, Nashimoto A, Ito S, Kaji M, Imamura H, Fukushima N, Fujitani K (2017) Stomach Cancer Study Group of the Japan Clinical Oncology Group. Randomized controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric carcinoma. Ann Surg 265(2):277–283

  20. Gulas E, Wysiadecki G, Szymański J, Majos A, Stefańczyk L, Topol M, Polguj M (2018) Morphological and clinical aspects of the occurrence of accessory (multiple) renal arteries. Arch Med Sci 14(2):442–453

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Authors and Affiliations

  1. Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan

    Keiji Hayata, Toshiyasu Ojima, Masaki Nakamura, Junya Kitadani, Akihiro Takeuchi & Hiroki Yamaue

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  1. Keiji Hayata
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  2. Toshiyasu Ojima
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  3. Masaki Nakamura
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  4. Junya Kitadani
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  5. Akihiro Takeuchi
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  6. Hiroki Yamaue
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Contributions

Study conception and design: Keiji Hayata, Toshiyasu Ojima, Masaki Nakamura, and Hiroki Yamaue. Acquisition of data: Keiji Hayata, Junya Kitadani, and Akihiro Takeuchi. Analysis and interpretation of data: Keiji Hayata, Junya Kitadani, and Akihiro Takeuchi. Drafting of manuscript: Keiji Hayata, Toshiyasu Ojima, and Hiroki Yamaue. Critical revision of manuscript: Keiji Hayata, Toshiyasu Ojima, and Hiroki Yamaue.

Corresponding author

Correspondence to Toshiyasu Ojima.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The present retrospective study was approved by the Institutional Review Board of the Wakayama Medical University Hospital, with a waiver of the written informed consent from all patients concerned.

Conflict of interests

The authors declare no competing interests.

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Supplementary Information

Video

After gastrectomy, the transverse colon is lifted to the cranial side. The duodenum is mobilized above layer of retroperitoneum, the Gerota’s fascia, and the IVC is revealed. The dorsal side of mesocolon including the IMV is dissected above the retroperitoneal layer until identification of the left gonadal vein and the left renal vein. The retroperitoneal space is fully exposed. The retroperitoneum is divided into four sections by the cross of the aorta and the left renal vein.

Part 1 of PAN dissection is at the No.16b1lat station. To identify the left gonadal vein, the retroperitoneum is dissected laterally from the root of the IMA. The caudal lymphatic ducts in level of the IMA root are also clipped to prevent lymphatic leakage. On the dorsal side of the left gonadal vein, there is a dissectible layer between 16b1lat and perinephric fat tissue. The dissection in the medial side is performed along the aorta. The left renal artery is exposed on the cranial side.

Part 2 of PAN dissection is at the No.16b1int station. A Nathanson retractor is hooked onto the mesocolon and the body of the pancreas to secure the surgical field. On the lateral side, the retroperitoneum is longitudinally divided to expose the adventitia of the IVC. The dissection in the medial side is performed along the aorta. The caudal lymphatic ducts in level of the IMA root are also clipped to prevent lymphatic leakage. The anterior longitudinal ligament is exposed on the dorsal side. On the cranial side, the right renal artery is exposed.

Part 3 of PAN dissection is at the No.16a2lat station. In this case, the left adrenal vein was dissected with clipping because left adrenal metastasis was suspected. The cranial side of the left renal artery dissected. Next, the surgical field is changed to a suprapancreatic view and the splenic artery is taped. The body of pancreas is mobilized by caudally retracting the taping of splenic artery. When the retropancreatic fascia is divided, the retroperitoneal space dissected from the caudal side is opened. The dissection line of the medial side is the lateral side of the inferior phrenic artery, celiac ganglion, superior mesenteric artery, and aorta.

Part 4 of PAN dissection is at the No.16a2int station. The approach is again shifted to the infra-mesocolon view. The cranial side of the right renal artery is dissected. After placing a gauze over the surface of the right renal artery and the left renal vein, the surgical field is changed to a suprapancreatic view. The dissection line of medial side is celiac ganglion, and the crus of diaphragm with resection of the greater and lesser splanchnic nerve. The dissection line of lateral side is the surface of left adrenal vein under the IVC.

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Hayata, K., Ojima, T., Nakamura, M. et al. Curative para-Aortic lymph node dissection Via INfra-mesocolonic approach in laparoscopic Gastrectomy (CAVING approach). Langenbecks Arch Surg 406, 2067–2074 (2021). https://doi.org/10.1007/s00423-021-02198-6

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  • DOI: https://doi.org/10.1007/s00423-021-02198-6

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