LYMPHADENECTOMY IN CARCINOMA STOMACH

Dr.A.Joseph Stalin PG

PROF.DR.R.RAJARAMAN’S UNITDEPT OF SURGICAL ONCOLOGYGOVT ROYAPETTAH HOSPITAL

CHENNAI

CONTENTS

• BASIC PRINCIPLES

• TECHNIQUE

• FUTURE PROSPECTIVE

PRINCIPLES

• Role of lymphadenectomy

STAGING LOCO REGIONALCONTROL

SURVIVAL BENEFIT

Japanese concept• Gastric cancer spreads in a orderly pattern from tier I node to

tier 2 nodes and then to tier 3 node/systemic spread .

• Removal of one nodal basin more than involved region highly increase the chance of cure.

• T1 tumours :D1 lymphadenectomy• T2,T3,T4 tumours :D2 lymphadenectomy

Western Concept

• Lymphadenectomy done mainly for staging purpose not to improve survival.

• Survival benefit of D2 lymphadenectomy if any is negated by high morbidity and mortality associated with the procedure.

SURVIVAL

• Overall 5yr survival

EAST(Japan,Korea) : 60%

WEST(Europe,USA):20 %

Shachelford 6th Edition

Why this Difference?

PATIENT/DISEASE FACTORS

EAST (Japan,Korea)

• Incidence: 75/Lakh• Younger age• Lower BMI• Higher incidence of H.Pylori

infection• More of Distal tumours• Detected at early stage

WEST (Europe,USA)

• Incidence:5/lakh• Older age • Higher body mass index• Lower incidence of H. pylori

infection• More of proximal tumors• Present at advanced stage

SURGICAL FACTORS

EAST• Japanese are the first to

stage gastric cancer in 1962.• First to describe nodal

station.• Described D2

lymphadenectomy in 1960’s practising since then.

• High volume centre :200 gastric cancer surgery/year

WEST• Practising D2

lymphadenectomy since 1990’s.

• Technique of lymphadenectomy not yet standardised.

• 20 gastric cancer surgery/year

D1 Versus D2 Lymphadenectomy for Gastric CancerBENJAMIN SCHMIDT, MD and SAM S. YOON, MD*

J Surg Oncol. 2013 March ; 107(3): 259–264. doi:10.1002/jso.23127

• Mortality and morbidity following D2 lymphadenectomy East :0.5 % mortality,20% morbidity. West :4-9 % mortality,40% morbidity.

• Even after adjustment for age, sex,tumor location, Lauren classification, number of lymph nodes resected (negative and positive), and depth of invasion ,

Eastern patients have 30% better disease specific survival rate.

Japanese Gastric CancerAssociation (JGCA)

• JGCA guidelines -1963• Upper, middle and lower portions

• 16 nodal stations

• Grouped N0-N4 according to the location and extension of the primary tumor

• Designations changed based on the primary location of the tumor (i.e., upperthird, middle third, and lower third)

LYMPH NODE STATION

The JGCA recently abandoned their N designation of nodal stations

• The N groupings have changed considerably over time.

• Current definitions include only node levels from N1 thorough N3 (i.e., no N4).

• 20 stations

Evolution of Nomenclature of Lymphadenectomy in Japan

Orig

inal

des

crip

tion

D 1 – 3, N 1-3 based on location of the growth

Japa

nese

gui

delin

e 20

01

D 0 : Incomplete D 1

D 1 : 1 – 6D 2 : + 7 – 11, 1 4 v

D 3 : + 12 – 1 4D 4 : + 15 , 16

Japa

nese

gui

delin

es 2

011

D 0D 1D 1 +D 2D 2 +

Total gastrectomy

• D0: Lymphadenectomy less than D1• D1: Nos. 1–7• D1+: D1 and Nos. 8a, 9, 11p• D2: D1 and Nos. 8a, 9, 10, 11p, 11d, 12a.

For tumors invading the esophagus, D1+ includes No.110, D2 includes Nos. 19, 20, 110, and 111.

Japanese gastric cancer treatment guidelines 2010 (ver. 3)

Distal gastrectomy

• D0: Lymphadenectomy less than D1• D1: Nos. 1, 3, 4sb, 4d, 5, 6, 7• D1+: D1 and Nos. 8a, 9• D2: D1 and Nos. 8a, 9, 11p, 12a.

Japanese gastric cancer treatment guidelines 2010 (ver. 3)

D 2 in Distal

Gastrectomy

8a9

11p

1

2

34

5

6

7

10

11d

12a

8a9

11p

1

2

34

5

6

7

10

11d

12a

Omit Stations 2, 4sa , 10 and 11d

4sa

INDICATION• D1 or a D1+ lymphadenectomy : cT1N0

• D1 lymphadenectomy :T1a tumors that do not meet the criteria for endoscopic mucosal resection (EMR)/ endoscopic submucosal resection (ESD), and for cT1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.

• D1+ lymphadenectomy : cT1N0 tumors other than the above

INDICATION• D2 : cN+ or cT2-T4 tumors.

• The benefit of prophylactic para-aortic lymphadenectomy (D3)was denied by the Japanese randomized controlled trial (RCT) JCOG 9501

Lymphadenectomy NOT indicated :

• T1a & < 2cm, well differentiated without ulceration ( EMR / ESD )

• Palliative gastrectomy

TECHNIQUE

Sequence of Operative Procedures

• Mobilization of the greater curvature with bursectomy /omentectomy and division of the left gastroepiploic artery

• Infrapyloric mobilization with ligation of the right gastroepiploic artery and vein as it enters the gastrocolic trunk

• Suprapyloric mobilization with ligation of the right gastric artery• Duodenal transection

• Lymphadenectomy with dissection of the porta hepatis, common hepatic artery, left gastric artery, celiac axis, and splenic artery .

• ligation of left gastric artery

• Gastric transection

• Reconstruction by loop or Roux-en-Y gastrojejunostomy

Bursectomy

Omentum

Duodenum

Ant. sheet of transv. mesocolon

Post. sheet of transv. mesocolon

Completion of Bursectomy

Pancreatic tail

Exposure of the Gastro-colic Trunk

Middle colic V.

rt. colic V.

Rt. gastro-epiploic V.

Ant. sup. panc. duod. V.

Sup. mesenteric V.

Gastro-colic trunk

Division of the Right Gastro-epiploic Vein

Exposure of the Supra-pyloric Area

Rt. gastric A.

Sup. duodenal A.

Pylorus

Exposure of the Right Gastric Argery

Gastroduodenal A.

Rt. gastric A.

Transection of the Duodenum

Dissection of the Upper Border of the Pancreas

Identification of the Splenic Artery

Splenic A.

Gastroduodenal A.

No. 8a LN

Common hepatic A.

Dissection of the No. 12a Nodes

No. 12a LN

Common hepatic A.Proper hepatic A.

Portal V.

Taping of the Common Hepatic Artery

Lymphadenectomy along the Splenic Artery

Great pancreatic A.

Splenic V.

Post. gastric A.

Splenic A.

Division of the Left Gastric Artery

Lt. gastric A. stump

Lymphadenectomy along Esophageal Hiatus

Diaphragmatic crus

Post. wall of the cardiaPost. vagal trunk

DISTAL GASTRECTOMY +D2

DISTAL GASTRECTOMY +D2

DISTAL GASTRECTOMY + D2

Table S1. Evaluation criteria for completeness of subtotal D2 lymphadenectomy

Surgical Video Assessment Form Video ID: ___________________________ Reviewer ID: _________________________________ Please indicate whether or not the surgeon meets the requirements of the D2 lymph node dissection in the video you are reviewing by encircling either “yes” or “no” next to the 22 defined elements of the procedure. In cases where the surgeon fails to perform the required dissection, please identify the reason the requirement was not met. Procedure Station Requirement Meets the

requirement In case of “No” please identify the reason

1. Total omentectomy No injury was made to the any other organ. Yes / No 2. Division of left gastroepiploic artery (It is not necessary to dissect the root of left gastroepiploic artery if the tumor is located in lower third of the stomach.)

4Sb The left gastroepiploic artery and left gastroepiploic vein are divided at least below the bifurcation of the first gastric branch.

Yes / No

No injury was made to the colon of splenic flexure. Yes / No 4d The branch of right gastroepiploic artery and vein are

retrieved. Yes / No

3. Appropriate extent of No. 6 lymph node (LN) dissection

6 The right gastroepiploic vein is divided just above the bifurcation of the anterior superior pancreaticoduodenal vein and the right gastroepiploic vein.

Yes / No

The right gastroepiploic artery is divided just peripheral to the bifurcation of the right gastroepiploic artery and the anterior superior pancreaticoduodenal artery.

Yes / No

The lowest anterior superior pancreaticoduodenal vein is identified and exposed.

Yes / No

The prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein are completely removed.

Yes / No

The prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein are completely removed.

Yes / No

No injury was made to the pancreatic parenchyma. Yes / No

4. Appropriate extent of No. 5 LN dissection

5 The root of right gastric artery is identified and exposed.

Yes / No

5. Appropriate extent of No. 12a LN dissection

12a The lower half of the proper hepatic artery is exposed; at least its anterior and left surfaces.

Yes / No

The left side of the portal vein is identified and exposed and soft tissues are completely removed.

Yes / No

6 .Appropriate extent of No. 8a LN dissection

8a The common hepatic artery is exposed; at least its anterior and superior surfaces.

Yes / No

The soft tissues above the upper edge of the pancreas are completely removed.

Yes / No

7. Appropriate extent of No. 9 LN dissection (resection of the celiac plexus is not necessary)

9 The retroperitoneal membrane is divided along the boundary between the right crus and the soft tissues around the celiac trunk to completely dissect No. 9 LNs.

Yes / No

8. Appropriate extent of No. 7 LN dissection

7 The root of the left gastric artery is exposed and ligated.

Yes / No

9.Appropriate extent of No. 11p LN dissection

11p The proximal half of the splenic artery is exposed, from its root to the site where the meandering splenic artery is in the closest vicinity to the stomach.

Yes / No

The splenic vein is identified and exposed, or at least the dorsal side of pancreatic parenchyma is exposed.

Yes / No

10.Prevention of pancreatic injury during suprapancreatic LN dissection

No pancreatic injury by heat of energy devices and/or assistant’s forceps was caused.

Yes / No

11.Appropriate extent of No. 1 and 3 LN dissection

1, 3 The soft tissue attached to the lesser curvature side of gastric wall is completely removed.

Yes / No

No esophageal and/or gastric injury by heat of energy devices and/or blind manipulation was caused.

Yes / No

General impression and comments:

COMPLICATIONS

%• Pancreatitis 3.7• Pancreatic fistula 4.6• Abdominal abscess 4.6• Obstruction /ileus 1.9• Lymphorrhea 0.9• Wound infection 1.9• Pneumonia 5.7• Anastamotic leak 1.9• Cardiac 0.9• Reoperation 2.8• Mortality 4• Morbidity 33

• ANNALS OF GASTROENTEROLOGY 2010, 23(3)

FUTURE PROSPECTIVE

48

Sentinel Lymph Node (SLN) Biopsy • Injection of Isosulfan blue Indocyaninegreen • Technetium 99 m - radioisotope– Intraoperative endoscopic injection (standard)– Intraoperative subserosal injection

• Injections are carried out in four quadrants of the tumor

49

SUITABLE PATIENT SUBGROUP

• Eastern studies node-negative T1 and T2 patients

• Western institutions have included T3 tumors as well

50

• Authors from Asia reported an accuracy of more than 98% in particular in early stages (T1-T2)

• Whereas other series from Western countries, the accuracy was about 80% , with the false negative SLN rate ranging from 15% to 20%

• Patients with sentinel nodes containing metastasis should be treated with the D2 procedure (Miwa et al., 2001).

51

SNB

• Complex lymphatic drainage of the stomach and fear of skip metastasis - make the selection of patients difficult

• Further studies are needed before this method can be introduced into daily practice.

CONCLUSION• Entire concept of lymphatic spread and lymphadenectomy

first conceived and practised by Japanese.

• Lymphadenectomy classified based on the type of gastric resection done since 2010.

• Total gastrectomy : D1 : 1-7• D2 :D1 + 8a,9,10,11p,11d,12a.• Distal gastrectomy : D1 :1-7 (except 2,4sa)• D2 :D1 + 8a,9,11p,12a

CONCLUSION

• D2 lymphadenectomy done in Japan has low morbidity and mortality with increased survival advantage.

• Same results are not reproduced by Western surgeons.

• D2 lymphadenectomy has to be standardised and practised uniformly by all surgeons to come to an meaningful conclusion about it’s efficacy

THANK U………