Is splenic hilar lymph node dissection necessary for proximal gastric cancer surgery?

Abstract

Advanced proximal gastric cancer sometimes metastasizes to the splenic hilar lymph nodes (No. 10 LN). Total gastrectomy combined with splenectomy is performed for complete removal of the No. 10 LN and was historically a standard procedure in Japan. However, splenectomy is associated with several disadvantages for patients, such as increased postoperative morbidity, risk of thrombogenic disease, fatal infection from encapsulated bacteria, and the development of other types of cancer in the long term because of loss of immune function. Therefore, splenectomy should only be performed when its estimated oncological effect exceeds such disadvantages. A Japanese randomized controlled trial (JCOG0110) clearly demonstrated that prophylactic splenectomy is not necessary unless the tumor has invaded the greater curvature; thus, splenectomy is no longer routinely performed in Japan. However, several retrospective studies have shown a comparatively high incidence of No. 10 LN metastasis and therapeutic value from LN dissection at that station in the tumors invading the greater curvature. Similar tendencies have also been reported in type 4 or remnant gastric cancer involving the greater curvature. In view of these facts, No. 10 LN dissection is presently recommended for such patients; however, robust evidence is lacking. In recent years, laparoscopic/robotic spleen‐preserving splenic hilar dissection utilizing augmented visualization without pancreatic mobilization has been developed. This procedure is expected to replace prophylactic splenectomy and provide an equal oncological effect with lower morbidity. In Japan, a prospective phase‐II study (JCOG1809) is currently ongoing to investigate the safety and feasibility of this procedure.

Is D2 laparoscopic gastrectomy essential for elderly patients with advanced gastric cancer? A propensity score matched analysis

“…One patient underwent LTG with splenectomy (LTGS). LTGS was reported to be associated with a high incidence of intra-abdominal infectious complications due to pancreatic ischemia or congestion, and mechanical damage to the pancreas (23). However, the others underwent LDG.…”

Survival outcomes of laparoscopic versus open total gastrectomy with nodal dissection for gastric cancer in a high‐volume Japanese center: A propensity score‐matched analysis

“…Laparoscopy is expected to allow spleen‐preserving splenic hilar dissection, and such procedures are included in this study cohort. A phase‐II multicenter study (JCOG1809) is under way in Japan 22 to determine the safety and efficacy of laparoscopic spleen‐preserving splenic hilar dissection for proximal advanced gastric cancer that invades the greater curvature.…”

Efficacy of the No. 10 lymphadenectomy with spleen preservation on patients with gastric cancer and/or esophagogastric junction adenocarcinoma who underwent total gastrectomy: a systematic review and meta-analysis

“…10 LND for the total gastrectomy in previous years (36,37). However, the gastrectomy combined with the resection of spleen is reported to result in higher morbidity, larger blood loss, and could not show a superiority on survival rates compared with that of splenic preservation (38,39). Moreover, the loss of the antitumor and the anti-infection functions found that the 5-year overall survival rates of two arms are 75.1% and 76.4%, respectively (P>0.05); and confirmed the noninferiority of the spleen preservation.…”