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Totally Laparoscopic Total Gastrectomy with D2+ Para-aortic Lymph Node Dissection

Authors
Charleen Yeo, Aung Myint Oo

Affiliations
Department of General Surgery, Tan Tock Seng Hospital, Singapore

Introduction
Para-aortic lymphadenopathy is considered metastatic disease in gastric cancer. The role of preoperative chemotherapy followed by gastrectomy with para-aortic lymph node dissection remains controversial, however studies have demonstrated potential survival benefit in a select group of patients1,2.

Methods
This is a surgical video case presentation on a patient who underwent laparoscopic total gastrectomy with para-aortic lymph node dissection. We describe a case of a 72 year-old gentleman who presented with dyspepsia for 1 year. Investigations showed a lesser curve gastric adenocarcinoma with enlarged peri-gastric and para-aortic lymph nodes which were FDG-avid on pre-operative positron emission tomography (PET) scan. He underwent 12 cycles of preoperative chemotherapy (folinic acid, fluorouracil, oxaliplatin), and a repeat PET scan showed resolution of his lymphadenopathy and regression of his gastric tumour. His case was discussed in our institution’s tumour board and he underwent a totally laparoscopic total gastrectomy with D2+ para-aortic lymphadenectomy and Roux-en-Y reconstruction via the CAVING technique described by Hayata et al3. Para-aortic lymph nodes (16a2 and 16b1) were dissected completely (Image 1).

Results
He was discharged well on post-operative day 9, and was tolerating soft diet. Final histology showed a ypT3N3a gastric adenocarcinoma, with 8/91 lymph node involved (7/62 regional lymph nodes, 1/29 para-aortic lymph nodes). Patient was offered adjuvant chemotherapy post-surgery however he declined and was placed on surveillance. A repeat computed tomography 6 months post-surgery showed no recurrence.

Conclusion
A totally laparoscopic approach to D2+ gastrectomy with para-aortic lymph node dissection is feasible. The role of D2+ para-aortic lymphadenectomy in a select group of patients can be considered on a case-by-case basis and in conjunction with our medical oncology colleagues.

References

  1. Yu, P., Hu, C., Wang, Y. et al. Preoperative chemotherapy combined with para-aortic lymph node dissection has clinical value in the treatment of gastric cancer with para-aortic lymph node metastases. BMC Surg 22, 401 (2022). https://doi.org/10.1186/s12893-022-01844-0
  2. A Tsuburaya, J Mizusawa, Y Tanaka, N Fukushima, A Nashimoto, M Sasako, on behalf of the 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, British Journal of Surgery, Volume 101, Issue 6, May 2014, Pages 653–660, https://doi.org/10.1002/bjs.9484Hayata, K., Ojima, T., Nakamura, M., Kitadani, J., Takeuchi, A., & Yamaue, H. (2021). Curative para-Aortic lymph node dissection Via INfra-mesocolonic approach in laparoscopic Gastrectomy (CAVING approach). Langenbeck's archives of surgery, 406(6), 2067–2074. https://doi.org/10.1007/s00423-021-02198-6