Gastric Resection with D2 Nodal Dissection for Gastric Adenocarcinoma



Gastric Resection with D2 Nodal Dissection for Gastric Adenocarcinoma


Hisakazu Hoshi



As the incidence of gastric cancer declines, gastrectomy for gastric carcinoma is becoming one of the rarely performed operations for general surgeons. The extent of nodal dissection associated with the operation is a topic of debate but current national guidelines recommend resection of regional lymph nodes. This chapter reviews anatomy and technique of both distal and total gastrectomies with D2 nodal dissection. Additional material on technique of gastrectomy and BI and BII reconstructions is given in Chapter 61.

SCORE™, the Surgical Council on Resident Education, classified partial and total gastrectomies as “ESSENTIAL UNCOMMON” procedures.

STEPS IN PROCEDURE

Gastrectomy with D2 Nodal Dissection (Common Portion)



  • Upper midline incision and through abdominal exploration


  • Assess resectability, undetected metastatic disease


  • Retract greater omentum cephalad and detach from transverse colon, preserving mesentery to colon


  • Dissect infrapyloric nodal station and ligate right gastroepiploic vessels


  • Ligate right gastric artery and dissect suprapyloric nodal station


  • Divide duodenum with stapler


  • Divide lesser omentum to the GE junction


  • Dissect nodes along the hepatic artery


  • Elevate stomach and divide left gastric artery at its origin


  • Dissect celiac and proximal splenic nodal stations

Distal Gastrectomy



  • Dissect right paracardiac nodes and lesser curvature nodes toward resection line


  • Ligate left gastroepiploic vessels and dissect greater curvature nodes toward resection line


  • Divided stomach with 3 to 5 cm margin

Total Gastrectomy



  • Ligate left gastroepiploic vessels and divide gastrosplenic ligament by ligating all short gastric arteries


  • Isolate distal esophagus and divide

For Roux-en-Y Reconstruction



  • Divide upper jejunum 20 to 30 cm past ligament of Treitz


  • Pass jejunum to stomach or esophagus (if total gastrectomy)


  • Antecolic, or through hole in transverse mesocolon (retrocolic)


  • End-to-side esophagojejunostomy with circular staple or end-to-end gastrojejunostomy (stapled or sutured)


  • Jejunojejunostomy (stapled or sutured)


  • Side-to-side jejunojenunostomy 40 to 45 cm from anastomosis

HALLMARK ANATOMIC COMPLICATIONS



  • Injury to



    • common bile duct


    • celiac artery branches


    • portal or splenic vein


    • spleen


    • pancreas


  • Gastric remnant necrosis from splenic artery injury

LIST OF STRUCTURES



  • Esophagus


  • Right diaphragmatic crus


  • Stomach


  • Lesser curvature


  • Greater curvature


  • Antrum



  • Esophagogastric junction


  • Pylorus


  • Duodenum


  • Ligament of Treitz


  • Spleen


  • Transverse colon


  • Transverse mesocolon


  • Greater omentum


  • Lesser omentum


  • Lesser sac


  • Hepatoduodenal ligament


  • Middle colic vessels


  • Right accessory colic vein


  • Right gastroepiploic vein


  • Gastro colic trunk


  • Right gastroepiploic artery


  • Right gastric artery


  • Pancreas


  • Common bile duct


  • Celiac artery


  • Common hepatic artery


  • Proper hepatic artery


  • Splenic artery


  • Posterior gastric artery


  • Left gastric artery


  • Left gastric vein (coronary vein)


  • Left gastroepiploic artery


  • Portal vein


  • Splenic vein


  • Liver


  • Left lateral lobe of liver


  • Caudate lobe


  • Gastrosplenic ligament


  • Short gastric arteries


Definition of the Nodal Stations and the D1 and D2 Nodal Dissections

The nodal stations around the stomach are anatomically defined and numerically classified by the Japanese Classification of Gastric Carcinoma published by Japanese Gastric Cancer Association (JGCA) (Fig. 62.1, Table 62.1). Perigastric nodal stations are numbered 1 to 6 and regional nodal stations are 7 to 12. Nodal stations numbered higher than 12 are generally considered “distant” nodal stations and are not dissected for the standard D2 nodal dissection except nodal station 14v.

The level of the nodal dissection, known as D number, is defined by the guidelines from JGCA. While the classic D1 nodal dissection is defined by complete dissection of the first-tier nodal stations (which are determined by the location of the primary lesion and is most compatible with current concept of the “D1 nodes, perigastric nodes [stations 1 to 6]” in western literature), current (2010) definition of D1 nodal dissection in Japan includes left gastric artery node station (station 7) in addition to the perigastric nodal stations due to the observed high rate of metastasis in this nodal station by the early gastric cancer.






Figure 62.1 A and B: Location and border of lymph node stations by Japanese Gastric Cancer Association (from Japanese Gastric Cancer Association. Figure 7. In: Japanese Classifications of Gastric Carcinoma. 14th ed. Tokyo, Japan: Kanehara & Co. Ltd., with permission).









Table 62.1 Anatomical Definitions of Lymph Node Stations










































































































No. Definition
1 Right paracardial LNs, including those along the first branch of the ascending limb of the left gastric artery
2 Left paracardial LNs including those along the esophagocardiac branch of the left subphrenic artery
3a Lesser curvature LNs along the branches of the left gastric artery
3b Lesser curvature LNs along the second branch and distal part of the right gastric artery
4sa Left greater curvature LNs along the short gastric arteries (perigastric area)
4sb Left greater curvature LNs along the left gastroepiploic artery (perigastric area)
4d Right greater curvature LNs along the second branch and distal part of the right gastroepiploic artery
5 Suprapyloric LNs along the first branch and proximal part of the right gastric artery
6 Infrapyloric LNs along the first branch and proximal part of the right gastroepiploic artery down to the confluence of the right gastroepiploic vein and the anterior superior pancreatoduodenal vein
7 LNs along the trunk of the left gastric artery between its root and the origin of its ascending branch
8a Anterosuperior LNs along the common hepatic artery
8p Posterior LNs along the common hepatic artery
9 Celiac artery LNs
10 Splenic hilar LNs including those adjacent to the splenic artery distal to the pancreatic tail, and those on the roots of the short gastric arteries and those along the left gastroepiploic artery proximal to its first gastric branch
11p Proximal splenic artery LNs from its origin to halfway between its origin and the pancreatic tail end
11d Distal splenic artery LNs from halfway between its origin and the pancreatic tail end to the end of the pancreatic tail
12a Hepatoduodenal ligament LNs along the proper hepatic artery, in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas
12b Hepatoduodenal ligament LNs along the bile duct, in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas
12p Hepatoduodenal ligament LNs along the portal vein in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas
13 LNs on the posterior surface of the pancreatic head cranial to the duodenal papilla
14v LNs along the superior mesenteric vein
15 LNs along the middle colic vessels
16a1 Para-aortic LNs in the diaphragmatic aortic hiatus
16a2 Para-aortic LNs between the upper margin of the origin of the celiac artery and the lower border of the left renal vein
16b1 Para-aortic LNs between the lower border of the left renal vein and the upper border of the origin of the inferior mesenteric artery
16b2 Para-aortic LNs between the upper border of the origin of the inferior mesenteric artery and the aortic bifurcation
17 LNs on the anterior surface of the pancreatic head beneath the pancreatic sheath
18 LNs along the inferior border of the pancreatic body
19 Infradiaphragmatic LNs predominantly along the subphrenic artery
20 Paraesophageal LNs in the diaphragmatic esophageal hiatus
110 Paraesophageal LNs in the lower thorax
111 Supradiaphragmatic LNs separate from the esophagus
112 Posterior mediastinal LNs separate from the esophagus and the esophageal hiatus
Adapted from: Japanese Gastric Cancer Association. Table 5. In: Japanese Classifications of Gastric Carcinoma. 14th ed. Tokyo, Japan: Kanehara & Co. Ltd., with permission.







Figure 62.2 Right side border of lesser sac. The yellow line indicates peritoneal incision to further separate the greater omentum and the transverse colon mesentery (from Hoshi H. Standard D2 and modified nodal dissection for gastric adenocarcinoma. Surg Oncol Clin N Am. 2012;21(1):57–70).


The Technique of the D2 Nodal Dissection (Common Portion for Both a Distal and a Total Gastrectomy) (Figs. 62.2 and 62.3)

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Sep 14, 2016 | Posted by in GENERAL SURGERY | Comments Off on Gastric Resection with D2 Nodal Dissection for Gastric Adenocarcinoma

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