Successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly
© The Author(s). 2016
Received: 16 March 2016
Accepted: 31 May 2016
Published: 3 June 2016
We report a case of successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. A 76-year-old female patient was admitted with a diagnosis of advanced gastric cancer at the anterior wall to the lesser curvature of the antrum (cT3N0M0 cStage IIA). Dynamic computed tomography showed the ectopia of the common hepatic artery branched from the left gastric artery. We made a diagnosis of an Adachi type VI (group 26) vascular anomaly and performed the abovementioned operation. In this anomaly pattern, scrupulous attention is required to remove the suprapancreatic lymph nodes because the portal vein is located immediately dorsal to those lymph nodes and is at increased risk for the injury in this situation. The common hepatic artery is branched from the left gastric artery, and the hepatic perfusion from the superior mesenteric artery is not present in group 26. Planning to preserve the artery will improve safety when it is possible oncologically. There were no postoperative complications, and the patient was discharged 9 days after the operation. To our knowledge, the present case is the first reported case of a laparoscopic distal gastrectomy with D2 lymph node dissection with an Adachi type VI (group 26) vascular anomaly. Preoperative diagnostic imaging is very important to prevent surgical complications because the reliable identification of vascular anomaly during an operation is very difficult.
Gastric cancer is a common malignant disease worldwide. The standard surgical procedure for patients with resectable gastric cancer is gastrectomy with lymph node dissection. Recently, laparoscopic gastrectomy can be performed for not only early gastric cancer but also advanced gastric cancer at some specialized institutions . It is very important that we understand the branching types of the celiac artery through the use of multi-detector row computed tomography because the range of suprapancreatic lymph node dissection differs between D1 and D2 lymph node dissection . Adachi classified branching types of the celiac artery into 6 types and 28 groups . In Adachi type VI, the common hepatic artery is not detected at the superior border of the pancreas, and its frequency is approximately 2 % . Additionally, in group 26, the common hepatic artery is branched from the left gastric artery, and the frequency is approximately 0.4 % . We report a case of advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly that was successfully treated by laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery. The International Union Against Cancer (UICC) TNM staging system for gastric cancer was used for tumor staging . The lymph node stations were defined according to the definitions of the Japanese Gastric Cancer Association (JGCA) .
A 76-year-old female patient was admitted to our hospital with a gastric cancer identified by gastroduodenal endoscopic examination. No physical abnormalities were observed, and laboratory data, including hematologic and biochemical analyses, revealed no abnormalities.
This patient was enrolled in the randomized trial of open and laparoscopic distal gastrectomy with D2 lymph node dissection for locally advanced gastric cancer conducted within the framework of the Japanese Laparoscopic Surgery Study Group (JLSSG 0901 trial) . This case was randomly allocated to the laparoscopic surgery group.
In our institution, the laparoscopic distal gastrectomy was performed using five trocars. The first 12-mm trocar was inserted transumbilically, 12- and 5-mm trocars were inserted above and to the right side of the umbilicus, and the other two 12-mm trocars were inserted above and to the left side of the umbilicus. Carbon dioxide pneumoperitoneum was maintained at 10 mmHg, and lymph node dissection was carried out using an ultrasonically activated device through the four operative trocars.
The pathological examination revealed a type 3 tumor (35 × 30 mm) in the stomach exhibiting well and moderately differentiated tubular adenocarcinoma with no metastases in 58 harvest lymph nodes (pT2N0M0 pStageIB).
Recently, the number of patients undergoing laparoscopic gastrectomy for gastric cancer has increased . Because many studies reported that laparoscopic distal gastrectomy for patients with early gastric cancer was a minimally invasive procedure, and that long-term outcomes were comparable with open distal gastrectomy, laparoscopic distal gastrectomy for patients with early gastric cancer has been widely accepted [8–11]. Although the results of the multi-institutional randomized phase II trial (JLSSG 0901 trial) demonstrated the technical safety of laparoscopic distal gastrectomy with D2 lymph node dissection for patients with advanced gastric cancer, a phase III trial (JLSSG 0901 trial) which is the extension of the study that compared laparoscopic surgery with open surgery in term of oncological outcome is ongoing .
Laparoscopic surgeons can perform a precise operation, because the magnified surgical field is provided by laparoscopic surgery. However, the procedure is potentially disadvantageous because the identification of the anatomy is difficult due to an absence of thigmesthesia. Therefore, the identification of a vascular anomaly prior to surgery is very important for the safety and accuracy of the operation. It has been reported that multi-detector computed tomography is useful preoperatively to plan surgical strategy, thereby optimizing the safety and efficacy of laparoscopic gastrectomy . In gastric surgery, the area of the suprapancreas is one of the most challenging sites; we perform lymph node dissection strictly and carefully because of its various anatomical variants of the vessels.
To our knowledge, this is the first case report on laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery with an Adachi type VI (group 26) vascular anomaly. Because the laparoscopic surgery is potentially disadvantage due to an absence of thigmesthesia, it is very difficult to detect an Adachi type VI (group 26) vascular anomaly reliably during an operation. Therefore, preoperative diagnostic imaging is very important for the prevention of the surgical complications, thereby minimally invasive surgery can be safely performed as well as open surgery.
In summary, we reported a successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. Special attention should be paid to the vascular anatomy using preoperative diagnostic imaging.
Written informed consent was obtained from the patient for publication of this case report and the accompanying images.
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