Overview
Definition:
Left gastric artery lymphadenectomy (LGAL) is a crucial component of D2 lymphadenectomy in the surgical management of gastric adenocarcinoma
It involves the meticulous dissection and removal of lymph nodes located along the left gastric artery and its branching points from the celiac trunk
This procedure aims to achieve oncological clearance by removing regional lymph node metastases, which significantly impacts prognosis.
Epidemiology:
Gastric cancer remains a significant global health challenge, with variations in incidence worldwide
The prevalence of lymph node metastasis varies by tumor stage, location, and histological subtype
LGAL is particularly relevant for tumors located in the upper and middle thirds of the stomach, and tumors with a higher risk of nodal involvement.
Clinical Significance:
The extent of lymphadenectomy, including LGAL, is directly correlated with patient survival in gastric cancer
Inadequate lymph node dissection is associated with higher rates of local recurrence and poorer outcomes
Comprehensive lymphadenectomy, guided by staging systems like the Japanese Gastric Cancer Association (JGCA) guidelines, is essential for accurate staging and effective oncologic treatment, directly impacting patient care and improving the chances of long-term survival.
Indications
Surgical Indications:
LGAL is indicated as part of a radical lymphadenectomy (typically D2 or more extensive) for all potentially curable gastric adenocarcinomas
This includes clinically resectable tumors where a complete gastrectomy is planned
The specific indication is often determined by tumor location, size, depth of invasion, and preoperative staging.
Neoadjuvant Chemotherapy Considerations:
For patients receiving neoadjuvant chemotherapy, LGAL is still considered an integral part of surgical resection
Its role in assessing the response to neoadjuvant therapy and in achieving complete oncologic resection remains critical.
Palliation Considerations:
In select cases of unresectable disease with symptoms related to nodal mass effect, palliative resection with lymphadenectomy may be considered, though LGAL is primarily an oncologic procedure for curative intent.
Preoperative Preparation
Diagnostic Workup:
Comprehensive preoperative evaluation includes endoscopy with biopsy, contrast-enhanced CT scan for staging (assessing primary tumor, nodal status, and distant metastasis), and potentially PET-CT
Endoscopic ultrasound (EUS) can further refine nodal staging.
Nutritional Assessment:
Patients with gastric cancer often present with malnutrition
Preoperative nutritional support, including consultation with a dietitian and potentially enteral or parenteral nutrition, is vital for optimal recovery.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful hemodynamic monitoring and fluid management are essential given the extensive dissection and potential for blood loss.
Informed Consent:
Detailed discussion with the patient and family regarding the risks, benefits, and alternatives of gastrectomy and extensive lymphadenectomy, including the potential for complications and the rationale for LGAL, is mandatory.
Procedure Steps
Approach And Exposure:
The procedure typically involves a midline laparotomy or laparoscopic approach
Careful mobilization of the stomach and surrounding organs is performed to expose the celiac axis and the origin of the left gastric artery
Anatomical landmarks, including the common hepatic artery and splenic artery, are identified.
Dissection Of The Left Gastric Artery:
The lymph nodes and surrounding fatty tissue along the left gastric artery are meticulously dissected from its origin at the celiac trunk proximally, following the artery distally to its branching points to the stomach
Care is taken to identify and preserve the common hepatic artery, splenic artery, and the portal vein.
Lymph Node Stations Involved:
LGAL specifically targets lymph node station no
7 (paracardial nodes) and station no
8 (left gastric artery nodes)
Depending on the tumor location and extent, other stations (e.g., no
1, no
2, no
9, no
11, no
12) may also be dissected as part of a comprehensive lymphadenectomy.
Vessel Ligation:
The left gastric artery is typically ligated distally after thorough lymph node dissection, ensuring no residual nodal tissue remains along its course
Hemostasis is meticulously maintained throughout the dissection.
Gastric Resection:
Following lymphadenectomy, the appropriate type of gastrectomy (e.g., total or subtotal gastrectomy) is performed, ensuring adequate margins around the tumor
Reconstruction of the gastrointestinal tract is then completed.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, urine output, and laboratory parameters (hemoglobin, electrolytes) is crucial
Pain management with adequate analgesia (patient-controlled analgesia or epidural) is essential.
Fluid And Electrolyte Management:
Intravenous fluid therapy is managed carefully to maintain euvolemia
Electrolyte imbalances, particularly hypoalbuminemia and hyponatremia, should be monitored and corrected promptly.
Nutritional Support:
Early initiation of enteral feeding, usually through a nasojejunal tube placed during surgery, is encouraged to promote gut healing and prevent malnutrition
Parenteral nutrition may be used if enteral feeding is not tolerated or feasible.
Mobilization And Ambulation:
Early mobilization and ambulation are encouraged to prevent complications such as deep vein thrombosis, pulmonary embolism, and pneumonia
Gradual resumption of oral intake is guided by bowel function.
Drainage Management:
Surgical drains are typically placed in the operative bed and removed when drainage is minimal
Monitoring for drain output and characteristics is important to detect potential complications like leaks or bleeding.
Complications
Early Complications:
Bleeding from dissected vessels, pancreatic fistula (if dissection is too close to the pancreas), splenic injury, injury to the common hepatic artery or portal vein, intra-abdominal abscess, anastomotic leak, and ileus are potential early complications
Pancreatitis can also occur due to manipulation of the pancreas.
Late Complications:
Dumping syndrome, diarrhea, malnutrition due to malabsorption, marginal ulcer formation, and gastrojejunal stenosis are common late complications
Recurrence of cancer, either locally or distantly, is the most feared late complication.
Prevention Strategies:
Meticulous surgical technique, including careful anatomical identification, precise dissection, and effective hemostasis, is paramount
Prophylactic antibiotics, adequate nutritional support, early mobilization, and close postoperative monitoring aid in preventing complications
Adherence to oncologic principles during lymphadenectomy ensures minimal risk of local recurrence.
Prognosis
Factors Affecting Prognosis:
Prognosis is significantly influenced by the stage of the disease at diagnosis, including tumor depth, lymph node metastasis (particularly station 7 and 8 involvement), distant metastasis, histological subtype, and the achievement of R0 resection
The extent and thoroughness of lymphadenectomy, including LGAL, are critical prognostic factors.
Outcomes:
For patients undergoing curative intent surgery with complete lymphadenectomy, long-term survival rates can be significantly improved, especially for early-stage disease
Advanced stage disease or extensive nodal involvement has a poorer prognosis despite radical surgery.
Follow Up:
Postoperative follow-up typically involves regular clinical examinations, laboratory tests (including tumor markers like CEA), and imaging (CT scans) at set intervals to monitor for recurrence, metastasis, and the development of late complications
Endoscopic surveillance may also be performed.
Key Points
Exam Focus:
LGAL is part of D2 lymphadenectomy for gastric cancer
Key stations involved are 7 and 8
Accurate anatomical identification of the celiac trunk and left gastric artery origin is critical
Injury to adjacent vessels (hepatic, splenic, portal vein) is a significant risk
Prognosis is heavily influenced by lymph node status.
Clinical Pearls:
In difficult dissections, gentle retraction and good lighting are crucial
Use of indocyanine green (ICG) fluorescence angiography can help identify gastric perfusion and aid in decisions regarding resection margins
Consider intraoperative ultrasound for indeterminate nodal lesions
Always confirm the absence of residual disease along the dissected artery.
Common Mistakes:
Incomplete dissection of lymph nodes along the entire course of the left gastric artery
Premature ligation of the artery before adequate nodal clearance
Injury to major celiac axis branches
Failure to achieve R0 resection due to inadequate margins
Not performing LGAL when indicated for upper-third tumors.