Overview
Definition:
Right gastric artery lymphadenectomy is the meticulous dissection and removal of lymph nodes originating from or draining into the right gastric artery and its surrounding perivascular tissues
This procedure is an integral part of lymph node dissection (LND) for gastric adenocarcinoma, particularly in D1 and D2 dissections as per Japanese Gastric Cancer Association (JGCA) guidelines.
Epidemiology:
Gastric cancer is a significant cause of cancer-related mortality worldwide
The incidence varies geographically, being higher in East Asia
Lymph node metastasis is a primary determinant of prognosis, making comprehensive lymphadenectomy crucial for staging and treatment planning.
Clinical Significance:
Accurate and complete lymphadenectomy, including stations related to the right gastric artery (typically considered part of No
7, the left lobe of the liver, or No
12a, the hepatoduodenal ligament, depending on the classification system), is essential for achieving negative margins, accurate pathological staging, and improving long-term survival in patients with gastric cancer
Inadequate LND can lead to local recurrence and distant metastasis.
Indications
Surgical Indications:
Resectable gastric adenocarcinoma is the primary indication for lymphadenectomy
The extent of lymphadenectomy (D1, D2, etc.) is determined by tumor stage, location, and surgeon preference, guided by staging investigations like EUS and CT scans.
Lymph Node Stations:
The right gastric artery is associated with lymph node stations No
7 (para-aortic nodes along the left gastric artery origin) and No
12a (nodes along the common hepatic artery and in the hepatoduodenal ligament)
Dissection of these stations is indicated in D2 lymphadenectomy and in select cases of D1 dissection for tumors with higher risk of nodal involvement.
Factors Influencing Decision:
Tumor invasion depth, presence of lymphovascular invasion, histologic type, and lymph node status on preoperative imaging all influence the decision on the extent of lymphadenectomy.
Preoperative Preparation
Patient Assessment:
Thorough preoperative assessment including history, physical examination, baseline blood investigations (CBC, LFTs, RFTs, coagulation profile), and cardiopulmonary evaluation is mandatory
Nutritional status should be optimized.
Imaging Studies:
Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for nodal staging and contrast-enhanced CT scan of the abdomen and pelvis are crucial for assessing tumor resectability and nodal involvement.
Informed Consent:
Detailed discussion with the patient regarding the surgical procedure, potential risks, benefits, and alternatives, including the extent of lymphadenectomy, is essential for obtaining informed consent.
Procedure Steps
Approach:
Right gastric artery lymphadenectomy is typically performed as part of a total gastrectomy or proximal gastrectomy, via open laparotomy or minimally invasive surgery (laparoscopy or robotic assistance).
Dissection Technique:
The dissection begins by identifying the origin of the right gastric artery from the proper hepatic artery or common hepatic artery
The lymph nodes and surrounding fatty tissue are dissected meticulously along the artery proximally towards its origin and distally along its branches supplying the stomach
Care is taken to preserve the gastroduodenal artery and portal vein
The specimen is usually en bloc with the resected stomach and other nodal stations.
Anatomical Considerations:
Accurate identification of the right gastric artery is critical to avoid injury to adjacent structures like the common bile duct, proper hepatic artery, and portal vein
The dissection planes should be carefully maintained to ensure complete nodal clearance.
Hemostasis And Drainage:
Meticulous hemostasis is achieved throughout the dissection
Drains are typically placed in the dissected areas to monitor for bleeding or leakage.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and drain output is essential
Patients are monitored for signs of bleeding, infection, or anastomotic leak.
Pain Management:
Adequate pain control is provided using multimodal analgesia, including patient-controlled analgesia (PCA) where appropriate.
Nutritional Support:
Intravenous fluid management and early enteral feeding are prioritized
Patients may require parenteral nutrition initially, followed by a gradual transition to oral intake as tolerated.
Mobilization And Ambulation:
Early mobilization and ambulation are encouraged to prevent complications such as deep vein thrombosis (DVT) and pneumonia.
Complications
Early Complications:
Hemorrhage from the dissected vessels
Injury to adjacent structures (e.g., portal vein, hepatic artery, common bile duct)
Pancreatitis due to proximity to the pancreatic head
Bleeding or leakage from the stomach remnant or anastomosis
Surgical site infection.
Late Complications:
Nutritional deficiencies (e.g., B12 deficiency)
Dumping syndrome
Bowel obstruction due to adhesions
Incisional hernia.
Prevention Strategies:
Careful anatomical identification and dissection
Meticulous hemostasis
Prophylactic antibiotics
Early mobilization
Appropriate nutritional support
Careful surgical technique to avoid injury to vital structures.
Prognosis
Factors Affecting Prognosis:
The number and location of positive lymph nodes are critical prognostic factors
Other factors include tumor stage, histological subtype, presence of lymphovascular invasion, and R0 resection
Adequate lymphadenectomy is directly linked to better prognosis.
Outcomes:
Successful completion of R0 resection with adequate lymphadenectomy generally leads to improved long-term survival for gastric cancer patients
The 5-year survival rates vary significantly based on the stage of the disease and the thoroughness of the surgical intervention.
Follow Up:
Postoperative follow-up typically includes regular clinical examinations, laboratory tests (e.g., CEA levels), and periodic imaging studies (CT scans) to detect recurrence or metastasis
The frequency and duration of follow-up are guided by established protocols.
Key Points
Exam Focus:
Understand the anatomical location of lymph node stations associated with the right gastric artery (No
7, No
12a)
Recognize its importance in D1 vs
D2 lymphadenectomy for gastric cancer
Recall potential complications related to its dissection.
Clinical Pearls:
Always identify the proper hepatic artery and common hepatic artery before dissecting the right gastric artery to avoid inadvertent injury
Dissect in layers and maintain a clear surgical field
Consider the origin of the right gastric artery which can vary (from proper hepatic or common hepatic artery).
Common Mistakes:
Incomplete dissection of nodal stations
Injury to the proper hepatic artery, common hepatic artery, or portal vein
Failure to achieve R0 resection due to inadequate lymph node clearance
Overlooking the significance of nodal involvement in prognosis.