|Year : 2018 | Volume
| Issue : 8 | Page : 197-201
Guiding values of multislice spiral computed tomography angiography in laparoscopic D2 radical gastrectomy of local advanced gastric carcinoma
Wang Chen1, Jianbo Gao2, Diansen Chen3
1 Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052; Department of Imaging, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang 471003, Henan, China
2 Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
3 Department of Imaging, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang 471003, Henan, China
|Date of Web Publication||26-Mar-2018|
Department of Radiology, The First Affiliated Hospital of Zhengzhou University, No. 1, East Jianshe Road, Zhengzhou 450052, Henan
Source of Support: None, Conflict of Interest: None
Objective: This study aims to investigate the application values of preoperative multislice spiral computed tomography angiography (MSCTA) in laparoscopic radical resection of gastric carcinoma (GC).
Materials and Methods: A total of 108 GC patients were divided into Groups I (i.e., where preoperative MSCTA was performed; n = 60) and II (i.e., where preoperative MSCTA was not performed; n = 48). Surgery was performed by the same group of surgeons.
Results: Seven cases of blood vascular variation were detected in Group I during surgery, whereas four cases were detected in Group II. The operation time for Group I ([207 ± 24] min) was shorter than that for Group II ([260 ± 31] min) (95% confidence interval [95% CI]: −21.543–−0.920, P = 0.044). The operation time of patients with gastric vascular anatomic variation in Group I ([189 ± 49] min) was shorter than that of patients in Group II ([257 ± 61] min) (95% CI: −99.68–−3.201, P = 0.048). The differences in the number of lymph node dissection, average blood loss, eating time, complication rate, and postoperative hospital stay between the two groups was not statistically significant (P > 0.05).
Conclusions: MSCTA before endoscopic radical resection exhibits guiding values in assessing blood vascular variations and shortening operation times.
Keywords: Gastric carcinoma, laparoscopy, radical resection, tomography, X-ray computer
|How to cite this article:|
Chen W, Gao J, Chen D. Guiding values of multislice spiral computed tomography angiography in laparoscopic D2 radical gastrectomy of local advanced gastric carcinoma. J Can Res Ther 2018;14, Suppl S1:197-201
|How to cite this URL:|
Chen W, Gao J, Chen D. Guiding values of multislice spiral computed tomography angiography in laparoscopic D2 radical gastrectomy of local advanced gastric carcinoma. J Can Res Ther [serial online] 2018 [cited 2020 Jun 3];14:197-201. Available from: http://www.cancerjournal.net/text.asp?2018/14/8/197/183211
| > Introduction|| |
Laparoscopy-assisted D2 radical resection is one of the currently used effective treatments for gastric cancer. This procedure requires not only the removal of affected organs and tissues but also lymph node dissection based on reserving major perigastric arteries, such as the celiac trunk and the common hepatic, proper hepatic, and splenic arteries. A comparison with D1 dissection shows that perigastric D2 lymphadenectomy could significantly improve the prognosis of patients.,, Most lymph nodes distribute around blood vessels. Plenty of perigastric vascular variations and tumor invasions are found in these vessels, which normally increases the difficulties and risks of surgery. The laparoscopic radical resection of gastric cancer requires minimal invasion; hence, its clinical applications are wide. The only disadvantage is the small endoscopic surgical field, which may induce larger flaws in the operating space and tissue localization than traditional radical gastrectomy  and immense surgical risks. When the location, direction, and variation of major perigastric vessels are properly assessed, preoperative multislice spiral computed tomography (CT) angiography (MSCTA) might be able to play a very important guiding role in the radical surgery of gastric cancer. MSCTA has been widely used to evaluate vascular anatomies before liver and kidney surgeries., However, its clinical value in D2 radical resection of gastric cancer has been rarely reported. This study analyzes the clinical data obtained from sixty patients, who underwent preoperative MSCTA, to understand the effects of this procedure on radical resection of gastric cancer. These data are then compared with those of 48 patients, who underwent radical resection of gastric cancer without preoperative MSCTA, during the same period. This study aims to explore the clinical significance of this examination toward radical resection of gastric cancer.
| > Materials and Methods|| |
A total of 108 patients, who underwent surgical indications without contraindications and scheduled for laparoscopic D2 radical resection of gastric cancer in our hospital from June 1, 2012, to June 1, 2014, were asked to participate. These patients were scheduled for 1st-time surgery. The patients were asked for informed consent and divided into the MSCTA (Group I, n = 60) and non-MSCTA groups (Group II, n = 48) according to their own willingness. The same group of surgeons performed the operation. All patients pathologically confirmed. The differences in age, sex, tumor location, intraoperative blood loss, and other data between the two groups showed no statistical significance (P > 0.05) [Table 1].
Computed tomography methods
The Auqio ONE 320-slice spiral CT machine (Toshiba, Japan) was used for Group I. The postprocessing of the thin-layer volume imaging data was performed in an HP ZR2440W processing workstation. All three-dimensional reconstructed images were obtained in the same workstation. These images displayed the main blood vessels in the upper and middle parts of the abdomen, gastric feeding, and perigastric vessels, and tumor blood supply. They also illustrated the relationships between the tumor and the adjacent vessels. Positioning and staging of the tumor were performed. The previously discussed information was used to guide the selection and development of surgical programs. The scanning range for Group I was from the diaphragmatic dome to the spina iliaca plane. The slice thickness was 1 mm, and the reconstruction pitch was 0.5–1.0 mm. The contrast agent was 370 mg I/mL iopromide. The injection flow rate was 3.5–5.0 mL/s. The amount of contrast agent was calculated based on the patient's body weight (i.e., 2.0–2.5 mL/kg body weight). The scanning range for Group II was from the diaphragmatic dome to the umbilical plane. The slice thickness was 1.0 mm, and the layer spacing was 0.7 mm. The contrast agent was 300 mg I/mL iopromide. The injection flow rate was 3.0 mL/s. The amount of contrast agent was calculated using 1.5 mg/kg body weight for plain and Phase III dynamic-enhanced scanning. Arterial phase scanning was started 20–25 s after injecting the contrast agent. Portal phase scanning began 20–40 s after the arterial phase scanning procedure. Balance phase scanning was started 40–50 s after the arterial phase scanning.
Three experienced diagnostic radiologists and one surgeon consistently examined the processed images. They mainly focused on observing the starting positions and variations of gastric feeding and perigastric arterial blood vessels. Surgeons should confirm and record these conclusions during surgery.
Clinical surgical procedures
Sufficient and effective preoperative preparations were performed. Subsequently, continuous general or epidural anesthesia with tracheal catheterization was performed in the two groups. The surgery followed the principle of laparoscopic D2 radical resection of gastric cancer. The surgery procedures included the following steps: (1) Radical distal subtotal gastrectomy; (2) radical proximal subtotal gastrectomy; and (3) radical total gastrectomy.
The data obtained for the two groups were analyzed using SPSS 16.0 statistical package (SPSS Inc, Chicago, IL, USA). The average levels were expressed as x̄± s because all the measurement data met normal distribution as shown in the normality test. All had P > 0.05. The nonnormally distributed and counting data were calculated using the Wilcoxon rank sum and χ2 tests, respectively. Accordingly, P < 0.05 was considered statistically significant.
| > Results|| |
Conditions of vascular variations
Group I underwent MSCTA. Preoperative CT angiography clearly showed the origins and directions of perigastric major vessels, as well as their relationships with cancer. A total of seven (11.6%) variations were found in gastric feeding or perigastric vessels. The intraoperative findings were 100% coincidental with the MSCTA diagnosis [Figure 1]a. Case 1 involved a 61-year-old male patient, with gastric antral adenocarcinoma displaying a normal celiac trunk and several branch vessels [Figure 1]b. Case 2 was presented by a 59-year-old male patient, with gastric antral adenocarcinoma displaying a right accessory hepatic artery that originated from superior mesenteric artery [Figure 1]c. Case 3 involved a female patient, who is 72-year-old, with gastric antral adenocarcinoma displaying a left gastric artery that originated from the abdominal aorta [Figure 1]d. Case 4 was presented by a 61-year-old male patient with gastric angular adenocarcinoma displaying a left accessory hepatic artery that originated from the starting section of the celiac trunk [Figure 1]e. Case 5 involved a 68-year-old male patient with cardial adenocarcinoma displaying a splenic artery that originated from the superior mesenteric artery [Figure 1]f. Case 6 was presented by a 67-year-old male patient with gastric antral adenocarcinoma displaying alternative common hepatic artery that originated from the superior mesenteric artery. A total of four variations in gastric feeding or perigastric vessels were found in Group II. These included two cases of the right gastric artery loss, once case of proper hepatic artery loss, and another case of the left gastric artery variation.
|Figure 1: (a) Case 1, male, 61-year-old, gastric antral adenocarcinoma, displaying normal celiac trunk and several branch vessels. (b) Case 2, male, 59-year-old, gastric antral adenocarcinoma, displaying right accessory hepatic artery originated from superior mesenteric artery. (c) Case 3, female, 72-year-old, gastric antral adenocarcinoma, displaying left gastric artery originated from abdominal aorta. (d) Case 4, male, 61-year-old, gastric angular adenocarcinoma, displaying left accessory hepatic artery originated from the starting section of celiac trunk. (e) Case 5, male, 68-year-old, cardial adenocarcinoma, displaying splenic artery originated from superior mesenteric artery. (f) Case 6, male, 67-year-old, gastric antral adenocarcinoma, displaying alternative common hepatic artery originated from superior mesenteric artery|
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Clinical surgical results
A comparison of the average operation times between Groups I and II showed that μ1–μ2 of 95% confidence interval: −22.45–−0.919 and μ1< μ2 not including 0. The difference was statistically significant at P < 0.05. Seven cases presenting left perigastric arterial anatomic abnormality were found in Group I. A comparison of the mean operation times for patients with perigastric arterial anatomic abnormality in Group II also showed a statistically significant difference at P < 0.05. The mean intraoperative blood loss, which included the gastric arterial anatomic abnormality cases, number of lymph node dissection, postoperative complication, postoperative feeding time, and postoperative hospital stay between the two groups did not have any statistically significant difference (P > 0.05) [Table 1].
| > Discussion|| |
Laparoscopy has been increasingly and widely used in gastric cancer surgeries, that is, from early gastric cancer to standard D2 surgery of advanced gastric cancer., However, the limitation of this technique is the very small surgical field, which hinders fully observing the locations and directions of the perigastric vessels. This disadvantage results in prolonged operation time for intraoperative vascular ligation and isolation, as well as increased surgical failure risks. Accordingly, the risk of vascular injury during lymph node dissection increases, which easily leads to bleeding. The precision of surgical field observation is also affected. However, the complete dissection of perigastric metastatic lymph nodes is the key of radical surgery. This technique could significantly improve a patient's 5-year survival rate. Therefore, understanding perigastric feeding arteries and their variations before the operation would be necessary for a safe and effective laparoscopic surgery.
Many kinds of variations can be found in perigastric and gastric feeding arteries, and the uncertainty of their directions is huge. The celiac trunk and branch vessel variations are also high. Therefore, understanding the blood vessel locations and variations before the operation would help avoid damaging these vessels during surgery. This will also shorten the operation time and reduce postoperative complications. In this study, the vascular variations in patients with gastric arterial anatomical variation (Group I) have been precisely understood before surgery. Therefore, no abnormality in the origin and direction of the left gastric artery is displayed before surgery in Case 1. The same is observed for the anatomic structures of the celiac trunk branches. Therefore, the surgery is more on target, and surgeons can also save operation time. The preoperative imaging data in Case 2 show that the variant hepatic artery has been successfully exposed intraoperatively. This indicates that the damage or misligation in the variant right accessory hepatic artery, as well as serious consequences, such as hepatic ischemia and infarction, has been avoided. Furthermore, surgeons save systemic dissection time. The risk of accidentally damaging the superior mesenteric artery, which could cause abdominal bleeding, is also reduced. As regards Case 3, the time to search for and separate the left gastric artery is bound to increase if the origin of its variant is not sufficiently understood before surgery. Moreover, this vessel will easily be misligated or accidentally injured, thereby causing ischemia and necrosis in blood feeding tissues and organs. The type of blood vascular variation in Case 4 is less common. Therefore, performing the intraoperative lymph node dissection without sufficient knowledge of the location and variations of the variant abdominal artery may accidentally damage the vessel. This may also cause bleeding, which seriously affects the observation made in the surgical field and takes up more time. Case 5 presents a very rare variation with an incidence of about 0.65%. Herein, the splenic artery originates from the superior mesenteric artery. Preoperative MSCTA reveals the presence of this variation. Therefore, the surgery can avoid harming the splenic vein and the pancreas. Intraoperative bleeding, risk of postoperative pancreatic leakage, and operation time have also been significantly reduced. In Case 6, the patient's common hepatic artery originates from the superior mesenteric artery. This variation is also relatively rare., Performing MSCTA avoids hepatic blood supply disorder if this variant artery is accidentally damaged during gastric cancer D2 surgery. Serious consequences, such as liver infarction if this variant vessel is damaged intraoperatively, are also avoided.
In this study, MSCTA could directly exhibit four major gastric feeding arteries. The intraoperative findings in Group I are 100% coincidental with those revealed in MSCTA (60/60). Moreover, the average operation time for Group I is shorter than that for Group II. The mean operation time for the seven patients with anatomical variant arteries is also shorter than that for three cases in Group II (P < 0.05). In other words, preoperative abdominal MSCTA could accurately locate and stage gastric cancer. It can also display and assess the locations and variations of the involved major perigastric vessels. Therefore, preoperative MSCTA would have important effects in the selection and preparation of surgical options, as well as in the correct judgment of the surgery possibility.
Preoperative MSCTA has not been performed for Group II. Accordingly, a total of four variant gastric vessels have been found intraoperatively. These include two cases of the right gastric arterial defect, one case of proper hepatic arterial defect, and another of left gastric arterial variation. The blood vessel variations in this group are not sufficiently understood before surgery. Therefore, searching for, dissecting, and isolating the associated vessels and lymph nodes in the corresponding regions increase the operation time and difficulty even if no intraoperative hemorrhea occurred. Patients in Group I have stayed in the hospital for a less amount of time than those in Group I. However, the difference is not statistically significant (P > 0.05).
This study shows that the variations of the origin or direction of the perigastric vessels, especially in the celiac trunk artery and its branches, are not rare (10.2%, 11/108). Studies have reported the variation rate of the gastric feeding arteries around 10.0%, which is consistent with the results of this study. Therefore, blood vessels and organs may easily be damaged during surgery if preoperative MSCTA is not performed before radical gastrectomy and if the conditions of anatomic variations and blood-supplying vessels in the gastric tumor could not be evaluated preoperatively. These vessel damages may, therefore, affect lymph node dissection and blood supply to corresponding tissues. A minor surgery mistake will easily cause hemorrhea or ischemic necrosis of tissues and organs, thereby increasing surgical difficulties and risks. Currently, laparoscopy has been widely applied to radical gastrectomy. This procedure requires more sophisticated surgeon operations, accurate dissections, and control of intraoperative blood loss. In summary, preoperative MSCTA could clearly display each patient's circumstances of gastric feeding and perigastric arteries, thereby exhibiting important clinical values.,,
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Conflicts of interest
There are no conflicts of interest.
| > References|| |
Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010;60:277-300.
El-Sedfy A, Dixon M, Seevaratnam R, Bocicariu A, Cardoso R, Mahar A, et al.
Personalized surgery for gastric adenocarcinoma: A meta-analysis of D1 versus D2 lymphadenectomy. Ann Surg Oncol 2015;22:1820-7.
Galizia G, Lieto E, De Vita F, Castellano P, Ferraraccio F, Zamboli A, et al.
Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis. Surgery 2015;157:285-96.
Degiuli M, Sasako M, Ponti A, Vendrame A, Tomatis M, Mazza C, et al.
Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer. Br J Surg 2014;101:23-31.
Gordon AC, Kojima K, Inokuchi M, Kato K, Sugihara K. Long-term comparison of laparoscopy-assisted distal gastrectomy and open distal gastrectomy in advanced gastric cancer. Surg Endosc 2013;27:462-70.
Waddell T, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D; European Society for Medical Oncology (ESMO); European Society of Surgical Oncology (ESSO); European Society of Radiotherapy and Oncology (ESTRO). Gastric cancer: ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24 Suppl 6:vi57-63.
Buchs NC, Morel P. Three-dimensional laparoscopy: A new tool in the surgeon's armamentarium. Surg Technol Int 2013;23:19-22.
Miyaki A, Imamura K, Kobayashi R, Takami M, Matsumoto J, Takada Y. Preoperative assessment of perigastric vascular anatomy by multidetector computed tomography angiogram for laparoscopy-assisted gastrectomy. Langenbecks Arch Surg 2012;397:945-50.
Lee SS, Kim TK, Byun JH, Ha HK, Kim PN, Kim AY, et al.
Hepatic arteries in potential donors for living related liver transplantation: Evaluation with multi-detector row CT angiography. Radiology 2003;227:391-9.
Raman SS, Pojchamarnwiputh S, Muangsomboon K, Schulam PG, Gritsch HA, Lu DS. Utility of 16-MDCT angiography for comprehensive preoperative vascular evaluation of laparoscopic renal donors. AJR Am J Roentgenol 2006;186:1630-8.
Mingoli A, Sgarzini G, Binda B, Brachini G, Belardi V, Huscher CG, et al.
Totally laparoscopic approach for treatment of early and advanced gastric cancer. J Am Coll Surg 2007;204:187-8.
Lee J, Kim W. Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: Analysis of consecutive 106 experiences. J Surg Oncol 2009;100:693-8.
Pugliese R, Maggioni D, Sansonna F, Ferrari GC, Forgione A, Costanzi A, et al.
Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures. Eur J Surg Oncol 2009;35:281-8.
Iino I, Sakaguchi T, Kikuchi H, Miyazaki S, Fujita T, Hiramatsu Y, et al.
Usefulness of three-dimensional angiographic analysis of perigastric vessels before laparoscopic gastrectomy. Gastric Cancer 2013;16:355-61.
Natsume T, Shuto K, Yanagawa N, Akai T, Kawahira H, Hayashi H, et al.
The classification of anatomic variations in the perigastric vessels by dual-phase CT to reduce intraoperative bleeding during laparoscopic gastrectomy. Surg Endosc 2011;25:1420-4.
Edge SB, Compton CC. The American Joint Committee on Cancer: The 7th
edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol 2010;17:1471-4.
Matsuki M, Kani H, Tatsugami F, Yoshikawa S, Narabayashi I, Lee SW, et al.
Preoperative assessment of vascular anatomy around the stomach by 3D imaging using MDCT before laparoscopy-assisted gastrectomy. AJR Am J Roentgenol 2004;183:145-51.
Matsuki M, Tanikake M, Kani H, Tatsugami F, Kanazawa S, Kanamoto T, et al.
Dual-phase 3D CT angiography during a single breath-hold using 16-MDCT: Assessment of vascular anatomy before laparoscopic gastrectomy. AJR Am J Roentgenol 2006;186:1079-85.
Martínez-Ramos D, Miralles-Tena JM, Cuesta MA, Escrig-Sos J, Van der Peet D, Hoashi JS, et al.
Laparoscopy versus open surgery for advanced and resectable gastric cancer: A meta-analysis. Rev Esp Enferm Dig 2011;103:133-41.
Tanimura S, Higashino M, Fukunaga Y, Takemura M, Tanaka Y, Fujiwara Y, et al.
Laparoscopic gastrectomy for gastric cancer: Experience with more than 600 cases. Surg Endosc 2008;22:1161-4.