Goto et al. Surgical Case Reports (2016) 2:55 DOI /s

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1 Goto et l. Surgicl Cse Reports (2016) 2:55 DOI /s CASE REPORT Successful lproscopic distl gstrectomy with D2 lymph node dissection preserving the common heptic rtery rnched from the left gstric rtery for dvnced gstric cncer with n Adchi type VI (group 26) vsculr nomly Open Access Hironou Goto 1*, Tkshi Ysud 1, Tro Oshikiri 2, Ttsuy Imnishi 1, Hironori Ymshit 1, Msto Oym 1, Keitro Kkinoki 1, Tdyuki Ohr 1, Hiroyoshi Sendo 1, Ysuhiro Fujino 1, Mshiro Toming 1 nd Yoshihiro Kkeji 2 Astrct We report cse of successful lproscopic distl gstrectomy with D2 lymph node dissection preserving the common hepticrteryrnchedfromtheleftgstricrteryfordvnced gstric cncer with n Adchi type VI (group 26) vsculr nomly. A 76-yer-old femle ptient ws dmitted with dignosis of dvnced gstric cncer t the nterior wll to the lesser curvture of the ntrum (ct3n0m0 cstge IIA). Dynmic computed tomogrphy showed the ectopi of the common heptic rtery rnched from the left gstric rtery. We mde dignosis of n Adchi type VI (group 26) vsculr nomly nd performed the ovementioned opertion. In this nomly pttern, scrupulous ttention is required to remove the suprpncretic lymph nodes ecuse the portl vein is locted immeditely dorsl to those lymph nodes nd is t incresed risk for the injury in this sitution. The common heptic rtery is rnched from the left gstric rtery, nd the heptic perfusion from the superior mesenteric rtery is not present in group 26. Plnning to preserve the rtery will improve sfety when it is possile oncologiclly. There were no postopertive complictions, nd the ptient ws dischrged 9 dys fter the opertion. To our knowledge, the present cse is the first reported cse of lproscopic distl gstrectomy with D2 lymph node dissectionwithnadchitypevi(group26)vsculrnomly. Preopertive dignostic imging is very importnt to prevent surgicl complictions ecuse the relile identifiction of vsculr nomly during n opertion is very difficult. Keywords: Advnced gstric cncer, Lproscopic distl gstrectomy, D2 lymph node dissection, Adchi type VI vsculr nomly Bckground Gstric cncer is common mlignnt disese worldwide. The stndrd surgicl procedure for ptients with resectle gstric cncer is gstrectomy with lymph node dissection. Recently, lproscopic gstrectomy cn e performed for not only erly gstric cncer ut lso * Correspondence: hirogoto0403@yhoo.co.jp 1 Division of Gstroenterologicl Surgery, Hyogo Cncer Center, 13-70, Kitoji-cho, Akshi, Hyogo , Jpn Full list of uthor informtion is ville t the end of the rticle dvnced gstric cncer t some specilized institutions [1]. It is very importnt tht we understnd the rnching types of the celic rtery through the use of multidetector row computed tomogrphy ecuse the rnge of suprpncretic lymph node dissection differs etween D1 nd D2 lymph node dissection [2]. Adchi clssified rnching types of the celic rtery into 6 types nd 28 groups [3]. In Adchi type VI, the common heptic rtery is not detected t the superior order of the pncres, nd its frequency is pproximtely 2 % [3] The Author(s). Open Access This rticle is distriuted under the terms of the Cretive Commons Attriution 4.0 Interntionl License ( which permits unrestricted use, distriution, nd reproduction in ny medium, provided you give pproprite credit to the originl uthor(s) nd the source, provide link to the Cretive Commons license, nd indicte if chnges were mde.

2 Goto et l. Surgicl Cse Reports (2016) 2:55 Pge 2 of 5 Additionlly, in group 26, the common heptic rtery is rnched from the left gstric rtery, nd the frequency is pproximtely 0.4 % [3]. We report cse of dvnced gstric cncer with n Adchi type VI (group 26) vsculr nomly tht ws successfully treted y lproscopic distl gstrectomy with D2 lymph node dissection preserving the common heptic rtery rnched from the left gstric rtery. The Interntionl Union Aginst Cncer (UICC) TNM stging system for gstric cncer ws used for tumor stging [4]. The lymph node sttions were defined ccording to the definitions of the Jpnese Gstric Cncer Assocition (JGCA) [5]. Cse presenttion A 76-yer-old femle ptient ws dmitted to our hospitl with gstric cncer identified y gstroduodenl endoscopic exmintion. No physicl normlities were oserved, nd lortory dt, including hemtologic nd iochemicl nlyses, reveled no normlities. A gstroduodenl endoscopic exmintion nd upper gstrointestinl series reveled the presence of type 3 gstric tumor (30 mm) t the nterior wll to the lesser curvture of the ntrum (Fig. 1, ). A iopsy of the tumor ws performed, nd the pthologicl dignosis ws well-differentited tuulr denocrcinom of the stomch. The enhnced computed tomogrphy scn showed wll thickening of the stomch tht ws suspected invsion of the suseros (Fig. 2). Additionlly, there were no lymph node metstsis nd no metstsis in other orgns, such s the liver nd lungs (ct3n0m0 cstge IIA). The dynmic computed tomogrphy nd computed tomogrphy ngiogrm showed the ectopi of the common heptic rtery rnched from the left gstric rtery, nd we dignosed n Adchi type VI (group 26) vsculr nomly (Fig. 2, c). This ptient ws enrolled in the rndomized tril of open nd lproscopic distl gstrectomy with D2 lymph node dissection for loclly dvnced gstric cncer conducted within the frmework of the Jpnese Lproscopic Surgery Study Group (JLSSG 0901 tril) [1]. This cse ws rndomly llocted to the lproscopic surgery group. In our institution, the lproscopic distl gstrectomy ws performed using five trocrs. The first 12-mm trocr ws inserted trnsumiliclly, 12- nd 5-mm trocrs were inserted ove nd to the right side of the umilicus, nd the other two 12-mm trocrs were inserted ove nd to the left side of the umilicus. Cron dioxide pneumoperitoneum ws mintined t 10 mmhg, nd lymph node dissection ws crried out using n ultrsoniclly ctivted device through the four opertive trocrs. In intr-dominl findings, there were no distnt metsttic lesions in other orgns, such s the liver nd peritoneum, nd primry lesion could not e detected from the visile surfce of the stomch. Sline ws used to irrigte the Pouch of Dougls, nd the cytologicl exmintion showed no mlignncy. Lproscopic distl gstrectomy with D2 lymph node dissection ws performed ccording to the Jpnese Gstric Cncer tretment guidelines (2010) [2]. The right nd left greter omentum nd lymph nodes were dissected long the gstroepiploic rtery nd infrpyloric vessels, nd the duodenum ws trnsected y liner stpler. The left loe of the liver ws retrced using the Nthnson liver retrctor (Cook Jpn, Tokyo, Jpn), nd the suprpncretic lymph node dissection ws strted. The dipose tissue contining the suprpncretic lymph nodes ws stretched nd dissected long the outermost lyer of the proper heptic rtery due to replcing the common heptic rtery. The lesser omentum ws divided, nd the common heptic rtery in the lesser omentum ws encircled (Fig. 3). The right gstric rtery ws divided, nd the dissection of sttion 12 nd exposure of the portl vein ws performed (Fig. 3). The lymphtic connection etween the dissected tissue nd prortic lymph nodes ws seprted, nd the tissue contining sttions 8, Fig. 1, Findings of the upper gstrointestinl series. A type 3 tumor ws shown, with ulcertion t the nterior wll to the lesser curvture of the ntrum of the stomch

3 Goto et l. Surgicl Cse Reports (2016) 2:55 Pge 3 of 5 c Fig. 2 Findings of the enhnced computed tomogrphy scn. Wll thickening of the stomch tht ws suspected invsion of the suseros., c:the dynmic computed tomogrphy nd computed tomogrphy ngiogrm showed the ectopi of the common heptic rtery rnched from the left gstric rtery 9, nd 12 ws removed long the right diphrgmtic crus. The nterior surficil tissue of the left gstric rtery ws divided like clmshell door (Fig. 3c). The ftty tissue contining sttions 8, 9, nd 12 ws trnsferred through the posterior of the left gstric nd the common heptic rtery, nd the gstric rnch from the left gstric rtery ws divided. It ws showed the detil of the lymph node dissection round the root of the left gstric rtery (Fig. 4). The tissue contining sttion 11p ws freed from Gerot s fsci, therey delineting the dorsl re of the sttion 11p lymph node, nd dissection long the splenic rtery ws performed (Fig. 3d). Finlly, the stomch ws divided PV c d Fig. 3 The common heptic rtery of the lesser omentum ws encircled. The dissection of sttion 12 nd exposure of the portl vein ws performed. c The nterior surficil tissue of the left gstric rtery ws divided like clmshell door. d The lymph node dissection of sttion 11p long the splenic rtery ws performed. common heptic rtery, PV portl vein, left gstric rtery, splenic rtery

4 Goto et l. Surgicl Cse Reports (2016) 2:55 Pge 4 of 5 PV Pncres Fig. 4 The lymph node dissection round the root of the left gstric rtery. 1 The tissue contining suprpncretic lymph nodes ws removed, nd the root of the left gstric rtery ws detected. 2 The spce etween the left gstric rtery nd the tissue contining sttion 11p ws seprted. 3 The nterior surficil tissue of the left gstric rtery ws divided like clmshell door. 4 The rtery of gstric rnch from the left gstric rtery ws divided. common heptic rtery, left gstric rtery, splenic rtery, PV portl vein into 5 cm proximlly to the tumor y liner stpler fter the lymph node dissection of the lesser curvture. The loction of the tumor ws mrked with lck ink during n endoscopy efore the surgery. The excised specimen ws removed through the umilicl trocr site using g. The Billroth-I reconstruction ws performed intrcorporelly with delt-shped nstomosis [6]. The opertion time ws 353 min, nd the lood loss ws 20 g. There were no postopertive complictions, nd the ptient ws dischrge 9 dys fter the opertion. The pthologicl exmintion reveled type 3 tumor (35 30 mm) in the stomch exhiiting well nd modertely differentited tuulr denocrcinom with no metstses in 58 hrvest lymph nodes (pt2n0m0 pstgeib). Discussion Recently, the numer of ptients undergoing lproscopic gstrectomy for gstric cncer hs incresed [7]. Becuse mny studies reported tht lproscopic distl gstrectomy for ptients with erly gstric cncer ws minimlly invsive procedure, nd tht long-term outcomes were comprle with open distl gstrectomy, lproscopic distl gstrectomy for ptients with erly gstric cncer hs een widely ccepted [8 11]. Although the results of the multi-institutionl rndomized phse II tril (JLSSG 0901 tril) demonstrted the technicl sfety of lproscopic distl gstrectomy with D2 lymph node dissection for ptients with dvnced gstric cncer, phse III tril (JLSSG 0901 tril) which is the extension of the study tht compred lproscopic surgery with open surgery in term of oncologicl outcome is ongoing [1]. Lproscopic surgeons cn perform precise opertion, ecuse the mgnified surgicl field is provided y lproscopic surgery. However, the procedure is potentilly disdvntgeous ecuse the identifiction of the ntomy is difficult due to n sence of thigmesthesi. Therefore, the identifiction of vsculr nomly prior to surgery is very importnt for the sfety nd ccurcy of the opertion. It hs een reported tht multidetector computed tomogrphy is useful preopertively to pln surgicl strtegy, therey optimizing the sfety nd efficcy of lproscopic gstrectomy [12]. In gstric surgery, the re of the suprpncres is one of the most chllenging sites; we perform lymph node dissection strictly nd crefully ecuse of its vrious ntomicl vrints of the vessels. Adchi clssified the ntomy of the common heptic rtery, the left gstric rtery, nd the splenic rtery originting from the celic rtery into 6 types nd 28 groups [3]. In Adchi type VI, the common heptic rtery is not detected t the superior order of the pncres, nd lood flow to the liver is supplied from the ccessory heptic rtery (Fig. 5). In this nomly pttern, scrupulous ttention is required to remove the suprpncretic lymph nodes ecuse the portl vein is locted immeditely dorsl to those lymph nodes nd is t n incresed risk for injury in this sitution. The heptic perfusion from the superior mesenteric rtery is present in the Adchi type VI, ut not in group 26. Therefore, the ccessory heptic rtery in the lesser omentum cn e divided. However, it is necessry to understnd tht the common heptic rtery is rnched from the left gstric rtery nd the heptic perfusion from the superior mesenteric rtery is not present in group 26. Even if Group 24 Group 25 Group 26 Group 27 Group 28 Fig. 5 Adchi type VI vsculr nomly. proper heptic rtery, gstroduodenl rtery, left gstric rtery, splenic rtery, superior mesenteric rtery

5 Goto et l. Surgicl Cse Reports (2016) 2:55 Pge 5 of 5 the left gstric rtery is divided t the root, the heptic perfusion my e of no consequence ecuse of the lood flow from round the pncretic hed, t lest in theory. We should pln to preserve the rtery to improve sfety when it is possile oncologiclly. In the present cse, we dignosed no lymph node metstsis preopertively nd removed the lymph nodes preserving the common heptic rtery. When lymph node metstsis is suspected nd the rtery cnnot e preserved, we should confirm tht the left gstric rtery is clmped nd check the color of the liver nd pulstion of the proper heptic rtery. According to circumstnces, Doppler ultrsonogrphy of the liver my e very useful. To our knowledge, this is the first cse report on lproscopic distl gstrectomy with D2 lymph node dissection preserving the common heptic rtery rnched from the left gstric rtery with n Adchi type VI (group 26) vsculr nomly. Becuse the lproscopic surgery is potentilly disdvntge due to n sence of thigmesthesi, it is very difficult to detect n Adchi type VI (group 26) vsculr nomly relily during n opertion. Therefore, preopertive dignostic imging is very importnt for the prevention of the surgicl complictions, therey minimlly invsive surgery cn e sfely performed s well s open surgery. distl gstrectomy with D2 lymph node dissection for loclly dvnced gstric cncer (JLSSG 0901). World J Surg. 2015;39: Jpnese Gstric Cncer Assocition. Jpnese gstric cncer tretment guidelines 2010 (ver.3). Gstric Cncer. 2011;14: Adchi B, Kihr T: Ds Arteriensystem der Jpner, Verlg der Kiserlich-Jpnischen Universitt, zu Kyoto. In Kommission ei Mruzen Co. 1928; Biondi A, Hyung WJ. Seventh edition of TNM clssifiction for gstric cncer. J Clin Oncol. 2011;29: Jpnese Gstric Cncer Assocition. Jpnese clssifiction of gstric crcinom 3rd English edition. Gstric Cncer. 2011;14: Kny S, Gomi T, Momoi H, Tmki N, Isoe H, Ktym T, et l. Delt-shped nstomosis in totlly lproscopic Billroth I gstrectomy: new technique of intrdominl gstroduodenostomy. J Am Coll Surg. 2002;195: Etoh T, Inomt M, Shirishi N, Kitno S. Minimlly invsive pproches for gstric cncer-jpnese experiences. J Surg Oncol. 2013;107: Kitno S, Shirishi N, Uym I, Sugihr K, Tnigw N. Jpnese Lproscopic Surgery Study Group: multicenter study on oncologic outcome of lproscopic gstrectomy for erly cncer in Jpn. Ann Surg. 2007;245: Tnimur S, Higshino M, Fukung Y, Tkemur M, Tnk Y, Fujiwr Y, et l. Lproscopic gstrectomy for gstric cncer: experience with more thn 600 cses. Surg Endosc. 2008;22: Lee SW, Nomur E, Bours G, Tokuhr T, Tsunemi S, Tnigw N. Long-term oncologic outcomes from lproscopic gstrectomy for gstric cncer: single-center experience of 601 consecutive resections. J Am Coll Surg. 2010;211: Huscher CG, Mingoli A, Sgrzini G, Snsonetti A, Di Pol M, Recher A, et l. Lproscopic versus open sutotl gstrectomy for distl gstric cncer: five-yer results of rndomized prospective tril. Ann Surg. 2005;241: Kwski K, Knji S, Koyshi I, Fujit T, Kominmi H, Ueno K, et l. Multidetector computed tomogrphy for preopertive identifiction of left gstric vein loction in ptients with gstric cncer. Gstric Cncer. 2010;13:25 9. Conclusions In summry, we reported successful lproscopic distl gstrectomy with D2 lymph node dissection preserving the common heptic rtery rnched from the left gstric rtery for dvnced gstric cncer with n Adchi type VI (group 26) vsculr nomly. Specil ttention should e pid to the vsculr ntomy using preopertive dignostic imging. Consent Written informed consent ws otined from the ptient for puliction of this cse report nd the ccompnying imges. Competing interests The uthors declre tht they hve no competing interests. Authors contriutions HG, TY, nd MT prticipted in the tretment for this ptient, nd HG drfted the mnuscript. All uthors red nd pproved the finl mnuscript. Author detils 1 Division of Gstroenterologicl Surgery, Hyogo Cncer Center, 13-70, Kitoji-cho, Akshi, Hyogo , Jpn. 2 Division of Gstrointestinl Surgery, Deprtment of Surgery, Grdute School of Medicine, Koe University, 7-5-2, Kusunoki-cho, Chuo-ku, Koe, Hyogo , Jpn. Received: 16 Mrch 2016 Accepted: 31 My 2016 References 1. Inki N, Etoh T, Ohym T, Uchiym K, Ktd N, Koed K, et l. A multiinstitutionl, prospective, phse II fesiility study of lproscopic-ssisted Sumit your mnuscript to journl nd enefit from: 7 Convenient online sumission 7 Rigorous peer review 7 Immedite puliction on cceptnce 7 Open ccess: rticles freely ville online 7 High visiility within the field 7 Retining the copyright to your rticle Sumit your next mnuscript t 7 springeropen.com