Gastric lymphatic flows may change before and after endoscopic submucosal dissection: in vivo porcine survival models
Background and study aim
Standard gastrectomy with lymphadenectomy is recommended following endoscopic submucosal dissection (ESD) due to the risk of lymph-node metastasis for resected cancers. However, when lymphatic flows remain unchanged after ESD, a minimally invasive function-preserving surgery based on the sentinel node (SN) concept may be applicable. In this study, using porcine survival models, we aimed to investigate whether gastric lymphatic flows were modified following ESD.
Twelve pigs, each with one simulating lesion 3 cm in size, were used. Indocyanine green (ICG) fluid was endoscopically injected into the submucosa in four quadrants surrounding the lesion. Following laparoscopic observation of lymphatic flows, the lesions were resected by ESD. After 4 weeks, ICG fluid was injected in four quadrants surrounding the scar and lymphatic flows were observed in the same manner as the initial procedure. The distribution of lymphatic flows, including stained SNs, was compared.
In ten lesions (83.3%), the distribution of flows remained unchanged. However, in one lesion, the flow along the right gastric epiploic artery (R-GEA) disappeared on the lesser curvature of the middle stomach. In addition, in one lesion, the flow along R-GEA emerged on the lesser curvature of the lower stomach.
Our study revealed that, despite ESD, lymphatic flows remained unchanged in most parts of the stomach. The SN concept may be applied after ESD, except for lesions on the lesser curvature. However, in the case of the lesser curvature, special care must be given to the SN concept.
KeywordsSentinel lymph node Early gastric cancer Endoscopic submucosal dissection
This study was partly supported by a Grant-in-Aid for Scientific Research (C) from the Ministry of Education, Culture, Sports, Science and Technology in Japan in 2015–2017 (Grant No. 15K09061).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflicts of interest.
All institutional and national guidelines for the care and use of laboratory animals were followed.
The study was approved by the institutional review board of the Laboratory Animal Center at Keio University School of Medicine (IRB no.14067). This article does not contain any studies with human performed by any of the authors.
- 1.Japanese gastric cancer treatment guidelines. Gastric Cancer. 2014;ver. 4:2017;20(1):1–19.Google Scholar
- 6.An JY, Min JS, Lee YJ, Jeong SH, Hur H, Han SU, et al. Which factors are important for successful sentinel node navigation surgery in gastric cancer patients? Analysis from the SENORITA prospective multicenter feasibility quality control trial. Gastroenterol Res Pract. 2017;2017:1732571.CrossRefGoogle Scholar
- 19.Aoyama J, Kawakubo H, Goto O, Nakahara T, Mayanagi S, Fukuda K, et al. Potential for local resection with sentinel node basin dissection for early gastric cancer based on the distribution of primary sites. Gastric Cancer. 2018;1:1–6.Google Scholar
- 26.Horii J, Goto O, Shimoda M, Sasaki M, Fujimoto A, Ochiai Y, et al. Which part of a porcine stomach is suitable as an animal training model for gastric endoscopic submucosal dissection? Endoscopy. 2016;48(2):188–93.Google Scholar