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Laparoscopic-assisted total gastrectomy with D2 lymph node dissection in a case of a 12-year-old child with advanced gastric cancer
Runing head Laparoscopic gastrectomy for a child
Abstract:Gastric cancer is extremely rare in children. Laparoscopic gastrectomy is widely performed in adult patients with gastric cancer; however, there is no reported case of laparoscopic gastrectom in a child with gastric cancer. We report a case of a 12-year-old-girl with gastric cancer who underwent laparoscopy-assisted radical total gastrectomy (D2). The tumor was located in the greater curvature of the upper gastric body, close to the fundus. Pathological examination showed gastric ulcerative signet-ring cell cancer (pT4NOM0, stage IIb). She has been tumor-free for 33 months. We believe that laparoscopic gastrectomy can be a safe, feasible, and minimally invasive approach in children and provides a quicker recovery time than an open approach.
We generally identify gastric cancer (GC) in children under 18 years of age1 as rare. Primary GC in children comprises just 0.05% of all childhood cancers.2 Currently, therapeutic approaches to children with gastric cancer are mostly based on adult studies, with surgical resection as the most important. Laparoscopic gastrectomy is widely performed in adult patients with gastric cancer; however, there is no report on laparoscopic gastrectomy in a child with gastric cancer. We retrospectively analyze the clinic-pathological data of a girl with gastric cancer, diagnosed in December 2011, and discuss the diagnostic and treatment approaches to pediatric gastric cancer.
A 12-year-old girl presented to our institution with complaints of hematemesis and melena on December 17, 2011. There was no history of childhood tumors or gastrointestinal malignancies in the family and close relatives. Preoperative endoscopy and biopsy showed a signet-ring cell carcinoma in the body of the stomach, close to the fundus (whichmeasured approximately 2x1.5 cm in diameter); Helicobacter pylori assays were positive. Both ultrasonography and computerized tomography showed no mass and no distant metastases, both of which were read as normal. Routine laboratory test results were nonspecific. Serum tumor markers, such as carcinoembryonic antigen alpha-fetoprotein (AFP), antigen (CEA), and carbohydrate antigen 19-9, were negative. Her blood group was O rh (+).
She was admitted for surgery in December, 2011 (see Video, Supplemental Digital Content 1, which shows the operation). At surgery, we found an irregularly circumferential solid mass located in the greater curvature of the upper gastric body, close to the fundus, measuring approximately 3x2 cm in diameter; the mass was penetrating the serosa. The liver and other intraperitoneal organs appeared free of gross disease. Laparoscopy-assisted radical total gastrectomy (LATG) with D2 lymph node dissection was performed. The total operation time was 180 min, and the total blood loss was 20 ml. We also find two anatomic variants of perigastric vessels: absenceof the coronary vein (Fig. 1) and a common hepatic artery that ran behind the portal vein (Fig. 2). Pathological examination showed gastric ulcerative signet-ring cell carcinoma (pT4a, pN0, sM0, Stage IIB); the number of dissected LNs was 56 (Fig. 3). The margin of the resected specimen was free of tumor. The postoperative course was generally unremarkable, with the child resuming normal diet by postoperative day (POD) 4. She was sent home on POD 9. At the time of this report, the patient had been tumor-free for 33 months.
Gastric cancer is extremely rare in childhood.1-8 There have been only 6 previously reported cases of primary gastric cancer in patients under the age of 12 years.1, 4-8 The etiology of gastric adenocarcinoma in children remains unknown. It may be associated with autosomal recessive agammaglobulinemia (ARA).2 Gastric cancer may develop in three distinct manners in the pediatric population: de novo, as part of a polyposis syndrome, or after treatment of a gastric lymphoma.7 Helicobacter pylori may be one of the most important risk factors for gastric cancer, causing chronic active inflammation in the gastric mucosa.1, 2 Potential factors such as diet, Epstein-Barr virus infection, and family history as independent risk factors for gastric cancer in children are controversial.6, 7 The diagnosis of gastric cancer is difficult to make in children because initial symptoms are often mild and indefinite. Gastric cancer may present with abdominal pain, anorexia, nausea, vomiting, weight loss, and gastrointestinal bleeding. Early upper gastrointestinal endoscopy with biopsy is regarded as the most important and accurate way of making a definitive diagnosis. Gastrointestinal radiography, ultrasonography, and computerized tomography may also be helpful, but are non-diagnostic; in addition, these modalities may produce false-negative results, as in our case. There is an emphasis on early diagnosis and treatment of gastric cancer in children.5 Often, children will present with symptoms of idiopathic hematemesis, melena, and weight loss, which mimic other disease processes, including Helicobacter pylori infection, familial adenomatosis polyposis, and lymphoma of the stomach; an early upper gastrointestinal endoscopy with biopsy prevents a delay in the diagnosis of stomach cancer.
Gastric cancer in children is highly malignant and has a lower differentiation, lower radical resection rate, and poorer prognosis in reported cases than in adults; the median survival has been reported as only 5 months.7 Therapeutic approaches to children with gastric cancer are mostly based on adult studies. Complete surgical resection could offer a potential cure. Subbiah et al1 reported a 8.6-year-old child who survived, with no signs of the disease 102 months after receiving radial surgical resection. Therefore, surgery is the most efficient treatment for gastric cancer in children without metastasis. Laparoscopic gastrectomy (LG) is widely performed in adult patients with gastric cancer. Preoperative chemoradiation or post-operative adjuvant chemoradiation is commonly practiced and has been shown to improve survival1. However there is no consensus regarding the standard of care for gastric cancer in children5. It is unknown whether chemoradiation may have an effect on the growth, development, and reproduction of children; it is also unknown whether perioperative chemoradiation should be used in children with gastric cancer following radial surgical resection, as there are no reports.
Laparoscopic techniques in children are used in fundoplication, cholecystectomy, appendectomy, herniorrhaphy, and other abdominal benign diseases. Laparoscopy has less side effects on the internal organs, causes less disruption of the normal physiology of the body, uses a smaller incision in the abdominal wall, and produces a decreased trauma response, when compared with traditional open surgery.9-12 Following a meta-analysis of laparoscopic versus open appendectomy in the pediatric population, Aziz et al9 suggested that laparoscopic appendectomy in children reduces complications. Andrew et al10 reported that laparoscopic cholecystectomy is safe and efficacious in children, with benefits including decreased pain and ileus after surgery, shortened hospitalization, and improved cosmesis. In recent years, the development of specific pediatric laparoscopic devices has increased the number of laparoscopic surgeries performed in children with benign diseases. Laparoscopic gastrectomy in children with gastric cancer are more difficult to perform because of the paucity of patient cases, smaller abdominal operating space, more fragile and easily bleeding tissue, smaller and difficult to identify vessels (including the complexity of the splenic hilar vessels), and narrow and deep space at the splenic hilum.11-13 Therefore, despite the fact that laparoscopic gastrectomy (LG) is widely performed in adult patients with gastric cancer; there is no report of laparoscopic gastrectomy in children with gastric cancer. After completing more than 1000 laparoscopic gastrectomy cases at our center, we performed a laparoscopic gastrectomy on a 12-year-old child. There is a magnification effect and appropriately identified anatomic layers under laparoscopic visualization. The laparoscopic amplification elaborately shows the finer structures of the vasculature, nerves, and fascia in children, which helps surgeons identify a specific fascial plane and facilitates lymph node dissection within the vascular sheath. Furthermore, the ultrasonic scalpel is an effective instrument for cutting, providing hemostasis, and minimizing damage to the surrounding tissues, which is suitable for vascular separation and lymph node dissection. The procedure went well without any intraoperative complication, including conversion to open surgery. As mentioned before, there were two anatomic variants of the perigastric vessels in this case: absenceof the coronary vein and a common hepatic artery that ran behind the portal vein. The total operation time was 180 min, and the total blood loss was 20 ml. The number of dissected LNs was 56. The postoperative course was generally unremarkable; there were no complications, and at the time of this case report, the patient had been tumor-free for 33 months, demonstrating favorable short-term efficacy.
With the increase in laparoscopic surgery cases in gastric cancer and increased surgeon experience, laparoscopy-assisted radical gastrectomy (D2) may be appropriate in the pediatric population as well. Is worth noting that laparoscopic gastrectomy in children is a more difficult procedure and should be performed by an experienced surgeon.
Fig.1 Absenceof the coronary vein (a. Left gastric artery, b. Portal veins, c. Splenic artery)
Fig.2 A common hepatic artery that ran behind the portal vein¼ˆd. Common hepatic artery, e. Right gastric artery¼‰
Fig.3 Resected specimen and histological findings¼ˆ→¼šTumor location¼‰