Perineural Invasion Underlines the Necessity of Upper Lesser Curvature Skeletonization in Radical Distal Gastrectomy for Locally Advanced Gastric Cancer

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We read with great interest the study by Liebl and colleagues1 that found a significant association between worse survival outcome and gastric cancer with perineural invasion. Perineural invasion has been found as a useful factor, analogous to vessel permeation, for assessing the malignant potential of gastric cancer in previous studies.2–4 Therefore, Jiang et al5 suggested a potential consideration of perineural invasion into future TNM staging system for gastric cancer. The authors additionally concluded that perineural invasion might contribute to stratification of individualized postoperative adjuvant therapy.1 It is possible to be commonly adopted by both oncological surgeons and oncologists that perineural invasion presenting patients need more intensive adjuvant chemotherapy or chemoradiotherapy. However, direct invasion of vagus nerve at the lesser curvature possibly occurs for locally advanced gastric cancer, but it is unable to be predicted preoperatively. Despite lymph node metastasis negative cases, perineural invasion can still be found among a few of them. Therefore, we hypothesize that it is necessary to skeletonize the lesser curvature of the stomach within a radical distal gastrectomy for the sake of diminishing local recurrence.
The surgical technique of upper lesser curvature skeletonization is to completely dissect both the fat-lymphoid and perineural tissues surrounding the upper lesser curvature of remnant stomach in the en bloc manner.6 We consider that a standard upper lesser curvature skeletonization needs to visually expose the subserosal muscularis propria of the lesser curvature and right lateral wall of the abdominal esophagus and the posterior wall of the lesser curvature up to the right side of the posterior gastric artery. As cancer cells infiltrate and spread along with the nerve tract, right-side vagectomy is required to be performed at the site of diaphragmatic hiatus. Application of an ultrasonic scalpel is therefore suggested for clearance of fat tissue and devascularization at the upper lesser curvature. In contrast, conventional technique of suture and ligation may lead to more residual fat-lymphoid and nerve tissues. In addition, our experiences demonstrate that the technique of the lesser curvature skeletonization is relatively safe by experienced surgeons and does not increase the risk of postoperative morbidity and mortality.6 In short, concerning the possibility of perineural invasion of lesser curvature gastric cancer, the standard procedure of upper lesser curvature skeletonization is theoretically recommendable in radical distal gastrectomy, whereas its survival benefit needs further investigation among locally advanced gastric cancer patients.

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