Initial experience with limited gastric resection and nodal basin lymphadenectomy guided by fluorescence for early gastric cancer in a Western center.

Abstract

Background: With the increasing age of patients and the higher incidence of proximal gastric tumours, it is important to offer early gastric cancer (EGC) treatments that minimise post-operative morbidity and preserve quality of life. While several endoscopic and laparoscopic approaches have been established as standard treatments, total or subtotal gastrectomy with D2 lymphadenectomy remains the standard in Western countries, except for T1a lesions smaller than 2 cm. This study aims to explore the feasibility of stomach-preserving techniques combined with fluorescence-guided nodal basin harvesting in a Western setting for EGC.

Methods: From July 2021 to November 2023, 12 patients (mean age 75, range 59-87) with cT1N0M0 gastric cancer underwent sentinel nodal basin harvesting after peritumoral injection of indocyanine green (ICG). Stomach-preserving surgery was performed in all patients: intraoperative endoscopic resection in two cases, stapler resection in four, and partial gastrectomy via gastrotomy in six cases. Lymphatic basins were dissected according to tumour location, and fluorescent nodes were separately analysed. Follow-up included CT scans and upper gastrointestinal (GI) endoscopy every six months for two years.

Results: A total of 151 nodes were harvested (mean 12 per patient, range 5-22). Eleven cases were staged pT1N0; one 82-year-old patient with severe schizophrenia had pT3N2 disease, for which a completion total gastrectomy was suggested but declined. One patient experienced a Clavien-Dindo grade II complication. Mean hospitalisation was four days. After a median follow-up of 21.9 months (range 8-36), no recurrence was observed. Mapping confirmed that all metastases remained within the sentinel basin.

Conclusions: Fluorescence-guided nodal basin harvesting combined with limited gastric resection is technically feasible in a Western context and does not compromise short-term oncological outcomes. Patient selection, meticulous staging, and consideration of possible secondary surgery are essential. Long-term oncological safety requires further investigation.