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Jeong SH, Park M, Seo KW, Kim RB, Min JS. A Comparative Study of Postoperative Complications Associated with Distal Gastrectomy and Pylorus-Preserving Gastrectomy among Gastric Cancer Patients Based on Nationwide Survey Data and Propensity Score Weighting. Cancers (Basel) 2024; 16:2203. [PMID: 38927908 PMCID: PMC11202269 DOI: 10.3390/cancers16122203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND/OBJECTIVE This study aimed to compare complication rates between pylorus-preserving gastrectomy (PPG) and distal gastrectomy (DG) using Korean nationwide survey data and propensity score weighting (PSW). PPG preserves gastric function but may lead to more postoperative complications than DG. METHODS AND RESULTS We analyzed 9424 gastric cancer patients who underwent either DG (n = 9183) or PPG (n = 241). PSW balanced variables such as age, sex, TNM stage, comorbidities, ASA score, and surgical approach. Before PSW, 87.8% of DG patients and 87.1% of PPG patients had no complications (p = 0.053). Severe complications (Clavien-Dindo IIIa or higher) were more frequent in PPG (6.6%) than in DG (3.8%) (p = 0.039). After PSW, overall complication rates (p = 0.960) and severe complication rates (p = 0.574) were similar between groups. Incidence rates of anastomotic stricture and leakage were higher in PPG (2.9% and 1.7%) compared to DG (0.6% and 0.5%) (p = 0.001 and 0.036) before PSW, but these differences were not significant after PSW (p = 0.999 and 0.123). CONCLUSION The PSW-adjusted analysis indicates no significant difference in overall and severe complication rates between PPG and DG in gastric cancer patients.
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Affiliation(s)
- Sang-Ho Jeong
- Department of Surgery, Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
| | - Miyeong Park
- Department of Anesthesiology, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
| | - Kyung Won Seo
- Department of Surgery, Kosin University Gospel Hospital, Busan 49267, Republic of Korea;
| | - Rock Bum Kim
- Regional Cardiocerebrovascular Disease Center, Gyeongsang National University Hospital, Jinju 52727, Republic of Korea;
| | - Jae-Seok Min
- Department of Surgery, Korea University College of Medicine, and Division of Foregut Surgery, Korea University Anam Hospital, Seoul 02841, Republic of Korea
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Harada H, Eto K, Ohashi M, Kurihara N, Ri M, Makuuchi R, Ida S, Hayami M, Kumagai K, Sano T, Nunobe S. Equal short-term outcomes of intracorporeal mechanical gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for cT1N0 gastric cancer in the middle stomach compared with the extracorporeal hand-sewing method. Surg Endosc 2024; 38:3115-3125. [PMID: 38619559 DOI: 10.1007/s00464-024-10823-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Intracorporeal mechanical gastrogastrostomy (IMG) techniques have recently been developed and their short-term safety was presented in their initial evaluation. However, whether they are comparable to extracorporeal hand-sewing gastrogastrostomy (EHG) remains unclear. The aim of the study is to establish the safety of IMG in totally laparoscopic pylorus-preserving gastrectomy (TLPPG) compared to EHG in laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). METHODS We retrospectively analyzed the short-term outcomes of patients with middle-third early gastric cancer who underwent LAPPG or TLPPG between 2005 and 2022. The primary objective of this study was to evaluate the non-inferiority of IMG to EHG in terms of safety, with the primary endpoint being the risk difference in anastomosis-related complications (ARCs). The sample size required to achieve a statistical power of 80% for the non-inferiority test was 971 with a one-sided alpha level of 5% and non-inferiority of 5%. RESULTS The analysis included a total of 1,021 patients who underwent LAPPG or TLPPG during the study period. Among them, 488 patients underwent EHG, while 533 underwent IMG. The incidences of ARCs were 11.3% and 11.4% in EHG and IMG, respectively. The observed difference in incidence was 0.0017 (90% confidence interval - 0.0313 to 0.0345), which statistically demonstrated the non-inferiority of IMG to EHG in the incidence of ARCs. Among other complications, the incidence of wound infection in IMG was lower than that in EHG. CONCLUSION IMG is safe regarding ARCs compared with EHG. These results will encourage surgeons to introduce IMG for patients with early middle gastric cancer.
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Affiliation(s)
- Hiroki Harada
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Nozomi Kurihara
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Motonari Ri
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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Sun KK, Wu YY. Pylorus-preserving gastrectomy for early gastric cancer. World J Gastrointest Oncol 2024; 16:653-658. [PMID: 38577445 PMCID: PMC10989389 DOI: 10.4251/wjgo.v16.i3.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Pylorus-preserving gastrectomy (PPG) has been widely accepted as a function-preserving gastrectomy for middle-third early gastric cancer (EGC) with a distal tumor border at least 4 cm proximal to the pylorus. The procedure essentially preserves the function of the pyloric sphincter, which requires to preserve the upper third of the stomach and a pyloric cuff at least 2.5 cm. The suprapyloric and infrapyloric vessels are usually preserved, as are the hepatic and pyloric branches of the vagus nerve. Compared with distal gastrectomy, PPG has significant advantages in preventing dumping syndrome, body weight loss and bile reflux gastritis. The postoperative complications after PPG have reached an acceptable level. PPG can be considered a safe, effective, and superior choice in EGC, and is expected to be extensively performed in the future.
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Affiliation(s)
- Ke-Kang Sun
- Department of Gastrointestinal Surgery, The Affiliated Kunshan Hospital to Jiangsu University, Suzhou 215300, Jiangsu Province, China
| | - Yong-You Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
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Otake R, Kumagai K, Ohashi M, Makuuchi R, Ida S, Sano T, Nunobe S. Reflux Esophagitis After Laparoscopic Pylorus-Preserving Gastrectomy for Gastric Cancer. Ann Surg Oncol 2023; 30:2294-2303. [PMID: 36509874 DOI: 10.1245/s10434-022-12902-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic pylorus-preserving gastrectomy (LPPG) is performed for cT1N0 gastric cancer as a function-preserving surgery, but reflux esophagitis can develop as a mid- to long-term complication postoperatively. We aimed to clarify the incidence rate of this complication and the factors correlated with it. METHODS Patients with gastric cancer who underwent LPPG between 2005 and 2017 were analyzed. Postoperative reflux esophagitis was evaluated with esophagogastroduodenoscopy; patients were diagnosed as having reflux esophagitis with erosive esophagitis using the modified Los Angeles classification. The incidence rate of postoperative reflux esophagitis was estimated; factors correlated with postoperative reflux esophagitis were analyzed using the logistic regression model. RESULTS During the study period, 813 patients underwent LPPG for gastric cancer, and 127 (15.6%) of them developed grade B or more severe postoperative reflux esophagitis. The factors correlated with postoperative reflux esophagitis were male sex (odds ratio, 2.68; 95% confidence interval, 1.77-4.05; P < 0.001), preoperative grade A reflux esophagitis (odds ratio, 3.05; 95% confidence interval, 1.28-7.27; P = 0.012), body mass index of ≥ 23 kg/m2 at 1 year postoperatively (odds ratio, 2.18; 95% confidence interval, 1.34-3.53; P = 0.002), postoperative hiatal hernia (odds ratio, 4.35; 95% confidence interval, 2.35-8.04; P < 0.001), and long-term stasis (odds ratio, 1.58; 95% confidence interval, 1.01-2.47; P = 0.044). CONCLUSIONS Careful attention should be paid in performing LPPG and in postoperative management after LPPG for gastric cancer patients with those risk factors.
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Affiliation(s)
- Reiko Otake
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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Choi J, Kim S, Chung H, Kong SH, Cho SJ, Park DJ, Lee HJ, Kim SG, Yang HK. Safety of pylorus-preserving gastrectomy for gastric cancer combined with antral high-risk lesions: a comparison with endoscopic submucosal dissection. Surg Endosc 2022; 37:2987-2996. [PMID: 36517703 DOI: 10.1007/s00464-022-09791-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) is a surgical treatment option for cT1N0M0 gastric cancer located in the middle third of the stomach. However, data for the long-term post-PPG clinical outcomes related to metachronous gastric neoplasms (mGNs) in the residual stomach are currently lacking. Therefore, we aimed to evaluate the safety of PPG by focusing on mGNs. METHODS In this single-center, retrospective study, we reviewed the data for 362 patients who underwent PPG with a 3-cm antral cuff and 139 who underwent endoscopic submucosal dissection (ESD) for middle-third gastric cancer between January 2013 and December 2015. The histopathologic features of the antrum in the ESD group, which could not be determined in the PPG group, were analyzed to investigate the risk factors for mGNs. The estimated and actual incidence of mGNs in the antrum were compared in the PPG group. RESULTS The incidence of mGNs was 6.5% (9/139) in the ESD group. The presence of a synchronous adenoma (odds ratio [OR], 8.46; 95% confidence interval [CI], 1.55-46.34), carcinoma (OR, 15.71; 95% CI, 2.67-92.56) and moderate-to-severe intestinal metaplasia (OR, 9.77; 95% CI, 1.14-83.92) were associated with a higher risk of overall mGNs. However, when confined to the antrum, no significant association was observed between these factors and mGNs. In the ESD group, 2 of 9 mGNs (1.4%) were located at the 3-cm antral cuff. In the PPG group, both mGNs (0.6%) were located in the proximal remnant stomach. CONCLUSION Pylorus-preserving gastrectomy was a safe therapeutic option with regard to the occurrence of metachronous adenomas or carcinomas in our series. Despite the low mGN incidence in the 3-cm antral cuff after PPG, the presence of synchronous neoplasms or moderate-to-severe intestinal metaplasia was a risk factor for mGNs in the ESD group; thus, further studies on longer antral cuffs with long-term follow-up are needed.
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Affiliation(s)
- Jinju Choi
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro Jongno-Gu, Seoul, Korea
- Department of Gastroenterology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sara Kim
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro Jongno-Gu, Seoul, Korea.
- Department of Medical Device Development, Seoul National University Graduate School, Seoul, Korea.
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, Korea.
- VITCAL, Co., Ltd, Seoul, Korea.
| | - Soo-Jeong Cho
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro Jongno-Gu, Seoul, Korea
| | - Do-Joong Park
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Sang Gyun Kim
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro Jongno-Gu, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
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Intracorporeal hand-sewn anastomosis following pylorus-preserving gastrectomy: surgical technique and short-term surgical outcome. Langenbecks Arch Surg 2022; 407:1711-1720. [PMID: 35670857 DOI: 10.1007/s00423-022-02575-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 05/29/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although several procedures for mechanical anastomosis have recently been reported, intracorporeal manually hand-sewn anastomosis for totally laparoscopic pylorus-preserving gastrectomy (TLPPG) is considered technically difficult. Here, we report a new technique for laparoscopic reconstruction using hand-sewn sutures. METHODS Together with a proper lymphadenectomy, the stomach was detached and resected using separate two-layer incisions, similar to the original laparotomy method. An approximately 5-cm antral cuff was left in place. The essential concept of this new method was to align the anastomotic site by rotating each clamped gastric stump. This allowed us to perform a secure, hand-sewn, two-layer anastomosis successfully. The short-term surgical outcome after TLPPG was retrospectively compared with that for patients who underwent a conventional laparoscopy-assisted procedure (LAPPG). RESULTS Of the 20 consecutive patients who underwent pylorus-preserving gastrectomy in our department between 2014 and 2021, the first 8 patients and the subsequent 12 patients underwent LAPPG and TLPPG, respectively. The operation time was significantly longer in the TLPPG group (median, 302 vs. 269 min). The morbidity was comparable (8.3% in TLPPG vs. 12.5% in LAPPG). Postoperative delayed gastric emptying was only observed in one patient in the LAPPG group. TLPPG reduced the cost of the operation by reducing the number of linear stapler cartridges required. CONCLUSION A purely hand-sewn gastrogastrostomy is safe, feasible, and cost-effective, and it omits the need for a mini-laparotomy in the upper abdomen.
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Shimada A, Ishii S, Tanaka H, Okamoto T, Mishima K, Nakanishi R, Hosaka M, Ozaki T, Igarashi K, Honda M, Funamizu N, Tsutsui A, Omura K, Wakabayashi G. Outcomes of Distal Gastrectomy for Elderly Patients With Advanced Gastric Cancer: Comparison With Non-Elderly Patients and the Utility of Laparoscopic Distal Gastrectomy for Elderly Patients. Int Surg 2021; 105:679-687. [DOI: 10.9738/intsurg-d-20-00042.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2025] Open
Abstract
Background
As the elderly population increases, cases of elderly advanced gastric cancer (AGC) also increase. This study aims to investigate the safety and utility of curative gastrectomy, as well as the efficacy of laparoscopic gastrectomy, for these elderly patients.
Methods
We retrospectively analyzed the surgical outcomes of patients with cStage IB-III AGC who underwent distal gastrectomy (DG) with D2 lymph node dissection in our institution. We compared the results between elderly patients (>75 years) and non-elderly patients (<75 years). We further divided the elderly patients into 2 groups: those who underwent laparoscopic DG (LDG) and those who underwent open DG (ODG). Further, we compared the results of the 2 groups.
Results
From January 2014 to March 2019, 84 patients underwent DG with D2 lymph node dissection for cStage IB-III AGC (52 elderly patients and 32 non-elderly patients). ASA was significantly higher in elderly patients; however, there was no significant difference in surgical outcomes nor in overall survival (OS) and recurrence-free survival (RFS) between the 2 groups. Among 52 elderly patients, 19 had LDG, whereas 33 had ODG. The LDG group had a significantly shorter length of hospital stay and a significantly less amount of blood loss. There was no significant difference in RFS and OS between these 2 groups.
Conclusions
Safety and oncologic curability may be achieved in elderly patients with AGC. LDG may be safely performed as ODG in elderly patients with AGC and it is expected to benefit them by achieving minimally invasive surgery.
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Affiliation(s)
- Ayako Shimada
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare, Narita Hospital, Chiba, Japan
| | - Satoru Ishii
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Hiroto Tanaka
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Tomomi Okamoto
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Kohei Mishima
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Ryo Nakanishi
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Miki Hosaka
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Takahiro Ozaki
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Kazuharu Igarashi
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Masayuki Honda
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Naotake Funamizu
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Atsuko Tsutsui
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Kenji Omura
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Go Wakabayashi
- Department of Gastrointestinal Surgery, Ageo Central General Hospital, Saitama, Japan
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Park JH, Kong SH, Choi JH, Park SH, Suh YS, Park DJ, Lee HJ, Yang HK. Proximal Anterior-Antrum Posterior (PAAP) Overlapping Anastomosis in Minimally Invasive Pylorus-Preserving Gastrectomy for Early Gastric Cancer Located in the High Body and Posterior Wall of the Stomach. J Gastric Cancer 2020; 20:277-289. [PMID: 33024584 PMCID: PMC7521977 DOI: 10.5230/jgc.2020.20.e26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/23/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose To evaluate the feasibility and safety of intracorporeal overlapping gastrogastrostomy between the proximal anterior wall and antrum posterior wall (PAAP; PAAP anastomosis) of the stomach in minimally invasive pylorus-preserving gastrectomy (PPG) for early gastric cancer (EGC). Materials and Methods From December 2016 to December 2019, 17 patients underwent minimally invasive PPG with PAAP anastomosis for EGC in the high body and posterior wall of the stomach. Intraoperative gastroscopy was performed with the rotation maneuver during proximal transection. A longer antral cuff (>4-5 cm) was created for PAAP than for conventional PPG (≤3 cm) at the point where a safe distal margin and good vascular perfusion were secured. Because the posterior wall of the proximal remnant stomach was insufficient for intracorporeal anastomosis, the anterior wall was used to create an overlapping anastomosis with the posterior wall of the remnant antrum. The surgical and oncological outcomes were analyzed, and the stomach volume was measured in patients who completed the 6-month follow-up. The results were compared to those after conventional PPG (n=11 each). Results PAAP anastomosis was successfully performed in 17 patients. The proximal and distal resection margins were 2.4±1.9 cm and 4.0±2.6 cm, respectively. No postoperative complications were observed during the 1-year follow-up esophagogastroduodenoscopy (n=10). The postoperative remnant stomach (n=11) was significantly larger with PAAP than with conventional PPG (225.6±118.3 vs. 99.1±63.2 mL; P=0.001). The stomach length from the anastomosis to the pylorus was 4.9±2.4 cm after PAAP. Conclusions PAAP anastomosis is a feasible alternative for intracorporeal anastomosis in minimally invasive PPG for highly posteriorly located EGC.
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Affiliation(s)
- Ji-Hyeon Park
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jong-Ho Choi
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Shin-Hoo Park
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Do-Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
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Takahashi R, Ohashi M, Hiki N, Makuuchi R, Ida S, Kumagai K, Sano T, Nunobe S. Risk factors and prognosis of gastric stasis, a crucial problem after laparoscopic pylorus-preserving gastrectomy for early middle-third gastric cancer. Gastric Cancer 2020; 23:707-715. [PMID: 31916027 DOI: 10.1007/s10120-019-01037-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) is a function-preserving procedure for cT1N0 gastric cancer located in the middle-third of stomach, which is currently performed through a laparoscopic approach (LPPG). PPG is sometimes associated with a crucial problem during the early postoperative course, designated gastric stasis. However, information regarding gastric stasis remains to be fully elucidated. METHODS The study included 897 patients who underwent LPPG between 2005 and 2017. Early postoperative gastric stasis (E-stasis) was defined when the following conditions were fulfilled: upper abdominal distension, remnant stomach fullness on radiography image, and period of starvation exceeding 72 h within 1 month postoperatively. To evaluate long-term outcomes of E-stasis, late postoperative food residue (L-residue) was defined as grade 2 or higher food residue endoscopically according to the RGB (residue, gastritis, bile) classification at 1 year postoperatively. Risk factors and long-term outcomes of E-stasis were retrospectively analyzed. RESULTS E-stasis was the most common complication during the early postoperative course. E-stasis occurred in 68 (7.6%) patients. Multivariate analysis identified age (≥ 61 years), DM, and postoperative intraabdominal infection as risk factors. At 1 year postoperatively, relative body weight ratio and postoperative serum albumin in the patients who experienced E-stasis was significantly lower than those in the other patients (P = 0.042 and 0.011, respectively). Of the patients who suffered from E-stasis, 42.5% experienced L-residue. CONCLUSIONS E-stasis after LPPG occurs in 7.6% of patients. Age, DM, and intraabdominal infection are significantly related to E-stasis. E-stasis is associated with poorer nutritional and functional outcomes even at 1 year postoperatively.
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Affiliation(s)
- Ryo Takahashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Manabu Ohashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Naoki Hiki
- Department of Upper Gastrointestinal Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Rie Makuuchi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Tsujiura M, Nunobe S. Functional and nutritional outcomes after gastric cancer surgery. Transl Gastroenterol Hepatol 2020; 5:29. [PMID: 32258533 DOI: 10.21037/tgh.2019.11.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022] Open
Abstract
Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.
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Affiliation(s)
- Masahiro Tsujiura
- Department of Surgery, Saiseikai Shiga Hospital, Ritto City, Japan.,Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ward, Tokyo, Japan
| | - Souya Nunobe
- Department of Surgery, Saiseikai Shiga Hospital, Ritto City, Japan
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11
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Eom BW, Park B, Yoon HM, Ryu KW, Kim YW. Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: A retrospective study of long-term functional outcomes and quality of life. World J Gastroenterol 2019; 25:5494-5504. [PMID: 31576095 PMCID: PMC6767989 DOI: 10.3748/wjg.v25.i36.5494] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/08/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was known to have benefits of function-preserving surgery compared to laparoscopy-assisted distal gastrectomy (LADG). However, in clinical settings, delayed gastric emptying and esophageal reflux following LAPPG can be serious issues, making surgeons reluctant to perform LAPPG. It is unclear that LAPPG had better long-term functional outcomes and quality of life compared to LADG.
AIM To evaluate the long-term functional outcomes and patient-reported quality of life of LAPPG compared to those of LADG.
METHODS We reviewed the clinicopathological data of 195 patients who underwent LADG with Billroth II anastomosis and 101 patients who underwent LAPPG for cT1N0 gastric cancer in the middle third of the stomach between 2012 and 2015. Postoperative complications, nutritional parameters, and survey results of the European Organization for Research and Treatment of Cancer Questionnaire C30 and STO22 questionnaire were compared between the two groups.
RESULTS The serum hemoglobin level was significantly higher in the LAPPG group than in the LADG group (P < 0.001). In the endoscopic findings, incidence of bile reflux was lower (P < 0.001); however, the incidence of residual food was higher in the LAPPG group than in the LADG group (P < 0.001). Regarding the quality of life score, the LAPPG group had a better physical functioning score (86.7 vs 90.0, P = 0.032) but also greater pain and reflux when compared to the LADG group [8.3 vs 16.7 in pain, 11.1 (interquartile range, 0, 22.2) vs 11.1 (interquartile range, 11.1, 33.3) in reflux, P = 0.034 and 0.001, respectively].
CONCLUSION LAPPG is beneficial to recovery of anemia and to bile reflux, however, it might be unfavorable in terms of pain and reflux symptoms compared to LADG with Billroth II anastomosis.
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Affiliation(s)
- Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang 10408, South Korea
| | - Boram Park
- Biostatistics Collaboration Team, Research Core, Research institute, National Cancer Center, Goyang 10408, South Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, Goyang 10408, South Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang 10408, South Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang 10408, South Korea
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A Comparison of Totally Laparoscopic Pylorus Preserving Gastrectomy and Laparoscopy-Assisted Pylorus Preserving Gastrectomy for Early Gastric Cancer. THE JOURNAL OF MINIMALLY INVASIVE SURGERY 2019; 22:113-118. [PMID: 35599699 PMCID: PMC8980167 DOI: 10.7602/jmis.2019.22.3.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/04/2019] [Accepted: 07/10/2019] [Indexed: 11/08/2022]
Abstract
Purpose Methods Results Conclusion
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Wang ZL, Miao RL, Gao C, Tang L, Li ZY, Sun YS, Ji JF. Computed Tomography Arteriography for Detecting the Origin of the Inferior Pyloric Artery in Patients with Gastric Cancer. Korean J Radiol 2019; 20:422-428. [PMID: 30799573 PMCID: PMC6389803 DOI: 10.3348/kjr.2018.0270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Zhi Long Wang
- Department of Radiology, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Ru Lin Miao
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Chao Gao
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Lei Tang
- Department of Radiology, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Zi Yu Li
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Ying Shi Sun
- Department of Radiology, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China
| | - Jia Fu Ji
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, China.
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Lymphadenectomy along the infrapyloric artery may be dispensable when performing pylorus-preserving gastrectomy for early middle-third gastric cancer. Gastric Cancer 2017; 20:543-547. [PMID: 27516348 DOI: 10.1007/s10120-016-0632-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/02/2016] [Indexed: 02/07/2023]
Abstract
This study investigated the incidence of gastric cancer metastasis to the lymph nodes along the infrapyloric artery (IPA), namely no. 6i, by reviewing our medical records of 348 patients who underwent complete no. 6 dissection. Metastasis to these nodes was observed in 11 (3.2 %) patients. In these patients, one huge tumor was located in the middle third and ten including two early tumors were located in the lower third; the metastasis rate in early lower-third tumors was 2.1 % and reached 19.5 % in advanced tumors. In contrast, no early middle-third gastric cancers had no. 6i metastasis. The median diameter of 6i-positive tumors was 62 (range 18-115) mm, and the distance from the distal tumor border to the pyloric ring was no more than 44 mm. Lymphadenectomy along the IPA is important for treating gastric cancer invading the antrum, but may be dispensable when performing pylorus-preserving gastrectomy for early middle-third cancer.
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Tsujiura M, Hiki N, Ohashi M, Nunobe S, Kumagai K, Ida S, Hayami M, Sano T, Yamaguchi T. Excellent Long-Term Prognosis and Favorable Postoperative Nutritional Status After Laparoscopic Pylorus-Preserving Gastrectomy. Ann Surg Oncol 2017; 24:2233-2240. [PMID: 28280944 DOI: 10.1245/s10434-017-5828-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic pylorus-preserving gastrectomy (LPPG) has been introduced as a minimally invasive function-preserving operation for early gastric cancer (GC). This study aimed to investigate the surgical and prognostic outcomes after LPPG at the authors' institution. METHODS This study analyzed 465 patients who underwent LPPG for cT1 N0 GC located in the middle part of the stomach between 2006 and 2012. Short- and long-term surgical outcomes including 5-year survival rates, postoperative nutritional data, and body weight change were retrospectively investigated. RESULTS Regarding short-term surgical results, 14 (3%) of the 465 patients had severe complications classified as Clavien-Dindo grade 3a or above, and no mortality occurred (no in-hospital deaths). The median follow-up period was 1829 days (range 226-3197 days), and the 5-year overall survival and relapse-free survival rates were respectively 98% (95% confidence interval [CI] 96.1-99.0%) and 98% (95% CI 96.1-99.0%). Only two cases of postoperative recurrence were confirmed, and their recurrence sites were not in the remnant stomach or regional lymph nodes. The postoperative nutritional status, in terms of serum total protein, albumin, and hemoglobin levels, was well maintained, and the mean relative body weight (postoperative/preoperative) was 93.24 ± 7.29% after LPPG. CONCLUSIONS For the first time, we have clarified the detailed long-term survival outcomes of LPPG for cT1 N0 GC. LPPG is an acceptable and favorable operative method for clinically diagnosed early-stage GC, in terms of long-term survival and postoperative nutrition.
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Affiliation(s)
- Masahiro Tsujiura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Hiki
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiharu Yamaguchi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Preserving infrapyloric vein reduces postoperative gastric stasis after laparoscopic pylorus-preserving gastrectomy. Langenbecks Arch Surg 2016; 402:49-56. [PMID: 27815708 DOI: 10.1007/s00423-016-1529-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/18/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE Laparoscopic pylorus-preserving gastrectomy (LPPG) is performed to preserve function in treating early gastric cancer. However, gastric stasis is a potential complication of LPPG that could decrease postoperative quality of life, possibly due to gastric edema of the pyloric cuff caused by venous stasis. We introduced an infrapyloric vein (IPV)-preserving LPPG (iLPPG) procedure to prevent pyloric cuff edema and thus minimize the incidence of gastric stasis and investigated the early clinical outcomes of iLPPG. METHODS We reviewed 150 patients with gastric cancer who underwent LPPG between August 2011 and June 2013 at the Cancer Institute Hospital and analyzed postoperative complications, incidence of gastric stasis (requiring starvation longer than 72 h or an invasive treatment), and transient delayed gastric emptying (TDGE). RESULTS Of the 150 patients, 56 underwent iLPPG and 94 underwent conventional LPPG without preservation of the IPV (cLPPG). Morbidity rates were 5.4% in the iLPPG group and 23.4% in the cLPPG group (P = 0.003). The incidence of both gastric stasis and TDGE was significantly lower in the iLPPG group than in the cLPPG group (0 vs. 8.5%, P = 0.03 and 0 vs. 7.4%, P = 0.046, respectively). Median postoperative stay was significantly shorter in the iLPPG group compared to the cLPPG group (9 vs. 11 days, P < 0.001, respectively). CONCLUSIONS Preservation of the IPV might prevent the incidence of postoperative gastric stasis after LPPG, resulting in a shorter postoperative stay.
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Shimada A, Takeuchi H, Ono T, Kamiya S, Fukuda K, Nakamura R, Takahashi T, Wada N, Kawakubo H, Saikawa Y, Omori T, Nakahara T, Jinzaki M, Murakami K, Kitagawa Y. Pylorus-Preserving Surgery Based on the Sentinel Node Concept in Early Gastric Cancer. Ann Surg Oncol 2016; 23:4247-4252. [PMID: 27364500 DOI: 10.1245/s10434-016-5358-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with early stage gastric cancer in the middle third of the stomach, pylorus-preserving gastrectomy (PPG) can be an option as function-preserving surgery, although its oncologic safety is not definitively defined. This issues may be overcome using the sentinel node (SN) concept. The aim of this study was to investigate the effectiveness of the SN concept in early gastric cancer patients who are candidates for PPG. METHODS One hundred fifty-six patients with middle-third location of cT1N0 gastric cancer (single lesion, <4 cm) underwent distal gastrectomy with SN mapping. As a tracer, technetium-99 tin colloid solution and blue dye were endoscopically injected into the submucosal layer surrounding the primary tumor. RESULTS SN detection rate was 100 % (156 of 156), and the accuracy of the nodal evaluation of metastasis was 99 % (155 of 156). Suprapyloric lymph node (LN; LN No. 5) and infrapyloric LN (LN No. 6) were detected as SNs in 6 and 14 % of the patients, respectively. We also found two cases with metastasis to LN No. 5 or LN No. 6. DISCUSSION When performing PPG, the possibility of LN metastasis, especially to LN No. 5 and LN No. 6, cannot be underestimated. SN mapping can play an important role to predict the possibility of metastasis to LN No. 5 and LN No. 6.
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Affiliation(s)
- Ayako Shimada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Taiki Ono
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Kamiya
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | | | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiro Saikawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tai Omori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tadaki Nakahara
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Koji Murakami
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Oh SY, Lee HJ, Yang HK. Pylorus-Preserving Gastrectomy for Gastric Cancer. J Gastric Cancer 2016; 16:63-71. [PMID: 27433390 PMCID: PMC4944004 DOI: 10.5230/jgc.2016.16.2.63] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 05/23/2016] [Indexed: 12/19/2022] Open
Abstract
Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.
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Affiliation(s)
- Seung-Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Son T, Hyung WJ. Laparoscopic gastric cancer surgery: Current evidence and future perspectives. World J Gastroenterol 2016; 22:727-735. [PMID: 26811620 PMCID: PMC4716072 DOI: 10.3748/wjg.v22.i2.727] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/16/2015] [Accepted: 11/19/2015] [Indexed: 02/07/2023] Open
Abstract
Laparoscopic gastrectomy has been widely accepted as a standard alternative for the treatment of early-stage gastric adenocarcinoma because of its favorable short-term outcomes. Although controversies exist, such as establishing clear indications, proper preoperative staging, and oncologic safety, experienced surgeons and institutions have applied this approach, along with various types of function-preserving surgery, for the treatment of advanced gastric cancer. With technical advancement and the advent of state-of-the-art instruments, indications for laparoscopic gastrectomy are expected to expand as far as locally advanced gastric cancer. Laparoscopic gastrectomy appears to be promising; however, scientific evidence necessary to generalize this approach to a standard treatment for all relevant patients and care providers remains to be gathered. Several multicenter, prospective randomized trials in high-incidence countries are ongoing, and results from these trials will highlight the short- and long-term outcomes of the approach. In this review, we describe up-to-date findings and critical issues regarding laparoscopic gastrectomy for gastric cancer.
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Namikawa T, Hiki N, Kinami S, Okabe H, Urushihara T, Kawahira H, Fukushima N, Kodera Y, Yumiba T, Oshio A, Nakada K. Factors that minimize postgastrectomy symptoms following pylorus-preserving gastrectomy: assessment using a newly developed scale (PGSAS-45). Gastric Cancer 2015; 18:397-406. [PMID: 24760336 DOI: 10.1007/s10120-014-0366-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 03/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) is sometimes performed as a function-preserving surgery for the treatment of early gastric cancer. The aim of this study was to use an integrated assessment scale for postgastrectomy syndrome to determine the appropriate indicators and optimal methods for PPG. METHODS The Postgastrectomy Syndrome Assessment Study (PGSAS) is a multicenter survey based on an integrated questionnaire (PGSAS-45) consisting of 45 items. Questionnaire responses were retrieved from a total of 2,520 patients, each of whom had undergone one of six different types of gastrectomy procedures; 313 responses from patients who had received PPG were analyzed here. RESULTS The size of the proximal gastric remnant (less than one-quarter, about one-third, or more than one-half of the original size) significantly influenced the change in body weight, the scores for dissatisfaction at the meal, and dissatisfaction for daily life subscale (P = 0.030, P = 0.005, P = 0.034, respectively). The nausea score in patients who underwent hand-sewn anastomosis was significantly lower than in those who underwent anastomosis with a linear stapler (P = 0.006). The scores for diarrhea subscale, increased passage of stools, and sense of foods sticking differed significantly depending on the length of the preserved pyloric cuff (P = 0.047, P = 0.021, P = 0.046, respectively). CONCLUSIONS The results suggest that preservation of a sufficient proximal gastric remnant is recommended when utilizing PPG as function-preserving surgery.
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Affiliation(s)
- Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan,
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Totally laparoscopic pylorus-preserving gastrectomy for early gastric cancer in the middle stomach: technical report and surgical outcomes. Gastric Cancer 2015; 18:183-7. [PMID: 24481853 DOI: 10.1007/s10120-014-0337-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 12/30/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The feasibility, safety, and improved quality of postoperative life following laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with a hand-sewn anastomosis via a mini-laparotomy for early gastric cancer (EGC) have been previously established. Here we describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy (TLPPG) using an intracorporeal delta-shaped anastomosis technique, and the short-term surgical outcomes of 60 patients with EGC in the middle stomach are reported. METHODS After lymphadenectomy and mobilization of the stomach, intraoperative gastroscopy was performed in order to verify the location of the tumor, and then the distal and proximal transecting lines were established, 5 cm from the pyloric ring and just proximal to Demel's line, respectively. Following transection of the stomach, a delta-shaped intracorporeal gastrogastrostomy was made with linear staplers. RESULTS There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 259 min and 28 mL, respectively. Twelve patients (20.0%) experienced postoperative complications classified as grade II using the Clavien-Dindo classification, with the most frequent complication being gastric stasis (6 cases, 10.0 %). The incidence of severe complications classified as grade III or above was 1.7%; only one patient required reoperation and intensive care due to postoperative intraabdominal bleeding and subsequent multiple organ failure. CONCLUSION TLPPG with an intracorporeal delta-shaped anastomosis was found to be a safe procedure, although it tended to require a longer operating time than the well-established LAPPG with a hand-sewn gastrogastrostomy.
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Abstract
Minimally invasive surgery, which has been extensively used to treat gastric adenocarcinoma, is now regarded as one of the standard treatments for early gastric cancer, and its suitability for advanced gastric cancer is being investigated. The use of cutting-edge techniques for minimally invasive surgery enables surgeons to deliver various treatment options to minimize a patient's distress and to maintain oncologic safety. Ongoing multicenter prospective studies aim to validate the efficacy of these surgical techniques and to expand the indications of minimally invasive surgery for the treatment of gastric cancer. In this review, we summarize the current status and issues regarding minimally invasive surgery for the treatment of gastric cancer.
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Affiliation(s)
- Taeil Son
- Department of Surgery, Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - In Gyu Kwon
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Gastric Cancer Clinic and Robot and MIS Center, Severance Hospital, Yonsei University Health System, Seoul, Korea
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Saito T, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Current status of function-preserving surgery for gastric cancer. World J Gastroenterol 2014; 20:17297-17304. [PMID: 25516640 PMCID: PMC4265587 DOI: 10.3748/wjg.v20.i46.17297] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/16/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023] Open
Abstract
Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer (GC) at an early stage. Due to the low incidence of lymph node metastasis and favorable prognosis in early GC, function-preserving surgery which improves postoperative quality of life may be possible. Pylorus-preserving gastrectomy (PPG) is one such function-preserving procedure, which is expected to offer advantages with regards to dumping syndrome, bile reflux gastritis, and the frequency of flatus, although PPG may induce delayed gastric emptying. Proximal gastrectomy (PG) is another function-preserving procedure, which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach, although the incidence of heartburn or gastric fullness associated with this procedure is high. However, these disadvantages may be overcome by the reconstruction method used. The other important problem after PG is remnant GC, which was reported to occur in approximately 5% of patients. Therefore, the reconstruction technique used with PG should facilitate postoperative endoscopic examinations for early detection and treatment of remnant gastric carcinoma. Oncologic safety seems to be assured in both procedures, if the preoperative diagnosis is accurate. Patient selection should be carefully considered. Although many retrospective studies have demonstrated the utility of function-preserving surgery, no consensus on whether to adopt function-preserving surgery as the standard of care has been reached. Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.
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Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q. Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer. J Laparoendosc Adv Surg Tech A 2014; 24:718-27. [PMID: 25243417 DOI: 10.1089/lap.2014.0123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) has been performed to reduce postprandial symptoms for some early gastric cancer (EGC) cases. The aim of this study was to evaluate the possible advantages after PPG for middle-third EGC in comparison with distal gastrectomy. MATERIALS AND METHODS We searched Medline, Embase, and Science Citation Index Expanded for relevant studies. Statistical analyses were conducted to calculate the summary weighted mean differences (WMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) using random-effects models. RESULTS We identified 15 nonrandomized controlled trials (16 studies) with 1774 patients, which consisted of 11 studies for conventional PPG (CPPG) versus conventional distal gastrectomy (CDG) and 5 studies for laparoscopy-assisted PPG (LAPPG) versus laparoscopy-assisted distal gastrectomy (LADG). Meta-analysis of CPPG versus CDG revealed that CPPG had the advantage of prevention of early dumping syndrome (OR=0.18; 95% CI 0.12, 0.27), gastritis (OR=0.19; 95% CI 0.07, 0.53), duodenal juice reflux (OR=0.20; 95% CI 0.06, 0.66), and regaining of weight (WMD=3.53; 95% CI 2.34, 4.72). However, the incidence of gastric stasis was higher in the CPPG group than in the CDG group (OR=1.70; 95% CI 1.13, 2.57). Meta-analysis of LAPPG versus LADG revealed that LAPPG shortened the operation time (WMD=-21.12; 95% CI -31.33, -10.90) and did not increase the occurrence of postoperative complication (OR=0.72; 95% CI 0.41, 1.27). CONCLUSIONS With the benefits of prevention of early dumping syndrome, duodenal juice reflux, gastritis, and regaining of weight, PPG can be an excellent option for middle-third EGC.
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Affiliation(s)
- Peng Song
- 1 Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University , Nanjing, China
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El-Sedfy A, Brar SS, Coburn NG. Current role of minimally invasive approaches in the treatment of early gastric cancer. World J Gastroenterol 2014; 20:3880-3888. [PMID: 24833843 PMCID: PMC3983444 DOI: 10.3748/wjg.v20.i14.3880] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/29/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.
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Hiki N, Nunobe S, Kubota T, Jiang X. Function-preserving gastrectomy for early gastric cancer. Ann Surg Oncol 2013; 20:2683-92. [PMID: 23504120 DOI: 10.1245/s10434-013-2931-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Indexed: 12/17/2022]
Abstract
The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures. Applications of function-preserving gastric cancer surgery may therefore also be increasing because of its low incidence of lymph node metastasis, excellent survival rates, and the possibility of less-invasive procedures such as laparoscopic gastrectomy being used in combination. Pylorus-preserving gastrectomy (PPG) with radical lymph node dissection is one such function-preserving procedure that has been applied for EGC, with the indications, limitations, and survival benefits of PPG already reported in several retrospective studies. Laparoscopy-assisted proximal gastrectomy has also been applied for EGC of the upper third of the stomach, although this procedure can be associated with the 2 major problems of reflux esophagitis and carcinoma arising in the gastric stump. In the patient with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved very small stomach may provide a better quality of life for the patients and fewer postoperative complications. Finally, the laparoscopy endoscopy cooperative surgery procedure combines endoscopic submucosal dissection with laparoscopic gastric wall resection, which prevents excessive resection and deformation of the stomach after surgery and was recently applied for EGC cases without possibility of lymph node metastasis. Function-preserving laparoscopic gastrectomy is recommended for the treatment of EGC if the indication followed by accurate diagnosis is strictly confirmed. Preservation of remnant stomach sometimes causes severe postoperative dysfunctions such as delayed gastric retention in PPG, esophageal reflux in PG, and gastric stump carcinoma in the remnant stomach. Moreover, these techniques present technical difficulties to the surgeon. Although many retrospective studies showed the functional benefit or oncological safety of function-preserving gastrectomy, further prospective studies using large case series are necessary.
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Affiliation(s)
- Naoki Hiki
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Tokyo, Japan.
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Tsujimoto H, Uyama I, Yaguchi Y, Kumano I, Takahata R, Matsumoto Y, Yoshida K, Horiguchi H, Aosasa S, Ono S, Yamamoto J, Hase K. Outcome of overlap anastomosis using a linear stapler after laparoscopic total and proximal gastrectomy. Langenbecks Arch Surg 2012; 397:833-40. [PMID: 22398434 DOI: 10.1007/s00423-012-0939-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 02/20/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recently, novel intracorporeal esophagojejunostomy using a linear stapler after laparoscopic total gastrectomy (LTG) was reported and termed as the overlap method. In this study, we evaluated the feasibility and safety of the overlap method for esophagojejunostomy or esophagogastrostomy after LTG or laparoscopic proximal gastrectomy (LPG), respectively. METHODS Twenty-five patients underwent anastomosis using a linear stapler during esophagojejunostomy and esophagogastrostomy after LTG and LPG, respectively. Clinicopathological data and surgical outcomes were evaluated. RESULTS The average surgical duration for LTG was 236.8 min compared with 224.1 min for LPG. Postoperative complications were observed in four patients (16.0%); these included a wound infection, an intestinal obstruction, an afferent loop syndrome, and a reflux symptom. The average postoperative hospital stay of the patients was 12.5 days. There was no case of conversion to open surgery, anastomotic leakage or stenosis, or mortality. CONCLUSIONS The overlap method for esophagojejunostomy or esophagogastrostomy after LTG or LPG is safe and feasible and does not require an additional minilaparotomy, which may result in less pain and favorable cosmetic outcomes.
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Affiliation(s)
- Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
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Shibata C, Saijo F, Kakyo M, Kinouchi M, Tanaka N, Sasaki I, Aikou T. Current Status of Pylorus-Preserving Gastrectomy for the Treatment of Gastric Cancer: A Questionnaire Survey and Review of Literatures. World J Surg 2012; 36:858-63. [DOI: 10.1007/s00268-012-1491-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Koeda K, Nishizuka S, Wakabayashi G. Minimally invasive surgery for gastric cancer: the future standard of care. World J Surg 2011; 35:1469-77. [PMID: 21476116 DOI: 10.1007/s00268-011-1051-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.In the near future, sentinel node navigation and robotic surgery will become additional options in minimally invasive surgery (MIS) involving LG. Such developments will improve the quality of life of patients following gastric cancer surgery.
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Affiliation(s)
- Keisuke Koeda
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Japan.
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Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Ann Surg 2011; 253:928-33. [PMID: 21358534 DOI: 10.1097/sla.0b013e3182117b24] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was introduced as a function-preserving and minimally invasive operation for early gastric cancer (EGC) in Japan. This study investigated the postoperative outcomes, complications, and associated risk factors of the procedure. METHODS From January 2005 to December 2009, 307 patients with EGC diagnosed before surgery underwent LAPPG. The postoperative outcomes and complications were assessed in this study. Postoperative complications were classified according to the Clavien-Dindo classification of surgical complications, and risk factors related to complications were analyzed. RESULTS The mean operation time for LAPPG was 229.4 ± 47.5 minutes and estimated blood loss was 49.1 ± 62.0 mL. The mean total number of dissected lymph nodes was 31.6 ± 10.4, with nodal involvement observed in 25 patients (8.5%). The preoperative diagnostic accuracy of EGC was 93.2%. Complications developed in 53 patients (17.3%), and major complications, classified as grades greater than Clavien-Dindo classification IIIa, were observed in 4 patients (1.3%). The most frequent complication was gastric stasis, occurring in 19 patients (6.2%). Body mass index (BMI) and surgical experience of LAPPG were identified as significant risk factors of postoperative complications. Body mass index was related to severity of the complications. The patients' serum total protein and albumin did not change significantly after surgery. CONCLUSIONS Laparoscopy-assisted pylorus-preserving gastrectomy is a safe operation with excellent postoperative outcomes in terms of minimized major complications based on the Clavien-Dindo classification in patients with EGC in the middle third of the stomach. To prevent postoperative complications, surgeons need to ensure an extra leaning period for LAPPG, and LAPPG should be performed cautiously in patients with high BMI.
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31
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Laparoscopic surgery for gastric cancer: a collective review with meta-analysis of randomized trials. J Am Coll Surg 2010; 211:677-86. [PMID: 20869270 DOI: 10.1016/j.jamcollsurg.2010.07.013] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 07/11/2010] [Accepted: 07/14/2010] [Indexed: 02/08/2023]
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Jiang X, Hiki N, Yoshiba H, Nunobe S, Kumagai K, Sano T, Yamaguchi T. Laparoscopy-assisted gastrectomy in patients with previous endoscopic resection for early gastric cancer. Br J Surg 2010; 98:385-90. [PMID: 21254013 DOI: 10.1002/bjs.7358] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2010] [Indexed: 01/14/2023]
Abstract
BACKGROUND Some patients undergoing endoscopic resection for early gastric cancer need further surgical treatment to achieve cure. However, the influence of endoscopic resection on subsequent laparoscopy-assisted gastrectomy (LAG) remains unclear. METHODS A total of 711 patients who underwent LAG were analysed retrospectively; 111 patients had undergone endoscopic resection previously and the remaining 600 had no history of endoscopic resection. Patient characteristics, operative and postoperative outcomes were compared between the two groups. Risk factors associated with postoperative complications were analysed. RESULTS Duration of operation and blood loss were comparable between the two groups. Patients who had undergone endoscopic resection had fewer dissected lymph nodes and a lower rate of preservation of the coeliac branch of the vagus nerve, especially those who had LAG within 2 months after endoscopic resection. Early postoperative outcomes, including complications, gastrointestinal recovery and length of postoperative hospital stay, were not significantly different between the two groups. Previous endoscopic resection was not a risk factor for postoperative complications. CONCLUSION LAG can be performed safely even after endoscopic resection. Endoscopic resection might increase the difficulty of subsequent LAG, including lymph node dissection and preservation of the coeliac branch of the vagus nerve; however, it has little influence on early postoperative outcome.
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Affiliation(s)
- X Jiang
- Department of Gastroenterological Surgery, Gastroenterological Centre, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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33
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Long-term outcome and survival with laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc 2010; 25:1182-6. [PMID: 20844895 DOI: 10.1007/s00464-010-1336-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 08/17/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopically assisted pylorus-preserving gastrectomy (LAPPG) is introduced as a function-preserving operation with minimal invasion for early gastric cancer (EGC). This study aimed to investigate the long-term outcome and survival with LAPPG. METHODS From January 2005 to July 2008, 188 patients with EGC underwent LAPPG. The surgical and long-term outcomes and survival were assessed retrospectively. RESULTS The accuracy of the preoperative EGC diagnosis was 92.6%. The median follow-up period was 38 months (range, 2-63 months). Two patients experienced gallstones, and three patients experienced a second primary EGC. One patient with T3N0 gastric cancer died of peritoneal metastasis, and four patients died of other causes. The overall 3-year survival rate was 97.8%, and the disease-specific 3-year survival rate was 99.3%. CONCLUSIONS The LAPPG procedure is safe in terms of satisfactory long-term outcome and survival for patients with EGC in the middle third of the stomach.
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Hyung WJ, Kim YS, Lim JS, Kim MJ, Noh SH, Kim KW. Preoperative imaging of sentinel lymph nodes in gastric cancer using CT lymphography. Yonsei Med J 2010; 51:407-13. [PMID: 20376894 PMCID: PMC2852797 DOI: 10.3349/ymj.2010.51.3.407] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Preoperative identification of the sentinel lymph node (SLN) in gastric cancer (GC) patients may have great advantages for the minimally invasive treatment. This study was performed to evaluate the possibility of preoperative SLN detection using CT lymphography. MATERIALS AND METHODS Fourteen patients with early GC were enrolled. CT images were obtained before and at 1, 3, and 5 minutes after endoscopic submucosal peritumoral injection of 2 mL iopamidol. For patients with clearly identified SLNs, to make comparisons with the CT lymphography results, intraoperative SLN detection was performed using subserosally injected Indocyanine green (ICG) lymphography and ex vivo ICG and iopamidol lymphography using mammography was also performed. RESULTS CT lymphography clearly visualized draining lymphatics and SLNs in 4 (28.6%) out of 14 patients. All clearly visualized SLNs (one to three SLNs per patient) under preoperative imaging were detected in the same location by intraoperative ICG lymphography and ex vivo ICG and iopamidol lymphography using mammography. All preoperative SLN detections were observed with the primary tumors in the lower third of the stomach. CONCLUSION Although our study demonstrated a SLN detection rate of less than 30%, CT lymphography with radio-contrast showed potential as a method of preoperative SLN detection for GC.
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Affiliation(s)
- Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Soo Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seok Lim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong-Jin Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Whang Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Hur H, Park CH. [Surgical treatment of gastric carcinoma]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2009; 54:83-98. [PMID: 19696536 DOI: 10.4166/kjg.2009.54.2.83] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The gastric cancer is the most common cancer in Korea. The only treatment modality showing improved survival for gastric cancer is curative surgical resection, which comprises the resection of stomach, proper lymphadenectomy, and reconstruction. However, specific surgical procedures should be decided according to the location of the cancer, advancement of the tumor, and patients condition. Surgical treatment for gastric cancer has been developed toward two directions that are minimal invasive surgery for early gastric cancer and multi-disciplinary approach for advanced gastric cancer. Laparoscopic surgery for early gastric cancer has been accepted for minimally invasive surgery. Moreover, the advancement of diagnostic tools to assess biological aggressiveness of the tumor enables physicians to perform endoscopic resection or minimized resection for early gastric cancer. Recently, surgeons try to extend the application of laparoscopic gastric resection and D2 lymphadenectomy to advanced gastric cancer. However, technical and oncological evidences based on clinical trials should be filed up before adopting it as a standard therapy. In case of advanced gastric cancer, in addition to radical surgery, various treatment modalities including chemotherapy, radiation, and molecular target therapy also have been applied in many clinical trials. However, it should be stressed that a prerequisite for precise evaluation of the efficacy of these combined treatment modalities would be the standardization of surgical procedure.
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Affiliation(s)
- Hoon Hur
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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36
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Hiki N, Sano T, Fukunaga T, Ohyama S, Tokunaga M, Yamaguchi T. Survival benefit of pylorus-preserving gastrectomy in early gastric cancer. J Am Coll Surg 2009; 209:297-301. [PMID: 19717032 DOI: 10.1016/j.jamcollsurg.2009.05.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 05/26/2009] [Accepted: 05/26/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) is performed in some patients for the treatment of early gastric cancer. The aim of this study was to investigate longterm survival for patients having PPG with extensive lymph node dissection, except for the suprapyloric nodes, for early gastric cancer. STUDY DESIGN From January 1995 to December 2006, 305 patients underwent PPG if they met the following criteria: cT1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach. Overall 5-year survival, cancer-related mortality, and freedom from recurrence were assessed retrospectively. RESULTS The median followup period was 61 months (range 27 to 144 months). Seven patients died, and the overall 5-year survival probability was 98%. Gastric cancer-related mortality was 0% and none of the patients had evidence of tumor recurrence. The accuracy of the preoperative diagnosis of T1 gastric cancer using endoscopy or endoscopic ultrasonography was 95.7%. CONCLUSIONS PPG may provide a longterm survival benefit for patients with clinically diagnosed T1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach, only when the accuracy of preoperative diagnosis can be assured.
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Affiliation(s)
- Naoki Hiki
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Nunobe S, Hiki N, Fukunaga T, Tokunaga M, Ohyama S, Seto Y, Yamaguchi T. Previous laparotomy is not a contraindication to laparoscopy-assisted gastrectomy for early gastric cancer. World J Surg 2008; 32:1466-72. [PMID: 18340481 DOI: 10.1007/s00268-008-9542-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic procedures have generally been considered to be contraindicated in patients with a history of laparotomy because of a high risk of enteric injury during the procedure. Laparoscopy-assisted gastrectomy (LAG) has been used increasingly in the treatment of early gastric cancer, but its indication for patients with a history of laparotomy remains unclear. The aim of the present study was to estimate whether LAG is contraindicated for the patient with a history of laparotomy (PSURG). METHODS From January 2003 to March 2006, 139 patients with early gastric cancer underwent LAG with curative intent in our institute. Fifty were PSURG patients, and the remaining 89 patients underwent LAG without any history of laparotomy (NSURG). Operative and early postoperative outcomes were compared between the groups. RESULTS Appendectomy and gynecological surgery were the predominant procedures performed in the PSURG group prior to undergoing LAG, involving 28 patients (56.0%) and 16 patients (32.0%), respectively. Detachment of adhesion above the umbilicus was required in 25 PSURG patients (50.0%). There was no significant difference in operative and postoperative results between the two groups, although 1 PSURG patient developed symptoms of bowel injury on the first postoperative day, probably caused during the laparoscopic procedure for dissection of a jejuno-jejunal adhesion. CONCLUSIONS There was no difference in outcome following LAG between the PSURG and NSURG groups in the present study. The PSURG patient is not contraindicated for LAG assuming careful attention is given for all operative procedures, including port insertion and dissection of intra-abdominal adhesions.
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Affiliation(s)
- Souya Nunobe
- Department of Surgery, Cancer Institute Hospital, 10-6 Ariake 3-chome, Koto-ku, Tokyo 135-8550, Japan
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Laparoscopy-assisted pylorus-preserving gastrectomy: preservation of vagus nerve and infrapyloric blood flow induces less stasis. World J Surg 2008; 31:2335-40. [PMID: 17952497 DOI: 10.1007/s00268-007-9262-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) prevents postprandial symptoms; however, delayed gastric retention due to aberrant pylorus function can occur during the early postoperative period. This study aimed to establish a stasis-less PPG procedure with preservation of the vagal nerve and blood flow to the pyloric cuff, and to apply the technique for laparoscopy-assisted PPG. METHODS Ninety patients with T1 gastric cancer located in the middle third of the stomach were enrolled in this study for surgery from January 2003 to March 2006, undergoing either laparoscopy-assisted PPG (LAPPG; 39 patients) or conventional PPG (CPPG; 51 patients). Operative and early postoperative outcomes were compared between the two groups. RESULTS Relatively low rates of gastric stasis were observed in both the LAPPG (8%) and CPPG (6%) groups. Estimated blood loss in LAPPG (65.4 +/- 12.3 ml) patients was significantly lower than in the CPPG group (160.7 +/- 19.6 ml) (p < 0.001), and the total number of dissected lymph nodes was significantly greater in the LAPPG group (36.2 +/- 1.8) than in the CPPG group (29.0 +/- 1.3) (p = 0.001). CONCLUSIONS A PPG procedure with less postoperative stasis and adequate lymph node retrieval was established and applied successfully in laparoscopy-assisted surgery.
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Hiki N, Shimoyama S, Yamaguchi H, Kubota K, Kaminishi M. Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation. J Am Coll Surg 2006; 203:162-9. [PMID: 16864028 DOI: 10.1016/j.jamcollsurg.2006.05.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Revised: 03/17/2006] [Accepted: 05/03/2006] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) with extensive lymph node dissection is useful for treatment of early gastric cancer with preservation of function. This technique could be improved by using laparoscopy-assisted gastrectomy. STUDY DESIGN Between September 2000 and September 2004, 109 patients with T1 gastric cancer underwent surgical treatment; 72 underwent laparoscopy-assisted PPG (LAPPG) and 37 underwent conventional PPG (CPPG). Total numbers of dissected lymph nodes, retrieval at each lymph node station, intraoperative blood loss, and operation times were used as measures of the quality of lymph node dissection to compare the procedures. Continuous data are summarized as mean +/- SE. RESULTS Operation times with the LAPPG procedure (279 +/- 6 minutes) were significantly, but only 20 minutes, longer than with CPPG (259 +/- 8 minutes) (p = 0.047), although estimated blood loss for LAPPG patients (153 +/- 13 mL) was not significantly different for those undergoing CPPG (184 +/- 13 mL, p = 0.13). Mean total number of dissected lymph nodes was 32.3 +/- 1.6 in the LAPPG group and 28.5 +/- 2.2 in the CPPG group (p = 0.16). There was no significant difference in the number of lymph nodes retrieved for any of the nodal stations between the LAPPG and CPPG procedures. CONCLUSIONS Clinical outcomes of surgical treatment were comparable for gastric cancer patients who underwent LAPPG and those treated with CPPG in terms of station-dependent lymph node dissection and estimated blood loss.
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Affiliation(s)
- Naoki Hiki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute, Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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