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Ye YX, Wu CY, Chen LQ, Wu SJ, Ye K. Controversies and consensus surrounding laparoscopic pylorus-preserving gastrectomy for early gastric cancer. World J Gastrointest Surg 2025; 17:105295. [DOI: 10.4240/wjgs.v17.i5.105295] [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: 01/17/2025] [Revised: 02/28/2025] [Accepted: 03/10/2025] [Indexed: 05/23/2025] Open
Abstract
In recent years, the detection rate of early gastric cancer in China has significantly increased. Early gastric cancer is associated with a favourable prognosis; thus, enhancing the postoperative quality of life for patients has become an increasingly pressing issue in treating gastric cancer. Consequently, function-preserving gastrectomy has emerged as a viable option. This surgical approach aims to minimize the extent of resection while preserving some gastric function, all within the framework of radical tumour excision. Pylorus-preserving gastrectomy (PPG) serves as a representative example of a function-preserving technique and is particularly suitable for early-stage gastric cancer of the middle segment of the stomach. Compared with distal gastrectomy, laparoscopic PPG offers several advantages: (1) Results in less surgical trauma; and (2) Reduces the incidence of postoperative complications such as dumping syndrome, bile reflux gastritis, and gallstones while also improving nutritional status postsurgery. However, the implementation of PPG remains contentious within the medical community. In light of new Japanese guidelines for gastric cancer treatment and informed by current research trends along with relevant evidence-based medicine principles, this review examines various aspects related to laparoscopic PPG, including its definition and indications, safety profile, benefits, technical considerations, methods for digestive tract reconstruction and postoperative complications.
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Affiliation(s)
- Ying-Xuan Ye
- School of Medicine, South China University of Technology, Guangzhou 510000, Guangdong Province, China
| | - Chu-Ying Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Li-Quan Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Si-Jia Wu
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Kai Ye
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
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Kim SH, Signorini FJ, Park K, Kim C, Kim J, Cho YS, Kong SH, Park DJ, Lee HJ, Yang HK. Long-term natural course of patients with lymph node station 6 metastasis after pylorus-preserving gastrectomy. Gastric Cancer 2025:10.1007/s10120-025-01600-2. [PMID: 40249528 DOI: 10.1007/s10120-025-01600-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 02/11/2025] [Indexed: 04/19/2025]
Abstract
BACKGROUND Meticulous lymph node 6 station (LN#6) dissection is mandatory in pylorus-preserving gastrectomy (PPG), but can increase the risk of complications, such as postoperative delayed gastric emptying. With analyzing lymphatic spread patterns based on cross-sectional tumor location, we planned to predict the surgical burden of LN#6 dissection, balancing oncological safety and risk of postoperative complications. METHODS We included consecutive PPG cases at Seoul National University Hospital (2007-2017) to assess the incidence, 5-year survival rate (5YSR), and 3-year recurrence-free survival (3RFS) of LN#6 metastasis. Cox regression analyzed the impact of LN#6 metastasis itself on 5YSR and 3RFS. The effect of tumor location among gastric middle-third tumors on LN#6 metastasis was evaluated. The therapeutic indices (TI) of LN#6 based on tumor location were calculated. RESULTS Among 1070 PPG patients, 5YSR and 3RFS were 97.0% and 98.9%. LN#6 metastasis was found in 11 patients (1.03%), with 3 recurrences observed among them (3/11, 0.28%). LN#6 metastasis itself did not significantly affect 5YSR (p = 0.266) or 3RFS (p = 0.075). Tumor location showed a significant association for LN#6 metastasis (p = 0.015), with low body greater curvature (LB-GC) showing the highest prevalence (5/11, 45.45%). TI of LN#6 for LB-GC tumors was 3.76, while TI for low body lesser curvature (LB-LC) and midbody lesser curvature (MB-LC) tumors was 0.0. CONCLUSIONS LN#6 metastasis is infrequent and does not affect 5YSR or 3RFS in PPG patients. Tumors in LB-GC demonstrated a higher tendency for lymphatic spread to LN#6, while those in lesser curvature demonstrated a lower spread, suggesting a reduced surgical burden for lesser curvature tumors. This study evaluated LN#6 metastasis in 1070 PPG patients, demonstrating low incidence and favorable oncological outcomes, supporting tailored LN#6 dissection for lesser curvature tumors to minimize complications without compromising safety.
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Affiliation(s)
- Sa-Hong Kim
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | | | - Kyoyoung Park
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chungyoon Kim
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeesun Kim
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yo-Seok Cho
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Joong Park
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Eom SS, Park SH, Rhee YS, Kim SH, Lee HJ, Kim YW, Yang HK, Park DJ, Han SU, Kim HH, Hyung WJ, Park JH, Suh YS, Kwon OK, Kim W, Park YK, Yoon HM, Ahn SH, Kong SH, Ryu KW. The Impact of Vascular Anatomic Variations in the Infra-Pyloric Area on the Surgical Outcomes of Laparoscopic Pylorus-Preserving Gastrectomy in Early Gastric Cancer: A Post Hoc Analysis of a Multicenter Prospective Trial (KLASS-04). J Clin Med 2025; 14:2508. [PMID: 40217957 PMCID: PMC11989293 DOI: 10.3390/jcm14072508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2025] [Revised: 03/28/2025] [Accepted: 04/02/2025] [Indexed: 04/14/2025] Open
Abstract
Background/Objectives: During laparoscopic pylorus-preserving gastrectomy (LPPG), the preservation of the infra-pyloric artery (IPA) and dissection of the infra-pyloric lymph node (LN) station 6 are essential, underscoring the importance of understanding the anatomical structure of the IPA. This study aimed to investigate anatomical variations in the IPA and surgical outcomes based on data from a multicenter prospective trial. Methods: A post hoc analysis was conducted based on the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial, in which patients randomly underwent LPPG or laparoscopic distal gastrectomy (LDG). The IPA variations were categorized into three groups: distal, caudal, and proximal. Clinicopathological characteristics and surgical outcomes were analyzed according to the IPA type. Results: Among the 192 patients, the distribution of IPA types was as follows: 45 (23.44%) distal, 74 (38.54%) caudal, and 73 (38.02%) proximal. There were no significant differences in the clinicopathological characteristics between the IPA types. Of the 119 patients who underwent LPPG, a significant difference in operative time was observed based on the IPA type, with a longer duration observed with the distal type compared to that of the proximal type (distal type vs. proximal type: 202.5 (150-275) vs. 170 (105-265) min, p = 0.0300). No significant differences were observed in other surgical outcomes. Conclusions: The distribution of IPA types was more diverse than that reported in previous studies. There was a statistically significant difference in the operating time based on the IPA type. Identifying IPA variations during LPPG may be beneficial for gastric cancer surgeons.
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Affiliation(s)
- Sang Soo Eom
- Department of Surgery, Inje University College of Medicine, Ilsan Paik Hospital, Goyang 10380, Republic of Korea
| | - Sin Hye Park
- Department of Gastrointestinal Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Young Shick Rhee
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsanseo-gu, Goyang 10408, Republic of Korea
| | - Sa-Hong Kim
- Department of Surgery, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Hyuk-Joon Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsanseo-gu, Goyang 10408, Republic of Korea
| | - Han-Kwang Yang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Do Joong Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Sang Uk Han
- Department of Surgery, Ajou University Hospital, Suwon 16499, Republic of Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University Severance Hospital, Seoul 03722, Republic of Korea
| | - Ji-Ho Park
- Department of Surgery, Gyeongsang National University Hospital, Daegu 52727, Republic of Korea
| | - Yun-Suhk Suh
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Oh-Kyung Kwon
- Department of Surgery, Kyungpook National University Hospital, Daegu 41566, Republic of Korea
| | - Wook Kim
- Department of Surgery, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul 14662, Republic of Korea
| | - Young-Kyu Park
- Department of Surgery, Chonnam National University Medical School, Hwasun 58128, Republic of Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsanseo-gu, Goyang 10408, Republic of Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Seong-Ho Kong
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsanseo-gu, Goyang 10408, Republic of Korea
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Qiao Y, Kang B, Zhang Y, Song J, Liu S, Wang Q, Guo Y, Li Y, Zhu J, Li J. Short- and long-term outcomes of robotic- versus laparoscopic-assisted early-onset gastric cancer: a propensity score-matched retrospective cohort study. BMC Cancer 2025; 25:361. [PMID: 40016662 PMCID: PMC11866809 DOI: 10.1186/s12885-025-13767-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Accepted: 02/18/2025] [Indexed: 03/01/2025] Open
Abstract
BACKGROUND Early-onset gastric cancer (EOGC) is a distinct subtype of gastric cancer with increasing incidence, characterized by unique clinical and pathological features. This propensity score-matched retrospective cohort study aims to compare the perioperative safety and outcomes of EOGC patients who underwent laparoscopic versus robotic radical gastrectomy, providing a scientific basis for surgical treatment of EOGC. MATERIALS AND METHODS We included 252 patients diagnosed with EOGC at or before the age of 45, who underwent robotic or laparoscopic radical gastrectomy between January 2015 and April 2021. After propensity score matching, 47 patients in the robotic surgery group and 94 in the laparoscopic surgery group were compared. The study evaluated intraoperative and postoperative outcomes, pathological results, and long-term survival. RESULTS The robotic surgery group showed less intraoperative bleeding (50 ml vs. 100 ml, p = 0.042) and shorter postoperative hospital stays (6 days vs. 7 days, p = 0.008) compared to the laparoscopic group. The number of positive lymph nodes was higher in the robotic group (median 2 vs. 1, p = 0.016), but the number of lymph nodes harvested did not significantly differ. No significant differences were found in overall survival (3-year OS: 65.9% vs. 62.5%, p = 0.596) and disease-free survival (3-year DFS: 61.4% vs. 61.7%, p = 0.765) between the two groups. CONCLUSIONS Robotic resection for EOGC is non-inferior to laparoscopic surgery in terms of perioperative outcomes and long-term prognosis. This study suggests that robotic surgery may be a viable option for the treatment of EOGC.
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Affiliation(s)
- Yihuan Qiao
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Boyu Kang
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yichao Zhang
- Department of General Surgery, Peking University People's Hospital, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Jiawei Song
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Shuai Liu
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Qi Wang
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yajie Guo
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yunlong Li
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
| | - Jun Zhu
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
- Department of General Surgery, The Southern Theater Air Force Hospital, Guangzhou, China.
| | - Jipeng Li
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
- Department of Experiment Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China.
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Lastoria DAA, Benny CK. Variations in the origin of the infrapyloric artery: A systematic review and meta-analysis. Ann Anat 2023; 249:152109. [PMID: 37207852 DOI: 10.1016/j.aanat.2023.152109] [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: 04/14/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND The infrapyloric artery (IPA) supplies the pylorus and the large curvature of the antrum. Its common origin points include the gastroduodenal artery (GDA) and right gastroepiploic artery (RGEA). The prevalence of variations in IPA origins can be of interest to gastric cancer surgeons who wish to increase their understanding of this vessel. The primary aim of this study was to perform a systematic review and meta-analysis on the origin of the IPA. The secondary aims were to assess imaging identification accuracy, to identify IPA morphological features, and to explore the relationship of IPA origin and clinicopathological characteristics. METHODS Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched through March 2023. There were no constraints based on language, publication status, or patient demographics. Database search, data extraction and risk of bias assessment were performed independently by two reviewers. The point of origin of the IPA was the primary outcome. Secondary outcomes were imaging identification accuracy, relationship between IPA origin and clinicopathological characteristics, and IPA morphological features. A random-effects meta-analysis of the prevalence of different IPA origins was conducted. Secondary outcomes were narratively synthesized given the heterogeneity of studies reporting on these. RESULTS A total of 7279 records were screened in the initial search. Seven studies were included in the meta-analysis, assessing 998 patients. The IPA arose most frequently from the anterior superior pancreaticoduodenal artery (ASPDA), with a pooled prevalence of 40.4% (95% CI 17.1 - 55.8%), followed by the RGEA with a pooled prevalence of 27.6% (95% CI 8.7 - 43.7%), and the GDA with a pooled prevalence of 23.7% (95% CI 6.4 - 39.7%). Cases of multiple IPAs had a pooled prevalence of 4.9% (95% CI 0 - 14.3%). The IPA was absent in 2.6% (95% CI 0 - 10.3%) of cases and arose from the posterior superior pancreaticoduodenal artery (PSPDA) in the remaining 0.8% (95% CI 0 - 6.1%). Distance between the pylorus and the proximal branch of the IPA and distance from the pylorus to the first gastric branch of the RGEA when the IPA originated from the ASPDA and RGEA were longer than when the IPA originated from the GDA. The IPA is a small vessel (<1mm), and its origin is not related to clinicopathological characteristics including patient sex, age, and tumor stage and location. CONCLUSIONS Surgeons must be aware of the most common origin points of the IPA. Recommendations for future study include the stratification of IPA origin according to demographic characteristics, and further investigation into IPA morphological parameters such as tortuosity, course and relation to adjacent lymph nodes, aiding the creation of a standardized classification system pertaining to the anatomy of this vessel.
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Brisinda G, Chiarello MM, Fico V, Puccioni C, Crocco A, Bianchi V, Vanella S. Pattern of Distribution of Lymph Node Metastases in Individual Stations in Middle and Lower Gastric Carcinoma. Cancers (Basel) 2023; 15:2139. [PMID: 37046800 PMCID: PMC10093249 DOI: 10.3390/cancers15072139] [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: 02/19/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: Lymph node (LN) dissection is the cornerstone of curative treatment of GC. The pattern of distribution of LN metastases is closely related to several factors. The aim of this study is to evaluate the factors determining the distribution of nodal metastases in a population of N+ distal GC patients undergoing gastrectomy and D2 lymphadenectomy. (2) Methods: The medical charts of 162 N+ GC patients who underwent surgical resection over a 15-year period were retrospectively analyzed. Clinical, pathological and anatomical characteristics were evaluated to identify the factors affecting the patterns and prevalence of metastases in individual LN stations. (3) Results: LN metastasis is correlated with the depth of the tumor and to diffuse-type tumors. A higher number of metastatic nodes was documented in patients with middle-third tumors (8.2 ± 7.3 vs. 4.5 ± 5.0 in lower-third tumors, p = 0.0001) and in patients with tumors located on the lesser curve. Station 4 showed the highest rate of metastases (53.1%). Concerning stations 7 to 12, station 8 showed the highest metastasis rate (28.4%). Metastases at stations 1, 2, 4 and 7 to 11 were dominant in middle-third cancer, whereas stations 5 and 6 were dominant in lower-third cancers. Station 4, 5, 6, 10 and 11 metastases were dominant when the cancer was located on the greater curve, whereas stations 1, 2, 7, 8 and 12 were dominant in lesser-curve cancers. (4) Conclusions: The study documented that in patients with distal GC, the distribution of nodal metastases at individual stations is closely related to primary tumor location.
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Affiliation(s)
- Giuseppe Brisinda
- Dipartimento Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Maria Michela Chiarello
- Unità Operativa di Chirurgia Generale, Dipartimento di Chirurgia, Azienda Sanitaria Provinciale, 87100 Cosenza, Italy
| | - Valeria Fico
- Unità Operativa di Chirurgia d’Urgenza e del Trauma, Dipartimento Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Caterina Puccioni
- Unità Operativa di Chirurgia d’Urgenza e del Trauma, Dipartimento Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Anna Crocco
- Unità Operativa di Chirurgia Oncologica della tiroide e della paratiroide, Istituto Nazionale Tumori, IRCCS Fondazione Pascale, 80131 Napoli, Italy
| | - Valentina Bianchi
- Unità Operativa di Chirurgia d’Urgenza e del Trauma, Dipartimento Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Serafino Vanella
- Unità Operativa di Chirurgia Generale e Oncologica, Azienda Ospedaliera San Giuseppe Moscati, 83100 Avellino, Italy
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Iino I, Kikuchi H, Suzuki T, Kawabata T, Jindo O, Uno A, Fukazawa A, Matsumoto K, Ochiai H, Sakaguchi T, Takeuchi H, Konno H, Suzuki S. Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography. BMC Surg 2022; 22:403. [PMID: 36404317 PMCID: PMC9677658 DOI: 10.1186/s12893-022-01836-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data. METHODS Perigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery. RESULTS Of the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively. CONCLUSIONS Preoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.
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Affiliation(s)
- Ichirota Iino
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Hirotoshi Kikuchi
- grid.505613.40000 0000 8937 6696Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Toshiyuki Suzuki
- grid.414861.e0000 0004 0378 2386Department of Radiological Technology, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Toshiki Kawabata
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Osamu Jindo
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Akihiro Uno
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Atsuko Fukazawa
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Keigo Matsumoto
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Hideto Ochiai
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
| | - Takanori Sakaguchi
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan ,grid.505613.40000 0000 8937 6696Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Hiroya Takeuchi
- grid.505613.40000 0000 8937 6696Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Hiroyuki Konno
- grid.505613.40000 0000 8937 6696Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192 Japan
| | - Shohachi Suzuki
- grid.414861.e0000 0004 0378 2386Department of Surgery, Iwata City Hospital, 512-3 Okubo, Iwata, 438-8550 Japan
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Hou S, Liu F, Gao Z, Ye Y. Pathological and oncological outcomes of pylorus-preserving versus conventional distal gastrectomy in early gastric cancer: a systematic review and meta-analysis. World J Surg Oncol 2022; 20:308. [PMID: 36153587 PMCID: PMC9508780 DOI: 10.1186/s12957-022-02766-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/06/2022] [Indexed: 01/30/2023] Open
Abstract
Abstract
Background
Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC) in the middle third of the stomach. According to the literature reports, PPG decreases the incidence of dumping syndrome, bile reflux, gallstone formation, and nutritional deficit compared with conventional distal gastrectomy (CDG). However, the debates about PPG have been dominated by the incomplete lymphadenectomy and oncological safety. We carried out a systematic review and meta-analysis to evaluate the pathological and oncological outcomes of PPG.
Methods
The protocol was registered in PROSPERO under number CRD42022304677. Databases including PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials were searched before February 21, 2022. The outcomes included the pooled odds ratios (ORs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. For all outcomes, 95% confidence intervals (CIs) were calculated. Meta-analysis was performed using STATA software (Stata 14, Stata Corporation, Texas) and Review Manager 5.4.
Results
A total of 4500 patients from 16 studies were included. Compared with the CDG group, the PPG group had fewer lymph nodes harvested (WMD= −3.09; 95% CI −4.75 to −1.43; P < 0.001). Differences in the number of resected lymph nodes were observed at stations No. 5, No. 6, No. 9, and No. 11p. There were no differences in lymph node metastasis at each station. Shorter proximal resection margins (WMD = −0.554; 95% CI −0.999 to −0.108; P = 0.015) and distal resection margins (WMD = −1.569; 95% CI −3.132 to −0.007; P = 0.049) were observed in the PPG group. There were no significant differences in pathological T1a stage (OR = 0.99; 95% CI 0.80 to 1.23; P = 0.88), T1b stage (OR = 1.01; 95% CI 0.81 to 1.26; P = 0.88), N0 stage (OR = 0.97; 95% CI 0.63 to 1.48; P = 0.88), tumor size (WMD = −0.10; 95% CI −0.25 to 0.05; P = 0.187), differentiated carcinoma (OR = 1.04; 95% CI 0.74 to 1.47; P = 0.812) or signet ring cell carcinoma (OR = 1.22; 95% CI 0.90 to 1.64; P = 0.198). No significant differences were observed between the groups in terms of overall survival (HR = 0.63; 95% CI 0.24 to 1.67; P = 0.852) or recurrence-free survival (HR = 0.29; 95% CI 0.03 to 2.67; P = 0.900).
Conclusions
The meta-analysis of existing evidence demonstrated that the survival outcomes of PPG may be comparable to those of CDG. However, fewer lymph nodes at stations in No. 5, No. 6, No. 9, and No. 11p were harvested with PPG. We also found shorter proximal resection margins and distal resection margins for PPG, meaning more remnant stomachs would be preserved in PPG.
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Piozzi GN, Rusli SM, Baek SJ, Kwak JM, Kim J, Kim SH. Infrapyloric and gastroepiploic node dissection for hepatic flexure and transverse colon cancer: A systematic review. Eur J Surg Oncol 2021; 48:718-726. [PMID: 34893366 DOI: 10.1016/j.ejso.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 12/02/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The hepatic flexure and transverse colon have a complex intermingled lymphovascular anatomy crossing between mesocolon and mesogastrium. Few studies have investigated the oncological relevance of metastatic infrapyloric and gastroepiploic lymph nodes (IGLN) from hepatic flexure and transverse colon tumors. This study aimed to evaluate the incidence and risk factors for IGLN metastases, and the indications, surgical morbidities, and oncological outcome following extended lymphadenectomy. MATERIALS AND METHODS According to the PRISMA statement, a systematic review on IGLN lymphadenectomy for colon cancer was conducted into PubMed, Embase, and Cochrane databases. A critical appraisal of study was performed according to the Joanna Briggs Institute Tools. RESULTS Nine studies were included. IGLN metastases incidence ranged 0.7-22%. IGLN positivity for patients with metastatic mesocolic lymph nodes ranged 1.7-33.3%. Postoperative complication rate ranged 8.5-36.9%, mostly low grade according to Clavien-Dindo's classification. Postoperative mortality rate ranged 0-5.4% at 30-days. IGLN metastases were associated with advanced disease with a 5-year progression-free survival rate up to 33.9%. Two authors reported perineural invasion and N stage as risk factors, while another reported endoscopic obstruction, signet ring adenocarcinoma, CEA level ≥17 ng/ml, and M1 stage to be risk factors for IGLN involvement. Apart from one study, all other studies were of moderate/high quality. CONCLUSIONS Metastatic IGLNs are not uncommon and should be highly considered. IGLN metastases could be potentially associated with an aggressive disease. IGLN dissection is not associated with higher morbidity and mortality than standard CME. Preoperative risk factors of IGLN involvement could guide surgical indication for extended lymphadenectomy.
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Affiliation(s)
- Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Siti Mayuha Rusli
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Se-Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung-Myun Kwak
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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10
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Shinohara H, Kurahashi Y, Ishida Y. Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema. Gastric Cancer 2021; 24:273-282. [PMID: 33387120 DOI: 10.1007/s10120-020-01142-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery. METHODS Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium. RESULTS The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs. CONCLUSION The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.
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Affiliation(s)
- Hisashi Shinohara
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Yasunori Kurahashi
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshinori Ishida
- Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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11
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Sun Y, Zhang D, Feng Y, Wang Y, Xu Z, Tang J, Huang Y, Zhang C. Infrapyloric lymph node dissection in right hemicolectomy for colon cancer: Should prophylactic resection be recommended? J Surg Oncol 2021; 123 Suppl 1:S30-S35. [PMID: 33646617 DOI: 10.1002/jso.26388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/27/2020] [Accepted: 12/31/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Infrapyloric lymph node dissection in right colon cancer patients remains controversial. We aimed to investigate the pattern of infrapyloric lymph node metastasis in right colon cancer patients. METHODS Clinical and pathological data of 140 colon cancer patients who underwent radical right hemicolectomy and infrapyloric lymph node dissection were retrospectively examined. Patient characteristics, intraoperative conditions, postoperative recovery information, postoperative pathological findings, and follow-up data were examined. RESULTS About 19, 44, 73, and 4 patients had tumors located in the cecum, ascending colon, hepatic flexure, and right side of the transverse colon, respectively. The median number of harvested lymph nodes and that of positive lymph nodes were 24 (16-30) and 1 (0-7.75), respectively. The lymph node metastasis rate was 41.43% (58/140). The corresponding values for infrapyloric lymph nodes were 3 (1-4), 0 (0-0), and 0.71% (1/140), respectively. The median follow-up duration was 19 (0-65) months in 131 (93.6%) patients. The 5-year overall and disease-free survival rates were 86.3% and 73.5%, respectively. CONCLUSION Given the low rate of infrapyloric lymph node metastasis in right colon cancer, lymph node dissection is recommended in patients with locally advanced colon cancer at the hepatic flexure and those with suspected infrapyloric lymph node metastasis.
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Affiliation(s)
- Yueming Sun
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dongsheng Zhang
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yifei Feng
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Wang
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ziwei Xu
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junwei Tang
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanjian Huang
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chuan Zhang
- Department of Colorectal Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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12
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Sugawara T, Shinohara H, Haruta S, Shindoh J, Ueno M, Udagawa H. Total Amylase Value in Drains After Gastrectomy for Predicting Postoperative Pancreatic Fistula. Int Surg 2021; 105:570-575. [DOI: 10.9738/intsurg-d-17-00127.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2025] Open
Abstract
Objective
Postoperative pancreatic fistula (POPF) is defined using the ratio of the amylase concentration in abdominal drainage fluid to the upper normal range of serum amylase level. However, we hypothesized that the total amylase value in discharge (AVD) on postoperative day (POD) 3 may be more sensitive for predicting grade II or higher severe POPF (sPOPF) and compared the predictive power of the conventional definition of POPF and AVD for sPOPF.
Methods
One hundred fifty-one patients who underwent gastrectomy between October 2011 and February 2013 were analyzed. A drainage tube was placed in all the cases through the stump of the right gastroepiploic vein and the front of the pancreas to the back of the anastomotic site. The drainage volume and amylase concentration in the discharge were examined on POD 1, 3, and 5. AVD was calculated by multiplying the volume by the amylase concentration.
Results
Eight patients (5.3%) developed sPOPF. In univariate analysis, both AVD and the amylase concentration ratio was significantly correlated with sPOPF (P = 0.002 and 0.007, respectively). AVD on POD 3 showed the best predictive performance compared with the amylase concentration ratio on POD 3 (area under the curve 0.876 versus 0.844). Based on the cutoff values calculated from the receiver operating characteristic curves, AVD was more specific than amylase concentration ratio in predicting sPOPF (specificity: 97.6% versus 86.0%; positive predictive value: 62.5% vs. 23.1%).
Conclusion
AVD on POD 3 is a more specific parameter than conventional amylase concentration ratio in predicting sPOPF.
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Affiliation(s)
- Toshitaka Sugawara
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Hisashi Shinohara
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Shusuke Haruta
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Junichi Shindoh
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masaki Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Harushi Udagawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
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Near-infrared fluorescence-guided surgery using indocyanine green facilitates secure infrapyloric lymph node dissection during laparoscopic distal gastrectomy. Surg Today 2020; 50:1187-1196. [PMID: 32246228 DOI: 10.1007/s00595-020-01993-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/06/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE We aimed to investigate the usefulness of near-infrared indocyanine green (ICG)-enhanced fluorescence guidance for infrapyloric LN dissection in laparoscopic distal gastrectomy. METHODS This study enrolled patients with early gastric cancer scheduled for laparoscopic distal gastrectomy. After intraoperative submucosal injection of ICG (0.1 mg/mL), LN dissection was conducted under near-infrared ICG fluorescence guidance. The operation time, bleeding events during infrapyloric LN dissection were analyzed. Cases were retrospectively 1:3 propensity-score matched to patients who underwent laparoscopic distal gastrectomy without ICG injection. RESULTS The mean time from midline omentectomy to exposure of the right gastroepiploic vein was significantly shorter in the ICG group (n = 20) than in the non-ICG group (n = 60) (13.05 ± 5.77 vs 18.68 ± 7.92 min; p = 0.001), and the incidence of bleeding during infrapyloric LN dissection was lower in the ICG group (20% vs 68.3%, p < 0.001). The two groups did not differ significantly regarding the number of LNs retrieved from the infrapyloric area (p = 0.434). CONCLUSIONS Near-infrared ICG fluorescence guidance facilitates safe and fast infrapyloric LN dissection in laparoscopic distal gastrectomy.
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14
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Kaji S, Makuuchi R, Irino T, Tanizawa Y, Bando E, Kawamura T, Omori H, Fujiya K, Nishiwaki N, Furukawa K, Nakamura K, Koseki Y, Waki Y, Asaoka R, Terashima M. Preventive effect on delayed gastric emptying of preserving the infra-pyloric vein in laparoscopic pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc 2019; 34:3853-3860. [DOI: 10.1007/s00464-019-07151-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/24/2019] [Indexed: 12/19/2022]
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15
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Nakamura T, Shinohara H, Okada T, Hisamori S, Tsunoda S, Obama K, Kurahashi Y, Takai A, Shimokawa T, Matsuda S, Makishima H, Takakuwa T, Yamada S, Sakai Y. Revisiting the infracardiac bursa using multimodal methods: topographic anatomy for surgery of the esophagogastric junction. J Anat 2019; 235:88-95. [PMID: 30977530 DOI: 10.1111/joa.12989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/30/2022] Open
Abstract
In embryology, the infracardiac bursa (ICB) is a well-known derivative separated from the omental bursa. During surgeries around the esophagogastric junction (EGJ), surgeons often encounter a closed space considered to be equivalent to the ICB, but the macroscopic anatomy in adults is hardly known. This study aimed to revisit the ICB using multimodal methods to show its development from the embryonic to adult stage and clarify its persistence and topographic anatomy. Histological sections of 79 embryos from Carnegie stage (CS) 16 to 23 and magnetic resonance (MR) images of 39 fetuses were examined to study the embryological development of the ICB. Horizontal sections around the EGJ obtained from three adult cadavers were examined to determine the topographic anatomy and histology of the ICB. Further, 32 laparoscopic surgical videos before (n = 16) and after (n = 16) the start of this study were reviewed to confirm its remaining rate and topographic anatomy in surgery. The ICB was formed in 1 out of 10 CS17 samples, and in 8 out of 10 CS18 samples. Further, it was observed in all CS19-23 except one CS23 sample and in 25 (64%) out of 39 fetus samples. Three-dimensional reconstructed MR images of fetuses revealed that the ICB was located at the right alongside the esophagus and the cranial side of the diaphragmatic crus. In one adult cadaver, the caudal end of the ICB arose from the level of the esophageal hiatus and the cranial end reached up to the level of the pericardium. The inner surface cells of the space consisted of the mesothelium. In laparoscopic surgery, the ICB was identified in only 11 (69%) out of 16 surgeries before. However, subsequently we were able to identify the ICB reproducibly in 15 (94%) out of 16 surgeries. Thus, the ICB is the structure commonly remaining in almost all adults as a closed space located at the right alongside the esophagus and the cranial side of the diaphragmatic crus. It may be available as a useful landmark in surgery of the EGJ.
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Affiliation(s)
- Tatsuro Nakamura
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Tomoaki Okada
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeo Hisamori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazutaka Obama
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Akihiro Takai
- Department of HBP and Breast Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tetsuya Shimokawa
- Department of Anatomy and Embryology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Seiji Matsuda
- Department of Anatomy and Embryology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Haruyuki Makishima
- Congenital Anomaly Research Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Takakuwa
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigehito Yamada
- Congenital Anomaly Research Center, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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16
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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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17
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Zhang WH, Song XH, Chen XZ, Yang K, Liu K, Chen ZX, Zhou ZG, Hu JK. Characteristics and survival outcomes related to the infra-pyloric lymph node status of gastric cancer patients. World J Surg Oncol 2018; 16:116. [PMID: 29925390 PMCID: PMC6011414 DOI: 10.1186/s12957-018-1412-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 06/07/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To study metastasis to the infra-pyloric (no. 6) lymph nodes and their subgroups and the related risk factors of gastric cancer patients. METHODS Gastric cancer patients who underwent gastrectomy with complete postoperative pathological information on the no. 6 lymph node station and its subgroups from January 1, 2008, to December 31, 2011, were included. The clinicopathological characteristics and survival outcomes were analyzed. RESULTS A total of 121 patients were included; they had 6.1 ± 7.7 positive lymph nodes, and 35.1 ± 14.2 lymph nodes were examined. The overall lymph node positivity rate was 67.8% (82/121) with a positivity rate of 28.1% (34/121) for the no. 6 lymph nodes. The metastasis rate was 6.6% for the no. 6a nodes, 6.6% for the no. 6b nodes, and 21.5% for the no. 6c nodes. Also, no. 8a (OR = 1.329, p = 0.017) and no. 9 (OR = 1.250, p = 0.022) nodal positivity and lower third tumor location (OR = 1.278, p = 0.001) were independent risk factors for no. 6 lymph nodal metastasis. There was a significant survival difference between patients with positive and negative no. 6 lymph nodes and patients with metastasis to other lymph node stations (p < 0.001). CONCLUSIONS Patients with no. 6 lymph node metastasis have poor survival outcomes. Complete infra-pyloric lymphadenectomy is necessary and crucial for gastric cancer patients.
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Affiliation(s)
- Wei-Han Zhang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Xiao-Hai Song
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Kun Yang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Kai Liu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Zhi-Xin Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China
| | - Zong-Guang Zhou
- Department of Gastrointestinal Surgery and Laboratory of Digestive Surgery, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, No. 37 Guo Xue Xiang Street, Chengdu, Sichuan Province, China.
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18
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Variations of Gastrocolic Trunk of Henle and Its Significance in Gastrocolic Surgery. Gastroenterol Res Pract 2018; 2018:3573680. [PMID: 29977286 PMCID: PMC6011069 DOI: 10.1155/2018/3573680] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/02/2018] [Indexed: 12/22/2022] Open
Abstract
Due to the increasing incidence of gastrointestinal (GI) tumors, more and more importance is attached to radical resection and patients' survival, which requires adequate extent of resection and radical lymph node dissection. Blood vessels around the gastrointestinal tract, as anatomical landmarks for tumor resection and lymph node dissection, play a key role in the successful surgery and curative treatment of gastrointestinal tumors. In the isolation of subpyloric area or hepatic flexure of the colon for gastrectomy or right hemicolectomy, lymph node dissection and ligation are often performed at the head of the pancreas and superior mesenteric vein, during which even a minor inadvertent error may lead to unwanted bleeding. Among these blood vessels, the venous system composed of Henle's trunk and its tributaries is the most complex, which has a direct influence on the outcome and postoperative recovery of the patients. There are many variations of Henle's trunk, with complicated courses and various locations, attracting more and more researchers to study it and tried to analyze the influence of its variations on gastrointestinal surgeries. We characterized various variants and tributaries of Henle's trunk using autopsy, vascular casting, 3D CT reconstruction, intraoperative anatomy, and Hisense CAS system and summarized and analyzed the tributaries of Henle's trunk, to determine its influence on GI surgeries.
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Miao R, Qu J, Li Z, Wang D, Yu J, Zang W, Li Y, Liu F, Zhang J, Song W, Ye K, Yan S, Wang W, Ren S, Zang L, Jing C, Zhang L, Wang K, Fu W, Fan L, Liang B, Zhao G, Cai J, Yang L, Zhu J, You J, Yang K, Huang Q, Niu Z, Ning N, Qiu X, Ji G, Liang F, Huang H, Gao C, Shan F, Li S, Jia Y, Zhang L, Ying X, Zhang Y, Bu Z, Su X, Zhao G, Li Z, Ji J. Anatomical variation of infra-pyloric artery origination: A prospective multicenter observational study (IPA-Origin). Chin J Cancer Res 2018; 30:500-507. [PMID: 30510361 PMCID: PMC6232364 DOI: 10.21147/j.issn.1000-9604.2018.05.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Infra-pyloric artery (IPA) is an important anatomical landmark in treatment of gastric cancer and is the key vessel for pylorus-preserving gastrectomy and subgroup of infra-pyloric lymph nodes. However, its anatomical variation is not thoroughly understood. Our study aimed to clarify the origination of the IPA. Methods We did this prospective, multicenter, open-label, observational study at gastric surgery departments of 34 hospitals in China. Gastric cancer patients aged 18 years or older and scheduled to undergo elective total or distal gastrectomy were assigned. During the surgery, IPA dissecting and exposing the origination point with photographs or video clips were required. The primary outcome was the origination of the IPA. Analysis of variance, χ2 tests and Fisher’s tests were used to analyze the differences between groups. The study is registered at Clinicaltrials.gov (No. NCT03071237).
Results Between May 8 and July 31, 2017, 429 patients were assigned for the study, and 419 (97.7%) patients had the IPA dissected and recorded through photograph or video and were included in the primary outcome analysis. The median age was 62 years old, and 73.7% were male. Among the patients, 78.5% received laparoscopic surgery. Single IPA origination was identified in 398 (95.0%) patients, including gastroduodenal artery (GDA) in 154 (36.8%) patients, anterior superior pancreaticoduodenal artery (ASPDA) in 130 (31.0%) patients, and right gastroepiploic artery (RGEA) in 114 (27.2%) patients. Fifteen (3.6%) patients were identified with multiple IPA and 6 (1.4%) patients were identified as IPA absence. The differences in the distribution of surgical approach (P=0.003) and geographic area (P=0.030) were statistically significant. No difference was shown in sex, age, gastrectomy type, tumor location, and clinical T, N and M stage. Conclusions Our study found that the IPA originates from GDA, ASPDA and RGEA in similar proportions. Laparoscopic surgery may be more helpful in dissection of the IPA than open surgery.
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Affiliation(s)
- Rulin Miao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jianjun Qu
- Department of Surgical Oncology, Weifang People's Hospital, Weifang 261000, China
| | - Zhengrong Li
- Department of General Surgery, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Daguang Wang
- Department of Gastrointestinal Surgery, the First Hospital of Jilin University, Changchun 130021, China
| | - Jiang Yu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Weidong Zang
- Department of Gastrointestinal Cancer Surgery, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
| | - Yong Li
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Fenglin Liu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jian Zhang
- Department of Gastrointestinal Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
| | - Wu Song
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Kai Ye
- Department of Surgical Oncology, the Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, China
| | - Su Yan
- Department of Surgical Oncology, Affiliated Hospital of Qinghai University, Xining 810001, China
| | - Wei Wang
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Shuangyi Ren
- Department of General Surgery, the Second Hospital of Dalian Medical University, Dalian 116023, China
| | - Lu Zang
- Department of General Surgery, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Li Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
| | - Kuan Wang
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Weihua Fu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Lin Fan
- Department of General Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Bin Liang
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing 100044, China
| | - Gang Zhao
- Department of General Surgery, National Center of Gerontology, Beijing 100730, China
| | - Jun Cai
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Li Yang
- Department of Gastrointestinal Surgery, Jiangsu Province Hospital, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210005, China
| | - Jiaming Zhu
- Department of Gastrointestinal Surgery, the Second Hospital of Jilin University, Changchun 130041, China
| | - Jun You
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Qingxing Huang
- Department of Digestive Endoscopic and Minimally Invasive Surgery, Shanxi Provincial Cancer Hospital, Taiyuan 030013, China
| | - Zhaojian Niu
- Department of General Surgery, the Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Ning Ning
- Department of Gastrointestinal Surgery, Peking University International Hospital, Beijing 102206, China
| | - Xingfeng Qiu
- Department of Gastrointestinal Surgery, Zhongshan Hospital Xiamen University, Xiamen 361004, China
| | - Gang Ji
- Department of Gastrointestinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Feng Liang
- Department of General Surgery, the 307th Hospital of Chinese People's Liberation Army, Beijing 100071, China
| | - Hua Huang
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Chao Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Fei Shan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shuangxi Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yongning Jia
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Lianhai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiangji Ying
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhaode Bu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Gang Zhao
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Ziyu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jiafu Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Process of Pancreas Head as a Risk Factor for Postoperative Pancreatic Fistula in Laparoscopic Gastric Cancer Surgery. World J Surg 2017; 40:2194-201. [PMID: 27142626 DOI: 10.1007/s00268-016-3536-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF)-often caused by pancreatic injury during dissection of the peripancreatic lymph nodes-is a serious complication after gastric cancer surgery. We defined protruding pancreatic tissue on the anterior side of the pancreas head as "process of the pancreas head" (PPH) and investigated whether PPH is a predictable risk factor for POPF after laparoscopic gastrectomy. METHODS We reviewed 255 patients who underwent laparoscopic total or distal gastrectomy for gastric cancer. The perioperative outcomes of 142 patients operated in the study's early phase were investigated to evaluate the risk factors for POPF. To evaluate whether preoperative identification of PPH by computed tomography (CT) and intraoperative prediction of pancreas head outline could reduce the risk of POPF, the outcomes of 113 patients operated in the late phase were assessed. RESULTS Of the 142 early-phase patients, PPH was identified intraoperatively in 38 patients (26.8 %). A total of 13 patients (9.1 %) developed POPF > grade 2. PPH was identified as a risk factor for POPF (P < 0.01). In early-phase patients with PPH, the POPF rate was 21.0 %; in the late phase, it decreased to 4.3 %. Further, the POPF rate in early-phase patients with BMI > 25 and PPH was 42.6 %, decreasing to 0 % in the late-phase patients. CONCLUSIONS The presence of PPH is a risk factor for POPF after laparoscopic gastrectomy for gastric cancer. Identifying PPH using preoperative CT images and predicting the shape of the pancreas head during infrapyloric lymph node dissection are valuable in preventing POPF following laparoscopic gastric cancer surgery.
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Shinohara H, Kurahashi Y, Haruta S, Ishida Y, Sasako M. Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts. Ann Gastroenterol Surg 2017; 2:28-36. [PMID: 29863126 PMCID: PMC5881305 DOI: 10.1002/ags3.12048] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/21/2017] [Indexed: 12/23/2022] Open
Abstract
Gastrointestinal cancer surgery aims at en bloc removal of the primary tumor with its lymphatic drainage by excising organ-specific mesentery as an "intact package". This concept was advocated in colorectal cancer surgery as total mesorectal excision (TME) or complete mesocolic excision (CME) procedures, but is not directly applicable to stomach cancer as a result of the morphological complexities of the gastric mesentery. In this review, we discuss the unique anatomical features of the mesogastrium by introducing its embryology, disclose its similarity to the mesosigmoid, and then propose a theoretical concept to mesentery-based D2 gastrectomy, namely systematic mesogastric excision, which can universalize the operative strategy of stomach cancer with that of TME and CME colorectal counterparts.
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Affiliation(s)
| | | | - Shusuke Haruta
- Department of Gastroenterological Surgery Toranomon Hospital Minato-ku Japan
| | - Yoshinori Ishida
- Department of Surgery Hyogo College of Medicine Nishinomiya Japan
| | - Mitsuru Sasako
- Department of Surgery Hyogo College of Medicine Nishinomiya Japan
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Kim M, Son SY, Cui LH, Shin HJ, Hur H, Han SU. Real-time Vessel Navigation Using Indocyanine Green Fluorescence during Robotic or Laparoscopic Gastrectomy for Gastric Cancer. J Gastric Cancer 2017; 17:145-153. [PMID: 28680719 PMCID: PMC5489543 DOI: 10.5230/jgc.2017.17.e17] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/08/2017] [Accepted: 05/22/2017] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Identification of the infrapyloric artery (IPA) type is a key component of pylorus-preserving gastrectomy. As the indocyanine green (ICG) fluorescence technique is known to help visualize blood vessels and flow during reconstruction, we speculated that this emerging technique would be helpful in identifying the IPA type. MATERIALS AND METHODS From August 2015 to February 2016, 20 patients who underwent robotic or laparoscopic gastrectomy were prospectively enrolled. After intravenous injection of approximately 3 mL of ICG (2.5 mg/mL), a near-infrared fluorescence apparatus was applied. The identified shape of the IPA was confirmed by examining the actual anatomy following infrapyloric dissection. RESULTS The mean interval time between ICG injection and visualization of the artery was 22.2 seconds (range, 14-30 seconds), and the mean duration of the arterial phase was 16.1 seconds (range, 9-30 seconds). The overall positive predictive value (PPV) of ICG fluorescence in identifying the IPA type was 80% (16/20). The IPA type was incorrectly predicted in four patients, all of whom were obese with a body mass index (BMI) of more than 25 kg/m2. CONCLUSIONS Our preliminary results indicate that intraoperative vascular imaging using the ICG fluorescence technique may be helpful for robotic or laparoscopic pylorus-preserving gastrectomy.
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Affiliation(s)
- Mina Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Long-Hai Cui
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Ho-Jung Shin
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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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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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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Ohkura Y, Haruta S, Shindoh J, Tanaka T, Ueno M, Udagawa H. Effectiveness of postoperative intravenous acetaminophen (Acelio) after gastrectomy: A propensity score-matched analysis. Medicine (Baltimore) 2016; 95:e5352. [PMID: 27858921 PMCID: PMC5591169 DOI: 10.1097/md.0000000000005352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/29/2016] [Accepted: 10/05/2016] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to investigate the efficacy of postoperative scheduled intravenous acetaminophen to reduce the opioid use and enhance recovery after gastrectomy.Opioid use is reportedly associated with delayed recovery of gastrointestinal (GI) peristalsis and postoperative nausea/vomiting (PONV) despite of acceptable efficacy for pain control.Of 147 and 96 consecutive patients who underwent gastrectomy for gastric cancer before and after introduction of postoperative scheduled intravenous acetaminophen, propensity score matched population was created and short-term clinical outcomes were compared.Significant defervescence was demonstrated in Acetaminophen group (A-group) compared with control group (C-group) during the perioperative period (P < 0.001), whereas no significant difference was observed in postoperative inflammatory parameters. The incidence of postoperative complications was similar between the groups. The number of patient-controlled analgesia (PCA) pushes was significantly reduced in the A-group (P = 0.007) and the frequency of use of other nonopioid analgesics was also significantly reduced in the A-group (P < 0.001). Both daily and cumulative opioid use was significantly reduced in the A-group (P < 0.001). The time to first flatus and defecation was decreased in the A-group (P < 0.001 and P = 0.038, respectively). The incidence of PONV was significantly reduced from 26.0% to 12.5% after introduction of intravenous acetaminophen (P = 0.017), and hospital stay tended to be decreased in the A-group (13.2 vs 14.7 days, P = 0.069)Postoperative scheduled intravenous acetaminophen decreased opioid use and may be associated with enhanced recovery after gastrectomy.
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Affiliation(s)
- Yu Ohkura
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
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Kodera Y. The current state of stomach cancer surgery in the world. Jpn J Clin Oncol 2016; 46:1062-1071. [DOI: 10.1093/jjco/hyw117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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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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Degiuli M, De Manzoni G, Di Leo A, D’Ugo D, Galasso E, Marrelli D, Petrioli R, Polom K, Roviello F, Santullo F, Morino M. Gastric cancer: Current status of lymph node dissection. World J Gastroenterol 2016; 22:2875-2893. [PMID: 26973384 PMCID: PMC4779911 DOI: 10.3748/wjg.v22.i10.2875] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/09/2015] [Accepted: 01/18/2016] [Indexed: 02/06/2023] Open
Abstract
D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.
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