Current status of function-preserving gastrectomy for gastric cancer

Pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy (PPG) has been widely accepted as a function-preserving gastrectomy for middle-third early gastric cancer (EGC) with a distal tumor border at least 4 cm proximal to the pylorus. The procedure essentially preserves the function of the pyloric sphincter, which requires to preserve the upper third of the stomach and a pyloric cuff at least 2.5 cm. The suprapyloric and infrapyloric vessels are usually preserved, as are the hepatic and pyloric branches of the vagus nerve. Compared with distal gastrectomy, PPG has significant advantages in preventing dumping syndrome, body weight loss and bile reflux gastritis. The postoperative complications after PPG have reached an acceptable level. PPG can be considered a safe, effective, and superior choice in EGC, and is expected to be extensively performed in the future.

BROCK, ORITA HAJIME, FUKUNAGA TETSU. Totally Laparoscopic Pylorus-Preserving Gastrectomy (TLPPG) is Safe and Effective for Early Gastric Cancer Treatment

Background

Compared to distal gastrectomy (DG), pylorus-preserving gastrectomy (PPG), a peristaltic function-preserving surgery for early gastric cancer (EGC), is advantageous as it leads to a more improved nutritional status and quality of life (QOL) of patients. In recent years, total laparoscopic PPG (TLPPG), an anastomosis which is performed intracorporeally, has increasingly replaced laparoscopic-assisted PPG (LAPPG) due to its minimal invasiveness.

Aim

To evaluate the safety and feasibility of TLPPG in terms of perioperative efficacy.

Patients

Three patients underwent TLPPG in the Affiliated Hospital of Changzhi Medical College from September 2021 to March 2022.

Methods

Surgical safety analysis: Our three cases (TLPPG group) were compared to data from the CLASS-02 study, which collected data from multiple centers across China for the laparoscopic total gastrectomy (LTG group). The CLASS-02 study provides data from the most invasive type of gastric surgery, providing solid comparative data to our own.Postoperative short-term efficacy analysis: Patient questionnaire responses provided data on postoperative nutritional and QOL status. Results from our three cases were compared to the Japanese multicenter data PGSAS-37 (PGSAS group).

Results

There were no complications or deaths occurred during or after operation in our cases. Compared to the PGSAS group, our cases scored lower for abdominal pain, dyspepsia, and weight loss.

Conclusion

Although more case information is needed, our findings demonstrate that TLPPG may be a possible and effective treatment for EGC in China, similar to that in Japan.

Laparoscopic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (ROSF): a case-series study

BACKGROUND

There is no standard reconstruction method following proximal gastrectomy, of which gastroesophageal reflux and anastomotic complications are of great concern. Though several techniques have been devised to overcome these postoperative complications, such as double tract reconstruction, double-flap technique and side overlap fundoplication by Yamashita, none of them is considered a perfect solution. Herein, we designed a novel method of esophagogastrostomy after laparoscopic proximal gastrectomy (LPG), named right-sided overlap and single-flap valvuloplasty (ROSF).

METHODS

Between March 2021 and December 2021, 20 consecutive patients underwent LPG-ROSF at Department of Gastrointestinal Surgery, Second Affiliated Hospital of Soochow University. Surgical outcomes and postoperative complications were recorded. All patients were followed-up until December 2022. Endoscopy and assessment of gastrointestinal symptoms were performed 1 year after surgery. Nutrition-related parameters including total body weight, hemoglobin, lymphocyte count, serum total protein, serum albumin and serum prealbumin were evaluated 1 year after surgery and compared with those before surgery.

RESULTS

The mean surgery time and anastomosis time was 285.3 ± 71.3 and 61.3 ± 11.2 min respectively. None of the patients had gastrointestinal early postoperative complications. Symptomatic reflux was observed in one patient (5%) while reflux esophagitis (Los Angeles Grade A) was observed in another patient (5%). Four patients (20%) had mild dysphagia (Visick score = II) but none of them had anastomotic stenosis. There were no significant changes in nutritional status postoperatively.

CONCLUSIONS

ROSF can be safely performed after LPG and has satisfactory outcomes in preventing reflux and stenosis, and maintaining nutritional status. This technique requires further validation.

Significance of Preoperative Pulmonary Function on Short- and Long-Term Outcomes Following Gastrectomy for Gastric Cancer

BACKGROUND

Preoperative pulmonary function assessment is useful for selecting surgical candidates and operative methods and assessing the risk of postoperative pulmonary complications. However, few studies have investigated the relationship between preoperative pulmonary function and short- and long-term outcomes in patients who underwent gastrectomy for gastric cancer.

METHODS

Of the 1040 patients with gastric cancer (stages I-III) who had undergone R0 gastrectomy between 2009 and 2020, 750 who underwent preoperative spirometry were included. Restrictive ventilatory impairment was defined as a vital capacity of the predicted value (%VC) < 80%, while obstructive ventilatory impairment was defined as forced expiratory volume in one second (FEV1%) < 70%. Postoperative complications were assessed using the Clavien-Dindo (CD) classification. The relationship between clinical factors, including %VC, FEV1%, severe postoperative complications (CD ≥ 3b), overall survival (OS), and relapse-free survival, were assessed.

RESULTS

The mean age of the 750 patients was 68 ± 10.5 years. Severe postoperative complications were observed in 25 (3.3%) patients and were significantly associated with FEV1% < 70% in the univariate analysis. The 5-year OS was 72.5%. Multivariate analysis showed that the cancer stage, age > 75 years, preoperative comorbidities, %VC < 80%, total gastrectomy, severe postoperative complications, and postoperative adjuvant chemotherapy were the significant independent factors affecting OS. Pneumonia was significantly associated with %VC < 80%.

CONCLUSIONS

FEV1% < 70%was associated with the development of severe postoperative complications, while %VC < 80% was associated with poor OS independent of the cancer stage because of death from pneumonia. Spirometry helps surgeons and patients discuss the risks and benefits of surgery.

Late complication after gastrectomy for clinical stage I cancer: supplementary analysis of JCOG0912

BACKGROUND

Late complications following gastric cancer surgery, including postgastrectomy syndromes, are complex problems requiring a solution. Reported risk factors for developing late complications include surgery-related factors, such as the surgical approach and the extent of resection and reconstruction. However, this has not been assessed in a prospective study with a large sample size. Therefore, this study aimed to evaluate associations between surgery-related factors and the development of late complications. Data from the JCOG0912 trial were used. It compared laparoscopy-assisted distal gastrectomy (LADG) to open distal gastrectomy (ODG) in clinical stage I gastric cancer patients.

METHODS

This study included 881/921 patients enrolled in the JCOG0912 trial. The incidence of late complications was compared between the ODG and the LADG arms. In addition, associations between surgery-related factors and the development of late complications were assessed by multivariable analyses using the proportional odds model to identify relevant risk factors.

RESULTS

There was no difference in the type or number of patients with late complications between the LADG and the ODG arms. The multivariable analysis for each late complication revealed that the Billroth-I reconstruction (vs. R-en-Y or Billroth-II) had a lower risk of cholecystitis [odds ratio (OR) 0.187, 95% confidence interval (CI) 0.039-0.905, P = 0.037] or ileus (OR 0.116, 95%CI 0.033-0.406, P < 0.001), and pylorus-preserving gastrectomy (vs. R-en-Y or Billroth-II) had a higher risk of reflux esophagitis (OR 3.348, 95% CI 1.371-8.176, P = 0.008). The surgical approach was not a risk factor for any late complications.

CONCLUSION

Differences in surgical approaches did not constitute a risk for developing late complications after gastrectomy. Billroth-I reconstruction reduced the risk of ileus and cholecystitis, but pylorus-preserving gastrectomy carried a risk for reflux esophagitis.

Study protocol for comparing the efficacy of left-open single-flap technique versus double-flap technique after proximal gastrectomy: A multicenter randomized controlled trial

BACKGROUND

Proximal gastrectomy has gradually gained more attention due to its superiority in retaining the function of part of the stomach. The inevitable loss of the antireflux barrier and postoperative complications resulting from proximal gastrectomy can severely affect the quality of life. Continuous improvements in digestive tract reconstruction after proximal gastrectomy have yielded the development of a variety of methods with antireflux functions. Recently, our center attempted the left-open single-flap technique and initiated a multicenter, prospective, randomized controlled trial for patients undergoing proximal gastrectomy to reduce the difficulty of surgical anastomosis and the incidence of perioperative complications compared with the double-flap technique. These findings will provide more evidence-based medical research for the development of clinical guidelines.

METHODS/DESIGN

This study is a prospective, multicenter, randomized controlled clinical trial. We plan to recruit 250 patients who are eligible for proximal gastrectomy. After informed consent is obtained, patients will be randomly assigned to the trial group (left-open single-flap technique) and the control group (double-flap technique) in a 1:1 allocation ratio.

DISCUSSION

Increasingly, clinical studies have focused on the improvement of reconstruction modalities after proximal gastrectomy. Among these methods, the double-flap technique is a clinically effective method. The purpose of this study is to establish a prospective randomized controlled trial to compare the efficacy of the left-open single-flap technique versus the double-flap technique after proximal gastrectomy, aiming to provide more evidence-based medical studies for digestive tract reconstruction in proximal gastrectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier [NCT05418920].

Pathological and oncological outcomes of pylorus-preserving versus conventional distal gastrectomy in early gastric cancer: a systematic review and meta-analysis

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.

Gastric Metastasis of Primary Lung Cancer: Case Report and Systematic Review With Pooled Analysis

Background

Gastric metastasis from lung cancer (GMLC) is a rare occurrence. The clinicopathological characteristics, outcomes, and prognostic factors remain largely elusive.

Methods

We conducted a systematic review on case reports and case series of GMLC by scanning MEDLINE, Embase, and ISI Web of Knowledge. Data involving the clinicopathological features, treatment, and outcomes were extracted and analyzed. Survival analysis was performed using Kaplan–Meier method. The Cox proportional hazards regression model was used to identify potential prognostic factors associated with survival. Furthermore, a case of metastatic gastric adenocarcinoma of pulmonary origin with epidermal growth factor receptor (EGFR) L858R+T790M mutation was also described and included.

Results

Seventy-eight records involving 114 cases (including ours) were finally included. The median age on admission was 65 years with a male predominance of 79.8%. Lung adenocarcinoma (42.1%), located in the right upper lobe (30.3%), was the most frequent primary tumor. Bleeding (36.7%) and abdominal pain (35.8%) were the two most common symptoms. Endoscopically, gastric lesions were typically presented as elevated lesions with or without volcano-like ulceration, or ulcerative lesions, mostly involving the gastric corpus. The median overall survival time and survival time after diagnosis of metastatic cancer were 11 months [95% confidence interval (CI): 7–14] and 4.5 months (95% CI: 3–9), respectively. The survival analyses revealed that surgical interventions (including lung surgery and/or abdominal surgery) and systemic therapy (including chemotherapy, radiotherapy, and/or targeted therapy) seemed to be positive prognostic factors for both overall survival and survival after diagnosis of metastatic cancer.

Conclusions

Clinicians should be alerted to the occurrence of gastric metastasis in lung cancer patients. Comprehensive evaluation and appropriate treatment for specific patients may improve the survival rate of GMLC patients.

Surgical and oncological outcomes of distal gastrectomy compared to total gastrectomy for middle‑third gastric cancer: A systematic review and meta‑analysis

Distal gastrectomy (DG) and total gastrectomy (TG) are the most common types of radical surgery for patients with middle-third gastric cancer (MTGC). However, the indications and benefits of the two procedures still remain controversial. The present meta-analysis aimed to compare the surgical and oncological outcomes of DG and TG in the treatment of MTGC. A rigorous literature review was performed in the databases of PubMed, Embase, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature to retrieve studies published up to February 2022. The Newcastle-Ottawa Scale was used to assess the quality of included studies and a meta-analysis was performed using RevMan 5.3 software. A total of 12 retrospective studies performing comparisons of DG and TG were included in the present meta-analysis. For patients who underwent DG, a lower rate of overall post-operative complications, anastomosis leakage and intro-abdominal infection was determined. No significant difference was observed between DG and TG in the 5-year overall survival when the proximal resection margin ranged from 3 to 5 cm. Although DG was associated with a higher 5-year overall survival rate when compared to TG, there was no significant difference in the stratified analyses by TNM stage. In conclusion, the prognosis of MTGC did not depend on the extent of gastrectomy. With lower complications and acceptable oncological outcomes, DG was a safe and feasible surgical procedure for MTGC when a negative proximal margin was confirmed.

Clinical Outcomes of Laparoscopic Proximal Gastrectomy With Double-Flap Reconstruction for Tumors in the Upper Third of the Stomach

PURPOSE

Laparoscopic proximal gastrectomy (LPG) has been a standard surgery for early gastric cancer in the upper third of the stomach and large esophagogastric junction gastrointestinal stromal tumor. However, how to reconstruct the stomach after LPG is still debated. This study aimed to evaluate the results of LPG with double-flap reconstruction.

METHODS

A retrospective study was performed with 14 patients undergoing LPG with double-flap reconstruction for early gastric cancer or large tumors in the upper third of the stomach from 2018 to 2021. We evaluated postoperative complications, gastroesophageal reflux and the gastric remnant's function using endoscopy in accordance with the Los Angeles and Residue-Gastritis-Bile classifications, and patients' quality of life by the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire.

RESULTS

Median age was 54 years and 10 patients were male. There were 7 patients with gastrointestinal stromal tumor, 4 with leiomyoma and 3 with early-stage adenocarcinoma. No patient had major complications or required conversion to open surgery. During a median follow-up period of 24.6 months, 1 patient had late anastomotic stricture, 2 had metastasis, and 1 died. Endoscopic evaluation at 6 and 12 months showed good function of the gastric remnant in most patients. Patients' quality of life improved over time: mean GSRS score was 26.9±12.6, 20.3±7.2, and 18.8±4.2 at 6, 12, and 24 months, respectively.

CONCLUSIONS

LPG with double-flap reconstruction is feasible and safe for early gastric cancer or large tumors in the upper third of the stomach. The long-term functional outcomes and patients' quality of life were acceptable.

Laparoscopic Esophagogastric Anastomosis With Stapled Pseudo-Fornix for Reflux Esophagitis Prevention After Proximal Gastrectomy

Laparoscopic esophagogastric anastomosis is not commonly performed after proximal gastrectomy (PG) because of its technical complexity and the lack of a gold standard for reconstruction. We describe a simple and convenient technique of laparoscopic esophagogastrostomy with stapled pseudo-fornix for reflux esophagitis (RE) prevention after PG.

Laparoscopic PG (LPG) was performed in four patients with gastric cancer in the upper third of the stomach, and the remnant stomach was prepared for reconstruction. After making a small hole on the anterior wall of the remnant stomach 45 mm distal to the proximal stump and on the dorsal side of the esophageal stump, a 45 mm no-knife linear stapler was applied. To create a "pseudo-fornix," a common lumen was made by cutting the center of the four staple rows at a length of 15 mm. The entry hole was closed using the laparoscopic hand-sewn suturing technique.

The mean operation time was 240 min, with an estimated blood loss of <10 ml. No intraoperative complications or conversion to open surgery were observed. One patient developed stenosis of the esophagogastrostomy successfully treated by endoscopic balloon dilatation. Endoscopic surveillance three months after surgery revealed no incidence of RE in any of the patients.

Laparoscopic esophagogastric anastomosis with stapled pseudo-fornix is convenient and beneficial in preventing RE after PG and should be considered the treatment of choice for reconstruction after LPG in selected patients with proximal gastric cancer.

Modern surgical therapy for gastric cancer-Robotics and beyond

The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.

Function-Preserving Gastrectomy for Early Gastric Cancer

Simple Summary

For patients with early gastric cancer (EGC), a good prognosis is achieved by conventional standard gastrectomy with radical lymphadenectomy. However, postgastrectomy syndrome is often inevitable and results in decreased quality of life (QOL). To improve patients’ QOL, proximal gastrectomy instead of total gastrectomy and pylorus-preserving gastrectomy instead of distal gastrectomy have been widely accepted as function-preserving gastrectomies. Recently, personalized, minimized gastrectomy with sentinel node navigation surgery has been developed and is expected to be an ideal treatment option for patients with EGC. Herein, we review the indications, surgical techniques, and postoperative outcomes of function-preserving gastrectomy.

Abstract

Recently, minimally invasive (endoscopic or laparoscopic) treatment for early gastric cancer (EGC) has been widely accepted. However, a standard gastrectomy with radical lymphadenectomy is generally performed in patients with EGC who have no indications for endoscopic resection, and postgastrectomy dysfunction is one of the problems of standard gastrectomy. Function-preserving gastrectomy, such as proximal gastrectomy and pylorus-preserving gastrectomy, can be considered when attempting to preserve the patient’s quality of life (QOL) postoperatively. In addition, sentinel node navigation surgery for EGC has been applied in clinical practice in several prospective studies on function-preserving personalized minimized gastrectomy. In the near future, the sentinel lymph node concept is expected to form the basis for establishing an ideal, personalized, minimally invasive function-preserving treatment for patients with EGC, which will improve their postoperative QOL without compromising their long-term survival. In this review article, we summarize the current status, surgical techniques, and postoperative outcomes of function-preserving gastrectomy for EGC.