Clinical outcome of pylorus-preserving gastrectomy in gastric cancer in comparison with conventional distal gastrectomy with Billroth I anastomosis

The long-term quality of life after distal and pylorus-preserving gastrectomy for stage I gastric cancer: A prospective multi-institutional study (CCOG1601)

PURPOSE

While regarded as function-preserving gastrectomy, few prospective longitudinal clinical trials have addressed the postoperative quality of life (QOL) after pylorus-preserving gastrectomy (PPG). We prospectively compared chronological changes in postoperative body weight and the QOL between PPG and distal gastrectomy (DG) for pathological Stage I gastric cancer (GC).

METHODS

We conducted a multi-institutional prospective study (CCOG1601) to evaluate patients who underwent DG and PPG. The QOL was examined using the European Organization for Research and Treatment of Cancer Quality of life questionnaire-C30 (EORTC QLQ-C30) and the Post-Gastrectomy Syndrome Assessment Scale-37 (PGSAS-37). A total of 295 patients were enrolled from 15 institutions, and propensity score matching was performed to adjust for the essential variables for comparison analyses.

RESULTS

After propensity score matching, 25 pairs of patients were identified. In the first postoperative month, DG achieved a superior nausea and vomiting score (EORTC QLQ-C30) and meal-related distress, indigestion, and dumping scores (PGSAS-37). No significant differences were noted between DG and PPG in the long-term QOL. Postoperative body weight loss was similar in both groups.

CONCLUSIONS

This prospective observational study failed to demonstrate the superiority of PPG over DG in terms of postoperative body weight changes and the QOL.

A Comparative Study of Postoperative Complications Associated with Distal Gastrectomy and Pylorus-Preserving Gastrectomy among Gastric Cancer Patients Based on Nationwide Survey Data and Propensity Score Weighting

BACKGROUND/OBJECTIVE

This study aimed to compare complication rates between pylorus-preserving gastrectomy (PPG) and distal gastrectomy (DG) using Korean nationwide survey data and propensity score weighting (PSW). PPG preserves gastric function but may lead to more postoperative complications than DG.

METHODS AND RESULTS

We analyzed 9424 gastric cancer patients who underwent either DG (n = 9183) or PPG (n = 241). PSW balanced variables such as age, sex, TNM stage, comorbidities, ASA score, and surgical approach. Before PSW, 87.8% of DG patients and 87.1% of PPG patients had no complications (p = 0.053). Severe complications (Clavien-Dindo IIIa or higher) were more frequent in PPG (6.6%) than in DG (3.8%) (p = 0.039). After PSW, overall complication rates (p = 0.960) and severe complication rates (p = 0.574) were similar between groups. Incidence rates of anastomotic stricture and leakage were higher in PPG (2.9% and 1.7%) compared to DG (0.6% and 0.5%) (p = 0.001 and 0.036) before PSW, but these differences were not significant after PSW (p = 0.999 and 0.123).

CONCLUSION

The PSW-adjusted analysis indicates no significant difference in overall and severe complication rates between PPG and DG in gastric cancer patients.

Equal short-term outcomes of intracorporeal mechanical gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for cT1N0 gastric cancer in the middle stomach compared with the extracorporeal hand-sewing method

BACKGROUND

Intracorporeal mechanical gastrogastrostomy (IMG) techniques have recently been developed and their short-term safety was presented in their initial evaluation. However, whether they are comparable to extracorporeal hand-sewing gastrogastrostomy (EHG) remains unclear. The aim of the study is to establish the safety of IMG in totally laparoscopic pylorus-preserving gastrectomy (TLPPG) compared to EHG in laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG).

METHODS

We retrospectively analyzed the short-term outcomes of patients with middle-third early gastric cancer who underwent LAPPG or TLPPG between 2005 and 2022. The primary objective of this study was to evaluate the non-inferiority of IMG to EHG in terms of safety, with the primary endpoint being the risk difference in anastomosis-related complications (ARCs). The sample size required to achieve a statistical power of 80% for the non-inferiority test was 971 with a one-sided alpha level of 5% and non-inferiority of 5%.

RESULTS

The analysis included a total of 1,021 patients who underwent LAPPG or TLPPG during the study period. Among them, 488 patients underwent EHG, while 533 underwent IMG. The incidences of ARCs were 11.3% and 11.4% in EHG and IMG, respectively. The observed difference in incidence was 0.0017 (90% confidence interval - 0.0313 to 0.0345), which statistically demonstrated the non-inferiority of IMG to EHG in the incidence of ARCs. Among other complications, the incidence of wound infection in IMG was lower than that in EHG.

CONCLUSION

IMG is safe regarding ARCs compared with EHG. These results will encourage surgeons to introduce IMG for patients with early middle gastric cancer.

Vagal Sparing Gastrectomy: A Systematic Review and Meta-Analysis

INTRODUCTION

Radical gastrectomy is associated with significant functional complications. In appropriate patients may be amenable to less invasive resection aimed at preserving the vagal trunks. The aim of this systematic review and meta-analysis was to assess the functional consequences and oncological safety of vagal sparing gastrectomy (VSG) compared to conventional non-vagal sparing gastrectomy (CG).

METHODS

A systematic review of four databases in accordance with PRISMA guidelines was undertaken for studies published between January 1, 1990, and December 15, 2021, comparing patients who underwent VSG to CG. We meta-analysed the following outcomes: operative time, blood loss, nodal yield, days to flatus, body weight changes, as well as the incidence of post-operative cholelithiasis, diarrhoea, delayed gastric emptying, and dumping syndrome.

RESULTS

Thirty studies were included in the meta-analysis with a selection of studies qualitatively analysed. VSG was associated with a lower rate of cholelithiasis (OR: 0.25, 95% CI: 0.15-0.41, p < 0.010) and early dumping syndrome (OR: 0.42, 95% CI: 0.21-0.86; p = 0.02), less blood loss (mean difference [MD]: -51 mL, 95% CI: -89.11 to -12.81 mL, p = 0.009), less long-term weight loss (MD: 2.03%, 95% CI: 0.31-3.76%, p = 0.02) and a faster time to flatus (MD: -0.42 days, 95% CI: -0.48 to 0.36, p < 0.001). There was no significant difference in nodal harvest, overall survival, and all other endpoints.

CONCLUSION

VSG significantly reduces the incidence of post-operative cholelithiasis and dumping syndrome, decreases weight loss, and facilitates an earlier return of gut motility. Although technically more challenging, VSG should be considered for prophylactic surgery.

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.

Comparison between laparoscopic pylorus-preserving gastrectomy and laparoscopic distal gastrectomy for overweight patients with early gastric cancer

Purpose

Laparoscopic pylorus-preserving gastrectomy (LPPG) has a nutritional advantage over laparoscopic distal gastrectomy (LDG), however, may be less beneficial in overweight patients in terms of weight loss. The purpose of this study was to compare LPPG and LDG in overweight patients with early gastric cancer.

Methods

Clinicopathologic data of overweight patients (body mass index [BMI], ≥25 kg/m²) who underwent LPPG (n = 63) or LDG (n = 183) in 2016-2018 were retrospectively reviewed. In the LDG group, patients with Billroth-II anastomosis were separately grouped (LDG B-II, n = 66). Changes in BMI, hemoglobin, albumin, and total protein were compared among groups.

Results

Changes in BMI were not significant different among groups. The LPPG group had significantly higher albumin than the LDG group at postoperative 6 months and 1 year. The LPPG group had higher total protein than the LDG group at postoperative 2 years. The LPPG group had a higher complication rate of Clavien-Dindo classification III or higher (20.6%) than the LDG group (8.2%, P = 0.007). However, after excluding pyloric stenosis, there was no significant difference among groups (LPPG vs. LDG, P = 0.290; LPPG vs. LDG B-II, P = 0.921).

Conclusion

LPPG and LDG groups showed similar weight loss. However, the LPPG group had higher albumin and protein levels than the LDG group of overweight patients. Thus, it is not necessary to select LDG only for weight loss. LPPG may be selected as one option due to its potential nutritional benefit when pyloric stenosis is properly managed.

A continuous muscle-sparing advantage of pylorus-preserving gastrectomy for older patients with cT1N0M0 gastric cancer in the middle third of the stomach

In older patients with cT1N0M0 gastric cancer in the middle third of the stomach, LPPG has advantages over LDGB1 in maintaining skeletal muscle mass.

BACKGROUND

Laparoscopic pylorus-preserving gastrectomy (LPPG) for early gastric cancer in the middle third of the stomach is expected to be an alternative procedure to laparoscopic distal gastrectomy (LDG). However, whether LPPG is safe and more useful than LDG in older patients is unclear because of their comorbidities and organ dysfunctions.

METHODS

We retrospectively analyzed the data of consecutive patients aged 75 or over who underwent LDG with Billroth I reconstruction (LDGB1) or LPPG for cT1N0M0 gastric cancer in the middle third of the stomach between 2005 and 2019. After propensity score matching was used to improve the comparability between the LDGB1 and LPPG groups, we compared surgical and postoperative nutritional outcomes, including the postoperative trends of bodyweight (%BW) and skeletal muscle index (%SMI).

RESULTS

A total of 132 patients who underwent LDGB1 (n = 88) and LPPG (n = 44) were collected for this study. No significant difference in postoperative complications was observed. The total protein levels after LPPG were significantly higher than those after LDGB1 for 4 postoperative years. Both %BW and %SMI after LPPG were significantly maintained compared with those after LDGB1 during the first year after surgery. For the subsequent years, %BW after LPPG became similar to that after LDGB1, while %SMI after LPPG was significantly larger than LDGB1 continuously.

CONCLUSIONS

LPPG has a great advantage in maintaining the postoperative skeletal muscle mass as well as the nutritional parameters of older patients. LPPG is expected to be an alternative to LDG in older patients.

Feasibility and safety of inserting transient biodegradable stents in the pylorus during pylorus-preserving gastrectomy for gastric cancer: a preliminary study in a porcine for proof of concept

BACKGROUND

To evaluate whether insertion of self-biodegradable stent into the pylorus to prevent delayed-gastric emptying after pylorus-preserving gastrectomy is feasible and safe through porcine experiment.

METHODS

Self-biodegradable dumbbell-shaped pyloric stents were designed from absorbable suture materials: poly(glycolide-co-caprolactone) (PGCL) or poly-p-dioxanone (PPDO). After gastrotomy on ten pigs, each stent was inserted: two shams, four PGCL stents, and four PPDO stents. Body weight (Bwt), body temperature (BT), complete blood cell (CBC) count, and plain X-ray were evaluated. On postoperative day (POD) 13, euthanasia was performed for histologic evaluation.

RESULTS

Operation was successfully performed in all ten pigs. Without tagging suture, both stents migrated before POD 3. The migration was delayed up to POD 13, when the tagging sutures (-t) were applied between stent and stomach wall. Self-degradation of PGCL started from POD 3, and stents were completely excreted from the abdomen by POD 8. Although PPDO were also weakened as self-degradation progressed, its shape was maintained in gastrointestinal tract for 13 days. Unexpected sudden death occurred in the pig with PPDO-t2 on POD 10, which is more likely due to acute volvulus rather than stent-related complication. There was no significant difference between three groups in terms of Bwt, BT, CBC, and histology (sham vs. PGCL vs. PPDO, all p > 0.05).

CONCLUSION

The concept of biodegradable stents made of absorbent suture material seems feasible in porcine experiment. Among them, PGCL which has shown rapid absorption, appears to be a more suitable material for transient pyloric absorbable stent when considering safety aspect.

Safety of pylorus-preserving gastrectomy for gastric cancer combined with antral high-risk lesions: a comparison with endoscopic submucosal dissection

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is a surgical treatment option for cT1N0M0 gastric cancer located in the middle third of the stomach. However, data for the long-term post-PPG clinical outcomes related to metachronous gastric neoplasms (mGNs) in the residual stomach are currently lacking. Therefore, we aimed to evaluate the safety of PPG by focusing on mGNs.

METHODS

In this single-center, retrospective study, we reviewed the data for 362 patients who underwent PPG with a 3-cm antral cuff and 139 who underwent endoscopic submucosal dissection (ESD) for middle-third gastric cancer between January 2013 and December 2015. The histopathologic features of the antrum in the ESD group, which could not be determined in the PPG group, were analyzed to investigate the risk factors for mGNs. The estimated and actual incidence of mGNs in the antrum were compared in the PPG group.

RESULTS

The incidence of mGNs was 6.5% (9/139) in the ESD group. The presence of a synchronous adenoma (odds ratio [OR], 8.46; 95% confidence interval [CI], 1.55-46.34), carcinoma (OR, 15.71; 95% CI, 2.67-92.56) and moderate-to-severe intestinal metaplasia (OR, 9.77; 95% CI, 1.14-83.92) were associated with a higher risk of overall mGNs. However, when confined to the antrum, no significant association was observed between these factors and mGNs. In the ESD group, 2 of 9 mGNs (1.4%) were located at the 3-cm antral cuff. In the PPG group, both mGNs (0.6%) were located in the proximal remnant stomach.

CONCLUSION

Pylorus-preserving gastrectomy was a safe therapeutic option with regard to the occurrence of metachronous adenomas or carcinomas in our series. Despite the low mGN incidence in the 3-cm antral cuff after PPG, the presence of synchronous neoplasms or moderate-to-severe intestinal metaplasia was a risk factor for mGNs in the ESD group; thus, further studies on longer antral cuffs with long-term follow-up are needed.

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.

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.

Short-term Outcomes of Pylorus-Preserving Gastrectomy for Early Gastric Cancer: Comparison Between Extracorporeal and Intracorporeal Gastrogastrostomy

Purpose

This study aimed to compare the surgical and oncological outcomes between totally laparoscopic pylorus-preserving gastrectomy (TLPPG) with intracorporeal anastomosis and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with extracorporeal anastomosis.

Materials and Methods

A retrospective analysis was performed in 258 patients with cT1N0 gastric cancer who underwent laparoscopic pylorus-preserving gastrectomy using two different anastomosis methods: TLPPG with intracorporeal anastomosis (n=88) and LAPPG with extracorporeal anastomosis (n=170). The following variables were compared between the two groups to assess the postoperative surgical and oncological outcomes: proximal and distal margins, number of resected lymph nodes (LNs) in total and in LN station 6, operation time, postoperative hospital stay, and postoperative morbidity including delayed gastric emptying (DGE).

Results

The average length of the proximal margin was similar between the TLPPG and LAPPG groups (2.35 vs. 2.73 cm, P=0.070). Although the distal margin was significantly shorter in the TLPPG group than in the LAPPG group (3.15 vs. 4.08 cm, P=0.001), no proximal or distal resection margin-positive cases were reported in either group. The average number of resected LN was similar in both groups (36.0 vs. 33.98, P=0.229; LN station 6, 5.72 vs. 5.33, P=0.399). The operation time was shorter in the TLPPG group than in the LAPPG (200.17 vs. 220.80 minutes, P=0.001). No significant differences were observed between the two groups in terms of postoperative hospital stay (9.38 vs. 10.10 days, P=0.426) and surgical complication rate (19.3% vs. 22.9%), including DGE (8.0% vs. 11.8%, P=0.343).

Conclusions

The oncological safety and postoperative complications of TLPPG with intracorporeal anastomosis are similar to those of LAPPG with extracorporeal anastomosis.

Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial)

BACKGROUND

There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer.

METHODS

The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days.

RESULTS

Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups.

CONCLUSION

Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov).

Surgical Treatment for Gastric Cancer

Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.

Laparoscopic surgery for gastric cancer: Current status and future direction

Gastric cancer is still a major cause of death worldwide. While laparoscopic gastrectomy (LG) has gained evidence as a standard treatment for early gastric cancer in the distal stomach, there are still concerns regarding its application for gastric cancer in the upper stomach and advanced gastric cancer. Nevertheless, LG has shown to have faster recovery, shorter hospital stay, less pain, and less blood loss in many retrospective and prospective studies. The application of LG has now extended from conventional radical gastrectomy to novel approaches such as function-preserving gastrectomy and sentinel-node navigated surgery. Studies on the use of laparoscopy in treatment for stage IV gastric cancer are rare, but show that there may be some roles of LG in selected cases. With the development of new laparoscopic tools that augment human ability, the future of LG should move on from proving non-inferiority to demonstrating superiority compared to the traditional open gastrectomy.

Radiologic intervention due to delayed gastric emptying after pylorus preserving gastrectomy for gastric cancer does not affect pyloric function

Purpose

The purpose of this study is to evaluate whether radiologic intervention in the pylorus decreases its function for delayed gastric emptying (DGE) patients after pylorus preserving gastrectomy (PPG) for gastric cancers and to determine the optimal interventional algorithm.

Methods

PPG patients who underwent intervention for DGE from January 2013 to December 2017 and a control group using propensity score matching were identified. Pyloric function was compared by subjective symptoms, postoperative upper gastrointestinal series at 3 months (short-term function), and esophagogastroduodenoscopy findings at 12 months (long-term function). Serum albumin levels and body weight change, 6 months and 12 months postoperatively, were compared to evaluate nutritional status. Interventional success rate, mean hospital stay, and recurrence of DGE were analyzed to determine the optimal intervention plan.

Results

Fifty-one out of 677 patients (7.53%) received intervention. There was no difference in pyloric function and nutritional status between the intervention and control groups. The interventional success rate for first-time balloon dilatation was 41.7% (20/48). If a second intervention was required and balloon dilatation was done, the success rate was 45.5% (5/11). However, if stent insertion was done, the success rate was 100% (17/17). Subsequent stent insertion after balloon dilatation resulted in a shorter mean hospital stay. Intervention including stent insertion had a lower recurrence of DGE than balloon only intervention (1.96% vs. 5.88%, P=0.041).

Conclusion

Radiologic intervention did not decrease long-term pyloric function. For treating DGE, if at first balloon dilatation fails, retrievable stent insertion can be considered as a second choice.

Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared with laparoscopy-assisted distal gastrectomy for early gastric cancer

BACKGROUND AND AIM

This study aimed to investigate the postoperative quality of life (QOL) between laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) and laparoscopy-assisted distal gastrectomy with Billroth I anastomosis (LADGBI) in patients with middle-third early gastric cancers (EGC).

METHODS

From January 2015 to August 2017, a total 91 patients with EGC underwent LAPPG or LADGBI procedure with complete QLQ-C30 and QLQ-STO22 in Ren Ji Hospital. Not only do surgical and oncological safety as well as clinicopathologic characteristics analyze, but also chronological changes of QOL and nutritional status were compared for the evaluation of functional advantages.

RESULTS

There was no significant difference in clinicopathologic characteristics and perioperative recovery between LAPPG and LADGBI. During postoperative 2-year follow up, LAPPG showed significant advantages over LADGBI in emotional functioning, insomnia, appetite loss, reflux, and taste problem and presented larger area in global and functional scales and less area in symptom scales, which means that LAPPG tended to present better improvement and less symptoms than LADGBI for QOL 2 years after surgery. Furthermore, LAPPG could bring about significant improvement in total protein and hemoglobin compared to LADGBI at postoperative 2 years.

CONCLUSION

LAPPG obtains QOL as well as total protein and hemoglobin superiority and could be recommended to patients with EGC whose tumor located in the middle third of the stomach.

Gastric cancer

Gastric cancer is the fifth most common cancer and the third most common cause of cancer death globally. Risk factors for the condition include Helicobacter pylori infection, age, high salt intake, and diets low in fruit and vegetables. Gastric cancer is diagnosed histologically after endoscopic biopsy and staged using CT, endoscopic ultrasound, PET, and laparoscopy. It is a molecularly and phenotypically highly heterogeneous disease. The main treatment for early gastric cancer is endoscopic resection. Non-early operable gastric cancer is treated with surgery, which should include D2 lymphadenectomy (including lymph node stations in the perigastric mesentery and along the celiac arterial branches). Perioperative or adjuvant chemotherapy improves survival in patients with stage 1B or higher cancers. Advanced gastric cancer is treated with sequential lines of chemotherapy, starting with a platinum and fluoropyrimidine doublet in the first line; median survival is less than 1 year. Targeted therapies licensed to treat gastric cancer include trastuzumab (HER2-positive patients first line), ramucirumab (anti-angiogenic second line), and nivolumab or pembrolizumab (anti-PD-1 third line).

A comparison between pylorus-preserving and distal gastrectomy in surgical safety and functional benefit with gastric cancer: a systematic review and meta-analysis

BACKGROUND

Due to better functional outcomes, pylorus-preserving gastrectomy (PPG) has been widely applied for early gastric cancer (EGC) patients as an alternative to distal gastrectomy (DG). However, controversies still persist regarding the surgical efficacy and oncological safety of PPG.

METHODS

Original studies comparing PPG and DG for EGC were searched in PubMed, Embase, and the Cochrane Register of Controlled Trials up to December 2019. The weight mean difference, standardized mean difference, or odds risk was used to calculate the short-term and long-term outcomes between the two groups.

RESULTS

Twenty-one comparative studies comprising 4871 patients (1955 in the PPG group and 2916 in the DG group) were enrolled in this systematic review and meta-analysis. PPG showed longer hospital day, decreased harvested lymph nodes, and more delayed gastric emptying. However, PPG had the benefits of lower incidence of anastomosis leakage, early dumping syndrome, gastritis and bile reflux, and better recovery of total protein, albumin, hemoglobin, and weight. No difference was found in operative time, blood loss, and overall complications. Moreover, the long-term survival and recurrence rate were similar in two groups.

CONCLUSION

Owing to the non-inferiority of surgery and oncology outcomes and the superiority of function outcomes in PPG, we revealed that PPG can be clinically applicable instead of DG in EGC. However, more high-quality comparative studies and randomized clinical trials would be required for further confirmation.

Functional and nutritional outcomes after gastric cancer surgery

Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.

Should pylorus-preserving gastrectomy be performed for overweight/obese patients with gastric cancer?

BACKGROUND

Pylorus-preserving gastrectomy is an alternative to distal gastrectomy for early gastric cancer, and is expected to have postoperative advantages including maintenance of body weight. Overweight/obesity is a risk factor for chronic disorders, including hypertension and diabetes mellitus; in these conditions, body weight control is frequently required as part of treatment. It remains unknown whether pylorus-preserving gastrectomy should be performed in overweight/obese patients because excess body weight may be maintained postoperatively.

METHODS

We retrospectively investigated body weight changes and postoperative nutritional status of overweight/obese patients who underwent laparoscopic distal gastrectomy (LDG) or laparoscopic pylorus-preserving gastrectomy (LPPG) between 2006 and 2015. Among 349 overweight patients (BMI ≥ 25 kg/m²), 101 LDG and 101 LPPG cases were compared after propensity score matching to adjust for patient characteristics.

RESULTS

The mean relative body weight ratios (postoperative/preoperative ratios) were 87.5 ± 8.0% after LDG and 89.6 ± 6.7% after LPPG (difference not significant, p = 0.088). The prealbumin level at 2 years and hemoglobin levels at 6 months, 1 year and 2 years were significantly well maintained after LPPG than after LDG. Prealbumin and hemoglobin levels at 2 years had almost returned to baseline levels in the LPPG group. The superiority of LPPG in the hemoglobin level was confirmed regardless of reconstruction methods after LDG.

CONCLUSIONS

For overweight/obese patients, LDG and LPPG resulted in similar degrees of postoperative weight loss, with patients achieving near-ideal body weight. The postoperative nutritional advantages of LPPG were confirmed. LPPG seemed to be better even for overweight/obese patients who meet indication criteria.

Management of Early Stage Gastric and Gastroesophageal Junction Malignancies

Esophageal and gastric carcinomas are prevalent malignancies worldwide. In contrast to the poor prognosis associated with advanced stages of disease, early stage disease has a favorable prognosis. Early stage gastric cancer (ESGC) is defined as cancer in which the depth of invasion is limited to the submucosal layer of the stomach on histologic examination, regardless of lymph node status. ESGC that meets standard or expanded criteria can be treated via endoscopic mucosal resection and endoscopic submucosal dissection. Similar indications for endoscopic interventions exist for gastroesophageal junction and esophageal malignancies."

Clinical outcomes of intraoperative manual dilatation of pylorus in pylorus-preserving gastrectomy: a retrospective analysis

BACKGROUND

Delayed gastric emptying is one of the most disturbing complications of pylorus-preserving gastrectomy (PPG) and it increases hospital stay. We investigated the clinical outcome of intraoperative manual dilatation of the pylorus as a preventive method of pyloric spasm after PPG.

MATERIALS AND METHODS

We reviewed gastric cancer patients who underwent PPG between January 2014 and December 2016 at Seoul National University Hospital by a single surgeon. During operation, manual dilatation (MD) was performed after laparoscopic dissection and gastric resection by mini-laparotomy. Pyloric stenosis was diagnosed by the finding of severe narrowing in pylorus on upper gastrointestinal series (UGIS), if patients suffered from postprandial abdominal fullness and discomfort. Patient's characteristics, surgical data and complication data were reviewed and compared between the groups (MD vs non-MD).

RESULTS

232 patients were included in this study. 93 patients underwent manual dilatation (40.1%). The overall complication rate was 12.9% in the MD group and 18.7% in the non-MD group (p = 0.242). Mean postoperative stay was 10.0 ± 5.8 in the MD group versus 10.9 ± 8.4 in the non-MD group (p = 0.304). Only one case suffered pylorus stenosis in the MD group (1.1%) but there were twelve cases seen in the non-MD group (8.6%), which reflects a significant difference (p = 0.019).

CONCLUSION

Simple intraoperative manual dilatation of pylorus may provide prevention from pyloric stenosis caused by pyloric spasms for patients who undergo PPG.

Correlation Between Bile Reflux Gastritis and Biliary Excreted Contrast Media in the Stomach

OBJECTIVE

This study aimed to evaluate the relationship between biliary excreted contrast media in the stomach and the presence of bile reflux gastritis.

METHODS

Consecutive 111 patients who underwent both gadoxetic acid-enhanced magnetic resonance cholangiography (gadoxetic MRC) and gastric endoscopy were included in this study. We performed a review of the gadoxetic-MRC image sets acquired 60 minutes after intravenous injection of contrast media and endoscopic images. We recorded amount of contrast media in the stomach. The sensitivity, specificity, and accuracy of duodenogastric bile reflux diagnosis were evaluated for the gadoxetic MRC. Statistical analysis was performed using the Fisher exact test and the linear-by-linear association test.

RESULTS

Among the 111 patients, 39 had 60-minute delayed images showing the presence of contrast media in the stomach. Of these 39 patients, 13 had bile reflux gastritis and 5 showed bile in the stomach without evidence of erythematous gastritis. Of the 72 patients who did not show contrast media in the stomach, none had bile reflux gastritis and 2 patients showed bile staining in the stomach without evidence of erythematous gastritis. Bile reflux gastritis was significantly more frequent in patients with contrast media in the stomach on gadoxetic MRC than in those without. Patients with high-grade extension of contrast media in the stomach had significantly frequent bile reflux gastritis than did those with low-grade extension.

CONCLUSION

Biliary excreted contrast media in the stomach on 60-minute delayed gadoxetic MRC has a correlation with the presence of bile reflux gastritis on endoscopic examination.

功能保留手术在早期胃癌治疗中的作用

随着人们健康意识的增加和胃镜等医疗诊断技术的不断进步, 早期胃癌的诊断率逐年上升. 早期胃癌的功能保留胃切除术是在根治原发病灶, 行标准淋巴结清扫前提下, 限制胃切除范围, 同时保留幽门及迷走神经功能, 以达到改善患者术后生活质量的目的, 其手术方式包括: 保留幽门的胃切除术, 近端胃切除术, 胃节段切除以及局部切除. 此外, 内镜下黏膜切除术和黏膜剥离也被认为属于功能保留胃切除术范畴. 对于大部分早期胃癌患者, 根治性手术具有良好的治疗效果, 其5年生存率在90%以上. 因此, 在达到手术根治目的的前提下, 保留部分胃的解剖和生理功能, 提高患者术后的生活质量, 对早期胃癌患者具有重要的意义.

Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features

This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.

Oncological outcomes of function-preserving gastrectomy for early gastric cancer: a multicenter propensity score matched cohort analysis comparing pylorus-preserving gastrectomy versus conventional distal gastrectomy

OBJECTIVE

This study aimed to clarify the oncological safety of pylorus-preserving gastrectomy (PPG) compared with conventional distal gastrectomy (DG).

METHODS

From three institutions specializing in cancer, the medical records for a cohort of 2898 consecutive patients who had undergone DG (n = 2208) or PPG (n = 690) for clinical stage I gastric cancer between January 2006 and December 2012 were analyzed. A propensity score for each patient was estimated on the basis of 38 preoperative clinical and tumor-related factors. After propensity score matching had been done, 1004 patients (502 DG patients, 502 PPG patients) were included in the analysis. The overall survival, relapse-free survival, and occurrence of secondary gastric cancer were then compared. The median observation period was 48.6 months (range 1-109.8 months).

RESULTS

The 5-year overall survival rate was 98.4 % for the PPG group and 96.6 % for the DG group (hazard ratio 0.48, 95 % confidence interval 0.21-1.09, P = 0.07). The 3-year relapse-free survival rate was 99.5 % for the PPG group and 98.0 % for the DG group (hazard ratio 0.39, 95 % confidence interval 0.12-1.33, P = 0.12). Postoperative secondary gastric cancer was encountered in eight patients (1.6 %) in the PPG group and four patients (0.8 %) in the DG group. No significant differences in either overall survival, relapse-free survival, or the occurrence of secondary gastric cancer were observed between the two groups.

CONCLUSIONS

Given the adequate estimation of the clinical tumor stage, the oncological safety of PPG for clinical T1N0 gastric cancer in the middle portion of the stomach was comparable to that of DG.

Lymphadenectomy along the infrapyloric artery may be dispensable when performing pylorus-preserving gastrectomy for early middle-third gastric cancer

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.

Excellent Long-Term Prognosis and Favorable Postoperative Nutritional Status After Laparoscopic Pylorus-Preserving Gastrectomy

BACKGROUND

Laparoscopic pylorus-preserving gastrectomy (LPPG) has been introduced as a minimally invasive function-preserving operation for early gastric cancer (GC). This study aimed to investigate the surgical and prognostic outcomes after LPPG at the authors' institution.

METHODS

This study analyzed 465 patients who underwent LPPG for cT1 N0 GC located in the middle part of the stomach between 2006 and 2012. Short- and long-term surgical outcomes including 5-year survival rates, postoperative nutritional data, and body weight change were retrospectively investigated.

RESULTS

Regarding short-term surgical results, 14 (3%) of the 465 patients had severe complications classified as Clavien-Dindo grade 3a or above, and no mortality occurred (no in-hospital deaths). The median follow-up period was 1829 days (range 226-3197 days), and the 5-year overall survival and relapse-free survival rates were respectively 98% (95% confidence interval [CI] 96.1-99.0%) and 98% (95% CI 96.1-99.0%). Only two cases of postoperative recurrence were confirmed, and their recurrence sites were not in the remnant stomach or regional lymph nodes. The postoperative nutritional status, in terms of serum total protein, albumin, and hemoglobin levels, was well maintained, and the mean relative body weight (postoperative/preoperative) was 93.24 ± 7.29% after LPPG.

CONCLUSIONS

For the first time, we have clarified the detailed long-term survival outcomes of LPPG for cT1 N0 GC. LPPG is an acceptable and favorable operative method for clinically diagnosed early-stage GC, in terms of long-term survival and postoperative nutrition.

Preserving infrapyloric vein reduces postoperative gastric stasis after laparoscopic pylorus-preserving gastrectomy

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.

Factors affecting the quality of life of patients after gastrectomy as assessed using the newly developed PGSAS-45 scale: A nationwide multi-institutional study

AIM

To identify certain clinical factors other than the type of gastrectomy which affect the postoperative quality of life (QOL) of patients after gastrectomy.

METHODS

The postgastrectomy syndrome assessment scale (PGSAS)-45 was designed to assess the severity of symptoms, the living status and the QOL of gastrectomized patients. It consists of 45 items, of which 22 are original items while 23 were retrieved from the SF-8 and Gastrointestinal Symptoms Rating Scale questionnaires with permission. A nationwide surveillance study to validate PGSAS was conducted and 2368 gastric cancer patients who underwent various types of gastrectomy at 52 medical institutions were enrolled. Of these, 1777 patients who underwent total gastrectomy (TG) reconstructed with Roux-Y (n = 393), distal gastrectomy (DG) reconstructed with Billroth-I (n = 909), or DG reconstructed with Roux-Y (n = 475) were evaluated in the current study. The influence of the type of gastrectomy and other clinical factors such as age, sex, duration after surgery, the symptom severity, the degree of weight loss, dietary intake, and the ability for working on the postoperative QOL (i.e., dissatisfaction for daily life subscale, physical component summary and mental component summary of the SF-8) were examined by multiple regression analysis (MRA). In addition, importance of various symptoms such as esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation and dumping on the postoperative living status and QOL were also appraised by MRA.

RESULTS

The postoperative QOL were significantly deteriorated in patients who underwent TG compared to those after DG. However, the extent of gastrectomy was not an influential factor on patients’ QOL when adjusted by the MRA. Among various clinical factors, the symptom severity, ability for working, and necessity for additional meals were the most influential factors to the postoperative QOL. As for the individual symptoms, meal-related distress, dumping, abdominal pain, and esophageal reflux significantly affected the postoperative QOL in that order, while the influence of indigestion, diarrhea and constipation was insignificant.

CONCLUSION

Several clinical factors such as the symptom severity (especially in meal-related distress and dumping), ability for working and necessity for additional meals were the main factors which affected the patients’ well-being after gastrectomy.

Pylorus-Preserving Gastrectomy for Gastric Cancer

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.

Ongoing surgical clinical trials on minimally invasive surgery for gastric cancer: Korea

Since Korean Laparoscopic Gastrointestinal Surgery Study (KLASS) group was activated in 2003, several randomized controlled trials (RCTs) have finished or are ongoing in Korea to evaluate oncologic safety and feasibility of minimally invasive surgery (MIS) for gastric cancer by KLASS group as well as other expert surgeons. MIS in gastric cancer is regarded as one of standard treatment modality for early gastric cancer (EGC) and the indication is going expansion with the accumulation of evidence. This review covers current status of ongoing clinical trials on MIS for gastric cancer in Korea.

Sentinel lymph node navigation surgery for gastric cancer: Does it really benefit the patient?

Sentinel lymph node (SLN) navigation surgery is accepted as a standard treatment procedure for malignant melanoma and breast cancer. However, the benefit of reduced lymphadenectomy based on SLN examination remains unclear in cases of gastric cancer. Here, we review previous studies to determine whether SLN navigation surgery is beneficial for gastric cancer patients. Recently, a large-scale prospective study from the Japanese Society of Sentinel Node Navigation Surgery reported that the endoscopic dual tracer method, using a dye and radioisotope for SLN biopsy, was safe and effective when applied to cases of superficial and relatively small gastric cancers. SLN mapping with SLN basin dissection was preferred for early gastric cancer since it is minimally invasive. However, previous studies reported that limited gastrectomy and lymphadenectomy may not improve the patient’s postoperative quality of life (QOL). As a result, the benefit of SLN navigation surgery for gastric cancer patients, in terms of their QOL, is limited. Thus, endoscopic and laparoscopic limited gastrectomy combined with SLN navigation surgery has the potential to become the standard minimally invasive surgery in early gastric cancer.

Assessment of postoperative quality of life following pylorus-preserving gastrectomy and Billroth-I distal gastrectomy in gastric cancer patients: results of the nationwide postgastrectomy syndrome assessment study

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is increasingly being used to treat early gastric cancer in the middle third of the stomach, with the hope of ameliorating postoperative dysfunction and improving quality of life (QOL). We evaluated symptoms of postgastrectomy syndrome (PGS) and QOL by means of a newly developed integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), and compared PPG with Billroth-I distal gastrectomy (DGBI).

METHODS

The PGSAS-45 consists of 45 items, including items from the SF-8 and GSRS instruments, as well as 22 newly selected items. It was designed to assess the severity of PGS and the living status and QOL of gastrectomized patients. The nationwide PGSAS surveillance study enrolled 2,368 gastric cancer patients who underwent various types of gastrectomy. In this study we analyzed 313 PPG patients and 909 DGBI patients.

RESULTS

Body weight loss was -6.9% in the PPG group and -7.9% in the DGBI group (P = 0.052). The PPG group scored better on the diarrhea subscale (PPG; 1.8 vs. DGBI; 2.1, P < 0.0001), dumping subscale (1.8 vs. 2.0, P = 0.003), and frequency of additional meals (1.8 vs. 1.9, P = 0.034). Multiple regression analysis revealed that age and the preservation of the celiac branch of the vagus nerve were independent factors predicting diarrhea and dumping.

CONCLUSIONS

It has been suggested that PPG is superior to DGBI for ameliorating PGS. Preservation of the celiac branch of the vagus nerve is recommended to reduce postoperative disorders regardless of the reconstruction method used.

Efficacy of Gastric Balloon Dilatation and/or Retrievable Stent Insertion for Pyloric Spasms after Pylorus-Preserving Gastrectomy: Retrospective Analysis

Purpose

We retrospectively investigated the feasibility and clinical efficacy of balloon dilatation and subsequent retrievable stent insertion, when necessitated, for pyloric spasms after pylorus-preserving gastrectomy (PPG).

Materials and Methods

Forty-five patients experiencing pyloric spasms after PPG underwent fluoroscopic balloon dilations to alleviate obstructive symptoms due to delayed gastric emptying. Patients showing poor response to balloon dilation underwent subsequent retrievable stent insertion. Safety of the procedures was analyzed, and subjective symptoms and objective signs of pyloric spasms were analyzed and compared before and after treatment.

Results

Thirty-three patients (73.3%, 33/45) showed good response to balloon dilatation requiring no further treatment (balloon group). Conversely, 12 patients (26.7%, 12/45) showed poor or no response after balloon dilation requiring subsequent stent insertion (stent group). Balloon dilations and/or stent insertions were safely performed in all patients except one patient who suffered a transmural tear after balloon dilatation. In both groups, mean subjective symptom score was significantly improved and mean pyloric canal-to-height of the adjacent vertebral body ratio was significantly increased after the procedures (P <.05).

Conclusion

Balloon dilation is a safe and effective treatment for patients with pyloric spasms after PPG. In patients refractory to balloon dilations, retrievable stent placement can be a safe alternative tool.

Clinical Outcome of Modified Laparoscopy-Assisted Proximal Gastrectomy Compared to Conventional Proximal Gastrectomy or Total Gastrectomy for Upper-Third Early Gastric Cancer with Special References to Postoperative Reflux Esophagitis

Purpose

This study evaluated the functional and oncological outcomes of proximal gastrectomy (PG) in comparison with total gastrectomy (TG) for upper-third early gastric cancer (EGC).

Materials and Methods

The medical records of upper-third EGC patients who had undergone PG (n=192) or TG (n=157) were reviewed. The PG group was further subdivided into patients who had undergone conventional open PG (cPG; n=157) or modified laparoscopy-assisted PG (mLAPG; n=35). Patients who had undergone mLAPG had a longer portion of their intra-abdominal esophagus preserved than patients who had undergone cPG. Surgical morbidity, recurrence, long-term nutritional status, and the incidence of reflux esophagitis were compared between the groups.

Results

The rate of postoperative complications was significantly lower for PG than TG (16.7% vs. 31.2%), but the five-year overall survival rate was comparable between the two groups (99.3% vs. 96.3%). Postoperative levels of hemoglobin and albumin were significantly higher for patients who had undergone PG. However, the incidence of reflux esophagitis was higher for PG than for TG (37.4% vs. 3.7%; P<0.001). mLAPG was related to a lower incidence of reflux esophagitis after PG (P<0.001).

Conclusions

Compared to TG, PG showed an advantage in terms of postoperative morbidity and nutrition, and there was a comparable prognosis between the two procedures. Preserving the intra-abdominal esophagus may lower the incidence of reflux esophagitis associated with PG.

Time trends of clinicopathologic features and surgical treatment for gastric cancer: Results from 2 high-volume institutions in southern China

BACKGROUND

The objective of this study was to evaluate the time-related trends of tumor characteristics and postoperative survival of patients with gastric cancer (GC) in 2 high-volume centers in high incidence areas of southern China.

METHODS

Based on the meticulously collected data from 5,327 patients with GC treated with operative intervention at Sun Yat-sen University Cancer Center and Fujian Medical University Union Hospital, we analyzed the differences in clinicopathologic features and postoperative survival over the following 4 consecutive periods: 1991-1995 (period 1), 1996-2000 (period 2), 2001-2005 (period 3), and 2006-2010 (period 4).

RESULTS

Tumor size decreased (P = .001), but the proportion of poorly differentiated tumors increased (P < .001) over the study periods. Early GC was diagnosed more often in later periods, gradually increasing from 7 to 15% (P < .001). A surprising improvement was observed in the mean number of retrieved lymph nodes, ranging from 10.36 to 26.22 (P < .001). The radical resection rate increased from 88 to 93%. The overall 5-year survival rate improved steadily over the 4 periods, from 39 to 53% (P < .001). Multivariate analysis revealed that age, tumor location, histologic type, tumor size, depth of invasion, lymphatic invasion, number of retrieved lymph nodes, radical resection, and time periods were independent prognostic factors.

CONCLUSION

The clinicopathologic features of tumors changed during the observation period in our region. The increasingly early detection of patients with GC and more standardized regimens for operative management, including routinely performed D2 lymphadenectomy, most likely resulted in the increase in overall survival.

A new stage of sentinel node navigation surgery in early gastric cancer

Sentinel node (SN) navigation surgery is expected to realize organ- and function-preserving surgery with SN mapping, and has been applied in operations for breast cancer and melanoma. But there has been no definite evidence for the SN concept in gastric cancer. A prospective multicenter trial to confirm the SN concept for gastric cancer conducted by the Japan Society of Sentinel Node Navigation Surgery reported that the SN detection rate, sensitivity of positive SNs, and accuracy of nodal status are 97.5% (387/397), 93% (53/57), and 99% (383/387), respectively. A detailed analysis of the trial suggested that strictly the "lymphatic basin concept" rather than the "SN concept" was confirmed in early gastric cancer. The Japan Society of Sentinel Node Navigation Surgery started a new trial of function-preserving gastrectomy with lymphatic basin dissection (LBD) for early gastric cancer without metastasis in SNs on the basis of this promising outcome of the trial. It is supposed that LBD guarantees curability in SN navigation surgery for early gastric cancer. Full-thickness resection or endoscopic submucosal dissection in combination with laparoscopic LBD will soon be a new treatment option for early gastric cancer.

Factors that minimize postgastrectomy symptoms following pylorus-preserving gastrectomy: assessment using a newly developed scale (PGSAS-45)

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is sometimes performed as a function-preserving surgery for the treatment of early gastric cancer. The aim of this study was to use an integrated assessment scale for postgastrectomy syndrome to determine the appropriate indicators and optimal methods for PPG.

METHODS

The Postgastrectomy Syndrome Assessment Study (PGSAS) is a multicenter survey based on an integrated questionnaire (PGSAS-45) consisting of 45 items. Questionnaire responses were retrieved from a total of 2,520 patients, each of whom had undergone one of six different types of gastrectomy procedures; 313 responses from patients who had received PPG were analyzed here.

RESULTS

The size of the proximal gastric remnant (less than one-quarter, about one-third, or more than one-half of the original size) significantly influenced the change in body weight, the scores for dissatisfaction at the meal, and dissatisfaction for daily life subscale (P = 0.030, P = 0.005, P = 0.034, respectively). The nausea score in patients who underwent hand-sewn anastomosis was significantly lower than in those who underwent anastomosis with a linear stapler (P = 0.006). The scores for diarrhea subscale, increased passage of stools, and sense of foods sticking differed significantly depending on the length of the preserved pyloric cuff (P = 0.047, P = 0.021, P = 0.046, respectively).

CONCLUSIONS

The results suggest that preservation of a sufficient proximal gastric remnant is recommended when utilizing PPG as function-preserving surgery.

Current status of function-preserving surgery for gastric cancer

Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer (GC) at an early stage. Due to the low incidence of lymph node metastasis and favorable prognosis in early GC, function-preserving surgery which improves postoperative quality of life may be possible. Pylorus-preserving gastrectomy (PPG) is one such function-preserving procedure, which is expected to offer advantages with regards to dumping syndrome, bile reflux gastritis, and the frequency of flatus, although PPG may induce delayed gastric emptying. Proximal gastrectomy (PG) is another function-preserving procedure, which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach, although the incidence of heartburn or gastric fullness associated with this procedure is high. However, these disadvantages may be overcome by the reconstruction method used. The other important problem after PG is remnant GC, which was reported to occur in approximately 5% of patients. Therefore, the reconstruction technique used with PG should facilitate postoperative endoscopic examinations for early detection and treatment of remnant gastric carcinoma. Oncologic safety seems to be assured in both procedures, if the preoperative diagnosis is accurate. Patient selection should be carefully considered. Although many retrospective studies have demonstrated the utility of function-preserving surgery, no consensus on whether to adopt function-preserving surgery as the standard of care has been reached. Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.

How much progress has been made in minimally invasive surgery for gastric cancer in Korea?: a viewpoint from Korean prospective clinical trials

Gastric cancer is the most common cancer in Korea. Because the incidence of gastric cancer is still high even with early detection and because of developments in surgical instruments and technological advances, minimally invasive surgery has rapidly become an accepted treatment for gastric cancer in Korea. Many Korean gastric surgeons have contributed to the rapid adaptation of minimally invasive surgery for gastric cancer: not only the Korean Laparoscopic Gastrointestinal Surgery Study (KLASS) group, but also other expert surgeons after the 2000s. Thanks to their vigorous efforts involving active learning, education, workshops, academic communications, and international communications with active laparoscopic gastric surgeons in Korea, numerous results and well-designed large-scale clinical studies have been published or are actively ongoing, thus increasing its wide acceptance as an option for gastric cancer. Now, Korea has become one of the leading countries using minimally invasive surgery for the treatment of gastric cancer. This review article will summarize the current status and issues, as well as the clinical trials that have finished or are ongoing, regarding minimally invasive surgery for gastric cancer in Korea.

Comparison of Surgical Outcomes of Robot-Assisted and Laparoscopy-Assisted Pylorus-Preserving Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

BACKGROUND

The three-dimensional view and articulating devices in robot system might have a benefit performing the delicate procedure of pylorus-preserving gastrectomy. This study was conducted to evaluate the feasibility and safety of robot-assisted pylorus-preserving gastrectomy (RAPPG) and to compare the perioperative outcomes and oncologic safety between RAPPG and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) for middle-third early gastric cancer.

METHODS

Between June 2008 and December 2013, we retrospectively collected data of 68 patients with RAPPG and propensity score matched 68 patients with LAPPG for the treatment of early gastric cancer at Seoul National University Hospital. The covariates for propensity score matching were: age, sex, American Society of Anesthesiologists score, body mass index, and operators. Clinicopathologic characteristics and surgical outcomes were compared between the two groups.

RESULTS

All RAPPG cases were performed successfully without open or laparoscopic conversion. Patient demographics and perioperative outcomes did not differ between the two groups except in operation time (258.3 vs. 193.9 min; P < 0.001). There was no significant difference in complication rates between the two groups (19.1 vs. 22.1 %; P = 0.671). The mean number of examined lymph nodes (33.4 vs. 36.5; P = 0.153), and the mean number of lymph nodes at each station was not different between the two groups.

CONCLUSIONS

RAPPG can be a safe treatment option for middle-third early gastric cancer in terms of surgical complications and oncologic outcomes. However, RAPPG has no benefit over LAPPG in this study.

Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer

BACKGROUND

Pylorus-preserving gastrectomy (PPG) has been performed to reduce postprandial symptoms for some early gastric cancer (EGC) cases. The aim of this study was to evaluate the possible advantages after PPG for middle-third EGC in comparison with distal gastrectomy.

MATERIALS AND METHODS

We searched Medline, Embase, and Science Citation Index Expanded for relevant studies. Statistical analyses were conducted to calculate the summary weighted mean differences (WMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) using random-effects models.

RESULTS

We identified 15 nonrandomized controlled trials (16 studies) with 1774 patients, which consisted of 11 studies for conventional PPG (CPPG) versus conventional distal gastrectomy (CDG) and 5 studies for laparoscopy-assisted PPG (LAPPG) versus laparoscopy-assisted distal gastrectomy (LADG). Meta-analysis of CPPG versus CDG revealed that CPPG had the advantage of prevention of early dumping syndrome (OR=0.18; 95% CI 0.12, 0.27), gastritis (OR=0.19; 95% CI 0.07, 0.53), duodenal juice reflux (OR=0.20; 95% CI 0.06, 0.66), and regaining of weight (WMD=3.53; 95% CI 2.34, 4.72). However, the incidence of gastric stasis was higher in the CPPG group than in the CDG group (OR=1.70; 95% CI 1.13, 2.57). Meta-analysis of LAPPG versus LADG revealed that LAPPG shortened the operation time (WMD=-21.12; 95% CI -31.33, -10.90) and did not increase the occurrence of postoperative complication (OR=0.72; 95% CI 0.41, 1.27).

CONCLUSIONS

With the benefits of prevention of early dumping syndrome, duodenal juice reflux, gastritis, and regaining of weight, PPG can be an excellent option for middle-third EGC.

Length of negative resection margin does not affect local recurrence and survival in the patients with gastric cancer

AIM: To investigate the influence of the resection margin on local recurrence and survival in gastric cancer patients.

METHODS: We reviewed the medical records of 1788 patients who had undergone gastrectomy for gastric cancer at the Seoul National University Bundang Hospital, South Korea, between May 2003 and July 2009. The patients were divided into early and advanced gastric cancer groups. In each group, we analyzed the relationship between clinicopathologic factors and survival outcomes, and compared the hazard rates of event occurrence between patients with resection margins above and below the cut-off value, using a Cox proportional hazard model.

RESULTS: The early and advanced gastric cancer groups included 1001 and 787 patients, respectively. The hazard rates of event occurrence did not significantly differ between the patients with resection margins above the cut-off value and those with resection margins below the cut-off value (P > 0.05, in all comparisons). Based on the multivariable analyses, the proximal and distal resection margins were not significantly associated with survival outcomes and local recurrence (P > 0.05, in all analyses).

CONCLUSION: The proximal or distal resection margins did not affect the prognosis of patients with gastric cancer if the margins were pathologically negative.

Current role of minimally invasive approaches in the treatment of early gastric cancer

Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.

Laparoscopy-assisted pylorus-preserving gastrectomy is better than laparoscopy-assisted distal gastrectomy for middle-third early gastric cancer

OBJECTIVE

The purpose of this study is to compare the surgical, oncologic safety and the nutritional, functional benefit of laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy (LADG) for middle-third early gastric cancers (EGC).

BACKGROUND

Of those patients with middle-third EGC, it is still difficult to determine which procedure is better between LADG and LAPPG despite alleged advantages of LAPPG.

METHODS

For middle-third EGC, a retrospective analysis was performed comparing those who underwent LADG and those who underwent LAPPG. To evaluate surgical and oncologic safety, clinicopathologic differences including the postoperative morbidity, the pattern of lymph node metastasis and recurrence were analyzed. Postoperative protein, albumin, quantification of abdominal fat area using abdomen computed tomography, and the incidence of postoperative gallstone were compared for the evaluation of functional advantages.

RESULTS

The overall postoperative morbidity rate was similar between LADG (n = 176) and LAPPG (n = 116). Delayed gastric emptying was less frequent in LADG than in LAPPG (1.7% vs 7.8%); however, the rates of all the other complications were significantly higher in LADG than in LAPPG (17.0% vs 7.8%). The number of examined lymph nodes and metastatic lymph nodes at each lymph node station was not significantly different and 3-year recurrence-free survival rates were also similar between LADG and LAPPG (98.8% vs 98.2%). Decreases in serum protein and albumin in postoperative 1 to 6 months and abdominal fat area in postoperative 1 year were significantly greater in LADG than in LAPPG. The 3-year cumulative incidence of gallstone was significantly higher in LADG than in LAPPG (6.5% vs 0.0%).

CONCLUSIONS

For middle-third EGC, LAPPG can be considered as a better treatment option than LADG in terms of nutritional advantage and lower incidence of gallstone.

Prospective randomized clinical trial of a change in gastric emptying and nutritional status after a pylorus-preserving pancreaticoduodenectomy: comparison between an antecolic and a vertical retrocolic duodenojejunostomy

BACKGROUND

Although an antecolic duodenojejunostomy was reported to reduce post-operative delayed gastric emptying (DGE) compared with a retrocolic duodenojejunostomy after a pylorus-preserving pancreaticoduodenectomy (PPPD), the long-term effects of these procedures have rarely been studied. The aim of this prospective, randomized, clinical trial was to investigate the influence of the reconstruction route on post-operative gastric emptying and nutrition.

METHODS

Reconstruction was performed in 116 patients with an antecolic duodenojejunostomy (A group, n = 58) or a vertical retrocolic duodenojejunostomy (VR group, n = 58). Post-operative complications, including DGE, gastric emptying variables assessed by (13) C-acetate breath test and nutrition, were compared between the two groups for 1 year post-operatively.

RESULTS

The incidence of DGE was not significantly different between the procedures (A group: 12.1%; VR group: 20.7%, P = 0.316). At post-operative month 1, gastric emptying was prolonged in the VR versus the A group but not significantly so. At post-operative month 6, gastric emptying was accelerated significantly in the A versus the VR group. Post-operative weight recovery was significantly better in the VR versus the A group at post-operative month 12 (percentage of pre-operative weight, A group: 93.8 ± 1.2%; VR group: 98.5 ± 1.3%, P = 0.015).

CONCLUSIONS

A vertical retrocolic duodenojejunostomy was an acceptable procedure for the lower incidence of DGE and may contribute to better weight gain affected by moderate gastric emptying.

Oncologic safety of pylorus-preserving gastrectomy in the aspect of micrometastasis in lymph nodes at stations 5 and 6

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is a function-preserving gastrectomy for early gastric cancers (EGCs) that are preoperatively assessed as pN0 tumors and located in the middle portion of the stomach. In PPG, dissection of the lymph nodes at stations 5 and 6 is frequently incomplete, and this may be worrisome in terms of oncologic safety.

METHODS

We examined lymph nodes collected from stations 5 and 6 from 196 patients who had undergone conventional distal gastrectomy (CDG) for EGC located in the middle portion of the stomach and from 24 patients who had undergone PPG.

RESULTS

The average number of lymph nodes collected at station 5 was significantly lower with PPG than with CDG (0.08 vs. 1.32, respectively; P = 0.008). However, such a difference was not noted for station 6 nodes. The rate of macrometastasis was very low in all station 5 nodes (1 of 220, 0.45%) and station 6 nodes (1 of 220, 0.45%). Immunohistochemical analysis of cytokeratin in 109 cases of the CDG group and 21 cases of the PPG group showed that micrometastasis of single isolated tumor cell type was observed in only one station 6 lymph node of a patient who was initially diagnosed with pN0 EGC. There were no cases of micrometastasis in station 5 nodes.

CONCLUSIONS

The possibility of micrometastasis to station 5 and/or 6 lymph nodes may be negligible for EGC located in the middle portion of the stomach, and PPG thus might be the oncologically safe procedure when considering micrometastasis in remaining nodes in vivo at stations 5 and 6.

Laparoscopic gastrectomy for gastric cancer

Laparoscopic gastrectomy for gastric cancer is rapidly becoming popular because of the technical developments and the accumulated data of laparoscopic surgery in gastric cancer patients. The aim of this review is to present the current body of evidence and to highlight controversial issues of laparoscopic gastrectomy for gastric cancer. Laparoscopic distal gastrectomy (LDG) provides better or comparable outcomes compared to conventional open distal gastrectomy (ODG) in terms of short-term results. The long-term survival of LDG is expected to be comparable to that of ODG in early-stage gastric cancer, and an ongoing Korean multicenter randomized controlled trial (KLASS-01) will provide more clear evidence. Laparoscopic total gastrectomy is still selectively performed compared to LDG, and there is still debate on the safety of the laparoscopic esophagojejunostomy technique. Laparoscopic pylorus-preserving gastrectomy seems to be preferred for early gastric cancer in the middle third of the stomach in terms of functional advantages and comparable oncologic outcome. Evidence for LDG for advanced gastric cancer is still insufficient and the issue of lack of generalization still remains, even after ongoing multicenter randomized controlled trials have revealed clinical evidence. Laparoscopic sentinel node navigation surgery is still experimental and the surgical procedure has yet to be standardized. Robotic gastrectomy is feasible for early gastric cancer in terms of similar outcome, but is much more expensive in comparison to laparoscopic surgery. Its benefit over the conventional laparoscopic gastrectomy has not yet been proven.