Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer. Ann Surg. 2011;253:928-933. [PMID: 21358534 DOI: 10.1097/sla.0b013e3182117b24]

Laparoscopic Pylorus-preserving Gastrectomy Versus Distal Gastrectomy for Early Gastric Cancer: A Multicenter Randomized Controlled Trial (KLASS-04)

OBJECTIVE

To evaluate the long-term outcomes of laparoscopic pylorus-preserving gastrectomy (LPPG) with laparoscopic distal gastrectomy (LDG) for early gastric cancer.

BACKGROUND

Pylorus-preserving gastrectomy is considered a function-preserving surgery for early gastric cancer. However, there has been no multicenter randomized controlled trial comparing pylorus-preserving gastrectomy with distal gastrectomy until now.

METHODS

A multicenter randomized controlled trial (KLASS-04) with 256 patients with cT1N0M0 gastric cancer located in the mid portion of the stomach was conducted. The primary endpoint was the incidence of dumping syndrome at postoperative 1 year. Secondary endpoints included survival and recurrence, gallstone formation, nutritional parameters, gastroscopic findings, and quality of life for 3 years.

RESULTS

In the intention-to-treat analyses, there was no difference in the incidence of dumping syndrome at 1 year postoperatively (13.2% in LPPG vs 15.8% in LDG, P = 0.622). Gallstone formation after surgery was significantly lower in LPPG than in LDG (2.33% vs 8.66%, P = 0.026). Hemoglobin (+0.01 vs -0.76 gm/dL, P < 0.001) and serum protein (-0.15 vs -0.35 gm/dL, P = 0.002) were significantly preserved after LPPG. However, reflux esophagitis (17.8% vs 6.3%, P = 0.005) and grade IV delayed gastric emptying (16.3% vs 3.9%, P = 0.001) were more common in LPPG. Changes in body weight and postoperative quality of life were not significantly different between groups. Three-year overall survival and disease-free survival were not different (1 case of recurrence in each group, P = 0.98).

CONCLUSIONS

LPPG can be used as an alternative surgical option for cT1N0M0 gastric cancer in the mid portion of the stomach.

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.

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.

Novel Clean End-to-End Anastomosis Method, Without Opening the Stomach Lumen, in Totally Laparoscopic or Robotic Pylorus-Preserving Gastrectomy

PURPOSE

Intra-abdominal infection is a common postoperative complication of laparoscopic pylorus-preserving gastrectomies (PPGs). Many studies have reported that intra-abdominal infectious complications after gastrectomy adversely affect patient survival outcomes. To prevent gastric fluid leakage into the abdominal cavity, we developed a novel anastomosis method in which the stomach lumen is not opened (termed the non-opened clean end-to-end anastomosis method [NoCEAM]) and evaluated its feasibility.

MATERIALS AND METHODS

Subsequent to lymphadenectomy, the oral and anal resection lines were sutured using an intraoperative endoscope. After closing the stomach circumferentially with clips, the specimen was rolled outward like a "donut." We resected the specimen circumferentially using a linear stapler, and anastomosis was completed simultaneously. We examined the feasibility of this procedure ex vivo, using three porcine stomachs, and in vivo, using one pig. Subsequently, we applied the procedure to 13 consecutive patients with middle-third early gastric cancer utilizing laparotomic, laparoscopic, and robotic PPG.

RESULTS

NoCEAM was completed in all porcine models and human cases. In the human cases, the mean operation time (±standard deviation) was 279±51 minutes, and mean blood loss volume was 22±45 mL. The mean number of linear staples used was 5.06±0.76. None of the patients had complications, and all were discharged on the eighth postoperative. The serum total protein, serum albumin, and hemoglobin levels did not change significantly after surgery.

CONCLUSIONS

NoCEAM is feasible and safe for performing totally laparoscopic or robotic PPG. It may reduce postoperative complications, such as intra-abdominal infections.

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.

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.

Intracorporeal hand-sewn anastomosis following pylorus-preserving gastrectomy: surgical technique and short-term surgical outcome

BACKGROUND

Although several procedures for mechanical anastomosis have recently been reported, intracorporeal manually hand-sewn anastomosis for totally laparoscopic pylorus-preserving gastrectomy (TLPPG) is considered technically difficult. Here, we report a new technique for laparoscopic reconstruction using hand-sewn sutures.

METHODS

Together with a proper lymphadenectomy, the stomach was detached and resected using separate two-layer incisions, similar to the original laparotomy method. An approximately 5-cm antral cuff was left in place. The essential concept of this new method was to align the anastomotic site by rotating each clamped gastric stump. This allowed us to perform a secure, hand-sewn, two-layer anastomosis successfully. The short-term surgical outcome after TLPPG was retrospectively compared with that for patients who underwent a conventional laparoscopy-assisted procedure (LAPPG).

RESULTS

Of the 20 consecutive patients who underwent pylorus-preserving gastrectomy in our department between 2014 and 2021, the first 8 patients and the subsequent 12 patients underwent LAPPG and TLPPG, respectively. The operation time was significantly longer in the TLPPG group (median, 302 vs. 269 min). The morbidity was comparable (8.3% in TLPPG vs. 12.5% in LAPPG). Postoperative delayed gastric emptying was only observed in one patient in the LAPPG group. TLPPG reduced the cost of the operation by reducing the number of linear stapler cartridges required.

CONCLUSION

A purely hand-sewn gastrogastrostomy is safe, feasible, and cost-effective, and it omits the need for a mini-laparotomy in the upper abdomen.

Extensive Dissection at No. 12 Station During D2 Lymphadenectomy Improves Survival for Advanced Lower-Third Gastric Cancer: A Retrospective Study From a Single Center in Southern China

BACKGROUND

D2 lymphadenectomy including No. 12a dissection has been accepted as a standard surgical management of advanced lower-third gastric cancer (GC). The necessity of extensive No. 12 nodes (No. 12a, 12b, and 12p) dissection remains controversial. This study aims to explore its impact on long-term survival for resectable GC.

METHODS

From 2009 to 2016, 353 advanced lower-third GC patients undergoing at least D2 lymphadenectomy during a radical surgery were included, with 179 patients receiving No. 12a, 12b, and 12p dissection as study group. A total of 174 patients with No. 12a dissection were employed as control group. Surgical and long-term outcomes including 90-day complications incidence, therapeutic value index (TVI), 3-year progression-free survival (PFS), and 5-year overall survival (OS) were compared between both groups.

RESULTS

No. 12 lymph node metastasis was observed in 20 (5.7%) patients, with 10 cases in each group (5.6% vs. 5.7%, p = 0.948). The metastatic rates at No. 12a, 12b, and 12p were 5.7%, 2.2%, and 1.7%, respectively. The incidence of 90-day complications was identical between both groups. Extensive No. 12 dissection was associated with increased TVI at No. 12 station (3.9 vs. 0.6), prolonged 3-year PFS rate (67.0% vs. 55.9%, p = 0.045) and 5-year OS rate (66.2% vs. 54.0%, p = 0.027). The further Cox-regression analysis showed that the 12abp dissection was an independent prognostic factor of improved survival (p = 0.026).

CONCLUSION

Adding No. 12b and 12p lymph nodes to D2 lymphadenectomy might be effective in surgical treatment of advanced lower-third GC and improve oncological outcomes compared with No. 12a-based D2 lymphadenectomy.

Function-Preserving Gastrectomy for Early Gastric Cancer

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.

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).

Current status of function-preserving gastrectomy for gastric cancer

Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.

Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy

BACKGROUND

Injury to the vagus nerve has been proposed to be associated with occurrence of gallstones after gastrectomy. We investigated the effect of preservation of hepatic branch of the vagus nerve on prevention of gallstones during laparoscopic distal (LDG) and pylorus-preserving gastrectomy (LPPG).

METHODS

Preservation of the vagus nerve was reviewed of cT1N0M0 gastric cancer patients underwent LDG (n = 323) and LPPG (n = 144) during 2016-2017. Presence of gallstones was evaluated by ultrasonography (US) and computed tomography (CT). Incidences of gallstones were compared between the nerve preserved (h-DG, h-PPG) group and sacrificed (s-DG, s-PPG) group. Clinicopathological features were also compared.

RESULTS

The 3-year cumulative incidence of gallstones was lower in the h-DG (2.7%, n = 85) than the s-DG (14.6%, n = 238) (p = 0.017) and lower in the h-PPG (1.6%, n = 123) than the s-PPG (12.9%, n = 21) (p = 0.004). Overall postoperative complication rate was similar between the h-DG and s-DG (p = 0.861) as well as between the h-PPG and s-PPG (p = 0.768). The number of retrieved lymph nodes station #1 and 3-year recurrence-free survival were not significantly different between the preserved group and sacrificed group. Injury to the vagus nerve (p = 0.001) and high body mass index (BMI) (≥ 27.5 kg/m²) (p = 0.040) were found to be independent risk factors of gallstone formation in multivariate analysis.

CONCLUSIONS

Preservation of hepatic branch of the vagus nerve can be recommended for LDG as well as LPPG of early gastric cancer patients to reduce postoperative gallstone formation.

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.

Examination of Prognostic Factors Affecting Long-Term Survival of Patients with Stage 3/4 Gallbladder Cancer without Distant Metastasis

In advanced gallbladder cancer (GBC) radical resection, if multiple prognostic factors are present, the outcome may be poor; however, the details remain unclear. To investigate the poor prognostic factors affecting long-term surgical outcome, we examined 157 cases of resected stage 3/4 GBC without distant metastasis between 1985 and 2017. Poor prognostic factors for overall survival and treatment outcomes of a number of predictable preoperative poor prognostic factors were evaluated. The surgical mortality was 4.5%. In multivariate analysis, blood loss, poor histology, liver invasion, and ≥4 regional lymph node metastases (LNMs) were independent prognostic factors for poor surgical outcomes; invasion of the left margin or the entire area of the hepatoduodenal ligament and a Clavien–Dindo classification ≥3 were marginal factors. The analysis identified outcomes of patients with factors that could be predicted preoperatively, such as liver invasion ≥5 mm, invasion of the left margin or the entire area of the hepatoduodenal ligament, and ≥4 regional LNMs. Thus, the five-year overall survival was 54% for zero factors, 34% for one factor, and 4% for two factors (p < 0.05). A poor surgical outcome was likely when two or more factors were predicted preoperatively; therefore, new treatment strategies are required for such patients.

Feasibility of totally laparoscopic pylorus-preserving gastrectomy with intracorporeal gastro-gastrostomy for early gastric cancer: a retrospective cohort study

Background

Pylorus-preserving gastrectomy (PPG) has been accepted as a function-preserving surgery for the treatment of early gastric cancer in East Asian countries. Therefore, this study aimed to evaluate the feasibility and safety of totally laparoscopic PPG (TLPPG) with intracorporeal anastomosis.

Methods

A total of 43 patients with early gastric cancer underwent laparoscopy-assisted PPG (LAPPG) with extracorporeal anastomosis between May 2006 and November 2012. The operative outcomes of 22 patients who underwent TLPPG between November 2012 and February 2019 were evaluated, and data were compared with that of the LAPPG group.

Results

No significant difference in the operative time was observed between the two groups. Blood loss was lower in the TLPPG group (18.5 mL) than in the LAPPG group (30.7 mL, p = 0.008), and the length of abdominal incision was shorter in the TLPPG group (3.8 cm) than in the LAPPG group (4.7 cm, p < 0.001). No significant difference in the complication rate was observed between the two groups (13.6% in the TLPPG vs. 9.3% in the LAPPG group, p = 0.594). No anastomosis-related complications occurred in either group. No significant between-group difference was observed in the delayed gastric emptying (TLPPG, 9.1 vs. LAPPG, 7%, p = 0.762). The initiation of postoperative fluid (TLPPG, 1.0 day vs. LAPPG, 3.0 days, p < 0.001) and meal (TLPPG, 3.0 days vs. LAPPG, 4.0 days, p < 0.001) intake was earlier in the TLPPG group than in the LAPPG group. No significant between-group difference was observed in the postoperative hospital stay.

Conclusions

The findings of this study suggest that TLPPG with intracorporeal reconstruction not only is as feasible and safe as LAPPG for the treatment of patients with early gastric cancer but also provides certain advantages such as reduced blood loss and wound size.

Risk factors and prognosis of gastric stasis, a crucial problem after laparoscopic pylorus-preserving gastrectomy for early middle-third gastric cancer

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is a function-preserving procedure for cT1N0 gastric cancer located in the middle-third of stomach, which is currently performed through a laparoscopic approach (LPPG). PPG is sometimes associated with a crucial problem during the early postoperative course, designated gastric stasis. However, information regarding gastric stasis remains to be fully elucidated.

METHODS

The study included 897 patients who underwent LPPG between 2005 and 2017. Early postoperative gastric stasis (E-stasis) was defined when the following conditions were fulfilled: upper abdominal distension, remnant stomach fullness on radiography image, and period of starvation exceeding 72 h within 1 month postoperatively. To evaluate long-term outcomes of E-stasis, late postoperative food residue (L-residue) was defined as grade 2 or higher food residue endoscopically according to the RGB (residue, gastritis, bile) classification at 1 year postoperatively. Risk factors and long-term outcomes of E-stasis were retrospectively analyzed.

RESULTS

E-stasis was the most common complication during the early postoperative course. E-stasis occurred in 68 (7.6%) patients. Multivariate analysis identified age (≥ 61 years), DM, and postoperative intraabdominal infection as risk factors. At 1 year postoperatively, relative body weight ratio and postoperative serum albumin in the patients who experienced E-stasis was significantly lower than those in the other patients (P = 0.042 and 0.011, respectively). Of the patients who suffered from E-stasis, 42.5% experienced L-residue.

CONCLUSIONS

E-stasis after LPPG occurs in 7.6% of patients. Age, DM, and intraabdominal infection are significantly related to E-stasis. E-stasis is associated with poorer nutritional and functional outcomes even at 1 year postoperatively.

Eroded adjustable gastric band migration causing gastric obstruction and perforation in a pregnant lady

•

Laparoscopic adjustable gastric banding (LAGB) was considered as one of the most effective management for morbid obesity, with outstanding long-term results on weight loss, comorbidities, and quality of life.

•

Reported complications of LAGB include erosion, infection, migration, obstruction, and rarely ischemia.

•

We report a case of pregnant woman who underwent LAGB 12 years ago diagnosed as gastric obstruction and perforation that was managed by central gastrectomy with gastro-gastrostomy.

•

We encourage the bariatric surgeons to be attentive LAGB complications among women planning for pregnancy.

Background

The laparoscopic adjustable gastric band is the least invasive bariatric surgery, which has the advantage of preserving the anatomy of the gastrointestinal tract. In the last two decades, the laparoscopic adjustable gastric band (LAGB) has largely been replaced by other surgical techniques for weight loss because of its high inseparable complications. Although a popular surgical technique at the time of its introduction in 1993, LAGB nowadays reports for not more than 5.5% of all bariatric procedures. The estimated overall long term complication rates of LAGB are ranging from 0.1% to 28%.

Objective

In this report, we review one of the cases that are considered as an anecdotic event that might follow one of the bariatric procedures.

Methods

We reported a pregnant lady who undergoes gastric banding 12 years ago. presented with progressively increasing colicky epigastric pain, nausea, and vomiting. The investigations show gastric obstruction and perforation secondary to eroded gastric band and migration.

Results

The management was completed by the elimination of the gastric band proceed with central gastrectomy plus gastro-gastrostomy with an excellent outcome for the patient and her baby.

Conclusion

This case highlights an absolutely rare serial complication, that may happen even when the patient presents with a vague complaint. Intraoperative findings can determine the way of management to achieve suitable results. Lastly; we encourage the young Women who underwent or planning for bariatric surgery to do a careful follow-up.

Effect of Standardizing the Incision Line on Delayed Gastric Emptying After Laparoscopic Gastrectomy: A Retrospective Preliminary Analysis

Background

The use of totally laparoscopic surgery with Billroth-I reconstruction (delta-shaped anastomosis) has rapidly become widespread in recent years. However, we experienced delayed gastric emptying (DGE) in the early period after introduction of this technique. To the best of our knowledge, there are no reports that mention the incision line when discussion prevention of DGE in distal gastrectomy. In the present study, we standardized the surgical techniques, including the gastric incision line, and compared the short-term results before and after standardization.

Methods

A total of 86 patients were enrolled in this study. Twenty-eight procedures were performed in the early period, 58 procedures were performed in the late period, and the 2 groups were compared retrospectively.

Results

The operation time decreased significantly after standardization from 288 to 224 minutes (P &lt; 0.001). The median value of perioperative bleeding volume decreased from 22.5 to 12.5 mL (P = 0.060). There were no postoperative complications related to the site of anastomosis in either group. Five cases of DGE (17.8%) were noted in the early period, but only 2 cases (3.4%) were noted in the late period (P = 0.022).

Conclusions

Standardization of the incision line after laparoscopic gastrectomy resulted in a decrease in the incidence of DGE.

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.

Size-dependent differences in the proximal remnant stomach: how much does a small remnant stomach after subtotal gastrectomy work?

BACKGROUND

The application of laparoscopic subtotal gastrectomy (LsTG) in the management of early gastric cancer located in the upper third of the stomach creates an extremely small remnant stomach (SRS). However, it is unclear whether retaining such an SRS improves patients' postoperative outcomes in a similar manner to a conventional remnant stomach (CRS).

METHODS

Four hundred and nine of 878 patients undergoing laparoscopic distal gastrectomy (LDG) between 2006 and 2012 underwent Roux-en-Y reconstruction. Among them, we selected 73 patients who underwent LsTG with an SRS (SRS group), and 83 patients with the tumor in the lower third of the stomach who underwent LDG with a CRS (CRS group). The surgical outcomes at 1 and 6 months, 1, 2, and 3 years after gastrectomy were retrospectively analyzed and compared between the two groups.

RESULTS

One year after gastrectomy, the postoperative:preoperative bodyweight ratio of the SRS group was 2% lower than that of the CRS group. Both groups had comparable total protein and albumin levels, and incidence of reflux esophagitis; however, hemoglobin was lower in the SRS group. This difference in hemoglobin level between the SRS and CRS groups became larger over time, although the total protein and albumin levels of the two groups remained similar.

CONCLUSION

An SRS slightly decreases bodyweight and hemoglobin level compared with a CRS. Several objective outcomes of the SRS group are almost equal to those of the CRS group, which suggests LsTG is worth performing even though its remnant stomach is very small.

Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: A retrospective study of long-term functional outcomes and quality of life

BACKGROUND

Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was known to have benefits of function-preserving surgery compared to laparoscopy-assisted distal gastrectomy (LADG). However, in clinical settings, delayed gastric emptying and esophageal reflux following LAPPG can be serious issues, making surgeons reluctant to perform LAPPG. It is unclear that LAPPG had better long-term functional outcomes and quality of life compared to LADG.

AIM

To evaluate the long-term functional outcomes and patient-reported quality of life of LAPPG compared to those of LADG.

METHODS

We reviewed the clinicopathological data of 195 patients who underwent LADG with Billroth II anastomosis and 101 patients who underwent LAPPG for cT1N0 gastric cancer in the middle third of the stomach between 2012 and 2015. Postoperative complications, nutritional parameters, and survey results of the European Organization for Research and Treatment of Cancer Questionnaire C30 and STO22 questionnaire were compared between the two groups.

RESULTS

The serum hemoglobin level was significantly higher in the LAPPG group than in the LADG group (P < 0.001). In the endoscopic findings, incidence of bile reflux was lower (P < 0.001); however, the incidence of residual food was higher in the LAPPG group than in the LADG group (P < 0.001). Regarding the quality of life score, the LAPPG group had a better physical functioning score (86.7 vs 90.0, P = 0.032) but also greater pain and reflux when compared to the LADG group [8.3 vs 16.7 in pain, 11.1 (interquartile range, 0, 22.2) vs 11.1 (interquartile range, 11.1, 33.3) in reflux, P = 0.034 and 0.001, respectively].

CONCLUSION

LAPPG is beneficial to recovery of anemia and to bile reflux, however, it might be unfavorable in terms of pain and reflux symptoms compared to LADG with Billroth II anastomosis.

Pylorus-preserving gastrectomy for early cancer involving the upper third: can we go higher?

BACKGROUND

Pylorus-preserving gastrectomy (PPG) is commonly performed for early gastric cancer (EGC) located in middle third of the stomach. We investigated the surgical, oncological, and functional outcomes of PPG involving the upper third of stomach.

METHODS

We included all patients of the period 2013-2016 who underwent PPG, distal subtotal gastrectomy (DSG), and total gastrectomy (TG) for EGC involving the upper third by carefully defining the localization. Surgical, oncological, and functional outcome analyses included postoperative morbidity, lymph-node metastasis, tumor recurrence, postoperative body weight, body mass index, hemoglobin, total protein, albumin, quantification of intraabdominal fat, and gallstone development.

RESULTS

Overall, 288 cases were analyzed: 145 PPG, 61 DSG, and 82 TG. In the study period, patients potentially underwent PPG for EGC involving the upper third, if enough proximal remnant stomach was found whilst achieving a sufficient proximal margin. PPG resulted in less operation time (p < 0.001), less blood loss (p = 0.002) and lower postoperative morbidity compared to TG. For lymph-node (LN) stations being resected in all groups, no difference was found in number of resected LN. Recurrence-free survival was similar for all groups. PPG showed advantages regarding postoperative body weight, hemoglobin, total protein, albumin in postoperative 6 and 12 month follow-up. Lowest decrease of abdominal fat area after 12 months was seen for PPG. Gallstone incidence was significantly lower after PPG compared to TG (p < 0.001).

CONCLUSIONS

For EGC involving the upper third, PPG can be another good option with lower postoperative morbidity, better functional outcomes, and same oncological safety.

Objective evaluation of clinical outcomes of laparoscopy-assisted pylorus-preserving gastrectomy for middle-third early gastric cancer

Background

Laparoscopic-assisted pylorus-preserving gastrectomy (LAPPG) is a minimally invasive function-preserving surgery for early gastric cancer. This study was designed to investigate the clinical outcomes between LAPPG and laparoscopy-assisted distal gastrectomy (LADG) by objective evaluation.

Methods

A total 167 pT1N0M0 gastric cancer patients underwent LAPPG(n = 70) and LADG(n = 97) were retrospectively analyzed. By evaluating the functional advantages, objective short-term and one year follow-up outcomes were compared.

Results

There is no significant difference in perioperative clinical characteristics as well as pathologic results between LAPPG and LADG group while the cost is higher in latter(p = 0.004). The Clavien–Dindo grade II or higher complications were 15.7 and 13.4% in LAPPG and LADG group respectively(p = 0.824). In one year follow-up, nutritional status was significantly better in LAPPG group accompanied by better pylorus function preserving.

Conclusion

LAPPG is an acceptable surgical procedure for pT1N0M0 middle portion gastric cancer patients in terms of nutritional and economic advantage.

Trial registration

Chinese Clinical Trial Registry (ChiCTR-PIC-17012358, Date of Registration:2017-08-14).

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

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.

Perioperative outcomes of laparoscopy-assisted pylorus and vagus nerve-preserving gastrectomy and distal gastrectomy for middle-third early gastric cancer

AIM

To compare the surgical safety, postoperative compli-cations and hospitalization expenses of laparoscopy-assisted pylorus and vagus nerve-preserving gastrectomy (LAPPG) and distal gastrectomy (LADG) in order to evaluate the feasibility of LAPPG in the treatment of middle-third early gastric cancer.

METHODS

The clinical and pathological data, surgical procedure, postoperative outcomes and hospitalization expenses of 112 patients with middle-third early gastric cancer treated from June 2016 to August 2017 at Department of Gastrointestinal Surgery of Renji Hospital were analyzed retrospectively. Forty-six patients received LAPPG, and 66 cases underwent LADG.

RESULTS

There were no significant differences between the two groups in age, sex, BMI, tumor differentiation, operative time, estimated blood loss, tumor diameter, resected lymph nodes, or metastatic lymph nodes (P > 0.05). Proximal and distal resection margins were significantly shorter in the LAPPG group than in the LADG group (P < 0.05). For postoperative outcomes, there were no significant differences in hospital stay, time to first flatus, time to gastric tube removal, time to first ambulation, time to first fluid diet, or postoperative complications (≥Dindo grade Ⅱ) (P > 0.05). Hospitalization expense of LAPPG was significantly lower than that of LADG [4.6 ± 0.5 vs 5.3 ± 0.4 (ten thousand yuan), P = 0.004].

CONCLUSION

On the premise of oncologic safety and efficacy, LAPPG is a cost-effective and feasible treatment for middle-third early gastric cancer.

A novel method of intracorporeal end-to-end gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for early gastric cancer, including a unique anastomotic technique: piercing the stomach with a linear stapler

BACKGROUND

Delta-shaped anastomosis is usually applied for an intracorporeal gastrogastrostomy in totally laparoscopic pylorus-preserving gastrectomy (TLPPG). However, the remnant stomach is slightly twisted around the anastomosis because it connects in side-to-side fashion. To realize an intracorporeal end-to-end gastrogastrostomy using an endoscopic linear stapler, we invented a novel method including a unique anastomotic technique.

MATERIALS AND METHODS

In this new approach, we first made small gastrotomies at the greater and lesser curvatures of the transected antrum and then pierced it using an endoscopic linear stapler. After the pierced antrum and the proximal remnant stomach were mechanically connected, the gastrotomies and stapling lines were transected using an endoscopic linear stapler, creating an intracorporeal end-to-end gastrogastrostomy. We have named this technique the "piercing method" because piercing the stomach is essential to its implementation. Between October 2015 and June 2017, 26 patients who had clinically early gastric cancer at the middle third of the stomach without clinical evidence of lymph node metastasis underwent TLPPG involving the novel method.

RESULTS

The 26 patients successfully underwent an intracorporeal mechanical end-to-end gastrogastrostomy by the piercing method. The median operation time of the 26 patients was 272 min (range 209-357 min). With the exception of one gastric stasis, no problems associated with the piercing method were encountered during and after surgery.

CONCLUSION

The piercing method can safely create an intracorporeal mechanical end-to-end gastrogastrostomy in TLPPG. Piercing the stomach using an endoscopic linear stapler is a new technique for gastrointestinal anastomosis. This method should be considered if the surgical aim is creation of an intracorporeal end-to-end gastrogastrostomy in TLPPG.

Impact of anatomical position of the pancreas on postoperative complications and drain amylase concentrations after laparoscopic distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopic surgery for gastric cancer requires traction or compression of the pancreas, with the extent depending on the anatomical position of the pancreas. This study investigated the impact of the position of the pancreas on postoperative complications and drain amylase concentrations after laparoscopic distal gastrectomy (LDG).

METHODS

Gastric cancer patients who underwent LDG were assessed retrospectively. The following anatomical parameters were measured retrospectively in preoperative computed tomography sagittal projections: the length of the vertical line between the pancreas and the aorta (P-A length), representing the height of the slope looking down the celiac artery from the top of the pancreas, and the angle between a line drawn from the upper border of the pancreas to the root of the celiac artery and the aorta (UP-CA angle), representing the steepness of the slope. Correlations between each parameter and postoperative complications were analyzed by logistic regression analysis. Pearson's product-moment correlation coefficients were calculated for scatter diagrams for each parameter and drain amylase concentration on postoperative day 1.

RESULTS

Analyses were performed in 394 patients. P-A length [odds ratio (OR) 1.905; 95% confidence interval (CI) 1.100-3.300; P = 0.021] was significantly correlated with pancreatic fistula. P-A length (OR 2.771; 95% CI 1.506-5.098; P = 0.001), UP-CA angle (OR 2.323; 95% CI 1.251-4.314; P = 0.008), and low preoperative serum albumin (OR 2.082; 95% CI 1.050-4.128; P = 0.036) were significantly correlated with overall postoperative complications defined as Clavien-Dindo ≥ grade II. P-A length and UP-CA angle showed significant positive correlations with drain amylase concentration on postoperative day 1.

CONCLUSION

The position of the pancreas is an independent predictor of pancreatic fistula and/or postoperative complications and correlates with drain amylase concentration after LDG for gastric cancer.

Function-preserving surgery for gastric cancer: current status and future perspectives

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures including endoscopy and screening systems. Therefore, function-preserving gastrectomy (FPG) for EGC with the expectation of better quality of life (QOL) after surgery may be increasingly utilized, due to its association with low rate of lymph node metastasis and excellent survival and the possibility of employing less invasive procedures such as laparoscopic gastrectomy in combination. Pylorus-preserving gastrectomy (PPG) with curative intent lymph node dissection is a representative FPG that has been used in EGC, and its superiorities, indications, limitations, and survival benefits have already been reported in several retrospective studies. Laparoscopic proximal gastrectomy (LAPG) has also been employed in EGC of the upper third of the stomach; however, LAPG was found to be associated with major issues in achieving a balance between swallowing and reflux prevention. In patients with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved, albeit very small, stomach may provide a better QOL and fewer postoperative complications. FPG is recommended as a surgical treatment for EGC if the indication is accurately diagnosed and strictly confirmed; however, these techniques in laparoscopic surgery present technical difficulties to surgeons without a certain degree of skills. Although many retrospective studies revealed the functional benefits or oncological safety with FPG, further prospective studies using large case series are necessary to reveal the value of FPG compared with the conventional procedures.

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.

Botulinum Toxin Injection for the Treatment of Delayed Gastric Emptying Following Pylorus-Preserving Gastrectomy: an Initial Experience

Purpose

To report our experience of endoscopic botulinum toxin injection in patients who experienced severe delayed gastric emptying after pylorus-preserving gastrectomy (PPG).

Materials and Methods

We reviewed the medical records of 6 patients who received the botulinum toxin injection. They presented with severe delayed gastric emptying in the early postoperative period. Endoscopic botulinum toxin was administered as 4 injections of 25−50 IU into each of the 4 quadrants of the prepyloric area.

Results

All botulinum toxin injections were successful without any complications, enabling 5 patients to tolerate soft solid diets and one to tolerate a soft fluid diet within 10 days. The endoscopic criteria of 4 patients improved. Symptom recurrence caused 2 patients to undergo repeat injections that were successful. The median follow-up period was 27 months, and all patients could ingest normal regular diets at the last follow-up.

Conclusions

Endoscopic botulinum toxin injection is a feasible treatment option for early delayed gastric emptying after PPG.

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.

Pylorus-Preserving Surgery Based on the Sentinel Node Concept in Early Gastric Cancer

BACKGROUND

In patients with early stage gastric cancer in the middle third of the stomach, pylorus-preserving gastrectomy (PPG) can be an option as function-preserving surgery, although its oncologic safety is not definitively defined. This issues may be overcome using the sentinel node (SN) concept. The aim of this study was to investigate the effectiveness of the SN concept in early gastric cancer patients who are candidates for PPG.

METHODS

One hundred fifty-six patients with middle-third location of cT1N0 gastric cancer (single lesion, <4 cm) underwent distal gastrectomy with SN mapping. As a tracer, technetium-99 tin colloid solution and blue dye were endoscopically injected into the submucosal layer surrounding the primary tumor.

RESULTS

SN detection rate was 100 % (156 of 156), and the accuracy of the nodal evaluation of metastasis was 99 % (155 of 156). Suprapyloric lymph node (LN; LN No. 5) and infrapyloric LN (LN No. 6) were detected as SNs in 6 and 14 % of the patients, respectively. We also found two cases with metastasis to LN No. 5 or LN No. 6.

DISCUSSION

When performing PPG, the possibility of LN metastasis, especially to LN No. 5 and LN No. 6, cannot be underestimated. SN mapping can play an important role to predict the possibility of metastasis to LN No. 5 and LN No. 6.

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.

Multivariate logistic regression analysis of postoperative complications and risk model establishment of gastrectomy for gastric cancer: A single-center cohort report

BACKGROUND

Reporting of surgical complications is common, but few provide information about the severity and estimate risk factors of complications. If have, but lack of specificity.

METHODS

We retrospectively analyzed data on 2795 gastric cancer patients underwent surgical procedure at the Affiliated Hospital of Qingdao University between June 2007 and June 2012, established multivariate logistic regression model to predictive risk factors related to the postoperative complications according to the Clavien-Dindo classification system.

RESULTS

Twenty-four out of 86 variables were identified statistically significant in univariate logistic regression analysis, 11 significant variables entered multivariate analysis were employed to produce the risk model. Liver cirrhosis, diabetes mellitus, Child classification, invasion of neighboring organs, combined resection, introperative transfusion, Billroth II anastomosis of reconstruction, malnutrition, surgical volume of surgeons, operating time and age were independent risk factors for postoperative complications after gastrectomy. Based on logistic regression equation, p=Exp∑BiXi / (1+Exp∑BiXi), multivariate logistic regression predictive model that calculated the risk of postoperative morbidity was developed, p = 1/(1 + e((4.810-1.287X1-0.504X2-0.500X3-0.474X4-0.405X5-0.318X6-0.316X7-0.305X8-0.278X9-0.255X10-0.138X11))). The accuracy, sensitivity and specificity of the model to predict the postoperative complications were 86.7%, 76.2% and 88.6%, respectively.

CONCLUSIONS

This risk model based on Clavien-Dindo grading severity of complications system and logistic regression analysis can predict severe morbidity specific to an individual patient's risk factors, estimate patients' risks and benefits of gastric surgery as an accurate decision-making tool and may serve as a template for the development of risk models for other surgical groups.

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.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.

Influence of endoscopic submucosal dissection on additional gastric resections

BACKGROUND

Widespread application of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) results in noncurative resection in some patients. The influence of preceding ESD on additional gastric resections has not been completely evaluated.

METHODS

Endoscopic, surgical, and pathological records of 255 patients who underwent additional gastrectomy after noncurative ESD at a single prefectural cancer center from September 2002 to December 2010 were reviewed. The estimated gastric resection based on endoscopic images before ESD was compared with the actual gastric resection performed after ESD.

RESULTS

Altered gastric resection was performed in 4 (1.6%) of the 255 patients. In 3 patients, total gastrectomy was performed instead of distal gastrectomy; in 1 patient, distal gastrectomy was performed instead of pylorus-preserving gastrectomy because of an insufficient distance from the cardia or pylorus caused by contraction of the ESD scar. Standard gastrectomy including total or distal gastrectomy with D2 lymph node dissection was performed in 33 patients because of deep submucosal invasion with positive/indefinite vertical margins. The final pathology revealed pT2 or deeper in 10 patients.

CONCLUSIONS

In conclusion, 98.4% patients underwent the scheduled gastric resection before ESD, and the preceding gastric ESD had almost no influence on changing the gastric resection of the additional surgery. Although rare, the preceding ESD may necessitate alterations in gastric resection to widen the surgical area because of contraction of ESD scar for lesions near the cardia or pylorus. MINI ABSTRACT: A retrospective study of additional gastrectomy after noncurative ESD showed that the preceding ESD had almost no influence on changing the gastric resection of the additional surgery.

Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy

BACKGROUND

The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications.

METHODS

The study included 189 patients aged 70 years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed.

RESULTS

The overall complication rate was 24.9 % (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8 %). Severe complications classified as grade III or above in the Clavien-Dindo grading system were found in 20 (10.6 %) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95 % CI, 1.706-15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95 % CI, 1.103-11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95 % CI, 1.378-18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients.

CONCLUSION

The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0 g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.

Totally laparoscopic pylorus-preserving gastrectomy for early gastric cancer in the middle stomach: technical report and surgical outcomes

INTRODUCTION

The feasibility, safety, and improved quality of postoperative life following laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with a hand-sewn anastomosis via a mini-laparotomy for early gastric cancer (EGC) have been previously established. Here we describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy (TLPPG) using an intracorporeal delta-shaped anastomosis technique, and the short-term surgical outcomes of 60 patients with EGC in the middle stomach are reported.

METHODS

After lymphadenectomy and mobilization of the stomach, intraoperative gastroscopy was performed in order to verify the location of the tumor, and then the distal and proximal transecting lines were established, 5 cm from the pyloric ring and just proximal to Demel's line, respectively. Following transection of the stomach, a delta-shaped intracorporeal gastrogastrostomy was made with linear staplers.

RESULTS

There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 259 min and 28 mL, respectively. Twelve patients (20.0%) experienced postoperative complications classified as grade II using the Clavien-Dindo classification, with the most frequent complication being gastric stasis (6 cases, 10.0 %). The incidence of severe complications classified as grade III or above was 1.7%; only one patient required reoperation and intensive care due to postoperative intraabdominal bleeding and subsequent multiple organ failure.

CONCLUSION

TLPPG with an intracorporeal delta-shaped anastomosis was found to be a safe procedure, although it tended to require a longer operating time than the well-established LAPPG with a hand-sewn gastrogastrostomy.

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.