保留幽门胃切除术治疗慢性胃溃疡的疗效观察

目的 观察保留幽门胃切除术（PPG）治疗慢性胃溃疡的疗效。方法 对24例胃酸较低的慢性胃溃疡患者施行PPG。术后观察指标：以中和滴定法测定胃酸；以放射免疫法测定血清胃泌素；口服钡餐在X线下了解幽门括约肌功能；观察术后恢复过程和并发症的发生情况。结果 PPG术后基础胃酸分泌量（BAO）和最大胃酸分泌量（MAO）下降60％，空腹及餐后血清胃泌素降低下降256％和45％，幽门括约肌功能良好，无明显的胃排空和溃疡复发。结论 PPG对胃酸较低的部分慢性胃溃疡患者不失为一种可供选择的良好术式。     

保留幽门和迷走神经的胃部分切除手术对早期胃癌的疗效观察

目的 探讨保留幽门和迷走神经的胃部分切除手术（PPG）对早期胃癌的疗效.方法 回顾性分析1995年8月至2005年12月对52例早期胃癌患者行保留幽门和迷走神经的胃部分切除术（PPG组）的临床资料和随访结果;并与同期行远端胃切除术伴淋巴结清除的159例早期胃癌患者（对照组）的临床资料进行比较.结果 PPG组早期胃癌的淋巴结转移率为9.6%,对照组淋巴结转移率为17.0%;两组比较,差异无统计学意义（P＞0.05）.PPG组淋巴结清除范围D1为25%,D1＋α（α=No.7）为25%,D1＋β（β=No.8a和No.9）为34.6%,D2为15.3%;对照组121例（76.1%）D2以下,33例（20.7%）D2,5例（3.1%）D3;两组比较,差异无统计学意义（P＞0.05）.术后累计5年生存率PPG组为92.3%,对照组93.1%,两组差异无统计学意义（P=0.881）.其中淋巴结不同清除程度的累计5年生存率PPG组：D1为100%,D1＋α为92.3%,D1＋β为88.9%,D2为87.5%;对照组：D1为92.3%,D1＋α为93.3%,D1＋β为91.7%,D2为93.9%;两组比较,差异无统计学意义（P＞0.05）.PPG组术后的复发率为5.7%,对照组则为5.6%,两组差异无统计学意义（P＞0.05）.结论 PPG对于早期胃癌的治疗是有效的.     

保留幽门的胃癌根治术的理论与实践

胃癌是人类常见的恶性疾患,传统固定的胃大范围切除,扩大的淋巴结廓清模式,已向多样化、个体化治疗模式转化.     

日本胃癌根治手术保留幽门的术式选择和解剖学基础

胃癌根治手术切除胃幽门可出现倾倒综合征、胆汁返流性胃炎、小细胞性贫血、骨病等并发症。保留幽门的胃部分切除术(pylorus preserving gastrectomy，PPG)时切除远侧胃，保留距幽门括约肌1．5cm幽门管和残胃吻合，最初在治疗胃溃疡时，是作为胃肠道机能性再建的术式而应用于临床。随着早期胃癌发现增加，为了选择不影响胃癌根治性，并使保留幽门括约肌的再建术式合理化、规范化，因此对保留幽门括约肌的血管解剖学基础及手术的评价等需要探讨。     

Indications for a pylorus-preserving gastrectomy for gastric cancer with proper muscle invasion

HYPOTHESIS: Our previous demonstrations of the feasibility of a pylorus-preserving gastrectomy with a wider-scope lymphadenectomy for early gastric cancer (GC) have raised the possibility of applying pylorus-preserving gastrectomy to a broader segment of GC patients, such as those having GC with invasion extending into the proper muscle layer (GCpm). DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: This study comprised 107 patients with solitary primary GCpm located in the middle or lower third of the stomach. INTERVENTION: All patients underwent gastrectomy, using at least the former D2 dissection of the American Joint Committee on Cancer. MAIN OUTCOME MEASURES: Patterns and sites of nodal involvement were analyzed in relationship to other clinicopathologic characteristics, including preoperative and intraoperative evaluations of tumor depth (cT), nodal involvement (cN), and serosal involvement. The conditions required were serosal negativity and measurements less than or equal to cT2 cN0 with histologic proof of node negativity, or if positive, the positive nodes had to be confined to the first or selective second tier. The selective second-tier nodes were defined as those along the left gastric, common hepatic, and celiac arteries. RESULTS: The factors favoring node negativity were serosal negativity, cN0, or both. For tumors that were serosal-negative and less than or equal to cT2 cN0 to meet the above conditions, a tumor in the middle third of the stomach had to be less than or equal to 2 cm in the maximum diameter, and that in the lower third could be any size. No patients with serosal negativity and cT2 cN0 GCpm less than or equal to 2 cm in diameter died of cancer or had positive nodes beyond the selective second tier. CONCLUSIONS: Considering the required distance between the pyloric ring and distal margin of the tumor to avoid a positive resection margin, pylorus-preserving gastrectomy with a selective second-tier node dissection is optimal for tumors that are serosal negative, less than or equal to cT2 cN0, and less than or equal to 2 cm in maximum diameter when located in the middle or lower third of the stomach.     

Early results of pylorus-preserving gastrectomy for duodenal ulcer

Twenty patients with duodenal ulcer were treated by pylorus-preserving gastrectomy. Post operative reduction in maximal acid output was 65%. Gastric emptying was slow without producing stasis.A provocative test showed that dumping was almost completely eliminated and was very mild in the one case in which it did occur.Short-term review between 2 and 3 years postoperatively showed continuing satisfactory results with no gastric stasis and an absence of early recurrence.The results are compared with the results of proximal selective vagotomy, and the mechanism of maintenance of a functioning pylorus is discussed.     

Long-term outcome and survival with laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer

Background  

Laparoscopically assisted pylorus-preserving gastrectomy (LAPPG) is introduced as a function-preserving operation with minimal invasion for early gastric cancer (EGC). This study aimed to investigate the long-term outcome and survival with LAPPG.     

Long-term follow-up study after pylorus-preserving gastrectomy for gastric ulcer

The long-term follow-up study of pylorus-preserving gastrectomy (PPG) for benign gastric ulcer was described in terms of postoperative subjective symptoms related to gastrectomy and recurrent ulceration. Of 134 patients who underwent PPG, 5 patients died within one month after operation, 33 patients died in the follow-up period and 22 patients have not been traced. Seventy-four patients were available for a 3-24 year follow-up (mean 16.6 years) Recurrent ulcer developed in 4 patients, 1, 2, 9 and 11 years after surgery at the greater curvature of pre-pyloric region in all cases. Two patients underwent reoperation. These patients revealed higher gastric acid secretion as compared with that of one month after primary operation. But gastrin hypersecretion and G-cell hyperplasia were not recognized in these patients. According to detailed questionnaires, no patient showed the symptoms of dumping syndrome. The results indicate that PPG is preferable for the surgical treatment of gastric ulcer.     

Massive postoperative polyuria following total gastrectomy for gastric cancer

Massive postoperative polyuria is rare, except in neurosurgery patients. Here we report excessive polyuria in a 59-year-old woman following total gastrectomy for advanced gastric cancer. The etiology of the patient's polyuria was unknown. Urine output was measured hourly and replaced with Ringer's lactate solution at 80% of measured volume. The rate of urine output during 9 postoperative days ranged from 900 to 2700 ml·h⁻¹. Several administrations of an antidiuretic hormone (ADH) analogue were ineffective in reducing urine output, suggesting a possible relationship of the massive polyuria to nephrogenic diabetes insipidus. Following oral administration of a thiazide diuretic, known to exert an antidiuretic action in nephrogenic diabetes insipidus, urine output was dramatically reduced. We conclude that this case of massive polyuria probably resulted from postoperative nephrogenic diabetes insipidus.     

Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation

BACKGROUND: Pylorus-preserving gastrectomy (PPG) with extensive lymph node dissection is useful for treatment of early gastric cancer with preservation of function. This technique could be improved by using laparoscopy-assisted gastrectomy. STUDY DESIGN: Between September 2000 and September 2004, 109 patients with T1 gastric cancer underwent surgical treatment; 72 underwent laparoscopy-assisted PPG (LAPPG) and 37 underwent conventional PPG (CPPG). Total numbers of dissected lymph nodes, retrieval at each lymph node station, intraoperative blood loss, and operation times were used as measures of the quality of lymph node dissection to compare the procedures. Continuous data are summarized as mean +/- SE. RESULTS: Operation times with the LAPPG procedure (279 +/- 6 minutes) were significantly, but only 20 minutes, longer than with CPPG (259 +/- 8 minutes) (p = 0.047), although estimated blood loss for LAPPG patients (153 +/- 13 mL) was not significantly different for those undergoing CPPG (184 +/- 13 mL, p = 0.13). Mean total number of dissected lymph nodes was 32.3 +/- 1.6 in the LAPPG group and 28.5 +/- 2.2 in the CPPG group (p = 0.16). There was no significant difference in the number of lymph nodes retrieved for any of the nodal stations between the LAPPG and CPPG procedures. CONCLUSIONS: Clinical outcomes of surgical treatment were comparable for gastric cancer patients who underwent LAPPG and those treated with CPPG in terms of station-dependent lymph node dissection and estimated blood loss.     

保留幽门胃部分切除术治疗早期胃癌临床效果及生活质量系统评价

目的 系统评价保留幽门胃部分切除术（PPG）治疗早期胃癌的临床效果及生活质量。方法 计算机检索1995年1月至2010年12月PubMed、Wiley Online Library、中国生物医学数据库（CBM）、CNKI、VIP及万方数据库关于PPG和传统远端胃切除术（CDG）治疗早期胃癌的随机对照试验。RevMan 5.0进行Meta分析。结果 纳入2个随机对照试验和11个临床对照试验,共1011例病人。PPG和CDG相比,术后能减少倾倒综合征、残胃炎的发生,病人营养状况和体重恢复较好;但总并发症、胆结石、反流性食管炎无显著差别。结论 现有研究表明,早期胃癌行PPG后生活质量较好。由于纳入研究方法学质量低、数量少,期待更多高质量试验提供高质量证据。     

A novel laparoscopic procedure for treating proximal early gastric cancer: laparoscopy-assisted pylorus-preserving nearly total gastrectomy

Purpose

Pylorus-preserving nearly total gastrectomy (PPNTG) is a function-preserving gastrectomy for treating proximal early gastric cancer that prevents rapid gastric emptying and reflux. In this report, we present a surgical technique for performing laparoscopy-assisted PPNTG (LAPPNTG).

Methods

The resection of the stomach was similar to that during conventional total gastrectomy, with the key difference being that the pyloric cuff was preserved to a length of 3–4 cm. Compared with standard total gastrectomy, the lymph node dissection along the right gastric vessels and the infrapyloric vessels were omitted. Reconstruction was performed with a jejunal interposition that was 30 cm in length, with preservation of the marginal vessels in a retrocolic fashion.

Results

Thirteen patients with cT1 cN0 proximal gastric cancer underwent LAPPNTG at our institution. The median length of the operation and estimated blood loss were 329 min and 138 ml, respectively. All resected specimens had tumor-free margins, and the median number of removed lymph nodes was 40. There were no serious postoperative complications and no patients underwent conversion to laparotomy.

Conclusions

Performing LAPPNTG with a jejunal interposition is feasible and might be an appropriate treatment for proximal early gastric cancer.     

Microbiological evaluation after gastrectomy and reconstruction for gastric cancer

The purpose of this study was to evaluate microbial flora in the mucosa of reconstructed organs after gastrectomy for gastric cancer and improve postoperative quality of life by treating the flora. The number of aerobes was significantly higher in the gastric remnant in the proximal gastrectomy-jejunal pouch interposition group (n=8) than the distal gastrectomy-Billroth II reconstruction (G-BII) group (n=2) or the pylorus-preserving gastrectomy (PPG) group (n=8). The mean number and positive rate of anaerobes tended to be higher in jejunal pouch reconstruction groups. No Helicobacter pylori were detected in any specimens after the G-BII and jejunal pouch reconstruction. However, the gastric remnant and duodenum in the distal gastrectomy-Billroth I reconstruction group (n=5; positive rate of 80% and 20%, respectively) and the PPG group (positive rate of 63% and 25%, respectively) showed H. pylori. We concluded that more anaerobes tended to grow in the mucosa of reconstructed organs after jejunal pouch reconstruction than other procedures. Some patients after jejunal pouch reconstruction worried about their halitosis. Therefore, elimination of anaerobes may relieve it and improve postoperative quality of life.     

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6-9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.     

Purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy for early gastric cancer: a case and technical report

For the purpose of prevention of postgastrectomy syndrome and a less invasive and yet curative oncological resection, a purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy was performed for a patient with early gastric cancer located in the middle third of the stomach. The patient's postoperative course was uneventful. During his postoperative recovery, the patient experienced very little pain and used analgesic medication only one time. This operation appeared to be oncologically adequate. As of the seventh postoperative month, the patient never experienced dumping syndrome or alkaline reflux gastritis. This procedure is technically feasible and an excellent option because of its reduced surgical invasiveness and better postoperative quality of life.