Evaluation of a pylorus-preserving gastrectomy for patients preoperatively diagnosed with early gastric cancer located in the middle third of the stomach

Purpose  

Patients diagnosed with early gastric cancer located in the middle third of the stomach have two major surgical options, namely a conventional distal gastrectomy with Billroth I anastomosis (DG) or a pylorus-preserving gastrectomy (PPG). Pyloruspreserving gastrectomy is thought to have greater functional benefits than DG, but the evaluation of its prognosis and outcome has so far been insufficient.     

早期胃癌行保留迷走神经及幽门的胃切除术

胃癌的外科治疗经历了原创期、根治时期和合理手术期后进入了个体化治疗时期。因而，对于早期胃癌在保证根治的前提下以改善生活质量（quality of life，QOL）为目的缩小手术被推崇和广泛应用。缩小手术除胃切除的范围和淋巴结廓清范围的缩小，还要考虑保存器官的功能和低侵袭性。缩小手术中的保留迷走神经、幽门胃部分切除手术作为保存功能的手术，     

Surgical results of performing R4 gastrectomy for gastric cancer located in the upper third of the stomach

Because gastric cancers located in the upper third of the stomach are difficult to detect at an early stage, the surgical results remain poor. We performed R4 gastrectomy as a radical procedure for 25 patients, involving complete resection of the latero-aortic and interaorticovenous lymph modes above and below the left renal vein, in combination with the ordinary R2 or R3 gastrectomy (the R4 group). These patients were compared with 156 others who underwent R2 gastrectomy alone (the R2 group). There were no significant differences in operation time, blood loss, or the incidence of complications between the two groups; however, when the survival rates of the patients with tumors invading beyond the subserosa were compared, the 5-year survival rate was found to be significantly higher in the R4 group than in the R2 group. Furthermore, in patients with para-aortic nodal involvement, a significant survival advantage was observed in the R4 group, as compared with the R2 group. These results suggest that the R4 gastrectomy is a rational approach for patients with advanced gastric cancer located in the upper third of the stomach.     

Prospective study of proximal gastrectomy for early gastric cancer in the upper third of the stomach

BACKGROUND: Total gastrectomy with D2 dissection is the standard treatment in Japan for early upper-third gastric cancer. The purpose of this study was to confirm the safety and radicality of proximal gastrectomy as an alternative operation. METHODS: Between 1993 and 1999, 45 patients with an apparent primary early gastric cancer in the upper third of the stomach were treated by proximal gastrectomy with jejunal interposition. The spleen was preserved, but the suprapancreatic nodes were cleared. RESULTS: Histology confirmed early gastric cancer in 37 patients while eight had advanced disease. Nodal metastasis was observed in six patients. There was no hospital death and no early postoperative complications. One patient died from nodal recurrence and two from unrelated causes. Two patients had reflux symptoms without endoscopic oesophagitis. Mean weight loss was 11.5 per cent of initial bodyweight. CONCLUSION: Proximal gastrectomy for early upper-third gastric cancer can be performed safely with an excellent cure rate. This procedure deserves further clinical evaluation to assess patients' quality of life.     

Clinical outcome of high segmental gastrectomy for early gastric cancer in the upper third of the stomach

BACKGROUND: Reflux oesophagitis is commonly encountered in the surgical treatment of cancer of the upper third of the stomach. The aim of this study was to describe a novel surgical technique and evaluate the clinical outcome of high segmental gastrectomy for early-stage proximal gastric cancer. METHODS: Thirty consecutive patients with early gastric cancer located in the upper third of the stomach were included, of whom 12 underwent high segmental gastrectomy and 18 underwent proximal gastrectomy with jejunal interposition. The incidence of reflux oesophagitis and nutritional parameters were compared between the two groups at 1 year after operation. RESULTS: One patient had mild reflux symptoms and two had endoscopic evidence of oesophagitis 1 year after high segmental gastrectomy. Half of the patients who had proximal gastrectomy had reflux symptoms of varying severity and 14 had endoscopic evidence of oesophageal changes at 1 year after surgery. There were significant differences between groups in the incidence of reflux symptoms (P = 0.016) and endoscopically detected gastro-oesophagitis (P < 0.001). There were no adverse events in either group, and the survival rate after high segmental gastrectomy appeared favourable. CONCLUSION: Selected patients with early-stage proximal gastric cancer benefit from high segmental gastrectomy in terms of reduced reflex oesophagitis, without jeopardizing curability.     

Subtotal gastrectomy for cancer located in the greater curvature of the middle stomach with prevention of the left gastric artery

BACKGROUND: A novel distal subtotal gastrectomy was performed in 5 patients with macroscopically node-positive gastric cancer located in the greater curvature of the middle stomach. In these patients, total gastrectomy or standard distal subtotal gastrectomy has been typically performed. In these typical gastrectomies, the hepatic and the coeliac branches of the vagi are removed en bloc with the left gastric artery and the whole of the lesser omentum because the lymphatics along the left gastric artery are in the lower stream-regions of lymph flow from the cancer and metastases exist potentially. METHODS: During novel distal subtotal gastrectomy the activated carbon method confirmed that the lymphatics along the ascending branch of the left gastric artery were not in the lower stream-region of lymph flow from the cancer. Then, we preserved the hepatic and coeliac branches of the vagi as well as the ascending branch of the left gastric artery and the upper part of the lesser omentum. The other arteries feeding the stomach were removed with the surrounding lymphatics. In novel distal subtotal gastrectomy the remnant stomach was fed only by the ascending branch of the left gastric artery, while in standard distal subtotal gastrectomy the remnant stomach was fed by the short gastric arteries. CONCLUSIONS: Although further examinations are necessary, novel distal subtotal gastrectomy may have superior merit such as good function of gallbladder because of the preservation of the vagal nerve system, compared with total gastrectomy or standard distal subtotal gastrectomy.     

Functional characteristics of the pylorus in patients undergoing pylorus--preserving gastrectomy for early gastric cancer

BACKGROUND: This study investigates the functional characteristics of the pylorus in patients undergoing pylorus-preserving gastrectomy (PPG) for early gastric cancer. METHODS: In study 1, postprandial symptoms and gastric emptying were compared between 2 groups of 12 patients with early gastric cancer more than 1 year after either PPG (PPG group) or distal gastrectomy (DG) (DG group). Gastric emptying was evaluated with the dual isotope technique for liquids and solids separately. In study 2, pyloric motility was evaluated with a sleeve/sidehole manometric assembly in 7 patients undergoing PPG, which was compared with that in the preoperative patients. RESULTS: In study 1, the overall modified Visick score of postprandial symptoms and the Sigstad dumping score were significantly lower in the PPG group compared with the DG group (P <.05). Early accelerated gastric emptying was observed in both groups for liquids, but only in the DG group for solids. In study 2, isolated pyloric pressure waves induced by intraduodenal lipid infusion and phase III-like activity induced by intravenous erythromycin infusion were preserved after PPG. CONCLUSIONS: The quantitative analysis of postoperative symptoms revealed that PPG patients were associated with better clinical conditions than DG patients. The clinical benefits of PPG are considered to be based on the function of the preserved pylorus.     

Indications for total gastrectomy combined with pancreaticosplenectomy in the treatment of middle gastric cancer

Of 1725 patients with middle gastric cancer (M, MA, MC) on whom radical surgery was performed (except for absolute non-curative resection) from 1960 to 1984 at the Cancer Institute Hospital, 238 patients in whom total gastrectomy or proximal partial gastrectomy combined with pancreaticosplenectomy was carried out, were submitted for both clinico-pathological and prognostic examination. The following results were obtained: 1. There are few indications for total gastrectomy plus pancreaticosplenectomy in patients with middle gastric cancer in which the lesions are superficial or semi-superficial. 2. For patients in whom the cancer occupies portions of the greater curvature, on posterior wall of the stomach, the whole stomach, or is of a non-localized type, the metastatic rate of lymph nodes No (10) or lymph nodes No (11) is high, then total gastrectomy plus pancreaticosplenectomy should be considered. 3. Lymph nodes No (2), (4d), (4sb) (7) and (9) can be good indices indicating presence or absence of metastasis of lymph nodes No (10) and lymph nodes No (11). 4. Radical surgery as well as effective adjuvant therapy are required for gastric cancer with invasion of the serosa.     

Surgical outcomes for early gastric cancer in the upper third of the stomach

BACKGROUND: Although outcomes of operations for advanced gastric cancer in the upper third of the stomach are said to be poorer, outcomes of operations for early gastric cancer in the upper third of the stomach have been less well studied. The aim of this study is to analyze and establish a therapeutic strategy for early tumors in the upper third of the stomach. STUDY DESIGN: Patients (n = 673; 79 patients were located in the upper third of the stomach and 594 in more distal sites) with early gastric cancer who underwent curative gastrectomy were included in this study. Clinicopathologic characteristics and results of operations for early tumors were compared between the two groups. Prognostic factors were evaluated with uni- and multivariate analyses. RESULTS: Tumors in the upper third of the stomach were more often protruded, differentiated, submucosa invasive, and located at the posterior wall, and more often involved venous invasion and adjacent metastatic lymph nodes. Lymph node metastasis, but not tumor location, was an independent prognostic factor in all registered patients. Results of operations were not different between the two groups. CONCLUSIONS: Early proximal tumors show distinct features, but prognosis after curative operation is as good as that of distal two-third tumors.     

National trends in total vs subtotal gastrectomy for middle and distal third gastric cancer

BackgroundTo identify trends in total and subtotal gastrectomy for middle and distal third gastric adenocarcinoma in the U.S.MethodsNCDB was queried for patients with stage 0-III middle or distal gastric adenocarcinoma treated with total or subtotal gastrectomy. Statistical analysis including cox proportional hazards model was performed to examine overall survival by stage.Results1,628 (85%) underwent subtotal gastrectomy and 283 (15%) underwent total. 1113 patients (58%) had distal tumors and 798 (42%) had middle tumors. Total gastrectomy patients more often had poor tumor grade (60% vs 50%,p < 0.01), larger size (46.3 mm vs 37.8 mm,p < 0.0001), had positive nodes (3.6 ± 5.9 vs 2.2 ± 4.1,p < 0.0001), underwent chemoradiation (13% vs 6%,p < 0.0001), and were higher clinical stage (p < 0.05). An overall survival curve showed an adjusted HR of 2.7 for total vs subtotal gastrectomy at clinical stage 3 (p < 0.05).ConclusionsTotal gastrectomy is performed for larger, more aggressive tumors with higher stage. Subtotal gastrectomy may have a survival benefit for stage III gastric cancers.     

全腹腔镜次全胃切除术在中上部早期胃癌治疗中的应用

目的:探讨全腹腔镜次全胃切除术治疗中上部早期胃癌的临床价值及近期疗效.方法:收集2018年1月至2020年12月收治的31例中上部早期胃癌并接受全腹腔镜次全胃切除术患者的临床资料,采用回顾性横断面描述性研究方法.结果:31例患者均在全腹腔镜下完成清扫及消化道重建,无一例需腹腔镜辅助与中转开腹.手术时间平均(167.5±...     

The operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach

While proximal gastrectomy is often performed for early gastric cancer in Japan, it remains unclear whether or not proximal gastrectomy should be performed for advanced gastric cancer. This study was designed to determine the operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach. A total of 1691 patients with gastric cancer were reviewed retrospectively from hospital records during the period from 1969 to 1994, and the clinicopathologic characteristics of 82 patients who underwent proximal gastrectomy were compared with those of 150 patients who underwent total gastrectomy. Lymph node metastasis along the lower part of the stomach was observed in gastric cancers which had invaded beyond the muscularis propria of the stomach, but not in those confined to the muscularis propria. Three patients with gastric cancer that had invaded beyond the muscularis propria and metastasized to nodes along the lower part of the stomach were cured by total gastrectomy. However, there was no difference in the postoperative survival rates of the patients treated with proximal gastrectomy and those treated with total gastrectomy, irrespective of tumor stage and depth of invasion. Thus, proximal gastrectomy should be performed for gastric cancer when the depth of invasion is confined to the muscularis propria of the stomach.     

保留幽门单腔P形空肠代胃术的临床应用

对27例贲门、胃底体癌病人施行保留幽门全胃切除(TG)后，行单腔P形空肠顺蠕动式问置代胃重建，食管空肠端侧吻合，空肠幽门端端吻合，P形袢间行侧侧吻合手术者，术后观察治疗效果并随访，以探讨TG后代胃重建的有效术式。结果显示：无手术死亡，无吻合口瘘发生。术后2～4个月随访均恢复至进半流质饮食，每日4～6餐，体重增加，血清蛋白正常，无贫血者；钡餐检查代胃空肠充盈蠕动良好，钡剂分别于40～150min后排空，1例少量钡剂反入食管，很快排出；5～6个月行胃镜检查各吻合口正常，代胃空肠黏膜皱襞增粗，蠕动正常，无食物潴留，食管黏膜正常，3例有轻度胆汁反流；随访1～5年无倾倒综合征，仅1例有轻度反流食管炎症状，2例进食后有轻度上腹饱胀不适感，生存质量均满意。提示P形空肠间置代胃有较好代胃作用，是TG后值得推广应用的一种代胃术式。     

保留幽门及迷走神经的胃部分切除术治疗早期胃癌

Objective To discuss the effect of pylorus-preserving gastrectomy for early gastric cancer(EGC). Methods Between August 1995 and December 2005, 52 cases of EGC underwent pyloruspreserving gastrectomy(PPG) and 159 cases of EGC underwent distal gastrectomy(DG), Clinicopathlogic data and follow-up results of the two groups were analyzed retrospectively, and gastric emptying and gallbladder function of 15 cases PPG and 17 cases DG were compared at the same time.Results Compared with DG group, patients in PPG group maintain the body weight, gastric emptying and gallbladder function. There was no significant difference between PPG group (92. 3% ) and DG group (93.1% ) in overall 5-year survival rate ( P = 0. 881 ). The 5-year survival rate of the the PPG group with lymph node dissection was D1 100%, D1+α 92. 3%, D1+β 88.9%, D2 87. 5% respectively.Conclusions For early gastric cancer, the pylorus-preserving gastrectomy is effective for maintaining the postoperative function with similar long term survival as that of distal gastrectomy.     

保留幽门及迷走神经的胃部分切除术治疗早期胃癌

Objective To discuss the effect of pylorus-preserving gastrectomy for early gastric cancer(EGC). Methods Between August 1995 and December 2005, 52 cases of EGC underwent pyloruspreserving gastrectomy(PPG) and 159 cases of EGC underwent distal gastrectomy(DG), Clinicopathlogic data and follow-up results of the two groups were analyzed retrospectively, and gastric emptying and gallbladder function of 15 cases PPG and 17 cases DG were compared at the same time.Results Compared with DG group, patients in PPG group maintain the body weight, gastric emptying and gallbladder function. There was no significant difference between PPG group (92. 3% ) and DG group (93.1% ) in overall 5-year survival rate ( P = 0. 881 ). The 5-year survival rate of the the PPG group with lymph node dissection was D1 100%, D1+α 92. 3%, D1+β 88.9%, D2 87. 5% respectively.Conclusions For early gastric cancer, the pylorus-preserving gastrectomy is effective for maintaining the postoperative function with similar long term survival as that of distal gastrectomy.     

保留幽门及迷走神经的胃部分切除术治疗早期胃癌

目的 探讨早期胃癌的保留幽门及迷走神经的胃部分切除手术的疗效.方法 回顾性分析了1995年8月至2005年12月行保留幽门及迷走神经的胃部分切除术(pylorus-preserving gastrectomy,PPG)的早期胃癌52例和行远端胃切除(distal gastrectomy,DG)的早期胃癌159例的临床病理资料及长期随访结果,同时比较了PPG组(15例)和DG组(17例)患者的胃排空和胆囊收缩功能.结果 术后PPG组比DG组患者能更好地维持体重,食物的胃排空状态近乎正常,胆囊的收缩功能及长期生存状态良好.PPG组患者累积5年生存率为92.3%,与DG组患者的93.1%之间相比差异无统计学意义(P=0.881),其中D1为100%,D1+α为92.3%,D1+β为88.9%,D2为87.5%.结论 PPG手术可以维持早期胃癌患者的正常生理功能,且具有与DG相同的长期生存效果.

Abstract：

Objective To discuss the effect of pylorus-preserving gastrectomy for early gastric cancer(EGC). Methods Between August 1995 and December 2005, 52 cases of EGC underwent pyloruspreserving gastrectomy(PPG) and 159 cases of EGC underwent distal gastrectomy(DG), Clinicopathlogic data and follow-up results of the two groups were analyzed retrospectively, and gastric emptying and gallbladder function of 15 cases PPG and 17 cases DG were compared at the same time.Results Compared with DG group, patients in PPG group maintain the body weight, gastric emptying and gallbladder function. There was no significant difference between PPG group (92. 3% ) and DG group (93.1% ) in overall 5-year survival rate ( P = 0. 881 ). The 5-year survival rate of the the PPG group with lymph node dissection was D1 100%, D1+α 92. 3%, D1+β 88.9%, D2 87. 5% respectively.Conclusions For early gastric cancer, the pylorus-preserving gastrectomy is effective for maintaining the postoperative function with similar long term survival as that of distal gastrectomy.     

保留幽门胃切除术治疗早期胃癌

目的：探讨保留幽门胃切除术(PPG)治疗早期胃癌的效果。
方法：22例PPG手术的临床资料。22例均为早期胃癌,病灶位于胃的中1/3者16例,胃下1/3者6例,离幽门均在5 cm以上,均行PPG。
结果：全组患者术后住院期间无餐后消化道不适症状出现;有饥饿感者20例（90.91%）。随访期间有2例出现餐后消化道不适症状,其中1例是上腹饱胀隐痛,另1例是呕吐;有饥饿感的是18例（81.82%）。
结论：胃中部早期胃癌患者采用PPG手术,既能达到理想的根治效果,又能满意地保存了幽门功能,有利于患者的康复。