腹腔镜下迷走神经后干及其属支临床解剖研究

目的 观察、测量并分析腹腔镜手术迷走神经后干及其属支与胃左动脉的解剖关系。方法 选择2017-11-13至2018-11-16大连医科大学附属第一医院胃肠外科行腹腔镜保留胃功能的胃切除术41例胃癌病人，腹腔镜下观察迷走神经后干及其属支与胃左动脉关系，并进行分型。测量迷走神经后干、腹腔支的长度以及神经与胃左动脉共干长度、胃左动脉长度。结果 迷走神经后干、腹腔支、胃支出现率为100%。迷走神经后干及其属支与胃左动脉关系分型：紧密型9例（22.0%）、中间型25例（61.0%）、游离型7例（17.0%）。远端切缘为（2.7±1.0）cm，近端切缘为（4.9±2.6）cm，胃左动脉长度为（4.0±0.6）cm，迷走神经后干长度为（5.1±1.2）cm，腹腔支长度为（4.2±0.6）cm，神经与胃左动脉共干长度为（2.1±0.9）cm。结论 充分了解迷走神经后干及其属支与胃左动脉的解剖关系对完成腹腔镜下保留幽门及迷走神经胃部分切除术有重要指导意义。     

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.     

保留迷走神经腹腔支胃癌根治术的临床研究

目的探讨保留迷走神经腹腔支胃癌根治术的临床应用价值。方法 128例胃癌病例随机分为两组,各64例,分别实行保留迷走神经腹腔支胃癌根治术（观察组）和传统胃癌根治术（对照组）,并进行胃肠动力学和胃肠激素分泌水平的对比。结果观察组在术后首次排气时间、首次排便时间优于对照组（P〈0.05）,而淋巴结清扫个数与对照组无明显区别（P〉0.05）。观察组血清胃泌素和基础胃酸分泌量明显低于对照组（P=0.001或P〈0.05）,而空腹血浆胰多肽水平明显高于对照组（P〈0.05）。空腹血清胰岛素水平两组无明显差异（P〉0.05）。结论保留迷走神经腹腔支的胃癌根治术能加快病人胃肠道功能的恢复和更好的营养吸收。     

Improved physical condition by limiting lymphadenectomy around the coeliac artery after distal gastrectomy for gastric cancer.

OBJECTIVE: To find out whether a less extensive lymphadenectomy could relieve the postoperative symptoms associated with D2 resection of gastric cancer. DESIGN: Retrospective study. SETTING: Teaching hospital, Japan. SUBJECTS: 142 patients who had dissection along the left gastric and common hepatic arteries and dissection of the perigastric nodes during curative distal gastrectomy without splenectomy or pancreatectomy between 1990 and 1994. 79 who had no dissection around the coeliac artery were compared with 63 who had. INTERVENTIONS: Questionnaires sent out in February 1996. MAIN OUTCOME MEASURES: Short term and long term morbidity. RESULTS: The patients who had had coeliac dissection were significantly more likely to prefer digestible and light food (p = 0.006); and were significantly more likely to complain of diarrhoea (p = 0.001), abdominal pain (p = 0.02), and late dumping (p = 0.03) than those who did not. Patients who had had coeliac dissection tended to eat more digestible foods in smaller volumes/meal during the early postoperative years, and had more abdominal pain, fullness, and oesophageal reflux during the later years. CONCLUSION: Limiting coeliac dissection during curative distal gastrectomy can improve the patients' physical condition postoperatively.     

多层螺旋CT腹腔干重建在腹腔镜胃癌根治术术前评价的价值

目的评价多层螺旋CT血管造影（multi-slice spiral CT angiography,MSCTA）对腹腔干及其分支血管的三维重建能力,探讨MSCTA在进展期胃癌腹腔镜手术前的评估价值。方法25例拟行腹腔镜辅助胃癌D2根治术行腹部螺旋CT增强扫描,用容积再现（volume rendering,VR）进行三维血管造影（CT angiography,CTA）,根据其CTA表现评价腹腔干及其分支血管的空间解剖特征,将所得的解剖学资料与腹腔镜下血管解剖对比。结果MSCTA准确显示胃左动脉25例,胃右动脉12例,胃十二指肠动脉全部显示,其中胃十二指肠动脉2例起自肝左动脉,1例起自肝右动脉。脾动脉起源相对固定。根据MSCTA结果指导腹腔镜下进展期胃癌D2根治术,手术均顺利完成,无中转开腹。重建的腹腔干及分支与术中活体解剖完全吻合。结论MSCTA能清晰显示腹腔动脉解剖和正确的空间关系,是一种有价值的腹腔镜辅助进展期胃癌D2根治术术前检查方法,可能为相关血管周围淋巴结的清扫提供线索。     

胃癌根治术中No.12a淋巴结正确清扫的意义和技巧

目的探讨胃癌根治术中No.12a淋巴结清扫的意义和技巧。方法回顾性分析笔者所在科室行No.12a淋巴结清扫的68例Ⅳ期胃癌患者的临床资料,结合笔者的手术实践提出在胃癌根治术时,清扫该组淋巴结的经验和体会。结果 68例Ⅳ期胃癌中共检出No.12a淋巴结556枚(5～11枚/例),平均8.17枚/例,No.12a淋巴结转移率为33.27%(185/556)。本组病例术后无吻合口漏、淋巴管瘘、出血等并发症发生。结论熟悉肝固有动脉周围解剖以及鞘内淋巴结清扫,胃左静脉和胃右动脉自根部结扎以及门静脉前壁和胃十二指肠动脉的充分显露是彻底清扫No.12a淋巴结的关键。     

腹腔镜远端胃癌D2 根治术临床疗效与相关解剖分析

目的：探讨腹腔镜辅助远端胃癌D2根治术的临床疗效及术中胃周血管解剖特点。 方法：回顾2011年6月—2013年6月45例腹腔镜下远端胃癌D2根治术的胃癌患者,对临床疗效及术中胃周血管解剖特点进行分析。 结果：45例患者中43例完成腹腔镜手术,平均手术时间（178.75±44.32）min,术中出血（100± 50）mL,清扫淋巴结（27.55±7.52）枚,术后胃肠功能恢复时间（3.2±1.1）d,下床活动时间（2.5±1.0）d,住院时间（11.5±7.5）d,术后并发症发生率为9.3%;胃周血管解剖中,胃网膜左血管主要起自脾动脉第3段,位于在胰尾上缘的胰前间隙。肠系膜上血管主要在胰颈下缘的胰后间隙,胰腺钩突及十二指肠水平部前方。胃网膜右血管主要在幽门下方与胰头之前的网膜内,但变异较大。腹腔干及其分支主要在胰体上缘的胰后间隙。胃胰襞、脾胰襞和肝胰襞是分别定位胃左动脉、脾动脉和肝总动脉的解剖标志。 结论：腹腔镜远端胃癌D2根治术是安全可行的,掌握好胃周血管解剖及定位是手术成功的关键。     

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.     

A Gastrectomy for early-stage gastric cancer patients with or without preserving celiac branches of vagus nerves: A meta-analysis

BackgroundVagus nerve-preserving gastrectomy is increasingly popular in treating gastric cancer in the early stage, however the long and short-term outcomes after gastrectomy while preserving the celiac branch of the vagus nerve are not well defined. We aimed to summarize and compare perioperative and longer-term outcomes after celiac branch vagus nerve-preserving gastrectomy (CBP, preserving both the celiac and hepatic branches of the vagus nerve), compared to those without CBP (non-CBP, only the hepatic branch of the vagus nerve is preserved).MethodsWe searched the Embase, PubMed, Cochrane Library and Web of Science databases for papers published before October 2021. The primary results were evaluated by short-term and long-term postoperative complications, whereas the secondary outcomes included surgery-related parameters, recovery-related parameters and overall survival. Random-effects or fixed-effects model were used to estimate odds ratio, and weighted mean difference for the outcomes. The underlying publication bias was identified via funnel charts, Begg's test and Egger's test. Sensitivity analysis was conducted by removing the research one by one.ResultsA total of 9 studies consisting of 8 retrospective studies and one randomized control trial were included. The analysis included 1,109 patients, with 568 (51.2%) of patients receiving CBP and 541 (48.8%) patients who received non-CBP. The CBP group had a shorter time in terms of first flatus (weighted mean difference = -0.436, 95% confidence interval: -0.603 to -0.269; P < 0.001) and hospital stay (weighted mean difference = -0.456, 95% confidence interval: -0.874 to -0.037, P = 0.033) than the non-CBP group, but the time to the start of oral intake was comparable between the groups. Regarding short-term complications and surgery-related parameters, between CBP and non-CBP, no evident differences were observed in pancreatic complications, anastomotic leakage, postoperative bleeding, operation time, blood loss or lymph nodes examined. In terms of long-term complications, the incidence of gallstones in CBP was lower than that in non-CBP (odds ratio = 0.582, 95% confidence interval: 0.356–0.953, P = 0.031), and the incidence of bile reflux in CBP was lower than that in non-CBP (odds ratio = 0.473, 95% confidence interval: 0.280–0.800, P = 0.005). However, the prevalence rates of diarrhea, early dumping syndrome, esophageal reflux, and delayed gastric emptying were comparable between CBP and non-CBP.ConclusionThe present research showed that gastric cancer patients in the early stage under CBP were superior to those without CBP in terms of incidence of gallstones, bile reflux, time of first flatus and hospital stay. Furthermore, it is imperative to conduct randomized control studies with larger sample sizes to determine the oncological survival outcomes when preserving the celiac branch.     

胃癌患者手术前胃左动脉的CT三维血管重建检查

目的 术前了解胃癌患者胃左动脉的解剖,指导术中N07组淋巴结的清扫.方法 利用64排螺旋CT三维血管重建技术在术前检查胃癌患者胃左动脉的起始位置.结果 本组共观察731例.胃左动脉起于腹腔动脉干者635例,其中起于肝总动脉和脾动脉分支处者176例,起于腹腔干前1/3者292例,起于中1/3者135例,起于后1/3者32例.起于其他地方者共78例,其中起于腹腔干与腹主动脉夹角处者9例,起于腹主动脉者28例,起于胃脾动脉干者27例,起于脾动脉者4例,起于肝总动脉者4例,起于肝左动脉者1例,起于肝胃动脉干者4例,起于肠系膜上动脉者1例.15例胃左动脉缺如.3例特殊变异.结论 术前掌握胃癌患者胃左动脉起始位置及变异情况对顺利清扫其周围淋巴结,避免血管损伤有重要意义.     

Laparoscopy-assisted distal gastrectomy for early gastric cancer

Background Laparoscopy-assisted distal gastrectomy (LADG) is gaining wider acceptance for the treatment of early gastric cancer. However, firm evidence supporting its safety and usefulness is scant, and no study has compared the outcomes of various procedures for LADG. We examined the surgical outcomes of LADG performed using different methods for lymph node dissection. Methods Between September 1998 and January 2005, we performed LADG in 111 patients with early gastric cancer. In the 55 patients treated initially, group 2 lymph node dissection was performed through a small, 7-cm-long incision (minilaparotomy). In 43 of these patients, hand-assisted laparoscopic surgery (HALS) was done. In the 56 patients treated more recently, lymph node dissection was performed laparoscopically. In 31 of these patients, the celiac branches of the vagus nerve were preserved. Clinical outcomes of these procedures were compared. Results In the first 55 patients, HALS significantly shortened the operation time (277 vs 243 min, p < 0.05). In the latter 56 patients, LADG with preservation of the celiac branches of the vagus nerve was associated with a longer operation time (283 vs 228 min, p < 0.01) and higher blood loss (150 vs 92 g, p < 0.05) than with LADG without celiac branch preservation. There were no differences among the various operative procedures in postoperative course, including the length of the postoperative hospital stay or the rate of complications. Conclusions LADG is a safe and technically feasible procedure for the treatment of early gastric cancer. Laparoscopic lymph node dissection provided a good visual field and was easier to perform and required less time when the celiac branches of the vagus nerve were not preserved, with no negative effect on outcome.     

早期胃癌的诊断与外科治疗

目的总结14例早期胃癌临床特点及诊治经验，并探讨最佳诊治方法。方法对14例早期胃癌患者的资料进行回顾性分析。结果本组病例全部接受纤维胃镜或电子胃镜检查，确诊率96．8％；本组2例采用内镜粘膜切除术：2例采用保留迷走神经胃段切除术；其余10例采用D2根治术8例，Dt根治术2例。结论早期胃癌缺乏特异症状、早期误诊率高，胃镜检查是诊断早期胃癌的首选方法。D2根治术应做为根治早期胃癌的标准术式．内镜下粘膜切除术、保留迷走神经胃段切除术有利于保持患者术后生存质量。     

多层螺旋CT血管成像对腹腔镜辅助下胃切除术的价值

目的探讨腹腔镜辅助下胃切除术前多层螺旋CT血管造影（MSCTA），评价胃周血管解剖中的价值。方法30例拟行腹腔镜辅助下胃远端切除术的患者行多层螺旋CT双期扫描，其动、静脉期图像采用容积再现重建技术分别行三维CT血管造影（CTA）。3位观察者根据其CT血管成像表现，评价胃左动脉、胃右动脉、替代肝左动脉以及胃左静脉解剖，其结果与手术对照。结果三维CTA准确显示胃左动脉30例、胃右动脉29例，胃左静脉30例。1例胃右动脉CTA未能发现，但术中发现其管径细小。6例患者CTA发现伴有替代肝左动脉。根据三维CTA制定手术方案，所有30例患者腹腔镜辅助下胃远端切除术均获得成功。以手术结果为对照，CTA显示胃左动脉、胃左静脉和替代肝左动脉敏感性和阳性预测值均为100％；显示胃右动脉敏感性为100％，阳性预测值为96％。结论MSCTA能够准确评价胃的血管解剖，有利于安全快速进行腹腔镜辅助下胃远端切除术。     

Pylorus-preserving gastrectomy in gastric cancer surgery—open and laparoscopic approaches

Background and aims Pylorus-preserving gastrectomy (PPG) has been accepted as a function-preserving procedure for early gastric cancer for the prevention of postgastrectomy syndrome. In general, PPG procedures have not included suprapyloric lymph node dissection to preserve the pyloric branch of the vagal nerve and the right gastric artery. The aim of this article is to describe procedures for PPG. The technique of laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) is also introduced because PPG is an ideal application for laparoscopic surgery.Patients/methods Between September 2000 and September 2004, we performed 37 cases of conventional PPG and further 73 cases of LAPPG. In these patients, PPG including complete lymph node dissection around the remnant pyloric cuff was performed. For this purpose, it is recommended that the blood flow to the pyloric cuff be maintained by preserving the infrapyloric artery.Results All the patients showed good postoperative recovery, and no intraoperative or postoperative major complications were observed. No sign of recurrence was found in these 110 patients, and none of them demonstrated dumping syndrome.Conclusion The procedures of both PPG and LAPPG are technically feasible and have an important role in the surgical management of early gastric cancer in terms of better quality of postoperative life, even with lymphadenectomy including combined suprapyloric lymph node dissection and right gastric artery division.     

The hepatic artery: a reminder of surgical anatomy

This study was carried out to document the anatomy of the hepatic artery with the purpose of reminding surgeons of the need for this essential knowledge in order to practice safe hepatobiliary surgery. Repeated surgical mistakes on patients referred to our unit prompted the study. One hundred and eighty consecutive livers procured for transplantation was studied, and the anatomy drawn immediately after dissection. The left hepatic artery arose from the left gastric artery in 15%, and either the splenic, gastroduodenal artery or the aorta in 4% of cases. The right hepatic artery arose from the superior mesenteric artery in 15%, the gastroduodenal, right gastric artery or aorta in 10% of cases. There was a major variation of the coeliac axis in 9% of cases studied. Overall, there was an abnormality in 43% of dissections: 48% were multiple and 27% had more than two vascular variations. A constant pattern of abnormalities occurred in the anatomy of the hepatic artery. Realisation of this vascular pattern should make identification of the anatomy easier. When there is one vascular variation, there is a high chance of there being multiple variations.     

刮吸解剖法在进展期胃癌淋巴结清扫术中的应用

目的　探讨刮吸解剖法在进展期胃癌淋巴结清扫术中的应用效果。方法　回顾性总结行刮吸法淋巴结清扫术的28例进展期胃癌患者的临床资料。行远端胃切除11例,近端胃切除11例（其中3例附加脾切除）,全胃切除6例（其中1例附加左肝外叶及双侧附件切除）。淋巴结清扫标准为D219例,选择性D39例。结果　所有手术均顺利完成,未发生血管损伤等严重并发症,术中平均出血290 m l。28例共清除淋巴结609枚,平均21.7枚/例。25例随访6-24月,7例复发,6例死亡（其中3例为复发者）,15例无瘤存活。结论　刮吸法行胃癌淋巴结清扫安全性高、出血量小、并发症少,淋巴结清扫和术后恢复均较满意,值得临床进一步探索和应用。     

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.     

胃癌第2站淋巴结清扫方法的研究

目的总结胃癌第2站淋巴结清扫的手术体会。方法对57例胃癌D2淋巴结清扫手术方法及结果进行回顾性研究,统计淋巴结清扫数目、手术失血量、术后并发症,总结安全彻底的胃癌第2站淋巴结清扫经验及术中注意事项。结果 57例胃癌患者D2手术均取得成功,共清扫淋巴结1543枚,平均27.07枚;淋巴结癌转移共486枚,转移率31.5%。手术失血量平均244.7ml。术后并发症发生率22.8%,未出现淋巴结清扫相关的并发症。结论在熟悉胃周局部解剖,掌握淋巴结清扫技术,遵循解剖层次分离的基础上,是可以安全彻底地进行胃癌第2站淋巴结清扫的。     

Comparison of long-term prognosis of laparoscopy-assisted gastrectomy and conventional open gastrectomy with special reference to D2 lymph node dissection

Background

Laparoscopy-assisted gastrectomy (LAG) is becoming widely used for early gastric cancer. However, how the curability and long-term prognosis of LAG and open gastrectomy (OG) for early and advanced gastric cancer compare remains unclear. This study assessed short- and long-term outcomes after LAG with lymph node dissection in early and advanced gastric cancer.

Methods

A total of 332 patients who underwent LAG or OG for early and advanced gastric cancer from January 2001 through December 2010 were reviewed retrospectively. The mean operating time, estimated mean blood loss, number of dissected lymph nodes, and survival rates were compared between LAG and OG for early and advanced gastric cancer.

Results

Overall, 47.6% (158/332) of patients underwent LAG; D1, D1+ lymph node dissection was carried out in 77.2%, with D2 dissection in 22.8%. Only one patient required conversion to OG. Comparing LAG and OG with D1, D1+ lymph node dissection for early gastric cancer (EGC), mean operating time was significantly longer, estimated mean blood loss was significantly smaller, and the average number of retrieved lymph nodes was significantly greater with LAG. The rate of specific postoperative morbidity was 17.2% for LAG patients and 25.0% for OG patients, with no postoperative mortality. Survival and recurrence rates were not significantly different. Comparing LAG and OG with D2 lymph node dissection for advanced gastric cancer (AGC), mean operating time was significantly longer and estimated mean blood loss was significantly smaller with LAG, while the average number of retrieved lymph nodes, specific postoperative morbidity and mortality, and survival and recurrence rates were not significantly different.

Conclusions

LAG with D1, D1+ lymph node dissection for EGC is safe and equivalent to open gastrectomy in curability. Moreover, LAG with D2 lymph node dissection for AGC is comparable to OG with D2 lymph node dissection with regard to short- and long-term results.     

Gastric cancer occurred after coronary artery bypass grafting using the right gastroepiploic artery.

We recently encountered a rare case where gastric cancer developed in the long-term postoperative stage after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and distal partial gastrectomy was performed to treat the cancer. The patient was a 64-year-old man. In November 2001, he underwent three-vessel CABG, involving bypassing between the right coronary artery (RCA) and the RGEA, to treat an old myocardial infarction. In May 2003, he was admitted to our hospital because of exacerbation of diabetes mellitus and anemia. Gastric endoscopy revealed gastric cancer affecting the pylorus. Preoperative abdominal angiography showed the RGEA graft remained well patent. In June 2003, he underwent distal partial gastrectomy and regional lymph node dissection. Because the RGEA had been freed adequately to the point of bifurcation of the gastroduodenal artery during the previous CABG, the RGEA graft was preserved during distal partial gastrectomy. When the RGEA is used for CABG, it seems advisable to free the RGEA adequately to a point of bifurcation of the gastroduodenal artery. If done so, regional lymph node dissection around the RGEA is easier to perform when gastric cancer has occurred in these cases, eventually reducing the risk for injury of the graft. Following CABG with the RGEA, it seems essential to perform periodical checks for gastric cancer to facilitate early detection of gastric cancer. The necessity of close follow-up of these cases is endorsed by the fact that healing of gastric cancer by endoscopic mucosal resection (EMR) is highly probable if the cancer is detected at early stages.