Conventional Distal Gastrectomy Research Articles

Robotic distal gastrectomy plus spleen-preserving distal pancreatectomy: optimal resection for simultaneous gastric cancer and intraductal papillary mucinous neoplasm of the pancreatic body

BackgroundOrgan-preserving surgery has recently gained increasing attention. However, performing the surgery for duplicated gastric and distal pancreatic tumors is difficult because of procedural complexity and concerns of remnant gastric necrosis. We present the first case of simultaneous robotic distal gastrectomy plus spleen-preserving distal pancreatectomy in a patient with overlapping gastric cancer and intraductal papillary mucinous neoplasm.Case presentationA 78-year-old man was diagnosed with gastric cancer in the middle stomach and intraductal papillary mucinous neoplasm of the pancreatic body. Radical cure surgery was performed using the da Vinci Xi robotic system. Conventional distal gastrectomy was initially completed using near-infrared ray guidance when transecting the stomach. After dividing the pancreas, the parenchyma of the distal pancreas was detached from the splenic artery and vein; multiple branches from these splenic vessels were dissected. Indocyanine green imaging confirmed sufficient blood flow in the splenic vessels and perfusion of the remnant stomach. Ultimately, gastrointestinal reconstruction was performed, and the postoperative course was uneventful.ConclusionsThe robotic distal gastrectomy plus spleen-preserving distal pancreatectomy procedure was safely performed. Compared to the total gastrectomy plus distal pancreatectomy with splenectomy procedure, this technique may improve the quality of dietary life, reduce weight loss, and prevent complications associated with splenectomy.

Pylorus-preserving gastrectomy for early middle gastric cancer (T1a-bN0M0) is safer and more effective than distal gastrectomy: a narrative review

As a treatment option for early middle gastric cancer, pylorus-preserving gastrectomy (PPG) has been shown to exhibit good clinical efficacy in Japan and Korea and has attracted widespread attention in China. PPG has a similar surgical safety to conventional distal gastrectomy (DG). The incidence of postoperative complications (such as dumping syndrome, bile reflux gastritis, gallstones, weight loss, and malnutrition) has been shown to be lower, while that of delayed gastric emptying (DGE) was higher after PPG than after DG. However, preserving the vagus nerve, blood supply to the pylorus, and adequate antral cuff length can effectively reduce DGE after PPG. Whether or not incomplete lymphadenectomy affects tumor safety is a primary focus for concern. According to the analysis of lymph node metastasis rates in early middle gastric cancer, the metastasis rates of lymph nodes No. 5 and No. 6 were low, providing a theoretical basis for performing limited lymph node dissection.

Pathological and oncological outcomes of pylorus-preserving versus conventional distal gastrectomy in early gastric cancer: a systematic review and meta-analysis

BackgroundPylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC) in the middle third of the stomach. According to the literature reports, PPG decreases the incidence of dumping syndrome, bile reflux, gallstone formation, and nutritional deficit compared with conventional distal gastrectomy (CDG). However, the debates about PPG have been dominated by the incomplete lymphadenectomy and oncological safety. We carried out a systematic review and meta-analysis to evaluate the pathological and oncological outcomes of PPG.MethodsThe protocol was registered in PROSPERO under number CRD42022304677. Databases including PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials were searched before February 21, 2022. The outcomes included the pooled odds ratios (ORs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. For all outcomes, 95% confidence intervals (CIs) were calculated. Meta-analysis was performed using STATA software (Stata 14, Stata Corporation, Texas) and Review Manager 5.4.ResultsA total of 4500 patients from 16 studies were included. Compared with the CDG group, the PPG group had fewer lymph nodes harvested (WMD= −3.09; 95% CI −4.75 to −1.43; P < 0.001). Differences in the number of resected lymph nodes were observed at stations No. 5, No. 6, No. 9, and No. 11p. There were no differences in lymph node metastasis at each station. Shorter proximal resection margins (WMD = −0.554; 95% CI −0.999 to −0.108; P = 0.015) and distal resection margins (WMD = −1.569; 95% CI −3.132 to −0.007; P = 0.049) were observed in the PPG group. There were no significant differences in pathological T1a stage (OR = 0.99; 95% CI 0.80 to 1.23; P = 0.88), T1b stage (OR = 1.01; 95% CI 0.81 to 1.26; P = 0.88), N0 stage (OR = 0.97; 95% CI 0.63 to 1.48; P = 0.88), tumor size (WMD = −0.10; 95% CI −0.25 to 0.05; P = 0.187), differentiated carcinoma (OR = 1.04; 95% CI 0.74 to 1.47; P = 0.812) or signet ring cell carcinoma (OR = 1.22; 95% CI 0.90 to 1.64; P = 0.198). No significant differences were observed between the groups in terms of overall survival (HR = 0.63; 95% CI 0.24 to 1.67; P = 0.852) or recurrence-free survival (HR = 0.29; 95% CI 0.03 to 2.67; P = 0.900).ConclusionsThe meta-analysis of existing evidence demonstrated that the survival outcomes of PPG may be comparable to those of CDG. However, fewer lymph nodes at stations in No. 5, No. 6, No. 9, and No. 11p were harvested with PPG. We also found shorter proximal resection margins and distal resection margins for PPG, meaning more remnant stomachs would be preserved in PPG.

Reduced-port totally robotic distal subtotal gastrectomy for gastric cancer: 100 consecutive cases in comparison with conventional robotic and laparoscopic distal subtotal gastrectomy

By overcoming technical difficulties with limited access faced when performing reduced-port surgery for gastric cancer, reduced-port totally robotic gastrectomy (RPRDG) could be a safe alternative to conventional minimally invasive gastrectomy. An initial 100 consecutive cases of RPRDG for gastric cancer were performed from February 2016 to September 2018. Short-term outcomes for RPRDG with those for 261 conventional laparoscopic (CLDG) and for 241 robotic procedures (CRDG) over the same period were compared. Learning curve analysis for RPRDG was conducted to determine whether this procedure could be readily performed despite fewer access. During the first 100 cases of RPRDG, no surgeries were converted to open or laparoscopic surgery, and no additional ports were required. RPRDG showed longer operation time than CLDG (188.4 min vs. 166.2 min, p < 0.001) and similar operation time with CRDG (183.1 min, p = 0.315). The blood loss was 35.4 ml for RPRDG, 85.2 ml for CLDG (p < 0.001), and 41.2 ml for CRDG (p = 0.33). The numbers of retrieved lymph nodes were 50.5 for RPRDG, 43.9 for CLDG (p = 0.003), and 55.0 for CRDG (p = 0.055). Postoperative maximum C-reactive protein levels were 96.8 mg/L for RPRDG, 87.8 mg/L for CLDG (p = 0.454), and 81.9 mg/L for CRDG (p = 0.027). Learning curve analysis indicated that the overall operation time of RPRDG stabilized at 180 min after 21 cases. The incidence of major postoperative complications did not differ among groups. RPRDG for gastric cancer is a feasible and safe alternative to conventional minimally invasive surgery. Notwithstanding, this procedure failed to reduce postoperative inflammatory responses.

Comparison Surgical Outcomes between Laparoscopic and Conventional Distal Gastrectomy for Early Gastric Cancer in Obese Patients

Comparison Surgical Outcomes between Laparoscopic and Conventional Distal Gastrectomy for Early Gastric Cancer in Obese Patients

Reduced port surgery and reduced surgical staff surgery for gastric cancer

Background: We have been performing a triple incision lapa-roscopic distal gastrectomy (TIL-DG) as a reduced port surgery. This procedure is also useful for reducing the number of required surgical staff, since a TIL-DG requires only two operators. This concept can also be applied to a laparoscopic total gastrectomy (LTG). Methods: A total of 121 patients underwent a TIL-DG, and a total of 39 patients underwent a laparoscopic total gastrectomy performed by two surgical staff members (re-LTG). These cases were compared with those in a conventional laparo-scopic distal gastrectomy (LDG) group (59 cases) and a conventional LTG group (79 cases). Results: No significant differences were observed between the TIL-DG group and the LDG group in terms of the mean operative time, blood loss, or the length of the postoperative hospital stay. The mean number of retrieved lymph nodes in the TIL-DG group was slightly higher than that in the LDG group. No significant differences were observed between the Re-LTG group and the LTG group in terms of the mean op-erative time, blood loss, the number of retrieved lymph nodes, or the length of the post-operative hospital stay. Conclusions: TIL-DG and re-LTG are feasible and safe pro-cedures.

Phase II, prospective, single-arm, single-institutional, open-label clinical trial on laparoscopic sentinel node navigation surgery in early gastric cancer.

90 Background: The aim of this study was to evaluate the feasibility and safety of laparoscopic limited gastrectomy with sentinel basin (SB) dissection for gastric cancer using simultaneous indocyanine green and 99mTc-antimony sulfur colloid injections. Methods: The primary end point was the 3-year relapse-free survival rate of the patients who underwent laparoscopic sentinel node navigation surgery (SNNS). Secondary end points included sentinel node (SN) detection rate, false negative rate of intraoperative pathologic examinations for metastatic SN detection, postoperative morbidity and mortality, quality of life (QOL), and overall survival. Results: From July 2010 to April 2013, 100 patients were enrolled to this study. The SBs were identified in all patients (100%) by dual method. The mean number of SN and non-SN was 6.07 ± 3.84 [range 0-17] and 4.60 ± 4.76 [range 0-25]. Eleven patients had SN metastasis and they were converted to conventional laparoscopic gastrectomy with radical lymphadenectomy. Among 89 patients with negative SNs, 3 patients were considered as false negative of intraoperative pathological examination (3.37%). There was no significant difference between SN negative (n = 89) and positive (n = 11) groups in estimated blood loss, postoperative hospital stays and complication rate. Overall, QOL scores are more likely to be better in SNNS group than in conventional laparoscopic distal gastrectomy group. After median follow-up periods of 47.5 months in all patients, 4 patients who underwent SNNS died, and 2 patients who underwent SNNS had recurrences of cancer. The 3-year relapse-free survival rate for all patients (n = 100) was 97.0 %. In the subgroup analysis, the 3-year relapse-free for the SN negative group was 96.6%, and 100% for the SN positive group (P = 0.374). The 3-year overall survival rate was 98.0% for all patients; 97.7% for the SN negative group and 100% for the SN positive group (P = 0.418). Conclusions: Laparoscopic SNNS was feasible and safe in early gastric cancer. Phase III randomized controlled trial on comparing laparoscopic SNNS and conventional laparoscopic gastrectomy will be needed based on the present study. Clinical trial information: NCT01441310.

Commentary on a randomized controlled trial of vagus nerve- preserving distal gastrectomy in early gastric cancer

The rst randomized controlled trial (RCT) of vagal nerve- preserving distal gastrectomy (VPDG) was reported by Kim and colleagues. The study was performed in a single Korean institution (1). This RCT showed several advantages with respect to the postoperative quality of life (QoL). Patients with a diagnosis of early gastric cancer without lymph node metastasis were randomly assigned in a 1:1 ratio to VPDG or conventional distal gastrectomy (CDG). Both the hepatic branch of the anterior vagal nerve and the celiac branch of the posterior vagal nerve were preserved in the VPDG group, while both branches were resected proximally in the CDG group. QoL was assessed by a validated Korean version of the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire before gastrectomy and 3 and 12 months postoperatively. Scores of diarrhea symptoms and appetite loss were significantly lower in the VPDG group than in the CDG group 3 and 12 months postoperatively. VPDG thus reduced diarrhea and anorexia.

A Randomized Controlled Trial of Vagus Nerve-preserving Distal Gastrectomy Versus Conventional Distal Gastrectomy for Postoperative Quality of Life in Early Stage Gastric Cancer Patients

To compare the postoperative quality of life of vagus nerve preserving distal gastrectomy (VPG) vs conventional distal gastrectomy (CG) in patients with early-stage gastric cancer. Randomized controlled clinical trial. Large tertiary comprehensive cancer center in Korea. One hundred sixty-three patients with early gastric cancer 18 years of age or older expected to undergo curative gastric resection. Patients were randomized 1:1 to VPG (n = 85) or CG (n = 78). European Organization for Research and Treatment of Cancer (EORTC) gastric module (STO22). Patients assigned to VPG showed less diarrhea 3 and 12 months after surgery (P = 0.040 and 0.048, respectively) and less appetite loss at 12 months (P = 0.011) compared with those assigned to CG. In both groups, fatigue, anxiety, eating restriction, and body image deteriorated at 3 months after surgery and did not regain baseline levels 12 months after surgery. There were no significant differences between the 2 groups in cancer recurrence and death over 5 years of follow-up. Early gastric cancer patients undergoing VPG reported significantly less diarrhea and appetite loss at 12 months postsurgery compared with those undergoing CG, with no differences in long-term clinical outcomes. VPG may improve the quality of life after gastrectomy in early gastric cancer patients compared with CG.

Oncological outcomes of function preserving gastrectomy for early gastric cancer: A multicenter case-controlled analysis comparing pylorus-preserving gastrectomy versus conventional distal gastrectomy.

4034Background: The aim of this study was to clarify the oncological safety of pylorus-preserving gastrectomy (PPG) compared with conventional distal gastrectomy (DG). Methods: From three instituti...

A new oval multichannel port to facilitate reduced port distal gastrectomy

Background: This report describes the techniques and outcomes of reduced port distal gastrectomy (RPDG) using a new oval multichannel port. Material and methods: We performed reduced port distal gastrectomy through the E·Z Access™ oval type device with three trocars in the umbilical incision, plus the use of additional 5 mm and 2 mm ports. All routine procedures performed in conventional laparoscopic distal gastrectomy (CLDG) were achieved in RPDG. Results: We employed this technique without the use of additional trocars or conversion to laparotomy in all 25 patients. The median length of the operation was 340 (range, 220–487) minutes, and the median estimated blood loss was 30 (range, 5–440) ml. Neither major postoperative complications, such as anastomotic leakage and stricture, nor postoperative mortality were observed. The mean length of the hospital stay was 11 days. The umbilical wound was indistinct. The patients were also highly satisfied with the cosmetic outcome. Conclusion: Reduced port surgery using the E·Z Access™ oval type device was successfully applied for gastric cancer. This method is technically feasible, produces superior cosmetic results and thus could be an attractive surgical option for gastric cancer patients.

128. The short-term outcomes of conventional and pure single-incision laparoscopic distal gastrectomy for early gastric cancer

128. The short-term outcomes of conventional and pure single-incision laparoscopic distal gastrectomy for early gastric cancer

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

Pylorus-preserving gastrectomy (PPG) has been performed to reduce postprandial symptoms for some early gastric cancer (EGC) cases. The aim of this study was to evaluate the possible advantages after PPG for middle-third EGC in comparison with distal gastrectomy. We searched Medline, Embase, and Science Citation Index Expanded for relevant studies. Statistical analyses were conducted to calculate the summary weighted mean differences (WMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) using random-effects models. We identified 15 nonrandomized controlled trials (16 studies) with 1774 patients, which consisted of 11 studies for conventional PPG (CPPG) versus conventional distal gastrectomy (CDG) and 5 studies for laparoscopy-assisted PPG (LAPPG) versus laparoscopy-assisted distal gastrectomy (LADG). Meta-analysis of CPPG versus CDG revealed that CPPG had the advantage of prevention of early dumping syndrome (OR=0.18; 95% CI 0.12, 0.27), gastritis (OR=0.19; 95% CI 0.07, 0.53), duodenal juice reflux (OR=0.20; 95% CI 0.06, 0.66), and regaining of weight (WMD=3.53; 95% CI 2.34, 4.72). However, the incidence of gastric stasis was higher in the CPPG group than in the CDG group (OR=1.70; 95% CI 1.13, 2.57). Meta-analysis of LAPPG versus LADG revealed that LAPPG shortened the operation time (WMD=-21.12; 95% CI -31.33, -10.90) and did not increase the occurrence of postoperative complication (OR=0.72; 95% CI 0.41, 1.27). With the benefits of prevention of early dumping syndrome, duodenal juice reflux, gastritis, and regaining of weight, PPG can be an excellent option for middle-third EGC.

Is Pylorus-preserving Gastrectomy Universally Applicable to Early Gastric Cancer of the Mid Stomach?

Recent advances in endoscopic diagnosis have allowed gastric cancer to be diagnosed early, often in asymptomatic patients. Currently, endoscopic mucosal resection and endoscopic submucosal dissection are accepted as the least invasive procedures when managing early gastric cancer (cT1). An important intermediate option before open gastrectomy is laparoscopic gastrectomy. Advanced laparoscopic gastrectomy contributes to both improved esthetics and earlier postoperative recovery. However, quality of life is mainly affected by late-postoperative phase complications, such as dumping syndrome and loss in body weight resulting from reduced oral intake. Pylorus-preserving gastrectomy (PPG), with limited stomach resection and lymph node dissection, is an example of function-preserving surgery that can improve late-postoperative phase function. In general, PPG is applicable to patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the middle third of the stomach, when the distal tumor border is C4 cm away from the pylorus. During the procedure, infrapyloric vessels are routinely preserved to maintain a suitable blood supply to the pyloric cuff, as is the root of the right gastric artery. Furthermore, the hepatic and pyloric branches of the vagus nerves are routinely preserved. More recently, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with lymphadenectomy has presented an attractive option. Several groups have indicated that LAPPG is a feasible and reliable procedure with satisfactory postoperative symptoms and functional outcomes. However, the incidence of metastasis in the preserved regional lymph nodes remains an obstacle to the wider application of the function-preserving surgery. In particular, lymph nodes at the suprapyloric and infrapyloric stations may be incompletely dissected when preserving nerve and arterial branches in either PPG or LAPPG. Therefore, metastatic tumor in residual suprapyloric and infrapyloric lymph nodes may contribute to disease recurrence in patients who undergo PPG. Although several studies have indicated acceptable long-term outcomes and survival rates after both PPG and LAPPG, neither has gained widespread use in standard clinical practice. Recently, Kim et al. attempted to evaluate the status of micrometastasis in suprapyloric and infrapyloric lymph nodes in early gastric cancers that are located in the mid stomach and managed with PPG. They found that the mean number of collected suprapyloric lymph nodes was significantly lower after PPG than with conventional distal gastrectomy; the findings were not significant for infrapyloric lymph nodes. Moreover, they determined that all metastasis (both macro and micro) to suprapyloric and infrapyloric lymph nodes are essentially very rare and that the long-term survival of patients after PPG was acceptable. They concluded that micrometastasis to the suprapyloric and infrapyloric lymph nodes may be negligible, and that PPG may be a safe procedure for early gastric cancer located in the mid stomach. This study essentially supports earlier work evaluating the oncological reliability of PPG. However, this study should be interpreted with caution because it was retrospective in design and involved a single-center cohort with a relatively small number of patients. Furthermore, the study failed to completely assess the primary tumor location (e.g., lesser curvature side, anterior wall). When evaluating a surgical procedure in a single-center study, results can be biased by the surgical skill base at that institution. In particular, LAPPG is a technically difficult surgery for inexperienced surgeons, involving precise Society of Surgical Oncology 2013

Oncologic Safety of Pylorus-preserving Gastrectomy in the Aspect of Micrometastasis in Lymph Nodes at Stations 5 and 6

Pylorus-preserving gastrectomy (PPG) is a function-preserving gastrectomy for early gastric cancers (EGCs) that are preoperatively assessed as pN0 tumors and located in the middle portion of the stomach. In PPG, dissection of the lymph nodes at stations 5 and 6 is frequently incomplete, and this may be worrisome in terms of oncologic safety. We examined lymph nodes collected from stations 5 and 6 from 196 patients who had undergone conventional distal gastrectomy (CDG) for EGC located in the middle portion of the stomach and from 24 patients who had undergone PPG. The average number of lymph nodes collected at station 5 was significantly lower with PPG than with CDG (0.08 vs. 1.32, respectively; P = 0.008). However, such a difference was not noted for station 6 nodes. The rate of macrometastasis was very low in all station 5 nodes (1 of 220, 0.45%) and station 6 nodes (1 of 220, 0.45%). Immunohistochemical analysis of cytokeratin in 109 cases of the CDG group and 21 cases of the PPG group showed that micrometastasis of single isolated tumor cell type was observed in only one station 6 lymph node of a patient who was initially diagnosed with pN0 EGC. There were no cases of micrometastasis in station 5 nodes. The possibility of micrometastasis to station 5 and/or 6 lymph nodes may be negligible for EGC located in the middle portion of the stomach, and PPG thus might be the oncologically safe procedure when considering micrometastasis in remaining nodes in vivo at stations 5 and 6.

Relationship between Inter-digestive Migrating Motor Complex and Quality of Life in Patients after Conventional Distal Gastrectomy for Gastric Cancer

To clarify the significance of duodenal interdigestive migrating complex (IMMC) in patients after conventional distal gastrectomy (COG), we studied the relationships between lMMC and postoperative quality of life (QOL). A total of 48 patients (32 males, 16 females; 39 to 68 years, mean, 57.4 years) at two years after CDG for gastric cancer (Billroth I, D2 lymph node dissection, curability A) were divided into two groups (IMMC-positive group; 34 patients, IMMC-negative group; 14 patients) according to the occurrence of IMMC from duodenum and their postoperative QOL was compared. IMMC was only found from the duodenum, and not from the remnant stomach. 1) Patients in the IMMC-positive group had evidently more appetite and ate more food with less decrease in body weight compared with the IMMC-negative group; 2) Patients in the IMMC-positive group had clearly less symptoms such as early dumping symptoms, symptoms of reflux esophagitis, nausea, abdominal pain, diarrhea, abdominal fullness, borborygmus and diarrhea compared with the negative group. The IMMC-positive group showed more satisfactory QOL compared with the negative group.

The benefits of laparoscopically assisted distal gastrectomy for obese patients

In Japan, the number of obese patients with gastric cancer is increasing. This study aimed to evaluate the advantages of laparoscopically assisted distal gastrectomy (LADG) for obese patients relative to those of conventional distal gastrectomy (DG). Between January 2004 and June 2009, a total of 197 consecutive patients with gastric carcinoma underwent curative distal gastrectomy with Billroth 1 reconstruction in the Gunma University Hospital. The patients were assigned to undergo LADG (n = 120) or DG (n = 77) according to the depth of tumor invasion and lymph node status. A body mass (BMI) of 25 kg/m(2) or higher was defined as obesity, and the amounts of blood loss, the operating time, the number of lymph nodes dissected, and the postoperative complications experienced by obese and nonobese patients were compared. None of the patients in the LADG group required conversion to laparotomy. In the DG group, significantly fewer lymph nodes were retrieved from the obese patients (22.5 ± 3.4) than from the nonobese patients (31.9 ± 2.0; P < 0.05). However, among the obese patients, the number of lymph nodes retrieved did not differ significantly between the LADG and DG groups. In the LADG group, the obese patients had a longer operating time (206.6 ± 6.3 vs. 192.0 ± 3.1 min; P < 0.05) and a greater estimated blood loss (158.2 ± 24.7 vs. 101.9 ± 10.4 ml; P < 0.05) than the nonobese patients. The estimated blood loss correlated the surgical procedures and BMI. No significant difference in postoperative complications was noted between the obese and nonobese groups after each procedure. Relative to DG, LADG did not affect the radicality of the procedure for the obese patients, and there is no significant difference in the operating time. The estimated blood loss was significantly less for LADG than for DG. Surgeons should elect to perform LADG for obese patients with gastric cancer.

Transectional gastrectomy: An old but renewed concept for early gastric cancer

Segmental resection of the stomach was first described at the end of the 19th century by Mikulicz, who devised it to preserve the pylorus when performing gastric ulcer surgery. Although this technique was abandoned because of delayed gastric emptying, in 1967 Maki et al. developed a new improved concept of segmental gastrectomy: pylorus-preserving gastrectomy (PPG). The dramatic decrease in the occurrence of gastric ulcers limited the opportunity to perform these operations; however, PPG was then used for treating early gastric cancer, the incidence of which has increased remarkably over the last two decades. From the viewpoint of surgical oncology, a rationale to justify reducing the range of lymphadenectomy is required for preserving the curability. Therefore, we devised a new technique of transectional gastrectomy using sentinel node navigation for early gastric cancer located in the middle third of the stomach. The results of a questionnaire about postoperative symptoms and endoscopic assessment indicated the superiority of transectional gastrectomy over conventional distal gastrectomy. Future confirmation of the sentinel node concept through a multi-institutional validation study conducted by the Japanese Society of Sentinel Node Navigation Surgery would lead to widespread adoption of transectional gastrectomy.

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

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. Between 1997 and 2007, 133 patients were diagnosed with early gastric cancer located in the middle third of the stomach. Distal gastrectomy was performed in 87 and PPG was performed in 46 of these patients. The clinicopathological characteristics were compared between the groups. There were fewer dissected lymph nodes in PPG (mean: 21.9) than in DG (mean: 30.4, P = 0.001). Complications were detected in 16.1% of DG patients and in 6.5% of PPG patients. The occurrence of stasis after PPG (6.5%) was similar to that observed after DG (6.9%). One patient in the DG group died from cancer recurrence, but cancer recurrence was not detected in the PPG group. Although the difference was not significant, the overall 5-year survival rate in the 46 PPG patients (95%) was better than that in the 87 DG patients (86%, P = 0.087). Pylorus-preserving gastrectomy patients had fewer postoperative complications than DG patients. The long-term follow-up of these patients will clarify the nutritional and prognostic benefits of PPG.

Clinical Outcome of Pylorus‐preserving Gastrectomy in Gastric Cancer in Comparison with Conventional Distal Gastrectomy with Billroth I Anastomosis

Pylorus-preserving gastrectomy (PPG) was originally a treatment option in gastric ulcer surgery and is now being performed as a limited surgery in some early gastric cancer cases. This study was designed to evaluate the postoperative functional characteristics of PPG versus conventional distal gastrectomy with Billroth I anastomosis (BI). Patients who underwent PPG (study group) between November 1999 and April 2003 were enrolled and BI patients (control group) were matched for number, gender, age, weight, height, stage, and follow-up period. We evaluated postprandial symptoms and nutritional status. Gastric emptying studies with a 99mTc gamma camera, follow-up endoscopies with random biopsies of remnant gastric mucosa to evaluate bile reflux gastritis, and ultrasonography to detect gallbladder stones were performed. Recurrence and survival also were investigated. Twenty-two PPG patients (study group) and 17 BI patients (control group) were enrolled. Overall modified Visick scores of postprandial symptoms were lower in PPG patients than in BI patients (0.9 +/- 0.7 vs. 2.3 +/- 1.4; p = 0.018). Gastric emptying was delayed in PPG patients versus BI patients for solids (p < 0.05). Moderate gastritis, bile reflux, and gallbladder stone were observed only in BI patients. Remnant stomach pathologic findings corresponding to bile reflux gastritis in the two groups were similar, except for Helicobacter pylori colonization. No recurrence occurred in either group (mean follow-up period = 41 +/- 9.5 months). PPG patients had fewer subjective postprandial symptoms than BI patients. The present study also suggests that PPG has advantages over BI in terms of the avoidance of bile reflux and gallbladder stones.