Function-preserving Gastrectomy Research Articles

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

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). 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 3-4cm. 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 30cm in length, with preservation of the marginal vessels in a retrocolic fashion. Thirteen patients with cT1 cN0 proximal gastric cancer underwent LAPPNTG at our institution. The median length of the operation and estimated blood loss were 329min and 138ml, 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. Performing LAPPNTG with a jejunal interposition is feasible and might be an appropriate treatment for proximal early gastric cancer.

Functional outcomes by reconstruction technique following laparoscopic proximal gastrectomy for gastric cancer: double tract versus jejunal interposition

BackgroundFor early gastric cancer located in the upper third of the stomach, we have adopted laparoscopic 1/2-proximal gastrectomy (PG) with two types of reconstruction: double tract reconstruction (L-DT) and jejunal interposition reconstruction with crimping of the jejunum on the anal side of the jejunogastrostomy with a knifeless linear stapler (L-JIP).MethodsFunctional outcomes were prospectively compared between these two types of reconstruction following laparoscopic PG. Resection and reconstruction were performed using L-DT (n = 10) and L-JIP (n = 10) alternately. Quality of life was evaluated through a questionnaire and endoscopic examination of the ten patients in each group, and functional evaluations were carried out in five patients of each group.ResultsThe postoperative/preoperative body weight ratio was significantly higher in the L-JIP group than in the L-DT group. While the incidence of reflux esophagitis was 10% in both groups, the endoscope could reach the remnant stomach in all patients. In the L-DT group, the plasma acetaminophen concentration at 15 minutes and the insulin level at 30 minutes were markedly increased after oral administration, while the increases in the blood sugar level at 30 and 60 minutes were more gradual than in the L-JIP group.ConclusionsWhile L-JIP may be thought of as the ideal method for function-preserving gastrectomy, L-DT may be suitable for gastric cancer patients with impaired glucose tolerance. These results raise the possibility of individualized selection of reconstruction for gastric cancer patients with various kinds of preoperative complications.

Feasibility and functional efficacy of distal gastrectomy with jejunal interposition for gastric cancer: A case series

IntroductionDistal gastrectomy with jejunal interposition (DGJI) has been used in our institution for selected patients with gastric cancer as a function-preserving gastrectomy. The aim of this retrospective study was to clarify the feasibility and functional efficacy of DGJI. MethodsA retrospective analysis was performed in 61 patients who underwent DGJI between 2002 and 2011. ResultsMean operation time was 393.8 min and blood loss was 463.3 ml. Postoperative early major complications developed in 2 (3.3%) patients. The most common complication was gastric stasis, occurring in 7 (11.5%) patients. All patients with complications recovered with conservative treatment, and no operative mortality occurred. Endoscopy 1 year after operation revealed reflux gastritis in 1 patient. Reflux esophagitis was not found in any patient. However, anastomotic ulcer was found in 12 (22.2%) patients over the 1-year period after operation. No patient reported symptoms of early and late dumping syndrome, and 1 (1.9%) patient self-reported diarrhea. ConclusionsDGJI was a feasible and safe procedure with several advantages in terms of less incidence of reflux gastritis and esophagitis, dumping syndrome and diarrhea. However, this procedure is complicated and time-consuming, and it is necessary to be aware of the potential occurrence of an anastomotic ulcer at the site of the gastrojejunostomy after DGJI.

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.

Function-Preserving Gastrectomy for Early Gastric Cancer

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures. Applications of function-preserving gastric cancer surgery may therefore also be increasing because of its low incidence of lymph node metastasis, excellent survival rates, and the possibility of less-invasive procedures such as laparoscopic gastrectomy being used in combination. Pylorus-preserving gastrectomy (PPG) with radical lymph node dissection is one such function-preserving procedure that has been applied for EGC, with the indications, limitations, and survival benefits of PPG already reported in several retrospective studies. Laparoscopy-assisted proximal gastrectomy has also been applied for EGC of the upper third of the stomach, although this procedure can be associated with the 2 major problems of reflux esophagitis and carcinoma arising in the gastric stump. In the patient with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved very small stomach may provide a better quality of life for the patients and fewer postoperative complications. Finally, the laparoscopy endoscopy cooperative surgery procedure combines endoscopic submucosal dissection with laparoscopic gastric wall resection, which prevents excessive resection and deformation of the stomach after surgery and was recently applied for EGC cases without possibility of lymph node metastasis. Function-preserving laparoscopic gastrectomy is recommended for the treatment of EGC if the indication followed by accurate diagnosis is strictly confirmed. Preservation of remnant stomach sometimes causes severe postoperative dysfunctions such as delayed gastric retention in PPG, esophageal reflux in PG, and gastric stump carcinoma in the remnant stomach. Moreover, these techniques present technical difficulties to the surgeon. Although many retrospective studies showed the functional benefit or oncological safety of function-preserving gastrectomy, further prospective studies using large case series are necessary.

Sentinel lymph node and prognostic factors in gastric cancer

We would like to respond to the letter by Hanisch and Batsis entitled ‘‘Sentinel lymph node biopsy in laparoscopic surgical oncology’’ [1] in which some interesting concerns have been raised regarding the association of minimally invasive surgery and sentinel lymph node (SLN) navigation procedure described in our case report published in the September issue of Surgical Endoscopy [2]. In fact, there are several reservations in the application of SLN mapping in gastric cancer. Unexpected anatomical skip metastases might be accounted for by aberrant drainage routes from the primary lesion [3]. Unneglectable false-negative rates have been reported due to a number of factors. The most common one is the obstruction of lymphatic vessels due to cancer invasion. In these cases, the tracer is not able to reach the initial SLN and will be deviated to second tier or false SLNs. Other risk factors associated with false-negative SLN are surgeon inexperience, male gender, and a small number of SLNs (B3) [4]. The limitations of SLN navigation have been overcome with the restriction of its indication to early-stage cases, the introduction of technical improvements like the combination of dye-guided and radio-guided methods, and sentinel lymphatic basin dissection [5]. Some Eastern authors have proposed testing the SLN navigation association with conservative visceral resection such as function-preserving gastrectomy, endoscopic mucosal resection, or endoscopic submucosal dissection [6, 7]. This way, the morbidity and functional disturbances related to not only the extended lymphadenectomy but also to total or subtotal gastric resection are avoided. The attempts to reduce the adverse effects and invasiveness of early gastric cancer surgery are also translated in the association of SLN navigation with the laparoscopic procedure [8]. Such proposals should be substantiated by more consistent data. Reading carefully the letter of Hanisch and Batsis, it is possible to surmise that they did not see the possible operational or methodological caveats of our laparoscopic SLN navigation. Their final intention was not to discuss the conceptual limitations of the SLN procedure. The ultimate topic that they were trying to address was the lack of reliable prognostic markers in gastric cancer that would enable the correct modulation of surgical radicality in early-stage disease. They conclude that basic and translational research on genomics and epigenetics would provide not only the understanding of mechanisms underlying the tumor progression but also more robust predictive factors of long-term oncological outcome of gastric cancer. Gastric carcinogenesis is a multistep process involving genetic and epigenetic alteration of protein-coding proto-oncogenes and tumorsuppressor genes. Single nucleotide variants (SNVs), present as either germline or somatic point mutations, are essential drivers of tumorigenesis and cellular proliferation in many human cancer types because they were proven to be involved in DNA repair and tumor suppression [9]. Recent discoveries have shed new light on the involvement of a class of noncoding RNA known as microRNA (miRNA) in gastric cancer [10]. Genes coding these miRNAs have been characterized as novel protooncogenes and tumor-suppressor genes based on findings that these miRNAs control malignant phenotypes of gastric cancer cells. In this sense, miRNA dysregulation promotes cell-cycle progression [11], confers resistance to apoptosis [11, 12], and enhances invasiveness and metastasis [13]. Moreover, several miRNAs have also been shown to E. Orsenigo (&) S. Kusamura C. Staudacher Department of Surgery, University Vita-Salute San Raffaele, Via Olgettina, 60-20132 Milan, Italy e-mail: orsenigo.elena@hsr.it

Clinical Significance of the Pattern of Lymph Node Metastasis Depending on the Location of Gastric Cancer

PurposeWhen performing a laparoscopic assisted gastrectomy, a function-preserving gastrectomy is performed depending on the location of the primary gastric cancer. This study examined the incidence of lymph node metastasis by the lymph node station number by tumor location to determine the optimal extent of the lymph node dissection.Materials and MethodsThe subjects consisted of 1,510 patients diagnosed with gastric cancer who underwent a gastrectomy between 1996 and 2005. The patients were divided into three groups: upper, middle and lower third, depending on the location of the primary tumor. The lymph node metastasis patterns were analyzed in the total and early gastric cancer patients.ResultsIn all patients, lymph node station numbers 1, 2, 3, 7, 10 and 11 metastases were dominant in the cancer originating in the upper third, whereas station numbers 4, 5, 6 and 8 were dominant in the lower third. In early gastric cancer patients, the station number of lymph nodes with a metastasis did not show a significant difference in stage pT1a disease. On the other hand, a metastasis in lymph node station number 6 was dominant in stage pT1b disease that originated in the lower third of the stomach.ConclusionsWhen performing a laparoscopic-assisted gastrectomy for early gastric cancer, a limited lymphadenectomy is considered adequate during a function-preserving gastrectomy in mucosal (T1a) cancer. On the other hand, for submucosal (T1b) cancer, a number 6 node dissection should be performed when performing a pylorus preserving gastrectomy.

Segmental gastrectomy with radical lymph node dissection for early gastric cancer

To describe a new surgical technique and evaluate the early results of segmental gastrectomy (SG) with modified D2 lymph node (LN) dissection for early gastric cancer (EGC). Fourteen patients with EGC underwent SG with modified D2 dissection from 2006 to 2008. Their operative results and postoperative courses were compared with those of 17 patients who had distal gastrectomy (DG) for EGC during the same period. Operating time, blood loss, and hospital stay were similar between the 2 groups. Postoperative complications developed significantly more frequently in the DG group than in the SG group. Mean number of dissected LNs per each station in the SG group was comparable with that in the DG group. Postoperative recovery of body weight was significantly better in the SG group than in the DG group. The incidence of reflux esophagitis and gastritis after surgery was less frequent in the SG group than in the DG group. SG with modified D2 LN dissection may be a new function-preserving gastrectomy that is feasible for treatment of EGC with possible LN involvement.

PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow

We propose a new classification for the location of gastric cancer - the PTD classification (i.e., zones P, T, and D; see below), with the zones classified according to the physiological lymphatic flow. Three hundred and thirty-six patients with T1 or small T2 gastric cancer who underwent sentinel node mapping at our hospital were enrolled. The relationship between the location of the gastric cancer and the physiological lymphatic flow derived from sentinel node mapping was investigated. Lymphatic basins were defined as lymphatic zones divided by the stream of stained lymphatic canals. One hundred and forty-six patients underwent standard gastrectomy with more than D2 dissection and the other 190 patients underwent function-preserving gastrectomy with the omission of lymph node dissection outside the lymphatic basin. In the former group, the progression pattern of lymph node metastasis was observed; nodal metastasis occurred in sentinel nodes first, and rarely extended outside the lymphatic basin. In the latter group, none of the patients have had a recurrence. The PTD classification we propose is as follows: the dividing line between the proximal region (zone P) and the transitional region (zone T) is the line that links the point of the watershed between the left gastroepiploic artery and right gastroepiploic artery, to the point that is the inflow point of the first descending branch of the left gastric artery; and the dividing line between zone T and the distal region (zone D) is an arc at a radius of 8 cm from the pylorus. There were no lymphatic basins within the right gastric artery area for tumors located in zone T. The advantage of the PTD classification is that if the PTD classification were to be used as a guide for gastric resection procedures, preservation of the pylorus would become possible without diminishing the prognosis in patients with cT1N0 cancer located in zone T.

Individualized surgery for early gastric cancer guided by sentinel node biopsy

We have reported that lymphatic mapping using indocyanine green (ICG) solution can be a good tool for identifying sentinel nodes (SNs) in gastric cancer. The purpose of this study was to evaluate individualized operations for gastric cancer guided by SN biopsy and to explore the possibility for more limited operative procedures using SN technology. SNs were identified by using (99m)Tc-labeled tin colloid and ICG solution in patients with clinically T1N0M0 gastric cancer. When pathologic examination by frozen section revealed metastasis in SNs, we performed a standard D2 gastrectomy. Less extensive lymphadenectomy preserving vagus and pylorus was applied when the SN biopsy was negative. Then, postoperative pathology was analyzed. Among the 80 enrolled patients, 7 patients with apparent node metastasis or T2-3 neoplasms and 10 patients with positive metastasis in SNs underwent D2 gastrectomy. Sixty-one patients with negative metastasis in SNs underwent a less extensive, function-preserving gastrectomy. The false-negative rate in sentinel node biopsy was 23% (3/13) for frozen section and 7% (1/14) for postoperative pathology. In 3 patients with a false-negative result, metastasis was found in lymph nodes located at the station where the tracers were distributed. Of the 7 patients in whom metastasis was detected in 2 or more SNs by frozen section, postoperative pathology revealed that 3 patients (43%) belonged to the N2 category. SN biopsy is a useful tool for individualizing the operative procedure for early gastric cancer. Dissecting the lymph node stations only where the tracers are distributed may be a promising procedure for patients with no metastatic SNs.