Laparoscopy-assisted Pylorus-preserving Gastrectomy Research Articles

Equal short-term outcomes of intracorporeal mechanical gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for cT1N0 gastric cancer in the middle stomach compared with the extracorporeal hand-sewing method.

Intracorporeal mechanical gastrogastrostomy (IMG) techniques have recently been developed and their short-term safety was presented in their initial evaluation. However, whether they are comparable to extracorporeal hand-sewing gastrogastrostomy (EHG) remains unclear. The aim of the study is to establish the safety of IMG in totally laparoscopic pylorus-preserving gastrectomy (TLPPG) compared to EHG in laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). We retrospectively analyzed the short-term outcomes of patients with middle-third early gastric cancer who underwent LAPPG or TLPPG between 2005 and 2022. The primary objective of this study was to evaluate the non-inferiority of IMG to EHG in terms of safety, with the primary endpoint being the risk difference in anastomosis-related complications (ARCs). The sample size required to achieve a statistical power of 80% for the non-inferiority test was 971 with a one-sided alpha level of 5% and non-inferiority of 5%. The analysis included a total of 1,021 patients who underwent LAPPG or TLPPG during the study period. Among them, 488 patients underwent EHG, while 533 underwent IMG. The incidences of ARCs were 11.3% and 11.4% in EHG and IMG, respectively. The observed difference in incidence was 0.0017 (90% confidence interval - 0.0313 to 0.0345), which statistically demonstrated the non-inferiority of IMG to EHG in the incidence of ARCs. Among other complications, the incidence of wound infection in IMG was lower than that in EHG. IMG is safe regarding ARCs compared with EHG. These results will encourage surgeons to introduce IMG for patients with early middle gastric cancer.

Short-term Outcomes of Pylorus-Preserving Gastrectomy for Early Gastric Cancer: Comparison Between Extracorporeal and Intracorporeal Gastrogastrostomy.

PurposeThis study aimed to compare the surgical and oncological outcomes between totally laparoscopic pylorus-preserving gastrectomy (TLPPG) with intracorporeal anastomosis and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with extracorporeal anastomosis.Materials and MethodsA retrospective analysis was performed in 258 patients with cT1N0 gastric cancer who underwent laparoscopic pylorus-preserving gastrectomy using two different anastomosis methods: TLPPG with intracorporeal anastomosis (n=88) and LAPPG with extracorporeal anastomosis (n=170). The following variables were compared between the two groups to assess the postoperative surgical and oncological outcomes: proximal and distal margins, number of resected lymph nodes (LNs) in total and in LN station 6, operation time, postoperative hospital stay, and postoperative morbidity including delayed gastric emptying (DGE).ResultsThe average length of the proximal margin was similar between the TLPPG and LAPPG groups (2.35 vs. 2.73 cm, P=0.070). Although the distal margin was significantly shorter in the TLPPG group than in the LAPPG group (3.15 vs. 4.08 cm, P=0.001), no proximal or distal resection margin-positive cases were reported in either group. The average number of resected LN was similar in both groups (36.0 vs. 33.98, P=0.229; LN station 6, 5.72 vs. 5.33, P=0.399). The operation time was shorter in the TLPPG group than in the LAPPG (200.17 vs. 220.80 minutes, P=0.001). No significant differences were observed between the two groups in terms of postoperative hospital stay (9.38 vs. 10.10 days, P=0.426) and surgical complication rate (19.3% vs. 22.9%), including DGE (8.0% vs. 11.8%, P=0.343).ConclusionsThe oncological safety and postoperative complications of TLPPG with intracorporeal anastomosis are similar to those of LAPPG with extracorporeal anastomosis.

Objective evaluation of clinical outcomes of laparoscopy-assisted pylorus-preserving gastrectomy for middle-third early gastric cancer

BackgroundLaparoscopic-assisted pylorus-preserving gastrectomy (LAPPG) is a minimally invasive function-preserving surgery for early gastric cancer. This study was designed to investigate the clinical outcomes between LAPPG and laparoscopy-assisted distal gastrectomy (LADG) by objective evaluation.MethodsA total 167 pT1N0M0 gastric cancer patients underwent LAPPG(n = 70) and LADG(n = 97) were retrospectively analyzed. By evaluating the functional advantages, objective short-term and one year follow-up outcomes were compared.ResultsThere is no significant difference in perioperative clinical characteristics as well as pathologic results between LAPPG and LADG group while the cost is higher in latter(p = 0.004). The Clavien–Dindo grade II or higher complications were 15.7 and 13.4% in LAPPG and LADG group respectively(p = 0.824). In one year follow-up, nutritional status was significantly better in LAPPG group accompanied by better pylorus function preserving.ConclusionLAPPG is an acceptable surgical procedure for pT1N0M0 middle portion gastric cancer patients in terms of nutritional and economic advantage.Trial registrationChinese Clinical Trial Registry (ChiCTR-PIC-17012358, Date of Registration:2017-08-14).

Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared With laparoscopy-assisted distal gastrectomy: A cross-sectional postal questionnaire survey

BackgroundLittle is known about postgastrectomy syndrome and quality of life (QOL after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). The aim of this study was to assess postgastrectomy syndrome and QOL after LAPPG as compared with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGBI). MethodsPostgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaires were sent by mail to 167 patients. To balance the characteristics of the groups, propensity score matching was performed. ResultsOf the 167 patients sent questionnaires, 112 (67%) responded, including 47 who underwent LAPPG and 65 who underwent LADGBI. After propensity score matching, the LAPPG group scored significantly better on the diarrhea and dumping subscales. Multiple regression analysis showed that female sex and LADGBI were independent factors predicting dumping. Evaluation of outcome measures for singular symptom showed that the LAPPG group scored significantly worse on the acid regurgitation subscale, but significantly better on the lower abdominal pain and early dumping abdominal subscales. ConclusionLAPPG is superior to LADGBI for ameliorating postgastrectomy syndrome and maintaining QOL. LAPPG is recommended for patients with cT1N0 middle third gastric cancer.

Intracorporeal reconstruction after laparoscopic pylorus-preserving gastrectomy for middle-third early gastric cancer: a hybrid technique using linear stapler and manual suturing.

Laparoscopy-assisted pylorus-preserving gastrectomy has been increasingly reported as a treatment for early gastric cancer located in the middle third of the stomach because of its low invasiveness and preservation of pyloric function. Advantages of a totally laparoscopic approach to distal gastrectomy, including small wound size, minimal invasiveness, and safe anastomosis, have been recently reported. Here, we introduce a new procedure for intracorporeal gastro-gastrostomy combined with totally laparoscopic pylorus-preserving gastrectomy (TLPPG). The stomach is transected after sufficient lymphadenectomy with preservation of infrapyloric vessels and vagal nerves. The proximal stomach is first transected near the Demel line, and the distal side is transected 4 to 5cm from the pyloric ring. To create end-to-end gastro-gastrostomy, the posterior wall of the anastomosis is stapled with a linear stapler and the anterior wall is made by manual suturing intracorporeally. We retrospectively assessed the postoperative surgical outcomes via medical records. The primary endpoint in the present study is safety. Sixteen patients underwent TLPPG with intracorporeal reconstruction. All procedures were successfully performed without any intraoperative complications. The mean operative time was 275min, with mean blood loss of 21g. With the exception of one patient who had gastric stasis, 15 patients were discharged uneventfully between postoperative days 8 and 11. Our novel hybrid technique for totally intracorporeal end-to-end anastomosis was performed safely without mini-laparotomy. This technique requires prospective validation.

Pylorus-Preserving Gastrectomy for Gastric Cancer.

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.

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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.

Laparoscopy-Assisted Pylorus-Preserving Gastrectomy Is Better Than Laparoscopy-Assisted Distal Gastrectomy for Middle-Third Early Gastric Cancer

The purpose of this study is to compare the surgical, oncologic safety and the nutritional, functional benefit of laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy (LADG) for middle-third early gastric cancers (EGC). Of those patients with middle-third EGC, it is still difficult to determine which procedure is better between LADG and LAPPG despite alleged advantages of LAPPG. For middle-third EGC, a retrospective analysis was performed comparing those who underwent LADG and those who underwent LAPPG. To evaluate surgical and oncologic safety, clinicopathologic differences including the postoperative morbidity, the pattern of lymph node metastasis and recurrence were analyzed. Postoperative protein, albumin, quantification of abdominal fat area using abdomen computed tomography, and the incidence of postoperative gallstone were compared for the evaluation of functional advantages. The overall postoperative morbidity rate was similar between LADG (n = 176) and LAPPG (n = 116). Delayed gastric emptying was less frequent in LADG than in LAPPG (1.7% vs 7.8%); however, the rates of all the other complications were significantly higher in LADG than in LAPPG (17.0% vs 7.8%). The number of examined lymph nodes and metastatic lymph nodes at each lymph node station was not significantly different and 3-year recurrence-free survival rates were also similar between LADG and LAPPG (98.8% vs 98.2%). Decreases in serum protein and albumin in postoperative 1 to 6 months and abdominal fat area in postoperative 1 year were significantly greater in LADG than in LAPPG. The 3-year cumulative incidence of gallstone was significantly higher in LADG than in LAPPG (6.5% vs 0.0%). For middle-third EGC, LAPPG can be considered as a better treatment option than LADG in terms of nutritional advantage and lower incidence of gallstone.

Totally laparoscopic pylorus-preserving gastrectomy for early gastric cancer in the middle stomach: technical report and surgical outcomes

The feasibility, safety, and improved quality of postoperative life following laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with a hand-sewn anastomosis via a mini-laparotomy for early gastric cancer (EGC) have been previously established. Here we describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy (TLPPG) using an intracorporeal delta-shaped anastomosis technique, and the short-term surgical outcomes of 60 patients with EGC in the middle stomach are reported. After lymphadenectomy and mobilization of the stomach, intraoperative gastroscopy was performed in order to verify the location of the tumor, and then the distal and proximal transecting lines were established, 5 cm from the pyloric ring and just proximal to Demel's line, respectively. Following transection of the stomach, a delta-shaped intracorporeal gastrogastrostomy was made with linear staplers. There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 259 min and 28 mL, respectively. Twelve patients (20.0%) experienced postoperative complications classified as grade II using the Clavien-Dindo classification, with the most frequent complication being gastric stasis (6 cases, 10.0 %). The incidence of severe complications classified as grade III or above was 1.7%; only one patient required reoperation and intensive care due to postoperative intraabdominal bleeding and subsequent multiple organ failure. TLPPG with an intracorporeal delta-shaped anastomosis was found to be a safe procedure, although it tended to require a longer operating time than the well-established LAPPG with a hand-sewn gastrogastrostomy.

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

Quality of life after laparoscopy-assisted pylorus-preserving gastrectomy: an evaluation using a questionnaire mailed to the patients

This study investigated the postoperative quality of life (QOL) after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) in comparison to laparoscopy-assisted distal gastrectomy (LADG). Twenty-one patients with early-stage gastric cancer underwent minimally invasive LADG (n = 12) or LAPPG (n = 9). Demographic and cancer-related data were obtained retrospectively from medical records. QOL was assessed using a 13-item questionnaire and the Japanese edition of the Gastrointestinal Symptom Rating Scale, which were mailed to patients twice postoperatively. Body weight and hemoglobin levels were measured at the same time. Early upper abdominal pain was rated as significantly worse with LAPPG than with LADG at the first checkup (1.4 vs. 1.0, P = 0.02) but not at the second checkup (1.3 vs. 1.0, P = 0.07). There was a trend toward less body weight loss in the LAPPG patients in comparison to the LADG patients. The serum hemoglobin levels of LAPPG patients at the second checkup showed significantly higher than LADG patients (13.3 vs. 11.6 g/dL, P < 0.05). LAPPG and LADG produce similar QOL in patients. Trends toward less body weight loss and improved anemia in LAPPG patients may therefore become more pronounced in future studies that have adequate number of the patients and longer follow-up periods.

Prospect of laparoscopic surgery for gastric cancer

Laparoscopic surgery has been adopted for the treatment of gastric cancer in recent years around the world.New advances in these techniques have been achieved. This paper provides an overview of the clinical outcome of laparoscopic surgery for early gastric cancer and advanced gastric cancer,the application of laparoscopy-assisted pylorus-preserving gastrectomy,the technical characteristics of laparoscopy-assisted total gastrectomy,the values of single-incision laparoscopically assisted surgery and the application status and prospect of robotassisted laparoscopic gastrectomy for gastric cancer. Key words: Gastric neoplasms; Laparoscopy, single incision; Da Vinci robotic surgical system

Postoperative Outcomes and Complications After Laparoscopy-assisted Pylorus-preserving Gastrectomy for Early Gastric Cancer

Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was introduced as a function-preserving and minimally invasive operation for early gastric cancer (EGC) in Japan. This study investigated the postoperative outcomes, complications, and associated risk factors of the procedure. From January 2005 to December 2009, 307 patients with EGC diagnosed before surgery underwent LAPPG. The postoperative outcomes and complications were assessed in this study. Postoperative complications were classified according to the Clavien-Dindo classification of surgical complications, and risk factors related to complications were analyzed. The mean operation time for LAPPG was 229.4 ± 47.5 minutes and estimated blood loss was 49.1 ± 62.0 mL. The mean total number of dissected lymph nodes was 31.6 ± 10.4, with nodal involvement observed in 25 patients (8.5%). The preoperative diagnostic accuracy of EGC was 93.2%. Complications developed in 53 patients (17.3%), and major complications, classified as grades greater than Clavien-Dindo classification IIIa, were observed in 4 patients (1.3%). The most frequent complication was gastric stasis, occurring in 19 patients (6.2%). Body mass index (BMI) and surgical experience of LAPPG were identified as significant risk factors of postoperative complications. Body mass index was related to severity of the complications. The patients' serum total protein and albumin did not change significantly after surgery. Laparoscopy-assisted pylorus-preserving gastrectomy is a safe operation with excellent postoperative outcomes in terms of minimized major complications based on the Clavien-Dindo classification in patients with EGC in the middle third of the stomach. To prevent postoperative complications, surgeons need to ensure an extra leaning period for LAPPG, and LAPPG should be performed cautiously in patients with high BMI.

Minimally Invasive Surgery for Gastric Cancer: The Future Standard of Care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.In the near future, sentinel node navigation and robotic surgery will become additional options in minimally invasive surgery (MIS) involving LG. Such developments will improve the quality of life of patients following gastric cancer surgery.

Triangulating Stapling Technique for Anastomosis in Laparoscopy-Assisted Pylorus-Preserving Gastrectomy

Background/Aims: The anastomosis performed during laparoscopy-assisted pylorus-preserving gastrectomy (PPG) is usually handsewn; however, the technique is sometimes difficult because it is done through a small incision and the level of skill of each operator may vary. The present study describes a triangulating stapling technique used during an anastomosis in laparoscopy-assisted pylorus-preserving gastrectomy. Method: The 80-mm stapler was used 3 times for the triangulating stapling technique. The posterior walls, including the stay sutures, were joined by firing the stapler, and the anterior stomach ends were stapled in an everting fashion using two firings of the stapler. Both the anterior staple lines should overlap in the middle. Patient demographics and the operative data were examined. Results: The triangulating stapling technique was performed during laparoscopy-assisted PPG in 9 patients. The median time for the anastomosis during laparoscopy-assisted PPG using the triangulating stapling technique was 19.0 min (16.0–31.0). Postoperative complications, including gastric stasis and anastomotic failure, were not found in any of the present patients. Conclusion: The triangulating stapling technique using a linear stapler is a safe and reliable technique to perform and can be easily conducted in a short time. We therefore consider it a useful anastomosis method for laparoscopy-assisted pylorus-preserving gastrectomy, even by unskilled surgeons.

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

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. From January 2005 to July 2008, 188 patients with EGC underwent LAPPG. The surgical and long-term outcomes and survival were assessed retrospectively. The accuracy of the preoperative EGC diagnosis was 92.6%. The median follow-up period was 38 months (range, 2-63 months). Two patients experienced gallstones, and three patients experienced a second primary EGC. One patient with T3N0 gastric cancer died of peritoneal metastasis, and four patients died of other causes. The overall 3-year survival rate was 97.8%, and the disease-specific 3-year survival rate was 99.3%. The LAPPG procedure is safe in terms of satisfactory long-term outcome and survival for patients with EGC in the middle third of the stomach.

Laparoscopy-assisted pylorus-preserving gastrectomy: a matched case–control study

Pylorus-preserving gastrectomy (PPG) has been widely accepted as the standard treatment for early gastric cancer, and the laparoscopic approach has been gradually introduced. The aim of this study is to investigate the short-term outcome of laparoscopy-assisted PPG (LAPPG) in comparison with open PPG (OPPG). Between April 2006 and May 2009, a cohort of 418 patients with early gastric cancer in the middle third of the stomach underwent PPG, and 90 of the LAPPG patients and 90 of the OPPG patients among them were matched for sex, age, and body mass index. The outcomes of the patients in the two groups were then compared. Operation time was significantly longer in the LAPPG group than in the OPPG group (270 vs. 195 min, P < 0.001), and there was significantly less blood loss in the LAPPG group than in the OPPG group (29 vs. 97 ml, P < 0.001). The overall incidence of surgery-related complications in the two groups was similar (8.9 vs. 11.1%). The proportion of patients who used analgesics after postoperative day 5 was significantly lower in the LAPPG group than in the OPPG group (35.6 vs. 61.1%, P = 0.001). There was no significant difference between the two groups in the interval between surgery and resumption of oral feeding, the interval between surgery and first flatus, number of patients with body temperature of 38°C or more, or length of hospital stay. LAPPG can be performed safely in terms of short-term outcome.

The Early Experience with a Laparoscopy-assisted Pylorus-preserving Gastrectomy: A Comparison with a Laparoscopy-assisted Distal Gastrectomy with Billroth-I Reconstruction

목적: 유문부보존 위절제술(pylorus-preserving gastrectomy, PPG)은 유문륜을 보존하여 잔위의 배출기능을 보존하고 담즙 역류를 방지할 수 있는 기능 보존 수술법으로 조기위암 치료에 적용되고 있다. 저자들은 복강경 보조 유문부보존 위절제술(laparoscopy-assisted pylorus-preserving gastrectomy, LAPPG)의 초기 경험을 LADG 후 Billroth-I 재건술과 비교 분석하였다. 대상 및 방법: 2006년 11월부터 2007년 9월까지 원자력병원 외과에서 복강경 보조 위절제술을 시행 받은 39명의 조기위암 환자 중 LAPPG (n=9)와 LADG 후 Billroth-I 재건술(n=18)을 시행 받은 27명의 환자를 대상으로 하였고, 양 군간의 임상병리학적 변수를 비교하였다. 저자들은 LAPPG 시행 중 유문하동맥, 우위동맥, 미주신경 간지, 유문지 및 복강지를 보존하였으며, 림프절 절제술은 우위동맥 림프절(No. 5)을 제외한 D1+ $\beta$ 술식을 시행하였고, 유문륜 상방 $3{\sim}4\;cm$ 에서 원위부 위절제를 시행하였다. 결과: LAPPG을 시행 받은 환자 9명의 평균 연령은 $59.9{\pm}9.4$ 세였으며 남녀 성비는 1.3 : 1.0 (남자 5명, 여자 4명)이었고, LADG 후 Billroth-I 재건술을 시행 받은 환자 18명의 평균 연령은 $64.1{\pm}10.0$ 세였으며 남녀 성비는 2.6 : 1.0 (남자 13명, 여자 5명)이었다. LAPPG 군과 LADG 후 Biliroth-I 재건술을 시행받은 군에서 절제된 림프절의 개수는 각각 $28.3{\pm}11.9$ 개 $28.1{\pm}8.9$ 개, 수술 시간은 각각 $269.0{\pm}34.4$ 분, $236.3{\pm}39.6$ 분, 술 중 출혈량은 각각 $191.1{\pm}85.7\;ml$ , $218.3{\pm}156.6\;ml$ , 술 후 첫 가스 배출은 각각 $3.6{\pm}0.9$ 일, $3.5{\pm}0.8$ 일에 있었고 술 후 첫 유동식은 각각 $5.1{\pm}0.9$ 일, $5.1{\pm}1.7$ 일에 섭취하였고 술 후 재원 기간은 각각 $10.1{\pm}4.0$ 일, $9.2{\pm}3.0$ 일로 모두 통계학적으로 유의한 차이가 없었다(P>0.05). 술 후 합병증은 LAPPG 군에서 위저류증 1예와 창상 장액종 1예가 발생하였고, LADG 후 Biliroth-I 재건술을 시행 받은 군에서는 좌외측간엽경색 1예가 발생하였다. 결론: 조기위암의 치료에 있어서 LAPPG는 기능 보존 수술 법으로 적용 가능하며, 적절한 적응증을 사용하면 임상종양학적 측면에서도 LADG 후 Billroth-I 재건술과 동등한 결과를 보일 것으로 기대된다. 【Purpose: Pylorus-preserving gastrectomy (PPG), which retains pyloric ring and gastric function, has been accepted as a function-preserving procedure for early gastric cancer for the prevention of postgastrectomy syndrome. This study was compared laparoscopy-assisted pylorus-preerving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGB I). Materials and Methods: Between November 2006 and September 2007, 39 patients with early gastric cancer underwent laparoscopy-assisted gastrectomy in the Department of Surgery at Korea Cancer Center Hospital. 9 of these patients underwent LAPPG and 18 underwent LADGBI. When LAPPG was underwent, we preserved the pyloric branch, hepatic branch, and celiac branch of the vagus nerve, the infrapyloric artery, and the right gastric artery and performed D1+ $\beta$ lymphadenectomy to the exclusion of suprapyloric lymph node dissection. The distal stomach was resected while retaining a $2.5{\sim}3.0\;cm$ pyloric cuff and maintaining a $3.0{\sim}4.0\;cm$ distal margin for the resection. Results: The mean age for patients who underwent LAPPG and LADGBI were $59.9{\pm}9.4$ year-old and $64.1{\pm}10.0$ year-old, respectively. The sex ratio was 1.3 : 1.0 (male 5, female 4) in the LAPPG group and 2.6 : 1.0 (male 13, female 5) in the LADGBI group. Mean total number of dissected lymph nodes ( $28.3{\pm}11.9$ versus $28.1{\pm}8.9$ ), operation time ( $269.0{\pm}34.4$ versus $236.3{\pm}39.6$ minutes), estimated blood loss ( $191.1{\pm}85.7$ versus $218.3{\pm}150.6\;ml$ ), time to first flatus ( $3.6{\pm}0.9$ versus $3.5{\pm}0.8$ days), time to start of diet ( $5.1{\pm}0.9$ versus $5.1{\pm}1.7$ days), and postoperative hospital stay ( $10.1{\pm}4.0$ versus $9.2{\pm}3.0$ days) were not found significant differences (P>0.05). The postoperative complications were 1 patient with gastric stasis and 1 patient with wound seroma in LAPPG group and 1 patient with left lateral segment infarct of liver in the LADGB I group. Conclusion: Patients treated by LAPPG showed a comparable quality of surgical operation compared with those treated by LADGBI. LAPPG has an important role in the surgical management of early gastric cancer in terms of quality of postoperative life. Randomized controlled studies should be undertaken to analyze the optimal survival and long-term outcomes of this operative procedure.】

Laparoscopy‐assisted Pylorus‐preserving Gastrectomy: Preservation of Vagus Nerve and Infrapyloric Blood Flow Induces Less Stasis

Pylorus-preserving gastrectomy (PPG) prevents postprandial symptoms; however, delayed gastric retention due to aberrant pylorus function can occur during the early postoperative period. This study aimed to establish a stasis-less PPG procedure with preservation of the vagal nerve and blood flow to the pyloric cuff, and to apply the technique for laparoscopy-assisted PPG. Ninety patients with T1 gastric cancer located in the middle third of the stomach were enrolled in this study for surgery from January 2003 to March 2006, undergoing either laparoscopy-assisted PPG (LAPPG; 39 patients) or conventional PPG (CPPG; 51 patients). Operative and early postoperative outcomes were compared between the two groups. Relatively low rates of gastric stasis were observed in both the LAPPG (8%) and CPPG (6%) groups. Estimated blood loss in LAPPG (65.4 +/- 12.3 ml) patients was significantly lower than in the CPPG group (160.7 +/- 19.6 ml) (p < 0.001), and the total number of dissected lymph nodes was significantly greater in the LAPPG group (36.2 +/- 1.8) than in the CPPG group (29.0 +/- 1.3) (p = 0.001). A PPG procedure with less postoperative stasis and adequate lymph node retrieval was established and applied successfully in laparoscopy-assisted surgery.