Pylorus-preserving Gastrectomy Group Research Articles

Long-Term Outcomes of Pylorus-Preserving Gastrectomy for Early Gastric Cancer.

In the short term, pylorus-preserving gastrectomy (PPG) has been reported to have advantages over distal gastrectomy (DG) with regard to postprandial symptoms and dumping syndrome. We aimed to evaluate the quality of life after PPG for early gastric cancer in the long term in comparison to that after DG. Twenty-six patients who underwent gastrectomy (11 PPG, 15 DG) for early gastric cancer at Osaka University Hospital participated and were followed for more than 4years. Body weight changes, nutritional status, dual-phase scintigraphy findings, endoscopic survey results, and questionnaire responses after gastrectomy were examined. There were significantly lower ratios of weight changes in PPG than in DG, 5years after surgery. There were no differences in the clinicopathological characteristics, nutritional parameters, questionnaire responses, and endoscopic findings between the two groups. Based on gastric scintigraphy, although the gastric emptying of liquids showed similar curves in the two groups, gastric emptying of solids was significantly slower in the PPG group than in the DG group (P = .039). PPG had advantages with regard to long-term outcomes over DG in terms of weight maintenance and the prevention of rapid gastric emptying. PPG might be efficient in patients with early gastric cancer.

Safety of pylorus-preserving gastrectomy for gastric cancer combined with antral high-risk lesions: a comparison with endoscopic submucosal dissection.

Pylorus-preserving gastrectomy (PPG) is a surgical treatment option for cT1N0M0 gastric cancer located in the middle third of the stomach. However, data for the long-term post-PPG clinical outcomes related to metachronous gastric neoplasms (mGNs) in the residual stomach are currently lacking. Therefore, we aimed to evaluate the safety of PPG by focusing on mGNs. In this single-center, retrospective study, we reviewed the data for 362 patients who underwent PPG with a 3-cm antral cuff and 139 who underwent endoscopic submucosal dissection (ESD) for middle-third gastric cancer between January 2013 and December 2015. The histopathologic features of the antrum in the ESD group, which could not be determined in the PPG group, were analyzed to investigate the risk factors for mGNs. The estimated and actual incidence of mGNs in the antrum were compared in the PPG group. The incidence of mGNs was 6.5% (9/139) in the ESD group. The presence of a synchronous adenoma (odds ratio [OR], 8.46; 95% confidence interval [CI], 1.55-46.34), carcinoma (OR, 15.71; 95% CI, 2.67-92.56) and moderate-to-severe intestinal metaplasia (OR, 9.77; 95% CI, 1.14-83.92) were associated with a higher risk of overall mGNs. However, when confined to the antrum, no significant association was observed between these factors and mGNs. In the ESD group, 2 of 9 mGNs (1.4%) were located at the 3-cm antral cuff. In the PPG group, both mGNs (0.6%) were located in the proximal remnant stomach. Pylorus-preserving gastrectomy was a safe therapeutic option with regard to the occurrence of metachronous adenomas or carcinomas in our series. Despite the low mGN incidence in the 3-cm antral cuff after PPG, the presence of synchronous neoplasms or moderate-to-severe intestinal metaplasia was a risk factor for mGNs in the ESD group; thus, further studies on longer antral cuffs with long-term follow-up are needed.

Efficacy and safety of pylorus-preserving gastrectomy for early gastric cancer located in the middle third of the stomach: a meta-analysis

Objective: It is yet to be clarified whether pylorus-preserving gastrectomy (PPG) for early gastric cancer will bring the risk of radical tumor resection, whether it will increase the incidence of postoperative complications, and how much is the benefit of the quality of life for patients after surgery, these issues are not clear. This meta-analysis aims to evaluate the efficacy and safety of pylorus-preserving gastrectomy (PPG) for early middle gastric cancer. Methods: The Chinese and English literatures about PPG and distal gastrectomy (DG) for early gastric cancer were searched from PubMed, Embase, The Cochrane Library, Web of Science, CNKI net and Wanfang database. Literature inclusion criteria: (1) Prospective or retrospective cohort study of PPG and DG for early middle-third gastric cancer published publicly; (2) Patients with early middle-third gastric cancer; (3) The enrolled literatures include at least one of the following outcome indicators: the efficacy indicators include gallstone, residual gastritis, bile reflux, delayed gastric emptying, dumping syndrome, reflux esophagitis and overall complication; the long-term prognostic indicators include 5-year survival rate and 5-year tumor recurrence. Literature exclusion criteria: (1) Reviews, case reports, conference summaries and other non-control studies; (2) Repeated published studies, incomplete studies and unextractable studies; (3) The depth of tumor invasion exceeding submucosa. The search time ended in July 2020. The basic information and evaluation indicators included in the article were extracted. The retrospective study was evaluated using Newcastle-Ottawa literature quality evaluation scale. The prospective randomized controlled study was evaluated using Jadad modified scale. Meta-analysis was performed using Review Manager 5.3. Publication bias was assessed using funnel map. Publication bias was tested using Egger tools. Results: A total of 717 literatures were retrieved, and 17 literatures were enrolled finally, including 2 randomized controlled trials and 15 retrospective studies. A total of 2427 patients were enrolled, including 948 in PPG group and 1479 in DG group. The meta-analysis of the efficacy indicators showed that there were significant differences in gallstones incidence (OR=0.42, 95% CI: 0.28-0.65, P<0.001), residual gastritis incidence (OR=0.50, 95% CI: 0.32-0.77,P=0.002), bile reflux incidence (OR=0.30, 95% CI: 0.20-0.45, P<0.001), delayed gastric emptying incidence (OR=2.40, 95% CI:1.67-3.45, P<0.001), and postoperative dumping syndrome incidence (OR=0.28, 95% CI: 0.15-0.51, P<0.001), while there were no significant differences in postoperative overall complications (OR=0.97, 95% CI: 0.69-1.35, P=0.840), reflux esophagitis incidence (OR=0.79, 95% CI: 0.39-1.61, P=0.520) between the two groups. The meta-analysis of the long-term prognostic indicators showed that no significant differences of 5-year survival (OR=1.02, 95% CI: 0.61-1.71, P=0.940) or 5-year tumor recurrence (OR=0.77, 95% CI: 0.36-1.68, P=0.520) were observed between the two groups. Conclusion: The incidences of gallstone, residual gastritis, dumping syndrome, bile reflux are lower after PPG in early gastric cancer, while the postoperative overall complications and long-term survival are comparable between PPG and DG, indicating that PPG is quite safe and feasible.

A comparison between pylorus-preserving and distal gastrectomy in surgical safety and functional benefit with gastric cancer: a systematic review and meta-analysis

BackgroundDue to better functional outcomes, pylorus-preserving gastrectomy (PPG) has been widely applied for early gastric cancer (EGC) patients as an alternative to distal gastrectomy (DG). However, controversies still persist regarding the surgical efficacy and oncological safety of PPG.MethodsOriginal studies comparing PPG and DG for EGC were searched in PubMed, Embase, and the Cochrane Register of Controlled Trials up to December 2019. The weight mean difference, standardized mean difference, or odds risk was used to calculate the short-term and long-term outcomes between the two groups.ResultsTwenty-one comparative studies comprising 4871 patients (1955 in the PPG group and 2916 in the DG group) were enrolled in this systematic review and meta-analysis. PPG showed longer hospital day, decreased harvested lymph nodes, and more delayed gastric emptying. However, PPG had the benefits of lower incidence of anastomosis leakage, early dumping syndrome, gastritis and bile reflux, and better recovery of total protein, albumin, hemoglobin, and weight. No difference was found in operative time, blood loss, and overall complications. Moreover, the long-term survival and recurrence rate were similar in two groups.ConclusionOwing to the non-inferiority of surgery and oncology outcomes and the superiority of function outcomes in PPG, we revealed that PPG can be clinically applicable instead of DG in EGC. However, more high-quality comparative studies and randomized clinical trials would be required for further confirmation.

Assessment of postoperative quality of life following pylorus-preserving gastrectomy and Billroth-I distal gastrectomy in gastric cancer patients: results of the nationwide postgastrectomy syndrome assessment study.

Pylorus-preserving gastrectomy (PPG) is increasingly being used to treat early gastric cancer in the middle third of the stomach, with the hope of ameliorating postoperative dysfunction and improving quality of life (QOL). We evaluated symptoms of postgastrectomy syndrome (PGS) and QOL by means of a newly developed integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), and compared PPG with Billroth-I distal gastrectomy (DGBI). The PGSAS-45 consists of 45 items, including items from the SF-8 and GSRS instruments, as well as 22 newly selected items. It was designed to assess the severity of PGS and the living status and QOL of gastrectomized patients. The nationwide PGSAS surveillance study enrolled 2,368 gastric cancer patients who underwent various types of gastrectomy. In this study we analyzed 313 PPG patients and 909 DGBI patients. Body weight loss was -6.9% in the PPG group and -7.9% in the DGBI group (P = 0.052). The PPG group scored better on the diarrhea subscale (PPG; 1.8 vs. DGBI; 2.1, P < 0.0001), dumping subscale (1.8 vs. 2.0, P = 0.003), and frequency of additional meals (1.8 vs. 1.9, P = 0.034). Multiple regression analysis revealed that age and the preservation of the celiac branch of the vagus nerve were independent factors predicting diarrhea and dumping. It has been suggested that PPG is superior to DGBI for ameliorating PGS. Preservation of the celiac branch of the vagus nerve is recommended to reduce postoperative disorders regardless of the reconstruction method used.

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.

Efficacy observation after pylorus-preserving gastrectomy for early gastric cancer

To evaluate the outcomes after pylorus-preserving gastrectomy (PPG) for early gastric cancer(EGC). Clinicopathologic data of 52 patients with EGC undergoing PPG between August 1995 and December 2005 were analyzed retrospectively. A total of 159 patients of EGC who underwent distal gastrectomy with lymph node dissection(control group) were compared with those who received PPG. The lymph node metastasis rate of EGC was 9.6% in PPG group, including 9.6% in No.3, 3.9% in No.4, 3.9% in No.6, and 3.9% in No.7. In the control group, the lymph node metastasis rate was 17.0%, including N1(14.5%) and N2(2.5%). There were no significant differences between the PPG group and the control group (P>0.05). In the PPG group, D1 dissection was 25%, D1+α was 25%, D1+β was 34.6%, and D2 was 15.3%. In control group, 121 patients(76.1%) had less than D2 dissection, while there were 33(20.7%) D2, and 5(3.1%) D3, and the difference was not statistically significant(P>0.05). There were no significant differences between the two groups in overall 5-year survival rate(92.3% vs. 93.1%, P=0.881). The 5-year survival rate in the PPG group was 100% for D1, 92.3% for D1+α, 88.9% for D1+β, and 85.7% for D2, while the 5-year survival rate in the control group was 92.3% for D1, 93.3% for D1+α, 91.7% for D1+β, and 93.9% for D2. The difference was not statistically significant(P>0.05). The recurrence rate was comparable (5.7% vs. 5.6%, P>0.05). Pylorus-preserving gastrectomy may provide long-term survival benefits for patients with early gastric cancer.

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.

Symptom evaluation of long-term postoperative outcomes after pylorus-preserving gastrectomy for early gastric cancer

Since the early 1990s, pylorus-preserving gastrectomy (PPG) has been used in the treatment of patients with early gastric cancer in order to reduce postprandial symptoms. To date, there have been few reports of long-term symptom evaluation following this procedure. The aim of this study was to evaluate long-term postoperative outcomes after PPG. Three hundred and ninety-seven patients with early gastric cancer were enrolled in this study: 194 patients who underwent PPG and 203 who underwent distal gastrectomy with Billroth-I reconstruction (DGBI). We compared the symptoms for the two groups in a questionnaire on postoperative functional outcomes, endoscopy findings and the appearance of gallstones after surgery. The incidence of symptoms suggesting early dumping syndrome was significantly lower in the PPG group compared with the DGBI group (P < 0.05). The incidences of disturbed bowel habit and frequent flatus were significantly lower in the PPG than in the DGBI group. The average relative body weight (actual BW/ BW immediately before the surgery) was significantly better in the PPG than in the DGBI group (P < 0.001). The long-term results show that PPG has clear advantages over DGBI in terms of postoperative symptoms and functional outcomes. These results imply that PPG should be the recommended procedure for early gastric cancers located in the middle third of the stomach.

Endoscopic evaluation of the remnant stomach after gastrectomy: proposal for a new classification

In Japan, approximately half of gastric cancers are diagnosed in the early stage. Longer survival has been provided for patients with early gastric cancer (EGC). Several new surgical procedures have been employed for some EGCs. To compare the functional results of these techniques with those of classic distal gastrectomy, it is important to evaluate the remnant stomach in relation to quality of life (QOL) and secondary cancers. We propose a new endoscopic classification, regarding several aspects of the remnant stomach, which enables common understanding and description of the condition. Of 651 patients who underwent a distal gastrectomy or pylorus-preserving gastrectomy (PPG), 324 had at least one upper gastrointestinal (GI) endoscopy during the follow-up period. Ninety-three of the 324 patients underwent a Roux-en-Y reconstruction (RY); 175, Billroth type 1 (B1); and 56, PPG. Endoscopic findings regarding residual food, gastritis, and bile reflux in the gastric stump were investigated for these patients. We classified the amount of residual food into five grades, the degree and the extent of gastritis into five grades, and bile reflux into two grades. First, we evaluated the consistency of diagnosis between two endoscopists, in the first 200 patients, and then we applied the classification to all 324 patients to examine the usefulness of this classification. Consistency of diagnosis was obtained between two endoscopists who classified the patients independently. The agreement rate was 98.5% for residual food, 93% for gastritis, and 100% for bile reflux. Residual food was observed in 14.0% of the RY group, 22.3% of the B1 group, and 37.5% of the PPG group. These differences were significant (RY versus B1; P < 0.05 and RY versus PPG; P < 0.01). The remnant stomach after B1 showed significantly more severe and extensive gastritis than that after RY and PPG ( P < 0.01). As for bile reflux, there was no significant difference among the three groups. The classification (RGB classification: Residue, Gastritis, Bile) can be used easily and is practical. The results suggest some important differences among methods of reconstruction. This classification seems to be useful to describe these findings and to further evaluate these reconstructive methods.

胃癌患者における胃切除術後の薬物吸収動態

We investigated the absorption rates of acetaminophen, theophyline and lansoprazole after pylorus preserving-gastrectomy (PPG) with preservation of the vagal nerve as a treatment for patients with early gastric cancer. Postoperative functioning of the residual stomach 6 months after the operation in patients with early gastric cancer who had undergone PPG (PPG group, n=5) was compared with that in patients who had undergone distal gastrectomy (DG group, n=4). We also investigated recovery of body weight, findings in a series of gastrointestinal X-rays, gastroscopic findings, hormonal secretion and digestive and absorbtive abilities.The postoperative absorption rates of acetaminophen in the PPG group were almost the same as those before the operation, but they were slower in the PPG group than in the DG group.The absorption rate of theophyline from a sustained release formulation was faster in the DG group, and slower in the PPG group compared to the preoperative absorption rates. In the DG group, the absorption rate of an enteric-coated preparation of lansoprazole did not differ greatly from that before the operation. In the PPG group, however, there were large individual differences and a notable delay in absorption and reduction in the amount of absorption in the early stage.Recovery of body weight at 6 months after the operation was not significantly different in the PPG and DG groups. In the PPG group, postoperative gastrointestinal X-rays showed that the pyloric form had been retained, and gastroscopic examination showed that there had been no reflux gastritis or esophagitis. The rates of digestion and absorption were faster in the DG group than in the PPG group, and the plasma levels of glucose were higher but the serum levels of gastrin were lower in the DG group than in the PPG group.Furthermore, hormonal secretion in the PPG group was close to the normal physiological range.These results indicate that the rate of absorption was faster in the DG group and slower in the PPG group.The absorbability of drugs following gastric resection varies depending on the type of operation and the properties of the drug preparation.

Feasibility of pylorus-preserving gastrectomy with a wider scope of lymphadenectomy.

To demonstrate the feasibility and safety of pylorus-preserving gastrectomy (PPG) accompanied by complete suprapyloric and infrapyloric lymph node dissection. Retrospective review. A university hospital in Japan. Fifteen patients underwent PPG, and 28 patients underwent conventional distal gastrectomy (CDG) with Billroth I anastomosis. All patients had early gastric cancer, with either limited invasion in the mucosal layer or invasion into the submucosal layer. In the PPG procedure, the distal part of the stomach was resected while retaining a 1.5-cm pyloric cuff. The right gastroepiploic artery, the right gastric artery, and hepatic and pyloric branches of the vagus nerve were divided, and the infrapyloric artery was preserved. A modified D1 or D2 lymphadenectomy accompanied the PPG. Patients undergoing the PPG and CDG procedures were assessed 1 year after their surgical procedure. Changes in body weight, serum total protein levels, and serum albumin levels, the incidence of dumping syndromes, and endoscopic findings in the gastric remnant were compared between the 2 groups. Weight loss was significantly less in the PPG group than in the CDG group (P=.02). The incidences of early dumping syndromes, especially vasomotor symptoms, were significantly lower in the PPG group than in the CDG group (P=.03 and P=.02, respectively). The pyloric sphincter function was preserved, and there was no anastomotic leakage in the PPG group. The PPG procedure with complete D2 lymphadenectomy can be performed safely with a low incidence of major complications and a better postoperative outcome than the CDG procedure. The PPG procedure can be recommended for the treatment of early gastric cancer with broader indications.

Postoperative evaluation of pylorus-preserving gastrectomy for early gastric cancer

Physical results after pylorus-preserving gastrectomy (PPG) with preservation of the vagus nerve were evaluated. The status of 15 patients with early gastric cancer after PPG was compared with that of 14 patients after distal gastrectomy (DG). The postoperative/preoperative body-weight ratio of the PPG group (0.99) was significantly greater than that of the DG group (0.92). Patients who had PPG had fewer postoperative abdominal symptoms than those who underwent DG. The gastric emptying pattern of patients who had a pylorus-preserving procedure was slower than that of those who had conventional gastrectomy, and more similar to the preoperative pattern. Contraction of the gallbladder after PPG was better than after DG. Gastroscopy revealed that the mucosa of the stomach remnant after PPG was less abnormal than after DG. In conclusion, PPG is a more physiological operation than conventional DG and should be applied in carefully selected cases of early gastric cancer.