Pylorus-preserving gastrectomy for early cancer involving the upper third: can we go higher?

Abstract

Background Pylorus-preserving gastrectomy (PPG) is commonly performed for early gastric cancer (EGC) located in middle third of the stomach. We investigated the surgical, oncological, and functional outcomes of PPG involving the upper third of stomach. Methods We included all patients of the period 2013-2016 who underwent PPG, distal subtotal gastrectomy (DSG), and total gastrectomy (TG) for EGC involving the upper third by carefully defining the localization. Surgical, oncological, and functional outcome analyses included postoperative morbidity, lymph-node metastasis, tumor recurrence, postoperative body weight, body mass index, hemoglobin, total protein, albumin, quantification of intraabdominal fat, and gallstone development.Results Overall, 288 cases were analyzed: 145 PPG, 61 DSG, and 82 TG. In the study period, patients potentially underwent PPG for EGC involving the upper third, if enough proximal remnant stomach was found whilst achieving a sufficient proximal margin. PPG resulted in less operation time (p < 0.001), less blood loss (p = 0.002) and lower postoperative morbidity compared to TG. For lymph-node (LN) stations being resected in all groups, no difference was found in number of resected LN. Recurrence-free survival was similar for all groups. PPG showed advantages regarding postoperative body weight, hemoglobin, total protein, albumin in postoperative 6 and 12 month follow-up. Lowest decrease of abdominal fat area after 12 months was seen for PPG. Gallstone incidence was significantly lower after PPG compared to TG (p < 0.001). Conclusions For EGC involving the upper third, PPG can be another good option with lower postoperative morbidity, better functional outcomes, and same oncological safety.

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

“…This meta-analysis presented that similar operation duration and blood loss was observed between PPG and DG. Interestingly, shorter operative time and lesser blood loss were associated with PPG in several prospective cohort studies [5,8] In addition, compromising hepatic and pyloric branches of the vagus nerve can increase the incidence of gallstones. In PPG, the physiological reconstruction without vagotomy maintain the contraction of Oddi sphincter and secretion of cholecystokinin [37,38].…”

“…Since the first application of PPG in 1967 [3], this approach has been introduced as a minimally invasive surgery and even extended to combine with laparoscopic technique. Moreover, the retainment of pyloric cuff and vagal nerve in PPG provided advantages such as ameliorating postoperative gastritis, bile reflux, early dumping syndromes and improving nutritional status [4,5]. In PPG, the infrapyloric LNs are routinely dissected with preserving the infra-pyloric vessels, and the supra-pyloric LNs are usually omitted to preserve the right gastric artery and the hepatic branch of the vagal nerve [6,7].…”

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

“…The first meta-analysis, which was published in 2014 [10], demonstrated that PPG had superior benefits in terms of lower incidence rates of early dumping syndrome, gastritis, and bile reflux as well as regaining of weight. According to the Japanese Gastric Cancer Treatment Guidelines and considerable newly published studies with relatively comprehensive data [5,7,11,12], indications as well as standardized management and treatment for PPG have been well established. Therefore, we performed an updated meta-analysis to demonstrate the surgery efficacy, oncologic safety, and function recovery of PPG.…”

“…Since the first application of PPG in 1967 [ 3 ], this approach has been introduced as a minimally invasive surgery and even extended to combine with laparoscopic technique. Moreover, the retainment of pyloric cuff and vagal nerve in PPG provided advantages such as ameliorating postoperative gastritis, bile reflux, early dumping syndromes, and improving nutritional status [ 4 , 5 ]. In PPG, the infra-pyloric lymph nodes (LNs) are routinely dissected with preserving the infra-pyloric vessels, and the supra-pyloric LNs are usually omitted to preserve the right gastric artery and the hepatic branch of the vagal nerve [ 6 , 7 ].…”

Proximal Anterior-Antrum Posterior (PAAP) Overlapping Anastomosis in Minimally Invasive Pylorus-Preserving Gastrectomy for Early Gastric Cancer Located in the High Body and Posterior Wall of the Stomach

“…PPG can be performed for cT1N0M0 gastric cancer located in the middle one-third of the stomach, approximately 4–5 cm away from the pylorus [ 4 5 ]. However, our group recently reported that PPG is also an alternative treatment for early gastric cancer (EGC) involving the upper one-third of the stomach, because it is associated with lower postoperative morbidity, better functional outcomes, and the same oncological safety as distal gastrectomy or total gastrectomy [ 6 ].…”