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

Abstract

Introduction 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. Methods 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 deltashaped intracorporeal gastrogastrostomy was made with linear staplers. Results 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. Conclusion 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 wellestablished LAPPG with a hand-sewn gastrogastrostomy.

Preservation of the celiac branch of the vagal nerve for pylorus-preserving gastrectomy: is it meaningful?

“…PPG was first performed as a treatment for gastric ulcers in 1967 [24]. Recently, LPPG has become one of the surgical modalities used for early gastric cancer to reduce invasion [8,17,[25][26][27]. However, the clinical significance of the CBVN preservation, which has an advantage in distal gastrectomy, has not been clear in PPG [14].…”

“…The LPPG technique consisted of the following procedures, as previously described [6,17], with D1+ lymphadenectomy performed according to the 2nd edition of the Japanese Classification of Gastric Cancer (JCGC) [19]. A summary of our LPPG procedures is as follows: (1) the greater omentum was dissected; (2) the right gastroepiploic vein and artery were divided while preserving the infrapyloric vessels to maintain blood supply to the remaining pyloric cuff; (3) the suprapyloric lymph nodes were picked up if required, and the right gastric artery and the pyloric branch of the vagal nerve were preserved; (4) the lesser omentum was dissected, and the hepatic branch of the vagal nerve was preserved; (5) the trunk of the left gastroepiploic artery and vein were divided; (6) the greater curvature was rolled up toward the abdominal wall, and the suprapancreatic lymph nodes along the common hepatic artery and splenic artery were dissected; (7) when the CBVN was not preserved, the root of the left gastric artery was divided; (8) when the CBVN was preserved, the CBVN was made visible from the left side of the gastropancreatic ligament, the left gastric artery was divided at the distal site where the CBVN met, the CBVN was carefully skeletonized using an ultrasonically activated device so as not to cause thermal injury [20], and the posterior gastric branch of the vagal nerve was cut [17]; (9) the cardiac lymph nodes and the lymph nodes along the lesser curvature of the stomach were dissected; and (10) the stomach was transected 3-5 cm proximal to the pylorus and at the proximal site of the tumor, depending on the negative-confirmation biopsy. After the transection of the stomach, a gastro-gastro anastomosis was made by hand-suturing or using a linear stapler.…”

“…Pylorus-preserving gastrectomy (PPG) has been widely accepted as one type of function-preserving gastrectomy for EGC located in the middle third of the stomach, and the procedure is now performed through a laparoscopic approach (LPPG) in many institutions [6][7][8]. Compared with conventional distal gastrectomy, PPG has been reported to have several advantages in postoperative dumping syndrome, including postoperative nutritional status, bile reflux, and prognosis [9,10].…”

Function-preserving surgery for gastric cancer: current status and future perspectives

“…During LAPPG, anastomosis can be easily performed directly from the small upper abdominal middle incision, as the site for anastomosis site is immediately under the incision for hand-sewn procedures. In reports of complete intracorporeal anastomosis during LAPPG, delta- shaped anastomosis was performed with demonstrated feasibility and safety in initial experiences ( Figure 2) (14,15). Conversely, reports of intracorporeal end-toend anastomosis after LAPPG were also published, where anastomosis was performed using a combination of a stapler and a hand-sewn procedure (16).…”

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

“…PPG for EGC in the middle portion of the stomach, with the distal tumor border at least 4 cm proximal to the pylorus, has been recognized as a modification of resection for EGC (8). However, using the laparoscopic approach for PPG is difficult because it should preserve the pyloric and hepatic branches of the vagus nerve and infrapyloric vessels (49)(50)(51). In Japan, Jiang et al reported a retrospective analysis of the postoperative outcomes of 307 laparoscopic-assisted pylorus-preserving gastrectomies (LAPPG) (52).…”