Meta-analysis of subtotal stomach-preserving pancreaticoduodenectomy vs pylorus preserving pancreaticoduodenectomy

AIM: To investigate the differences in outcome following pylorus preserving pancreaticoduodenectomy(PPPD) and subtotal stomach-preserving pancreaticoduodenectomy(SSPPD).METHODS: Major databases including Pub Med(Medline), EMBASE and Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials(CENTRAL) in The Cochrane Library were searched for comparative studies between patients with PPPD and SSPPD published between January 1978 and July 2014. Studies were selected based on specific inclusion and exclusion criteria. The primary outcome was delayed gastric emptying(DGE). Secondary outcomes included operation time, intraoperative blood loss, pancreatic fistula, postoperative hemorrhage, intraabdominal abscess, wound infection, time to starting liquid diet, time to starting solid diet, period of nasogastric intubation, reinsertion of nasogastric tube, mortality and hospital stay. The pooled odds ratios(OR) or weighted mean difference(WMD) with 95% confidence intervals(95%CI) were calculated using either a fixed-effects or random-effects model. RESULTS: Eight comparative studies recruiting 650 patients were analyzed, which include two RCTs, one non-randomized prospective and 5 retrospective trial designs. Patients undergoing SSPPD experienced significantly lower rates of DGE(OR = 2.75; 95%CI: 1.75-4.30, P < 0.00001) and a shorter period of nasogastric intubation(OR = 2.68; 95%CI: 0.77-4.58,P < 0.00001), with a tendency towards shorter time to liquid(WMD = 2.97, 95%CI:-0.46-7.83; P = 0.09) and solid diets(WMD = 3.69, 95%CI:-0.46-7.83; P = 0.08) as well as shorter inpatient stay(WMD = 3.92, 95%CI:-0.37-8.22; P = 0.07), although these latter three did not reach statistical significance. PPPD, however, was associated with less intraoperative blood loss than SSPPD [WMD =-217.70, 95%CI:-429.77-(-5.63); P = 0.04]. There were no differences in other parameters between the two approaches, including operative time(WMD =-5.30, 95%CI:-43.44-32.84; P = 0.79), pancreatic fistula(OR = 0.91; 95%CI: 0.56-1.49; P = 0.70), postoperative hemorrhage(OR = 0.51; 95%CI: 0.15-1.74; P = 0.29), intraabdominal abscess(OR = 1.05; 95%CI: 0.54-2.05; P = 0.89), wound infection(OR = 0.88; 95%CI: 0.39-1.97; P = 0.75), reinsertion of nasogastric tube(OR = 1.90; 95%CI: 0.91-3.97; P = 0.09) and mortality(OR = 0.31; 95%CI: 0.05-2.01; P = 0.22).CONCLUSION: SSPPD may improve intraoperative and short-term postoperative outcomes compared to PPPD, especially DGE. However, these findings need to be further ascertained by well-designed randomized controlled trials.

Vagus effect on pylorus preserving gastrectomy

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Gastroduodenal ulcer treated by pylorus and pyloric vagus-preserving gastrectomy

AIM To evaluate the curative effect of pylorus and pyloric vagus-preserving gastrectomy (PPVPG) on peptic ulcer.METHODS Treating 132 cases of GU and DU with PPVPG, and comparative studies made with 24 cases treated with Billroth Ⅰ (BⅠ) and 20 cases with Billroth Ⅱ (BⅡ); advantages and shortcomings evaluated.RESULTS Not a single death after PPVPG. No recurrence of the disorder in the subsequent follow-up for an average of 6.5 years. Curative effect (visik Ⅰ & Ⅱ) 97.7%. Acidity reduction similar to that found in BⅠ and BⅡ, but 97.7% of the BⅠ and all BⅡ cases having more than second degree intestinal fluid reflux, in contrast to 7.1% in PPVPG cases. Dumping syndrome occurred in the BⅠ and BⅡ cases, none in PPVPG cases. With regard to gastric emptying, food digestion, absorption, body weight and life quality, PPVPG proved to be superior to Billroth procedure.CONCLUSION PPVPG has the advantages of conventional Billroth gastrectomy in reducing acid, removing ulcer focus, and at the same time preserves the pylorus and pyloric vagus for maintaining the normal gastric physiological function. Dumping syndrome, intestinal fluid reflux and other complications of conventional gastrectomy may be avoided.

Retroperitoneal cavernous hemangioma resected by a pylorus preserving pancreaticoduodenectomy

A retroperitoneal hemangioma is a rare disease. We report on the diagnosis and treatment of a retroperitoneal hemangioma which had uncommonly invaded into both the pancreas and duodenum, thus requiring a pylorus preserving pancreaticoduodenectomy (PpPD). A 36-year-old man presented to our hospital with abdominal pain. An enhanced computed tomography scan without contrast enhancement revealed a 12 cm × 9 cm mass between the pancreas head and right kidney. Given the high rate of malignancy associated with retroperitoneal tumors, surgical resection was performed. Intraoperatively, the tumor was inseparable from both the duodenum and pancreas and PpPD was performed due to the invasive behavior. Although malignancy was suspected, pathological diagnosis identified the tumor as a retroperitoneal cavernous hemangioma for which surgical resection was the proper diagnostic and therapeutic procedure. Reteoperitoneal cavernous hemangioma is unique in that it is typically separated from the surrounding organs. However, clinicians need to be aware of the possibility of a case, such as this, which has invaded into the surrounding organs despite its benign etiology. From this case, we recommend that combined resection of inseparable organs should be performed if the mass has invaded into other tissues due to the hazardous nature of local recurrence. In summary, this report is the first to describe a case of retroperitoneal hemangioma that had uniquely invaded into surrounding organs and was treated with PpPD.

Acquired double pylorus:Clinical and endoscopiccharacteristics and four-year follow-up observations

Double pylorus(DP), or duplication of the pylorus, is an uncommon condition that can be either congenital or acquired. Acquired DP(ADP) occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. The clinical features and endoscopic characteristics of four patients with ADP were reviewed and compared with previously reported cases. An accessory channel connects the lesser curvature of the prepyloric antrum with the duodenal bulb, and in all cases, a peptic ulcer was located in or immediately adjacent to the accessory channel. In one of the patients, the bridge between the double-channel pylorus disappeared, resulting in a single large opening and duodenal kissing ulcer after two years and three months. Finally, nonsteroidal anti-inflammatory drugs, Helicobacter pylori and other risk factors associated with ADP are assessed.

Pylorus- and vagus-nerve-preserving partial gastrectomy (D2 dissection)

Pylorus- and vagus nerve-preserving partial gastrectomy is important in improving the prognosis of early gastric cancer surgery, reducing surgical complications and improving the quality of life for such patients. In the present case, pylorus- and vagus nerve-preserving partial gastrectomy was performed using the bipolar electrocautery dissection technique combined with D2 dissection along the lesser sac.

Acquired double pylorus,due to penetrating gastric ulcer,presenting with melena

Acquired double pylorus (DP) is an uncommon condition consisting of two communicating channels between the gastric antrum and the first part of duodedum.Little is known about the origin of DP.As there is no specific gastrointestinal symptom due to DP,most often it is diagnosed by gastroscopy while performing for other indicationsFew data are also known about the clinical course of DP.In the patients with peptic ulcer symptoms,the pyloroplasty-like drainage effect,improving gastric emptying after the estabilishment of the fistula,could relieve these symptoms.This represents an unresolved issues about the necessity of repeating endoscopy to document in the patients with DP its final outcome,as the risk of ulcer recurrence.We describe a case of a 76-years-old woman admitted to our department for hyposideremic anemia associated to a recent history of melena.

Performing robot-assisted pylorus and vagus nerve-preserving gastrectomy for early gastric cancer:A case series of initial experience

BACKGROUND Pylorus and vagus nerve-preserving gastrectomy(PPG)is a function-preserving surgery for early gastric cancer(GC)that has gained considerable interest in the recent years.The operative technique performed using the Da Vinci Xi robot system is considered ideal for open and laparoscopic surgery.AIM To introduce Da Vinci Xi robot-assisted PPG(RAPPG)-based operative procedure and technical points as well as report the initial experience based on the clinical pathology data of eight cases of early GC.METHODS Da Vinci Xi robot-assisted pylorus and vagus nerve-preserving gastrectomy(RAPPG)was performed for 11 consecutive patients with middle GC from December 2020 to July 2021.Outcome measures were postoperative morbidity,operative time,blood loss,number of lymph nodes harvested,postoperative hospital stay,time to first flatus,time to diet,and resection margins.RESULTS Eight of the 11 patients who were pathologically diagnosed with early GC were enrolled in a retrospective study to assess the feasibility and safety of RAPPG.The mean operative time,mean blood loss,mean number of lymph nodes harvested,length of preserved pylorus canal,distal margin,and proximal margin were 330.63±47.24 min,57.50±37.70 mL,18.63±10.57,3.63±0.88 cm,3.50±1.31 cm,and 3.63±1.19 cm,respectively.None of the cases required conversion to laparotomy.Postoperative complications occurred in two(25.0%)patients.Postoperative complications were hyperamylasemia and gastric stasis in one case and incision infection in the other.Time to first flatus was 3.75±2.49 d after the operation,andpostoperative hospital stay was 10.13±4.55 d.CONCLUSIONThe core technique in the Da Vinci Xi RAPPG is lymph node dissection and the anatomic methodof the nerve.Robotic surgical procedures are feasible and safe.With the progress of surgicaltechnology,optimization of medical insurance structure,and emergence of evidence-basedmedicine,automated surgery systems will have a broad application in clinical treatment.

Acquired double pylorus:A case report

Double pylorus is one of the rare anomalies of the gastrointestinal tract,it can be congenital or acquired.In this case we report a case of double pylorus because of chronic peptic ulcer.Upper GI endoscopy revealed gastroduodenal fistula located on the lesser curve of the antrum,the patient’s symptoms were improved rapidly by intensive antiulcer treatment.

Is There Comparable Morbidity in Pylorus-preserving and Pylorus-resecting Pancreaticoduodenectomy? A Meta-analysis

Summary： Pancreaticoduodenectomy （PD） is the most effective treatment for patients with pancreatic head or periampullary lesions. Two major strategies exist： pylorus-preserving pancreaticoduodenectomy （PPPD） and pylorus-resecting pancreaticoduodenectomy （PRPD）. However, it is yet unclear regarding the morbidity after PPPD and PRPD. This study analyzed the morbidity after PPPD and PRPD to de- termine the optimal surgical treatment of masses in the pancreatic head or periampullary region. A sys- tematic search of databases identifying randomized controlled trials （RCTs） from the Cochrane Library, PubMed, EMBASE and Web of Science was performed. Outcome was compared by postoperative mor- bidity including overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and delayed gastric emptying （DGE） rate between PPPD and PRPD. The DGE rate in the PRPD subgroups （conventional PD [CPD] and subtotal stomach-preserving PD [SSPPD], respec- tively） was also analyzed. The results showed that 9 RCTs including 722 participants were included for meta-analysis. Among these RCTs, 7 manuscripts described PRPD as CPD, and 2 manuscripts described PRPD as SSPPD. There were no significant differences in the overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, or biliary leakage between PPPD and PRPD. There was a lower rate of DGE with PRPD than that with PPPD （RR=2.15, P=0.03, 95% CI, 1.09-4.23）. Further subgroup analysis indicated a comparable DGE rate for the CPD but a lower DGE rate for the SSPPD group than the PPPD group. However, the result did not indicate any difference between CPD and SSPPD regarding the DGE rate （P=-0.92）. It is suggested that PPPD is comparable to PRPD in overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding and biliary leakage. The current data are not sufficient to draw a conclusion regarding which surgical procedure is associated with a lower postoperative DGE rate. Our conclusions were limited by the available data. Further evaluations of RCTs are needed.

65 CASES OF PRESERVING PYLORUS PANCREATODUODENECTOMY：EXPERIENCE AND PROBLEMS

Sixty-five patients with neoplasm (62 cases) or pancreatitis (3 cases) were treated with preserving pylorus pancreatoduodenectomy (PPPD) from 1984 to 1991. One postoperative death occurred. Follow-up studies were performed in 35 patients who had been treated by PPPD or the standard Whipple's procedure; they were questioned carefully concerning clinical symptoms. Further studies were porformed in 20 patients with or without pylorus preservation (10 patients, respectively). Nutritional status and gastrointestinal digestive and absorptive functions were evaluated by detemination of serum components, gastric analysis, barium emptying time, D-xylose absorption test,14CO2 breath test, PABA, and other methods. The results demonstrated malnutrition and postgastrectomy syndromes in some patients after the standard Whipple' s procedure, but not in those with PPPD. The quality of life was better in the latter. Pylorus preservation may be the main reason for this above difference. Delayed gastric emptying in the early postoperative period was a complication in some patients(21%) treated by PPPD.We recommend PPPD for pancreatoduodenectomy.

Effect of Lonicerae Flos extracts on reflux esophagitis with antioxidant activity

AIM： To observe the effects of traditional antiinflammatory medicine Lonicerae FIos （LF） on rat reflux esophagitis （RE） induced by pylorus and forestomach ligation compared with the well-known proton antioxidant, α-tocopherol. METHODS： Rats were pretreated with three different dosages of LF （500, 250 and 125 mg/kg） orally, once a day for 14 d before pylorus and forestomach ligation. Nine hours after pylorus and forestomach ligation, changes to the stomach and esophagus lesion areas, gastric volumes, acid and pepsin outputs, antioxidant effects, esophageal lipid peroxidation, superoxide dismutase （SOD）, catalase （CAT）, malondialdehyde （MDA）, myeloperoxidase and glutathione （GSH） levels, and collagen contents （marker of flexibility） were observed on the esophageal and fundic histopathology. The results were compared with an α-tocopherol （once orally, 1 h before operation, 30 mg/kg） treated group in which the effects on RE were already confirmed.RESULTS： Pylorus and forestomach ligations caused marked increases of gross esophageal and gastric mucosa lesion areas, which corresponded with histopathological changes. In addition, increases of esophageal lipid peroxidation, decreases of SOD, CAT, and GSH-free radical scavengers, increases of collagen were observed. However, these pylorus and forestomach ligation induced RE were dose-dependently inhibited by treatment of 500, 250 and 125 mg/kg of LF extract, mediated by antioxidant effects. RE at 250 mg/kg showed similar effects α-tocopherol. CONCLUSION： The results suggest that antioxidant effects of LF could attenuate the severity of RE and prevent the esophageal mucosal damage, and validate its therapeutic use in esophageal reflux disease.

Current role of minimally invasive approaches in the treatment of early gastric cancer

Despite declining incidence,gastric cancer remains one of the most common cancers worldwide.Early detection in population-based screening programs has increased the number of cases of early gastric cancer,representing approximately 50%of newly detected gastric cancer cases in Asian countries.Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis.Laparoscopic and robotic resections for early gastric cancer,including function-preserving resections,have propagated through advances in technology and surgeon experience.The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.

Current status of function-preserving surgery for gastric cancer

Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer(GC)at an early stage.Due to the low incidence of lymph node metastasis and favorable prognosis in early GC,function-preserving surgery which improves postoperative quality of life may be possible.Pylorus-preserving gastrectomy(PPG)is one such function-preserving procedure,which is expected to offer advantages with regards to dumping syndrome,bile reflux gastritis,and the frequency of flatus,although PPG may induce delayed gastric emptying.Proximal gastrectomy(PG)is another functionpreserving procedure,which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach,although the incidence of heartburn or gastric fullness associated with this procedure is high.However,these disadvantages may be overcome by the reconstruction method used.The other important problem after PG is remnant GC,which was reported to occur in approximately 5%of patients.Therefore,the reconstruction technique used with PG should facilitate postoperativeendoscopic examinations for early detection and treatment of remnant gastric carcinoma.Oncologic safety seems to be assured in both procedures,if the preoperative diagnosis is accurate.Patient selection should be carefully considered.Although many retrospective studies have demonstrated the utility of function-preserving surgery,no consensus on whether to adopt functionpreserving surgery as the standard of care has been reached.Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.

Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple's technique

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard procedure for resecting tumors arising from the periampullary area and the pancreatic head. Nevertheless this procedure is inherently difficult and associated with high morbidity and mortality. Besides, the technique applied for exposing the portal and superior mesenteric veins is time-consuming, difficult and associated with the risk of major venous injury. Recently we have introduced a modified approach for making this part of the procedure quick, safe and bloodless, which constitutes the subject of this study. METHODS: Patients who underwent pylorus preserving pancreaticoduodenectomy (PPPD) either by superior approach technique (group 1) or by classical Whipple’s technique (group 2) were retrospectively identified. Age-sex composition, body mass index (BMI), total operative time, operative blood loss, intraoperative blood transfusion requirement, morbidity, mortality and length of hospital stay were compared between the two groups. RESULTS: Between January 1997 and December 2011, 72 patients underwent PPPD by the superior approach technique (group 1) and 38 underwent PPPD by the classical Whipple’s technique (group 2) at our institution. Statistically significant differences were observed in operative time (208.1±46.3 minutes in group 1 vs 322.0±33.8 minutes in group 2), operative blood loss (601.0±250.3 mL in group 1 vs 1371.5±471.8 mL in group 2), and intraoperative blood transfusion requirement [10 (13.9%) patients in group 1 and 24 (63.2%) in group 2]. Among 18 (16.4%) obese patients, significant differences in operativetime, operative blood loss and intraoperative blood transfusion requirement were observed between groups 1 and 2. There was no significant inter-group difference in complication rate among obese patients, but comparing obese patients with normal weight patients revealed higher rates of complications like pancreatic fistula (27.8% vs 6.5%), delayed gastric emptying (16.7% vs 5.4%), and infective complications like wound infection and intra abdominal collection (44.4% vs 5.4%). CONCLUSIONS: On the basis of analytical data, we conclude that the superior approach technique is effective for PD compared with the classical Whipple’s technique. It allows fast, safe and virtually bloodless dissection for exposure of the superior mesenteric and portal veins during early steps of PD. PD is normally a difficult and tedious procedure carrying a remote risk of major venous injury leading to substantial blood loss.

Effect of gastrectomy on G-cell density and functional activity in dogs

INTRODUCTION Billroth gastrectomy has some advantages ofinhibiting acid secretion,low ulcer recurrence andlow mortality. However, postoperativecomplications,such as dumping syndrome andreflux gastritis,often occurred as a result ofpylorectomy.To minimize these complications,pylorus-preserving gastrectomy(PPG)had beenperformed for gastric ulcer with satisfied clinicalresults.Positive correlation was not found betweenulcer recurrence and serum gastrin level.In

Underwater endoscopic mucosal resection for neoplasms in the pyloric ring of the stomach: Four case reports

BACKGROUND Tumors located in the pylorus are technically more complex to resect by endoscopic resection,as the anatomical characteristics of this region can affect the adequate assessment of margins and performance of the procedure.We reported the results of underwater endoscopic mucosal resection(UEMR)of benign mucosal neoplasms located in the pyloric ring.CASE SUMMARY This case series describes 4 patients with 4 mucosal neoplasms located in the pyloric ring.The diameter of each neoplasm was less than 15 mm.We performed UEMR for the lesions.Water immersion enabled slight floating of the lesions,resulting in easy identification.We achieved en bloc resection with a snare and electrosurgical unit.All procedure were performed within 3 min without adverse events.Pathologic examination showed low-grade dysplasia with clear resection margins in one case and hyperplastic polyps in three cases.CONCLUSION UEMR can be an effective and safe treatment method for neoplasms in the gastric pyloric ring.

Steroid responsive eosinophilic gastric outlet obstruction in a child

Gastric outlet obstruction is a rare complication of eosinophilic gastroenteritis, most commonly treated surgically. We report a case of eosinophilic gastric outlet obstruction in a child that responded to conservative medical management. A brief review of this clinical entity is also provided.

Protective roles of Vigna subterranea(Bambara nut) in rats with aspirin-induced gastric mucosal injury

Objective： Vigna subterranea is widely consumed as a traditional staple food in Nigeria and some West African countries. The ethanolic seed extract of V. subterranea （EEVS） was investigated for its gastroprotective effects on aspirin plus pylorus ligation-induced gastric ulcerated rats using an in vivo assay. Methods： Gastric mucosal ulceration was induced experimentally in Groups 2 to 5 using aspirin plus pylorus ligation. Rats in Group I were orally pretreated with 3% Tween 80 only as normal control. Groups 2 to 5 were pretreated with 3% Tween B0 （ulcer group）, 20 mg/kg of omeprazole （positive group）, and 200 and 400 mg/kg of EEVS （experimental groups）, respectively, once daily for 21 days before ulcer induction. Parameters including those for gastric secretions, ulcerated areas and gastric wall histology were assessed. Levels of superoxide dismutase （SOD）, glutathione peroxidase （GPx）, and malondialdehyde （MDA） in the gastric tissue homogenate were also determined. Results： Pretreatment with EEVS significantly （P 〈 0.05） reduced the ulcer index, gastric volume and total acidity in rats with aspirin plus pylorus ligation-induced ulcer. The pH and mucus of gastric content increased significantly （P 〈 0.05） while the levels of SOD and GPx were observed to be elevated with a reduced amount of MDA. Significant severe gastric mucosal injury was exhibited in the ulcer group and EEVS or omeprazole offered significant （P〈0.05） protection against mucosal ulceration. Histologically, the gastric submucosal layer showed remarkable decrease in edema and leucocytes infiltration compared with ulcer group. Conclusion： The study suggests that EEVS offered a protective action against aspirin plus pylorus ligationinduced gastric ulcers in Wistar rats. The protective effect might be mediated via antisecretory, cytopro- tective and antioxidative mechanisms.

Gastroprotective Effects of Ascaridole on Gastric Ulcer in Rats

Objective To evaluate the gastroprotective activity of ascaridole. Methods The gastroprotective effect of ascaridole was evaluated on ulcer healing in rats with acetic acid-induced chronic gastric ulcer, pylorus ligation- and Aspirin-induced gastric ulcer. Ascaridole was ig administered with the dosages of 10 and 20 mg/kg once daily for 7 d. Results Ascaridole showed the significant anti-ulcer effects. In acetic acid-induced gastric ulcer rats, the ulcer areas after 10 and 20 mg/kg of ascaridole treatment were (65.1 ± 20.0) and (50.6 ± 11.0) mm2, respectively, which were significant lower (P < 0.01) than that of the control group [(116.7 ± 35.8) mm2]. For pylorus ligation model, ascaridole showed a gastric ulcer healing effect in a dose-dependent manner. Ascaridole at the dose of 20 mg/kg showed 50% ulcer protection and had a significant (P < 0.05) gastroprotective activity since it decreased the total acidity and pepsin activity. Compared to the control group, the two dosages of ascaridole showed the significant reduction (P < 0.05) in the ulcer index on Aspirin-induced ulcer. Conclusion This study provides evidence that ascaridole shows potential efficacy on the healing of gastric ulcers induced by acetic acid, Aspirin, and pylorus ligation.