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.

Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy

Objective: This case report aimed to demonstrate a possible neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in association with sleeve gastrectomy plus antrojejunostomy, in order to reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients with previous Sleeve Gastrectomy (SG) who had had weight regain, with or without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique, which may require a revisional procedure. RYGB is an option in such a situation but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient would be of great value for the patients. Methods: We describe herein two cases of SG revision for weight regain and GERD, with a follow-up of one year. Gastroesophageal reflux disease was evaluated by validated questionnaire, upper endoscopy, seriography, high resolution manometry (HRM) and impedance pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve Gastrectomy with antrojejunal anastomosis was done in both cases, after informed consents. The Latarjet nerves were transected in one case, due to a bleeding in the left gastric vessels and a truncal vagotomy was required in the other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both cases, during seriography and endoscopy, kept until the one-year follow-up. There was unidirectional contrast flow to the gastrointestinal anastomosis, filling the jejunal limb, in radiologic contrast study. No contrast passed through the pylorus. Nonetheless, the duodenum was kept endoscopically accessible. In the one-year evaluation, weight loss was adequate and GERD resolution was obtained in both cases, confirmed by endoscopic and functional esophageal assessment, together with symptoms questionnaire. Conclusion: The association of Latarjet nerves sectioning or truncal vagotomy with re-sleeve gastrectomy plus gastrointestinal anastomosis (antrojejunal), in a revision for a failed sleeve, can represent a technical approach, to reproduce RYGB results, without exclusions and with duodenum endoscopic accessibility maintenance. It maybe could be applied for primary surgeries. Additional studies are necessary to confirm this hypothesis.

Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: A retrospective study of long-term functional outcomes and quality of life

BACKGROUND Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was known to have benefits of function-preserving surgery compared to laparoscopy-assisted distal gastrectomy (LADG). However, in clinical settings, delayed gastric emptying and esophageal reflux following LAPPG can be serious issues, making surgeons reluctant to perform LAPPG. It is unclear that LAPPG had better longterm functional outcomes and quality of life compared to LADG. AIM To evaluate the long-term functional outcomes and patient-reported quality of life of LAPPG compared to those of LADG. METHODS We reviewed the clinicopathological data of 195 patients who underwent LADG with Billroth II anastomosis and 101 patients who underwent LAPPG for cT1N0 gastric cancer in the middle third of the stomach between 2012 and 2015. Postoperative complications, nutritional parameters, and survey results of the European Organization for Research and Treatment of Cancer Questionnaire C30 and STO22 questionnaire were compared between the two groups. RESULTS The serum hemoglobin level was significantly higher in the LAPPG group than in the LADG group (P < 0.001). In the endoscopic findings, incidence of bile reflux was lower (P < 0.001);however, the incidence of residual food was higher in the LAPPG group than in the LADG group (P < 0.001). Regarding the quality of life score, the LAPPG group had a better physical functioning score (86.7 vs 90.0, P = 0.032) but also greater pain and reflux when compared to the LADG group [8.3 vs 16.7 in pain, 11.1 (interquartile range, 0, 22.2) vs 11.1 (interquartile range, 11.1, 33.3) in reflux, P = 0.034 and 0.001, respectively]. CONCLUSION LAPPG is beneficial to recovery of anemia and to bile reflux, however, it might be unfavorable in terms of pain and reflux symptoms compared to LADG with Billroth II anastomosis.

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.

Relationships between Length of the Antral Cuff and Postgastrectomy Disorders and Gastric Empting Function in Patients after Pylorus-Preserving Gastrectomy for Early Gastric Cancer

Objectives: To clarify the optimal length of the antral cuff (LAC) in patients after pylorus-preserving gastrectomy (PPG), we investigated relationships between LAC and postgastrectomy disorder (PGD) such as postprandial abdominal fullness (PAF), and between LAC and gastric empting function (GEF) in PPG patients. Background: The main cause of PGD in PPG patients has been considered to be LAC. Relationships between LAC and PGD and GEF in PPG patients are still unknown. Methods: Of 50 patients who underwent PPG in our hospital from January 2001 to December 2015 were divided into 2 groups [Group A, short LAC of 1.5 to 2.5 cm (n = 24);Group B, long LAC of 2.6 to 3.5 cm (n = 26)]. The relationships among LAC, PGD, and GEF were retrospectively studied. Results: LAC was clearly shorter in group A than group B (P < 0.01). PAF, appetite and food consumption per meal were clearly more favorable in group B than in group A (P < 0.01, respectively). Symptomatic reflux esophagitis (RE), early dumping syndrome, decreased percent body weight for pre-illness, endoscopic RE and endoscopic gastritis in the remnant stomach were more frequent in group A than group B. Gastric stasis in the remnant stomach was clearly more frequent in group A than group B (P < 0.01). GEF with the solid diet in group A was clearly more delayed than in group B (P Conclusions: Patients with a short LAC showed worse postoperative QOL and delayed GEF with the solid diet compared with a long LAC.

Relationship between Gastric Stasis in the Remnant Stomach and Interdigestive Migrating Complex in Patients after Pylorus-Preserving Gastrectomy for Gastric Cancer

Objectives: The demerit of pylorus-preserving gastrectomy (PPG) is gastric stasis in the remnant stomach (GSRS). We investigated the relationship between postgastrectomy disorder (PGD), especially GSRS, and interdigestive migrating complex (IMC) in PPG patients. Background: The cause of GSRS is still unknown. Therefore, we studied relationship between GSRS and IMC. Methods: 24 PPG patients (16 men and 8 women;mean, 61.2 years) were divided into groups A (12 patients without GSRS) and B (12 patients with GSRS). The relationship between GSRS and IMC was studied. Results: Length of the antral cuff (LAC) was significantly longer in group A than group B (P < 0.0001). IMC and appetite were significantly more common in group A than in group B (P = 0.0465, P = 0.0186, respectively). Postprandial abdominal fullness (PAF) was significantly more common in group B than in group A (P = 0.0061). Reflux esophagitis (RE) and body weight loss were found in group B more than in group A. Dumping syndrome was not found in either group. Endoscopic gastritis was found significantly more in group B than in group A (P = 0.0047). Conclusions: In PPG patients with a short LAC, GSRS may occur by the decrease of IMC occurrence.

Vagus effect on pylorus preserving gastrectomy

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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.

保留幽门的胃切除术在早期胃癌外科治疗中的应用及相关指南共识解读

目前早期胃癌的治疗以内镜下切除和腹腔镜手术为主要方式。对于不符合内镜切除适应证的病人,需接受标准的胃切除术和根治性淋巴结清扫,但这会造成术后功能障碍,严重降低生活质量。保留幽门的胃切除术(pylorus-preserving gastrectomy, PPG)是一种治疗早期胃癌并保留胃功能的手术,其在短期并发症发生方面与根治性手术相当,对长期的营养状态及生活质量有积极作用。在回顾性匹配队列研究中PPG与远端胃大部切除有相似的5年生存率,但胃延迟排空是PPG术后短期和长期出现的共性问题。PPG淋巴结清扫范围有限导致预后的不确定性,所以未广泛应用,前哨淋巴结引导手术可能为病人提供更个性化、微创的手术,从而最大限度地保留胃功能。

完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除在胃体癌的应用

目的探讨完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除治疗中段胃体癌的可行性及安全性。方法采用描述性病例系列研究方法,回顾性收集并分析2023年5月至2023年9月期间中南大学湘雅二医院胃肠外科完成的7例完全机器人手术系统联合术中胃镜行双镜联合的保留幽门的中段胃体癌根治术的临床资料。术中胃镜钛夹定位病变位置,采用5孔法放置Trocar,完全机器人下行中段胃切除,行胃底胃体端端手工缝合。观察手术情况、围手术期情况和术后病理以及随访情况。计量资料采用平均数(范围)或M(范围)来表示,计数资料用频数表示。结果7例患者手术均成功实施完全机器人手术系统联合术中胃镜行双镜联合的保留幽门的中段胃体癌根治术,无中转开腹或术中输血。全组患者全组患者平均手术时间182(165~195)min,平均术中出血量45(40~60)ml,平均手术切口长度3.3(3.0~4.0)cm,平均术后排气时间为2.4(2.0~3.0)d,平均术后首次排便时间3.0(2.0~4.0)d,平均术后进流食时间为3.9(3.0~5.0)d,平均术后住院天数为7.6(7.0~9.0)d,平均术后拔出腹腔引流管时间为4.9(4.0~6.0)d,平均术后拔除尿管时间1.3(1.0~2.0)d,平均术后首次下床活动时间2.3(2.0~3.0)d,住院期间无严重手术相关并发症发生。电话随访患者术后6个月,全组术后切口愈合良好,无术后胃穿孔、术后吻合口出血、吻合口瘘、吻合口狭窄、无胃瘫或无病人出现严重营养不良,仅1例患者出现胃排空障碍导致的反酸、嗳气、腹胀轻微症状,其他患者均无严重餐后不适或胆汁反流性胃炎症状,主观整体营养评分均在A或B级,无病人发生肿瘤复发,转移或死亡,所有患者术后饮食、排便规律,生活质量满意。结论完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除在胃体癌中具有独特优势,具有良好的安全性和可行性,且术后短期预后良好,有利于改善病人术后生活质量。

保留迷走神经、幽门胃部分切除手术在早期胃体癌中的应用

目的 探讨保留迷走神经、幽门胃部分切除手术在早期胃体癌中的应用效果。方法 选取120例早期胃体癌患者为研究对象,按照完全随机原则,将以上患者随机分为PPG组和DG组,其中PPG组患者手术方式选择保留迷走神经、幽门胃部分切除术,DG组患者给予传统远端胃切除术。观察比较两组患者术后返流、食物阻滞及倾倒综合征等术后并发症发生情况;且分别于术后1个月、3个月、6个月、12个月、18个月及24个月测量PPG组和DG组两组患者体重、血浆白蛋白、血胆固醇等指标恢复情况及胆结石发生情况;定期复查胃镜,观察两组患者食管炎、残胃炎及食物潴留发生情况;术后对患者进行随访,期限为5年,观察记录两组患者术后5年肿瘤复发情况及5年生存率。结果 (1)PPG组患者的返流、食物阻滞及倾倒综合征等术后并发症发生率分别为1.7%、15.3%、0.0%均显著低于DG组患者的11.5%、18.0%、8.2%,以上差异具有统计学意义(P<0.05)。(2)PPG组患者术后胆结石发生率显著低于PPG组,以上差异具有统计学意义(P<0.05)。(3)PPG组患者术后食管炎与残胃炎发生率分别为6.8%、28.9%均略低于DG组患者的8.1%、31.1%;PPG组术后食物潴留发生率8.5%、胆汁返流发生率为0.0%显著低于DG组的19.7%、8.2%,以上差异均具有统计学意义(P<0.05)。(4)DG组术后5年肿瘤复发率为6.6%,以黏膜下层癌为主,5年生存率为91.8%;PPG组术后5年肿瘤复发率为5.1%,几乎全部为黏膜下层癌,5年生存率为93.2%;但两组以上差异均无统计学意义(P肿瘤复发率=0.72,P5年生存率=0.61)。结论 保留迷走神经、幽门胃部分切除手术在早期胃体癌的临床治疗中可有效预防返流、食物阻滞及倾倒综合征等术后并发症、术后胆结石及胆汁返流的发生,在改善患者的生存质量中具有重要的临床价值。

比较腹腔镜辅助保留幽门胃切除术与远端胃大部切除术对早期胃癌患者术后继发性胆汁反流性胃炎的影响

目的:探析胃体中部早期胃癌患者采用腹腔镜辅助保留幽门胃切除术(laparoscopy assisted pylorus preserving gastrectomy,LAPPG)与腹腔镜辅助远端胃大部切除术(laparoscopy assisted distal gastrectomy,LADG)治疗的效果及对术后继发性胆汁反流性胃炎(bile reflux stomach,BRG)的影响。方法:选取2019年6月—2020年12月罗山县人民医院收治的60例胃体中部早期胃癌患者作为研究对象,分析患者临床病例资料后将患者分为观察组和对照组,每组各30例。对照组患者行LADG治疗,观察组患者行LAPPG治疗。比较两组患者手术相关指标、术后出现消化道相关症状的情况以及术后6个月被诊断为BRG的比例。结果:观察组患者手术相关指标和对照组患者对比,差异无统计学意义(t=0.790、0.215、0.028、0.120、0.271、0.065,P>0.05);观察组患者术后消化道症状的发生率和对照组患者对比,差异无统计学意义(χ^(2)=2.464、1.925、1.925、3.576、2.464、0.538,P>0.05);与对照组患者比较,观察组患者在随访6个月后被诊断BRG的概率更低,差异有统计学意义(χ^(2)=33.110,P<0.05)。结论:对胃体中部早期胃癌患者行LAPPG或LADG治疗均具有较好的效果,而LAPPG可降低患者术后出现BRG的概率。

腹腔镜下迷走神经肝支保护降低远端胃癌根治术后胆囊结石发生率的临床疗效观察

目的:评价在腹腔镜远端胃癌根治术中实施迷走神经肝支保护以降低术后胆囊结石发生率的作用。方法:选取81例胃癌患者进行前瞻性研究,随机分为迷走神经保护组(研究组)与非迷走神经保护组(对照组),行腹腔镜胃癌根治术加迷走神经保护或单纯腹腔镜胃癌根治术。观察两组术中出血量、手术时间、术后淋巴结清扫数量、术后并发症等指标,并随访两年,了解是否发生胆囊结石。结果:两组术中出血量[(91.3±42.8) mL vs.(108.5±54.9) mL,P=0.151]、手术时间[(202.1±48.6) min vs.(184.5±54.1) min,P=0.175]、淋巴结清扫数量[(22.7±10.1) vs.(22.3±9.26),P=0.885]、术后并发症发生率(8.20%vs. 15%,P=0.379)差异无统计学意义。术后胆囊结石发生率研究组低于对照组(4.92%vs. 20%,P=0.038)。结论:腹腔镜下迷走神经肝支保护是安全的,可保证手术的根治程度,同时降低术后胆囊结石发生率。

从术后功能状态评价保留迷走神经、幽门的胃切除术

目的探讨保留迷走神经、幽门的胃切除手术的术后残胃功能状态。方法对保留迷走神经、幽门的胃切除术病例（ＰＰＧ）（１７例）、远端胃切除病例（１５例）的胃排空功能、胆囊收缩功能、ＣＣＫ分泌状态进行对比分析。结果保留迷走神经、幽门的胃切除术组病人的胃排空状态类似于术前；而远端胃切除组则呈坠落状态。胆囊收缩动态测定显示进食６０ｍｉｎ后，ＰＰＧ组胆囊收缩率为４０％，而远端胃切除组为２３％（Ｐ＜０．０５）。ＣＣＫ值测定显示ＰＰＧ组变化幅度小，ＤＲ组１５ｍｉｎ时明显升高后很快下降。结论ＰＰＧ手术组病人具有近于正常的胃排空功能和胆囊收缩功能，是胃切除术中具有保留胃和胆囊功能。

保留迷走神经、幽门的胃部分切除术治疗早期胃癌

保留幽门的胃部分切除手术(pylorus-preservinggastrectomy,PPG),最初是针对胃溃疡保存功能的手术。20世纪80年代以来,PPG被用于早期胃癌的外科治疗,伴随淋巴结的廓清、血管的处理和迷走神经的切断,使幽门的血流低下,功能受影响。近年来作为胃癌的保留功能的术式,PPG被赋予了新的内容即在淋巴结廓清的同时,保留迷走神经、幽门,在早期胃癌治疗中显示出术后良好的肝、胆、胰的功能和胃肠道的运动功能,为早期胃癌患者提供了良好的生活质量。我科自1995年以来对早期胃癌实施了按照根治度要求的伴随淋巴结廓清的PPG手术46例,取得了良好的效果。本文就伴有淋巴结廓清的PPG和迷走神经保留手术做一介绍。

腹腔镜下早期胃癌节段切除术

目的探讨胃节段切除在分化型早期胃癌手术中的可行性。方法严格挑选2013年8月至2015年6月间4例中段早期胃癌病人,实施腹腔镜下胃节段切除并D1+或D2淋巴结清扫。观察淋巴结清扫数目、术后并发症等情况。结果在清扫小弯侧淋巴结过程中没有保留迷走神经。远端切缘距离幽门4 cm以上,平均淋巴结获取数目为18.5枚。在术后1年内均存在胃排空缓慢的症状和影像学征像,1年后得到缓解。结论经腹腔镜行早期胃癌节段切除在技术上安全可行,是否保留迷走神经有待于进一步的观察。

保留迷走神经胃癌根治术治疗胃癌患者的临床疗效

目的:分析保留迷走神经胃癌根治术治疗胃癌患者的临床疗效。方法:将114例胃癌患者分为观察组(64例)与对照组(50例),分别采用保留迷走神经胃癌根治术和传统胃癌根治术治疗,对手术出血量、手术时间、术后肛门排气和排便时间,以及术中淋巴结扫描比、手术并发症发生率和5年生存率分别统计比较。结果:在手术出血量和手术时间上,两组差异无统计学意义;术后排气和排便时间观察组相对更短;另外,观察组手术淋巴结扫描比更高,术后并发症发生率更低,5年生存率明显更高;术后12个月观察组患者进食情况明显更佳;观察组手术整体效果更为明显。结论:保留迷走神经胃癌根治术在胃癌治疗中临床效果显著,值得推广应用。

保留迷走神经胃癌根治术治疗42例胃癌患者临床疗效观察

目的:探讨保留迷走神经胃癌根治术治疗胃癌患者的临床疗效。方法:收治胃癌患者84例,随机分为保留迷走神经胃癌根治术治疗组(观察组)和传统胃癌根治术治疗组(对照组),每组42例。比较两组治疗后的临床疗效。结果:两组手术时间和术中出血量比较,差异无统计学意义(P>0.05)。观察组首次排气时间及排便时间均少于对照组,组间比较差异有统计学意义(P<0.05)。观察组术后并发症发生率为7.1%,显著低于对照组(26.2%),两组并发症发生率情况比较,差异有统计学意义(P<0.05)。结论:采用保留迷走神经胃癌根治术治疗胃癌患者临床疗效确切,术后并发症发生率低,能够显著改善患者术后的生活质量。

保留迷走神经-幽门的胃癌根治术在早期胃癌治疗中的作用

目的研究保留迷走神经-幽门的胃癌根治术在早期胃癌治疗中的作用。方法选取从2011年1月~2013年12月于我院进行治疗的早期胃癌患者40例,以随机数字表法随机分为观察组及对照组各20例。其中给予观察组患者行保留迷走神经-幽门的胃癌根治术治疗,而对照组患者则给予用D2淋巴结清扫加至少2/3的胃切除进行治疗。对比两组效果。结果观察组患者住院时间、住院费用以及术后并发症发生率均显著低于对照组;观察组胃排空功能恢复时间和CCK水平显著低于对照组,而胆囊收缩率显著高于对照组;观察组术后肠蠕动恢复时间、肛门排气时间、胃肠减压量以及腹痛腹胀发生率均明显少于对照组,差异有统计学意义（P〈0.05）。结论保留迷走神经-幽门的胃癌根治术在早期胃癌治疗中效果显著,能有效减轻患者痛苦,减少并发症发生率,促进患者早日康复,安全性好,值得临床推广应用。