Pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy(PPG)has been widely accepted as a function-preserving gastrectomy for middle-third early gastric cancer(EGC)with a distal tumor border at least 4 cm proximal to the pylorus.The procedure essentially preserves the function of the pyloric sphincter,which requires to preserve the upper third of the stomach and a pyloric cuff at least 2.5 cm.The suprapyloric and infrapyloric vessels are usually preserved,as are the hepatic and pyloric branches of the vagus nerve.Compared with distal gastrectomy,PPG has significant advantages in preventing dumping syndrome,body weight loss and bile reflux gastritis.The postoperative complications after PPG have reached an acceptable level.PPG can be considered a safe,effective,and superior choice in EGC,and is expected to be extensively performed in the future.

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.

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy:A review of the literature and critical reappraisal of the implicated pathomechanism

Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.

Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis

AIM:To evaluate whether antecolic reconstruction for duodenojejunostomy (DJ) can decrease delayed gastric emptying (DGE) rate after pylorus-preserving pancreaticoduodenectomy (PPPD) through literature review and meta-analysis. METHODS:Articles published between January 1991 and April 2012 comparing antecolic and retrocolic reconstruction for DJ after PPPD were retrieved from the databases of MEDLINE (PubMed), EMBASE, OVID and Cochrane Library Central. The primary outcome of interest was DGE. Either fixed effects model or random effects model was used to assess the pooled effect based on the heterogeneity. RESULTS:Five articles were identified for inclusion:two randomized controlled trials and three non-randomized controlled trials. The meta-analysis revealed that antecolic reconstruction for DJ after PPPD was associated with a statistically significant decrease in the incidence of DGE [odds ratio (OR), 0.06; 95% CI, 0.02-0.17; P < 0.00 001] and intra-operative blood loss [mean difference (MD), -317.68; 95% CI, -416.67 to -218.70; P < 0.00 001]. There was no significant difference between the groups of antecolic and retrocolic reconstruction in operative time (MD, 25.23; 95% CI, -14.37 to 64.83; P = 0.21), postoperative mortality, overall morbidity (OR, 0.54; 95% CI, 0.20-1.46; P = 0.22) and length of postoperative hospital stay (MD, -9.08; 95% CI, -21.28 to 3.11; P = 0.14). CONCLUSION:Antecolic reconstruction for DJ can decrease the DGE rate after PPPD.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM:To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy(PpPD).METHODS:In October 2010,we introduced a mechanical anastomotic technique of gastro-or duodenojejunostomy using staplers during PpPD.We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy(stapled anastomosis group)and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy(hand-sewn anastomosis group).RESULTS:The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group(186.0±29.4 min vs 219.7±50.0 min,P=0.02).In addition,intraoperative blood loss was significantly less(391.0±212.0 mL vs 647.1±482.1 mL,P=0.03)and the time to oral intake was significantly shorter(5.4±1.7d vs 11.3±7.9 d,P=0.002)in the stapled anastomosis group than in the hand-sewn anastomosis group.There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.CONCLUSION:These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy? Prevention and management

AIM： To explore some operative techniques to prevent the occurrence of delayed gastric emptying （DGE） alter pylorus-preserving pancreaticoduodenectomy （PPPD）.METHODS： One hundred and eighty-six patients in a single medical center who accepted PPPD were retrospectively studied. The incidence of DGE was investigated and the influence of some operative techniques on the prevention of DGE was analyzed.RESULTS： During the operative process of PPPD, the methods of detached drainage of pancreatic fluid and bile and gastric fistulization were used. Postoperatively, six patients suffered DGE among the 186 cases; the incidence was 3.23% （6/186）. One of them was complicated with intraabdominal infection at the same time, and two with pancreatic leakage.CONCLUSION： Appropriate maneuvers during operation are essential to avoid postoperative DGE in PPPD. The occurrence of DGE is avoidable. It should not be used as an argument to advocate hemigastrectomy in PPPD.

Surgical anatomy of the innervation of pylorus in human and Suncus murinus, in relation to surgical technique for pylorus-preserving pancreaticoduodenectomy

AIM： To clarify the innervation of the antro-pyloric region in humans from a clinico-anatomical perspective. METHODS： The stomach, duodenum and surrounding structures were dissected in 10 cadavers, and immersed in a 10mg/L solution of alizarin red S in ethanol to stain the peripheral nerves. The distribution details were studied to confirm innervations in the above areas using a binocular microscope. Similarly, innervations in 10 Suncus murinus were examined using the method of whole-mount imm unohistochemistry. RESULTS： The innervation of the pyloric region in humans involved three routes： One arose from the anterior hepatic plexus via the route of the suprapyloric/supraduodenal branch of the right gastric artery; the second arose from the anterior and posterior gastric divisions, and the third originated from the posterior-lower region of the pyloric region, which passed via the infrapyloric artery or retroduodenal branches and was related to the gastroduodenal artery and right gastroepiploic artery. For Suncus murinus, results similar to those in humans were observed. CONCLUSION： There are three routes of innervation of the pyloric region in humans, wherein the route of the right gastric artery is most important for preserving pyloric region innervation. Function will be preserved by more than 80% by preserving the artery in pylorus-preserving pancreaticoduodenectomy （PPPD）. However, the route of the infrapyloric artery should not be disregarded. This route is related to several arteries （the right gastroepiploic and gastroduodenal arteries）, and the preserving of these arteries is advantageous for preserving pyloric innervation in PPPD. Concurrently, the nerves of Latarjet also play an important role in maintaining innervation of the antro-pyloric region in PPPD. This is why pyloric function is not damaged in some patients when the right gastric artery is dissected or damaged in PPPD.

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.

保留幽门胰十二指肠切除术在胰腺癌手术中的应用

目的探讨保留幽门胰十二指肠切除术(PPPD)在胰腺癌手术中的临床应用价值。方法回顾性分析98例胰腺癌手术患者的临床资料,将行胰十二指肠切除术(PD)的患者40例设为对照组,行保留幽门胰十二指肠切除术(PPPD)的58例患者为观察组,观察2组患者的临床疗效。结果 PPPD组患者手术时间明显短于PD组,胃排空延迟的发生率明显高于PD组(P<0.05),但是2组患者术中输血、术后住院时间、淋巴结清扫总数和5、6组淋巴结数、术后并发症的发生率及1年生存率均无明显差异(P>0.05)。结论 PPPD与PD疗效相似,不影响手术根治性,但PPPD保留了胃的贮存和消化功能,能提高患者远期生活质量。

健康宣教对胰十二指肠切除术后可预防性再入院发生率的影响

目的了解胰十二指肠切除术后患者再入院率、再入院的原因以及对患者出院前的健康宣教情况。方法回顾性描述分析2010年1月至2015年1月接受胰十二指肠切除术68例患者的医疗资料。数据从住院患者的电子记录中提取,按照研究方案,录入Excel进行分析。主要调查胰十二指肠切除术后再入院的发生率、原因及对这部分患者的出院宣教情况。结果患者平均术后15.7 d出院,再次入院发生率39%。重新入院的原因是脱水和营养不良(n=9,13%)及手术部位感染(n=5,7%);8例患者(12%)存在脱水、营养不良。结论胰十二指肠切除术后的患者出院前应增加自我护理的宣教,以防发生因脱水和营养失调所致的再入院。在患者出院前要对其出院宣教的情况做一个强制性的评估。