Pylorus-Preserving Gastrectomy for Gastric Cancer

Abstract

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.

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

“…For early gastric cancer, surgeons started to consider functional preserving gastrectomy to improve the functional outcome and quality of life (QOL) without compromising oncological safety [5][6][7][8][9][10]. Pylorus-preserving gastrectomy (PPG) is such kind of function-preserving surgery, which has gained popularity in East Asian countries [5,[11][12][13]. PPG has become an optional method in Japanese Gastric Cancer Treatment Guideline for tumor located in the middle third portion of the stomach [14].…”

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

“…It is also reported that PHCV are necessary for pyloric sphincter functioning in patients after PPG [11] [12]. In recent years the vagal nerves, including hepatic and pyloric branches, have been preserved to prevent PGD including PAF and endoscopic GSRS [13]. Nakabayashi et al [6] suggested that gastric stasis during the early postoperative period in patients after PPG without preservation of the pyloric branch of the vagal nerve is due to tonic and phasic contractions of the pylorus.…”

“…According to this data, the size of LAC may be related to the delayed gastric emptying of a diet. Although the LAC gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm or more currently, its optimal length still remain unclear [13] [17]. As for the interviews in this study, PAF was observed at a rate of 100% in patients with a short LAC (1.5 to 2.5 cm) and at 7.7% in those with a long LAC (2.6 to 3.5 cm).…”

“…It is reported that PPG patients show a GEF delay in a solid and semisolid diet [1] [2] [3] [5] [6] [7] [8]. The main cause of postgastrectomy disorders (PGD), especially PAF, due to delayed GEF after PPG has been considered to be the length of the antral cuff (LAC) [2] [11] [12] [13]. However, the optimal LAC still unknown [13].…”

“…The main cause of postgastrectomy disorders (PGD), especially PAF, due to delayed GEF after PPG has been considered to be the length of the antral cuff (LAC) [2] [11] [12] [13]. However, the optimal LAC still unknown [13].…”