Pylorus-preserving gastrectomy for early middle gastric cancer (T1a-bN0M0) is safer and more effective than distal gastrectomy: a narrative review

Abstract

As a treatment option for early middle gastric cancer, pylorus-preserving gastrectomy (PPG) has been shown to exhibit good clinical efficacy in Japan and Korea and has attracted widespread attention in China. PPG has a similar surgical safety to conventional distal gastrectomy (DG). The incidence of postoperative complications (such as dumping syndrome, bile reflux gastritis, gallstones, weight loss, and malnutrition) has been shown to be lower, while that of delayed gastric emptying (DGE) was higher after PPG than after DG. However, preserving the vagus nerve, blood supply to the pylorus, and adequate antral cuff length can effectively reduce DGE after PPG. Whether or not incomplete lymphadenectomy affects tumor safety is a primary focus for concern. According to the analysis of lymph node metastasis rates in early middle gastric cancer, the metastasis rates of lymph nodes No. 5 and No. 6 were low, providing a theoretical basis for performing limited lymph node dissection.

Keywords

Pylorus-preserving gastrectomy / lymph node metastasis rate / lymph node dissection / delayed gastric emptying

References

[1] Azagra JS,Ibañez FJ.Current status of gastrectomy for cancer: "less is often more".Cir Esp2018;96:603-5

[2] Huang C,Zhao G.Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared with laparoscopy-assisted distal gastrectomy for early gastric cancer.J Gastroenterol Hepatol2020;35:1712-9

[3] Nomura E.Function-preserving gastrectomy for gastric cancer in Japan.World J Gastroenterol2016;22:5888-95 PMCID:PMC4948261

[4] Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition).Gastric Cancer21;24:1-21 PMCID:PMC7790804

[5] Choi J,Chung H.Safety of pylorus-preserving gastrectomy for gastric cancer combined with antral high-risk lesions: a comparison with endoscopic submucosal dissection.Surg Endosc2023;37:2987-96

[6] Maki T,Hatafuku T.Pylorus-preserving gastrectomy as an improved operation for gastric ulcer.Surgery1967;61:838-45

[7] Kodama M.Indications for pylorus preserving gastrectomy for early gastric cancer located in the middle third of the stomach.World J Surg1991;15:628-33; discussion 633

[8] Nomura E,Fujii K.Postoperative evaluation of function-preserving gastrectomy for early gastric cancer.Hepatogastroenterology2003;50:2246-50

[9] Xia X,Zhu C,Yu F.Objective evaluation of clinical outcomes of laparoscopy-assisted pylorus-preserving gastrectomy for middle-third early gastric cancer.BMC Cancer2019;19:481 PMCID:PMC6532154

[10] Park DJ,Jung HC,Lee KU.Clinical outcome of pylorus-preserving gastrectomy in gastric cancer in comparison with conventional distal gastrectomy with Billroth I anastomosis.World J Surg2008;32:1029-36

[11] Zhu CC,Berlth F.Pylorus-preserving gastrectomy for early cancer involving the upper third: can we go higher?.Gastric Cancer2019;22:881-91

[12] Ikeguchi M,Yamamoto M.Evaluation of a pylorus-preserving gastrectomy for patients preoperatively diagnosed with early gastric cancer located in the middle third of the stomach.Surg Today2010;40:228-33

[13] Suh YS,Kong SH.Laparoscopy-assisted pylorus-preserving gastrectomy is better than laparoscopy-assisted distal gastrectomy for middle-third early gastric cancer.Ann Surg2014;259:485-93

[14] Aizawa M,Hiki N.Oncological outcomes of function-preserving gastrectomy for early gastric cancer: a multicenter propensity score matched cohort analysis comparing pylorus-preserving gastrectomy versus conventional distal gastrectomy.Gastric Cancer2017;20:709-17

[15] Eom BW,Yoon HM,Kim YW.Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: a etrospective study of long-term functional outcomes and quality of life.World J Gastroenterol2019;25:5494-504 PMCID:PMC6767989

[16] Han WH,Yoon HM,Kim DH.A comparison of totally laparoscopic pylorus preserving gastrectomy and laparoscopy-assisted pylorus preserving gastrectomy for early gastric cancer.J Minim Invasive Surg2019;22:113-8 PMCID:PMC8980167

[17] Akiyama Y,Iwaya T.Feasibility of totally laparoscopic pylorus-preserving gastrectomy with intracorporeal gastro-gastrostomy for early gastric cancer: a retrospective cohort study.World J Surg Oncol2020;18:170 PMCID:PMC7366885

[18] Hiki N,Yamaguchi H,Kaminishi M.Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation.J Am Coll Surg2006;203:162-9

[19] Lee SW,Bouras G,Tsunemi S.Long-term oncologic outcomes from laparoscopic gastrectomy for gastric cancer: a single-center experience of 601 consecutive resections.J Am Coll Surg2010;211:33-40

[20] Tsujiura M,Ohashi M.Should pylorus-preserving gastrectomy be performed for overweight/obese patients with gastric cancer?.Gastric Cancer2019;22:1247-55

[21] Park DJ,Yang HK.Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial).Br J Surg2021;108:1043-9

[22] Nunobe S,Fukunaga T.Laparoscopy-assisted pylorus-preserving gastrectomy: preservation of vagus nerve and infrapyloric blood flow induces less stasis.World J Surg2007;31:2335-40

[23] Nishizawa N,Shinohara H.Anatomical Knowledge for the Infra-Pyloric Vein Preservation during the Laparoscopy-Assisted Pylorus-Preserving Gastrectomy.Dig Surg2016;33:363-70

[24] Kaji S,Irino T.Preventive effect on delayed gastric emptying of preserving the infra-pyloric vein in laparoscopic pylorus-preserving gastrectomy for early gastric cancer.Surg Endosc2020;34:3853-60

[25] Takahashi R,Hiki N.Risk factors and prognosis of gastric stasis, a crucial problem after laparoscopic pylorus-preserving gastrectomy for early middle-third gastric cancer.Gastric Cancer2020;23:707-15

[26] Furukawa H,Honda M.Preservation of the celiac branch of the vagal nerve for pylorus-preserving gastrectomy: is it meaningful?.Gastric Cancer2018;21:516-23

[27] Kinami S,Urushihara T.Background factors influencing postgastrectomy syndromes after various types of gastrectomy.World J Clin Cases2018;6:1111-20 PMCID:PMC6306647

[28] Nakane Y,Inoue K.Length of the antral segment in pylorus-preserving gastrectomy.Br J Surg2002;89:220-4

[29] Jiang X,Nunobe S.Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer.Ann Surg2011;253:928-33

[30] Kodama M,Chida T,Tur G.Early postoperative evaluation of pylorus-preserving gastrectomy for gastric cancer.World J Surg1995;19:456-60; discussion 461

[31] Imada T,Takahashi M.Postoperative functional evaluation of pylorus-preserving gastrectomy for early gastric cancer compared with conventional distal gastrectomy.Surgery1998;123:165-70.

[32] Namikawa T,Kinami S.Factors that minimize postgastrectomy symptoms following pylorus-preserving gastrectomy: assessment using a newly developed scale (PGSAS-45).Gastric Cancer2015;18:397-406

[33] Hosoda K,Sakuramoto S.Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared with laparoscopy-assisted distal gastrectomy: a cross-sectional postal questionnaire survey.Am J Surg2017;213:763-70

[34] Tomita R,Tanjoh K.Pathophysiological studies on the relationship between postgastrectomy syndrome and gastric emptying function at 5 years after pylorus-preserving distal gastrectomy for early gastric cancer.World J Surg2003;27:725-33

[35] Shibata C,Funayama Y.Outcomes after pylorus-preserving gastrectomy for early gastric cancer: a prospective multicenter trial.World J Surg2004;28:857-61

[36] Nabae T,Konomi H.Effect of prepyloric gastric transection and anastomosis on sphincter of oddi cyclic motility in conscious dogs.J Gastroenterol2001;36:530-7

[37] Fukagawa T,Saka M,Sano T.Gallstone formation after gastric cancer surgery.J Gastrointest Surg2009;13:886-9

[38] Montesani C,Santella S.Billroth I versus Billroth II versus Roux-en-Y after subtotal gastrectomy. Prospective [correction of prespective] randomized study.Hepatogastroenterology2002;49:1469-73.

[39] Hotta T,Kobayashi Y.Postoperative evaluation of pylorus-preserving procedures compared with conventional distal gastrectomy for early gastric cancer.Surg Today2001;31:774-9

[40] Tanizawa Y,Kawahira H.Japan postgastrectomy syndrome working partyspecific features of dumping syndrome after various types of gastrectomy as assessed by a newly developed integrated questionnaire, the PGSAS-45.Dig Surg2016;33:94-103

[41] Fujita J,Urushihara T.Assessment of postoperative quality of life following pylorus-preserving gastrectomy and Billroth-I distal gastrectomy in gastric cancer patients: results of the nationwide postgastrectomy syndrome assessment study.Gastric Cancer2016;19:302-11

[42] Wang F,Mao P.Relationship between the body mass index and tumor site postoperative complications and prognosis in gastric adenocarcinoma.Am Surg2018;84:1861-8.

[43] Migita K,Matsumoto S.Impact of being underweight on the long-term outcomes of patients with gastric cancer.Gastric Cancer2016;19:735-43

[44] Otake R,Ohashi M.Reflux esophagitis after laparoscopic pylorus-preserving gastrectomy for gastric cancer.Ann Surg Oncol2023;30:2294-303

[45] Kim JH,Jun KH.The prevalence and clinical significance of postgastrectomy anemia in patients with early-stage gastric cancer: a retrospective cohort study.Int J Surg2018;52:61-6

[46] Annibale B,Delle Fave G.The stomach and iron deficiency anaemia: a forgotten link.Dig Liver Dis2003;35:288-95

[47] Kim BH,Kim JW,Yoon SO.Oncologic safety of pylorus-preserving gastrectomy in the aspect of micrometastasis in lymph nodes at stations 5 and 6.Ann Surg Oncol2014;21:533-8

[48] Kong SH,Lee HJ.The safety of the dissection of lymph node stations 5 and 6 in pylorus-preserving gastrectomy.Ann Surg Oncol2009;16:3252-8

[49] Khalayleh H,Yoon HM.Assessment of lymph node metastasis in patients with gastric cancer to identify those suitable for middle segmental gastrectomy.JAMA Netw Open2021;4:e211840 PMCID:PMC7970333

[50] Shimada A,Ono T.Pylorus-preserving surgery based on the sentinel node concept in early gastric cancer.Ann Surg Oncol2016;23:4247-52

[51] Haruta S,Ueno M,Sakai Y.Anatomical considerations of the infrapyloric artery and its associated lymph nodes during laparoscopic gastric cancer surgery.Gastric Cancer2015;18:876-80

[52] Mizuno A,Haruta S.Lymphadenectomy along the infrapyloric artery may be dispensable when performing pylorus-preserving gastrectomy for early middle-third gastric cancer.Gastric Cancer2017;20:543-7

[53] Surgery Group, Surgery Branch, Chinese Medical Association, Oncology Surgery Group, Surgical} Branch, Chinese Medical Doctor Association, Upper Gastrointestinal Group, Surgical Branch, Chinese Medical Doctor Association, Cancer Gastroenterology Society, Chinese Anticancer Association. [Chinese expert consensus on function-preserving gastrectomy for gastric cancer (2021 edition)].Zhonghua Wei Chang Wai Ke Za Zhi2021;24:377-82

[54] Hu X,Cao L.[Efficacy analysis of laparoscopy-assisted pylorus-vagus nerve preserving gastrectomy in the treatment of early middle gastric cancer].Zhonghu Wei Chang Wai Ke Za Zhi2016;19:892-7.