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Tanaka C, Kanda M, Misawa K, Mochizuki Y, Watanabe T, Hattori M, Ishigure K, Sueoka S, Teramoto H, Ishiyama A, Nonogaki I, Matsushita H, Murotani K, Kodera Y. The long-term quality of life after distal and pylorus-preserving gastrectomy for stage I gastric cancer: A prospective multi-institutional study (CCOG1601). Surg Today 2025; 55:162-171. [PMID: 38904882 DOI: 10.1007/s00595-024-02881-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/25/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE While regarded as function-preserving gastrectomy, few prospective longitudinal clinical trials have addressed the postoperative quality of life (QOL) after pylorus-preserving gastrectomy (PPG). We prospectively compared chronological changes in postoperative body weight and the QOL between PPG and distal gastrectomy (DG) for pathological Stage I gastric cancer (GC). METHODS We conducted a multi-institutional prospective study (CCOG1601) to evaluate patients who underwent DG and PPG. The QOL was examined using the European Organization for Research and Treatment of Cancer Quality of life questionnaire-C30 (EORTC QLQ-C30) and the Post-Gastrectomy Syndrome Assessment Scale-37 (PGSAS-37). A total of 295 patients were enrolled from 15 institutions, and propensity score matching was performed to adjust for the essential variables for comparison analyses. RESULTS After propensity score matching, 25 pairs of patients were identified. In the first postoperative month, DG achieved a superior nausea and vomiting score (EORTC QLQ-C30) and meal-related distress, indigestion, and dumping scores (PGSAS-37). No significant differences were noted between DG and PPG in the long-term QOL. Postoperative body weight loss was similar in both groups. CONCLUSIONS This prospective observational study failed to demonstrate the superiority of PPG over DG in terms of postoperative body weight changes and the QOL.
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Affiliation(s)
- Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8560, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8560, Japan
| | - Kazunari Misawa
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | | | - Takuya Watanabe
- Department of Surgery, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Masashi Hattori
- Department of Surgery, NHO Nagoya Medical Center, Nagoya, Japan
| | | | - Satoshi Sueoka
- Department of Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Hitoshi Teramoto
- Department of Surgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | | | - Ikue Nonogaki
- Department of Surgery, Tokai Central Hospital, Kakamigahara, Japan
| | | | - Kenta Murotani
- Biostatistics Center, Graduate School of Medicine, Kurume University, Kurume, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8560, Japan.
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Ito N, Tsujimoto H, Kumano I, Fujishima S, Kariya R, Uehata N, Fukuoka Y, Suzuki T, Itazaki Y, Horiguchi H, Yaguchi Y, Ueno H. Significance of resected stomach measurements in postoperative delayed gastric emptying following laparoscopic pylorus-preserving gastrectomy. Asian J Endosc Surg 2024; 17:e13392. [PMID: 39379049 DOI: 10.1111/ases.13392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/18/2024] [Accepted: 09/22/2024] [Indexed: 10/10/2024]
Abstract
PURPOSE We investigated the relationship between the resected stomach measurements, the incidence of delayed gastric emptying (DGE), and food residue 1 year after surgery in patients who underwent laparoscopic pylorus-preserving gastrectomy (PPG). MATERIALS AND METHODS The DGE group included 10 patients fasting due to nausea, vomiting, abdominal distension, or remnant stomach distension on radiographs; the control group included 36 patients without these symptoms. We compared the size and length of lesser and greater curvatures of the resected stomach and endoscopic findings after 1 year. RESULTS No significant differences were observed between groups in terms of sex, body mass index, gross type, histology, tumor progression, number of dissected lymph nodes, operating time, or blood loss. The DGE group was older, had a longer postoperative stay, and showed a smaller size and shorter greater curvature of the resected stomach than the control group (p < 0.01 for all). No difference was observed in the length of the lesser curvature of the resected stomach. In addition, there were no disparities in residual food, degree and extent of gastritis, or bile reflux 1 year after gastrectomy. CONCLUSIONS Measurements of the resected stomach suggest that preventing DGE may be achievable by removing a larger area of the greater curvature and/or stomach during laparoscopic PPG. This implies potential surgical strategy improvements for better outcomes. Further multicenter trials are needed to validate and refine techniques.
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Affiliation(s)
- Nozomi Ito
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Isao Kumano
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | | | - Risa Kariya
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Naoyuki Uehata
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Yusuke Fukuoka
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Takafumi Suzuki
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Yujiro Itazaki
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Hiroyuki Horiguchi
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Yoshihisa Yaguchi
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
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Atici AE, Ozocak AB, Kayaci AE, Ozturk EG, Kararmaz A, Yegen SC. Impact of marmara-yegen cuttıng gastrojejunostomy on delayed gastrıc emptyıng after pancreatoduodenectomy: ınıtıal results. Langenbecks Arch Surg 2024; 409:291. [PMID: 39331186 DOI: 10.1007/s00423-024-03482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 09/17/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common reasons for morbidity after pancreatoduodenectomy. The technical characteristics of anastomosis that could be affected by surgeon may offer a relevant chance to improve postoperative DGE rates. We investigated the effect of a technical modification of gastrojejunostomy after the classical pancreaticoduodenectomy on DGE. MATERIALS AND METHODS A total of 161 patients underwent classical pancreaticoduodenectomy (with 20-40 percent antrectomy) due to pancreatic adenocarcinoma at the Department of General Surgery, Marmara University, School of Medicine Hospital, from February 2019 to May 2023, and those who met the inclusion criteria were enrolled. One hundred twenty patients had undergone classical end-to-side gastrojejunostomy (Classical GJ group), and 41 had undergone Marmara-Yegen cutting side-to-side gastrojejunostomy (M-Yc group). DGE was defined according to the International Working Group on Pancreatic Surgery, and postoperative DGE rates of both groups were compared. In addition, multivariate analysis was performed to identify possible independent predictive factors for DGE. RESULTS The total incidence of DGE was 31% in the Classical GJ group and 17% in the (M-Yc group). Although there was no significant difference between the groups regarding DGE and DGE grades (p = 0.1), DGE was distinctly lower in the M-Yc GJ group. In multi-variant analysis, Clavien-Dindo grade 3a and above postoperative complication was determined as independent predictors for DGE. CONCLUSIONS We tried to explain the mechanism of DGE in terms of anatomical configuration. The incidence and severity of DGE decreased in patients who underwent M-Yc GJ.
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Affiliation(s)
- Ali Emre Atici
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey.
| | - Ayşegul Bahar Ozocak
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ayse Eren Kayaci
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ecem Guclu Ozturk
- Faculty of Medicine, Department of Anesthesiology, Marmara University, Pendik Education and Research Hospital, 34899, Pendik, Istanbul, Turkey
| | - Alper Kararmaz
- Faculty of Medicine, Department of Anesthesiology, Marmara University, Pendik Education and Research Hospital, 34899, Pendik, Istanbul, Turkey
| | - Sevket Cumhur Yegen
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
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Jeong SH, Park M, Seo KW, Kim RB, Min JS. A Comparative Study of Postoperative Complications Associated with Distal Gastrectomy and Pylorus-Preserving Gastrectomy among Gastric Cancer Patients Based on Nationwide Survey Data and Propensity Score Weighting. Cancers (Basel) 2024; 16:2203. [PMID: 38927908 PMCID: PMC11202269 DOI: 10.3390/cancers16122203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND/OBJECTIVE This study aimed to compare complication rates between pylorus-preserving gastrectomy (PPG) and distal gastrectomy (DG) using Korean nationwide survey data and propensity score weighting (PSW). PPG preserves gastric function but may lead to more postoperative complications than DG. METHODS AND RESULTS We analyzed 9424 gastric cancer patients who underwent either DG (n = 9183) or PPG (n = 241). PSW balanced variables such as age, sex, TNM stage, comorbidities, ASA score, and surgical approach. Before PSW, 87.8% of DG patients and 87.1% of PPG patients had no complications (p = 0.053). Severe complications (Clavien-Dindo IIIa or higher) were more frequent in PPG (6.6%) than in DG (3.8%) (p = 0.039). After PSW, overall complication rates (p = 0.960) and severe complication rates (p = 0.574) were similar between groups. Incidence rates of anastomotic stricture and leakage were higher in PPG (2.9% and 1.7%) compared to DG (0.6% and 0.5%) (p = 0.001 and 0.036) before PSW, but these differences were not significant after PSW (p = 0.999 and 0.123). CONCLUSION The PSW-adjusted analysis indicates no significant difference in overall and severe complication rates between PPG and DG in gastric cancer patients.
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Affiliation(s)
- Sang-Ho Jeong
- Department of Surgery, Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
| | - Miyeong Park
- Department of Anesthesiology, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
| | - Kyung Won Seo
- Department of Surgery, Kosin University Gospel Hospital, Busan 49267, Republic of Korea;
| | - Rock Bum Kim
- Regional Cardiocerebrovascular Disease Center, Gyeongsang National University Hospital, Jinju 52727, Republic of Korea;
| | - Jae-Seok Min
- Department of Surgery, Korea University College of Medicine, and Division of Foregut Surgery, Korea University Anam Hospital, Seoul 02841, Republic of Korea
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Sun KK, Wu YY. Pylorus-preserving gastrectomy for early gastric cancer. World J Gastrointest Oncol 2024; 16:653-658. [PMID: 38577445 PMCID: PMC10989389 DOI: 10.4251/wjgo.v16.i3.653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
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.
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Affiliation(s)
- Ke-Kang Sun
- Department of Gastrointestinal Surgery, The Affiliated Kunshan Hospital to Jiangsu University, Suzhou 215300, Jiangsu Province, China
| | - Yong-You Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215008, Jiangsu Province, China
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Kinami S, Kaida D, Okamoto K, Fujimura T, Iida Y, Inaki N, Takamura H. Long‑term survival prognosis of function‑preserving curative gastrectomy for early gastric cancer. Oncol Lett 2024; 27:115. [PMID: 38304174 PMCID: PMC10831417 DOI: 10.3892/ol.2024.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
Segmental gastrectomy, mini-distal gastrectomy and local resection of the stomach are function-preserving curative gastrectomies (FPGs), which are used to treat gastric cancer in specialized centers. These surgical options are less invasive and can alleviate postgastrectomy symptoms more than standard gastrectomy; however, their association with prognosis remains to be fully elucidated. The present study aimed to compare the survival prognosis of patients diagnosed as node-negative by sentinel node biopsy (SNB) treated via FPG with reduced lymph node dissection with that of patients who underwent guideline gastrectomy (GL). This retrospective study was conducted between April 1999 and March 2016. The inclusion criteria were a diagnosis of gastric cancer type 0, of ≤5 cm, located in L or M areas, and pT1N0. Patients who underwent distal gastrectomy and pylorus-preserving gastrectomy were included as controls in the GL group. Among the 146 and 300 patients in the FPG and GL groups, respectively, only 1 patient in the GL group experienced recurrence. The overall survival (OS) of the FPG group was 96.6% at 5 years and 92.5% at 10 years, which was significantly higher than that of the GL group (P<0.05). In addition, the cumulative incidence of non-cancer-related deaths, especially pulmonary diseases, was lower in the FPG group than that in the GL group (P<0.05). Notably, the OS and non-cancer death rate in the FPG group remained significantly better after propensity score-matching analysis. In conclusion, for early gastric cancer located in M or L areas, patients treated via FPG guided by SNB have a better prognosis and fewer deaths caused by respiratory disease than those treated via GL. The present clinical trial was registered under the following trial registration numbers: UMIN000010154 (2013/3/4), UMIN000023828 (2016/8/29), jRCTs041180006 (2018/10/9).
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Affiliation(s)
- Shinichi Kinami
- Department of Surgical Oncology, Kanazawa Medical University, Kahoku, Ishikawa 920-0293, Japan
| | - Daisuke Kaida
- Department of Surgical Oncology, Kanazawa Medical University, Kahoku, Ishikawa 920-0293, Japan
| | - Koichi Okamoto
- Department of Surgical Oncology, Kanazawa Medical University, Kahoku, Ishikawa 920-0293, Japan
| | - Takashi Fujimura
- Department of Surgery, Toyama City Hospital, Toyama, Toyama 939-8511, Japan
| | - Yasuo Iida
- Department of Mathematics, Division of General Education, Kanazawa Medical University, Kahoku, Ishikawa 920-0293, Japan
| | - Noriyuki Inaki
- Department of Gastrointestinal Surgery, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Takamura
- Department of Surgical Oncology, Kanazawa Medical University, Kahoku, Ishikawa 920-0293, Japan
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Otake R, Kumagai K, Ohashi M, Makuuchi R, Ida S, Sano T, Nunobe S. Reflux Esophagitis After Laparoscopic Pylorus-Preserving Gastrectomy for Gastric Cancer. Ann Surg Oncol 2023; 30:2294-2303. [PMID: 36509874 DOI: 10.1245/s10434-022-12902-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic pylorus-preserving gastrectomy (LPPG) is performed for cT1N0 gastric cancer as a function-preserving surgery, but reflux esophagitis can develop as a mid- to long-term complication postoperatively. We aimed to clarify the incidence rate of this complication and the factors correlated with it. METHODS Patients with gastric cancer who underwent LPPG between 2005 and 2017 were analyzed. Postoperative reflux esophagitis was evaluated with esophagogastroduodenoscopy; patients were diagnosed as having reflux esophagitis with erosive esophagitis using the modified Los Angeles classification. The incidence rate of postoperative reflux esophagitis was estimated; factors correlated with postoperative reflux esophagitis were analyzed using the logistic regression model. RESULTS During the study period, 813 patients underwent LPPG for gastric cancer, and 127 (15.6%) of them developed grade B or more severe postoperative reflux esophagitis. The factors correlated with postoperative reflux esophagitis were male sex (odds ratio, 2.68; 95% confidence interval, 1.77-4.05; P < 0.001), preoperative grade A reflux esophagitis (odds ratio, 3.05; 95% confidence interval, 1.28-7.27; P = 0.012), body mass index of ≥ 23 kg/m2 at 1 year postoperatively (odds ratio, 2.18; 95% confidence interval, 1.34-3.53; P = 0.002), postoperative hiatal hernia (odds ratio, 4.35; 95% confidence interval, 2.35-8.04; P < 0.001), and long-term stasis (odds ratio, 1.58; 95% confidence interval, 1.01-2.47; P = 0.044). CONCLUSIONS Careful attention should be paid in performing LPPG and in postoperative management after LPPG for gastric cancer patients with those risk factors.
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Affiliation(s)
- Reiko Otake
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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Terayama M, Ohashi M, Makuuchi R, Hayami M, Ida S, Kumagai K, Sano T, Nunobe S. A continuous muscle-sparing advantage of pylorus-preserving gastrectomy for older patients with cT1N0M0 gastric cancer in the middle third of the stomach. Gastric Cancer 2023; 26:145-154. [PMID: 36207477 DOI: 10.1007/s10120-022-01345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/30/2022] [Indexed: 02/07/2023]
Abstract
In older patients with cT1N0M0 gastric cancer in the middle third of the stomach, LPPG has advantages over LDGB1 in maintaining skeletal muscle mass. BACKGROUND Laparoscopic pylorus-preserving gastrectomy (LPPG) for early gastric cancer in the middle third of the stomach is expected to be an alternative procedure to laparoscopic distal gastrectomy (LDG). However, whether LPPG is safe and more useful than LDG in older patients is unclear because of their comorbidities and organ dysfunctions. METHODS We retrospectively analyzed the data of consecutive patients aged 75 or over who underwent LDG with Billroth I reconstruction (LDGB1) or LPPG for cT1N0M0 gastric cancer in the middle third of the stomach between 2005 and 2019. After propensity score matching was used to improve the comparability between the LDGB1 and LPPG groups, we compared surgical and postoperative nutritional outcomes, including the postoperative trends of bodyweight (%BW) and skeletal muscle index (%SMI). RESULTS A total of 132 patients who underwent LDGB1 (n = 88) and LPPG (n = 44) were collected for this study. No significant difference in postoperative complications was observed. The total protein levels after LPPG were significantly higher than those after LDGB1 for 4 postoperative years. Both %BW and %SMI after LPPG were significantly maintained compared with those after LDGB1 during the first year after surgery. For the subsequent years, %BW after LPPG became similar to that after LDGB1, while %SMI after LPPG was significantly larger than LDGB1 continuously. CONCLUSIONS LPPG has a great advantage in maintaining the postoperative skeletal muscle mass as well as the nutritional parameters of older patients. LPPG is expected to be an alternative to LDG in older patients.
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Affiliation(s)
- Masayoshi Terayama
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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Zhang C, Wei MH, Cao L, Liu YF, Liang P, Hu X. Performing robot-assisted pylorus and vagus nerve-preserving gastrectomy for early gastric cancer: A case series of initial experience. World J Gastrointest Surg 2022; 14:1107-1119. [PMID: 36386400 PMCID: PMC9640333 DOI: 10.4240/wjgs.v14.i10.1107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/15/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023] Open
Abstract
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, and postoperative hospital stay was 10.13 ± 4.55 d.
CONCLUSION The core technique in the Da Vinci Xi RAPPG is lymph node dissection and the anatomic method of the nerve. Robotic surgical procedures are feasible and safe. With the progress of surgical technology, optimization of medical insurance structure, and emergence of evidence-based medicine, automated surgery systems will have a broad application in clinical treatment.
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Affiliation(s)
- Chi Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Mao-Hua Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Liang Cao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Yan-Feng Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Pin Liang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Xiang Hu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
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Choi S, Hyung WJ. Modern surgical therapy for gastric cancer-Robotics and beyond. J Surg Oncol 2022; 125:1142-1150. [PMID: 35481911 DOI: 10.1002/jso.26841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/19/2022] [Indexed: 11/06/2022]
Abstract
The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.
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Affiliation(s)
- Seohee Choi
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
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Deng Y, Huang S, Huang M, Wang X, Huang Y, Chi P. Gastrocolic ligament lymph-node dissection may increase the incidence of delayed gastric emptying after colon cancer surgery with D3 lymphadenectomy. Surg Today 2021; 51:897-905. [PMID: 33389191 DOI: 10.1007/s00595-020-02200-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/18/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Delayed gastric emptying (DGE) is associated with prolonged hospital stay and higher healthcare costs. This study aimed to investigate the risk factors for DGE after D3 radical resection for colon cancer and to build a nomogram for this complication. METHODS We analyzed, retrospectively, 1160 consecutive patients who underwent surgery with D3 lymphadenectomy for colon cancer between January, 2012 and June, 2018. A multivariate logistic regression analysis was used to identify the risk factors for DGE and to build a DGE nomogram model. RESULTS There were ten, six and four patients with DGE classified as grades A, B and C, respectively, representing a DGE rate of 1.7%. Multivariate analysis revealed that age (P = 0.001), dissection of the gastrocolic ligament lymph nodes (GCLNs) (P = 0.001), surgical duration (P = 0.017) and preoperative hemoglobin level (P = 0.016) were independent risk factors, and were included to build a predictive model for DGE. The therapeutic index of GCLN dissection was approximately half that of D3 lymphadenectomy (2.9 vs. 5.6). CONCLUSIONS DGE is more likely to develop in patients aged > 75 years, those with a preoperative hemoglobin < 90 g/L, those with a surgical duration > 210 min, and those who undergo GCLN dissection. The nomogram may facilitate the stratification of patients at risk for DGE following D3 lymphadenectomy for colon cancer. Assessing long-term outcomes will help to evaluate the survival benefit of GCLN dissection in the future, to avoid unnecessary dissection and reduce the incidence of DGE.
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Affiliation(s)
- Yu Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Mingjin Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
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12
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Kosuga T, Tsujiura M, Nakashima S, Masuyama M, Otsuji E. Current status of function-preserving gastrectomy for gastric cancer. Ann Gastroenterol Surg 2021; 5:278-286. [PMID: 34095717 PMCID: PMC8164463 DOI: 10.1002/ags3.12430] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 12/17/2022] Open
Abstract
Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.
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Affiliation(s)
- Toshiyuki Kosuga
- Department of SurgerySaiseikai Shiga HospitalRittoJapan
- Division of Digestive SurgeryDepartment of SurgeryKyoto Prefectural University of MedicineKyotoJapan
| | | | | | | | - Eigo Otsuji
- Division of Digestive SurgeryDepartment of SurgeryKyoto Prefectural University of MedicineKyotoJapan
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13
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Khalayleh H, Kim YW, Yoon HM, Ryu KW. Assessment of Lymph Node Metastasis in Patients With Gastric Cancer to Identify Those Suitable for Middle Segmental Gastrectomy. JAMA Netw Open 2021; 4:e211840. [PMID: 33729506 PMCID: PMC7970333 DOI: 10.1001/jamanetworkopen.2021.1840] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Segmental gastrectomy, a type of function-preserving surgery, is not broadly studied but can improve postoperative function and quality of life among patients with gastric cancer (GC). OBJECTIVE To establish an indication for middle segmental gastrectomy (MSG) as a treatment for middle-body (MB) and high-body (HB) GC. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed patients with GC undergoing surgery between January 2000 and December 2015 in the National Cancer Center, Goyang, Korea, a high-volume cancer center with a structured database and accurate long-term follow-up. Inclusion criteria were age 18 to 85 year, histologically proven adenocarcinoma located in the HB or MB, cT1 to cT3 category cancers, curative resection with negative margins performed, and follow-up for at least 3 years. Exclusion criteria were Borrmann type 4 GC, T4 category cancer, neoadjuvant chemotherapy, and a history of other cancers. Data analysis was performed from December 2018 to May 2020. EXPOSURES Total or subtotal gastrectomy and LN dissection. MAIN OUTCOME AND MEASURES The primary outcome was the rate of metastasis at LN stations 2, 4sa, 5, 6, and 11d, which cannot be dissected during MSG. RESULTS Among 9952 patients who underwent surgery for GC, 8219 underwent either laparoscopic or open total or subtotal gastrectomy. Seven hundred seventy-three patients (mean [SD] age, 56.21 [12.16] years; 464 men [60.0%]) had GC in the MB or HB of the stomach. Among the 701 patients included in the final analysis after exclusion of the cN2/N3 carcinomas, the mean (SD) age was 56.35 (12.24) years, and 418 (59.6%) were men. The incidence of LN metastasis was 0% at station 5 for cT1-3N0/1M0 cancers, station 4sa for cT1-2N0/1M0 cancers, station 2 for cT1N0/1M0 cancers, station 6 for cT1N1M0 cancers, station 11d for cT1N1M0-cT2N0/1M0 cancers, and station 12a for cT1N0/1M0-T2N1M0 cancers, regardless of size and differentiation. The rates of LN metastasis for cT1N0M0 cancers were 0.3% (1 of 396 LNs) at station 6 and 0.8% (1 of 129 LNs) at station 11d. Tumors 4 cm or smaller were associated with a lower risk of LN metastasis compared with tumors 4.1 cm or larger (odds ratio, 2.10; 95% CI, 1.20-3.67; P = .009), and well-differentiated tumors were associated with lower risk of LN metastasis compared with poorly differentiated tumors (odds ratio, 2.88; 95% CI, 1.45-5.73; P = .002). CONCLUSIONS AND RELEVANCE These findings suggest that MSG with dissection of stations 1, 3, 4sb, 4d, 7, 8a, 9, 11p, and 12a could be done for HB and MB cT1N0/1M0 gastric cancers 4 cm or smaller and well-differentiated cT2N0/1M0 cancers.
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Affiliation(s)
- Harbi Khalayleh
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- The Department of Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
- National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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14
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Wang CJ, Kong SH, Park JH, Choi JH, Park SH, Zhu CC, Alzahrani F, Alzahrani K, Suh YS, Park DJ, Lee HJ, Cao H, Yang HK. Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy. Gastric Cancer 2021; 24:232-244. [PMID: 32705445 DOI: 10.1007/s10120-020-01106-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Injury to the vagus nerve has been proposed to be associated with occurrence of gallstones after gastrectomy. We investigated the effect of preservation of hepatic branch of the vagus nerve on prevention of gallstones during laparoscopic distal (LDG) and pylorus-preserving gastrectomy (LPPG). METHODS Preservation of the vagus nerve was reviewed of cT1N0M0 gastric cancer patients underwent LDG (n = 323) and LPPG (n = 144) during 2016-2017. Presence of gallstones was evaluated by ultrasonography (US) and computed tomography (CT). Incidences of gallstones were compared between the nerve preserved (h-DG, h-PPG) group and sacrificed (s-DG, s-PPG) group. Clinicopathological features were also compared. RESULTS The 3-year cumulative incidence of gallstones was lower in the h-DG (2.7%, n = 85) than the s-DG (14.6%, n = 238) (p = 0.017) and lower in the h-PPG (1.6%, n = 123) than the s-PPG (12.9%, n = 21) (p = 0.004). Overall postoperative complication rate was similar between the h-DG and s-DG (p = 0.861) as well as between the h-PPG and s-PPG (p = 0.768). The number of retrieved lymph nodes station #1 and 3-year recurrence-free survival were not significantly different between the preserved group and sacrificed group. Injury to the vagus nerve (p = 0.001) and high body mass index (BMI) (≥ 27.5 kg/m2) (p = 0.040) were found to be independent risk factors of gallstone formation in multivariate analysis. CONCLUSIONS Preservation of hepatic branch of the vagus nerve can be recommended for LDG as well as LPPG of early gastric cancer patients to reduce postoperative gallstone formation.
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Affiliation(s)
- Chao-Jie Wang
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pu Jian Road, Shanghai, 200127, China
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Ji-Hyeon Park
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jong-Ho Choi
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Shin-Hoo Park
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Chun-Chao Zhu
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pu Jian Road, Shanghai, 200127, China
| | - Fadhel Alzahrani
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Surgery, King Faisal Hospital, Makkah, Saudi Arabia
| | - Khalid Alzahrani
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Taif University, Taif, Saudi Arabia
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do-Joong Park
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hui Cao
- Department of Gastrointestinal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pu Jian Road, Shanghai, 200127, China.
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
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15
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Akiyama Y, Sasaki A, Iwaya T, Fujisawa R, Sasaki N, Nikai H, Endo F, Baba S, Hasegawa Y, Kimura T, Takahara T, Nitta H, Otsuka K, Koeda K. Feasibility of totally laparoscopic pylorus-preserving gastrectomy with intracorporeal gastro-gastrostomy for early gastric cancer: a retrospective cohort study. World J Surg Oncol 2020; 18:170. [PMID: 32677964 PMCID: PMC7366885 DOI: 10.1186/s12957-020-01955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pylorus-preserving gastrectomy (PPG) has been accepted as a function-preserving surgery for the treatment of early gastric cancer in East Asian countries. Therefore, this study aimed to evaluate the feasibility and safety of totally laparoscopic PPG (TLPPG) with intracorporeal anastomosis. Methods A total of 43 patients with early gastric cancer underwent laparoscopy-assisted PPG (LAPPG) with extracorporeal anastomosis between May 2006 and November 2012. The operative outcomes of 22 patients who underwent TLPPG between November 2012 and February 2019 were evaluated, and data were compared with that of the LAPPG group. Results No significant difference in the operative time was observed between the two groups. Blood loss was lower in the TLPPG group (18.5 mL) than in the LAPPG group (30.7 mL, p = 0.008), and the length of abdominal incision was shorter in the TLPPG group (3.8 cm) than in the LAPPG group (4.7 cm, p < 0.001). No significant difference in the complication rate was observed between the two groups (13.6% in the TLPPG vs. 9.3% in the LAPPG group, p = 0.594). No anastomosis-related complications occurred in either group. No significant between-group difference was observed in the delayed gastric emptying (TLPPG, 9.1 vs. LAPPG, 7%, p = 0.762). The initiation of postoperative fluid (TLPPG, 1.0 day vs. LAPPG, 3.0 days, p < 0.001) and meal (TLPPG, 3.0 days vs. LAPPG, 4.0 days, p < 0.001) intake was earlier in the TLPPG group than in the LAPPG group. No significant between-group difference was observed in the postoperative hospital stay. Conclusions The findings of this study suggest that TLPPG with intracorporeal reconstruction not only is as feasible and safe as LAPPG for the treatment of patients with early gastric cancer but also provides certain advantages such as reduced blood loss and wound size.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan.
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Ryosuke Fujisawa
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Noriyuki Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Iwate, Japan
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16
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Mao X, Xu X, Zhu H, Ji C, Lu X, Wang B. A comparison between pylorus-preserving and distal gastrectomy in surgical safety and functional benefit with gastric cancer: a systematic review and meta-analysis. World J Surg Oncol 2020; 18:160. [PMID: 32641052 PMCID: PMC7346397 DOI: 10.1186/s12957-020-01910-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Due to better functional outcomes, pylorus-preserving gastrectomy (PPG) has been widely applied for early gastric cancer (EGC) patients as an alternative to distal gastrectomy (DG). However, controversies still persist regarding the surgical efficacy and oncological safety of PPG. METHODS Original studies comparing PPG and DG for EGC were searched in PubMed, Embase, and the Cochrane Register of Controlled Trials up to December 2019. The weight mean difference, standardized mean difference, or odds risk was used to calculate the short-term and long-term outcomes between the two groups. RESULTS Twenty-one comparative studies comprising 4871 patients (1955 in the PPG group and 2916 in the DG group) were enrolled in this systematic review and meta-analysis. PPG showed longer hospital day, decreased harvested lymph nodes, and more delayed gastric emptying. However, PPG had the benefits of lower incidence of anastomosis leakage, early dumping syndrome, gastritis and bile reflux, and better recovery of total protein, albumin, hemoglobin, and weight. No difference was found in operative time, blood loss, and overall complications. Moreover, the long-term survival and recurrence rate were similar in two groups. CONCLUSION Owing to the non-inferiority of surgery and oncology outcomes and the superiority of function outcomes in PPG, we revealed that PPG can be clinically applicable instead of DG in EGC. However, more high-quality comparative studies and randomized clinical trials would be required for further confirmation.
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Affiliation(s)
- Xinyu Mao
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China
| | - Xinlei Xu
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China
| | - Hua Zhu
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China
| | - Chunpeng Ji
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China
| | - Xu Lu
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China
| | - Baolin Wang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Road, Nanjing, 210011, Jiangsu, China.
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17
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Takahashi R, Ohashi M, Hiki N, Makuuchi R, Ida S, Kumagai K, Sano T, Nunobe S. Risk factors and prognosis of gastric stasis, a crucial problem after laparoscopic pylorus-preserving gastrectomy for early middle-third gastric cancer. Gastric Cancer 2020; 23:707-715. [PMID: 31916027 DOI: 10.1007/s10120-019-01037-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pylorus-preserving gastrectomy (PPG) is a function-preserving procedure for cT1N0 gastric cancer located in the middle-third of stomach, which is currently performed through a laparoscopic approach (LPPG). PPG is sometimes associated with a crucial problem during the early postoperative course, designated gastric stasis. However, information regarding gastric stasis remains to be fully elucidated. METHODS The study included 897 patients who underwent LPPG between 2005 and 2017. Early postoperative gastric stasis (E-stasis) was defined when the following conditions were fulfilled: upper abdominal distension, remnant stomach fullness on radiography image, and period of starvation exceeding 72 h within 1 month postoperatively. To evaluate long-term outcomes of E-stasis, late postoperative food residue (L-residue) was defined as grade 2 or higher food residue endoscopically according to the RGB (residue, gastritis, bile) classification at 1 year postoperatively. Risk factors and long-term outcomes of E-stasis were retrospectively analyzed. RESULTS E-stasis was the most common complication during the early postoperative course. E-stasis occurred in 68 (7.6%) patients. Multivariate analysis identified age (≥ 61 years), DM, and postoperative intraabdominal infection as risk factors. At 1 year postoperatively, relative body weight ratio and postoperative serum albumin in the patients who experienced E-stasis was significantly lower than those in the other patients (P = 0.042 and 0.011, respectively). Of the patients who suffered from E-stasis, 42.5% experienced L-residue. CONCLUSIONS E-stasis after LPPG occurs in 7.6% of patients. Age, DM, and intraabdominal infection are significantly related to E-stasis. E-stasis is associated with poorer nutritional and functional outcomes even at 1 year postoperatively.
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Affiliation(s)
- Ryo Takahashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Manabu Ohashi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Naoki Hiki
- Department of Upper Gastrointestinal Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Rie Makuuchi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeshi Sano
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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18
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Zhou J, Du R, Zhang Q, Wang D. Laparoscopy-assisted pylorus-preserving gastrectomy versus laparoscopy-assisted distal gastrectomy for early gastric cancer in perioperative outcomes: A meta-analysis. Asian J Surg 2020; 43:862-863. [PMID: 32527581 DOI: 10.1016/j.asjsur.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/06/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jiajie Zhou
- Dalian Medical University, Dalian, 116044, China.
| | - Rui Du
- Dalian Medical University, Dalian, 116044, China
| | - Qi Zhang
- Yangzhou University, Yangzhou, 225001, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu Province Hospital, Clinical Medical College, Yangzhou University, Institute of General Surgery - Yangzhou University, Yangzhou, China.
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19
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Tsujiura M, Nunobe S. Functional and nutritional outcomes after gastric cancer surgery. Transl Gastroenterol Hepatol 2020; 5:29. [PMID: 32258533 DOI: 10.21037/tgh.2019.11.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022] Open
Abstract
Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.
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Affiliation(s)
- Masahiro Tsujiura
- Department of Surgery, Saiseikai Shiga Hospital, Ritto City, Japan.,Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-ward, Tokyo, Japan
| | - Souya Nunobe
- Department of Surgery, Saiseikai Shiga Hospital, Ritto City, Japan
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Kaji S, Makuuchi R, Irino T, Tanizawa Y, Bando E, Kawamura T, Omori H, Fujiya K, Nishiwaki N, Furukawa K, Nakamura K, Koseki Y, Waki Y, Asaoka R, Terashima M. Preventive effect on delayed gastric emptying of preserving the infra-pyloric vein in laparoscopic pylorus-preserving gastrectomy for early gastric cancer. Surg Endosc 2019; 34:3853-3860. [DOI: 10.1007/s00464-019-07151-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/24/2019] [Indexed: 12/19/2022]
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Kinami S, Nakamura N, Tomita Y, Miyata T, Fujita H, Ueda N, Kosaka T. Precision surgical approach with lymph-node dissection in early gastric cancer. World J Gastroenterol 2019; 25:1640-1652. [PMID: 31011251 PMCID: PMC6465935 DOI: 10.3748/wjg.v25.i14.1640] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/09/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
The gravest prognostic factor in early gastric cancer is lymph-node metastasis, with an incidence of about 10% overall. About two-thirds of early gastric cancer patients can be diagnosed as node-negative prior to treatment based on clinic-pathological data. Thus, the tumor can be resected by endoscopic submucosal dissection. In the remaining third, surgical resection is necessary because of the possibility of nodal metastasis. Nevertheless, almost all patients can be cured by gastrectomy with D1+ lymph-node dissection. Laparoscopic or robotic gastrectomy has become widespread in East Asia because perioperative and oncological safety are similar to open surgery. However, after D1+ gastrectomy, functional symptoms may still result. Physicians must strive to minimize post-gastrectomy symptoms and optimize long-term quality of life after this operation. Depending on the location and size of the primary lesion, preservation of the pylorus or cardia should be considered. In addition, the extent of lymph-node dissection can be individualized, and significant gastric-volume preservation can be achieved if sentinel node biopsy is used to distinguish node-negative patients. Though the surgical treatment for early gastric cancer may be less radical than in the past, the operative method itself seems to be still in transition.
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Affiliation(s)
- Shinichi Kinami
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Naohiko Nakamura
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Yasuto Tomita
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Takashi Miyata
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Hideto Fujita
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Nobuhiko Ueda
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Takeo Kosaka
- Department of Surgical Oncology, Kanazawa Medical University, Ishikawa 920-0293, Japan
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Zeng Q, Wang J. Precision and innovation in minimal invasion: A report of 2018 International Conference of Minimally Invasive Surgery, West Lake Summit. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2018. [DOI: 10.1016/j.lers.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Zhu CC, Kim TH, Berlth F, Park SH, Suh YS, Kong SH, Lee HJ, Cao H, Yang HK. Clinical outcomes of intraoperative manual dilatation of pylorus in pylorus-preserving gastrectomy: a retrospective analysis. Gastric Cancer 2018. [PMID: 29536295 DOI: 10.1007/s10120-018-0814-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed gastric emptying is one of the most disturbing complications of pylorus-preserving gastrectomy (PPG) and it increases hospital stay. We investigated the clinical outcome of intraoperative manual dilatation of the pylorus as a preventive method of pyloric spasm after PPG. MATERIALS AND METHODS We reviewed gastric cancer patients who underwent PPG between January 2014 and December 2016 at Seoul National University Hospital by a single surgeon. During operation, manual dilatation (MD) was performed after laparoscopic dissection and gastric resection by mini-laparotomy. Pyloric stenosis was diagnosed by the finding of severe narrowing in pylorus on upper gastrointestinal series (UGIS), if patients suffered from postprandial abdominal fullness and discomfort. Patient's characteristics, surgical data and complication data were reviewed and compared between the groups (MD vs non-MD). RESULTS 232 patients were included in this study. 93 patients underwent manual dilatation (40.1%). The overall complication rate was 12.9% in the MD group and 18.7% in the non-MD group (p = 0.242). Mean postoperative stay was 10.0 ± 5.8 in the MD group versus 10.9 ± 8.4 in the non-MD group (p = 0.304). Only one case suffered pylorus stenosis in the MD group (1.1%) but there were twelve cases seen in the non-MD group (8.6%), which reflects a significant difference (p = 0.019). CONCLUSION Simple intraoperative manual dilatation of pylorus may provide prevention from pyloric stenosis caused by pyloric spasms for patients who undergo PPG.
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Affiliation(s)
- Chun-Chao Zhu
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea.,Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tae-Han Kim
- Department of Surgery, Gyeongsang National University Hospital, Jinju, South Korea
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Shin-Hoo Park
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea.,Cancer Research Institute, Seoul National University, Seoul, South Korea
| | - Hui Cao
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Daehak-ro 101, Jongno-gu, 03080, Seoul, South Korea. .,Cancer Research Institute, Seoul National University, Seoul, South Korea.
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A novel method of intracorporeal end-to-end gastrogastrostomy in laparoscopic pylorus-preserving gastrectomy for early gastric cancer, including a unique anastomotic technique: piercing the stomach with a linear stapler. Surg Endosc 2018; 32:4337-4343. [PMID: 29785457 DOI: 10.1007/s00464-018-6237-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/09/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delta-shaped anastomosis is usually applied for an intracorporeal gastrogastrostomy in totally laparoscopic pylorus-preserving gastrectomy (TLPPG). However, the remnant stomach is slightly twisted around the anastomosis because it connects in side-to-side fashion. To realize an intracorporeal end-to-end gastrogastrostomy using an endoscopic linear stapler, we invented a novel method including a unique anastomotic technique. MATERIALS AND METHODS In this new approach, we first made small gastrotomies at the greater and lesser curvatures of the transected antrum and then pierced it using an endoscopic linear stapler. After the pierced antrum and the proximal remnant stomach were mechanically connected, the gastrotomies and stapling lines were transected using an endoscopic linear stapler, creating an intracorporeal end-to-end gastrogastrostomy. We have named this technique the "piercing method" because piercing the stomach is essential to its implementation. Between October 2015 and June 2017, 26 patients who had clinically early gastric cancer at the middle third of the stomach without clinical evidence of lymph node metastasis underwent TLPPG involving the novel method. RESULTS The 26 patients successfully underwent an intracorporeal mechanical end-to-end gastrogastrostomy by the piercing method. The median operation time of the 26 patients was 272 min (range 209-357 min). With the exception of one gastric stasis, no problems associated with the piercing method were encountered during and after surgery. CONCLUSION The piercing method can safely create an intracorporeal mechanical end-to-end gastrogastrostomy in TLPPG. Piercing the stomach using an endoscopic linear stapler is a new technique for gastrointestinal anastomosis. This method should be considered if the surgical aim is creation of an intracorporeal end-to-end gastrogastrostomy in TLPPG.
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Nunobe S, Hiki N. Function-preserving surgery for gastric cancer: current status and future perspectives. Transl Gastroenterol Hepatol 2017; 2:77. [PMID: 29034350 DOI: 10.21037/tgh.2017.09.07] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 12/13/2022] Open
Abstract
The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures including endoscopy and screening systems. Therefore, function-preserving gastrectomy (FPG) for EGC with the expectation of better quality of life (QOL) after surgery may be increasingly utilized, due to its association with low rate of lymph node metastasis and excellent survival and the possibility of employing less invasive procedures such as laparoscopic gastrectomy in combination. Pylorus-preserving gastrectomy (PPG) with curative intent lymph node dissection is a representative FPG that has been used in EGC, and its superiorities, indications, limitations, and survival benefits have already been reported in several retrospective studies. Laparoscopic proximal gastrectomy (LAPG) has also been employed in EGC of the upper third of the stomach; however, LAPG was found to be associated with major issues in achieving a balance between swallowing and reflux prevention. In patients with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved, albeit very small, stomach may provide a better QOL and fewer postoperative complications. FPG is recommended as a surgical treatment for EGC if the indication is accurately diagnosed and strictly confirmed; however, these techniques in laparoscopic surgery present technical difficulties to surgeons without a certain degree of skills. Although many retrospective studies revealed the functional benefits or oncological safety with FPG, further prospective studies using large case series are necessary to reveal the value of FPG compared with the conventional procedures.
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Affiliation(s)
- Souya Nunobe
- Department of Gastroenterological surgery, Cancer Institute Ariake Hospital, Tokyo, Japan
| | - Naoki Hiki
- Department of Gastroenterological surgery, Cancer Institute Ariake Hospital, Tokyo, Japan
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