保留幽门的胃切除术在早期胃癌外科治疗中的应用及相关指南共识解读

doi:10.16139/j.1007-9610.2024.01.13

摘要/Abstract

摘要：

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

关键词: 早期胃癌, 保留幽门的胃切除术, 胃延迟排空, 淋巴结清扫

Abstract:

Endoscopic resection (ER) and laparoscopic surgery are the main methods for treatment of early gastric cancer (EGC). Radical gastrectomy(RG) and lymph node dissection are required for the patients who don’t meet the indications of ER, but it may cause postoperative stomach dysfunction and reduce quality of life (QOL). Pylorus-preserving gastrectomy (PPG) is one of the function-preserving gastrectomy for EGC. The short-term complications of PPG are equal to that of RG and it is also beneficial to long-term nutritional status and QOL. The 5-year survival rate of PPG is similar to that of distal subtotal gastrectomy (DSG) according to a retrospective study of the matched cohort. But delayed gastric emptying (DGE) is a common problem in the short and long term after PPG. The limited lymph node dissection of PPG makes its application not widely promoted. Sentinel node navigation surgery (SNNS) may provide more personalized and minimally invasive surgery, in order to preserve the gastric function to the maximum extent.

Key words: Early gastric cancer, Pylorus-preserving gastrectomy, Delayed gastric emptying, Lymph node dissection

中图分类号:

R735.2

于素悦, 陆爱国. 保留幽门的胃切除术在早期胃癌外科治疗中的应用及相关指南共识解读[J]. 外科理论与实践, 2024, 29(01): 81-86.

YU Suyue, LU Aiguo. Application of pylorus-preserving gastrectomy in surgical treatment for early gastric cancer and interpretation of guidelines and consensus[J]. Journal of Surgery Concepts & Practice, 2024, 29(01): 81-86.

参考文献 54

[1]	CHEN J, ZHAO G, WANG Y. Analysis of lymph node metastasis in early gastric cancer: a single institutional experience from China[J]. World J Surg Oncol, 2020, 18(1):57. doi: 10.1186/s12957-020-01834-7 pmid: 32197625
[2]	MAKI T, SHIRATORI T, HATAFUKU T, et al. Pylorus-preserving gastrectomy as an improved operation for gastric ulcer[J]. Surgery, 1967, 61(6):838-845.
[3]	KODAMA M, KOYAMA K. Indications for pylorus preserving gastrectomy for early gastric cancer located in the middle third of the stomach[J]. World J Surg, 1991, 15(5):628-633. pmid: 1949863
[4]	NAKAJIMA T. Gastric cancer treatment guidelines in Japan[J]. Gastric Cancer, 2002, 5(1):1-5. doi: 10.1007/s101200200000 pmid: 12021853
[5]	Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018(5th edition)[J]. Gastric Cancer, 2021, 24(1):1-21.
[6]	MORII Y, ARITA T, SHIMODA K, et al. Indications for pylorus-preserving gastrectomy for gastric cancer based on lymph node metastasis[J]. Hepatogastroenterology, 2002, 49(47):1477-1480.
[7]	Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2021 (6th edition)[J]. Gastric Cancer, 2023, 26(1):1-25.
[8]	YANG J, XIE J, XU L, et al. Clinical experience of intracorporeal hand-sewn anastomosis following totally laparoscopic pylorus-preserving gastrectomy for middle-third early gastric cancer[J]. J Gastrointest Surg, 2022, 26(3):659-661.
[9]	Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3)[J]. Gastric Cancer, 2011, 14(2):113-123. doi: 10.1007/s10120-011-0042-4 pmid: 21573742
[10]	SMYTH E C, VERHEIJ M, ALLUM W, et al. Gastric cancer:ESMO clinical practice guidelines for diagnosis,treatment and follow-up[J]. Ann Oncol, 2016, 27(suppl 5):v38-v49.
[11]	AJANI J A, D’AMICO T A, BENTREM D J, et al. Gastric cancer,version 2.2022,NCCN clinical practice guidelines in oncology[J]. J Natl Compr Canc Netw, 2022, 20(2):167-192.
[12]	ISOBE Y, NASHIMOTO A, AKAZAWA K, et al. Gastric cancer treatment in Japan: 2008 annual report of the JGCA nationwide registry[J]. Gastric Cancer, 2011, 14(4):301-316. doi: 10.1007/s10120-011-0085-6 pmid: 21894577
[13]	DRAGANOV P V, WANG A Y, OTHMAN M O, et al. AGA institute clinical practice update: endoscopic submucosal dissection in the united states[J]. Clin Gastroenterol Hepatol, 2019, 17(1):16-25.
[14]	PIMENTEL-NUNES P, DINIS-RIBEIRO M, PONCHON T, et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline[J]. Endoscopy, 2015, 47(9):829-854.
[15]	PIMENTEL-NUNES P, LIBÂNIO D, BASTIAANSEN B A J, et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) guideline - update 2022[J]. Endoscopy, 2022, 54(6):591-622.
[16]	HASUIKE N, ONO H, BOKU N, et al. A non-randomized confirmatory trial of an expanded indication for endoscopic submucosal dissection for intestinal-type gastric cancer (cT1a): the Japan Clinical Oncology Group study (JCOG0607)[J]. Gastric Cancer, 2018, 21(1):114-123. doi: 10.1007/s10120-017-0704-y pmid: 28224238
[17]	KINAMI S, NAKAMURA N, TOMITA Y, et al. Precision surgical approach with lymph-node dissection in early gastric cancer[J]. World J Gastroenterol, 2019, 25(14):1640-1652.
[18]	HUH C W, KIM G J, KIM B W, et al. Long-term clinical outcomes and risk of peritoneal seeding after endoscopic submucosal dissection for early gastric cancer: a focus on perforation during the procedure[J]. Gut Liver, 2019, 13(5):515-521. doi: 10.5009/gnl18350 pmid: 30970443
[19]	ODA I, SUZUKI H, NONAKA S, et al. Complications of gastric endoscopic submucosal dissection[J]. Dig Endosc, 2013, 25(Suppl 1):71-78.
[20]	PARK D J, KIM Y W, YANG H K, et al. Short-term outcomes of a multicentre randomized clinical trial compa-ring laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial)[J]. Br J Surg, 2021, 108(9):1043-1049.
[21]	TSUJIURA M, HIKI N, OHASHI M, et al. Excellent long-term prognosis and favorable postoperative nutritional status after laparoscopic pylorus-preserving gastrectomy[J]. Ann Surg Oncol, 2017, 24(8):2233-2240. doi: 10.1245/s10434-017-5828-0 pmid: 28280944
[22]	KIYOKAWA T, HIKI N, NUNOBE S, et al. Preserving infrapyloric vein reduces postoperative gastric stasis after laparoscopic pylorus-preserving gastrectomy[J]. Langenbecks Arch Surg, 2017, 402(1):49-56.
[23]	KAJI S, MAKUUCHI R, IRINO T, et al. Preventive effect on delayed gastric emptying of preserving the infra-pyloric vein in laparoscopic pylorus-preserving gastrectomy for early gastric cancer[J]. Surg Endosc, 2020, 34(9):3853-3860. doi: 10.1007/s00464-019-07151-9 pmid: 31598877
[24]	NAKANE Y, MICHIURA T, INOUE K, et al. Length of the antral segment in pylorus-preserving gastrectomy[J]. Br J Surg, 2002, 89(2):220-224.
[25]	TAKAHASHI R, OHASHI M, HIKI N, et al. Risk factors and prognosis of gastric stasis, a crucial problem after laparoscopic pylorus-preserving gastrectomy for early middle-third gastric cancer[J]. Gastric Cancer, 2020, 23(4):707-715. doi: 10.1007/s10120-019-01037-4 pmid: 31916027
[26]	FURUKAWA H, OHASHI M, HONDA M, et al. Preservation of the celiac branch of the vagal nerve for pylorus-preserving gastrectomy: is it meaningful?[J]. Gastric Cancer, 2018, 21(3):516-523. doi: 10.1007/s10120-017-0776-8 pmid: 29127549
[27]	WANG C J, KONG S H, PARK J H, et al. Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy[J]. Gastric Cancer, 2021, 24(1):232-244.
[28]	FUJITA J, TAKAHASHI M, URUSHIHARA T, et al. 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[J]. Gastric Cancer, 2016, 19(1):302-311.
[29]	OKUBO K, ARIGAMI T, MATSUSHITA D, et al. Evaluation of postoperative quality of life by PGSAS-45 following local gastrectomy based on the sentinel lymph node concept in early gastric cancer[J]. Gastric Cancer, 2020, 23(4):746-753. doi: 10.1007/s10120-020-01047-7 pmid: 32086650
[30]	TSUJIURA M, HIKI N, OHASHI M, et al. Should pylorus-preserving gastrectomy be performed for overweight/obese patients with gastric cancer?[J]. Gastric Cancer, 2019, 22(6):1247-1255. doi: 10.1007/s10120-019-00951-x pmid: 30888536
[31]	XIA X, XU J, ZHU C, et al. Objective evaluation of clinical outcomes of laparoscopy-assisted pylorus-preserving gastrectomy for middle-third early gastric cancer[J]. BMC Cancer, 2019, 19(1):481. doi: 10.1186/s12885-019-5695-0 pmid: 31117975
[32]	LEE C M, JEE Y S, LEE J H, et al. Length of negative resection margin does not affect local recurrence and survival in the patients with gastric cancer[J]. World J Gastroenterol, 2014, 20(30):10518-10524.
[33]	ONO H, YAO K, FUJISHIRO M, et al. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition)[J]. Digestive Endoscopy, 2021, 33(1):4-20.
[34]	WU Y Z, LI G H, ZHOU Z H, et al. The risk of lymph node metastasis in gastric cancer conforming to indications of endoscopic resection and pylorus-preserving gastrectomy: a single-center retrospective study[J]. BMC Cancer, 2021, 21(1):1280. doi: 10.1186/s12885-021-09008-8 pmid: 34837993
[35]	ABDELFATAH M M, BARAKAT M, LEE H, et al. The incidence of lymph node metastasis in early gastric cancer according to the expanded criteria in comparison with the absolute criteria of the Japanese Gastric Cancer Association: a systematic review of the literature and meta-analysis[J]. Gastrointest Endosc, 2018, 87(2):338-347.
[36]	AN J Y, MIN J S, HUR H, et al. Laparoscopic sentinel node navigation surgery versus laparoscopic gastrectomy with lymph node dissection for early gastric cancer: short-term outcomes of a multicentre randomized controlled trial (SENORITA)[J]. Br J Surg, 2020, 107(11):1429-1439.
[37]	OH S Y, LEE H J, YANG H K. Pylorus-preserving gastrectomy for gastric cancer[J]. J Gastric Cancer, 2016, 16(2):63.
[38]	SUH Y S, HAN D S, KONG S H, et al. Laparoscopy-assisted pylorus-preserving gastrectomy is better than laparoscopy-assisted distal gastrectomy for middle-third early gastric cancer[J]. Ann Surg, 2014, 259(3):485-493.
[39]	MIZUNO A, SHINOHARA H, HARUTA S, et al. Lymphadenectomy along the infrapyloric artery may be dispensable when performing pylorus-preserving gastrectomy for early middle-third gastric cancer[J]. Gastric Cancer, 2017, 20(3):543-547. doi: 10.1007/s10120-016-0632-2 pmid: 27516348
[40]	ZHANG C D, YAMASHITA H, OKUMURA Y, et al. Signature and prediction of perigastric lymph node metastasis in patients with gastric cancer and total gastrectomy: is total gastrectomy always necessary?[J]. Cancers (Basel), 2022, 14(14):3409.
[41]	WANG F H, ZHANG X T, LI Y F, et al. The Chinese Society of Clinical Oncology (CSCO): clinical guidelines for the diagnosis and treatment of gastric cancer, 2021[J]. Cancer Commun (Lond), 2021, 41(8):747-795.
[42]	KIM D H, CHOI M G, NOH J H, et al. Clinical significance of skip lymph node metastasis in gastric cancer patients[J]. Eur J Surg Oncol, 2015, 41(3):339-345. doi: 10.1016/j.ejso.2014.09.009 pmid: 25454830
[43]	POKALA S K, ZHANG C, CHEN Z, et al. Lymph node metastasis in early gastric adenocarcinoma in the United States of America[J]. Endoscopy, 2018, 50(5):479-486. doi: 10.1055/s-0043-122379 pmid: 29228402
[44]	YOSHIKAWA T, TSUBURAYA A, KOBAYASHI O, et al. Indications of limited surgery for gastric cancer with submucosal invasion-analysis of 715 cases with special reference to site of the tumor and level 2 lymph nodes[J]. Hepatogastroenterology, 2003, 50(53):1727-1730.
[45]	KATAI H, ISHIKAWA T, AKAZAWA K, et al. Five-year survival analysis of surgically resected gastric cancer cases in Japan: a retrospective analysis of more than 100,000 patients from the nationwide registry of the Japanese Gastric Cancer Association (2001-2007)[J]. Gastric Cancer, 2018, 21(1):144-154. doi: 10.1007/s10120-017-0716-7 pmid: 28417260
[46]	MA M, CHEN S, ZHU B, et al. The clinical significance and risk factors of solitary lymph node metastasis in gastric cancer[J]. PLoS One, 2015, 10(1):e0114939.
[47]	MUNS R, MANZANILLA E G, SOL C, et al. Piglet behavior as a measure of vitality and its influence on piglet survival and growth during lactation[J]. J Anim Sci, 2013, 91(4):1838-1843. doi: 10.2527/jas.2012-5501 pmid: 23408816
[48]	TAJIMA Y, MURAKAMI M, YAMAZAKI K, et al. Sentinel node mapping guided by indocyanine green fluorescence imaging during laparoscopic surgery in gastric cancer[J]. Ann Surg Oncol, 2010, 17(7):1787-1793. doi: 10.1245/s10434-010-0944-0 pmid: 20162462
[49]	HUANG Y, PAN M, CHEN B. A systematic review and meta-analysis of sentinel lymph node biopsy in gastric cancer, an optimization of imaging protocol for tracer mapping[J]. World J Surg, 2021, 45(4):1126-1134. doi: 10.1007/s00268-020-05900-9 pmid: 33389000
[50]	ZHONG Q, CHEN Q Y, HUANG X B, et al. Clinical implications of indocyanine green fluorescence imaging-guided laparoscopic lymphadenectomy for patients with gastric cancer: a cohort study from two randomized, controlled trials using individual patient data[J]. Int J Surg, 2021,94:106120.
[51]	KIM Y W, MIN J S, YOON H M, et al. Laparoscopic sentinel node navigation surgery for stomach preservation in patients with early gastric cancer: a randomized clinical trial[J]. J Clin Oncol, 2022, 40(21):2342-2351.
[52]	HIKI N, SANO T, FUKUNAGA T, et al. Survival benefit of pylorus-preserving gastrectomy in early gastric cancer[J]. J Am Coll Surg, 2009, 209(3):297-301.
[53]	HOU S, LIU F, GAO Z, et al. Pathological and oncological outcomes of pylorus-preserving versus conventional distal gastrectomy in early gastric cancer: a systematic review and meta-analysis[J]. World J Surg Oncol, 2022, 20(1):308.
[54]	KINAMI S, AIZAWA M, YAMASHITA H, et al. The incidences of metachronous multiple gastric cancer after va-rious types of gastrectomy: analysis of data from a nationwide Japanese survey[J]. Gastric Cancer, 2021, 24(1):22-30.