Objectives: To clarify the optimal length of the antral cuff (LAC) in patients after pylorus-preserving gastrectomy (PPG), we investigated relationships between LAC and postgastrectomy disorder (PGD) such as postprandial abdominal fullness (PAF), and between LAC and gastric empting function (GEF) in PPG patients. Background: The main cause of PGD in PPG patients has been considered to be LAC. Relationships between LAC and PGD and GEF in PPG patients are still unknown. Methods: Of 50 patients who underwent PPG in our hospital from January 2001 to December 2015 were divided into 2 groups [Group A, short LAC of 1.5 to 2.5 cm (n = 24); Group B, long LAC of 2.6 to 3.5 cm (n = 26)]. The relationships among LAC, PGD, and GEF were retrospectively studied. Results: LAC was clearly shorter in group A than group B (P < 0.01). PAF, appetite and food consumption per meal were clearly more favorable in group B than in group A (P < 0.01, respectively). Symptomatic reflux esophagitis (RE), early dumping syndrome, decreased percent body weight for pre - illness, endoscopic RE and endoscopic gastritis in the remnant stomach were more frequent in group A than group B. Gastric stasis in the remnant stomach was clearly more frequent in group A than group B (P < 0.01). GEF with the solid diet in group A was clearly more delayed than in group B (P < 0.01). Conclusions: Patients with a short LAC showed worse postoperative QOL and delayed GEF with the solid diet compared with a long LAC.
In clinicopathological analyses, PPG are associated with clearly lower incidences of early dumping syndrome (EDS), gastritis in the remnant stomach and reflux esophagitis (RE) as well as a significant decrease in postoperative malnutrition due to loss of appetite and postoperative body weight loss [
Generally well-known GEF tests are the radioisotope method where gastric emptying of a semisolid diet or solid diet is examined, and the acetaminophen method where gastric emptying of a liquid diet is examined [
Aim of the study
We studied the correlations between LAC and PGD including PAF and GSRS, and between LAC and GEF of the residual stomach in patients who underwent PPG for early gastric cancer.
From January 2001 to December 2015, 50 patients with early gastric cancer without lymph node metastasis in the lower and/or middle stomach visited our hospital. Fifty patients (30 men and 20 women aged 33 to 79 years with a mean age of 66.7 years) with early gastric M (mucosa) or SM1 (submucosa 1; macroscopically, 1/2 or less submucosal invasion of cancer) cancer of N0 (no lymph node metastasis) underwent PPG with preservation of the pyloric, hepatic and celiac branches of the vagal nerve (PHCV) (M cancer, D1 lymph node dissection; SM1 cancer, D1 + α lymph node dissection in radical curability) [
Follow up periods were from 1.5 to 5 years after PPG. This study was performed to each patient at 1.5 years after PPG.
Symptomes of PAF, appetite, food consumption per meal compared with at normal status, symptoms of RE (e.g., heartburn, feeling of regurgitation, difficulty swallowing), EDS, and percent body weight compared with before illness were inquired of all subjects 1.5 years after operations.
Patients with or without RE, gastritis in the remnant stomach (GRS), and GSRS were also examined by esophagogastric endoscopy.
GEF for solid diet (radioisotope method) and GEF for liquid diet (acetaminophen method) were performed in all patients. In GEF for solid diet (radioisotope method), after 99mTc tin colloid was added to the diet (200 g of rice gruel with a raw egg) and mixed well, the total quantity was ingested by subjects within 5 minutes in a sitting position. Measurement was performed with a scintillation camera (Hitachi HARP I, Tokyo, Japan). Scanning (imaging) was performed from the abdominal (front) side in a supine position for one minute. The scanning time was from 0 (immediately after the completion of ingestion) to 120 minutes. The data were put into a computer to count radioactivity in the region of interest (ROI) of the stomach. After adjusting for the half-life of 99mTc, the time for the residual rate (%) of the radioactivity in the stomach on completing ingestion (time 0) to reach 50% of the residual rate after ingestion was calculated, considering the residual rate at time 0 as 100. Residual rates (%) at 120 min in the remnant stomach were also calculated.
After 1 g of acetaminophen (Yamanouchi, Tokyo, Japan) was dissolved in 250 ml of orange juice and mixed well, the orange juice was promptly drunk by subjects in a sitting position. Subjects adopted the same supine position as for the radioisotope method for blood collection. This was considered as time 0, and blood collection was performed at 45 minutes. The blood concentration of acetaminophen was determined with a whole blood concentration determination system (TDX; Abbott, Abbott Park, IL, USA) based on the principle of the immunofluorescence polarization assay.
Subjects discontinued any drugs that might affect gastrointestinal movement from one week before the examination, and did not take any food and drink from the evening (9:00 p.m.) before the examination. The examination was performed from 9:00 a.m. on the following day. GEF with the solid diet was followed by the determination for the liquid diet with an interval of one week.
Informed consent was obtained from all individuals participating in the present study. The present study was approved by the Ethical Committee of Nihon University School of Medicine (Tokyo, Japan).
Early M or SM1 cancers at the lower and/or middle third of the stomach were selected, where N0 was confirmed by ultrasonic endoscopy, computed tomography and magnetic resonance imaging in preoperative examinations. Furthermore, all cases in this study were unsuited for endoscopic mucosa resection or partial excision of the stomach. Cases in which the remnant stomach would be 1/3 or more were also included (in the present study, the remnant stomach in both groups were 1/3). According to our data, in M cancer the distance from the anal-side margin of the tumor to the pyloric sphincter was 2.5 cm or more and that in SM1was 3.5 cm or more, and the resected margin was free from cancer cells, microscopically. In this surgical technique, the pyloric antrum (i.e., length of the pyloric cuff; LPC) 1.5 to 3.5 cm from the pyloric sphincter was preserved. Regarding lymph node dissection [according to Japanese general rules for Gastric Cancer Study in Surgery and Pathology (the Japanese Classification of Gastric carcinoma), D1 lymph node (numbers 1, 3, 4sb, 4d, 5, 6 and 7) was excised in M cancer while preserving PHCV [
Statistical analyses were conducted using the non-parametric Kruskal-Wallis test with Bonferroni correction (StatView version 5.0 for Macintosh; Abacus Concepts Inc., Berkeley, CA.). Results are expressed as the mean ± standard deviation (SD). For statistical analysis of the interviews, the chi-squared test was used. For statistical analysis of the percent body weight of the pre-illness weight, the Student’s t-test was used. A P value less than 0.05 was regarded as significant.
There were no significant differences in patients’ characteristics between groups A and B except for LAC. LAC in group A was 2.0 ± 0.4 cm (1.5 to 2.5 cm) and that in group B 3.0 ± 0.3 cm (2.6 to 3.5 cm). In addition, LAC was clearly shorter in group A than group B (P < 0.01;
Factors | Group A (n = 24) | Group B (n = 26) | P value |
---|---|---|---|
Male/Female | 16/8 | 18/8 | ns |
Age (years) | 66.8 (40 - 79) | 64.2 (33 - 78) | ns |
Depth of cancer invasion | |||
Mucosa | 79.2% (19/24) | 76.9% (20/26) | ns |
Submucosa | 21.8% (5/24 | 23.1% (6/10) | |
Lymph node metastasis | |||
No | 100% (24/24) | 100% (26/26) | |
Pathological stage | |||
Stage IA | 100% (24/24) | 100% (26/26) | |
Lymphnode resection | |||
D1 | 79.2% (19/24) | 80.8% (21/26) | ns |
D1 + α | 20.8% (5/24) | 19.2% (5/26) | |
PHCV preservation | |||
Preservation | 100% (24/24) | 100% (26/26) | |
No preservation | 0% (0/24) | 0% (0/26) | |
Resected stomach | |||
1/3 | 100% (12/12) | 100% (10/10) | |
Length of antral cuff (cm) | |||
2.0 ± 0.4 3.0 ± 0.3 < 0.01 | |||
Past history | |||
No | 100% (24/24) | 100% (26/26) | |
Postoperative complications | |||
Wound infection | 4.2% (1/24) | 7.7% (2/26) | ns |
Postoperative chemotherapy | |||
No | 100% (24/24 | 100% (26/26) |
Group A: PPG patients with a short length of the antral cuff (LAC); Group B: PPG patents with a long length of LAC; PPG: Pylorus-preserving gastrectomy; PHCV: Pyloric, hepatic and celiac branches of vagal nerve; Age: Data are mean (range); ns: not significant.
PAF was observed at a rate of 100% (24/24) in group A and 7.7% (2/26) in group B. In addition, PAF was clearly more frequent in group A compared with that in group B (P < 0.01). The remaining cases in group B had no PAF (
Group A (n = 24) | Group B (n = 26) | P value | |
---|---|---|---|
Postprandial abdominal fullness 100% (24/24) | 7.7% (2/26) | <0.01 | |
Appetite | |||
No change vs. normal status | 54.2% (13/24) | 92.3% (24/26) | <0.01 |
Decreased vs. normal status | 45.8% (11/24) | 7.7% (2/26) | |
Food consumption per meal compared with at normal status | |||
2/3 or more | 50.0% (12/24) | 92.3% (24/26) | <0.01 |
less than 2/3 | 50.0% (12/24) | 7.7% (2/26) | |
Symptomatic reflux esophagitis | |||
Negative | 79.2% (19/24) | 88.5% (23/26) | <0.01 |
Positive | 20.8% (5/24) | 11.5% (3/26) | |
Early dumping syndrome (systemic symptoms) | |||
Negative | 91.7% (22/24) | 96.2% (25/26) | <0.01 |
Positive | 8.3% (2/24) | 3.8% (1/26) | |
Percent body weight for pre-illness weight (%) | |||
91.2 ± 5.8 | 92.8 ± 4.2 | ns |
Group A: PPG patients with a short length of the antral cuff (LAC); Group B: PPG patients with a long LAC; PPG: Pylorus-preserving gastrectomy; ns: not significant.
group B. There was no significant difference between the groups (ns). Body weight decreased in all patients, but the decrease in the percent body weight compared to pre-illness was greater in group A than in group B (
PAF, appetite and food consumption per meal were clearly more favorable in group B than group A. Symptomatic RE, EDS and decreased percent body weight compared with pre-illness were more frequent in group A than in group B.
Patients with or without RE, gastritis in the remnant stomach (GRS), and GSRS were examined by esophagogastric endoscopy. Endoscopic RE (Los Angeles classification Grade A) was noted in 16.7% (2/12) of group A and 3.8% (1/26) of group B. It was less frequent in group B compared with group A (ns). The remaining cases in both groups had no endoscopic RE (
Endoscopic RE and GRS were more frequently detected in group A than in group B. GSRS was clearly more prevalent in group A than in group B.
The time to 50% residual rates were 77.4 ± 8.2 minutes in group A and 61.8 ± 6.9 minutes in group B. The rate in group A was clearly delayed compared with that in group B (P < 0.01;
Group A (n = 24) | Group B (n = 26) | P value | |
---|---|---|---|
Reflux esophagitis | |||
Negative | 83.3% (20/24) | 96.2% (25/26) | ns |
Positive | 16.7% (4/24) | 3.8% (1/26) | |
Gastritis | |||
Negative | 66.7% (16/24) | 84.6% (22/26) | ns |
Positive | 33.3% (8/24) | 15.4% (4/26) | |
Gastric stasis in the remnant stomach | |||
Negative | 58.3% (14/24) | 76.2% (20/26) | <0.01 |
Positive | 41.7% (10/24) | 23.1% (6/26) |
Group A: PPG patients with a short length of the antral cuff (LAC); Group B: PPG patients with a long LAC; PPG: Pylorus-preserving gastrectomy; ns: not significant.
Parameters | Group A (n = 24) | Group B (n = 26) | P value | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Time to 50% residual rate in the remnant stomach (minutes) | ||||||||||
77.4 ± 8.2 | 61.8 ± 6.9 | <0.01 | ||||||||
The residual rates at 120 minutes in the remnant stomach (%) | ||||||||||
49.8 ± 8.6 | 37.6 ± 6.2 | <0.01 | ||||||||
Blood concentration of acetoaminophen at 45 minutes (μg/ml) | ||||||||||
46.2 ± 5.7 | 45.5 ± 4.8 | ns | ||||||||
Group A: PPG patients with a short length of the antral cuff (LAC); Group B: PPG patients with a long LAC; PPG: Pylorus-preserving gastrectomy; ns: not significant.
The blood concentration of acetoaminophen at 45-minute was 46.2 ± 5.7 μg/ml in group A and 45.5 ± 4.8 μg/ml in group B. There were no significant differences in the blood concentration of acetoaminophen at 45-minutes in between groups A and B (
According to these results, GEF with the solid food was clearly delayed in group A compared with group B. However, there was no difference in the liquid empting time in between groups.
Even for early gastric cancer located in the middle and/or lower stomach, the distal part of the stomach including the pylorus has conventionally been resected with D2 lymph node dissection without preserving PHCV (i.e., conventional distal gastrectomy) [
It is considered that PGD, especially PAF with GSRS, after PPG is due to damage to PHCV and infrapyloric vesscels (artery and vein) as a result of skeletonization of the subpyloric region with the subpyloric lymph node dissection [
Preserving the pyloric sphincter prevents EDS due to the rapid emptying of food and prevents RE, alkaline GRS due to reflux of duodenal juice into the remnant stomach and esophagus [
Antropyloroduodenal coordination is very important to transport gastric contents to the duodenum [
The postoperative pathophysiology of the GEF of a solid diet in patients after PPG has been assessed in detail. Generally, 99mTc tin colloid or 99mTc-DTPA is used for the solid diet as a nuclide [
This was a retrospective study. A randomized control trial comparing the postoperative states after PPG with a short LAC and with a long LAC should be performed in the future. Moreover, the mechanism of antropyloroduodenal coordination and/or motility in humans is complicated and its control probably involves the functioning of the neural systems including central, peripheral, and entric nervous systems [
PAF, appetite and food consumption per meal were clearly more favorable in PPG patients with a long LAC [3.0 ± 0.3 cm (2.6 to 3.5 cm)] than a short LAC [2.0 ± 0.4 cm (1.5 to 2.5 cm)]. Symptomatic RE, EDS, decreased percent body weight compared with pre-illness, endoscopic RE and GRS were more frequent in PPG patients with a short LAC than in those with a long LAC. GSRS was clearly more prevalent in PPG patients with a short LAC than in those with a long LAC. GEF with solid food was clearly delayed in PPG patients with a short LAC compared with a long LAC. However, there was no difference in the liquid empting time between PPG patients with a short LAC and those with a long LAC. Patients with a short LAC showed a poor postoperative QOL and delayed gastric emptying of a solid food compared to those with a long LAC.
The authors have read the manuscript and have approved this submission. And there are no no conflicts of interest in association with this study.
Ryouichi Tomita have operated these cases and analyzed all data. Shigeru Fujisaki and Kenichi Sakurai did assistant of the operation.
Tomita, R., Sakurai, K. and Fujisaki, S. (2017) Relationships between Length of the Antral Cuff and Postgastrectomy Disorders and Gastric Empting Function in Patients after Pylorus-Preserving Gastrectomy for Early Gastric Cancer. Journal of Cancer Therapy, 8, 867-879. https://doi.org/10.4236/jct.2017.810076