Abstract
Both basic and clinical studies were undertaken to determine the indications for pylorus preserving gastrectomy for patients with early gastric cancer located in the middle third of the stomach. This procedure is different from conventional subtotal gastrectomy in that it retains a 1.5 cm length of the pyloric cuff and it neglects to dissect the suprapyloric lymph node, with the remaining pyloric branch of the vagal nerve being preserved. Therefore, it is essential that this limited operation be performed only in cases without metastasis to the suprapyloric lymph node. The distance from the caudal end of the tumor to the cut edge is far enough when the tumor is in the middle third of the stomach. The direction of lymph flow, as determined in 14 cases by activated carbon particles (CH-40), suggests that there is limited lymph flow towards the suprapyloric lymph node from the middle third of the stomach. Lymph node involvement was investigated in 154 patients with early gastric cancer located in the middle third of the stomach who had undergone conventional subtotal gastrectomy with regional lymph node dissection between 1976 and 1989. By analysis of the relationship between lymph node metastasis and the clinicopathologic findings revealed before operation, i.e. gross appearance, histological classification, and tumor size, the indications for pylorus preserving gastrectomy were determined as follows: (1) any case with tumors smaller than 2.0 cm in maximum length, and (2) cases with a tumor of 2.0 to 4.0 cm if it is a mucosal cancer, if it is located at the greater curvature, or if it is an elevated type IIa cancer. This operation has been performed on 11 patients to date without postoperative complaints or sequelae.
Résumé
La gastrectomie avec conservation du pylore a été réalisée chez certains patients ayant un cancer superficel du tiers moyen de l'estomac (early gastic cancer). L'indication a été posée sur des données cliniques et biologiques. Cette technique diffère de celle de la gastrectomie subtotale classique car elle conserve 1.5 cm du canal pylorique. On ne réalise pas volontairement la dissection des ganglions sus-pyloriques et on préserve la branche pylorique du nerf vague. Il est donc essentiel que cette opération limitée soit réalisée chez un patient indemne de métastase au niveau de la chaîne suspylorique, ce qui est en principe le cas lorsqu'il s'agit d'un cancer superficiel du tiers moyen de l'estomac. En effet, la direction du courant lymphatique, déterminee par des investigations isotopiques utilisant des particules de carbone marqué dans 14 cas (CH-40), suggère qu'il est peu probable que cette chaîne soit envahie dans ce cas. L'état des ganglions lymphatiques a été évalué chez 154 patients ayant eu une gastrectomie subtotale avec curage lymphatique classique pour cancer superficiel du tiers moyen de l'estomac entre 1976 et 1989. En analysant les relations entre les métastases lymphatiques et les données clinicopathologiques préopératories (aspect macroscopique, la classification histologique et la taille de la tumeur), les indications de la gastrectomie avec conservation du pylore sont: 1) tumeur gastrique dont la taille est inférieure à 2 cm dans son plus grand diamètre, 2) tumeur d'une taille de 2 à 4 cm si elle siège uniquement dnas la muqueuse, ou si la tumeur est localisée sur la grande courbure ou s'il s'agit d'un stade IIa (type surélevé). Cette opération a été réalisée dnas 11 cas sans complication ou séquelle postopératoires.
Resumen
La indicatión para realizar la gastrectomía con preservatión del píloro en pacientes con cáncer gástrico temprano ubicado en el tercio medio del estómago ha sido definida con base en estudios básicos y clínicos. La operatión difiere de la gastrectomía subtotal en que se retiene un manguito pilórico de 1.5 cm de longitud, y en que no se hace la disección del ganglio linfático suprapilórico, el cual, con la rama pilórica remanente del nervio vago, permanecen intactos. La distancia entre el borde distal del tumor y la línea de sección es suficiente cuando la lesión está ubicada en el tercio medio del estómago. La dirección del flujo linfático, determinada mediante partículas activades de carbono (CH-40) en 14 casos, sugiere que existe un flujo linfático limitado hacia el ganglio suprapilórico a partir del tercio medio del estómago. Se investigó la invasión ganglionar en 154 pacientes con cáncer gástrico temprano ubicado en el terico medio del estómago que habían sido sometidos a gastrectomía subtotal convencional con disección ganglionar regional entre 1976 y 1989, Mediante el análisis de la relatión entre las metástasis ganglionares y los hallazgos clinicopatológicos antes de la operación, i.e. apariencia macroscópica, clasificación histológica y tamaño del tumor, se determinó la indicatión para gastrectomía con preservatión del píloro en la siguente forma: 1) cualiquier caso con tumores menores de 2.0 cm de longitud máxima; 2) tumores de 2.0 a 4.0 cm si se trataba de cáncer mucosa; 3) tumor ubicado sobre la curvatura mayor; 4) un cáncer elevado tipo II a. Esta operación ha sido realizada en 11 pacientes, hasta la fecha, sin complicaciones o secuelas postoperatorias.
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Kodama, M., Koyama, K. Indications for pylorus preserving gastrectomy for early gastric cancer located in the middle third of the stomach. World J. Surg. 15, 628–633 (1991). https://doi.org/10.1007/BF01789211
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DOI: https://doi.org/10.1007/BF01789211