0
Original Article |

Pancreas-Preserving Total Gastrectomy for Gastric Cancer FREE

Giovanni Battista Doglietto, MD; Fabio Pacelli, MD; Paola Caprino, MD; Maurizio Bossola, MD; Carmine Di Stasi, MD
[+] Author Affiliations

From the Departments of Digestive Surgery (Drs Doglietto, Pacelli, Caprino, and Bossola) and Radiology (Dr Stasi), Catholic University, Rome, Italy.


Arch Surg. 2000;135(1):89-92. doi:10.1001/archsurg.135.1.89.
Text Size: A A A
Published online

Background  Pancreas-preserving total gastrectomy for gastric cancer has been proposed to remove lymph nodes along the upper border of the pancreas without performing a distal pancreatic resection. However, the original technique includes the ligation of the splenic artery at its origin and thus carries the risk of pancreatic necrosis.

Hypothesis  A technique of pancreas-preserving total gastrectomy that includes ligation of the splenic artery approximately 5 cm distally from the root may reduce the risk of postoperative pancreatic necrosis.

Design  Case series.

Setting  Both primary and referral hospital care.

Patients  Hospital records of 228 consecutive patients who, according to a personal technique, underwent D3 pancreas-preserving total gastrectomy for gastric cancer from 1981 to 1997 were reviewed.

Main Outcome Measures  Surgical complications, postoperative deaths, and survival.

Results  Hospital morbidity and mortality were 33.3% and 3.9%, respectively. No patients experienced pancreatic necrosis. The 5-year survival rate after curative resection was 53.6%: 96.9% for stage IA, 76.3% for stage IB, 63.0% for stage II, 35.6% for stage IIIA, 27.0% for stage IIIB, and 20.3% for stage IV (N3-positive patients) disease.

Conclusion  Results of the present study show the efficacy of this method of radical resection for gastric cancer as demostrated by the low incidence of postoperative complications and high survival rates.

Figures in this Article

PANCREAS-PRESERVING total gastrectomy for gastric cancer has been proposed to remove lymph nodes along the upper border of the pancreas without performing a distal pancreatic resection.1 The surgical technique includes the ligation of the splenic artery at its origin, which is effective in achieving a complete D2 nodal dissection and in reducing the incidence of complications related to pancreatic resection, but carries the risk of pancreatic necrosis.1

We have developed a technique of pancreas-preserving total gastrectomy for gastric cancer2 that reduces the risk of pancreatic necrosis.

The aim of the present study is to report early and long-term results of our technique of pancreas-preserving total gastrectomy for gastric cancer.

Between 1981 and 1997, 279 patients underwent total gastrectomy at our department for the primary surgical treatment of gastric adenocarcinoma.

This population accounts for 37.6% (279 of 742) of all patients with primary gastric cancer observed in our unit during the same period.

Patients undergoing pancreatic resection for macroscopic infiltration of the gland after both radical (n = 11) and palliative (n = 7) surgery and those undergoing simple D1 palliative gastrectomy (n = 33) were excluded from the analysis. The remaining 228 patients underwent D3 pancreas-preserving total gastrectomy and constitute the population of the present study.

The surgical procedure involves dissection of the entire greater omentum, the superior leaf of the mesocolon, and the serosa of the pancreatic surface; node dissection is then performed in the infraduodenal and supraduodenal areas, along the retropancreatic region (node region 13 according to the Japanese Research Society Committee on Histological Classification of Gastric Cancer [JRSGC]3), the hepatic pedicle (node region 12), the mesenteric root (node region 14), and along the common hepatic (node region 8), and celiac (node region 9) arteries. The left gastric artery (node region 7) is ligated at its origin, and node dissection (node region 11) is extended along the proximal third of the splenic artery, which is ligated distally approximately 5 cm from its origin. The spleen and the distal pancreas are then mobilized and retracted. The tail of the pancreas is carefully exposed, and the splenic vein and caudal pancreatic arteries are ligated and divided. Finally, the upper border of the pancreas is exposed, and the spleen (node region 10) and the middle and distal third of the splenic artery with the surrounding fatty connective tissue and nodes (node region 11) are removed en bloc with the stomach, gastric omentum, and perigastric nodes (node regions 1-6). The pancreatic parenchyma and splenic vein are preserved (Figure 1). The intestinal continuity was restored by a Roux-en-Y esophagojejunostomy in all cases.

Place holder to copy figure label and caption
Figure 1.

Reported technique of pancreas-preserving total gastrectomy. The splenic artery is ligated approximately 5 cm distal from its origin to preserve the blood supply to the left pancreas through the dorsal pancreatic artery. Proximal splenic nodes are removed together with the splenic artery, the surrounding fatty tissue, and the spleen. The pancreatic parenchyma and the splenic vein are preserved. LN indicates lymph nodes.

Graphic Jump Location

Demographic data, tumor location and gross appearance, histological type according to the Lauren classification,4 regional extent of nodal involvement according to the JRSGC, and hospital morbidity and mortality were recorded. The staging of the disease was performed according to the TNM classification.

Comparison of the rate of occurrence of events was performed using the Fisher exact test. Survival was calculated on the basis of the actuarial life-table method.5

Patients' status was determined by follow-up examination or telephone contact. A total of 160 patients (70.1%) were followed up for at least 5 years after hospital discharge.

Patients' characteristics are shown in Table 1. Overall, the incidence of postoperative complications and postoperative mortality after pancreas-preserving total gastrectomy (Table 2) was lower than that observed among patients who underwent total gastrectomy associated with pancreatic resection: 76/228 (33.3%) vs 11/18 (61.1%) (P = .02) and 9/228 (3.9%) vs 4/18 (22.2%) (P = .01).

Table Graphic Jump LocationTable 1. Characteristics of 228 Patients Undergoing Pancreas-Preserving Total Gastrectomy
Table Graphic Jump LocationTable 2. Postoperative Complications in Patients Undergoing Pancreas-Preserving Total Gastrectomy

No patients developed postoperative pancreatic necrosis after pancreas-preserving total gastrectomy, and only 2 patients (0.9%) experienced pancreatic fistula. By contrast, the incidence of pancreatic fistula was higher after total gastrectomy associated with pancreatic resection: 2/18 (11.1%; P = .02), as was the incidence of esophagojejunostomy leak 5/18 (27.8%) vs 22/228 (9.6%) (P = .03).

The mean ± SD number of dissected nodes per operative specimen was 43.4 ± 22.3; the incidence of nodal metastasis was 60.9% (139/228): 37.7% (86/228) for N1, 16.2% (38/228) for N2, and 6.6% (15/228) for N3 involvement. Table 3 shows the mean number of dissected nodes and the percentage of metastatic involvement to individual node stations.

Table Graphic Jump LocationTable 3. Number of Dissected Nodes and Metastatic Involvement to Individual Node Stations in Patients Undergoing Pancreas-Preserving Total Gastrectomy

Five-year survival rate after curative resection (228 patients) was 53.6%: 96.9% for stage IA, 76.3% for stage IB, 63.0% for stage II, 35.6% for stage IIIA, 27.0% for stage IIIB, and 20.3% for stage IV (N3-positive patients) disease (Figure 2).

Place holder to copy figure label and caption
Figure 2.

Survival curves of 228 patients undergoing curative pancreas-preserving total gastrectomy according to cancer stage.

Graphic Jump Location

Despite the unfavorable results of recent studies,7,8 the extended D2 lymphadenectomy is commonly accepted as the treatment of choice of curable gastric cancer not only by Japanese authors, but also by the majority of Western authors.913

According to Japanese nomenclature, a complete D2 dissection for tumor located at the upper and middle third of the stomach necessarily requires the dissection of nodes along the splenic artery (JRSGC node region 11) and at the splenic hilum (JRSGC node region 10). For that reason, many authors have routinely associated the resection of the distal portion of the pancreas with total gastrectomy for the radical treatment of upper and middle curable gastric tumors.14,15 However, complications related to the pancreatic resection were frequently experienced, such as pancreas juice leakage, acute pancreatitis, left subphrenic abscess, and postoperative diabetes.15 Even in recent prospective studies on lymphadenectomy for gastric cancer, pancreatic resection had a significant adverse effect on both morbidity and mortality. The Medical Research Council (MRC) trial8 reported significantly higher postoperative morbidity and mortality rates after pancreas removal: 56% vs 28% (P<.001) and 16% vs 7% (P = .01), respectively. The Dutch Gastric Cancer Trial7 found by univariate and multivariate analyses of postoperative risk factors16 that distal pancreatectomy had the largest relative risk for postoperative complications both in the univariate (5.04) and multivariate (3.34) model. As shown by the present study, the distal pancreatectomy, performed "de necessitate" only in patients with direct infiltration of the gland, also had negative effects on postoperative outcome. Moreover, even in the absence of overt pancreatic fistula, the subclinical leakage of pancreatic juice after pancreatic resection would accumulate in close proximity to the proximal reconstructive anastomosis, thus affecting the healing process. In this context, Japanese authors have lately stressed that extended lymphadenectomy for gastric cancer should, whenever possible, be undertaken without distal pancreatectomy—the pancreas-preserving technique, with ligation of the splenic artery at its origin, has been proposed.1 The original technique, however, carries the risk of pancreatic necrosis; in fact, the dorsal pancreatic artery usually arises from the proximal third of the splenic artery17,18 and joins the posterosuperior pancreaticoduodenal artery (so-called Kirk arcade) after the emergence of the transverse pancreatic artery. In the absence of the Kirk arcade (about 40% of cases), the dorsal pancreatic artery is the sole blood supply to the left pancreas (Figure 3). Thus, ligation of the origin of the splenic artery exposes 2 of 10 patients to the risk of pancreatic necrosis.

Place holder to copy figure label and caption
Figure 3.

Left, Celiac trunk selective angiogram showing the emergence of the dorsal pancreatic artery (arrow) from the proximal third of the splenic artery and the absence of the Kirk arcade. Right, Splenic artery selective catheterization in the same patient showing the dorsal pancreatic artery (arrow) with its terminal branches and confirming the absence of the Kirk arcade. The ligation of the origin of the splenic artery would expose this patient to the risk of pancreatic necrosis.

Graphic Jump Location

For that reason, we preserve the proximal third of the splenic artery in all cases of pancreas-preserving total gastrectomy by ligating the splenic artery approximately 5 cm distally from the root to preserve the blood supply to the left pancreas through the dorsal pancreatic artery. Proximal splenic nodes are removed en bloc with those of the left gastric artery, and distal splenic nodes are removed together with the splenic artery, the surrounding fatty tissue, and the spleen. The pancreatic parenchyma and the splenic vein are preserved.

Results of the present study show the efficacy of this method of radical resection for curable gastric cancer as demonstrated by the low incidence of postoperative complications and high survival rates.

Reprints: Fabio Pacelli, MD, Istituto di Clinica Chirurgica, Universitá Cattolica del Sacro Cuore, Largo A. Gemelli n. 8, 00168 Roma, Italy (e-mail: fpacelli@hotmail.com).

Maruyama  KSasako  MKinishita  T  et al.  Pancreas-preserving total gastrectomy for proximal gastric cancer. World J Surg. 1995;19532- 536
Pacelli  FAlfieri  SDoglietto  GB  et al.  Avoiding pancreatic necrosis following pancreas preserving D3 lymphadenectomy for gastric cancer. Br J Surg. 1998;85125- 126
Japanese Research Society Committee on Histological Classification of Gastric Cancer, The general rules for the gastric cancer study in surgery and pathology, part II: histological classification of gastric cancer. Jpn J Surg. 1981;11140- 145
Lauren  P The two histological main types of gastric carcinoma: diffuse and so-called intestinal type carcinoma. Acta Pathol Microbiol Scand. 1965;6431- 49
Cox  DR Regression models and life-tables. J R Stat Soc B. 1972;34187- 220
Pacelli  FBellantone  RDoglietto  GB  et al.  Risk factors contributing to postoperative morbidity and mortality after total gastrectomy in aged patients. Am Surg. 1991;57341- 345
Bonenkamp  JJHermans  JSasako  M  et al.  Extended lymph-node dissection for gastric cancer. N Engl J Med. 1999;340908- 914
Cuschieri  AFayers  PFielding  J  et al.  Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. Lancet. 1996;347995- 999
Pacelli  FDoglietto  GBBellantone  R  et al.  Extensive versus limited lymph node dissection for gastric cancer: a comparative study of 320 patients. Br J Surg. 1993;801153- 1156
Siewert  JRBöttcher  KStein  HJ  et al.  Relevant prognostic factors in gastric cancer. Ann Surg. 1998;228449- 461
Smith  JWShiu  MHKelsey  L  et al.  Morbidity of radical lymphadenectomy in the curative resection of gastric carcinoma. Arch Surg. 1991;1261469- 1473
Brennan  MF Lymph-node dissection for gastric cancer [editorial]. N Engl J Med. 1999;340956- 958
Pacelli  FSgadari  ADoglietto  GB Lymph-node dissection for gastric cancer [letter]. N Engl J Med. 1999;341538
Noguchi  YImada  T Radical surgery for gastric cancer: a review of the Japanese experience. Cancer. 1989;642053- 2062
Lundell  LGrip  IOlbe  L Pancreatic resection additional to gastrectomy for gastric cancer: effect on postoperative morbility. Acta Chir Scand. 1986;152145- 149
Sasako  M Risk factors for surgical treatment in the Dutch Gastric Cancer Trial. Br J Surg. 1997;841567- 1571
Mellierè  MMDMoullè  P Variations des arteres hepatiques et du carrefour pancreatique. Classification et frequence. Depistage arteriographique et operatoire. Incidences sur la chirurgie du pedicule hepatique, les exereses pancreatiques et les greffes de foie et de pancreas. J Chir. 1968;955- 42
Skandalakis  LJRowe  JS  JrGray  SWSkandalakis  JE Surgical embriology and anatomy of the pancreas. Surg Clin North Am. 1993;73667- 697

Figures

Place holder to copy figure label and caption
Figure 1.

Reported technique of pancreas-preserving total gastrectomy. The splenic artery is ligated approximately 5 cm distal from its origin to preserve the blood supply to the left pancreas through the dorsal pancreatic artery. Proximal splenic nodes are removed together with the splenic artery, the surrounding fatty tissue, and the spleen. The pancreatic parenchyma and the splenic vein are preserved. LN indicates lymph nodes.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Survival curves of 228 patients undergoing curative pancreas-preserving total gastrectomy according to cancer stage.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Left, Celiac trunk selective angiogram showing the emergence of the dorsal pancreatic artery (arrow) from the proximal third of the splenic artery and the absence of the Kirk arcade. Right, Splenic artery selective catheterization in the same patient showing the dorsal pancreatic artery (arrow) with its terminal branches and confirming the absence of the Kirk arcade. The ligation of the origin of the splenic artery would expose this patient to the risk of pancreatic necrosis.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of 228 Patients Undergoing Pancreas-Preserving Total Gastrectomy
Table Graphic Jump LocationTable 2. Postoperative Complications in Patients Undergoing Pancreas-Preserving Total Gastrectomy
Table Graphic Jump LocationTable 3. Number of Dissected Nodes and Metastatic Involvement to Individual Node Stations in Patients Undergoing Pancreas-Preserving Total Gastrectomy

References

Maruyama  KSasako  MKinishita  T  et al.  Pancreas-preserving total gastrectomy for proximal gastric cancer. World J Surg. 1995;19532- 536
Pacelli  FAlfieri  SDoglietto  GB  et al.  Avoiding pancreatic necrosis following pancreas preserving D3 lymphadenectomy for gastric cancer. Br J Surg. 1998;85125- 126
Japanese Research Society Committee on Histological Classification of Gastric Cancer, The general rules for the gastric cancer study in surgery and pathology, part II: histological classification of gastric cancer. Jpn J Surg. 1981;11140- 145
Lauren  P The two histological main types of gastric carcinoma: diffuse and so-called intestinal type carcinoma. Acta Pathol Microbiol Scand. 1965;6431- 49
Cox  DR Regression models and life-tables. J R Stat Soc B. 1972;34187- 220
Pacelli  FBellantone  RDoglietto  GB  et al.  Risk factors contributing to postoperative morbidity and mortality after total gastrectomy in aged patients. Am Surg. 1991;57341- 345
Bonenkamp  JJHermans  JSasako  M  et al.  Extended lymph-node dissection for gastric cancer. N Engl J Med. 1999;340908- 914
Cuschieri  AFayers  PFielding  J  et al.  Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. Lancet. 1996;347995- 999
Pacelli  FDoglietto  GBBellantone  R  et al.  Extensive versus limited lymph node dissection for gastric cancer: a comparative study of 320 patients. Br J Surg. 1993;801153- 1156
Siewert  JRBöttcher  KStein  HJ  et al.  Relevant prognostic factors in gastric cancer. Ann Surg. 1998;228449- 461
Smith  JWShiu  MHKelsey  L  et al.  Morbidity of radical lymphadenectomy in the curative resection of gastric carcinoma. Arch Surg. 1991;1261469- 1473
Brennan  MF Lymph-node dissection for gastric cancer [editorial]. N Engl J Med. 1999;340956- 958
Pacelli  FSgadari  ADoglietto  GB Lymph-node dissection for gastric cancer [letter]. N Engl J Med. 1999;341538
Noguchi  YImada  T Radical surgery for gastric cancer: a review of the Japanese experience. Cancer. 1989;642053- 2062
Lundell  LGrip  IOlbe  L Pancreatic resection additional to gastrectomy for gastric cancer: effect on postoperative morbility. Acta Chir Scand. 1986;152145- 149
Sasako  M Risk factors for surgical treatment in the Dutch Gastric Cancer Trial. Br J Surg. 1997;841567- 1571
Mellierè  MMDMoullè  P Variations des arteres hepatiques et du carrefour pancreatique. Classification et frequence. Depistage arteriographique et operatoire. Incidences sur la chirurgie du pedicule hepatique, les exereses pancreatiques et les greffes de foie et de pancreas. J Chir. 1968;955- 42
Skandalakis  LJRowe  JS  JrGray  SWSkandalakis  JE Surgical embriology and anatomy of the pancreas. Surg Clin North Am. 1993;73667- 697

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 18

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
Osteoclastic giant cell tumor of the pancreas. Int J Surg Case Rep Published online Feb 21, 2014.;
JAMAevidence.com

The Rational Clinical Examination
Case 2