Yonago Acta medica 2011;54:59–63

Operative Procedure for Laparoscopy-Assisted Vagus
Nerve and Pylorus-Preserving Gastrectomy (LAVNPPG)
for Early Gastric Cancer
Masahide Ikeguchi, Joji Watanabe, Hirohiko Kuroda, Yoji Fukumoto, Tomohiro
Osaki, Hiroaki Saito, Shigeru Tatebe and Toshiro Wakatsuki
Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University
Faculty of Medicine, Yonago 683-8504, Japan

Laparosocpy-assisted pylorus-preserving gastrectomy (LAPPG) is a widely accepted surgical procedure for the treatment of early gastric cancer in the middle third of the stomach.
We have been performing this operation since 2007. Compared with traditional distal
gastrectomy, LAPPG has postoperative nutritional benefits for patients. However, this procedure preserves only the pyloric branch of the vagus nerve and not the celiac branch. We
found that patients retain a large amount of residual food in the gastric remnant, whichinterferes with the detection of secondary cancer on endoscopic follow-up. To improve thepyloric function and postoperative gastrointestinal motility, we changed our procedure
during 2009 to preserve both the pyloric and celiac branches of the vagus nerve, and we
named this new procedure laparoscopy-assisted vagus nerve and pylorus-preserving gastrectomy (LAVNPPG). From 2009 to 2011, 11 patients underwent LAVNPPG at our hospital. Retrospective comparison of the safety of operation, postoperative complications, andcondition of the gastric remnant between LAPPG (n = 13) and LAVNPPG (n = 11) foundthat the occurrence of postprandial stasis and food residue in the gastric remnant tended
to be lower following LAVNPPG, though the differences were not significant. These findings indicate that LAVNPPG may be an operative procedure that could replace LAPPG.
Key words: gastrectomy; gastric cancer; laparoscopy-assisted; pylorus; vagus nerve

Distal gastrectomy is the most common surgicalprocedure for treating gastric cancer. However,this procedure often leads to nutritional disadvantages, such as weight loss, dumping syndrome, andesophageal regurgitation (Katsube et al., 2008).
Pylorus-preserving gastrectomy (PPG) was originally used in gastric ulcer surgery to prevent dumping syndrome and duodenal juice reflux (Maki etal., 1967). Recently, this procedure has been recognized as a treatment options for patients with earlygastric cancer located in the middle third of thestomach (Morita et al., 2008). We have previously
demonstrated that PPG can provide nutritional andimmunological benefits over distal gastrectomy inpatients with early gastric cancer (Ikeguchi et al.,2010a, 2010b).
As early gastric cancer has a low recurrence
rate and a long survival time after surgical treatment, the current focus is on developing functionpreserving and less invasive operations to improve

Abbreviations: LAPPG, laparoscopy-assisted PPG; LAVNPPG, laparoscopy-assisted vagus nerve and PPG; LCS, laparoscopic coagulating shears; PPG, pylorus-preserving gastrectomy59

M. Ikeguchi et al.

postoperative quality of life. Laparoscopy is being
used with the aim of achieving minimally invasive surgery for early gastric cancer. Laparoscopyassisted PPG (LAPPG) is widely accepted for thesurgical treatment of patients diagnosed with earlygastric cancer in the middle third of the stomach(Tanaka et al., 2011). Our data and other previous
studies have demonstrated that PPG patients havea large amount of food residue in the gastric remnant on endoscopy (Imada et al., 1998; Nunobu etal., 2007; Ikeguchi et al., 2010b). This food residue
may interfere with the detection of secondary cancer in the gastric remnant (Nagao et al., 2004).
To retain pyloric function and improved postoperative gastrointestinal motility including motility of the residual stomach, we performed LAPPG
with preservation of both the pyloric and celiac
branches of the vagus nerve. The clinical benefitsof this new operative technique have been previously reported (Tsujii et al., 2003).
In the present study, we introduce the operative procedure for this vagus nerve preserving
LAPPG, named laparoscopy-assisted vagus nerve
and pylorus-preserving gastrectomy (LAVNPPG).
We also retrospectively compare the occurrence ofstasis and the amount of food residue in the gastricremnant between LAPPG and LAVNPPG.

CHA
IPA
RGEA

GDA
Pancreas

Fig. 1. Dissection of station 6 lymph nodes with preservation of the IPA. CHA, common hepatic artery; IPA, infrapyoric artery; GDA, gastroduodenal artery; RGEA, right
gastroepiploic artery.

scopic and histopathological examinations and thedepth of invasion was evaluated by endosonography.
Surgical procedure
A pneumoperitoneum was created by injection ofcarbon dioxide insufflation at 8 to 10 mmHg, andthe laparoscope was inserted through the umbilical port. Four 5 to 12-mm ports were inserted under direct vision: one in each of the left upper, left
lower, right upper and right lower quadrants. The
gastrocolic ligament was divided 4 cm distal tothe epiploic arcade towards the lower pole of thespleen by laparoscopic coagulating shears (LCS).
During dissection of the left gastroepiploic vein
and artery above the pancreatic tail, the station
4Sb lymph nodes were dissected. Station 6 nodes
were then dissected with preservation of the infrapyloric artery. The right gastroepiploic artery wasclipped and dissected from the gastroduodenalartery (Fig. 1).
In order to preserve pyloric function and to retain the blood flow to the remnant antral segment,
the pyloric and hepatic branches of the vagus nerve

Subjects and Methods
Patients
The indications for PPG have previously been described as follows: i) a diagnosis of early gastriccancer, ii) tumor located in the middle third of thestomach, iii) no lymph node metastasis and iv) tumor less than 5.0 cm in diameter (Ikeguchi et al.,2010a). We used LAPPG during 2007 and 2008
and performed the procedure in 13 patients. During 2009, we changed to using LAVNPPG andperformed the new procedure in 11 patients witha preoperative diagnosis of early gastric cancer inthe middle third of the stomach and no lymph nodemetastasis. The diagnosis was established by endo60

Pylorus-preserving gastrectomy

and the right gastric artery were preserved (Fig. 2).
As a result, the station 5 and 12 lymph nodes were
not dissected in this procedure. A 3-cm length ofantral segment of the distal stomach was preserved.
The common hepatic artery was exposed towards
the root of the left gastric artery. The lymph nodes
at stations 7, 8a, 9 and 11p were dissected. During
this procedure, the celiac branch of the posterior
vagal trunk was identified near the left gastric artery (Fig. 3). The celiac branch was taped and separated from the left gastric artery, and the left gastricartery was clipped and cut by LCS. The cardiac
lymph nodes (station 1) and the lymph nodes along
the lesser curvature of the stomach (station 3) were
removed. The celiac branch of the vagus nerve wasleft intact by this procedure (Fig. 4).
The proximal stomach was divided approximately 3 cm distal to the primary tumor. End-toend anastomosis was performed using the Gambee
suture technique.

Anterior
vagal trunk
Hepatic branchofvagus nerve

Fig. 2. The hepatic branch of the vagus nerve is preserved.

Clinicopathological findings
The histopathological findings, stage classification,
depth of tumor invasion, lymph node grouping,and curability of gastric resection were reported
according to the Japanese Classification of Gastric
Carcinoma (1998).
Fig. 3. The celiac branch of the posterior vagal trunk is
identified.

Endoscopic evaluation
Gastrointestinal endoscopy was performed at 6
or 12 months after gastrectomy for these patients.
The Los Angeles Classification was used to diagnose and describe erosive esophagitis (Lundell etal., 1999). The degree of residual gastritis and theamount of food residue in the gastric remnant wereclassified according to a previous report (Kubo etal., 2002).
Statistical analysis
Chi-squared and Fisher’s exact probability tests
were used to compare the distribution of individual
variables between the patient groups. Differencesin the data between the two groups were evaluatedFig. 4. The celiac branch of the posterior vagal trunk istaped, and separated from the left gastric artery. Station 1
lymph nodes are then dissected.

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M. Ikeguchi et al.

Table 1. Clinical differences between LAPPG and LAVNPPG

Number of patients			
Male/female			
Mean age(yr)Mean operation time(min)
Mean intraoperative blood loss(mL)
Mean postoperative hospital stay(d)
Stasis (yes)(%)
Endoscopic evaluation
Esophagitis (yes)(%)
Food residue in the gastric remnant (yes) (%)

LAPPG
2007–2008

LAVNPPG
2009–2011

13
7/6
65.3
330
124
15
5 (38.6%)

11
4/7
60.4
367
62
14
1 (9.1%)

0.392
0.368
0.118
0.304
0.836
0.1

1 (7.7%)9 (69.2%)

1 (9.1%)6 (54.5%)

0.227
0.459

P

LAPPG, laparoscopy-assisted pylorus-preserving gastrectomy; LAVNPPG, laparoscopy-assisted vagus nerve
and pylorus-preserving gastrectomy.

case 14 months after LAPPG. Food residue in thegastric remnant was observed more frequently in
the LAPPG group (69.2%) than in the LAVNPPG
group (54.5%), however this difference was not
significant.

using the Mann-Whitney U test. P < 0.05 was regarded as statistically significant.

Results
During 2007 and 2008, we undertook LAPPG inpatients with early gastric cancer located in the
middle third of the stomach. We introduced thisLAVNPPG for these in early 2009. The safety ofsurgery, postoperative complications, and amountof food residue in the gastric remnant were compared between the LAPPG and LAVNPPG groups(Table 1). There were no differences in operation
time, intraoperative blood loss, or postoperative
hospital stay between the groups. Postoperativecomplications, such as anastomotic leakage or intraabdominal abscess, were not detected in eithergroup. Food intake disturbances, such as stasis ora sense of abdominal fullness were more frequentin the LAPPG group than the LAVNPPG group,
but these differences were not significant.
We investigated the postoperative conditionof the esophagus and the gastric remnant in all
24 cases by endoscopy. Mild esophagitis was detected in 1 of 11 patients in the LAVNPPG group(9.1%). Sever reflux esophagitis was found in 1
of 13 (7.7%) patients in the LAPPG group, and a
Roux-en-Y reconstruction was performed in thisDiscussion
The nutritional benefits of PPG compared withconventional distal gastrectomy have been widely
recognized. However, some PPG patients occasionally experience a sensation of gastric fullness after
food intake, and some have long-term retention offood in the gastric remnant. In PPG, the pyloric
branch of the vagus nerve is preserved to retain
pyloric function. However, our data and other previous studies have demonstrated that these patients
have a large amount of residual food in the gastricremnant on endoscopy (Ikeguchi et al., 2010b). In a
scintigraphic demonstration, gastric emptying wasdelayed following PPG compared to distal gastrectomy, even with preservation of the pyloric branchof the vagus nerve (Nishikawa et al., 2002). This
indicates that preservation of the pyloric branch of
the vagus nerve may not be sufficient to maintainnormal pyloric function. Food residue may interfere with the detection of secondary cancer in thegastric remnant on endoscopic follow-up after PPG.

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Pylorus-preserving gastrectomy

According to Tsujii et al. (2003), preservationof the celiac branch of the vagus nerve at gastrectomy improved postoperative gastrointestinal
motility, including motility of the gastric remnant.
However, the functional benefit of preservation of
the celiac branch of the vagus nerve in PPG has notbeen clearly demonstrated. In our present study,
we demonstrated that operation time, intraoperative blood loss, and the incidence of postoperativecomplications were almost the same in LAVNPPGand LAPPG. These findings may indicate thatLAVNPPG is a safe procedure. Although thesample size of our study is small, the safety and thequality of operation may be based on progression oftechnique of surgeons. Our study was a retrospective study, in which the occurrence of postprandialstasis and food residue in the gastric remnant werelower with LAVNPPG compared with LAPPG.
In the present study, we introduce the operative procedure for LAVNPPG for early gastriccancer. Further studies will be required to conclude
that the LAVNPPG procedure may be of use forresolving the limitation of LAPPG.

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Received September 16, 2011; accepted October 5, 2011
Corresponding author: Masahide Ikeguchi, MD

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