J Yeungnam Med Sci.  2022 Jul;39(3):235-243. 10.12701/yujm.2021.01550.

Preemptive pyloroplasty for iatrogenic vagus nerve injury in intrahepatic cholangiocarcinoma patients undergoing extensive left-sided lymph node dissection: a retrospective observational study

• Hwang S
• Jung DH
• Jwa EK
• Kim Y

• KMID: 2532077
• DOI: http://doi.org/10.12701/yujm.2021.01550

Abstract

Background
Intrahepatic cholangiocarcinoma (ICC) of the left liver often shows left-sided lymph node (LN) metastasis. If gastric lesser curvature is extensively dissected, it can induce an iatrogenic injury to the extragastric vagus nerve branches that control motility of the pyloric sphincter and lead to gastric stasis. To cope with such LN dissection-associated gastric stasis, we performed pyloroplasty preemptively. The objective of this study was to analyze our 20-year experience of preemptive pyloroplasty performed in 10 patients.
Methods
We investigated clinical sequences of 10 patients with ICC who underwent preemptive pyloroplasty following left hepatectomy and extended left-sided LN dissection. Incidence of gastric stasis and oncological survival outcomes were analyzed.
Results
All 10 patients were classified as stage IIIB due to T1-3N1M0 stage according to the 8th edition of American Joint Committee on Cancer staging system. The overall patient survival rate was 51.9% at 1 year, 25.9% at 2 years, and 0% at 3 years. Seven patients showed uneventful postoperative recovery after surgery. Two patients suffered from gastric stasis, which was successfully managed with supportive care. One patient suffered from overt gastric paresis, which was successfully managed with azithromycin administration for 1 month.
Conclusion
We believe that preemptive pyloroplasty is an effective surgical option to prevent gastric stasis in patients undergoing extensive left-sided LN dissection. Azithromycin appears to be a potent prokinetic agent in gastroparesis.

Keyword

Pylorus; Vagus nerve; Gastric emptying; Gastric stasis; Gastric paresis

Figure

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  Fig. 1. Preoperative abdominal computed tomography of patients with left-sided intrahepatic cholangiocarcinoma. (A, B) Regional lymph node metastasis is identified around the lesser curvature of the stomach (arrows) in a 59-year-old male patient and (C, D) a 57-year-old female patient.

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  Fig. 2. The extent of vagus nerve injury according to extensive left-sided lymph node dissection. (A) Intraoperative photograph showing denuding of the serosa (arrow) at the lesser curvature of the stomach. (B) Illustration of the extragastric vagus nerve innervation. The encircled area indicates the extent of vagus nerve injury. Post VT, the posterior vagus nerve trunk; Ant VT, anterior vagus nerve trunk; NL, the nerve of Latarjet; Hb, hepatic branches; Pb, pyloric branches.

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  Fig. 3. Intraoperative procedure for Heineke-Mikulicz pyloroplasty. (A) The lesser curvature of the stomach is extensively dissected. (B) The wall of the distal antrum and the duodenal first portion is longitudinally incised (arrow) with electrocautery. (C) The incised wound is transversely repaired by inner continuous sutures using 4-0 absorbable monofilament. (D) The serosa is closed with 3-0 black silk sutures.

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  Fig. 4. Kaplan-Meier overall patient survival curve. Red cross markers indicate censored cases.

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  Fig. 5. Intraoperative photograph of a 57-year-old patient undergoing left hepatectomy and choledochal cyst excision.

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  Fig. 6. Postoperative simple abdominal X-ray images follow-up. (A, B) Images taken on the postoperative 8th day show marked gaseous distension of the stomach with air-fluid level. (C, D) Images taken on the postoperative 20th day show stagnated gastrograffin within the stomach at (C) 1 hour and (D) 6 hours after oral intake.

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  Fig. 7. Postoperative simple abdominal X-ray follow-up images after azithromycin administration. The images taken at (A, B) hospital discharge and (C, D) 2 weeks later show no significant abnormal finding.

Reference

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