A new technique for the resection of gastric cancer: modified Appleby procedure with reconstruction of hepatic artery.

The Appleby operation allows resection of gastric cancer with lymph nodes around the stomach and celiac axis en bloc. Hepatic arterial blood flow after resection of the celiac axis is supplied by the superior mesenteric artery. In some patients, however, hepatic arterial flow becomes decreased after resection of the celiac axis. This abrupt reduction of hepatic arterial blood flow sometimes causes postoperative complications such as severe liver dysfunction or gallbladder necrosis. To prevent the reduction of hepatic arterial blood flow and to perform the Appleby operation more safely, we modified the Appleby operation to include reconstruction of the hepatic artery. We found that after dissection of lymph nodes around the hepatoduodenal ligament, the proper hepatic artery and gastroduodenal artery can be well mobilized and it becomes possible to anastomose the celiac axis to the common hepatic artery directly without using anticoagulants. From May, 1989 to November, 1990, 15 patients with advanced gastric cancer underwent the modified Appleby procedure at Kinan General Hospital. Postoperatively, serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were determined for evaluation of liver function. These levels were almost the same as those found after traditional total gastrectomy without resection of the celiac axis. Indocyanine green (ICG) clearance tests were performed before and 1 month after operation. There was no significant difference between the preoperative and postoperative values. Common hepatic arterial flow after celiacohepatic anastomosis was 390 ml/min on average. The modified Appleby procedure can be done quite safely.