Pylorus-Preserving Gastrectomy for Gastric Cancer: Current Evidence and Future Directions

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for clinically T1N0M0 (cT1N0M0) early gastric cancer (EGC) located in the middle third of the stomach, at least 4 cm proximal from the pylorus. By preserving the peri-pyloric tissues, including the hepatic branch of the vagus nerve and the infrapyloric vessels, PPG maintains physiological pyloric function without compromising oncologic safety. Several randomized controlled trials (RCTs) have demonstrated the functional advantages of PPG. In particular, the Korean multicenter RCT (KLASS-04) reported a lower incidence of gallstone formation, bile reflux, and postoperative nutritional deficiencies. While PPG is technically demanding and associated with concerns regarding delayed gastric emptying (DGE), recent advances in minimally invasive surgery and intraoperative assessment tools, including augmented imaging technology using indocyanine green (ICG), have facilitated its safe implementation. Although PPG is currently indicated for cT1N0M0 EGC, emerging evidence suggests that patients pathologically confirmed as advanced disease postoperatively may still achieve favorable outcomes with standard adjuvant therapy without requiring additional surgery, suggesting potential oncological acceptability of PPG in carefully selected patients with advanced disease. The integration of robotic platforms and navigation-guided visualization with augmented imaging technology may further enhance oncologic safety and technical feasibility. This review aims to outline the current evidence and future directions of PPG, focusing on the feasibility of extending its application beyond its traditional indications.