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Lee S, Son WJ, Roh YH, Song JH, Park SH, Cho M, Kim YM, Hyung WJ, Kim HI. Indication of Proximal Gastrectomy for Advanced Proximal Gastric Cancer Based on Lymph Node Metastasis at the Distal Part of the Stomach. ANNALS OF SURGERY OPEN 2021; 2:e107. [PMID: 37637877 PMCID: PMC10455053 DOI: 10.1097/as9.0000000000000107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022] Open
Abstract
Objective To suggest the possible indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach. Background Proximal gastrectomy has been an alternative surgical procedure for early proximal gastric cancer due to its benefits for quality of life while maintaining oncological outcomes. However, the oncological safety of proximal gastrectomy for advanced tumors remains unclear. Methods We retrospectively reviewed data from 878 patients who underwent radical total gastrectomy from 2003 to 2018 for pathologic T2-T4 gastric cancer in the upper third of the stomach. We identified risk factors for lymph node metastasis at the distal part of the stomach, which was not dissected in proximal gastrectomy. Subsequently, we evaluated the metastasis rate and therapeutic value index of lymph nodes at the distal part of the stomach in patients with none of these risk factors. Results Multivariable analysis revealed that esophagogastric junction (EGJ)-tumor epicenter distance >30 mm, tumor size >70 mm, macroscopic type IV tumor, and serosal invasion were risk factors for lymph node metastasis at the distal stomach. In patients without risk factors, the therapeutic value index for any lymph nodes at the distal stomach was 0.8, suggesting that lymph node dissection could be omitted in these patients. Conclusions EGJ-tumor epicenter distance ≤ 30 mm, tumor size ≤ 70 mm, not a macroscopic type IV tumor, and no serosal invasion could be an indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.
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Affiliation(s)
- Sejin Lee
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Won Jeong Son
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong Ho Song
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Sung Hyun Park
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Minah Cho
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Yoo Min Kim
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Woo Jin Hyung
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyoung-Il Kim
- From the Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Republic of Korea
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Ko HJ, Kim KH, Lee SH, Choi CW, Kim SJ, In Choi C, Kim DH, Kim DH, Hwang SH. Can Proximal Gastrectomy with Double-Tract Reconstruction Replace Total Gastrectomy? A Propensity Score Matching Analysis. J Gastrointest Surg 2020; 24:516-524. [PMID: 30937710 DOI: 10.1007/s11605-019-04195-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND This retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical outcomes. METHODS All consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008-2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality. RESULTS Of 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (p = 0.02), smaller proximal and distal resection margins (p = 0.01, p < 0.01), and fewer retrieved lymph nodes (p < 0.01). PG-DTR associated with shorter times to diet and hospital stay (both p = 0.02). Groups did not differ in early (11.3 vs. 19.2%, p = 0.19), late (1.9 vs. 5.7%, p = 0.31), or severe complication rates (7.7 vs. 13.5%, p = 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (p = 0.02), respectively. CONCLUSION PG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.
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Affiliation(s)
- Hyo Jung Ko
- Department of Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, 50612, Republic of Korea
| | - Ki Hyun Kim
- Department of Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, 50612, Republic of Korea
| | - Si-Hak Lee
- Department of Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, 50612, Republic of Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Chang In Choi
- Department of Surgery, Pusan National University, Pusan, Republic of Korea
| | - Dae-Hwan Kim
- Department of Surgery, Pusan National University, Pusan, Republic of Korea
| | - Dong-Heon Kim
- Department of Surgery, Pusan National University, Pusan, Republic of Korea
| | - Sun-Hwi Hwang
- Department of Surgery and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, 50612, Republic of Korea.
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Proximal Gastrectomy versus Total Gastrectomy for Siewert Type II Adenocarcinoma of the Esophagogastric Junction: A Comprehensive Analysis of Data from the SEER Registry. DISEASE MARKERS 2019; 2019:9637972. [PMID: 31976023 PMCID: PMC6955131 DOI: 10.1155/2019/9637972] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/19/2019] [Indexed: 01/23/2023]
Abstract
Background To determine the ideal surgical approach (total gastrectomy (TG) vs. proximal gastrectomy (PG)) for Siewert type II adenocarcinoma of the esophagogastric junction (AEG), we searched and analyzed the Surveillance, Epidemiology, and End Results (SEER) data. Methods Patients with Siewert type II AEG treated by TG or PG were identified from the 2004–2014 SEER dataset. We obtained the patients' overall survival (OS) and cancer-specific survival (CSS) and stratified the patients by surgical approach. We performed a propensity score 1 : 1 matching (PSM) analysis and a univariate and multivariate Cox proportional hazards model. Results A total of 2,217 patients with 6th AJCC stage IA–IIIB Siewert type II AEG was examined: 1,584 patients (71.4%) underwent PG, and 633 patients (28.6%) underwent TG. The follow-up time was 1–131 months. OS favored total gastrectomy before the PSM analysis (χ2 = 3.952, p = 0.047), but after this analysis, there was no significant difference between TG and PG (χ2 = 2.227, p = 0.136). The univariate and multivariate analyses identified age as an independent factor, and an X-tail analysis revealed 70 years as a cut-off point. The patients aged ≥ 70 years obtained a significant long-term OS benefit from PG compared to TG (χ2 = 8.245, p = 0.004), and those aged < 70 years showed no difference between TG and PG (χ2 = 0.167, p = 0.682). Conclusions PG showed an equivalent survival benefit to TG in both the early and locally advanced stages of Siewert type II AEG. For elderly patients, PG is strongly recommended because of its clearer OS benefit compared to TG.
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Korean Practice Guideline for Gastric Cancer 2018: an Evidence-based, Multi-disciplinary Approach. J Gastric Cancer 2019; 19:1-48. [PMID: 30944757 PMCID: PMC6441770 DOI: 10.5230/jgc.2019.19.e8] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
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Rosa F, Quero G, Fiorillo C, Bissolati M, Cipollari C, Rausei S, Chiari D, Ruspi L, de Manzoni G, Costamagna G, Doglietto GB, Alfieri S. Total vs proximal gastrectomy for adenocarcinoma of the upper third of the stomach: a propensity-score-matched analysis of a multicenter western experience (On behalf of the Italian Research Group for Gastric Cancer-GIRCG). Gastric Cancer 2018; 21:845-852. [PMID: 29423892 DOI: 10.1007/s10120-018-0804-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 01/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study is to compare surgical outcomes including postoperative complications and prognosis between total gastrectomy (TG) and proximal gastrectomy (PG) for proximal gastric cancer (GC). Propensity-score-matching analysis was performed to overcome patient selection bias between the two surgical techniques. METHODS Among 457 patients who were diagnosed with GC between January 1990 and December 2010 from four Italian institutions, 91 underwent PG and 366 underwent TG. Clinicopathologic features, postoperative complications, and survivals were reviewed and compared between these two groups retrospectively. RESULTS After propensity-score matching had been done, 150 patients (75 TG patients, 75 PG patients) were included in the analysis. The PG group had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the TG group. N stages and 5-year survival rates were similar after TG and PG. Postoperative complication rates after PG and TG were 25.3 and 28%, respectively, (P = 0.084). Rates of reflux esophagitis and anastomotic stricture were 12 and 6.6% after PG and 2.6 and 1.3% after TG, respectively (P < 0.001 and P = 0.002). 5-year overall survival for PG and TG group was 56.7 and 46.5%, respectively (P = 0.07). Survival rates according to the tumor stage were not different between the groups. Multivariate analysis showed that type of resection was not an independent prognostic factor. CONCLUSION Although PG for upper third GC showed good results in terms of survival, it is associated with an increased mortality rate and a higher risk of reflux esophagitis and anastomotic stricture.
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Affiliation(s)
- Fausto Rosa
- Department of Digestive Surgery, "A. Gemelli" Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Giuseppe Quero
- Department of Digestive Surgery, "A. Gemelli" Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Claudio Fiorillo
- Department of Digestive Surgery, "A. Gemelli" Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy
| | | | | | - Stefano Rausei
- Department of Surgical Sciences, University of Insubria (Varese-Como), Varese, Italy
| | - Damiano Chiari
- Department of Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Ruspi
- Department of Surgical Sciences, University of Insubria (Varese-Como), Varese, Italy
| | | | - Guido Costamagna
- Department of Digestive Endoscopy, "A. Gemelli" Hospital, Catholic University of Rome, Rome, Italy
| | - Giovanni Battista Doglietto
- Department of Digestive Surgery, "A. Gemelli" Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Sergio Alfieri
- Department of Digestive Surgery, "A. Gemelli" Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy
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Park DJ, Park YS, Ahn SH, Kim HH. [Laparoscopic Proximal Gastrectomy as a Surgical Treatment for Upper Third Early Gastric Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 70:134-140. [PMID: 28934829 DOI: 10.4166/kjg.2017.70.3.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Recently, the incidence of upper third gastric cancer has increased, and with it the number of endoscopic submucosal dissection (ESD) procedures performed has been increasing. However, if ESD is not indicated or non-curable, surgical treatment may be necessary. In the case of lower third gastric cancer, it is possible to preserve the upper part of the stomach; however, in the case of upper third gastric cancer, total gastrectomy is still the standard treatment option, regardless of the stage. This is due to the complications associated with upper third gastric cancer, such as gastroesophageal reflux after proximal gastrectomy rather than oncologic problems. Recently, the introduction of the double tract reconstruction method after proximal gastrectomy has become one of the surgical treatment methods for upper third early gastric cancer. However, since there has not been a prospective comparative study evaluating its efficacy, the ongoing multicenter prospective randomized controlled trial (KLASS-05) comparing laparoscopic proximal gastrectomy with double tract reconstruction and laparoscopic total gastrectomy is expected to be important for determining the future of treatment of upper third early gastric cancer.
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Affiliation(s)
- Do Joong Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung Ho Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Laparoscopic proximal gastrectomy for early gastric cancer. Surg Today 2016; 47:538-547. [PMID: 27549773 DOI: 10.1007/s00595-016-1401-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/24/2016] [Indexed: 12/14/2022]
Abstract
The incidence of proximal early gastric cancer (EGC) is increasing, and while laparoscopic proximal gastrectomy (LPG) has been performed as a surgical option, it is not yet the standard treatment, because there is no established common reconstruction method following proximal gastrectomy (PG). We reviewed the English-language literature to clarify the current status and problems associated with LPG in treating proximal EGC. This procedure is considered indicated for EGC located in the upper third of the stomach with clinical T1N0, but not when it can be treated endoscopically. No operative mortality or conversion to open surgery was reported in our review, suggesting that this procedure is technically feasible. The most frequent postoperative complication involved problems with anastomoses, possibly caused by the technical complexity of the reconstruction. Although various reconstruction methods following open PG (OPG) and LPG have been reported, there is no standard reconstruction method. Well-designed multicenter, randomized, controlled, prospective trials to evaluate the various reconstruction methods are necessary.
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Sugoor P, Shah S, Dusane R, Desouza A, Goel M, Shrikhande SV. Proximal gastrectomy versus total gastrectomy for proximal third gastric cancer: total gastrectomy is not always necessary. Langenbecks Arch Surg 2016; 401:687-97. [PMID: 27143021 DOI: 10.1007/s00423-016-1422-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 03/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The appropriate extent of gastric resection for patients with proximal third gastric cancer is controversial. This study addresses whether the choice of surgical strategy (proximal gastrectomy [PG] versus total gastrectomy [TG]) influences the outcomes for proximal third gastric adenocarcinoma. MATERIALS AND METHODS Review of prospective database at Tata Memorial Hospital from January 2010 to December 2012 identified 343 patients diagnosed and treated for gastric cancer. Of these, 75 underwent curative resections with D2 lymphadenectomy for proximal third gastric adenocarcinoma, which entailed proximal gastrectomy in 43 and total gastrectomy in 32 patients, depending on the epicenter of the primary and its relation with the mid-body of the stomach. Morbidity, lymph node yield, resection margins, patterns of recurrence, and survival were compared between these two groups. RESULTS 41/75 tumors were pT3 (23 cases [53.4 %] in the PG and 18 cases [56.3 %] in the TG group). Thirty-six patients [83.7 %] in PG and 29 patients [90.6 %] in TG group received neoadjuvant chemotherapy (NACT). There were no significant differences with regard to median blood loss, general complication rates and length of hospitalization between the two groups. The lymph node yield was comparable between the two procedures [PG = 14; TG = 15]. Positive proximal resection margin rates were comparable between the two groups [PG = 4.7 %; TG = 9.4 %], and there was no statistical difference observed in the distal resection margin positivity rates [PG = 4.7 %; TG = 3.1 %]. Regarding the patterns of recurrence, local recurrence in PG was 4.7 % and there was no local recurrence in the TG group (p = 0.08). Distant recurrence rates was dominant in TG [PG = 30.2 % versus TG = 53.1 %]. The overall 2-year survival following PG and TG was 73.8 and 49.9 %, respectively, and not statistically different (p = 0.10). CONCLUSIONS The extent of resection for proximal third gastric cancer does not influence the clinical outcome. PG and TG have similar survival rates. Both procedures can be accomplished safely. Therefore, PG should be an alternative to TG, even in locally advanced proximal gastric cancers treated by NACT, provided that the tumor size and location permit preservation of adequate remnant of stomach without compromising oncological resection margins. Future QOL studies would further lend credence to the concept of PG for proximal third gastric cancer.
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Affiliation(s)
- Pavan Sugoor
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Sanket Shah
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Rohit Dusane
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Ashwin Desouza
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Mahesh Goel
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
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Surgical techniques to prevent reflux esophagitis in proximal gastrectomy reconstructed by esophagogastrostomy with preservation of the lower esophageal sphincter, pyloric and celiac branches of the vagal nerve, and reconstruction of the new His angle for early proximal gastric cancer. Surg Today 2015; 46:827-34. [PMID: 26671623 DOI: 10.1007/s00595-015-1269-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 08/19/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE This article describes the surgical techniques to prevent reflux esophagitis (RE) after proximal gastrectomy reconstructed by esophagogastrostomy (PGE) preservation of the lower esophageal sphincter (LES) and both pyloric and celiac branches of the vagal nerve (PCVN), and reconstruction of the new His angle (HA) for early proximal gastric cancer (PGC). METHODS Twenty patients after PGE were divided into 2 groups (group A: 10 patients without preserved LES and PCVN for advanced PGC; group B: 10 patients with preserved LES and PCNV and the addition of a new HA for early PGC). A postoperative interview on gastroesophageal reflux disease (GERD) and satisfaction with this procedure and the collection of endoscopic findings for RE and stasis of the remnant stomach (SRS) were conducted 1 year after PGE in groups A and B. RESULTS The rates of proton pump inhibitor administration and the symptoms of GERD, RE and SRS in group A were significantly higher than those in group B (p = 0.0433, p = 0.0190, p = 0.0253, p = 0.0190, respectively). Seven out of 10 patients in group A voiced dissatisfaction. Patients in group B were significantly more satisfied with this procedure than those in group A (p = 0.0010). CONCLUSION This method is useful for preventing postoperative GERD including RE in early PGC patients.
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Jung DH, Ahn SH, Park DJ, Kim HH. Proximal Gastrectomy for Gastric Cancer. J Gastric Cancer 2015; 15:77-86. [PMID: 26161281 PMCID: PMC4496445 DOI: 10.5230/jgc.2015.15.2.77] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 12/19/2022] Open
Abstract
Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.
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Affiliation(s)
- Do Hyun Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Son MW, Kim YJ, Jeong GA, Cho GS, Lee MS. Long-Term Outcomes of Proximal Gastrectomy versus Total Gastrectomy for Upper-Third Gastric Cancer. J Gastric Cancer 2014; 14:246-51. [PMID: 25580356 PMCID: PMC4286903 DOI: 10.5230/jgc.2014.14.4.246] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/10/2014] [Accepted: 10/28/2014] [Indexed: 12/27/2022] Open
Abstract
PURPOSE There are two surgical procedures for proximal early gastric cancer (EGC): total gastrectomy (TG) and proximal gastrectomy (PG). This study aimed to compare the long-term outcomes of PG with those of TG. MATERIALS AND METHODS Between January 2001 and December 2008, 170 patients were diagnosed with proximal EGC at Soonchunhyang University Cheonan Hospital, of which 64 patients underwent PG and 106 underwent TG. Clinicopathologic features, postoperative complications, blood chemistry data, changes in body weight, and oncological outcomes were analyzed and retrospectively compared between both groups. RESULTS Tumor size was smaller and the number of retrieved lymph nodes was lower in the PG group. The postoperative complication rate was 10.9% in the TG group and 16.9% in the PG group. The incidence of Los Angeles grade C and D reflux esophagitis was significantly higher in the TG group. Hemoglobin level was higher and body weight loss was greater in the TG group at 2, 3, and 5 years postoperatively. The albumin levels at 3 and 5 years were lower in the TG group. There was no significant difference in the 5-year overall survival rates between the two groups (P=0.789). CONCLUSIONS Postoperative complications and oncologic outcomes were observed to be similar between the two groups. The PG group showed better laboratory data and weight loss than did the TG group. Moreover, severe reflux esophagitis occurred less frequently in the PG group than in the TG group. PG can be considered as an effective surgical treatment for proximal EGC.
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Affiliation(s)
- Myoung Won Son
- Department of Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Korea
| | - Yong Jin Kim
- Department of Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Gui Ae Jeong
- Department of Surgery, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Gyu Seok Cho
- Department of Surgery, Soonchunhyang University Hospital Bucheon, Bucheon, Korea
| | - Moon Soo Lee
- Department of Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Korea
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Isobe T, Hashimoto K, Kizaki J, Matono S, Murakami N, Kinugasa T, Aoyagi K, Akagi Y. Reconstruction methods and complications in proximal gastrectomy for gastric cancer, and a comparison with total gastrectomy. Kurume Med J 2014; 61:23-29. [PMID: 25152248 DOI: 10.2739/kurumemedj.ms64003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Proximal gastrectomy (PG) is a widely accepted, efficient treatment for upper-third early gastric cancer. However, it is associated with reduced quality of life (QOL) following surgery, and cancer recurrence in the remaining stomach. Various reconstruction methods have been proposed, but the optimal method has yet to be determined. We investigated the clinicopathological characteristics, reconstruction methods, and postoperative complications in 101 cases of PG, and additionally compared 93 cases of early gastric cancer treated by PG, and 38 cases treated by total gastrectomy (TG). We found that esophagogastrostomy was superior in terms of operation time, intraoperative blood loss, and postoperative hospital stay, while no significant differences were observed in postoperative complications compared with jejunal interposition or jejunal pouch interposition. We found more cases of multiple gastric cancers and advanced-stage cancer in the TG group than in the PG group. The TG group also had a significantly higher proportion of cases with large tumor diameters, low degrees of differentiation, many lymph node metastases, and advanced-stage disease. There were no differences in the recurrence rate or survival rate between the PG and TG groups. The PG group also showed significantly better results in operating time, intraoperative blood loss, and postoperative complications, with a tendency toward shorter hospital stays. In conclusion, PG is a curative but less invasive treatment for upper-third early gastric cancer, and esophagogastrostomy can be considered the most satisfactory reconstruction method following PG.
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Affiliation(s)
- Taro Isobe
- Department of Surgery, Kurume University School of Medicine
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Esophagogastrostomy plus gastrojejunostomy: a novel reconstruction procedure after curative resection for proximal gastric cancer. J Gastrointest Surg 2014; 18:497-504. [PMID: 24163139 DOI: 10.1007/s11605-013-2391-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 10/07/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The choice of surgical strategy for patients with proximal gastric cancer remains controversial. In this study, we recommend that a new reconstruction procedure be performed following proximal gastrectomy. METHODS We conducted a retrospective study involving 71 patients who underwent gastrectomy for proximal gastric cancer. Clinicopathological features, postoperative complications, nutritional status, and overall survival (OS) rate were compared among three different reconstruction approaches. RESULTS There were 34 cases of proximal gastrectomy followed by esophagogastrostomy reconstruction (EG), 16 cases of total gastrectomy and Roux-en Y reconstruction (RY) and 21 cases of proximal gastrectomy followed by esophagogastrostomy plus gastrojejunostomy reconstruction (EGJ). Though the clinicopathological features, the nutritional status and OS rate were similar among the three groups of patients, the incidence of reflux esophagitis was significantly higher in the EG group (35.3%) than the RY (6.2%) and EGJ (9.6%) groups(P < 0.05). Few EGJ patients suffered from either reflux esophagitis or anastomotic stenosis. CONCLUSIONS The EGJ reconstruction method helps to resolve the syndrome of reflux esophagitis. Our data indicates that it is a simple, safe, and effective reconstruction procedure for PGC.
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Gunji S, Ueda S, Yoshida M, Kanai M, Terajima H, Takabayashi A. Effects of rikkunshito, a kampo medicine, on quality of life after proximal gastrectomy. J Surg Res 2013; 185:575-80. [DOI: 10.1016/j.jss.2013.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/18/2013] [Accepted: 06/05/2013] [Indexed: 12/13/2022]
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Laparoscopy-assisted proximal gastrectomy for early gastric cancer is an ugly duckling with unsolved concerns: oncological safety, late complications, and functional benefit. Gastric Cancer 2013; 16:448-50. [PMID: 23483303 DOI: 10.1007/s10120-013-0245-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 02/05/2013] [Indexed: 02/07/2023]
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16
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Nozaki I, Hato S, Kurita A. A new technique for resecting gastric remnant cancer after proximal gastrectomy with jejunal interposition. Surg Today 2012; 42:1135-8. [PMID: 22688565 DOI: 10.1007/s00595-012-0212-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 10/16/2011] [Indexed: 12/11/2022]
Abstract
Surgery for gastric remnant cancer after distal gastrectomy is well established; however, little is known about the removal of remnant gastric cancer following proximal gastrectomy with jejunal interposition. We introduce a surgical technique for removing remnant cancer under these circumstances. We used this technique to remove a total gastric remnant with radical lymph node dissection, while preserving the interposed jejunum for easy re-reconstruction by Roux-en-Y anastomosis, in five patients. The median operating time was 199 min and the median blood loss was 330 ml. There were no postoperative deaths or major complications and all five patients were discharged within 14 days after surgery. Our technique for total resection of the gastric remnant after proximal gastrectomy and re-reconstruction with preserved interposed jejunum is easy, safe, and effective.
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Affiliation(s)
- Isao Nozaki
- Department of Surgery, Division of Gastroenterology, National Hospital Organization Shikoku Cancer Center, 160 Minami-umemoto, Matsuyama, 791-0280, Japan.
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Kim JW, Yoon H, Kong SH, Kim JS, Paeng JC, Lee HJ, Lee KU, Yang HK. Analysis of esophageal reflux after proximal gastrectomy measured by wireless ambulatory 24-hr esophageal pH monitoring and TC-99m diisopropyliminodiacetic acid (DISIDA) scan. J Surg Oncol 2010; 101:626-33. [PMID: 20461772 DOI: 10.1002/jso.21560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Reflux is one of the most common sequela after proximal gastrectomy (PG). The aim of this study was to find a predicting factor related to the character of esophageal reflux after PG. METHODS Wireless ambulatory 24-hr pH monitoring (for acid reflux, AR) and diisopropyliminodiacetic acid hepatobiliary scan (for bile reflux, BR) were performed on 24 patients who had reflux symptoms after PG with esophagogastrostomy from July 2008 to March 2009. Endoscopic examination was done and the length of remnant stomach (LoRS) was measure by postoperative UGI series. RESULTS Eleven patients (45.8%) had only BR, 7 (29.2%) had AR only, Two patients (8.3%) had both acid and BR, and 3 (12.5%) had neither. The LoRS along greater curvature was significantly shorter in patients with only BR (16.11 +/- 2.87 cm) than in patients with only AR (23.69 +/- 6.15 cm, P = 0.003). Severity of symptoms or esophagitis was not significantly correlated with the content of acid or BR. CONCLUSION Reflux symptom after PG is caused by either bile or acid rather than both. Character of reflux was related to the LoRS.
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Affiliation(s)
- Jong Won Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Abstract
BACKGROUND The operative methods for proximal gastric cancer differ depending on the institution, thus there is no optimal therapeutic strategy. A splenic hilum lymph node (No. 10) dissection is necessary for D2 operation for proximal gastric cancer, which means it requires splenectomy. However, unnecessary splenectomy should be avoided. METHODS A total of 127 proximal gastric cancer cases from our institution were studied retrospectively. In addition, 1,569 cases were collected from the literature and were used as pooled data for further analysis. All cases were examined for the depth of tumor invasion and lymph node metastasis. RESULTS A retrospective analysis revealed that proximal gastric cancer within submucosa (40 cases) had no N2 lymph node metastasis in our study. The 5-year overall survival of all cases was 25.2% and the disease-free survival was 23.6%. From the pooled data analysis, No. 10 lymph node metastasis was observed in 0.9% of the patients with submucosa proximal gastric cancer. Furthermore, there was no No. 4d lymph node metastasis when the depth of cancer was limited to within the subserosa. CONCLUSIONS Although a randomized, controlled trial concerning survival is necessary, according to this study, there is a possibility that limited resection might be accepted for proximal gastric cancer according to the depth of wall invasion.
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Zhang H, Sun Z, Xu HM, Shan JX, Wang SB, Chen JQ. Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction. World J Gastroenterol 2009; 15:3183-90. [PMID: 19575501 PMCID: PMC2705744 DOI: 10.3748/wjg.15.3183] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare postoperative quality of life (QOL) in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy.
METHODS: QOL assessments that included functional outcomes (a 24-item survey about treatment-specific symptoms) and health perception (Spitzer QOL Index) were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy.
RESULTS: Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty (EA group); 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis (EP group); and 50 patients had reconstruction by esophagogastric end-to-end anastomosis (EE group). The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups.
CONCLUSION: Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.
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Kim JH, Park SS, Kim J, Boo YJ, Kim SJ, Mok YJ, Kim CS. Surgical outcomes for gastric cancer in the upper third of the stomach. World J Surg 2006; 30:1870-6; discussion 1877-8. [PMID: 16957826 DOI: 10.1007/s00268-005-0703-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The proportion of gastric cancers affecting the upper third of the stomach has been increasing. At our surgical service we perform total and proximal gastrectomy for this condition. The purpose of this study was to investigate the surgical outcome of the two operative procedures and determine an optimal surgical approach. METHODS Data from 147 patients who underwent resection for gastric cancer affecting the proximal one-third of the stomach were retrospectively analyzed. The patients were classified into a total gastrectomy (TG) group or a proximal gastrectomy (PG) group, and the clinicopathologic characteristics and surgical results were compared. We analyzed survival rates using Kaplan-Meier methods and made comparisons using a log-rank test across the same stage of the gastric cancer. RESULTS From 1992 to 2000, a total of 104 total gastrectomies and 43 proximal gastrectomies for gastric cancer affecting the upper one-third of the stomach were performed. Our investigation revealed significantly different clinicopathologic characteristics in Borrmann type, length of the resection margin, degree of lymph node dissection, and lymph node stage. During the procedure, a combined resection of other organs was performed in 30 TG and 27 PG patients. Postoperative complications developed in 15 TG and 22 PG patients. The cancer recurrence rate was 4.8% for the TG group and 39.5% for the PG group; it was highest when the length of the proximal resection margin was < 1 cm. When we compared 5-year survival rates between the two groups, each at the same cancer stage, a significant difference was noted for stage III and IV gastric cancers. CONCLUSIONS Proximal gastrectomy may be performed during the early stage of proximal gastric cancer; but because of the high frequency of complications and cancer recurrence, an additional procedure should be expected afterward. When the cancer stage is advanced, total gastrectomy should be performed with sufficient length of the proximal resection margin.
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Affiliation(s)
- Jong Han Kim
- Department of Surgery, Korea University College of Medicine, 126-1, 5-ga, Anam-dong, Sung buk-gu, 136-705, Seoul, Korea
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21
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Current Controversy in the Treatment of Proximal Gastric Cancer. World J Surg 2006. [DOI: 10.1007/s00268-006-0340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Yoo CH, Sohn BH, Han WK, Pae WK. Proximal gastrectomy reconstructed by jejunal pouch interposition for upper third gastric cancer: prospective randomized study. World J Surg 2006; 29:1592-9. [PMID: 16311849 DOI: 10.1007/s00268-005-7793-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal gastrectomy with jejunal pouch interposition (PGJP) has been advocated as an alternative operation for upper third gastric cancer. However, there has been no prospective randomized trial comparing PGJP with total gastrectomy with Roux-en-Y esophagojejunostomy (TGRY). The aim of this study was to compare the short- and medium-term results of PGJP and TGRY in a randomized clinical trial. Fifty-one patients with upper third gastric cancer were randomized to either PGJP (n = 25) or TGRY (n = 26). Outcome measures were postoperative complications, nutritional status assessed by serum nutritional parameters, and postgastrectomy symptoms. There were no significant differences in operating time, hospital stay, and postoperative complications. Blood loss was significantly less in the PGJP group (P = 0.036). Nineteen patients (73%) in the TGRY group had one or more postgastrectomy symptoms, which was significantly more frequent than in the PGJP group (32%; P = 0.012). There were also significant differences between the two groups with regard to food intake, weight recovery, hemoglobin, and serum vitamin B12 levels in favor of PGJP. In conclusion, proximal gastrectomy with jejunal pouch interposition for upper third gastric cancer is safe, and is associated with a greater reduction in postgastrectomy symptoms and better nutritional status compared with conventional total gastrectomy.
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Affiliation(s)
- Chang Hak Yoo
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-dong, Jongro-ku, Seoul, 110-746, Korea.
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Yoo CH, Sohn BH, Han WK, Pae WK. Long-term results of proximal and total gastrectomy for adenocarcinoma of the upper third of the stomach. Cancer Res Treat 2004; 36:50-5. [PMID: 20396565 PMCID: PMC2855111 DOI: 10.4143/crt.2004.36.1.50] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Accepted: 12/24/2003] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The choice of surgical strategy for patients with adenocarcinoma of the upper one third of the stomach is controversial. This study was performed to analyze the surgical results of a 11-year experience with these lesions. MATERIALS AND METHODS From January 1990 to December 2000, 259 patients with upper third gastric cancer underwent proximal gastrectomy (n=74) or total gastrectomy (n=185) through an abdominal approach. Morbidity, mortality, recurrence patterns, and survival were compared between these two groups retrospectively. RESULTS There were no significant differences in general complication and mortality rates between the two groups. However, the incidences of reflux esophagitis (16.2%) and anastomotic stricture (35.1%) were more common in the proximal gastrectomy group compared with the total gastrectomy group (0.5 and 8.1%). Regarding the main patterns of recurrence, local recurrence was dominant in the proximal gastrectomy group, whereas distant recurrence was dominant in the total gastrectomy group. Five-year overall survival (54.8 versus 47.8%) and survival according to tumor stage were no different between the groups. Multivariate analysis showed that the extent of resection was not an independent prognostic factor. CONCLUSION The extent of resection for upper third gastric cancer did not appear to affect long-term outcome. However, proximal gastrectomy is associated with an increased risk of reflux esophagitis, anastomotic stricture, and local recurrence.
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Affiliation(s)
- Chang Hak Yoo
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Korea.
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Abstract
Abstract
Professor Keizo Sugimachi, Editor-in-Chief of Surgery Today (The Japanese Journal of Surgery), has selected from the October to December 1997 issues of his journal for this quarter's digest. A digest of BJS for the same period written by Mr Colin Johnson, European Editor, appears in the Japanese journal.
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Kakisako K, Tamura Y, Katsuta T, Kai T, Tanimura H, Kaketani K, Adachi Y, Kitano S. Endoscopic evaluation of reconstruction after proximal gastrectomy for cancer: Gastric tube versus jejunal interposition. Dig Endosc 2002. [DOI: 10.1046/j.1443-1661.2001.00142.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
| | | | | | | | | | | | - Yosuke Adachi
- Department of Surgery I, Oita Medical University, Oita, Japan
| | - Seigo Kitano
- Department of Surgery I, Oita Medical University, Oita, Japan
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