Similar hematologic and nutritional outcomes after proximal gastrectomy with double-tract reconstruction in comparison to total gastrectomy for early upper gastric cancer

Comparing the antireflux effect of laparoscopic proximal gastrectomy with double-flap technique reconstruction versus laparoscopic total gastrectomy with Roux-en-Y reconstruction for proximal early gastric cancer: study protocol for a multicentre, prospective, open-label, randomised controlled trial

INTRODUCTION

Laparoscopic proximal gastrectomy with double flap technique (LPG-DFT) reconstruction has been used for proximal early gastric cancer in recent years. However, its feasibility and safety remain uncertain, as only a few retrospective studies have contained postoperative complications and long-term survival data. LPG-DFT for proximal early gastric cancer is still in the early stages of research. Large-scale, prospective randomised controlled trials (RCTs) are necessary to assess the value of LPG-DFT for proximal early gastric cancer.

METHODS AND ANALYSIS

This study is a multicentre, prospective, open-label, RCT that investigates the antireflux effect of LPG-DFT compared with laparoscopic total gastrectomy with Roux-en-Y (LTG-RY) reconstruction for proximal early gastric cancer. A total of 216 eligible patients will be randomly assigned to the LPG-DFT group or the LTG-RY group at a 1:1 ratio using a central, dynamic and stratified block randomisation method, if inclusion criteria are met. General and clinical data will be collected when the patient is enrolled in the study and keep pace with the patient at each stage of his medical and follow-up pathway. The primary endpoint is the proportion of patients with reflux esophagitis (Los Angeles Grade B or more) within 12 months postoperatively. The secondary endpoints included intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, postoperative quality of life, postoperative nutrition status, morbidity and mortality rate, and oncological outcomes (3-year overall survival (OS), 3-year disease-free survival (DFS), 5-year DFS and 5-year OS).

ETHICS AND DISSEMINATION

The protocol is approved by the Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University ethics committee (registration number: SYSKY-2022-276-02) on 28 September 2022.We will report the positive as well as negative findings in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05890339.

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Food passage following proximal gastrectomy with double-tract reconstruction and its effect on nutritional status in early gastric cancer: a prospective single-center cohort study

Purpose

Laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DTR) expectedly results in improved nutritional status and less body weight loss than conventional total gastrectomy in upper-third gastric cancer. This study aimed to investigate the food passage patterns following LPG-DTR and its effect on nutritional outcomes up to 1 year after surgery.

Methods

This prospective cohort study recruited 10 patients with early gastric cancer scheduled for LPG-DTR. Nutritional indices and body composition were assessed every 3 months up to 12 months. Liquid and solid food transits were evaluated with fluoroscopic upper gastrointestinal study and radionuclide scintigraphy, respectively.

Results

At 12 months, patients exhibited a body weight loss of 14.5% ± 3.6%. The main passage routes for liquid and solid foods differed, primarily via the interposed jejunum for liquids, whereas via both tracts for solids. The median half-life of solid food emptying from the remnant distal stomach was 105.1 minutes (range, 50.8-2,194.2 minutes), and duodenal passage of solid food was noted in 9 of 10 patients. Those with gastric half-emptying time >3 hours demonstrated greater weight loss (19.5% ± 1.4% vs. 12.5% ± 1.1%, P = 0.024) and more pronounced reduction in serum albumin levels (-0.5 ± 0.3 g/dL vs. 0.0 ± 0.2 g/dL, P = 0.024) after 12 months.

Conclusion

LPG-DTR demonstrated varying food passage patterns depending on the food contents and delayed solid food emptying from the remnant stomach was associated with more substantial weight loss.

Double tract reconstruction improves the quality of life and better maintain the BMI of patients with proximal gastric cancer

PURPOSE

The aim of this study is to investigate the effect of double-tract reconstruction on short-term clinical outcome, quality of life and nutritional status of patients after proximal gastrectomy by comparing with esophagogastrostomy and total gastrectomy with Roux-en-Y reconstruction.

METHODS

The clinical data of patients who underwent double tract reconstruction (DTR), esophagogastrostomy (EG), total gastrectomy with Roux-en-Y reconstruction (TG-RY) were retrospectively collected from May 2020 to May 2022. The clinical characteristics, short-term surgical outcomes, postoperative quality of life and nutritional status were compared among the three groups.

RESULTS

Compared with the DTR group, the operation time in the TG group was significantly shorter (200(180,240) minutes vs. 230(210,255) minutes, p < 0.01), and more lymph nodes were removed (28(22, 25) vs. 22(19.31), p < 0.01), there were no significant differences in intraoperative blood loss, first flatus time, postoperative hospital stay and postoperative complication rate among the three groups. Postoperative digestive tract angiography was completed in 36 patients in the DTR group, of which 21 (58.3%) showed double-tract type of food passing. The incidence of postoperative reflux symptoms was 9.2% in the DTR group, 43.8% in the EG group and 23.2% in the TG group, repectively (P < 0.01). EORTCQLQ-STO22 questionnaire survey showed that compared with EG group, DTR group had fewer reflux symptoms (P < 0.05), fewer anxiety symptoms (P < 0.05) and more swallowing symptoms (P < 0.05). Compared with TG group, DTR group had fewer reflux symptoms (P < 0.05). There were no other significant differences between the two groups. Compared with TG group and EG group, DTR can better maintain postoperative BMI, and there is no statistical difference between the three groups in terms of hemoglobin and albumin.

CONCLUSIONS

Although partial double-tract reconstruction approach does not always ensure food to enter the distal jejunum along the two pathways as expected, it still shows satisfactory anti-reflux effect. Moreover, it might improve patients' quality of life and maintain better nutritional status comparing with gastroesophageal anastomosis and total gastrectomy with Roux-en-Y reconstruction.

Long-Term Outcome of Proximal Gastrectomy for Upper-Third Advanced Gastric and Siewert Type II Esophagogastric Junction Cancer Compared With Total Gastrectomy: A Propensity Score-Matched Analysis

BACKGROUND

This study aimed to investigate the oncologic long-term safety of proximal gastrectomy for upper-third advanced gastric cancer (AGC) and Siewert type II esophagogastric junction (EGJ) cancer.

METHODS

The study enrolled patients who underwent proximal gastrectomy (PG) or total gastrectomy (TG) with standard lymph node (LN) dissection for pathologically proven upper-third AGC and EGJ cancers between January 2007 and December 2018. Propensity score-matching with a 1:1 ratio was performed to reduce the influence of confounding variables such as age, sex, tumor size, T stage, N stage, and tumor-node-metastasis (TNM) stage. Kaplan-Meier survival analysis was performed to analyze oncologic outcome. The prognostic factors of recurrence-free survival (RFS) were analyzed using the Cox proportional hazard analysis.

RESULTS

Of the 713 enrolled patients in this study, 60 received PG and 653 received TG. Propensity score-matching yielded 60 patients for each group. The overall survival rates were 61.7 % in the PG group and 68.3 % in the TG group (p = 0.676). The RFS was 86.7 % in the PG group and 83.3 % in the TG group (p = 0.634). The PG group showed eight recurrences (1 anastomosis site, 1 paraaortic LN, 1 liver, 1 spleen, 1 lung, 1 splenic hilar LN, and 2 remnant stomachs). In the multivariate analysis, the operation method was not identified as a prognostic factor of tumor recurrence.

CONCLUSION

The patients who underwent PG had a long-term oncologic outcome similar to that for the patients who underwent TG for upper-third AGC and EGJ cancer.

Study of Short-Term and Long-Term Outcomes Between Esophagogastrostomy and Double-Tract Reconstruction After Proximal Gastrectomy

BACKGROUND

As the opportunities for proximal gastrectomy (PG) for early gastric cancer in the upper third stomach have been increasing, the safety and feasibility of PG have been a great concern in recent years. This study aimed to compare the short-term and long-term outcomes between patients who underwent esophagogastrostomy (EG) and those who underwent double-tract reconstruction (DTR) after PG.

METHODS

We retrospectively reviewed the medical records of 34 patients who underwent EG and 39 who underwent DTR at our hospital between 2011 and 2022. We compared the procedure data and postoperative complications including anastomotic complications within 1 year after surgery as short-term outcomes and the rates of change in nutritional status, skeletal muscle mass, and 3-year survival as long-term outcomes.

RESULTS

Although operation time of the DTR group was significantly longer than that of the EG group, there were no significant differences in postoperative complications between 2 groups. Regarding the endoscopic findings, the incidence of anastomotic stenosis and reflux esophagitis was significantly higher in the EG group than in the DTR group (26.5% vs 0%, p < 0.001; 15.2% vs 0%, p = 0.020). In long-term outcomes, there were no significant differences in body weight, BMI, laboratory data, and skeletal muscle mass index between 2 groups for 3 years. The 3-year overall survival rates of 2 groups were similar.

CONCLUSION

DTR after PG could prevent the occurrence of anastomotic complications in comparison to EG. The long-term outcomes were similar between these 2 types of reconstruction.

Trans-pacific multicenter collaborative study of minimally invasive proximal versus total gastrectomy for proximal gastric and gastroesophageal junction cancers

BACKGROUND

The current standard operation for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal extension is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to the loss of gastric functions such as production of ghrelin and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) can mitigate these problems by preserving gastric function. However, PG with direct esophagogastric reconstruction is associated with severe postoperative reflux, delayed gastric emptying, and poor quality of life (QoL). Minimally invasive PG (MIPG) with antireflux techniques has been increasingly performed by experts but is technically demanding owing to its complexity. Moreover, the actual advantages of MIPG over minimally invasive TG (MITG) with regards to postoperative QoL are unknown. Our overall objective of this study is to determine the short-term QoL benefits of MIPG. Our central hypotheses are that MIPG is safe and that patients have improved appetite after MIPG with effective antireflux techniques, which leads to an overall QoL improvement when compared with MITG.

METHODS

Enrollment of a total of 60 patients in this prospective survey-collection study is expected. Procedures (MITG versus MIPG, antireflux techniques for MIPG [double-tract reconstruction versus the double-flap technique]) will be chosen based on surgeon and/or patient preference. Randomization is not considered feasible because patients often have strong preferences regarding MITG and MIPG. The primary outcome is appetite level (reported on a 0-10 scale) at 3 months after surgery. With an expected 30 patients per cohort (MITG versus MIPG), this study will have 80% power to detect a one-point difference in appetite level. Patient-reported outcomes will be longitudinally collected (including questions about appetite and reflux), and specific QoL items, body weight, body mass index and ghrelin, albumin, and hemoglobin levels will be compared.

DISCUSSION

Surgeons from the US, Japan, and South Korea formed this collaboration with the agreement that the surgical approach to P/GEJ cancers is an internationally important but controversial topic that requires immediate action. At the completion of the proposed research, our expected outcome is the establishment of the benefit and safety of MIPG.

TRIAL REGISTRATION

This trial was registered with Clinical Trials Reporting Program Registration under the registration number NCI-2022-00267 on January 11, 2022, as well as with ClinicalTrials.gov under the registration number NCT05205343 on January 11, 2022.

Systematic review and meta-analysis comparing proximal gastrectomy with double-tract-reconstruction and total gastrectomy in gastric and gastroesophageal junction cancer patients: Still no sufficient evidence for clinical decision-making

BACKGROUND

To compare proximal gastrectomy with double-tract reconstruction and total gastrectomy in patients with gastroesophageal junction (AEG II-III) and gastric cancer.

METHODS

We conducted systematic searches in Medline, Web of Science, and Cochrane Library until December 20, 2021 (PROSPERO registration number: CRD42021291500). Risk of bias was assessed using the revised Cochrane risk of bias tool and the ROBINS-I tool, as applicable. Evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

One randomized controlled trial (RCT) and 13 non-RCTs with 1,317 patients (715 patients with total gastrectomy and 602 patients with proximal gastrectomy with double-tract reconstruction) were included. Patients treated by total gastrectomy had a significantly higher proportion of advanced cancer stages International Union Against Cancer IB-III (odds ratio: 0.68, 95% confidence interval: 0.51-0.91, P = .01). This heterogeneity biases the observed improved overall survival of patients after proximal gastrectomy with double-tract reconstruction (odds ratio: 0.67, 95% confidence interval: 0.44-1.01, P = .05). Both procedures were comparably efficient regarding perioperative parameters. Postoperative/preoperative bodyweight ratio (mean difference: 3.56, 95% confidence interval: 1.32-5.79, P = .002), postoperative/preoperative serum-hemoglobin ratio (mean difference 3.73, 95% confidence interval: 1.59-5.88, P < .001), and postoperative serum vitamin B₁₂ levels (mean difference 42.46, 95% confidence interval: 6.37-78.55, P = .02) were superior after proximal gastrectomy with double-tract reconstruction, while postoperative/preoperative serum-albumin ratio (mean difference 1.24, 95% confidence interval: -4.76 to 7.24, P = .69) and postoperative/preoperative serum total protein ratio (mean difference 1.12, 95% confidence interval: -2.77 to 5.00, P = .57) were not different. Health-related quality of life data were reported in only 2 studies, which found no significant advantages for proximal gastrectomy with double-tract reconstruction.

CONCLUSION

Proximal gastrectomy with double-tract reconstruction offers advantages in postoperative nutritional parameters compared to total gastrectomy (GRADE: moderate quality of evidence). Oncological effectiveness of proximal gastrectomy with double-tract reconstruction cannot be assessed (GRADE: very low quality of evidence). Further thoroughly planned randomized controlled trials in Western patient cohorts are necessary to improve treatment for gastric cancer patients.

The comparison of long-term oncological outcomes and complications after proximal gastrectomy with double tract reconstruction versus total gastrectomy for proximal gastric cancer

BACKGROUND

Conventional methods for treating patients with proximal gastric cancer (PGC) include proximal gastrectomy (PG) and total gastrectomy (TG) and such methods have become challenging due to double tract reconstruction (DTR). However, the clinical outcomes remain unclear. This study was performed with the aim of verifying that PG-DTR was beneficial in terms of reducing the incidence of postoperative complications and improving the prognosis.

METHODS

The PGC patient cohort was retrospectively grouped into the PG-DTR and TG groups. Clinicopathological features, complications, and survival data were compared between the two groups.

RESULTS

A total of 388 patients were included in the analyses. Patients who were subjected to TG tended to have more severe gastroesophageal reflux (GR) (P = 0.041), anemia (P = 0.007), and hypoalbuminemia (P < 0.001). Overall survival rates, regardless of clinical stage, were significantly different between the PG-DTR and TG groups (all P < 0.05). The multivariate Cox regression analysis confirmed that surgical procedure, tumor size, infiltration depth, lymph node metastasis, differentiation, and age were independent risk factors. The patients were likely to benefit from PG-DTR (all HR > 1 and P < 0.05). However, no significant differences were observed in the risks of GR, anemia, and hypoalbuminemia (all P > 0.05). Moreover, the nomogram derived from significant parameters showed great calibration and discrimination ability and significant clinical benefit.

CONCLUSIONS

The patients who underwent PG-DTR had a favorable prognosis. The risk of postoperative complications, such as severe GR, anemia, and hypoalbuminemia, was lower in PG-DTR than in TG. Thus, PG-DTR is more beneficial for patients with PGC and may be a valuable and promising surgical procedure.

Clinical outcomes of proximal gastrectomy with gastric tubular reconstruction and total gastrectomy for proximal gastric cancer: A matched cohort study

Background

Proximal gastrectomy with gastric tubular reconstruction is a surgical procedure that can preserve function in patients with proximal gastric cancer. However, whether gastric tubular reconstruction with proximal gastrectomy has certain advantage in some aspects over total gastrectomy is controversial. To evaluate the benefit of gastric tubular reconstruction after proximal gastrectomy, we compared gastric tubular reconstruction with total gastrectomy for proximal gastric cancer.

Method

A total of 351 patients were enrolled. Concurrent total gastrectomy patients matched with the Proximal gastrectomy group in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Preoperative basic information, perioperative indicators, histopathological features, postoperative complications and nutritional status, reflux were compared between the two groups.

Results

There was no significant difference in the incidence of reflux between two groups (14.8% and 6.5% respectively, P = 0.085). There were significant differences between the two groups in bowel function recovery (2.29 ± 1.16 vs. 3.01 ± 1.22; P = 0.039) and start of soft diet (4.06 ± 1.81 vs. 4.76 ± 1.69; P = 0.047). There were no significant differences between the two groups in nutritional status one year after surgery. However, the decrease in serum hemoglobin in the TG group at 3 and 6 months after surgery was significantly higher than that in the PG group (P = 0.032 and 0.046, respectively). One month after surgery, %BW loss in TG group was significantly lower than that in the PG group (P = 0.024).

Conclusion

The Proximal gastrectomy group has better clinical outcome and gastric tubular reconstruction is simple, similar complications and reflux rates, gastric tubular reconstruction may be more suitable for proximal gastric cancer.

Laparoscopic Function-Preserving Gastrectomy for Proximal Gastric Cancer or Esophagogastric Junction Cancer: A Narrative Review

Function-preserving procedures to maintain postoperative quality of life are an important aspect of treatment for early gastric cancer. Laparoscopic proximal gastrectomy (LPG) and laparoscopic distal gastrectomy with a small remnant stomach, namely laparoscopic subtotal gastrectomy (LsTG), are alternative function-preserving procedures for laparoscopic total gastrectomy of early proximal gastric cancer. In LPG, esophagogastrostomy with techniques to prevent reflux and double-tract and jejunal interposition including esophagojejunostomy is usually chosen for reconstruction. The double-flap technique is currently a preferred reconstruction technique in Japan as an esophagogastrostomy approach to prevent reflux esophagitis. However, standardized reconstruction methods after LPG have not yet been established. In LsTG, preservation of the esophagogastric junction and the fundus prevents reflux and malnutrition, which may maintain quality of life. However, whether LsTG is an oncologically and nutritionally acceptable procedure compared with laparoscopic total gastrectomy or LPG is a concern. In this review, we summarize the status of reconstruction in LPG and the oncological and nutritional aspects of LsTG as a function-preserving gastrectomy for early proximal gastric or esophagogastric junction cancer.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Long-term nutritional status after total gastrectomy was comparable to proximal gastrectomy but with much less reflux esophagitis and anastomotic stenosis

AIM

To compare the long-term nutritional status, reflux esophagitis and anastomotic stenosis, between total gastrectomy (TG) and proximal gastrectomy (PG).

METHODS

Patients who underwent PG or TG in this single institution between January 2014 and December 2016 were included in this study. The inclusion and exclusion criteria were defined. One-to-one propensity score matching (PSM) by the demographic and pathological characteristics was performed to compare the long-term outcomes between the two groups. The primary endpoint was long-term nutritional status, and the second endpoints were reflux esophagitis and anastomotic stenosis. Long-term nutritional status was valued by percentage of body mass index (%BMI), body weight, and blood test including total protein, prealbumin, hemoglobin and total leukocytes.

RESULTS

Totally 460 patients received PG or TG in our institution for the treatment between January 2014 and December 2016 and according to the inclusion and exclusion criteria 226 cases were included in this study finally. There was no significant difference as to nutritional status in the end of first 5 years after PG or TG. While reflux esophagitis and anastomotic stenosis were significantly higher in the PG group than in the TG group (54.4% versus 26.8%, p < 0.001; 14.9% versus 4.5%, p=0.015; respectively). Overall survival rates were similar between the two groups after PSM (5-year survival rates: 65.4% versus 61.5% in the PG and TG groups, respectively; p = 0.54). The rate of carcinoma of remnant stomach after PG was 3.5% in this group of patients.

CONCLUSIONS

TG should be more aggressively recommended for the similar nutritional status, significantly lower reflux esophagitis and anastomotic stenosis, and free of carcinoma of remnant stomach compared with PG.

Clinical Comparison of Proximal Gastrectomy With Double-Tract Reconstruction Versus Total Gastrectomy With Roux-en-Y Anastomosis for Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction

Purpose

The incidence of adenocarcinoma of the esophagogastric junction (AEG) has increased in recent years, and the optimal surgical strategy for AEG remains highly controversial. We aimed to evaluate the safety and efficacy of proximal gastrectomy with double-tract reconstruction (PG-DT) for the treatment of patients with AEG.

Materials and Methods

We retrospectively analyzed patients with Siewert type II/III AEG between January 2013 and July 2018. Clinicopathological characteristics, survival, surgical outcomes, quality of life (QOL), and nutritional status were compared between the PG-DT and total gastrectomy with Roux-en-Y anastomosis (TG-RY) groups.

Results

After propensity score matching, 33 patients in each group were analyzed. There were no statistical differences between the 2 groups in terms of disease-free survival and overall survival. The surgical option was not an independent prognostic factor based on the multivariate analysis. In addition, no differences were found in terms of surgical complications. There were no significant differences in QOL assessed by the Visick grade, Gastrointestinal Symptom Rating Scale, or endoscopic findings. Furthermore, the long-term nutritional advantage of the PG-DT group was significantly greater than that of the TG-RY group.

Conclusions

PG-DT is a safe and effective procedure for patients with local Siewert type II/III AEG, regardless of the TNM stage.

“A review on double tract reconstruction after proximal gastrectomy for proximal gastric cancer.”

Gastric cancer remains one of the deadliest malignancies on the planet, accounting for the fourth highest cause of death by cancer worldwide. While trends indicate that its incidence is decreasing globally, it remains a concern, particularly when identified at an advanced stage with a high mortality rate. The best treatment option for early proximal stomach cancer has been identified as surgical resection followed by an acceptable reconstructive procedure.

One such surgical management called Double Tract Reconstruction (DTR), has piqued surgeons' interest. DTR has been found to be a potential reconstructive strategy for reducing esophagogastric reflux or post-gastrectomy gastritis and esophagitis. Not only does this technique ensure adequate vitamin B12 maintenance post surgically, but it is also a safe and effective procedure. According to several researchers, the benefits may be comparable to those of total gastrectomy as it relates to, post-operative recovery time, operation time, intraoperative complications, and early complications. DTR is still being studied, and gastrointestinal surgeons worldwide are looking for new ways to improve this method and increase overall survival of gastric cancer.

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Double tract reconstruction is a safe and promising reconstructive procedure.

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Double tract reconstruction decreases esophagogastric reflux.

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Double tract reconstruction maintains vitamin B1₂ level post-surgery.

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Double tract reconstruction-proximal gastrectomy is comparable to total gastrectomy.

Comparison of the prognosis of four different surgical strategies for proximal gastric cancer: a network meta-analysis

BACKGROUND

There is controversy regarding the long-term prognosis and short-term postoperative complications of different surgical strategies for proximal gastric cancer (PGC).

METHODS

We searched for articles published in Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science between January 1, 1990, and February 1, 2021. We screened out the literature comparing different surgical strategies. We then evaluated the long-term and short-term outcome of different surgical strategies using a network meta-analysis, which summarizes the hazard ratio, odds ratio, mean difference, and 95% confidence interval.

RESULTS

There were no significant differences between different surgical strategies for 5-year overall survival (OS), anastomotic leakage, or weight loss after 1 year. Compared with total gastrectomy with Roux-en-Y reconstruction (TG-RY) and proximal gastrectomy with double tract reconstruction (PG-DTR), the proximal gastrectomy with esophagogastrostomy (PG-EG) strategy significantly increased the incidence of reflux esophagitis; and the operation time and blood loss of the PG-EG strategy were significantly less than those of the other surgical strategies. The anastomotic stenosis rates of the PG-EG and proximal gastrectomy with jejunum interstitial (PG-JI) strategies were significantly higher than those of TG-RY and PG-DTR; the hemoglobin level after 1 year for the PG-DTR strategy was significantly higher than that of the TG-RY strategy.

CONCLUSION

Our comprehensive literature research found that different surgical strategies had no significant difference in the long-term survival of PGC, but the incidence of reflux esophagitis and anastomotic stenosis after PG-DTR and TG-RY was significantly reduced.

Trends in clinical outcomes and long-term survival after robotic gastrectomy for gastric cancer: a single high-volume center experience of consecutive 2000 patients

BACKGROUND

Minimally invasive surgery is now a standard treatment for gastric cancer. Many retrospective studies have reported that robotic gastrectomy is safe and feasible, with similar short- and long-term outcomes as laparoscopic gastrectomy. However, no studies have reported the details of surgical and survival outcomes for robotic gastrectomy. This study aimed to evaluate the surgical trends and techniques of robotic gastrectomy and analyze the surgical outcomes of 2000 consecutive patients with gastric cancer who underwent robotic gastrectomy over 14 years.

METHODS

Between July 2005 and January 2019, 2000 consecutive robotic gastrectomies were performed. We evaluated short- and long-term outcomes as well as surgical trends after robotic gastrectomy.

RESULTS

There were 1,560 subtotal gastrectomies (78%), 324 total gastrectomies (16.2%), 83 proximal gastrectomies (4.2%), and 33 completion total gastrectomies (1.7%). The rates of major complications and mortality were 3.1% and 0.3%, respectively. In a subgroup analysis, there were no significant differences in the rate of complications over time (P = 0.696). Five-year overall survival rates were 97.6% for stage I, 91.9% for stage II, and 69.2% for stage III, with a total recurrence rate of 5.3%. Since its adoption in 2005, the proportion of robotic gastrectomies, as well as technically demanding procedures have increased over time.

CONCLUSIONS

Our 14 years' experience of 2000 robotic gastrectomies has shown the proportion, as well as the number of robotic gastrectomies, have tended to increase and trends toward to technically demanding procedures. Outcomes of robotic gastrectomy appear safe and feasible with acceptable short- and long-term outcomes.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy for proximal gastric cancer with stage cT1-2

ABSTRACT

This study aimed to evaluate the feasibility and nutritional benefits of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) in comparison with laparoscopic total gastrectomy (LTG).The demographic, clinical, and pathological data and postoperative nutritional status of patients undergoing LPG with DTR (n = 21) or LTG (n = 26) at Sir Run Run Shaw Hospital between January 2016 and January 2019 were retrospectively reviewed and compared.The operative time in the LPG group was slightly longer than that in the LTG group; however, the difference was not statistically significant. Blood loss was not significantly different between groups. The mean number of retrieved lymph nodes was higher in the LTG group than in the LPG group (P = .02). The time to first flatus, postoperative hospital stay, and postoperative complications were comparable between the groups. During the 3-year postoperative follow-up, a statistically significant decrease in hemoglobin level was observed in the LTG group. There were no differences between the two groups of patients before and after the operation regarding albumin levels. The mean vitamin B12 level was higher in the LPG group than in the LTG group from 12 to 18 months postoperatively.LPG with DTR is an acceptable procedure for patients with upper gastric cancer. LPG with DTR has numerous potential advantages in preserving the physiological and nutritional functions of the remnant stomach and the conservation of the gastric reservoir.

Indication of Proximal Gastrectomy for Advanced Proximal Gastric Cancer Based on Lymph Node Metastasis at the Distal Part of the Stomach

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.

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

BACKGROUND

The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).

METHODS

A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.

RESULTS

Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.

CONCLUSION

This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.

Risk factors of post-operative pneumonia in elderly patients with gastric cancer: a retrospective cohort study

BACKGROUND

Post-operative pneumonia is a major complication after general elective surgery in elderly patients and is often caused by aspiration associated with oesophageal reflux. The aim of this study was to identify the risk factors of post-operative pneumonia after gastrectomy in elderly patients with gastric cancer with two potential risk factors of ageing and oesophageal reflux.

METHODS

We retrospectively examined the data of 251 patients ≥75 years old who underwent gastrectomy between January 2014 and December 2018 in our institution. The reconstruction methods were Billroth-I or Roux-Y after distal gastrectomy, jejunal interposition or double tract after proximal gastrectomy and Roux-Y after total gastrectomy. The severity of pneumonia was evaluated by the Clavien-Dindo classification.

RESULTS

Post-operative pneumonia was identified in 15 patients (5.9%) and was significantly associated with an age ≥80 years old, poor performance status, history of smoking and cardia-non-preserving gastrectomy (total gastrectomy and proximal gastrectomy) in univariate analyses. Multivariate analyses showed that a poor performance status and cardia-non-preserving gastrectomy were independent risk factors for post-operative pneumonia. The patients who suffered post-operative pneumonia required a longer hospital stay than those without post-operative pneumonia (P = 0.002).

CONCLUSION

We identified a poor performance status and cardia-non-preserving gastrectomy, which are likely to lead to oesophageal reflux, as risk factors for post-operative pneumonia in elderly patients with gastric cancer. These results warrant further prospective studies to evaluate their utility for reducing the rate of post-operative pneumonia in elderly patients through cardia-preserving gastrectomy or anti-reflux reconstruction.

Oncologic Feasibility of Proximal Gastrectomy in Upper Third Advanced Gastric and Esophagogastric Junctional Cancer

Purpose

The aim of this study was to investigate the oncologic safety and identify potential candidates for proximal gastrectomy (PG) in upper third advanced gastric cancer (AGC) and esophagogastric junction (EGJ) cancers.

Materials and Methods

Among 5,665 patients who underwent gastrectomy for gastric adenocarcinoma between January 2011 and December 2017, 327 patients who underwent total gastrectomy with standard lymph node (LN) dissection for upper third AGC and Siewert type II EGJ cancers were enrolled. We analyzed the correlation between the metastatic rates of distal LNs (No. 4d, 5, 6, and 12a) around the lower part of the stomach and the clinicopathological characteristics. We identified subgroups with no metastasis to the distal LNs.

Results

The metastatic rate of distal LNs in proximal AGC and Siewert type II EGJ cancers was 7.0% (23 of 327 patients). On multivariate analysis, pathological T stage (P=0.001), tumor size (P=0.043), and middle third invasion (P=0.003) were significantly associated with distal LN metastases. Pathological ‘T2 stage’ (n=88), or ‘T3 stage with ≤5 cm tumor size’ (n=87) showed no metastasis in distal LNs, regardless of middle third invasion. Pathological T3 stage with tumor size > 5 cm (n=61) and T4 stage (n=91) had metastasis in the distal LNs.

Conclusions

In the upper third AGC and Siewert type II EGJ cancer, pathological T2 and small-sized T3 stage groups are possible candidates for PG in cases without distal LN metastasis. Further validation studies are required for clinical application.

Intracorporeal Esophagojejunostomy during Reduced-port Totally Robotic Gastrectomy for Proximal Gastric Cancer: a Novel Application of the Single-Site® Plus 2-port System

Purpose

Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy.

Materials and Methods

We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site^® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures.

Results

Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period.

Conclusions

Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

Double-tract reconstruction for oesofagocardial gastric cancer: A systematic review

The number of people with gastric cardia and distal oesophageal cancers has increased in the last five years. The surgical treatment method of choice is proximal gastrectomy, with an option being reconstruction of the gastrointestinal tract. There are many reconstruction techniques for anastomosis of the oesophagus and distal parts of the digestive tract. However, all can result in complications. This systematic review aims to identify the efficacy of the double-tract reconstruction method after gastric resection. Different operative techniques for gastric reconstruction have been included in this review. The double-tract reconstruction method, which is gaining popularity among surgeons in Asia and Europe, is a promising technique that improves the early and late results of surgical treatment. This method is associated with low complications related to gastroesophageal reflux disease and dysphagia. Double-tract reconstruction is a promising method for the treatment of patients with esofagocardial gastric cancer. However, further studies are required on the long-term complications and side effects.

Current status of function-preserving gastrectomy for gastric cancer

Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.

Comparison of nutrition and quality of life of esophagogastrostomy and the double-tract reconstruction after laparoscopic proximal gastrectomy

This study aims to compare the nutritional outcomes and quality of life between patients who underwent esophagogastrostomy (EG) and those who underwent the double-tract reconstruction (DTR) after laparoscopic proximal gastrectomy for early gastric cancer.We retrospectively reviewed the prospectively established database of 45 patients who underwent EG with anti-reflux procedure and 58 patients who underwent the DTR after laparoscopic proximal gastrectomy between December 2013 and June 2017. Then, we compared the baseline characteristics, clinical outcomes, postoperative nutritional parameters, and quality of life (QOL) using European Organization for Research and Treatment of Cancer (EORTC) QLQ STO-22 between the EG and DTR groups.In the postoperative 1-year endoscopic findings, the incidence of esophageal reflux was higher in the EG group (17.8% vs 3.4%, P = .041) and there was no significant difference in anastomotic stricture. Nutritional status was evaluated via body mass index, serum albumin, protein, hemoglobin, and ferritin; we found no significant differences. The incidences of iron deficiency anemia and vitamin B12 deficiency also showed no significant difference between the 2 groups. With regards to the quality of life, the difference values between preoperative and postoperative 1-year were evaluated; there was no significant difference between the EG with anti-reflux procedure and DTR groups.EG had higher incidence of esophageal reflux and similar nutritional outcomes and QOL compared with the double-tract reconstruction after laparoscopic proximal gastrectomy. Additional large-scale research is needed to evaluate the long-term functional outcomes of EG and the double-tract reconstruction.

Clinical outcomes of gastric tube reconstruction following laparoscopic proximal gastrectomy for early gastric cancer in the upper third of the stomach: experience with 100 consecutive cases

BACKGROUND

Gastric tube reconstruction is a form of esophagogastrostomy performed after laparoscopic proximal gastrectomy (LPG). It is a simple and safe technique, but it may cause reflux esophagitis (RE) and impair postsurgical QOL. For several years, we have developed the gastric tube reconstruction and performed it on more than 100 patients. This study aimed to determine whether gastric tube reconstruction can be a feasible choice after LPG in regard to surgical safety and postoperative nutritional status.

METHODS

The subjects consisted of 171 patients who underwent LPG (n = 102) or laparoscopic total gastrectomy (LTG) (n = 69). We compared the two groups in terms of surgical outcomes, incidence rate of RE, and nutritional status including postoperative weight loss and hemoglobin levels.

RESULTS

There were no significant differences with regard to the surgical duration and blood loss between the two groups. The incidence of RE was not significantly higher with LPG than with LTG (16.7% vs. 10.1%, respectively; P = 0.07). Later than 2 years and 6 months after surgery, the body weight percentage of preoperative body weight in the LPG group was significantly higher than that in the LTG group. Hemoglobin and ferritin levels in the LPG group were significantly higher than those in the LTG group, later than one after surgery. The overall survival rates were similar between the two groups (5-year survival rates: 97.1% vs. 94.2% in the LPG and LTG groups, respectively; P = 0.69).

CONCLUSIONS

Gastric tube reconstruction after LPG is simple and had better outcomes than LTG in terms of postoperative nutritional status.

Evaluation of Lymph Node Metastasis Among Adults With Gastric Adenocarcinoma Managed With Total Gastrectomy

IMPORTANCE

It is unclear whether proximal gastrectomy (PG) can replace total gastrectomy (TG), even in cases of advanced gastric carcinoma.

OBJECTIVES

To evaluate the oncologic safety of PG based on the lymph node (LN) metastasis rate and develop a selection diagram for PG eligibility.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, a retrospective analysis of a prospective database of gastric carcinoma surgery was performed including procedures that took place between December 1, 2000, and December 31, 2015, in the National Cancer Center, Korea, a high-volume carcinoma center with a structured database and accurate long-term follow-up. Among 9952 patients who underwent surgery for gastric carcinoma, 2347 underwent TG. Six-hundred fifty-five (564 in a second statistical analysis) had gastric carcinoma in the upper third of the stomach. The inclusion criteria were age 18 to 85 years, histologically proven adenocarcinoma (any size or differentiation) located in the upper third of the stomach, curative R0 TG performed, and postoperative follow-up for at least 3 years. Exclusion criteria included Borrmann type 4 carcinoma, T4 category, use of neoadjuvant chemotherapy, and a history of other carcinomas. Data analysis was performed from December 1, 2019, to May 30, 2020.

EXPOSURES

Total gastrectomy and LN dissection.

MAIN OUTCOMES AND MEASURES

The primary end point was the rate of LN metastasis at LN stations 4d, 5, and 6, which are usually not dissected during PG.

RESULTS

Among the 655 study patients, the mean (SD) age was 57.7 (11.9) years, and 462 (70.5%) were men. Only those with poorly differentiated cT3 category carcinomas had an increased incidence of LN metastasis at stations 4d (2 of 32 [6.3%]) and 11d (T3N0: 2 of 22 [9.1%], T3N1: 3 of 27 [11.1%]), independent of tumor size. For cT1-T3N0/1M0 category carcinomas, the incidence of station 5 LN metastasis was 0, irrespective of tumor size and differentiation. The LN metastasis rate at stations 4d and 6 for cT1-T3N0/1M0 differentiated tumors was also 0. Tumor size greater than or equal to 4.1 cm was associated with significantly increased LN metastasis compared with tumors less than 4.1 cm (40.0% vs 20.4%, P = .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that PG can be safely performed for cT1-T2N0/1M0 tumors less than 4.1 cm in diameter that are located in the upper third of the stomach. The cT3N0/1M0-differentiated tumors less than 4.1 cm may also be eligible for PG, whereas poorly differentiated cT3 tumors and any cT4 or cN2/3 diseases require TG.

Efficacy of intraoperative ICG fluorescence imaging evaluation for preventing anastomotic leakage after left-sided colon or rectal cancer surgery: a propensity score-matched analysis

BACKGROUND

Intestinal perfusion at the anastomotic site is thought to be one of the most influential risk factors for postoperative anastomotic leakage (AL). We evaluated the efficacy of indocyanine green (ICG) fluorescence imaging at the stump of the proximal colon in left-sided colectomy or rectal resection in terms of decreasing the incidence of AL.

METHODS

Prospectively collected data were retrospectively evaluated. Patients who underwent left-sided colectomy or rectal resection were enrolled (ICG group; n = 197), and patients who had undergone a similar procedure before the ICG group were enrolled from the charts as historical controls (HC group; n = 187). After ICG evaluation, anastomosis was performed where fluorescence was sufficient. The incidence of AL was compared between the ICG and HC groups. Propensity score (PS)-matched data were analyzed to clarify the risk of AL.

RESULTS

AL occurred in 6 patients (3.3%) in the ICG group and 17 (10.7%) in the HC group. ICG evaluation revealed 179 patients with good fluorescence and 18 with poor/none perfusion (9.1%). The transection line was changed in all patients with poor/none fluorescence. Three of these 18 patients developed AL (16.7%), though transection line was changed at which is thought to be good. We hope AL in poor/none fluorescence can be prevented at the same rate of cases with good fluorescence. Actually, the rate of that was significantly higher compared with good fluorescence patients (P = 0.038). 93 patients in each group were compared by PS-matched data analysis, which showed the AL rate in the ICG group was significantly lower than that in the HC group (3.2% vs 10.8%, respectively; P = 0.046).

CONCLUSIONS

Even though this study has limitations of comparison of data prospectively collected and retrospectively analyzed, intraoperative ICG fluorescence imaging evaluation could significantly decrease the incidence of AL.

Postoperative nutritional outcomes and quality of life-related complications of proximal versus total gastrectomy for upper-third early gastric cancer: a meta-analysis

Although proximal gastrectomy (PG) provides superior nutritional outcomes over total gastrectomy (TG) in upper-third early gastric cancer (EGC), surgeons are reluctant to perform PG due to the high rate of postoperative reflux. This meta-analysis aimed to comprehensively compare operative outcomes, nutritional outcomes, and quality of life-related complications between TG and PG performed with esophagogastrostomy (EG), jejunal interposition, or double-tract reconstruction (DTR) to reduce reflux after PG. After searching PubMed, Embase, Medline, and Web of Science databases, 25 studies comparing PG with TG in upper-third EGC published up to October 2020 were identified. PG with DTR was similar to TG regarding operative outcomes. Patients who underwent PG with DTR had less weight reduction (weighted mean difference [WMD] 4.29; 95% confidence interval [0.51–8.07]), reduced hemoglobin loss (WMD 5.74; [2.56–8.93]), and reduced vitamin B₁₂ supplementation requirement (odds ratio [OR] 0.06; [0.00–0.89]) compared to patients who underwent TG. PG with EG caused more reflux (OR 5.18; [2.03–13.24]) and anastomotic stenosis (OR 3.94; [2.40–6.46]) than TG. However, PG with DTR was similar to TG regarding quality of life-related complications including reflux, anastomotic stenosis, and leakage. Hence, PG with DTR can be recommended for patients with upper-third EGC considering its superior postoperative nutritional outcomes.

Clinical Outcomes of Proximal Gastrectomy versus Total Gastrectomy for Proximal Gastric Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

The extent of optimal gastric resection for proximal gastric cancer (PGC) continues to remain controversial, and a final consensus is yet to be met. The current study aimed to compare the perioperative outcomes, postoperative complications, and overall survival (OS) of proximal gastrectomy (PG) versus total gastrectomy (TG) in the treatment of PGC through a meta-analysis.

METHODS

We systematically searched PubMed, Embase, The Cochrane Library, and Web of Science for articles published in English since database establishment to October 2019. Evaluated endpoints were perioperative outcomes, postoperative complications, and long-term survival outcomes.

RESULTS

A total of 2,896 patients in 25 full-text articles were included, of which one was a prospective randomized study, one was a clinical phase III trial, and the rest were retrospective comparative studies. The PG group showed a higher incidence of anastomotic stenosis (OR = 2.21 [95% CI: 1.08-4.50]; p = 0.03) and reflux symptoms (OR = 3.33 [95% CI: 1.85-5.99]; p < 0.001) when compared with the TG group, while no difference was found in PG patients with double-tract reconstruction (DTR). The retrieved lymph nodes were clearly more in the TG group (WMD = -10.46 [95% CI: -12.76 to -8.17]; p < 0.001). The PG group was associated with a better 5-year OS relative to TG with 11 included studies (OR = 1.35 [95% CI: 1.03-1.77]; p = 0.03). After stratification for early gastric cancer and PG with DTR groups, however, there was no significant difference between the 2 groups (OR = 1.35 [95% CI: 0.59-2.45]; p = 0.62).

CONCLUSION

In conclusion, PG was associated with a visible improved long-term survival outcome for all irrespective of tumor stage, while a similar 5-year OS for only early gastric cancer patients between the 2 groups. Future randomized clinical trials of esophagojejunostomy techniques, such as DTR following PG, are expected to prevent postoperative complications and assist surgeons in the choice of surgical approach for PGC patients.

Validation of a novel reconstruction method of laparoscopic gastrectomy for proximal early gastric cancer: a systematic review and meta-analysis

Background

Recently, a novel surgical procedure, named as laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR), has been reported to provide surgical benefits in the treatment of proximal early gastric cancer (EGC) over traditional laparoscopic total gastrectomy (LTG). These benefits include a lower incidence of some surgical complications and better postoperative nutritional status. However, the number of relevant studies is still too low to validate such benefits. Therefore, this systematic review and meta-analysis aimed to assess the surgical features, complications, and postoperative nutritional status of LPG with DTR in comparison to those of LTG.

Methods

Online databases (PubMed, Web of Science, Cochrane Library, and EMBASE) were scoured for relevant studies published by April 2020. The quality assessment of the included articles was evaluated using the Newcastle-Ottawa scale. Egger’s test was utilized to assess publication bias.

Results

Nine studies (687 patients) were enrolled for this meta-analysis, and we found that LPG with DTR and LTG had similar surgical features. However, LPG with DTR was superior to LTG in the incidence of reflux syndrome [OR = 0.185; 95%CI 0.083, 0.414; P = 0.000], postoperative nutritional status (hemoglobin [WMD = − 2.326; 95%CI − 4.491, − 0.160; P = 0.035], vitamin B12 [WMD = − 13.072; 95%CI − 22.850, − 3.294; P = 0.009], and body weight [WMD = − 3.514; 95%CI − 5.579, − 1.449; P = 0.001]).

Conclusions

LPG with DTR has better performance in the incidence of reflux syndrome and postoperative nutritional status compared with LTG. This surgical procedure may therefore have more benefits for patients with proximal EGC.

Totally laparoscopic proximal gastrectomy with double tract reconstruction: outcomes of 37 consecutive cases

Introduction

Proximal gastrectomy is an alternative treatment modality for gastric cancer in the upper third of the stomach. Though several reconstruction methods have been introduced, there is no standardization. We investigated the outcomes of laparoscopic proximal gastrectomy with double tract reconstruction (LPG-DTR).

Aim

To investigate the outcomes of LPG-DTR.

Material and methods

We evaluated 37 patients who underwent curative LPG with DTR between December 2013 and December 2018. Less than half of the proximal stomach was laparoscopically resected. We performed LPG-DTR after resection.

Results

A total of 37 patients were included in this study, 25 (70%) of whom were male and 12 (30%) of whom were female. Overall, 31 (83.7%) patients were diagnosed with gastric cancer, 5 (13.5%) with gastrointestinal stromal tumors, and 1 (2.8%) with leiomyoma. There were 3 (9.6%) complications. However, there were no complications of grade 3 or above. We did not observe postoperative mortality or recurrence after surgery. All patients underwent postoperative endoscopic surveillance successfully. None of the patients had postoperative reflux esophagitis or stenosis. The body weight and hemoglobin levels of the patients were lowest 12 months after surgery and gradually increased thereafter. Similarly, their vitamin B₁₂ levels were lowest 6 months after surgery. However, iron been increased after surgery until 24 months after surgery.

Conclusions

LPG-DTR is a favorable treatment modality for gastric cancer in the upper third of the stomach.

Digestive tract reconstruction options after laparoscopic gastrectomy for gastric cancer

In addition to the popularity of laparoscopic gastrectomy (LG), many reconstructive procedures after LG have been reported. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer (GC). Presently, no consensus exists regarding the optimal reconstructive procedure. In this review, the current state of digestive tract reconstruction after LG is reviewed. According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction, we divide these reconstruction procedures into three categories consistent with the resection procedures. We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes (length of surgery and blood loss) and postoperative complications (anastomotic leakage and stricture) to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

Systematic assessment of complications after robotic-assisted total versus distal gastrectomy for advanced gastric cancer: A retrospective propensity score-matched study using Clavien-Dindo classification

BACKGROUND

Despite increasing evidence demonstrated robot-assisted distal gastrectomy (RADG) is safe and feasible for the treatment of advanced gastric cancer (AGC), robot-assisted total gastrectomy (RATG) remains a challenging procedure due to its technical difficulties and possible postoperative complications (POCs). This study aimed to systematically evaluate POCs following RATG.

METHODS

Between January 2017 and January 2019, 319 AGC patients with pathological stage T2-4aN0-3M0 who underwent RADG or RATG were enrolled. POCs were stratified using the Clavien-Dindo classification. One-to-one propensity score matching was performed to reduce confounding differences.

RESULTS

After matching, 266 patients met the criteria for further analysis. Ultimately, 64 patients (24.1%) who developed POCs had 126 clinical manifestation events. Overall the POCs rate was significantly greater after RATG in comparison with RADG (29.3% vs. 18.8%; P = 0.045), and more major POCs (Clavien-Dindo grade ≥ IIIa) were observed in the RATG group (14.3% vs. 5.3%; P = 0.013). The POCs were then classified into local and systemic POCs. The rates of local POCs (35.3% vs. 19.5%; P = 0.004) and systemic POCs (24.8% vs. 15.0%; P = 0.046) were significantly higher in the RATG group than the RADG group. Subgroup analysis showed that the anastomotic leakage rate was higher after RATG (5.3% vs. 0.8%; P = 0.031), whereas the remaining POCs were similar between the two groups. Patients with higher POCs significantly had longer postoperative length of stay (R = 0.895, P = 0.003). Multivariate analysis confirmed age, extent of resection, and TNM stage were risk factors for all POCs.

CONCLUSIONS

These findings demonstrated that RATG is technically feasible and safe for treatment of AGC with acceptable morbidity and mortality rates. The POCs rate of RATG was higher than RADG, especially for anastomotic leakage. More effective anastomotic techniques are needed in RATG to prevent leakage.

A meta-analysis of comparison of proximal gastrectomy with double-tract reconstruction and total gastrectomy for proximal early gastric cancer

Background

In theory, proximal gastrectomy with double-tract reconstruction (PG-DT) was superior to total gastrectomy (TG) in hematologic and nutritional outcomes. However, its clinical effects in proximal early gastric cancer (EGC) have been controversial.

Methods

The purpose of this study was to investigate the outcomes of laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DT) for proximal EGC. For this systematic review and meta-analysis, we searched for articles published before December of 2018 in the following databases: PubMed, Web of Science, EBSCO, Medline, and Cochrane Library.

Results

The results showed no significant difference in the anastomotic stenosis (OR = 0.91, 95%CI = 0.33–2.50, p = 0.85) and reflux esophagitis (OR = 1.87, 95%CI = 0.62–5.65, p = 0.27) between LPG-DT and laparoscopic total gastrectomy (LTG). The vitamin B12 supplementation rate in the LPG-DT group was lower than the LTG group (OR = 0.06, 95%Cl = 0.01–0.59, p = 0.02).

Conclusions

Due to comparable clinical effect, PG-DT is comparable to TG for patients with proximal EGC. In addition, LPG-DT not only appears superior to TG in terms of preventing vitamin B12 deficiency, but also does not increase the risk of anastomotic stricture and reflux esophagitis.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0584-7) contains supplementary material, which is available to authorized users.

Similar Operative Outcomes between the da Vinci Xi® and da Vinci Si® Systems in Robotic Gastrectomy for Gastric Cancer

Purpose

The robotic system for surgery was introduced to gastric cancer surgery in the early 2000s to overcome the shortcomings of laparoscopic surgery. The more recently introduced da Vinci Xi^® system offers benefits allowing four-quadrant access, greater range of motion, and easier docking through an overhead boom rotation with laser targeting. We aimed to identify whether the Xi^® system provides actual advantages over the Si^® system in gastrectomy for gastric cancer by comparing the operative outcomes.

Materials and Methods

We retrospectively reviewed all patients who underwent robotic gastrectomy as treatment for gastric cancer from March 2016 to March 2017. Patients' demographic data, perioperative information, and operative and pathological outcomes were collected and analyzed.

Results

A total of 109 patients were included in the Xi^® group and 179 in the Si^® group. Demographic characteristics were similar in both groups. The mean operative time was 229.9 minutes in the Xi^® group and 223.7 minutes in the Si^® group. The mean estimated blood loss was 72.7 mL in the Xi^® group and 62.1 mL in the Si^® group. No patient in the Xi^® group was converted to open or laparoscopy, while 3 patients in the Si^® group were converted, 2 to open surgery and 1 to laparoscopy, this difference was not statistically significant. Bowel function was resumed 3 days after surgery, while soft diet was initiated 4 days after surgery.

Conclusions

We found no difference in surgical outcomes after robotic gastrectomy for gastric cancer between the da Vinci Xi^® and da Vinci Si^® procedures.