Clinicopathology and Survival in Patients with Gastroesophageal Reflux After Radical Surgery of Proximal Gastric Cancer

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 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.

Treatment Selection and Survival Outcomes in Locally Advanced Proximal Gastric Cancer: A National Cancer Data Base Analysis

Background: We aimed to assess long-term survival between locally advanced proximal gastric cancer (LAPGC) patients who underwent proximal gastrectomy (PG) and those who underwent total gastrectomy (TG) to evaluate the optimal extent of resection and adjuvant therapy.

Materials and Methods: Patients diagnosed with locally advanced proximal gastric adenocarcinoma were selected from the National Cancer Data Base (2004–2015) in America. Survival analysis was performed via Kaplan-Meier and Cox proportional hazards models.

Results: A total of 4,381 eligible patients were identified, 1,243 underwent PG and 3,138 underwent TG. Patients in TG group had a poor prognosis (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 1.03–1.25) compared with those in PG group. Moreover, postoperative chemoradiation therapy was associated with improved overall survival compared to surgery alone (HR = 0.71, 95% CI: 0.53–0.97) in LAPGC patients who had PG, while preoperative chemotherapy (HR = 0.74, 95% CI: 0.59–0.92) was associated with improved survival among patients who had TG.

Conclusions: Our study suggested that LAPGC patients underwent PG experienced better long-term outcomes than those underwent TG. It also suggested that multimodality treatment of LAPGC, including preoperative chemotherapy followed by TG or postoperative chemotherapy followed by PG, should be considered to achieve better long-term outcomes.

A new technology for reducing anastomotic fistula in the neck after esophageal cancer surgery

Background

To explore the risk factors and prevention methods of cervical mechanical anastomotic fistula and stenosis after the radical resection of esophageal cancer.

Methods

From March 2018 to November 2018, 128 patients undergoing mechanical anastomosis of esophageal cancer were selected from the Department of Thoracic Surgery of The First Affiliated Hospital of Zhengzhou University. All the enrolled patients were operated on using the Mckeown method, and a retrospective study was conducted. Data for preoperative and postoperative test indices, intraoperative embedding materials, postoperative complications, and preoperative and postoperative treatment were collected, and the relationship between various factors and the incidence of cervical anastomotic fistula and stenosis was analysed. Univariate analysis was conducted using t tests or Fisher's exact probability method, and multivariate analysis was conducted using logistic regression models.

Results

All 128 patients successfully underwent surgery without dying. The enrolled patients were evaluated using the Stooler classification, with 28 patients having grade 0, 41 patients having grade 1, 34 patients having grade 2, 21 patients having grade 3, and 4 patients having grade 4 stenosis. Patients with stenosis of grade 3 or above had obvious choking sensation, which could only be relieved by balloon dilation. Symptoms in all patients with stenosis were relieved by balloon dilation. There were no significant differences between the two groups regarding embedding materials, preoperative choking history, history of alcohol consumption, history of hypertension, history of coronary heart disease, history of diabetes, postoperative calcium concentration, average albumin concentration, average platelet concentration, body mass index, anastomotic fistula, preoperative chemotherapy, postoperative chemotherapy, or postoperative cough (P>0.05). There were significant differences in postoperative reflux (χ²=11.338, P<0.05) and scar constitution (χ²=12.497, P<0.05). The effects of embedding materials in patients with anastomotic fistula were significantly different (χ²=4.372, P<0.05).

Conclusions

Postoperative reflux and scar constitution may be risk factors for postoperative anastomotic stenosis after resection of esophageal cancer. There was almost no difference in the effects on esophageal anastomotic stenosis between embedding materials and the omentum majus, but Neoveil^® may have certain advantages in preventing cervical anastomotic fistula, and thus may have certain clinical application value.

Kamikawa Double-Flap Reconstruction After Minimally Invasive Ivor-Lewis Esophagectomy

Despite the high incidence of reflux esophagitis, there are few reports of antireflux modifications for minimally invasive Ivor-Lewis esophagectomy. We present the case of a 63-year-old man with mid-thoracic esophageal squamous cell carcinoma who underwent minimally invasive Ivor-Lewis esophagectomy after neoadjuvant chemoradiotherapy. Laparoscopic dissection, gastric tube creation, and mobilization was performed. Thoracoscopic esophageal dissection, subcarinal, paraesophageal and diaphragmatic lymphadenectomy were performed, followed by esophagogastric anastomosis with double seromuscular flap reconstruction to recreate the lower esophageal sphincter. The operation was completed in 618 minutes with 200 mL blood loss and the patient recovered uneventfully. A morphologic sphincter was seen on postoperative contrast study.